Hierarchical regression of ASA prediction model in predicting mortality prior to performing emergency laparotomy a systematic review
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ABSTRACT: Background
In light of increasing litigations around performing emergency surgery, various predictive tools are used for prediction of mortality prior to surgery. There are many predictive tools reported in literature, with ASA being one of the most widely accepted tools. Therefore, we attempted to perform a systematic review and meta-analysis to conclude ASA's ability in predicting mortality for emergency surgeries. Methods
A wide literature search was conducted across MEDLINE and other databases using PubMed and Ovid with the following keywords; “Emergency laparotomy”, “Surgical outcomes”, “Mortality” and “Morbidity.” A total of 3989 articles were retrieved and only 11 articles met the inclusion criteria for this meta-analysis. Data was pooled and then analysed using the STATA 16.1 software. We conducted hierarchal regression between the following variables; mortality, gender, low ASA (ASA 1–2) and high ASA (ASA 3–5). Results
1. High ASA was associated with a higher rate of mortality in males with ‘p’ value of 0.0001 at alpha value of 0.025. 2. The female gender itself showed a significantly high mortality rate, irrespective of low ASA or high ASA with ‘p’ value of 0.04 at alpha value of 0.05. 3. ITU admissions with a high ASA had a greater number of deaths compared to low ASA. ‘p’ value of 0.0054 at alpha value of 0.01. Conclusion
Higher ASA showed a direct association with mortality and the male gender. The female gender was associated with a higher risk of mortality regardless of the ASA grades. Highlights • ASA is one of the most widely accepted predictive tools.• Higher ASA showed a direct association with mortality and the male gender.• The female gender was associated with higher risk of mortality regardless of the ASA.• ASA 4 and above are high-risk for emergency laparotomy. They should all be admitted to ITU for pre- and post-operative care.
SUBMITTER: Akhtar M
PROVIDER: S-EPMC7779956 | biostudies-literature | 2020 Dec
REPOSITORIES: biostudies-literature
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Project description:BackgroundGeriatric patients frequently undergo emergency general surgery and accrue a greater risk of postoperative complications and fatal outcomes than the general population. It is highly relevant to develop the most appropriate care measures and to guide patient-centered decision-making around end-of-life care. Portsmouth - Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) has been used to predict mortality in patients undergoing different types of surgery. In the present study, we aimed to evaluate the relative importance of the P-POSSUM score for predicting 90-day mortality in the elderly subjected to emergency laparotomy from statistical aspects.MethodsOne hundred and fifty-seven geriatric patients aged ?65?years undergoing emergency laparotomy between January 1st, 2015 and December 31st, 2016 were included in the study. Mortality and 27 other patient characteristics were retrieved from the computerized records of Örebro University Hospital in Örebro, Sweden. Two supervised classification machine methods (logistic regression and random forest) were used to predict the 90-day mortality risk. Three scalers (Standard scaler, Robust scaler and Min-Max scaler) were used for variable engineering. The performance of the models was evaluated using accuracy, sensitivity, specificity and area under the receiver operating characteristic curve (AUC). Importance of the predictors were evaluated using permutation variable importance and Gini importance.ResultsThe mean age of the included patients was 75.4 years (standard deviation =7.3 years) and the 90-day mortality rate was 29.3%. The most common indication for surgery was bowel obstruction occurring in 92 (58.6%) patients. Types of post-operative complications ranged between 7.0-36.9% with infection being the most common type. Both the logistic regression and random forest models showed satisfactory performance for predicting 90-day mortality risk in geriatric patients after emergency laparotomy, with AUCs of 0.88 and 0.93, respectively. Both models had an accuracy >?0.8 and a specificity ?0.9. P-POSSUM had the greatest relative importance for predicting 90-day mortality in the logistic regression model and was the fifth important predictor in the random forest model. No notable change was found in sensitivity analysis using different variable engineering methods with P-POSSUM being among the five most accurate variables for mortality prediction.ConclusionP-POSSUM is important for predicting 90-day mortality after emergency laparotomy in geriatric patients. The logistic regression model and random forest model may have an accuracy of >?0.8 and an AUC around 0.9 for predicting 90-day mortality. Further validation of the variables' importance and the models' robustness is needed by use of larger dataset.
