压疮患者皮瓣修复术后疗效不佳的影响因素

潘南芳; 梁尊鸿; 林萍; 王欣; 林师帅; 黄阳君; 陈仙娴; 潘云川

doi:10.3760/cma.j.cn501225-20220228-00041

压疮患者皮瓣修复术后疗效不佳的影响因素

doi: 10.3760/cma.j.cn501225-20220228-00041

海南省人民医院　海南医学院附属海南医院烧伤与皮肤修复外科，海口　　570311

基金项目:

海南省院士创新平台科研专项 ysptzx202028

海南省卫生计生行业科研项目 19A200080

详细信息

通讯作者:
潘云川，Email：pychuan@qq.com

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出版历程
- 收稿日期: 2022-02-28

Influence factors of poor efficacy after flap repair operation in patients with pressure ulcers

Department of Burn and Skin Repair, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou 570311, China

Funds:

The Specific Research Fund of the Innovation Platform for Academicians of Hainan Province of China ysptzx202028

Hainan Health and Family Planning Industry Scientific Research Program 19A200080

More Information

Corresponding author: Pan Yunchuan, Email: pychuan@qq.com

摘要

摘要: 目的探讨压疮患者皮瓣修复术后疗效不佳的影响因素。方法采用回顾性病例系列研究方法。2011年1月—2021年6月，海南省人民医院收治符合入选标准的125例行皮瓣修复手术的Ⅲ、Ⅳ期压疮患者，其中男82例、女43例，年龄15~90（57±20）岁。根据术后疗效，将患者分为疗效不佳组（47例）、疗效佳组（78例）。统计2组患者年龄、性别，压疮发生的部位、分期、面积、骨外露情况，术前创面分泌物标本微生物培养情况，合并骨髓炎、糖尿病、下肢阵发性肌痉挛及大小便失禁情况，手术清创联合负压伤口疗法次数，皮瓣类型，术后卧位情况，术前白蛋白、白细胞、C反应蛋白（CRP）及血红蛋白等临床资料。对数据行独立样本t检验、Mann-Whitney U检验、χ²检验。行二分类多因素logistic回归分析，筛选影响125例Ⅲ、Ⅳ期压疮患者皮瓣修复术后疗效不佳的独立危险因素。结果疗效不佳组患者发生下肢阵发性肌痉挛的比例为22/47，明显高于疗效佳组的3/78，χ²=33.83，P<0.01；疗效不佳组患者术前血红蛋白水平为（102±17）g/L，明显低于疗效佳组的（113±20）g/L（t=-3.24，P<0.01）；疗效不佳组患者术前CRP水平为39.1（14.1，91.6）mg/L，明显高于疗效佳组的15.3（6.6，42.0）mg/L（Z=-3.04，P<0.01）；2组患者其余指标比较，差异均无统计学意义（P>0.05）。多因素logistic回归分析显示，年龄、下肢阵发性肌痉挛、术前血红蛋白是压疮患者皮瓣修复术后疗效不佳的独立危险因素（比值比分别为1.03、40.69、0.97，95%置信区间分别为1.00~1.06、9.18~180.39、0.95~1.00，P<0.05或P<0.01）。结论多种因素会导致压疮患者皮瓣修复手术后疗效不佳，其中年龄、下肢阵发性肌痉挛、术前血红蛋白水平是独立危险因素。
- 压疮 /
- 外科皮瓣 /
- 影响因素分析 /
- 创面修复
Abstract: Objective To investigate the influence factors of poor efficacy after flap repair operation in patients with pressure ulcers. Methods The retrospective case series study was conducted. From January 2011 to June 2021, 125 patients with stage Ⅲ and Ⅳ pressure ulcers treated in Hainan General Hospital met the inclusion criteria. There were 82 males and 43 females, aged 15-90 (57±20) years. According to the postoperative effects, the patients were divided into poor efficacy group (47 cases) and good efficacy group (78 cases). The clinical data of patients in the two groups were collected, including the age, gender, location, stage, size, and bone exposure of pressure ulcers, preoperative microorganism culture results of wound exudate sample, whether combined with osteomyelitis, diabetes, lower limb paroxysmal myospasm, and gatism or not, the number of surgical debridement combined with negative-pressure wound therapy, type of surgical flap, postoperative position, and preoperative albumin, leukocyte, C-reactive protein (CRP), and hemoglobin. Data were statistically analyzed with independent sample t test, Mann-Whitney U test, and chi-square test. The binary multivariate logistic regression analysis was conducted to screen the independent risk factors influencing the poor efficacy after flap repair operation in 125 patients with stage Ⅲ and Ⅳ pressure ulcers. Results The ratio of patients with lower limb paroxysmal myospasm in poor efficacy group was 22/47, which was significantly higher than 3/78 in good efficacy group (χ²=33.83, P<0.01). The preoperative hemoglobin level of patients in poor efficacy group was (102±17) g/L, which was significantly lower than (113±20) g/L in good efficacy group (t=-3.24, P<0.01). The preoperative CRP level of patients was 39.1 (14.1, 91.6) mg/L in poor efficacy group, which was significantly higher than 15.3 (6.6, 42.0) mg/L in good efficacy group (Z=-3.04, P<0.01). There were no statistically significant differences in other indexes between patients in the two groups (P>0.05). Multivariate logistic regression analysis showed that age, lower limb paroxysmal myospasm, and preoperative hemoglobin level were the independent risk factors for poor efficacy after flap repair operation in patients with pressure ulcers (with odds ratios of 1.03, 40.69, and 0.97, 95% confidence intervals of 1.00-1.06, 9.18-180.39, and 0.95-1.00, respectively, P<0.05 or P<0.01). Conclusions Poor efficacy after flap repair operation in patients with pressure ulcers is affected by many factors, among which the age, lower limb paroxysmal myospasm, and preoperative hemoglobin level are the independent risk factors.
- Pressure ulcer /
- Surgical flaps /
- Root cause analysis /
- Wound repair
潘南芳：酝酿和设计研究、实施研究及撰写论文；梁尊鸿：酝酿和设计研究、修改论文；林萍、黄阳君、陈仙娴：实施研究、采集数据；王欣、林师帅：分析/解释数据；潘云川：酝酿和设计研究、指导研究、修改论文

