Soft Tissue Infection Killers Necrotizing soft tissue infections

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Soft Tissue Infection -Killers강사 이진희

Soft Tissue Infection -Killers강사 이진희

Necrotizing soft tissue infections • Gas gangrene – Clostridial myonecrosis – Nonclostridial myonecrosis •

Necrotizing soft tissue infections • Gas gangrene – Clostridial myonecrosis – Nonclostridial myonecrosis • Necrotizing fasciitis – Type I : Polymicrobial infection – Type II : Group A Streptococcus – Type III : Vibrio infection * Fournier’s Gangrene

Pathology_1 • Widespread necrosis of – Superficial fascia – Subcutaneous fat – Nerves –

Pathology_1 • Widespread necrosis of – Superficial fascia – Subcutaneous fat – Nerves – Arteries and vein • Superficial skin is spared

Pathology_2 • Early – Vasculitis c microangiopathic thrombosis – Acute inflammation in the subcutaneous

Pathology_2 • Early – Vasculitis c microangiopathic thrombosis – Acute inflammation in the subcutaneous tissue • As the process advances – – Liquefaction necrosis of all tissue levels Fascia : swollen, dull grey discoloration Subepidermal necrotic bullae Noninflammatory intravascular coagulation & hemorrhage – myonecrosis

Pathology_3 • To the surgeon – “Passing a probe or finger” • Remarkable lack

Pathology_3 • To the surgeon – “Passing a probe or finger” • Remarkable lack of resistance of muscular fascia blunt dissection – Little bleeding of fascia during dissection – Foul-smelling, dishwater exudate

Clinical features_1

Clinical features_1

Clinical features_2 • Hard signs of NF – – – Crepitance Skin necrosis Bullae

Clinical features_2 • Hard signs of NF – – – Crepitance Skin necrosis Bullae Focal anesthesia Rapid progression of lesion – Gas on x-ray – Hemodynamic instability – Systemic toxicity • Red flags – Edema extending beyond area – Absence of lymphagitis or lymphadenopathy – Tachycardia – Myalgia – Constitutional symptoms – Altered mental status – Slow/absent response to antibiotics

Initial Later Red, smooth, tense, diffuse erythema Purple to blue-grey, hemorrhagic bullae

Initial Later Red, smooth, tense, diffuse erythema Purple to blue-grey, hemorrhagic bullae

Clinical features_3 • The most important determinant of patient survival The time Onset ~

Clinical features_3 • The most important determinant of patient survival The time Onset ~ the first operative debridement

Diagnosis_1 • Hard clinical sign Immediate surgical evaluation • Red flags further diagnostic consideration

Diagnosis_1 • Hard clinical sign Immediate surgical evaluation • Red flags further diagnostic consideration of NF • If diagnosis is in doubt frequent and repeated examinations !!

Diagnosis_2 • LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) – CRP, WBC, Hb, Na+,

Diagnosis_2 • LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) – CRP, WBC, Hb, Na+, Cr, glucose – < 5 : < 50% NF – 6 -7 : 50 -75% NF – >8 : 75% NF

Diagnosis_3 • Radiographic evaluation – Should not delay appropriate surgical management of highly suspicious

Diagnosis_3 • Radiographic evaluation – Should not delay appropriate surgical management of highly suspicious cases !!! – Plain x-ray • Detecting gas in the soft tissues – CT, MRI, U/S – Gold standard • Finding of fascial necrosis at the time of surgery • Finger test • Frozen section tissue biopsy

Treatment_1 • Aggressive surgical debridement < 24 hrs !!! • Broad-spectrum antibiotics • Hemodynamic

Treatment_1 • Aggressive surgical debridement < 24 hrs !!! • Broad-spectrum antibiotics • Hemodynamic support • Hyperbaric oxygen, IV Ig, Activated protein C

Treatment_2

Treatment_2

Treatment_3 • Antibiotics – G(-), anaerobes, G(+) – B-lactam/b-lactamase combination • • Ampicillin/sulbactam Piperacillin/tazobactam

Treatment_3 • Antibiotics – G(-), anaerobes, G(+) – B-lactam/b-lactamase combination • • Ampicillin/sulbactam Piperacillin/tazobactam Ticarcillin/clavulanate 3, 4 th generation cephalosporin + metronidazole or clindamycin

Treatment_4 • Supportive care – Metabolic and hemodynamic support – Hypotension, respiratory distress, shock

Treatment_4 • Supportive care – Metabolic and hemodynamic support – Hypotension, respiratory distress, shock – Analgesia – Nutritional support

법정에서 용서받지 못할 열가지 변명 중 • What’s the big deal about his alcohol

법정에서 용서받지 못할 열가지 변명 중 • What’s the big deal about his alcohol consumption? He only has a small laceration on his foot from stepping on an oyster shell Vibrio vulnificus • I made the diagnosis of necrotizing fasciitis, gave antibiotics, and even got a hyperbaric consult. I did everything right The single most important intervention is a telephone call-to a surgeon

Reference

Reference