早期压疮的诊断和治疗新进展

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早期压疮的诊断和治疗新进展

常淑文,乔炎,束余声

综述了国内外压疮早期诊断、治疗新进展，早期诊断方法包括早期炎性介质检测法、皮肤温度监测法、影像技术、局部血流监测等；早期治疗及护理压疮的方法包括湿性敷料或蜂蜜医用敷料应用、光线疗法、自体脂肪组织移植法、集束化护理及综合疗法等。早期发现、早期干预可以降低压疮发生率、缩短治疗时间、提高病人的生活质量。

压疮；早期诊断；早期治疗；组织反射光谱法；炎性介质；皮肤温度；影像技术；敷料

压疮又称压力性损伤(pressure injury,PI)，是2016年美国压疮咨询委员会(National Pressure Ulcer Advisory Panel，NPUAP)关于压疮的最新定义，是指皮肤或皮下组织由于压力或联合有剪切力或(和)摩擦力作用而发生在骨隆突处的局限性损伤[1]。压力可以导致组织缺血、炎症性改变，损伤程度从皮肤压红到全层组织缺失后而暴露出肌肉、筋膜、骨骼等[2]。随着人口老龄化的进展，压疮已成为一个越来越严重的慢性病并发症[3]，如能早期发现、早期干预可使压疮的发病率大大降低。在对国内外文献回顾的基础上，旨在阐述关于压疮的早期诊断及治疗方法的现状，以期为医护人员和照顾者早期发现压疮、早期干预提供参考。

1 压疮的流行病学调查

流行病学调查显示：压疮的患病率在普通病房约为12%、急诊病房约为23%[4-7]。2007年欧洲住院病人发病率为4.7%～32.1%，养老机构中发病率为22%[8]；Amir等[9]2016年调查总体发病率为8.0%、医院内获得性压疮为4.5%。英国的调查显示：以压疮为主的慢性伤口治疗每年花费3.28亿英镑，1例病人约1 727英镑[10]。压疮不但延长住院时间、增加发病率和死亡率、降低生活质量[11]、影响病人康复，还会增加医疗成本[12]。因此，早预防、早发现、早治疗是压疮护理的核心内容[13]。

2 早期发现、早期诊断的意义

荷兰一项调查显示约50%的压疮为Ⅰ期压疮[14]。Krishnan等[15]发现：约47%的病人是在急性住院期间或康复期间形成压疮，炎性介质能够早期识别脊髓损伤病人压疮的发生，从而在压疮发生前即可初步确诊；Ⅰ期压疮病人在所有压疮病人中所占比例较高，且大多数早期压疮会恶化成Ⅱ期或更严重阶段[16]；Halfens等[17]通过对Ⅰ期压疮的早期干预使得发生率降低50%。综合文献可看出早期发现、早期诊断、早期治疗对于疾病的康复和病人生活质量都有较大的改善[2-3,14,17]。

3 早期诊断方法

3.1组织反射光谱法(tissue reflectance spectroscopy,TRP) Riordan等[18]研究结果显示：运用TRP进行早期压疮诊断，能够在各种不同色素沉着的皮肤上进行反应性红斑检测，并具有较好的信效度。

3.2早期炎性介质检测Krishnan等[15]在脊髓损伤病人中发现：若病人发生压疮则血浆中干扰素诱导蛋白-10 (IP-10)升高，而尿液中干扰素-α(IFN-α)下降；若未发生压疮则血浆中的粒-巨噬细胞集落刺激因子(GM-CSF)升高。针对这些炎症因子的变化及时采取预防措施，可降低压疮的发生率。

3.3皮肤温度变化有研究发现：手术时间较长的病人皮肤温度会发生明显变化，可使用温度分布图对病人受压部位进行评价[19]。Nakagami等[20]使用热成像仪器根据温度变化对压疮伤口评估来预测创面愈合时间,并给予适当治疗，可以降低压疮发生率。Fard等[21]开发一种连续的压力和温度监测系统，该系统设置了压力和温度报警设置，在压疮的早期诊断和预防上具有可行性。

3.4影像技术Marylou等[22]使用扫描电镜发现压红或Ⅰ期压疮局部比正常人皮下水分含量增加，全身性水肿严重者高于无水肿者，进而说明表皮及皮下水分含量的变化可预测压疮发生，并作为诊断早期压疮的实验基础。

