High-frequency generator in the treatment of necrotizing fasciitis in a person with diabetes

1.Prefeitura de Sorocaba – Sorocaba/SP – Brazil 2.Universidade Estadual de Campinas – Programa de Pós-Graduação da Enfermagem – Campinas/SP – Brazil 3.Universidade Vale do Rio Verde – Curso de Enfermagem – Três Corações/MG – Brazil 4.Universidade Estadual de Campinas – Campinas/SP – Brazil Correspondence author: uiara_oliveira@hotmail.com Received: Jan. 22, 2019 | Accepted: Aug. 28, 2019 ABSTRACT Objective: A case report on the treatment of necrotizing fasciitis with the use of high frequency (HF) generator in a person with diabetes. Methods: This is descriptive study of applied nature developed in an outpatient clinic in Minas Gerais. The patient underwent dressing sessions three times a week for high frequency application. Healing was weekly evaluated using the Pressure Ulcer Scale Healing (PUSH) instrument and Image J software. Results: The area was signifi cantly reduced, which was measured during six weekly evaluations. In the fi rst four evaluations, a progressive reduction of the lesion was obtained in 11.78 cm2, that is, 90% of the area. Conclusion: The use of the AF generator was eff ective in the treatment of necrotizing fasciitis, reducing the lesion area.


INTRODUCTION
Diabetes mellitus is one of the major chronic diseases a ecting the world's population and is becoming a public health problem. In Brazil, estimates veri ed that 11.9 million individuals, between 20 and 79 years old, have diabetes, classifying the country as the fourth in the world ranking of diabetes mellitus 1 . Several complications are resulting from the disease, which includes macrovascular, microvascular complications, neuropathies, and greater susceptibility to Necrotizing fasciitis is a rare and severe infection characterized by extensive and rapidly progressive necrosis.
It was described in 1871 by surgeon Dr. Joseph Jones, however, the term necrotizing fasciitis began to be used by Wilson Ben in 1952, to describe its main characteristic: necrosis of the subcutaneous cellular tissue maintaining the underlying muscle preserved. Its incidence is higher in adults with predisposing risk factors, such as type 2 diabetes,

RESUMEN
Objetivo: Relato de caso sobre el tratamiento de la fasciitis necrotizante con la utilización del generador de alta frecuencia (AF) en una persona com diabetes. Métodos: Se trata de un estudio descriptivo de naturaleza aplicada, desarrollado en un ambulatorio en el interior de Minas Gerais. La paciente fue sometida a sesiones de curativo durante tres veces a la semana para aplicación de alta frecuencia. La cicatrización fue evaluada semanalmente a través del instrumento Pressure Ulcer Scale Healing (PUSH) y área de la lesión por el software Image J. Resultados: Hubo una reducción signifi cativa en el área de la lesión, que se midió durante seis evaluaciones semanales. Durante las cuatro primeras evaluaciones se obtuvo una reducción progresiva de la lesión en 11,78 cm², es decir, el 90% del área. Conclusión: El uso del generador de AF fue efectivo en el tratamiento de la fascitis necrotizante, con reducción del área de la lesión. Ozone is a powerful oxidant with antimicrobial and fungicidal e ects that, when in contact with organic uids, forms reactive oxygen molecules, which in turn provide benefits to tissue repair through biochemical events of cellular metabolism 11 .

DESCRIPTORES:
Ozone therapy is a technique that uses ozone as a therapeutic agent. In the treatment of chronic wounds, its use stimulates the granulation tissue formation and neoangiogenesis 11 . e HF generator is capable of producing physiological e ects, such as peripheral vasodilation, increased blood ow, and consequently greater demand for oxygenation and cellular metabolism, favoring the healing process. is happens due to the thermal e ects that are produced by an electric current that traverses the organism, creating the ozone e ect by the electric spark that crosses the electrode, eliminating the pathogens and oxygen, responsible for the broplasia for intercellular matrix preparation 10 .
Recommendations for the therapeutic use of the highfrequency generator and ozone therapy are diverse, and there is evidence proving its e cacy. Its advantages include powerful antimicrobial action, easy application, low cost, and no adverse e ects. Its clinical results make the highfrequency device an ally for the treatment of injuries 10 .
However, despite all the beneficial effects that qualify the high-frequency generator as a viable tool for treating injuries, there is a shortage of scientific studies on its use.
Considering these facts, this study aimed to report the effects on the healing process in the treatment of necrotizing fasciitis, using the HF generator in a person with diabetes.

