Preliminary Experience with Carbon Dioxide Therapy In the Treatment of Pressure Ulcers In a Bedridden Elderly Patient

Aging leads to a significant increase in comorbidities in elderly adults, including pressure ulcers. Pressure ulcers compromise quality of life and increase by five times the risk of death. The cost of treating an ulcer in the United States is estimated at approximately $11 billion per year.1 Pressure ulcers are common complications in people who are bedridden, especially elderly adults with dementia. The prevalence of these lesions is approximately 10% to 14% of hospital inpatients and 24% of institutionalized individuals.1 Longer hospital stays and higher treatment costs related to the treatment of these lesions affect the health system.2 Although several contributing factors have been described, pressure of a surface against the fragile skin and the consequent shortage of blood supply in the affected area are certainly the main causes of ulcer formation.2 Infections are common complications and usually become a portal of entry for microorganisms into the bloodstream, resulting in septicemia.1 The most common wound care practices include occlusive dressings, hydrocolloid dressings, activated charcoal, and surgical debridement, but all of these options are costly.2, 3 Treatment modalities based on occlusive dressings are of uncertain effectiveness.1 In addition, most of the alternative treatments available (e.g., laser therapy, ultrasound) are considered to be adjuvant therapies alongside dressings. The therapeutic mechanism proposed for carbon dioxide (CO2) therapy is based on the relationship between CO2 tissue concentration, blood flow improvement, and interference with the oxyhemoglobin dissociation curve. This explains the improvement of ulcers after oxygen deprivation (e.g., in vascular ulcers).4 The technique employs a CO2 cylinder, coupled with a 0.33-mm-caliber, 18-mm-long needle. A device that promotes CO2 heating and controls the flow of air, approximately 40 mL/min of CO2, is injected subcutaneously into the wound edge, with 2-cm spacing between injection sites and one injection inside the ulcer. Topical 2% lidocaine cream is applied to the skin before the procedure. Caregivers are instructed to turn the patient every 2 hours. Use of an appropriate mattress, a balanced diet, and wound cleansing with neutral soap and water are also recommended. The Research Ethics Committee of Hospital Universitário de Brasília approved experimental use of this technique. An 80-year-old woman with a 10-year history of severe dementia according to Clinical Dementia Rating and without comorbidities developed right and left trochanteric Stage III pressure ulcers, two Stage II ulcers in the right heel, and one Stage III ulcer in the sacral region after an episode of delirium secondary to urinary tract infection and a 15-day hospitalization. Calcium alginate dressings and hydrocolloid dressings provided no improvement. Carbon dioxide therapy was proposed as a treatment (Figure 1). Carbon dioxide therapy, widely used for aesthetic enhancement, has been proposed as an alternative treatment for vascular ulcers. Carbon dioxide administered percutaneously promotes dilation of precapillary arterioles, reperfusion of occluded capillaries, reduction in blood viscosity, stimulation of skin heat receptors, and inhibition of cold receptors.4, 5 Although only a few reports have been found in the literature, the technique has been used in an off-label manner to treat several conditions, including peripheral arterial disease, venous insufficiency, and leg ulcers.4, 5 Regarding local complications, there are reports in the literature of erythema, ecchymosis, pain, and a sensation of crepitation resulting from CO2 therapy. Danger of gas emboli with CO2 injections has not been reported. The treatment is especially beneficial for elderly adults with pressure ulcers due to immobility because they may have injections at home, avoiding hospitalization. The technique can improve tissue oxygenation, contributing to ulcer healing. Carbon dioxide therapy may be a safe option for the treatment of pressure ulcers. It is a rapidly effective, low-cost technique that is easy to perform and has a low risk of side effects. Randomized controlled studies are required to provide further evidence of the effectiveness of CO2 therapy in elderly adults with pressure ulcers. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: LPP: Study conception, interpretation of data, drafting and revision of manuscript, final approval. LLL: Data collection and interpretation, revision of manuscript, final approval. FMS: Data interpretation, drafting and revision of manuscript, final approval; MEGM: Data collection (application of the technique), revision of manuscript, final approval. JBS: Data interpretation, revision of manuscript, final approval. Sponsor's Role: The study received no financial support.