Utility of the Surgical Apgar Score in a district general hospital

Surgical Apgar scores predict complications after emergency general surgery laparotomy

BACKGROUND

The Surgical Apgar Score (SAS) is a 10-point validated score comprised of three intraoperative variables (blood loss, lowest heart rate, and lowest mean arterial pressure). Lower scores are worse and predict major postoperative complications. The SAS has not been applied in emergency general surgery (EGS) but may help guide postoperative disposition. We hypothesize that SAS can predict complications in EGS patients undergoing a laparotomy.

METHODS

We performed a retrospective review of adult patients at a single, quaternary care center who underwent an exploratory laparotomy for EGS conditions within 6 hours of surgical consultation from 2015 to 2019. Patients were grouped by whether they experienced a postoperative complication (systemic, surgical, and/or death). Multivariable regression was performed to predict complications, accounting for SAS and other statistically significant variables between groups. Using this model, predicted probabilities of a complication were generated for each SAS.

RESULTS

The cohort comprised 482 patients: 32.8% (n = 158) experienced a complication, while 67.2% (n = 324) did not. Patients with complications were older, frailer, more often male, had worse SAS (6 vs. 7, p < 0.0001) and American Society of Anesthesiologists scores, and higher rates of perforated hollow viscus ( p = 0.0003) and open abdomens ( p < 0.0001). On multivariable regression, an increasing SAS independently predicted less complications (adjusted odds ratio, 0.85; 95% confidence interval, 0.75-0.96; p = 0.009). An SAS ≤4 was associated with a 49.2% predicted chance of complications, greater rates of septic shock (9.7% vs. 3%, p = 0.01), respiratory failure (20.5% vs. 10.8%, p = 0.02), and death (24.1% vs. 7.5%, p < 0.0001). An SAS ≤ 4 did not correlate with surgical complications ( p = 0.1).

CONCLUSION

The SAS accurately predicts postoperative complications in EGS patients undergoing urgent laparotomy, with an SAS ≤ 4 identifying patients at risk for septic shock, respiratory failure, and mortality. This tool can aid in rapidly determining postoperative disposition and resource allocation.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Would surgical Apgar score be useful to predict postoperative complications after proximal femoral fracture surgery? - A retrospective cohort study

BACKGROUND

The surgical Apgar score (SAS) is a perioperative risk evaluation score, which considers intraoperative minimum heart rate, minimum mean arterial pressure and estimated blood loss. Although validated in multiple surgical fields, SAS remains quite controversial in the orthopedic one. The main purpose of this study was to investigate if SAS relates with the occurrence of complications during the first 30-days after proximal femoral fracture surgery.

METHODS

Retrospective study including all consecutive patients submitted to proximal femoral fracture surgery between January and July 2019. Patients with no information about SAS were excluded. Patients were divided in two groups, based on the occurrence of complications during the first 30 post-operative days and their SAS calculated. Receiver operating characteristic (ROC) curves were used to assess SAS power as a predictive model of complications.

RESULTS

Forty-two percent (n = 76) of the 181 patients included in the study developed complications during the first 30 postoperative days. Eight patients (4,4%) died during that period. The patient's mean age was 79 years and 30,9% (n = 56) were men. Heart failure, pacemaker use, chronic kidney disease, chronic obstructive pulmonary disease and dementia were significantly associated with post-operative morbidity. There was no significant correlation between SAS and the occurrence of complications during the first 30 postoperative days. The AUC of SAS as a predictive model for postoperative complications after proximal femoral fracture surgery was 0,522, being insufficient to be considered an accepted model of prediction.

CONCLUSION

Based on this study, we conclude that SAS is not predictive of the development of complications in the first 30 post-operative days in patients submitted to proximal femoral fracture surgery. However, other clinical factors have been identified as associated with postoperative morbidity. In the future, prospective-based studies with higher samples may better clarify the role of SAS in this context.

Implementation of the Surgical Apgar Score in Laboratory Animal Science: A Showcase Pilot Study in a Porcine Model and a Review of the Literature

INTRODUCTION

In an attempt to further improve surgical outcomes, a variety of outcome prediction and risk-assessment tools have been developed for the clinical setting. Risk scores such as the surgical Apgar score (SAS) hold promise to facilitate the objective assessment of perioperative risk related to comorbidities of the patients or the individual characteristics of the surgical procedure itself. Despite the large number of scoring models in clinical surgery, only very few of these models have ever been utilized in the setting of laboratory animal science. The SAS has been validated in various clinical surgical procedures and shown to be strongly associated with postoperative morbidity. In the present study, we aimed to review the clinical evidence supporting the use of the SAS system and performed a showcase pilot trial in a large animal model as the first implementation of a porcine-adapted SAS (pSAS) in an in vivo laboratory animal science setting.

