History
A sample history for an acute arterial insufficiency follows. (Please note that advancement of a chronic arterial process with sudden exacerbation is not an acceptable indication for hyperbaric oxygen therapy.)
"Mr. Simpson is a 65 y/o man who was in his usual state of health until this morning. He noted onset of sudden pain, coolness, and pallor of the left lower leg from the mid-calf down to the foot. He has never had significant arterial disease, but he has had atrial fibrillation which had been treated medically. He is also taking a daily anticoagulant and has blood levels monitored frequently.
Emergency arteriogram in radiology shows an arterial clot at the trifurcation of the left knee. There are only scant spiderwebs of arteries supplying blood to the lower leg and foot. No identifiable arteries were noted. The interventional radiologist tried to remove the clot in the radiology suite. The report indicates success in restoring some blood flow, but this was incomplete.
After the radiological procedure, the patient's left leg is swollen, purple, and mottled. There is no evidence of pulsatile blood flow by Doppler ultrasound in the recovery room.
Our vascular surgeon has been called for an emergent femoral popliteal bypass and potential for further bypass as indicated in the operating room. He asked that we consider using the hyperbaric chamber to provide oxygen to the foot and potential limb salvage from this limb-threatening condition. The hyperbaric indication would be an acute peripheral arterial insufficiency with adjunctive hyperbaric oxygen therapy as a bridge to operative care. We have agreed to see the patient and will start hyperbaric therapy immediately."
Physical Exam
Physical examination to include:
- External appearance and temperature of the skin of the patient’s affected extremity. Limb may also appear mottled or marbled,
- Presence or absence of peripheral pulses,
- Evaluation of sensation,
- 6 P's- Pain, pallor, paresthesia, paralysis, pulselessness, and poikilothermia
Impression
- Acute Peripheral Arterial Insufficiency Refer to the ICD-10 Crosswalk
Plan
"A typical hyperbaric regimen for a patient with acute peripheral arterial insufficiency consists of daily 2.0 to 2.5 ATA hyperbaric oxygen treatments with 90 minutes of oxygen breathing time. Treatment with hyperbaric oxygen is generally once daily. However, in the presence of advancing ischemia, twice daily treatments may be required."
Risk and Benefit of Hyperbaric Oxygen Therapy
- Please refer to topic "Documentation HBO: Risks and Benefits"
Indication for Hyperbaric Oxygen Therapy (HBOT)
"Acute peripheral arterial insufficiency covers a spectrum of diseases, which includes acute traumatic and non-traumatic events sharing the common feature of sudden occlusion of the arterial blood supply. The resultant tissue hypoxia and ischemia leads to CO2 retention with increased local concentrations of cellular byproducts, compromised microcirculation, advancing hypoxia and decreased nutrient delivery to the end tissues, vascular membrane breakdown, and edema formation. These factors threaten wound healing and contribute to advancing infectious processes.
Hyperbaric oxygen can be beneficial in managing acute peripheral arterial insufficiency by several mechanisms: 1) Increasing tissue oxygen concentrations over 1000%, thus preventing cellular death, 2) stimulating fibroblasts and macrophages to secrete collagen and enhance neovascularization, 3) Reducing edema formation by reducing capillary leakage and tissue swelling, thus increasing tissue perfusion, and 4) maintaining the bacterial killing ability of leukocytes after phagocytosis."
Sample Order
- See Sample Physician Order
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