WELCOME

臨床高壓氧之併發症-20664 人次治療分析 吳文宏 M.D. 光田綜合醫院 外科部 整形外科  

Purpose: Clinical HBOT for various dis. is much more popular today. 2. Large series, longterm follow-up complication reports in Taiwan are still rare.  

  Materials and methods : . 1286 p’ts ( from Aug. of 2000 to Jul. of 2016) . M:F=766:520 ( 1.5:1 ) . Age: 3-90 years old (mean: 49.2) . 10-140 tx. for each p’t (mean:16, total:20664) . Test dose for each p’t before standard dose

Materials and methods : . Test dose: 1.9 ATA for 35 min. . Standard dose: 2.4 ATA for 120 min. . Follow up: 1-60 months (mean: 3 months) . 18 patients had ear membrane ventilation tube insertion (18/1286=1.40%) . 10/18 (55.56%) for intolerance of air pressure . 8/18 (44.44%) unclear patients for prevention of barotrauma  

Results: (complications) 1) Middle ear effusion: 6 p’ts (10ears)(6/1286=0.467%) 2) Myopia: 2 p’ts (2/1286=0.156%) one got 3 diopters after 140 tx. one got 1.7 diopters after 80 tx, 3) Oxygen seizure: 3 p’t (3/20664)=0.01452%) 4) Mild oxygen toxicity: 1 p’t

DISCUSSION :

46feet=2.4ATA

Why did we use 1.9 ATA as the testing dose? . The incidence of seizure is reported to be 0.01% in 28700 treatments at 2.4 ATA. . Use of pressure at 1.5 ATA does not lead to any oxygen induced-seizures when the duration of treatment was kept below one hour. . So we used the middle pressure of 1.5 to 2.4 ATA as the testing dose ( 1.9 ATA ) Davis JC, Dunn JM, Heimbach RD ( 1988 ) Hyperbaric medicine; patient selection, treatment procedures and side effects. In Davis JC, Hunt TK ( eds ) Problem wounds: the role of oxygen Elsevier, New York p225-235

Indications of Hyperbaric Oxygen Therapy Uses of HBO Approved by the Undersea and Hyperbaric Medical Society (Thom SR : Hyperbaric Oxygen Therapy : A Committee Report,Bethesda, Undersea & Hyperbaric Medical Society 1996) K.K.JAIN TEXTBOOK OF HYPERBARIC MEDICINE 5th Revised and Updated Edition P76 2009

1. Air of gas embolism 2. Carbon monoxide poisoning and inhalation injury 3. Clostridial myonecrosis (gas gangrene) 4. Crush injury, the compartment syndrome, and other acute traumatic ischemisa 5. Decompression sickness 6. Enhancement of healing in selected problem wounds.

7. Exceptional anemia resulting from blood loss 8. Necrotizing soft tissue infections (of subcutaneous tissue, muscle, or fascia) 9. Refractory osteomyelitis 10. Radiation tissue damage (Osteoradionecrosis) 11. Compromised skin grafts and flaps 12. Thermal burns 13. Brain abscess K.K.JAIN TEXTBOOK OF HYPERBARIC MEDICINE 5th Revised and Updated Edition P76 2009

Contraindications for HBO therapy 1. Absolute . Untreated tension pneumothorax 2. Relative 1) Upper respiratory infections 2) Emphysema with CO2 retension 3) Asymptomatic air cysts or blebs in the lungs seen on chest X-ray K.K.JAIN TEXTBOOK OF HYPERBARIC MEDICINE 5th Revised and Updated Edition P76 2009

Contraindications for HBO therapy 4) History of thoracic or ear surgery 5) Uncontrolled high fever 6) Pregnancy 7) Claustrophobia K.K.JAIN TEXTBOOK OF HYPERBARIC MEDICINE 5th Revised and Updated Edition P76 2009

Complications of Hyperbaric Oxygen Therapy 1)Middle ear barotrauma 2)Sinus pain 3)Myopia and cataract 4)Pulmonary barotrauma 5)Oxygen seizure 6)Decompression sickness 7)Genetic effects 8)Claustrophobia K.K.JAIN TEXTBOOK OF HYPERBARIC MEDICINE 5th Revised and Updated Edition P77 2009

