Comparison of different methods of risk stratification in urgent and emergency surgery.

BACKGROUND: The aim was to compare a number of risk scoring systems prospectively in a cohort of patients who underwent non-elective surgery. METHODS: This was a cohort study of 2349 consecutive patients who had urgent or emergency surgery in a district general hospital in the UK. All patients were scored prospectively using the Revised Goldman Cardiac Risk Index (RGCRI), Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), Surgical Risk Score (SRS) and Biochemistry and Haematology Outcome Models (BHOM). Actual 30-day and 1-year survival rates were compared with the predicted outcomes using receiver-operator characteristic (ROC) curves and Hosmer-Lemeshow analysis. RESULTS: Some 141 patients (6.0 per cent) died within 30 days of operation. This increased to 254 (10.8 per cent) by 1 year. The area under the ROC curve for death within 30 days was 0.90 for P-POSSUM, 0.85 for SRS, 0.84 for BHOM and 0.73 for RGCRI. Only the first three risk scores were able to discriminate accurately within the groups (area under ROC curve over 0.8), with no significant variation between expected and observed mortality rates confirmed by Hosmer-Lemeshow analysis. Similar results were found for the ability of each score to predict outcome at 1 year. CONCLUSION: P-POSSUM, SRS and BHOM scoring systems were all able to predict outcome after emergency and urgent surgery, but the SRS had the advantage of ease of calculation. BHOM requires only the most commonly available blood test data and the computer holding these data can easily perform the calculation.

Lessons learned from a randomised controlled study of perioperative beta blockade in high risk patients undergoing emergency surgery.

BACKGROUND: Perioperative beta blockade has been shown to reduce mortality after major elective surgery. The aim of this study was to determine whether it could reduce the rate of death and morbidity from cardiac complications in high risk patients undergoing emergency surgery. METHODS: Over a one-year interval all patients undergoing major non-elective orthopaedic or general surgery were screened to identify those at high risk of cardiac complications. Consenting, high risk patients were randomly allocated atenolol or placebo for seven days, commencing at anaesthetic induction. Deaths and cardiac complications within 30 days were recorded. RESULTS: Some 2351 patients had an emergency operation; 145 were at high risk and eligible for the study. Of 89 patients approached, 57 initially consented. Only 38 patients, however, completed the study protocol, 19 were withdrawn. Of those who completed the study, 5/20 patients in the placebo group and 3/18 in the treatment group died before hospital discharge (p=0.520). Four others in the placebo group and two in the atenolol group had post-operative non-fatal cardiac events (positive troponin T), p=0.311. CONCLUSIONS: This study of emergency surgery proved more difficult than similar trials in elective surgery. The final study groups were small and there were no significant differences in outcomes. A much larger study is required for a definitive answer.

Identifying high-risk patients undergoing urgent and emergency surgery.

INTRODUCTION: The aim was to identify high-risk patients undergoing non-elective orthopaedic and general surgery. PATIENTS AND METHODS: This was a retrospective cohort study of all non-elective general and orthopaedic surgical procedures performed in a 1-year interval in a district general hospital. A total of 1869 patients underwent urgent or emergency surgery in the calendar year 2000. Outcomes were identified from various related hospital databases. Case notes of those who died were reviewed. Risk factors for mortality were examined using univariate and multivariate analysis. RESULTS: The mortality rates were 89/1869 (5%) at 30 days and 216 (12%) after 1 year. The high initial death rate continued for about 100 days after surgery. Increasing age (P < 0.0001), size of operation (P = 0.004) and American Society of Anesthesiologists (ASA) fitness grade (P < 0.0001) were associated with significantly higher risk of death at 1 year on multivariate analysis. A high risk group was identified of 273 patients aged over 50 years, of ASA Grade III or above who needed major surgery; they had a 30-day mortality rate of 18%. CONCLUSIONS: A simple scoring system could be used to identify high-risk patients who require non-elective surgery that could be a target for interventions to try and reduce their risk of death.

Comparison of POSSUM scoring and the Hardman Index in selection of patients for repair of ruptured abdominal aortic aneurysm.

BACKGROUND: The aim was to assess to what extent the POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) and Hardman scoring systems were predictive of outcome after surgery for ruptured abdominal aortic aneurysm (RAAA). METHODS: From January 1990 to December 2001, 232 patients presented with RAAA. Forty-one were treated conservatively and all died; the remainder had emergency surgery. The case notes of all but three of these patients were reviewed retrospectively. POSSUM and Hardman scores were calculated and related to mortality. RESULTS: The mortality rate after emergency repair was 54 per cent (104 of 191). The physiology-only POSSUM score specific for RAAA and the Hardman Index score were both significantly associated with increased mortality after operation (P < 0.001). Most non-operated patients were in the highest risk bands. CONCLUSION: Both POSSUM and Hardman scoring systems predicted outcome after emergency surgery for RAAA. The Hardman Index was simpler to calculate, but POSSUM identified a higher number of patients at risk. Risk scoring may help identify patients with RAAA for whom surgery is futile.

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM).

BACKGROUND AND METHODS: The development of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is described and its methods of analysis and value in a modern surgical practice are reviewed. A computerized search of all published data in Medline, the Cochrane Library and Embase was made for the last 12 years. Relevant articles were then searched manually for further papers on risk analysis, case-mix comparison and POSSUM methodology. RESULTS AND CONCLUSION: POSSUM has been evaluated extensively in both general and specialist surgery. While there are problems with both data collection and analysis, when used correctly POSSUM can usefully compare outcomes between surgeons and between hospitals. In specialist surgery, individual regression equations may be needed for each index procedure.