Comparison of Acute Physiology and Chronic Health Evaluation (APACHE) II score with organ failure scores to predict hospital mortality

This study compared the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II score with two organ failure scores in predicting hospital mortality of critically ill patients. A total of 1311 consecutive adult patients in a tertiary 22-bed multidisciplinary intensive care unit (ICU) in Western Australia were considered. The APACHE II score had a better calibration and discrimination than the Max Sequential Organ Failure Score (Max SOFA) (area under receiver operating characteristic (ROC) curve 0.858 vs 0.829), Admission SOFA (area under ROC 0.858 vs 0.791), and the first day or cumulative 5-day Royal Perth Hospital Intensive Care Unit (RPHICU) organ failure score (area under ROC 0.858 vs 0.822 and 0.819, respectively) in predicting hospital mortality. The APACHE II score predicted hospital mortality of critically ill patients better than the SOFA and RPHICU organ failure scores in our ICU.     

Validierung des Acute Physiology and Chronic Health Evaluation (APACHE) III Scoringsystems und Vergleich mit APACHE II auf einer deutschen Intensivstation

Objectives: The aim of the study was to systematically validate the APACHE III scoring system concerning severity of illness classification and prediction of hospital mortality. Such data have not yet been determined in a large population of critically ill patients in germany. Methods: 531 patients (ICU stay >4?hours) were prospectively and consecutively investigated. The day-1-scores and risk-of-death predictions of APACHE III and APACHE II were determined. A comparison was performed between both scoring systems, and the correlation with the observed hospital mortality was examined. Results: For both main validation criteria, as were discrimination (areas under the ROC-curves: APACHE III 0.873; APACHE II 0.859) and calibration (goodness-of-fit testings; p>0.05), both scoring systems provided satisfying results concerning hospital mortality, no system showing a significantly superior performance. Compared to the observed hospital mortality (13.4%), the prediction of APACHE III (13.2%) was extremely accurate, whereas the prediction of APACHE II was higher (16.8%). The standard (mortality index not significantly <or>1.0) provided by APACHE III was fulfilled, while the standard given by APACHE II was surpassed. The mean scores and the mean risk-of-death predictions for non-survivors were significantly higher compared to survivors (p<0.001). The individual score values of both systems were found to have a strong correlation (r=0.922). Conclusions: APACHE III (like APACHE II) provides a sufficient severity of disease classification and accurately predicts overall hospital mortality in a representatively large german population of a medical ICU. Therefore APACHE III can be regarded as validated for the use in comparable german ICUs. For use as a standard the more recently introduced APACHE III seems to be superior to the established but older APACHE II. However, each user will – depending on the particular questions to be addressed – carefully have to evaluate, if the improvement of prognostic accuracy really justifies the increased amount of workload necessary for calculating APACHE III score and risk prediction.     

Severity scoring for prognostication in patients with severe acute pancreatitis: comparative analysis of the Ranson score and the APACHE III score

BACKGROUND: Despite a paucity of validation, the Ranson score is still the most popular method for gauging the severity of pancreatitis. HYPOTHESES: The Ranson score more accurately predicts outcomes in patients with severe acute pancreatitis (SAP) when compared with APACHE (Acute Physiology and Chronic Health Evaluation) III scores, and the individual components of the Ranson score differ in their capacities to predict outcome in patients with SAP. METHODS: Patients admitted with SAP to a university surgical intensive care unit (ICU) were studied prospectively. Each component and the total Ranson score were recorded. Also recorded were the APACHE II and III scores. These Ranson variables were compared using univariate analysis of variance for mortality, need for operative debridement, and need for an ICU stay for longer than 7 days. Significant variables were then analyzed by a multivariate analysis of variance to assess independent predictors of mortality, the need for debridement, and prolonged length of stay. Data are given as the mean +/- SEM. RESULTS: Seventy-six patients (21.1% mortality), aged 61.8 +/- 1.9 years, were studied. The mean APACHE III score was 48.2 +/- 3.3, and the mean ICU stay was 10.4 +/- 2.1 days. The number of positive Ranson variables was significantly higher in nonsurvivors compared with survivors (5.6 +/- 0.5 vs 3.4 +/- 0.2; P<.001), as were the APACHE III score (76.9 +/- 9.9 vs 40.5 +/- 2.5; P<.001) and ICU stay (24.9 +/- 7.5 vs 76.5 +/- 1.9 days; P =.002). Ranson variables that predicted mortality included values for blood urea nitrogen, calcium, base deficit, and fluid sequestration. CONCLUSIONS: The Ranson score remains a valid predictor of outcomes in patients with SAP, and individual Ranson variables determined 48 hours after hospital admission predicted adverse outcomes more accurately than early Ranson variables in patients with SAP.     

