Evaluation of POSSUM and P-POSSUM scoring systems for predicting the mortality in elective neurosurgical patients

Craniotomies at an overseas military treatment facility: Maintaining readiness for the unit and the surgeon

INTRODUCTION

Craniotomy and craniectomy are common neurosurgical procedures with wide applications in both civilian and military practice. Skill maintenance for these procedures is required for military providers in the event they are called to support forward deployed service members suffering from combat and non-combat injuries. The presents investigation details the performance of such procedures at a small, overseas military treatment facility (MTF).

MATERIALS AND METHODS

A retrospective review of craniotomy procedures performed at an overseas military treatment facility (MTF) over a 2-year period (2019-2021) was performed. Patient and procedural data were collected for all elective and emergent craniotomies including surgical indications, outcomes, complications, military rank, and impact on duty status and tour curtailment.

RESULTS

A total of 11 patients underwent a craniotomy or craniectomy procedure with an average follow-up of 496.8 days (range 103-797). Seven of the 11 patients were able to undergo surgery, recovery, and convalesce without transfer to a larger hospital network or MTF. Of the 6 patients that were active duty (AD), one returned to full duty while three separated and two remain in partial duty status at latest follow-up. There were four complications in four patients with one death.

CONCLUSIONS

In this series, we demonstrate that cranial neurosurgical procedures can be performed safely and effectively while at an overseas MTF. There are potential benefits to the AD service members, their unit, and family as well as to the hospital treatment team and surgeon as this represents a clinical capability requisite to maintain trauma readiness for future conflicts.

Association between Preoperative Medication Lists and Postoperative Hospital Length of Stay after Endoscopic Transsphenoidal Pituitary Surgery

Background: Endoscopic transsphenoidal surgery is the most common technique for the resection of pituitary adenoma. Data on factors associated with extended hospital stay after this surgery are limited. We aimed to characterize the relationship between preoperative medications and the risk of prolonged postoperative length of stay after this procedure. Methods: This single-center, retrospective cohort study included all adult patients scheduled for transsphenoidal pituitary surgery from 1 July 2016 to 31 December 2019. Anatomical Therapeutic Chemical codes were used to identify patients’ preoperative medications. The primary outcome was a prolonged postoperative hospital length of stay. Secondary outcomes included unplanned admission to the Intensive Care Unit, and in-hospital and one-year mortality. We developed a descriptive logistic model that included preoperative medications, obesity and age. Results: Median postoperative length of stay was 3 days for the 704 analyzed patients. Patients taking ATC-H drugs were at an increased risk of prolonged length of stay (OR 1.56, 95% CI 1.26−1.95, p < 0.001). No association was found between preoperative ATC-H medication and unplanned ICU admission or in-hospital mortality. Patients with multiple preoperative ATC-H medications had a significantly higher mean LOS (5.4 ± 7.6 days) and one-year mortality (p < 0.02). Conclusions: Clinicians should be aware of the possible vulnerability of patients taking systemic hormones preoperatively. Future studies should test this medication-based approach on endoscopic transsphenoidal pituitary surgery populations from different hospitals and countries.

Preanesthetic Evaluation and Preparation for Neurosurgical Procedures: An Indian Perspective

Background A questionnaire-based survey was conducted to determine the preanesthetic evaluation (PAE) practices among the members of the Indian Society of Neuroanesthesiology and Critical Care (ISNACC). The survey aimed to assess the current clinical practice of PAE and optimization of neurosurgical patients in India.

Methods An online questionnaire was designed by the working group of ISNACC and circulated among its active members. Response to individual questions was considered significant if 50% or more respondents concurred. The survey questions to which less than 50% of respondents concurred were identified as inconclusive results.

Results Out of 438 active ISNACC members, 218 responded. Responses were obtained from various parts of the country. The majority of participants were practicing neuroanesthesiology. Questions asked were regarding clinical assessment, preoperative optimization, prognostication, and airway management in neurosurgery. More than 50% of practitioners acceded to most of the questions; however, the percentage of responses varied across different questions (50–100%). The questions related to preoperative duplex scanning in chronically immobilized patients, preoperative cognitive testing, and risk stratification during neurosurgical procedures received an inconclusive response (< 50%).

