The value of C-reactive protein and lactate in the acute abdomen in the emergency department

Utility of Serum L-lactate in Identifying Ischemia in Acute Intestinal Obstruction: A Prospective Observational Study

Introduction In cases of intestinal obstruction, increasing luminal dilatation compromises bowel wall perfusion, eventually resulting in intestinal ischemia and bowel necrosis in advanced cases. Elevated L-lactate, as a biomarker of ischemia, may indicate the presence of bowel ischemia in cases of obstruction. The objective of this study was to evaluate the value of serum L-lactate measurement in predicting the presence of intraoperatively observed intestinal ischemia in patients with acute intestinal obstruction. Methods Patients diagnosed with acute intestinal obstruction were prospectively studied over an 18-month period. Serum L-lactate values were assayed twice: at the time of presentation and following appropriate fluid resuscitation. Receiver operating characteristic (ROC) curve analysis was applied to determine the predictive value of serum L-lactate in detecting intestinal ischemia. Results One hundred forty-four cases of intestinal obstruction were included in this study, of which 91 underwent operative intervention. Intestinal ischemia was identified in 52 cases and categorized intra-operatively as reversible (n = 33) and irreversible (n = 19). ROC analysis showed a good predictive value of serum L-lactate after fluid resuscitation for irreversible intestinal ischemia (area under the curve (AUC) = 0.884, 95% confidence interval (CI), 0.812-0.956). An L-lactate cut-off of 19.1 mg/dL following fluid resuscitation was determined to have a sensitivity of 89.5%, a specificity of 72.9%, a positive predictive value of 46.6%, and a negative predictive value of 96.3% for gangrenous bowel. Conclusion Serum L-lactate is a good predictive tool for identifying intestinal ischemia during the management of intestinal obstruction. Serum L-lactate after resuscitation showed better predictive value for ischemic bowel.

The NSW Pathology Atlas of Variation: Part I-Identifying Emergency Departments With Outlying Laboratory Test-Ordering Practices

STUDY OBJECTIVE

Abdominal pain and chest pain are leading reasons for emergency department (ED) presentations, with laboratory tests frequently ordered to aid the diagnostic process. Our study aims to identify EDs with outlying laboratory ordering practices for patients presenting with undifferentiated abdominal pain and chest pain.

METHODS

This was a retrospective observational study of 519,597 patients who presented with the complaint of abdominal or chest pain at 44 major hospital EDs across New South Wales, Australia, from January 2017 to September 2018. For each condition, we evaluated the risk-adjusted rate of ordering at least 1 laboratory test and of each of the top 15 ordered tests. We used funnel plots to graph variations in test ordering and identify EDs with outlying test-ordering practices. EDs lying above or below the 99.8% funnel control limits were regarded as outliers.

RESULTS

From 3,360,152 unplanned presentations, abdominal pain and chest pain represented 8.8% (n=296,809) and 6.6% (n=222,788) of all cases, respectively. No major outliers were observed for ordering at least one laboratory test; however, variations were observed for individual tests. For abdominal pain, the top 3 tests with the highest ordering variation included glucose (20 outlier EDs), C-reactive protein (10 outliers), and calcium-magnesium-phosphate (7 outliers). For chest pain, the top 3 tests with the highest ordering variation were glucose (21 outlier EDs), C-reactive protein (17 outliers), and liver function test (14 outliers).

CONCLUSION

Identifying EDs with outlying laboratory-ordering practices is the first step in initiating context-specific evaluation of whether outlying variations are unwarranted.

Advantage of laparoscopic peritoneal toileting in acute peritonitis with unclear etiology: A case report with inspiring outcome (with video)

INTRODUCTION

Acute peritonitis is a surgical emergency and is conventionally managed with exploratory laparotomy in many centers, but laparoscopy is not contraindicated in such conditions. Operative management remains a cornerstone treatment in peritonitis irrespective of the primary pathology.

PRESENTATION OF CASE

A 32-years-old man was admitted with acute diffuse peritonitis. As he was clinically stable, we proceeded with conservative treatment and diagnostic workup. He did not respond by 24 h and CT imaging showed ascites, but no definite diagnosis could be made. Diagnostic laparoscopy was performed, thorough peritoneal toileting was done but surprisingly the etiology was unclear. Following laparoscopy, he responded well with an uneventful recovery.

DISCUSSION

Timely proper evaluation and correct intervention are a paramount concern for the positive outcome. Regarding the most effective operative approach (laparotomy or laparoscopy) in acute peritonitis remains controversial in the literature and laparoscopy has been considered as a relative contraindication. However, the laparoscopy is gaining wider acceptance as the limitations of laparoscopy are declining rapidly. We experienced a case of extensive peritonitis with unclear etiology which we managed successfully by laparoscopy.

