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PubMed2004

Outcome of patients with end-stage renal disease admitted to the intensive care unit.

OBJECTIVES: To describe the clinical course of patients with end-stage renal disease (ESRD) admitted to the intensive care unit (ICU) and to compare the performance of Acute Physiology and Chronic Health Evaluation (APACHE) III and Sequential Organ Failure Assessment (SOFA) in predicting their outcome. PATIENTS AND METHODS: This retrospective cohort study consisted of patients with ESRD admitted to 3 ICUs between January 1, 1997, and November 30, 2002. Data on demographics, APACHE III score, SOFA score, development of sepsis and organ failure, use of mechanical ventilation, and mortality were collected. RESULTS: Of the 476 patients with ESRD who underwent dialysis during the study period, 93 (20%) required admission to the ICU. The most common ICU admission diagnosis was gastrointestinal bleeding. The first day median (Interquartile range) APACHE III score, SOFA score, and APACHE III predicted hospital mortality rate were 64 (47-79), 6 (5-8), and 12.9% (4.2%-30.8%), respectively. The observed ICU, hospital, and 30-day mortality rates were 9%, 16%, and 22%, respectively. Nonrenal organ failure developed in 48 patients (52%) and sepsis in 15 patients (16%). Mechanical ventilation was required In 26 patients (28%). The area under the receiver operating characteristic curve for the first-day APACHE III probability of hospital death in predicting 30-day mortality was 0.78 (95% confidence interval, 0.68-0.86) compared with 0.66 (95% confidence interval, 0.55-0.76) for the SOFA score (P = .16). CONCLUSIONS: The observed hospital mortality of patients with ESRD admitted to the ICU is relatively low. There is no statistically significant difference in the performance of APACHE III and SOFA prognostic models in discriminating between 30-day survivors and nonsurvivors.

APACHE↗

PubMed1995

Difficulties in predicting outcome in cardiac surgery patients.

OBJECTIVE: To evaluate a novel combination of preoperative, intraoperative, and postoperative variables (including the Parsonnet, and the Acute Physiology and Chronic Health Evaluation II and III [APACHE II and III] scores) in cardiac surgery patients in order to predict hospital outcome, complications, and length of stay. DESIGN: Prospective survey. SETTING: Adult intensive care unit (ICU) at a tertiary care cardiothoracic surgery center. PATIENTS: All cardiac surgery patients admitted to the ICU over a 1-yr period. INTERVENTIONS: Medical history, Parsonnet score, intraoperative data (including bypass and ischemic times), APACHE II and III scores, complications, and outcome were collected for each patient. MEASUREMENTS AND MAIN RESULTS: One thousand eight patients were entered into the study. The mean Parsonnet score was 7.8 (range 0 to 33), mean APACHE II score 11.8 (range 2 to 33), and mean APACHE III score 42.5 (range 9 to 132). ICU mortality rate was 2.7% and hospital mortality rate was 3.8%. The mean APACHE II predicted risk of dying was 5.31%, which gave a standardized mortality ratio of 0.71. The above scores were all statistically well correlated with hospital mortality. Further, a logistic regression model was developed for the probability of hospital death. This model (which included bypass time, need for inotropes, mean arterial pressure, urea, and Glasgow Coma Scale) had an area under the receiver operating characteristic curve of 0.87, while the Parsonnet score had an area of 0.82 and the APACHE II risk of dying had an area of 0.84. CONCLUSIONS: Cardiac surgery remains a difficult area for outcome prediction. A combination of intraoperative and postoperative variables can improve predictive ability.

APACHE↗

PubMed1996

Utility of illness severity scoring for prediction of prolonged surgical critical care.

