| Skin,as the largest organ in the body,plays an important role in protecting and regulating the environment and excreting metabolites.Burn is a common traumatic disease in surgery.Burn patients,especially those with deep burn,face many complex situations in the course of treatment.The most important problem is wound healing.Choosing the appropriate treatment strategy to treat the necrotic tissue of the wound is of great significance to improve the healing efficiency of deep burn wound,reduce the formation of scar and improve the prognosis of burn patients.Dermabrasion or tangential excision of eschar is a common surgical debridement method for deep burn patients at present,but the comparative study of the two methods in clinical application is extremely limited.There are still many disputes among scholars about the scope of the two surgical methods,the effect of improving wound healing and prognosis.In addition,there is no comprehensive evaluation study on the safety of dermabrasion in shock stage for patients with extensive deep burn.Therefore,it is urgent to adopt the combination method.Rational clinical research evaluates the applicability of the two methods and provides reference for their standardized use in the future.Because of the loss of body fluid,the decrease of effective blood volume and the obvious change of blood circulation in the patients with large area burn,the treatment of large area tangential excision in the early stage after injury will theoretically affect the whole body blood flow including hemodynamics,hemorheology,tissue microcirculation and wound healing.Therefore,in the study of the effects of different treatment schemes on hemorheology,local microcirculation and wound healing,the large area deep partial-thickness burn patients with an area of more than 30%TBSA are better research objects.However,in the study of the effects of different treatment schemes on the ecological tissues between local wounds,our previous experimental results show that the burn area of patients has no significant impact on the experimental results.Due to the limitation of clinical experimental conditions,when we study the effects of different treatment schemes on the ecological tissue and wound healing and other indicators,we choose the deep partial-thickness burn patients whose area is between 10%TBSA and 30%TBSA as the research objects.In the study of the influence of different treatment schemes on hemorheology,local microcirculation and wound healing,the patients with large area deep second degree burn between 30%TBSA and 50%TBSA were selected as the research objects.In this study,we selected deep partial-thickness burn patients with different burn areas who were treated with dermabrasion,tangential excision of eschar or conservative treatment strategies as the research objects.The hemorheological indexes,microcirculation indexes of wounds at different time after treatment,the state of ecological tissue between wounds and the effectiveness of wound healing were discussed in order to make clear.There are differences in the application of three therapeutic strategies in the treatment of deep burn.This study provides a reference for the application of three therapeutic strategies in the treatment of deep burn in the future.It also provides a basis for the rationality of extensive dermabrasion in shock stage.Objective:1.To make comparison of the impacts of dermabrasion,tangential excision of eschar and eschar reserving on the ecological organization of deep partial-thickness burn wound.2.To clarify the effects of dermabrasion,tangential excision of eschar or conservative treatment on hemorheology,microcirculation and prognosis of large area deep partial-thickness burn patients,and to preliminarily explore the rationality of dermabrasion in shock stage of large area deep burn patients from the above indicators.3.To explore the effect of dermabrasion on wound healing and microcirculation in rats with deep partial-thickness scald.Methods:1.Objectives 1:Ninety patients with deep partial-thickness burn,whose area ranged from 10%TBSA to 30%TBSA,were randomly divided into three groups:A,B and C,30 cases in each group.The wounds of the three groups were treated by dermabrasion,tangential excision of eschar and conservative dressing change.2.Shock index method was used to compare the shock degree of three groups.Thigh circumference was measured at admission,Id,3d and 5d after treatment in three groups.Non-burn tissues adjacent to eschar were taken from the three groups for 2,5,8 and 10 days.The positive rates of bacterial culture in tissue homogenate were calculated for 2,5,8 and 10 days after treatment in the three groups.Digital pain intensity scale was used to evaluate and record the pain scores of 1,3 and 5d after treatment in the three groups.HE staining was used to observe the histopathological characteristics of wound healing in group