Conclusion The survey highlights the variable PAE practices perused by ISNACC members across the country. A guideline for uniform PAE practices may help to enhance research and improve perioperative care.

Tools and scores for general and cardiovascular perioperative risk assessment: a narrative review

The number of surgical procedures in the world is large and in Brazil it has been expressing a growth trend higher than the population growth. In this context, perioperative risk assessment safeguards the optimization of the outcomes sought by the procedures. For this evaluation, anamnesis and physical examination constitute an irreplaceable initial stage which may or may not be followed by complementary exams, interventions for clinical stabilization and application of risk estimation tools. The use of these tools can be very useful in order to obtain objective data for decision making by weighing surgical risk and benefit. Global and cardiovascular risk assessments are of greatest interest in the preoperative period, however information about their methods is scattered in the literature. Some tools such as the American Society of Anesthesiologists Physical Status (ASA PS) and the Revised Cardiac Risk Index (RCRI) are more widely known, while others are less known but can provide valuable information. Here, the main indices, scores and calculators that address general and cardiovascular perioperative risk were detailed.

Validity of P-POSSUM in adult cancer surgery (PACS)

Background and Aims:

Objective prediction of postoperative morbidity and mortality can help clinicians for appropriate resource allocation and counseling of patients and their kin. Among different scoring systems, “Portsmouth- Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity” (P-POSSUM) includes both preoperative and intraoperative parameters for postoperative risk prediction. The aim of this study was to investigate the validity of morbidity prediction by P-POSSUM in patients requiring intensive care after undergoing major surgeries for gastrointestinal and gynecological malignancies.

Material and Methods:

All adult patients (>18 years) undergoing gastrointestinal and gynecological cancer surgeries who were shifted to intensive care unit (ICU) or high dependency unit (HDU) for postoperative care were included and P-POSSUM was measured. Postoperative complications were graded as per Clavien–Dindo (CD) grading and have been compared with predicted complications as per P-POSSUM.

Results:

143 patients were included in the study and the median P-POSSUM score was 35. The mean predicted morbidity was 55.28% (SD 25.54%) and the observed complications were 45.45%, which shows P- POSSUM has over predicted morbidity. At P-POSSUM values 60 and above, the incidence of major complications was 22.22%, compared to 6.25% for the rest (Odds ratio 4.286).

Conclusion:

P-POSSUM is not a reliable predictor of postoperative morbidity for patients undergoing major gynecological and gastrointestinal surgeries for cancer in our institution. But there is a significant incidence of major complications with P- POSSUM morbidity prediction score 60 or higher leading to the need for more stringent assessment and monitoring in that subgroup.

Early Postoperative Morbidity After Chronic Subdural Hematoma: Predictive Usefulness of the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity, American College of Surgeons National Surgical Quality Improvement Program, and American Society of Anesthesiologists Grade in a Prospective Cohort

BACKGROUND

Although chronic subdural hematoma (CSDH) is generally benign, long-term survival (LTS) after CSDH is poor in a significant subgroup. This dichotomy has been compared to fractured neck of femur. However, although early postoperative mortality (within 30 days of CSDH) is well recorded with CSDH and similar to fractured neck of femur (4%-8%), scant accurate data exist regarding early postoperative morbidity (POMB). POMB, which prolongs length of stay (LOS) after major nonneurosurgery, is associated with decreased LTS. One recent CSDH study suggested a POMB standard of 10% i.e., notably less than with fractured neck of femur (45%).

METHODS

POMB was recorded in a novel prospective single-center cohort after CSDH. The POSSUM (Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity), American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) score, and American Society of Anesthesiologists (ASA) grade were assessed as tools for potentially predicting POMB. Receiver operating characteristic (ROC) curves were calculated.

