Anesthesiology – ClinCaseQuest https://clincasequest.hospital Medical education in clinical cases Tue, 30 Aug 2022 09:15:39 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.11 https://clincasequest.hospital/wp-content/uploads/sites/7/2020/02/logo-ru-project-90x90.png Anesthesiology – ClinCaseQuest https://clincasequest.hospital 32 32 Karnofsky Performance Status Scale Online Calculator https://clincasequest.hospital/karnofsky-performance-status-scale/ Mon, 29 Aug 2022 07:21:53 +0000 https://clincasequest.hospital/?p=34206 Karnofsky performance status scale determines ability of patient to tolerate chemotherapy. For patients ≥ 16 years old. Useful to use over time to track disease…

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]]> Karnofsky performance status scale determines ability of patient to tolerate chemotherapy.

For patients ≥ 16 years old.

Useful to use over time to track disease progression.

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The Karnofsky Performance Status Scale (KPS)  is widely used for a variety of purposes, including response to chemotherapy for cancer and assessment of chronic disease. This scale can be used to assess patients with advanced cancer or other chronic diseases, as well as progressive debility in the elderly.

The Karnofsky Performance Status Scale quantifies a patient’s functional ability and the effect of treatment, such as chemotherapy, on their basic functional ability. It is sometimes also used for prognostic purposes and to guide treatment.

The score on the scale is highly correlated with survival time and need for home care. It can also help predict the ability to progress with invasive and intensive treatments.

Patient Description  Points*Result
Normal no complaints; no evidence of disease  100Able to carry on normal activity and to work; no special care needed.
Able to carry on normal activity; minor signs or symptoms of disease  90Able to carry on normal activity and to work; no special care needed.
Normal activity with effort; some signs or symptoms of disease  80Able to carry on normal activity and to work; no special care needed.
Cares for self; unable to carry on normal activity or to do active work  70Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed.
Requires occasional assistance, but is able to care for most of his personal needs  60Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed.
Requires considerable assistance and frequent medical care  50Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed.
Disabled; requires special care and assistance  40Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly.
Severely disabled; hospital admission is indicated although death not imminent  30Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly.
Very sick; hospital admission necessary; active supportive treatment necessary  20Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly.
Moribund; fatal processes progressing rapidly  10Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly.
Dead0Dead.
*% Survival correlates with points assigned

The lower the Karnofsky score, the worse the prognosis, which may be due to:

  • Intolerance to therapy
  • Decreased survival rates
ECOG PERFORMANCE STATUSKARNOFSKY PERFORMANCE STATUS
0—Fully active, able to carry on all pre-disease performance without restriction100—Normal, no complaints; no evidence of disease
 90—Able to carry on normal activity; minor signs or symptoms of disease
1—Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work80—Normal activity with effort, some signs or symptoms of disease
 70—Cares for self but unable to carry on normal activity or to do active work
2—Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours60—Requires occasional assistance but is able to care for most of personal needs
 50—Requires considerable assistance and frequent medical care
3—Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours40—Disabled; requires special care and assistance
 30—Severely disabled; hospitalization is indicated although death not imminent
4—Completely disabled; cannot carry on any selfcare; totally confined to bed or chair20—Very ill; hospitalization and active supportive care necessary
 10—Moribund
5—Dead0—Dead

The Karnofsky Performance Status Scale and other performance scales should be used for the holistic assessment of cancer patients, although its accuracy as a prognostic tool in some cases has not yet been sufficiently proven.

The Karnofsky Performance Status Scale is useful to clinicians in daily clinical practice, and this performance scale should be used to improve understanding of a patient’s needs and abilities, and potentially for prediction.

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Literature

  1. Karnofsky DA Burchenal JH. (1949). ‘The Clinical Evaluation of Chemotherapeutic Agents in Cancer.’ In: MacLeod CM (Ed), Evaluation of Chemotherapeutic Agents. Columbia Univ Press. Page 196.
  2. Crooks, V, Waller S, et al. The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. J Gerontol. 1991; 46: M139-M144.
  3. Hollen PJ, Gralla RJ, et al. Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. Cancer. 1994; 73: 2087-2098.
  4. O’Toole DM, Golden AM. Evaluating cancer patients for rehabilitation potential. West J Med. 1991; 155:384-387.
  5. Schag CC, Heinrich RL, Ganz PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. J Clin Oncology. 1984; 2:187-193.


Read also:

ECOG Performance Status of the general condition of a cancer patient

Interactive OSCE Checklist – Emergency care of a patient with chest pain – Acute Coronary Syndrome with ST-segment elevation and equivalents

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• Opening the consultation

• Availability of a defibrillator

• Presenting complaint

• History of presenting complaint

• Past medical history

• Drug history

• Physical examination

• Intravenous access

• Registration of a 12-channel ECG

• Express test for the determination of cardiac troponin, myoglobin, creatine phosphokinase-MB, if possible

• Making preliminary diagnosis

• Drug therapy (basic)

• Evaluation of the door-balloon time (the choice of further reperfusion strategy aimed as soon as possible to restore the coronary blood flow in the infarct-dependent artery)

• Call the nearest reperfusion center

• P2Y12 receptor inhibitor prescription depending on the chosen strategy of reperfusion therapy

• Carrying out thrombolytic therapy as needed

• Transportation to the nearest reperfusion center

Total: 0 / 62
Additional materials: https://clincasequest.hospital/chest-pain-history-taking/ https://clincasequest.hospital/pericarditis/ https://clincasequest.hospital/stephen-smiths-formula/ https://clincasequest.hospital/wellens-syndrome/ https://clincasequest.hospital/aslangers-pattern/ Register on our website right…
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]]> Drug Resistance in Pneumonia (DRIP) Score. Online Calculator https://clincasequest.hospital/drip-score/ Wed, 10 Aug 2022 18:38:22 +0000 https://clincasequest.hospital/?p=34177 The purpose of the DRIP score is to determine when broad-spectrum antibiotics should be used to ensure treatment is effective and to avoid increasing antibiotic…

Сообщение Drug Resistance in Pneumonia (DRIP) Score. Online Calculator появились сначала на ClinCaseQuest.

]]> The purpose of the DRIP score is to determine when broad-spectrum antibiotics should be used to ensure treatment is effective and to avoid increasing antibiotic resistance.

May be used in patients with community-acquired pneumonia.

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• Major Risk Factors

(including long term acute care, skilled nursing, and inpatient rehabilitation but not assisted living or group home facilities)

• Minor Risk Factors

Karnofsky Performance Status <70 or non-ambulatory status

For research purposes only; answer does NOT impact results

* Required


The DRIP score is a clinical predictive tool that helps predict which cases of bacterial pneumonia may be resistant to antibiotic therapy.

The DRIP score for drug resistance in pneumonia requires the addition of the selected points, if available:

Major Risk Factors
Antibiotic use within 60 days+2
Long term care resident (including long term acute care, skilled nursing, and inpatient rehabilitation but not assisted living or group home facilities).+2
Tube feeding nasogastral, nasojejunal, or percutaneous endoscopic gastrostomy (PEG)+2
Prior drug-resistant pneumonia diagnosis within 1 year+2
Minor Risk Factors 
Hospitalization within 60 days+1
Chronic pulmonary disease+1
Poor functional status
Karnofsky Performance Status <70 or non-ambulatory status		+1
H2 blocker or PPI within 14 days+1
Active wound care at time of admission+1
MRSA colonization within 1 year+1
Is this a COVID-19 patient?
For research purposes only; answer does NOT impact results		Confirmed positive
 Suspected
 Unlikely
 Confirmed negative

Interpretation:

DRIP ScoreInterpretation
<4Low risk of drug-resistant pneumonia. Consider treating without extended-spectrum antibiotics.
≥4High risk of drug-resistant pneumonia. Extended-spectrum antibiotics likely necessary.

The DRIP score is more sensitive (82% vs. 79%), more specific (81% vs. 65%), and reduces the use of unnecessary extended-spectrum antibiotics compared to the HCAP score by 38%.

The DRIP score was also more specific and accurate than eight other predictive models, including the Shorr score.

  • A patient with a DRIP <4 can be effectively treated without the use of broad-spectrum antibiotics.
  • A patient with a DRIP score of ≥4 is more likely to need broad-spectrum antibiotics.

At a cut-off value of ≥4 points, DRIP optimally differentiates between high and low risk, confirming its usefulness as a clinical decision tool for empiric antibiotic choice.

The DRIP score should only be used for bacterial causes of pneumonia.

  • False negative results may occur in the following situations: Methicillin-resistant Staphylococcus aureus (MRSA) or P. aeruginosa, severe COPD (requiring O₂ and steroids), intravenous drug use, psychiatric illness, and homeless status.
  • False positive results may occur with S. pneumoniae and methicillin-susceptible Staphylococcus aureus (MSSA).

The DRIP study confirmed that antibiotic use and hospitalization 60 days prior were major causes of drug resistance, but did not find a strong association between disease severity and drug resistance.


