Hyperbaric Oxygen and Medication-Related Osteonecrosis of the Jaw (MRONJ): An Integrative Review

ABSTRACT: Some adjuvant treatments are available for Medication-Related Osteonecrosis of the Jaw (MRONJ) to help the pain and improve quality of life. Among these treatments is hyperbaric oxygen (HBO) which has presented controversial findings in the literature in recent years. This integrative review analyzed the results among studies published during the pas t 10 years using HBO. The PICO strategy was used and the databases PubMed, LILACS, and SCOPUS. The final search resulted in the inclusion of 7 articles. The main conclusion is that, in the majority of cases, using HBO as an adjuvant to the basic therapy improved the quality of life and/or pain of the patients.

RESUMEN: Existen algunos tratamientos adyuvantes para la osteonecrosis de la mandíbula relacionada con medicamentos (MRONJ) para aliviar el dolor y mejorar la calidad de vida de los pacientes. Entre estos tratamientos se encuentra el oxígeno hiperbárico (OHB) que ha presentado resultados controvertidos en la literatura durante los últimos años. En esta revisión integrada se analizaron los resultados de los estudios publicados durante los últimos 10 años utilizando OHB. Se utilizó la estrategia PICO y las bases de datos PubMed, LILACS y SCOPUS. La búsqueda final resultó en la inclusión de 7 artículos. La principal conclusión es que, en la mayoría de los casos, el uso de OHB como adyuvante de la terapia básica mejoró la calidad de vida y / o el dolor de los pacientes.

Relación Dosis de oxígeno-Celeridad en la oxigenación hiperbárica para intoxicación con monóxido de carbono / Oxygen Dose-Implementation Celerity relationship in hyperbaric oxygenation for carbon monoxide poisoning

Resumen Se realiza una revisión narrativa que plantea una reflexión acerca del rol de la oxigenación hiperbárica en la recuperación de los intoxicados con monóxido de carbono (ICO). La relación presión de tratamiento de oxigenación hiperbárica (TOHB), o sea dosis de oxígeno, y demora en su implementación son descriptas en esta revisión. Se presentan 9 casos de pacientes con ICO tratados con TOHB a 1,45 ATA (Atmósferas absolutas) por falta de acceso a TOHB de alta presión. Si bien es necesario investigación adicional, sugerimos que esta modalidad terapéutica a 1,45 ATA para ICO debe ser elegida frente al oxígeno normobárico, y considerada cuando las instalaciones de alta presión no están disponibles a distancias razonables.

Abstract A narrative review that raises a reflection about the role of hyperbaric oxygenation in the recovery of monoxide carbon (CO) poisoning is carried out. A description of the relationship of the pressure of hyperbaric oxygen therapy (HBOT), oxygen dosage, and the delay in its implementation was done. Nine cases of intoxications treated with HBOT at 1.45 ATA due to lack of access to high-pressure HBOT were presented. While additional research is necessary, we suggest that this therapeutic modality at 1.45 ATA (Absolute Atmospheres) should be chosen instead of normobaric oxygen therapy for CO poisoning, and considered when high pressure facilities are not available at reasonable distances.

Seguridad y experiencia en el uso del oxígeno hiperbárico en el paciente con infarto agudo al miocardio con elevación del ST / Safety and experience of the use of hyperbaric oxygen in the patient with acute myocardial infarction with ST elevation

