Surgical Apgar Score: Utility in Predicting Postoperative Outcome in Cases of Exploratory Laparotomy

Aims and Objective: The aim of this study is to correlate SURGICAL APGAR score in predicting post-operative mortality and morbidity. Materials and Method: This was a prospective study. All patients fulfilling the inclusion criteria in Krishna institute of medical sciences karad were included in the study which was conducted from December 2019 to July 2021. All patients undergoing exploratory laparotomy were scored according to surgical Apgar scoring system and their score was correlated with post-operative outcome. Result: In our study, the mean surgical Apgar score among study subjects was 4.68 ±1.67. Majority of the study subjects had surgical APGAR score between 5 to 6 (51.43%), followed by 3 to 4 (28.57%). The p<0.0001 is highly significant in our study. Statistically significant results were seen in the score groups, with score groups of 0-2 showing 7.14%, 3-4 with 2.85%, 5-6 with 1.42%, 7-10 with 0% mortality. Conclusion: From the study it was concluded that SURGICAL APGAR score is an excellent predictor of post operative outcomes in regard to complications and mortality. Original Research Article Srivastava and Bagawan; JPRI, 34(16A): 50-64, 2022; Article no.JPRI.83618 51


INTRODUCTION
The prediction of complications is an essential part of risk management in surgical practice. Surgeons and health care units consistently make efforts to lower the occurrence of any complications to a patient undergoing any procedure. Early recognition of patients at high risk of developing postoperative outcomes will substantially post-operative management of patients [1]. Variability in outcome due to difference in preoperative risk factors is inevitable but intraoperative response of the body in terms of vital parameters like heart rate, blood pressure, blood loss, tissue perfusion, etc. have a major influence on post-operative outcome [2]. Therefore the ideal model to predict complications in surgical patients should be simple, readily available and it should properly define the complications, accurately estimate their incidence and have a low threshold to detect them.
With evolution of monitoring techniques there is wide range of scoring systems available like Acute Physiology Age Chronic Health Evaluation II (APACHE score) or Physiological and operative severity score for predicting Mortality and Morbidity(POSSUM) or TRIOS(Three days Recalibrated ICU Outcome Score). However those require a huge amount of data collection and rely on laboratories which makes them more vulnerable to errors [3,4].
A ten point Surgical APGAR score provides surgeons with a simple, objective and readily available data to predict post operative outcomes. Surgical APGAR Score (SAS) uses 3 parameters lowest heart rate, lowest mean arterial pressure and Estimated blood loss.
A score built from those three parameters has proved to be a strong predictor of postoperative outcomes of the patient and due to its availability, inexpensively collectable data and low reliance on technological capacity and resource of the health care centre it is a simple and powerful tool, for assessing risk of post-operative outcomes [5,6]. Since its introduction capability of surgical apgar score in predicting post operative outcomes after different kinds of surgeries and even in predicting outcomes after ICU admissions has been correlated, most of the studies found surgical apgar score to be a strong predictor of the outcomes [7,2,8,9,10].
In this study we will study the ability of Surgical APGAR score in predicting post-operative outcome in cases of exploratory laparotomy, without any other additional expenditure for the patient. It is bedside clinical scoring system as far as surgical outcome of the patient is concerned.  (Any bradyarrhythmia which includes sinus arrest, atrio-ventricular block or dissociation, junctional and asystole, also receives 0 points for lowest heart rate)

Sample Size
Score is categorized into 0-2,3-4,5-6,7-8,9-10 for simplicity data such as lowest heart rate and lowest mean arterial pressures are noted intra operatively and collected from the anesthesiologists records(manual /electronic).

Gender Distribution
In the present study we assessed the gender wise distribution among the study subjects. We observed that majority of the study subjects were males (67.14%).
The male: female ration in the current study was Table 1.

Age Distribution
In the present study we assessed the Age distribution among the study subjects. We observed that majority of the subjects belonged to the age group of 56 to 65 years (25.71%), followed by 26 to 35 years (21.43%). The mean age of the study subjects was 47.34 ± 14.86 years.

Previous History of Hypertension
In the present study we assessed the previous history of Hypertension among the study subjects. We observed that 15.71% subjects had previous history of Hypertension.

Previous History of DM
In the present study we assessed the previous history of DM among the study subjects. We observed that 15.71% subjects had previous history of DM.

Previous History of CARDIAC DISEASE
In the present study we assessed the previous history of CARDIAC DISEASE among the study subjects. We observed that 1.43% subjects had previous history of CARDIAC DISEASE.

Previous History of COPD
In the present study we assessed the previous history of COPD among the study subjects. We observed that 1.43% subjects had previous history of COPD.

Heart Rate
In the present study we assessed the heart rate among the study subjects. We observed that the mean Pre-operative heart rate was 100.21 ±7.14 per minute, Mean Post-operative heart rate was 80.94 ± 7.15 per minute.

Heart Rate Score
In the present study we assessed the HR score among the study subjects. We observed that majority of the study subjects had HR score of 1 (61.43%), followed by score 0 (24.29%).

