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    Patent Pending

    Surgical Apgar Score (SAS) for Postoperative Risk

    Predicts postoperative risk of major complication, including death.
    When to Use
    Pearls/Pitfalls
    Why Use

    The SAS can be applied to any patient who is postop from major surgery.

    The “Apgar Score for Surgery“ (or “Surgical Apgar Score“) was developed by Gawande et. al in 2007 to try to predict risk of complication and poor outcome after major surgery, instead of using subjective measures to gauge risk (as is often done by surgeons). They wanted to develop a simple score that could be quickly and easily calculated “to grade the condition of patients at the end of any general or vascular surgery procedure.“ It is named after the APGAR Score used by obstetricians to rate neonatal outcome.

    • It was developed by collecting and analyzing 99 pre-, intra-, and post-operative variables in patients undergoing major general or vascular surgery.
    • It was developed first in two cohorts of colectomy patients (chosen due to the procedure's known high risk of complications) and then validated in a cohort of general and vascular surgery patients (n = 767).
    • The Surgical Apgar Score correlates directly with outcome -- the higher the score, the lower the risk of complication.
    • Scoring was developed without the use of an electronic anesthesia record, which may document more fluctuations in vital signs; the authors report they are currently developing a model for use with electronic anesthesia records.

    The SAS can often predict the risk of complication more objectively than clinician gestalt; in one study, it correlated well with admission to an ICU setting (when not initially admitted to an intensive care setting).

    >1000 mL
    0
    601-1000 mL
    +1
    101-600 mL
    +2
    ≤100 mL
    +3
    <40 mmHg
    0
    40-54 mmHg
    +1
    55-69 mmHg
    +2
    ≥70 mmHg
    +3
    >85 bpm
    0
    76-85 bpm
    +1
    66-75 bpm
    +2
    56-65 bpm
    +3
    ≤55 bpm
    +4
    Pathologic bradyarrhythmia or asystole
    0

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    Next Steps
    Evidence
    Creator Insights
    Dr. Atul Gawande

    About the Creator

    Atul Gawande, MD, MPH, is a surgeon, writer, and public health researcher. He is most widely known as the critically acclaimed author of Complications: A Surgeon’s Notes on an Imperfect Science as well as several other bestsellers, including Being Mortal; The Checklist Manifesto: How to Get Things Right; and Better. He practices general and endocrine surgery at Brigham and Women’s Hospital and is professor in both the Department of Health Policy and Management at the Harvard School of Public Health and the Department of Surgery at Harvard Medical School. He is Executive Director of Ariadne Labs, a joint center for health systems innovation, and Chairman of Lifebox, a nonprofit organization making surgery safer globally.

    To view Dr. Atul Gawande's publications, visit PubMed

    Are you Dr. Atul Gawande? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
    Dr. Scott E. Regenbogen

    From the Creator

    Why did you develop the Surgical Apgar Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

    We sought to develop a surgical outcome score that would be: (i) simple for teams to collect immediately upon completion of an operation for any patient in any setting, regardless of resource and technological capacity; (ii) valid for predicting major postoperative complications and death; and (iii) applicable throughout at least the fields of general and vascular surgery. 

    Even after accounting for fixed preoperative risk—due to patients’ acute condition, comorbidities and/or operative complexity—the Surgical Apgar Score appears to detect differences in intraoperative management that reduce odds of major complications by half, or increase them by nearly three-fold.

    The Surgical Apgar Score, therefore, conveys useful prognostic information, either in isolation or in combination with assessments of the risks that patients brought to the operating room. It also may provide an immediate assessment of how well or poorly the operation has gone for a patient.

    What pearls, pitfalls and/or tips do you have for users of the Surgical Apgar Score? Do you know of cases when it has been applied, interpreted, or used inappropriately?

    The score is just a measure of intraoperative hemodynamic stability. It was developed in general and vascular surgery and has been extended to a variety of other operations. However, it is not likely to be associated with outcomes of some other operations, and may not predict long-term outcomes.

    What recommendations do you have for doctors once they have applied the Surgical Apgar Score? Are there any adjustments or updates you would make to the score based on new data or practice changes?

    It can be a useful perioperative communication tool and prognostic indicator. It could be used for triage of perioperative care and it might allow for tiered surveillance for postoperative complications but it probably should not supersede clinical judgment and intuition.

    How do you use the Surgical Apgar Score in your own clinical practice? Can you give an example of a scenario in which you use it?

    The Surgical Apgar Score has been used both to evaluate unexpected low (high risk) scores, and possible overtreatment of high (low risk) scoring patients.

    In particular, at Brigham and Women's Hospital, we would review all elective operations with scores of 4 or less and all patients admitted to the ICU after operations with scores of 8 or greater.

    About the Creator

    Scott E. Regenbogen, MD, MPH, is an associate professor of surgery at the University of Michigan in Ann Arbor, MI. He is also the chief of the division of colorectal surgery and the associate chief clinical officer for surgical specialties at the University of Michigan Medical Group. Dr. Regenbogen’s primary research is focused on surgical management of colon cancer.

    To view Dr. Scott E. Regenbogen's publications, visit PubMed

    Are you Dr. Scott E. Regenbogen? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
    About the Creator
    Dr. Atul Gawande
    Are you Dr. Atul Gawande?
    Dr. Scott E. Regenbogen
    Are you Dr. Scott E. Regenbogen?