Perioperative Risk Stratification: A Need for an Improved Assessment in Surgery and Anesthesia—A Pilot Study

Background and Objectives: Numerous scoring systems have been introduced into modern medicine. None of the scoring systems assessed both anesthetic and surgical risk of the patient, predict the morbidity, mortality, or the need for postoperative intensive care unit admission. The aim of this study was to compare the anesthetic and surgical scores currently used, for a better evaluation of perioperative risks, morbidity, and mortality. Material and Methods: This is a pilot, prospective, observational study. We enrolled 50 patients scheduled for elective surgery. Anesthetic and surgery risk was assessed using American Society of Anesthesiologists (ASA) scale, Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM), Acute Physiology and Chronic Health Evaluation (APACHE II), and Surgical APGAR Score (SAS) scores. The real and the estimated length of stay (LOS) were registered. Results: We obtained several statistically significant positive correlations: ASA score–P-POSSUM (p < 0.01, r = 0.465); ASA score–SAS, (p < 0.01, r = −0.446); ASA score–APACHE II, (p < 0.01 r = 0.519); predicted LOS and ASA score (p < 0.01, r = 0.676); predicted LOS and p-POSSUM (p < 0.01, r = 0.433); and predicted LOS and APACHE II (p < 0.01, r = 0.454). A significant negative correlation between predicted LOS, real LOS, ASA class, and SAS (p < 0.05) was observed. We found a statistically significant difference between the predicted and actual LOS (p < 001). Conclusions: Anesthetic, surgical, and severity scores, used together, provide clearer information about mortality, morbidity, and LOS. ASA scale, associated with surgical scores and severity scores, presents a better image of the patient’s progress in the perioperative period. In our study, APACHE II is the best predictor of mortality, followed by P-POSSUM and SAS. P-POSSUM score and ASA scale may be complementary in terms of preoperative physiological factors, providing valuable information for postoperative outcomes.

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Decisions to operate: the ASA grade 5 dilemma

Annals of The Royal College of Surgeons of England ◽

10.1308/003588411x581367 ◽

2011 ◽

Vol 93 (5) ◽

pp. 365-369 ◽

Cited By ~ 8

Author(s):

J Horwood ◽

S Ratnam ◽

A Maw

Keyword(s):

High Risk ◽

Scoring Systems ◽

Apache Ii ◽

Ageing Population ◽

Mortality And Morbidity ◽

High Risk Patients ◽

Operative Severity Score ◽

Grade 5 ◽

Number Of Patients ◽

Risk Patients

INTRODUCTION Deciding to operate on high risk patients suffering catastrophic surgical emergencies can be problematic. Patients are frequently classed as American Society of Anesthesiologists (ASA) grade 5 and, as a result, aggressive but potentially lifesaving intervention is withheld. The aim of our study was to review the short-term outcomes in patients who were classed as ASA grade 5 but subsequently underwent surgery despite this and to compare the ASA scoring model to other predictors of surgical outcome. METHODS All patients undergoing emergency surgery with an ASA grade of 5 were identified. Patient demographics, indications for surgery, intraoperative findings and outcomes were recorded. In addition to the ASA scores, retrospective Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P POSSUM) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated and compared to the observed outcomes. RESULTS Nine patients (39%) survived to discharge. ASA grade was a poor predictor of outcome. P POSSUM and APACHE II scores correlated significantly with each other and with observed outcomes when predicting surgical mortality. The median stay for survivors in the intensive care unit was nine days. CONCLUSIONS In times of an ageing population, the number of patients suffering catastrophic surgical events will increase. Intervention, with little hope of a cure, a return to independent living or an acceptable quality of life, leads to unnecessary end-of-life suffering for patients and their relatives, and consumes sparse resources. The accuracy and reliability of ASA grade 5 as an outcome predictor has been questioned. P POSSUM and APACHE II scoring systems are significantly better predictors of outcome and should be used more frequently to aid surgical decision-making in high risk patients.

