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1. Pengaruh Terapi Oksigen Hiperbarik di bidang Orthopedi-1

PENGARUH THERAPY OKSIGEN HYPERBARIK PADA BIDANG ORTHOPAEDI-1

Oleh Dr H Subagyo SpB - SpOT

 

BAB  I

PENDAHULUAN

Therapy oksigen hyperbarik adalah bernapas dengan 100% oksigen dengan peningkatan tekanan atmosfer ( di atas tekanan permukaan laut ) di dalam kamar bertekanan.

Pada tahun 1930, angkatan laut Amerika Serikat ( US Navy ) memulai penelitian terhadap therapy oksigen hyperbarik untuk mengobati penyakit decompressi dan emboli udara pada arteri yang dialami oleh para penyelam militer. Mereka menemukan therapy tersebut membuahkan hasil yang sangat baik sehingga pada tahun 1940, US Navy menetapkan therapy oksigen hyperbarik sebagai therapy standard untuk pada penyelam militer yang menderita penyakit dekompresi dan emboli udara pada arteri.

Terdapat 2 macam kamar bertekanan ( chamber) yaitu tipe A ( multiplace chamber ) dengan multi ruang untuk dua pasien atau lebih dan tipe B ( monoplace chamber) dengan satu ruangan untuk satu pasien. Pada pasien dengan kondisi umum yang buruk atau yang menggunakan alat bantuan, multiplace chamber dipilih karena mempunyai keuntungan yaitu alat-alat bantu tersebut dapat dimasukkan ke dalam chamber dan perawat dapat ikut memonitor kondisi pasien tersebut.

Saat therapy oksigen hyperbarik, hemoglobin pada pembuluh darah vena juga tersaturasi penuh sehingga tekanan oksigen meningkat pada pembuluh darah. Difusi oksigen bergantung pada perbedaan tekanan sehingga oksigen akan dialirkan ke jaringan dari pembuluh darah. Umumnya tekanan minimal yang digunakan adalah sebesar 2 atm selama 60 menit.Banyaknya sesi therapy tergantung pada kondisi pasien dengan rentang satu sesi untuk keracunan ringan karbon monoksida hingga enam puluh sesi atau lebih untuk lesi diabetic pada kaki.

Pada tahun 2003 ,The American Society of Hyperbaric Medicine ( Underwater and Hyperbaric Medical Society, UHMS ) mempublikasikan indikasi-indikasi untuk therapy oksigen hyperbarik yang disetujui oleh komite tersebut berdasarkan bukti ilmiah yang ada.

  • Emboli udara
  • Keracunan karbon monoksida
  • Keracunan karbon monoksida dan cyanida
  • Clostridial myositis dan myonecrosis ( gas gangrene )
  • Crush injury compartment syndrome, dan iskemi traumatic akut lainnya
  • Penyakit dekompresi
  • Penyembuhan yang dipercepat pada beberapa luka yang bermasalah
  • Anemia karena perdarahan
  • Abses intracranial
  • Infeksi nekrosis jaringan lunak
  • Osteomyelitis refrakter
  • Delayed radiation injury
  • Compromised skin grafts and flaps
  • Luka bakar

Telah banyak dilakukan penelitian dan dokumentasi tentang efektifitas terapi oksigen hiperbarik pada bidang selular  tubuh. Oleh karena itu, penulis tertarik mengetahui penggunaan therapy oksigen hyperbarik pada bidang orthopaedi.

 BAB II

FISIOLOGI TULANG

Tulang adalah suatu organ padat yang membentuk bagian dari endoskeleton vertebrata.Fungsinya adalah untuk bergerak, menyangga, dan melindungi berbagai macam organ dalam tubuh kita, memproduksi sel darah merah, sel darah putih, dan sebagai tempat penyimpanan mineral.Jaringan tulang adalah jaringan penghubung yang padat.Tulang mempunyai bentuk yang bervariasi dan mempunyai struktur internal dan external yang komplek.Tulang ini ringan, kuat dan keras, hal ini juga agar memenuhi fungsi tulangnya sendiri.Salah satu type dari jaringan yang membuat mineralisasi tulang adalah jaringan osseous, yang menyebabkan tulang itu padat dan memberikan bentuk seperti sarang tawon pada struktur internalnya.Jaringan lainya yang ditemukan pada tulang termasuk sumsum tulang (bone marrow), endosteum dan periosteum, syaraf, pembuluh darah, dan cartilago. Ada sekitar 206 tulang terdapat pada anatomi tubuh manusia, dan terdapat sekitar 300 tulang pada infant

Fungsi:

1. Mekanikal

    a)    Proteksi

          Tulang sebagai pelindung organ dalam, contohnya seperti tulang tengkorak melindungi otak atau tulang iga untuk melindungi

           jantung dan paru.

     b)   Bentuk :   Tulang memberikan struktur untuk menyokong tubuh

     c)   Pergerakan :Tulang, otot rangka, tendon, ligament, dan sendi secara bersamaan berfungsi dan bekerja bersama dalam

           melakukan gerakan.

     d)   Transduksi suara :Tulang penting pada aspek mekanik pada overshadowedhearing, atau pada tulang pendengaran untuk 

           mentransfer suara.

2. Sintetis

     a)   Produksi darah :Sumsum tulang, yang terletak diantara rongga medular dari tulang panjang, yang memproduksi sel darah

           merah, sel darah putih, thrombosit pada suatu proses yang disebut hematopoiesis.

