practice
Role of hyperbaric medicine for intractable leg ulcers: a case report We present a case report of intractable multifactorial leg ulcer that was treated successfully with multiple approaches including hyperbaric oxygen treatment (HBOT) to prepare for skin grafting . A 66-year-old female with a history of rheumatoid arthritis and Felty’s syndrome presented with a nonhealing ulcer on her left leg that was caused by a trauma. She failed multiple treatment options including debridement, different wound dressings, antibiotics, anti-inflammatories and vein closure procedure. She finally healed with skin graft following HBOT that prepared the wound bed before the procedure. ulcer ; venous stasis; autoimmune disorder; hyperbaric medicine
Conflict of Interest: none
S18
patients with rheumatoid arthritis had a leg ulcer,5 increasing to 22% of patients with Felty’s syndrome,6 a condition where rheumatoid arthritis is complicated by neutropenia and splenomegaly. Patients with rheumatoid arthritis and vasculitic ulcers have a higher mortality rate and worse prognosis when compared with patients with rheumatoid arthritis.7 Occasionally, ulcers can represent a combination of the aforementioned types.8 In wound care, hyperbaric oxygen therapy (HBOT) has been used as an management option for diabetic foot ulcers, acute ischemic ulcers and crush injuries.9 It delivers 100% oxygen at an increased atmospheric pressure inside a pressurised mono or multiplace chamber.9 A monoplace chamber is a Fig 1. Wound at presentation.
ltd
Email: Nedaa.Skeik@ allina.com
D
ifferent types of ulcers are classified based on aetiology, location and appearance; and tend to have different management options. Venous leg ulceration is the most common type, with a prevalence of 1% in the United States and comprising up to 80% of lower extremity ulcers. It is more common among women and the elderly.1 Venous leg ulcers develop due to stagnant venous bloodflow caused by underlying chronic venous insufficiency. They are not usually very painful and mostly located at the malleolar areas. The skin is typically erythematous, scaly, and crusty with fibrinous exudate.2 Risk factors are old age, obesity, previous leg injury, deep vein thrombosis, and phlebitis. Management should focus on closing the culprit vein. Other management strategies include compression, leg elevation, debridement, dressings, negative pressure wound therapy (NPWT), skin grafting if required, and antibiotics in cases of infection.1 Diabetic foot ulcers result from multiple factors including neuropathy, autonomic dysfunction, vascular insufficiency and infection. Such ulcers arise in areas of repeated trauma, and have undermined borders and excessive hyperkeratotic tissue. Patients usually have a loss of sensation so these ulcers are typically painless.2 Ischaemic ulcers develop when arterial circulation is interrupted, causing inadequate blood perfusion. They are usually located distally and/or over boney areas. They are painful, have punched out wound margins, and have a gray, yellow, or pale wound bed.2 Inflammatory ulcers are skin manifestation of an inflammatory disorder such as rheumatoid arthritis and lupus.3 The prevalence of leg ulcers is higher among patients with rheumatoid arthritis. While only 1% of the adult population will develop a chronic leg ulcer,4 Thurtle et al showed 9% of
© 2014 MA Healthcare
N. Skeik,1 MD, FACP, FSVM, Section Head, Vascular Medicine Medical Director, Hyperbaric Oxygen Center; F Kia,1 Research Intern; D, Klosterman,2 HBO, Supervisor Technician. 1 Minneapolis Heart Institute; Minneapolis Heart Institute Research Foundation; 920 E 28th Street, Minneapolis MN 55449. 2 Abbott Northwestern Hospital, 920 E 28th Street, Minneapolis MN 55449.
J O U R N A L O F WO U N D C A R E C A S E S U P P L E M E N T V O L 2 3 , N O 1 0 , 2 0 1 4
Journal of Wound Care.Downloaded from magonlinelibrary.com by 130.088.053.018 on October 19, 2014. For personal use only. No other uses without permission. . All rights reserved.
