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创面感染作为骨科临床中常见的并发症,一直是骨科临床工作中的一大难点。治疗不当不仅会增
加病人住院时间、治疗费用,加重病人心理创伤,严重时甚至会导致病人肢体功能障碍,影响病人生活质量。负压封闭引流(vacuum sealing drainage,VSD)技术又称负压创面治疗(negative pressure wound therapy, NPWT)技术,吸引创面闭合治疗(sealing wound closure therapy, SWCT)技术或真空辅助闭合(vacuum assisted closure,VAC)技术,由德国ULM大学创伤外科Fleischman博士于1992年首创[1]。VSD是在负压条件通过封闭伤口并引流清除伤口分泌物及坏死组织等促进创面愈合的新型治疗技术[2],目前VSD技术已广泛应用于临床感染性创面的治疗,相较于传统的消毒换药等治疗方法,它能够促进血液循环,增加创面血供[3],减轻创周水肿,加速创面愈合[4],抑制细菌繁殖,控制感染范围[5],有效机械牵拉,刺激肉芽生长[6]。但相关的研究[7]显示,VSD仍然存在不足,如难以完全封闭创面、抑菌能力有限以及可能增加厌氧菌感染等问题,导致部创面感染控制效果不佳。如何完善VSD技术的不足是临床研究的热点和亟待解决的问题。近年来的研究[8-9]显示,臭氧水对细菌、病毒、真菌等均有较好的杀灭作用,且臭氧水代谢后分解为氧气和水,反复使用不会有耐药菌的产生。夏平光等[10]采用臭氧水作用4 min后对创面β-内酰胺酶大肠埃希菌的杀菌率高达100%。而欧翰杰等[11]研究发现臭氧水冲洗还具有改善创面组织缺氧、缺血状态,促进创面愈合等作用。但目前VSD联合臭氧水治疗在骨科感染性创面中的应用效果临床鲜有报道,基于此,本研究就VSD联合臭氧水在骨科感染性创面中治疗效果展开研究,旨在为临床提供参考。
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研究对象选择2019年我院收治的骨科创面感染病人40例。纳入标准:(1)所有病人均符合骨科创面感染治疗的适应证;(2)病人及家属均签署知情同意书,积极服从治疗;(3)病人无药物过敏史;(4)未接受其他抗感染治疗。排除标准:(1)急性传染病病人;(2)病人患有严重心脑血管疾病;(3)病人伴有其他部位感染;(4)凝血机制异常者。本研究经我院伦理学会批准进行。按照随机数字表法将病人随机分为观察组和对照组,各20例,2组病人年龄、性别、创面部分及面积等一般资料比较差异无统计学意义(P>0.05)(见表 1),具有可比性。
分组 n 男 女 年龄(x±s)/岁 创面面积(x±s)/cm2 感染创面分布 小腿 前臂 足部 观察组 20 12 8 47.34±6.22 62.84±10.32 9 6 5 对照组 20 14 6 45.90±4.01 59.90±9.88 11 7 2 χ2 — 0.44 0.87* 0.92* 1.56 P — >0.05 >0.05 >0.05 >0.05 *示t值 表 1 2组病人一般资料比较(n)
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术前对所有病人均行创面分泌物细菌培养及药敏实验。对照组:予以常规VSD治疗。具体操作:对创面进行常规清创,根据创面大小修剪带有输入管及引流管的聚烯醇明胶海绵材料,并使其覆盖在创面上,然后利用生物透性薄膜密闭创面。调整负压为50~60 kPa,行持续负压吸引。7 d后取出VSD装置。
观察组:采用与对照组相同的VSD操作,并在其基础上,联合使用10 mg/L臭氧水冲洗创面。具体操作:经静脉泵将20 mL臭氧水泵入VSD冲洗管,在保证臭氧水充分循环后(约30 min)由引流管引出。保证每天2次。7 d后取出VSD装置。
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(1) 2组病人术后7 d创面愈合面积、肉芽组织菌落计数以及细菌清除率:术后7 d,观察2组病人感染性创面愈合面积,同时采用无菌操作,取约25 mm2肉芽组织进行研磨,并用1 mL 0.9%氯化钠溶液稀释后进行平板接种,37 ℃培养1 h,计算菌落数量。细菌清除率=(初始菌落数-术后7 d的细菌菌落数)/术后7 d的细菌菌落数×100%。(2)2组病人术后7 d创面白细胞介素(IL-1)、肿瘤坏死因子(TNF-α)以及血管内皮生长因子(VEGF)水平:术前,术后3、7 d,利用酶联免疫吸附法检测创面渗液IL-1及TNF-α水平。术后7 d,利用免疫组织化学法检测肉芽组织中VEGF表达水平,并计算2组病人切片中的标记指数(LI),LI=阳性细胞/(阳性细胞+阴性细胞)。(3)2组病人创面愈合时间及治疗结局:创面完全愈合,且未出现渗液等症状为显效;创面基本愈合,存在轻微渗液为有效;无明显变化为无效。
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采用χ2检验和t(或t′)检验。
