Necrotizing Fasciitis: What I do and When William Obremskey MD MPH MMHC Vanderbilt University Medical Center
Disclosures • Board SEFC • OTA EBQVS Chair • No Industry Conflicts
Necrotizing Fasciitis Basem Attum, MD Addison K. May, MD, FACS, FCCM John Schoenecker MD PhD Megan Mignemi MD William Obremskey, MD, MPH, MMHC Vanderbilt University Medical Center Created August 2017
Necrotizing Fascitis • JAAOS Article – Coming Soon
“My Summer Vacation with Necrotizing Fasciitis” William T Obremskey MD MPH MMHC Vanderbilt Orthopedic Trauma
Necrotizing Fasciitis
Classification of SSTIs 1) superficial cellulitis 2) superficial abscesses DEPTH 3) deep abscesses 4) necrotizing cellulitis 5) necrotizing fasciitis 6) myonecrosis
Hippocrates, ~5 th Century BC “Many were attacked by the erysipelas all over the body…Flesh, sinews and bones fell away in large quantities…The flux which formed was not like pus but a different sort of putrefaction with a copius and varied flux…There were many deaths.”
Frank Meleney ‘Infections of Skin and the Subcutaneous Tissue’ in 1930, published in the Bulletin of the New York Academy of Medicine. • Page 370 ‘Hemolytic streptococcus gangrene’ which is a classic description of what we call ‘necrotizing fasciitis’ • ‘We do not know the cause of this unusually rapid development of necrosis in these cases; whether it is due to a peculiar quality of the infecting organisms or the hypersensitive state of the patient.’
Frequency of soft tissue infections increasing Pallin DJ : Annals of Emergency Med – 2008
Goals and objectives • Necrotizing Fasciitis: What I do and When • 1) Diagnosis • 2) Operate Early • 3) Transfer if needed AFTER surgery • 4) Know Pathogens and AB selection • 5) Avoid Transmission
Diagnosis of Necrotizing SSTI: • “Hard signs” for the presence of a necrotizing process: presence of bullae 1) skin ecchymosis that precedes skin necrosis 2) 3) presence of gas in tissues by exam or on radiographs 4) cutaneous anesthesia – Present in 7- 44% of cases • Other suggestive signs: 5) pain disproportionate to examination (Like Compartment Syndrome!!) 6) edema extending beyond skin erythema 7) systemic toxicity 8) progression of infection despite antibiotic therapy
Risk Factors +/- history of trauma Diabetes Obesity Vascular Disease IV drug use ETOH abuse Malnutrition Smoking Cardiac disease Steroid use Immunosuppression Cancer Age
Risk Factors • 50% No Trauma • Diabetes present in 18-60% • > 50% Healthy Pts
Necrotizing skin and soft tissue infections (SSTI) Mortality from necrotizing SSTI remains high • 67 retrospective reports since 1980 • 3302 patients • Overall – Amputation 33% – mortality – 23.5% May AK. Surg Clin N Am. 2009; 89:403–420
Most common in necrotizing SSTI May AK. Surg Clin N Am. 2009. 89: 403–420
Clinical Findings Mild skin changes
Clinical Findings Mild skin changes Rapid progression
Clinical Findings Mild skin changes Rapid progression
Clinical Findings Mild skin changes Rapid progression
Clinical Findings Mild skin changes Rapid progression Blisters/Bullae Bruising Necrotic Skin
Clinical Findings Mild skin changes Rapid progression Blisters/Bullae Bruising Necrotic Skin Systemic changes: Hypotension Tachycardia AMS Pain
Bullae, ecchymosis, loss of sensation
Necrotizing Streptococcal Cellulitis
Staphyloccal Toxic Shock
Staphyloccal Toxic Shock
Objective Criteria to Distinguish Necrotizing from Non-necrotizing Infection Positive Negative Sensitivity Specificity Predictive Predictive (%) (%) Value (%) Value (%) Tense Edema 38 100 100 62 Gas on XR 39 95 88 62 Bullae 24 100 100 57 WBC > 14 x 10 9 /L 81 76 77 80 Sodium < 135 mmol/L 75 100 100 77 Chloride < 95 mmol/L 30 100 100 55 BUN > 15 mg/dL 70 88 88 71 Wall DB et al. Am J Surg . 2000;179:17-21.
Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score Laboratory parameter, LRINEC Laboratory parameter, LRINEC units points units points CRP, mg/L Sodium, mmol/L ≥135 <150 0 0 ≥150 4 <135 2 Total WBC, k/mm 3 Creatinine, mg/dL ≤1.6 <15 0 0 15-25 1 >1.6 2 >25 2 Glucose, mg/dL ≤180 Hb, g/dL 0 >13.5 0 >180 1 11–13.5 1 <11 2 31 Modified from Abrahamian FM, et al. Infect Dis Clin North Am . 2008;22:89-116; Wong CH, et al. Crit Care Med. 2004;32:1535-1541. 31
LRINEC Score: Corresponding Risk and Probability of Necrotizing SSTI Probability of Necrotizing Fasciitis (%) 110 100 LRINEC Score 90 80 Probability of 70 LRINEC Risk necrotizing 60 score category SSTI 50 ≤5 Low <50% 40 6–7 Intermediate 50%–75% 30 ≥8 20 High >75% 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 LRINEC Score Finding abnormalities that make up the LRINEC score in patients with SSTI should increase suspicion of a necrotizing infection such that further observation and evaluation should be considered 32 Wong CH, et al. Crit Care Med . 2004;32:1535-1541. 32 Abrahamian FM, et al. Infect Dis Clin North Am. 2008;22:89-116, vi.
Treatment • Fluid support • Ventilatory support • OPERATE EARLY – Treat like CPS – ABOS Q’s – Recert exam – JAAOS – Coming soon • Antibiotics – – multiple broad – Culture directed • Steroids - ? If “toxic”
Clostridial Myonecrosis: 36 Hrs-Untreated Stab Wound
Independent Predictors for Mortality Retrospective reviews identify several factors: • Time to first debridement • Inadequate first debridement • Extent of tissue involvement • Age > 60 years • Bacteremia • # Failed organs on admission • Elevated lactate Bosshardt TL. Arch.Surg . 1996;131:846-52 Elliott DC. Ann.Surg . 1996; 224:672-83 Bilton BD. Am.Surg. 1998; 64:397-400
Treatment of necrotizing SSTI • Surgical debridement is mainstay of therapy • Aggressive debridement of all involved tissues • Average number of débridements 3-4 / patient • STSG or flap coverage most commonly used for coverage of tissue defects • Studies suggest that early and aggressive surgical therapy can reduce mortality to < 10% Bosshardt TL. Arch.Surg . 1996;131:846-52 Gunter OL Surg. Infect. 2008; 9:443-450 Elliott DC. Ann.Surg . 1996; 224:672-83 Bilton BD. Am.Surg. 1998; 64:397-400
Summary of surgical approach • HARD signs = necrotizing infection and require OR – Bullae, cutaneous anesthesia, ecchymosis, tense edema, gas • Early and aggressive surgical debridement improves outcome with achievable mortality of < 10% • Carefully consider factors that suggest necrotizing process • Empiric surgical exploration if in doubt!
How to Avoid Transmission?
Index patient: 34 yo M LE nec fasc, taken to OR for debridement 48 h postop HCW 1 (resp therapist): + GAS pharyngitis
Transmission through aerosols: Open wounds Secretions
The best treatment places healthcare workers at risk Protect your oropharynx!
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