Hyperbaric oxygen therapy in diabetic foot.
N Doctor, S Pandya, A Supe
Dept of Surgery, Seth GS Medical College, Parel, Bombay, Maharashtra.
Dept of Surgery, Seth GS Medical College, Parel, Bombay, Maharashtra.
To study the effect of hyperbaric oxygen therapy in chronic diabetic foot lesions, a prospective controlled study was undertaken. Thirty diabetics with chronic foot lesions were randomised to study group (conventional management and 4 sessions of hyperbaric oxygen therapy) and control group (conventional management). The patients were assessed for average hospital stay, control of infection and wound healing. The control of infection spread was quicker. Positive cultures decreased from initial 19 to 3 in study group as against from 16 to 12 in the control group. (p < 0.05). This difference was most pronounced for Escherichia coli. Also, the need for major amputation was significantly less in the study group (n = 2) as against the control group (n = 7) (p < 0.05). The average hospital stay was not affected. We conclude that hyperbaric oxygen therapy can be safely used and is beneficial as an adjuvant therapy in chronic diabetic foot lesions.
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Doctor N, Pandya S, Supe A. Hyperbaric oxygen therapy in diabetic foot. J Postgrad Med 1992;38:112-114
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Doctor N, Pandya S, Supe A. Hyperbaric oxygen therapy in diabetic foot. J Postgrad Med [serial online] 1992 [cited 2019 Nov 12 ];38:112-114
Available from: http://www.jpgmonline.com/text.asp?1992/38/3/112/700
Diabetes mellitus is the most common of the serious metabolic disorders characterised by long-term complications involving eyes, kidneys, nerves and blood vessels,,,,, Diabetic angiopathy leads to chronic foot lesions and has a higher risk of amputation than non-diabetics due to poor control of infection. The emergence of hyperbaric oxygen therapy (HBOT) as an adjunct to therapy of diabetic foot lesions has its basis in the fact that it can reduce anaerobic infection, can improve blood supply and can decrease ischaemic damage to nerves. This prospective study was carried out to evaluate the effect of hyperbaric oxygen in diabetic foot lesions and its use as an adjunctive measure.
Thirty diabetics with chronic foot lesions were studied over a period of 2 years at our hospital. All patients were admitted. All patients received regular surgical treatment consisting pf incision and drainage of abscesses and debridement of wound. Locally, the wounds were dressed with eusof (1.25% w/v boric acid and 1.25% w/v of bleaching powder) and / or glycerine acriflavine. In those patients in whom the gangrene/infection ascended above the ankle, amputation was performed to limit the spread of infection and resulting toxemia. Major amputation was defined as an amputation done, above the ankle joint. All others were considered as minor amputations. Antibiotics were administered along with metronidazole for 3 days. Antibiotics commonly used were cephalosporins and aminoglycosides and were changed according to sensitivity patterns. Diabetic control was achieved by crystalline insulin given subcutaneously daily in 3 doses. Two patients with diabetic ketoacidosis were initially treated with intravenous plain insulin.
The patients were randomly allotted to one of the two groups. One received a complete course of HBOT as an adjunct to the above mentioned treatment (the study group) and the other group (control) received only conventional therapy. The HBOT was given in a monoplace hyperbaric oxygen chamber at the Kasturba Hospital, Bombay in four separate sittings over a period of 2 weeks. The HBOT was administered at 3 atmospheres pressure for a period of 45 minutes at each sitting. Fig. 1 illustrates the equipment used Vickers clinical hyperbaric system. This consists of a pressure chamber and a recirculation console. The pressure chamber is a double acrylic airtight chamber ith a maximal normal rate of compression or of inch/min. The recirculation console supplies oxygen from a liquid oxygen tank. It has CO2 absorbers, pressure gauge selectors, oxygen supply valve and an intercom facility for patient communication. The patient is slid completely into the chamber and the chamber is connected to the patient monitoring panel. Oxygen flow is started (flushing phase) for 2 - 3 minutes till high oxygen concentration is achieved. The chamber pressure is gradually raised to 3 atmospheric pressures after selecting closed circuit mode. After the therapy, the chamber pressure is gradually reduced to normal.
To study the effects of HBOT the following parameters were evaluated: 1) wound cultures-before and after each sitting 2) assessment of local wound daily. In case of amputations, skin flaps were assessed. The other parameters studied were hospital stay, need for amputation and level of amputation if necessary.
Patients were also investigated with complete hemogram, liver and renal profile, X ray chest, ECG, impedance plethysmography (IPG) and serial blood sugars. Urine sugar chart was maintained as a guide to daily diabetic control.
The statistical analysis was carried out by chi-square test.
The two groups were matched for age and sex as shown in [Table:1]. The average hospital stay and amputation rates are depicted in [Table:2]. The average hospital stay in the study group was less but this was statistically not significant. The need for major amputation in the study group was significantly less. The mode of wound healing is shown in [Table:3]. The number of patients requiring skin grafts was higher in the study group as there was better local control of infection with HBO and lesser amputations. The results of pre-and post-procedural wound cultures are charted in Table-4. In the study group, there was a significant overall control of wound infections, especially of Pseudomonas and E.coli. Though there was reduction in the staphylococcal and anaerobic infections, it was comparable with the control group. There were no complications related to the HBOT.
One of the most destructive complications of diabetes is loss of a limb. Three factors lead to tissue necrosis in the diabetic foot viz. neuropathy, infection and ischaemia. Peripheral ischaemia may also result from small vessel disease. However, it is unlikely that the microvascular disease itself is responsible for foot ulcers. Anaerobic bacteria coexist with aerobic bacteria in most of the cases. Increased partial pressure of oxygen in tissues with HBOT bypasses the specific oxygen carrying systems by overloading the amount of dissolved oxygen making haemoglobin superfluous. Whether HBOT is useful in diabetic foot lesions where the microvascular disease compromises the delivery system is not known.
In the present study, a reduction in hospital stay was found in patients receiving HBOT. Though not statistically significant, it shows that aggressive medical and surgical management remains essential if the effects of HBO are to be realised. Consequently, this group had a higher rate of skin graftings, minor amputations and repeated debridements in the salvaged limb. The major effect of HBO was seen as the significantly reduced rate of major amputations in the study group. This is because HBO may have successfully achieved local control and prevented spread of the infection proximally. Patients were therefore able to maintain a bipedal gait, with a greatly reduced morbidity. The effects on bacteriology were rather surprising. Overall, HBO controlled the wound infection. Specifically Pseudomonas and Ecoli were eliminated better than in the controls but elimination of Staphylococci and anaerobes though good was about the same as the controls with conventional therapy.
The beneficial effects of HBO may be explained on the following grounds. HBO improves microvascular supply by increasing the amount of oxygen so that gaseous diffusion can occur in relatively avascular or ischaemic areas. Normal fibrobiast proliferation and collagen production requires a local oxygen tension level of 20 - 40 mm of Hg. Raising this threshold level to 40 - 50 mm of Hg stimulates greater degree of neovascularisation which may favour definitive local healing. Oxygen is bactericidal to certain anaerobic or microaerophilic organisms because they lack the appropriate enzymes (superoxide dismutase and catalase) necessary to protect them in highly oxygenated environments.
We thank the Dean, Seth GS Medical College and King Edward Memorial Hospital for permitting us to publish this data. We are also thankful to Kasturba Hospital, HBOT department for their kind cooperation.
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