Oxigenoterapia Hiperbárica em Queimados

Luis Eduardo Fontes

Petrópolis – RJ
Semana Científica FMP-FASE 2011
Conflito de Interesse
SIM
 Declaração de Pesquisa de Literatura

 Cochrane Library
 Trip Database
 Embase
 Pubmed
 LILACS
Mesh Terms
"Burns"[Majr] AND "Hyperbaric Oxygenation"[Mesh]
Evidence-based hierarchy
6

90
Hyperbaric oxygen therapy for thermal burns.
Villanueva E, Bennett MH, Wasiak J, Lehm JP. Cochrane Database Syst Rev. 2004;(3):
CD004727. Review

SELECTION CRITERIA:
All randomised controlled trials that compared the effect of HBOT with no HBOT (no
treatment or sham).

MAIN RESULTS:
 Four randomised controlled trials were identified, of which two satisfied the inclusion
criteria. The trials were of poor methodological quality.
 One trial reported no difference in length of stay, mortality, or number of surgeries
between the control and HBO-treated groups once these variables were adjusted for the
patient's condition.
 The second trial reported mean healing times that were shorter in patients exposed to
HBOT (mean: 19.7 days versus 43.8 days)

REVIEWERS' CONCLUSIONS:
This systematic review has not found sufficient evidence to support or refute the
effectiveness of HBOT for the management of thermal burns. Evidence from the two
randomised controlled trials is insufficient to provide clear guidelines for practice. Further
research is needed to better define the role of HBOT in the treatment of thermal burns.
Hyperbaric oxygen therapy for treating acute surgical and traumatic wounds.
Eskes A, Ubbink DT, Lubbers M, Lucas C, Vermeulen H.
Cochrane Database Syst Rev. 2010 Oct 6; (10):CD008059. Epub 2010 Oct 6.

SELECTION CRITERIA:
Randomised controlled trials (RCTs) comparing HBOT with other interventions or
comparisons between alternative HBOT regimens.

MAIN RESULTS:
 Three trials involving 219 participants .
 The studies were clinically heterogeneous, therefore a meta-analysis was inappropriate.

 One trial (48 participants with burn wounds undergoing split skin grafts) compared HBOT
with usual care and reported a significantly higher complete graft survival associated with
HBOT (95% healthy graft area risk ratio (RR) 3.50; 95% confidence interval (CI) 1.35 to
9.11).

AUTHORS' CONCLUSIONS:
There is a lack of high quality, valid research evidence regarding the effects of HBOT on
wound healing. Whilst two small trials suggested that HBOT may improve the outcomes of
skin grafting and trauma these trials were at risk of bias. Further evaluation by means of
high quality RCTs is needed.
Hyperbaric oxygen therapy for the treatment of non-healing, refractory wounds in non-
diabetic patients and refractory soft tissue radiation injuries
http://www.msac.gov.au/internet/msac/publishing.nsf/Content/completed-assessments
2003

Study selection: specific interventions

 Studies that assessed HBOT compared with procedures not using HBO, including standard
or conventional therapy, normobaric oxygen or placebo, were eligible for inclusion.
 The frequency and duration of HBOT varied considerably across the studies. Only English
written.

 Sixty-five studies with more than 5,856 participants were reported: 2 systematic reviews,
38 randomised controlled trials (RCTs), 21 comparative studies, 3 comparative studies with
historical controls, and 1 case series.

 Thermal burns (8 studies): the studies were clinically and methodologically heterogeneous.
Overall, there was little evidence to support the use of HBOT for this indication.

