Assessing the severity of the patient's condition and predicting the outcome

WA Knauss et al. (1981) developed and implemented a classification system based on the APACHE (Acute Physiology and Chronic Health Evaluation) assessment, applicable to adults and older children, which involves the use of routine parameters in the intensive care unit and is designed to evaluate all major physiological systems. A distinctive feature of this scale was that assessments that use specific parameters of organ system dysfunction are limited to diseases of these systems, while the evaluation of systems that could provide more extensive information about the patient's condition requires extensive invasive monitoring.

Initially, the APACHE scale contained 34 parameters, and the results obtained in the first 24 hours were used to determine the physiological status in the acute period. The parameters were estimated from 0 to 4 points, the health assessment was determined from A (total health) to D (acute polyorganic insufficiency). Probable outcome was not determined. In 1985, after the revision (APACHE II), 12 basic parameters that determine the main processes of vital activity remained in the scale (Knaus WA et al., 1985). In addition, it turned out that a range of indicators, such as glucose and albumin concentrations in plasma, central venous pressure or diuresis, are of little significance in assessing the severity of the scale and more reflect the treatment process. The Glasgow scale was rated from 0 to 12, and creatinine, which replaced urea, was 0 to 8 points.

Direct determination of oxygen in the arterial blood was only performed with Fi02 less than 0.5. The other nine parameters did not change their estimate. The general state of health is assessed separately. And patients without surgery or with surgery for emergency indications were much less likely to survive compared with the planned patients. The total age and general health score can not exceed 71 points, in persons with an assessment of up to 30-34 points, the likelihood of a fatal outcome is significantly higher than in patients with a higher score.

In general, the risk of developing a lethal outcome varied with different diseases. Thus, mortality in individuals with small-scale ejection syndrome is higher than in patients with sepsis, with the same score on the scale. It was possible to introduce coefficients that take into account these changes. In the case of a relatively favorable outcome, the coefficient has a large negative value, and with an unfavorable prognosis this coefficient is positive. In the case of the pathology of an individual organ, there is also a certain coefficient.

One of the main limitations of the APACHE E scale is that the mortality risk prognosis is based on the results of treatment of patients in the ICU from 1979 to 1982. In addition, initially the scale was not designed to predict death for an individual patient and had an error level of approximately 15% when predicting hospital mortality. Nevertheless, some researchers used the APACHE II scale to determine the prognosis for each individual patient.

The APACHE II scale consists of three blocks:

1. assessment of acute physiological changes (acute physiology score-APS);
2. age estimation;
3. assessment of chronic diseases.

Data on the "Assessment of acute physiological changes" block are collected during the first 24 hours of admission to the ICU. The worst-case estimate received during this time period is included in the table.

[1], [2], [3]

Scale for assessing acute physiological disorders and chronic disorders

Acute Physiology and Chronic Health Evaluation II (APACHE II) (Knaus WA, Draper EA et al., 1985)

Assessment of acute physiological changes - Acute Physiology Score, APS

Symptom	Value	Points
Rectal temperature, С	> 41	4
	39-40,9	+3
	38.5-38.9	+1
	36-38.4	0
	34-35.9	+1
	32-33.9	+2
	30-31.9	+3
	<29.9	4
Mean arterial pressure, mm Hg. Art.	> 160	4
	130-159	+3
	110-129	+2
	70-109	0
	50-69	+2
	<49	4
Heart rate, min	> 180	4
	140-179	+3
	110-139	+2
	70-109	0
	55-69	+2
	40-54	+3
	<39	4
BH, min	> 50	4
	35-49	+3
	25-34	+1
	12-24	0
	10-11	+1
	6-9	+2
	<5	4

Symptom	Value	Points
Oxygenation (A-a002 or Pa02)	A-aD02> 500 and PFiO2> 0.5	4
	A-aD0, 350-499 and Fi02> 0.5	+3
	A-aD02 200-349 and Fi02> 0.5	+2
	A-aD02 <200 and Fi02> 0.5	0
	Pa02> 70 and Fi02 <0.5	0
	Pa02 61-70 and Fi02 <0.5	+!
	Pa02 55-60 and Fi02 <0.5	+3
	Pa02 <55 and Fi02 <0.5	4
PH of arterial blood	> 7.7	4
	7.6-7.69	+ 3
	7.5-7.59	+ 1
	7.33-7.49	0
	7.25-7.32	+2
	7.15-7.24	+3
	<7.15	4
Sodium serum, mmol / l	> 180	4
	160-179	+3
	155-159	+2
	150-154	+ 1
	130-149	0
	120-129	+2
	111-119	+3
	<110	4
Serum potassium, mmol / l	> 7.0	4
	6.0-6.9	+3
	5.5-5.9	+ 1
	3.5-5.4	0
	3.0-3.4	+1
	2.5-2.9	+2
	<2.5	4

