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PubMed2005

Influence of time elapsed from end of emergency surgery until admission to intensive care unit, on Acute Physiology and Chronic Health Evaluation II (APACHE II) prediction and patient mortality rate.

CONTEXT AND OBJECTIVE: Patients are often admitted to intensive care units with delay in relation to when this service was indicated. The objective was to verify whether this delay influences hospital mortality, length of stay in the unit and hospital, and APACHE II prediction. DESIGN AND SETITNG: Prospective and accuracy study, in intensive care unit of Santa Casa de São Paulo, a tertiary university hospital. METHODS: We evaluated all 94 patients admitted following emergency surgery, from August 2002 to July 2003. The variables studied were APACHE II, death risk, length of stay in the unit and hospital, and hospital mortality rate. The patients were divided into two groups according to the time elapsed between end of surgery and admission to the unit: up to 12 hours and over 12 hours. RESULTS: The groups were similar regarding gender, age, diagnosis, APACHE II score and hospital stay. The death risk factors were age, APACHE II and elapsed time (p < 0.02). The mortality rate for the over 12-hour group was higher (54% versus 26.1%; p = 0.018). For the over 12-hour group, observed mortality was higher than expected mortality (p = 0.015). For the up to 12-hour group, observed and expected mortality were similar (p = 0.288). CONCLUSION: APACHE II foresaw the mortality rate among patients that arrived faster to the intensive core unit, while the mortality rate was higher among those patients whose admission to the intensive care unit took longer.

APACHE↗
PubMed2004

Predictive comparisons of procalcitonin (PCT) level, arterial ketone body ratio (AKBR), APACHE III score and multiple organ dysfunction score (MODS) in systemic inflammatory response syndrome (SIRS).

Procalcitonin (PCT) is a newly introduced marker of systemic inflammation and bacterial infection. A marked increase in circulating PCT level in critically ill patients has been related with the severity of illness and poor survival. The goal of this study was to compare the prognostic power of PCT and three other parameters, the arterial ketone body ratio (AKBR), the acute physiology, age, chronic health evaluation (APACHE) III score and the multiple organ dysfunction score (MODS), in the differentiation between survivors and nonsurvivors of systemic inflammatory response syndrome (SIRS). The study was performed in 95 patients over 16 years of age who met the criteria of SIRS. PCT and AKBR were assayed in arterial blood samples. The APACHE III score and MODS were recorded after the first 24 hours of surgical ICU (SICU) admission and then daily for two weeks or until either discharge or death. The patients were divided into two groups, survivors (n=71) and nonsurvivors (n=24), in accordance with the ICU outcome. They were also divided into three groups according to the trend of PCT level: declining, increasing or no change. Significant differences between survivors and nonsurvivors were found in APACHE III score and MODS throughout the study period, but in PCT value only up to the 7th day and in AKBR only up to the 3rd day. PCT values of the three groups were not significantly different on the first day between survivors and nonsurvivors. Receiver operating characteristic (ROC) curves for prediction of mortality by PCT, AKBR, APACHE III score and MODS were 0.690, 0.320, 0.915 and 0.913, respectively, on the admission day. In conclusion, PCT could have some use as a mortality predictor in SIRS patients but was less reliable than APACHE III score or MODS.

APACHE↗
PubMed2005

Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II scoring system in predicting acute pancreatitis outcome.