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Evaluation of the validity of POSSUM and P-POSSUM score in predicting the risk of morbidity and mortality respectively in patients undergoing emergency laparotomy

International Surgery Journal ◽

10.18203/2349-2902.isj20203968 ◽

2020 ◽

Vol 7 (10) ◽

pp. 3224

Author(s):

Vivian Anandith Paul ◽

Agnigundala Anusha ◽

Alluru Sarath Chandra

Keyword(s):

Mortality Rate ◽

Linear Method ◽

Morbidity And Mortality ◽

Emergency Laparotomy ◽

Medical Sciences ◽

Mortality And Morbidity ◽

Possum Score ◽

Operative Severity Score ◽

Significant Difference ◽

Predicted Values

Background: Aim of this study is to examine the efficacy of Physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and Portsmouth predictor modification (P-POSSUM) equations in predicting morbidity and mortality in patients undergoing emergency laparotomy, to study the morbidity and mortality patterns in patients undergoing emergency laparotomy at Malla Reddy Institute of Medical Sciences, Hyderabad. Methods: The study was conducted for a period of 2 years from February 2018 to February 2020. 100 Patients undergoing emergency laparotomy were studied in the Department of General surgery MRIMS, Hyderabad. POSSUM and P-POSSUM scores are used to predict mortality and morbidity. The ratio of observed to expected deaths (O:E ratio) was calculated for each analysis. Results: The study included total 100 patients, 83 men and 17 women. Observed mortality rate was compared to mortality rate with POSSUM, the O:E ratio was 0.62, and there was no significant difference between the observed and predicted values (χ²=10.79, 9 degree of freedom (df) p=0.148). Observed morbidity rates were compared to morbidity rates predicted by POSSUM, there was no significant difference between the observed and predicted values (χ²=9.89, 9 df, p=0.195) and the overall O:E ratio was 0.91. P-POSSUM predicted mortality equally well when the linear method of analysis was used, with an O:E ratio of 0.65 and no significant difference between the observed and predicted values (χ²= 5.33, 9 df, p= 0.617).Conclusion: POSSUM and P-POSSUM scoring is an accurate predictor of mortality and morbidity following emergency laparotomy and is a valid means of assessing adequacy of care provided to the patient.

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Evaluation of the Use of POSSUM and P-POSSUM Score as a Tool for Prediction of Surgical Outcome

Journal of Surgical Sciences ◽

10.3329/jss.v21i1.43832 ◽

2019 ◽

Vol 21 (1) ◽

pp. 11-14

Author(s):

Mohammad Saif Uddin ◽

Samiron Kumar Mondal ◽

Sharmistha Roy ◽

Masrur Akbar Khan ◽

ABM Khurshid Alam ◽

...

Keyword(s):

Surgical Outcome ◽

Pearson Correlation ◽

Area Under The Curve ◽

Scoring Systems ◽

Surgical Patient ◽

P Value ◽

Mortality And Morbidity ◽

Exact Test ◽

Possum Score ◽

Operative Severity Score

Background: There are many scoring systems that predict the risk of mortality with varyingdegrees of accuracy. The ideal scoring system for surgical outcome should be quick andeasy to use and should be applicable to all general surgical procedures. POSSUM(Physiological and Operative Severity Score for enumeration of Mortality and Morbidity) andP-POSSUM (Portsmouth POSSUM) are the most appropriate scoring systems currentlyavailable in general surgery to predict thirty days mortality and morbidity. Objective: The study was done to assess the value of POSSUM in predicting the morbidityrate and the value of P-POSSUM in predicting the mortality rate in general surgical patientsof our country. Methods: Aprospective study was performed in 120 general surgical patient. The risks ofmorbidity and mortality were calculated by using the POSSUM equation for morbidity andthe P-POSSUM equation for mortality in each patient. The predicted risks were comparedwith the observed risks of morbidity and mortality for 30 days after surgery and statisticallyanalysed. Results: The difference in p value of predicted risk of morbidity by POSSUM equation andobserved morbidity; calculated by chi square test(x2 =1.36, d.f=4,p=0.24,0/P ratio was1.18); which was not statistically significant. The predicted mortality by P-POSSUM equationand observed mortality; calculated by Fisher's exact test(p=1) was not found statisticallysignificant. The Pearson correlation has shown significant correlation at the 0.01 level (2tailed) for the observed and predicted mortality and morbidity(r=O. 701).ROC analysesshowed both POSSUM and P-POSSUM scores to be good predictors of 30-day morbidity andmortality with area under the curve values (AUC) of 0.887 and 0.991 respectively. ConclusionPOSSUM and P-POSSUM can be used as a valid tool for using risk prediction of morbidityand mortality in our set up. Journal of Surgical Sciences (2017) Vol. 21 (1) :11-14

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Assessment of surgical outcome in emergency gastrointestinal surgeries using P-POSSUM score

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20172978 ◽

2017 ◽

Vol 5 (7) ◽

pp. 3007

Author(s):

Prasan Kumar Hota ◽

Harshita Yellapragada

Keyword(s):

