DO SERUM ACUTE PHASE REACTANTS PREDICT CLINICAL OUTCOME IN EMERGENCY GENERAL SURGICAL ADMISSIONS?

Saad Ullah Khan, Jun Yi Soh, Aikaterini Peleki, Muhammad Abdullah, Shafquat Zaman, Peter William Waterland

Abstract


Background: Identifying general surgical patients at risk of poor outcome can be a diagnostic challenge. This study aimed to determine the significance of admission serum acute phase reactants in predicting emergency general surgical outcome. Methods: An electronic database containing all acute general surgical admissions over two years was analysed to correlate admission acute phase reactants (including C-reactive protein (CRP), absolute neutrophil count (ANC) and serum albumin) with outcome. Study endpoints included: cross-sectional imaging, surgery, intensive care admission, in-hospital mortality and length-of-stay (LOS). Results: A total of 9738 patients were enrolled in the study. Elevated CRP (n= 4635; 47%) was associated with:  advanced imaging 17% vs 30% (p=0.0001), surgery 15% vs 28% (p=0.0001), ITU admission 3% vs 7% (p=0.0001) and mortality 0.5% vs 2% (p=0.0001). A cut-off level of >150 mg/L was most significant. Abnormal ANC (n= 4104; 42%) was significant in predicting advanced imaging 15% vs 55% (p=0.0001), surgery 17% vs 27% (p=0.0001), and ITU admission 3% vs 8% (p=0.0001). Hypoalbuminaemia (n= 1392; 14%) was associated with a 12-fold rise in mortality 0.5% vs 6%. Normal CRP, ANC with hypoalbuminaemia was a strong negative predictor of mortality (0.015% vs 1.24%), while an abnormal combination was associated with mortality of 8%. Conclusion: Admission acute phase reactants are useful to enhance acute surgical patient stratification during clinical decision making. An admission CRP above 150 should alert the clinician of a potentially high-risk patient who may require prompt intervention. A combination of abnormal results has the highest in-hospital mortality.

Keywords: General surgery; C-reactive protein; Serum albumin; Neutrophils; Acute abdomen; Emergency Treatment


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References


Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med 1995;13(3):301–3.

Silen W. Cope's early diagnosis of the acute abdomen. 18th ed. New York, NY: Oxford Press; 1991.

Laurell H, Hansson LE, Gunnarsson U. Diagnostic pitfalls and accuracy of diagnosis in acute abdominal pain. Scand J Gastroenterol 2006;41(10):1126–31.

Sala E, Watson CJ, Beadsmoore C, Groot-Wassink T, Fanshawe TR, Smith JC, et al. A randomized, controlled trial of routine early abdominal computed tomography in patients presenting with non-specific acute abdominal pain. Clin Radiol 2007;62(10):961–9.

Ng CS, Watson CJ, Palmer CR, See TC, Beharry NA, Housden BA, et al. Evaluation of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause: prospective randomised study. BMJ 2002;325(7377):1387.

Lameris W, van Randen A, van Es HW, van Heesewijk JP, van Ramshorst B, Bouma WH, et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 2009;338:b2431.

Pepys, MB, Baltz, ML. Acute phase proteins with special reference to C-reactive protein and related proteins (pentaxins) and serum amyloid A protein. Adv Immunol 1983;34:141–212.

Bray C, Bell LN, Liang H, Haykal R, Kaiksow F, Mazza JJ, et al. Erythrocyte Sedimentation Rate and C-reactive Protein Measurements and Their Relevance in Clinical Medicine. WMJ 2016;115(6):317–21.

Mitaka C. Clinical laboratory differentiation of infectious versus non-infectious systemic inflammatory response syndrome. Clin Chim Acta 2005;351(1-2):17–29.

Nader D, Davari-Farid S. Neutrophilia: Overview, Causes, Development of Neutrophils [Internet]. [cited 2018 Jun 1st ]. Available from: https://emedicine.medscape.com/article/208576-overview

Tsushima Y, Yamada S, Aoki J, Motojima T, Endo K. Effect of contrast-enhanced computed tomography on diagnosis and management of acute abdomen in adults. Clin Radiol 2002;57(6):507–13.

Pooler BD, Lawrence EM, Pickhardt PJ. MDCT for suspected appendicitis in the elderly: diagnostic performance and patient outcome. Emerg Radiol 2012;19(1):27–33.

Sengupta A, Bax G, Paterson-Brown S. White cell count and C-reactive protein measurement in patients with possible appendicitis. Ann R Coll Surg Engl 2009;91(2):113–5.

Woeste G, Muller C, Bechstein WO, Wullstein C. Increased serum levels of C-reactive protein precede anastomotic leakage in colorectal surgery. World J Surg 2010;34(1):140–6.

Coyle JP, Brennan CR, Parfrey SF, O’Connor OJ, Mc Laughlin PD, Mc Williams SR, et al. Is serum C-reactive protein a reliable predictor of abdomino-pelvic CT findings in the clinical setting of the non-traumatic acute abdomen? Emerg Radiol 2012;19(5):455–62.

Chundadze T, Steinvil A, Finn T, Saranga H, Guzner-Gur H, Berliner S, et al. Significantly elevated C-reactive protein serum levels are associated with very high 30-day mortality rates in hospitalized medical patients. Clin Biochem 2010;43(13–14):1060–3.

Fransen EJ, Maessen JG, Elenbaas TW, van Aarnhem EE, van Dieijen-Visser MP. Enhanced preoperative C-reactive protein plasma levels as a risk factor for postoperative infections after cardiac surgery. Ann Thorac Surg 1999;67(1):134–8.

Siewert B, Raptopoulos V, Mueller MF, Rosen MP, Steer M. Impact of CT on diagnosis and management of acute abdomen in patients initially treated without surgery. AJR Am J Roentgenol 1997;168(1):173–8.

Koutalonis M, Horrocks J. Justification in clinical radiological practice: A survey among staff of five London hospitals. Radiat Prot Dosimetry 2011;149(2):124–37.

Cardoso FS, Ricardo LB, Oliveira AM, Canena JM, Horta DV, Papoila AL, et al. C-reactive protein prognostic accuracy in acute pancreatitis: timing of measurement and cutoff points. Eur J Gastroenterol Hepatol 2013;25(7):784–9.

Ortega-Deballon P, Radais F, Facy O, d'Athis P, Masson D, Charles PE, et al. C-reactive protein is an early predictor of septic complications after elective colorectal surgery. World J Surg 2010;34(4):808–14.

Vermeire S, Van Assche G, Rutgeerts P. C-reactive protein as a marker for inflammatory bowel disease. Inflamm Bowel Dis 2004;10(5):661–5.


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