-> Education -> Excellence

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1 Quality Conference 5/2557 Extravasations: Event -> Education -> Excellence รศ.นพ. รว ศ เร องตระก ล สาขาว ชาก มารศ ลยศาสตร ภาควชาศลยศาสตร

2 Extravasations: Event 1. Thrombophlebitis - superficial vein 2. Acute lymphangitis - superficial lymphatic system 3. Cellulitis - subcutaneous tissue 4. Necrotizing fasciitis - superficial fascia 5. Myositis - muscle

3 Cellulitis : Superficial Infection - erythematous, pain, edema - ill-defined border Lymphangitis : - red streak in lymphatic drainage, - tender, lymphadenopathy Deep Infection Deep infection Necrotizing fasciitis - Osteomyelitis

4 Thrombophlebitis Thrombophlebitis (1) Blood clot in vein cause inflammation Common site = legs Superficial (near skin) / Deep (within muscles) Risk factor = prolonged inactivity

5 Thrombophlebitis (2) Diagnosisi + Clinical : tender-swollen-red-warm - Superficial red, hard, tender cord under skin - Deep swollen, tender and painful esp. when standing/walking ± fever + Lymphangitis must be excluded d + Investigation : U/S Thrombophlebitis (3)

6 Acute Lymphangitis Acute Lymphangitis (1) Bacterial infection through skin injury (most commonly Streptococcus pyogenes) Clinical manifestation - Painful red streaks below the skin - High fever

7 Acute Lymphangitis (2) Acute Lymphangitis (3)

8 Cellulitis Cellulitis (1) Bacterial infection (esp. gr. A Strep, Staph. aureus) Clinical manifestation - swollen, red, warm, tender - common site = lower legs - may spread rapidly - can spread to lymph node and bloodstream - spreading infection may be life-threatening Risk factors old age, DM, immunosuppressed, IV drug use, lymphedema

9 Cellulitis (2) Cellulitis (3)

10 Management in Cellulitis (1) Self care at home *** - Rest and elevate the area of body involved - Use pain relievers (e.g. paracetamol, ibuprofen) - Oral antibiotics for 7-14 days IV antibiotics if - Severe infection / sepsis - Other medical problems (e.g. DM) - Very young / very old age - Infection involving/close to the vital structures (e.g. cellulitis liti around the eye socket) Management in Cellulitis (2) Oral Antibiotics 1. β-lactams - Cephalexin 500 mg PO q 6 hr - Dicloxacillin illi 500 mg PO q 6 hr 2. Fluoroquinolone - Levofloxacin 500 mg PO once daily for 5 days 3. Macrolides & Lincosamides - Clindamycin 300 mg PO q 6 hr - Azithromycin / Clarithromycin

11 Management in Cellulitis (3) IV Antibiotics Nafcillin 2 givq4 hr In case of MRSA : - Vancomycin 15 mg/kg IV q 6 hr if normal renal function IV for 3-5 days if afebrile and skin lesion resolved turn to PO form Management in Cellulitis (4) Penicillin-allergic Patients Oral form - Clindamycin 300 mg PO q 6 hr - Levofloxacin 500 mg PO once daily IV form - Clindamycin 600 mg IV q 8 hr - Vancomycin 15 mg/kg IV q 12 hr Immunocompromised host Antibiotics combination - Clindamycin + Ceftriaxone - Nafcillin + Fluoroquinolones

12 Necrotizing Fasciitis Necrotizing Fasciitis (1) A deep infection of the subcutaneous tissue progressive destruction of fascia and fat Presentations: Erythematous (without sharp margins), Swollen, warm Exquisitely tender changes in skin color from red-purple to patches of blue-gray

13 Necrotizing Fasciitis (2) Presentations (continue): Skin breakdown with bullae (containing i thick pink or purple fluid) The development of anesthesia may precede the appearance of skin necrosis Advanced infection: high fever and systemic toxicity Necrotizing Fasciitis (3) Type I : Polymicrobial TpeII Type : Group A strep. Type III : Gram-negative monomicrobial Type IV : Candida NF Davoudian, P. and N. J. Flint (2012).

14 Necrotizing Fasciitis (4) Clinical manifestation + Early : - Flu-like like symptoms (fever, chill, weakness, nausea, tachycardia), - Tender-swollen-red-warm red warm + Advanced : - Excessively swollen, - Skin discoloration/gangrene - Large dark mark becoming blister filled with yellow-green necrotic fluid Necrotizing Fasciitis (5) Example I Calcium leakage

15 Depth of infection General appearance Cellulitis Dermis and subcutaneous layer Chill, fever, malaise but survivable NF Crepitus No Yes Loss of sensation No Yes Subcutaneous layer and fascia Toxic appearance Discoloration of skin Erythema Erythema to Blue-grey gey (gangrene) Bullae Rare Yes X-ray imaging - +/- air in subcutaneous tissue Necrotizing Fasciitis (6) Specific treatment - ATB therapy - Early aggressive surgical exploration - Complete debridement -IVIG - Hyperbaric oxygen therapy

16 Necrotizing Fasciitis (7) Necrotizing Fasciitis (8) Post spit thickness skin graft

17 Necrotizing Fasciitis (9) Investigation - Blood chem. : Cr, CPK, glucose, albumin, bicarbonate, Ca 2+ - Hemoculture & Susceptibility testing - Imaging g : X-ray, CT, MRI Treatment - Emergency debridement - IV antibiotics - Hyperbaric oxygen therapy - Soft tissue reconstruction ti Necrotizing Fasciitis (10 10) Gas in subcutaneous tissue

18 Necrotizing Fasciitis (11 11) Example II Calcium leakage Necrotizing Fasciitis (12 12)

19 Necrotizing Fasciitis (13 13) Post spit thickness skin graft Necrotizing Fasciitis (14) TPN leakage

20 Antibiotic principle Broad-spectrum antimicrobial therapy + maximum dose Recommended regimen Carbapenem (20 mg/kg/d g q6h) + Clindamycin (40 mg/kg/d q6-8h) Beta-lactam/Beta-lactamase inhibitor + Clindamycin (Ampicillin-sulbactam g IV q6-8h) (Piperacillin-tazobactam g IV q6-8h) Management of the wound Extensive debridement Control of infection Good local wound care Kept clean and moist but free of excessive fluids E.g. Use vacuum dressing Underlying disease

21 Vacuum-assisted assisted closure (VAC) negative pressure removes edema fluid increased blood flow to the wound and greater cell proliferation reduction in bacterial colonization of the wound enhances the formation of granulation tissue Vacuum-assisted assisted closure (VAC) Insert foam into the wound to expose tissue negative pressure effect and prevent occlusion Insert drain tube to drain fluid form the wound Covered wound with a transparent adhesive membrane

22 Vacuum-assisted assisted closure (VAC) Advantages over other treatments Reduce the length of a hospital stay Faster wound healing, less discomfort and pain, a greater sense of well-being A change of dressing only every 48 hours Adjuvant treatment IVIG Theoretical bind staphylococcal and streptococcal derived exotoxin Controversial data Should be restricted to critically ill patients with either staphylococcal or streptococcal NSTI Hyperbaric oxygen therapy Controversial data May benefit for Clostridial infection