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PubMed1991

A comparison of APACHE II and a clinical sickness score. A study of 97 consecutive admissions to a district general hospital intensive care unit.

The aim of this study was to compare the predictive power of a simple illness severity score (Clinical Sickness Score) to that of APACHE II in a District General Hospital intensive therapy unit. A prospective comparison was carried out on 97 consecutive adult patients whose severity of illness was scored one hour after admission using both the Clinical Sickness Score and APACHE II. Intensive Therapy Unit and hospital outcomes were recorded for each patient. The Clinical Sickness Score and APACHE II identified survivors and nonsurvivors with similar power (p less than 0.001). There was a highly significant correlation between the two scoring systems for hospital survivors and nonsurvivors together (r = 0.5418, r2 = 0.28, p = less than 0.0001) and for hospital survivors alone (r = 0.6102, r2 = 0.37, p = 0.0001). Correlation for hospital nonsurvivors was not significant (r = 0.1629, r2 = 0.027, p = 0.3134). The positive predictive values of APACHE II were between 5% and 10% more sensitive than the Clinical Sickness Score for hospital outcome. Admission Clinical Sickness Score and APACHE II scores had similar predictive power in this study.

Adult↗
PubMed1991

Combined APACHE II score and serum lactate dehydrogenase as predictors of in-hospital mortality caused by first episode Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome.

We retrospectively analyzed data from 75 hospitalized patients with a first episode of Pneumocystis carinii pneumonia to compare the ability of four parameters, including admission serum albumin, serum lactate dehydrogenase (LDH), alveolar-arterial oxygen gradient, and the APACHE II score, to predict mortality and response to initial antipneumocystis therapy. The eight patients who died due to pneumocystosis and the 12 who failed initial antipneumocystis therapy had significantly higher admission mean APACHE II scores and serum LDH levels and lower mean serum albumin levels than did the 65 who survived and the 61 who responded to initial therapy (p less than 0.05 for each). Differences in mean alveolar-arterial oxygen gradients were not statistically significant with respect to survival or response to initial therapy. In a stepwise discriminant analysis of parameters associated with mortality, APACHE II score and LDH level were statistically significant (p less than 0.0001 for each). In a stepwise discriminant analysis of parameters associated with response to initial therapy, APACHE II score and LDH level were again statistically significant (p less than 0.0001, respectively). The addition of the alveolar-arterial oxygen gradient and serum albumin level did not further increase the predictive ability of the discriminant analyses. When analyzed alone, neither the alveolar-arterial oxygen gradient nor the serum albumin were statistically significant in each discriminant analysis. The APACHE II score combined with the serum LDH may be more useful than other parameters, singly or combined, to more closely match patients with regard to severity of illness due to first episode Pneumocystis carinii pneumonia when comparing experimental new therapies with standard agents.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Severity of illness: APACHE II analysis of an ICU population.

We reviewed the population of a surgical intensive care unit from July 1, 1987 to June 30, 1988, adjusting for severity of illness using the APACHE II system. Nineteen different departments admitted a total of 613 patients to the surgical intensive care unit. Predicted mortality was 22.9%; actual mortality was 15.7%. APACHE II generated reports which included analysis by age, mortality risk, department, primary physician, and diagnosis. We recommend reporting intensive care unit outcome by APACHE criteria to allow more meaningful comparisons of data and standardization of quality assurance programs. Finally, we present a critical review of the current APACHE II system and describe developments to be included in APACHE III.

Adolescent↗
PubMed1992

[Severity evaluation of ventilated patients at a respiratory intensive care unit with the APACHE II system].

