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PubMed1997

Cytokine profile and correlation to the APACHE III and MPM II scores in patients with sepsis.

In 35 patients fulfilling the criteria of systemic inflammatory response syndrome (SIRS) of infectious origin, tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), tumor necrosis factor-soluble receptor (TNF-sR), and interleukin-12 (IL-12), C-reactive protein (CRP) levels and the Acute Physiology, and Chronic Health Evaluation III score (APACHE III) were determined on days 1 to 7, 14, 21, and 28. The Mortality Probability Models (MPM) II sepsis score was assessed at the time of admission into the study. The MPM II sepsis score correlated with IL-6 plasma levels on day 1. The APACHE III scores correlated with plasma levels of TNF-sR on days 2-7, with IL-6 levels on days 3-7, and with CRP levels on days 4-7 (p < 0.01). The MPM II sepsis score, the APACHE III score, and the IL-6, TNF-sR, and CRP levels were significantly different between survivors and nonsurvivors and between patients with and without shock (p < 0.05). A significant decrease of the APACHE III scores, IL-6, and CRP levels was observed over the study period in the survivor group only (p < 0.05), while neither the dynamics of TNF-alpha nor IL-12 plasma levels contributed to the risk estimation of mortality.

APACHE↗
PubMed1999

Comparison of outcome from intensive care admission after adjustment for case mix by the APACHE III prognostic system.

STUDY OBJECTIVES: To evaluate the acute physiology, age, chronic health evaluation III (APACHE III) scoring system in the context of general adult ICUs in the United Kingdom. DESIGN: Prospective, noninterventional, cohort study. SETTING: Seventeen general adult ICUs in a discrete area of southwest England. PATIENTS: 12,793 patients admitted between April 1, 1993 and December 31, 1995. MEASUREMENTS: Sociodemographic and severity-of-illness data were collected for all patients admitted to the study units. Formal goodness-of-fit tests were applied and observed mortality was compared with that predicted by using the APACHE III system. RESULTS: For the group of ICUs as a whole, the risk-adjusted standardized mortality ratio (SMR) was 1.23 (95% confidence intervals, 1.12-1.25). For 11 out of 17 ICUs, the SMR was significantly greater than unity (p < 0.05). Calibration, as tested by Hosmer-Lemeshow statistics, was poor (H2 = 312.54; C2 = 332.85; df = 8; p < 0.01); however, model discrimination was good with a total correct classification rate of 82.9% and an area under the receiver operating characteristic curve of 0.89. CONCLUSIONS: The excess mortality observed after case-mix adjustment using the APACHE III system in this study may be the result of either poor intensive care performance as compared with the United States or a failure of the APACHE III equation to fit the UK data.

APACHE↗
PubMedDate not supplied

[Prognostic systems in intensive care: TRISS, SAPS II, APACHE III].

BACKGROUND: To validate the accuracy of SAPS II, APACHE III and TRISS for the prediction of mortality in Intensive Care Unit (ICU) at polytrauma patients admission. The outcome of multiple trauma patients is often linked to the degree of physiologic dysfunction and to the extension of anatomic lesions, the age of the patient and the lesion mechanism. METHODS: The study population consisted of 93 cases of multiple injured patients hospitalised at the ICU of the Padua hospital from October 1998 to October 1999; the term polytraumatized patient is referred to patients who have multiple lesions of which at least one potentially endangers, immediately or in a short term, their life. These cases were evaluated with the APACHE III, SAPS II, Revised Trauma Score and Injury Severity Score. The predictive power of each system was evaluated by using decision matrix analysis to compare observed and predicted outcome with a decision criterion of 0.50 and 0.40 for risk of hospital death. RESULTS: All trauma score systems under study showed high accuracy rates, above all if they are used with a 40% positive test. CONCLUSIONS: The prognostic scales used in this study showed a good correlation between expected and observed cases, particularly with TRISS and APACHE III systems. The APACHE III system seems to be the most reliable of the different methods analysed. These prognostic systems are seldom or occasionally used in the ICU, in Padua and in the whole of Italy, so Italian data are not suitable to be compared to international ones. Due to urgency, the importance of the evaluation scales is often underestimated, but even if they require time and attention, they surely can be useful in the evaluation of the treatment, and not only of a polytraumatized patient.