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Project description:BackgroundEmergency laparotomy (EL) is a central, high-risk procedure in emergency surgery. Patients in need of an EL present an acute pathology in the abdomen that must be operated on in order to save their lives. Usually, the underlying condition produces an affected physiology. The perioperative management of this critically ill patient group in need of high-risk surgery and anaesthesia is challenging and related to high mortality worldwide. However, outcomes in Sweden have yet to be studied. This retrospective cohort study explores the perioperative management and outcome after 710 ELs by investigating mortality, overall length of stay (LOS) in hospital, need for care at the intensive care unit (ICU), surgical complications and a general review of perioperative management.MethodsMedical records after laparotomy was retrospectively analysed for a period of 38 months (2014-2017), the emergency cases were included. Children (< 18 years), aortic surgery, second look and other expected reoperations were excluded. Demographic, management and outcome data were collected after an extensive analysis of the cohort.ResultsA total of 710 consecutive operations, representing 663 patients, were included in the cohort (mean age 65.6 years). Mortality (30 days/1 year) after all operations was 14.2% and 26.6% respectively. The mean LOS in hospital was 12 days, while LOS in the ICU was five days. Of all operations, 23.8% patients were admitted at any time to the ICU postoperatively and the 30-day mortality seen among ICU patients was 37.9%. Mortality was strongly correlated to existing comorbidity, high ASA classification, ICU care and faecal peritonitis. The mean/median time from notification to operate until the first incision was 3:46/3:02 h and 87% of patients had their first incision within 6 h of notification.ConclusionsIn this present Swedish study, high mortality and morbidity were observed after emergency laparotomy, which is in agreement with other recent studies.Trial registrationThe study has been registered with ClinicalTrials.gov (NCT03549624, registered 8 June 2018).
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Project description:BACKGROUND:Laparotomy remains one of the commonest emergency surgical procedures. Early prognostic evaluation would aid in selecting the high-risk patients for an aggressive treatment. Awareness about risks could potentially contribute to the quality of perioperative care and optimum utilization of resources. Portsmouth modification of Physiological and operative severity for the enumeration of mortality and morbidity (P-POSSUM) and the acute physiology and chronic health evaluation II (APACHE-II) have been the most widely used scoring systems for emergency laparotomies. It is always better to have a single scoring system to predict outcomes and audit healthcare organizations. AIM:To compare the ability of APACHE-II and P-POSSUM to predict postoperative morbidity and mortality in patients undergoing emergency laparotomy. METHODS:All patients undergoing emergency laparotomy at the Tata Main Hospital, Jamshedpur between December 2013 and November 2014 were included in the study. In this observational study, P-POSSUM and APACHE-II scoring were done, and the outcome analysis evaluated with mortality being the primary outcome. RESULTS:For P-POSSUM, at a cut off value of 63 to predict mortality using receiver operating characteristics curve analysis, the area under the curve was 0.989; and for APACHE-II, at the cut off value of 24, the area under the curve was 0.965. CONCLUSION:Because the ability of APACHE-II to predict mortality was similar to P-POSSUM and APACHE-II does not need scoring for intra-operative findings and histopathology reports, APACHE-II can be used pre-operatively to assess the risk in patients undergoing emergency laparotomy. However, for audit purposes, either of the two scoring systems can be used.
