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PubMed2001

Prediction of in-hospital mortality in patients with myocardial infarction using APACHE II system.

BACKGROUND: The acute physiology and chronic health evaluation (APACHE) scoring system has been validated in many different patient populations, however, patients with myocardial infarction (MI) were not included in the original data base. To evaluate the ability of APACHE scoring system in predicting in-hospital mortality, 694 patients with MI were studied. METHODS: Data had been collected prospectively in an ICU computer database in the past 3 years. Patients admitted in coronary care unit with acute MI or acute coronary syndrome who had previous history of MI were all included. Patients were divided into survivor and non-survivor data sets. Multiple logistic regression analysis was evaluated on the variables of APACHE II score to determine which variables could predict in-hospital mortality. A logistic regression model was used to study the mortality curves. The differences of APACHE II scores between survivors and non-survivors were compared. Correlation between observed and predicted mortality was also assessed. RESULTS: According to the statistical analysis, the non-survivors tended to have significantly greater APACHE II scores than those of survivors. The APACHE II values of non-survivors and survivors were 23.64 +/- 9.41 versus 13.35 +/- 7.14 (p < 0.001), respectively. Using multiple logistic regression analysis, we found that age, creatinine, coma scale, sodium and APACHE II score were capable of predicting the in-hospital mortality (p < 0.05). With use of the logistic model, a good correlation of predicted mortality rate to observed mortality rate was found (r = 0.992). This study demonstrated that lower APACHE II scores predicted survival while high scores predicted mortality. Mortality rate increased significantly when APACHE II score was > 25. An APACHE II score greater than 28.25 predicted a more than 50% in-hospital mortality. CONCLUSIONS: This study demonstrates that the APACHE II scoring system is capable of predicting mortality in patients with MI, which makes this modality more applicable in the busy intensive care unit.

APACHE↗
PubMed1997

Leakage of intrathoracic oesophagovisceral anastomoses in adenocarcinoma of the gastric cardia: changes in serial APACHE II scores and their prognostic significance.

OBJECTIVE: To evaluate changes in serial Acute Physiology and Chronic Health Evaluation (APACHE) II scores in patients with intrathoracic oesophageal anastomotic leaks and to assess their prognostic significance. DESIGN: Retrospective study. SETTING: Teaching hospital, Taiwan. SUBJECTS: 18 patients (4%) who developed intrathoracic oesophageal anastomotic leaks in a total of 491 patients who underwent oesophagogastrectomy for adenocarcinoma of the gastric cardia between 1980 and 1994. MAIN OUTCOME MEASURE: APACHE II scores in those that survived (n = 10) compared with those who died (n = 8). RESULTS: Of the 18 patients, 8 (44%) died. The preoperative general condition, biochemical data, and perioperative APACHE II scores were similar in the two groups. Leakage from the oesophageal anastomoses caused similar degrees of sepsis in the two groups in terms of APACHE II scoring, but the APACHE II scores of survivors started to decline within a week of initial management. In contrast, the APACHE II scores of those who died had increased one week after the leak had been diagnosed despite initial management. There were significant differences in the APACHE II scores of survivors and those who died from one week after leakage until discharge or death (p < 0.001). Only one patient (1/9) survived if the APACHE II score one week after diagnosis of the leak was more than 10. None died of the leak if the APACHE II scores were equal to or less than 10 after a week. CONCLUSIONS: Adequate surgical drainage, antibiotic cover according to the microbiological picture, and nutritional support are essential in the management of intrathoracic oesophageal fistulas. Early reoperation to close early leaks by simple suture or secondary wrapping and to improve local drainage is recommended. The APACHE II scoring system is valuable in evaluating the severity of sepsis caused by intrathoracic oesophagovisceral anastomosis leaks and may serve as an indicator of adequate management. Aggressive surgical measures should be considered if APACHE II scores rise during initial management.

APACHE↗
PubMed1991

Predicting outcome in critical care: the current status of the APACHE prognostic scoring system.

