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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 61-64

A prospective study of outcome of acute physiology and chronic health evaluation ii score in critically ill surgical patients


1 General Surgery, Dist. Hospital, Dausa, Rajasthan, India
2 Department of Surgery, S.P. Medical College, Bikaner, Rajasthan, India
3 General Surgery, Community Health Centre, Mahwa, Rajasthan, India

Date of Web Publication28-Apr-2017

Correspondence Address:
Rambabu Meena
Department of General Surgery, S.P. Medical College, Bikaner, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AIHB.AIHB_43_16

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  Abstract 

Background: The acute physiology score is determined from the most deranged (worst) physiologic value, for example, the lowest blood pressure or the highest respiratory rate, during the initial 24 h after Intensive Care Unit (ICU) admission. The aim of present study is to apply Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system to surgical patients who have been critically ill preoperatively requiring elective surgical intervention or who underwent extensive elective surgery thereby requiring post-operative critical care monitoring and treatment in the post-operative ward or ICU or surgical ward. Materials and Methods: This prospective study was carried out on critically ill surgical patients from August 2012 to December 2013 in M. G. Hospital, Department of Surgery attached to Dr. S.N. Medical College and Associated Group of Hospitals, Jodhpur. The APACHE II score in the first 24 h of admission or operation and expected risks of death was calculated. Results: This study observed that 67.74% recovered male and 81.58% female and mortality rate increase when APACHE II score of patients increases. From the 100 patients enrolled the mean age was 47.38 ± 18.37 the overall median APACHE II score for all critically ill surgical patient was 9 with a range of 2–44 (minimum 2 and maximum 44). There was a significant difference between the APACHE II score of survivors and non-survivors. Conclusion: This scoring still provides a basic idea and uniform comparison of critical patients, thus help in research activities database validation. Few pitfalls related in the present study could have been avoided had there been large number of cases and more so of specific procedure-related patients necessitating critical care.

Keywords: Acute Physiology and Chronic Health Evaluation, critical care, Intensive Care Unit, mortality


How to cite this article:
Singh R, Meena R, Khokad M. A prospective study of outcome of acute physiology and chronic health evaluation ii score in critically ill surgical patients. Adv Hum Biol 2017;7:61-4

How to cite this URL:
Singh R, Meena R, Khokad M. A prospective study of outcome of acute physiology and chronic health evaluation ii score in critically ill surgical patients. Adv Hum Biol [serial online] 2017 [cited 2020 Jun 2];7:61-4. Available from: http://www.aihbonline.com/text.asp?2017/7/2/61/205395


  Introduction Top


The basis for Acute Physiology and Chronic Health Evaluations (APACHE's) development was the hypothesis that the severity of acute disease can be measured by quantifying the degree of abnormality of multiple physiologic variables. One of intensive care's major functions is to detect and treat life-threatening acute physiologic derangements and that a severity classification system must be based on objective physiologic measurements and be as independent of therapy as possible.[1] Finally, the index should be valid for a wide range of diagnoses, easy to use and based on data available in most hospitals.[2]

The acute physiology score (APS) is determined from the most deranged (worst) physiologic value, for example, the lowest blood pressure or the highest respiratory rate, during the initial 24 h after Intensive Care Unit (ICU) admission. The 24 h period ensures that all pertinent physiologic values are available, and clinical judgement ensures that each value is legitimate. Because severe chronic disease significantly reduces the probability of survival during acute illness, the original APACHE system incorporates a four-letter (A, B, C and D) designation corresponding to a spectrum ranging from excellent health (A) to severe chronic organ system insufficiency (D).[2]

APACHE is a reliable and useful means of classifying ICU patients. Increases in APS are associated with increased risk of subsequent hospital death.[2] APACHE has also proved useful in evaluating outcome from intensive care and in comparing the success of different treatment programmes.[3],[4] However, the original APACHE system is complex and needed formal multi-institutional validation.[5] The APACHE II system is the result of efforts to simplify and present a more clinically useful yet statistically accurate and valid patient classification system.

