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Abstract: This study reports on the case of an elderly patient, with oxygen therapy (HBOT). After 60 sessions of the therapy, almost
diabetes, and a bullous wound on the left big toe that led to an complete closure of the wound was observed. There were no reports of
amputation of the first and second left toes. The amputation was discomfort or infection during the treatment. After seven months of
because of deep injury as it was not able to heal with a conventional treatment almost complete healing was observed with no infection.
treatment. After completing the normal treatment and the removal of a This treatment appears to be effective and should be recommended for
bacterial infection in the lesion, the patient underwent a treatment that the treatment of DFUs.
was based on a hydrogel gel (0.9% saline solution) and hyperbaric Declaration of interest: Nothing to declare.
D
iabetic foot ulcer (DFU) is a serious to absorb wound exudate, the amount varying
complication of diabetes and the main between different brands.5 Hydrogels promote wound
reason for amputations involving the lower debridement by the rehydration of the non-viable
limbs.1 Risk factors for a DFU include diabetes tissue facilitating the process of natural autolysis.5
for >10 years, male, peripheral neuropathy, This study was approved by the Ethics of the Santa
abnormal structure of the foot, peripheral arterial disease Casa de Misericordia of Rio Grande Committee, RS,
(PAD), smoking, a history of previous ulcers or Brazil, under Protocol No 021/2014.
amputations, and poor glycaemic control.2 This study demonstrates the efficacy of topical
There are a huge amount of options for the treatment hydrogel in conjunction with HBOT on the healing
of DFUs, such as hyperbaric oxygen therapy (HBOT). process of a diabetic foot wound improving recovery
Treatment with HBOT involves an intermittent and quality of life (QoL).
administration of 100% oxygen, at pressures greater
than sea level, usually in daily sessions. This presents Case report
itself to be a promising treatment for severe cases of A 71-year-old male with type 2 diabetes for 10 years
DFU, as well as for some difficult healing of wounds (treated with metformin 850mg) presented with a
that are resistant to other therapies.3 myocardial infarction requiring angioplasty six months
Difficult healing wounds can be treated with saline before observing the wound. In December 2014, the
solutions as it has been shown to promote autolysis patient presented with a bullous wound on the left big
and the formation of granulation tissue.4 Hydrogel, toe that deteriorated, until March, when amputation of
prepared from 0.9% saline with 1% carbomer has both the first and second left toes was required. The
been successfully used for maintaining the wound angiotomography of the lower limbs showed a marked
bed and for promoting granulation tissue4 Hydrogels atheromatous disease of the arterial vessels, with a
consist of a matrix of insoluble polymers, with up to moderate stenosis (50–75%) in the middle third of the
96% water content, enabling them to donate water left superficial femoral artery. The postoperative wound
molecules to the wound’s surface and to maintain a was deep, significantly painful, had foul-smelling
moist environment at the wound bed. As the polymers serosanguinous drainage, and a necrotic area with
are only partially hydrated, hydrogels have the ability exposed muscle and tendon. The wound was topically
treated with sunflower oil, vitamins A and E, silicone,
Brazilian nut oil, and medium chain triglycerides, as
© 2017 MA Healthcare ltd
P. Aguiar,1 PhD; C. Amaral,2 MD; A. Rodrigues,1 Pharmacy Technician; *A.H. de Souza,3 well as oral therapy with 500mg of ciprofloxacin twice
PhD, Lecturer a day and 30mg codeine/500mg paracetamol when
*Corresponding author email: alessandrahubnersouza@gmail.com
there was local pain.
1 Federal University Hospital of Rio Grande, Rio Grande do Sul Brazil. 2 Hyperbaric Oxygen
Therapy Clinic of Rio Grande 3 Universidade Luterana do Brasil, Rio Grande, Rio Grande do Since the wound did not show any sign of
Sul, Brazil. improvement and the patient suffered a risk of further
BP—blood pressure; HR—heart rate; RR—respiratory rate; T—temperature; BG—blood glucose; days 1 to 60 of treatment in a hyperbaric oxygen therapy chamber
amputation, he sought the help of the Hyperbaric After seven days of treatment, there was reduction in
Medical Center of Rio Grande, RS, in March 2015. oedema, with a small amount of fibrinous material and
Tests were performed confirming hyperglycaemia granulation tissue in the wound base. At session 19
and wound cultures revealed the presence of Klebsiella (Fig 1b), intense granulation was observed. In addition,
oxytoca. The patient received 400mg sulfamethoxazole we noted some wound contraction and epithelialisation
and 80mg trimethoprim every 12 hours for seven days. with continued decrease in wound bed.
