The Extended Postoperative Care-Score (EXPO-Score)—An Objective Tool for Early Identification of Indication for Extended Postoperative Care
Abstract
:1. Introduction
2. Experimental Section
2.1. Study Population
2.2. Primary Outcome: Indication for ICU
2.3. Choice of Included Risk Factors
2.4. Study Design
- Pilot period; staff training (data excluded).
- Extended Postoperative Care-Score (EXPO)-Score generation period (Period 1); data collection for 16 weeks.
- EXPO-Score validation period (Period 2); data collection for eight weeks.
2.5. Sample Size Rationale
2.6. Statistical Analysis
3. Results
4. Discussion
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Indications for ICU Admission |
---|
Hemodynamic instability (e.g., vasopressor therapy) n = 372 |
Respiratory instability (e.g., re-intubation) n = 72 |
Massive intraoperative bleeding/transfusion n = 34 |
New severe cardiac arrhythmia (e.g., ventricular tachycardia) n = 15 |
Severe pre-existing disease (e.g., myasthenia, ejection fraction < 25%) n = 79 |
Surgery-related risk factor (e.g., liver transplantation) n = 479 |
Altered consciousness (e.g., delirium) n = 38 |
Hypothermia (body core temperature <36° Celsius) n = 13 |
High nursing care effort needed (e.g., immobility) n = 53 |
Other n = 108 |
Clinical Comorbidities |
---|
Cardiovascular (e.g., heart failure NYHA III-IV) |
Pulmonary (e.g., COPD) |
Liver cirrhosis/insufficiency (e.g., GOT/GPT > 2 × normal value) |
Renal failure (e.g., creatinine > 200 µmol/L) |
Neurologic disorders (e.g., stroke) |
Sepsis/infection |
Isolation/infection prevention (e.g., MRSA) |
Endocrinopathy (e.g., complex diabetes mellitus) |
Characteristics & Risk Factors | With Indication for ICU (n = 866) | No Indication for ICU (n = 3176) | p Value |
---|---|---|---|
Sex | <0.001 | ||
Men | 556 (26.8) | 1519 (73.2) | |
Women | 310 (15.8) | 1657 (84.2) | |
Age (years) | <0.001 | ||
<50 | 94 (7.4) | 1179 (92.6) | |
50–59 | 124 (18.3) | 555 (81.7) | |
60–69 | 210 (26.4) | 584 (73.6) | |
70–79 | 298 (31.9) | 635 (68.1) | |
80–89 | 124 (37.3) | 208 (62.7) | |
>90 | 16 (51.6) | 15 (48.4) | |
BMI kg/m−2 (Median (IQR)) | 26 (23–30) | 26 (23–30) | 0.49 |
ASA | <0.001 | ||
I | 13 (1.9) | 662 (98.1) | |
II | 90 (5.1) | 1660 (94.9) | |
III | 592 (41.7) | 828 (58.3) | |
IV | 171 (86.8) | 26 (13.2) | |
Priority of Surgery | <0.001 | ||
Elective | 659 (19.2) | 2769 (80.8) | |
N0 | 51 (61.4) | 32 (38.6) | |
N1 | 53 (47.3) | 59 (52.7) | |
N2 | 63 (27.2) | 169 (72.8) | |
N3 | 33 (20.4) | 129 (79.6) | |
Preconditions | |||
Cardiovascular | 514 (57.7) | 377 (46.3) | <0.001 |
Pulmonary | 124 (34.8) | 232 (65.2) | <0.001 |
Liver insufficiency | 24 (66.7) | 12 (33.3) | <0.001 |
Renal insufficiency | 71 (51.4) | 67 (48.6) | <0.001 |
Endocrinopathy | 64 (27.2) | 171 (71.8) | 0.033 |
Neurologic | 112 (45.0) | 137 (55.0) | <0.001 |
Infection/Sepsis | 32 (69.6) | 14 (30.4) | <0.001 |
Isolation/Infection (e.g., MRSA) | 29 (70.7) | 12 (29.3) | <0.001 |
Hemoglobin g/dl (Median [IQR]) | 13 (11–14) | 14 (12–15) | <0.001 |
Physical Activity | <0.001 | ||
≥4 MET | 486 (14.6) | 2848 (83.4) | |
<4 MET | 376 (53.7) | 324 (46.3) | |
Planned Postoperative Unit | <0.001 | ||
Post anesthetic care unit | 48 (1.6) | 2983 (98.4) | |
Intermediate care unit | 27 (20.5) | 105 (79.5) | |
Intensive care unit | 781 (91.8) | 70 (8.2) | |
Planned surgery | <0.001 | ||
Thoracic with OLV | 13 (36.1) | 23 (63.9) | |
Upper abdomen | 25 (37.9) | 41 (62.1) | |
Hip/knee arthroplasty | 22 (15.7) | 118 (84.3) | |
Large ENT/maxillofacial tumor | 23 (50.0) | 23 (50.0) | |
