Derivation and Validation of the ED-SAS Score for Very Early Prediction of Mortality and Morbidity with Acute Pancreatitis: A Retrospective Observational Study

Abstract

Background: Existing scoring systems to predict mortality in acute pancreatitis may not be directly applicable to the emergency department (ED). The objective of this study was to derive and validate the ED-SAS, a simple scoring score using variables readily available in the ED to predict mortality in patients with acute pancreatitis.Methods: This retrospective observational study was performed based on patient level data collected from electronic health records across 2 independent health systems, one used for the derivation cohort and one for the validation cohort. Adult patients who were eligible presented to the ED, required hospital admission, and had a confirmed diagnosis of acute pancreatitis. Patients with chronic or recurrent episodes of pancreatitis were excluded. The primary outcome was 30-day mortality. Analyses tested and derived candidate variables to establish a prediction score and that was subsequently applied to the validation cohort to assess odds ratio for the primary and secondary outcomes. Results: The derivation cohort included 599 patients, and the validation cohort 2011 patients. Thirty-day mortality was 4.2% and 3.9% respectively. From the derivation cohort, 3 variables were established for use in the predictive scoring score: ≥2 systemic inflammatory response syndrome (SIRS) criteria, age >60 years, and SpO2 <96%. Summing the presence or absence of each variable yielded an ED-SAS score ranging from 0 to 3. In the validation cohort, the odds of 30-day mortality increased with each subsequent ED-SAS point: 4.4 (95% CI 1.8 – 10.8) for 1 point, 12.0 (95% CI 4.9 – 29.4) for 2 points, and 41.7 (95% CI 15.8 – 110.1) for 3 points (c-statistic = 0.77).Conclusion: An ED-SAS score that incorporates SpO2, age, and SIRS measurements provides a rapid method for predicting 30-day mortality in acute pancreatitis.

How to score acute pancreatitis in the emergency setting: five systems against ED-SAS

“…The receiver operating characteristic (ROC) analysis was used to identify the cut-off levels of the risk scores in estimating death rates. The methodology launched by DeLong et al [22] was employed to compare the ROC curves of the risk scores. The significance level was taken as P < 0.05.…”

“…APACHE II, Ranson, and BISAP are among the most frequently used evaluation systems [27], which are widely employed to predict death resulting from AP. However, since these scoring systems were not devised to be used in the emergency department, they require data that cannot be rapidly obtained in this setting [22,27].…”

“…It is known that presence of SIRS criteria has an effect on the outcome in AP [20]. SIRS is one of the early predictors of severe AP, and there are studies showing that patients presenting with SIRS on the first day of manifestations experience more severe AP [13,20,22,30]. However, the SIRS score significantly increases with the increasing age.…”

“…This allows for different or more aggressive approaches to be considered when planning the treatment modalities of patients diagnosed during the initial presentation. A strong feature of ED-SAS is that it is calculated based on parameters that can be easily obtained for each patient and does not contain specific findings [22].…”

“…Some studies have shown that especially the first 24-hour period after symptomatology is critical for identifying those patients carrying greater likelihood to develop untoward events and/or mortality [4,21]. In light of this information, in previous studies, the ED-SAS scoring system was derived from simple variables, namely SIRS criteria, age and oxygen saturation levels evaluated in the emergency department in the 24 hours following manifestations [22][23][24].…”