Implementation of the Surgical Apgar Score in Laboratory Animal Science: A Showcase Pilot Study in a Porcine Model and a Review of the Literature

<b><i>Introduction:</i></b> In an attempt to further improve surgical outcomes, a variety of outcome prediction and risk-assessment tools have been developed for the clinical setting. Risk scores such as the surgical Apgar score (SAS) hold promise to facilitate the objective assessment of perioperative risk related to comorbidities of the patients or the individual characteristics of the surgical procedure itself. Despite the large number of scoring models in clinical surgery, only very few of these models have ever been utilized in the setting of laboratory animal science. The SAS has been validated in various clinical surgical procedures and shown to be strongly associated with postoperative morbidity. In the present study, we aimed to review the clinical evidence supporting the use of the SAS system and performed a showcase pilot trial in a large animal model as the first implementation of a porcine-adapted SAS (pSAS) in an in vivo laboratory animal science setting. <b><i>Methods:</i></b> A literature review was performed in the PubMed and Embase databases. Study characteristics and results using the SAS were reported. For the in vivo study, 21 female German landrace pigs have been used either to study bleeding analogy (<i>n</i> = 9) or to apply pSAS after abdominal surgery in a kidney transplant model (<i>n</i> = 12). The SAS was calculated using 3 criteria: (1) estimated blood loss during surgery; (2) lowest mean arterial blood pressure; and (3) lowest heart rate. <b><i>Results:</i></b> The SAS has been verified to be an effective tool in numerous clinical studies of abdominal surgery, regardless of specialization confirming independence on the type of surgical field or the choice of surgery. Thresholds for blood loss assessment were species specifically adjusted to &#x3e;700 mL = score 0; 700–400 mL = score 1; 400–55 mL score 2; and &#x3c;55 mL = score 3 resulting in a species-specific pSAS for a more precise classification. <b><i>Conclusion:</i></b> Our literature review demonstrates the feasibility and excellent performance of the SAS in various clinical settings. Within this pilot study, we could demonstrate the usefulness of the modified SAS (pSAS) in a porcine kidney transplantation model. The SAS has a potential to facilitate early veterinary intervention and drive the perioperative care in large animal models exemplified in a case study using pigs. Further larger studies are warranted to validate our findings.

The Impact of the Surgical Apgar Score On Oncological Outcomes in Patients With Colorectal Cancer: A Single-Center Retrospective Cohort Study

Background: The surgical Apgar score (SAS) predicts postoperative complications (POCs) following gastrointestinal cancer surgery. Recently, the SAS was reported to be a predictor of not only POCs but also the prognosis. However, the impact of the SAS on oncological outcomes in patients with colorectal cancer (CRC) has not been fully examined. The present study therefore explored the oncological significance of the SAS in patients with CRC.Methods: We retrospectively analyzed 639 patients who underwent radical surgery for CRC. The SAS was calculated based on three intraoperative parameters: estimated blood loss, lowest mean arterial pressure and lowest heart rate. The optimal cut-off value of the SAS was determined by receiver operating characteristic curves. All patients were classified into 2 groups based on the SAS (≤6 and >6). The association of the SAS with the recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS) was analyzed.Results: Univariate analyses revealed that a lower SAS (≤6) was significantly associated with a worse RFS, OS and CSS. A multivariate analysis revealed that age ≥75 years old, Charlson comorbidity index ≥1, ASA-Physical Status ≥3, SAS ≤6, histologically undifferentiated tumor type and an advanced pStage were independent factors for the OS, and an SAS ≤6 and advanced pStage were independent factors for the CSS.Conclusions: A lower SAS (≤6) was an independent prognostic factor for not only the OS but also the CSS in patients with CRC, suggesting that the SAS might be a useful biomarker predicting oncological outcomes in patients with CRC.

The Surgical Apgar Score Predicts Postoperative Complications in Elderly Patients After Surgery for Colorectal Cancer

Objective The surgical Apgar score (SAS) has been validated as a risk assessment tool for postoperative complications. However, the utility of the SAS in elderly patients with colorectal cancer remains unclear. In this study, we evaluated the utility of the SAS for predicting the severe complications in elderly patients with colorectal cancer. Methods We retrospectively analyzed 295 patients underwent radical surgery for colorectal cancer in elderly patients ≥75 years old. The SAS was calculated based on 3 intraoperative parameters: estimated blood loss (EBL), lowest mean arterial pressure, and lowest heart rate. Severe complications were defined as Clavien-Dindo classification grade ≥ IIIa. We divided all patients into 2 groups according to with or without severe complications. The optimal cut-off value of SAS for severe complications has been determined by receiver operator characteristic curve. Predictors for severe complications were analyzed by logistic regression modeling. Results Severe complications were observed in 57 patients (19.3%). Male, rectal cancer, operation time (>240 minutes), EBL (≥120 mL), and a low SAS (≤6) were significantly associated with severe complications in univariate analysis. A multivariate analysis revealed that male, rectal cancer, and a low SAS (≤6) were independent predictors for severe complications. Conclusions A low SAS (≤6) was associated with severe complications after colorectal cancer surgery in elderly patients. The SAS is a valuable predictor for severe complications in elderly patients with colorectal cancer.

