management of necrotizing fasciitis followed by C/D

1. Case presentation
on Necrotizing
Fasciitis
Management
Presenter: Dr Ahmed (Surgery Resident)
Moderator : Tadele ( OGR IV)
Invited: Dr Gosa (MD, Asst.prof General
Surgery

2. Objective
Case
Summary
Discussion References
Contents
Dr Ahmed NEC 2
4/28/2023

3. Case Presentation On Necrotizing
Fasciitis

4. Objective

5. Objective
 To discuss on management necrotizing
Fasciitis taking case as entry point
Dr Ahmed NEC 5
4/28/2023

6. Case
summary

7. Case Summary

8. Case Summary
• Identification:-
• Name M.N
• Age :31 year
• Residency : Wanji
• Marital status: Married
• MRN:1321024
• Date of admission :23/07/2015
• Date of discharge : 12/08/2015
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9. Case summary
C/C: Surgical wound discharge/3days
HPP
• P I(CD alive) mother on 8th Post op day after LUST C/S was done
for indication of prolonged LFSOL +NRFHP(P. tachycardia)
• Currently she come with referral with the Dx. of SSI+ abdominal
cellulitis +8th post C/D
• She has hx of pain & offensive discharge from surgical site.
• She has hx of high grade intermittent fever, chills and riggers
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10. cont’d
• Otherwise she has no hx of
• headache ,epigastric pain and bluring of vision
• No hx urinary frequency, urgency
• No hx of hypertension and DM
Dr Ahmed NEC 10
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11. Physical examination
G/A: ASL
V/S BP= BP=90/60mmHg PR=102/min RR=22 T=37.5
HEENT: pale conjunctiva, NIS
ABD:
 Tenderness and darkish skin discoloration which started from edge of
incision site on lower abd.
 Indurated skin and crepitation on palpation with offensive discharge
from surgical site,
 18 weeks sized uterus and contracted
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12. cont’d
GUS:
Offensive discharge on examining finger
with cervical motion tenderness
MS=No deformity and no edema
CN/S: COTPP
Pelvic U/S
• Uterus empty
• Measure 12cmx9cm
• 8x4cm of pelvic collection
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13. Cont’d
• Ass= : Deep SSI with pelvic collection+ ?Necrotizing fasciitis +
Puerperal sepsis 2 to endomyometritis + 8th post C/D
Plan –To do CBC,BG,
 Prepare for re-laparotomy + debridement
 Consult surgical side
 Ceftriaxone 1gm IV BID
 Metronidazole 500mg IV TID
 Gentamycin 80mg IV TID
Dr Ahmed NEC
CBC:
WBC=7.4000,
G=78.8%, HGB
=9.2g/dl,
PLT=215
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14. Operation note
• Operation Note written as usual.
• Type of Anesthesia:-General Anesthesia
• Type of operation:-Debridement and lavage
• Indication: Deep SSI with necrotizing fasciitis
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15. • Intra OP Findings
• There was around 300ml of offensive puss in the pelvic cavity,
• with darkish necrotic tissue involved skin,
• subcutaneous tissue and fascia on lower abdomen more on Rt side
• Uterus & incision site of Uterus & bowel looks normal
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16. Cont’d
• Done :
• Puss was sucked out
• Debridement of necrotic tissue
• The wound was thoroughly washed with H2O2 and normal saline
• Drainage tube was kept
• Fascia was approximated
• Wound left open for wound care and dressed
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17. Post op order
• Keep NPO till bowel active
• MF:NS,DNS,RL over 24 hour
• Ceftrazone 1gm IV BID
• Metrinidazole 500mg IV TID
• Gentamycin 80mg IV TID
• Tramadol 100mg IV TID
• Diclofenac 75mg IMBID
• Wound care after 24 hours and then BID
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18. Vital signs 23 to 30/7/2015
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19. Vital sign follow up chart 1/8/15-09/8/15
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20. Progress note
• Progress note was written on, 25,28/7/15 & 2/08/15 and there is no
derangement interms of V/S & clinical status of the patient & she was
improving
• IV antibiotics was discontinued on 02/08/15.
• The wound was on a daily wound care with wet to dry dressings applied
and after surgical re-assessment, confirmed that the wound is clean and
ready for closure, on 15 days postoperatively
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21. Progress
• The wound was finally closed with using
delayed primary closure17 days
postoperatively
• The patient was discharged 19 days after the
operation with follow up appointment.
Dr Ahmed NEC 21
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22. Case
Discussion

