Hyperbaric oxygen: value in management of nonhealing saphenectomy wounds.

The greater saphenous vein is commonly used as a conduit for arterial bypass in both cardiac and peripheral vascular operations. Although saphenectomy wound complications occur infrequently, such problems may be quite serious. We report a case in which hyperbaric oxygen therapy was extremely valuable in the management of a very difficult saphenectomy wound.     

A systematic review and meta-analysis of hyperbaric oxygen therapy for diabetic foot ulcers with arterial insufficiency

BackgroundDiabetic foot ulcers (DFUs) are frequently associated with peripheral arterial occlusive disease (PAOD) and may ultimately lead to amputations of the lower extremity. Adjuvant hyperbaric oxygen treatment (HBOT) might foster better wound healing and lower amputation rates in patients with DFU and PAOD. A systematic review was conducted to assess the effects of HBOT as an adjunctive therapy to standard treatment for patients with DFUs with PAOD.MethodsSystematic review using the MEDLINE, EMBASE, and Cochrane CENTRAL databases (from inception to October 2018). All original, comparative studies on the effect of HBOT on DFUs with PAOD were eligible. The primary outcome measures were amputation rate, amputation-free survival, complete ulcer healing, and mortality.ResultsEleven studies, totaling 729 patients, were included for analysis, including 7 randomized clinical trials, 2 controlled clinical trials, and 2 retrospective cohorts. Four were used for quantitative synthesis. Meta-analysis showed a significantly fewer major amputations in the HBOT group (10.7% vs 26.0%; risk difference, −15%; 95% confidence interval [CI], −25 to −6; P = .002; number needed to treat, 7; 95% CI, 4-20). No difference was found for minor amputations (risk difference, 8%; 95% CI, −13 to 30; P = .46). Three studies reporting on complete wound healing showed contrasting results. No significant difference was found for mortality or amputation-free survival.ConclusionsCurrent evidence shows that adjuvant HBOT improves major amputation rate, but not wound healing, in patients with DFUs and PAOD. Given the wide range of patients included in the trials, better patient selection may help define which patients with DFUs and PAOD benefit most from HBOT as standard adjunctive treatment.     

Free tissue transfer provides durable treatment for large nonhealing venous ulcers

BACKGROUND: Most venous ulcers (VUs) will heal with conventional treatment, which focuses on improving regional venous hemodynamics. This treatment, however, often fails to heal large, recurrent VUs that are associated with severe lipodermatosclerosis (LDS). These complicated ulcers may require correction of local venous hemodynamics and replacement of the surrounding LDS with healthy tissue. We report our experience managing 24 especially difficult VUs with debridement and free flap coverage. PATIENTS AND METHODS: Between 1987 and 1997, 25 free flap procedures were performed in 22 patients for 24 recalcitrant VUs. Ulcers had been present for a mean of 5.24 years and had failed to heal with conservative therapy and split-thickness skin grafts (STSGs) (mean, 2.2). Eleven patients (46%) had exposed bone, tendon, or joint. At operation the area of LDS was excised, and all perforating veins were ablated. The defects after excision ranged from 100 to 600 cm(2) (mean, 237 cm(2)). The free flap was inset within the defect and covered with an STSG. RESULTS: We healed all 24 ulcers with free tissue transfer (one patient required a second flap after the first failed). There were no deaths. Local complications that required repeat STSG occurred in three (13%) of the 24 successful flap transfers. Four other flaps had minor local complications that healed with local wound care. Follow-up was available for 21 of the 24 successful flap transfers. No recurrent ulcers were identified in the territory of the flap after a mean of 58 months, but three patients had new ulcers in the same leg after 6 to 77 months. Patients with severe complications were hospitalized longer than those with minor or no complications (45.7 vs 12.8 days, P <.01), and their hospital charges were greater ($76,681 vs $30,428, P <.01). CONCLUSION: Free tissue transfer can provide rapid healing and long-term relief from severe VUs that are unable to be treated with conventional therapy. This technique improves venous hemodynamics, removes all liposclerotic tissue, provides an abundant blood supply, and resolves the tissue-related components of chronic ulceration. Although further work is needed to determine the optimal indications, this technique provides a durable treatment for especially recalcitrant ulcers.     

