Article – 1 - Necrotizing soft tissue infection
Title: Adjuvant hyperbaric oxygen therapy (HBO2)for treatment of necrotizing fasciitis reduces mortality and amputation rate.
Authors: Escobar, SJ; Slade Jr, JB; Hunt, TK; Cianci, PE
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: A retrospective analysis of 42 patients with necrotizing soft tissue infections treated with adjunctive HBO2 to ascertain efficacy and safety. Overall mortality was 11.9% and morbidity 5%. Necrotizing soft tissue infections have historically high rates of mortality and morbidity, including amputation. Common misconceptions that prevent widespread use of adjunctive HBO2 for this diagnosis include delays to surgery, increased morbidity, and significant complications. Forty-two consecutive patients (average age 56.1) with necrotizing fasciitis presenting to a major referral center were treated with adjunctive HBO2 as part of an aggressive program of surgery, antibiotics, and critical care. Involved areas included the lower abdomen (15 patients), thigh and perineum (9 patients), flank (4 patients), lower leg (3 patients), and arm, shoulder, and axilla (2 patients). Co-morbidities included diabetes mellitus, chronic renal failure, intravenous drug abuse, peripheral vascular disease, and malignancy.
Results: Mortality was 11.9% (5 patients). Both amputations (a finger and a penis), occurred prior to transport to our facility. The average number of surgical debridements was 2.8 per patient; 1.25 performed prior to the start of HBO. The infectious process was controlled after an average of 7 HBO2 treatments were administered to ensure successful wound closure. Complications consisted of only mild ear barotrauma in 3 patients (7%), and confinement anxiety in 17 (41%) but did not prevent treatment.
Conclusion: Compared to national reports of outcomes with "standard" regimens for necrotizing fasciitis, our experience with HBO2, adjunctive to comprehensive and aggressive management, demonstrates reduced mortality (34% v. 11.9%), and morbidity (amputations 50% v. 0%). The treatments were safe and no delays to surgery or interference with standard therapy could be attributed to HBO2.
Article – 2 - Necrotizing soft tissue infection
Title: Necrotizing soft tissue infections
Authors: John D Urschel
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Abstract: Necrotizing soft tissue infections are a group of highly lethal infections that typically occur after trauma or surgery. Many individual infectious entities have been described, but they all have similar pathophysiologies, clinical features, and treatment approaches. The essentials of successful treatment include early diagnosis, aggressive surgical debridement, antibiotics, and supportive intensive treatment unit care. The two commonest pitfalls in management are failure of early diagnosis and inadequate surgical debridement. These life-threatening infections are often mistaken for cellulitis or innocent wound infections, and this is responsible for diagnostic delay. Tissue gas is not a universal finding in necrotizing soft tissue infections. This misconception also contributes to diagnostic errors. Incision and drainage is an inappropriate surgical strategy for necrotizing soft tissue infections; excisional debridement is needed. Hyperbaric oxygen therapy may be useful, but it is not as important as aggressive surgical therapy. Despite advances in antibiotic therapy and intensive treatment unit medicine, the mortality of necrotizing soft tissue infections is still high.
Conclusion: This article emphasizes common treatment principles for all of these infections, and reviews some of the more important individual necrotizing soft tissue infectious entities.
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Article – 3- Necrotizing soft tissue infection
Title: Necrotizing Soft-Tissue Infection: Diagnosis and Management
Authors: Ellie J. C. Goldstein, Daniel A. Anaya and E. Patchen Dellinger
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Keywords: Nil
Abstract: Necrotizing soft-tissue infections (NSTIs) are highly lethal. They are frequent enough that general and specialty physicians will likely have to be involved with the management of at least 1 patient with NSTI during their practice, but they are infrequent enough that familiarity with the disease will seldom be achieved. Establishing the diagnosis of NSTI can be the main challenge in treating patients with NSTI, and knowledge of all available tools is key for early and accurate diagnosis. The laboratory risk indicator for necrotizing fasciitis score can be helpful for distinguishing between cases of cellulitis, which should respond to medical management alone, and NSTI, which requires operative debridement in addition to antimicrobial therapy. Imaging studies are less helpful. The mainstay of treatment is early and complete surgical debridement, combined with antimicrobial therapy, close monitoring, and physiologic support.
