術後傷口負壓治療Prevena不建議用來預防常規骨科手術的傷口感染

游朝慶醫師

    自從2016年WHO發表新的預防手術部位感染指引後(Global Guidelines for the Prevention of Surgical Site Infection1,2)，術後傷口負壓治療(Incisional Negative Pressure Wound Therapy，iNPWT，iVAC，ci-NPT) 便被各國普遍使用，使用最廣的商業套件應為KCI的Prevena及S＆N的PICO，這條建議指引是說:『建議考慮資源的同時，在成年病人高風險傷口進行初次縫合手術時，使用預防性負壓傷口治療，也許可以預防手術部位感染』，然而近年來，這指引卻被愈來愈多的醫師濫用，對每一個乾淨傷口都使用，導至醫療的浪費，因這指引明明是說高風險傷口high-risk wounds，且其證據品質為低。

    讓我們看看骨科的共識及指引怎麼說，2018年第二次的肌肉骨頭感染全球共識會議 International Consensus Meeting on Musculoskeletal Infection (ICMMI)於美國賓州費城舉行³，有超過800個代表參加，而美國疾管局CDC在制訂預防手術部位感染指引時便參考了2013年這第一屆共識會的結論，故這一次會議的共識⁴其實會影響之後CDC新的指引。下面為這篇共識⁴的文章翻譯。

    在回顧性研究中，iNPWT對髖部及膝蓋骨折手術患者有較低的併發症及感染⁵，在全人工髖/膝關節再置換手術中，iNPWT也會改善傷口癒合並降低傷口染率，但對傷口裂開、深層感染及再次手術沒有影響^6,7。全踝關節置換術（total ankle arthroplasty）⁸、長段胸椎融合手術long-segment thoracolumbar fusions⁹、及高風險的肌肉骨骼癌症傷口¹⁰也有相同的結論。此外，許多前瞻性隨機研究顯示iNPWT可有效降低血腫(hematoma) 、血清腫(seroma)及傷口乾掉的時間，如高能量外傷(High energy trauma，如劇烈撞擊)手術後¹¹，半人工髖關節置換術(Hemiarthroplasty,Bipolar)¹²，全髖關節置換術(THA)¹³，及脊椎骨折手術等¹⁴。然而目前已有愈來愈多的證據說iNPWT其實在血腫、血清腫及傷口滲液的功效只是普通而已。

    無論如何，iNPWT用於常規手術並無任何好處，Redfern的研究¹⁵顯示iNPWT用於常規的THA或TKA，其淺部感染及深層感染的機會和傳統紗布一樣。有三個前瞻性隨機試驗研究iNPWT預防骨科手術感染：Crist等人¹⁶發現在非複雜性髖臼骨折的外固定手術ORIF中，深層感染的機會和傳統紗布一樣；在常規的THA及TKA手術中，也有相同的結果^17,18，此外，iNPWT還會有不必要的額外費用，及可能會導致醫源性傷害，如皮膚產生水泡^19,20。

    最後，有證據顯示，iNPWT對術後導致的早期、良性傷口滲液也許有效。一個回顧性研究109個患有早期、良性傷口滲液的關節置換術患者，使用iNPWT的結果，發現大多數患者都能有效停止滲液，且不需要接受手術²¹，且沒有併發症。

     結論是，iNPWT適合用於傷口癒合困難的骨科手術患者，且沒必要常規使用於所有開刀患者，此外對於術後併發早期、良性的傷口滲液，也可以試著使用iNPWT。

1. WHO預防手術部位感染指引 https://www.who.int/gpsc/SSI-outline.pdf?ua=1

2. 中文版WHO預防手術部位感染指引https://www.jct.org.tw/dl-2210-e33eb682dbe048c69bb9e53772354689.html

3. International Consensus on Musculoskeletal Infection – Research Agenda Workgroup https://www.ors.org/icm-2018-research-agenda-workgroup/

4. QUESTION 36: What is the role for vacuum-assisted incisional dressings (iVAC) in orthopaedic patients? https://www.ors.org/wp-content/uploads/2019/01/Question-36.pdf

5. Cooper HJ, Roc GC, Bas MA, Berliner ZP, Hepinstall MS, Rodriguez JA, et al. Closed incision negative pressure therapy decreases complications after periprosthetic fracture surgery around the hip and knee. Injury. 2018;49:386–391. doi:10.1016/j.injury.2017.11.010.

6. Cooper HJ, Bas MA. Closed–incision negative–pressure therapy versus antimicrobial dressings after revision hip and knee surgery: a comparative study. J Arthroplasty. 2016;31:1047–1052. doi:10.1016/j.arth.2015.11.010.

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14. Nordmeyer M, Pauser J, Biber R, Jantsch J, Lehrl S, Kopschina C, et al. Negative pressure wound therapy for seroma prevention and surgical incision treatment in spinal fracture care. Int Wound J. 2016;13:1176–1179. doi:10.1111/iwj.12436.

15. Redfern RE, Cameron–Ruetz C, O’Drobinak SK, Chen JT, Beer KJ. Closed incision negative pressure therapy effects on postoperative infection and surgical site complication after total hip and knee arthroplasty. J Arthroplasty. 2017;32:3333–3339. doi:10.1016/j.arth.2017.06.019

16. Crist BD, Oladeji LO, Khazzam M, Della Rocca GJ, Murtha YM, Stannard JP. Role of acute negative pressure wound therapy over primarily closed surgical incisions in acetabular fracture ORIF: A prospective randomized trial. Injury. 2017;48:1518–1521. doi:10.1016/j.injury.2017.04.055.

17. Karlakki SL, Hamad AK, Whittall C, Graham NM, Banerjee RD, Kuiper JH. Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: a randomised controlled trial. Bone Joint Res. 2016;5:328–337. doi:10.1302/2046–3758.58.BJR–2016–0022.R1.

18. Manoharan V, Grant AL, Harris AC, Hazratwala K, Wilkinson MPR, McEwen PJC. Closed incision negative pressure wound therapy vs conventional dry dressings after primary knee arthroplasty: a randomized controlled study. J Arthroplasty. 2016;31:2487–2494. doi:10.1016/j.arth.2016.04.016.

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21. Hansen E, Durinka JB, Costanzo JA, Austin MS, Deirmengian GK. Negative pressure wound therapy is associated with resolution of incisional drainage in most wounds after hip arthroplasty. Clin Orthop Relat Res. 2013;471:3230–3236. doi:10.1007/s11999–013–2937–3.