Necrotizing Fasciitis


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necrotizing fasciitis is a life threatening condition. this ppt highlights causes, microbiology and treatment of the condition.

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Necrotizing Fasciitis

  2. 2. Outline <ul><li>Definition </li></ul><ul><li>Causes. </li></ul><ul><li>Pathophysiology. </li></ul><ul><li>Clinical features. </li></ul><ul><li>Diagnosis </li></ul><ul><li>D.D. </li></ul><ul><li>Complications. </li></ul><ul><li>Treatment </li></ul>
  3. 3. Definition <ul><li>A progressive life-threatening soft-tissue infection (with liquifactive necrosis of subcutaneous fat and fascia) ± skin . </li></ul><ul><li>Cheng NC, Su YM, Kuo YS, Tai HC, Tang YB. Factors affecting the mortality of necrotizing fasciitis involving the upper extremities.  Surg Today . 2008;38(12):1108-13. </li></ul><ul><li>Early reports date back to the 5th century B.C. , when Hippocrates described a complication of erysipelas. </li></ul><ul><li>The term “ necrotizing fasciitis” was first used on 1952 </li></ul>
  4. 4. Causes <ul><li>Surgery may induce local tissue injury and bacterial invasion (e.g. intraperitoneal or perianal abscesses) </li></ul><ul><li>Trauma. </li></ul><ul><li>IM injections. </li></ul><ul><li>Local hypoxia with systemic illnes s ( immunosuppression or DM  compromise of the fascial blood supply ) Schwartz’s principles of surgery, 9 th ed. </li></ul><ul><li>A possible relationship between the use of NSAIDs ( as ibuprofen ) and development of necrotizing fasciitis during varicella infections has been shown. </li></ul><ul><li>Zerr DM, Alexander ER, Duchin JS, et al .  A case - control study of necrotizing fasciitis during primary varicella .   Pediatrics .  Apr 1999;103 ( 4 Pt 1 ): 783-90 . </li></ul>
  5. 5. Idiopathic necrotizing fasciitis <ul><ul><li>No obvious portal of entry. </li></ul></ul><ul><ul><li>typically involves genetalia ( Fourniere Gangrene ) or lower extremities. </li></ul></ul><ul><ul><li>caused by single organism (e.g. Strep. pyogenes) </li></ul></ul><ul><ul><li>May be due to unrecognized breaks in skin or hematogenous spread </li></ul></ul>
  6. 6. Pathophysiology <ul><li>1ry site of pathology is the superficial fascia. </li></ul><ul><li>Surgery / Trauma  tissue hypoxia  PMNL dysfunction  good environment for f acultative aerob es  more ↓ oxidation  proliferat ion of anaerobic bacteria  angiothrombotic microbial invasion  liquefactive necrosis </li></ul><ul><li>Microbiology: </li></ul><ul><li>- G roup A h a emolytic streptococci . </li></ul><ul><li>- Staph. Aureus. </li></ul><ul><li>- O ther s : Bacteroides, Clostridium, and ( Vibrio vulnificus often in chronic liver D .) </li></ul><ul><li>- Fungi (Rare and less aggressive forms) SCH </li></ul><ul><li>A erobic metabolism  C o 2 + H 2 O . </li></ul><ul><li>Ana erobic metabol .  H, N , H 2 S. </li></ul>
  7. 7. <ul><li>Type I </li></ul><ul><li>Polymicrobial ( aerobic and anaerobi c) </li></ul><ul><li>C ommon with DM and PVD, after surgical procedures </li></ul><ul><li>Type II </li></ul><ul><li>- Monomicrobial (primarily by GAS, occasionally caused by community-associated MRSA). </li></ul>
  8. 8. Clinical features <ul><li>♂ : ♀ ratio = 2-3 : 1, adult or elderly. </li></ul><ul><li>History of recent trauma or surgery. </li></ul><ul><li>sudden onset of pain and swelling . </li></ul><ul><li>hours to days </li></ul><ul><li>anaesthesia . </li></ul><ul><li>Early Diagnosis can be challenging as p hysical findings may be out of proportion with degree of patient discomfort (high degree of suspicion is mandatory). </li></ul>
