Necrotizing fasciitis

Transcription

1 Necrotizing fasciitis Falco Hietbrink Surgeon, MD/PhD

2 Disclosure form No conflict of interest Images with approval for educational purposes Please, no cellphonepictures of slides

3 Soft tissue infections In which layer? Which pathogen?

4 Diagnosis Erysipelas Cellulitis Necrotizing fasciitis Type 1 Type 2 (Type 3)

5 Cellulitis: conservative

6 Erysipelas: conservative

7 Necrotizing fascitis: operative

8 Diagnosis Erysipelas Streptococcen (groep A) Cellulitis Staphylococcen Mengflora / Streptococcen Necrotiserende fasciitis Type 1 Polymicrobieel Staphylococcen Enterobacterien / Anaeroben Type 2 Monomicrobieel Streptococcen groep A (Type 3 Vibrio species)

9 Etiology of GAS Groep A hemolytische Streptococ (GAS) Greek: streptos =chain and kokkus = grape First described in 1874 Theodor Billroth (German surgeon)

10 Etiology of GAS In 1928: β hemolytic streptococcus were divided based on group specific polysaccharides in A / E by Rebecca Lancefield Streptococcus: α, β, γ hemolytic activity β hemolysis: full erythrocyt lysis (hemolysin) α hemolysis: erythrocytes intact but pigment change (red to green) γ hemolytic activity: no change in erythrocytes

11 Etiology of GAS Recognition in 80 s in young healthy adults Media: flesh eating bacteria Necrotizing fasciitis: severe necrotizing soft tissue disease Can happen to everyone (Pubmed): Fournier's Gangrene due to Masturbation in an Otherwise Healthy Male

12 Epidemiology Medline: >3700 hits 0.4 / Increase incidence with age: <18 years 0.08 / >80 years 12 / High mortality (10-70%) and morbidity rates Low, Current Op Infect Dis 1998 Lanceretto, J Trauma 2012 Dixon, Lancet Infect Disease 2008

13 Epidemiology Scary disease : can occur in seemingly healthy patients 50% of patients have (severe) co-morbidities Both blunt and penetrating trauma are risk factors Really scary disease : Progression while watching Up-to-date 2012 Barrie, Crit Care 2004 Lanceretto, J Trauma 2012 Sartelli, WJES 2014

14 Classification According to microbiology: -Type 1: Polymicrobial (55-90%) -Type 2: Monomicrobial (GAS) -Type 3: Virulent gram positive/negative bacilli -(Type 4: Fungi) Geography dependent (no MRSA in NL, Vibrio species in Asia) According to location Different specialties -Maxillofacial / Ludwigs angina / Trunk / Extremity / Fournier Morgan, J Hosp Infect 2010 Stevens, Clin Infect Dis 2014 Sartelli, WJES 2014 Lamb, Lancet Infect Disease 2015

15 Diagnostics Signs and symptoms - Rapid onset / progression - Disproportional pain - Classical signs: only 10-40% / late signs Wong, Crit Care Med 2004 Misiakos, Frontiers in Surgery 2014 Couto, Crit Care 2013 Mann, J Burn Care Res 2013

16 Recognition by the untrained eye? Courtesy by Marike Kokke

17 Recognition by the untrained eye? 40 Mortality reported in series (%) Initially missed cases (%) Goh, BJS 2013 Tsitsilonis, Langenbecks Arch Surg 2013

18 Diagnostics Early surgical debridement within 24 hours was associated with 6% mortality versus 25% when treatment was delayed Improved awareness Mortality decreased last decade Early stages are more difficult to diagnose Lille, JACS 1996 Mok, Lupus 2006 Ustin, Crit Care 2011 McHenry, Ann Surg 1995

19 Laboratory tests LRINEC score (CRP, Leukocyte, Hb, Sodium, Creatinin, Glucose) Arterial Blood Gas: Bicarbonate, Base deficit, Lactate Provides insight in illness severity of the patient Not for diagnosing the disease itself! Wong, Crit Care Med 2004 Chao, JOT 2012 Eachempati, Arch Surg 2002 Mann, J Burn 2013 Hakkarainen, Curr Probl Surg 2014

20 Imaging diagnostics(?) X-ray, CT-scan, MRI: If desired, only in stable patients Analysis should not lead to paralysis Barrie, Crit Care 2004 Misiakos, Frontiers in Surgery 2014 Chaudhry, AJR Am J Roentg 2015 Couto, Crit Care 2013

21 Standardized approach Philosophy: Early recognition + Aggressive treatment Search and destroy Bilton, Am Surg 1998 Tu, Infection 2013 Majeski, South Med 1997 Elliot, Ann Surg 1996 Hakkarainen, Curr Probl 2014

22 Multidisciplinary approach Always: Intensivist / Microbiologist / Surgeon Optional: Plastic surgery / Ophthalmologist / ENT Support: Physiotherapist / Social worker / Dietician Ludwigs Angina progression Orbital necrotizing fasciitis Tambe, Eye 2012 Tu, Infection 2013 Garssen, NTVG 2013 Chueng, Case Otolaryngology 2012

23 Early diagnostics by standardized approach If suspicion to OR for biopsy (improve early diagnostics) Skin sparing is a tool, not the mission (time more important) Aggressive resuscitation (even when not deemed sick ) Aim = 1) Survival 2) Limb salvage 3) Functional recovery One chance to get it right!

24 Clinical awareness (education) When suspected: Consult surgeon -Laboratory testing (standard, ABG, cultures) -Marking skin changes (non-washable marker) In case of severe sepsis: resuscitate To operation room: fascia biopsy for triple diagnostics Clinical diagnosis + Cito Gram staining + Intra-operative frozen section

25 Standardized approach: Adjuncts Gold standard in ambivalent cases: The combination of surgical exploration, microbiological and histopathological analysis of soft tissue Cito Gram stain: Presence of bacteria Poly or mono-microbial Frozen section: Tissue necrosis Leukocyte infiltration Misiakos, Frontiers in Surg 2014 Tsitsilonis, Langenbecks Arch Surg 2013

26 Standardized approach: Frozen section Courtesy by Marike Kokke Stamenkovic, NEJM 1984

27 Standardized approach: Clinical diagnosis: confirmed Courtesy by Luke Leenen

28 Standardized approach: Clinical diagnosis: negative Frozen section negative / Gram stain positive GAS

29 Standardized approach: Necrotizing fasciitis found proximal of the skin marks

30 Standardized approach: Clinical diagnosis: ambivalent Gram stain some bacteria / Frozen section positive

31 Standardized approach: Necrotic tissue (incl. fascia) at disseminated sites

32 Standardized approach: Clinical diagnosis ambivalent. Gram stain negative. Frozen section negative.

33 Standardized approach: Clinical awareness Necrotizing fasciitis suspected Blood cultures Antibiotics: Penicillin, Clindamycin, Gentamycin Laboratory tests (LRINEC + ABG) Mark skin lesions AND Call surgeon NF suspected to OR for biopsy No clinical signs of NF Assured clinical diagnosis Clinical diagnosis indistinct Treat condition: -Erysipelas -Cellulitis -Abscess Either one positive Extension of incisions Frozen section Both negative Gram stain Aggressive surgical debridement AND Re-evaluate every 6 hours Close wound AND Re-evaluate every hour Immunoglobulins (GAS) Hyperbaric oxygen (Clostridium) Multidisciplinary team: Surgery, ICU, MMB

34 When diagnosed early and treated aggressively, satisfactory results can be achieved Courtesy by Mirjam de Jong

35 Thank you for your attention!