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Admission physiology criteria upon presentation to combat support hospitals; are current critical vital signs effective?
QUALITY, OUTCOMES AND COSTS III Underuse of staging laparoscopy for gastric cancer results in a high rate of futile laparotomy in the USA Paul J Karanicolas MD, PhD, Elena B Elkin PhD, Lindsay M Jacks MSc, Vivian E Strong MD, FACS, Murray F Brennan MD, FACS, Daniel G Coit MD, FACS Memorial Sloan-Kettering Cancer Center, New York, NY INTRODUCTION: Staging laparoscopy can detect radiographically occult peritoneal metastases and prevent futile laparotomy in patients with gastric adenocarcinoma. The use of staging laparoscopy and the incidence of non-therapeutic laparotomy in the USA are unknown. METHODS: Using Surveillance, Epidemiology and End Results (SEER) population-based cancer registry data linked with Medicare claims, we identified all patients aged 65 or older diagnosed with gastric adenocarcinoma between 1998 and 2005. We defined staging laparoscopy as a laparoscopic procedure from the date of diagnosis until death, and futile laparotomy as a laparotomy in the absence of a therapeutic intervention. RESULTS: 11,759 patients with gastric adenocarcinoma were identified, of whom 5585 (47.5%) had at least one surgical procedure. Staging laparoscopy was performed in 464 (8.3%) patients who had any surgery, and 141 (30.4%) of these patients did not have a therapeutic intervention. Of the remaining 5121 patients who did not have staging laparoscopy, 571 (11.2%) had a claim for laparotomy in the absence of a therapeutic intervention. CONCLUSIONS: Our findings in this large, population-based cohort suggest that staging laparoscopy is infrequently used in the management of older patients with gastric adenocarcinoma in the USA. When staging laparoscopy was performed, almost one third of cases did not have a later therapeutic intervention. Increased use of staging laparoscopy could reduce the morbidity and cost associated with non-therapeutic laparotomy.
Acute kidney injury in burn intensive care unit patients: RIFLE vs AKIN classification John Simmons MD, Kevin K Chung MD, FACP, Christopher E White MD, MSc, FACS, Mark O Hardin MD, John D Ritchie MD, John A Jones BS, Evan M Renz MD, FACS, Steven E Wolf MD, FACS, Charles E Wade PhD, Lorne H Blackbourne MD, FACS Brooke Army Medical Center, Fort Sam Houston, TX INTRODUCTION: The Acute Kidney Injury Network (AKIN) criterion improves the sensitivity of diagnosing acute kidney injury (AKI) over RIFLE criteria in medical ICU patients. The purpose of this study was to compare the two criteria for mortality risk stratification in the burn population. METHODS: We performed a retrospective analysis of consecutive patients admitted to our academic Level I Trauma Center Burn ICU with burns from June 2003 through December 2008. Our primary outcome measure was mortality. Patients undergoing dialysis were excluded. Significance was set at p ⬍ 0.05.
© 2010 by the American College of Surgeons Published by Elsevier Inc.
RESULTS: 1722 patients were evaluated. 503 (29%) AKIN 1, 87 (5%) AKIN 2, 96 (6%) AKIN 3. 134 (7%) classified as Risk, there were no differences in Injury or Failure patients. The AUC for mortality was 0.847 for AKIN (p ⬍ 0.001) and 0.816 for RIFLE (p ⬍ 0.001) (AUC vs. AUC, p ⫽ 0.03). The relative risk of mortality for AKIN1 was 8.5 (4.5-16.2), AKIN2 was 27.0 (12.7-57.2), AKIN3 was 92.0 (46.0-184.9) compared to 8.8 (5.0-15.3) for RIFLE-R, 12.8 (7.0-23.2) for RIFLE-I and 43.6 (25.8-73.8) for RIFLE-F. CONCLUSIONS: AKIN realized a more than 100% increase in patients with AKI. The significance of this is highlighted by the improved AUC, similar OR for mortality for AKIN 1 and RIFLE-R as well as the two-fold increase in OR for AKIN 2 and 3 compared to RIFLE-I and RIFLE-F. AKIN better stratified the mortality risk in severely burned patients by identifying a subset of patients previously missed by the RIFLE criteria.