3. Metabolik

     a)    Tempat penyimpanan mineral :Tulang sebagai tempat penting penyediaan mineral dalam tubuh, seperti kalsium dan

             fosforus.

      b)   Penyimpanan factor pertumbuhan :Mineral matrix tulang terdapat factor pertumbuhan yang penting seperti insuline like

            growth factors, transforming growth factor, morphogenetic protein tulang, dan lain-lain.

      c)   Penyimpanan lemak  :Sumsum tulang yang berwarna kuning berfungsi sebagai tempat penyediaan asam lemak.

      d)   Keseimbangan asam-basa  :Tulang sebagai buffer asam-basa menyebabkan darah tidak berlebih dalam menyebabkan

            perubahan pH dengan cara mengabsorbsi ataupun melepaskan garam alkalin.

      e)   Detoksifikasi  :Jaringan tulang bisa juga menyimpan elemen dari luar tubuh, memindahkan dari darah, dan mengurangi

            efeknya pada jaringan yang lainya, yang kemudian bisa dengan pelan-pelan dikeluarkan melalui excresi.

Dengan demikian,  fungsi tulang adalah sebagai penunjang, pelindung organ internal vital, membantu pergerakan tubuh dengan memberikan tempat perlekatan bagi otot dan membentuk tuas, sebagai tempat pembentukan sel darah merah(sum-sum tulang) tempat penyimpanan Ca++ dan PO4 yang dapat dipertukarkan dengan plasma untuk mempertahankan konsentrasi elektrolit-elektrolit tersebut dalam plasma.

Struktur Tulang Individual

Tulang tidaklah seutuhnya terdiri dari materi padat, tetapi lebih cenderung mempunyai jarak diantara elemennya yang keras tersebut.

Tulang Kortikal (compact bone)

Lapisan keras bagian luar dari tulang terdiri dari jaringan yang disebut tulang padat (compact bone), disebut demikian dikarenakan kecilnya celah dan rongga yang tedapat pada lapisan ini.Jaringan ini membuat tulang tampak halus, putih, dan terlihat lebih padat, dengan nilai masa 80% dari tubuh orang dewasa. Compact bone ini juga disamakan dengan suatu istilah yang disebut ”dense bone”

Tulang Trabekular

Yang mengisi bagian dalam dari tulang ini adalah jaringan trabekular tulang (yang juga disebut sebagai tulang spongy (spongy bone) yang terdiri dari jaringan batang dan plate-like  yang membuat secara keseluruhan tulang ini lebih ringan, dan terdapat ruangan untuk pembuluh darah dan sumsum tulang. Tulang trabekular sekitar 20% masanya dari seluruh masa tulang.

Struktur Selular

Ada beberapa tipe sel yang terdapat pada tulang

  1. Osteoblast adalah sel mononukleasi pembentuk tulang terdapat pada sel osteoprogenitor. Osteoblast ini terletak di permukaan lapisan osteoid, osteoblast ini juga membuat suatu campuran protein yang disebut osteoid. Osteoid terutama terdiri dari kolagen tipe 1. Osteoblast juga menghasilkan hormone, seperti hormone prostaglandin, untuk bekerja juga pada tulang itu sendiri. Osteoblast ini juga memproduksi alkalin phosphatase, yaitu suatu enzim yang mempunyai peran pada mineralisasi tulang. Osteoblast ini adalah sel tulang yang belum matang ( immature)
  2. Osteosit berasal dari osteoblast yang bermigrasi kedalam dan dikelilingi oleh matrix tulang. Rongga dimana terdapat osteosit ini disebut lakuna. Osteosit ini fungsinya bervariasi: membentuk tulang, untuk mengatur matrix tulang dan homeostatis kalsium. Osteosit ini adalah sel tulang yang sudah matang (mature).
  3. Osteoklast adalah suatu sel tulang yang bertanggung jawab akan resorpsi tulang (untuk remodeling tulang). Osteoklast ini bentuknya besar, dengan sel multinukleasi yang terletak pada permukaan tulang pada suatu tempat yang dinamakan howship’s lakuna atau suatu tempat untuk peresorpsian. Lakuna ini, tidak terlalu berarti bila terjadi fraktur pada permukaan tulang. Karena osteoklast ini berasal dari suatu line sel-monocyte stem, maka osteoklast ini dilengkapi dengan suatu mekanisme menyerupai fagositosis yang digunakan untuk sirkulasi makrofag. 

Fisiologis Pertumbuhan Tulang

Pertumbuhan tulang panjang yang menyebabkan penambahan tinggi tubuh adalah efek paling dramatis dari hormon pertumbuhan. Tulang adalah jaringan hidup,yang merupakan suatu bentuk jaringan ikat. Tulang terdiri dari sel dan matriks organik ekstrasel yang dihasilkan oleh sel.

Sel tulang yang menghasilkan matriks organik terdiri dari serat-serat kolagen dalam gel semipadat yang kaya mukopolisakarida yang disebut juga sebagai bahan dasar (ground substance).Matriks ini memiliki konsistensi seperti karet dan menentukan daya rentang tulang (ketahanan tulang terhadap kerusakan ketika mendapat tekanan).Tulang menjadi keras karena pengendapan kristal-kristal kalsium fosfat di dalam matriks.Kristal anorganik ini memberikan kekuatan kompresi (kemampuan tulang untuk mempertahankan bentuknya ketika ditekan) pada tulang.  Jika hanya terdiri dari kristal anorganik, tulang akan rapuh seperti kapur tulis. Tulang memiliki kekuatan struktural yang mendekati beton bertulang, namun tulang tidak rapuh dan jauh lebih ringan akibat pencampuran struktural matriks organik yang diperkuat oleh kristal anorganik. Tulang rawan ( cartilago) serupa dengan tulang hanya tulang rawan tersebut tidak mengalami kalsifikasi.

Sebuah tulang panjang pada dasarnya terdiri dari batang silindris yang relatif uniform, yaitu diafisis, dan epifisis, yaitu benjolan persendian di kedua ujungnya.