Middle ear barotrauma Carlson et al 1992 . Frenzel’s maneuver can solve the problem. . May lead to permanent hearing loss & vertigo. . Unconscious p’ts. & infants are more likely . Nasal decongestants for prevention? ( No evidence ) Carlson et al 1992

  Middle ear barotrauma . More than 20% centers always do routine prophylactic myringotomies on intubated p’ts( 30/126) & infants (19/86) . Less than 50% of the centers never performed the procedures as routine prophylaxis. . 33% centers (49/145) routinely administered prophylactic drugs before HBOT ( topical nasal decongestants: oxymetazoline ) Capes & Tomaszewski 1996

Eustachian tube dysfunction   . 87% developed serious otitis media. . 47% of serious otitis media p’ts required tympanostomy tubes. . E - tube dysfunction after first HBOT has high risk of serious otitis media with subsequent txs. Fernau et al 1992

Incidence of seizure in HBOT? Wu WH, 2010 0.015% 20664tx., 1286 case, 2.4ATA Huang KC, 2006 0.109%, 4638 tx. 240 cases 2.4 ATA Huang KC, J Trauma. 2006 Oct;61(4):913-7.

Hemodynamic changes in HBOT Cardiac output decreased from 13.91 to 8.91(min-liter) (64.05%) Heart rate decreased from 104.7 to 94.0 (89.78%) Stroke volume decreased from 133 to 96 (ml) (72.18%) Elevation of blood pressure Int Arch Occup Environ Health. 2001 Mar;74(2):119-22. Carotid body, aortic body: PO2 receptors, carotid sinus(bifucation), aortic sinus(arch): BP receptors

HBO vs BLOOD PRESSURE HBO caused significant elevation in SBP (11%) and DBP (12%) and a decrease in HR (18%) (p <0.001). Patients with DM and HTN showed higher elevation in SBP and DBP. HBO caused a marked elevation in SBP and DBP when basal SBP was >140 mmHg. Critical elevation was obtained when SBP was >160 mmHg. The use of beta blockers caused significant elevation of blood pressure while reducing HR. Arch Med Res. 2006 Nov;37(8):991-7.

HBO vs BSL (blood sugar level) HBO(2) lowered BGL by 23% (p <0.001). When basal BGL was in the range of 120-170 mg/dl, it dropped to <100 mg/dl in 31/60 treatment sessions (52%). When basal BGL was <120 mg/dl it dropped to <70 mg/dl in 8/34 sessions. There was a possibility of lowered BGL when basal BGL was <170 mg/dl and a marked reduction in BGL occurred when basal BGL was <120 mg/dl. Arch Med Res. 2006 Nov;37(8):991-7.

HBO vs DM HBO causes elevation of blood pressure and lowering of HR and BGL (blood glucose level), which were augmented in the presence of HTN, DM, or beta blocker. The use of beta blockers for the management of HTN should be avoided during HBO therapy. Arch Med Res. 2006 Nov;37(8):991-7.

Drug effect with HBOT Digitalis: HBOT increase digitalis effection Insulin: HBOT delay insulin peak level time Nicotine: increase incidence of seizure Nitroprusside: vessel dilutation; HBOT: vasoconstriction Sulfamylon: peripheral vessel dilutation: HBOT: more proximal vessel constriction; leads to higher motality Thyroid hormone: increase incidence of seizure Inderal: check heart rate before HBOT Tenormin: check heart rate before HBOT

Conclusion: 1. No lethal complications (2.4 ATA. For 20664 Tx.)   Conclusion: 1. No lethal complications (2.4 ATA. For 20664 Tx.) 2. Hx. taking, vital signs, eardrum exam.,CxPA, CBC, and blood sugar are important before treatment. 3. HBO test dose is useful for reducing complications.

4. For seizure patient treatment, a multiplace chamber equipped with an antechamber is possibly the better facility in consideration of safety.

Radiation induced cystitis 96-2-3 96-1-27