预测儿童非心脏手术围术期死亡的风险评分
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Development of a Pediatric Risk Assessment Score to Predict Perioperative Mortality in Children Undergoing Noncardiac Surgery
背景与目的
尽管目前有许多预测成人围术期死亡风险的方法，但并没有研发出一个客观模式的儿科患者围术期死亡风险评估方法。我们本次研究的目的是研发出一个预测儿科非心脏手术患者围术期死亡风险的儿科风险评估（PRAm）评分。
方 法
我们将美国外科医生协会的国家外科质量改进项目中儿科数据库中2012年-2013年期间所有儿科患者作为对照组，而2014年期间所有儿科患者作为试验组。将住院期间的死亡率作为主要结局指标。其中对照组一共纳入115,229（63%）例患者，实验组纳入68,194（37%）例患者，采用多变量逻辑回归分析方法确定死亡率的预测因素并以此设计PRAm评分。
结 果
根据多变量回归分析，我们研发了一个简单风险评估方法（PRAm评分），其评分波动范围为0～≥9，评分内容包括是否存在任何合并症，危重症，年龄＜12月龄，需要紧急手术以及患有肿瘤。PRAm评分在对照组具有极好的分辨能力表现为阳性部位在受试者操作特征曲线（ROC曲线）下面积（AUC）的数值为0.950（95%置信区间（CI）,0.942-0.957），而在试验组也呈现出相似结果AUC的数值为0.950（95% CI,0.938-0.961）。其中AUC也先采用共益程序（bootstrap procedure）计算再用于原始样本推导以确认每个阳性的样本具有0.943（95% CI,0.929-0.9956）的AUC数值。当阳性数值为0.007时，对应的阳性校正区域的AUC数值为0.943。校正是通过直观的评估观测结局指标绘制的曲线是否与预测死亡率相悖（Pearson 相关系数=0.995，校正刻度=0.001[P=0.974]，校正斜率=0.927）。
结 论
本研究中，我们研发了一种简易的PRAm方法（PRAm评分）用于儿科非心脏手术患者围术期死亡风险的预测。PRAm评分的精确度很高，但ASA分级≥4的患儿中客观地获得的PRAm评分却存在很大变异性。
原始文献摘要
Nasr V G, DiNardo J A, Faraoni D. Development of a Pediatric Risk Assessment Score to Predict Perioperative Mortality in Children Undergoing Noncardiac Surgery.[J]. Anesthesia and analgesia, 2017,124(5):1514-1519.
BACKGROUND: Although there have been numerous attempts to predict perioperative mortality in adults, an objective model to predict mortality in children has not been developed. In this study, we aimed to develop a Pediatric Risk Assessment (PRAm) score to predict perioperative mortality in children undergoing noncardiac surgery.
METHODS: We included all children recorded in the 2012 and 2013 American College of Surgeons National Surgical Quality Improvement Program Pediatric databases in a derivation cohort and those from the 2014 database in a validation cohort. The primary outcome was the incidence of in-hospital mortality. A total of 115,229 (63%) were included in the derivation cohort and 68,194 (37%) in the validation cohort. We used multivariable logistic regression to determine the predictors for mortality and designed the PRAm score.
RESULTS: On the basis of the multivariable regression model, we created a simplified risk assessment tool (PRAm score) ranging from 0 to >/=9, including the presence of any comorbidities, factors of critical illness, age <12 months, the requirement for an urgent procedure, and the diagnosis of a neoplasm. The PRAm score showed an excellent discriminative ability with an apparent "optimistic" area under the receiver operating characteristic curve (AUC) of 0.950 (95% confidence interval [CI], 0.942-0.957) in the derivation cohort. In the validation cohort, we observed similar performances with an area under the "naive" receiver operating characteristic curve of 0.950 (95% CI, 0.938-0.961). The AUC was also calculated from a bootstrap procedure and then applied to the original derivation sample to estimate "optimism" for each bootstrap sample with an AUC of 0.943 (95% CI, 0.929-0.9956). The optimism in apparent performance was 0.007, corresponding to an optimism-corrected area of 0.943. Calibration was assessed graphically by plotting the observed outcome against the predicted mortality (Pearson correlation coefficient = 0.995, calibration in the large = 0.001 [P = .974], calibration slope = 0.927).
CONCLUSIONS: In this study, we developed a simplified PRAm tool (PRAm score) as a predictor of perioperative mortality in children undergoing noncardiac surgery. The PRAm score has excellent accuracy. In patients assigned American Society of Anesthesiologists physical status classification >/=4, there is wide variability in objectively obtained PRAm scores.
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