title: Use of the surgical Apgar score to guide postoperative care.
abstract: BACKGROUND
  The surgical Apgar score (SAS) can predict 30-day major complications or death after surgery. Studies have validated the score in different patient populations and suggest it should be used to objectively guide postoperative care. We aimed to see whether using the SAS in a decisive approach in a future randomised controlled trial (RCT) would be likely to demonstrate an effect on postoperative care and clinical outcome.
  
  
  METHODS
  A total of 143 adults undergoing general/vascular surgery in 9 National Health Service hospitals were recruited to a pilot single blinded RCT and the data for 139 of these were analysed. Participants were randomised to a control group with standard postoperative care or to an intervention group with care influenced (but not mandated) by the SAS (decisive approach). The notional primary outcome was 30-day major complications or death.
  
  
  RESULTS
  Incidence of major complications was similar in both groups (control: 20/69 [29%], intervention: 23/70 [33%], p=0.622). Immediate admissions to the critical care unit was higher in the intervention group, especially in the SAS 0-4 subgroup (4/6 vs 2/7) although this was not statistically significant (p=0.310). Validity was also confirmed in area under the curve (AUC) analysis (AUC: 0.77).
  
  
  CONCLUSIONS
  This pilot study found that a future RCT to investigate the effect of using the SAS in a decisive approach may demonstrate a difference in postoperative care. However, significant changes to the design are needed if differences in clinical outcome are to be achieved reliably. These would include a wider array of postoperative interventions implemented using a quality improvement approach in a stepped wedge cluster design with blinded collection of outcome data.
authors.affiliation: London Surgical Research Group.
authors.forename: J B
authors.initials: JB
authors.lastname: Haddow
authors.forename: H
authors.initials: H
authors.lastname: Adwan
authors.forename: S E
authors.initials: SE
authors.lastname: Clark
authors.forename: S
authors.initials: S
authors.lastname: Tayeh
authors.forename: S S
authors.initials: SS
authors.lastname: Antonowicz
authors.forename: P
authors.initials: P
authors.lastname: Jayia
authors.forename: D W
authors.initials: DW
authors.lastname: Chicken
authors.forename: T
authors.initials: T
authors.lastname: Wiggins
authors.forename: R
authors.initials: R
authors.lastname: Davenport
authors.forename: S
authors.initials: S
authors.lastname: Kaptanis
authors.forename: M
authors.initials: M
authors.lastname: Fakhry
authors.forename: C H
authors.initials: CH
authors.lastname: Knowles
authors.forename: A S
authors.initials: AS
authors.lastname: Elmetwally
authors.forename: E
authors.initials: E
authors.lastname: Geddoa
authors.forename: M S
authors.initials: MS
authors.lastname: Nair
authors.forename: I
authors.initials: I
authors.lastname: Naeem
authors.forename: S
authors.initials: S
authors.lastname: Adegbola
authors.forename: L J
authors.initials: LJ
authors.lastname: Muirhead
mesh_terms: D000328:Adult; D019540:Area Under Curve; D006801:Humans; D010808:Physical Examination / Q000379:methods*; D010865:Pilot Projects; D011182:Postoperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000628:therapy