高频超声在深Ⅱ度烧伤患者磨痂术中的应用

发布时间：2018-03-19 02:00

  本文选题：烧伤　切入点：超声检查　出处：《山东大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究背景:深Ⅱ度烧伤目前仍是烧伤外科治疗的重点及难点,保守治疗因需多次换药,不同程度增加患者的疼痛,并且创面易感染加深,勉强愈合会增加瘢痕的发生率,影响外观及正常生理功能。磨痂术是近十几年来烧伤外科新开展的治疗方法,可以有效去除坏死组织,保留间生态组织,促进创面愈合,缩短病程。因真皮层的厚度不一,故深Ⅱ度烧伤的深浅也不一,浅的接近浅Ⅱ度,深的则临界Ⅲ度。已有研究表明,Ⅱ度烧伤诊断的准确率为50%～60%。由此增加了临床医师判断是否可行磨痂术的难度,过深行磨痂术会增加手术难度,降低手术成功率,坏死组织无法完全磨除。目前许多辅助诊断设备已经在文献中报道,例如超声,激光散斑成像,数字热成像,超声弹性成像,激光多普勒血流量计和组织分光光度测定法,动态热成像技术等。然而,这些仪器还没有被广泛应用于临床研究中。在20世纪70年代超声被广泛应用于医学领域。Goans等人在动物试验中的研究结果表明:超声可以作为一种定量的方法应用于烧伤的评估。该研究是用超声检测以分辨凝固性坏死层与剩余的有活力真皮层的分界,还检测了真皮深层与皮下脂肪的分界,对剩余的有活力真皮层进行了测量。基于这一研究,Kalus等人应用了分辨率为5MHz的超声,对两位烧伤患者,进行了愈合时间和切痂手术的研究。随后,超声作为一种无创、方便的检测方法,被许多学者用于烧伤深度诊断的动物模型研究中。随着科技的进步,超声的频率不断优化,频率为10MHz和18.5MHz的超声应用于人体皮肤疾病的研究,例如对黑色素瘤和银屑病的研究。高频超声由于具有低穿透性和高精确性的特点,因此成像频率大于15 MHz的高频超声目前应用于观察皮肤不同层次的解剖和组织结构学特征,也广泛应用于各种皮肤疾病的辅助诊断中。成像频率大于20 MHz的高频超声具有更好的图像分辨率,用于表浅组织结构的检测。目前对烧伤深度的诊断大部分主要依靠有经验医师主观上的判断,以病理组织学检查作为烧伤深度诊断的金标准,具有区域局限性和创伤性且耗时较长,耽误最佳手术时期。高频超声可以从影像学角度省时无创地为深Ⅱ度烧伤初步诊疗方案的制订提供客观依据,判断磨痂术的可行性。研究目的:探讨高频超声在深Ⅱ度烧伤患者磨痂术中的应用,研究深Ⅱ度烧伤患者创面磨痂术前后皮肤组织结构和血流信号变化及其与愈合时间的关系,以期为磨痂术在临床的应用提供客观的影像学依据。研究方法:2015年3月—2016年3月,笔者单位收治符合入选标准的住院治疗的26例深Ⅱ度烧伤患者,均在全身麻醉下行磨痂术。采用22.0 MHz高频超声检测患者磨痂术前健侧正常皮肤、创面,术后即刻及术后1、3、5、7、10、14、21d创面皮肤组织结构和彩色多普勒血流信号。根据术前创面彩色多普勒血流信号百分比与正常参考值的对比结果,分为血流信号无明显降低组19例和明显降低组7例。记录2组患者创面愈合时间。对数据行重复测量方差分析、LSD检验、t检验和χ 2检验,对26例患者术前创面血流信号百分比和愈合时间行Spearman相关性分析。研究结果:(1)2组患者术前正常皮肤高频超声图像示表皮层呈连续平滑线状强回声,真皮层回声低于表皮层,真皮-皮下分界呈较真皮层强的不连续线状回声,逐渐过渡到皮下组织。无明显降低组,术前深Ⅱ度烧伤创面表皮层呈连续性中断的不光滑线状回声,回声低于正常表皮层,真皮-皮下组织分界未见明显异常。术后即刻表皮层完全脱失,未见表皮层线状强回声,真皮及皮下回声较术前未见明显改变,真皮层表面平整,伴有真皮浅层部分磨失,但真皮组织总体保存较完好。术后3 d、5 d可见表皮层呈不连续线状强回声。术后7 d、10 d可见部分连续表皮层,呈部分连续线状强回声。术后14 d,再生的表皮层厚于正常表皮层且呈不光滑线状强回声,厚度不均匀。术后21 d,再生的表皮层厚于正常表皮层呈较光滑线状强回声,厚度较均匀。明显降低组,术前及术后即刻深Ⅱ度烧伤创面表皮层和真皮层组织结构与无明显降低组大体相似,但真皮-皮下组织分界回声呈不同程度降低。术后3 d、5 d,未见表皮层线状强回声。术后7 d、10 d可见不连续表皮层再生,呈不连续线状强回声。术后14 d,可见部分连续表皮层再生,呈部分连续线状强回声。术后21 d,仍未见完全连续表皮层线状强回声。(2)无明显降低组血流信号百分比在术前、术后即刻、术后1 d分别为(3.1±1.3)%,(6.5±2.0)%,(5.3±1.9)%高于明显降低组(0.9±1.1)%,(3.5±1.3)%,(3.6±0.9)%(P0.05或P0.01),2组患者其余时相点血流信号百分比相近(P值均大于0.05。与组内正常参考值(3.2±0.7)%比较,无明显降低组在术后即刻、术后1d血流信号百分比明显升高(P值均小于0.01),术后3d起各时相点血流信号百分比无明显变化(P值均大于0.05)。明显降低组术前血流信号百分比为(0.9±1.1)%明显小于正常参考值(2.8±0.6)%(P0.01),术后即刻起各时相点血流信号百分比与正常参考值相近(P值均大于0.05)。无明显降低组创面愈合时间为(16.2±2.5)d,短于明显降低组的(30.9±2.9)d(t=12.67,P0.01)。26例患者术前创面血流信号百分比与愈合时间呈负相关(r=-0.77,P0.01)。研究结论:高频超声可较好地观察深Ⅱ度烧伤磨痂术前后超声影像学特点,为深Ⅱ度烧伤行磨痂术的临床研究提供了客观的影像学依据。
[Abstract]:Background: the current focus and difficult treatment of burn surgery is still the deep second degree burn, conservative treatment due to multiple dressing, different degrees of increase the patient's pain, and wound infection deepened, barely healing will increase the incidence of scar, affecting the appearance and normal physiological function. Dermabrasion treatment in recent years burn carry out new surgery, can effectively remove the necrotic tissue, preserving ecological organization, promote wound healing, shorten the course. Because of the thickness of the dermis is not the same, so the deep second degree burn depth is not a close, superficial second degree shallow, deep third degree. The critical studies have shown that the accuracy rate of second degree burn the diagnosis is 50% ~ 60%., thus increasing the clinician to determine whether feasible Woundabrasion difficult, too deep for dermabrasion will increase the difficulty of operation, reduce the success rate of surgery, not completely removing necrotic tissue. At present, many auxiliary diagnosis set Preparation such as ultrasound has been reported in the literature, laser speckle imaging, digital thermal imaging, ultrasound elasticity imaging, laser Doppler blood flowmeter and spectrophotometry, the dynamic thermal imaging technology. However, these instruments have not been widely used in clinical research. Widely used in medical field study by.Goans et al. In the animal experiment results showed that in 1970s: ultrasonic evaluation of ultrasonic can be used as a quantitative method to burn. The study is by ultrasound to distinguish with boundary layer of the dermis activity of coagulation necrosis and residual layer, also detected boundaries and subcutaneous fat deep dermis, the remaining viable dermis the measurements were carried out. Based on this study, Kalus et al. Application of the 5MHz resolution of ultrasound, two