Integrating HBOT into Surgical Practice

A Practical Framework for Using Hyperbaric Oxygen in Tissue Salvage, Reconstruction, Trauma, Infection, and Radiation-Damaged Wounds

Hyperbaric oxygen therapy, commonly abbreviated as HBOT, can support selected surgical patients when tissue viability is threatened by hypoxia, ischemia, radiation injury, severe edema, or impaired microvascular function. Its role is adjunctive. It should strengthen an appropriate operative plan rather than replace debridement, revascularization, fracture stabilization, drainage, reconstruction, or postoperative surveillance.

The Undersea and Hyperbaric Medical Society recognizes several indications that intersect directly with surgical practice. These include compromised grafts and flaps, crush injury and other acute traumatic ischemias, delayed radiation injury, chronic refractory osteomyelitis, selected advanced diabetic foot wounds, and certain severe infections. Medicare covers a related but narrower group of conditions and applies diagnosis-specific requirements. (UHMS)

Successful integration begins before the patient reaches the chamber. Surgeons and hyperbaric physicians must agree on the diagnosis, correct remediable surgical problems, identify the tissue being preserved, coordinate treatment around the operating schedule, and define how clinical response will be measured.

HBOT Is a Surgical Adjunct, Not a Rescue for Incomplete Source Control

HBOT increases arterial oxygen tension and the amount of oxygen dissolved in plasma. This can extend oxygen diffusion from functioning capillaries into hypoxic tissue and support cellular activity in areas where edema or microvascular injury limits ordinary oxygen delivery.

Potentially relevant effects include:

• Increased oxygen delivery to viable hypoxic tissue
• Reduction of selected forms of edema
• Support for fibroblast activity and collagen production
• Promotion of angiogenic signaling
• Improved oxygen-dependent leukocyte function
• Modulation of ischemia-reperfusion injury
• Support for graft, flap, bone, and soft tissue healing

These effects require at least some functioning circulation. HBOT cannot deliver an adequate oxygen dose through a completely occluded artery. It cannot remove devitalized tissue, stabilize infected hardware, drain an abscess, evacuate a hematoma, or correct a thrombosed vascular anastomosis.

The surgical team should first ask whether the patient has a correctable mechanical, vascular, or infectious problem. Hyperbaric consultation becomes most useful after those problems have been addressed or while definitive treatment is being organized without unnecessary delay.

Build HBOT Into the Operative Strategy Early

Late referral is one of the most common barriers to effective surgical use. A hyperbaric center may be contacted only after a flap has become necrotic, a traumatic wound has undergone extensive conversion, or irradiated tissue has failed several operations.

Earlier consultation does not mean every patient should begin treatment. It allows the teams to determine:

• Whether a recognized indication exists
• Whether viable tissue remains
• What operation should occur first
• Whether treatment should begin before or after surgery
• What chamber capability the patient requires
• Whether the anticipated benefit justifies transfer and treatment burden

Three referral pathways are useful.

Emergency consultation is appropriate when tissue, limb, organ, or neurologic function is being lost rapidly. Examples include acute traumatic ischemia, arterial gas embolism during surgery, and selected severe crush injuries.

Urgent consultation is appropriate for a compromised flap, failing graft, threatened replantation, progressive postoperative ischemia, or a severe infection after emergency surgical evaluation.

Planned consultation may be appropriate for chronic refractory osteomyelitis, delayed radiation injury, selected diabetic foot wounds, and complex reconstruction within a severely irradiated field.

Compromised Flaps Are a Time-Sensitive Application

A healthy flap does not require routine HBOT. The treatment becomes relevant when a flap is hypoxic or ischemic and remains potentially salvageable.

Warning findings may include:

• Increasing pallor
• Dark venous congestion
• Cool tissue
• Delayed capillary refill
• Progressive edema
• Loss or deterioration of a Doppler signal
• Epidermolysis
• Poor bleeding after pinprick
• Expanding necrosis

The operating surgeon must first evaluate for arterial thrombosis, venous obstruction, pedicle kinking, hematoma, excessive tension, compression, or technical failure. These problems may require immediate exploration or revision.