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治疗后7 d,观察组创面愈合面积明显大于对照组,创面细菌清除率明显高于对照组,创面菌落计数明显少于对照组(P < 0.01)(见表 2)。
分组 n 创面愈合面积/cm2 菌落计数/104 细菌清除率/% 观察组 20 23.15±8.80 5.31±0.89 98.45±1.24 对照组 20 12.18±5.33 316±15 90.26±1.37 t — 4.77 92.47 19.82 P — < 0.01 < 0.01 < 0.01 表 2 2组病人治疗效果比较(x±s)
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术前,2组病人IL-1及TNF-α水平及VEGF标记指数差异均无统计学意义(P>0.05)。2组病人术后7 d创面IL-1及TNF-α水平均明显低于术前,而VEGF明显高于术前(P < 0.01),其中观察组病人创面IL-1及TNF-α水平明显明显低于对照组(P < 0.05和P < 0.01)(见表 3)。
分组 n IL-1/(pg/L) TNF-α/(pg/L) VEGF标记指数 术前 对照组 20 39.27±4.10 66.78±4.86 0.23±0.11 观察组 20 40.08±3.83 65.44±5.14 0.24±0.13 t — 0.65 0.85 0.26 P — >0.05 >0.05 >0.05 术后7 d 对照组 20 20.13±4.99** 51.33±7.25** 0.73±0.15** 观察组 20 15.92±5.62** 45.15±6.45** 0.75±0.25** t — 2.51 2.85 0.31# P — < 0.05 < 0.01 >0.05 组内配对t检验:**P < 0.01;#示t′检验 表 3 2组病人治疗前后IL-1、TNF-α水平及VEGF标记指数变化(x±s)
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治疗后7 d,观察组病人创面愈合时间(10.12±4.56) d,显著低于对照组的(17.44±5.10)d(t=4.79,P < 0.01)。2组疗效比较,差异无统计学意义(P>0.05)(见表 4)。
分组 n 显效 有效 无效 总有效/% uc P 观察组 20 12 7 1 19(95.00) 对照组 20 9 5 6 14(70.00) 0.52 >0.05 合计 40 21 12 7 33(82.50) 表 4 2组病人治疗结局比较[n;百分率(%)]
VSD联合臭氧水治疗骨科感染性创面的临床研究
Clinical study on the VSD combined with ozone water in the treatment of orthopaedic infectious wounds
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摘要:
目的探究负压封闭引流术(VSD)联合臭氧水治疗骨科感染性创面的临床效果。 方法选取感染性创面病人40例,并按照随机数字表法分为观察组和对照组,各20例。观察组予以VSD联合臭氧水冲洗治疗,对照组予以常规VSD治疗,比较2组病人术后7d创面愈合情况、肉芽组织菌落计数、细菌感染情况,创面渗液白细胞介素(IL-1)、肿瘤坏死因子(TNF-α)以及血管内皮生长因子(VEGF)表达水平,比较2组治疗结局。 结果观察组病人术后7d创面愈合面积、细菌清除率均大于对照组,肉芽组织菌落计数明显低于对照组(P < 0.01);与术前相比,2组病人术后7 d创面IL-1及TNF-α水平明显降低,VEGF标记指数明显提高(P < 0.01),且观察组病人创面IL-1及TNF-α水平均明显低于对照组(P < 0.05和P < 0.01);观察组病人术后创面愈合时间明显短于对照组(P < 0.01)。观察组总有效率为95.00%,对照组为70.00%,但差异无统计学意义(P>0.05)。 结论VSD联合臭氧水冲洗治疗骨科感染性创面,可有效减小细菌菌落计数,促进创面愈合,降低病人再次感染风险。 Abstract:ObjectiveTo explore the clinical effects of vacuum sealing drainage(VSD) combined with ozone water in the treatment of orthopedic infectious wounds. MethodsForty patients with infection wound were divided into the observation group and control group according to the random number table.The observation group was treated with VSD combined with ozone water, while the control group was treated with the conventional VSD.The wound healing, granulation tissue