Hyperbaric oxygen for the treatment of fournier's gangrene

PURPOSE: Fournier's gangrene is a necrotizing fasciitis of the genitalia that is associated with high morbidity and mortality. Groups at many institutions have initiated routine adjuvant hyperbaric oxygen (HBO) therapy. We examined whether HBO has made a difference in the morbidity, mortality and costs associated with treating this disease. We also analyzed predictors of extended hospital stay and mortality. MATERIALS AND METHODS: The records of patients with the hospital discharge diagnoses of Fournier's gangrene, necrotizing fasciitis, gangrene of the genitalia and scrotal gangrene from 1993 to 2002 were reviewed. Data concerning clinical presentation characteristics, hospital stay, complications, hospital charges and outcomes, including graft failure and death, were analyzed. RESULTS: A total of 42 patients were identified and followed a median 4.2 years. Of the patients 16 underwent surgical debridement and antibiotic therapy alone, and 26 were treated with HBO plus surgery and antibiotics. Overall disease specific mortality was 21.4%, that is 12.5% in the nonHBO group and 26.9% in the HBO group. Three or more complications occurred in 13% of nonHBO and in 19% of HBO cases, of which the most common was myocardial infarction. The skin graft failure rate was 6% (nonHBO) and 8% (HBO). Physical disability was a statistically significant predictor of extended hospital stay (p <0.01). There was a trend toward a correlation between known coronary artery disease and death (p = 0.2). A statistically significant difference was noted in average daily hospital charges in nonHBO vs HBO cases ($2,552 vs $3,384 daily, p <0.01). CONCLUSIONS: These data do not support routine HBO in the treatment of Fournier's gangrene. There was a trend toward higher morbidity and mortality in the HBO group, suggesting that treatment may have been given to patients who were more ill.     

Hyperbaric oxygen therapy for nonischemic diabetic ulcers: A systematic review

Diabetic foot ulcers are a common complication of diabetes, which affects 25% of patients and may ultimately lead to amputation of affected limbs. Research suggests hyperbaric oxygen therapy improves healing of these ulcers. However, this has not been reflected in previous reviews, possibly because they did not differentiate between patients with and without peripheral arterial occlusive disease. Therefore, we performed a systematic review of published literature in the MEDLINE, Embase, and Cochrane CENTRAL databases on nonischemic diabetic foot ulcers with outcome measures including complete ulcer healing, amputation rate (major and minor), and mortality. Seven studies were included, of which two were randomized clinical trials. Two studies found no difference in major amputation rate, whereas one large retrospective study found 2% more major amputations in the hyperbaric oxygen group. However, this study did not correct for baseline differences. Two studies showed no significant difference in minor amputation rate. Five studies reporting on complete wound healing showed no significant differences. In conclusion, the current evidence suggests that hyperbaric oxygen therapy does not accelerate wound healing and does not prevent major or minor amputations in patients with a diabetic foot ulcer without peripheral arterial occlusive disease. Based on the available evidence, routine clinical use of this therapy cannot be recommended. However, the available research for this specific subgroup of patients is scarce, and physicians should counsel patients on expected risks and benefits. Additional research, focusing especially on patient selection criteria, is needed to better identify patients that might profit from this therapy modality.     

Hyperbaric oxygen for the treatment of early-phase Dupuytren's contracture

Dupuytren's disease (DD) is a proliferative disorder of autosomal-dominant inheritance, with variable penetrance of gene expression. The treatment of DD is challenging. Both operative and nonoperative approaches were reported for treatment of the disease, but no perfect approach has gained popularity as the best choice of treatment. Most of the emphasis has been placed on surgical techniques, but outcomes were reported to be dependent on some variables such as case selection, timing of surgery, and the surgeon's training and experience. In this paper, we report on a hyperbaric oxygen (HBO) treatment for early-phase DD. HBO treatment was applied to a female aged 23 years who had a mild form of DD. Physical findings and complaints before and after HBO treatment were compared. Total relief of symptoms as well as physical findings were obtained with HBO treatment. HBO for the treatment of DD is a novel concept. Having treated only one case is not enough to conclude that HBO is the only effective mode of treatment for DD. HBO should also be tried to treat early-phase or mild contractures of DD. Unfortunately, HBO has a disadvantage, i.e., cost. But HBO is not invasive, and because of the nature of HBO treatment, most of the complications seen after surgeries, e.g., wound-healing problems, damage to the digital nerves and vessels, buttonholing of the skin, and tendon sheath opening, are not seen.     

