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Schuster K, Davis K, Hernandez M, Holena D, Salim A, Crandall M. American Association for the Surgery of Trauma emergency general surgery guidelines gap analysis. J Trauma Acute Care Surg 2019; 86:909-915. [PMID: 30768554 DOI: 10.1097/ta.0000000000002226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) has been rapidly adopted as one of the major components of acute care surgery. Although heterogenous, the most common disease states that comprise EGS often have published guidelines containing recommendations for their diagnosis and management. Not all diseases included within EGS however have published guidelines and existing guidelines may have important gaps in their recommendations. We present a thorough assessment of the existing guidelines for the most common EGS diseases and highlight gaps that will require additional literature review or new research to fill. METHODS Literature searches for existing comprehensive guidelines were performed. These guidelines were summarized based on level of supporting evidence and further subcategorized based on American Association for the Surgery of Trauma (AAST) grade of disease. Using these summaries, gaps in the exiting recommendations were then generated and refined through review by at least two authors. RESULTS The initial gap analysis focused on diverticulitis, acute pancreatitis, small bowel obstruction and acute cholecystitis. Despite extensive research into each of these disease processes, critical questions regarding diagnosis and management remain to be answered. Gaps were the result of either low quality research or a complete lack of research. The use of the AAST grade of disease established a framework for evaluating these guidelines and grouping the recommendations. CONCLUSIONS Despite extensive prior research, EGS diseases have multiple areas where additional research would likely result in improved patient care. Consensus on the most important areas for additional research can be obtained through analysis of gaps in existing guidelines. This gap analysis has the potential to inform efforts around developing a research agenda for EGS.
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Affiliation(s)
- Kevin Schuster
- From the Department of Surgery (K.S.), Department of Surgery (K.D.), Yale School of Medicine, New Haven, Connecticut; Department of Surgery (M.H.), Mayo Medical Center, Rochester, Minnesota; Department of Surgery (D.H.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (M.C.), Brigham and Women's Hospital, Boston, Massachusetts
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Howell EC, Keeley JA, Kaji AH, Deane MR, Kim DY, Putnam B, Lee SL, Woods AL, Neville AL. Chance to cut: defining a negative exploration rate in patients with suspected necrotizing soft tissue infection. Trauma Surg Acute Care Open 2019; 4:e000264. [PMID: 30899795 PMCID: PMC6407535 DOI: 10.1136/tsaco-2018-000264] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Necrotizing soft tissue infections (NSTI) are aggressive infections associated with significant morbidity and mortality. Despite multiple predictive models for the identification of NSTI, a subset of patients will not have an NSTI at the time of surgical exploration. We hypothesized there is a subset of patients without NSTI who are clinically indistinguishable from those with NSTI. We aimed to characterize the differences between NSTI and non-NSTI patients and describe a negative exploration rate for this disease process. Methods We conducted a retrospective review of adult patients undergoing surgical exploration for suspected NSTI at our county-funded, academic-affiliated medical center between 2008 and 2015. Patients were identified as having NSTI or not (non-NSTI) based on surgical findings at the initial operation. Pathology reports were reviewed to confirm diagnosis. The NSTI and non-NSTI patients were compared using χ2 test, Fisher's exact test, and Wilcoxon rank-sum test as appropriate. A p value <0.05 was considered significant. Results Of 295 patients undergoing operation for suspected NSTI, 232 (79%) were diagnosed with NSTI at the initial operation and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess and 58 (92%) had cellulitis resulting in a total of 237 patients (80%) with a surgical disease process. Patients with NSTI had higher white cell counts (18.5 vs. 14.9 k/mm3, p=0.02) and glucose levels (244 vs. 114 mg/dL, p<0.0001), but lower sodium values (130 vs. 134 mmol/L, p≤0.0001) and less violaceous skin changes (9.2% vs. 23.8%, p=0.004). Eight patients (14%) initially diagnosed with cellulitis had an NSTI diagnosed on return to the operating room for failure to improve. Conclusions Clinical differences between NSTI and non-NSTI patients are subtle. We found a 20% negative exploration rate for suspected NSTI. Close postoperative attention to this cohort is warranted as a small subset may progress. Level of evidence Retrospective cohort study, level III.