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Project description:There is a great deal of prior knowledge about gene function and regulation in the form of annotations or prior results that, if directly integrated into individual prognostic or diagnostic studies, could improve predictive performance. For example, in a study to develop a predictive model for cancer survival based on gene expression, effect sizes from previous studies or the grouping of genes based on pathways constitute such prior knowledge. However, this external information is typically only used post-analysis to aid in the interpretation of any findings. We propose a new hierarchical two-level ridge regression model that can integrate external information in the form of "meta features" to predict an outcome. We show that the model can be fit efficiently using cyclic coordinate descent by recasting the problem as a single-level regression model. In a simulation-based evaluation we show that the proposed method outperforms standard ridge regression and competing methods that integrate prior information, in terms of prediction performance when the meta features are informative on the mean of the features, and that there is no loss in performance when the meta features are uninformative. We demonstrate our approach with applications to the prediction of chronological age based on methylation features and breast cancer mortality based on gene expression features.
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Project description:BACKGROUND: Emergency laparotomies in the U.K., U.S.A. and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6?h, goal-directed fluid therapy and postoperative intensive care. METHODS: The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model. RESULTS: Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6.47 in the baseline interval (299 patients included) to 12.44 after implementation (427 patients included) (P?<?0.001). The overall case mix-adjusted risk of death decreased from 15.6 to 9.6 per cent (risk ratio 0.614, 95 per cent c.i. 0.451 to 0.836; P?=?0.002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0.197 and 0.223 before and after implementation respectively; P?=?0.395). CONCLUSION: Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.
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Project description:BackgroundThe World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy.MethodsIn two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation.ResultsOf 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle (753 of 1242, 60·6 per cent; odds ratio (OR) 0·17, 95 per cent c.i. 0·14 to 0·21, P < 0·001) or low (363 of 860, 42·2 per cent; OR 0·08, 0·07 to 0·10, P < 0·001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -9·4 (95 per cent c.i. -11·9 to -6·9) per cent; P < 0·001), but the relationship was reversed in low-HDI countries (+12·1 (+7·0 to +17·3) per cent; P < 0·001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries.ConclusionChecklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.
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Project description:Past studies have highlighted variation in in-hospital mortality rates among hospitals performing emergency laparotomy for large bowel perforation. The aim of this study was to investigate whether failure to rescue (FTR) contributes to this variability. Patients aged 18 years or over requiring surgery for large bowel perforation between 2013 and 2016 were extracted from the National Emergency Laparotomy Audit (NELA) database. Information on complications were identified using linked Hospital Episode Statistics data and in-hospital deaths from the Office for National Statistics. The FTR rate was defined as the proportion of patients dying in hospital with a recorded complication, and was examined in hospitals grouped as having low, medium or high overall postoperative mortality. Overall, 6413 patients were included with 1029 (16.0 per cent) in-hospital deaths. Some 3533 patients (55.1 per cent) had at least one complication: 1023 surgical (16.0 per cent) and 3332 medical (52.0 per cent) complications. There were 22 in-hospital deaths following a surgical complication alone, 685 deaths following a medical complication alone, 150 deaths following both a surgical and medical complication, and 172 deaths with no recorded complication. The risk of in-hospital death was high among patients who suffered either type of complication (857 deaths in 3533 patients; FTR rate 24.3 per cent): 172 deaths followed a surgical complication (FTR-surgical rate 16.8 per cent) and 835 deaths followed a medical complication (FTR-medical rate of 25.1 per cent). After adjustment for patient characteristics and hospital factors, hospitals grouped as having low, medium or high overall postoperative mortality did not have different FTR rates (P = 0.770). Among patients having emergency laparotomy for large bowel perforation, efforts to reduce the risk of in-hospital death should focus on reducing avoidable complications. There was no evidence of variation in FTR rates across National Health Service hospitals in England.