APACHE II system, is a simple and inexpensive method to evaluate severity of Intensive Care Patients. In a 2 years period (between 1988 and 1990), grading severity using APACHE II system, was performed on 498 consecutive mechanical Ventilated Patients in a Respiratory Intensive Care Unit. APACHE II was higher in COPD patients, but patients with Pneumonia and Organophosphate Poisoning had higher mortality. Correlating the different components of APACHE II with the results, we verified that Prognosis was not influenced by the Previous Health Status. Mortality was higher with increasing age, in patients with COPD and Organophosphate Poisoning. APS was the most important index for prognosis. Patients with Pneumonia and Organophosphate Poisoning had the highest APS. The Authors conclude that APACHE II is an objective and not time consuming method to evaluate severity in ICU Patients. However indexes measured on the first 24 hours of ICU staying are a result of severity of illness, treatment performed and time elapsed before ICU admission, and, this may be a possible source of bias when comparing different Unit results.

Adolescent↗
PubMed1991

Correlation of APACHE II score, drainage technique and outcome in postoperative intra-abdominal abscess.

The APACHE II Score was used to stratify retrospectively severity of illness in 91 patients postoperatively undergoing drainage of intra-abdominal abscesses. The method of initial abscess drainage (percutaneous or operative) was selected by the attending physician. The two groups of patients, those whose initial drainage was performed percutaneously versus operatively were similar with respect to age, sex, abscess location and, most importantly, severity of illness as assessed by the APACHE II score calculated on the day of their abscess drainage. Over-all, the mortality rate was 29 per cent (26 of 91 patients). Only 1.7 per cent of the patients with an APACHE II score of less than 15 died compared with 78 per cent when APACHE II was equal to or more than 15 (p less than 0.0001). Only 8 per cent of patients with APACHE II equal to or more than 15 undergoing percutaneous drainage survived compared with 30 per cent of patients who underwent surgical drainage procedures. While chi-square analysis demonstrated independence between outcome and drainage technique, outcome was dependent upon severity of illness (p less than 0.0005). Paradoxically, despite the attractiveness of a percutaneous technique for abscess drainage in the most ill patients, in this series, a better, although not statistically improved, chance for survival was noted with surgical treatment. We recommend that an objective severity scoring system be used whenever assessing results of treatment of intraabdominal infection and that surgical treatment not be avoided because the patient is considered to be too ill.

Abdomen↗
PubMed1991

Experience with the APACHE II severity of disease scoring system in predicting outcome in a surgical intensive therapy unit.

The APACHE II system, a severity of disease scoring system, has been used to identify intensive therapy unit patients in whom prolonged treatment is unlikely to be beneficial. Fifty-nine surgical patients admitted to the intensive care unit over a 6-month period underwent a single APACHE II scoring in the first 24 h. The overall 30-day mortality rate was 34%. The range of APACHE II scores was 3-29. The survivors had significantly lower scores (mean 11) than those who died (mean 19). Most patients (53%) had a score greater than or equal to 11 to less than or equal to 22 and had an equal chance of living or dying. No patient with a score greater than 22 survived and at this level the APACHE II score was highly specific (100%) but with a very low sensitivity (30%). APACHE II scores greater than 22 may be useful as an adjunct to a clinical decision to withhold treatment, but scores below that level lack the specificity and sensitivity to be of any value.

Aged↗
PubMed1989

Prognosis of critically-ill patients with acute renal failure: APACHE II score and other predictive factors.

The survival from acute renal failure requiring renal replacement therapy was studied in 90 critically-ill patients admitted to an intensive care unit. Mean age (+/- SD) was 51 +/- 14.6 (range 17 to 81) years. Mechanical ventilation was required in 88 patients and 71 patients received total parenteral nutrition. Thirty-three per cent of patients left the intensive care unit alive and 24 per cent survived to leave hospital. Final survival was 20 per cent in medical patients (n = 49), 29 per cent in surgical patients (n = 38) and 100 per cent in obstetric patients (n = 3). Hypotension, requirement for inotropic support, oliguria and sepsis were all associated with a poorer prognosis. The mode of renal replacement therapy did not affect survival, but additional haemodialysis was required in 33 of 65 patients treated by continuous arteriovenous haemofiltration but none of 22 treated with continuous arteriovenous haemodialysis (p less than 0.001). APACHE II score was calculated for 87 patients. Mean APACHE II score was 26.1 +/- 6.9 (range 14 to 44). APACHE II score on admission predicted the likelihood of survival well. No patients with a score of more than 40 survived, compared to 40 per cent of those with scores of 10 to 19. Pre-existing organ insufficiency or immunosuppression meriting a CHE score of 5 was associated with a very poor survival (1 of 30 patients). APACHE II score is a reliable indicator of severity of illness and likelihood of survival in critically-ill patients with acute renal failure. The widespread adoption of APACHE II scoring for patients with acute renal failure requiring intensive care would facilitate medical audit and comparison of studies from various centres.