A,B and C.The contents of IL-6 and IL-8 in wound exudates were measured before operation,1,3 and 7 days after operation.The average dressing change times,hospitalization days and wound healing rate at 14 days were counted.3.Objectives 2:58 patients with deep partial-thickness burn between 30%TBSA and 50%TBSA admitted from January 2013 to January 2017 were randomly divided into group A(20cases),group B(20cases)and group C(18cases).The wounds of the three groups were treated by dermabrasion,tangential excision of eschar and conservative dressing change.4.The degree of shock at admission was recorded and the amount of fluid infusion during perioperative period was counted.The wound healing time of the three groups was compared.The hemorheological indexes were measured by hemorheological analyzer before operation,Id,3d and 7d after operation.The microcirculation blood perfusion of wound surface was measured by laser Doppler microcirculation imager before operation,1 d,3d and 7d after operation in the three groups.5.The rat model of deep partial-thickness scald was established by hot water scald method.The wound appearance was observed and recorded after dermabrasion.The healing percentage and eschar removal rate were calculated at 3,7 and 14 days.The pathological changes of wounds at different time points were observed by HE staining.The expression of CD31 in microvessels of wounds was detected by immunohistochemistry.Microvessel density was calculated.and compared.Results:1.There was no significant difference in shock index between the three groups(P>0.05).There was no significant difference in leg circumference between the three groups at 1 day after operation.The changes of leg circumference in the dermabrasion group(group A),tangential excision of eschar group(group B)and the conservative dressing change group(group C)were(1.49±0.51)cm,(1.56±0.76)cm and(1.68±0.59)cm,respectively.The mean change of leg circumference was(5.12±1.24)cm in group A after 3 days of treatment.Compared with 1d after operation,the leg circumference of group A decreased at 3d,suggesting that the swelling degree of wound was reduced.The mean changes of leg circumference in tangential excision of eschar group(group B)and non-surgical conservative dressing change group(group C)were(3.98±1.16)cm and(2.68±1.65)cm,respectively.Compared with the dermabrasion group(group A),the changes of leg circumference in tangential excision of eschar group(group B)and non-surgical conservative dressing change group(group C)were smaller,and the results were statistically significant.(P<0.05);After 5 days of treatment,the mean changes of leg circumference were(7.89±1.76)cm in group A,(6.33±1.09)cm in group B and(2.90±0.93)cm in group C,respectively.Comparing the results of the three groups,it can be seen that the wound swelling degree of the three groups has been improved in varying degrees after treatment,especially in the dermabrasion group(Group A)and the tangential excision of eschar group(Group B),and the leg circumference of the dermabrasion group(Group A)is significantly better than that of the tangential excision of eschar group(Group B)and the conservative dressing change group(Group C)(P<0.05).2.The pain index was evaluated by digital pain intensity scale on the 1st,3rd and 5th day after operation in three groups.The results showed that the pain scores of group A,B and C at the 1st day after operation were(8.87±1.04),(9.02±0.89)and(8.76±1.01),respectively.There was no significant difference among the three groups(P>0.05).Compared with 1 day after treatment,the pain scores of the three groups decreased in varying degrees on the 3rd and 5th day after operation,suggesting that the degree of wound pain was alleviated after treatment,but there was no significant difference among the three groups(P>0.05).3.Histological changes of wounds were observed by HE staining before and 14 days after operation in three groups.The results showed that A,C and E were the tissue structure of wounds before operation.Under light microscope,the changes of wound tissue accorded with the characteristics of deep partial-thickness burn wounds Hyperemia and edema could be seen in the subeschar tissue,and the skin from epidermis to dermal reticular layer was damaged,but the deep dermis and the skin in it were damaged.The deep structure of the appendix(hair follicle,sweat gland,sebaceous gland,etc.)is still alive.The fibrillary structure of the necrotic dermis disappears,and the collagen fibers swell and fuse.Occasionally,"leukocyte infiltration zone" can be seen between the necrotic layer and the surviving tissue.On the 14th day after operation,the epidermis structure of the patients in group A was relatively complete,with thicker stratified epithelium,more skin appendages and less inflammatory cell infiltration.In group B,the epidermis of the patients in group B was keratinized obviously,and the stratified