D69 to D70

7th to 8th

Use of IV Immunoglobulin and full anticoagulation with unfractionated heparin infusion pump. New fever peak in the first postoperative day, operative wound with hyperemia and drainage of serohematic secretion. Amikacin was added to the scheme with Vancomycin and Meropenem. Patient continues to be feverish and leukocytosis worsens (33,000). Abdominal tomography showed signs of thrombosis in the right gonadal vein, grouped fluid collections with gaseous bubbles permeating next to the infraumbilical anterior abdominal wall musculature, and small accumulation of fluid and densification of adipose planes in the pelvis. Operative wound evolved with necrosis, crepitation and fluctuation. Amikacin is suspended and Polymyxin B is initiated for necrotizing fasciitis.

D71 to D75

9th to 13rd

First debridement of the operative wound, with purulent discharge and muscular involvement (Figure 2). Negative culture of abdominal wall necrosis for coagulase-negative Staphylococcus. Patient stays at ICU in the postoperative period. Polymyxin B, Clindamycin, Vancomycin and Meropenem were maintained, and unfractionated heparin was reinstated. New febrile peak at D6 post hysterectomy, elevation of C-reactive protein and leukocytosis. Operative wound with blisters, exudate and fibrin. Fluconazole is initiated. New worsening of the medical state.

D76 to D79

13th to 16th

New debridement (Figure 3) of operative wound in D9 post hysterectomy showed bullous areas at its borders, rectus abdominis muscle with infiltration, areas of purulent suppuration and accumulation of devitalized tissue at the lower edge of the wound. Retraction of left rectum muscle and removal of left bullous areas was performed until viable tissue was found. Fluconazole, Clindamycin, Polymyxin B, Meropenem and Vancomycin maintained. Intubation is necessary at D11 post hysterectomy. Worsening of the suprapubic and lateral infiltrate of the operative wound, with extension to the left iliac fossa and inguinal region, where areas of necrosis with blisters were found. New febrile peak and worsening of renal function. A dose of immunoglobulin and a new debridement in postoperative D11 were prescribed.

D80 to D86

17th to 22th

Patient returned from debridement in severe septic shock. She was in mechanical ventilation requiring increasing doses of vasopressin and hydrocortisone. Hemodialysis was started. In postoperative D13, new debridement of surgical wound and vacuum dressing exchange. Patient showed hemodynamic improvement, when sedation was paused and vasopressors were suspended. Hemodialysis stopped at D18 after hysterectomy.

D87 to D100

23rd to 40th

Patient is discharged from ICU at postoperative D25, hemodynamically stable and without vasoactive drugs. No signs of sepsis or organic dysfunction were found, and renal function was preserved. She was discharged from the hospital in postoperative D32 (D100 of hospitalization) using warfarin but without antibiotics. Her skin color was modified, with a darker shade than previously (Figure 4).

D101

Patient was discharged in good conditions.