Article – 1 - Intracranial Abscess
Title: Hyperbaric Oxygen in Intracranial Abscesses.
Authors: Lamp, LA; Frey, G; Dietze, T; Trauschel, M
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Keywords: intracranial abscess, anaerobes, perifocal edema, intracranial pressure, hyperbaric oxygen
Abstract: The benefit of hyperbaric oxygen (HBO) in the treatment of anaerobic infections is widely documented and, in part, currently accepted, although the rationale for this therapeutic approach is not yet clearly established in several disorders of that origin. Intracranial abscesses, e.g., brain abscesses or empyemas, are well known to be predominantly caused by anaerobic organisms (up to 60% pure anaerobic cultures, additionally some 25% miscellaneous aerobic or anaerobic findings). The main therapeutic principles of HBO in intracranial abscesses are the influence on anaerobic or miscellaneous floras, the enhancement of host defense mechanisms, and the edema-reduc¬ing effect in cases of perifocal brain swelling or elevated intracranial pressure. The latter may be of crucial importance for the outcome. Based on a review of the current international literature, we describe the role of HBO in the multidisciplinary management of intracranial abscesses, including data from 10 unselected patients treated from 1983 to 1989.
Conclusion: HBO proved to be highly beneficial as an adjunctive treatment in these serious infections.
Article – 2 - Intracranial Abscess
Title: Transient Effect of Hyperbaric Oxygen on Cerebral Blood Flow and Intracranial Pressure.
Authors: Ohta, H; Hadeishi, H; Nemoto, M; Kawamura, S; Hinuma, Y; Suzuki, E
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Keywords: cerebral blood flow, Ijyperharic oxygen, intracranial pressure
Abstract: The effect of hyperbaric oxygen (HBO) on cerebral blood flow (CBF) and intracranial pressure (1CP) was studied to evaluate its usefulness in the treatment of patients with increased 1CP. Of the 7 patients studied, 6 had subarachnoid hemorrhage due to rupture of an intracranial aneurysm and 1 had an intracerebral hematoma secondary to hypertension. CBF measurements using the l53Xe intravenous injection method were performed before the HBO (baseline), under 2 absolute atmospheres with 100% oxygen inhalation (HBO: 2 ATA • 02) and after decompression while breathing room air (posttreat¬ment). ICP was monitored continuously throughout the study. Baseline CBF, as evaluated by the initial slope index, was 38.2 ± 6.3 and the ICP was 24 ± 8 mmHg (mean ± sd). Under HBO, CBF decreased to 32.0 ± 7.7 (P < 0.05) and the ICP to 18 ± 6 mmHg (P < 0.01). Posttreatment CBF was 37.8 ± 5 7 and the ICP was 28 ± 8 mmHg. These values were almost the same as the baseline values. Some patients showed a rebound increase in ICP after HBO.
Conclusion: Hyperoxemia during HBO presumably caused vasoconstriction of the cerebral vessels which reduced CBF and ICP. These results confirmed that HBO therapy can reduce intracranial hypertension, but its efficacy' is only transient.
Article – 3 - Intracranial Abscess
Title: [abstract] HYPERBARIC OXYGEN IN INTRACRANIAL ABSCESSES 3 EXEMPLARY RECENT CASES.
Authors: Lampl, LA; Frey, G; Helm, M; Waldbaur, H; Bock, KH
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Keywords: Nil
Abstract: Hyperbaric Oxygen Therapy is considered an effective adjuvant mode of therapy in the treatment of intracranial abscesses, especially in the following conditions: * multiple abscesses * abscess in a deep or dominant location * early abscess stage (without the need for surgery) * poor patient condition * anaerobic or miscellaneous bacteriology. In order to illustrate the comprehensive therapeutic approach, including neurosurgery, intensive care, antibiotics and hyperbaric oxygen, the cases of three recent consecutive patients treated at our facilities in 1990 and 1991 are presented: 1) Male, 21 years: Multiple brain abscesses, right temporo-parietal region, rhinogenic origin; 2) Male, 52 years: solitary brain abscess, left frontal lobe, origin unknown; 3) Male, 49 years, subdural empyema and brain abscess, left frontal lobe, presumably rhinogenic origin. All three patients underwent initial neurosurgery (primary abscess resection in 1, abscess drainage followed by topic antibiotic irrigation in 2, secondary subtotal resection of the abscess capsula in 1).The mean stay on the ICU was 21 (18-32) days, two patients had to be on the ventilator for 19 resp. 8 days. Bacteriologically, in every case anaerobic or microaerophilic streptococci were the only bacteria cultivated from abscess material. The mean number of HBO-sessions was 13,3 (12-15) at 2,5 bar, 1 hour per day, started as early as possible following initial neurosurgery.