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Literature

  1. Webb BJ, Dascomb K, Stenehjem E, et al. Derivation and Multicenter Validation of the Drug Resistance in Pneumonia Clinical Prediction Score. Antimicrob Agents Chemother. 2016;60(5):2652-63. https://journals.asm.org/doi/pdf/10.1128/AAC.03071-15
  2. Webb BJ, Dascomb K, Stenehjem E, et al. Derivation and Multicenter Validation of the Drug Resistance in Pneumonia Clinical Prediction Score. Antimicrob Agents Chemother. 2016;60(5):2652-63. https://journals.asm.org/doi/pdf/10.1128/AAC.03071-15
  3. Webb BJ, Sorensen J, Mecham I, et al. Antibiotic Use and Outcomes After Implementation of the Drug Resistance in Pneumonia Score in ED Patients With Community-Onset Pneumonia. Chest. 2019. https://journal.chestnet.org/article/S0012-3692(19)31012-8/fulltext


Read also:

Karnofsky Performance Status Scale Online Calculator

Interactive OSCE Checklist – Emergency care of a patient with chest pain – Acute Coronary Syndrome with ST-segment elevation and equivalents

• Opening the consultation

• Availability of a defibrillator

• Presenting complaint

• History of presenting complaint

• Past medical history

• Drug history

• Physical examination

• Intravenous access

• Registration of a 12-channel ECG

• Express test for the determination of cardiac troponin, myoglobin, creatine phosphokinase-MB, if possible

• Making preliminary diagnosis

• Drug therapy (basic)

• Evaluation of the door-balloon time (the choice of further reperfusion strategy aimed as soon as possible to restore the coronary blood flow in the infarct-dependent artery)

• Call the nearest reperfusion center

• P2Y12 receptor inhibitor prescription depending on the chosen strategy of reperfusion therapy

• Carrying out thrombolytic therapy as needed

• Transportation to the nearest reperfusion center

Additional materials: https://clincasequest.hospital/chest-pain-history-taking/ https://clincasequest.hospital/pericarditis/ https://clincasequest.hospital/stephen-smiths-formula/ https://clincasequest.hospital/wellens-syndrome/ https://clincasequest.hospital/aslangers-pattern/ Register on our website right…
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Сообщение Drug Resistance in Pneumonia (DRIP) Score. Online Calculator появились сначала на ClinCaseQuest.

]]> Focused Assessment with Sonography for Trauma (FAST): Online Calculator https://clincasequest.hospital/fast/ Sat, 21 May 2022 16:28:07 +0000 https://clincasequest.hospital/?p=34015 Focused Assessment with Sonography for Trauma (FAST) predicts the presence of pericardial or intra-abdominal injury after penetrating or blunt trauma. FAST should be used liberally…

Сообщение Focused Assessment with Sonography for Trauma (FAST): Online Calculator появились сначала на ClinCaseQuest.

]]> Focused Assessment with Sonography for Trauma (FAST) predicts the presence of pericardial or intra-abdominal injury after penetrating or blunt trauma.

  • FAST should be used liberally in the evaluation of trauma patients.
  • Especially useful in patients with penetrating thoracic trauma and in unstable patients after blunt abdominal trauma.

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FAST is a rapid, non-invasive, and repeatable imaging modality that can guide the surgeon in the decision to operate.

Performed in trauma bay (does not require patient transport out of the emergency department, which is risky in unstable patients).

FAST results alone should not determine the decision to operate. However, FAST can be a helpful adjunct in clinical decision making, particularly in an unstable blunt trauma patient in order to rapidly assess the chest and abdomen for potential causes of hypotension.

Most clinicians use the low-frequency phased array ultrasound probe (a.k.a. cardiac probe), to obtain all windows in FAST.

  
Pericardial fluidAbsent
 Present
 Equivocal
Right upper quadrant (Morison’s pouch) fluid  Absent
 Present
 Equivocal
Left upper quadrant (splenorenal recess) fluid  Absent
 Present
 Equivocal
Suprapubic fluid  Absent
 Present
 Equivocal

Most clinicians use the low-frequency phased array ultrasound probe (a.k.a. cardiac probe), to obtain all windows in FAST.

Pericardial  place the probe in the subxiphoid area and orient it towards the patient’s left shoulder. Apply downward pressure to look under the costal margin and towards the heart. The heart and pericardium will come into view, allowing inspection for hemopericardium and ultrasound findings of cardiac tamponade.
Right upper quadrant  place probe in right anterior to the midaxillary line (between 11th–12th ribs). Visualization of the hepatorenal recess (Morison’s pouch) allows the assessment of hemoperitoneum in the right upper quadrant. Blood most likely accumulates here if hemoperitoneum is present.
Left upper quadrant  apply transducer firmly onto the skin in the left posterior axillary line (between the 9th–10th ribs) to visualize splenorenal and subphrenic spaces. In practice, it is important to remember that the right and left upper quadrant views are often more posterior than anticipated. It can be helpful to bring the probe all the way down to the stretcher in order to best visualize these windows.
Suprapubicplace transducer superior to pubic symphysis and fan probe inferiorly to visualize the bladder.

Using bedside ultrasound, assess for fluid in each of the following areas:

 Fluid present?
Pericardial fluidAbsentPresentEquivocal
Right upper quadrant (Morison’s pouch) fluidAbsentPresentEquivocal
Left upper quadrant (splenorenal recess) fluidAbsentPresentEquivocal
Suprapubic fluidAbsentPresentEquivocal

Management

Suggested management (clinician must consider additional clinical information including hemodynamic stability and clinical suspicion for injury):

Pericardial FAST (penetrating thoracic trauma)   
Positive   emergent surgical intervention recommended. Median sternotomy preferred if the patient is stable; otherwise, use left anterolateral thoracotomy.
Equivocal  pericardial window or formal transthoracic echocardiography (TTE) is recommended.
Negative  close clinical monitoring or discharge is recommended, according to clinical suspicion for injury.
Abdominal FAST (blunt abdominal trauma) 
Positivein the unstable patient, emergent exploratory laparotomy is recommended. In a stable patient, cross-sectional imaging (CT scan) is recommended.
Equivocalin the unstable patient, diagnostic peritoneal aspiration (DPA) is recommended. In a stable patient, cross-sectional imaging (CT scan) is recommended.
Negativein the unstable patient, diagnostic peritoneal aspiration (DPA) is recommended if clinical suspicion for intra-abdominal bleeding exists. In a stable patient, a CT scan, close clinical monitoring, or discharge is recommended, according to clinical suspicion for injury.

NB!

  • Repeating FAST while preparing to perform diagnostic peritoneal aspiration is useful to quickly reassess unstable patients with blunt abdominal trauma with initially negative FAST. Intra-abdominal hemorrhage may not be significant enough on presentation to be FAST-positive initially.
  • Be cautious if pericardial FAST is negative in patients with penetrating thoracic trauma, especially if unstable. Cardiac injuries can decompress through the injured pericardium, most commonly into the left hemithorax, resulting in negative pericardial FAST. Therefore, unstable patients with this mechanism of injury and FAST finding should undergo a chest x-ray. If it reveals a hemothorax, a chest tube must be placed. Ongoing or high-volume chest tube output in this clinical context may be from a cardiac injury.
  • If the pericardial fluid is seen in the subxiphoid view, surgical intervention is warranted.
  • If intra-abdominal fluid is seen in any of the three abdominal views, emergent laparotomy is indicated in unstable patients.
  • Stable patients with intra-abdominal fluid should proceed to cross-sectional imaging. 

More recently, thoracic views have been added to the FAST exam and termed eFAST. These windows assess the chest bilaterally for pneumo- and hemothorax. In some series, the reported sensitivities of eFAST (86–100%) are superior to that of chest x-ray (27–83%) in the detection of pneumothoraces (Governatori 2015, Nandipati 2011, Wilkerson 2010).

The extended FAST (eFAST) has entered into clinical practice with the addition of bilateral thoracic views to assess for pneumo- and hemothorax.

Negative FAST does not exclude injury. Ultrasound is user-dependent; therefore, clinicians should be cautious in interpreting negative FAST. Sensitivities of abdominal and suprapubic views in FAST vary widely, with ranges of 22–98% reported in recent literature

If clinical suspicion for injury persists despite negative FAST, FAST should be repeated, additional investigations should be performed, or intervention should be pursued, depending on patient’s clinical condition.

.

Literature

  1. Rozycki GS, Ochsner MG, Jaffin JH, Champion HR. Prospective evaluation of surgeons’ use of ultrasound in the evaluation of trauma patients. J Trauma. 1993 Apr;34(4):516-26.
  2. Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg. 1998 Oct;228(4):557-567.
  3. Rozycki GS, Ochsner MG, Schmidt JA, et al. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma. 1995 Sep;39(3):492-8.
  4. Rozycki GS, Feliciano DV, Ochsner MG, et al. The Role of Ultrasound in Patients with Possible Penetrating Cardiac Wounds: A Prospective Multicenter Study. J Trauma. 1999 Apr;46(4):543-51.
  5. Richards JR, McGahan JP. Focused Assessment with Sonography in Trauma (FAST) in 2017: What Radiologist Can Learn. Radiology. 2017 Apr;283(1):30-48.
  6. Ball CG, Williams BH, Wyrzykowski AD, et al. A Caveat to the Performance of Pericardial Ultrasound in Patients with Penetrating Cardiac Wounds. J Trauma. 2009 Nov;67(5):1123-4.
  7. Nandipati KC, Allamaneni S, Kakarla R, et al. Extended Focused Assessment with Sonography for Trauma (EFAST) in the Diagnosis of Pneumothorax: Experience at a Community Based Level I Trauma Center. Injury. 2011 May;42(5):511-4.
  8. Governatori NJ, Saul T, Siadecki SD, et al. Ultrasound in the Evaluation of Penetrating Thoraco-Abdominal Trauma: A Review of the Literature. Med Ultrason. 2015 Dec;17(4):528-34.
  9. Wilkerson RG, Stone MB. Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma. Acad Emerg Med. 2010 Jan;17(1):11-7.
  10. Matsushima K, Khor D, Berona K, Antoku D, Dollbaum R, Khan M, Demetriades D. Double Jeopardy in Penetrating Trauma: Get FAST, Get It Right. World J Surg. 2017 Aug 4. [Epub ahead of print]
  11. Carter JW, Falco MH, Chopko MS, Flyn WJ Jr, Wiles Iii CE, Guo WA. Do we really rely on fast for decision-making in the management of blunt abdominal trauma?. Injury. 2015 May;26(5):817-21.

