切开时机：界定疑似坏死性软组织感染患者的阴性探查率
Chance to cut: defining a negative exploration rate in patients with suspected necrotizing soft tissue infection.
作者信息
Howell Erin C, Keeley Jessica A, Kaji Amy H, Deane Molly R, Kim Dennis Y, Putnam Brant, Lee Steven L, Woods Alexis L, Neville Angela L
机构信息
Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA.
Department of Surgery, University of California, San Francisco East Bay, Oakland, California, USA.
出版信息
Trauma Surg Acute Care Open. 2019 Feb 27;4(1):e000264. doi: 10.1136/tsaco-2018-000264. eCollection 2019.
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 χ 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/mm, 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.
背景
坏死性软组织感染（NSTI）是一种侵袭性感染，与显著的发病率和死亡率相关。尽管有多种用于识别NSTI的预测模型，但一部分患者在手术探查时并无NSTI。我们推测存在一部分无NSTI的患者，其在临床上与有NSTI的患者无法区分。我们旨在描述NSTI患者与非NSTI患者之间的差异，并阐述该疾病过程的阴性探查率。
方法
我们对2008年至2015年间在我们县资助的、与学术机构相关的医疗中心因疑似NSTI接受手术探查的成年患者进行了回顾性研究。根据初次手术的手术结果将患者确定为患有NSTI或未患有NSTI（非NSTI）。审查病理报告以确认诊断。根据情况使用χ检验、Fisher精确检验和Wilcoxon秩和检验对NSTI患者和非NSTI患者进行比较。p值<0.05被认为具有统计学意义。
结果
在295例因疑似NSTI接受手术的患者中，232例（79%）在初次手术时被诊断为NSTI，63例（21%）未被诊断为NSTI。在这63例患者中，5例（7.9%）有脓肿，58例（92%）有蜂窝织炎，导致共有237例（80%）患者存在手术疾病过程。NSTI患者的白细胞计数较高（18.5对14.9×10³/mm³，p = 0.02）和血糖水平较高（244对114mg/dL，p<0.0001），但钠值较低（130对134mmol/L，p≤0.0001），且皮肤紫绀变化较少（9.2%对23.8%，p = 0.004）。8例最初被诊断为蜂窝织炎的患者在因病情未改善返回手术室时被诊断为NSTI。
结论
NSTI患者与非NSTI患者之间的临床差异很细微。我们发现疑似NSTI的阴性探查率为20%。鉴于一小部分患者可能会病情进展，因此有必要对这组患者进行密切的术后观察。
证据级别
回顾性队列研究，III级。
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