Original Research

Necrotizing Infection of the Upper Extremity: A Veterans Affairs Medical Center Experience (2008-2017)

Necrotizing infection of the upper extremity is a rare pathology with a substantial risk of amputation and mortality that requires a high index of suspicion and expeditious referral to a hand surgeon.

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References

Necrotizing infection of the extremity is a rare but potentially lethal diagnosis with a mortality rate in the range of 17% to 35%.1-4 The plastic surgery service at the Malcom Randall Veterans Affairs Medical Center (MRVAMC) treats all hand emergencies, including upper extremity infection, in the North Florida/South Georgia Veterans Heath System. There has been a well-coordinated emergency hand care system in place for several years that includes specialty templates on the electronic health record, pre-existing urgent clinic appointments, and single service surgical specialty care.5 This facilitates a fluid line of communication between primary care, emergency department (ED) providers, and surgical specialties. The objective of the study was to evaluate our identification, treatment, and outcome of these serious infections.

Methods

The MRVAMC Institutional Review Board approved a retrospective review of necrotizing infection of the upper extremity treated at the facility by the plastic surgery service. Surgical cases over a 9-year period (June 5, 2008-June 5, 2017) were identified by CPT (current procedural technology) codes for amputation and/or debridement of the upper extremity. The charts were reviewed for evidence of necrotizing infection by clinical description or pathology report. The patients’ age, sex, etiology, comorbidities from their problem list, vitals, and laboratory results were recorded upon arrival at the hospital. Time from presentation to surgery, treatment, and outcomes were recorded.

Results

Ten patients were treated for necrotizing infection of the upper extremity over a 9-year period; all were men with an average age of 64 years. Etiologies included nail biting, “bug bites,” crush injuries, burns, suspected IV drug use, and unknown. Nine of 10 patients had diabetes mellitus (DM). Most did not show evidence of hemodynamic instability on hospital arrival (Table). One patient was hypotensive with a mean arterial blood pressure < 65 mm Hg, 2 had heart rates > 100 beats/min, 1 patient had a temperature > 38° C, and 7 had elevated white blood cell (WBC) counts ranging from 11 to 24 k/cmm. Two undiagnosed patients with DM (patients 1 and 8) expressed no complaints of pain and presented with blood glucose > 450 mg/dL with hemoglobin A1c levels > 12%.

Infectious disease and critical care services were involved in the treatment of several cases when requested. A computed tomography (CT) scan was used in 2 of the patients (patients 1 and 4) to assist in the diagnosis (Figure 1).

The patient with the largest debridement (patient 4) had a CT that was not suspicious for necrotizing infection the day prior to emergent surgery. Patient 3 was found to have a subclavian stenosis on CT angiography early in the postoperative course and was treated with a carotid to subclavian bypass by the vascular service.

Seven patients out of 10 were treated with surgery within 24 hours on hospital arrival. The severity of the pathology was not initially recognized in 2 of the patients earlier in the review. A third patient resisted surgical treatment until the second hospital day. Four patients had from 1 to 3 digital amputations, 2 patients had wrist disarticulations, and 1 had a distal forearm amputation.

The proximal amputations were patients with DM who went to the operating room within 24 hours of admission. Cultures grew a wide range of microorganisms, including methicillin-resistant Staphylococcus aureus (MRSA), methicillin-susceptible Staphylococcus aureus (MSSA), β-hemolytic Streptococcus, Streptococcus viridans, Klebsiella pneumoniae, and Prevotella.

Antibiotics were managed by critical care, hospitalist, or infectious disease services and adjusted once final cultures were returned (Table).

The patients all had a minimum of 2 procedures (range 2-5), including debridement and closure (Figures 2A and 2B and 3A and 3B). There were no perioperative deaths.

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