【作者】 杨杰；

【导师】 宁宁；

【作者基本信息】 四川大学 ， 护理学， 2021， 硕士

【摘要】 背景:重度压力性损伤(severe pressure injury)创面经消毒、清创后,往往会伴有皮肤全层缺损,暴露皮下深层组织,如脂肪组织、肉芽组织等。严重者甚至伴有筋膜、肌肉、韧带及骨的外露。脊髓损伤患者肢体存在运动功能障碍,需长时间卧床或借助轮椅转移,是重度压力性损伤的好发人群。目前针对重度压力性损伤的治疗方法主要包括清创术、植皮术或皮瓣移植术、负压封闭引流术等,这些方法具有一定的创面治疗效果,但存在治疗时间长、治疗费用高昂等不足。创面修复涉及到一系列连续复杂的生物学过程,需多种生长因子参与其中。而现有的创面治疗方法不具备促进创面修复的生物修复功能,因此寻求一种具有生物修复功能的治疗方法成为当前创面治疗的研究热点,富血小板血浆治疗技术就是其中之一。富血小板血浆是经患者外周静脉抽取适量静脉血,将其注入专用离心管并置于离心机中经一次或两次高速离心后,获得的血小板浓缩物,其血小板含量是全血的4~8倍。再使用凝血酶等作为激活剂,将其制作成富血小板凝胶填塞于创面处,其可在短时间内释放出具有促进创面局部组织修复作用的数种生长因子,在创面治疗中取得良好效果。本研究选择脊髓损伤并发重度压力性损伤的患者为研究对象,研究富血小板血浆治疗该类患者重度压力性损伤的应用效果。观察其创面治疗有效率,探讨其促进创面愈合趋势、感染控制情况及安全性,以期为脊髓损伤并发重度压力性损伤患者提供更加有效、安全的创面治疗方法,从而提高脊髓损伤患者康复治疗效果,减轻患者及家属精神及经济负担,改善患者生存质量。目的:1将富血小板血浆应用于治疗脊髓损伤并发重度压力性损伤患者中,探究其创面治疗有效性。2将富血小板血浆应用于治疗脊髓损伤并发重度压力性损伤患者中,分析其创面感染控制效果。3将富血小板血浆应用于治疗脊髓损伤并发重度压力性损伤患者中,验证其创面治疗的安全性。方法:根据纳入标准,选取2019年7月至2020年11月,四川省某三甲医院康复医学中心收治入院的60例脊髓损伤并发重度压力性损伤的患者为本研究研究对象。通过查阅随机数字表,将本研究所纳入的60例研究对象分配到试验组和对照组。在积极处理影响患者创面愈合进程的原发疾病(如低蛋白、高血糖等)的基础上,对照组患者创面经清创后,根据创面情况选择合适的功能性敷料予以换药治疗,2~3天换药一次,期间若敷料浸湿或脱落时予以及时换药,观察患者创面治疗过程前4周的创面修复情况。试验组患者在对照组的基础上,每周行一次PRP治疗,观察患者创面治疗过程前4周的创面修复情况。通过滴管抽吸0.9%氯化钠注射液滴入创面,直至液面与创缘相平为止的方法(滴入创面的液体量即为创面的容积),记录患者治疗前创面容积(V0)和治疗后第四周创面容积(V1),从而计算创面容积缩小率[=(V0-V1)/V0*100%]。再根据计算所得的创面容积缩小率,将创面愈合情况分为4个等级,分别为痊愈、显效、有效和无效。从而计算并比较两组患者创面治疗有效率(=创面愈合达有效及以上等级的例数/总例数*100%)。采用Bates-Jensen伤口评估工具(Bates-Jensen Wound Assessment Tool,BWAT)从与创面愈合趋势相关的13个方面,对压力性损伤愈合趋势进行动态评估,以治疗前、治疗后第一周、二周、三周及四周为观察时间节点,比较两组患者在这5个观察时间点的BWAT得分情况。通过留取创面分泌物行细菌培养,以了解创面细菌培养转阴情况,比较两组患者压力性损伤创面感染控制水平;观察治疗过程中两组患者是否出现体温升高、过敏反应等,比较两组患者创面治疗的安全性。结果:1一般资料比较在年龄、性别、脊髓损伤分级、压力性损伤分期及部位、白蛋白水平、日常生活自理能力(activity of daily living,ADL)评分、创面起始容积V0、身体质量指数(body mass index,BMI)等一般资料方面,试验组与对照组两者比较,差异无统计学意义(P>0.05),具有可比性。2创面治疗有效率比较通过4周的治疗,试验组创面愈合情况达显效和有效等级的例数分别为3例(10.00%)和25例(83.33%),计算所得创面治疗有效率为93.33%(28/30)。对照组创面愈合情况达有效等级的例数为19例(63.33%),计算所得创面治疗有效率为63.33%(19/30)。试验组创面治疗有效率高于对照组,差异有统计学意义(P<0.05)。3压力性损伤愈合趋势评估表BWAT得分比较3.1 BWAT总分比较:干预前,试验组BWAT总分为(38.13±5.18)分,对照组为(36.53±5.58)分,两组比较差异无统计学意义(t=1.151,P=0.254),具有可比性。治疗后第一周及第二周2个时间点的BWAT总分比较,差异无统计学意义(P>0.05)。而在治疗后第三周,试验组和对照组BWAT总分分别为(26.57±3.42)分和(32.80±4.60)分;治疗后第四周分别为(24.40±3.29)分、(30.57±3.86)分。在这两个2个时间点上两者比较,试验组得分低于对照组,差异有统计学意义(P<0.05)。3.2 BWAT量表各评分条目比较:组内比较:创面治疗后第一周、第二周、第三周及第四周,对照组在创面大小、边缘、坏死组织类型及数量、渗液类型及量、肉芽组织、外周组织水肿、上皮化9个条目得分,与治疗前比较,都呈现出好转的趋势,且差异有统计学意义(P<0.05)。而试验组BWAT量表中所涉及的13个条目得分,与治疗前比较,均呈现出好转的趋势,且差异有统计学意义(P<0.05)。组间比较:干预前,试验组BWAT量表中的13个条目得分分别为(2.87±0.90)分、(3.13±0.97)分、(3.43±0.90)分、(1.20±0.61)分、(2.13±1.50)分、(2.20±1.58)分、(3.57±0.94)分、(4.17±0.83)分、(2.77±1.22)分、(2.33±0.55)分、(1.33±0.48)分、(4.17±0.46)分、(4.83±0.38)分;对照组分别为(2.77±0.73)分、(2.90±0.84)分、(3.17±0.46)分、(1.57±1.07)分、(1.93±1.39)分、(1.93±1.39)分、(3.40±0.97)分、(3.87±0.90)分、(2.27±1.34)分、(2.60±0.50)分、(1.17±0.38)分、(4.20±0.61)分、(4.77±0.43)分,组间比较差异无统计学意义,(P>0.05),具有可比性。在治疗后第一周及第二周2个时间点的BWAT量表各条目比较,差异无统计学意义(P>0.05)。而在治疗后第三周,试验组创面深度得分为(2.23±0.63)分、边缘得分为(2.33±0.80)分、潜行得分为(1.10±0.31)分、坏死组织类型得分为(1.00±0.00)分、坏死组织数量得分为(1.00±0.00)分、渗液类型得分为(2.23±0.43)分、外周组织水肿得分为(1.60±0.62)分、肉芽组织得分为(2.23±0.50)分、上皮化得分为(3.13±0.86)分;对照组上述9个条目得分分别为:(2.77±0.77)分、(2.97±0.18)分、(1.43±0.82)分、(1.57±0.86)分、(1.43±1.04)分、(3.20±0.92)分、(2.33±0.55)分、(3.53±0.90)分、(4.17±0.83)分,上述9个条目比较,差异有统计学意义(P<0.05),试验组得分优于对照组。且在治疗后第四周,上述9个条目得分试验组仍优于对照组,且差异有统计学意义(P<0.05)。BWAT量表中的创面大小和渗液量2个条目,在治疗后第四周,试验组得分分别为(1.87±0.86)分和(2.70±0.65)分;对照组得分分别为(2.27±0.64)分和(3.23±0.82)分,试验组得分均低于对照组,且差异有统计学意义(P<0.05)。而该量表中的周围皮肤颜色、外周组织硬结2个条目,试验组与对照组在各时间点比较,差异均无统计学意义(P>0.05)。3.4 BWAT总分及各条目评分重复测量方差分析比较:两组患者组间比较,在BWAT总分、外周组织水肿、肉芽组织、上皮化4个方面存在差异,且差异有统计学意义(P<0.05)。说明试验组患者在上述4个方面的改善较对照组更为显著。而在不同治疗时间点比较,两组患者BWAT总分及BWAT量表所涉及的13个条目比较,均存在差异,且差异有统计学意义(P<0.05)。