Apgar score for surgery predicts mortality in veterans

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1. Surgical Apgar Score (SAS) predicted the risk of overall morbidity and 30-day mortality in a large veteran patient population. 

2. A SAS score below 5 correlated with an increased risk of postoperative complications and mortality: those with SAS 0-4 had 51.7% and 17.2% overall morbidity and 30-day mortality rates respectively, while patients with SAS 5-10 had 6.0% and 0.3% respectively. 

Evidence Rating Level: 2 (Good)           

Study Rundown: Similar to the Apgar score used for newborns, SAS is a 10-point score. It is based on three easily determined clinical factors: estimated blood loss, lowest operative heart rate and lowest mean arterial pressure (MAP) while under anesthesia. This score, originally developed by Gawande et al, has been validated across almost 5,000 patients, including those undergoing general, vascular, urologic orthopedic and pancreatic surgery. This study aimed to validate SAS in the veteran population, which has distinct socioeconomic factors and may have a higher rate of comorbidities compared to the general population. Results were similar to multiple studies that have previously been conducted in general surgery patients. However, this study had the advantage of near-perfect rate of data documentation due to a robust database and very well-recorded follow-up: the VA’s national EHR. Though the presented results are statistically significant, over 50% of the patients received a SAS core between 9 and 10, with less than 2% of the patients under SAS of 4. Additionally, those with a high SAS were younger than low-SAS patients, had better pre-operative functional status and less co-morbidities.

Click to read the study in Journal of the American College of Surgeons

Relevant Reading: An Apgar score for surgery

In-Depth [retrospective cohort]: This study queried the New York Harbor Healthcare System database to assign a SAS score to 2125 veterans who underwent general surgery between 2006 and 2011. Patients were mostly men (91.9%), who underwent minor or intermediate procedures. A smaller number underwent major intra-abdominal (24.1%) or extensive cancer (9.3%) surgery. The score was calculated from anesthesia records in an independent and prospective fashion. Complications were then correlated to SAS by separating patients into groups by their score: SAS equal or less than 4, 5-6, 7-8 and 9-10. The surgical Apgar score predicted both overall morbidity and 30-day mortality (p<0.001 for all groups). The correlation remained significant for major and extensive surgery as well as minor and intermediate surgery when considered separately. Independent predictors of overall morbidity and 30-day mortality were identified by multiple regression analysis. These included SAS, functional status and ASA classification, which correlated with both endpoints. Age was an independent predictor of overall morbidity, while history of ascites correlated with 30-day mortality.

By Asya Ofshteyn and Allen Ho

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