PU-VSD辅助局部皮瓣修复臀部压疮的临床研究

发布时间：2018-05-16 04:30

本文选题：压疮 + 皮瓣　；参考：《南方医科大学》2016年硕士论文

【摘要】：研究背景压疮,又称褥疮,是指局部组织长时间受压,血液循环障碍,局部持续缺血、缺氧、营养不良而致的软组织破损和坏死。引起压疮最基本、最重要的因素是压力,故目前倾向于将压疮改称为“压力性溃疡”。常见于瘫痪和长期卧床患者,营养不良、年龄大于70岁、身体衰弱、大小便失禁及石膏固定的患者均属于高危人群。压疮多发生于受压和缺乏脂肪组织保护、无肌肉包裹或肌层较薄的骨隆突处,并与卧位有密切的关系。平卧位,好发于枕部、肩胛、肘部、骶尾、足跟；俯卧位,好发于面颊、肩峰、膝部、足趾：侧卧位,好发于耳部、肩峰、髋部、膝关节内外侧及内外踝。美国全国压疮顾问小组2007年最新分期：可疑深部组织受损皮下软组织受到压力或剪切力的损害,局部皮肤完整但可出现颜色改变如紫色或褐红色,或导致充血的水疱。Ⅰ期：非苍白性发红皮肤完整,发红,与周围皮肤界限清楚,压之不褪色,常局限于骨凸处。Ⅱ期：部分皮层受损部分表皮受损,皮肤表浅溃疡,基底红,无结痂,也可为完整或破溃的血泡。Ⅲ期：全层皮肤缺失全层皮肤缺失,但肌肉,肌腱和骨骼尚未暴露,可有结痂、皮下隧道。Ⅳ期：全层组织缺失全层皮肤缺失伴有肌肉,肌腱,和骨骼的暴露,常有结痂和皮下隧道。不能分期：全层皮肤或组织缺失,溃疡底部被腐肉和/或焦痂完全覆盖。伤口的真正深度需将腐肉或焦痂完全清除后才能确定。随着社会人口老龄化,压疮的发病率逐年升高。临床上发生在骶尾部、坐骨结节、股骨大转子等臀部的位置最常见。臀部压疮作为一种难治性疾病不仅给患者带来痛苦、影响生活质量,给患者家庭带来沉重的经济和社会负担,严重者发生系统感染危及患者生命。压疮的治疗多种多样,传统换药疗法、中医膏药贴服疗法、VSD引流、外科手术、干细胞和细胞因子的治疗等众多方法均在现代诊疗活动中有所涉及。Ⅲ、Ⅳ期压疮自愈性差,需要手术用皮瓣来修复创面。臀部皮肤软组织丰富并且移动度相对较大,不同部位的压疮修复均有多种不同的局部皮瓣可选择。常用的皮瓣有臀大肌皮瓣、股后皮神经营养血管皮瓣、阔筋膜张肌皮瓣及各种形式的筋膜皮瓣等。术后通常用纱布、棉垫、绷带来包扎和固定。然而,术后护理困难,存在“动”和“不动”的矛盾。术后要求患者俯卧位限动,至少臀部限动；压疮预防要求患者每2小翻身1次,翻身时包扎松散、敷料移位、皮瓣失去包扎作用,伤口易受牵拉裂开。故皮瓣修复术一次手术成功率不高,常出现伤口裂开、基底不粘连等并发症。究其原因在于反复体位变化让绷带松动,失去包扎固定的作用；翻身时术区与周围组织因相对运动导致剪切力产生影响伤口愈合；不同卧位姿势臀部组织因重力和摩擦力的作用导致伤口张力增大,裂开。一些医院术后用翻身床护理有较好的效果,但应用翻身床费时费力、护理负担大,对患者的干扰也大。还有一些医院应用悬浮床,悬浮床让组织不受压,患者可以不动,但费用太贵,一般医院也没有。临床上需要一种应用便宜、操作简单,又解决了术后“动”和“不动”的矛盾,能提高一次手术成功率的方法。负压创面治疗技术(negative pressure Wound therapy, NPWT)是一种加快伤口愈合的方法,临床应用有20余年。用含有引流管的医用海棉来覆盖或填充皮肤软组织缺损的创面,再用生物半透膜对之进行封闭,使其成为一个密闭空间,最后把引流管接通负压源,组成的高效引流系统。NPWT所用的医用海绵主要有聚氨酯PU (Polyurethane)和聚乙烯醇酯PVA (Polyyinyl alcohol)两种。以聚氨酯为负压材料的技术称为PU-VSD,以聚乙烯醇酯为负压材料的技术称为PVA-VSD。聚氨酯敷料生物相溶性好,无毒无刺激、透气透水性能好、不会变干变硬,在国外应用广泛。聚乙烯醇酯内面密布大量彼此相通的直径0.2mm-1.0mm的空隙,具有很强的吸附机体分泌物的特性。缺点为失水会干燥变硬。2004年湖北武汉威斯第公司成功自主合成PVA后,PVA-VSD应用在我国迅速推开,广泛应用临床多个多科修复各种复杂的创面。针对引流存在堵管、负压大小有差异等方面的问题,该技术也在不断完善,第三代具有间歇性低负压+双压力控制显示+智能创面排阻+创面封闭式自动冲洗功能的VSD已经应用在大面积软组织缺损、关节腔感染切开引流、急慢性骨髓炎开窗引流、手术后伤口感染、糖尿病足、压疮等难治性创面。实验研究VSD技术促进创面修复的机制：(1)提高创面微循环的血流速度,扩张了微血管,从而增加了创面的血供;(2)及时吸引创面渗出物,减轻创面的水肿,有利于创面的修复；(3)密闭湿润的环境抑制细菌的繁殖,防止外界污染和感染。(4)机械的牵拉作用,机械应力诱导组织细胞的生长。第3点显示VSD有包扎创面的作用；第4点机械的牵拉作用提示VSD有固定的功能。包扎和固定是手术的重要组成部分,其适当与否,可直接影响手术的成败。比如植皮术,包扎固定欠妥,皮片就不能与基底组织建立血供导致皮片不能成活,手术失败。VSD的生物半透膜让创面与外界隔离起来,提供有利于创面的愈合的环境,起到包扎作用；负压形成后机械的牵拉力使敷料覆盖的区域及周围的皮肤固定变成一个整体。这个整体随着体位变化有所变化,但里面的组织不发生移位：并且海绵对基底产生正向压力。因材料的固有特性,PVA失水干燥变成和石膏一样坚硬,不适宜用在皮肤表面。PU-VSD才适合用来包扎和固定,外置的聚氨酯材料非常便宜。一些国内外学者将皮片移植后用VSD加压固定,发现与传统的打包加压包扎相比提高皮片的存活率。VSD同期应用在皮瓣上的经验较少。临床中很多学者报道VSD与皮瓣联合应用的病例,VSD主要被用于组织瓣转移前的创面准备。国内有学者将VSD海棉开“观察窗”后同期应用皮瓣表面,通过窗口观察皮瓣的血运,发现应VSD能促进皮瓣的存活,但负压的大小适宜值需要探讨。臀部压疮皮瓣术后“动”和“不动”的矛盾,可以缩小范围到臀部切口周围组织的“动”与“不动”的矛盾。术后同期应用PU-VSD固定皮瓣周围组织是一个可行的解决方法。PU-VSD用于皮瓣表面时操作过程简单,无需反复搬动患者。负压形成后将皮瓣周围的组织固定形成一个整体,不会因为翻身而发生移位：整体移位少,皮瓣切口受到牵拉力也变小。本研究先探讨PU-VSD能不能减小其固定的臀部皮肤在不同体位受到牵拉力,再观察PU-VSD同期应用在臀部压疮皮瓣术后的效果,能否提高臀部皮瓣术后一次手术的成功率,降低并发症。评估其临床应用价值。研究目的1、探讨应用PU-VSD固定的臀部皮肤作为“整体”在体位变化移动时这个整体里面的皮肤受到牵拉力的变化。2、观察PU-VSD辅助局部皮瓣修复臀部压疮的临床效果,评估其临床应用价值。材料与方法材料：医用聚氨酯海绵(山东创康)；医用吸痰管；生物半透性薄膜(英国安舒妥公司)及可调的负压源(天津医疗器械二厂)。纱块、棉垫、绷带。方法1：选择2013年在我科住院的15名臀部皮肤无破损的患者作为志愿者。先俯卧位在患者尾骨上8cm作臀沟的垂直线,在直线上交点的两侧标记两点,两点间距离为18cm。测量各个志愿者在立位、左侧卧位和右侧卧位下臀部两个标记点的直线距离。然后应用VSD后2小时再次测量不同体位下两标记点间距离。将立位、左侧卧位和右侧卧位下臀部两个标记点的直线距离分别与俯卧位比较,计算差值。比较固定前后不同体位的差值。方法2：选择科室2012年8月‖2014年12月因臀部Ⅳ期压疮拟行局部皮瓣手术修复的患者随机、双盲分成2组。术前常规治疗,术中皮瓣设计、主刀医师均为同一位副主任医师。术后观察组16例,皮瓣表面应用PU-VSD辅助固定,负压值在-15kpa至-20kpa；对照组18例,切口内置无菌纱块后,用棉垫绷带包扎固定。能自主活动的患者不限制床上活动,活动受限的患者由受过专业培训的陪护人员每2小时翻身1次。观察组VSD持续负压吸引,发现漏气及时处理。对照组及时更换污染的敷料和及时重新固定松动的敷料。术后5天观察两组一次手术成功的例数,出现并发症的原因。处理并发症。观察组继续PU-VSD辅助固定1周,切口术后2周拆线。对照组继续棉垫绷带包扎固定,裂开伤口及时再次缝合。比较两组一次手术成功率、并发症发生率；创面治愈后比较患者创面愈合时间及住院时间。统计学分析：SPSS 16.0统计学软件录入分析上述数据,计数资料率表示,计量资料均数±标准差表示,t检验,P0.05时差异有统计学意义。结果结果1、在不同的体位,志愿者臀部标记的两点间测量值不同,和俯卧位的差值明显。PU-VSD应用在臀部表面后,不同的体位标记的两点间测量值变化很小,差值在1cm内。志愿者应用PU-VSD前后的不同体位的差值,前者均比后者明显,P0.05有统计学意义。结果2、两组患者术后5天一次手术成功率及并发症发生情况比较：观察组一次手术成功率93.75%,对照组一次手术成功率61.11%,两组比较差异有统计学意义(P0.05)。观察组16例患者中并发症1例,控制感染后再次手术。对照组18例患者中并发症6例,需再次手术,其中感染1例、裂开3例、与基底未粘连2例。两组并发症发生率比较,差异有统计学意义(P0.05)。创面治愈后两组创面愈合时间、住院时间比较：观察组创面愈合时间、住院时间明显短于对照组,差异有统计学意义(P0.05)。结论：1、应用PU-VSD固定臀部皮瓣周围的皮肤作为“整体”在体位变化移动时,这个整体里的皮瓣切口受到的牵拉力减小。2、PU-VSD同期应用在臀部压疮皮瓣术后能够显著提高一次手术成功率、减少并发症、缩短创面愈合时间和住院时间,值得在临床推广。
