Tasty Morsels of Critical Care 022 | Necrotising fasciitis
Welcome back to the tasty morsels of critical care podcast. Continuing along a theme of words with with too many i’s in them, (see TM 007 for more) today we look at necrotising fasciitis or “nec fasc” to its friends. What clinical signs might help us find this? * necrotic skin * bullous changes * dishwater coloured drainage from the bullae/tissue * everyone’s favourite: POOP or pain out of proportion * crepitus * people with DM, immunosuppression, lines in situ or water exposure * the other thing I’ve found useful over the years is that whenever you see a cellulitis with hypotension or a cellulitis going to ICU then you should be strongly considering nec fasc that you just haven’t found yet. Many of you will have heard of the LRINEC score but, like many of these scores for uncommon critically illnesses, it’s not that useful for making decisions but does highlight some of the features that should prompt you to think about it. You can diagnose it clinically with plain film, ultrasound, with CT or god help us all… MRI. (it’s not that MRI isn’t good, but any time you combine “time dependant surgical diagnosis” with MRI you’re in for diffs…) First amongst the lesser known facts about nec fasc comes the various types it is split into. * Type 1: polymicrobial infection affecting the trunk perineum, typically in poorly controlled diabetics. * Type 2: monomicrobrial infection (usually a beta haemolytic strep), mainly affecting the limbs of usually fairly normal patients * Type 3: Clostridial infections or gram -ve, possibly even vibro. Can affect limbs, trunk, perineum and be associated with trauma or water exposure * Type 4: candida, typically in the immunosuppressed as you might expect Obviously types 1 and 2 are what we see most of. There are some identifiable risk factors for nec fasc but type 2 infections, being mainly group A strep often have no risk factors so this list is more for the other types. * Diabetes * Alcohol misuse * PVD * Renal failure * Recent surgery or trauma * Malignancy/immunosuppression * Injection drug use * VZV is an unusual but well described risk factor in kids If you weren’t already aware then a key take home point is that surgical debridement is of the essence here. Surgery involves removing everything where the fascia pulls away when it’s not meant to. Generally a second look at 24-48 hrs to see if there’s been any progression is good idea. Medical treatment lies more in our domain as intensivists. Antibiotics are the mainstay and recommendations will vary by country and hospital. For example my current hospital’s empiric recommendations are * ben pen and flucloxacillin * ciprofloxacin * gentamicin * clindamycin MRSA is relatively uncommon so simple penicillins are ...