Tools and scores for perioperative pulmonary, renal, hepatobiliary, hematological, and surgical site infection risk assessment: an update

MORAES, CAIO MAZZONETTO TEÓFILO DE; CORRÊA, LUISA DE MENDONÇA; PROCÓPIO, RICARDO JAYME; CARMO, GABRIEL ASSIS LOPES DO; NAVARRO, TULIO PINHO

doi:10.1590/0100-6991e-20223125-en

CAIO MAZZONETTO TEÓFILO DE MORAES

- Universidade Federal de Minas Gerais - Belo Horizonte - MG - Brasil

http://orcid.org/0000-0002-7614-433X

LUISA DE MENDONÇA CORRÊA

- Faculdade Ciências Médicas de Minas Gerais - Belo Horizonte - MG -Brasil

http://orcid.org/0000-0003-2328-4811

RICARDO JAYME PROCÓPIO

- Universidade Federal de Minas Gerais, Hospital das Clínicas, Unidade Endovascular - Belo Horizonte - MG - Brasil

http://orcid.org/0000-0003-0094-8945

GABRIEL ASSIS LOPES DO CARMO

- Universidade Federal de Minas Gerais, Departamento de Clínica Médica - Belo Horizonte - MG - Brasil

http://orcid.org/0000-0002-3610-6507

TULIO PINHO NAVARRO

- Universidade Federal de Minas Gerais, Departamento de Cirurgia - Belo Horizonte - MG - Brasil

http://orcid.org/0000-0001-8134-5825

Mailing address:
Tulio Pinho Navarro E-mail: tulio.navarro@gmail.com

Conflict of interest:

no.

Tables (16)

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Table 1
Risk factors and postoperative Respiratory Failure Risk Index scores ¹⁸18 Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery. Ann Surg. 2000;232(2):242-53. doi: 10.1097/00000658-200008000-00015.
https://doi.org/10.1097/00000658-2000080... .

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Table 2
Classes, scoring and estimated risk by postoperative Respiratory Failure Risk Index ¹⁸18 Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery. Ann Surg. 2000;232(2):242-53. doi: 10.1097/00000658-200008000-00015.
https://doi.org/10.1097/00000658-2000080... .

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Table 3
Risk factors and scores for the Postoperative Pneumonia Risk Index ¹⁹19 Arozullah AM, Khuri SF, Henderson WG, Daley J. Development and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery. Ann Intern Med. 2001 20;135(10):847. doi: 10.7326/0003-4819-135-10-200111200-00005.
https://doi.org/10.7326/0003-4819-135-10... .

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Table 4
Classes , scoring and estimated risk by the Postoperative Pneumonia Risk Index ¹⁹19 Arozullah AM, Khuri SF, Henderson WG, Daley J. Development and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery. Ann Intern Med. 2001 20;135(10):847. doi: 10.7326/0003-4819-135-10-200111200-00005.
https://doi.org/10.7326/0003-4819-135-10... .

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Table 5
Postoperative pulmonary risk factors and scores according to the ARISCAT index ²⁰20 Canet J, Gallart L, Gomar C, Paluzie G, Vallès J, Castillo J, et al. Prediction of Postoperative Pulmonary Complications in a Population-based Surgical Cohort. Anesthesiology. 2010;113(6):1338-50. doi: 10.1097/ALN.0b013e3181fc6e0a.
https://doi.org/10.1097/ALN.0b013e3181fc... .

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Table 6
Risk levels of pulmonary complications estimated by ARISCAT ²⁰20 Canet J, Gallart L, Gomar C, Paluzie G, Vallès J, Castillo J, et al. Prediction of Postoperative Pulmonary Complications in a Population-based Surgical Cohort. Anesthesiology. 2010;113(6):1338-50. doi: 10.1097/ALN.0b013e3181fc6e0a.
https://doi.org/10.1097/ALN.0b013e3181fc... .

