A special case: treatment of a patient with necrotising fasciitis Jolanda Alblas, Rutger J Klicks, Anneke Andriessen
Abstract
The case study in this article describes the rapid and accurate diagnosis of a critically ill patient with necrotising fasciitis (NF). Fullthickness patchy skin necrosis of the right thigh, buttock and flank was detected on admission. Prompt radical debridement together with aggressive fluid resuscitation and broad-spectrum antibiotic administration was initiated. Case ascertainment was used to evaluate the effectiveness of a debridement and wound treatment regime, using a monofilament debridement product, negative wound pressure treatment and, after the critical period had ended, a bio-cellulose + polyhexamethylene biguanide (PHMB) dressing, followed by a collagen dressing. NF after open haemorrhoidectomy represents a life-threatening complication to otherwise healthy patients. Accurate diagnosis, prompt critical care and surgical treatment, together with debridement using the monofilament product and effective wound bed preparation, lead to a successful outcome. Key words: Necrotising fasciitis ■ Wound management
■
Diagnosis
■
Debridement
N
ecrotising fasciitis (NF) is a rare infection in the deeper layers of the skin and subcutaneous tissues, easily spreading across the fascial plane (Poromanski, 2004). It is also known as flesheating disease, Fournier’s gangrene and necrotising cellulitis. Fascial planes are bands of connective tissue that surround muscles, nerves and blood vessels. They can bind structures together as well as allow body structures to slide over each other effectively. The most common predisposing factors for the development of NF are considered to be diabetes, steroid use, chronic alcoholism and advanced age (Lehnhardt, 2004). For Fournier’s gangrene, anorectal, urogenital and local dermatological sources are implicated in the pathogenesis of the disease, with a predominance of anorectal infections, namely perianal, perirectal and ischiorectal abscesses, anal fissure and colonic perforations (Korkut, 2003). NF may develop post-surgical intervention in otherwise healthy Jolanda Alblas is a Physician Assistant and Rutger J Klicks is an Oncological Surgeon at Wound Expert Center, Bovenij Hospital, Amsterdam, The Netherlands. Anneke Andriessen is CEO at Andriessen Consultants, Malden, and a Lecturer at UMC St Radboud, Nijmegen, The Netherlands. Accepted for publication: April 2013
S22
subjects, such as after the removal of haemorrhoids (Lehnhardt, 2004; Yanar, 2006). NF, in most cases, is caused by group A beta-haemolytic streptococci (Streptococcus pyogenes), however, different bacteria, either alone or together, can also cause the disease. Clostridium bacteria should be considered as a cause especially if gas is found in the infected tissue (Lee, 2007). Because of better microbial isolation techniques for anaerobic bacteria, bacteria such as Bacteroides, Peptostreptococcus and Clostridium are often cultured from the infected area (Wong, 2004). Frequently, culture of tissue involved by NF also shows a mixture of other non-anaerobic bacterial types such as Escherichia coli, Klebsiella, Pseudomonas and others (Malik, 2010). Once NF reaches and proliferates in connective tissue, the spread of the infection can be very fast (Jain, 2009). Unless quickly diagnosed and treated the infection will be difficult to stop even with radical surgery (Poromanski, 2004). Mortality rates have been reported as high as 75% for NF associated with Fournier’s (genital region) gangrene (Lee, 2007). Patients with NF have an ongoing medical emergency that often leads to death or disability if not promptly and effectively treated. Despite the improvements for early diagnosis and refinements in surgical and medical therapeutic interventions, outcomes remain relatively poor (Lehnhardt, 2004; Yanar, 2006). Moreover, neither extended spectrum antibiotic administration nor advanced medical care seem to be efficient in providing accurate survival benefit (Yanar, 2006). The mainstays of effective management depend on early diagnosis and immediate radical debridement to improve clinical outcome in this quickly progressing and severe disease (Lee, 2007). In addition to surgical debridement a monofilament debridement product may be used to debride slough (Bahr, 2011). For continuous removal of bacteria from the wound bed, the use of a bio-cellulose dressing impregnated with polyhexamethylene biguanide (PHMB) has been shown to be effective (Piatkowski, 2011).When the wound bed is clean, granulation and epithelialisation can be stimulated using a collagen dressing (Piatkowski, 2012). The aim of the case study was to evaluate the effectiveness of a debridement and wound treatment regime, using a monofilament debridement product, negative wound pressure treatment and after the critical period had ended, a biocellulose + PHMB dressing, followed by a collagen dressing.
