The Apgar challenge
2006; Elsevier BV; Volume: 149; Issue: 4 Linguagem: Inglês
10.1016/j.jpeds.2006.08.023
ISSN1097-6833
Autores Tópico(s)Infant Development and Preterm Care
ResumoVirginia Apgar’s most enduring contribution is the Apgar score for neonatal assessment, which is used in virtually every country in the world. Apgar developed a simple method to evaluate the newly born infant. She hoped that the score would provide additional focus on the infant’s well being, generate a systematic, easily done evaluation to facilitate a number of perinatal comparisons, and serve as an index of the effects of resuscitation.1Apgar V. A proposal for a new method of evaluation of the newborn infant.Curr Res Anesth Analg. 1953; 32: 260-267Crossref PubMed Scopus (1387) Google Scholar Although the Apgar score at 1 minute has been used to determine whether active resuscitation should be initiated, Apgar herself stated characteristically that “this, of course, is wrong.”2Apgar V. The newborn (Apgar) scoring system.Ped Clin North Am. 1960; 13: 645-650Google ScholarSee related article, p 486 See related article, p 486 The usefulness of the Apgar score has been questioned because of its limited, but not negligible, predictive value for early neonatal acidosis, mortality, asphyxial syndrome, and long-term outcome.3Sykes G.S. Johnson P. Ashworth F. Malloy P.M. Gu W. Stirral G. Do Apgar scores indicate asphyxia?.Lancet. 1982; 1: 494-496Abstract PubMed Scopus (336) Google Scholar, 4Nelson K.B. Ellenberg J.H. Apgar scores as predictors of chronic neurologic disability.Pediatrics. 1981; 68: 36-44PubMed Google Scholar Others, including Apgar, have stated that color as part of the score has little predictive value and that prematurity influences the vigor of respiratory effort, muscle tone, and reflex responses, which make up a significant portion of the score.5Catlin E.A. Carpenter M.W. Brann B.S. Mayfield S.R. Shaul PW Goldstein M. et al.The Apgar score revisted: influence of gestational age.J Pediatr. 1986; 109: 865-868Abstract Full Text PDF PubMed Scopus (169) Google Scholar Parent and provider expectations are known to significantly inflate the score, and the lack of contemporaneous assessment likely contributes to considerable variability. The continuing value of the Apgar score was recently examined in 2 large neonatal cohorts.6Thorngren-Jerneck K. Herbst A. Low 5-minute Apgar score: a population-based register study of 1 million term births.Obstet Gynecol. 2001; 98: 65-70Crossref PubMed Scopus (261) Google Scholar, 7Casey B.M. McIntyre D.D. Leveno K.J. The continuing value of the Apgar score for the assessment of newborn infants.N Engl J Med. 2001; 344: 467-471Crossref PubMed Scopus (611) Google Scholar The relative mortal risks of newborns with low 5-minute scores compared with newborns with high 5-minute scores were 14.4 and 59 in these studies. The difficulties that individual professionals have with Apgar assessment itself have been pointed out often. Paneth and Fox8Paneth N. Fox H.E. The relationship of Apgar score to neurologic handicap: a survey of clinicians.Obstet Gynecol. 1983; 61: 547-550PubMed Google Scholar identified a 10-fold overestimate of the impact of a low 5-minute score on handicap by 172 maternal and other health care professionals. Clark and Hakason9Clark D.A. Hakanson D.O. The inaccuracy of Apgar scoring.J Perinatol. 1988; 8: 203-205PubMed Google Scholar used descriptive cases to test Apgar score assignments by 223 providers of neonatal care and found that only 40% of those tested accurately characterized all 8 case senarios. Lopriore et al10Lopriore E. van Burk G.F. Walther F.J. de Beaufort A.J. Correct use of the Apgar score for resuscitated and intubated newborn babies: questionnaire study.BMJ. 2004; 329: 143-144Crossref PubMed Google Scholar used 3 case descriptions to test 166 pediatric professionals; correct responses ranged from 16% to 68% for the 3 groups. In their study reported in this issue of The Journal, O’Donnell et al11O’Donnell C.P.F. Kamlin C.O.F. Davis P.G. Carlin J.B. Morley C.J. Interobserver variability of the 5-minute Apgar score.J Pediatr. 2006; 149: 486-489Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar assessed the assignment of 5-minute Apgar scores in a tertiary care setting. Post hoc assessments using video recordings taken 5 minutes after delivery were compared with the clinical assessments made by a neonatal care provider. Color, which Apgar felt was the least useful score component, was not used. A maximum score under these circumstances was 8. The variability among the 42 video scorers was substantial, the reliability was poor for all 4 elements of the score, and the standard deviation of the total video scores was 1.9. The scores determined clinically varied significantly from the video assessments, with only 9 of the 30 clinical assessments included within the interquartile range of the video assessments. Twenty of the 30 clinical assessments were 2 or more points higher than the corresponding video assessment, with greater deviation at lower scores. How are we to respond to these appalling data, which, although gathered uniquely, are consistent with previous observations? Should fiction or fantasy be tolerated at the bedside? Do we give up? A 1998 editorial in Lancet called for the Apgar score to “… be pensioned off.”12Is the Apgar score outmoded?.Lancet. 1989; 1: 591-592PubMed Google Scholar On the other hand, the Apgar score’s overall usefulness has been well demonstrated, and it still has value in systemic assessment of the newborn. In view of this current study and others cited, the sustained value of the Apgar score requires improved reliability, confrontation of sources of variance, unequivocal performance expectations, better training, and investment in quality control. We can do better, and improved neonatal assessment in the delivery setting is the minimum we owe to the vulnerable neonatal population and to honor the lady of the score, Virginia Apgar. Interobserver variability of the 5-minute Apgar scoreThe Journal of PediatricsVol. 149Issue 4PreviewTo assess interobserver variability of Apgar scores assigned with video recordings of neonatal resuscitation (ASvideo) and compare the scores assigned by observers of videos to the Apgar score given by staff attending the delivery (ASdel). Full-Text PDF
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