practice pressurised vessel that fits one person, while a multiplace chamber fit two or more patients.9 The duration of treatment can vary between 90 and 120 minutes and the pressure can range from two to three times atmospheric pressure. The number of treatments can vary (10–60 treatments) based on the indication, aiming at once or multiple times a day.10 Oxygen is mainly transported by binding to haemoglobin, which is close to saturation in room air. With hyperbaric oxygen supplementation haemoglobin becomes fully oxygenated. According to Henry’s law, as pressure increases, oxygen dissolves into blood plasma, increasing the amount of free oxygen available to be delivered from the capillaries to ischaemic tissue.11,12 The clinical indications for HBOT are determined by the Undersea and Hyperbaric Medical Society and the Centers for Medicare and Medicaid Services. Although similar, some indications vary (Table 1).13,14
Case report A 66-year-old female with history of rheumatoid arthritis and Felty’s syndrome presented with a fullthickness ulcer on the left medial calf caused by a minor trauma 10 months earlier. She had developed spontaneous left leg blisters that broke up into ulcerations and enlarged over time. She underwent multiple treatment options including debridement, different wound dressings, NPWT and multiple antibiotics for acquired infections with partial improvement. She also had an incompetent greater saphenous vein post-radiofrequency ablation. She had a long history of rheumatoid arthritis and Felty’s syndrome with chronic severe neutropenia that had been managed with rituximab, methorexate, and steroids. Vital signs revealed a blood pressure of 105/60mmHg, temperature of 37.8°C, respiratory rate of 12 breaths per minute, and body mass index of 28.84kg/m2. Physical examination revealed a full-thickness ulcer at the medial aspect of the left distal calf measuring 6cm wide and 12cm long with a fibrinous cap, surrounding erythema, and serous discharge (Fig 1). She also had ulnar deviation, swan neck deformities and normal pedal pulses. The rest of the physical exam was unremarkable. The wound diameter, volume and wound bed characteristics were document-
Table 1. Indications for HBOT from undersea and hyperbaric medical society vs. centers for medicare and medicaid services. Undersea and hyperbaric medical society
Centers for medicare and medicaid services
Carbon monoxide poisoning
Acute carbon monoxide intoxication
Decompression sickness
Decompression illness
Air and gas embolism
Gas embolism
Gas Gangrene
Gas gangrene
Acute traumatic ischemias
Acute traumatic peripheral ischaemia
Crush injury wounds
Crush injuries and suturing of severed limbs
Necrotising soft tissue infections
Progressive necrotising infections
Arterial insufficiencies
Acute peripheral arterial insufficiency
Compromised grafts and flaps
Preparation and preservation of compromised skin grafts
Osteomyelitis
Chronic refractory osteomyelitis
Cyanide poisoning
Cyanide poisoning
Delayed radiation injury
Soft-tissue radionecrosis as an adjunct to conventional treatment Osteoradionecrosis as an adjunct to conventional treatment Actinomycosis, only as an adjunct to conventional therapy Diabetic wounds of the lower extremities with Wagner grade III or higher
Idiopathic sudden sensorineural hearing loss Intracranial abscess Compartment syndrome Acute thermal brain injury Severe anaemia
ed at each visit, when the wound was also photographed. Laboratory findings revealed a white blood cell count of 0.88thou/cumm (normal range 4.5– 13thou/cumm), an absolute neutrophil count (ANC) of 0.2thou/cumm, (normal range 1.5–8thou/ cumm), a Hgb haemoglobin count of 8.6g/dl (normal range 13–16g/dl), a haematocrit of 26.7% (normal range 35-51%), and platelet count of 119thou/ cumm (normal range 140–440thou/cumm). She had an unremarkable complete metabolic profile including renal and hepatic function tests. Immu-
Placement
TcPO2 reading in Room Air (mmHg)
TcPO2 reading with100% oxygen supplementation (mmHg)
Right upper chest
64
152
Left mid-calf proximal to wound
36
148
Left medial ankle posterior to wound
64
196
Left medial foot distal to wound
79
170
s
© 2014 MA Healthcare
ltd
Table 2.Transcutaneous oxygen pressure (TcPO2) levels at presentation
J O U R N A L O F WO U N D C A R E
C A S E S U P P L E M E N T VO L 2 3 , N O 1 0 , 2 0 1 4
S19
Journal of Wound Care.Downloaded from magonlinelibrary.com by 130.088.053.018 on October 19, 2014. For personal use only. No other uses without permission. . All rights reserved.
practice Fig 2. Wound healing throughout Hyperbaric Oxygen Therapy (HBOT) which was continued for 32 days. Days are provided based on the HBOT start date.
