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Perioperative Mortality in Pediatric Patients: A Systematic Review of Risk Assessment Tools for Use in the
Virginia E Tangel1, Stephan D Krul2, Robert Jan Stolker2
1Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Anesthesiology, Weill Cornell Medicine, New York, New York.
Insights
This systematic review found multiple pediatric risk scores for perioperative mortality. While effective, many scores have bias and lack external validation, limiting their clinical use.
Area of Science:
- Pediatric Anesthesiology
- Surgical Outcomes Research
- Healthcare Risk Assessment
Background:
- Multiple preoperative risk scores exist for pediatric mortality.
- This study aimed to systematically describe and compare existing patient-specific, multispecialty risk prediction scores for pediatric perioperative mortality.
- The goal is to guide clinicians in selecting appropriate preoperative risk assessment tools.
Approach:
- Systematic literature review of studies developing, updating, or validating risk scores for pediatric all-cause mortality (up to 30 days postoperatively).
- Included scores applicable to multiple noncardiac surgical specialties and calculable by anesthesiologists preoperatively.
- Assessed study quality based on clinical applicability, feasibility, and risk of bias.
Key Points:
- 1,681 titles were reviewed, with 10 studies meeting inclusion criteria.
- Seven studies utilized National Surgical Quality Improvement Program-Pediatric data.
- Mortality rates ranged from 0.3% to 3.6%; predictors included demographics and chronic conditions.
- All validated models demonstrated good discrimination (AUC > 0.8).
- Most risk scores had high or unclear risks of bias.
Conclusions:
- Numerous pediatric mortality prediction scores exist with good performance.
- However, many scores suffer from high or unclear risks of bias.
- A significant limitation is the lack of external validation for most scores.
Background:
There are multiple preoperative risk scores for pediatric mortality. The aim of this study was to systematically describe and compare the existing studies of patient-specific multispecialty risk prediction scores for perioperative mortality in pediatric populations, with the goal of guiding clinicians on which may be most appropriate for use in the preoperative setting.
Methods:
This study is a systematic literature review of published journal articles that presented the development, extension/updating, and/or validation of a risk core that predicted all-cause mortality (up to 30 days postoperatively) in pediatric patients undergoing a procedure in which anesthesia was used. Scores needed to be applicable to surgeries in more than one noncardiac surgical specialty and had to be able to be calculated by the anesthesiologist at the time of the preanesthetic assessment. Two investigators independently screened studies for inclusion and assessed study quality in the domains of clinical applicability, feasibility/ease of use in the clinical setting, and risk of bias.
Results:
A total of 1,681 titles were retrieved. Of these, 10 studies met inclusion criteria: 9 reported the development and validation of scores, and 1 was an external validation of an existing score. Seven studies used varying years of multicenter data from the National Surgical Quality Improvement Program-Pediatric Participant Use File for development and/or validation. The unadjusted rate of mortality in the studies ranged from 0.3 to 3.6%. The preoperative predictors of mortality used in score development included patient demographics, preoperative therapies, and chronic conditions, among others. All models showed good discrimination upon validation (area under the receiver operating characteristics curve greater than 0.8). Most risk scores had high or unclear risks of bias.
Conclusions:
There are numerous scores available for the prediction of mortality in pediatric populations, all of which exhibited good performance. However, many have high or unclear risks of bias, and most have not undergone external validation.
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