IFI CONSIDERATIONS

IFIs are opportunist infections which tend to occur at the far end on the spectrum of war wound severity. IFIs are so devastatingly morbid and lethal they have their own CPG (Invasive Fungal Infections in War Wounds). However, because there are clinical factors that can predict wounds at greatest risk for IFI and because the irrigation and dressings for these wounds should be managed differently from what has been mentioned above (using Dakin’s solution), these differences will be highlighted here.

During the first debridement, assess patients for IFI risk factors:

- Dismounted blast injury
- Above knee immediate amputation
- Extensive perineal/genitourinary/rectal injury
- Massive transfusion of >20 units in the first 24 hours (or anticipation of 20 units)

If three of the above factors are present, switch irrigation to high-volume Dakin’s solution and dressings should be wet-to-dry using Dakin’s solution. Furthermore, because IFI also occurs with wounds not initially meeting the criteria listed above, additional criteria seen after subsequent debridement should also prompt the same change to Dakin’s irrigation and dressings.

Look out for these additional IFI risk factors on subsequent inspections of wounds not previously considered at risk of IFI:

- Progression from below-knee to through-knee to above-knee amputation
- Recurrent necrosis following at least two consecutive debridements

(Refer to the Invasive Fungal Infection in War Wounds CPG for more discussion of steps taken at Roles 3, 4 and 5 for suspected IFI.)