Tao GL,Liu YK,Tang JJ,et al.Application value of flexible endoscopy and rigid endoscopy in the clinical examination of chronic sinus tract wounds with different shapes[J].Chin J Burns,2021,37(8):747-751.DOI: 10.3760/cma.j.cn501120-20200318-00179.
Citation: Zhang W,Huang HJ,Zhang JF,et al.Prevalence and risk factors of deep venous thrombosis of lower extremity in patients with stage Ⅲ and Ⅳ pressure ulcers on admission[J].Chin J Burns Wounds,2022,38(6):549-554.DOI: 10.3760/cma.j.cn501120-20210419-00134.

Prevalence and risk factors of deep venous thrombosis of lower extremity in patients with stage and pressure ulcers on admission

doi: 10.3760/cma.j.cn501120-20210419-00134
Funds:

Joint Construction Project of Medical Science and Technology in Henan Province LHGJ2019001

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  •   Objective  To investigate the incidence and risk factors of deep venous thrombosis (DVT) of lower extremity in patients with stage Ⅲ and Ⅳ pressure ulcer on admission.  Methods  A retrospective case series study was conducted. A total of 241 patients with stage Ⅲ and Ⅳ pressure ulcers who met the inclusion criteria and were discharged from the Department of Wound Repair of the First People's Hospital of Zhengzhou from January 1, 2015 to December 31, 2019 were enrolled in this study, including 134 males and 107 females, aged 22 to 93 years, with a median age of 68 years; 37 patients were with stage Ⅲ pressure ulcers and 204 patients were with stage Ⅳ pressure ulcers. The DVT occurrence of patients was recorded. According to whether DVT of lower extremity veins was diagnosed by color Doppler ultrasound within 48 h after admission or not, the patients were divided into DVT group (n=37) and non-DVT group (n=204). Data of patients in the two groups were collected and compared, including gender, age, duration of pressure ulcer, time in bed, and combination with diabetes, hypertension, coronary heart disease, cerebral infarction, pneumonia, sepsis/septic shock, and paraplegia, and the plasma D-dimer level and Caprini score within 24 h after admission. Data were statistically analyzed with independent sample t test, Mann-Whitney U test, chi-square test, and Fisher's exact probability test. The indicators with statistically significant differences between the two groups were analyzed with multivariate logistic regression analysis to screen the independent risk factors influencing the DVT of lower extremity in 241 patients with stage Ⅲ and Ⅳ pressure ulcers on admission.  Results  The incidence of DVT of lower extremity was 15.4% (37/241), of which 86.5% (32/37) were asymptomatic DVT. Among the DVT of 46 lower limbs, only 29 involved the inferior genicular veins, accounting for 63.0%. There were no statistically significant differences in gender, duration of pressure ulcer, combination with diabetes, hypertension, coronary heart disease, cerebral infarction, pneumonia, and sepsis/septic shock of patients between the two groups (P>0.05), while there were statistically significant differences in age, time in bed, combination with paraplegia, the plasma D-dimer level and Caprini score of patients between the two groups(t=-3.19, Z=-2.04, χ2=4.44, Z=-3.89, t=-2.14, respectively, P<0.05 or P<0.01). Multivariate logistic regression analysis showed that age and plasma D-dimer level were independent risk factors influencing the DVT of lower extremity in 241 patients with stage Ⅲ and Ⅳ pressure ulcers on admission (with odds ratios of 1.03 and 1.18, respectively, with 95% confidence intervals of 1.00-1.06 and 1.05-1.33, respectively, P<0.05 or P<0.01).  Conclusions  The patients with stage Ⅲ and Ⅳ pressure ulcers have a higher incidence of DVT on admission, with age and plasma D-dimer level being the independent risk factors for DVT of lower extremity. It is necessary to pay attention to the targeted screening of DVT and education of its prevention.

     

  • 窦道型慢性创面是临床中比较常见的慢性创面,目前尚无统一定义1,通常是指开口于体表,向深部组织走行的慢性创面。近年来,窦道型慢性创面的诊断和治疗受到了多位学者的关注2, 3, 4, 5,也已引起各国卫生组织的高度重视6。创面测量在监测创面愈合过程和评估治疗效果方面具有重要意义27, 8,付小兵9院士也指出对创面进行客观准确的评估是判断疾病状况、评价各种治疗方式的根本。明确窦道型慢性创面的窦道长度、形态及内部病理学特征将有助于此类创面的诊治,但是传统方法通过探针凭经验探查创面,既无法充分获得窦道的真实长度10,又无法观测到窦道内部的病理特征。