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Table 7
Risk Index for Acute Kidney Injury in General Surgery ²⁹29 Kheterpal S, Tremper KK, Heung M, Rosenberg AL, Englesbe M, Shanks AM, et al. Development and Validation of an Acute Kidney Injury Risk Index for Patients Undergoing General Surgery. Anesthesiology. 2009;110(3):505-15. doi: 10.1097/ALN.0b013e3181979440.
https://doi.org/10.1097/ALN.0b013e318197...

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Table 8
Preoperative risk factors for renal risk and their SPARK scores ³¹31 Park S, Cho H, Park S, Lee S, Kim K, Yoon HJ, et al. Simple Postoperative AKI Risk (SPARK) Classification before Noncardiac Surgery: A Prediction Index Development Study with External Validation. JASN. 2019;30(1):170-81. doi: 10.1681/ASN.2018070757.
https://doi.org/10.1681/ASN.2018070757... .

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Table 9
Classes and estimated Renal risk according to SPARK Index ³¹31 Park S, Cho H, Park S, Lee S, Kim K, Yoon HJ, et al. Simple Postoperative AKI Risk (SPARK) Classification before Noncardiac Surgery: A Prediction Index Development Study with External Validation. JASN. 2019;30(1):170-81. doi: 10.1681/ASN.2018070757.
https://doi.org/10.1681/ASN.2018070757... .

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Table 10
Parameters for Hepatobiliary risk according to the Child-Turcotte-Pugh score ⁴⁶46 Pugh RNH, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60(8):646-9. doi: 10.1002/bjs.1800600817.
https://doi.org/10.1002/bjs.1800600817... .

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Table 11
Classes ⁴⁶46 Pugh RNH, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60(8):646-9. doi: 10.1002/bjs.1800600817.
https://doi.org/10.1002/bjs.1800600817... and perioperative mortality due to hepatobiliary risk according to the Child-Turcotte-Pugh score ³³33 Neeff H, Mariaskin D, Spangenberg H-C, Hopt UT, Makowiec F. Perioperative Mortality After Non-hepatic General Surgery in Patients with Liver Cirrhosis: an Analysis of 138 Operations in the 2000s Using Child and MELD Scores. J Gastrointest Surg. 2011;15(1):1-11. doi: 10.1007/s11605-010-1366-9.
https://doi.org/10.1007/s11605-010-1366-... ^, ³⁷37 Mansour A, Watson W, Shayani V, Pickleman J. Abdominal operations in patients with cirrhosis: Still a major surgical challenge. Surgery. 1997;122(4):730-6. doi: 10.1016/s0039-6060(97)90080-5.
https://doi.org/10.1016/s0039-6060(97)90... .

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Table 12
Risk factors for venous thromboembolism according to the modified Caprini score (ACCP) ⁵⁸58 Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of VTE in Nonorthopedic Surgical Patients. Chest. 2012;141(2):e227S-e277S. doi: 10.1378/chest.11-2297.
https://doi.org/10.1378/chest.11-2297... .

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Table 13
Risk factors for venous thromboembolism according to the Rogers score ⁶⁴64 Rogers SO, Kilaru RK, Hosokawa P, Henderson WG, Zinner MJ, Khuri SF. Multivariable Predictors of Postoperative Venous Thromboembolic Events after General and Vascular Surgery: Results from the Patient Safety in Surgery Study. J Am Coll Surg. 2007;204(6):1211-21. doi: 10.1016/j.jamcollsurg.2007.02.072.
https://doi.org/10.1016/j.jamcollsurg.20... .

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Table 14
Risk levels for venous thromboembolism according to the Rogers score ⁶⁴64 Rogers SO, Kilaru RK, Hosokawa P, Henderson WG, Zinner MJ, Khuri SF. Multivariable Predictors of Postoperative Venous Thromboembolic Events after General and Vascular Surgery: Results from the Patient Safety in Surgery Study. J Am Coll Surg. 2007;204(6):1211-21. doi: 10.1016/j.jamcollsurg.2007.02.072.
https://doi.org/10.1016/j.jamcollsurg.20... .

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Table 15
Surgical site infection risk index of the SENIC project, 1985 ⁷⁴74 Haley RW, Culver DH, Morgan WM, White JW, Emori TG, Hooton TM. Identifying patients at high risk of surgical wound infection. Am J Epidemiol. 1985;121(2):206-15. doi: 10.1093/oxfordjournals.aje.a113991.
https://doi.org/10.1093/oxfordjournals.a... .

