By Lauren Lazarevski, RN, BSN, CWOCN
As summer begins to wind down and we look ahead to Halloween, let’s discuss some “creepy crawlies” we may encounter in wound care that may cause apprehension in even the most seasoned health care staff.
By Lydia A Meyers RN, MSN, CWCN
Radiation necrosis can be defined as cell death as a result of high doses of radiation as used with aggressive tumors. The dead cells caused by the loss of blood flow can be located anywhere in line with the radiation treatments. This damage can cause wounds that will not heal, pain and skin that can be easily damaged. Radiation necrosis can be divided into the following classifications: acute, sub-acute and delayed complications. Acute damage is direct in-line damage as well as that in the surrounding area. The cells receive damage in the DNA structure enough to prevent mitosis. This damage does not last and can be treated by controlling the symptoms. Sub-acute damage is related to the treatment of lung cancer and mimics bronchitis. Another injury that can happen is related to temporary demylinization of the spinal cord and causes Lhermitte’s syndrome. With Lhermitte’s syndrome the patient suffers electric-like shocks in the legs when stretching the spine. Delayed injuries can happen from all types of treatments and from six months to many years after the initial treatment. This could also include acute injuries that were never resolved and became chronic injuries.
Hyperbaric oxygen therapy is 100% oxygen at 2.0 atmospheres to 3.0 atmosphere of pressure. This causes the creation of angiogenesis and increased blood flow to areas that are compromised. This therapy is used in many areas of wound care such as: carbon monoxide poisoning, gas gangrene, chronic refractory osteomyelitis, diabetic ulcers, necrotizing fasciitis, cyanide poisoning, compromised graft or flaps, crush injuries or compartment syndrome, arterial insufficiencies, radiation necrosis and acute thermal burns.
This therapy can take from 1 to 2 hours, 5 days per week and does have some side-effects. These include: middle ear barotrauma, sinus squeeze, claustrophobia, progressive myopia, progression of cataract, and oxygen toxicity. The side effects can be reduced or eliminated by following procedures and proper assessment before entering and after exiting the chamber. Education of the patients will reduce anxieties and increase compliance. Each side effect has research-guided studies and evidence-based procedures. The research has shown that the higher pressures and longer treatments increase the chances for side effects. Most eye effects are eliminated quickly and without lasting effects.
HBOT is useful in radiation necrosis related to increasing vascularization and fibrosis by stimulating angiogenesis and increased oxygenation. By increasing oxygenation, hypoxic tissues are given life again as proven in studies with the use of transcutaneous oxygen studies (TCOM), pre- and post-treatment. A reported story: A young man with a brain tumor, received radiation therapy after surgery. The young man lost some ability to speak, had difficulty walking and caring for himself. The young man was setup for HBOT, MMSE was performed before, halfway through and at the end of treatment. The results showed improvement in the scores especially in the short-term thinking skills. The patient showed measurable improvement in speaking, walking and self-care.
The last of the information is about the treatment of mandibular osteoradionecrosis, which was previously thought of as mandibular osteomyelitis. The main component of treatment is appropriate surgical intervention without which, no improvement has been noted. Dr Robert Marx, D.D.S. has done research to show how helpful HBOT can be with the improvement of blood flow. Dr Marx also developed the staging system for classification of mandibular necrosis as follows: Stage I ORN: is related to having exposed bone without serous manifestations. These patients begin treatment with only minor bone debridement. Stage II ORN: once patient has received 30 treatments with no progression noted, the patient needs more extensive surgical debridement and will require 10 post-operative treatments. Stage III ORN: these patients can have pathologic fracture, orocutaneous fistulae or damage to inferior mandibular border. These patients need reconstructive treatment as well as HBOT. This is 30 treatments, reconstruction and then 10 more treatments. These patients can also receive a myocutaneous flap. At times, especially with the Stage III ORN, the patient may need to receive 40 treatments and then 10 more treatments.
The importance of HBOT for radiation necrosis and osteo-radiation necrosis is well-documented and noteworthy. The use of HBOT is very expensive, but with knowledge about proper wound care and the importance of research- and evidence-based care, the treatment will only increase in effectiveness. The cost of suffering for the patient and the pain of improper care are decreased. The increase in quality of life has only begun. Is that not what medicine is about? First and always "Do no harm." Improve quality of life.
About the Author
Lydia Meyers RN, MSN, CWCN has been a certified wound care nurse for over 15 years with experience working in home healthcare, extended care facilities, hospice care, acute care, LTAC, and wound clinics. Her nursing philosophy to "heal wounds as quickly as possible" is the guiding force behind her educational pursuits, both as a teacher and a student.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.