Necrotizing Fasciitis: What I do and When William Obremskey MD MPH - - PowerPoint PPT Presentation

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Necrotizing Fasciitis: What I do and When William Obremskey MD MPH - - PowerPoint PPT Presentation

Aug 15, 2023 114 likes •571 views

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,

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Necrotizing Fasciitis: What I do and When William Obremskey MD MPH MMHC

Vanderbilt University Medical Center

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Disclosures

  • Board SEFC
  • OTA EBQVS Chair
  • No Industry Conflicts
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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

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Necrotizing Fascitis

  • JAAOS Article

– Coming Soon

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William T Obremskey MD MPH MMHC Vanderbilt Orthopedic Trauma

“My Summer Vacation with Necrotizing Fasciitis”

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Necrotizing Fasciitis

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Classification of SSTIs

1) superficial cellulitis 2) superficial abscesses 3) deep abscesses 4) necrotizing cellulitis 5) necrotizing fasciitis 6) myonecrosis

DEPTH

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“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.”

Hippocrates, ~5th Century BC

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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.’

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Pallin DJ : Annals of Emergency Med – 2008

Frequency of soft tissue infections increasing

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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
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Diagnosis of Necrotizing SSTI:

  • “Hard signs” for the presence of a necrotizing process:

1) presence of bullae 2) skin ecchymosis that precedes skin necrosis 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

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Risk Factors

+/- history of trauma Diabetes Obesity Vascular Disease IV drug use ETOH abuse Malnutrition Smoking Cardiac disease Steroid use Immunosuppression Cancer Age

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Risk Factors

  • 50% No Trauma
  • Diabetes present in 18-60%
  • > 50% Healthy Pts
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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

Necrotizing skin and soft tissue infections

(SSTI)

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Most common in necrotizing SSTI

May AK. Surg Clin N Am. 2009. 89: 403–420

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Clinical Findings

Mild skin changes

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Clinical Findings

Mild skin changes Rapid progression

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Clinical Findings

Mild skin changes Rapid progression

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Clinical Findings

Mild skin changes Rapid progression

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Mild skin changes Rapid progression Blisters/Bullae Bruising Necrotic Skin

Clinical Findings

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Clinical Findings

Mild skin changes Rapid progression Blisters/Bullae Bruising Necrotic Skin Systemic changes: Hypotension Tachycardia AMS Pain

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Bullae, ecchymosis, loss of sensation

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Necrotizing Streptococcal Cellulitis

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Staphyloccal Toxic Shock

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Staphyloccal Toxic Shock

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Sensitivity (%) Specificity (%) Positive Predictive Value (%) Negative Predictive Value (%) Tense Edema 38 100 100 62 Gas on XR 39 95 88 62 Bullae 24 100 100 57 WBC > 14 x 109/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

Objective Criteria to Distinguish Necrotizing from Non-necrotizing Infection

Wall DB et al. Am J Surg. 2000;179:17-21.

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Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score

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.

Laboratory parameter, units LRINEC points Laboratory parameter, units LRINEC points CRP, mg/L Sodium, mmol/L <150 ≥135 ≥150 4 <135 2 Total WBC, k/mm3 Creatinine, mg/dL <15 ≤1.6 15-25 1 >1.6 2 >25 2 Glucose, mg/dL Hb, g/dL ≤180 >13.5 >180 1 11–13.5 1 <11 2

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LRINEC Score: Corresponding Risk and Probability of Necrotizing SSTI

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

Wong CH, et al. Crit Care Med. 2004;32:1535-1541. Abrahamian FM, et al. Infect Dis Clin North Am. 2008;22:89-116, vi.

LRINEC Score LRINEC score Risk category Probability of necrotizing SSTI ≤5 Low <50% 6–7 Intermediate 50%–75% ≥8 High >75%

10 20 30 40 50 60 70 80 90 100 110 1 2 3 4 5 6 7 8 9 10 11 12 13

LRINEC Score Probability of Necrotizing Fasciitis (%)

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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”
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Clostridial Myonecrosis: 36 Hrs-Untreated Stab Wound

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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

Independent Predictors for Mortality

Bosshardt TL. Arch.Surg. 1996;131:846-52 Elliott DC. Ann.Surg. 1996; 224:672-83 Bilton BD. Am.Surg. 1998; 64:397-400

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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 Elliott DC. Ann.Surg. 1996; 224:672-83 Gunter OL Surg. Infect. 2008; 9:443-450 Bilton BD. Am.Surg. 1998; 64:397-400

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Summary of surgical approach

  • HARD signs = necrotizing infection and require OR

– Bullae, cutaneous anesthesia, ecchymosis, tense edema, gas

  • Early and aggressive surgical debridement improves
  • utcome with achievable mortality of < 10%
  • Carefully consider factors that suggest necrotizing

process

  • Empiric surgical exploration if in doubt!
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How to Avoid Transmission?

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Index patient: 34 yo M LE nec fasc, taken to OR for debridement

48 h postop HCW 1 (resp therapist): + GAS pharyngitis

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Transmission through aerosols: Open wounds Secretions

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The best treatment places healthcare workers at risk Protect your oropharynx!

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Enjoy this!