I have a patient who had a failed mesh placement and a panniculectomy and who has developed at least three separate fistulas with a very large amount of output (3-4 L/24 hrs). Any suggestions? I am using an Eakin wound management pouch hooked up to wall suction.
Hyperbaric Oxygen Therapy Used to Treat Radiation Injury: Two Case Reports
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Radiation is widely used in medicine, industry, agriculture, and research. Despite improvements in radiation safety, accidents with serious health consequences still occur. The harmful effects of ionizing radiation are well documented. Radiological accidents due to radioactive substance contamination are rare; local acute reaction to radiation exposure (which can be acute, protracted, or fractioned) is seen more frequently than whole body radiation complications and may occur alone or together with other injury such as trauma or thermal burn. Symptoms observed within a few months following radiation exposure are collectively called acute radiation syndrome. The clinical features and severity of acute radiation syndrome depend on the amount and velocity of the dose, tissue sensitivity, body site, and the width of the affected area. Extremities, especially the hands, are the sites most affected by local radiation injury.1-3
Diagnosis of Acute Radiation Syndrome
Diagnosis of acute radiation syndrome is based on clinical features and laboratory tests. Early diagnosis of radiation injury includes blood count (absolute lymphocyte) and cytogenetic measurement (at least 48 to 72 hours after exposure). Using the cytogenetic method, the minimum dose of radiation exposure that can be detected is 200 mGy for X- and g-ray and 10 to 20 mGy for fission spectrum neutrons.4,5 Chromosomal aberrations may indicate radiation injury but do not provide sufficient information to determine the offending dose.6
Detection
Chromosomal aberration analysis takes 3 days because of the 48-hour lymphocyte metaphase period. Lymphocytes are the cells most sensitive to radiation; therefore, the most sensitive and useful laboratory test in the early diagnosis of radiation injury is the absolute lymphocyte count in the blood. A complete blood count must be performed immediately and repeated in 6 hours. A decrease in absolute lymphocyte numbers suggests a recent exposure. If initial white cell and platelet counts on admission are abnormally low, the exposure probably took place a few days to a week earlier. Immunologic disorders occur in the first 48 hours.7
Clinical findings of local radiation injury are erythema, blisters, edema, loss of skin continuity, dry and wet desquamation, open wound, and necrosis. Direct contamination is not uncommon in local radiation injury.8
Management
Medical management of radiation injury depends on the level of emergency. Early clinical signs and symptoms of physical trauma, thermal or chemical burns, and radiation injury determine the classification and manner of first aid. Local injuries require appropriate wound care: the basic principles of treating local injury are moist and frequently changed dressings, debridement of the necrotic areas, and infection avoidance. Amputation is sometimes required.8,9 Local radiation injuries caused by high doses of radiation (>8 to 10 Gy) resemble thermal burns except for delayed (a few days to weeks) signs and symptoms.
Hyperbaric Oxygen Therapy
Hyperbaric oxygen (HBO) therapy is a form of treatment in which a patient breathes 100% oxygen intermittently in a special chamber at 2 to 3 absolute atmospheres (ATA). Hyperbaric oxygen therapy has been used for chronic and delayed radiation injuries for 30 years10 and improves fibroblast growth, collagen formation, neovascularization, epithelialization, and leukocyte bactericidal activity. It also reduces tissue edema. All of these effects are beneficial to wound healing.11
References:
1. Diagnosis and Treatment of Radiation Injuries. International Atomic Energy Agency, Safety Report Series, No. 2, I.A.E.A. Vienna, Austria;1998. Available at: http://www-pub.iaea.org/MTCD/publications/ PDF/P040_scr.pdf.
2. Planning the Medical Response to Radiological Accidents. International Atomic Energy Agency, Safety Report Series No. 4, I.A.E.A. Vienna, Austria;1998. Available at: http://www-pub.iaea.org/MTCD/publications/PDF/Pub1055_web.pdf.
3. Health Surveillance of Persons Occupationally Exposed to Ionizing Radiation: Guidance for Occupational Physicians. International Atomic Energy Agency Safety Report Series, No. 5, I.A.E.A. Vienna, Austria;1998. Available at: http://www.iaea.org.