3.5皮肤镜检查Shigeki等[23]研究发现：早期压疮是一种混合性的压红，包括能够缓解的压红(指压变白)和不能缓解的(指压不变白)。皮肤镜下可见压红不缓解病人毛细血管持续存在扩张性条纹和紫癜，这些特点有助于压疮的早期诊断。

3.6血流监测激光多普勒血流仪(laser doppler flowmetry,LDF)是无创性皮肤血流监测工具[24]，应用LDF可对压疮高危病人进行血流检测，并评估组织缺血的严重程度，可作为压疮风险评估的一种方法[25]。Liao等[26]关于大鼠压力对皮肤血流的影响研究，使用LDF对负重缺血部位皮肤血液的排量波动监测(blood flow oscillations，BFO)显示预测压疮是可行的。Chenu等[27]使用TexiCare系统对骶尾部进行血流监测，实时记录和分析臀部的压力变化并提出危险警告，可预防长期坐轮椅病人骶尾部压疮的发生。

4 早期压疮的治疗及护理

4.1预防性皮肤护理保持皮肤完整是预防压疮的重要环节[28]，因此应早期实施预防性皮肤护理[29]。如尽可能避免使红斑区域受压的体位；使用pH值平衡的清洁剂；保持皮肤清洁干燥；不按摩或用力擦洗存在压疮风险的区域；实施个体化的大、小便失禁管理；避免皮肤暴露在过度潮湿的环境中；使用润肤剂保持皮肤湿润等[30]。同时注意控制微环境、使用预防性敷料、使用降低剪切力与摩擦力的纺织物[31]。

4.2缩短受压时间预防压疮首先要降低压力、摩擦力和剪切力[32],最常用的方法为变换体位。目前关于翻身时间间隔尚未明确，临床中使用较多的是2 h翻身1次,可根据病人实际情况适当延长或缩短[33]。减压床垫的使用可以减轻局部压力的效果确切,已被广泛用于预防压疮[34]。澳大利亚医学研究显示：羊皮是一种新型减压工具，已被证实能有效降低病人压疮的发生[35]。

4.3外用药物或敷料压疮愈合的关键因素是保持一个潮湿、闭合的伤口愈合环境[36]。有研究表明：湿性敷料(如聚合物泡沫敷料、水凝胶、藻酸盐敷料、银离子敷料、水凝胶敷料及生物膜等)有保护皮肤、抗菌或促进肉芽组织再生的功能，可降低压疮发生率，比传统纱布敷料更有效[37-38]。Milne等[39]研究发现低pH值的敷料在伤口愈合过程中发挥作用较大。

4.4物理因子或光线疗法紫外线(ultraviolet，UV)，尤其是短波紫外线(UVC,200 nm～280 nm)能够杀灭细菌、真菌和病毒[40]，还能促进皮肤释放免疫因子、加速组织修复及镇痛等[41]。使用紫外线灯(254 nm)在小鼠三度烧伤皮肤照射治疗证明紫外线照射可明显降低烧伤创面真菌感染[40]。有研究表明：使用UVC治疗后，创面面积缩小对创面愈合具有显著疗效[42-43]。Chen等[44]使用光线疗法治疗压疮,创面渗出减少、肉芽组织增生明显，有助于缩短压疮愈合时间。

4.5自体脂肪组织移植随着对脂肪再生性能的深入了解，目前已被引入到各个领域，包括压疮的防治。Marangi等[45]发现通过对移植区域和正常区域在皮肤厚度、筋膜完整性及皮下血管情况等方面进行比较，发现两者在相关参数上是相似的，说明使用脂肪移植可有效治疗早期压疮。

4.6集束化护理集束化护理即应用多个核心、有效的干预方法对病人进行综合干预[46]，体现了措施的针对性、综合性及科学性。如浮动床的使用、全身皮肤评估、皮肤润滑、压力再分配装置的早期运用、体位变换等集束化护理的实施，可减少医院获得性压疮的发生[47]。 Vélez-Díaz-Pallarés等[48]总结了非药物性综合治疗的研究主要集中在支撑面、营养、电疗及其他辅助治疗(超声、负压、激光、电磁或振动疗法)，使用单独一种非药物治疗对于创面愈合效果是不确定的，但多种方法的综合治疗可增加老年压疮病人的愈合率。

