Acute Physiology And Chronic Health Evaluation Score Research Articles

QS7. Using Apache ® III-J to Predict Outcome in Patients Undergoing Pericardial Window for Malignant Pericardial Effusion

Introduction: The Acute Physiology and Chronic Health Evaluation (APACHE) III-J system has been used to predict mortality in hospitalized ICU patients. Patients presenting with suspected malignant pericardial effusions needing urgent therapy are generally felt to be poor operative candidates with dismal long-term survival. Options for therapy include urgent percutaneous pericardial drainage with a pigtail catheter or more definitive surgical pericardial window. We hypothesized that the APACHE III-J system can be used to predict long-term survival in these patients and can be used to triage patients with a high APACHE score to percutaneous drainage rather than surgical window.

Risk Factors for Pressure Ulcer Development in a Best Practice Surgical Intensive Care Unit

We describe the incidence of and define risk factors for pressure ulcers (PU) in the surgical intensive care unit (ICU). Twelve months of data were collected on all patients admitted to the intensivist-run surgical ICU of a university hospital. PU patients were those who developed a new stage II or greater lesion during or after a surgical ICU stay as identified in Project Impact, ICD9 discharge, or ICU complications databases. Patients were nursed in pressure-relieving beds with nutrition initiated by 72 hours. Chi2, t test, and logistic regression statistics were used. Three percent (25/820) developed PU. Age, ICU length of stay, Acute Physiology and Chronic Health Evaluation Score (APACHE), and gender were not different between those with and without PU. Patients with PU had a higher blood urea nitrogen/creatinine (30.5/2.2 mg/dL vs 22.0/1.6 mg/dL) and were more frequently vascular patients (28 vs 14.1%), diabetics (40 vs 17.2%), paraplegics (8 vs 0.2%) (all P < 0.01), and patients on pressors (28.0 vs 11.8%, P < 0.02). Multivariate analysis revealed that diabetes (odds ratio [OR] 2.7, 95%, confidence interval [CI] 1.1-6.4), spinal cord injury (OR 16.8, 95%, CI 1.5-183), age > 60 years (OR 2.9, 95%, CI 1.2-7.1), and a creatinine >3 mg/dL (OR 3.7, 95%, CI 1.2-9.3) were independent predictors of PU. Despite universal use of specialty beds and early nutrition, pressure ulcers developed in 3 per cent. Independent risk factors include age greater than 60 years, diabetes, spinal cord injury, and renal insufficiency. Additional modalities, such as aggressive early mobilization, might be warranted in this cohort.

Error Rates Among Clinical Pharmacists in Calculating the APACHE II Score

The Food and Drug Administration recently advocated the use of acuity scoring to determine those patients whose mortality benefits outweigh risks of adverse effects from drotrecogin alfa (activated). Many institutions have adopted an Acute Physiology and Chronic Health Evaluation (APACHE) II cutoff score of 25 (i.e., if > or = 25, administer the agent) as a component in determining eligibility for treatment with this agent. Concern is increasing that errors in the acquisition of APACHE scores can lead to prescribing errors with drotrecogin alfa (activated). To determine the ability of clinical pharmacists in ascertaining APACHE II scores. Fifteen clinical pharmacists calculated APACHE II scores for the clinical scenarios of three patients. End points were the pharmacists' APACHE II score calculation, decision to start drotrecogin alfa (activated) treatment, and evaluation of individual components of the APACHE II scores. Of the 15 pharmacists, correct APACHE II scores were derived by nine (60%) pharmacists for patient no. 1 (APACHE score 44), by two (13%) pharmacists for patient no. 2 (APACHE score 22), and by two (13%) pharmacists for patient no. 3 (APACHE score 19). Scoring errors occurred in 32 of the 45 (71%) derivations. The pharmacists were significantly more likely to correctly prescribe drotrecogin alfa for the two patients with true APACHE scores of 19 and 44 than for the patient whose score was 22, which was closer to the prescribing cutoff score of 25 (both p<0.001, patient no. 1 vs no. 2, and patient no. 2 vs no. 3, Fisher exact test) All individual components of the score were correctly evaluated at least 80% of the time, except for mean arterial pressure, respiratory rate, and Glasgow Coma Scale score. Caution must be used in applying results of APACHE II scores estimated by only one trained individual when deciding to administer or withhold drotrecogin alfa (activated).