  9. 9. Physical findings <ul><li>Toxaemia (esp. late) </li></ul><ul><li>area of erythema </li></ul>quickly spreads into normal skin without sharp demarcation dusky or purplish skin m ultiple identical patches of gangrenous skin <ul><li>- large area of skin gangren e. </li></ul><ul><li>Bullae with putrid discharge. </li></ul><ul><li>Local crepitus (infrequent) </li></ul><ul><li>Fascial necrosis . </li></ul><ul><li>Without ttt  myonecrosis. </li></ul><ul><li>Fever. </li></ul><ul><li>Shock. </li></ul><ul><li>MOF </li></ul>
  10. 10. <ul><li>Important distinguishing features: (SABISTON’S TEXTBOOK OF SURGERY) </li></ul><ul><li>wooden hard feel of subcutaneous Tissue. </li></ul><ul><li>while yeilding in cellulitis and erysipelas. </li></ul><ul><li>If an open wound  probing allows easy dissection of superficial fascial planes beyound wound margins with little pain. </li></ul>
  12. 12. <ul><li>A. This patient developed pain on moving the rt hip with cellulitis 2 weeks after total colectomy. </li></ul><ul><li>B. Cellulitis didn’t respond to medical ttt, and surgery was done showing dishwater oedema of sc tissue. </li></ul><ul><li>C. Muscles were viable. </li></ul><ul><li>Source: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL: Schwatrz’s Principles of Surgery. 9 th ed . All rights reserved </li></ul>A B C
  13. 13. Can affect any part of body <ul><ul><li>Perineum : </li></ul></ul><ul><ul><li>neglected ischiorectal/perineal abscess. </li></ul></ul><ul><ul><li>Vulva: </li></ul></ul><ul><ul><li>Bartholin’s gland duct abscess </li></ul></ul><ul><ul><li>vulvar abscess </li></ul></ul><ul><ul><li>post-op wound infection from C-section or episiotomy. </li></ul></ul><ul><ul><li>Fourniere gangrene: </li></ul></ul><ul><ul><li>GU infection or surgery. </li></ul></ul><ul><ul><li>traumatic instrumentation </li></ul></ul><ul><ul><li>Scalp/Periorbital : trauma, eyelid infections. </li></ul></ul><ul><ul><li>Face/Neck : progressive dental infections, peritonsillar abscess, salivary gland infections, cervical adenitis, otologic sources </li></ul></ul><ul><li>- Trauma </li></ul><ul><ul><li>drug abuse </li></ul></ul><ul><ul><li>insect bites (rare). </li></ul></ul>post-op complication of abd surgery Complication of percutaneous catheter placement: chest tube or percutaneous drain of abd. abscess
  14. 14. Diagnosis <ul><li>It is mainly a Clinical Diagnosis . </li></ul><ul><li>LAB: LRINEC </li></ul><ul><li>L ab R isk I ndicator for NEC rotizing fascii. </li></ul><ul><ul><li>> 6 should raise suspicion of NF </li></ul></ul><ul><ul><li>> 8 is highly predictive of NF Imaging </li></ul></ul>1 > 180 mg % Serum Glucose 2 < 135 Meq / L Serum Na 1 2 11 – 13 g% < 11 g% Hb 1 2 15 – 25 X 103 > 25 X 103 Leucocytosis 4 > 150 mg/L CRP POINTS PARAMETER
  15. 15. PLAIN X RAY of an established case of necrotizing fasciitis of lower limb (stage 3) showing: 1- Soft tissue thickening 2- Subcutaneous gas 1 1 2 2 2
  16. 16. <ul><li>acute inflammatory cells in the necrotic tissue . - Bacteria are located in the haziness of their cytoplasm. - Obliterative thrombosis of a,v </li></ul><ul><li>Imaging techniques ( such as MRI ) and frozen section biopsies, have been reported to be of value in early recognition of necrotizing fasciitis . </li></ul><ul><li>Curr Opin Infect Dis 18:101–106. # 2005 Lippincott Williams & Wilkins. </li></ul>
