title: Temporizing surgical management improves outcome in patients with Vibrio necrotizing fasciitis complicated with septic shock on admission.
abstract: BACKGROUND
  Necrotizing fasciitis (NF) caused by Vibrio infection is one of the most fatal diseases, resulting in high morbidity and mortality. Early diagnosis and effective surgical intervention are the mainstays for better outcomes for affected patients. Currently, standard surgical management calls for prompt and aggressive debridement and amputation. However, due to its rapid progression and deterioration, 50-60% of Vibrio NF cases present with septic shock and multiple organ dysfunction on admission. These patients, who usually have many surgical contraindications, are unable to tolerate a prolonged aggressive surgical debridement. Therefore, determining the optimal surgical intervention for these particularly severe patients remains a formidable problem in emergency medicine.
  
  
  METHODS
  A retrospective study was conducted on patients who underwent surgery for Vibrio NF and septic shock on admission to the emergency room from April 2001 to October 2012. These patients received the same treatment protocol, with the exception of the initial surgical intervention strategy. Nineteen patients were treated with a temporizing strategy, which called for simple incisions and drainage under regional anesthesia, followed by complete debridement 24h later. Another fifteen patients underwent aggressive surgical debridement during the first operative procedure. Basic demographics, laboratory results on admission, clinical course and outcomes were compared to assess the efficacy and safety of two initial surgical treatment methods: the temporizing strategy and the aggressive strategy.
  
  
  RESULTS
  Thirty-four patients were included in this study, and the average age was 51.65 years. Chronic liver disease was the most prevalent preexisting condition (50.00%) and the lower limbs were most commonly involved in infection (76.47%). In this patient population, 19 cases underwent surgery with a temporizing therapeutic strategy, while the remaining 15 cases were treated with an aggressive surgical strategy. There were no differences between the two groups with respect to demographics, severity of illness and laboratory data. Compared with those treated with the aggressive strategy, patients treated with the temporizing strategy had shorter operation time (40.79 ± 16.61 vs. 102.00 ± 18.97 min, p<0.001), less bleeding (120.53 ± 67.20 vs. 417.33 ± 134.72 mL, p<0.001), a reduced amount of intraoperatively administrated fluid (3144.70 ± 554.71 vs. 1637.40 ± 302.11 mL, p<0.001), decreased maximum dose of dopamine (15.73 ± 5.64 vs. 10.47 ± 5.61 μg/kg/min, p=0.011) and noradrenaline (20.13 ± 7.50 vs. 13.37 ± 6.18 μg/kg/min, p=0.007), lower arterial lactate values at the end of surgery (5.56±1.99 vs. 8.66 ± 3.25 mmol/L, p=0.004), and, most importantly, lower mortality (26.32% vs. 60.00%, p=0.048). All other treatment conditions, such as duration of vasopressor therapy, number of debridement procedures, rate of amputation, ICU length of stay and hospital length of stay, were the same for both groups.
  
  
  CONCLUSIONS
  The temporizing strategy, with early initiation of simple incisions and drainage under regional anesthesia followed by complete debridement 24h later, is more feasible and effective for patients with Vibrio NF complicated with septic shock, as compared with the aggressive surgical debridement strategy.
authors.affiliation: Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, China.
authors.forename: Guang-Liang
authors.initials: GL
authors.lastname: Hong
authors.affiliation: Department of General Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, China.
authors.forename: Xiao-Qin
authors.initials: XQ
authors.lastname: Dai
authors.affiliation: Department of Burns Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, China.
authors.forename: Cai-Jiao
authors.initials: CJ
authors.lastname: Lu
authors.affiliation: School of Environmental Science and Public Health, Wenzhou Medical University, Wenzhou 325035, Zhejiang, China.
authors.forename: Jia-Ming
authors.initials: JM
authors.lastname: Liu
authors.affiliation: Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, China.
authors.forename: Guang-Ju
authors.initials: GJ
authors.lastname: Zhao
authors.affiliation: Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, China.
authors.forename: Bin
authors.initials: B
authors.lastname: Wu
authors.affiliation: Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, China.
authors.forename: Meng-Fang
authors.initials: MF
authors.lastname: Li
authors.affiliation: Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, China. Electronic address: lzq640815@163.com.
authors.forename: Zhong-Qiu
authors.initials: ZQ
authors.lastname: Lu
mesh_terms: D000328:Adult; D000368:Aged; D000671:Amputation, Surgical / Q000379:methods*; D015331:Cohort Studies; D003646:Debridement / Q000379:methods*; D004322:Drainage / Q000379:methods*; D019115:Fasciitis, Necrotizing / Q000150:complications / Q000601:surgery*; D005260:Female; D005440:Fluid Therapy; D006801:Humans; D007022:Hypotension / Q000188:drug therapy; D007431:Intraoperative Complications / Q000628:therapy; D008107:Liver Diseases / Q000150:complications; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D012189:Retrospective Studies; D012772:Shock, Septic / Q000150:complications*; D013997:Time Factors; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use; D014735:Vibrio Infections / Q000150:complications / Q000601:surgery*; D044149:Vibrio alginolyticus / Q000302:isolation & purification; D041261:Vibrio vulnificus / Q000302:isolation & purification
chemical_list: D014662:Vasoconstrictor Agents
keywords: Aggressive debridement; Incision and drainage; Septic shock; Surgical strategy; Treatment; Vibrio necrotizing fasciitis