METHODS

A literature review was performed in the PubMed and Embase databases. Study characteristics and results using the SAS were reported. For the in vivo study, 21 female German landrace pigs have been used either to study bleeding analogy (n = 9) or to apply pSAS after abdominal surgery in a kidney transplant model (n = 12). The SAS was calculated using 3 criteria: (1) estimated blood loss during surgery; (2) lowest mean arterial blood pressure; and (3) lowest heart rate.

RESULTS

The SAS has been verified to be an effective tool in numerous clinical studies of abdominal surgery, regardless of specialization confirming independence on the type of surgical field or the choice of surgery. Thresholds for blood loss assessment were species specifically adjusted to >700 mL = score 0; 700-400 mL = score 1; 400-55 mL score 2; and <55 mL = score 3 resulting in a species-specific pSAS for a more precise classification.

CONCLUSION

Our literature review demonstrates the feasibility and excellent performance of the SAS in various clinical settings. Within this pilot study, we could demonstrate the usefulness of the modified SAS (pSAS) in a porcine kidney transplantation model. The SAS has a potential to facilitate early veterinary intervention and drive the perioperative care in large animal models exemplified in a case study using pigs. Further larger studies are warranted to validate our findings.

Development of the PIP score: A metric for predicting Intensive Care Unit admission among patients undergoing emergency laparotomy

Background

Emergency laparotomy cases account for a significant proportion of the surgical caseload requiring postoperative intensive care. However, access to Intensive Care Unit (ICU) services has been limited by the scarcity of resources, lack of guidelines, and paucity of triaging tools.

Objective

This study aimed at developing a feasible Post-emergency laparotomy ICU admission Predictive (PIP) scoring tool.

Methodology

A case-control study utilizing the records of 108 patients who underwent emergency laparotomy was conducted. The primary outcome was the postoperative disposition status. Cases were defined as emergency laparotomy patients admitted to the ICU. The control group constituted patients admitted to the general ward. Logistic regression analysis was performed to identify the perioperative predictors of outcome. The PIP score was developed as a composite of each statistically significant variable remaining in the final logistic regression model.

Results

The significant positive predictors of ICU admission included a worsening American Society of Anesthesiologists - Physical Status, decreasing preoperative baseline axillary temperature, increasing preoperative baseline pulse rate, and intraoperative blood-product transfusion. The scoring system incorporating the identified predictors was presented as a numeric scale ranging from zero to four. Two levels of prediction were defined with reference to the optimum cut-off value; a score of <3 (low-intermediate prediction) and a score of ≥3 (high prediction [OR = 37.00, 95% CI = 11.22-122.02, p <0.001]). The score demonstrated an excellent predictive ability on the Receiver Operator Characteristic Curve (Area Under the Curve = 0.91, 95% CI = 0.851-0.973, p <0.001).

Conclusion

The PIP score proves useful as a feasible postoperative triaging adjunct for emergency laparotomy cases. Nonetheless, further validation studies are required.

The Surgical Apgar Score: A Systematic Review of Its Discriminatory Performance

To review the current literature evaluating the performance of the Surgical Apgar Score (SAS).

Background

The SAS is a simple metric calculated at the end of surgery that provides clinicians with information about a patient's postoperative risk of morbidity and mortality. The SAS differs from other prognostic models in that it is calculated from intraoperative rather than preoperative parameters. The SAS was originally derived and validated in a general and vascular surgery population. Since its inception, it has been evaluated in many other surgical disciplines, large heterogeneous surgical populations, and various countries.

Methods

A database and gray literature search was performed on March 3, 2020. Identified articles were reviewed for applicability and study quality with prespecified inclusion criteria, exclusion criteria, and quality requirements. Thirty-six observational studies are included for review. Data were systematically extracted and tabulated independently and in duplicate by two investigators with differences resolved by consensus.

Results

All 36 included studies reported metrics of discrimination. When using the SAS to correctly identify postoperative morbidity, the area under the receiver operating characteristic curve or concordance-statistic ranged from 0.59 in a general orthopedic surgery population to 0.872 in an orthopedic spine surgery population. When using the SAS to identify mortality, the area under the receiver operating characteristic curve or concordance-statistic ranged from 0.63 in a combined surgical population to 0.92 in a general and vascular surgery population.

Conclusions

The SAS provides a moderate and consistent degree of discrimination for postoperative morbidity and mortality across multiple surgical disciplines.

The utility of surgical Apgar score in predicting postoperative morbidity and mortality in general surgery

Objectives

Many surgical scoring systems are used to predict operative risk but most are complicated. The aim of the study was to determine the utility of the Surgical Apgar Score (SAS) in predicting post operative mortality and morbidity in general surgical cases.

Material and Methods

This was a prospective observational study. All adult patients for emergency and elective general surgical procedures were included. Intraoperative data was collected, and post operative outcomes were followed up till 30 days. SAS was calculated from intraoperative lowest heart rate, lowest MAP and blood loss.

