Scoring systems, classifications and criteria Flashcards
Revised Cardiac Risk Index (Lee) and Original Cardiac Risk Index (Goldman)
RCRI (Lee 1999)
- 6 factors
- IHD, CCF, CVD, IDDM, CKD, high risk surgery (suprainguinal vascular, intraperitoneal or thoracic)
- Risk of cardiac death, non-fatal MI and non-fatal cardiac arrest = 0.4% (0 risk factors), 0.9% (1), 6.6% (2), 11% (3 or more)
- Does not cover all cause mortality or complications beyond inpatient stay; underestimates risk in vascular surgery
OCRI (Goldman 1977)
- RFs: S3 (11), elevated JVP (11), MI last 6/12 (10), ECG atrial ectopics or not SR (7), ECG >5 ventricular ectopics/min (7), age >70 (5), emergency procedure (4), intrathoracic/intra-abdo/aortic surgery (3), poor general status/metabolic/bedridden (3)
- Score <6 = 0.2% mortality, 1% morbidity
- 6-12 = 7% morbidity
- 13-35 = 14% morbidity
- > 26 = 78% morbidity, 56% mortality
Other (more cumbersome but ?more accurate) risk calculators include:
- Gupta MICA NSQIP (MI/Cardiac Arrest)
- ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program)
Acute Physiology, Age and Chronic Health Evaluation (APACHE)
APACHE I-IV, but II most widely used
Score 0-71 on 12 variables (APACHE 4 has 129 variables!)
Score >25 is roughly 35% or 55% mortality (operative vs non-operative)
Basis: 3 factors influence outcome in critically ill patients: chronic background disease, patient reserve, severity of acute illness
Based on the most abnormal measurements in the first 24 hours of ICU stay
Describes case mix, workload
Discriminates between survivors and non-survivors and can predict LoS
Significant burden of data entry
Problems: lead-time bias (patients referred to tertiary centre have their mortality underestimated)
Variables
Clinical (5): HR, RR, MAP, temperature, GCS
Lab (7): HCt, WBC, Na+, K+, creatinine, arterial pH, PaO2
POSSUM
Physiology and Operative Severity Score for enUmeration of Mortality
12 acute physiological parameters (surgery and severity of surgery)
Meant to predict death but was found to over predict
P-POSSUM – Portsmouth: predicts hospital mortality more accurately
V-POSSUM – vascular surgery
Cr-POSSUM – colon cancer resection
Richmond Agitation-Sedation Scale (RASS)
+4 to -5
0 awake and calm
Atrial fibrillation (CHA2DS2VASc and HAS-BLED)
CHA2DS2VASc CCF, HTN, age>75, DM, stroke, vascular disease, age>65, sex category (female) 1 = 1.3% risk, 9 = 15.2% risk 0 or 1 = low risk, aspirin 2+ = warfarin/NOAC
HAS-BLED HTN (SBP>160) Abnormal renal/liver function Stroke Bleeding Labile INR Elderly Drugs/alcohol
3 or more = high risk, caution and regular review
Liver scores (Child-Pugh, MELD, Maddrey’s discriminant function)
Child-Pugh: albumin, bilirubin, INR, ascites, encephalopathy each scored 1-3 (score 5-15). Class A: 5-6 (100% 1y survival), B: 7-9 (80%), C: 10-15 (45%).
MELD: INR, creatinine, bilirubin, Na+ (latter added 2016). Prioritisation of transplant candidates. PELD in children.
Maddrey: PT, bilirubin. Score > 32 in alcoholic hepatitis suggests poor prognosis and possible benefit from steroids.
PONV (Apfel)
- Female (strongest RF)
- Non-smoker
- Previous PONV and/or motion sickness
- Opiates postop
PONV risk: 0 factors: 10% 1: 20% 2: 40% 3: 60% 4: 80%
Overall PONV incidence = 30%.
Any single antiemetic reduces PONV risk by 25% (RRR). Propofol TIVA reduces it by 30%.
Rescue tx should be of a different class; a second dose of ondansetron is same as giving placebo. Metoclopramide 10mg does nothing - need 25-50mg.
New antiemetics: neurokinin-1 antagonists (aprepitant) - reduces PONV by 80% but expensive.
POVOC score for children (surgery duration ≥30 min, age ≥3, strabismus surgery, hx/Fhx PONV - 9%, 10%, 30%, 55%, 70%).