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Table 16
Main advantages and limitations of risk assessment tools by system.

Risk factors	Score
Type of surgery
Abdominal aortic aneurysm	27
Thoracic	21
Neurosurgery, upper abdominal, or peripheral vascular	14
Neck	11
Emergency surgery	11
Albumin <30g/L	8
Urea >62mg/dL	8
Total or partial functional dependence	7
History of chronic obstructive pulmonary disease	6
Risk factors	Score
Age
≥70 years	6
60-69 years	4

Class	Score	Risk of postoperative respiratory failure (%)
I	≤10	0.5
II	11-19	2.2
III	20-27	5
IV	28-40	11.6
V	>40	30.5

Risk factors	Score
Type of surgery
Abdominal aortic aneurysm repair	15
Thoracic	14
Risk factors	Score
Upper abdominal	10
Neck	8
Neurosurgery	8
Vascular	3
Age
≥80 years	17
70-79 years	13
60-69 years	9
50-59 years	4
Functional status
Totally dependent	10
Partially dependent	6
Weight loss >10% in the last 6 months	7
History of chronic obstructive pulmonary disease	5
General anesthesia	4
Impaired Sensory	4
History of stroke	4
Urea
<17mg/dL	4
47-64mg/dL	2
≥64mg/dl	3
Transfusion >4 units of packed blood cells	3
Emergency surgery	3
Chronic steroid use	3
Active smoker (in the last year)	3
Alcohol consumption >2 drinks/day in the prior 2 weeks	2

Class	Score	Risk of postoperative pneumonia (%)
I	0-15	0.2
II	16-25	1.2
III	26-40	4
IV	41-55	9.4
V	> 55	15.3

Risk factors	Score
Age
51-80	3
>80	16
Preoperative PaO2 (%)
91-95	8
≤90	24
Respiratory tract infection in the last month	17
Preoperative anemia (Hb ≤10g/dL)	11
Surgical incision
Upper abdominal	15
Intrathoracic	24
Surgery duration (hours)
2-3	16
>3	23
Emergency procedure	8

Risk level	Score	Risk of postoperative pulmonary complications (%)
Low	<26	0.7 - 1.6
Moderate	26-44	6.3 - 13.3
High	≥45	42.1 - 44.9

Independent risk factors	Class (risk factors present)	Risk of AKI (%)
Age ≥56 years	I (0-2)	0.2
Male	II (3)	0.8
Cardiac insufficiency	III (4)	1.8-2
Ascites	IV (5)	3.3-3.6
Hypertension	V (6 or more)	8.9-9.5
Emergency surgery
Intraperitoneal surgery
Mild or moderate renal impairment*
Diabetes mellitus under treatment**

Risk factor	Score	Risk factor	Score
Age years)		Estimated GFR (mL/min/1.73m²)
<40	0	≥60	0
≥40 and <60	6	≥45 and <60	8
≥60 and <80	9	≥30 and <45	15
≥80	13	≥15 and <30	22
Emergency surgery	7	Albuminuria on the tape test	6
Expected duration of surgery (hours)	5	Diabetes mellitus	4
Sex		Use of RAAS blocker*	6
Male	0	Hypoalbuminemia (<3.5g/dL)	8
Female	8	Anemia*	4
		Hyponatremia (<135mEq/L)	3

Parameters	Points
	1	2	3
Encephalopathy	Absent	Grade I or II	Grade III or IV
Ascites	Absent	Mild	Moderate
Total bilirubin (mg/dL)	<2	2-3	>3
Albumin (g/L)	>3.5	2.8-3.5	<2.8
Prothrombin time (extended seconds)	<4	4-6	>6