Pada tulang yang sedang tumbuh, diafisis dipisahkan dari epifisis di kedua ujungnya oleh sebuah lapisan tulang rawan yang dikenal sebagai epiphyseal plate.Rongga sentral tulang terisi oleh sumsum tulang, yang merupakan tempat produksi sel-sel darah.

Pertumbuhan ketebalan tulang dicapai oleh penambahan tulang baru di atas tulang yang sudah ada di permukaan luarnya.Pertumbuhan ini terjadi melalui aktivitas osteoblas di dalam perosteum, suatu pembungkus jaringan ikat yang menutupi permukaan luar tulang.Sewaktu tulang baru diendapkan oleh osteoblas di permukaan external, sel-sel lain di dalam tulang, osteoklas melarutkan jaringan tulang di permukaan dalam yang berdekatan dengan rongga sumsum. Dengan cara ini, rongga sumsum membesar mengimbangi peningkatan lingkaran batang tulang.

Pertumbuhan panjang tulang panjang dilakukan oleh mekanisme yang berbeda dengan pertumbuhan ketebalan.Tulang bertambah panjang sebagai akibat proliferasi sel tulang rawan di epifisis metabolike.Selama pertumbuhan, dihasilkan sel-sel tulang rawan (kondrosit) baru melalui pembelahan sel di batas luar epiphyseal plate yang berdekatan dengan epifisis.Saat kondrosit baru sedang dibentuk di batas epifisis, sel-sel tulang rawan lama kearah batas diafisis membesar. Kombinasi proliferasi sel tulang rawan baru dan hipertrofi kondrosit yang mature menyebabkan epiphyseal plate (epiphysis metabolike) mengalami peningkatan ketebalan tulang. Penebalan epiphyseal plate ini menyebabkan epifisis terdorong menjauhi diafisis.Matriks yang mengelilingi kartilago tua yang hipertrofi dengan segera mengalami kalsifikasi.  Karena tulang rawan tidak memiliki jaringan kapiler sendiri, kelangsungan hidup sel sel tulang rawan bergantung pada difusi nutrien dan oksigen melalui ground substance, suatu proses dihambat oleh adanya endapan garam-garam kalsium.

Akibatnya, sel sel tulang rawan tua yang terletak di batas diafisis mengalami kekurangan nutrient dan mati.

 Osteoklast membersihkan kondrosit yang mati dan matriks yang mengalami kalsifikasi  yang mengelilinginya, daerah ini kemudian diinvasi oleh osteoblas yang berkerumun  ke atas dari diafisis, dan meletakan tulang disekitar bekas sisa tulang rawan dekat epiphyseal plate dan diganti oleh tulang baru. Apabila proses osifikasi ini selesai, tulang pada sisi diafisis telah bertambah panjang, dan epiphyseal plate telah kembali kembali ke ketebalannya semula. Tulang rawan yang diganti oleh tulang di ujung epiphyseal plate memiliki ketebalan yang setara dengan pertumbuhan tulang rawan baru di ujung epiphyseal plate.

Ketika matriks ekstrasel yang dihasilkan oleh osteoblas mengalami kalsifikasi, osteoblas terperangkap oleh matriks yang mengendap di sekitarnya.Namun, osteoblas yang terperangkap didalam matriks yang terkalsifikasi tidak mati karena sel sel tersebut mendapat pasokan nutrient dari saluran saluran kecil yang dibentuk oleh osteoblas itu sendiri dengan menjulurkan tonjolan tonjolan sitoplasma menembus matriks tulang.Dengan demikian, terbentuk jaringan saluran yang memancar dari setiap osteoblas yang terperangkap yang berfungsi sebagai system penyalur untuk penyampaian nutrient dan pengeluaran zat sisa.Osteoblas yang terperangkap disebut osteosit, berhenti melaksanakan tugas membentuk tulang dan tidak dapat lagi membentuk tulang baru.Namun, sel sel ini ikut serta dalam pertukaran kalsium antara tulang dan darah yang diatur oleh hormone. Pertukaran ini berada dibawah control hormone paratiroid.

Hormone pertumbuhan meningkatkan pertumbuhan tulang baik tebal maupun panjangnya.Hormone ini merangsang proliferasi tulang rawan epifisis, sehingga menyediakan lebih banyak ruang untuk membentuk tulang serta juga merangsang aktivitas osteoblast.Hormone pertumbuhan dapat meningkatkan pemanjangan tulang panjang selama epiphyseal plate tetap berupa tulang rawan.Pada akhir masa remaja, dibawah pengaruh hormone hormone seks, epiphyseal plate ini mengalami penulangan sempurna atau tertutup, sehingga tulang tidak lagi dapat bertambah panjang walaupun terdapat hormone pertumbuhan.

BAB III

TERAPI OKSIGEN HIPERBARIK

3.1      DEFINISI TERAPI OKSIGEN HIPERBARIK

Terapi oksigen hiperbarik adalah bernapas dengan 100% oksigen dengan peningkatan tekanan atmosfer (di atas tekanan permukaan laut) di dalam kamar bertekanan.

Terapi oksigen topikal adalah bernapas dengan oksigen 100% dalam tekanan 1 atmosfer atau tereksposenya bagian tubuh tertentu dengan oksigen 100%, menurut Undersea and Hyperbaric Medical Society tidak termasuk ke dalam definisi terapi oksigen hiperbarik.

