ReviewHyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis
Section snippets
Physiologic basis
Tissues at rest require 60 mL oxygen/L blood flow to maintain adequate cellular metabolism. At normal atmospheric pressure plasma oxygen concentration is only 3 mL/L [13], and oxygen is delivered to tissues mainly by hemoglobin. If the inspired oxygen concentration is increased to 100%, the amount dissolved in the plasma will increase to 20 mL/L. At a hyperbaric pressure of 3 atmosphere absolute (ATA) (304 kPa), the dissolved plasma oxygen increases to 70 mL/L, which exceeds the resting tissue
Cellular, tissue, and systemic effects
Oxygen is necessary for cellular metabolism, promotion of the hosts’ defenses, and tissue repair [15]. When administered at pressures >1 ATA, oxygen assumes properties more akin to a drug [16]. White cells’ ability to kill aerobic bacteria is enhanced [17]; collagen formation is stimulated [18]; and levels of superoxide dismutase (resulting in better tissue survival) are increased [19]. Macroscopically, HBO decreases tissue edema through vasoconstriction and thus improves local tissue swelling
Methods of administration
HBO therapy can be accomplished by way of commercially constructed monoplace (Vickers, USA; Oxycom, Finland) or multiplace chambers (Rauma Oceanics, Finland; Hytech, Netherlands). The former accommodates a single patient, and the chamber is pressurized with 100% oxygen, thus negating the need for a mask or a hood. Portability and relatively low cost have made monoplace chambers the most common type of chamber worldwide [25]. Multiplace chambers are large tanks that permit medical staff to
Clinical evidence
There is general consensus that resuscitation, radical debridement, and broad-spectrum antibiotics form the corner stones of management of NF [1]. HBO must compliment and not substitute these interventions. However, few hospitals possess hyperbaric facilities [16], and the critical status of patients often precludes lengthy transport to these specialized units. These factors are probably responsible for the relative scarcity of reported studies in the literature (Table 1). The bona fide impact
Complications of HBO therapy
The potential risks and complications of HBO have often been overestimated. There are few absolute contraindications—such as untreated pneumothorax and chemotherapy with cis-platinum and adriamycin—because it has been shown that the cytotoxicity of these agents is potentiated by HBO therapy [36]. Relative contraindications include poorly controlled asthma, pregnancy, bone cysts, malignancy, and lung bullae. The possibility of active neoplastic processes is considered a contraindication caused
Comments
There is physiologic rationale for the use of HBO in the treatment of NF. However, the results of clinical studies have been inconsistent. The main advantages of addition of HBO to standard regimes appear to be tissue preservation and decreased mortality. Thus, the ongoing use of adjuvant HBO therapy in institutions with such facilities can be justified. Despite the paucity of serious complications, more robust evidence, preferably by way of randomized controlled trials, is necessary before
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