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Health

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

, medical expert
Last reviewed: 23.04.2024
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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.

trusted-source[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.

trusted-source[4], [5], [6]

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

trusted-source[7], [8], [9], [10]

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

trusted-source[11], [12], [13], [14], [15], [16], [17]

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.

trusted-source[18], [19], [20], [21], [22], [23], [24]

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.

trusted-source[25], [26],

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))).

trusted-source[27], [28], [29], [30], [31]

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)

  1. Increase in the concentration of serum creatine and in 1.5 times
  2. Reduction in the glomerular filtration rate (GFR) by more than 25%

More than 0.5ml / kg / h for 6 hours

High
sensitivity

I (damage)

  1. Increase in serum creatinine concentration 2 times or.
  2. Reduction of GFR by more than 50%

More than 0.5 ml / kg / h for 12 hours

F (insufficiency)

  1. Increase in serum creatinine concentration 3 times
  2. Reduction of GFR by more than 75%
  3. 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.

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