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The Surgical Apgar Score Is Associated With the Need for Post-Operative ICU Admission
Nina E. Glass*1,2, Antonio Pinna3,2, Antonio Masi1,2, Alan S. Rosman4, Dena Neihaus1, Shunpei Okochi1, John K. Saunders1,2, Ioannis Hatzaras1,2, Steven Cohen1,2, Russell S. Berman1,2, Elliot Newman1,2, H. Leon Pachter1,2, Thomas H. Gouge1,2, Marcovalerio Melis1,2
1Surgery, NYHHS VAMC, New York, NY; 2Surgery, NYU School of Medicine, New York, NY; 3Surgery, University of Sassari, Sassari, Italy; 4Medicine, James J. Peters VAMC, Bronx, NY
Background: The surgical Apgar score (SAS) is a 10-point scoring system calculated with limited intra-operative data (blood loss, lowest mean arterial pressure, lowest heart rate), that predicts postoperative morbidity and mortality. This study evaluates whether SAS may be used to predict the need for post-operative ICU stay.
Methods: We prospectively collected data on demographics, medical history, type of surgery, and post-operative outcomes for any veteran undergoing general surgery during the period Oct 2006-Jul 2009 at the New York Harbor VA Medical Center. We categorized patients into 4 groups according to SAS. Differences between SAS groups were evaluated with Pearson's χ2 and ANOVA as appropriate. The study end-points were length of post-operative stay in the ICU and need for transfer or re-admission to the ICU.
Results: During the study period 2198 patients underwent general surgery. After exclusion of patients with pacemakers and/or missing variables, 2125 were available for analysis (SAS ≤4: n=29; SAS 5-6: n=227; SAS 7-8: n=797; SAS 9-10: n=1072). Demographics and baseline characteristics, intra-operative and post-operative outcomes are summarized in Table 1. Patients in the lower SAS groups had worse functional status, higher ASA score and higher number of existing comorbidities. SAS scores were lower after major or extensive surgery. Low SAS scores were associated with significant post-operative morbidity and 30-day mortality. Poor SAS were associated with high probability of ICU admission (79% vs. 57.3% vs. 34.3% vs. 17.0%, p<0.001). This association was maintained in a logistic regression controlling for sex, age, ASA, and other comorbidities, with SAS being the strongest predictor of prolonged ICU stay with a beta coefficient of -0.17 (p<0.01). Among the 608 (28.6%) patients admitted to the ICU, a low SAS was associated with longer ICU stay (mean 17.3 vs. 14.6 vs. 9.7 vs. 9.9 days, p = 0.009). Of the 1517 (71.4%) patients initially admitted to the regular floor, 148 (9.8%) required subsequent ICU admission. Among patients initially triaged to the regular floor, SAS was strongly associated with need for subsequent admission to the ICU (100%, 49.5%, 13.4, and 2.7% for SAS 0-4, 5-6, 7-8, and 9-10 respectively (p<0.001).
Conclusions: In our experience SAS was associated with need for ICU admission and length of ICU stay. Furthermore, poor SAS was strongly associated with need for ICU admission in patients initially triaged to regular floor after surgery. Table 1 | Group | Apgar 0-4 N=29 1.4% | Apgar 5-6 N=227 10.7% | Apgar 7-8 N=797 37.5% | Apgar 9-10 N=1072 50.4% | P value | | Age (years) | 69.3 ± 12.1 | 66.9 ± 13.4 | 63.5 ± 14.3 | 63.5 ± 14.4 | 0.001 | | Proportion male | 28 (96.6%) | 216 (95.2%) | 731 (91.7%) | 977 (91.1%) | 0.17 | | Functional status | | Independent | 8 (27.6%) | 132 (58.1%) | 675 (84.7%) | 1011 (94.3%) | < 0.001 | | Partially dependent | 7 (24.1%) | 44 (19.4%) | 79 (9.9%) | 47 (4.4%) | | Totally dependent | 14 (48.3%) | 51 (22.5%) | 43 (5.4%) | 14 (1.3%) | | ASA classification | | ASA 1 | 0 | 0 | 29 (3.6%) | 62 (5.8%) | <0.001 | | ASA 2 | 0 | 18 (7.9%) | 170 (21.3%) | 296 (27.6%) | | ASA 3 | 8 (27.6%) | 117 (51.5%) | 506 (63.5%) | 663 (61.8%) | | ASA 4 | 19 (65.5%) | 82 (36.1%) | 87 (10.9%) | 51 (4.8%) | | ASA 5 | 2 (6.9%) | 10 (4.4%) | 5 (0.6%) | 0 | | Pre-Operative Conditions | | Severe COPD | 9 (31.0%) | 42 (18.5%) | 107 (13.4%) | 91 (8.5%) | < 0.001 | | Non-diabetic Diabetic-oral meds Diabetic- insulin | 22 (75.9%) 2 (6.9%) 5 (17.2%) | 160 (70.5%) 32 (14.1%) 35 (15.4%) | 622 (78.0%) 106 (13.3%) 69 (8.7%) | 899 (83.9%) 112 (10.4%) 61 (2.9%) | < 0.001 | | Prior MI | 2 (6.9%) | 8 (3.5%) | 6 (0.8%) | 5 (0.5%) | < 0.001 | | CHF within 30 days prior OR | 4 (13.8%) | 9 (4.0%) | 16 (2.0%) | 5 (0.5%) | < 0.001 | | Acute renal failure | 3 (10.3%) | 17 (7.5%) | 5 (0.6%) | 2 (0.2%) | < 0.001 | | Dyspnea None Minimal exertion Rest | 18 (62.1%) 7 (24.1%) 4 (13.8%) | 197 (86.8%) 18 (7.9%) 12 (5.3%) | 733 (92.0%) 45 (5.6%) 19 (2.4%) | 1031(96.3%) 37 (3.5%) 3 (0.3%) | < 0.001 | | Outcomes | |
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| Overall morbidity | 15 (51.7%) | 97 (42.7%) | 151 (18.9%) | 63 (5.9%) | <0.001 | | Number of complications | 1.24 ± 1.6 | 0.83 ± 1.2 | 0.34 ± 0.9 | 0.09 ± 0.4 | <0.001 | | 30-day mortality | 5 (17.2%) | 28 (12.3%) | 21 (2.6%) | 3 (0.3%) | <0.001 | | Admission to ICU after surgery | 23 (79%) | 130 (57.3%) | 273 (34.3%) | 182 (17.0%) | < 0.001 | | Initial length of ICU stay (days) | 17.3 ± 21.2 | 14.6 ± 20.0 | 9.7 ± 15.3 | 9.9 ± 15.4 | 0.009 |
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