Method Written informed consent was obtained from the patient before starting the case study. Case ascertainment was used to evaluate the effectiveness of a debridement and wound treatment regime in a critically ill patient with NF.
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 15
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 26, 2015. For personal use only. No other uses without permission. . All rights reserved.
Case study
Figure 1: Radical surgical debridement was performed and drains were put in place
Figure 2: Debridement was repeated and the drains were removed
Figure 3: Situation direct after radical surgical debridement and debridement using Debrisoft
Figure 4: Copious amounts of exudate that were managed with a superabsorbent dressing
Case study outcomes The case study outcome was based on accuracy and fast diagnosis of NF, time to wound healing, efficacy of debridement using a monofilament debrider (Debrisoft, Lohmann and Rauscher), patient-reported wound pain and comfort of the treatment regime and safety of the treatment regime.
Wound status and wound size were documented using standardised (light, background, distance and angle) digital photographs, a digital assessment tool as well as wound tracings and the measurement of ulcer diameter. Patientreported pain was assessed using a ten-point visual analogue scale (VAS).The patient was asked about any discomfort upon
Suprasorb X +PHMB ®
The right properties for managing wound pain with infection
Activa® is the registered trademark of Activa Healthcare Ltd.
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 15
or sk n l f t ri tio ea a c Id nts infe tie nd pa ou w of
Thinking of moving away from silver?
Fast, long-lasting antimicrobial effect Unique HydroBalance 1,2
Pain relieving properties 1
Available on Drug Tariff
1 PHMB: a well-tolerated antiseptic with no reported toxic effects. Gilliver, S. Journal of Wound Care/Activa Healthcare Supplement 2009. 2 Comparison of PHMB-containing dressing and silver dressings in patients with critically colonised or locally infected wounds. Eberlein, T. et al. Journal of Wound Care Vol.21, (1), January 2012.
For more information visit our website: www.activahealthcare.co.uk To receive titles from our series of PHMB wound infection booklets call our customer care line: 08450 606707
ADV068 V1.2
S23
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 26, 2015. For personal use only. No other uses without permission. . All rights reserved.
Figure 5: A collagen dressing is used to support wound bed preparation
severe incapacitating pain (VAS 10). Immediately after surgery, the patient reported that the excruciating pain (VAS 10) persisted. The surgical site showed erythema and swelling. After one and a half days, he developed a sepsis with extensive induration of the right thigh, buttock and flank (see Figure 1). Although he had received morphine the excruciating pain (VAS 10) persisted. The affected area was explored in the operating room (OR), where an extensive necrotising infection was diagnosed while the fascia appeared unaffected (see Figure 2) (Poromanski, 2004). Broad spectrum intravenous antibiotics, including piperacillin/tazobactam and vancomycin was started. Radical surgical debridement was performed and drains were put in place to keep the area open. Biopsies were taken for bacteriological testing (Wong, 2004). Postoperatively, the patient was kept in the intensive care unit on a ventilator and remained septic. His condition rapidly deteriorated.
Results a
b Figure 6a and 6b: Situation after eight weeks. The wound bed has been prepared for surgical closure to be performed as soon as the patients’ condition allows for the procedure to take place
Figure 7: Situation after 12 weeks. All but one wound have closed.The patient receives community care from a specialised nurse and comes to the wound healing clinic every second week.The wound bed is covered with healthy granulation tissue and epithelialisation is evident.The patient prefers conservative wound closure over skin grafting.Treatment was continued with an adhesive foam dressing, with twice-weekly dressing changes
the debridement procedure and dressing changes. Finally, the clinicians were asked their opinion on debridement product (Haemerle, 2011) and dressing use. Study duration was 4 weeks with standardised digital photographs and clinical evaluation of the patient condition, wound status and quality of life aspects at baseline (start) and daily evaluations up to week 4 (end).The patient was then followed up to wound closure.