UHMS guidance states that HBOT is neither necessary nor recommended for normal, uncompromised grafts or flaps. When compromise is caused by reduced perfusion, irradiation, or hypoxia, early treatment may help maximize the amount of viable tissue and reduce the need for complete regrafting or repeat flap reconstruction. (UHMS)

The referral should communicate:

• Type and location of the flap
• Date and time of reconstruction
• Arterial and venous anatomy
• Time that compromise was first recognized
• Clinical and Doppler findings
• Operative revision already completed
• Current photographs
• Tissue or structure requiring coverage
• Planned return to the operating room

The objective should be specific. Examples include preserving coverage over exposed hardware, reducing the area requiring debridement, or avoiding another free-tissue transfer.

Skin Grafts Require Contact With a Viable Recipient Bed

Skin graft survival depends on close contact with the recipient surface, early diffusion of oxygen and nutrients, and subsequent vascular connection.

Before considering HBOT, surgeons should correct:

• Hematoma
• Seroma
• Graft displacement
• Excessive movement or shear
• Constricting dressings
• Infection
• Inadequate wound-bed preparation
• Arterial insufficiency

HBOT may support a graft when hypoxia remains after these issues have been addressed. It cannot cause a graft floating on fluid to adhere or make exposed avascular structures suitable for grafting without additional reconstruction.

Clinical reviews describe potential benefits in composite graft survival, skin graft uptake, neovascularization, fibroblast function, and ischemia-reperfusion injury. The evidence includes laboratory research, case series, reviews, and limited controlled data, so expectations should remain individualized. (PubMed)

Medicare covers preparation and preservation of compromised skin grafts, while distinguishing this use from primary management of an ordinary wound. (Centers for Medicare & Medicaid Services)

Acute Trauma Requires Parallel Surgical and Hyperbaric Planning

Crush injury, severe open fracture, vascular disruption, reperfusion, and compartment syndrome can create a cycle of edema, microvascular compression, tissue hypoxia, inflammation, and progressive necrosis.

HBOT may help interrupt this cycle by increasing oxygen delivery while reducing edema. UHMS describes acute traumatic ischemias as conditions in which tissue survival, infection control, and healing may be threatened by the combined effects of ischemia and hypoxia. (UHMS)

Treatment must not delay:

• Hemorrhage control
• Revascularization
• Fracture reduction and stabilization
• Fasciotomy
• Debridement
• Management of rhabdomyolysis
• Antibiotic treatment
• Critical-care stabilization

The international HOLLT randomized trial evaluated early HBOT after initial surgery for severe lower-limb trauma. The study reported less tissue necrosis and better selected long-term outcomes in the HBOT group, although the combined primary endpoint of necrosis or infection was not statistically significant. The findings support selective use in severe trauma rather than routine treatment of every open fracture. (PubMed)

A trauma referral should include the injury mechanism, vascular status, fracture classification, operative reports, compartment findings, debridement history, fixation, current photographs, and planned reoperations.

Compartment Syndrome Still Requires Surgical Decompression

Acute compartment syndrome is a surgical emergency. HBOT should not be used to postpone fasciotomy when clinical findings or pressure measurements support decompression.

Possible postoperative roles include supporting muscle that remains hypoxic after fasciotomy, reducing edema, and preserving marginal tissue following a severe crush injury. The surgeon must continue to assess compartment release, muscle viability, perfusion, renal risk, and the need for repeat debridement.

A wound that continues to deteriorate after HBOT requires renewed surgical evaluation. Chamber treatment should never be interpreted as evidence that another operation is unnecessary.

Replantation and Revascularization May Leave Microvascular Risk

Restoring major arterial inflow does not immediately normalize tissue oxygenation. Replanted or revascularized tissue may remain at risk because of venous congestion, edema, endothelial injury, microvascular thrombosis, and reperfusion injury.

The surgical team must first confirm that the repair remains mechanically and technically intact. Loss of inflow, venous obstruction, a constricting closure, or compressive hematoma requires direct correction.

HBOT may then be considered when macroscopic circulation is present but marginal tissue remains threatened. Monitoring should include Doppler signals, capillary refill, temperature, motor and sensory findings, edema, compartment status, and progression of necrosis.

