1. Pediatric Necrotizing Fasciitis
David Zeltser

2. Overview Basics of necrotizing fasciitis Neutropenic patients
Compartment syndrome
Functional outcomes

3. Necrotizing Fasciitis in Children
Mortality usually lower in children.
Trunk most common
Usually monomicrobial
Necrosis of superficial muscle fascia and deeper layers of dermis.
Thrombosis of vessels  necrosis
Multiorgan failure and shock

4. Predisposing Factors in Children
Omphalitis
Circumcision
Trauma
Surgery
Burns
Eczema
Less common: insect bites, perirectal abscesses, incarcerated hernias, SQ injections, varicella, GABHS pharyngitis
Varicella

5. Microbiology Type 1: Polymicrobial
GNRs, Peptostreptococcus, Clostridium
Diabetes, peripheral vascular disease
Myonecrosis
Type 2: Group A beta-hemolytic Streptoccocus
Trauma, varicella, burns, cuts
Most common form in children
Type 3: Marine (Vibrio species)
Least common

6. Immunocompetent Patients
Erythema, swelling, induration
Pain out of proportion
Systemic signs: fever, tachycardia
Emergent debridement
Intraoperative frozen sections
Usually skin flora

8. Neutropenic Oncology Patients
Fever
Pain out of proportion
Unwillingness to move extremity
Erythema & induration are subtle
Mucositis  GI flora, GNRs, VRE
MRI (should not delay surgery)
Frozen sections less helpful
Usually GI/GU flora
Simultaneous myonecrosis & necrotizing fasciitis

9. Sonographic Features of NF
Distorted & thickened fascia
Turbid fluid or loculate abscess in fascial plane
Subcutaneous swelling
Normal muscle plane

11. Case 5:
Pseuodomonas NSTI in AML

12. Management… Intensive care Hyperbaric oxygen therapy
Cytokine therapy  stimulate bone marrow
Granulocyte colony stimulating factor (GCSF)
Granulocyte infusion if remained neutropenic

13. Compartment Syndrome Usually long bone fractures
Soft tissue injuries: 20%
Infection uncommon (pyomyositis, necrotizing fasciitis)
Normal compartment pressure = mmHg
35 mmHg

14. Compartment Syndrome of Forearm
10 yr old girl
“Pinch”
Septic shock
Ulnar fasciotomy & debridement
Group A Strep
IV Abx
STSG after 10 days
Aggressive PT
Full ROM POD#28

15. Functional Outcomes Limited adult studies No studies in children
Harborview Study:
VAC systems for clean, granulating wounds
Coverage: skin autograft, flap, secondary intention
OT/PT until discharge
AMA Guides to the Evaluation of Permanent Impairment – Borrowed from burns.

16. Harborview

17. Mean age 44
40% IVDU
82% Extremities

18. Mean Hospital LOS: 38.5 days Mean ICU LOS: 7.6 days
Mean Functional Limitation: 7.1%
Wound contraction before coverage
Peripheral neuropathy
Deconditioning
Likelihood of functional limitation (AMA Guides to the Evaluation of Permanent Impairment):
Extremity involvement  1.8
ICU LOS, time to PT/OT consult
Extremity involvement independently associated with higher functional limitation (multivariate analysis).

19. Conclusions
Think NSTI when pain out of proportion in neutropenic fever
Need studies of functional outcomes in children

20. References
TN Pham et al. Assessment of functional limitation after necrotizing soft tissue infection. Journal of Burn Care & Research (2009). 30(2).p301-6.
DL Johnston, JHT Waldhausen, JR Park. Deep soft tissue infections in the neutropenic pediatric oncology patient. J Pediatric Heme/Onc (2001). 23(7). p443-7.
Frank et al. Musculoskeletal Infections in Children. p
C Ramos et al. Nontraumatic compartment syndrome of the extremities in children. J Pediatric Surgery (2006). 41(E5-7).
M Bingol-Kologlu et al. Necrotizing fasciitis in children: diagnostic and therapeutic aspects. J Pediatric Surgery (2007)
TH Jaing et al. Surgical Implications of Pseudomonas aeruginosa necrotizing fasciitis in a child with acute lymphoblastic leukemia. J Pediatric Surgery (2001). 36(6)