Conclusion: Within 4 to 6 months after their discharge from the ICU all three patients had returned to their former occupational work with only minimal or no neurologic defects remaining.
Article – 4 - Intracranial Abscess
Title: [abstract] HYPERBARIC OXYGEN IN INTRACRANIAL ABSCESSES - UPDATE OF A SERIES OF 13 PATIENTS.
Authors: Lampl, LA; Frey, G; Bock, KH
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Keywords: Nil
Abstract: At present, the adjuvant HBO-therapy of intracranial abscesses (ICA, including brain abscess, subdural and epidural empyema) is an indication accepted for further research by the UHMS' Hyperbaric Oxygen Committee. The major rationales for HBO's therapeutic effect are derived from * the predominantly anaerobic flora found * the beneficial influence on perifocal brain swelling * the enhanced host defense mechanisms * the favourable effects in case of a concomitant skull osteomyelitis. The risk/benefit-ratio seen so far (1) seems to be compellingly high, though, as a consequence of the low incidence of ICA (2), only a multicenter study with a central data retrieval system will lead to an even statistically convincing number of cases.
Conclusion: The medical basis of adjuvant HBO in ICA will be outlined by means of an update of our own case series of, at this writing, 13 patients (multiple abscesses in 3, solitary abscess in 8, epidural resp. subdural empyema each in 1). Ref: (1) Lampl LA, Frey G, Dietze T, Trauschel M. Hyperbaric oxygen in intracranial abscesses. J Hyperbaric Med 1989; 4 (3): 111-126. (2) Harris LF, MacCubbin DA, Triplett JN Jr, Haws FP. Brain abscess: recent experience at a community hospital. South Med J 1985; 78 (6): 704-707.
Article – 5 - Intracranial Abscess
Title: [abstract] HYPERBARIC OXYGEN IN INTRACRANIAL ABSCESSES - REVIEW OF 10 CASES.
Authors: Lampl, LA; Frey, G
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: The main therapeutic principles of HBO in intracranial abscesses are (1) the impact on predominantly anaerobic or miscellaneous floras, (2) the enhancement of host defence mechanisms, (3) the edema-reducing effect in perifocal brain-swelling or increased intracranial pressure. In addition, a reversible opening of the blood-brain-barrier leading to an improved antibiotic penetration might be of importance. Based upon these rationales, the cases of 10 unselected consecutive patients (7 male, 3 female, aged 13 -47 years) with intracranial abscesses (single abscess in 7, multiple abscesses in 1, epidural resp. subdural empyema each in 1 patient) are discussed. These patients were treated by adjunctive HBO at our facilities from 1983 to 1989. 16 bacteria were identified, and in 5 patients more than one strain was cultivated from the intracranial focus. In 8 patients, the bacteriologic findings proved pure anaerobes including micro-aerophilic streptococci. The individual number of HBO sessions applied in each patient varied from 4 to 27 (usually once per day, 60 to 90 minutes each at 2,5 bar) in a multiplace chamber. No signs of cerebral oxygen toxicity nor other adverse effects were observed. HBD was stopped depending on the patient's recovery in accordance with the neurosurgical evaluation as well as repeated head scans.
Conclusion: Complete recovery occured in 4 patients, slight to moderate disability was seen in 5, only 1 patient remained severely disabled due to the underlying disease which originally had been the source of his intracranial abscesses.
Article – 6- Intracranial Abscess
Title: [abstract] SUCCESSFUL TREATMENT OF CERVICAL SPINAL EPIDURAL ABSCESS BY COMBINED HYPERBARIC OXYGENATION
Authors: Mizoguchi, Y; Toyonaga, J; Kohshi, K; Shimokobe, M
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Keywords: Nil
Abstract: Spinal epidural abscess (SEA) is uncommon but a potentially serious condition that requires urgent treatment. Early diagnosis with sophisticated imaging techniques, prompt surgical intervention, and the introduction of effective antibiotics have led to a gradual decrease in mortality rates; however the rates still hover around 20percent even in modern series. Hyperbaric oxygen (HBO) therapy has been used to treat a variety of infected, hypoperfused, and hypoxic wounds. We present a patient whose cervical SEA was successfully managed conservatively with antibiotic treatment combined with HBO therapy.
