Wound Care Expertise at Point-of-Care

Patient Care

Patient Care

Patient Care

ADVANCED DIRECTIVE

The “Patient Self Determination Act” states that competent adults may provide instructions, either written or oral, regarding their future treatments in the event that they lose the capacity to make health care decisions. These are known as Advanced Directives.

Procedures

When a patient presents an Advanced Directive:

  • A copy will be placed in the chart.
  • The chart will be marked for easy identification and reference.
  • Status shall be documented in the patient’s medical record.
  • The Advanced Directive will be honored to the extent permitted by law.

AIR BREAK SYSTEM

Introduction

During monoplace hyperbaric oxygen therapy, it is necessary to provide an alternative air breathing medium. This may also be necessary to greatly minimize the risk of central nervous system oxygen toxicity in the general hyperbaric patient population

Description

The air breathing system consists of an independent high-pressure compressed air source, a pressure-reducing regulator, a chamber interconnection and an oral/nasal demand mask. The demand valve within the mask has been adapted for use at increased atmospheric pressures. [1]

Air-break delivery systems available for this purpose: free flow non-rebreather mask that offers improved infection control capability (ensure the elastic band is removed and vent holes taped over); a face tent for patients who are unable to manipulate other masks; and a trach collar assembly to be used for those patients with tracheotomies. 


These masks can be assigned to one patient, cleaned prn and disposed of once the treatment series is completed. These masks are connected to bubble tubing attached to the inside chamber door with a “Christmas tree”. Ensure only a one-quarter turn to the left on the meter valve to start the airflow to the mask.

Equipment Set-up

  • A medical grade compressed air cylinder, H size, with high-pressure reducing regulator
  • Supply hose with chamber door interconnections
  • Demand valve and mask, face tent, non-rebreather or trach collar
  • Connect the equipment from cylinder to mask; set the reducing regulator to70 psig
  • Test the system prior to initiating compression
  • Explain to the patient the rationale for using this system and the importance of carefully following instructions during treatment procedure
  • The metering valve on the air line should be opened one-quarter turn for air break mask delivery. The valve on the high pressure cylinders should be wide open throughout the treatment

Procedure

All patients treated in the monoplace hyperbaric chamber will have with the capability of administering an "air break" at any point during his/her treatment.

  • With the exception of unique treatment tables, all patients who are treated at pressures in excess of 2 ATA 02 will be scheduled with ‘air breaks’ as follows:
    • Compression -oxygen
    • 30 minutes -oxygen
    • 10 minutes
 -air
    • 30 minutes -oxygen
    • 10 minutes
 -air
    • 30 minutes
 -oxygen
    • Decompression
 -oxygen
  • Where an increased risk of central intolerance to oxygen exists, all patients who are treated at 2 ATA 02 will be provided an "air break".
    Examples include:
    • Febrile state (oral temperature >100oF)
    • Seizure history
    • Associated head injury
    • Concurrent administration of medication known to lower seizure thresholds
      (i.e., Phenergan, Penicillin)
  • This air break will be provided as follows:
    • Compression -oxygen
    • 45 minutes -oxygen
    • 10 minutes -air
    • 45 minutes -oxygen
    • Decompression -oxygen

NOTES:

  • If using the face tent, a minimal flow of 100% oxygen is fed to the patient during the oxygen-breathing segment of the treatment, to avoid carbon dioxide accumulation. To institute an air break, the gas supply to the face tent is switched to air in the same manner it is switched for the ventilator. Once the 10-minute cycle is complete, the supply is changed back to 100% oxygen. It is important that gas flows through the face tent throughout therapy, in order to avoid carbon dioxide accumulation. The chamber door air shut-off valve is to remain closed until the scheduled air break. Immediately upon completion of the "air break", the shut-off valve is to be closed (exception: with the use of the face tent where a constant gas flow is necessary)
  • For any CNS complications that develop during a patient's HBO procedure, refer to: ‘Emergency Procedures: Oxygen Toxicity’

BLOOD GLUCOSE LEVEL AND HBOT

To ensure that all patients who are currently being treated for irregular blood glucose levels do not experience a hypoglycemic event as result of ongoing hyperbaric oxygen therapy.

Background 

Most studies suggest that blood glucose (BG) decreases in diabetics undergoing Hyperbaric Oxygen Therapy (HBOT). This decrease in BG is estimated at 50 mg/dl. The effect of HBOT may also be less on non-insulin dependent diabetes mellitus patients.reference HBO nursing

The goal is to ensure that all patients who are currently being treated, do not experience a hypoglycemic event as result of ongoing hyperbaric oxygen therapy.

Policy Elements

The following standards should be utilized for those patients receiving hyperbaric oxygen therapy

  • Diabetic Patients (IDDM and NIDDM): blood glucose measurements by fingerstick are mandatory for all diabetic patients prior to and after hyperbaric oxygen treatment.
    • Diabetic Inpatients: If the patient's BG has been checked while inpatient within 1 hour of HBO treatment, the HBO staff does not need to repeat the BG unless insulin was given. If more than an hour has passed since BG was checked, the HBO staff should recheck BG before treating the patient. 
    • Diabetic Outpatients: BG must be checked by the hyperbaric staff on ALL diabetic patients prior to initiation of hyperbaric oxygen therapy.
  • The following guidelines should be used for all diabetic patients.
    • Blood Glucose level:
      • 100mg/dl – 120mg/dl: Patient should be given 4 oz of juice to drink pre-treatment and also 4 oz to drink during treatment.
      • ≤ 99mg/dl: Hold HBO treatment until further direction is given by the hyperbaric physician.
    • For Diabetic patients, blood glucose measurement should be performed after every treatment.  
    • No patient should be released with blood glucose of 100 or less even if asymptomatic. It is possible that the blood glucose will continue to decrease even after the patient is removed from the chamber.  Patients with blood glucose of 100 or less should be fed prior to leaving the facility.
    • Glucose gel should always be kept available for use.

CARDIAC MONITORING

To ensure that signs and symptoms of dysrhythmia are recognized and promptly addressed.

  • As ordered, patients will be placed on a cardiac monitor while in the chamber.
  • Patients will be placed on the cardiac monitor during their initial treatment. This is standard operating procedure and is not affected by the lack of underlying etiology.
  • All patients undergoing cardiac monitoring will have ECG monitoring during hyperbaric treatment:
    • Alarm settings will be set to 20 above and 20 below patient heart rate or per physician's order.
    • The alarms should NOT be turned off at any time during patient treatment.
  • After the patient reaches the prescribed pressure or ectopy is detected at any time, a rhythm strip should be printed and scanned into the electronic medical record or placed in the patient's chart.
  • Notify the hyperbaric physician of ectopy or dysrhythmia. Oxygen toxicity is commonly preceeded by tachycardia. 
  • Notify the hyperbaric physician as needed.

