question 55

GAS GANGRENE. PATHOGENS, CLASSIFICATION,

CLINIC AND DIAGNOSTICS, MODERN PRINCIPLES
OF TREATMENT. PREVENTION OF ANAEROBIC
INFECTION.
 GANGRENE
Gangrene is one of the forms of
necrosis, predetermined by
infringement of blood circulation and
the development of dead tissue. The
most often reason for the
development of gangrene is acute or
chronic arterial insufficiency.

Dry, or coagulative, and humid(wet)

gangrene are distinguished.

 DRY GANGRENE
Dry gangrene affects the extremities more often. It is characterized by fast drying of dead tissue without infection and
it appears mummification of dead tissue. The tissue quickly becomes dehydrated and dries up, turning brown or blue-
black.

The necrosis process is limited and usually does not progress. Histologically in the tissue coagulative necrosis with the
disintegration of the cellular nucleus, erythrocytes, leukocytes and settlement of protein in the plasma is marked.

Clinically in the initial stage, strong ischemic pains in the extremities more distal from the damage, as a rule, are
observed. The extremity becomes pale and is cold to the touch; the skin gradually gets a marble look.

Superficial and deep sensitivity becomes dull and then completely disappears; the function of the extremities is
broken. Pulse on the peripheral arteries is not determined. If at the same time with occlusion of the main vessel there is
resistant spasm of the collaterals, the necrosis zone becomes more extensive. Further a demarcation shaft, which limits
the living tissue from the dead ones, develops.

The dead tissue comes off, and at the demarcation line the connective tissue cells multiple, the leukocytes accumulate
and granulations form. The border between the alive and dead tissue goes deeper, untill the necrotic area rejects, after
which there is a granulating wound, which slowly heals. As a result of the mummification of dead tissue during dry
gangrene, absorption of toxic substances of tissue disintegration is not significant and intoxication does not occur. The
general condition of the patient is good.

 TREATMENT
In order to prevent the occurrence of local complications, the infection of dead tissue and the transition of dry
gangrene into humid during redressing, it is necessary to strictly follow the rules of aseptics.

The extremity is immobilized, dry bandages are applied, physiotherapeutic procedures (quartz irradiation) are
conducted. Necrectomy, i.e. surgical removal of necrotic tissue, as well as amputation of the extremity is necessary
to postpone until the occurrence of a demarcation shaft is in full view.

If gangrene is caused by direct damage of tissue, necrectomy is necessary to conduct behind the demarcation line.

If gangrene developed as a result of infringement of arterial blood circulation, the amputation of the extremity is
conducted considerably more proximal, i.e. within the borders of absolutely viable tissue with good blood supply.

In order to prevent the development of dry gangrene, early diagnosis and treatment of blood vessels diseases,
which can lead to the development of necrosis and gangrene (thromboses, obliterating endarteritis and
atherosclerosis) have crucial importance. It is necessary to improve blood circulation, promote the development of
collaterals, and liquidate the spasm of blood vessels. It is necessary to conduct in due time reconstructive
operations on vessels to normalize the blood supply of the extremities.

 WET GANGRENE
Humid gangrene is also a kind of necrosis. It develops mainly in obese, pastous patients as a result of acute infringement of blood
circulation. Purulent or putrefactive infection frequently accompanies humid gangrene. The development of humid gangrene is also
promoted by hypostases, which results from cardiac failure, renal diseases and diabetes.

With humid gangrene, the dead tissue does not dry up and become a good nutrient medium for infection. Putrefactive (protruding)
disintegration of tissue develops, which is quite often accompanied by anaerobic infection (gas gangrene).