 3.2     SEJARAH TERAPI OKSIGEN HIPERBARIK

Pada tahun 1930, angkatan laut Amerika Serikat ( US Navy ) memulai penelitian terhadap terapi oksigen hiperbarik untuk mengobati penyakit dekompresi dan emboli udara pada arteri yang dialami oleh para penyelam militer. Mereka menemukan terapi tersebut membuahkan hasil yang sangat baik sehingga pada tahun 1940, US Navy menetapkan terapi oksigen hiperbarik sebagai terapi standar untuk pada penyelam militer yang menderita penyakit dekompresi dan emboli udara pada arteri. Pada tahun yang sama, standar keamanan dan indikasi terapi oksigen hiperbarik dibuat. Pada tahun 1956, terapi oksigen hiperbarik pertama kali digunakan pada penyakit yang tidak berhubungan dengan penyelaman.Seorang dokter bedah berkebangsaan Belanda, Boerema, melalukan operasi di dalam kamar bertekanan tinggi. Kondisi di dalam kamar tekanan tinggi tersebut membuat sirkulasi pasien teroklusi dalam rentang waktu yang lama sehingga memungkinkan sang dokter melakukan operasi yang tidak mungkin dilakukan pada jaman tersebut. Pada tahun 1960 dan 1970, terapi oksigen hiperbarik mulai digunakan untuk berbagai penyakit.

Boerema saat melakukan operasi di dalam kamar bertekanan tinggi

Kamar bertekanan tinggi sendiri pertama kali diciptakan sekitar tahun 1600 oleh pendeta berkebangsaan Inggris bernama Henshaw.Ia membangun sebuah struktur bernama domicilium yang digunakan untuk mengobati bermacam-macam penyakit. Kamar tersebut diberikan tekanan.Ide mengobati pasien dibawah tekanan tinggi dikembangkan lagi oleh dokter bedah berkebangsaan Perancis bernama Fontaine pada tahun 1879. Dr. Orville Cunningham, seorang professor dalam bidang anestesi, mendirikan sebuah bangunan bernama Steel Ball Hospital pada tahun 1928. Bangunan tersebut terdiri atas 6 lantai dan diameter 64 kaki.Bangunan tersebut mempunyai tekanan 3 atmosfer.Rumah sakit tersebut ditutup pada tahun 1930 karena tidak mempunya bukti ilmiah yang cukup yang mengindikasikan terapi tersebut memperingan penyakit.

Mesin Hiperbarik yang dikembangkan oleh Fontaine

Steel Ball Hospital

3.3      MACAM-MACAM KAMAR BERTEKANAN

Terdapat 2 macam kamar bertekanan ( chamber ) yaitu tipe A ( multiplace chamber ) dengan multi ruang untuk dua pasien atau lebih dan tipe B ( monoplace chamber )dengan satu ruangan untuk satu pasien. Kamar tipe A dapat dimasuki oleh beberapa orang pasien sekaligus dan dapat disertai dengan perawat atau pendamping yang mengobservasi pasien dan membantu di saat gawat darurat. Pasien dalam multiplace chamber menghirup oksigen 100% melalui masker.Pada monoplace chamber, pasien tidak menggunakan masker untuk menghirup oksigen 100% karena udara di dalam chamber tersebut telah dialiri oleh oksigen 100%. Pada pasien dengan kondisi umum yang buruk atau yang menggunakan alat bantuan, multiplace chamber dipilih karena mempunyai keuntungan yaitu alat-alat bantu tersebut dapat dimasukkan ke dalam chamber dan perawat dapat ikut memonitor kondisi pasien tersebut.

Multiplace Chamber

Monoplace Chamber

3.4      FISIKA PENYELAMAN

Berikut adalah hukum-hukum fisika yang penting berkenaan dengan kegunaan pengobatan secara klinis.

Tekanan udara di permukaan laut yaitu sekitar 70 mmHg ( 1 atm ). Tekanan menurun pada ketinggian karena atmosfir di atasnya berkurang sehingga berat udara pun berkurang.

Apabila seseorang menyelam di bawah permukaan air, tekanan akan meningkat karena berat atmosfir dan berat dari air di atas sang penyelam. Menurut hukum Pascal, tekanan akan meningkat sebesar 1 atm ( 760 mmHg ) untuk setiap kedalaman 10 meter.

Kedalaman

Tekanan absolut

Gauge pressure

Di permukaan

1 ATA

0 ATG

10 meter

2 ATA

1 ATG

20 meter

3 ATA

2 ATG

30 meter

4 ATA

3 ATG

Hukum Boyle

Hukum ini menegaskan hubungan antara tekanan dan volume dari suatu kumpulan gas akan berbanding terbalik dengan tekanan absolut.

Bilamana tekanan meningkat, volume dari suatu kumpulan gas akan berkurang dan sebaliknya. Hubungan ini berlaku terhadap semua gas-gas di dalam ruangan tubuh sewaktu penyelam masuk ke dalam air maupun naik ke permukaan.Sebagai contoh, seorang penyelam yang menghirup nafas penuh ( 6 liter ) pada kedalaman 10 meter ( 2 atm ) menahan nafasnya lalu naik ke permukaan ( 1 atm ), udara di dalam parunya akan melipat gandakan volume menjadi 12 liter. Ia harus menghembuskan udara 6 liter saat naik untuk menghindari pneumothoraks.

Pada telinga bagian tengah, tekanan air akan dihantarkan oleh cairan tubuh ke rongga udara di dalam telinga bagian tengah. Selama tekanan meningkat, volume akan berkurang dan karena telinga bagian tengah berada dalam rongga tulang yang kaku makan rongga yang sebelumnya terisi oleh udara akan diisi oleh jaringan yang membengkak, berdarah dan menonjol ke dalam gendang telinga. Pencegahan terhadap perusakan jaringan lebih lanjut, dilakukan maneuver yaitu udara ditiupkan ke dalam saluran Eustachius dari tenggorokan untuk menjaga agar volume gas yang ada di telinga bagian tengah tetap konstan sehingga tekanannya menyamai tekanan air. Proses serupa terjadi di dalam rongga sinus akan tetapi karena rongga sinus berhubungan langsung dengan rongga hidung maka keseimbangan dapat terjadi dengan sendirinya.

