Necrotizing Fasciitis
Necrotizing Fasciitis
Necrotizing Fasciitis
This can be seen in these two illustrations. The left diagram represents a healthy persons tissue, whereas the illustration on the right depicts a person affected by necrotizing fasciitis. As you can see, the bacteria have caused the destruction of the epidermis, dermis and subcutaneous tissue tissue. This induces oedema and further reduces blood flow by allowing plasma to escape into the extravascular space (outside the vessels). As a result, this prevents the body from healing the damaged tissue. Therefore, this diagram highlights the extensive damage caused by the disease and why it is such a grave threat
Fasciitis
The condition goes through three different phases. Firstly, there are initial effects, which are felt within 24 hours of the bacteria entering the body. The patient will have a fever, feel nauseous, want to vomit and have a headache. Furthermore, the pain felt by the patient will be much greater than one would expect from a small wound or injury. However, the problem of necrotizing fasciitis is that these symptoms are often related to flu and, therefore, can lead to misdiagnosis (5). After 36-48 hours, the progressive effects are felt, whereby the site of infection will become swollen and will turn a dark purple colour. Blisters will form and they will appear like a rash. Finally, the final effects are felt whereby the infection spreads over the whole body and it becomes apparent that the patient is suffering from Necrotizing Fasciitis. Only then is the presentation of the condition more clear and the doctors can clearly diagnose the patient. The patient may even go into systematic shock due to the dangerously high level of toxins that have been released by the bacteria. Systematic shock is when the bodys bloody pressure drops at an alarming rate and the person suffers from hypotension, causing them to possibly become unconscious. Thus, systematic shock will increase the difficulty of saving the patients life. Overall, these symptoms portray the severe pain suffered by patients of Necrotizing Fasciitis.
Haran Devakumar L6HVB limbs from amputation, but more importantly hundreds that died from the disease. On average, the mortality rate for necrotizing fasciitis is as high as 25% worldwide (8).
Main Solution
The main solution for Necrotizing Fasciitis is to perform surgical debridement as soon as possible. Surgical debridement is a type of surgery that uses various instruments, such as a scalpels and scissors, to cut necrotic (dead) tissue from the infected wound, where the bacteria are located. The surgeon begins with flushing the area infected with saline (saltwater) solution, and then applies a local anaesthesia to the edges of the wound, in order to minimize the pain (9). Then the surgeon uses forceps to get hold of the devitalized tissue and gradually removes it using a scalpel or scissors, shown (10) Figure 2 - method of by A on the illustration. Devitalised tissue acts Surgical Debridement as a culture medium that promotes bacterial growth and the spread of infection. Therefore, removing tissue, which is heavily contaminated with dirt and bacteria, prevents any further infection. In addition, as debridement progresses, cytokine (toxin) release reduces and the patient usually becomes hemodynamically more stable, which means the patient is significantly more protected from anymore invasive organisms (11).
Haran Devakumar L6HVB There are a few implications to the surgery. Firstly, there is a social cost involved because after surgical debridement, the skin is removed, leaving behind a vast amount of raw material open to infection: skin grafting is needed in order to replace the skin. Skin grafting forces the patient to require a lengthy period of recovery, which is often accompanied by anxiety and depression. This is because the patient is worried about their future and how their body might turn out (13). Another social cost produced from the surgery is extreme agony for the patient because the wound is extremely painful after debridement. In addition, the patient might need to undergo extensive debridement in order to fully control the infection and prevent it from spreading further, therefore the volume of pain felt by the patient will increase (14). Another implication of the solution is that although the procedure itself is quick, the recovery time is not. The average length of stay for patients recovering from necrotizing fasciitis is 11 days in a High Dependency Unit. Therefore, this puts an economical cost on the NHS because High Dependency Units cost roughly 700 per bed per day in an Adult High Dependency Unit in the UK. These beds are very expensive and are a limited resource because they provide specialized monitoring equipment, a high degree of medical expertise and constant access to highly trained nurses (usually one nurse for each bed) (15).
Haran Devakumar L6HVB much longer period of time because multiple debridements are required. Another disadvantage of the surgery is that it cannot be performed without placing the patient under general anaesthesia. General anaesthesia can cause complications, such as allergic reactions to certain anaesthetic agents it contains. Experts estimate that a complication occurs to 1 person in every 14,000 (18). However, the main disadvantage is that surgical debridement leaves behind a vast amount of raw material, which forces the patient to undergo skin grafting. As mentioned before, skin grafting places the patient in a state of anxiety and worry because their physical appearance will be changed forever.
