Multiple Dimensions of Caring for a Patient with Acute Necrotizing Fasciitis

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Multiple Dimensions of Caring for a Patient With Acute Necrotizing Fasciitis

Lisa Ruth-Sahd, RN, DEd, CEN, CCRN; Mike Gonzales, RN

Critical care nurses within acute care settings are responsible for providing healthcare to a wide variety of patients and, consequently, knowledge regarding how to care for a patient with acute necrotizing fasciitis is imperative. A case study is presented to evidence the need for a multidisciplinary approach. Necrotizing fasciitis is defined and treatment options are presented. Caring for this patient is very challenging and demands a multidisciplinary team to coordinate all aspects of care to promote better patient outcomes. Keywords: Necrotizing fasciitis, Hyperbaric oxygenation therapy, Wound care.

[DIMENS CRIT CARE NURS. 2006;25(1):15/21]

M.S., a 55-year-old man presented to the emergency raphy of his abdomen revealed a ruptured diverticulum department via ambulance with acute abdominal pain, which created an enterocutaneous fistula. profound hypotension (BP = 80/40 mm Hg), tachycar- M.S. was admitted to the intensive care unit and dia (HR = 140), and hyperthermia (T = 103.4). He was immediately started on a wide variety of antibiotics initially unresponsive en route to the emergency depart- including Levofloxacin (Levaquin), a fluoroquinolone; ment, but after fluid resuscitation with a liter of normal Metronidazole (Flagyl), an anti-infective used to treat saline, he regained consciousness and his blood pressure anaerobic infections; and Pipercillin/Tazobactam (Zosyn), was starting to come back within the normal range another anti-infective which is an extended-spectrum (BP = 90/50) and heart rate decreased to 120. On penicillin. Within 24 hours of his hospital admission physical assessment, he was found to have a large, soft he was taken to the operating room for an exploratory abdomen with diffuse tenderness, severe localized pain, laparoscopy. Surgery revealed a perforated viscus with and crepitus on palpation along the left lateral abdomi- abscess formation, which required a Hartmans Sigmoid nal wall, left hip, and left upper thigh. His initial colectomy. diagnosis was an acute abdomen, possibly peritonitis, One day later, his left leg and flank increased in with subcutaneous emphysema. A plain film of the circumference at which time a tissue culture was abdomen revealed a large amount of air in the soft performed that identified a gram-positive cocci charac- tissues of the left flank. A STAT computerized tomog- teristic of streptococcus and gram-negative rods. The

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Caring for a Patient With Acute Necrotizing Fasciitis group A streptococcus confirmed what the doctors had crease is thought to be largely due to many strains of already suspected: necrotizing fasciitis (NF)Va disease the flesh-eating organisms that are more virulent and that was eating his epidermis, subcutaneous fat, and more resistant to antibiotics. Additionally, an increase in muscle. As a result of the diagnosis of NF, M.S. immunocompromised patients with cancer, alcoholism, underwent a fasciotomy of the left flank and thigh and vascular insufficiencies, organ transplants, HIV, or extensive soft tissue debridement of gangrenous, neutropenia.3,10 necrotic skin and subcutaneous tissue. Cultures and Gram stains were also performed at this time. This PROGRESSION OF NECROTIZING FASCIITIS article will discuss M.S. and the multiple dimensions of Necrotizing fasciitis is a progressive, rapidly spreading, care required to holistically assess, diagnose, and treat inflammatory infection located in the deep fascia, patients with this rare but life-threatening condition. causing secondary necrosis of the subcutaneous tissues. Because of the presence of gas-forming organisms, CASES NOTED IN THE LITERATURE subcutaneous air is classically identified by palpation Review of the literature revealed several causes of NF re- or on x-ray.5,13 The expansion moves along the deep sulting from many etiologies such as post paraumbilical fascial plane and is directly proportional to the thickness hernia repair, trauma, self-injection of kerosene, cancer, of the subcutaneous layer. the development of an enterocutaneous fistula, dental Historically, NF is challenging to recognize in the infections, peritonsillar abscesses, facial insults, intra- early stages, often being initiated by an innocuous minor muscular injections, intravenous infusions, insect bites, Y trauma such as an insect bite, skin contusion, or chronic frostbite, paraplegia, chicken pox, and decubitus ulcer.1 12 leg ulcer. The patient may initially present to their family doctor complaining of pain, redness, and swelling There are several causes of NF and be diagnosed with cellulitis. The visual assessment resulting from many etiologies. of the skin reveals only the tip of the iceberg. The bacteria under the skin may be devouring up to 1 inch of flesh per hour. The redness and pain quickly get worse to the point that the patient complains of severe It was also noted in the literature that multiple terms pain that does not seem to match the skin redness. The are used to describe NF. NF is referred to as hemolytic patient may then develop eccymosis with vesicles that streptococcal gangrene, acute nonclostridial crepitant enlarge to become purple bullae. These bullae contain cellulitis, nonclostridial gas gangrene, necrotizing cellu- foul-smelling ‘‘dishwater pus’’ which may be hemor- litis, Meleney ulcer, acute dermal gangrene, hospital rhagic and lead to significant blood loss if ruptured or gangrene, bacterial synergistic gangrene, gangrenous or broken.14 As the disease progresses, the patient will necrotizing erysipelas, hemolytic streptococcal gangrene, complain of numbness instead of pain due to the suppurative fasciitis, and synergistic necrotizing celluli- destruction of subcutaneous nerves and the development tis. Fournier gangrene, first described by Fournier in of gangrene within 4 to 5 days.3,15 Untreated, severe 1883, is a form of NF that is localized to the scrotal, sloughing of the tissue will begin by the second week, penile, or perineal area.10 Regardless of the cause or the releasing toxins into the bloodstream, leading to sepsis name associated with it, NF has gained attention of and possible death within 24 to 96 hours. Other critical care workers and hospital staff because of the complications adding to the morbidity include dissemi- frightening mortality of 74%, aggressive progression, nated intravascular coagulation, respiratory failure, and and high rate of systemic toxicity. multisystem organ failure.