Results

A total of 220 patients were included in the study. All consecutive general surgical procedures were included. Sixty of the 220 cases were emergency and the rest were elective. Forty-five (20.5%) of the patients developed complication. Mortality rate was 3.2% (7 out of 220). The cases were divided into high risk (0-4), moderate risk (5-8) and low risk (9-10) based on SAS. Complication and mortality rates were 50% and 8.3% in the high risk group, 23% and 3.7% in the moderate risk and 4.2% and 0 in the low risk group, respectively.

Conclusion

The surgical Apgar score is a simple and valid predictor of postoperative morbidity and 30-day mortality among patients undergoing general surgeries. It is applicable to all types of surgeries for emergency and elective cases and irrespective of the patient general condition and type of anesthesia and surgery planned.

Surgical Apgar Score predictive value for early postoperative organ dysfunction in cancer patients

BACKGROUND

Surgical APGAR Score (SAS) is based only on intraoperative data and has the advantage of being easy to calculate. Low SAS was associated with an increased risk for postoperative complications, but its utility for specific outcomes prediction, such as postoperative cardiovascular, renal, or metabolic dysfunction is less investigated. Our study aimed to investigate SAS predictive value for early postoperative organ dysfunction in a surgical oncological population.

METHODS

This is a prospective observational study that enrolled all consecutive patients submitted to oncologic surgery over 20-days. Registered parameters included demographics, comorbidities, diagnosis and surgery data, SAS score, postoperative complications, organ dysfunction and in-hospital mortality. SAS predictive value for postoperative organ dysfunction was assessed using logistic regression and ROC curves.

RESULTS

The study included 205 oncological patients with a mean age (standard deviation) of 60 (12.8) years. SAS was between 8 and 10 in 60% of patients and between 0 and 7 in 40% of patients. Postoperative complications developed in 33 patients (16.1%) and organ dysfunction in 26 patients (12.7%). The rates of postoperative complications, organ dysfunction and mortality, were significantly higher in patients with a low SAS (0-7) than high SAS (8-10). SAS had a low discrimination capacity to distinguish between patients who will develop postoperative complications and those who will not (AUROC 0.65) but was more accurate in identifying surgical oncological patients at risk for cardiovascular and metabolic dysfunction (AUROC 0.83 and 0.85 respectively).

CONCLUSION

SAS may be a useful tool to identify cancer surgery patients at risk for postoperative cardiovascular and metabolic dysfunction.

de Izquierdo S, García-Gallont R. Utilidad del puntaje Apgar quirúrgico como factor pronóstico de complicaciones postoperatorias

Introducción: El puntaje Apgar Quirúrgico (SAS) es un sistema de evaluación simple y confiable que identifica a los pacientes que presentan riesgos de eventos perioperatorios.  Objetivo: Determinar la utilidad del puntaje SAS como factor pronóstico de complicaciones mayores en los 30 días postoperatorios. Metodología: Este es un estudio de serie de casos, retrospectivo transversal, desarrollado con información de expedientes clínicos de 263 pacientes sometidos a cirugía mayor en el Hospital Herrera Llerandi de la Ciudad de Guatemala, durante los meses de enero a abril, 2018. Resultados: utilizando la prueba de Chi cuadrado se comprobó que existe relación entre el puntaje SAS y la presencia de complicaciones postoperatorias. Conclusión: El puntaje SAS es útil como factor pronóstico de complicaciones postoperatorias.

Detecting Major Complications and Death After Emergency Abdominal Surgery Using the Surgical Apgar Score: A Retrospective Analysis in a Caribbean Setting

Objective

The Surgical Apgar Score (SAS) is a simple 10-point scoring system that has been shown to be predictive of major postoperative complications and death after surgery. We evaluated the predictive ability of this score in a cohort of patients undergoing emergency abdominal surgery in a Caribbean tertiary hospital.

Methods

The SAS was calculated retrospectively from the anaesthesia records of all patients undergoing emergency abdominal surgery during a 12-month period. The postoperative surgical records of these patients were then examined for the presence of major complications and death. The association between the SAS and outcomes was tested using binary logistic regression, and the SAS discriminatory ability was determined from the receiver-operating curve (ROC) analysis.

Results

Of the 220 patients studied, 72 (33%) suffered an in-hospital major complication or death. The highest complication rate occurred in the low-scoring groups, with 68% of those scoring <4 being affected. Low-scoring patients (<4) had four times the risk of major complications when compared to higher-scoring groups (relative risk [RR], 4.21; 95% confidence interval [CI], 2.5-7.3; p<0.001). The odds ratio (OR) for major complications or death per unit increase in the SAS was 0.58 (95% CI, 0.47-0.72; p<0.001). The c-statistic of the SAS for predicting major complications or death was 0.71 (95% CI, 0.68-0.73; p<0.0001).

