The intraoperative Surgical Apgar Score predicts postdischarge complications after colon and rectal resection

Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA.
Surgery (Impact Factor: 3.38). 03/2010; 148(3):559-66. DOI: 10.1016/j.surg.2010.01.015
Source: PubMed


We previously developed an intraoperative 10-point Surgical Apgar Score-based on blood loss, lowest heart rate, and lowest mean arterial pressure-to predict major complications after colorectal resection. However, because complications often arise after uncomplicated hospitalizations, we sought to evaluate whether this intraoperative metric would predict postdischarge complications after colectomy.
We linked our institution's National Surgical Quality Improvement Program database with an Anesthesia Intraoperative Management System for all colorectal resections over 4 years. Using Chi-square trend tests and logistic regression, we evaluated the Surgical Apgar Score's prediction for major postoperative complications before and after discharge.
Among 795 colectomies, there were 230 (29%) major complications within 30 days; 45 (20%) after uncomplicated discharges. Surgical Apgar Scores predicted both inpatient complications and late postdischarge complications (both P < .0001). Late complications occurred from 0 to 27 (median, 11) days after discharge; the most common were surgical site infections (42%), sepsis (24%), and venous thromboembolism (16%). In pairwise comparisons against average-scoring patients (Surgical Apgar Scores, 7-8), the relative risk of postdischarge complications trended lower, to 0.6 (95% confidence interval [CI], 0.2-1.7) for those with the best scores (9-10); and were significantly higher, at 2.6 (95% CI, 1.4-4.9) for scores 5-6, and 4.5 (95% CI, 1.8-11.0) for scores 0-4.
The intraoperative Surgical Apgar Score remained a useful metric for predicting postcolectomy complications arising after uncomplicated discharges. Even late complications may thus be related to intraoperative condition and events. Surgeons could use this intraoperative metric to target low-scoring patients for intensive postdischarge surveillance and mitigation of postdischarge complications after colectomy.

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    • "Recently, a simple surgical score inspired by the Apgar Score of Obstetrics was developed to predict the occurrence of 30-day major postoperative complications and mortality [1]. Originally developed in patients undergoing general and vascular surgery, the Surgical Apgar Score (SAS) has later been validated in different surgical specialties, including colorectal, urological, and gynecological surgery [2] [3] [4], as well as in diverse international settings [5] [6] [7] [8]. This 10- point score, which allows risk stratification in the postoperative setting, is based on three variables: the estimated blood loss (EBL), lowest heart rate (HR), and lowest mean arterial pressure (MAP) during surgery (Table 1). "
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    ABSTRACT: The Surgical Apgar Score (SAS), a simple metric based on intraoperative heart rate, blood pressure, and blood loss, was developed in general and vascular surgery to predict 30-day major postoperative complications and mortality. No validation of SAS has been performed in spine surgery. To perform a prospective assessment of SAS in spine surgery. Prospective study. Two hundred sixty-eight consecutive patients undergoing major and intermediate spinal surgeries in an 18-month period. Occurrence of major complications or death within 30 days of surgery. Intraoperative parameters were registered, and SAS was calculated immediately after surgery. Outcome data were collected during a 30-day follow-up. The relationship between SAS and the outcomes was analyzed calculating relative risks (RRs) and likelihood ratios (LRs) for different scoring groups. A univariate logistic regression analysis was also performed. The discriminatory accuracy of SAS was evaluated calculating a C-statistic. Eighteen patients had ≥1 complications (6.72%). Patients with SAS 9-10 exhibited a 1.64% complication rate (RR=1; LR=0.23), which monotonically augmented as the score decreased: (SAS 7-8=2.75%; RR=1.68; LR=0.39), (SAS 5-6=13.33%; RR=8.13; LR=2.14), (SAS≤4=17.39%; RR=10.61; LR=2.92). The regression analysis odds ratio was 0.66 (95% confidence interval, 0.54-0.82), p<.01. The C-statistic was 0.77 (95% confidence interval, 0.66-0.88). Surgical Apgar Score allows risk stratification and has a good discriminatory power in patients undergoing spine surgery.
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    • "Major preoperative risk factors for post colorectal surgery complications include age (> 75),[55] ASA grade (> 2),[56] pre-existing comorbidities (e.g., cardiorespiratory),[57] low functional capacity as measured by the cardiopulmonary exercise test (CPET),[58] reduced preoperative nutritional status[5960] (e.g., anemia, hypoproteinemia, weight loss), smoking,[59] obesity,[60] type of surgery, and its indication (e.g., elective vs. emergency, cancer vs. non-cancer, right- vs. left-sided lesions), and presence of shock (in case of emergency surgery). Important intraoperative risk factors for postoperative complications are duration of surgery[61] (for both laparoscopic and open surgery), blood loss and blood transfusion,[62] open vs laparoscopic procedure, conversion to open procedure (in case of laparoscopy),[63] Mannheim peritonitis index,[19] Hinchey grade for perforation,[64] presence of shock, hypothermia, excessive fluid and sodium administration, and surgical Apgar score[65] (based on blood loss, lowest heart rate, and lowest mean arterial blood pressure). Postoperative risk factors for developing complications are conventional recovery pathways (compared to enhanced recovery), inadequate pain relief, excessive fluid and sodium administration,[30] low ScvO2,, sepsis, and late enteral feeding. "
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    ABSTRACT: Colorectal surgery carries significant morbidity and mortality, which is associated with an enormous use of healthcare resources. Patients with pre-existing morbidities, and those undergoing emergency colorectal surgery due to complications such as perforation, obstruction, or ischemia / infarction are at an increased risk for adverse outcomes. Fluid therapy in emergency colorectal surgical patients can be challenging as hypovolemic and septic shock may coexist. Abdominal sepsis is a serious complication and may be diagnosed during pre-, intra-, or postoperative periods. Early suspicion and recognition of medical and / or surgical complications are essential. The critical care management of complicated colorectal surgical patients require collaborative and multidisciplinary efforts.
    Journal of Anaesthesiology Clinical Pharmacology 07/2012; 28(3):304-13. DOI:10.4103/0970-9185.98321
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