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Pengobatan Hiperbarik Oksigen dibidang klinik Suyanto Sidik RSAL Dr.Mintohardjo JKT

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Presentasi berjudul: "Pengobatan Hiperbarik Oksigen dibidang klinik Suyanto Sidik RSAL Dr.Mintohardjo JKT"— Transcript presentasi:

1 Pengobatan Hiperbarik Oksigen dibidang klinik Suyanto Sidik RSAL Dr.Mintohardjo JKT

2 Jabatan : Ka Kelompok Ahli RSAL Dr.Mintohardjo Pendidikan: Dokter FK Gadjah Mada Yk 1979 Hyperbaric and under sea Australia 1983 Ahli Peny dalam FK UNAIR Sby 1992 Endoscopy-Gastro intestinal FKUI 1996 Doktor FKUI Jkt 2006 Konsultan Gastro-Hepatologi 2007 Spesiali Kedokteran Kelautan 2009 Dr.dr.Suyanto Sidik SpPD KGEH SpKL RSAL Dr.Mintohardjo Jakarta

3 HISTORY OF HYPERBARIC MEDICINE 1900 Behnke US navy—DCS 1900 Behnke US navy—DCS 1956 Dr I Boerma cardio pulm surg Dr I Boerma cardio pulm surg Conggres I HBO Proef Boerema 1963 Conggres I HBO Proef Boerema 2002 Conggres XIV Cramer & Shefield Sanfransisco, USA 2002 Conggres XIV Cramer & Shefield Sanfransisco, USA 2005 Conggres XV Barcelona Jordi de sola 2005 Conggres XV Barcelona Jordi de sola 2008 Conggres XVI Becker & Cramer Beijing 2008 Conggres XVI Becker & Cramer Beijing

4 1 ST INTERNATIONAL CONGRESS ON HYPERBARIC OXYGENATION, 1963 Australia 9 th 1987 Amsterdam 10 th 1990 CHINA 11, 16 th 1993, 2008 Italy 12 th 1996 Japan 13 th 1999 America 8,14 th 1984, 2002 Spanyol 15 th 2005 Beijing 16 th 2008

5 Contraindications Absolute AbsolutePneumothoraxRelative: Upper Resp Inf Seizure disorders Malignant disease Pregnancy

6 a. Paul Bert Effect in CNS.  Nausea  Nausea  Twitching  Twitching  Convultion  Convultion b. Lorrain Smith Effect in pulmonal Cough Dyspnea Substernal pain 6 I Intermiten O 2 Prev O 2 toxcicity

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8 INDICATION HBOT UHMS 1. Air or gas embolism 6 2. CO poisoning 5 3. Gas gangrene 8 4. Crush injury 3 5. DCS 7 6. Enhancement of healing 1 7. Anemia Intracranial absces Necrotizing soft tissue infections Osteomyelitis Delayed radiation injury Skin grafts & flaps Thermal burns 11

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11 in the world in Europe HBO chambers in Japan, 2004 Hosps: 617 mono: 758 multi: 57 Textbook of HBO by Jain, 2004 Distribution of HBO chambers in the world

12 172 HBO doctors since 2000 Specialties of HBO doctor in Japan

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17 There are eight principal methods in which HBO is capable of affecting tissue: Pressure effects of oxygen Vasoconstrictive effects of oxygen. 100% oxygen concentration effects on the diffusion gradient. Hyperoxygenation of ischemic tissue. Down regulation of inflammatory cytokines. Up-regulation of growth factors. Leukocyte effects. Antibacterial effects.

18 HBOT should be used to compliment conventional therapies and treatments. HBOT is very cost effective. HBOT is very cost effective. HBOT is noninvasive. HBOT is noninvasive. HBOT is safe. HBOT is safe. HBOT works well with other treatments. HBOT works well with other treatments.

19 HBOT has five actions which have been used to combat clinical infection: 1.Tissue rendered hypoxic by infection is supported by oxygen. 2.Neutrophils are activated and rendered more efficient. 3.Machrophage activity is enhanced. 4.Bacterial growth is inhibited. 5.The effect of antibiotics is potentiated.

