Patient Presentation
Patient S.G., a 52 year old woman presented to outside hospital ER c/o
extreme weakness/lethargy, elevated temperature for past 5 days, and newly
noticed vaginal drainage with foul odor. While she denied any past
medical history, she had not seen an MD since her youngest child was born
12 years earlier. S.G. was “wheelchair dependent” due to decreased
mobility secondary to morbid obesity. Weight on admission was 230 kg.
VS were: temp 40C, BP 92/55, HR 128, RR 34, SaO2 92% on 3L NC. Relevant
labs were: WBC 24, lactate 6, H+H stable at 12 & 36. ABG showed
combined respiratory and metabolic acidosis: pH 7.2, PaCO2 50, PaO2 85,
base excess -14. Additionally, her HbA1C was 9%.
Differential
Suspected sepsis
R/O STI’s
Diagnosis
Patient was transferred to our STICU after wound and blood cultures came
back positive for gram + cocci and S.G. was becoming increasingly
hemodynamically unstable regardless of antibiotics. It was concluded that
the patient had necrotizing fasciitis; initial source was debated, and the
most likely candidate was Staphylococcus aureus, but definitively unknown.
Treatment
Upon arrival to our facility, S.G. was taken immediately to the OR for
massive wound debridement of bilateral upper, inner thighs/groin, perineum
and vagina, as well as lower panniculus. A diverting colostomy was
temporarily placed to promote optimal wound healing.
S.G. arrived in the STICU postop intubated and sedated, hypothermic, and
hypotensive requiring massive fluid resuscitation as well as vasopressors
including vasopressin and phenylephrine. A bear hugger was placed;
insulin gtt was started per hospital protocol. Frequent lab draws were
done to monitor effectiveness of interventions. Continuation of fluid
replacement via fluid warmers, based on both measurable and insensible
fluid loss, as well as aggressive antibiotic therapy was done. S.G.
returned to the OR every other day for a week for aggressive washouts
until attainable at the bedside with wound care RNs.
Outcome
Dressing changes were done q shift using Dakin’s solution and kerlix gauze
packing. S.G. endured 2 weeks in the STICU. Her infection was eventually
controlled and after PICC placement, she was discharged with her colostomy
and scheduled for long term antibiotic therapy, as well as future
colostomy reversal and skin grafting for her wounds. A new diagnosis of
diabetes as well as sleep apnea was made and proper education was
provided.
Case created by Shanna Got, 2011.