RISK FACTORS PATHOPHYSIOLOGY M.S. had a history of hypertension, coronary artery Chapnik and Abter16 discuss 2 types of NF. Type 1 disease, chronic obstructive pulmonary disease, and involves several bacteria (aerobic and anaerobic) occur- diverticulosis. Like many patients who develop NF ring with facultative bacteria. This is often seen in today, M.S. had relatively few predisposing factors. postoperative patients or patients with a history of Once thought to occur only in patients with risk factors diabetes mellitus and accounts for 90% of all cases. such as diabetes mellitus, obesity, immunosuppression, Type 2 may occur in any age group of patients who may or intravenous drug use, today NF is increasing in oc- or may not have a major illness and is caused by group currence in any patient with or without trauma and A Streptococci with or without Staphylococcus. Type 2 with or without a history of comorbidities. This in- accounts for 10% of all NF cases.

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The majority of necrotizing soft tissue infections in the soft tissue infection. These gases, except carbon have anaerobic bacteria present, usually in combina- dioxide, accumulate in tissues because of reduced water tion with aerobic gram-negative organisms. These solubility. For the pathophysiology of NF see Figure 1. organisms proliferate in an environment of local tissue hypoxia and in the case of M.S. it was the ruptured DIAGNOSIS diverticulum. In NF, group A $-hemolytic streptococci Due to NFs rapid progression, the critical care nurse and Staphylococcus aureus are frequently the initiating must identify that pain that is out of proportion to the infecting bacteria, either alone or in synergism with appearance of the site, increased edema, and bullae for- other aerobic and anaerobic pathogens. Common aerobes mation are the key initial identifying factors. Recog- include group A $-hemolytic streptococci (Spyogenes), nizing these signs and symptoms early is the hallmark Escherichia coli, Klebsiella,andPseudomonas.Common to preventing misdiagnosis and initiating treatment anaerobes include Peptostreptococcus, peptococcus, and promptly. Other diagnostic criteria are listed in Table 1. clostridium. Other bacterial microorganisms include Computed tomography and or magnetic resonance Bacteroides fragilis, Enterobacteriaceae, coliforms, imaging identifies pockets of subcutaneous air and gas. Proteus, and S marcescens. Commonly, NF is poly- Diagnosis may also be confirmed during surgical microbial in etiology, which was true in the case of M.S., debridement when the skin characteristically separates making the treatment that much more challenging. or lifts from the underlying necrotic tissue. Facultative aerobic organisms grow since polymor- phonuclear leukocytes function is impaired under TREATMENT hypoxic conditions. This growth enables more anaerobic Quintessential to the successful treatment of NF is early proliferation and accelerates the disease process. Once diagnosis, early administration of broad-spectrum anti- the tissue is destroyed, carbon dioxide, water, hydrogen, biotics, and rapid surgical debridement of the involved nitrogen, hydrogen sulfide, and methane are produced area and, in some cases, the use of hyperbaric oxygen- from the combination of aerobic and anaerobic bacteria ation therapy (HBO) is indicated.17,18

Figure 1. Pathophysiology of necrotizing fasciitis.

