Factors Associated with Mortality and Amputation Caused by Necrotizing Soft Tissue Infections of the Upper Extremity: A Retrospective Cohort Study

Abstract

Background It is unclear what the exact short-term outcomes of necrotizing soft tissue infections (NSTIs), also known and necrotizing fasciitis of the upper extremity, are and whether these are comparable to other anatomical regions. Therefore, the aim of this study is to assess factors associated with mortality within 30-days and amputation in patients with upper extremity NSTIs. Methods A retrospective study over a 20-year time period of all patients treated for NSTIs of the upper extremity was carried out. The primary outcomes were the 30-day mortality rate and the amputation rate in patients admitted to the hospital for upper extremity NSTIs. Results Within 20 years, 122 patients with NSTIs of the upper extremity were identified. Thirteen patients (11%) died and 17 patients (14%) underwent amputation. Independent risk factors for mortality were an American Society of Anesthesiologists (ASA) classification of 3 or higher (OR 9.26, 95% CI 1.64-52.31) and a base deficit of 3 meq/L or greater (OR 10.53, 95% CI 1.14-96.98). The independent risk factor for amputation was a NSTI of the nondominant arm (OR 3.78, 95% CI 1.07-13.35). Length of hospital stay was 15 (IQR 9-21) days. Conclusion Upper extremity NSTIs have a relatively low mortality rate, but a relatively high amputation rate compared to studies assessing NSTIs of all anatomical regions. ASA classification and base deficit at admission predict the prognosis of patients with upper extremity NSTIs, while a NSTI of the non-dominant side is a risk factor for limb loss.

Necrotizing Soft Tissue Infections, the Challenge Remains

“…Patients with type I NSTIs usually have more and severe comorbidities (such as diabetes mellitus, peripheral vascular disease, chronic renal failure) ( 2 , 6 , 39 ). This could indicate that especially younger and healthier patients present with early systemic toxicity, while notable the older patients with severe and/or multiple comorbidities present with late systemic toxicity and have a higher risk of expiring ( 3 , 28 , 39 , 42 ). Therefore, the absence of systemic toxicity can be misleading, but should be kept in mind as diagnostic pitfall.…”

“…Type I is polymicrobial and generally consists of various species of gram-positive cocci, gram-negative rods and anaerobes (2,10). Type II is monomicrobial with GAS being the most common microbe found (39,42). Recently an attempt was made to categorize specific strains of bacteria in their presentation, as Type III consists of more rare isolated 3) symptoms upon presentation.…”

Necrotizing fasciitis at the extremities and its management

“…In upper extremity preexisting comorbidities and patients presenting with septic symptoms had a greater risk of dying [80,81] . Indeed, a higher ASA classification and base deficit at admission have been linked to higher mortality [82] . In lower limb, the factors associated with increased risk of postoperative mortality are age >60 years, PTT >38 seconds, serum albumin <2.0 mg/dL, coagulopathy, ASA class IV-V, COPD, postoperative ARDS, and postoperative septic shock [83] .…”

Emergency Hand and Reconstructive Microsurgery in the COVID-19–Positive Patient

“…There are similar criteria for specific infections such as flexor tenosynovitis 29 and necrotizing fasciitis. 30 , 31 These criteria enable hand surgeons to identify patients with a poor prognosis, particularly in the setting of an established COVID infection, and early amputation may be considered rather than attempting repeated efforts at digit or limb salvage. In the current setting where operating room resources are limited, we drain localized infections (eg, paronychia) in the ward or an ambulatory facility.…”