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Ang KL, Wormald J, Farag S, Ng M, Lane J, Furniss D. Epidemiology of upper limb necrotising fasciitis in England: A national study (1998-2018). J Plast Reconstr Aesthet Surg 2025; 104:334-338. [PMID: 40158410 DOI: 10.1016/j.bjps.2025.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Revised: 02/17/2025] [Accepted: 03/08/2025] [Indexed: 04/02/2025]
Abstract
BACKGROUND Necrotising fasciitis (NF) is a surgical emergency characterised by rapidly progressive infection of the subcutaneous tissues and fascial planes, leading to widespread fascial necrosis and systemic toxicity. Although NF can affect any part of the body, the upper limbs are a notable site, accounting for 27% of cases. Antibiotics and surgical debridement form the basis of treatment. METHODOLOGY We conducted a retrospective study on NF of the upper limb requiring surgical intervention from 1998-2018 using data from Hospital Episode Statistics. Age, sex, deprivation index, length of stay (LOS) and complications were analysed. RESULTS We identified 728 patients, comprising 468 males and 260 females, with a mean age of 54.97 years (95% CI: 53.76-56.17 years). The incidence of NF in the upper limb increased from 0.0035 per 100,000 in 1998 to 0.01 per 100,000 in 2018. Lower index of multiple deprivation scores correlated with higher NF prevalence, with 67.32% (n=474) presenting scores between 0 and 5. The average LOS was 27.55 days (95% CI: 25.08-30.02 days). Complications within 30 days of surgery included 8 (1.10%) cases of renal failure, 8 (1.10%) urinary tract infections (UTIs), and 103 (14%) deaths. Meanwhile, 90-day complications included 23 (3.15%) cases of renal failure, 6 (0.82%) pulmonary embolisms, 22 (3.02%) UTI, and 113 (16%) deaths. CONCLUSION This study highlights the impact of upper limb NF and provides crucial insights into its incidence, demographic correlations, and clinical outcomes, which can inform clinical management.
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Affiliation(s)
- Ky-Leigh Ang
- Department of Plastic Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Justin Wormald
- Department of Plastic Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK.
| | - Soma Farag
- Department of Plastic Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Michael Ng
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Jennifer Lane
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK; Barts Bone and Joint Health, Queen Mary University of London, London, UK
| | - Dominic Furniss
- Department of Plastic Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
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Tedesco S, Di Grezia M, Tropeano G, Altieri G, Brisinda G. Necrotizing soft tissue infections: a surgical narrative review. Updates Surg 2025:10.1007/s13304-025-02222-0. [PMID: 40295449 DOI: 10.1007/s13304-025-02222-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2025] [Accepted: 04/15/2025] [Indexed: 04/30/2025]
Abstract
Necrotizing soft tissue infections represent a spectrum of diseases characterized by extensive necrosis involving the skin, subcutaneous tissues, fascia or muscles. These infections are generally severe and rapidly progressive, often accompanied by sepsis, septic chock, multiple organ failure and, ultimately, death. Several classifications have been developed based on multiple parameters, such as the anatomical location of the disease, the depth of the lesion or the microbiology. Numerous clinical factors predispose individuals to the development of necrotizing soft tissue infections. The clinical presentation is not always characterized by local signs and systemic symptoms of infection, which can lead to delays in both diagnosis ad treatment. Broad-spectrum antibiotic directed at the likely organisms is essential early in the treatment course, but do not substitute surgical management. Antibiotic therapy should be subsequently tailored to the etiologic micro-organism. Rapid recognition and early surgical intervention form the mainstay of management of necrotizing soft tissue infections. Initial surgical debridement should be promptly performed preferably at the presenting hospital, when adequate infrastructure and personnel are available. Transfer to a referral center may be necessary for definitive surgical and complex wound care. Most patients require more than one debridement. A multidisciplinary approach is also essential to improve the results in the treatment of these patients.
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Affiliation(s)
- Silvia Tedesco
- Emergency Surgery and Trauma Center, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, 00168, Rome, Italy
| | - Marta Di Grezia
- Emergency Surgery and Trauma Center, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, 00168, Rome, Italy
| | - Giuseppe Tropeano
- Emergency Surgery and Trauma Center, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, 00168, Rome, Italy
| | - Gaia Altieri
- Emergency Surgery and Trauma Center, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, 00168, Rome, Italy
| | - Giuseppe Brisinda
- Emergency Surgery and Trauma Center, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, 00168, Rome, Italy.
- Catholic School of Medicine, "Agostino Gemelli", 00168, Rome, Italy.
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Kariksiz M, Ates O. Treatment and clinical outcomes in lower extremity necrotizing soft tissue infection. Eur J Trauma Emerg Surg 2025; 51:148. [PMID: 40126628 DOI: 10.1007/s00068-025-02835-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2025] [Accepted: 03/13/2025] [Indexed: 03/26/2025]
Abstract
BACKGROUND Necrotizing soft tissue infection (NSTI) is a rapidly progressing infection of the soft tissues under the skin, which poses a life-threatening risk if not treated promptly. Due to the non-specific nature of symptoms at presentation, the diagnosis is often delayed, leading to a high mortality rate and increased risk of amputation. Early treatment requires both surgical intervention and antibiotic therapy. This study aims to investigate the effects of clinical parameters, applied treatments, and initial interventions on mortality and amputation rates in patients with NSTI. MATERIALS AND METHODS In a retrospective study, 50 patients diagnosed with NSTI between 2021 and 2024 were included. Patient demographic characteristics (age, gender, comorbidities), isolated microorganisms, antibiotics administered, interventions performed, and the final outcomes were analyzed. Additionally, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, duration of intensive care unit (ICU) stay, length of hospital stay, rates of mortality and amputation were examined. RESULTS Among the 50 patients in this study, the mortality rate due to NSTI was 20% (10 patients), and the amputation rate was 60% (30 patients). Both the length of hospital stay and duration of ICU stay were significantly associated with mortality. Diabetes mellitus (DM) was found to be significantly related to amputation. The LRINEC score, presence of chronic renal failure, sepsis, hyperbaric oxygen therapy (HBOT), smoking, and timing of surgical intervention were not significantly associated with amputation rates. The most common isolated microorganism was Streptococcus pyogenes. CONCLUSION Although the LRINEC score is widely used, it does not play a critical role in the management of NSTI. Factors like underlying comorbidities and hospital stay more significantly affect mortality and amputation rates. Early diagnosis and treatment are recommended to improve patient outcomes.
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Affiliation(s)
- Mesut Kariksiz
- Department of Orthopedic and Traumatology, Basaksehir Cam and Sakura City Hospital, University of Health Sciences, Istanbul, Turkey.
| | - Okan Ates
- Department of Orthopedic and Traumatology, Gazi Yasargil Training and Research Hospital, University of Health Sciences, Diyarbakir, Turkey
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Hainsworth L, Vaughan A, Picardo N, Gough AT. Necrotising fasciitis of the upper limb: a review of the literature. Musculoskelet Surg 2024; 108:377-381. [PMID: 38954324 DOI: 10.1007/s12306-024-00843-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 06/21/2024] [Indexed: 07/04/2024]
Abstract
Necrotising fasciitis is an uncommon life-threatening surgical emergency. While most commonly seen in the lower limb it can also affect the upper limb. This article reviews and summarises the current literature on necrotising fasciitis in the upper limb, covering common predisposing factors, clinical presentations, scoring systems, common organism types and the timing of surgical treatment. The key to managing this condition continues to be early clinical diagnosis and aggressive surgical debridement to attempt to reduce the morbidity and mortality of this condition.