a Day 4
bDay 8
c Day 18
d Day 25
e Day 29
f Day 36
g Day 57
h Day 71
S20
Discussion HBOT has been recognised as a supplementary management tool for ulcers including diabetic foot, acute ischaemic ulcers and wounds with a history of chronic refractory osteomyelitis and radiation. It can also be used to prepare the wound site for skin grafting. HBOT plays different roles in managing
ltd
ver sulphadiazine cream once a day. The patient underwent selective excisional ulcer debridement including skin, subcutaneous tissue, and underlying muscle and tendon after which NPWT was applied for eight days. HBOT and the other wound managements strategies mentioned above improved the wound remarkably (Fig 2). After a total of 23 HBOT treatments, successful sclerotherapy treatment for the two incompetent perforator veins feeding into the ulceration was performed and a 120cm2 split-thickness skin graft from the left thigh was placed on the left leg. The wound completely healed after an additional 13 HBOT treatments post-graft implantation as shown in Fig 2.
© 2014 MA Healthcare
nology work up revealed elevated erythrocyte sedimentation rate which was 58mm/hour and C-reactive protein of 8.3mg/dl, but was negative for anti-neutrophil cytoplasmic antibody (ANCA) which ruled out ANCA related vasculitis. Transcutaneous oxygen pressure measurements revealed moderate decreased TcPO2 value at the left mid-calf proximal to the wound with good response to oxygen challenge (Table 2). Venous insufficiency ultrasound revealed two incompetent perforating veins proximal to the wound. Management was started with wound debridement, foam dressing, leg elevation and compression. Based on the TcPO2 results and the wound assessment that revealed large mottled base, and given that the patient failed many treatment modalities, she was deemed high risk for skin graft failure and so HBOT was started at 2.0ATA without oxygen breaks to prepare the wound bed for skin grafting. A few days later, the wound became infected with Escherichia coli, Proteus mirabilis, Enterococcus, and Pseudomonas, which was managed with intravenous imipenem-cilastatin (500 mg every 6 hours) and sil-
J O U R N A L O F WO U N D C A R E C A S E S U P P L E M E N T V O L 2 3 , N O 1 0 , 2 0 1 4
Journal of Wound Care.Downloaded from magonlinelibrary.com by 130.088.053.018 on October 19, 2014. For personal use only. No other uses without permission. . All rights reserved.
practice Table 3.TcPO2 interpretation guide. Grade
TcPO2 Value in mmHg
Normal
>45
Mild
40–45
Moderate
20–39
Severe
1–20
Critical
0
References 1. Collins, L., Seraj, S. Diagnosis and Treatment of Venous Ulcers. Am Fam Physician 2010; 81: 8, 989–996. 2. Lazarides, M.K., Giannoukas, A.D. The role of hemodynamic measurements in the
J O U R N A L O F WO U N D C A R E
management of venous and ischemic ulcers. Int J Low Extrem Wounds 2007; 6: 4, 254–261. 3. Hoffman, M.D. Inflammatory Ulcers. Clinical Dermatol 2007; 25:1, 131–138. 4. McRorie, E.R., Jobanputra, P., Ruckley, C.V., Nuki, G. Leg
Conclusion Our report represents a unique case where the wound healing was delayed by multiple factors including systemic inflammation, neutropenia (Felty’s syndrome), infection, and trauma. Initially, the wound failed to heal despite intensive conventional wound care, but HBOT proved to be an effective method when used in adjunct with other modalities including skin grafting. We believe that HBOT is underused even when it is indicated for wound healing. We recommend considering HBOT as an adjunctive modality when indicated for wound management.n ulceration in rheumatoid arthritis. Br J Rheumatol 1994; 33: 11,1078–1184. 5. Thurtle, O.A., Cawley, M.I.D. The frequency of leg ulceration in rheumatoid arthritis: a survey. J Rheumatol 1983; 10: 3, 507–509.
