Necrotizing fasciitis is a disease characterized by necrosis of the skin, subcutaneous tissue, and superficial fascia. It rarely involves muscles, generally occurs in loose tissue sites, and most of them start dangerously and spread quickly in local tissues. If not handled properly, patients often die of sepsis and septic shock, and the later stages of the disease are usually accompanied by multiple organ failures [1、2]. Due to the relative backwardness of the economy in western China, most of the reasons for the onset of patients are due to the lack of attention to foreign body puncture, or the formation of bedsores due to long-term improper bed care of paraplegic patients, and they did not seek medical treatment in time after the formation of bedsores. At the same time, many patients only come to our hospital for treatment when their limbs are swollen and their systemic symptoms are obvious, and they do not improve after seeing a local hospital. Therefore, patients are often accompanied by septic shock and complications such as sepsis, hypoproteinemia, anemia, electrolyte imbalance and so on.
This shows that early diagnosis is very important to the treatment of the disease, but necrotizing fasciitis is easy to be misdiagnosed and missed in the early stage. We conducted a retrospective analysis and found that early necrotizing fasciitis has some characteristics. 1. Small trauma such as mosquito bites, pressure sores, and local trauma; 2. Patients suffering from minor trauma did not receive regular treatment in time, and only went to the hospital when local redness, pain, and dysfunction occurred, and were misdiagnosed as cellulitis;3. When a paraplegic patient has a Sacrococcygeal pressure ulcer and has whole-body fever or low-grade fever, and there is inflammation around the pressure ulcer, and redness and swelling spread to one lower limb or both lower limbs, necrotizing fasciitis should be highly suspected; 4. Patients’ wounds cannot be debrided in a timely and effective manner. Generally, inexperienced doctors have incomplete incision and drainage, which causes necrosis to continue to spread along the fascia to the distal limbs.
Early and thorough debridement after the correction of the internal environment is a key step in the treatment of necrotizing fasciitis. A retrospective analysis found that some patients had a clear diagnosis in the primary hospital, but the surgical treatment failed to fully open and drain, causing the necrosis to continue to spread along the fascial space to the distal limbs.Therefore, perioperative systemic comprehensive treatment is the key to the treatment of necrotizing fasciitis. For patients with a prolonged course of disease, it is often accompanied by severe anemia, hypoalbuminemia, and electrolyte disorders, which should be actively corrected. However, most of these patients have a long history of bedridden, so they often have poor cardiopulmonary function, which makes the treatment of patients very difficult. Patients with septic shock and hypoalbuminemia have poor cardiopulmonary conditions and need to limit fluid replacement. Thus, this group of patients corrected septic shock with Picco's effective detection of blood flow, to maximize the time for treatment. Due to the disease characteristics of necrotizing fasciitis, surgical debridement should pay attention to the breadth and depth of debridement. Limb necrotizing fasciitis rarely involves muscles, but it can reach deep fascia in depth. In general, the deep fascia of long-term and critically ill patients is often stained and needs to be removed. The breadth refers to the extent of the wound margin. Sneak creep is a characteristic of the disease. According to clinical experience, it is necessary to remove at least 1 cm of skin and subcutaneous tissue around the wound margin, especially the edges of both sides of the long axis of the limb, until it is not seen directly necrotic tissue. Even so, it is difficult for patients with the critical or prolonged course of disease to entirely debridement at one time, and most patients need to debridement for three or more times to completely debridement and cover the wound. This also indicates that the range of necrotizing fasciitis infection or necrosis exceeds the range estimated under direct vision [3-5]. If the patient's wound still has secretions or persistent high fever after surgery, a second surgical treatment should be performed immediately under relatively stable internal conditions. And if the patient's necrotic tissue cannot be productively removed, its symptoms cannot be effectively improved. It can be seen that thorough debridement is the key to treating necrotizing fasciitis, because this can solve the problem from the source.
When patients are admitted without direct bacteriological support, treatment with broad-spectrum antibiotics based on clinical experience is an important auxiliary means. However, since the disease is often not diagnosed early, most patients have been using multiple antibiotics for a long time by the time of definite diagnosis, which increases the resistance of the bacteria. Even so, the use of broad-spectrum antibiotics in the perioperative period still has a certain effect on the prognosis of patients. In this group of patients, Imipenem is generally selected for treatment during the perioperative period. After the wound culture and blood sample culture results are obtained, sensitive and relatively narrow-spectrum antibiotics are selected. In patients with necrotizing fasciitis, when there is no obvious systemic inflammatory response, debridement should be given priority, and the use of antibiotics is only an auxiliary method. Therefore, it is worthwhile for each of our clinicians to consider whether all patients with this disease are suitable for powerful broad-spectrum antibiotics What is the treatment effect and whether super-strong broad-spectrum antibiotics can cause the spread of necrosis?
As we all know, bacteriological examination has very important clinical significance in the treatment of infectious diseases. However, the current detection rate of anaerobic bacteria in the clinic is low, so it will greatly reduce the guiding significance for clinical treatment. Necrotizing fasciitis is usually caused by anaerobic and aerobic bacterial infections [3-5]，but bacterial culture often does not help diagnose the disease. Because the bacterial culture period is long, and the detection rate of anaerobic bacteria is low. Most of the patients in this group have been treated in more than two hospitals, and more than seven or eight kinds of bacteria have been detected. Antibiotics have been given according to drug sensitivity experiments, but the effect is not good. Therefore, the disease cannot be overly dependent on the results of bacterial drug sensitivity tests during the treatment of the disease, but should be based on clinical manifestations and surgical treatment, with bacteriology testing only as a reference for treatment.
In summary, early and thorough debridement after the correction of the internal environment is the key link in the treatment of necrotizing fasciitis. And perioperative systemic comprehensive treatment is an important guarantee for the treatment of necrotizing fasciitis.
In summary, 1. The diagnosis of necrotizing fasciitis mainly depends on clinical manifestations, and early diagnosis is the key; 2. When the patient has local trauma with local inflammation, and fever or hypothermia throughout the body, necrotizing fasciitis should be highly suspected, and the differential diagnosis should be made with cellulitis. When it is difficult to distinguish, a diagnostic surgical incision can be performed; 3. The operation should be thorough, fully cut and drained to avoid necrosis spreading to the distal limbs along the fascial space; 4. Necrotizing fasciitis should be systemic comprehensive treatment, rational use of antibiotics, correction of water and electrolyte disorders, early active and thorough debridement, and effective sealing of the wound.