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Affiliation(s)
- L Hainsworth
- Musgrove Park Hospital, Somerset NHS Foundation Trust, Parkfield Drive, Taunton, TA1 5DA, UK.
| | | | | | - A T Gough
- Musgrove Park Hospital, Somerset NHS Foundation Trust, Parkfield Drive, Taunton, TA1 5DA, UK
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Lipatov KV, Asatryan A, Melkonyan G, Kazantcev AD, Solov’eva EI, Krivikhin DV, Gorbacheva IV, Cherkasov UE. Effectiveness of negative pressure wound therapy in complex surgical treatment of necrotizing fasciitis of the upper limb. World J Orthop 2024; 15:1015-1022. [PMID: 39600855 PMCID: PMC11586739 DOI: 10.5312/wjo.v15.i11.1015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 09/22/2024] [Accepted: 10/10/2024] [Indexed: 11/15/2024] Open
Abstract
BACKGROUND Necrotizing fasciitis (NF) of the upper extremities is a severe surgical pathology, and the incidence of this disease has been steadily increasing in recent decades. Surgical treatment is accompanied by the formation of extensive wounds, which can be treated with significant difficulties. In recent years, negative pressure wound therapy (NPWT) has proven to be highly effective. It is also promising for the treatment of NF. AIM To explore the effectiveness of NPWT in the treatment of NF of the upper extremities. METHODS The results of the treatment of 36 patients with NF of the upper extremities in two groups (NPWT group and control group; 2022-2023) were retrospectively analyzed. In the NPWT group, the NPWT method (120 mmHg; constant mode) was used after surgical treatment. The number of vacuum-assisted dressings in patients ranged from 1 to 3, depending on the dynamics of the wound process. The duration of fixation of one bandage was up to 2-3 d. In the control group, conventional methods of local wound treatment were used. The following indicators were analyzed: The treatment delay, the prevalence of inflammation, the microbial landscape, the number of debridements, the duration of wound preparation for surgical closure, and the nature of skin plastic surgery. RESULTS Most patients experienced a significant treatment delay [4 d, interquartile range (IQR): 2-7 d], which led to the spread of the pathological process to the forearm and shoulder. The most common pathogens were Staphylococcus aureus (14; 38.9%) and Streptococcus pyogenes (22; 61.1%). The average number of debridements per patient was 5 (IQR: 3-7), with no difference between groups. The average time to prepare wounds for surgical closure was 11 ± 4 d in the NPWT group and 29 ± 10 d (P = 0.00001) in the control group. In the NPWT group, the wounds were more often closed with local tissues (15; 83.3%), and in the control group, split-thickness skin grafts were more often used (4; 50%). CONCLUSION The predominant isolation of Staphylococcus aureus and/or Streptococcus pyogenes from the lesions allowed us to classify these patients as NF type II. Multiple debridement procedures have become a feature of this disease treatment. The use of NPWT has significantly reduced the time required to prepare wounds for surgical closure. Early closure of wounds allows for more frequent use of local tissue repair, which ensures better results. NPWT is a highly effective way to prepare wounds for early surgical closure in patients with upper extremity NF.
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Affiliation(s)
- Konstantin V Lipatov
- Department of General Surgery, Institute of Clinical Medicine named after N.V. Sklifosovsky, Sechenov First Moscow State Medical University (Sechenov University), Moscow 119021, Russia
| | - Arthur Asatryan
- Department of General Surgery, Wound and Wound Infection Surgery, State Budgetary Institution “City Clinical Hospital named after S.S. Yudin of Moscow Healthcare Department”, Moscow 115446, Russia
| | - George Melkonyan
- Department of General Surgery, Physician of The Hospital for War Veterans No 3, Moscow 129336, Russia
| | - Aleksandr D Kazantcev
- Department of General Surgery, Institute of Clinical Medicine named after N.V. Sklifosovsky, Sechenov First Moscow State Medical University (Sechenov University), Moscow 119021, Russia
| | - Ekaterina I Solov’eva
- Department of General Surgery, I.M. Sechenov First Moscow State Medical University, Moscow 119048, Russia
| | - Denis V Krivikhin
- Department of General Surgery, Wound and Wound Infection Surgery, State Budgetary Institution “City Clinical Hospital named after S.S. Yudin of Moscow Healthcare Department”, Moscow 115446, Russia
| | - Irina V Gorbacheva
- Department of General Surgery, I.M. Sechenov First Moscow State Medical University, Moscow 119048, Russia
| | - Urii E Cherkasov
- Department of General Surgery, I.M. Sechenov First Moscow State Medical University, Moscow 119048, Russia
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Uwumiro F, Okpujie V, Ajiboye A, Abesin O, Ogunfuwa O, Mojeed O, Borowa A, Alemenzohu H, Hassan J, Ajayi O. Association between Insurance Status and Outcomes of Hospitalizations for Necrotizing Soft Tissue Infections. Surg Infect (Larchmt) 2024; 25:459-469. [PMID: 38985696 DOI: 10.1089/sur.2023.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024] Open
Abstract
Background: Lack of insurance is associated with poorer outcomes in hospitalized patients. However, few studies have explored this association in hospitalizations for necrotizing soft tissue infections (NSTIs). This study examined the impact of insurance status on the outcome of NSTI admissions. Methods: All adult hospitalizations for necrotizing fasciitis, gas gangrene, and Fournier gangrene between 2016 and 2018 were examined using the Nationwide Inpatient Sample database. Insurance status was categorized as insured (including Medicare, Medicaid, and Private, including Health maintenance organization (HMO) or uninsured (Self-pay). Outcome measures included mortality rates, limb loss, length of hospital stay, prolonged hospital stay, and critical care admissions. Statistical analysis included weighted sample analysis, chi-square tests, multivariate regression analysis, and negative binomial regression modeling. Results: Approximately 29,705 adult hospitalizations for NSTIs were analyzed. Of these, 57.4% (17,065) were due to necrotizing fasciitis, 22% (6,545) to gas gangrene, and 20.5% (6,095) to Fournier gangrene. Approximately 9.7% (2,875) were uninsured, whereas 70% (26,780) had insurance coverage. Among the insured, Medicare covered 39.6% (10,605), Medicaid 29% (7,775), and private insurance 31.4% (8,400). After adjustments, Medicare insurance was associated with greater odds of mortality (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: 1.33-2.47; p = 0.001). Medicaid insurance was associated with increased odds of amputation (aOR: 1.81; 95% CI: 1.33-2.47; p < 0.001), whereas private insurance was associated with lower odds of amputation (aOR: 0.70; 95% CI: 0.51-0.97; p = 0.030). Medicaid insurance was associated with greater odds of prolonged hospital stay (aOR: 1.34; 95% CI: 1.09-1.64; p < 0.001). No significant association was observed between the lack of insurance or self-pay and the odds of primary or secondary outcomes. Conclusion: Medicare insurance was correlated with greater odds of mortality, whereas Medicaid insurance was associated with increased odds of amputation and longer hospital stay. Uninsured status was not associated with significant differences in NSTI outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Azabi Borowa
- College of Medicine, University of Lagos, Lagos, Nigeria
| | | | - Judith Hassan
- Department of Health Sciences and Social Work, Western Illinois University, Macomb, Illinois, USA
