Biological scoring system for early prediction of acute bowel ischemia after cardiac surgery: the PALM score

Abstract

BackgroundBowel ischemia is a life-threatening emergency defined as an inadequate vascular perfusion leading to bowel inflammation resulting from impaired colonic/small bowel blood supply. Main issue for physicians regarding bowel ischemia diagnosis lies in the absence of informative and specific clinical or biological signs leading to delayed management, resulting in a poorer prognosis, especially after cardiac surgery. The aim of the present series was to propose a simple scoring system based on biological data for the diagnosis of bowel ischemia.MethodsIn a retrospective monocentric study, patients admitted in cardiac ICU, after cardiovascular surgery, were screened for inclusion. According to a 1:2 ratio (case–control), matching between two groups was based on sex, type of cardiovascular surgery, and the operative period (per month). Patients were divided into two groups: “ischemic group” which corresponds to patients with confirmed bowel ischemia and “non-ischemic group” which corresponds to patients without bowel ischemia. Primary objective was the conception of a scoring system for the diagnosis of bowel ischemia. Secondary objectives were to detail the postoperative morbidity and the diagnostic features for the distinction between acute mesenteric ischemia and ischemic colitis.ResultsForty-eight patients (1.3%) had confirmed bowel ischemia (“ischemic group”). According to the 2:1 matching, 96 patients were included in the “non-ischemic group.” Aspartate aminotransferase > 449 UI/L, lactate > 4 mmol/L, procalcitonin > 4.7 μg/L, and myoglobin > 1882 μg/L were found to be independently associated with bowel ischemia. Based on their respective odds ratios, points were assigned to each item ranging from 4 to 8. AUROCC [95% confidence interval] of the scoring system to diagnose bowel ischemia was 0.93 [0.91–0.95], p < 0.001. The optimal threshold after bootstrapping was ≥ 14 points; this yielded a sensitivity of 85.4%, a specificity of 94.8%, a positive likelihood ratio of 16.42, a negative likelihood ratio of 0.15, a Youden’s index of 0.802, and a diagnostic odds ratio of 106.62.ConclusionsA biological scoring system based on PCT, ASAT, lactate, and myoglobin measurement allows the diagnosis of bowel ischemia after cardiac surgery with high accuracy. This score could help clinician to propose an early diagnosis and an early treatment in this high mortality disease.Electronic supplementary materialThe online version of this article (10.1186/s13613-018-0395-5) contains supplementary material, which is available to authorized users.

Gastrointestinal complications following cardiac surgery

“…Bowel ischemia is a life-threatening condition with a mortality rate of more than 40%. 30 A retrospective study by Eris and colleagues 31 concluded that the condition appears to be more frequent in patients undergoing isolated CABG, reporting a mean postoperative onset at 1 to 30 days. However, it can also occur a few hours after cardiac surgery, leading to a more ominous prognosis compared to a later onset.…”

“…Further investigation showed that a procalcitonin level of more than 0.57 ng·mL −1 requires surgical resection due to intractable gut ischemia. The PALM score devised by Zogheib and colleagues, 30 based on serum procalcitonin, lactate, aspartate aminotransferase, and myoglobin levels, allows early diagnosis of bowel ischemia after cardiac surgery, with a high degree of accuracy. Lactate is produced by anaerobic glycolysis that occurs due to decreased perfusion, whereas procalcitonin secretion is increased in ischemia due to the production of interleukin-6 and tumor necrosis factor-α.…”

The relationship of systemic inflammatory biomarkers and cardiac parameters with malignancy in patients with soft tissue tumors located in the extremity

“…[ 10 , 11 ] The Youden index was used to determine the cut-off value calculated as max (sensitivity + specificity - 1). [ 12 ] A p value of <0.05 was considered statistically significant.…”

Association of Serum Creatinine Level with Prognosis of Laparotomy for Acute Mesenteric Ischemia after Cardiovascular Surgery

“…The estimated incidence of AMI was reportedly 1–3% after cardiovascular surgery (CS) [ 5 – 8 ]. Several factors, such as advanced age, hypertension, heart failure, prolonged ventilation, use of norepinephrine, and elevated serum levels of procalcitonin, myoglobin, lactate, and aspartate aminotransferase (AST), are reported to be risk factors for AMI after CS [ 9 – 11 ].…”

“…Furthermore, the mortality risk formula was modified to establish a P-POSSUM score that can predict a mortality rate more accurately [ 15 ]. The mortality rate in cases of AMI after CS was reportedly 52.9–81.3% [ 7 , 9 ]. However, a few studies have evaluated predictors of clinical outcomes of patients after surgery for AMI following CS.…”