背景:感染的手术伤口通常会被清创,因为临床医生认为去除坏死或感染的组织可能会加速伤口愈合。有许多可用的清创方法,但对于哪一种对手术伤口最有效尚无共识。
目的:评估不同清创方法对手术创面清创率和愈合的影响。
方法:在2021年10月,我们搜索了Cochrane伤口专业注册,中部,MEDLINE,Embase,和CINAHL。为了确定更多的研究,我们在临床试验登记处搜索正在进行的和未发表的研究,以及相关纳入研究的扫描参考清单,reviews,荟萃分析,和健康技术报告。语言没有限制,发布日期,或学习设置。
方法:我们纳入了随机对照试验(RCT),纳入了需要清创的手术伤口患者,并报告完成伤口清创的时间或伤口愈合的时间,或者两者兼而有之。
方法:两位综述作者独立进行研究选择,使用RoB1工具评估偏差风险,数据提取,和证据确定性的等级评估。
结果:在第四次更新中,我们确定了另外一项纳入研究.审查现在包括六项研究,265名参与者3岁至91岁。在1979年至1990年之间发表了五项研究,在2014年发表了一项研究。这些研究是在中国的医院环境中进行的,丹麦,比利时,和英国。六项研究提供了六项比较。由于研究的异质性,进行荟萃分析是不合适的.四项研究评估了右旋聚体珠/糊的有效性;然而,每个研究都使用了不同的比较器(Eusol浸泡的敷料,10%水性聚乙烯吡咯烷酮,0.1%氯胺浸泡包装,和有机硅泡沫弹性体敷料)。一项研究比较了链激酶/链脲酶与盐水浸泡的敷料,其中一项比较了内镜手术清创术与传统的“开放式”手术清创术。五项研究报告了完成清创的时间(报告为清洁伤口床的时间),三项报告了完成愈合的时间。一项研究报告了效果估计(通过内窥镜进行手术清创与手术清创),以达到清洁伤口床的时间和完成伤口愈合的时间。并且可以计算另一项研究(右旋体糊剂与有机硅泡沫弹性体)的效果估计值,以确定完成伤口愈合的时间。对于其他四项没有报告效果估计的研究,由于差异缺失和参与者排除,无法计算到清洁伤口床的时间或完成伤口愈合的时间.纳入的研究均未报告与完全愈合的伤口比例有关的结果,伤口大小的减小率,感染率,或生活质量。所有研究至少有一个关键领域存在不明确或高风险的偏倚。右旋聚体糊剂/珠子(自溶清创术)与四种不同的比较物比较四项研究比较了右旋聚体糊剂或珠子与Eusol浸泡的纱布(20名参与者),10%水性聚乙烯吡咯烷酮(40名参与者),0.1%氯胺浸泡敷料(28名参与者),或有机硅泡沫弹性体(50名参与者)。有非常低的确定性证据表明,在右旋粒珠子和Eusol纱布之间,清洁伤口床的时间可能没有明显差异。该研究未报告不良事件。有非常低的确定性证据表明,在右旋体糊剂和10%水性聚乙烯吡咯烷酮纱布之间,清洁伤口床的时间可能没有差异。有低确定性证据表明,死亡和严重不良事件可能没有差异。右旋聚体糊剂和0.1%氯胺之间可能存在直到伤口临床清洁的时间和完成伤口愈合的时间差异,但是我们非常不确定。有低确定性证据表明,死亡和严重不良事件可能没有差异。存在非常低的确定性证据,表明在右旋聚体珠和有机硅泡沫弹性体之间可能没有时间上的完全愈合的差异。该研究未报告不良事件。链激酶/链脲酶溶液(酶)与盐水浸泡敷料的比较一项研究(21名参与者)比较了酶清创与盐水浸泡敷料。有低确定性的证据表明,链激酶/链球菌酶和盐水浸泡的敷料之间在清洁伤口床或二次缝合的时间上可能没有差异。有非常低的确定性证据表明,死亡和严重不良事件可能没有差异。通过内窥镜(\'锁孔\')手术进行的手术清创与通过\'开放\'手术(使用手术刀打开伤口)进行的手术清创相比一项研究(106名参与者)报告了完成伤口愈合的时间和清洁伤口床的时间。有低确定性的证据表明,完成伤口愈合的时间可能会减少,而极低确定性的证据表明,与“开放式”手术清创相比,通过内窥镜进行手术清创的伤口床清洁时间可能没有差异。该研究未报告不良事件。总的来说,所有结局的证据都低至极低的确定性.1991年之前发表了五项纳入的研究,调查了不再可用的治疗方法。全球生产的右旋糖酐产品已经停止,除了右旋糖膏,目前仅在南非可用。此外,Eusol,在一项研究中用作右旋体的比较物,由于对健康组织有害影响的风险而很少使用,并且酶剂链激酶/链脲酶在全球范围内不再可用。
结论:不同清创方法对手术伤口完全清创和愈合的影响的证据尚不清楚。足够的动力,需要在方法学上稳健的RCT评估当代手术伤口清创干预措施,以指导临床决策.