FEEDING TUBES

To provide a process for effectively managing patients with feeding tubes in place during hyperbaric oxygen therapy. Patient feeding via the feeding tube will be discontinued during hyperbaric oxygen therapy. 

Procedureedited all

  • Explain to the patient the need to discontinue feeding.
  • Clamp and disconnect line from the patient’s feeding tube.
  • Open clamp to feeding tube. Flush with 10-15 ml of water (do not use saline in the stomach) and reclamp. Begin hyperbaric treatment.
  • Upon completion of hyperbaric treatment and removal of the patient from the chamber, reconnect the feeding tube. Unclamp the tube and restart the pump.

    Note: Nasoduodenal feeding tubes like the dobhoff are inserted into the stomach and duodenum. There is no risk of barotrauma due to gas expansion during ascent. The gastrostomy tube/ feeding tube is a tube is inserted though abdomen into the stomach.  


    MANAGEMENT OF DRAINAGE TUBES

    Avoidance of gastric distention which could lead to aspiration of gastric contents can be achieved with the continued use of nasogastric tube during HBOT

    • Bladder distention can be avoided with the use of a foley catheter.
    • It is important to follow hyperbaric procedures for the care and function of drainage tubes to prevent backflow of drainage or air. 

    Procedure for nasogastric (NG) tube:

    • Non-ventilated/alert patients:
      • Disconnect NG tube from suction and cap the tube during treatment. 
      • NB tube should be visible to chamber operator at all times. 
      • Ensure the tube is properly secured to the nose.

    Procedure for Foley Catheteredited all

    • Prior to hyperbaric treatment, unclamp the drain hose on collection bag and empty all contents into measuring device to record output. Report urinary output to the inpatient nurse
    • Expel air from the foley bag by rolling it up, re-clamp the exit port and then unroll the bag to allow for gravity drainage during HBOT and expansion of bag on ascent. 
    • Ensure main foley tube is secured to patient's leg
    • Check to ensure the tubing running from the patients bladder to the collection bag is patent, unkinked and unclamped. 

      Procedure for Hemovacs and Jackson Pratt drainsedited all

      • Prior to hyperbaric treatment, uncap the drain and empty contents into a measuring device.
      • Expel the air from the drain and close the cap. This will allow for the drain to continue functioning during HBOT. 
      • Ensure the drain is visible to the chamber operator at all times and secured to the patient.
      • If the patient reports pain during ascent or descent, pause the chamber pressure, assess and resume gradually once the patient is pain free. If pain at the drain site, persists, notify the provider and plan ascend patient. 

      EARLY ASCENT DURING HBOT

      To ensure that the occurrence of early ascent during hyperbaric oxygen therapy is reviewed and recorded.

      The Hyperbaric Medicine Service is aware that early ascent during HBOT may be necessary.

        • Any occurrence of early ascent or termination of a treatment before the prescribed actual bottom time is complete, will be reviewed by the hyperbaric physician and Safety Lead.
        • The attending clinical staff member and physician shall complete an early scent form.
        • Copies of the form should be provided to the Medical Director and Safety Lead. A copy should also be placed in the patient’s chart or scanned into the electronic medical record.added this line
        • After completion of the form/document, the documentation will be entered into the monthly QA.
        • Any action required, as a result of the early ascent, will be at the discretion of the 
          hyperbaric physician.

        FAMILY VISITATION

        To prevent an influx of visitors that might impede safe and effective patient care and maintain patient privacy.

        Policy Elements

        The hyperbaric staff member(s) present have the ultimate authority to permit/not permit visitors/patient family members at any time in the hyperbaric facility.

        • In general, visitors are discouraged from entering the hyperbaric medicine facility, unless they have been approved in advance.
        • An inpatient's family members/friends are advised to wait in the patient's hospital room or in one of the hospital waiting areas, while the hyperbaric treatment is underway.
        • Outpatient family members/friends who travel daily with the patient should be asked to wait for the patient in designated waiting areas, not in the hyperbaric facility.
        • In the event that the patient may benefit by having someone with him/her during their initial treatments (i.e., pediatric patient or confinement anxiety), one family member may sit beside the chamber and communicate with the patient. The visitor must leave the facility whenever other patient care needs arise, as necessary.
        • If it becomes necessary for a visitor to enter the facility (i.e., family traveled some distance to see patient; critical care patient treated during visiting hours), two (2) family members may stay at chamber side for 5-10 minutes. Only the hyperbaric facility staff may give out information about patient’s hyperbaric status.
        • Visitors are not entitled to move freely around the hyperbaric facility.
        • For visits/observations by individuals or groups not associated with the patient:
          • Such individuals or groups will be expected to make arrangements ahead of time and will be admitted with the consent of the patient and/or his/her significant other.
          • Such visits during patient treatments will be at the discretion of the hyperbaric staff.
        • Visitors with contagious diseases or known infections will not be allowed to enter the hyperbaric facility.

        FETAL MONITORING OF PREGNANT PATIENT WITH ACUTE CO POISONING

        It is the policy of the Hyperbaric Medicine Service that any patient admitted/evaluated who is known to be pregnant will have her Obstetrician/Family Practice physician identified for the purposes of responsibility for the pregnancy. The patient admitted for CO poisoning will be required to have fetal assessment before and after hyperbaric oxygen therapy. This policy will coordinate with institutional policy.

        • The physician caring for the pregnancy will be notified when possible within ONE hour of admission or prior to treatment to give appropriate fetal monitoring orders
        • The OB physician on emergency call list will assume care for the pregnancy during the hospitalization if the patient’s physician is not on staff and the patient has identified no other staff physician.
        • Patients known to be pregnant, seen in the hyperbaric unit, will receive fetal assessment, ordered by either the attending OB physician, designated physician, the OB physician on call, or the hyperbaric physician, according to the gestational age, either in the Emergency Department or LD, depending on presenting symptoms (obstetric vs. non-obstetric)
        • The hyperbaric staff assesses patient as to attending physician, LMP etc.
        • If chief complaint is a pregnancy-related problem, the hyperbaric personnel will notify Labor and Delivery that the patient is en route to the Labor and Delivery unit, her name, due date if known, and current status.
        • The hyperbaric personnel will assure transfer of patient quickly to Labor and Delivery in appropriate manner (wheelchair, cart).
        • The hyperbaric personnel will admit patient to the hyperbaric unit after evaluation and fetal assessment. When indicated by the hyperbaric physician, the patient will be treated utilizing the acute CO poisoning treatment protocol.
        • Department personnel notifies patient’s obstetrician or notifies obstetrician on call list that patient has been admitted, current status and receives orders for transfer to Labor and Delivery for fetal monitoring, as appropriate. If patient is unstable and/or transfer to Labor and Delivery is not recommended the hyperbaric staff will notify Labor and Delivery to come to the hyperbaric unit to do post treatment fetal assessment.
        • When post treatment fetal assessment has been completed, evaluation by the OB, family practice or the hyperbaric medicine physician will be done. At that point the patient will be admitted or discharged.
        • Discharged patients will be given follow up instructions.

