Severity of disease scoring systems and mortality after non-cardiac surgery

Reis, Pedro Videira; Sousa, Gabriela; Lopes, Ana Martins; Costa, Ana Vera; Santos, Alice; Abelha, Fernando José

doi:10.1016/j.bjane.2017.11.008

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Scientific Articles • Rev. Bras. Anestesiol. 68 (3) • May-Jun 2018 • https://doi.org/10.1016/j.bjane.2017.11.008 copy

Severity of disease scoring systems and mortality after non-cardiac surgery

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

Mortality after surgery is frequent and severity of disease scoring systems are used for prediction. Our aim was to evaluate predictors for mortality after non-cardiac surgery.

Methods:

Adult patients admitted at our surgical intensive care unit between January 2006 and July 2013 was included. Univariate analysis was carried using Mann-Whitney, Chi-square or Fisher's exact test. Logistic regression was performed to assess independent factors with calculation of odds ratio and 95% confidence interval (95% CI).

Results:

4398 patients were included. Mortality was 1.4% in surgical intensive care unit and 7.4% during hospital stay. Independent predictors of mortality in surgical intensive care unit were APACHE II (OR = 1.24); emergent surgery (OR = 4.10), serum sodium (OR = 1.06) and FiO₂ at admission (OR = 14.31). Serum bicarbonate at admission (OR = 0.89) was considered a protective factor. Independent predictors of hospital mortality were age (OR = 1.02), APACHE II (OR = 1.09), emergency surgery (OR = 1.82), high-risk surgery (OR = 1.61), FiO₂ at admission (OR = 1.02), postoperative acute renal failure (OR = 1.96), heart rate (OR = 1.01) and serum sodium (OR = 1.04). Dying patients had higher scores in severity of disease scoring systems and longer surgical intensive care unit stay.

Conclusion:

Some factors influenced both surgical intensive care unit and hospital mortality.

KEYWORDS
Postoperative mortality; Severity of disease scoring systems; APACHE II; SAPS II; Surgical intensive care unit; Non-cardiac surgery