Health Care ◽

Surgical Outcome ◽

Scoring System ◽

Statistical Significance ◽

Surgical Care ◽

Mortality And Morbidity ◽

Possum Score ◽

Operative Severity Score ◽

Significant Difference

Background: The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and its modification, Portsmouth-POSSUM (P-POSSUM), are considered as methods of risk scoring. Application of this scoring system helps in assessing the quality of the health care provided and surgical outcome. Its utilization in our country where the level of healthcare and resources differ is limited. Hence, a prospective study to assess the outcome of emergency GI surgeries using P-POSSUM scoring system in a teaching hospital at district level was taken up.Methods: 80 cases which underwent emergency GI surgeries were studied. Using P-POSSUM equation, predicted mortality and morbidity rates were calculated and compared with the actual outcome. Statistical significance was calculated using chi square test.Results: An observed to expected ratio of 0.71 and 0.60 was obtained for mortality and morbidity respectively. No significant difference was noted between expected to observed mortality and morbidity rates with P=0.23 and P=0.09 for mortality and morbidity respectively, suggesting a reasonably good quality of outcome. P-POSSUM over predicted mortality and morbidity in low risk groups while it accurately predicted the outcome in high risk groups.Conclusions: The quality of surgical care provided and surgical outcome are comparable to other health care systems, with observed to expected mortality and morbidity ratio being nearly same. P-POSSUM can be used as a tool for outcome audits.

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Severity and prognosis in intensive care: prospective application of the Apache II Index

Sao Paulo Medical Journal ◽

10.1590/s1516-31801999000500005 ◽

1999 ◽

Vol 117 (5) ◽

pp. 205-214 ◽

Cited By ~ 8

Author(s):

Joel Isidoro Costa ◽

José Luiz Gomes do Amaral ◽

Masashi Munechika ◽

Yara Juliano ◽

José Gomes Bezerra Filho

Keyword(s):

Intensive Care ◽

Mortality Rate ◽

Elective Surgery ◽

Tertiary Care ◽

Prognostic Index ◽

Clinical Severity ◽

Apache Ii ◽

Sample Population ◽

Significant Difference ◽

Critical Patients

CONTEXT: The performance of each ICU needs to be assessed within the overall context of medical care, as well as by the institution which the ICU forms part of. Evaluation mechanisms in the field of intensive care have been developed that are recognized worldwide within the scientific literature. OBJECTIVE: To study outcomes from groups of critical patients and to compare their actual and estimated mortality rates. DESIGN: Prospective study of patients' outcomes. SETTING: A tertiary care unit for a period of 13 months (anesthesiology intensive care unit at the Escola Paulista de Medicina). PARTICIPANTS: 520 patients selected according to sex, age and nature of hospitalization. DIAGNOSTIC TEST: The modified APACHE II prognostic index was applied in order to assess clinical severity and anticipation of mortality in three groups who had non-surgical treatment, emergency surgery and elective surgery. MAIN MEASUREMENTS: The APACHE II index. RESULTS: The application of this index allowed patients to be stratified and expected death risks for both subgroups and the entire sample population to be calculated. The observed mortality rate was greater than the expected rate (28.5% versus 23.6%, respectively), with a statistically significant difference. The standardized mortality rate was 1.20. Patients who obtained scores above 25 presented a significant outcome towards death. The most severe and worst evolving cases were, in decreasing order: non-surgical, emergency surgical and scheduled surgical patients; the actual general mortality rate was higher than the expected one. CONCLUSIONS: The use of the APACHE II index made it possible to stratify critical patient groups according to the severity of their condition.

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POSSUM escore como preditor de mortalidade em pacientes cirúrgicos

Revista da Escola de Enfermagem da USP ◽

10.1590/s0080-62342009000100003 ◽

2009 ◽

Vol 43 (1) ◽

pp. 23-29 ◽

Cited By ~ 2

Author(s):

Adriana Cristina Galbiatti Parminondi Elias ◽

Tiemi Matsuo ◽

Cíntia Magalhães Carvalho Grion ◽

Lucienne Tibery Queiroz Cardoso ◽

Paulo Henrique Verri

Keyword(s):

Severity Score ◽

Apache Ii ◽

Mortality And Morbidity ◽

Operative Severity Score

O estudo avaliou a utilização do escore POSSUM (Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity) para predizer a mortalidade na prática cirúrgica.Foram analisados 416 pacientes cirúrgicos com internação na UTI para cuidados de pós-operatório. Foram realizadas comparações entre as taxas de mortalidade predita e observada de acordo com 4 grupos de risco: 0-4%, 5-14%, 15-49%, 50% ou mais, e calculada a área sob a curva ROC do escore POSSUM e APACHE II para a mortalidade. A taxa de mortalidade foi de 22,4%. O escores POSSUM e APACHE II superestimaram o risco de morte, e a área sob a curva ROC do POSSUM foi de 0,762 e a do APACHE II de 0,737, sugerindo a utilização do POSSUM como ferramenta auxiliar na predição de risco de morte em pacientes cirúrgicos.

