|Year : 2021 | Volume
| Issue : 2 | Page : 85-90
Validation of surgical APGAR score in abdominal surgeries at a tertiary care teaching hospital in South India
K Yadhu Bhushanam, Aloka Samantaray, Kaarthika Thottikat, Hemalatha Pasupuleti, R Sri Devi, Mangu Hanumantha Rao, Sumadhu Chukkaluru
Department of Anaesthesiology and Critical Care Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
|Date of Submission||29-Apr-2020|
|Date of Decision||09-Sep-2020|
|Date of Acceptance||01-Feb-2021|
|Date of Web Publication||17-Jul-2021|
Professor and HOD, Department of Anaesthesiology and Critical Care Medicine, Sri Venkateswara Institute of Medical Sciences, Alipiri Road, Tirupati - 517 507, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: A ten-point surgical APGAR score (SAS) has been previously developed and validated that provides surgeons with a simple, objective and direct rating of operative performance and risk. This score has been evaluated in different types of surgeries till date. We validated SAS in both elective and emergency abdominal surgeries separately which was not done previously.
Methods: In this prospective, observational and longitudinal study, 105 surgical cases undergoing open abdominal surgeries were studied. The SAS was calculated for all patients, patients were followed up for the occurrence of any major complications or mortality during hospital stay after surgery. All the patients were divided into three groups based on their SAS score (high risk: SAS 0–4, moderate risk: SAS 5–7 and low risk: SAS 8–10) using a threshold that has been previously established.
Results: The occurrence of major complications was significantly higher in high-risk SAS group (12%) than in the moderate risk group (5%). In the low-risk SAS group, the occurrence of major complications was low (1%). The mortality rate in high-risk SAS was more than that in low-risk SAS group with statistical significance both in elective and emergency cases.
Conclusions: In our study, we found that patients who belong to high-risk SAS group were significantly associated with post-operative major complications and mortality in both elective and emergency surgeries. A patient with low intraoperative SAS should be considered at risk and monitored meticulously.
Trial Registration: Clinical Trials Registry-India (CTRI) identifier No. CTRI/2019/02/017567.
Keywords: Abdominal surgeries, haemorrhage, surgical apgar score
|How to cite this article:|
Bhushanam K Y, Samantaray A, Thottikat K, Pasupuleti H, Devi R S, Rao MH, Chukkaluru S. Validation of surgical APGAR score in abdominal surgeries at a tertiary care teaching hospital in South India. J Clin Sci Res 2021;10:85-90
|How to cite this URL:|
Bhushanam K Y, Samantaray A, Thottikat K, Pasupuleti H, Devi R S, Rao MH, Chukkaluru S. Validation of surgical APGAR score in abdominal surgeries at a tertiary care teaching hospital in South India. J Clin Sci Res [serial online] 2021 [cited 2021 Aug 3];10:85-90. Available from: https://www.jcsr.co.in/text.asp?2021/10/2/85/321697
| Introduction|| |
The post-operative scoring system the surgical APGAR score (SAS), was developed by modifying and adjusting the national surgical quality improvement program (NSQIP) variables., The SAS predicts an individual patient's risk for major post-operative complications defined by the NSQIP and death within 30 days following surgery. It is an outcome score that teams could calculate at the end of any surgical procedure to accurately grade major complications or death. To date, SAS has been studied in colorectal surgery, vascular surgery and certain gynaecologic and urological procedures.,,,, There are only few studies which validated the use of SAS in both elective and emergency surgeries with the same set of surgical team in a single centre. Hence, we designed this prospective, observational study to validate the utility of SAS in elective and emergency surgical cases in our hospital set up, to assess how far the SAS can be utilised for prognostication of our patient's in our hospital setup and thereby improving their outcome.
