Evaluation of risk prediction models, V-POSSUM and GAS, in patients with acute abdominal aortic rupture treated with EVAR or an open procedure.

BACKGROUND: In this time of outcome measurements predictive models are needed for correction of comorbidity, in order to perform audits on the outcome of patients. The aim of this study was to evaluate the use of risk-predicting scoring methods in the treatment of RAAA with emergency endovascular aneurysm repair (eEVAR) and open repair in order to analyze outcomes. METHODS: Two hundred and six consecutive patients underwent open repair or eEVAR for RAAA. Patients data were compared with preoperative risk assessments according to the V-POSSUM and the Glasgow Aneurysm Score (GAS). RESULTS: The 30-day mortality rate was 45/206 (22%) in the whole cohort, 41/179 (23%) (95% Confidence Interval [CI] 17-30) after open repair and 4/27 (15%, 95% CI 6-32) after eEVAR. The patient population did not significantly change over time, according to age, gender, V-POSSUM and GAS, neither did the 30-day mortality. The GAS appeared to be a reasonable predictor of postoperative outcome for both open and endovascular RAAA repair, with an area under the curve (AUC) of 0.73 (SD 0.04; 95% CI 0.65-0.80; P<0.001). The V-POSSUM predicted mortality was somewhat less accurate: AUC 0.69 (SD 0.05; 95% CI 0.60-0.77; P<0.001). The only pre-operative variables independently predicting 30-day mortality were age (P=0.006) and lowest pre-operative systolic blood pressure (P=0.032). CONCLUSIONS: Preoperative risk assessment with either V-POSSUM or GAS does not identify patients with fatal outcome at the individual level. However, these risk models may be useful as a relative estimate, in surgical audit or for inter- and intra-hospital comparisons.

Can serum L-lactate, D-lactate, creatine kinase and I-FABP be used as diagnostic markers in critically ill patients suspected for bowel ischemia.

BACKGROUND: The prognostic value of biochemical tests in critically ill patients with multiple organ failure and suspected bowel ischemia is unknown. METHODS: In a prospective observational cohort study intensive care patients were included when the attending intensivist considered intestinal ischemia in the diagnostic workup at any time during intensive care stay. Patients were only included once. When enrolment was ended each patient was classified as 'proven intestinal ischemia', 'ischemia likely', 'ischemia unlikely' or 'no intestinal ischemia'. Proven intestinal ischemia was defined as the gross disturbance of blood flow in the bowel, regardless of extent and grade. Classification was based on reports from the operating surgeon, pathology department, endoscopy reports and CT-scan. Lactate dehydrogenase (LDH), creatine kinase (CK), alanine aminotransferase (ALAT), L-lactate were available for the attending physician. D-lactate and intestinal fatty acid binding protein (I-FABP) were analysed later in a batch. I-FABP was only measured in patients with proven ischemia or no ischemia. RESULTS: For 44 of the 120 included patients definite diagnostic studies were available. 23/44 patients (52%) had proven intestinal ischemia as confirmed by surgery, colonoscopy, autopsy and/or histopathological findings. LDH in these patients was 285 U/l (217-785) vs 287 U/l (189-836) in no-ischemia; p = 0.72. CK was 226 U/l in patients with proven ischemia (126-2145) vs 347 U/l (50-1427), p = 0.88. ALAT was 53 U/l (18-300) vs 34 U/l (14-34), p-0,56. D-lactate 0.41 mmol/l (0.11-0.75) vs 0.56 mmol/l (0.27-0.77), p = 0.46. L-lactate 3.5 mmol/l (2.2-8.4) vs 2.6 mmol/l (1.7-3.9), p = 0.09. I-FABP 2872 pg/ml (229-4340) vs 1020 pg/ml (239-5324), p = 0.98. Patient groups proven and likely ischemia together compared to unlikely and no-ischemia together showed significant higher L-lactate (p = 0.001) and higher D-lactate (p = 0.003). CONCLUSIONS: Measurement of LDH, CK, and ALAT did not discriminate critically ill patients with proven intestinal ischemia from those with definite diagnosis no-ischemia. However, L-lactate and D-lactate levels were higher in patients with proven or likely ischemia and need further study just as I-FABP.

Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients.

INTRODUCTION: More than half of in-hospital adverse events can be attributed to a surgical discipline. Checklists can effectively decrease errors and adverse events. However, the mechanisms by which checklists lead to increased safety are unclear. This study aimed to assess the number, nature and timing of incidents intercepted by use of the Surgical Patient Safety System (SURPASS) checklist, a patient-specific multidisciplinary checklist that covers the entire surgical patient pathway. METHODS: The checklist was implemented in two academic hospitals and four teaching hospitals in the Netherlands. Users of the checklist had three options for each item that was checked: 'not applicable', 'yes' and 'intercepted by checklist'. In each hospital, the first 1000 completed checklists were entered into an online central database. RESULTS: In six participating hospitals, 6313 checklists were collected. One or more incidents were intercepted in 2562 checklists (40.6%). In total, 6312 incidents were intercepted. After correction for the number of items and the extent of adherence in each part of the checklist, the number of intercepted incidents was highest in the preoperative and postoperative stages. CONCLUSIONS: The checklist intercepts many potentially harmful incidents across all stages of the surgical patient pathway. The majority of incidents were intercepted in the preoperative and postoperative stages of the pathway. The degree to which these incidents would have been intercepted by a single checklist in the operating room only, compared with a checklist for the entire surgical pathway, remains a subject for future study.