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Pre-NELA vs NELA – has anything changed, or is it just an audit exercise?

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2016.0248 ◽

2016 ◽

Vol 98 (8) ◽

pp. 554-559 ◽

Cited By ~ 3

Author(s):

M Mak ◽

AR Hakeem ◽

V Chitre

Keyword(s):

Critical Care ◽

High Risk ◽

Uneventful Recovery ◽

Emergency Laparotomy ◽

Mortality And Morbidity ◽

High Risk Patients ◽

Possum Score ◽

Operative Severity Score ◽

Risk Patients ◽

Set Up

BACKGROUND Following evidence suggestive of high mortality following emergency laparotomies, the National Emergency Laparotomy Audit (NELA) was set up, highlighting key standards in emergency service provision. Our aim was to compare our NHS trust’s adherence to these recommendations immediately prior to, and following, the launch of NELA, and to compare patient outcome. METHODS This was a retrospective study of patients who underwent an emergency laparotomy over the course of 6 months – 3 months either side of the initiation of NELA. RESULTS There were 44 patients before the initiation of NELA (pre-NELA, PN group) and 55 in the first 3 months of NELA (N group). We saw a significant increase in the proportion of patients whose decision to operate was made by the consultant: 75.0% in the PN group vs 100% in N group (subsequent data presented in this order) (P < 0.001). The presence of a consultant surgeon (75.0% vs 83.6%, P = 0.321) and anaesthetist (100.0% vs 90.9%, P = 0.064) in theatres were comparable in both groups. Risk stratification based on Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) score showed no difference in high-risk patients in both groups (47.7% vs 36.4%, P = 0.306). With the NELA initiative, however, significantly more patients were admitted directly from theatres to the critical care unit, when compared with the pre-NELA period (9.1% vs 27.3%, P = 0.038). This also reflected a significant reduction in unexpected escalation to a higher level of care during this period (10.0% vs 0%, P = 0.036). Significantly more patients had uneventful recovery in the NELA period (52.3 vs 76.4%, P = 0.018), although there was no difference in 30-day mortality between the groups (2.3% vs 7.3%, P = 0.378). CONCLUSIONS This study demonstrated a greater degree of consultant involvement in the decision to operate during NELA. More high-risk patients have been identified preoperatively with diligent risk assessment and, hence, have been proactively admitted to critical care units following laparotomy, which may account for the significant reduction in unexpected escalation to level 2 or level 3 care and thus in overall better patient outcomes.

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Evaluation of Nottingham Hip Fracture Score, Age-Adjusted Charlson Comorbidity Index and the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity as predictors of mortality in elderly neck of femur fracture patients

SAGE Open Medicine ◽

10.1177/2050312120918268 ◽

2020 ◽

Vol 8 ◽

pp. 205031212091826 ◽

Cited By ~ 1

Author(s):

Michael James Nelson ◽

Justin Scott ◽

Palvannan Sivalingam

Keyword(s):

Hip Fracture ◽

Charlson Comorbidity Index ◽

Operating Characteristic ◽

Characteristic Curve ◽

Mortality Prediction ◽

Mortality And Morbidity ◽

Operative Severity Score ◽

Significant Difference ◽

Comorbidity Index ◽

Operating Characteristic Curve

Background: This study evaluated the use of several risk prediction models in estimating short- and long-term mortality following hip fracture in an Australian population. Methods: Data from 195 patients were retrospectively analysed and applied to three models of interest: the Nottingham Hip Fracture Score, the Age-Adjusted Charlson Comorbidity Index and the Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity. The performance of these models was assessed with receiver operating characteristic curve as well as logistic regression modelling. Results: The median age of participants was 83 years and 69% were women. Ten percent of patients were deceased by 30 days, 25% at 6 months and 31% at 12 months post-operatively. While there was no statistically significant difference between the models, the Age-Adjusted Charlson Comorbidity Index had the largest area under the receiver operating characteristic curve for within 30 day and 12 month mortality, while the Nottingham Hip Fracture Score was largest for 6-month mortality. There was no evidence to suggest that the models were selecting a specific subgroup of our population, therefore, no indication was present to suggest that using multiple models would improve mortality prediction. Conclusions: While there was no statistically significant difference in mortality prediction, the Nottingham Hip Fracture Score is perhaps the best suited clinically, due to its ease of implementation. Larger prospective data collection across a variety of sites and its role in guiding clinical management remains an area of interest.