AIM: Acute pancreatitis (AP) is a process with variable involvement of regional tissues or organ systems. Multifactorial scales included the Ranson, Acute Physiology and Chronic Health Evaluation (APACHE II) systems and Balthazar computed tomography severity index (CTSI). The purpose of this review study was to assess the accuracy of CTSI, Ranson score, and APACHE II score in course and outcome prediction of AP. METHODS: We reviewed 121 patients who underwent helical CT within 48 h after onset of symptoms of a first episode of AP between 1999 and 2003. Fourteen inappropriate subjects were excluded; we reviewed the 107 contrast-enhanced CT images to calculate the CTSI. We also reviewed their Ranson and APACHE II score. In addition, complications, duration of hospitalization, mortality rate, and other pathology history also were our comparison parameters. RESULTS: We classified 85 patients (79%) as having mild AP (CTSI <5) and 22 patients (21%) as having severe AP (CTSI > or =5). In mild group, the mean APACHE II score and Ranson score was 8.6+/-1.9 and 2.4+/-1.2, and those of severe group was 10.2+/-2.1 and 3.1+/-0.8, respectively. The most common complication was pseudocyst and abscess and it presented in 21 (20%) patients and their CTSI was 5.9+/-1.4. A CTSI > or =5 significantly correlated with death, complication present, and prolonged length of stay. Patients with a CTSI > or =5 were 15 times to die than those CTSI <5, and the prolonged length of stay and complications present were 17 times and 8 times than that in CTSI <5, respectively. CONCLUSION: CTSI is a useful tool in assessing the severity and outcome of AP and the CTSI > or =5 is an index in our study. Although Ranson score and APACHE II score also are choices to be the predictors for complications, mortality and the length of stay of AP, the sensitivity of them are lower than CTSI.

APACHE↗
PubMedDate not supplied

[Prognostic value of SAPS II and APACHE II scales in patients with multiple organ failure syndrome during early postoperative period after oncological surgery].

The key fixed task was the following: detection, as soon as possible, of patients with a high risk of lethal outcome; an objective assessment of the condition of patients during the early postoperative period by using a quantitative evaluation (SAPS II, APACHE II); and defining of the prognostic value of SAPS II and APACHE II after oncology surgeries. The in-hospital lethality amounted to 53% in 73 patients with MOFS during the early postoperative period after oncology surgeries. The formalized (numerical) score, according to SAPS II and APACHE II, made it possible to detect patients with a higher risk of lethal outcome yet during the very first day after oncology surgeries. If the score of SAPS II or APACHE II topped 30 (on the first day after surgery), then the in-hospital lethality exceeded 50%. The information density of the SAPS II and APACHE II systems turned out to be identical, however, SAPS II appears to be more convenient in terms of practical usage since it demands the evolution of a smaller number of physiological parameters.

APACHE↗
PubMed1995

Comparison of APACHE II scoring in liver and kidney transplant recipients versus trauma and general surgical patients in a single intensive-care unit.

Over a 26-month period we assessed the ability of APACHE II, scored on admission to the surgical intensive care unit (SICU), to predict the in-hospital mortality of liver and kidney transplant recipients either post-operatively or after subsequent complications, and compared these results to non-transplant SICU admissions. There were 866 SICU admissions, of which 128 were liver transplant recipients, 112 were renal transplant recipients, 211 were trauma admissions and 415 were non-transplant/non-trauma admissions. In hospital mortalities among all liver transplant admissions were 0%, 10%, 38%, and 82% for APACHE II ranges of 0-10, 11-20, 21-30 and > 30, respectively, with differences between the second and third, and third and fourth ranges significant (p < or = 0.05 by chi-square analysis). These differences were also seen when examining scores following the primary transplantation alone. Mortalities in corresponding APACHE II ranges for trauma and nontransplant/nontrauma admissions were similar. APACHE II scoring was not useful for renal transplant recipient, as it consistently overpredicted mortality. We conclude that APACHE II scoring may be useful in predicting outcome in post-operative liver transplant recipients, but is not useful in stratifying risk in renal transplant recipients due to the inherently low mortality involved.

APACHE↗
PubMed1997

APACHE II in a postoperative intensive care unit in Thailand.

In order to evaluate the effectiveness of an intensive care unit (ICU), the case-mix has to be considered. This was a cohort study. By using Acute Physiology and Chronic Health Evaluation scores (APACHE II score), we evaluated the case-mix and mortality rate of 282 patients who were treated in our postoperative ICU. The overall mortality rate was 10.6 per cent. Higher Acute physiology scores and emergency surgery in the presence of chronic health status were related to higher mortality, but age was not. However, the original APACHE II model could not precisely predict the mortality of Thai patients. We used stepwise logistic regression to determine the predictors of death and found the prediction model to be -7.24 + 0.37 (APACHE II score) + 1.46 (postemergency surgery). The actual mortality for patients with APACHE II score > 15 in our ICU was higher than that predicted by the original APACHE II model. The causes of this difference might be difference in methodology, characteristics of ICU and the quality of care.

