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Kusen JQ, Beeres FJP, van der Vet PCR, Poblete B, Geuss S, Babst R, Knobe M, Wijdicks FJG, Link BC. Inter-rater agreement in pPOSSUM scores of geriatric trauma patients: a prospective evaluation. Arch Orthop Trauma Surg 2022; 142:3869-3876. [PMID: 35031826 DOI: 10.1007/s00402-021-04275-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/21/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Risk prediction models are widely used in the perioperative setting to identify high-risk patients who may benefit from additional care and to aid clinical decision-making. pPOSSUM is such a prediction model, however, little is known about the inter-rater agreement when scoring subjective parameters. This study assessed the inter-rater agreement between clinicians of different specialties and work-level when scoring 30 clinical case reports of geriatric hip fracture patients with pPOSSUM. METHODS Eighteen clinicians of the department of Surgery (three specialists, four residents), Anaesthesiology (four specialists, two residents) and Emergency Medicine (three specialists, two residents) who were familiar with the pPOSSUM scoring system were asked to calculate the scores. The kappa statistic and the statistical method of Fleiss were used to analyse inter-rater agreement. RESULTS The response rate was 100%. Among surgeons, Anaesthesiologists and Emergency department doctors (ED), the overall mean kappa values were 0.42, 0.08 and 0.20, respectively. Among surgery, anaesthesiology and ED residents the overall mean kappa values were 0.21, 0.33 and 0.37, respectively. Within the department of Surgery, Anaesthesiology and Emergency Medicine the overall mean kappa values were 0.23, 0.12 and 0.22, respectively. An overall mean kappa value of 0.19 was seen among all specialists. All residents had an overall mean kappa value of 0.21 and all clinicians had an overall mean kappa value of 0.21. CONCLUSION The overall inter-rater agreement of clinicians and interdisciplinary agreement when scoring geriatric hip fracture patients with pPOSSUM was low and prone to subjectivity in our study. A higher work-experience level did not lead to better agreement. When pPOSSUM is calculated without clinical assessment by the same clinician, caution is advised to prevent over-reliance on the pPOSSUM risk prediction model. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jip Q Kusen
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalsstrasse, CH-6000, Lucerne, Switzerland.
- Department of Orthopaedic and Trauma Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands.
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalsstrasse, CH-6000, Lucerne, Switzerland
| | - Puck C R van der Vet
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalsstrasse, CH-6000, Lucerne, Switzerland
- Department of Orthopaedic and Trauma Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Beate Poblete
- Department of Anaesthesiology, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Steffen Geuss
- Department of Emergency Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalsstrasse, CH-6000, Lucerne, Switzerland
- Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalsstrasse, CH-6000, Lucerne, Switzerland
| | - Franciscus J G Wijdicks
- Department of Orthopaedic and Trauma Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Björn C Link
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalsstrasse, CH-6000, Lucerne, Switzerland.
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Mao D, Rey-Conde T, North JB, Lancashire RP, Naidu S, Chua TC. Critical Analysis of the Causes of In-Hospital Mortality following Colorectal Resection: A Queensland Audit of Surgical Mortality (QASM) Registry Study. World J Surg 2022; 46:1796-1804. [PMID: 35378596 PMCID: PMC9174313 DOI: 10.1007/s00268-022-06534-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2022] [Indexed: 11/30/2022]
Abstract
Background Colorectal resection is a major gastrointestinal operation. Improvements in peri-operative care has led to improved outcomes; however, mortalities still occur. Using data from the Queensland Audit of Surgical Mortality (QASM), this study examines the demographic and clinical characteristics of patients who died in hospital following colorectal resection, and also reports the primary cause of death in this population. Methods Patients who died in hospital following colorectal resection in Queensland between January 2010 and December 2020 were identified from the QASM database. Results There were 755 patients who died in the 10 year study period. Pre-operatively, the risk of death as subjectively determined by operating surgeons was ‘considerable’ in 397 cases (53.0%) and ‘expected’ in 90 cases (12.0%). The patients had a mean of 2.7 (±1.5) co-morbidities, and a mean American Society of Anaesthesiologists (ASA) score of 3.6 (±0.8). Operations were categorised as emergency in 579 patients (77.2%), with 637 patients (85.0%) requiring post-operative Intensive Care Unit (ICU) support. The primary cause of death was related to a surgical cause in 395 patients (52.7%) and to a medical cause in 355 patients (47.3%). The primary causes of death were advanced surgical pathology (n=292, 38.9%), complications from surgery (n=103, 13.7%), complications arising from pre-existing medical co-morbidity (n=282, 37.6%) or new medical complications unrelated to pre-existing conditions (n=73, 9.7%). Conclusions Patients who died had significant co-morbidities and often presented emergently with an advanced surgical pathology. Surgical and medical causes of death both contributed equally to the mortality burden. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-022-06534-9.