Prognostic value of Sequential Organ Failure Assessment and Simplified Acute Physiology II score compared with trauma scores in the outcome of multiple-trauma patients

Background

Prospective data regarding the prognostic value of the Sequential Organ Failure Assessment (SOFA) score in comparison with the Simplified Acute Physiology Score (SAPS II) and trauma scores on the outcome of multiple-trauma patients are lacking.

Methods

Single-center evaluation (n = 237, Injury Severity Score [ISS] >16; mean ISS = 29). Uni- and multivariate analysis of SAPS II, SOFA, revised trauma, polytrauma, and trauma and ISS scores (TRISS) was performed.

Results

The 30-day mortality was 22.8% (n = 54). SOFA day 1 was significantly higher in nonsurvivors compared with survivors (P < .001) and correlated well with the length of intensive care unit stay (r = .50, P < .001). Logistic regression revealed SAPS II to have the best predictive value of 30-day mortality (area under the receiver operating characteristic = .86 ± .03). The SOFA score significantly added prognostic information with regard to mortality to both SAPS II and TRISS.

Conclusions

The combination of critically ill and trauma scores may increase the accuracy of mortality prediction in multiple-trauma patients.     

Evaluation of predicted and actual length of stay in 22 Scottish intensive care units using the APACHE III system. Acute Physiology and Chronic Health Evaluation

The most recent edition of the Acute Physiology and Chronic Health Evaluation provides a prediction of intensive care unit length of stay in addition to the probability of hospital mortality. Intensive care length of stay is an important determinant of intensive care costs and may be an important indicator of quality of care. Data were collected from 22 Scottish intensive care units over a 2-year period to allow comparison of actual intensive care unit length of stay with that predicted by the Acute Physiology and Chronic Health Evaluation III system. Correlation between actual and predicted stay for individual patients was poor. However, performance of the model for patients, grouped either by predicted length of stay or by intensive care unit, indicated that the model stratified patient groups appropriately while demonstrating a consistent bias. Length of stay in Scottish intensive care units was found to be consistently lower than that predicted by a model which is based on intensive care practice in the USA. Variations in severity of illness in intensive care unit populations cannot readily explain differences in intensive care unit length of stay. The availability of a model capable of predicting length of intensive care stay, based on data reflecting practice in the UK, would compliment current methods of assessing effectiveness of intensive care.     

Prognostic Value of Acute Physiology and Chronic Health Evaluation II and Organ System Failure in Patients with Acute Renal Failure Requiring Dialysis

Background. Despite advances in modern technology of dialysis, prognosis of patients with acute renal failure (ARF) remains poor. To give the clinicians the most useful information, a model that accurately predicts outcome early in the course of ARF is required. However, because ARF is a heterogeneous syndrome and occurs in patients with diverse etiologies and some coexisting diseases, predicting outcome early is hard. The aim of this study is to evaluate prospectively the Acute Physiology and Chronic Health Evaluation (APACHE II) and organ system failure (OSF) models, evaluated prior to dialysis, in predicting hospital mortality. Methods. From June 2002 to March 2004, ARF patients requiring dialysis at Chang Gung Memorial Hospital, Chiayi, were prospectively recruited for this study. The worst clinical and laboratory data in the 24 hours before initiation of dialysis were prospectively evaluated, and the patients' APACHE II score and OSF number were assessed. Results. A total of 61 patients (40 male and 21 female) were enrolled, of whom 38 (62.3%) died before discharge. By multivariate logistic regression, the APACHE II score (odds ratio 1.3 per increase in one score; P< 0.001), or OSF number (odds ratio 1.9 per increase in one OSF; P< 0.01) and oliguria (odds ratio 4.2; P = 0.04), were found to be statistically significant prognostic factors for hospital mortality. Mortality increased progressively and significantly as OSF number (chi-square for trend; P = 0.001) or the APACHE II score (chi-square for trend; P< 0.001) increased. By using Youden's index, the best cut-off value for APACHE II was 24, with 63% sensitivity and 96% specificity. The best cut-off value for OSF number was 2, with a sensitivity of 81.6% and a specificity of 60.9%. The areas under the receiver operating characteristic curves for APACHE II and OSF number were 0.847 (95% confidence interval (CI)= 0.752–0.942; P< 0.01) and 0.769 (95% CI = 0.646–892; P< 0.001), respectively, indicating good model discrimination. Conclusions. This study concludes that APACHE II and OSF number measured prior to initiation of dialysis reliably predict outcomes of ARF patients requiring dialysis. The mortality rates increase as the APACHE II score or OSF number increases. For predicting mortality, the APACHE II score ≥ 24 was found to have 63% sensitivity and 96% specificity, and OSF number ≥ 2 had 81.6% sensitivity and 60.9% specificity.     

