Introduction
Materials and methods
Study design
The approach of triple diagnostics
Group 1 | Intra-operative findings of necrotic fascia and/or muscle resulting in immediate decision to perform debridement |
Group 2 | Intra-operative findings of fascial edema combined with positive intra-operative results of the fascia frozen section OR Gram staining, requiring further exploration and debridement |
Group 3 | Negative exploration with no macroscopic intra-operative abnormalities or macroscopic fascial edema, together with negative intra-operative results of the fascia frozen section AND Gram staining |
Statistical analysis
Results
Patient demographics
Total | Group 1 | Group 2 | Group 3 | |
---|---|---|---|---|
n = 36 | n = 16 (44%) | n = 12 (33%) | n = 8 (22%) | |
Age in years, mean ± SD | 54 ± 16 | 55 ± 17 | 52 ± 16 | 54 ± 15 |
ASA classification, n (%) | ||||
I | 7 (20) | 6 (37) | 1 (8) | 0 (0) |
II | 5 (14) | 3 (19) | 1 (8) | 1 (12.5) |
III | 12 (33) | 3 (19) | 6 (50) | 3 (37.5) |
IV | 12 (33) | 4 (25) | 4 (34) | 4 (50) |
Medical history, n (%) | ||||
Diabetes mellitus | 5 (14) | 2 (13) | 2 (17) | 1 (12.5) |
Cardiovascular disease | 15 (42) | 7 (44) | 5 (42) | 3 (37.5) |
Pulmonary disease | 11 (31) | 4 (25) | 5 (42) | 2 (25) |
Malignancy | 5 (14) | 3 (19) | 1 (8) | 1 (12.5) |
Auto-immune disease | 13 (36) | 3 (19) | 6 (50) | 4 (50) |
Morbid obesity (body mass index ≥35 kg/m2) | 3 (8) | 1 (6) | 2 (17) | 0 (0) |
Surgery within past 30 days | 8 (22) | 5 (31) | 2 (17) | 1 (12.5) |
Locations with signs of SNSTD n (%) | ||||
Head/neck | 3 (8) | 2 (12.5) | 1 (8) | 0 (0) |
Upper extremity | 3 (8) | 2 (12.5) | 1 (8) | 0 (0) |
Trunk | 6 (17) | 4 (25) | 1 (8) | 1 (12.5) |
Perineum | 2 (6) | 2 (12.5) | 0 (0) | 0 (0) |
Lower extremity | 21 (58) | 6 (37.5) | 8 (66) | 7 (87.5) |
Whole body (>50% of total body surface area affected) | 1 (3) | 0 (0) | 1 (8) | 0 (0) |
Vital functions at presentation, median (IQR) | ||||
Systolic blood pressure in mmHga | 117 (90–139) | 110 (80–120) | 118 (87–148) | 131 (115–140) |
Pulse rate in beats per minuteb | 104 (87–114) | 109 (84–114) | 107 (84–119) | 100 (91–112) |
Breathing frequency per minutec | 20 (18–28) | 20 (18–29) | 18 (16–40) | 28 |
LRINEC Scoreb, mean ± SD | 6 ± 3 | 7 ± 2 | 5 ± 3 | 5 ± 3 |
Laboratory results | ||||
Leukocytes in 10 × 9/L (normal range: 4.0–10.0 10 × 9/L) median (IQR) | 11.7 (6.8–18.3) | 13.2 (5.5–21.6) | 11.6 (8.7–13.2) | 10.5 (5.1–16.5) |
CRP in mg/La (normal range: <10 mg/L), mean ± SD | 231 ± 144 | 278 ± 137 | 216 ± 157 | 168 ± 124 |
Hemoglobin in mmol/L (normal range: ♂ 8.6–10.7 mmol/L; ♀ 7.4–9.6 mmol/L), mean ± SD | 7.6 ± 1.3 | 7.8 ± 1.2 | 7.4 ± 1.6 | 7.5 ± 1.4 |
Sodium in mmol/L (normal range: 136–146 mmol/L), median (IQR) | 135 (133–137) | 135 (133–136) | 135 (133–137) | 134 (132–139) |
Creatinine in μmol/L (normal range: ♂ 64–104 μmol/L; ♀49–90 μmol/L)a, median (IQR) | 112 (78–196) | 167 (107–338) | 119 (58–216) | 79 (65–97) |
Glucose in mmol/L (normal range: 3.5–7.8 mmol/L), median (IQR) | 6.6 (5.7–7.5) | 7.1 (6.1–7.7) | 6.3 (5.5–7.4) | 6.3 (5.6–7.3) |
Creatine kinase in U/L (♂ < 170 U/L; ♀ < 145 U/L)d, median (IQR) | 156 (74–395) | 231 (61–345) | 110 (36–682) | 124 (88 - 180) |