The Patient The 63-year-old otherwise healthy male received surgical intervention on acutely thrombosed haemorrhoids, causing
S24
The cultures that were taken in the OR showed positive for streptococcus Group A and E. coli.The patient developed acute tubular necrosis and continuous venovenous haemofiltration was started. At this point his condition had dramatically deteriorated. His family stayed at his bedside fearing the worst. After five days, debridement in the OR was again performed as well as using a monofilament debridement product (Bahr, 2011) wetted with polyhexanide for the removal of slough (see Figure 3). This debridement procedure was also used on each dressing change, for the following 10 days. After surgery, negative pressure wound therapy was applied. Wound inspections took place daily to monitor the situation. At day 6, the patient’s general condition had stabilised and the infection parameters had decreased. Defecation was initiated with enemas and faeces were collected using a specific device. Further contamination of the wound area was thus prevented. The patient’s general condition as well as the condition of his wounds had improved. At treatment day 12, the patient was weaned off the ventilator and haemofiltration as well as antibiotic treatment was discontinued. After 2 days, he was transferred to the surgical department. The wound treatment regime now comprised a bio-cellulose dressing plus PHMB (Suprasorb X + polyhexanide), covered with a superabsorbent dressing (Vliwasorb, both dressings Lohmann and Rauscher), with once-daily dressing changes for observation purposes (see Figure 4). After one week, the dressing regime was changed to a collagen dressing (Suprasorb C, Lohmann and Rauscher) covered with an absorbent dressing, with dressing changes taking place three times a week (see Figure 5). Gradually, his condition improved and mobilisation was started (see Figure 6). After wound bed preparation was completed, the extensive defect was left to close conservatively (see Figure 7).
Discussion The present report describes a case of NF after open hemorrhoidectomy without a predisposing factor. Similar cases have been reported in previously healthy patients
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 15
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 26, 2015. For personal use only. No other uses without permission. . All rights reserved.
Key points n Necrotising fasciitis (NF) is a rare infection in the deeper layers of the skin and subcutaneous tissues n The most common predisposing factors for the development of NF are diabetes, steroid use, chronic alcoholism and advanced age n Once NF reaches and proliferates in connective tissue, the spread of the infection can be very fast n If not promptly diagnosed and surgically treated mortality rates can be as high as 70% n The mainstay of treatment is prompt diagnosis and radical surgical debridement, use of a monofilament product is recommended
(Lehnhardt, 2004). NF causes excruciating pain, dangerously low blood pressure, confusion, high fever, and severe dehydration due to the toxins poisoning the body (Shah, 2004). Death from this condition is not uncommon, however, many patients are successfully treated (Jain, 2009). In the early stages of NF, signs of inflammation may not be apparent if the bacteria are deep within the tissue. This may explain why many cases are misdiagnosed. If they are not deep, signs of inflammation, such as redness and swollen or hot skin, develop very quickly. Patients typically have fever and are critically ill. If not promptly diagnosed and surgically treated mortality rates can be as high as 70% (Poromanski, 2004). This typical pattern was also observed in the patient described in the case study. If NF is detected during the early stages, before toxic shock, the need for excision can be limited to the removal of subcutaneous tissue and fat only. Although bacteria-causing NF usually do not attack muscle or bone, it can happen. In more advanced cases, major tissue excision is necessary to save the patients’ life (Jain, 2009; Malik, 2010). The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was used to risk stratify the patients’ signs of cellulitis to determine the likelihood of NF being present (Wong, 2004). The score uses six serologic measures: C-reactive protein, total white cell count, haemoglobin, sodium, creatinine and glucose. A score greater than six indicated that NF was present (Wong, 2004). Diagnosis was confirmed by visual examination of the tissues and by tissue samples sent for microscopic evaluation. The mainstay of treatment is prompt diagnosis and radical surgical debridement. In advanced NF, aggressive surgical debridement is always necessary to keep it from spreading and is the only effective treatment available, at this stage (Poromanski, 2004). Radical excision of all necrotic tissues, regardless of the nature of the defect created, is therefore strongly recommended (Lehnhardt, 2004). Broad-spectrum antibiotic therapy should be instituted empirically, regardless of Gram stain and culture results (Lehnhardt, 2004; Yanar, 2006). The patients should receive antibiotic therapy, including regimens against aerobic and anaerobic microorganisms (Yanar, 2006). This treatment goal can be achieved by means of a penicillin-based drug in combination with metronidazole (Shah, 2004). The prompt surgery (Shah, 2009) and effective wound treatment regime supported wound bed preparation, enabling final surgical closure. In addition to the tissue decay in the affected area, the
S26
bacteria causes the rest of the body’s organs to go into systemic shock. This may result in respiratory failure, heart failure, low blood pressure and renal failure (Poromanski, 2004). Basically, every system of the body can fail as a result of the severe infection and toxicity of the system (Wong, 2004), as was the case in the patient in this case study. NF is not a reoccurring condition. During treatment, surgical sites are left open for a sufficient period of time and inspected daily to be sure that the remaining tissue is no longer being destroyed. When physicians are confident that the infection has been stopped, the wound bed is prepared, followed by either conservative or surgical wound closure, typically with skin grafting. The recovery process can be lengthy and involves physical therapy and longterm psychological, emotional and spiritual recovery. Unless accurately diagnosed and effectively treated, NF can be a truly devastating disease.