Symptom	Value	Points
	> 3,5 without arresters	4
	2,0-3,4 without arresters	+3
	1,5-1,9 without arresters	+2
	0,6-1,4 without arresters	0
Creatinine, mg / 100 ml	<0.6 without arresters	+2
	> 3.5 s arrester	+8
	2,0-3,4 with arresters	+6
	1.5-1.9 with arresters	4
	0.6-1.4 with arresters	0
	<0.6 s arrester	4
	> 60	4
	50-59.9	+2
Hematocrit,%	46-49.9	+ 1
	30-45.9	0
	20-29.9	+2
	<20	4
	> 40	4
	20-39.9	+2
Leukocytes	15-19.9	+1
(mm3 x 1000 cells)	3-14.9	0
	1-2.9	+2
	<1	4
Score of Glasgow	3-15 points in Glasgow

Note: Evaluation for serum creatinine is duplicated if the patient has acute renal failure (ARF). Mean arterial pressure = ((AD system) + (2 (AD diast.)) / 3.

If no blood gas analysis data is available, then serum bicarbonate can be used (the authors recommend using this indicator instead of arterial pH).

Symptom	Value	Points
Bicarbonate (mmol / l)	> 52.0	4
	41.0-51.9	+3
	32.0-40.9	+ 1
	22.0-31.9	0
	18.0-21.9	+2
	15.0-17.9	+3
	<15.0	4

Estimating patient's age

Age	Points
<44	0
45-54	2
55-64	3
65-74	5
> 75	6th

Assessment of concomitant chronic diseases

Operative intervention	Concomitant pathology	Points
Unoperated patients	In the history of severe organ failure OR immunodeficiency state	5
	In the anamnesis there is no severe organ failure and immunodeficiency state	0
Patients after emergency operations	In the history of severe organ failure OR immunodeficiency state	5
	In the anamnesis there is no severe organ failure and immunodeficiency state	0
Patients after scheduled operations	In the history of severe organ failure OR immunodeficiency state	2
	In the anamnesis there is no serious organ failure and immunodeficiency state	0

Note:

• Insufficiency of the organ (or system) or immunodeficiency state preceded the current hospitalization.
• Immunodeficiency status is determined if: (1) the patient received therapy that reduces protective forces (immunosuppressive
• therapy, chemotherapy, radiation therapy, long-term steroids or short-term high-dose steroids), or (2) has diseases that suppress the immune function, such as malignant lymphoma, leukemia, or AIDS.
• Hepatic failure if: there is liver cirrhosis, confirmed by biopsy, portal hypertension, episodes of bleeding from the upper digestive tract in the background of portal hypertension, previous episodes of hepatic insufficiency, coma or encephalopathy.
• Cardiovascular failure is class IV according to the New York classification.
• Respiratory failure: if there is a restriction of breathing due to chronic restrictive, obstructive or vascular diseases, documented chronic hypoxia, hypercapnia, secondary polycythemia, severe pulmonary hypertension, respiratory dependence.
• Renal failure: if the patient is on chronic dialysis.
• Assessment by APACH EII = (scores on the scale of acute physiological changes) + (points for age) + (points for chronic diseases).
• High scores on the APACHE II scale are associated with a high risk of mortality in the ICU.
• The scale is not recommended for use in patients with burns and after coronary artery bypass grafting.

Disadvantages of the APACHE II scale:

1. Impossibility of use till 18 years.
2. The general state of health should be assessed only in severe patients, otherwise the addition of this indicator leads to a reassessment.
3. There is no evaluation before admission to the intensive care unit, (appeared on the APACHE III scale).
4. In the case of death in the first 8 hours after admission, the evaluation of the data does not make sense.
5. In sedated, intubated patients, the Glasgow score should be 15 (normal), in the case of a history of neurological pathology, this estimate may be reduced.
6. With frequent reuse, the scale gives a somewhat higher rating.
7. A number of diagnostic categories are missed (pre-eclampsia, burns and other conditions), the coefficient of the injured organ does not always give an accurate picture of the condition.
8. With a smaller diagnostic coefficient, the scale score is more significant.

