Does an objective system-based approach improve assessment of perioperative risk in children? A preliminary evaluation of the 'NARCO'.
BACKGROUND
This study evaluated whether an objective tool would provide a more reliable and valid assessment of perioperative risk compared with the ASA-physical status (ASA-PS) in children.


METHODS
A system-based risk assessment tool was developed using these categories: Neurological, Airway, Respiratory, Cardiovascular, and Other (NARCO) with a subcomponent grading surgical severity (SS). Anaesthesiologists reviewed the preoperative assessments and assigned NARCO, SS, and ASA-PS scores independently. Perioperative outcomes were recorded by trained observers. Validity and reliability of the tools were evaluated.


RESULTS
NARCO correlated with ASA-PS (ρ=0.664; P<0.01) supporting its criterion validity. Inter-rater reliability of the measures was supported (intraclass correlation coefficients 0.71-0.96; κ 0.43-0.87) except for the Airway category. Measures of exact agreement were slightly better for NARCO compared with ASA-PS. NARCO, SS, and ASA-PS scores correlated significantly with perioperative escalation of care, adverse events (AE), hospital length of stay, and admission status. Correlations between NARCO and ASA-PS and outcomes improved when SS was factored into their coding. There were significant, but low, correlations between all measures and mortality. The odds of having escalation of care, AE, and mortality were 5-47 times greater among children with higher risk scores.


CONCLUSIONS
Findings suggest that all measures of outcome have acceptable to excellent reliability with a slight improvement in agreement for the NARCO compared with the ASA-PS. This study supports the validity of both the NARCO and the ASA-PS in predicting perioperative risk in children with a slight improvement in correlations when combined with the SS score.
The University of Michigan Health System, F3900 C.S. Mott Hospital SPC 5211, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5211, USA. smalviya@umich.edu
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Malviya
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Voepel-Lewis
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Chiravuri
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Gibbons
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Chimbira
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Nafiu
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Reynolds
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Tait
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D006305:Health Status Indicators; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007431:Intraoperative Complications; D019990:Perioperative Care / Q000379:methods; D011183:Postoperative Complications; D011300:Preoperative Care / Q000379:methods*; D011379:Prognosis; D011594:Psychometrics; D018570:Risk Assessment / Q000379:methods