Acute Kidney Injury↗
PubMedDate not supplied

Comparison of clinical assessment with APACHE II for predicting mortality risk in patients admitted to a medical intensive care unit.

The APACHE II (Acute Physiology and Chronic Health Evaluation) system has been widely used as an objective means of predicting outcome in critically ill patients. We prospectively evaluated patients consecutively admitted to the medical intensive care unit to compare the predictive accuracy of APACHE II with clinical assessment by critical care personnel. At the time of admission to the intensive care unit, the house staff and nurse responsible for each patient were asked to estimate the patient's hospital mortality risk. The patient's APACHE II score was calculated and a prediction of the patient's hospital mortality risk was then computed on the basis of this score. A total of 366 patients were studied. Mortality predictions were obtained from 57 physicians and 33 critical care nurses. We were unable to demonstrate a significant difference in the accuracy of APACHE II predictions compared with either physicians' or nurses' predictions. Clinical assessment and APACHE II were both highly predictive of outcome.

Critical Care↗
PubMed1993

Validation of APACHE II score in a surgical intensive care unit.

The APACHE II scoring system was applied to 301 surgical intensive care admissions over a 9-month period. The mean age of patients admitted was 52.39 years (SD 19.3) and the mean duration of stay was 5.37 days (SD 8.93). The overall mortality was 17.27%. The mean APACHE II scores for survivors was 12.94 (SD 7.43) and non-survivors 28.19 (SD 10.43). There was good correlation between expected mortality predicted by the APACHE II system and observed mortality (r = 0.9732). Using a predicted risk criterion of 0.5 to distinguish between those predicted to survive and die, of the 45 patients predicted to die, only 30 actually did so. No patient survived with an APACHE II score of more than 40 and with a predicted risk of death greater than 0.87. We found the APACHE II system useful for evaluating ICU performance and risk stratification for the purpose of therapeutic trials but not as a triage tool.

Adolescent↗
PubMed1993

The effect of the APACHE II score and selected clinical variables on survival following cardiopulmonary resuscitation.

BACKGROUND AND OBJECTIVES: The purpose of this analysis is to determine the effect of the Acute Physiology and Chronic Health Evaluation (APACHE) II score and other clinical variables on survival following cardiopulmonary resuscitation (CPR) and to identify patient subpopulations with extremely poor survival. METHODS: A retrospective chart review was performed on 218 consecutive adult inpatients undergoing CPR on the general wards and in the intensive care units of a community hospital between January 1, 1989, and July 1, 1991. The patient's age, sex, prior residence, reason for admission, discharge diagnoses, discharge disposition, APACHE II score, and cardiac ejection fraction by echocardiography were recorded. RESULTS: The age, sex, and reason for admission were not significant predictors of survival following CPR. Multiple variable analysis revealed that an increasing APACHE II score (P = .05), a serum creatinine greater than 311 mumol per L (3.5 mg per dL, P = .02), and metastatic cancer (P = .04) were each related to a decreased rate of survival to discharge following CPR. Patient subpopulations with a 0% rate of survival to discharge included those with metastatic cancer (n = 26, P = .02), a serum creatinine greater than 311 mumol per L (3.5 mg per dL) on admission (n = 22, P = .03), and a diagnosis of cardiovascular disease with an APACHE II score greater than 15 on admission (n = 18, P = .007). CONCLUSIONS: The APACHE II score is a useful predictor of failure to survive to discharge following CPR. Several groups of patients were identified with negligible rates of survival to discharge. Physicians should use such prediagnostic information to provide patients with informed consent when discussing do-not-resuscitate (DNR) orders. We suggest that physicians make a special effort to address the DNR status of patients falling to one of the negligible-survival groups identified by this study.