23. List of problems
Necrotizing fasciitis
Deep SSI
Puerperal sepsis
Dr Ahmed NEC
EPIDEMIOLOGY PRESENTATION RISK FACTORS INVESTIGATIONS
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24. Introduction
Dr
Ahmed
NEC
• NF is a rapidly progressive soft tissue infection that
involves the superficial and deep fascia,
• leading to thrombosis of the cutaneous vessels and
gangrene of the underlying tissue.
• Is also known as flesh-eating disease
• Initially, the overlying tissue can appear unaffected
which makes difficult to diagnose without direct
visualization of the fascia.
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25. Epidemiology
Dr
Ahmed
NEC
• It is a rare infection
• Estimated incidence of 0.4 per 100,000 in the general
population and a mortality rate of up to 34%
• Both sexes are affected equally
• Become more severe in older and immune
compromised
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26. Epidemiology
Dr
Ahmed
NEC
• Necrotizing fasciitis had been earlier described by
Hippocrates in the 5th century BC.
• Its association with caesarean section was first
reported 1962.
• Since then, in an 8-year retrospective analysis of
5048 caesarean deliveries reported 9 cases, giving an
incidence rate of 1.8 per 1000 caesarean deliveries.
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27. Case report of necrotizing fasciitis after caesarean
Article May 2017
• 19-year-old para II mother. On her 4th pod after CS
• She complained of lower abdominal pains.
• On examination, she was afebrile (temperature 37.1°C); other vital
signs were within normal ranges.
• The incision site was clean with no evidence of surgical site infection.
• She was managed with analgesics (tramadol) and ampicillin was
continued as part of her routine postoperative care.
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28. Cont’d
• By day 5 postop, she developed an acute abdomen.
• The incision site had become very tender and soft tissue crepitation
was noted on either side of the incision
• Investigated with WBC=39.800cells/mm3, RBS=116mg/dl, HIV
negative, HGB=8.3g/dl
• A decision to do an exploratory laparotomy was taken.
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29. Operation note
• Upon reopening the lower segment incision (Pfannenstiel)
• IOF
• A pungent and offensive greenish seropurulent discharge oozed
from the site.
• Revealed abundant foul smelling ascites and an extensive spread of
greyish necrotic tissues involving the skin, subcutaneous tissue,
recti muscles, fascia, and anterior serosa of myometrium.
• The hysterotomy site was nondraining and hyperemic.
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30. Done:
• An intraoperative diagnosis of necrotizing fasciitis was made.
• All necrotic tissues were excised;
• Peritoneal cavity was thoroughly washed out.
• Two drainage tubes were also inserted.
• Anterior abdominal wound was left open to heal by secondary
intention.
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31. Done:
• She was transfused a whole blood in the immediate postoperative
period.
• Empiric broad spectrum intravenous antibiotics (metronidazole,
ceftriaxone, and gentamycin)
• Daily wound care was kept
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32. • She was deteriorated subsequently (septic shock)
managed by continuation of empiric antibiotics and
IV crystalloids:
• There was abundant drainage, and continual
progression of necrosis,
• the wound was extensively debrided approximately
2 cm beyond the bleeding edges to ensure adequate
resection on day 6 after laparotomy.
• The large defect with neither recti muscles nor fascia
was covered with the improvised abdominal mop
after each daily wound dressing
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33. • Finally as routine daily wound care did not show
further necrosis, and there were decreased drainage
and a marked improvement in her overall clinical
