[Necrotising soft-tissue infections: diagnostics and treatment]. / Necrotiserende wekedeleninfecties: diagnostiek en behandeling.

Necrotising soft-tissue infections occur in the soft tissue compartment consisting of the dermis, subcutaneous tissue, superficial fascia (fascia of Scarpa), deep fascia and muscle. Although this severe and acutely life-threatening infection has a low incidence, both GPs and specialists will see a necrotizing soft-tissue infection more than once during their career. The mortality related to necrotising soft-tissue infections has been halved during the past 15 years from nearly 40 to 20% due to adequate treatment. Laboratory examination and X-ray findings could be of added value, but the gold standard remains biopsy of the fascia and Gram staining. Treatment consists of prompt volume resuscitation in case of sepsis, administration of broad spectrum antibiotics and surgical debridement; this debridement should be as skin-sparing as possible. The use of hyperbaric oxygen therapy has remained a controversial issue, unless a patient has gas gangrene, caused by Clostridium species. A multidisciplinary treatment and admission to a tertiary intensive care unit are indispensable for the treatment of a septic patient with necrotizing soft-tissue infection.

Complex wounds and their management.

Complex wounds present a challenge to both the surgeon and patient in operative management, long-term care, cosmetic outcome, and effects on lifestyle, self-image, and general health. Each patient with complex wounds usually manifests multiple risk factors for their development. This article focuses on complex wounds involved with traumatic and orthopedic blunt or penetrating injuries, particularly in the extremities, as well as massive soft tissue infections including necrotizing fasciitis, gas gangrene, and Fournier gangrene. The principles of management of complex wounds involve assessing the patient's clinical status and the wound itself, appropriate timing of intervention, providing antibiotic therapy when necessary, and planning and executing surgical therapy, including the establishment of a clean wound bed and closure/reconstructive strategies.

[Hyperbaric oxygenation: utility in intensive therapy - part 2]. / Hyperbare Oxygenation - Stellenwert in der Intensivtherapie - Teil 2.

Gangrene, non-clostridial myonecroses and intracranial abscesses are clinical entities for which hyperbaric oxygenation can be used therapeutically. Mortality and invalidity can be reduced by this means. Except for gangrene, HBO is used merely as an adjuvant for these diseases when conventional surgical, antibiotic and intensive therapy measures are not sufficient. The action of HBO is based on several points of attack: it reduces the formation of oedema, inhibits the production of alpha-toxins of the Clostridia, has a bacteriotoxic action, increases the effectivity of antibiotics and improves the immune defense system. An early start is decisive for the success of HBO therapy.

[Complicated skin and soft tissue infections]. / Komplizierte Haut- und Weichgewebsinfektionen.

Skin and soft tissue infections are common diseases. The spectrum ranges from slight furuncles to severe necrotizing soft tissue infections. Grampositive bacteria account for 70-80 % of cases as causative organisms. Diagnostics include rapid evaluation of locally limited or diffuse spreading extent of the disease. In complicated skin and soft tissue infections, surgical intervention with debridement and necronectomy is indicated. Necrotizing skin and soft tissue infections call for programmed redebridement. If systemic signs of inflammation are present (fever > 38 degrees C, leukocytosis, CRP elevation) or significant comorbidity exists, application of antibiotics is indicated. The prognosis in operatively treated patients is dependent on the time of surgical intervention.

Gas gangrene and necrotizing fasciitis in the upper extremity.

Necrotizing soft tissue infections encompass a wide variety of clinical syndromes resulting from introduction of various pathogens into injured or devitalized tissue. The extent of microbial involvement in such tissue may range from simple contamination to overt and progressive local tissue necrosis, which, if untreated, may lead to septicemia and death. Early differentiation among these infections is not always possible, as there are overlapping classification criteria. These infections exist along a continuum of clinical severity with different etiological agents and associated medical conditions. The often subtle clues heralding the presence of a necrotizing soft tissue infection must be sought so that expeditious surgical debridement and broad-spectrum antibiotic management are initiated. Although experience enables the clinician to make a specific diagnosis based on early findings, aggressive and proper treatment of suspected infections remains the priority. The purpose of the article is to provide an overview of necrotizing soft tissue infections in the upper extremity, focusing on gas gangrene, or clostridial myonecrosis, and necrotizing fasciitis, to facilitate early diagnosis and optimal management of these lethal diseases.