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Postel F, Gandolfi S, Coquerel-Beghin D, Delas F, Auquit-Auckbur I. Necrotizing soft-tissue infection of the upper limb: A single-center study of 24 cases. HAND SURGERY & REHABILITATION 2024; 43:101718. [PMID: 38782364 DOI: 10.1016/j.hansur.2024.101718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Necrotizing soft-tissue infection and necrotizing fasciitis of the upper limb are infrequent. Studies are rare, and often include other anatomical regions. The specificities and particularities of this pathology are not well known. The aim of this study was to report diagnosis and treatment aspects. METHODS A retrospective study was conducted over 10 years on every patient treated for necrotizing fasciitis of the upper limb with clinical, bacteriological and histological confirmation. One hundred ninety-eight items were extracted for each patient concerning clinical, biological, radiological and therapeutic data. RESULTS During 10 years, 24 patients were diagnosed with necrotizing fasciitis of the upper limb: 18 males, 6 females; mean age, 59.9 years; mean body mass index, 25. Local erythema, pain and fever were the most frequent symptoms. Skin necrosis was present in fewer than 40% of patients. Sixteen cases (66.6%) had prior skin lesions and/or an entry point on the limb. Ten had non-steroidal anti-inflammatory drug prescription before acute symptom onset (42%), requiring intensive care unit admission. Treatment comprised surgical resection, resuscitative measures, antibiotic therapy and reconstructive surgery. Seven patients (30.4%) had 1 session of cutaneous excision, and the others had more than 2. Microbiological analysis found mono-microbial beta-hemolytic group A streptococci (BHGAS) infection in 14 patients (58.4%). Antibiotics were prescribed in 91% of cases before surgery, and in 100% after. The most frequently prescribed substance was clindamycin (18 patients, 75%). Ten patients (42%) stayed in the intensive care unit during treatment. Seventeen patients (70.8%) had thin skin graft reconstruction, including 50% with dermal substitute. Five patients (20.8%) had partial upper limb amputation. Two patients (8.3%) died in the 30 days following diagnosis. CONCLUSIONS The death rate in necrotizing fasciitis of the upper limb was rather low but the amputation rate was higher than in other locations. This study shows the specific clinical, biological and treatment features of this rare but serious pathology of the upper limb.
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Affiliation(s)
- François Postel
- Plastic and Hand Surgery Department, Charles Nicolle University Hospital, Rouen, France.
| | - Silvia Gandolfi
- Plastic and Reconstructive Surgery, Toulouse University Hospital, Toulouse, France
| | | | - Florian Delas
- Plastic and Hand Surgery Department, Charles Nicolle University Hospital, Rouen, France
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Christopoulos G, Khoury A, Johnson M, Sergentanis TN. Necrotizing Fasciitis Originating in the Hand: A Systematic Review and Meta-Analysis. Hand (N Y) 2024; 19:568-574. [PMID: 36544252 PMCID: PMC11141413 DOI: 10.1177/15589447221141486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Necrotizing Fasciitis (NF) is a rapidly progressive and potentially lethal infection. This systematic review focused on the treatment and prognosis of the NF of the hand. The literature search was performed in PubMed database, and cohort studies and case reports were deemed eligible. Proportions were pooled to estimate overall mortality and amputation rates, and a logistic regression analysis was performed to evaluate predictors of amputation and mortality. The search algorithm resulted in 51 eligible articles including 48 case reports (54 patients) and 3 larger retrospective cohort studies (107 patients). Most patients had a monomicrobial infection, a surgical debridement on the day of admission, and hospital stay of more than 10 days. The estimated overall amputation rate was 28%, whereas overall mortality was equal to 8%. In the pooled set of case reports, mortality was significantly associated with age older than 54 years and marginally with diabetes mellitus. Necrosis expanding more proximally to the forearm correlated with both amputation and mortality. It is reiterated that early diagnosis of NF is of paramount importance and that early and decisive surgical intervention should have low threshold, especially when potential risk factors are identified.
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Montravers P, Soussan R, Tanaka S. Identifying patients with difficult-to-treat acute bacterial skin infections. Curr Opin Infect Dis 2024; 37:87-94. [PMID: 38037891 DOI: 10.1097/qco.0000000000000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF REVIEW The early recognition of acute bacterial skin infections (ABSIs) and their swift and adequate care are the major determinants of success. The features that can hamper or delay surgical and medical management can lead to 'difficult-to-treat' ABSIs. RECENT FINDINGS Delayed diagnosis and belated management are the key obstacles to be overcome. Clinicians should be careful about underestimating the severity of ABSIs and overlooking comorbidities, especially immunosuppression. Many conditions can lead to delayed source control, including a misdiagnosis, interhospital transfers, delayed re-exploration, or extensive injuries. Difficult therapeutic issues can occur, including rapidly destructive infections from highly pathogenic microorganisms (Group-A-streptococci, Vibrio spp., Clostridium spp. and Staphylococcus aureus ) or inadequate antibiotic therapy resulting from multidrug-resistant bacteria. Impaired pharmacokinetic capacities of antibiotic agents should also be considered as a source of clinical failure due to insufficient antimicrobial activity at the site of infection. SUMMARY Microbiological samples should be used for guiding antimicrobial therapy. Risk factors for multidrug-resistant bacteria should be considered, including local epidemiology and comorbidities. The optimization of antibiotic therapy should be achieved. Optimized care should be achieved through multidisciplinary management involving professionals with sufficient and appropriate training.
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Affiliation(s)
- Philippe Montravers
- Université Paris Cité
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
- PHERE, Physiopathology and Epidemiology of Respiratory Diseases, French Institute of Health and Medical Research (INSERM) U1152, Paris
| | - Romy Soussan
- Université Paris Cité
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
| | - Sébastien Tanaka
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
- DéTROI, Institute of Health and Medical Research (INSERM) U1188, Saint-Pierre, Reunion Island, France
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Suijker J, Pijpe A, Hoogerbrug D, Heymans MW, van Zuijlen PPM, Halm JA, Meij-de Vries A. IDENTIFICATION OF POTENTIALLY MODIFIABLE FACTORS TO IMPROVE RECOGNITION AND OUTCOME OF NECROTIZING SOFT-TISSUE INFECTIONS. Shock 2024; 61:585-591. [PMID: 38315508 DOI: 10.1097/shk.0000000000002325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
ABSTRACT Background : Necrotizing soft-tissue infections (NSTIs) present a surgical emergency of increasing incidence, which is often misdiagnosed and associated with substantial mortality and morbidity. A retrospective multicenter (11 hospitals) cohort study was initiated to identify the early predictors of misdiagnosis, mortality, and morbidity (skin defect size and amputation). Methods : Patients of all ages who presented with symptoms and were admitted for acute treatment of NSTIs between January 2013 and December 2017 were included. Generalized estimating equation analysis was used to identify early predictors (available before or during the first debridement surgery), with a significance level of P < 0.05. Results : The median age of the cohort (N = 216) was 59.5 (interquartile range = 23.6) years, of which 138 patients (63.9%) were male. Necrotizing soft-tissue infections most frequently originated in the legs (31.0%) and anogenital area (30.5%). More than half of the patients (n = 114, 54.3%) were initially misdiagnosed. Thirty-day mortality was 22.9%. Amputation of an extremity was performed in 26 patients (12.5%). Misdiagnosis was more likely in patients with a higher Charlson Comorbidity Index (β = 0.20, P = 0.001), and less likely when symptoms started in the anogenital area (β = -1.20, P = 0.003). Besides the established risk factors for mortality (septic shock and age), misdiagnosis was identified as an independent predictor of 30-day mortality (β = 1.03, P = 0.01). The strongest predictors of the final skin defect size were septic shock (β = 2.88, P < 0.001) and a skin-sparing approach to debridement (β = -1.79, P = 0.002). Conclusion : Recognition of the disease is essential for the survival of patients affected by NSTI, as is adequate treatment of septic shock. The application of a skin-sparing approach to surgical debridement may decrease morbidity.
