Necrotizing Nightmare to Closure without Grafting

Necrotizing fascitis, also known as "flesh eating disease", is an infection that can progress quickly and develop tissue necrosis at the fascia level.  A 54 year old patient with hypertension, hyperlipidemia, chronic back pain and methadone use was admitted to the hospital with a severe infection of the right forearm and hand related to a bee sting. He had been trying to manage the wound for a week.  He was in significant pain and had to be pre-medicated prior to dressing changes.  On initial evaluation, the wound had been debrided by the orthopedic surgeon the day before and was still highly exudative, malodorous with necrotic tissue present.  NPWT was initiated at bedside to manage the exudate, pain and edema.  Within 24 hours the pain, edema and odor had improved.  The culture result was beta-hemolytic streptococcus and the patient was taken back to surgery for two additional surgical debridements.  Excision of necrotic tissue produced muscle, multiple tendons from the elbow to the dorsal and volar surface of the right hand.  NPWT was applied in the operating room with the use of the silver nonadherent contact layer and normal saline impregnated foam. Application of the dressings at bedside were tolerated well.  He was discharged to a wound care center for three times a week dressing changes.  With the participation of the patient with dressing changes and the use of the nonadherent contact layer and foam, the patient was able to tolerate the dressing changes without the use of topical anesthesia.  Aided by an interdisciplinary team consisting of occupational therapy, orthopedic surgeon, physician assistant, nutritional counseling, certified nursing assistant and the WOC nurse, the wound was closed without the use of skin graft or skin substitutes within three months with the use of the NPWT.