Initial and Preoperative Management

If there is doubt about the diagnosis of Fournier's gangrene, imaging and laboratory studies maybe requested, but this should not delay definitive surgical management.

The cause of the infection should be established, bearing in mind that urogenital causes (urethral stricture) and anorectal infections are the most common etiological factors. Passing an F16 transurethral catheter should exclude or confirm a urethral stricture, and painful digital rectal examination may indicate an ischiorectal abscess. If rectal examination is too painful, it can be performed in the operating room with the patient under anesthesia, just before debridement.

Aggressive fluid resuscitation with crystalloid or colloid fluids is essential to optimize the hemodynamic status in these volume-depleted, septic patients.

Anemia should be corrected to a hemoglobin greater than 10 g/dl. Coagulopathy (raised international normalized ratio [INR], PT and PTT, or platelets <100,000) should be diagnosed preoperatively and platelets should be given intraoperatively if the patient is severely thrombocytopenic. Diabetic patients usually have severe hyperglycemia, which should be corrected with a glucose-insulin sliding scale. Electrolyte abnormalities must be corrected as far as possible, without incurring unnecessary delay of surgical debride-ment.

Antibiotic therapy must be initiated promptly, after appropriate specimens have been obtained for bacteriological culture. High-dose, broad-spectrum parenteral antibiotics covering Gram-positive and Gram-negative aerobe as well as anaerobe organisms should be used (Baskin et al. 1990; Paty and Smith 1992; Hejase et al. 1996; Smith et al. 1998). Aminoglycosides and third-or fourth-generation cephalosporins are effective against Gram-negative bacteria, metronidazole against anaerobic infection, and penicillins against Gram-positive bacteria. Usually combined use of three antibiotics, one from each of these groups, is clinically effective. However, to ensure adequate cover against enterococci, some groups advocate the combined use of the ureido-penicillin piperacillin with the beta-lactamase inhibitor tazobactam. It is important to note that antibiotics will not penetrate ischemic and necrotic tissues, and therefore serve only as an adjunct to definitive surgical management (Baskin et al. 1990). Tetanus toxoid should also be given to all patients (Laucks 1994).

The onset of septic shock is heralded by signs such as altered sensorium, hypotension, hypoperfusion, oli-guria, and lactic acidosis. Multiorgan failure should be anticipated and prevented by aggressive fluid management and invasive vascular monitoring. A mean arterial pressure over 65 mmHg and a central venous pres sure (CVP) of8-12 cmH2O should be maintained. The mainstay of management is to optimize oxygen delivery by striving to:

• Keep oxygen saturation above 90 % using an oxygen mask, continuous positive airway pressure (CPAP) or mechanical ventilation Optimize cardiac output by improving the heart rate and stroke volume, using sympathomimetics and volume expansion

Optimize oxygen transport by using packed red cells to maintain a hemoglobin above 10 g/dl

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