Elliott D C, Kufera J A, Myers R A
Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA.
Ann Surg. 1996 Nov;224(5):672-83. doi: 10.1097/00000658-199611000-00011.
The authors evaluate in a retrospective fashion the factors influencing outcome in a large group of patients presenting with necrotizing soft tissue infections, and, based on this analysis, propose a plan for optimal care of such patients.
In many smaller series of patients with necrotizing soft tissue infections, similar analyses of risk factors for mortality have been performed, producing conflicting conclusions regarding optimal care. In particular, debate exists regarding the impact of concurrent physiologic derangements, type and extent of infection, and the role of hyperbaric oxygen in treatment.
A retrospective chart review of 198 consecutive patients with documented necrotizing soft tissue infections, treated at a single institution during an 8-year period, was conducted. Using a model for logistic regression analysis, characteristics of each patient and his/her clinical course were tested for impact on outcome.
The mortality rate among the 198 patients was 25.3%. The most common sites of origin of infection were the perineum (Fournier's disease; 36% of cases) and the foot (in diabetics; 15.2%). By logistic regression analysis, risk factors for death included age, female gender, extent of infection, delay in first debridement, elevated serum creatinine level, elevated blood lactate level, and degree of organ system dysfunction at admission. Diabetes mellitus did not predispose patients to death, except in conjunction with renal dysfunction or peripheral vascular disease. Myonecrosis, noted in 41.4% of the patients who underwent surgery, did not influence mortality.
Necrotizing soft tissue infections represent a group of highly lethal infections best treated by early and repeated extensive debridement and broad-spectrum antibiotics. Hyperbaric oxygen appears to offer the advantage of early wound closure. Certain markers predict those individuals at increased risk for multiple-organ failure and death and therefore assist in deciding allocation of intensive care resources.
作者以回顾性方式评估了一大群患有坏死性软组织感染患者的预后影响因素，并基于此分析提出了对此类患者的最佳护理方案。
在许多关于坏死性软组织感染患者的较小系列研究中，已对死亡率的危险因素进行了类似分析，但对于最佳护理得出了相互矛盾的结论。特别是，关于并发生理紊乱、感染类型和范围以及高压氧在治疗中的作用存在争议。
对在一家机构8年期间治疗的198例有记录的坏死性软组织感染患者进行了回顾性病历审查。使用逻辑回归分析模型，测试了每位患者的特征及其临床病程对预后的影响。
198例患者的死亡率为25.3%。感染最常见的起源部位是会阴部（福尼尔氏病；36%的病例）和足部（糖尿病患者；15.2%）。通过逻辑回归分析，死亡的危险因素包括年龄、女性性别、感染范围、首次清创延迟、血清肌酐水平升高、血乳酸水平升高以及入院时器官系统功能障碍程度。糖尿病本身并不会使患者易患死亡，除非合并肾功能不全或外周血管疾病。在接受手术的患者中，41.4%出现了肌坏死，但这并未影响死亡率。
坏死性软组织感染是一组高致死性感染，最好通过早期和反复广泛清创以及广谱抗生素进行治疗。高压氧似乎具有促进伤口早期愈合的优势。某些指标可预测那些发生多器官功能衰竭和死亡风险增加的个体，因此有助于决定重症监护资源的分配。