[A rare case of gaseous gangrenous mediastinitis]. / Rzadki przypadek zgorzeli gazowej sródpiersia.

We report a case of a cervical phlegmone and mediastinitis descending from peridental abscess in 32-year old student. Emergency left thoracotomy was performed after CT evaluation in which multiple fluid levels and gas spaces were found. After 72 hours bacterial strains showed Clostridium perfringens in fluid taken from left pleural cavity and patient was sent to Hiberbaric Center in Gdynia, where he underwent hyperbaric oxygen therapy. After 10 days the patient was brought back in good condition to our Department. After 3 days he died because of sudden massive bleeding caused by necrosis of aorta wall.

[Gas gangrene and hyperbaric oxygenation--a lesson forgotten or never learned?]. / Plinska gangrena i hiperbaricna oksigenacija--zaboravljena ili nikad naucena lekcija?

Gas gangrene develops in devitalized hypoxic tissue. It spreads rapidly under strong influence of enzymes produced by the causing bacteria and often results in fatal outcome. It is of utmost importance to stop toxin production as soon as possible, which is most effectively achieved by early application of hyperbaric oxygenation (HBO2), as the first measure in a "trident" (HBO2, antibiotics, surgical measures). The paper reviews the most important data from microbiology, pathophysiology and epidemiology of gas gangrene, current clinical practice, scientific basis for application of HBO2 in the treatment of this disease, and data from the archives of the Naval Medical Institute of the Croatian Navy in Split (NMI). At the NMI, in the period from 1982 to 2000, HBO2 was administered in the treatment of 21 patients with gas gangrene, of average age 41.6 +/- 16.3 years. The average treatment consisted of 6.8 +/- 3.8 sessions. 13 (76%) patients were cured.

Hyperbaric oxygen.

This cutting edge article discusses the most frequent uses of hyperbaric oxygen for the orthopedic surgeon. Hyperbaric oxygen therapy is an adjunct to orthopedic interventions when healing problems are anticipated due to wound hypoxia or uncontrolled infection.

Treatment outcome of nonclostridial gas gangrene at a Level 1 trauma center.

OBJECTIVE: To evaluate the results of treatment of nonclostridial gas gangrene at a Level 1 trauma center. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS: Seven patients with nonclostridial gas gangrene were studied. The average age of all patients at the time of admission was 40.3 years (range 14 to 67 years). RESULTS: Three of seven patients had posttraumatic infection, and the remaining four were strongly associated with underlying diseases: diabetes mellitus in three and paraplegia as the result of a spinal cord injury in two. The time of symptom onset was clearly defined in four cases, and the average interval between symptom onset and transfer to our hospitals was six days (range 2 to 10 days). Surgical debridement was performed immediately on admission in six patients (86 percent). A triple antibiotic regimen consisting of penicillin, gentamicin, and clindamycin was used initially in all patients. In three patients, hyperbaric oxygen therapy was also used. The overall mortality rate was 42.9 percent (three of seven patients). In these patients, the interval from onset of symptom to transfer to our hospital was ten days in one patient, which was longer than average, and was not accurately known in the other two patients. CONCLUSION: Nonclostridial gas gangrene is extremely rare but life-threatening. The greatest pitfall for the emergency department physician is failure to suspect it clinically. Aggressive treatment, including surgical debridement and intravenous antibiotics with or without hyperbaric oxygen therapy, must be initiated immediately to minimize morbidity and mortality.

Recurrent crepitant cellulitis caused by Clostridium perfringens.

A previously healthy 13-year-old boy developed extensive subcutaneous emphysema of the lower limb after a penetrating injury to the knee. Clostridium perfringens was isolated from the wound. Despite surgical debridement and appropriate antibiotics, the emphysema recurred, and prolonged antibiotic treatment was required. This case highlights the distinction between gas gangrene and the lesser known entity of clostridial crepitant cellulitis.

