Prospective study on the influence of dobutamine on blood perfusion in free flap repair of diabetic foot wounds
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摘要:
目的 探讨临床应用多巴酚丁胺对糖尿病足创面游离皮瓣修复术中血流灌注的影响。 方法 采用前瞻性自身对照研究方法。2022年1—11月，遵义医科大学附属医院烧伤整形外科收治20例符合入选标准的糖尿病足患者，其中男9例、女11例，年龄44~75岁，足部创面大小为5 cm×4 cm~20 cm×10 cm，均采用游离股前外侧皮瓣修复。记录麻醉诱导前、血管再通后10 min、泵注多巴酚丁胺后达目标血压［即平均动脉压（MAP）较麻醉诱导前高6~10 mmHg（1 mmHg=0.133 kPa）］时、拔出气管导管后10 min的心率及MAP；血管再通后10 min及泵注多巴酚丁胺后达目标血压时，静脉推注造影剂吲哚菁绿，采用红外显像仪观测皮瓣血流灌注情况，计算皮瓣高、低灌注面积比；记录皮瓣切取面积、手术时长、输液总量、多巴酚丁胺的泵注剂量及使用总量、术中不良事件、术后皮瓣并发症及随访情况。对数据行配对样本 t检验、重复测量方差分析、Bonferroni法及广义估计方程法分析。 结果 与麻醉诱导前比较，患者血管再通后10 min心率与MAP均明显降低（ P<0.05），泵注多巴酚丁胺后达目标血压时心率与MAP均明显升高（ P<0.05）；与血管再通后10 min比较，患者泵注多巴酚丁胺后达目标血压时、拔出气管导管后10 min心率与MAP均明显升高（ P<0.05）；与泵注多巴酚丁胺后达目标血压时比较，患者拔出气管导管后10 min心率与MAP均明显降低（ P<0.05）。患者泵注多巴酚丁胺后达目标血压时皮瓣高灌注面积比为0.63±0.11，明显高于血管再通后10 min的0.31±0.09（ t=-9.92， P<0.05）；患者泵注多巴酚丁胺后达目标血压时皮瓣低灌注面积比为0.12±0.05，明显低于血管再通后10 min的0.45±0.10（ t=17.05， P<0.05）。患者皮瓣切取面积为（174±35）cm 2，手术时长为（372±52）min，输液总量为（2 485±361）mL，多巴酚丁胺泵注剂量为3~13 μg·kg -1·min -1、使用总量为5.7（2.1，9.7）mg。2例患者泵注多巴酚丁胺期间MAP较血管再通后10 min明显升高，但在还未达到比麻醉诱导前高6 mmHg时，已达最大心率（130次/min以上），停止泵注多巴酚丁胺后心率逐渐恢复至90 次/min左右。术后2 d，1例患者皮瓣远端部分坏死，移植对侧大腿薄中厚皮片修复。术后随访3~6个月，皮瓣均存活良好，质地柔软、形态饱满，患者未发生不良心血管意外事件。 结论 将多巴酚丁胺应用于糖尿病足创面游离皮瓣修复术中，可明显提升患者MAP，扩大高灌注区域，缩小低灌注范围，增加皮瓣活力，且近期随访效果好，适宜在临床应用中推广。 Abstract:Objective To investigate the influence of clinical administration of dobutamine on blood perfusion in free flap repair of diabetic foot wounds. Methods A prospective self‐controlled study was conducted. From January to November 2022, 20 patients with diabetic foot who met the inclusion criteria were hospitalized in the Department of Burns and Plastic Surgery of Affiliated Hospital of Zunyi Medical University, including 9 males and 11 females, aged from 44 to 75 years, with the foot wounds area ranging from 5 cm×4 cm to 20 cm×10 cm, which were repaired by free anterolateral thigh flaps. Heart rate (HR) and mean arterial pressure (MAP) were recorded before anesthesia induction, 10 minutes after vascular recanalization, when the target blood pressure (i.e., MAP being 6-10 mmHg (1 mmHg=0.133 kPa) higher than that before anesthesia induction) was reached after infusion of dobutamine, and 10 minutes after tracheal catheter removal. Additionally, indocyanine green, a contrast agent, was injected intravenously at 10 minutes after vascular recanalization and when the target blood pressure was reached after infusion of dobutamine to assess flap blood perfusion using infrared imager, and the area ratio of flaps with hyperperfusion and hypoperfusion was calculated. Other recorded variables included flap harvesting area, surgical duration, total fluid infusion amount, infusion dose and total usage of dobutamine, intraoperative adverse events, postoperative flap complications, and follow‐up outcomes. Data were statistically analyzed with paired sample t test, analysis of variance for repeated measurement, Bonferroni method, and generalized estimating equation. Results Compared with those before anesthesia induction, HR and MAP of patients were significantly decreased at 10 minutes after vascular recanalization ( P<0.05), while HR and MAP of patients were significantly increased when the target blood pressure was reached after infusion of dobutamine ( P<0.05). Compared with those at 10 minutes after vascular recanalization, HR and MAP of patients were significantly increased when the target blood pressure was reached after infusion of dobutamine and at 10 minutes after tracheal catheter removal ( P<0.05). Compared with those when the target blood pressure was reached after