epithelium was thinner.A small number of skin appendages such as hair follicles,sweat glands and sebaceous glands could be seen,which were also distributed with grinding.Compared with group A,there were a large number of inflammatory cells infiltration in the tissues of group B.In group C.the epidermis structure was incomplete and the epidermis keratinized seriously.There were only a few epithelial cell clusters in the patient's tissues.There were no skin appendages such as hair follicles,sweat glands and sebaceous glands.At the same time,a large number of inflammatory cells infiltrated into the epidermis.Comparing the wound tissue structure of the three groups after operation,it can be seen that the wound structure of group A is the most complete,while that of group C is the worst,and the degree of inflammatory cell infiltration is the most serious4.The levels of IL-6 in wound exudates of patients in the preoperative dermabrasion group,tangential excision of eschar group and conservative treatment group were(0.13±0.02)pg/ml,(0.15±0.04)pg/ml and(0.15±0.05)pg/ml,respectively On the 3rd day after operation,the levels of IL-6 in the three groups increased to(0.27±0.04)pg/ml,(0.26±0.04)pg/ml and(0.25±0.05)pg/ml.On the 7th day after operation,the IL-6 content of wound exudates in the dermabrasion and tangential excision of eschar groups decreased,and there was a significant difference with that in the conservative treatment group(P<0.05)5.The levels of IL-8 in wound exudates of patients in the preoperative dermabrasion group,the tangential excision of eschar group and the conservative treatment group were(0.50±0.12)pg/ml,(0.47±0.08)pg/ml and(0.47±0.11)pg/ml,respectively.At 3 days after operation,the levels of IL-8 in the dermabrasion group and the tangential excision of eschar group showed an increasing trend,which were(0.72±0.16)pg/ml and(0.79±0.20)pg/ml,respectively,while those in the conservative treatment group were(0.79±0.20)pg/ml.The level of IL-8 in wound exudates of patients in the treatment group did not change significantly.At 7 days after operation,the IL-8 content of wound exudate in the dermabrasion and tangential excision of eschar group was more stable than that in the 3 days after operation,and its level was significantly higher than that in the conservative treatment group(P<0.05)6.Quantitative culture of bacteria in tissue homogenate was used to analyze the bacterial clearance of wounds after operation.The results showed as shown in Figure 1-10.The total bacterial counts of adjacent non-burn tissues in group A,B and C 2 days after operation were(100.3±5.32)CFU/g,(108.6±4.96)CFU/g and(151.6±8.16)CFU/g,respectively.On the 5th day after operation,the total bacterial count of the adjacent non-burn tissues in group A,B and C were(72.9±3.12)CFU/g,(104.9±4.12)CFU/g and(125.8±7.07)CFU/g,respectively.On the 8th day after operation,the total bacterial count of the adjacent non-burn tissues in group A,B and C were(46.5±2.42)CFU/g,(64.9±3.03)CFU/g and(76.9±1.58)CFU/g.The total number of bacteria in subeschar adjacent non-burn tissues of group A,B and C at 10 days after operation was(34.7±1.02)CFU/g,(49.5±1.14)CFU/g and(56.9±0.84)CFU/g,respectively Comparing the total bacterial count in the adjacent non-burn tissues under eschar of the three groups at different time points after treatment,it can be seen that the total bacterial count in the tissues of each group showed a decreasing trend with the continuation of treatment time,and the total bacterial count in the dermabrasion group(group A)was significantly lower than that in the tangential excision of eschar group(group B)and the conservative dressing changing group(group C)patients(P<0.05),suggesting that dermabrasion treatment has a better effect on bacterial clearance of wound tissue.7.The wound healing time of patients with three treatment strategies was recorded The results showed that the wound healing time of patients treated with dermabrasion or tangential excision was 5-9 days earlier than that of non-operation group.The difference was statistically significant,suggesting that the effect of dermabrasion and tangential excision was better than that of conservative treatment strategy.Comparing the wound healing time of dermabrasion group(group A)and tangential excision of eschar group(group B),it can be seen that dermabrasion treatment can significantly shorten the wound healing time of patients,suggesting that dermabrasion can promote the wound healing of patients compared with tangential excision treatment.The wound healing rates of group A,B and C at 14 days after operation were(82±12)%?(53±9)%?