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Affiliation(s)
- Derek Mao
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Therese Rey-Conde
- Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, Brisbane, QLD, Australia
| | - John B North
- Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, Brisbane, QLD, Australia
| | - Raymond P Lancashire
- Department of General Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Sanjeev Naidu
- Department of General Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Terence C Chua
- Department of General Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia. .,School of Medicine, Griffith University, Gold Coast, QLD, Australia. .,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
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Stout A, Hamer J, Sharples T, Tahmasebi F. Less Is More: A Narrative Review of Deciding When Surgical Intervention Should Be Withheld. Cureus 2022; 14:e23285. [PMID: 35449641 PMCID: PMC9013421 DOI: 10.7759/cureus.23285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 11/05/2022] Open
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Madrazo Z, Osorio J, Videla S, Sainz B, Rodríguez-González A, Campos A, Santamaría M, Pelegrina A, González-Serrano C, Aldeano A, Sarriugarte A, Gómez-Díaz CJ, Ruiz-Luna D, García-Ruiz-de-Gordejuela A, Gómez-Gavara C, Gil-Barrionuevo M, Vila M, Clavell A, Campillo B, Millán L, Olona C, Sánchez-Cordero S, Medrano R, López-Arévalo CA, Pérez-Romero N, Artigau E, Calle M, Echenagusia V, Otero A, Tebé C, Pallarès N, Biondo S. P-POSSUM as mortality predictor in COVID-19-infected patients submitted to emergency digestive surgery. A retrospective cohort study. Int J Surg 2021; 96:106171. [PMID: 34774727 PMCID: PMC8580568 DOI: 10.1016/j.ijsu.2021.106171] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND COVID-19 infection is associated with a higher mortality rate in surgical patients, but surgical risk scores have not been validated in the emergency setting. We aimed to study the capacity for postoperative mortality prediction of the P-POSSUM score in COVID-19-positive patients submitted to emergency general and digestive surgery. MATERIAL AND METHODS Consecutive patients undergoing emergency general and digestive surgery from March to June 2020, and from March to June 2019 in 25 Spanish hospitals were included in a retrospective cohort study. MAIN OUTCOME 30-day mortality. P-POSSUM discrimination was quantified by the area under the curve (AUC) of ROC curves; calibration was assessed by linear regression slope (β estimator); and sensitivity and specificity were expressed as percentage and 95% confidence interval (CI). RESULTS 4988 patients were included: 177 COVID-19-positive; 2011 intra-pandemic COVID-19-negative; and 2800 pre-pandemic. COVID-19-positive patients were older, with higher surgical risk, more advanced pathologies, and higher P-POSSUM values (1.79% vs. 1.09%, p < 0.001, in both the COVID-19-negative and control cohort). 30-day mortality in the COVID-19-positive, intra-pandemic COVID-19-negative and pre-pandemic cohorts were: 12.9%, 4.6%, and 3.2%. The P-POSSUM predictive values in the three cohorts were, respectively: AUC 0.88 (95% CI 0.81-0.95), 0.89 (95% CI 0.87-0.92), and 0.91 (95% CI 0.88-0.93); β value 0.97 (95% CI 0.74-1.2), 0.99 (95% CI 0.82-1.16), and 0.78 (95% CI 0.74-0.82); sensitivity 83% (95% CI 61-95), 91% (95% CI 84-96), and 89% (95% CI 80-94); and specificity 81% (95% CI 74-87), 76% (95% CI 74-78), and 80% (95% CI 79-82). CONCLUSION The P-POSSUM score showed a good predictive capacity for postoperative mortality in COVID-19-positive patients submitted to emergency general and digestive surgery.
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Affiliation(s)
- Zoilo Madrazo
- Department of Surgery, Hospital Universitari de Bellvitge, L'Hospitalet del Llobregat, Barcelona, Spain Clinical Research Support Unit (HUB-IDIBELL), Clinical Pharmacology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain Department of Surgery, Complejo Hospitalario de Navarra, Pamplona, Spain Department of Surgery, Donostia University Hospital, San Sebastian, Spain Department of Surgery, Parc Taulí Health Corporation, Sabadell Hospital, Sabadell, Spain Department of Surgery, Arnau de Vilanova University Hospital, Lleida, Spain Department of Surgery, Hospital del Mar University Hospital, Barcelona, Spain Department of Surgery. Basurto University Hospital, Bilbao, Spain Department of Surgery, Granollers General Hospital, Granollers, Spain Department of Surgery, Cruces University Hospital, Bilbao, Spain Department of Surgery, Althaia Foundation, Manresa, Spain Department of Surgery, Terrassa Health Consortium, Terrassa Hospital, Terrassa, Spain General Surgery Department, Vall d'Hebrón University Hospital, Barcelona, Spain Hepatobiliopancreatic Surgery and Transplantation Department, Vall d'Hebrón University Hospital, Barcelona, Spain Department of Surgery, Viladecans Hospital, Viladecans, Spain Department of Surgery, Mataró Hospital, Maresme Health Consortium, Mataró, Spain Department of Surgery, Germans Trias i Pujol University Hospital, Badalona, Spain Department of Surgery, Sant Joan de Deu Hospital Foundation, Martorell, Spain Department of Surgery, Dr. José Molina Orosa Hospital, Lanzarote, Spain Department of Surgery, Joan XXIII University Hospital, Tarragona, Spain Department of Surgery, Igualada University Hospital, Anoia Health Consortium, Igualada, Spain Department of Surgery, Sant Pau University Hospital, Barcelona, Spain Department of Surgery. Moisès Broggi Hospital, Sant Joan Despí, Spain Department of Surgery, Mútua de Terrassa University Hospital, Terrassa, Spain Department of Surgery, Girona Dr.Josep Trueta University Hospital, Girona, Spain Department of Surgery, Alto Deba Hospital, Mondragon, San Sebastián, Spain Department of Surgery, Araba University Hospital, Txagorritxu Hospital, Vitoria, Spain Clinical Research Support Unit, Bellvitge University Hospital/Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet del Llobregat, Barcelona, Spain Biostatistics Unit of the Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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Gwilym BL, Waldron CA, Thomas-Jones E, Preece R, Milosevic S, Brookes-Howell L, Pallmann P, Harris D, Massey I, Burton J, Stewart P, Samuel K, Jones S, Cox D, Edwards A, Twine C, Bosanquet DC. The PERCEIVE quantitative study: PrEdiction of Risk and Communication of outcome following major lower-limb amputation: protocol for a collaboratiVE study. BJS Open 2021; 5:zrab118. [PMID: 34849576 PMCID: PMC8634116 DOI: 10.1093/bjsopen/zrab118] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 08/21/2021] [Accepted: 10/19/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Accurate prediction of outcomes following surgery with high morbidity and mortality rates is essential for informed shared decision-making between patients and clinicians. It is unknown how accurately healthcare professionals predict outcomes following major lower-limb amputation (MLLA). Several MLLA outcome-prediction tools have been developed. These could be valuable in clinical practice, but most require validation in independent cohorts before routine clinical use can be recommended. The primary aim of this study is to evaluate the accuracy of healthcare professionals' predictions of outcomes in adult patients undergoing MLLA for complications of chronic limb-threatening ischaemia (CLTI) or diabetes. Secondary aims include the validation of existing outcome-prediction tools. METHOD This study is an international, multicentre prospective observational study including adult patients undergoing a primary MLLA for CLTI or diabetes. Healthcare professionals' accuracy in predicting outcomes at 30-days (death, morbidity and MLLA revision) and 1-year (death, MLLA revision and ambulation) will be evaluated. Sixteen existing outcome-prediction tools specific to MLLA will be examined for validity. Data collection began on 1 October 2020; the end of follow-up will be 1 May 2022. The C-statistic, Hosmer-Lemeshow test, reclassification tables and Brier score will be used to evaluate the predictive performance of healthcare professionals and prediction tools, respectively. STUDY REGISTRATION AND DISSEMINATION This study will be registered locally at each centre in accordance with local policies before commencing data collection, overseen by local clinician leads. Results will be disseminated to all centres, and any subsequent presentation(s) and/or publication(s) will follow a collaborative co-authorship model.
