负压封闭引流联合含氧液冲洗修复糖尿病患者慢性创面的效果观察
부압봉폐인류연합함양액충세수복당뇨병환자만성창면적효과관찰
Effects of vacuum sealing drainage combined with irrigation of oxygen loaded fluid on chronic wounds in diabetic patients
  • 万方数据
    中华烧伤杂志 중화소상잡지
    16
    2014年 2期 116-123 ,共8页

    张美光%李志清%王甲汉%吴起%温皇鼎

    장미광%리지청%왕갑한%오기%온황정

    负压伤口疗法%糖尿病%氧%冲洗治疗%创面床 負壓傷口療法%糖尿病%氧%遲洗治療%創麵床
    부압상구요법%당뇨병%양%충세치료%창면상
    Negative-pressure wound therapy%Diabetes mellitus%Oxygen%Irrigation therapy%Wound bed
    目的 评估VSD联合含氧液冲洗治疗糖尿病患者慢性创面的效果. 方法 2010年9月-2013年6月,将南方医科大学南方医院收治的符合纳入标准的26例糖尿病下肢慢性溃疡患者,按随机数字表法分为单纯VSD组8例、VSD+冲洗对照组9例、VSD+含氧液冲洗组9例.入院后行大体观察、取创面分泌物行细菌培养后清创,术中留取创面肉芽组织用ELISA法检测乳酸脱氢酶(LDH)和琥珀酸脱氢酶(SDH)活性.术后单纯VSD组仅行VSD治疗(负压为-30～-25 kPa,下同),VSD+冲洗对照组行VSD联合生理盐水冲洗治疗,VSD+含氧液冲洗组行VSD联合含氧液(纯氧流量为1 L/min)冲洗治疗.治疗过程中记录引流管堵塞率.治疗7d后,抽取组织渗出液采用血气分析仪检测组织液氧分压;撤除VSD装置,同前行细菌培养计算细菌清除率;计算肉芽组织覆盖率后留取创面中心肉芽组织,HE染色行组织病理学观察,透射电镜观察肉芽组织线粒体密度与形态,同前检测LDH和SDH活性,CD31染色计数微血管密度(MVD).之后行Ⅱ期手术,记录Ⅱ期手术方式及移植皮片或皮瓣成活率.对数据进行单因素方差分析、LSD-t检验、秩和检验或行Fisher确切概率法分析. 结果 (1)大体观察显示,清创前3组患者创面均有坏死组织存在,无肉芽组织.治疗7d,3组患者创面均出现新生肉芽组织.HE染色显示VSD+含氧液冲洗组创面肉芽组织内有较多新生毛细血管,Fb密集分布;VSD+冲洗对照组肉芽组织新生毛细血管较VSD+含氧液冲洗组少,Fb分布较稀疏;单纯VSD组肉芽组织新生毛细血管和Fb稀疏.(2)3组间引流管堵塞率、肉芽组织覆盖率、细菌清除率总体比较均有明显差异(F值为10.98 ～770.24,P值均小于0.01).VSD+冲洗对照组和VSD+含氧液冲洗组引流管堵塞率分别为(2.0±0.4)％和(1.9±0.6)％,均明显低于单纯VSD组的(16.0±1.3)％(t值分别为28.77和29.20,P值均小于0.01).(3)治疗7d后,VSD+含氧液冲洗组、VSD+冲洗对照组、单纯VSD组创面局部组织液氧分压分别为(111 ±4)、(43±4)、(40 ±4) mmHg(1 mmHg =0.133 kPa,F=882.76,P＜0.01).(4) VSD+含氧液冲洗组肉芽组织线粒体密度明显大于另外2组,且形状圆滑,外膜完整,无空泡化改变.(5)清创术中,3组患者创面肉芽组织LDH、SDH活性总体比较无明显差异(F值分别为0.80、1.03,P值均大于0.05).治疗7d,VSD+含氧液冲洗组创面肉芽组织LDH活性为(103 ±15)U/L,低于VSD+冲洗对照组的(136±16)U/L(t =4.49,P＜0.0l),VSD+冲洗对照组LDH活性低于单纯VSD组[(155±16) U/L,t=2.47,P＜0.05];VSD+含氧液冲洗组创面肉芽组织SDH活性为(2.93 ±0.27) U/L,高于VSD+冲洗对照组的(1.77±0.22) U/L和单纯VSD组的(1.61 ±0.19)U/L,t值分别为10.21和11.65,P值均小于0.01.(6)治疗7d,VSD+含氧液冲洗组创面组织CD31阳性表达比另外2组丰富.单纯VSD组、VSD+冲洗对照组、VSD+含氧液冲洗组MVD分别为每400倍视野下(109 ±5)、(124±5)、(141±6)个(F=68.78,P＜0.01).(7)3组患者Ⅱ期手术以皮片和皮瓣移植为主.VSD+含氧液冲洗组皮片和皮瓣成活率均高于单纯VSD组与VSD+冲洗对照组(t值为3.32～8.26,P＜0.05或P＜0.01),且VSD+冲洗对照组高于单纯VSD组(t值分别为2.67、3.18,P值均小于0.05). 结论 VSD联合含氧液冲洗可有效减少VSD引流管堵塞率,清除创面坏死组织和细菌,纠正创面组织的缺血缺氧,为修复提供新鲜“创面床”,提高移植皮片或皮瓣成活率.
