Necrotizing fasciitis: Difference between revisions

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==Background==
==Background==
*A rare, rapidly progressive infection primarily involving the fascia and subcutaneous tissue
*A rapidly progressive infection primarily involving the fascia and subcutaneous tissue
*Gas-formation is NOT a requirement for diagnosis, and radiographical lack of the classically taught gas formation should NEVER rule out necrotizing infection<ref>Misiakos EP et al. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014. 1:36.</ref>
*Most severe form of soft tissue infection and potentially limb and life threatening
*Most severe form of soft tissue infection and potentially limb and life threatening
*Early recognition and aggressive debridement are major prognostic determinants and delay increases mortality<ref>Wong CH, Khin LW, Heng KS, Tan KC, Low CO (2004). "The LRINEC Laboratory Rother soft tissue infections". Critical Care Medicine 32 (7): 1535–1541. doi:10.1097/01.CCM.0000129486.35458.7D. PMID 15241098</ref>
*Early recognition and aggressive debridement are major prognostic determinants and delay increases mortality<ref>Wong CH, Khin LW, Heng KS, Tan KC, Low CO (2004). "The LRINEC Laboratory Rother soft tissue infections". Critical Care Medicine 32 (7): 1535–1541. doi:10.1097/01.CCM.0000129486.35458.7D. PMID 15241098</ref>
*Categories:
**Type I, polymicrobial
**Type II, group A streptococcal
**Type III, gas gangrene or clostridial myonecrosis


===Risk Factors===
===Risk Factors===

Revision as of 21:22, 14 December 2016

Background

  • A rapidly progressive infection primarily involving the fascia and subcutaneous tissue
  • Gas-formation is NOT a requirement for diagnosis, and radiographical lack of the classically taught gas formation should NEVER rule out necrotizing infection[1]
  • Most severe form of soft tissue infection and potentially limb and life threatening
  • Early recognition and aggressive debridement are major prognostic determinants and delay increases mortality[2]
  • Categories:
    • Type I, polymicrobial
    • Type II, group A streptococcal
    • Type III, gas gangrene or clostridial myonecrosis

Risk Factors

  • DM
  • Drug use
  • Obesity
  • Immunosuppression
  • Recent surgery
  • Traumatic wounds

Clinical Features

Nectrotizing fasciitis
CT of necrotizing fasciitis
  • Skin exam
    • Erythema (without sharp margins)
    • Exquisitely tender (pain out of proportion to exam)
      • Caveat - some patients present with "la belle indifference"
      • May be a result of ischemic, insensate tissue[3]
    • Skip lesions
    • Hemorrhagic bullae (violaceous bullae)
      • May be preceded by skin anesthesia (destruction of superficial nerves)
    • Crepitus (in type I infections)
  • Swelling/edema may produce compartment syndrome
  • Constitutional
    • Fever
    • Tachycardia
    • Systemic toxicity

Differential Diagnosis

Skin and Soft Tissue Infection

Look-A-Likes

Necrotizing rashes

Evaluation

Work-Up

  • CBC
  • Chem
  • PT/PTT/INR
  • CK
  • Lactate

Evaluation

  • Surgical exploration is the ONLY way to definitively establish the diagnosis of necrotizing infection
  • Imaging
    • Should not delay surgical exploration
    • CT is study of choice - soft tissue gas, edema and fluid collections, fascial thickening with fat stranding
    • US may show thickened fascial planes, fluid between fascial planes, irregularity of the fascia, subcutaneous emphysema. The study may be limited by soft tissue gas
    • MRI - T2 subcutaneous, intramuscular, and fascial edema

Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score[4]

Has not been prospectively validated, index of suspicion is key and 10% of the patients with a score < 6 had Necrotizing Fasciitis. A score > 6 has PPV of 92% and NPV of 96% for necrotizing fasciitis.

  1. CRP (mg/L) ≥150: 4 points
  2. WBC count (×103/mm3)
    • <15: 0 points
    • 15–25: 1 point
    • >25: 2 points
  3. Hemoglobin (g/dL)
    • >13.5: 0 points
    • 11–13.5: 1 point
    • <11: 2 points
  4. Sodium (mmol/L) <135: 2 points
  5. Creatinine (umol/L) >141: 2 points
  6. Glucose >180 mg/dL (10 mmol/L): 1 point

Grouping by Scores

  • Low Risk: score 5 (10% of pts with score < 6 still had nec fasc)
  • Moderate Risk: score 6– 7
  • High Risk: score >8

Proposed algorithm

HUCLA NF vs Non-NF Criteria:[5]

  • Retrospective study discovered:
    • WBC count >15.4(x103/mm3) OR Na <135(mmol/L)
    • Associated with NF and combo of both increased likelihood of NF
    • PPV 26%/NPV 99%
  • Useful tool to rule out NF, not a good tool for confirming presence of NF
    • Helps distinguish NF from non-NF infection, when classic 'hard' signs of NF are absent however clinical judgment should still be used in patient with high suspicion of the disease

Management

  • Surgical exploration and debridement is both the definitive diagnostic modality and the definitive treatment
    • Indicated in setting of severe pain, toxicity, fever, elevated CK (with or without radiographic evidence)
  • Antibiotics
  • In diabetics, maintain strict glycemic control (with IVFs and IV insulin if necessary)

Disposition

  • Admit to ICU

See Also

Video

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References

  1. ↑ Misiakos EP et al. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014. 1:36.
  2. ↑ Wong CH, Khin LW, Heng KS, Tan KC, Low CO (2004). "The LRINEC Laboratory Rother soft tissue infections". Critical Care Medicine 32 (7): 1535–1541. doi:10.1097/01.CCM.0000129486.35458.7D. PMID 15241098
  3. ↑ TheHealthScience. Emergent Management of Necrotizing Soft Tissue Skin Infections. Nov 22, 2013. https://thehealthscience.com/topics/emergent-management-necrotizing-soft-tissue-skin-infections.
  4. ↑ Wong C. "The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections". Crit Care Med. 2004. 32(7):1535-41.
  5. ↑ Wall DB et al. A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection. J Am Coll Surg. 2000 Sep;191(3):227-31.
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