[Abstract]:Background pressure sore, also known as bedsore, refers to the long compression of local tissue, disturbance of blood circulation, local continuous ischemia, hypoxia, and malnutrition in soft tissue damage and necrosis. Pressure ulcers are the most basic and most important factor in pressure ulcers. Therefore, the pressure ulcers are often referred to as "stress ulcers". Patients with malnutrition, age more than 70 years old, debilitated, incontinence, incontinence and plaster fixation are all high-risk groups. Pressure sore occurs mostly in compression and lack of fat tissue protection, without muscle parcels or thinner bone protuberance, and has a close relationship with the supine position. Decubitus, good hair on cheek, acromion, knee, toe: lateral position, good hair in the ear, shoulder, hip, knee and outer and internal and external malleolus. The latest staging of National Pressure Ulcer Advisory Group of the United States in 2007: suspected deep tissue damaged subcutaneous soft tissues are damaged by pressure or shear force, local skin is complete but can appear color changes such as purple or brown. Red, or hyperemia blister. Stage 1: non pallid redness skin complete, redness, clear boundaries with surrounding skin, constant pressure, and often limited to bony protruding. Stage II: partial cortex damaged parts, superficial skin ulcers, basal red, scab, and complete or broken blisters. Stage III: full layer full layer skin deletion Lack of skin, but the muscles, tendons and bones have not yet been exposed and can have scab, subcutaneous tunnel. Stage IV: full layer deletion of full layer tissue in full layer tissue with muscle, tendon, and bone exposure, often scab and subcutaneous tunnel. No stages: full layer skin or tissue loss, full cover of the bottom of the ulcer and / or eschar. The true depth of the wound As the social population is aging, the incidence of pressure sores is increasing year by year. The position of the buttocks, such as sacrococcygeal, sciatic nodules and femur trochanter, is the most common. The hip pressure ulcer, as a refractory disease, not only brings pain to the patients, affects the quality of life, and gives the patient family Heavy economic and social burdens, serious infections endanger patients' lives. The treatment of pressure sores is varied. Traditional dressing therapy, traditional Chinese medicine plaster therapy, VSD drainage, surgery, stem cell and cytokine treatment are all involved in modern diagnosis and treatment activities. The skin flap is used to repair the wound. The soft tissue of the buttocks is rich and the mobility is relatively large. There are many different local flaps in the repair of pressure sores in different parts. The common flaps are the gluteal musculocutaneous flap, the posterior femoral cutaneous nerve nutrient vessel flap, the fascia lata flaps and various forms of fasciocutaneous flaps. Cloth, cotton pad, bandage to be bandaged and fixed. However, the postoperative care is difficult, there is a "move" and "move" contradictions. After the operation, the patient's prone position is limited, at least the hip limit is required; pressure sore prevention requires the patient to turn over every 2 small 1 times, the body is loose, the dressing is displaced, the skin flap loses the binding