Resumen El oxígeno hiperbárico (HBO2) es un tratamiento útil para enfermedades isquémicas; sin embargo, como tratamiento coadyuvante en el infarto al miocardio (IAM), existe muy poca experiencia a nivel mundial; ha sido utilizado en algunos trabajos de investigación como tratamiento único en una sola exposición en el contexto de un infarto agudo con elevación del segmento ST (IAMCEST) y adicional a la trombólisis. Nuestro estudio describe la factibilidad y seguridad de dosis continuas de tratamiento con HBO2 después de un infarto al mejorar la función del ventrículo izquierdo. Objetivo El objetivo de este trabajo es describir la experiencia y la seguridad de las dosis de HBO2 en el paciente con IAMCEST llevado a angioplastia primaria para mejorar la función del ventrículo izquierdo. Material y métodos Se reunieron 24 pacientes aleatorizados en dos grupos: 13 en el de casos y 11 controles. Ambos grupos fueron llevados a angioplastia primaria y tratamiento convencional. Se valoró la función ventricular izquierda con SPECT CT; el grupo de casos recibió 15 sesiones repetidas de 90 minutos de isopresión a 2.0 ATA. Resultados Los dos grupos eran de similares características; ingresaron al hospital con un IAMCEST y fueron llevados a angioplastia primaria, aleatorizados en dos grupos; el de casos fue llevado a la cámara hiperbárica para recibir dosis diarias por 15 días de HBO2 a 2 ATA por 90 minutos de isopresión. No se presentaron durante el tratamiento con oxígeno hiperbárico complicaciones cardiovasculares: reinfarto, sangrados, descontrol hipertensivo, arritmias ni datos de insuficiencia cardiaca. En cuanto a complicaciones propias de la cámara hiperbárica, sólo un paciente presentó claustrofobia importante. Además, se observó un beneficio adicional al tratamiento convencional del IAMCEST: la fracción de expulsión del ventrículo izquierdo (FEVI) en el IAM anteroseptal mejoró significativamente en el grupo de casos. Conclusiones El oxígeno hiperbárico a dosis continuas es seguro y factible como tratamiento adicional al paciente con IAMCEST llevado a angioplastia primaria, además de mejorar la función ventricular izquierda en los infartos extensos.

Abstract Hyperbaric oxygen (HBO2) is a useful treatment for ischemic diseases; however, as an adjuvant treatment in myocardial infarction (MI), there is very little experience worldwide. It has been used in some research work as a single treatment in a single exposure in the context of an ST-segment elevation myocardial infarction (STEMI) and in addition to thrombolysis. Our study describes the feasibility and safety of continuous doses of HBO2 after a heart attack by improving left ventricular function. Objective The objective of this study is to describe the experience and safety of HBO2 doses in the patient with STEMI taken to primary angioplasty to improve left ventricular function. Material and methods 24 randomized patients were collected and divided into two groups: 13 in the case group and 11 control patients. Both groups were taken to primary angioplasty and conventional treatment. Left ventricular function was assessed with SPECT CT; the case group received 15 repeated 90-minute sessions of isopressure at 2.0 ATA. Results The two groups were similar in characteristics; they were admitted to the hospital with an STEMI, taken to primary angioplasty, randomized into two groups. The group of cases was taken to the hyperbaric chamber to receive daily doses of HBO2 for 15 days at 2 ATA for 90 minutes of isopressure. There were no cardiovascular complications during the treatment with hyperbaric oxygen: reinfarction, bleeding, hypertensive disorder, arrhythmias or heart failure data. Complications typical of the hyperbaric chamber: only one patient presented significant claustrophobia. In addition to the benefits of the conventional treatment of STEMI, the left-ventricular ejection fraction (LVEF) in anteroseptal MI was significantly improved in the group of cases. Conclusions Continuous-dose hyperbaric oxygen is safe and feasible as an additional treatment for patients with STEMI taken to primary angioplasty, in addition to improving left ventricular function in extensive heart attacks.

Anti-inflammatory effects of hyperbaric oxygen on irradiated laryngeal tissues / Efeitos anti-inflamatórios do oxigênio hiperbárico sobre tecidos laríngeos irradiados

