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EDITORIAL
Transforming Training in Marine Medicine
-Surgeon Commodore VSSR Ryalt, Surgeon Captain George Varghese
REVIEW ARTICLES ••..
Recent Advances in Hospital Informatics
Surg Cdr K Bose
Long Bone Radiology Screening for Dysbaric Osteonecrosis
Surg Capt G Vargh,ese, ColtR Ravi Kumar, Surg Lt Cdr Rohit verma, Surg Lt Cdr LVV Rao
UPDATE ARTICLES
COBcepts and Controversies in Fost Traumatic Epilepsy
Surg Capt Kl Mathai, Surg Cdr KBose
Medical Organisation During Submarine Operations
Surg Cdr CS Saxena
ORIGINAL ARTICLES
Experience ofNimotuzurnab with Concurnmt Chemoradiotherapy
Surg Cdr Hari Mukundan, Surg Capt Subhash Ranjan, VSM; Surg Cdr R Shankaran
Hyperbaric Oxygen Therapy in Non Healing Wounds
Surg Lt Cdr Sourabh Bhutani, Surg Lt Cdr Rohit Verma
Respiratory Muscle Training for 'Enhanced Endurance
Surg Lt Cdr LV Visweswararao
Effect ofJIyperbaric Oxygen Therapy on Pulmonary Indices
Surg Lt Cdr Rohit Verma
QT Dispersion in Diabetic Patients on Hyperbaric Oxygen
Surg Lt Cdr SS Dalawayi, Surg Cdr RBS Chaudhry
Dlsabilites in Naval Aircrew Applicants
Surg Cdr PD Ayengar, Gp Capt N Taneja
Troxerutin in Management of Haem orrho ids
Surg Cdr Ashutosh Chauhan, Maj Sangeeta Tiwari, Col PK Bhatia, Brig AK Gupta
CME
Fear of Flying in Trained Aircrew
Surg Cdr RC Verma (Retd)
MCQ
Surg Lt Cdr Rohit Verma
CASE REPORTS
Infant with Diabetic Ketoacidosis
Surg Cdr Ashok K Yadav, Surg Capt KM Adhikari, Surg Cmde GGupt~, NM
Pleural Effusion in Extramedullary Myeloma
Surg Capt SRanjan, VSM, Surg Lt Cdr Harimukundan, Surg Cmde SR Gedela,
Brig UK Sharma, Surg Capt Naveen Chawla
, Fingertip Pain due to Glomus Tumor
Surg Capt GVishwanath, Maj Atul Sahai, Maj Raj Singh, Surg Capt Naveen Chawla
Letters to the Editor
Subject Index
Author Index
Contents
Original Article
Hyperbaric Oxygen Therapy in Non Healing Wounds
Surg Lt Cdr Sourabh Bhutani*, Surg Lt Cdr Rohit Verma#
Abstract
Background: Hyperbaric oxygen therapy (HBOT) is accepted as an adjunctive therapy for non-healing wounds.
Ischemia and infection are the common causes of non-healing.
Material and Methods: A retrospective analysis of 46 cases of non-healing wounds on HBOT was carried out. The
primary end point was the appearance of healthy granulation tissue over 50 %of the surface area of the ulcer. All
patients continued concurrent medical and surgical management.
Results: Out of 46 patients with non-healing ulcers of the lower limb, 39 (84.7 %) were due to diabetes. Forty three
patients completed the treatment and "Satisfactory Healing" was seen in 38 (88.37 %). Average sittings required for
healing were 14.2. Five patients (11.63 % ) failed to respond despite the therapy being extended upto 20 sittings.
Amputation rate was 6.9 %. Three patients (6.5 %) did not complete the treatment and aural barotrauma was seen in
12 cases (26.08 % ).
Conclusion: HBOT improved healing in chronic wounds possibly by reducing ischemia and infection. Alternating
hypoxia and hyperoxia during HEOT may optimise the healing process.
Key Words: Hyperbaric oxygen, Problem wounds, Hypoxic wounds, Diabetic foot, Transcutaneous oximetry
Introduction
Hyperbaric oxygen therapy is the use of 100%
oxygen at pressures greater than atmospheric
pressure. The patient breathes 100% oxygen
intermittently while the pressure of the treatment
chamber is increased to greater than 1 atmosphere
absolute (ATA) [1-5]. HBOTis an accepted adjunctive
therapy for a variety of indications based on randomised
~ontrolled trials and established protocols (Table 1)
[2,3,5]. It has also been useful for other indications for
which firm evidence in the form of large multicentre
randomized controlled trials are still not available (Table
2) [3,5,6].