Obstructive Sleep Apnoea (STOP-BANG and Epworth)
Snoring (loud) Tired in daytime (has to be present to call it 'OSA syndrome' and justify NIV) Observed apnoea Pressure (HTN) BMI >35 Age >50 Neck circumference >16" F / >17" cm M Gender (male)
0-2 low risk
3-4 intermediate
5+ high risk
Other RFs not included: alcohol, smoking, pregnancy, low exercise, surgical patient, unemployed, craniofacial syndromes, neuromuscular disease.
Prevalence 5-10% adults, 2:1 M.
Epworth Sleepiness Scale 8 situations are rated on chance of falling asleep/dozing during them (0-3). Up to 10 normal 11-14 mild 15-18 moderate 19+ severe daytime sleepiness
NB: other types of sleep apnoea: central and mixed (i.e. central and obstructive).
Investigations
- Home overnight oximetry and oxygen desaturation index (ODI >5/15/30 correlates with AHIs of the same values)
- Polysomnography
Structured modified Brice interview for awareness
- What was the last thing you remembered before you went to sleep?
- What was the first thing you remembered after your operation?
- Can you remember anything in between?
- Can you remember if you had any dreams during your operation?
- What was the worst thing about your operation?
Asked postop, at 24h and 30d later.
MUST (Malnutrition Universal Screening Tool)
Three factors scored 0-2
- BMI: >20 (0), 20-18.5 (1), <18.5 (2)
- Unintentional weight loss in last 3-6/12: <5% (0), 5-10% (1), >10% (2)
- If acutely ill AND no nutrition (or likely not to have) for >5 days = 2
Total score:
0 - low risk, routine care
1 - medium risk, monitor diet
2+ - high risk, refer to dietician, monitor diet
Difficult airway (Modified Mallampati)
Class I: Soft palate, uvula, fauces, pillars
Class II: Soft palate, uvula, fauces
Class III: Soft palate, base of uvula
Class IV: Only hard palate
Class III/IV predicts difficult intubation but only 5% prove to be so.
Laryngoscopy (Cormack and Lehane)
Grade 1: Full view of glottis
Grade 2a: Partial view of glottis
Grade 2b: Only posterior extremity of glottis seen or only arytenoid cartilages
Grade 3: Only epiglottis seen
Grade 4: Neither glottis nor epiglottis seen
Grade 2b+ predicts difficult intubation.
Perioperative nerve injuries (Seddon, Sunderland)
Seddon
Class 1 - neuropraxia (temporary, physiological)
Class 2 - axonotmesis (relative loss of continuity, can regenerate)
Class 3 - neurotmesis (total severance, surgery required)
Sunderland is similar but with 5 classes (class 3 is split into three)
Hypersensitivity reactions (Gell and Coombs)
Type 1 (immediate): IgE-mediated mast cell degranulation e.g. anaphylaxis, allergic asthma Type 2 (cytotoxic): IgG/M antibodies e.g. haemolytic anaemia, HIT, Graves, MG Type 3 (immune complex): complex deposition in vessels e.g. RA, SLE Type 4 (delayed): T cell mediated e.g. contact dermatitis
Adverse drug reactions
Type A: 90%. Predictable, dose-related, can happen to any pt. e.g. diarrhoea from abx, gastritis from NSAIDs.
Type B: 10%. Dose-unrelated, unpredictable, idiosyncratic hypersensitivity reactions, occurring in susceptible pts. Subdivided into hypersensitivity reactions 1-4.
(Also WHO classification: 6 groups)
Serotonin syndrome (Hunter criteria)
Having taken a serotonergic agent and presenting with one of more of: Clonus Agitation Diaphoresis Tremor Hyperreflexia Hypertonia Pyrexia
Duke Activity Status Index
1-4 METs: dressing, eating, walking on the flat
4: climbing one flight of stairs (18-21 steps; traditional marker of fitness for major surgery; equivalent to VO2 max 15ml/kg/min)
5-7: moderate function (two flights of stairs without stopping)
8-11: carrying shopping upstairs, cycling, jogging, swimming
Golf - with buggy 2 METs, walking 4 METs!
1 MET = 3.5ml O2 consumption/kg/min (70kg, 40yo man at rest)
Poor: <4 METs
Moderate: 4-7
Excellent: >7
Le Fort fractures
1 - horizontal
2 - pyramidal
3 - transverse
Maastricht classification of DCD
1 - DOA 2 - unsuccessful resuscitation 3 - anticipated cardiac arrest 4 - cardiac arrest in brain dead donor 5 - unexpected arrest in ICU patient
Only 3 and 4 are controlled modes. Uncontrolled modes can only be considered in transplant centres. Difference = decision for donation is made after rather than before death.
