坏死性软组织感染评分的前瞻性推导与验证：一项东部创伤外科学会多中心试验

Prospective derivation and validation of a necrotizing soft tissue infections score: An EASTmulticenter trial.

作者信息

Kim Dennis Y, Lavasile Amanda, Kaji Amy H, Nahmias Jeffry, Grigorian Areg, Mukherjee Kaushik, Penaloza Liz, Posluszny Joseph, Logan Charles D, Michelin Erika, Serena Thomas, Sahr Sheryl, Bekdache Khaldoun, Stoddard Nathan, Choudhry Asad, Encalada Ronald Zerna, Saltzman Darin, Padilla Reynaldo, Truitt Michael, Grossman Verner Heather, Hunt Darren, Purvis Victoria, Ross Samuel Wade, Mallah Mike M, Dultz Linda, Kuhlenschmidt Kali, Mentzer Caleb J, Lonkar Adwait, Chang Grace, Lemon Brittney, de Virgilio Christian

机构信息

From the Division of Trauma/Acute Care Surgery/Surgical Critical Care (D.Y.K.), Harbor-UCLA Medical Center, Torrance; Western University of Health Sciences (A.I.), Pomona; Department of Emergency Medicine (A.H.K.), Harbor-UCLA Medical Center, Torrance; Division of Trauma, Burns, Critical Care and Acute Care Surgery, Department of Surgery (J.N.), UCI School of Medicine, Irvine; University of Southern California (A.G.), Los Angeles; Division of Acute Care Surgery (K.M., L.P.), Loma Linda University Medical Center, Loma Linda, California; Division of Trauma and Critical Care (J.P.), Northwestern University Feinberg School of Medicine; Surgical Outcomes and Quality Improvement Center, Department of Surgery (C.D.L.), Northwestern Medicine, Chicago, Illinois; Department of Surgery (E.M., T.S.), Beaumont Health, Dearborn, Michigan; Department of Trauma Research (S.S.), Sanford Health, Sioux Falls, South Dakota; Section of Trauma and General Surgery (K.B.), Northern Light Eastern Maine Medical Center, Portland; College of Osteopathic Medicine (N.S.), University of New England, Biddeford, Maine; Department of Surgery (A.C., R.Z.E.), SUNY Upstate Medical University, Syracuse, New York; Olive View-UCLA Medical Center (D.S., R.P.), Olive View-UCLA Education and Research Institute, Sylmar, California; Department of Surgery (M.T.), and Methodist Health Systems CRI, Methodist Dallas Medical Center (H.G.V.), Dallas, Texas; Division of Trauma (D.H., V.P.), University of Tennessee, Chattanooga, Tennessee; Division of Acute Care Surgery (S.W.R., M.M.M.), Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, North Carolina; Division of Burns, Trauma, Acute and Critical Care Surgery (L.D., K.K.), University of Texas Southwestern Medical Center, Dallas, Texas; Division of Trauma/Acute Care Surgery/Surgical Critical Care (C.J.M., A.L.), Spartanburg Regional Medical Center, Spartanburg, South Carolina; Division of Trauma (G.C., B.L.), Mount Sinai Hospital, Chicago, Illinois; and Department of Surgery (C.d.V.), Harbor-UCLA Medical Center, Torrance, California.

出版信息

J Trauma Acute Care Surg. 2024 Dec 1;97(6):910-917. doi: 10.1097/TA.0000000000004374. Epub 2024 May 9.

DOI:10.1097/TA.0000000000004374

PMID:38720193

Abstract

BACKGROUND

Although several risk indices have been developed to aid in the diagnosis of necrotizing soft tissue infections (NSTIs), these instruments suffer from varying levels of reproducibility and failure to incorporate key clinical variables in model development. The objective of this study was to derive and validate a clinical risk index score, NECROSIS, for identifying NSTIs in emergency general surgery (EGS) patients being evaluated for severe skin and soft tissue infections.

METHODS

We performed a prospective study across 16 sites in the United States of adult EGS patients with suspected NSTIs over a 30-month period. Variables analyzed included demographics, admission vitals and laboratories, physical examination, radiographic, and operative findings. The main outcome measure was the presence of NSTI diagnosed clinically at the time of surgery. Multivariate analysis was performed to identify independent predictors for the presence of NSTI using the Hosmer-Lemeshow test and the Akaike information criteria.

RESULTS

Of 362 patients, 297 (82%) were diagnosed with an NSTI. Overall mortality was 12.3%. Multivariate analysis identified three independent predictors for NSTI: systolic blood pressure of ≤120 mm Hg, violaceous skin, and white blood cell count of ≥15 × 10 3 /μL. Multivariate modeling demonstrated Hosmer-Lemeshow goodness of fit ( p = 0.9) with a c statistic for the prediction curve of 0.75. Test characteristics of the NECROSIS score were similar between the derivation and validation cohorts.

CONCLUSION

NECROSIS is a simple and potentially useful clinical index score for identifying at-risk EGS patients with NSTIs. Future validation studies are warranted.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level III.

摘要

背景

尽管已经开发了几种风险指数来辅助诊断坏死性软组织感染（NSTIs），但这些工具在可重复性方面存在不同程度的问题，并且在模型开发中未能纳入关键临床变量。本研究的目的是推导并验证一种临床风险指数评分NECROSIS，用于识别在接受严重皮肤和软组织感染评估的急诊普通外科（EGS）患者中是否存在NSTIs。

方法

我们在美国16个地点对成年EGS疑似NSTIs患者进行了一项为期30个月的前瞻性研究。分析的变量包括人口统计学、入院生命体征和实验室检查、体格检查、影像学检查以及手术结果。主要结局指标是手术时临床诊断的NSTIs的存在情况。使用Hosmer-Lemeshow检验和赤池信息准则进行多变量分析，以确定NSTIs存在的独立预测因素。

结果

362例患者中，297例（82%）被诊断为NSTIs。总体死亡率为12.3%。多变量分析确定了NSTIs的三个独立预测因素：收缩压≤120 mmHg、皮肤呈紫罗兰色以及白细胞计数≥15×10³/μL。多变量建模显示Hosmer-Lemeshow拟合优度良好（p = 0.9），预测曲线的c统计量为0.75。推导队列和验证队列之间NECROSIS评分的检验特征相似。