CONCLUSION

Laparoscopic approach in peritonitis is effective and helpful for accurate diagnosis and to minimize the hazards of an unnecessary laparotomy. This case report might encourage many surgeons to consider laparoscopic approach in peritonitis with confidence and to perform further studies.

Lactic acid level as an outcome predictor in pediatric patients with intussusception in the emergency department

Background

Intussusception decreases blood flow to the bowel, and tissue hypoperfusion results in increased lactic acid levels. We aimed to determine whether lactic acid levels are associated with pediatric intussusception outcomes.

Methods

The electronic medical records of our emergency department pediatric patients diagnosed with intussusception, between January 2015 and October 2018, were reviewed. An outcome was considered poor when intussusception recurred within 48 h of reduction or when surgical reduction was required due to air enema failure.

Results

A total of 249 patients were included in the study, including 39 who experienced intussusception recurrence and 11 who required surgical reductions; hence, 50 patients were included in the poor outcome group. The poor and good outcome groups showed significant differences in their respective blood gas analyses for pH (7.39 vs. 7.41, P = .001), lactic acid (1.70 vs. 1.30 mmol/L, P < .001), and bicarbonate (20.70 vs. 21.80 mmol/L, P = .036). Multivariable logistic regression analyses showed that pH and lactic acid levels were the two factors significantly associated with poor outcomes. When the lactic acid level cutoff values were ≥ 1.5, ≥2.0, ≥2.5, and ≥ 3.0 mmol/L, the positive predictive values for poor outcomes were 30.0, 34.6, 50.0, and 88.9%, respectively.

Conclusion

Lactic acid levels affect outcomes in pediatric patients with intussusception; higher lactic acid levels are associated with higher positive predictive values for poor outcomes.

Procalcitonin in the recognition of complications in critically ill surgical patients

BACKGROUND

Procalcitonin (PCT) is a relatively new, promising indirect parameter for infection. In the intensive care unit (ICU) it can be used as a marker for sepsis. However, in the ICU there is a need for reliable markers for clinical deterioration in the critically ill patients. This study determines the clinical value of PCT concentrations in recognizing surgical complications in a heterogeneous group of general surgical patients in the ICU.

MATERIAL AND METHODS

We prospectively collected PCT concentration data from April 2010 to June 2012 for all general surgical patients admitted to the ICU. Both the relationships between PCT levels and events (diagnostic and therapeutic interventions) as well as between PCT levels and surgical complications (abscesses, bleeding, perforation, ischemia, and ileus) were studied.

RESULTS

PCT concentrations were lower in patients who developed complications than those who did not develop complications on the same day, although not significant (P = 0.27). A 10% increase in PCT levels resulted in a 2% higher complication odds, but again this was not significant (odds ratio [OR], 1.020; 95% confidence interval [CI], 0.961-1.083; P = 0.51). Even a 20% or 30% increase in PCT concentrations did not result in higher complication probability (OR, 1.039; 95% CI, 0.927-1.165 and OR, 1.057; 95% CI, 0.897-1.246). Furthermore, an increase in PCT levels did not show an increase or a reduction in the number of diagnostic and therapeutic interventions.

CONCLUSIONS

An increase in PCT levels does not help to predict surgical complications in critically ill surgical patients.

Diagnostic value of lactate levels in acute abdomen disorders

The supply of oxygen is limited in certain intra abdominal conditions due to direct vascular invasion or inflammatory process, resulting in high lactate levels. Aim of this study was to find the predictive value of lactate levels in the peritoneal fluid (PF) and blood of patients with acute abdomen. The study comprised of fifty patients with acute abdominal conditions, admitted in emergency ward of tertiary care hospital, thirty patients were with surgical abdomen (group I) and twenty patients with non surgical abdomen (group II). Lactate was estimated in PF and blood on Blood Gas Analyzer (NOVA, M-7). The mean lactate levels in PF were significantly higher in group I as compared to group II (14.65 ± 1.195 vs. 5.92 ± 0.97 mmol/L, p < 0.001). There was no significant difference in blood lactate levels in both the groups. When PF and blood lactate levels were compared within groups, we found that PF levels were significantly higher than blood in group I (14.65 ± 1.195 vs. 3.85 ± 0.54 mmol/L, p < 0.001) but not in group II (5.92 ± 0.97 vs. 4.36 ± 0.95 mmol/L). Diagnostic value was obtained using ROC curve. Cut off values obtained for PF lactate, difference and ratio of PF and blood lactate (≥6.4 mmol/L, ≥3.3 and ≥2.1 respectively) are at very high degree of sensitivity and specificity. So it can be useful marker of surgical emergency in patients with acute intra abdominal pathology, especially in clinically ill patients or in whom physical examination is not yielding because of neurologic disorders or unresponsiveness.