Surgical wounds that become infected are often debrided because clinicians believe that removal of this necrotic or infected tissue may expedite wound healing. There are numerous methods of debridement available, but no consensus on which one is most effective for surgical wounds.
To assess the effects of different methods of debridement on the rate of debridement and healing of surgical wounds.
In October 2021, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL. To identify additional studies, we searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies, reviews, meta-analyses, and health technology reports. There were no restrictions on language, date of publication, or study setting.
We included randomised controlled trials (RCTs) that enrolled people with a surgical wound that required debridement, and reported time to complete wound debridement or time to wound healing, or both.
Two review authors independently performed study selection, risk of bias assessment using the RoB 1 tool, data extraction, and GRADE assessment of the certainty of evidence.
In this fourth update, we identified one additional study for inclusion. The review now includes six studies, with 265 participants, aged three to 91 years. Five studies were published between 1979 and 1990 and one published in 2014. The studies were carried out in hospital settings in China, Denmark, Belgium, and the UK. Six studies provided six comparisons. Due to the heterogeneity of studies, it was not appropriate to conduct meta-analyses. Four studies evaluated the effectiveness of dextranomer beads/paste; however, each study used a different comparator (Eusol-soaked dressings, 10% aqueous polyvinylpyrrolidone, 0.1% chloramine-soaked packs, and silicone foam elastomer dressing). One study compared streptokinase/streptodornase with saline-soaked dressings, and one compared endoscopic surgical debridement with conventional \'open\' surgical debridement. Five studies reported time to complete debridement (reported as time to a clean wound bed) and three reported time to complete healing. One study reported effect estimates (surgical debridement via endoscopy versus surgical debridement) for time to a clean wound bed and time to complete wound healing, and it was possible to calculate effect estimates for one other study (dextranomer paste versus silicone foam elastomer) for time to complete wound healing. For the other four studies that did not report effect estimates, it was not possible to calculate time to a clean wound bed or time to complete wound healing due to missing variance and participant exclusions. None of the included studies reported outcomes pertaining to proportion of wounds completely healed, rate of reduction in wound size, rate of infection, or quality of life. All studies had unclear or high risk of bias for at least one key domain. Dextranomer paste/beads (autolytic debridement) compared with four different comparators Four studies compared dextranomer paste or beads with Eusol-soaked gauze (20 participants), 10% aqueous polyvinylpyrrolidone (40 participants), 0.1% chloramine-soaked dressings (28 participants), or silicone foam elastomer (50 participants). There is very low-certainty evidence that there may be no clear difference in time to a clean wound bed between dextranomer beads and Eusol gauze. The study did not report adverse events. There is very low-certainty evidence that there may be no difference in time to a clean wound bed between dextranomer paste and 10% aqueous polyvinylpyrrolidone gauze. There was low-certainty evidence that there may be no difference in deaths and serious adverse events. There may be a difference in time until the wounds were clinically clean and time to complete wound healing between dextranomer paste and 0.1% chloramine favouring 0.1% chloramine, but we are very uncertain. There is low-certainty evidence that there may be no difference in deaths and serious adverse events. There is very low-certainty evidence that there may be no difference in time to complete healing between dextranomer beads and silicone foam elastomer. The study did not report adverse events. Streptokinase/streptodornase solution (enzymatic) compared with saline-soaked dressings One study (21 participants) compared enzymatic debridement with saline-soaked dressings. There is low-certainty evidence that there may be no difference in time to a clean wound bed or secondary suture between streptokinase/streptodornase and saline-soaked dressings. There is very low-certainty evidence that there may be no difference in deaths and serious adverse events. Surgical debridement via endoscopic (\'keyhole\') surgery compared with surgical debridement by \'open\' surgery (the wound is opened using a scalpel) One study (106 participants) reported time to complete wound healing and time to a clean wound bed. There is low-certainty evidence that there may be a reduction in time to complete wound healing and very low-certainty evidence that there may be no difference in time to a clean wound bed with surgical debridement via endoscopy compared to \'open\' surgical debridement. The study did not report adverse events. Overall, the evidence was low to very low-certainty for all outcomes. Five included studies were published before 1991 and investigated treatments that are no longer available. Worldwide production of dextranomer products has been discontinued, except for dextranomer paste, which is currently only available in South Africa. Furthermore, Eusol, used in one study as the comparator to dextranomer, is rarely used due to risk of harmful effects on healthy tissue and the enzymatic agent streptokinase/streptodornase is no longer available worldwide.
Evidence for the effects of different methods of debridement on complete wound debridement and healing of surgical wounds remains unclear. Adequately powered, methodologically robust RCTs evaluating contemporary debridement interventions for surgical wounds are needed to guide clinical decision-making.