Fournier’s gangrene (Fournier’s syndrome, multiple bacteria, synergistic Fournier’s gangrene, FG) is an infection-origin disease concerning soft tissues of the perineum, male reproductive organs and perianal soft tissues. As regards classification, it is one of necrotising soft tissue infections (NSTI). It is a type of necrotising fasciitis (NF) with multiple bacteria aetiology. The first description of the disease in literature made by Baurienne in 1764, the more widely known description by Fournier, a Parisian venereologist on the basis of a group analysis of 5 patients dating back to 1883 (1, 2). The disease has a severe, aggressively progressing course and apart from local soft tissue degeneration, it causes direct threat to the life of the patient due to severe inflammation. The new definition of sepsis proposed in 2016 defines sepsis to be a life-threatening organ dysfunction caused by the disturbed systemic response to infection regulation. Its diagnosis criteria were based on the SOFA score (sudden increase in the score by ≥ 2 points in the case of infection or its suspicion) and qSOFA (≥ 2 due to the following symptoms: disorders of consciousness, systolic blood pressure ≤ 100 mmHg, frequency of breathing ≥ 22/min) (3).

Case was presented of a septic shock in the course of Fournier’s gangrene requiring interdisciplinary treatment, in particular treating shock and organ failure under intensive care unit conditions.

A 64-year-old patient admitted to the Surgery Ward of the local hospital on 5 May 2016 due to a fracture near the right wrist. The patient lives alone, poor hygiene observed, injured at home. On examination, a spread cutaneous necrotic lesion was observed in the perianal and perineal area and on the buttocks, huge inflammatory reaction and developing Fournier’s gangrene. History: fracture within the right wrist fixed with a plaster cast, hypertension, type 2. diabetes, depression and chronic pain in the form of lumbar discopathy, treated at the Pain-treating Outpatient Clinic. Condition following a cervical spine surgery. Medium paresis of the upper limbs due to cervical spine discopathy. Temperature up to 39°C.

Additional examination: blood smear proved increase in leukocytosis up to 17.8 thousand/μl, increase in polymorphism (86%), elevated C-reactive protein (CRP 340 mg/d1). Moreover, low level of albumins in the serum was observed (2.5 g/dl) and low level of total protein (4.8 g/dl) and lowered haemoglobin concentration (9 g/dl). Elevated glucose concentration in blood serum (260 mg/d) and slightly increased creatinine concentration (1.8 mg/dl).

Admitted to the General Surgery Ward to treat necrotic lesions within the perineum and the perianal area. Operated on the first day of stay, wide tissue revision of the perineal tissue and necrectomy (fig. 1). Following the operation, due to anaemia, the patient required having erythrocyte concentrate transfused and due to clotting disturbances of freshly-frozen plasma empirical antibiotics therapy was started from the first day of stay by administering intravenously tazocin in the dose 3 x 4.5 g, clindamycin 2 x 600 mg, metronidazole 3 x 500 mg after consulting the hospital epidemiologist. The supply of fluids and oral nutrition were stopped. Central insertion of a needle to the right subclavian vein was performed and parenteral nutrition was started. Glycaemia was controlled with a continuous intravenous insulin infusion. Deterioration in the general condition of the patient observed on the tenth day of stay. Dyspnoea at rest was observed with deterioration in arterial blood oxygenation despite passive supply of oxygen using a face mask with the flow of 4 l/min, arterial pressure dropped, tachycardia observed, perspiring skin of the patient. Following consultation with an anaesthetist, qualified and admitted to the Anaesthesiology and Intensive Care Unit. Transportation from the Surgery Ward to the Anaesthesiology and Intensive Care Unit (AICU) was performed with the help of the anaesthetists’ team. During admission to AICU, deterioration in general condition was observed with acute respiratory failure, which required endotracheal intubation and mechanical ventilation as well as acute circulatory failure making it necessary to perform intensive fluid therapy and pressor amine treatment. General condition of the patient following admission: serious; nervous system: conscious patient, mentally slow with impeded logical contact; circulatory system failure, arterial pressure measured non-invasively 80/40 mmHg, marmoration of the lower limb skin. Function of the heart rhythmic, accelerated with frequency of 126/min; respiratory system failure; dyspnoea at rest, percutaneous saturation of arterial blood SpO₂ 74% at through-mask oxygen supply. On auscultation, over the lung field, acute alveolar murmur, rattling sound on both sides in the basal area of the lungs. Abdomen elevated above the thorax, soft, no pathological resistance, peristalsis audible, quiet. Diuresis supported with furosemide in fractions, oliguria. Skin: on the post-surgery skin of the perineum, wide incisions of the skin and subcutaneous tissues dressed. Lower limbs with trophic lesions from the groin to the knees. Having been admitted to AICU, the patient was informed about the proposed plan of treatment. The patient expressed consent to the proposed procedure in the presence of witnesses, was unable to sign the consent for treatment at AICU in person. Following propofol sedation, respiratory tract of the patient in direct laryngoscopy visualised and intubated, then the patient was under a respirator, mechanical ventilation started in the mode of pressure controlled synchronised intermittent mandatory ventilation – SIMV/PC + PSV, at the beginning with 100% oxygen concentration in the inhalation mixture FiO₂ 1.0, later lowered to FiO₂ 0.4 under the control of arterial blood gasometry testing. Aspirate from the respiratory tract, urine and peripheral blood collected for culture. Antibiotics therapy modified taking into account the present results of culture. Midazolam and morphine sedation applied. Due to low arterial pressure values, intravenous, continuous norepinephrine infusion applied by dosing the infusion depending on the arterial blood pressure level to reach mean systemic arterial pressure above 65 mmHg. A follow-up radiological image of the thorax performed to make visible the progression of parenchymal lesions in the right lung. After a few hours the circulatory system stabilised, invasive arterial blood pressure measurement at the level of 140/70 mmHg. Furosemide-supported diuresis in a continuous intravenous infusion on the first day of treatment at AICU 2220 ml. Fluid balance – 170 ml. Patient had no pyrexia. In gasometry – high values of pCO₂ despite increasing the minute mechanical ventilation. Mechanical ventilation stopped on the 8^th day of treatment at AICU. Pharmacological circulation support stopped on the 9^th day of treatment at AICU. Intravenous nutrition treatment continued for two weeks of stay at AICU and the following three weeks of treatment at the General Surgery Ward. While treatment at AICU, general condition of the patient improved as well as the local condition of the wound in the perineal and perianal area. Patient in a general good condition, conscious, respiratory and circulatory efficiency, on the 12^th day of treatment at AICU transported to the Surgery Ward to continue treatment. Currently, the patient is awaiting a surgery, post-surgery wound reconstruction (fig. 2).