A 38-year-old man with type 1 diabetes mellitus presents with two days of severe thigh pain. You are called to see him because of hypotension. On examination he is drowsy, BP 80/60 mmHg, HR 140/min and temperature of 40.2°C. There is gross swelling on the medial aspect of his right thigh with clear cellulitis and visible central necrosis.
Describe the management priorities in the first 24 hours and briefly justify your responses.
• High flow oxygen,
• Support BP with fluids +/- vasopressors
• Measure & fix BSL
• The presentation is that of necrotising fasciitis. T1DM a significant risk factor.
Group A streptococcus (type 2) or polymicrobial aerobic and anaerobic organisms (type1) are both possible. Initial cover should be broad and include an extended spectrum beta-lactam or meropenem, and clindamycin. Clindamycin suppresses toxin formation from GAS, has other favourable in-vitro effects (facilitating phagocytosis).
• Further survey: extent of cellulitis, perineal involvement.
3. Surgical Referral and post-operative management
• Requires urgent debridement, with removal of dead/infected tissue back to bleeding tissue
• Takes priority over other therapies including hyperbaric O2
• Expectation of major blood loss and massive transfusion
• Likely to be highly unstable post-operatively with major support requirement
• Routine ICU care of patient with severe sepsis
4. Specific Therapies
• In vitro neutralisation of streptococcal super-antigens and clostridial toxins
• Streptococcal toxic shock syndrome (with or without nec. fasc.) listed as “emerging”
indication for IVIG by ARCBS, and available for use
5. Hyperbaric O2
• Observational studies only
• Conflicting results with both reduction and increases in mortality seen cf. observational controls
• Possible reduction in need for debridement
• Usually bd to tds dives of 90 min at 3 atm.
• Severe organ failure may limit logistics
So, the college has presented us with a picture of a diabetic who clearly has a necrotising fasciitis.
A boringly algorithmic answer to this question would look something like this:
The key points to remember are:
Hasham, Saiidy, et al. "Necrotising fasciitis." Bmj 330.7495 (2005): 830-833.
Mulla, Zuber D. "Treatment options in the management of necrotising fasciitis caused by Group A Streptococcus." Expert opinion on pharmacotherapy 5.8 (2004): 1695-1700.
Darenberg, Jessica, et al. "Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial." Clinical infectious diseases 37.3 (2003): 333-340.
Brown, D. Ross, et al. "A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy." The American journal of surgery 167.5 (1994): 485-489.
Soh, Chai R., et al. "Hyperbaric oxygen therapy in necrotising soft tissue infections: a study of patients in the United States Nationwide Inpatient Sample." Intensive care medicine 38.7 (2012): 1143-1151.