APACHE↗
PubMed2005

Computed tomography severity index, APACHE II score, and serum CRP concentration for predicting the severity of acute pancreatitis.

CONTEXT: The assessment of the severity of pancreatitis is important for proper management of this challenging disease. A highly accurate system which could predict the severity and identify the local extent and complications of a serious inflammation, is beneficial for patient outcome. OBJECTIVE: The aim was to establish the value of the computed tomography severity index in predicting the severity of acute pancreatitis and to compare it with the accuracy of the APACHE II score and serum CRP concentrations. DESIGN: Prospective clinical series. PATIENTS: Fifty-five consecutive patients (37 women, 18 men; mean age 57 years) with a clinical and laboratory diagnosis of acute pancreatitis. INTERVENTIONS: Clinical evaluation, biochemical analysis of blood and contrast-enhanced abdominal CT. MAIN OUTCOME MEASURES: Computed tomography severity index within the first 5 days, serum CRP level, and clinical APACHE II score at 48 hours after admission. RESULTS: Thirteen patients had severe pancreatitis according to the Atlanta classification. The mean values of predictive markers in the mild and the severe pancreatitis groups were: computed tomography severity index 1.26 and 6.30 (P<0.001); APACHE II 4.14 and 8.61 (P<0.001); and CRP 96.0 mg/L and 192.4 mg/L (P<0.001), respectively. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated for the CTSI (greater than 3: 85%, 98%, 92%, 95%, and 95%), for APACHE II (equal to, or greater than 7: 62%, 86%, 57%, 88%, and 80%) and for CRP (equal to, or greater than 150 mg/L: 85%, 74%, 50%, 94%, and 76%). CONCLUSION: The computed tomography severity index is a reliable method for staging the severity of acute pancreatitis; moreover, CT has the ability of showing the local extent of the inflammation and the occurrence of local complications.

APACHE↗
PubMed1995

APACHE II scoring for predicting outcome in cerebral malaria.

The APACHE II (Acute Physiology and Chronic Health Evaluation) severity-of-disease classification system was used to stratify the prognosis of 72 adult patients with cerebral malaria. Overall mortality was 13.89%. With the cut-off point at a score of 24, the APACHE II score stratified the patients' mortality outcome with 95.8% accuracy. High APACHE II score, deep unconsciousness, acute renal failure and acidaemia were identified as poor prognostic factors. We suggest that the APACHE II system is useful for stratifying the prognosis of group outcome in cerebral malaria patients.

APACHE↗
PubMed1995

[Assessment of intensive therapy: 4-year experience using the Apache II severity score].

OBJECTIVE: To determine the outcome of critically ill patients and to study the characteristics of the population admitted to the intensive care unit. DESIGN: Retrospective chart review. SETTING: Intensive Care Unit in a civic hospital. METHODS: The medical records of 1156 patients admitted to the intensive care unit over a period of 4 years were analysed according to the Apache II system on day one of admission. Demographic information, severity of illness, major interventions; mortality rate were examined. RESULTS: Of 1156 patients 888 (76.8%) survived and 268 (23.2%) died. The mean Apache II score was 17 (SD 6), 15 (SD6) and 22 (SD7) for survivors and non-survivors respectively, the mean risk of death was 29 (SD 14), 25 (SD14) for survivors and 43 (SD 21) for nonsurvivors. mortality in emergency surgical admission was 28.3%, in booked elective surgical admission 3.8% and 14.3% in unbooked admission after elective surgery, against a predicted mortality of 34%, 16% and 27% respectively. No significant variations of the number of admissions were observed for each month of the year, day of the week and daily duty. Mortality ratio (actual death/predicted death) was 0.79. Apache II score showed in this series a specificity of 95.72% and a sensitivity of 25.37%. CONCLUSION: These findings suggest that Apache II score is able to investigate critical ill patients, to stratify patients into disease groups and to quantify correctly the overall risk of death but cannot be used in decision making or to govern admissions in intensive care unit.

APACHE↗
PubMed1995

Transjugular intrahepatic portosystemic shunting: decreased survival for patients with high APACHE II scores.