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Affiliation(s)
| | | | | | - Martijn W Heymans
- Amsterdam, Department of Epidemiology and Data Science, Amsterdam, The Netherlands
| | | | - Jens A Halm
- Trauma Unit, Amsterdam UMC location AMC, Amsterdam, The Netherlands
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Hansen SUB, Jespersen FVB, Markvart M, Hyldegaard O, Plaschke CC, Bjarnsholt T, Nielsen CH, Jensen SS. Characterization of patients with odontogenic necrotizing soft tissue infections in the head and neck area. A retrospective analysis. Acta Odontol Scand 2024; 82:40-47. [PMID: 37688516 DOI: 10.1080/00016357.2023.2254389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/13/2023] [Accepted: 08/27/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE Necrotizing soft-tissue infection (NSTI) in the head and neck area may develop from odontogenic infections. The aim of this study was to characterize patients with NSTI in the head and neck with odontogenic origin in a well-defined prospectively collected cohort. MATERIAL AND METHODS Patients with NSTI in the head and neck, hospitalized between 2013 and 2017 at Copenhagen University Hospital and registered in the Scandinavian INFECT database were included. Medical records of identified patients and from the INFECT database were screened for a defined set of data including the primary focus of infection, comorbidities, predisposing factors, clinical and radiographic diagnostics, course of treatment, and treatment outcome. RESULTS Thirty-five patients with NSTI in the head and neck area were included in the study. A total of 54% had odontogenic origin, primarily from mandibular molars, and 94% had radiographic signs of infectious oral conditions. Overall, comorbidities were reported in 51% with cardiovascular disease being the most prevalent. In 20%, no comorbidities or predisposing conditions could be identified. The overall 30-day mortality rate was 9%. CONCLUSIONS More than half of NSTI cases in the head and neck region had an odontogenic origin, and special attention should be paid to infections related to mandibular molars.
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Affiliation(s)
| | | | - Merete Markvart
- Department of Odontology, University of Copenhagen, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christina Caroline Plaschke
- Department of Otorhinolaryngology Head and Neck Surgery and Audiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Bjarnsholt
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Immunology and Microbiology, Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark
| | - Claus Henrik Nielsen
- Department of Odontology, University of Copenhagen, Copenhagen, Denmark
- Institute for Inflammation Research, Copenhagen University Hospital, Copenhagen, Denmark
| | - Simon Storgård Jensen
- Department of Odontology, University of Copenhagen, Copenhagen, Denmark
- Deparment of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Copenhagen, Denmark
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Nagira K, Ogoshi T, Akahori K, Enokida S, Enokida M, Ueda T, Homma M, Nagashima H. Factors associated with mortality in patients with extremity necrotizing soft-tissue infections: a single academic center experience. Langenbecks Arch Surg 2023; 408:189. [PMID: 37166568 DOI: 10.1007/s00423-023-02929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 05/04/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Necrotizing soft-tissue infection (NSTI) is a surgical emergency associated with high mortality. This study primarily aimed to identify the factors associated with in-hospital mortality due to NSTI in the extremities at a single institution. Secondarily, we aimed to clarify the effectiveness of the optimal combination of hyperbaric oxygen therapy (HBOT) and surgery for NSTI treatment. STUDY DESIGN Retrospective observational study. METHODS This study included all patients newly diagnosed with NSTI in the extremity from 2003 to 2021 in our hospital. Factors associated with mortality, including patient's characteristics, duration from onset to hospitalization, NSTI type, and clinical data at the initial visit; acute disseminated intravascular coagulation (DIC), laboratory risk indicator for necrotizing fasciitis score, and sequential organ failure assessment score; treatment, initial surgery, surgery times, amputation, HBOT, combined surgery with HBOT, and clinical outcomes; amputation rate, mortality rate, and hospitalization duration were examined. RESULTS A total of 37 cases were treated for NSTIs. The median age was 64 years (range: 22-86). Five cases (13.5%) died during hospitalization. Ten patients were diagnosed with DIC at the initial visit, of whom four died. HBOT combined with surgery was performed in 23 cases, and 16 cases underwent multiple surgeries. Factors associated with mortality included DIC (p = 0.015, 95% confidence interval [CI]: 0.015-0.633) and multiple surgeries combined with HBOT (p = 0.028, 95% CI: 1.302-95.418). CONCLUSION This study demonstrates that DIC at the initial visit is associated with mortality in extremity NSTI. Additionally, HBOT might improve prognosis when combined with multiple surgeries.
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Affiliation(s)
- Keita Nagira
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan.
| | - Tomofumi Ogoshi
- Department of Emergency and Disaster Medicine, Tottori University, Tottori, Japan
| | - Keiichi Akahori
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
| | - Shinpei Enokida
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
| | - Makoto Enokida
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
| | - Takahiro Ueda
- Department of Emergency and Disaster Medicine, Tottori University, Tottori, Japan
| | - Masato Homma
- Department of Emergency and Disaster Medicine, Tottori University, Tottori, Japan
| | - Hideki Nagashima
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
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13
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The impact of necrotizing soft tissue infections on the lives of survivors: a qualitative study. Qual Life Res 2023:10.1007/s11136-023-03371-8. [PMID: 36840905 DOI: 10.1007/s11136-023-03371-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE Necrotizing soft tissue infections (NSTI) are potentially lethal infections marked by local tissue destruction and systemic sepsis, which require aggressive treatment. Survivors often face a long recovery trajectory. This study was initiated to increase understanding of the long-term impact of NSTI on health related quality of life (HRQoL), and how care may be improved. METHODS Thematic analysis was applied to qualitative data from 25 NSTI-survivors obtained through two focus groups (n = 14) and semi-structured interviews (n = 11). RESULTS The median age of the participants was 49 years, 14 were female. The median time since diagnosis was 5 years. Initial misdiagnosis was common, causing delay to treatment. Survivors experienced long-term physical consequences (scarring, cognitive impairment, fatigue, sleeping problems, recurrent infections), psychological consequences (traumatic stress symptoms, fear of relapse, adjusting to an altered appearance, sexual issues) and social and relational consequences (changes in social contacts, a lack of understanding). The disease also had a major psychological impact on family members, as well as major financial impact in some. There was a strong desire to reflect on 'mistakes' in case of initial misdiagnosis. To improve care, patient and family centered care, smooth transitions after discharge, and the availability of understandable information were deemed important. CONCLUSION This study reveals that NSTI have a large impact on physical and psychosocial wellbeing of survivors and their relatives. Except for a few differences (misdiagnosis, fear for re-infection and actual re-infection), the patient experience of patients with NSTI is largely similar to those of burn survivors. Thus, questionnaires to assess HRQoL in burn survivors may be used in future NSTI studies.
