Decisions to operate: the ASA grade 5 dilemma

INTRODUCTION Deciding to operate on high risk patients suffering catastrophic surgical emergencies can be problematic. Patients are frequently classed as American Society of Anesthesiologists (ASA) grade 5 and, as a result, aggressive but potentially lifesaving intervention is withheld. The aim of our study was to review the short-term outcomes in patients who were classed as ASA grade 5 but subsequently underwent surgery despite this and to compare the ASA scoring model to other predictors of surgical outcome. METHODS All patients undergoing emergency surgery with an ASA grade of 5 were identified. Patient demographics, indications for surgery, intraoperative findings and outcomes were recorded. In addition to the ASA scores, retrospective Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P POSSUM) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated and compared to the observed outcomes. RESULTS Nine patients (39%) survived to discharge. ASA grade was a poor predictor of outcome. P POSSUM and APACHE II scores correlated significantly with each other and with observed outcomes when predicting surgical mortality. The median stay for survivors in the intensive care unit was nine days. CONCLUSIONS In times of an ageing population, the number of patients suffering catastrophic surgical events will increase. Intervention, with little hope of a cure, a return to independent living or an acceptable quality of life, leads to unnecessary end-of-life suffering for patients and their relatives, and consumes sparse resources. The accuracy and reliability of ASA grade 5 as an outcome predictor has been questioned. P POSSUM and APACHE II scoring systems are significantly better predictors of outcome and should be used more frequently to aid surgical decision-making in high risk patients.

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Pre-NELA vs NELA – has anything changed, or is it just an audit exercise?

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2016.0248 ◽

2016 ◽

Vol 98 (8) ◽

pp. 554-559 ◽

Cited By ~ 3

Author(s):

M Mak ◽

AR Hakeem ◽

V Chitre

Keyword(s):

Critical Care ◽

High Risk ◽

Uneventful Recovery ◽

Emergency Laparotomy ◽

Mortality And Morbidity ◽

High Risk Patients ◽

Possum Score ◽

Operative Severity Score ◽

Risk Patients ◽

Set Up

BACKGROUND Following evidence suggestive of high mortality following emergency laparotomies, the National Emergency Laparotomy Audit (NELA) was set up, highlighting key standards in emergency service provision. Our aim was to compare our NHS trust’s adherence to these recommendations immediately prior to, and following, the launch of NELA, and to compare patient outcome. METHODS This was a retrospective study of patients who underwent an emergency laparotomy over the course of 6 months – 3 months either side of the initiation of NELA. RESULTS There were 44 patients before the initiation of NELA (pre-NELA, PN group) and 55 in the first 3 months of NELA (N group). We saw a significant increase in the proportion of patients whose decision to operate was made by the consultant: 75.0% in the PN group vs 100% in N group (subsequent data presented in this order) (P < 0.001). The presence of a consultant surgeon (75.0% vs 83.6%, P = 0.321) and anaesthetist (100.0% vs 90.9%, P = 0.064) in theatres were comparable in both groups. Risk stratification based on Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) score showed no difference in high-risk patients in both groups (47.7% vs 36.4%, P = 0.306). With the NELA initiative, however, significantly more patients were admitted directly from theatres to the critical care unit, when compared with the pre-NELA period (9.1% vs 27.3%, P = 0.038). This also reflected a significant reduction in unexpected escalation to a higher level of care during this period (10.0% vs 0%, P = 0.036). Significantly more patients had uneventful recovery in the NELA period (52.3 vs 76.4%, P = 0.018), although there was no difference in 30-day mortality between the groups (2.3% vs 7.3%, P = 0.378). CONCLUSIONS This study demonstrated a greater degree of consultant involvement in the decision to operate during NELA. More high-risk patients have been identified preoperatively with diligent risk assessment and, hence, have been proactively admitted to critical care units following laparotomy, which may account for the significant reduction in unexpected escalation to level 2 or level 3 care and thus in overall better patient outcomes.

