循证医学证据来了!伤口冲洗该怎么做才更有利于愈合?

2021-11-12 MedSci原创 MedSci原创

最佳伤口护理需要一种以消毒和冲洗为中心的多模式方法。而在临床上伤口冲洗是灵活可变的,并不总以证据为基础。但在循证医学数据的基础上,决定采用何种冲洗方式及灌洗液则是较为科学的决策。

近一个世纪以来,伤口冲洗和消毒一直是预防感染和促进愈合的最重要手段。尽管消毒的效用已得到充分证实,但还没有任何指南用于指导伤口冲洗。

伤口冲洗是用液体冲击和清除松散附着的碎片。该标准实践已被证明可以降低细菌数量和总体感染率。此外,通过减少微生物数量和延迟形成生物膜,治疗和冲洗已被证实可以改善伤口环境并加速愈合。

需要冲洗的伤口护理包括急性软组织创伤、开放性骨折、压力性溃疡、糖尿病足溃疡和不愈合或术后慢性裂开伤口以及感染创面等创面,

就急性软组织创伤而言,已有研究显示自来水与生理盐水灌注冲洗处理后的创面感染率没有显著差异。在一项采取灌注冲洗和清创术治疗指甲撕脱伤的研究中,报告了与单独使用生理盐水或0.2%呋喃西林相比,0.1%聚己酰胺治疗的患者的细菌负荷和随后感染的显著减少。亦有一项纳入25名患者的临床随机对照试验报告了,与高压平行冲洗相比,压力为15 psi的高压脉冲灌洗足以减少细菌数量。

综以上三项试验而言,自来水与生理盐水灌注冲洗二者的感染率无差异。而与生理盐水灌注冲洗相比,含聚己酰胺的冲洗液灌注冲洗显著降低了感染率。当将高压平行水射流与高压脉冲灌洗进行比较时,细菌负荷没有差异。

因此在这一点上,则建议在处理急性软组织创伤时,应持续采用含聚己酰胺的冲洗液灌洗。

针对相对复杂的创面,包括开放性骨折、压力性溃疡、糖尿病足溃疡和不愈合或术后慢性裂开伤口等创面,可采取的伤口冲洗液和方法又有不同。

在一项比较0.45%橄榄皂和生理盐水冲洗开放性骨折伤口的研究中,报告了0.45%橄榄皂冲洗后的再手术率显著高于生理盐水冲洗组。而另一项手术范围位于股骨近端、髋部和骨盆区域的临床前瞻性研究显示,与不冲洗相比,关闭创口前应用3.5%聚维酮碘可降低术后感染率(0%vs。2.74%).而与负压伤口灌注生理盐水相比,负压伤口灌注聚己内酯可减少愈合时间。另一项研究显示,与灌注冲洗相比,脉冲灌洗显著缩小伤口、降低了细菌负荷和加快伤口闭合(p<0.001)。

但伤口冲洗的方法不仅仅是灌注、脉冲灌洗或高压冲洗,还有已广泛应用于创面治疗的负压创面治疗。其中大量的研究报告了负压灌注创伤治疗的好处。与单纯负压创面治疗相比,负压灌注创面治疗有助于促进形成肉芽组织,显著缩短了伤口闭合时间。就患者而言,这显著减少了其住院天数和平均治疗费用。

综上,复杂创面应接受持续负压创面治疗,并建议采用负压聚己胺溶液灌注治疗。若采用普通灌洗方法,则建议优先采用脉冲灌洗而非连续灌洗。

此处,回到开放性创伤容易出现的感染创面。这一类型创面多需保持创面潮湿,故创面处理与以上略有不同。

有研究报道,相对于生理盐水湿敷,采用硝酸银溶液型负压灌注创面治疗可以更早地控制住临床感染情况,住院天数较少,治疗天数更少,伤口愈合时间较短。另一项回顾性研究显示,与单纯负压创面治疗相比,聚己内酯溶液负压灌注创面治疗后,显著减少了感染创面患者的手术次数和住院天数和革兰氏阳性菌数量,伤口在出院前愈合的比例更高。