    本课题组引入了内镜联合CT造影检查的方法,其中CT造影检查基本可以反映窦道型慢性创面中窦道的真实长度,内镜通过窦道外口伸入可观察到窦道内部的情况,该方法有望成为此类创面有效且微创的诊治手段11, 12。本课题组前期研究使用的是硬性内镜,在临床实践中了解到当窦道型慢性创面的窦道出现一定程度的弯曲时,通过硬性内镜无法观察到完整的窦道内部情况10,因此本课题组进一步引入了软性内镜进行研究。本研究旨在比较软性内镜和硬性内镜在不同形态窦道型慢性创面临床检查中的应用价值。

    本回顾性观察性研究经上海交通大学医学院附属瑞金医院伦理委员会批准,批号:20170701。

    纳入标准:创面表现为皮肤表面溃疡并向深部组织走行者,病程30 d以上者,完成CT造影、硬性内镜及软性内镜全部检查者。排除标准:窦道型慢性创面已进入体腔者,有认知障碍无法配合研究者。

    2019年1月1日—12月23日,上海交通大学医学院附属瑞金医院创面修复中心收治的46例窦道型慢性创面患者符合入选标准,纳入本研究。患者中男、女各23例,年龄18~81(48±21)岁。窦道型慢性创面病因分类:医源性23例、感染性16例、压力性7例。在回顾性收集数据前,入组患者签署书面知情同意书。

    用于CT检查的对比剂为质量浓度350 mg/mL的碘海醇注射液,购自通用电气药业(上海)有限公司。uCT 510型CT机购自上海联影医疗科技有限公司,Mimics 17.0 CT图像测量软件购自比利时Materialise公司,千牧Q8000-L25型内窥镜系统(含长18 cm、0°、直径2.7 mm、光学放大倍率20倍的硬性内镜和图像显示仪及冷光源)购自广州市千牧电子有限公司,电子鼻咽喉内镜系统(含长51 cm、0°、直径2.6 mm、光学放大倍率20倍的软性内镜和图像显示仪及冷光源)购自日本奥林巴斯株式会社。

    入院时,对患者行CT造影、硬性内镜和软性内镜检查,其中硬性内镜和软性内镜检查免费。CT造影检查过程如下:(1)清除窦道内渗出物和脱落的坏死组织;(2)注射对比剂碘海醇注射液填充窦腔;(3)保持患者在一个适当的位置1 min;(4)采用CT机行CT检查。利用Mimics17.0 CT图像测量软件对图像进行三维重建,得到窦道的长度。硬性内镜检查过程如下:采用千牧Q8000-L25型内窥镜系统,将硬性内镜伸入窦道型慢性创面内部至可见视野最远端,并用直尺测量硬性内镜的进入长度。软性内镜检查过程如下:采用电子鼻咽喉内镜系统,将软性内镜伸入窦道型慢性创面内部至可见视野最远端,并用直尺测量软性内镜的进入长度。

    (1)根据CT造影及三维重建的形态结果,对窦道型慢性创面进行分类;将含明显弯曲、无明显弯曲窦道的创面分别归入曲线组、直线组。(2)记录“CT造影检查测得的创面窦道长度”(下称参考长度),计算各组创面中软性内镜或硬性内镜检查测得的“创面窦道长度与参考长度的偏差率”(下称长度偏差率),长度偏差率=(参考长度-软性内镜或硬性内镜检查测得的创面窦道长度)÷参考长度×100%,比较各组创面中软性内镜与硬性内镜检查测得的长度偏差率及二者与参考长度偏差率(0)之间的差异。

    采用SPSS 22.0统计软件进行数据分析。计量资料数据符合正态分布者以x¯±s表示,采用配对样本t检验;不符合正态分布者以MP25P75)表示,采用Wilcoxon符号秩和检验。P<0.05为差异有统计学意义。

    CT造影及三维重建显示,本组患者创面窦道形态大致可分为4种,包括管状(36/46)、片状(4/46)、棒槌状(4/46)及不规则状(2/46),其中,管状进一步分为I型(23/36)、L型(4/36)和Y型(9/36)。见图1。共31个含I型管状、片状或棒槌状窦道的创面归为直线组,占67.4%;共15个含Y型管状、L型管状或不规则状窦道的创面归为曲线组,占32.6%。

    1  窦道型慢性创面CT造影及三维重建形态。1A.I型管状;1B.L型管状;1C.Y型管状;1D.片状;1E.棒槌状;1F.不规则状
    注:各图中左下角红框中图片为箭头指示处创面形态的放大图

    在直线组中,硬性内镜、软性内镜检查测得的长度偏差率均为0。在曲线组中,软性内镜检查测得的长度偏差率为0(0,0.58%),明显低于硬性内镜检查测得的41.18%(31.68%,48.41%),Z=-3.408,P=0.001;硬性内镜检查测得的长度偏差率(40±19)%明显高于参考长度偏差率(t=8.343,P<0.001),软性内镜检查测得的长度偏差率与参考长度偏差率相近(Z=-1.342,P=0.180)。