OBJECTIVE: To determine whether APACHE III and multiple organ dysfunction syndrome scores can predict a prolonged length of stay for critically ill surgical patients in the intensive care unit. DESIGN: Prospective, inception-cohort study. SETTING: Surgical intensive care unit (SICU) of an urban, tertiary care hospital. PATIENTS: 2,295 consecutive admissions for critical surgical illness, postoperative complications, or postoperative monitoring in 2,058 patients. INTERVENTIONS: Calculation of Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scores 24 hours after admission to the SICU. Serial quantitation of organ dysfunction for the duration of hospitalization according to the multiple organ dysfunction score. Patients were stratified by survival and time intervals for the duration of critical care, and followed until discharge or death. MAIN OUTCOME MEASURES: Hospital mortality and length of stay in the SICU. RESULTS: The mean APACHE II and APACHE III scores were 14.0 +/- 0.2 and 45.2 +/- 0.6 points, respectively (mean +/- SEM). The incidence of organ dysfunction was 43%, and the hospital mortality was 9.7%. The mean ICU length of stay was 6.1 +/- 0.2 days, but decreased progressively from 6.8 +/- 0.5 days in 1991 to 5.3 +/- 0.6 days in 1995 (p < 0.01) with no change in either illness severity or the number of admissions. By univariate analysis, increased length of stay in the ICU was associated with increasing APACHE scores, an increased incidence of emergency admissions, and the incidence and magnitude of organ dysfunction (all p < 0.01). Severity indices appeared to plateau in magnitude in patients whose ICU stay ultimately exceeded 21 days. By multivariate analysis of variance (MANOVA), independent predictors of a prolonged stay in the SICU were APACHE III (p = 0.0023), emergency admission (p = 0.0007), and the magnitude of organ dysfunction (p < 0.00001), but not APACHE II. Only an emergency admission (p = 0.0005) and the magnitude of organ dysfunction (p < 0.00001) predicted a prolonged stay independently in survivors. In contrast, only the admission APACHE III score(p = < 0.0001) and the magnitude of organ dysfunction (p = 0.0001) were independently predictive of mortality by MANOVA. CONCLUSIONS: The development of multiple organ dysfunction syndrome is a powerful predictor of a prolonged ICU course in critical surgical illness, even in survivors. Increased risk of a prolonged stay in the ICU plateaued at 21 days, making 21 days an appropriate definition of prolonged care for future studies. Predictive models should account for organ dysfunction and very long stays in future estimations. The combined use of APACHE III and the multiple organ dysfunction score may provide improved prediction of a prolonged stay in the ICU, but further enhancements are needed before prediction of outcome in individual patients is reliable.

APACHE↗

PubMed1996

Intensive care management of acute pancreatitis: recognition of patients at high risk of developing severe or fatal complications.

The clinical spectrum of acute pancreatitis ranges from mild, self-limiting disease of fulminant illness that may rapidly lead to multiple organ failure and death. To identify factors associated with a subsequent severe course and/or high mortality we investigated retrospectively 91 patients admitted to the medical intensive care unit (ICU) with acute pancreatitis during a 2 year period. 67% of the attacks were mild (< or = 1 complication). The overall mortality rate was 9%, whereby 3% of patients with alcoholic and 13% with biliary pancreatitis died. 75% of the patients in the group with a fatal outcome were aged over sixty and 30% in the group with a mild course (p < 0.05). Females with pancreatitis of biliary origin had a mild course in 57% and a severe (> or = 2 complications) or fatal outcome in 43%. In males with alcohol abuse we observed a mild form of pancreatitis in 79% and a severe or fatal course in 21%. The delay between onset of abdominal pain and commencement of treatment in hospital was greater than 12 hours in 70% of all patients studied and there was no association with severity and development of subsequent complications. The median of the acute physiology and chronic health evaluation scoring system (APACHE-III) on the day of admission was 19 in patients with mild disease, which was significantly lower than in patients with severe (40) or fatal acute pancreatitis (53) (p < 0.0001). Serial APACHE-III measurements over 5 days after admission provided further differentiation between mild and severe or fatal cases (p < 0.0001), but no significant difference was observed between survivors with severe course and fatal outcome. In addition, RANSON scores were calculated for comparison with APACHE-III at admission and after 48 hours: concerning the recognition between mild and severe/fatal pancreatitis both scoring systems exhibited similar significant differences on day 1 and day 2. The RANSON scoring system provided further a significant differentiation between survivors with a severe course of pancreatitis when compared to deaths on day 2, whereas the APACHE-III scoring system did not. Advanced age, female sex, biliary obstruction and elevated RANSON and APACHE-III scores are risk factors for an increased rate of life-threatening complications in acute pancreatitis. The daily assessment of such scoring systems may allow the recognition of such patients and may be helpful in the routine clinical management and monitoring of acute pancreatitis.

APACHE↗

PubMed2005

Predicting outcome in aged and severely ill patients with prolonged respiratory failure.