RESULTS

Early postoperative mortality (within 30 days of CSDH) occurred in 3 of 114 patients (3%). Seventy-one POMB events occurred in 54 of 114 patients (47%), with 27 of 54 (50%) having a Clavien-Dindo grade ≥2. Most POMB was neurologic (n = 47/71, 66%). Age (P = 0.01), Glasgow Coma Scale (GCS) score (P = 0.001), Markwalder grade (P = 0.01), hypertension (P = 0.047), and/or ≥1 preexistent comorbidity (P = 0.041) were predictive. LOS (P = 0.01) and discharge modified Rankin Scale score (P < 0.001) were significantly associated. Predicted and observed POMB with POSSUM were significantly disparate (χ² = 15.23; P = 0.001): POSSUM area under ROC (AUROC = 0.611) was also nondiscriminatory. ACS-NSQIP (χ² = 18.51; P < 0.001; AUROC = 0.629) and ASA grades (P = 0.25) were also nonpredictive.

CONCLUSIONS

POMB was frequently disabling, mostly neurologic, and as frequent and diverse as with fractured neck of femur. POMB was significantly correlated with LOS and discharge modified Rankin Scale score. Surprisingly, POSSUM, ACS-NSQIP, and ASA grades were not predictive and would not aid consent. Simple parameters (age, Glasgow Coma Scale, Markwalder grade, hypertension, and/or ≥1 other comorbidity) were instead predictive. Longitudinal follow-up will determine whether POMB affects LTS. CSDH, like fractured neck of femur, is distinct.

O-POSSUM score predicts morbidity and mortality in patients undergoing hip fracture surgery

PURPOSE

The aim of this study is to evaluate the O-POSSUM score capacity to predict the morbidity and mortality of patients undergoing hip fracture surgery.

MATERIAL AND METHODS

We retrospectively reviewed the clinical records of patients older than 65years old, operated on for hip fractures between January 2012 and December 2013. Of 229 patients, the mean age was 82.3years and 170 were women. We collected comorbidities, type of surgery, and expected morbidity and mortality O-POSSUM values.

RESULTS

After a minimum follow up of one year, 38 deaths were reported and 77 patients had complications. The expected mortality according to the O-POSSUM was 35 patients and expected morbidity 132.

CONCLUSION

By comparing the observed results with those predicted, the O-POSSUM scale is reliable in predicting mortality and overestimates morbidity.

Utility of the Surgical Apgar Score for Patients Who Undergo Surgery for Spinal Metastasis

STUDY DESIGN

Retrospective review of patients who underwent surgery for spinal metastasis between 2005 and 2011.

OBJECTIVE

To assess the utility of the surgical Apgar score (SAS) in patients who underwent surgery for spinal metastasis.

SUMMARY OF BACKGROUND DATA

Surgery for spinal metastasis can be associated with relatively high morbidity and mortality. Consequently, identifying patients at risk for major postoperative complications is important. Several studies have validated SAS for predicting 30-day complication risk.

METHODS

SASs were calculated and patients stratified into 5 groups: scores 0-2, 3-4, 5-6, 7-8, 9-10 points. Multivariate logistic regression assessed whether SAS was an independent predictor of major complication 30 days after surgery. Multivariate analysis of covariance assessed whether SAS was independently associated with length of stay.

RESULTS

Ninety-seven patients with a variety of metastatic tumors were analyzed. There was no obvious trend in complication rates, or significant association between SAS and complication rate (P=0.413). Complication rates were 25.0% for SASs 0-2, 33.3% for 3-4, 18.4% for 5-6, 10.0% for 7-8, and 33.3% for 9-10 points. On multivariate analysis, SAS was not independently associated with complications; age above 65 years (odds ratio 4.19; 95% confidence interval, 1.31-52.27; P=0.028) and preoperative Karnofsky Performance Score of 10-40 (odds ratio 9.13; 95% confidence interval, 1.42-58.63; P=0.020) were associated with higher odds of complication. SASs 0-2 were an independent predictor of longer hospital stay (P=0.004).

CONCLUSIONS

Our findings suggest that SAS is not a significant predictor of major perioperative complications after spinal metastasis surgery; preoperative functional status and age are stronger predictors. The need continues for a preoperative scoring system to reliably predict risk for perioperative complications after spinal metastasis surgery.

