Modern Concepts of the Diagnosis and Treatment of Necrotizing Fasciitis

Background: Necrotizing fasciitis is a potentially fatal infection involving rapidly progressive, widespread necrosis of the superficial fascia. Objectives: The purpose of this collective review is to review modern concepts of the treatment and diagnosis of necrotizing fasciitis. Discussion: Necrotizing fasciitis is characterized by widespread necrosis of the subcutaneous tissue and the fascia. Although the pathogenesis of necrotizing fasciitis is still open to speculation, the rapid and destructive clinical course of necrotizing fasciitis is thought to be due to multibacterial symbiosis. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is usually polymicrobial, rather than monomicrobial. Although there has been no published well-controlled, clinical trial comparing the efficacies of various diagnostic imaging modalities in the diagnosis of necrotizing infections, magnetic resonance imaging (MRI) is the preferred technique to detect soft tissue infection. MRI provides unsurpassed soft tissue contrast and spatial resolution, has high sensitivity in detecting soft tissue fluid, and has multiplanar capabilities. Percutaneous needle aspiration followed by prompt Gram's staining and culture for a rapid bacteriologic diagnosis in soft tissue infections is recommended. Surgery complemented by antibiotics is the primary treatment of necrotizing fasciitis. Conclusion: Wide, extensive debridement of all tissues that can be easily elevated off the fascia with gentle pressure should be undertaken. Successful use of intravenous immunoglobulin has been reported in the treatment of streptococcal toxic shock syndrome. The use of adjunctive therapies, such as hyperbaric oxygen therapy, for necrotizing fasciitis infection continues to receive much attention.     

The Nurse's Role in Managing Necrotizing Fasciitis

NECROTIZING FASCIITIS (NF), also known as “flesh-eating disease,” is a rapid-acting, potentially deadly infection.THIS CONDITION is devastating in its ability to spread through the body at an alarming rate. It can be caused by almost any type of injury that introduces microorganisms into the subcutaneous tissues.THE INITIAL ASSESSMENT can be deceptive, so awareness is the key to recognition. This condition often goes unrecognized until it is too late or major disfigurement results. Vital nursing strategies for managing the care of patients with NF include early recognition, accurate assessment, and aggressive treatment. AORN J 88 (December 2008) 977–982. © AORN, Inc, 2008.     

D-二聚体与急性肺栓塞预后的关系

[目的]研究D-二聚体（D-D）对1年内的肺栓塞的复发率和病死率的预测价值.[方法]测定71例肺栓塞患者血浆中D-D.并进行1年随访,了解是否出现复发或死亡.[结果]病情程度不同各组间D-D水平有显著性差异（P〈0.001）.直线相关分析显示D-D与复发率和病死率呈独立负相关关系（r=-0.613,P〈0.001） .[结论]D-二聚体水平可以作为急性肺栓塞预后的预测指标.     

危重病人高血糖反应与炎性细胞因子及预后的相关性研究

目的:探讨危重病人高血糖反应与炎性细胞因子及预后的关系.方法:选择65例危重病人,在入院24小时内测定空腹血糖、肿瘤坏死因子-α(TNF-α)、白介素-6(IL-6)水平,随机分成胰岛素治疗组和常规治疗组,追踪观察1个月后疗效.结果:危重病人血糖、TNF-α、IL-6含量明显升高,与正常对照组比较差异有显著性意义(P＜0.01,P＜0.001);与APACHEⅡ计分、预后显著相关(P＜0.01);血糖含量与TNF-α、IL-6水平呈显著正相关(r=0.6256,r=0.5674);用胰岛素治疗组与常规治疗组预后无显著性差异(P＞0.05).结论:对危重病人高血糖反应的处理应采取综合措施,因此拮抗TNF-α、IL-6等炎症因子,提高胰岛素的敏感性是治疗危重病人高血糖反应的关键.     

Point-of-Care Ultrasound Diagnosis of Necrotizing Fasciitis Missed By Computed Tomography and Magnetic Resonance Imaging

Background

Necrotizing fasciitis (NF) is a rare but deadly disease. Diagnosis of necrotizing soft tissue infections can be challenging for a variety of reasons. Point-of-care (POC) ultrasound (US) has been described as a diagnostic tool to help the acute care clinician make the early diagnosis that is imperative to optimize outcomes.

