Correlação do EuroSCORE com o surgimento de lesão renal aguda pós- operatória em cirurgia cardíaca. Rev. bras. ter. intensiva [online]. , vol, n. 3. A recent update (EuroSCORE II) is currently being validated with results .. simples e acurado para avaliação do risco em cirurgia cardíaca. Estimate risk of in-hospital death after cardiac surgery.
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EuroSCORE has been used in cardiac surgery operative risk assessment, despite important variables were not included. The objective of this study was to validate EuroSCORE on mortality prediction in a Brazilian cardiovascular surgery center, defining the influence of type of procedure and surgical team. Between January and Juneconsecutive adult patients were studied. In the present population, EuroSCORE overestimates mortality in very high risk patients, being influenced by type of procedure and surgical team.
The most appropriate surgical team may minimize risks imposed by preoperative profiles.
Euroscore cirugia cardiaca pdf files | cq
The scores of preoperative risk aim to estimate the mortality of certain surgical procedures in order to meet the interests of individuals patients and physicianshospitals and health managers. The risk prediction is important in medical practice, as it allows objective comparisons between institutions and surgeons to adjust the characteristics of severity of disease.
Moreover, the scores of preoperative risk are useful in clarifying and preoperative consent, in quality control of services and the selection or exclusion of patients in controlled clinical studies. It was created in [ 1 ]with data collected between September and December in European centers. Inthe logistic EuroSCORE was introduced using the same original database in order to improve the performance of the score in high risk patients [ 2 ].
External validation of the EuroSCORE in various populations around the world occurred initially with good results [ 3 – 5 ].
Use of EuroSCORE as a predictor of morbidity after cardiac surgery
However, most authors have recently demonstrated that the logistic EuroSCORE overestimates the expected mortality, although some developing countries show the opposite [ 6 – 8 ]. The reasons for this discrepancy in model validation involve multiple factors: Moreover, the first version of the EuroSCORE did not take into account all types of surgical procedures used in cardiac surgery because the vast majority of patients underwent isolated CABG, which may lead to misinterpretation in various possibilities of combined procedures [ 10 ].
The influence of the hospital unit or a system of national health outcome in cardiac surgery has been studied in this context [ 11 ].
The study shows that in a three-year ccirurgia, there was great variability in the results of hospitals with wide confidence intervals, thus questioning cirrgia validity of such comparisons. The inaccuracy of mathematical models of risk, reflecting differences in severity of disease and risk factors not measured, may reflect results of random variations rather than real ones.
The aim of this study was to validate the EuroSCORE in predicting cardiovascular mortality in a Brazilian center surgery, defining the influence of the type of procedure and surgeon factor. From January to Juneconsecutive adult patients who had undergone surgery were included in this study. The preoperative, intraoperative and postoperative patient characteristics were prospectively collected and stored in an electronic database. All patients underwent surgery in the same hospital following the same protocols.
The procedures were coronary artery bypass grafting CABG isolated in The latter included surgical treatment of isolated aortic diseases, congenital heart disease in adult, pericardiectomy, septal myectomy, resection of cardiac tumors, VSD repair or post-myocardial infarction heart failure and surgical treatment of endomyocardial fibrosis. The primary outcome was mortality at 30 days.
There was no loss of patient follow up at 30 days. The calculation of careiaca EuroSCORE was prospectively performed by a single examiner who strictly followed the definitions of pre- and intraoperative characteristics of patients.
The calculation of the additive and logistic score of each patient was then determined electronically accessing http: Table 1 defines the prevalence of variables used in calculating the score compared to the same used in the formation of the original statistical model. Prevalence of variables included in the calculation icrurgia the EuroSCORE compared with data from the original publication. The relationship between mortality observed O and the expected E according to the logistic EuroSCORE was calculated for each group, procedures and surgeons.
Comparison of categorical variables was performed using the chi-square test and continuous using Student’s T test, as indicated. In the latter analysis, all patients were included.
The correlation between mortality and the risk score, type of procedure ciruggia surgical team was obtained by logistic regression, ROC receiver-operating characteristic curve was obtained and calculated the area under the curve AUC. In logistic regression analysis, the variables whose P value was less than or equal to 0. The latter was performed using the backward stepwise technique, and the variables were selected with a P value less than 0.
Statistical analyzes were performed using JMP software, version 9. The sensitivity was Still, the surgeon A was inversely related to the primary event for the same model. There was a higher mortality in emergency operations than in elective As shown in Table 3there were differences cirurgka estimating operative risk according to severity.
There cardkaca no exclusions in this analysis. Table 4 shows the different relationship of the estimation of operative risk according to the type of surgical procedure performed. In this analysis, patients who did not fit the types of procedures listed above were excluded. The influence of the surgeon in estimating operative risk was variable, as shown in Table 5.
There was a tendency to overestimate mortality for surgeon C, and underestimate the surgeons D and E. Cqrdiaca this analysis, patients were excluded regarding the operations performed by 14 surgeons whose volume was less cifurgia operations during the study period. Results from other surgeons were variable. There were significant differences among surgeons with eurosocre to the type of procedures performed by each. The surgeon factor neutralized the biggest trend of risk in combined operations.
Relation between types of procedure and the surgeon factor in estimating operative risk. In this analysis, patients were excluded relating to 14 surgeons whose volume was less than operations during the study period or patients who do not fit the procedures listed above.