C A S E S U P P L E M E N T VO L 2 3 , N O 1 0 , 2 0 1 4
6. Laszlo, J., Jones, R., Silberman, H.R., Banks, P.M. Splenectomy for Felty’s syndrome. Clinicopathological study of 27 patients. Arch Intern Med 1978; 138: 4, 597–602. 7. Oien, R.F., Hakansson, A., Hansen, B.U. Leg ulcers in
s
© 2014 MA Healthcare
ltd
non-healing ulcers by enriching oxygen, fighting infection and promoting the healing process.15-17 It increases the amount of oxygen-free radicals, creating a gradient around a wound that has little or no oxygen supply. Oxygen is then able to diffuse from healthy capillaries to hypoxic tissue areas, providing enough oxygen for the wound to heal.18 The rise in oxygen promotes collagen formation and cross-linking, fibroblast differentiation and proliferation, angiogenesis, and the antibacterial function of leuocytes.17 HBOT can help prepare for a skin graft or preserve compromised flaps by increasing oxygen supply to graft and or flap sites. Once the graft is in place, it relies on the diffusion of oxygen and angiogenesis from the wound site.9 If considered prior and post skin graft implantation, HBOT can maximise the oxygen diffusion to the wound bed and graft tissues A study performed by Feldmeier indicates that HBOT increases the amount of oxygen transferred by 16 times, and increases the amount of oxygen between the wound bed, margins, and graft by 1500%.19 In a prospective randomised, , clinical trial by Perrins et al., 24 patients were treated with HBOT after receiving a skin graft, and 24 patients were part of the placebo group. Complete graft take (defined as >95% total surface area take) occurred in 64% of the treatment group vs. 17% of the control group, suggesting that HBOT drastically improves the chances of graft survival.20 In the treatment group, 100% demonstrated greater than 60% graft take, and 84% demonstrated permanent graft survival.20 In a study by Bowersox et al. 91% of patients recommended skin grafts recovered following HBOT.21 Even though one randomised clinical trial performed by Hammarlund et al. showed that HBOT resulted in a 33% decrease in venous leg ulcer wound size compared with a control group,22 venous leg ulcers are not yet an approved indication for HBOT. A main form of treatment for lower extremity venous
leg ulcers is currently oedema reduction therapy.9 Transcutaneous oxygen pressure (TcPO2) measures tissue oxygen perfusion at the capillary level and thus reflects microcirculation status.23 Transcutaneous oximetry helps determine the probability of wound healing or tissue salvage by measuring regional tissue oxygenation. For instance, periwound TcPO2 levels below 30mmHg can reliably predict poor healing with complications.19 TcPO2 grades and corresponding values in mmHg are shown in Table 3.19 Measuring TcPO2 may help assess candidacy for HBOT and the likelihood of HBOT benefit.23 A good candidate for HBOT would be a patient with abnormal TcPO2 in room-air (
Role of hyperbaric medicine for intractable leg ulcers: a case report We present a case report of intractable multifactorial leg ulcer that was treated successfully with multiple approaches including hyperbaric oxygen treatment (HBOT) to prepare for skin grafting . A 66-year-old female with a history of rheumatoid arthritis and Felty’s syndrome presented with a nonhealing ulcer on her left leg that was caused by a trauma. She failed multiple treatment options including debridement, different wound dressings, antibiotics, anti-inflammatories and vein closure procedure. She finally healed with skin graft following HBOT that prepared the wound bed before the procedure. ulcer ; venous stasis; autoimmune disorder; hyperbaric medicine
Conflict of Interest: none
S18
patients with rheumatoid arthritis had a leg ulcer,5 increasing to 22% of patients with Felty’s syndrome,6 a condition where rheumatoid arthritis is complicated by neutropenia and splenomegaly. Patients with rheumatoid arthritis and vasculitic ulcers have a higher mortality rate and worse prognosis when compared with patients with rheumatoid arthritis.7 Occasionally, ulcers can represent a combination of the aforementioned types.8 In wound care, hyperbaric oxygen therapy (HBOT) has been used as an management option for diabetic foot ulcers, acute ischemic ulcers and crush injuries.9 It delivers 100% oxygen at an increased atmospheric pressure inside a pressurised mono or multiplace chamber.9 A monoplace chamber is a Fig 1. Wound at presentation.