Non-healing or chronic wounds are those. that fail to
heal within 8 weeks with standard wound care. It may
also be defined as a wound that fails to proceed through
an orderly and timely healing process to produce
anatomic and functional integrity [3,4,7]. This, group
includes diabetic foot ulcers, arterial insufficiency ulcers,
ulcers due to venous stasis, decubitus ulcers and fungal
infections of the foot such as Madura foot. Ischemia
and infection are the most common causes of non-healing
[8]. Infection increases the inflammatory process
thereby inducing wound hypoxia through high oxygen
consumption and reduced local blood flow due to tissue
oedema. Collagen deposition, epithelialisation and wound
contraction either do not occur or occur only to alimited
extent [3,4,9]. Although anaerobic metabolism is possible
Table 1 : Indications for HBOT
1. Thermal burns
2. Clostridial myonecrosis
3. Enhancement of healing in selected problem wounds
• Diabetic foot
• Fungal infections like Madura foot
• Ulceration due to arterial insufficiency
• Venous stasis ulcer
• Decubitus ulcers
4. N ecrotising soft tissue infections
5. Compromised skin grafts and flaps
6. Refractory osteomyelitis
7. Crush injury, compartment syndrome, and other acute
traumatic ischemia
8. Late radiation induced tissue damage, e.g. Proctitis, cystitis
9. Air/gas embolism ".
10. Decompression sickness
11. Carbon monoxide poisoning and smoke inhalation
12. Exceptional blood loss anemia
13. Intracranial abscess
'Resident, Marine Medicine, Undersea Medicine Department, INHS Asvini, Mumbai 05. #PMO &Graded Specialist, Marine Medicine, INS
Nireekshak, c/o Fleet Mail Office, Kochi 682004.
Jour. Marine Medical Society, 2010, Vol. 12, No.2 89
Table 3 : Number of cases as per indication
1. Diabetic ulcer 39
• Post amputation stump ulcer 3
• Pre gangrene/Gangrene of toes 5
• Fournier's gangrene 1
2. Decubitus ulcer 2
3. Venousulcer 3
4. Arterial insufficiency ulcers 2
10 sittings was done depending on response to HBOT.
No patient was administered more than 20 sittings at a
time.
The primary end point of treatment was the
appearance of healthy granulation tissue over 50% of
the surface area of the ulcer which was considered as
"Satisfactory healing". "Failure of treatment" was
considered when granulation tissue covered less than
50% of the surface area after 20 sittings or gangrene or
pre gangrene necessitated urgent limb amputation.
All patients continued standard medical and surgical
management apart from HBOT. Medical management
included strict glycemic control for diabetic patients and
medications for any other co-morbidity. Surgical
management included wound debridement, daily
dressings, appropriate antibiotics and non-weight bearing
measures.
Results
A total of 46 patients were seen with non-healing
ulcers of the lower limb (Table 3). An overwhelming
majority (39 cases, 84.7%) were associated with
diabetes, the rest being' arterial insufficiency ulcers (2
cases, 4%), venous ulcers (3 cases, 6%) and decubitus
ulcers (2 cases, 6%). Only one case (- 2%) did not have
a lower limb ulcer (Fournier's gangrene). Out ofth~ 39
diabetic patients, three cases (7.7 %of all diabetic cases)
reported for treatment of non healing ulcers on the
amputation stump (above knee in 2 cases and below
knee in 1) and 5 cases (12.8%) showed signs of pre-
gangrene or gangrene of one or more digits of either
feet.
Three patients (6.5%) did not complete the treatment
as per the protocol. One (- 2%of all cases) patient opted
out due to intense claustrophobia during the second
session, a second patient cited long distance travel and
a third patient did not complete treatment due to aural
barotrauma. Aural barotrauma was seen in 12 cases
(26.08%), 11 (91.7%) of whom were Teed gradel, while
46
No of patientsDiagnosis
Total
in a hypoxic wound, it cannot generate the vast quantity
of energy required for normal healing [3,4,10]. Hypoxia
leads to impaired fibroblast production, failure of
maturation of new capillary network and impairment of
body's defence mechanisms against bacterial invasion
[11]. However, hypoxia is a potent stimulus for secretion
of angiogenic factors, migration of fibroblasts and
induction of pro-collagen synthesis [3,4,12]. On the other
hand, a normal oxygen pressure is needed for formation
of a capillary network, proliferation and maturation of
fibroblasts and formation of resilient collagen. Alternating
hypoxia and hyperoxia during HBOT optimises the
healing process by providing the stimulus of hypoxia and
also the needed oxygen substrate [3,4,13,14].
Material and Methods
A retrospective analysis of 46 cases of non-healing
wounds referred to the Undersea Medicine Department
for HBOT between Jun 09 and Nov 09 was carried
out. Pre HBOT evaluation included clinical examination
with emphasis on the respiratory system and a chest
roentgenogram. Those with a past or concurrent history
of pulmonary Koch's, thoracic surgery, consolidation,
pulmonary fibrosis, pneumothorax, pleural effusion,
spontaIlCOUSpneumothorax or a cavitary lesion were
excluded due to the risk of pulmonary barotrauma.
Further, any with history of ear surgery, tympanoplasty,
otosclerosis or otomycosis were excluded as these
predispose to barotrauma of the ear. A resting 12 lead
EeG was taken to rule out arrhythmias which may
worsen in the hyperbaric atmosphere.
