Surgical considerations in pediatric necrotizing fasciitis

Necrotising soft-tissue infections

The incidence of necrotising soft-tissue infections has increased during recent decades such that most physicians might see at least one case of these potentially life-threatening infections in their career. Despite advances in care, necrotising soft-tissue infections are still associated with high morbidity and mortality, underlining a need for continued education of the medical community. In particular, failure to suspect necrotising soft-tissue infections, fuelled by poor awareness of the disease, promotes delays to first surgical debridement, amplifying disease severity and adverse outcomes. This Review will focus on practical approaches to management of necrotising soft-tissue infections including prompt recognition, initiation of specific management, exploratory surgery, and aftercare. Increased alertness and awareness for these infections should improve time to diagnosis and early referral to specialised centres, with improvement in the prognosis of necrotising soft-tissue infections.

Morbidity and Mortality of Necrotizing Fasciitis and Their Prognostic Factors in Children

BACKGROUND

This is a prospective study of the clinico-etiologic profile and factors affecting outcomes in 40 children managed for necrotizing fasciitis (NF).

MATERIALS AND METHODS

Demographic details, clinical characteristics, and laboratory parameters were recorded, and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was calculated. Primary outcome (survival vs. nonsurvival) was noted, and prognostic factors were identified.

RESULTS

Initiating factors included boils (45%), i.v. cannula extravasations (22.5%), and blunt trauma (17.5%). Lesion (s) were predominantly on the lower limbs (35%) and trunk (25%). Twenty-two patients (55%) had <5% body surface area (BSA) involved. Severely deranged clinical and laboratory parameters were common. Ultrasound localized fluid collections. Pus cultures showed methicillin-resistant Staphylococcus aureus (52.5%), methicillin-sensitive S. aureus [27.5%], and polymicrobial growth (20%). Blood culture was positive in 24 patients (60%). Most isolates were sensitive to clindamycin and amoxy-clavulanate. Prognostic factors for mortality (n = 6; 15%) included categorization as "Sick," BSA involvement >10%, thrombocytopenia, raised serum creatinine, late debridement, and polymicrobial blood culture isolates. All six nonsurvivors had a LRINEC score of ≥8 and positive blood cultures. Six patients (20.7%) developed unsightly scars and 5 (17.24%) contractures across joints.

CONCLUSIONS

Pediatric NF has significant morbidity and mortality. Patients with adverse prognostic factors can benefit from early referral to a facility with a critical care unit. Adequate wound management is essential to minimize residual deformity.

Optimal timing of initial debridement for necrotizing soft tissue infection: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Necrotizing soft tissue infections (NSTI) are rare, life-threatening, soft-tissue infections characterized by rapidly spreading inflammation and necrosis of the skin, subcutaneous fat, and fascia. While it is widely accepted that delay in surgical debridement contributes to increased mortality, there are currently no practice management guidelines regarding the optimal timing of surgical management of this condition. Although debridement within 24 hours of diagnosis is generally recommended, the time ranges from 3 hours to 36 hours in the existing literature. Therefore, the objective of this article is to provide evidence-based recommendations for the optimal timing of surgical management of NSTI.

METHODS

The MEDLINE database using PubMed was searched to identify English language articles published from January 1990 to September 2015 regarding adult and pediatric patients with NSTIs. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework were used. A single population [P], intervention [I], comparator [C], and outcome [O] (PICO) question was applied: In patients with NSTI (P), should early (<12 hours) initial debridement (I) versus late (≥12 hours) initial debridement (C) be performed to decrease mortality (O)?

RESULTS

Two hundred eighty-seven articles were identified. Of these, 42 papers underwent full text review and 6 were selected for guideline construction. A total of 341 patients underwent debridement for NSTI. Of these, 143 patients were managed with early versus 198 with late operative debridement. Across all studies, there was an overall mortality rate of 14% in the early group versus 25.8% in the late group.

CONCLUSION

For NSTIs, we recommend early operative debridement within 12 hours of suspected diagnosis. Institutional and regional systems should be optimized to facilitate prompt surgical evaluation and debridement.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level IV.

Does Topical Application of Placental Extract Gel on Postoperative Fibrotomy Wound Improve Mouth Opening and Wound Healing in Patients With Oral Submucous Fibrosis?

