Israel Naval Medical Institute Hyperbaric Oxygen Therapy in the Pediatric Patient: The Experience of the

The pediatric patient is to be found in hyperbaric facilities throughout the world, receiving hyperbaric oxygen (HBO) therapy for both life-threatening and chronic diseases. Objective. To review the experience accumulated at the Israel Naval Medical Institute in the treatment of pediatric patients. Design. A retrospective analysis and review of all records of patients younger than age 18 years. Results. Between 1980 and 1997, 139 pediatric patients age 2 months to 18 years (mean, 7.7 years) received HBO treatment at the Israel Naval Medical Institute. Of the children, 111 (79%) suffered from acute carbon monoxide (CO) poisoning; 13 (9.2%) were treated after crush injury, traumatic ischemia, or compartment syndrome; 4 (2.8%) had clostridial myonecrosis; 1 (0.7%) had necrotizing fasciitis; 5 (3.6%) had refractory osteomyelitis; 2 (1.4%) had suffered massive air embolism; 2 (1.4%) had purpura fulminans; and 1 (0.7%) suffered from decompression sickness. Outcome, judged by neurologic sequelae, mortality, and extent of soft tissue loss and limb amputation, was favorable in 129 patients (93%). Two patients (1.4%) died, 1 as a result of CO poisoning and the other, gas gangrene; 2 of the patients in the CO group (1.4%) remained with neurologic sequelae, and 6 patients in the acute traumatic ischemia group (4.3%) underwent limb amputation. Conclusions. We had a favorable experience with 129 of a total 139 pediatric patients treated at our facility for the indications listed. A basic knowledge of HBO therapy is needed to refer the pediatric patient for treatment when indicated. The needs of the pediatric patient, especially the critically ill, require specific skills and equipment inside the hyperbaric chamber. Close collaboration between the pediatrician and the hyperbaric medicine physician is essential to ensure adequate care for infants and children. Pediatrics 1998;102(5). URL: http://www.pediatrics.org/cgi/ content/full/102/5/e53; hyperbaric oxygenation, pediatrics, carbon monoxide poisoning, crush injury, gas gangrene, necrotizing fasciitis, refractory osteomyelitis, purpura fulminans, decompression sickness, arterial gas embolism. ABBREVIATIONS. HBO, hyperbaric oxygen; ICU intensive care unit; INMI, Israel Naval Medical Institute; ATA, atmospheres absolute; AGE, arterial gas embolism; DCS, decompression sickness; CNS, central nervous system; CO, carbon monoxide; GG, gas gangrene. There are numerous reports in the pediatric, hyperbaric, and general medical literature of children treated with hyperbaric oxygen (HBO) therapy. However, there are very few reports that include a broader review of specific approaches to the pediatric patient in the hyperbaric chamber.1–4 All branches of pediatric medicine—the general pediatrician, the pediatric intensive care unit (ICU), the neonatal ICU, and the pediatric surgeon and orthopedic surgeon—may be involved in treating a child with one of the conditions that can benefit from HBO therapy. In the present article, we emphasize the importance of consultation and collaboration between the pediatrician and the staff at the hyperbaric chamber. This starts in the emergency room, pediatric ICU, or neonatal ICU, where the pediatrician should be capable of recognizing those indications for which HBO may be of benefit. It continues during the HBO sessions, with proper management of the pediatric patient, especially critically ill children, to meet their particular requirements. The results of our experience at the Israel Naval Medical Institute (INMI) will be presented for each of the major clinical indications for hyperbaric treatment. Indications relevant to pediatric patients, based on current clinical practice and reviews, are listed in Table 1.2–6 HBO—PRINCIPLES AND MECHANISMS OF ACTION HBO therapy uses intermittent breathing of 100% oxygen at pressures .1 atmosphere absolute (ATA). Animal studies, clinical trials, and a growing body of clinical experience have shown HBO to be effective in a number of indications.5,6 The therapeutic effect of HBO is attributable to the mechanical effect of increased environmental pressure on gas-containing spaces in the body and the physiologic changes induced by hyperoxia. The inspiration of high levels of oxygen has a negligible impact on the total hemoglobin oxygen content. However, HBO increases the amount of oxygen dissolved in plasma, from 0.32 to 6 mL O2/100 mL of blood when breathing 100% O2 at 3 ATA. This considerable increase in the amount of oxygen made available to the tissues is of great importance when tissue oxygenation is impaired. According to Boyle’s law, which states that the product of pressure and volume is constant, any increase in environmental pressure will affect gas bubble size. Thus, elevation of the ambient pressure From the Departments of *Neonatology, ‡Otolaryngology, and §Cardiology, Carmel Medical Center and Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; iIsrael Naval Medical Institute, Haifa, Israel; and ¶Hyperbaric Medical Center–Elisha-Rambam Hospitals, Haifa, Israel. Received for publication Jan 28, 1998; accepted Jun 23, 1998. Reprint requests to (D.W.) Department of Neonatology, Carmel Medical Center, 7 Michal St, 34 362 Haifa, Israel. PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad-