Treatment for Necrotizing Fasciitis - Essay Example

? Case Study On A Patient With Necrotic Fasciitis Introduction. Necrotizing Fasciitis (NF) is a condition involving a soft tissue severe infection, which is often associated with fast progressing necrosis, and the tissue subcutaneous. This condition though rare, has been shown to have a high rate of mortality. This has, in effect, necessitated the use of radical antibiotics and debridement for purposes of diagnosing and a treating it (Ahn, Mulligan, & Salcido, 2008). The disease causes severe damage to the skin as it affects the deeper layers of the skin particularly the subcutaneous tissues. It spreads easily on the focal plane within the affected tissue. Depending on their origin, they can be categorized as poly or microbial. The monomicrobial infections occur due to group A streptococcus. It is common among the healthiest individuals, and those who historically experienced such cases such as trauma, intravenous drug, and surgery. Studies indicate that the post-operative necrotizing fasciitis accounts for twenty eight percent of all the other cases (Davis et al, 2008) . As noted by Chsn, Withey, and Butler (2006) 3 percent of wound infection occur as a result of a vein stripping, and saphenofemoral junction. Other studies showed that incidences of NF have increased and there occurance rate is thought to range between 0.4 to 0.53 each year in the U.S (Anaya & Dellinger, 2006). Worth noting, is the fact that both pre-existing co-morbidities, the young and healthy persons are affected. Various studies have explored this area, however, early diagnosis for a satisfactory treatment is still a challenge (Balaji, 2008; Anaya & Dellinger, 2006; Cha & Falanga, 2007). With a view to close up this gap, this paper explores the case study of a twenty one year old woman with a history of Knee trivial injury (Diagram 1). The patient was first treated and admitted for septic arthritis. It was followed by diagnosing her with necrotizing fasciitis, which was treated successfully. Background information. NF or the Necrotizing fasciitis involves a soft tissue severe infection reported to rapidly progress into the human tissue (Balaji, 2008). The disease progresses into the subcutaneous and fascia tissues and in some cases can affect the skin and other muscles. From the 18th century, this rare infection has been identified by different names such as hospital gangrene, Foutnier’s gangrene, phagedena gangrenosum, and the Meleney’s gangrene (Ahn, Mulligan, & Salcido, 2008). Ahn, Mulligan, & Salcido, 2008), Anaya & Dellinger, 2006). This disease is common to individuals with immune systems that are compromised after some chronic illness. A good number of infections are as a result of organisms which can be found in the skin of an individual (Chan, Withey, & Butler, 2006). The disease occurs in those individuals having an apparent normal condition. It starts locally at the trauma site which could be minor, non-apparent, or even severe. The patients have been reported to have pain complaints, which may appear excessive even from the extern skin appearance. The patients, on the other hand, have been reported to display signs such as fever, inflammation, and tachycardia (Balaji, 2008. The Case study. A twenty one year old woman from an emergency department of a different hospital was referred to the orthopedic unit. The patient had no co-morbidities, and had a trivial injury history of her right knee. Accidentally, she hit his right knee to a wall some days back, thus sustaining an abrasion on the knee. She complained of pain on her knee the following day hence being forced to stop working. The pain increased during the night, and was forced to attend the department of emergency the following day. She had been referred to the emergency unit with suspicions of cullulitis or sepatic arthritis. When she arrived, she had a systematically stable and a febrile though considerable pain. Her joint had reduced movements, but increased pain. The vascular and the neurological limb examinations of the patient were satisfactory. The blood investigation showed out that the count of the white cell was 18.6 x 10^9/L, hemoglobin level 15 g/dl, and a C-reactive protein 63.1mg/L. The right knee x-ray failed to display the injury to the bone or the soft tissue gas. She was diagnosed with sepatic arthritis she had suffered from before. Additionally, a knee arthroscopic washout was done and the secondary to wound trauma was made. The Arthroscopy displayed inflamed synovium, whereby the knee had been drained of 10 cc fluid. The gram stain, and microscopy of the fluid together with the culture did not show any organism. The intravenous flucloxacillin, post-operatively, gentamycin, and benzyl penicillin was continued. The patient was still showing symptoms even after seventy two hours of antibiotic use. Even though she remained afebrile at all times, her tenderness and pain increased in the distal thigh. The investigations of the blood showed a high increase in the markers of inflammation. Regarding the failure in responding to the intravenous