Letter to the Director
Oxygen dissolved in plasma does matter. Tissue oxygen monitoring to assess the feasability of a microvascular flap in a patient undergoing hyperbaric oxygen therapy
El oxígeno disuelto en plasma sí importa… Empleo de la monitorización tisular de oxígeno para valorar la viabilidad de un colgajo microvascular en paciente sometido a oxigenoterapia hiberbárica
R. Navarro Suaya,
, M.N. Escolán Gonzalvob, M.A. de Nicolás Álvarezb, M.Á. Brinquis Crespoc
Corresponding author
a Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Central de la Defensa Gómez Ulla, Instituto Mixto de Investigación de la Defensa (IMIDEF), Madrid, Spain
b Servicio de Cirugía Plástica, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
c Servicio de Medicina Subacuática e Hiperbárica, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
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Tissue oxygen monitoring to assess the feasability of a microvascular flap in a patient undergoing hyperbaric oxygen therapy" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1050 "Ancho" => 1867 "Tamanyo" => 237834 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Exterior de la cámara hiperbárica del Hospital Central de la Defensa Gómez Ulla de Madrid. B) Tratamiento del paciente dentro de la cámara OHB. C) Pierna del paciente tras la realización de la primera cirugía. 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Tissue oxygen monitoring to assess the feasability of a microvascular flap in a patient undergoing hyperbaric oxygen therapy" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "119" "paginaFinal" => "120" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. Navarro Suay, M.N. Escolán Gonzalvo, M.A. de Nicolás Álvarez, M.Á. Brinquis Crespo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Navarro Suay" "email" => array:1 [ 0 => "r_navarro_suay@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.N." 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"apellidos" => "Brinquis Crespo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Central de la Defensa Gómez Ulla, Instituto Mixto de Investigación de la Defensa (IMIDEF), Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía Plástica, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Subacuática e Hiperbárica, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El oxígeno disuelto en plasma sí importa… Empleo de la monitorización tisular de oxígeno para valorar la viabilidad de un colgajo microvascular en paciente sometido a oxigenoterapia hiberbárica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1050 "Ancho" => 1867 "Tamanyo" => 237058 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Outside of the hyperbaric chamber in the Hospital Central de la Defensa Gómez Ulla of Madrid. (B) Treatment of the patient inside the OHB chamber. (C) Patient's leg after the first surgery. (D) Invos<span class="elsevierStyleSup">®</span> monitoring of tissue oxygen saturation in the healthy area (ankle: 68) and the graft (leg: 67) after hyperbaric oxygen therapy. Photographs taken by the authors.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Under normobaric conditions (1 ATA), oxygen is transported in the blood in 2 ways: bound to haemoglobin (98%) and physically dissolved in the plasma (2%) at a concentration of 0.3<span class="elsevierStyleHsp" style=""></span>ml O<span class="elsevierStyleInf">2</span>/100<span class="elsevierStyleHsp" style=""></span>ml of blood. According to Henry's Law, when treating a patient with hyperbaric oxygen therapy (HBOT), the amount of O<span class="elsevierStyleInf">2</span> dissolved in plasma increases in proportion to the pressure of the medium. The aforementioned dissolved O<span class="elsevierStyleInf">2</span> in the blood is the fraction that increases the most, since haemoglobin-bound O<span class="elsevierStyleInf">2</span> barely changes (because haemoglobin saturation is measured at practically atmospheric pressure). Elevating the partial pressure of O<span class="elsevierStyleInf">2</span> in blood produces tissue and cellular hyperoxia that may be beneficial in patients with compromised grafts or skin flaps.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Near-infrared spectroscopy can be used to determine the degree of hypoxia in tissue and, therefore, can be effective in monitoring the viability of flaps in the patient.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We describe the case of a patient diagnosed with squamous cell carcinoma in the right lower limb who was treated with surgery and hyperbaric oxygen therapy and monitored with near-infrared spectroscopy.</p><p id="par0020" class="elsevierStylePara elsevierViewall">This is a 54-year-old man, ex-smoker of 10 years pack/years, hypertensive, with a past history of traumatic amputation of the left lower limb at the femoral diaphysis as a result of an explosion 33 years ago. As a result of this trauma, the right lower extremity was reconstructed using a bone graft and a regional pedicle flap. The patient progressed poorly, and was re-operated 5 years later.