Evaluation of POSSUM and P-POSSUM as a tool for prediction of surgical outcomes in the Indian population

Use of POSSUM (Physiologic and Operative Severity Score for the Study of Mortality and Morbidity) and Portsmouth-POSSUM for Surgical Assessment in Patients Undergoing Emergency Abdominal Surgeries

INTRODUCTION

The POSSUM (Physiologic and Operative Severity Score for the Study of Mortality and Morbidity) and Portsmouth-POSSUM (P-POSSUM) models have been popularly recommended as appropriate for predicting postoperative mortality and morbidity in surgical practice. This study aims to evaluate the efficacy and accuracy of both scoring systems for surgical risk assessment in predicting postoperative mortality and morbidity in patients undergoing emergency abdominal surgeries.

METHODOLOGY

The study was conducted as a part of a post-doctoral fellowship program. A total of 150 patients, undergoing emergency abdominal surgery in a tertiary care hospital in Bhubaneswar, were evaluated using POSSUM and P-POSSUM. Physiological scoring was done prior to surgery and operative scoring was performed intra-operatively. Patients were followed up for 30 days after the operative period. The observed mortality rate was then compared with POSSUM and P-POSSUM predicted mortality rates.

RESULTS

POSSUM predicted a morbidity rate of 116, whereas the actual morbidity rate was 92 (p < 0.05). P-POSSUM predicted a morbidity rate of 109, whereas the actual morbidity rate was 92 (p < 0.05). POSSUM predicted a mortality rate of 23, whereas the actual mortality rate was 21 (p < 0.05). P-POSSUM predicted a mortality rate of 25, whereas the actual mortality rate was 21 (p < 0.05).

CONCLUSIONS

With a reasonably good prediction of morbidity and mortality rate, POSSUM and P-POSSUM scores are both effective scoring systems in clinical practice for use in abdominal surgery.

A retrospective analysis of postoperative patients admitted to the intensive care unit

BACKGROUND

The aim of this retrospective study was to evaluate postoperative patients admitted to the intensive care unit (ICU) and to describe their characteristics and outcomes.

METHODS

We performed a retrospective chart review of 1,756 postoperative patients admitted to the ICU of a tertiary referral hospital from January 2008 to December 2012. For each patient we recorded: demographic data, reason for admission to the ICU, duration of mechanical ventilation, elective versus emergency surgery, type of anaesthesia, American Society of Anesthesiologists (ASA) physical status, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Glasgow Coma Score (GCS), and outcome.

RESULTS

During the study period, the rate of postoperative ICU admission increased each year, and the number of ICU beds was increased in order to perform a greater number of elective surgical procedures for patients who required postoperative ICU care. In 2008, 20.80 % of the patients were postoperatively admitted to the ICU; 58.97 % were in 2012. The mean ratio of five years was 46.97 %. Median age was 63 (1-94) years, and 57.4 % of the patients were male. The most common reasons for admission were major surgery (41.90 %) and comorbidities (34.10 %). Mortality rates were higher in patients that underwent emergency surgery, received general anesthesia, were operated on by a general surgeon, or had low GCS scores coupled with high ASA or APACHE II scores.

CONCLUSIONS

The postoperative patients who had metabolic or hemodynamic instability, high ASA or APACHE II scores, and low GCS had higher mortality rates despite ICU care. Hippokratia 2016, 20(1): 38-43.

Assessing the risk: Scoring systems for outcome prediction in emergency laparotomies

Emergency laparotomy is the commonest emergency surgical procedure in most hospitals and includes over 400 diverse surgical procedures. Despite the evolution of medicine and surgical practices, the mortality in patients needing emergency laparotomy remains abnormally high. Although surgical risk assessment first started with the ASA Physical Status score in 1941, efforts to find an ideal scoring system that accurately estimates the risk of mortality, continues till today. While many scoring systems have been developed, no single scoring system has been validated across multiple centers and geographical locations. While some scoring systems can predict the risk merely based upon preoperative findings and parameters, some rely on intra-operative assessment and histopathology reports to accurately stratify the risk of mortality. Although most scoring systems can potentially be used to compare risk-adjusted mortality across hospitals and amongst surgeons, only those which are based on preoperative findings can be used for risk prognostication and identify high-risk patients before surgery for an aggressive treatment. The recognition of the fact, that in the absence of outcome data in these patients, it would be impossible to evaluate the impact of quality improvement initiatives on risk-adjusted mortality, hospital groups and surgical societies have got together and started to pool data and analyze it. Appropriate scoring systems for emergency laparotomies would help in risk prognostication, risk-adjusted audit and assess the impact of quality improvement initiative in patient care across hospitals. Large multi-centric studies across varied geographic locations and surgical practices need to assess and validate the ideal and most apt scoring system for emergency laparotomies. While APACHE-II and P-POSSUM continue to be the most commonly used scoring system in emergency laparotomies,studies need to compare them in their ability to predict mortality and explore if either has a higher sensitivity and specificity than the other.