Identifying chronic heavy alcohol use in emergency general surgery patients: a pilot study

background Chronic heavy alcohol (CHA) use has been associated with perioperative complications. Emergency general surgery (EGS) patients are not routinely screened for CHA. If screened, it is usually for hazardous use of alcohol, using a survey such as the Alcohol Use Disorders Identification Test (AUDIT). This study screened EGS patients for CHA use using serum carbohydrate-deficient transferrin (%dCDT) level, a biomarker that has been validated as an indicator for CHA use, as well as the AUDIT. The purpose of this study was to determine the percent of EGS patients with CHA (as indicated by elevated %dCDT), and the relationship between %dCDT and AUDIT. Secondary aims included comparing the characteristics of EGS patients with and without CHA use, and evaluating the association of CHA use with negative clinical outcomes. Methods EGS patients aged 21 and older admitted to the general surgery inpatient service of a tertiary hospital from July 2014 to June 2016 were invited to participate in this study. %dCDT levels above 1.7% were considered positive for CHA use, as were AUDIT scores ≥8. results 195 EGS patients were screened for inclusion and 91 (46.7%) agreed to participate. 14 (15.4%) were positive for hazardous alcohol use on AUDIT and 5 (5.5%) were positive for CHA by %dCDT. Positive predictive value of AUDIT for CHA was 21.4%. There was no correlation between positive scores on AUDIT and %dCDT. Discussion Identifying at risk patients early on in their hospital course may allow clinicians to institute treatments to mitigate and/or circumvent complications in such patients. This pilot study determined that 17.6% of participating EGS patients were positive for some type of alcohol misuse, but only 5.5% had CHA. Further research is needed to determine whether routine use of %dCDT would be beneficial in reducing perioperative complications in this patient population. Level of evidence III (diagnostic test). bAckgrounD Alcohol misuse is considered one of the modifiable behaviors that increase the risk of perioperative complications.1 The identification of patients who misuse alcohol remains difficult, likely due to the stigma associated with alcohol misuse and a lack thereof of awareness. An Australian study found that self-reporting surveys regularly underestimated the actual burden of alcohol-related disease due to under-reporting.2 Excessive alcohol use is the third leading preventable cause of mortality in the USA, claiming the lives of more than 88 000 people annually and leading to 2.5 million years of potential life lost.3 4 It is estimated that 4% to 40% of admitted medical and surgical patients suffer complications related to their alcohol use.5 In a study of inpatients at The Johns Hopkins University, 23% of general surgery patients admitted to the hospital screened positive for a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSMIV) criteria of alcohol dependence.6 Patients with trauma who tested positive for alcohol at admission had a twofold increased risk of developing pneumonia and other infections and were 2.5 times more likely to be readmitted to the hospital.7 8 Numerous studies have supported the link between chronic alcohol misuse and perioperative complications.9–13 Although patients with chronic heavy alcohol (CHA) use represent a higher risk category in the perioperative period, routine alcohol screening is still not performed in most centers. Identifying patients with CHA use early on in their admission can empower clinicians to implement strategies for managing these patients, potentially mitigating complications during the acute care process.14 15 The Alcohol Use Disorders Identification Test (AUDIT) developed by the WHO allows clinicians to identify alcohol use disorders in a variety of patient populations.16 17 The AUDIT screening tool is designed to identify hazardous or harmful alcohol use, and has a reported sensitivity and specificity of identifying alcohol dependence in general medical patients of 90% and 80% to 90%, respectively.18 19 Carbohydrate-deficient transferrin (%dCDT) is a serum biomarker and is an objective tool used to identify CHA use.10 20–24 Serum levels of %dCDT rise in patients who consume 50 g to 80 g of alcohol per day for at least a week with a half-life of 15 days; thus, %dCDT can be used to identify moderate to heavy alcohol consumption occurring during a longer period.22 25 Given the increased risk of perioperative morbidity associated with CHA use, the primary aim of this study was to determine the percent of emergency general surgery (EGS) patients with CHA (as indicated by elevated %dCDT), as well as the relationship between CDT and AUDIT scores. The secondary aims were to compare the characteristics of our EGS patients with and without CHA use, and to evaluate the association of CHA use with negative outcomes. Identifying chronic heavy alcohol use in emergency general surgery patients: a pilot study Maher M Matar,1 Brent Jewett,2 Samir M Fakhry,1 Dulaney A Wilson,1 Pamela L Ferguson,1 Raymond F Anton,1,3 Joseph V Sakran1,4 to cite: Matar MM, Jewett B, Fakhry SM, et al. Trauma Surg Acute Care Open 2017;2:1–5. ► Additional material is published online only. To view please visit the journal online (http:// dx. doi. org/ 10. 1136/ tsaco2017000098). 1Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA 2Department of Surgery, Trident Medical Center, Charleston, South Carolina, USA 3The Charleston Alcohol Center, Medical University of South Carolina, Charleston, South Carolina, USA 4Division of Acute Care Surgery, The Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, Maryland, USA correspondence to Dr Joseph V Sakran, Division of Acute Care Surgery, The Johns Hopkins University, 1800 Orleans Street, Sheikh Zayed Tower, Baltimore, Maryland 21287, USA; jsakran1@ jhmi. edu Received 8 March 2017 Revised 28 May 2017 Accepted 29 May 2017 Original article group.bmj.com on October 17, 2017 Published by http://tsaco.bmj.com/ Downloaded from