Comparison of Postoperative Outcomes in Elderly Patients With a Do-Not-Resuscitate Order Undergoing Elective and Nonelective Hip Surgery

PURPOSE

Emergency hip surgery generally has worse outcomes than elective hip surgery, even when adjusted for patient and surgical factors. Do-not-resuscitate (DNR) status patients are typically at higher perioperative risk and undergo a narrow range of surgical procedures. We aimed to compare the outcomes after hip surgery of differing degrees of urgency in this cohort.

MATERIALS AND METHODS

Using National Surgical Quality Improvement Program (NSQIP) data, we conducted univariate and multivariate analyses comparing outcomes of DNR status patients after emergency and nonemergency hip surgery (2007-2013). We conducted a subanalysis of mortality in elective versus nonelective cases (elective variable introduced from 2011).

RESULTS

Of 668 hip surgery cases in DNR status patients, 210 (31.4%) were emergency and 458 (68.8%) were nonemergency. There were no significant associations between emergency and nonemergency surgery regarding patient demographics, comorbidities, functional capacity, anesthesia type, or operative duration. There was no significant difference in the 30-day postoperative mortality between emergency (21.4%) and nonemergency (16.4%) or between elective (19.6%) and nonelective (18.3%) hip fracture surgeries performed in patients with preexisting DNR status. Morbidity patterns in emergency vs nonemergency cases demonstrated no significant differences, with the commonest 3 complications being transfusion (21.0% and 21.4%, respectively), urinary tract infection (9.5% and 7.9%, respectively), and pneumonia (both at 5.2%). The 30-day home discharge rates were low at 4.7% and 5.6%, respectively. Multivariate analysis demonstrated no significant associations between emergency and nonemergency surgery for mortality, discharge destination, length of stay or complications, except perioperative myocardial infarction (3.7% vs 1.3%, P < .04).

CONCLUSION

For patients with DNR status, both emergent and non-emergent hip surgery carries high mortality, greatly exceeding rates predicted for that patient by American College of Surgeons NSQIP risk calculators. Morbidity rates and patterns for patients with DNR status are also similar in emergency and nonemergency groups. These data may be useful in discussing risk and obtaining adequately informed consent in DNR patients undergoing hip surgery.

Preoperative Score to Predict Postoperative Mortality (POSPOM)

Background

An accurate risk score able to predict in-hospital mortality in patients undergoing surgery may improve both risk communication and clinical decision making. The aim of the study was to develop and validate a surgical risk score based solely on preoperative information, for predicting in-hospital mortality.

Methods

From January 1, 2010, to December 31, 2010, data related to all surgeries requiring anesthesia were collected from all centers (single hospital or hospitals group) in France performing more than 500 operations in the year on patients aged 18 yr or older (n = 5,507,834). International Statistical Classification of Diseases, 10th revision codes were used to summarize the medical history of patients. From these data, the authors developed a risk score by examining 29 preoperative factors (age, comorbidities, and surgery type) in 2,717,902 patients, and then validated the risk score in a separate cohort of 2,789,932 patients.

Results

In the derivation cohort, there were 12,786 in-hospital deaths (0.47%; 95% CI, 0.46 to 0.48%), whereas in the validation cohort there were 14,933 in-hospital deaths (0.54%; 95% CI, 0.53 to 0.55%). Seventeen predictors were identified and included in the PreOperative Score to predict PostOperative Mortality (POSPOM). POSPOM showed good calibration and excellent discrimination for in-hospital mortality, with a c-statistic of 0.944 (95% CI, 0.943 to 0.945) in the development cohort and 0.929 (95% CI, 0.928 to 0.931) in the validation cohort.

Conclusion

The authors have developed and validated POSPOM, a simple risk score for the prediction of in-hospital mortality in surgical patients.

Conscious sedation and local anesthesia for patients undergoing neurotologic and complex otologic procedures

OBJECTIVE

Is conscious sedation an effective, safe, and efficient anesthetic choice in patients undergoing select neurotologic and otologic procedures?