Aplikasi dari hukum Boyle diterapkan dalam terapi oksigen hiperbarik dalam mengobati fenomena emboli seperti penyakit dekompresi atau emboli udara dalam arteri.Saat tekanan meningkat, volume gelembung yang menyebabkan emboli menurun.Berdasarkan hukum ini pula, pasien dilarang untuk menahan napas selama dilakukan dekompresi agar volume dalam paru tidak berlebih sehingga tidak terjadi pneumothorax.

Hukum Dalton

Hukum ini menjelaskan tentang tekanan parsial dari campuran gas. Udara yang kita hirup pada 1 atm terdiri atas :

Nitrogen = 80% dari 1 atm = 0.8 atm

Oksigen = 20% dari 1 atm = 0.2 atm

Sehingga apabila seseorang melakukan penyelaman, maka tekanan parsial yang ia hirup adalah sebesar :

Permukaan    = 1 atm = 0.8 atm N2 + 0.2 atm O2

10 meter       = 2 atm = 1.6 atm N2 + 0.4 atm O2

30 meter       = 3 atm = 3.2 atm N2 + 0.8 atm O2

40 meter       = 4 atm = 4.0 atm N2 + 1.0 atm O2

Dari tabel di atas, diketahui bahwa pada kedalaman 40 meter, penyelam menghirup oksigen dengan tekanan parsial 1 atm. Tekanan tersebut sama seperti ia menghirup 100% oksigen di permukaan air.

Hukum ini penting untuk mengetahui efek toksik pernafasan pada kedalaman, penyakit dekompresi, dan penggunaan oksigen maupun campuran- campuran gas untuk tujuan pengobatan.

Hukum Henry

Hukum ini berhubungan dengan penyerapan gas di dalam cairan. Di permukaan laut( 1 atm ), di dalam tubuh manusia terdapat sekitar 1 liter larutan nitrogen. Bila seorang penyelam turun hingga kedalamam 10 meter ( 2 atm ), tekanan parsial dari nitrogen yang dihirup menjadi dua kali lipat yaitu sebesar 2 liter.

Bilamana tekanan yang terdapat dalam larutan terlalu cepat berkurang, gas keluar dari larutan dalam bentuk gelembung-gelembung gas. Pelepasan gelembung ini dapat menyumbat pembuluh darah atau merusak jaringan-jaringan sehingga menyebabkan berbagai pengaruh dari penyakit dekompresi atau yang dapat disebut dengan bends.

Aplikasi hukum ini dalam terapi oksigen hiperbarik adalah dengan menaikkan tekanan di dalam chamber, semakin banyak oksigen terlarut dalam plasma.

Hukum Charles

Hukum ini menjelaskan apabila pembuluh darah tertekan, maka suhu meningkat dan suhu menurun apabila tekanan dalam pembuluh darah hilang.Hal ini penting untuk diingat apabila seorang anak atau pasien dengan kondisi umum yang jelek atau diintubasi.

3.5      FISIOLOGI HIPERBARIK

Saat terapi oksigen hiperbarik, hemoglobin pada pembuluh darah vena juga tersaturasi penuh sehingga tekanan oksigen meningkat pada pembuluh darah. Difusi oksigen bergantung pada perbedaan tekanan sehingga oksigen akan dialirkan ke jaringan dari pembuluh darah.

Tidak terdapat definisi yang pasti akan tekanan dan durasi yang digunakan untuk sesi terapi oksigen hiperbarik. Umumnya tekanan minimal yang digunakan adalah sebesar 2,4 atm selama 90 menit. Banyaknya sesi terapi tergantung pada kondisi pasien dengan rentang satu sesi untuk keracunan ringan karbon monoksida hingga enam puluh sesi atau lebih untuk lesi diabetic pada kaki.

Mekanisme Fisiologis Pada Terapi Oksigen Hiperbarik

Mekanisme

Referensi

Aplikasi Klinis

  1. 1.    Hiperoksigenisasi

Boerema

Penyakit dekompresi, emboli udara arteri

Bassett BE

Keracunan CO

Bird AD

Oklusi arteri sentral retina

Crush injury, compartment syndrome

Compromised grafts and flaps

Anemia akibat perdarahan hebat

  1. 2.    Mengurangi ukuran gelembung udara

Hukum Boyle

Emboli udara

  1. 3.    Vasokonstriksi *

Nylander G

Crush injury, compartment syndrome

 

Sukoff MH

Luka bakar

  1. 4.    Angiogenesis

Knighton DR

Luka yang bermasalah

Compromised grafts and flaps

Delayed radiation injury

  1. 5.    Proliferasi fibroblast / sintesis kolagen

Hunt TK

Luka yang bermasalah

Delayed radiation injury

  1. 6.    Membunuh leukocyte oxidative#

Mader JT

Infeksi nekrosis jaringan lunak

Park MK

Osteomyelitis refrakter

Mandell GL

Luka yang bermasalah

  1. 7.    Mengurangi perlengketan leukosit intravascular

Zamboni WA

Crush injury, compartment syndrome

 

Thom SR

 

  1. 8.    Mengurangi peroksidasi lipid

Thom SR

Keracunan CO

 

 

Crush injury, compartment syndrome

  1. 9.    Inhibisi racun

Van Unnik A

Clostridial myonecrosis

10. Sinergi antibiotik

Mirhij NJ

Infeksi nekrosis jaringan lunak

 

Keck PE

Osteomyelitis refrakter

 

Mendel V

 

 

 

Hyperoksia pada jaringan normal akan menyebabkan vasokonstriksi tetapi hal ini dikompensasi dengan peningkatan oksigen dalam plasma dan aliran darah mikrovaskular. Vasokonstriksi ini mempunyai efek mengurangi edema jaringan post-trauma yang berkontribusi terhadap terapi crush injuries, compartment syndromes, dan luka bakar.

