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PubMed2002

Clinical relevance of intracellular cytokines IL-6 and IL-12 in acute pancreatitis, and correlation with APACHE III score.

Pro-inflammatory cytokines are involved in the pathogenesis of acute pancreatitis (AP). Here, we measure and correlate clinically the percentages of peripheral blood mononuclear cells (PBMC) that contain interleukin (IL)-6 and IL-12 and compare these with acute physiology and chronic health evaluation (APACHE III) scores in 30 patients with AP. Severity of AP is determined according to the Atlanta criteria. Patients with severe AP (n = 15) had significantly higher IL-6 values compared to those with mild AP (n = 15). IL-12 levels correlated well with aetiological factors (alcohol and biliary pathology) in patients with AP. Correlation was seen between IL-6 value and APACHE score in severe AP. A score of 30 points was used as the cut off between mild (<30) and severe (>30) cases, with a sensitivity of 80% and specificity of 100%. Cut off percentages for IL-6- and IL-12-positive PBMCs were >25% (positive predictive value [PPV]: 100%) and >9% (PPV: 70%), respectively. Based on these results, it would seem logical to use both APACHE III score and IL-6 percentage to assess severity in patients with AP.

APACHE↗
PubMed1996

Plasma proinflammatory cytokine concentrations, Acute Physiology and Chronic Health Evaluation (APACHE) III scores and survival in patients in an intensive care unit.

OBJECTIVE: To more clearly define the relationships between plasma proinflammatory cytokine concentrations, physiologic disturbance, and survival in severely ill patients. DESIGN: Prospective, longitudinal, cohort analytic study. SETTING: Teaching hospital intensive care unit (ICU). PATIENTS: Two hundred fifty-one consecutive nonselected patients admitted to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Daily Acute Physiology and Chronic Health Evaluation (APACHE) III scores were calculated from clinical and laboratory data. In concurrent blood samples, plasma concentrations were measured of four proinflammatory cytokines (tumor necrosis factor-[TNF] alpha, interleukin [IL]-1 beta, IL-6, and IL-8), all of which are believed to be of central importance in host proinflammatory and immune responses. Plasma TNF concentrations were increased in 42 patients, plasma IL-1 beta in 15 patients, IL-6 in 194 patients, and IL-8 in 52 patients at presentation. Although admission plasma IL-1 beta, IL-6, and IL-8 concentrations were higher in patients who died in the ICU compared with survivors (n = 33; p < .02, p < .01, p < .02, respectively), only admission plasma IL-8 concentrations were higher in patients with a fatal outcome if all in-hospital deaths were considered (n = 53; p = .05). APACHE III score was the best predictor of mortality (odds ratio 11.41; p = .003). Detection, but not the absolute level, of TNF bioactivity in plasma was a weak independent predictor of death (odds ratio 3.17; p = .02). There was no relationship between bacteremia or presence of the systemic inflammatory response syndrome and plasma cytokine concentrations. Nineteen patients were in the ICU for > or = 10 days, and of these 19 patients, 16 patients had prolonged increases of plasma cytokines. Two patients with persistently increased plasma TNF concentrations died. Otherwise, persistently increased plasma cytokine concentrations had a variable relation to daily APACHE scores and to mortality. CONCLUSIONS: Plasma cytokine concentrations fluctuate in serious illness and have a poor correlation with derangement of whole body physiology in seriously ill patients. Only the presence of bioactive TNF in plasma was an independent predictor of mortality. Daily measurement of plasma proinflammatory cytokine concentrations is unlikely to have clinical application in the ICU setting, except possibly in specific subgroups of patients.

APACHE↗
PubMed2001

[Severity assessment by APACHE III system in Spain].

BACKGROUND: To assess the performance of the prediction equation of the APACHE(Acute Physiology Age and Chronic Health Evaluation) III prognostic scoring system when applied in Spain. PATIENTS AND METHOD: Prospective multicenter cohort study that included 10786 adult patients from 86 Spanish intensive care units (ICU). Data collection during first 24 hours of admission: acute physiology score, age and comorbilties,for calculating APACHE III score; treatment location prior to ICU admission and main diagnosis admission category for applying the mortality prediction equation of APACHE III system. Main outcome was observed hospital mortality. RESULTS: Age was 57.74 (0.16); 68% males. Non-operative patients represented 76% of sample. APACHE III score was 53.75(0.26); observed and predicted hospital mortality were 21.2% and 19.8% respectively, with a standardized mortality ration of 1.07. The Chi2 Hosmer-Lemershow statistic was (H) 135.6, (C) 133.91: p < 0.001. The area under the Receiver Operating Curve (ROC) was 0.808, and correct classification at mortality risk of 50% was 82%. Uniformity of fit was better for non-operative diagnoses and for patients admitted from the emergency area. Calibration was excellent for risk lower than 60% but slightly underestimated observed risks above this level. CONCLUSIONS: The American APACHE III equation fit well when applied to Spanish critical patients but with limitations. Discrepancies could be attributed to differences in case-mix and variations in practice style.