Conclusion Accurate diagnosis, prompt critical care and surgical treatment together with debridement using a monofilament product and wound bed preparation using a treatment regime with a bio-cellulose + PHMB dressing and later a collagen dressing BJN lead to a successful outcome. Conflict of interest: The study was supported with a scientific grant from Lohmann and Rauscher. Bahr S, Mustafi N, Hättig P, Piatkowski A et al (2011) Clinical efficacy of a new monofilament fibre-containing wound, J Wound Care 20(5): 250-6 Dissemond J, Gerber V, Kramer A et al (2010) A practice-orientated recommendation for treatment of critically colonized and locally infected wounds using polihexanide. J Tissue Viability 19(3): 106-15 Haemerle G, Duelli H, Abel M, Strohal R (2011) The wound debrider: a new monofilament fibre technology. Br J Nurs 20(6):S35-6, S38, S40-2 Jain A, Varma A, Mangalanandan Kumar PH, Bal A (2009) Surgical outcome of necrotizing fasciitis in a diabetic lower limb. Journal of Diabetic Foot Complications 1(4): 80-4. Kingsley A, Tadej M, Colbourn A et al (2009) Suprasorb X+PHMB: antimicrobial and HydroBalance action in a new wound dressing. Wounds UK 5(1): 72-7 Korkut M, Içöz G, Dayangaç M et al (2003) Outcome analysis in patients with Fournier’s gangrene: report of 45 cases. Dis Colon Rectum 46: 64952 Lehnhardt M, Steinstraesser L, Druecke D, Muehlberger T, Steinau HU, Homann HH (2004) Fournier’s gangrene after Milligan-Morgan hemorrhoidectomy requiring subsequent abdominoperineal resection of the rectum: report of a case. Dis Colon Rectum 47: 1729-33 Lee TC, Carrick MM, Scott BG, Hodges JC, Pham HQ (2007) Incidence and clinical characteristics of methicillin-resistant fasciitis in a large urban hospital. Am J Surg 194(6): 809-13 Malik V, Gadepalli C, Agrawal S, Inkster C, Lobo C (2010) An Algorithm for Early Diagnosis of Cervicofacial Necrotizing Fasciitis. Eur Arch Otorhinolaryngol 267(8): 1169-77 Piatkowski A, Drummer N, Andriessen A, Ulrich D, Pallua N (2011) Randomized controlled single center study comparing a polyhexanide containing biocellulose dressing with silver sulfadiazine cream in partial thickness wounds. Burns 37(5): 800-4 Piatkowski A, Ulrich D, Seidel D, Abel M, Pallua N, Andriessen A (2012) Randomised, controlled pilot to compare collagen and foam in stagnating pressure ulcers. J Wound Care 21(10): 505-11. Poromanski I, Andriessen A (2004) Developing a tool to diagnose cases of necrotising fasciitis. J Wound Care 13(8): 307-10 Shah AK, Kumar NB, Gambhir RP, Chaudhry R (2009) Integrated clinical care pathway for managing necrotising soft tissue infections. Indian J Surg 71(5): 254-7 Wong CH, Khin LW, Heng KS, Tan KC, Low CO (2004) The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 32(7): 1535-41 Yanar H, Taviloglu K, Ertekin C et al (2006) Fournier’s gangrene: risk factors and strategies for management. World J Surg 30(9): 1750-4
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 15
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 26, 2015. For personal use only. No other uses without permission. . All rights reserved.