Conclusion

The SAS is a simple 10-point score that can be used in patients undergoing emergency surgery in a Caribbean setting to help identify those that are at a higher risk of postoperative complications. Due to its ease in calculation, it can be added to other commonly used criteria to help triage the postoperative patient.

Does the Surgical Apgar Score predict serious complications after elective major cancer surgery?

BACKGROUND

Major cancer surgery is associated with significant risks of perioperative morbidity and mortality, resulting in delayed adjuvant therapy, higher recurrence rates, and worse overall survival. Previous retrospective studies have used the Surgical Apgar Score (SAS) for perioperative risk assessment. This study prospectively evaluated the predictive value of SAS to predict serious complication (SC) after elective major cancer surgery.

METHODS

Demographic, comorbidity, procedure, and intraoperative data were collected prospectively for 405 patients undergoing elective major cancer surgery between 2014-17. The SAS was calculated immediately postoperative and outcome data were collected prospectively. Rates of SC according to SAS risk category were compared using Cochran-Armitage trend test. Receiver operating characteristic curves and area under the receiver operating characteristic curves were generated and 95% confidence intervals were calculated.

RESULTS

Eighty percent, 17.3%, and 2.7% of patients were low (SAS 7-10), intermediate (SAS 5-6), and high risk (SAS 0-4), respectively, for SC based on their SAS. Forty-six (11.4%) had an SC within 30 days; 3.7% returned to the operating room, 3.7% experienced a urinary tract infection, 3.2% experienced a respiratory complication, 2.7% experienced a wound complication, and 1.2% experienced a cardiac complication. Overall, 9.3%, 18.6%, and 27.3% of patients with SAS 7-10, 5-6, and 0-4 experienced an SC, respectively (P = 0.005). The overall discriminatory ability of the SAS was modest (area under the receiver operating characteristic curves 0.661; 95% confidence intervals, 0.582-0.740).

CONCLUSIONS

Although there was an overall association between SAS and higher risk of subsequent postoperative SC in our cohort, the ability of the SAS to accurately predict risk of postoperative SC at the patient level was limited.

The Surgical Apgar Score can help predict postoperative complications in femoral neck fracture patients: a 6-year retrospective cohort study

Introduction

The postoperative mortality rate following a femoral neck fracture remains high. The Surgical Apgar Score (SAS), based on intraoperative blood loss, the lowest mean arterial pressure, and the lowest heart rate, was created to predict 30-day postoperative major complications. Here, we evaluated the relationship between the SAS and postoperative complications in patients who underwent femoral neck surgeries.

Methods

We retrospectively collected data from patients with femoral neck surgeries performed in 2012–2017 at Kumamoto Central Hospital. The variables required for the SAS and the factors presumably associated with postoperative complications including the patients’ characteristics were collected from the medical charts. Intergroup differences were assessed with the χ² test with Yates’ correlation for continuity in category variables. The Mann-Whitney U test was used to test for differences in continuous variables. We assessed the power of the SAS value to distinguish patients who died ≤ 90 days post-surgery from those who did not, by calculating the area under the receiver operating characteristic curve (AUC).

Results

We retrospectively examined the cases of 506 patients (94 men, 412 women) aged 87 ± 6 (range 70–102) years old. The 90-day mortality rate was 3.4% (n = 17 non-survivors). There were significant differences between the non-survivors and survivors in body mass index (BMI), the presence of moderate to severe valvular heart disease, albumin concentration, the American Society of Anesthesiologists (ASA) classification, and the SAS. The 90-day mortality rate in the SAS ≤ 6 group (n = 97) was 10.3%, which was significantly higher than that in the SAS ≥ 7 group (n = 409), 1.7%. The AUC value to predict the 90-day mortality was 0.70 for ASA ≥ 3 only, 0.71 for SAS ≤ 6 only, 0.81 for SAS ≤ 6 combined with ASA ≥ 3, and 0.85 for SAS ≤ 6 combined with albumin concentration < 3.5 g/dl, BMI ≤ 20, and the presence of moderate to severe valvular heart disease.

Conclusions

Our results suggest that the SAS is useful to evaluate postoperative complications in patients who have undergone a femoral neck surgery. The ability to predict postoperative complications will be improved when the SAS is used in combination with the patient’s preoperative physical status.

[CR-POSSUM and Surgical Apgar Score as predictive factors for patients' allocation after colorectal surgery]

BACKGROUND AND OBJECTIVES

Surgical patients frequently require admission in high-dependency units or intensive care units. Resources are scarce and there are no universally accepted admission criteria, so patients' allocation must be optimized. The purpose of this study was to investigate the relationship between postoperative destination of patients submitted to colorectal surgery and the scores ColoRectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (CR-POSSUM) and Surgical Apgar Score (SAS) and, secondarily find cut-offs to aid this allocation.

