HBO therapy - HKSCCM

HBO therapy - HKSCCM

Dive for Life Hyperbaric Oxygen for Fourniers Gangrene Speaker: Dr Chan Chin Pang Ian Chairperson: Dr Lee Kar Lung Intensive Care Unit United Christian Hospital 21 July 2009 1 Intensive Care Unit

United Christian Hospital 2 History

M/39 Sales Unremarkable past health Came to AED alone c/o chest pain radiating to back, with associated dizziness Apparently being unwell 3 Vital Signs

BP 98/63. P110 regular RR 18 / min GCS 15/15 SpO2 100% (on 100% O2) Hstix 23.9 ECG: Sinus tachycardia. No acute

ischemic change 4 Physical Examination Found to have darkened scrotum while attempting to insert Foley

catheter Evidence of cellulitis over Rt perinium and Rt lower abdominal wall Crepitus over Rt precordium and neck 5 CXR on Admission 6

X- Ray 7 Imaging Emergency contrast CT Thorax + Abdomen + Pelvis performed:

Severe surgical emphysema over Rt thigh, perinium scrotum and Rt side of trunk up to lower thorax. Pneumomediastinum, pneumoperitonium and pneumoretroperitoneum seen 8 CT Abdomen

9 Diagnosis Fourniers Gangrene 10 Operation

Emergency laparotomy confirmed presence of free peritoneal gas, with air trapped at Rt anterior thigh subfascial space with gangrenous change of fascia and abscess collection 10cm subfascial abscess collection at Rt scrotum and R inguinal region, with necrotic R scrotal fascia Necrosis of preperitoneal fat with abscess collection

11 Operation Bowels intact Testes viable Drainage of abscess (total 200ml pus

drained) + extensive debridement + transverse colostomy done Post-op ICU care 12 13 14

15 ICU Progress

Put on IV Tazocin + Flagyl + Clindamycin Insulin infusion for glycemic control Borderline hemodynamic Worsening RFT / metabolic acidosis requiring CVVH HbA1c 11.8% R scrotal abscess swab & peritoneal fluid grew Bacteriodes sp. & Propionibacterium Granulosum 16 ICU Progress

Multiple sessions of follow-up debridement Started hyperbaric oxygen therapy (HBO) after 2nd debridement (2.5 ATM for 1.5 hours Daily) Unable to tolerate air-break during

ascending phase after 2 sessions of HBO therapy with near-arrest requiring adrenaline injection 17 ICU Progress

Patient undergone repeated debridement with uncontrollable intraabdominal sepsis and VAP Blood culture with candida and burkholderia septicaemia Eventually died in ICU 18 Fourniers Gangrene 19

20 Infective necrotizing fasciitis of the perineal, genital or perianal regions, usually in male

First described by Baurienne in 1764 and is named after Jean-Alfred Fournier (a French venereologist) following 5 cases he presented in clinical lectures in 1883 21

Surg Clin North Am. 2002 Dec;82(6):1213-24. 22 Surg Clin North Am. 2002 Dec;82(6):1213-24. Infectious causes of soft tissue gas

Clostridial myonecrosis Clostridial anaerobic cellulitis Nonclostridial anaerobic cellulitis Synergistic necrotizing cellulitis Necrotizing fasciitis Nonclostridial crepitant myositis 23

Fourniers Gangrene NF of the genitalia and perineum Aetiology: Polymicrobial infection - aerobic strept., staph., E-coli, P-aeroginosa, klebsiella - anaerobic bacteroides, clostridia 24 Bacteriology

Polymicrobial in most cases Combination of aerobes and anaerobes Commensals from skin, urogenital tract and anorectal region 25 Treatment of NF

aggressive, early surgical debridement broad-spectrum antibiotic therapy directed at presumed causative agents. HBO in NF : complimentary and adjunctive role

Surgical treatment includes the excision of necrotic fascia, compromised skin, and subcutaneous tissue. 26 Necrotizing Fasciitis and Fourniers gangrene Riseman and colleagues reported that addition of HBO to surgical and

antibiotic treatment reduced mortality versus surgery and antibiotics alone. May suppress growth of anaerobic organisms May increase leukocyte function and suppress bacterial growth 27

Hyperbaric oxygen treatment 28 Adjunctive Treatment for Fourniers Gangrene 29 Hyperbaric oxygen treatment protocol for necrotizing fasciitis

