Case 10: Rapidly evolving necrotising fasciitis causing death

Plastic Surgery

CASE SUMMARY A 48-year-old woman was transferred from a regional hospital to a major teaching hospital. The patient had fallen at a racetrack, where she had been an employee, the previous day. In the fall, she had sustained a laceration over the anterior aspect of her knee, which was significantly contaminated with dirt, mud and water. She attended a local regional hospital where the wound was washed out under local anaesthetic and then stapled. There was some possible delay in commencing oral antibiotics due to the pharmacy being closed, but she was placed on flucloxacillin at that time. She reattended the ED of the regional hospital the following day with increasing pain, redness and reduced range of motion of the leg. Her pain was significant, and it was noted that there was cellulitis extending to the thigh. She was transferred to the tertiary hospital via the Royal Flying Doctor Service with IV cefazolin being instituted.

Her arrival at the tertiary hospital was at 21:30 that same day. She was seen by an orthopaedic registrar at 23:50 the same evening and was noted to have cellulitis that had spread since her review at the regional hospital, significant pain and reduced range of motion. It was noted in the file by the orthopaedic registrar that she was at increased risk of necrotising fasciitis. Her IV antibiotics were changed to piperacillin/tazobactam. The plan was to keep her fasted and perform a CT scan of the leg in the morning, or earlier if there were worsening signs. Theatre for debridement of the wound was planned for the morning. At approximately 02:30 the morning following admission, there was a medical emergency team call to the ward to address the patient, who had suffered a hypotensive episode and was showing signs of haemodynamic instability. She was resuscitated and then an urgent CT scan was performed, which showed circumferential swelling of the thigh with thickening of the subcutaneous tissues and loss of clear planes between the muscle groups. There was no obvious gas evidence on the scan.

A decision was made to start IV vancomycin, clindamycin and meropenem, and a request was made for a review by Plastic Surgery at 03:00. The Plastic Surgery registrar reviewed the patient and felt that urgent operative intervention was required due to the unstable nature of the patient’s blood pressure and deteriorating vital signs. At 05:00, she was taken to the operating theatre by the

Plastic Surgery registrar and Plastic Surgery consultant. It was noted there was turbid fluid within the lateral leg and anterior knee. In the left lateral thigh, there was a large area of unhealthy fatty tissue and some necrotic fascia. The posterior compartment muscles were dark in colour and there was ‘dishwater fluid noted’. Following the procedure, the patient was transferred to ICU at approximately 09:00. By 12:00 there was a further deterioration in her general condition with blood pressure that needed to be maintained with inotropic support. She had started to develop a coagulopathy, renal failure and abnormal LFT. A review of the wound showed increasing necrosis of the muscles. A further CT scan was performed to ascertain the level of spread of the infection and then at 15:00 she was taken to the operating theatre again by the Plastic Surgery consultant and Plastic Surgery registrar, where a high transfemoral amputation took place. Following this procedure, the patient continued to deteriorate and developed multi-organ failure and metabolic acidosis in the ICU, as well as continuing deterioration in her haemodynamic status. At 04:45 the morning following the first debridement, the patient passed away. Organisms isolated from the wound became noted approximately 12 hours after the first debridement and proved to be predominately Aeromonas species.

DISCUSSION

This patient had a rapidly evolving and deteriorating clinical condition as a result of necrotising fasciitis. There certainly was some initial delay between her first review by the orthopaedic registrar and the first debridement under the care of the Plastic Surgery team but, given the rapid deterioration, it is quite likely that the end outcome would have been the same regardless of the timing of debridement once she had arrived at the tertiary hospital. This obviously is a tragic outcome for an otherwise fit and healthy 48-year-old woman, but it would not appear that any steps in her management had been missed, and it is unlikely that more expedient surgical intervention would have made any huge difference.

CLINICAL LESSONS Given that the patient had been noted to have fallen over into a muddy puddle at a racetrack, which was likely going to be contaminated with more than Staphylococcus, a broader spectrum of antibiotic coverage may have been more suitable. However, it would appear that the transfer of the patient was expedient to the tertiary hospital once the spreading nature of the cellulitis had been noted, and the patient ultimately was in the operating theatre within 5 hours of her arrival at the tertiary hospital for her first debridement.