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表1 2组行皮瓣修复术的Ⅲ期或Ⅳ期压疮患者临床资料比较

组别	例数	年龄（岁， x ¯ ± s ）	性别（例）		压疮部位（例）			压疮分期（例）		压疮面积［cm²，M（Q ₁ ，Q ₃）］	骨外露（例）		合并骨髓炎（例）
组别	例数	年龄（岁， x ¯ ± s ）	男	女	骶尾部	坐骨结节	股骨大转子	Ⅲ期	Ⅳ期	压疮面积［cm²，M（Q ₁ ，Q ₃）］	有	无	是	否
疗效不佳组	47	59±19	28	19	30	13	4	1	46	35.0（15.0，80.0）	24	23	6	41
疗效佳组	78	56±20	54	24	41	34	3	4	74	27.5（15.0，65.0）	28	50	3	75
统计量值		t=0.94	χ ²=1.21		χ ²=3.77			χ ²=0.69		Z=-0.87	χ ²=2.78		χ ²=3.49
P值		0.348	0.271		0.152			0.407		0.384	0.096		0.062
注：NPWT为负压伤口疗法；白蛋白、白细胞、C反应蛋白及血红蛋白为术前水平；疗效不佳：缝合线明显裂开、发生血肿、皮瓣感染坏死，经保守换药难以痊愈，需再次手术修复；疗效佳：手术切口愈合、无感染，2~3周内拆线或皮瓣边缘发红渗出裂开或坏死结痂，但经过局部换药处理1个月内基本愈合，无须再次手术修复

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表2 影响125例Ⅲ期或Ⅳ期压疮患者皮瓣修复手术后疗效的二分类多因素logistic回归分析阳性结果

因素	β值	标准误	Wald值	比值比	95%置信区间	P值
年龄（岁）	0.03	0.01	4.26	1.03	1.00~1.06	0.039
下肢阵发性肌痉挛情况	3.71	0.76	23.79	40.69	9.18~180.39	<0.001
血红蛋白（g/L）	-0.03	0.01	4.20	0.97	0.95~1.00	0.040
注：血红蛋白为术前水平

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参考文献(37)

