Necrotizing Fasciitis

Necrotizing Fasciitis Cindy A. Fehr Malaspina University-College BSN Program NRSG 335 Fall 2005

What Is It? • Soft tissue infection that unleashes damaging toxins & enzymes that can consume flesh • Progressively destroys connective tissue causing disabling injuries and death • Life threatening infection • 30% mortality rate

Cause • Any toxin-causing bacterium, usually anaerobic • Type I • Polymicrobial • Usually affects older adults with pre-existing conditions such as diabetes mellitus • Type II • Most common is Group A beta hemolytic streptococci in previously healthy individuals • Other Causative Organisms • Clostridium, peptococcus, E. coli, Streptococcus pyrogenes, S. aureus, S. marcescens

Bacterial Action • Injury point (minor trauma to skin) but no skin damage or opening necessary • Insect bite, contusion, frost bite, chronic leg ulcer, surgical incision • Bacteria begin to multiply & travel along fascial plane, release exotoxins that destroy superficial & deep fascia and SQ fat

Common Sites • Extremities • Abdominal wall • Perineum • Post-op wounds Left upper extremity shows necrotizing fascitis in an individual who used illicit drugs. eMedicine Images Necrotizing fasciitis. Sixty-year-old woman who had undergone postvaginal hysterectomy eMedicine Images

Signs & Symptoms • Early S&S: • Mimic common, less serious conditions • Acute illness, low grade fever • Tachycardia •  WBC > 11,000 • HCT < 36% • Metabolic acidosis • Erythematous, edema, very tender area of cellulitis at infection site • As Infection Continues: • Severe pressure-like pain greater than visible signs • If Continues Further deeper tissue damage, progressing to less pain and numbness

Stages of Skin Damage • Early • Skin pink, painful, edema beyond area of erythema • Skin smooth, shiny • Quickly spreading erythema & ecchymosis • Middle • As endotoxins destroy flesh, gas produced from this process accumulates • Skin turns more bluish-grey to purple • Wound leading edge can advance > 2 inches (5 cm) per hour

Stages of Skin Damage • Late • Bullae/vesicles (often purple) appear with yellow serous progressing to sanguinous (hemorrhagic)  blood loss & anemia • As SQ fat necroses, watery thin foul-smelling fluid oozes from wounds • Purple-blue spot progressing to graying-green slough & deep blue and purple (almost black) areola which spreads rapidly This is an example of the large black, liquid filled blisters that are sometimes associated with NF. Source: National Necrotizing Fasciitis Foundation

Diagnosis • Early • CT, MRI (detecting signs of gas in soft tissues) • U/S, bedside biopsy • Surgical diagnosis  fascia normally adheres to bone but on dissection, no resistance with NF • Labs •  antistreptolysin O antibody titre •  sedimentation rate •  WBC count with shift to left •  HCT •  creatinine phosphokinase (if muscle involvement) • Hypoalbuminemia • Anemia typify presentation • Hyperbilirubinemia

Treatment & Nursing Interventions • Early recognition and treatment crucial to positive outcomes • Surgery • remove diseased tissue (cut larger than area involved) • Frequent & numerous  risks associated with multiple anesthetics, hypothermia, mentation changes (esp. with older adults), fluid shifts, blood loss • A 30 y.o. man developed rapidly progressivePainful erythema and edema to right foot Following a bee sting. NF developed within2 days and upon diagnosis area wasAggressively debrided in OR • Antibiotics • halt infection • Penicillin 1st choice with strep infections; combined with clindamycin, erythromycin, ceftriaxone • Vasc damage s blood flow to SQ tissue & prevents abx from reaching intended site • Clotting around sx excision s abx to tissues

Treatment & Nursing Interventions cont. • IV immunoglobulin Therapy • to support natural immune system • Heparin •  risk of vasculitis, thrombosis & DIC • Hyperbaric Chamber • Controversial •  O2 to tissue  slow anaerobic multiplication (change growth environment) while also support healthy, healing tissue & cells • Strict Isolation • Mask, gloves, gown, goggles if splashing possible • Thought to be very contagious

Treatment & Nursing Interventions cont. • Nursing • Assess & recognize & early interventions • VS hourly; chest assess, ABG, oxygen saturations • Frequent lab values • wound & blood cultures before abx begin • Frequent dressing changes & wound measurements • date & time erythema q 1-4 hrs – watch wound parametersfor signs of progression • Remember: extent of fascial necrosis more extensive than what seen on surface of skin • Wet to dry dressings with topical antimicrobials at least q4h • Medications – hemodynamic support, abx, analgesics • Strict monitoring of in/out – hourly monitoring • Keep family & patient informed

Treatment & Nursing Interventions cont. • Nursing cont. • Plenty emotional support  uncertainty, vulnerability • Pain relief • Immobilize & elevate affected area to  swelling which can further compromise blood flow to tissues • IV hydration d/t losses through excised area & fluid shifts • S&S sepsis & shock •  temp,  HR,  mentation, weak PP,  u/o, cap refill >3sec, low syst BP • Aggressive enteral/parenteral nutrition to support wound healing • > 2X normal basal metabolic needs • Risk for acid/base imbalances

Treatment & Nursing Interventions cont. • After Controlling Infection • Skin grafts • Emotional & psychological support – body image, life changing stressor, pain, depression, anxiety, fear, anger, hopelessness, role changes during rehabilitation/convolescence During Acute Treatment Original injury was minimal to her ring finger This photo shows an amazing lifelike armcover that completely covers the scars Side view of arm

Necrotizing Fasciitis