(42±6)%,respectively.The results showed that the wound healing rate of group A was significantly higher than that of group B and group C at 14 days after operation(P<0.05)8.The average hospitalization time of group A,B and C was(21.3±3.56),(26.5±4.16)and(32.9±7.91).Compared with tangential excision of eschar group,the hospitalization time of tangential excision of eschar group was shortened by 5-9 days,with significant difference(P<0.05).Compared with the three groups,the average times of dressing change in group A,B and C were(6.12±0.98),(11.3±1.34)and(15.2±2.97),respectively.It can be seen that the times of dressing change in group A,B and C were significantly reduced(P<0.05).9.Included in the study,all burn patients showed shock in different degrees at admission,and there was no significant difference in hypovolemic shock among the three groups at admission(P>0.05).The average plasma rehydration volume of dermabrasion group and tangential excision of eschar group patients were(2.21±0.57)ml/kg·d and(2.45±0.53)ml/kg·d,respectively.There was no significant difference between the two groups.The volume of plasma rehydration in the conservative treatment group was(2.89±0.38)ml/kg·dl.Compared with the scab group,the volume of plasma rehydration in the conservative treatment group increased significantly,(P<0.05).The healing time of dermabrasion group was significantly shorter than that of tangential excision of eschar group and conservative group(P<0.05)10.The plasma viscosities of the dermabrasion group,the tangential excision of eschar group and the conservative treatment group were(2.57±0.56)mPa.s,(2.48±0.47)mPa.s and(2.64±0.49)mPa.s,respectively.Compared with the normal population,the plasma viscosity of the patients with extensive burn increased significantly.The plasma viscosity of the three groups continued to increase at 1 day after operation.The plasma viscosity of the three groups decreased in varying degrees until 3 days.At 7 days,the plasma viscosity of the dermabrasion group and the tangential excision of eschar group decreased significantly compared with the conservative treatment group.Compared with the normal population,the platelet adhesion rate of the three groups increased significantly,and the level of platelet adhesion decreased in varying degrees after operation,but there was no significant difference in the platelet adhesion rate between the three groups on the 1st,3rd and 7th day after operation.In this study,we measured the specific volume of erythrocyte,erythrocyte sedimentation rate and erythrocyte rigidity index in three groups.The results showed that the specific volume of erythrocyte and erythrocyte rigidity index in three groups increased significantly before operation,while the erythrocyte sedimentation rate decreased significantly compared with the normal population.The three groups were observed from 1 to 7 days after operation.Erythrocyte specific volume and erythrocyte rigidity index decreased while erythrocyte sedimentation rate increased after operation.Compared with the results of three groups,the improvement of erythrocyte specific volume and erythrocyte rigidity index in dermabrasion group and tangential excision of eschar group was significantly better than that in conservative treatment group.The blood fibrinogen levels of the three groups were also measured.As shown in Fig.2-4,the blood fibrinogen levels of the three groups before operation were(2.03±0.84)g/L,(2.18±0.45)g/L and(2.34±0.79)g/L,respectively.Compared with the normal population,the levels of fibrinogen in blood of the three groups were significantly lower.On the 1st day after operation,the levels of fibrinogen in the three groups were(1.89±0.67)g/L,(1.70±0.47)g/L and(1.90±0.79)g/L,respectively.Compared with those before operation,the levels of fibrinogen in the three groups decreased in different degrees on the 1st day after operation.The fibrinogen content in the three groups increased to(3.56±1.21)g/L,(4.06±0.87)g/L and(4.90±1.16)g/L on the 3rd day.By the 7th day,the fibrinogen content in the dermabrasion and dermabrasion groups had basically reached the normal level,while the fibrinogen content in the conservative treatment group was significantly higher than that in the dermabrasion and dermabrasion groups on the 7th day11.In this study,we measured the MPV of wound surface in three groups to evaluate microcirculation.There was no significant difference in MPV between the three groups before treatment.The MPV values of wound surface in three groups were(1.89±0.23)V,(2.16±0.33)V and(1.79±0.21)V at the first day of treatment,respectively.Compared with those before treatment,MPV of the three groups had no significant difference.The MPV values of the three groups increased in varying degrees at 3 days,especially in the dermabrasion and tangential excision of eschar groups,and the improvement of wound microcirculation in the dermabrasion group was significantly better than that in the tangential excision of eschar group.At 7 days,the MPV values of the three groups increased to(5.31±0.61)V,(3.82±0.34)V and(2.97±0.31)V.The MPV values in the dermabrasion group were significantly higher than those in the conservative