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Project description:AimThere is evolving evidence that preoperative frailty predicts outcomes of older adults undergoing emergency laparotomy (EmLap). We assessed frailty scoring in an emergency surgical population that included patients of all ages and then compared this to an established perioperative prognostic score.MethodData from the prospective Emergency Laparoscopic and Laparotomy Scottish Audit (ELLSA; November 2017-October 2018) was used. All adults over 18 were included. Frailty was measured using 7-point clinical frailty score (CFS).Outcome measures30-day mortality, hospital length of stay (LOS), 30-day readmission. Areas under the receiver-operating characteristic (ROC) curves were calculated for CFS (1-7) and compared to the National Emergency Laparotomy Audit (NELA) score with Forest plots used to compare 30-day mortality across CFS and NELA categories.ResultsA total of 2246 patients (median age 65 years [IQR 51-75]; female 51%) underwent EmLap (60% for colorectal pathology). A total of 10.6% were frail preoperatively (≥CFS 5). As CFS increased so did 30-day mortality (2.1% CFS1 to 25.3% CFS6 and 7; ꭓ2 78.2, p < 0.001) and median LOS (10 days CFS1 to 20 days CFS6 and 7; p < 0.001). Readmission rates did not differ significantly across CFS. ROC (95% CI) for mortality was 0.71 (0.65-0.77) for CFS and 0.84 (0.78-0.89) for NELA. Addition of CFS to NELA did not increase ROC value.ConclusionThis study supports the prognostic role of frailty in the emergency surgical setting, finding increasing frailty to be associated with increased mortality and longer LOS in adults of all ages. Although NELA performed better, CFS remained predictive and has the advantage of being calculated preoperatively to aid decision-making and treatment planning.
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Project description:PURPOSE:Sepsis is a common acute life-threatening condition that emergency physicians routinely face. Diagnostic options within the Emergency Department (ED) are limited due to lack of infrastructure, consequently limiting the use of invasive hemodynamic monitoring or imaging tests. The mortality rate due to sepsis can be assessed via multiple scoring systems, for example, mortality in emergency department sepsis (MEDS) score and sepsis patient evaluation in the emergency department (SPEED) score, both of which quantify the variation of mortality rates according to clinical findings, laboratory data, or therapeutic interventions. This study aims to improve the management processes of sepsis patients by comparing SPEED score and MEDS score for predicting the 28-day mortality in cases of emergency sepsis. METHODS:The study is a cross-sectional, prospective study including 61 sepsis patients in ED in Suez Canal University Hospital, Egypt, from August 2017 to June 2018. Patients were selected by two steps: (1) suspected septic patients presenting with at least one of the following abnormal clinical findings: (a) body temperature higher than 38 °C or lower than 36 °C, (b) heart rate higher than 90 beats/min, (c) hyperventilation evidenced by respiratory rate higher than 20 breaths/min or PaCO2 lower than 32 mmHg, and (d) white blood cell count higher than 12,000/?L or lower than 4000/?L; (2) confirmed septic patients with at least a 2-point increase from the baseline total sequential organ failure assessment (SOFA) score following infection. Other inclusion criteria included adult patients with an age ?18 years regardless of gender and those who had either systemic inflammatory response syndrome or suspected/confirmed infection. Patients were shortly follow-up for the 28-day mortality. Each patient was subject to SPEED score and MEDS score and then the results were compared to detect which of them was more effective in predicting outcome. The receiver operating characteristic curves were also done for MEDS and SPEED scores. RESULTS:Among the 61 patients, 41 died with the mortality rate of 67.2%. The mortality rate increased with a higher SPEED and MEDS scores. Both SPEED and MEDS scores revealed significant difference between the survivors and nonsurvivors (p = 0.004 and p < 0.001, respectively), indicating that both the two systems are effective in predicting the 28-day mortality of sepsis patients. Thereafter, the receiver operating characteristic curves were plotted, which showed that SPEED was better than the MEDS score when applied to the complete study population with an area under the curve being 0.87 (0.788-0.963) as compared with 0.75 (0.634-0.876) for MEDS. Logistic regression analysis revealed that the best fitting predictor of 28-day mortality for sepsis patients was the SPEED scoring system. For every one unit increase in SPEED score, the odds of 28-day mortality increased by 37%. CONCLUSION:SPEED score is more useful and accurate than MEDS score in predicting the 28-day mortality among sepsis patients. Therefore SPEED rather than MEDS should be more widely used in the ED for sepsis patients.
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