Necrotizing fasciitis:Etiology, symptoms, examination, diagnosis and treatment.

Necrotizing fasciitis is a widespread and rapid soft tissue infection characterized by subcutaneous tissue and fascia necrosis, often accompanied by systemic toxic shock. This disease is a mixed infection of a variety of bacteria, mainly Streptococcus pyogenes and Staphylococcus aureus and other aerobic bacteria. The infection of the disease only damages the subcutaneous tissue and fascia, and does not involve the muscle tissue of the infected site is an important feature of the disease.

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KKKhealth Information form
English name Necrotic Fascilitis
Common etiology Synergistic effects of aerobic and anaerobic bacteria
Medical department Orthopedic
Common symptoms Flake redness, pain, pain relief, suffering from numbness, smell of bloody bleeding fluid

Necrotizing fasciitis:Cause

Necrotizing fasciitis is often a mixed infection of many bacteria, including Gram-positive hemolytic streptococcus, Staphylococcus aureus, Gram-negative bacteria and anaerobic bacteria. With the development of anaerobic culture technology, it is proved that anaerobic bacteria is an important pathogenic bacterium, and necrotizing fasciitis is often the result of synergistic effect of aerobic and anaerobic bacteria. Necrotizing fasciitis is often associated with systemic and local immune impairment, such as after a bruise, contusion, insect bites and other skin mild injury, the cavity viscera surgery, perianal abscess drainage, extraction, laparoscopic operation, or even after injection (more after injecting drugs) can occur. The long-term use of corticosteroids and immunosuppressive agents good hair disease.

Clinical manifestations

1. Local SymptomsOnset of acute, early local signs are often more obscure without causing attention to patients, within 24 hours can affect the entire body.

(1) flaky redness, pain early skin redness, purple-red flakes, the border is not clear, pain. At this time the subcutaneous tissue has been necrotic, because the lymphatic pathway has been rapidly destroyed, it is rare lymphatic inflammation and lymphadenitis. Infection in 24h can affect the whole limb. Individual cases can be slow and early in the latent state. Affected skin redness or whitish, edema, tenderness is obvious, the lesion boundary is unclear, diffuse honeycomb weaving inflammation.

(2) pain relief, suffering from numbness as a result of inflammatory material stimulation and pathogen invasion, early infection local severe pain. When the sensory nerve in the lesion is destroyed, severe pain can be replaced by numbness or paralysis, which is one of the characteristics of this disease.

(3) hemorrhagic blister because of the destruction of nutrient vessels and vascular embolism, the skin color gradually purple, black, the occurrence of hemorrhagic fluid blister or blister.

(4) foul-smelling hemorrhagic fluid infiltration subcutaneous fat and fascia edema, fluid-viscous, turbid, black, and eventually liquefaction necrosis. The exudate is hemorrhagic serous liquid with a strange odor. Necrosis is widespread, is stealthy, and sometimes produces subcutaneous gas, check can be found in the twist of pronunciation.

2. Symptoms of systemic poisoningEarly disease, local infection symptoms are light, the patient is cold, high fever, anorexia, dehydration, consciousness disorders, hypotension, anemia, jaundice and other serious systemic poisoning symptoms. If not timely treatment, diffuse intravascular coagulation and toxic shock can occur. The main characteristic of this disease is that local signs are not commensurate with the severity of systemic symptoms.

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Check

1. Blood Routine

(1) Red cell count and hemoglobin assay because of the inhibition of hematopoietic function of bone marrow by bacterial hemolysis toxin and other toxins, the erythrocyte and hemoglobin of 60%~90% patients decreased slightly to moderate.

(2) White blood cell count is a kind of leukemia reaction, the number of leukocytes increased, the count is mostly in (20~30) x109Between/L, there is a nuclear left shift, and toxic particles appear.

2. Serum electrolytecan appear low blood calcium.

3. Urine examination

(1) Urine volume, urine specific gravity in the liquid supply sufficient when there is less urine or no urine, urine specific gravity, etc., contribute to the early diagnosis of kidney function damage.

(2) urine protein qualitative urine protein positive suggests glomerular and renal tubules have impairment.