Charlson Comorbidity Index (CCI) Online Calculator

Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

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History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

Chronic cognitive deficit

Any history of treatment for ulcer disease or history of ulcer bleeding

Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

* Required
VariablePointsAge <50…
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Multiple Myeloma Diagnostic Criteria – Online Calculator

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≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

* Required
For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
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]]> Interactive OSCE Checklist – Emergency care of a patient with chest pain – Acute Coronary Syndrome with ST-segment elevation and equivalents https://clincasequest.hospital/osce-checklist-chest-pain-emergency/ Sat, 14 May 2022 12:10:00 +0000 https://clincasequest.hospital/?p=33535 Additional materials: Register on our website right now to have access to more learning materials! Register Subscribe to our pages:

Сообщение Interactive OSCE Checklist – Emergency care of a patient with chest pain – Acute Coronary Syndrome with ST-segment elevation and equivalents появились сначала на ClinCaseQuest.

]]>

• Opening the consultation

• Availability of a defibrillator

• Presenting complaint

• History of presenting complaint

• Past medical history

• Drug history

• Physical examination

• Intravenous access

• Registration of a 12-channel ECG

• Express test for the determination of cardiac troponin, myoglobin, creatine phosphokinase-MB, if possible

• Making preliminary diagnosis

• Drug therapy (basic)

• Evaluation of the door-balloon time (the choice of further reperfusion strategy aimed as soon as possible to restore the coronary blood flow in the infarct-dependent artery)

• Call the nearest reperfusion center

• P2Y12 receptor inhibitor prescription depending on the chosen strategy of reperfusion therapy

• Carrying out thrombolytic therapy as needed

• Transportation to the nearest reperfusion center



Additional materials:

Chest Pain History Taking / OSCE guide
Pericarditis: symptoms, diagnosis, treatment
Stephen Smith’s formula for Subtle Anterior STEMI online Calculator
Two masks of the same syndrome: Wellens syndrome
Aslanger’s Pattern

Register on our website right now to have access to more learning materials!

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Takotsubo syndrome

Takotsubo syndrome is a condition characterized by the sudden onset of acute, transient (lasting up…

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Lyme disease is an infectious disease caused by the spirochete Borrelia burgdorferi, which is transmissible…

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]]> Maximum Allowable Blood Loss (ABL) Without Transfusion: Online calculator https://clincasequest.hospital/abl-online-calculator/ Thu, 12 May 2022 10:31:12 +0000 https://clincasequest.hospital/?p=33802 Maximum Allowable Blood Loss (ABL) Without Transfusion formula can be used in patients with blood loss, typically during surgery, who may need transfusion. The Maximum…

Сообщение Maximum Allowable Blood Loss (ABL) Without Transfusion: Online calculator появились сначала на ClinCaseQuest.

]]> Maximum Allowable Blood Loss (ABL) Without Transfusion formula can be used in patients with blood loss, typically during surgery, who may need transfusion. The Maximum Allowable Blood Loss Without Transfusion calculator suggests how much blood can be lost, typically during surgery, before transfusion should be considered.

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Weight

Hemoglobin initial

Hemoglobin final (lowest acceptable hemoglobin, by clinical judgment units)

* Required

Maximum Allowable Blood Loss (ABL) Without Transfusion formula helps with determining when to transfuse a patient if blood count values are not immediately available.

Maximum Allowable Blood Loss (ABL) Without Transfusion calculated based on formula:

ABL = [EBV x (Hi-Hf)] / Hav, where EBV = body weight, kg x average blood volume*, mL/kg and other variables are as follows:

VariableDescription
ABLAllowable blood loss
EBVEstimated blood volume
HiInitial hemoglobin
HfFinal hemoglobin (cutoff for transfusion)
HavAverage of initial and final hemoglobin

*Average blood volume by age:

AgeAverage blood volume, mL/kg
Adult man75
Adult woman65
Infant80
Neonate85
Premature neonate96

Transfusion triggers vary by patient and clinical presentation.

Patients with hemoglobin concentrations below 6 g/dL almost always require transfusion. In stable patients with hemoglobin values 6-10 g/dL, the decision whether to transfuse is based on an evaluation of clinical status; patients with values above 10 g/dL rarely require transfusion unless they are unstable or have signs/symptoms consistent with continued hemorrhage.

During blood loss, dilution of remaining hemoglobin occurs as intravascular volume is maintained by fluid shifts and administration of fluids. Consider transfusing if estimated blood loss exceeds calculated allowable blood loss.

Estimating blood loss intraoperatively can be done via direct measure of blood in suction canister along with measuring soiled sponges.

This method is only an estimate to measure blood loss. Patient vitals and clinical signs should be evaluated clinically first.

Capacity by sponge type:

  • 4x4s: ~10 mL blood
  • Gauze sponges (Ray-Tec):~10-20 mL blood
  • Laparotomy (lap) sponges: ~50-100 mL blood

Consider timing of blood loss. Acute blood loss may not present with a drop in hemoglobin. Always monitor clinical metrics such as hemodynamics and respiratory status along with anticipated blood loss.

The trigger to transfuse varies by patient.

The maximum allowable blood loss equation was developed by Jeffrey Gross based on an accepted equation for blood loss and incorporating a correction for isovolumetric hemodilution using a mathematical differential.

Gross in 1983 showed that a blood loss greater than 20% of estimated blood volume will cause the maximum allowable value to be inaccurate.

Register on our website right now to have access to more learning materials!

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Literature

  1. Gross JB. Estimating Allowable Blood Loss Corrected for Dilution. Anesthesiology 58.2 (1983): 277-280.
  2. Practice Guidelines for blood component therapy: A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy.
  3. Practice guidelines for blood transfusion: a compilation from recent peer-reviewed literature. American Red Cross.

Charlson Comorbidity Index (CCI) Online Calculator

Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

Chronic cognitive deficit

Any history of treatment for ulcer disease or history of ulcer bleeding

Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

VariablePointsAge <50…
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Multiple Myeloma Diagnostic Criteria – Online Calculator

≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
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]]> Revised Cardiac Risk Index for Pre-Operative Risk (RCRI) Online Calculator https://clincasequest.hospital/rcri-online-calculator/ Tue, 10 May 2022 09:44:47 +0000 https://clincasequest.hospital/?p=33790 The revised cardiac risk index for preoperative risk may be used in patients ≥45 years old (or 18–44 years with significant cardiovascular disease*) undergoing elective…

Сообщение Revised Cardiac Risk Index for Pre-Operative Risk (RCRI) Online Calculator появились сначала на ClinCaseQuest.

]]> The revised cardiac risk index for preoperative risk may be used in patients ≥45 years old (or 18–44 years with significant cardiovascular disease*) undergoing elective non-cardiac surgery or urgent/semi-urgent (non-emergent) non-cardiac surgery.

*Known history of ischemic heart disease, cerebrovascular disease, peripheral arterial disease, congestive heart failure, severe pulmonary hypertension, or severe obstructive intracardiac abnormality (eg, severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

NB! The RCRI score should be used with caution in patients requiring urgent surgery, as this scale is not well validated in this population.

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* Required

The revised cardiac risk index for preoperative risk accurately risk-stratifies patients and helps patients understand individualized risk prior to undergoing surgery, which can be helpful in discussions of informed consent.

In patients with elevated risk (RCRI ≥1, age ≥65, or age 45-64 with significant cardiovascular disease), helps direct further preoperative risk stratification (e.g. with serum NT-proBNP or BNP) and determine appropriate cardiac monitoring post-op (ECG, troponins).

*Known history of coronary artery disease, cerebral vascular disease, peripheral artery disease, congestive heart failure, severe PHTN or a severe obstructive intracardiac abnormality (e.g. severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

 Points
Elevated-risk surgery (Intraperitoneal; intrathoracic; suprainguinal vascular)1
History of ischemic heart disease (history of myocardial infarction (MI); history of positive exercise test; current chest pain considered due to myocardial ischemia; use of nitrate therapy or ECG with pathological Q waves)1
History of congestive heart failure (pulmonary edema, bilateral rales or S3 gallop; paroxysmal nocturnal dyspnea; chest x-ray (CXR) showing pulmonary vascular redistribution)1
History of cerebrovascular disease (prior transient ischemic attack (TIA) or stroke)1
Pre-operative treatment with insulin1
Pre-operative creatinine >2 mg/dL (176.8 µmol/L)1

Interpretation:

RCRI ScoreRisk of major cardiac event (95% CI) (defined as death, myocardial infarction, or cardiac arrest at 30 days after noncardiac surgery)
03,9% (2,8-5,4%)
16,0% (4,9-7,4%)
210,1% (8,1-12,6%)
≥315% (11,1-20,0%)

According to the 2016 CCS Perioperative Guidelines:

  • If the RCRI is ≥1, the patient’s age is ≥65, or they are between 45-64 with significant cardiac disease*, the next step is to measure the patient’s NT-ProBNP or BNP if this is available at your institution.
  • If the NT-ProBNP is ≥300 ng/L or BNP is ≥92 ng/L, then there should be an EKG ordered in the PACU and troponins should be measured daily for 48-72 hours.
  • If, after risk stratification, the NT-ProBNP is <300 ng/L or BNP <92 ng/L, no routine postoperative cardiac monitoring is warranted.
  • If the institution does not have these assays available, then all patients should be monitored with an EKG in the PACU and troponin measurements daily for 48-72 hours if they meet one of the following: RCRI ≥1, age ≥65, or age 45-64 with the aforementioned cardiac disease.*

*Known history of coronary artery disease, cerebral vascular disease, peripheral artery disease, congestive heart failure, severe PHTN or a severe obstructive intracardiac abnormality (e.g. severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

The data supporting the use of NT-ProBNP/BNP comes from a large 2014 meta-analysis of 18 studies with a total of 2,477 patients (Rodseth 2014). This study, which was in agreement with multiple previous meta-analyses, noted that for those patients with a pre-operative NT-ProBNP of <300 ng/l or BNP <92 ng/l, the rate of 30-day postoperative non-fatal MI or Death was 4.9% (3.9%-61%), and was 21.8% (19.0%-24.8%) in those with pre-operative NT-ProBNP is ≥300 ng/L or BNP is ≥92 ng/L.