[4], [5], [6], [7], [8], [9], [10]

Later, the scale was transformed into the APACHE III scale

APACHE III was developed in 1991 to expand and improve the APACHE II predictive assessments. The database for the scale was collected from 1988 to 1990 and included data on 17 440 patients in intensive care units. The study included 42 departments in 40 different clinics. In the scale, urea, diuresis, glucose, albumin, bilirubin were added to improve the prognosis. The parameters of interaction between different variables (serum creatinine and diuresis, pH and pC02) have been added. In the APACHE III scale, more attention is paid to the state of immunity (Knaus WA et al., 1991).

The development of APACHE III pursued the following objectives:

1. Reassess the sample and significance of deviations, using objective statistical models.
2. Update and increase the size and representativeness of the data in question.
3. To assess the relationship between the results on the scale and the time of the patient's stay in the intensive care unit.
4. To differentiate the use of prognostic assessments for patient groups from the prognosis of lethal outcome in each specific case.

The APACHE III system has three main advantages. The first is that it can be used to assess the severity of the disease and patients at risk in one diagnostic category (group) or independently selected patient group. This is due to the fact that the increase in values on a scale correlates with the growing risk of hospital mortality. Second, the APACHE III scale is used to compare outcomes in patients in intensive care units, while the diagnostic and screening criteria are similar to those used in the development of the APACHE III system. Third, APACHE III can be used to predict treatment outcomes.

APACHE III predicts hospital mortality for groups of patients in resuscitation departments by matching the characteristics of patients on the first day in the ICU with 17 440 patients who originally entered the database (between 1988 and 1990) and 37,000 patients admitted to the departments resuscitation in the United States, which entered the updated database (1993 and 1996).

Scale for assessing acute physiological disorders and chronic disorders of state III

Acute Physiology and Chronic Health Evaluation III (APACHE III) (Knaus WA et al., 1991)

The APACHE III score consists of assessments of several components - age, chronic diseases, physiological, acid-base and neurological conditions. In addition, assessments reflecting the patient's condition at the time of admission to the ICU and the category of underlying disease are also taken into account.

Based on the assessment of the severity of the state, the risk of the likelihood of a fatal outcome in the hospital is calculated.

Assessment of the patient's condition before admission to the ICU

Assessment of the condition before admission to the ICU for patients with a therapeutic profile

The primary place of hospitalization before admission to the ICU	Evaluation
Emergency department
Other department of the hospital	0,2744
Delivered from another hospital
Other ORIT
Re-entry into the ICU
Operational or postoperative room

Assessment of admission to the ICU for surgical patients

Type of surgical intervention before admission to the ICU	Evaluation
Emergency Surgery	0.0752
Routine Surgery

[11], [12], [13], [14], [15]

The category of the main disease for patients of therapeutic profile

System of organs	Pathological condition	Evaluation
The cardiovascular system	Cardiogenic shock	1.20
	Heart failure	1.24
	Aortic aneurysm	1D1
	Congestive heart failure	1.30

System of organs	Pathological condition	Evaluation
	Diseases of peripheral vessels	1.56
	Rhythm disturbances	1.33
	Acute myocardial infarction	1.38
	Hypertension	1.31
	Other SSS diseases	1.30
Respiratory system	Parasitic pneumonia	1.10
	Aspiration pneumonia	1.18
	Tumors of the respiratory system, including the larynx and the trachea	1.12
	Stop breathing	1.17
	Noncardiogenic pulmonary edema	1.21
	Bacterial or viral pneumonia	1.21
	Chronic Obstructive Pulmonary Diseases	1.28
	PE	1.24
	Mechanical obstruction of the respiratory tract	1.30
	Bronchial asthma	1.40
	Other diseases of the respiratory system	1.22
Gastrointestinal tract	Liver failure	1.12
	Perforation or obstruction of the "intestine"	1.34
	Bleeding from varicose veins of the gastrointestinal tract	1.21
	Inflammatory diseases of the digestive tract (ulcerative colitis, Crohn's disease, pancreatitis)	1.25
	Bleeding, perforation of the stomach ulcer	1.28
	Gastrointestinal bleeding caused by diverticulum	1.44
	Other diseases of the digestive tract	1.27

System of organs	Pathological condition	Evaluation
Diseases of the nervous system	Intracranial hemorrhage	1.37
	Subarachnoid haemorrhage	1.39
	Stroke	1.25
	Infectious diseases of the National Assembly	1.14
	Tumors of the nervous system	1.30
	Neuromuscular diseases	1.32
	Convulsions	1.32
	Other nerve diseases	1.32
Sepsis	Not associated with the urinary tract	1.18
	Urinary septicemia	1.15
Injury	With or without combined injury	1.30
	Combined injury without TBI	1.44
Metabolism	Metabolic coma	1.31
	Diabetic ketoacidosis	1.23
	Overdose of drugs	1.42
	Other metabolic diseases	1.34
Diseases of the blood	Coagulopathy, neutropenia or thrombocytopenia	1.37
	Other blood diseases	1.19
Kidney Diseases		1.18
Other internal diseases		1.46