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TABLE 1 Diagnostic Criteria for Necrotizing Fasciitis 1. Mental status changes* 2. Generalized malaise, tachycardia* 3. Systemic toxic reactions: fever, increased white blood cell count, positive blood cultures* 4. Focal necrosis, microvascular thrombosis, and leukocytes identified from involved tissue samples* 5. Extensive necrosis of the superficial; fascia in the absence of microvascular occlusion 6. Pain that is out of proportion to the visual assessment*

7. Little or no resolution of the signs and symptoms after treatment Figure 2. Location of surgical debridement to L. abdomen, hip with antibiotics and thigh.

*These signs and symptoms were exhibited by M.S. these challenging wound closure situations. Surgical The administration of several broad-spectrum anti- excision and prompt wound closure have been found 23 biotics used in combination therapy is the best treatment to lessen morbidity and improve survival. approach. Very commonly, there is more than one Hyperbaric oxygenation therapy is an option for bacteria associated with NF which requires more than patients who are hemodynamically stable enough to one antibiotic.19,20 M.S. was treated with Levofloxacin undergo the treatment. Secondly, HBO is indicated if (Levaquin), a fluoroquinolone; Metronidazole (Flagyl), surgical debridement is contraindicated because too 3,24 an anti-infective used to treat anaerobic infections; and much of the patients skin has been destroyed. HBO Pipercillin/Tazobactam (Zosyn), another anti-infective is used as an adjunct to antibiotic therapy. This therapy which is an extended-spectrum penicillin. increases tissue oxygenation and epithelialization, strengthens the ability of the white blood cells to fight infection, and promotes the formation of new blood The administration of several vessels. This was not used in the case of M.S. as he was broad-spectrum antibiotics used in initially thought to be too unstable to withstand a trans- fer to a hyperbaric facility. combination therapy is the best treatment approach. NURSING DIAGNOSIS AND CARE The critical care nurse must provide aggressive care that is multidimensional and collaborative in nature in order Concurrent with the initiation of antibiotic therapy is to afford the patient the best possible outcome. This care the use of surgical debridement. Radical debridement is must include skin care, pain management, antibiotic ther- the most effective and reliable treatment of NF.21,22 This apy, nutritional support, vigilant patient monitoring, soft is done to remove necrotic tissue up to bleeding viable skin in order to prevent the progression of infection.3 M.S. had several surgical debridements. The first occurred almost 24 hours after admission and the second took place 12 days later where he had more debridement with the application of soft tissue skin grafts, harvested bilaterally from the inner aspects of the thighs (see Figure 2). A month after this surgery, he underwent another surgery to apply additional skin grafts (see Figure 3). These skin grafts healed very nicely (see Figure 4). An option for large soft tissue skin closures that are challenging to treat surgically, is bilaminate bioartificial skin substitutes such as INTEGRA, a dermal regener- ation template. Integra is used prior to autografting in Figure 3. Additional skin grafts on L. thigh.

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interfere with sleep, meals, visiting hours, or activities such as physical therapy. Pain management is of utmost importance because as NF progresses it is very painful and then later the pain is replaced by numbness. The critical care nurse must assess the location, intensity (0-10), and quality of pain and administer pain medications as ordered. In this case, M.S. received 2 to 4 mg of morphine as needed every 2 to 4 hours. M.S. also had a patient-controlled analgesia pump that allowed him some control over the medication administration. M.S. was also turned and repositioned frequently to promote comfort. Antibiotic therapy is important in treating the Figure 4. Healing of skin grafts on L. thigh. patient with NF. Antibiotics are administered round the clock and often through a central line. The critical tissue reconstruction, physical therapy, psychological care nurse must monitor the patient for allergic reac- support, as well as patient and significant other education. tions as well as adverse effects of the prescribed medi- Skin care involves very challenging dressing cations. The patient’s renal and liver function must also changes. These are challenging for several reasons: first, be evaluated. M.S. had a central line, which was essen- they are often very large, as one can see looking at the tial in delivering his many antibiotics. Not only were pictures of M.S. (see Figure 5); second, they must be intravenous antibiotics administered to M.S., but also completed frequently, usually once or twice a shift; in addition, when changing his dressings, silver sulfa- third, the patient is in isolation; and fourth, oftentimes diazine (Silvadene), a topical anti-infective, was applied the dressings demand more than 1 nurse. to his open wounds. Silver nitrate sticks were used as needed to treat small bleeding areas noted when chang- Skin care involves very challenging ing the dressing. Later in the treatment regimen of M.S., dressing changes. the physician ordered an alginate dressing (Kaltostat, ConvaTech) to pack the wound. This foam dressing was then covered by ABD pads and changed twice a day. When changing the dressing, the critical care nurse Nutritional support is important to help the patient must note the color, odor, and amount of drainage. The heal the wounds and fight off the infection. In collab- area of the NF must also be noted by marking and oration with a nutritionist, the critical care nurse dating the area of erythema and necrosis. The nurse may calculates the amount of calories that the patient will also be required to assist the physician with bedside require per day. The amount of calories and protein debridement. The dressing changes for M.S. consisted of should be double that of the normal basal requirements. cleansing the large open wound with normal saline M.S. required enormous amounts of nutrition in order solution, applying Silvadene which aided in the preven- to heal his wound properly. The critical care nurse pro- tion of bacteria growth, placing 4 Â 4 pads against the vided M.S. with Impact, a form of parental nutrition, wound, and then covering them with an outer dressing of ABD pads. This was performed while maintaining strict sterile technique. Krasner25 suggested vacuum-assisted devices to help close the wound and keep the blood vessels open, supply blood flow to the wound, and consequently, promote healing. The challenge in using this for M.S. and many other patients with NF is the large size of the wound does not allow for an adequate vacuum to form when using these kinds of devices. Time management is crucial in order to promote patient comfort during these painful dressing changes. It is prudent nursing care to premedicate the patient for pain prior to the dressing change. It is also wise to schedule the dressing changes during times that will not Figure 5. A patient with necrotizing fasciitis.