RCRI score easy to use by any involved specialty, including general internal medicine, cardiology, anesthesia, or surgery, and very well validated. It can be used in the inpatient or outpatient preoperative setting.

At the same time, the RCRI score includes a limited number of risk factors it includes, in part because the original studies could not include a sufficient number of patients for every important risk factor (e.g. underestimates hemodynamic and cardiovascular outcomes in valvular disease).

NB! Other patient important outcomes that are not assessed by this tool include:

  • risk of stroke,
  • major bleeding,
  • prolonged hospitalization,
  • ICU admission.

Alternative perioperative cardiac risk scores like the Myocardial Infarction and Cardiac Arrest (MICA) Score and the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Score have been validated only retrospectively and therefore underestimate the risk of myocardial ischemia compared with the RCRI, which has been validated by multiple studies over the past 15 years including a very large 2010 systematic review (24 studies and 792,740 patients) which found moderate discrimination in predicting major perioperative cardiac complications.

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Literature

  1. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O’Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977 Oct 20;297(16):845-50. https://pubmed.ncbi.nlm.nih.gov/904659/
  2. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999 Sep 7;100(10):1043-9. https://pubmed.ncbi.nlm.nih.gov/10477528/
  3. VISION Pilot Study investigators, Devereaux PJ, Bradley D, Chan MT, et al. An international prospective cohort study evaluating major vascular complications among patients undergoing noncardiac surgery: the VISION Pilot Study. Open Med. 2011;5(4):e193-200. https://pubmed.ncbi.nlm.nih.gov/22567075/
  4. Ausset S, Auroy Y, Lambert E, et al. Cardiac troponin I release after hip surgery correlates with poor long-term cardiac outcome. Eur J Anaesthesiol. 2008;25(2):158-64. https://pubmed.ncbi.nlm.nih.gov/17666156/
  5. Sheth T, Chan M, Butler C, et al. Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study. BMJ. 2015;350:h1907. https://pubmed.ncbi.nlm.nih.gov/25902738/
  6. Ford MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med. 2010;152(1):26-35. http://www.ncbi.nlm.nih.gov/pubmed/20048269
  7. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007;50(17):1707-32. https://pubmed.ncbi.nlm.nih.gov/17950159/
  8. Duceppe E, Parlow J, Macdonald P, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017;33(1):17-32. https://pubmed.ncbi.nlm.nih.gov/27865641/
  9. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):2215-2245. https://pubmed.ncbi.nlm.nih.gov/25085962/
  10. Rajagopalan S, Croal BL, Bachoo P, Hillis GS, Cuthbertson BH, Brittenden J. N-terminal pro B-type natriuretic peptide is an independent predictor of postoperative myocardial injury in patients undergoing major vascular surgery. J Vasc Surg. 2008;48(4):912-7. https://pubmed.ncbi.nlm.nih.gov/18586440/
  11. Rodseth RN, Biccard BM, Le manach Y, et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol. 2014;63(2):170-80. https://pubmed.ncbi.nlm.nih.gov/24076282/
  12. Devereaux PJ, Duceppe E, Guyatt G, et al. Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial. Lancet. 2018;391(10137):2325-2334. https://pubmed.ncbi.nlm.nih.gov/29900874/

Charlson Comorbidity Index (CCI) Online Calculator

Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

Chronic cognitive deficit

Any history of treatment for ulcer disease or history of ulcer bleeding

Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

VariablePointsAge <50…
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Multiple Myeloma Diagnostic Criteria – Online Calculator

≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
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Сообщение Revised Cardiac Risk Index for Pre-Operative Risk (RCRI) Online Calculator появились сначала на ClinCaseQuest.

]]> POSSUM for Operative Morbidity and Mortality Risk – Online Calculator https://clincasequest.hospital/possum/ Tue, 15 Feb 2022 08:15:00 +0000 https://clincasequest.hospital/?p=33500 POSSUM calculates the risk of surgical morbidity and mortality, which can be used to help patients and their families make informed decisions about surgery.POSSUM for…

Сообщение POSSUM for Operative Morbidity and Mortality Risk – Online Calculator появились сначала на ClinCaseQuest.

]]> POSSUM calculates the risk of surgical morbidity and mortality, which can be used to help patients and their families make informed decisions about surgery.
POSSUM for Operative Morbidity and Mortality Risk can be used in patients undergoing emergency and elective general surgical procedures. Risk estimates can help patients and family members in the process of informed consent and in management of expectations.

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Physiological score

Norm: 100-120 mm Hg

Norm: 60-100 beats/min

Norm: 120-170 g/L (12-17 g/dL)

Norm: 3,7-10,7×10³ cells/µL (3,7-10,7×10⁹ cells/L)

Norm: 2,9-7,1 mmol/L (8-20 mg/dL)

Norm: 136-145 mmol/L (136-145 mEq/L)

Norm: 3,5-5 mmol/L (3,5-5 mEq/L)

Operative severity score

Diagnosed before or during surgery

* Required


The Physiological and Operating Severity Scale for Mortality and Morbidity (POSSUM) estimates morbidity and mortality in general surgery.

It can be used for both emergency and planned surgery. The POSSUM should be calculated when the decision to operate is made. The percentages can be shared with the patient when discussing the risks of the operation.

To score on the POSSUM scale is an addition of selected points.

Physiological score and operation severity score are weighted differently.

Assessment parameter Points
Physiological score  
Age, years≤601
 61-702
 ≥714
CardiacNo failure1
 Diuretic, digoxin or angina/hypertension meds2
 Peripheral edema, warfarin, or borderline cardiomegaly on chest X-ray (CXR)4
 Raised jugular venous pressure, or cardiomegaly on CXR8
RespiratoryNo dyspnea1
 Exertional dyspnea or mild COPD on CXR2
 Limiting dyspnea or moderate COPD on CXR4
 Dyspnea at rest or fibrosis/consolidation on CXR8
sBP mm Hg
Norm: 100-120 mm Hg		≤898
 90-994
 100-1092
 110-1301
 131-1702
 ≥1714
HR, beats/min
Norm: 60-100, beats/min		≤398
 40-492
 50-801
 81-1002
 101-1204
 ≥1218
Glasgow Coma Scale151
 12-142
 9-114
 ≤88
Hemoglobin
Norm: 120-170 g/L (12-17 g/dL)		  
g/Lg/dL 
130-16013-161
115-12911.5-12.92
161-17016.1-17.02
100-11410.0-11.44
171-18017.1-18.04
≤ 99≤ 9.98
≥181≥18.18
WBC
Norm: 3,7-10,7×103 cells/µL (3,7-10,7×109 cells/L)		4-101
 10.1-20.02
 3.1-4.02
 ≥20.14
 ≤3.04
BUN
Norm: 2,9-7,1 mmol/L (8-20 mg/dL)
mg/dLmmol/L 
≤ 45≤7.51
46-607.6-10.02
61-9010.1-15.04
≥90≥15.18
Sodium
Norm: 136-145 mmol/L (136-145 mEq/L)		≥1361  
 131-135 2
 126-1304
 ≤1258
Potassium
Norm: 3,5-5 mmol/L (3,5-5 mEq/L)		3.5-5.01
 3.2-3.4 2
 5.1-5.32
 2.9-3.14
 5.4-5.94
 ≤2.88
 ≥6.08
   
ECGNormal1
 Atrial fibrillation (HR 60-90)4
 Any other abnormal rhythm, or 5 ectopic beats/min, Q waves or ST/T wave changes8
Operative severity score  
Operative severityMinor1
 Moderate (appendectomy, cholecystectomy, mastectomy, transurethral resection of the prostate)2
 Major (laparotomy, bowel resection, cholecystectomy w choledochotomy, peripheral vascular procedure or major amputation)4
 Major+ (aortic procedure, abdominoperineal resection, pancreatic or liver resection, esophagogastrectomy)8
Number of procedures11
 24
 >28
Estimated blood loss, ml  
 ≤1001
 101-5002
 501-9994
 ≥10008
Peritoneal soilingNone1
 Minor (serous fluid)2
 Local pus4
 Free bowel content, pus or blood8
Presence of malignancy
Diagnosed before or during surgery		None1
 Primary only2
 Lymph node mets4
 Distant mets8
Mode of surgeryElective1
 Emergency (within 24h), resuscitation >2h possible4
 Emergency (within 2h)8

Severity of surgeries:

  • Moderate: appendectomy, cholecystectomy, mastectomy, TURP
  • Major: laparotomy, bowel resection, cholecystectomy w choledochotomy, peripheral vascular procedure or major amputation
  • Major+: aortic procedure, abdominoperineal resection, pancreatic or liver resection, esophagogastrectomy

The POSSUM morbidity and mortality formulas are shown below:

  • Morbidity ln[R/(1-R)] = – 5,91 + (0,16 x Physiological score) + (0,19 x operation severity score) (P<0,001).
  • Mortality  ln [R/(1 –R)] = -7,04+ (0,13 x Physiological score) + (0,16 x operation severity score) (P <0,001).

