What are the treatments for necrosis?

Treatment of Necrosis

The most critical factor for reducing mortality in necrotizing tissue infections is early recognition and urgent operative debridement, which should be performed as soon as possible in patients with tissue necrosis to avoid death. 1

Diagnosis and Assessment

• Necrotizing infections may present with:

  • Severe pain out of proportion to physical findings
  • Signs of systemic toxicity (fever, tachycardia, altered mental status)
  • Rapid progression of symptoms
  • Skin changes (erythema, edema, crepitus, bullae, or frank necrosis)

• Warning signs of severe cases (quick SOFA criteria) 1:

  • Low blood pressure (systolic ≤100 mmHg)
  • High respiratory rate (≥22 breaths per minute)
  • Altered mentation (Glasgow coma scale <15)

Treatment Algorithm

1. Surgical Management (Primary Treatment)

• Radical surgical debridement is the cornerstone of treatment for necrotizing infections 1

  • All obvious transmural necrotic tissues must be resected during the initial operation
  • Reoperation should be undertaken promptly if ongoing necrosis is suspected
  • Multiple debridement procedures may be required until all necrotic tissue is removed

• Specific surgical approaches based on location:

  • For gastrointestinal necrosis: Resection of affected segments with appropriate reconstruction 1
  • For pancreatic necrosis: Step-up approach starting with percutaneous drainage before considering surgical necrosectomy 1
  • For soft tissue necrosis: Wide debridement with removal of all non-viable tissue 1

2. Antimicrobial Therapy

• Broad-spectrum antibiotics should be administered immediately 1
  • Coverage should include gram-negative, gram-positive, and anaerobic organisms
  • Adjust based on culture results when available
  • Continue until there are no signs of ongoing infection

3. Hemodynamic Support and Critical Care

• Fluid resuscitation to enhance tissue perfusion 1

  • Careful crystalloid infusion to avoid abdominal compartment syndrome
  • Monitoring of lactate clearance and central venous oxygen saturation
  • Correction of electrolyte abnormalities

• Physiological restoration is multifactorial 1

  • May require vasopressor support in cases of septic shock
  • Consider damage control procedures in hemodynamically unstable patients

4. Wound Management

• Open abdomen techniques may be necessary after extensive debridement 1

  • Negative pressure wound therapy is commonly used
  • Constant traction on fascia to facilitate closure

• Specialized wound care after initial debridement 1

  • Multiple dressing changes
  • Consider skin grafting or flap reconstruction after infection is controlled

5. Nutritional Support

• Early enteral nutrition (within 24-72 hours) when possible 2
• Feeding jejunostomy is indicated at the end of operation for extensive gastrointestinal necrosis 1
• Parenteral nutrition may be required in cases where enteral feeding is not possible

Special Considerations for Specific Types of Necrosis

Necrotizing Soft Tissue Infections (NSTI)

• Require coordination between surgeons, intensivists, and infectious disease specialists 1
• Multidisciplinary approach is mandatory for management
• Rehabilitation is essential for recovery after extended hospitalization

Mesenteric Ischemia/Necrosis

• For mesenteric venous thrombosis: Continuous infusion of unfractionated heparin 1
• For non-occlusive mesenteric ischemia (NOMI): Focus on correcting underlying cause and restoring mesenteric perfusion 1
• Planned re-laparotomy is essential for reassessing bowel viability 1

Pancreatic Necrosis

• Infected pancreatic necrosis requires intervention, preferably starting with percutaneous drainage 1
• Surgical debridement may be necessary if percutaneous drainage fails
• Consider minimally invasive approaches when possible 1

Pitfalls and Caveats

1. Delayed recognition leads to increased mortality - maintain high index of suspicion
2. Inadequate debridement is a common error - all necrotic tissue must be removed
3. Premature closure of wounds can lead to recurrent infection
4. Overlooking nutritional support can impair healing and recovery
5. Failure to reassess for ongoing necrosis may result in progressive disease

Long-term Management

• Extended physical therapy often required to regain functional independence 1
• Regular follow-up to monitor for complications and recurrence
• Psychiatric evaluation when indicated (e.g., in cases of caustic ingestion) 1

Remember that necrosis represents a true surgical emergency, and the outcome depends heavily on prompt recognition and aggressive surgical intervention combined with appropriate supportive care.