Hyperbaric oxygen therapy and free radical production: an experimental study in doxorubicin (Adriamycin) extravasation injuries

Development of Anticancer Ferric Complex Based on Human Serum Albumin Nanoparticles That Generate Oxygen in Cells to Overcome Hypoxia-Induced Resistance in Metal Chemotherapy

To achieve the remarkable therapeutic efficacy of a ferric (Fe) complex via a reactive oxygen species (ROS) mechanism in solid tumors, a therapeutic Fe-based Schiff-base complex (Fe1) was synthesized and encapsulated in human serum albumin (HSA) nanoparticles (NPs), which generated oxygen (O2) in cancer cells in situ. The HSA-Fe1-O2 NP (HSA-Fe1-O2NP) delivery system effectively overcame hypoxia-induced resistance in metal chemotherapy, alleviated the hypoxic condition of tumor tissues, and showed excellent tumor suppression by generating excess ROS and promoting the apoptosis of SK-N-MC tumor cells. The HSA-Fe1-O2NPs not only enhanced the ability of the Fe1 complex to target tumor cells but also decreased adverse effects in vivo.

Effects of Hyperbaric Oxygen Preconditioning on Doxorubicin Cardiorespiratory Toxicity

Cardiorespiratory dysfunction resulting from doxorubicin (DOX) chemotherapy treatment is a debilitating condition affecting cancer patient outcomes and quality of life. DOX treatment promotes cardiac and respiratory muscle pathology due to enhanced reactive oxygen species (ROS) production, mitochondrial dysfunction and impaired muscle contractility. In contrast, hyperbaric oxygen (HBO) therapy is considered a controlled oxidative stress that can evoke a substantial and sustained increase in muscle antioxidant expression. This HBO-induced increase in antioxidant capacity has the potential to improve cardiac and respiratory (i.e., diaphragm) muscle redox balance, preserving mitochondrial function and preventing muscle dysfunction. Therefore, we determined whether HBO therapy prior to DOX treatment is sufficient to enhance muscle antioxidant expression and preserve muscle redox balance and cardiorespiratory muscle function. To test this, adult female Sprague Dawley rats received HBO therapy (2 or 3 atmospheres absolute (ATA), 100% O₂, 1 h/day) for 5 consecutive days prior to acute DOX treatment (20 mg/kg i.p.). Our data demonstrate that 3 ATA HBO elicits a greater antioxidant response compared to 2 ATA HBO. However, these effects did not correspond with beneficial adaptations to cardiac systolic and diastolic function or diaphragm muscle force production in DOX treated rats. These findings suggest that modulating muscle antioxidant expression with HBO therapy is not sufficient to prevent DOX-induced cardiorespiratory dysfunction.

Effect of hyperbaric oxygenation on random rat skin flaps vascularization

Purpose:

To evaluate the effect of hyperbaric oxygenation (HBO) on angiogenesis in random rat skin flaps, by immunoexpression of vascular endothelial growth factor A (VEGF-A).

Methods:

Forty adult rats were divided into four groups: GE) epilated; GE/HBO) epilated subjected to HBO; GER) epilated submitted to dorsal skin flap; GER/HBO) epilated subjected to dorsal skin flap + HBO. HBO was performed with rats inside a chamber under atmosphere close to 100% oxygen and pressure of 2.4 absolute atmospheres, 2h per day during seven consecutive days. GE and GER groups were placed in the hyperbaric chamber without HBO. Then, under anesthesia, skin flaps were removed and separated into three portions relative to pedicle fixation. The samples were fixed in formalin and processed for paraffin embedding. Histological sections were submitted to immunohistochemistry for VEGF-A detection. The number of immunostained-blood vessels were counted under light microscopy.

Results:

GE and GE/HBO groups showed normal and similar skin morphology in the three flap portions. A fibrin-leukocyte crust, along with denatured collagen and intense leukocyte infiltrate, was mainly observed in the dermis of the medial and distal flap portions of GER group. Meanwhile, the GER/HBO group presented more regions with intact collagen and small areas of leukocyte infiltrate in the three flap regions. VEGF-A-immunostained blood vessels were largely seen in all regions of GE and GE/HBO groups, whereas no significant differences were found between these groups. A decrease in vascularization was noticed in GER and GER/HBO groups, which was more evident in the most distal portion of the flaps. However, the number of VEGF-A-immunostained blood vessels in GER/HBO group was significantly higher when compared to GER group.