Abstract
The case study in this article describes the rapid and accurate diagnosis of a critically ill patient with necrotising fasciitis (NF). Fullthickness patchy skin necrosis of the right thigh, buttock and flank was detected on admission. Prompt radical debridement together with aggressive fluid resuscitation and broad-spectrum antibiotic administration was initiated. Case ascertainment was used to evaluate the effectiveness of a debridement and wound treatment regime, using a monofilament debridement product, negative wound pressure treatment and, after the critical period had ended, a bio-cellulose + polyhexamethylene biguanide (PHMB) dressing, followed by a collagen dressing. NF after open haemorrhoidectomy represents a life-threatening complication to otherwise healthy patients. Accurate diagnosis, prompt critical care and surgical treatment, together with debridement using the monofilament product and effective wound bed preparation, lead to a successful outcome. Key words: Necrotising fasciitis ■ Wound management
■
Diagnosis
■
Debridement
N
ecrotising fasciitis (NF) is a rare infection in the deeper layers of the skin and subcutaneous tissues, easily spreading across the fascial plane (Poromanski, 2004). It is also known as flesheating disease, Fournier’s gangrene and necrotising cellulitis. Fascial planes are bands of connective tissue that surround muscles, nerves and blood vessels. They can bind structures together as well as allow body structures to slide over each other effectively. The most common predisposing factors for the development of NF are considered to be diabetes, steroid use, chronic alcoholism and advanced age (Lehnhardt, 2004). For Fournier’s gangrene, anorectal, urogenital and local dermatological sources are implicated in the pathogenesis of the disease, with a predominance of anorectal infections, namely perianal, perirectal and ischiorectal abscesses, anal fissure and colonic perforations (Korkut, 2003). NF may develop post-surgical intervention in otherwise healthy Jolanda Alblas is a Physician Assistant and Rutger J Klicks is an Oncological Surgeon at Wound Expert Center, Bovenij Hospital, Amsterdam, The Netherlands. Anneke Andriessen is CEO at Andriessen Consultants, Malden, and a Lecturer at UMC St Radboud, Nijmegen, The Netherlands. Accepted for publication: April 2013
S22
subjects, such as after the removal of haemorrhoids (Lehnhardt, 2004; Yanar, 2006). NF, in most cases, is caused by group A beta-haemolytic streptococci (Streptococcus pyogenes), however, different bacteria, either alone or together, can also cause the disease. Clostridium bacteria should be considered as a cause especially if gas is found in the infected tissue (Lee, 2007). Because of better microbial isolation techniques for anaerobic bacteria, bacteria such as Bacteroides, Peptostreptococcus and Clostridium are often cultured from the infected area (Wong, 2004). Frequently, culture of tissue involved by NF also shows a mixture of other non-anaerobic bacterial types such as Escherichia coli, Klebsiella, Pseudomonas and others (Malik, 2010). Once NF reaches and proliferates in connective tissue, the spread of the infection can be very fast (Jain, 2009). Unless quickly diagnosed and treated the infection will be difficult to stop even with radical surgery (Poromanski, 2004). Mortality rates have been reported as high as 75% for NF associated with Fournier’s (genital region) gangrene (Lee, 2007). Patients with NF have an ongoing medical emergency that often leads to death or disability if not promptly and effectively treated. Despite the improvements for early diagnosis and refinements in surgical and medical therapeutic interventions, outcomes remain relatively poor (Lehnhardt, 2004; Yanar, 2006). Moreover, neither extended spectrum antibiotic administration nor advanced medical care seem to be efficient in providing accurate survival benefit (Yanar, 2006). The mainstays of effective management depend on early diagnosis and immediate radical debridement to improve clinical outcome in this quickly progressing and severe disease (Lee, 2007). In addition to surgical debridement a monofilament debridement product may be used to debride slough (Bahr, 2011). For continuous removal of bacteria from the wound bed, the use of a bio-cellulose dressing impregnated with polyhexamethylene biguanide (PHMB) has been shown to be effective (Piatkowski, 2011).When the wound bed is clean, granulation and epithelialisation can be stimulated using a collagen dressing (Piatkowski, 2012). The aim of the case study was to evaluate the effectiveness of a debridement and wound treatment regime, using a monofilament debridement product, negative wound pressure treatment and after the critical period had ended, a biocellulose + PHMB dressing, followed by a collagen dressing.
