대한족부족관절학회지 : 제 8 권제 1 호 2004 J Korean Foot Ankle Soc. Vol 8. No. 1. pp.26-30, 2004 국립의료원정형외과 Wall-Suction Assisted Vacuum Sealing for Treatment of Infected Diabetic Foot Ulcer Su-Young Bae, M.D., Chang-Wook Lee, M.D., In-Seock Seo, M.D. Department of Orthopaedic Surgery, National Medical Center, Seoul, Korea =Abstract= Purpose: The infected diabetic foot patients were reviewed to analyze the result of new dressing methods using a wall-suction instruments. Materials and Methods: Eighteen patients treated with wall-suction assisted vacuum dressing were included. After debridement under local anesthesia, a sponge pad, a drain, and a surgical drape were used to seal the wound. Negative pressure applied by the wall-suction at around 200 mmhg and dressing were repeated in every two to three days. The results of repeated wound cultures, growth of granulation tissues, and CRP level were closely observed on the regular basis. Results: Rapid growth of granulation tissues was noticed around the wound in 16 cases. No organism was obtained in an average 5 days and wound coverage was possible in an average 18 days. The CRP level returned to normal in an average 4 weeks. Two patients with end stage renal disease, who were regularly hemodialised, underwent major amputation. Conclusion: New dressing method has the following advantages: a rapid wound improvement in the patients with infected diabetic foot, less expensive, less painful, impediment of bacterial contamination in the hospital room. However, further study will be needed for the end stage renal disease patients. Key Words: Diabetic foot, Infected ulcer, Wall-suction assisted vacuum sealing Address for correspondence Su-Young Bae, M.D. 18-79 Ulchiro-6ga Jung-gu, Seoul, 100-799, Korea, Department of Orthopaedic Surgery, National Medical Center Tel:+82-2-2260-7198 Fax:+82-2-2278-9570 E-mail:osnmc@yahoo.co.kr * 본논문의요지는 2004 년도대한족부족관절학회춘계학술대회에서발표되었음. 서론당뇨발은당뇨환자의가장흔한합병증중하나로일생동안 15% 정도는당뇨성족부궤양을경험하게되고당뇨환자 1000명중 0.5명에서 5명정도는하지의절단 (major amputation) 을겪게된다 7). 더구나감염된당뇨병성족부궤양은환자의면역력저하와허혈, 혈류감소로인한항생 - 26 -
제투여효과저하로치료에어려움이따르며절단에이르게될위험이높다. 일단하지절단에이르게되면환자의가동력이떨어져여명단축과밀접한관계가있으므로감염성족부궤양에대한적극적인치료가강조되고있다. 여러새로운방법들이시도되고있으나실질적적용에는제한이따르며이미개발되어쓰이고있는 VAC (vacuum assisted closure) 장치는고가의장비구입과유지비가필요하여환자들에게실제로적용하는데한계가있다. 이에저자들은병실내벽매립형중앙흡인장치 (wall-suction) 를이용한창상의밀봉치료를고안하여족부궤양을치료하고그결과를보고하고자한다. 대상및방법 1. 대상 결과 1. 균배양검사초기의균배양검사에서는 18예중 16예에서 Staphylococcus aureus, Enterococcus fecalis, Proteus mirabillis, Klebsiela, Proteus vulgaris, Enterococcus coli 등다양한균이검출되었고이들중 6예에서는 2가지이상균주의혼합감염이확인되었다. 18예중 2예에서는육안적화농이뚜렷함에도불구하고균주가확인되지않았다. 병실내벽매립형중앙흡인장치 (wall-suction) 를이용한밀봉치료를시작한후 2일혹은 3일마다반복시행한균배양검사상평균 5.2일 ( 범위 : 3~7일 ) 만에균배양음성의결과를얻었고한번균배양검사음성의결과를얻은후에다시양성으로바뀐예는없었다. 