Surgical Apgar score: a predictor of Postoperative complication in patients Undergoing surgery for traumatic brain injury.

Abstract

Background: Health facilities strive to offer quality surgical care by minimizing postoperative complications. Predicting complications facilitates objective clinical decision making during recovery. Compared to existing morbidity and mortality predictive scores, the Surgical Apgar Score is simple and effective. Morbidity and mortality in neurotrauma patients are high; an effective scoring system can reduce these. Objective: To determine the utility of the Surgical Apgar Score in predicting the ‘thirty day major postoperative complications rates for patients with traumatic brain injury. Study design: Prospective descriptive study. Study population: Two hundred and three patients aged 13 years and above undergoing surgery for traumatic brain injury at Kenyatta National Hospital were selected by consecutive sampling until the desired sample size was achieved. Study duration: Four months from 23rd December 2014 to 15th April 2015. Material and methods: Intra operative values of the lowest mean arterial pressure, the lowest heart rate and the blood loss were collected using a questionnaire immediately after surgery and the Surgical Apgar Score was derived for each patient. The occurrence of major complications and the mortality rate was determined during a thirty day period starting immediately after surgery. Data was obtained from the admitting ward, the ICU and neurosurgical outpatient clinic notes. Major complication definitions were according to American College of Surgeons’ National Surgical Quality Improvement Program with inclusion of seizure. Data collected was entered and analyzed using SPSS version 17software. P values were generated using t test for means, x2 for comparison of proportions, analysis of variance (ANOVA) and where applicable Fischer’s exact test. Results were presented in graph, tables and charts. Results Two hundred and seven (207) patients were recruited of which six were lost on follow up. Mean age was 32.7 year with male to female ratio of 22:1. One hundred and sixteen(56%) of the patients developed one or more major complications during the 30 day period post surgery. Need for intensive care (43.1%) and development of neurological deficit (38.8%) xi were the common post operative complications. While older age was associated with more complications, no significant difference in complication rates was found between male and female patients. Most patients 40(19%) had a SAS of 6 with a mean of 5.72. The mean SAS for patients without complications was 7.04(±0.29) while for patients with complications was 4.80(±0.30) (p-value < 0.001). High risk SAS category patients (78%) developed more major postoperative complications compared to medium and low risk SAS category patients. Thirty day mortality and need of intensive care were also linked with high risk SAS. SAS was found to have a strong correlation with occurrence of major complication during the 30 day post surgery period. Conclusion Surgery for neurotrauma is associated with significant morbidity and mortality. The SAS, despite using simple and widely available intra-operative parameters, is useful tool to predict occurrence of 30 day major complications and mortality following surgery in patients with traumatic brain injury.