OBJECTIVES: Consultations for tracheotomy are often sought on aged and severely ill patients with respiratory insufficiency. This patient population has high short-term mortality rates and is difficult to stratify on the basis of expected outcome. We examined whether APACHE III (Acute Physiology and Chronic Health Evaluation III) scores or neurologic status assessment (NSA) scores in sedated individuals are predictive of outcome. METHODS: We performed a retrospective study examining aged patients who underwent tracheotomy for respiratory insufficiency and prolonged intubation. The APACHE III scores (n = 30) and NSA (based on a modified Glasgow Coma Scale) scores (n = 37) were calculated before tracheotomy. All patients were mildly sedated. Using APACHE III and NSA scores as predictor variables and using death and ability to be weaned from the ventilator as outcome variables, we performed a Kaplan-Meier survival analysis and a Cox proportional hazard regression. RESULTS: The APACHE III was not significantly predictive of either outcome. Higher NSA scores were associated with increased survival rates (log rank = 19.7, p < .0001) and longer median survival (88 days versus 16 days for lower scorers). Higher NSA scores also predicted a higher rate of ventilator independence. CONCLUSIONS: Neurologic function in sedated patients (and not APACHE III scores) can be used to stratify aged individuals with respiratory insufficiency on the basis of expected outcome.

Aged↗

PubMed2003

Outcome prediction in terms of functional disability and mortality at 1 year among ICU-admitted severe stroke patients: a prospective epidemiological study in the south of the European Union (Evascan Project, Andalusia, Spain).

OBJECTIVES: To analyse 1-year mortality and functional disability outcomes and resource use in critical stroke patients admitted to ICU. DESIGN AND SETTING: Multi-centre, prospective, observational study in 28 Spanish hospitals. PATIENTS. Patients admitted for acute stroke from March-August 1999. INTERVENTION: Collection of data on: severity by Apache III and Glasgow Coma Score; neurological lesion, hospital and 1-year mortality; functional disability at 1 year by Barthel Index and Glasgow Outcome Scale; ICU length of stay, life support techniques, and neurosurgical interventions. MEASUREMENT AND RESULTS: We studied 132 patients: 21% with subarachnoid haemorrhage (SAH), 58% intracerebral haemorrhage (ICH), 20% ischaemic stroke (ISC); Apache III 63+/-29 ICU stay 13+/-12 days; 74% required mechanical ventilation. Hospital and 1-year mortality was 33% (22%:ISC, 32%:SAH, 37%:ICH) and 53.8% (66%:ISC, 39%:SAH, 54%:ICH), respectively. Age, APACHE III, and diagnosis defined hospital mortality. Age, APACHE III, and Glasgow Coma Score defined 1-year mortality. Barthel Index score improved ( P<0.001) between discharge and 1 year; 73% of patients presented severe disability at discharge vs. 26% at 1 year; 8% minimal/no disability at discharge vs. 43.3% at 1 year. Only 17% of subarachnoid haemorrhage patients presented severe disability at 1 year. Admission Apache III and hospital-discharge Barthel Index scores were related to functional outcome at 1 year. CONCLUSIONS: Critical stroke patients are characterized by high severity of illness, elevated resource consumption, and poor outcomes that are mainly influenced by severity and age. Glasgow Coma Score-measured neurological severity is the main determinant of future functional capacity, which is greater at 1 year.

Aged↗

PubMed2000

Outcome and prognostic factors in critically ill cancer patients admitted to the intensive care unit.