[1]	LefèvreC,Bellier-WaastF,LejeuneF,et al.Ten years of myocutaneous flaps for pressure ulcers in patients with spinal lesions: analysis of complications in the framework of a specialised medical-surgical pathway[J].J Plast Reconstr Aesthet Surg,2018,71(11):1652-1663.DOI: 10.1016/j.bjps.2018.07.007.
[2]	ChengJ,ZhangQ,FengS,et al.Clover-style fasciocutaneous perforator flap for reconstruction of massive sacral pressure sores[J].Ann Plast Surg,2021,86(1):62-66.DOI: 10.1097/SAP.0000000000002442.
[3]	刘本全,董德升,史明艳,等.En bloc切除清创联合臀大肌肌瓣治疗坐骨结节压疮合并慢性骨髓炎的临床效果[J].中华烧伤与创面修复杂志,2022,38(4):363-368.DOI: 10.3760/cma.j.cn501120-20210122-00032.
[4]	孙佳琳,郭鹏飞,崔正军,等.臀上动脉穿支接力皮瓣修复骶尾部压疮的临床效果[J].中华烧伤杂志,2020,36(8):726-729.DOI: 10.3760/cma.j.cn501120-20190607-00265.
[5]	曹世坤,余道江,安璐,等.自由式穿支皮瓣在臀部压疮修复中的应用[J].中华解剖与临床杂志,2020,25(4):365-370.DOI: 10.3760/cma.j.cn101202-20200130-00023.
[6]	BambaR,MaddenJJ,HoffmanAN,et al.Flap reconstruction for pressure ulcers: an outcomes analysis[J].Plast Reconstr Surg Glob Open,2017,5(1):e1187.DOI: 10.1097/GOX.0000000000001187.
[7]	MendozaRA,LorussoGA,FerrerDA,et al.A prospective, randomised controlled trial evaluating the effectiveness of the fluid immersion simulation system vs an air-fluidised bed system in the acute postoperative management of pressure ulcers: a midpoint study analysis[J].Int Wound J,2019,16(4):989-999.DOI: 10.1111/iwj.13133.
[8]	PrimianoM,FriendM,McClureC,et al.Pressure ulcer prevalence and risk factors during prolonged surgical procedures[J].AORN J,2011,94(6):555-566.DOI: 10.1016/j.aorn.2011.03.014.
[9]	KarahanA,AAbbasoğluA,IşıkSA,et al.Factors affecting wound healing in individuals with pressure ulcers: a retrospective study[J].Ostomy Wound Manage,2018,64(2):32-39.
[10]	LuoM,LongXH,WuJL,et al.Incidence and risk factors of pressure injuries in surgical spinal patients: a retrospective study[J].J Wound Ostomy Continence Nurs,2019,46(5):397-400.DOI: 10.1097/WON.0000000000000570.
[11]	段红杰,柴家科,郝岱峰,等.影响Ⅲ期与Ⅳ期压疮愈合的因素分析[J/CD].中华损伤与修复杂志: 电子版,2015,10(6):466-469.DOI: 10.3877/cma.j.issn.1673-9450.2015.06.002.
[12]	IkechukwuEC, AyodiipoIO, EmekaAD,et al. Prevalence and factors associated with healing outcomes of hosprital-acquired pressure ulcers among patients with sprinal cord injury[J]. J Public Health Epridemiol, 2012,4(2):44-47.DOI: 10.5897/JPHE11.181.
[13]	LiuY, XiaoB, ZhangC, et al.Occipital pressure sores in two neonates[J/OL].Burns Trauma, 2015,3:22[2022-11-25]. https://pubmed.ncbi.nlm.nih.gov/27574668/.DOI: 10.1186/s41038-015-0021-9.
[14]	BettexQ,PhilandrianosC,JalouxC,et al.Surgical treatment of recurrent pressure ulcers in spinal cord injured patients[J].Ann Chir Plast Esthet,2019,64(5/6):674-684.DOI: 10.1016/j.anplas.2019.05.008.
[15]	VeithJP,CollierW,KimJ,et al.A national analysis of readmissions for wound healing complications following the repair of lower back, hip, and buttock pressure ulcers using the Nationwide Readmissions Database[J].Am J Surg,2019,217(4):658-663.DOI: 10.1016/j.amjsurg.2018.12.013.
[16]	张伟,黄红军,张俊峰,等.Ⅲ期与Ⅳ期压疮患者入院时并发下肢深静脉血栓形成情况及其危险因素[J].中华烧伤与创面修复杂志,2022,38(6):549-554.DOI: 10.3760/cma.j.cn501120-20210419-00134.
[17]	RedelingsMD,LeeNE,SorvilloF.Pressure ulcers: more lethal than we thought?[J].Adv Skin Wound Care,2005,18(7):367-372.DOI: 10.1097/00129334-200509000-00010.
[18]	BauerK,RockK,NazzalM,et al.Pressure ulcers in the United States' inpatient population from 2008 to 2012: results of a retrospective nationwide study[J].Ostomy Wound Manage,2016,62(11):30-38.
[19]	梁尊鸿,潘云川,陈贻梆,等.修复老年患者全身多部位难愈性压疮十例[J].中华烧伤杂志,2018,34(2):120-121.DOI: 10.3760/cma.j.issn.1009-2587.2018.02.013.