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14
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Nawijn F, Kerckhoffs MC, van Heijl M, Keizer J, van Koperen PJ, Hietbrink F. Impact of Comorbidities on the Cause of Death by Necrotizing Soft Tissue Infections. Surg Infect (Larchmt) 2022; 23:729-739. [PMID: 36067160 DOI: 10.1089/sur.2022.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: The aim of this study was to identify the cause of death in patients with necrotizing soft tissue infections (NSTIs) stratified by patient's pre-existing comorbidities (American Society of Anesthesiologists [ASA] classification 3/4 vs. ASA 1/2). Differences in clinical presentation, mortality rate, and factors associated with mortality between those two comorbidity groups were investigated. Patients and Methods: A retrospective multicenter study of patients with NSTIs between 2010 and 2020 was conducted. The primary outcome was the cause of death within the first 30 days. Furthermore, factors associated with mortality were identified. All analysis were stratified by severity of comorbidities (ASA 1/2 or ASA 3/4). Results: Of the 187 patients, 39 patients (21%) died within 30 days. American Society of Anesthesiologists 1/2 patients (overall mortality rate, 11%) died more often as direct result of the infection compared with ASA 3/4 patients (overall mortality rate, 33%) (ASA 1/2 group: 92% vs. ASA 3/4 group: 48%; p = 0.013). American Society of Anesthesiologists 3/4 patients died more often due to withdrawal of life-sustaining therapies based on assumed poor outcome after severe critical illness (ASA 1/2 group: 52% vs. ASA 3/4 group: 8%; p = 0.013). Conclusions: Mortality rates of patients with NSTIs varied from 11% in previously healthy patients to 33% in patients with multiple or severe comorbidities. The predominant cause of mortality was overwhelming infection and associated sepsis in healthy patients whereas in patients with multiple or severe pre-existing medical disease, death most often occurred after treatment limitations based on patient's wishes and prognosis.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Monika C Kerckhoffs
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands
| | - Jort Keizer
- Department of Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - Paul J van Koperen
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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15
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Ditsios K, Chitas K, Christidis P, Charatsis K, Katsimentzas T, Papadopoulos P. Necrotizing Fasciitis of the Upper Extremity - A Review. Orthop Rev (Pavia) 2022; 14:35320. [PMID: 36034724 PMCID: PMC9404292 DOI: 10.52965/001c.35320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/29/2022] [Indexed: 09/04/2024] Open
Abstract
Necrotizing fasciitis is a soft tissue infection that habitually originates from the fascial sheaths, expands at a volant pace, leads to extensive necrosis of the subcutaneous tissues, and eventually ends up in a life-threatening condition with notably elevated amputation and mortality rates. Factors that induce interruption of skin integrity, such as trauma or intravenous drug use, are the most common inciting events. Specific clinical signs heralding its presence are usually absent in the early stages, often resulting in misdiagnosis. Early recognition, prompt and aggressive surgical debridement, antibiotic use, and supportive care constitute the fundamental principles to lean on for a better prognosis. Necrotizing fasciitis of the upper extremity is relatively rare and consequently holds a limited place in the literature. Only a few studies assess it as a separate entity, with most of them being case reports or small case series. We, therefore, performed a review of the current literature, to assemble the dispersed results of different studies and clarify the various aspects of upper limb necrotizing fasciitis. In this systematic review, we present the epidemiological data, the causative events, the most frequent underlying diseases, the risk factors, the amputation and mortality rates, the pathogenic microorganisms, the clinical characteristics, the diagnostic tools, the medical and surgical management concerning necrotizing fasciitis of the upper limb. Finally, the results indicating its differentiation compared to necrotizing fasciitis of other anatomic sites are remarkably highlighted.
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Affiliation(s)
- Konstantinos Ditsios
- 2nd Academic Department of Orthopedic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | - Konstantinos Chitas
- 2nd Academic Department of Orthopedic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | | | - Konstantinos Charatsis
- 2nd Academic Department of Orthopedic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | - Triantafyllos Katsimentzas
- 2nd Academic Department of Orthopedic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | - Pericles Papadopoulos
- 2nd Academic Department of Orthopedic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
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16
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Use of Clindamycin for Necrotizing Soft Tissue Infection Decreases Amputation Rate. J Orthop Trauma 2022; 36:327-331. [PMID: 35727000 DOI: 10.1097/bot.0000000000002324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To identify the impact of clindamycin use on mortality and amputation rates in patients with necrotizing fasciitis. DESIGN Retrospective review. SETTING Level 1 trauma center, single-center study. PATIENTS/PARTICIPANTS All patients from 2008 to 2019 with a diagnosis of necrotizing fasciitis. One hundred ninety patients were included in statistical analysis. INTERVENTION Use of clindamycin in the initial antibiotic regimen in the treatment of necrotizing soft tissue infection. MAIN OUTCOME MEASUREMENTS Amputation and mortality rates. RESULTS Patients who received clindamycin had 2.92 times reduced odds of having an amputation when compared with their counterparts, even when American Society of Anesthesiologist scores, comorbidities, smoking, drug use, alcohol consumption, race, ethnicity, sex, and age were controlled for and regardless of other antibiotics started (P = 0.015). There was no significant difference in mortality rate between those patients who did and did not receive clindamycin as part of their initial antibiotic regimen (8.3% vs. 11.6%, respectively; P = 0.453). CONCLUSION The use of clindamycin in the initial antibiotic regimen for treatment of NSTI was shown to significantly decrease rates of amputation but not mortality. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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17
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Crowe CS, Yu JL, Yesantharao P, Keys K, Kennedy SA. Predictors of Mortality and Amputation in Patients With Necrotizing Soft Tissue Infections of the Upper Extremity. J Hand Surg Am 2022; 47:629-638. [PMID: 35537969 DOI: 10.1016/j.jhsa.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 12/23/2021] [Accepted: 02/09/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Necrotizing soft tissue infection (NSTI) of the upper extremity is characterized by rapid progression, local tissue necrosis, systemic toxicity, and a high mortality rate. The negative consequences of debridement are balanced against preservation of life and limb. The primary objective of this study was to identify predictors of mortality in upper extremity NSTI. Secondary objectives were to identify predictors of amputation, final defect size, length of stay, and readmission within 30 days. METHODS An institutional registry for patients with NSTI was retrospectively queried from a single tertiary center covering a large referral population. Data on confirmed upper extremity NSTI were used to determine patient characteristics, infection data, and operative factors. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) and Quick Sequential Organ Failure Assessment (qSOFA) scores were calculated from primary data to provide a measure of clinical severity. Bivariate screening identifying possible predictors of mortality and multivariable regression was performed to control for confounding. Similar analyses were performed for amputation, final defect size, and readmission within 30 days. RESULTS A total of 99 patients met the study criteria. In-hospital mortality occurred in 12 patients, and amputation was performed in 7 patients. Etiology, causative organism, and clinical severity scores were variable. Logistic regression showed mortality to be independently predicted by vasopressor dependency outside of operative anesthesia. The relatively low number of case events, limited sample size, and multiple comparisons limited the evaluation of lesser predictor variables. The LRINEC score did not strongly predict amputation or death in this series. CONCLUSIONS Necrotizing soft tissue infection of the upper extremity carries risk of mortality and amputation, and effective treatment requires prompt recognition, early goal-directed resuscitation, and early debridement. The strongest independent predictor of in-hospital mortality was vasopressor dependence outside operative anesthesia. The LRINEC score did not strongly predict death or amputation in upper extremity NSTI. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Christopher S Crowe
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Jenny L Yu
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Pooja Yesantharao
- Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA
| | - Kari Keys
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Stephen A Kennedy
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA.