20 Prinsip Wound Care O2 Nutrisi Edema Glucose Lipid Infeksi Trauma Chronic Hematology Disease Social economy Autoimmune Medicine Psychosocial Like a Like Diagnose Everyday Care RA

21 HBO THERAPY OXYGEN 100%, Pressure 2 – 3 ATA  Hyperbaric Chamber OXYGEN 100%, Pressure 2 – 3 ATA  Hyperbaric Chamber Decompresion sickness tx Decompresion sickness tx Tissue damage: wound healing, hipoksia Tissue damage: wound healing, hipoksia  Fibroblast, synthesis collagen, ratio RNA/DNA,  leucocyte killing, angiogenesis  neovascularisation of the wound  Fibroblast, synthesis collagen, ratio RNA/DNA,  leucocyte killing, angiogenesis  neovascularisation of the wound  & mikrovasc blood flow, dens cap  iskhaemi – reperfussion  & mikrovasc blood flow, dens cap  iskhaemi – reperfussion  NO 4- 5 X  HBOT 2-3 ATA - 2 hours  NO 4- 5 X  HBOT 2-3 ATA - 2 hours Healing of tissue damage Healing of tissue damage

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23 SMITH S. HYPERBARIC TEXT BOOK OF SURGERY PREOPERATIVE CARE, 2002

24 eNOS nNOS iNOS FAD + FMD L-ARGININE+n NADPH + O 2 L-CITRULINE + NO + NADP + BH4 O 2 NO VASOKONSTRIKSI CO 2 NO VASODILATASI 24 SMITH S. HYPERBARIC TEXT BOOK OF SURGERY PREOPERATIVE CARE, 2002

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27 CD4+TCR Th1CD4+TCRTh2CD4+TCR SP B STRESSOR OHB CD8+TCR MHCI APC IFN Ƴ IgG IL APC MHCII OHB & IMMUNOHUMORAL

28 CD4+TCR Th1CD4+TCRTh2CD4+TCR B STRESSOR OHB IFN Ƴ IgE IL APC MHCII OHB & IMMUNOSUPRESI IgG

29 HBOT FOR ANTI- INFLAMATORY 1.Sumen G, Cimsit M, Eroglu L. HBOT reduces carrageenan-induced acute inflammation in rats. Eur J Pharmacoln2001: 431; Haapaniemi T, Nylander G, Sirsyo A et al. Hyperbaric oxygen reduces ischemia- induced skeletal muscle injury. Plast Reconstr Surg 1996: 97: Waisman d, Brod V, Wolf R et al.Effects hyperoxia on local and remote circulatory inflammatory response alter splanchnic ischemia and reperfusion. Am J Physiol Heart Circ Physiol 2003:285: H

30 HBO for Treatment RA Mc Carty 1981, Warren et al 1979, Shakbazylan et al 1988 HBOT 1.5 – 3 ATA: 1,5 – 3 times development clinical early state Mc Carty 1981, Warren et al 1979, Shakbazylan et al 1988 HBOT 1.5 – 3 ATA: 1,5 – 3 times development clinical early state Kamada 1985 SOD ↑, Lipid peroxide activity decrease, ESR loxubury index ↓ Kamada 1985 SOD ↑, Lipid peroxide activity decrease, ESR loxubury index ↓ Salkovsky et al 1986 HBOT of 20 RA Salkovsky et al 1986 HBOT of 20 RA Lukich et al 1991 HBOT 21 Pres1.7 ATA 40 minut supres T lymphocyt. Lukich et al 1991 HBOT 21 Pres1.7 ATA 40 minut supres T lymphocyt.

31 1995 Proceding ICHM-11 th HBOT in treating RA in Europe and Asia Rui-Chang Cured 24.4% Cured 24.4% Obvious effect 51.4% Obvious effect 51.4% Improvement 16.2% Improvement 16.2% No effect 8.1% No effect 8.1% Effective HBOT RA 91,9% Effective HBOT RA 91,9% 1.The repercusision of the joint is fast, the effect of analgesia is good. 2.The curative and obcious rate is high.

