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早期壓瘡的診斷和治療新進(jìn)展

常淑文,喬炎,束余聲

綜述了國內(nèi)外壓瘡早期診斷、治療新進(jìn)展，早期診斷方法包括早期炎性介質(zhì)檢測法、皮膚溫度監(jiān)測法、影像技術(shù)、局部血流監(jiān)測等；早期治療及護(hù)理壓瘡的方法包括濕性敷料或蜂蜜醫(yī)用敷料應(yīng)用、光線療法、自體脂肪組織移植法、集束化護(hù)理及綜合療法等。早期發(fā)現(xiàn)、早期干預(yù)可以降低壓瘡發(fā)生率、縮短治療時(shí)間、提高病人的生活質(zhì)量。

壓瘡；早期診斷；早期治療；組織反射光譜法；炎性介質(zhì)；皮膚溫度；影像技術(shù)；敷料

壓瘡又稱壓力性損傷(pressure injury,PI)，是2016年美國壓瘡咨詢委員會(National Pressure Ulcer Advisory Panel，NPUAP)關(guān)于壓瘡的最新定義，是指皮膚或皮下組織由于壓力或聯(lián)合有剪切力或(和)摩擦力作用而發(fā)生在骨隆突處的局限性損傷[1]。壓力可以導(dǎo)致組織缺血、炎癥性改變，損傷程度從皮膚壓紅到全層組織缺失后而暴露出肌肉、筋膜、骨骼等[2]。隨著人口老齡化的進(jìn)展，壓瘡已成為一個(gè)越來越嚴(yán)重的慢性病并發(fā)癥[3]，如能早期發(fā)現(xiàn)、早期干預(yù)可使壓瘡的發(fā)病率大大降低。在對國內(nèi)外文獻(xiàn)回顧的基礎(chǔ)上，旨在闡述關(guān)于壓瘡的早期診斷及治療方法的現(xiàn)狀，以期為醫(yī)護(hù)人員和照顧者早期發(fā)現(xiàn)壓瘡、早期干預(yù)提供參考。

1 壓瘡的流行病學(xué)調(diào)查

流行病學(xué)調(diào)查顯示：壓瘡的患病率在普通病房約為12%、急診病房約為23%[4-7]。2007年歐洲住院病人發(fā)病率為4.7%～32.1%，養(yǎng)老機(jī)構(gòu)中發(fā)病率為22%[8]；Amir等[9]2016年調(diào)查總體發(fā)病率為8.0%、醫(yī)院內(nèi)獲得性壓瘡為4.5%。英國的調(diào)查顯示：以壓瘡為主的慢性傷口治療每年花費(fèi)3.28億英鎊，1例病人約1 727英鎊[10]。壓瘡不但延長住院時(shí)間、增加發(fā)病率和死亡率、降低生活質(zhì)量[11]、影響病人康復(fù)，還會增加醫(yī)療成本[12]。因此，早預(yù)防、早發(fā)現(xiàn)、早治療是壓瘡護(hù)理的核心內(nèi)容[13]。

2 早期發(fā)現(xiàn)、早期診斷的意義

荷蘭一項(xiàng)調(diào)查顯示約50%的壓瘡為Ⅰ期壓瘡[14]。Krishnan等[15]發(fā)現(xiàn)：約47%的病人是在急性住院期間或康復(fù)期間形成壓瘡，炎性介質(zhì)能夠早期識別脊髓損傷病人壓瘡的發(fā)生，從而在壓瘡發(fā)生前即可初步確診；Ⅰ期壓瘡病人在所有壓瘡病人中所占比例較高，且大多數(shù)早期壓瘡會惡化成Ⅱ期或更嚴(yán)重階段[16]；Halfens等[17]通過對Ⅰ期壓瘡的早期干預(yù)使得發(fā)生率降低50%。綜合文獻(xiàn)可看出早期發(fā)現(xiàn)、早期診斷、早期治療對于疾病的康復(fù)和病人生活質(zhì)量都有較大的改善[2-3,14,17]。

