Revolutionizing Patient Care: Unveiling the Potential of Enhanced Recovery After Surgery (ERAS) Pathway in Enhancing Recovery and Quality of Life for Lower Limb Necrotizing Fasciitis Patients
Authors: Basani Mounika , Chandra J Nemi , Parveen Heena , Manivasagam Sri Saran , Belsariya Vivek , Khuraria Vaibhav , Raju Hinduja , Singamsetty Madhuri , Kordcal Sandeep Rao 
Published: July 2024

Background: A subtype of severe skin and soft tissue infections (SSTIs) known as necrotizing fasciitis (NF) results in the necrosis of subcutaneous tissues and muscle fascia. Necrotizing fasciitis has a 50% death rate in the absence of adequate resuscitation and prompt surgical intervention. Enhanced Recovery After Surgery (ERAS) programs alter the physiological reactions of the body to major surgeries and promote early recovery. The objective of this study is to study the role of the Enhanced Recovery After Surgery (ERAS) pathway in the management of patients with lower limb necrotizing fasciitis in terms of time taken for healthy granulation after radical debridement and negative pressure wound therapy (NPWT) and length of hospital stay. Materials and Methods: A prospective observational cohort study was conducted to include 150 patients with lower limb necrotizing fasciitis, aged more than 12 years, who presented to the Surgery outpatient department of VMMC and Safdarjung Hospital, New Delhi, between January 2022 and January 2023. After a detailed history and clinical, biochemical, and radiological examination, patients were adequately resuscitated and managed according to the ERAS protocol. They underwent radical debridement followed by NPWT dressings in multiple sittings until the formation of healthy granulation tissue. They were regularly assessed by the Bates Jensen Wound Assessment Tool (BWAT) score. Once healthy granulation tissue is formed, wound coverage is done with skin grafting. The primary endpoint of the study was the achievement of early granulation and early wound coverage. Categorical variables were presented in numbers and percentages (%), and continuous variables were presented as mean ± SD and median. The normality of the data was tested by the Kolmogorov-Smirnov test. Quantitative variables were compared using a paired t-test or Wilcoxon signed rank test (when the data sets were not normally distributed) across follow-up within mildly severe and moderately severe groups. A p-value of <0.05 was considered statistically significant. Results: The mean age was 46.63 years. 73.3% of the participants were male, while 26.7% were female. The mean BMI was 22.61 kg/m². The majority of patients (66.70%) had no co-morbidities. 20% of patients were diabetic, and 6.7% were hypertensive. 63.3% (n = 95) of the participants belonged to the ‘Mild severity’ group (BWAT Score: 20 to 30), while 36.7% (n = 55) of the participants belonged to the ‘Moderate severity’ group (BWAT Score: 31 to 40). The mean time for ambulation was 1.17 days. The most common organism in the study population was Staphylococcus aureus (40%), followed by polymicrobials at 26.7%. The mean time for granulation in the mild severity group was 15.68 days, and in the moderate severity group, it was 23.56 days. Ten patients (6.6%) who had wound complications had to undergo amputation as a lifesaving procedure for control of ongoing sepsis. Rest 140 patients got adequate wound coverage. The mean length of stay for the mild severity group was 17.21 days, and the moderate severity group was 24.91 days. Conclusion: ERAS pathways can be safely implemented in patients with lower limb necrotizing fasciitis to improve postoperative outcomes such as reduced length of hospital stay, early wound granulation, reduced wound-related complications, and the need for amputation.