Medicare includes acute traumatic peripheral ischemia and crush injuries involving the suturing of severed limbs among its covered hyperbaric conditions when function, limb, or life is threatened. (Centers for Medicare & Medicaid Services)

Chronic Refractory Osteomyelitis Requires an Integrated Operative Plan

HBOT is not first-line treatment for every bone infection. It may be considered for chronic refractory osteomyelitis that persists or recurs despite appropriate surgical and antimicrobial management.

Before referral, the surgical team should address:

• Sequestrated or necrotic bone
• Abscesses
• Infected or unstable hardware
• Mechanical instability
• Sinus tracts
• Vascular insufficiency
• Inadequate soft tissue coverage
• Need for bone or deep tissue cultures

UHMS notes that randomized clinical trials are lacking, but available animal studies, human case series, and nonrandomized research generally support adding HBOT to surgery and antibiotics in previously refractory disease. (UHMS)

The treatment objective may be infection remission, support before reconstruction, healing after debridement, or preservation of a limb. HBOT cannot sterilize an undebrided sequestrum or overcome unstable fixation.

The surgeon, infectious disease physician, and hyperbaric physician should agree on the sequence of debridement, antimicrobial therapy, reconstruction, and chamber treatment.

Selected Diabetic Foot Operations May Benefit From HBOT

A diabetic foot wound should not be referred simply because it is chronic, deep, or postoperative.

The patient requires comprehensive evaluation of:

• Peripheral arterial disease
• Infection and osteomyelitis
• Pressure and offloading
• Necrotic tissue
• Glucose management
• Nutrition
• Foot structure and biomechanics
• Reconstructive options

The 2023 IWGDF guideline conditionally recommends considering systemic HBOT for neuro-ischemic or ischemic diabetes-related foot ulcers when standard care has failed and appropriate treatment resources already exist. The certainty of evidence is low, reinforcing the need for selective use. (IWGDF Guidelines)

Medicare generally requires a diabetes-related lower-extremity wound classified as Wagner grade III or higher and no measurable healing after at least 30 days of standard treatment. HBOT must continue alongside vascular management, debridement, offloading, glucose optimization, infection control, and appropriate wound care. (Centers for Medicare & Medicaid Services)

Surgery should not be postponed when the patient has gangrene, deep abscess, necrotizing infection, severe ischemia, or unstable osteomyelitis. The 2023 IWGDF and IDSA infection guideline emphasizes urgent or early surgical involvement for severe and selected moderate diabetes-related foot infections. It also advises against using HBOT solely to treat infection because evidence for infection control alone is limited. (IDSA)

Radiation-Damaged Tissue Requires Organ-Specific Planning

Radiation may produce progressive small-vessel injury, fibrosis, chronic hypoxia, and reduced healing capacity months or years after treatment.

Surgeons may encounter:

• Soft tissue radionecrosis
• Osteoradionecrosis
• Chronic ulceration
• Fistula
• Wound breakdown after surgery
• Failure of grafts or flaps
• Poor tissue quality before reconstruction

HBOT is an established indication for selected delayed radiation injuries, but the evidence is not identical across every organ or operation. (UHMS)

The referral should include:

• Cancer diagnosis
• Radiation field, dose, and dates
• Current imaging
• Pathology or biopsy findings
• Previous operations
• Extent of soft tissue and bone injury
• Evidence excluding recurrent malignancy
• Planned debridement or reconstruction

A new wound or mass within an irradiated field should not automatically be labeled radionecrosis. Recurrent cancer, infection, vascular disease, and a second malignancy may need to be excluded.

Avoid Automatic HBOT for Dental Surgery in Irradiated Bone

Historical protocols frequently used HBOT around dental extraction or mandibular surgery after head and neck radiation. Current evidence supports a more selective approach.

The 2024 ISOO-MASCC-ASCO guideline concluded that routine use of HBOT for prevention or management of jaw osteoradionecrosis remains largely unjustified because supporting evidence is limited. (ASCO Publications)

Consultation may still be considered for established osteoradionecrosis, combined bone and soft tissue injury, failed prior management, or complex reconstruction in a markedly compromised field. The decision should be individualized by oral surgery, head and neck oncology, reconstructive surgery, and hyperbaric medicine.

A history of radiation alone should not trigger an automatic chamber protocol.

Necrotizing Infection Requires Cautious Integration

Necrotizing soft tissue infection and clostridial myonecrosis require immediate surgery, broad antimicrobial therapy, resuscitation, and critical care.