Conclusions:

Hyperbaric oxygenation was associated with increased angiogenesis and improved viability of rat skin flaps.

Association between Vitamin D Supplements, Oxidative Stress Biomarkers, and Hyperbaric Therapy in Patients with Sudden Sensorineural Hearing Loss

The effect of vitamin D supplementation to patients with sudden sensorineural hearing loss (SSNHL), treated with hyperbaric oxygen (HBO) therapy, on the markers of the oxidant-antioxidant equilibrium was investigated. Patients were divided into two groups: those who did and did not receive vitamin D (cholecalciferol at 4000 IU/24 h). Concentrations of the following compounds, thiobarbituric acid reactive substances (TBARS), malondialdehyde (MDA), conjugated dienes (CD) in plasma and erythrocytes and activities of catalase (CAT), superoxide dismutase (SOD) and glutathione peroxidase (GPx) in erythrocytes, were determined. Haemoglobin (HGB) and haematocrit (HCT) were measured. Blood for analyses was collected from the basilic vein at three time points: before the first HBO procedure, up to 5 min after the first procedure, and after 14 procedures. No statistically significant differences in parameters tested were found between patients who did and did not receive vitamin D. In patients without supplementation, an increase of 53.2% (P ≤ 0.05) in erythrocyte TBARS was observed after the first HBO treatment. In patients receiving vitamin D, a reduction of 27.6% (P ≤ 0.05) was observed in erythrocyte MDA after 14 HBO treatments vs. that after the first treatment. In both groups, a decrease of 33.3% in plasma CD was observed after 14 treatments vs. that after the first treatment (P ≤ 0.05 and P ≤ 0.01, respectively). No statistically significant changes were observed in the erythrocyte SOD, GPx, and CAT activities and in HCT. A reduction of HGB concentration of 10.9% (P ≤ 0.05) was demonstrated in nonsupplemented patients after 14 treatments compared with baseline. The results confirm that the effect of HBO therapy on oxidative stress markers is inconclusive and complex. Repeated HBO procedures can induce adaptive changes which protect against disruption of the oxidant-antioxidant equilibrium. It is possible that vitamin D supplementation inhibits the process of lipid peroxidation in erythrocytes.

An Overview of Pharmacological and Non-Pharmacological Treatment as a Useful Tool for the Protection from Cardiotoxicity of Antineoplastic Drugs

Unfortunately, in patients with cancer disease, clinical application of antineoplastic drug results in severe side effects of cardiotoxicity.

We aim to review the research focused on elimination or reduction of antineoplastic drug-induced cardiotoxicity without affecting its anticancer efficacy by different agens.

This study is based on pertinent papers that were retrieved by a selective search using relevant keywords in PubMed and ScienceDirect. Based on mentioned purpose, various strategies were investigated and proposed, and thousands of compounds were screened. The literature mainly focusing on drugs, natural products and herb extracts with therapeutic efficacies as well as non-pharmacological treatment against differently induced cardiotoxicity during treatment in patients with cancers.

Larger future studies are necessary to reach a point of secure cytostatic therapy, improved patient survival and quality of life. Until that moment, baseline and serial cardiac evaluation is recommended to facilitate early identification and treatment of cardiotoxicity.

A review of oxygen therapy in ischemic stroke

Neuroprotective drugs have so far failed clinical trials, at high cost, and intravenous tissue plasminogen activator (i.v. tPA) remains the only FDA-approved acute stroke therapy. Hyperoxia, acting via multiple direct and indirect mechanisms, may be a powerful neuroprotective strategy to salvage acutely ischemic brain tissue and extend the time window for acute stroke treatment. Of the available oxygen delivery methods, hyperbaric oxygen therapy (HBO) appears to be the most potent, while even normobaric oxygen therapy (NBO) may be effective if started promptly after stroke onset. HBO has so far failed to show efficacy in three clinical trials. The failure of these trials is probably attributable to factors such as delayed time to therapy, inadequate sample size and use of excessive chamber pressures. Previous trials did not assess long-term benefit in patients with tissue reperfusion. In this modern era of stroke thrombolysis and advanced neuroimaging, oxygen therapy may have renewed significance. If applied within the first few hours after stroke onset or in patients with imaging evidence of salvageable brain tissue, oxygen therapy could be used to 'buy time' for the administration of thrombolytic or neuroprotective drugs. This article reviews the history and current rationale for using oxygen therapy in stroke, the mechanisms of action of HBO and the results of animal and human studies of hyperoxia in cerebrovascular diseases.