Thyroid hormone levels improve the prediction of mortality among patients admitted to the intensive care unit.

As hormones are strongly associated with mortality in critically ill patients, we investigated whether mortality prediction based on the Acute Physiology and Chronic Health Evaluation (APACHE) is improved by combining this score with hormone measurements. Intensive care units in three hospitals. 113 patients admitted to. Within the first hour after ICU admission we measured total triiodothyronine, total thyroxine, free thyroxine, thyrotropin, cortisol, growth hormone, dehydroepiandrosterone, and prolactin levels and administered the APACHE. Patients were followed until they died or were discharged from the ICU. The best logistic regression model for ICU mortality included the APACHE score and thyroid-stimulating hormone and triiodothyronine levels. This model had an area under the receiver operating characteristic curve of 0.88, significantly higher than the APACHE score alone with 0.75. The model with hormone levels and APACHE score was also significantly better calibrated than the model with only the APACHE score. The addition of thyroid hormones to the APACHE score improves the prediction of mortality for ICU patients.

Discharge Decision-Making by Intensivists on Readmission to the Intensive Care Unit

Patients readmitted to the intensive care unit (ICU) have a significantly higher mortality rate. The role of intensivists in judging when to discharge patients from the ICU is very important. We undertook this study to evaluate the effect of the intensivists' discharge decision-making on readmission to ICU. The intensivists actively participated in the discharge decision-making, with the discharge guideline taken into consideration, in respect of group 1 patients, but not in respect of group 2. The readmission rate in group 1 was lower than that in group 2. The readmission in patients in each group was associated with higher mortality rates and longer lengths of stay at the ICU. Respiratory failure was the major cause of readmission. In the non-survivors out of the readmitted patients, the Acute Physiology and Chronic Health Evaluation (APACHE) scores on the initial discharge and readmission, the multiple organ dysfunction syndrome (MODS) scores on the initial admission, discharge and readmission were higher than the corresponding indices in the survivors. We conclude that the readmission rate was lower when intensivists participated in the discharge decision-making, and that APACHE and MODS scores on the first discharge and readmission were significant prognostic factors in respect of the readmitted patients.

Feasibility of acute physiology and chronic health evaluation (APACHE) II and III score-based screening in patients receiving allogeneic hematopoietic stem-cell transplantation.

Patients who require management in the intensive care unit (ICU) for complications after allogeneic hematopoietic stem-cell transplantation (HSCT) generally have a poor outcome. We retrospectively studied whether the risk-prediction stratification systems commonly used for patients admitted to the ICU, that is, the Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III systems, could be useful for identifying patients who should receive intensive care earlier. We reviewed the medical records of 210 patients who underwent allogeneic HSCT and found that 18 (8.6%) had been admitted to the ICU for acute respiratory failure (n=9), acute renal failure (n=7), and septic shock (n=2). The median APACHE II and III scores were, respectively, 16 (10-27) and 55 (22-87) at the onset of complications and 26 (15-43) and 101 (65-157) upon admission to the ICU. Thus, both the APACHE II and APACHE III scores at ICU admission were higher than those at the onset of complications (P <0.0001). Seventeen patients (94%) subsequently died, with a median ICU stay of 7.5 days (1-51 days), as a result of multiorgan failure (n=14), respiratory failure (n=2), and septic shock (n=1). The APACHE II and III scores of the sole surviving patient were, respectively, 21 and 71 at the onset and 24 and 86 upon transfer to the ICU. Thus, the APACHE scores in this study were lower than those reported for other surgical or medical patients treated in the ICU, despite their uniform poor prognosis. Although nine patients had developed grade III to IV acute graft-versus-host disease, which is the most common cause of morbidity and mortality after allogeneic HSCT, this was not fully evaluated in the current scoring systems. Application of these systems to HSCT will require adequate modification, with particular attention to organ dysfunction secondary to graft-versus-host disease.