OBJECTIVE: To assess survival in cancer patients admitted to an intensive care unit (ICU) with respect to the nature of malignancy, cause of ICU admittance, and course during ICU stay as well as to evaluate the prognostic value of the Acute Physiology and Chronic Health Evaluation (APACHE) III score. DESIGN: Retrospective cohort study. SETTING: ICU at a university cancer referral center. PATIENTS: A total of 414 cancer patients admitted to the ICU during a period of 66 months. INTERVENTIONS: None. MEASUREMENTS: Charts of the patients were analyzed with respect to underlying disease, cause of admission, APACHE III score, need and duration of mechanical ventilation, neutropenia and development of septic shock, as well as ICU survival and survival after discharge. Mortality data were compared with two control groups: 1362 patients admitted to our ICU suffering from diseases other than cancer and 2,776 cancer patients not admitted to the ICU. MAIN RESULTS: ICU survival was 53%, and 1-yr survival was 23%. The 1-yr mortality rate was significantly lower in both control groups. Patients admitted after bone marrow transplantation had the highest mortality. In a multivariate analysis, prognosis was negatively influenced by respiratory insufficiency, the need of mechanical ventilation, and development of septic shock during the ICU stay. Admission after cardiopulmonary resuscitation yielded high ICU mortality but a relatively good long-term prognosis. Admission after surgery and as a result of acute hemorrhage was associated with a good prognosis. Age, neutropenia, and underlying disease did not influence outcome significantly. Admission APACHE III scores were significantly higher in nonsurvivors but failed to predict individual outcome satisfactorily. All patients with APACHE III scores of >80 died at the ICU. CONCLUSION: A combination of factors must be taken into account to estimate a critically ill cancer patient's prognosis in the ICU. The APACHE III scoring system alone should not be used to make decisions about therapy prolongation. Admission to the ICU worsens the prognosis of a cancer patient substantially; however, as ICU mortality is 47%, comparable with severely ill noncancer patients, general reluctance to admit cancer patients to an ICU does not seem to be justified.

APACHE↗

PubMed1995

A comparison of severity of illness scoring systems for intensive care unit patients: results of a multicenter, multinational study. The European/North American Severity Study Group.

OBJECTIVE: To compare the performance of three severity of illness scoring systems used commonly for intensive care unit (ICU) patients in a large international data set. The systems analyzed were versions II and III of the Acute Physiology and Chronic Health Evaluation (APACHE) system, versions I and II of the Simplified Acute Physiology Score (SAPS), and versions I and II of the Mortality Probability Model (MPM), computed at admission and after 24 hrs in the ICU. DESIGN: A multicenter, multinational cohort study. SETTING: One hundred thirty-seven ICUs in 12 European and North American countries. PATIENTS: During a 3-month period, 14,745 patients were consecutively admitted to 137 ICUs enrolled in the study. INTERVENTIONS: Collection of information necessary to compute the APACHE II and APACHE III scores, SAPS I and SAPS II, and MPM I and MPM II scores. Patients were followed until hospital discharges. Statistical comparison, including indices of calibration (goodness-of-fit) and discrimination (area under the receiver operating characteristic curve). MEASUREMENTS AND MAIN RESULTS: Despite having acceptable receiver operating characteristic areas, the older versions of the systems analyzed (APACHE II, SAPS, and MPM I computed at admission-MPM I computed after 24 hrs in the ICU) demonstrated poor calibration for the whole database. The new versions of the systems (SAPS II and MPM II) were superior to their older counterparts. This superiority is reflected by larger receiver operating characteristic areas and better fit. The APACHE III system improved its receiver operating characteristic area compared with the APACHE II system, which showed the best fit of the old systems analyzed. CONCLUSIONS: The new versions of the severity systems analyzed (APACHE III, SAPS II, MPM II) perform better than their older counterparts (APACHE II, SAPS I, and MPM I). APACHE II, SAPS II, and MPM II show good discrimination and calibration in this international database.

APACHE↗

PubMed2000

Acute respiratory distress syndrome in trauma patients: ICU mortality and prediction factors.

OBJECTIVES: To study the factors that influence the intensive care unit (ICU) mortality of trauma patients who develop acute respiratory distress syndrome (ARDS) and to evaluate determinants of length of ICU stay among these patients. DESIGN: Study on a prospective cohort of 59 trauma patients that developed ARDS. SETTING: ICU of a referral trauma center. Fifty-nine patients were included during the study period from 1994 to 1997. METHODS: The dependent variables studied were the mortality and length of ICU stay. The main independent variables studied included the general severity score APACHE III, the revised trauma and injury severity scores (RTS, ISS), emergency treatment measures, the gas exchange index (PaO2/FIO2) recorded after the onset of ARDS and the development of multiple system organ failure (MSOF). Univariate and multivariate analyses were performed. RESULTS: The mean age of patients was 42.1 +/- 16.7 years, 49 patients (83 %) were male, the mean APACHE III score was 52.7 +/- 33.7 points, the ISS 28.5 +/- 11.4 points and the RTS 8.9 +/- 2.5 points. ICU length of stay was 28.5 +/- 24.5 days and the mortality rate 31.7 % (19 deaths). Mortality was associated with the following: PaO2/FIO2 ratio on the 3rd, 5th and 7th days post-ARDS; high volume of crystalloid/colloid infusion during resuscitation; the APACHE III score; and the development of MSOF According to the multivariate analysis, the mortality of these patients was correlated with the PaO2/FIO2 ratio on the 3rd day of ARDS, the APACHE III score and the development of MSOF. This analysis also showed days on mechanical ventilation to be the only variable that predicted ICU length of stay. CONCLUSIONS: The ICU mortality of trauma patients with ARDS is related to the APACHE III score, the gas exchange evolution as measured by the PaO2/FIO2 on the 3rd day and the progressive complications indicated by the onset of MSOF. The length of ICU stay of these patients is related to the number of days on mechanical ventilation.