        FLUID VOLUME DEFICIT

        Ensure that the signs and symptoms of fluid volume deficit will be recognized and promptly addressed.

        • Assess patient’s potential for fluid imbalance i.e.: dialysis, diuretics, diarrhea, vomiting, fever. 
        • Assess skin turgor and oral mucous membranes for signs of dehydration.
        • Assess for alteration in mentation (confusion, agitation, slowed response)
        • Assess fluid and electrolyte balance. Maintain hydration and blood pressure support as indicated by physician order.
        • Monitor patients Intake & Output , as directed by physician order.
        • Monitor patient’s vital signs.

        HEIMLICH VALVE

        To avoid over expansion of the lungs and maintain drainage of chest tubes during hyperbaric oxygen therapy for those patients with chest tubes in place.

        Before Hyperbaric Treatment

        • Assess respiratory status of patient. Determine if a large air leak is present requiring suction. If so, notify HBO physician to determine if HBO should be held.
        • Clamp off chest tube with hemostats
        • Disconnect from underwater seal drainage.
        • Connect Heimlich valve to the end of the chest tube. NOTE: be sure the arrow on the valve is pointing AWAY from the patient’s chest. Quickly unclamp chest tube and secure the Heimlich valve with a friction seal and tape.
        • Connect distal end of Heimlich valve to a drainage container:
          • If drainage is present, may use sterile urinary drainage bag.
          • If no drainage, may use vented sterile glove.
        • Check for negative seal to prevent leakage and/or accidental dislodging.
        • Assess respiratory status of patient.

        After Hyperbaric Treatment

        • Assess respiratory status of patient.
        • Clamp off chest tube with hemostats
        • Reconnect distal end of the Heimlich valve or chest tube to underwater seal drainage.
        • Unclamp chest tube
        • Assess respiratory status of patient.

        INTRAVENOUS INFUSION

        To administer IV infusion of fluids and medications as required during hyperbaric oxygen therapy; to minimize risk of iatrogenic air embolism; to maintain patency of IV lines.

        Background

        Patients presenting for hyperbaric oxygen therapy often have special needs or require special attention to particular facets of their treatment. One such issue is that of intravenous infusions therapy. This is particularly true when monoplace chambers are employed. The unique environment of the monoplace chamber requires that tubing for all such infusions pass through the chamber door or bulkhead. Externally located intravenous infusion pumps must be capable of generating pressures sufficient to overcome flow impediment as a consequence of increased internal chamber pressures. As a result, the necessary increased line pressures can preclude line occlusion warning capabilities, which may lead to infiltration of the IV site. This is particularly true of older pumps commonly employed in many hyperbaric units e.g. IVAC® 530 and Abbott® Hyperbaric pumps. Clinical Concerns: Infiltration of intravenous lines may have only minimal consequences for the patient such as minor swelling, inflammation, and discomfort. Unfortunately, serious consequences may ensue as a result of the pressure causing effects of fluids confined within soft tissues (compartment syndrome), severe ischemia from vasoconstriction (vasoactive sympathomimetic amines i.e. pressors), or frank necrosis from chemotherapeutic agents. Additionally, patient may be put at risk should the dosage of pressor agents fail to reach therapeutic levels when not properly infused. Loss or inappropriate dosing of analgesic or sedative medications may likewise have adverse effects particularly in the mechanically ventilated patient.

        Recommendations

        • All IV sites should be thoroughly assessed prior to, every 15 minutes during treatment, and upon completion of hyperbaric treatments. Special attention should be given to the tubing and the respective IV sites after the patient is positioned in the chamber as tubing may become kinked or dislodged. The nurse shall document these assessments.
        • During treatment, IV sites should be periodically visualized such that swelling or discoloration may be identified in a timely fashion.
        • Intravenous infusions should be stopped should any signs indicative of IV infiltration be identified. The appropriate nurse manager and attending physician should be promptly notified.
        • Suspicious or negative findings shall be documented in the patient chart along with necessary corrective interventions.
        • Use of arm boards or splints should be considered when the location of intravenous access may result in positional occlusion e.g. antecubital fossa, dorsum of hand.
        • Judicious and proper use of restraints must be employed for those under going treatment as is appropriate. Gauze utilized for restraints should be tied with a non-slipping knot (e.g. bowline) to avoid ischemia distal to the restraint. This is especially important when IV sites are located distal to the restraint (e.g. wrist restraints with IV in the dorsum of the hand).

        Safeguards

        • Procedure for Chamber Setup/Removal
          • Slightly loosen metal nut on outside of chamber door
          • Slide the IV back check extension through the IV port on the chamber door from the inside to the outside. Tighten the nut at the outside of the door.
          • Ensure patency of IV site.
          • Attach IV tubing from IV solution (outside the chamber door). When the solution fills the tubing, then connect the 3-way stop cock (comes in extension set tubing), followed by connecting the back check tubing to the patient’s IV port.
          • Be sure backcheck valve is between patient and chamber door
          • Tighten down an Interlink cap (or other needleless hub) on open port of stop-cock
          • Place IV tubing through appropriate pumping device
          • Check to see that all clamps are open; confirm tubing is bubble free
          • Check for correctly ordered rate of flow and functioning of equipment before closing chamber door
          • When the patient has exited the chamber, remove back check tubing from inner chamber door, replace metal port, and tighten metal nut.
        • Procedure for PRN medication administration
          • Turn off the pump.
          • Close the 3-way valve of the stop cock to the pump.
          • Push the medication through the cap/hub, follow with a 10cc saline flush.
          • Turn the 3-way stop cock to close off the open port (open access from the pump to the patient).
          • Turn on IV pump

        MEDICATIONS IN THE HYPERBARIC ENVIRONMENT

        Goal: maximize patient safety during HBO therapy.

        Policy Compliance

        The Hyperbaric Medicine service will adhere to the institutional policies for the preparation, dispensing and procurement of medications. Emergency medications are consistently available. A crash cart will be immediately available to the Hyperbaric Medicine Service.

        Policy Elements

        When administered in concentrations greater than those found under ambient room air conditions, oxygen can put forth clinical effects having a therapeutic profile not unlike other pharmaceutical agents. As a drug, oxygen is most notable in the setting of hyperbaric oxygen therapy where the partial pressure (dosage) of oxygen prescribed is significantly higher than that which is typically encountered in routine clinical practice. As with any drug, the benefits of hyperbaric oxygen as well as the possible side effects, toxicities, and complications must be considered in determining its efficacy. Furthermore, in a time when polypharmacy is commonplace, drug-on-drug interactions should be given due consideration. Unfortunately, the pharmacokinetics and pharmacodynamics of most pharmaceuticals have generally not been studied under hyperoxic conditions. Despite a lack of specific information, a number of animal studies and clinical observations have provided valuable insight into potential problems with the concomitant administration of HBO and certain classes of drugs. 

