With the rapid development of transportation and industry, there are more and more cases of soft tissue defect and wound infection caused by motor vehicle injury and machine strangulation. Controlling wound infection, promoting wound healing, reducing complications and promoting functional recovery are one of the important topics in trauma surgery. In the past, conventional drainage, dressing change and secondary wound closure were mainly used, but this method has some problems such as long healing time, wound infection, great pain for patients, high cost and many complications. From July 2003 to June 2005, 65438+ 10, 6 patients with severe soft tissue trauma were treated with continuous negative pressure closed drainage, and the effect was satisfactory.
1 data and methods
1. 1 General data There were 6 cases in this group, including 4 males and 2 females, aged 19 ~ 37 years, with an average of 29 years. Among them, there were 4 traffic accident injuries, machine strangulation injuries 1 case and falling injuries 1 case. The injury site is: (1) a large area of skin avulsion injury on the back of the left foot, tendon exposure and wound infection, with an area of about10cm× 6cm; (2) Open fracture of the left tibial plateau, skin avulsion and partial defect in the lateral area of the left knee, and serious wound pollution; (3) The dorsal skin avulsion defect of the right forearm, with an area of about 65438 0.2 cm× 8 cm; (4) Bilateral calcaneal fracture, bilateral severe comminuted fracture of tibia and fibula, osteofascial compartment syndrome caused by calf incision and release; (5) Open multiple fractures of the right lower limb, and wound infection was open 10 day after release of the right hip joint; (6) Abdominal closed multiple organ injury, multiple postoperative abdominal infections, incision infections, and massive pus leakage.
1.2 material (1)vacusal (willow stripe injury) material: a medical foam dressing made of high molecular material polyvinyl alcohol, which is spongy, white, non-toxic, non-immune, corrosion-resistant, excellent in adsorption and water permeability, soft in texture and strong in tension resistance. Original package 650. Equipped with two hard silica gel drainage tubes with multilateral holes, with a diameter of 0.5cm. (2) Biopermeable membrane: (tegaderm transparent dressing, produced by American 3M company). Good air permeability, waterproof, can prevent bacteria from invading, and has no irritation to skin. (3) Negative pressure drainage source: this group of patients choose central negative pressure suction or electric negative pressure suction device for continuous suction.
1.3 Treatment (1) Complete debridement; (2) placing vacuum material: trimming the vacuum material into a shape consistent with the size of the wound surface/cavity, covering the wound surface or placing it in the wound surface cavity, and intermittently fixing the edge with several needles, and extracting two silicone tubes on the foam material from the normal subcutaneous tissue about 5cm away from the wound surface/cavity by poking holes or "mesangial method". (3) sealing the wound surface/cavity: cleaning and drying the skin around the wound surface, and sealing the whole wound surface to the edge of the wound surface about 3-4 cm with a bio-permeable membrane. (4) negative pressure connection: connect the drainage tube to the negative pressure bottle for central negative pressure suction or electric suction, and adjust the negative pressure to 60-80 kPa until the dressing shrinks and hardens and the liquid is discharged. (5) In case 6, because the drainage fluid was viscous and there were many necrotic tissues, an intravenous infusion tube was placed at the same time when the drainage fluid was changed for the second time, and 0.9%NS250ml+ chymotrypsin 8000u was dripped intermittently every day. The negative pressure was turned off for a short time during the drip, and the drainage fluid became clear after 1 week. When replacing the drainage, unplug the irrigation tube and continue to seal the drainage with negative pressure.
Two results
After 5 ~ 7 days of continuous negative pressure drainage, the vacuum was taken out, and 3 cases of wounds healed after skin grafting. 2 cases of wounds were directly sutured and healed; 1 case, replace the vacuum sealing material every 5 ~ 10 days, * * 8 times, and adjust the depth of the vacuum sealing material according to the situation of the wound/cavity and drainage fluid. After the injured mouth became shallow, it was changed into ordinary dressing change and healed after 7 days.
3 discussion
3. 1 Advantages of continuous closed drainage (1) Continuous negative pressure closed drainage uses polymer foam as the intermediary between the negative pressure drainage tube and the wound, which is not limited by body position and realizes full drainage of the wound. The drainage object and the drainage tube are separated by foam material, which is not easy to block the lumen and the drainage is smooth. (2) The premise of closed continuous negative pressure drainage is to seal the wound with a bio-permeable membrane to isolate the wound from the outside world, which constitutes a barrier to prevent bacterial invasion, effectively prevent pollution and infection caused by routine dressing change and drainage, and maintain a continuous high negative pressure state. (3) Negative pressure drainage is the key to this technology. First, the exudate and necrotic tissue in the drainage area can be removed in time, so that the drainage area can achieve "zero accumulation", and the wound surface can quickly obtain a clean environment, reduce the number of bacteria on the wound surface, and prevent the spread of infection and the absorption of toxins; Secondly, the continuous negative pressure state is beneficial to the improvement of local microcirculation and the regression of tissue edema, and stimulates the growth of granulation tissue. Even if there is a large cavity, the cavity will accelerate its contraction due to the existence of high negative pressure. Histological examination confirmed that the infiltration of lymphocytes in the wound surface of negative pressure closed drainage subsided quickly, the collagen synthesis was earlier in the proliferative phase, and the contraction fiber synthesis was enhanced in the repair phase [2]. (4) One-time closed drainage can keep effective drainage for 5-7 days, without changing medicine every day, which not only reduces the pain and economic burden of patients, but also reduces the workload of medical staff. (5) The operation is simple and easy, and it can be carried out by bedside when necessary. (6) Transparent film sealing is more conducive to wound observation and B-ultrasound examination than conventional dressing. Through the observation of this group of cases, the author thinks that continuous negative pressure closed drainage is an ideal choice for early treatment of patients with severe soft tissue defect complicated with infection.
