Hyperbaric oxygen therapy for patients with diabetic foot: an observer’s perspective

As a part of my observership in a Mumbai based hospital, I got to witness the case of an elderly patient that suffered from dry gangrene in his foot due to long term diabetes. When the case was first introduced to me I gathered the line of treatment was clear: the gangrenous portion of his foot (this being the 5th digit) would have to be amputated to prevent the ischemia of surrounding tissue. The morning of the procedure I was very excited to witness my first amputation, and also follow the patient’s postoperative care to see the curtailment of this necrosis. During the procedure, I learnt that gangrene spreads along the long tendinous sheaths of the foot and it was important to remove the blackened, ischemic tissue and clean these tracts. As a first year medical student, the end of the procedure, like other surgeries I had observed seemed like the end of the treatment.

When I arrived at the hospital the morning after the surgeon, a team of anesthetists and nurses were frantically running around prepping for a procedure in the operation room. With no case scheduled the night before, I confusedly asked the receptionists what happened, and to my surprise found out the gangrene had spread to the sole of the foot and to salvage the foot it was important to remove more of the tissue. The surgeon then briefed me outside the operation room and told me this was the last surgical attempt; to which I was baffled as I wasn’t aware of any alternative treatment for a gangrenous limb. The sole of the foot was cut almost entirely cut away and a sterile dressing was applied but any more amputation would cause the loss of the foot as they would have to perform a Syme’s amputation

Over the next couple of hours, the consultant was on a mission to suggest a non-surgical alternative to save the foot and not reduce the patient’s mobility as not being able to walk at the age of 85 would greatly reduce his quality of life. This holistic thought process lead to the suggestion of Hyperbaric oxygen therapy. Having read about it as a well-established treatment for decompression sickness experienced by scuba divers (1), I had never come across it as a treatment to battle gangrene in diabetic patients. This therapy involves intermittent dosages of 100% oxygen under a pressure greater than 1 atm, in this case, while the patient is in a chamber (2). The introduction of this as a possible therapy lead me to find a single center prospective study conducted from January 2007 to March 2015 by the surgery department of a Delhi based hospital. The study involved 240 consenting patients with foot ulcers and these patients were randomized into 2 groups with the help of a random number generator each comprising 120 patients: the HBOT group (to receive hyperbaric oxygen therapy along with standard wound care) and the ASD group (to receive standard wound care only).

Overall the duration of diabetes was not statistically significant (p-value 0.707). In the study group, the wounds of 22 (88) (73.3%) patients healed in less than eight weeks (i.e. 56 days), vs. only 4(16) (13.3%) patients in the control group, which was statistically significant (p value <0.001) (3).

The patient is still receiving the HBOT and the foot is being monitored but in a population so infested with diabetes and its related complications it was enlightening to learn about these new less aggressive but effective alternatives for patients affected by extreme complications like gangrene.

Word Count of Article: 597

References

Figure 1: Harris RI. Syme's amputation. Bone & Joint Journal. 1956 Aug 1;38(3):614-32.

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