antibiotics, arthroscopy that was negative, and increased distal thigh tenderness, suspicions of necrotizing fasciitis was established. There was an urgent contrast with the diagnosis, which facilitated a CT scan (Computed Tomogram) of her knee, and the right thigh be made (Broughton, Janis, & Attinger, 2006). This diagnosis revealed increased inflammatory stranding and reduced attenuation with the necrosis suspicion , especially in the vastus lateralis, and the rectus femoris. It was prudent to take the patient to theatre urgently to perform a fasciotomy via the antero-lateral method of the thigh. This disgnoses was a confirmation of the CT findings of the muscles and fascia. A thorough rectus femoris debridement and vastus lateralis was done. The wound was cleaned thoroughly and wrapped in swabs soaked with betadine. This is displayed in diagram 1. Diagram 1: Right thigh CT scan displaying inflammatory stranding with reduced attenuation in the latralis vastus. A microbiologist discussed this case and ciproflaxicin, intra-venous clindamycin was increases together with benzyl penicillin, and flucloxacillin. Throughout the process, the oxygen therapy and IV hydration therapy were maintained while closely observing the renal functions that were still stable. After this the patient was then taken to the theatre in duration of forty-eight hours of re examination. This examination displayed increased necrotic regions in the muscle of rectus as a result of debridation. Other two washouts in duration of 48 hours failed to display any necrosis progression and the wound gradually closed using the staples, and the shoelace method. About IV antibiotics were administered in a duration of four 14 days then an additional oral ciprofloxacin, and clindamycin for a period of five weeks. Systematically, she remained stable and responded to the provided treatment well. This was evidenced by the normalization of the markers of inflammation. A tissue histology confirmed the diagnosis, but the causative organism was still unidentified. The patient displayed a wonderful recovery of her limbs and other conditions of her lifetime. This was made possible through a multi-disciplinary approach that involved the general surgery, orthopaedics, microbiology, radiology, dieticians, and physiotherapy. She was discharged after 19 days of admission. With a follow up of about three months, the patient had full category of movements on his right knee together with the knee grade 4 power extensors. Discussion. NF (Necrotizing Fasciitis) includes a rare, but fatal infection associated with widespread necrosis of the skin, subcutaneous tissue, and the superficial fascia. This illness had gained recognition by many researchers from the 18th century (Anaya & Dellinger, 2006). One study conducted a necrotizing infection description on the soft tissues of soldiers in an American war, and displayed a forty six percent rate of mortality (Bjarnsholt et al, 2008). Another similar study to this one was conducted on the perineum of five male participants. In the year 1952, the infection was defined as nectrotizing fasciitis, and for the first time it included the non-gas-forming, and the gas forming necrotizing (Brem & Tomic-Canic, 2007). This study argued that fascial necrosis was the sine Qua non of the whole process. Another recent study on this field reported that the term necrotizing of the soft tissue includes all the other necrotizing infections advocating for an approach, which utilizes certain treatment and diagnostic strategies (Burgess, 2008). This gave a room for the earlier expedited and diagnosis treatment that are essential in improving the results and reduce the mortalities amount the patients having necrotizing soft tissue infection (Campos, Groth & Branco, 2008). NSTI (necrotizing soft tissue infection) can be categorised in accordance with the anatomic location that was involved or the infection depth (Brem & Tomic-Canic, 2007). In this case, it can be classified as adiposities, myosites, and fasciitis (Brem & Tomic-Canic, 2007). In terms of the microbiology, NSTI can be classified as type I, type II, polymicrobial, type III, marine species, and monomicrobial. This classification is said not to be significant to the clinical application, as it does not the patient management. A condition of this kind can affect any section of the body, but it may primarily affect the abdomen, extremities, and the perineum. A study conducted on one hundred and fifty necrotizing fasciitis cases established the extremities as being the most common infection site (57.8%) followed by the perineum, and abdomen (Campos, Groth & Branco, 2008). Pathophysiology. NF is associated with the rapid spread of the infection within the subcutaneous tissues. The invasion of the microbial SC (subcutaneous) tissues happens through a direct spread or the external trauma from a viscus perforated colon, anus or rectum (Brem & Tomic-Canic, 2007). The bacteria do track SC giving out exotoxins, and end that makes the micro-vascular thrombosis, system illness, tissue ischemia, and liquefactive necrosis, that can advance towards the septic