本文選題：燒傷　切入點：超聲檢查　出處：《山東大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：研究背景:深Ⅱ度燒傷目前仍是燒傷外科治療的重點及難點,保守治療因需多次換藥,不同程度增加患者的疼痛,并且創(chuàng)面易感染加深,勉強愈合會增加瘢痕的發(fā)生率,影響外觀及正常生理功能。磨痂術(shù)是近十幾年來燒傷外科新開展的治療方法,可以有效去除壞死組織,保留間生態(tài)組織,促進(jìn)創(chuàng)面愈合,縮短病程。因真皮層的厚度不一,故深Ⅱ度燒傷的深淺也不一,淺的接近淺Ⅱ度,深的則臨界Ⅲ度。已有研究表明,Ⅱ度燒傷診斷的準(zhǔn)確率為50%～60%。由此增加了臨床醫(yī)師判斷是否可行磨痂術(shù)的難度,過深行磨痂術(shù)會增加手術(shù)難度,降低手術(shù)成功率,壞死組織無法完全磨除。目前許多輔助診斷設(shè)備已經(jīng)在文獻(xiàn)中報道,例如超聲,激光散斑成像,數(shù)字熱成像,超聲彈性成像,激光多普勒血流量計和組織分光光度測定法,動態(tài)熱成像技術(shù)等。然而,這些儀器還沒有被廣泛應(yīng)用于臨床研究中。在20世紀(jì)70年代超聲被廣泛應(yīng)用于醫(yī)學(xué)領(lǐng)域。Goans等人在動物試驗中的研究結(jié)果表明:超聲可以作為一種定量的方法應(yīng)用于燒傷的評估。該研究是用超聲檢測以分辨凝固性壞死層與剩余的有活力真皮層的分界,還檢測了真皮深層與皮下脂肪的分界,對剩余的有活力真皮層進(jìn)行了測量�；谶@一研究,Kalus等人應(yīng)用了分辨率為5MHz的超聲,對兩位燒傷患者,進(jìn)行了愈合時間和切痂手術(shù)的研究。隨后,超聲作為一種無創(chuàng)、方便的檢測方法,被許多學(xué)者用于燒傷深度診斷的動物模型研究中。隨著科技的進(jìn)步,超聲的頻率不斷優(yōu)化,頻率為10MHz和18.5MHz的超聲應(yīng)用于人體皮膚疾病的研究,例如對黑色素瘤和銀屑病的研究。高頻超聲由于具有低穿透性和高精確性的特點,因此成像頻率大于15 MHz的高頻超聲目前應(yīng)用于觀察皮膚不同層次的解剖和組織結(jié)構(gòu)學(xué)特征,也廣泛應(yīng)用于各種皮膚疾病的輔助診斷中。成像頻率大于20 MHz的高頻超聲具有更好的圖像分辨率,用于表淺組織結(jié)構(gòu)的檢測。目前對燒傷深度的診斷大部分主要依靠有經(jīng)驗醫(yī)師主觀上的判斷,以病理組織學(xué)檢查作為燒傷深度診斷的金標(biāo)準(zhǔn),具有區(qū)域局限性和創(chuàng)傷性且耗時較長,耽誤最佳手術(shù)時期。高頻超聲可以從影像學(xué)角度省時無創(chuàng)地為深Ⅱ度燒傷初步診療方案的制訂提供客觀依據(jù),判斷磨痂術(shù)的可行性。研究目的:探討高頻超聲在深Ⅱ度燒傷患者磨痂術(shù)中的應(yīng)用,研究深Ⅱ度燒傷患者創(chuàng)面磨痂術(shù)前后皮膚組織結(jié)構(gòu)和血流信號變化及其與愈合時間的關(guān)系,以期為磨痂術(shù)在臨床的應(yīng)用提供客觀的影像學(xué)依據(jù)。研究方法:2015年3月—2016年3月,筆者單位收治符合入選標(biāo)準(zhǔn)的住院治療的26例深Ⅱ度燒傷患者,均在全身麻醉下行磨痂術(shù)。采用22.0 MHz高頻超聲檢測患者磨痂術(shù)前健側(cè)正常皮膚、創(chuàng)面,術(shù)后即刻及術(shù)后1、3、5、7、10、14、21d創(chuàng)面皮膚組織結(jié)構(gòu)和彩色多普勒血流信號。根據(jù)術(shù)前創(chuàng)面彩色多普勒血流信號百分比與正常參考值的對比結(jié)果,分為血流信號無明顯降低組19例和明顯降低組7例。記錄2組患者創(chuàng)面愈合時間。對數(shù)據(jù)行重復(fù)測量方差分析、LSD檢驗、t檢驗和χ 2檢驗,對26例患者術(shù)前創(chuàng)面血流信號百分比和愈合時間行Spearman相關(guān)性分析。研究結(jié)果:(1)2組患者術(shù)前正常皮膚高頻超聲圖像示表皮層呈連續(xù)平滑線狀強回聲,真皮層回聲低于表皮層,真皮-皮下分界呈較真皮層強的不連續(xù)線狀回聲,逐漸過渡到皮下組織。無明顯降低組,術(shù)前深Ⅱ度燒傷創(chuàng)面表皮層呈連續(xù)性中斷的不光滑線狀回聲,回聲低于正常表皮層,真皮-皮下組織分界未見明顯異常。術(shù)后即刻表皮層完全脫失,未見表皮層線狀強回聲,真皮及皮下回聲較術(shù)前未見明顯改變,真皮層表面平整,伴有真皮淺層部分磨失,但真皮組織總體保存較完好。術(shù)后3 d、5 d可見表皮層呈不連續(xù)線狀強回聲。術(shù)后7 d、10 d可見部分連續(xù)表皮層,呈部分連續(xù)線狀強回聲。術(shù)后14 d,再生的表皮層厚于正常表皮層且呈不光滑線狀強回聲,厚度不均勻。術(shù)后21 d,再生的表皮層厚于正常表皮層呈較光滑線狀強回聲,厚度較均勻。明顯降低組,術(shù)前及術(shù)后即刻深Ⅱ度燒傷創(chuàng)面表皮層和真皮層組織結(jié)構(gòu)與無明顯降低組大體相似,但真皮-皮下組織分界回聲呈不同程度降低。術(shù)后3 d、5 d,未見表皮層線狀強回聲。術(shù)后7 d、10 d可見不連續(xù)表皮層再生,呈不連續(xù)線狀強回聲。術(shù)后14 d,可見部分連續(xù)表皮層再生,呈部分連續(xù)線狀強回聲。術(shù)后21 d,仍未見完全連續(xù)表皮層線狀強回聲。(2)無明顯降低組血流信號百分比在術(shù)前、術(shù)后即刻、術(shù)后1 d分別為(3.1±1.3)%,(6.5±2.0)%,(5.3±1.9)%高于明顯降低組(0.9±1.1)%,(3.5±1.3)%,(3.6±0.9)%(P0.05或P0.01),2組患者其余時相點血流信號百分比相近(P值均大于0.05。與組內(nèi)正常參考值(3.2±0.7)%比較,無明顯降低組在術(shù)后即刻、術(shù)后1d血流信號百分比明顯升高(P值均小于0.01),術(shù)后3d起各時相點血流信號百分比無明顯變化(P值均大于0.05)。明顯降低組術(shù)前血流信號百分比為(0.9±1.1)%明顯小于正常參考值(2.8±0.6)%(P0.01),術(shù)后即刻起各時相點血流信號百分比與正常參考值相近(P值均大于0.05)。無明顯降低組創(chuàng)面愈合時間為(16.2±2.5)d,短于明顯降低組的(30.9±2.9)d(t=12.67,P0.01)。26例患者術(shù)前創(chuàng)面血流信號百分比與愈合時間呈負(fù)相關(guān)(r=-0.77,P0.01)。研究結(jié)論:高頻超聲可較好地觀察深Ⅱ度燒傷磨痂術(shù)前后超聲影像學(xué)特點,為深Ⅱ度燒傷行磨痂術(shù)的臨床研究提供了客觀的影像學(xué)依據(jù)。