effect, and the wound is easily pulled and pulled apart. Therefore skin flap repair is easy to repair. The success rate of one operation was not high, and there were often complications such as wound dehiscence and non adhesion on the base. The reason was the loosening of the bandage, the loss of the bandage and the fixation of the bandage, and the effect of the shear force on the wound healing caused by the relative movement of the surgical area and the surrounding tissue; the hip tissues in different position positions were caused by gravity and friction. The effect of the force causes the wound tension to increase and split. Some hospitals have good effect on the bed care after the operation, but the use of the body turn bed is time-consuming and laborious, the burden of nursing is great and the patient is disturbed too. There are some hospitals using the suspended bed, the suspension bed makes the tissue not pressed, the patient can not move, but the cost is too expensive, and the general hospital is also not. Negative pressure Wound therapy (NPWT) is a method to accelerate wound healing. It should be used for more than 20 years. The wound of the skin soft tissue defect is filled with the biological semi permeable membrane, making it a closed space, and finally connecting the drainage tube to the negative pressure source, and the medical sponges used in the high efficiency drainage system.NPWT are two kinds of polyurethane PU (Polyurethane) and polythyl alcohol ester PVA (Polyyinyl alcohol). The technology of material is called PU-VSD, and the technology of polyvinyl alcohol ester as negative pressure material is called PVA-VSD. polyurethane dressing with good biocompatibility, nontoxic and non irritating, good permeability and pervious performance, no dry and hard, widely used in foreign countries. The gap of the diameter of 0.2mm-1.0mm with a large number of each other interlinked with polyvinyl alcohol ester has a strong adsorption body. The characteristics of the secretions. The shortcoming is that after the loss of water will be dry and hardened in.2004, Wuhan, Hubei, after the successful self synthesis of PVA, the application of PVA-VSD in our country quickly pushes open and widely applies multiple clinical multiple families to repair a variety of complicated wounds. The three generation of VSD with intermittent low negative pressure + double pressure control display + Intelligent wound drainage and closed automatic flushing of wound surface has been used in large area soft tissue defect, incision and drainage of joint cavity infection, acute and chronic osteomyelitis open window drainage, postoperative wound infection, diabetic foot, pressure sore and other refractory wounds. Experimental study of VSD technology promotion The mechanism of wound repair: (1) improve the blood flow velocity of microcirculation of the wound, expand the microvascular, increase the blood supply of the wound; (2) attract the wound exudation in time, reduce the edema of the wound, and help the repair of the wound; (3) the closed and humid environment inhibits the propagation of bacteria and prevents the external pollution and infection. (4) mechanical traction, machinery Stress induced the growth of tissue cells. Third points show that VSD has the effect of wrapping the wound; fourth point mechanical traction suggests that VSD has a fixed function. Binding and fixation are important parts of the operation. It can directly affect the success or failure of the operation. For example, skin grafting, binding and fixation are not appropriate, and the skin can not be established with the basal tissue. The blood supply