4.7改善营养状况病人营养状态与压疮的发生、发展和预后密切相关，如近期失重、低体重指数、蛋白质摄入减少、进食困难及低营养摄入者等[49-50]是发生压疮的高风险人群。因此，改善营养状况、纠正低蛋白血症是预防压疮的根本措施[50]。维生素A能够刺激成纤维细胞促进胶原沉积，影响伤口愈合进程；维生素C影响结缔组织蛋白的分泌、成纤维细胞增殖及血管形成，早期压疮病人建议每日服用维生素C 100 mg～200 mg，严重者1 000 mg～2 000 mg[51-52]；镁是体内酶或其他蛋白、胶原形成、组织生长必需的辅因子,与三磷酸腺苷一起促进胶原合成；铜可加强胶原蛋白交联,稳定胶原框架[53]；锌主要参与DNA合成、细胞增殖和伤口愈合[51，54]。在压疮高危人群中予以补充适量的微量元素对于压疮的预防和发展有较大的改善作用。

4.8蜂蜜蜂蜜作为伤口愈合的佐剂已被使用了数百年，在伤口愈合中的主要作用机制包括抗菌能力、免疫调节和维持生理平衡等[55]。目前，已有医用蜂蜜敷料应用于伤口护理，研究表明医用蜂蜜敷料在急、慢性伤口和压力性溃疡等伤口管理上是安全、有效、低成本的治疗方案[56]。

4.9医护人员及照顾者的培训医务人员对于压疮风险评估的态度也影响压疮的发病率[57]，对医护人员进行相关培训可以提高判定压疮的准确率和界定压疮种类的正确率[58]，加强对照顾者的教育可影响压疮的发展和预后[59]。

5 小结

压红不缓解或Ⅰ期压疮的皮肤完整性未受损害，如及时采取措施去除病因，皮肤改变可恢复正常，也可防止压疮的进一步进展。因此，在护理工作中压疮的早期诊断、早期治疗尤为重要。综合文献资料可见，早期诊断压疮方法主要集中在影像技术、受压部位血流监测及炎性介质早期检测等方面，如能广泛使用简单、易行、可视化的操作工具，对于高危人群进行诊断并早期使用保护性敷料，可以大大降低压疮的发病率，并能改善压疮高危者的生活质量。

[1] Panpp IA,Haesler E.Prevention and treatment of pressure ulcers:clinical practice guideline[M].Perth:Cambridge Media,2014:12.

[2] Wang Y,Pu L,Li Z,etal.Hypoxia-inducible factor-1α gene expression and apoptosis in ischemia-reperfusion injury:a rat model of early-stage pressure ulcer[J].Nursing Research,2016,65(1):35-46.

[3] Wentworth K.Diagnosis,management,and prevention of pressure ulcers[J].Hospital Medicine Clinics,2013,2(2):e274-e291.

[4] Moore Z,Cowman S.Pressure ulcer prevalence and prevention practices in care of the older person in the republic of Ireland[J].Journal of Clinical Nursing,2012,21(3/4):362-371.

[5] Apold J,Rydrych D.Preventing device-related pressure ulcers:using data to guide statewide change[J].Journal of Nursing Care Quality,2012,27(1):28-34.

[6] Santos CTD,Oliveira MC,Pereira AGDS,etal.Indicador de qualidade assistencial úlcera por pressão:análise de prontuário e de notificaãço de incidente[J].Rev Gaúcha Enferm,2013,34(1):111-118.

[7] Vangilder C,Lachenbruch C,Algrim-Boyle C,etal.The international pressure ulcer prevalence survey:2006-2015:a 10-year pressure injury prevalence and demographic trend analysis by care setting[J].Journal of Wound Ostomy & Continence Nursing Official Publication of the Wound Ostomy & Continence Nurses Society,2017,44(1):20-28.

[8] Vanderwee K,Clark M,Dealey C,etal.Pressure ulcer prevalence in Europe:a pilot study[J].Journal of Evaluation in Clinical Practice,2007,13(2):227-235.

