A 50 year old female presented to Emergency Department (ED), with a large area of cellulitis to abdominal apron spreading towards umbilicus, malodourous and purulent exudate.
Hx: Bells palsy, T2DM – previously diet controlled, High BMI 140kgs, Current smoker,
Social Hx: Married with children – supportive family, Full time work in public service.
Medical team query abdominal wall abscess and sepsis. Further investigations to define diagnosis – CT abdominal, blood cultures and wound swab. Commenced IV Flucloxacillin. General Surgical review – possible Necrotising Fasciitis.
Diagnosis of necrotising fasciitis, patient was sent to operating theatre (OT) for; abdominal wall wound debridement and washout for right lower abdominal necrotising fasciitis.
OT report nil extension to muscle.
Day 1 post-op, Tissue viability unit (TVU) was contacted to review patient. Wound assessment: Size 18cm x 3cmx 6cm Sinus at 9-10 O\’clock position 10cm depth. Area 84cm2.
10cm depth granulation tissue with fascia to abdomen. Moderate haemoserous exudate, periwound normal – blanching. Nil malodour. The patient reported moderate amount of pain experienced currently.
Decision was made with inclusion of the patient and medical team. Commencement of Negative Pressure Wound Therapy with Instillation and Dwell (NPWTi-d) V.A.C VERAFLO with 0.9% normal saline instillation solution, dwell time of 10 minutes, cycle frequency of 3.5 hours and NPWT setting of -125mmHg. This dressing regime was continued for 4 days, and then step down to VAC dressing with granufoam with NPWT – 125mmHg.
- Day 6, TVU review, output in NPWT canister remains high (300mls) haemoserous in 24hours, large NPWT Ultra VAC device still required. Dressing remained intact. Patient pain management under control with paracetamol.
- Day 7, TVU review, output in NPWT canister low (50ml) haemoserous, wound measurements 17cm x 2cm x 4.5cm, sinus at 9-10 o’clock position 4cm depth = area 40cm2.
Discharge plan: Transfer home. Community nurse referral to continue NPWT dressings using Activac with granufoam, therapy settings continuous, -125mmHg.
Day 54 (6 weeks post-op) NPWT ceased in Outpatients department.
Results: Inpatient NPWTi-d for 4 days + NPWT for 3 days = reduction in wound area of 44cm2 (52%). Hospital inpatient stay 7 days with nil readmission to theatre or readmission to emergency department (ED) after transfer home into the community.
• NPWT in community 47 days – Wound healed.
Clinical Outcomes/ Conclusion:
Patient presented promptly upon symptoms.
- Timely assessment and diagnosis of Necrotising Fasciitis.
- Collaboration of multi-disciplinary team.
- Early commencement of IV antibiotics.
- Surgical debridement prior to commencement of NPWTi-d.
- Cost of inpatient care estimated $1,123 per day (products and hospital stay).
- Cost of community care estimated $140 per day (products and nursing visits).
- Prompt and suitable wound management plan using npwti-d to reduce hospital length of stay and facilitate earlier discharge with lower cost of care.