The APACHE (Acute Physiology and Chronic Health Evaluation) prognostic scoring system was developed in 1981 at the George Washington University Medical Center as a way to measure disease severity. APACHE II, introduced in 1985, was a simplified modification of the original APACHE. The APACHE II score consisted of three parts: 12 acute physiological variables, age and chronic health status. Probability of death can be derived by using the disease category and the APACHE II score. The uses of APACHE II include risk stratification to account for case mix in clinical studies, comparison of the quality of care among ICUs, and assessment of group and individual prognoses. APACHE III, a refinement of APACHE II, will be introduced in late 1990. The APACHE III data base includes 17,457 patients from a representative sample of 40 American hospitals. Additional potential uses of APACHE III include the identification of factors in the ICU which contribute to outcome and assistance in individual patient decision-making. This article reviews the development, current uses and potential applications of the APACHE system.

Critical Care↗
PubMed1992

Further appraisal of APACHE II limitations and potential.

Hemodynamically unstable patients selected for invasive cardiovascular monitoring were divided into APACHE II subgroups for risk stratification to study interrelationships among monitoring, therapy, resulting cardiovascular function and outcome. When compared by regression analysis, there were no clinically relevant relationships between APACHE II scores and total intervention points (r2 = 0.02), days of invasive monitoring (r2 = 0.000001), initial cardiovascular function (r2 = 0.069) and final cardiovascular function (r2 = 0.05). Analysis of variance (ANOVA) was done between APACHE subgroups and total points (zero of 20 intragroup comparisons were different by the Scheffé test; p = 0.33), days of monitoring (zero of 20 were different; p = 0.61), initial cardiovascular function (three of 20 comparisons were different; p = 0.003) and final cardiovascular function (zero of 20 were different; p = 0.24). Opposite relationships in patients who lived and died were noted between total intervention points and APACHE II subgroups (p = 0.028, two-way ANOVA). There was an increasing number of total intervention points in patients who ultimately lived in ascending initial APACHE II subgroups. In contrast, there was a decreasing number of total intervention points in patients who ultimately died in the same APACHE II subgroups. APACHE II stratification failed to help understand the relationships among clinically important parameters. At the same time, while APACHE scores are claimed to be independent of therapy, the score seemed to be extremely sensitive to interventions, especially important in surgical populations. Should the APACHE II scores remain high in the face of continued maximal intervention, fatal outcome can be predicted. This pattern is remarkably similar across the entire initial APACHE spectrum. The predicated attributes of APACHE II scores, that is, risk stratification and independence from therapy, are neither necessary or desirable. Understanding patterns that are associated with survival or death may require alternative mathematic approaches, such as group and set theory manipulated by principles of Boolean algebra. New approaches may be more fruitful than further attempts to refine existing systems.

Analysis of Variance↗
PubMed1998

Predicting survival, length of stay, and cost in the surgical intensive care unit: APACHE II versus ICISS.

BACKGROUND: Risk stratification of patients in the intensive care unit (ICU) is an important tool because it permits comparison of patient populations for research and quality control. Unfortunately, currently available scoring systems were developed primarily in medical ICUs and have only mediocre performance in surgical ICUs. Moreover, they are very expensive to purchase and use. We conceived a simple risk-stratification tool for the surgical ICU that uses readily available International Classification of Diseases, Ninth Revision, codes to predict outcome. Called ICISS (International Classification of Disease Illness Severity Score), our score is the product of the survival risk ratios (obtained from an independent data set) for all International Classification of Diseases, Ninth Revision, diagnosis codes. METHODS: A total of 5,322 noncardiac patients admitted to a surgical ICU during an 8-year period had their Acute Physiology and Chronic Health Evaluation (APACHE) II scores compared with their ICISS as predictors of outcome (survival/nonsurvival, length of stay, and charges). RESULTS: ICISS proved to be a much better predictor of survival than APACHE (receiver operating characteristic (ROC) APACHE = 0.806; Hosmer-Lemeshow (HL) APACHE = 22.56; ROC ICISS = 0.892; HL ICISS = 12.06) or the APACHE survival probability (ROC = 0.836; HL = 34.47). These differences were highly statistically significant (p < 0.001). ICISS was also better correlated with ICU length of stay (APACHE R2 = 0.06; ICISS R2 = 0.32) and ICU charges (APACHE R2 = 0.07; ICISS R2 = 0.39). When combined in a logistic model with ICISS, APACHE II added slightly to the predictive power of ICISS alone (combined ROC = 0.903) but degraded the calibration of the model (combined HL = 16.29; p = 0.038). CONCLUSION: Because ICISS is both more accurate and much less expensive to calculate than APACHE II score, ICISS should replace APACHE II score as the standard risk stratification tool in surgical ICUs.

