Purpura Fulminans Managed with Multi-Limb Amputation: Substituted Judgment and Surrogate Decision-Making in the Surgical Management of Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTIs) require prompt diagnosis and treatment. Early identification of patients at greatest risk of limb amputation and death may help in targeting aggressive medical and surgical management. The aim of this study was to assess predictors of limb loss and mortality in patients with NSTI based on admission variables. We performed a retrospective review of two hospitals that care for a large volume of patients with NSTI. Univariate and multi-variable analyses were used to determine the association of admission biochemical markers to limb loss and mortality. Of 174 patients with NSTI, there were 19 deaths (10.9%) and 42 required amputations (24.1%). Multivariable logistic regression analysis revealed that only arterial lactate was predictive for both mortality (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1 to 2.0; P = 0.009) and limb loss (OR, 1.3; 95% CI, 1.0 to 1.7; P = 0.02). In patients with a suspected NSTI, an arterial lactate should be ordered early on to guide aggressive therapeutic interventions and to provide information with regard to long-term outcomes of amputation and death that is needed for early discussion with the patient and family.

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Burn Center Treatment of Necrotizing Soft Tissue Infections: Necrotizing Fasciitis, Fournier Gangrene, and Purpura Fulminans

Problems in General Surgery ◽

10.1097/00013452-200303000-00018 ◽

2003 ◽

Vol 20 (1) ◽

pp. 138-145 ◽

Cited By ~ 1

Author(s):

Daniel M. Caruso ◽

Kevin N. Foster ◽

Annapoorani Chellappan

Keyword(s):

Soft Tissue ◽

Necrotizing Fasciitis ◽

Purpura Fulminans ◽

Soft Tissue Infections ◽

Burn Center ◽

Fournier Gangrene ◽

Necrotizing Soft Tissue Infections

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Substituted decision making and the dispositional choice account

Journal of Medical Ethics ◽

10.1136/medethics-2016-103672 ◽

2018 ◽

Vol 44 (10) ◽

pp. 703.1-709 ◽

Cited By ~ 3

Author(s):

Anna-Karin Margareta Andersson ◽

Kjell Arne Johansson

Keyword(s):

Decision Making ◽

Best Interests ◽

Surrogate Decision Making ◽

Substituted Judgment ◽

Legal Context ◽

Surrogate Decision ◽

Best Interests Standard ◽

Unconscious Patients ◽

Substituted Judgment Standard

There are two main ways of understanding the function of surrogate decision making in a legal context: the Best Interests Standard and the Substituted Judgment Standard. First, we will argue that the Best Interests Standard is difficult to apply to unconscious patients. Application is difficult regardless of whether they have ever been conscious. Second, we will argue that if we accept the least problematic explanation of how unconscious patients can have interests, we are also obliged to accept that the Substituted Judgment Standard can be coherently applied to patients who have never been conscious at the same extent as the Best Interests Standard. We then argue that acknowledging this result is important in order to show patients respect.

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