colony count between two groups were compared after 7 d of operation.The treatment outcome was compared between two groups. ResultsThe wound healing area and bacteria clearance rate in observation group were higher than those in control group on the seventh day after operation, and the colony count of granulation tissue in observation group was significantly lower than that in control group(P < 0.01).Compared with the preoperative level, the levels of inter interleukin 1(IL-1) and tumor necrosis factor α(TNF-α) in the wound surface of two groups significantly reduced, the vascular endothelial growth factor labeling index significantly increased(P < 0.01), and the levels of IL-1 and TNF-α in the wound surface of the observation group were significantly lower than those of the control group(P < 0.05 and P < 0.01).The healing time of the wound surface in observation group was significantly shorter than that in control group(P < 0.01).The total effective rates in the observation group and control group were 95.00% and 70.00%, respectively, and the difference of which was not statistically significant (P>0.05). ConclusionsVSD combined with ozone water in treating orthopedic infectious wounds can effectively reduce the bacterial colony count, promote wound healing, and reduce the risk of infection. -
表 1 2组病人一般资料比较(n)
分组 n 男 女 年龄(x±s)/岁 创面面积(x±s)/cm2 感染创面分布 小腿 前臂 足部 观察组 20 12 8 47.34±6.22 62.84±10.32 9 6 5 对照组 20 14 6 45.90±4.01 59.90±9.88 11 7 2 χ2 — 0.44 0.87* 0.92* 1.56 P — >0.05 >0.05 >0.05 >0.05 *示t值 表 2 2组病人治疗效果比较(x±s)
分组 n 创面愈合面积/cm2 菌落计数/104 细菌清除率/% 观察组 20 23.15±8.80 5.31±0.89 98.45±1.24 对照组 20 12.18±5.33 316±15 90.26±1.37 t — 4.77 92.47 19.82 P — < 0.01 < 0.01 < 0.01 表 3 2组病人治疗前后IL-1、TNF-α水平及VEGF标记指数变化(x±s)
分组 n IL-1/(pg/L) TNF-α/(pg/L) VEGF标记指数 术前 对照组 20 39.27±4.10 66.78±4.86 0.23±0.11 观察组 20 40.08±3.83 65.44±5.14 0.24±0.13 t — 0.65 0.85 0.26 P — >0.05 >0.05 >0.05 术后7 d 对照组 20 20.13±4.99** 51.33±7.25** 0.73±0.15** 观察组 20 15.92±5.62** 45.15±6.45** 0.75±0.25** t — 2.51 2.85 0.31# P — < 0.05 < 0.01 >0.05 组内配对t检验:**P < 0.01;#示t′检验 表 4 2组病人治疗结局比较[n;百分率(%)]
分组 n 显效 有效 无效 总有效/% uc P 观察组 20 12 7 1 19(95.00) 对照组 20 9 5 6 14(70.00) 0.52 >0.05 合计 40 21 12 7 33(82.50) -
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