APACHE↗
PubMed2005

[APACHE II, APACHE III, SOFA scoring systems, platelet counts and mortality in septic and nonseptic patients].

BACKGROUND: The aim of the current prospective study was to examine the prognostic value of APACHE II, APACHE III (Acute Physiology and Chronic Health Evakuation II and III) and SOFA (Sepsis-related Organ Failure Assessment) scores and platelet counts in septic and nonseptic patients hospitalized and treated in ICU units. METHODS: One hundred and twenty ICU patients were included in this study. Patients were grouped as septic survivors, septic nonsurvivors, nonseptic survivors and nonseptic nonsurvivors. The SOFA, APACHE II and III scores, and platelet counts were recorded at the admission in the ICU units and discharge.from the hospital. RESULTS: Patients were grouped as septic survivors (n=42), septic nonsurvivors (n=14), nonseptic survivors (n=48) and nonseptic nonsurvivors (n=16). The highest SOFA, APACHE II and III scores and the lowest platelet counts were observed in septic nonsurvivors when compared with the other patient groups. All score values and platelet counts were found to be significant in prediction of mortality in septic patients. CONCLUSIONS: According to our results obtained in septic and non-septic patients, we concluded that SOFA, APACHE II and III scores and platelet counts might be used in the prediction of mortality in septic patients.

APACHE↗
PubMed2002

Comparison of Ranson, APACHE II and APACHE III scoring systems in acute pancreatitis.

INTRODUCTION: Acute pancreatitis runs an unpredictable course. The early prediction of the severity of an acute attack has important implications for management and timely intervention. AIM: To assess the prognostic accuracy of Ranson and APACHE II and III scoring systems in predicting the severity of acute pancreatitis. METHODS: One hundred fifty-three patients with acute pancreatitis (67.3% gallstone-related, 9.2% alcoholic, 17% idiopathic, and 6.5% of miscellaneous causes) were studied prospectively. Data conforming to the scoring systems were recorded 24 (the APACHE scores) and 48 hours (the Ranson score) after admission. Analysis was performed by using receiver operating characteristic curves (ROC), area under a curve (AUC), and by comparing likelihood ratios of positive test (LRPT). RESULTS: One hundred nineteen cases of pancreatitis were classified as mild, and 34 were classified as severe. The mortality rate was 3.2%. All three scores correlated with length of stay and disease severity. AUC for Ranson was found to be significantly larger than AUC for APACHE II and APACHE III score (0.817, cut-off > or =3; 0.618, cut-off, > or =10; and 0,676, cut-off > or =42 respectively). The Ranson score achieved the highest sensitivity and the lowest false-negative rate, but the positive and negative predictive values and LRPT were of similar extent for all three scores. CONCLUSION: The APACHE III offers little, if any, advantage over the APACHE II score. Ranson criteria proved to be as powerful a prognostic model as the more complicated APACHE II and III scoring systems, but with the disadvantage of a 24-hour delay.

APACHE↗
PubMed2005

The influence of missing components of the Acute Physiology Score of APACHE III on the measurement of ICU performance.

OBJECTIVE: To determine the impact of missing Acute Physiology Score (APS) values on risk-adjusted mortality. DESIGN: Retrospective review of prospectively collected Acute Physiology and Chronic Health Evaluation (APACHE) III database. SETTING: The intensive care units (ICUs) of an academic medical center. PATIENTS: 38,411 patients admitted to ICU between October 1994 and December 2003. MEASUREMENTS AND RESULTS: Data were collected on ICU type, missing first ICU day APS values, predicted and observed hospital mortality, standardized mortality ratio (SMR), 95% confidence interval (CI), odds ratio (OR). The overall observed and predicted hospital mortality rates were 8.7% and 10.8%, respectively, with SMR of 0.806 (95% CI 0.779-0.834). Complete data were available in 829 (2.2%). Vital signs were missing in almost none and serum albumin and bilirubin in over 80% of the patients. The number of missing variables was higher in less sick and surgical ICU patients. Logistic regression analysis showed that the risk of dying in the hospital was significantly associated with the number of missing APS variables (OR 1.058, 95% CI 1.027-1.090) when adjusted for the severity of illness. The risk of death was also associated with the type of missing variables. CONCLUSIONS: Since missing APS values may lead to underestimation of the predicted mortality rates, the number and type of missing variables should be taken into consideration when assessing the performance of an ICU. Unless data collection is standardized, future prognostic models should use variables that are routinely measured in most critically ill patients without sacrificing statistical precision.