본원에서 2002년도부터 2004년도 2월까지병실내벽매립형중앙흡인장치를이용해치료했던감염성당뇨병성족부궤양 21예 ( 남자 14예, 여자 7예 ) 중혈관조영검사상주혈관의폐색이관찰되는폐색성동맥경화증이같이있어혈관우회술을같이시행했던 3예를제외하였고, 육안으로화농성조직을확인하여감염성당뇨병성족부궤양으로뚜렷이구분되는 18예 ( 남자 13예, 여자 5예 ) 를대상으로하였다. 2. 육아조직의관찰 16예에서는평균 18일후에피부이식또는피판이식등이가능할정도로건강한육아조직이형성되었다 (Fig. 1). 2예에서는 1달이상관찰중건강한육아조직형성이관찰되지않아 1예에서는하퇴절단을, 다른 1예에서는대퇴절단을시행하였다. 2. 방법 3. CRP 수치의변화 모든환자에서는먼저창상의균배양검사를시행한후부분마취하에창상의변연절제술을시행하고출혈을유도한뒤소독된스펀지와배액관, 써지칼드레이프를이용하여창상을밀봉하였다. 스펀지는창상의모양과크기에맡게재단한후배액관을통과시키고창상을덮은뒤써지칼드레이프를이용하여밀봉하고배액관의끝은병실내벽매립형중앙흡인장치에연결하였다. 음압 200 mmhg 전후로유지하고 2일내지 3일마다세척과출혈유도후밀봉치료를반복하였다. 매번세척전에창상의육아조직형성을관찰하고균배양검사를반복시행하되균배양검사가연속하여음성으로보고되면균배양검사를중단하였다. 또한주 2회 CRP 검사를시행하였다. 균배양검사상음성으로판정되고건강한육아조직이궤양면적의전체를덮게되면분층식피술또는피판성형술을시행하여창상치유를완료하였다. 주 2회반복시행한 CRP 검사는하지절단을시행해야했던 2예를제외하고는평균 4주에정상화되었다. 하지절단을시행하였던 2예에서는절단술시행시점까지 CRP의정상화혹은급속한 CRP 수치의저하를관찰할수없었다. 고찰감염된당뇨병성족부궤양은주로혐기성균과호기성균의혼합감염으로심부농양을형성하고근막을따라빠르게전파되고, 허혈과대식세포의기능저하등면역력이저하되며신장기능저하로전신적항생제투여에반응이뚜렷하지않고혼합치료 (cocktail therapy) 가곤란하여치료에어려움이따른다 7,11). 이에당뇨성족부궤양치료에많은새로운방법들이개발되어시도되고있으나제한점들이있다. 산소고압치료 (hyperbaric oxygen therapy) 는장비의구비가필요하고합병증으로이통이나난청등이있어순응도가떨어지며 11), 성장인자 (growth factor) 는감염된당뇨 - 27 -
Figure 1. Photograph shows infected diabetic foot of 48-year-old man with large amount of pus (A). Sterilized sponge was cut out matched with the shape of the wound (B). After sealing with surgical drape the drain was connected with wall-suction line (C). Healthy granulation tissue was found after 18 days (D). 족에적용하기곤란하고 15), 유충 (larva) 을이용한치료는더연구가필요할뿐아니라국내에서는아직사용할수없다 13). 한편난치성창상치료에음압을이용하는방법이최근소개되어응용되고있으며 1,2,4,6,8-10,12,16,17) 이를당뇨병성족부궤양의치료에적용하고자하는노력이기울여지고있다 3,5). 이최신의치료방법은이미 VAC (vacuum-assisted closure, KCI, Sanantonio, USA) 이라는상품으로개발되어주로난치성급만성창상에쓰이고있으나고가의장비구비가필요하고역시고가의유지비가필요하여장기간치료가필요한당뇨병성족부궤양환자에서는실제로적용하기가어려웠다. 이치료방법의기본원리는창상변연에국소혈류를증가시키고세균의수를감소시키며육아조직의형성을돕는다는 Argenta 등의보고 1) 에근거를두고있어저자들은이원리를벗어나지않으면서도쉽게환자에적용할수있고비용이저렴한방법을고안하였다. 즉환자의입원병실내에존재하는벽매립형중앙흡인장치 (wallsuction) 를이용한창상의밀봉치료는결과에서드러나듯이빠른육아조직의형성과감염의억제를보여주는데이는 기존에창상치료에쓰여왔던습식드레싱등에서볼수없었던획기적인창상의호전을보여주면서도비용의부담이적고적용이쉬워 VAC에견줄만한결과로생각된다. 다만이연구에있어경제적인이유로 VAC과병행하여비교할수는없었던점, 당뇨병성족부궤양의특성상넓이와깊이, 감염의정도와파급범위, 혈류상태, 환자의전신상태등을모두고려하여체계적분석이나전향적연구가불가능한점등은한계라고할수있겠으나이런한계를고려하더라도임상적인결과는창상의개선이뚜렷하였다. Argenta 등 1) 의보고에서는급성창상에 125 mmhg의음압을, 만성창상에 175 mmhg의음압을적용하는것을권장하였고 Eginton 등 3) 과 Morykwas 등 9) 은 125 mmhg의음압환경에서혈류증가의효과가가장뚜렷하다고하였으나본연구에서는 wall-suction 으로정교한음압을유지하기어렵고감염된당뇨병성족부궤양의특성상감염의억제가중요한목표이며이전의음압적용보고와는달리이미당뇨병성혈관병증으로말초의허혈이진행된상태이므로대부분의환자가통증을느끼지않는최대음압을유지 - 28 -