Pressure: HBO treatments started at 2.02.5 ATA Duration: 90120 minutes

Frequency: Treatment is initially done twice daily Treatments: Treatments can continue until clinical improvement is maximized. Use review: The continued use of HBO should be reviewed after 30 treatments. 30 HISTORY OF HBO Compressed Air Theory

Henshaw (British, 1662): treatment of acute disease with increased pressure The chamber was fitted with a large pair of organ bellows, with valves placed so that air could either be compressed into the chamber or extracted from it. In the domicilium increased pressures were used for the treatment of acute disease, and reduced pressures for the treatment of chronic diseases. 31 History of HBO Fontaine (1879): pressurized mobile

operating room 32 History of HBO (Air) Cunningham (Lawrance Kansas, 1918): used compressed air to combat heart disease, circulatory disorders, and other anerobic related diseases.

Claimed good results in influenza patients who were profoundly hypoxic and comatose. Complete resolution of uremic symptoms in Timkin (Ball Bearing Manufacturer) 33 Definition of HBO

Breathing 100 % O2 intermittently Chamber pressure increased at least 1.4 atmosphere absolute 34 Hyperbaric Oxygen Therapy Modern scientific use of hyperbaric chamber in clinical medicine began in

1955 by Church-Davidson HBO potentiates radiotherapy Boerma (1955-Univ Amsterdam) Life without Blood HBO in cardiac surgery

35 Boerma: Life without blood. 3 ATA 36 HBO 1. Tissue Hyperoxia a. Dissolves extra oxygen into the

blood b. Angiogenesis in wound areas c. Sufficient oxygenation to ischemic tissues @ Useful in the treatment of anemias, ischemias and some poisonings 37 Oxygen Effects on tissues.

Increased hyaluronic acid and proteoglycans by fibroblasts Inc Endothelial cell proliferation Restoration of fibroblast growth and collagen production Preservation of cell membrane ATP Enhanced osteoblast/osteoclast

function 38 HBO 2. Bubble size reduction ( Boyles Law ): Any free gas trapped in the body will decrease in volume as the pressure on it increases @2ATA (50%vol), @3ATA ( 1/3vol ), @4ATA (25% vol ) Successfully applied to air embolism and decompression sickness

39 Tissue Hyperoxia At sea level, room air, only 3ml/L of oxygen dissolved in blood Tissue requirement ~60ml/L/min at

rest At 3ATA of pure O2, dissolved oxygen ~60ml/L 40 Tissue oxygen tension measurement 41 HBO

3. Gas wash out effect The flooding of the body with any one gas tends to "wash out" all others. @Treatment for CO intoxication COHB T1/2 RA 240-360min vs @100% O2T1/2~80-100min vs HBO Rx T1/[email protected]~20min 42 Oxygen Effects on Blood Flow

Blood flow Preserved in ischemic tissues Improved perfusion in acute wounds (Hammarlund) Improved flow in ischemic flaps (Zamboni 1992)

43 HBO 4. Bacteriostasis: Inhibits growth of anaerobic as well as some aerobic organisms @3ATA bactericidal for clostridium perfringens inhibit Alpha toxin production 44

Mechanisms of antimicrobial effect Enhancement of leukocyte-killing activity

Bacterial growth suppression in hyperoxic tissues Enhancement of antibiotic effects Improvement in tissue repair Effects on anaerobic bacteria 45 indications HBO is generally used as an adjunctive therapy; it does not compete with or replace other treatment methods

Air or gas embolism Selected refractory anaerobic infections CO poisoning Cyanide poisoning Gas gangrene

Crush injury and other Necrotizing soft tissue acute traumatic infections ischemias Refractory Decompression sickness osteomyelitis Enhancement of healing Radiation Necrosis

in selected problem Compromised Skin wounds Grafts or Flaps Blood loss anemia that Thermal Burns refused transfusion 46

HBO Trial A retrospective study conducted by Korhonen in Finland evaluated outcome of 33 patients with perineal necrotizing fasciitis treated with surgical debridement + antibiotics + HBO @2.5 ATA pressure (2-12 times) between 1971 - 1996

3 patients died (mortality 9.1%) Ann Chir Gynaecol, suppl., 89: 7, 2000 47 HBO Trial Mindrup identified 42 patients with