Urogenital | 20 (16.9) | 98 (83.1) | |
Vascular | 38 (35.2) | 70 (64.8) | |
Endovascular aortic repair | 30 (75.0) | 10 (25.0) | |
Cardiac | 300 (99.0) | 3 (1.0) | |
Non-cardiac with planned ICU | 94 (94.9) | 5 (5.1) | |
Miscellaneous minor | 94 (4.0) | 2246 (96.0) | |
Miscellaneous intermediate | 132 (20.5) | 513 (79.5) | |
Miscellaneous major | 73 (74.5) | 25 (25.5) |
Statistical Measure | Period 1 | Period 2 | |||||||
---|---|---|---|---|---|---|---|---|---|
Number of Variables | |||||||||
9 | 7 | 6 | 5 | 4 | 3 | 2 | Grey Zone | 3 | |
Specificity | 0.91 | 0.90 | 0.91 | 0.87 | 0.89 | 0.91 | 0.88 | 0.91 | 0.92 |
Sensitivity | 0.90 | 0.91 | 0.89 | 0.93 | 0.90 | 0.87 | 0.89 | 0.82 | 0.88 |
AUC | 0.96 | 0.96 | 0.96 | 0.96 | 0.96 | 0.96 | 0.95 | 0.92 | 0.96 |
(95% CI) | (0.96–0.97) | (0.96–0.97) | (0.96–0.97) | (0.95–0.97) | (0.95–0.97) | (0.95–0.96) | (0.94–0.96) | (0.91–0.94) | (0.95–0.97) |
Accuracy | 0.91 | 0.90 | 0.91 | 0.88 | 0.89 | 0.90 | 0.88 | 0.83 | 0.91 |
Threshold | 0.21 | 0.18 | 0.21 | 0.16 | 0.20 | 0.23 | 0.26 | 0.23 | 0.23 |
Variable | Regression Coefficient | Standard Error | Odds Ratio | p Value |
---|---|---|---|---|
ASA status | ||||
ASA I | Reference | |||
ASA II | 0.40 | 0.37 | 1.49 | 0.27 |
ASA III | 2.32 | 0.36 | 10.18 | <0.001 |
ASA IV | 4.56 | 0.43 | 95.58 | <0.001 |
Physical exercise status | ||||
≥4 MET | Reference | |||
<4 MET | 1.26 | 0.15 | 3.53 | <0.001 |
Conducted surgery | ||||
Miscellaneous minor | Reference | |||
Miscellaneous intermediate | 1.78 | 0.18 | 5.93 | <0.001 |
Miscellaneous major | 4.37 | 0.31 | 79.04 | <0.001 |
Vascular | 1.20 | 0.27 | 3.32 | <0.001 |
Hip/knee arthroplasty | 1.27 | 0.30 | 3.56 | <0.001 |
Urogenital | 1.61 | 0.31 | 5.00 | <0.001 |
Thoracic with OLV | 2.32 | 0.41 | 10.18 | <0.001 |
Upper abdomen | 2.95 | 0.33 | 19.11 | <0.001 |
Endovascular aortic repair | 3.51 | 0.43 | 33.45 | <0.001 |
Large ENT/maxillofacial tumor | 3.83 | 0.37 | 46.06 | <0.001 |
Non-cardiac with planned ICU | 6.79 | 0.50 | 888.91 | <0.001 |
Cardiac | 7.11 | 0.60 | 1224.15 | <0.001 |
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Iden, T.; Caliebe, A.; Renner, J.; Hertz, M.-B.; Höcker, J.; Suvanto-Scholz, P.; Steinfath, M.; Weiler, N.; Gruenewald, M. The Extended Postoperative Care-Score (EXPO-Score)—An Objective Tool for Early Identification of Indication for Extended Postoperative Care. J. Clin. Med. 2019, 8, 1666. https://doi.org/10.3390/jcm8101666
Iden T, Caliebe A, Renner J, Hertz M-B, Höcker J, Suvanto-Scholz P, Steinfath M, Weiler N, Gruenewald M. The Extended Postoperative Care-Score (EXPO-Score)—An Objective Tool for Early Identification of Indication for Extended Postoperative Care. Journal of Clinical Medicine. 2019; 8(10):1666. https://doi.org/10.3390/jcm8101666
Chicago/Turabian StyleIden, Timo, Amke Caliebe, Jochen Renner, Maj-Britt Hertz, Jan Höcker, Päivi Suvanto-Scholz, Markus Steinfath, Norbert Weiler, and Matthias Gruenewald. 2019. "The Extended Postoperative Care-Score (EXPO-Score)—An Objective Tool for Early Identification of Indication for Extended Postoperative Care" Journal of Clinical Medicine 8, no. 10: 1666. https://doi.org/10.3390/jcm8101666
APA StyleIden, T., Caliebe, A., Renner, J., Hertz, M.-B., Höcker, J., Suvanto-Scholz, P., Steinfath, M., Weiler, N., & Gruenewald, M. (2019). The Extended Postoperative Care-Score (EXPO-Score)—An Objective Tool for Early Identification of Indication for Extended Postoperative Care. Journal of Clinical Medicine, 8(10), 1666. https://doi.org/10.3390/jcm8101666