Sedation (ASA)
- Minimal (anxiolysis; no airway/ventilation/CVS unaffected)
- Moderate (conscious sedation; purposeful verbal contact maintained, airway/vent/CVS maintained)
- Deep (rousable to pain; may require airway intervention; vent may be inadequate, CVS maintained)
- GA (unrousable; airway, ventilatory and sometimes CVS support required)
Pulmonary hypertension (WHO)
MPAP>25mmHg at rest. Mod >35, >50 severe.
Group 1 is PAH (arterial), others are PH (venous).
Group 1: pulmonary arterial HTN of any cause (e.g. inherited - BMPR2 mutation, CTDs, drugs, portal HTN, congenital heart disease) Group 2: left heart disease Group 3: chronic lung disease Group 4: thromboembolic disease Group 5: unclear/multifactorial e.g. SCD
Cardiac disease in pregnancy (WHO)
1 - low risk, no increase in mortality, up to mild increase in morbidity e.g. repaired A/VSD, uncomplicated PDA
2 - 5-15% increased mortality e.g. unoperated A/VSD, repaired TOF/COA
3 - 25-50% increased mortality e.g. Fontan, mechanical valve. Relative CI for pregnancy, expert MDT involvement required.
4 - extremely high risk, pregnancy CI e.g. primary PHTN, Eisenmenger’s, LVEF<30%, NYHA 3/4, severe AS/MS
Composite airway scoring systems (Wilson Sum Risk Score and Simplified Airway Risk Index)
Wilson Sum Risk Score
- Weight, head and neck movement, jaw movement, receding mandible, buck teeth
- Score 4 or more predicts 90% of difficult intubations
SARI
- MO, thyromental distance, MP, neck movement, underbite, body weight, intubation history
- Score 4 or more = difficulty predicted
Simplified Acute Physiology Score (SAPS)
I-III, III most commonly used
20 variables
Worst values in first hour of ICU admission
Sequential Organ Failure Assessment (SOFA) and qSOFA
Originally designed/validated in sepsis
6 organs and grades of organ function (score 1-4 for RS, CVS, CNS, renal, liver, coag)
Daily and composite scores possible
Simple and take into account supportive treatments
Good way of tracking patient morbidity
Often used to analyse secondary endpoints in research trials
SOFA 2 or greater = 10% mortality
SOFA 2 or greater + lactate >2 + inotrope requirement = 40% mortality
qSOFA (to identify early sepsis outside ICU setting) - RR > 22 - SBP 100 or lower - GCS anything other than 15 2 or more = poor prognosis
Mortality Prediction Model (MPM)
I-II
Outcome prediction at 24, 48 and 72 hrs
AAA scores (Hardman Index and Glasgow Aneurysm Score (GAS))
For ruptured AAA outcome prediction. 5 factors.
Age>76, creat>190, Hb<9, ischaemic ECG, LOC after hospital arrival.
Score of 2 or more = >80% mortality.
GAS is an alternative, similar categories, can be used in both elective and emergency repair.
European System for Cardiac Operative Risk Evaluation (EuroSCORE)
Euroscore 20 or higher = too high risk for AVR, consider TAVI
Standardised Mortality Ratio
.
CAM-ICU
(RASS to be -3 or above)
- Acute onset or fluctuating course
- Inattention (SAVE A HAART)
- RASS anything other than 0
- Disorganised thinking (yes/no Qs and commands)
CAM-ICU positive if 1, 2 and either 3 or 4 are present.
