CARE STUDY
Management of a patient with
postoperative necrotizing fasciitis
Samantha Holloway, Jonathan Ryder
T
he most common postoperative com-
plication is infection (Emmerson et al,
1996); with necrotizing fasciitis the
patient is at further risk in terms of morbidi-
ty and mortality. The aim of management is
therefore one that achieves a positive out-
come. This case report describes the care of a
patient with an infection following a paraum-
bilical hernia repair.
CASE REPORT
Mrs T, a 69-year-old retired woman, was
admitted to a general surgical ward for an
elective paraumbilical hernia repair in May
2000. Her concurrent health problems
included type II diabetes, hypertension and
psoriasis of the scalp. She was on a combi-
nation of metformin and gliclazide for her
diabetes and nifedipine and aspirin for her
hypertension. She lived alone as she was
widowed within the last year.
Mrs T’s postoperative period passed with-
out any significant complications and she
was discharged home within 7 days of
surgery. However, in a matter of days Mrs T
noticed a foul smell that seemed to be ema-
nating from the wound. She began to feel
cold and shaky, with associated nausea and
vomiting. The community nurse notified the
GP, who arranged for Mrs T’s immediate
readmission to hospital.
On clinical examination the wound was
malodorous and exuding heavily. She was
pyrexic and feeling generally unwell.
Biochemistry investigations were undertaken,
which showed that her serum albumin
was 34 g/l, C-reactive protein was 312 mg/l
(normal range <6 mg/l) and the ESR (erythro-
cyte sedimentation rate) was 85 mm/hr (nor-
mal range 1–10 mm/hr). These results were
all highly suggestive of an infective process,
requiring urgent surgical management.
Mrs T underwent extensive debridement of
gangrenous, necrotic skin and subcutaneous
tissue. The wound was cleansed with hydro-
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Abstract
This case study highlights the care of a diabetic woman who had
previously undergone elective surgery for a hernia repair, and who later
presented with necrotizing fasciitis. The need for a flexible approach
to dressing choice is emphasized, in terms of patient comfort and ease
of management in the community.
gen peroxide and packed with a Betadine
(SSL International) wick. The wound was left
to heal by secondary intention.
Further microscopy investigations revealed
numerous Gram-positive cocci but no leuco-
cytes were seen; a moderate growth of mixed
anaerobes were cultured that were sensitive
to metronidazole. A moderate growth of
Streptococcus spp. was also cultured that
was sensitive to penicillin and ampicillin.
Pathological examination revealed that the
skin, subcutaneous fat and fascia had exten-
sive cellulitis and purulent infiltrate; overall,
the histological evidence was in keeping with
necrotizing fasciitis.
The initial assessment of Mrs T by the
wound care team in the hospital revealed an
open abdominal surgical wound. The wound
bed was both granulating (80%) and
sloughy (20%) with undermining present.
The wound was heavily exuding but the sur-
rounding skin was normal. The wound was
only painful when being dressed.
An alginate dressing (Kaltostat,
ConvaTec) was used to pack the undermin-
ing area. A conforming foam dressing was
then inserted (Cavicare, Smith & Nephew)
to pack the cavity. Initially, six foam dress-
Samantha Holloway is
ings were being used to make the stent and Lecturer, Wound Healing
secondary absorbent pads were used and Research Unit, Cardiff
changed as required. The whole dressing Medicentre,
and Jonathan Ryder
was secured using tape. The stent was is a third-year medical
removed and cleansed twice a day as speci- undergraduate, University
fied in the manufacturer’s (Smith & of Wales College
of Medicine, Cardiff
Nephew’s) instructions.
Mrs T’s appetite was very poor while in Accepted for publication:
hospital and her blood glucose varied as a July 2002
result; at worst it was 2–3 mmols. Her serum
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 CARE STUDY
albumin level was 34 g/l as previously men-
tioned. This is just below normal range;
therefore, a dietitian was asked to review her
and advice was given on an appropriate diet
and nutritional supplements. However, Mrs
T’s appetite remained a considerable problem
during and after discharge.