[20]	王欣,梁尊鸿,黄阳君,等.多部位难愈性压疮的个体化序贯性治疗[J/CD].中华损伤与修复杂志:电子版,2019,14(4):300-302.DOI: 10.3877/cma.j.issn.1673-9450.2019.04.012.
[21]	王君,潘云川,徐家钦,等.双侧臀部旋转皮瓣修复骶尾部巨大压疮52例[J].中华烧伤杂志,2017,33(12):775-777.DOI: 10.3760/cma.j.issn.1009-2587.2017.12.011.
[22]	SameemM,AuM,WoodT,et al.A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores[J].Plast Reconstr Surg,2012,130(1):67e-77e.DOI: 10.1097/PRS.0b013e318254b19f.
[23]	LuoJ,CarterGC,AgarwalJP,et al.The 5-factor modified frailty index as a predictor of 30-day complications in pressure ulcer repair[J].J Surg Res,2021,265:21-26.DOI: 10.1016/j.jss.2021.03.011.
[24]	JenkinsDA,MohamedS,TaylorJK,et al.Potential prognostic factors for delayed healing of common, non-traumatic skin ulcers: a scoping review[J].Int Wound J,2019,16(3):800-812.DOI: 10.1111/iwj.13100.
[25]	AlashramAR,AnninoG,MercuriNB.Changes in spasticity following functional electrical stimulation cycling in patients with spinal cord injury: a systematic review[J].J Spinal Cord Med,2022,45(1):10-23.DOI: 10.1080/10790268.2020.1763713.
[26]	RekandT,HagenEM,GrønningM.Spasticity following spinal cord injury[J].Tidsskr Nor Laegeforen,2012,132(8):970-973.DOI: 10.4045/tidsskr.10.0872.
[27]	AtiyehBS,HayekSN.Pressure sores with associated spasticity: a clinical challenge[J].Int Wound J,2005,2(1):77-80.DOI: 10.1111/j.1742-4801.2005.00075.x.
[28]	GoodmanBL,SchindlerA,WashingtonM,et al.Factors in rehospitalisation for severe pressure ulcer care in spinal cord injury/disorders[J].J Wound Care,2014,23(4):165-166, 168, 170-172 passim.DOI: 10.12968/jowc.2014.23.4.165.
[29]	TakahashiPY,KiemeleLJ,ChandraA,et al.A retrospective cohort study of factors that affect healing in long-term care residents with chronic wounds[J].Ostomy Wound Manage,2009,55(1):32-37.
[30]	李菁,万里红,梅克文,等.老年卧床病人骶尾部压力性损伤的多因素分析[J].护理研究,2019,33(1):97-101.DOI: 10.12102/j.issn.1009-6493.2019.01.022.
[31]	European Pressure Ulcer Advisory Panel National Pressure Advisory Panel Prevention and treatment of pressure ulcers: quick reference guide 2022-02-28 http://96bda424cfcc34d9dd1a-0a7f10f87519dba22d2dbc6233a731e5.r41.cf2.rackcdn.com/custom-medicalsolutions/education/NPUAPReferenceGuide.pdf European Pressure Ulcer Advisory Panel, National Pressure Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide[EB/OL]. [2022-02-28]. http://96bda424cfcc34d9dd1a-0a7f10f87519dba22d2dbc6233a731e5.r41.cf2.rackcdn.com/custom-medicalsolutions/education/NPUAPReferenceGuide.pdf.
[32]	EglseerD,HödlM,LohrmannC.Nutritional management of older hospitalised patients with pressure injuries[J].Int Wound J,2019,16(1):226-232.DOI: 10.1111/iwj.13016.
[33]	TaylorC.Importance of nutrition in preventing and treating pressure ulcers[J].Nurs Older People,2017,29(6):33-39.DOI: 10.7748/nop.2017.e910.
[34]	WurzerP,WinterR,StemmerSO,et al.Risk factors for recurrence of pressure ulcers after defect reconstruction[J].Wound Repair Regen,2018,26(1):64-68.DOI: 10.1111/wrr.12613.
[35]	ScivolettoG,FuocoU,MorgantiB,et al.Pressure sores and blood and serum dysmetabolism in spinal cord injury patients[J].Spinal Cord,2004,42(8):473-476.DOI: 10.1038/sj.sc.3101622.
[36]	Tchanque-FossuoCN,KuzonWM.An evidence-based approach to pressure sores[J].Plast Reconstr Surg,2011,127(2):932-939.DOI: 10.1097/PRS.0b013e3182046a02.
[37]	SinghR, SinghR, RohillaRK, et al. Surgery for pressure ulcers improves general health and quality of life in patients with spinal cord injury[J]. J Spinal Cord Med, 2010,33(4):396-400. DOI: 10.1080/10790268.2010.11689718.