infusion of dobutamine, HR and MAP of patients were significantly decreased at 10 minutes after tracheal catheter removal ( P<0.05). The area ratio of flaps with hyperperfusion of patients was 0.63±0.11 when the target blood pressure was reached after infusion of dobutamine, which was significantly higher than 0.31±0.09 at 10 minutes after vascular recanalization ( t=-9.92, P<0.05). The area ratio of flaps with hypoperfusion of patients was 0.12±0.05 when the target blood pressure was reached after infusion of dobutamine, which was significantly lower than 0.45±0.10 at 10 minutes after vascular recanalization ( t=17.05, P<0.05). The flap harvesting area of patients was (174±35) cm², the surgical duration was (372±52) min, the total fluid infusion amount was (2 485±361) mL, the infusion dose of dobutamine was 3-13 μg·kg⁻¹·min⁻¹, and the total usage of dobutamine was 5.7 (2.1, 9.7) mg. Two patients showed a significant increase in MAP during the infusion of dobutamine compared with that at 10 minutes after vascular recanalization, but before reaching 6 mmHg higher than that before anesthesia induction, their HR had reached the maximum (over 130 beats/min). The HR gradually returned to around 90 beats/min after the infusion of dobutamine was stopped. On post operation day 2, one patient had partial necrosis at the distal part of the flap, which was repaired by transplantation of thin split-thickness skin graft from the opposite thigh. During the follow‐up of 3 to 6 months after operation, all the flaps survived well, with soft texture and well-formed shape, and no adverse cardiovascular events of patients were reported. Conclusions The administration of dobutamine in free flap repair of diabetic foot wounds can significantly improve the MAP of patients, expand the area of hyperperfusion, reduce the area of hypoperfusion, and enhance the flap viability, with promising short‐term follow‐up results, which is suitable for promotion in clinical applications. -
Key words:
- Diabetic foot /
- Dobutamine /
- Surgical flaps /
- Blood perfusion
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窦雪娇：酝酿和设计试验，采集数据，数据分析整理，起草文章；王海英：研究指导，经费、行政、技术、材料支持，对文章内容作批评性审阅；陈伟、周健：酝酿和设计研究，采集数据，分析解释数据；魏在荣：分析解释数据，对文章内容作批评性审阅所有作者均声明不存在利益冲突
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参考文献
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1 多巴酚丁胺对患者糖尿病足溃疡创面游离股前外侧皮瓣修复术中血流灌注的影响。1A.术前见右足第2~5趾缺失，仅残存第1足趾，跖骨及跟骨外露；1B.术前下肢动脉CT血管造影见右下肢胫前动脉及腓动脉连续性中断，胫后动脉通畅；1C.术中血管吻合完毕，血管再通后10 min吲哚菁绿荧光造影，黑白显像模式下可见皮瓣蒂部皮下血管网络，但边缘血管网显示偏少；1D.血管再通后10 min皮瓣微循环色阶图像见皮瓣中心区域血流灌注良好（红色），边缘存在较大部分低灌注区（蓝色）；1E.使用多巴酚丁胺前见皮瓣苍白；1F.泵注多巴酚丁胺后达目标血压时吲哚菁绿荧光造影，黑白显像模式下见皮瓣中央区域荧光显示强烈呈片状融合，中心偏外可见血管网明显一直延伸至大部分皮瓣边缘；1G.泵注多巴酚丁胺后达目标血压时皮瓣微循环色阶图像，皮瓣整体血流灌注充盈（红色），部分呈高灌注（暗红色），低灌注（蓝色）区域明显减少；1H.使用多巴酚丁胺3 min后皮瓣红润，外观饱满；1I.术后5个月，皮瓣外观良好
注：目标血压指平均动脉压较麻醉诱导前高6 mmHg（1 mmHg=0.133 kPa）
表1 20例行股前外侧皮瓣游离移植修复术的糖尿病足患者各时间点部分生命体征的比较
时间点 心率（次/min， MAP［mmHg， M（ Q 1 ，Q 3）］ 麻醉诱导前 83±10 101.5（88.5，104.5） 血管再通后10 min 66±9 64.5（60.0，66.0） 泵注多巴酚丁胺后达目标血压时 94±15 106.0（96.0，110.0） 拔出气管导管后10 min 78±11 99.5（91.5，105.5） 统计量值 F=25.55 Wald χ 2=595.10 P值 <0.001 <0.001 P 1值 <0.001 <0.001 P 2值 0.001 <0.001 P 3值 0.066 0.764 P 4值 <0.001 <0.001 P 5值 0.004 <0.001 P 6值 <0.001 <0.001 注：目标血压指平均动脉压（MAP）较麻醉诱导前高6~10 mmHg（1 mmHg=0.133 kPa）；统计量值、 P值为各时间点间总体比较所得； P 1值、 P 2值、 P 3值分别为血管再通后10 min、泵注多巴酚丁胺后达目标血压时、拔出气管导管后10 min与麻醉诱导前的各指标比较所得， P 4值、 P 5值分别为泵注多巴酚丁胺后达目标血压时、拔出气管导管后10 min与血管再通后10 min各指标比较所得， P 6值为拔出气管导管后10 min与泵注多巴酚丁胺后达目标血压时各指标比较所得 
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1. 周小金，吕国忠，杨敏烈，姜东林，王泳，谢小为. 分级诊疗路径管理对慢性创面患者延续治疗的效能. 中华烧伤杂志. 2020(07): 547-552 . 
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