Application of Surgical Apgar Score in intracranial meningioma surgery

RESEARCH ARTICLE Application of Surgical Apgar Score in intracranial meningioma surgery Shih-Yuan Hsu1‡, Chien-Yu Ou1,2‡, Yu-Ni Ho3, Yu-Hua Huang1* 1 Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, 2 Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, 3 Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan ‡ SYH and CYO are equal first authors on this work * a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Hsu S-Y, Ou C-Y, Ho Y-N, Huang Y-H (2017) Application of Surgical Apgar Score in intracranial meningioma surgery. PLoS ONE 12(4): e0174328. https://doi.org/10.1371/journal. pone.0174328 Editor: Jonathan H Sherman, George Washington University, UNITED STATES Received: January 18, 2017 Accepted: March 7, 2017 Published: April 6, 2017 Copyright: © 2017 Hsu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: The authors received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Abstract Surgical resection is the main therapeutic option for intracranial meningiomas, but it is not without significant morbidities. The Surgical Apgar Score (SAS), assessed by intraoperative blood pressure, heart rate, and blood loss, was developed for prognostic prediction in general and vascular surgery. We aimed to examine whether the application of SAS in patients undergoing craniotomy for meningioma resection can predict postoperative major complications. We retrospectively enrolled 99 patients that had undergone intracranial meningioma surgery. The patients were subdivided into 2 groups based on whether major complications were present (N = 34) or not (N = 65). We recognized the intergroup differences in SAS and clinical variables. The incidence of 30-day major complications in patients after operation was 34.3%. The lengths of ICU and hospital stay for the morbid cases were prolonged significantly (p = 0.009, p < 0.001, respectively). In the multivariate logistic regression model, SAS was an independent predicting factor of major complications following surgery for intracranial meningiomas (odds ratio, 95% confidence interval = 0.57, 0.38–0.87; p = 0.009), and thus a decrease of one mean SAS increased the rate of major complications by 43%. In conclusions, SAS is an independent predictor of major complications in patients undergoing intracranial meningioma surgery, and provides acceptable risk discrimination. Since this scoring system is relatively simple, objective, and practical, we suggest that SAS be included as an indicator in the guidance for the level of care after craniotomy for meningioma resection. Introduction Meningiomas are composed of neoplastic arachnoidal cells imbedded in the meninges, and constitute 13%–26% of primary intracranial tumors [1, 2]. Most meningiomas are slowly growing and benign, and tend to compress the adjacent structures rather than infiltrate them. Because of the relatively clear operative plane, surgery aimed at total resection of the tumors is the main therapeutic option. While surgical removal of intracranial meningiomas can be curative and allow timely reduction of the mass effect, it is not without significant adverse events. Particularly, the incidence of meningiomas peaks after the fifth decade of life, and elderly PLOS ONE | https://doi.org/10.1371/journal.pone.0174328 April 6, 2017 1 / 11 Surgical Apgar Score in meningioma surgery Table 1. The 10-Point Surgical Apgar Score No. of Pointsa 0 1 2 3 4 Estimated blood loss, ml >1000 601–1000 101–600 ≦100 ─ Lowest mean arterial pressure, mmHg <40 40–54 55–69 ≧70 ─ Lowest heart rate, beats per min >85 76–85 66–75 56–65 ≦55b a The Surgical Apgar Score is calculated at the end of operation and is the sum of the points from each category. b Occurrence of pathologic bradyarrhythmia, including sinus arrest, atrioventricular block or dissociation, junctional or ventricular escape rhythms, and asystole, also receives 0 points for lowest heart rate. https://doi.org/10.1371/journal.pone.0174328.t001 patients are more likely to have complications following surgery [3, 4]. Thus the ability to identify the immediate postoperative state and determine a patient’s risk of complications is quite important, and can guide the level of care and alleviate the effect of morbidities. In 2007, Gawande et al. introduced the Surgical Apgar Score (SAS) to predict the occurrence of major postoperative morbidities and mortality after general and vascular surgery [5]. SAS is a 10-point score based on 3 easily obtained parameters: the estimated blood loss, lowest heart rate, and lowest mean arterial pressure during surgery (Table 1). This scoring system has been validated more broadly for use in several cohorts of patients undergoing orthopedic, gynecologic, traumatic, urologic, or colorectal surgery [6, 7, 8]. In addition, Ziewacz et al. showed that the use of SAS in a general neurosurgical population can allow risk stratification [9]. However, the diversity of the neurosurgical field, from emergency to elective or brain to spinal surgery, should be taken into consideration, and the efficacy of SAS in the setting of each procedure should be accessed. Whether SAS applied with patients undergoing intracranial meningioma surgery differentiates and predicts prognosis remains to be elucidated. In the present study, we collected clinical data and quantified the relationship between SAS and major complications after craniotomy for meningioma resection. Materials and methods Data collection This study was retrospectively conducted at Kaohsiung Chang Gung Memorial Hospital, a 2686-bed tertiary referral institute in Taiwan. After being approved by the institutional review board, we reviewed the documents of patients that had undergone craniotomy for intracranial meningioma resection from February 2009 through December 2013. Patients who were treated for recurrent tumors or tissue biopsy alone were excluded. A total of 99 cases were included for assessment. The research staff collected clinical information, consisting of the demographic data, presenting symptoms/signs, preoperative laboratory examinations, Karnofsky Performance Scale (KPS) score, and American Society of Anesthesiologists (ASA) Physical Status Classification. Details of the operations for the calculation of SAS, including intraoperative blood loss, lowest heart rate, and lowest mean arterial pressure, were recorded from computerized or paper m (...truncated)