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The Plastic Surgery department of our hospital diagnosed an infected necrotic ulcer in the right leg, compatible with the pathological diagnosis of Marjolin's ulcer. It was decided to remove the ulcer, debride, and cover with a microvascular flap in 2 stages. During the first intervention, wide excision was performed, which resulted in loss of circumferential substance at the level of the middle third of the right leg, and preservation of only the deep posterior compartment. Coverage was deferred for 1 week—due to the patient's haemodynamic status—using an anterolateral right thigh flap anastomosed to popliteal vessels (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">After the surgery, the patient underwent 11 75-minute sessions of HBOT (descent for 10<span class="elsevierStyleHsp" style=""></span>min, 60<span class="elsevierStyleHsp" style=""></span>min on the bottom, and 5<span class="elsevierStyleHsp" style=""></span>min ascent) at 2.4 ATA (equivalent to 14<span class="elsevierStyleHsp" style=""></span>m depth), with 100% oxygen. The hyperbaric treatment was uneventful.</p><p id="par0035" class="elsevierStylePara elsevierViewall">During his hospital stay, the Invos<span class="elsevierStyleSup">®</span> oxygen tissue saturation monitor was used intermittently minutes before the surgery, and at 1 and 6<span class="elsevierStyleHsp" style=""></span>h post surgery. It was also used 1<span class="elsevierStyleHsp" style=""></span>h before and 6<span class="elsevierStyleHsp" style=""></span>h after each HBOT session. During both surgical and HBOT monitoring, one sensor was placed on the flap and another on the healthy area of the same limb. Initial tissue oxygen saturation in the affected area was 60, and the last parameter recorded in the same area was 67.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The Undersea & Hyperbaric Medical Society defines HBOT as “an intervention in which an individual breathes near 100% oxygen intermittently while inside a hyperbaric chamber that is pressurised to greater than sea level pressure”. The oxygen is usually delivered via a face mask, head hood or endotracheal tube.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Hyperoxia causes rapid and significant vasoconstriction in healthy tissues, compensated by the increase in oxygen and microvascular flow in ischaemic tissues. It is indicated in various situations: air or gas embolism, carbon monoxide poisoning, decompression sickness, gas gangrene, crush injuries, refractory ulcers, severe anaemia without the possibility of transfusion (as in the case of Jehovah's Witnesses), intracranial abscess, necrotising soft tissue infections, chronic refractory osteomyelitis, soft tissue and bone necrosis following radiation, and compromised grafts and flaps. Most of the 113 patients undergoing HBOT in our hospital over a period of 16 months presented radiation injury (52%) and ulcers (23%).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The only absolute contraindication for this treatment is untreated pneumothorax. HBOT is usually well tolerated, and the most frequent complication is reversible myopia due to lenticular toxicity (20%).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Anaesthesia may be an important and decisive factor in the success in this type of surgery, given its role in maintaining haemodynamic stability and regional blood flow.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Monitoring tissue oxygen saturation can help in the diagnosis and treatment of these patients.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Although this monitor was only used occasionally during hospitalisation of a single patient, it enabled us to quantify the evolution of the graft in the patient treated with HBOT, and can be used to monitor patients treated with HBOT in whom levels of oxygen dissolved in plasma are particularly important.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Navarro Suay R, Escolán Gonzalvo MN, de Nicolás Álvarez MA, Brinquis Crespo MÁ. El oxígeno disuelto en plasma sí importa… Empleo de la monitorización tisular de oxígeno para valorar la viabilidad de un colgajo microvascular en paciente sometido a oxigenoterapia hiberbárica. Rev Esp Anestesiol Reanim. 2018;65:119–120.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1050 "Ancho" => 1867 "Tamanyo" => 237058 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Outside of the hyperbaric chamber in the Hospital Central de la Defensa Gómez Ulla of Madrid. (B) Treatment of the patient inside the OHB chamber. (C) Patient's leg after the first surgery. (D) Invos<span class="elsevierStyleSup">®</span> monitoring of tissue oxygen saturation in the healthy area (ankle: 68) and the graft (leg: 67) after hyperbaric oxygen therapy. Photographs taken by the authors.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Principios fisiológicos de la oxigenoterapia hiperbárica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. 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