Dive for Life Hyperbaric Oxygen for Fourniers Gangrene

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

Intensive Care United Christian Hospital 2

History ß ß ß 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 ß ß ß BP 98/63. P 110 regular RR 18 / min GCS 15/15 Sp. O 2 100% (on 100% O 2) H’stix 23. 9 ECG: Sinus tachycardia. No acute ischemic change 4

Physical Examination ß ß ß 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 ß Emergency contrast CT Thorax + Abdomen + Pelvis performed: Ø Ø 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 ß ß ß 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 10 cm subfascial abscess collection at Rt scrotum and R inguinal region, with necrotic R scrotal fascia Necrosis of preperitoneal fat with abscess collection 11

Operation ß ß Bowels intact Testes viable Drainage of abscess (total 200 ml pus drained) + extensive debridement + transverse colostomy done Post-op ICU care 12

14

15

ICU Progress ß ß ß Put on IV Tazocin + Flagyl + Clindamycin Insulin infusion for glycemic control Borderline hemodynamic Worsening RFT / metabolic acidosis requiring CVVH Hb. A 1 c 11. 8% R scrotal abscess swab & peritoneal fluid grew Bacteriodes sp. & Propionibacterium Granulosum 16

ICU Progress ß ß ß Multiple sessions of follow-up debridement Started hyperbaric oxygen therapy (HBO) after 2 nd 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 ß ß ß 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

ß ß 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

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

Treatment of NF ß ß 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 ß Riseman and colleagues reported that addition of HBO to surgical and antibiotic treatment reduced mortality versus surgery and antibiotics alone. Þ Þ 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 ß ß ß 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) ß 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. ß Complete resolution of uremic symptoms in Timkin (Ball Bearing Manufacturer) ß 33

Definition of HBO ß ß Breathing 100 % O 2 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 Þ HBO potentiates radiotherapy ß Boerma (1955 -Univ Amsterdam) – Þ Life without Blood Þ HBO in cardiac surgery ß 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. ß ß ß 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” @2 ATA (50%vol), @3 ATA ( 1/3 vol ), @4 ATA (25% vol ) Successfully applied to air embolism and decompression sickness 39

Tissue Hyperoxia ß ß ß At sea level, room air, only 3 ml/L of oxygen dissolved in blood Tissue requirement ~60 ml/L/min at rest At 3 ATA of pure O 2, dissolved oxygen ~60 ml/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 T 1/2 RA 240 -360 min vs @100% O 2 T 1/2~80 -100 min vs HBO Rx T 1/2@~20 min 42

Oxygen Effects on Blood Flow ß Blood flow Þ 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 @3 ATA bactericidal for clostridium perfringens inhibit Alpha toxin production 44

Mechanisms of antimicrobial effect ß ß ß 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 ß ß ß ß Air or gas embolism CO poisoning Cyanide poisoning Crush injury and other acute traumatic ischemias Decompression sickness Enhancement of healing in selected problem wounds Blood loss anemia that refused transfusion ß ß ß ß 46 Selected refractory anaerobic infections Gas gangrene Necrotizing soft tissue infections Refractory osteomyelitis Radiation Necrosis Compromised Skin Grafts or Flaps Thermal Burns

HBO Trial ß ß 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 ß ß ß Mindrup identified 42 patients with Fournier’s gangrene diagnosed between 1993 – 2002 in Lowa, USA 26 patients received surgical debridement + antibiotic + 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 ß ß Mortality: 12. 5% (non. HBO) Vs 26. 9% (HBO), p=0. 44 Average daily hospital charges: USD$2, 552 (non. HBO) Vs USD$3, 384 (HBO), p < 0. 01 50 J Urol. 2005 Jun; 173(6): 1975 -77

Risk of HBO ß Barotrauma Þ Þ ß Ear damage – barotitis media 24% require tympanostomy Sinus damage Ruptured middle ear Lung damage Oxygen toxicity Þ Þ Brain: Convulsion (rare 1/100, 000 ) Lung: Pulmonary edema, hemorrhage Respiratory failure due to pulmonary fibrosis 51

Risk of HBO ß ß ß Decompression Illness Pneumothorax Gas emboli 52

Oxygen Toxicity ß ß Hypoglycemia Pulmonary (>0. 5 ATA) Þ Þ Þ ß Intratracheal and bronchial irritation Initial cough, dysnea, tightness Pulm edema and ARDS possible Occular Þ Þ Progressive myopia (20 -40% incidence) recovery w/in 2 months post tx. Cataracts- new and progression increase risk for repeated exposure 53

Contraindication ß ß Absolute: Untreated pneumothorax Relative: Þ URI Þ Emphysema with CO 2 retention Þ Pulmonary lesion in CXR Þ Uncontrolled high fever Þ Claustrophobia Þ Seizure disorder Þ Malignant disease 54

Issue of HBO ß ß never substitute for the primary interventions Never delay the planned surgical treatment 55

HBO in HK ß 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. ß ß ß 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 ß 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? ß ß Contact the duty officer of the occupational Health Service Call list and phone number can be assess via the AED your Hospital 58

ß Monoplace Chamber 59

Multiplace Chamber 60

61

Fire Hazard ß ß 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 ß ET cuff air replaced with water ß 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 ß 75

Escort staff ß ß ß No claustrophobia Able to equalize middle ear pressure by Valsava manoeuvre No URTI symptom 76

Patient monitoring and management ß ß ß 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 20 drop/ml ) Handheld suction equipment Ambubag and resuscitation instructment No defribrillator 77

Patient monitoring and management ß ß ß 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 ß ß ß 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 is available 79

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

Precaution ß ß ß 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 ß ß ß 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