32 Use coal stov es CO poisoning ↑ COHb ↑ HBO tratmen 2-2,5 ATAfor mnt Risk neuropsyc hological deficit ↓ Mild poisoning  1 sesion Moderate poisoning  2 sesion

33 ESA : 50 – 70 % ESL : 2,5 – 25 % LASHNER GILINSKY TERGANTUNG : DOSIS FRAKSINASI LUAS TEKNIK RADIASI GEJALA ESL : ~ ESA + LEBIH BERAT DIARE LENDIR + DARAH GEJALA ESA : SAKIT PERUT TENESMUS HEMATOCHEZIA 33

34 Treatment of Radiation Proctitis and Enteritis 34 Author Type of Report NCl Grade Clinical Eviden Comments Bouachour (1990) 59 Charneau (1991) 60 Nakada (1993) 61 Feldmeier (1995) 63 Feldmeier (1996) 63 Woo (1997) 64 Case Series-8 patients Single case report Animal study Case series-8 patients: 7 proctitis/colitis; 1 enteritis Case series-18 patients 3ii Not clinical 3ii Likely to be Benefical Positive Case Unknown Effectiveness Single Positive Case Not clinical but Positive Study Likely to be Beneficial 6 of 8 patients with hemorrhagic proctitis resolved Single patient with succesful treatment of hemorrhagic proctitis Reduced fibrosis and reduced gross appereance of enteritis in murine ileum 4 of 7 proctitis/colitis resolved; 1 enteritis did not resolve 2 patient had complete resolution; 8 partial and no change in 8

35 35 Author Type of Report NCl Grade Clinical Eviden Comments Warren (1997) 65 Bredfelt (1998) 66 Feldmeier (1998) 67 Carl (1998) 68 Gouello (1999) 69 Bem (2000) 70 Meyer (2001) 52 Boyle (2002) 71 Case series-14 patients Case series-19 patients Animal study Case Series-2 patients Case series-36 patients Case series-2 patients Case series – 10patients Case series- 19 patients 3ii Not clinical 3ii Likely to be Benefical Not clinical but positive study Likely to be Benefical 7 patients complete resolution; 2 improved 5 patient non-responder Complete resolution in 47%; 37% improved 16% non-responder Quantitative morphometry showed decreased Collagen in Bowel Wall One patient completely rsolved;the other stopped at 38 treatments without improvement 2/3’s patients followed long term were improved or cured; 1/3 failed to improved Both patients with anorectal ulcers resolved 5 of 5 with rectal bleeding resolved; Statistically significant decrease in late morbidity score 13 of 19 patients had major resolution of symptoms at completion of hyperbaric

36 KERANGKA TEORI 36 OHBT PENYEMBUHAN LUKA PERBAIKAN STRUKTUR JARINGAN AGREGASI TROMBOSIT EPITEL SEL ENDOTEL LISIS KOLAGEN SINTESIS KOLAGEN MAKROFAG GRANULOSIT VASODILATASIVASODILATASI 9 5 V A S O K O NT R I K S I 1 Keterangan : - NOS = Nitric oxide syntethase - Lingkaran – lingkaran kuning menunjukan tempat-tempat kerja OHB 1.Vasokonstriksi. 2. Peningkatan kemampuan sel endotel 3. Peningkatan VEGF 4. Peningkatan reseptor epitel vaskular 5. Pengurangan inflamasi 6. Kolagen sintesis. 7. Kolagen lisis 8. Perbaikan struktur jaringan. 9. Penyembuhan luka

37 METODE DAN ALUR PENELITIAN 03 y P RS Kontrol Eksperimen 01 X Keterangan Keterangan P= Seleksi Pasien Penelitian P= Seleksi Pasien Penelitian R= Randominasi R= Randominasi S= Sampel Penelitian S= Sampel Penelitian 01= Pretes pok pasien tanpa perlakuan sbg kontrol 01= Pretes pok pasien tanpa perlakuan sbg kontrol 02= Postes pok pasien tanpa perlakuan sbg kontrol 02= Postes pok pasien tanpa perlakuan sbg kontrol 03= Pretes pok pasien dgn perlakuan 03= Pretes pok pasien dgn perlakuan 04= Postes pok pasien dgn perlakuan 04= Postes pok pasien dgn perlakuan 37

