Necrotising fasciitis is a surgical emergency and a life threatening one. If you are reading this because someone at home has severe pain, spreading redness and fever, take them to an emergency department now. This article is for families whose relative has already been admitted and operated on, and it describes what commonly happens during the first week, so that the pace of events and the decisions being made are easier to follow.
Why is surgery done so quickly?
Because the infection spreads along the tissue planes under the skin far faster than antibiotics can act, and because the dying tissue has lost its blood supply, so medicine cannot reach it. The first operation usually happens within hours of arrival, sometimes before all test results are back. Fluids, oxygen and broad antibiotics are given at the same time. Waiting for imaging or for a confirmed diagnosis costs tissue, and the diagnosis is often made in the operation theatre.
Day one and two: the first operations
At the first operation the surgeon opens the affected area and removes all dead and infected tissue until healthy bleeding tissue is reached. The extent is decided by what is found, not by what was visible from outside, and it is frequently much larger than the redness suggested. Tissue samples are sent for culture so that antibiotics can be narrowed to the organisms responsible.
The wound is deliberately left open and dressed rather than stitched closed, because closing it would trap infection. Expect to be told that the wound looks alarming. That is the nature of the treatment and it is not a sign that something has gone wrong. Where the infection cannot be controlled by removing tissue alone, amputation of a limb is sometimes necessary to save life, and the surgical team will discuss this frankly if it becomes likely.
Why are there repeated operations?
Tissue that looked borderline at the first operation often declares itself over the next day, and the infection may have travelled further than was apparent. For this reason the patient is usually taken back to the theatre every day or every second day for re examination and further clearance until the surgeon is satisfied that nothing dead remains. Several procedures in the first week are normal. Each one is a planned step, not a setback, and families should expect to be asked to consent more than once.
What happens in intensive care?
Many patients spend the early days in an intensive care or high dependency unit, because this infection can affect the whole body. Support may include fluids and medicines to hold up blood pressure, oxygen or a breathing machine, dialysis if the kidneys are struggling, close monitoring of blood sugar, and transfusion. Sedation is often used around the operations. Confusion and disturbed sleep are common in this setting and usually improve as the illness settles.
Antibiotics continue throughout, given through a vein and adjusted once culture results arrive. Nutrition is started early, sometimes through a tube, because the body needs a great deal of protein and energy to fight infection and rebuild tissue.
Physiotherapy usually begins earlier than families expect, often while the patient is still in intensive care. Chest physiotherapy helps keep the lungs clear, and gentle movement of joints prevents the stiffness that follows days of lying still. Where a limb is involved, positioning and splinting are used to keep joints in a useful posture while the wound heals. Blood thinning injections to prevent clots and measures to protect pressure areas are also part of routine care during this period.
You will be asked to give consent more than once, because each return to theatre is a separate procedure. Ask what is planned each time and what the surgeon expects to find. If a decision such as amputation is being weighed, ask what the alternatives are and what would happen if it were delayed.
How is the open wound managed?
Between operations the wound is packed or covered with dressings chosen to control fluid loss and protect the exposed tissue. Negative pressure dressings, which apply gentle suction through a sealed dressing, are often used once the wound is clean, since they help manage heavy discharge and encourage healthy tissue to form. Dressing changes may need sedation or anaesthesia because the area is large and painful.
Pain control is planned rather than left to chance, usually with medicines through a vein at first. Tell the nursing staff plainly if the pain is not controlled, particularly if it is rising, since increasing pain can also signal that the infection is advancing again.
When does reconstruction happen?
Not in the first week. Reconstruction is the final stage, not the first, and it begins only once the infection is fully controlled, the wound bed is clean and healthy, and the patient is medically stable. That usually takes weeks. At that point a plastic and reconstructive surgeon plans cover for the defect using skin grafts or flaps, depending on the size and depth of the area and what structures are exposed. Dr. Ashutosh Shah practises this reconstructive work in Surat, and a written estimate is given before planned admission for such surgery.
In the first week it is enough to know that the raw open wound you are being shown is a stage in treatment, and that closing it is a separate operation planned for later.
What should families ask and expect?
Ask for one clear update each day and, if possible, nominate one family member as the point of contact so information is consistent. Useful questions are whether the infection is being controlled, whether another operation is planned, how the kidneys and blood pressure are behaving, whether amputation is being considered, and what the plan is for the next forty eight hours.
Be prepared for the outlook to be uncertain in the early days. Doctors will usually avoid firm predictions because this illness can change quickly in either direction. Progress in week one looks like fever settling, blood pressure needing less support, blood tests improving, the wound edges becoming healthy rather than dusky, and fewer trips to the theatre. Deterioration means more support and more surgery. Ask for the reasoning behind each decision, and ask again if the answer was not clear.