APACHE↗
PubMed2006

Obesity increases the severity of acute pancreatitis: performance of APACHE-O score and correlation with the inflammatory response.

BACKGROUND: Obese patients appear to be at risk for complications of acute pancreatitis (AP). APACHE-O score has been suggested to improve APACHE-II accuracy in predicting severe outcome in AP. AIMS: To determine if APACHE-O adds any predictive value to APACHE-II score and to test the hypothesis that obese patients are at increased risk of severe AP (SAP) because of a more intense inflammatory response to pancreatic injury. METHODS: 102 AP patients were prospectively studied. Using a body mass index (BMI) >30, 28% of the subjects were obese. Nineteen patients developed organ dysfunction and were classified as SAP. Receiver-operating curves for prediction of SAP were calculated using admission APACHE-II and APACHE-O scores. Binary logistic regression was performed to assess if obesity is a risk for SAP and to determine the clinical factors associated with severe disease. Serum levels of IL-6, MCP-1 and CRP as well as Ranson's scores were compared between obese and non-obese patients. RESULTS: Admission APACHE-O (area under the curve AUC 0.895) and APACHE-II (AUC 0.893) showed similar accuracy in predicting severe outcome. BMI was identified as a significant risk for SAP (OR 2.8, p = 0.048) and mortality (OR 11.2, p = 0.022). CRP levels were significantly higher in obese AP patients (p = 0.0001) as well as Ranson's score (p = 0.021). IL-6 and MCP-1 levels were higher in obese patients but did not reach statistical significance. CONCLUSIONS: Obesity is an independent risk for SAP. Admission APACHE-O score is not more accurate than APACHE-II. Our study results suggest that obesity increases the severity of AP by amplifying the immune response to injury.

APACHE↗
PubMed1995

Use of APACHE II classification to evaluate outcome and response to therapy in acute renal failure patients in a surgical intensive care unit.

The study objective was to determine the applicability of the acute physiology and chronic health evaluation (APACHE) II score in surgical patients with acute renal failure (ARF) requiring dialytic support, and to assess its utility in evaluating data from this specific disease group. This was a retrospective, partly prospective follow-up study of patients who developed ARF during their course of stay on the surgical intensive care unit (ICU) of a Dutch university hospital from January 1, 1986, to January 31, 1994. A total of 111 patients were identified, of whom 104 patients were considered eligible for this study. Data for the individual APACHE II scores were calculated from the most deranged values during the initial 24 h of ICU admission (APACHE II1) and on the day dialytic support was instituted (APACHE II2). The ratio between the two APACHE II scores was also calculated for each patient (AP2/AP1 ratio). Receiver operating characteristic curves (ROC) were constructed. Other variables evaluated included age, sex, serum creatinine, diagnostic category, time from ICU admission to start of dialytic support, and the type of dialytic support. Of these 104 patients (median age 64; range 23-85 years), 51 (50%) survived to leave the ICU, of whom 47 (46%) survived to leave hospital. The APACHE II2 score (27.0 +/- 4.4 vs. 22.4 +/- 3.5; p < 0.001) and AP2/AP1 ratio (1.12 +/- 0.09 vs. 0.97 +/- 0.06; p < 0.001) were significantly higher for nonsurvivors as compared to survivors. The ROC curve was most discriminative for the AP2/AP1 ratio (area under the curve 0.92) and to a lesser extent for the APACHE II2 score (area under the curve 0.78). Estimated risk of death with the APACHE II equation did not improve predictive power. Multivariate analysis of various variables revealed the AP2/AP1 ratio as the single most important factor predicting death (odds ratio 13.8, p < 0.001). Adjusting for the AP2/AP1 ratio, no impact on outcome was observed for age, diagnostic category, time from ICU admission to start of dialytic support, and the type of dialytic support. Above a value of 1.0 of the AP2/AP1 ratio, logistic regression revealed a sharp increase in death probability with increasing AP2/AP1 ratio. APACHE II, when used at the time of initiation of dialytic support, proved to be a valid way in our surgical ICU to stratify ARF patients by the severity of their illness. Moreover, use of the AP2/AP1 ratio further improved the usefulness of this severity index and may help to identify patients who have little chance of survival. Predicting death with the APACHE II equation did not improve predictive power.

