Hyperbaric Oxygen Treatment and Hypoglycemia

  Hyperbaric oxygen (HBO) treatment can save a limb for the patient with a diabetic foot ulcer. But what if that same patient experiences a wide range of glucose levels? Consider this real life scenario: A patient arrives for his HBO treatment, and his blood glucose is tested pre-treatment in accordance with the typical policy. The result is 81 mg/dL. I have posed this to several wound care practitioners and the responses I received vary greatly from acceptable to deeply concerning. Let’s examine them one by one:

    1. “That result is fine, and we would proceed with the treatment because our policy states that the lower limit is 70 mg/dL.” This is concerning to me, because HBO treatment can cause lower glucose levels during the treatment. According to the Undersea and Hyperbaric Medical Society, HBO supersaturates plasma with oxygen, one of the substrates for metabolic energy generation, driving glucose consumption. In addition, increased aerobic metabolism in the pancreatic islets of Langerhans during HBO may stimulate insulin secretion. A study by Capelli-Schellpfeffer, et al1 suggests the average drop in glucose during treatment is 21 mg/dL. If that is true, a result of 81 mg/dL is too close for comfort for me.

    2. “We would give the patient a candy bar before treatment; we stocked up at Costco and have Reese’s Peanut Butter Cups by the case-full.” This approach is problematic for me, because many patients with diabetes, especially older ones, have been taught for years to avoid concentrated sweets. Asking a patient to gobble down a package of peanut butter cups before treatment feels wrong on many levels, and gives the patient a mixed message.

    3. “At our center, we would give orange juice and graham crackers. We cannot keep sending people home for low blood sugars because it affects our bottom line and creates a scheduling nightmare if we cancel too many treatments.” Although I fully understand the financial and scheduling complexities, my Number One rule is to never compromise patient safety. Period. Orange juice will surely raise the glucose level, but I wonder if it the quick rise will sustain the patient throughout the entire length of the treatment.

  So where do we go from here as wound care specialists? I am opening the conversation on a topic not frequently discussed. Ideally, I would like to see more data collected to verify the average drop in glucose levels, more consistent protocols nationwide, and patient education. The patient must be involved and needs to understand the necessity of arriving at the center with an appropriate blood glucose level. Trying to quickly raise it upon arrival is a sticky situation. When a limb is at stake, I agree we cannot afford to cancel HBO treatments, but in an entirely different sense of the word afford. Nutrition truly affects every aspect of wound treatment, including HBO.

--Nancy Collins, PhD, RD, LD/N, FAPCWA

1. Capelli-Schellpfeffer M, Pilipson LH, Bier M, Howe L, Boddie A. HBO and Hyploglycemia in Diabetic Surgical Patients With Chronic Wounds. Available at http://archive.rubicon-foundation.org/xmlui/handle/123456789/569

A Tribute to Jill Kinmont Boothe

2/10/12

  I was absolutely devastated to wake up and read that Jill Kinmont Boothe died last night. In case you do not know, Jill was the subject of the movie "The Other Side of the Mountain." In early 1955, she was the reigning national champion in the slalom and a top prospect for a medal at the 1956 Winter Olympics. While competing in the downhill at the Snow Cup in Alta, Utah, on January 30, 1955, she suffered a near-fatal accident which resulted in paralysis from the neck down. It occurred the same week that she was featured on the cover of Sports Illustrated magazine dated January 31, 1955.

  Jill was an inspiration to me since 8th grade. I remember the day I found I was going to meet her and work with her through my research on the use of oxandrolone as a treatment for pressure ulcers. I was so excited I thought I might faint! I called my husband and I told him one of my dreams was coming true! He even flew to Nashville with me to be there for this momentous occasion. When we met, Jill was so personable and gracious and knowledgeable on pressure ulcers, having had several herself after all the years in a wheelchair. She signed my copy of Sports Illustrated with her on the cover and took many photos with me. I have them all framed in my office right above my desk. Jill meant a lot to me so this is a very sad day. I heard she ultimately died from complications related to an infected pressure ulcer, which somehow seems so unfair. Jill knew more about pressure ulcers than some practitioners I work with. We need to keep educating people on pressure ulcer prevention and treatment and cannot relax on our mission in Jill's memory.

  The LA Times article is located here: http://lat.ms/xGfnjR.

– Nancy Collins, PhD, RD, LD/N, FAPWCA

ADA: New Name, Same Commitment to the Public’s Nutritional Health

2/7/12

  The American Dietetic Association, the world's largest organization of food and nutrition professionals, has officially changed its name to the Academy of Nutrition and Dietetics. The change took effect January 1, 2012. You may wonder why an association would take on the extra expense and possible confusion to change its name, so let me explain the reasons behind ADA’s decision:
    • Protecting the public’s health is the highest priority of the ADA and its members; consumer confusion over who are the real nutrition experts can have negative consequences for people’s health.

   • Although the ADA’s name reflected what registered dietitians (RDs) did in the early part of the 20th century when ADA was founded (“applying nutritional principles to the planning and preparation of foods and regulation of the diet”), the name lacked relevance to the work of RDs in the 21st century, which now is much more related to overall health and wellness with a focus on nutrition.

