CASE MANAGEMENT, PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON COMPLICATED SKIN AND SOFT TI...
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JONATHAN R. MALABANAN,MD DEPARTMENT OF SURGERY OSPITAL NG MAYNILA PowerPoint PPT Presentation


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CASE MANAGEMENT, PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON COMPLICATED SKIN AND SOFT TISSUE INFECTION. JONATHAN R. MALABANAN,MD DEPARTMENT OF SURGERY OSPITAL NG MAYNILA. C.S. 63M PANDACAN, MANILA. CHIEF COMPLAINT. Swelling, scrotal area. HISTORY OF PRESENT ILLNESS.

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JONATHAN R. MALABANAN,MD DEPARTMENT OF SURGERY OSPITAL NG MAYNILA

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Jonathan r malabanan md department of surgery ospital ng maynila

CASE MANAGEMENT, PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON COMPLICATED SKIN AND SOFT TISSUE INFECTION

JONATHAN R. MALABANAN,MD

DEPARTMENT OF SURGERY

OSPITAL NG MAYNILA


Jonathan r malabanan md department of surgery ospital ng maynila

C.S.

63M

PANDACAN, MANILA


Chief complaint

CHIEF COMPLAINT

Swelling, scrotal area


History of present illness

HISTORY OF PRESENT ILLNESS

10 DAYS PTC  SWELLING AND ERYTHEMA OF THE SCROTAL AREA

PAIN AND TENDERNESS

CRUSTING SKIN LESIONS

(-) CONSULT OMMC OPD

1 DAY PTC INCREASED SEVERITY OF SWELLING , ERYTHEMA, PAIN AND TENDERNESS

FEVER AND CHILLS

(+) CONSULT OMMC SURGERY ER


Jonathan r malabanan md department of surgery ospital ng maynila

  • PAST MEDICAL HISTORY

    - HPN X 20YRS, Metoprolol 50 mg tab BID

    - (+) DM

  • FAMILY HISTORY

    - UNREMARKABLE

  • PERSONAL/SOCIAL HISTORY

    - SMOKER, 25 pack years

    -NON- ALCOHOLIC BEVERAGE DRINKER


Physical examination

PHYSICAL EXAMINATION

GENERAL: CONSCIOUS, COHERENT, NICRD

BP: 130/90 CR= 90RR=24T=38.9 WT= 57 kg

HEENT: PINK PALPEBRAL CONJUNCTIVA, ANICTERIC SCLERA, NO TPC, (-) CLAD,

CHEST/LUNGS: SCE, NO RETRACTIONS, CLEAR BREATH SOUNDS

HEART: ADYNAMIC PRECORDIUM, NRRR, NO MURMUR


Physical examination1

PHYSICAL EXAMINATION

>Perineum: (+) erythematous swelling scrotal area

crusting skin lesion of the scrotum

Tenderness

Foul smelling d/c

DRE: (+) hemorrhoidectomy site good sphincteric tone, tenderness Right anterolateral area


Salient features

SALIENT FEATURES

  • 63/M, DM

    2. (+) erythematous swelling on the scrotal area, crusting skin lesion of the scrotum

    Tenderness

    Foul smelling d/c

    3. FEVER AND CHILLS


Jonathan r malabanan md department of surgery ospital ng maynila

SCROTAL MASS

NON-INFLAMMATORY

NON-INFLAMMATORY

INFLAMMATORY

INFLAMMATORY

TUMOR

TUMOR

RUBOR

DOLOR

MALIGNANT

MALIGNANT

BENIGN

BENIGN

TUMOR

CALLOR


Jonathan r malabanan md department of surgery ospital ng maynila

INFLAMMATORY

UNCOMPLICATED

COMPLICATED

SKIN

-EPIDERMIS

-DERMIS

FOLLICULITIS

FURUNCLE

SSS

SUBCUTANEOUS

TISSUE

SUBCUTANEOUS

ABSCESS

CELLULITIS

NECROTIZING

FASCITIS

FASCIA

PYOMYOSITIS

MYONECROSIS

MUSCLE

MYOSITIS


Clinical diagnosis

CLINICAL DIAGNOSIS


Do i need a paraclinical diagnostic procedure

DO I NEED A PARACLINICAL DIAGNOSTIC PROCEDURE?