ltd
Email: Nedaa.Skeik@ allina.com
D
ifferent types of ulcers are classified based on aetiology, location and appearance; and tend to have different management options. Venous leg ulceration is the most common type, with a prevalence of 1% in the United States and comprising up to 80% of lower extremity ulcers. It is more common among women and the elderly.1 Venous leg ulcers develop due to stagnant venous bloodflow caused by underlying chronic venous insufficiency. They are not usually very painful and mostly located at the malleolar areas. The skin is typically erythematous, scaly, and crusty with fibrinous exudate.2 Risk factors are old age, obesity, previous leg injury, deep vein thrombosis, and phlebitis. Management should focus on closing the culprit vein. Other management strategies include compression, leg elevation, debridement, dressings, negative pressure wound therapy (NPWT), skin grafting if required, and antibiotics in cases of infection.1 Diabetic foot ulcers result from multiple factors including neuropathy, autonomic dysfunction, vascular insufficiency and infection. Such ulcers arise in areas of repeated trauma, and have undermined borders and excessive hyperkeratotic tissue. Patients usually have a loss of sensation so these ulcers are typically painless.2 Ischaemic ulcers develop when arterial circulation is interrupted, causing inadequate blood perfusion. They are usually located distally and/or over boney areas. They are painful, have punched out wound margins, and have a gray, yellow, or pale wound bed.2 Inflammatory ulcers are skin manifestation of an inflammatory disorder such as rheumatoid arthritis and lupus.3 The prevalence of leg ulcers is higher among patients with rheumatoid arthritis. While only 1% of the adult population will develop a chronic leg ulcer,4 Thurtle et al showed 9% of
© 2014 MA Healthcare
N. Skeik,1 MD, FACP, FSVM, Section Head, Vascular Medicine Medical Director, Hyperbaric Oxygen Center; F Kia,1 Research Intern; D, Klosterman,2 HBO, Supervisor Technician. 1 Minneapolis Heart Institute; Minneapolis Heart Institute Research Foundation; 920 E 28th Street, Minneapolis MN 55449. 2 Abbott Northwestern Hospital, 920 E 28th Street, Minneapolis MN 55449.
J O U R N A L O F WO U N D C A R E C A S E S U P P L E M E N T V O L 2 3 , N O 1 0 , 2 0 1 4
Journal of Wound Care.Downloaded from magonlinelibrary.com by 130.088.053.018 on October 19, 2014. For personal use only. No other uses without permission. . All rights reserved.
practice pressurised vessel that fits one person, while a multiplace chamber fit two or more patients.9 The duration of treatment can vary between 90 and 120 minutes and the pressure can range from two to three times atmospheric pressure. The number of treatments can vary (10–60 treatments) based on the indication, aiming at once or multiple times a day.10 Oxygen is mainly transported by binding to haemoglobin, which is close to saturation in room air. With hyperbaric oxygen supplementation haemoglobin becomes fully oxygenated. According to Henry’s law, as pressure increases, oxygen dissolves into blood plasma, increasing the amount of free oxygen available to be delivered from the capillaries to ischaemic tissue.11,12 The clinical indications for HBOT are determined by the Undersea and Hyperbaric Medical Society and the Centers for Medicare and Medicaid Services. Although similar, some indications vary (Table 1).13,14
Case report A 66-year-old female with history of rheumatoid arthritis and Felty’s syndrome presented with a fullthickness ulcer on the left medial calf caused by a minor trauma 10 months earlier. She had developed spontaneous left leg blisters that broke up into ulcerations and enlarged over time. She underwent multiple treatment options including debridement, different wound dressings, NPWT and multiple antibiotics for acquired infections with partial improvement. She also had an incompetent greater saphenous vein post-radiofrequency ablation. She had a long history of rheumatoid arthritis and Felty’s syndrome with chronic severe neutropenia that had been managed with rituximab, methorexate, and steroids. Vital signs revealed a blood pressure of 105/60mmHg, temperature of 37.8°C, respiratory rate of 12 breaths per minute, and body mass index of 28.84kg/m2. Physical examination revealed a full-thickness ulcer at the medial aspect of the left distal calf measuring 6cm wide and 12cm long with a fibrinous cap, surrounding erythema, and serous discharge (Fig 1). She also had ulnar deviation, swan neck deformities and normal pedal pulses. The rest of the physical exam was unremarkable. The wound diameter, volume and wound bed characteristics were document-
Table 1. Indications for HBOT from undersea and hyperbaric medical society vs. centers for medicare and medicaid services. Undersea and hyperbaric medical society