The weights for the nine remaining physiologic variables used in APCHE II are the same as in the original APCHE system. The recorded value is still based on the most deranged reading during each patient's initial 24 h in an ICU. Unlike APACHE, however, measurement of all 12 physiologic values is mandatory when using APCHE II. This eliminates the problem of missing values and concerns about the assumption that an unmeasured variable was normal.[5],[6] Although arterial blood gas measurements may be inappropriate for some patients, exclusion of these values is not encouraged and should only be done when clinical judgement strongly suggests the results would be within normal limits.

Because age and severe chronic health problems reflect diminished physiologic reserve, they have been directly incorporated into APCHE II. Chronologic age is a well-documented risk factor for death from acute illness, that is independent of the severity of disease.[7],[8] The weights assigned to age in APACHE II are based on their relative impact within this validation.

We discovered that when we controlled for acute physiologic derangement and age, three of the four chronic health classifications (B, C and D) were associated with higher death rates. However, only the most severe chronic organ system insufficiency or immunocompromised state (class D) markedly influenced outcome.[7] We also discovered that non-operative and emergency surgery admissions had a substantially higher risk for death from their prior organ system insufficiency than elective surgical admissions (Surgery or post-operative patients are those admitted to the ICU directly from the operating or recovery room. All others are non-operative). This was probably because patients with the most severe chronic conditions are not considered to be candidates for elective surgery. Therefore, non-operative or emergency operative admissions with a severe chronic organ system dysfunction are given an additional 5 points, while similar elective surgical admissions are only given 2 points.

The aim of present study is to apply APACHE II scoring system to surgical patients who have been critically ill preoperatively requiring elective surgical intervention or who underwent extensive elective surgery thereby requiring post-operative critical care monitoring and treatment in the post-operative ward or ICU or surgical ward.


  Materials and Methods Top


This prospective study was carried out on critically ill surgical patients from August 2012 to December 2013 in M. G. Hospital, Department of Surgery attached to Dr. S.N. Medical College and Associated Group of Hospitals, Jodhpur.

Inclusion criteria

  1. Emergency surgical procedures


    • Perforation peritonitis
    • Appendicular peritonitis
    • SAIO, etc.


  2. High-risk patients


    • Heart rate >110
    • Glasgow Coma Scale <13
    • Total leukocyte count >11,000/mm 3.


  3. Elective major surgical procedures


    • Whipple's/triple bypass surgery
    • Esophagectomy
    • Low anterior resection.


  4. Major surgical illness


    • Pancreatitis
    • Fournier's gangrene
    • Blunt trauma.


Some of these patients underwent emergency surgery.

Patients of both sexes were included.

Exclusion criteria

  • Patient <16 years of age
  • Patient with coronary artery bypass graft surgery
  • Burn patient.


The APACHE II score in the first 24 h of admission or operation and expected risks of death was calculated. [Table 1]
Table 1: Interpretation of score

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Validity was tested by analysing the accuracy of the predicted probabilities overall and within various APACHE score groups compared with observed mortalities using the Chi-square test and linear regression techniques. The comparison was reported statically significant at P < 0.05.


  Results Top


The present study showed that the maximum number of patients was ≤44 years of age [Table 2]. Most of the patient in the present study belongs to APCHE II score 5–8 and least number of patients belongs to 29–32 APACHE II score [Table 3].
Table 2: Age wise sex distribution

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Table 3: Acute Physiology and Chronic Health Evaluation II score distribution

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This study observed that 67.74% recovered male and 81.58% female [Table 4] and mortality rate increase when APACHE II score of patients increases [Table 5]. From the 100 patients enrolled the mean age was 47.38 ± 18.37 the overall median APACHE II score for all critically ill surgical patient was 9 with a range of 2–44 (minimum 2 and maximum 44). There was a significant difference between the APACHE II score of survivors and non-survivors [Table 6].
Table 4: Final outcome

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Table 5: Mortality rate

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Table 6: Comparison between survivors and non-survivors

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  Discussion Top


The disparity between demands and available health-care resources is a universal problem and ICU is an area where this disparity exists up to the maximum, especially in developing countries like India. When it comes to treatment, patients can generally be divided into three groups, who will benefit, those likely to benefit and those who will not. The relative size of these three groups will depend on the selection criteria used in the assessment. By not treating patients in ICU, who will not benefit, cost-effectiveness is increased in addition to avoiding a vegetative life.