Conclusion: Novel therapeutic strategies, including hyperbaric oxygen and intravenous immunoglobulin, have been described, but their effect is controversial. Identification of patients at high risk of mortality is essential for selection of patients that may benefit from future novel treatments and for development and comparison of future trials.
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Article – 4 - Necrotizing soft tissue infection
Title: Hyperbaric Oxygen in Trauma and Surgical Emergencies
Authors: Campbell MacFarlane, Hons. BA, BSc (Hons), MBChB, MMed (Surg), PhD, FRCS (Ed), FRCS (Eng), FACS, ACEM (Hon.), FFAEM, MRACMA, DMCC, Frans J Cronjé, BSc (Hons) Aerosp Med, MBChB and Carol-Ann Benn, MBBCh, FCS(SA), DIP.PEC(SA), Consultant Surgeon
Digital Object Identifier (or PMID etc): PMID: 11143686
Keywords: Combined Modality Therapy, Emergency Treatment/methods, Ethics, Medical, Evidence-Based Medicine, Humans, Hyperbaric Oxygenation/adverse effects, Hyperbaric Oxygenation/contraindications, Hyperbaric Oxygenation/methods, Military Medicine/education, Military Medicine/methods, Patient Selection, Wounds and Injuries/surgery, Wounds and Injuries/therapy
Abstract: Hyperbaric oxygen therapy (HBO), that is the administration of 100% oxygen delivered under pressure, has a beneficial effect in several surgical conditions. Its use has been assessed and audited and its pharmacological effects demonstrated. It is appropriate for use in several acute surgical conditions as evidence-based therapy. These are: Gas Gangrene Crush Injuries, Compartment Syndromes & Acute Traumatic Ischaemias Enhancement of Healing in Selected Problem Wounds Exceptional Blood loss Anaemia Necrotising Soft Tissue Infections Compromised Skin Grafts & Flaps Thermal Burns HBO therapy suffers from previous inappropriate use, lack of knowledge, and scarce hyperbaric facilities. Hyperbaric therapy, when properly supervised by a physician trained in its use, working closely with a surgeon, and ethically used for appropriate indications, can be a useful adjunct to surgical practice.
Conclusion: Military surgeons may be in a situation in which they can utilize HBO in acute surgical conditions and trauma. They are urged to identify HBO facilities, both fixed and portable, and to establish communication with hyperbaric therapy colleagues.
Source URL:
http://www.ncbi.nlm.nih.gov/pubmed/11143686
Full text URL:
http://jramc.bmj.com/content/146/3/185.long
Article – 5 - Necrotizing soft tissue infection
Title: Treating necrotizing fasciitis with or without hyperbaric oxygen therapy.
Authors: Hassan, Z; Mullins, RF; Friedman, BC; Shaver, JR; Brandigi, C; Alam, B; Mian, MA
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: There is not enough clinical data to support the benefit of adjuvant HBO2 therapy for necrotizing fasciitis (NF). We retrospectively reviewed our 67 NF cases to compare the outcomes of adjuvant HBO2 therapy versus non-HBO2 therapy. The overall outcome and morbidity criteria were compared between a group of 29 NF patients who received the adjuvant HBO2 and a group of the remaining 38 NF patients treated by only surgery and other standards of care. This study did not find any difference between the groups in average length of hospital stay, and their mortality. However, six (25%) of the non-HBO2 group patients required amputation of extremities compared to one of the HBO2 group (Fisher exact p = 0.09). Although the benefit of adjuvant HBO2 therapy remains controversial for NF, and the outcomes of this study are not statistically significant, there is a trend in clinical outcomes which shows that the therapy has the potential to reduce the number of amputation and salvage extremities.