Variables	Total (n = 4398)	Survival group (n = 4338)	Mortality group (n = 60)	p-Value
Gender, n (%)				0.518^a a Chi-square test.
Male	2681 (61.0)	2642 (60.9)	39 (65.0)
Female	1717 (39.0)	1696 (39.1)	21 (35.0)
Age, median (IQR)	65.0 (54.0-74.0)	65.0 (53.0-74.0)	72.5 (59.5-79.8)	<0.001^b b Mann-Whitney test.
Type of admission, n (%)				<0.001^a a Chi-square test.
Elective surgery	3827 (87.0)	3803 (87.7)	24 (40.0)
Non-elective surgery	571 (13.0)	535 (12.3)	36 (60.0)
Mechanical ventilation at admission, n (%)	1341 (30.5)	1291 (29.8)	50 (83.3)	<0.001^a a Chi-square test.
Organ insufficiency,^d d Organ insufficiency: presence of at least one organ failure defined by APACHE II. n (%)	682 (15.5)	658 (15.2)	24 (40.0)	<0.001^a a Chi-square test.
Hematocrit, median (IQR)	33.0 (29.8-36.3)	33.0 (29.9-36.4)	28.8 (22.9-33.0)	<0.001^b b Mann-Whitney test.
Body temperature, median (IQR)	35.4 (34.6-36.0)	35.8 (34.6-36.0)	34.0 (33.0-35.3)	<0.001^b b Mann-Whitney test.
Systolic pressure, median (IQR)	122.0 (102.0-144.0)	122.0 (102.0-144.0)	76.5 (66.0-88.8)	<0.001^b b Mann-Whitney test.
Mean arterial pressure, median (IQR)	85.0 (71.0-96.0)	85.0 (71.0-96.0)	53.0 (47.3-63.0)	<0.001^b b Mann-Whitney test.
Heart rate, median (IQR)	83 (69-98)	83 (68-98)	112 (88-133)	<0.001^b b Mann-Whitney test.
Respiratory rate, median (IQR)	14 (12-16)	14 (12-16)	16 (14-16)	<0.001^b b Mann-Whitney test.
Serum urea, median (IQR)	30.0 (20.0-40.0)	30.0 (20.0-40.0)	45.0 (23.5-70.0)	0.001^b b Mann-Whitney test.
Serum creatinine, median (IQR)	8.3 (6.5-11.0)	8.2 (6.5-11.0)	15.6 (9.0-25.3)	<0.001^b b Mann-Whitney test.
Total bilirrubin, median (IQR)	4.0 (1.0-7.0)	4.0 (1.0-7.0)	6.0 (4.0-10.8)	<0.001^b b Mann-Whitney test.
FiO ₂ , median (IQR)	0.40 (0.35-0.40)	0.40 (0.34-0.40)	0.52 (0.40-1.00)	<0.001^b b Mann-Whitney test.
PaO ₂ , median (IQR)	100.0 (100.0-110.0)	100.0 (100.0-110.0)	98.0 (75.5-138.6)	0.039^b b Mann-Whitney test.
PaCO ₂ , median (IQR)	39.5 (35.0-45.0)	39.4 (35.0-45.0)	42.7 (36.0-54.0)	0.001^b b Mann-Whitney test.
Serum bicarbonate, median (IQR)	22.0 (21.0-24.0)	22.0 (21.0-24.0)	19.4 (17.0-22.0)	<0.001^b b Mann-Whitney test.
pH, median (IQR)	7.40 (7.35-7.40)	7.40 (7.35-7.40)	7.28 (7.17-7.35)	<0.001^b b Mann-Whitney test.
Serum potassium, median (IQR)	3.80 (3.40-4.10)	3.80 (3.40-4.10)	3.90 (3.13-4.45)	0.806^b b Mann-Whitney test.
Serum sodium, median (IQR)	140 (137-142)	140 (137-142)	145 (140-152)	<0.001^b b Mann-Whitney test.
Leucocytes count, median (IQR)	11.0 (8.0-14.0)	11.0 (8.0-11.0)	9.5 (4.0-19.0)	0.230^b b Mann-Whitney test.
Glasgow coma scale (<9), n (%)	54 (1.2)	46 (1.1)	8 (13.3)	<0.001^e e p-Value with Fisher's exact test.
Acute renal failure,^c c Previous renal insufficiency: creatinine >2 mg.dL-1 and/or oliguria <500 mL.day-1. n (%)	285 (6.5)	264 (6.1)	21 (35.0)	<0.001^e e p-Value with Fisher's exact test.

Variables	Total (n = 4398)	Survival group (n = 4338)	Mortality group (n = 60)	p-Value
High-risk surgery, n (%)	2382 (54.2)	2334 (53.8)	48 (80.0)	<0.001^a a Chi-square test.
History of ischemic heart disease, n (%)	617 (14.0)	607 (14.0)	10 (16.7)	0.554^a a Chi-square test.
History of congestive heart disease, n (%)	691 (15.7)	673 (15.5)	18 (30.0)	0.002^a a Chi-square test.
Preoperative insulin therapy, n (%)	215 (4.9)	213 (4.9)	2 (3.3)	1^c c p-Value with Fisher's exact test.
Preoperative serum creatinine >2.0 mg.dL^-1, n (%)	281 (6.4)	272 (6.3)	9 (15.0)	0.013^c c p-Value with Fisher's exact test.
History of cerebrovascular disease, n (%)	559 (12.7)	548 (12.6)	11 (18.3)	0.188^a a Chi-square test.
RCRI ≥2, n (%)	328 (7.5)	317 (7.3)	11 (18.3)	0.004^c c p-Value with Fisher's exact test.
APACHE II, median (IQR)	8.0 (6.0-12.0)	8.0 (6.0-12.0)	22.0 (19.0-26.0)	<0.001^b b Mann-Whitney test.
SAPS II, median (IQR)	18.0 (13.3-26.7)	18.0 (13.3-25.0)	43.7 (37.8-57.8)	<0.001^b b Mann-Whitney test.
SICU LOS (hours), median (IQR)	20.0 (16.0-42.0)	20.0 (16.0-41.0)	46.0 (19.5-82.8)	<0.001^b b Mann-Whitney test.