Predicied versus observed rates for mortality and morbidity*

Predicted risk (%)MortalityMorbidity
8586.584.3
7578.375.7
6567.767.3
5556.456.9
4546.047.5
3538.537.4
2529.326.4

Morbidity was defined as any of the following:

  • Wound haemorrhage: local haematoma requiring evacuation
  • Deep haemorrhage: postoperative bleeding requiring re-exploration
  • Chest infection: production of purulent sputum with positive

bacteriological cultures, with or without chest radiography changes or pyrexia, or consolidation seen on chest radiograph

  • Woundinfection: wound cellulitis or the discharge ofpurulent exudate
  • Urinary infection: the presence of z lo5 bacteria/ml with the presence of white cells in the urine, in previously clear urine
  • Deep infection: the presence of an intra-abdominal collection confirmed clinically or radiologically.
  • Septicaemia: positive blood culture
  • Pyrexia of unknown origin: any temperature above 37°C for more than 24 h occurring after the original pyrexia following surgery (if present) had settled, for which no obvious cause could be found
  • Wound dehiscence: superficial or deep wound breakdown
  • Deep venous thrombosis and pulmonary embolus: when suspected, confirmed radiologically by venography or ventilation/perfusion scanning, or diagnosed at post mortem
  • Cardiac failure: symptoms or signs of left ventricular or congestive cardiac failure which required an alteration from preoperative therapeutic measures
  • Impaired renal function: arbitrarily defined as an increase in blood urea of > 5 mmol/l from preoperative levels
  • Hypotension: a fall in systolic blood pressure below 90 mmHg for more than 2 h as determined by sphygmomanometry or arterial pressure transducer measurement
  • “Any other complication”

The POSSUM was originally developed by Copeland and colleagues in 1991 to assess quality of care and provide a scoring system for surgical audit. Physiological and operative severity score data were obtained from 1,372 patients.

The original POSSUM was modified to the Portsmouth POSSUM, or P-POSSUM, in 1998 by Prytherch and colleagues, who derived a more accurate prediction for the mortality component.

Both the POSSUM and P-POSSUM slightly overestimate both morbidity and mortality.

Since the original publication of POSSUM, the score has been modified and validated for numerous subtypes of surgeries and clinical scenarios, including:

  • Colorectal surgery
  • Vascular surgery
  • Oncologic gastric surgery
  • Hepatectomy
  • Emergency laparotomy
  • Orthopedic surgery

The original POSSUM was modified by researchers in Portsmouth who derived a more accurate prediction of mortality, and the P-POSSUM model is now more commonly used to calculate the mortality component.

The POSSUM data set excludes trauma patients, so POSSUM should NOT be used to predict morbidity and mortality after trauma surgery.

The POSSUM should NOT dictate the decision to operate, which is a clinical decision.

Physiological score should be calculated at the time of surgery, not at the time of admission.

The definitions of surgical procedures are guidelines only. Not all procedures are listed, and the closest approximation should be selected.

The POSSUM may overestimate risk in hepatopancreaticobiliary surgery.

Similar / alternative tools:

  • There are procedure-specific models for colorectal surgery (CR-POSSUM), vascular surgery (Vascular-POSSUM), and esophagogastric surgery (O-POSSUM, O for oesophagogastric).
  • APACHE II is a similar assessment tool but is applied to intensive care patients and only assesses the risk of mortality.
  • The Surgical Apgar Score (SAS) offers similar estimates for morbidity and mortality.
  • The POSSUM is more comprehensive than the SAS (which is calculated based on 3 parameters), but the SAS is more objective.
  • The SAS uses intraoperative parameters exclusively, whereas the POSSUM uses preoperative parameters.
  • The ACS NSQIP risk calculator is a newer, similar assessment. It has not yet been as rigorously validated as the POSSUM.
  • Other disease-specific scores may be used to assess risk, e.g. Revised Cardiac Risk Index for Pre-Operative Risk.

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Literature

  1. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg 1991;78(3):355-60. https://pubmed.ncbi.nlm.nih.gov/2021856/
  2. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. Br J Surg 1998 Sep;85(9):1217-20. https://pubmed.ncbi.nlm.nih.gov/9752863/
  3. Ramkumar T, Ng V, Fowler L, Farouk R. A comparison of POSSUM, P-POSSUM and colorectal POSSUM for the prediction of postoperative mortality in patients undergoing colorectal resection. Dis Colon Rectum. 2006 Mar;49(3):330-5. https://pubmed.ncbi.nlm.nih.gov/16421662/
  4. Tez M, Yoldaş O, Gocmen E, Külah B, Koc M. Evaluation of P-POSSUM and CR-POSSUM scores in patients with colorectal cancer undergoing resection. World J Surg. 2006 Dec;30(12):2266-9. https://pubmed.ncbi.nlm.nih.gov/17103102/
  5. Lam CM, Fan ST, Yuen AW, Law WL, Poon K. Validation of POSSUM scoring systems for audit of major hepatectomy. Br J Surg. 2004 Apr;91(4):450-4. https://pubmed.ncbi.nlm.nih.gov/15048745/
  6. Mohil RS, Bhatnagar D, Bahadur L, Rajneesh, Dev DK, Magan M. POSSUM and P-POSSUM for risk-adjusted audit of patients undergoing emergency laparotomy. Br J Surg. 2004 Apr;91(4):500-3. https://pubmed.ncbi.nlm.nih.gov/15048756/
  7. van Zeeland ML, Genovesi IP, Mulder JW, Strating PR, Glas AS, Engel AF. POSSUM predicts hospital mortality and long-term survival in patients with hip fractures. J Trauma. 2011 Apr;70(4):E67-72. https://pubmed.ncbi.nlm.nih.gov/21613973/
  8. Chen T, Wang H, Wang H, Song Y, Li X, Wang J. POSSUM and P-POSSUM as predictors of postoperative morbidity and mortality in patients undergoing hepato-biliary-pancreatic surgery: a meta-analysis. Ann Surg Oncol. 2013 Aug;20(8):2501-10. https://pubmed.ncbi.nlm.nih.gov/23435569/
  9. Copeland GP. The POSSUM System of Surgical Audit. Arch Surg. 2002;137(1):15-19. doi:10.1001/archsurg.137.1.15. http://jamanetwork.com/journals/jamasurgery/fullarticle/212013

Interactive OSCE Checklist – Emergency care of a patient with chest pain – Acute Coronary Syndrome with ST-segment elevation and equivalents

• Opening the consultation

• Availability of a defibrillator

• Presenting complaint

• History of presenting complaint

• Past medical history

• Drug history

• Physical examination

• Intravenous access

• Registration of a 12-channel ECG

• Express test for the determination of cardiac troponin, myoglobin, creatine phosphokinase-MB, if possible

• Making preliminary diagnosis

• Drug therapy (basic)

• Evaluation of the door-balloon time (the choice of further reperfusion strategy aimed as soon as possible to restore the coronary blood flow in the infarct-dependent artery)

• Call the nearest reperfusion center

• P2Y12 receptor inhibitor prescription depending on the chosen strategy of reperfusion therapy

• Carrying out thrombolytic therapy as needed

• Transportation to the nearest reperfusion center

Additional materials: https://clincasequest.hospital/chest-pain-history-taking/ https://clincasequest.hospital/pericarditis/ https://clincasequest.hospital/stephen-smiths-formula/ https://clincasequest.hospital/wellens-syndrome/ https://clincasequest.hospital/aslangers-pattern/ Register on our website right…
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Сообщение POSSUM for Operative Morbidity and Mortality Risk – Online Calculator появились сначала на ClinCaseQuest.

]]> Interactive Checklist of differential diagnoses of DILI and HILI https://clincasequest.hospital/checklist-differential-diagnoses-dili-hili/ Thu, 03 Feb 2022 07:55:00 +0000 https://clincasequest.hospital/?p=33174 Differential diagnoses of drug-induced and herb-induced liver disease: Checklist of differential diagnoses of DILI and HILI. This tabular listing, although not comprehensive, is to be…

Сообщение Interactive Checklist of differential diagnoses of DILI and HILI появились сначала на ClinCaseQuest.

]]> Differential diagnoses of drug-induced and herb-induced liver disease: Checklist of differential diagnoses of DILI and HILI.

This tabular listing, although not comprehensive, is to be used as a guide and in connection with the updated RUCAM, derived from a previous publication.