Abstract Introduction To manage the complications of irradiation of head and neck tissue is a challenging issue for the otolaryngologist. Definitive treatment of these complications is still controversial. Recently, hyperbaric oxygen therapy is promising option for these complications. Objective In this study, we used biochemical and histopathological methods to investigate the efficacy of hyperbaric oxygen against the inflammatory effects of radiotherapy in blood and laryngeal tissues when radiotherapy and hyperbaric oxygen are administered on the same day. Methods Thirty-two Wistar Albino rats were divided into four groups. The control group was given no treatment, the hyperbaric oxygen group was given only hyperbaric oxygen therapy, the radiotherapy group was given only radiotherapy, and the radiotherapy plus hyperbaric oxygen group was given both treatments on the same day. Results Histopathological and biochemical evaluations of specimens were performed. Serum tumor necrosis factor-α, interleukin-1β, and tissue inflammation levels were significantly higher in the radiotherapy group than in the radiotherapy plus hyperbaric oxygen group, whereas interleukin-10 was higher in the radiotherapy plus hyperbaric oxygen group. Conclusion When radiotherapy and hyperbaric oxygen are administered on the same day, inflammatory cytokines and tissue inflammation can be reduced in an early period of radiation injury.

Resumo Introdução O manejo das complicações da irradiação do tecido da cabeça e pescoço é uma questão desafiadora para o otorrinolaringologista. O tratamento definitivo dessas complicações ainda é controverso. Recentemente, a oxigenoterapia hiperbárica tem sido uma opção promissora para essas complicações. Objetivo Nesse estudo foram usados métodos bioquímicos e histopatológicos para investigar a eficácia do oxigênio hiperbárico contra os efeitos inflamatórios da radioterapia no sangue e nos tecidos laríngeos, quando a radioterapia e oxigênio hiperbárico são administrados no mesmo dia. Métodos Trinta e dois ratos Wistar albinos foram divididos em quatro grupos. O grupo controle nao recebeu tratamento, o grupo de oxigenio hiperbarico recebeu apenas oxigenoterapia hiperbarica, o grupo de radioterapia recebeu apenas radioterapia e o grupo de radioterapia com oxigenio hiperbarico recebeu ambos os tratamentos no mesmo dia. Resultados Foram realizadas avaliaçoes histopatologicas e bioquimicas dos especimes. Os niveis sericos de fator de necrose tumoral-α, interleucina-1β e inflamaçao tecidual foram significativamente maiores no grupo de radioterapia do que no grupo de radioterapia mais oxigenio hiperbarico, enquanto que a interleucina-10 foi maior no grupo de radioterapia mais oxigenio hiperbarico. Conclusão Quando a radioterapia e o oxigênio hiperbárico são administrados no mesmo dia, as citocinas inflamatórias e a inflamação tecidual podem ser reduzidas no período inicial da radiação.

Surgical management of mandibular ameloblastoma and immediate reconstruction with nonvascularized bone graft and hyperbaric oxygen therapy / Tratamiento quirúrgico de ameloblastoma mandibular y la reconstrucción inmediata con injerto oseo libre y terapia con oxígeno hiperbárico

Extensive resection of tumor often results in bone and soft tissue defects that cause functional and esthetic consequences. The reconstructive surgery is extremely important for the rehabilitation of these patients. The purpose of this study is to report on the use of Hyperbaric Oxygen therapy (HBO) in the case of a large ameloblastoma treated with segmental resection and reconstructed immediately with nonvascularized bone graft (NVBGs) from iliac crest. A 41-year-old woman was referred to our department because of paresthesia of the inferior alveolar nerve and history of swelling in the molar and ramus region of the left mandible. Panoramic radiograph depicting well-defined multilocular radiolucency extending from second pre-molar region to the left ramus region. An incisional biopsy confirms the diagnosis of solid ameloblastoma. The treatment of choice was segmental mandibular resection and immediate mandibular reconstruction using NVBGs from iliac crest, followed by removal of internal fixation and placement of dental implants with immediate loading. The patient received preoperative HBO (a 90-min session at 2.2-2.4 atmospheres, five times per week for two weeks, for a total of up to 10 sessions). Postoperative HBO (10 further 90-min sessions) was administered within 2weeks. The patient received rehabilitation with a mandibular implant-supported fixed complete dental prosthesis. The present study showed successful management of mandibular ameloblastoma that associated extensive surgery, immediate reconstruction with NVBGs from iliac crest, hyperbaric oxygen therapy and dental implants. These combined procedures allowed removal of lesion and reestablishment of mandibular contour and function.

