VSD持续负压吸引联合创面冲洗治疗重症毒蛇.docx

          VSD持续负压吸引联合创面冲洗治疗重症毒蛇                    郴州市第一人民医院急诊科1，3，通讯作者 湖南郴州423000郴州市第三人民医院康复科2 湖南郴州423000【摘要】目的：观察应用负压封闭引流技术（VSD）进行持续负压吸引联合创面冲洗治疗重症毒蛇咬伤的临床效果方法：选取研究对象为2018年3月至2019年11月在本院就诊的72例重症毒蛇咬伤患者，以随机双盲的原则将其分为研究组36例和对照组36例其中对照组接受传统治疗，研究组接受VSD持续负压吸引联合创面冲洗治疗比较2组疗效及二期缝合/植皮时间、住院时间、住院费用等指标，并观察治疗前后2组患者血清相关指标变化和疼痛程度盖上情况结果：2组患者经治疗后均无死亡情况出现，且研究组治疗后总有效率94.44%，远高于对照组77.78%(P＜0.05)研究组二期缝合/植皮时间和住院时间均明显短于对照组，而住院费用明显高于对照组（P＜0.05）.治疗前，2组患者血清肌红蛋白和肌酸激酶水平、疼痛视觉模拟（VAS）评分比较差异均无统计学意义（P＞0.05）；治疗后，2组患者血清肌红蛋白和肌酸激酶水平、VSP评分均比治疗降低（P＜0.05）；且治疗后研究组血清肌红蛋白和肌酸激酶水平、VSP评分均明显低于对照组（P＜0.05）。

结论：VSD持续负压吸引联合创面冲洗治疗重症毒蛇咬伤效果好，可明显缩短二期缝合/植皮时间和住院时间，尽快减轻患者疼痛关键词】负压封闭引流技术；持续负压吸引；创面冲洗；重症毒蛇咬伤；临床效果The clinical effrct of VSD continuous negative pressure suction combined with wound washing in the treatment of severe snake biteLiu Junhong,Kuang Xiangliu,Jiang Tao,Tan YongpingEmergency department of Chenzhou first people's Hospital,Chenzhou 423000,Hunan[Abstract] Objective: To observe the clinical effect of vacuum sealing drainage (VSD) continuous negative pressure suction combined with wound washing in the treatment of severe snake bite. Methods: A total of 72 patients with severe snake bite from March 2018 to November 2019 in our hospital were selected as the subjects, and they were randomly pided into study group (36 cases) and control group (36 cases) according to the principle of random double blindness. The control group received traditional treatment, and the study group received VSD continuous negative pressure suction combined with wound washing treatment. The therapeutic effect, the time of second stage suture / skin grafting, the hospital stay and the cost of hospitalization were compared between the two groups, and the changes of serum related indexes and the improvement of pain degree were observed before and after treatment. Results: There was no death in the two groups after treatment, and the total effective rate in the study group was 94.44%, which was much higher than that in the control group (77.78%) (P < 0.05). The secondstage suture / skin grafting time and hospitalization time in the study group were significantly shorter than those in the control group, while the hospitalization cost was significantly higher than that in the control group (P < 0.05). Before treatment, there was no significant difference in serum myoglobin and creatine kinase levels and pain visual analogue (VAS) score between the two groups (P > 0.05); after treatment, the levels of serum myoglobin, creatine kinase and VAS score of the two groups were lower than those before treatment (P < 0.05); after treatment, the levels of serum myoglobin, creatine kinase and VAS score in the study group were significantly lower than those in the control group (P < 0.05). Conclusions: VSD continuous negative pressure suction combined with wound washing is effective in the treatment of severe snake bite. It can significantly shorten the time of second stage suture / skin grafting and hospital stay, and reduce the pain of patients as soon as possible.[Key words] vacuum sealing drainage; continuous negative pressure suction; wound washing; severe snake bite; clinical effect毒蛇咬伤在临床急危重症科较为常见，是指咬伤后毒液经过伤口进入人体，导致人体出现全身急性中毒的疾病。

