糖尿病足的高壓氧治療

中文摘要 近年來台灣糖尿病的盛行率不斷增加，再加上糖尿病人壽命隨著醫療科技的進步不斷延長，於是因為糖尿病引起的慢性併發症-足部感染和壞疽經常可見。傳統治療糖尿病足的方法費時費力，因此就有了許多新的輔助方法產生，其中高壓氧輔助治療糖尿病足已經在很多報告中被証實有效，但是如何增進高壓氧治療的成功率卻很少人報告，這篇研究的目的是來評估高壓氧治療的失敗因素，藉由避免失敗因素提高治療的成功率。 從西元1999年7月到2001年10月，總共收集了49位糖尿病足病人，接受高壓氧治療，19位女性和30位男性，平均年齡66.7歲。我們定義成功的治療是傷口癒合或低位截肢(足踝以下截肢)，然後利用獨立樣本t檢定(independent sample t test)與費氏精確測驗法(Fisher’s exact test)統計分析，比較成功的病例和失敗的病例，在年齡、血糖、周邊血管疾病(peripheral vessel disease)、白血球指數(Leukocyte count)、細菌感染數目與尿毒症等方面是否有顯著差異，以相關統計分析兩者之顯著差異因素與結果的關聯性，以邏輯式回歸(Logistic regression)找出影響治療結果的因素。 49位病人有31位成功，18位失敗，利用獨立樣本t檢定與費氏精確測驗法統計分析成功的病例和失敗的病例，發現在年齡、血糖、周邊血管疾病、白血球指數、與尿毒症等方面有顯著差異;然後以相關統計分析兩者之顯著差異因素(年齡、血糖、周邊血管疾病、白血球指數、與尿毒症)與結果的關聯性，發現年齡、周邊血管疾病、白血球指數與尿毒症與結果有相關，再以邏輯式回歸找出最直接影響治療結果的因素，得到周邊血管疾病是影響治療結果最重要因素，其次是白血球指數的升高。 雖然高壓氧的作用機轉對糖尿病足治療有相當幫助而且許多研究報告也証實高壓氧治療對糖尿病足是一種有效的輔助性治療方法，但至今在台灣仍舊未被廣泛的接受用來做為糖尿病足的輔助治療，原因除了價格昂貴和健保不給付以外，醫護人員無法清楚地預測治療後的結果是最大的原因。根據本篇研究的結果顯示周邊血液循環改善與感染控制是非常重要的治療預後因子，高壓氧治療前的評估和準備工作是很重要的，因此我們建議了一個治療流程表。 關鍵詞: 糖尿病足，高壓氧輔助治療，低位截肢，周邊血管疾病，白血球指數

Abstract The prevalence of diabetes mellitus has increased in Taiwan recently. Foot infection and gangrene are frequent complication of DM patients. In many reports, hyperbaric oxygen therapy(HBOT) has been approved as an adjunctive therapy in the management of diabetic foot. But few publications show how to improve the success rate of HBOT in diabetic foot. The purpose of this study is an attempt to evaluate the failure factors of HBOT. From July 1999 to Dec. 2001, we retrospectively collected data on 49 patients with diabetic foot treated by HBOT. There were 19 females and 30 males, with an average age of 66.7 years. We defined successful treatment as wound healing or a low level amputation. Independent sample t-test and Fisher’s exact test were used to compare the successful cases with the failed cases according to age, blood sugar, peripheral vessel disease, leukocyte count, bacterial numbers and uremia. Using a Statistic Correlation to find the significant factors between success group and failure group related with the result of treatment. Logistic regression was used to identify the prognostic factors associated with the outcome of treatment. Of the 49 patients, 31 patients(success rate:63.3%) succeeded and 18 patients(failure rate:36.7%) failed in treating their diabetic foot by HBOT. We analyzed the data statistically and found the most important prognostic factor of treatment was peripheral vessel disease in hyperbaric oxygen therapy. Although many reports claimed that adjunctive hyperbaric oxygen therapy is a useful tool in treatment of diabetic foot, currently it is not recognized as a routine adjunctive method. The reason is that we can’t clearly predict HBO treatment result and it is costly in Taiwan. According to this study, we understand that peripheral circulation is the most important prognostic factor. Therefore, careful evaluation and preparation of patients is necessary before using HBOT. A treatment protocol for HBOT is proposed in Fig 1. Key words: Diabetic foot, Hyperbaric oxygen therapy, low level amputation, peripheral vessel disease, and leukocyte count