Adult↗

PubMed1998

Evaluation of acute physiology and chronic health evaluation III predictions of hospital mortality in an independent database.

OBJECTIVE: To assess the accuracy and validity of Acute Physiology and Chronic Health Evaluation (APACHE) III hospital mortality predictions in an independent sample of U.S. intensive care unit (ICU) admissions. DESIGN: Nonrandomized, observational, cohort study. SETTING: Two hundred eighty-five ICUs in 161 U.S. hospitals, including 65 members of the Council of Teaching Hospitals and 64 nonteaching hospitals. PATIENTS: A consecutive sample of 37,668 ICU admissions during 1993 to 1996; including 25,448 admissions at hospitals with >400 beds and 1,074 admissions at hospitals with <200 beds. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used demographic, clinical, and physiologic information recorded during ICU day 1 and the APACHE III equation to predict the probability of hospital mortality for each patient. We compared observed and predicted mortality for all admissions and across patient subgroups and assessed predictive accuracy using tests of discrimination and calibration. Aggregate hospital death rate was 12.35% and predicted hospital death rate was 12.27% (p =.541). The model discriminated between survivors and nonsurvivors well (area under receiver operating curve = 0.89). A calibration curve showed that the observed number of hospital deaths was close to the number of deaths predicted by the model, but when tested across deciles of risk, goodness-of-fit (Hosmer-Lemeshow statistic, chi-square = 48.71, 8 degrees of freedom, p< .0001) was not perfect. Observed and predicted hospital mortality rates were not significantly (p < .01) different for 55 (84.6%) of APACHE III's 65 specific ICU admission diagnoses and for 11 (84.6%) of the 13 residual organ system-related categories. The most frequent diagnoses with significant (p < .01) differences between observed and predicted hospital mortality rates included acute myocardial infarction, drug overdose, nonoperative head trauma, and nonoperative multiple trauma. CONCLUSIONS: APACHE III accurately predicted aggregate hospital mortality in an independent sample of U.S. ICU admissions. Further improvements in calibration can be achieved by more precise disease labeling, improved acquisition and weighting of neurologic abnormalities, adjustments that reflect changes in treatment outcomes over time, and a larger national database.

APACHE↗

PubMed2001

Quality of life before intensive care unit admission and its influence on resource utilization and mortality rate.