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Caring for a Patient With Acute Necrotizing Fasciitis running at 110 mL per hour for 12 hours via a naso- parents were permitted to visit whenever they could and gastric tube. Placement of the tube, residuals, and skin were not limited to the hospital visiting hours. breakdown around the tube were checked according to Patient and significant other education is important hospital protocols. Essential labs such protein, blood so they understand the need for prolonged hospital- sugar, albumin, prealbumin, electrolytes, hemoglobin, ization, frequent dressing changes, and need for the hematocrit, and urinary nitrogen levels were also critical care expertise including monitoring, tube feed- checked frequently. Weights were checked daily and ings, intravenous lines, and urine output measurement. then were checked every other day as M.S. improved. The nature of NF can be very frightening as often the Vigilant patient monitoring is carried out by the patient enters the hospital with a small wound and later critical care nurse not only to assess the patient’s base- has a large wound exposed and debrided. lines, but moreover to quickly detect changes from the baseline to rapidly pick up on any complications that SUMMARY may develop. The critical care nurse must also look for Due to the multidimensional care that was provided to patterns in the patient’s assessment findings and listen to M.S., he was successfully treated and discharged from his or her gut feeling that may alert him or her to subtle the hospital 73 days after his admission. He was changes in the patient’s status early enough to take transferred to a local nursing home, infection free and quick action. hemodynamically stable. The nursing home facility was M.S. had frequent EKGs, vital signs to determine needed only to carry out the extensive dressing changes hemodynamic stability, daily intake and output, capillary as well as to continue physical rehabilitation. As was refill checks, visual and sensory skin assessments to note evident in this case, immediate recognition, early temperature and appearance to detect the progression of surgical debridement, prompt initiation of antibiotic the NF. Daily chest x-rays and arterial blood gases were therapy, clinical expertise of critical care nurses, as well completed initially when M.S. required ventilatory sup- as nursing compassion and holistic care all contributed port to detect changes in his respiratory system. to the successful treatment of M.S. and can help patients Soft tissue reconstruction is a priority when the survive and successfully fight NF. patient is stable and all the affected tissue has been debrided. M.S. had a tissue graft harvested off of his References 1. Holloway S, Ryder J. Case study: management of a patient right thigh and placed over part of his left thigh. This with postoperative necrotizing fasciitis. Br J Nurs. 2002; graft healed very nicely (see Figure 4). Patients who have 11(160):S25-S26, S30, S32. large areas of skin involved may not have a site to 2. Irion GL. Fournier’s gangrene. Acute Care Perspect. 2002; 11(4):14-15. harvest a graft from in which case they may then benefit 3. Ruth-Sahd L, Pirrung M. The infection that east patients alive. from alternative skin and dermal substitutes such as RN. 1997:28-35. B B Alloderm or Integra . This offers protection from 4. Awe A, Soliman MA, Gourdie RW. Necrotizing fasciitis induced by self-injection of kerosene. Ann Saudi Med. bacteria infection and provides an immediate way to 2003;23(6):388-390. reduce fluid, protein, and electrolyte loss. 5. Umeda M, Minamikawa T, Komatsubara H, et al. Nectrotiz- Physical therapy is essential to keep the patient ing fasciitis caused by dental infection: a retrospective analysis of 9 cases and a review of the literature. Oral Surg Oral Med mobile as well as to prevent deep vein thrombosis and Oral Pathol Oral Radiol Endod. 2003;95(3):283-290. other complications related to prolonged bed rest. M.S. 6. Skitarelic N, Mladina R, Morovic M. Cervical necrotizing was on bed rest for the initial 4 weeks of his treatment fasciitis: sources and outcomes. Infection. 2003;31(1):39-44. 7. Benevides G, Blanco P, Pinedo R. Necrotizing fasciitis of the due to his hemodynamic instability, need for frequent face: a report of one successfully treated case. Otolaryngol surgeries, pain level, location of the NF, and the Head Neck Surg. 2003;128(60):894-896. purulent drainage that was seeping from the wound. 8. Nouraei SA, Hodgson EL, Malata C. Cervicofacial necrotising fasciitis: management with neck dissection and topical negative He was then allowed to be out of bed to the chair and pressure. J Wound Care. 2003;12(4):147-149. later was encouraged to ambulate in the halls. During 9. Majeski J. Necrotizing fasciitis developing following a brown his prolonged bed rest, M.S. was on Heparin and had recluse spider bite. Am Surg. 2001;67(2):188-190. 10. Maynor M. Necrotizing fasciitis. Available at: http://www. antithrombotic pump stockings to prevent the develop- emedicine.com/EMERG/topic332.htm. Accessed December 27, ment of deep vein thrombosis. 2004. Psychological support for M.S. was very important. 11. Clark P, Davidson D, Letts M, Lawron L, Jawadi A. Necro- tizing fasciitis secondary to chicken pox infection in children. Because of his prolonged hospitalization, nature of the Can J Surg. 2003;26(1):9-14. wound, and pain, he became very depressed. About a 12. Gavrankapetanovic I, Gavrankapetanovic F. Necrotizing fas- month after his hospitalization he developed a very flat ciitis and decubitus ulcer in the ischial area. Med Arch. 1998; 54(2):113-114. affect, and requested a psychiatric consult. He was then 13. Fritzsche S. Soft-tissue infection: necrotizing fasciitis. Plast placed on an antidepressant medication. His wife and Surg Nurs. 2003;23(4):155.