Results: A 49-year-old hard working laborer experienced left neck pain 3 months after neck sprain. His MRI showed a cervical spinal abscess compressed the spinal cord. The SEA was initially treated with antibiotics for 5 days; despite treatment, his general and neurological conditions deteriorated. After the introduction of HBO (2.5 ATA, 60 min) with the use of the same antibiotics, his clinical conditions improved and the lesion regressed completely. He was evaluated 6 months later and no recurrence of symptoms suggestive of a relapse of the epidural infection.
Conclusion: The patient did not initially respond to antibiotics alone, and only after the introduction of HBO therapy to the treatment regimen his symptoms and laboratory data improved and the spinal lesion on MRI regressed markedly. This case illustrates a cervical SEA that was successfully treated with antibiotics combined with HBO therapy.
Article – 7 - Intracranial Abscess
Title: [abstract] Intracranial Monitoring In The Severe Traumatic Brain Injured Patient Undergoing Hyperbaric Oxygen Treatment.
Authors: Rockswold, GL; Gossett, W; Rockswold, SB; Adkinson, C
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Keywords: Nil
Abstract: Hyperbaric oxygen (HBO) is currently under consideration as a therapy for severe traumatic brain injury (TBI). One of the challenges in establishing HBO as an accepted therapy for severe TBI is to establish its safety and practicality as well as the efficacy of the treatment. The purpose of this report is to relate our experience in the management and intracranial monitoring of severe TBI patients undergoing HBO treatment. One hundred forty-six TBI patients received 1,908 HBO treatments in a monoplace chamber, and 24 patients received 79 treatments in a multiplace chamber. The mean age was 33 years, and the mean Glasgow Coma Scale (GCS) score was 5.8. All patients were treated at 1.5 atmospheres absolute (ATA) for 60 minutes.
Results: All patients underwent intracranial pressure (ICP) monitoring during HBO sessions. This was accomplished in most patients using a ventriculostomy. An intraparenchymal ICP monitor (Camino) was also used for continuous accumulation of ICP data. There has been a consistent and statistically significant decrease in elevated ICP following HBO treatments. Brain tissue oxygen (PtO2) monitoring has been successfully accomplished in 46 patients. Probes have been routinely placed in the least injured frontal lobe. Brain PtO levels achieved with HBO are 7.5 times greater than those induced by normobaric baseline oxygenation (30 mmHg compared with 225 mmHg) and 2.5 times greater than those generated by normobaric 100% oxygen (90 mmHg compared with 225 mmHg). Cerebral microdialysis has also been performed in 46 patients. Analysis of microdialysate data reveals improvement in cerebral metabolism post HBO treatment. There has been no evidence for cerebral toxicity, and discontinuation of HBO treatment due to pulmonary complications has been relatively infrequent.
Conclusion: HBO treatments at a depth of 1.5 ATA can be delivered repetitively to the severe TBI patient in either a monoplace or multiplace chamber with relative safety and low risk of oxygen toxicity.
Article – 8 - Intracranial Abscess
Title: [abstract] Noncompliance To Hyperbaric Oxygen Therapy
Authors: Lo, T; Mendez, V; Christenson, D
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: Noncompliance has become an escalating problem as Hyperbaric Oxygen Therapy(HBOT) is being utilized with increased frequency for the delayed effect(s) versus its acute mechanism(s) of action. It affects the scheduling of treatment personnel, increasing the institution's financial burden, and may affect the patient's ultimate outcome. A review of the scientific literature reveals no reference of compliance statistics in HBOT. The purpose of this study is to report on our noncompliance experience and to heighten the HBOT professional's awareness of the problem. A retrospective chart review of all patients who received HBOT at our institution from January through November 2000 was performed. 127 new patients were started during this time period with a total of 3119 compressions. Noncompliance to HBOT was documented each time the patient was unable to undergo a treatment, the reason recorded, and the treating physician notified.
