VA Resident Report: Review of Fournier’s gangrene

The Bottom Line: Fournier’s gangrene is a progressive necrotizing soft-tissue infection (NSTI) of the external genitalia and/or perineum. It is a urological emergency requiring prompt diagnosis and treatment — even with administration of parenteral broad-spectrum antibiotics and expedited aggressive surgical debridement, the disease can be fatal.

References: Hagedorn, J., & Wessells, H. (n.d.). A contemporary update on Fournier’s gangrene. Nature Reviews., 14(4), 205-214.

Summary: A high level of suspicion with prompt resuscitation and surgical intervention are the key for optimizing patient outcomes. For equivocal cases, several diagnostic tools, including laboratory tests and imaging, have been developed to be used in conjunction with physical examination findings. Most infections are polymicrobial, requiring broad-spectrum antibiotics and wide surgical debridement. Wound preparation with dressing changes and further debridements are essential for successful reconstruction once the local necrotic process and systemic infection has been treated.
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Use of beta blockers in patients undergoing noncardiac surgery

Excerpt from “2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines.”

“Class IIb
In patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification tests, it may be reasonable to begin perioperative beta blockers (225). (Level of evidence: C)

Class IIb
In patients with 3 or more RCRI risk factors (e.g., diabetes mellitus, HF, CAD, renal insufficiency, cerebrovascular accident), it may be reasonable to begin beta blockers before surgery (248). (Level of Evidence: B)”

For a discussion of the controversy involving administration of beta blockers to patients undergoing noncardiac surgery, see the following article.

Friedell, Mark L, et al. “β-Blockade and Operative Mortality in Noncardiac Surgery: Harmful or Helpful?.” JAMA surgery (2015)

Guideline:
Fleisher, Lee A, et al. “2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines.” Journal of the American College of Cardiology 64.22 (2014):e77-137.