Terapi oksigen hiperbarik meningkatkan produksi oksigen radikal bebas yang mengoksidasi protein dan membrane lipid, merusak DNA, menghambat fungsi metabolic bakteri.Terapi oksigen metabolic terutama efektif untuk kuman anaerob dan memfasilitasi system peroksidase yang tergantung pada oksigen dimana sel darah putih membunuh bakteri.

Terdapat bukti ilmiah bahwa terapi oksigen hiperbarik mengubah tingkatan mediator proinflamasi dan dapat melumpuhkan kaskade inflamasi.Studi lebih lanjut dibutuhkan untuk mempelajari interaksi tersebut.

Terapi oksigen hiperbarik menurunkan denyut jantung sehingga curah jantung menurun.Dalam waktu yang bersamaan, melalui vasokonstriksi sistemik, terapi oksigen hiperbarik meningkatkan afterload.Kombinasi efek tersebut dapat mengeksaserbasi gagal jantung kongestif pada pasien dengan penyakit berat tetapi secara klinis, hal ini jarang terjadi.

3.6      INDIKASI TERAPI OKSIGEN HIPERBARIK

Pada tahun 2003 ,The American Society of Hyperbaric Medicine

( Underwater and Hyperbaric Medical Society, UHMS) mempublikasikan indikasi-indikasi untuk terapi oksigen hiperbarik yang disetujui oleh komite tersebut berdasarkan bukti ilmiah yang ada.

1

Emboli udara

2

Keracunan karbon monoksida

Keracunan karbon monoksida dan sianida

3

Clostridial myositis dan myonecrosis ( gas gangrene )

4

Crush injury compartment syndrome, dan iskemi traumatic akut lainnya

5

Penyakit dekompresi

6

Penyembuhan yang dipercepat pada beberapa luka yang bermasalah

7

Anemia karena perdarahan

8

Abses intracranial

9

Infeksi nekrosis jaringan lunak

10

Osteomyelitis refrakter

11

Delayed radiation injury

12

Compromised skin grafts and flaps

13

Luka bakar

The European Committee for Hyperbaric Medicine( EHCM ) membagi indikasi terapi oksigen hiperbarik ke dalam empat kategori berdasarkan rekomendasi terkuat.

  • Sangat dianjurkan
  • Dianjurkan
  • Optional
  • Indikasi lain ( tidak diterima oleh komite )

KONDISI

DITERIMA

TIDAK DITERIMA

LEVEL OF EVIDENCE

LEVEL OF EVIDENCE

A

B

C

D

E

F

Sangat dianjurkan

Keracunan CO

 

 

 

 

 

Crush injury

 

 

 

 

 

Pencegahan osteoradionekrosis setelah pencabutan dental

 

 

 

 

 

Osteonescrosis mandibular

 

 

 

 

 

Radionekrosis jaringan lunak

 

 

 

 

 

Kecelakaan dekompresi

 

 

 

 

 

Emboli gas

 

 

 

 

 

Infeksi bakteri anaerobic atau campur

 

 

 

 

 

Dianjurkan

Lesi diabetic pada kaki

 

 

 

 

 

Compromised skin graft and musculocutaneus flap

 

 

 

 

 

Osteoradionekrosis tulang lainnya

 

 

 

 

 

Radio-induced enteritis

 

 

 

 

 

Lesi radio-induced pada jaringan lunak

 

 

 

 

 

Tindakan bedah dan implantasi pada jaringan  yang belum diradiasi

 

 

 

 

 

Tuli mendadak

 

 

 

 

 

Ulkus iskemik

 

 

 

 

 

Osteomyelitis refrakter kronik

 

 

 

 

 

Neuroblastoma tahap IV

 

 

 

 

 

Optional

Ensefalopati pasca anoksia

 

 

 

 

 

Radionekrosis laring

 

 

 

 

 

Lesi SSP radio-induced

 

 

 

 

 

Paska prosedur sindroma vascular reperfusi

 

 

 

 

 

Pemasangan kembali ekstremitas

 

 

 

 

 

Luka bakar >20% dan derajat 2

 

 

 

 

 

Kelainan iskemik akut mata

 

 

 

 

 

Beberapa luka yang tidak menyembuh sekunder terhadap proses inflamasi

 

 

 

 

 

Indikasi lain

Paska sternotomi mediastinitis

 

 

 

 

 

Stroke

 

 

 

 

 

Penyakit sickle cell

 

 

 

 

 

Otitis eksterna maligna

 

 

 

 

 

Infark miokard akut

 

 

 

 

 

Nekrosis kaput femoral

 

 

 

 

 

Tinnitus

 

 

 

 

 

Bell’s palsy

 

 

 

 

 

Cerebral palsy

 

 

 

 

 

Multiple sclerosis

 

 

 

 

 

Fetoplacental insufficiency

 

 

 

 

 

 

A  : sedikitnya studi acak terkontrol, besar, double-blind dengan sedikit atau tidak ada bias secara metodologi

B  : studi acak, double-blind terkontrol tetapi dengan kesalahan metodologi; studi dengan sample sedikit atau hanya satu studi saja

C  : opini konsensus para ahli

D  : hanya studi tidak terkontrol tanpa opini konsensus para ahli

E  : tidak terdapat bukti ilmiah yang menguntungkan atau secara metodologi atau interpretasi bias

F  : bukti ilmiah yang ada menyatakan tidak pada terapi oksigen hiperbarik

 