OBJECTIVE: To analyze the quality of life of critically ill patients before their intensive care admission and its relation to age, variables measured in the intensive care unit (ICU; severity of illness, therapeutic effort, resource utilization, and length of stay), and in-hospital mortality rate. DESIGN: Observational prospective multicenter study. SETTING: Eighty-six medical-surgical ICUs in Spain, including coronary patients. PATIENTS: We studied 8,685 patients between 1992 and 1993. Patients <16 yrs old and those dying within the first 6 hrs were excluded. MEASUREMENTS AND MAIN RESULTS: Data collection included age, gender, admission diagnosis, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) III, quality of life survey score, therapeutic activity level by Therapeutic Intervention Scoring System (TISS), and ICU and hospital mortality rate. Pre-ICU quality-of-life score was 3.74 +/- 4.42 points; 33.24% of patients had a normal quality of life (0 points), and numbers of patients declined logarithmically in relationship to increasing quality-of-life scores, with only 189 patients having a score >15 points. Pre-ICU quality-of-life score correlated with age (r =.289, p <.001), with severity level by APACHE III score (r =.217, p <.001), and weakly with TISS (r =.067, p <.001). There was no correlation between quality of life and length of ICU stay. Patients dying in hospital after ICU discharge (n = 429) had worse quality of life (5.88 +/- 5.38 points) than those dying in the ICU (n = 1,453, 4.8 +/- 4.94), who themselves had a worse quality of life than hospital survivors (n = 6,803, 5.05 +/- 5.07; p <.0001 by analysis of variance), with significant differences between all three groups. In the multivariate analysis, pre-ICU quality-of-life was related to age, APACHE III score, and hospital mortality rate but not to TISS or ICU length of stay. Pre-ICU quality of life was introduced as a variable in the APACHE III prediction model and entered the model after acute physiology score, diagnosis, and age and before prior patient location and comorbidities. The area under the receiver operating characteristics curve was 0.834 when quality-of-life was included and 0.83 when not. CONCLUSIONS: In Spain, the quality of life of critically ill patients before their ICU admission is good, and only a small proportion of patients have a low quality of life before admission. Previous quality of life is related to hospital mortality rate but contributes very little to the discriminatory ability of the APACHE III prediction model and has little influence on ICU resource utilization as measured by length of stay and therapeutic activity.

APACHE↗

PubMed2004

Continuous venovenous hemodiafiltration versus hemodialysis as renal replacement therapy in patients with acute renal failure in the intensive care unit.

OBJECTIVE: Hemodialysis (HD) and continuous venovenous hemodiafiltration (CVVHDF) have been adopted as forms of renal replacement therapy (RRT) in patients with acute renal failure (ARF). Although CVVHDF has many advantages, previous studies reported no definite improvement in survival rate compared to HD. MATERIAL AND METHODS: In this retrospective study, 148 intensive care unit patients underwent HD (70 males, 25 females; mean age 45 +/- 17 years) or CVVHDF (42 males, 11 females; mean age 52 +/- 18 years). The severity of illness was estimated at the initiation of RRT and on the third day of RRT and presented using the APACHE III scoring system. The number of organ failures was checked at the initiation of RRT. RESULTS: The survival rate was 46% in the HD group and 21% in the CVVHDF group (p = 0.002). CVVHDF was applied to the more severely ill patients, who had longer periods using a ventilator (p = 0.002) and/or vasopressor (p < 0.001), higher numbers of organ failures (p < 0.001) and higher initial APACHE III scores (p < 0.001). Among patients with APACHE III scores > 103, the survival rate was 13% in the CVVHDF group and 0% in the HD group. In patients with kidney failure and failure of two other organs, the survival rate was 9% in the HD group and 36% in the CVVHDF group (p = 0.035). CONCLUSION: The mortality rate in the CVVHDF group was higher than that in the HD group, which may have been because CVVHDF was applied to the more severely ill patients. In contrast, CVVHDF may give a chance of survival to patients with APACHE III scores > 103 and may be more useful than HD in patients with failure of three or more organs.

Acute Kidney Injury↗

PubMed2001

Assessment of factors predicting outcome of acute respiratory distress syndrome in North India.

OBJECTIVES: Information on the spectrum and outcome of acute respiratory distress syndrome (ARDS) in tropical countries is scanty. This study was designed to assess the factors predicting the outcome of ARDS in North India. METHODOLOGY: Consecutive patients requiring mechanical ventilation for ARDS over a 2 year period at the Respiratory Intensive Care Unit (RICU) of a tertiary referral hospital were studied. Hospital survival was correlated with age, aetiology, disease severity scores (APACHE III, SAPS II, lung injury score) and organ failure using univariate analysis. Factors significantly influencing mortality were examined by multivariate analysis to identify factors independently affecting outcome. RESULTS: Sepsis (28.6%), followed by malaria (21.4%), were the commonest risk factors. Seven out of eight patients (87.5%) with sepsis died. The presence of sepsis, more than three organ failure prior to admission, APACHE III score > 57 and SAPS II score > 39 were significantly associated with mortality. Only APACHE III score > 57 or SAPS II score > 39 were, however, independently predictive of a poor outcome following multivariate analysis. CONCLUSIONS: Sepsis, associated with a very poor outcome, and malaria were important risk factors for the development of ARDS. APACHE III score > 57 or SAPS II score > 39 were associated with increased risk of mortality.