Category of underlying disease for patients with surgical profile

System	Type of operation	Evaluation
The cardiovascular system	Operations on the aorta	1.20
	Surgery on peripheral vessels without prosthetics	1.28
	Heart valve operations	1.31
	Operations for abdominal aortic aneurysm	1.27
	Surgery on peripheral arteries with prosthetics	1.51

System	Type of operation	Evaluation
	Carotid endarterectomy	1.78
	Other SSS diseases	1.24
Respiratory system	Respiratory tract infection	1.64
	Lung swelling	1.40
	Tumors of the upper respiratory tract (oral cavity, sinuses, larynx, trachea)	1.32
	Other respiratory diseases	1.47
Gastrointestinal tract	Perforation of the digestive tract or rupture	1.31
	Inflammatory diseases of the digestive tract	1.28
	Gastrointestinal obstruction	1.26
	Gastrointestinal bleeding	1.32
	Liver transplantation	1.32
	Tumors of the digestive tract	1.30
	Cholecystitis or cholangitis	1.23
	Other diseases of the digestive tract	1.64
Nervous diseases	Intracranial bleeding	M7
	Subural or epidural hematoma	1.35
	Subarachnoid haemorrhage	1.34
	Laminectomy or other operations on the spinal cord	1.56,
	Trepanation of the skull over a tumor	1.36
	Other diseases of the nervous system	1.52
Injury	With or without combined injury	1.26
	Combined injury without TBI	1.39
Kidney Diseases	Renal Tumors	1.34
	Other kidney diseases	1.45
Gynecology	Hysterectomy	1.28
Orthopedics	Fractures of the hip and extremities	.... .119

[16], [17], [18], [19], [20], [21], [22], [23], [24], [25]

Physiological scale APACHE III

The physiological scale is based on a variety of physiological and biochemical parameters, with estimates presented according to the severity of the pathological condition at the present time.

The calculation is based on the worst values for 24 hours of observation.

If the indicator has not been investigated, then its value is taken as normal.

Pulse, beats / min	Evaluation
<39	8
40-49	5
50-99	0
100-109	1
110-119	5
120-139	7th
140-154	13
> 155	17th

Mean blood pressure	Evaluation
<39	23
40-59	15
60-69	7th
70-79	6th
80-99	0
100-119	4
120-129	7th
130-139	9
> 140	10

Temperature, ° С	Evaluation
<32.9	20
33-33.4	16
33.5-33.9	13
34-34.9	8
35-35,9	2
36-39.9	0
> 40	4

Breathing rate	Evaluation
£ 5	17th
6-11	8, if there is no ventilation; 0 if ventilator is being used
12-13	7 (0 if BH = 12 and ventilation is performed)
14-24	0
25-34	6th
35-39	9
40-49	Eleven
> 50	18

Pa02, mm He	Evaluation
<49	15
50-69	5
70-79	2
> 80	0

A-ah BO,	Evaluation
<100	0
100-249	7th
250-349	9
350-499	Eleven
£ 500	14

Hematocrit,%	Evaluation
<40.9	3
41-49	0
> 50	3

Leukocytes, μL	Evaluation
<1000	19
1000-2900	5
3000-19 900	0
20 000-24 999	1
> 25,000	5

Creatinine, mg / dL, excluding acute renal failure	Evaluation
<0.4	3
0.5-1.4	0
1.5-1.94	4
> 1.95	7th

Diuresis, ml / day	Evaluation
<399	15
400-599	8
600-899	7th
900-1499	5
1500-1999	4
2000-3999	0
> 4000	1

Residual urea nitrogen, mg / dL	Evaluation
<16.9	0
17-19	2
20-39	7th
40-79	Eleven
> 80	12

Sodium, meq / liter	Evaluation
<119	3
120-134	2
135-154	0
> 155	4

Albumin, g / dL	Evaluation
<1.9	Eleven
2.0-2.4	6th
2.5-4.4	0
> 4.5	4

Bilirubin, mg / dL	Evaluation
<1.9	0
2.0-2.9	5
3.0-4.9	6th
5.0-7.9	8
> 8.0	16

Glucose, mg / dL	Evaluation
<39	8
40-59	9
60-199	0
200-349	3
> 350	5

Note.

