Skin Deep Dr Deirdre Hussey

Mr AD 34 yr old male self presentation to A/E c/o: 3/7 hx of swollen right upper thigh Haematoma secondary to mild trauma 4 days previously Extending to groin Severe pain Unable to weight bear Fever and rigors x 24hrs Vomiting x 3 occasions on day of admission

Mr AD Meds: Zimovane

Mr AD Nil of note in family history Smoker Lives with wife and 2 daughters ROS- nil of note

Mr AD Referred to surgical team on call at 21:30 WCC (neut 18.10) Platelets 260 HB 12.4 Urea 8.9 Na 131 K 4.8 Creat 108 Bilirubin 8 ALT 12 Alk phos 111 INR 1.28 CRP 385 ESR 90

Mr AD Examination: 22:00 hrs In obvious distress Pale and clammy Unable to stand, all movements of right leg painful BP 112/68 HR 115 reg Temperature 34.3 RR 12 Oxygen Sats 100% on room air

Mr AD Dx: Severe Cellulitis, strong possibility of progression to necrotising fasciitis Management: Admission, urgent bed request as currently on chair Benzylpenicillin and flucloxacillin (double dose) Analgesia Wound review every 30 minutes by A/E nursing staff

Mr AD Post call ward round 08:00- patient still in A/E dept

Mr AD

Initial exploration + debridement: Incisions extended medially and laterally Necrotic fascia debrided until healthy tissue reached Copious washout with hydrogen peroxide Wound packed Intraoperative tissue and fluid specimens sent 7 repeat visits to theatre during admission

Mr AD Post operative day 1: BP 60/40, HR 115, Afebrile BP slow to recover despite fluid resuscitation Patient very drowsy and difficult to rouse Wound review Repeat boods Cause?

Mr AD Proteus mirabilis (resistant to ampicillin) Bacteroides fragilis and enterococcus faecalis Subsequent cultures positive for heavy growth of Pseudomonas aeruginosa and Klebsiella Commenced on Vancomycin, Meropenem, Clindamycin and Ciproxin as per sensitivities

Mr AD Plastic Surgery consult Underwent SSG with donor site from adjacent lateral thigh tissue Discharged, for OPD follow up

Necrotising Fasciitis Definition: Progressive, rapidly spreading, inflammatory infection within the deep fascia, with secondary necrosis of the subcutaneous tissues. Trauma Recent surgery/ Im or iv injections at the site Diabetes Alcoholism Idiopathic

Necrotising Fasciitis Pain typically out of proportion to clinical findings at onset Initial area of erythema, rapid spread Skin discoloration bullae Tissue necrosis Putrid discharge bullae gas production Subcutaneous emphysema/crepitus Systemic signs

Necrotising Fasciitis

Group A haemolytic streptococcus +/- staph aureus commonest initiating organisms Often polymicrobial: Bacteroides fragilis Clostridium Enterobacteria Coliforms Proteus, Pseudomonas Klebsiella

Necrotising Fasciitis Diagnosis: Predominantly clinical, high index of suspicion Plain films CT Should not delay operative intervention

Necrotising Fasciitis Skovsen et al, Feb 2010, Denmark Retrospective Study, 85 patients, % cases polymicrobial:40% single pathogen (74% BHS) 2/3 presented with septic shock Raised BMI and diabetes mellitus commonest risk factors ITU mortality 6 % 30 day mortality 9.5%

Necrotising Fasciitis Management: ABC's- aggressive fluid resuscitation Early surgical consultation and intervention (multiple) Early microbiology advice Hyperbaric oxygen therapy- not standardized practice

Teaching Points Monitor cutaneous infections closely Identify risk factors for progression High mortality, early intervention Multidisciplinary approach- Micro, Plastics