Fourniers gangrene diagnosed between 1993 2002 in Lowa, USA 26 patients received surgical debridement + antibiotic + HBO HBO 30 to 90 minutes per dive, 2.4 to 3 ATM per dive and 1 to 3 dives daily, depending on severity of illness 48 J Urol. 2005 Jun; 173(6):1975-77 49

HBO Trial Mortality: 12.5% (nonHBO) Vs 26.9% (HBO), p=0.44 Average daily hospital charges: USD$2,552 (nonHBO) Vs USD$3,384 (HBO), p < 0.01

50 J Urol. 2005 Jun; 173(6):1975-77 Risk of HBO Barotrauma

Ear damage barotitis media 24% require tympanostomy Sinus damage Ruptured middle ear Lung damage Oxygen toxicity

Brain: Convulsion (rare 1/100,000 ) Lung: Pulmonary edema, hemorrhage Respiratory failure due to pulmonary fibrosis 51 Risk of HBO

Decompression Illness Pneumothorax Gas emboli 52 Oxygen Toxicity Hypoglycemia

Pulmonary (>0.5 ATA) Intratracheal and bronchial irritation Initial cough, dysnea, tightness Pulm edema and ARDS possible Occular

Progressive myopia (20-40% incidence) recovery w/in 2 months post tx. Cataracts- new and progression increase risk for repeated exposure 53 Contraindication

Absolute: Untreated pneumothorax Relative: URI Emphysema with CO2 retention

Pulmonary lesion in CXR Uncontrolled high fever Claustrophobia Seizure disorder Malignant disease 54 Issue of HBO

never substitute for the primary interventions Never delay the planned surgical treatment 55 HBO in HK

Public Facility -Run by the HKSAR located at the stonecutter island near Kwai Chung container pier ( multiplace chamber only ) -two multiplace chambers linked by an antechamber and was manufactured by Haux of Germany in 1994.

Pirvate Facility Hong Kong Diving & Hyperbaric Medicine Center ( monoplace chamber avaliable ) 56 Government HBO Facility 1. 2.

3. Jointly run by the Fire service department Occupational Health service of the labour department Maintanance by the E&M department 57

How to arrange? Contact the duty officer of the occupational Health Service Call list and phone number can be assess via the AED your Hospital 58

Monoplace Chamber 59 Multiplace Chamber 60 61 Fire Hazard

there was 60 fatalities from 24 chamber fire accidents between 1967-1996 You are at risk of combusted to ashes within minute accelerated by the high ambient oxygen 62

63 64 65 66 67 68

Safety and emergency measures 69 Where numbers really count ! 70 These are all for you!

71 72 73 74 Patient preparation for ventilated patient Prophylactic myringotomy

ET cuff air replaced with water All close system with potentially affected by pressure change should be open to ambient air pressure i.e. Ryles tube, abdominal drain *All vessel contain air should not be a close system 75

Escort staff No claustrophobia Able to equalize middle ear pressure by Valsava manoeuvre No URTI symptom

76 Patient monitoring and management

Space Lab monitor device with continuous ECG, oximeter monitor and NIBP at regular interval Arterial line not available No infusion pump ( use mircodrip set with manual calibration 20drop/ml ) Handheld suction equipment Ambubag and resuscitation instructment No defribrillator

77 Patient monitoring and management

Use soft plastic bag fluid only A Drager Oxylog ventilator is avaliable for use Only VCV mode can be used Only two ventilators has been approved by the European nations (French RCH LAMA and the Italian Siaretron 1000 Iper ) A Wright spirometer to monitor the tidal volume is connected to the breathing circuit 78

Patient monitoring and management Monitor the change in tidal volume especially during ascending and descending to avoid volume trauma Handbagging is an alternative during

rapid ascent and descent. Chest drain with Heimlich valve valve is available 79 Scenario for desaturation

1. airbreak period to prevent O2 toxicity 2. if ambient O2 concentration of the chamber is too high, O2 supply will be cut back to 21% ( you and your patient as well ) Ascent Phase 80 Precaution

Oxygen at high pressure is highly combustible ( ambient oxygen monitor within the chamber and control < 24% ) You can be burn into ashes within minutes with a single spark

Straight fire precaution protocol should be comply 81 HBO and Fourners Gangrene As adjunct therapy May increase patient survival

Not suitable for unstable patients i.e. on high ventilation demand, inotrope dependent and not fir for transfer. 82 End Thank You 83

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