OBJECTIVES: To determine which clinical characteristics are associated with decreased survival after transjugular intrahepatic portosystemic shunting (TIPS). METHODS: Forty-nine consecutive patients were treated with TIPS; 46 of them had refractory variceal bleeding. Univariate statistics and logistic regression analyses were used to determine the relationship between clinical, biochemical, and hemodynamic variables and 30-day) survival. RESULTS: Shunt insertion was successful in 48 (98.0%) of 49 cases. Median portal-systemic gradient was reduced from 22.5 (range 9-36) [median (5th-95th percentile)] to 12 (range 4-20) mm Hg. Thirty (61.2%) of 49 patients survived more than 30 days; four patients died more than 30 days after TIPS in mean follow-up of 8.4 months. Significant differences (p < 0.05) were found between those who survived more than 30 days and those who did not, with respect to preprocedural prothrombin time, bilirubin, albumin, alanine aminotransferase, and treatment with vasopressin and nitrates, balloon tamponade, or mechanical ventilation. Whereas there were no significant differences between the pre- and post-TIPS portal vein pressures and portal-systemic gradients in survivors and non-survivors, the pre- and post-TIPS hepatic vein pressures were significantly lower in survivors. Survival was inversely proportional to Child-Pugh class (p < 0.01) and to APACHE II score (p < 0.01). The single determinant most closely associated with decreased survival in the month after TIPS was the APACHE II score, a score of 18 stratifying patients into those at low and high risk of mortality [odds ratio 21.7 (CI 3.6-131.7)]. Only 1 (7.7%) of 13 patients with Child-Pugh C cirrhosis and an APACHE II score exceeding 18 survived more than 30 days. CONCLUSIONS: Patients with advanced cirrhosis, especially those with high pre-TIPS APACHE II scores, are at high risk for reduced survival after TIPS, despite adequate portal decompression.

APACHE↗
PubMed1995

[Prognosis of acute pancreatitis: Ranson or APACHE II?].

OBJECTIVE: The aim of this paper is to determine which is the best early prognostic score in acute pancreatitis among those we have studied. DESIGN: Prospective study of acute pancreatitis cases during a 5 year period. PATIENTS: 113 patients, biliary etiology in 93 cases, (average age: 63 years) and 66% females. The diagnostic accuracy of Ranson, Imrie, Osborne and apache II scores was analyzed. RESULTS: There were complications in 12%, and mortality was 8%. Among all the systems analyzed the Ranson criteria achieved the highest sensitivity (79%), although sensitivity was improved with Apache II at admission to the hospital (86%). We have obtained the best specificity with the Apache II (89%) and with the Osborne criteria (88%). The modification of Ranson's criteria for biliary etiology didn't improve the sensitivity (56%) to detect severe cases of acute pancreatitis. CONCLUSIONS: The Apache II system was the best for the early detection of severe acute pancreatitis. Its diagnostic sensitivity was higher than the multiple laboratory criteria analyzed.

APACHE↗
PubMed1995

[Evaluation of the prognosis of critically ill surgical patients by APACHE II score system].

A prospective trial was conducted in 386 critically ill surgical patients, the APACHE II score was used to quantify the severity of illness and to judge the outcome. Admission APACHE II score of these patients averaged 15.6 +/- 5.4, the mortality rates rose from 1.9% to 100% when the APACHE II score increased from 0 to 38. The score was closely correlated with the subsequent risk of hospital death for these patients (r = 0.75 P < 0.001). Critically ill surgical patients would be well served by APACHE II for quality assurance or outcome.

APACHE↗
PubMed1997

Accuracy and efficiency of an automated system for calculating APACHE II scores in an intensive care unit.

We evaluated the reliability and efficiency of an automated system for calculating APACHE II scores. We imported an automated APACHE II scoring system developed at another institution. We scored a convenience sample of 50 consecutive intensive care unit (ICU) admissions using three methods: (1) the automated system (2) an expert scorer using a manual data abstraction method, and (3) the current manual scoring method used in the ICU. We analyzed interrater reliability among the three groups, and compared scoring time between the automated and the expert groups. Interrater reliability testing demonstrated a very high agreement between the computer and the expert scorers, (r = 0.97 p < 0.01) and a high agreement between the computer and the nursing staff (r = 0.80, p < 0.01). The mean time required to complete the data sheet manually and input data into a standalone computer manually was 4 minutes and 55 seconds, compared to total mean time of 33 seconds for the automated system. Automated APACHE II scoring yielded results more reliable than those of an expert scorer, as judged by a second researcher. The time required to score patients was reduced and reliability of scores was improved with use of an automated APACHE II scoring system.