When the dead tissue breaks up, it turns into a wet dirty mass of grayish-green color with an unpleasant odour. Intensive absorption
of the disintegration products, which quickly results in severe intoxication leading to the death of the patient, is observed. With
humid gangrene the demarcation line is not formed, the process spreads quickly to the external tissue. The extremities become
pale, cold to the touch and then cyanotic-red dots appear; the epidermis exfoliates and blisters, filled with bloody, stinking
exudate, form; hypostasis of tissue sharply increases. Severe pain occurs in the damaged extremity. The mentioned above local
phenomena are accompanied by systematic intoxication. The patient’s face becomes grey; tongue is dry; pulse is of weak filling and
pressure; the arterial pressure is low, complete apathy and high temperature of hectic origin is observed.

The course of diabetic gangrene is especially severe. Patients with diabetes have decreased resistancy and tissue regenerative
properties and increased susceptibility of an organism to pathogenic organisms of pyo-septic infection. Because of this, patients
with diabetes easily get secondary inflammations, and the wounds regenerate very badly. Humid gangrene can damage different
organs and as a result the clinical picture is diverse. It depends upon the type of tissue, the character and localization of the
damaged organ. Gangrene of internal organs occurs only as humid gangrene and is accompanied by symptoms of peritoneal
irritation and peritonitis development. Pulmonary gangrene has its own clinical signs.

 TREATMENT
The treatment for humid gangrene is directed on fast elimination of damaged cells, struggle against intoxication and
infection, correction of metabolism infringement.

Necrectomy with humid gangrene is not effective because it does not improve the patient’s condition, does not liquidate
the source of intoxication.

With gangrene of the abdominal organs, emergency laparotomy, the removal of the damaged organ and sanitation of the
abdominal cavity, is done.

Broad-spectrum antibiotics, sulfamidin and nitrofuran preparations, antiseptics, vaccines and serum, immunomodulators
are applied to struggle against infection.

For struggle against intoxication all the available methods of intra- and extracorporal detoxification are used: introduction
of great amount of crystalloids (isotonic solution of sodium chloride, 5–10% solution of glucose), haemotransfusion,
plasma, albumin, haemodesum and other blood substitutes, lactosol, low-molecular polyglucin in combination with
cardiac and diuretic substances (technique of forced diuresis).

It is necessary to apply also haemosorption, plasmosorption, ultra-violet irradiation of blood (UVIB).

Along with the therapist-endocrinologist, correction of the carbohydrate metabolism disorders are conducted for patients
with diabetes.

 GAS GANGRENE
Gas gangrene/muscle necrosis (clostridial myonecrosis, gas gangrene)

1. Etiology

1) C. perfringens (80%)

2) Cause: trauma (especially deep muscle laceration), surgery, intramuscular

injection

3) Risk factors: DM, leukemia, chemotherapy, radiation therapy, AIDS, etc.

immunosuppression

2. Clinical features

1) Incubation period: Short (less than 3 days, usually within 24 hours).

2) Sudden pain at the wound site, which turns pale after the onset and causes
swelling

3) Afterwards, dermal gangrene and muscle necrosis, copper-colored induration

and discoloration of the lesion, formation of bluish-brown bullae, and necrosis to
the fascia cutaneous n. Pain can be lost due to necrosis

4) Crepitus , foul smell from the lesion

5) Shock, renal failure, consciousness disorder and death if further progress

6) Mortality : morethan 50%

 GAS GANGRENE
3. Diagnosis

1) Gram staining of exudate: many gram (+) rods, few inflammatory cells

2) frozen-section biopsy of the affected muscle

3) X-ray: Detect gas in muscle and subcutaneous tissue

4) Surgical exploration: m/i, treatment is possible at the same time

4. Treatment

1) Surgery: debridement (m/i), amputation in severe cases

2) systemic antibiotic penicillin (resistance increase)， clindamycin, clindamycin+penicillin G

3) The effects of hyperbaric oxygen and antitoxin are controversial.

※ Deep infection or necrotizing fasciitis, similar to necrotizing fasciitis, is distinguished by necrosis only to the fascia, while gas gangrene invades the
dermal muscle and necrotizes the muscle as well.

THANK YOU