Comprehensive Risk Assessment of Morbidity in Pediatric Patients Undergoing Noncardiac Surgery: An Institutional Experience.


  • Data for all noncardiac paediatric surgical patients at Boston Children’s Hospital was collected retrospectively over a defined time period (derivation cohort of 16,724 cases and validation dataset of 9043 cases).
  • Primary outcome was a composite morbidity: unplanned transfer to an intensive care unit within 72 hours, acute respiratory failure requiring intubation, postoperative non-invasive or invasive positive pressure ventilation within 48 hours, or cardiac arrest.
  • Predictor variables collected were: intrinsic surgical risk (ISR), chronic condition indicator (CCI), urgent procedure (defined as non-elective), patient age and critical illness (mechanical ventilation, inotropic support or preoperative cardiopulmonary resuscitation).
  • A multivariable logistic regression model was fit with binary predictors in addition to the indicators for urgent procedure and critical illness to determine the independent associations with the composite morbidity outcome to develop the RAMPS score.
  • Both internal and external validation were performed.


  • Based on statistical analysis, the RAMPS score was developed (0 to 10 points and risk of composite morbidity ranging from 1.8% to 42.7%).
    • The included predictor variables (with corresponding points) are those that reached statistical significance for the composite outcome: age <5 years (+1), critically ill (+1), (CCI) ≥3 (+2), significant CCI ≥2 (+2), and ISR quartile ≥3 (+4).
  • The validation results for the RAMPS score in predicting the composite outcome in the derivation cohort yielded an AUC of 0.805 (95% CI, 0.795–0.816).
  • Both good internal validity and good external validity) were demonstrated.

Conclusion and Take Home Messages

  • Patient characteristics and comorbidities, as well as intrinsic surgical risk (ISR), contribute to the determinants of perioperative risk in children.
  • Existing tools for predicting peri-operative paediatric morbidity risk include:
    • A Novel Multispecialty Surgical Risk Score for Children (not externally validated), and
    • The ACS NSQIP Pediatric Surgical Risk Calculator (not publicly validated).
  • This investigation demonstrates that the risk assessment of morbidity in paediatric surgery using the RAMPS score is highly predictive of composite postoperative morbidity in paediatric patients undergoing non-cardiac surgery.
  • Of note, common procedures, including tonsillectomy and strabismus surgery were not part of the dataset due to an inability to derive an ISR for these procedures.
  • The validated RAMPS tool has good generalisability and can aid in perioperative planning to improve patient outcomes and health resource allocation.


Reviewed by Dr Chloe Heath