- Current Concepts in the Management of Necrotizing Fasciitis
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As soon as there is a reasonable suspicion or a NSTI or gas gangrene, then surgical consultation must be sought, since this is a surgical emergency. If the patient is confirmed to have a NSTI or gas gangrene, then prompt surgical exploration and aggressive surgical debridement of the affected fascia are mandatory.
Current Concepts in the Management of Necrotizing Fasciitis
For a NSTI, after the initial debridement procedure has been completed, the patient will require re-exploration in 24 hours, and this will need to be done daily, until it has been confirmed that all non-viable tissue has been resected. Many patients with a NSTI will require four or five debridement procedures during their first hospital admission. The likely requirement for several surgical debridements over a period of many days also applies to patients with gas gangrene.
At the time of the initial diagnosis of either a NSTI or gas gangrene, it may be necessary to promptly arrange for transfer to a facility that has expertise with the management of complex wounds. Some have advocated that patients with a NSTI should receive care in a burn center, but it is unclear as to whether or not this decreases mortality.
It is essential to immediately start broad-spectrum antibiotic therapy that provides adequate coverage for the most likely causative organisms. Antibiotic therapy may be eventually discontinued, that is, several days after the last surgical debridement has been performed. Currently, there are no established guidelines that specify the optimal length of treatment with antibiotic therapy.
For patients with type II NSTI who develop streptococcal toxic shock syndrome, which is associated with increased capillary permeability and hypotension, there may be a need for the very aggressive administration of IV fluids, that is liters per day , and pressor support may also be required.
It is important to be aware that the use of either epinephrine or norepinephrine in this setting may be associated with the development of symmetrical gangrene. Since it is not widely available, and has not been well-studied, there is only limited evidence to support the use of HBO for the treatment of NSTI. Some patients with NSTI may develop respiratory failure, and then will require mechanical ventilation. Initially admitting the patient to the intensive care unit ICU should be strongly considered, to allow for close monitoring of his or her hemodynamic status. Nutritional support in the form of supplemental enteral or parenteral nutrition is essential for patients with a NSTI, and this should be provided as soon as the patient is hemodynamically stable.
Postoperative wound management will be necessary after the patient undergoes surgical debridements. The placement of split-thickness skin grafts, full-thickness skin grafts, or temporary skin substitutes such as cadaveric skin allografts or porcine skin xenografts may be necessary, if the postoperative wound is not suitable for primary closure. Broad-spectrum antibiotics must be started immediately in the emergency department. Appropriate antibiotic coverage for adults with NSTIs is indicated below:. Anaerobic coverage must be provided, since the infection is usually polymicrobial.
Empiric antibiotic therapy options are:.
Careful assessment of the areas that have been surgically debrided is important, to ensure that the NSTI or gas gangrene has been adequately treated. If there are any skin areas that are concerning, then the surgeon should be advised about this, since the patient may require another debridement procedure. Since intravascular hemolysis can occur in bacteremic patients with traumatic gas gangrene, they require a daily CBC, until repeat blood cultures become negative.
Long-term management of the NTSI or gas gangrene, that is, after the patient has undergone surgical debridement procedures, would most likely be coordinated by the surgeon. This is because the patient may have extensive surgical wounds, for which a skin graft or temporary skin substitute may be needed for closure. Surgical follow-up would be necessary to ensure that these wounds are adequately addressed. Urgent surgical consultation is required for patients suspected of having either a NSTI or Clostridial myonecrosis gas gangrene.
Do not delay surgical evaluation pending imaging studies. Antibiotic therapy must be started immediately for patients with either a NSTI or Clostridial myonecrosis gas gangrene. Renal Insufficiency.
The antibiotics that are administered for the treatment of the NSTI or gas gangrene Clostridial myonecrosis would need to be renally dosed. Since patients with NSTI and gas gangrene often require fluid resuscitation, care would need to be taken to avoid the development of acute decompensated heart failure, as a result of the aggressive administration of IV fluids. Sign-out considerations While Hospitalized.
Careful monitoring of all surgically debrided areas is important to ensure that evidence of a NSTI does not recur. This would be an indication for the patient to promptly undergo additional surgical debridement.
Monitor the hemoglobin in a bacteremic patient with traumatic gas gangrene Clostridial myonecrosis , since intravascular hemolysis may develop and is associated with increased morbidity and mortality. A patient who presents with a NSTI or gas gangrene Clostridial myonecrosis will likely require multiple surgical debridements, and often requires stabilization in the ICU during his or her hospital admission.
There is no evidence that a NSTI or gas gangrene Clostridial myonecrosis is still present, including no signs of systemic toxicity.
When should clinic follow up be arranged and with whom? Surgical follow-up within 1 week, for monitoring of the wounds that resulted from surgical debridements.
If the patient required extensive surgical debridements for treatment of the NSTI or gas gangrene Clostridial myonecrosis , then placement in an LTAC or SNF, that is equipped to properly manage complex wounds, may be necessary. Patient Safety and Quality Measures. Core Indicator Standards and Documentation.
The importance of appropriate wound care for the wounds that developed as a result of surgical debridement, need to be stressed to the patient. Doing so may help to reduce the likelihood that an infection will develop at these sites. J Foot Ankle Surg. Hussein, Q, Anaya, D. Crit Care Clin. Mullangi, P, Khardori, N. Med Clin N Am. Clin Infect Dis. J Intensive Care Med. J Trauma. Ustin, J, Malangoni, M. Crit Care Med. Intensive Care Med. Arch Surg. Hakkarainen, T. Curr Problems Surg. J Burn Care and Res. J Emerg Med. Rheum Dis Clin N Am.
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