Variables	Simple OR	p-Value	Adjusted OR (95% CI)^b b A logistic regression analysis with inclusion severity of disease scoring systems' variables with p ≤ 0.001 was used.	p-Value^a a Adjusted for age, mechanical ventilation on admission, previous renal insufficiency, organ insufficiency, hematocrit, body temperature, systolic pressure, mean arterial pressure, heart rate, respiratory rate, urea, creatinine, total bilirubin, FiO2, PaCO2, serum bicarbonate, pH, Serum sodium, Glasgow coma scale and SAPS II.
Age	1.04 (1.02-1.06)	<0.001	-
Non-elective surgery	10.66 (6.31-18.01)	<0.001	3.88 (2.02-7.46)	<0.001
Mechanical ventilation	11.80 (5.96-23.34)	<0.001	-
Organ insufficiency	3.78 (2.21-6.34)	<0.001	-
Hematocrit	0.86 (0.83-0.90)	<0.001	-
Body temperature	0.53 (0.45-0.62)	<0.001	-
Systolic pressure	0.95 (0.94-0.96)	<0.001	-
Mean arterial pressure	0.92 (0.91-0.94)	<0.001	-
Heart rate	1.05 (1.04-1.06)	<0.001	-
Respiratory rate	1.04 (1.01-1.07)	0.023	-
Serum urea	1.02 (1.01-1.02)	<0.001	-
Serum creatinine	1.04 (1.03-1.05)	<0.001	-
Total bilirrubin	1.00 (1.00-1.01)	0.252	-
FiO₂	1.08 (1.07-1.09)	<0.001	1.03 (1.02-1.05)	<0.001
PaCO₂	1.07 (1.05-1.09)	<0.001	-
Serum bicarbonate	0.74 (0.67-0.81)	<0.001	0.88 (0.82-0.95)	0.001
pH, median	0.86 (0.84-0.88)	<0.001	-
Serum sodium	1.23 (1.18-1.28)	<0.001	1.06 (1.01-1.11)	0.010
Glasgow coma scale	0.72 (0.67-0.78)	<0.001	-
Acute renal failure	8.3 (4.8-14.3)	<0.001	-
APACHE II	1.38 (1.31-1.41)	<0.001	1.25 (1.18-1.31)	<0.001
SAPS II	1.14 (1.12-1.16)	<0.001	-
SICU LOS (hours)	1.01 (10.1-1.01)	<0.001	-
High-risk surgery	3.4 (1.8-6.5)	<0.001	-