APACHE↗
PubMed1988

Predicting outcome among intensive care unit patients using computerised trend analysis of daily Apache II scores corrected for organ system failure.

Daily Apache II scores were determined prospectively on 310 consecutive adult Intensive Care Unit (ICU) patients to reflect the dynamic pathophysiological processes affecting ICU patients. Organ failure scores were derived from the Apache II scores by applying a coefficient which corresponded to the number and duration of organ failures to account for the increased mortality associated with established major organ-system failures. Computerised trend analysis of data from the first 100 patients was used to develop criteria for predicting hospital outcome of the ICU patients. The analysis took into account the absolute value of the daily scores and the rate of change relative to that of the previous day. Allowance was made for changes in scores as a result of surgery or major iatrogenic complications arising after admission to the ICU. The criteria were then tested prospectively on the next 210 consecutive ICU patients. Predictions by Apache II assessments were NOT used to influence clinical decisions during the study period. It was possible to predict with a specificity of 100% 37 out of the 72 deaths in the test group. The predictive power of daily organ failure scores was superior to those obtained from a single Apache II assessment or from daily Apache II scores by a factor of 5.3 and 1.4 respectively. The estimated long-term risk of a false prediction is 1.4% at the 95% confidence level.

Critical Care↗
PubMed2002

CT-guided percutaneous drainage of intra-abdominal abscesses: APACHE III score stratification of 1-year results. Acute Physiology, Age, Chronic Health Evaluation.

Our objective was to evaluate the clinical success rates of percutaneously drained intra-abdominal abscesses using a risk stratification score for severely ill patients (APACHE III; Acute Physiology, Age, Chronic Health Evaluation). In 75 patients CT-guided percutaneous abscess drainage was performed to treat intra-abdominal abscesses. The clinical success rate based on a 1-year follow-up was correlated with abscess etiology, size, and structure, as well as with the initial APACHE III score. Clinical success, i.e., the complete removal of the abscess without surgical treatment, was observed in 62 of 75 patients (83%). Abscess size (<200 cm(3)) and abscesses with a simple structure correlated with higher clinical success rates. Patients presenting with APACHE III scores below 30 were treated by percutaneous abscess drainages (PAD) alone significantly more often than patients presenting with higher APACHE scores. The percutaneous drainage of intra-abdominal abscesses shows good long-term results as long as abscesses are singular, small (<200 cm(3)), and located in well accessible regions in combination with low APACHE scores (<30).

Abdominal Abscess↗
PubMed1993

Comparison of APACHE II, Trauma Score, and Injury Severity Score as predictors of outcome in critically injured trauma patients.

Trauma Score (TS), APACHE II score, and Injury Severity Score (ISS) have been utilized to quantitate severity of illness in various groups of patients. The purpose of this study was to compare the relationship of the APACHE II score, TS, and "computer-derived" ISS with outcome in critically injured trauma patients. Data were recorded prospectively in a computer database for 428 consecutive trauma admissions. Stepwise discriminate analysis was utilized to determine the best predictor of both intensive care unit (ICU) and hospital outcome. Forty-two patients died in the ICU (10%), and another 18 patients died after leaving the ICU (4%), for a total mortality rate of 14%. The mean p value and partial R2 value obtained from stepwise discriminant analysis of the relationships between APACHE II score, TS, and ISS to ICU and hospital survival are shown. APACHE II score was the best predictor of both ICU and hospital outcome in these critically ill trauma patients. However, when combining all three measures (APACHE II score, TS, and ISS), only a portion of the variance in outcome is explained by the scores (R2 < 0.05). We conclude that scoring systems for outcome prediction should be utilized only as an adjunct to clinical assessment in the evaluation of the severity of illness and mortality risk in critically ill trauma patients.