3 早期診斷方法

3.1組織反射光譜法(tissue reflectance spectroscopy,TRP) Riordan等[18]研究結(jié)果顯示：運(yùn)用TRP進(jìn)行早期壓瘡診斷，能夠在各種不同色素沉著的皮膚上進(jìn)行反應(yīng)性紅斑檢測，并具有較好的信效度。

3.2早期炎性介質(zhì)檢測Krishnan等[15]在脊髓損傷病人中發(fā)現(xiàn)：若病人發(fā)生壓瘡則血漿中干擾素誘導(dǎo)蛋白-10 (IP-10)升高，而尿液中干擾素-α(IFN-α)下降；若未發(fā)生壓瘡則血漿中的粒-巨噬細(xì)胞集落刺激因子(GM-CSF)升高。針對這些炎癥因子的變化及時(shí)采取預(yù)防措施，可降低壓瘡的發(fā)生率。

3.3皮膚溫度變化有研究發(fā)現(xiàn)：手術(shù)時(shí)間較長的病人皮膚溫度會發(fā)生明顯變化，可使用溫度分布圖對病人受壓部位進(jìn)行評價(jià)[19]。Nakagami等[20]使用熱成像儀器根據(jù)溫度變化對壓瘡傷口評估來預(yù)測創(chuàng)面愈合時(shí)間,并給予適當(dāng)治療，可以降低壓瘡發(fā)生率。Fard等[21]開發(fā)一種連續(xù)的壓力和溫度監(jiān)測系統(tǒng)，該系統(tǒng)設(shè)置了壓力和溫度報(bào)警設(shè)置，在壓瘡的早期診斷和預(yù)防上具有可行性。

3.4影像技術(shù)Marylou等[22]使用掃描電鏡發(fā)現(xiàn)壓紅或Ⅰ期壓瘡局部比正常人皮下水分含量增加，全身性水腫嚴(yán)重者高于無水腫者，進(jìn)而說明表皮及皮下水分含量的變化可預(yù)測壓瘡發(fā)生，并作為診斷早期壓瘡的實(shí)驗(yàn)基礎(chǔ)。

3.5皮膚鏡檢查Shigeki等[23]研究發(fā)現(xiàn)：早期壓瘡是一種混合性的壓紅，包括能夠緩解的壓紅(指壓變白)和不能緩解的(指壓不變白)。皮膚鏡下可見壓紅不緩解病人毛細(xì)血管持續(xù)存在擴(kuò)張性條紋和紫癜，這些特點(diǎn)有助于壓瘡的早期診斷。

3.6血流監(jiān)測激光多普勒血流儀(laser doppler flowmetry,LDF)是無創(chuàng)性皮膚血流監(jiān)測工具[24]，應(yīng)用LDF可對壓瘡高危病人進(jìn)行血流檢測，并評估組織缺血的嚴(yán)重程度，可作為壓瘡風(fēng)險(xiǎn)評估的一種方法[25]。Liao等[26]關(guān)于大鼠壓力對皮膚血流的影響研究，使用LDF對負(fù)重缺血部位皮膚血液的排量波動監(jiān)測(blood flow oscillations，BFO)顯示預(yù)測壓瘡是可行的。Chenu等[27]使用TexiCare系統(tǒng)對骶尾部進(jìn)行血流監(jiān)測，實(shí)時(shí)記錄和分析臀部的壓力變化并提出危險(xiǎn)警告，可預(yù)防長期坐輪椅病人骶尾部壓瘡的發(fā)生。

4 早期壓瘡的治療及護(hù)理

4.1預(yù)防性皮膚護(hù)理保持皮膚完整是預(yù)防壓瘡的重要環(huán)節(jié)[28]，因此應(yīng)早期實(shí)施預(yù)防性皮膚護(hù)理[29]。如盡可能避免使紅斑區(qū)域受壓的體位；使用pH值平衡的清潔劑；保持皮膚清潔干燥；不按摩或用力擦洗存在壓瘡風(fēng)險(xiǎn)的區(qū)域；實(shí)施個(gè)體化的大、小便失禁管理；避免皮膚暴露在過度潮濕的環(huán)境中；使用潤膚劑保持皮膚濕潤等[30]。同時(shí)注意控制微環(huán)境、使用預(yù)防性敷料、使用降低剪切力與摩擦力的紡織物[31]。