Objective

To report a case of Group A Streptococcus NF recognized with POC US, and subsequent negative findings on computed tomography (CT) and magnetic resonance imaging (MRI).

Case Report

A 54-year-old diabetic woman presented to the Emergency Department with atraumatic right foot and lower leg pain associated with fever. Examination was concerning for NF, and a POC US was performed, which showed thickened deep fascia and fluid tracking along the deep fascial plane, with fluid pockets measuring 6 mm in depth, consistent with NF. Surgical consultation was obtained. Per request, CT and MRI of the patient's lower extremity were performed; both were interpreted by the radiologist as showing changes consistent with cellulitis. Septic shock and multisystem organ failure ensued; the patient was eventually taken to the operating room, where operative findings were consistent with NF. Operative cultures grew Streptococcus pyogenes.

Conclusion

NF is a surgical emergency. Early and accurate diagnosis is critical to ensure the necessary aggressive management needed to optimize outcomes. This case illustrates the utility of POC US to make the prompt diagnosis of NF, particularly in light of subsequently negative CT and MRI.     

高血压脑出血术后脑灌注压与预后的关系研究

【目的】通过研究高血压脑出血术后脑灌注压（CPP）与预后的关系,探讨术后适宜的CPP阈值。 【方法】对87例高血压脑出血手术病人术后CPP进行测定,按CPP值将病人分为3组。其中A组：CPP〈60mmHg;B组：60mmHg≤CPP〈80mmHg;C组：CPP〉80mmHg。术后1个月时对3组病例行GOS评分对预后进行比较。【结果】术后60mmHg≤CPP〈80mmHg的病例组预后要优于其他两组（P〈0．05）。【结论】高血压脑出血术后CPP维持在60-80mmHg阈值范围内的病例预后较好。     

急性肾衰竭220例临床和预后分析

【目的】总结急性肾功能衰竭(ARF)的病因、临床特征和预后的关系。【方法】对本院2000年1月至2003年12月220例ARF患者的临床资料进行回顾性分析。【结果】肾前性ARF为16.4%;单纯肾实质性ARF占56.8%,其中药物引起者占32.8%,病因以氨基糖甙类抗生素多见,碘造影剂占第2位;肾后性ARF高达26.8%。ARF患者病死率为11.4%,6.4%的病人放弃治疗,完全治愈率为40.9%,好转率为41.4%。单因素分析显示:年龄、蛋白尿、器官衰竭数目是影响预后的因素。【结论】小管间质病变和结石梗阻是ARF病人的主要病因,肾前性ARF病死率最高。早期诊断,预防多器官功能衰竭有助于提高ARF患者存活率。     

羊水B超检测法诊断胎儿畸形价值的研究

已知胎儿畸形常伴有羊水增多。本文以B超检测152例畸形胎儿和134例正常胎儿羊水为例,应用拟然比对这一特征提出新的诊断方法。结果表明,羊水最大深度≥80mm,表现出与胎儿畸形的高度相关性。其特异性98.5％,敏感性65.13％,阳性拟然比43.6,阴性拟然比0.35。     

超声定量分析脂肪肝图像与肝功能的关系

目的：探讨肉眼观察超声显示脂肪肝衰减情况及定量测量肝灰阶值反映相对衰减程度与肝功能的关系。方法超声检查90例体检人群；所有检查保证超声调节条件一致；肉眼观察肝脏图像按衰减程度分正常组，轻度脂肪肝，中度脂肪肝和重度脂肪肝；采图后用PHOTOSHOP软件定制直方图取样范围，测量肝深层灰阶值（GSLD）、肝浅层灰阶值（GSLS）、右肾皮质灰阶值（GSK），并计算肝脏浅深层部灰阶比值（GSLS／GSLD）及肝浅层肾脏皮质灰阶比值（GSLS／GSK）反映相对衰减程度；抽血检查谷丙转氨酶（ALT）、门冬氨酸转氨酶（AST）、γ-谷氨酰转肽酶（GGT）。结果所有肉眼观察脂肪肝人群ALT高于正常组；中、重度脂肪肝AST、GGT高于正常组。ALT、AST、GGT与肉眼观察脂肪肝程度呈正相关。ALT、AST，GGT阳性组GSLS、GSK、GSLS／GSLD、GSLS／GS较AL．T、AST，GGT正常组有显著性差异。GSLS、GSLS／GSLD、GSLS／GSK与脂肪肝程度呈正相关。多元回归分析显示，相对衰减程度GSIS／GSLD、GSLS／GS与肝功能关系最大。结论超声图像灰阶测量可用于定量评估脂肪肝。     