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INTEGRATION OF APACHE II AND III SCORING SYSTEMS IN EXTREMELY HIGH RISK PATIENTS WITH ACUTE RENAL FAILURE TREATED BY DIALYSIS

Renal Failure ◽

10.1081/jdi-120005362 ◽

2002 ◽

Vol 24 (3) ◽

pp. 285-296 ◽

Cited By ~ 4

Author(s):

Yung-Chang Chen ◽

Hsiang-Hao Hsu ◽

Chen-Yin Chen ◽

Ji-Tseng Fang ◽

Chiu-Ching Huang

Keyword(s):

Renal Failure ◽

Acute Renal Failure ◽

High Risk ◽

Scoring Systems ◽

Apache Ii ◽

High Risk Patients ◽

Risk Patients

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APACHE IV system helps to determine cholecystostomy role in elderly patients with acute cholecystitis

10.21203/rs.3.rs-27767/v1 ◽

2020 ◽

Author(s):

Hua Jiang ◽

Guo Guo ◽

Zhimin Yao ◽

Yuehua Wang

Keyword(s):

High Risk ◽

Acute Cholecystitis ◽

Therapeutic Effect ◽

Scoring System ◽

Scoring Systems ◽

Percutaneous Cholecystostomy ◽

High Risk Patients ◽

Before And After ◽

Risk Patients ◽

Apache Iv

Abstract Background Cholecystostomy offers an alternative method for patients unfit to undergo immediate cholecystectomy. Nevertheless, the role of cholecystostomy in the clinical management of high-risk surgical patients remains unclear. One of the main problems concerning the therapeutic effect in critically ill patients with acute cholecystitis is the lack of validated, well-established scoring systems to stratify the severity of patient disease states. APACHE IV scoring system was useful to estimate the hospital mortality for high-risk patients. We try to evaluate the performance of the APACHE IV scoring system in patients over 65 years of age with acute cholecystitis and the therapeutic effect of percutaneous cholecystostomy. Methods 597 patients over 65 years of age with acute cholecystitis between January 2011 and December 2018 were retrospectively analyzed with the APACHE IV scores. Results Among the 597 patients, 52 successfully underwent cholecystectomy (2 died, 3.85%), 65 underwent percutaneous cholecystostomy (1 died, 1.54%), and 480 received conservative therapy (27 died, 5.63%). The fitness of the APACHE IV score prediction is good with the area under the ROC curve of 0.894. The APACHE IV models were well-calibrated (with the Hosmer-Lemeshow statistic). Using the method of binary regression analysis, for the patients whose estimated mortality rate was more than 10%, cholecystostomy was an important factor for prognosis (P = 0.048). The estimated mortality of PC patients before and after operation was compared, which indicated that the estimated mortality after puncture was significantly decreased, either in the whole patient group (P = 0.004) or in the group with an estimated mortality greater than 10% (P = 0.008). Conclusion The APACHE IV scoring system showed that cholecystostomy was a safe and effective treatment for elderly high-risk patients with acute cholecystitis.

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Good Response to Decitabine in an Elderly Patient with MDS (Refractory Anemia with Excess Blasts RAEB-2) after Failure of Azacitidine.

Blood ◽

10.1182/blood.v110.11.4597.4597 ◽

2007 ◽

Vol 110 (11) ◽

pp. 4597-4597

Author(s):

Ashraf R. Aziz

Keyword(s):

High Risk ◽

Objective Response ◽

Risk Groups ◽

Iron Chelator ◽

Multicenter Trial ◽

Refractory Anemia ◽

High Risk Patients ◽

Normal Limits ◽

Number Of Patients ◽

Risk Patients

Decitabine, A pyrimidine nucleoside analog of cytidine, 5-aza-2′-deoxycytidine strongly inhibits DNA methylation, is capable of inducing cell differentiation, In a phase II multicenter trial of 66 patients with MDS (median age 68 years, range: 38 to 84), DAC was given in a dose of 15 mg/m2 IV over 4 hours every eight hours for three consecutive days; cycles were repeated every six weeks. The overall response rate was 25, 48, and 64 percent for those in the intermediate-I, intermediate-II, and high IPSS risk groups, respectively. The median survival time from the start of treatment for the IPSS high risk patients was 1.2 years, considerably longer than the expected survival of 0.3 to 0.5 years for high risk patients treated with supportive care alone. Response to Decitabine after failure of Azaitadine was mentioned only in one abstract presented in the American society of hematology meeting 2006 in 22 patients. We present a case of an 83 y/o gentleman with RAEB-2 with IPSS of 1 Intermediate I with normal cytogenetics, trilineage pancytopenia, was heavily transfusion dependent with both red cells and platelets on a weekly bases. The patient was treated initially with Revlamide for 3 months, followed by Azacitadine for total of 4 cycles, along with Exjade as an iron chelator without any objective response or reduction in his transfusion requirement. The patient eventually was switched to Decitabine 20 mg SC daily for 5 days every 28 days. The patient started to have a response after the 4 th cycle with prolongation of his transfusion intervals. After the 5 th cycle the patient did not need transfusions with platelets within normal limits. Since there is paucity of data regarding the response to these new agents, our case may be added to the small number of patients that was presented to try to create a data pool that helps clinicians to manage this difficult disease.