Moreover, the surgeon factor also influenced the tendency to overestimate the operations of CABG and valve. This study sought to examine the first version of the EuroSCORE, in order to validate the score in a Brazilian center for cardiovascular surgery, and determine the impact of the type of procedure and surgeon factor in predicting day mortality.
We observed that the EuroSCORE correlates with overall mortality of our service as well as others in our country [ 13 ] had already shown. The EuroSCORE overestimated mortality in patients at very high risk and there was still a tendency to overestimate mortality in low-risk patients. These findings are consistent with the most recent case series from developed countries [ 14 ]unlike other series [ 6 – 8 ] have shown exactly the opposite. The reasons for this discrepancy are various.
First, there was cirurrgia great progression of cases of perioperative care since the original publication of the EuroSCORE, which certainly had an impact in reducing operative mortality in centers of excellence. Moreover, these improvements were not incorporated in the same proportion and speed in centers of which the result is unsatisfactory. Structural problems in the health system and hospitals, teaming and unfavorable patient characteristics contribute to accentuate these differences.
Thus, the risk scores present better performance when the preoperative characteristics and treatment regimens are comparable to those in which the score was derived.
Any risk score can only be used reliably when tested in the local population and when treatment regimens did not show substantial differences after the development of risk score [ 9 ]. Only the validation of risk scores in different populations in different continents is essential for their clinical applicability.
Euroscoore creation of an own risk score that takes into account the peculiar characteristics of the population would be ideal [ 15 ].
Different risk scores may exist between the models and also with different ciryrgia that affect the risk prediction [ 16 ].
As regards the type of procedure, there was a tendency in this study to overestimate the mortality of isolated CABG and valve operations, and a tendency to underestimate the mortality of combined operations. Several studies in international [ 1718 ] literature have shown the same results in coronary operations. Although the original database from EuroSCORE cifurgia a minority of valve operations, our findings are also consistent with other studies in the literature [ 141920 ]although the characteristics of the patients in our country are particularly different for the prevalence ckrurgia rheumatic disease, large proportion euroscoe reoperations and pulmonary hypertension.
The group cirurgi valve diseases has gained particular interest in the advent of percutaneous aortic prostheses, whose indication takes much into account the scores of operative risk as the current recommendation restricts inoperable [ 21 ] or high surgical risk cases. However, the indication of these procedures euuroscore be decided with great care without relying solely on risk scores, as they proved to be inadequate for this purpose.
Regarding the combined operations, our findings are also consistent with other studies [ 14 ]. This is the group most difficult to assess due to the variability of combining procedures. Due to the restricted denominator for cirugia type individually, it is difficult to predict mortality accurately. The difficulty of comparison between hospitals and individuals is to adjust the complexity of cases among groups.
Simple adjustment of mortality risk does not eliminate all selection biases and can influence the test results. However, the design of performance studies is observational and in the real world and with risk adjustment.
Such analyzes would be comparable with a valid reference standard with the same characteristics of patients, usually within the same population ehroscore individuals [ 22 ]. Considering the same limitations noted above, the impact of the surgeon factor may be important in influencing the severity of patients and the type of procedure. This was further supported by the negative effect exerted by the surgeon A on mortality by multivariate analysis. Generally, the surgeon had a positive impact on all grades of risk, particularly in severe cases and combined operations, unlike the surgeon B.
Impact of type of procedure and surgeon on EuroSCORE operative risk validation
The influence of the surgeon unlike the hospital reinforces the notion that within a high complex service, heterogeneity of surgeons’ performance may exist determining impact on results. The surgical volume, training and technical and clinical experience of each team member must be taken into consideration at the time of surgical scheduling, as well as the expertise and personal familiarity with each procedure to ensure the best possible outcome for the patient.
The formation and maintenance of integrated multidisciplinary teams engaged in developing systematic health care programs and quality control [ 23 ] programs have shown positive impact on surgical outcomes in cardiac surgery [ 2425 ].
Based on our findings, it is important that the risk score has constant updating and validation in Brazilian centers. The risk score should not be used alone in indicating whether or not a surgical procedure, cirurvia being part of a broader context of clinical surgical discussion, because there are unmeasured factors that may influence the risk prediction. The present study has several limitations inherent to its euroscofe mainly.
Because of the risk scores were constructed for use in large populations, analysis of subgroups with smaller denominator reduces the statistical power and can lead to misleading interpretations.
The differences in the proportion of patients undergoing different degrees of complexity among surgeons may have cardjaca selection bias. However, we were careful to adjust the mortality rates for the same severity group of patients in order to minimize these limitations.
The ideal, however, would have been adjusted for each value of the risk score, which would entail further reduced denominator. The authors acknowledge that there are no perfect mathematical models, and thus our findings may be subject to errors. Previous studies [ 12euroscoe ] have shown that there can be large fluctuations results in the classification of hospitals and surgeons, whose final interpretation questioned the statistical validity of the model. However, there is validity to demonstrate these results as a form of quality control, as usually the critical analysis euroscoee the results leads to subsequent improvement in outcomes [ 27 ].
In the population studied, the first version of the EuroSCORE overestimates mortality in patients at very high risk and may be influenced by the type of surgery proposed and the surgeon factor. We must also choose the most appropriate surgeon for each severity from patient to minimize the risk imposed by preoperative characteristics. National Center for Biotechnology InformationU. Rev Bras Cir Cardiovasc. Author information Article notes Copyright and License information Disclaimer.
Received Oct 1; Accepted Feb