METHODS

A cross-sectional prospective observational study, including all adult patients undergoing colorectal surgery during a 2 years period. Data collected from the electronic clinical process and anesthesia records.

RESULTS

A total of 358 patients were included. Median score for SAS was 8 and CR-POSSUM had a median mortality probability of 4.5%. Immediate admission on high-dependency units/intensive care units occurred in 51 patients and late admission in 18. Scores from ward and high-dependency units/intensive care units patients were statistically different (SAS: 8 vs. 7, p<0.001; CR-POSSUM: 4.4% vs. 15.9%, p<0.001). Both scores were found to be predictors of immediate postoperative destination (p<0.001). Concerning immediate high-dependency units/intensive care units admission, CR-POSSUM showed a strong association (AUC 0.78, p=0.034) with a ≥9.16 cut-off point (sensitivity: 62.5%; specificity: 75.2%), outperforming SAS (AUC 0.67, p=0.048), with a ≤7 cut-off point (sensitivity: 67.3%; specificity: 56.1%).

CONCLUSIONS

Both CR-POSSUM and SAS were associated with the clinical decision to admit a patient to the high-dependency units/intensive care units immediately after surgery. CR-POSSUM alone showed a better discriminative capacity.

Validation of the Surgical Apgar Score After Laparotomy at a Tertiary Referral Hospital in Rwanda

BACKGROUND

The surgical Apgar score (SAS) has demonstrated utility in predicting postoperative outcomes in a variety of surgical disciplines. However, there has not been a study validating the utility of the SAS in surgical patients in low-income countries. We conducted a prospective, observational study of patients undergoing laparotomy at a tertiary referral hospital in Rwanda and determined the ability of SAS to predict inpatient major complications and mortality.

METHODS

All adult patients undergoing laparotomy in a tertiary referral hospital in Rwanda from October 2014 to January 2015 were included. Data were collected on patient and operative characteristics. SAS was calculated and patients were divided into four SAS categories. Primary outcomes were in-hospital mortality and major complications. Rates and odds of in-hospital mortality and major complications were examined across the four SAS categories. Logistic regression modeling and calculation of c-statistics was used to determine the discriminative ability of SAS.

RESULTS

218 patients underwent laparotomy during the study period. One hundred and forty-three (65.6%) were male, and the median age was 34 years (IQR 27-51 years). The most common diagnosis was intestinal obstruction (97 [44.5%]). A high proportion of patients (170 [78%]) underwent emergency surgery. Thirty-nine (18.3%) patients died, and 61 (28.6%) patients had a major complication. In-hospital mortality occurred in 25 (50%) patients in the high-risk group, 12 (16%) in the moderate-risk group, 2 (3%) in the mild-risk group and there were no deaths in the low-risk group. Major complications occurred in 32 (64%) patients in the high-risk group, 22 (29%) in the moderate-risk group, 7 (11%) in the mild-risk group and there were no complications in the low-risk group. SAS was a good predictor of postoperative mortality (c-statistic 0.79) and major complications (c-statistic 0.75).

CONCLUSIONS

SAS can be used to predict in-hospital mortality and major complications after laparotomy in a Rwandan tertiary referral hospital.

The Reliability of Surgical Apgar Score in Predicting Immediate and Late Postoperative Morbidity and Mortality: A Narrative Review

Surgical Apgar Score is a simple, 10-point scoring system in which a low score reliably identifies those patients at risk for adverse perioperative outcomes. Surgical techniques and anesthesia management should be directed in such a way that the Surgical Apgar Score remains higher to avoid postoperative morbidity and mortality.

Application of Surgical Apgar Score in intracranial meningioma surgery

Surgical resection is the main therapeutic option for intracranial meningiomas, but it is not without significant morbidities. The Surgical Apgar Score (SAS), assessed by intraoperative blood pressure, heart rate, and blood loss, was developed for prognostic prediction in general and vascular surgery. We aimed to examine whether the application of SAS in patients undergoing craniotomy for meningioma resection can predict postoperative major complications. We retrospectively enrolled 99 patients that had undergone intracranial meningioma surgery. The patients were subdivided into 2 groups based on whether major complications were present (N = 34) or not (N = 65). We recognized the intergroup differences in SAS and clinical variables. The incidence of 30-day major complications in patients after operation was 34.3%. The lengths of ICU and hospital stay for the morbid cases were prolonged significantly (p = 0.009, p < 0.001, respectively). In the multivariate logistic regression model, SAS was an independent predicting factor of major complications following surgery for intracranial meningiomas (odds ratio, 95% confidence interval = 0.57, 0.38–0.87; p = 0.009), and thus a decrease of one mean SAS increased the rate of major complications by 43%. In conclusions, SAS is an independent predictor of major complications in patients undergoing intracranial meningioma surgery, and provides acceptable risk discrimination. Since this scoring system is relatively simple, objective, and practical, we suggest that SAS be included as an indicator in the guidance for the level of care after craniotomy for meningioma resection.