APACHE↗
PubMed1994

Steroids, APACHE II score, and the outcome of abdominal infection.

OBJECTIVE: To compare the outcome of abdominal infection in patients with or without previous systemic glucocorticoid therapy and to determine the effect of steroid administration on the relationship between APACHE II (Acute Physiology and Chronic Health Evaluation) scores and mortality. HYPOTHESIS: Steroid therapy leads to greater mortality and relatively lower APACHE II scores. DESIGN: Prospective cohort study. SETTING: University hospital. PATIENTS: Two hundred ninety-seven consecutive adult patients with abdominal infection treated by surgical or percutaneous drainage. Treatment was at the clinician's discretion. Seventy-one patients received systemic steroid therapy. OUTCOME MEASURES: APACHE II score, clinical course, and death in hospital; relationship between APACHE II score and mortality in the steroid and no steroid groups. RESULTS: Thirty-three patients receiving steroid therapy (46%) died vs 55 (24%) of 226 patients not receiving steroid therapy. The APACHE II score (P < .0001) and steroid administration (P = .04) were each independently associated with death. Steroid-treated patients had the same probability of dying as "nonsteroid" patients with an APACHE II score a mean of 3.7 points higher (95% confidence limits, 0.03 and 7.7). The confidence that 2, 3, or 4 extra APACHE II points is the appropriate correction for steroid-treated patients is 80%, 60%, or 40%, respectively. CONCLUSIONS: Patients receiving steroid therapy appear to be at higher risk of dying of abdominal infection than predicted by APACHE II scores. The number of patients receiving cancer chemotherapy was too small to determine whether this was an additional risk factor. In the design of clinical trials stratified by APACHE II scores, steroid-treated patients should either be excluded or assigned two extra APACHE II points.

Abdomen↗
PubMed1997

Prognostic indicators in acute pancreatitis: CT vs APACHE II.

PURPOSE: To investigate the correlation between established contrast-enhanced computed tomography (CECT) criteria of disease severity in acute pancreatitis and the APACHE (Acute Physiology and Chronic Health Evaluation) II score and to assess the utility of each as prognostic indicators in acute pancreatitis. MATERIALS AND METHODS: Over a 1-year period, prospective, consensus interpretation of the CECTs of 35 consecutive inpatients was performed with determination of the CECT grade, degree of necrosis, and severity index. The APACHE II score was calculated within 24 h of CECT. Multiple clinical endpoints were recorded: local complications (pseudocyst, abscess, or acute fluid collections requiring urgent surgical or radiological intervention), systemic disease (intensive care unit admission), and duration of hospitalization. Statistical analysis was performed to determine correlations. RESULTS: No statistically significant correlation existed between the APACHE II score and CECT grade, the degree of necrosis, or the CECT severity index. Only the CECT grade and severity index correlated significantly with the occurrence of local complications (P = 0.0035 and 0.0048, respectively). The APACHE II score was superior to the CECT grade as a predictor of the need for ICU admission (P = 0.022 vs P = 0.035), and no other CECT criteria was a significant predictor of ICU admission. CONCLUSION: The preferred clinical and imaging prognostic measures in acute pancreatitis, the APACHE II score and CECT criteria, do not correlate with one another in the commonly encountered, mixed primary and tertiary care population. The mathematical integration of CECT criteria and the APACHE II score fails to yield a predictor of outcome superior to the use of any one measure alone. CECT criteria best define local anatomic abnormality, and are superior to the APACHE II score as predictors of local complications. The APACHE II score is superior to all CECT criteria as an indicator of systemic disease severity (reflected in the need for ICU admission). The most effective initial triage would be immediate APACHE II calculation. Further use of imaging vs clinical assessment can then be individualized.

APACHE↗
PubMed2003

APACHE II predicts long-term survival in COPD patients admitted to a general medical ward.

