Ann Thorac Surg 2009;87:1613-1614. doi:10.1016/j.athoracsur.2008.10.019
© 2009 The Society of Thoracic Surgeons
Case Reports
Adjunctive Use of Superoxidized Solution in Chest Wall Necrotizing Soft Tissue Infection
Mahadevan D. Tata, MD*,
Kong C. Kwan, MD,
Mohammed R. Abdul-Razak, MD,
Sharminithevi Paramalingam, MD,
Wing C. Yeen, MD
Division of Cardiothoracic Surgery, Department of Surgery, University of Malaya Medical Center, Kuala Lumpur, Malaysia
Accepted for publication October 10, 2008.
* Address correspondence to Dr Tata, Division of Cardiothoracic Surgery, Department of Surgery, University of Malaya Medical Center, Lembah Pantai, Kuala Lumpur, 59100, Malaysia (Email: madheaven{at}gmail.com).
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Abstract
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A 39-year-old Indian man presented with necrotizing soft tissue infection of his right forearm and previously undiagnosed diabetes mellitus. The infection progressively worsened to involve his right lateral chest wall despite multiple debridements and systemic antibiotics. His right arm was eventually disarticulated along with wide debridement of the surrounding tissue. Aggressive wound debridement, mechanical scrubbing, and irrigation were then initiated every 8 hours. A superoxidized solution was later introduced as a wound irrigant and dressing agent. The large defect was suitable for split-thickness skin grafting after 16 days of a strict wound management routine with the superoxidized solution.
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Introduction
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Necrotizing soft tissue infection (NSTI) is a fulminant condition that usually affects immunocompromised patients with an underlying comorbidity such as diabetes mellitus, arteriosclerosis, AIDS, chronic renal failure, or malnutrition. It commonly affects the extremities, abdominal wall, and perineum, but has rarely been reported involving thoracic wall, head, and neck region [1, 2]. Current standard therapies include broad-spectrum antibiotics, aggressive surgical debridement, hyperbaric oxygen, and supportive intensive care [3]. We describe the adjunctive use of a superoxidized solution (SOS) as part of an integrated management of this condition.
A 39-year-old Indian man with previously undiagnosed diabetes mellitus initially presented to another institution with a small abscess on his right index finger due to an insect bite. Incision and drainage was performed, but the infection progressed proximally towards his elbow. He presented to our hand surgery team 6 days later with persistent pain and swelling of his right forearm. His random blood glucose level was 32.1 mmol/L. A plain roentgenogram of his right arm showed diffuse soft tissue lucency consistent with gas gangrene.
Wound debridement, fasciotomy, and below elbow amputation was done immediately. Three further debridements were done as the infection continued to progress. On day 7, the cardiothoracic team was involved when his right arm had to be disarticulated along with wide debridement of the rotator cuff and chest wall muscles, leaving a raw surface of 40 x 35 cm (Fig 1A). Notably, the patient had been spiking a fever up to 39.8°C daily despite antibiotics coverage with piperacillin-tazobactam and clindamycin based on initial culture result of Escherichia coli and Streptococcus, which were modified later to gentamicin, ciprofloxacin and amoxicillin-clavulanic acid to cover for the Pseudomonas aeruginosa in the wound.
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Fig 1. (A) Infected chest wall wound before usage of superoxidized solution, exposing (a) right pectoralis major muscle and (b) glenoid fossa. (B) Granulating wound ready for skin grafting 16 days after superoxidized solution usage. (C) Postoperative day 6 split thickness skin grafting, remnant deltoid muscle used as a flap to cover the (c) previously exposed glenoid fossa.
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The patient subsequently underwent under a regimented wound care strategy in the intensive care unit (ICU) involving enteral feeding, continued use of multiple appropriate systemic antibiotics, and debridement, mechanical scrubbing, and dressing change under general anesthesia every 8 hours. However, the foul-smelling exudate persisted along with the fever spikes. On hospital day 9, a SOS (Dermacyn Wound Care, Oculus Innovative Sciences, Sittard, the Netherlands) was introduced as a wound irrigant and dressing agent during each session of wound debridement.
Upon removal of the dressing, the wound surface was covered with SOS-soaked rolled gauze for 10 minutes. It was then curetted and underwent mechanical scrubbing before being irrigated with 1 L of normal saline and 0.5 L of SOS in succession. Finally, SOS-soaked rolled gauze was applied with an overlying dry dressing. This was repeated every 8 hours until the wound was granulating well (Fig 1B), leading to skin grafting on hospital day 24 (Fig 1C). The patient was discharged home on hospital day 36. He began to learn to use his remaining nondominant left upper extremity for his activities of daily living.
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Comment
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NSTI of the chest wall normally follows a thoracic surgical intervention [4]. In this case, the primary source of the NSTI was an insect bite on the right finger. Early surgical intervention with wide debridement of all necrotic and infected tissue is critical in improving the outcome [1, 2]. This will leave behind a large defect that can be challenging to manage. The healing process will commence once the infectious process is under control with broad-spectrum antibiotic therapy and diligent wound care along with adequate nutrition and meticulous nursing hygiene.
Broad-spectrum antibiotic and hyperbaric oxygen treatments fail to influence morbidity and mortality [1]. In our center, hyperbaric oxygen therapy was not available. The use of antiseptic agents like povidone iodine and silver sulfadiazine is not desirable due to the narrow antimicrobial spectrum and cytotoxicity against the patient's dermal and epidermal cells. Furthermore, the opaque povidone precludes early detection of underlying infection of the wound bed.
Many studies have reported the use of SOS on humans for various indications, including the treatment of infectious skin ulcers, peritonitis, and intraperitoneal abscesses, and mediastinal irrigation [5–7]. SOS has been shown to have broad-spectrum antimicrobial activity, including bactericidal property against methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. It is tuberculocidal, virucidal against HIV type 1 and human T-lymphotropic virus, fungicidal, and sporicidal, without inducing cytotoxicity, genotoxicity, and dermal sensitization. SOS has been reported to enhance wound healing by reducing the bacterial load and providing a neutral pH environment for healing [8]. After the introduction of SOS in wound care, the patient's fever spikes resolved in the next few days. A concomitant qualitative decline was noted in the bacterial load in the wound culture. The wound began to granulate 9 days after the initial treatment with SOS.
In conclusion, we describe the successful management of a life-threatening chest wall NSTI with a strict and regimented wound care approach that included mechanical debridement and the adjunctive use of SOS. This was in addition to early recognition, aggressive source removal, treatment of the bacteremia, and supportive care in the ICU setting.
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Acknowledgments
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Sincere gratitude to Dyamed Biotech Sdn Bhd, Malaysia, for providing us the Dermacyn Wound Care solution.
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References
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- Inoue Y, Endo S, Kondo K, Ito H, Omori H, Saito K. Trial of electrolyzed strong acid aqueous solution lavage in the treatment of peritonitis and intraperitoneal abscess Artif Organs 1997;21:28-31.[Medline]
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- Andres AG. The science behind stable, super-oxidized water Wounds 2006;18(suppl):7-10.
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Abstract
Introduction