Surgical apgar score predicts early complication in transfemoral amputees: Retrospective study of 170 major amputations

AIM

To assess whether the surgical apgar score (SAS) is a prognostic tool capable of identifying patients at risk of major complications following lower extremity amputations surgery.

METHODS

This was a single-center, retrospective observational cohort study conducted between January 2013 and April 2015. All patients who had either a primary transtibial amputation (TTA) or transfemoral amputation (TFA) conducted at our institution during the study period were assessed for inclusion. All TTA patients underwent a standardized one-stage operative procedure (ad modum Persson amputation) performed approximately 10 cm below the knee joint. All TTA procedures were performed with sagittal flaps. TFA procedures were performed in one stage with amputation approximately 10 cm above the knee joint, performed with anterior/posterior flaps. Trained residents or senior consultants performed the surgical procedures. The SAS is based on intraoperative heart rate, blood pressure and blood loss. Intraoperative parameters of interest were collected by revising electronic health records. The first author of this study calculated the SAS. Data regarding major complications were not revealed to the author until after the calculation of SAS. The SAS results were arranged into four groups (SAS 0-4, SAS 5-6, SAS 7-8 and SAS 9-10). The cohort was then divided into two groups representing low-risk (SAS ≥ 7) and high-risk patients (SAS < 7) using a previously established threshold. The outcome of interest was the occurrence of major complications and death within 30-d of surgery.

RESULTS

A logistic regression model with SAS 9-10 as a reference showed a significant linear association between lower SAS and more postoperative complications [all patients: OR = 2.00 (1.33-3.03), P = 0.001]. This effect was pronounced for TFA [OR = 2.61 (1.52-4.47), P < 0.001]. A significant increase was observed for the high-risk group compared to the low-risk group for all patients [OR = 2.80 (1.40-5.61), P = 0.004] and for the TFA sub-group [OR = 3.82 (1.5-9.42), P = 0.004]. The AUC from the models were estimated as follows: All patients = [0.648 (0.562-0.733), P = 0.001], for TFA patients = [0.710 (0.606-0.813), P < 0.001] and for TTA patients = [0.472 (0.383-0.672), P = 0.528]. This indicates moderate discriminatory power of the SAS in predicting postoperative complications among TFA patients.

CONCLUSION

SAS provides information regarding the potential development of complications following TFA. The SAS is especially useful when patients are divided into high- and low-risk groups.

Surgical apgar score in patients undergoing lumbar fusion for degenerative spine diseases

OBJECTIVE

Lumbar fusion is a procedure broadly performed for degenerative diseases of spines, but it is not without significant morbidities. Surgical Apgar Score (SAS), based on intraoperative blood loss, blood pressure, and heart rate, was developed for prognostic prediction in general and vascular operations. We aimed to examine whether the application of SAS in patients undergoing fusion procedures for degeneration of lumbar spines predicts in-hospital major complications.

METHODS

One hundred and ninety-nine patients that underwent lumbar fusion operation for spine degeneration were enrolled in this retrospective study. Based on whether major complications were present (N=16) or not (N=183), the patients were subdivided. We identified the intergroup differences in SAS and clinical parameters.

RESULTS

The incidence of in-hospital major complications was 8%. The duration of hospital stay for the morbid patents was significantly prolonged (p=0.04). In the analysis of multivariable logistic regression, SAS was an independent predicting factor of the complications after lumbar fusion for degenerative spine diseases [p=0.001; odds ratio (95% confidence interval)=0.35 (0.19-0.64)]. Lower scores were accompanied with higher rates of major complications, and the area was 0.872 under the receiver operating characteristic curve.

CONCLUSION

SAS is an independent predicting factor of major complications in patients after fusion surgery for degenerative diseases of lumbar spines, and provides good risk discrimination. Since the scoring system is relatively simple, objective, and practical, we suggest that SAS be included as an indicator in the guidance for level of care after lumbar fusion surgery.

Preoperative Pancreatic Resection (PREPARE) score: a prospective multicenter-based morbidity risk score

OBJECTIVES

Development of a simple preoperative risk score to predict morbidity related to pancreatic surgery.

BACKGROUND

Pancreatic surgery is standardized with little technical diversity among institutions and unchanging morbidity and mortality rates in recent years. Preoperative identification of high-risk patients is potentially one of the rare avenues for improving the clinical course of patients undergoing pancreatic surgery.

METHODS

Using a prospectively collected multicenter database of patients undergoing pancreatic surgery (n=703), surgical complications were classified according to the Clavien-Dindo classification. A new scoring system for preoperative identification of high-risk patients that included only objective preoperatively assessable variables was developed using a multivariate regression model. Subsequently, this scoring system was prospectively validated from 2011 to 2013 (n=429) in a multicenter setting.