        Antineoplastic Drugs

        • Bleomycin (Blenoxane®, Blenomax®)
          • Bleomycin is a polypeptide, which fights against a number of tumors. The exact mechanisms of action of this drug are not clear; however, its cytotoxic effects are likely mediated through inhibition of cell cycle progression and the synthesis of DNA and protein. This drug distributes widely into total body water and is significantly concentrated in the lungs. A number of reports have implicated Bleomycin in the development of severe interstitial pneumonitis. This life-threatening condition is felt to be more likely in the setting of even small increases in the fraction of inspired oxygen (FiO2). Upon review of the available data, a history of Bleomycin therapy should be considered as a relative contraindication to hyperbaric oxygen therapy.
        • Cis-platinum (Cisplatin®, Platinol®)
          • Cis-platinum has been used for a number of years in a variety of cancer treatment protocols. The therapeutic benefit of this drug is realized through its ability to inhibit DNA synthesis. Interference with DNA synthesis effectively inhibits fibroplasia and collagen production resulting in delayed or ineffective wound healing. Diminished wound healing has been noted in animal studies where cis-platinum was used in conjunction with HBO. Based on these findings, concomitant Cis-platinum is a relative contraindication in patients who suffer from chronic, non-healing wounds and should not be considered for hyperbaric oxygen therapy. In emergency situations (i.e., CO poisoning, necrotizing fasciitis, DCS etc.), the benefits outweigh the risks of treating the patient.
        • Doxorubicin (Adriamycin®, Doxil®, Rubex®)
          • Doxorubicin interferes with DNA and protein synthesis. This drug is widely distributed in the body, but has particularly high concentrations in the heart, liver, and kidneys. Adverse reactions such as cardiac dysrhythmias, acute left ventricular failure, and irreversible cardiomyopathies have been reported. Extravasation of this drug typically results in significant tissue damage. Hyperbaric oxygen was studied in a murine model in hopes of finding benefit in this scenario. With concomitant use of HBO, the authors noted an 87% mortality rate which was attributed to apparent cardiac toxicity. This proved to be the case even after a reduction in the hyperbaric oxygen dosing to once per day. Based on these findings, HBO is considered an absolute contraindication and it is therefore prudent to delay hyperbaric oxygen exposure until well after doxorubicin has been eliminated from the tissues.

        Drugs Which Enhance Oxygen Toxicity

        • Narcotic Analgesics
          • Narcotic analgesics may increase the risk of CNS oxygen toxicity. In higher dosages these drugs may cause respiratory depression resulting in carbon dioxide retention. This hypercapnea promotes CNS vasodilation and increases oxygen delivery to the brain.
        • Antipsychotics (Phenothiazines)
          • Chlorpromazine (Thorazine®, Largactil®)
            • Chlorpromazine has been studied with regards to oxygen toxicity. This medication showed a protective effect against CNS oxygen-induced seizures. Phenothiazines that have minimal effect on CNS vasomotor tone (those containing a piperazine side chain) should also have a similar benefit.
        • Disulfuram (Antabuse®)
          • Disulfuram is an irreversible inhibitor of aldehyde dehydrogenase which is responsible for oxidation of alcohol at the acetaldehyde level. Initially, animal studies showed promising results with the use of Disulfuram for the prevention of both pulmonary and central nervous system oxygen toxicity. This protective effect proved to be dramatic even with oxygen exposures as high as 6 atmospheres absolute (ATA). Subsequent studies, however, showed that Disulfuram also blocks the production of superoxide dismutase (SOD), a major defense against oxidative stress. Theoretically, Disulfuram may be protective for single hyperbaric treatments but may enhance toxicity with multiple treatments.
        • Sympathomimetic Amines
          • Dopamine (Intropin®)
          • Dobutamine (Dobutrex®)
          • Epinephrine (Adrenalin)
            • Epinephrine was noted to increase pulmonary and CNS oxygen toxicity as early as the 1950’s. The mechanisms of this enhanced toxicity are not well understood; however, this must be given due consideration in the critical care setting where adrenergic agents are commonly utilized.
          • Norepinephrine (Levophed®)
        • Thyroid Hormone (Synthroid®, Levoxyl®, Cytomel®)
          • Thyroid supplementation resulting in a hyperthyroid state increases both pulmonary and CNS oxygen toxicity. This is likely mediated through increased sympathetic tone.
        • Corticosteroids (Deltasone®, Decadron®, Solu-Medrol®, Solu-Cortef®)
          • Corticosteroids increase the risk for oxygen toxicity. Homeopathic doses do not elevate the risk for oxygen toxicity.
        • Central Nervous System Vasodilator
          • Acetozolamide (Diamox®)
            • Acetozolamide acts as a carbonic anhydrase inhibitor and has diuretic effects. It is commonly used for prophylaxis against high altitude sickness. Through its CNS vasodilatory affects and consequent enhanced CNS oxygen delivery, the risk for oxygen toxic seizures is increased. HBO pressures should be limited to 2.0 ATA in this setting. Addition of air breaks should also be considered.
        • Insulin
          • Insulin must be administered with caution in the hyperbaric oxygen setting. Diabetic patients exposed to hyperbaric oxygen may experience decreases in serum glucose of up to 70mg/dl. Insulin dosages, timing, and caloric intake should be closely scrutinized to avoid hypoglycemia and the commensurate increased risk of oxygen seizures.

        Anticonvulsants

        Anticonvulsants are not generally prescribed prophylactically in the hyperbaric oxygen setting. While these drugs may prevent grand mal seizures while at pressure, they do not prevent the oxygen toxicity to the tissues.

        • Phenobarbital (Luminal®)
          • Phenobarbital is efficacious in the prevention of CNS oxygen-induced seizures; however, respiratory depression must be considered which could lead to elevated levels of CO2, thereby increasing the risk of CNS oxygen-induced seizures
        • Benzodiazepines (Ativan®, Valium®, Librium®)
          • Benzodiazepines are effective as anticonvulsants and are generally well tolerated in the hyperbaric patient.
        • Phenytoin / Phosphenytoin (Dilantin®)

        Anxiolytics

        Benzodiazepines are useful in treating patients with significant confinement anxiety. There is likely a protective effect against oxygen toxicity induced seizures. A decrease in cortical benzodiazepine receptors has been demonstrated in animal studies suggesting that the dose may need to be increased to achieve an equivalent effect.

        Transdermal Delivery Systems

        Transdermal medications are becoming more commonplace. While there have been no definitive studies, medication delivery through these systems is likely unaffected although one might consider HBO’s vasoconstrictive effect and the potential for temporary altered absorption in a hyperbaric environment. The potential risk of fire exists with the addition of adhesives and other hydrocarbon vehicles within the respective systems. As a general rule it is felt prudent to remove the patches and use an acceptable alternative medication or mode of delivery.