APACHE↗
PubMed2002

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.

Acute Disease↗
PubMed1988

APACHE II score and abdominal sepsis. A prospective study.

Therapeutic trials for intra-abdominal sepsis require pretreatment stratification; physiologic scoring has been recently proposed for this purpose. We have prospectively tested the validity of one such scoring system, namely, the Acute Physiology and Chronic Health Evaluation (APACHE II). As part of a larger database, we correlated APACHE II scores with mortality in 100 patients hospitalized for generalized peritonitis or abdominal abscess. Use of steroids was recorded because of our suspicion that steroids increase mortality but blunt the physiologic response to sepsis. Thirty-one patients died, including 12 of 19 patients receiving steroids. Stepwise discriminant analysis revealed that the APACHE II score and steroid use were each independently associated with the rate of mortality. We report a prospective validation of pretreatment APACHE II scoring in abdominal sepsis. Steroid use is an independent risk factor.

Abscess↗
PubMed1989

Comparison of two simplified severity scores (SAPS and APACHE II) for patients with acute myocardial infarction.

The Simplified Acute Physiology Score (SAPS), the Acute Physiology and Chronic Health Evaluation II (APACHE II), the Acute Physiology Score (APS), and the Coronary Prognostic Index (CPI), calculated within the first 24 h of ICU admission, were compared in 76 patients with acute myocardial infarction (AMI). Sixteen (21%) patients subsequently died in the ICU. The nonsurvivors had significantly higher SAPS, APACHE II, and CPI scores than the survivors. ROC curves drawn for each severity index were in a discriminating position. There were no significant differences either between the areas under the ROC curves drawn for SAPS, APACHE II, and CPI, or between the overall accuracies of these indices. APS provided less homogeneous information. We conclude that SAPS and APACHE II, two severity indices which are easy to use, assess accurately the short-term prognosis, i.e., the ICU outcome, of patients with AMI.

Aged↗
PubMed1987

One year's experience with the APACHE II severity of disease classification system in a general intensive care unit.

The APACHE II sickness score was applied prospectively for one year in a general intensive care unit in Saudi Arabia. Two hundred and ten patients were studied, 66 of whom died in hospital. The mean APACHE II score of survivors was 11 (SD 7.1) and of non-survivors, 25.3 (SD 8.8). The mean Risk of Death was 13.3% (SD 13.1) for the survivors and 47.2% (SD 25.8) for non-survivors. The differences in APACHE score and Risk of Death between survivors and non-survivors are highly significant (p less than 0.0005 for both). No patient survived who had a Risk of Death greater than 60% and none died with a Risk of Death less than 7%. The sensitivity of the APACHE II system in predictions of death can be improved if the scores on the day of admission and on the 3rd day are taken into account.

Adult↗
PubMed1990

The principle of parsimony: Glasgow Coma Scale score predicts mortality as well as the APACHE II score for stroke patients.

Although the development and use of severity-of-illness measures has gained widespread enthusiasm, uncertainty remains as to the optimal measure for stroke patients. The Health Care Financing Administration recently derived a severity-of-illness measure based on the APACHE II system to explain differences in Medicare mortality rates among hospitals treating stroke patients. We hypothesized that the Glasgow Coma Scale score provides prognostic information of accuracy comparable to that of the APACHE II score for stroke patients, yet is simpler and cheaper to abstract from the medical record. We therefore studied 246 patients hospitalized with stroke, including 49 oversampled mortalities. The Glasgow Coma Scale score was as accurate as the APACHE II score in predicting stroke mortality both before (r = -0.50 and r = 0.50, respectively) and after (r = -0.40 and r = 0.38, respectively) the oversampled mortalities were excluded. The APACHE II score required abstraction of 16 variables from the medical record compared with three for the Glasgow Coma Scale score and required more than three times the time to abstract from the medical record. Therefore, in the interest of parsimonious data collection, the Glasgow Coma Scale may be a preferable severity-of-illness measure for patients with stroke.