    목적 평고VSD연합함양액충세치료당뇨병환자만성창면적효과. 방법 2010년9월-2013년6월,장남방의과대학남방의원수치적부합납입표준적26례당뇨병하지만성궤양환자,안수궤수자표법분위단순VSD조8례、VSD+충세대조조9례、VSD+함양액충세조9례.입원후행대체관찰、취창면분비물행세균배양후청창,술중류취창면육아조직용ELISA법검측유산탈경매(LDH)화호박산탈경매(SDH)활성.술후단순VSD조부행VSD치료(부압위-30～-25 kPa,하동),VSD+충세대조조행VSD연합생리염수충세치료,VSD+함양액충세조행VSD연합함양액(순양류량위1 L/min)충세치료.치료과정중기록인류관도새솔.치료7d후,추취조직삼출액채용혈기분석의검측조직액양분압;철제VSD장치,동전행세균배양계산세균청제솔;계산육아조직복개솔후류취창면중심육아조직,HE염색행조직병이학관찰,투사전경관찰육아조직선립체밀도여형태,동전검측LDH화SDH활성,CD31염색계수미혈관밀도(MVD).지후행Ⅱ기수술,기록Ⅱ기수술방식급이식피편혹피판성활솔.대수거진행단인소방차분석、LSD-t검험、질화검험혹행Fisher학절개솔법분석. 결과 (1)대체관찰현시,청창전3조환자창면균유배사조직존재,무육아조직.치료7d,3조환자창면균출현신생육아조직.HE염색현시VSD+함양액충세조창면육아조직내유교다신생모세혈관,Fb밀집분포;VSD+충세대조조육아조직신생모세혈관교VSD+함양액충세조소,Fb분포교희소;단순VSD조육아조직신생모세혈관화Fb희소.(2)3조간인류관도새솔、육아조직복개솔、세균청제솔총체비교균유명현차이(F치위10.98 ～770.24,P치균소우0.01).VSD+충세대조조화VSD+함양액충세조인류관도새솔분별위(2.0±0.4)％화(1.9±0.6)％,균명현저우단순VSD조적(16.0±1.3)％(t치분별위28.77화29.20,P치균소우0.01).(3)치료7d후,VSD+함양액충세조、VSD+충세대조조、단순VSD조창면국부조직액양분압분별위(111 ±4)、(43±4)、(40 ±4) mmHg(1 mmHg =0.133 kPa,F=882.76,P＜0.01).(4) VSD+함양액충세조육아조직선립체밀도명현대우령외2조,차형상원활,외막완정,무공포화개변.(5)청창술중,3조환자창면육아조직LDH、SDH활성총체비교무명현차이(F치분별위0.80、1.03,P치균대우0.05).치료7d,VSD+함양액충세조창면육아조직LDH활성위(103 ±15)U/L,저우VSD+충세대조조적(136±16)U/L(t =4.49,P＜0.0l),VSD+충세대조조LDH활성저우단순VSD조[(155±16) U/L,t=2.47,P＜0.05];VSD+함양액충세조창면육아조직SDH활성위(2.93 ±0.27) U/L,고우VSD+충세대조조적(1.77±0.22) U/L화단순VSD조적(1.61 ±0.19)U/L,t치분별위10.21화11.65,P치균소우0.01.(6)치료7d,VSD+함양액충세조창면조직CD31양성표체비령외2조봉부.단순VSD조、VSD+충세대조조、VSD+함양액충세조MVD분별위매400배시야하(109 ±5)、(124±5)、(141±6)개(F=68.78,P＜0.01).(7)3조환자Ⅱ기수술이피편화피판이식위주.VSD+함양액충세조피편화피판성활솔균고우단순VSD조여VSD+충세대조조(t치위3.32～8.26,P＜0.05혹P＜0.01),차VSD+충세대조조고우단순VSD조(t치분별위2.67、3.18,P치균소우0.05). 결론 VSD연합함양액충세가유효감소VSD인류관도새솔,청제창면배사조직화세균,규정창면조직적결혈결양,위수복제공신선“창면상”,제고이식피편혹피판성활솔.
