Necrotising fasciitis is a rapidly progressing infection of the skin and can cause extensive necrosis of the fascia and subcutaneous tissue leading to severe systemic toxicity, and the importance of early aggressive surgical intervention has been noted1,2. Postoperative management of the surgical wound is important for the patient’s survival, along with proper nutrition2. Chronic wounds impose huge cost, both financial and personal3,4.
This case study documents the wound care of a 43yr old man facing significant personal challenges. His previous medical history includes alcohol and substance dependency, epilepsy secondary to head injury, depression, deliberate overdose, and he is hepatitis C positive. He had a 2½ year history of extensive lower leg wounds following surgery for necrotising fasciitis.
The patient had originally been in compression but this was discontinued when friction and shear on the uneven, delicate post-surgical granulation tissue and underlying dermal tissues resulted in bleeding. Wounds within the folds in the skin were particularly challenging (Fig:1&2) when making primary dressing choice. AQUACEL® Extra™ dressing was chosen to fill the cavity of the deeper wounds with AQUACEL® Foam dressing as a secondary cover dressing. For shallow areas of tissue breakdown AQUACEL® Foam dressing was applied as the primary dressing.
Initial findings were that exudate reduced after the first week and bleeding ceased. After three months compression therapy recommenced and improvement continued through to full healing.(Fig: 3) Ankle measurement reduced from 33cm to 27.5 and calf 55cm to 46cm. Once compression therapy was discontinued supportive bandaging was applied until hosiery was fitted. For long term prevention of recurrence, made to measure flat knit hosiery was provided.(Fig: 4) Achieving wound healing has had a significant impact on the patient’s life. As the exudate and wound size reduced he became motivated to making lifestyle changes. Alterations to his diet and increasing his exercise resulted in losing 3 stone in weight. Medication has been reduced meaning he isn’t so sleepy and speech is less slurred.
Primary dressing choice was important to deal with the local wound problems. AQUACEL® Extra™ dressing filled the cavity with direct contact on the wound bed to minimise voids where bacteria can grow and AQUACEL® Foam dressing was gentle and conformable for the more shallow area of wound. Both dressings contain Hydrofiber® technology which absorbed and retained exudate resulting in protection for the peri wound area. Compression therapy was an important element of the management plan and the patient is committed to continuing this long term. As the wound progressed towards healing and the leg reduced in size (Fig: 3), the patients mobility improved which helped keep the patient concordant with the treatment plan. Anecdotally patients with chronic wounds can become less concordant and motivated if they do not perceive results in line with their expectations. Commitment from the patient helped the clinician to facilitate long term compression therapy.(Fig: 4)