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Screening for Thyroid Dysfunction in 1st Trimester of Pregnancy

Journal of SAFOG with DVD ◽

10.5005/jp-journals-10006-1407 ◽

2016 ◽

Vol 8 (2) ◽

pp. 154-156

Author(s):

Bharath Ramji ◽

Kavitha Karthikeyan ◽

Prabha Swaminathan ◽

Amrita Priscilla Nalini ◽

Annie Thatheus

Keyword(s):

High Risk ◽

Thyroid Dysfunction ◽

Strong Association ◽

Thyroid Stimulating Hormone ◽

Low Risk ◽

Routine Screening ◽

High Risk Patients ◽

Number Of Patients ◽

Risk Patients ◽

In Pregnancy

ABSTRACT This study was done to find the prevalence of newly diagnosed thyroid dysfunction in early pregnancy in patients attending the antenatal clinic and to emphasize the need for routine screening for thyroid dysfunction in pregnancy. Free thyroxine (FT4) and thyroid stimulating hormone (TSH) levels were measured and cut-off levels set at FT4 0.86—1.86 ng/dl, TSH 0.1—2.5 mIU/l in 1st trimester, TSH 0.1—3 mIU/l in 2nd and 3rd trimesters. A total of 956 pregnant women were screened in 1st trimester after excluding patients with known thyroid dysfunction. About 13.2% were diagnosed as hypothyroid and 1.6% as hyperthyroid. Incidence in high-risk patients was 21.7% and in low-risk was 10.4%. High-risk factors have a strong association for hypothyroidism (p < 0.001). Screening only high-risk patients will miss a significant number of patients seen positive in the low-risk group. Hence, it is essential to do routine screening for thyroid dysfunction in pregnancy. How to cite this article Karthikeyan K, Swaminatan P, Nalini AP, Ramji B, Thatheus A. Screening for Thyroid Dysfunction in 1st Trimester of Pregnancy. J South Asian Feder Obst Gynae 2016;8(2):154-156.

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Successful rechallenge of rituximab following severe rituximab-induced acute thrombocytopenia in a patient with splenic marginal zone lymphoma

Journal of Oncology Pharmacy Practice ◽

10.1177/1078155219890023 ◽

2019 ◽

Vol 26 (5) ◽

pp. 1248-1253

Author(s):

Adam C Robinson ◽

Victoria R Nachar

Keyword(s):

High Risk ◽

Marginal Zone ◽

Improve Patient Safety ◽

Rare Complication ◽

Marginal Zone Lymphoma ◽

Splenic Marginal Zone Lymphoma ◽

Split Dose ◽

High Risk Patients ◽

Number Of Patients ◽

Risk Patients

Rituximab-induced acute thrombocytopenia (RIAT) is a relatively rare complication of rituximab treatment that has been infrequently reported in a number of patients with malignant lymphoma. Most commonly encountered in mantle cell lymphoma, the extent to which RIAT occurs in splenic marginal zone lymphoma is unknown. In this report, we describe a case of RIAT in a patient with splenic marginal zone lymphoma. Rituximab was safely rechallenged with increased premedications and slowed infusion rate. While the exact mechanism of this phenomenon has yet to be elucidated, diligent monitoring of platelet counts following rituximab infusion can be considered in high-risk patients to avoid potential adverse events. Split dose rituximab for high-risk patients may provide an alternative approach to improve patient safety.

