Critical Care Scoring Systems: Approach to the Critically Ill Patient: Merck Manual Professional

Critical Care Medicine

Approach to the Critically Ill Patient

Critical Care Scoring Systems

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Critical Care Scoring Systems

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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 Table 4: Approach to the Critically Ill Patient: 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) and several mortality probability models.

Table 4

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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) Fio₂ ≥ 0.5: use A-aDO₂	≥ 500	350–499	200–349	—	< 200	—	—	—	—
5	b) Fio₂ < 0.5: use Pao₂ (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 4: Coma and Impaired Consciousness: 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 HCO₃ (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 DO₂ = alveolar–arterial oxygen gradient; Fio₂ = fractional inspired O₂.
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.

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) Fio₂ ≥ 0.5: use A-aDO₂	≥ 500	350–499	200–349	—	< 200	—	—	—	—
5	b) Fio₂ < 0.5: use Pao₂ (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 4: Coma and Impaired Consciousness: 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 HCO₃ (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 DO₂ = alveolar–arterial oxygen gradient; Fio₂ = fractional inspired O₂.
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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Last full review/revision October 2012 by Soumitra R. Eachempati, MD

Content last modified November 2012

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