Hyperbaric oxygen therapy in emergencies: approaches to mechanical ventilation and anesthesia

Aims: The aim of this study is to evaluate the epidemiology, anesthesia management, mechanical ventilator (MV) modes, sedative agents, drug dosages, and complications in mechanically ventilated patients undergoing hyperbaric oxygen therapy (HBOT). Methods: This study was conducted retrospectively and observationally in a tertiary care center. Intubated adult and pediatric patients who received anesthesia and sedation under emergency conditions for HBOT between February 10, 2023, and May 15, 2024, were included. Data were obtained from the hospital information system, patient discharge summaries, and anesthesia observation forms. Patients' demographic data, indications, comorbidities, respiratory parameters, intravenous agents and their dosages, MV parameters, and complications were analyzed. Results: HBOT was applied to 560 patients, of whom 3.75% (21 patients) received anesthesia and sedation. Among these patients, 29.4% (5 patients) were children, and 70.6% (12 patients) were adults, with an age range of 2 to 93 years. The indications included carbon monoxide intoxication (COI) (75%), COI with burns (17.6%), COI with synthetic cannabinoid intoxication (5.9%), and purpura fulminans (5.9%). A total of 44 sessions were conducted, ranging from 1 to 8 sessions per patient. The drugs used included midazolam (35.3%), dexmedetomidine (29.4%), remifentanil (23.5%), propofol, ketamine, and rocuronium bromide (64.7%). The ventilation modes utilized were SIMV-VC, SIMV-PC, PRVC, and PC. MV-patient asynchrony was observed in 88.2% of cases due to increased sedation dose requirements. Complications included bradycardia, nausea and vomiting, hypo/hypertension, self-extubation, desaturation, and session incompletion. The in-hospital mortality rate was 29.4%. Conclusion: Anesthesia management in a hyperbaric environment requires a multidisciplinary approach due to the unique physical conditions of the procedure. In intubated patients, the increased need for sedation must be met, and asynchrony should be prevented. During HBOT, propofol, ketamine, dexmedetomidine, remifentanil, and midazolam can be safely used in combination to optimize sedation. Anesthesia management should be individualized to prevent complications.