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Six patients underwent eight neurotologic procedures including cerebrospinal fluid leak and encephalocele repair, and primary and revision cochlear implant surgery. Patients were deemed poor candidates for general anesthesia secondary to medical comorbidities. These were compared to 11 control patients who underwent same procedures under general anesthesia with intubation.

INTERVENTION

Dexmedetomidine infusion was utilized as the primary agent for conscious sedation in this high-risk patient population because, unlike other commonly used sedatives, it preserves normal respirations while providing adequate analgesia.

MAIN OUTCOME MEASURES

Preoperative Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) scores were calculated for the study group. We measured total anesthesia, and perioperative and recovery times. Cost of anesthetic agents was considered and any adverse effects were noted. Patient satisfaction with the operative experience was assessed with telephone surveys.

RESULTS

P-POSSUM scores were high for the study group. Postoperative anesthesia was shorter for the study patients undergoing conscious sedation. Difference in cost of anesthetic agents was negligible. The adverse effects were few and as expected for the type of procedure. Patients reported satisfaction and comfort with their operative experience.

CONCLUSION

Select neurotologic and otologic procedures can be safely, effectively, and efficiently performed under conscious sedation with dexmedetomidine infusion as the primary anesthetic choice for patients who are deemed poor medical candidates for general endotracheal anesthesia.

The P-POSSUM scoring systems for predicting the mortality of neurosurgical patients undergoing craniotomy: Further validation of usefulness and application across healthcare systems

BACKGROUND AND AIMS

Continuous audit of clinical practice is an essential part of making improvements in medicine and enhancing patient care. Validated tools are needed to gather evidence for comparisons. Recently, Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scores were evaluated in Indian patients undergoing elective craniotomy and it was concluded that P-POSSUM was highly accurate in predicting overall mortality. We wished to study whether this system could be used in a different country and health care system [United Kingdom, UK]. We have evaluated these scores in patients undergoing elective and emergency craniotomies in a tertiary centre in the UK.

METHODS

Data was collected from all neurosurgical patients who underwent craniotomy overone year. Preoperative variables were collected prior to induction of anaesthesia, and operative variables were also collected. Chi-square test was used for expected and actual mortality differences. Survivor and non-survivor demographics were compared by one-way ANOVA for continuous and Chi-square for categorical variables.

RESULTS

One hundred and forty-five patients were studied. Mean [SD] physiologic score of the patients was 18.83 [5.07], and mean [SD] operative score was 18.09 [3.75]. P-POSSUM was a better predictor for elective patients and for those undergoing immediate life-saving surgery.

CONCLUSION

This study confirms and validates the findings of previous work that P-POSSUM is an accurate and reliable tool for estimating in-hospital mortality. It also confirms its usefulness in comparison of results across healthcare systems internationally. Larger scale evaluations may be needed to examine its usefulness in emergency procedures.

Predictive value of E-PASS and POSSUM systems for postoperative risk assessment of spinal surgery

Object

The Estimation of Physiological Ability and Surgical Stress (E-PASS) and Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) systems are surgical risk scoring systems that take into account both the patient's preoperative condition and intraoperative variables. While they predict postoperative morbidity and mortality rates for several types of surgery, spinal surgeries are currently not included. The authors assessed the usefulness of E-PASS and POSSUM algorithms and compared the predictive ability of both systems in patients with spinal disorders considered for surgery.

Methods

The E-PASS system includes a preoperative risk score, a surgical stress score, and a comprehensive risk score that is determined by both the preoperative risk score and surgical stress score. The POSSUM system is composed of a physiological score and an operative severity score; its total score is based on both the physiological score and operative severity score. The authors calculated the E-PASS and POSSUM scores for 601 consecutive patients who had undergone spinal surgery and investigated the relationship between the individual scores of both systems and the incidence of postoperative complications. They also assessed the correctness of the predicted morbidity rate of both systems.