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Abbreviations: AAA, Anti-actin antibodies; AMA, Antimitochondrial antibodies; ANA, Antinuclear antibodies; ASGPR, Asialo-glycoprotein-receptor; BMI, Body mass index; CT, Computed tomography; CYP, Cytochrome P450; PDH, Pyruvate dehydrogenase; HAV, Hepatitis A virus; HBc, Hepatitis B core; HBV, Hepatitis B virus; HCV, Hepatitis C virus; HEV, Hepatitis E virus; HILI, Herb induced liver injury; HIV; human immunodeficiency virus; LKM, Liver kidney microsomes; LP, Liver-pancreas antigen; LSP, Liver specific protein; MRC, Magnetic resonance cholangiography; MRT, Magnetic resonance tomography; p-ANCA, Perinuclear antineutrophil cytoplasmic antibodies; PCR, Polymerase chain reaction; RUCAM, Roussel Uclaf Causality Assessment Method; SLA, Soluble liver antigen; SMA, Smooth muscle antibodies; TSH, Thyroid stimulating hormone; TTG, Tissue transglutaminase

Differential Diagnosis / Diagnostic Parameters

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See also:

RUCAM scale to estimate the probability of the drug-induced liver injury (DILI) and herb induced liver injury (HILI) online calculator
Child-Pugh Score for Cirrhosis Mortality: online calculator
King’s College Criteria for Non- Acetaminophen Toxicity acute hepatic failure
King’s College Criteria for Acetaminophen Toxicity

Сообщение Interactive Checklist of differential diagnoses of DILI and HILI появились сначала на ClinCaseQuest.

]]> RUCAM scale to estimate the probability of the drug-induced liver injury (DILI) and herb induced liver injury (HILI) online calculator https://clincasequest.hospital/rucam-scale/ Tue, 01 Feb 2022 07:15:00 +0000 https://clincasequest.hospital/?p=32949 The RUCAM score (Roussel Uclaf Causality Assessment Method) helps to assess the likelihood of drug-induced liver injury (DILI), as well as the assessment of the…

Сообщение RUCAM scale to estimate the probability of the drug-induced liver injury (DILI) and herb induced liver injury (HILI) online calculator появились сначала на ClinCaseQuest.

]]> The RUCAM score (Roussel Uclaf Causality Assessment Method) helps to assess the likelihood of drug-induced liver injury (DILI), as well as the assessment of the likelihood of herb-induced liver injury (HILI). Previous name CIOMS (Council for International Organizations of Medical Sciences).

Causality assessment by the updated RUCAM requires prior evaluation of liver injury criteria and its pattern in each suspected case 

Respective criteria are readily assessable by initial measurement of ALT (alanine aminotransferase) and ALP (alkaline phosphatase).

Updated RUCAM for the Hepatocellular Liver Injury of DILI and HILI.

Drug-induced liver injury is a diagnosis of exclusion, even in cases where the liver injury is likely to be drug-related, the doctor needs to perform a detailed analysis according to certain parameters given in the rating scale.

To assess the causality of drug-induced liver injury (DILI) on the RUCAM scale, it is necessary to select the variant of liver injury (hepatocellular or cholestatic/mixed) and evaluate the indicators corresponding to the variant of liver damage, after the assessment, it is necessary to sum the scale indicators and interpret the scores.

Evaluation of causality using the updated RUCAM requires a preliminary assessment of the criteria for liver injury and its nature in each suspected case.

Appropriate criteria are easily assessed by initially measuring ALT (alanine aminotransferase) and ALP (alkaline phosphatase).

Liver injury is defined by increased serum activities of ALT of at least 5N and/or of ALP of at least 2N, best assessed simultaneously on the day of first presentation (N – upper limit of normal). These thresholds will increase the specificity of the hepatotoxicity causality assessment, eliminates false positive cases, and substantiates hepatotoxicity causality at a high level of probability. They are also in line with a recent consensus on DILI. However, when ALT is within the normal range, ALP increases should be paralleled by increased γ-glutamyltranspeptidase or better 5’ nucleosidase to rule out isolated increases of ALP activities due to bone or another origin rather than hepatobiliary disease

In accordance with the original RUCAM, the updated RUCAM takes into account divergent laboratory constellation of the liver injury and provides two different subscales: one for the hepatocellular type of injury and the other one for the cholestatic or mixed type of injury. These types can be differentiated using the ratio R, calculated as the ALT/ ALP activity measured at the time liver injury is suspected, with both activities expressed as multiples of N.

  • The liver injury is hepatocellular if ALT > 5N and ALP ≤ N, or if both ALT and ALP are elevated, R ≥ 5;
  • the liver injury is cholestatic if ALP > 2N and ALT ≤ N, or if both ALT and ALP are elevated, R ≤ 2;
  • the liver injury is mixed if ALT > 5N and ALP > N and 2 < R < 5.

This classification of liver injury pattern clearly assigns each DILI or HILI case to the updated RUCAM, either for the hepatocellular injury (Table Hepatocellular Liver Injury) or the cholestatic and mixed liver injury (Table Cholestatic or Mixed Liver injury).

Pregnancy is a risk factor only for the cholestatic and mixed liver injury, not for the hepatocellular injury (Table Cholestatic or Mixed Liver injury).

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According to your lab

According to your lab

* Required


RUCAM scale online calculator

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Select the type of liver injury: hepatocellular or cholestatic/mixed:

1. Time to onset from the beginning of the drug/herb

2. Course of ALT after cessation of the drug/herb

(percentage difference between ALT peak and N)

2. Course of ALP after cessation of the drug/herb

(percentage difference between ALP peak and N)

3. Risk factors

4. Concomitant use of drug(s)/herb(s)

5. Search for alternative causes

Check out the causes that can be ruled out!

Check out the causes that can be ruled out!

6. Previous hepatotoxicity of the drug/herb

7. Response to unintentional reexposure

Abbreviations: ALT, Alanine aminotransferase; AST, Aspartate aminotransferase; CMV, Cytomegalovirus; CT, Computer tomography; DILI, Drug induced liver injury; EBV, Epstein Barr virus; HAV, Hepatitis A virus; HBc, Hepatitis B core; HBsAg, Hepatitis B antigen; HBV, Hepatitis B virus; HCV, Hepatitis C virus; HEV, Hepatitis E virus; HILI, Herb induced liver injury; HSV, Herpes simplex virus; MRC, Magnetic resonance cholangiography; N, upper limit of the normal range; RUCAM, Roussel Uclaf Causality Assessment Method; VZV, Varicella zoster virus. Total score and resulting causality grading: ≤0, excluded; 1–2, unlikely; 3–5, possible; 6–8, probable; and ≥9, highly probable


Evaluation of the relationship between liver injyry and taking the drug by the number of points:

Each element of the updated RUCAM is assigned an individual score, and the sum of the individual scores gives the final score for the case. From +14 to -9 points, there is a wide range of final grades.Total score and resulting causality grading:

  • ≤0 points – excluded
  • 1-2 points – unlikely
  • 3-5 points – possible
  • 6-8 points – probable
  • >9  points  – highly probable

What should be considered when using this rating scale?

Operational Information on the Updated RUCAM

  1. RUCAM affords prospective use, since retrospective scoring is less accurate.
  2. RUCAM is to be calculated individually for each co-administered product.        
  3. RUCAM is conceptualized primarily for idiosyncratic, not for intrinsic reactions.
  4. RUCAM excludes cases with onset of hepatic injury before start of product use.
  5. RUCAM is applicable only for acute liver injury, not for preexisting chronic liver disease.        
  6. RUCAM cannot correctly assess when ALP is elevated for non-hepatic reasons. 
  7. Concomitant use of drugs and herbs is a crucial item that is best inquired and documented at first presentation when liver injury is suspected. Details of a temporal association and potential hepatotoxic features of the used product are to be assessed and documented. For reasons of comparison and transparency, each comedicated drug or herb requires a separate analysis by the complete updated RUCAM. In patients with use of multiple drugs or herbs, the final causality should be attributed primarily to the product with the highest score achieved with the updated RUCAM.

Previous Hepatotoxicity

Hepatotoxicity listed in the product information sheet (e.g., Summary of product characteristics in the EU or product information in the US) must be checked, although the terms used to express the liver injury may vary and usually do not refer to specific definitions. If it is mentioned, then the hepatotoxicity is considered as known for that compound. If this toxicity is not mentioned, a quick literature search in PubMed and the well documented NIH LiverTox website are recommended to determine whether the product has already been involved in published DILI and HILI.

Response to Unintentional Reexposure

A positive reexposure test result is a hallmark and gold standard in DILI cases and recognized by respective scores. To classify a reexposure test as positive, few criteria are required, as specified. The respective criteria were based on the conclusions of International Consensus Meetings in 1988 and 1990, as reviewed previously and recently. For the hepatocellular type of injury, the defining criteria are ALT levels before reexposure (designated as baseline ALT or ALTb), and reexposure ALT levels (designated as ALTr). The reexposure test is positive if ALTb is <5N and ALTr is ≥2ALTb, negative if one or both criteria are not fulfilled, and uninterpretable if data are lacking for one or both criteria. For the cholestatic or the mixed liver injury, the assessment criteria and interpretation of results are similar, with ALT replaced by ALP (Table).

Conditions of unintentional reexposure tests in suspected DILI and HILI cases.

Reexposure Test ResultHepatocellular Injury Cholestatic or Mixed Liver Injury 
 ALTbALTrALPbALPr
●   Positive<5N≥2ALTb<2N≥2ALPb
●   Negative<5N<2ALTb<2N<2ALPb
●   Negative≥5N≥2ALTb≥2N≥2ALPb
●   Negative≥5N<2ALTb≥2N<2ALPb
●   Uninterpretable<5Nn.a.<2Nn.a.
●   Uninterpretablen.a.≥2ALTbn.a.≥2ALPb
●   Uninterpretablen.a.n.a.n.a.n.a.