Practice management guidelines for geriatric trauma: the EAST Practice Management Guidelines Work Group.

Advanced age is a well-recognized risk factor for adverse outcomes after trauma. A substantial body of literature, much of it cited within this article, demonstrates increased morbidity and mortality in geriatric trauma patients compared with their younger counterparts. Whether this outcome difference is because of the decreased physiologic reserve that accompanies aging, a higher incidence of preexisting medical conditions in the geriatric patient, or other factors yet to be identified remains unclear. It is clear, however, that good outcomes can be achieved in this patient population when appropriately aggressive trauma care is directed toward geriatric patients with survivable injuries. Implicit in the above statement is the need to identify, as soon as possible after injury, those patients who will benefit from aggressive resuscitation, timely injury management, and posttrauma rehabilitation. It is equally important, however, to limit these intensive and expensive treatment modalities to patients whose injuries are not only survivable but also compatible with an acceptable quality of life. Our purpose in developing this guideline was to provide the trauma practitioner with some evidence-based recommendations that could be used to guide decision-making in the care of the geriatric trauma patient. We began this process by first developing a series of questions, the answers to which we hoped could be supported by the existing scientific literature. The initial set of questions were as follows: 1. Is age itself a marker of increased morbidity/ mortality? If so, what age should be used? 2. Is age instead a surrogate for increased preexisting conditions (PECs)? If so, which premorbid conditions are particularly predictive of poor outcomes? 3. Should age itself be a criterion for triage from the field directly to a trauma center, regardless of Glasgow Coma Scale (GCS) score, Trauma Score (TS), and so forth? If so, what age should be used? 4. Do trauma centers have better outcomes with geriatric trauma than nontrauma centers? 5. Are there specific injuries, scores (e.g., Injury Severity Score [ISS], TS, GCS score), or PEC/age combinations in geriatric trauma patients that are so unlikely to be survivable that a nonaggressive approach from the outset could be justified? 6. What resuscitation end-points should be used for the geriatric trauma patient? 7. Should all geriatric trauma patients receive invasive hemodynamic monitoring? If so, what specific types of monitoring should be used? If not, which geriatric patients benefit from invasive monitoring? Unfortunately, after examining the available literature, it is clear that evidence-based responses to all of the questions raised above are not possible. As the evidentiary tables demonstrate, there are few, if any, prospective, randomized, controlled trials that definitively address any of the above issues. Second, there is a lack of uniformity as to a specific age criterion for geriatric trauma. As shown in the evidentiary tables, geriatric trauma is variously defined in the literature as age greater than or equal to 55, 60, 65, 70, 75, and even 80 years of age. There is even literature support for increased mortality from trauma beginning at age 45! Furthermore, because age is a continuous variable, and not a dichotomous one, adverse outcomes associated with geriatric trauma are likely to increase in a continuous fashion with age as opposed to a stepwise leap as a given patient reaches a specific age. Third, there is no concise definition of a geriatric trauma patient. In some studies, all patients over a given age are included, whereas in others, patients with penetrating injuries, burns, and minor injuries, such as slip-and-falls, are excluded. Some studies include all patients regardless of hemodynamic instability or injury severity, whereas others impose strict entrance criteria or exclude patients who do not survive for a predetermined period of time after admission. Such lack of uniformity regarding inclusion criteria makes it Submitted for publication October 3, 2001. Accepted for publication September 16, 2002. Copyright © 2003 by Lippincott Williams & Wilkins, Inc. From the Carolinas Medical Center (D.G.J.), Charlotte, North Carolina, Trauma Service, Bronson Hospital (B.R.P.), Kalamazoo, and Trauma Burn Center, University of Michigan Health System (W.W.), Ann Arbor, Michigan, New York Hospital–Cornell Medical Center (P.S.B.), New York, New York, Robert Wood Johnson Medical School (J.S.H.), New Brunswick, New Jersey, Mt. Sinai Hospital (M.R.H.), Chicago, Illinois, Morehouse School of Medicine (K.E.S.), Atlanta, Georgia, and R Adams Cowley Shock Trauma Center, University of Maryland Medical Center (T.M.S.), Baltimore, Maryland. Address for reprints: David G. Jacobs, MD, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232; email: djacobs@carolinas.org.