  17. 17. D.D - - - + ++++ DM - - ++++ + ++++ Obvious portal of entry - - ++++ - ++ Gas in tissue + + ++++ ++++ ++ Systemic Toxicity ++ ++ ++++ ++++ ++ Local Pain ++++ + + + + Diffuse Pain ++ ++ +++ ++++ ++ Fever Myositis viral/ parasitic Pyomyositis Gas Gangrene Type 2 Type 1 Clinical Findings
  18. 18. Complications: <ul><li>- Overall mortality is up to 30% from: </li></ul><ul><li>MOF </li></ul><ul><li>Septic shock. </li></ul><ul><li>Toxic shock syndrome (TSS) </li></ul><ul><li>Contributing factors: </li></ul><ul><li>* Old age. * DM. * Missed early diagnosis. </li></ul><ul><li>* Trunkal invol. * Anorectal invol. </li></ul><ul><li>* Late pres. * Failure after 1 st op. </li></ul><ul><li>File TM, Tan JS .  Group A strept. necrotizing fasciitis .   Compr Ther.  2000;26 ( 2 ): 73-8. </li></ul>
  19. 19. Treatment <ul><li>D elay in diagnosis and treatment of necrotizing fasciitis increase s mortality </li></ul><ul><li>McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality in necrotizing soft tissue infections. Ann Surg 1995; 221:558–563. </li></ul><ul><li>Aggressive ttt is needed even for suspected cases to reduce mortality . </li></ul>
  20. 20. <ul><li>ABC. </li></ul><ul><li>A ntibiotics as soon as possible ( aerobic and anaerobic bacteria ) </li></ul><ul><li>Surgery: </li></ul><ul><li>Aggressive resuscitation followed by aggressive debridement of all necrotic tissue . </li></ul><ul><li>may need to be repeated ( careful daily postop inspection ). </li></ul><ul><li>fasciotomies in extremities . </li></ul><ul><li>Amputation for myonecrosis in limbs </li></ul><ul><li>Postop use of unprocessed honey </li></ul><ul><li>Stimulates epithelialization. </li></ul><ul><li>Debrides </li></ul><ul><li>Deodourizes wound </li></ul><ul><li>Dehydrates </li></ul><ul><li>Akram Rajiput, Waseem Abul Samad, Mortality in necrotizing fasciitis. J Ayub Med Coll Abbottabad 2008; 20(2) </li></ul>
  21. 21. <ul><li>IV IG (UNDER STUDY) </li></ul><ul><li>Hyperbaric oxygen therapy </li></ul><ul><li>( HBO ) </li></ul><ul><li>Def. = use of 100 % O 2 at +++ pressure (3 AP). </li></ul><ul><li>↑ normal O 2 saturation in infected wounds by a thousand fold: </li></ul><ul><li> bacteriocidal effect. </li></ul><ul><li> ↑ PMN function </li></ul><ul><li> ↓ clostridial α toxin </li></ul><ul><li>production. </li></ul><ul><li> enhanced wound healing . </li></ul><ul><li>Mulla ZD. Hyperbaric oxygen in necrotizing fasciitis.  Plast Reconstr Surg .  Dec 2008;122 (6):1984-5. </li></ul>
  22. 22. Hyperbaric oxygen therapy <ul><li>Untreated pneumothorax </li></ul><ul><li>Asthma </li></ul><ul><li>COPD </li></ul><ul><li>Eustachian tube dysfunction </li></ul><ul><li>Pregnancy </li></ul><ul><li>Claustrophobia </li></ul><ul><li>Air embolism </li></ul><ul><li>CO poisoning </li></ul><ul><li>Necrotizing soft tissue infections </li></ul><ul><li>Gas gangrene </li></ul><ul><li>Crush injury </li></ul><ul><li>Decompression sickness </li></ul><ul><li>Enhancement of healing in selected wounds </li></ul><ul><li>Osteomyelitis (refractory) </li></ul><ul><li>Compromized skin grafts </li></ul>Contraindications Indications
  23. 23. <ul><li>HBO cannot replace surgery . The best outcome is obtained using a combined approach of antibiotics, surgery, and HBO, when readily available . </li></ul>