shock, death or even dysfunction of the multisystem (Choudhry &Chaudry, 2006). The tissue ischemia is known to hinder the bacteria oxidative destruction through polymorphonuclesr cells thus preventing the adequate antibiotic delivery. The debridement of surgery is the main therapy for the disease, and the therapy of antibiotics alone may mask the symptom severity, and has little value (Brem & Tomic-Canic, 2007). Risk Factors. From the assessment of the patient it is true to say that the most common factor of NF of extremity involves the history of multiple and drug abuse required to puncture the affected area (Calabro & Yeh, 2007). This was established as being 129 or 33% patients in the NF systematic review of the lower and the upper limb. Trauma, burns, fish-fin injury, skin ulcer, insect bite, post operative infection of wound and colo-cutaneous fistula are other factors of predisposing. One of the leading condition of predisposing is diabetes mellitus as a result of periphery neuropathy, immmuno-suppression, and peripheral vascular illness (Calabro & Yeh, 2007). Studies conducted in this field showed that the diabetes mellitus presence might not influence the mortality unless the occurrence is coupled with other diseases. Besides this, other linked diseases include alcoholism, immune deficiency, liver cirrhosis, chronic renal failure, HIV, steroids, malignancy, and peripheral vascular illness. Overall assessment. In wound healing, dressing is part of the holistic management of the wound with the goals of the affected patient. This holistic assessment is vital because it facilitates a faster healing of the wound through providing the required environment for the proceed of healing. The overall assessment of the wound extends the holistic approach that is in existence removing the healing barriers making the repair of the wound to occur naturally (Boyapati & Wang, 2007). In this case, the goal of management would be achieving a wound that is stable having healthy granulation of tissue and a well-vascularized wound bed. In this study, observation, questionnaire, and an interview were the major tools used to gather background information. The identification fo the factors that influenced the tissue viability was vital in increasing the rate at which the wound was healing. In this case, factors that prolonged wound healing like lack of oxygen, and infection were dealt with fast to increase the speed of wound healing. Factors that influence tissue viability. From the assessment of the patient it was evidence that the factors which affected her wound healing included the infection of the patient,oxygenation, cleaning, medication, and swab. Oxygen is vital for the metabolism of the cell especially the production of energy through ATP (adrinosine triphosphate), thus critical for healing of wounds. It protects the wound from induces angiogenesis, infections, increased keratinocyte, re-epitheliazation, and migration (Boyapati & Wang, 2007). Oxygen enhances collagen synthesis, and fibroblast proliferation thus facisitating the contraction of the wound. Additionally, the superoxide production level by polymorphonuclear is vital and relies on the levels of oxygen. As a result of high consumption of oxygen, and vascular disruption by the active metabolic cells, the early wound microenvironment is reduced of oxygen hence hypoxia (Brem & Tomic-Canic, 2007). A number of systematic conditions such as diabetes or an advanced age could establish impaired vascular flow hence setting a condition of poor oxygenation of the tissues. In regards to the healing context, the poor perfusion establishes a hypoxic wound (Calabro & Yeh, 2007). The wounds that are chronic have been reported as being extremely hypoxic. In this case, the tissue oxygen is reported to be measured from 5 to 20 mm HG, in contrast to the tissue control values of about 30 to 50 mm Hg (Brem & Tomic-Canic, 2007). In the assessed case, the patient’s wound had been denied of oxygen hence impairing the healing process. After injury, temporary hypoxia stimulates the rate of wound healing, whereas chronic or prolonged hypoxia would delay the healing of the wound (Cha & Falanga, 2007). In the case of acute wounds, hypoxia would act as a sign , which stimulates many different aspects of wound healing (Calabro & Yeh, 2007). It induces cytokine and the factors of growth production from macrophages, fibroblast, and keratinocytes. For a normal wound healing, ROS (reactive oxygen species) like superoxide, and hydrogen peroxide, are believed to function as cellular messengers which stimulates the vital processes that are linked to the healing of a wound like the cytokine action, motility, and angiogenesis. The hyperoxia and hypoxia make the production of the ROS to increase (Bishop, 2008). Infection is another factor that influence the viability of the tissue. As in the case of the patient, once the skin was injured, the microorganism presently sequestered on the surface of the skin gained access inside the underlying tissues (Brem & Tomic-Canic, 2007). The replication and the infection state of the micro-organisms determined