Physiologic Modification of the American Society of Anaesthesiology Score (ASA) for Prediction of Morbidity and Mortality after Emergency Laparotomy

摘要

Background and aims:Laparotomy is commonly performed as an emergency operation. It is often performed on elderly patients with high risks of mortality and morbidity. Currently there is no accurate scoring system to predict preoperatively mortality and morbidity in these circumstances. This study was conducted to develop a scoring system that can accurately predict the risk of in-hospital mortality and complications for these patients in the emergency department prior to surgery. Patients and methods:Middlemore Hospital data were searched for patients who underwent emergency laparotomy for an acute abdominal condition between January 1997 and December 2006. Data collected included age, gender, presenting diagnosis, indications for surgery, acute physiological parameters and also data on associated comorbidities. We categorized patients for the risk of morbidity and 30-day mortality. The risk categorization was based on preoperative existing comorbidities and acute disturbances of physiological parameters. Regression analysis was used to correlate acute laboratory parameters, patients’ age and gender, clinical pre-morbid conditions and surgical procedures with the risk of mortality and rates of complications. Results:Emergency laparotomy was performed on 1712 patients. The median age was 58 and there were 896 male patients. Patients with one or two minor comorbidities had comparable mortality and complication rates to those with no comorbidities. There was high correlation between factors that denoted the onset of multiple organ failure and in-hospital mortality and complication rate; this allowed us to divide patients into four groups with increasing mortality and morbidity. Conclusions:Mortality and morbidity after emergency laparotomy is closely related to the presence or absence of severe acute physiological impairment and the presence or absence of chronic system organ failure. The SPI score is a simple scoring system for prediction of mortality and morbidity prior to emergency laparotomy. Introduction Emergency laparotomy is a commonly performed operation. It is frequently performed on elderly patients with a variety of acute pathological disorders that render these patients dehydrated, hypovolemic, and suffering from a systemic inflammatory response often with incipient multiple organ failure 12 . Compared with elective surgery, emergency abdominal surgery is associated with a higher risk of morbidity and mortality, especially in patients over the age of 65 345 , where 50% of these patients have significant associated comorbidities 6 . Mortality in such patients has been reported to be between 22% and 44% 35 , and morbidity around 50% 7 .Mortality and complications in elderly patients undergoing emergency laparotomy for acute abdomen depend on perioperative risk factors and delay in presentation and treatment. Patients with conditions that only permit palliative surgery such as cancer and those who have acute mesenteric ischaemia, have particularly high mortality rates 5 . The acute physiological insult of abdominal pathology, added to chronic ill health, complicates the postoperative course 35 .Many scoring systems have been designed to predict mortality and morbidity in surgical patients; however, these systems are complex and require the collection of several clinical and pathological parameters that may not be available before the patent is taken for emergency surgery 8910 . As a result, none of these classification systems has found a place as a routine part of clinical practice in surgery.It would therefore be very useful to have a classification system based on clinical and laboratory measures that is able to provide an objective assessment of morbidity and mortality before undertaking surgical management 1112 . In the elective surgery setting, the ASA score is a commonly used system for prediction of morbidity and mortality; however, it is not specific to any particular procedure or specialty and does not allow fo