Results: Of the 3119 compressions, there were 401(12.9percent) missed treatments cancelled by the referring or treating physician. In addition, 225 (7.2percent) were missed for all the other reasons combined. NUMBER OF MISSED TREATMENTS BY REASON:n=324, Sickness/illness 77(23.8percent), Cancelled/conflicting appointment 62(19.1percent), Unstable vital signs 62(19.1percent), Claustrophobia 41(12.7percent), No show/no reason 39(12.0percent), Personal/family problem 21(6.5percent), Transportation issue 14(4.3percent), Other 8(2.5percent), NUMBER OF MISSED TREATMENTS BY DIAGNOSIS:n=57, Skin Grafts and Flaps(Compromised) 27(47.4percent), Osteomyelitis(Refractory) 11(19.3percent), Osteoradionecrosis 5(8.8percent), Soft Tissue Radiation Necrosis 4(7.0percent), Necrotizing Fasciitis 4(7.0percent), Acute Arterial Insufficiency 4(7.0percent), Fournier's Gangrene 1(1.8percent), Intracranial Abscess 1(1.8percent).
Conclusion: 1. HBOT physicians must recognize the multitude of reasons for noncompliance and should respond to those factors that are under the control of the medical community. 2. Physician's cancellation comprised the majority of the HBOT's noncompliance in this study. 3. Over 60percent of the missed treatments are due to sickness/illness, conflicting appointment, or unstable vital signs. 4. Compromised skin graft/flap cases comprised the major diagnosis for missed treatments.
Article – 9 - Intracranial Abscess
Title: [abstract] Effect Of Hyperbaric Oxygenation On Mortality In A Rat Model Of Intra-Abdominal Infection.
Authors: Muhvich, KH; Myers, RAM; Marzella, L
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Keywords: Nil
Abstract: Recent work has shown that hyperbaric oxygen (HBO) may promote survival of rats with intra-abdominal sepsis (Thom et al. 1986. J.lnfect.Dis.154:504-509). We have tested the generality of this protective effect in a rat model of intra-abdominal infection. Bacteroides fragilis (10^8) alone or in combination with Escherichia coli (10^6) was mixed with sterile feces and agar. The inoculum was implanted in the peritoneal cavity of male Sprague-Dawley rats. The rats were divided into four treatment groups: Group I Untreated; Group II -HBO; Group III -Antimicrobials; Group IV -HBO and Antimicrobials. All rats developed abscesses. The mortality was as follows: Bacteria Grp I Grp II Grp III Grp IV; B. fragilis 0 0 0 0; B. fraailis and E. coli 67 86 0 14. We conclude that HBO does not affect the mortality in rats with an intra-abdominal abscess caused by a strict anaerobe. HBO increases the mortality in rats with an undrained mixed aerobic-anaerobic abscess.
Conclusion: HBO may raise oxygen tensions in the undrained abscess to levels necessary for metabolism and growth of facultative anaerobes such as E. coli.
Article – 10 - Intracranial Abscess
Title: [abstract] Characterization Of Organ Blood Flows In Rats With Controlled Sepsis During Hyperbaric Oxygen (2 ATA) Exposure.
Authors: Muhvich, KH; Piano, MR; Myers, RAM; Ferguson, JL; Marzella, L
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Keywords: Nil
Abstract: We have recently reported that hyperoxia causes a transient decrease in the splanchnic blood flows of rats with an antibiotic-controlled intra-abdominal abscess (Muhvich et al., Circ. Shock, 1988, 24:281). We report here on organ blood flows to heart, lung, brain, muscles, bone, adrenals and kidneys in rats with antibiotic-controlled sepsis. Intra-abdominal abscesses were established in rats by inoculating a fecal-agar pellet containing known numbers and strains of live Escherichia coli and Bacteroides fragilis. Mortality was prevented by subcutaneous injection of trimethoprim-sulfamethoxazole. Sham-operated rats served as controls. Cardiac output (CO) and blood flow (BF) measurements were determined prior to, during and post HBO exposure using radiolabelled microspheres (MS). To this end, cannulas were placed in both groups in the left ventricle and tail artery for the injection of MS and for a reference withdrawal site. No significant difference was seen in hemodynamic parameters between groups or over the course of the experiments. No alteration was seen in regional cerebral BF during or post HBO exposure. In both groups of rats, BF to the heart, lung, kidneys and adrenals was not significantly different from basal values during or post HBO exposure. BF to muscle and bone was also unaltered during HBO exposure. BF in rats with controlled intra-abdaninal sepsis is unaltered in non-splanchnic vascular beds.
Conclusion: We conclude that standard HBO exposure should not cause significant hemodynamic or blood flow changes in patients with controlled sepsis.