38 Tabel 7. Variabel penelitian pada pemeriksaan pertama Data deskriptif variabel penelitian yg akan di analisis dpt dilihat pada tabel VARIABEL KELOMPOK OHBT RERATA + SD KONTROL RERATA + SD K-1 73,8 ± 6,0 74,6 ± 8,3 Lent-1 7,7 ± 2,0 6,8 ± 2,3 MVD-1 7,8 ± 3,9 9,3 ± 3,4 Keterangan : K; karnofsky Lent: LENT-SOMA MVD: MICRO VASCULER DENSITY Keterangan : K; karnofsky Lent: LENT-SOMA MVD: MICRO VASCULER DENSITY

39 Ratio beda pemeriksaan sebelum perlakuan s/d bulan ke-6 setelah perlakuan yang dinyatakan dalam persen. Tabel VARIABEL KELOMPOK OHBTKONTROL Δ K 2-1 (%) 19,67 ± 9,644, ,74 Δ K 3-1 (%)15, ,742, ,11 Δ Lent 1-2 (%)44, ,220, ,16 Δ Lent 1-3 (%)33, ,64 -19, ,44 Prevalensi proktitis 6 ( 13% ) 11 ( 23,9% ) Keterangan : ΔK 21 = Perbedaan kualitas hidup seblm perlakuan & segera setelah perlakuan ΔK 31= Perbedaan kualitas hidup seblm perlakuan & bulan ke-6 setelah perlakuan ΔLent 12= Perbedaan efek samping seblm perlakuan & segera setelah perlakuan ΔLent 13= Perbedaan efek samping seblm perlakuan & segera bulan ke-6 setelah perlakuan) Keterangan : ΔK 21 = Perbedaan kualitas hidup seblm perlakuan & segera setelah perlakuan ΔK 31= Perbedaan kualitas hidup seblm perlakuan & bulan ke-6 setelah perlakuan ΔLent 12= Perbedaan efek samping seblm perlakuan & segera setelah perlakuan ΔLent 13= Perbedaan efek samping seblm perlakuan & segera bulan ke-6 setelah perlakuan)P < 0,001 0,007 0,008 0,026

40 HUBUNGAN OHBT DGN PREVALENSI PROKTITIS RADIASI 40 Tabel 9. Hasil analisis statistik chi-square untuk kejadian proktitis radiasi pada kelompok OHBT dan kontrol pada bulan ke-6 perlakuan Tabel 9. Hasil analisis statistik chi-square untuk kejadian proktitis radiasi pada kelompok OHBT dan kontrol pada bulan ke-6 perlakuanKelompok Angka Kejadian Proktitis (%) TotalPYaTidak OHBT (%) 6 (13%) 20 (43,5%) 26 (56.5%) Kontrol (%) 11 (23,9%) 9 (19,6%) 20 (43,5%) Total (%) 17 (37%) 29 (63%) 46 (100%) Keterangan : OHBT = Oksigen Hiperbarik Terapi Keterangan : OHBT = Oksigen Hiperbarik Terapi

41 Ratio beda pemeriksaan sebelum perlakuan dan setelah perlakuan yang dinyatakan dalam prosen. 41 VARIABEL KELOMPOK Sebelum OHBSesudah OHB CD 31( 30pasien )7,83±3,9110,03±5,29 Keterangan : CD31 =Cluster define 31 OHB = Oksigen hiperbarik Keterangan : CD31 =Cluster define 31 OHB = Oksigen hiperbarikP < 0,001

42 Hubungan korelasi efek samping dengan MVD pada OHB 42 Keterangan : ESA Lent21 =Efek samping akut menurut LENT SOMA segera setelah perlakuan dibanding sebelum perlakuan MVD21 =Densitas vaskuler segera setelah perlakuan dibanding sebelum perlakuan Keterangan : ESA Lent21 =Efek samping akut menurut LENT SOMA segera setelah perlakuan dibanding sebelum perlakuan MVD21 =Densitas vaskuler segera setelah perlakuan dibanding sebelum perlakuanMean Standar Deviasi N Korelasi Pearson PESALent213,51,8320,550**0,002 MVD213,57,329 Tabel Korelasi ESA radiasi dengan MVD 12 pada OHB

