Abdul Q. Alarhayem

Compensatory reserve index: Performance of a novel monitoring technology to identify the bleeding trauma patient

Introduction: Hemorrhage is one of the most substantial causes of death after traumatic injury. Standard measures, including systolic blood pressure (SBP), are poor surrogate indicators of physiologic compromise until compensatory mechanisms have been overwhelmed. Compensatory Reserve Index (CRI) is a novel monitoring technology with the ability to assess physiologic reserve. We hypothesized CRI would be a better predictor of physiologic compromise secondary to hemorrhage than traditional vital signs. Methods: A prospective observational study of 89 subjects meeting trauma center activation criteria at a single level I trauma center was conducted from October 2015 to February 2016. Data collected included demographics, SBP, heart rate, and requirement for hemorrhage-associated, life-saving intervention (LSI) (i.e., operation or angiography for hemorrhage, local or tourniquet control of external bleeding, and transfusion >2 units PRBC). Receiver-operator characteristic (ROC) curves were formulated and appropriate thresholds were calculated to compare relative value of the metrics for predictive modeling. Results: For predicting hemorrhage-related LSI, CRI demonstrated a sensitivity of 83% and a negative predictive value (NPV) of 91% as compared with SBP with a sensitivity to detect hemorrhage of 26% (P < 0.05) and an NPV of 78%. ROC curves generated from admission CRI and SBP measures demonstrated values of 0.83 and 0.62, respectively. CRI identified significant hemorrhage requiring potentially life-saving therapy more reliably than SBP (P < 0.05). Conclusion: The CRI device demonstrated superior capacity over systolic blood pressure in predicting the need for posttraumatic hemorrhage intervention in the acute resuscitation phase after injury.

Comparison of Compensatory Reserve and Arterial Lactate as Markers of Shock and Resuscitation

BACKGROUND During traumatic hemorrhage, the ability to identify shock and intervene prior to decompensation is paramount to survival. Lactate is extremely sensitive to shock and its clearance has been demonstrated a useful gauge of shock and resuscitation status. Though lactate can be measured in the field, logistical constraints render it impractical in certain environments. The Compensatory Reserve represents a new clinical measurement reflecting the remaining capacity to compensate for hypoperfusion. We hypothesized the compensatory reserve index (CRI) would be an effective surrogate marker of shock and resuscitation compared to lactate. METHODS The CRI device was placed on consecutive patients meeting trauma center activation criteria and remained on the patient until discharge, admission, or transport to operating suite. All subjects had a lactate level measured as part of their routine admission metabolic analysis. Time-corresponding CRI and lactate values were matched in regards to initial and subsequent lactate levels. Mean time from lactate sample collection to data availability in the electronic medical record was calculated. Predictive capacity of CRI and lactate in predicting hemorrhage was determined by receiver-operative characteristic curve analysis. Correlation analysis was performed to determine if any association existed between changing CRI and lactate values. RESULTS Receiver-operator characteristic (ROC) curves were generated and area under the curve was 0.8052 and 0.8246 for CRI and lactate, respectively. There was no significant difference in each parameters ability to predict hemorrhage (p= 0.8015). The mean duration from lactate sample collection to clinical availability was 44 minutes while CRI values were available immediately. Analysis of the concomitant change in serial CRI and lactate levels revealed a Spearmans correlation coefficient of -0.73 (p < 0.01). CONCLUSION CRI performed with equivalent predictive capacity to lactate with respect to identifying initial perfusion status associated with hemorrhage and subsequent resuscitation. LEVEL OF EVIDENCE II.BACKGROUND During traumatic hemorrhage, the ability to identify shock and intervene before decompensation is paramount to survival. Lactate is extremely sensitive to shock, and its clearance has been demonstrated a useful gauge of shock and resuscitation status. Though lactate can be measured in the field, logistical constraints render it impractical in certain environments. The compensatory reserve represents a new clinical measurement reflecting the remaining capacity to compensate for hypoperfusion. We hypothesized the compensatory reserve index (CRI) would be an effective surrogate marker of shock and resuscitation compared to lactate. METHODS The CRI device was placed on consecutive patients meeting trauma center activation criteria and remained on the patient until discharge, admission, or transport to operating suite. All subjects had a lactate level measured as part of their routine admission metabolic analysis. Time-corresponding CRI and lactate values were matched in regards to initial and subsequent lactate levels. Mean time from lactate sample collection to data availability in the electronic medical record was calculated. Predictive capacity of CRI and lactate in predicting hemorrhage was determined by receiver-operator characteristic curve analysis. Correlation analysis was performed to determine if any association existed between changing CRI and lactate values. RESULTS Receiver-operator characteristic (ROC) curves were generated and area under the curve was 0.8052 and 0.8246 for CRI and lactate, respectively. There was no significant difference in each parameter’s ability to predict hemorrhage (p = 0.8015). The mean duration from lactate sample collection to clinical availability was 44 minutes whereas CRI values were available immediately. Analysis of the concomitant change in serial CRI and lactate levels revealed a Spearman’s correlation coefficient of −0.73 (p < 0.01). CONCLUSION CRI performed with equivalent predictive capacity to lactate with respect to identifying initial perfusion status associated with hemorrhage and subsequent resuscitation. LEVEL OF EVIDENCE Diagnostic, Level II.

Management of the Clinically Node-Negative Axilla in Primary Breast Cancer

Axillary lymph node status is an important prognostic factor in patients with primary breast cancer. Yet, management of the axilla in these patients has been controversial. Sentinel lymph node biopsy (SLNB) is a less morbid procedure with similar survival and recurrence when compared to axillary lymph node dissection (ALND) and has emerged as the standard of care for staging patients with clinically node-negative disease. The results of three randomized trials seem to suggest that completion ALND may not be necessary in all women with T1/T2 tumors that have sentinel node-positive tumors and a low burden of axillary disease. However, while patients with isolated tumor cells or micrometastatic disease in the sentinel node may forego further axillary treatment, we believe that those with macrometastatic disease on SLNB should undergo additional axillary treatment (either ALND or radiotherapy) until further evidence defining which patients may benefit from observation alone emerges.