APACHE↗

PubMed2004

[Analysis of prognosis assessment with acute physiology and chronic health evaluation III, multiple organ dysfunction score and sequential organ failure assessment for the postoperative patients in cardiovascular surgery].

OBJECTIVE: To analyze the clinical significance of the prognosis assessment with acute physiology and chronic health evaluation III (APACHEIII), multiple organ dysfunction score (MODS) and sequential organ failure assessment (SOFA) for postoperative patients in cardiovascular surgery. METHODS: Prognosis of 68 patients undergoing cardiovascular operation from February 2004 to June 2004 in our ward was assessed by APACHE III, MODS and SOFA. Then the scores were calculated and compared everyday while they stayed in Cardiac Surgery Intensive Care Unit (CSICU). RESULTS: The scores of three methods showed no significant difference from one another in the first three postoperative days, but were significantly higher than all the scores calculated just after the entrance to the CSICU (A0, M0, S0; all P<0.01). There were no differences in the changes of APACHE III, MODS and SOFA(DeltaA, DeltaM and DeltaS) in the first three postoperative days respectively, although they all showed a decreasing tendency. APACHE III scores were positively correlated with MODS although the correlation were diminishing (P<0.01 at first day but P<0.05 at third day), while they were positively correlated with SOFA only in the first two days (both P<0.01). The MODS was positively correlated with SOFA at various time points (P<0.001). The length of stay in CSICU was positive correlated with A0 and maximum of APACHEIII (Amax, P<0.05), and M0, maximum of MODS (Mmax) as well as S0, maximum of SOFA (Smax, P<0.001), respectively. CONCLUSION: For the patients who have undergone cardiovascular operation, A0 could assess the prognosis fairly precisely, but MODS and SOFA assessment seem to be better than APACHE III. Individual Smax and kinetic DeltaS might be the most suitable indexes for cardiovascular surgery.

APACHE↗

PubMed2002

Comparison of multiple organ dysfunction scores in the prediction of hospital mortality in the critically ill.

OBJECTIVE: To compare the scales and predictive power for hospital mortality of three recent multiple organ dysfunction scores. DESIGN: Prospective, observational, validation cohort study. SETTING: A ten-bed medical-surgical intensive care unit in a Finnish tertiary care hospital. PATIENTS: Among the 591 consecutive patients admitted, 520 patients who stayed >4 hrs were studied. MEASUREMENTS AND MAIN RESULTS: Clinical and laboratory data were collected daily. Acute Physiology and Chronic Health Evaluation (APACHE) III, Multiple Organ Dysfunction Score, Logistic Organ Dysfunction score, and Sequential Organ Failure Assessment score all were calculated and compared for hospital mortality. The areas under receiver operating curves (SE) for day-1 scores were 0.825 (0.02) for APACHE III, 0.805 (0.02) for Logistic Organ Dysfunction, 0.776 (0.02) for SOFA, and 0.695 (0.02) for Multiple Organ Dysfunction Score in prediction of hospital mortality. The highest discriminative power was revealed with total maximum scores. No statistical differences existed between the total maximum scores (p values,.06 to.97). Calibration was good for all scores of day-1 multiple organ dysfunction scales and APACHE III by chi-square test (values between 10.14 and 5.42). CONCLUSIONS: Discriminative power (ability to distinguish between patients who die and those who live) of day-1, of daily maximum, and especially of total maximum multiple organ dysfunction scores, were rather good, comparable with each other, and comparable with APACHE III in prediction of hospital mortality.

APACHE↗

PubMed2000

The weaning continuum use of Acute Physiology and Chronic Health Evaluation III, Burns Wean Assessment Program, Therapeutic Intervention Scoring System, and Wean Index scores to establish stages of weaning.