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Affiliation(s)
- Brenig L Gwilym
- Gwent Vascular Institute, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, UK
| | | | | | - Ryan Preece
- Department of Vascular Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | | | | | - Debbie Harris
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Ian Massey
- Artificial Limb and Appliance Centre, Rookwood Hospital, Cardiff and Vale University Health Board, Cardiff, UK
| | - Jo Burton
- Artificial Limb and Appliance Centre, Rookwood Hospital, Cardiff and Vale University Health Board, Cardiff, UK
| | - Philippa Stewart
- Artificial Limb and Appliance Centre, Rookwood Hospital, Cardiff and Vale University Health Board, Cardiff, UK
| | - Katie Samuel
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | - Sian Jones
- C/O INVOLVE Health and Care Research Wales, Cardiff, UK
| | - David Cox
- C/O INVOLVE Health and Care Research Wales, Cardiff, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Chris Twine
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - David C Bosanquet
- Gwent Vascular Institute, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, UK
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Madrazo Z, Osorio J, Otero A, Biondo S, Videla S. Postoperative complications and mortality following emergency digestive surgery during the COVID-19 pandemic: A multicenter collaborative retrospective cohort study protocol (COVID-CIR). Medicine (Baltimore) 2021; 100:e24409. [PMID: 33592888 PMCID: PMC7870207 DOI: 10.1097/md.0000000000024409] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/25/2020] [Accepted: 01/04/2021] [Indexed: 01/19/2023] Open
Abstract
ABSTRACT Infection with the SARS-CoV-2 virus seems to contribute significantly to increased postoperative complications and mortality after emergency surgical procedures. Additionally, the fear of COVID-19 contagion delays the consultation of patients, resulting in the deterioration of their acute diseases by the time of consultation. In the specific case of urgent digestive surgery patients, both factors significantly worsen the postoperative course and prognosis. Main working hypothesis: infection by COVID-19 increases postoperative 30-day-mortality for any cause in patients submitted to emergency/urgent general or gastrointestinal surgery. Likewise, hospital collapse during the first wave of the COVID-19 pandemic increased 30-day-mortality for any cause. Hence, the main objective of this study is to estimate the cumulative incidence of mortality at 30-days-after-surgery. Secondary objectives are: to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for COVID-19-infected patients.A multicenter, observational retrospective cohort study (COVID-CIR-study) will be carried out in consecutive patients operated on for urgent digestive pathology. Two cohorts will be defined: the "pandemic" cohort, which will include all patients (classified as COVID-19-positive or -negative) operated on for emergency digestive pathology during the months of March to June 2020; and the "control" cohort, which will include all patients operated on for emergency digestive pathology during the months of March to June 2019. Information will be gathered on demographic characteristics, clinical and analytical parameters, scores on the usual prognostic scales for quality management in a General Surgery service (POSSUM, P-POSSUM and LUCENTUM scores), prognostic factors applicable to all patients, specific prognostic factors for patients infected with SARS-CoV-2, postoperative morbidity and mortality (at 30 and 90 postoperative days). The main objective is to estimate the cumulative incidence of mortality at 30 days after surgery. As secondary objectives, to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for SARS-CoV-2 infected patients.The protocol (version1.0, April 20th 2020) was approved by the local Institutional Review Board (Ethic-and-Clinical-Investigation-Committee, code PR169/20, date 05/05/20). The study findings will be submitted to peer-reviewed journals and presented at relevant national and international scientific meetings.ClinicalTrials.gov Identifier: NCT04479150 (July 21, 2020).
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Affiliation(s)
- Zoilo Madrazo
- Department of General and Digestive Surgery, Bellvitge University Hospital
| | - Javier Osorio
- Department of General and Digestive Surgery, Bellvitge University Hospital
| | - Aurema Otero
- Clinical Research Support Unit, Clinical Pharmacology Department, Bellvitge University Hospital/Bellvitge Biomedical Research Institute (IDIBELL)
| | - Sebastiano Biondo
- Department of General and Digestive Surgery, Bellvitge University Hospital
| | - Sebastian Videla
- Clinical Research Support Unit, Clinical Pharmacology Department, Bellvitge University Hospital/Bellvitge Biomedical Research Institute (IDIBELL)
- Department of Pathology and Experimental Therapeutics, Faculty of Medicine, Universitat de Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain
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Petring Hasselager R, Foss NB, Andersen O, Cihoric M, Bay‐Nielsen M, Nielsen HJ, Camilla Andresen L, Toft Tengberg L. Mortality and major complications after emergency laparotomy: A pilot study of risk prediction model development by preoperative blood-based immune parameters. Acta Anaesthesiol Scand 2021; 65:151-161. [PMID: 33108695 DOI: 10.1111/aas.13722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 09/04/2020] [Accepted: 09/28/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Emergency laparotomy is associated with high risk of postoperative complications and mortality. Preoperative identification of patients at high risk of adverse outcome is important. The immune response to conditions requiring emergency laparotomy is not understood in detail. The present study describes preoperative blood-based immune profiles and their potential value in surgical risk assessment. METHOD Patients (N = 100) referred for emergency laparotomy at Hvidovre Hospital were consecutively included from 3 June 2013-11 April 2014. All patients had blood samples collected before surgery and the immune parameters c-reactive protein (CRP), Interleukin-6 (IL-6), Interleukin-10 (IL-10), interferon-γ induced protein 10 kDa (IP-10), tumor necrosis factor α (TNF-α) and soluble urokinase plasminogen receptor activator (suPAR) were determined. Patients were stratified according to major postoperative complications (including death), 30- and 180-day mortality. Using logistic regression models and receiver operating characteristics curves the predictive ability of the immune parameters were estimated. RESULTS Major complications were recorded in 45 (45.0%) of the patients, whereas 30-day and 180-day mortalities were 17 (17.0%) and 25 (25.0%), respectively. Concentrations of suPAR and TNF-α were associated with major complications while CRP, IL-6, suPAR and TNF-α were associated with mortality. Adding the combined immune parameters to a regression model including age, sex, American Society of Anesthesiologists physical status and Eastern Cooperative Oncology Group Performance Status significantly improved the predictive ability for major complications, 30-day mortality and 180-day mortality. CONCLUSION In emergency laparotomy, preoperative blood-based immune parameters added predictive power to regression models and could be considered in risk prediction model development.