Adolescent↗
PubMed2003

Increasing age and APACHE II scores are the main determinants of outcome from pancreatic necrosectomy.

BACKGROUND: The aim of this study was to identify factors associated with death after surgery in patients with extensive pancreatic necrosis. METHODS: Sixty-four patients who underwent pancreatic necrosectomy between 1996 and 2002 were studied. RESULTS: The median age was 60.5 (95 per cent confidence interval (c.i.) 57 to 64) years and 40 patients (62.5 per cent) were tertiary referrals. The initial median Acute Physiology And Chronic Health Evaluation (APACHE) II score was 9 (95 per cent c.i. 7.9 to 10.1) and there were 21 deaths (32.8 per cent). Twenty-eight patients (43.8 per cent) underwent minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) and the remainder had open pancreatic necrosectomy (OPN); 44 (72.1 per cent) of 61 patients had infected pancreatic necrosis at the time of the first procedure. Seven patients who underwent MIRP died compared with 14 after OPN (P = 0.240). Patients who died were older than those who survived, with higher APACHE II scores at presentation, and before and after surgery (P = 0.001). Survivors had significantly longer times to surgery than those who died (P = 0.038). All 21 patients who died required intensive care compared with 26 of 43 survivors (P < 0.001). Thirty of 36 patients who had the OPN procedure required intensive care compared with only 17 of 28 patients who had MIRP (P = 0.042). Logistic regression analysis showed that only postoperative APACHE II score was an independent predictor of increased mortality (P = 0.031). CONCLUSION: Advanced age and increasing APACHE II score, and a need for postoperative intensive care, were the most important predictors of outcome after pancreatic necrosectomy.

APACHE↗
PubMed1996

The effect of casemix adjustment on mortality as predicted by APACHE II.

OBJECTIVE: To describe the effect of casemix on mortality as predicted by APACHE II scoring. DESIGN: Retrospective analysis of an ICU database. PATIENTS AND PARTICIPANTS: All patients admitted to 19 ICU between 1 January 1992 and 31 May 1994 on whom data had been entered into a database. Excluded from the analysis were those readmitted to ICU, those aged under 16 years, those admitted after cardiac surgery or with burns, those for whom physiological data was incomplete and those for whom hospital outcome was unknown. Data on the remaining 6258 patients are reported. MEASUREMENTS AND RESULTS: APACHE II scores were calculated from the worst values within 24 h of ICU admission. Hospital mortality was predicted with the published equation and coefficients. Mortality ratios (observed hospital deaths divided by predicted hospital deaths) were calculated for various groups. Mortality ratios varied widely by subgroup, and observed hospital deaths were greater than predicted, particularly for the following patient groups: those with predicted mortality of less than 70%, those with APACHE II scores in the range of 5-19, those older than 55 years, those with a Glasgow Coma Score of 15 or in the range 9-14, those not having emergency surgery, those with either 0 or 4 chronic health points and those in non-operative respiratory or neurological categories. The mortality ratio was markedly less than 1.0 only among non-operative cardiovascular patients. CONCLUSIONS: APACHE II did not accurately adjust for casemix in our data. Unless account is taken of differences in casemix, using mortality ratios to compare ICU is likely to be inaccurate and misleading.

APACHE↗
PubMed1997

POSSUM and APACHE II scores do not predict the outcome of ruptured infrarenal aortic aneurysms.