    患者男,80岁,主诉骶尾部窦道创面形成3个月入院。该患者因大面积脑梗死卧床4年,3个月前骶尾部出现破溃,自行处置后未见愈合并形成窦道创面,无其他系统疾病和长期服药史,诊断为压力性窦道型慢性创面。门诊即行一般检查,骶尾部偏左侧可见约1.0 cm×0.5 cm皮肤破溃,创周质韧,色白,窦口未见明显渗出。入院时,CT造影及三维重建检查显示该创面窦道呈L型管状(曲线组),测得窦道长度为5.04 cm;应用硬性内镜只能检查从窦口到窦道拐点处,无法了解窦道内部全部情况,测得窦道长度为2.50 cm,长度偏光率为49.41%;应用软性内镜检查测得窦道长度为4.95 cm,与CT造影及三维重建检测结果相近,长度偏光率为1.79%。见图2

    2  不同方法检查患者压力性窦道型慢性创面情况。2A.骶尾部偏左侧可见约1.0 cm×0.5 cm皮肤破溃,创周色白,窦口未见明显渗出;2B.CT造影及三维重建检查显示窦道呈L型管状,长度为5.04 cm;2C.硬性内镜检查测得窦道长度为2.50 cm;2D.软性内镜检查测得窦道长度为4.95 cm

    关于窦道型慢性创面的窦道实际长度及形态的获得方法,理论上应在外科完整切除窦道后测量4,但考虑到伦理要求和实际处理情况,不能为了测量而切除所有患者的窦道型慢性创面。研究显示CT造影及三维重建对创面的范围和形状有一定的判断价值,还可以明确其与周围组织器官的关系13, 14, 15, 16, 17,因此本研究选用了CT造影检查后三维重建来获得窦道的长度及形态,以做参考。随着硬性内镜的普及和成本的降低18, 19,本课题组在前期研究中将其引入窦道型慢性创面的诊治研究中,以获得窦道型慢性创面内部病理特征。将硬性内镜从窦道型慢性创面体表的伤口伸入窦道,可以清晰地观察到部分窦道型慢性创面的内部病理特征,包括渗出情况、有无异物、有无坏死组织及纤维增生等情况。

    在前期研究的基础上,本课题组引入了一种能控制前端弯曲的软性内镜,在CT造影检查的配合下,希望可以利用其获得所有窦道型慢性创面的窦道有效长度、形态及内部病理特征。为了消除个体差异和主观偏倚,最大限度地提高统计效率20,本研究比较了同一个窦道型慢性创面通过硬性内镜和软性内镜检查测得的长度偏差率。本课题组前期研究已经证实硬性内镜测量的长度偏差率优于传统的探针测量2,所以如果软性内镜检查测得的长度偏差率优于硬性内镜,那么则可以说明软性内镜更适合用于窦道型慢性创面的诊疗。CT造影及三维重建检查结果显示,本组窦道型慢性创面可分为I型管状、L型管状、Y型管状、片状、棒槌状及不规则状,其中窦道路径表现出明显弯曲的占32.6%。本课题组观察到在曲线组窦道型慢性创面中,软性内镜检查测得的长度偏差率明显低于硬性内镜,进一步分析得知,软性内镜检查测得的长度偏差率与CT造影及三维重建所得相近,这说明软性内镜基本可以充分观察到弯曲型窦道型慢性创面的内部情况。在直线组窦道型慢性创面中,软性内镜、硬性内镜及CT造影检查所得的长度偏差率均为0,这说明硬性内镜及软性内镜均可以充分观察到直线型窦道型慢性创面的内部情况。

    需要指出的是,虽然本研究结果证实软性内镜在窦道型慢性创面的测量和观察方面具有优势,有望成为窦道型慢性创面诊断和治疗的有效手段;但目前我国软性内镜相关市场几乎被国外内镜公司垄断21,导致软性内镜价格普遍高于硬性内镜,这可能不利于软性内镜在基层医院的推广和使用。软性内镜及硬性内镜在直线型窦道型慢性创面内部病理特征的观察方面无明显差异,此类创面可以选用成本较低的硬性内镜作为诊疗工具。对于弯曲型窦道型慢性创面,如无软性内镜条件,建议到上级医院检查,否则可能延误治疗。

    综上所述,软性内镜在窦道型慢性创面的临床检查中能更大范围地观察窦道内部特征,尤其对于弯曲型窦道的探查具有明显优势,这种方法的推广将有利于窦道型慢性创面的诊断及治疗。本研究也存在一定的局限性,首先样本量较小,其次没有进行前瞻性研究,下一步本课题组将进行大样本、多中心的临床研究,以进一步说明软性内镜在窦道型慢性创面诊疗中的优势。此外,本研究仅提供了窦道型慢性创面窦道长度、形态及可视范围的相关诊断方法,此类创面的其他诊断内容,包括超声诊断、病理诊断等有待进一步研究。

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