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Neue aggressive Therapiestrategien zur Vermeidung von Wundheilungsstörungen bei DiabetikerInnen nach kardiochirurgischen Eingriffen

New more aggressive therapy strategies for the prevention of wound-healing defects in diabetics after cardiosurgical procedures

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Zusammenfassung

Grundlagen: Rund ein Drittel unserer kardiochirurgischen PatientInnen sind DiabetikerInnen. Gerade diese PatientInnen weisen eine besonders hohe Prädisposition für Wundheilungsstörungen (WHS) und Infektionen auf. Ausgehend von der Portland-Studie vonA. P. Furnary et al. entwickelten wir ein aggressiveres Behandlungskonzept.

Methodik: Zwischen April und Oktober 1999 wurden 25 PatientInnen peri- und postoperativ mittels Perfusor kontinuierlich intravenös mit Insulin substituiert, mit dem Ziel, den Blutglukosespiegel permanent unter 200 mg/dl zu halten. Die Blutzucker-Messungen (BZ-Messungen) wurden 2-stündlich durchgeführt, zweimal täglich wurde der Serumkaliumspiegel kontrolliert. Am 4. postoperativen Tag (POT) wurde auf subkutane Applikationsform umgestellt. Wir verglichen die Ergebnisse mit im selben Zeitraum behandelten, retrospektiv untersuchten DiabetikerInnen, die auf Grund ihrer niederen Ausgangsblutzuckerwerte keine Perfusortherapie benötigten. Bei beiden Gruppen wurde 4–6 Wochen postoperativ eine Wundkontrolle durchgeführt.

Ergebnisse: Der durchschnittliche HbAlc-Wert der intravenösen Gruppe (IV-Gruppe) betrug 7,7 (4,9–12 %), der der subkutanen Gruppe (SC-Gruppe) 7,2 (5,3–9,7 %). 68 % der IV-Gruppe wurden bereits präoperativ mit Insulin substituiert, aber nur 34,6 % der SC-Gruppe. Der mittlere Blutglukosespiegel (in mg/dl) betrug in der IV-Gruppe vs. der SC-Gruppe am 1. POT 191,1 vs. 185,8, am 2. POT 194,8 vs. 189,1, am 3. POT 184,4 vs. 187,6 und am 4. POT 167,4 vs. 179,6. Bei Entlassung fanden sich in der IV-Gruppe 4 % oberflächliche und keine tiefen WHS im Sternalbereich, in der SC-Gruppe fanden sich 5,2 % oberflächliche und 7,6 % tiefe WHS im selben Bereich. In der IV-Gruppe fanden sich 12 % oberflächliche WHS nach Saphenektomie am Bein ohne Entwicklung eines Ulcus cruris, in der SC-Gruppe entwickelten sich 15,4 % WHS nach Saphenektomie, wobei 7,7 % daraus nach 4–6 Wochen ein Ulcus cruris entwickelten.

Schlussfolgerungen: Durch eine aggressivere Behandlung der diabetischen Stoffwechselstörung prä-, peri- und postoperativ und eine dauerhaften Senkung des Blutglukosespiegels unter 200 mg/dl sowie die Verhinderung großer Blutglukoseschwankungen konnte das Risiko einer Wundheilungsstörung minimiert werden, tiefe Wundinfektionen ließen sich gänzlich vermeiden.

Summary

Background: One third of our cardiosurgical patients are diabetics. They clearly have a higher predisposition for wound-healing defects and infections. After studying the Portland-Protocol byA. P. Furnary et al. we developed a more aggressive concept for prevention.

Methods: Between April and October 1999 we treated 25 patients peri- and postoperatively by continuous intravenous substitution of insulin by a perfusor with the aim of a constant bloodglucose-level below 200 mg/dl. Every two hours we controlled the blood glucose level, twice a day the serum-potassium level. On the fourth postoperative day we switched to subcutaneous form of application. We compared the results with diabetics, who were treated in the same period, but were not intravenously substituted because of lower blood glucose levels on arrival. Both groups had a wound control 4 to 6 weeks postoperatively.

Results: The average HbAlc-level of the IV-group was 7.7 (4.9–12), of the subcutan SC-group 7.2 (5.3–9.7). 68 % of the IV-group have had insulin-therapy preoperatively, but only 34.6 % of the SC-group. The average blood-glucose level in mg/dl IV vs. SC was on the first POD 191.1 vs. 185.8, on the second POD 194.8 vs. 189.1, on the third POD 184.4 vs. 1876 and on the fourth POD 167.4 vs. 179.6. When discharged 4 % of the IV-group, but 5.2 % of the SC-group developed superficial healing defects at the chest; 7.6 % of the SC-group developed deep sternal infections but none of the IV-group. 12 % of the IV-group suffered from superficial defects or infections after saphenectomy, none of them developed an ulcus cruris. 15.4 % of the SC-group developed defects after saphenectomy, after 4–6 weeks 7.7 % developed an ulcus cruris.

Conclusions: With a more aggressive treatment of the diabetic metabolic situation pre-, peri- and postoperatively and the resulting stable decrease of blood-glucose levels below 200 mg/dl and the prevention of great fluctuations we could minimize this risk and avoid deep wound infections.

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  1. Aus der Universitätsklinik für Herz- und Thoraxchirurgie der Berufsgenossenschaftlichen Kliniken Bergmannsheil, Bochum, Deutschland

    Marion H. Avanzini, J. Reichert, U. Fuchs & A. Laczkovics

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Avanzini, M.H., Reichert, J., Fuchs, U. et al. Neue aggressive Therapiestrategien zur Vermeidung von Wundheilungsstörungen bei DiabetikerInnen nach kardiochirurgischen Eingriffen. Acta Chir. Austriaca 33, 138–142 (2001). https://doi.org/10.1007/BF02949467

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