Hyperbaric oxygen for the treatment of radiation cystitis and proctitis

Chronic radiation cystitis and radiation proctitis are known complications of the use of radiotherapy in the treatment of pelvic malignancies. These complications are, in part, due to endothelial damage and decreased vascularity and oxygenation to pelvic tissues. Hyperbaric oxygen therapy may be able to improve oxygenation and induce angiogenesis in damaged organs, resulting in recovery from radiation injury. Several studies have shown significant rates of response to hyperbaric oxygen treatment, however, no randomized trial exists to definitively demonstrate its effectiveness for cystitis and proctitis. In addition, concerns exist regarding the durability of the beneficial effect.     

Hyperbaric oxygen therapy for massive arterial air embolism during cardiac operations

BACKGROUND: Massive arterial air embolism is a rare but devastating complication of cardiac operations. Several treatment modalities have been proposed, but hyperbaric oxygen is the specific therapy. METHODS: The Israel Naval Medical Institute is the only referral hyperbaric center in this country for acute care patients. We reviewed our experience in the hyperbaric oxygen treatment of massive arterial air embolism during cardiac operations. RESULTS: Seventeen patients were treated between 1985 and 1998. Eight patients (47.1%) experienced a complete neurologic recovery; 6 patients (35.3%) remained unconscious at discharge, and 3 patients (17.6%) died. Mean (+/- SD) delay from the end of the operation to hyperbaric therapy was 9.6 +/- 7.4 hours (range, 1-20 hours). This delay was 4.0 +/- 3.4 hours (1-12 hours) for patients who had a full neurologic recovery, 12.8 +/- 7.1 hours (5-20 hours) for patients with severe neurologic disability, and 18.0 +/- 2.0 hours (16-20 hours) for patients who died (1-way analysis of variance; P =.002). The source of variance among the groups mainly resulted from the short delay for patients who experienced complete recovery compared with the other 2 groups (Tukey test). All 5 patients who were treated within 3 hours from the operation and 50% (2 of 4 patients) of those patients treated 3 to 5 hours from operation experienced a full neurologic recovery. With a delay of 9 to 20 hours, only 1 of 8 patients had a full neurologic recovery. The association between outcome and treatment delay was found to be statistically significant (tau = 0.65 with exact 2-sided P value =.0007). CONCLUSION: Hyperbaric oxygen therapy should be administered as soon as possible after massive arterial air embolism during cardiac operations.     

Hyperbaric oxygenation in the treatment of bleeding gastroduodenal ulcers]

It is shown on the basis of analysis of the results of treatment of 179 patients that the use of hyperbaric oxygenation in the complex surgical management of ulcerative gastroduodenal bleeding reduced the number of postoperative complications by a factor of 3.3 and led to a decrease of mortality from 20 to 1%. The authors confirm the expedience of including hyperbaric oxygenation in the complex of therapeutic measures in patients with bleeding ulcers under conditions of accomplished hemostasis by conservative or surgical methods in one of three suggested variants: in preparation of the patients for operation in the postponed period; after operative interventions carried out at the peak of bleeding; before and after operations on patients with moderate and severe blood loss and concomitant diseases. The sessions should be conducted under pressure of 2 atm for 60 minutes.     

Hyperbaric oxygen in the treatment of burns.

