Il ruolo del chirurgo nella gestione delle infezioni di cute e tessuti molli

Transcription

1 Il ruolo del chirurgo nella gestione delle infezioni di cute e tessuti molli Massimo Sartelli U.O. Chirurgia Generale Ospedale di Macerata

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3 Surgical Site infections Incisional - Superficial - Deep Non-necrotizing SSTIs Superficial infections (Impetigo, erysipelas, cellulitis) Simple abscess, boils and carbuncles Complex abscesses Necrotizing SSTIs (NSTIs) Necrotizing cellulitis Necrotizing fasciitis Fournier s gangrene Necrotizing myositis WSES Classification

4 Superficial infections

5 Superficial abscess

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7 Complex abscess

8 Perianal abscess

9 Abscess in diabetic patients

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11 Necrotizing infections

12 Necrotizing infections NSTIs include necrotizing cellulitis, necrotizing fasciitis, Fournier s gangrene and necrotizing myositis. They are life-threatening, invasive, soft tissue infections caused by aggressive, usually gas-forming bacteria. Delay in diagnosing and treating these infections increases the risk of mortality.

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16 Diagnosis Patients with necrotizing soft tissue infections usually present with severe pain that is out of proportion to the physical findings.

17 LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score Wong CH, Khin LW, Heng KS, Tan KC, Low CO: The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004, 32:1535.

18 Fournier's gangrene severity index Roghmann F, von Bodman C, Löppenberg B, Hinkel A, Palisaar J, Noldus J. Is there a need for the Fournier's gangrene severity index? Comparison of scoring systems for outcome prediction in patients with Fournier's gangrene. BJU Int Nov;110(9):

19 Diagnosis

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23 Pathophysiology Local Direct cellular injury from bacterial endo/exotoxins Significant inflammatory oedema within a closed tissue compartment, Thrombosis of local blood vessels and Tssue ischemia. Systemic Circulating toxins may cause systemic illness which can progress to septic shock, multisystem organ dysfunction, and death

24 Treatment

25 Source control

26 Source control Although some tissues may appear normal, at microscopic level thrombosis and vasculitis render them unsalvageable: normal-appearing tissues that overlie or are adjacent to an infection site are usually subject to full-thickness loss

27 Source control 1. Radical surgical debridement of the entire affected area should be performed, continuing the debridement into the healthy-looking tissue. 2. In the setting of Fournier s gangrene, diverting colostomy has been demonstrated to improve the outcome and the need for fecal diversion depends upon severity of the disease. 3. Recently rectal diversion devices have been marketed.they are silicone catheters designed to divert fecal matter in patients with diarrhea, local burns, or skin ulcers. The devices protect the wounds from fecal contamination and reduce in the same way a colostomy does.

28 Source control Any patient with extensive necrosis or who is considered to have not be adequately debrided at the initial operation should be returned to the operating room in hours for a second look.

29 Source control Several reports have documented the utility of negative pressure wound therapy (NPWT) therapy for managing patients who have acute NSTI demonstrating that NPWT technique of wound closure is effective in managing non-healing limb wounds consequential to surgical treatment for patients suffering from acute necrotizing fasciitis

30 NPWT in necrotizing soft tissue infection

31 NPWT in necrotizing soft tissue infection

32 Conclusion High level of suspicion

33 Thank you