Recently published papers: inflammation, elucidation, manipulation?

Recently published papers: inflammation, elucidation, manipulation?

Respiratory intensive care unit resource use and outcomes in Taiwan.

Based on a revision of Donabedian's classic structure, process, and outcome conceptual framework, this study examined the relationship between resource use (length of stay) and outcome (transfer status) in two respiratory intensive care units (ICUs). Medical records of respiratory ICU patients (N = 194) from a medical center in northern Taiwan were reviewed. Data collection focused on patient demographic profile (age, gender, and medical diagnosis), Acute Physiology and Chronic Health Evaluation (APACHE) score, nursing diagnoses, ICU length of stay, and transfer status. The results indicate that patients with lower APACHE scores and more nursing diagnoses had a longer ICU length of stay. In addition, both the number of nursing diagnoses and APACHE scores significantly explained the variance in the length of stay. Nonetheless, a higher APACHE score was correlated with a poor transfer status. These findings indicate that, in addition to the traditional indicators, nursing diagnoses may be a vital variable in predicting ICU length of stay. The results also imply that patients with lower APACHE scores are in better physical condition and are therefore institutionalized longer in ICUs.

Levels of soluble FcγRIII correlate with disease severity in sepsis

Neutrophil activation is thought to play a crucial role in the pathogenesis of sepsis. During activation, neutrophils adhere to and migrate through the endothelium. Therefore, the amount of circulating neutrophils does not adequately reflect the total amount of neutrophils that are involved in the pathophysiologic process of this condition. In this study we test the hypothesis that the severity of sepsis is associated with the total body mass of neutrophils as reflected in the plasma concentration of soluble Fc gamma receptor type III (sFc gammaRIII). Nineteen patients with sepsis (12 male, seven female, median age of 69 years, range 29-87 years) were included in this study. Ten healthy volunteers served as controls. Plasma sFc gammaRIII concentrations were measured by ELISA. Other parameters that were studied were leucocyte count, plasma concentrations of lactoferrin and soluble L-selectin, and surface expression of CD11b and CD66b on circulating neutrophils. Disease activity was measured using the Acute Physiology and Chronic Health Evaluation (APACHE) II score. Soluble Fc gammaRIII levels were elevated in sepsis patients whereas soluble L-selectin levels were moderately decreased compared with healthy controls. Markers of cell activation were significantly increased in sepsis patients. Soluble Fc gammaRIII correlated with disease severity as measured by the APACHE score (P<0.05, r=0.53), whereas the other parameters did not correlate with the APACHE score. In conclusion, this study demonstrates that soluble Fc gammaRIII is a useful marker for disease severity in patients with sepsis.

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

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

Should the pre-sedation Glasgow Coma Scale value be used when calculating Acute Physiology and Chronic Health Evaluation scores for sedated patients?