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Affiliation(s)
| | - Nicolai Bang Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital Hvidovre Denmark
| | - Ove Andersen
- Department of Clinical Research and the Emergency Department Hvidovre Hospital Hvidovre Denmark
| | - Mirjana Cihoric
- Department of Anesthesiology and Intensive Care Hvidovre Hospital Hvidovre Denmark
| | - Morten Bay‐Nielsen
- Department of Surgery Bispebjerg and Frederiksberg Hospital Copenhagen Denmark
| | - Hans J. Nielsen
- Department of Surgical Gastroenterology 360 Hvidovre Hospital Hvidovre Denmark
| | - Linda Camilla Andresen
- Department of Clinical Research and the Emergency Department Hvidovre Hospital Hvidovre Denmark
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Dilaver NM, Gwilym BL, Preece R, Twine CP, Bosanquet DC. Systematic review and narrative synthesis of surgeons' perception of postoperative outcomes and risk. BJS Open 2019; 4:16-26. [PMID: 32011813 PMCID: PMC6996626 DOI: 10.1002/bjs5.50233] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The accuracy with which surgeons can predict outcomes following surgery has not been explored in a systematic way. The aim of this review was to determine how accurately a surgeon's 'gut feeling' or perception of risk correlates with patient outcomes and available risk scoring systems. METHODS A systematic review was undertaken in accordance with PRISMA guidelines. A narrative synthesis was performed in accordance with the Guidance on the Conduct of Narrative Synthesis In Systematic Reviews. Studies comparing surgeons' preoperative or postoperative assessment of patient outcomes were included. Studies that made comparisons with risk scoring tools were also included. Outcomes evaluated were postoperative mortality, general and operation-specific morbidity and long-term outcomes. RESULTS Twenty-seven studies comprising 20 898 patients undergoing general, gastrointestinal, cardiothoracic, orthopaedic, vascular, urology, endocrine and neurosurgical operations were included. Surgeons consistently overpredicted mortality rates and were outperformed by existing risk scoring tools in six of seven studies comparing area under receiver operating characteristic (ROC) curves (AUC). Surgeons' prediction of general morbidity was good, and was equivalent to, or better than, pre-existing risk prediction models. Long-term outcomes were poorly predicted by surgeons, with AUC values ranging from 0·51 to 0·75. Four of five studies found postoperative risk estimates to be more accurate than those made before surgery. CONCLUSION Surgeons consistently overestimate mortality risk and are outperformed by pre-existing tools; prediction of longer-term outcomes is also poor. Surgeons should consider the use of risk prediction tools when available to inform clinical decision-making.
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Affiliation(s)
- N M Dilaver
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK.,Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - B L Gwilym
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
| | - R Preece
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - C P Twine
- Division of Population Medicine, Cardiff University, Cardiff, UK.,Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - D C Bosanquet
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
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Simpson G, Saunders R, Wilson J, Magee C. The role of the neutrophil:lymphocyte ratio (NLR) and the CRP:albumin ratio (CAR) in predicting mortality following emergency laparotomy in the over 80 age group. Eur J Trauma Emerg Surg 2017; 44:877-882. [PMID: 29134253 DOI: 10.1007/s00068-017-0869-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Emergency laparotomy in the elderly is an increasingly common procedure which carries high morbidity and mortality. Risk prediction tools, although imperfect, can help guide management decisions. Novel markers of surgical outcomes may contribute to these scoring systems. The neutrophil:lymphocyte ratio (NLR) and CRP:albumin ratio (CAR) have been associated with outcomes in malignancy and sepsis. We assessed the use of ratio NLR and CAR as prognostic indicators in patients over the age of 80 undergoing emergency laparotomy. METHODS A retrospective analysis of all patients over the age of 80 who underwent emergency laparotomy during a 3 year period was conducted. Pre and post-operative NLR and CAR were assessed in relation to outcome measures including inpatient, 30-day and 90-day mortality. Statistical analysis was conducted with Mann-Whitney U, receiver operating characteristics, Spearmans rank correlation coefficient and chi-squared tests. RESULTS One hundred and thirty-six patients over the age of 80 underwent emergency laparotomy. Median age was 84 years (range 80-96 years). Overall inpatient mortality was 19.2%. Pre-operative and post-operative NLR and CAR were significantly raised in patients with sepsis v no sepsis (p < 0.05). Pre-operative NLR was significantly associated with inpatient (p = 0.046), 30-day (p = 0.02) and 90-day mortality (p = 0.01) in patients with visceral perforation. A pre-operative NLR value of greater than 8 was associated with significantly increased mortality (p = 0.016, AUC:0.78). CAR was not associated with mortality. CONCLUSION Pre-operative NLR is associated with mortality in patients with visceral perforation undergoing emergency laparotomy. NLR > 8 is associated with a poorer outcome in this group of patients. CAR was not associated with mortality in over-80s undergoing emergency laparotomy.
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Affiliation(s)
- G Simpson
- Division of GI Surgery, Wirral University Teaching Hospitals, Wirral, UK
| | - R Saunders
- University of Liverpool Division of Oncology and Surgery, Liverpool, UK
| | - J Wilson
- Division of GI Surgery, Wirral University Teaching Hospitals, Wirral, UK
| | - C Magee
- Division of GI Surgery, Wirral University Teaching Hospitals, Wirral, UK.
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Olufajo OA, Reznor G, Lipsitz SR, Cooper ZR, Haider AH, Salim A, Rangel EL. Preoperative assessment of surgical risk: creation of a scoring tool to estimate 1-year mortality after emergency abdominal surgery in the elderly patient. Am J Surg 2016; 213:771-777.e1. [PMID: 27743591 DOI: 10.1016/j.amjsurg.2016.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/07/2016] [Accepted: 08/07/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND The risk of mortality after emergency general surgery (EGS) in elderly patients is prolonged beyond initial hospitalization. Our objective was to develop a preoperative scoring tool to quantify risk of 1-year mortality. METHODS Three hundred ninety EGS patients aged 70 years or more were analyzed. Risk factors for 1-year mortality were identified using stepwise-forward logistic multivariate regression and weights assigned using natural logarithm of odds ratios. A geriatric emergency surgery mortality (GEM) score was derived from the aggregate of weighted scores. Leave-one-out cross-validation was performed. RESULTS One-year mortality was 32%. Risk factors and their weights were: acute kidney injury (2), American Society of Anesthesiology class greater than or equal to 4 (2), Charlson Comorbidity Index greater than or equal to 4 (1), albumin less than 3.5 mg/dL (1), and body mass index (less than 18.5 kg/m2 [1]; 18.5 to 29.9 kg/m2 [0]; ≥30 kg/m2 [-1]). One-year mortality was: GEM 0 to 1 (0% to 7%); GEM 2 to 5 (32% to 68%); GEM 6 to 8 (94% to 100%). C-statistics were .82 and .75 in training and validation data sets, respectively. CONCLUSIONS A simple score using 5 clinical variables predicts 1-year mortality after EGS with reasonable accuracy and assists in preoperative counseling.
