Practical guideline on the prevention and management of diabetic foot in China (Ⅰ)
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摘要: 糖尿病足是糖尿病患者常见的严重并发症之一,足畸形、溃疡、缺血以及可能合并的感染等是导致患者截肢和/或死亡的重要原因。为进一步规范我国糖尿病足防治实践过程,提升医疗同质化水平,推动专病分级诊疗体系建设,中华医学会烧伤外科学分会、长三角一体化糖尿病足专病联盟和《中华烧伤与创面修复杂志》编辑委员会组织多学科专家团队,确定糖尿病足诊断、治疗和预防等方面的临床问题,并运用推荐意见分级的评估、制订与评价系统评估相关证据的质量等级,制订了《中国糖尿病足防治实践指南》。该指南共形成了46条推荐意见,内容涵盖全面医学评估,控制血糖、血压、血脂及抗栓和抗感染等内科治疗,围手术期的风险评估和管理,清创、血管重建和组织修复手术等外科治疗,以及足病预防、多学科团队合作和分级诊疗体系建设等,旨在为中国糖尿病足的临床实践提供指导。Abstract: Diabetic foot is one of the common and serious complications among the patients with diabetes mellitus. The major causes of amputation and/or death in the patients are foot deformities, ulcers, ischemia, and possible concurrent infections. To further standardize diabetic foot prevention and treatment in China, improve its diagnostic and therapeutic consistency, and promote the development of a specialized tiered care system, Chinese Burn Association, Yangtze River Delta Integrated Diabetic Foot Alliance, and Editorial Committee of Chinese Journal of Burns and Wounds organized a multidisciplinary expert team. The team determined clinical issues related to the diagnosis, treatment, and prevention of diabetic foot and evaluated the quality grades of relevant evidence using the grading of recommendations assessment, development, and evaluation system, and eventually developed the Practical guideline on the prevention and management of diabetic foot in China. There were 46 recommendations formed in the guideline, covering comprehensive medical assessment, internal medical treatments such as control of blood glucose, blood pressure, and blood lipid, antithrombotic and anti-infection therapy, perioperative risk assessment and management, surgical treatments such as debridement, vascular reconstruction, and tissue repair surgeries, as well as foot disease prevention, multidisciplinary team cooperation, and the construction of a tiered care system, aiming to provide guidance for the clinical practice of diabetic foot in China.
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Key words:
- Diabetic foot /
- Infections /
- Peripheral arterial disease /
- Peripheral neuropathy /
- Wound repair
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参考文献
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Table 1. 基于GRADE系统的证据质量等级