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18
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Soft Tissue Reconstruction for Upper Extremity Necrotizing Soft Tissue Infections. Ann Plast Surg 2022; 89:631-636. [PMID: 35703211 DOI: 10.1097/sap.0000000000003237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION One of the main aspects of management for necrotizing soft tissue infection (NSTI) is surgical excision and debridement, which can result in large soft tissue defects. This study examined the reconstructive options and outcomes of patients with upper extremity NSTIs. METHODS A retrospective chart review was performed on patients from a single institution who were diagnosed with an upper extremity NSTI between 2014 and 2019. Patient characteristics, infectious etiology, surgical debridements, reconstructive procedures, and secondary procedures were analyzed. RESULTS There were 99 patients included in the study. The median size of the wound from the initial surgical debridement was 100 cm2 (interquartile range, 300 cm2). The mean number of debridements was 3.4. Seven patients underwent amputations, and 12 patients died. Most wounds were reconstructed via delayed primary closure (15 patients), skin grafting (16 patients), or a combination of the two (30 patients). Three patients underwent reverse radial forearm flaps, 1 patient underwent a groin flap, 3 patients underwent pedicled latissimus muscle flaps, and 2 patients underwent local flexor carpi ulnaris muscle flaps. Seven patients did not undergo any surgical reconstruction, and their wounds were managed with local wound care. Eight patients had complete or partial failure of their initial soft reconstruction requiring an additional operation, and 5 patients had secondary operations for neuromas and/or contractures. CONCLUSIONS Overall, patients with upper extremity NSTIs survive and undergo successful reconstruction of their wounds. Few patients required additional procedures for reconstructive failure or sequela of their wounds.
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19
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Dienemann L, Betz T, Töpel I, Steinbauer M. Persönliche Wahrnehmung der CoV-2-Pandemie und reales Risiko einer nekrotisierenden Fasziitis. GEFÄSSCHIRURGIE 2022; 27:51-54. [PMID: 34975232 PMCID: PMC8713545 DOI: 10.1007/s00772-021-00830-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Lucas Dienemann
- Klinik für Gefäßchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049 Regensburg, Deutschland
| | - Thomas Betz
- Klinik für Gefäßchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049 Regensburg, Deutschland
| | - Ingolf Töpel
- Klinik für Gefäßchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049 Regensburg, Deutschland
| | - Markus Steinbauer
- Klinik für Gefäßchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049 Regensburg, Deutschland
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20
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Chaomuang N, Khamnuan P, Chuayunan N, Duangjai A, Saokaew S, Phisalprapa P. Novel Clinical Risk Scoring Model for Predicting Amputation in Patients With Necrotizing Fasciitis: The ANF Risk Scoring System. Front Med (Lausanne) 2021; 8:719830. [PMID: 34869417 PMCID: PMC8639526 DOI: 10.3389/fmed.2021.719830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/18/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Necrotizing fasciitis (NF) is a life-threatening infection of the skin and soft tissue that spreads quickly and requires immediate surgery and medical treatment. Amputation or radical debridement of necrotic tissue is generally always required. The risks and benefits of both the surgical options are weighed before deciding whether to amputate or debride. This study set forth to create an easy-to-use risk scoring system for predicting the risk scoring system for amputation in patients with NF (ANF). Methods: This retrospective study included 1,506 patients diagnosed with surgically confirmed NF at three general hospitals in Thailand from January 2009 to December 2012. All diagnoses were made by surgeons who strictly observed the guidelines for skin and soft tissue infections produced by the Infectious Diseases Society of America. Patients were randomly allocated to either the derivation (n = 1,193) or validation (n = 313) cohort. Clinical risk factors assessed at the time of recruitment were used to create the risk score, which was then developed using logistic regression. The regression coefficients were converted into item scores, and the total score was calculated. Results: The following four clinical predictors were used to create the model: female gender, diabetes mellitus, wound appearance stage 3 (skin necrosis and gangrene), and creatinine ≥1.6 mg/dL. Using the area under the receiver operating characteristic curve (AuROC), the ANF system showed moderate power (78.68%) to predict amputation in patients with NF with excellent calibration (Hosmer-Lemeshow χ2 = 2.59; p = 0.8586). The positive likelihood ratio of amputation in low-risk (score ≤ 4) and high-risk (score ≥ 7) patients was 2.17 (95%CI: 1.66–2.82) and 6.18 (95%CI: 4.08–9.36), respectively. The ANF system showed good performance (AuROC 76.82%) when applied in the validation cohort. Conclusion: The developed ANF risk scoring system, which includes four easy to obtain predictors, provides physicians with prediction indices for amputation in patients with NF. This model will assist clinicians with surgical decision-making in this time-sensitive clinical setting.
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Affiliation(s)
- Natthaya Chaomuang
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | | | | | - Acharaporn Duangjai
- Unit of Excellence on Herbal Medicine, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Biofunctional Molecule Exploratory Research Group, Biomedicine Research Advancement Centre, School of Pharmacy, Monash University Malaysia, Bandar Sunway, Malaysia.,Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia.,Department of Physiology, School of Medical Sciences, University of Phayao, Phayao, Thailand
| | - Surasak Saokaew
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Unit of Excellence on Herbal Medicine, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Biofunctional Molecule Exploratory Research Group, Biomedicine Research Advancement Centre, School of Pharmacy, Monash University Malaysia, Bandar Sunway, Malaysia.,Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Pochamana Phisalprapa
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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21
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Nawijn F, de Gier B, Brandwagt DAH, Groenwold RHH, Keizer J, Hietbrink F. Incidence and mortality of necrotizing fasciitis in The Netherlands: the impact of group A Streptococcus. BMC Infect Dis 2021; 21:1217. [PMID: 34872527 PMCID: PMC8650531 DOI: 10.1186/s12879-021-06928-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Little is known about the exact incidence of necrotizing soft tissue infections. The few incidences reported in international literature are not directly relatable to the Netherlands, or other European countries, due to geographic heterogeneity in causative micro-organisms involved. This resulted in the aim of this study to map the incidence, mortality rate and hospital course of necrotizing fasciitis infections in the Netherlands to gain insight in the incidence of necrotizing fasciitis in the Netherlands and the associated mortality and health care burden. METHODS This nationwide retrospective database study used three distinct data sources to map the incidence of necrotizing fasciitis in the Netherlands between 2014 and 2019, being data from the Dutch Hospital Data (DHD) foundation, data from Osiris-AIZ, which is a database of notifiable diseases managed by regional Public Health Services (GGD) and the National Institute for Public Health and the Environment (RIVM), and previously published studies on necrotizing fasciitis conducted in the Netherlands. RESULTS The incidence of necrotizing fasciitis in the Netherlands is estimated to be approximately 1.1 to 1.4 cases per 100,000 person years, which corresponds to 193-238 patients per year. Of all necrotizing fasciitis infections, 34 to 42% are caused by the group A Streptococcus. Annually, 56 patients die as a result of a necrotizing fasciitis infection (mortality of 23-29%) and 26 patients undergo an amputation for source control (11-14%). Patients stay a mean of 6 to 7 days at the intensive care unit and have a mean hospital length of stay of 24 to 30 days. CONCLUSION The combination of nationwide databases provides reliable insight in the epidemiology of low-incidence and heterogenic diseases. In the Netherlands, necrotizing fasciitis is a rare disease with group A Streptococcus being the most common causative micro-organism of necrotizing fasciitis. The prior Dutch cohort studies on necrotizing fasciitis report slightly higher sample mortality rates, compared to the population mortality. However, necrotizing fasciitis remain associated with substantial morbidity and mortality, risk at amputation and health care burden characterized by prolonged ICU and hospital stay.