1. Mean BP = Systolic AD + (2 x Diastolic BP) / 3.
2. The assessment of Pa02 is not used in intubated patients Fi02> 0.5.
3. A-a D02, is used only in intubated patients with Fi02> 0.5.
4. The diagnosis of OPN is made with a concentration of creatinine> 1.5 mg / dl, a diuresis rate <410 ml / day and no chronic dialysis.

(Evaluation of the pulse) + + (Evaluation of the pulse) + (Evaluation of the temperature) + (Evaluation of the BP) + (Evaluation of Pa02 or A-a D02) + (Assessment of hematocrit) + (Evaluation of leukocytes) + (Evaluation of the level of the creatinine + (Estimate of diuresis) + (Evaluation of residual diarrhea) + (Evaluation of residual azog) + (Assessment of nagria) + (Evaluation of albumin) + (Evaluation of bilirubin) + (Assessment of glucose).

Interpretation:

• The minimum score is 0.
• Maximum score: 192 (due to limitations of Pa02, A-aD02 and creatinine). 2.5.

Assessment of the acid-base state

Assessment of pathological conditions of CBS is based on the study of the content of pC02 and the pH of the patient's arterial blood.

The calculation is based on the worst values within 24 hours. If the value is not available, it is recognized as normal.

[26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36]

Evaluation of neurological status

Evaluation of neurological status is based on the patient's ability to open his eyes, the presence of verbal contact and motor reaction. The calculation is based on the worst values for 24 hours. If the value is not available, it is recognized as normal.

The APACHE III scale for assessing the severity of ICU patients can be used throughout hospitalization to predict the likelihood of death in the hospital.

Each day of the patient's stay in the ICU, an APACHE III score is recorded. Based on the developed multi-factor equations, using the daily estimates for APACHE III, it is possible to predict the probability of a patient's death on the present day.

Daily risk = (Score on the scale "Acute physiology" of the first day of the patient's stay in the ICU) + (Assessment on the scale "Acute physiology" during the current day) + (Changes in the evaluation according to the scale "Acute physiology" of the previous day).

Multifactorial equations for estimating the daily mortality risk are protected by copyright. They are not published in the literature, but are available to subscribers of the commercial system.

Once the parameters included in the APACHE III scale are tabulated, an assessment of the severity of the condition and the likelihood of fatal outcome in the hospital can be calculated.

Data requirements:

• The evaluation is performed to determine the indications of hospitalization in the ICU.
• If the patient has a therapeutic pathology, select the appropriate evaluation before entering the ICU.
• If the patient has been operated on, select the type of surgery (emergency, planned).
• The assessment is made for the main category of the disease.
• If the patient has a therapeutic profile, select the main pathological condition requiring hospitalization in the ICU.
• If the patient has undergone surgery, select the main pathological condition among surgical diseases requiring hospitalization in the ICU.

[37], [38], [39], [40], [41]

Overall assessment of APACHE III

Overall score APACHE III = (Points for age) + (Points for chronic pathology) + (Points for physiological status) + (Points acid-base balance) + (Points for neurological status)

The minimum overall score on the APACHE scale III = O

The maximum overall score for the APACHE III scale is 299 (24 + + 23 + 192 + 12 + 48)

Assessment of the severity of the condition according to APACHE III = (Evaluation before admission to the ICU) + (Assessment of the main category of the disease) + + (0.0537 (0 the total number of points for APACHE III)).

The probability of death in the hospital = (exp (Assessment of the severity of the state according to APACHE III)) / ((exp (risk equation APACHE III)) + 1)

Once again, we emphasize that the prognosis scales are not intended to predict the death of an individual patient with absolute accuracy. High scores on the scale do not mean total hopelessness, just as low scores do not insure against the development of unforeseen complications or accidental death. Despite the fact that the prediction of death using indicators obtained on the first day in the ICU on the APACHE III scale is reliable, it is still rare to determine the exact prognosis for an individual patient after the first day of intensive care. The ability to predict individual survival probabilities for a patient depends, among other things, on how he or she responds to therapy over time.

Clinicians using prognostic models should be mindful of the possibilities of modern therapy and understand that confidence intervals for each value are increasing day by day, increasing the number of positive outcomes that are more important than absolute values, and that some factors and response rates for Therapy is not determined by acute physiological abnormalities.

In 1984, the SAPS (UFSO) scale was proposed, the main goal of which was to simplify the traditional method of assessing severe patients (APACHE). In this version, 14 easily identifiable biological and clinical indices are used that sufficiently reflect the risk of death in intensive care patients (Le Gall JR et al., 1984). Indicators are evaluated in the first 24 hours after admission. This scale correctly classified patients in groups of increased probability of death, regardless of diagnosis, and was comparable with the physiological scale of acute conditions and other assessment systems used in intensive care units. The UFSE was the simplest and took much less time to evaluate it. Moreover, as it turned out, it is possible to conduct a retrospective assessment of the condition, since all parameters used in this scale are routinely registered in most intensive care units.