OBJECTIVE: The Acute Physiology and Chronic Health Evaluation II (APACHE II) was developed to predict intensive-care unit (ICU) resource utilization. This study tested APACHE II's ability to predict long-term survival of patients with chronic obstructive pulmonary disease (COPD) admitted to general medical floors. DESIGN: We performed a retrospective cohort study of patients admitted for COPD exacerbation outside the ICU. APACHE II scores were calculated by chart review. Mortality was determined by the Social Security Death Index. We tested the association between APACHE II scores and long-term mortality with Cox regression and logistic regression. PATIENTS: The analysis included 92 patients admitted for COPD exacerbation in two Burlington, Vermont hospitals between January 1995 and June 1996. MEASUREMENTS AND MAIN RESULTS: In Cox regression, APACHE II score (hazard ratio [HR] 1.76 for each increase in a 3-level categorization, 95% confidence interval [CI] 1.16 to 2.65) and comorbidity (HR 2.58; 95% CI, 1.36 to 4.88) were associated with long-term mortality (P <.05) in the univariate analysis. After controlling for smoking history, comorbidity, and admission pCO2, APACHE II score was independently associated with long-term mortality (HR 2.19; 95% CI, 1.27 to 3.80). In univariate logistic regression, APACHE II score (odds ratio [OR] 2.31; 95% confidence internal [CI] 1.24 to 4.30) and admission pCO2 (OR 4.18; 95% CI, 1.15 to 15.21) were associated with death at 3 years. After controlling for smoking history, comorbidity, and admission pCO2, APACHE II score was independently associated with death at 3 years (OR 2.62; 95% CI, 1.12 to 6.16). CONCLUSION: APACHE II score may be useful in predicting long-term mortality for COPD patients admitted outside the ICU.

APACHE↗
PubMed2000

APACHE II scores and deaths after upper gastrointestinal endoscopy in hospital inpatients.

Advanced age and comorbidity as well as gastrointestinal (GI) disease contribute to the increased mortality after upper GI endoscopy in inpatients when compared to outpatients. The aim of this study was to measure comorbidity in inpatients undergoing endoscopy using the Acute Physiology and Chronic Health Evaluation (APACHE) II severity of disease classification and to assess the usefulness of the APACHE II system in predicting outcome. During a 10-week period, 155 consecutive inpatients undergoing upper GI endoscopy were prospectively scored using APACHE II. They were followed up for 30 days, the measured endpoint being death. Of these, 92 (59%) inpatients were admitted with GI hemorrhage, 14 (9%) were admitted for other reasons but subsequently bled, and 49 (32%) were endoscoped for reasons other than bleeding. The mean (SEM) APACHE II score in patients with GI bleeding was 8.0 (0.5), and in patients without bleeding was 6.5 (0.6; p = 0.07). Eighteen patients (12%) died within 30 days of endoscopy. APACHE scores were higher at 10.5 (1.2) in patients who died, compared to 7.1 (0.4) in those who lived (p < 0.01). Increased acute physiology scores led to this difference. Age and chronic health scores were similar in both groups. In the 18 patients who died, 9 had GI bleeding and their mean APACHE score was 13.8 (1.5); 9 had been endoscoped for other reasons and had a lower score of 7.2 (1.3; p < 0.01). These latter 9 deaths amounted to a 18% mortality in the nonbleeding group, which was greater than expected. APACHE II scores can help predict poor outcome in inpatients referred for endoscopy. However, the APACHE II system has limitations and failed to identify (by means of a high score) some patients without GI bleeding who subsequently died. A tool to measure comorbidity, such as the APACHE II system, is necessary when comparing groups of patients in different settings.

APACHE↗
PubMed2006

Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients.

OBJECTIVE: To improve the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE) method for predicting hospital mortality among critically ill adults and to evaluate changes in the accuracy of earlier APACHE models. DESIGN: : Observational cohort study. SETTING: A total of 104 intensive care units (ICUs) in 45 U.S. hospitals. PATIENTS: A total of 131,618 consecutive ICU admissions during 2002 and 2003, of which 110,558 met inclusion criteria and had complete data. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We developed APACHE IV using ICU day 1 information and a multivariate logistic regression procedure to estimate the probability of hospital death for randomly selected patients who comprised 60% of the database. Predictor variables were similar to those in APACHE III, but new variables were added and different statistical modeling used. We assessed the accuracy of APACHE IV predictions by comparing observed and predicted hospital mortality for the excluded patients (validation set). We tested discrimination and used multiple tests of calibration in aggregate and for patient subgroups. APACHE IV had good discrimination (area under the receiver operating characteristic curve = 0.88) and calibration (Hosmer-Lemeshow C statistic = 16.9, p = .08). For 90% of 116 ICU admission diagnoses, the ratio of observed to predicted mortality was not significantly different from 1.0. We also used the validation data set to compare the accuracy of APACHE IV predictions to those using APACHE III versions developed 7 and 14 yrs previously. There was little change in discrimination, but aggregate mortality was systematically overestimated as model age increased. When examined across disease, predictive accuracy was maintained for some diagnoses but for others seemed to reflect changes in practice or therapy. CONCLUSIONS: APACHE IV predictions of hospital mortality have good discrimination and calibration and should be useful for benchmarking performance in U.S. ICUs. The accuracy of predictive models is dynamic and should be periodically retested. When accuracy deteriorates they should be revised and updated.

