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Hyperbaric Oxygen Treatment for Diabetic Foot Wounds

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Hyperbaric Oxygen Treatment is breathing 100% oxygen at an ambient pressure ... 'Diabetic wounds including diabetic gangrene and diabetic foot ulcers. ... – PowerPoint PPT presentation

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Title: Hyperbaric Oxygen Treatment for Diabetic Foot Wounds


1
Hyperbaric Oxygen Treatment for Diabetic Foot
Wounds
  • Dr David Wilkinson
  • Director
  • Hyperbaric Medicine Unit
  • Royal Adelaide Hospital
  • August 2008

2
Plan
  • What is HBO?
  • How is it administered?
  • What does it do for the diabetic wound?
  • What is the evidence for it?
  • A plan of care

3
What is HBO?
Hyperbaric Oxygen Treatment is breathing 100
oxygen at an ambient pressure greater than 1
atmosphere absolute
  • It is not
  • Breathing 100 oxygen at normobaric pressure
  • Topical application of hyperbaric oxygen to a limb

4
Hyperbaric Chambers
  • Multiplace
  • Accommodate several people
  • Compress on air
  • Staff present inside chamber
  • Monoplace
  • One person
  • Compress with oxygen

5
HBO treatment profile
  • Compression of the chamber to 2.0 2.8
    atmospheres over 5 minutes
  • Equalise middle ear
  • Breathe oxygen for 60 - 90 minutes
  • Decompress to 1 atmosphere over 15 30 minutes

6
Table 109030
7
How does HBO work? HBO effect
  • Physical
  • Arterial oxygen partial pressure 1000-1800 mmHg
  • 10-20 times usual pressure
  • Oxygen will diffuse 3-4 times further
  • Improved oxygenation ? improved cell function
  • Hyperoxygenated for 2 hours out of 24
  • Relative hypoxia for 22 hours
  • High oxygen pressure leads to changes in cell
    function
  • Hypoxia and erythropoietin release in the kidney
    and chemoreceptor activity in the aortic arch and
    carotid body

8
HBO effect
  • Biochemical
  • Oxygen acts as a signal messenger for cell
    function
  • Fibroblast proliferation and collagen formation
  • Endothelial budding and angiogenesis
  • Functional receptor changes on Neutrophil

9
Theory of Wound Healing
  • Identify hypoxia as a cause of non-healing
  • Fibroblast function poor with PtcO2 lt 40mmHg
  • Neutrophil function poor with PtcO2 lt 30mmHg
  • Administer HBO2 if indicated
  • Transcutaneous Oximetry (PtcO2)

10
Transcutaneous Oximetry
  • PtcO2 prospectively used to predict healing of
    limb wound
  • Bunt, Ann Vasc Surg, 1996
  • PtcO2 a better predictor of healing than Doppler
    arterial pressures and ABI
  • Padberg, J Surg Res, 1996
  • PtcO2 predicts likely response to HBO
  • Smith, Wound Rep Reg, 1996

11
Published evidence
12
Diabetic problem wounds
  • RCT
  • Doctor, J Postgrad Med 1992
  • Faglia, Diabetes Care 1996
  • Abidia, Eur J Endovasc Surg 2003
  • Kessler, Diabetes Care 2003
  • Controlled studies

13
Medicare Review
  • Medicare Services Advisory Committee
  • 1999-2000
  • Supporting Committee reporting to MSAC
  • Review of Hyperbaric Oxygen Therapy
  • Assessment Report
  • November 2000

14
Medicare Review
  • Pooled results from diabetic studies
  • Major amputation
  • Minor amputation

15
Major amputation - relative risk reduction with
HBO.
16
Major amputation absolute risk reduction with
HBO Number needed to Treat (NNT) 5
17
Medicare Review
  • MSAC recommended that public funding for
    hyperbaric oxygen therapy should be supported for
    HBOT administered for the following indications
  • Diabetic wounds including diabetic gangrene and
    diabetic foot ulcers. There is evidence that
    HBOT is effective in promoting wound healing, and
    reducing the length of hospital stays and the
    likelihood of major amputations in patients with
    diabetic wounds. There may also be cost savings
    associated with treatment benefits.

18
Cochrane Review
  • Kranke P, Bennett M, Roeckl-Wiedmann I, Debus S.
    Hyperbaric oxygen therapy for chronic wounds
    (Cochrane Review). In The Cochrane Library,
    Issue 2, 2004.
  • In people with foot ulcers due to diabetes, HBOT
    significantly reduced the risk of major
    amputation and may improve the chances of healing
    at 1 year
  • May be justified where HBOT facilities available
  • Need ecomonic evaluation
  • Need appropriately powered trial of high
    methodological rigour

19
A plan of care
  • Persons with diabetes require a systematic,
    integrated, multidisciplinary assessment
  • HBO may be indicated if local tissue hypoxia is
    thought to be involved
  • Any vascular surgery for large vessels is first
  • Transcutaneous oximetry
  • To identify likely benefit
  • Assimilate HBO treatment into care plan
  • 20- 30 sessions

20
Summary
  • HBO is a relatively safe, validated therapy
  • It does take time 30 daily sessions
  • It works best in tissues that are hypoxic to some
    degree
  • Improved oxygenation
  • Enhanced cell function (fibroblasts,
    angiogenesis)
  • Angiogenesis means the benefits of HBO will carry
    over for several months
  • We have a cheerful, committed team to facilitate
    the course of treatment
  • It is approved by Medicare

21
  • Intellectual property
  • This presentation remains the intellectual
    property of the author. No part of this
    presentation shall be reproduced, saved or
    altered without the authors express permission.
  • Disclaimer
  • The views presented are those of the author and
    may not reflect the views of SAWMA. The
    information contained in this presentation is
    intended as a general guide only. Application of
    this information should consider each persons
    individual circumstances. No responsibility is
    taken by RDNS for any harm to person or property
    arising from the information contained in this
    presentation. No responsibility is accepted by
    RDNS for the consequence of inaccuracy or
    omission of information contained in this
    presentation. Provision of this information by
    RDNS does not constitute endorsement of any
    product or organisation.
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