La resección extensa de un tumor a menudo da lugar a defectos del hueso y de los tejidos blandos, que causan consecuencias funcionales y estéticas. La cirugía reconstructiva es extremadamente importante para la rehabilitación de estos pacientes. El propósito de este estudio fue informar sobre el uso de la terapia de oxígeno hiperbárico (HBO) en un caso de un ameloblastoma de gran tamaño, tratado con resección segmentaria y reconstruido inmediatamente con injerto óseo no vascularizado (IONV) de la cresta ilíaca. Una mujer de 41 años fue derivada a nuestro servicio por parestesia del nervio alveolar inferior e historia de hinchazón en la región molar y ramina de la mandíbula izquierda. Radiografía panorámica que muestra una radiolucencia multilocular bien definida que se extiende desde la segunda región pre-molar hasta la región de la rama izquierda. Una biopsia incisional confirma el diagnóstico de ameloblastoma sólido. El tratamiento de elección fue la resección mandibular segmentaria y la reconstrucción mandibular inmediata mediante IONV de cresta ilíaca, seguido de la eliminación de la fijación interna y la colocación de implantes dentales con carga inmediata. La paciente recibió OHB preoperatoria (una sesión de 90 minutos a 2.2-2.4 atmósferas, cinco veces por semana durante dos semanas, para un total de hasta 10 sesiones). La OHB postoperatoria (10 sesiones adicionales de 90 minutos) se administró en 2 semanas. La paciente recibió rehabilitación con una prótesis dental fija con implante mandibular. El presente estudio mostró un manejo exitoso del ameloblastoma mandibular asociado a una cirugía extensa, reconstrucción inmediata con IONV de cresta ilíaca, oxigenoterapia hiperbárica e implantes dentales. Estos procedimientos combinados permitieron la extirpación de la lesión y el restablecimiento del contorno y la función mandibular.

Infecciones necrotizantes de tejidos blandos: Mionecrosis por Clostridium

Las infecciones necrotizantes de los tejidos blandos varían en su presentación clínica, pero en general son de curso grave y alta mortalidad. El cuadro clínico incluye: fiebre, celulitis, edema, crepitación, bulas, necrosis y sepsis; con frecuencia existe un antecedente traumático o quirúrgico. Como hallazgo operatorio se encuentra necrosis de la piel y tejido subcutáneo, con o sin mionecrosis. El tratamiento debe ir dirigido a compensar el estado general de los pacientes aunado al temprano desbridamiento y remoción de tejido necrótico y contaminado y cobertura antibiótica de amplio espectro. Se expone el caso clínico de un paciente indígena de 2 años, sin antecedentes patológicos previos que desarrolló un proceso compatible con una infección necrotizante de partes blandas (INPB) en miembro superior e inferior izquierdo. Se realizó de urgencia una fasciotomía de miembro superior Derecho y desarticulación de cadera izquierda y se instauró tratamiento antibiótico con meropenem y vancomicina, sesiones con oxígenos hiperbárico.

Necrotizing soft tissue infections vary in their clinical presentation, but are generally severe course and high mortality. The clinical picture includes fever, cellulitis, edema, crepitus, bullae, necrosis and sepsis; there is often a traumatic or surgical history. As surgical finding is necrosis of the skin and subcutaneous tissue, with or without myonecrosis. Treatment should be directed to compensate the general state of patients coupled with early debridement and removal of necrotic tissue and contaminated and broad-spectrum antibiotics.The clinical case of an patient two years, without previous pathological antecedents who developed a process compatible with necrotizing soft tissue infection into upper and lower left limb is exposed. Performed emergency fasciotomy of right upper limb and left hip disarticulation and antibiotic treatment was started with meropenem and vancomycin, hyperbaric oxygen sessions.