原发性高血压左心室肥厚并急性心肌梗死心电图特征与临床近期预后关系

目的：观察原发性高血压左心室肥厚患者首发急性心肌梗死（AMI）时心电图某些指标与临床近期预后的关系。方法：将住院的629例AMI患者分为左心室肥厚（LVH）组（I组），无LVH组（Ⅱ组）和血压正常组（Ⅲ组）进行心电图检查并分析3组心电图特征与临床高危特点。结果：I组心电图指标Ptfv1（心房张末电势）异常，∑ST段抬高振幅，ST段抬高导联数，对应性导联ST段压低振幅，QTc间期延长和室性心律失常及前壁或复合前壁AMI发生率明显增高，与Ⅱ、Ⅲ组比较，差异有显著性（P＜0．05，P＜0．01）。临床并发泵衰竭AMI扩展和住院期间病死率与Ⅱ、Ⅲ组比较也明显增多（P＜0．05，P＜0．01）。结论：原发性高血压LVH患者多项心电图指标异常则其临床近期预后险恶，应积极采取综合措施改善预后。     

超声评价颈动脉硬化斑块与脑梗死的关系

目的 探讨脑梗死与颈动脉粥样硬化的关系。方法 对84例经CT、MBI证实的脑梗死患者和84例非脑梗死患者行超声检查，观察颈动脉内壁光滑程度和有无动脉粥样硬化斑块。结果 84例脑梗死患者中，58例有不同程度的颈动脉斑块形成，发生率68．3％；非脑梗死组84例中有30例，发生率35．7％，两组间有显著性差异(P＜0．05)。非梗死组60岁以上患者有颈动脉粥样斑块者22例，无粥样斑块者25例；60岁以下患者有颈动脉粥样斑块者8例，无粥样斑块者29例，60岁以上组和60岁以下组在统计学上有显著性差异(P＜0．05)。结论 颈动脉粥样硬化与脑梗死有密切的相关性；年龄越大，颈动脉粥样硬化斑块发生率越高。超声检查能早期发现颈动脉粥样硬化，对有效预防脑梗死的发生有重要意义。     

312例急性肾功能衰竭患者的临床特征与预后的关系

[目的]探讨急性肾功能衰竭(acute renal failure,ARF)的病因特点、治疗情况及其与预后的关系,为临床治疗ARF 提供依据.[方法]回顾性分析312例ARF的临床资料,采用逻辑斯蒂回归分析方法分析各种因素与患者预后的关系.[结果]312例ARF中内科病因引起的占55.4%,其次为外科病因,占29.8%,肿瘤病因占10.9%,儿科和妇产科病因所占的比例较低.老、少患者的病死及未愈率之和均高于青壮年(P＜0.05);少尿型、非少尿型ARF死亡及未愈率合计分别为60.1%和34.7% ,两者相比差异有显著性(P＜0.01);无并发症与合并多脏器功能衰竭的ARF病死及未愈率合计分别为43.9%和90.2% ,两者相比差异有显著性(P＜0.01).[结论]内科病因引起的ARF居首位,其次为外科病因和肿瘤;老、少患者,少尿型患者,合并多脏器功能衰竭患者病死率较高;透析可降低ARF患者的病死率.     

Group A Streptococcal Necrotizing Fasciitis in the Emergency Department

Background

Group A Streptococcal (GAS) necrotizing fasciitis is a critical emergency. Patients with necrotizing fasciitis principally present to emergency departments (EDs), but most studies are focused on hospitalized patients.

Objective

An ED patient-based retrospective study was conducted to investigate the clinical characteristics, associated factors, and outcomes of GAS necrotizing fasciitis in the ED.

Methods

Patients visiting the ED from January 2005 through December 2011 with the diagnosis of GAS necrotizing fasciitis were enrolled. All patients with the diagnosis of noninvasive skin and soft-tissue infections caused by GAS were included as the control group.