        Implantable Medication Delivery Systems

        A number of medication pumps are available to deliver medications on a continuous basis. The specific medication utilized must be considered in each case. Additionally, the delivery device must be approved for use under hyperbaric conditions. Product specifications should be obtained from the manufacturer to determine if the device may be used.

        Topical Medications

        • Sulfamylon (Mafenide)
          • Sulfamylon is a topical antibacterial agent historically used for burn patients. This drug acts as a carbonic anhydrase inhibitor resulting in local vasodilatation and a metabolic acidosis. This increases the risk of oxygen toxicity. This, in combination with the central vasoconstriction resulting from hyperbaric oxygen, may result in a worse outcome than with either therapy used alone. This drug should be discontinued prior to initiation of hyperbaric oxygen therapy. Silvadene (Silver Sulfonamide) is the more common, safe alternative in the hyperbaric chamber.

        Antiarrhythmic Agents

        • Amiodarone
          • Amiodarone has been extensively utilized as a potent antiarrhythmic agent in the United States for decades. This drug has been shown to be highly efficacious in the treatment of both ventricular and supraventricular dysrhythmias. Unfortunately, Amiodarone also exhibits a significant adverse risk profile affecting the liver, neuromuscular system, skin, thyroid, cornea, and lung. Perhaps the most clinically significant adverse effect of Amiodarone is the development of Amiodarone Pulmonary Toxicity (APT). Often called Amiodarone Lung or Amiodarone Pneumonitis, this drug-induced lung injury has been recognized since the early 1980’s. Amiodarone lung toxicity is more prevalent in men with an increasing age-related incidence. It may occur within a few days of taking the medication or may be seen years later. It also appears to be dose-dependent with a higher incidence in those taking doses greater than 200mg/day. On average, APT will develop in approximately 5% to 15% of patients who take ≥500 mg/day and 0.1% to 0.5% who take up to 200 mg/day. Clinically, APT is characterized by increasing shortness of breath with decreased lung diffusion capacity; however, the clinical presentation is not consistent. Findings may be that of patchy infiltrates on plain films to interstitial pneumonitis or that of a rapidly progressing, and sometimes fatal, acute respiratory distress syndrome.

        While definitive articles addressing concomitant use of Amiodarone and HBO are not available at the present time, there are isolated case reports of those developing APT after exposure to elevated concentrations of oxygen. In addition, there have been other reports of APT associated with mechanical ventilation accompanied by high-inspired fractions of oxygen.

        Although there is no definitive evidence for increased risk of APT in the setting of HBO, treatment of a patient who is currently suffering from possible APT should not be pursued without serious consideration given to the possible risks including possible death. One must consider the risk/benefit ratio of using HBO in patients on Amiodarone based on their indication for treatment. Those with emergent indications may be considered for a trial of pressure. Those with elective indications should be referred to their cardiologist to determine if an equally efficacious antiarrhythmic drug could be substituted. In the later case it is important to remember that Amiodarone and its active metabolite desethyl-amiodarone (DEAm) have extremely long half lives in lung tissue – on the order of 100 and 500 fold that of the serum respectively. Waiting the traditional 5 half-lives to assure trivial lung tissue drug levels will potentially require months.

        MODIFICATION OF TREATMENT PROTOCOL

        To ensure that any modification in treatment protocol is done within the appropriate treatment guidelines.

        The Hyperbaric Medicine Service is aware of the potential to modify or change a patient’s treatment protocol (i.e. Diabetic Foot Wound being modified to Compromised Flap following surgery).

        • The hyperbaric physician and Program Director will review any occurrence of a modification or change in treatment protocol.
        • The attending clinical staff member and physician shall complete a modification in treatment protocol form.
        • Copies of the form should be provided to the Medical director, Safety Director, and Program Director. A copy should also be placed in the patient’s chart or completed electronically.
        • The physician ordering the modification or change in treatment protocol may dictate a note regarding the change in protocol.
        • After completion of the form/document, the documentation will be entered into the monthly QA.
        • Any action required, as a result of the modification or change in the current treatment protocol, will be at the discretion of the medical director.

        NEBULIZER INHALATION THERAPY

        To establish procedures through which patients may safely be provided nebulized aerosols while in the hyperbaric chamber.

        Policy Elements

        Special consideration must be given to patients with a history of bronchospastic disease while treated in the monoplace chamber. While acute bronchospasm is a contraindication to HBO treatment, many patients have stable pulmonary disease but, for various reasons, are at risk of developing bronchospasm while at pressure. Decreased humidity, temperature changes, anxiety, and recumbent positioning are a few factors that may exacerbate or incite bronchospasm. Pulmonary gas trapping at pressure may lead to pulmonary barotrauma and air embolism during the decompression phase. Therefore, it is prudent to have bronchodilating medications available to those patients who are perceived to be a greater risk of bronchospasm.

        Providing nebulized medications in the monoplace hyperbaric chamber requires appropriate chamber door penetrators and IV tubing which can be connected to oxygen supply tubing outside of the chamber. However, there have been several case reports where oxygen tubing has been inadvertently connected to intravenous catheters leading to gas embolism. Several of these cases resulted in death. This potentially fatal error is particularly an issue in the hyperbaric environment where intravenous lines exiting the chamber door are identical to the tubing used to provide nebulized medications.

        To prevent a potentially catastrophic injury, the following procedures must be followed:

        • Tubing utilized for nebulizer therapy exiting the chamber door should be placarded with tape with the annotation “nebulizer.”
        • Oxygen supply tubing must be connected only to that tubing identified as above.
        • All staff should trace the tubing in question to its source within the chamber as a further precaution prior to connecting the oxygen line.
        • All staff should undergo appropriate training and periodic in-service on the proper use of a nebulizer set up within the chamber.

        PAIN ASSESSMENT

        Provide optimal pain assessment and management. Each patient has the right to pain assessment and management appropriate to their age and condition.

        Policy Elements

        Pain is a complex and personal phenomenon that requires multi-disciplinary collaboration and patient involvement. Unrelieved pain can cause severe adverse physiological and psychological sequelae. The patient’s own report is the most reliable indicator of pain. When patients are unable to provide self-reports of pain, other systematic processes for assessment must be substituted. Language and culture affect the patient’s experience and communication of pain.

        Pain Assessment

        • All patients are assessed for pain at time of consult, during every pre-treatment assessment, after any intervention is applied, and as appropriate if the patient’s status changes.
        • Use the standard self report pain rating scale appropriate to the patient.
        • Assessment findings will be documented in the patient chart.

        Pain Management

        • Pain management strategies include both pharmacological and non-pharmacological interventions provided by the multi-disciplinary team.
        • Interventions are individualized to meet the cultural and developmental needs of a diverse patient population.