Blood Pressure
In the present study we assessed the Blood pressure among the study subjects. We observed that the mean SBP was 85.37 ± 10.37 mmHg, Mean DBP was 60.74 ± 9.28 mmHg, and Mean MAP was 68.95 ± 9.46 mmHg.

MAP Score
In the present study we assessed the MAP score among the study subjects. We observed that majority of the subjects had MAP score of 3 (45.71%), followed by score 2 (42.86%).

Mean Hemoglobin Levels
In the present study we assessed the mean blood loss and Mean hemoglobin levels among the study subjects. We observed that mean Pre operative hemoglobin level was 12.05 ± 2.13 g/dl, Mean Post-operative hemoglobin level was 2.73 ±10.9 g/dl, and Mean amount of Blood loss was 893.55 ±1039.03 ml.

Emergency
In the present study we observed that 92.86% study subjects presented as a medical emergency at emergency department.

Blood Loss Score
In the present study we assessed the Blood loss score among the study subjects. We observed that majority of the study subjects had score of 2 (51.43%), followed by score 0 (30%).

Blood Transfusion
In the present study we assessed the Blood transfusion among the study subjects. We observed that blood transfusion was required among 17.14% subjects.

Surgical APGAR Score
In the present study we assessed the Surgical APGAR score among the study subjects. We observed that majority of the study subjects had surgical APGAR score between 5 to 6 (51.43%), followed by 3 to 4 (28.57%). The mean surgical APGAR score among study subjects was 4.68 ±1.67. (Table 15)

Morbidity
In the present study we assessed the morbidity among the study subjects. We observed that various forms of morbidity was observed among 30% study subjects.

Mortality
In the present study we assessed the mortality among the study subjects. We observed that the mortality was observed among 11.43% subjects. 88.57% subjects were cured and discharged.

Comparison of Surgical APGAR Score with Outcome
In the present study we assessed the Comparison of surgical APGAR score with outcome among the study subjects. We observed that mortality was associated with lesser surgical APGAR score, as compared to those subjects who were cured and discharged.
The observations were found to be statistically significant. (The chi-square statistic is 25.1069. The p-value is < 0.00001. The result is significant at p < .05.).

DISCUSSION
A 10 point Surgical APGAR score is a simple scoring system which is based on easily available and recordable parameters like lowest mean arterial pressure, lowest heart rate and blood loss during a surgery, which provides precise estimate of patient's post-operative outcome.
All 70 patients were admitted and treated and evaluated in department of general surgery KIM's karad with methods as described earlier. • Atul Gawande et al.
In patients with scores of 9 or 10 (29% of sample) had a <4% incidence of major comlications, and no deaths. In contrast, those with scores of < 4 had a >50% risk of major complications, including a 14% mortality rate. Despite the relatively low prevalence of scores < 4 %( 4% of the sample size), the c-statistic of 0.75 suggests that the score has good overall discriminative ability.
 In our study, the mean surgical apgar score among study subjects was 4.68 ±1.67. Majority of the study subjects had surgical APGAR score between 5 to 6 (51.43%), followed by 3 to 4 (28.57%). The p<0.0001 is highly significant in our study.  Out of 27 patients who had score of less than 4 29.6% had complications and 25.9% patients had mortality whereas 43 patients had score of above 4 out of which 18.6% had complications and 2%(1) had mortality.  Statistically significant results were seen in the score groups, with score groups of 0-2 showing 7.14%, 3-4 with 2.85%, 5-6 with 1.42%, 7-10 with 0% mortality.  Morbidity percentage was higher in score groups of 3-4 and 5-6 with both being 10%.

SUMMARY
70 patients who underwent exploratory laparotomy either on elective or emergency basis were included in the study. Mean age group of the study was 47.34±14.86 years with 64.2% of the patients above 40 years, there was male preponderance in the study but with no significant association. 57.8% patients above 55 years of age had complications and only 16% had complications in younger age group.
15.7% patients had diabetes mellitus and hypertension and the study found that hypertension was significantly related to postoperative complications and mortality.
Blood transfusion was given in 12 patients out which 33% had mortality which gives the scope for studying Modified surgical APGAR score where blood transfusion is included in the scoring system.
Mean surgical APGAR score of the study was 4.68 ±1.67 with majority of them being in group of 5-6. Patients who had score of less than 4 had higher rate of post-op complications and mortality than patients with score 0f 6 and above.
Study was statistically significant and showed that Surgical APGAR score is an excellent predictor of post operative outcomes in regard to complications and mortality and can be an efficient tool in monitoring and taking decisions in resource poor hospital setups and countries.

CONCLUSIONS
-The male: female ration in the current study was 2.04:1 -The mean age of the study subjects was 47.34 ± 14.86 years. -We observed mortality among 11.43% subjects. 88.57% subjects were cured and discharged. -The mean surgical APGAR score among study subjects was 4.68 ±1.67. -Intraoperative hemodynamics and blood loss may affect postoperative transfer to the ICU and that the surgical APGAR score is strongly associated with postoperative ICU admission in patients undergoing all types of surgeries.
-The surgical APGAR score remains a powerful tool that can be used to facilitate clinical decision making with regard to the immediate transfer of patients to the ICU after surgery.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.