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Brechje de Gier
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Utrecht, The Netherlands
| | - Diederik A H Brandwagt
- Department of Infectious Diseases, Public Health Service (GGD) Region Utrecht, Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jort Keizer
- Department of Surgery, Sint Antonius Hospital, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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22
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[Infections of the hand and forearm]. Unfallchirurg 2021; 125:9-18. [PMID: 34820739 DOI: 10.1007/s00113-021-01106-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
Infections of the hand and forearm are a frequently seen surgical emergency of the hand. Patients of all age groups are affected and underlying systemic diseases are risk factors. Posttraumatic causes are the leading cause of infections. This includes cuts and stab wounds, animal and human bites but often also minor injuries. Due to the anatomical peculiarities of the hand, rapid progression of initially inconspicuous infections can occur resulting in functional limitations. If an infection is suspected, a symptom-oriented evaluation by a hand surgeon should be performed. This includes a detailed patient history, clinical examination, laboratory analyses and imaging. This is followed by the development of an individualized and interdisciplinary treatment concept with the aim of achieving the shortest possible rehabilitation period. The treatment includes surgical cleansing of the infection, accompanied by antibiotic treatment taking the expected possible spectrum of pathogens into account. Cephalosporins and aminopenicillins in combination with beta-lactamase inhibitors are the antibiotics of first choice. Follow-up treatment includes early functional exercise under the guidance of a hand therapist to minimize postinfectious restrictions in the range of motion and to enable occupational rehabilitation. In rare cases, fulminant necrotizing infections with resulting skin and soft tissue defects can occur. In these cases, secondary plastic reconstruction is usually required after cleansing of the infection.
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23
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Nawijn F, Hietbrink F, Peitzman AB, Leenen LPH. Necrotizing Soft Tissue Infections, the Challenge Remains. Front Surg 2021; 8:721214. [PMID: 34568417 PMCID: PMC8458892 DOI: 10.3389/fsurg.2021.721214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Necrotizing Soft Tissue Infections (NSTIs) are uncommon rapidly spreading infection of the soft tissues for which prompt surgical treatment is vital for survival. Currently, even with sufficient awareness and facilities available, ambiguous symptoms frequently result in treatment delay. Objectives: To illustrate the heterogeneity in presentation of NSTIs and the pitfalls entailing from this heterogeneity. Discussion: NSTI symptoms appear on a spectrum with on one side the typical critically ill patient with fast onset and progression of symptoms combined with severe systemic toxicity resulting in severe physical derangement and sepsis. In these cases, the suspicion of a NSTI rises quickly. On the other far side of the spectrum is the less evident type of presentation of the patient with gradual but slow progression of non-specific symptoms over the past couple of days without clear signs of sepsis initially. This side of the spectrum is under represented in current literature and some physicians involved in the care for NSTI patients are still unaware of this heterogeneity in presentation. Conclusion: The presentation of a critically ill patient with evident pain out of proportion, erythema, necrotic skin and bullae is the classical presentation of NSTIs. On the other hand, non-specific symptoms without systemic toxicity at presentation frequently result in a battery of diagnostics tests and imaging before the treatment strategy is determined. This may result in a delay in presentation, delay in diagnosis and delay in definitive treatment. This failure to perform an adequate exploration expeditiously can result in a preventable mortality.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Dhanasekara CS, Marschke B, Morris E, Kahathuduwa CN, Dissanaike S. Global patterns of necrotizing soft tissue infections: A systematic review and meta-analysis. Surgery 2021; 170:1718-1726. [PMID: 34362585 DOI: 10.1016/j.surg.2021.06.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/29/2021] [Accepted: 06/21/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Frequency, microbiology, and outcomes of necrotizing soft tissue infections vary based on locoregional and environmental factors; however, there has been no global survey of these patterns. We performed a systematic review/meta-analysis on published reports of necrotizing soft tissue infections from across the globe. METHODS Peer-reviewed empirical studies examining rates of polymicrobial and monomicrobial necrotizing soft tissue infections with microbial isolation and overall mortality rate were extracted along with geographic location using PubMed, Scopus, ProQuest, and Web of Science. Random-effects meta-analyses and sensitivity analyses were performed, adjusting for publication bias. Meta-regression analyses examined moderator effects of risk factors. RESULTS One hundred and five studies (8,718 total patients) were included. Pooled prevalence of polymicrobial and monomicrobial infections were 53% and 37.9%, respectively. Truncal necrotizing soft tissue infections were commonly polymicrobial (P < .001), whereas monomicrobial infections prevailed in extremities (P = .008). Global prevalence of monomicrobial necrotizing soft tissue infections was observed to increase by 1.1% annually (P = .003). Staphylococcus aureus was the most common organism globally and in North America, Asia, the Middle East, and Africa, followed by Streptococcus pyogenes and Escherichia coli. Methicillin-resistant S. aureus accounted for 16% of necrotizing soft tissue infections globally. Overall mortality was 23.1%, observed to decline globally over the last decade (P = .020). No regional differences were noted for mortality. CONCLUSION Although polymicrobial infections remain predominant worldwide, the incidence of monomicrobial infections is increasing. The observed decline in necrotizing soft tissue infection-related mortality is encouraging and may reflect advances in management, despite major variations in available healthcare resources globally.
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Affiliation(s)
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX
| | - Chanaka N Kahathuduwa
- Department of Psychiatry, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; Department of Laboratory Sciences and Primary Care, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX.