Biochemical identification of patients with gallstones associated with acute pancreatitis on the day of admission to hospital.

Current trends in the treatment of gallstone pancreatitis require rapid diagnosis of cholelithiasis. This study evaluates the diagnostic potential of plasma aspartate aminotransferase (AST), alkaline phosphatase, and bilirubin on the day of admission to hospital in 215 attacks of acute pancreatitis. The optimal diagnostic cut-off level for AST was 60 IU/1. A transient elevation above 60 IU/1 was recorded in 111 (84.1%) of 132 attacks associated with gallstones, but in only 12 (14.5%) of 83 attacks without stones, and was unrelated to the severity of the attack. Elevated levels of alkaline phosphatase and bilirubin were also more common in attacks associated with gallstones but were less reliable for the identification of cholelithiasis than AST. As a sensitive indicator of hepatocyte disruption, the early and transient rise in plasma AST is consistent with the concept of transient ampullary obstruction in gallstone pancreatitis, and may be useful in identifying patients who require urgent surgical or endoscopic disimpaction.     

APACHEII模式联合MELD评分在预测活体肝移植围手术期预后中的作用

目的探讨APACHE(急性生理学和慢性健康评分)II模式联合MELD(终末期肝病模型)评分如何准确地评估活体肝移植围手术期预后。方法总结2006年6月至2009年5月在上海交通大学附属瑞金医院行活体肝移植术38例病人临床资料。结果围手术期存活组与死亡组病人的APACHE II分值分别为13.03±3.47和23.67±3.27;死亡风险度分别为(7.05±3.70)%和(25.07±9.34)%。两组病人的APACHE II分值、死亡风险度差异具统计学意义(P<0.001)。排除外科因素后APACHE II模式对预后的评估具有更好的准确性。MELD>25分与MELD<25分的病人预期病死率分别为(7.10±3.84)%和(15.11±11.93)%,差异具统计学意义(P<0.05)。APACHE II评分和MELD评分的接受者操作特征曲线(ROC)界值分别为20分和25分。结论应用APACHE模式对活体肝移植进行评估时应注意避免外科因素干扰;校正后APACHE II模式预测准确性更佳;APACHE II>20分或MELD>25分的病人预期病死率则显著增高。     

Combining sequential organ failure assessment (SOFA) score with acute physiology and chronic health evaluation (APACHE) II score to predict hospital mortality of critically ill patients

The ability to accurately adjust for the severity of illness in outcome studies of critically ill patients is essential. Previous studies have showed that Sequential Organ Failure Assessment (SOFA) score and Acute Physiology and Chronic Health Evaluation (APACHE) II score can predict hospital mortality of critically ill patients. The effects of combining these two scores to predict hospital mortality of critically ill patients has not been evaluated. This cohort study evaluated the performance of combining the APACHE II score with SOFA score in predicting hospital mortality of critically ill patients. A total of 1311 consecutive adult patients admitted to a tertiary 22-bed multidisciplinary intensive care unit (ICU) in Western Australia were considered. The APACHE II, Admission SOFA, Delta SOFA and maximum SOFA score were all related to hospital survival in the univariate analyses. Combining Max SOFA (area under receiver operating characteristic curve 0.875 vs. 0.858, P = 0.014; Nagelkerke R2: 0.411 vs. 0.371; Brier Score: 0.086 vs. 0.090) or Delta SOFA score (area under receiver operating characteristic curve 0.874 vs. 0.858, P = 0.003; Nagelkerke R2: 0.412 vs. 0.371; Brier Score: 0.086 vs. 0.090) with the APACHE II score improved the discrimination and overall performance of the predictions when compared with using the APACHE II score alone, especially in the emergency ICU admissions. Combining Max SOFA or Delta SOFA score with the APACHE II score may improve the accuracy of risk adjustment in outcome studies of critically ill patients.     