causes the skin to not survive. The surgical failure of the.VSD's biological semi permeable membrane makes the wound isolated from the outside, provides the healing environment for the wound, and plays a binding role. The mechanical traction force after the negative pressure forms the area and the surrounding skin of the dressings into a whole. This whole changes with the position of the body. But the tissue inside does not shift: and the sponge has positive pressure on the base. Because of the intrinsic properties of the material, the PVA dehydration drying becomes as hard as plaster, it is not suitable to be used on the skin surface.PU-VSD for binding and fixing. The external polyurethane material is very cheap. Some domestic and foreign scholars use VSD to pressurize the skin after transplantation. Fixed, the survival rate of the skin slice was improved compared with the traditional packing pressure bandage..VSD was less experienced on the skin flap during the same period. Many scholars reported the case of combined use of VSD and skin flap in clinic. VSD was mainly used for the preparation of wound surface before tissue flap transfer. Some scholars used the "observation window" of the VSD sea cotton to use the skin flap in the same period. Through the window observation of the blood flow of the skin flap, it is found that VSD can promote the survival of the skin flap, but the appropriate value of the negative pressure needs to be discussed. The contradiction between "movement" and "movement" after the operation of the hip pressure ulcer flap can reduce the contradiction between "movement" and "immobility" around the hips around the incision. After the operation, the skin flap around the flap is used around the same period. Tissue is a feasible solution to the skin flap, the operation process is simple, it does not need to move the patient repeatedly. After the negative pressure is formed, the tissue around the skin flap is fixed to form a whole, and it will not shift because of the flaps: the whole displacement is less, and the skin flap incision is reduced by the pull force. This study first explores whether the PU-VSD can be reduced. The effect of PU-VSD applied to hip pressure sore flap in the same period was observed, and the success rate of the first operation after the hip flap operation was improved and the complications were reduced. The clinical application value of the hip skin flap was evaluated. Objective 1 to explore the application of PU-VSD fixed hip skin as a "whole" body. The changes in the skin of the whole skin were changed.2, the clinical effect of PU-VSD assisted local flap for the repair of hip pressure sores was observed and its clinical application value was evaluated. Materials and methods: medical polyurethane sponge (Shandong Chuang Kang), medical sputum suction tube, raw material semi permeable membrane (UK annulas) and adjustable Negative pressure source (Tianjin medical instrument factory two). Gauze, cotton pad, bandage. Method 1: select 15 undamaged hips in our hospital in 2013 as volunteers. First, the prone position on the patient's tail bone is the vertical line of the hip groove on 8cm, and the two sides of the intersection are marked on the straight line, and the distance between two points is 18cm.. The distance between the two mark points of the buttocks at the left lateral position and the right lateral position. Then the distance between the two marking points under different body positions was measured again after VSD 2 hours. The linear distance between the upright position, the left lying position and the two mark points in the buttocks was compared with