4AT
Alertness
AMT4 (age, DOB, place, year)
Attention (months backwards)
Acute change or fluctuating course
Score 4 or above significant (each item has several points)
ABCD2
Age >60 (1)
BP >140/90 (1)
Clinical - unilateral weakness (2), speech difficulty alone (1)
Duration - <10m (0), 10-60m (1), >1h (2)
DM (1)
2-day stroke risk
0-3 - 1%
4-7 - 4% (admit)
8-13 - 8% (admit)
Need CT brain, ECG, echo, carotid Dopplers, bloods inc glucose and lipids
NYHA
1: asymptomatic on ordinary activity
2: mild symptoms on ordinary activity
3: moderate symptoms but comfortable at rest
4: severe symptoms, symptomatic at rest
By EF: normal 60-70, mild 40-50, moderate 30-40, severe <30
King’s transplant criteria
Arterial pH <7.3 (or 7.25 if had NAC) Grade 3/4 encephalopathy Creatinine >300 INR >6.5 Lac >3.4 at 4h or >3 at 12h
Traumatic Brain Injury
Minor: GCS 13-15; mortality 0.1%
Moderate: GCS 9-12; mortality 10%
Severe: GCS <9; mortality 40%
Poor prognostic factors: lower GCS, age >45, comorbidities, other injuries, duration that ICP>20, mx in non-neuro centre
Encephalopathy (West Haven and World Health Congress of Gastroenterology)
West Haven
0 - normal
1 - mild impairment (sleep disturbance, subtle personality change, short attention span, asterixis)
2 - moderate impairment (lethargy, disorientation, ataxia, slurred speech)
3 - severe impairment (somnolence or agitation, nystagmus, clonus, upgoing plantars)
4 - coma
World Health Congress of Gastroenterology (Vienna)
- Type A (acute) - acute liver failure, typically with cerebral oedema
- Type B (bypass) - caused by porto-systemic shunting without intrinsic liver disease
- Type C (cirrhosis) - in patients with cirrhosis; subdivided into episodic, persistent and minimal encephalopathy
Cardiomyopathy
Primary - intrinsic
- Genetic e.g. HCM (aut dom, variable penetrance and variable expressivity)
- Acquired e.g. PPCM
Secondary - extrinsic (primary pathology outside the myocardium) e.g. ischaemic (CAD), metabolic (amyloidosis), neuromuscular (MD), toxicity (doxorubicin)
American Spinal Injury Association impairment scale for spinal injury
A: complete
B: incomplete - sensory function preserved
C: incomplete - motor function partially preserved (MRC <3)
D: incomplete - motor function partially preserved (MRC >3)
E: normal
MRC grades 1-5
Specific cord syndromes: central cord, Brown-Sequard, anterior spinal artery, conus medullaris, cauda equina
Light’s criteria
Exudate if:
Pleural fluid:serum protein >0.5
Pleural fluid:serum LDH >0.6
Pleural fluid LDH >2/3 serum ULN
Transudate: “failures’ - heart/liver/renal, PE, low albumin
Exudate: infection, ca, RA, pancreatitis
Bone Cement Implantation Syndrome
Grade 1: SpO2 <94% or BP drop >20%
Grade 2: SpO2 <88% or BP drop >40% or LOC
Grade 3: CV collapse requiring CPR
Clinical Pulmonary Infection Score (VAP)
6 factors: temp, WBC, secretions, PFR, CXR, sputum cultures. Each max score 2. Total score 6 or more suggests VAP but poorly sensitive and specific.
Evan’s score/PRST (awareness)
P - pressure (SBP)
R - rate (HR)
S - sweating
T - tears
Each scored 0-2 so total is 0-8. Non-specific, very variable between pts, inadequate alone.
Berlin criteria (ARDS)
Timing - within 1/52 of known insult
Imaging - bilateral opacities not fully explained by effusions
Not fully explained by cardiac failure
Mild: PFR 39.9 down to 26.6kPa (27% mortality)
Moderate: 26.6 down to 13.3kPa (32% mortality)
Severe: <13.3kPa (45% mortality)
All with PEEP at least 5 cmH2O
LSCS categories
Cat 1 - immediate threat to life of woman or fetus; decision to delivery interval (DDI) <30m
Cat 2 - maternal or fetal compromise but not immediately life threatening; DDI <75m
Cat 3 - no compromise but for early delivery
Cat 4 - elective, at time to suit woman and unit
Types of myocardial infarction
- Spontaneous atherosclerotic plaque rupture
- Supply/demand mismatch
- Sudden cardiac death
- PCI-related
5 CABG-related
KDIGO
Stage 1: creat 1.5-1.9x baseline, UO <0.5ml/kg/h for 6-12h
Stage 2: creat 2-2.9x baseline, UO <0.5ml/kg/h for >12h
Stage 3: creat 3x baseline, UO <0.3ml/kg/h for >24h or anuria >12h or RRT
Fitness for thoracic surgery
FEV1>2 for pneumonectomy
FEV1>1.5 for lobectomy
If not –> V/Q
ppo FEV1 > 40% ok
If not –> CPET
VO2 max >15 and AT >11 desirable, below this is high risk/consider non-operative options
CAGE questionnaire
Cut down
Angry
Guilty
Eye opener
(2 or more significant)
COPD
FEV1:FVC <0.7
Reversibility <12%
FEV1 >80 - mild 50-80 moderate 30-50 severe <30 very severe (NICE/GOLD criteria)
BMI
<18.5 underweight 18.5-25 normal 25-30 overweight 30-35 obese 35-55 morbidly obese >55 supermorbidly obese
WFNS (SAH)
1 - GCS 15, no motor deficit
2 - GCS 13/14, no motor deficit
3 - GCS 13/14 with motor deficit
4 - GCS 7-12 with or without motor deficit
5 - GCS 3-6 with or without motor deficit
Others = Hunt and Hess (clinical features), Fischer (CT).
