During surgical intervention, the following signs are of greatest importance for the NF diagnosis: grayish necrotic deep fascia, a lack of resistance of normally adherent

muscular fascia to blunt finger dissection (“”Finger test”"), lack of bleeding from the fascia and the presence of dish-water pus [6, 36]. Based on our surgical practice we also recommend an early and very aggressive debridement of all involved tissue that can be easily elevated off of the fascia with gentle GDC-0449 clinical trial pressure or finger spreading. The surgical intervention in which we removed all infected tissue in a single operation, rapidly improved the clinical Smad phosphorylation course of the infection. All deep fascia and muscle should be inspected for potential involvement with streptococcal myositis or clostridium infection. We believe that the mass and the extension of soft tissue that must be initially excised Cell Cycle inhibitor depend on the body region in which the infection appeared. Nevertheless, the extent of debridement should not be needlessly limited because the novel plastic surgical techniques can cover every wound defect

size. Special attention should be paid to the upper and lower extremities, AW with intra-abdominal infection such as secondary peritonitis, and on the CW with persisting sternum infection and mediastinitis [8, 11, 26]. The extent of debridement is very important on the extremities. In cases with compromised viability and compartment syndrome additional fasciotomies of all fascio-cutaneous spaces should be performed [36]. A suspected case of clostridial myonecrosis requires early

surgical exploration and extensive debridement of all involved muscle structures [36]. A tourniquet should be used during the limb surgery to reduce blood loss and offer better examination [36]. The incision proceeds proximally from the infected area in a longitudinal manner, until healthy fascia adherent to the overlying subcutaneous tissue and underlying muscle is encountered. In that moment, the tourniquet should be deflated, the check details wound checked to confirm tissue viability, and then meticulous hemostatis should be performed [36]. Still, controversy exists regarding how much tissue should be initially excised because the skin may often appear normal. Andreasen et al. [22] investigated the normal-appearing tissue microscopically, and found that soft tissue had extensive vascular micro-thromboses as well as vasculitis. Their finding indicated that this tissue, which has a normal external appearance, has a high risk of full thickness necrosis [22]. Poor prognostic indicators for limb amputation very often include old age, peripheral vascular disease and diabetes [36, 44, 45]. Amputation must be obligatory considered if the extent of infection includes a large joint and most muscle groups or if the infection is rapidly spreading towards the torso [36, 46]. Postoperative wound management consists of serial dressing changes, until the wound becomes free of recurrent or progressive skin and soft tissue necrosis.