| Material and Methods|| |
We conducted a prospective, observational and longitudinal study after taking approval from Thesis Protocol Approval Committee and the Institutional Ethics Committees. After obtaining a written informed consent from the study participants, this study was conducted in the Surgical Gastroenterology Theatre of our institute from 1st April 2018 to 1st April 2019. The sample size was calculated based on three intraoperative variables, namely estimated blood loss (EBL), mean arterial pressure (MAP) and heart rate (HR). All patients posted for both elective and emergency surgeries were screened for the study, out of them 105 patients were included according to the inclusion and exclusion criteria. Patients willing to participate in the study, aged between 18 and 75 years, of either gender, with American Society of Anesthesiologists physical status (ASA PS) including E undergoing elective and emergency open abdominal surgeries were included in the study. Patients with established metastatic and/or unresectable tumours and patients undergoing minilaparotomy or laparoscopic surgery were excluded from our study. During the pre-operative visit, patient's detailed history was recorded along with demographic data. Any pulmonary comorbidities (defined as pre-existing chronic obstructive pulmonary disease, ventilator dependence and pneumonia), any cardiovascular co-morbidities (defined as prior myocardial infarction [MI], angina, congestive heart failure, coronary revascularisation or valvular heart disease), any history of stroke or transient ischemic attack with or without residual neurologic deficit, any history of renal disorders (acute renal failure and chronic kidney disease) was recorded; as defined by the NSQIP. For elective surgeries, patients were kept nil per oral after midnight. Tablet alprazolam 0.5 mg was given the night before surgery and Tablet ranitidine 150 mg was given the night before surgery and in the morning on the day of surgery. After shifting the patient to the operating room (OR), intravenous (IV) access was established. Routine monitoring was connected including non-invasive blood pressure (IBP) or IBP of upper limb or lower limb (as per requirement of the surgery), pulse-oximetry (spO2), electrocardiography and end-tidal carbon dioxide (etCO2). IV fluids were administered throughout the surgery as per requirement. Anaesthesia was administered routinely according to the standard practice of our institution. Baseline value of systolic blood pressure is defined as the average value of systolic blood pressure measured during the pre-operative evaluation of patients in the OR before induction of anaesthesia). Intraoperative hypotension (defined as a decrease in systolic blood pressure of 20% or more over the basal value for 15 min) was treated first by using crystalloid solutions, then colloid solution and then vasopressors such as ephedrine 0.06 mg/kg, then inotropic infusions were started like norepinephrine or dopamine (at the discretion of treating physician).
Intraoperative hypertension (MAP ≥20% from mean baseline for 2–3 min) and intraoperative tachycardia (absolute value of >100/min from baseline values for ≥1 min) were managed by providing adequate analgesia, adjusting the depth of anaesthesia and correcting hypovolemia and by using drugs. We have used clinical variables for confirming the adequacy of depth of anaesthesia. For intraoperative bradycardia (defined as a HR of <50 beats per minute), atropine was used in the dose of 0.5–1.0 mg (IV bolus), repeated every 3–5 min, up to (max. dose = 0.04 mg/kg). Intraoperative blood loss more than the maximum allowable blood loss was replaced by packed red blood cells. The maximum allowable blood loss was calculated based on a formula using target haematocrit (Hct) as 25% and considering blood volume as 70 ml/kg.
At the end of the surgery, the EBL was calculated by the principal investigator using the formula:
EBLn = ([EBV × (Hi − Hf)/(Hi + Hf)/2]) + (500 × Tu) where estimated blood volume (EBV) was assumed to be 70 ml/kg; Hi and Hf represent Hgbi and Hgbf for one computation and Hcti and Hctf for the second computation, where Hgbi and Hcti are pre-operative haemoglobin and Hct, Hgbf and Hctf are post-operative haemoglobin and Hct values, respectively. Post-operative values were be calculated using blood sample that has sent immediately after shifting the patient from OR to the recovery room. Tu was the sum of number of units of autologous whole blood and packed red blood cells transfused.
This same formula was used again to calculate EBLn, except that instead of using haemoglobin for Hi and Hf, Hct was used for Hi and Hf. The two computations of EBLn were averaged to determine EBL.
Lowest invasive or non-invasive MAP and lowest HR were taken by analysing the trends of the electronic monitor or PAC chart. Extraphysiologic values of HR (<20/min or >200/min) and MAP (<25 mm Hg or > 180 mm Hg) were excluded. SAS was calculated at the end of the surgery based on EBL, lowest MAP and lowest HR that were collected during surgery. Patients were followed up for the occurrence of any major complications or death during hospital stay after surgery as per [Table 1]. Major complications were defined as Clavien Class III or more complications and those defined by NSQIP. Acute renal failure, bleeding that requires transfusion of four units or more of red blood cells within 72 h of surgery, cardiac arrest requiring cardiopulmonary resuscitation (CPR), coma of 24 h or longer, deep-venous thrombosis, MI, unplanned intubation, ventilator use for 48 h or more, pneumonia, pulmonary embolism, stroke, wound disruption, deep or organ space surgical site infection, sepsis, septic shock, systemic inflammatory response syndrome (SIRS), complication requiring surgical, endoscopic or radiological intervention or intensive care admission or are life-threatening, death (superficial surgical site infection and urinary tract infection not considered major complications) as defined by the ACS NSQIP.
