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

The purpose of this study is to provide external validation to a tool that can be used to predict mortality risk in children undergoing non-cardiac surgery. The Paediatric Risk Assessment (PRAm) has been derived from an American Paediatric Surgical Quality Improvement Database (NSQIP). There are five variables in the score: whether the procedure was urgent (+1 point), whether there was at least one comorbidity (+2 points), whether the child had features of critical illness (mechanical ventilation, inotropes, preoperative CPR) (+3 points), age less than 12 months (+3 points) and procedures in those with neoplasm (+4 points). Having devised the score, the authors (from Boston Children’s Hospital) applied it prospectively to all non-cardiac surgical patients presenting between July 2017 and July 2018 at their hospital, a total of 13,530 cases. The primary outcome was 30-day all-cause mortality.

The incidence of mortality was found to be 0.21%, notable as this is lower than what was reported in the nationally reported incidence from which the score was derived (0.7%). The PRAm score was determined to have extremely good discriminatory capacity, with an AUC of 0.956 and several other complex statistical calculations confirming its ability to discriminate between patients with and without mortality. The authors thus concluded that the score was well validated.

Take Home Message

It seems this score is effective at predicting mortality in children undergoing non-cardiac surgery. The ability to accurately predict mortality in children undergoing non-cardiac surgery is not without its benefits, but given how rare 30-day mortality is, it is not likely to have a high degree of day-to-day clinical utility. A more useful score might look at risk of or need for post-operative ICU, length of hospital stay or even cardiac or respiratory adverse events. Also, this score does not take into account the type of surgery being performed, even though the authors found a significant correlation between certain types of surgery and mortality. The question is whether widespread implementation of this score could be used in a practical way to improve mortality outcomes, and there is a lot more work to do to establish that at this stage. Important take-away points are that the score does suggest that children with cancer carry significantly higher risk, also that small babies are much higher risk, and that critically ill children remain challenging – none of which is a surprise to those who anaesthetise children regularly.

Reviewed by:  Dr Amanda Dalton