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POSSUM in colorectal surgery

POSSUM in colorectal surgery. Dermot Burke The General Infirmary at Leeds. APACHE. APACHE (1981) 34 physiological variables APACHE II (1985) 12 physiological variables age and chronic health history. APACHE III (2001) 17 physiologic variables age and chronic health history

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POSSUM in colorectal surgery

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  1. POSSUMincolorectal surgery Dermot Burke The General Infirmary at Leeds

  2. APACHE APACHE (1981) 34 physiological variables APACHE II (1985) 12 physiological variables age and chronic health history. APACHE III (2001) 17 physiologic variables age and chronic health history prior diagnosis

  3. APACHE II • Temperature - core • Mean arterial pressure • Heart rate • Respiratory rate • Oxygenation • FIO2 • Arterial pH • Serum sodium • Serum potassium • Serum creatinine • Haematocrit • White blood cell count

  4. APACHE II Developed for use in intensive care setting Takes no account of surgical insult

  5. “The POSSUM score is the most appropriate of the currently available scores for general surgical practice…… in the estimation of risk of dying.” Jones HJ et al Value of a surgical high-dependency unit. Br J Surg. 1999 Dec; 86: 1578-1582

  6. What is POSSUM? Physiological and Operative Severity Score for the enUmeration of Morbidity and Mortality

  7. What is POSSUM? A method of operative risk prediction that allows for case-mix

  8. What is POSSUM? 18 variables 12 physiological 6 operative

  9. PhysiologicalOperative Age OperationCardiac status Number of proceduresECG Blood lossRespiratory status Peritoneal contaminationBP Extent of malignancy Pulse Elective / emergency GCS HbWCCUreaSodiumPotassium

  10. POSSUM maths Each variable divided into 1, 2, 3, or 4 levels weighting of 1, 2, 4 or 8 applied to that level e.g. blood loss Amount (ml) <100 101- 500 501 – 1000 >1000 Level 1 2 3 4 Weighting 1 2 4 8

  11. POSSUM maths Physiology weighting numbers added together to give a physiology score Operative weighting numbers added together to give an operative severity score Scores put into equations

  12. Original POSSUM equations Morbidity In [R/(1-R)] = -5.91 + (0.16*phys score) + ( 0.19*op sev score) Mortality In [R/(1-R)] = -7.04 + (0.13*phys score) + ( 0.16*op sev score) Minimum risk of mortality = 0.40%

  13. P-POSSUM In [R/(1-R)] = -9.06 + (0.169*phys score) + (0.155*op sev score) Minimum risk of mortality = 0.22%

  14. Differences between Possum and P-Possum The main difference is in the statistical method of analysis Difference in minimum risk of morbidity

  15. POSSUMs around the body Lung surgery Brunelli et al Ann Thorac Surg. 1999; 67 :329-331 Bariatric surgery Cagigas et al Obes Surg. 1999; 9: 279-281 Ruptured AAA Lazarides et al Ann Vasc Surg. 1997; 11: 155-158 General vascular Midwinter et al Br J Surg. 1999; 86: 471-474 D2 gastrectomy Parikh et al Br J Surg. 1996; 83: 1595-1599 Colorectal Sagar et al Br J Surg. 1994 ; 81: 1492-1494

  16. POSSUMsin Colorectal Surgery Tekkis et al (GI) Dis Col Rect 2000, 43: 1528-1532 Tekkis et al Br J Surg 2003, 90: 340-345 Overpredicts young, fit, elective Underpredicts elderly, emergency

  17. CR-POSSUM PhysiologicalOperative Age Cardiac status BP Pulse Hb Urea Operation Peritoneal contamination Extent of malignancy Emergency / Elective Minimum risk of mortality = 0.27%

  18. Practicalities Calculating POSSUM Calculate P-POSSUM and CR-POSSUM directly at http://www.riskprediction.org.uk Downloading POSSUM Download ACCESS 97 database from www.edu.rcsed.ac.uk/lectures/lt1.htm

  19. Practicalities

  20. Practicalities Download POSSUM for use on Palm PDA and Pocket PC at www.gaspalm.co.uk/

  21. How the NHS has used last year's performance indicators Outcomes of Surgery ********** City Hospital was prompted by last year's clinical indicator on 'deaths following surgery' to investigate this issue and develop initiatives to ensure risks of death following surgery are as low as possible. A key development in Nottingham City Hospital's general surgery directorate has been the introduction of a robust risk assessment system called POSSUM (Physiological and Operative Severity Score for enumeration for Mortality and Morbidity). This is designed to quantify each patient's vulnerability by taking into account factors of their condition and the procedure they are to undergo. This accurate assessment allows doctors and nurses to design care packages which best meet their individual needs - patients with high POSSUM scores are targeted for higher levels of support and patients with medium scores are monitored more closely to ensure they do not deteriorate. The plan is to 'roll out' the system to other surgical directorates and POSSUM is clearly expected to improve the outcomes for more and more patients following surgery at *********City Hospital.

  22. How the NHS has used last year's performance indicators clearly expected for more and more patients to improve the outcomes POSSUM

  23. Government unveils hospital league tablesDavid BattyTuesday September 25, 2001TheGuardian

  24. Man Utd Newcastle Man City Liverpool Chelsea Everton Arsenal Leeds Utd Aston Villa Tottenham South’ton Leicester Mid’brough Birm’ham Wolves Bolton Blackburn Charlton Portsmouth Fulham Man Utd Man City Liverpool Everton Leeds Utd Bolton

  25. P W D L F A W D L F A GD PTS Arsenal 28 11 2 0 26 9 10 5 0 29 9 37 70 Chelsea 28 8 2 3 22 10 11 2 2 28 11 29 61 Man Utd 28 9 3 2 30 13 9 1 4 22 16 23 58 Charlton 28 6 3 5 22 22 6 4 4 17 12 5 43 Newcastle 28 8 3 3 23 9 2 9 3 15 20 9 42 Birm’ham 28 7 4 4 19 16 4 5 4 11 14 0 42 Aston Villa 28 7 4 2 19 12 4 3 8 17 20 4 40 Liverpool 27 6 2 4 18 13 4 7 4 20 18 7 39 Fulham 28 8 3 4 24 16 3 3 7 17 22 3 39 Tottenham 28 8 2 5 29 23 3 2 8 11 20 -3 37 South’ton 28 7 4 4 18 11 2 5 6 11 16 2 36 Mid’brough 28 4 4 6 12 16 5 3 6 17 19 -6 34 Bolton 28 3 7 4 15 16 5 3 6 17 28 -12 34 Everton 28 7 4 4 22 15 1 4 8 12 24 –5 32 Man City 28 3 7 4 21 17 4 2 8 19 23 0 30 Blackburn 28 3 3 8 20 26 4 4 6 19 20 -7 28 Leicester 28 2 7 5 14 23 3 4 7 24 28 -13 26 Portsmouth 27 6 2 5 23 15 0 4 10 6 26 -12 24 Wolves 28 5 5 4 17 26 0 4 10 7 30 -32 24 Leeds Utd 28 3 5 6 15 22 2 2 10 11 33 -29 22

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