|
Overview :
The APACHE (Acute Physiology And Chronic Health Evaluation)
is a system for classifying patients in the intensive care unit. Patients are
evaluated by physiologic scores and evaluation of chronic health status.
Physiologic scores correlate with severity of illness. Results of the evaluation
can be used to estimate the mortality rate for patients in the ICU and during
the hospitalization.
Physiologic classes of variables (total 8 classes with 34
variables):
(1) cardiovascular: 7 variables
(2) respiratory: 3 variables
(3) renal: 3 variables
(4) gastrointestinal: 6 variables
(5) hematologic: 4 variables
(6) septic: 4 variables
(7) metabolic: 6 variables
(8) neurologic: 1 variable
Scoring:
• The
physiologic data is evaluated during the first 32 hours after admission to the
ICU.
• Each
variable is assigned a value of 0 to 4, based on significance of deviation from
normal, with more severe deviations given higher values.
Cardiovascular
|
Parameter |
Finding |
Points |
|
heart rate ventricular response |
>= 180 |
+4 |
|
|
141 – 179 |
+3 |
|
|
111- 140 |
+2 |
|
|
70 – 110 |
0 |
|
|
56 – 69 |
+2 |
|
|
41 – 55 |
+3 |
|
|
<= 40 |
+4 |
|
mean arterial pressure in mm Hg |
>= 160 |
+4 |
|
|
131 – 159 |
+3 |
|
|
111 – 130 |
+2 |
|
|
70 – 110 |
0 |
|
|
51 – 69 |
+2 |
|
|
<= 50 |
+4 |
|
right atrial pressure or central venous pressure in mm
HG |
>= 26 |
+2 |
|
|
16 - 25 |
+1 |
|
|
1 - 15 |
0 |
|
|
< 1 |
+1 |
|
evidence of acute MI |
Yes |
+4 |
|
|
No |
0 |
|
ECG arrhythmias |
atrial arrhythmias and hemodynamic instability |
+3 |
|
|
atrial arrhythmias alone |
+2 |
|
|
> 6 PVCs per minute |
+3 |
|
|
ventricular tachycardia or fibrillation |
+4 |
|
serum lactate in mg/dL |
> 72 |
+4 |
|
|
30.7 – 72 |
+3 |
|
|
0 – 36.6 |
0 |
|
arterial pH |
>= 7.70 |
+4 |
|
|
7.60 – 7.69 |
+3 |
|
|
7.51 – 7.59 |
+1 |
|
|
7.33 – 7.50 |
0 |
|
|
7.25 – 7.32 |
+2 |
|
|
7.15 – 7.24 |
+3 |
|
|
< 7.15 |
+4 |
where:
• mean
arterial blood pressure = (((systolic blood pressure) + (2 * (diastolic blood
pressure))) / 3)
• Evidence of an acute MI may include ECG, serum marker
changes, or other.
• serum
lactate expressed in mEq/L, which is no longer used routinely. This was assumed
to be equivalent to mmol/L, which is converted to mg/dL by multiplying by 9
Respiratory
|
Parameter |
Finding |
Points |
|
respiratory rate nonventilated |
>= 50 |
+4 |
|
|
35 – 49 |
+3 |
|
|
26 – 34 |
+1 |
|
|
12 – 25 |
0 |
|
|
10 – 11 |
+1 |
|
|
7 – 9 |
+2 |
|
|
<= 6 |
+4 |
|
P(A-a)O2 with FIO2 = 1.0 |
>= 500 |
+4 |
|
|
351 – 499 |
+3 |
|
|
200 – 350 |
+1 |
|
|
< 200 |
0 |
|
PaCO2 |
>= 70 |
+4 |
|
|
61 - 69 |
+3 |
|
|
50 - 60 |
+2 |
|
|
30 - 49 |
0 |
|
|
25 - 29 |
+2 |
|
|
20 - 24 |
+3 |
|
|
< 20 |
+4 |
where:
• The
P(A-a)O2 for FIO2 is given as ((FIO2 as fraction from 0.21 to 1.00) * 713) -
PaCO2 - PaO2); however, the decision points for lower FIO2s are not given. These
are unlikely to be comparable to those of an FIO2 of 1.00.
