Anesthetic experience of patients with Fournier's syndrome

Corresponding author: Jun Rho Yoon, M.D., Depatment of Anesthesiology and Pain Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 2, Sosa-dong, Wonmi-gu, Bucheon 420-717, Korea. Tel: 82-32-340-7075, Fax: 82-32-340-2544, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Fournier’s syndrome is defined as a suppurative bacterial infection of the perineal, genital, or perianal regions. Those conditions often lead to thrombosis of subcutaneous vessels and with infection, resulting in the development of gangrene of the overlying skin and subcutaneous tissue [1]. This rare syndrome is a rapidly progressive and potentially lethal necrotizing fasciitis caused by invasive infections of the lower part of the genitourinary tract, anorectal soft tissue, and genital skin [1,2]. The devastating rapidity is typical, as evidenced by the fact that the mean duration of symptoms to become the target of emergency operation is just a few days, and a majority of patients are seriously ill at the time of admission. Anesthetic management of patients with this syndrome is often difficult, due to its devastating nature as well as significant comorbid diseases. However, because of the infrequency of the syndrome, there is limited information regarding the anesthetic management of this disease. We recently encountered the anesthetic management in three cases of patients with Fournier’s syndrome. There were three initial emergency and six additional elective operations under general anesthesia, except one spinal anesthesia in an elective case. Therefore, we report these cases and review the relevant literatures. Immediate and, if required, repetitive operation is important for saving lives in patients with this syndrome [1-3]. Fournier’s syndrome is frequently associated with certain diseases and conditions. Diabetes mellitus is probably the most common comorbid disease, as evidenced by our cases [1]. Even when the patient has diabetes, as in our two patients, Fournier’s syndrome might be the first clinical disease to be detected. The second common condition is alcoholism, such as in all our patients, because any disorder that compromises the immunity enhances development of a severe infection [1,2]. The other associated clinical features are malnutrition, prolonged hospitalization, radiation therapy, chemotherapy, neurologic deficits, cirrhosis, leukemia, renal failure, organic heart disease, vasculitis, intravenous drug abuse, lupus, cirrhosis, AIDS and steroid medications. In obstetric anesthesia, cervical or pudendal nerve block can induce the syndrome as well [1]. Abnormal laboratory results include hyperglycemia, hypocalcemia, anemia, leukocytosis and thrombocytopenia, as evidenced by our patients [1]. Most of those abnormalities are due to sepsis. The systemic manifestations include fever, tachycardia, and volume depletion similar to those of severe peritonitis [1]. All our patients also had sepsis in terms of the preoperative definition. Two patients looked to be in late distributive shock and the other patient in early distributive shock, respectively. In the case of no active bleeding, delayed or inadequate volume resuscitation is a significant error that would have detrimental effects on the patients’s outcome in septic shock. If initial crystalloid fluid resuscitation is insufficient to raise the mean arterial pressure to 65 mmHg and the CVP to 8 to 12 mmHg, then vasopressors and inotropes are needed as the second step in the guidelines of early goal-directed therapy [4]. It is rational to use a blood transfusion when the hematocrit is below 30% when invasive monitoring might be indicated [4]. Among two patients in late septic shock, one patient fortunately responded to our initial fluid resuscitation, whereas the other patient needed dopamine for hypotension. In another patient, early shock occurred, and a blood transfusion and dopamine and norepinephrine were required to achieve an adequate cardiac output and oxygen delivery to maintain vital organ function were needed, because his affected area including