Method Written informed consent was obtained from the patient before starting the case study. Case ascertainment was used to evaluate the effectiveness of a debridement and wound treatment regime in a critically ill patient with NF.
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 15
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 26, 2015. For personal use only. No other uses without permission. . All rights reserved.
Case study
Figure 1: Radical surgical debridement was performed and drains were put in place
Figure 2: Debridement was repeated and the drains were removed
Figure 3: Situation direct after radical surgical debridement and debridement using Debrisoft
Figure 4: Copious amounts of exudate that were managed with a superabsorbent dressing
Case study outcomes The case study outcome was based on accuracy and fast diagnosis of NF, time to wound healing, efficacy of debridement using a monofilament debrider (Debrisoft, Lohmann and Rauscher), patient-reported wound pain and comfort of the treatment regime and safety of the treatment regime.
Wound status and wound size were documented using standardised (light, background, distance and angle) digital photographs, a digital assessment tool as well as wound tracings and the measurement of ulcer diameter. Patientreported pain was assessed using a ten-point visual analogue scale (VAS).The patient was asked about any discomfort upon
Suprasorb X +PHMB ®
The right properties for managing wound pain with infection
Activa® is the registered trademark of Activa Healthcare Ltd.
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 15
or sk n l f t ri tio ea a c Id nts infe tie nd pa ou w of
Thinking of moving away from silver?
Fast, long-lasting antimicrobial effect Unique HydroBalance 1,2
Pain relieving properties 1
Available on Drug Tariff
1 PHMB: a well-tolerated antiseptic with no reported toxic effects. Gilliver, S. Journal of Wound Care/Activa Healthcare Supplement 2009. 2 Comparison of PHMB-containing dressing and silver dressings in patients with critically colonised or locally infected wounds. Eberlein, T. et al. Journal of Wound Care Vol.21, (1), January 2012.
For more information visit our website: www.activahealthcare.co.uk To receive titles from our series of PHMB wound infection booklets call our customer care line: 08450 606707
ADV068 V1.2
S23
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 26, 2015. For personal use only. No other uses without permission. . All rights reserved.
Figure 5: A collagen dressing is used to support wound bed preparation
severe incapacitating pain (VAS 10). Immediately after surgery, the patient reported that the excruciating pain (VAS 10) persisted. The surgical site showed erythema and swelling. After one and a half days, he developed a sepsis with extensive induration of the right thigh, buttock and flank (see Figure 1). Although he had received morphine the excruciating pain (VAS 10) persisted. The affected area was explored in the operating room (OR), where an extensive necrotising infection was diagnosed while the fascia appeared unaffected (see Figure 2) (Poromanski, 2004). Broad spectrum intravenous antibiotics, including piperacillin/tazobactam and vancomycin was started. Radical surgical debridement was performed and drains were put in place to keep the area open. Biopsies were taken for bacteriological testing (Wong, 2004). Postoperatively, the patient was kept in the intensive care unit on a ventilator and remained septic. His condition rapidly deteriorated.
Results a
b Figure 6a and 6b: Situation after eight weeks. The wound bed has been prepared for surgical closure to be performed as soon as the patients’ condition allows for the procedure to take place
Figure 7: Situation after 12 weeks. All but one wound have closed.The patient receives community care from a specialised nurse and comes to the wound healing clinic every second week.The wound bed is covered with healthy granulation tissue and epithelialisation is evident.The patient prefers conservative wound closure over skin grafting.Treatment was continued with an adhesive foam dressing, with twice-weekly dressing changes
the debridement procedure and dressing changes. Finally, the clinicians were asked their opinion on debridement product (Haemerle, 2011) and dressing use. Study duration was 4 weeks with standardised digital photographs and clinical evaluation of the patient condition, wound status and quality of life aspects at baseline (start) and daily evaluations up to week 4 (end).The patient was then followed up to wound closure.