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Affiliation(s)
- Olubode A Olufajo
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Gally Reznor
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Zara R Cooper
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Adil H Haider
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Erika L Rangel
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA.
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12
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Laor A, Tal S, Guller V, Zbar AP, Mavor E. The Charlson Comorbidity Index (CCI) as a Mortality Predictor after Surgery in Elderly Patients. Am Surg 2016. [DOI: 10.1177/000313481608200113] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The increasing range of surgery in elderly patients reflects the changing demography where in the next 10 years one quarter of the population will be 65 years of age or older. There is presently no consensus concerning the optimal predictive markers for postoperative morbidity and mortality after surgery in older patients with an appreciation that physical frailty is more important than chronological age. In this retrospective analysis, we have compared the impact of age and the calculated preoperative Charlson Comorbidity Index (CCI) on early (30-day) and late (one-year) mortality in a group of patients >75 years of age dividing them into an “older old” cohort (75–84 years of age, Group A) and an “oldest old” group (≥85 years of age, Group B). Increased age was associated with a higher death rate after emergency surgery, with late deaths after elective surgery exceeding those after emergency operations. A higher mean CCI was noted in both age groups in early nonsurvivors after both elective and emergency surgery with a more significant effect of the preoperative CCI than chronological age for the prediction of late postoperative death for both groups after elective and emergency operations. Although the CCI was not designed to predict perioperative mortality in surgical cohorts, it correlates with a greater risk than age for perioperative death in the elderly.
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Affiliation(s)
- Anat Laor
- Department of Surgery, Kaplan Medical Center, Rehovot, Israel (Affiliated with the Hebrew University of Jerusalem)
| | - Sari Tal
- Department of Geriatrics, Kaplan Medical Center, Rehovot, Israel (Affiliated with the Hebrew University of Jerusalem)
| | - Vladimir Guller
- Department of Geriatrics, Kaplan Medical Center, Rehovot, Israel (Affiliated with the Hebrew University of Jerusalem)
| | - Andrew P. Zbar
- Department of Surgery, Kaplan Medical Center, Rehovot, Israel (Affiliated with the Hebrew University of Jerusalem)
- Department of Anatomy, School of Medical Sciences and Center for Bioengineering and Nanomedicine, University of Otago, Dunedin, New Zealand
| | - Eli Mavor
- Department of Surgery, Kaplan Medical Center, Rehovot, Israel (Affiliated with the Hebrew University of Jerusalem)
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13
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Abstract
Emergency abdominal surgery has a high mortality, with an incidence of around 15% for all patients. Mortality in elderly patients is up to 25%, and 1-year mortality for emergent colorectal resection for patients over 80 years is around 50%. Patients presenting to hospital are often given low priority. Definitive surgery is not always possible and it may be more important to control the septic focus and to revisit surgery later. The literature is poor for such a common procedure, but there is evidence that a standardized pathway focusing on rapid diagnosis; resuscitation; sepsis treatment; and, if appropriate, urgent surgery followed by admission to intensive care improves outcomes.
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Affiliation(s)
- Carol Peden
- Royal United Hospital, Combe Park, Bath BA1 3NG, UK.
| | - Michael J Scott
- Department of Anesthesia and Perioperative Medicine, Royal Surrey County Hospital NHS Foundation Trust, Surrey, Guildford GU1 7XX, UK; Surrey Perioperative Anesthesia Critical Care Research Group (SPACeR), University of Surrey, Surrey, Guildford GU2 7XH, UK
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14
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Mortality after emergency surgery continues to rise after discharge in the elderly: Predictors of 1-year mortality. J Trauma Acute Care Surg 2015; 79:349-58. [PMID: 26307865 DOI: 10.1097/ta.0000000000000773] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND It is known that emergency surgery in the elderly is associated with high short-term mortality, but longer-term outcomes are not well described. We hypothesized that 30-day mortality may underestimate the true operative mortality experienced in this cohort. The purposes of this study were to characterize postoperative mortality rates extending to 1 year and to identify preoperative predictors of 1 year mortality after emergency abdominal surgery. METHODS We retrospectively reviewed the records of all patients older than 70 years who underwent emergency abdominal surgery at a major teaching hospital between 2006 and 2011. Demographics, preoperative physiology, prehospital status, body mass index, laboratory values, Charlson scores, comorbid conditions, American Society of Anesthesiologists classification, and operative details were recorded. The primary end point was 1-year mortality. Complementary log-log binary regression was used to determine independent predictors of death. Model discrimination was evaluated using the c statistic. RESULTS A total of 390 patients met our inclusion criteria. The mean age was 79 years, and 56% were women. Postoperative mortality was 16.2% at 30 days and 32.5% at 1 year, reflecting a doubling of mortality over 11 months. Independent preoperative predictors of 1-year mortality were Charlson score of 4 or higher (hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.38-2.34), American Society of Anesthesiologists class of 4 or higher (HR, 1.66; 95% CI, 1.22-2.21), albumin less than 3.5 (HR, 1.71; 95% CI, 1.31-2.28), and body mass index lower than 18.5 (HR, 3.36; 95% CI, 1.48-6.86). The c statistic was 0.81. CONCLUSION The 1-year mortality after emergency surgery in the elderly is significantly higher than that at 30 days. We identified a constellation of preoperative clinical markers that were highly predictive of this poor late outcome. The presence of these findings in the emergency setting should prompt preoperative discussion about treatment goals and encourage surgeons to set realistic expectations about outcomes with the patient and family. Future studies will develop a clinical scoring tool that can be applied at the bedside to provide more effective counseling for this high-risk population. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III; therapeutic study, level IV.
