A rare case of necrotising fasciitis after spinal anaesthesia.

Sir,

Necrotizing fasciitis (NASTI) is a progressive, lethal and often polymicrobial bacterial infection of the fascia and surrounding soft tissue. The risk of infection during regional anaesthesia is very low. We present a case of necrotising fasciitis as a result of E. coli complicating operating room spinal anaesthesia injection.

A 27-year-old female was admitted in the emergency department with severe pain, swelling, erythema and blackening involving nearly whole of the back, part of anterior abdomen and gluteal regions accompanied by fever and chills. The patient had a history of caesarean section delivery for non-progression of labour with fetal distress 20 days back in a hospital near by her residence for which spinal anesthesia was given. There was no history of diabetes mellitus, chronic infections, immunosupressive medications intake and leukemias or lymphomas. She took inj.diclofenac sodium intravenously on 1st post operative day and thereafter switched to oral tablet. On examination, the patients general condition was very poor. Her temperature was 40°C, pulse rate was 130/minute, blood pressure was 84/52 mmHg and respiratory rate was 24/minute. There was extensive deep necrotizing fasciitis of the whole of back and part of anterior abdomen and gluteal regions with gangrene and foul smelling exudates [Figure 1]. Early goal directed therapy (EGDT) for septic shock (1) central venous pressure (CVP) 8-12 cm H2O, (2) mean arterial pressure (MAP) ≥65 mm Hg, (3) urine Output ≥0.5 ml/kg/hr, (4) central venous oxygen saturation (ScVO2) ≥70% was initiated immediately. Central venous cannulation was performed and fluid resuscitation started. Blood sample for cultures were sent. Foley's catheterisation was performed and intravenous antibiotics were adminstered. CVP was measured to be 9 cm H2O. The patient remained hypotensive, tachycardiac and oliguric. Inj.Noradrenaline (2 μg/min) and Inj. Dopamine (16 μg/kg/min) were started and the MAP slowly raised to above 65 mmHg. Laboratory findings showed TLC of 24,000/mm3 with increased polymorphs and hemoglobin of 6.7 g/dl. Serum creatinine was 3.2 mg/dl and blood urea nitrogen was 98 mg/dl. Serum electrolytes showed hyponatremia, hypocalcemia and hyperkalemia. Arterial blood gas analysis revealed metabolic acidosis with pH 7.2. Other laboratory results were normal. Cental venous saturation (ScvO2) was 60%. ECG showed sinus tachycardia at a rate of 120/minute. Chest radiograph was normal. Computed tomography, Doppler ultrasonogram and magnetic resonance imaging were not advised as the patient was critically ill. The patient was shifted to operation theatre and surgical debridement of the devitalised tissues was done under total intravenous anaesthesia (TIVA) with inj.ketamine and inj.midazolam and spontaneous mask ventilation maintained with oxygen. One unit blood and two units of fresh frozen plasma were transfused intraoperatively. The operative findings revealed diffuse necrosis of the skin, fascia and muscles. Wound swab culture and tissue biopsy were sent. The patient was shifted to intensive care unit in the post-operative period. After 12 hours, the patient became drowsy, hypotensive and tachypneic with glassgow coma scale of 7/15. Tracheal intubation was done and ventilatory support was provided. Inj.Dobutamine (5 μg/kg/min) was started and dose of noradrenaline and dopamine was increased. The patient became anuric and hemodynamically unstable. Despite all aggressive medical and surgical interventions, the patient died on the third day of admission in the ICU due to sepsis-induced multiorgan failure. Blood and swab culture report revealed luxuriant growth of E. coli. Histopathological examination confirmed the diagnosis of necrotizing fasciitis with myonecrosis [Figure 2].

Figure 1

Extensive deep necrotizing fasciitis of the whole of back and part of anterior abdomen and gluteal regions with gangrene and foul smelling exudate

Figure 2

Histopathological section showing epidermis and dermis with ballooning degeneration of the epidermal cells and mild neutrophilic infiltration in the dermis

Necrotising fasciitis is associated with high mortality and long-term morbidity.[1] In this case, the use of NSAIDs for post-operative pain would have masked the early symptoms.[2] The development of pain and erythema first at lumbar region shows the route of entry is through spinal injection. Erythema, blister, discharge, necrosis and hemorrhagic bullae may be present. Viral symptoms may be present in the form of chills, fever, myalgia and diarrhea. Late stages may land in multiorgan failure and disseminated intravascular coagulation.[3] Laboratory tests, tissue biopsies and cultures along with appropriate imaging studies may facilitate the diagnosis of necrotizing fasciitis.[4] Treatment includes broad spectrum antibiotics, aggressive debridement of suspected deep-seated infection and supportive measures for the management of septic shock and multiorgan failure. Hyperbaric oxygen therapy and intravenous immunoglobulins have been shown to reduce the mortality.[56] In this case, unfortunately no exact records were obtained regarding the aseptic techniques followed in operating room while giving spinal anesthesia. Other potential source of infection could be contaminated anesthetic solution or syringes.[7] A portal of entry from the patient's skin or from the oropharyngeal cavity of the operating room personnel was suspected based on the studies.[8] Wearing a facemask before entering the operating room and allowing time to ensure effective antibacterial action of antiseptics have been recommended for the practice of regional anaesthesia. Delay in diagnosis and surgical treatment probably ended in mortality in this case. Strict adherence to the principles of asepsis is the foundation of regional anesthesia-related infection prevention.