Necrotising Soft Tissue Infections
Necrotising Soft Tissue Infections
Objectives
Diagnosis
Criteria for HBO therapy
Work-up considerations
Treatment
Suggested treatment threshold
ICD 10 codes
Level of evidence
Objectives
Alleviate wound and surrounding tissue hypoxia. Inhibit bacterial organisms and enhance host defence mechanisms via oxygenation of polymorphonuclearleukocytes. Help demarcate necrotic tissue from potentially viable tissue to enable more effective and conservative surgery. Potentiate antibiotic effectiveness and improve delivery.
Diagnosis
Aggressive soft tissue infection spreading along fascial planes resulting in necrosis. Gas may be present in tissues. Foul smelling exudate. Toxic, ill patient. Polymicrobial infection.
Criteria for HBO therapy
Clinical diagnosis. Rapidly spreading soft tissue infection not responding to appropriate antibiotics or adequate surgical debridement. Compromised hosts.
Work-up considerations
- Patient needs to be referred from or discussed with surgical specialist.
- Medical history & physical examination.
- Lab work in order – bloods & cultures, including aerobic and anaerobic.
- ECG.
- X-ray’s – chest & affected soft tissue.
- Wound Photography (consented).
- Transcutaneous oxygen measurements if appropriate.
- Optimal stabilisation and maintenance of medical treatment i.e. IVI fluids, analgesia, appropriate IVI antibiotics, urinary catheter, NG tube, central lines, glucose control, etc.
- Timing of HBO: Surgery and antibiotic therapy should precede HBO therapy.
- Consider emergency myringotomies or placement of ventilation tubes with initial surgery.
- Avoid petroleum based dressings or ointments.
- Signed informed consent for HBO.
- Comply with appropriate infection control measures.
- Critical care support.
Treatment
- HBO at 2.5 ATA for 90 minutes, with two 5 minute air breaks after 30 minute oxygen intervals BID until infection controlled and no advancement. May give 3 treatments in the 1st 24 hours. If the patient experiences any signs or symptoms due to central nervous system oxygen toxicity, consider treating patient at 2.0 ATA or give 10 min air breaks. Look for predisposing factors and try to limit or control as best possible.
- Treatment schedule: First treatment ASAP, then q8-12 hrly for 1st 24 hours, then q12 hrly until marked clinical improvement, infection controlled and no further debridement needed. May then continue with daily treatments as needed or to assist wound healing where needed.
- Document wound progress.
Suggested treatment threshold
5 – 15 treatments, according to clinical response; until the surgical margins are stable.
ICD 10 codes
- M72.6 - Necrotising fasciitis
- N49.8 - Fournier’s disease - male
- N76.8 - Fournier’s disease – female
Level of evidence
Level C