Rehabilitación protésica implanto-soportada previo protocolo de terapia de oxígeno hiperbárico, posterior a resección de carcinoma epidermoide de piso de boca y radioterapia: Reporte clínico / Implant-supported prosthetic rehabilitation prior to conducting hyperbaric oxygen therapy and after having completed resection of an epidermoid carcinoma from the floor of the mouth and radiotherapy: Clinical case report

En este artículo se presenta la rehabilitación implanto-soportada de un paciente previamente tratado mediante resección de carcinoma epidermoide de piso de boca y radioterapia (dosis total de 56 Gy). El tratamiento consistió en la administración de terapia de oxígeno hiperbárico mediante el siguiente protocolo: previa a la colocación de los implantes de 20 sesiones diarias con 100% de oxígeno a 2.4 ATM de presión, durante 90 minutos y 10 sesiones diarias con 100% de oxígeno, a 2.4 ATM de presión durante 90 minutos posterior a la colocación de los implantes. La rehabilitación protésica fue realizada seis meses posteriores a la colocación de los implantes mediante una prótesis removible implanto-soportada con sistema de anillos para la retención de la misma. Actualmente, el paciente se encuentra a dos años de seguimiento de la rehabilitación, libre de actividad tumoral en la zona tratada y con un adecuado resultado funcional y estético.

The present article purports to present a case of implant-supported rehabilitation of a patient who had previously undergone a procedure of floor of the mouth squamous cell carcinoma resection followed by radiotherapy (56 Gy total). Treatment consisted on hyperbaric oxygen therapy by means of the following protocol: previous to implant placement: 20 daily sessions, 100% oxygen at 2.4 ATM pressure during 90 minutes as well as 10 daily sessions of 100% oxygen at 2.4 ATM pressure, during 90 minutes after implant placement. Prosthetic rehabilitation was conducted six months after implant placement. It consisted of an implant-supported removable prosthesis with a ring system to achieve retention. Presently the patient is at a two year follow-up period after rehabilitation, and is free of tumor activity in the treated zone. The patient has so far achieved appropriate esthetic and functional results.

Oxígeno hiperbáiico en el manejo de radionecross del tallo cerebral en una pacciente con méduloblastmma / Hyperbarc oxygenn in the management of radionecrosis bran stem in a pattient with medulloblastoma / Oxigenoerapia hiiperbárica na gestão de radionecrose brain stem em um paciente com meduloblastoma

La radionecrosis del tallo cerebral es una de las complicaciones de la radioterapia en pacientes que han recibido tratamiento para un tumor intracraneal, y aunque afortunadamente no es lo más frecuente, sus consecuencias pueden ser devastadoras, pues la importancia del tejido comprometido hace que se generen lesiones que pueden producir secuelas altamente incapacitantes y hasta la muerte del paciente como en efecto sucedió en el presente caso. Según la FDA (Food and Drug Administration) el Oxígeno Hiperbárico (OHB) se encuentra indicado en la radionecrosis ósea y radionecrosis de tejidos blandos (1); el Comité Europeo para Medicina Hiperbárica incluyó la radionecrosis del tejido nervioso central en las indicaciones del oxígeno hiperbárico (2). El caso reportado es el de una paciente de 28 años de edad, con un meduloblastoma de fosa posterior que fue tratado con cirugía y químio-radioterapia, quedando la paciente muy bien clínicamente. 21 meses después del tratamiento inicial presenta síntomas que sugieren una lesión en el tallo cerebral, por lo que nuevamente consulta y posterior a estudios imagenológicos se logra determinar que se trata de una lesión del tallo cerebral por radionecrosis. En julio de 2011 la paciente ya presentaba disartria, bradilalia, lateropulsión izquierda, diplopía, cefalea, marcha atáxica y espasticidad de las cuatro extremidades con predominio del hemicuerpo izquierdo. Al momento de iniciar el tratamiento con OHB (septiembre de 2011), se encontró cuadriparesia no funcional. Se realizaron 6 sesiones con OHB, tratamiento con bevacizumab y corticoides, a pesar de lo cual, la evolución de la paciente fue tórpida y rápidamente fulminante llevándola a la muerte en menos de seis meses. La discusión que surge con este caso clínico, es si el tratamiento con OHB debería ser más enfocado a la prevención y profilaxis que al tratamiento de lesiones que por su ubicación anatómica revisten una alta gravedad y pueden ser irreversibles, una vez que se encuentran instauradas.