[Abstract]:Background: the current focus and difficult treatment of burn surgery is still the deep second degree burn, conservative treatment due to multiple dressing, different degrees of increase the patient's pain, and wound infection deepened, barely healing will increase the incidence of scar, affecting the appearance and normal physiological function. Dermabrasion treatment in recent years burn carry out new surgery, can effectively remove the necrotic tissue, preserving ecological organization, promote wound healing, shorten the course. Because of the thickness of the dermis is not the same, so the deep second degree burn depth is not a close, superficial second degree shallow, deep third degree. The critical studies have shown that the accuracy rate of second degree burn the diagnosis is 50% ~ 60%., thus increasing the clinician to determine whether feasible Woundabrasion difficult, too deep for dermabrasion will increase the difficulty of operation, reduce the success rate of surgery, not completely removing necrotic tissue. At present, many auxiliary diagnosis set Preparation such as ultrasound has been reported in the literature, laser speckle imaging, digital thermal imaging, ultrasound elasticity imaging, laser Doppler blood flowmeter and spectrophotometry, the dynamic thermal imaging technology. However, these instruments have not been widely used in clinical research. Widely used in medical field study by.Goans et al. In the animal experiment results showed that in 1970s: ultrasonic evaluation of ultrasonic can be used as a quantitative method to burn. The study is by ultrasound to distinguish with boundary layer of the dermis activity of coagulation necrosis and residual layer, also detected boundaries and subcutaneous fat deep dermis, the remaining viable dermis the measurements were carried out. Based on this study, Kalus et al. Application of the 5MHz resolution of ultrasound, two burn patients were studied, and the healing time of excision surgery. Then, ultrasound As a noninvasive, convenient detection method, many scholars used to study the animal model of burn depth diagnosis. With the progress of science and technology, constantly optimize the ultrasonic frequency, the frequency of 10MHz and 18.5MHz ultrasound applied to human skin diseases, such as research on melanoma and high frequency ultrasound with psoriasis. Low penetrability and high precision characteristics, high frequency ultrasound imaging so frequency more than 15 MHz currently used in the observation of skin anatomy and histological structure of different levels of learning characteristics, auxiliary diagnosis is also widely used in various skin diseases. The broken image resolution high frequency ultrasound imaging has better frequency greater than 20 MHz, for detection shallow structure. At present the diagnosis of burn depth of the most experienced physicians rely mainly on subjective judgments, the histopathological examination as the gold standard in the diagnosis of burn depth, With regional limitations and traumatic and time-consuming, delay the best operation period. High frequency ultrasound