After completing the antibiotic course, he was then At session 26 there was well-vascularised granulation
treated with HBOT and topical hydrogel. tissue, a lower amount of fibrinous material, less
In April 2015, the HBOT treatment began (five times surrounding oedema and an improved appearance with
per week for 90 minutes), along with hydrogel daily regular wound edges and decreased wound size. The
dressing changes. The wound was cleansed with 0.9% hydrogel kept the moisture level in the wound stable
saline, then the hydrogel layer was applied and it was without causing cutaneous maceration.
© 2017 MA Healthcare ltd
covered with a gauze dressing. In addition, the patient At session 46, the granulation tissue formation
was instructed to protect the injury from trauma and to remained, as well as the presence of fibrinous material
rest. Diet guidelines were made in order to control the and decreasing wound depth, with continued decrease
patient’s blood glucose level (Table 1) and favour in open area. New epithelium was covering almost the
healing (Fig 1a, day 0). entire surface and the edges of the wound and its crust
Discussion
Open wounds heal by contraction of the edges and
migration of cells to the centre of the wound. The
wound bed is filled through fibroblast migration and b
the formation of new vessels that originate from
capillaries around the wound.6,7 Wound contraction
depends on the capacity of fibroblasts to migrate
through the extracellular matrix (ECM) and this
capacity is negatively influenced by many factors,
such as the use of steroids, a diagnosis of diabetes,
infection and vitamin deficiency.8 Our research has
found similar results from another group for a study
where hydrogel was used as control with a group of
153 patients. The healing rate, of the control group,
in that study was 32% after 16 weeks and complete
wound closure within 78 days. 11 This result
demonstrates hydrogel’s healing capacity,9 consistent
with the American Society of Plastic Surgeons’ c
recommendation that wound healing is promoted by
the maintenance of a moist environment.10
Hydrogels have been produced for use in tissue
engineering both in the pharmaceutical and
biomedical fields, due to their high capacity for water
absorption and biocompatibility.11 We chose to
combine hydrogel with HBOT, since HBOT accelerates
the tissue regeneration process of the wound and it is
a safe and effective therapy with few adverse events.12
Adverse events when they do occur include: pulmonary
toxicity, neurological toxicity, auditory discomfort
and barotraumas, facial sinus discomfort and transient
visual changes.13 HBOT accelerates the healing process
by increasing the capillary oxygenation, and thus,
promoting angiogenesis.14 Exposure to increased
barometric pressure inside a hyperbaric chamber Conclusion
increases the oxygen dissolved in the plasma. This DFUs are a major health problem and are an important
dissolved oxygen is the metabolically active fraction cause of morbidity, mortality and financial burden.19
that penetrates compromised tissues. 15 Treatment of comorbidites aids wound healing, as can
Neoangiogenesis and vasculogenesis occur due to the be seen in our study, where the blood glucose levels
stimulation of bone marrow-derived progenitor remain controlled.20
cells.16 Treatment with HBOT has antimicrobial effects The results of our case suggest that healing of DFUs
© 2017 MA Healthcare ltd
and increases intracellular leukocyte killing by the may be facilitated by a combination of topical hydrogel
oxygen-dependent peroxidase system.17 Wounds that and a higher oxygen supply as provided by using a
fail to progress through the normal phases of healing hyperbaric oxygen chamber. In this patient, the use of
demonstrate significant tissue hypoxia due to a poor hydrogel in conjunction with HBOT promoted healing
local perfusion.18,19 of a DFU. JWC
References Practice Guideline: Chronic Wounds of the Lower Extremity. 2007; 1–21
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Dermatology
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Practice Nursing Editorial Board er of the
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