Aged↗
PubMed1992

High incidence rates of invasive pneumococcal disease in the White Mountain Apache population.

OBJECTIVE: In this article we determine the incidence and clinical spectrum of invasive pneumococcal disease in the White Mountain Apache population, a group known to have a high incidence of invasive disease due to Haemophilus influenzae type b. DESIGN: Patients from whom cultures of normally sterile body sites yielded Streptococcus pneumoniae were identified retrospectively through review of hospital laboratory records from a 6.8-year period. Clinical data were reviewed and incidence rates were computed. SETTING: The Whiteriver Indian Health Service Hospital is located on the 1.7-million-acre White Mountain Apache Reservation in eastern Arizona. PATIENTS: Approximately 10,000 members of the White Mountain Apache Tribe reside on or near the reservation and receive health care through the Whiteriver Indian Health Service Hospital. OUTCOME MEASURES: The average annual incidence rates of invasive pneumococcal disease were calculated and clinical characteristics were reviewed. RESULTS: One hundred thirty-eight cases of invasive pneumococcal disease were identified. The average annual incidence rate was 207 per 100,000 population, and 156 per 100,000 population when adjusted for age by direct standardization to the 1988 US population. The incidence rate was highest in children between 1 and 2 years--2396 per 100,000. The overall case-fatality rate was 5%. Pneumococcal pneumonia was the diagnosis in 79% of the patients 5 years of age or older. Alcohol abuse, identified in 66% of the cases in adults, was the most common underlying medical condition. CONCLUSION: The incidence rates in White Mountain Apaches are the highest reported for any population. A vaccine effective in children would greatly benefit this population.

Adolescent↗
PubMed1992

[Logistic model for predicting the prognosis in patients with intra-abdominal infection based on the APACHE II index].

BACKGROUND: The APACHE II method has been widely used to classify patients according to disease severity. The high mortality and the lack of reliable prognostic parameters justify the study and application of indexes of severity (IS) and prognostic indexes (PI) in patients with intraabdominal sepsis. METHODS: A prospective study is presented concerning 100 patients with intraabdominal sepsis in whom a prognostic index derived from the APACHE II method by means of a logistic regression model was applied. In this model the APACHE II score is used as the only independent variable with the aim of predicting the outcome (mortality or survival) at the time of hospital admission. RESULTS: The predictive values obtained, with a 70% probability of mortality taken as the cut-off point, were: sensitivity 100%, specificity 87.7% and total predictive capacity 91%. CONCLUSIONS: It was concluded that the logistic prediction model of prognosis shows a high correlation with patient outcome and the application of the APACHE II score is useful in patients with intraabdominal infection.

Abdomen↗
PubMed1991

Analysis of morbidity and mortality rates in right hepatectomy with the preoperative APACHE II score.

Morbidity and mortality rates in 70 patients who underwent major liver resection for liver tumors (primary and metastatic) were determined and correlated with the preoperative APACHE II score. Patients were divided into three groups according to their preoperative APACHE II score: low (0 to 3), mid (4 to 7), and high (8 and above). A higher score was closely correlated with increased postoperative morbidity and operative mortality rates. The group with low scores had a postoperative morbidity rate of 34% and a mortality rate of 0%, the group with mid scores had a postoperative morbidity rate of 54% and a mortality rate of 3%, and the group with high scores had a postoperative morbidity rate of 80% and a mortality rate of 20%. Age did not correlate with morbidity. It was therefore postulated that morbidity and mortality rates were related to the combination of points for abnormal physiologic variables and points for chronic health, or APACHE II score minus points for age. As the combination of these points increases the postoperative morbidity and operative mortality rates increase significantly (from 24% in the 0-point group to 69% in the greater than or equal to 3-point group). Also the two deaths occurred in the group with 3 or more points. The preoperative APACHE II score may be used by clinicians to evaluate before surgery the risk of postoperative morbidity and death in elective major liver surgery.

Adult↗