All cases were initially given 10 sittings of HBOT at
2.5 ATA pressure for 60 minutes each, six days a week.
Wound evaluation was done clinically and photographs
of the wound were taken on days 0, 5, and 10 for
objective wound analysis. Extension of treatment by 4-
Table 2 : Research indications
1. Post sternotomy mediastinitis
2. Stroke
3. Sickle cell disease
4. Malignant otitis externa
5. Acute myocardial infarction
6. Femoral head necrosis
7. Retinitis pigmentosa
8. Tinnitus
9. Interstitial cystitis
10. Facial (Bell's) palsy
11. Cerebral palsy
12. Multiple sclerosis
13. Feto-placental insufficiency
90 Jour. Marine Medical Society, 2010, Vol. 12, No.2
Patient Response
Fig. 1: Treatmentfailure and success rates.
the remaining one was Teed grade III who showed
persistent inability to equalize despite slow pressurization
and had to be discontinued HBOT. Rest of the 11
patients were managed conservatively for barotrauma
and resumed HBOT after a break of 2 - 3 days. No
cases of pulmonary barotrauma or oxygen toxicity were
seen.
Of the 43 patients who completed treatment protocol
(Fig. 1), "Satisfactory Healing" was seen in 38
(88.37%). Fourteen patients (32.5% of those w~o
completed the protocol and 36.8% of those showing
"satisfactory healing") responded well in 10 sittings but
29 (67.4% ofthose who completed the protocol) had to
be given from 14 to 20 sittings for healing to occur.
Average number of sittings required for healing were
14.2 sittings. Five patients (11.63 %) failed to respond to
HBOT despite therapy being extended upto 20 sittings.
Of these 5,3 (6.9%) had to undergo amputation, 2 below
knee and 1above knee.
Discussion
Hyperbaric oxygen increases tissue oxygen pressures
by increasing arterial oxygen pressure (Pa02). Using
Krogh's mathematical model, oxygen partial pressure
at any point may be predicted in relation to the distance
from a capillary and the oxygen pressure over the whole
length of the capillary [3,4,15]. By applying Krogh's
model, when arterial oxygen preSsure is increased from
100 mmHg (with the patient breathing air at atmospheric
pressure) to 2000 mmHg (with the patient breathing pure
oxygen at 3 ATA), there is a four-fold increase in the
oxygen diffusion distance at the capilla17Yarterial end
and a twofold increase at the venous end [3,16]. Using
the Krogh model, it is possible to predict the ability of
HBOT to increase tissue oxygen pressure in different
forms of hypoxia like (1) where there is an increase in
inter-capillary distance due to edema; (2) with vascular
destruction due to infection, diabetes or radionecrosis,
and (3) where the vascular flow is reduced due to
vasculitis or arteriosclerosis.
HBOT corrects wound hypoxia by increasing blood
Jour. Marine Medical Society, 2010, Vol. 12, No.2
oxygen content via dissolved oxygen [16]. HBOT
enhances cell metabolism, preserves intracellular ATP
and reduces oxidative injury to cells [13]. HBOT
stimulates fibroblast proliferation, improves extracellular
matrix synthesis, increases collagen formation and
deposition and promotes rapid growth of capillaries and
formation of functional microcirculatory network [17,18].
HBOT reduces oedema and increases wound tensile
strength. HBOT reduces wound infection by direct effect
on anaerobic bacteria and by enhancing the microbicidal
capability of polymorphonuclear leukocytes.
In our study, benefit was reported by 88% of the
patients whereas 12% patients failed to respond to
HBOT (Fig. 1). This correlates with other studies which
have reported similar healing rates [4,5,19]. Poor efficacy
of HBOT in some patients is possibly due to
compromised vascular supply which can only be
substantiated by transcutaneous oximetry (TcP02)
[19-22]. TcP02 measurements have been used
sporadically in our centre and efforts are on to use them
con a routine basis. Major lower limb amputation rates
ranging from 5% to 12% have been reported across
various studies and our rates (7%) correlate well with
them (Fig. 1) [21,22].
Conflicts of Interest
None Identified
References
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Diabetes Care Vol 19, Issue 12: 1338-43.
I~
CONTINUING MEDICAL EDUCATION (CME)
Continuing Medical Education (CME) consists of topics of common interest to ship borne medical officers
which are written by specialists in various fields of marine medical sciences. The topics selected should
be of relevance and should address day to day medical problems onboard ships. The topics should be
ontemporary, should quote the latest references and should be written in a lucid style. The CME should
provide practical information on the diagnosis and management of commonly occurring medical problems
onboard ships with the help of algorithms, diagrams and photographs. The CME should not exceed 2500
words, should have less than 8 tables and figures and not more than 30 references. The editorial board
pr0poses to continue the current practice of publishing at least one CME in each of the issues to make
e<iucative reading to young naval medical officers.
Jour. Marine Medical Society, 2010, Vol. 12, No.2