Alternative Solutions
One alternative solution to treat necrotizing fasciitis is hyperbaric oxygen therapy. This treatment places the patient in a specially designed chamber, which is similar to the decompression chambers used by deep-sea divers in order to avoid decompression sickness (the bends). In this instance, the chamber is filled with oxygen at a much higher pressure than the normal level of oxygen in the atmosphere, hence making it hyperbaric. The benefit of this higher pressure is that high levels of oxygen can now be dissolved into the blood stream, thus resulting in more oxygen reaching the gangrenous (dead) regions, which prevents the bacteria from causing any further infection. This is because bacteria cannot survive in an oxygen-rich atmosphere. Overall, this treatment is especially useful in reducing a patients risk of amputation whilst also causing less pain (19). Another alternative solution is antimicrobial therapy, which is given alongside surgical debridement. A combination of intravenous antibiotic drugs like Penicillin, Clindamycin and Vancomycin are given immediately. These are used to provide broad bacterial coverage whilst a tissue sample is taken and the actual infecting bacteria are identified. Once the bacteria are identified, they can be categorized into one of the three different types: gram-positive, gram-negative and anaerobic bacteria. Then various antibiotics can be given to target the particular type of bacteria. For example, Penicillin and Gentamicin are given to tackle gram-negative and gram-positive organisms (aerobic infection), whereas Metronidazole is given to combat anaerobic infection (20).
Bibliography
(1) Author: Charles Davis; Title: Necrotizing Fasciitis: Publication:
http://www.medicinenet.com/necrotizing_fasciitis/article.htm; Date accessed: 20/03/11. (2) Author: Richard Salcido and Chulhyun Ahn; Title: Advances in Skin and Wound care; Publication: The Journal for Prevention and Healing; Date
(3) Author: Linda Vorvick, Daniel Levy; Title: Necrotizing soft tissue
infection; Publication: PubMed Health; Date 12/2007; Date accessed: 20/02/11.
(8) Author: Amanda Hu; Title: the Case of Necrotizing Fasciitis; Publication:
Journal of Young Investigators; Date: Vol. 5 2010.
(10) Author: Precise Medical Demonstrative Evidence; Title: Infected Left Ankle
Wound with Surgical Debridement and Drainage; Publication: http://preciselaw.medicalillustration.com/generateexhibit.php?ID=71241&TC=&A=59501; Date accessed: 15/03/11.
(11)
Author: Lee A. Fleisher; Title: Anaesthesia and Uncommon Diseases; Publication: Esevier Health Sciences; Date: 10/2005. (12) Author: Jason Cheung, Boris Fung; Title: A review of necrotizing fasciitis in the extremities; Publication: Hong Kong Medical Journal; Date: Vol. 15, No. 1, 02/2009.
(13)
Author: Michelle Kerns; Title: Necrotizing Fasciitis effects; Publication: http://www.ehow.com/about_5554828_necrotizing-fasciitis-effects.html; Date accessed: 24/02/11.
(14)
Author: Steven E. Doerr; Title: Necrotizing Fasciitis; Publication: http://www.emedicinehealth.com/necrotizing_fasciitis/page3_em.htm; Date accessed: 20/03/11. (15) Author: Dr S. Das; Title: an interview with Dr S. Das, consultant surgeon; Location: Hillingdon Hospital; Date: 20/02/11.
Haran Devakumar L6HVB (17) Author: Wound Care Information Network; Title: Surgical Debridement;
Publications: http://www.medicaledu.com/debridhp.htm; Date accessed: 15/03/11.
Evaluation of validity of Source (7) The mortality rate of 25% was collected from an article in the Journal of Young Investigators (7). Amanda Hu, from the University of Toronto Medical School, wrote the article. Her methods of collecting data were reliable because her sole aim was to investigate the dangers of Necrotizing Fasciitis. Therefore, she has no reason to be biased or unjust. The article was also peer reviewed by doctors at the Toronto Medical School. Peer Review is a process in which the article is evaluated before it is published. This is normally carried out by respected members in the field and helps to maintain or enhance the quality of the article. More importantly, it discourages cronyism (favouritism shown to friends and family) and obtains an unbiased evaluation. Therefore, I think the results are reliable because these people have great expertise in this particular field and would know the facts behind Necrotizing Fasciitis. Furthermore, when I cross-referenced this source with source (6) and (12), I found that the mortality rate was also calculated at 25%, which means the data is accurate. In conclusion, I
Evaluation of validity of Source (17) Haran Devakumar L6HVB In source (17), Lisabetta Divita explains antibacterial therapy, one of the alternative solutions. She is a physician who was exposed to all facets of the medical field during her training. Her writings are currently featured in prominent medical magazines and various online publications. She holds a doctorate in medicine, a master's in biomedicine, and a Bachelor of Science in biology from Boston College. Therefore, I believe she is unbiased because she is a respected member of the medical industry and so her reputation is on the line. Furthermore, the data is accurate because she witnessed antibacterial therapy being given to a Necrotizing Fasciitis patient during her period as a medical student. In addition, this article was peer reviewed, which means it is reliable because specialists in this field agree with her. Furthermore, I interviewed Dr S.Das (5), who treats the disease at Hillingdon Hospital. He agreed with the article and said that when patients suffering from necrotizing