表明随着创面治疗进行,患者BWAT总分及BWAT量表所涉及的13个条目得分都会有所改善。BWAT总分及BWAT量表中的创面大小及深度、边缘、渗液类型及量、外周组织水肿、肉芽组织、上皮化8个条目得分比较,存在干预-时间交互作用(P<0.05),说明随着创面治疗时间的延长,试验组和对照组BWAT总分及BWAT量表中的上述8个条目有显著差异,即与对照组相比,随着创面治疗时间的延长,试验组BWAT总分及BWAT量表中的上述8个条目改善情况更为明显。4感染控制比较干预前、治疗后第一周及第二周创面细菌培养结果阳性例数,对照组分别为21例(70.00%),19例(63.33%)和14例(46.67%)。试验组分别为20例(66.67%),15例(50.00%)及8例(26.67%)。在治疗后,两组患者创面分泌物细菌培养阳性例数均降低,而在治疗后第二周,试验组显著低于对照组,差异有统计学意义(χ~2)=6.239,P<0.05)。5不良反应情况试验组及对照组患者在为期4周的创面治疗过程中,均无患者出现体温升高、过敏反应等不良反应。结论:PRP可以为创面修复提供具有生物修复作用的生长因子,可起到有效促进脊髓损伤患者重度压力性损伤创面的愈合的作用,亦可对创面局部感染因素起到有效控制作用,为创面修复创造良好的前提条件。同时PRP治疗创面过程中患者未出现发热、过敏等不良反应,因此亦是一种相对安全的创面治疗方法。更多还原

【Abstract】 Background:Severe pressure injury wounds after disinfection and debridement are often accompanied by full-thickness skin defects,exposing deep subcutaneous tissues,such as adipose tissue and granulation tissue.In severe cases,it is even accompanied by exposure of fascia,muscles,ligaments and bones.Spinal cord injury patients have limbs with motor dysfunction and need to stay in bed for a long time or use a wheelchair to transfer.They are the most common people with severe pressure injuries.The current treatment methods for severe pressure injuries mainly include debridement,skin grafting or flap transplantation,negative pressure sealing drainage,etc.These methods have certain wound treatment effects,but they have disadvantages such as long treatment time and high treatment costs.Wound repair involves a series of continuous and complex biological processes,in which a variety of growth factors are involved.However,the existing wound treatment methods do not have the bioremediation function to promote wound surface repair.Therefore,seeking a treatment method with bioremediation function has become the current research hot spot of wound treatment.Platelet-rich plasma treatment technology is one of them.Platelet-rich plasma is a platelet concentrate with a platelet content 4 to 8 times that of whole blood after an appropriate amount of venous blood is drawn from the patient’s peripheral vein,injected into a special centrifuge tube and placed in a centrifuge after one or two high-speed centrifugation.Then thrombin is used as an activator to make it into a platelet-rich gel to fill the wound surface,which can release several growth factors that can promote the repair of local tissues of the wound surface in a short time and can effectively promote the healing of the wound surface.In this study,patients with spinal cord injury complicated with severe pressure injury were selected as the research object,and platelet-rich plasma wound treatment technology was applied to the treatment of severe pressure injury in this type of patients,to observe the effective rate of wound treatment,and to explore the trend of promoting wound healing,infection control and safety,with the hope that the spinal cord injury complicated by severe patients with pressure injury provide more effective and safe wound treatment methods.Thereby improving the rehabilitation effect of patients with spinal cord injury,reducing the mental and economic burden of patients and their families and improving the quality of life.Objective:1 To explore the effectiveness of platelet rich plasma in the treatment of spinal cord injury complicated with severe stress injury.2 To analyze the effect of wound infection control of platelet rich plasma in the treatment of patients with spinal cord injury complicated with severe stress injury.3 To verify the safety of platelet rich plasma in the treatment of patients with spinal cord injury complicated