Journal Logo

VIEWPOINTS

Early Radical Surgery and Antimicrobial Therapy with Hyperbaric Oxygen in Necrotizing Fasciitis

Anwar, M Umair F.C.P.S., F.R.C.S.(Glasg.); Haque, A K. M. Fazal F.R.C.S.; Rahman, J; Morris, R; McDermott, J

Author Information
Plastic and Reconstructive Surgery: January 2008 - Volume 121 - Issue 1 - p 360-361
doi: 10.1097/01.prs.0000300344.42545.e7
  • Free

Sir:

Necrotizing fasciitis is a rare but serious progressive infection characterized by necrosis of subcutaneous tissue and fascia followed by gangrene of the skin. Mainstays of management are resuscitation, antibiotics, and radical debridement. Selective centers also use hyperbaric oxygen therapy in addition to the above, claiming better survival rates, although no large randomized controlled trial of the method exists.1

The Undersea and Hyperbaric Medical Society lists progressive necrotizing infections as one of the indications for hyperbaric oxygen therapy.2 Hyperbaric oxygen therapy refers to treatment in which the patient is placed in a chamber and breathes oxygen at an atmospheric pressure greater than normal.

The physiologic effects of hyperbaric oxygen therapy include increased leukocyte and fibroblast activity, antianaerobic activity, decreased tissue edema, and increased collagen formation.3 Thus, hyperbaric oxygen is useful in the presence of polybacterial synergistic, anaerobic infection and with tissue necrosis due to an extensive disseminated microvascular obstruction within the affected area.3

A retrospective analysis was performed of all patients admitted with a diagnosis of necrotizing fasciitis at Derriford Hospital from 1997 to 2002. Clinical considerations included an unwell patient, local skin discoloration, necrotic soft tissue, blebs, and drainage of murky, grayish (dishwater) fluid from wounds. The finger test (little resistance on subcutaneous finger sweep) was performed on each patient. Wound swabs were obtained for culture and sensitivity. Treatment planning included senior assessment (plastic surgery/ITU/hyperbaric oxygen teams), immediate resuscitation, empiric broad-spectrum intravenous antibiotics (clindamycin plus meropenem), radical debridement (every 24 hours), and hyperbaric oxygen therapy. Antibiotic therapy was reviewed on the basis of repeated cultures. Hyperbaric oxygen treatment consisted of 90 minutes in the oxygen tank at 2.4 ATM starting immediately after the first wound debridement.

A total of 28 patients (20 men and eight women) were admitted with the diagnosis of necrotizing fasciitis (Table 1). Their mean age was 48 years (range, 27 to 77 years). Twenty-six patients had polymicrobial infection. The two monomicrobial cases were due to beta-hemolytic streptococci. On average, four debridements (range, three to seven) were performed. Hyperbaric oxygen treatments were given twice daily. On average, each patient had 13 hyperbaric oxygen treatments (range, eight to 28). The average ITU stay was 6 days (range, 4 to 33 days); the average hospital stay was 13 days (range, 6 to 37 days). The overall mortality rate was 14.3 percent.

Table 1
Table 1:
Presentation, Comorbid State, and Site Involved

Most authorities agree that hyperbaric oxygen is to be recommended in the treatment of necrotizing fasciitis as an adjunct, if facilities are available and there is no delay in surgical debridement.3 However, most studies regarding the efficacy of hyperbaric oxygen are anecdotal, and there is a distinct lack of properly designed, prospective, randomized controlled trials. Then again, there are relatively few articles that disregard hyperbaric oxygen as a valid adjunct in the management of necrotizing fasciitis. The 14.3 percent death rate at Derriford Hospital in patients with necrotizing fasciitis using hyperbaric oxygen compares quite favorably with the death rate of various other studies on necrotizing fasciitis1,4–6 (Table 2). Our study, however, is limited in the sense that there was no control group for treatment without hyperbaric oxygen, because, as a policy, all patients with necrotizing fasciitis receive hyperbaric oxygen therapy regardless of their clinical picture.

Table 2
Table 2:
A Comparison of Various Articles on Necrotizing Fasciitis, Hyperbaric Oxygen, and Mortality Rates

As far as other determinants are concerned (age, comorbidity, antibiotics, anatomic area, operating room visits, hyperbaric oxygen treatment sessions, intensive care unit stay), our sample is comparable to that of other published series.1,3

Although the lack of randomized controlled trials is understandable and significant, the lack of any worthwhile articles negating the benefits of hyperbaric oxygen therapy is even more apparent. Thus, we conclude that, when available, hyperbaric oxygen therapy is a useful adjunct in necrotizing fasciitis.

M. Umair Anwar, F.C.P.S., F.R.C.S.(Glasg.)

A. K. M. Fazal Haque, F.R.C.S.

J. Rahman

R. Morris

J. McDermott

Derriford Hospital

Plymouth, United Kingdom

Bradford Royal Infirmary

Bradford, United Kingdom

REFERENCES

1. Gozal, D., Ziser, A., Shupak, A., et al. Necrotizing fasciitis. Arch. Surg. 121: 233, 1986.
2. The Undersea and Hyperbaric Medical Society. Indications. Available at http://www.uhms.org/Indications.
3. Kindwall, E. P., Gottlieb, L. J., and Larson, D. L. Hyperbaric oxygen therapy in plastic surgery: A review article. Plast. Reconstr. Surg. 88: 898, 1991.
4. Riseman, J. A., Zamboni, W. A., Curtis, A., et al. Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery 108: 847, 1990.
5. Brown, D. R., Davis, N. L., Lepawsky, M., Cunningham, J., and Kortbeek, J. A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy. Am. J. Surg. 167: 485, 1994.
6. Hollabaugh, R. S., Dmochowski, R. R., Hickerson, E. L., et al. Fournier’s gangrene: Therapeutic impact of hyperbaric oxygen. Plast. Reconstr. Surg. 101: 94, 1998.

Section Description

GUIDELINES

Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2008American Society of Plastic Surgeons