The surgical apgar score: Gawande et. al.

The Surgical Apgar Score

One of the most important parts and, in fact, one of the principles of associated projects and publications, is the operating room visit. This is the part that patients cannot judge for themselves and is rarely judged by others; yet the surgical procedure itself plays a monumental role in determining outcomes.

The surgical Apgar score, devised by Gawande et. al in 2007, determined that independent of pre-operative patient risk classification, that three intra-operative risk factors played the biggest role in determining the development of major complications 30 days post-operatively. These three risk factors were: estimated blood loss (EBL), lowest heart rate and lowest mean arterial pressure (MAP)[1].

Using this information, Gawande et. al. devised a 10 point tool which assigns a score to intra-operative management. From this score we are able to estimate the risk of complications, and the risk varies dramatically with the score. For example, with a score of 9 or 10 (the highest), the risk of complications is about 5 percent. However, this risk increases to 56% with a score of 4 or less[2]. In patients that did develop post-operative complications, Regenborgen & Gawande demonstrated in a large-scale study, those patients with a score of 2 or less were twenty times more likely to die than patients with a score of 9 or 10.

This tool has been well-tested and validated in several large studies involving thousands of patients making it a valid measurement of performance and an essential tool for objective intra-operative assessment[3]. One of the reasons this scale is so powerful, is that it is able to determine risk independent of patient factors such as advanced age and underlying co-morbidities. In fact, by using this scale as part of intra-operative assessment, surgeons and anesthesiologists can reduce their patients’ risk of complications dramatically.

During application of this scale to cases witnessed, the main area of point loss was consistently heart rate control. This meant that an otherwise excellent surgery, with a lowest heart rate of 86 lost all four possible points for the category. This tool is also an excellent assessment tool for surgeons to apply to see where necessary improvements should be made.


[1] Mean arterial blood pressure is an average derived from both the systolic and diastolic values.

[2] Regenbogen, S. E., Lancaster, R. T., Lipsitz, S. R., Greenberg, C. C., Hutter, M. M., & A. A. Gawande. (2008). Does the surgical Apgar score measure intraoperative performance. Ann. Surg. 2008, Aug; 248(2): 320 – 328.

[3] Regenbogen, S.E., Bordeianou, L., Hutter, M. M., & A. A. Gawande (2010). The intraoperative surgical Apgar score predicts post-discharge complications after colon and rectal resection. Surgery. 2010 Sep, 148(3):559-66.

Ohlsson, H. & Winso, O. (2011). Assessment of the surgical Apgar score in a Swedish setting. Acta Anaesthesiol. Scand. 2011 Mar 21, epub.

Haynes, A. B., Regenbogen, S. E., Weiser, T. G., Lipsitz, S. R., Dzieken, G., Berry, W. R. & A. A. Gawande. (2011). surgical outcome measurement for a global patient population: validation of the surgical Apgar score in 8 countries. Surgery. 2011, epub Jan 8.