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Hyperbaric Oxygen Treatment for Diabetic Foot Wounds






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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. Hyperbaric Oxygen Treatment is breathing 100% oxygen at an ambient pressure greater than 1 atmosphere absolute. It is not:Breathing 100% oxygen at normobaric pressureTopical application of hyperbaric oxygen to a limb.
Hyperbaric Oxygen Treatment for Diabetic Foot Wounds

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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?

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

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 < 40mmHg Neutrophil function poor with PtcO2 < 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

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 author?s 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 person?s 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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