G. Francis1, S. Vavilov1, D. Eliezer1, P. Pockney1,2 1John Hunter Hospital,Surgical Services,Newcastle, NEW SOUTH WALES, Australia 2University of Newcastle,School Of Medicine And Public Health,Newcastle, NEW SOUTH WALES, Australia
Introduction: Emergency laparotomies performed in high risk patients can lead to significant morbidity and mortality. Portsmouth Physiological and Operative Severity Score for the enumeration of mortality (P-POSSUM) is a widely used pre-operative risk stratification tool used for estimating operative mortality with good sensitivity. We hypothesize the sensitivity of this prediction could be improved by performing a dynamic scoring (the difference between pre and post-operative scoring) which has been useful in other clinical scenarios.
Methods: A retrospective review of all emergency laparotomies undertaken at four different sized Australian surgical centers was performed between January 2016 and December 2018. Patient demographics, pre-operative clinical findings, hematology and biochemistry results, intra-operative data and post-operative course documentation were extracted from records. An online P-POSSUM calculator was used to estimate a 30-day mortality risk using pre- and post-operative data as two separate scores. Further information was collected on high risk patients (>10% mortality risk) including mortality at 30 days, length of hospital stay (LOS), length of intensive care unit stay (ICU LOS) and unplanned readmissions to ICU. The analysis was performed of these outcomes in relation to dynamic scoring for patients whose mortality risk either increased or decreased by greater than 5 points postoperatively.
Results: There were 821 patient charts reviewed during the study period. Patient demographics included 383 males (46.7%), mean age: 64.8 years, median ASA: 3, mean LOS: 14.0 days and mean ICU LOS: 1.8 days. There were 74 patients who died within 30 days (9.0%). Thirty-six patients had unplanned readmission to ICU. Pre-operative P-POSSUM score >10% risk was able to identify 54 deaths at 30 days (Sensitivity = 73.0%). For dynamic scoring, 624 patients had post-operative scores within 5 points of their pre-operative score while 109 had scores that improved by ≥5 points and 88 had scores that worsened by ≥5 points. Of the 109 patients with improving scores, there were 15 deaths within 30 days and three (2.7%) unplanned admissions to ICU. Of the 88 patients within worsening scores, there were 13 deaths within 30 days and 11 (12.5%) unplanned admissions to ICU. Using a Chi-square test, there was a statistical difference between the two groups for unplanned ICU admissions (p=0.008). There was no statistical difference in 30-day mortality (p=0.84) or 90-day mortality (p=0.48). There was also no difference when comparing LOS (17.7 ± 14.6 vs 22.3 ± 20.2, p=0.06) and ICU LOS (2.9 ± 3.8 vs 3.7 ± 5.1, p=0.22).
Conclusion: Dynamic scoring predicts the need for admission to ICU and may help to plan post-operative patient destination and resource allocation better than isolated pre-operative scoring. Within our patient cohort, we were unable to demonstrate a statistical difference in the 30-day mortality, hospital LOS or ICU LOS. We believe further prospective study in this field is warranted given the clinical utility of this method.