To assess the effect on the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III of two different approaches to scoring the Glasgow Coma Scale (GCS) in sedated patients. The first approach was to assume that the GCS score was normal, and the second was to use the GCS value recorded before the patient was sedated. Prospective cohort study over 2 yrs. Twenty-two general adult intensive care units in Scotland. 13,291 consecutive admissions to the participating intensive care units. After exclusion of patients according to standard, predefined criteria, the Acute Physiology and Chronic Health Evaluation II and III systems were used to calculate the probability of hospital mortality for patients included in the study. In patients whose GCS scores could not be assessed accurately during the first 24 hrs, the APACHE II and III predictions were calculated twice: first, assuming that the GCS score was normal; and second, substituting the GCS score recorded before sedation. This generated two different databases for each system, and the predictions for both were compared with the observed hospital mortality rate. The effect of the two different approaches to the GCS on the performance of both APACHE II and APACHE III was assessed using measures of discrimination (area under the receiver operating characteristic curve) and goodness of fit (calibration curves and the Hosmer-Lemeshow statistic). Analysis was undertaken for both the entire cohort and for the group of patients whose APACHE scores were altered. There was a wide variation in the number of patients who had their scores altered between participating units. There were also differences between diagnostic groups. Overall, however, 50% of the patients were sedated and 22% had their scores altered. Using the presedation GCS score increased the discrimination of both APACHE II and APACHE III. The calibration of APACHE III was also improved but that of APACHE II deteriorated. The calibration improved, however, in those patients with altered scores, suggesting that the overall deterioration is attributable to other limitations in the fit of the model to these data. Although changes had the greatest effect in patients with a neurologic or trauma diagnosis, the changes were important in most diagnostic groups. The GCS is an important component of both APACHE II and APACHE III. It should be assessed directly whenever possible. When patients are sedated, using the GCS score recorded before sedation is preferable to the assumption of normality. The variations between different units and different diagnostic groups highlight the possible effects of case mix on the performance of prognostic scoring systems.

A prospective study of fever in the intensive care unit.

To determine the epidemiology of fever on the intensive care unit (ICU). Prospective, observational study. Nine-bed general ICU in a 500-bed tertiary care inner city institution. 100 consecutive admissions of 93 patients over a 4-month period between July and October 1996. All patients were seen and examined by one investigator within 24 h of ICU admission. Patients were followed up on a daily basis throughout their ICU stay, and all clinical and laboratory data were recorded during the admission. Fever (core temperature > or = 38.4 degrees C) was present in 70% of admissions, and it was caused by infective and non-infective processes in approximately equal number. Most fevers occurred early in the course of the admission, within the first 1-2 days, and most lasted less than 5 days. The median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15 (+/- 0.6). The 70 episodes associated with fever at any time were associated with a significantly higher APACHE II score on admission than the afebrile episodes (15.8 +/- 6.1 vs 12.1 +/- 6.7, p = 0.04). The most common cause of non-infective fever was in the group designated post-operative fever (n = 34). All the patients in the post-operative fever group were febrile on day 0 or day 1; their mean admission APACHE score was 12.4 (+/- 4.4) compared to 15.9 (+/- 7.1) for the remaining patients (p = 0.01). Fever alone was not associated with a higher mortality: 26/70 (37%) of febrile patients died, compared to 8/30 (27%) of afebrile patients, (chi 2 = 1.23, p = 0.38). Prolonged fever (> 5 days) occurred in 16 patients. In 13 cases, fever was due to infection, and in the remaining 3 both infective and non-infective processes occurred concurrently. The mortality in the group with prolonged fever was 62.5% (10/16) compared to 29.6% (16/54) in patients with fever of less than 5 days' duration, a highly significant difference (p < 0.0001). Fever is a common event on the intensive care unit. It usually occurs early in the course, is frequently non-infective and is often benign. Prolonged fever is associated with a poor outcome. Post-operative fever is a well-recognised but poorly defined syndrome which requires further study.

Evaluation of triage decisions for intensive care admission.