NO.

  • I AM QUITE CERTAIN OF MY DIAGNOSIS

  • IT WILL NOT CHANGE MY TREATMENT PLAN


Goals of treatment

GOALS OF TREATMENT

  • RESOLUTION OF INFECTION

  • PREVENT RECURRENCE OF INFECTION


Pre treatment diagnosis

PRE-TREATMENT DIAGNOSIS


Treatment options

TREATMENT OPTIONS


Pre treatment preparation

PRE-TREATMENT PREPARATION

  • PSYCHOSOCIAL SUPPORT

  • SCREENING FOR MEDICAL PROBLEMS:

    - OPTIMIZE PHYSICAL CONDITION OF THE PATIENT

    - ADEQUATE HYDRATION

    - ANALGESICS FOR PAIN AND FEVER


Treatment plan

TREATMENT PLAN:

Emergency Radical Wound Debribement

Parenteral Antibiotic with coverage involving Streptococcus pyogenes

benzylpenicillin 100,000 IU/kg i.v. every 6 hours

And Metronidazole 500 mg Q8

Tetanus Prophylaxis 6,000 units TIM ( ) ANST

Tetanus toxoid .5 ml TIM


Operative technique

OPERATIVE TECHNIQUE

  • Patient supine under SAB

  • Asepsis, Antisepsis

  • Sterile drapes placed

  • Longitudinal scrotal incision carried down from skin to dartos fascia

  • Intraop Findings noted


Intraop findings

Intraop Findings

  • Necrotic tissue

    • Skin

    • Subq

    • Fascia

  • Normal tissue overlying necrotic tissue over the perineal area

  • Foul smelling discharge


Jonathan r malabanan md department of surgery ospital ng maynila

  • Radical debridement done

  • NSS Flushing

  • Correct Instrument, Needle, and Sponge Count

  • Wet to Dry sterile dressing


Treatment

TREATMENT

  • Radical Wound Debribement

  • MEDICAL:

    • Penicillin G 5 M units TIV q6

    • Metronidazole 500 mg Q8

    • Ketorolac 75 mg TIV q8 for pain and swelling

    • Intermediate Insulin


Post treatment diagnosis

POST-TREATMENT DIAGNOSIS

Fournier’s Gangrene S/P Radical Wound Debribement


Course in the ward

Course in the Ward

  • IV antibiotics given

  • Adequate pain control

  • 6 hours post op

    • Arrested


Post treatment care

POST-TREATMENT CARE

  • SUPPLY THE BASIC NEEDS OF THE PATIENT

    • COMFORT

    • ANALGESICS

    • MEDICATIONS – ANTIBIOTICS

    • ADEQUATE SUGAR CONTROL

    • SUPPORT ORGAN FUNCTION

  • MONITORING FOR COMPLICATIONS

  • TISSUE COVERAGE

  • ADVICE ON

    • HOME CARE

    • FOLLOW-UP PLAN


  • Sharing of information

    Sharing of Information


    Fournier s gangrene

    Fournier’s gangrene

    • Polymicrobial necrotizing fasciitis of the

      perineal- 21%

      perirectal-33%

      genital area-45%

      that extend rapidly along fascial planes to involve the groin, thighs, and abdominal wall


    Epidemiology

    Epidemiology

    • According to CDC, 3/10,000 patient’s are diagnosed with Fournier’s Gangrene

    • Sex: M:F of 10:1

    • Age: Mostly <3 months and aged 30- 60 y.o.