4. Bender MA. Cytogenetics research in radiation biology. Stem Cells. 1995;13(suppl):172–181.
5. Darroudi F, Natarajan AT. Premature chromosome condensation, a novel method for biological dosimetry. In: Sohrabi M. Proceeding of the 10th International Conference on High Levels of Natural Radiation. Vienna, Austria: I.A.E.A.1993:479–485.
6. Sreedevi B, Rao BS, Nagaraj H, Pal NK. Chromosome aberration analysis in radiotherapy patients and simulated partial body exposures: biological dosimetry for non-uniform exposures. Radiat Prot Dosimetry. 2001;94(4):317–322.
7. Waselenko JK, Macvittie TJ, Blakely WF et al. Medical Management of the Acute Radiation Syndrome: Recommendations of the Strategic National Stockpile Radiation Working Group Ann Intern Med. 2004;140:1037–1051.
8. Ilyin LA. Chernobyl — Myth and Reality. Moscow: Megapolis;1995.
9. Medical Handling of Accidentally Exposed Individuals, International Atomic Energy Agency Safety Series No. 88, I.A.E.A. Vienna, Austria;1988. Available at: http://www.iaea.org.
10. Jain KK. Hyperbaric oxygen therapy in the management of radionecrosis. In: Jain KK, ed. Textbook of Hyperbaric Medicine, 4th ed. Germany: Hogrefe & Huber Publishers Inc;2004:67–79.
11. Niinikoski JH. Clinical hyperbaric oxygen therapy, wound perfusion, and transcutaneous oximetry. World J Surg. 2004;28(3):307–311.
12. Feldmeier JJ. Problem wounds: The irradiated wound. In: Sheffield PJ, Smith AP, Fife CE, eds. Wound Care Practice. Flagstaff, AZ: Best Publishing Company; 2004:369–385.
13. Fajardo LF, Stewart JR. Pathogenesis of radiation-induced myocardial fibrosis. Lab Invest. 1973;29:244–57.
14. Russell RC, Roth AC, Kucan JO, Zook EG. A review. Reperfusion injury and oxygen free radicals: a review. J Reconstr Microsurg. 1989;5:79–84.
15. Marx RE, Ehler WJ. Relationship of oxygen dose to angiogenesis induction in irradiated tissue. Am J Surg. 1990;160:519–524.
16. Feldmeier JJ, Davolt DA, Court WS, et al. Histologic morphometry confirms a prophylactic effect for hyperbaric oxygen in the prevention of delayed radiation enteropathy. Undersea Hyperb Med. 1998;25:93–97.
17. Feldmeier JJ, Jelen I., Davolt DA, et al. Hyperbaric oxygen as a prophylaxis for radiation-induced delayed enteropathy. Radiother Oncol. 1995;35:138–144.
18. Bernstein, EF, Sullivan, FJ, Mitchel JB. Biology of chronic radiation effect on tissues and wound healing. Clin Plast Surg. 1993;20(3):435–453.
19. Goldschmidt H, Breneman JC, Breneman DL. Ionizing radiation therapy in dermatology. J Am Acad Dermatol. 1994;30:157–182.
20. Etlik O, Tomur A, Dundar K, Erdem A, Gundogan NU. The effect of antioxidant vitamins E and C on lipoperoxidation of erytrocyte membranes during hyperbaric oxygenation. Basic Clin Physiol Pharmacol. 1997;8:269–277.
21. Peacock MD, Schenk DA, Lawrence RA, Morgan JA, Jenkinson SG. Elimination of glutathione induced protection from hyperbaric hyperoxia by acivicin. J Appl Physiol. 1994;76:1279–1284.
22. Zircle LG, Mengel CE, Horton BD, Duffy EJ. Studies of oxygen toxicity in the central nervous system. Aerospace Med. 1965;36:27–32.
23. Dennog C, Hartman A, Frey G, Speit G: Detection of DNA damage after hyperbaric oxygen (HBO) therapy. Mutagenesis. 1996;11:605–609.
24. Zamboni WA. The microcirculation and ischemia-reperfusion: basic mechanisms of hyperbaric oxygen. In: Kindwall EP, ed. Hyperbaric Medicine Practice, 2nd ed. Flagstaff, AZ: Best Publishing Company;2002:779–795.
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