Authors' conclusions
Insufficient or conflicting evidence was found for the indications of thermal burns
 Hyperbaric oxygen therapy in the management of carbon monoxide poisoning,
osteoradionecrosis, burns, skin grafts, and crush injury.
Saunders PJ.
Int J Technol Assess Health Care. 2003 Summer;19(3):521-5. Review

OBJECTIVES:
To systematically assess the evidence for effectiveness of hyperbaric oxygen therapy in the
treatment of conditions of significance in the West Midlands region and to determine whether
there is a case for establishing a hyperbaric oxygen unit in the region.
METHODS:
Systematic review of the literature assessing randomized controlled trials from 1968 onward.
RESULTS:
A total of 154 full-text articles was obtained of which 13 relevant randomized control trials
were identified. There was little consistency in the studies. Treatment protocols, study groups,
time to treatment, and other characteristics and outcomes measured all varied considerably.
No convincing evidence of effectiveness was identified.
CONCLUSIONS:
Although hyperbaric oxygen therapy is clearly appropriate in the treatment of decompression
sickness and air/gas embolism, there is no convincing evidence of effectiveness for the
conditions reviewed, despite its widespread use. Although this review has found no evidence
to support the establishment of a unit in the West Midlands, there is a physiological case for an
effect in conditions involving hypoxia and, given the limited volume (and in some cases quality)
of published research, a case for a national research program.
Effects of hyperbaric oxygen therapy on experimental burn wound healing in rats: a
randomized controlled study.
Bilic I, Petri NM, Bezic J, Alfirevic D, Modun D, Capkun V, Bota B.
Undersea Hyperb Med. 2005 Jan-Feb;32(1):1-9.

 Deep second degree burns were produced on the depilated backs of 70 male Wistar rats
using a validated burn protocol.
 Randomly to one of two groups: 35 to the control group (silver sulphadiazine and
placebo gas) 35 to the experimental group(silver sulphadiazine and HBO2).
 The main outcome = wound healing, characterized by formation of post-burn edema,
neoangiogenesis, number of regeneratory active follicles, necrosis staging, margination of
leukocytes, and time of epithelization.
 Reduction of the post-burn edema after treatment with HBO2 (p = 0.009)
 HBO2 had a beneficial effect on neoangiogenesis (p = 0.009).
 The number of preserved regeneratory active follicles was significantly higher (p = 0.009)
and epithelial regeneration was more rapid in the experimental group (p = 0.048).
 There were no significant differences for margination of leukocytes (p = 0.55) or necrosis
staging (p = 1.00).
 These data further support earlier conclusions that HBO2 is beneficial in the healing of
burn wounds
The use of oxygen as drug and its relevance for wound healing.
Andel H, Kamolz L, Andel D, Brenner L, Frey M, Zimpfer M.
Handchir Mikrochir Plast Chir. 2007 Oct;39(5):328-32

 2220 hyperbaric treatments

 322 in critically ill patients with severe burns.
 Our experience with the use of oxygen under hyperbaric conditions so far has been good
enough to consider this kind of therapy at least in our centre as an option in the
adjunctive treatment for the so far used indications.

 However, it has to be mentioned that there is still lack of prospective randomised

controlled studies to introduce this kind of therapy as a level 1 indication in clinical
routine
 Hyperbaric Oxygen Therapy: solution for difficult to heal acute wounds? Systematic Review
Eskes A. et al World J Surg, 35:535-542, 2011.
Hyperbaric Oxygen Therapy: solution for difficult to heal acute wounds? Systematic
Review
Eskes A. et al World J Surg, 35:535-542, 2011
Hyperbaric Oxygen Therapy: solution for difficult to heal acute wounds? Systematic
Review
Eskes A. et al World J Surg, 35:535-542, 2011

