Monday, June 3, 2019

Necrotizing Fasciitis (NF): Causes and Treatment

Necrotizing Fasciitis (NF) Causes and TreatmentAbstractNecrotizing Fasciitis (NF) is a rare only if severe image of bacteriuml transmittance that affects the soft create from raw material and fascia. Because of how rapidly the infection spreads it has a high mortality rate and the report to a successful recovery is former(a) diagnosing and treatment. Since the discovery of this disorder, little progress has been made to cliff the mortality rate, further emphasizing the importance of health bid providers ability to detect and treat the infection early so that the patient will have a fighting chance. This article will discuss the history, pathophisiology, clinical manifestations, diagnostics and treatments, and interventions as it relates to the Nurse practitioners utilization in caring for a patient with NF.History and BackgroundNecrotizing Fasciitis (NF) is a rare but rapidly progressing inflammatory infection that results in the extensive desolation of soft tissue paper a nd fascia. In the earlier stages of the infection muscle and skin are not touched (Ruth-Sahd Gonzalez, 2006). NF involves the superficial fascia, hypodermic fat (which has nerves and vascular structures) and deep fascia (Green, Dafoe, Raffin, 1996). Thrombosis of the microvasculature derives but there is an absence of myonecrosis (Giuliano, Lewis, Hadsley, Blaisdel, 1977). NF was first described as a complication of erysipelas by Hippocrates in the 5th century B.C. (Descamps, Aithence, Lee, 1994). During the civilian war confederate army surgeon Joseph Jones described it as hospital gangrene in which 46% of the 2,642 soldiers who were infected died from NF complications. The cause of the disease was identified as a bacteriuml infection in 1915. It wasnt until 1952 that the soft tissue infection was named necrotic Fasciitis by Wilson (Wilson, 1952). Cases of NF were sporadically occurring throughout the 19th and 20th century but remained restricted to military hospitals durin g the war with a few outbreaks occurring in civilian populations.EpidemiologyThe centers for Disease control and Prevention (CDC) reported that rates of NF increased worldwide from the mid(prenominal) 1980s to early 1990s. According to the CDC the increases in the rate and severity of NF are correlated with increase in the prevalence of toxin producing strains of S. Pyogenes (M-1 and M-3 serotypes). The CDC reported approximately 600 plates of NF in the U.S. in 1999 (Hu, 2002).Disease progressionNF causes when bacteria enters the carcass usually through a minor trauma for example a laceration, bruise, or bug bite. Some cases occur after surgeries for example abdominal surgeries the bacterium enters the surgical incision. The bacteria attacks the soft subcutaneous tissue releasing toxins that kill the tissue and affect blood carry to the infected area causing it to become gangrenous. If left untreated the skin, fat, muscle sheath, and later the muscle become involved. The infecti on spreads unseen moving up the affected body part at a rate of 3 cen epochters per hour up to 1 inch of tissue per hour (Ruth-Sahd and Gonzales, 2006). Once necrosis of the tissue occurs that area has to be surgically removed. The bacteria seat in addition cause the patient to go into systemic shock, which can lead to hypotension, respiratory failure, renal failure, and emotional state failure. If the infection is severe death can occur within 18 hours (Astorino, Genrich, MacGregor, Victor, Eckhouse, Barbour Barbour, 2009)PathophysiologyTissue destruction is possible once the bacterium has been introduced under the skin via a cut or penetrable wound. The pathogens begin to rapidly multiply spreading from the subcutaneous tissue along fascial planes, and then invading the blood watercrafts and lymphatic system. The bacteria release toxins that decrease the protective tissue factors in order to inhibit the immune systems ability to combat the bacteria. In the bodies attempt to co mbat the bacteria at the tissue level. The blood vessels in the area begin to reservation water due to the effects of the bacteria in the tissue, the immune response becomes hyperactive, which results in blood vessel dilation in order to facilitate the immune response to the area affected. Unfortunately the cells in the tissue begin to die as the blood vessels leak and decrease the oxygen supply to the cells due to the increase in permeability. Since there is a decrease in blood flow and oxygen supply to the tissue from the infection, tissue necrosis and ischemia occur. As tissue necrosis worsens, nerve damage takes place, which can be seen, as the patient will report the decrease or absence of pain at the area affected. As the infection progresses septicemia will also develop (Astorino, et al. 2009).Causative factorsNF is caused by a bacterium named Streptococcus pyogenes or Group A streptococcus (GAS). GAS can be found in peoples throats or on their skin and they will be asympto matic. S. pogenes is a cause for non-invasive GAS diseases for example rheumatic fever, strep throat, and skin infections like impetigo. When GAS travels to areas of the body where bacteria isnt found it is called invasive GAS disease example would be blood or lungs. More than 10 million non-invasive GAS cases occur annually. A rare but most severe case of invasive GAS is NF. These bacterium evolve quickly and scientist believe that GAS makes proteins that cause the immune system to attack the tissue directly thus the body destroys itself (Hu, 2002). NF has been classified into two types based upon the bacterium identified upon culture. Type 1 in a polymicroial infection including both gram-positive and