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

Valencia, Eleonore MD*; Staffa, Steven J. MS*; Faraoni, David MD, PhD, FAHA; DiNardo, James A. MD, FAAP*; Nasr, Viviane G. MD*

doi: 10.1213/ANE.0000000000004197
Patient Safety: Original Clinical Research Report

BACKGROUND: Early identification of children at high risk for perioperative mortality could lead to improved outcomes; however, there is a lack of well-validated risk prediction tools. The Pediatric Risk Assessment (PRAm) score is a new model to prognosticate perioperative risk of mortality in pediatric patients undergoing noncardiac surgery. It was derived from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Pediatric database. In this study, we aimed to externally validate the PRAm score at 1 large institution.

METHODS: A PRAm score was prospectively assigned by the primary anesthesia team to children ≤18 years of age undergoing noncardiac surgery between July 2017 and July 2018 at a tertiary care pediatric hospital. The primary outcome was the PRAm score’s ability to predict 30-day mortality. The area under the receiver operating characteristic (ROC) curve was utilized to determine discriminative ability. Sensitivity and specificity at varying cutoffs were considered. Youden J index and the gray zone approach were applied to determine the optimal PRAm cutoff for predicting 30-day mortality.

RESULTS: Among the 13,530 cases included in the external validation cohort, the incidence of 30-day mortality was 0.21% (29/13,530). The PRAm score was found to predict 30-day mortality with an area under the curve (AUC) of 0.956 (95% confidence interval [CI], 0.938–0.974; P < .001). Youden J index determined the optimal PRAm score threshold to be ≥5 with a sensitivity of 86% and a specificity of 91%. The gray zone identified an inconclusive risk of mortality in 6.93% (938/13,530) of patients who had PRAm scores of 4 or 5 (sensitivity or specificity <90%, respectively), therefore refining the optimal cutoff point to be a PRAm score of ≥6. The incidence of mortality for patients with an American Society of Anesthesiologists Physical Status (ASA PS) ≤3 (0.06%, 8/13,530) increased 8-fold for those with an ASA PS of ≤3 and a PRAm score of ≥6.

CONCLUSIONS: The PRAm score is a simple and objective tool that has excellent ability to predict perioperative risk of mortality in pediatric patients undergoing noncardiac surgery and can be easily used by clinicians. The application of the PRAm score could have important implications on the safety and quality of care delivered to infants and children and on the resource utilization in the pediatric health care system.

From the *Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Published ahead of print 21 March 2019.

Accepted for publication March 21, 2019.

Funding: This study was solely supported by the Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Viviane G. Nasr, MD, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. Address e-mail to

Copyright © 2019 International Anesthesia Research Society
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