Original simplified scale for assessing physiological disorders

Original Simplified Acute Physiology Score (SAPS) (Le Gall JR, 1984)

A simplified scale of acute physiological states (SAPS) is a simplified version of APACHE of acute physiological states (APS). It makes it easy to calculate scores using the available clinical information; The scores correspond to the risk of mortality in the ICU.

Data:

• received within the first 24 hours after admission to the ICU;
• 14 information values against 34 values according to APACHE APS.

Parameter	Value	Points
Age, years	<45	0
	46-55	1
	55-65	2
	66-75	3
	> 75	4
Heart rate, ud./min	> 180	4
	140-179	3
	110-139	2
	70-109	0
	55-69	2
	40-54	3
	<40	4
Systolic blood pressure, mm Hg. Art.	> 190	4
	150-189	2
	80-149	0
	55-79	2
	<55	4
Body temperature, "С	> 41	4
	39-40,9	3
	38.5-38.9	I
	36-38.4	0
	34-35.9	1
	32-33.9	2
	30-31.9	3
	<30	4
Self-breathing, BH, min	> 50	4
	35-49	3
	25-34	1
	12-24	0
	10-11	1
	6-9	2
	<6	4
	On ventilation or CPAP	3

Parameter	Value	Points
	55700	2
	3.5-4.99	1
Diuresis after 24 h, l	0.70-3.49	0
	0.50-0.69	2
	0.20-0.49	3
	<0.20	4
	£ 154	4
	101-153	3
Urea, mg / dL	81-100	2
	21-80	1
	10-20	0
	<10	1
	> 60	4
	50-59.9	2
Hematocrit,%	46-49.9	1
	30-45.9	0
	20.0-29.9	2
	<20.0	4
	> 40	4
	20-39.9	2
	15-19.9	1
	3.0-14.9	0
	1.0-2.9	2
	<1.0	4
Leukocytes, 1000 / l	> 800	4
	500-799	3
	250-499	1
	70-249	0
	50-69	2
	29-49	3
	<29	4

Parameter	Value	Points
Potassium, meq / liter	> 7.0	4
	6.0-6.9	3
	5.5-5.9	1
	3.5-5.4	0
	3.0-3.4	1
	2.5-2.9	2
	<2.5	4
Sodium, meq / liter	> 180	4
	161-179	3
	156-160	2
	151-155	1
	130-150	0
	120-129	2
	119-110	3
	<110	4
HC03 meq / L	> 40	3
	30-39.9	1
	20-29.9	0
	10-19.9	1
	5,0-9,9	3
Glasgow Coma Scale, points	<5.0	4
	13-15	0
	10-12	1
	7-9	2
	4-6	3
	3	4

Notes:

1. Glucose is converted to mg / dL from mol / l (mol / l multiplied by 18.018).
2. Urea is converted to mg / dL from mol / l (mol / L multiply by 2.801). Overall score on the scale SAPS = Sum of scores on all scales. The minimum value is 0 points, and the maximum is 56 points. The likelihood of developing a lethal outcome is presented below.

SAPS	Risk of death
4
5-6	10.7 ± 4.1
7-8	13.3 ± 3.9
9-10	19.4 ± 7.8
11-12	24.5 ± 4.1
13-14	30.0 ± 5.5
15-16	32.1 ± 5.1
17-18	44.2 ± 7.6
19-20	50.0 ± 9.4
> 21	81.1 ± 5.4

Later the scale was modified by the authors and became known as SAPS II (Le Gall JR et al., 1993).

A new simplified scale for assessing physiological disorders II

New Simplified Acute Physiology Score (SAPS II) (Le Gall JR, et al., 1993; Lemeshow S. Et al., 1994)

The new simplified scale of acute physiological states (SAPS II) is a modified simplified scale of acute physiological states. It is used to assess ICU patients and can foresee the risk of mortality, based on 15 key variables.

Compared to SAPS:

• Excluded: glucose, hematocrit.
• Added: bilirubin, chronic diseases, cause of admission.
• Changed: Pa02 / Fi02 (zero points, if not for ventilation, or for CPAP).

The score for SAPS II varies from 0 to 26 against from O to 4 on SAPS.

