Review
Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis

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Abstract

Background

Necrotizing fasciitis (NF) is an uncommon but serious infection of fascia and skin associated with considerable morbidity and mortality. One modality proposed for improving the outcome of this condition is hyperbaric oxygen (HBO) therapy. This is a form of medical treatment that involves intermittent inhalation of 100% oxygen under pressures exceeding the atmosphere. The aim of this article is to review current practice and evidence for the use of HBO as adjunctive therapy in the management of NF.

Methods

A survey of published English literature through searches of Medline and PubMed was carried out using the following key words: “necrotizing fasciitis,” “Fournier’s gangrene,” “necrotizing soft tissue infections,” “hyperbaric oxygen therapy,” “and hyperbaric oxygen chambers.”

Results

The results of studies on the use of HBO therapy in NF are inconsistent. Some studies have demonstrated that HBO can improve patient survival and decrease the number of debridements required to achieve wound control, whereas others have failed to show any beneficial effect.

Conclusions

Encouraging results have been achieved with the addition of HBO therapy to standard treatment regimes, thus justifying further research in this field. More robust evidence by way of a prospective randomized trial is necessary before widespread and routine use of HBO in the management of NF can be recommended.

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

References (41)

  • C.R. McHenry et al.

    Determinants of mortality for necrotizing soft-tissue infections

    Ann Surg

    (1995)
  • A. Fustes-Morales et al.

    Necrotising soft tissue infectionreport of 39 pediatric cases

    Arch Dermatol

    (2002)
  • N. Skitarelić et al.

    Necrotising soft tissue infection after peritonsillar abscess in an immunocompetent patient

    J Laryngol Otol

    (1999)
  • C. Dunn et al.

    The use of maggots in head and neck necrotizing fasciitis

    J Laryngol Otol

    (2002)
  • W.H. Brummelkamp et al.

    Treatment of anaerobic infections by drenching the tissue with oxygen under high atmospheric pressure

    Surgery

    (1961)
  • G.H. Cohn

    Hyperbaric oxygen therapy—promoting healing in difficult cases

    Postgrad Med J

    (1986)
  • J.C. Bowersox et al.

    Clinical experience with hyperbaric oxygen therapy in the salvage of ischemic skin grafts and flaps

    J Hyperb Med

    (1986)
  • C.J. Lambertsen et al.

    Oxygen toxicityeffects in man of oxygen inhalation at 1 and 3.5 atmosphere upon blood gas transport, cerebral circulation and cerebral metabolism

    J Appl Physiol

    (1953)
  • R.M. Leach et al.

    Hyperbaric oxygen therapy

    Br Med J

    (1998)
  • W.A. Zamboni

    Application of hyperbaric oxygen therapy in plastic surgery

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