The Patient The 63-year-old otherwise healthy male received surgical intervention on acutely thrombosed haemorrhoids, causing
S24
The cultures that were taken in the OR showed positive for streptococcus Group A and E. coli.The patient developed acute tubular necrosis and continuous venovenous haemofiltration was started. At this point his condition had dramatically deteriorated. His family stayed at his bedside fearing the worst. After five days, debridement in the OR was again performed as well as using a monofilament debridement product (Bahr, 2011) wetted with polyhexanide for the removal of slough (see Figure 3). This debridement procedure was also used on each dressing change, for the following 10 days. After surgery, negative pressure wound therapy was applied. Wound inspections took place daily to monitor the situation. At day 6, the patient’s general condition had stabilised and the infection parameters had decreased. Defecation was initiated with enemas and faeces were collected using a specific device. Further contamination of the wound area was thus prevented. The patient’s general condition as well as the condition of his wounds had improved. At treatment day 12, the patient was weaned off the ventilator and haemofiltration as well as antibiotic treatment was discontinued. After 2 days, he was transferred to the surgical department. The wound treatment regime now comprised a bio-cellulose dressing plus PHMB (Suprasorb X + polyhexanide), covered with a superabsorbent dressing (Vliwasorb, both dressings Lohmann and Rauscher), with once-daily dressing changes for observation purposes (see Figure 4). After one week, the dressing regime was changed to a collagen dressing (Suprasorb C, Lohmann and Rauscher) covered with an absorbent dressing, with dressing changes taking place three times a week (see Figure 5). Gradually, his condition improved and mobilisation was started (see Figure 6). After wound bed preparation was completed, the extensive defect was left to close conservatively (see Figure 7).
Discussion The present report describes a case of NF after open hemorrhoidectomy without a predisposing factor. Similar cases have been reported in previously healthy patients
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 15
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 26, 2015. For personal use only. No other uses without permission. . All rights reserved.
Key points n Necrotising fasciitis (NF) is a rare infection in the deeper layers of the skin and subcutaneous tissues n The most common predisposing factors for the development of NF are diabetes, steroid use, chronic alcoholism and advanced age n Once NF reaches and proliferates in connective tissue, the spread of the infection can be very fast n If not promptly diagnosed and surgically treated mortality rates can be as high as 70% n The mainstay of treatment is prompt diagnosis and radical surgical debridement, use of a monofilament product is recommended
(Lehnhardt, 2004). NF causes excruciating pain, dangerously low blood pressure, confusion, high fever, and severe dehydration due to the toxins poisoning the body (Shah, 2004). Death from this condition is not uncommon, however, many patients are successfully treated (Jain, 2009). In the early stages of NF, signs of inflammation may not be apparent if the bacteria are deep within the tissue. This may explain why many cases are misdiagnosed. If they are not deep, signs of inflammation, such as redness and swollen or hot skin, develop very quickly. Patients typically have fever and are critically ill. If not promptly diagnosed and surgically treated mortality rates can be as high as 70% (Poromanski, 2004). This typical pattern was also observed in the patient described in the case study. If NF is detected during the early stages, before toxic shock, the need for excision can be limited to the removal of subcutaneous tissue and fat only. Although bacteria-causing NF usually do not attack muscle or bone, it can happen. In more advanced cases, major tissue excision is necessary to save the patients’ life (Jain, 2009; Malik, 2010). The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was used to risk stratify the patients’ signs of cellulitis to determine the likelihood of NF being present (Wong, 2004). The score uses six serologic measures: C-reactive protein, total white cell count, haemoglobin, sodium, creatinine and glucose. A score greater than six indicated that NF was present (Wong, 2004). Diagnosis was confirmed by visual examination of the tissues and by tissue samples sent for microscopic evaluation. The mainstay of treatment is prompt diagnosis and radical surgical debridement. In advanced NF, aggressive surgical debridement is always necessary to keep it from spreading and is the only effective treatment available, at this stage (Poromanski, 2004). Radical excision of all necrotic tissues, regardless of the nature of the defect created, is therefore strongly recommended (Lehnhardt, 2004). Broad-spectrum antibiotic therapy should be instituted empirically, regardless of Gram stain and culture results (Lehnhardt, 2004; Yanar, 2006). The patients should receive antibiotic therapy, including regimens against aerobic and anaerobic microorganisms (Yanar, 2006). This treatment goal can be achieved by means of a penicillin-based drug in combination with metronidazole (Shah, 2004). The prompt surgery (Shah, 2009) and effective wound treatment regime supported wound bed preparation, enabling final surgical closure. In addition to the tissue decay in the affected area, the
S26
bacteria causes the rest of the body’s organs to go into systemic shock. This may result in respiratory failure, heart failure, low blood pressure and renal failure (Poromanski, 2004). Basically, every system of the body can fail as a result of the severe infection and toxicity of the system (Wong, 2004), as was the case in the patient in this case study. NF is not a reoccurring condition. During treatment, surgical sites are left open for a sufficient period of time and inspected daily to be sure that the remaining tissue is no longer being destroyed. When physicians are confident that the infection has been stopped, the wound bed is prepared, followed by either conservative or surgical wound closure, typically with skin grafting. The recovery process can be lengthy and involves physical therapy and longterm psychological, emotional and spiritual recovery. Unless accurately diagnosed and effectively treated, NF can be a truly devastating disease.
