Surgical Decision Making by Rifat Latifi

Author:Rifat Latifi
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

The Management

The aforementioned case example and data from our own clinical practice demonstrate that surgical intervention within the first 6 h after diagnosis of NSTIs improves hospital outcomes in terms of shortening both the hospital length of stay (LOS) and intensive care unit (ICU) LOS [22]. In our study, the overall mortality was 12.5 % (or 11/87), which is less than has been reported in many previous studies [13, 23–25]. Although there was a clinically significant difference in the mortality between the groups based on the timing of surgical intervention (17.5 % in late vs. 7.5 % in early intervention group), this did not reach statistical significance.

NSTIs, in particular necrotizing fasciitis, remain the most deadly surgical infections if not treated aggressively with resuscitation and surgical debridement . Early diagnosis, early antibiotic treatment, and early surgical debridement remain the cornerstone of care for these patients. While “early” has not been clearly defined, we believe that surgery in these patients should be performed within the first few hours and no longer than 6 h [22]. In a study by McHenry et al., the mean time from admission to operation was 45 h (range: 1.7–312 h), while average time from admission to operation was 90 h for non-survivors versus 25 h in the survivors group (p = 0.0002) [26]. In our study, we found that patients with NSTIs required an operation as soon as possible and certainly no later than 6 h after their arrival or presentation to the emergency department. In fact, most of our early group patients underwent an operation even earlier, within a mean time of 2.95 ± 1.1 h.

In patients with NSTIs, the most common reason for a delay in surgery is difficulty in making the correct diagnosis. Erythema, tenderness, and swelling are all common. The clinical presentation can be deceiving, particularly in immunocompromised patients, ranging from indolent wound infections to severe gangrene with septic shock, as defined with end organ failure requiring vasopressors despite adequate fluid resuscitation [27]. Often patients seem too sick to be immediately operated on, so clinicians will attempt to resuscitate them first, resulting in significantly delayed surgery or the clinical presentation is deceiving, particularly in immunocompromised patients [28]. However, one has to keep in mind that source control of the infection is the priority in the management of any critically ill patients. These patients should be treated with the same urgency as a gunshot wound or any other major insult to the body.

Despite numerous scoring systems and models introduced to discriminate between NSTIs and non-necrotizing soft tissue infections, making the diagnosis, predicting mortality and limb loss in NSTIs is still difficult [29, 30] and the most important element remains early clinical recognition (Fig. 12.1a–d). Yet, there can be considerable diagnostic challenges when one is faced with “bad-looking” cellulitis and trying to distinguish it from NSTs. While we do not have a set protocol managing these patients, most patients will get a CT scan or more commonly an MRI if no clear clinical indication for surgery exists. As mentioned

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