Mrs T was discharged following 10 days in
hospital. She continued to be followed up in
a specialist wound clinic. At her initial
appointment to the clinic her wound mea-
sured 18.0 cm (length) by 9.5 cm (width) by
4.0 cm (depth), with an area of undermining
of 4.5 cm (Figure 1). The wound bed was
granulating, with a small area of slough on
the base. There was heavy exudate, but the
surrounding skin was normal. A number of
problems were identified on this first visit, by
both nursing staff and the occupational ther-
apist (OT), which are listed in Table 1.
Following identification of these problems
a number of solutions were put into action.
First, it was arranged for Mrs T to see a phys-
iotherapist to help her cope with her mobility
issues. The OT was able to provide a number
of simple aids to help Mrs T around the
house. With the right community support
Mrs T was able to manage at home and main-
tain some degree of independence.
Figure 1. Wound on initial presentation as an
outpatient.
Table 1. Problem identification
Large, open abdominal wound with ulcer surrounding skin
Lives alone, has no local family
Diabetes, difficulty in shopping, preparing and carrying food
Difficulty using stairs/getting in and out of chairs and bed
Unable to perform housework
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Mrs T attended the clinic for 2 months, vis-
iting weekly to have the stent changed (Figure
2). The community nurses initially visited
twice a day, but as the exudate lessened they
were able to reduce this to once daily. Mrs T
did experience some skin irritation on the sur-
rounding skin, for which a barrier product
was chosen (Cavilon No-Sting Barrier Film,
3M). This was applied every 72 hours and
was effective in preventing any further skin
stripping. Figure 3 shows the secondary
dressing in place, secured by a semipermeable
film product (Tegaderm, 3M). At such time
when the wound was considerably smaller in
terms of depth (6 cm length x 5 cm
width x 0.8 cm diameter) an alginate dressing
was used daily (Kaltostat, ConvaTec).
Mrs T continued to attend the clinic
until she moved out of the area, in which time
she showed significant improvement, not
only in terms of wound healing but also
in her general ability to return to some degree
of independence.
DISCUSSION
Mrs T experienced wound dehiscence after
elective surgery for a paraumbilical hernia
repair. This was the result of an overwhelming
infective process. Infection is the most com-
mon postoperative complication and its inci-
dence has been shown to be between 3.5%
and 12.8% of all surgical patients (Meers et
al, 1989), depending on the type of surgery;
abdominal surgery has a 5% rate of infection
(Krukowski and Matheson, 1988). As surgical
Figure 2. Wound showing conforming foam
dressing in situ.
BRITISH JOURNAL OF NURSING, 2002 (SUPPLEMENT) VOL 11, NO 16
 CARE STUDY
wounds are only very briefly exposed to pos-
sible contaminants in a controlled environ-
ment, it is thought that the two main aetio-
logical factors that predispose to wound infec-
tion are the bacterial count and host resistance
(Bennett and Brachman, 1986). Further fac-
tors that may have predisposed this patient to
infection are outlined below and in Table 2.
Predisposing factors to infection
Site of surgical incision: the body’s natural
creases are known as Langer’s lines; cutting
across these lines for access in operations may
have important consequences for healing
(Briggs, 1997).
Length of operation: there is a correlation
between the length of the operation and the
risk of wound infection. Any operation
longer than 2 hours appears to increase the
risk of developing a postoperative wound
infection. Cruse and Foord (1980) found that
for every hour the operation went on, the risk
of infection approximately doubled.
Skin preparation: before making the skin inci-
sion, there seems to be no difference in
wound infection rates between manually
scrubbing the skin for 10 minutes with an
antiseptic soap and using povidone-
iodine/chlorhexidine solution. Alcohol-based
preparations are thought to be better because
they have a more rapid kill factor, but there is
an increased risk of diathermy burns and
damage to mucous membranes (Ayliffe, 1984;
Byrne et al, 1990).
Methods of wound closure: choice of suture
and technique depend to a large extent on the
type of tissue or wound. Since sutures are for-
eign bodies they can set up an inflammatory
response and potentially delay wound healing
(Capperauld, 1989).
Dressings and use of drains: the purposes of
wound dressings and their use on surgical
wounds is to protect the wound from exoge-
Table 2. Predisposing factors to infection
Site of surgical incision (Briggs, 1997)
Length of operation (Cruse and Foord, 1980)
Skin preparation of the operation site (Ayliffe, 1984; Byrne et al, 1990)
Methods of wound closure (Capperauld, 1989)
Dressings and use of drains (Raves et al, 1984)
Washing and bathing after surgery (Gilchrist, 1990)
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nous contamination and to absorb exudate
until the incision has healed. However, there
is no clear evidence to suggest that one
dressing is better than another. The main
benefit of using a wound drain is to elimi-
nate dead space and to prevent haematoma
formation (Smith and Gilmore, 1985).