Renal
|
Parameter |
Finding |
Points |
|
urine output in L per day |
>= 5 |
+2 |
|
|
> 3.5 to < 5.0 |
+1 |
|
|
0.7 to 3.5 |
0 |
|
|
0.48 to < 0.70 |
+2 |
|
|
0.12 – 0.47 |
+3 |
|
|
< 0.12 |
+4 |
|
serum BUN in mg/dL |
> 150 |
+4 |
|
|
101 – 150 |
+3 |
|
|
81 – 100 |
+2 |
|
|
21- 80 |
+1 |
|
|
10 – 20 |
0 |
|
|
< 10 |
+2 |
|
serum creatinine in mg/dL |
> 7.0 |
+4 |
|
|
3.6 – 7.0 |
+3 |
|
|
2.1 – 3.5 |
+2 |
|
|
1.6 – 2.0 |
+1 |
|
|
0.6 – 1.5 |
0 |
|
|
< 0.6 |
+1 |
Gastrointestinal
|
Parameter |
Finding |
Points |
|
serum amylase in IU |
> 2,000 |
+4 |
|
|
501 – 1,999 |
+3 |
|
|
<= 500 |
0 |
|
serum albumin in g/dL |
> 8 |
+4 |
|
|
3.5 – 8.0 |
0 |
|
|
2.5 – 3.4 |
+1 |
|
|
< 2.5 |
+2 |
|
total bilirubin in mg/dL |
>= 15 |
+3 |
|
|
5.1 – 14.9 |
+1 |
|
|
0 - 5 |
0 |
|
alkaline phosphatase in IU |
> 160 |
+1 |
|
|
0 - 160 |
0 |
|
SGOT |
>= 1,500 |
+2 |
|
|
101 – 1,499 |
+1 |
|
|
0 - 101 |
0 |
|
anergy by skin testing |
total |
+4 |
|
|
relative |
+2 |
|
|
none |
0 |
where:
• total
anergy = no response to all provocative skin tests including mumps and
fungal
• relative
anergy = reduced response to skin tests indicative of compromised cellular
immunity
Hematological
|
Parameter |
Finding |
Points |
|
hematocrit in percent |
> 60 |
+4 |
|
|
51 – 60 |
+2 |
|
|
47 – 50 |
+1 |
|
|
30 – 46 |
0 |
|
|
20 – 29 |
+2 |
|
|
< 20 |
+4 |
|
WBC in thousands per µL |
> 40 |
+4 |
|
|
> 20 to 40 |
+2 |
|
|
> 15 to 20 |
+1 |
|
|
> 3 to 15 |
0 |
|
|
1 – 3 |
+2 |
|
|
< 1 |
+4 |
|
platelet count in thousands per µL |
> 1000 |
+2 |
|
|
> 600 to 1000 |
+1 |
|
|
80 to 600 |
0 |
|
|
20 to < 80 |
+2 |
|
|
< 20 |
+4 |
|
prothrombin time in seconds greater than control |
> 12.0 |
+4 |
|
|
5.1 – 12.0 |
+3 |
|
|
3.1 – 5.0 |
+2 |
|
|
0 – 3.0 |
0 |
where:
• Prothrombin time is that of the patient when not
anticoagulated.
Septic
|
Parameter |
Finding |
Points |
|
CSF positive culture |
Yes |
+4 |
|
|
No |
0 |
|
blood culture positive |
Yes |
+4 |
|
|
No |
0 |
|
fungal culture positive |
blood and/or CSF positive for fungi |
+4 |
|
|
2 sites other than blood or CSF positive for
fungi |
+3 |
|
|
1 site other than blood or CSF positive for
fungi |
+1 |
|
|
No |
0 |
|
rectal temperature in °C |
> 41°C |
+4 |
|
|
39.1 – 41.0 |
+3 |
|
|
38.6 – 39.0 |
+1 |
|
|
36.0 – 38.5 |
0 |
|
|
34.0 – 35.9 |
+1 |
|
|
32.0 – 33.9 |
+2 |
|
|
30.0 – 31.9 |
+3 |
|
|
<= 29.9 |
+4 |
Metabolic
|
Parameter |
Finding |
Points |
|
serum calcium in mg/dL |
>= 16 |
+4 |
|
|
14.0 – 15.9 |
+2 |
|
|
11.1 – 13.9 |
+1 |
|
|
8.0 – 11.0 |
0 |
|
|
5.0 – 7.9 |
+2 |
|
|
< 5.0 |
+4 |
|
serum glucose in mg/dL |
> 800 |
+4 |
|
|
500 - 800 |
+3 |
|
|
251 – 499 |
+1 |
|
|
70 – 250 |
0 |
|
|
50 – 69 |
+2 |
|
|
30 – 49 |
+3 |
|
|
< 30 |
+4 |
|
serum sodium in mEq/L |
> 180 |
+4 |
|
|
161 – 180 |
+3 |
|
|
156 – 160 |
+2 |
|
|
151 – 155 |
+1 |
|
|
130 – 150 |
0 |
|
|
120 – 129 |
+2 |
|
|
110 – 119 |
+3 |
|
|
< 110 |
+4 |
|
serum potassium in mEq/L |
> 7.0 |
+4 |
|
|
6.1 – 7.0 |
+3 |
|
|
5.6 – 6.0 |
+1 |
|
|
3.5 – 5.5 |
0 |
|
|
3.0 – 3.4 |
+1 |
|
|
2.5 – 2.9 |
+2 |
|
|
< 2.5 |