        Pain Education

        • Education regarding pain, its management and the patient’s role in assessment is provided on a continuing basis.
        • Patient pain education is developmentally appropriate and considers literacy, culture, and language.
        • Patient is taught how to use the appropriate pain scale to self report.
        • Use the Wong-Baker FACES Pain Rating Scale and the 0-10 Numeric Rating Scale as appropriate for the patient.
        • Patient is taught specific details about pain medication ordered including potential side-effects.
        • When appropriate, patient is educated on self-care measures and/or complementary measures he/she can use to prevent, alleviate, or cope with pain.

        Procedure

        • Pain management is the responsibility of all clinical disciplines.
        • All patients are assessed for pain.
        • Collaboration in pain management is vital, particularly for patients unable to participate in assessment due to level of development or medical condition.
        • Evaluation of the treatment plan is driven by ongoing reassessment and includes consideration of continuity in other settings.
        • Assessment, plan of care, and intervention are documented in a way that facilitates reassessment and follow-up.
        • The attending physician documents the plan-of-care and writes orders for medications and other interventions to implement the plan.

        PATIENT EDUCATION

        Policy Elements

        • Every patient of the hyperbaric medicine service will receive information about their diagnosis, condition, treatment, procedures, and activities related to his/her self care needs. The patient, when he/she has capacity, may ask to have others included in the educational process and the teaching will include only those designated by the patient. When the patient lacks capacity, the teaching will be given to the designated caregiver or the legal guardian.
        • Every patient of the hyperbaric medicine service will receive information about their diagnosis, condition, treatment, procedures, and activities related to his/her self care needs. The patient, when he/she has capacity, may ask to have others included in the educational process and the teaching will include only those designated by the patient. When the patient lacks capacity, the teaching will be given to the designated caregiver or the legal guardian.
        • The Interdisciplinary Patient Education process is focused on improving health outcomes by promoting recovery with optimal functioning and promoting healthy behaviors that support Patient/caregiver in his/her care and decisions.
        • Healthcare providers are provided with appropriate resources to support the educational process.

        Procedure

        • Upon admission, or initial point of care, the care provider assesses the learning needs, abilities, preferences, readiness and barriers of the patient or designee. The assessment considers education appropriate to length of stay. Reassessment is completed as necessary with a change in care planning or care setting. This assessment is documented per documentation standards.
        • Patient's rights to confidentiality are protected by asking whom they would like included in the educational process and documenting that request. When the patient lacks capacity the education involves the designated caregiver or the legal guardian. Individuals with a diagnosis of chemical/substance abuse and/or HIV/AIDS will be asked to sign a "Release of Information" authorization form to obtain consent prior to involving others in the educational process.
        • Patient education includes instruction in the specific knowledge and skills needed by the patient/caregiver to meet the patient's ongoing healthcare needs, as identified during the assessment. Instruction includes, but is not limited to:
          • diagnosis/condition
          • plan of care/treatment plan
          • safe and effective use of medications including potential drug/food and drug/drug interactions
          • safe and effective use of appropriate medical equipment or supplies
          • instruction and counseling on nutrition interventions, modified diets and oral health) how to access community resources; when and how to obtain further care, services or treatment
          • habilitation or rehabilitation techniques to help them be more functionally independent with self-care activities
          • pain and managing pain as part of treatment
          • personal responsibilities in the treatment process, and their role in helping to facilitate the safe delivery of care
        • Education is adapted as appropriate to the age, culture and language of the patient. Interventions to meet special needs are documented.
        • When the patient/caregiver are unable to meet the learning goal/objectives before dismissal, there will be a follow-up plan noted on the discharge summary.
        • Educational resource materials (print and video) are available to support the efforts of the health care educators and resource utilization is documented per documentation standards.

        PATIENT HYPERBARIC TREATMENT

        Goal: To maintain a high standard of patient care, and to optimize patient safety.

        All patients will be treated upon:

        • Referral to the hyperbaric medicine facility.
        • Consultation and approval by a member of the hyperbaric physician team.

        Pre-Treatment Checklist

        • Determine ancillary equipment requirements.
        • Confirm patient is dressed in 100% cotton (exception: necessary wound dressings which, if extensive, should be covered with moist cotton towel).
        • Check that the patient has no prohibited items, which might be carried, inadvertently or otherwise, into the chamber.
        • Confirm patient preparation has taken place.
        • Re-enforce ear equalization procedure.
        • An assessment, including vital signs, should be undertaken and recorded on all patients prior to each treatment.
        • Assessments such as ECG, ear exam, LOC, and wound evaluation as indicated/ordered.
        • Provide water cup as necessary/requested.
        • Provide urinal as necessary/requested.
        • Connect ECG leads when in-chamber monitoring planned, and attach the patient ground system.
        • Confirm operation or air breathing system. When using a chamber fitted for ventilator support, confirm oxygen analyzer reads 21% and constant analyzer gas flow.
        • Record patient temperature pre-treatment (if 100° F or greater, institute Policy on Hyperbaric Oxygen-Induced Seizure Prophylaxis.)
        • All patients being treated at pressures greater than 2.0 ATA, and all those patients considered at increased risk for oxygen-induced seizures will undergo scheduled air breaks.
        • Notes: Patients will be placed on the cardiac monitor during their initial treatment. EKG monitoring is recommended for every treatment in patients at high risk for CNS oxygen toxicity, and should be considered at pressures greater than 2.5 ATA.

          Alarms are set to 20 +/- patient heart rate (an abrupt 20 +/- change in heart rate may be indicative of developing CNS oxygen toxicity.)

        • During chamber operations with an occupant in the chamber, a CHT, CHRN, ACHRN or hyperbaric trained physician shall be physically present and shall maintain visual or audible contact with the control panel or the chamber’s occupants.
        • Diabetic Patients (IDDM and NIDDM): Finger stick blood glucose checks are mandatory for all diabetic patients prior to and after hyperbaric oxygen treatment.
          • Diabetic Inpatients: If blood sugar has been checked on floor within 1 hour prior to treatment, it is not necessary to recheck unless the patient has received insulin. If blood glucose level has not been checked (or more than 1 hour has elapsed), then blood sugar must be taken and recorded pre treatment.
          • Diabetic Outpatients: Blood sugar must be checked on ALL diabetic patients prior to initiation of hyperbaric oxygen therapy
          • The following guidelines should be used for all diabetic patients.
                Blood Glucose level:
            • 100mg/dl – 120mg/dl: Patient should be given one glass of orange juice to drink pre-treatment
              and also one to drink during treatment.
            • ≤ 99mg/dl: Hold HBO treatment until further direction is given by the hyperbaric physician.

        Post-Treatment Checklist

        • Visualize tympanic membranes on first time patients and in any case of patient equalization difficulty. If any barotrauma noted, notify hyperbaric physician
        • Recheck patient’s blood glucose level to ensure normal levels before leaving the facility.
        • Complete patient charting.

        PATIENT ORIENTATION TO HYPERBARIC MEDICINE

        To optimally prepare the patient and minimize apprehension in those who are scheduled to undergo hyperbaric oxygen therapy.

