Surviving Fournier’s Gangrene Utilizing VAC Veraflo Therapy

Background

• Fournier’s gangrene is a rapid and aggressive form of necrotizing fasciitis of the external genitalia. The reported mortality rate varies, but can range as high as 45%.¹
• Most patients have such a high mortality rate due to multisystem organ failure that occurs from sepsis.
• Aggressive surgical debridement needs to be performed. The resulting large tissue defects usually remain on an already compromised body.

Purpose

• As a wound care coordinator for a 150 bed hospital in a rural area, this case study is meant to share my experience in the management of this deadly infection and its aftermath of tissue destruction using a picture diary.

Methods

• Negative pressure wound therapy with instillation and dwell time (NPWTi-d)* was applied to the wounds on Day 4 after the initial surgical debridement.
• Normal saline was instilled at 3 wound locations and allowed to dwell for 2-minutes, with 2-hour cycles at continuous -125 mmHg.
• For extensive cleansing of thick exudate and wound debris, reticulated open cell foam dressings with through holes (ROCF-CC)† were used.
• For continued cleansing of smaller debris and medium-to-light exudate, NPWTi-d was applied with standard foam dressings (ROCF-V)‡.
• NPWTi-d dressings were changed every 2-3 days, or as necessary.
• Systemic antibiotics were administered for infection control.
• The midline abdominal wound was managed with conventional NPWT§ at -150 mmHg using polyvinyl alcohol foam dressings** and closed by secondary intention.
• The wounds on the left flank, right groin, penis, and scrotum were closed using split thickness skin grafts (STSG) from the left thigh. Conventional NPWT was applied to bolster the grafts over the left flank (-75 mmHg) and right groin (-125 mmHg).
• The penis and scrotum wounds were managed using bacitracin solution-soaked gauze with a foam dressing.

Case Presentation

• The patient was a 67-year-old male, who presented to emergency room 1 week after undergoing robotic hernia repair. Purulent drainage was exuding from the midline incision and pain was radiating from the abdomen to groin.
• The patient was taken to the operating room for surgical exploration and mesh removal after a CT scan showed evidence of infection. An infected hematoma was discovered, and the patient was taken to intesive care unit on a ventilator.
• The patient continually got worse with a climbing white blood cell count, worsening kidney function, and general worsening anasarca. The patient remained on ventilator support, required continuous renal replacement therapy, and was administered multiple intravenous antibiotics. Enteral feeding was attempted.
• I was consulted for moisture-related skin damage to scrotum, which within 2 days became necrotic with crepitus. Urology was consulted and patient was taken to operating room for aggressive debridement at multiple sites due to necrotizing fasciitis (Figures 1A, 2A).
• NPWTi-d was initiated to manage the wound exudate output of 3000cc/day. Total parenteral nutrition was implemented.
• The patient became more stable and tissue granulation occurred rapidly with use of NPWTi-d (Figures 1B-1E and Figures 2B-2C).
• STSGs were applied to all wound sites (Figures IF, 2D). Graft adhesion was at 100% within 10 days of application.
• The patient was discharged to a rehabilitation facility for continued management of his closed wounds.

Conclusions

• Early recognition and aggressive treatment is key to having a positive outcome for this type of patient, no matter where they may be receiving treatment.

Reference
1. Spirnak JP, Resnick MI, Hampel N, Persky L; Fournier’s gangrene: report of 20 patients. J Urol. 1984; 131 (2): 289-91.