Female↗
PubMed1989

APACHE-II score for assessment and monitoring of acute pancreatitis.

The value of the Acute Physiology and Chronic Health Enquiry (APACHE-II) score, the Simplified Acute Physiology score, and the Medical Research Council (MRC) sepsis score were compared with clinical assessment and Ranson and Imrie scores in the evaluation and monitoring of acute pancreatitis in 290 attacks. Attacks were graded mild (231) if uncomplicated, or severe (59) when major organ failure or a pancreatic collection occurred. Only APACHE-II scores were available at the time of admission; they correctly predicted outcome in 77% of attacks and identified 63% of severe attacks, compared with 44% achieved by clinical assessment. After 48 h, APACHE-II was most accurate, and correctly predicted outcome in 88% of attacks, compared with 69% for Ranson and 84% for Imrie scores. APACHE-II predicted 73% of pancreatic collections at 48 h, compared with 65% for Ranson and 58% for Imrie scores. In acute pancreatitis, APACHE-II may facilitate rapid selection of patients for intensive therapy or clinical trials, improve comparison between groups of patients, and indicate that a pancreatic collection is probable.

Abscess↗
PubMed1990

Impaired antibody response to Haemophilus influenzae type b polysaccharide and low IgG2 and IgG4 concentrations in Apache children.

BACKGROUND AND METHODS: Because Native American children are at much higher risk for invasive Haemophilus influenzae type b infection than white children, we compared the antibody responses to H. influenzae type b polysaccharide vaccine in healthy Apache and white children. RESULTS: The concentrations of H. influenzae type b antibody after immunization with polysaccharide vaccine were approximately 10-fold lower in 24-month-old Apache children than in whites of a similar age (P less than 0.01). The decreased response involved H. influenzae type b antibodies of the IgG, IgM, and IgA classes. Concentrations of IgG antibody to tetanus toxoid did not differ significantly, and IgG antibodies to diphtheria toxoid were only twofold lower (P = 0.028). Although total IgG, IgM, and IgA levels were higher in two-year-old Apaches than in whites (all P less than 0.001), IgG2 and IgG4 subclasses were lower (both P less than 0.001). Among the Apaches, individual immunoglobulin levels and allotypes were not significantly correlated with their antibody responses to H. influenzae type b polysaccharide. CONCLUSIONS: Apache children have significant impairment of their antibody response to H. influenzae type b polysaccharide and little or no impairment of their antibody responses to protein toxoids. This immunodeficiency may explain the high incidence of H. influenzae type b infection in this population.

Antibodies, Bacterial↗
PubMed1991

Clinical outcome of seriously ill surgical patients with intra-abdominal infection depends on both physiologic (APACHE II score) and immunologic (DTH score) alterations.

The delayed-type hypersensitivity (DTH) response and the APACHE II score in 118 patients with surgical infections were measured prospectively and related to outcome. Logistic regression analysis generated the equation: [formula: see text]. The risk assessment as calculated by this model was compared to that using the APACHE II system alone in a separate group of 354 patients. There was an improvement in the predictive capacity of the APACHE II + DTH equation compared to APACHE II alone, as shown by a better fit of expected and observed deaths, an improved Goodman-Kruskal G statistic, and a larger area under the receiver operating characteristic curve. It is concluded that the DTH response (a broad marker of immunocompetence) is an independent prognostic factor in surgical patients and can be used in combination with the APACHE II score (a measure of acute physiology) to estimate better the outcome of surgical patients.

Abdomen↗
PubMed1981

APACHE-acute physiology and chronic health evaluation: a physiologically based classification system.

Investigations describing the utilization pattern and documenting the value of intensive care are limited by the lack of a reliable and valid classification system. In this paper, the authors describe the development and initial validation of acute physiology and chronic health evaluation (APACHE), a physiologically based classification system for measuring severity of illness in groups of critically ill patients. APACHE uses information available in the medical record. In studies on 582 admissions to a university hospital ICU and 223 admissions to a community hospital ICU, APACHE was reliable in classifying ICU admissions. In validation studies involving these 805 admissions, the acute physiology score of APACHE demonstrated consistent agreement with subsequent therapeutic effort and mortality. This was true for a broad range of patient groups using a variety of sensitivity analyses. After successful completion of multi-institutional validation studies, the APACHE classification system could be used to control for case mix, compare outcomes, evaluate new therapies, and study the utilization of ICUs.