4. Bacteriological Examination of Blood

(1) smear microscopy to take the secretion and blister fluid at the edge of the lesion for smear examination.

(2) Bacteria culture the secretion and blister liquid are respectively in aerobic bacteria and anaerobic culture, and it is not found that Clostridium difficile is helpful for the diagnosis of this disease.

5. Serum antibodyThe antibody produced by Streptococcus in the blood (the release of hyaluronic acid and DNA B by Streptococcus can induce a high titer of antibody) and help diagnose it.

6. Serum bilirubinThe elevated blood bilirubin suggested the hemolysis of RBC.

7. Imaging examination

(1) x-ray film there is gas in the subcutaneous tissue.

(2) CT displays small bubbles in your organization.

8. Living Tissue Inspection It is also helpful for the diagnosis to take the fascia tissue for the frozen section.

The diagnosis

Fisher proposes six diagnostic criteria:

1. Diffuse necrosis of superficial superficial fascia is accompanied by extensive infiltration of the tunnel, spreading to surrounding tissues.

2. Moderate to severe systemic poisoning symptoms accompanied by changes in consciousness.

3. No muscle.

4. No clostridium difficile was found in wound and blood culture.

5. No significant vascular obstruction.

6. The debridement biopsy found extensive leukocyte infiltration, fascia and adjacent tissue focal necrosis and microvascular embolism. Bacteriological examination is of great significance for the diagnosis, and it is better to develop the edge and blisters from the progressive lesions and to make smear tests, and to develop aerobic bacteria and anaerobic bacteria respectively. The determination of antibodies produced by streptococcus in the blood (streptococcus luciferase and deoxyribonuclease B, which can produce a high titer of antibodies) is helpful in the diagnosis.

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treatment

Necrotizing fasciitis is a surgical emergency. The treatment principle is: early diagnosis, early debridement, application of a large number of effective antibiotics and whole-body support treatment.

1. The antibiotics

Necrotizing fasciitis is a mixed infection of a variety of bacteria (all kinds of aerobic and anaerobic bacteria). The symptoms of systemic poisoning are early and serious, and antibiotics should be applied in combination.

2. Debridement drainage.

There are extensive blood vessel thrombosis in the lesion tissue and the surrounding area. The drug is often difficult to reach, so it should be treated immediately after the active and high-dose antibiotic treatment has no obvious effect for 1 ~ 3 days. Thorough debridement is the key to successful treatment. The operation should thoroughly remove the necrotic fascia and subcutaneous tissue until the fingers are separated. Common methods:

(1) remove necrotic tissue and clean the wound surface; Free skin grafts cover the wound surface. This method can prevent a large amount of serum exudation, which is beneficial to maintain the balance of fluid and electrolyte after operation.

(2) remove the necrotic fascine membrane and adipose tissue, and rinse the wound with 3% hydrogen peroxide, methyl nitrate solution or 0.5% ~ 1.5% potassium permanganate solution, so as to create an environment that is not conducive to the growth of anaerobic bacteria; Then apply the gauze with antibiotic liquid, and apply it every 4 to 6 hours. It is necessary to probe whether there is any skin, subcutaneous tissue and deep fascia separation in order to decide whether to further expand the drainage.

(3) when the skin defect is large, it is difficult to recover from the skin. After the inflammation subsides, the skin grafting should be selected. Attention should be paid to the protection of healthy fascia in operation, which can cause the spread of infection after injury. Metronidazole local wet application can delay the growth of skin, not suitable for long-term application.

3. Supportive treatment

Positive correction of water and electrolyte disorders. Anemia and hypoalbuminemia can be injected with new blood, albumin or plasma; Can adopt the nasal feeding or vein high nutrition, the factor diet and so on to ensure adequate caloric intake.

4. Hyperbaric oxygen therapy.

In recent years, the mixed infection of anaerobe in surgical infection is increasing, while hyperbaric oxygen is effective for obligate anaerobic bacteria.

5. Observation of complications.

In the treatment of the whole all should closely observe the patient’s blood pressure, pulse, urine output, hematocrit, electrolytes, blood coagulation mechanism, blood gas analysis, such as inspection, timely treatment of heart failure, prevent the happening of the diffuse intravascular coagulation and shock.

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