Carnitine or dimethyl sulfoxide, or both, for the treatment of anthracycline extravasation in rats

This study aimed to compare the efficacy of topical dimethyl sulfoxide (DMSO), intralesional and systemic carnitine as monotherapy and in combination against ulceration in rats induced by intradermal doxorubicin extravasation. Sixty-nine 3-month-old male Wistar albino rats, weighing between 200-225 g, were used in this study. Rats were applied monotherapy or a combination of topical DMSO, intraperitoneal or intralesional carnitine. Control groups received saline or no drug. The necrotic area was measured and extravasated neutrophil leukocytes were counted in healthy tissue adjacent to necrotic areas. Monotherapy with topical and systemic carnitine did not significantly reduce the size of necrotic areas. However, topical DMSO had reduced necrotic areas and inflammatory cells significantly and the addition of systemic carnitine to topical DMSO had increased the efficacy. DMSO is an effective, safe, and easy-to-apply treatment for doxorubicin-induced extravasation. Further clinical studies are needed to evaluate the use of carnitine in combination with DMSO.

Similarities and differences of hyperbaric oxygen and medical ozone applications

Hyperbaric oxygen (HBO) treatment is based on the principle of having the patient breath 100% oxygen in an environment above atmospheric pressure. Ozone (O(3)) is a colourless gas with a specific odour and consists of three oxygen atoms. The classical scientific understanding is that the world has become a place suitable for life for aerobic organisms with the increasing oxygen in the atmosphere billions of years ago. The formation of ozone after oxygen has then protected aerobic creatures from harmful rays. We now use these two gases for treatment purposes. It is noteworthy that the oxygen and ozone molecules that are formed by the same atom in different numbers are used for similar medical indications. We will try to emphasize the similarities and differences of HBO and medical ozone applications in this article.

A sarcoma at the site of previous extravasation of adriamycin

We report the case of a 66-year-old man presenting with a high-grade pleomorphic sarcoma at the left elbow 16 years after the extravasation of adriamycin given for a malignant ifbrous histiocytoma of the tibia.We suggest that this sarcoma originated in a multistep way over many years, out of the chronic inflammatory tissue that developed due to a non-specific cellular damage at the nuclear level, interfering with normal cell replication necessary for normal healing tissue healing. As a result, the non-healed chronic inflammatory tissue transformed over several years into a preneoplastic mesenchymal tumour and later into a high-grade pleomorphic sarcoma.

Infiltration and extravasation: update on prevention and management

Infiltration and extravasation are risks of intravenous administration therapy involving unintended leakage of solution into the surrounding tissue. Consequences range from local irritation to amputation. While immediate action using appropriate measures (ie, dilution, extraction, antidotes, and supportive treatments) can decrease the need for surgical intervention, many injuries may be prevented by following established policy and procedures. However, timely surgical intervention, when necessary, can prevent more serious adverse outcomes. Clinicians should be prepared to act promptly when an event occurs. Thorough incident documentation helps determine whether infusion care meets the standard of practice and is a keystone to medicolegal defense.

Anthracycline extravasation injuries: management with dexrazoxane

The application of anthracyclines in anticancer therapy may result in accidental extravasation injury and can be a serious complication of their use. Tissue necrosis with skin ulceration is a possible outcome in the inadvertent extravasation of anthracyclines during intravenous administration. Until recently, there has been no effective treatment against the devastating effect of extravasated anthracycline. Preclinical and clinical studies are leading to the clinical implementation of dexrazoxane as the first and only proven antidote in anthracycline extravasation. In two multicenter studies dexrazoxane has proven to be highly effective in preventing skin necrosis and ulceration. This review focuses on the development and management of dexrazoxane in anthracycline extravasation injuries.

