【作者】 宋瑞捧；

【导师】 秦贵军；

【作者基本信息】 郑州大学 ， 内科学（专业学位）， 2013， 硕士

【摘要】 背景及目的随着经济的发展、人民生活水平的提高以及人口的老龄化,2型糖尿病的发病率在全球范围内呈逐年增加趋势。糖尿病足是2型糖尿病并发症的一种,是中晚期2型糖尿病患者致残、致死的重要原因之一。Khanolkar等认为,与普通人群相比,糖尿病患者下肢截肢的机会要高出15～40倍,其中老年患者的危险性更高。在我国2型糖尿病患者中,有15%～18%的患者有足部并发症,截肢率高达20%～30%。较为严重糖尿病足发病和血管神经感染等多种因素有关,故治疗起来难度大,愈合由多重因素共同作用,主要包括控制感染、血运重建、治疗神经病变和清创换药等,这些因素可以影响和促进伤口愈合,任何一种单一治疗效果都不太理想。本研究通过多学科综合治疗糖尿病足并观察治疗效果,分析寻找促进糖尿病足患者伤口愈合的因素。方法选取2010年5月至2012年8月在我院内分泌科因糖尿病足住院患者120例,所有患者均符合1999年WHO糖尿病诊断标准,确诊为2型糖尿病,排除糖尿病足0级病变患者。120例入选患者单足或者双足均有溃疡,其中单足72例,双足48例,1-2级合并水泡(摩擦伤、自发性大泡、烧伤等)胼胝体、冻伤等表浅溃疡的67例,3级深达肌肉肌腱的30例。4级局部坏疽17例。5级全足坏疽6例。其中湿性坏疽34例,混合坏疽63例,干性坏疽23例。所有患者治疗前第一天抽取空腹血液测定空腹血糖(FBG)、餐后2小时血糖(2hBG)、糖化血红蛋白(HbAlc)、总胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白(LDL-C)、高密度脂蛋白(HDL-C),测量收缩压(SBP)、舒张压(DBP)及踝肱指数(ABI),测量皮温,行四肢神经肌电图检查是否有糖尿病周围神经病变,行下肢动脉血管彩超检查是否有下肢血管病变,疗程完毕后再次复查上述指标。患者均行内科疗法治疗即降压、降脂、降糖、营养神经、改善循环以及抗感染清创换药等治疗,有选择的进行进一步检查,部分行介入治疗和负压吸引术,疗程为3月,可对比患者治疗前后一般情况及创面生长情况。结果经过3个月的多学科综合治疗后,120位患者中71人(59.17%)完全痊愈,而治疗无效患者2人(1.67%)。将治疗前后生化指标进行对比,可发现FPG、2hPG、HbAlc、SBP、LDL-C、皮温、缺血足的ABI在治疗前后有明显变化(P<0.05),由此可认为控制好血糖、SBP、LDL-C,提高ABI及改善皮温有利于糖尿病足溃疡的愈合。将治疗前后合并神经或血管病变的患者人数进行对比,二者无明显差异(P>0.05)。糖尿病足发病原因是血管神经病变为基础,感染为诱因的一种严重并发症,本研究通过抗感染,改善循环,营养神经,部分通过介入治疗,负压吸引技术,120例患者完全痊愈患者达到59.17%,明显好转患者达到23.33%,无效截肢患者1.67%。糖尿病足溃疡大部分合并感染,通过治疗感染大部分可以控制,多重耐药菌感染控制不好也可导致截肢,分泌物培养加药敏不能完全代表人体内对药物的敏感性,故不能作为抗生素应用的唯一标准,应根据临床症状体征经验用药加上参考药敏结果来选择适当的抗生素。结论本研究通过多学科综合疗法治疗糖尿病足切实有效值得临床推广。更多还原

