Page 9 - 61 surgical-infection&infestations20-24_opt

132 Necrotising Fasciitis
Complete Blood Count tissue necrosis in NF. 2–4,6–12 Adequate arrangements for possible blood
A haemogram should be ascertained; white cell count may indicate transfusion should be made during such necrosectomies, as this exer-
leucocytosis. cise may be attended by blood loss that could be significant to the child,
Exclusion of Underlying Illness especially the neonate.
Any underlying or predisposing illness should be excluded; often, Debridement may be done by the bedside in very ill patients who are
this may involve HIV testing, blood film for malaria parasites, hae- poor anaesthetic risks, especially neonates.
moglobin electrophoresis for sickle cell disease, and blood sugar to Wound resurfacing
exclude diabetes mellitus. Doing any of these tests should be guided Significant wound contraction could occur following adequate wound
by clinical suspicion. care, especially on the face, trunk, and perineum; the final mode of
Treatment wound closure also depends on the initial size, however. Smaller
wounds may contract adequately to heal by secondary intention or
Resuscitation require direct suturing, whereas larger but granulating wounds will
Correction of depletion require skin grafting. In the event of three-dimensional tissue loss
It is important to correct any existing physiological derangements, such (such as check, lip, nose), or exposure of bare surfaces (tendon, bone,
as fluid and electrolyte imbalance. Blood transfusion may be necessary nerve, or blood vessels), local, regional, or distant flap reconstruction
6,8,12,26
to correct anaemia. will be required.
Rehabilitation
Antibiotics and antimicrobials
The initial choice of parenteral antibiotics should take cognizance of Rehabilitation efforts are directed at preserving the child’s physi-
the polymicrobial nature of the disease, previous knowledge of the cal function and supporting the child emotionally through the use
24
microbiology of NF, and local sensitivity patterns. This should be of activity. The pain of the local infection may cause the patient to
broad-based and must take control of gram-negative, gram-positive, voluntarily immobilise affected areas of the body, so both passive and
aerobic, and anaerobic microorganisms. Combinations of penicillins, active movements should be encouraged as soon as pain and other
aminoglycosides, and metronidazole (or cephalosporins with metro- preconditions allow.
nidazole) have been found useful in most studies. 2–4,6–12 Some reports As the wounds heal, prevention of deformity by minimising the
have found the use of quinolones equally effective in the treatment of effects of joint stiffness or scar contracture should take priority.
25
NF; others, however, have avoided it because of the potential effect on Accordingly, appropriate splint(s) should be applied when and where
the growth plate of bones in young children, although this risk is now indicated. The goal is to attain a position that opposes the forces of
considered quite minimal. contracture, provide safe joint alignment, and maintain tendon balance
8
In severe cases with systemic toxaemia, as in StrepTSS, intravenous without causing stretch or pressure injuries to the peripheral nerves
human immunoglobulin has been found useful in neutralising the or skin.
exotoxin already present in the system. Intravenous amphotericin B Role of Hyperbaric Oxygen
may be administered if the presence of hyphae on gram stain or on As in clostridial myonecrosis (gas gangrene), the use of hyperbaric
histologic section suggests phycomycotic NF. 4 oxygen in NF is still controversial. Although experimental results in
Analgesia animals appear promising, its usefulness is less specific in NF than gas
4
In the early stage and when pain is a prominent symptom, appropriate gangrene following clinical trials in humans.
analgesics should be given. This will facilitate wound care and also Treatment of Underlying Condition
help in preventing later joint stiffness. Any identified underlying or predisposing condition should be treated
appropriately. This treatment must be simultaneous with treatment of
Tetanus prophylaxis
Tetanus immunisation (both active and passive) will be necessary in the NF to avoid relentless progression of the latter.
most African settings. Prognosis and Outcome
Nutritional support Factors that may affect outcome and prognosis are the following:
Appropriate nutritional support should be provided, especially for those • age (neonates fare poorly);
patients who are malnourished. • overall general condition of the patient at presentation;
Surgical Intervention
• pre- or co-morbid conditions;
Fasciotomy
Even in the absence of obvious tissue necrosis, fasciotomy in the • virulence of the offending organisms versus host immunity; and
form of single or multiple linear incision(s) over the affected area • promptness/aggressiveness of resuscitative, surgical, and supportive
may be necessary to achieve adequate compartmental decompression. forms of therapy.
Thorough wound irrigation with antiseptics such as hydrogen peroxide Despite the aggressive use of antibiotics and surgical intervention,
or cetrimide and warm normal saline, then gentle packing with gauze morbidity and mortality following NF remain very high. 2–4,6–12 Mortality
in EUSOL (hypochlorite solution) or natural honey helps to control rates range from 20% to 80%, but are frequently between 60% and
local infection and halts progression of the disease. At the time of 80%. Death results commonly from overwhelming infection and
fasciotomy, partial wound approximation could be effected without multiple organ failure. Those who survive are faced with a prolonged
tension by using sutures, rubber bands, or special devices. About 5–7 hospital stay and multiple surgical and reconstructive procedures, with
days after fasciotomy, when oedema would have subsided and infection their anaesthetic and socioeconomic implications.
26
is reasonably controlled, skin closure could be achieved directly or by
skin grafting. Prevention
Necrotising fasciitis is largely a preventable disease, 26,27 but prevention
Debridement
will involve a multidisciplinary commitment and action by individuals,
Prompt, adequate and sequential debridement of all necrotic tissues
health personnel, and policy makers. Preventive measures involve:
(see Figure 21.1) is of utmost importance in arresting progression of
• good oral and general body hygiene;