Evaluation of TCOM/HBOT practice guideline for the treatment of foot burns occurring in diabetic patients.

OBJECTIVES: A multidisciplinary team developed an evidence-based guideline for the management of foot burns occurring in diabetic patients that included transcutaneous oxygen measurements (TCOM) and application of hyperbaric oxygen therapy (HBOT) to selected patients. This report represents an evaluation of preliminary TCOM/HBOT data. METHODS: This is a retrospective review of patients with diabetes mellitus (DM) who were admitted to a single American Burn Association (ABA) verified burn center for the treatment of foot burns. Patients were treated via the guideline if they were over the age of 16, admitted for the initial care of burns involving the feet between 4/01/2012 and 7/22/2013, and had a known or new diagnosis of DM. RESULTS: Eighteen patients were treated according to the guideline, 14 men and 4 women. Average age was 54 years+14.78. Average BMI was 30.63+6.34. Median burn size was 0.88% TBSA (median partial thickness of 1% and median full thickness of 0.5%). The average HbA1c was 9.08+2.42. Seven patients received pre-operative HBOT, two received post-operative HBOT and three patients healed their wounds with HBOT alone. Average hospital length of stay was 13.39 days+9.94 and was significantly longer for the group receiving HBOT. Admission HbA1c was not a predictor of the need for HBOT. CONCLUSIONS: While TCOM/HBOT therapy has not been widely applied to the management of diabetic foot burns, the use of an evidence-based guideline incorporating TCOM/HBOT can provide a systematic way to evaluate the patients' microcirculation and ability to heal burns of the foot. The incorporation of TCOM determination and application of HBOT in selected patients with DM and burns of the feet warrant continued study.

A clinician's guide to the treatment of foot burns occurring in diabetic patients.

INTRODUCTION: Diabetes mellitus affects 25.8 million Americans and is predicted to almost double by 2050. The presence of diabetes complicates hospital courses because of the microvascular complications associated with disease progression. Patients with diabetes represent 18.3% of annual burn admissions to our unit and 27% have burns to the feet. The purpose of this project was to develop an evidence-based guideline for care of the patient with diabetes and foot burns METHODS: A multidisciplinary group was charged with developing an evidence-based guideline for the treatment of foot burns in patients with diabetes. Evidence was evaluated in the areas of diabetes, burn care, hyperbaric medicine, care of diabetic foot wounds and physical therapy. After guideline development and approval, key aspects were incorporated into order sets. RESULTS: Key aspects of this guideline are the ability to identify patients with undiagnosed diabetes, assess diabetic control, optimize glycemic and metabolic control, optimize burn wound management, treat microvascular disease, and provide education and a discharge plan. Evaluated outcomes are glycemic control, length of stay, complication rates, amputation rates, infection rates and the use of hyperbaric oxygen. CONCLUSIONS: Best outcomes for this high risk population will be attainable with an evidence based guideline.

Hyperbaric oxygen: applications in infectious disease.

This article reviews the applications of hyperbaric oxygen (HBO) as an adjunctive treatment of certain infectious processes. Infections for which HBO has been studied and is recommended by the Undersea and Hyperbaric Medicine Society include necrotizing fasciitis, gas gangrene, chronic refractory osteomyelitis (including malignant otitis externa), mucormycosis, intracranial abscesses, and diabetic foot ulcers that have concomitant infections. In all of these processes, HBO is used adjunctively along with antimicrobial agents and aggressive surgical debridement. This article describes the details of each infection and the research that supports the use of HBO.

Topical oxygen therapy induces vascular endothelial growth factor expression and improves closure of clinically presented chronic wounds.

1. Chronic wounds, especially in diabetics, represent a serious threat to human health. 2. Correcting a compromised state of tissue oxygenation by the administration of supplemental O(2) is known to benefit wound healing. Beyond its role as a nutrient and antibiotic, O(2) supports wound healing by driving redox signaling. 3. Hyperbaric oxygen (HBO) therapy is widely used and approved by Center for Medicare and Medicaid Services to treat specific ulcerations. The current literature supports the notion that approaches to topically oxygenate wounds may be productive. 4. Here, we present the results of two simultaneous studies testing the effects of HBO and portable topical oxygen (TO) therapies. These two therapeutic approaches have several contrasting features. 5. In total, 1854 patients were screened in outpatient wound clinics for non-randomized enrolments into the HBO (n = 32; 31% diabetic) and TO (n = 25; 52% diabetic) studies. 6. Under the conditions of the present study, HBO treatment seemed to benefit some wounds while not benefiting others. Overall, HBO did not result in statistically significant improvements in wound size in the given population over the time monitored in the present study. 7. However, TO significantly improved wound size. Among the three O(2)-sensitive genes (VEGF, TGFbeta1 and COL1A1) studied in wound edge tissue biopsies, TO treatment was associated with higher VEGF165 expression in healing wounds. Expression of the other genes mentioned was not affected by TO. There was no significant change in the expression levels of any of genes studied in patients in the HBO study. This establishes a link between VEGF gene expression and healing outcome for TO therapy. 8. Taken together, the present study provides evidence demonstrating that TO treatment benefits wound healing in patients suffering from chronic wounds. Treatment with TO is associated with an induction of VEGF expression in wound edge tissue and an improvement in wound size.