[9] Amir Y,Lohrmann C,Halfens RJ,etal.Pressure ulcers in four Indonesian hospitals:prevalence,patient characteristics,ulcer characteristics,prevention and treatment[J].International Wound Journal,2016，14(1)：184-193.

[10] Phillips CJ,Humphreys I,Fletcher J,etal.Estimating the costs associated with the management of patients with chronic wounds using linked routine data[J].International Wound Journal,2015,10(18):2546-2548.

[11] Padula WV,Mishra MK,Makic MB,etal.Improving the quality of pressure ulcer care with prevention:a cost-effectiveness analysis[J].Medical Care,2011,49(4):385-392.

[12] 赵红亮,张萍,李莉,等.压疮管理流程在重症病人皮肤护理中的应用[J].护理研究,2015,29(8B):2941-2942.

[13] Parish RC,Trei JE.Re:prevention and management of pressure ulcers in primary and secondary care:summary of NICE guidance[J].BMJ,2014,348(apr 231):g2592.

[14] Bours G,Laat E,Halfens R,etal.Prevalence,risk factors and prevention of pressure ulcers in Dutch intensive care units[J].Intensive Care Medicine,2001,27(10):1599-1605.

[15] Krishnan S,Karg P,Boninger M,etal.Early detection of pressure ulcer development following traumatic spinal cord injury using inflammatory mediators[J].Archives of Physical Medicine & Rehabilitation,2016,96(12):e22.

[16] Moore Z,Johansen E,Mv E,etal.Pressure ulcer prevalence and prevention practices:a cross-sectional comparative survey in Norway and Ireland[J].Journal of Wound Care,2015,24(8):333-339.

[17] Halfens RJ,Bours GJ,Van AW.Relevance of the diagnosis ’stage 1 pressure ulcer’:an empirical study of the clinical course of stage 1 ulcers in acute care and long-term care hospital populations[J].Journal of Clinical Nursing,2001,10(6):748-757.

[18] Riordan B,Sprigle S,Linden M.Testing the validity of erythema detection algorithms[J].Journal of Rehabilitation Research & Development,2001,38(1):13-22.

[19] Allegretti AL,Malkiewicz A,Brienza DM.Measuring interface pressure and temperature in the operating room[J].Advances in Skin & Wound Care,2012,25(5):226-230.

[20] Nakagami G,Sanada H,Iizaka S,etal.Predicting delayed pressure ulcer healing using thermography:a prospective cohort study[J].Journal of Wound Care,2010,19(11):465-472.

[21] Fard FD,Moghimi S,Lotfi R.Design and evaluation of a pressure and temperature monitoring system for pressure ulcer prevention[J].Iranian Journal of Medical Physics,2014,11(2):242-252.

[22] Marylou G,Barbara MB,Sophia C,etal.Assessing the feasibility of subepidermal moisture to predict erythema and stage 1 pressure ulcers in persons with spinal cord injury:a pilot study[J].Journal of Spinal Cord Medicine,2012,35(1):46-52.

[23] Shigeki I,Hitoshi I,Satoshi I.Dermoscopic evaluation of erythema associated with pressure ulcers[J].International Journal of Dermatology,2011,50(8):945-947.

[24] Von AK,Haunschild J,Hoyer A,etal.Non-invasive spinal cord oxygenation monitoring:validating collateral network near-infrared spectroscopy for thoracoabdominal aortic aneurysm repair[J].European Journal of Cardio-thoracic Surgery:Official Journal of The European Association For Cardio-Thoracic Surgery,2016，50(4)：675-683.

[25] Jan YK,Liao F,Rice LA,etal.Using reactive hyperemia to assess the efficacy of local cooling on reducing sacral skin ischemia under surface pressure in people with spinal cord injury:a preliminary report[J].Archives of Physical Medicine & Rehabilitation,2013,94(10):1982-1989.

[26] Liao F,O’Brien WD,Jan YK.Assessing complexity of skin blood flow oscillations in response to locally applied heating and pressure in rats:implications for pressure ulcer risk[J].Physica A Statistical Mechanics & Its Applications,2013,392(20):4905-4915.