status.
• In addition to her regular daily meals, & nutritional
support.
• Two weeks after extensive debridement, a granulating
and healthy looking wound was seen.
• By the 15th week, the abdominal defect had closed.
• She was discharged to be followed up on an
outpatient basis
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34. Presentation
Dr
Ahmed
NEC
Symptoms
• early
• localized abscess or cellulitis with rapid
progression
• minimal swelling
• no trauma or discoloration
• late findings
• severe pain
• high fever, chills and rigors
• tachycardia.
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35. Presentation
Dr
Ahmed
NEC
Physical exam
• skin bullae
• discoloration
• ischemic patches
• cutaneous gangrene
• swelling, edema
• dermal induration and erythema
• subcutaneous emphysema (gas producing
organisms)
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36. Risk factors & Etiology
• immune suppression
• diabetes
• AIDS
• cancer
• obesity
• bacterial introduction
• IV drug use
• hypodermic therapeutic injections
• insect bites
• skin abrasions
• Abdominal and perineal surgery
In obstetrics, it can follow
cesarean delivery but can
also
• Complicate perineal
wounds
• Episiotomies
• Vulvar infections in diabetic
and immunosuppressed
women.
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37. Classification
Dr
Ahmed
NEC
• Based on the microbiological pathogens,
necrotizing fasciitis is classified into 4types
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38. Dr Ahmed NEC
• Is caused by aerobic and anaerobic bacteria.
• At least one anaerobic species most commonly
• Bacteroides, Clostridium, or Peptostreptococcus is isolated
• In combination with Enterobacteriaceae eg Escherichia
coli, Enterobacter, Klebsiella, Proteus
• And one or more facultative anaerobic streptococci (other than
group A Streptococcus [GAS]) .
Type I (poly microbial)
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39. Dr Ahmed NEC
• Obligate aerobes (such as Pseudomonas aeruginosa)
are rarely components of such mixed infections.
• Uncommonly, fungi (predominately Candida species)
are recovered in (type I) necrotizing infection
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40. Dr Ahmed NEC
• Usually caused by GAS or other beta-hemolytic streptococci.
• Infection may also occur as a result of Staphylococcus aureus
• Infection with no clear portal of entry occurs in about half of
cases
• In such circumstances, the pathogenesis of infection likely
consists of hematogenous translocation of GAS from the
throat (asymptomatic or symptomatic pharyngitis) to a site of
blunt trauma or muscle strain.
• Cause toxic shock syndrome
Monomicrobial (type II)
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41. Dr Ahmed NEC
• The causes of type III necrotizing infection include
• Vibrio vulnificus
• Gramm negative rods
• Infections due to these pathogens typically occur in the setting
of traumatic injury associated with sea water.
Type IV
• MRSA
Type III
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42. Investigations
• Blood cultures (two sets) should be obtained prior to administration of
antimicrobial therapy.
• Reasonable serum laboratory testing includes
• CBC, RBS, Chemistries. Liver function tests , Creatinine, Coagulation
studies, Creatine kinase concentration, Lactate concentration, and
inflammatory markers (C-reactive protein and/or erythrocyte
sedimentation rate).
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43. LRINEC Scoring
system
• score > 6 has PPV of 92% of having necrotizing
fasciitis
• CRP (mg/L)
• ≥150: 4 points
• WBC count (×103/mm3)
• <15: 0 points
• 15–25: 1 point
• >25: 2 points
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• Hemoglobin (g/dL)
• >13.5: 0 points
• 11–13.5: 1 point
• <11: 2 points
• Sodium (mmol/L)
• <135: 2 points
• Creatinine (umol/L)
• >141: 2 points
• Glucose (mmol/L)
• >10: 1 point

