Transcutaneous Oximetry Optimizes Clinical Management and Cost-Effectiveness of Diabetic Foot Ulcers Treated with Hyperbaric Oxygen: A Review of Point-of-Care Vascular Screening Options.

Hyperbaric oxygen therapy has been employed to treat diabetic foot ulcers for more than four decades. While supported by some high-quality evidence, there is sufficient conflicting data to render its use open to criticism. Even systematic and other reviews favorably disposed to this treatment adjunct invariably plead for better patient selection. Common among several causes of non-healing ulcers is persistent hypoxia. Transcutaneous oximetry uniquely measures tissue oxygen tension. Combination air and oxygen testing provides an evidence-based approach to hyperbaric patient selection through demonstration of locally reversible hypoxia. Transcutaneous oximetry differentiates hyperbaric responders from non- responders early in their treatment course by detecting neoangiogenesis, thereby providing a basis for continuing hyperbaric dosing only in those who benefit. Finally, such testing guides therapeutic endpoint determination, namely, normalized peri-ulcer oxygen tensions. This contrasts with continuing medically unnecessary and costly hyperbaric treatments until wound closure. Measurements of blood pressure and blood flow are imperfect surrogates for oxygen delivery. Recently introduced near-infrared spectroscopy and long-wave infrared thermography provide insights into tissue oxygen saturation and changes in micro-vascular density, respectively. Neither, however, guides clinically efficacious and cost-effective hyperbaric oxygenation in the manner afforded by transcutaneous oximetry. This paper describes evidence-based guidance on hyperbaric oxygen dosing for diabetic foot ulcers, reviews point-of-care screening options, and argues for the continued superiority of transcutaneous oximetry in the current era.