can save time for noninvasive formulation of deep second degree burn in preliminary diagnosis and treatment provide an objective basis from the perspective of imaging, to judge the feasibility of dermabrasion. Objective: To investigate the application of high frequency ultrasonic grinding excision in patients with deep second degree study on the relationship between burn, deep second degree burn wound grinding changes skin structure and blood flow signals before and after excision and healing time, in order to provide an objective image of dermabrasion in clinical application basis. Research methods: March 2015 - March 2016, 26 cases of deep second degree burn patients hospitalized with hospitalization the inclusion criteria, were under general anesthesia dermabrasion. 22 MHz patients using high-frequency ultrasound dermabrasion before the contralateral normal skin, the wound immediately after surgery and postoperative 1,3,5,7,10,14,21d The skin tissue structure and color Doppler flow signal. According to the comparison results of preoperative wound color Doppler flow signal and the percentage of normal reference value of the divided flow signal did not significantly reduce the group of 19 cases and significantly reduced the group 7 cases. 2 groups were recorded. The wound healing time of the data row repeated measures analysis of variance, LSD test, t test and 2 test, 26 cases of patients with preoperative wound healing time and the percentage of blood flow signal by Spearman correlation analysis. Results: (1) 2 groups of patients with normal skin before high frequency ultrasound image shows the epidermal layer with smooth linear strong echo, echo below the epidermis dermis, the dermal subcutaneous boundary is dermal layer strong discontinuous linear echo, a gradual transition to subcutaneous tissue. No obvious reduction group, preoperative deep second degree burn wound epidermis showed discontinuity of smooth linear echo, echo is lower than that of normal skin The dermal layer, the subcutaneous tissue boundaries no obvious abnormalities. Immediately after the epidermis to complete depigmentation, no epidermis dermis and subcutaneous linear strong echo echo than before surgery was no significant change in the dermis with smooth surface, superficial dermal part lost, but the overall dermis is well preserved. After 3 D, 5 d the epidermis is not continuous linear strong echo. After 7 d, 10 d visible part of the epidermal layer is continuous, continuous linear strong echo. After 14 d, the thickness of epidermis regeneration in normal epidermis and a smooth linear strong echo, uneven thickness. After 21 d, epidermis regeneration the epidermal layer is thicker than the normal smooth linear hyperechoic, more uniform thickness. Group was decreased, the preoperative and postoperative deep second degree burn wound at the epidermis and dermis structure and did not significantly reduce the group generally similar, but the dermal subcutaneous tissue boundary echo showed different degrees of reduction 浣，

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