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    Surgical Apgar Score (SAS) for Post-Operative Risk

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

    The SAS can be applied to any patient who is post-op 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).

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    Consider admission to a closely monitored setting (ICU, stepdown unit) for patients with low Surgical Apgar Scores as they are high risk for requiring ICU-level care within the next 72 hours.

    Management

    • For patients with scores ≥ 7, consider usual care.
    • Patients with scores ≤6, consider close observation with a low-threshold for testing if or when a patient begins to show signs of surgical complication, given they are at high risk for complication, along with usual standard of care. It may also be useful to make nursing aware of these patients who are particularly high risk so the care team can be notified early of any signs of decompensation.

    Critical Actions

    Patients with a score of 6 or less are high risk for major complication, and patients with a score of 4 or less are very high risk and should be considered at high risk of decompensation and monitored very closely, often in an ICU setting.

    Formula

    Addition of the selected points; points assigned below:

    Facts & Figures

    Criteria Value Points
    Estimated blood loss (mL) > 1,000 0
    600-1,000 + 1
    101 - 600 + 2
    ≤ 100 + 3
    Lowest mean arterial pressure (mmHg) < 40 0
    40 - 54 + 1
    55 - 69 + 2
    ≥ 70 + 3
    Lowest heart rate (beats / min) > 85 0
    76 - 85 + 1
    66 - 75 + 2
    56 - 65 + 3
    ≤ 55 + 4

    Complications in this study were defined as:

    • Acute renal failure,
    • Bleeding requiring ≥ 4 U red cell transfusion within 72 hours after operation
    • Cardiac arrest requiring CPR
    • Coma for 24 hours or longer
    • Deep venous thrombosis
    • Septic shock
    • MI
    • Unplanned intubation
    • Ventilator use for ≥48 hours
    • Pneumonia
    • Pulmonary embolism
    • Stroke
    • Wound disruption
    • Deep or organ-space surgical site infection,
    • Sepsis
    • Systemic inflammatory response syndrome and
    • Vascular graft failure, according to NSQIP’s established definitions

    All deaths were considered major complications.

    Patients having complications categorized in the database as “other occurrence” were reviewed individually to determine the severity of the complication. Anastomotic leak, cystic duct leak after cholecystectomy, pericardial effusion requiring drainage, and gastric outlet obstruction requiring reoperation were identified on review of these individual occurrences and classified as major complications.

    Superficial surgical site infection and urinary tract infection were not major complications.

    Evidence Appraisal

    • The Surgical Apgar Score has been validated in other surgical populations requiring “major surgery” or general or epidural anesthesia including trauma, head and neck, oncology, orthopedic, and transplant surgery with good correlations with survival at 7, 30, and 90 days.
    • Some authors have found similar correlations of survival/mortality with a cohort of “triple low” (low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia) patients and suggest these two scores could be combined to risk stratify patients even further.
    • Of note, the SAS seemed to correlate least well with patients undergoing major burn surgery.

    Literature

    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