To assess physician decision-making in triage for intensive care and how judgments impact on patient survival. Prospective, descriptive study. General intensive care unit, university medical center. All patients triaged for admission to a general intensive care unit were studied. Information was collected for the patient's age, diagnoses, surgical status, admission purpose, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and mortality. The number of available beds at the time of triage and reasons for refused admission were obtained. Of 382 patients, 290 were admitted, 92 (24%) were refused admission, and 31 were admitted at a later time. Differences between admission diagnoses were found between patients admitted or not admitted (p < .001). Patients refused admission had higher APACHE II scores (15.6+/-1.5 admitted later and 15.8+/-1.4 never admitted) than did admitted patients (12.1+/-.4; p < .001). The frequency of admitting patients decreased when the intensive care unit was full (p < .001). Multivariate analysis revealed that triage to intensive care correlated with age, a full unit, surgical status, and diagnoses. Hospital mortality was lower in admitted (14%) than in refused patients (36% admitted later and 46% never admitted; p < .01) and in admitted patients with APACHE II scores of 11 to 20 (p = .02). The 28-day survival of patients was greater for admitted patients compared with patients never admitted (p = .01). Physicians triage patients to intensive care based on the number of beds available, the admission diagnosis, severity of disease, age, and operative status. Admitting patients to intensive care is associated with a lower mortality rate, especially in patients with APACHE scores of 11 to 20.

Albumin kinetics in hypoalbuminemic patients receiving total parenteral nutrition.

By using undenatured purified albumin preparations radiolabeled with iodine, the half-life of serum albumin in well patients who are stable is known to be approximately 17 days. However, when a patient is suffering with an acute illness such as sepsis, trauma, burns or after an extensive operative procedure, the serum albumin level decreases. It is not known whether this fall in serum albumin is due to increased catabolism, decreased synthesis, or a combination of both factors. This study explores the kinetics of albumin catabolism under these circumstances to clarify the issue. 125I-labeled albumin was administered intravenously to 10 critically ill, hypoalbuminemic patients receiving total parenteral nutrition (TPN). Each subject had frequent blood samples taken for at least 10 days to measure the decline of plasma radioactivity over time. None was receiving unlabeled albumin during the investigation. It was assumed that the plasma decay would follow first-order kinetics after the early equilibration phase. Radioactivity of heparinized blood samples (counts/2 mL sample) were counted and the results were graphically expressed. One subject was not evaluated because he was discharged on the 8th day. The APACHE (acute physiology and chronic health evaluation) score for the other nine subjects ranged from 4 to 18 (mean, 7.5). The serum albumin remained below 3.0 g/dL in each subject and did not change statistically throughout the study. The radioiodinated albumin half-life ranged from 5.52 to 11.76 days (mean 9.10 days; compared with published normal of approximately 17 days). The equilibration time was 3 to 7 days. The average albumin catabolized for this group is similar to previously reported normal subjects, 0.18 g/kg/d. Hypoalbuminemic patients receiving TPN have markedly shortened plasma albumin half-lives, but the albumin catabolized per day is similar to normal patients. These data argue for both a synthetic and catabolic defect that explains the hypoalbuminemia in this patient group.

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

To more clearly define the relationships between plasma proinflammatory cytokine concentrations, physiologic disturbance, and survival in severely ill patients. Prospective, longitudinal, cohort analytic study. Teaching hospital intensive care unit (ICU). Two hundred fifty-one consecutive nonselected patients admitted to the ICU. None. 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. 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.

Hypocholesterolemia and risk of death in the critically ill surgical patient.

