ICU management of complicated sepsis secondary to necrotizing fasciitis

In this report we present a case of sepsis secondary to necrotizing fasciitis and its complications. case presentation A 37-year-old woman from a Northern Ontario community presented to the nursing station with a 3-day history of gradual-onset swelling and pain in the left arm. Upon arrival the patient was alert, oriented, and had no respiratory, abdominal, or cardiovascular symptoms. She had high-grade fever, chills, and night sweats. The arm was tender and swollen with visible hemorrhagic areas. She is a long-standing IV drug abuser and admitted to missing the vein when she injected drugs 5 days ago. Since then, the patient had noticed reddening of the right arm and complained of flu-like symptoms. Relevant past medical history included intravenous (IV) drug use, hepatitis C positive status, and narcotic abuse. She had a previous MRSA positive nasal swab during a hospital admission and has a documented penicillin allergy (rash). The patient is a tobacco smoker with a 10-pack-year history. A provisional diagnosis of severe cellulitis in the left arm was made. The patient was admitted to the local hospital and started on IV ceftriaxone, IV normal saline, ibuprofen, and acetaminophen. Blood cultures and complete blood count (CBC) were ordered. Over the course of the next 3 days a high-grade fever persisted and swelling of the arm worsened in spite of parenteral antibiotics. She developed hypotension and was noted to have worsening renal function on blood tests indicating acute kidney injury. Intravenous fluid resuscitation was commenced, vancomycin and clindamycin were added to the antibiotic regimen, and the patient was transferred to Thunder Bay Regional Health Sciences Centre (TBRHSC) for further management. Upon arrival at TBRHSC the patient was hemodynamically stable (blood pressure 108/59[75], heart rate [HR] 80+, oxygen saturation 95%, respiratory rate [RR] normal, temperature 35.4˚C) after 6L of crystalloid resuscitation. A provisional diagnosis of necrotizing fasciitis (NF) was made and plastic surgery was consulted. The patient was taken to the operating room (OR) for emergency surgery. Postoperatively she was extubated and admitted to the intensive care unit (ICU) for ongoing care. A broad-spectrum antibiotic regimen using ceftriaxone, vancomycin, clindamycin, and metronidazole was initiated postoperatively in conjunction with morphine for pain control. At admission to the ICU the patient was hypotensive, tachypneic (respiratory rate 20/min), and intermittently confused with poor urine output. Vital signs were blood pressure 112/72, HR 72, and oxygen saturation 94% on 4L nasal prongs. Lactate levels were elevated at 5 mmol/L. Arterial blood gases (ABG) showed uncompensated metabolic acidosis and hypoxemia. Chest x-ray showed bilateral interstitial shadowing with interspersed areas of focal consolidation. Blood cultures from the previous hospital were positive for gram-positive cocci. A diagnosis of septic shock secondary to NF and complicated by acute respiratory distress syndrome (ARDS) was made. In the ICU, IV crystalloids and broad-spectrum antibiotics (ceftriaxone, clindamycin, vancomycin) were continued, a central line inserted and vasopressor therapy with norepinephrine initiated. Within a few hours the patient required intubation and mechanical ventilation for increasing oxygen requirements and work of breathing according to the ARDS Network protocol for protective lung ventilation. ICU management also included correction of electrolyte imbalances and close monitoring of fluid status with central venous pressure and central venous oxygen status measurements.