| Abstract | UVOD: Cilj ove studije bio je da odredi učinak terapije hiperbaričnim kisikom (HBOT) kod zbrinjavanja složenih ratnih ozljeda gornjih i donjih ekstremiteta kod pacijenata koji su početno liječeni po NATO i non-NATO doktrini hitne ratne kirurgije. ISPITANICI I METODE: U studiju je uključeno 388 pacijenata muškog spola koji su zadobili ratne ozljeda ekstremiteta, tip III A, B i C po Gustilu, a liječeni su na Klinici za kirurgiju, Univerzitetskog kliničkog centra Split, od 1991. do 1995. godine. Praćena je pojavnost glavnih komplikacija liječenja (duboke infekcije mekog tkiva, osteomijelitisa, liza transplantata kože i nekroza režnja), kao i protok vremena od ranjavanja do stvaranja granulacijskog tkiva. Utjecaj NATO doktrine hitne ratne kirurgije kao i HBOT na komplikacije u liječenju ratnih ozljeda izračunate su u svakoj skupini rana pomoću χ2 testa i Mann-Whitney-eva testa. Omjera izgleda (OR) s 95% intervalom pouzdanosti (CI) izračunat je za svaku komplikaciju rane, uvažavajući utjecaj NATO doktrine hitne ratne kirurgije i HBOT na te iste komplikacije. REZULTATI: Od ukupnog broja od 388 pacijenata, 310 (80%) je početno tretirano po NATO doktrini hitne ratne kirurgije, a 99 (25%) ih je primilo HBOT. Duboka infekcija mekog tkiva povajila se u 196 (68%) pacijenata koji nisu primili HBOT i u 35 (35%) koji su je primili (P<0.001). Osteomijelitis se pojavio kod 24 (74%) pacijenata koji nisu primili HBOT i u 62 (63%) onih koji jesu primili terapiju (P=0.030). Liza transplnatata kože i nekroza režnja se pojavila se u 151 (52%) i 147 (1%) pacijenata koji nisu primili HBOT i kod 23 (23%) i 15 (15%) onih koji su primili terapiju (P<0.001 za obje skupine). Median vremena do stvaranja svježih granulacija je bitno kraći kod pacijenata koji su primili HBOT, što iznosi 9 (5-57) dana, nasuprot 12 (1-12) dana kod onih koji nisu primili HBOT (P<0.001). Pacijenti koji su liječeni po non-NATO doktrini hitne ratne kirurgije imali su veći omjer izgleda (OR) za pojavnost duboke infekcije mekog tkiva (OR, 10.7, 95% CI, 3.5-32.0) i nekroze režnja (OR, 9.5, 95% CI, 2.9-31.0) ako nije primijenjena HBOT. Oni koji su bili liječeni po NATO doktrini hitne ratne kirurgije, kod njih je omjer izgleda za nastanak osteomijelitisa bio (OR, 1.7, 95% CI, 1.0-2.9), a za lizu transplantata kože (OR, 4.5, 95% CI, 2.4-8.5). HBOT znakovito reducira vrijeme do stvaranja svježih granulacija (P<0.001). ZAKLJUČAK: HBOT znakovito reducira učestalost komplikacija s ranom u pacijenata sa složenim ozljedama ekstremiteta tip III A, B i C po Gustilu i skraćuje vrijeme stvaranja svježih granulacija. Istovremeno i NATO doktrina hitne ratne kirurgije ima utjecaja na pojavnost granulacijskog tkiva. Ključne riječi: Komplikacije ratne rane, adjuvantna terapije hiperbaričnim kisikom, kirurške procedure, operacijske metode, ratne rane i ozljede. |
| Abstract (english) | AIM: To determine the effects of hyperbaric oxygen therapy (HBOT) on complications of severe war wounds to the upper and lower extremities both in patients in which NATO strategy of emergency war surgery was and was not applied. METHOD: We retrospectively analyzed data on 388 male patients undergoing reconstructive surgery for Gustilo type III A, B, and C war wounds to the extremities at the Department of Reconstructive Surgery, Split University Hospital Center, between 1991 and 1995. We recorded the occurrence of the main wound complications (deep infection, osteomyelitis, skin grafts lyses, and flap necrosis) and time from wounding to granulation formation. The occurrence of wound complications between comparable groups of patients in whom HBOT was and was not applied was evaluated by χ2 test and time to granulation formation by Mann-Whitney test. Odds ratio (OR) with 95% confidence intervals (CI) were calculated for occurrence of wound complications with respect to HBOT and adjusted for NATO surgical strategy by logistic regression. The interaction between HBOT and NATO surgical protocol was assessed by patients’ stratification. RESULTS: Of 388 patients, 310 (80%) were initially treated according to the NATO surgical strategy and 99 (25%) patients received HBOT. Deep soft-tissue infection developed in 196 (68%) patients who did not receive HBOT and 35 (35%) who did receive it (P<0.001). Osteomyelitis developed in 214 (74%) of patients who did not receive HBOT and 62 (63%) who did (P=0.030). Skin graft lysis and flap necrosis occurred in 151 (52%) and 147 (51%) patients who did not receive HBOT and 23 (23%) and 15 (15%) of those who did receive it, respectively (P<0.001 for both). Median time to granulation formation was significantly shorter in patients who received HBOT, i.e. 9 (5-57) days as opposed to 12 (1-12) days in those who did not (P<0.001). These results were consistent over the groups of patients stratified according to wound severity and remained unaltered after the adjustment for NATO surgical strategy. The effect of HBOT was greater in non-NATO than in NATO treated patients in case of deep soft-tissue infection (OR, 10.7 vs. OR, 3.8; P=0.031 for interaction) and apparently for flap necrosis (OR, 9.5 vs. OR, 5.4,;P=0.061 for interaction). CONCLUSION: HBOT reduces the frequency of wound complications in patients with Gustilo type III wounds and shortens the time to granulation formation. HBOT is more important in non-NATO than in NATO treated patients for prevention of deep soft-tissue infection and possibly flap necrosis. |