However, drains can act as direct conduits
for bacteria and could present a further
infection risk (Raves et al, 1984).
Washing and bathing after surgery: once skin
edges have been sealed, bathing or showering
is not likely to present any further risk.
Gilchrist (1990) suggests that a shower may
be preferable to a bath following surgery as
there is less possibility of cross-infection from
a previous user.
Necrotizing fasciitis
Necrotizing fasciitis is a rapidly progressing
soft tissue infection involving the superficial
and deep fascia that leads to thrombosis of
the cutaneous vessels and gangrene of the
underlying tissues (Hancevic et al, 1998). If
left undebrided, it will eventually affect mus-
cle and other tissues via secondary infection
(Neal, 1999). It was first described by
Fournier in 1883 in patients presenting with
scrotal and penile gangrene and as such is
also known as Fournier’s gangrene (Burge
and Watson, 1994). Two types of this infec-
tion occur — one is a polymicrobial form and
the other is a pure group A streptococcal
infection (Neal, 1999).
Figure 3. Secondary dressing in place (some
surrounding skin irritation can be seen).
BRITISH JOURNAL OF NURSING, 2002 (SUPPLEMENT) VOL 11, NO 16
 CARE STUDY
Figure 4. Conforming wound dressing removed,
demonstrating ability to mould to the exact
shape of the wound.
Risk factors for necrotizing fasciitis include
conditions where the immune system may be
compromised, such as old age, diabetes melli-
tus, renal impairment, malignancy, trauma,
chronic skin sepsis, steroid use or use of non-
steroidal anti-inflammatory drugs (Cox,
1999; Neal, 1999). This serious complication
can develop very insidiously. A painful area
on the skin may be followed by numbness as
the nerves are destroyed by the infection. The
KEY POINTS first visual sign may be duskiness on the skin,
progressing to purple areas. Signs of shock,
■ Necrotizing fasciitis
tachycardia and pyrexia may be present
can start in surgical
depending on the degree of toxaemia present
wounds and if left
(Burge and Watson, 1994; Cox, 1999; Neal,
undebrided can affect
1999). The patient in this case study present-
muscle
ed early with a number of these symptoms
and other tissues.
and was treated promptly with wide excision
■ Early diagnosis is of the affected area.
essential so that
treatment can be Effects of diabetes
undertaken as soon The effects of diabetes on wound healing and
as possible, in this immunity are well documented (Anderson et
al, 1980) and may appear as a delay in
case, antibiotic
therapy and extensive wound healing, infection or chronic non-
healing wounds. In this particular case, the
debridement of
affected tissue. patient underwent a planned surgical proce-
dure which was complicated by a potentially
■ Once the affected
life-threatening infection. With prompt surgi-
tissue has been
cal intervention the outcome was satisfactory
excised it is possible
in terms of the patient surviving and the
to manage the wound
wound progressing towards healing.
effectively with
Mrs T had a large, open abdominal wound
a combination
which was healing by secondary intention.
of dressings
The aims of management were to control
to include alginates
excessive exudate and to prevent further
and foams.
infection. A conforming dressing was chosen
because it does not damage granulating or
epithelializing tissue and it has the ability to
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fit the wound dimensions exactly (Figure 4).
In this particular case, a combination of
dressings was used because it was a large cav-
ity, with heavy amounts of exudate and there
was not one particular dressing that could
address all these particular requirements.
However, in terms of patient comfort, man-
agement of exudate and reduced dressing
changes they achieved wound healing.
CONCLUSION
This case highlights the potential complica-
tions that a diabetic patient undergoing what
is fairly routine surgery can experience. The
importance of a multidisciplinary approach to
the patient’s care is significant in terms of the
surgical, dietetic and specialist wound clinic
service required. It also demonstrates the need
for collaboration between the primary care
sector to ensure continuity of treatment. There
also needs to be emphasis on the flexible
approach healthcare practitioners need to
adopt in terms of dressing selection. BJN
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