HBOT must never delay the initial debridement or a necessary return to the operating room. Professional guidance is not uniform. UHMS recognizes selected severe infections within its indication framework, while the IDSA skin and soft tissue infection guideline does not recommend HBOT for clostridial myonecrosis because proven benefit is lacking and transfer or treatment may delay resuscitation and debridement. (UHMS)

A responsible approach is to consider HBOT only when:

• Source control has already begun
• Broad antimicrobial therapy is active
• The patient is sufficiently stabilized
• The chamber is located within a facility capable of continuing surgical and intensive care
• Treatment will not delay another operation
• A qualified team identifies a specific adjunctive objective

The operating surgeon retains responsibility for repeated wound exploration and source control.

Plan HBOT Around the Operating Room

The chamber schedule should accommodate surgery, not compete with it.

The surgical and hyperbaric teams should agree on:

• Whether HBOT should occur before or after the operation
• The timing of dressing changes
• When the wound will be inspected
• Whether the patient needs repeated debridement
• How grafts or flaps must be positioned
• Which drains and devices can enter the chamber
• Criteria requiring immediate return to surgery
• Treatment continuation and discontinuation criteria

For a compromised reconstruction, treatment may begin after surgical revision and continue once or twice daily during the early salvage period. For chronic radiation injury or refractory osteomyelitis, treatment may occur once daily over several weeks and may be coordinated around a planned operation.

There is no single perioperative HBOT schedule appropriate for all surgical indications. Pressure, duration, frequency, air breaks, and total sessions should be prescribed according to the diagnosis, urgency, response, and patient tolerance.

Define the Endpoint Before Treatment Begins

A course should begin with a measurable clinical objective.

Possible surgical endpoints include:

• Preservation of a flap
• Increased percentage of graft uptake
• Reduction in the area requiring debridement
• Coverage of exposed bone, tendon, vessel, or hardware
• Preservation of a replanted body part
• Infection remission after osteomyelitis treatment
• Preparation of irradiated tissue for reconstruction
• Healing of a qualifying diabetic wound
• Avoidance of a more proximal amputation

The treatment plan should also define reasons to stop or revise therapy:

• Progressive necrosis
• Loss of vascular inflow
• Recurrent hematoma or venous obstruction
• Uncontrolled infection
• Need for urgent surgery
• Lack of objective improvement
• Achievement of the clinical goal
• Treatment-related risk exceeding expected benefit

Chamber attendance is not an outcome. Durable tissue survival, infection control, wound closure, functional preservation, and successful reconstruction are outcomes.

Review Dressings and Surgical Devices Before Treatment

Products that are safe in the operating room or wound clinic are not automatically safe inside a hyperbaric chamber.

The hyperbaric safety team should review:

• Negative-pressure wound systems
• External fixation
• Drains and collection devices
• Implanted electronic devices
• Infusion pumps
• Warming devices
• Topical preparations
• Petroleum-containing products
• Silver-containing dressings
• Batteries and electrical equipment
• Synthetic clothing and linens

Some devices may remain in place with modification, while others must be removed, substituted, isolated, or managed outside the chamber.

In August 2025, the FDA reminded healthcare facilities to follow chamber manufacturers’ instructions, maintain fire-prevention systems, control electrical and static-producing items, supervise patients continuously, and complete required maintenance. The communication followed reports of serious injuries and deaths associated with HBOT devices. (U.S. Food and Drug Administration)

Match the Patient to the Facility’s Capability

Not every hyperbaric center can treat every surgical patient.

A stable outpatient with delayed radiation injury may be appropriate for a wound-center program. A ventilated trauma patient receiving vasoactive medication requires a hospital-based chamber with compatible equipment, trained personnel, critical-care support, and a plan for deterioration under pressure.

Before transfer, confirm:

• A hyperbaric physician has accepted the patient
• The facility treats the specific indication
• The chamber can accommodate the patient’s size, position, and devices
• Ventilation, infusions, and monitoring can continue safely
• Surgical and critical-care services remain available
• Transfer will not delay a more urgent procedure

The presence of a chamber does not establish the ability to provide critical-care HBOT.