    Objective To evaluate the therapeutic effects of VSD combined with irrigation of oxygen loaded fluid on chronic wounds in diabetic patients.Methods Twenty-six diabetic patients hospitalized in Nanfang Hospital of Southern Medical University from September 2010 to June 2013,with chronic ulcers on lower extremities conforming to the inclusive criteria,were divided into group VSD (n =8),VSD + irrigation control group (VSD + IC,n =9),VSD + oxygen loaded fluid irrigation group (VSD + OLI,n =9) according to the random number table.After gross observation was conducted and wound secretion was sent for bacterial culturing right after admission,debridement was performed.During the debridement,granulation tissue of wound center was harvested for determination of the activity of lactate dehydrogenase (LDH) and succinate dehydrogenase (SDH) with ELISA.After debridement,the patients in group VSD were treated with VSD (negative pressure from-30 to-25 kPa,the same below) ; the patients in group VSD + IC were treated with VSD combining irrigation of normal saline; the patients in group VSD + OLI were treated with VSD combining normal saline loaded with oxygen (flow of 1 L/min) irrigation.Drainage tube blockage was recorded and its incidence rate was recorded during the treatment.On post treatment day (PTD) 7,tissue exudates were collected and analyzed with blood gas analyzer for determining the partial pressure of oxygen of the exudate.After the VSD was terminated,bacterial culture was conducted as before,and the bacterial clearance rate was calculated.After the calculation of granulation tissue coverage rate,the granulation tissue in the center of the wound was harvested for histopathological observation with HE staining; morphological characteristics and density of mitochondria were observed with transmission electron microscopy; the activity of LDH and SDH was estimated as before; microvascular density (MVD) was counted after CD31 antibody immunohistochemical staining.Then the second stage operation was performed.The method of second stage operation was recorded and survival rate of grafted skin or flap was calculated.Data were processed with oneway analysis of variance,LSD-t test,rank sum test,or Fisher's exact test.Results (1) The gross observation showed that before debridement there was only necrotic tissue without granulation tissue in the wounds of patients in all the 3 groups.On PTD 7,granulation tissue was found in the wounds of patients in all the 3 groups.HE staining showed that there were more abundant newborn microvessels and regularly arranged fibroblasts in the wounds of group VSD + OLI ; less newborn microvessels and relatively sparsely fibroblasts were observed in the wounds of group VSD + IC.There were only sparse newborn microvessels and fibroblasts in the wounds of group VSD.(2) Rates of drainage tube blockage,granulation tissue coverage,and bacterial clearance showed significant differences among the 3 groups (with F values from 10.98 to 770.24,P values below 0.01).The drainage tube blockage rate was significantly lower in groups VSD + IC andVSD+OLI [(2.0±0.4)％ and (1.9 ±0.6)％] than in group VSD [(16.0±1.3)％,with t values respectively 28.77 and 29.20,P values below 0.01].(3) On PTD 7,the partial pressure values of oxygen of the exudate in groups VSD + IC,VSD + OLI,and VSD were respectively (111 ± 4),(43 ± 4),and (40 ± 4) mmHg (1 mmHg=0.133 kPa,F =882.76,P ＜0.01).(4) The density of mitochondria in group VSD + OLI was obviously higher than that of the other 2 groups,full in shape,with complete outer membrane and no vacuotization.(5) During debridement,the activity of LDH and SDH in 3 groups showed no significant differences (with F values respectively 0.08 and 1.03,P values above 0.05).On PTD 7,the activity of LDH was lower in group VSD + OLI [(103 ± 15) U/L] than in group VSD + IC [(136 ± 16) U/L,t =4.49,P ＜0.01],while it was higher in group VSD [(155 ± 16) U/L] than in group VSD + IC (t =2.47,P ＜ 0.05).The activity of SDH was higher in group VSD + OLI [(2.93 ± 0.27) U/L] than that in group VSD + IC [(1.77 ±0.22) U/L] or group VSD [(1.61 ±0.19) U/L,with t values respectively 10.21 and 11.65,P values below 0.01].(6) On PTD 7,there was more positive expression of CD31 in group VSD + OLI than in the other 2 groups.The MVD of groups VSD,VSD + IC,and VSD + OLI were respectively (109 ±5),(124 ±5),(141 ±6) per400 times visual field (F =68.78,P ＜0.01).(7) The patients in 3 groups mainly received skin or flap grafting as the second stage operation.The survival rates of skin and flap in group VSD + OLI were higher than those of groups VSD + IC and VSD (with t values from 3.32 to 8.26,P ＜ 0.05 or P ＜ 0.01),and the rates were higher in group VSD + IC than in group VSD (with t values respectively 2.67 and 3.18,P values below 0.05).Conclusions VSD + OLI is effective in reducing drainage tube blockage,removing necrotic tissue and bacteria,ameliorating ischemia and hypoxia of wound tissue,providing fresh wound bed for wound healing,and improving skin or flap graft survival rates.
    원문보기 원문다운로드 사이트로이동
저자의 최근 논문