但在一项比较负压创伤治疗与生理盐水灌注与0.1%聚己内酯、0.25%醋酸和10%聚维酮碘的系统综述中,Back等人建议预防性使用负压创伤治疗与聚己内酯、醋酸或聚维酮碘治疗。

就数据结果而言,感染创面应接受持续的负压创面治疗,可以根据个体情况或最新研究结果,选择硝酸银、聚己酰胺、醋酸或聚维酮碘溶液灌注。

烧伤患者因烧伤类型不同,其创面处理方法亦各有差异。

一项化学烧伤创面临床研究显示,与单纯湿敷相比,立即手术治疗后持续自来水冲洗显著缩短了恢复时间和住院时间。而中厚皮片移植治疗烧伤创面研究显示,移植后与生理盐水灌注冲洗相比,移植前将中厚皮片浸泡于2%过氧化氢可提高移植成功率。

因此,持续冲洗较湿敷更加,若采用皮片移植,2%过氧化氢浸泡的效果较生理盐水灌注冲洗更好,

最后,再次总结循证医学证据提供的建议:

  1. 于急性软组织损伤而言,应采用注射器抽取聚己酰溶液胺持续灌注冲洗。
  2. 对于复杂伤口,应采用持续负压创面治疗,并注入聚己胺溶液。若采仅冲洗则建议优先采用脉冲灌洗。
  3. 对于感染创面,应采用持续负压创面治疗,并注入硝酸银、聚己酰胺、醋酸乙烯酯或聚维酮碘溶液。但尚不确定这几种溶液何种最优,应根据临床实际情况灵活应用。
  4. 在术中关闭伤口时,与盐水冲洗相比,更建议使用聚维酮碘冲洗,手术部位感染显著减少。

最佳伤口护理需要一种以消毒和冲洗为中心的多模式方法。而在临床上伤口冲洗是灵活可变的,并不总以证据为基础。但在循证医学数据的基础上,决定采用何种冲洗方式及灌洗液则是较为科学的决策。需要进行更多高质量的研究,以进一步建立循证冲洗指南。

参考文献:

Huang CY, Choong MY, Li TS. Cleansing of wounds by tap water? An evidence-based systemic analysis. Int Wound J. 2015;12:493–494.

Becerro De Bengoa Vallejo R, Losa Iglesias ME, Cervera LA, Fernández DS, Prieto JP. Efficacy of intraoperative surgical irrigation with polyhexanide and nitrofurazone in reducing bacterial load after nail removal surgery. J Am Acad Dermatol. 2011;64:328–335.

Granick MS, Tenenhaus M, Knox KR, Ulm JP. Comparison of wound irrigation and tangential hydrodissection in bacterial clearance of contaminated wounds: Results of a randomized, controlled clinical study. Ostomy Wound Manage. 2007;53:64–66, 68–70, 72.

Bhandari M, Jeray KJ, Petrisor BA, et al. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015;373:2629–2641.

Shetty R, Barreto E, Paul KM. Suction assisted pulse lavage: Randomised controlled studies comparing its efficacy with conventional dressings in healing of chronic wounds. Int Wound J. 2014;11:55–63.

Gabriel A, Shores J, Heinrich C, et al. Negative pressure wound therapy with instillation: A pilot study describing a new method for treating infected wounds. Int Wound J.  2008;5:399–413.

Kim PJ, Attinger CE, Steinberg JS, et al. The impact of negative-pressure wound therapy with instillation compared with standard negative-pressure wound therapy: A retrospective, historical, cohort, controlled study. Plast Reconstr Surg. 2014;133:709–716.

Saeg Fouad,Schoenbrunner Anna R,Janis Jeffrey E,Evidence-Based Wound Irrigation: Separating Fact from Fiction.[J] .Plast Reconstr Surg, 2021, undefined: undefined.

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    2022-08-03 xiongcj5518

    生理盐水,应该是最经济的冲洗方式

    0

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    2021-11-30 ms3000000503434779

    学习啦

    0

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    2021-11-13 云舒

    临床多用的还是生理盐水吧?

    0

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    2021-11-12 ms6000000177538915

    学习了

    0

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