        • Assess the patient’s readiness for hyperbaric oxygen treatments.
          • Ask patient if he/she knows what hyperbaric oxygen therapy entails.
          • Prior to the procedure (whenever possible), verify and document that the hyperbaric physician and hyperbaric staff member have discussed the risks and expectations of hyperbaric oxygen treatments with the patient and/or significant other. Risks and side effects, and complications may include:
            • ear, sinus, pulmonary, or dental barotrauma
            • oxygen seizures
            • numbness and tingling in the fingers and toes
            • visual changes (including increased cataract growth especially in diabetic and systemic steroids dependent patients, or myopia)
            • diabetic hypoglycemia
            • fire
        • Document patient/family/significant other understanding of the above.
          • Emphasize desirability of NO SMOKING for the duration of the course of hyperbaric oxygen treatments in wound healing referrals.
          • Provide patient and/or significant other Patient Information Brochure. Document patient and/or significant other understanding of the procedure, and questions answered.
        • Familiarize the patient and/or significant other with the procedure, anticipated beneficial effects, and safety precautions relating to his/her treatments.
          • Answer patient’s questions regarding treatments.
          • Discuss risks, emphasize safety precautions including elimination of petroleum or alcohol based substances. Only 100% cotton gowns will be worn during treatment. No personal garments or unnecessary items will be permitted. Earplugs are not permitted.
        • Familiarize patient with diversion activities available, and hyperbaric visitor policy.
        • Hyperbaric physician to obtain informed consent for hyperbaric treatment, photographs, perform needle myringotomy, or refer to ENT where indicated.
        • Screen present medications. Note if there are medications being used that may be influenced by the hyperbaric oxygen environment. These include aspirin, steroids, Diamox, insulin, nicotine, hallucinogens, Vitamin C, stimulants, morphine, and digitalis (refer to “Policy on Medications”).
        • Patient’s ears to be checked prior to and after the first treatment and then PRN.
        • Offer emotional support. Use desensitization process or relaxation techniques as appropriate.
        • Hyperbaric physician to screen for medical conditions that may be absolutely or relatively contraindicated.

        PEDIATRIC PATIENTS

        To maximize the safety and effectiveness of hyperbaric treatments provided on behalf of pediatric patients.

        • Indications
          • The indications for the use of HBO in the pediatric population are no different from those of the adult population.
          • The range of pediatric pathophysiological states includes disease processes where HBO therapy is indicated as definitive or adjunctive therapy.
        • Contraindications and Risk-Benefit Ratio
          • The side effects observed in adults, based on similarities in physiologies, are likely to be the same for children.
          • The only unique relative contraindications are significant prematurity and the presence of a complex congenital cardiac malformation where systemic circulation is dependent on a patent ductus arteriosus, or the immature retinal vascularity of the premature infant.
        • Treatment Specifics
          • An infant or toddler can be accompanied in the monoplace chamber unless they are ventilator-dependent.
        • Critically-Ill Cases
          • Hyperbaric staff member may accompany the patient during the treatment. This decision will include the medical director and safety officer. The staff member must be medically cleared by the hyperbaric physician.
        • Elective and Stable States
          • A family member is permitted, providing a hyperbaric physician has medically cleared them.
          • Whether tended or untended, an infant in the monoplace chamber will be restrained in a method appropriate for his/her physical development, whenever considered necessary., and in accordance with institutional policy on the use of restraints.
        • Oxygen Administration and Oxygen Doses
          • Standard adult regimes of oxygen partial pressures and durations can safely be used in the care of pediatric patients. Consequently, the indications for alteration of oxygen dosage and institutions of air breaks are the same for infants and children as they are for adults.
        • Middle Ear Pressure Equalization
          • The prevention of middle ear barotrauma is similar in pediatric patients to that of adults. Swallowing is a natural phenomenon and can be elicited by giving small amounts of water by cup, bottle or nipple. A pacifier nipple can be substituted. Infants that are allowed to suck on a bottle or pacifier should be burped prior to decompression as an expanding air bubble in the stomach may lead to emesis. Crying by itself may lead to middle ear ventilation.
        • Children and Adolescents
          • Children in this age range can be taught to equalize by swallowing or by Toynbee maneuvers. Individual evaluation of each child is performed to determine in advance the probability of success as, at any given age, the ability to understand instructions and carry them out varies greatly.
          • Indications for Myringotomy are the same for children as in adults.
        • Sedation and Restraint:
          • The judicious use of safe and humane physical restraining measures to prevent the pediatric patient from inadvertently sabotaging their own treatment is appropriate. The use of pharmacological sedatives as a form of restraint is also appropriate and can help minimize anxiety.
          • Sedatives are not needed for every pediatric patient. If patients are scheduled for a series of treatments, sedatives may be needed only in the short term until accommodation has taken place.
        • Resuscitation and Miscellaneous Equipment
          • A range of sizes of endotracheal tubes, laryngoscope blades and oral airways, vascular access supplies, appropriately sized suction catheters for all endotracheal tubes, and a range of sizes of central line placement catheters should be available in the hyperbaric facility.
          • Various sizes of blood pressure cuffs are available as a backup to invasive monitoring devices.
          • A manual providing age appropriate medicinal doses per weight and normal values for vital sign parameters and laboratory values should be immediately available.

        PREVENTION AND MANAGEMENT OF CENTRAL NERVOUS SYSTEM OXYGEN TOXICITY

        To define procedures that minimizes the risk of CNS oxygen toxicity. To identify potential contributing factors, such as elevated temperature, strenuous exercise, high/low blood sugar in diabetic patients, pharmacological effects, recent sickle cell crisis, carbon dioxide buildup, apprehension, acidosis, and past history of a seizure disorder.

        Resolve/Eliminate Precipitating Factors:

        • Review past medical history including medication list – note if recent doses of PCN or Phenergan have been administered.
        • Pre-treatment temperature:
          • For temperature greater than 100 degrees F, institute CNS oxygen toxicity prophylaxis procedures.
          • If extreme elevation, (> 103ºF), aggressively attempt to reduce it:
            • Tylenol P.O. or rectal prior to treatment.
            • Ice compresses to axilla and groin area during treatment.
            • Cool IV’s by placing tubing in ice filled basin.
        • Correct acidosis if indicated.
        • Blood sugar levels will be assessed via glucometer on all IDDM and NIDDM patients within 1 hour prior to each treatment. Check “Policy on Patient Hyperbaric Treatment”.

        Observe Patient Closely for Premonitory Signs, such as:

        • Nausea
        • Auditory hallucinations
        • Visual hallucinations
        • Tachycardia
        • Bradycardia
        • Diaphoresis
        • Slurred speech
        • Fine tremors
        • Face/hand muscle twitching
        • or if there is a sudden change in:
          • Affect
          • Behavior
          • Mental status
        • Expression of anxiety
        • or of a non-descriptive complaint like, “I just don’t feel right”.

