Is Norton Score a useful tool for identifying high-risk patients prior to emergency surgery?

BACKGROUND: Emergency surgery in elderly patients is associated with high mortality rates. Various scoring systems may be valuable in predicting mortality and morbidity rates. It has been suggested that the Norton Score (NS) could be used to quantify frailty. We hypothesized that NS could be a useful tool for identifying high-risk patients before emergency/urgent surgeries. METHODS: A retrospective study was conducted in the Department of Surgery at Kaplan Medical Center, Rehovot, Israel. INCLUSION CRITERIA: age ≥50 years, American Society of Anesthesiologists (ASA) physical status score ≥3 and urgent/emergency laparotomy. A total of 400 patients were identified, and 150 (37.5%) matched the inclusion criteria. RESULTS: A total of 150 patients with ASA scores of 3-5 and who underwent emergent/urgent laparotomy from 1 January 2011 through 31 January 2013 were included. Mean age was 77 ± 9.7 years. The mortality rate at 1 month was 44% (66 patients) and at 1 year was 54.7% (82 patients). A higher ASA score was significantly associated with mortality (P < 0.001). Survivors had lower frailty scores and presented significantly higher preoperative NS (Modified Frailty Index 2.45 versus 3.06, P < 0.05; NS 16.09 versus 12.94, P < 0.01). Preoperative NS was the most significant variable that predicted poor patient prognosis (odds ratio 0.84; 95% confidence interval 0.73-0.96). For ASA 3 and ASA 4, the grade of daily personal independence in activities showed a positive correlation with survival (P < 0.001). CONCLUSION: NS can be a very useful and quick tool to evaluate surgical risk in emergency surgery. Our study supports the use of NS in the perioperative evaluation prior to emergency surgery.

Temporal trends in patient characteristics and survival of intensive care admissions with sepsis: a multicenter analysis*.

OBJECTIVE: To estimate in-hospital, 1-yr, and long-term mortality and to assess time trends in incidence and outcomes of sepsis admissions in the intensive care unit. DESIGN: A population-based, multicenter, retrospective cohort study. PATIENTS: Patients hospitalized with sepsis in the intensive care unit in seven general hospitals in Israel during 2002-2008. INTERVENTIONS: None. MEASUREMENTS: Survival data were collected and analyzed according to demographic and background clinical characteristics, as well as features of the sepsis episode, using Kaplan-Meier approach for long-term survival. MAIN RESULTS: A total of 5,155 patients were included in the cohort (median age: 70, 56.3% males; median Charlson comorbidity index: 4). The mean number of intensive care unit admissions per month increased over time, while no change in in-hospital mortality was observed. The proportion of patients surviving to hospital discharge was 43.9%. The 1-, 2-, 5-, and 8-yr survival rates were 33.0%, 29.8%, 23.3%, and 19.8%, respectively. Mortality was higher in older patients, patients with a higher Charlson comorbidity index, and those with multiorgan failure, and similar in males and females. One-year age-standardized mortality ratio was 21-fold higher than expected, based on the general population rates. CONCLUSIONS: Mortality following intensive care unit sepsis admission remains high and is correlated with underlying patients' characteristics, including age, comorbidities, and the number of failing organ systems.

Stereotactic biopsy complicated by pneumocephalus and acute pulmonary edema.

BACKGROUND: The aim of this study was to describe pneumocephalus as a rare complication of stereotactic biopsy and as a possible cause of acute neurogenic pulmonary edema. CASE DESCRIPTION: A case of frameless stereotactic biopsy complicated by pneumocephalus presenting with acute lung injury 48 hours after the procedure. A frameless stereotactic procedure was performed in the standard fashion. Immediate postoperative CT showed no intracranial air except for a gas inclusion at the biopsy site within the lesion. The skin staple placed at the end of surgery on the skin incision was removed 36 hours later. A CT scan performed 48 hours postoperatively showed new pneumocephalus. The patient exhibited acute respiratory distress but no new neurologic symptoms. There was no detectable systemic cause for the pulmonary edema. The patient received supportive respiratory treatment and fully recovered. CONCLUSION: Pneumocephalus is apparently a rare complication of stereotactic brain biopsy and one that may result from early removal of the skin staple or suture. The occurrence of acute neurogenic pulmonary edema may be attributed to the pneumocephalus.

