Attention of application of NPWT in Diabetic Foot Ulcer · 2015-03-02 · Application of NPWT in...
Transcript of Attention of application of NPWT in Diabetic Foot Ulcer · 2015-03-02 · Application of NPWT in...
Application of NPWT in Diabetic Foot Ulcer
이대목동병원 성형외과 서현석
서울아산병원 성형외과 홍준표
Session 4 : Management of Diabetic Foot Ulcer in Plastic Surgery
NPWT
• 효과
• 편리성
• 당뇨발에서 적응증
• 당뇨발 환자에서의 팁과 주의사항
• 사용례
• 2012.12 부터 보험 적용 시작 (국민건강보험 요양급여의 기준)
Mechanical stimulus Chemical activity
Mechanical stimulus Chemical activity
• Human studies
– inflammatory response locally
• angiogenesis (via VEGF)
• cell recruitment (via IL-8)
• reduced metalloproteinase expression
효과
Reduce edema
Adaquate moisture Promote granulation formation
Stimulation of cell proliferation : fibroblasts , endothelial cells and vascular smooth muscle Removal of healing inhibitors (MMP)
Reduction in bacterial wound burden
편리성
• 드레싱 횟수 줄여준다.
당뇨발에서 언제 사용?
• 당뇨발 환자에서 NPWT는 다른가?
• -125mmHg continuous?
Pressure Mode
Ann Plast Surg 1997;38:553-562
• Blood flow study
-125mmHg
Wound size reduction
• 음압창상치료는
– 내용물을 다 빨아들이고 있는가?
• 우리 팔에 NPWT를 적용해보면?
– 살이 빨려나가는 느낌일까?
– 압박 받는 느낌일까?
Direct suction
Soft cover tube Hard cover syringe
In NPWT
Soft cover tube
In NPWT
Hard cover syringe
Positive Pressure under NPWT !!!!
• 두 개의 차이는 무엇인가?
Non-circumferential apply +2~10mmHg (-150mmHg NPWT)
Circumferential apply +10~40mmHg (-150mmHg)
‘Positive Pressure’ compress the vessel under ‘NPWT’
• Normal capillary perfusion pressure
– 10~35mmHg
• In severely compromised perfusion area
– Lower than 10mmHg
High Compression pressure may cause tissue ischemia in CLI
Non-circumferential apply +2~10mmHg (-150mmHg NPWT)
Circumferential apply +10~40mmHg (-150mmHg)
Negative pressure in microenvironment !
400~600㎛
• But grossly NPWT is Possitive Pressure Wound Therapy!!!
• High Compression pressure may cause tissue ischemia in CLI.
• NPWT can cause further Necrosis in Ischemic Wound.
• How low is low?
Low pressure No effect Maceration
High pressure Ischemia
-80 mmHg as bad as -125 mmHg
• Does Lower pressure have an effect?
-50 mmHg
• Is low pressure effective in mechano- cheminal transduction?
Mechanical Stimulation Chemical, Hormonal Activity
at -30 mmHg 50 % Half-maximum (50 %) wound surface area reduction(mechanical stimulus)
• Indivisualizing Pressue Setting….
• Indivisualizing Pressue Setting
by Skin Perfusion Pressure
Just proximal to the wound
Using Laser doppler, pressure cuff
Monitoring pressure in which blood flow initiates
More like toe-pressue (rather than TCPO2)
<30 indicated CLI
High Compression pressure may cause tissue ischemia in CLI
Non-circumferential apply +2~10mmHg (-150mmHg NPWT)
Circumferential apply +10~40mmHg (-150mmHg)
Compression pressure < SPP(Skin perfusion pressure)
Indivisualizing Pressue Setting
• Lower the pressure as low as the compression effect of NPWT is lesser than Skin perfusion pressure (SPP)
• -50 mmHg NPWT in skin perfusion pressure of 20~30mmHg • in lower skin perfusion? Use cyclic/intermittent mode
• Adverse effect of Lower pressure?
– Lower pressure means…
• less power to compress the sponge
more space in sponge for exudates
more change of maceration
Tips
connector on dependent position
예 1)
• DM foot with severe infection
서울아산병원 홍준표교수님사진
예2)
• 당뇨병성 족부병변 치료 과정에서의 훌륭한 드레싱 방법.