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Necrotizing Fasciitis Dr. Shirish Silwal House Officer Dept. of General Surgery & Urology B & B Hospital Pvt. Ltd.

Necrotizing faciitis

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Page 1: Necrotizing faciitis

Necrotizing Fasciitis

Dr. Shirish SilwalHouse Officer

Dept. of General Surgery & UrologyB & B Hospital Pvt. Ltd.

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Case 1 Mr BKB, 54 years presented in the Emergency on

2070/3/31. Swelling and Pain in left lower leg . Watery discharge with skin blisters. H/O small wound due to insect bite a month ago. H/O Fever on and off for 3 days, not associated with

chills or rigor. Primary management done in other center took

antibiotic for 1 day and Hot water bath taken. K/C/O HTN, NO PREVIOUS H/O DIABETES.

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GENERAL EXAMINATIONGeneral condition- Fair JALCCOD - Nil , Vitals – T 97° F, BP 110/80 mm of Hg

SYSTEMIC EXAMINATION Per Abdominal Findings

Soft & non tender, bowel sound (+),No organomegaly

Respiratory system FindingsB/L vesicular breathe sound, No added sound

Other systemic findings NAD

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LOCAL EXAMINATION OF LEFT LEG Inspection

• Discoloration of skin (+)• Redness and swelling up to knee region • Bulla with serous discharge present at the dorsum of

foot and ankle• Movement of distal joint (+)

Palpation• Tenderness present• Increased local temperature• Neurovascular system not assessable due to edema

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INVESTIGATION CBC• WBC- 8400/Cumm• Neutrophils - 85%• Lymphocyte- 15%• Platelets - 153000 RFT• Urea- 75mg/dl• Creatinine- 1mg/dl• Na+ 125mmol/L,• K+ 2.5mmol/L

Blood sugar- 230 mg/dl LIVER FUNCTION TEST • Billirubin Total-1.0 mg/dl• Billirubin Direct- 1.0 mg/dl• SGPT/ALT- 39 IU/L• SGOT/AST- 50 IU/L• AlkalinePhosphatase- 128 IU/L• URINE RME - NAD• VENOUS DOPPLER - NORMAL

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CULTUREWound/pus culture: No growth (2070/3/31)No growth (2070/4/16)Heavy growth of pseudomonas sp.(2070/4/22) Pseudomonas aeroginosa(2070/4/24) national

reference lab.No growth after 48 hours(2070/4/28)

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(2070/4/5) After Fasciotomy

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(2070/4/11)- Continuous Debridement and hot water bath

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(2070/5/2)- After Skin Grafting

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Treatment Diagnosed as uncontrolled diabetics with Cellulitis with

Necrotizing fasciitis Insulin on sliding scale IV antibiotics GentamycinMetronidazolePenicillinClindamycin Blood transfusion VIII bag

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Surgery Fasciotomy done on (2070/4/2)Daily debridement, dressing and foot bath.Debridement with povidone iodine, washing

powder, Neosporin powder, placentex.Skin grafting on (2070/4/31)

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Skin graft Requirement of survival Bed must be well vascularized. The contact between graft and recipient must be fully immobile. Low bacterial count at the site. Cause of failure Systemic Factors

Malnutrition Sepsis Medical Conditions (Diabetes) Medications

Steroids Antineoplastic agents Vasoconstrictors (e.g. nicotine)

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Post-operative statusPatient is stable and afebrile.Skin grafting 90% accepted.No foul smell from wound.Diabetes and Blood Pressure under control.

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Necrotizing fasciitis

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Past history Hippocrates in the 5th century BC noted known as malignant ulcer, gangrenous ulcer ,

putrid ulcer, and hospital gangrene in the 18th century

In 1871 after the Civil War was called hospital gangrene by a war surgeon

In 1924 called hemolytic streptococcal gangreneIn 1952 called “necrotizing fasciitis”

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DefinitionCharacterized by fulminant destruction of tissue,

systemic signs of toxicity, and a high mortality rate.

Pathologic features include extensive tissue destruction, thrombosis of blood vessels, abundant bacterial spread along fascial planes, and unimpressive infiltration of acute inflammatory cells.