RESULTS

Eight independent preoperatively assessable variables were identified and included in the scoring system: systolic blood pressure, heart rate, hemoglobin level, albumin level, ASA (American Society of Anesthesiologists) score, surgical procedure, elective surgery or not, and disease of pancreatic origin or not. On the basis of 3 subgroups (low risk, intermediate risk, high risk), the proposed scoring system reached an accuracy of 75% for correctly predicting occurrence or nonoccurrence of major surgical complications in 80% of all analyzed patients within the validation cohort (c-statistic index=0.709, P<0.001, 95% confidence interval=0.657-0.760).

CONCLUSIONS

We present an easily applied scoring system with convincing accuracy for identifying low-risk and high-risk patients. In contrast to other systems, the score is exclusively based on objective preoperatively assessable characteristics and can be rapidly and easily calculated.

An assessment of the Surgical Apgar Score in spine surgery

BACKGROUND CONTEXT

The Surgical Apgar Score (SAS), a simple metric based on intraoperative heart rate, blood pressure, and blood loss, was developed in general and vascular surgery to predict 30-day major postoperative complications and mortality. No validation of SAS has been performed in spine surgery.

PURPOSE

To perform a prospective assessment of SAS in spine surgery.

STUDY DESIGN

Prospective study.

PATIENT SAMPLE

Two hundred sixty-eight consecutive patients undergoing major and intermediate spinal surgeries in an 18-month period.

OUTCOME MEASURES

Occurrence of major complications or death within 30 days of surgery.

METHODS

Intraoperative parameters were registered, and SAS was calculated immediately after surgery. Outcome data were collected during a 30-day follow-up. The relationship between SAS and the outcomes was analyzed calculating relative risks (RRs) and likelihood ratios (LRs) for different scoring groups. A univariate logistic regression analysis was also performed. The discriminatory accuracy of SAS was evaluated calculating a C-statistic.

RESULTS

Eighteen patients had ≥1 complications (6.72%). Patients with SAS 9-10 exhibited a 1.64% complication rate (RR=1; LR=0.23), which monotonically augmented as the score decreased: (SAS 7-8=2.75%; RR=1.68; LR=0.39), (SAS 5-6=13.33%; RR=8.13; LR=2.14), (SAS≤4=17.39%; RR=10.61; LR=2.92). The regression analysis odds ratio was 0.66 (95% confidence interval, 0.54-0.82), p<.01. The C-statistic was 0.77 (95% confidence interval, 0.66-0.88).

CONCLUSIONS

Surgical Apgar Score allows risk stratification and has a good discriminatory power in patients undergoing spine surgery.

A nomogram to predict major complications after hip and knee arthroplasty

We aimed to develop a nomogram for risk stratification of major postoperative complications in hip and knee arthroplasty based on preoperative and intraoperative variables, and assessed whether this tool would have better predictive performance compared to the Surgical Apgar Score (SAS). Logistic regression analysis was performed to develop a nomogram. Discrimination and calibration were assessed. Net reclassification improvement (NRI) was used to compare to the SAS. All variables were found to be statistically significant predictors of post-operative complications except race and lowest heart rate. The concordance index was 0.76 with good calibration. Compared to the SAS, the NRI was 71.5% overall. We developed a clinical prediction tool, the Morbidity and Mortality Acute Predictor for arthroplasty (arthro-MAP) that might be useful for postoperative risk stratification.

Use of the surgical Apgar score to guide postoperative care

INTRODUCTION

The surgical Apgar score (SAS) can predict 30-day major complications or death after surgery. Studies have validated the score in different patient populations and suggest it should be used to objectively guide postoperative care. We aimed to see whether using the SAS in a decisive approach in a future randomised controlled trial (RCT) would be likely to demonstrate an effect on postoperative care and clinical outcome.

METHODS

A total of 143 adults undergoing general/vascular surgery in 9 National Health Service hospitals were recruited to a pilot single blinded RCT and the data for 139 of these were analysed. Participants were randomised to a control group with standard postoperative care or to an intervention group with care influenced (but not mandated) by the SAS (decisive approach). The notional primary outcome was 30-day major complications or death.

RESULTS

Incidence of major complications was similar in both groups (control: 20/69 [29%], intervention: 23/70 [33%], p=0.622). Immediate admissions to the critical care unit was higher in the intervention group, especially in the SAS 0-4 subgroup (4/6 vs 2/7) although this was not statistically significant (p=0.310). Validity was also confirmed in area under the curve (AUC) analysis (AUC: 0.77).

CONCLUSIONS

This pilot study found that a future RCT to investigate the effect of using the SAS in a decisive approach may demonstrate a difference in postoperative care. However, significant changes to the design are needed if differences in clinical outcome are to be achieved reliably. These would include a wider array of postoperative interventions implemented using a quality improvement approach in a stepped wedge cluster design with blinded collection of outcome data.