3.7     KONTRAINDIKASI TERAPI OKSIGEN HIPERBARIK

Kontraindikasi absolut

Alasan

Kondisi yang dibutuhkan sebelum terapi oksigen hiperbarik

Pneumothoraks yang tidak diterapi

Emboli gas

Torakostomi

Tension pneumotoraks

Pneumomediastinum

Bleomycin

Interstitial pneumonitis

Rentang waktu yang lama sejak dimulai medikasi hingga terapi oksigen hiperbarik akan dimulai

Cisplatin

Penyembuhan luka yang tidak sempurna

Disulfiram

Menghalangi dismutase superoxide yang melindungi dari toksisitas oksigen

Medikasi dihentikan

Doxorubicin

Toksik terhadap jantung

Sulfamylon

Penyembuhan luka yang tidak sempurna

 

Kontraindikasi relatif

Alasan

Kondisi sebelum terapi oksigen hiperbarik

Asma

Terjebaknya udara yang dapat mengakibatkan pneumothoraks

Terkontrol baik dengan medikasi

Klaustrofobia

Kecemasan

Pengobatan dengan benzodiazepine

Spherocytosis kongenital

Hemolysis berat

Terapi oksigen hiperbarik hanya untuk keadaan gawat saja

PPOK

Hilangnya dorongan hipoksia untuk bernapas

Observasi dalam chamber

Disfungsi tuba Eustachian

Barotrauma pada membrane timpani

Latihan, PE tubes

Demam tinggi

Resiko tinggi kejang

Antipiretik

Alat pacu jantung

Malfungsi alat

Memastikan alat dapat menahan tekanan hingga seberapa dalam

Kehamilan

Efek yang belum diketahui terhadap fetus

Terapi oksigen hiperbarik hanya untuk keadaan gawat saja

Kejang

Ambang batas kejang yang rendah

Stabil dengan medikasi terlebih dahulu

Infeksi saluran pernapasan atas

Barotrauma

Disembuhkan dahulu dengan medikasi

 

 

3.8    KOMPLIKASI TERAPI OKSIGEN HIPERBARIK

 

Komplikasi

Presentasi

Terapi

Barotrauma

Telinga tengah

Nyeri pada telinga, telinga terasa penuh

Valsava manuever

Pendengaran tidak jelas

Pseudoephedrine/ oxymetazoline

Tympanostomy tube

Tunggu hingga infeksi pernapasan atas sembuh

Sinus

Nyeri pada sinus atau perdarahan

Pseudoephedrine/ oxymetazoline

Antihistamine

Semprotan hidung steroid

Gigi

Nyeri pada gigi

Penggantian tambal gigi atau mahkota ( gelembung udara dibebaskan )

Paru

Batuk kering

Tidak menahan napas

Nyeri dada atau terasa terbakar

Torakostomi bila pneumothoraks

Kapasitas vital berkurang

Waktu dekompresi ditingkatkan

Jendela telinga dalam

Tuli mendadak

Valsava dihentikan

Tinnitus

Rujuk THT

Nystagmus, vertigo

Refraksi visus berubah

Morfologi lensa

Myopia progresif

Kebanyakan teratasi spontan ketika terapi selesai

Katarak

Pandangan berkabut

Skrining katarak, terapi oksigen hiperbarik tidak menimbulkan formasi katarak

Toksisitas oksigen

SSP

Kejang

Sumber oksigen dilepas

Terapi oksigen dilanjutkan dengan periode yang lebih singkat

Medikasi tidak dibutuhkan

Terapi hipoglikemia bila ada

Terapi demam bila ada

Paru

Batuk kering

Mengurangi waktu tereksposenya dengan oksigen termasuk di luar terapi oksigen hiperbarik

Nyeri dada atau rasa terbakar

 

Berkurangnya kapasitas vital

Persiapan Terapi Oksigen Hiperbarik

  1. Pasien diminta untuk menghentikan kebiasaan merokoknya 2 minggu sebelum proses terapi dimulai. Tobacco mempunyai efek vasokonstriksi sehingga mengurangi penghantaran oksigen ke jaringan
  2. Beberapa medikasi dihentikan 8 jam sebelum memulai terapi oksigen hiperbarik antara lain vitamin C, morfin, dan alcohol.
  3. Pasien diberikan pakaian yang terbuat dari 100% bahan katun dan tidak memakai perhiasan, alat bantu dengar, lotion yang terbuat dari bahan dasar petroleum, kosmetik, bahan yang mengadung plastik, dan alat elektronik.
  4. Pasien juga tidak diperbolehkan membawa koran, majalah, atau buku untuk menghindari percikan api karena tekanan oksigen yang tinggi beresiko menimbulkan kebakaran.
  5. Sebelum pasien mendapatkan terapi oksigen hiperbarik, pasien dievaluasi terlebih dahulu oleh seorang dokter yang menguasai bidang hiperbarik. Evaluasi mencakup penyakit yang diderita oleh pasien, apakah ada kontraindikasi terhadap terapi oksigen hiperbarik pada kondisi pasien.
  6. Sesi perawatan hiperbarik tergantung pada kondisi penyakit pasien.  Pasien umumnya berada pada tekanan 2.4 atm selama 90 menit 2 jam kemudian diselingi pasien keluar dari ruangan hiperbarik agar komplikasi oksigen hiperbarik dapat dihindari.
  7. Terapi oksigen hiperbarik memerlukan kerja sama multidisiplin sehingga satu pasien dapat ditangani oleh berbagai bidang ilmu kedokteran.
  8. Pasien dievaluasi setiap akhir sesi untuk perkembangan hasil terapi dan melihat apakah terdapat komplikasi hiperbarik pada pasien.

