title: Utility of the Surgical Apgar Score in a district general hospital.
abstract: BACKGROUND
  The Surgical Apgar Score (SAS) is a simple tool for intraoperative risk stratification. The aim of this prospective observational study was to assess its performance in predicting outcome after general/vascular and orthopedic surgery and its utility in a U.K. district general hospital.
  
  
  METHODS
  A prospective cohort of 223 consecutive general, vascular, and orthopedic surgical cases was studied. The SAS was calculated for all patients, and its relationship to 30 day mortality and major complication assessed with reference to the mode of surgery (elective or emergent). Statistical analysis of categorical data was performed with Fisher's exact test and the AUC (area under the curve) on receiver operating characteristic (ROC) analysis. Selected cases were reviewed to assess the potential of the SAS to modify postoperative management.
  
  
  RESULTS
  The proportion of patients who died or experienced major complications increased monotonically with Surgical Apgar Score category in general and vascular but not orthopedic cases. The relative risks of mortality or major complication between SAS categories were less marked than in previous publications. The SAS performed variably on ROC curve analysis, with an AUC of 0.62-0.73. Discrimination achieved significance in general and vascular cases (p = 0.0002) but not in orthopedic cases (p = 0.15). Subgroup analysis of high (SAS < 7) and low risk (SAS ≥ 7) groups demonstrated utility of the score in general surgery and vascular cases overall (p < 0.0001), and in the emergency (p = 0.004) but not elective (p = 0.12) subgroups. Case note review of those patients who died indicated that despite their identification by the SAS, there would have been limited scope to modify outcome.
  
  
  CONCLUSIONS
  This study provides further evidence that the SAS is a simple and effective predictive tool in the emergency general and vascular surgical setting. It appears to have a limited role in the management of individual patients after orthopedic surgery and elective general/vascular surgery. The SAS has been proven to reliably stratify risk in larger populations and might be applied most usefully as a marker of quality. Further studies are required to determine whether its application can influence outcome.
authors.affiliation: Department of Surgery, Barnet General Hospital, Wellhouse Lane Barnet, Hertfordshire, EN5 3DJ, UK. christhorn77@yahoo.com.|Level 5, St. Marks Hospital, Northwick Park, Watford Road, London, HA1 3UJ, UK. christhorn77@yahoo.com.
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Thorn
authors.affiliation: Department of Surgery, Barnet General Hospital, Wellhouse Lane Barnet, Hertfordshire, EN5 3DJ, UK.
authors.forename: Melanie
authors.initials: M
authors.lastname: Chan
authors.affiliation: Department of Surgery, Barnet General Hospital, Wellhouse Lane Barnet, Hertfordshire, EN5 3DJ, UK.
authors.forename: Nihal
authors.initials: N
authors.lastname: Sinha
authors.affiliation: Department of Surgery, Barnet General Hospital, Wellhouse Lane Barnet, Hertfordshire, EN5 3DJ, UK.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Harrison
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical; D001794:Blood Pressure; D003661:Decision Support Techniques; D017558:Elective Surgical Procedures / Q000401:mortality; D004630:Emergencies; D006305:Health Status Indicators; D006339:Heart Rate; D006767:Hospitals, District; D006769:Hospitals, General; D006801:Humans; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D019637:Orthopedic Procedures / Q000401:mortality; D011183:Postoperative Complications / Q000517:prevention & control*; D011379:Prognosis; D012372:ROC Curve; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods; D006113:United Kingdom; D014656:Vascular Surgical Procedures / Q000401:mortality; D055815:Young Adult