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Predictors of Maternal Mortality and Prognostic Models in Obstetric Patients

Seminars in Respiratory and Critical Care Medicine ◽

10.1055/s-0037-1602244 ◽

2017 ◽

Vol 38 (02) ◽

pp. 191-200 ◽

Cited By ~ 3

Author(s):

Jezid Miranda ◽

Jose Rojas-Suarez ◽

Andrew Levinson

Keyword(s):

High Risk ◽

Maternal Morbidity ◽

Prediction Models ◽

Severity Of Illness ◽

Scoring Systems ◽

Morbidity And Mortality ◽

Prognostic Models ◽

High Risk Patients ◽

Maternal Morbidity And Mortality ◽

Risk Patients

AbstractThe use of predictive models has been proposed as a potential tool to reduce maternal morbidity and mortality, by aiding in the timely identification of potential high-risk patients. Prognostic models in critical care have been used to characterize the severity of illness of specific diseases. Physiological changes in pregnancy may result in general critical illness prediction models overestimating mortality in obstetric patients. Models that specifically reflect the unique characteristics of obstetric patients may have better prognostic value. Recently developed tools have focused on identifying at-risk patients before they require intensive care unit (ICU) admission to target early interventions and prevent acute clinical decompensation. The aim of the newest scoring systems, specifically designed for groups of obstetric patients receiving non-ICU care, is to reduce maternal morbidity and mortality by identifying early high-risk patients and initiating prompt effective medical responses.

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Early Outcome of on Pump Beating Heart CABG Surger

Cardiovascular Journal ◽

10.3329/cardio.v12i1.43413 ◽

2019 ◽

Vol 12 (1) ◽

pp. 13-19

Author(s):

Md Mainul Kabir ◽

AM Asif Rahim ◽

ASM Iftekher Hossain ◽

Nazmul Hossain ◽

Syed Monirul Islam ◽

...

Keyword(s):

High Risk ◽

Myocardial Ischemia ◽

Artery Bypass ◽

Operation Time ◽

Beating Heart ◽

Total Blood ◽

Mortality And Morbidity ◽

High Risk Patients ◽

Postoperative Ventilation ◽

Risk Patients

Background: Current cardioplegic technique during conventional coronary artery bypass grafting (CABG) does not consistently avoid myocardial ischemic damage in high risk patients. Alternatively revascularization without CPB is not always technically feasible. The on-pump beating technique eliminates global myocardial ischemia and thus reduce the mortality and morbidity in high risk patients. This study evaluates the early surgical outcomes of on-pump beating-heart CABG in comparison to conventional CABG. Methods: In this prospective study 60 high risk patients with EURO-SCORE of 6 and above were prospectively allocated into two groups in non-randomized way. Among them 30 patients underwent on-pump beating-heart CABG and 30 patients underwent conventional CABG. The early surgical clinical outcomes were compared between the groups. Results: On-pump beating heart CABG significantly reduced the duration of operation time, cardiopulmonary bypass time, postoperative ventilation time and intensive care unit (ICU) stay. Total blood loss and transfusion requirement were less with reduced Peak Creatine-Kinase level in On-pump beating heart CABG. 30 day mortality was less in On-pump beating heart CABG group (6.7% versus 13.3%). No significant differences between the groups were found in morbidity regarding stroke, renal failure, mediastinitis and atrial arrhythmia. Conclusion: On-pump beating heart CABG can be performed safely in high risk patients. It is still associated with the detrimental effect of CPB but eliminates intra-operative global myocardial ischemia. Cardiovasc. j. 2019; 12(1): 13-19

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Post-operative Complications Following Emergency Laparotomy are Common and Associated with Increased Late Mortality – a Retrospective Multi-centre Study.