Baux score (burns)
%BSA x age (+17 if inhalational injury)
> 140 considered unsurvivable
Burn severity
Superficial (first degree) - erythema, pain Partial thickness (second) - erythema, pain, blistering Full thickness (third) - charring, white, painless
Burns unit referral criteria
BSA>10% adults, >5% children (2/3rd degree) NAI (children or adults) Associated traumatic injuries Pregnancy Special areas - hands, feet, perineum Inhalational injury Chemical or electrical burns
Hypovolaemic shock
I: up to 750ml/15% blood volume; all parameters normal
II: 750ml-1.5L/15-30%; HR/DBP/RR/cap refill start to rise
III: 1.5-2L/30-40%; BP starts to drop, GCS affected
IV: >2L/>40%; BP falls, HR very high, drowsy
Fluid challenge: responders, non-responders, partial responders.
Weaning indices
VC >10-15ml/kg VT >5ml/kg MIP > -30 PFR>300 RSBI (RR/VT) <80 predicts success, >105 failure P.01 (normal = 1.5cmH2O)
(Also CROP, IEQ, WI, IWI)
Weaning is simple in 70%, difficult (up to 3 attempts) or prolonged.
Apgar
Appearance (colour) Pulse Grimace Activity Respiration
Each scored 0-2
Done at 1 and 5 mins post birth
7 or more is normal
WHO performance status
0: normal, unrestricted
1: strenuous activity restricted
2: able to self-care but not work, in bed <50% waking hours
3: limited self-care, in bed >50% waking hours
4: disabled, bed/chairbound
5: dead
GI bleed (Rockall, Glasgow-Blatchford)
Glasgow-Blatchford - Hb, urea - HR, BP - Syncope, malaena - Cardiac failure, liver disease Score 6+ = 50% risk of needing intervention
Rockall
- Pre-scope (out of 7): age, shock, comorbidity
- Post-scope (out of 11): diagnosis, stigmata of recent haemorrhage
Score <3 good, >8 bad outcome
Early warning scores
- NEWS
- PEWS
- MEOWS
Parameters: RR, SpO2, HR, BP, temperature, AVPU
Identifies pts at risk of deterioration, so that medical teams can identify problem and treat accordingly
1-4 low - RN review
5-6 medium (or any one RED score) - doctor/NP review
7+ high - critical care review
Ranson (pancreatitis)
11 parameters
- 5 on admission (age, glu, WBC, LDH, AST)
- 6 during next 48h (HCt, urea, Ca, PaO2, BE, fluid sequestration)
Score <3 = up to 3%
3-6 11-15%
6+ 40%
Poor severity prediction on meta-analysis but still used
ISS and RSS
ISS - anatomical
RSS - physiological
HIT score
Thrombocytopenia
Timing
Thrombosis
The exclusion of other causes
Levels of evidence
1a: systematic review or meta-analysis
1b: RCT
2a: non-randomised controlled trial
2b: quasi-experimental e.g. cohort study
3: descriptive e.g. case-control
4: expert opinion
Recommendations are then made A-D based on the above.
Types of data
Categorical - Nominal (blood groups) - Ordinal (ASA grade) Numerical - Discrete (no. of pts) - Interval (centigrade) - Ratio (Kelvin) - Continuous (weight)
SPRINT hip fracture audit 2014 recommendations
- Consultant/SAS anaesthetist
- Consider neuraxial in all pts
- Spinal using heavy bupivacaine <10mg with pt bad hip down
- Intrathecal opioids - fentanyl only
- Sedation - midazolam or propofol
- Always give supplemental O2
- Consider gas induction
- SV rather than IPPV
- Consider nerve blocks in all pts
- Do not combine GA/neuraxial
- Avoid hypotension
- Assess all for BCIS
Endocarditis
Duke
Aortic dissection
Stanford
NIH Stroke Scale
Complicated
VAP
CPIS