Variables	Total (n = 4398)	Survival group (n = 4071)	Mortality group (n = 327)	p-Value
Gender, n (%)				0.938^a a Chi-square test.
Male	2681 (61.0)	2481 (60.9)	200 (61.2)
Female	1717 (39.0)	1590 (39.1)	127 (38.8)
Age, median (IQR)	65 (54-74)	65 (53-74)	71 (59-78)	<0.001^b b Mann-Whitney test.
Type of admission, n (%)				<0.001^a a Chi-square test.
Elective surgery	3827 (87.0)	3598 (88.4)	229 (70.0)
Non-elective surgery	571 (13.0)	535 (12.3)	98 (30.0)
Mechanical ventilation at admission, n (%)	1341 (30.5)	1181 (29.0)	160 (48.9)	<0.001^a a Chi-square test.
Organ insufficiency,^d d Organ insufficiency: presence of at least one organ failure defined by APACHE II. n (%)	682 (15.5)	585 (14.4)	97 (29.7)	<0.001^a a Chi-square test.
Hematocrit, median (IQR)	33.0 (29.8-36.3)	33.0 (30.0-36.5)	31.0 (27.0-34.9)	<0.001^b b Mann-Whitney test.
Body temperature, median (IQR)	35.4 (34.6-36.0)	35.8 (34.7-36.0)	35.2 (34.0-36.0)	<0.001^b b Mann-Whitney test.
Systolic pressure, median (IQR)	122.0 (102.0-144.0)	122.0 (103.0-144.0)	112.0 (87.0-138.0)	<0.001^b b Mann-Whitney test.
Mean arterial pressure, median (IQR)	85.0 (71.0-96.0)	85.0 (71.0-96.0)	78.0 (60.0-91.0)	<0.001^b b Mann-Whitney test.
Heart rate, median (IQR)	83 (69-98)	82 (68-96)	89 (78-108)	<0.001^b b Mann-Whitney test.
Respiratory rate, median (IQR)	14 (12-16)	14 (12-16)	14 (12-16)	0.113^b b Mann-Whitney test.
Serum urea, median (IQR)	30.0 (20.0-40.0)	30.0 (20.0-40.0)	36.0 (20.0-50.0)	<0.001^b b Mann-Whitney test.
Serum creatinine, median (IQR)	8.3 (6.5-11.0)	8.1 (6.4-10.7)	9.7 (7.0-16.0)	<0.001^b b Mann-Whitney test.
Total bilirrubin, median (IQR)	4.0 (1.0-7.0)	4.0 (1.0-7.0)	6.0 (3.0-9.0)	<0.001^b b Mann-Whitney test.
FiO ₂ , median (IQR)	0.40 (0.35-0.40)	0.40 (0.35-0.40)	0.40 (0.40-0.50)	<0.001^b b Mann-Whitney test.
PaO ₂ , median (IQR)	100.0 (100.0-110.0)	100.0 (100.0-110.0)	100.0 (90.0-120.0)	0.151^b b Mann-Whitney test.
PaCO ₂ , median (IQR)	39.5 (35.0-45.0)	39.1 (35.0-45.0)	41.0 (35.0-45.0)	0.007^b b Mann-Whitney test.
Serum bicarbonate, median (IQR)	22.0 (21.0-24.0)	22.0 (21.0-24.0)	22.0 (20.0-24.0)	0.003^b b Mann-Whitney test.
pH, median (IQR)	7.40 (7.35-7.40)	7.40 (7.35-7.40)	7.36 (7.30-7.40)	<0.001^b b Mann-Whitney test.
Serum potassium, median (IQR)	3.80 (3.40-4.10)	3.8 (3.5-4.0)	3.7 (3.3-4.1)	0.078^b b Mann-Whitney test.
Serum sodium, median (IQR)	140 (137-142)	140 (137-142)	141 (138-142)	<0.001^b b Mann-Whitney test.
Leucocytes count, median (IQR)	11.0 (8.0-14.0)	11.0 (8.0-14.0)	11.7 (7.5-16.0)	0.134^b b Mann-Whitney test.
Glasgow coma scale (<9), n (%)	54 (1.2)	37 (0.9)	17 (5.2)	<0.001^e e p-Value with Fisher's exact test.
Acute Renal failure,^c c Previous renal insufficiency: creatinine >2 mg.dL-1 and/or oliguria <500 mL.day-1. n (%)	285 (6.5)	222 (5.5)	63 (19.3)	<0.001