[27] Chenu O,Vuillerme N,Bucki M,etal.Texicare:an innovative embedded device for pressure ulcer prevention.Preliminary results with a paraplegic volunteer[J].Journal of Tissue Viability,2013,22(3):83-90.

[28] Gill EC.Reducing hospital acquired pressure ulcers in intensive care[J].BMJ,2015,4(1):U205599.

[29] Niederhauser A,Vandeusen LC,Parker V,etal.Comprehensive programs for preventing pressure ulcers:a review of the literature[J].Advances in Skin & Wound Care,2012,25(4):167-188：648-649.

[30] Cuddigan JE,Kottner J,Haesler E.Treatment of pressure ulcers[J].Annals of Internal Medicine,2015,163(8):648-649.

[31] Demarre L,Verhaeghe S,Van Hecke A,etal.Factors predicting the development of pressure ulcers in an at-risk population who receive standardized preventive care:secondary analyses of a multicentre randomised controlled trial[J].Journal of Advanced Nursing,2014,71(2):391-403.

[32] Dumville JC,Jammali A.Support surfaces for treating pressure ulcers[J].Cochrane Database of Systematic Reviews,2011,12(12):CD009490.

[33] Meah YS,Gliatto PM,Ko FC,etal.Wound care in home-based settings[M]//Geriatric Home-Based Medical Care.Switzerlands:Springer,2016：1.

[34] Clavagnier I.Prevention of pressure ulcers[J].Revue De Linfirmiere,2016,65(218):1.

[35] Mistiaen P,Jolley DJ,Mcgowan S,etal.Australian medical sheepskin for prevention of pressure ulcers:individual patient data meta-analysis shows effectiveness[J].Nederlands Tijdschrift Voor Geneeskunde,2011,155(18):1.

[36] 穆鑫馨,王俊杰.人性化护理干预结合湿性愈合疗法在乳腺癌压疮患者中的应用效果[J].中华全科医学,2017,15(1):157-159.

[37] Thorpe E.Prophylactic use of dressings for pressure ulcer prevention in the critical care unit[J].British Journal of Nursing,2016,25(12):S6-S12.

[38] Chaiken N.Reduction of sacral pressure ulcers in the intensive care unit using a silicone border foam dressing[J].Journal of Wound Ostomy & Continence Nursing Official Publication of the Wound Ostomy & Continence Nurses Society,2012,39(2):143-145.

[39] Milne SD,Connolly P.The influence of different dressings on the pH of the wound environment[J].Journal of Wound Care,2014,23(2):56-57.

[40] Dai T,Kharkwal GB,Zhao J,etal.Ultraviolet-C light for treatment of Candida albicans,burn infection in Mice[J].Photochemistry & Photobiology,2011,87(2):342-349.

[41] Yin R,Dai T,Avci P,etal.Light based anti-infectives:ultraviolet C irradiation,photodynamic therapy,blue light,and beyond[J].Current Opinion in Pharmacology,2013,13(5):731-762.

[42] Nussbaum EL,Flett H,Hitzig SL,etal.Ultraviolet-C irradiation in the management of pressure ulcers in people with spinal cord injury:a randomized,placebo-controlled trial[J].Archives of Physical Medicine & Rehabilitation，2013,94(4):650-659.

[43] Woods JA,Evans A,Forbes PD,etal.The effect of 222 nm UVC phototesting on healthy volunteer skin:a pilot study[J].Photodermatology Photoimmunology & Photomedicine,2014,31(3):159-166.

[44] Chen C,Hou WH,Chan ES,etal.Phototherapy for treating pressure ulcers[J].Cochrane Database of Systematic Reviews,2014,7(7):CD009224.

[45] Marangi GF,Pallara T,Cagli B,etal.Treatment of early-stage pressure ulcers by using autologous adipose tissue grafts[J].Plastic Surgery International,2014,2014:817283.

[46] Coyer F,Gardner A,Doubrovsky A,etal.Reducing pressure injuries in critically ill patients by using a patient skin integrity care bundle (InSPiRE)[J].American Journal of Critical Care,2015,24(3):199-209.

[47] Anderson M,Finch GP,Kraft W,etal.Universal pressure ulcer prevention bundle with WOC nurse support[J].Journal of Wound Ostomy & Continence Nursing Official Publication of the Wound Ostomy & Continence Nurses Society,2015,42(3):217-225.