Forty consecutive patients were admitted alive to the operating theater with ruptured infrarenal aoritc aneurysms in a 3-year period and were assessed preoperatively with two scoring systems: the POSSUM (physiological and operative severity score for the enumeration of mortality) and the APACHE II (acute physiologic and chronic health evaluation). The aim of the study was to investigate the capacity of the two scores to predict the patients' outcome. The operative mortality of the series was 55% (22/40). The average POSSUM score was 63.3 for survivors and 66.5 for the nonsurvivors (difference not statistically significant). APACHE II score averaged 11.3 in survivors and 14.5 in nonsurvivors (p = 0.02). APACHE II score 17 was the threshold value with the highest combined specificity and sensitivity; however, at this point the positive predictive value for a death was 92% and the negative predictive value was 63%. Interestingly, the only single factor in univariate analysis affecting mortality was the preoperative platelet count and is not taken into account in neither of the two scoring systems. POSSUM failed in predicting the outcome of ruptured infrarenal aortic aneurysms. APACHE II was a good predictor of outcome; however, its power to predict the outcome in any given individual patient was limited. As precise prediction is impossible, repair in every patient should not be denied.

APACHE↗
PubMed2002

Automatic calculation of a modified APACHE II score using a patient data management system (PDMS).

OBJECTIVE: To investigate a fully automated and modified APACHE II score calculation exclusively based on routine data supplied by patient data management system, the ICUData, and to assess the predictive performance of this score using analysis of discrimination and calibration at an operative ICU. METHOD: SQL scripts (calculation programs) were developed to calculate the scores of 524 patients who stayed at the ICU between April 1st, 1999 and March 31st, 2000. The calculation programs considered unavailable data as 'not pathological'. The main outcome measure was survival status at ICU discharge. The discriminative power on mortality of this modified APACHE II score was checked with a receiver operating characteristic (ROC) curve. Calibration was tested using the Hosmer-Lemeshow goodness-of-fit test. RESULTS: The 459 survivors had an average APACHE score of 17.8+/-5.3. The score of the 65 deceased patients averaged 22.7+/-4.6. The area under the ROC curve of 0.790 was significantly >0.5 (P<0.01) and had a 95% confidence interval (CI) of 0.712-0.825. The goodness-of-fit test showed a good calibration (H=4.89, P=0.70, dof 7, C=6.96, P=0.541, dof 8). CONCLUSION: A prediction model based on completely automatically calculated 'modified APACHE II scores' can be constructed using data collected with PDMS. However, due to differences in the patient collective and methods used, the results need validation and can only be partially compared to results from other studies.

APACHE↗
PubMed2000

Predicting in-hospital mortality in acute myocardial infarction: impact of thrombolytic therapy on APACHE II performance.

OBJECTIVE: To study the usefulness of the Second Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system for prognostication of in-hospital mortality in patients with acute myocardial infarction treated with thrombolysis. DESIGN: A prospective validation study was conducted at a medical intensive care unit at a university hospital. Over a 3-year period, 1714 patients with acute myocardial infarction were studied (mean age 72+/-10 years). Thrombolytic therapy was the prescribed treatment for 316 patients and total hospital mortality was 16%. RESULTS: The patients who received thrombolysis were younger, had higher blood pressure, lower heart and respiratory rates and higher Glasgow Coma Scale scores. Total in-hospital mortality was 9.5% in patients treated with thrombolysis and 17.1% in untreated patients (p < 0.01). Corresponding APACHE II predictions of mortality were 11.8 and 15.8% (p < 0.01). There was no significant difference between observed and predicted mortality. When a decision rule of 50% predicted risk of death was employed, sensitivity was 20% and specificity 99% in the thrombolytic group, while the corresponding figures in the nonthrombolytic group were 31% and 97%, respectively. CONCLUSIONS: In-hospital mortality in groups of patients treated with or without thrombolysis for acute myocardial infarction could be predicted with the APACHE II scoring system. Prognostication in individual patients is not possible with the APACHE II system.

APACHE↗
PubMed1996

Mortality predicted by APACHE II. The effect of changes in physiological values and post-ICU hospital mortality.