OBJECTIVE: To determine whether four stages of weaning (acute, prewean, wean, and outcome) could be identified by using clinical instruments designed to quantify severity of illness, patient stability, or weaning readiness. The instruments used were the Acute Physiology and Chronic Health Evaluation (APACHE III), the Therapeutic Intervention Scoring System (TISS), the Burns Wean Assessment Program (BWAP), and the Wean Index (WI). The stages were adapted from those proposed by the American Association of Critical Care Nurses Third National Study Group's Weaning Continuum Model. DESIGN: Prospective, convenience cohort. This study was part of a larger study designed to test an outcomes managed approach to weaning by using an outcomes manager and a clinical pathway. SETTING: University medical intensive care unit. PATIENTS: Adult patients requiring mechanical ventilation >3 days admitted to the medical intensive care unit between November 1994 and May 1995. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Scores for the APACHE III, TISS, BWAP, and WI were collected on 97 patients every other day until they weaned, were transferred, or died. Outcomes described for each stage of weaning were dated on the clinical pathway when achieved. Comments about patient stability and ventilator progress also were recorded along with a subjective determination of the stage of weaning. We used decision rules to identify time intervals for each stage of weaning and outcomes attained by stage. Finally, APACHE III, TISS, BWAP, and WI scores were placed in each stage by date for analysis. The APACHE III, TISS, and BWAP scores were able to differentiate the acute, prewean, and wean stages but not the outcome stage. CONCLUSIONS: By identifying distinct scores for each stage, we may be able to better explore appropriate interventions for the stages as well as predict weaning outcomes. Indices that include physiologic and respiratory factors can differentiate weaning stages, but respiratory factors alone cannot.

APACHE↗

PubMed2001

Improved outcome prediction for patients with multiple organ failure undergoing continuous hemodiafiltration.

A number of patients with multiple organ failure (MOF) regardless of accompanying acute renal failure have been treated with continuous hemodiafiltration (CHDF). However, despite its high cost, the costs/benefits of CHDF for MOF patients still need to be evaluated. Although many scoring systems were established to predict the outcome of MOF, their predictive powers were not estimated in MOF patients undergoing CHDF. Therefore, using 52 Japanese patients with MOF treated with CHDF for more than 1 week, we estimated the predictive powers of multiple organ dysfunction (MOD) scores and acute physiology and chronic health evaluation (APACHE) III scores, retrospectively. The patients were divided into 2 groups according to outcome at Day 28 after the initiation of CHDF. In both scoring systems, the median values at Day 0 were not significantly different between the survival (n = 19) and the nonsurvival (n = 33) groups. In contrast, at Day 3, the median values of MOD scores was 4 (0-14) in the survival group and 9 (1-12) in the nonsurvival group (p = 0.0035). The median value of APACHE III scores were 37 (19-97) and 87 (16-150) at Day 3, respectively (p < 0.0001). In the survival group, APACHE III scores significantly decreased from the median value of 64 (32-89) to 37 (p = 0.0269), and in the nonsurvival group, it increased significantly from the median value of 70 (29-103) to 87 (p = 0.0116). In contrast, no significant changes were observed in the MOD scores. In conclusion, the MOD score and the APACHE III score systems had less power to predict the outcome of MOF patients undergoing CHDF at Day 0. However, rescoring at Day 3 of each index was much more powerful to accurately predict the outcome of such patients.

APACHE↗

PubMed1994

Modeling the severity of illness of ICU patients. A systems update.

OBJECTIVE: To review recent revisions of systems for estimating the probability of hospital mortality of adult intensive care unit (ICU) patients. Emphasis on comparison of components of systems and potential uses. DATA SOURCES: Published articles in which the systems were presented. STUDY SELECTION: Acute Physiology and Chronic Health Evaluation (APACHE III), Simplified Acute Physiology Score (SAPS II), and Mortality Probability Models (MPM II) are the major severity systems for ICU patients. DATA EXTRACTION: Information on variables collected in the systems, characteristics of databases from which they were developed, and reported performance of models were evaluated from published articles. DATA SYNTHESIS: APACHE III and SAPS II produce a score and probability of hospital mortality based on worst values of several variables during the first 24 hours in ICU. The MPM II system has four models, one at ICU admission and one at 24, 48, and 72 hours into the ICU stay. The SAPS II and MPM II models can be implemented from published information. The APACHE III score can be calculated from published information; weights to convert score to probability are proprietary. All reported good areas under receiver operating characteristic curve. Goodness of fit was good for SAPS II and MPM II models and was not reported for APACHE III models. CONCLUSIONS: All models were based on rigorous research and reported performance is good. All can be used to assist in assessing prognosis, to compare ICU performance, and to stratify patients for clinical trials. Direct comparison on a common cohort is needed.

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