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15
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Kim SH, Kil HK, Kim HJ, Koo BN. Risk Assessment of Mortality Following Intraoperative Cardiac Arrest Using POSSUM and P-POSSUM in Adults Undergoing Non-Cardiac Surgery. Yonsei Med J 2015; 56:1401-7. [PMID: 26256987 PMCID: PMC4541674 DOI: 10.3349/ymj.2015.56.5.1401] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 10/20/2014] [Accepted: 10/27/2014] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) and its Portsmouth modification (P-POSSUM) are comprehensive assessment methods for evaluating patient and surgical factors widely used to predict 30-day mortality rates. In this retrospective study, we evaluated the usefulness of POSSUM and P-POSSUM in predicting 30-day mortality after intraoperative cardiac arrests in adult patients undergoing non-cardiac surgery. MATERIALS AND METHODS Among 190486 patients who underwent anesthesia, 51 experienced intraoperative cardiac arrest as defined in our study protocol. Predicted mortality rates were calculated using POSSUM and P-POSSUM equations and were compared with actual outcomes using exponential and linear analyses. In addition, a receiver operating characteristic curve analysis was undertaken, and area-under-the-curve (AUC) values with confidence intervals (CIs) were calculated for POSSUM and P-POSSUM. RESULTS Among the 51 patients with intraoperative cardiac arrest, 32 (62.7%) died within 30 days postoperatively. The overall predicted 30-day mortality rates using POSSUM and P-POSSUM were 65.5% and 57.5%, respectively. The observed-to-predicted (O:E) ratio for the POSSUM 30-day mortality was 1.07, with no significant difference between the observed and predicted values (χ²=4.794; p=0.779). P-POSSUM predicted mortality equally well, with an O:E ratio of 1.10 (χ²=8.905; p=0.350). AUC values (95% CI) were 0.771 (0.634-0.908) and 0.785 (0.651-0.918) for POSSUM and P-POSSUM, respectively. CONCLUSION Both POSSUM and P-POSSUM performed well to predict overall 30-day mortality following intraoperative cardiac arrest in adults undergoing non-cardiac surgery at a university teaching hospital in Korea.
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Affiliation(s)
- Shin Hyung Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hae Keum Kil
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Jin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Bon Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Moonesinghe SR, Mythen MG, Das P, Rowan KM, Grocott MPW. Risk stratification tools for predicting morbidity and mortality in adult patients undergoing major surgery: qualitative systematic review. Anesthesiology 2014; 119:959-81. [PMID: 24195875 DOI: 10.1097/aln.0b013e3182a4e94d] [Citation(s) in RCA: 221] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Risk stratification is essential for both clinical risk prediction and comparative audit. There are a variety of risk stratification tools available for use in major noncardiac surgery, but their discrimination and calibration have not previously been systematically reviewed in heterogeneous patient cohorts.Embase, MEDLINE, and Web of Science were searched for studies published between January 1, 1980 and August 6, 2011 in adult patients undergoing major noncardiac, nonneurological surgery. Twenty-seven studies evaluating 34 risk stratification tools were identified which met inclusion criteria. The Portsmouth-Physiology and Operative Severity Score for the enUmeration of Mortality and the Surgical Risk Scale were demonstrated to be the most consistently accurate tools that have been validated in multiple studies; however, both have limitations. Future work should focus on further evaluation of these and other parsimonious risk predictors, including validation in international cohorts. There is also a need for studies examining the impact that the use of these tools has on clinical decision making and patient outcome.
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Affiliation(s)
- Suneetha Ramani Moonesinghe
- * Director, University College London, University College London Hospitals' Surgical Outcomes Research Center, London, United Kingdom; Honorary Senior Lecturer, University College London; and Consultant, Anaesthesia and Critical Care, University College Hospital. † Professor, Smiths Medical Professor of Anaesthesia and Critical Care, University College London; and Honorary Consultant, Anaesthesia, University College Hospital. ‡ Research Fellow, University College London, University College London Hospitals' Surgical Outcomes Research Center, University College Hospital. § Professor and Director, Intensive Care National Audit and Research Center, London, United Kingdom. ‖ Professor of Critical Care Medicine, University of Southampton, Southampton, United Kingdom; Honorary Consultant, Critical Care, Southampton University Hospital; and Director, National Institute for Academic Anaesthesia's Health Services Research Center, London, United Kingdom
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17
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Hirose J, Taniwaki T, Fujimoto T, Okada T, Nakamura T, Okamoto N, Usuku K, Mizuta H. Predictive value of E-PASS and POSSUM systems for postoperative risk assessment of spinal surgery. J Neurosurg Spine 2014; 20:75-82. [DOI: 10.3171/2013.9.spine12671] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Jun Hirose
- 1Departments of Orthopaedic Surgery and
- 2Medical Information Science and Administration Planning, Kumamoto University Hospital, Kumamoto, Japan
| | | | | | | | | | | | - Koichiro Usuku
- 2Medical Information Science and Administration Planning, Kumamoto University Hospital, Kumamoto, Japan
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Matsuyama T, Iranami H, Fujii K, Inoue M, Nakagawa R, Kawashima K. Risk factors for postoperative mortality and morbidities in emergency surgeries. J Anesth 2013; 27:838-43. [PMID: 23700220 DOI: 10.1007/s00540-013-1639-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 05/08/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Emergency surgery itself induces high risk for postoperative mortality and morbidities; however, it remains unknown which concomitant pathological conditions of emergency surgeries are causative factors of deteriorating outcomes. This study examined the causal factors of postoperative mortality and morbidity in cases of emergency surgery. METHODS Patients undergoing emergency surgery from January to December 2007 were enrolled in this retrospective cohort study. Causal relationships were analyzed by stepwise multivariate logistic regression analysis between possible independent factors (sex, age, kind of surgical department, timing of surgery, duration of surgery, blood transfusion, deteriorated consciousness level, shock state, abnormal coagulate state, and history of hypertension, diabetes, ischemic heart disease, chronic obstructive pulmonary disease, renal failure, and anemia) and postoperative mortality or morbidities (failure of removal of tracheal tube after operation, tracheotomy, cerebral infarction, massive hemorrhage, severe hypotension, severe hypoxemia, and severe arrhythmia during or after surgery). RESULTS Shock, deteriorated consciousness level, chronic obstructive lung disease, and ischemic heart disease were significant risk factors for mortality (OR 14.2, 7.9, 6.4, and 3.8, respectively), and deteriorated consciousness level, blood transfusion, shock, chronic obstructive lung disease, diabetes, cardiovascular surgery, and operation longer than 2 h were significant risk factors for morbidity (OR 19.1, 3.3, 3.0, 2.5, 2.4, 2.4, and 1.8, respectively). CONCLUSION State of shock, deteriorated consciousness level, chronic obstructive lung disease, ischemic heart disease, hemorrhage requiring blood transfusion, age over 80 years, cardiovascular surgery, surgeries at night, and surgeries of duration more than 2 h cause patients to be strongly susceptible to postoperative mortality or morbidity in emergency surgeries.
