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4th World Trauma Congress Article
Chance to cut: defining a negative exploration rate in patients with suspected necrotizing soft tissue infection
  1. Erin C Howell1,
  2. Jessica A Keeley2,
  3. Amy H Kaji3,
  4. Molly R Deane1,
  5. Dennis Y Kim1,
  6. Brant Putnam1,
  7. Steven L Lee4,
  8. Alexis L Woods5,
  9. Angela L Neville1
  1. 1 Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
  2. 2 Department of Surgery, University of California, San Francisco East Bay, Oakland, California, USA
  3. 3 Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
  4. 4 Division of Pediatric Surgery, UCLA Mattel Children’s Hospital, Los Angeles, California, USA
  5. 5 David Geffen School of Medicine at UCLA, Los Angeles, California, USA
  1. Correspondence to Dr Angela L Neville, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA 90509, USA; aneville{at}dhs.lacounty.gov

Abstract

Background Necrotizing soft tissue infections (NSTI) are aggressive infections associated with significant morbidity and mortality. Despite multiple predictive models for the identification of NSTI, a subset of patients will not have an NSTI at the time of surgical exploration. We hypothesized there is a subset of patients without NSTI who are clinically indistinguishable from those with NSTI. We aimed to characterize the differences between NSTI and non-NSTI patients and describe a negative exploration rate for this disease process.

Methods We conducted a retrospective review of adult patients undergoing surgical exploration for suspected NSTI at our county-funded, academic-affiliated medical center between 2008 and 2015. Patients were identified as having NSTI or not (non-NSTI) based on surgical findings at the initial operation. Pathology reports were reviewed to confirm diagnosis. The NSTI and non-NSTI patients were compared using χ2 test, Fisher’s exact test, and Wilcoxon rank-sum test as appropriate. A p value <0.05 was considered significant.

Results Of 295 patients undergoing operation for suspected NSTI, 232 (79%) were diagnosed with NSTI at the initial operation and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess and 58 (92%) had cellulitis resulting in a total of 237 patients (80%) with a surgical disease process. Patients with NSTI had higher white cell counts (18.5 vs. 14.9 k/mm3, p=0.02) and glucose levels (244 vs. 114 mg/dL, p<0.0001), but lower sodium values (130 vs. 134 mmol/L, p≤0.0001) and less violaceous skin changes (9.2% vs. 23.8%, p=0.004). Eight patients (14%) initially diagnosed with cellulitis had an NSTI diagnosed on return to the operating room for failure to improve.

Conclusions Clinical differences between NSTI and non-NSTI patients are subtle. We found a 20% negative exploration rate for suspected NSTI. Close postoperative attention to this cohort is warranted as a small subset may progress.

Level of evidence Retrospective cohort study, level III.

  • necrotizing soft tissue infections
  • necrotizing fasciitis
  • diagnosis
  • debridement
  • negative exploration

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/tsaco-2018-000264

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    Footnotes

    • Presented at Presented as an oral presentation on September 27, 2018 at the 4th World Trauma Congress in San Diego, CA.

    • Contributors All authors made significant contributions to this project and have had input on the final submission of this article. ECH, ALN: study inception/design, data collection, data analysis, creating tables/figures, drafting and critical revisions of the article. JAK: study inception/design, data collection, creating tables/figures, drafting and critical revisions of the article. AHK: study inception/design, data analysis, drafting and critical revisions of the article. MRD, DYK, BP, SLL: study inception/design, critical revisions of the article. ALW: data collection, drafting and critical revision of the article.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval Institutional Review Board at Harbor-UCLA Medical Center, and Los Angeles Biomedical Institute.

    • Provenance and peer review Not commissioned; externally peer reviewed.