Screen for Hyperbaric Risks

The hyperbaric physician performs the final medical assessment, but surgeons should identify issues that may affect treatment planning.

These include:

• Known or suspected pneumothorax
• Recent thoracic trauma or surgery
• Significant pulmonary air trapping
• Mechanical ventilation
• Uncontrolled seizure activity
• Ear or sinus disease
• Hemodynamic instability
• Heart failure
• Glucose instability
• Severe claustrophobia
• Pregnancy
• Implanted medical devices

An untreated pneumothorax is a critical concern because trapped gas may expand during decompression. Trauma and postoperative patients require particular attention to chest imaging, drains, airway status, and pulmonary history.

Potential HBOT complications include middle-ear or sinus barotrauma, transient visual change, glucose disturbance, pulmonary pressure injury, and rare oxygen-induced seizure.

Document Medical Necessity Precisely

A surgical note should not request HBOT merely for “wound healing.”

Documentation should establish:

• The exact diagnosis
• Why the tissue is compromised
• The operation or injury involved
• Corrective procedures already completed
• Perfusion and viability findings
• Infection and source-control status
• The tissue or function being preserved
• The expected benefit of HBOT
• The plan for surgical reassessment
• Objective response during treatment

Medicare covers defined conditions rather than every surgical wound. Covered surgical intersections include acute traumatic peripheral ischemia, crush injury, chronic refractory osteomyelitis, delayed radiation injury, compromised skin grafts, and selected advanced diabetic wounds. Each indication carries its own clinical and documentation expectations. (Centers for Medicare & Medicaid Services)

Clinical recognition, Medicare coverage, and commercial payer authorization are separate determinations. A clinically reasonable treatment may not be covered under a specific policy, while a covered diagnosis may still fail medical-necessity review if standard care or severity criteria are not documented.

Create a Surgical HBOT Pathway

Hospitals integrating HBOT into surgical practice should establish a written pathway rather than relying on individual familiarity.

The pathway should define:

1. Which surgical conditions qualify for emergency, urgent, and planned consultation.
2. Who contacts the hyperbaric physician.
3. Which operations or corrective procedures must occur first.
4. How the patient is screened for chamber safety.
5. Which service retains primary responsibility.
6. How treatments are coordinated with the operating room.
7. Which findings trigger return to surgery.
8. How response and complications are documented.
9. When treatment should be stopped.
10. How outcomes are reviewed.

Regular case conferences can help align plastic surgery, vascular surgery, orthopedics, trauma, podiatry, infectious disease, wound care, and hyperbaric medicine.

The pathway should also make nonreferral criteria explicit. Routine postoperative swelling, an uncomplicated incision, a normally perfused flap, or an ordinary graft does not justify HBOT.

Measure Surgical Outcomes, Not Chamber Volume

A program should evaluate whether HBOT changes outcomes that matter to surgical care.

Useful measures include:

• Complete or partial flap salvage
• Graft uptake
• Repeat operations
• Area of tissue necrosis
• Level of amputation
• Limb function
• Infection remission
• Hardware preservation
• Wound dehiscence
• Time to durable closure
• Rehospitalization
• Treatment complications

Outcomes should be reported by indication and severity. Combining traumatic ischemia, radiation injury, diabetic foot wounds, and compromised flaps into one success rate provides little clinical value.

The program should also include patients who did not complete treatment. Reporting only successful completers can make results appear stronger than the actual experience of every patient who began therapy.

Surgical Judgment Remains Central

Integrating HBOT into surgical practice does not mean referring every difficult wound. It means recognizing the limited group of patients in whom increased oxygen delivery can support a well-defined operative objective.

The most appropriate candidates have:

• A recognized or defensible indication
• Viable but threatened tissue
• Corrected mechanical and vascular problems
• Adequate source control
• A realistic reconstructive or functional objective
• A facility capable of treating them safely
• Objective criteria for reassessment

The least appropriate candidates have irreversible necrosis, untreated arterial obstruction, undrained infection, unresolved mechanical failure, or a need for surgery that would be delayed by chamber treatment.

HBOT is most valuable when surgeons involve the hyperbaric team early, while continuing to own the operation, source control, reconstruction, and postoperative surveillance. The chamber can improve the biologic environment in selected patients, but the surgical plan determines whether that opportunity becomes durable tissue salvage.