Class	Score	Mortality (%)
A	5-6	10
B	7-9	17-30
C	10-15	63-82

1 point	2 points	3 points	5 points
Age 41-60 years	Age 61-74 years	Age ≥75 years	Stroke (<1 month)
Minor surgery	Arthroscopy surgery	VTE history	Elective arthroplasty
BMI >25kg/m²	Major open surgery (>45 min)	VTE family history	Fracture of hip, pelvis, or leg
Lower limb edema	Laparoscopic surgery (45 min)	Factor V of Leiden	Acute spinal cord injury (<1 month)
Varicose veins	Malignancy	Prothrombin 202010A
Pregnancy or puerperium	Restricted to bed (>72h)	Lupus anticoagulant
History of recurrent or unexplained miscarriage	Immobilized or plastered	Anticardiolipin antibody
OAC use or hormone replacement	Central venous access	Elevated serum homocysteine
Sepsis (<1 month)		Heparin-induced thrombocytopenia
Major lung disease, including pneumonia (<1 month)		Other congenital or acquired thrombophilia
Altered lung function
Acute myocardial infarction
Heart failure (<1 month)
History of inflammatory bowel disease
Bedridden patient

Risk factor	Punctuation
Type of surgery (non-endocrinological)
Respiratory or blood	9
Thoracoabdominal aneurysm, embolectomy/thrombectomy, venous reconstruction, endovascular repair	7
Aneurysm	4
Mouth, palate	4
Stomach, intestines	4
Skin	3
Hernia	2
ASA rating
3, 4 or 5	2
2	1
Female	1
Relative unit of work (%)
>17	3
10-17	2
Widespread cancer	2
Chemotherapy for malignancy within 30 days after surgery	2
Preoperative sodium >145mmol/L	2
Transfusion >4 units of PBC up to 72h before surgery	2
Ventilator dependence	2
Potentially contaminated wound	1
Preoperative hematocrit ≤38%	1
Preoperative bilirubin >1.0mg/dL	1
Dyspnea	1
Albumin ≤3.5mg/dL	1
Emergency	1

Risk factors (one point each)	Score	Surgical site infection (%)
Abdominal surgery	0	1
Surgery duration >2 hours	1	3.6
Contaminated or infected surgery*	2	8.9
Patient has ≥3 diagnoses	3	17.2
	4	27

