ISCHAEMIC STROKE, PREVENTABLE WITH TISSUE ADHESIVE.

Many cases of gas embolism-related stroke are preventable by following guidelines.Sealing the tract where central venous catheters have been removed with tissue glue prevents air entrainment into the vascular system.Early hyperbaric treatment is essential, and the location of the nearest hyperbaric unit should be known whenever invasive procedures are undertaken.

Analysis of Anthrax Immune Globulin Intravenous with Antimicrobial Treatment in Injection Drug Users, Scotland, 2009-2010.

We studied anthrax immune globulin intravenous (AIG-IV) use from a 2009-2010 outbreak of Bacillus anthracis soft tissue infection in injection drug users in Scotland, UK, and we compared findings from 15 AIG-IV recipients with findings from 28 nonrecipients. Death rates did not differ significantly between recipients and nonrecipients (33% vs. 21%). However, whereas only 8 (27%) of 30 patients at low risk for death (admission sequential organ failure assessment score of 0-5) received AIG-IV, 7 (54%) of the 13 patients at high risk for death (sequential organ failure assessment score of 6-11) received treatment. AIG-IV recipients had surgery more often and, among survivors, had longer hospital stays than did nonrecipients. AIG-IV recipients were sicker than nonrecipients. This difference and the small number of higher risk patients confound assessment of AIG-IV effectiveness in this outbreak.

Hyperbaric oxygen for patients with chronic bowel dysfunction after pelvic radiotherapy (HOT2): a randomised, double-blind, sham-controlled phase 3 trial.

BACKGROUND: Hyperbaric oxygen has been used as a therapy for patients experiencing chronic intestinal syndromes after pelvic radiotherapy for decades, yet the evidence to support the use of this therapy is based almost exclusively on non-randomised studies. We aimed to provide conclusive results for the clinical benefits of hyperbaric oxygen in patients with chronic bowel dysfunction after radiotherapy for pelvic malignancies. METHODS: HOT2 was a double-blind, sham-controlled, phase 3 randomised study of patients (≥18 years) with chronic gastrointestinal symptoms for 12 months or more after radiotherapy and which persisted despite at least 3 months of optimal medical therapy and no evidence of cancer recurrence. Participants were stratified by participating hyperbaric centre and randomly assigned (2:1) by a computer-generated list (block size nine or 12) to receive treatment with hyperbaric oxygen therapy or sham. Participants in the active treatment group breathed 100% oxygen at 2·4 atmospheres of absolute pressure (ATA) and the control group breathed 21% oxygen at 1·3 ATA; both treatment groups received 90-min air pressure exposures once daily for 5 days per week for a total of 8 weeks (total of 40 exposures). Staff at the participating hyperbaric medicine facilities knew the allocated treatment, but patients, clinicians, nurse practitioners, and other health-care professionals associated with patients' care were masked to treatment allocation. Primary endpoints were changes in the bowel component of the modified Inflammatory Bowel Disease Questionnaire (IBDQ) score and the IBDQ rectal bleeding score 12 months after start of treatment relative to baseline. The primary outcome was analysed in a modified intention-to-treat population, excluding patients who did not provide IBDQ scores within a predetermined time-frame. All patients have completed 12 months of follow-up and the final analysis is complete. The trial is registered with the ISRCTN registry, number ISRCTN86894066. FINDINGS: Between Aug 14, 2009, and Oct 23, 2012, 84 participants were randomly assigned: 55 to hyperbaric oxygen and 29 to sham control. 75 (89%) participants received 40 pressure exposures, all participants returned the IBDQ at baseline, 75 (89%) participants returned the IBDQ at 2 weeks post-treatment, and 79 (94%) participants returned the IBDQ at 12 months post-start of treatment. Patients were excluded from analyses of co-primary endpoints if they had missing IBDQ scores for intestinal function or rectal bleeding at baseline or at 12 months. In an analysis of 46 participants in the active treatment group and 23 participants in the control group, we found no significant differences in the change of IBDQ bowel component score (median change from baseline to 12 months of 4 (IQR -3 to 11) in the treatment group vs 4 (-6 to 9) in the sham group; Mann-Whitney U score 0·67, p=0·50). In an analysis of 29 participants in the active treatment group and 11 participants in the sham group with rectal bleeding at baseline, we also found no significant differences in the change of IBDQ rectal bleeding score (median change from baseline to 12 months of 3 [1 to 3] in the treatment group vs 1 [1 to 2] in the sham group; U score 1·69, p=0·092). Common adverse events in both groups were eye refractive changes (three [11%] of 28 patients in the control group vs 16 [30%] of 53 patients in the treatment group), increased fatigue (three [11%] vs two [4%]), and ear pain (six [21%] vs 15 [28%]). Eight serious adverse events were reported in eight patients: two were reported in two patients in the control group (tonsillitis requiring surgery [grade 3]; recurrent cancer of the vulva [grade 4]) and six serious adverse events were reported in six patients in the treatment group (malignant spinal cord compression requiring surgery [grade 3]; malignant paraortic lymph node involvement requiring surgery [grade 3]; recurrence of vomiting and dehydration [grade 3]; diarrhoea and fever associated with Campylobacter infection [grade 3]; recurrence of abdominal pain, bloating, diarrhoea, and urinary tract infection [grade 3]; aneurysm [grade 4]), none of which were deemed treatment-related. INTERPRETATION: We found no evidence that patients with radiation-induced chronic gastrointestinal symptoms, including those patients with rectal bleeding, benefit from hyperbaric oxygen therapy. These findings contrast with evidence used to justify current practices, and more level 1 evidence is urgently needed. FUNDING: Cancer Research UK and National Health Service (NHS) funding to the National Institute of Health Research Biomedical Research Centre at The Royal Marsden and the Institute of Cancer Research.