Brain stem radionecrosis is a complication of radiotherapy in patients who have been treated for a tumor, and although fortunately not very common, its consequences can be devastating since the importance of the involved tissue causes generation of lesions which can give as a result highly disabling lesions or even the patient's death, as indeed happened in this case. According to the FDA (Food and Drug Administration), Hyperbaric Oxygen (HBO) is indicated in bone and soft tissues radionecrosis (Regulations, 2012), including in the latter the central nervous system. The reported case is a 28-year female patient presenting with a posterior fossa medulloblastoma that was treated with surgery and chemo-radiotherapy. Twenty one months after the initial treatment, she presents with symptoms suggestive of a brain stem lesion for which reason she consults once again, and after imaging studies, a brain stem lesion due to radionecrosis is ascertained. In July 2011 the patient was already presenting with dysarthria, bradilalia, left lateropulsion, diplopy, cephalea, ataxic gait and symmetrical spasticity with predominance of left hemibody. Upon treatment initiation with OHB (September 2011) nonfunctional quadriparesis was found. Six sessions with OHB were performed, and treatment with bevacizumab and corticosteroid agents was given despite which the patient's evolution was poor and fulminating leading to death within less than six months. The discussion rising from this clinical case is whether treatment with OHB should be more focused on prevention and prophylaxis than on treatment of lesions which, because of their anatomical location, entail high seriousness and can be irreversible once they are set up.

O radionecrose tronco cerebral é uma das complicações da radioterapia em pacientes tratados por um tumor intracraniano, e embora felizmente não tão freqüentes, as conseqüências podem ser devastadoras, como a importância da comprometidas causas lesão tecidual gerados que pode produzir altamente seqüelas incapacitantes e até mesmo a morte do paciente como de fato aconteceu neste caso. De acordo com o FDA (Food and Drug Administration) Oxigenoterapia Hiperbárica (OHB) a terapia é indicada na radionecrose radionecrose ossos e tecidos moles (1), o Comité Europeu de Medicina Hiperbárica incluído necrose radiação do tecido nervoso central nas indicações da oxigenoterapia hiperbárica (2). O caso é relatado de um 28-year-old com um meduloblastoma fossa posterior que foi tratado com cirurgia e quimio-radioterapia, o paciente permanecer clinicamente bem. 21 meses após o tratamento inicial tem sintomas que sugerem uma lesão no tronco cerebral, por isso novamente depois de estudos de consulta e de imagem foram capazes de determinar que é um prejuízo para o radionecrose tronco cerebral. Em julho de 2011, o paciente já teve disartria, bradilalia, lateropulsão esquerda, diplopia, cefaléia, ataxia de marcha e espasticidade de todos os quatro membros com dominância do hemisfério esquerdo. Ao iniciar o tratamento com HBO (Setembro de 2011), não encontrou quadriplegia funcional. Foram realizadas 6 sessões com OHB, bevacizumab e terapia com esteróides, apesar de que, a evolução do paciente foi entorpecida e rapidez fulminante levando à sua morte, em menos de seis meses.

