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					 Dive for Life
Hyperbaric Oxygen
        for
Fournier’s 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)
   H’stix 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
Fournier’s 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
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    敬請留意




     13
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                 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
Fournier’s Gangrene




         19
        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
20
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
           Fournier’s 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
              Fournier’s 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
  Fournier’s Gangrene




              29
        Hyperbaric oxygen treatment
       protocol for necrotizing fasciitis
   Pressure: HBO treatments started at 2.0–2.5 ATA
   Duration: 90–120 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 ( Boyle’s 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 T1/2@~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
   CO poisoning                         anaerobic infections
   Cyanide poisoning                   Gas gangrene
   Crush injury and other              Necrotizing soft tissue
    acute traumatic ischemias            infections
   Decompression sickness              Refractory osteomyelitis
   Enhancement of healing in           Radiation Necrosis
    selected problem wounds             Compromised Skin Grafts
   Blood loss anemia that               or Flaps
    refused transfusion                 Thermal Burns
                                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
    Fournier’s 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

                              J Urol. 2005 Jun; 173(6):1975-77
                         48
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




                             J Urol. 2005 Jun; 173(6):1975-77
                        50
                       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
   香港潛水及高壓氧治療中心 ( monoplace chamber avaliable )

                              56
       Government HBO Facility
    Jointly run by the
1.   Fire service department
2.   Occupational Health service of the labour
     department
3.   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
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Safety and emergency measures




              69
Where numbers really count !




             70
These are all for you!




                         71
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    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. Ryle’s 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 Fourner’s 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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