重症急性胰腺炎CT征象与预后的评价

目的 探讨重急性胰腺炎（ＳＡＰ）ＣＴ的诊断价值。方法 对６１例ＳＡＰ的ＣＴ检查资料进行回顾性分析。结果 按ＣＴ征象将病变严重程度分为４级,Ⅰ级１４例,Ⅱ级２３例,Ⅲ级１７例,Ⅳ级７例。ＣＴ检查与手术结果相符５６例,占９１．８％。６１例中治愈５７例,其中Ⅰ～Ⅲ级５４例,Ⅳ级３例,治愈率９３．４％,治愈病例从发病到ＣＴ扫描确诊时间均不超过１０ｄ,手术时间在确诊后８～１２ｄ内进行。死亡４例,死亡率７。．     

重症急性胰腺炎早期脏器功能不全持续时间对预后的影响

目的：比较重症急性胰腺炎（SAP）早期脏器功能不全持续时间对预后的影响。方法：回顾性分析2000年1月至2005年6月收治的74例存在早期脏器功能不全的SAP病人，按其脏器功能不全持续时间分为暂时性组（脏器功能不全持续≤3d，n=20例）和持续性组（脏器功能不全持续时间〉3d，n=54例）。比较两组病人SAP并发症和死亡率差异。结果：暂时性组并发症发生率和死亡率明显低于持续性组（分别为P=0．0376和P=0．0542）。结论：SAP早期脏器功能不全持续时间对病人预后具预测作用，脏器功能不全连续存在〉3d是SAP预示死亡的危险因素。     

The predictive performance of the lactate clearance rate combined with the APACHE II score in the prediction of sepsis-associated acute kidney injury in 7 days

BackgroundThe purpose of this study was to evaluate the accuracy of the lactate clearance rate (LCR) combined with the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in the prediction of sepsis-associated acute kidney injury (SAKI).MethodsSepsis patients were divided into the SAKI group and non-SAKI group. Arterial blood lactate was collected at 0 h (before treatment), 2 h, 4 h, 6 h, and 8 h (after treatment), and the LCR was calculated. The physiological parameters and laboratory test results were used to calculate the APACHE II score and the Sequential Organ Failure Assessment (SOFA) score. The receiver operating characteristic (ROC) curves of LCR, APACHE II score and SOFA score for predicting patients with SAKI were drawn. Two single indicators with high areas under the curves (AUCs) were selected to calculate the joint probability through regression analysis, and the prediction efficiency corresponding to each curve was analyzed.ResultsThere were significant differences in LCR between different groups and time periods (F^group=17.44, P^group ≤0.0001, F^time =11.71, P^time =0.0014). After 8 h of treatment, there was a significant difference in the overall compliance rate between the 2 groups (P<0.0001). In addition, after 24 h of treatment, the APACHE II score in the SAKI group was significantly higher than that in the non-SAKI group (P=0.0007), and SOFA score was also significantly higher than that in the non-SAKI group (P=0.0001). ROC curve showed that the 0–8 h LCR and APACHE II scores had a high predictive performance for the acute kidney injury (AKI) occurrence in sepsis patients, and AUCs were 0.7637 and 0.7517, respectively, while the combined AUC of the 2 indicators was 0.7975.ConclusionsThe 0–8 h LCR combined with APACHE II score can improve the early predictive value of SAKI, reduce the risk of AKI in patients with sepsis/septic shock, and reduce the social and family burden, which is worthy of clinical application.     

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目的回顾性分析原始和校正后两种急性生理学和慢性健康评分Ⅱ(APACHEⅡ)模式对肝移植预后评估的准确性。方法回顾性分析2004年3月至2005年8月上海交通大学医学院附属瑞金医院器官移植中心收治的74例肝移植病人的临床资料,应用原始和校正后APACHEⅡ模式计算并比较住院期间存活组(69例)和死亡组(5例)的两组病人的APACHEⅡ分值、死亡风险度、预期病死率。Hosmer-Lemeshow拟合优度、受试者操作特征曲线下面积分别评价两种APACHEⅡ模式的校准度、分辨度。结果两组病人APACHEⅡ分值、死亡风险度差异有统计学意义。原始APACHEⅡ模式的预期病死率明显高于住院期间病人的实际病死率,校正后A-PACHEⅡ模式的校准度、分辨率好于前者。结论原始APACHEⅡ模式对肝移植术后住院期间病死率预测过高,校正后APACHEⅡ模式对其预后的评估具有较好的准确性。     

SICU重症急性胰腺炎患者家属的幻灯片式健康教育

目的提高健康教育效果和护理服务满意度。方法对637例重症急性胰腺炎患者家属定人定时以幻灯片的形式进行健康教育,包括重症急性胰腺炎的相关知识、腹部引流管照护、康复功能锻炼等方面的健康教育,以及患者家属的心理指导等。结果患者家属疾病知识、导管护理知识、诊疗护理配合率及对护士的满意率达94.51%~98.12%。结论幻灯片式健康教育可有效提高健康教育效果,提高护理满意度。     

Arterial blood gases in patients with acute head injury at the accident site and upon hospital admission