Variables	Total (n = 4398)	Survival group (n = 4071)	Mortality group (n = 327)	p-Value
High-risk surgery, n (%)	2382 (54.2)	2153 (52.9)	229 (70.0)	<0.001^a a Chi-square test.
History of ischemic heart disease, n (%)	617 (14.0)	568 (14.0)	49 (15.0)	0.605^a a Chi-square test.
History of congestive heart disease, n (%)	691 (15.7)	616 (15.1)	75 (22.9)	<0.001^a a Chi-square test.
Preoperative insulin therapy, n (%)	215 (4.9)	198 (4.9)	17 (5.2)	0.787^c c p-Value with Fisher's exact test.
Preoperative serum creatinine >2.0 mg.dL^-1, n (%)	281 (6.4)	237 (5.8)	44 (13.5)	<0.001^c c p-Value with Fisher's exact test.
History of cerebrovascular disease, n (%)	559 (12.7)	515 (12.7)	44 (13.5)	0.674^a a Chi-square test.
RCRI ≥ 2, n (%)	328 (7.5)	287 (7.0)	41 (12.5)	<0.001^c c p-Value with Fisher's exact test.
APACHE II, median (IQR)	8.0 (6.0-12.0)	8.0 (6.0-11.0)	12.0 (9.0-18.0)	<0.001^b b Mann-Whitney test.
SAPS II, median (IQR)	18.0 (13.3-26.7)	17.8 (13.3-24.4)	26.7 (18.0-38.0)	<0.001^b b Mann-Whitney test.
SICU LOS (hours), median (IQR)	20.0 (16.0-42.0)	20.0 (16.0-41.0)	36.0 (19.0-68.0)	<0.001^b b Mann-Whitney test.

Variables	Simple OR	p-Value	Adjusted OR (95% CI)^b b A logistic regression analysis with inclusion severity of disease scoring systems' variables with p ≤ 0.001 was used.	p-Value^a a Adjusted for age, mechanical ventilation on admission, previous renal insufficiency, hematocrit, body temperature, systolic pressure, mean arterial pressure, heart rate, respiratory rate, serum urea, serum creatinine, total bilirubin, FiO2, PaCO2, serum bicarbonate, pH, serum sodium, Glasgow coma scale and SAPS II.
Age	1.03 (1.03-1.04)	<0.001	1.02 (1.01-1.03)	<0.001
Non-elective surgery	3.26 (2.52-4.20)	<0.001	1.82 (1.34-2.48)	<0.001
Mechanical ventilation	2.35 (1.87-2.94)	<0.001	-
Organ insufficiency	2.51 (1.95-3.24)	<0.001	-
Hematocrit	0.92 (0.90-0.94)	<0.001	-
Body temperature	0.78 (0.72-0.85)	<0.001	-
Systolic pressure	0.99 (0.98-0.99)	<0.001	-
Mean arterial pressure	0.98 (0.97-0.99)	<0.001	-
Heart rate	1.03 (1.02-1.03)	<0.001	1.01 (1.01-1.02)	<0.001
Serum urea	1.01 (1.01-1.01)	<0.001	-
Serum creatinine	1.03 (1.02-1.03)	<0.001	-
Total bilirrubin	1.00 (1.00-1.01)	0.116	-
FiO₂	1.05 (1.04-1.06)	<0.001	1.02 (1.01-1.03)	<0.001
pH	0.93 (0.91-0.94)	<0.001	-
Serum sodium	1.11 (1.09-1.14)	<0.001	1.04 (1.01-1.06)	0.003
Glasgow coma scale	0.80 (0.75-0.84)	<0.001	-
Acute renal failure	4.14 (3.05-5.62)	<0.001	1.86 (1.28-2.70)	0.001
APACHE II	1.18 (1.16-1.20)	<0.001	1.09 (1.06-1.12)	<0.001
SAPS II	1.07 (1.06-1.08)	<0.001	-
SICU LOS (hours)	1.01 (1.01-1.01)	<0.001	-
High-risk surgery	2.08 (1.63-2.66)	<0.001	1.61 (1.24-2.09)	<0.001
History of congestive heart disease	1.67 (1.27-2.19)	<0.001
Preoperative serum creatinine >2.0	4.14 (3.05-5.62)	<0.001

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[1] * Corresponding author. E-mail:fernando.abelha@gmail.com (F.J. Abelha).