the classification of the wound. In this case, the would could be classified as having local infection, contamination, colonization, and spreading invasive infection (Arnold & Barbul, 2006). Wound contamination occurs whenever the presence of organisms that are non-replicating on the wound exists. Colonization, on the other hand occurs whenever there exist replicating micro-organisms with no damage of the tissues. Local infection occurs in an intermediate stage having the replication of micro-organisms, and onset of local tissue responses. Cleaning the wound was also one of the factors that affected this patient’s wound healing. As evidenced in this case, the wound was cleaned thoroughly and wrapped in swabs soaked with betadine. This is because the bacteria have been known to impede the wound healing process. The patient wound was seemingly appearing chronic because of presence of bacteria. Therefore, there was need to take into consideration the cleaning process as was finally done to the patient. Wound management procedures including cleaning, the use of the absorptive dressing help reduce in bioburden. In cases where the wound is cleaned but it fails to heal, high levels of bacteria may be present. In such a case, it is recommented to use the semi-quantitative swab. The semi-quantitative swab helps make the wound care decisions. A wound with high levels of bacteria, as well requires more aggressive cleansing, adjunctive therapies, such as ultraviolet light, tropical antimicrobial cream, hyperbaric oxygen, and more absorptive dressing. Medication was also one of the factors that adversely affected this patient’s wound healing. Some of the medications such as those that interfere with platelet function, or clot formation, or cell proliferation and inflammatory responses have the capacity to affect the wound healing process. Some of the commonly used medications, which can significantly affect wound healing include chemotherapeutic drugs, non-steroidal anti-infalammatory drugs, and glucocorticoid steroids. Why Holistic Approach In Wound Healing Is Necessary For Effective Tissue Viability Assessment And Management. For all types of wounds, Holistic approach is part of the good wound management approach. This is because it takes into consideration the patients needs beyond the wound including the environmental and social issues which can greatly influence the outcomes of wound healing. Once a complete clinical history has been made and the the aetiology of the wound has been established, the assessment of the wound should be thorough because it permits differential diagnosis, provides a basis upon which the success of necessary management strategies are measured, facilitates timely referrals to other providers of healthcare and provides a baseline for a reatment plan. The management strategies applied need to be holistic and should include the local and systematic barriers to the healing process, and the wound bed. The assessed needs of the patients is derived from a holistic approach if not a service-led or narrow approaches may result into less accurate picture of needs of the patient, which ultimatetly leads to commissioning of a wrong mix of services resulting in huge waste of hospital resources. In this study, direct observation was the main tool of assessment used to gather background information about the patient. This tool of assessment was appropriate because it provided for direct access to the issue under consideration. Instead of overrelying on self-report, this tool of assessment provided for actual observation and recording of the behaviour of the situation. . It helped avoid problems often associated with self-report. In wound assessment, a specialized tool is necessary in evaluating the type of wound and infection. The wound of the patient in the case, was measured using the acetate method. Two layered transparent acetate was applied on the wound and the perimeter traced with the permeanent pen. The layer in contact with the wound was discarded and the top layer placed into the record of the client (Bishop, 2008). Despite the fact that there are other hand held tablets that are potable, which may take the measurements of a wound area, a digital planimetry would give out detailed and accurate measurements of a wound (Brem & Tomic-Canic, 2007). After taking the measurements of the wound, the relevant information regarding the patient’s wound was recorded for analysis. In this case, the medical history, causes of the damaged tissue, medication, other diseases, nutrition, lifestyle, impaired mobility, psychological problems, and impaired mobility of the patient was recorded. During the assessment of the wound, the etiology of the wound, local wound traits, the concerns of the patient, so rounding skin condition, and the colonization critical signs were recorded. A close examination of her right knee showed out increased temperature in the around the affected area, reduced superficial wound patella, grade 1 rejoint effusion and slight redness around the affected area. The joint had reduced movements, but increased pain. The vascular and the