Hyperbarics in Diabetic Wound Care. Aurel Mihai, MD & Brian Kline, MD

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1 Hyperbarics in Diabetic Wound Care Aurel Mihai, MD & Brian Kline, MD

2 Presentation Outline The Scope of the Problem Important Definitions Standard Wound Care Hyperbaric Oxygen as an Adjunct

3 Diabetic Foot Ulcers The Human Burden Disfiguring and debilitating In US: 30 million diabetics DFU prevalence: 8.1% Amputation prevalence: 1.8% 540,000 diabetic amputees The Financial Burden Amputation: $91,106 Lifetime amputee care: $509,275 Chronic wound healing: $3,297

4 Defining Chronic Pearl: if it doesn t heal halfway in 4 weeks it won t heal at 12 weeks. Advance of the wound edge of 0.15 cm / week or reduction in wound area of ~40% at 4 weeks are >90% specific for wound closure at 12 weeks

5 Common Chronic Wound Causes Arterial Insufficiency punched out Often painful Poor pulses

6 Common Chronic Wound Causes Arterial Insufficiency Venous Insufficiency Shallow and large Surrounding skin shows typical changes inverted champagne bottle lipodermatosclerosis

7 Common Chronic Wound Causes Arterial Insufficiency Venous Insufficiency Pressure Ulcers Neuropathic Ulcers

8 Common Chronic Wound Causes Arterial Insufficiency Venous Insufficiency Pressure Ulcers Neuropathic Ulcers Pearl: Document DFUs as such in your records. This will help with insurance coverage of certain treatments, including HBOT.

9 Wagner Ulcer Classification System Grade Lesion 0 No open lesions; may have deformity or cellulitis 1 Superficial diabetic ulcer (partial or full thickness) 2 Ulcer extension to ligament, tendon, joint capsule, or deep fascia without abscess or osteomyelitis 3 Deep ulcer with abscess, osteomyelitis, or joint sepsis 4 Gangrene localized to portion of forefoot or heel 5 Extensive gangrenous involvement of the entire foot Pearl: For documentation purposes, wounds can go up in Wagner grade, but not down, until they are fully healed.

10 Standard Wound Care TIME(S) mnemonic Tissue: assess and debride wound bed Frequency of debridement is key. Consider vascular assessment as part of tissue assessment. Infection / Inflammation: local and systemic NERDS & STONES Moisture: moist wounds heal faster Landmark study. Edge: advancement, undermining, surroundings Systemic: glycemic control, nutrition, comorbidities

11 What Next? Considering hyperbarics: Standard wound care continues. Optimize macrovasculature. Transcutaneous oximetry: Periwound TCOM < 20 mmhg incompatible with healing In chamber < 200 mmhg associated with 58% failure

12 Hyperbaric O2 UHMS recognizes enhancement of healing in selected problem wounds, compromised skin grafts and flaps, delayed radiation injury and refractory osteomyelitis as indications Journal of PM&R review: 44 studies Promotes wound healing in problem wounds 2015 Cochrane Review: 12 studies Significant improvement at 6 weeks, not at 1 year

13 Hyperbaric O2 Complications: Barotrauma CNS toxicity Pulmonary toxicity Ocular toxicity Contraindications: Untreated PTX Cavitary lung disease Pacemaker Claustrophobia Seizures / Epilepsy URI / Eustachian tube defect Fever Congenital spherocytosis Certain medications

14 Summary Check at risk patients for wounds regularly. Document wounds and perform standard wound care if comfortable, or refer out for this, but after 4 weeks without sufficient improvement consider adjuncts. HBOT safe in majority of patients, effective, and available locally (NE Med SJH, Upstate). Questions??

15 Works Cited Frykberg RG. Diabetic Foot Ulcers: Pathogenesis and Management. American Family Physician. 2002;1(66): Cardinal M, Eisenbud DE, Phillips T, Harding K. Early healing rates and wound area measurements are reliable predictors of later complete wound closure. Wound Repair and Regeneration. 2008;16(1): doi: /j x x. Margolis D, Malay DS, Hoffstad OJ, et al. Prevalence of diabetes, diabetic foot ulcer, and lower extremity amputation among Medicare beneficiaries, 2006 to Diabetic Foot Ulcers. Data Points #1 (prepared by the University of Pennsylvania DEcIDE Center, under Contract No. HHSA I). Rockville, MD: Agency for Healthcare Research and Quality. February AHRQ Publication No. 10(11)-EHC009-EF. National Diabetes Statistics Report, Centers for Disease Control and Prevention website. Updated August 8, Accessed February 22, Brem H, Sheehan P, Boulton AJ. Protocol for treatment of diabetic foot ulcers. The American Journal of Surgery. 2004;187(5). doi: /s (03)00299-x. Elraiyah T, Tsapas A, Prutsky G, et al. A systematic review and meta-analysis of adjunctive therapies in diabetic foot ulcers. Journal of Vascular Surgery. 2016;63(2). doi: /j.jvs Fife CE, Buyukcakir C, Otto GH, et al. The predictive value of transcutaneous oxygen tension measurement in diabetic lower extremity ulcers treated with hyperbaric oxygen therapy: a retrospective analysis of 1144 patients. Wound Repair and Regeneration. 2002;10(4): doi: /j x x. Huang ET. A clinical practice guideline for the use of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers. Undersea and Hyperbaric Medicine. 2015;42(3): Niinikoski J. Hyperbaric oxygen therapy of diabetic foot ulcers, transcutaneous oxymetry in clinical decision making. Wound Repair and Regeneration. 2003;11(6): Arsenault KA, Mcdonald J, Devereaux PJ, Thorlund K, Tittley JG, Whitlock RP. The use of transcutaneous oximetry to predict complications of chronic wound healing: A systematic review and meta-analysis. Wound Repair and Regeneration. 2011;19(6): doi: /j x x. Leaper DJ, Schultz G, Carville K, Fletcher J, Swanson T, Drake R. Extending the TIME concept: what have we learned in the past 10 years?*. International Wound Journal. 2012;9:1-19. doi: /j x x. Sibbald RG, Woo K, Ayello EA. Increased Bacterial Burden and Infection. Advances in Skin & Wound Care. 2006;19(8): doi: / Wilcox JR, Carter MJ, Covington S. Frequency of Debridements and Time to Heal. JAMA Dermatology. 2013;149(9):1050. doi: /jamadermatol

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