    • It was believed the organization’s name should include the word “nutrition,” which is well-understood by virtually everyone. In addition, the name should communicate broader concepts of wellness (including prevention of heath conditions) as well as treatment of conditions.

  Many colleagues have inquired why the Academy of Nutrition and Dietetics was selected as the new name. One of the definitions of “Academy” is “a society of learned persons organized to advance science.” This describes the organization and its members perfectly and immediately emphasizes the scientific basis of services, advice, and expertise within the areas of treatment and wellness. Adding “nutrition” to the organization’s name better communicates the members’ dedication to improving the nation’s health by translating science into healthy lifestyles for everyone. At the same time, retaining “Dietetics” as part of the organization’s name supports the association’s history as a food and science-based profession. Finally, there are no national organizations in the healthcare field whose name or abbreviation is similar to Academy of Nutrition and Dietetics, thereby confusion with other groups is avoided.

  The field of nutrition has changed over this century, and the Association is evolving to meet these needs—as the Academy of Nutrition and Dietetics.

– Nancy Collins, PhD, RD, LD/N, FAPWCA

Comments

This issue does deserve to be raised.

HBO therapy has a well known "insulin-like" effect in that it lowers blood glucose levels due to increased glucose uptake in muscle through a variety of proposed mechanisms. Unfortunately, the somewhat unpredictable effect has resulted in a wide variety of prophylactic regimens of glucose administration that do not always work equally well and may also confuse patients in terms of general glycemic control practices (i.e., high glucose levels are better for patient safety during HBO, but contrary to glycemic control objectives). As a result, there may indeed be a transient dysruption in overall glycaemic control. During the HBO sessions, glucose tends to be kept high (due to concerns about hypoglycemia), but these may drop inbetween HBO sessions due to a combination of "reactive" medication adjustments, the potentiating after-effects of the HBO on insulin sensitivity, and the general systemic improvements as wound infection is brought under control. Not infrequently, IDDM patient's insulin requirements need to be revised (lowered) significantly during and after HBO. Failure to realise this may precipitate hypoglycemic episodes. So, there are a lot of moving targets. Reasuringly, research has confirmed that variability in glucose levels does not affect the ultimate outcome of HBO treatments in diabetic foot problems. Nevertheless, there are several practical and patient-care concerns as Nancy has stated.

As yet, there is no "industry standard" for optimal dietary preparation; prophylactic prevention of hypoglycaemia; glucose surveillance during and after HBO; or optimal interventions as medication requirements change. Each hyperbaric center recognises the issue and has its own protocols to deal with them as best they can. Ours is no exception. However, I have to admit that we do sometimes succumb to the temptation of "getting the glucose levels high enough quickly" to be able to continue with the HBO in a timeous fashion. In our defense, I would like to add that there are many variables in this equation that make the tightrope harder to walk: (1) time since the last meal; (2) time since the last insulin administration; (3) single or multi drug regimens; (4) NPO patients; etc. So this requires more than a simple or cavalier answer.

Importantly, no-one would argue that insulin is harmful because it lowers blood glucose in diabetics! Similarly, HBO's insulin potentiating effect is actually evidence of improved physiological function and this should be understood as such. The key question is therefore how best to manage the changes in physiology so that homeostasis is achieved and preserved.

In closing I encourage those with a specific interest in this area to deliberately seek better solutions within our various multidisciplinary functions. We do need to be transparent about the frustrations and challenges we face. Solutions are to be found and discussions such as these provide the motivation for us to do so. Thank you, Nancy!

Kind regards,

Frans

Frans Cronje, MD, MSc
Hyperbaric Physician
Cape Town - South Africa

Glucose management in hyperbaric patients:

Glucose levels in patients undergoing hyperbaric treatments do require some consideration as well as maintaining a keen eye during their treatment. As a nurse and a certified hyperbaric technician, I have seen patients go in to the chamber with a glucose level of 300 mg/dl and finish a treatment with a level of 50 mg/dl. What makes these levels unpredictable at times? Several factors do play a role as Dr. Cronje has mentioned, such as timing of insulin administration and last meal taken. One thing that does vary is the treatment modalities that hyperbaric physicians prescribe. These range from giving oral glucose gel to IV Dextrose to even a small peanut butter sandwich prior to treatment. Each patient is different and some patients come in to our wound center feeling so sick and nauseated that the last thing they want to do is eat. In my experience, I tend to ask the patient if they have taken anything as an alternative means to lower blood glucose levels such as teas or herbs. Overall, yes, indeed hypoglycemia in the hyperbaric patient is a common occurrence, especially those on insulin regimen. As Dr. Cronje has mentioned, there is no set of standard interventions to prevent such occurrence without promoting hyperglycemia. The more discussions or forums are created for this issue should well stimulate the minds of those who have had success in managing such challenges and hopefully share those insights for the rest of us to benefit from.

Thank you

Hector Sanchez III RN-CHT
Wound Care Clinic/Hyperbarics
Valley Baptist Medical Center
Brownsville, Texas

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