Tool (year of publication)	Benefits	Limitations
Pulmonary risk
Respiratory Failure Risk Index (2000)¹⁸18 Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery. Ann Surg. 2000;232(2):242-53. doi: 10.1097/00000658-200008000-00015. https://doi.org/10.1097/00000658-2000080...	Simple application (sum of points). Considers type of surgery.	Only included male patients. Evaluates single outcome
Postoperative Pneumonia Risk Index (2001)¹⁹19 Arozullah AM, Khuri SF, Henderson WG, Daley J. Development and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery. Ann Intern Med. 2001 20;135(10):847. doi: 10.7326/0003-4819-135-10-200111200-00005. https://doi.org/10.7326/0003-4819-135-10...	Simple application (sum of points). Considers type of surgery.	Validated for population with high prevalence of comorbidities and low female participation. Evaluates single outcome
ARISCAT (2010)²⁰20 Canet J, Gallart L, Gomar C, Paluzie G, Vallès J, Castillo J, et al. Prediction of Postoperative Pulmonary Complications in a Population-based Surgical Cohort. Anesthesiology. 2010;113(6):1338-50. doi: 10.1097/ALN.0b013e3181fc6e0a. https://doi.org/10.1097/ALN.0b013e3181fc...	Simple application (sum of points). Evaluates multiple outcomes	Relatively small sample. Validated for specific population (Catalonia)
Kidney risk
AKI Risk Index in General Surgery (2009)²⁹29 Kheterpal S, Tremper KK, Heung M, Rosenberg AL, Englesbe M, Shanks AM, et al. Development and Validation of an Acute Kidney Injury Risk Index for Patients Undergoing General Surgery. Anesthesiology. 2009;110(3):505-15. doi: 10.1097/ALN.0b013e3181979440. https://doi.org/10.1097/ALN.0b013e318197...	Simple application (sum of points). Considers the operated site.	Vascular, urological, ophthalmological, and obstetric procedures excluded. Did not evaluate the use of nephrotoxic agents and intraoperative hydration.
Tool (year of publication)	Benefits	Limitations
Simple Risk of Postoperative AKI - SPARK (2019)³¹31 Park S, Cho H, Park S, Lee S, Kim K, Yoon HJ, et al. Simple Postoperative AKI Risk (SPARK) Classification before Noncardiac Surgery: A Prediction Index Development Study with External Validation. JASN. 2019;30(1):170-81. doi: 10.1681/ASN.2018070757. https://doi.org/10.1681/ASN.2018070757...	Simple application (sum of points). Uses several factors that can be preoperatively adjusted. Includes obstetric procedures	Reduced performance in urological and neurosurgical procedures. Did not evaluate the use of nephrotoxic agents. Developed in a specific population (South Korea).
Hepatobiliary Risk
Child-Turcotte-Pugh Score - CTP (1973)⁴⁶46 Pugh RNH, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60(8):646-9. doi: 10.1002/bjs.1800600817. https://doi.org/10.1002/bjs.1800600817...	Simple application (sum of points).	Possible variation between evaluators (degrees of ascites and encephalopathy).
Model for End-Stage Liver Disease - MELD (2000)⁴⁷47 Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PCJ. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 000;31(4):864-71. doi: 10.1053/he.2000.5852. https://doi.org/10.1053/he.2000.5852....	Quick application (requires calculator). Uses only 3 variables.	Few types of surgery (abdominal, orthopedic, cardiovascular)
Hematological and thromboembolic risk
Caprini (2005)⁵⁹59 Caprini JA. Thrombosis Risk Assessment as a Guide to Quality Patient Care. Dis Mon. 2005;51(2-3):70-8. doi: 10.1016/j.disamonth.2005.02.003. https://doi.org/10.1016/j.disamonth.2005...	Cut-off point indicating chemoprophylaxis for VTE. Considers the type of surgery.	Lengthy application (37 items to consider)
Rogers (2007)⁶⁴64 Rogers SO, Kilaru RK, Hosokawa P, Henderson WG, Zinner MJ, Khuri SF. Multivariable Predictors of Postoperative Venous Thromboembolic Events after General and Vascular Surgery: Results from the Patient Safety in Surgery Study. J Am Coll Surg. 2007;204(6):1211-21. doi: 10.1016/j.jamcollsurg.2007.02.072. https://doi.org/10.1016/j.jamcollsurg.20...	Considers the type of surgery.	Lengthy application (23 items to consider).
Surgical site infection
SENIC (1985)⁷⁴74 Haley RW, Culver DH, Morgan WM, White JW, Emori TG, Hooton TM. Identifying patients at high risk of surgical wound infection. Am J Epidemiol. 1985;121(2):206-15. doi: 10.1093/oxfordjournals.aje.a113991. https://doi.org/10.1093/oxfordjournals.a...	Simple application (sum of points).	Old, developed from hospital records from the years 1970-1976 in the United States.
SSIRS (2013)⁶⁷67 van Walraven C, Musselman R. The Surgical Site Infection Risk Score (SSIRS): A Model to Predict the Risk of Surgical Site Infections. McBryde ES, organizador. PLoS ONE. 2013;8(6):e67167. doi: 10.1371/journal.pone.0067167. https://doi.org/10.1371/journal.pone.006...	Simple application (digital calculator). Targets the specific type of surgery to be performed, including all specialties.	Risk in unclean wounds can be underestimated by the use of antibiotics. Of the 14 factors considered, only 2 are potentially modifiable (smoking and surgery time)

[1] Mailing address:
Tulio Pinho Navarro E-mail: tulio.navarro@gmail.com

SPARK Class	Score	Risk of AKI (%)	Critical AKI risk (%)
A	<20	<2	<2
B	20-39	≥2	<2
C	40-59	≥10	≥2
D	≥60	≥20	≥10

Brasil

Brasil

Tools and scores for perioperative pulmonary, renal, hepatobiliary, hematological, and surgical site infection risk assessment: an update

ABSTRACT

Introduction:

Method:

Results:

Conclusion:

Risk level	Score	Estimated VTE risk (%)
Low	<7	0.1
Moderate	7-10	0.5
High	>10	1.37