Results

Postoperative complications developed in 64 patients (10.6%); there were no in-hospital deaths. All EPASS scores (p ≤ 0.001) and the operative severity score and total score of the POSSUM (p < 0.03) were significantly higher in patients with postoperative complications than in those without postoperative complications. The morbidity rates correlated linearly and significantly with all E-PASS scores (p ≤ 0.001); their coefficients (preoperative risk score, ρ = 0.179; surgical stress score, ρ = 0.131; and comprehensive risk score, ρ = 0.198) were higher than those for the POSSUM scores (physiological score, ρ = 0.059; operative severity score, ρ = 0.111; and total score, ρ = 0.091). The area under the receiver operating characteristic curve for the predicted morbidity rate was 0.668 for the E-PASS and 0.588 for the POSSUM system.

Conclusions

As E-PASS predicted morbidity more correctly than POSSUM, it is useful for estimating the postoperative risk of patients considered for spinal surgery.

Validity of E-PASS System for Postoperative Morbidity of Spinal Surgery

STUDY DESIGN

A single-center retrospective cohort study.

OBJECTIVE

To evaluate the ability of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) system to predict postoperative risk in patients scheduled for spinal surgery.

SUMMARY OF BACKGROUND DATA

The E-PASS system is a surgical audit to predict postoperative morbidity and mortality in general surgery. It is currently not applied in patients with spinal disorders.

METHODS

The E-PASS system is comprised of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS). The latter reflects both the PRS and SSS. We calculated the E-PASS scores for 275 consecutive patients who underwent spinal surgery and evaluated the relationship between the incidence of postoperative complications and each score of the E-PASS system and their ability to predict postoperative morbidity.

RESULTS

Postoperative complications developed in 31 patients (11.3%). All E-PASS scores were significantly higher in patients with postoperative complications and they were linearly correlated with the overall incidence of postoperative complications. In particular, PRS was correlated with complications at nonsurgical sites and SSS with surgical site complications. The area under the receiver operating characteristic curve (AUC) for PRS and SSS was higher in patients with complications at nonsurgical and surgical sites, respectively. The AUC for CRS exhibited good predictive power for both types of complication.

CONCLUSIONS

The E-PASS system correctly predicted morbidity. The predictive ability of CRS was good for overall morbidity. The E-PASS system is useful for the accurate prediction of the risk for in-hospital morbidity in individual patients scheduled for spinal surgery.

Introduction to the postanaesthetic care unit

High-risk, noncardiac surgery represents only 12.5% of surgical procedures, but 83.3% of deaths. The postanaesthetic care unit (PACU) addresses the need for an improved level of care for these patients by providing postoperative high-dependency or intensive care (Level 2 or 3). The PACU aims to improve the structure of care provision for high-risk surgical patients. By maintaining 24-hour cover at the same staffing level, the risk of poorer ‘out-of- hours’ care is reduced. In a PACU, whose remit is solely postoperative care, evidence-based protocols can be established to standardize the care given. The aim is to provide 24 hours of postoperative optimized care, thus targeting the period when these patients are most vulnerable, to reduce the risk of complications developing and identify complications promptly, should they occur. The PACU is set up to facilitate certain processes to aid optimized care in the postoperative period. These include invasive and noninvasive ventilation, goal-directed haemodynamic management, invasive monitoring and optimal pain management. Identification of high-risk patients who might benefit from PACU care is not always straightforward. However, tools are available to aid the clinician, supplementing clinical assessment and basic investigations. These include clinical prediction rules and cardiopulmonary exercise testing. Both the setting up and the running of a PACU clearly have cost implications. However, the reduction in postoperative morbidity, and thus patients’ length of stay, should, overall, reduce costs. The benefits of a PACU should therefore be seen in terms of improved surgical outcomes, reducing postoperative morbidity and mortality, and cost savings.

Validation of the surgical Apgar score in a neurosurgical patient population

Object

The surgical Apgar score (SAS) reliably predicts postoperative death and complications and has been validated in a large cohort of general and vascular surgery patients. However, there has been limited study of the utility of the score in the neurosurgical population. The authors tested the hypothesis that the SAS would predict postoperative complications and length of stay after neurosurgical procedures.