APACHE↗
PubMed2002

Prospective independent validation of APACHE III models in an Australian tertiary adult intensive care unit.

Evaluation of the performance of the APACHE III (Acute Physiology and Chronic Health Evaluation) ICU (intensive care unit) and hospital mortality models at the Princess Alexandra Hospital, Brisbane is reported. Prospective collection of demographic, diagnostic, physiological, laboratory, admission and discharge data of 5681 consecutive eligible admissions (1 January 1995 to 1 January 2000) was conducted at the Princess Alexandra Hospital, a metropolitan Australian tertiary referral medical/surgical adult ICU ROC (receiver operating characteristic) curve areas for the APACHE III ICU mortality and hospital mortality models demonstrated excellent discrimination. Observed ICU mortality (9.1%) was significantly overestimated by the APACHE III model adjusted for hospital characteristics (10.1%), but did not significantly differ from the prediction of the generic APACHE III model (8.6%). In contrast, observed hospital mortality (14.8%) agreed well with the prediction of the APACHE III model adjusted for hospital characteristics (14.6%), but was significantly underestimated by the unadjusted APACHE III model (13.2%). Calibration curves and goodness-of-fit analysis using Hosmer-Lemeshow statistics, demonstrated that calibration was good with the unadjusted APACHE III ICU mortality model, and the APACHE III hospital mortality model adjusted for hospital characteristics. Post hoc analysis revealed a declining annual SMR (standardized mortality rate) during the study period. This trend was present in each of the non-surgical, emergency and elective surgical diagnostic groups, and the change was temporally related to increased specialist staffing levels. This study demonstrates that the APACHE III model performs well on independent assessment in an Australian hospital. Changes observed in annual SMR using such a validated model support an hypothesis of improved survival outcomes 1995-1999.

APACHE↗
PubMed2000

Comparison of APACHE II, MEES and Glasgow Coma Scale in patients with nontraumatic coma for prediction of mortality. Acute Physiology and Chronic Health Evaluation. Mainz Emergency Evaluation System.

INTRODUCTION: There are numerous prehospital descriptive scoring systems, and it is uncertain whether they are efficient in assessing of the severity of illness and whether they have a prognostic role in the estimation of the illness outcome (in comparison with that of the prognostic scoring system Acute Physiology and Chronic Health Evaluation [APACHE] II). The purpose of the present study was to assess the value of the various scoring systems in predicting outcome in nontraumatic coma patients and to evaluate the importance of mental status measurement in relation to outcome. PATIENTS AND METHODS: In a prehospital setting, postintervention values of the Mainz Emergency Evaluation System (MEES) and Glasgow Coma Scale (GCS) were measured for each patient. The APACHE II score was recorded on the day of admission to the hospital. This study was undertaken over a 2-year period (from January 1996 to October 1998), and included 286 consecutive patients (168 men, 118 women) who were hospitalized for nontraumatic coma. Patients younger than 16 years were not included. Their age varied from 16 to 87 years, with mean +/- standard deviation of 51.8 +/- 16.9 years. Sensitivity, specificity and correct prediction of outcome were measured using the chi2 method, with four severity scores. The best cutoff point in each scoring system was determined using the Youden index. The difference in Youden index was calculated using the Z score. For each score, the receiver operating characteristic (ROC) curve was obtained. The difference in ROC was calculated using the Z score. P < 0.05 was considered statistically significant. RESULTS: For prediction of mortality, the best cutoff points were 19 for APACHE II, 18 for MEES and 5 for GCS. The best cutoffs for the Youden index were 0.63 for APACHE II, 0.61 for MEES and 0.65 for GCS. The correct prediction of outcome was achieved in 79.9% for APACHE II, 78.3% for MEES and 81.9% for GCS. The area under the ROC curve (mean +/- standard error) was 0.86 +/- 0.02 for APACHE II, 0.84 +/- 0.06 for MEES and 0.88 +/- 0.03 for GCS. There were no statistically significant differences among APACHE II, MEES and GCS scores in terms of correct prediction of outcome, Youden index or area under ROC curve. CONCLUSIONS: APACHE II is not much better than prehospital descriptive scoring systems (MEES and GCS). APACHE II and MEES should not replace GCS in assessment of illness severity or in prediction of mortality in nontraumatic coma. For the assessment of mortality, the GCS score provides the best indicator for these patients (simplicity, less time-consuming and effective in an emergency situation.

