Surgical Apgar Score (SAS) for Postoperative Risk
Predicts postoperative risk of major complication, including death.
Result:
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.
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.
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.