APACHE↗
PubMed2003

A comparison of Child-Pugh, APACHE II and APACHE III scoring systems in predicting hospital mortality of patients with liver cirrhosis.

BACKGROUND: The aim of this study was to assess the prognostic accuracy of Child-Pugh and APACHE II and III scoring systems in predicting short-term, hospital mortality of patients with liver cirrhosis. METHODS: 200 admissions of 147 cirrhotic patients (44% viral-associated liver cirrhosis, 33% alcoholic, 18.5% cryptogenic, 4.5% both viral and alcoholic) were studied prospectively. Clinical and laboratory data conforming to the Child-Pugh, APACHE II and III scores were recorded on day 1 for all patients. Discrimination was evaluated using receiver operating characteristic (ROC) curves and area under a ROC curve (AUC). Calibration was estimated using the Hosmer-Lemeshow goodness-of-fit test. RESULTS: Overall mortality was 11.5%. The mean Child-Pugh, APACHE II and III scores for survivors were found to be significantly lower than those of nonsurvivors. Discrimination was excellent for Child-Pugh (ROC AUC: 0.859) and APACHE III (ROC AUC: 0.816) scores, and acceptable for APACHE II score (ROC AUC: 0.759). Although the Hosmer-Lemeshow statistic revealed adequate goodness-of-fit for Child-Pugh score (P = 0.192), this was not the case for APACHE II and III scores (P = 0.004 and 0.003 respectively) CONCLUSION: Our results indicate that, of the three models, Child-Pugh score had the least statistically significant discrepancy between predicted and observed mortality across the strata of increasing predicting mortality. This supports the hypothesis that APACHE scores do not work accurately outside ICU settings.

APACHE↗
PubMed2002

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

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

Acute Disease↗
PubMed2003

External validation of the SAPS II, APACHE II and APACHE III prognostic models in South England: a multicentre study.

OBJECTIVE: External validation of three prognostic models in adult intensive care patients in South England. DESIGN. Prospective cohort study. SETTING: Seventeen intensive care units (ICU) in the South West Thames Region in South England. PATIENTS AND PARTICIPANTS: Data of 16646 patients were analysed. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We compared directly the predictive accuracy of three prognostic models (SAPS II, APACHE II and III), using formal tests of calibration and discrimination. The external validation showed a similar pattern for all three models tested: good discrimination, but imperfect calibration. The areas under the receiver operating characteristics (ROC) curves, used to test discrimination, were 0.835 and 0.867 for APACHE II and III, and 0.852 for the SAPS II model. Model calibration was assessed by Lemeshow-Hosmer C-statistics and was Chi(2 )=232.1 for APACHE II, Chi(2 )=443.3 for APACHE III and Chi(2 )=287.5 for SAPS II. CONCLUSIONS: Disparity in case mix, a higher prevalence of outcome events and important unmeasured patient mix factors are possible sources for the decay of the models' predictive accuracy in our population. The lack of generalisability of standard prognostic models requires their validation and re-calibration before they can be applied with confidence to new populations. Customisation of existing models may become an important strategy to obtain authentic information on disease severity, which is a prerequisite for reliably measuring and comparing the quality and cost of intensive care.

APACHE↗
PubMed2006

Prospective cohort study comparing sequential organ failure assessment and acute physiology, age, chronic health evaluation III scoring systems for hospital mortality prediction in critically ill cirrhotic patients.