with severe stress injury.Methods:According to the inclusion criteria,60 patients who were admitted to the rehabilitation center of a tertiary hospital in Sichuan Province from July 2019 to November 2020 and with spinal cord injury and severe pressure injury were selected as the research objects of this study.By consulting the random number table,the 60investigators included in the study were equally allocated to the experimental group and the control group.On the basis of actively dealing with the primary diseases（such as low protein,high blood sugar,etc.）that affect the wound healing process of patients,the control group patients after debridement,choose appropriate functional dressings according to the wound condition for dressing treatment.The dressing should be changed once every2～3 days.During this period,if the dressing is soaked or fall off,the dressing should be changed in time,observing the wound healing of the patients in the first 4 weeks of the wound treatment process.On the basis of the control group,the patients in the experimental group received PRP treatment once a week and observing the wound healing of the patients in the first 4 weeks of the wound treatment process.Use a dropper to suck 0.9%sodium chloride injection into the wound until the liquid level is level with the wound edge（the amount of liquid dripped into the wound is the volume of the wound）and record the volume of the wound before treatment（V₀）and the wound volume（V₁）after the fourth week of treatment,then to calculate the wound volume reduction rate[=（V₀-V₁）/V₀*100%].Then,according to the calculated wound volume reduction rate,the wound healing is divided into 4 grades,which are respectively cured,markedly effective,effective and ineffective.According to the effective rate=the number of cases with effective wound healing and above/total number of cases*100%,the effective rate of wound healing of the two groups of patients was calculated,and the effective rate of wound healing of the two groups of patients was compared.Meanwhile,the Bates-Jensen Wound Assessment Tool（BWAT）was used to evaluate pressure injuries from 13 aspects related to the trend of wound healing.Trends are dynamically evaluated,and the BWAT scores of the two groups of patients before treatment,the first week,the second week,the third week and the fourth week are compared.The wound secretions are collected for culture examination to understand the negative status of the wound bacterial culture,to compare the infection control levels of the two groups of patients with pressure injury.Observing whether the two groups of patients have elevated body temperature,allergic reactions,etc during the treatment process,and compare the safety of the two groups of patients’wound treatments.Results:1 Comparison of general informationAge,gender,activity of daily living（ADL）score,grade of spinal cord injury,location and stage of pressure injury,body mass index（BMI）,albumin level,initial wound volume V₀,etc.According to general data,there was no statistically significant difference between experimental group and control group the（P>0.05）,so they were comparable.2 Comparison of effective rate of wound treatmentAfter 4 weeks of treatment,the number of cases in the experimental group with markedly effective and effective grades of wound healing were 3（10.00%）and 25（83.33%）respectively,and the calculated effective rate of wound treatment was93.33%（28/30）.In the control group,19 cases（63.33%）of wound healing reached the effective level,and the calculated effective rate of wound