43 Author Type of Report AHA Gra de NCI Clinical Eviden ce Comments Marx (1985) RCT-74 patient 1B1ii Benefi cial 5.4% ORN in HBO Group 29.9% in non-HBO Group Vudiniab ola (1999) Case Series- 37 patients 43ii Likely to be benefic ial 1 of 29 HBO and 7 of 8 non- HBO developed ORN David (2001) Case Series- 24 patients 53ii Likely to be benefic ial 1 of 24 developed ORN Published Report of Hyperbaric Oxygen for Prevention of Mandibular Necrosis 43

44 Author Type of Report AHA Grad e NCI Grad e Clinical Evidenc e Comments Mounse y (1993) Case Series- 41 patients 53ii Likely to be Benefici al 34 of 41 had significant improvement Van Merkest ey (1995) Case Series- 29 patients 53ii Likely to be Benefici al 20 of 29 patients resolved Maier (2000) Case Series- 41 patients 32 Not Benefici al A negative trial of hyperbaric compared o historic controls;13 of 20 HBO resolved Curi (2000) Case Series- 18 patients 53ii Likely to be Benefici al 14 of 18 resolved David (2001) Case Series- 51 patients 53ii Likely to be Benefici al 48 of 51 showed improvement Published Report of Hyperbaric Oxygen as Treatment for Mandibular Necrosis 44

45 AuthorType of ReportAHA Grade NCI Grade Clinical Evidence Comments Neovius (1997) Case Series-15 patients compared to historical control group 43iiLikely to be Beneficial Healing in 12 of 15 patients; 2 improved; 1 non-healing; compared to 7 of 5 healed in the control group with 1 fatal bleed Marx (1999) Prospective controlled but not randomized study of 160 patients 32Likely to be Beneficial Stat signfcnt reduct in wound infection, dehiscience & delayed healing in HBO group Filintisis (2000) Case Series-18 patients with laryngeal necrosis 53iiLikely to be Beneficial 13 of 18 had major improvement Nazrozny (2001) Case Series-2 patients soft tissue necrosis including larynx and pharynx 53iiLikely to be Beneficial Resolution in both patients Hyperbaric Oxygen as Treatment for Soft Tissue Radiation Injury of the Head and Neck 45

46 46 Hyperbaric Oxygen as Treatment for Radiation Cystitis Author Type of Report AHA Grade NCIGrade Clinical Evidence Comments Bevers (1995) Prspctive non- rndmized trial of 40 patients 53ii Likely to be Beneficial 37 of 40 resolved Del Pizzo (1998) Case Series- 11 patients 53ii Not Likely to be Beneficial 3 of 11 resolved Weiss (1998) Case Series- 29 patients 53ii Likely to be Beneficial 7 of 10 resolved Mathews (1999) Case Series- 17 patients 53ii Likely to be Beneficial 11 of 17 resolved Mayer (2001) Case Series- 8 patients 53ii Likely to be Beneficial 6 of 8 resolved Hendicks (2000) Case Series- 20 patients 53ii Likely to be Beneficial 14 of 20 resolved

47 47 Author Type of Report AHA Grade NCI Grade Clinical Evidence Comments Feldmeier (1995) Case Series- 23 patients softtissue-15 bone+soft tissue necrosis of chest wall 53ii Likely to be Beneficial 6 of 8 soft tissue resolved 8 of resolved 15 tissue+bone resolved Carl (1998) Case Report Single Positive case 53ii No category for single case report Resolution of breast edema and pain Carl (2001) Case Series- 44 patients 32 received HBO; 12 control 42 Likely to be Beneficial Statistically significant improvement in pain, erythema and edema of breast in HBO group compared to control Hyperbaric Oxygen as Treatment for Radiation Injury of the Chest Wall and Breast

48 48Author Type of Report AHAGradeNCIGrade Clinical Evidence Comments Farmer (1978) Single Case Report 53iiUnknown 1 of 1 failed to respond Effectiven ess Single Negative Case Feldme ier (2000) Case Series-17 patients 53ii Likely to be Beneficial 11 of 17 resolved; 11 of 13 if those lost to follow up or with active cancer are excluded Hyperbaric Oxygen as Treatment for Radiation Injuries of the Extremities

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