NECROTIZING FASCIITIS - EXPERIENCE OF A BURN CARE TEAM

Necrotizing fasciitis is a life-threatening soft tissue infection char acterized by extensive necrosis of the subcutaneous tissues due to pro gressive bacterial infection and thrombosis of the blood supply. These patients are usually septic and present both critical care and wound care challenges, particularly suitable for the Burn Team. We reviewed our three-year experience, providing care to 45 patients with necrotiz ing fasciitis. Patients were transferred from an outlying hospital or from another surgical service for wound and intensive care in the Burn Unit. The patients were debrided rapidly and repetitively until evide nce of bacteriologic control was obtained by tissue quantitative cultu re. Extensive dressing changes with topical antibiotics were accomplis hed daily with conscious sedation techniques within the Bum Unit, freq uently using ketamine for analgesia. Attention was particularly given to adequate nutritional support, splinting, and physical therapy. The mean patient age was 43.9 years (range 1 to 81), and 58 percent were m ale. Six patients died for a mortality rate of 13 percent. Necrotizing fasciitis was caused by drug injection (in 13 patients), trauma (7), perirectal abscess (4), skin infection (4), meningococcemia (3), intra abdominal infection (3), Fournier's gangrene (2), infected pressure ul cer (1), peripheral vascular disease (1), post-operative (1), and idio pathic (6). Strep was the most common organism, but 58 percent were po lymicrobial. The mean wound size was 9.8 percent TBSA (range 1 to 30 p ercent); 16 were truncal, 21 extremity, and 8 perineum. Forty-three pa tients needed 230 operative debridements total (average 5.35 each), an d 64 procedures for closure (58 skin grafts, 3 flaps, and 3 primary cl osures) in 37 patients. Sixty-two percent of the skin-grafted patients were closed with the first graft (average 1005 cm(2)). One survivor w as allowed to heal secondarily, and another was returned to his manage d care facility for closure. The patients required 30.3 days for hospi talization (range 3 to 102). In this selected group of patients with d ifficult wounds, burn service expertise produced an excellent survival rate of 87 percent. In addition, these patients kept the Bum Team bus y and maintained the intensive care unit census.