Centers for medicare and medicaid services
Carbon monoxide poisoning
Acute carbon monoxide intoxication
Decompression sickness
Decompression illness
Air and gas embolism
Gas embolism
Gas Gangrene
Gas gangrene
Acute traumatic ischemias
Acute traumatic peripheral ischaemia
Crush injury wounds
Crush injuries and suturing of severed limbs
Necrotising soft tissue infections
Progressive necrotising infections
Arterial insufficiencies
Acute peripheral arterial insufficiency
Compromised grafts and flaps
Preparation and preservation of compromised skin grafts
Osteomyelitis
Chronic refractory osteomyelitis
Cyanide poisoning
Cyanide poisoning
Delayed radiation injury
Soft-tissue radionecrosis as an adjunct to conventional treatment Osteoradionecrosis as an adjunct to conventional treatment Actinomycosis, only as an adjunct to conventional therapy Diabetic wounds of the lower extremities with Wagner grade III or higher
Idiopathic sudden sensorineural hearing loss Intracranial abscess Compartment syndrome Acute thermal brain injury Severe anaemia
ed at each visit, when the wound was also photographed. Laboratory findings revealed a white blood cell count of 0.88thou/cumm (normal range 4.5– 13thou/cumm), an absolute neutrophil count (ANC) of 0.2thou/cumm, (normal range 1.5–8thou/ cumm), a Hgb haemoglobin count of 8.6g/dl (normal range 13–16g/dl), a haematocrit of 26.7% (normal range 35-51%), and platelet count of 119thou/ cumm (normal range 140–440thou/cumm). She had an unremarkable complete metabolic profile including renal and hepatic function tests. Immu-
Placement
TcPO2 reading in Room Air (mmHg)
TcPO2 reading with100% oxygen supplementation (mmHg)
Right upper chest
64
152
Left mid-calf proximal to wound
36
148
Left medial ankle posterior to wound
64
196
Left medial foot distal to wound
79
170
s
© 2014 MA Healthcare
ltd
Table 2.Transcutaneous oxygen pressure (TcPO2) levels at presentation
J O U R N A L O F WO U N D C A R E
C A S E S U P P L E M E N T VO L 2 3 , N O 1 0 , 2 0 1 4
S19
Journal of Wound Care.Downloaded from magonlinelibrary.com by 130.088.053.018 on October 19, 2014. For personal use only. No other uses without permission. . All rights reserved.
practice Fig 2. Wound healing throughout Hyperbaric Oxygen Therapy (HBOT) which was continued for 32 days. Days are provided based on the HBOT start date.
a Day 4
bDay 8
c Day 18
d Day 25
e Day 29
f Day 36
g Day 57
h Day 71
S20
Discussion HBOT has been recognised as a supplementary management tool for ulcers including diabetic foot, acute ischaemic ulcers and wounds with a history of chronic refractory osteomyelitis and radiation. It can also be used to prepare the wound site for skin grafting. HBOT plays different roles in managing
ltd
ver sulphadiazine cream once a day. The patient underwent selective excisional ulcer debridement including skin, subcutaneous tissue, and underlying muscle and tendon after which NPWT was applied for eight days. HBOT and the other wound managements strategies mentioned above improved the wound remarkably (Fig 2). After a total of 23 HBOT treatments, successful sclerotherapy treatment for the two incompetent perforator veins feeding into the ulceration was performed and a 120cm2 split-thickness skin graft from the left thigh was placed on the left leg. The wound completely healed after an additional 13 HBOT treatments post-graft implantation as shown in Fig 2.
© 2014 MA Healthcare
nology work up revealed elevated erythrocyte sedimentation rate which was 58mm/hour and C-reactive protein of 8.3mg/dl, but was negative for anti-neutrophil cytoplasmic antibody (ANCA) which ruled out ANCA related vasculitis. Transcutaneous oxygen pressure measurements revealed moderate decreased TcPO2 value at the left mid-calf proximal to the wound with good response to oxygen challenge (Table 2). Venous insufficiency ultrasound revealed two incompetent perforating veins proximal to the wound. Management was started with wound debridement, foam dressing, leg elevation and compression. Based on the TcPO2 results and the wound assessment that revealed large mottled base, and given that the patient failed many treatment modalities, she was deemed high risk for skin graft failure and so HBOT was started at 2.0ATA without oxygen breaks to prepare the wound bed for skin grafting. A few days later, the wound became infected with Escherichia coli, Proteus mirabilis, Enterococcus, and Pseudomonas, which was managed with intravenous imipenem-cilastatin (500 mg every 6 hours) and sil-
J O U R N A L O F WO U N D C A R E C A S E S U P P L E M E N T V O L 2 3 , N O 1 0 , 2 0 1 4
Journal of Wound Care.Downloaded from magonlinelibrary.com by 130.088.053.018 on October 19, 2014. For personal use only. No other uses without permission. . All rights reserved.