证据质量等级 说明 高 非常确信真实的效应值,接近效应估计值 中等 对效应估计值有中等程度的信心,真实值有可能接近估计值,但仍存在两者大不相同的可能性 低 对效应估计值确信程度有限,真实值可能与估计值大不相同 极低 对效应估计值几乎没有信心,真实值很可能与估计值大不相同 注：GRADE为推荐意见分级的评估、制订与评价 
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Table 2. 基于GRADE系统的推荐强度分级
推荐强度 说明 强 做法好处明显大于风险,临床医师实施和人群接受可信度都高 弱 做法好处和风险相当,更依赖于特定临床情况。一般情况下,医师和患者的偏好在决策过程中起更重要的作用 注：GRADE为推荐意见分级的评估、制订与评价
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Table 3. 糖尿病足患者病史采集内容
项目 具体内容 一般情况 （1）生活方式；（2）职业需求及文化、心理和社会经济情况；（3）行为能力和精神状态；（4）穿鞋习惯和足部保暖情况；（5）机械外伤或有害化学物质暴露史 既往史 （1）糖尿病并发症或合并症史；（2）外伤和手术史（重点是足溃疡和下肢手术史）；（3）既往下肢疾病史,如下肢针刺感或疼痛史（包括间歇性跛行或静息痛史）、大腿近端肌肉萎缩和无力史、双侧或单侧下肢水肿史,以及足畸形、足趾关节活动度缺失、足底压力异常和胼胝史；（4）既往足病诊治史 足病现病史 （1）本次发病（是否复发）和就医情况；（2）溃疡的部位、大小（长、宽、深）、渗出和周围组织等变化情况；（3）可能干扰溃疡愈合的家庭和社会因素；（4）减压技术的使用情况
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Table 4. 糖尿病足患者下肢体格检查内容
项目 具体内容 皮肤检查 （1）温度、颜色、弹性、湿润程度、毛发生长、皲裂情况；（2）趾甲萎缩、增生或营养不良情况；（3）胼胝、鸡眼情况（皮肤压红,甚至出血）；（4）溃疡（位置、范围、深度、程度等）、坏疽情况；（5）足癣（真菌感染）、甲沟炎（细菌感染）、瘙痒挠痕（酵母菌感染）情况；（6）其他,浅棕色、鳞片斑块（糖尿病性皮肤病）,脂肪变性,大疱病,发疹性黄瘤病,远端硬化病,播散性环状肉芽肿和过敏反应情况 血管检查 （1）皮肤变薄（羊皮纸样外观）、发绀或红斑以及体位性色泽改变（肢体抬高及下垂试验）；（2）温度梯度（同侧上下、两侧对比）；（3）颈动脉、腹部动脉、股动脉、足背动脉听诊；（4）股动脉、足背动脉、胫后动脉触诊；（5）使用血压计和多普勒超声检查测量踝肱指数、趾肱指数 神经肌肉及骨骼系统检查 （1）振动觉、压力、触觉、痛觉、温度和深肌腱反射；（2）足畸形,如自发性肌肉萎缩、足下垂、跟腱挛缩或马蹄足、足趾畸形、𧿹趾关节骨性关节炎或僵𧿹、平足或高足弓、夏科神经骨关节病变、手术（包括截肢）后畸形；（3）下肢关节活动受限
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Table 5. 糖尿病足感染的鉴别诊断及治疗要点
疾病 常见病因 诊断要点 治疗要点 蜂窝织炎 链球菌、金黄色葡萄球菌感染 局部红肿热痛、边界不清,不侵犯深筋膜层,进展较慢,无皮肤坏死 局部处理+抗菌药物 坏死性筋膜炎 混合细菌（A组链球菌、肠杆菌、厌氧菌等）感染 剧痛与体征不成比例且常伴休克,累及筋膜层,严重时皮肤苍白或紫黑及有水疱、捻发音,进展快速 急诊手术+抗菌药物 气性坏疽 梭状芽孢杆菌属（产气荚膜梭菌）感染 肌肉坏死、剧烈疼痛、捻发音、恶臭分泌物、毒血症 急诊手术+抗菌药物 急性淋巴管炎 链球菌或葡萄球菌感染 从原发灶向近心端延伸的“红线”,伴压痛、局部淋巴结肿或发热 抗菌药物 血栓性静脉炎 血管损伤、高凝状态及卧床等 皮肤胀、痛、红或发绀,可能有肺栓塞,D-二聚体水平升高,超声检查可见静脉血栓 抗凝或溶栓 夏科神经骨关节病变 糖尿病周围神经病变导致的感觉丧失和关节不稳定 无痛性肿胀、变形,步态异常,X线片显示骨质破坏或脱位 全接触石膏固定等减压,必要时手术
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Table 6. 不同病因下肢溃疡的临床表现
类型 病因 好发部位 特点 静脉性溃疡 慢性静脉功能不全（静脉高压） 内踝区、胫前、下肢下1/3部位 浅,边缘不规则,基底有肉芽组织或纤维蛋白,伴水肿、色素沉着、硬皮病 动脉性溃疡 动脉粥样硬化、血栓形成 肢端或足外侧缘 深,边缘清晰、呈“凿缘”,基底苍白或坏死,疼痛剧烈（静息痛） 神经性溃疡 糖尿病、脊髓损伤、麻风等 受压部位 深、无痛、保护性感觉丧失、胼胝下溃疡多见 肿瘤性溃疡 原发性皮肤肿瘤或转移性肿瘤 小腿、足背、甲旁或甲下 边缘不规则、基底组织坏死、易出血、进展迅速且对常规治疗无效 药物性溃疡 使用药物（羟基脲、华法林、化学治疗药物等） 足踝部 干性坏死、边界清晰（使用血管收缩药或华法林导致的溃疡）,红肿、渗出,边缘不规则（如免疫相关溃疡） 代谢性溃疡 痛风、营养不良、钙化防御（肾衰竭） 关节周围、小腿远端前方 边缘不规则,基底白色痛风石或白色分泌物,干性坏疽 血液病相关性溃疡 镰状细胞贫血、血栓性血小板减少性紫癜等 下肢远端、足踝部、足背 易复发,伴贫血、骨痛、瘀斑、微血管病性溶血 自身免疫性疾病相关溃疡 血管炎、红斑狼疮、坏疽性脓皮病、抗磷脂综合征、白塞综合征等 小腿下部和踝周 深、疼痛、愈合困难、易复发
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