Conclusion: These findings necessitate multicenter, prospective, case control study to assess the possible benefit of adjuvant HBO2 therapy for NF.
Article – 6 - Necrotizing soft tissue infection
Title: Necrotizing soft tissue infections.
Authors: Bakker, DJ
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: Necrotizing soft tissue infections are an increasing problem in surgical and medical practice, especially in immune compromised patients. These diseases are difficult to classify and difficult to treat; morbidity and mortality are high. Bacteriologic and anatomic classifications of these disorders are proposed after a historical survey.
Conclusion: Finally, the role of surgery, antibiotics, and hyperbaric oxygen in the treatment of soft tissue infections is discussed.
Article – 7- Necrotizing soft tissue infection
Title: Necrotizing soft tissue infections. Risk factors for mortality and strategies for management.
Authors: Elliott DC, Kufera JA, Myers RA.
Digital Object Identifier (or PMID etc): PMID: 8916882, PMCID: PMC1235444
Keywords: Adolescent, Adult, Aged, Aged, 80 and over, Cellulitis*/complications, Cellulitis*/microbiology, Cellulitis*/mortality, Cellulitis*/pathology, Cellulitis*/therapy, Child, Fasciitis*/complications, Fasciitis*/microbiology, Fasciitis*/mortality, Fasciitis*/pathology, Fasciitis*/therapy, Female, Humans, Logistic Models, Male, Middle Aged, Muscular Diseases*/complications, Muscular Diseases*/microbiology, Muscular Diseases*/mortality, Muscular Diseases*/pathology, Muscular Diseases*/therapy, Necrosis, Retrospective Studies, Risk Factors
Abstract: 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.
Results: 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.
Conclusion: 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.
Source URL:
http://www.ncbi.nlm.nih.gov/pubmed/8916882
Full text URL:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1235444/
Article – 8 - Necrotizing soft tissue infection
Title: Contemporary trends in necrotizing soft-tissue infections in the United States.
Authors: Psoinos CM, Flahive JM, Shaw JJ, Li Y, Ng SC, Tseng JF, Santry HP.
Digital Object Identifier (or PMID etc): PMID: 23453328, PMCID: PMC3664142
Keywords: Adolescent, Adult, Aged, Amputation, Cohort Studies, Debridement, Female, Humans, Hyperbaric Oxygenation, Incidence, Male, Middle Aged, Necrosis, Soft Tissue Infections/epidemiology, Soft Tissue Infections/pathology, Soft Tissue Infections/therapy, Treatment Outcome, United States/epidemiology, Young Adult
Abstract: Necrotizing soft-tissue infections (NSTI) are rare, potentially fatal, operative emergencies. We studied a national cohort of patients to determine recent trends in incidence, treatment, and outcomes for NSTI. We queried the Nationwide Inpatient Sample (1998-2010) for patients with a primary diagnosis of NSTI. Temporal trends in patient characteristics, treatment (debridement, amputation, hyperbaric oxygen therapy [HBOT]), and outcomes were determined with Cochran-Armitage trend tests and linear regression. To account for trends in case mix (age, sex, race, insurance, Elixhauser index) or receipt of HBOT on outcomes, multivariable analyses were conducted to determine the independent effect of year of treatment on mortality, any major complication, and hospital length of stay (LOS) for NSTI.
