Surgical Apgar Score (SAS) for Postoperative Risk
Why Use
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).
When to Use
The SAS can be applied to any patient who is postop from major surgery.
Formula
Pearls / Pitfalls
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.
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.
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.
More Information
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.