To evaluate the additional information provided by the determination of cholesterolemia to the Acute Physiology and Chronic Health Evaluation (APACHE) II score. Retrospective evaluation of patients admitted to the intensive care unit (ICU). ICUs in a university hospital. 638 consecutive critically ill surgical patients. Surgical and medical therapy according to clinical status. Two indices were devised: DELCUPOS and DELCUNEG (cubed absolute value of the difference between measure cholesterol and the value of 190 mg/dl when cholesterolemia was, respectively, over and under 190 mg). The first estimation of cholesterolemia was taken upon admission to the ICU. The APACHE II score was computed from teh worst values obtained during the first 24h of the ICU stay, including the pre-operative period for patients transferred from the operating theatre. Mortality (24.4%) over the whole time of hospitalization has been considered. A stepwise linear logistic regression on APACHE II, DELCUPOS, DELCUNEG, and on interactions among these three factors has been carried out. A U-shaped relationship between cholesterolemia and morality was demonstrated. The significance of DELCUPOS (p = 0.0021) and DELCUNEG (p = 0.0002), considered together with the APACHE II score, has demonstrated an additive information content with respect to the APACHE score for the prediction of mortality. Both hyper- and hypocholesterolemia have a highly significant relationship to mortality. Cholesterolemia improves the prognostic power of the APACHE II score. This result could be used to create a more powerful prognostic index.

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

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. Prospective, inception-cohort study. Surgical intensive care unit (SICU) of an urban, tertiary care hospital. 2,295 consecutive admissions for critical surgical illness, postoperative complications, or postoperative monitoring in 2,058 patients. 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. Hospital mortality and length of stay in the SICU. 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. 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.

Development of multiple organ dysfunction syndrome in critically ill patients with perforated viscus. Predictive value of APACHE severity scoring.

To determine whether scoring on the Acute Physiology and Chronic Health Evaluation (APACHE) III at admission can predict the development of multiple organ dysfunction syndrome and mortality in critically ill surgical patients. Prospective, inception-cohort study. Surgical intensive care unit of an urban, tertiary-care hospital. One hundred fourteen critically ill patients with surgically treated perforated gastrointestinal viscus. Calculation of APACHE II and APACHE III scores 24 hours after admission to the surgical intensive care unit and serial quantitation of organ dysfunction for the duration of critical care according to two different predefined scoring systems. Patients were stratified by survival, the development of organ dysfunction, and colon vs noncolonic perforation. Hospital mortality, length of stay in the surgical intensive care unit, and the development of organ dysfunction or overt organ failure. The mean (+/- SEM) APACHE II and APACHE III scores were 17.4 +/- 0.6 (range, 6 to 37) and 59.0 +/- 2.2 (range, 15 to 141), respectively. The incidence of organ dysfunction was 73% (64% in survivors). All severity scores were identical for colon perforation and noncolonic perforation subgroups. Nonsurvivors invariably had organ dysfunction. Overall length of stay in the intensive care unit was 12.0 +/- 1.6 days (8.7 +/- 1.2 days for survivors and 22.7 +/- 5.0 days for nonsurvivors). The APACHE scores and organ dysfunction or failure scores were significantly higher in nonsurvivors, and APACHE scores were higher in survivors with organ dysfunction than in those without it. Significant linear relationships were identified for APACHE II vs APACHE III scores (R2 = .66) and for all four combinations of APACHE scores and organ dysfunction or failure scores (R2 = .43 to .52). By multivariate analysis of variance, independent predictors of organ dysfunction or failure were APACHE III, increased age, and a prolonged stay in the surgical intensive care unit, but not the type of perforation. Neither APACHE II or APACHE III predicted mortality independently. The development of multiple organ dysfunction syndrome correlated with higher APACHE III scores but was independent of the type of perforation. Only the development of overt multiple organ failure predicted death. Combined use of APACHE III and the multiple organ dysfunction score provides improved prediction of multiple organ dysfunction syndrome, but further enhancements are needed before prediction of outcome in individual patients is reliable.

APACHE scoring and prediction of survival in intensive care

EDITOR,—We are disappointed that Minerva has fallen into the same trap as others before her in misconstruing the role of the acute physiology and chronic health evaluation (APACHE) score in critically ill patients.1 Although the APACHE systems can be used to provide information on the risks of death for a group of patients suffering from a specific disease category that may require admission to an …