Brem Harold, Sheehan Peter, Rosenberg Harvey J, Schneider Jillian S, Boulton Andrew J M
Department of Surgery, Wound Healing Program, Columbia University College of Physicians and Surgeons, New York, NY, USA.
Plast Reconstr Surg. 2006 Jun;117(7 Suppl):193S-209S; discussion 210S-211S. doi: 10.1097/01.prs.0000225459.93750.29.
Diabetic foot ulcers are the single biggest risk factor for nontraumatic foot amputations in persons with diabetes. Foot ulcers occur in 12 to 25 percent of persons with diabetes and precede 84 percent of all nontraumatic amputations in this growing population. Because of the high incidence of foot ulcers, amputations remain a source of morbidity and mortality in persons with diabetes. Strict adherence to evidence-based protocols as described herein will prevent the majority of these amputations.
The collective experience of treating patients with neuropathic diabetic foot ulcers in four major diabetic foot programs in the United States and Europe was analyzed.
The following protocol was developed for patients with diabetic foot ulcers: (1) establishment of good communication among the patient, the wound healing team, and the primary medical doctor; (2) comprehensive, protocol-driven care of the entire patient, including hemoglobin A1c, microalbuminuria, and cholesterol as well as early treatment of retinopathy, nephropathy, and cardiac disease; (3) weekly objective measurement of the wound with digital photography, planimetry, and documentation of the wound-healing process using the Wound Electronic Medical Record, if available; (4) objective evaluation of blood flow in the lower extremities (e.g., noninvasive flow studies); (5) débridement of hyperkeratotic, infected, and nonviable tissue; (6) use of systemic antibiotics for deep infection, drainage, and cellulitis; (7) off-loading; (8) maintenance of a moist wound bed; (9) use of growth factor and/or cellular therapy if the wound is not healing after 3 weeks with this protocol; and (10) consideration of the use of vacuum-assisted therapy in complex wounds.
In diabetic foot ulcers, availability of the above modalities, in combination with early recognition and comprehensive treatment, ensures rapid healing, minimizes morbidity and mortality rates, and eliminates toe and limb amputations in the absence of ischemia and osteomyelitis.
糖尿病足溃疡是糖尿病患者非创伤性足部截肢的最大单一危险因素。12%至25%的糖尿病患者会发生足部溃疡，在这一不断增长的人群中，84%的非创伤性截肢都先有足部溃疡。由于足部溃疡的高发病率，截肢仍是糖尿病患者发病和死亡的一个原因。严格遵循本文所述的循证方案可预防大多数此类截肢。
分析了美国和欧洲四个主要糖尿病足项目中治疗神经性糖尿病足溃疡患者的集体经验。
为糖尿病足溃疡患者制定了以下方案：（1）患者、伤口愈合团队和初级医生之间建立良好沟通；（2）对整个患者进行全面的、方案驱动的护理，包括糖化血红蛋白、微量白蛋白尿和胆固醇，以及视网膜病变、肾病和心脏病的早期治疗；（3）每周用数码摄影、平面测量法对伤口进行客观测量，并使用伤口电子病历（如有）记录伤口愈合过程；（4）客观评估下肢血流（如无创血流研究）；（5）清除角化过度、感染和无活力的组织；（6）对深部感染、引流和蜂窝织炎使用全身性抗生素；（7）减轻负荷；（8）保持伤口床湿润；（9）如果按照该方案治疗3周后伤口仍未愈合，则使用生长因子和/或细胞疗法；（10）考虑对复杂伤口使用负压辅助治疗。
在糖尿病足溃疡中，上述治疗方法的可用性，结合早期识别和综合治疗，可确保快速愈合，将发病率和死亡率降至最低，并在不存在缺血和骨髓炎的情况下避免脚趾和肢体截肢。