Prior to the start of supportive therapy at the site of the accident, arterial blood samples from 47 patients with acute head injury were taken for blood gas analysis. At the same time, the degree of unconsciousness was assessed using the Glasgow-Coma-Scale. After transport to the hospital, arterial blood gases and the level of unconsciousness were again determined. A very close correlation was found between the initial depth of unconsciousness and the degree of hypercapnia (R = -0.90). Patients with head injury and other multiple injuries did not differ in this report (R = -0.95) from those with isolated head injury. The correlation between PaO2 and the degree of unconsciousness was less well defined, and the results showed a greater degree of scatter (R = 0.54). The acidosis observed resulted mainly from the rise in PaCO2. The absence of any correlation between the base excess and the Glasgow-Coma-Scale levels (R = -0.27) makes a common metabolic derangement unlikely. As a result of intubation and controlled ventilation, the hypercapnia of the comatose patients had been corrected, and a correlation could no longer be found between the Glasgow-Coma-Scale level and the PaCO2. In order to avoid hypoventilation, which carries with it the danger of a rise in intracranial pressure, all patients with severe head injury should be intubated and ventilated as soon as possible after the accident.     

119例重症急性胰腺炎的治疗方法与效果分析

目的 探讨重症急性胰腺炎severe acute pancreatitis,SAP）治疗方法与效果的关系。方法 将119例SAP作一回顾性分析。结果 手术治疗组与非手术治疗组的平均APACHEII评分分别为13．5±4．7和13．1±3．9,两组病情严重程度差异无统计学意义（P〉0．05）;平均病程分别为（51.4±40．3）d、（34．2±23．4）d,并发症发生率分别为48．8％（20／41）、37．2％（29／78）,病死率分别为26．8％（11／41）、11．5％（9／78）。两组比较,平均病程差异有统计学意义（P〈0．01）,并发症发生率差异无统计学意义（P〈0．05）,病死率差异有统计学意义（P〈0．05）。结论 对不伴胆道梗阻的SAP,以非手术治疗为主的个体化原则,综合治疗效果明显优于早期手术治疗：SAP伴有胆道梗阻者应急诊行EST、ENBD或开腹手术解除梗阻。     

特殊营养膳对重症急性胰腺炎患者的血糖调控作用

目的探讨特殊营养膳对重症急性胰腺炎患者的血糖调控作用。方法将60例重症急性胰腺炎患者随机分为对照组和治疗组,分别给予常规营养膳及特殊营养膳。在不同时间监测急性期反应、胰腺病变、血糖变化、感染及其相关并发症的发生率、病死率和住院天数。结果两组急性期反应指标及胰腺病变无明显差异,但治疗组各时间点血糖平均水平及胰岛素用量、感染及其相关并发症的发生率及住院天数显著低于对照组,但病死率无显著差别。结论特殊营养膳能有效缓解重症急性胰腺炎急性期反应,通过对血糖的调控减少感染及其相关并发症的发生。     

Improved outcome of APACHE II score-defined escalating systemic inflammatory response syndrome in patients post cardiac surgery in 1996 compared to 1988-1990: the ESSICS-study pilot project.

OBJECTIVE: Cardiac surgery using extracorporeal circulation leads to the release of cytokines and subsequently to a systemic inflammatory response syndrome, which is thought to be a negative prognostic factor for patients' outcome. A stratification for the risk of an escalating systemic inflammatory response syndrome had been achieved in a monocenter study carried out in 1988-1990, using APACHE II scoring on the morning of the 1st postoperative day. We now re-evaluated this concept prospectively in three independent centers. METHODS: The APACHE II based risk stratification was put to test in three independent heart surgery centers in the period from June to December 1996. Nine hundred and forty-five patients after elective cardiac surgery (excluding heart transplantation) with the assistance of the cardiopulmonary bypass were prospectively monitored. RESULTS: We found an increase in mortality with higher APACHE II score values determined on the 1st postoperative day. The mortality rose to nearly 50% with an APACHE II score of > or = 28. Patients at high risk for the development of a systemic inflammatory response syndrome (APACHE II score > or = 24) significantly differed from patients at lower risk (APACHE II score < 19) in the duration of mechanical ventilation and extracorporeal circulation, age and New York Heart Association (NYHA) classification (P < 0.05). CONCLUSION: The APACHE II score determined on the morning of the 1st postoperative day helps identifying the subgroup of patients with escalating systemic inflammatory response syndrome. Comparison with the data obtained in the years 1988-1990, suggests a better prognosis in the current trial for patients at high risk with a similar degree of escalating systemic inflammatory response syndrome.