treatment group and tangential excision of eschar group12.The rats in each group were sensitive and active to the sound stimulation after the model was established;fecal water intake was less than the adaptation period in the first three days after injury;stool color and hardness were normal,and no obvious diarrhea symptoms were observed;no obvious papules,rashes and allergies were observed in the normal skin around the wound;and no significant abnormal changes in body weight and temperature were observed in each group13.The back of the sham injury group was normal skin without obvious changes On the 3rd day after injury,there were a few black spots on the wound surface in the scald+dermabrasion group,but no exudation.Most of the wounds in the scald group were black,and some of them formed eschar,and a little exudation.On the 7th day after injury,dry scab was formed in scald+dermabrasion group,and the wound was smaller than before.In scald group,there was still a little exudation of eschar,which was slightly reduced and blackened.On the 14th day after injury,the wounds in scald+scald+ scab group were obviously reduced,dry and no exudation.The wounds in scald group were blackened and the scab was slightly reduced,but there were still large black necrosis defects,which were fused into pieces and a few purulent secretions around the necrotic wounds14.On the 3rd day after injury,there was no significant difference in the rate of scab removal between scald group and dermabrasion group.On the 7th and 14th days,the rate of scab removal in dermabrasion group was significantly higher than that in scald group(P<0.05),while there was no significant change in sham scald group15.On the 3rd day after injury,there was no significant difference in wound healing rate between scald group and dermabrasion group.On the 7th and 14th days,the wound healing rate of dermabrasion group was significantly higher than that of scald group(P<0.05),while there was no significant change in sham scald group16.There was no obvious neovascularization in the sham scald group.On the 3rd day after injury,there were more vascular endothelial cells and neovascularization in the deep partial-thickness scald model group,but the size was uneven.The microvascularization in the scab-grinding group was regular and closely arranged.On the 7th day after injury,the neovascularization and epithelial tissue in the dermabrasion group were mature,and the size and distribution of neovascularization were uniform.In the scald model group,neovascularization endothelial cells and microvascularization were observed,which were numerous but disorderly arranged 14 days after injury,most of the neovascularization in dermabrasion group were well-organized and evenly distributed.In scald model group,a large number of neovascularization,irregular shape,uneven distribution and large diameter were observed.Compared with scald model group and dermabrasion group,MVD in both groups showed an upward trend with time,but at 7 and 14days after injury,MVD in dermabrasion group was significantly higher than that in scald group(P<0.05).Conclusions:1.This study explored the application of dermabrasion,tangential excision and conservative treatment in the treatment of deep partial-thickness burn wounds.Compared with tangential excision and conservative treatment,early dermabrasion can effectively alleviate local inflammation,improve the degree of tissue edema around the wound and reduce the microgenesis of the wound.Infection,promote the process of epithelialization.2.Early dermabrasion treatment for deep partial-thickness burn can remove necrotic tissue sufficiently,reduce wound damage,promote wound healing,shorten wound healing time and improve wound healing quality.3.The changes of hemorheology and microcirculation of wound surface can be seen in patients with large area burn,which are manifested by the increase of plasma viscosity,the decrease of erythrocyte deformability and the risk of thrombosis.4.Surgical treatment of dermabrasion and tangential excision can improve the hemorheological indexes of burn wounds to a certain extent,and its effect is better than that of conservative treatment.5.Both dermabrasion and tangential excision can improve the local microcirculation disturbance of large area burn wound,and the effect of dermabrasion is better than that of tangential excision,which may be related to the mechanical friction process of dermabrasion.It also suggests that large area dermabrasion is feasible in shock stage.6.Obvious disturbance of microcirculation of wound surface after deep partial-thickness scald may be an important cause of early wound deepening in rats;dermabrasion can significantly improve microcirculation of wound surface in deep partial-thickness scald rats,promote microangiogenesis,improve wound prognosis and accelerate wound healing. |
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