A Case of Necrotising soft tissue injury.pptx

HBOT

1. Surg Lt Cdr Kshitij Lanjekar Resident (JR 2) Marine Medicine Department of Marine & Hyperbaric Medicine ROLE OF HBOT IN Necrotising soft tissue injury

2. INTRODUCTION Hyperbaric Oxygen Therapy has gained popularity across the globe and it has been useful in a huge variety and wide spectrum of disease. Cases well indicated for HBOT but not addressed in time have devastating outcomes. Physicians and Surgeons are the first points of contact.

3. AIM To spread the awareness about Hyperbaric Oxygen Therapy and its Indications amongst primary health care professionals

4. WE PRESENT…….. A case of Necrotising Fasciitis of Rt Lower Limb resulted due to a minor injury with multiple surgical interventions , managed with Skin Grafting and Hyperbaric Oxygen Therapy.

5. Patient particulars 58 years old, F/O Serving Medical Sailor Hailing from Belgaum, Karnataka History by self and relative Reliability fair

6. Chief complaints Presented with Wound on Rt Leg X 01 month Fever x 15 days

7. History of present illness Patient had an accidental injury to Rt Foot by an iron nail Wound over dorso -lateral aspect of Rt Foot – bleb size of small ball Localized Swelling of Rt Foot within 5 days Diagnosed as Compartment Syndrome Rt Lower Limb Underwent Fasciotomy and Debridement at Govt Hospital at Belgaum.

8. Serial photographs of wound Day 2 Day 4 Day 7

9. DEBRIDEMENT AND FASCIOTOMY RT FOOT MEDIAL ASPECT RT LEG LATERAL ASPECT RT LEG

10. History of present illness Swelling Rt leg progressively increased a/w Fever and Pain Diagnosed as case of Cellulitis with Necrotising Soft Tissue Infection Rt Leg. Underwent Re-Debridement NO SYMPTOMATIC IMPROVEMENT But advised for discharge with Only Conservative management INHS Asvini for further management

11. POST RE-DEBRIDEMENT

12. HBOT Split Skin Graft. PLAN AT ASVINI

13. AT INHS ASVINI (PRE HBOT)

14. Summary ?

15. SUMMARY 58 years old male, with no known co-morbidities, presented with an Open Wound having Pain and Swelling of Rt LL a/w High Grade Fever following Fasciotomy and Debridement suggestive of Necrotising Soft Tissue Injury.

16. GENERAL Examination Pulse -110/min BP -116/76 mm Hg , RR -14/min, SPO2- 99% Temp - 102º F No Pallor , No Icterus, No Cyanosis, No clubbing, No Lymphadenopathy Edema Rt Leg RS/ CVS/ PA/ CNS- WNL

17. LOCAL EXAMINATION Site Dorso -Lateral and Medial Aspect of Lower ½ of Rt Leg Shape Irregular approx. 30cms x 20 cms x 15cms dimension Edges Edematous and Sloping Margins Irregular Floor Slough with unhealthy granulation tissue Discharge Seropurulent, Foul smelling Surrounding Skin Edematous & Inflamed

18. LOCAL EXAMINATION Base Rt Tibia and Muscle mass Local Temperature Raised Tenderness Present Lymphadenopathy Absent Vascular Insufficiency No signs Distal/Peripheral pulsation Present Bleed to touch Yes TCPO 2 38 mmHg

19. What is TCPO2 ?

20. TCPO 2 (Transcutaneous PARTIAL PRESSURE OF OXYGEN) Measures the Local Oxygen tension in the skin Predicts wound healing potential Establishes candidacy for HBO Treatment Monitors efficacy of patients ongoing therapy REFERENCE VALUES 40-70 mm Hg Normal < 40 mm Hg Impaired wound healing < 30 mm Hg Critical Limb Ischemia Niinikoski , J. (2003), Hyperbaric oxygen therapy of diabetic foot ulcers, transcutaneous oximetry in clinical decision making. Wound Repair and Regeneration, 11: 458-461. https://doi.org/10.1046/j.1524-475X.2003.11610.x

21. TCPO 2 Chapter 463, Hyperbaric Oxygen Therapy, Michael H. Bennett, Simon J. Mitchell, Pg 3623, 21 st Edition , Harrisons Principle of Internal Medicine