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Affiliation(s)
- Tomonori Matsuyama
- Department of Anesthesia, Kyoto University Hospital, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
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Rymaruk S. Emergency laparotomy in high risk general surgical patients: a review of perioperative care. J Perioper Pract 2013; 22:349-53. [PMID: 23311015 DOI: 10.1177/175045891602201101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
High risk general surgical patients account for the largest proportion of surgical deaths. There is concern from the Royal College of Surgeons of England (RCSEng) and National Confidential Enquiry into Patient Outcome and Death (NCEPOD) that these patients may receive suboptimal care. Patients undergoing an emergency laparotomy were identified and the notes reviewed; patients had high observed and predicted mortalities. Consultant involvement, patient consent and nutritional planning were all assessed. An agreed method of patient identification and quantification of risk was recommended. The use of an emergency laparotomy proforma was suggested.
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20
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Pelavski AD, Lacasta A, de Miguel M, Rochera MI, Roca M. Mortality and surgical risk assessment among the extreme old undergoing emergency surgery. Am J Surg 2013; 205:58-63. [DOI: 10.1016/j.amjsurg.2012.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 03/05/2012] [Accepted: 03/05/2012] [Indexed: 11/27/2022]
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Al-Temimi MH, Griffee M, Enniss TM, Preston R, Vargo D, Overton S, Kimball E, Barton R, Nirula R. When is death inevitable after emergency laparotomy? Analysis of the American College of Surgeons National Surgical Quality Improvement Program database. J Am Coll Surg 2012; 215:503-11. [PMID: 22789546 DOI: 10.1016/j.jamcollsurg.2012.06.004] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 05/11/2012] [Accepted: 06/08/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND In an era of increasing demands to provide high-quality health care, surgeons need an accurate preoperative risk assessment tool to facilitate informed decision-making for themselves and their patients. Emergency laparotomy procedures have a high risk profile, but the currently available risk-assessment models for emergency laparotomy are either unreliable (eg, small sample size or single center study), difficult to calculate preoperatively, or are specific to the geriatric population. STUDY DESIGN The American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2009) was used to develop logistic regression models for 30-day mortality after emergency laparotomy. Two models were created, one with the knowledge of the postoperative diagnosis and one without. Models' calibration and discrimination were judged using the receiver operating characteristics curves and the Hosmer-Lemeshow test. RESULTS There were 37,553 patients who had undergone emergency laparotomy, with a 14% mortality rate. The American Society of Anesthesiologists classification system, functional status, sepsis, and age were the variables most significantly associated with mortality. Patients older than 90 years of age, with an American Society of Anesthesiologists class V, septic shock, dependent functional status, and abnormal white blood cell count have a <10% probability of survival. CONCLUSIONS The models developed in this study have a high discriminative ability to stratify the operative risk in a broad range of acute abdominal emergencies. These data will assist surgeons, patients, and their families in making end-of-life decisions in the face of medical futility with greater certainty when emergency surgery is being contemplated.
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Affiliation(s)
- Mohammed H Al-Temimi
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT 84132, USA
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Worku B, Naka Y, Pak SW, Cheema FH, Siddiqui OT, Jain J, Uriel N, Bhatt R, Colombo P, Jorde U, Takayama H. Predictors of Mortality After Short-Term Ventricular Assist Device Placement. Ann Thorac Surg 2011; 92:1608-12; discussion 1612-3. [DOI: 10.1016/j.athoracsur.2011.06.093] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 06/27/2011] [Accepted: 06/29/2011] [Indexed: 10/15/2022]
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Kumar S, Gupta A, Chaudhary S, Agrawal N. Validation of the use of POSSUM score in enteric perforation peritonitis - results of a prospective study. Pan Afr Med J 2011; 9:22. [PMID: 22145058 PMCID: PMC3215544 DOI: 10.4314/pamj.v9i1.71197] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Accepted: 03/28/2011] [Indexed: 11/17/2022] Open
Abstract
Introduction The objective of the study was to present our last 5-years experience of peritonitis and validate POSSUM score in predicting mortality and morbidity in patients of enteric perforation (EP) peritonitis. Methods Data was collected prospectively for all peritonitis cases admitted in single surgical unit from January 2005 to December 2009. Parameters for calculating POSSUM were also retrieved; in these patients, O:E (Observed vs. Expected) ratio of mortality and morbidity were estimated after calculating predicted mortality and morbidity by exponential regression equations. Results 887 patients with peritonitis were admitted and treated in this unit during the 5 years of study period. Duodenal (n=431; 48%) followed by ileal (n=380; 42.8%) perforations were the commonest. Mean age of the patients was 34 years and 86% were males. Mean delay in presentation was 78.5 hrs. Mean duration of hospital and ICU stay was 13 and 7.2 days. Postoperative complications were seen in 481 (54%) patients, and 90 (10%) patients died. POSSUM scores and predicted mortality/morbidity were calculated in 380 patients of ileal perforation peritonitis; O:E ratio of mortality and morbidity were 0.47 and 0.85 in these patients. Conclusion POSSUM and P-POSSUM are accurate tools for predicting morbidity and mortality respectively in EP patients. Though they may sometime over or under predict morbidity as well as mortality.
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Affiliation(s)
- Sunil Kumar
- Department of Surgery, University College of Medical Sciences and associated Guru Teg Bahadur Hospital, New Delhi-110095, India
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Kodama A, Narita H, Kobayashi M, Yamamoto K, Komori K. Usefulness of POSSUM physiological score for the estimation of morbidity and mortality risk after elective abdominal aortic aneurysm repair in Japan. Circ J 2011; 75:550-6. [PMID: 21282877 DOI: 10.1253/circj.cj-09-0576] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM), which consists of a physiological score (PS) and an operative severity score, is useful in determining the risk profile for patients with abdominal aortic aneurysms in Western countries, but no information is available on the use of this method in Japan. METHODS AND RESULTS A retrospective cohort study involving 225 patients was performed, and the prognostic factors for morbidity and in-hospital mortality including POSSUM were investigated. The morbidity rate was 26%. On univariate analysis age, renal disease, hemoglobin, albumin, operation time, blood loss and PS were significantly different. On multivariate analysis PS was significantly different. Using receiver operating characteristic (ROC) analysis, PS had an area under the curve (AUC) of 0.712 and the best cut-off point was 18. The in-hospital mortality rate was 2.2%. On univariate analysis renal disease, albumin and PS were significantly different, and on multivariate analysis PS was significantly different. On ROC analysis PS had an AUC of 0.921 and the best cut-off point was 22. CONCLUSIONS PS was the only independent risk factor for morbidity and in-hospital mortality. Further studies may be required to develop a risk-scoring system.