burn patients were studied, and the healing time of excision surgery. Then, ultrasound As a noninvasive, convenient detection method, many scholars used to study the animal model of burn depth diagnosis. With the progress of science and technology, constantly optimize the ultrasonic frequency, the frequency of 10MHz and 18.5MHz ultrasound applied to human skin diseases, such as research on melanoma and high frequency ultrasound with psoriasis. Low penetrability and high precision characteristics, high frequency ultrasound imaging so frequency more than 15 MHz currently used in the observation of skin anatomy and histological structure of different levels of learning characteristics, auxiliary diagnosis is also widely used in various skin diseases. The broken image resolution high frequency ultrasound imaging has better frequency greater than 20 MHz, for detection shallow structure. At present the diagnosis of burn depth of the most experienced physicians rely mainly on subjective judgments, the histopathological examination as the gold standard in the diagnosis of burn depth, With regional limitations and traumatic and time-consuming, delay the best operation period. High frequency ultrasound can save time for noninvasive formulation of deep second degree burn in preliminary diagnosis and treatment provide an objective basis from the perspective of imaging, to judge the feasibility of dermabrasion. Objective: To investigate the application of high frequency ultrasonic grinding excision in patients with deep second degree study on the relationship between burn, deep second degree burn wound grinding changes skin structure and blood flow signals before and after excision and healing time, in order to provide an objective image of dermabrasion in clinical application basis. Research methods: March 2015 - March 2016, 26 cases of deep second degree burn patients hospitalized with hospitalization the inclusion criteria, were under general anesthesia dermabrasion. 22 MHz patients using high-frequency ultrasound dermabrasion before the contralateral normal skin, the wound immediately after surgery and postoperative 1,3,5,7,10,14,21d The skin tissue structure and color Doppler flow signal. According to the comparison results of preoperative wound color Doppler flow signal and the percentage of normal reference value of the divided flow signal did not significantly reduce the group of 19 cases and significantly reduced the group 7 cases. 2 groups were recorded. The wound healing time of the data row repeated measures analysis of variance, LSD test, t test and 2 test, 26 cases of patients with preoperative wound healing time and the percentage of blood flow signal by Spearman correlation analysis. Results: (1) 2 groups of patients with normal skin before high frequency ultrasound image shows the epidermal layer with smooth linear strong echo, echo below the epidermis dermis, the dermal subcutaneous boundary is dermal layer strong discontinuous linear echo, a gradual transition to subcutaneous tissue. No obvious reduction group, preoperative deep second degree burn wound epidermis showed discontinuity of smooth linear echo, echo is lower than that of normal skin The dermal layer, the subcutaneous tissue boundaries no obvious abnormalities. Immediately after the epidermis to complete depigmentation, no epidermis dermis and subcutaneous linear strong echo echo than before surgery was no significant change in the dermis with smooth surface, superficial dermal part lost, but the overall dermis is well preserved. After 3 D, 5 d the epidermis is not continuous linear strong echo. After 7 d, 10 d visible part of the epidermal layer is continuous, continuous linear strong echo. After 14 d, the thickness of epidermis regeneration in normal epidermis and a smooth linear strong echo, uneven thickness. After 21 d, epidermis regeneration the epidermal layer is thicker than the normal smooth linear hyperechoic, more uniform thickness. Group was decreased, the preoperative and postoperative deep second degree burn wound at the epidermis and dermis structure and did not significantly reduce the group generally similar, but the dermal subcutaneous tissue boundary echo showed different degrees of reduction 浣，

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