    Predisposition to disease

    Predisposition toDisease

    Diabetes Mellitus- 60%

    Chronic Alcoholism-25-50%

    Immunosuppression

    Cigarette Smoking


    Etiology and pathogenesis

    Etiology and Pathogenesis

    • Polymicrobial infection

    • Mixed aerobic and anaerobic bacteria

    • Escherichia coli, Bacteroides, Clostridia, Staphylococci, Enterococci, Proteus and Pseudomonas


    Jonathan r malabanan md department of surgery ospital ng maynila

    • Common colorectal sources of infection

      perirectal, perianal, ischiorectal abscess

      perforation due to inflammatory disease

      neoplastic disease, instrumentation or trauma


    Causes of fournier s gangrene

    Causes of Fournier’s gangrene


    Jonathan r malabanan md department of surgery ospital ng maynila

    • Regardless of portal of entry

      • Local infection causes marked inflammatory reaction that extends to the deep fascial planes

      • Progresses to obliterative endarteritis and local ischemia


    Jonathan r malabanan md department of surgery ospital ng maynila

    • Direction of disease spread determined by the attachments of various fascial planes in the pelvis and perineum

    • Testes, epidydymes, bladder, and rectum are spared from necrosis because of the separate nonperineal blood supply


    Prognosis

    Prognosis

    • Mortality rates ranging from 20-25%

    • High morbidity exists among survivors

    • M/M increase with

      advanced age

      primary anorectal infection

      delayed treatment


    Jonathan r malabanan md department of surgery ospital ng maynila

    shock or sepsis at presentation

    renal failure

    greater disease extent

    DM

    immunosuppression


    Management

    Management

    • True surgical emergency that is rapidly progressive and potentially lethal

    • Once recognized: urgent surgical intervention with aggressive resuscitation

    • High dose parenteral antibiotics


    Jonathan r malabanan md department of surgery ospital ng maynila

    • Broad spectrum antibiotics

      ampisulbactam, ticarcillin/clavulanate, piperacillin/tazobactam, or imipinem, penicilinase-resistant, synthetic penicillin plus clindamycin plus antipseudomonal aminoglycoside


    Jonathan r malabanan md department of surgery ospital ng maynila

    SSSS

    • Staphylococcal scalded-skin syndrome (SSSS) occurs predominantly in neonates and is caused by an exotoxin from phage group II S aureus

    • Punch biopsy with frozen section is useful since the cleavage plane in SSSS is the stratum corneum


    Necrotizing fasciitis

    NECROTIZING FASCIITIS

    • Necrotizing fasciitis is a deep-seated infection of the subcutaneous tissue that results in the progressive destruction of fascia and fat

    • Predisposing factors for the development of necrotizing fasciitis due to Strep. pyogenes include varicella ,penetrating injuries, minor cuts, burns, splinters, surgical procedures, childbirth, blunt trauma, and muscle strain


    Necrotizing fasciitis1

    NECROTIZING FASCIITIS

    •    Type I necrotizing fasciitis is a mixed infection caused by aerobic and anaerobic bacteria and occurs most commonly after surgical procedures and in patients with diabetes.  90% of nec fasc falls into this polymicrobial category.

    •    Type II necrotizing fasciitis is caused by group A streptococcus (GAS, Streptococcus pyogenes).  This is the much feared “flesh eating bacteria” which can progress and cause death within 24hrs.  Approx. 50% of these cases produce TSS toxin.


    Necrotizing fasciitis2

    NECROTIZING FASCIITIS

    • Treatment consists of early and aggressive surgical exploration and debridement of necrotic tissue, antibiotic therapy, and hemodynamic support as needed.

    • In addition, the various types of infection require some specific modalities (such as the use of PCN & clindamycin for suspected GAS infectionà the clinda will block protein synthesis of the TSS toxin).

    • The best indication for surgical intervention is severe pain, toxicity, fever and elevated CPK with or without radiographic findings. 