Variable	Evaluation instructions
Age	In the years from the last birthday
Heart rate	The largest or smallest value in the last 24 hours, which will give the highest score
Systolic blood pressure	The largest or smallest value in the last 24 hours, which will give the highest score
Body temperature	The greatest value
Coefficient Pa02 / Fi02	Only if the ventilator or CPAP, using the lowest value
Diuresis	If the period is less than 24 hours, then bring it to the value in 24 hours
Urea of serum or BUN	The greatest value
Leukocytes	The largest or smallest value in the last 24 hours, which will give the highest score
Potassium	The largest or smallest value in the last 24 hours, which will give the highest score
Sodium	The largest or smallest value in the last 24 hours, which will give the highest score
Bicarbonate	The smallest value
Bilirubin	The smallest value
The Glasgow Coma Scale	The smallest value; if the patient is loaded (sedated), then use the data before loading
Type of receipt	Planned operation, if planned at least 24 hours prior to surgery; an unscheduled notification with less than 24 hours notice; for health reasons, if there were no operations for the last week before admission to the ICU
AIDS	HIV-positive with AIDS-associated opportunistic infection or tumor
Blood cancer	Malignant lymphoma; Hodgkin's disease; leukemia or generalized myeloma
Metastasis of cancer	Metastases detected by radiography or other accessible method

Parameter	Value	Points
Age, years	<40	0
	40-59	7th
	60-69	12
	70-74	15
	75-79	16
	80	18
Heart rate, ud./min	<40	Eleven
	40-69	2
	70-119	0
	120-159	4
	> 160	7th
Systolic blood pressure, mm Hg. Art.	<70	13
	70-99	5
	100-199	0
	> 200	2
Body temperature, ° С	<39	0
	> 39	3
Pa02 / Fi02 (if on ventilation or CPAP)	<100	Eleven
	100-199	9
	> 200	6th
Diuresis, l for 24 h	<0.500	Eleven
	0.500-0.999	4
	> 1,000	0
Urea, mg / dL	<28	0
	28-83	6th
	> 84	10
Leukocytes, 1000 / l	<1.0	12
	1.0-19.9	0
	> 20	3
Potassium, meq / liter	<3.0	3
	3.0-4.9	0
	> 5.0	3

Parameter	Value	Points
Sodium, meq / liter	<125	5
	125-144	0
	> 145	1
HC03, meq / L	<15	6th
	15-19	3
	> 20	0
Bilirubin, mg / dL	<4.0	0
	4.0-5.9	4
	> 6.0	9
Glasgow Coma Scale, points	<6	26th
	6-8	13
	9-10	7th
	11-13	5
	14-15	0
Chronic diseases	Metastatic carcinoma	9
	Blood cancer	10
	AIDS	17th
Type of receipt	Scheduled operation	0
	For health	6th
	Unplanned operation	8

> SAPS II = (Points for age) + (Points for heart rate) + (Points for systolic blood pressure) + (Points for body temperature) + (Points for ventilation) + (Points for diuresis) + (Points for blood urea nitrogen + (Points for the level of leukocytes) + (Points for the level of potassium) + (Points for the level of sodium) + (Points for the level of bicarbonates) + + (Points for the level of bilirubin) + (Points for assessment on the scale of Glasgow) + ( Points for a chronic illness) + (Points for the type of receipt).

Interpretation:

• Minimum value: O
• Maximum value: 160
• logit = (-7.7631) + (0.0737 (SAPSII)) + ((0.9971 (LN ((SAPSII) + 1))),
• The probability of death in a hospital is = exp (logit) / (1 + (exp (logit))).

[42], [43], [44], [45], [46], [47], [48], [49]

Scale of lung damage Lung Injury Score (Murray JF, 1988)

Estimated parameter	Index	Value	Evaluation
Chest x-ray	Alveolar consolidation	No alveolar consolidation	0
		Alveolar consolidation in one quadrant of the lungs	1
		Alveolar consolidation in two quadrants of the lungs	2
		Alveolar consolidation in three quadrants of the lungs	3
		Alveolar consolidation in four quadrants of the lungs	4
Hypoxemia	Pa02 / Рі02	> 300	0
		225-299	1
		175-224	2
		100-174	3
		<100	4
Compliance of the respiratory system, ml / cm H20 (with mechanical ventilation)	Compliance	> 80	0
		60-79	1
		40-59	2
		20-39	3
		<19	4
Positive end-expiratory pressure, cm H20 (with ventilation)	PEEP	<5	0
		6-8	1
		9-11	2
		12-14	3
		> 15	4
Total number of points	Presence of lung damage	No damage to the lungs	0
		Acute lung damage	0.1-2.5
		Severe lung damage (ARDS)	> 2.5

The RIFLE scale

(National Kidney Foundation: K / DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification and Stratification, 2002)

To unify the approaches to the definition and stratification of the severity of acute renal failure, the group of experts of the Acute Dialysis Quality Initiative (ADQI) created the RIFLE scale (rifle-rifle, English), which includes the following stages of renal failure:

• Risk - risk.
• Injury - damage.
• Failure is a failure.
• Loss - loss of function.
• ESKD (end stage renal disease) - the final stage of kidney disease = terminal renal failure.