Oxygen therapy in stroke: past, present, and future

Oxygen is frequently administered to patients with suspected stroke. However, the role of oxygen therapy in ischemic stroke remains controversial in light of the failure of three clinical trials of hyperbaric oxygen therapy to show efficacy, and the fear of exacerbating oxygen free radical injury. The previous trials had several shortcomings, perhaps because they were designed on basis of anecdotal case reports and little preclinical data. Most animal studies concerning oxygen therapy in stroke have been conducted over the last 6 years. Emerging data suggests that hyperbaric and even normobaric oxygen therapy can be effective if used appropriately, and raises the tantalizing possibility that hyperoxia can be used to extend the narrow therapeutic time window for stroke thrombolysis. This article reviews the history, rationale, mechanisms of action and adverse effects of hyperoxia, the key results of previous hyperoxia studies, and the potential role of oxygen therapy in contemporary stroke treatment.

The effect of hyperbaric oxygen therapy on tumour growth in a mouse model of colorectal cancer liver metastases

BACKGROUND AND AIMS

Hyperbaric oxygen (HBO) therapy involves the administration of 100% oxygen at high pressure. It has been used to treat a variety of conditions including non-healing wounds, carbon monoxide poisoning, and as an adjuvant to radiotherapy or chemotherapy. The effect of HBO alone on the growth of malignancy remains controversial. This study investigates the impact of HBO on tumour growth, kinetics and microcirculation of colorectal cancer liver metastases in an experimental model.

METHODS

Male CBA mice were induced with colorectal liver metastases via an intrasplenic injection of a murine derived colorectal cell line. Tumours were examined using quantitative stereological analysis, histology and scanning electron microscopy of microvascular resin casts. The effect of HBO on tumour proliferation and apoptosis was quantified using immunohistochemistry.

RESULTS

Daily exposure to HBO at 2.4 atm for 90 min had no effect on the volume of liver metastases. At day 13, HBO caused a significant reduction in tumour necrosis and proliferation compared to the non-HBO group (p=0.002 and p=0.008, respectively). By day 25 however, no differences were observed (p>0.05). No differences in apoptosis or microvascular architecture were observed.

CONCLUSION

HBO did not have a tumour stimulatory effect on colorectal liver metastases and may potentially be used safely in conjunction with other therapeutic treatment modalities.

Extravasation of chemotherapeutic agents: prevention and treatment

Most chemotherapeutic agents can cause varying degrees of local tissue injuries when extravasated. The medical treatment of extravasation is based on proper maintenance of the intravenous (IV) line and application of cold or warm compresses, plus the use of antidotes when available. Antidotes for extravasation that have been shown to be useful are sodium thiosulfate for nitrogen mustard, dimethylsulfoxide for anthracyclines and mitomycin, and hyaluronidase for the vinca alkaloids. New treatments include dexrazoxane, sargramostim, and hyperbaric oxygen for doxorubicin extravasations. Tissue damage secondary to drug infiltration occurs as a result of one of two major mechanisms: (1) the drug is absorbed by local cells in the tissue and binds to critical structures (eg, DNA, microtubules), causing cell death; and (2) the drug does not bind to cellular DNA. Damage to immediately adjacent tissue is more readily neutralized than is damage to surrounding tissue.

Protective effects of exogenously administered or endogenously produced melatonin on hyperbaric oxygen-induced oxidative stress in the rat brain

1. Hyperbaric oxygen (HBO) is a widely used treatment modality in many diseases. A known side-effect of HBO is the production of reactive oxygen species (ROS). Many anti-oxidants, such as vitamins C and E, riboflavin and selenium, have been used successfully to scavenge the ROS produced by HBO administration. 2. The aim of the present study was to determine whether melatonin, a newly discovered anti-oxidant, has a protective effect against the overproduction of ROS produced by HBO in rat brain tissue. 3. Seventy male Sprague-Dawley rats were divided into seven groups as follows: 1, daytime control; 2, daytime HBO; 3, melatonin; 4, daytime HBO plus melatonin; 5, night-time control; 6, night-time HBO; and 7, night-time HBO under light exposure. 4. Hyperbaric oxygen was administered at 303 kPa for 120 min. Melatonin was injected at a dose of 10 mg/kg, i.p. Brain malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidase (GPx) levels were measured to elucidate oxidant status. 4. The MDA and SOD levels of groups 2 and 7 increased significantly. Exogenous (group 4) and endogenous (group 6) melatonin protected against HBO-induced lipid peroxidation. Exogenously administered melatonin (groups 3 and 4) had increased levels of the anti-oxidant enzymes SOD and GPx. 5. In conclusion, HBO caused oxidative stress and melatonin exhibited protective effects. Both endogenously produced and exogenously administered melatonin were found to be effective.