Conclusions

 no significant differences in mortality rates between HBOT and

routine burn management (RR 0.98, 95% CI 0.37–2.64).
 no significant differences in length of hospital stay or number of
surgeries were found.
 significantly lower mean healing time in the HBOT-treated group
(mean 19.7 days) than in the sham-HBOT group (mean 43.8 days)
(P\0.005). No SD
 Alguns Casos
 GS, 29 anos, vítima de queimaduras I, II e III graus por
água quente.
 Alguns Casos
 GS, 29 anos, vítima de queimaduras I, II e III graus por
água quente.
 Alguns Casos
 GS, 29 anos, vítima de queimaduras I, II e III graus por
água quente. (23 sessões)
 Alguns Casos
 GS, 29 anos, vítima de queimaduras I, II e III graus por
água quente. (24 sessões)
 Alguns Casos
 MGS, 11anos, vítima de queimaduras I, II e III graus em
face por água quente.
 Alguns Casos
 WS, 41 anos, vítima de queimaduras I, II e III graus em
tronco e membros por àgua quente.
11a sessão
 Alguns Casos
 WS, 41 anos, vítima de queimaduras I, II e III graus em
tronco e membros por àgua quente. 30 sessões
 Alguns Casos
 GS, 26 anos, vítima de queimaduras I e II graus em dorso
por bolsa de água quente.
 Alguns Casos
 HAF, 27 anos, vítima de queimaduras I, II e III graus em
MS por água quente.
Inicio 10 sessões
INDICATIONS:

1. Air or Gas Embolism

2. Carbon Monoxide Poisoning
Carbon Monoxide Poisoning Complicated By Cyanide Poisoning
3. Clostridial Myositis and Myonecrosis (Gas Gangrene)
4. Crush Injury, Compartment Syndrome and Other Acute Traumatic Ischemias
5. Decompression Sickness
6. Arterial Insufficiencies:
Central Retinal Artery Occlusion
Enhancement of Healing In Selected Problem Wounds
7. Severe Anemia
8. Intracranial Abscess
9. Necrotizing Soft Tissue Infections
10. Osteomyelitis (Refractory)
11. Delayed Radiation Injury (Soft Tissue and Bony Necrosis)
12. Compromised Grafts and Flaps
13. Acute Thermal Burn Injury

Fonte : http://membership.uhms.org/?page=Indications
Resolução CFM Nº 1.457/95
...
RESOLVE:
- As aplicações clínicas atualmente reconhecidas da oxigenoterapia hiperbárica são as seguintes:
4.1 - Embolias gasosas;
4.2 - Doença descompressiva;
4.3 - Embolias traumáticas pelo ar;
4.4 - Envenenamento por monóxido de carbono ou inalação de fumaça;
4.5 - Envenenamento por cianeto ou derivados cianídricos;
4.6 - Gangrena gasosa;
4.7 - Síndrome de Fournier;
4.8 - Outras infecções necrotizantes de tecidos moles: celulites, fasciites e miosites;(incluindo infecção
do sitio cirúrgico)
4.9 - Isquemias agudas traumáticas: lesão por esmagamento, síndrome compartimental, reimplantação
de extremidades amputadas e outras;
4.10 - Vasculites agudas de etiologia alérgica, medicamentosa ou por toxinas biológicas (aracnídeos,
ofídios e insetos);
4.11 - Queimaduras térmicas e elétricas;
4.12 - Lesões refratárias: úlceras de pele, lesões pé-diabético, escaras de decúbito, úlcera por vasculites
auto-imunes, deiscências de suturas;
4.13 - Lesões por radiação: radiodermite, osteorradionecrose e lesões actínicas de mucosas;
4.14 - Retalhos ou enxertos comprometidos ou de risco;
4.15 - Osteomielites;
4.16 - Anemia aguda, nos casos de impossibilidade de transfusão sangüínea.
 Conclusões
OHB X queimados

 Carência de estudos científicos com poder de evidência

 Impossibilidade de refutar ou recomendar, na lógica da

Prática Clínica Baseada em Evidências

 Necessidade de pesquisas de alta qualidade (n,

randomização, cegamento, etc…)

 Observação prática claramente favorável

 Conclusões

"Como todo conhecimento médico, este também é

um bem que não pertence à quem o exerce mas sim a
quem dele necessita.“

Fonte : http://www.ohb-rio.med.br/charlatanismo.html