Critical Care↗
PubMed1990

APACHE II scoring in the injured patient.

The purpose of this study was to measure the predictive power of Acute Physiology and Chronic Health Evaluation (APACHE II) with respect to mortality in a group of seriously injured patients and to compare this predictive power with that of the Trauma Score (TS) and the Injury Severity Score (ISS). Six hundred ninety-one helicopter-transported patients were studied. Individual logistic regressions demonstrated that all three scores had significant predictive power when considered individually (TS chi 2 = 136, p less than .0001; APACHE II chi 2 = 171, p less than .0001; ISS chi 2 = 109, p less than .0001). In addition, each severity score added significantly to the predictive power in a stepwise logistic regression (TS chi 2 = 15, p less than .0001; APACHE II chi 2 = 45, p less than .0001; ISS chi 2 = 15, p less than .0001). Areas under the receiver operating curves for the three scores were not significantly different (TS 0.8116, SD 0.0245; APACHE II 0.8515, SD 0.0204; ISS 0.7967; SD 0.0223). APACHE II is a good predictor of mortality, and its predictive power is complemented by TS and ISS.

Adolescent↗
PubMed1991

Acute Physiology and Chronic Health Evaluation (APACHE II) score and outcome in the surgical intensive care unit: an analysis of multiple intervention and outcome variables in 1,238 patients.

OBJECTIVE: To assess the statistical association of the Acute Physiology and Chronic Health Evaluation (APACHE II) score with multiple intervention and outcome variables in surgical ICU patients. DESIGN: Continuous data collection on every patient admitted to the surgical ICU for a 21-month period. MATERIALS AND METHODS: For every admitted patient in the surgical ICU, APACHE II scores were calculated and the relationship between APACHE II score as an independent predictor of outcome was assessed with multiple outcome variables selected for study. The outcome and intervention variables tested included: treatment intervention measures such as days on ventilator; days with an arterial catheter, central venous catheter, triple lumen catheter, pulmonary artery catheter; days receiving total parenteral nutrition; days receiving tube feedings; number of transducers per days in the ICU; number of infusion pumps per ICU days, days in the hospital, number of complete blood counts; number of electrolyte determinations; number of blood gases; number of units of blood transfused; ICU and hospital mortality rates in the presence of complications, including: respiratory distress syndrome, renal failure, congestive heart failure, coma, requirement of cardiopulmonary resuscitation, and others. RESULTS: The APACHE II score was statistically associated with each intervention and outcome variable tested. Unfortunately, the associations, although consistent, were weak with r2 values ranging from .03 to a maximum of .22 for Pearson's correlation coefficients. CONCLUSION: The APACHE II score was statistically associated with all the variables examined in our surgical patients, but its predictive power for the individual surgical patient was limited. These findings suggest that the score may be useful for retrospective analyses of large cohorts of patients but should not be used as a triage tool or as a predictor of outcome for the individual patient. Triage decisions should continue to be based on the best available clinical judgment.

Adult↗
PubMed1992

Evaluation of the consistency of Acute Physiology and Chronic Health Evaluation (APACHE II) scoring in a surgical intensive care unit.

