1. 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

2. United Christian Hospital
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. Diagnosis Fournier’s Gangrene10

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

16. 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

17. 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

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

19. Fournier’s Gangrene 19

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.

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

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

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

26. 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.

27. Necrotizing Fasciitis and Fournier’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 function and suppress bacterial growth
Mechanisms and efficacy of HBO is difficult to assess because synergistic bacterial processes are dificult to establish. HBO may potentiate antibiotic efficacy and several animal models of bacteremia and sepsis have reported increased survival with HBO

28. Hyperbaric oxygen treatment

29. Adjunctive Treatment for Fournier’s Gangrene

30. 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 30 treatments.

31. 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

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

33. 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

34. Definition of HBO Breathing 100 % O2 intermittently
Chamber pressure increased at least 1.4 atmosphere absolute 34 34

35. Hyperbaric Oxygen Therapy
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 35

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

37. 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

38. 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

39. HBO
2. Bubble size reduction ( Boyle’s Law ): “Any free gas trapped in the body will decrease in volume as the pressure on it ( 1/3vol (25% vol ) Successfully applied to air embolism and decompression sickness 39

40. 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

41. Tissue oxygen tension measurement41 41

42. HBO
3. Gas wash out effect The flooding of the body with any one gas tends to "wash out" all for CO intoxication COHB T1/2 RA min O2T1/2~80-100min vs HBO Rx 42

43. Oxygen Effects on Blood Flow
Preserved in ischemic tissues
Improved perfusion in acute wounds (Hammarlund)
Improved flow in ischemic flaps (Zamboni 1992) 43

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

45. 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 45

46. 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

47. HBO Trial
A retrospective study conducted by Korhonen in Finland evaluated outcome of 33 patients with perineal necrotizing fasciitis treated with surgical debridement + antibiotics + ATA pressure (2-12 times) between
3 patients died (mortality 9.1%)
Ann Chir Gynaecol, suppl., 89: 7, 2000

48. HBO Trial
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
J Urol Jun; 173(6):

50. HBO Trial 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
J Urol Jun; 173(6):

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

52. Risk of HBO
Decompression Illness
Pneumothorax
Gas emboli

53. Oxygen Toxicity Hypoglycemia Pulmonary (>0.5 ATA) Occular
Intratracheal and bronchial irritation
Initial cough, dysnea, tightness
Pulm edema and ARDS possible
Occular
Progressive myopia (20-40% incidence) recovery w/in 2 months post tx.
Cataracts- new and progression increase risk for repeated exposure

54. Contraindication Absolute: Untreated pneumothorax Relative: URI
Emphysema with CO2 retention
Pulmonary lesion in CXR
Uncontrolled high fever
Claustrophobia
Seizure disorder
Malignant disease

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

56. HBO in HK 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
Pirvate Facility
Hong Kong Diving & Hyperbaric Medicine Center
 香港潛水及高壓氧治療中心 ( monoplace chamber avaliable )

57. Government HBO Facility
Jointly run by the
Fire service department
Occupational Health service of the labour department
Maintanance by the E&M department 57

58. How to arrange?
Contact the duty officer of the occupational Health Service
Call list and phone number can be assess via the AED your Hospital 58

59. Monoplace Chamber

60. Multiplace Chamber

62. Fire Hazard
there was 60 fatalities from 24 chamber fire accidents between
You are at risk of combusted to ashes within minute accelerated by the high ambient oxygen

69. Safety and emergency measures

70. Where numbers really count !

71. These are all for you!

75. Patient preparation for ventilated patient
Prophylactic myringotomy
ET cuff air replaced with water
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

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

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

78. Patient monitoring and management
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

79. Patient monitoring and management
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 valve is available 79

80. Scenario for desaturation
1. airbreak period to prevent O2 toxicity
2. if ambient O2 concentration of the chamber is too high, O2 supply will be cut back to 21% ( you and your patient as well )
Ascent Phase

81. Precaution
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

82. HBO and Fourner’s Gangrene
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.

83. End
Thank You