4.2縮短受壓時(shí)間預(yù)防壓瘡首先要降低壓力、摩擦力和剪切力[32],最常用的方法為變換體位。目前關(guān)于翻身時(shí)間間隔尚未明確，臨床中使用較多的是2 h翻身1次,可根據(jù)病人實(shí)際情況適當(dāng)延長或縮短[33]。減壓床墊的使用可以減輕局部壓力的效果確切,已被廣泛用于預(yù)防壓瘡[34]。澳大利亞醫(yī)學(xué)研究顯示：羊皮是一種新型減壓工具，已被證實(shí)能有效降低病人壓瘡的發(fā)生[35]。

4.3外用藥物或敷料壓瘡愈合的關(guān)鍵因素是保持一個(gè)潮濕、閉合的傷口愈合環(huán)境[36]。有研究表明：濕性敷料(如聚合物泡沫敷料、水凝膠、藻酸鹽敷料、銀離子敷料、水凝膠敷料及生物膜等)有保護(hù)皮膚、抗菌或促進(jìn)肉芽組織再生的功能，可降低壓瘡發(fā)生率，比傳統(tǒng)紗布敷料更有效[37-38]。Milne等[39]研究發(fā)現(xiàn)低pH值的敷料在傷口愈合過程中發(fā)揮作用較大。

4.4物理因子或光線療法紫外線(ultraviolet，UV)，尤其是短波紫外線(UVC,200 nm～280 nm)能夠殺滅細(xì)菌、真菌和病毒[40]，還能促進(jìn)皮膚釋放免疫因子、加速組織修復(fù)及鎮(zhèn)痛等[41]。使用紫外線燈(254 nm)在小鼠三度燒傷皮膚照射治療證明紫外線照射可明顯降低燒傷創(chuàng)面真菌感染[40]。有研究表明：使用UVC治療后，創(chuàng)面面積縮小對創(chuàng)面愈合具有顯著療效[42-43]。Chen等[44]使用光線療法治療壓瘡,創(chuàng)面滲出減少、肉芽組織增生明顯，有助于縮短壓瘡愈合時(shí)間。

4.5自體脂肪組織移植隨著對脂肪再生性能的深入了解，目前已被引入到各個(gè)領(lǐng)域，包括壓瘡的防治。Marangi等[45]發(fā)現(xiàn)通過對移植區(qū)域和正常區(qū)域在皮膚厚度、筋膜完整性及皮下血管情況等方面進(jìn)行比較，發(fā)現(xiàn)兩者在相關(guān)參數(shù)上是相似的，說明使用脂肪移植可有效治療早期壓瘡。

4.6集束化護(hù)理集束化護(hù)理即應(yīng)用多個(gè)核心、有效的干預(yù)方法對病人進(jìn)行綜合干預(yù)[46]，體現(xiàn)了措施的針對性、綜合性及科學(xué)性。如浮動床的使用、全身皮膚評估、皮膚潤滑、壓力再分配裝置的早期運(yùn)用、體位變換等集束化護(hù)理的實(shí)施，可減少醫(yī)院獲得性壓瘡的發(fā)生[47]。 Vélez-Díaz-Pallarés等[48]總結(jié)了非藥物性綜合治療的研究主要集中在支撐面、營養(yǎng)、電療及其他輔助治療(超聲、負(fù)壓、激光、電磁或振動療法)，使用單獨(dú)一種非藥物治療對于創(chuàng)面愈合效果是不確定的，但多種方法的綜合治療可增加老年壓瘡病人的愈合率。