+4 |
|
serum bicarbonate in mEq/L |
> 40 |
+3 |
|
|
31 – 40 |
+1 |
|
|
20 – 30 |
0 |
|
|
10 – 19 |
+1 |
|
|
5 – 9 |
+3 |
|
|
< 5 |
+4 |
|
serum osmolarity |
> 350 |
+4 |
|
|
321 – 350 |
+3 |
|
|
301 – 320 |
+1 |
|
|
260 – 300 |
0 |
|
|
240 – 259 |
+2 |
|
|
220 – 239 |
+3 |
|
|
< 220 |
+4 |
Neurological
|
Parameter |
Finding |
Points |
|
Glasgow coma score |
3 |
+4 |
|
|
4 – 6 |
+3 |
|
|
7 – 9 |
+2 |
|
|
10 – 12 |
+1 |
|
|
13 - 15 |
0 |
APACHE score =
= (points for cardiovascular status) + (points for
respiratory status) + (points for renal status) + (points for gastrointestinal
status) + (points for hematological status) + (points for septic status) +
(points for metabolic status) + (points for neurological status)
Preadmission Health Status
|
Qualifying
Questions, based on health status 3-6 months before
admission |
Group |
Description |
|
Did
the patient have weekly visits to a physician?
Was
the patient unable to work because of illness?
Was
the patient bedriddent or institutionalized because of illness?
Had
the patient suffered a relapse after systemic treatment for
carcinoma? |
D |
Severe restriction of activity due to disease; includes
patients bedridden or institutionalized due to illness |
|
Was
the patient's usual daily activity limited?
Did
symptoms occur with mild exercise?
Had
the patient received treatment for neoplasm with remission?
Had
the patient received uncomplicated hemodialysis? |
C |
chronic disease producing serious but not
incapacitating restriction of activity |
|
Did
the patient see a physician monthly?
Did
the patient take medication chronically?
Was
the patient mildly limited in activity level due to illness?
Did
the patient have diabetes mellitus, chronic renal failure, a bleeding
disorder, or chronic anemia? |
B |
mild to moderate limitation in activity because of
chronic health problem |
|
negative responses to all of the above questions |
A |
prior good health with no functional
limitations |
Interpretation:
• minimum score: 0
• maximum
score: 129 (cardiovascular 27; respiratory 12; renal 12; gastrointestinal 18;
hematological 16; septic 16; metabolic 24; neurological 4)
Probability of Death
in Hospital based on APACHE score
|
Score |
Mortality
Rate |
|
0 - 5 |
2.3% |
|
6 - 10 |
4.3% |
|
11 - 15 |
8.6% |
|
16 - 20 |
16.4% |
|
21 - 25 |
28.6% |
|
26 - 30 |
56.4% |
|
31+ |
70% |
data extrapolated from Figure 1, page 595
Relationship between
chronic health status and patient outcome
Overall
|
Preadmission Health
Status |
Probability of Dying in the
ICU |
Probability of Dying in the
Hospital |
|
A |
7.3% |
12% |
|
B |
5.9% |
12% |
|
C |
10.5% |
16.5% |
|
D |
11.7% |
25% |
Nonoperative
|
Preadmission Health
Status |
Probability of Dying in the
ICU |
Probability of Dying in the
Hospital |
|
A |
14% |
20.9% |
|
B |
10.1% |
20.2% |
|
C |
12.8% |
21.7% |
|
D |
22.2% |
50% |
Operative
|
Preadmission Health
Status |
Probability of Dying in the
ICU |
Probability of Dying in the
Hospital |
|
A |
3% |
6.2% |
|
B |
2.2% |
7.2% |
|
C |
8.6% |
12.3% |
|
D |
3% |
6% |
|