The Effect of Hyperbaric Oxygen Treatment on the Renal Functions in Septic Rats: Relation to Oxidative Damage

PURPOSE

To investigate the effects of hyperbaric oxygen (HBO) treatment on renal functions and damage in septic rats.

METHODS

The animals were divided into four groups, each containing ten animals: control, hyperbaric oxygen, sepsis, and sepsis/hyperbaric oxygen. One milliliter of saline containing live Escherichia coli cells (2.1 x 10(9)) was injected intraperitoneally to induce sepsis. The groups treated with HBO were given five sessions of 2 atmospheres absolute of 100% oxygen at intervals of 6 h. Blood, urine, and tissue samples were then collected, and the functional renal parameters, malondialdehyde (MDA) levels, and superoxide dismutase (SOD) and catalase activities were examined.

RESULTS

The reduced glomerular filtration rate and urine flow returned to normal levels after HBO treatment; however, the increase in fractionated sodium excretion continued. The increased MDA levels in the renal cortex and medulla also decreased to the level of the control group. In the sepsis group, both the SOD and catalase activities decreased in the renal cortex, while a reduction was observed only in the catalase activity in the medulla. The reduced enzyme activities significantly increased in the sepsis/hyperbaric oxygen group.

CONCLUSION

HBO treatment has a beneficial effect on renal dysfunction in sepsis. The probable reason for this effect is the reduction in oxidative damage because of the increase in antioxidative capacity.

Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis (NF) is an uncommon but serious infection of fascia and skin associated with considerable morbidity and mortality. One modality proposed for improving the outcome of this condition is hyperbaric oxygen (HBO) therapy. This is a form of medical treatment that involves intermittent inhalation of 100% oxygen under pressures exceeding the atmosphere. The aim of this article is to review current practice and evidence for the use of HBO as adjunctive therapy in the management of NF.

METHODS

A survey of published English literature through searches of Medline and PubMed was carried out using the following key words: "necrotizing fasciitis," "Fournier's gangrene," "necrotizing soft tissue infections," "hyperbaric oxygen therapy," "and hyperbaric oxygen chambers."

RESULTS

The results of studies on the use of HBO therapy in NF are inconsistent. Some studies have demonstrated that HBO can improve patient survival and decrease the number of debridements required to achieve wound control, whereas others have failed to show any beneficial effect.

CONCLUSIONS

Encouraging results have been achieved with the addition of HBO therapy to standard treatment regimes, thus justifying further research in this field. More robust evidence by way of a prospective randomized trial is necessary before widespread and routine use of HBO in the management of NF can be recommended.

Exogenously administered and endogenously produced melatonin reduce hyperbaric oxygen-induced oxidative stress in rat lung

Hyperbaric oxygen (HBO) is a widely used treatment modality in many diseases. A known side effect of HBO is the production of reactive oxygen species. Many antioxidants such as vitamins C and E, riboflavin and selenium have been used successfully to scavenge the reactive oxygen species caused by HBO administration. In this study, we aimed to see if melatonin, a newly discovered antioxidant, has a protective effect against the overproduction of reactive oxygen species produced by HBO in rat lung tissue. Sixty male Sprague-Dawley rats were divided into 5 groups as follows: control, daytime HBO (3 ATA, 120 min), daytime HBO plus melatonin (10 mg/kg), nighttime HBO and nighttime HBO (under light exposure). The MDA, SOD and CAT levels of daytime and nighttime HBO (under light exposure) increased significantly. This significance was not found in the daytime HBO plus melatonin and nighttime HBO groups when compared with the control. In this study, HBO caused oxidant stress, and melatonin decreased the levels of MDA, SOD and CAT. Moreover, endogenous melatonin was found to be a more effective antioxidant than exogenous 10 mg/kg melatonin.