Cerebral venous air embolism treated with hyperbaric oxygen: a case report.

We present a case of cerebral venous gas embolism. Our patient made a complete neurological recovery after hyperbaric oxygen therapy (HBOT). The principles of HBOT, compressing and eliminating air bubbles and decreasing Β-2 integrin function, thus improving microcirculation, can only be beneficial in a situation where neurological damage is likely. Retrograde cerebral venous gas embolism is a less well recognised variant of gas embolism than the arterial variant. Its existence as a different entity is better recognised in the forensic medicine and radiology literature than in other disciplines. There is evidence in the literature of patients dying from this complication and others seemingly experiencing very little effect. This case report highlights this condition, to encourage others to look out for it and report outcomes, and to serve as a reminder that peripheral lines may be a potential cause of gas embolism, although the portal of air entry in our case remains uncertain.

Malfunction of the Siaretron 1000 Iper™ hyperbaric ventilator.

INTRODUCTION: Patient ventilators for use in the hyperbaric chamber need to be of special design; any malfunction could have disastrous consequences. We report two serious problems with a recently purchased Siaretron 1000 Iper™ ventilator. METHODS: The ventilator was tested with a Biotek VT-Plus™ gas flow analyzer, which also measures O2 concentration. The changes in fraction of inspiratory oxygen (FiO2) were verified with a Teledyne Electronic Devices™ O2 analyzer. RESULTS: In volume control ventilation (VCV) mode: excessively large tidal volumes were delivered when the fraction of inspiratory oxygen (FiO2) was changed. In pressure control ventilation (PCV) mode: changing the FiO2 setting did not change the FiO2 delivered by the ventilator. The ventilator also exhibited an irregular flow pattern in PCV. CONCLUSIONS: These problems may cause serious diagnostic and clinical consequences if not identified as equipment malfunction issues. A malfunction of the integrated memory in the microchip on the main board was said to cause the PCV malfunction. The manufacturer replaced the main board, which corrected the problem. The solution offered for the VCV problem was to change FiO2 in steps of 0.1 per breath, which eliminates the tidal volume surges. We feel it is extremely important that all users of the Siaretron 1000 Iper™ are made aware of these problems as they are not described in the user manual or elsewhere.