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.