Since 1972, over 800 burn victims have been treated with hyperbaric oxygen at the Burn Center of Sherman Oaks Community Hospital in Los Angeles. HBO is used only as an adjuvant to standard resuscitation and is not intended to replace current accepted therapy. The results of the first three-year study program show definite changes in burn care delivery. There has been a definite decrease in the mortality as compared with our own predictions and statistics and with those of the N.B.I.E. In addition, a marked improvement in morbidity and a reduction in hospital stay were noted.     

Hyperbaric oxygen therapy for iatrogenic arterial gas embolism after CT-guided lung biopsy

Die Anaesthesiologie - Iatrogenic arterial gas embolism (AGE) can be life-threatening. The only causal treatment is immediate hyperbaric oxygen therapy (HBOT). This article reports on...     

Hyperbaric oxygen treatment of postoperative neurosurgical infections

OBJECTIVE: To evaluate the clinical usefulness of hyperbaric oxygen (HBO) therapy for neurosurgical infections after craniotomy or laminectomy. METHODS: The study involved review of medical records, office visits, and telephone contacts for 39 consecutive patients who were referred in 1996 to 2000. Infection control and healing without removal of bone flaps or foreign material, with a minimum of 6 months of follow-up monitoring, were considered to represent success. RESULTS: Successful results were achieved for 27 of 36 patients, with a mean follow-up period of 27 months (range, 6-58 mo). One patient discontinued HBO therapy because of claustrophobia, and two could not be evaluated because of death resulting from tumor recurrence. In Group 1 (uncomplicated cranial wound infections), 12 of 15 patients achieved healing with retention of bone flaps. In Group 2 (complicated cranial wound infections, with risk factors such as malignancy, radiation injury, repeated surgery, or implants), all except one infection resolved; three of four bone flaps and three of six acrylic cranioplasties could be retained. In Group 3 (spinal wound infections), all infections resolved, five of seven without removal of fixation systems. There were no major side effects of HBO treatment. CONCLUSION: HBO treatment is an alternative to standard surgical removal of infected bone flaps and is particularly useful in complex situations. It can improve outcomes, reduce the need for reoperations, and allow infection control without mandatory removal of foreign material. HBO therapy is a safe, powerful treatment for postoperative cranial and spinal wound infections, it seems cost-effective, and it should be included in the neurosurgical armamentarium.     

高压氧治疗眼烧伤患者的护理

目的探讨高压氧治疗化学性眼烧伤患者的效果和护理措施。方法对眼烧伤患者(视力为指数至0.8)立即冲洗患眼、药物散瞳、球结膜下注射,使用典必舒、贝复舒点眼,早期单人舱高压氧治疗。结果患者住院2~29 d出院,患眼视力0.6~1.0者54眼,指数5眼。随访3个月视力明显改善者54眼,视力无明显改善者5眼。眼球痊愈52眼,愈合不佳7眼。结论眼烧伤后早期应用高压氧治疗后角膜上皮损伤恢复快,透彻的健康教育、完善的入仓前准备及安全护理是获得较好疗效的基本保障。     

Hyperbaric oxygen in the treatment of clostridial gas gangrene

Thirty-two cases with clostridial gas gangrene were treated during the years 1971-87 in the Department of Surgery, Turku University Central Hospital. The presumptive diagnosis was made on the basis of the clinical appearance of the patient and presence of gram-positive bacilli on a smear. Each patient underwent surgical debridement, antibiotic therapy and hyperbaric oxygen treatment. Seventeen cases had diffuse spreading myonecrosis, 11 of whom survived. Fifteen patients developed clostridial cellulitis with toxicity, 12 survived. Thus the over-all mortality was 28.1%. All those patients who died had been transferred from other hospitals of the country and were already moribund on arrival. Twenty-two infections developed postoperatively, in 6 cases trauma was the antedecent cause and 4 were spontaneous infections. None of the patients with a posttraumatic infection died. The most common underlying disorders included arteriosclerosis, diabetes mellitus, malignancy and Buerger's disease. The addition of hyperbaric oxygenation to the treatment of gas gangrene--although strictly adjunctive to surgery, antibiotics and supportive therapy--has dramatically changed the surgical approach to treatment. Early diagnosis remains essential. Patient survival can be achieved if the disease is recognized early and appropriate therapy applied promptly.