Management of Necrotizing Soft Tissue Infection
Necrotizing soft tissue infection is a relatively rare, but highly morbid condition requiring immediate surgical evaluation and initiation of multimodal treatment. The key to effective treatment for NSTI is early recognition of the problem, facilitated by
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Heather Leigh Evans and Eileen M. Bulger
Case Presentation A 50 year-old woman with history of congestive heart failure presented to the emergency room of her local community hospital complaining of progressive right elbow pain and swelling that developed after a minor fall at home 4 days prior. Her husband reported that she had profuse watery diarrhea 1 week prior, while continuing to take her home medications, which included Lasix. Since the fall, she had remained in bed with generalized weakness and poor PO intake. In the ED, her initial systolic blood pressure is 70 mmHg and the right forearm is noted to be swollen and tense, erythematous, warm and exquisitely painful to passive range of motion. Induration extends to the proximal posterior upper arm. WBC is 21, lactic acid 10.8, creatinine 11, sodium 119. She rapidly receives ceftriaxone and clindamycin, 3 L of crystalloid resuscitation and norepinephrine and vasopressin infusions are started. The orthopedic surgeon on call takes her urgently to the operating room to treat what is strongly suspected to be a necrotizing soft tissue infection. The forearm skin is incised and the
H.L. Evans (*) Surgery, University of Washington/Harborview Medical Center, Seattle, WA, USA e-mail: [email protected] E.M. Bulger Surgery, University of Washington, Seattle, WA, USA
superficial volar compartment fascia released, the muscles are noted to be generally viable. No debridement is performed. A wound vacuum dressing is placed and she is transported to the ICU. Overnight, norepinephrine is discontinued, but her WBC increases to 36 and oliguria develops. She is transferred emergently to a tertiary care center, arriving in the emergency department intubated and sedated on mechanical ventilation, systolic blood pressure in the 80’s despite ongoing treatment with vasopressin and sodium bicarbonate infusion for progressive metabolic acidosis (pH 7.09). Her sodium level is 131. The Gram stain from blood cultures obtained at the prior facility shows Gram positive cocci in chains. Question What is the approach that should be applied to guide the management of this patient? Answer Surgical source control Norepinephrine is restarted, 3 L of lactated ringers fluid are administered immediately and additional antibiotics (vancomycin) are administered while the general surgeon on call evaluates the patient and arranges for emergent re- exploration. She is taken to the operating room where the wound vac dressing is removed. The wound is thoroughly evaluated, the incisions extended both proximally and distally to facilitate examination of the entire length of the forearm to the hand and the superficial and deep volar
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_85
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H.L. Evans and E.M. Bulger
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compartments to the forearm are found to be non- viable (Fig. 85.1). The general surgeon calls an emergent intra- operative consult to the on-call hand surgeon. Together, the two identify nec
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