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Clinical prediction rules
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The use of a scoring system based on patient- or procedure-related risk factors to quantify risk
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Often cost-neutral
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Estimates population risk for patient rather than providing an individualized risk assessment
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Requires no specialist knowledge [34]
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ASA-PS
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Six-point scale used to grade patient according to comorbidities [35]
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Validated in a number of settings [36–38]
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Inter-observer variability [39]
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Poor sensitivity and specificity for prediction of morbidity and mortality on an individual patient basis [33, 40]
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Lee Revised Cardiac Risk Index (RCRI)
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Scores patients according to six variables, including whether the surgery is high risk
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Discriminates moderately well between patients at low versus high risk for cardiac events after mixed noncardiac surgery [42]
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Designed to identify patients at risk of cardiac complications so may miss patients at risk of other complications who may benefit from PACU care
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Assesses cardiac risk [41]
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Well validated
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POSSUM
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A more detailed scoring system with 18 components, 6 operative variables and 12 physiological variables [46]
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A revision of POSSUM, the Portsmouth POSSUM [43] has been shown to be a better predictor of outcome in certain surgical settings [33, 44, 45]
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Some variables cannot be ascertained until after surgery, making it of limited use for preoperative identification of patients who may benefit from PACU care
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Variations in the model have been devised for specific patient groups, such as the Cr-POSSUM (colorectal), which has been shown to be a better predictor of outcome in this type of surgery [47]
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Cardiopulmonary exercise testing
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CPET is an integrative and quantitative measure of a patient’s cardiopulmonary reserve
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Good evidence that CPET is useful to help predict perioperative morbidity and mortality and may aid triage to an appropriate level of postoperative care [48–50]
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In 2008, 17% of Hospital Trusts in England had a CPET service, and a further 7% were in the process of setting one up [52]
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The assessment requires the patient to exercise (usually on a cycle ergometer) while oxygen consumption, carbon dioxide production, and other cardiorespiratory variables are measured
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RCT in progress to further evaluate its use to stratify to appropriate level of postoperative care [51]
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