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Surgical Apgar: Development of a novel outcomes score predicting major complication and mortality following radical cystectomy
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Surgical Apgar: Development of a novel outcomes score predicting major complication and mortality following radical cystectomy
Sandip M. Prasad, MD, M. Phil.1, Marcos Ferreira, M.D.2, Michaella M. Prasad, M.D.1, Stuart Lipsitz, Sc.D.3, Jerome P. Richie, M.D.1, Kevin R. Loughlin, M.D., M.B.A.1, Michael P. O'Leary, M.D., M.P.H.1, Christopher J. Doyle, M.D.1, Graeme S. Steele, M.D.1, Atul A. Gawande, M.D., M.P.H.4, Jim C. Hu, M.D., M.P.H.1.
1Harvard-Longwood Program in Urology, Boston, MA, USA, 2Brigham and Women's Hospital, Boston, MA, USA, 3Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA, 4Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
Background:
Presently, objective perioperative risk assessment metrics are lacking for radical cystectomy. Using a framework similar to neonatal assessment with a simple 10-point scale, we evaluated whether a surgical Apgar outcomes score calculated immediately following radical cystectomy could predict major complication and mortality.
Methods:
We identified 155 consecutive radical cystectomies performed between 2005 and 2007 at Brigham and Women’s Hospital, Boston, MA. Data was collected on 37 preoperative and intraoperative variables. We used a framework established by the National Surgical Quality Improvement Program to evaluate major complications within 30 days of surgery and death. A 10-point scoring system (previously validated in general and vascular surgery populations) was utilized comprised of estimated blood loss (EBL), lowest heart rate (HR), and lowest mean arterial pressure (MAP).
Surgical Apgar Scoring Methodology | | Allocated points per category | | Intraoperative variables | 0 | 1 | 2 | 3 | 4 | | EBL(cc) | >1500 | 1001−1500 | 601−1000 | ≤ 600 | ----- | | Lowest HR(beats/min) | >85 | 76−85 | 66−75 | 56−65 | ≤ 55 | | Lowest MAP(mmHg) | <40 | 40−54 | 55−69 | ≥ 70 | ----- | | Total score is the sum of the points in all three categories |
Results:
26% of all patients undergoing radical cystectomy experienced major complication or death within 30 days of the operation (p<0.001). 8% of patients with a score ≥8 experienced a major complication or death, while these occurred in 26% of patients with an intermediate surgical Apgar score 5-7. In the group with scores ≤4, 61% of patients experienced adverse events (relative risk between surgical Apgar ≤4 and ≥8 7.3; 95% CI, 2.3-23.0; p< 0.001). Coronary artery disease, ASA class, intraoperative blood transfusion, volume of intravenous fluid administered and female gender were also significant predictors of postoperative complication and death (p<0.05).
Surgical Apgar Score and Adverse Events| Risk category | Surgical Apgar score | Total patients | Adverse events | Percentage of patients with adverse events | | Low | 0-4 | 18 | 11 | 61% | | Intermediate | 5-7 | 101 | 26 | 26% | | High | 8-10 | 36 | 3 | 8% |
Conclusions:
For patients undergoing radical cystectomy, the surgical Apgar score is associated with major post-operative complication and death. This simple and objective metric can be utilized in the immediate post-operative environment to dictate intensity of care. Prospective studies are needed to determine if utilization of this scoring system influences patient outcome.
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