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14. Gillen PB. Necrotizing fasciitis: early recognition and aggres- 23. Demarest G, Resurrecion R, Lu S, Schermer C. Experience sive treatment remain important. J Wound Ostomy Care Nurs. with bilaminate bioartificial skin substitutes and ultrathin skin 1995;22(5):219-221. grafting in non-burn soft tissue wound defects. Wounds 15. Trent JT, Kirsner RS. Necrotizing fasciitis. Wounds Compen- Compendium Clin Res Pract. 2003;15(8):250-256. dium Clin Res Pract. 2002;14(8):284-292. 24. Citta K, Stearns S. HBO for necrotizing fasciitis. AJN. 16. Chapnik E, Abter E. Necrotizing soft-tissue infections. Infect 1997;97(7):17. Dis Clin North Am. 1996;10:835-843. 25. Krasner DL. Managing wound pain in patients with vacuum- 17. Jallali N. Necrotizing fasciitis: its aetiology, diagnosis and assisted closure devices. Ostomy Wound Manage. 2002;48(5): management. J Wound Care. 2003;12(8):297-300. 38-43. 18. Ribo JC, Merwarth D, Oliv J. Case report: implications for a patient diagnoses with Fournier’s gangrene. Wounds Compen- dium Clin Res Pract. 2002;14(9):340-347. 19. Speers D, Shurr D. Necrotizing fasciitis: an overview. J Prosth ABOUT THE AUTHOR Orthot. 2001;13(3):83-86. Lisa A. Ruth-Sahd, RN, DEd, CEN, CCRN, is an Associate Professor 20. Wong C, Change H, Pasupathy S, Khin L. Necrotizing of Nursing at York College of Pennsylvania and a Staff Nurse in the fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg. 2003;85(8):1454-1460. Intensive Care Unit at Lancaster General Hospital. 21. Bashford C, Yin T, Pack J. Necrotizing fasciitis: a model Michael Gonzales, RN, is presently a registered nurse in the nursing plan. MedSurg Nurs. 2002;11(1):37-43. Intermediate Intensive Care Unit at Lancaster General Hospital. 22. Purnell D, Hazlett T, Alexander SL. New weapon against severe sepsis related to necrotizing fasciitis. Dimens Crit Care Address correspondence and reprints to: Lisa Ruth-Sahd, RN, DEd, Nurs. 2004;23(1):18-23. CEN, CCRN, York College of PA, York, PA ([email protected]).

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