Admission physiology criteria upon presentation to combat support hospitals; are current critical vital signs effective? Vincent J Mase Jr, MD, David G Baer PhD, Charles E Wade PhD, Brian J Eastridge MD, Thomas W Walters PhD United States Army Insititute of Surgical Research, Fort Sam Houston, TX INTRODUCTION: Admission physiologic criteria aid in combat triage. However, it has been postulated that a significant number of patients in Class II, III, or IV shock compensate due to physiological conditioning, and present with noncritical vital signs (VS) delaying treatment and possibly death. Our objective was to determine the frequency of casualties presenting to Combat Support Hospitals (CSHs) with non-critical VS who die. METHODS: We retrospectively reviewed the Joint Theatre Trauma Registry. Inclusion criteria were combat casualties admitted to a CSH that died within 96 hours and met the following parameters: Body temperature ⬎96 degrees Fahrenheit, heart rate ⬍100, systolic blood pressure ⬎95, diastolic blood pressure ⬎55, respiratory rate ⬍20, and Glasgow Coma Scale ⬎8. Exclusion criteria were patients that arrived already intubated. RESULTS: Of 35,623 admissions over 168 combat months, there were 525 non-intubated casualties with all parameters recorded that died within 96 hours. Of these patients, 4 (0.76%) had noncritical VS. The predominant mechanisms were gunshot wound (75%) and blast injury (25%). The causes of death were head injury (50%), sepsis (25%) and unknown (25%). CONCLUSIONS: A small percentage (0.76%) of patients that died within 96 hours of admission to a CSH had noncritical VS. No previous work has validated the efficacy of admission VS in combat triage until now. This suggests that patients who die early almost always present with one or more abnormal vital signs. Attempts to develop triage tools to assist military providers with identifying patients at risk of death should focus on improving specificity not improving sensitivity.
ISSN 1072-7515/10/$34.00
S106
Acute kidney injury in burn intensive care unit patients: RIFLE vs AKIN classification John Simmons MD, Kevin K Chung MD, FACP, Christopher E White MD, MSc, FACS, Mark O Hardin MD, John D Ritchie MD, John A Jones BS, Evan M Renz MD, FACS, Steven E Wolf MD, FACS, Charles E Wade PhD, Lorne H Blackbourne MD, FACS Brooke Army Medical Center, Fort Sam Houston, TX INTRODUCTION: The Acute Kidney Injury Network (AKIN) criterion improves the sensitivity of diagnosing acute kidney injury (AKI) over RIFLE criteria in medical ICU patients. The purpose of this study was to compare the two criteria for mortality risk stratification in the burn population. METHODS: We performed a retrospective analysis of consecutive patients admitted to our academic Level I Trauma Center Burn ICU with burns from June 2003 through December 2008. Our primary outcome measure was mortality. Patients undergoing dialysis were excluded. Significance was set at p ⬍ 0.05.
© 2010 by the American College of Surgeons Published by Elsevier Inc.
RESULTS: 1722 patients were evaluated. 503 (29%) AKIN 1, 87 (5%) AKIN 2, 96 (6%) AKIN 3. 134 (7%) classified as Risk, there were no differences in Injury or Failure patients. The AUC for mortality was 0.847 for AKIN (p ⬍ 0.001) and 0.816 for RIFLE (p ⬍ 0.001) (AUC vs. AUC, p ⫽ 0.03). The relative risk of mortality for AKIN1 was 8.5 (4.5-16.2), AKIN2 was 27.0 (12.7-57.2), AKIN3 was 92.0 (46.0-184.9) compared to 8.8 (5.0-15.3) for RIFLE-R, 12.8 (7.0-23.2) for RIFLE-I and 43.6 (25.8-73.8) for RIFLE-F. CONCLUSIONS: AKIN realized a more than 100% increase in patients with AKI. The significance of this is highlighted by the improved AUC, similar OR for mortality for AKIN 1 and RIFLE-R as well as the two-fold increase in OR for AKIN 2 and 3 compared to RIFLE-I and RIFLE-F. AKIN better stratified the mortality risk in severely burned patients by identifying a subset of patients previously missed by the RIFLE criteria.
Admission physiology criteria upon presentation to combat support hospitals; are current critical vital signs effective? Vincent J Mase Jr, MD, David G Baer PhD, Charles E Wade PhD, Brian J Eastridge MD, Thomas W Walters PhD United States Army Insititute of Surgical Research, Fort Sam Houston, TX INTRODUCTION: Admission physiologic criteria aid in combat triage. However, it has been postulated that a significant number of patients in Class II, III, or IV shock compensate due to physiological conditioning, and present with noncritical vital signs (VS) delaying treatment and possibly death. Our objective was to determine the frequency of casualties presenting to Combat Support Hospitals (CSHs) with non-critical VS who die. METHODS: We retrospectively reviewed the Joint Theatre Trauma Registry. Inclusion criteria were combat casualties admitted to a CSH that died within 96 hours and met the following parameters: Body temperature ⬎96 degrees Fahrenheit, heart rate ⬍100, systolic blood pressure ⬎95, diastolic blood pressure ⬎55, respiratory rate ⬍20, and Glasgow Coma Scale ⬎8. Exclusion criteria were patients that arrived already intubated. RESULTS: Of 35,623 admissions over 168 combat months, there were 525 non-intubated casualties with all parameters recorded that died within 96 hours. Of these patients, 4 (0.76%) had noncritical VS. The predominant mechanisms were gunshot wound (75%) and blast injury (25%). The causes of death were head injury (50%), sepsis (25%) and unknown (25%). CONCLUSIONS: A small percentage (0.76%) of patients that died within 96 hours of admission to a CSH had noncritical VS. No previous work has validated the efficacy of admission VS in combat triage until now. This suggests that patients who die early almost always present with one or more abnormal vital signs. Attempts to develop triage tools to assist military providers with identifying patients at risk of death should focus on improving specificity not improving sensitivity.
ISSN 1072-7515/10/$34.00
S106