Arterial blood gas results at presentation, mean ± SD | ||||
pH (normal range: 7.37–7.45)e | 7.38 ± 0.11 | 7.34 ± 0.09 | 7.39 ± 0.10 | 7.48 ± 0.06 |
pCO2 in mmHg (normal range: 35–45 mmHg)f | 35 ± 9 | 34 ± 9 | 37 ± 10 | 34 ± 4 |
Bicarbonate in mmol/L (normal range: 22–29 mmol/L)e | 20 ± 5 | 18 ± 4 | 22 ± 5 | 25 ± 2 |
Base deficit in mmol/L (normal range: −3 to +3 mmol/L)e | 5 ± 6 | 8 ± 6 | 3 ± 6 | − 1 ± 2 |
Hours since onset symptoms, median (IQR) | 24 (20–66) | 24 (12–72) | 24 (20–48) | 42 (24–69) |
Hours from suspicion to surgery, median (IQR) | 1.5 (0.5–2) | 1 (0.5–2) | 2 (1.5–2.25) | 1.75 (0.75–2.5) |
Intra-operative macroscopic findings, n (%) | ||||
Necrotic fascia and/or muscle | 16 (44) | 16 (100) | 0 (0) | 0 (0) |
Edema of tissue and/or “dishwater” fluid | 16 (44) | 0 (0) | 12 (100) | 4 (50) |
No abnormalities | 4 (11) | 0 (0) | 0 (0) | 4 (50) |
Intra-operative fresh-frozen section results, n (%) | ||||
Necrosis of fascia | 14 (39) | 7 (44) | 7 (58) | 0 (0) |
Suggestive findings for SNSTD | 8 (22) | 2 (12) | 5 (42) | 1 (12.5) |
Inflammation surrounding fascia | 2 (6) | 0 (0) | 0 (0) | 2 (25) |
No abnormalities | 8 (22) | 4 (25) | 0 (0) | 4 (50) |
Not performed | 4 (11) | 3 (19) | 0 (0) | 1 (12.5) |
Intra-operative Gram stain results, n (%) | ||||
Bacteria in fascia | 28 (78) | 15 (94) | 12 (100) | 1 (12.5) |
No bacteria in fascia | 7 (19) | 0 (0) | 0 (0) | 7 (87.5) |
Not performed | 1 (3) | 1 (6) | 0 (0) | 0 (0) |
Type of SNSTDb, n (%) | ||||
Type I | 7 (26) | 4 (25) | 3 (27) | NA |
Type II | 18 (67) | 11 (69) | 7 (64) | NA |
Type III | 2 (7) | 1 (6) | 1 (9) | NA |
Final cultures, n (%) | ||||
Streptococcus pyogenes | 17 (61) | 10 (62.5) | 5 (42) | NA |
Mixed flora | 5 (18) | 3 (19) | 2 (17) | NA |
Vibrio species or Clostridium species | 1 (4) | 1 (6) | 0 (0) | NA |
Isolated other bacteria | 4 (14) | 2 (12.5) | 4 (33) | NA |
No further differentiation | 1 (4) | 0 (0) | 1 (8) | NA |
Type of debridement, n (%) | ||||
Skin-sparing debridement | 1 (4) | 0 (0) | 1 (8) | NA |
Partial skin-sparing debridement | 8 (28) | 5 (31) | 3 (25) | NA |
No attempt at skin-sparing debridement | 18 (64) | 11 (69) | 7 (59) | NA |
No resection due to “to much” | 1 (4) | 0 (0) | 1 (8) | NA |
Total SNSTD patients n = 28 (100%) | Group 1 n = 16 (57%) | Group 2 n = 12 (43%) | p value | |
---|---|---|---|---|
Length of hospital stay in days, median (IQR) | 18 (9–29) | 23 (12–34) | 167 (5–19) | 0.285 |
Length of intensive care stay in days, median (IQR) | 3 (1–8) | 6 (3–10) | 2 (0–3) |
0.031
|
Amputation, n (%) | 1 (4) | 1 (6) | 0 (0) | 1.000 |
In-hospital mortality rate, n (%) | 7 (25) | 4 (25) | 3 (25) | 1.000 |
ASA classification of deceased patients, median (IQR) | 4 (4–4) | 4 (4–4) | 4 (4–4) | NA |
Death SNSTD related (e.g., MOF) | 3 (11) | 2 (12.5) | 1 (8) | 1.000 |
Withdrawal of treatment due to comorbidities | 4 (14) | 2 (12.5) | 2 (17) | 1.000 |
Days until death, median (IQR) | 2 (1–7) | 5 (1–19) | 2 (1–3) | 0.593 |
Days until SNSTD-related death | 1 (0–1) | 1 (0–1) | 1 | 1.000 |
Days until death due to withdrawal of treatment due to comorbidities | 5 (3–19) | 19 (7–30) | 3 (2–3) | 0.121 |