Results

During the study period, 75 patients with GAS necrotizing fasciitis were identified. Males accounted for 84% of patients. The most prevalent underlying disease was diabetes mellitus (45.3%). Bullae were recognized in 37.3% of patients. One third of cases were complicated by bacteremia. Polymicrobial infections were found in 30.7% of patients. Overall mortality rate for GAS necrotizing fasciitis was 16%. Patients aged >60 years with diabetes mellitus, liver cirrhosis, and gout were considerably more likely to have GAS necrotizing fasciitis than noninvasive infections. Patients presenting with bacteremia, shock, duration of symptoms/signs <5 days, low white blood cell count, low platelet count, and prolonged prothrombin time were associated with increased mortality. Surgery is a significantly negative factor for mortality of patients with GAS necrotizing fasciitis (odds ratio = 0.16; 95% confidence interval 0.002−0.16; p < 0.001).

Conclusions

A better understanding of the associated factors and initiation of adequate treatments will allow for improved survival after GAS necrotizing fasciitis.     

心肌肌钙蛋白-Ⅰ在病毒性心肌炎诊断及预后中的应用

目的 :探讨心肌肌钙蛋白 Ⅰ (cTnI)在病毒性心肌炎诊断及预后判断中的应用。方法 :选择病毒性心肌炎患者 4 2例 ,测定血清cTnI及CK MB(肌磷酸激酶同功酶 ) ,采用超声心动图测定 ,观察心脏大小及心功能变化。结果 :(1)cTnI诊断病毒性心肌炎阳性率显著高于CK MB ;(2 )cTnI≥ 0 .2 5ng/ml患者 ,左室舒张末内径大于cTnI <0 .2 5ng/ml的患者。结论 :(1)血清cTnI作为心肌损伤指标优于CK MB ;(2 )病毒性心肌炎患者 ,血清cTnI水平高低与患者心脏大小以及远期心室功能发展有关。cTnI增高者 ,心脏呈扩大趋势 ,而心室功能测量则呈下降的趋势     

Necrotizing Fasciitis in the Adult Patient: Implications for Nurse Practitioners

Necrotizing fasciitis is a life-threatening skin and soft tissue infection associated with high morbidity and mortality in adult patients. Nurse practitioners in both outpatient and inpatient settings should be vigilant for the hallmark signs and symptoms, such as pain out of proportion to the wound appearance and gray or “dishwasher”-colored discharge from the wound. Prompt recognition of these signs and symptoms, rapid surgical debridement, and early initiation of broad-spectrum antimicrobial management are necessary for optimizing patient outcomes and reducing hospital length of stay, cost, morbidity, and mortality.     

心肌肌钙蛋白—I在病毒性心肌炎诊断及预后中的应用

目的：探讨心肌肌钙蛋白—I(cTnI)在病毒性心肌炎诊断及预后判断中的应用。方法：选择病毒性心肌炎患42例．测定血清cTnI及CK—MB(肌磷酸激酶同功酶)，采用超声心动图测定，观察心脏大小及心功能变化。结果：(1)cTnI诊断病毒性心肌炎阳性率显高于CK—MB；(2)cTnI≥0．25ng／m1患，左室舒张末内径大于cTnI＜o．25ng／m1的患。结论：(1)血清cTnI作为心肌损伤指标优于CK—MB；(2)病毒性心肌炎患，血清cTnI水平高低与患心脏大小以及远期心室功能发展有关。cTnI增高，心脏呈扩大趋势，而心室功能测量则呈下降的趋势。     

应激性高血糖与卒中患者预后的相关性分析

目的:探讨应激性高血糖与卒中患者预后的相关性。方法:选择2008年2月—2011年12月经影像学确诊的328例卒中患者,将其分为应激性高血糖组(201例)和正常血糖组(127例);依据空腹血糖水平又将应激性高血糖组分为3组,A组(7~10 mmol/L)100例,B组(10.1~15 mmol/L)75例,C组(15 mmol/L)26例。分析卒中患者急性期血糖与预后的关系。结果:卒中患者入院时病情越重,其应激性高血糖发生率越高;卒中患者血糖水平越高,病情越重,预后越差(P0.01);应激性高血糖组病死率高于正常血糖组,差异有统计学意义(P0.01)。结论:卒中患者的血糖水平可作为评价病情严重程度、判断预后的指标。早期监测并控制卒中患者的血糖水平有利于保护缺血区的脑细胞。