The contribution of physiological values to the APACHE II score was determined by retrospective analysis of 11348 patients undergoing intensive care. Eleven physiological variables contributed a mean of 8.9 points, 54% of the total APACHE II score. The mortality ratio (observed hospital mortality/hospital mortality predicted by APACHE II) was 1.13. We altered the APACHE II scores and post-intensive care hospital mortality in order to examine the effect on the mortality ratio of these changes. Increasing scores by two or four points decreased mortality ratios to 1.00 and 0.89 respectively: decreasing scores by two or four points to a minimum of zero increased mortality ratios to 1.27 and 1.44 respectively. A 25% increase or decrease in post-intensive care hospital mortality changed mortality ratios to 1.21 and 1.05 respectively. Physiological values vary with the timing of collection and accuracy of recording. Small consistent differences in scores cause potentially important changes in the mortality ratio. Unless data collection and the effect of management before and after intensive care are standardised, using mortality ratios to compare intensive care units is likely to be inaccurate and misleading.

APACHE↗
PubMed2003

Comparison of the rapid emergency medicine score and APACHE II in nonsurgical emergency department patients.

OBJECTIVES: To improve the Rapid Acute Physiology Score (RAPS) as a predictor of in-hospital mortality in the nonsurgical emergency department (ED) by including age and oxygen saturation, and to compare this new system, Rapid Emergency Medicine Score (REMS), with the Acute Physiology and Chronic Health Examination (APACHE II) with reference to predictive accuracy. METHODS: This was a prospective cohort study. One hundred sixty-two critically ill patients consecutively admitted to the intensive care unit (ICU) during the period of one year, and 865 nonsurgical patients presenting to an adult emergency department (ED) and admitted to a medical department of a 1200-bed university hospital during two months, were enrolled. For all entries to the ED, RAPS was calculated and developed to include noninvasive peripheral oxygen saturation and patient age (REMS), as well as laboratory tests (APACHE II). These scores were calculated for each patient. RESULTS: REMS was found to be superior to RAPS in predicting in-hospital mortality both in the critically ill patients admitted to the ICU and in the total sample (area under receiver-operating characteristic curve [AUC] 0.910 +/- 0.015 for REMS compared with 0.872 +/- 0.022 for RAPS, p < 0.001). An increase of 1 point in the 26-point REMS scale was associated with an odds ratio of 1.40 for in-hospital death (95% confidence interval = 1.36 to 1.45, p < 0.0001). The more advanced APACHE II was not found to be superior to REMS (AUC: 0.901 +/- 0.015, p = 0.218). CONCLUSIONS: RAPS could be improved as a predictor of in-hospital mortality in the nonsurgical ED by including oxygen saturation and patient age to the system. This new scoring system, REMS, had the same predictive accuracy as the well-established, but more complicated, APACHE II.

APACHE↗
PubMed2005

Machine learning can improve prediction of severity in acute pancreatitis using admission values of APACHE II score and C-reactive protein.

BACKGROUND: Acute pancreatitis (AP) has a variable course. Accurate early prediction of severity is essential to direct clinical care. Current assessment tools are inaccurate, and unable to adapt to new parameters. None of the current systems uses C-reactive protein (CRP). Modern machine-learning tools can address these issues. METHODS: 370 patients admitted with AP in a 5-year period were retrospectively assessed; after exclusions, 265 patients were studied. First recorded values for physical examination and blood tests, aetiology, severity and complications were recorded. A kernel logistic regression model was used to remove redundant features, and identify the relationships between relevant features and outcome. Bootstrapping was used to make the best use of data and obtain confidence estimates on the parameters of the model. RESULTS: A model containing 8 variables (age, CRP, respiratory rate, pO2 on air, arterial pH, serum creatinine, white cell count and GCS) predicted a severe attack with an area under the receiver-operating characteristic curve (AUC) of 0.82 (SD 0.01). The optimum cut-off value for predicting severity gave sensitivity and specificity of 0.87 and 0.71 respectively. The predictions were significantly better (p = 0.0036) than admission APACHE II scores in the same patients (AUC 0.74) and better than historical admission APACHE II data (AUC 0.68-0.75). CONCLUSIONS: This system for the first time combines admission values of selected components of APACHE II and CRP for prediction of severe AP. The score is simple to use, and is more accurate than admission APACHE II alone. It is adaptable and would allow incorporation of new predictive factors.

APACHE↗