The study population was categorised into three groups based on their SAS score (high risk: SAS 0–4, moderate risk: SAS 5–7, and low risk: SAS 8–10) using a threshold that has been previously established. Differences between SAS groups in pre-operative conditions and clinical outcomes were evaluated with Pearson's Chi-square test or one-way ANOVA as appropriate. Fischer's exact test was sued to analyse the differences in complication rates between these three groups separately for patients undergoing elective or emergency surgery. All statistical tests were two-tailed, and a P-value < 0.05 was taken as statistically significant. The Statistical Package for the Social Sciences software Program version 20 (SPSS Inc., Chicago, IL, USA) was used for the analysis.
| Results|| |
The demographic and baseline variables across the SAS risk groups is shown in [Table 2]. All the risk groups (high, moderate and low risk groups) were comparable. ASA grading was different across the groups. Out of 105 patients participated in our study, 78 underwent elective surgeries (53 belonging to ASA PS I, 22 belonging to ASA PS II and 3 belonging to ASA PS III) and 27 underwent emergency surgeries (22 belonging to ASAPS IE, four belonging to ASA PS IIE and one patient belonging to ASA PS IVE). Majority of patients who underwent elective surgeries (n = 57) were in the moderate risk group. Majority of patients who underwent emergency surgeries (n = 15) were in the high-risk group followed by moderate risk group patients (n = 11). Only one patient was in the low-risk group. The duration of surgery was also more in moderate risk group when compared to other two risk groups. In the total study population, 11 patients had associated co-morbid conditions in pre-operative period, out of which two patients had multiple co-morbidities. The most common type of co-morbidity observed in our study was CVS co-morbidity.
Out of the total 105 patients participated in our study, 18 patients developed major complications during the post-operative period. Twelve of them were in high-risk SAS group followed by five in moderate risk SAS group and one in low-risk SAS group. This was observed to be statistically significant (P < 0.001). Among the 16 observed complications, nine complications were found to be different significantly across the groups. These complications are those requiring surgical, endoscopic or radiological interventions not under GA for diagnosis, single organ dysfunction, multiorgan dysfunction, bleeding requiring >4 units of red cell transfusion within 72 h after operation, cardiac arrest requiring cardio pulmonary resuscitation, ventilator use >48 h, pneumonia, pulmonary embolism, major wound disruption, surgical site infection and sepsis, septic shock and SIRS.
[Table 3] shows comparison of occurrence of major complications and mortality across the SAS risk groups in elective surgeries (n = 78). Among the 78 patients who underwent elective surgeries in our study, nine patients developed major complications in the post-operative period. Five of them were in moderate risk group followed by three in high risk and one patient in low risk group. The occurrence of major complications in the post-operative period in the elective surgeries was significantly different across the groups. Out of the 16 major complications observed as per NSQIP, we found only two variables to be strongly associated with low SAS score. These two complications are bleeding requiring >4 units of red cell transfusion within 72 h after operation (P = 0.012) and sepsis, septic shock and SIRS (P = 0.012).
|Table 3: Comparison of occurence of major complications across the SAS risk groups in elective surgeries (n=78)|
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[Table 4] shows comparison of occurrence of major complications and mortality across the SAS risk groups in emergency surgeries (n = 27). Among the 27 patients who underwent emergency surgeries, nine patients developed major complications in the post-operative period, and all of them belong to high-risk SAS group (SAS 0–4). Out of the 16 major complications observed as per NSQIP in our study, we found a strong association between low SAS and three variables (single organ dysfunction, multiorgan dysfunction and ventilator use >48 h with P values of 0.034, 0.046 and 0.005, respectively). The other 13 variables were found to be statistically insignificant (P > 0.05).
|Table 4: Comparison of occurence of major complications across the SAS risk groups in emergency surgeries (n=27)|
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| Discussion|| |
The SAS was developed in 2007 by modifying and adjusting the NSQIP variables. The SAS has been validated in different international settings and has rightly found its place in the World Health Organisation guidelines for safe surgery.
There is only a single study from India validating the utility of SAS in a specific type of surgery, i.e., patients undergoing open abdominal surgeries. Moreover, none of the studies compared the prediction ability of SAS separately for elective and emergency surgical procedures. Hence, in the present study, we validated the utility of SAS in elective and emergency surgeries separately in a broad variety of open abdominal surgeries and how it helps in improving patient's outcome, i.e.,: post-operative complications and mortality.