3.2 Precautions for Continuous Negative Pressure Closed Drainage (1) Thoroughly debridement without leaving dead ends: Drainage cannot replace debridement, which is the basic principle of surgery. Although negative pressure sealing drainage has a certain cleaning function, necrotic tissue debris can be led out through the drainage tube, and a large amount of necrotic tissue will be adsorbed on the surface of medical foam material and removed when the drainage is replaced, but moderate cleaning is still needed to make the drainage area completely open, leaving no dead ends. (2) The width of foam material on both sides of each drainage tube should not exceed 2 ~ 3 cm to ensure sufficient negative pressure on the foam surface. The end hole and all side holes of porous drainage tube should be located in foam to avoid blockage. (3) Good sealing: Good sealing is the key to ensure the drainage effect. Clean and dry the surrounding skin, so that the biofilm adheres closely. The coverage of the film should include 34cm of healthy skin at the edge of the wound. The wounds of hands and feet can be closed by "crossing" method; The drainage tube can be poked out from the normal subcutaneous tissue 5cm away from the wound edge, or treated by "mesangial method" [3]; (4) Maintaining negative pressure: Continuous high negative pressure is an important feature of negative pressure closed drainage technology. The magnitude and interruption of negative pressure directly affect the drainage effect. Generally, the drainage effect should be maintained at 60 ~ 80 kPa (450 ~ 600 mmHg) with negative pressure less than 20kPa( 150mmHg), which is obviously not as good as that with negative pressure greater than 60kPa(450mmHg) [3], but the negative pressure is too large. The author thinks that the central negative pressure suction is ideal. If electric attraction is unconditionally available, the disadvantage is that it is noisy. If there is not much drainage, it is more convenient to use a negative pressure drainage bottle. (5) Intermittent washing with chymotrypsin: chymotrypsin can decompose peptide bonds, selectively decompose denatured proteins, dissolve necrotic tissues, dilute pus, facilitate drainage, eliminate cellulose deposition caused by inflammation, and promote granulation tissue growth [4]. The application effect of case 6 in this group is good, but the aseptic operation of catheterization and irrigation should be paid attention to to to avoid iatrogenic infection. (6) Reasonable anti-infection treatment: According to the results of drainage culture and drug sensitivity, choose antibiotics reasonably. (7) Reduce the negative nitrogen balance: The pumped exudate contains a lot of protein, and the metabolic reaction is high in the traumatic state, so it should be given nutritional support treatment, and growth hormone should be used for metabolic conditioning when necessary to promote the positive nitrogen balance. (8) Vacuum sealing drainage can generally maintain effective drainage for 3 ~ 10 days. If there are many necrotic tissues and the drainage is sticky, the time interval for replacing the drainage should be shorter; If the drainage is thin, the interval can be slightly longer, but it should not exceed 10 day.
The vacuum sealing drainage device for Wake's injury adopts foreign advanced wound treatment technology, which has good effects on refractory infectious wounds, persistent ulcers, skin defects, chronic infectious wounds, car accident wounds, burn wounds and various postoperative wound infections. This method is simple to operate, which avoids the pain of changing medicine every day (changing medicine many times a day), and the wound heals quickly, reducing wound infection and reducing the treatment cost as a whole.
Main indications:
1. Soft tissue injury and skin defect
For example, osteofascial compartment syndrome, car accident injury, open fracture and various compound injuries, Wake injury can simplify wound treatment, prevent infection, accelerate wound edema regression, promote wound healing, retain more limb integrity and function than traditional methods, and reduce pain.
2. Abdominal wound
Upper gastrointestinal leakage (fistula), abdominal wound dehiscence for a long time (such as fat liquefaction and infection), pancreatic leakage (fistula), duodenal leakage (fistula), and intra-abdominal infection caused by severe abdominal trauma. The treatment of negative pressure suction can remove secretions and necrotic tissues in time, fully drain, isolate wounds and accelerate healing.
3. Ulcers, old hematomas and abscesses that persist on the body surface.
Bedsore, ulcer and even other methods are used to treat ulcer wounds that do not heal for one or two years. The treatment of the wound can accelerate the growth of granulation tissue, and make the bedsore and ulcer wounds grow fresh granulation tissue quickly and heal in a short time.
Diabetic foot, also known as acromegaly, is the infection, ulceration, ulcer formation and deep tissue destruction of lower limbs caused by diabetic patients complicated with different degrees of neuropathy and peripheral vascular diseases. One foot is amputated every 30 seconds in the world because of diabetes. Most of the causes of foot amputation begin with foot ulcers. The vast majority of foot ulcers and amputations are completely preventable, and nearly 85% of them can be avoided. Now the application of negative pressure drainage in the treatment of conscious injury can improve blood supply, speed up wound recovery, reduce the pain and trouble of frequent dressing change and reduce amputation rate. The application of Vic wound in burn skin grafting can make the infected and edematous burn wound clean in a short time, and the wound is fresh, so skin grafting can be carried out early.
4. After radical mastectomy, due to the negative pressure suction of Wicker injury, the dead space is eliminated, the hydrops is avoided, and there is no need for pressure dressing, thus avoiding dyspnea caused by traditional postoperative pressure dressing or subcutaneous hydrops caused by loose dressing.