Prospective External Validation of the Pediatric Risk Assessment Score in Predicting Perioperative Mortality in Children Undergoing Noncardiac Surgery

Abstract

BACKGROUND: Early identification of children at high risk for perioperative mortality could lead to improved outcomes; however, there is a lack of well-validated risk prediction tools. The Pediatric Risk Assessment (PRAm) score is a new model to prognosticate perioperative risk of mortality in pediatric patients undergoing noncardiac surgery. It was derived from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Pediatric database. In this study, we aimed to externally validate the PRAm score at 1 large institution. METHODS: A PRAm score was prospectively assigned by the primary anesthesia team to children ≤18 years of age undergoing noncardiac surgery between July 2017 and July 2018 at a tertiary care pediatric hospital. The primary outcome was the PRAm score’s ability to predict 30-day mortality. The area under the receiver operating characteristic (ROC) curve was utilized to determine discriminative ability. Sensitivity and specificity at varying cutoffs were considered. Youden J index and the gray zone approach were applied to determine the optimal PRAm cutoff for predicting 30-day mortality. RESULTS: Among the 13,530 cases included in the external validation cohort, the incidence of 30-day mortality was 0.21% (29/13,530). The PRAm score was found to predict 30-day mortality with an area under the curve (AUC) of 0.956 (95% confidence interval [CI], 0.938–0.974; P < .001). Youden J index determined the optimal PRAm score threshold to be ≥5 with a sensitivity of 86% and a specificity of 91%. The gray zone identified an inconclusive risk of mortality in 6.93% (938/13,530) of patients who had PRAm scores of 4 or 5 (sensitivity or specificity <90%, respectively), therefore refining the optimal cutoff point to be a PRAm score of ≥6. The incidence of mortality for patients with an American Society of Anesthesiologists Physical Status (ASA PS) ≤3 (0.06%, 8/13,530) increased 8-fold for those with an ASA PS of ≤3 and a PRAm score of ≥6. CONCLUSIONS: The PRAm score is a simple and objective tool that has excellent ability to predict perioperative risk of mortality in pediatric patients undergoing noncardiac surgery and can be easily used by clinicians. The application of the PRAm score could have important implications on the safety and quality of care delivered to infants and children and on the resource utilization in the pediatric health care system.

Life-Threatening Bleeding in Children: A Prospective Observational Study

“…Children with surgical bleeding were substantially younger than those with bleeding due to trauma and medical causes. This is likely due to the combined surgical risk of young age and the type of procedures performed in young children, in particular, surgery for congenital deformities (e.g., craniofacial, heart, and liver) and neoplasms (e.g., neuroblastoma, Wilms tumor) (26)(27)(28). The effect of age-related maturation of the hemostatic system when considering approaches to life-threatening bleeding has not been thoroughly studied.…”

From the Ground Up: Esophageal Atresia Types, Disease Severity Stratification and Survival Rates at a Single Institution

“…Complexity of clinical status in the context of other comorbidities was assessed using two scoring systems: American Society of Anesthesiologists (ASA) (16) and Pediatric Risk Assessment (PRAm) (17)(18)(19) scores at the time of EA repair surgery. Assigning an ASA Physical Status classification level is a clinical decision based on several factors (16) and represents the most commonly used assessment of system level disease severity by anesthesiologists (Figure 3A-Table).…”

“…The primary goal of this study addresses the severity of EA disease as a blueprint for a subsequent myriad of caregiving conditions that might impose challenges to developing infants born with EA. Specifically, we conducted a retrospective analysis at a single institution to analyze incidence of EA by severity of disease using American Society of Anesthesiologists (ASA) (16) and Pediatric Risk Assessment (PRAm) (17)(18)(19) scores in the context of (i) sex, (ii) gestational age (term-born and premature), (iii) anatomical classification of EA types, and (iv) the type of surgical repair (viz. direct anastomosis vs. Foker Abbreviations: ASA, American Society of Anesthesiologist; EA, Esophageal atresia; CHARGE, Coloboma, Heart defects, choanal Atresia, growth Retardation, Genital abnormalities, and Ear abnormalities; PRAm, Pediatric Risk Assessment; TEF, Tracheo-esophageal fistula; VACTERL, Vertebral, Anorectal, Cardiac, Tracheo-esophageal fistula and/or Esophageal atresia, Renal, and Limb defects/malformations.…”

“…Graphs illustrate incidence of American Society of Anesthesiologists (ASA) Physical Status classification (A) and Pediatric Risk Assessment (PRAm) severity scores (B) in infants born with esophageal atresia (EA) that underwent primary repair at a single institution from 2009-2020 (n = 84). Definition of scoring is shown in summary tables on the right for both the ASA Physical Status (16) and PRAm scoring(17)(18)(19). Graphs show stratification by anatomical types of EA (type A-D) and gestational age (term-born and premature; see Methods section).…”

Creation of a Pediatric Sedation Risk Assessment Scoring System: A Novel Method to Stratify Risk

“…This more comprehensive view of the patient is also consistent with work being done in anesthesia to determine risk of perioperative mortality in both cardiac and noncardiac anesthesia. 16 17…”