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Affiliation(s)
- Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Jessica A Keeley
- Department of Surgery, University of California, San Francisco East Bay, Oakland, California, USA
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Molly R Deane
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Dennis Y Kim
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Brant Putnam
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Steven L Lee
- Division of Pediatric Surgery, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Alexis L Woods
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Angela L Neville
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
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Urbina T, Hua C, Sbidian E, Ingen-Housz-Oro S, Duong TA, Wolkenstein P, Bosc R, Razazi K, Carteaux G, Chosidow O, Mekontso Dessap A, de Prost N. Urgences dermatologiques en réanimation : infections nécrosantes de la peau et des parties molles et toxidermies graves. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les urgences dermatologiques nécessitant une admission en réanimation sont rares mais associées à une mortalité élevée et à de lourdes séquelles à long terme. Elles sont essentiellement représentées par les infections nécrosantes des tissus mous (également appelées : dermohypodermites bactériennes nécrosantes-fasciites nécrosantes [DHBN-FN]) et par les toxidermies graves que sont les nécrolyses épidermiques (comprenant le syndrome de Lyell ou nécrolyse épidermique toxique [NET], le syndrome de Stevens-Johnson [SJS] et le DRESS (drug reaction with eosinophilia and systemic symptoms)). Elles ont pour caractéristiques communes un diagnostic souvent difficile, la nécessité d’une approche multidisciplinaire et de soins paramédicaux lourds et spécifiques, imposant fréquemment le transfert dans un centre expert. Le traitement des DHBN-FN est médicochirurgical, associant un débridement chirurgical précoce et une antibiothérapie probabiliste à large spectre. La présence de signes de gravité locaux (nécrose, crépitation, douleur intense) ou généraux (sepsis, choc septique) est une indication d’urgence à l’exploration chirurgicale. Sa précocité est le principal facteur pronostique modifiable, les recommandations de thérapeutiques complémentaires (immunoglobulines intraveineuses, oxygénothérapie hyperbare, pansement à pressions négatives, ...) reposant à ce jour sur un faible niveau de preuve. L’élément essentiel de la prise en charge des toxidermies graves est la recherche et l’arrêt du médicament imputable, facteur essentiel du pronostic. Le SJS et le NET, en général associés à une ou plusieurs atteintes muqueuses, entraînent dans les formes les plus graves une défaillance cutanée aiguë. La prise en charge repose sur les soins de support (correction des troubles hydroélectrolytiques, prévention de l’hypothermie, prévention et traitement des épisodes infectieux, analgésie et anxiolyse, soins locaux). Les complications infectieuses et respiratoires sont les principales causes de décès à la phase aiguë. Aucun traitement spécifique n’a fait la preuve de son efficacité à ce jour. Le diagnostic de DRESS est difficile, et la prise en charge doit être multidisciplinaire. Sa gravité tient aux possibles atteintes viscérales associées (hépatique, rénale et cardiaque) qui justifient dans les formes graves d’une corticothérapie urgente.
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Sartelli M, Guirao X, Hardcastle TC, Kluger Y, Boermeester MA, Raşa K, Ansaloni L, Coccolini F, Montravers P, Abu-Zidan FM, Bartoletti M, Bassetti M, Ben-Ishay O, Biffl WL, Chiara O, Chiarugi M, Coimbra R, De Rosa FG, De Simone B, Di Saverio S, Giannella M, Gkiokas G, Khokha V, Labricciosa FM, Leppäniemi A, Litvin A, Moore EE, Negoi I, Pagani L, Peghin M, Picetti E, Pintar T, Pupelis G, Rubio-Perez I, Sakakushev B, Segovia-Lohse H, Sganga G, Shelat V, Sugrue M, Tarasconi A, Tranà C, Ulrych J, Viale P, Catena F. 2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg 2018; 13:58. [PMID: 30564282 PMCID: PMC6295010 DOI: 10.1186/s13017-018-0219-9] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/22/2018] [Indexed: 02/08/2023] Open
Abstract
Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.