Effects of intermittent exposure to hyperbaric oxygen for the treatment of an acute soft tissue injury

OBJECTIVE

To assess the hypothesis that subjects exposed to intermittent hyperbaric oxygen treatments would recover from signs and symptoms indicative of delayed-onset muscle soreness faster than subjects exposed to normoxic air.

DESIGN

Randomized, double-blinded study with a 4-day treatment protocol.

SETTING

University-based sports medicine clinic.

PARTICIPANTS

Sixteen sedentary female university students.

INTERVENTIONS

All subjects performed 300 maximal voluntary eccentric contractions (30 sets of 10 repetitions per minute) of their nondominant leg (110 to 35 degrees of knee flexion) at a slow speed (30 degrees per second) on a dynamometer to elicit muscle damage and injury. Hyperbaric oxygen treatments consisted of 100% oxygen for 60 minutes at 2.0 atmospheres absolute (ATA), while the control group received 21% oxygen at 1.2 ATA for the same amount of time. Both groups received treatment immediately after the induction of delayed-onset muscle soreness and each day thereafter for a period of 4 days (day 1 postexercise through day 4 postexercise).

MAIN OUTCOME MEASURES

Dependent variables (perceived muscle soreness, isokinetic strength, quadriceps circumference, creatine kinase, and malondialdehyde) were assessed at baseline (preexercise, day 0), 4 hours postexercise (day 1), 24 hours postexercise (day 2), 48 hours postexercise (day 3), and 72 hours postexercise (day 4). Magnetic resonance images (T2 relaxation time/short tip inversion recovery) were assessed at baseline (day 0), 24 hours postexercise (day 3), and 72 hours postexercise (day 5).

RESULTS

Repeated-measures analysis of variance was performed on all of the dependent variables to assess differences between treatment and control groups. Analyses revealed no significant differences between groups for treatment effects for any of the dependent variables (pain, strength, quadriceps circumference, creatine kinase, malondialdehyde, or magnetic resonance images).

CONCLUSIONS

The findings of this study suggest that hyperbaric oxygen therapy is not effective in the treatment of exercise-induced muscle injury as indicated by the markers evaluated.

Hyperbaric oxygen as a chemotherapy adjuvant in the treatment of metastatic lung tumors in a rat model

OBJECTIVES

The objectives of the study were to test the hypothesis that hyperbaric levels of oxygen enhance the sensitivity of a sarcoma cell line to doxorubicin (Adriamycin) both in vitro and in vivo in a rat model of pulmonary metastases and to test the feasibility of arterialization of mixed venous blood by direct injection of aqueous oxygen into the pulmonary artery in a rat model.

METHODS

Rat sarcoma (MCA-2) cells were incubated in the presence of increasing concentrations of doxorubicin (0.1-2.0 micromol/L). A dose-dependent toxicity relationship at 12 hours of treatment was examined with and without pretreatment with hyperbaric oxygen (3.7 atm absolute for 1.5-3.5 hours). In vivo, Sprague-Dawley rats (n = 24) were injected intravenously with 10(6) MCA-2 cells, and the lung tumors were allowed to mature for 14 days. At that time the animals were divided into four groups: control (no treatment), doxorubicin at 2 mg/kg, hyperbaric oxygen (oxygen at 2 atm absolute for 30 minutes), and hyperbaric oxygen plus doxorubicin. Seven days after treatment, the numbers of lung nodules were counted and the lung weights were determined. In additional rats (n = 7), aqueous oxygen (1 mL oxygen/g saline solution) was infused into the pulmonary artery to determine whether arterialization of mixed venous blood was comparable to pulmonary artery oxygenation with a hyperbaric chamber (n = 7).

RESULTS

Hyperbaric oxygen plus doxorubicin produced significantly greater cytolysis of MCA-2 cells (P <.01) than did doxorubicin alone. Hyperbaric oxygen plus doxorubicin also significantly decreased the number of lung metastases and the lung weight relative to doxorubicin alone (P <.01 and P <.01, respectively). The feasibility of arterialization of mixed venous blood (>100 mm Hg) with aqueous oxygen infusion was demonstrated.

