Risk assessment tools validated for patients undergoing emergency laparotomy: a systematic review

C M Oliver; E Walker; S Giannaris; M P W Grocott; S R Moonesinghe

doi:10.1093/bja/aev350

Risk assessment tools validated for patients undergoing emergency laparotomy: a systematic review

Br J Anaesth. 2015 Dec;115(6):849-60. doi: 10.1093/bja/aev350. Epub 2015 Nov 3.

Authors

C M Oliver¹, E Walker², S Giannaris³, M P W Grocott⁴, S R Moonesinghe²

Affiliations

¹ UCL/UCLH Surgical Outcome Research Centre (SOuRCe), 3rd Floor, Maples Link Corridor, University College Hospital, 235 Euston Road, London NW1 2BU, UK National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK Centre for Anaesthesia, University College London, London, UK cmoliver@hotmail.co.uk.
² UCL/UCLH Surgical Outcome Research Centre (SOuRCe), 3rd Floor, Maples Link Corridor, University College Hospital, 235 Euston Road, London NW1 2BU, UK National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK Centre for Anaesthesia, University College London, London, UK.
³ Centre for Anaesthesia, University College London, London, UK.
⁴ National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences Faculty of Medicine, University of Southampton, Southampton, UK University Hospital Southampton NHS Foundation Trust/University of Southampton, NIHR Respiratory Biomedical Research Unit, Southampton, UK.

PMID: 26537629
DOI: 10.1093/bja/aev350

Abstract

Emergency laparotomies are performed commonly throughout the world, but one in six patients die within a month of surgery. Current international initiatives to reduce the considerable associated morbidity and mortality are founded upon delivering individualised perioperative care. However, while the identification of high-risk patients requires the routine assessment of individual risk, no method of doing so has been demonstrated to be practical and reliable across the commonly encountered spectrum of presentations, co-morbidities and operative procedures. A systematic review of Embase and Medline identified 20 validation studies assessing 25 risk assessment tools in patients undergoing emergency laparotomy. The most frequently studied general tools were APACHE II, ASA-PS and P-POSSUM. Comparative, quantitative analysis of tool performance was not feasible due to the heterogeneity of study design, poor reporting and infrequent within-study statistical comparison of tool performance. Reporting of calibration was notably absent in many prognostic tool validation studies. APACHE II demonstrated the most consistent discrimination of individual outcome across a variety of patient groups undergoing emergency laparotomy when used either preoperatively or postoperatively (area under the curve 0.76-0.98). While APACHE systems were designed for use in critical care, the ability of APACHE II to generate individual risk estimates from objective, exclusively preoperative data items may lead to better-informed shared decisions, triage and perioperative management of patients undergoing emergency laparotomy. Future endeavours should include the recalibration of APACHE II and P-POSSUM in contemporary cohorts, modifications to enable prediction of morbidity and assessment of the impact of adoption of these tools on clinical practice and patient outcomes.

Keywords: emergency laparotomy; postoperative mortality; prognostic tool; risk adjustment; risk assessment.

Publication types

Review
Systematic Review

MeSH terms

APACHE
Emergencies
Humans
Laparotomy / adverse effects*
Laparotomy / mortality
Prognosis
Reproducibility of Results
Risk Assessment / methods*
Severity of Illness Index