The original RUCAM was tested for its validity with the use of DILI cases confirmed by positive rechallenge taken as the gold standard and DILI cases where there was strong evidence that drugs were not the culprit drugs. As the updated RUCAM does not change fundamentally the structure and the weights of the original method there is no reason to consider a change in its validity. Presently, all relevant clinical diagnostic parameters are included in the updated RUCAM and in the checklist. There is little evidence that liver histology adds substantially to the diagnosis of DILI or HILI, as these lack specific histopathological features since they mimic all primary hepatic and biliary diseases. Therefore, liver histology is not part of the diagnostic program of the updated RUCAM. However, it is possible to take into account the results of a liver biopsy examination to exclude an alternative cause but certainly not to confirm DILI or HILI.

Search for Alternative Causes

In this domain, the updated RUCAM scale considers the clinically most relevant alternative causes and complications of underlying disease(s). Antibodies are important tools but require assessment and approval by regulatory agencies. Problems of diagnosing infections by hepatitis E virus (HEV) are evident in the US with anti-HEV antibody tests that are not FDA approved. Most importantly, titer changes of antibodies in suspected hepatic viral infections are to be evaluated in the further clinical course to confirm or disprove an ongoing virus infection.

Rare alternative causes are included in a checklist of differential diagnoses as a reminder for the clinician that many diagnoses exist as alternatives to DILI and HILI. These other diagnoses are to be considered, excluded or verified in the context of clinical data and importance, financial resources, and benefit for the patient. Establishing alternative causes contributes to the accuracy of the updated RUCAM and often provides clues to possible specific therapies.

Checklist of differential diagnoses of DILI and HILI

Checklist of differential diagnoses of DILI and HILI. This tabular listing, although not comprehensive, is to be used as a guide and in connection with the updated RUCAM, derived from a previous publication.

Differential DiagnosisDiagnostic ParametersDiagnostic Exclusion Done for Patient’s Assessment  
  YesNoPartial
●   Hepatitis A virus (HAV)Anti-HAV-IgM□□□
●   Hepatitis B virus (HBV)HBV-DNA, anti-HBc-IgM□□□
●   Hepatitis C virus (HCV)HCV-RNA, anti-HCV□□□
●   Hepatitis E virus (HEV)HEV-RNA, titer change for anti-HEV-IgM/anti-HEV-IgG□□□
●   Cytomegalovirus (CMV)CMV-PCR, titer change for anti-CMV-IgM/anti-CMV-IgG□□□
●   Epstein Barr virus (EBV)EBV-PCR, titer change for anti-EBV-IgM/anti-EBV-IgG□□□
●   Herpes simplex virus (HSV)HSV-PCR, titer change for anti-HSV-IgM/anti-HSV-IgG□□□
●   Varicella zoster virus (VZV)VZV-PCR, titer change for anti-VZV-IgM/anti-VZV-IgG□□□
●   Other virus infectionsSpecific serology of Adenovirus, Coxsackie-B-Virus, Echovirus, Measles virus, Rubella virus, Flavivirus, Arenavirus, Filovirus, Parvovirus, HIV, and others□□□
●   Other infectious diseasesSpecific assessment of bacteria, fungi, parasites, worms, and others□□□
●   Autoimmune hepatitis (AIH) type IGamma globulins, ANA, SMA, AAA, SLA/LP, Anti-LSP, Anti-ASGPR□□□
●   Autoimmune hepatitis (AIH) type IIGamma globulins, Anti-LKM-1 (CYP 2D6), Anti-LKM-2 (CYP 2C9), Anti-LKM-3□□□
●   Primary biliary cholangitis (PBC)AMA, Anti PDH-E2□□□
●   Primary sclerosing cholangitis (PSC)p-ANCA, MRC□□□
●   Autoimmune cholangitis (AIC)ANA, SMA□□□
●   Overlap syndromesSee AIH, PBC, PSC, and AIC□□□
●   Non alcoholic steatohepatitis (NASH)BMI, insulin resistance, hepatomegaly, echogenicity of the liver□□□
●   Alcoholic liver disease (ALD)Patient’s history, clinical and laboratory assessment, other alcoholic disease(s)□□□
●   Drug induced liver injury (DILI) or herb induced liver injury (HILI)Patient’s history, clinical and laboratory assessment, sonography, use of the updated RUCAM□□□
●   Cocaine, ecstasy and other amphetaminesToxin screening□□□
●   Rare intoxicationsToxin screening for household and occupational toxins□□□
●   Hereditary hemochromatosisSerum ferritin, total iron-binding capacity, genotyping for C2824 and H63D mutation, hepatic iron content□□□
●   Wilson diseaseCopper excretion (24 h urine), ceruloplasmin in serum, free copper in serum, Coombs-negative hemolytic anemia, hepatic copper content, Kayser-Fleischer-ring, neurologic-psychiatric work-up, genotyping□□□
●   PorphyriaPorphobilinogen in urine, total porphyrines in urine□□□
●   α1—Antitrypsin deficiencyα1—Antitrypsin in serum□□□
●   Biliary diseasesClinical and laboratory assessment, hepatobiliary sonography, MRC□□□
●   Pancreatic diseasesClinical and laboratory assessment, sonography, CT, MRT□□□
●   Celiac diseaseTTG antibodies, endomysium antibodies, duodenal biopsy□□□
●   Anorexia nervosaClinical context□□□
●   Parenteral nutritionClinical context□□□
●   Cardiopulmonary diseasesCardiopulmonary assessment of congestive heart disease, myocardial infarction, cardiomyopathy, cardiac valvular dysfunction, pulmonary embolism, pericardial diseases, arrhythmia, hemorrhagic shock, and various other conditions□□□
●   Addison’s diseasePlasma cortisol□□□
●   Thyroid diseasesTSH basal, T4, T3□□□
●   Grand mal seizuresClinical context of epileptic seizure (duration > 30 min)□□□
●   Heat strokeShock, hyperthermia□□□
●   PolytraumaShock, liver injury□□□
●   Systemic diseasesSpecific assessment of sarcoidosis, amyloidosis, metastatic tumor, sepsis, and others□□□
●   Other diseasesClinical context□□□
Abbreviations: AAA, Anti-actin antibodies; AMA, Antimitochondrial antibodies; ANA, Antinuclear antibodies; ASGPR, Asialo-glycoprotein-receptor; BMI, Body mass index; CT, Computed tomography; CYP, Cytochrome P450; PDH, Pyruvate dehydrogenase; HAV, Hepatitis A virus; HBc, Hepatitis B core; HBV, Hepatitis B virus; HCV, Hepatitis C virus; HEV, Hepatitis E virus; HILI, Herb induced liver injury; HIV; human immunodeficiency virus; LKM, Liver kidney microsomes; LP, Liver-pancreas antigen; LSP, Liver specific protein; MRC, Magnetic resonance cholangiography; MRT, Magnetic resonance tomography; p-ANCA, Perinuclear antineutrophil cytoplasmic antibodies; PCR, Polymerase chain reaction; RUCAM, Roussel Uclaf Causality Assessment Method; SLA, Soluble liver antigen; SMA, Smooth muscle antibodies; TSH, Thyroid stimulating hormone; TTG, Tissue transglutaminase


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Abbreviations: AAA, Anti-actin antibodies; AMA, Antimitochondrial antibodies; ANA, Antinuclear antibodies; ASGPR, Asialo-glycoprotein-receptor; BMI, Body mass index; CT, Computed tomography; CYP, Cytochrome P450; PDH, Pyruvate dehydrogenase; HAV, Hepatitis A virus; HBc, Hepatitis B core; HBV, Hepatitis B virus; HCV, Hepatitis C virus; HEV, Hepatitis E virus; HILI, Herb induced liver injury; HIV; human immunodeficiency virus; LKM, Liver kidney microsomes; LP, Liver-pancreas antigen; LSP, Liver specific protein; MRC, Magnetic resonance cholangiography; MRT, Magnetic resonance tomography; p-ANCA, Perinuclear antineutrophil cytoplasmic antibodies; PCR, Polymerase chain reaction; RUCAM, Roussel Uclaf Causality Assessment Method; SLA, Soluble liver antigen; SMA, Smooth muscle antibodies; TSH, Thyroid stimulating hormone; TTG, Tissue transglutaminase

Differential Diagnosis / Diagnostic Parameters


Thus, the updated RUCAM can be used based on:

  • Type of the damage to the liver (hepatocellular, cholestatic, mixed type);
  • Detailing of the main elements of assessments (table hepatocellular, cholestatic/mixed type of damage);
  • Differential diagnosis (checklist table)
  • Reexposure criteria (table).

Correct Diagnoses

Results based on the updated RUCAM are quickly available for trained physicians with substantial clinical experience who then have to decide whether DILI or HILI is the most like diagnosis in their patients or any other differential diagnoses. Their decision is crucial, as DILI and HILI require discontinuation of the offending product whereas other diagnoses may require specific therapeutic modalities. The patient will immediately profit from the correct diagnosis achieved after using the updated RUCAM and the checklist.

Missed Diagnoses

Unrecognized alternative causes to the liver injury are a real clinical problem when caring for patients with initially assumed but later not confirmed DILI or HILI; the long list of missed diagnoses in the setting of initially assumed injury cases is indeed threatening. More recent evidence suggests that the problem of missed diagnoses is multifaceted and caused by incomplete case data collection, poor case data analysis, problems of appropriate case data transfer from medical files to the manuscript, and unjustified upgrading of causality scores. Missing the correct diagnosis may cause legal considerations that are better avoided by prior sophisticated clinical and regulatory approaches. Effective treatments would have been available for some patients with missed diagnoses, a critical situation in the clinical context.

Abbreviations: CMV, Cytomegalovirus; EBV, Epstein Barr virus; HSV Herpes simplex virus; LKM, Liver kidney microsomes; SMA, Smooth muscle antibodies; VZV, Varicella zoster virus.

