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Comprehensive Risk Assessment of Morbidity in Pediatric Patients Undergoing Noncardiac Surgery: An Institutional
Viviane G Nasr1, Eleonore Valencia1, Steven J Staffa1
1From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
Insights
A new Risk Assessment of Morbidity in Pediatric Surgery (RAMPS) score effectively identifies children at high risk for perioperative complications. This validated tool aids in improving surgical planning and resource allocation for pediatric patients.
Area of Science:
- Pediatric Surgery
- Surgical Risk Assessment
- Perioperative Morbidity
Background:
- Developing accurate predictive models for perioperative morbidity in pediatric surgery is crucial.
- Existing models may not fully capture the complexity of risk in young patients undergoing noncardiac procedures.
Purpose of the Study:
- To develop and validate a comprehensive predictive model for perioperative morbidity in children undergoing noncardiac surgery.
- To identify key factors contributing to surgical risk in pediatric patients.
Main Methods:
- Retrospective analysis of 25,767 noncardiac surgical cases from a tertiary children's hospital (July 2017-December 2019).
- Development of the Risk Assessment of Morbidity in Pediatric Surgery (RAMPS) score using multivariable logistic regression.
- Internal validation via bootstrap resamples and external validation using a separate cohort.
Main Results:
- The RAMPS score demonstrated very good predictive ability in the derivation cohort (AUC=0.805) and good external validity (AUC=0.783).
- Key predictors included age <5 years, critically ill status, and indicators of chronic conditions (CCI ≥3, significant CCI ≥2).
- The score effectively stratified risk, with morbidity ranging from 1.8% to 42.7%.
Conclusions:
- The RAMPS score is a validated, 5-component tool for identifying high-risk pediatric surgical patients.
- It offers potential to enhance perioperative planning, improve patient outcomes, and optimize healthcare resource allocation.
Background:
Utilizing the intrinsic surgical risk (ISR) and the patient's chronic and acute conditions, this study aims to develop and validate a comprehensive predictive model of perioperative morbidity in children undergoing noncardiac surgery.
Methods:
Following institutional review board (IRB) approval at a tertiary care children's hospital, data for all noncardiac surgical encounters for a derivation dataset from July 2017 to December 2018 including 16,724 cases and for a validation dataset from January 2019 to December 2019 including 9043 cases were collected retrospectively. The primary outcome was a composite morbidity score defined by unplanned transfer to an intensive care unit (ICU), acute respiratory failure requiring intubation, postoperative need for noninvasive or invasive positive pressure ventilation, or cardiac arrest. Internal model validation was performed using 1000 bootstrap resamples, and external validation was performed using the 2019 validation cohort.
Results:
A total of 1519 surgical cases (9.1%) experienced the defined composite morbidity. Using multivariable logistic regression, the Risk Assessment of Morbidity in Pediatric Surgery (RAMPS) score was developed with very good predictive ability in the derivation cohort (area under the curve [AUC] = 0.805; 95% confidence interval [CI], 0.795-0.816), very good internal validity using 1000 bootstrap resamples (bias-corrected Nagelkerke R = 0.21 and Brier score = 0.07), and good external validity (AUC = 0.783; 95% CI, 0.770-0.797). The included variables are age <5 years, critically ill, chronic condition indicator (CCI) ≥3, significant CCI ≥2, and ISR quartile ≥3. The RAMPS score ranges from 0 to 10, with the risk of composite morbidity ranging from 1.8% to 42.7%.
Conclusions:
The RAMPS score provides the ability to identify a high-risk cohort of pediatric patients using a 5-component tool, and it demonstrated good internal and external validity and generalizability. It also provides an opportunity to improve perioperative planning with the intent of improving both individual-patient outcomes and the appropriate allocation of health care resources.
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