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Lemsanni M, Najeb Y, Zoukal S, Chafik R, Madhar M, Elhaoury H. Necrotizing fasciitis of the upper extremity: a retrospective analysis of 19 cases. HAND SURGERY & REHABILITATION 2021; 40:505-512. [PMID: 33812083 DOI: 10.1016/j.hansur.2021.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 11/24/2022]
Abstract
Necrotizing fasciitis (NF) is both a limb-and life-threatening disease that affects skin, hypodermis as well as superficial fascia and deep fascia by rapidly progressive necrosis. Although this serious infection frequently occurs in the extremities, upper limb NF is a rare clinical presentation. The present study attempted to evaluate the clinical profiles, paraclinical findings, treatment modalities, outcomes and predictors of morbidity and mortality in patients with NF of the upper extremity. The validity of the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) scoring system was also assessed. Nineteen patients who were treated between January 2010 and December 2019 for NF of the upper extremity were eligible for this study. Data including demographics, clinical signs, paraclinical findings, treatment and outcomes were collected retrospectively from our medical records. Fisher's exact test was used to analyze predictive factors for mortality and morbidity. The mean age was 62 years, with a male predominance. The most common comorbidity was diabetes mellitus (42%). Main clinical manifestations were pain (79%), tense edema (79%) and a large infiltrated swollen erythematous plaque (58%). Severe sepsis and septic shock were identified in 32% and 21% of patients, respectively. Thirteen of our 19 patients (68%) were identified as having a high or intermediate likelihood of NF based of the LRINEC scoring system, while the other 6 (32%) were classified as having low likelihood. All patients received systemic broad spectrum antibiotic therapy in addition to surgical debridement. Two patients (10%) died and one (5%) required amputation. Mortality was associated with septic shock (p = 0.006), delay in surgery >24 h (p = 0.018), creatininemia >141 mmol/l (p = 0.018) and LRINEC score ≥ 8 (p = 0.035). Otherwise, anemia (p = 0.021), hypercreatininemia (p = 0.001) and delayed surgical debridement (p = 0.001) were risk factors for morbidity and mortality. The surviving patients underwent reconstructive surgery (skin grafting after wound preparation by using vacuum therapy) with positive outcome. Early diagnosis coupled with emergent surgical debridement and broad-spectrum empiric antibiotic therapy are the keystones of a successful outcome. The LRINEC score was not strongly correlated to the true diagnosis of NF and was a prognostic tool rather than a diagnostic one.
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Affiliation(s)
- M Lemsanni
- Department of Orthopedic and Trauma Surgery, Ibn Tofail Hospital, Mohammed VI University Hospital Center, Abdelouahab Derraq Street, PB 40000, Marrakesh, Morocco.
| | - Y Najeb
- Department of Orthopedic and Trauma Surgery, Ibn Tofail Hospital, Mohammed VI University Hospital Center, Abdelouahab Derraq Street, PB 40000, Marrakesh, Morocco
| | - S Zoukal
- Epidemiology Laboratory of the Faculty of Medicine and Pharmacy of Casablanca, Casablanca, Morocco
| | - R Chafik
- Department of Orthopedic and Trauma Surgery, Ibn Tofail Hospital, Mohammed VI University Hospital Center, Abdelouahab Derraq Street, PB 40000, Marrakesh, Morocco
| | - M Madhar
- Department of Orthopedic and Trauma Surgery, Ibn Tofail Hospital, Mohammed VI University Hospital Center, Abdelouahab Derraq Street, PB 40000, Marrakesh, Morocco
| | - H Elhaoury
- Department of Orthopedic and Trauma Surgery, Ibn Tofail Hospital, Mohammed VI University Hospital Center, Abdelouahab Derraq Street, PB 40000, Marrakesh, Morocco
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26
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Rampal S, Maniam S, Lim PY, Ramachandran R, Tan EK, Halim MAHA, Shamsudin Z, Singh SSS, Narayanan P, Neela VK. Necrotizing fasciitis, causative agents and management: a five-year retrospective study in two tertiary care hospitals in Central Malaysia. INTERNATIONAL ORTHOPAEDICS 2021; 45:1399-1405. [PMID: 33484294 DOI: 10.1007/s00264-020-04905-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Necrotizing fasciitis (NF) is a rapidly progressive inflammatory infection of the fascia, with secondary necrosis of the subcutaneous tissues. The severity of the disease depends on the virulence of the organism and host immunity. There is a paucity of reports on the prevalence of NF causing pathogens and management. METHODS Retrospective data of patients treated for NF were collected from two tertiary care hospitals in Central Malaysia between January 2014 and December 2018. RESULTS A total of 469 NF patients were identified. More than half of the NF patients were males (n = 278; 59.28%). The highest number of cases was found among age groups between 30 and 79, with mean age of 56.17. The majority of the NF cases (n = 402; 85.72%) were monomicrobial. Streptococcus spp. (n = 89; 18.98%), Pseudomonas aeruginosa (n = 63; 13.44%) and Staphylococcus spp. (n = 61; 13.01%) were identified as the top three microorganisms isolated. Among the 469 NF cases, 173 (36.8%) were amputated or dead while 296 (63.1%) recovered. Proteus spp. (n = 19; 12.93%), Klebsiella pneumoniae (n = 18; 12.24%) and Escherichia coli (n = 14; 9.52%) were associated with all types of amputations. The most common antibiotic prescribed was unasyn (n = 284; 60.56%), followed by clindamycin (n = 56; 11.94%) and ceftazidime (n = 41; 8.74%). A total of 239 (61.8%) recovered while 148 (38.2%) were either amputated or dead when managed with the unasyn, clindamycin or ceftazidime. CONCLUSION This study represents the largest NF cases series in Malaysia highlighting the causative agents and management.
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Affiliation(s)
- Sanjiv Rampal
- Department of Orthopaedic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Sandra Maniam
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Poh Ying Lim
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Rubenandran Ramachandran
- Department of Orthopaedic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Eng Kee Tan
- Department of Orthopaedic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Mohd Asyraf Hafizuddin Ab Halim
- Department of Orthopaedic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Zulfahrizzat Shamsudin
- Orthopaedic Department, Hospital Tuanku Ja'afar, Jalan Rasah, Bukit Rasah, 70300, Seremban, Negeri Sembilan, Malaysia
| | - Sandeep Singh Sarawan Singh
- Orthopaedic Department, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah, 68000, Ampang, Selangor Darul Ehsan, Malaysia
| | - Pravind Narayanan
- Department of Internal Medicine, Hospital Sarikei, Jalan Rentap, 96100, Sarikei, Sarawak, Malaysia
| | - Vasantha Kumari Neela
- Department of Medical Microbiology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia.
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Das De S, Liang ZC, Cheah AEJ, Puhaindran ME, Lee EY, Lim AYT, Chong AKS. Emergency Hand and Reconstructive Microsurgery in the COVID-19-Positive Patient. J Hand Surg Am 2020; 45:869-875. [PMID: 32888437 PMCID: PMC7388858 DOI: 10.1016/j.jhsa.2020.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/25/2020] [Accepted: 07/27/2020] [Indexed: 02/02/2023]
Abstract
The case spectrum in hand surgery is one of extremes-purely elective day surgery cases under local anesthesia to mangling limb injuries that require immediate, and frequently, lengthy, surgery. Despite the cancellation of most elective orthopedic and plastic surgical procedures, hand surgeons around the world continue to see a steady stream of limb-threatening cases such as severe trauma and infections that require emergent surgical care. With the increase in community-spread, an increasing number of COVID-19-infected patients may be asymptomatic or have mild, nonspecific or atypical symptoms. Some of them may already have an ongoing, severe infection. The time-sensitive nature of some of these cases means that hand surgeons may need to operate urgently on patients who may be suspected of COVID-19 infections, often before confirmatory test results are available. General guidelines for perioperative care of the COVID-19-positive patient have been published. However, our practices differ from those of general orthopedic and plastic surgery, primarily because of the focus on trauma. This article discusses the perioperative and technical considerations that are essential to manage the COVID-19 patient requiring emergency care, without compromising clinical outcomes and while ensuring the safety of the attending staff.
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Affiliation(s)
- Soumen Das De
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore,Corresponding author: Soumen Das De, MBBs, MPH, National University Health System, 1E Kent Ridge Rd., Singapore 119228
| | - Zhen Chang Liang
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Andre Eu-Jin Cheah
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Mark Edward Puhaindran
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Ellen Yutan Lee
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Aymeric Yu Tang Lim
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
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