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. 2015 Jul 26;4(3):240-7.
doi: 10.1016/j.amsu.2015.07.004. eCollection 2015 Sep.

Identification of the high risk emergency surgical patient: Which risk prediction model should be used?

Stephen Stonelake  1 , Peter Thomson  2 , Nigel Suggett  3
Affiliations

Identification of the high risk emergency surgical patient: Which risk prediction model should be used?

Stephen Stonelake et al. Ann Med Surg (Lond). .

Abstract

Introduction: National guidance states that all patients having emergency surgery should have a mortality risk assessment calculated on admission so that the 'high risk' patient can receive the appropriate seniority and level of care. We aimed to assess if peri-operative risk scoring tools could accurately calculate mortality and morbidity risk.

Methods: Mortality risk scores for 86 consecutive emergency laparotomies, were calculated using pre-operative (ASA, Lee index) and post-operative (POSSUM, P-POSSUM and CR-POSSUM) risk calculation tools. Morbidity risk scores were calculated using the POSSUM predicted morbidity and compared against actual morbidity according to the Clavien-Dindo classification.

Results: The actual mortality was 10.5%. The average predicted risk scores for all laparotomies were: ASA 26.5%, Lee Index 2.5%, POSSUM 29.5%, P-POSSUM 18.5%, CR-POSSUM 10.5%. Complications occurred following 67 laparotomies (78%). The majority (51%) of complications were classified as Clavien-Dindo grade 2-3 (non-life-threatening). Patients having a POSSUM morbidity risk of greater than 50% developed significantly more life-threatening complications (CD 4-5) compared with those who predicted less than or equal to 50% morbidity risk (P = 0.01).

Discussion: Pre-operative risk stratification remains a challenge because the Lee Index under-predicts and ASA over-predicts mortality risk. Post-operative risk scoring using the CR-POSSUM is more accurate and we suggest can be used to identify patients who require intensive care post-operatively.

Conclusions: In the absence of accurate risk scoring tools that can be used on admission to hospital it is not possible to reliably audit the achievement of national standards of care for the 'high-risk' patient.

Keywords: Emergency laparotomy risk prediction mortality.

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Figures

Fig. 1
Fig. 1
Inclusion and exclusion criteria.
Fig. 2
Fig. 2
Predicted percentage risk in emergency laparotomy according to different risk tools.
Fig. 3
Fig. 3
Frequency of complications following laparotomy.
Fig. 4
Fig. 4
Average predicted POSSUM morbidity in patient who developed complications according to Clavian–Dindo Classification.
Fig. 5
Fig. 5
Frequency of patients developing CD 0–3 and CD 4–5 complications in laparotomies where the POSSUM morbidity score was >50% or >85% morbidity risk.
Fig. 6
Fig. 6
The difference in predicted risk of patients who received Level 1 and Level 3 care immediately post-operatively.
See this image and copyright information in PMC

References

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