 

3.9  Penyakit Dekompresi

Penyakit dekompresi timbul sebagai akibat dari dekompresi yang tidak mencukupi ( terlalu cepat ) sehingga membentuk gelembung yang berlebihan dalam tubuh. Berdasarkan Hukum Henry, jika penyelam menghirup satu liter nitrogen pada permukaan laut, maka pada kedalaman 20 meter ( 3 atm ), ia menyerap tiga liter nitrogen. Nitrogen yang berlebihan itu oleh darah didistribusikan ke jaringan sesuai dengan kecepatan aliran darah ke jaringan tersebut serta daya gabung jaringan terhadap nitrogen.Jaringan lemak mempunyai daya gabung nitrogen yang tinggi dan melarutkan lebih banyak nitrogen daripada jaringan lainnya dalam tubuh.

Berdasarkan waktu yang dibutuhkan oleh jaringan untuk menyerap nitrogen dan mencapai tahap keseimbangan atau kejenuhannya dengan darah, jaringan-jaringan  dalam tubuh dibagi atas jaringan cepat dan jaringan lambat.

Darah termasuk ke dalam jaringan tercepat karena ia menghisap nitrogen langsung dari paru- paru dan mencapai keseimbangan dalam waktu beberapa menit. Otak juga termasuk ke dalam jaringan cepat karena pendarahannya yang banyak. Jaringan yang termasuk ke dalam jaringan lambat adalah tulang rawan yang membatasi permukaan sendi karena mempunyai pendarahan yang buruk sehingga memerlukan beberapa jam untuk mencapai keseimbangan. Ketika penyelam naik ke permukaan, darah melepaskan nitrogen kembali ke dalam paru-paru.Demikian pula jaringan-jaringan lain dalam tubuh melepaskan nitrogen kembali ke dalam darah. Tubuh memerlukan waktu 24 jam atau lebih untuk menghilangkan semua nitrogen berlebihan. Jika dekompresi terlalu cepat, nitrogen tidak dapat meninggalkan jaringan-jaringan dengan cepat dan teratur.

Gelembung di dalam pembuluh darah

Cara menyelam mempengaruhi daerah pembentukan gelembung nitrogen dan juga gejala dari penyakit dekompresi. Penyelam yang singkat dan dalam , misalnya dalam 5 menit menyelam 60 meter, menghasilkan beban nitrogen yang tinggi pada jaringan-jaringan cepat tetapi tidak cukup waktu untuk jaringan-jaringan yang lambat. Gelembung-gelembung akan terbentuk dalam darah karena tidak mempunyai waktu yang cukup bagi paru-paru untuk membersihkan darah dari nitrogen sehingga disarankan agar penyelam menggunakan waktu perlahan untuk mencapai permukaan laut yaitu 10 meter/ menit. Penyelaman yang lama ke tempat yang lebih dangkal juga mempunyai dampak pada jaringan-jaringan yang lambat. Nitrogen akan lebih banyak berkumpul pada jaringan tersebut sehingga cenderung menimbulkan “bends” pada persendian.

Bends pada persendian

Penyelam yang gemuk, berusia tua, bekerja di dalam air dingin, penyelam yang letih karena telah bekerja berat di dalam air, yang mempunyai cedera otot, mempunyai riwayat bends merupakan individu yang lebih rentan terhadap penyakit dekompresi walaupun telah melakukan dekompresi sesuai prosedur.  

Klasifikasi gambaran klinis penyakit dekompresi dibagi berdasarkan bagian tubuh yang terserang. Penyakit dekompresi terjadi beberapa saat setelah penyelam mulai naik, tersering terjadi dalam 1 jam pertama. Gejala juga dapat timbul setelah 24 jam.

  • Nyeri pada persendian

Sering disebut dengan istilah bends. Pada awalnya terasa kaku atau rasa tidak enak yang sukar dilukiskan di sekitar persendian atau otot-otot sekitarnya.

Mulanya gerakan-gerakan anggota tubuh mungkin dapat meringankan sakit tetapi pada jam-jam berikutnya rasa sakit yang sangat dan tidak enak muncul, kadang berupa rasa sakit yang tertusuk-tusuk atau berdenyut. Gerakan akan memperberat rasa sakit dan anggota badan berada dalam posisi yang paling enak biasanya pada posisi miring. Rasa sakit akan bertambah setelah 12-24 jam. Jika tidak diobati biasanya akan berubah menjadi rasa nyeri yang tumpul dalam waktu 3-7 hari. Tampak pula kemerahan dan bengkak pada daerah sendi sehingga menyebabkan salah diagnosa menjadi penyakit radang sendi.Bahu adalah persendian yang sering terserang yaitu sebesar 1/3 kasus. Persendian lain yang juga sering diserang adalah sendi siku, pergelangan, tangan, persendian tulang paha, lutut, dan pergelangan kaki. Persendian yang terserang jarang simetris. Sering kali persendian yang berdampingan pada anggota badan yang sama terserang sekaligus.

  • Susunan saraf

Gelembung dapat terbentuk dalam jaringan otak atau pembuluh darah yang mempendarahi otak sehingga dampaknya sama dengan gejala stroke akibat sumbatan pada pembuluh darah.

Gelembung yang terbentuk di cerebellum dapat memunculkan gejala hilangnya koordinasi, kesulitan bicara, atau tremor.Gelembung juga dapat terbentuk pada medulla spinalis atau pembuluh darah yang mempendarahi medulla spinalis.

  • Jantung dan paru
  • Gastrointestinal

Terapi :

Pada kasus yang ringan, dapat diterapi dengan menghirup oksigen 100%.Pengobatan terpenting adalah rekompresi.Transportasi pasien juga harus diperhitungkan tekanan udaranya sehingga tidak memperberat gejala.Penderita diberi oksigen 100% yang diselingi udara bebas selama 5 menit setelah 30 menit bernafas dengan oksigen 100%.Rekompresi bertujuan agar gelembung nitrogen berkurang ukurannya dan dengan bantuan oksigen yang melarutkan gelembung.

 

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