Cath Lab Digest

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  As a hyperbaracist actively practicing the specialty for more than 18 years, I have several thoughts on the articles included in “The oxygen issue” (June 2010) of Ostomy Wound Management.
  I am somewhat dismayed after reading Mutluoglu M, Uzun G, Yildiz S. Hyperbaric oxygen therapy in the treatment of diabetic foot ulcers — prudent or problematic. a case report. Ostomy Wound Manage. 2010;56(6):32–35. The authors have misled the readers by inappropriately titling the article. The title suggests that hyperbaric oxygen therapy (HBOT) in advanced wound care for diabetic wounds can cause problems. The title missed the importance of the article, which was the lack of basic wound care provided to the patient discussed in this case.
  The body of the article defines the importance of the advanced wound care role of hyperbaric oxygen in treating recalcitrant wounds. The authors also emphasize the importance of providing basic wound care for a diabetic neuropathic ulcer before considering any advanced modalities. There should never be a concern regarding the appropriate use and benefit of HBOT in treating recalcitrant diabetic foot ulcerations, especially when they meet the “appropriate” hyperbaric diagnostic criteria, which is not reflected in the article title. The authors also stated that the presence of a pedal pulse and a transcutaneous oxygen (TcpO2) >40 mm Hg was an indication that “HBOT is not recommended.” TcpO2 values are used for microvascular assessment and serve as a direct quantitative indicator of periwound skin oxygen availability. These values are a good predictor of negative wound healing and can further delineate the need for further vascular surgical assessment and intervention. Also, all diabetic foot ulcers deserve a formal vascular evaluation irrespective of presumed etiology or palpable pulses and should not stop short at a normal TcpO2 value (per national wound care guidelines). Lastly, TcpO2 results should be used cautiously and not determine the need for hyperbaric oxygen as an advanced wound care modality. TcpO2 cannot be used as a positive predictor of wound healing; rather, when critical ischemic TcpO2 values are demonstrated, it is as a useful predictor of failure to heal. More appropriately, the title should have focused on the importance of the multidisciplinary wound care team and the lack of basic wound care support in non-hospital-affiliated hyperbaric oxygen centers.
  In addition, Strilko’s Pearls for Practice (“Management of a Patient with Fournier’s Gangrene”) fails to mention the important role of adjuvant HBOT in treating this condition. The hyperbaracist is an important member of the multidisciplinary wound care team. When a hyperbaracist and hyperbaric facility are available to treat patients with life-threatening necrotizing infections such as Fournier’s gangrene, the role and importance of using hyperbaric oxygen should not be underscored or dismissed. Adjuvant hyperbaric oxygen, when available, is considered standard medical therapy in the treatment of Fournier’s gangrene and other necrotizing infections.
  Lastly, the article Blackman E, Moore C, Hyatt J, Railron R, Frye C. Topical wound oxygen therapy in the treatment of severe diabetic foot ulcers: a prospective controlled study (Ostomy Wound Manage. 2010;56[6]:24–31) was underpowered (28 patients), biased, and lacked randomization and blinding. An important take home message is that the “potential” benefit and “possible” physiologic mechanism of topical oxygen therapy should never be confused with the multiple proven benefits of systemic hyperbaric oxygen therapy. The positive physiologic, biochemical, and anatomical changes consistently identified in tissues treated with systemic hyperbaric oxygen could never be reproduced using topical oxygen therapy.