OBJECTIVES: To determine the applicability of the Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system in a Swiss ICU, and to evaluate its utility in evaluating data from 2 yrs of consecutive admissions to show that the predictability of outcome is similar to that predictability observed by Knaus et al. in 1985 (in 5,815 patients), with the provision that large numbers of patients are studied. DESIGN: Prospective clinical trial over 2 yrs, with statistical analysis of the Swiss patients, and between the Swiss patients and the patients studied by Knaus et al. Receiver operating characteristic curves were calculated. SETTING: Surgical ICU in a Swiss university hospital. PATIENTS: A total of 2,061 consecutive patients admitted to the surgical ICU who were classified as postoperative (elective or emergency) and nonoperative. Hospital mortality rate was considered. RESULTS: Patients were 53 +/- 16 yrs of age. Mean APACHE II score was 10.5 +/- 7.0. The mean APACHE II score was significantly (p < .001) lower in the 1,813 survivors (9.0 +/- 5.2) than in the 248 nonsurvivors (21.5 +/- 8.5). The mortality rate was higher among the Swiss patients when compared with the patients studied by Knaus et al. who had postoperative scores of 20 to 29 and nonoperative scores of > 24. The distribution of the scores and mortality rates were stable during the two study periods, as were the differences in mortality rates between the Swiss population and that population studied by Knaus et al. Sensitivity and specificity of the scores were highest in the emergency surgery group (87% and 78%), and lowest in the elective surgery group (76% and 73%). The APACHE equation underestimated the risk of death. CONCLUSIONS: The APACHE II score, because of its consistency over time and the stability of the mortality rates, can be used in our surgical ICU without modification. The calculated risk of death gives no additional information.

Adolescent↗
PubMed1994

Use of daily Acute Physiology and Chronic Health Evaluation (APACHE) II scores to predict individual patient survival rate.

OBJECTIVE: To evaluate the use of daily Acute Physiology and Chronic Health Evaluation (APACHE) II scoring in the prediction of individual mortality rates for intensive care unit (ICU) patients. DESIGN: A prospective study of consecutive patients admitted to four university-affiliated ICUs. SETTING: Medical-surgical ICUs of four tertiary care academic hospitals. PATIENTS: Daily data from 3,350 consecutive ICU admissions, excluding postoperative cardiac patients, were collected from January to December 1991. MEASUREMENTS AND MAIN RESULTS: Daily APACHE II scores were calculated for all patients and correlated with both ICU and hospital mortality. The ability of an absolute level or a predetermined algorithm, based on these scores, to predict mortality was examined. Day 1 APACHE II scores ranged from 0 to 55 (mean 18). We were unable to replicate the suggestion by Chang et al. that 100% hospital mortality was predicted by the following APACHE II scores: a) > 35 at admission; b) 30 to 35 at admission, with a decrease of < or = 3 from day 1 to day 2; or c) > 27 on any day, with an increase of > 2 from the previous day. We were unable to adjust these criteria to avoid a false prediction of death with any remaining useful sensitivity. Mortality rates of 158 (69%) deaths per 229 patients, 68 (62%) deaths per 110 patients, and 110 (48%) deaths per 230 patients were obtained, respectively, for these criteria. CONCLUSIONS: Admission or daily APACHE II scores do not predict individual patient mortality. The adjustments needed in the algorithm that was used to avoid a false prediction of death render sensitivity so low that it would be impractical to limit therapy on this basis alone.

Adolescent↗
PubMed1993

Evaluation of the clinical usefulness of APACHE II and SAPS systems in the initial prognostic classification of acute pancreatitis: a multicenter study.

The clinical usefulness of the APACHE II and SAPS systems in the early prognostic classification of patients with acute pancreatitis has been evaluated in a prospective multicenter study. We aimed to identify early those patients with acute pancreatitis who should be monitored closely to expedite the detection and treatment of complications. One hundred eighty-two patients with acute pancreatitis were included; 28 were classified as severe, having developed at least one major complication of the disease. The scores obtained through the APACHE II and SAPS systems in these severe cases were significantly higher than the scores in the mild cases of acute pancreatitis (p < 0.001). The sensitivity of these systems in the prognostic classification of acute pancreatitis was 70.4% for APACHE II and 66.7% for SAPS, and the specificity was 79.1% for both. When applying APACHE II and SAPS systems in the early phase of acute pancreatitis, the possibility of misdiagnosing the severity exists, thus limiting the application of these systems in the initial assessment of prognostic classification. In conclusion, APACHE II and SAPS systems are of limited clinical utility in the early prognostic evaluation of acute pancreatitis because of their low positive predictive value.

Acute Disease↗