Class	Whey creatinine	Rate of diuresis	Specificity / sensitivity
I (the risk)	Increase in the concentration of serum creatine and in 1.5 times Reduction in the glomerular filtration rate (GFR) by more than 25%	More than 0.5ml / kg / h for 6 hours	High sensitivity
I (damage)	Increase in serum creatinine concentration 2 times or. Reduction of GFR by more than 50%	More than 0.5 ml / kg / h for 12 hours
F (insufficiency)	Increase in serum creatinine concentration 3 times Reduction of GFR by more than 75% An increase in the serum creatinine concentration to 4 mg / dl (> 354 μmol / l) and more with a rapid increase> 0.5 mg / dL (> 44 μmol / L)	More than 0.3 ml / kg / h for 24 hours or anuria for 12 hours	High specificity
L (loss of kidney function)	Persistent arthritis (complete loss of kidney function) for 4 or more weeks
E (terminal renal failure)	Terminal renal failure more than 3 months

This classification system includes criteria for assessing creatinine clearance and tempo diuresis. In the study of the patient, only those estimates are used that indicate the patient has the most severe class of kidney damage.

It should be borne in mind that, with an initially elevated serum creatinine concentration (Scr), renal failure (F) is diagnosed even in cases where the increase in Scr does not reach a threefold excess above the baseline level. This situation is characterized by a rapid increase in Scr by more than 44 μmol / L to a serum creatinine concentration above 354 μmol / L.

The designation RIFLE-FC is used when a patient with chronic renal insufficiency has an acute impairment of renal function "arterial hypertension on CRF" and an increase in the serum creatinine level in comparison with the baseline level. In the event that renal failure is diagnosed on the basis of a decrease in the rate of hourly diuresis (oliguria), the designation RIFLE-FO is used.

"High sensitivity" of the scale means that most patients with these signs are diagnosed with moderate renal dysfunction, even in the absence of true renal failure (low specificity).

With "high specificity" there is virtually no doubt about the presence of severe kidney damage, although it may not be diagnosed in a number of patients.

One of the drawbacks of the scale is that for the stratification of the severity of arthritis it is necessary to know the baseline level of kidney function, however, in patients entering the ICU, it is usually unknown. This was the basis for another study, "Modification of Diet in Rénal Disease (MDRD)", based on the results of which the ADQI experts calculated the basal values of serum creatinine concentration at a given glomerular filtration rate of 75 ml / min / 1 , 73 m2.

Assessment of basal creatinine values in blood serum (μmol / L) corresponding to the glomerular filtration rate of 75 mg / min / 1.73 mg for persons of the Caucasoid race

Age, years	Men's	Women
20-24	115	88
25-29	106	88
30-39	106	80
40-54	97	80
55-65	97	71
> 65	88	71

Taking into account the obtained results, experts of Acute Kidney Injury Network (AKIN) subsequently proposed a system of stratification of gravity of arrester, which is a modification of the RIFLE system.

Kidney damage by AKIN

Stage	Concentration of creatinine in the patient's serum	Rate of diuresis
1	The concentration of creatinine in the blood serum (Beg)> 26.4 μmol / l or its increase by more than 150-200% of the baseline (1.5-2.0 times)	More than 0.5 ml / kg / h for six or more hours
2	Increase in Running concentration by more than 200% but less than 300% (more than 2 but less than 3 oases) from the baseline	More than 0.5 ml / kg / h for 12 hours or more
3	Increase in Running concentration by more than 300% (more than 3 times) from the initial concentration or a concentration of Be> 354 μmol / L with a rapid increase of more than 44 μmol / l	More than 0.3 ml / kg / h for 24 hours or anuria for 12 hours

The proposed system, based on changes in serum creatinine concentration and / or the rate of hourly diuresis, is similar in many respects to the RIFLE system, but still has a number of differences.

In particular, the classes L and E in the RIFLE system are not used in this classification and are considered as outcomes of acute renal damage. At the same time, the R category in the RIFLE system is equivalent to the first stage of the AKH in the AKIN system, and the RIFLE I and F classes correspond to the second and third stages in the AKIN classification.