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Affiliation(s)
| | - Xavier Guirao
- 0000 0000 9238 6887grid.428313.fUnit of Endocrine, Head, and Neck Surgery and Unit of Surgical Infections Support, Department of General Surgery, Parc Taulí Hospital Universitari, Sabadell, Spain
| | - Timothy C. Hardcastle
- Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R Mandela School of Clinical Medicine, Durban, South Africa
| | - Yoram Kluger
- 0000 0000 9950 8111grid.413731.3Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Marja. A. Boermeester
- 0000000404654431grid.5650.6Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - Kemal Raşa
- Department of Surgery, Anadolu Medical Center, Kocaali, Turkey
| | - Luca Ansaloni
- 0000 0004 1758 8744grid.414682.dGeneral Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- 0000 0004 1758 8744grid.414682.dGeneral Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Philippe Montravers
- 0000 0000 8588 831Xgrid.411119.dAnesthesiology and Critical Care Medicine, Paris Diderot Sorbonne Cite University, Bichat-Claude Bernard University Hospital, HUPNSV, Paris, France
| | - Fikri M. Abu-Zidan
- 0000 0001 2193 6666grid.43519.3aDepartment of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Michele Bartoletti
- 0000 0004 1757 1758grid.6292.fInfectious Diseases Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Matteo Bassetti
- 0000 0001 2113 062Xgrid.5390.fInfectious Diseases Division, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Intergrata di Udine, Udine, Italy
| | - Offir Ben-Ishay
- 0000 0000 9950 8111grid.413731.3Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter L. Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA USA
| | - Osvaldo Chiara
- General Surgery-Trauma Team, State University of Milano, Niguarda Hospital Milano, Milan, Italy
| | - Massimo Chiarugi
- grid.414498.4Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Raul Coimbra
- 0000 0000 9852 649Xgrid.43582.38Riverside University Health System Medical Center and Loma Linda University School of Medicine, Moreno Valley, CA USA
| | - Francesco Giuseppe De Rosa
- 0000 0001 2336 6580grid.7605.4Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Belinda De Simone
- Unit of General, Emergency and Trauma Surgery, Regional Hospital of Perpignan, Perpignan, France
| | - Salomone Di Saverio
- 0000 0004 0383 8386grid.24029.3dDepartment of Surgery, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maddalena Giannella
- 0000 0004 1757 1758grid.6292.fInfectious Diseases Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - George Gkiokas
- 0000 0001 2155 0800grid.5216.0Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | | | - Ari Leppäniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Andrey Litvin
- 0000 0001 1018 9204grid.410686.dDepartment of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russian Federation
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Leonardo Pagani
- Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
| | - Maddalena Peghin
- 0000 0001 2113 062Xgrid.5390.fInfectious Diseases Division, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Intergrata di Udine, Udine, Italy
| | - Edoardo Picetti
- grid.411482.aDepartment of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Tadeja Pintar
- 0000 0004 0571 7705grid.29524.38Department of Surgery, UMC Ljubljana, Ljubljana, Slovenia
| | - Guntars Pupelis
- 0000 0004 0375 2558grid.488518.8Department of General and Emergency Surgery, Riga East University Hospital ‘Gailezers’, Riga, Latvia
| | - Ines Rubio-Perez
- 0000 0000 8970 9163grid.81821.32General Surgery Department, Colorectal Surgery Unit, La Paz University Hospital, Madrid, Spain
| | - Boris Sakakushev
- 0000 0001 0726 0380grid.35371.33General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Helmut Segovia-Lohse
- 0000 0001 2289 5077grid.412213.7Second Department of Surgery, Hospital de Clínicas, Universidad Nacional de Asuncion, San Lorenzo, Paraguay
| | - Gabriele Sganga
- 0000 0001 0941 3192grid.8142.fEmergency Surgery (or Division of Emergency Surgery), Fondazione Policlinico Universitario A. Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vishal Shelat
- grid.240988.fGeneral Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Michael Sugrue
- 0000 0004 0617 6488grid.415900.9Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Cristian Tranà
- Department of Surgery, Macerata Hospital, Macerata, Italy
| | - Jan Ulrych
- 0000 0000 9100 9940grid.411798.2First Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pierluigi Viale
- 0000 0004 1757 1758grid.6292.fInfectious Diseases Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Fausto Catena
- 0000 0001 0941 3192grid.8142.fEmergency Surgery (or Division of Emergency Surgery), Fondazione Policlinico Universitario A. Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
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