Application of the surgical Apgar score (SAS) to predict postoperative complication(s) in the patients with traumatic brain injury: Study of single center in Indonesia

BACKGROUND: Traumatic brain injury (TBI) is a major health problem. Surgery in patients with TBI is associated with a high rate of complications and mortality. The surgical Apgar score (SAS) is a simple quantitative and objective intraoperative tool for predicting major post-operative complications including mortality. AIM: Our study aimed to analyze the use of SAS as a predictor of post-operative complications in patients with TBI. METHODS: This was a prospective cohort study at our center in RSHS, Bandung, Indonesia, throughout 2017 by assessing SAS based on calculating intraoperative estimated blood loss, lowest mean arterial pressure, and lowest heart rate for each patient with TBI, as well as the incident complications within 30 days post-operative were recorded. RESULTS: One hundred fifty-six patients with TBI underwent surgery in 2017 with 123 patients met the inclusion criteria. Among those, 63 patients (51.2%) developed major complications with 8 patients (12.7%) experienced death. The mean SAS for patients without complication was 8.20, whereas for patients with complication was 6.11. SAS has an inverse correlation (r = –0.754) and an association (p < 0.005) with post-operative complication (s) within 30 days. CONCLUSIONS: The SAS has an inverse correlation and an association with incidence of complications thus potentially useful as an intraoperative predictor for incident complications within 30 days post-operative care in patients with TBI.

A PROSPECTIVE STUDY TO DETERMINE POST OPERATIE MORBIDITY AND MORTALITY USING SURGICAL APGAR SCORE

Introduction: Predicting the post-operative complication earlier will help surgeons take necessary precautions Pre and Peri-operatively. It reduces the direct as well as indirect medical cost. The main risk factors which have effect on morbidity as well as mortality are Age ,Type of surgery, History of Diabetes, Hypertension, Smoking, Renal disease, Cardiovascular disease, COPD, Asthma, steroid intake etc. Atul Gawande et al developed a scoring system as a boon for surgeons termed as surgical Apgar scoring system. Though initially devised for Colorectal surgeries this scoring system can be applied for general surgical procedures and predicts major complications as well as mortality using Lowest Heart Rate intra operatively, Lowest Mean Arterial Pressure intra operatively and Estimated Blood Loss. Existing prediction scoring system that involve lab investigation needs meticulous procedure. Hence this study is being carried out to evaluate the ability of Surgical APGAR score to predict post-operative morbidity and 30 days for General Surgical procedures. Materials and methods: Descriptive longitudinal study carried out at Department of General surgery, Meenakshi Medical College & Research Institute, Kanchipuram, Tamil Nadu, for a period of 12 months With a sample size of 200 Inclusion criteria: Patients aged between 15-75 years undergoing Emergency or Elective General surgical procedures under General, Spinal or Epidural anesthesia. Exclusion criteria: Patient on Beta Blockers and those undergoing procedures under Local Anesthesia were excluded. Results: Among the comorbid conditions COPD, Asthma and Renal failure have statistically significant association with Surgical Apgar score. There is statistically significant association between type of surgery and Surgical Apgar score. There is statistically significant association between Surgical Apgar score and complications. There is statistically significant association between surgical Apgar score and mortality. Among 8 individuals who had high risk score 6 individuals had mortality. Conclusion: The 10-point Surgical Apgar Scoring system is an easy and fairly accurate method of identifying the patients at risk of complications and mortality in the post-operative period. Patients with low surgical Apgar score would require more intensive monitoring in the postoperative period even if they are undergoing a minor procedure.

Surgical Apgar score is strongly associated with postoperative ICU admission

Immediate postoperative intensive care unit (ICU) admission can increase the survival rate in patients undergoing high-risk surgeries. Nevertheless, less than 15% of such patients are immediately admitted to the ICU due to no reliable criteria for admission. The surgical Apgar score (SAS) (0–10) can be used to predict postoperative complications, mortality rates, and ICU admission after high-risk intra-abdominal surgery. Our study was performed to determine the relationship between the SAS and postoperative ICU transfer after all surgeries. All patients undergoing operative anesthesia were retrospectively enrolled. Among 13,139 patients, 68.4% and < 9% of whom had a SASs of 7–10 and 0–4. Patients transferred to the ICU immediately after surgery was 7.8%. Age, sex, American Society of Anesthesiologists (ASA) class, emergency surgery, and the SAS were associated with ICU admission. The odds ratios for ICU admission in patients with SASs of 0–2, 3–4, and 5–6 were 5.2, 2.26, and 1.73, respectively (P < 0.001). In general, a higher ASA classification and a lower SAS were associated with higher rates of postoperative ICU admission after all surgeries. Although the SAS is calculated intraoperatively, it is a powerful tool for clinical decision-making regarding the immediate postoperative ICU transfer.