4.7改善營養(yǎng)狀況病人營養(yǎng)狀態(tài)與壓瘡的發(fā)生、發(fā)展和預(yù)后密切相關(guān)，如近期失重、低體重指數(shù)、蛋白質(zhì)攝入減少、進(jìn)食困難及低營養(yǎng)攝入者等[49-50]是發(fā)生壓瘡的高風(fēng)險(xiǎn)人群。因此，改善營養(yǎng)狀況、糾正低蛋白血癥是預(yù)防壓瘡的根本措施[50]。維生素A能夠刺激成纖維細(xì)胞促進(jìn)膠原沉積，影響傷口愈合進(jìn)程；維生素C影響結(jié)締組織蛋白的分泌、成纖維細(xì)胞增殖及血管形成，早期壓瘡病人建議每日服用維生素C 100 mg～200 mg，嚴(yán)重者1 000 mg～2 000 mg[51-52]；鎂是體內(nèi)酶或其他蛋白、膠原形成、組織生長必需的輔因子,與三磷酸腺苷一起促進(jìn)膠原合成；銅可加強(qiáng)膠原蛋白交聯(lián),穩(wěn)定膠原框架[53]；鋅主要參與DNA合成、細(xì)胞增殖和傷口愈合[51，54]。在壓瘡高危人群中予以補(bǔ)充適量的微量元素對于壓瘡的預(yù)防和發(fā)展有較大的改善作用。

4.8蜂蜜蜂蜜作為傷口愈合的佐劑已被使用了數(shù)百年，在傷口愈合中的主要作用機(jī)制包括抗菌能力、免疫調(diào)節(jié)和維持生理平衡等[55]。目前，已有醫(yī)用蜂蜜敷料應(yīng)用于傷口護(hù)理，研究表明醫(yī)用蜂蜜敷料在急、慢性傷口和壓力性潰瘍等傷口管理上是安全、有效、低成本的治療方案[56]。

4.9醫(yī)護(hù)人員及照顧者的培訓(xùn)醫(yī)務(wù)人員對于壓瘡風(fēng)險(xiǎn)評估的態(tài)度也影響壓瘡的發(fā)病率[57]，對醫(yī)護(hù)人員進(jìn)行相關(guān)培訓(xùn)可以提高判定壓瘡的準(zhǔn)確率和界定壓瘡種類的正確率[58]，加強(qiáng)對照顧者的教育可影響壓瘡的發(fā)展和預(yù)后[59]。

5 小結(jié)

壓紅不緩解或Ⅰ期壓瘡的皮膚完整性未受損害，如及時(shí)采取措施去除病因，皮膚改變可恢復(fù)正常，也可防止壓瘡的進(jìn)一步進(jìn)展。因此，在護(hù)理工作中壓瘡的早期診斷、早期治療尤為重要。綜合文獻(xiàn)資料可見，早期診斷壓瘡方法主要集中在影像技術(shù)、受壓部位血流監(jiān)測及炎性介質(zhì)早期檢測等方面，如能廣泛使用簡單、易行、可視化的操作工具，對于高危人群進(jìn)行診斷并早期使用保護(hù)性敷料，可以大大降低壓瘡的發(fā)病率，并能改善壓瘡高危者的生活質(zhì)量。

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(本文編輯張建華)

Newprogressondiagnosisandtreatmentofearlypressuresores

ChangShuwen,QiaoYan,ShuYusheng

(School of Nursing,Yangzhou University,Jiangsu 225001 China)

It reviewed the new progress on early diagnosis and treatment of pressure sore at home and abroad.Early diagnostic methods included tissue reflex spectroscopy,early inflammatory mediators detection,skin temperature monitoring,imaging techniques and local blood flow monitoring.Early treatment and nursing methods of pressure sores included wet dressings or honey medical dressings applications,light therapy,autologous adipose tissue transplantation,cluster care and comprehensive therapy.Early detection,early intervention can reduce the incidence of pressure sores,shorten the treatment time and improve the quality of life of patients.

pressure sores；early diagnosis；early treatment；tissue reflectance spectroscopy；inflammatory mediators；skin temperature；image technology；dressing

常淑文,主管護(hù)師，碩士研究生在讀，單位：225001，揚(yáng)州大學(xué)護(hù)理學(xué)院(225001，江蘇省蘇北人民醫(yī)院)；喬炎單位：399-4117，日本長野縣看護(hù)大學(xué)；束余聲(通訊作者)單位：225001，江蘇省蘇北人民醫(yī)院。

信息 常淑文，喬炎，束余聲.早期壓瘡的診斷和治療新進(jìn)展[J].護(hù)理研究，2017，31(24)：2963-2966.

R472

：Adoi:10.3969/j.issn.1009-6493.2017.24.005

：1009-6493(2017)24-2963-04

2016-07-26；

2017-07-25)