[48] Vélez-Díaz-Pallarés M,Lozano-Montoya I,Abraha I,etal.Nonpharmacologic interventions to heal pressure ulcers in older patients:an overview of systematic of reviews (the senator-ontop series)[J].Journal of the American Medical Directors Association,2015,16(6):448-469.

[49] Thomas DR.Role of nutrition in the treatment and prevention of pressure ulcers[J].Nutrition in Clinical Practice Official Publication of the American Society for Parenteral & Enteral Nutrition,2014,29(4):466-472.

[50] Vincenzo Malafarina,Franciscoúriz-Otano,Fernández-Catalán C,etal.Nutritional status and pressure ulcers.Risk assessment and estimation in older adults[J].Journal of the American Geriatrics Society,2014,62(62):1209-1210.

[51] Chow O,Barbul A.Immunonutrition:role in wound healing and tissue regeneration[J].Advances in Wound Care,2014,3(1):46-53.

[52] Stechmiller JK.Understanding the role of nutrition and wound healing[J].Nutrition in Clinical Practice Official Publication of the American Society for Parenteral & Enteral Nutrition,2010,25(1):61-68.

[53] Abdullahi A,Jeschke MG.Nutrition and anabolic pharmacotherapies in the care of burn patients[J].Nutrition in Clinical Practice Official Publication of the American Society for Parenteral & Enteral Nutrition,2014,29(5):621-630.

[54] Wilkinson EA,Hawke CC.Oral zinc for arterial and venous leg ulcers[J].Cochrane Database of Systematic Reviews,2012,8(8):CD001273.

[55] Manochi P.Pressure ulcer management using medicinal honey[J].Ostomy/Wound Management,2015,61(3):8-10.

[56] Mcinnes E,Jammali-Blasi A,Bell-Syer S,etal.Preventing pressure ulcers-Are pressure-redistributing support surfaces effective? A Cochrane systematic review and meta-analysis [J].International Journal of Nursing Studies,2012,49(3):345-359.

[57] Van Dishoeck AM,Looman CWN,Steyerberg EW,etal.Performance indicators; the association between the quality of preventive care and the prevalence of hospital-acquired skin lesions in adult hospital patients[J].Journal of Advanced Nursing,2016，72(11)：2818-2830.

[58] Cooper L,Vellodi C,Stansby G,etal.The prevention and management of pressure ulcers:summary of updated NICE guidance[J].Journal of Wound Care,2015,24(4):179-184.

[59] Ham WHW,Schoonhoven L,Schuurmans MJ,etal.Pressure ulcer education improves interrater reliability,identification,and classification skills by emergency nurses and physicians[J].Journal of Emergency Nursing,2015,41(1):43-51.

(本文编辑张建华)

Newprogressondiagnosisandtreatmentofearlypressuresores

ChangShuwen,QiaoYan,ShuYusheng

(School of Nursing,Yangzhou University,Jiangsu 225001 China)

It reviewed the new progress on early diagnosis and treatment of pressure sore at home and abroad.Early diagnostic methods included tissue reflex spectroscopy,early inflammatory mediators detection,skin temperature monitoring,imaging techniques and local blood flow monitoring.Early treatment and nursing methods of pressure sores included wet dressings or honey medical dressings applications,light therapy,autologous adipose tissue transplantation,cluster care and comprehensive therapy.Early detection,early intervention can reduce the incidence of pressure sores,shorten the treatment time and improve the quality of life of patients.

pressure sores；early diagnosis；early treatment；tissue reflectance spectroscopy；inflammatory mediators；skin temperature；image technology；dressing

常淑文,主管护师，硕士研究生在读，单位：225001，扬州大学护理学院(225001，江苏省苏北人民医院)；乔炎单位：399-4117，日本长野县看护大学；束余声(通讯作者)单位：225001，江苏省苏北人民医院。

信息 常淑文，乔炎，束余声.早期压疮的诊断和治疗新进展[J].护理研究，2017，31(24)：2963-2966.

R472

：Adoi:10.3969/j.issn.1009-6493.2017.24.005

：1009-6493(2017)24-2963-04

2016-07-26；

2017-07-25)