treatment was 63.33%（19/30）.The effective rate of wound treatment in the experimental group was higher than that in the control group,and the difference was statistically significant（P<0.05）.3 Comparison of BWAT scores on the pressure injury healing tendency assessment table3.1 BWAT total score comparison:Before the intervention and after the first week and the second week of treatment,the total scores of the two groups of patients were compared,and there was not statistically significant（P>0.05）.After the third week of wound treatment,in the experimental group,the total BWAT score was（26.57±3.42）points,and the total BWAT score of the control group was（32.80±4.60）points.Contracted with the control group,the total BWAT score of the experimental group was much lower,and the difference was statistically significant（P<0.05）.After the fourth week of treatment,the total BWAT score of the experimental group was（24.40±3.29）points,and the control group was（30.57±3.86）points.The total BWAT score of the experimental group was still lower than the total BWAT score of the control group,and the difference was statistically significant（P<0.05）.3.2 Comparison of the scores of BWAT items:Intra-group comparison:In the control group,the scores of 9 items including wound size,margin,type and quantity of necrotic tissue,type and quantity of exudate,granulation tissue,peripheral tissue edema,and epithelialization,showed a decreasing trend compared with before treatment,and the difference was statistically significant and academic significance（P<0.05）.There were no statistically significant differences in the scores of the four items of depth,stealth,surrounding skin color,and peripheral tissue induration compared with those before treatment（P>0.05）.The scores of the above 13items in the experimental group showed a decreasing trend compared with those before treatment,and the difference was statistically significant（P<0.05）.Comparison between groups:Before intervention,the scores of 13 items in the BWAT scale of the experimental group were（2.87±0.90）points,（3.13±0.97）points,（3.43±0.90）points,（1.20±0.61）points,（2.13±1.50）points,（2.20±1.58）points,（3.57±0.94）points,（4.17±0.83）points,（2.77±1.22）points,（2.33±0.55）points,（1.33±0.48）points,（4.17±0.46）points and（4.83±0.38）points;the control group is（2.77±0.73）points,（2.90±0.84）points,（3.17±0.46）points,（1.57±1.07）points,（1.93±1.39）points,（1.93±1.39）points,（3.40±0.97）points,（3.87±0.90）points,（2.27±1.34）points,（2.60±0.50）points,（1.17±0.38）points,（4.20±0.61）points and（4.77±0.43）points.There was no statistically significant difference between the groups（P>0.05）,which was comparable.At the same time,there was no statistically significant difference in the BWAT scale items at the two time points after the first week and the second week of treatment（P>0.05）.While after the third week of treatment,the experimental group had a wound depth score of（2.23±0.63）,a marginal score of（2.33±0.80）,a stealth score of（1.10±0.31）,and a necrotic tissue type score of（1.00±0.00）points,the number of necrotic tissue scores was（1.00±0.00）points,the exudate type score was（2.23±0.43）points,the peripheral tissue edema score was（1.60±0.62）points,the granulation tissue score is（2.23±0.50）points,the score of epithelialization was（3.13±0.86）;the scores of the above 9 items in the control group were:（2.77±0.77）points,（2.97±0.18）points,（1.43±0.82）points,（1.57±0.86）points,（1.43±1.04）points,（3.20±0.92）points,（2.33±0.55）points,（3.53±0.90）points,（4.17±0.83）points,compared with the above 9 items,the difference is statistically