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Critical Care Scoring Systems

by Soumitra R. Eachempati, MD

Several scoring systems have been developed to grade the severity of illness in critically ill patients. These systems are moderately accurate in predicting individual survival. However, these systems are more valuable for monitoring quality of care and for conducting research studies because they allow comparison of outcomes among groups of critically ill patients with similar illness severity.

The most common system is the 2nd version of the Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) score introduced in 1985. It generates a point score ranging from 0 to 71 based on 12 physiologic variables, age, and underlying health (see Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II Scoring System*). The APACHE III system was developed in 1991. This system is more complex, has 17 physiologic variables, and is somewhat less used. There are many other systems, including the 2nd Simplified Acute Physiology Score (SAPS II), the Mortality Prediction Model (MPM), and the Sequential Organ Failure Assessment (SOFA) score.

Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II Scoring System*

Physiologic Variable

Point Score

+4

+3

+2

+1

0

+1

+2

+3

+4

1

Temperature, core (°C)

41°

39–40.9°

38.5–38.9°

36–38.4°

34–35.9°

32–33.9°

30–31.9°

29.9°

2

Mean arterial pressure (mm Hg)

160

130–159

110–129

70–109

50–69

49

3

Heart rate

180

140–179

110–139

70–109

55–69

40–54

39

4

Respiratory rate (nonventilated or ventilated)

50

35–49

25–34

12–24

10–11

6–9

5

5

Oxygenation: a) F io 2 0.5: use A-aDO 2

500

350–499

200–349

< 200

b) F io 2 < 0.5: use P ao 2 (mm Hg)

> 70

61–70

55–60

< 55

6

Arterial pH

7.7

7.6–7.69

7.5–7.59

7.33–7.49

7.25–7.32

7.15–7.24

< 7.15

7

Serum Na (mmol/L)

180

160–179

155–159

150–154

130–149

120–129

111–119

110

8

Serum K (mmol/L)

7

6–6.9

5.5–5.9

3.5–5.4

3–3.4

2.5–2.9

< 2.5

9

Serum creatinine (mg/dL); double point score for acute renal failure

3.5

2–3.4

1.5–1.9

0.6–1.4

< 0.6

10

Hct (%)

60

50–59.9

46–49.9

30–45.9

20–29.9

< 20

11

WBC (in 1000s)

40

20–39.9

15–19.9

3–14.9

1–2.9

< 1

12

Glasgow coma score (GCS)

Score = 15 minus actual GCS (see Table: Glasgow Coma Scale*)

Acute physiology score is the sum of the 12 individual variable points.

Add 0 points for age <44; 2 points, 45–54 yr; 3 points, 55–64 yr; 5 points, 65–74 yr; 6 points 75 yr.

Add chronic health status points: 2 points for elective postoperative patient with immunocompromise or history of severe organ insufficiency; 5 points for nonoperative patient or emergency postoperative patient with immunocompromise or severe organ insufficiency.

(13) §

Serum HCO 3 (venous–mmol/L)

52

41–51.9

32–40.9

22–31.9

18–21.9

15–17.9

< 15

*APACHE II score = acute physiology score + age points + chronic health points. Minimum score = 0; maximum score = 71. Increasing score is associated with increasing risk of hospital death.

Choose worst value in the past 24 h.

Chronic health status: Organ insufficiency (eg, hepatic, cardiovascular, renal, pulmonary) or immunocompromised state must have preceded current admission.

§ This variable is optional; use only if no ABGs are available.

A-a DO 2 = alveolar–arterial oxygen gradient; F io 2 = fractional inspired O 2 .

Adapted from Knaus WA, Draper EA, Wagner DP, Zimmerman JE: APACHE II: A severity of disease classification system. Critical Care Medicine 13:818–829, 1985.

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