Methods

A cohort of 918 intracranial and spine surgery patients treated over a 3-year period were retrospectively evaluated. The 10-point SAS was calculated and postoperative 30-day mortality and complications rates, intensive care unit (ICU) stay, and hospital stay were assessed by 2 independent raters. Univariate analysis and multivariate logistic regression were performed.

Results

There were 145 patients (15.8%) with at least 1 complication and 24 patients (2.6%) who died within 30 days of surgery. Surgical Apgar scores were significantly associated with the likelihood of postoperative complications (p < 0.001) and death (p = 0.002); scores varied inversely with postoperative complication and mortality risk in a multivariate analysis. Low SASs also predicted prolonged ICU and hospital stay. Patients with scores of 0–2 stayed a mean of 18.9 days (p < 0.001) and patients with scores of 3–4 stayed an average of 14.3 days (p < 0.001) compared with 4.1 days in patients with scores of 9–10.

Conclusions

The application of the surgical Apgar score to a neurosurgical cohort predicted 30-day postoperative mortality and complication rates as well as extended ICU and hospital stay. This readily calculated score may help neurosurgical teams efficiently direct postoperative care to those at highest risk of death and complications.

Evaluation of POSSUM and P-POSSUM as a tool for prediction of surgical outcomes in the Indian population

BACKGROUND

Increased scrutiny and the need to institute a truly patient centered approach to surgical care has motivated the growing interest in measuring the quality of surgical care through comparative surgical audit. This study aimed to assess the validity of the POSSUM (Physiological and Operative Severity Score for enumeration of Mortality and Morbidity) and P-POSSUM (Portsmouth-POSSUM) score in predicting the risk of morbidity and mortality respectively in general surgical patients presenting with conditions of various operative severities at a tertiary care centre in Haryana, a northern state of India.

METHOD

A prospective study was performed in 100 general surgical patients including an equal number of patients in each of the four groups of operative severity i.e. minor, moderate, major, major plus. The risks of mortality and morbidity were calculated by using the POSSUM equation for morbidity and the P-POSSUM equation for mortality in each patient. The predicted risks were compared with the observed risks of mortality and morbidity and statistically analysed.

RESULTS

The difference in p value of predicted risk of morbidity by POSSUM equation and observed morbidity; calculated by chi square test was 0.756 which was not statistically significant. The difference in p value of predicted mortality by P-POSSUM equation and observed mortality; calculated by chi square test was 0.472 which was also not statistically significant.

CONCLUSION

POSSUM and P-POSSUM appear to be good and valid indices for use in the risk prediction of morbidity and mortality in the north Indian population.

Patient-related risk factors for postoperative adverse events

PURPOSE OF REVIEW

The risk of adverse outcome in patients undergoing major surgery is affected both by cardiorespiratory fitness, and the presence and severity of comorbidities. Accurate risk stratification is essential for the identification of patients who may benefit from specific perioperative management strategies or from an augmented level of perioperative care. Risk stratification techniques include risk prediction models, assessment of functional capacity and novel biochemical markers. This review examines the evidence for the use of these different techniques in perioperative patients.

RECENT FINDINGS

There remains considerable variation in the predictive ability of risk stratification models, in part due to the subjective nature of some of the component variables. Whereas a basic assessment of functional capacity using structured questionnaires may be helpful, in patients thought to be at high risk, the most accurate technique may be cardiopulmonary exercise testing, although the strength of the hypothesized relationship between functional capacity and perioperative outcome has not been fully defined. There have been advances in the identification and refinement of biochemical markers for risk prediction, in particular, brain natriuretic peptide and C-reactive protein. Currently, few centres routinely systematically utilize these strategies to risk stratify perioperative patients.

SUMMARY

The development of improved risk stratification techniques would be assisted by large-scale epidemiological studies. Improvements to currently used risk prediction models are likely to result from the use of variables which more objectively measure patient health and fitness than current tools, and may use a combination of all the above techniques to improve predictive accuracy.