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Affiliation(s)
- Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
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Trauma intensive care unit survival: how good is an educated guess? ACTA ACUST UNITED AC 2010; 68:1279-87; discussion 1287-8. [PMID: 20539170 DOI: 10.1097/ta.0b013e3181de3b99] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resource utilization in medicine is becoming a more and more urgent issue with ongoing national discussions on healthcare coverage. In the management of a trauma system, large amounts of resources and money are expended on individual patients in hope of a "great save." In addition, those of us caring for these patients are required to estimate outcomes daily to the family in an effort to choose the best course of care for an individual patient. Hence, we undertook a study to analyze the accuracy of outcomes predictions of various members of the healthcare team. METHODS During a period of 38 months (July 2005 to August 2008), an observational study of patients admitted to a Level I Trauma Center Intensive Care Unit (ICU) was undertaken. Institutional Review Board permission was obtained before starting the study. Only patients older than 18 years were included. Patients who were moribund or expected discharge within 72 hours were excluded.Our traumatized ICU patients are cared for by a multidisciplinary team consisting of a trauma/ICU attending, all of whom have additional certification in surgical critical care and who rotate through the ICU on a weekly basis, a surgical ICU fellow, residents and medical students of several levels of training who rotate on a monthly basis, trauma advanced-level practitioners who rotate weekly, and bedside ICU nurses who work routine shifts. Respiratory therapists, nutritionists, ICU pharmacists, and other members of the rounding team were not included in the study because they do not provide global patient care. Regardless of admitting physician, the patients are managed by the team, and our practice of care is similar across the group, based on protocols and consensus.For each of the study patients, a survey tool was filled out by the ICU rounding team on hospital day 1 and hospital day 3. The tool was completed by members of the team providing global care to the patient and varied depending on the members of the group at each day's rounds. All current and admission data on injuries, study and laboratory results, and current patient status were available to all members of the team. Each member was expected to fill out the survey tool independently, and the results of the tool were not discussed during rounds.Concurrently, data were collected by the ICU fellow and research nurse. These data and the results of the survey tools were entered in a database for analysis after patient discharge. A retrospective analysis was undertaken to analyze the relative accuracy of the care, team members' assessment, and actual survival. Statistical analysis was done using by-chance accuracy comparisons. RESULTS Two hundred twenty-three patients had 326 observations performed. Day 3 accuracy improved for most groups. In all groups, accuracy was found to be statistically significantly better than by-chance accuracy. Given that the majority of patients in the trauma population are survivors, sensitivity and positive predictive value of the observer's ability to predict death were also evaluated. CONCLUSIONS Although significantly better than chance prediction, the ability of members of the ICU team to predict survival of trauma patients remains poor, particularly on initial evaluation. A period of clinical observation improves the accuracy. Unfortunately, experience of the observer does not seem to improve accuracy of survival prediction. This data indicate that care must be taken when describing likely outcomes to patient family members.
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Pasternak I, Dietrich M, Woodman R, Metzger U, Wattchow DA, Zingg U. Use of severity classification systems in the surgical decision-making process in emergency laparotomy for perforated diverticulitis. Int J Colorectal Dis 2010; 25:463-70. [PMID: 20091171 DOI: 10.1007/s00384-009-0852-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE Hartman's procedure (HP) or primary anastomosis (PA) are the two surgical techniques used in patients undergoing emergency colectomy for perforated diverticulitis. There are no objective criteria to guide the surgeon's choice of procedure. This study assesses whether classification and scoring systems can be used in the decision-making process. METHODS One hundred eleven patients undergoing emergency laparotomy for perforated diverticulitis were analyzed. Logistic regression and interaction models were used to determine the predictive value in the two settings. RESULTS Sixty five patients underwent HP and 46 patients underwent PA. Patients with HP had significantly higher scores, median age, and were more often on immunosuppressive medication. Mortality and surgical morbidity did not differ between the groups. The clinical anastomotic leak rate was 28.3% in the PA group. In the univariate logistic regression for in-hospital death, all scores showed a significant influence. The multivariate logistic regression analysis showed that only Charlson comorbidity index (CCI) and American Society of Anesthesiologists score had a significant influence on mortality. Each score was analyzed for its predictive value regarding mortality and morbidity with respect to type of operative procedure. Only CCI revealed a trend towards statistical significance. The risk of death increases with increasing CCI when PA is performed compared to HP. CONCLUSION None of the tested scores can be used to help the surgeon decide whether a PA or HP is appropriate in a specific patient. Comorbidity, represented as CCI in this study, might be more important than the locoregional situation.
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Affiliation(s)
- Itai Pasternak
- Department of Surgery, Triemli Hospital, 8063 Zurich, Switzerland
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Rix TE, Bates T. Pre-operative risk scores for the prediction of outcome in elderly people who require emergency surgery. World J Emerg Surg 2007; 2:16. [PMID: 17550623 PMCID: PMC1894959 DOI: 10.1186/1749-7922-2-16] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Accepted: 06/05/2007] [Indexed: 02/08/2023] Open
Abstract
Background The decision on whether to operate on a sick elderly person with an intra-abdominal emergency is one of the most difficult in general surgery. A predictive risk-score would be of great value in this situation. Methods A Medline search was performed to identify those predictive risk-scores relevant to sick elderly patients in whom emergency surgery might be life-saving. Results Many of the risk scores for surgical patients include the operative findings or require tests which are not available in the acute situation. Most of the relevant studies include younger patients and elective surgery. The Glasgow Aneurysm Score and Hardman Index are specific to ruptured aortic aneurysm while the Boey Score and the Hacetteppe Score are specific to perforated peptic ulcer. The Reiss Index and Fitness Score can be used pre-operatively if the elements of the score can be completed in time. The ASA score, which includes a significant element of subjective clinical judgement, can be augmented with factors such as age and urgency of surgery but no test has a negative predictive value sufficient to recommend against surgical intervention without clinical input. Conclusion Risk scores may be helpful in sick elderly patients needing emergency abdominal surgery but an experienced clinical opinion is still essential.
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Affiliation(s)
- Thomas E Rix
- Department of General Surgery, Eastbourne District General Hospital, Eastbourne, East Sussex, BN21 2UD, UK
| | - Tom Bates
- Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, Kent, CT2 7PD, UK
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