practice Table 3.TcPO2 interpretation guide. Grade
TcPO2 Value in mmHg
Normal
>45
Mild
40–45
Moderate
20–39
Severe
1–20
Critical
0
References 1. Collins, L., Seraj, S. Diagnosis and Treatment of Venous Ulcers. Am Fam Physician 2010; 81: 8, 989–996. 2. Lazarides, M.K., Giannoukas, A.D. The role of hemodynamic measurements in the
J O U R N A L O F WO U N D C A R E
management of venous and ischemic ulcers. Int J Low Extrem Wounds 2007; 6: 4, 254–261. 3. Hoffman, M.D. Inflammatory Ulcers. Clinical Dermatol 2007; 25:1, 131–138. 4. McRorie, E.R., Jobanputra, P., Ruckley, C.V., Nuki, G. Leg
Conclusion Our report represents a unique case where the wound healing was delayed by multiple factors including systemic inflammation, neutropenia (Felty’s syndrome), infection, and trauma. Initially, the wound failed to heal despite intensive conventional wound care, but HBOT proved to be an effective method when used in adjunct with other modalities including skin grafting. We believe that HBOT is underused even when it is indicated for wound healing. We recommend considering HBOT as an adjunctive modality when indicated for wound management.n ulceration in rheumatoid arthritis. Br J Rheumatol 1994; 33: 11,1078–1184. 5. Thurtle, O.A., Cawley, M.I.D. The frequency of leg ulceration in rheumatoid arthritis: a survey. J Rheumatol 1983; 10: 3, 507–509.
C A S E S U P P L E M E N T VO L 2 3 , N O 1 0 , 2 0 1 4
6. Laszlo, J., Jones, R., Silberman, H.R., Banks, P.M. Splenectomy for Felty’s syndrome. Clinicopathological study of 27 patients. Arch Intern Med 1978; 138: 4, 597–602. 7. Oien, R.F., Hakansson, A., Hansen, B.U. Leg ulcers in
s
© 2014 MA Healthcare
ltd
non-healing ulcers by enriching oxygen, fighting infection and promoting the healing process.15-17 It increases the amount of oxygen-free radicals, creating a gradient around a wound that has little or no oxygen supply. Oxygen is then able to diffuse from healthy capillaries to hypoxic tissue areas, providing enough oxygen for the wound to heal.18 The rise in oxygen promotes collagen formation and cross-linking, fibroblast differentiation and proliferation, angiogenesis, and the antibacterial function of leuocytes.17 HBOT can help prepare for a skin graft or preserve compromised flaps by increasing oxygen supply to graft and or flap sites. Once the graft is in place, it relies on the diffusion of oxygen and angiogenesis from the wound site.9 If considered prior and post skin graft implantation, HBOT can maximise the oxygen diffusion to the wound bed and graft tissues A study performed by Feldmeier indicates that HBOT increases the amount of oxygen transferred by 16 times, and increases the amount of oxygen between the wound bed, margins, and graft by 1500%.19 In a prospective randomised, , clinical trial by Perrins et al., 24 patients were treated with HBOT after receiving a skin graft, and 24 patients were part of the placebo group. Complete graft take (defined as >95% total surface area take) occurred in 64% of the treatment group vs. 17% of the control group, suggesting that HBOT drastically improves the chances of graft survival.20 In the treatment group, 100% demonstrated greater than 60% graft take, and 84% demonstrated permanent graft survival.20 In a study by Bowersox et al. 91% of patients recommended skin grafts recovered following HBOT.21 Even though one randomised clinical trial performed by Hammarlund et al. showed that HBOT resulted in a 33% decrease in venous leg ulcer wound size compared with a control group,22 venous leg ulcers are not yet an approved indication for HBOT. A main form of treatment for lower extremity venous
leg ulcers is currently oedema reduction therapy.9 Transcutaneous oxygen pressure (TcPO2) measures tissue oxygen perfusion at the capillary level and thus reflects microcirculation status.23 Transcutaneous oximetry helps determine the probability of wound healing or tissue salvage by measuring regional tissue oxygenation. For instance, periwound TcPO2 levels below 30mmHg can reliably predict poor healing with complications.19 TcPO2 grades and corresponding values in mmHg are shown in Table 3.19 Measuring TcPO2 may help assess candidacy for HBOT and the likelihood of HBOT benefit.23 A good candidate for HBOT would be a patient with abnormal TcPO2 in room-air (
