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Dive for Life Hyperbaric Oxygen for Fournier’s Gangrene

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. History. M/39 Sales Unremarkable past health

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Dive for Life Hyperbaric Oxygen for Fournier’s Gangrene

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  1. Dive for LifeHyperbaric 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

  2. Intensive Care Unit United Christian Hospital

  3. History M/39 Sales Unremarkable past health Came to AED alone c/o chest pain radiating to back, with associated dizziness Apparently being unwell

  4. 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

  5. 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

  6. CXR on Admission

  7. X- Ray

  8. 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

  9. CT Abdomen

  10. DiagnosisFournier’s Gangrene 10

  11. 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

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

  13. 以下圖片可能令人情緒不安敬請留意

  14. 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

  15. 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

  16. ICU Progress Patient undergone repeated debridement with uncontrollable intraabdominal sepsis and VAP Blood culture with candida and burkholderia septicaemia Eventually died in ICU 18

  17. Fournier’s Gangrene 19

  18. 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

  19. Surg Clin North Am. 2002 Dec;82(6):1213-24.

  20. Surg Clin North Am. 2002 Dec;82(6):1213-24.

  21. Infectious causes of soft tissue gas • Clostridial myonecrosis • Clostridial anaerobic cellulitis • Nonclostridial anaerobic cellulitis • Synergistic necrotizing cellulitis • Necrotizing fasciitis • Nonclostridial crepitant myositis

  22. Fournier’s Gangrene NF of the genitalia and perineum Aetiology: Polymicrobial infection - aerobic →strept., staph., E-coli, P-aeroginosa, klebsiella - anaerobic → bacteroides, clostridia 24

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

  24. 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.

  25. Necrotizing Fasciitis andFournier’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 functionand suppress bacterial growth

  26. Hyperbaric oxygen treatment

  27. AdjunctiveTreatment for Fournier’s Gangrene

  28. 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 30treatments.

  29. 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

  30. History of HBO Fontaine (1879): pressurized mobile operating room 32

  31. 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

  32. Definition of HBO Breathing 100 % O2intermittently Chamber pressure increased at least 1.4 atmosphere absolute 34

  33. 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 Hyperbaric Oxygen Therapy 35

  34. Boerma: “Life without blood.” 3 ATA 36

  35. 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

  36. 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

  37. 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

  38. 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

  39. Tissue oxygen tension measurement 41

  40. 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

  41. 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

  42. HBO 4. Bacteriostasis: Inhibits growth of anaerobic as well as some aerobic organisms @3ATA bactericidal for clostridium perfringens inhibit Alpha toxin production 44

  43. 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

  44. indications HBO is generally used as an adjunctive therapy; it does not compete with or replace other treatment methods 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 Selected refractory anaerobic infections Gas gangrene Necrotizing soft tissue infections Refractory osteomyelitis Radiation Necrosis Compromised Skin Grafts or Flaps Thermal Burns 46

  45. HBO Trial Ann Chir Gynaecol, suppl., 89: 7, 2000 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%)

  46. HBO Trial J Urol. 2005 Jun; 173(6):1975-77 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

  47. HBO Trial J Urol. 2005 Jun; 173(6):1975-77 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

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