Medical/Patient Care
Questions pertaining to medical or patient care
Any contraindication treating patient with patent foramen ovale?
Posted: 5/25/23
Q: Any contraindication treating patient with patent foramen ovale?
A: In the general population 30% of individuals have a PFO. Individuals with a PFO have a slightly increased risk of decompression sickness (DCS). However, the risk of DCS for a patient undergoing hyperbaric oxygen treatment is zero. Thus, for patients undergoing HBO2 treatment the presence of a PFO is irrelevant.
What is the main concern or danger with a systolic blood pressure below 100 pre HBO treatment assessment?
Posted:11/13/23
Q:
What is the main concern or danger with a systolic blood pressure below 100 pre HBO treatment assessment?
A:
There is nothing magic about a systolic BP less than 100mmHg in the hyperbaric environment. Various authors have studied the impact of BP as the result of hyperbaric treatments. We know that HBO2 causes arteriolar constrictions and increased afterload, sometimes leading to the occurrence or worsening of CHF. For most patients, the changes are negligible. But for a patient with hypotension in the chamber, the tendency is for a BP increase not a decrease.
I am not sure where you got this guidance. I would like to know for future reference. The thinking, I believe, arises out of caution because 100 mmHg systolic is a fairly low pressure and may be due to sepsis or blood loss. More than anything, I believe whoever authored this policy was trying to alert the treating HBO2 doctor that the patient may be having significant intercurrent disease symptoms and should be stabilized before going into the chamber.
There is a subset of slight young women who characteristically will run blood pressures like this. It is therefore important to get the patient’s history or check previous medical trecords to determine if this is a normal and usual pressure for your patient.
John J. Feldmeier, D.O.
Does a patients A1C need to be below a certain number before HBO tx is beneficial?
Posted: 6/20/24
Q: Does a patients A1C need to be below a certain number before HBO tx is beneficial?
A:
No. The question is if the email is referencing the wound care literature, which is split between those who feel better control equates to better outcomes and those who believe that all patients deserve a trial.
If the question is referencing the requirement for DFU and HBOT, then the question is more about documenting an A1C and then referring them to a nutritionist/PCP for counseling and intervention. There is a schism even within the diabetes community as to what constitutes good control; it varies depending upon the age of the patient and the co-morbidities.
https://diabetesjournals.org/care/article/46/Supplement_1/S216/148044/13-Older-Adults-Standards-of-Care-in-Diabetes-2023
Whether or not they have significant autonomic dysfunction and can sense hypoglycemia is a major risk factor that needs to be addressed.
There are multiple examples in the literature where A1C and outcomes are not linked in the hyperbaric medicine space.
Helen Gelly, MD, FUHM, FACCWS, UHM/ABPM
Thank you.
We have a patient with recent bilateral mastectomy and tissue expanders. What are the requirements if expanders are filled with air vs. saline for treating in hyperbaric? This question is urgent as the indication is flap failure.
Posted 7/11/24
Q: We have a patient with recent bilateral mastectomy and tissue expanders. What are the requirements if expanders are filled with air vs. saline for treating in hyperbaric? This question is urgent as the indication is flap failure.
A:
Patients referred for acute vascular ischemia of the breast tissue following mastectomy, including nipple areola complex ischemia, are referred for hyperbaric oxygen treatment (HBO2) in an attempt to arrest the ischemia and hypoxia produced from the extensive dissection necessary during the mastectomy.
First, tissue expanders used in breast reconstruction are almost always filled with saline. Here are some key points regarding the use of saline versus air:
- Saline: The standard practice is to fill tissue expanders with saline. Saline is preferred because it is not compressible under pressure changes, such as those experienced during hyperbaric oxygen therapy and air travel. This stability mitigates risk best with saline-filled expanders and more predictable as fluid does not respond to pressure changes in a hyperbaric chamber, pressurized aircraft, or moving from areas of high pressure to low pressure and vice versa.
- Air: Filling tissue expanders with air is extremely uncommon. Air-filled expanders are susceptible to compression and expansion with changes in atmospheric pressure posing risks in environments such as hyperbaric chambers, during flights in pressurized aircraft, and changes in atmospheric pressure from location to location. The use of air-filled expanders is typically limited to temporary situations or specific clinical scenarios where immediate, short-term expansion is needed, and the patient is not exposed to significant pressure changes.
Clinical Practice: Tissue expanders are usually filled with saline to mitigate risk and better ensure patient safety and optimal outcomes in various clinical situations and environmental pressure change.
To safely proceed with hyperbaric oxygen treatment and prevent worsening ischemia, it is recommended that:
- Tissue expander volume should be reduced: Remove enough saline (or air) from the expanders to decrease stress and tension on tissue and suture lines. This reduces pressure on the breast tissue, which could be contributing to the ischemia.
- If volume reduction is not possible: Remove the expanders as soon as feasible to alleviate pressure on the surrounding vessels post-mastectomy.
This approach ensures the patient can undergo HBO2 while minimizing the risk of exacerbating the ischemia.
In cases where tissue expanders are inserted following a bilateral mastectomy, where significant tissue removal has occurred, the immediate post-operative filling of tissue expanders requires careful consideration on the part of the plastic surgeon:
- Immediate Post Operative Filling: Typically, tissue expanders are filled with a small amount of saline at the time of placement to maintain their position and avoid collapse. This initial fill should be minimal to reduce the risk of excessive pressure on the newly operated tissue.
- Gradual Expansion: The expansion process should be gradual and carefully monitored. Regular follow-ups with the surgeon are necessary to incrementally increase the fill volume, allowing the tissue to stretch slowly and reducing the risk of complications such as ischemia or undue pressure on the tissue.
- Consideration of Ischemia Risk: In patients at risk of ischemia, particularly those referred for hyperbaric oxygen treatment, it may be prudent to delay significant filling of the expanders until the risk of ischemia has been thoroughly assessed and managed.
- Customizing to Patient Needs: The decision should be individualized based on the patient's condition, the extent of tissue removal, and the surgeon’s judgment. Close monitoring for signs of ischemia or other complications is essential.
In summary, while tissue expanders can be initially filled post-operatively, the volume should be minimal, with careful and gradual expansion thereafter. The specific approach should be tailored to the patient's needs and clinical situation, particularly if there is a significant risk of ischemia or ischemia becomes apparent. This response addresses the concerns about using HBO2 treatment with tissue expanders and provides guidelines for managing such cases.
Owen ONeill, MD, MPH, FUHM, FACHM