Experiência inicial da terapia hiperbárica na síndrome de fournier em um hospital de referência no sul catarinense / Initial experience hyperbaric therapy fournier syndrome in a referral hospital in southern Santa Catarina

Introdução: A Gangrena de Fournier é uma fasceítenecrotizante que afeta a região escrotal e a área perineal.Métodos: Foram revisados os prontuários de 8pacientes que tinham o diagnóstico de Gangrena deFournier e que foram submetidos ao tratamento de oxigenioterapiahiperbárica como forma adjuvante entre operíodo de março de 2010 a abril de 2011 no HospitalSão José, Criciúma,SC analisando-se as variáveis: sexo,idade, etiologia, localização da lesão, procedimentoscirúrgicos realizados. Resultados: A maioria foram homenscom idade média de 32,8 anos. O local mais comumde acometimento foi a região urogenital. Agenteetiológico mais frequentemente encontrado foi Enterobacteragglomerans. Todos foram submetidos à desbridamentocirúrgico, sendo que foi realizado colostomiaem três pacientes. A quantidade média de desbridamentoscirúrgicos foi de 2,5. O tempo médio de permanênciahospitalar foi de 45 dias. A média de sessõesem câmera hiperbárica foi de 20,2 sessões. Um pacienteevoluiu para óbito. Discussão: O diagnóstico precocedesta síndrome é fundamental para o sucesso no tratamentoque tem como base a estabilização clínica ecorreção de possíveis distúrbios, além do tratamentocirúrgico que consiste em extenso desbridamento detecidos lesados. A Oxigenioterapia Hiperbárica comométodo adjuvante tem mostrado excelentes resultadose deve ser utilizada como método adicional ao tratamentotradicional com estudos mostrando uma menortaxa de mortalidade. Esta é uma experiência, com númeropequeno de pacientes, porém com excelentes resultadosnos casos realizados.

Introduction: Fournier gangrene is a necrotizing fasciitisaffecting the scrotum and perineal area. Methods:We reviewed the medical records of eight patientswho were diagnosed with Fournier?s gangrene and whounderwent hyperbaric oxygen treatment as adjuvantform between the period march 2010 to april 2011in São José Hospital, Criciúma, SC analyzing variables:gender, age, etiology, lesion location, surgical proceduresperformed. Results: The majority were men with amean age of 32.8 years. The most common site of involvementwas the urogenital region. Etiologic agentwas most frequently found Enterobacter agglomerans.All underwent surgical debridement, and colostomywas performed in three patients. The average numberof debridements was 2.5. The mean hospital stay was45 days. The average number of sessions in the hyperbaricchamber sessions was 20.2. One patient died. Discussion:Early diagnosis of this syndrome is critical tosuccess in treatment is based on clinical stabilizationand correction of potential disturbances, and surgicaltreatment consisting of extensive debridement of injuredtissues. Hyperbaric Therapy as adjunctive methodhas shown excellent results and should be used as an72 additional method to traditional treatment with studiesshowing a lower mortality rate. This is an experience,with small number of patients, but with excellent resultsin cases performed.

Confecção de um modelo experimental in vitro do espaço subaracnóide eqüino para teste de opióides hiperbáricos / Making of an in vitro experimental model of equine subarachnoid space to test hyperbaric opioids

Com o objetivo de avaliar as características de distribuição de agentes hiperbáricos no líquido cérebro-espinhal (LCE) eqüino, é apresentado um modelo in vitro do espaço subaracnóide confeccionado em policloreto de vinila (PVC) transparente, no qual se adaptou um cateter para a infusão contínua de glicose a 10 por cento, morfina hiperbárica, buprenorfina hiperbárica e metadona hiperbárica marcadas com azul de metileno para permitir a visualização da distribuição destas substâncias no LCE. Avaliaram-se a distância alcançada pelos diferentes agentes minuto a minuto e a forma de distribuição dos mesmos. Todas as substâncias testadas mostraram comportamento de distribuição vertical a partir da extremidade do cateter, quando se deu o início da migração cranial no LCE, sendo que o avanço máximo registrado foi aos 15 minutos após o término da infusão, com migração de 15cm para glicose a 10 por cento, 13cm para a morfina hiperbárica, 18cm para a buprenorfina hiperbárica e 17cm para a metadona hiperbárica. O modelo proposto mostrou-se eficiente para a avaliação do comportamento físico dos agentes hiperbáricos no interior do espaço subaracnóide, oferecendo a possibilidade de teste de substâncias a serem utilizadas pela via subaracnóide de cavalos.