APACHE↗
PubMed2003

Severity assessment in acute paraquat poisoning by analysis of APACHE II score.

BACKGROUND AND PURPOSE: Several methods have been proposed to predict prognosis in patients with paraquat poisoning, but all have their limitations. This retrospective study evaluated the usefulness of Acute Physiology and Chronic Health Evaluation (APACHE) II scores in risk stratification for patients with paraquat poisoning. METHODS: Data from 58 adults with a diagnosis of paraquat poisoning presenting to a general hospital over a 10-year period were analyzed. APACHE II scores were calculated at 24 hours after admission and data on related parameters during the first 24 hours were collected for study. RESULTS: The overall in-hospital mortality was 72.4% and mortality in the intensive care unit was 82.2%. APACHE II scores were higher in non-survivors (n = 42, 23.3 +/- 12.4) than in survivors (n = 16, 6.7 +/- 4.1; p < 0.001). All 26 patients (44.8%) who received mechanical ventilation died. Of the 32 patients who received hemoperfusion, 25 (78.1%) died. Plasma paraquat concentration, estimated ingested amount of paraquat, and APACHE II score were significantly higher in non-survivors than in survivors (p < 0.05 for all comparisons). There were significant correlations between APACHE II score and the following variables: plasma paraquat concentration, estimated ingested amount of paraquat, and the peak values during the first 24 hours after admission for fraction of inspired oxygen, alveolar-arterial oxygen gradient, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and serum creatinine (p < 0.05 for all comparisons). Higher APACHE II score was associated with greater mortality. All patients who had an APACHE II score greater than 20 died before discharge. CONCLUSIONS: This study has demonstrated that the APACHE II score is positively correlated with plasma paraquat concentration and ingested amount of paraquat. An APACHE II score of 20 or higher is a good predictor of in-hospital mortality.

APACHE↗
PubMed1992

Independent validation of APACHE II severity of illness score for predicting mortality in patients with breast cancer admitted to the intensive care unit.

BACKGROUND: To determine the validity and predictive accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system for severity of illness by comparing the actual hospital mortality with the predicted mortality for patients with breast cancer admitted to the intensive care unit (ICU). METHODS: APACHE II scores were calculated based on retrospective evaluation of the medical records of 52 patients with breast cancer who received ICU care. The relationships between hospital mortality and APACHE II scores, number of sites of metastatic disease, duration of metastatic disease, number of chemotherapeutic regimens given for metastatic disease, presence of neutropenia or thrombocytopenia, age, reason for ICU admission, and length of ICU stay were assessed. RESULTS: Twenty-two patients (42%) died during the hospital stay during in which they were admitted to the ICU. Predicted mortality based on a logistic regression model using APACHE II scores was 21 patients (40%). APACHE II specificity was 87%; sensitivity was 54%. There were significant relationships between presence of metastatic disease, number of metastatic sites, reason for ICU admission, and length of ICU stay. Patients with more than two sites of metastatic disease and those with respiratory failure had particularly poor chances of survival. Regression analysis incorporating the number of sites of metastatic disease, reason for ICU admission (whether for a pulmonary or a cardiovascular problem), and APACHE II score suggested that APACHE II could predict hospital survival. CONCLUSIONS: This retrospective study showed that APACHE II scores were associated with hospital mortality in patients with breast cancer who were admitted to ICU. The number of metastatic sites and the type of major organ system failure were also associated with outcome. Regression analysis suggested that APACHE II scores were independently associated with survival outcome.