【Abstract】 Background and objectiveWith the development of economy, the improvement of people’s living standard and the aging of the population, the morbidity of type2diabetes is increasing year by year in the global scope. Diabetic foot, one complication of type2diabetes, is one of the important reasons for the disability and death of the mid-term and advanced patients with type2diabetes. According to Khanolkar, diabetic patients have15～40times more chances of lower limb amputation than general population, of whom elderly diabetic patients have higher risk.15%～18%of Chinese patients with type2diabetes have foot complications, the amputation rate of whom reaches up to20%-30%. Diabetic foot is caused by many factors like the infection of the nerve of blood vessel, which adds to the difficulty of treatment. Healing in diabetic foot depends on many factors, including infection control, revascularization, treatment of neuropathy and debridement dressing and so on, all of which can influence and promote wound healing. This research focuses on multidisciplinary sequential therapy in the treatment of diabetic foot, the observation of its effect, and the analysis of the factors for promoting diabetic foot patients’wound healing as well as the search for them. Method120patients selected, who were being treated in our hospital because of diabetic foot from2010May to2012August, were in accordance with WHO diagnosis standard in1999, and diagnosed with type2diabetes, with patients with diabetic foot0lesions excluded.120patients selected had single or double foot ulcer, including72cases of single foot ulcer,48cases of double foot ulcer,67cases of superficial ulcer such as the blisters of grade1-2(friction injury, spontaneous bulla, burns, frostbite) callosum and cold injury,30cases of ulcer of grade3as deep as muscle tendon,17cases of the local gangrene of grade4,6cases of full foot gangrene of grade5, with34cases of the wet gangrene,63cases of mixed gangrene, and23cases of dry gangrene. During the first day after their hospitalization all of these patients underwent the fasting blood determination to mensurate their fasting blood glucose (FBG), postprandial blood glucose (2hBG)2hours after eating, glycosylated hemoglobin (HbAlc), total cholesterol (TC), triglyceride (TG), low density lipoprotein (LDL-C), high density lipoprotein (HDL-C), systolic blood pressure (SBP), diastolic blood pressure (DBP) and ankle brachial index (ABI), the measurement of their skin temperature, the nerve EMG check which helps to diagnose diabetic peripheral neuropathy, and the color Dopplar ultrasound check of lower extremity artery which helps to diagnose lower extremity vascular disease, all of which were checked again after treatment. Sequential therapy was used for three months to treat these patients, which includes bringing high blood pressure down, lowering blood fat and sugar, maintaining nerve nutrition, improving circulation and giving anti-infection debridement dressing treatment, selecting further examination, treating some patients by using interventional therapy and suction drainage, and comparing the general condition and wound growth before and after treatment.ResultAfter3months of multidisciplinary treatment,71of120patients (59.17%) recovered completely, with the ineffective treatment of only2patients (1.67%).Comparing the biochemical indicators before and after treatment, I have found that FPG,2hPG, HbAlc, SBP, LDL-C, ABI, skin temperature all changed obviously before and after treatment (P＜0.05), which shows that the good control of blood glucose, SBP and LDL-C, together with increasing ABI and skin temperature is beneficial to the healing of diabetic foot ulcer. Comparing the numbers of patients with neurological or vascular lesions before and after treatment, I have found no significant difference between these two numbers (P＞0.05). Diabetic foot is a serious complication caused by infection and vascular neuropathy as the foundation. This research of treating by controlling the infection, improving circulation and maintaining the nerves, some with the further treatment of interventional therapy and suction drainage, led to the result that59.17%of120patients with diabetic feet fully recovered and23.33%improved obviously while only1.67%didn’t recover. Diabetic foot ulcers are mostly concurrent infection, most of which can be controlled by treating infection, with the ineffective control of the infection by the anti medicine germs leading to cutting legs. Secretion culture and drug sensitivity test can not be fully representative of the drug sensitivity of human body, so it can not be used as the only standard of antibiotic application. The treatment should be based on the clinical experience of symptoms and signs, and the appropriate antibiotics should be selected with the reference of the results of drug sensitivity.ConclusionThis research of treating diabetic foot by using multidisciplinary therapy is feasible and effective.更多还原