    References

    REFERENCES

    • Ameh EA, Dauda MM, Sabiu L, et. al. Fournier’s gangrene in neonates and infants. Eur J. Pediatr Surg 2004 Dec. 14 (6): 418-21.

    • Basoglu M, et. al. : Fournier’s gangrene: review of 15 cases. Am Surg 1997Nov; 63(11)1019-21.

    • Capeeli, TS, Schelfeffer M. Gerber GS: The use of hyperbaric oxygen in urology. J Urol 1999 Sept; 162 (3 Pt 1): 647-54.

    • Eke, N. Fournier’s gangrene: a review of 1726 cases, BJS 2000; 87(6): 718-728.

    • Pathy R, Smith AD . Gangrene and Fournier’s gangrene. Urol Clin North Am 1992; 19: 149-62.


    References1

    REFERENCES

    • Pingul, JA, Joson, RJ, Needle Aspiration vs. Surgical Drainage for Uncomplicated cutaneous abscess; OMMC; Manila Philippines


    Jonathan r malabanan md department of surgery ospital ng maynila

    MCQ

    • 1. Staphylococcal scalded skin syndrome

      a. is caused by an exotoxin

      b. is most frequently found in adolescent males

      c. is a toxic reaction to antibiotics used in treating abscess

      d. usually begins around a neglected carbuncle


    Jonathan r malabanan md department of surgery ospital ng maynila

    • 1. Staphylococcal scalded skin syndrome

      a. is caused by an exotoxin

      b. is most frequently found in adolescent males

      c. is a toxic reaction to antibiotics used in treating abscess

      d. usually begins around a neglected carbuncle


    Jonathan r malabanan md department of surgery ospital ng maynila

    MCQ

    • 2. The diagnosis of Fournier’s gangrene is based primarily on:

      a. gas in the scrotal wall which is a sonographic hallmark of fournier’s gangrene.

      b. CT scan which define extent of disease.

      c. clinical findings

      d. scrotal tissue edema on radiographs


    Jonathan r malabanan md department of surgery ospital ng maynila

    • 2. The diagnosis of Fournier’s gangrene is based primarily on:

      a. gas in the scrotal wall which is a sonographic hallmark of fournier’s gangrene.

      b. CT scan which define extent of disease.

      c. clinical findings

      d. scrotal tissue edema on radiographs


    Jonathan r malabanan md department of surgery ospital ng maynila

    MCQ

    • 3. The mortality rate for Fournier’s gangrene range from?

      • 3- 40%

      • 20-25%

      • 5-10%

      • 10-15%


    Jonathan r malabanan md department of surgery ospital ng maynila

    • 3. The mortality rate for Fournier’s gangrene range from?

      • 3- 40%

      • 20-25%

      • 5-10%

      • 10-15%


    Jonathan r malabanan md department of surgery ospital ng maynila

    MCQ

    • 4. Type II Necrotizing Fascitis is primarily caused by:

      • A. Staphylococcus aureus

      • B. E. coli

      • C. Streptococcus pyogenes

      • D. Pseudomonas


    Jonathan r malabanan md department of surgery ospital ng maynila

    • 4. Type II Necrotizing Fascitis is primarily caused by:

      • A. Staphylococcus aureus

      • B. E. coli

      • C. Streptococcus pyogenes

      • D. Pseudomonas


    Jonathan r malabanan md department of surgery ospital ng maynila

    MCQ

    • 5. Infection of the superficial perineal fascia may spread to the penis and scrotum via:

      A. Colles fascia

      b. Scarpa fascia

      c. Dartos fascia

      d. Camper’s fascia


    Jonathan r malabanan md department of surgery ospital ng maynila

    • 5. Infection of the superficial perineal fascia may spread to the penis and scrotum via:

      A. Colles fascia

      b. Scarpa fascia

      c. Dartos fascia

      d. Camper’s fascia


    Thank you

    Thank You


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