neurological limb examinations of the patient were satisfactory. The arthroscopy displayed inflamed synovium, whereby the knee had been drained of 10 cc fluid. This wound was classified as an arterial wound. It was positioned on the distal muscle, it was small in size, round in shape, shallow in depth, pale sorounding skin, and, smooth margins. The gram stain, and microscopy of the fluid together with the culture did not show any organism. Wound management skin. The skin of the patient was cleaned. The skin was rinsed with clear water. Tweezers and alcohol were used in removing the particles. A number of products were used in wound dressing. This included the wound cleanser, dressing, trash bag, tape, and disposable gloves (Arnold & Barbul, 2006). The best dressing was used in attending to the patient. There were no hand washing supplies that were used during dressing. Wash of hands during dressing helps in avoiding multi infection of other persons. In practice, the hands should be washed thoroughly before and after dressing. Gloves should be won during the car, the old dressing should be placed in a small sealable bag before being disposed. The wound was then cleaned and a new dressing used on the wound. Conclusion. Basing on the approach used in this study, it is prudent to conclude that factors that affect the wound healing include oxygenation, cleaning, medication, infection of the wound, and other factors such as age, smoking stress among others. As evidenced in this case, the best practice in tissue viability include cleaning the wound, preventing the wound from other infection, oxygenation, cleaning, providing the best medication, and swabbing. The best way that would have helped improve clinical outcomes were (1) providing oxygen to the wound to enhance the healing of the wound (2) preventing the wound from infection by applying appropriate preventive mechanism (3) using drugs that do not promote inflammation of the wound (4) cleaning the wound or using the absorptive dressing, which helps reduce in bioburden and (5) in cases where the wound is cleaned but it fails to heal, high levels of bacteria may be present. In such a case, it is recommented to use the semi-quantitative swab. The semi-quantitative swab helps make the wound care decisions. A wound with high levels of bacteria, as well requires more aggressive cleansing, adjunctive therapies, such as ultraviolet light, tropical antimicrobial cream, hyperbaric oxygen, and more absorptive dressing. However, worth contenting is that the wound was finally healed, and the needs of the patient were met. Recommendations for Necrotic Fasciitis The patient in the case should get back to the operation room within 24 to 36 hours after the initial debridement. She should, as well expected to get back each day up to when the surgical team finds no requirement for debridement. The patient should follow the antimicrobial therapy for a duration of 48 to 72 hours after the resolution of fever. In this case, the clinical improvement would be checked to confirm whether the patient would need any debridement. The patient would go through a gram stain together with a fungal stain to show the pathogens presence and give an early clue of the treatment preference. Since the history of the patient displayed sewage exposure, the gram negative coverage needs to be instituted for organisms like Aeromonas, and Pseudomonas. Action Plan Recommendation Rationale Factors that promote change Factors that Inhibit change Supportive theoretical reference/ policy (EBP) Identify how you would know if the change had been successful Penicillin 1-4 million UiV q4h Clindamycin 600-900 mg/kg IV q8h Penicillin 1-4 million UiV q4h Clindamycin 600-900 mg/kg IV q8h is necessary for in managing the gram positive chains of cocci Antibiotic use, Use of substratum due to the contaminated tissue of the patient Advanced age, Obesity, Poor nutrition, Smoking, The patirnt’s immunosuppression Of disease, Questioning the approach to the practice leading to the scientific experimentation. No pain or inflammation in the affected area. Clindamycin 600-900 mg/kg IV q8h Ampicillin sulbactam 1.5-3 g iVq6h For managing the gram positive rods Early intervention, Antibiotic use, Use of substratum due to the contaminated tissue of the patient, Therapy to enhance the progress of healing through a series of natural process. Traumatic injuries, Devitalized tissue, ontamination of the wounds. Meticulous enumeration, observation and analyzing anecdotal case description. No pain, pyrexia, or purulent in tfrom the affecte area Consent. The patient gave a written and informed consent, by allowing the publication of this case report, and the images that accompany References. Ahn, C., Mulligan, P., Salcido, S., 2008. Smoking—the bane of wound healing: biomedical interventions and social influences. Adv Skin Wound Care 21:227-238. Anaya, D., & Dellinger, P., 2006. The obese surgical patient: a susceptible host for infection. Surg Infect (Larchmt) 7:473-480. Arnold, M., & Barbul, A., 2006. Nutrition and wound healing. 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