伤口局部主要表现为肿胀、疼痛、皮下淤血、组织坏死等，若治疗不及时，可能会导致伤残，严重者甚至会引起死亡，极大危害人类的生命健康[1-3].因此，对毒蛇咬伤患者进行及时有效的治疗尤为重要临床治疗毒蛇咬伤主要以缓解患者伤口肿胀、压迫，尽可能排除毒液为原则[4].负压封闭引流技术被广泛应用于外伤性创面及相关感染等方面的治疗，并取得了较好疗效，其可有效减少伤口感染，缩短伤口愈合时间[5,6]但目前临床关于其他用于治疗毒蛇咬伤疗效的研究，结果尚且不一，急待进一步探索因此，本研究通过对72例重症毒蛇咬伤患者应用负压封闭引流技术（vacuum sealing,VSD）联合创面冲洗治疗，旨在观察该治疗方式的临床效果，结果报道如下：1 资料与方法1.a.b. 临床资料选取2018年3月至2019年11月期间于本院就诊的72例重症毒蛇咬伤患者为研究对象，随机分为2组，研究组和对照组各36例其中研究组男20例，女16例；平均年龄18~69岁，平均（47.76±6.35）岁；咬伤后就诊时间30min~12h，平均（7.24±1.56）h；咬伤部位：手部12例，前臂4例，足部14例，小腿6例；被咬伤毒蛇种类：竹叶青25例，眼镜蛇11例。

对照组男22例，女14例；年龄16~72岁，平均（48.12±6.61）岁；咬伤后就诊时间30min~12h，平均（7.67±1.48）h;咬伤部位：手部10例，前臂4例，足部15例，小腿7例；被咬伤毒蛇种类：竹叶青26例，眼镜蛇10例2组患者被咬伤的毒蛇种类、性别、年龄、咬伤后就诊时间和咬伤部位情况等一般临床资料比较，差异均无统计学意义（P＞0.05）1.b.c. 纳入与排除标准纳入标准：①符合《毒蛇咬伤的临床分型及严重程度评分标准》[7]中重症毒蛇咬伤的分型；②发现中毒至就诊时间在12h之类患者；③患者全身中毒症状严重，Downey[8]分级为4级；④患者伤侧肢体高度肿胀超过2个大关节，出现大面积皮下瘀斑，且局部张力水泡形成；另患肢运动功能受限，痛感下降符合知情同意原则，患者及其家属签署同意书排除标准：①临床资料缺失或失访患者；②既往合并有严重心、肝、肺、肾等脏器官异常患者；③存在脉管炎、糖尿病等会影响创面愈合的疾病患者；④依从性差，不能完全遵守医嘱患者本研究满足医学伦理学标准，并已经医院伦理委员会审批1.c.d. 治疗方法2组患者均给与注射破伤风抗毒素、大剂量青霉素、安定及鲁米那等预防感染，并根据毒蛇种类给与相应的抗毒蛇血清等全身治疗及抗过敏、补液、营养支持、利尿等对症治疗。

另对2组患者均进行切开减压手术，具体如下：对患者行局部麻醉，根据患者咬伤部位、伤口肿胀，牙痕、淤青及皮肤坏死等情况，在消毒后对伤口做一深约0.3~0.5cm,长度大于毒蛇牙距1.0~4.0cm的“＋”形切口，并清除全部失活组织（注意该过程中避开神经、血管等重要组织）对照组：切开减压手术后接受传统治疗用普通生理盐水引流条填塞引流创口，并每天更换引流条，连续引流一周研究组：切开减压手术后接受VSD持续负压吸引联合创面冲洗治疗具体如下：1.对患者创面进行消毒，并根据创面大小裁剪合适尺寸的聚乙烯醇泡沫敷料；2.将制备的敷料充分接触创面，不留死腔，同时保证敷料包引流管理所有侧孔及顶端；3.在创面周围覆盖生物半透薄膜，并用三通管合并所有引流管至一出口；4.连接负压设备，调整负压并使其保持在180~220mmHg范围内，进行持续负压吸引，并用生理盐水反复冲洗创面连续治疗7d待患者患肢肿胀明显消退，创面无感染、坏死、且肉芽组织生长良好情况下进行二期缝合；对于创面面积较大，无法进行直接缝合的患者进行植皮手术1.4 观察指标①疗效[9]:根据治疗后患者具体的临床症状评定疗效其中治愈：患者患肢肿胀于7d内消退，且肢体无局部皮肤组织坏死和功能障碍等症状；有效：患者患肢肿胀消退时间大于7d，需2次或多次应用负压封闭引流，且肢体无局部皮肤组织坏死和功能障碍等症状；无效：患者患肢皮肤组织坏死，肌肉缺血性挛缩。

总有效率＝（治愈例数+。