The ability of age and ASA as the predictors of clinical adversity after abdominal surgery was evaluated in a study. The authors reported that that age can be used to benchmark the outcome of abdominal surgery between institutions. Mean lowest HR in our study was significantly lower in the survivor group and mean lowest MAP also has shown similar course in both groups. The mean EBL was significantly lower in the survivor group than in the non-survivor group. In another study similar findings were reported and the three variables that contributed to the SAS were each significant univariate predictors of major complications, including death. Only EBL was significantly associated with complications in another study. Combination of SAS and ASA risk stratification had improved predictive ability relative to the SAS and ASA scores alone. However, we have found ASA risk stratification significant in our study. In our study, SAS was found to be a significant predictor of survival in abdominal surgeries. Some studies,, conducted in some tertiary centres had also used SAS score in major intraabdominal surgeries and found that SAS predicted survival after surgery. The incidence of major complications and mortality was higher in high-risk SAS group, and this has shown consistent trend of association with SAS score in predicting post-operative major complications. Similar results were reported in another study where there was monotonic relationship between SAS and risk of mortality and major complications in the general surgical and vascular cohort. The SAS could not predict unfavourable events in patients who underwent knee arthroplasties hysterectomy for malignancy and gastrectomy. Among the major complications, patients who required surgical, endoscopic or radiological intervention not under GA (n = 6) in the postop period, who developed single organ dysfunction (n = 8), multiorgan dysfunction (n = 8), bleeding requiring >4 units of red cell transfusion within 72 h after operation (n = 3), cardiac arrest requiring CPR (n = 10), unplanned intubation (n = 3), ventilator use >48 h (n = 14), major wound disruption and surgical site infection (n = 2) and sepsis, septic shock and SIRS (n = 5) were significantly higher in the non-survivor group than in the survivor group and they belong to high and moderate risk SAS group which was statistically significant. In a study SAS correlated with ICU stay and overall cost of treatment in kidney transplant patients. In another study the SAS along with other factors, such as, hypoalbuminaemia and blood transfusion correlated well with hospital stay and complications in pancreatic resection surgeries. Patients undergoing major abdominal surgeries with significant co-morbidities are expected to have adverse perioperative outcomes. In spite of this, SAS was able to predict the occurrence of life-threatening events in the post-operative period. By identifying the risk of occurrence of complications, SAS aids in assisting decision-making about post-operative monitoring of high-risk patients and implementation of risk modification strategies to decrease hospital stay and mortality. Thus, SAS can be adopted as regular screening tool in the OR. Although improving outcomes through post-operative interventions based on the SAS is only speculative at this point, the score does provide an objective adjunct to facilitate discussions of the surgeon, anaesthesiologist and intensive care unit physician in determining the need for these further or heightened post-operative care strategies. This allows the providers to select cases with a low SAS for additional screening and possible analysis for peer review or other improvement processes.
Future work should be directed toward improving the SAS and examining the usefulness of the score in guiding intraoperative techniques and post-operative interventions, such as intensive care unit admission or other escalation in diagnosis or therapy. Furthermore, it would be beneficial to note how the SAS compares with other current studies relating intraoperative cardiovascular and anaesthetic patterns to longer post-operative outcome.
We found that patients who belong to high-risk SAS group were significantly associated with post-operative major complications and mortality in both elective and emergency surgeries. A patient with low intraoperative SAS should be considered at risk and monitored meticulously.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Gawande AA, Kwaan MR, Regenbogen SE, Lipsitz SA, Zinner MJ. An Apgar score for surgery. J Am Coll Surg 2007;204:201-8.
Khuri SF, Daley J, Henderson W, Barbour G, Lowry P, Irvin G, et al
. The National Veterans Administration Surgical Risk Study: Risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg 1995;180:519-31.
Shaik SU, Akther MJ. Surgical APGAR Score, prediction of post emergency abdominal surgery outcome. J Surg 2016;12:141-5.
Chelawat P, Chandorkar SS. Surgical Apgar score predicts outcome of abdominal surgeries in Indian setting. Indian J Appl Res 2013;3:370-2.
Regenbogen SE, Ehrenfeld JM, Lipsitz SR, Greenberg CC, Hutter MM, Gawande AA. Utility of the surgical Apgar score: Validation in 4119 patients. Arch Surg 2009;144:30-6.