The aim of this study was to evaluate the distribution characteristics of hyperbaric solutions in equine cerebrospinal fluid (CSF), in an in vitro model of the subarachnoid space. The model was made with transparent PVC in which a catheter was adapted to infuse 10 percent glucose, 10 percent hyperbaric morphine, hyperbaric buprenorphine, and hyperbaric methadone, dyed with methilene blue in order to visualize the solutions distribution in the CSF. The distance in cm reached by the different agents every minute as well as the pattern of distribution were evaluated. All tested solutions distributed itself in a forward and vertically pattern from the tip of the catheter. Maximum distance reached after 15 minutes were 15cm for 10 percent glucose, 13cm for hyperbaric morphine, 18cm for hyperbaric buprenorphine, and 17cm for hyperbaric methadone. The proposed model was efficient to evaluate the distribution pattern of hyperbaric solutions in equine CSF, offering a new possibility to physically test the administration of solutions in the equine subarachnoid space.

Tratamiento adjunto con oxigenación hiperbárica en mucormicosis. Presentación de cinco casos tratados en la misma Institución y revisión de la literatura / Treatment of mucormycosis with adjunctive hyperbaric oxygen: five cases treated in the some institution and review of the literature

Introduction. Mucormycosis is an invasive fungal infection that affects decompensated diabetics, immunosupressed patients and occasionally healthy individuals. Despite advances in anti-fungal therapy and surgical techniques, the morbidity and mortality remain high. Adjuvant hyperbaric oxygen therapy (HBO) has been proposed based on pathophysiology and several favorable clinical reports. Material and methods. A chart review of mucormycosis patients referred to the HBO service was performed. Also an electronic search in Medline of relevant literature was undertaken. Results. Five mucormycosis patients referred for HBO had complete charts available. Four had craniofacial involvement and one had left upper extremity involvement. The predisposing diseases were leukemia (n = 3), diabetes mellitus plus sarcoidosis (n = 1), and trauma (n = 1). All patients were managed with amphotericin B, surgical debridement and HBO. Survival was 60% (3/5) three months after the diagnosis was established. The literature was scarce but favors HBO. Conclusion. Considering the pathophysiology of mucormycosis adjuvant HBO therapy seems reasonable. However, the clinical experience is still too limited to make HBO part of the standard of care. Prospective, randomized, controlled trials will help to define the role of HBO in this devastating infection.

Introducción. La mucormicosis es una infección micótica invasiva que se presenta principalmente en pacientes diabéticos descompensados, pacientes con afección del sistema inmune, e incluso en individuos previamente sanos. A pesar de los avances en medicamentos y técnicas quirúrgicas la morbimortalidad es todavía muy elevada. La terapia adjunta con oxígeno hiperbárico (OHB) ha sido sugerida con base en fundamentos fisiopatológicos y algunos reportes clínicos favorables. Material y métodos. Revisión de expedientes de pacientes referidos al Servicio de OHB con diagnóstico de infecciones micóticas invasivas. Búsqueda electrónica en Medline de literatura pertinente. Resultados. Cinco pacientes con diagnóstico clínico e histopatológico de mucormicosis con expediente completo fueron referidos a OHB para terapia adjunta. Cuatro presentaron afección craneofacial y uno afección de la extremidad superior izquierda. La enfermedad predisponente fue leucemia (n = 3), sarcoidosis y diabetes mellitus (n = 1) y trauma (n = 1). Todos fueron manejados con anfotericina B, debridación quirúrgica y OHB. La sobrevida fue 60% (3/5) tres meses después del diagnóstico. La literatura al respecto es escasa, pero favorece al OHB. Conclusión. Con base en la fisiopatología de la mucormicosis la terapia adjunta con OHB parece lógica. No obstante, la información clínica es todavía muy limitada para recomendar OHB rutinariamente en estos pacientes. Estudios prospectivos, aleatorios, controlados ayudarán a definir el papel del OHB en el manejo de esta devastadora infección.