The aim of the study was to evaluate the usefulness of sequential organ failure assessment (SOFA) and acute physiology, age, chronic health evaluation III (APACHE III) scoring systems obtained on the first day of intensive care unit (ICU) admission in predicting hospital mortality in critically ill cirrhotic patients. The study enrolled 102 cirrhotic patients consecutively admitted to ICU during a 1-year period. Twenty-five demographic, clinical and laboratory variables were analysed as predicators of survival. Information considered necessary to calculate the Child-Pugh, SOFA and APACHE III scores on the first day of ICU admission was also gathered. Overall hospital mortality was 68.6%. Multiple logistic regression analysis revealed that mean arterial pressure, SOFA and APACHE III scores were significantly related to prognosis. Goodness-of-fit was good for the SOFA and APACHE III models. Both predictive models displayed a similar degree of the best Youden index (0.68) and overall correctness (84%) of prediction. The SOFA and APACHE III models displayed good areas under the receiver-operating characteristic curve (0.917 +/- 0.028 and 0.912 +/- 0.029, respectively). Finally, a strong and significant positive correlation exists between SOFA and APACHE III scores for individual patients (r(2) = 0.628, p < 0.001). This investigation confirms the grave prognosis for cirrhotic patients admitted to ICU. Both SOFA and APACHE III scores are excellent tools to predict the hospital mortality in critically ill cirrhotic patients. The overall predictive accuracy of SOFA and APACHE III is superior to that of Child-Pugh system. The role of these scoring systems in describing the dynamic aspects of clinical courses and allocating ICU resources needs to be clarified.

APACHE↗
PubMed2006

[Use of acute physiology and chronic health evaluation III in evaluating prognosis of chronic obstructive pulmonary disease in elderly patients on mechanical ventilation].

OBJECTIVE: To investigate the feasibility of estimating risk of prognosis and hospital mortality in elderly patients (> or =60 years old) with chronic obstructive pulmonary disease (COPD) under the treatment of mechanical ventilation by using acute physiology and chronic health evaluation III (APACHE III). METHODS: Fifty elderly patients with COPD treated with mechanical ventilation were analyzed retrospectively. A risk estimation equation for hospital mortality was first developed by using APACHE III in evaluating 40 randomly-selected patients before mechanical ventilation. Changes in APACHE III on the 1 st, 3 rd and 7 th day for each patient after intubation were recorded and analyzed. RESULTS: The risk estimate equation for hospital mortality was developed as p=Apa(gamma)/(D(gamma)(50)+Apa(gamma)), D(50)=73.4, gamma=8 with 80% prediction accuracy. A statistical significant cutoff was developed by dynamically recording acute physiology scores after intubation, and a decrease of 32.8% or more (compared with APACHE III before intubation) of APACHE III on the 3 rd day predicted survival of the patient. CONCLUSION: APACHE III score and its dynamic change could be an ideal tool to predict risk for hospital mortality in elderly patients with COPD on mechanical ventilation.

APACHE↗
PubMed2004

[Comparison between tow methods of acute physiology and chronic health evaluation III and acute lung injury scale to evaluate the severity and prognosis of severe acute respiratory syndrome].

OBJECTIVE: To evaluate the acute physiology and chronic health evaluation III (APACHE III) and acute lung injury (ALI) scale in the severity and prognosis of severe acute respiratory syndrome (SARS). METHODS: The clinical data of 38 SARS patients, including survivors (24 cases) and no survivors (14 cases) were collected and evaluated with APACHE III and ALI scoring systems. The correlation of scores and prognosis was evaluated. RESULTS: The scores of APACHE III in the non survivors were higher remarkably than those in the survivor group (P < 0.001). The scores of APACHE III had positive correlation with the overall fatality rate. When the scores of APACHE III was higher than 60, the mortality increased obviously (chi(2) = 3.886, P < 0.05). Elderly patients with SARS who were over 60 years old had a high mortality (chi(2) = 8.660, P < 0.05). The scores of ALI in the non survivors had not statistical significance than those in the survivor group (P = 0.127). CONCLUSIONS: The score of APACHE III in the SARS are correlated with the patient's condition and prognosis. Elderly patients with SARS have a high mortality.

APACHE↗
PubMed2000

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

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

APACHE↗
PubMed1996

The importance of technology for achieving superior outcomes from intensive care. Brazil APACHE III Study Group.

OBJECTIVE: To test the hypothesis that technology availability, staffing, and diagnostic diversity in an intensive care unit (ICU) are associated with the ability to decrease hospital mortality. DESIGN: Prospective multicenter descriptive cohort study. SETTING: Ten Brazilian medical-surgical ICUs. PATIENTS: 1734 consecutive adult ICU admissions. MEASUREMENTS AND RESULTS: We recorded the amount of technology, number of diagnoses, and availability of nurses at each ICU. We also used demographic, clinical and physiologic information for an average of 173 admissions to each ICU to calculate standardized mortality ratios (SMRs) for each ICU. The mean SMR for the ten ICUs was 1.67 (range 1.01-2.30). A greater availability of ICU equipment and services was significantly (p < 0.001) associated with a lower SMR. CONCLUSION: The ability of Brazilian ICUs to reduce hospital mortality is associated with the amount of technology available in these units.

Adult↗