METHODS
This is a descriptive study, case report type, developed in an outpatient wound care clinic in the state of Minas Gerais, from August to October 2018. It was performed on a 52-year-old woman with type 2 diabetes mellitus and diagnosis of necrotizing fasciitis.
To evaluate the evolution of the wound, measurements were taken using a 12-megapixel camera with ƒ/2.2 aperture, digital zoom up to 5 times and true tone flash.
Image analysis was performed using the ImageJ software. e "amount of exudate present in the wound" item is evaluated after removal of the dirty coverage and before topical dressing application. It is classi ed as absent, small, moderate and large with scores ranging from 0 (absent) to 3 (large) 12 .
e "wound bed appearance" item represents the type of tissue present in the wound during the evaluation and is divided into: necrotic tissue (bedsores, black color), devitalized tissue (mucoid yellow); granulation tissue (pink or red color); epithelial tissue (pink or bright) and healed tissue (closed wound). e scores in these tissues are classi ed as 0 (closed injury), 1 (epithelial tissue), 2 (granulation tissue), 3 (slough), and 4 (necrotic tissue) 12 .
When the subscores of the items are totaled, a possible variation of 0 to 17 is obtained, and the higher scores indicate worse wound conditions 12 .
In the first consultation, the patient's history was collected to start the treatment of the wound, and she was invited to participate in the study. During the following discussions, the patient was referred to the dressing room.
Wound cleaning was performed with irrigation of 0.9% lukewarm saline solution and, after that, the application of the HF generator was performed three times a week with a duration of 1 min at the margins and in the bed, superimposed on sterile gauze.
As primary coverage, 2% papain gel and essential fatty acids were applied to the perilesional region of the wound, and the lesion was occluded with sterile gauze and xation with micropore.   After seven applications, the lesion presented an area of 4.58 cm², intact perilesional region, irregular and detached margin, 95% granulation tissue and 5% exposure of subcutaneous tissue, a moderate amount of exudate with serous appearance, odorless and yellowish in color, as shown in Fig. 2.
After 15 applications, the lesion presented an area of 1.94 cm², 95% granulation tissue, a small amount of exudate in serious aspect, odorless and yellowish in color. Concerning the area of the lesion, the patient presented a signi cant improvement in the healing process, measured using Image J software, from 13.09 to 1.94 cm², as shown in Fig. 3.
High-frequency generator in the treatment of necrotizing fasciitis in a person with diabetes In the graphic below (Fig. 4), the values of the PUSH scale used to measure the area in square centimeters, the quantity of exudate and type of tissue present in the lesion, are represented.
It can be evidenced that there was a signi cant improvement of the lesion during the six weeks of evaluation. In the initial assessment, a PUSH score of 13 was obtained, since the wound presented an area of 13.09 cm², a moderate amount of exudate and granulation tissue in greater evidence. In the three subsequent evaluations, a noticeable improvement of the lesion was observed, evidenced in the reduction of its area, which presented PUSH score 7 in the fourth evaluation, with an area of 1.31 cm², a limited amount of exudate and evident granulation tissue. In the sixth and last evaluation, PUSH score 7 was obtained, the lesion area was 1.94 cm² with a limited amount of exudate and evident granulation tissue.
In the graphic below (Fig. 5), the area of the lesion evaluated through the ImageJ software is presented. During the first four evaluations, a progressive reduction of the injury was obtained in 11.78 cm², that is, 90% of the area.
Considering the first and last evaluations, a decrease of 85.17% of the lesion area was obtained. It is noteworthy that the lack of periodicity of the patient in the nal two weeks of treatment may be indicative for the increase in the area of the lesion since there was an increase of 0.22 cm² in the area.    Two other studies with the use of HF generator for the treatment of pressure lesion were also adequate. In the rst, after ve weeks of treatment with the application of HF three times a day for 15 min, using the sparking technique, there was a reduction in the size of the lesion 11 . In the second study, the electrical sparking technique was also used, with an amplitude of 80% of the apparatus during 1 min per cm² of the lesion with an improvement in healing and a decrease in its area 10 .
ere is unanimity among several authors regarding the use of ozone, whether applied through ozonized sun ower oil or diluted in water, since ozone provides antimicrobial, bactericidal and fungicidal effects, in addition to its e ectiveness in tissue repair. In the treatment of chronic wounds, the use of ozone-induced the granulation tissue formation due to its antiseptic e ects 11 .
Chronic wounds have an impact on the burden on the Brazilian Uni ed Health System (SUS, acronym in Portuguese for Sistema Único de Saúde) and this issue has become widely discussed in health economic forums due to the exacerbated use of material resources and low resolution of the problem. erefore, the use of technological resources in a systematic way is crucial to provide a cure for patients 10 .
Nursing is a science that promotes prevention and rehabilitation through care. us, professionals should use existing technologies and resources to provide a good quality of care. Technologies have been used in the health area in educational and healthcare contexts as a complementary way of teaching methodologies 10 .
It is essential to develop studies and technological processes of practical application, to ensure that the nurse can always be updated. Technology, when used in daily nursing, brings possibilities to improve the care provided, principally to the person with wound 16 .

CONCLUSION
The use of HF generator was valid based on the result obtained, i.e., with signi cant reduction of the area of the lesion, however, it is necessary that the ndings evidenced in this study may be used to discuss and make feasible preventive and treatment measures and that new research related to the subject may be encouraged, with a more significant number of people, including other methodological approaches.