[Compartment syndrome or gas gangrene? A case report]. / Sindrome compartimentale o gangrena gassosa? Caso clinico.

A case of forearm compartment syndrome due to a minor trauma is reported. The severe clinical conditions due to a shock state lead to an initial misdiagnosis of clostridial myonecrosis. The patient, 68 y-old woman, was admitted to the intensive care unit of Authors' hospital for a traumatic injury of the right forearm. A diagnosis of gas gangrene due to clostridial myonecrosis was done and forearm amputation suggested. In spite of this indication a decompression fasciotomy of the forearm compartments was performed as well as a hyperbaric oxygene therapy. Since culture of necrotic tissue samples did not demonstrate any bacterial growth, the Authors decided to avoid amputation and perform a radial arteriovenous fistula to improve venous return and reduce distal edema and continuous bleeding, with a complete recovery within 40 days. Good evaluation of patient with suspected compartment syndrome means correct and not delayed treatment, avoiding invalidating outcome.

Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions.

Clostridial gas gangrene and perineal necrotizing fasciitis or Fournier's gangrene are rare but serious infections with an acute onset, rapid progression, systemic toxemia and a high mortality rate. The aim of this study was to investigate the efficacy of surgery, antibiotic treatment, surgical intensive care and in particular the role of hyperbaric oxygen (HBO) in the management of these infections. An experimental rat model was used to investigate the possibilities for measuring tissue oxygen and carbon dioxide tensions during hyperbaric oxygen treatment. In addition to this preliminary experimental study, Silastic tube tonometer and capillary sampling techniques were tested to measure the effect of hyperbaric oxygen treatment on subcutaneous oxygen and carbon dioxide tensions in patients with necrotizing fasciitis and healthy controls. Between January 1971 and April 1997, 53 patients with Clostridial gas gangrene were treated in the Department of Surgery, University of Turku. The patients underwent surgical debridement, broad spectrum antibiotic therapy and a series of hyperbaric oxygen treatments at 2.5 atmospheres absolute pressure (ATA). Twelve patients died (22.6%). Hyperbaric oxygen therapy in gas gangrene seems to be life-, limb- and tissue saving. Early diagnosis remains essential. Patient survival can be improved if the disease is recognized early and appropriate therapy instituted promptly. Between February 1971 and September 1996, 33 patients with perineal necrotizing fasciitis were treated in the Department of Surgery, University of Turku. The management included surgical debridement of the necrotic tissue with incisions and drainage of the involved areas, antibiotic therapy, hyperbaric oxygen treatment at 2.5 ATA pressure and surgical intensive care. Three patients died giving a mortality rate of 9.1%. The survivors received hyperbaric oxygen therapy for 2-12 times. Our results indicate that hyperbaric oxygenation is an important therapeutic adjunct in the treatment of Fournier's gangrene. Electrical equipment should not be used unsheltered in a hyperbaric chamber due to the increased risk of fire. The subcutaneous tissue gas tensions of rats were therefore measured using a subcutaneously implanted Silastic tube tonometer and a capillary sampling technique. The method was successfully adapted to hyperbaric conditions. The subcutaneous oxygen tension levels increased five fold and the carbon dioxide tension levels two fold compared to initial levels. The PO2 and PCO2 of subcutaneous tissue and arterial blood were measured directly in six patients with necrotizing fasciitis and three healthy volunteers in normobaric conditions and during hyperbaric oxygen exposure at 2.5 ATA pressure. The measurements were carried out in healthy tissue and at the same time in the vicinity of the infected area of the patients. During HBO at 2.5 ATA subcutaneous oxygen tensions increased several fold from baseline values and carbon dioxide tensions also increased, but to a lesser degree in both healthy and infected tissues. When examining the subcutaneous PO2 levels measured from patients with necrotizing fasciitis, the PO2 was regularly higher in the vicinity of the infected area than in healthy tissue. In general, HBO treatment resulted in a marked increase in tissue oxygenation in both healthy tissue and in the vicinity of infected tissue. The hyper-oxygenated tissue zone surrounding the infected area may be of significance in preventing the extension of invading microorganisms.