22. Investigations Hb – 13.5 gm/dl, TLC – 15100/mm3 (N-82%, E-1 % B-0% M-2 % L-12) Plt - 2.2 Lakhs/mm3 LFT, RFT- WNL HbsAg , HIV, Anti HCV- Negative Blood Sugar- F/PP- 90/125 gm/dl Pus Culture/ Swab Culture- Positive for Staph and Strep Pyogenes

23. 12 lead ECG - Sinus TACHYCARDIA Chest x-ray PRE HBOT WORKUP

24. WHY ECG AND CHEST X RAY ??

25. CONTRAINDICATIONS/ RISK FACTORS for hbot CARDIAC PULMONARY Arrythmias Blebs and Bullae Heart Blocks Pneumothorax Pressure Sensitive Implanted Medical Device Emphysema Congestive Heart Failure COPD Cavitatory Parenchymal lesion/ Fibrosis Gawdi R, Cooper JS. Hyperbaric Contraindications. [Updated 2023 Apr 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557661/

26. DIAGNOSIS Clinical diagnosis - Necrotising Soft Tissue Injury ICD 10 Diagnosis - Necrotising Fasciitis ICD 10 No - M 72.6

27. COURSE IN HOSPITAL HBOT at 2.4 ATA x 60 mins daily Post 5 sessions- Split Skin Grafting by Recon Surgeon Underwent 20 sessions post graft

28. HBOT Post 5 sessions Healthy granulation tissue Pin point bleeding Only serous discharge Healthy Base of ulcer Francis A, Baynosa RC. Hyperbaric Oxygen Therapy for the Compromised Graft or Flap. Adv Wound Care (New Rochelle). 2017 Jan 1;6(1):23-32. doi : 10.1089/wound.2016.0707. PMID: 28116225; PMCID: PMC5220535.

29. Post 6 th HBOT Session (Post Op Day 2) Post 10 Sessions GRAFT UPTAKE

30. FINAL OUTCOME (POST 20 SESSIONS)

31. FOLLOW UP Reviewed after 10 days & 20 days Asymptomatic Scar Healthy

32. NECROTISING FASCIITIS A subset of aggressive skin and soft tissue infections (SSTIs) that cause necrosis of the muscle fascia and subcutaneous tissues. The infection typically travels along the fascial plane, which has a poor blood supply. Gram-positive cocci - Staphylococcus aureus and Streptococci are responsible for the majority of these single-site source infections. Polymicrobial infections occur as well because of a combination of gram-negative and anaerobic involvement. Wallace HA, Perera TB. Necrotizing Fasciitis. [Updated 2023 Feb 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430756/

33. HBOT RATIONALE Chapter 463, Hyperbaric Oxygen Therapy, Michael H. Bennett, Simon J. Mitchell, Pg 3623, 21 st Edition , Harrisons Principle of Internal Medicine

34. CUMULATIVE EFFECTS INCREASED WOUND HEALING Improved Oxygen Delivery (Hyperoxia) Vasoconstriction of vessels Angiogenesis Antibacterial Action Reduction of Edema Alleva R, Tomasetti M, Sartini D, Emanuelli M, Nasole E, Di Donato F,et al. alpha-Lipoic acid modulates extracellular matrix and angiogenesis gene expression in non-healing wounds treated with hyperbaric oxygen therapy. Mol Med. 2008;14:175–83.

35. CUMULATIVE EFFECTS HYPEROXYGENATION Hyperoxia in normal tissues causes vasoconstriction , but this is well compensated by increased plasma oxygen content and microvascular blood flow. Increased oxygen free radicals and Oxygen-dependent peroxidase system has Antibacterial effect. HBO is particularly effective against anaerobes

36. CUMULATIVE EFFECTS NEO ANGIOGENESIS HBO magnifies the O2 gradient between normal and ischemic tissue this signals the macrophages to release angiogenic factor for capillary budding Hyperoxia-Hypoxia Paradox – HIF gene Increased fibroblast proliferation and collagen synthesis which aids in revascularization Stimulates synthesis of VEGF

37. CUMULATIVE EFFECTS

38. HBOT IN NECROTISING FASCIITIS

39. HBOT IN GRAFT UPTAKE

40. CARRY HOME MESSAGE Primary heath care professionals/Physicians to have an overview of Indications of HBOT HBOT should be considered in all cases of complicated & Infected wounds. Early Referrals and Multidisciplinary approach with Team work is a necessity for patient care.

41. THANK YOU