Adult↗
PubMed1991

Acute physiology and chronic health evaluation (APACHE II) and Glasgow coma scores as predictors of outcome from intensive care after cardiac arrest.

OBJECTIVES: a) To examine the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Glasgow Coma Scores as predictors of the outcome of patients following resuscitation from cardiac arrest; b) to study the impact of the components of APACHE II on the prediction. DESIGN: A nationwide study in Finland with prospectively collected data on all patients admitted to intensive care after cardiac arrest during a 14-month period. Two thirds of the cardiac arrest patients included in the study were randomly selected to derive predictive models, and the remaining one third constituted the validation sample. SETTING: A total of 25 medical and surgical ICUs in Finland (13 in tertiary referral centers). PATIENTS: Six-hundred nineteen consecutive cardiac arrest patients. Fifteen patients less than 16 yrs were excluded. MAIN OUTCOME MEASURES: Variables included in the APACHE II or Glasgow Coma Scores were collected at the time of ICU admission and then three times after admission, at 24-hr intervals. ICU- and hospital-mortality rates and a 6-month mortality rate after ICU admission were studied. RESULTS: Of 604 study patients, 370 (61.3%) patients died in the hospital. The most accurate prediction of hospital outcome was based on data collected after the first day of ICU care, not on the admission values. Twenty-one (21.9%) of 96 patients with a low APACHE II score (less than or equal to 9) died compared with 66 (84.6%) of 78 patients with a high APACHE II score (greater than or equal to 25) (p less than .001). Of 160 patients with a normal Glasgow Coma Score (14 to 15), 45 (28.1%) died, whereas there were 114 (81.4%) nonsurvivors among 140 patients with a low Glasgow Coma Score of 3 (p less than .001). The performance of predictive models, including age, the Chronic Health Evaluation, and either the Acute Physiology Score (Acute Physiology Score model) or the Glasgow Coma Score (Glasgow Coma Score model) were compared with the prediction according to the APACHE II in the validation sample. When using 80% probability of death as a decision rule, the Acute Physiology Score model determined 35 of 153 patients to have high risk of death, 29 of whom died (the positive predictive value being 82.9%). The Glasgow Coma Score model predicted 34 patients to die, 26 of whom died (positive predictive value 76.5%), and the APACHE II score predicted seven deaths, five of whom actually died (positive predictive value 71.4%). CONCLUSIONS: The APACHE II scoring system cannot be recommended as a prognostic tool to support clinical judgement in cardiac arrest patients, but by modifying it, a more accurate prediction of poor outcome could be achieved. The Glasgow Coma Score explained to a great extent the predictive power of the APACHE II.

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PubMed1994

Intensive Care Society's Acute Physiology and Chronic Health Evaluation (APACHE II) study in Britain and Ireland: a prospective, multicenter, cohort study comparing two methods for predicting outcome for adult intensive care patients.

OBJECTIVE: To compare the ability of two methods--Acute Physiology and Chronic Health Evaluation (APACHE II) and Mortality Prediction Model (MPM)--to predict hospital outcome for a large group of intensive care patients from Britain and Ireland. DESIGN: Prospective, multicenter, cohort study. SETTING: Twenty-six general intensive care units in Britain and Ireland. PATIENTS: A total of 8,724 patients admitted to the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Probabilities of hospital death for patients were estimated by applying APACHE II and MPM. Predicted risks of hospital death were compared with observed outcomes using four methods of assessing the overall goodness of fit. APACHE II performed better than MPM; the calibration curve for APACHE II lay closer to the line of perfect predictive ability. Lemeshow-Hosmer chi-square statistics were 81 and 57 for APACHE II, and 2515 and 1737 for MPM. The overall correct classification rate for APACHE II was 79%, and this classification rate was 74% for MPM, applying a decision criterion of 50%. The area under the receiver operating characteristic curve was 0.83 with APACHE II and 0.74 with MPM. Even after modifications to the MPM for the assessment of coma, the performance of APACHE II was superior. CONCLUSIONS: APACHE II demonstrated a higher degree of overall goodness of fit, which was superior to MPM for groups of intensive care patients from Britain and Ireland.

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