significant（P<0.05）,the experimental group scores better than the control group.And after the fourth week of treatment,the scores of the above 9 items in the experimental group were still better than the control group,and the difference was statistically significant（P<0.05）.After the fourth week of treatment,there are two items of wound size and exudate volume in the BWAT scale,the scores of the experimental group were（1.87±0.86）points and（2.70±0.65）points;the scores of the control group were（2.27±0.64）points and（3.23±0.82）points,the experimental group scores were lower than the control group,and the difference was statistically significant（P<0.05）.However,the two items of peripheral skin color and peripheral tissue induration in the scale were compared between the experimental group and the control group at each time point,and the difference was not statistically significant（P>0.05）.3.3 Comparison of BWAT total score and repeated measures analysis of variance for each item score:Compared between the two groups,there were differences in BWAT total score,peripheral tissue edema,granulation tissue,and epithelialization,and the differences were statistically significant（P<0.05）.It shows that the improvement in the above four aspects of the experimental group is more significant than that of the control group.Compared with different treatment time points,the total score of BWAT and the 13 items involved in the BWAT scale of the two groups were different,and the difference was statistically significant（P<0.05）.It shows that with the prolongation of wound treatment time,the total score of the patients’BWAT and the scores of 13items involved in the BWAT scale will improve.The BWAT total score and the wound size and depth,margin,type and amount of exudate,peripheral tissue edema,granulation tissue,and epithelialization in the BWAT scale were compared.There was an intervention-time interaction（P<0.05）,indicating that with the prolongation of wound treatment time,the experimental group and the control group BWAT total score and the above 8 items in the BWAT scale have significant differences,that means compared with the control group,with the prolonged wound treatment time,the experimental group BWAT total score and the above 8 items in the BWAT scale have improved more obviously.4 Comparison of infection control levelThe number of positive bacterial culture results on wounds before intervention,on the 7^thand14^thday after treatment,the control group was 21 cases（70.00%）,19cases（63.33%）and 14 cases（46.67%）.The experimental group were 20 cases（66.67%）,15 cases（50.00%）and 8 cases（26.67%）.After treatment,the number of positive bacterial cultures of wound secretions in the two groups decreased.On the14^thday after treatment,the experimental group was significantly lower than the control group,and the difference was statistically significant（χ²）=6.239,P<0.05).5 Adverse reactionsDuring the 4-week treatment,no patients in the experimental group and the control group had any adverse reactions such as elevated body temperature or allergic reactions.Conclusion:PRP can provide growth factors with bioremediation effects for wound repairandcan effectively promote the healing of severe pressure injury wounds in patients with spinal cord injury.It can also effectively control the local infection factors of the wound,and even create good prerequisites for wound repair.At the same time,PRP does not have any adverse reactions such as fever or allergies during the wound treatment process,so it is also a relatively safe wound treatment method.更多还原