Hyperbaric oxygen for the treatment of carbon monoxide-induced delayed neurological sequelae: a case report and review of the literature.

Introduction: Hyperbaric oxygen treatment (HBOT) remains a recognised treatment for acute carbon monoxide (CO) poisoning, but the utility of HBOT in treating CO-induced delayed neurological sequelae (DNS) is not yet established. Case description: A 26-year old woman presented with reduced consciousness secondary to CO exposure from burning charcoal. She underwent a single session of HBOT with US Navy Treatment Table 5 within six hours of presentation, with full neurological recovery. Eight weeks later, she represented with progressive, debilitating neurological symptoms mimicking Parkinsonism. Magnetic resonance imaging of her brain demonstrated changes consistent with hypoxic ischaemic encephalopathy. The patient underwent 20 sessions of HBOT at 203 kPa (2 atmospheres absolute) for 115 minutes, and received intravenous methylprednisolone 1 g per day for three days. The patient's neurological symptoms completely resolved, and she returned to full-time professional work with no further recurrence. Discussion: Delayed neurological sequelae is a well-described complication of CO poisoning. In this case, the patient's debilitating neurocognitive symptoms resolved following HBOT. Existing literature on treatment of CO-induced DNS with HBOT consists mainly of small-scale studies and case reports, many of which similarly suggest that HBOT is effective in treating this complication. However, a large, randomised trial is required to adequately determine the effectiveness of HBOT in the treatment of CO-induced DNS, and an optimal treatment protocol.

Assessment of hyperbaric patients at risk of malnutrition using the Malnutrition Screening Tool - a pilot study.

BACKGROUND: Nutritional assessment and support is essential for wound management. The hyperbaric oxygen clinic is a unique outpatient service where chronically unwell patients present daily for hyperbaric oxygen treatment (HBOT) over several weeks, allowing time for effective nutritional intervention. This is the first study to examine the prevalence of those at risk of malnutrition in a cohort of hyperbaric medical patients. METHODS: A prospective study was undertaken over six months. Following consent, 39 enrolled patients had the Malnutrition Screening Tool and Baseline Characteristic Collection Form completed. Those at risk of malnutrition were given an option to be assessed by a dietitian to complete a Subjective Global Assessment (SGA). At the completion of treatment, the patients completed a questionnaire. RESULTS: Twelve of the 39 patients screened were at risk of malnutrition using our screening process. Of these, all the patients with available SGA results were diagnosed with moderate to severe malnutrition. Patients receiving HBOT for non-healing wounds and osteoradionecrosis were most at risk of malnutrition. CONCLUSION: The prevalence of patients being at risk of malnutrition in our hyperbaric medical service was about one in three. Malnutrition screening should be part of routine patient assessment in order to ensure patients receive timely nutritional intervention. This may improve wound healing.

An Unusual Case of a Parturient with Uncorrected Pentalogy of Fallot Presenting for Elective Cesarean Section Delivery of Twins.

We present a 31-year-old primigravida with uncorrected pentalogy of Fallot, pregnant with monochorionic-diamniotic twins, undergoing elective lower segment cesarean section at 36 weeks gestation. Preoperative workup included a transthoracic echocardiogram which revealed a large ventricular septal defect of 1.8 cm with bidirectional shunting, a moderate size atrial septal defect of 1.8 cm with predominant left-to-right shunting, an overriding aorta, moderate right ventricular hypertrophy, and severe pulmonary valve stenosis. Notably, the patient was acyanotic with normal effort tolerance. Preoperative preparation involved the input of cardiologists and obstetric and cardiothoracic anesthetists. Issues such as the use of extracorporeal membrane oxygenation and cardiopulmonary support in the event of cardiac failure were discussed. Autotransfusion postdelivery was also addressed, and plans made for therapeutic venesection should need to arise. Intraoperatively, the planned anesthetic technique was slow and titrated combined spinal-epidural. However, a general anesthetic technique with rapid sequence induction was used in view of extreme patient anxiety. Intravenous induction was performed with ketamine and etomidate, followed by paralysis with succinylcholine. Anesthesia was maintained with desflurane on a mixture of air and oxygen. Phenylephrine infusion was titrated according to the patient's blood pressure and systemic vascular resistance. The uterotonic of choice was duratocin given as a slow bolus, followed by a 4-h infusion of oxytocin. The patient was put in a head-up position to prevent venous air embolism and to decrease autotransfusion to central circulation. Postoperatively, she was extubated and sent to the Intensive Care Unit for continuous monitoring with FloTrac®.