하려하였다. 200 mmhg의음압을적용한것은대개의환자가실제로통증없이견딜수있는음압이면서저시력의환자라도배액관을자가로연결할때쉽게음압을재조절할수있기때문이었는데본연구에서기존의음압보다다소높은음압을적용하여좋은결과를얻은것으로보아당뇨병성족부궤양에적용하여최대의효과를볼수있는적절한음압의수위에대하여는차후추가의연구가필요할것으로사료된다. 평균 5일후에는균배양검사가음성화되었는데이는 1회내지 2회드레싱교체시이미감염이조절된다는것을의미한다. 하지만모든환자에서는전신적항생제투여를병행하였기때문에투약에의한것인지처치에의한것인지는구분할수없었다. 또한 2예에서는균주가배양되지않았는데 1예는타원에서항생제전신적투여및항생제를이용한습식처치상태였으며다른 1예에서는육안으로확인되는백색의농양을관찰할수있었는데도균주가확인되지않았다. 이연구에포함되었던 18예중 2예에서는창상의호전이없고 1달간관찰하여건강한육아조직이형성되지않았고 CRP 수치도뚜렷하게저하되지않을뿐아니라창상흡입물의양이줄지않았고지속적으로알부민투여가필요했는데이들은둘다말기신부전으로혈액투석을시행하고있던환자였다. 이두환자에서는혈액투석및항응고제사용으로혈액응고인자와성장인자등이결여되고면역력또한다른환자에비해현저히떨어지며흡인장치적용이오히려저알부민혈증을유도하여창상회복에어려움이있었던것으로보인다. 하지만 2예에불과하기때문에이들혈액투석환자에서병실내벽매립형흡인장치를이용한치료에관하여는추가의연구가필요할것으로사료된다. 또한이새로운치료는창상의회복이빠르고감염억제가쉬운것외에도부종이쉽게조절되고드레싱교체시통증을줄일수있으며, 창상분비물이스며나와병실을오염시키는것을막을수있고, 기존의고식적인방법에비해의료인력을줄일수있다는장점이있다. 더나아가병실의벽매립형흡인장치에준하는운반용흡인장치 14) 사용이가능해진다면입원치료기간을획기적으로줄일수있기때문에감염된당뇨병성족부궤양의치료에도움이될것으로사료된다. 요약감염된당뇨병성족부궤양의병실내벽매립형중앙흡인장치를이용한창상밀봉관리로빠른창상의호전을얻을 수있었다. 이창상관리방법은빠른창상의호전외에도비용을획기적으로줄일수있으며환자의동통을줄이고병실내세균전파의위험이적으며필요인력축소등의장점이있으나말기신장부전환자에서의적용은추가의연구가필요할것으로사료된다. REFERENCES 1. Argenta LC and Morykwas MJ: Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Annals Plast Surg, 38: 563-577, 1997. 2. Cro C, George KJ, Donnelly J, Irwin ST and Gardiner KR: Vacuum assisted closure system in the management of enterocutaneous fistulae. Postgrad Med J, 78: 364-365, 2002. 3. Eginton MT, Brown KR, Seabook GR, Towne JB and Cambria RA: A prospective randomized evaluation of negative-pressure wound dreesings for diabetic foot wounds. Annals Vasc Surg, 17: 645-649, 2003. 4. Emohare O, Kowal-Vern A, Wiley D and Latenser BA: Vacuum-assisted closure use in calciphylaxis. J Burn Care Rehabil, 25: 161-164, 2004. 5. Espensen E, Nixon BP, Lavery LA and Armstrong DG: Use of subatmospheric therapy to improve bioengineered tissue grafting in diabetic foot wound. J Am Pod Med Assoc, 92: 395-397, 2002. 6. Herscovici D, Sanders RW, Scaduto JM, Infante A and DiPasquale T: Vacuum-assisted wound closure for the management patients with high-energey soft tissue injuries. J Orthop Trauma, 17: 683-688, 2003. 7. Jeffcoate WJ and Harding KG: Diabetic foot ulcer. The Lancet, 301: 1545-1551, 2003. 8. Miller CQ, Bird ME, Bird K, Meschter C and Moulton CMJ: Effect of subatmospheric pressure on the acute healing wound. Curr Surg, 61: 205-208, 2004. 9. Morykwas M, Faler BJ, Pearce DJ and Argenta LC: Effects of varying levels of subatmospheric pressure on therate of granulation tissue formation in experimental wounds in swine. Annals Plast Surg, 47: 547-551, 2001. 10. Muller T, Mrkonjic L, Kwasny O and Vecsei V: The use of negative pressure to promote the healing of tissue defects: a clinical trial using the vacuum sealing technique. Br J Plast Surg, 50: 194-199, 1997. 11. Park TW, Cho SD, Cho YS, Kim BS, Lew SG and Kim MC: The treatment of hyperbaric oxygen treatment of diabetic foot ulcer. J Korean Foot Ankle Soc, 6: 35-39, 2002. 12. Scherer LA, Shiver S, Chang M, Meredith W and Owings JT: The vacuum assisted closure device. Am Med Assoc, 137: 930-934, 2002. 13. Sherman RA: Maggot therapy for treating diabetic foot - 29 -
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