Regenbogen SE, Lancaster RT, Lipsitz SR, Greenberg CC, Hutter MM, Gawande AA. Does the surgical Apgar score measure intraoperative performance? Ann Surg 2008;248:320-8.
Zighelboim I, Kizer N, Taylor NP, Case AS, Gao F, Thaker PH, et al
. “Surgical Apgar Score” predicts postoperative complications after cytoreduction for advanced ovarian cancer. Gynecol Oncol 2010;116:370-3.
Prasad SM, Ferreria M, Berry AM, Lipsitz SR, Richie JP, Gawande AA, et al
. Surgical Apgar outcome score: Perioperative risk assessment for radical cystectomy. J Urol 2009;181:1046-52.
Kalezic N, Stojanovic M, Ladjevic N, Markovic D, Paunovic I, Palibrk I, et al
. Risk factors for intraoperative hypotension during thyroid surgery. Med Sci Monit 2013;19:236-41.
Lonjaret L, Lairez O, Minville V, Geeraerts T. Optimal perioperative management of arterial blood pressure. Integr Blood Press Control 2014;7:49-59.
Miller RD, Cohen NH, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL. Miller's Anesthesia. 8th ed. Elsevier Inc., Philadelphia,; 2010. p. 2784.
McCullough TC, Roth JV, Ginsberg PC, Harkaway RC. Estimated blood loss underestimates calculated blood loss during radical retropubic prostatectomy. Urol Int 2004;72:13-6.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13.
Hall JC, Hall JL. ASA status and age predict adverse events after abdominal surgery. J Qual Clin Pract 1996;16:103-8.
Regenbogen SE, Ehrenfeld JM, Lipsitz SR, Greenberg CC, Hutter MM, Gawande AA. Utility of the surgical Apgar score: Validation in 4119 patients. Arch Surg 2009;144:30-6.
Jering MZ, Marolen KN, Shotwell MS, Denton JN, Sandberg WS, Ehrenfeld JM. Combining the ASA physical classification system and continuous intraoperative surgical Apgar score measurement in predicting postoperative risk. J Med Syst 2015;39:147.
Masi A, Amodeo S, Hatzaras I, Pinna A, Rosman AS, Cohen S, et al
. Use of the surgical Apgar score to enhance veterans affairs surgical quality improvement program surgical risk assessment in veterans undergoing major intra-abdominal surgery. Am J Surg 2017;213:696-705.
Yamada T, Tsuburaya A, Hayashi T, Aoyama T, Fujikawa H, Shirai J, et al
. Usefulness of surgical Apgar score on predicting survival after surgery for gastric cancer. Ann Surg Oncol 2016;23:757-63.
Aoyama T, Kazama K, Murakawa M, Atsumi Y, Shiozawa M, Kobayashi S, et al
. The surgical Apgar score is an independent prognostic factor in patients with pancreatic cancer undergoing pan-creatoduodenectomy followed by adjuvant chemo-therapy. Anticancer Res 2016;36:2497-503.
Thorn CC, Chan M, Sinha N, Harrison RA. Utility of the surgical Apgar score in a district general hospital. World J Surg 2012;36:1066-73.
Wuerz TH, Regenbogen SE, Ehrenfeld JM, Malchau H, Rubash HE, Gawande AA, et al
. The Surgical Apgar score in hip and knee arthroplasty. Clin Orthop Relat Res 2011;469:1119-26.
Clark RM, Lee MS, Alejandro Rauh-Hain J, Hall T, Boruta DM, del Carmen MG, et al
. Surgical Apgar score and prediction of morbidity in women undergoing hysterectomy for malignancy. Gynecol Oncol 2015;136:516-20.
Miki Y, Tokunaga M, Tanizawa Y, Bando E, Kawamura T, Terashima M. Perioperative risk assessment for gastrectomy by surgical Apgar score. Ann Surg Oncol 2014;21:2601-7.
Stoll WD, Taber DJ, Palesch SJ, HebbarL. Utility of the surgical Apgar score in kidney transplantation: Is it feasible to predict ICU admission, hospital read-mission, length of stay, and cost in this patient population? Prog Transplant 2016;26:122-8.
La Torre M, Ramacciato G, Nigri G, Balducci G, Cavallini M, Rossi M, et al
. Post-operative morbidity and mortality in pancreatic surgery. The role of surgical Apgar score. Pancreatology 2013;13:175-9.
[Table 1], [Table 2], [Table 3], [Table 4]