PURPOSE

Placental extract has been used as a therapeutic agent with application in various fields of medicine. Placental extract is well known for its effects on wound healing with anti-inflammatory, antiplatelet, and angiogenic effects and is also a biogenic modulator. The present study evaluated the effect of placental extract on wound healing, mouth opening, and postoperative patient discomfort in patients with oral submucous fibrosis treated with fibrotomy with buccal fat pad coverage and coronoidectomy.

MATERIALS AND METHODS

Ten subjects with oral submucous fibrosis who presented with mouth opening less than 20 mm were enrolled in the present prospective randomized controlled trial to assess the effects of placental extract on the fibrotomy wound covered with a pedicled buccal pad fat (5 patients allocated to the study group, group S and 5 to the control group, group C). The following criteria were used to analyze the postoperative effect of placental extract on fibrotomy wounds compared with that of the controls: subjective assessment of the wound, postoperative discomfort, and postoperative mouth opening assessed at 1, 2, and 4 weeks postoperatively.

RESULTS

The average difference in the preoperative and fourth week postoperative mouth opening for group C was 13.8 ± 2.68 mm and was 21.20 ± 2.77 mm in group S. The median calculated for group C was a 15.0-mm increase in mouth opening and was 20.0 mm in group S.

CONCLUSION

The results obtained with topical application of placental extract on fibrotomy wound healing and postoperative mouth opening were superior to those of the control group in whom placental extract was not used.

Continuous renal replacement therapy as a supportive treatment for acute pediatric necrotizing fasciitis

Acute necrotizing fasciitis (NF) in children is a dangerous illness characterized by progressive necrosis of the skin and subcutaneous tissue. The present study summarizes our recent experience with the treatment of pediatric patients with severe NF. Between 2000 and 2009, eight children suffering from NF were admitted to our department. Four of the children received an active treatment strategy including continuous renal replacement therapy (CRRT), radical debridement, and broad-spectrum antibiotics. Another four children presented at a late stage of illness, and did not complete treatment. Clinical data for these two patient groups were retrospectively analyzed. The four patients that completed CRRT, radical debridement, and a course of broad-spectrum antibiotics were cured without any significant residual morbidity. The other four infants died shortly after admission. Early diagnosis, timely debridement, and aggressive use of broad-spectrum antibiotics are key factors for achieving a satisfactory outcome for cases of acute NF. Early intervention with CRRT to prevent septic shock may also improve patient outcome.

Necrotizing fasciitis of the perineum

BACKGROUND

Necrotizing fasciitis is a severe soft tissue infection characterized by rapidly progressing necrosis, involving subcutaneous tissues. This rare condition carries a high mortality rate and requires prompt diagnosis and urgent treatment with radical debridement and antibiotics; but early diagnosis, which is essential to successful treatment, remains a challenge.

METHODS

Physical examination findings, preoperative and operative findings, histopathological results of the structure, and follow-up results of the patient are discussed with related reports.

RESULTS

A 15-month old girl had a history of trivial perineal dermatitis after treatment of anemia and pneumonia. Perineal dermatitis progressed fastly as necrotizing fasciitis which was successfully managed with intensive medical treatment, surgical debridement and reconstructive surgery.

CONCLUSIONS

Lack of cutaneous findings early in the disease makes the diagnosis challenging, so a high suspicion is essential. Recovery of the patient from this life-threatening condition needs a multi-disciplinary approach involving pediatrics, pediatric surgery, and plastic and reconstructive surgery.

Fatal Necrotizing Fasciitis in a Child following a Blunt Chest Trauma

Necrotizing fasciitis is a serious soft tissue infection rarely occurring in children after blunt trauma. Due to its high morbidity and mortality rates, a high index of suspicion is necessary for prompt diagnosis and treatment. We describe a 6-year-old Costa Rican girl who died secondary to multiple complications following a posttraumatic necrotizing fasciitis.

Pseudomonas necrotizing fasciitis in an otherwise healthy infant

Necrotizing fasciitis is an uncommon rapidly progressing infection of soft tissue characterized by a severe inflammation of the fascia and soft tissue. The disease is associated with necrosis and subcutaneous gangrene of the inflamed tissue with systemic toxicity that carries a significant mortality unless timely diagnosed and aggressively treated. Monomicrobial necrotizing fasciitis caused by Pseudomonas aeruginosa is an exceptionally uncommon condition with only few cases reported in the literature so far. We are reporting a six-month-old female infant who was previously healthy and who presented with necrotizing fasciitis and isolates Pseudomonas aeruginosa both from the blood and tissue. The child improved after the intensive treatment.