May Renal Resistive Index be an early predictive tool of postoperative complications in major surgery? Preliminary results

Background. Patients who undergo high-risk surgery represent a large amount of post-operative ICU-admissions. These patients are at high risk of experiencing postoperative complications. Renal Resistive Index was found to be related with renal dysfunction, hypertension, and posttraumatic hemorrhagic shock, probably due to vasoconstriction. We explored whether Renal Resistive Index (RRI), measured after awakening from general anesthesia, could have any relationship with postoperative complications. Methods. In our observational, stratified dual-center trial, we enrolled patients who underwent general anesthesia for high-risk major surgery. After awakening in recovery room (or during awakening period in subjects submitted to cardiac surgery) we measured RRI by echo-color-Doppler method. Primary endpoint was the association of altered RRI (>0.70) and outcome during the first postoperative week. Results. 205 patients were enrolled: 60 (29.3%) showed RRI > 0.70. The total rate of adverse event was 27 (18.6%) in RRI ≤ 0.7 group and 19 (31.7%) in RRI > 0.7 group (P = 0.042). Significant correlation between RRI > 0.70 and complications resulted in pneumonia (P = 0.016), septic shock (P = 0.003), and acute renal failure (P = 0.001) subgroups. Patients with RRI > 0.7 showed longer ICU stay (P = 0.001) and lasting of mechanical ventilation (P = 0.004). These results were confirmed in cardiothoracic surgery subgroup. RRI > 0.7 duplicates triplicates the risk of complications, both in general (OR 2.03 93 95% CI 1.02–4.02, P = 0.044) and in cardiothoracic (OR 2.62 95% CI 1.11–6.16, P = 0.027) population. Furthermore, we found RRI > 0.70 was associated with a triplicate risk of postoperative septic shock (OR 3.04, CI 95% 1.5–7.01; P = 0.002).

Perioperative risk assessment for gastrectomy by surgical apgar score

BACKGROUND

Recently, a simple and easy complication prediction system, the surgical apgar score (SAS) calculated by three intraoperative parameters (estimated blood loss, lowest mean arterial pressure, and lowest heart rate), has been proposed for general surgery. In this study, we evaluated the predictability of the original SAS (oSAS) for severe complications after gastrectomy. In addition, the predictability of a modified SAS (mSAS) was evaluated, in which the cutoff value for blood loss was slightly modified.

METHODS

We investigated 328 patients who underwent gastrectomy at the Shizuoka Cancer Center in 2010. Clinical data, including intraoperative parameters, were collected retrospectively. Patients with postoperative morbidities classified as Clavien-Dindo grade IIIa or more were defined as having severe complications. Univariate and multivariate analyses were performed to elucidate factors that affected the development of severe complications.

RESULTS

Thirty-six patients (11.0 %) had severe complications postoperatively. Univariate analyses showed that the oSAS (p = 0.007) and mSAS (p < 0.001), as well as sex, preoperative chemotherapy, cStage, type of operation, thoracotomy, surgical approach, operation time, and extent of lymph node dissection, were associated with severe complications. Multivariate analysis showed that an mSAS ≤6 was found to be an independent risk factor for severe complication, while an oSAS ≤6 was not.

CONCLUSIONS

The oSAS was not found to be a predictive factor for severe complications following gastrectomy in Japanese patients. A slightly modified SAS (i.e. the mSAS) is considered to be a useful predictor for the development of severe complications in elective surgery.

Can the Surgical Apgar Score predict morbidity and mortality in general orthopaedic surgery?

PURPOSE

The Surgical Apgar Score (SAS) is a simple tally based on intra-operative heart rate, blood pressure and blood loss; it predicts 30-day major postoperative complications and mortality in different surgical fields, but no validation has been performed in general orthopaedic surgery.

METHODS

A prospective assessment of the SAS in 723 consecutive patients undergoing major and intermediate orthopaedic procedures was performed in an 18-month period. The SAS was calculated immediately after surgery, and the occurrence of major complications or death was registered within a 30-day follow-up.

RESULTS

Thirty-seven patients had ≥1 complication (5.12 %). The complication rate did not augment as the score decreased (SAS 9-10 = 6.56 %; SAS 7-8 = 2.62 %; SAS 5-6 = 7.21 %; SAS ≤4 = 10.2 %), the relative risk did not augment as the score decreased and the likelihood ratio did not increase with decreasing SAS values, except in the subgroup of patients undergoing spine surgery. The C-statistic was 0.59 (95 % confidence interval 0.48-0.69), a weak discriminatory value. Using a threshold of 7 to define high-risk and low-risk patients, the SAS allowed risk stratification only for spine surgery.

CONCLUSIONS

The SAS does not predict 30-day major complications and death in patients undergoing general orthopaedic surgery, but it is useful in the subgroup of patients undergoing spine surgery.