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New horizons in rib fracture management in the older adult

Age and Ageing ◽

10.1093/ageing/afz157 ◽

2019 ◽

Vol 49 (2) ◽

pp. 161-167 ◽

Cited By ~ 1

Author(s):

Roisin Coary ◽

Conor Skerritt ◽

Anthony Carey ◽

Sarah Rudd ◽

David Shipway

Keyword(s):

Older Adults ◽

Injury Severity ◽

Scoring Systems ◽

Pulmonary Complications ◽

Research Literature ◽

Rib Fractures ◽

Rib Fracture ◽

Mortality And Morbidity ◽

Severity Scores ◽

Fracture Management

Abstract Adults aged ≥60 years now represent the majority of patients presenting with major trauma. Falls are the most common cause of injury, accounting for nearly three-quarters of all traumas in this population. Trauma to the thorax represents the second most common site of injury in this population, and is often associated with other serious injuries. Mortality rates are 2–5 times higher in older adults compared to their younger counterparts, often despite equivalent injury severity scores. Risk scoring systems have been developed to identify rib fracture patients at high risk of deterioration. Overall mortality from rib fractures is high, at approximately 10% for all ages. Mortality and morbidity from rib fractures primarily derive from pain-induced hypoventilation, pneumonia and respiratory failure. The main goal of care is therefore to provide sufficient analgesia to allow respiratory rehabilitation and prevent pulmonary complications. The provision of analgesia has evolved to incorporate novel regional anaesthesia techniques into conventional multimodal analgesia. Analgesia algorithms may aid early aggressive management and escalation of pain control. The current role for surgical fixation of rib fractures remains unclear for older adults who have been underrepresented in the research literature. Older adults with rib fractures often have multi-morbidity and frailty which complicate their injuries. Trauma services are evolving, and increasingly geriatricians will be embedded into trauma services to deliver comprehensive geriatric assessment. This review aims to provide an evidence-based overview of the management of rib fractures for the physician treating older patients who have sustained trauma.

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Performance of Prognostic Scoring Systems in Trauma Patients in the Intensive Care Unit of a Trauma Center

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17197226 ◽

2020 ◽

Vol 17 (19) ◽

pp. 7226

Author(s):

Shao-Chun Wu ◽

Sheng-En Chou ◽

Hang-Tsung Liu ◽

Ting-Min Hsieh ◽

Wei-Ti Su ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Organ Dysfunction ◽

Scoring Systems ◽

Predictive Performance ◽

Apache Ii ◽

Trauma Patients ◽

Saps Ii ◽

Significant Difference ◽

Prognostic Scoring Systems

Background: Prediction of mortality outcomes in trauma patients in the intensive care unit (ICU) is important for patient care and quality improvement. We aimed to measure the performance of 11 prognostic scoring systems for predicting mortality outcomes in trauma patients in the ICU. Methods: Prospectively registered data in the Trauma Registry System from 1 January 2016 to 31 December 2018 were used to extract scores from prognostic scoring systems for 1554 trauma patients in the ICU. The following systems were used: the Trauma and Injury Severity Score (TRISS); the Acute Physiology and Chronic Health Evaluation (APACHE II); the Simplified Acute Physiology Score (SAPS II); mortality prediction models (MPM II) at admission, 24, 48, and 72 h; the Multiple Organ Dysfunction Score (MODS); the Sequential Organ Failure Assessment (SOFA); the Logistic Organ Dysfunction Score (LODS); and the Three Days Recalibrated ICU Outcome Score (TRIOS). Predictive performance was determined according to the area under the receiver operator characteristic curve (AUC). Results: MPM II at 24 h had the highest AUC (0.9213), followed by MPM II at 48 h (AUC: 0.9105). MPM II at 24, 48, and 72 h (0.8956) had a significantly higher AUC than the TRISS (AUC: 0.8814), APACHE II (AUC: 0.8923), SAPS II (AUC: 0.9044), MPM II at admission (AUC: 0.9063), MODS (AUC: 0.8179), SOFA (AUC: 0.7073), LODS (AUC: 0.9013), and TRIOS (AUC: 0.8701). There was no significant difference in the predictive performance of MPM II at 24 and 48 h (p = 0.37) or at 72 h (p = 0.10). Conclusions: We compared 11 prognostic scoring systems and demonstrated that MPM II at 24 h had the best predictive performance for 1554 trauma patients in the ICU.

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