The American Association for the Surgery of Trauma uniform grading of hemorrhagic emergency general surgery diseases
Emergency general surgery (EGS) includes a wide spectrum of diseases with 485 International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes constituting diseases encountered in EGS.1 Risk stratification and comparison of outcomes for these diseases have been difficult owing to a lack of standard definitions of disease severity. Current surgical databases may not be suitable for emergency surgery, as outcomes following emergency surgery are consistently worse than those following nonemergency surgery. In fact, analysis of the American College of Surgeons-National Surgical Quality Improvement Program database from 2008 to 2012 demonstrated a six-fold higher overall mortality for patients undergoing emergency versus nonemergency general surgical operations.2 One of the key components of a reliable database is standard disease definitions and terminology. The American Association for the Surgery of Trauma (AAST) Patient Assessment Committee has previously developed a standardized anatomic grading template for EGS diseases that are inflammatory or infectious in nature.3 The Committee designed this uniform grading template to focus on anatomic rather than physiologic criteria because other parameters available for risk adjustment (e.g., systolic blood pressure and white blood cell count) capture physiologic information. The template has been applied to 16 inflammatory or infectious EGS diseases following disease progression from minimal (Grade I) to severe (Grade V).3–5
Currently, no standard grading system is available for hemorrhagic surgical diseases encountered by the EGS surgeon. Various grading schemes are available of which the most common measure the amount of blood loss, often difficult to estimate. The Advanced Trauma Life Support classification of hemorrhage6 from Class I through Class IV includes specific amounts of blood loss for each class with associated physiologic parameters. However, its clinical ease of use and validity has been questioned.7 The World Health Organization’s five-point bleeding scale8 is more subjective with Grade zero, no blood loss; Grade 1, petechial bleeding; Grade 2, mild blood loss; Grade 3, gross blood loss; and Grade 4, debilitating blood loss. The specific aim of this project was to develop a uniform grading system for measuring anatomic severity of disease in hemorrhagic surgical conditions and then apply this grading template to four hemorrhagic surgical disease processes commonly treated by acute care surgeons.