Results: We identified 56,527 weighted NSTI admissions, with an incidence ranging from approximately 3,800-5,800 cases annually. The number of cases peaked in 2004 and then decreased between 1998 and 2010 (P < .0001). The percentage of female patients decreased slightly over time (38.6-34.1%, P < .0001). Patients were increasingly in the 18- to 34-year-old (8.8-14.6%, P < .0001) and 50- to 64-year-old age groups (33.2-43.5, P < .0001), Hispanic (6.8-10.5%, P < .0001), obese (8.9-24.6%, P < .0001), and admitted with >3 comorbidities (14.5-39.7%, P < .0001). The percentage of patients requiring only one operative debridement increased somewhat (43.2-46.2%, P < .0001), whereas the use of HBOT was rare and decreasing (1.6-0.8%, P < .0001). The percentage of patients requiring operative wound closure decreased somewhat (23.5-20.8%, P < .0001). Although major complication rates increased (30.9-48.2%, P < .0001), hospital LOS remained stable (18-19 days) and mortality decreased (9.0-4.9%, P < .0001) on univariate analyses. On multivariable analyses each 1-year incremental increase in year was associated with a 5% increased odds of complication (odds ratio 1.05), 0.4 times decrease in hospital LOS (coefficient -0.41), and 11% decreased odds of mortality (odds ratio 0.89).
Conclusion: There were potentially important national trends in patient characteristics and treatment patterns for NSTI between 1998 and 2010. Importantly, though patient acuity worsened and complication rates increased, but LOS remained relatively stable and mortality decreased. Improvements in early diagnosis, wound care, and critical care delivery may be the cause.
Source URL:
http://www.ncbi.nlm.nih.gov/pubmed/23453328
Full text URL:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3664142/
Article – 9 - Necrotizing soft tissue infection
Title: Hyperbaric oxygen therapy after Bothrops lanceolatus snake bites in Martinique: a brief report.
Authors: Hochedez, P; Thomas, L; Mehdaoui, H
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: Every year 10 to 20 cases of snake bites are reported on the Caribbean island of Martinique. The only snake involved, Bothrops lanceolatus, is endemic on the island, and its bite may lead to systemic multifocal thrombotic complications in the'absence of the monospecific antivenom. Between January 1988 and January 2009, more than 250 snake bites have been reported, and five patients were treated with hyperbaric oxygen (HBO2) therapy for local complications. The patients were male, bitten on the leg or the hand, and presented with severe complications such as necrotizing soft tissue infections, compartment syndrome or abscesses despite prompt wound care and administration of antivenomous serum. Outcomes were favorable for these five patients, except for one who was left with a functional defect of the hand.
Conclusion: Although snake bites are not part of the currently recommended indications for HBO2 therapy, local complications, namely compartment syndrome, necrotizing soft tissue infections and enhancement of healing in selected problem wounds, are approved uses of HBO2 therapy as defined by the Hyperbaric Oxygen Therapy Committee and would benefit from prospective studies.
Article – 10 - Necrotizing soft tissue infection
Title: Indication for hyperbaric oxygen treatment as a predictor of tympanostomy tube placement.
Authors: Fiesseler, FW; Silverman, ME; Riggs, RL; Szucs, PA
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: Hyperbaric oxygen therapy (HBO2) has been utilized for many years for a multitude of disease entities. One commonly encountered side-effect is otic barotrauma. To determine if patients with specific disease processes are at increased risk of requiring tympanostomy tubes during HBO2. Data was obtained from Jan. 2000 to Dec. 2004, retrospectively. The requirement for tympanostomy tubes during a course of HBO2 was established.
Results: 325 met inclusion criteria. Fifteen percent of patients overall (95% CI= 11-19%) required tympanostomy tubes. Tubes were required in: 5% necrotizing soft tissue infection (p=0.33); 10% failed/threatened graft (p=0.39); 15% problem wounds; 17% chronic refractory osteomyelitis (CRO) (p=0.64); 22% soft tissue radionecrosis (STRN)/osteoradionecrosis (ORN) (p=0.02); 33% of crush injuries (p=0.10). Twenty-nine percent of nasopharyngeal radiation injury patients (p=0.001) and 10% of the non-nasopharyngeal radiation patients (p=0.36) received tympanostomy tubes.
Conclusion: A significant increase in tympanostomy tubes were required in nasopharyngeal radiation injury patients.