gram- negative bacteria that can be anaerobic or aerobic. Type 1 is the most common, making up 90% of all the cases, striking abdominal or peritoneal tissue. be risk factors include postoperative, advanced age, or diabetes (McGee, 2005). Type 2 also known as the Flesh eating Bacteri a is the rarest out of the two making up about 10% of the cases. It is the most dangerous of the infections usually affecting the arms or legs and involves the Group A (beta)- hemolytic streptococcus with or without staphylococcus aureus. Type 2 does not discriminate on age, race, or sex (Astorino, et al. 2009).Signs and SymptomsEarly detection of NF is crucial it can be the difference between conduct and death. Health care providers need to be knowledgeable about the signs and symptoms of NF so that treatment can be started right away. Initial signs may be subdued and are often confused with cellulitis, signs include pain, edema, erythema, and fever. A definitive diagnosis can be made by visualization and dissection of the necrotic fascia. A key factor of NF is pain, which is disproportionate to the amount of redness. If suspected cellulitis fails to respond to antibiotics within 24-48 hours NF should be considered (Varma and Stashower, 2006). Early symptoms including pain, ma laise, fever, and thirst occur within the first 24 hours of invasion of bacteria. This is the time NF is usually misdiagnosed because progression of the disease is not visible until tissue destruction has already stated (McGee, 2005). Walter (2004) states that the hallmark of NF is erythema that spreads quickly with a margin of redness that extends to natural skin and is not raised. Advance symptoms occur 48-72 hours later and are characterized by significant pain at the wound site, increasing erythema, edema, and warmth. The skin tissue then becomes discolored and deteriorates further. The redness turns to dusky or blue and bullae (vesicles) appear. These bullae enlarge and then rupture leaking out dishwater pus a foul smelling, thin dirty gray watery (Kessenich, 2004) (Ruth-Sahd and Gonzales, 2008). 4-5 days after appearance of the first symptoms patients can begin to demonstrate critical symptoms ranging from numbness and hypotension to toxic shock and unconsciousness. From the re the patient can develop gangrene, sepsis, and then death may occur (McGee, 2005). When the initial symptoms are found it can be difficult to differentiate between NF and celluitis thus it is important to imagine the hallmark of NF. After 3-5 days of onset when there is skin breakdown, bullae, and cutaneous gangrene present which are definitive signs of NF and the involved area is usually not painful due to the are becoming anesthetic secondary to thrombosis of small vessels and nerve destruction located in the necrotic subcutaneous tissue Mandell, Bennett, and Dolin, 2005). testing ground and Imaging StudiesCommon laboratory studies used in diagnosing NF include complete blood cell count with differential (CBC), Electrolytes, Blood urea due north (BUN), Creatinine phoshokinase (CPK), rapid streptococcus test, and a culture and sensitivity. CBC may show an increase in WBC greater than 14,000/ul and the electrolytes may show a atomic number 11 level less than 135 mmol/L, which a re both indicative of NF (Schwartz, 2006). The BUN may also be elevated to 15 mg/ml and the CPK may be elevated, indicating the presence of tissue breakdown. A C S with a Gram stain can determine whether the infection is Type 1 or Type 2, which will help to determine what antibiotics to prescribe. Computed tomography (CT) scan and magnetic resonance imaging (MRI) can be used to help diagnose NF. Ct scans can visualize the subcutaneous air and find the anatomic site of involvement by detecting necrosis with asymmetric fascial thickening (Maynor, 2006). MRI is utile with guided rapid debridement of the wounds.TreatmentIn order to prevent significant disfigurement and/or death in the patient with NF is a quick diagnosis and very aggressive treatment is needed from the start. Broad spectrum antibiotics that treat gram-positive and negative aerobes and anaerobes are prescribed around the clock until the specific strain of the bacteria can be identified and treated appropriately. Due to the amount of antibiotics being administered and possible toxicity involved, Kidney and Liver function should be monitored during therapy. The patient will also need intravenous fluids, pain management, and possibly TPN. All necrotic tissue on the patient needs to be debrided with diligence in removing fascia, skin and subcutaneous tissue involved as early as possible, which may need to be performed multiple times to effectively remove all necrotic tissue. Hyperbaric therapy may be prescribed as an additional therapy.Role of the NPThe NP needs to be able to recognize the early symptoms of NF so that he or she will be able to begin treatment quickly. A collaborative multidisciplinary care approach needs to be used for the care of this type of patient. The care team will need to include Critical/Acute care, Dietitian, Physical therapy, and Wound care Nurse. The patient will need a lot of precept and psychological support as well.ConclusionNecrotizing Fasciitis is a very aggressive an d debilitating disease that has a very rapid progression. Since the disease is very slowly transmitted into the body with the potential of detection not until later stages due to the similarities to cellulitis. Rapid diagnosis and treatment is essential to prevent severe dismemberment and or death. So this makes the Nurse Practitioner working in ambulatory care the first line of defense against this rapidly debilitating disease.

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