The quinary pattern of blast injury.

OBJECTIVE: Bombing is the primary weapon of global terrorism, and it results in a complicated, multidimensional injury pattern. It induces bodily injuries through the well-documented primary, secondary, tertiary, and quaternary mechanisms of blast. Their effects dictate special medical concern and timely implementation of diagnostic and management strategies. Our objective is to report on clinical observations of patients admitted to the Tel Aviv Medical Center following a terrorist bombing. RESULTS: The explosion injured 27 patients, and three died. Four survivors who had been in close proximity to the explosion, as indicated by their eardrum perforation and additional blast injuries, were exposed to the blast wave. They exhibited a unique and immediate hyperinflammatory state, two upon admission to the intensive care unit and two during surgery. This hyperinflammatory state manifested as hyperpyrexia, sweating, low central venous pressure, and positive fluid balance. This state did not correlate with the complexity of injuries sustained by any of the 67 patients admitted to the intensive care unit after previous bombings. CONCLUSION: The patients' hyperinflammatory behavior, unrelated to their injury complexity and severity of trauma, indicates a new injury pattern in explosions, termed the "quinary blast injury pattern." Unconventional materials used in the manufacture of the explosive can partly explain the observed early hyperinflammatory state. Medical personnel caring for blast victims should be aware of this new type of bombing injury.

Pulmonary hypertension and predominant right heart failure in thyrotoxicosis.

In this report we discuss a patient with predominant right heart failure and pulmonary hypertension, caused by thyrotoxicosis due to Graves disease, which deteriorated to asystole, due to amiodarone administration for rapid atrial fibrillation.

Donor recruitment and selection for adult-to-adult living donor liver transplantation in urgent and elective circumstances.

BACKGROUND: Adult-to-adult living donor liver transplantation is becoming an alternative to cadaveric transplantation in urgent and elective settings. Donor selection crucially affects donor safety and recipient outcome. OBJECTIVE: To present our algorithm of urgent and elective donor selection. METHODS: Urgent selection is expeditious and protocol-based. Elective selection permits a comprehensive process. Both include medical, psychosocial and surgical-anatomic evaluations. Liver volumes and vascular anatomy are evaluated with computerized tomographic angiography. Informed consent is obtained after painstaking explanations. Independent institutional committees review and approve all cases. RESULTS: Between July 2003 and June 2004 we evaluated 43 potential live donors for 12 potential recipients (fulminant hepatic failure, n = 5; chronic end-stage liver disease, n = 6; primary graft non-function, n = 1). Thirty-three candidates (76%) were excluded due to blood type incompatibility (n = 14, 42%), incompatible anatomy (n = 8, 24%)--including problematic volume distribution (n = 2) or vascular anatomy (n = 6)--psychosocial issues (n = 4, 12%), or medical co-morbidity (n = 7, 22%). Five recipients (FHF, n = 4; chronic ESLD, n = 1) were successfully transplanted from living donors. In the acute setting, two patients (FHF, PGNF) died in the absence of an appropriate donor (cadaveric or living donor). In the elective group, one patient died of unexpected variceal bleeding and one received a cadaveric graft just before the planned living donor transplantation was performed. One candidate was transplanted overseas and two cases are scheduled. The ratio of compatibility for donation was 34% (10/29) for blood type-compatible candidates. CONCLUSIONS: Donor selection for living donor liver transplantation is a complex, labor-intensive multidisciplinary process. Most exclusions are due to blood type incompatibility or anatomic details. Psychosocial aspects of these donations warrant special attention.