Conclusion Accurate diagnosis, prompt critical care and surgical treatment together with debridement using a monofilament product and wound bed preparation using a treatment regime with a bio-cellulose + PHMB dressing and later a collagen dressing BJN lead to a successful outcome. Conflict of interest: The study was supported with a scientific grant from Lohmann and Rauscher. Bahr S, Mustafi N, Hättig P, Piatkowski A et al (2011) Clinical efficacy of a new monofilament fibre-containing wound, J Wound Care 20(5): 250-6 Dissemond J, Gerber V, Kramer A et al (2010) A practice-orientated recommendation for treatment of critically colonized and locally infected wounds using polihexanide. J Tissue Viability 19(3): 106-15 Haemerle G, Duelli H, Abel M, Strohal R (2011) The wound debrider: a new monofilament fibre technology. Br J Nurs 20(6):S35-6, S38, S40-2 Jain A, Varma A, Mangalanandan Kumar PH, Bal A (2009) Surgical outcome of necrotizing fasciitis in a diabetic lower limb. Journal of Diabetic Foot Complications 1(4): 80-4. Kingsley A, Tadej M, Colbourn A et al (2009) Suprasorb X+PHMB: antimicrobial and HydroBalance action in a new wound dressing. Wounds UK 5(1): 72-7 Korkut M, Içöz G, Dayangaç M et al (2003) Outcome analysis in patients with Fournier’s gangrene: report of 45 cases. Dis Colon Rectum 46: 64952 Lehnhardt M, Steinstraesser L, Druecke D, Muehlberger T, Steinau HU, Homann HH (2004) Fournier’s gangrene after Milligan-Morgan hemorrhoidectomy requiring subsequent abdominoperineal resection of the rectum: report of a case. Dis Colon Rectum 47: 1729-33 Lee TC, Carrick MM, Scott BG, Hodges JC, Pham HQ (2007) Incidence and clinical characteristics of methicillin-resistant fasciitis in a large urban hospital. Am J Surg 194(6): 809-13 Malik V, Gadepalli C, Agrawal S, Inkster C, Lobo C (2010) An Algorithm for Early Diagnosis of Cervicofacial Necrotizing Fasciitis. Eur Arch Otorhinolaryngol 267(8): 1169-77 Piatkowski A, Drummer N, Andriessen A, Ulrich D, Pallua N (2011) Randomized controlled single center study comparing a polyhexanide containing biocellulose dressing with silver sulfadiazine cream in partial thickness wounds. Burns 37(5): 800-4 Piatkowski A, Ulrich D, Seidel D, Abel M, Pallua N, Andriessen A (2012) Randomised, controlled pilot to compare collagen and foam in stagnating pressure ulcers. J Wound Care 21(10): 505-11. Poromanski I, Andriessen A (2004) Developing a tool to diagnose cases of necrotising fasciitis. J Wound Care 13(8): 307-10 Shah AK, Kumar NB, Gambhir RP, Chaudhry R (2009) Integrated clinical care pathway for managing necrotising soft tissue infections. Indian J Surg 71(5): 254-7 Wong CH, Khin LW, Heng KS, Tan KC, Low CO (2004) The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 32(7): 1535-41 Yanar H, Taviloglu K, Ertekin C et al (2006) Fournier’s gangrene: risk factors and strategies for management. World J Surg 30(9): 1750-4
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 15
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