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Optimal timing of initial debridement for necrotizing soft tissue infection

A Practice Management Guideline from the Eastern Association for the Surgery of Trauma

Gelbard, Rondi B., MD; Ferrada, Paula, MD; Yeh, D. Dante, MD; Williams, Brian H., MD; Loor, Michele, MD; Yon, James, MD; Mentzer, Caleb, DO; Khwaja, Kosar, MD, MBA, MSc; Khan, Mansoor A., MBBS, PhD; Kohli, Anirudh, MD; Bulger, Eileen M., MD; Robinson, Bryce R.H., MD

Journal of Trauma and Acute Care Surgery: July 2018 - Volume 85 - Issue 1 - p 208–214
doi: 10.1097/TA.0000000000001857
Guidelines
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BACKGROUND Necrotizing soft tissue infections (NSTI) are rare, life-threatening, soft-tissue infections characterized by rapidly spreading inflammation and necrosis of the skin, subcutaneous fat, and fascia. While it is widely accepted that delay in surgical debridement contributes to increased mortality, there are currently no practice management guidelines regarding the optimal timing of surgical management of this condition. Although debridement within 24 hours of diagnosis is generally recommended, the time ranges from 3 hours to 36 hours in the existing literature. Therefore, the objective of this article is to provide evidence-based recommendations for the optimal timing of surgical management of NSTI.

METHODS The MEDLINE database using PubMed was searched to identify English language articles published from January 1990 to September 2015 regarding adult and pediatric patients with NSTIs. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework were used. A single population [P], intervention [I], comparator [C], and outcome [O] (PICO) question was applied: In patients with NSTI (P), should early (<12 hours) initial debridement (I) versus late (≥12 hours) initial debridement (C) be performed to decrease mortality (O)?

RESULTS Two hundred eighty-seven articles were identified. Of these, 42 papers underwent full text review and 6 were selected for guideline construction. A total of 341 patients underwent debridement for NSTI. Of these, 143 patients were managed with early versus 198 with late operative debridement. Across all studies, there was an overall mortality rate of 14% in the early group versus 25.8% in the late group.

CONCLUSION For NSTIs, we recommend early operative debridement within 12 hours of suspected diagnosis. Institutional and regional systems should be optimized to facilitate prompt surgical evaluation and debridement.

LEVEL OF EVIDENCE Systematic review/meta-analysis, level IV.

From the Division of Trauma and Surgical Critical Care at Grady Memorial Hospital, Department of Surgery, Emory University School of Medicine (R.B.G.), Atlanta, Georgia; Division of Acute Care Surgery, Department of Surgery, Virginia Commonwealth University (P.F.), Richmond, Virginia; Division of Trauma and Critical Care, Department of Surgery, University of Miami (D.D.Y., C.M.), Miami, Florida; Department of Surgery, UT Southwestern Medical Center (B.H.W.), Dallas, Texas; Division of Critical Care and Acute Care Surgery, Department of Surgery, University of Minnesota (M.L.), Minneapolis, Minnesota; Department of Surgery, Swedish Medical Center (J.Y.), Englewood, Colorado; Department of Surgery and Critical Care Medicine, McGill University Health Centre (K.K.), Montreal, Canada; St. Mary’s Hospital Major Trauma Center, Imperial College Healthcare (M.K.), London, United Kingdom; Division of Acute Care Surgery, Department of Surgery, Thomas Jefferson University Hospital (A.K.), Philadelphia, Pennsylvania; and Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, Harborview Medical Center (E.M.B., B.R.H.R.), University of Washington, Seattle, Washington.

Submitted: October 4, 2017, Revised: January 18, 2018, Accepted: January 31, 2018, Published online: February 27, 2018.

Presented at: The Eastern Association for the Surgery of Trauma 30th Annual Scientific Assembly, January 10–14 2017, Hollywood, Florida.

Address for reprints: Rondi B. Gelbard, MD, Emory University School of Medicine, 69 Jesse Hill Jr. Drive, SE, Glenn Memorial Building, Room 315, Atlanta, Georgia 30303; email: rgelbar@emory.edu.

© 2018 Lippincott Williams & Wilkins, Inc.