CONCLUSIONS

Hyperbaric oxygen enhanced the chemotherapeutic effect of doxorubicin both in cell culture and in the rat model. Aqueous oxygen infusion can be used to oxygenate mixed venous blood at levels similar to those obtained with the use of a hyperbaric chamber.

Totally implantable venous-access ports: local problems and extravasation injury

Totally implantable venous-access ports (TIVAPs) are valuable instruments for long-term intravenous treatment of patients with cancer, but implantation and use of these devices are each associated with complications. In addition to the perioperative problems, long-term complications can arise; these can be classified in five categories-catheter malfunction, catheter-related venous thrombosis, catheter-related infection, port-related complications, and extravasation injury. Such complications reduce the benefits of reliable access to the venous system in patients with malignant tumours. The vast majority of such disadvantages are attributable to inexpert handling of ports and, therefore, should be avoidable. TIVAP placement procedures and TIVAP complications are discussed in this review, with special emphasis on local problems and extravasation injuries. To obtain maximum benefit from TIVAPs, all health-care personnel must be familiar with the use and routine maintenance procedures of the devices and treatment options for catheter-related complications.

Treatment options in extravasation injury: an experimental study in rats

Local skin necrosis after extravasation of doxorubicin hydrochloride (Adriamycin), a widely used chemotherapeutic agent, is a common problem in cancer patients. Even though several treatment options have been proposed for extravasation injury, there is still controversy regarding the management of such lesions. The aim of this study was to compare the efficacy of saline infiltration, vitamin C infiltration, suction technique, and early surgical excision as a treatment in a rat extravasation model. The authors planned their study in two stages. In stage 1, the lowest effective dose of doxorubicin at which a homogeneous skin necrosis was formed and the method of administration were investigated. Intradermal and subpannicular injections were made for six rats, using six different concentrations of doxorubicin (0.33, 0.5, 0.66, 1.0, 1.33, and 1.5 mg/ml). In stage 1, the intradermal injection produced homogeneous and uniform tissue necrosis. In stage 2, the efficacy of saline infiltration (group 1), vitamin C infiltration (group 2), suction (group 3), suction and saline washout (group 4), suction and vitamin C washout (group 5), and early surgical excision (group 6) was compared. The treatment options were applied 2 hours after doxorubicin injection. At the end of the seventh day, the presence and size of ulcers at the injection site were calculated. Fourteen days after injection, a histopathologic examination was performed for each treatment and control group. In groups 1 and 3, there was no statistically significant difference in the size of necrosis compared with the control groups. In groups 2, 4, and 5, the size of necrosis was smaller compared with the control groups, and this was statistically significant. Furthermore, in group 4 (suction and saline washout) and group 5 (suction and vitamin C washout), the calculated area of necrosis was smaller compared with other treatment groups, and this was statistically significant. The findings supported the assertion that suction and saline or vitamin C washout reduce necrotic tissue size in extravasation injury.

Use of subatmospheric pressure to prevent doxorubicin extravasation ulcers in a swine model

Application of subatmospheric pressure to sites injected with doxorubicin prevented ulcer formation in treated sites (0 ulcers/16 sites) compared to control wounds (10 ulcers/16 sites) in a pig model.

BACKGROUND AND OBJECTIVES

Extravasation of doxorubicin hydrochloride (Adriamycin) frequently causes chronic ulcers, which usually progress and expose underlying structures such as tendons and bone. The exact mechanism of action that causes cell death and the chronic ulcers is unknown.

METHODS

Eight sites were injected intradermally with doxorubicin on each of 4 pigs. Four sites on each animal served as untreated controls. The remaining four sites were exposed to 125 mm Hg subatmospheric pressure applied 1 h after injection. The sites were observed on a three times per week schedule. Sites that did not develop ulcers were re-injected up to a total of four injections. The animals were observed for 5 weeks.

RESULTS

Ten of sixteen control sites developed ulcers. No subatmospheric pressure treated sites developed ulcers. The incidence of ulcer formation was significantly less for treated wounds compared to control wounds at P < 0.001 by Fisher's exact test.

CONCLUSIONS

This physical modality appears to successfully prevent ulcer formation after doxorubicin injection.