the prone position, and the difference was calculated. The difference between the different positions before and after the fixed position was compared. Method 2: the patients were randomly divided into 2 groups, which were repaired by local flap in August 2012 due to stage IV pressure sores in the buttocks. They were divided into 2 groups. The preoperative routine treatment, the design of the skin flap, the chief surgeon were the same deputy chief physician. The postoperative observation group was 16 cases, the surface of the skin flap was fixed with PU-VSD and the negative pressure was from -15kpa to -20kpa In the control group, 18 cases, after the incision was built with the sterile yarn, were fixed with a cotton pad bandage. The patients who were able to operate independently were not restricted in bed, and the patients with limited activity were turned over 1 times every 2 hours by the trained escort. The observation group VSD continued negative pressure attraction, and found the leakage and timely treatment. The control group changed the contaminated dressings and timely. Refix the loosened dressings. 5 days after the operation, the number of successful cases in two groups was observed, and the complications were observed. The complications were treated. The observation group continued PU-VSD assisted fixation for 1 weeks, and the incision was taken 2 weeks after the incision. The control group continued to bandage the cotton pad bandage and split the wound in time. The success rate of the one operation in the two groups and the complications were compared. Ratio of birth rate; wound healing time and hospitalization time after the wound healing. Statistical analysis: SPSS 16 statistics software recorded the above data, the counting data rate expressed, the measurement data were mean, t test, P0.05 difference was statistically significant. Results the results were 1, in different postures, two points marked on the hip of volunteers were two points. The difference between the measured values and the prone position was obvious after the.PU-VSD application on the hips surface. The difference between the two points marked by different positions was small and the difference was in the 1cm. The difference values of the different body positions before and after PU-VSD were significantly higher than the latter, and the P0.05 had statistical significance. The results were 2, and the two groups were successfully operated on 5 days after operation. Rate and complication: the success rate of the first operation in the observation group was 93.75%, the success rate of the one operation in the control group was 61.11%, the difference between the two groups was statistically significant (P0.05). There were 1 cases in the 16 cases of the observation group and the reoperation after the control of the infection. 18 cases in the control group were diagnosed as 6 cases, including 1 cases of infection and 3 cases of cracking. The incidence of complications in the two groups was compared with 2 cases. The difference was statistically significant (P0.05). The healing time of the two groups after the wound healing and the time of hospitalization were compared: the time of wound healing in the observation group was significantly shorter than that in the control group (P0.05). Conclusion: 1, using PU-VSD to fix the skin around the buttocks flap. As the "whole" moved in position change, the pulling force of the flap incision in the whole area decreased by.2, and PU-VSD was applied to the buttocks simultaneously.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R632.1

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