        Course of Action:

        • Immediately direct patient to pick up the air mask/switch patient to air breathing.
          • If symptoms are promptly relieved, they may represent oxygen toxicity.
          • Within 1-2 minutes of the patient breathing air, ask the patient if complaint has resolved, improved, remained the same or worsened.
          • If the patient complaint has resolved or improved, the patient should complete the entire 10 minute air break.  The decision to continue or abort the treatment will rest with the hyperbaric physician.  It is important that the staff maintain direct visual observation of the patient throughout the ascent.
          • If the patient complaint is unresolved, then return the patient immediately to surface pressure while continuing to breathe air via mask.  The symptom may represent an alternate etiology and should be evaluated and treated accordingly
        • To prevent future occurrences, the treatment pressure may be decreased, with additional air breaks as indicated.
          • Example:
            For prescribed treatment pressures @ 2.0 ATA
            45 minutes 100% O2 – 10 minutes air (21% O2) – 45 minutes 100% O2
          • Example:
            For prescribed treatment pressures @ 2.0 ATA
            30 minutes 100% O2 – 10 minutes air (21% O2) – 30 minutes 100% O2 – 10 minutes air (21% O2)- 30 minutes 100% O2

        In-Chamber Seizure:

        • DO NOT decompress patient while actively seizing.
        • Wait until adequate ventilation has been established.
        • Decompress at normal rate (1.5-2 psi/minute).

        In the Electively Referred Patient:

        • Hold at stable pressure until adequate ventilation is observed.
        • Note time of occurrence and length of seizure activity
        • Report the reaction to the hyperbaric physician.
        • Reduce chamber pressure to zero @ normal rate of ascent (2 psi/minute) while continually assessing airway patency.
        • Reassure the patient
        • Remove patient from chamber.
        • Evaluation by hyperbaric physician.
        • Medicate as appropriate per physician order.
        • All follow-up hyperbaric oxygen treatments at 2.0 ATA using:
          45 minutes 100% O2 – 10 minutes air (21% O2) – 45 minutes 100% O2

                  30 minutes 100% O2 – 10 minutes air (21% O2) – 30 minutes 100% O2 – 10 minutes air (21% O2)- 30 minutes 100% O2

        In the Emergently Referred Patient:

        • Hold at a stable pressure until adequate ventilation is observed.
        • Note time of occurrence and length of seizure activity
        • Report the reaction to the hyperbaric physician
        • Reduce chamber pressure to 1.5 ATA while continually assessing airway patency.
        • Reassure the patient.
        • Give a 15 minute air break, and continue treatment as directed by the hyperbaric physician:
          (i.e. 30 minutes 100% O2 – 10 minutes air (21% O2) – 30 minutes 100% O2)
        • Evaluation per hyperbaric physician.
        • Medicate as appropriate per physician order.
        • Schedule next hyperbaric treatment as planned/ordered.
        • At completion of treatment, take vital signs and observe.
          Note: patient may be postictal and disoriented. In these cases, continually supply information to patient to aid in recovery.

        SEIZURE PROPHYLAXIS AND HBOT

        To minimize the risk of oxygen-induced seizures in all hyperbaric patients, and to identify and prophylax those considered at high risk.

        Policy Elements

        • Oral temperature is to be recorded on all patients immediately prior to treatment.
          • Temperatures of 100° F or greater increase the risk of oxygen toxicity. Advise hyperbaric physician and proceed as ordered.
        • Diabetic Patients (IDDM and NIDDM): Finger stick blood glucose checks are mandatory for all diabetic patients prior to and after hyperbaric oxygen treatment.
          • Diabetic Inpatients: If blood sugar has been checked on floor within 1 hour prior to treatment, it is not necessary to recheck unless the patient has received insulin. If blood glucose level has not been checked (or more than 1 hour has elapsed), then blood sugar must be taken and recorded pre treatment.
          • Diabetic Outpatients: Blood sugar must be checked on ALL diabetic patients prior to initiation of hyperbaric oxygen therapy
          • The following guidelines should be used for all diabetic patients.
            Blood Glucose level:
            • 100mg/dl – 120mg/dl: Patient should be given one glass of orange juice to drink pre-treatment and also one to drink during treatment.
            • ≤ 99mg/dl: Hold HBO treatment until further direction is given by the hyperbaric physician.
        • Provide a patient-state specific air break assembly for every patient on every treatment. Confirm with the patient their understanding of its use.
        • Consider ECG monitor for high-risk patients during treatment. Set alarm limits 20 above (high alarm) and 20 below (low alarm) resting heart rate.
        • Reinforce with the patient the importance of advising clinical staff of any change in their condition while in the chamber.
        • Pay close visual attention to the patient, and their heart rate, particularly during the latter stages of treatment.
        • Should there be an otherwise unexplained change in the patient’s status, have them begin air breathing immediately. Alert the hyperbaric physician and proceed as ordered.
        • In high risk patients, such as:
          • previous oxygen-induced seizure or premonitory signs
          • previous history of seizure(s)
          • febrile state
          • concurrent administration of neurotoxic medication
        • Evaluate the current treatment protocol and make any appropriate changes. Consider pharmacologic prophylaxis.

        THE USE OF RESTRAINTS

        Due to the unique nature of the monoplace hyperbaric chamber, which lacks a direct “hands-on” capability, restraints are occasionally used to prevent the patient who is exhibiting decreasing levels of consciousness, or agitation, from self-injury and equipment damage during the procedure. A restraint policy is also required to maintain compliance with hospital policy.

        • Assess the patient to determine if restraining is necessary.
        • Patient will be under constant observation by a hyperbaric staff member.
        • Restraints are to be used at the discretion of the hyperbaric staff, or by physician order.
        • Apply soft restraints and tie under the side bar of the hyperbaric gurney past the rollers.
          Do not allow restraints to interfere with wounds, dressings, vascular access, or impede circulation or other life sensitive systems.
        • Remove any Velcro and tape over metal on the restraint
        • Wrap patient’s hands with Kerlix if patient pulls at life sensitive equipment.
        • Once applied, blanch patient’s extremity distal to restraint to ensure circulation.
        • Conduct and document visual circulation checks (extremity color) every 15 minutes for the duration of hyperbaric treatment.
        • Chart use of, and reason for (medical or behavioral), restraints. Restraints are to be visible during treatment.
        • Restraints may be removed at the completion of treatment.

        Note: Adherence to the hospital’s “Restraint Policy” is mandatory, but can be modified to accommodate hyperbaric treatments, as noted above.

        Official reprint from WoundReference® woundreference.com ©2018 Wound Reference, Inc. All Rights Reserved
        Use of WoundReference is subject to the Subscription and License Agreement. ​
        NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

        REFERENCES

        1. National Baromedical Services. Introduction to Hyperbaric Medicine Primary Training Manual .;.

        SUBTOPICS