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Risk FactorsDrug useDiabetes mellitusObesityImmunosuppressionRenal failure

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Types of Necrotizing InfectionNecrotizing cellulitis

Clostridial cellulitisNonclostridial anaerobic cellulitisMeleney’s synergistic gangreneSynergistic necrotizing cellulitis

Necrotizing fasciitisType IType II

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Type I Necrotizing FasciitisMixed aerobic and anaerobic infectionBacteria almost always isolatedStaphylococcus aureus, Streptococci,

Enterococci, E.coli, Peptostreptococcus species, Prevotella, Porphyromonas, bacteroides fragilis and Clostridium species.

More common in diabetics, post op patients, and patients with peripheral vascular disease.

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Type I Cervical necrotizing fasciitis

Ludwig’s angina

Fournier’s gangreneCaused by penetration of the GI or urethral

mucosa by enteric organisms

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Type II Necrotizing Fasciitis Monomicrobial

Group A Strep ORSA

Can occur in any age group and in healthy patients Risk factors

H/o blunt trauma or laceration Varicella Injection drug use Post operative Post partum Burns Exposure to a case ?NSAIDs

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Type II Can result from hematogenous translocation

from GAS in throatNSAIDs thought to inhibit neutrophil function or

mask symptoms and delay diagnosis

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Pathophysiology"Flesh-eating bacteria" is a misnomer, as the

bacteria do not actually "eat" the tissue. They cause the destruction of skin and muscle by releasing toxins (virulence factors), which include streptococcal pyogenic exotoxins.

Streptococcus pyogenes produces an exotoxin known as a superantigen. This toxin is capable of activating T-cells non-specifically, which causes the overproduction of cytokines and severe systemic illness (Toxic shock syndrome).

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Clinical Manifestations

• Unexplained/disproportionate pain

• Blister and bullae formation• Signs of systemic toxicity

fever tachycardia hypotension• Tense edema outside the

involved skin• Crepitus/subcutaneous gas

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Why it is so aggressive?Toxins-host releases

cytokines, including interleukin-2, tumor necrosis factor and gamma-interferon. resulting in shock

substances cause vascular thrombosis and ischemic gangrene

tissue is consumed at 1 inch per hour

inoculation from subcutaneous tissuehematogenous spread from distant site found in post op complications of fecal

contaminated woundshock & multi system organ failure, ARDS

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Risk Score1) Serum CRP >= 150mg/L (4 pt)2) WBC 15K-25K (1 pt) or > 25K (2 pt)3) Hb 11-13.5 (1 pt) or <= 11 (2 pt)4) Na < 135 (2 pt)5) Cr >1.6 (2 pt)6) Glucose >180 (1 pt)

Score >/= 6 should raise suspicion for NF >/= 8 highly predictive of NF

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Diagnosis Imaging

Soft tissue X-rays, CT, MRI Can reveal gas in the tissues, but not as good as direct

surgical exploration

Role of Doppler these techniques showed changes in subcutaneous adipose tissue , fascia and muscle.

Cultures Blood Culture positive in 60% with type II, 20% with

type I Surgical wound cultures almost always positive

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Treatment Early and aggressive surgical exploration and debridement

Re exploration should be performed with in 24 hrs Antibiotic therapy

Type I: Ampicillin or Unasyn(Ampicillin + Sulbactam) with clindamycin or metronidazole

If recent hospitalization, use Zosyn (Piperacillin and Tazobactam Injection)or Timentin (Ticarcillin and Clavulanate) instead of Unasyn.

Type II: Penicillin G and clindamycin; vancomycin Hemodynamic support Intravenous immunoglobulin (currently under investigation, but not

recommended) well an attempt to reduce hyper proliferation of T cells inhibit production of tumor necrosis factor

Hyperbaric oxygen therapy

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Role of SurgeryNecrotizing fasciitis is a surgical

emergency, the patient should be admitted

immediately to a surgical intensive care unit in a setting such as a regional burn center or trauma center, where the surgical staff is skilled in performing extensive debridement and reconstructive surgery.

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Prognosis• Aggressive treatment- mortality 30%• Delayed treatment- mortality 92%• Patient with predisposing factor- mortality 80%• Ineffective debridement- mortality 83%• Death cause by sepsis and multi organ failure• Predictor for mortality WBC >30k,Creatinine>2 Clostridia infection Presence of heart disease during admission

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ConclusionNecrotizing fasciities is a aggressive disease.Rapid identification and rapid treatment is

essential for recovery from this aggressive disease.

Aggressive disease should be treated aggressively.

Tit For Tat.

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Thank You