10.21203/rs.3.rs-428635/v1 ◽

2021 ◽

Author(s):

shivam sharma ◽

Joseph Alderman ◽

Dhruv Parekh ◽

David Thickett ◽

Jaimin Patel

Keyword(s):

High Risk ◽

Length Of Stay ◽

Pulmonary Complications ◽

High Risk Group ◽

University Hospital ◽

Emergency Laparotomy ◽

Multi Centre Study ◽

Mortality And Morbidity ◽

High Risk Patients ◽

Risk Patients

Abstract BackgroundThe ﬁrst National Emergency Laparotomy Audit (NELA) highlighted that morbidity and mortality from emergency surgery remains elevated especially in high-risk patients deﬁned as a P-POSSUM mortality ≥ 5% and ASA ≥ 3. The incidence of postoperative pulmonary complications (PPCs) are thought to be high following emergency laparotomy but no recent studies have evaluated the incidence or consequences of PPC following emergency laparotomy in the UK.MethodsA retrospective cohort study was conducted at University Hospital Birmingham and Heartlands Hospital, Birmingham, to investigate the incidence of PPCs following emergency laparotomy. The NELA databases from the two Trusts were used to identify patients. Patients were retrospectively screened for the development of PPCs using the validated Melbourne Group Scale. Data was analysed using Chi-squared test for categorical data and continuous data displayed as medians with statistical analysis from a Mann–Whitney U test. Results A total of 362 correctly coded patients were identified. High-risk patients accounted for 62% (226) of the cohort. These patients were older (p < 0.001) and had higher baseline lactate (p = 0.04) and creatinine levels (p = 0.003). Median P-POSSUM mortality was 10.6% (5.6–31.4%) with 76.4% of patients having an ASA ≥ 3. These patients had an increased length of stay (p < 0.001) and accounted for nearly all the deaths (42 vs. 2; p < 0.001). The incidence of PPCs was 37%, again the incidence was greater in the high-risk group (37% vs. 6% p < 0.001). Development of a PPC was associated with an increased length of stay (17 d vs. 9 d; p < 0.001) as well as a 90, 180 and 360 day mortality.DiscussionThis study demonstrates that the sub-group of patients deemed ‘high-risk’ are at greatest risk of developing a PPC and consequently have an increased length of stay and an increased 90, 180 and 360 day mortality. This allowed us to identify a group of patients at high risk of PPC who we can target with potential novel therapies such as high-ﬂow nasal cannulae oxygen in clinical trials to reduce mortality and morbidity.

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812 Mortality Risk prediction in Emergency Laparotomy (ORIEL) Study Outcomes at Wythenshawe Hospital

British Journal of Surgery ◽

10.1093/bjs/znab259.521 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

C Carey ◽

B Pittam ◽

S Mobarak ◽

R Varley ◽

J Kingston ◽

...

Keyword(s):

High Risk ◽

Operative Mortality ◽

Scoring Systems ◽

Mortality Rates ◽

National Study ◽

Emergency Laparotomy ◽

Mortality And Morbidity ◽

Mortality Risks ◽

Acs Nsqip ◽

Risk Patients

Abstract Aim Emergency laparotomy is a high-risk procedure with significant morbidity and mortality. ORIEL is a multi-centre national study aiming to compare the 30-day mortality predictions generated by NELA, P-POSSUM, ACS-NSQIP and SORT risk calculators with observed 30-day mortality rates in patients undergoing emergency laparotomies. We present the data collected from Wythenshawe hospital. Method Data were collected retrospectively on adult patients undergoing an emergency laparotomy between 01/12/2017 to 30/11/2019 at Wythenshawe hospital from the online NELA database. The median pre-operative mortality risks were calculated using the four risk calculators for all patients. Mortality and morbidity were compared with data reported in the Sixth NELA report. Results The median predicted pre-operative mortality (IQR) for all patients studied using NELA, P-POSSUM, ACS-NSQIP and SORT were: 4.3 (13.0), 5.2 (14.2), 3.4 (8.2) and 2.9 (9.3) respectively. Among patients who were alive 30 days post-operatively, the median predicted mortalities (IQR) were: 3.8 (8.5), 4.8 (11.0), 2.6 (6.9) and 2.8 (7.1) respectively, and among those who died were: 30.8 (18.9), 30.3 (63.4), 16.9 (13.9) and 20.3 (16.2). Compared to the national average, mortality rates at Wythenshawe were lower (9% v 9.3%), the median length of stay in hospital was lower (12 days v 15.4 days) and the percentage of high-risk patients admitted to critical care was higher (93% v 85%). Conclusions Similar values were generated with all the scoring systems among all patients. Wythenshawe hospital reports lower mortality rates and shorter stays in hospital despite operating on higher risk patients (ASA grades 3-5).

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