Practical guideline on the prevention and management of diabetic foot in China (Ⅱ)
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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 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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图 4 跖骨头Weil截骨术及术后固定示意图。4A.跖骨头Weil截骨术方法；4B.跖骨头Weil截骨术后固定方式
注：图4A中箭头表示骨移位方向,阴影表示骨切除部分,虚线表示截骨线
图 15 远端跖骨干骺端截骨术及远端跖骨骨干截骨术示意图。15A.远端跖骨干骺端截骨术,左图为“V”形截骨线,右图为骨移位方向；15B.远端跖骨骨干截骨术,左图为截骨线,右图为骨移位方向
图 17 跖骨近端截骨+
趾Akin术示意图。17A.跖骨近端截骨术；17B.趾Akin术；17C.跖骨近端截骨+趾Akin术后注：图17B左侧虚线图为术前,右侧实线图为术后,阴影部分为骨切除部分
图 18 第5趾内翻畸形及其矫正手术示意图。18A.第5趾内翻畸形示意图；18B.髁突切除术示意图（虚线为截骨线）；18C.远端截骨术示意图,左图为术前（阴影部分为骨切除部分）,右图为术后；18D.近端截骨术示意图,左图示“Z”形截骨线,右图为截骨后螺钉固定
Table 7. 不同清创方法的原理及优点和不足
清创方法 作用原理 优点 不足 机械性清创 锐性清创 用锐利工具,手动切开引流和清除坏死组织 快速、费用低、特异性强 疼痛、创面扩大 手术清创 与锐性清创原理类似,需在手术室无菌环境中进行 清创彻底,可取标本进行活体组织检查,利于创面床的准备 技术要求高、疼痛、创面扩大、费用高 湿-干法清创 先湿敷,移除干燥敷料时带走部分坏死组织 费用低、操作方便、非特异性 易损伤其他组织、疼痛 超声清创 利用空化和微流效应,松动和去除坏死组织 快速、特异性 疼痛、费用高 水动力清创 利用高压水流清除坏死组织 快速、非特异性 感染扩散、疼痛、费用高 蛆虫清创 直接吞噬坏死组织和含酶分泌物或排泄物的化学作用 快速、特异性 蛆虫难获得,疼痛、发热或心理抗拒,大血管旁或可疑癌性创面禁用 非机械性清创 自溶性清创 用创面自身的酶和体液来软化并清除坏死组织 方便、不适感少、费用低、特异性 耗时长、增加感染风险 酶学清创 用外源性的酶类制剂直接降解坏死组织 操作方便、快速、特异性 耗时长、清创程度弱、成本高、存在过敏反应,严重感染禁用 
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Table 8. IWGDF风险分层系统和相应的临床表现及筛查频率
分级 DFU风险等级 临床表现 筛查频率 0 非常低 无LOPS且无PAD迹象 每年1次 1 低 LOPS或PAD 每6~12个月1次 2 中等 LOPS+PAD或LOPS+足畸形或PAD+足畸形 每3~6个月1次 3 高 LOPS或PAD合并以下1项或多项：足溃疡、下肢截肢术后（小截肢或大截肢）、终末期肾病 每1~3个月1次 注：IWGDF为国际糖尿病足工作组,DFU为糖尿病足溃疡,LOPS为保护性感觉丧失,PAD为外周动脉疾病
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