44. Investigations
• Radiologic studies are only considered as adjunct measures for doubtful
cases and cannot be used to exclude NF.
• A plain X-ray could show subcutaneous gas.
• CT-scan and MRI images could show asymmetrical fascial thickening,
fat stranding, and gas tracking along fascial planes.
• A gas on plain was revealed only 35% of radiographic studies.
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45. • Biopsy
• emergent frozen section can confirm diagnosis in early cases
• histological findings
• necrosis of fascial layer
• microorganisms within fascial layer
• PMN infiltration
• fibrinous thrombi in arteries and veins and necrosis of arterial and
venous walls
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46. Why is early diagnosis important?
• Delays in diagnosis associated with increased morbidity and mortality
• Predictors of mortality in NF :
– Time to first debridement
– Extent of tissue involvement
– # Failed organs on admission
– Inadequate first debridement
– Age > 60 years
– Bacteremia
– Elevated lactate
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47. Treatment
Dr
Ahmed
NEC
• NF is a medical emergency requiring prompt surgical
exploration and administration of intravenous broad
spectrum antibiotics.
• Aggressive and extensive debridement is the
mainstay of treatment.
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48. Antibiotics
Dr
Ahmed
NEC
• At the initiation of surgery, and with re-dosing
intraoperative, as determined by the length of the
procedure.
• Acceptable empiric antibiotic regimens include
• A carbapenem or beta-lactam-beta-lactamase
inhibitor plus
• An agent with activity against methicillin-
resistant S. aureus (MRSA; such as vancomycin
or linezolid plus Clindamycin, for its antitoxin
effects against toxin-elaborating strains of
streptococci and staphylococci (600 to 900 mg
intravenously [IV] every eight hours in adults;
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49. Approach to Surgical
Debridement
Dr
Ahmed
NEC
• OR as soon as the diagnosis is suspected
• Approach based upon tissues involved
• A circular pattern of debridement is advocated,
starting at the most severely involved region and
progressively working outwards until healthy soft
tissue is encountered
• Ensure adequate tissue perfusion and viability
• Prevent fluid pooling or collections
• Re-evaluate/return to OR in 24 hour
• Operative exploration is the gold
standard modality for diagnosis of NF
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50. Approach to Surgical
Debridement
Dr
Ahmed
NEC
• Intravascular volume should be maintained with
infusions
of crystalloid,
• Electrolyte abnormalities should be corrected.
• The abdominal wall, rectus sheath, omentum,
diverting colostomy for perineal/perianal
involvement and hysterectomy are also required for
extensive treatment, however in some cases reported
preservation of uterine.
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51. Approach to Surgical
Debridement
Dr
Ahmed
NEC
• At the initial and each subsequent debridement,
specimens at the margins of the wound should also
be sent for pathologic examination
• Once the debridement is completed, an antiseptic
dressing should be applied.
• We use an initial dressing of sodium hypochlorite
0.025% (1:20 Dakin solution [ie, 0.5% sodium
hypochlorite] diluted in sterile water or saline),
covered by absorptive layers of gauze secured in
place.
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52. Approach to Surgical
Debridement
Dr
Ahmed
NEC
Does time to re-debridement matter?
64 patients with NF at USC-LAC over 6 years
Practice algorithms by 2 different services
Short duration (24-48 hrs) vs Extended duration (> 48
hrs) until second debridement
Short duration associated with lower AKI and
mortality
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53. Conclusion
• Necrotizing fasciitis is a rapidly progressive, often lethal, infectious
disease process that requires early aggressive debridement.
• Any patient with inordinate pain and edema in the pelvis, especially in
the puerperium, should be suspected of having this disease
4/28/2023 Dr Ahmed NEC 53

54. Cont’d
• Radiographic studies are often diagnostic of this condition.
• The triad of, pain of out of proportion, edema, and any sign of
septicemia carries an extremely grave prognosis and mandates
immediate surgical intervention.
4/28/2023 Dr Ahmed NEC 54

55. comments
• Strength
• Diagnosis of necrotizing fasciitis to
OR time is early
• Surgical side involved in management
• Antibiotic started early
Dr Ahmed NEC 55
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56. comments
• Weakness
• Basic Investigations not
determined
• RBS
• OFT,
• C-reactive protein (CRP)
• Lactate
• procalcitonin (PCT)
• Sample was not sent to pathology
• Drug sensitivity culture not done
• Resuscitation points not mentioned
Dr Ahmed NEC 56
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57. Reference
Dr
Ahmed
NEC
• Schwartz’s Principles of Surgery 11th Edition
• Sabiston Textbook of Surgery 21st Edition
• Bailey and love’s short practice of surgery
• Uptodate 2022
• American journal of obstetrics and gynecology,
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58. THANK YOU
Dr
Ahmed
NEC
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