The role of surgery in the management of septic shock—extra-abdominal causes of sepsis

AORN Journal,  Jan, 2007  by George H. Sakorafas,  Adelais G. Tsiotou,  Maria Pananaki,  George Peros

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Early recognition of this severe, soft-tissue infection is of particular importance, and necrotizing fasciitis should be distinguished from cellulitis. Cellulitis is an infection that is limited to subcutaneous tissue and usually responds to conservative management (eg, antibiotic therapy alone). Necrotizing fasciitis causes deep fat, fascial, and muscle necrosis and requires aggressive management (eg, surgical debridement to remove the necrotic or infected soft tissues that continue to fuel the cascade of inflammatory reaction).

During the initial stages of illness, this differential diagnosis can be very difficult to determine. Severe, soft-tissue infections may be associated with skin that appears normal; and local signs of inflammation may be mild, despite the presence of an extensive, underlying, deep-tissue infection. (8) Extensive soft-tissue edema, crepitus, and cyanosis are late clinical manifestations. A high index of suspicion is required for early recognition of this serious form of the disease. Clinical findings that are useful for early recognition of necrotizing fasciitis include pain and fever that is out of proportion to the local physical findings and very high leukocytosis. (11)

Diagnosis can be confirmed by a CT or MRI scan that shows the presence of gas within soft tissues and thickening of the fascia with extensive muscle edema. Furthermore, the absence of tissue enhancement after IV contrast administration indicates the presence of tissue necrosis. (8,12)

When a diagnosis has been made, surgery is indicated. The goal is to perform complete surgical debridement by wide resection of all nonviable tissue until viable tissue is encountered. To address muscular necrosis, the fascial compartment should be opened wide to relieve increased pressure (ie, compartment syndrome) and allow adequate blood flow to the muscle. To achieve sufficient debridement, repeated interventions often are required for these patients. (1,7) If for any reason there is doubt about the diagnosis, it is better to perform surgical exploration of the area through a small incision to look for the presence of an underlying severe infection. The absence of hemorrhage is characteristic of necrotic tissue.

The first four to six hours are critically important for the prognosis of a patient who has necrotizing fasciitis. Ideally, surgical debridement should be performed within the first three hours but must be performed within 12 hours of the patient's admission. (13,14) Delaying surgery may result in death because the disease progresses so rapidly. (15) The morbidity of the surgical procedure, however, is very low. If surgical exploration is negative, the patient has an incision but does not have to undergo debridement. If, however, surgical exploration is positive, the procedure is advanced to surgical debridement in an effort to control the disease. During surgery, all necrotic tissues (ie, those tissues that do not bleed) should be removed. Insufficient removal of necrotic tissues, as well as delay of surgery, will increase the chance of mortality. (16)