Hyperbaric oxygen therapy in acute necrotizing infections. With a special reference to the effects on tissue gas tensions.

Clostridial gas gangrene and perineal necrotizing fasciitis or Fournier's gangrene are rare but serious infections with an acute onset, rapid progression, systemic toxemia and a high mortality rate. The aim of this study was to investigate the efficacy of surgery, antibiotic treatment, surgical intensive care and in particular the role of hyperbaric oxygen (HBO) in the management of these infections. An experimental rat model was used to investigate the possibilities for measuring tissue oxygen and carbon dioxide tensions during hyperbaric oxygen treatment. In addition to this preliminary experimental study, Silastic tube tonometer and capillary sampling techniques were tested to measure the effect of hyperbaric oxygen treatment on subcutaneous oxygen and carbon dioxide tensions in patients with necrotizing fasciitis and healthy controls. Between January 1971 and April 1997, 53 patients with Clostridial gas gangrene were treated in the Department of Surgery, University of Turku. The patients underwent surgical debridement, broad spectrum antibiotic therapy and a series of hyperbaric oxygen treatments at 2.5 atmospheres absolute pressure (ATA). Twelve patients died (22.6%). Hyperbaric oxygen therapy in gas gangrene seems to be life-, limb- and tissue saving. Early diagnosis remains essential. Patient survival can be improved if the disease is recognized early and appropriate therapy instituted promptly. Between February 1971 and September 1996, 33 patients with perineal necrotizing fasciitis were treated in the Department of Surgery, University of Turku. The management included surgical debridement of the necrotic tissue with incisions and drainage of the involved areas, antibiotic therapy, hyperbaric oxygen treatment at 2.5 ATA pressure and surgical intensive care. Three patients died giving a mortality rate of 9.1%. The survivors received hyperbaric oxygen therapy for 2-12 times. Our results indicate that hyperbaric oxygenation is an important therapeutic adjunct in the treatment of Fournier's gangrene. Electrical equipment should not be used unsheltered in a hyperbaric chamber due to the increased risk of fire. The subcutaneous tissue gas tensions of rats were therefore measured using a subcutaneously implanted Silastic tube tonometer and a capillary sampling technique. The method was succesfully adapted to hyperbaric conditions. The subcutaneous oxygen tension levels increased five fold and the carbon dioxide tension levels two fold compared to intial levels. The PO2 and PCO2 of subcutaneous tissue and arterial blood were measured directly in six patients with necrotizing fasciitis and three healthy volunteers in normobaric conditions and during hyperbaric oxygen exposure at 2.5 ATA pressure. The measurements were carried out in healthy tissue and at the same time in the vicinity of the infected area of the patients. During HBO at 2.5 ATA subcutaneous oxygen tensions increased several fold from baseline values and carbon dioxide tensions also increased, but to a lesser degree in both healthy and infected tissues. When examining the subcutaneous PO2 levels measured from patients with necrotizing fasciitis, the PO2 was regularly higher in the vicinity of the infected area than in healthy tissue. In general, HBO treatment resulted in a marked increase in tissue oxygenation in both healthy tissue and in the vicinity of infected tissue. The hyperoxygenated tissue zone surrounding the infected area may be of significance in preventing the extension of invading microorganisms.

Successful treatment of mediastinal gas gangrene due to esophageal perforation.

Esophageal perforation and mediastinal gas gangrene developed in a 55-year-old male after the endoscopic ethanol injection of a Mallory-Weiss ulcer. Initially, extensive gangrene of the esophagus and the mediastinum was treated by esophagectomy; however, an abundance of Clostridium perfringens in the Gram stain verified the presence of gas gangrene. Subsequently, the patient was transferred to a hyperbaric oxygen center, wherein a total of seven hyperbaric treatments were administered. The patient survived, and 4 months later, after having undergone several reoperations because of pleural empyema, mediastinal abscess, splenic rupture, and acalculous cholecystitis, was discharged and is still surviving.