Pediatric Surgical Risk Assessment Tools: A Systematic Review

A systematic review of neurological airway respiratory cardiovascular other-surgical severity (NARCO-SS) score as a pediatric perioperative scoring system

OBJECTIVE

To systematically identify and synthesize the available evidence of the neurological airway respiratory cardiovascular other-surgical severity (NARCO-SS) score as compared to other pediatric specific perioperative scoring systems.

DESIGN

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. All studies in all languages comparing NARCO-SS with pediatric perioperative scoring systems against outcomes were included. Records were screened and data were extracted by three independent reviewers into standardized pilot-tested extraction templates.

DATA SOURCES

Electronic searches were performed in MEDLINE, Embase, Scopus, and CINAHL (from inception to February 2023).

REVIEW METHODS

The references were uploaded to a validated software for systematic reviews (Rayyan) and screened against the inclusion criteria. Full text of included studies were reviewed and the available data were tabulated. We conducted Risk of Bias analysis on the included studies using the Prediction model Risk Of Bias ASsessment Tool (PROBAST).

RESULTS

A meta-analysis could not be performed due to differences in outcome definitions across the included studies. Correlations between NARCO-SS scores, ASA-PS scores and the predefined outcomes of each study were presented as a narrative synthesis. The included studies were determined to have a high risk of bias using the PROBAST.

CONCLUSIONS

This review has identified a need for high-quality studies assessing NARCO-SS before recommendations for clinical practice can be made. Addressing its limitations and enhancing the NARCO-SS through targeted refinements of its individual descriptive categories could potentially lead to improvement in its overall predictive accuracy and facilitate wider adoption into clinical practice.

Optimal Global Longitudinal Strain Thresholds for Pediatric Heart Surgery: Insights from a University Hospital

Congenital heart diseases impact millions annually, with pediatric care lacking suitable risk assessment tools. This research seeks to illuminate the association between the global longitudinal strain (GLS) and the subsequent impact on postoperative outcomes, contributing to a deeper understanding of its predictive value in the pediatric population affected by congenital heart diseases. An observational, analytic, longitudinal, and prospective study was conducted from May 2022 to May 2023, including all patients under 18 undergoing heart surgery with cardiopulmonary bypass (CBP). Patients not classifiable within the Risk Adjustment for Congenital Heart Surgery were excluded. Using transesophageal echocardiography, GLS was measured pre- and post-CPB. Receiver operating characteristic curve analysis determined GLS cut-off points for 30-day mortality risk, using Youden's method for optimal sensitivity and specificity. Bivariate and multivariate analysis identified the relationships between clinical variables. Eighty-nine patients undergoing congenital heart surgery were included. Fifteen deaths occurred. The area under the curve (AUC) for each GLS classification (pre, post, index) demonstrated effective discriminatory capacity (> 0.70) in predicting 30-day mortality. Pre-CBP GLS showed the strongest predictive power (AUC 0.833, IQR: 0.731 - 0.936) with a cut-off point of 12. Values lower than the cut-off point of pre-CPB GLS correlated with increased vasoactive-inotropic Scores and longer mechanical ventilation. GLS measurement is a reproducible method for assessing ventricular function in pediatric heart surgery, showing potential as a prognostic tool. This study marks the initial effort to establish cut-off points for preoperative GLS, postoperative GLS, and the strain index.

Perioperative mortality in pediatric patients: a systematic review of risk assessment tools for use in the preoperative setting

BACKGROUND

There are multiple preoperative risk scores for pediatric mortality. The aim of this study was to systematically describe and compare the existing studies of patient-specific multispecialty risk prediction scores for perioperative mortality in pediatric populations, with the goal of guiding clinicians on which may be most appropriate for use in the preoperative setting.

METHODS

We conducted a systematic literature review of published journal articles that presented the development, extension/updating, and/or validation of a risk score which predicted all-cause mortality (up to 30 days postoperatively) in pediatric patients undergoing a procedure in which anesthesia was used. Scores needed to be applicable to surgeries in more than one non-cardiac surgical specialty and had to be able to be calculated by the anesthesiologist at the time of the pre-anesthetic assessment. Two investigators independently screened studies for inclusion and assessed study quality in the domains of clinical applicability, feasibility/ease of use in the clinical setting, and risk of bias.

RESULTS

A total of 1,681 titles were retrieved. Of these, 10 studies met inclusion criteria: nine reported the development and validation of scores, and one was an external validation of an existing score. Seven studies used varying years of multicenter data from the National Surgical Quality Improvement Program - Pediatric Participant Use File for development and/or validation. The unadjusted rate of mortality in the studies ranged from 0.3% to 3.6%. The preoperative predictors of mortality used in score development included patient demographics, preoperative therapies, and chronic conditions, among others. All models showed good discrimination upon validation (AUC > 0.8). Most risk scores had high or unclear risks of bias.

CONCLUSION

There are numerous scores available for the prediction of mortality in pediatric populations, all of which exhibited good performance. However, many have high or unclear risks of bias, and most have not undergone external validation.

Risk factors associated with unplanned ICU admissions following paediatric surgery: A systematic review

Background

Unplanned admissions to the intensive care unit (ICU) have important implications in the general management of patients. Research in this area has been conducted in the adult and non-surgical population. To date, there is no systematic review addressing risk factors in the paediatric surgical population.

Objectives

To synthesise the information from studies that explore the risk factors associated with unplanned ICU admissions following surgery in children through a systematic review process.

Methods

We conducted a systematic review of published literature (PROSPERO registration CRD42020163766), adhering to the Preferred Reporting of Observational Studies and Meta-Analysis (PRISMA) statement. The Population, Exposure, Comparator, Outcome (PECO) strategy used was based on: population – paediatric population, exposure – risk factors, comparator – other, and outcome – unplanned ICU admission. Data that reported on unplanned ICU admissions following paediatric surgery were extracted and analysed. Quality of the studies was assessed using the Newcastle-Ottawa Scale.

Results

Seven studies were included in the data synthesis. Four studies were of good quality with the Newcastle-Ottawa Scale score ≥7 points. The pooled prevalence (95% confidence interval) estimate of unplanned ICU stay was 2.69% (0.05 - 8.6%) and ranged between 0.06% and 8.3%. Significant risk factors included abnormal sleep studies and the presence of comorbidities in adenotonsillectomy surgery. In the general surgical population, younger age, comorbidities and general anaesthesia were significant. Abdominal surgery and ear, nose and throat (ENT) surgery resulted in a higher risk of unplanned ICU admission. Owing to the heterogeneity of the data, a meta-analysis with risk prediction could not be performed.

Conclusion

Significant patient, surgical and anaesthetic risk factors associated with unplanned ICU admission in children following surgery are described in this systematic review. A combination of these factors may direct planning toward anticipation of the need for a higher level of postoperative care. Further work to develop a predictive score for unplanned ICU stay is desirable.

Contributions of the study

Unplanned admissions to the intensive care unit (ICU) have been acknowledged as an overall marker of safety.^[1] Awareness of this concept has encouraged research to determine the incidence and risk factors of these occurrences. This research has been interrogated in a systematic review process with beneficial conclusions drawn; however, these studies included adults and non-surgical patients.^[2–4] To date, we have not been able to find a systematic review addressing the risk factors associated with unplanned ICU admissions in paediatric surgical patients.