Missed diagnoses in cases of initially suspected hepatotoxicity by synthetic drugs or herbs. Adapted from previous reports, which provide the respective references for each missed diagnosis listed above.

Historical background

Previous synonym of RUCAM were CIOMS (Council for International Organizations of Medical Sciences) or CIOMS/RUCCAM.

The updated RUCAM is as good as physicians and assessors are handling this method and consider basic liver tests for the liver injury classification, the specific operational information, details of core elements and their scoring, differential diagnoses, and the reexposure criteria. RUCAM has not been designed for chronic DILI and HILI or when a suspected injury occurs on pre-existing liver disease, both complex conditions where an expert panel of hepatologists would provide a more accurate approach especially for the timing of the events and the exclusion of alternative causes.

Historical background and the original work confirm the use of RUCAM as single term for future cases, dismissing now the term CIOMS for reasons of simplicity and clarity. RUCAM represents a structured, standardized, validated, and hepatotoxicity specific diagnostic approach that attributes scores to individual key items, providing final quantitative gradings of causality for each suspect drug/herb in a case report.

Experts from Europe and the United States had previously established in consensus meetings the first criteria of RUCAM to meet the requirements of clinicians and practitioners in care for their patients with suspected DILI and HILI. RUCAM was completed by additional criteria and validated, assisting to establish the timely diagnosis with a high degree of certainty. In many countries and for more than two decades, physicians, regulatory agencies, case report authors, and pharmaceutical companies successfully applied RUCAM for suspected DILI and HILI. Their practical experience, emerging new data on DILI and HILI characteristics, and few ambiguous questions in domains such alcohol use and exclusions of non-drug causes led to the present update of RUCAM. The aim was to reduce interobserver and intraobserver variability, to provide accurately defined, objective core elements, and to simplify the handling of the items. The authors presented the update of the well accepted original RUCAM scale and recommend its use for clinical, regulatory, publication, and expert purposes to validly establish causality in cases of suspected DILI and HILI, facilitating a straightforward application and an internationally harmonized approach of causality assessment as a common basic tool.

RUCAM was not designed for chronic DILI and HILI, or when damage is suspected in pre-existing liver disease.

RUCAM scoring can help establish a clinical diagnosis, which can be useful for further choice of therapy.


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 Literature

  1. Danan G., Bénichou C. Causality assessment of adverse reactions to drugs—I. A novel method based on the conclusions of international consensus meetings: Application to drug-induced liver injuries. J. Clin. Epidemiol. 1993;46:1323–1330. doi: 10.1016/0895-4356(93)90101-6. [PubMed]
  2. Andrade RJ, Robles M, Fernández-Castañer A, López-Ortega S, López-Vega MC, Lucena MI (2007).
    “Assessment of drug-induced hepatotoxicity in clinical practice: a challenge for gastroenterologists.” World J. Gastroenterol. 13 (3): 329–40.
  3. Danan G, Teschke R. RUCAM in Drug and Herb Induced Liver Injury: The Update. Int J Mol Sci. 2015;17(1):14. Published 2015 Dec 24. doi:10.3390/ijms17010014
  4. Teschke R., Eickhoff A., Schwarzenboeck A., Schmidt-Taenzer W., Genthner A., Frenzel C., Wolff A., Schulze J. Clinical review: Herbal hepatotoxicity and the call for systematic data documentation of individual cases. J. Liver Clin. Res. 2015;2:1008. (Google Scholar)

See also:

Child-Pugh Score for Cirrhosis Mortality: online calculator
King’s College Criteria for Non- Acetaminophen Toxicity acute hepatic failure
King’s College Criteria for Acetaminophen Toxicity

Сообщение RUCAM scale to estimate the probability of the drug-induced liver injury (DILI) and herb induced liver injury (HILI) online calculator появились сначала на ClinCaseQuest.

]]> R-value for Liver Injury Online calculator https://clincasequest.hospital/r-value/ Wed, 19 Jan 2022 14:30:28 +0000 https://clincasequest.hospital/?p=32873 Can be used in patients with suspected drug induced liver injury (DILI) with abnormal liver chemistries. R-value= (patient’s ALT / upper limit of normal ALT…

Сообщение R-value for Liver Injury Online calculator появились сначала на ClinCaseQuest.

]]> Can be used in patients with suspected drug induced liver injury (DILI) with abnormal liver chemistries.

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According to your lab

According to your lab

* Required

R-value= (patient’s ALT / upper limit of normal ALT ) / ( patient’s ALP / upper limit of normal ALP )

Note: Normal values may vary by lab.

  • R-value calculation allows clinicians to collectively identify and describe the pattern of liver injury in an objective manner.
  • R-value calculation allows clinicians suspecting a diagnosis of DILI to formulate an organized diagnostic strategy to rule out other causes of acute liver injury and to narrow the list of possible culprit drugs based on the pattern of liver injury.
  • Recommended by guidelines.

Parameters that required for the assessment:

  • Patient’s ALT, U/L
  • Upper limit of normal ALT According to your lab, U/L
  • Patient’s ALP, U/L
  • Upper limit of normal ALP According to your lab, U/L

Interpretation:

R-value rangeThe type of the liver injury  Conclusion and Advise
<2 Cholestatic pattern of liver injury.  • Pancreatic malignancy, cholangiocarcinoma, primary malignancy of the gallbladder, choledocholithiasis, sepsis, TPN, heart failure, PSC, and PBC should be ruled out as causes
• Commonly used drugs that can cause this pattern of liver injury include: amoxicillin/clavulanate, trimethoprim/sulfamethoxazole, azathioprine, and anabolic steroids
• Recommend imaging studies (e.g. abdominal ultrasound)
2-5Mixed pattern of liver injury.  Recommend acute viral hepatitis serologies, HCV RNA and autoimmune hepatitis serologies, imaging studies (e.g. abdominal ultrasound)
>5Hepatocellular pattern of liver injury.  • Acute viral hepatitis, ischemic liver injury, Budd-Chiari syndrome, autoimmune hepatitis, and Wilson’s disease (in younger patients) should be ruled out as causes
• Commonly used drugs that can cause this pattern of liver injury include: isoniazid, macrolides, nitrofurantoin, minocycline, anti-epileptics, NSAIDs, green tea extract, and inhaled anesthetics
• Recommend acute viral hepatitis serologies, HCV RNA and autoimmune hepatitis serologies, imaging studies (e.g. abdominal ultrasound)

Futher diagnostic approach:

R FactorInjury typeRecommended 1st line tests*
>5HepatocellularAcute viral hepatitis serologies, HCV RNA and autoimmune hepatitis serologies, imaging studies (e.g. abdominal ultrasound)
2–5MixedAcute viral hepatitis serologies, HCV RNA and autoimmune hepatitis serologies, imaging studies (e.g. abdominal ultrasound)
<2CholestaticImaging studies (e.g. abdominal ultrasound)

*From Chalasani 2014

The R-value (also known as the R ratio or R factor) was introduced after an international consensus meeting in 1989 aimed at preparing definitions and criteria related to drug related liver injury. At the request of the Council for International Organizations of Medical Sciences (CIOMS), a pilot program led by pharmaceutical company Roussel Uclaf was initiated to help classify different patterns of acute liver injury, introducing the R-value.

The R-value itself has not been validated, but remains commonly used in clinical practice to objectively define different patterns of liver injury. The American College of Gastroenterology (ACG) has incorporated the R-value in its guidelines for diagnosis and management of idiosyncratic drug-induced liver injury.

Recommendations for workup based on R Factor, adapted from Chalasani 2014

  • The pattern of acute liver injury (and therefore the R-value) can vary throughout the clinical course of the illness.
  • Identifying the pattern of liver injury can guide diagnostic approach to DILI, including appropriate further diagnostic testing necessary to rule out other causes of liver injury.
  • Calculating the R-value is the first step in calculating the Roussel Uclaf Causality Assessment Method (RUCAM) when determining if liver injury is related to a specific drug.
  • Because the pattern of liver injury can evolve over time, the time point at which liver chemistries are used to calculate the R-value  can alter the final result. It is recommended that the initial liver chemistries suggesting liver injury be used, but ultimately left to the clinician to decide what set of liver chemistries to use when making an assessment.
  • The use of upper limit of normal (ULN) in the equation creates some room for variability. The ULN varies among different laboratories.
  • While not validated, the R-value is widely used and has been incorporated into guideline recommendations for assessing liver injury.
  • Though the R Factor does not incorporate coagulopathy (INR) and mental status, these two factors should always be immediately assessed in all cases of acute liver injury to rule out acute liver failure.

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Literature

  1. Bénichou C. Criteria of drug-induced liver disorders. Report of an international consensus meeting. J Hepatol. 1990 Sep;11(2):272-6. doi: 10.1016/0168-8278(90)90124-a. PMID: 2254635.
  2. Chalasani NP, Hayashi PH, Bonkovsky HL, Navarro VJ, Lee WM, Fontana RJ; Practice Parameters Committee of the American College of Gastroenterology. ACG Clinical Guideline: the diagnosis and management of idiosyncratic drug-induced liver injury. Am J Gastroenterol. 2014 Jul;109(7):950-66; quiz 967. doi: 10.1038/ajg.2014.131. Epub 2014 Jun 17. PMID: 24935270.
  3. Danan G, Teschke R. RUCAM in Drug and Herb Induced Liver Injury: The Update. Int J Mol Sci. 2015;17(1):14. Published 2015 Dec 24. doi:10.3390/ijms17010014

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