At present various scoring systems are used to predict outcome in critically ill patients: Although all lack 100% accuracy but play a vital role in audit of ICU performance and clinical research. The present study was conducted in a government College Hospital, for validation of APACHE II scoring system by prospective study, for defining outcome in 100 critically ill surgical patients.

The ability to survive an acute illness is related to a patient's condition before he or she becomes acutely ill, which can be judged by the patient's age, sex and APS or any chronic health disease. In the present study, it was found that there was no apparent correlation between age or sex and mortality; even in elderly patients, the response to surgery and treatment if instituted timely was not different from young ones. Lee et al.[9] had also reported fair outcome in elderly comparable to their younger counterparts in an analysis of Surgical ICU patients. This is in contrast to the general belief that advanced chronological age is associated with poor recovery from acute illness. The decrease in physiological function of many major organ systems that accompanies ageing may sometimes adversely affect the outcome. Mortality rate was unaffected by sex as well.

The APACHE II scoring system has been successfully used for prediction of outcome in majority of ICU patients by Knaus et al.,[10] Wagner et al. (1983),[7] Jordan et al.,[11] Purdie et al.,[12] Marks et al. (1991),[13] Brown et al.,[14] Van Le et al.,[15] Wang et al.,[16] Markgraf et al.[17] However, these trails are from western developed countries, where medical facilities, technical expertise, availability of funds and the facilities for research are at an optimal level. The present prospective study of 100 critically ill post-operative ICU patients showed a significant correlation between the APACHE II scores and prognosis. On applying the Chi-square test, the difference in survival score and non-survivor score was found to be statistically significant.

In calculating sensitivity (accuracy of prediction of non-survivors), death was selected as the 'outcome positive' and score greater or equal to 17 was taken as test positive. The sensitivity was calculated to be 77.78% while specificity was 93.15%. The cut-off value of APACHE II score was taken as 17 because it was found to offer the optimal values in terms of both sensitivity and specificity. Ridley et al.[18] had taken cut-off value as 20, Wang et al.[16] had taken 15. In the present study, the mean APCHE II scores for survivor and non-survivors was 8.41 and 23.37 respectively whereas Giangiuliani et al.[19] reported similar figures of 14.2 and 22.4, respectively. The observed mortality as per APACHE II score grading was highest in 21–30 range and lowest in 11–20 range (50%). Knaus et al.[9] proposed predicted mortality as (0–10) =0%, (11–20) =27.5%, (21–30) =64%, (31–40) =89% and >40 = 100%. The observed mortality rate in comparison in the present study was (0–10) =1.64%, (11–20) =50%, (21–30) =91.67% (31–40) =75%, >40 = 100%. The reason for higher observed mortality in the present study in relation to APACHE II score grading is probably delayed hospitalisation, lack of proper transport facilities and limited resources.


  Conclusion Top


This scoring still provides a basic idea and uniform comparison of critical patients, thus help in research activities database validation. Few pitfalls related in the present study could have been avoided had there been large number of cases and more so of specific procedure related patients necessitating critical care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Scheffler RM, Knaus WA, Wagner DP, Zimmerman JE. Severity of illness and the relationship between intensive care and survival. Am J Public Health 1982;72:449-54.  Back to cited text no. 1
    
2.
Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE-acute physiology and chronic health evaluation: A physiologically based classification system. Crit Care Med 1981;9:591-7.  Back to cited text no. 2
    
3.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE, Birnbaum ML, Cullen DJ, et al. Evaluating outcome from intensive care: A preliminary multihospital comparison. Crit Care Med 1982;10:491-6.  Back to cited text no. 3
    
4.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985;13:818-29.  Back to cited text no. 4
    
5.
Champion HR, Sacco WJ. Measurement of patient illness severity. Crit Care Med 1982;10:552-3.  Back to cited text no. 5
    
6.
Li TC, Phillips MC, Shaw L, Cook EF, Natanson C, Goldman L. On-site physician staffing in a community hospital Intensive Care Unit. Impact on test and procedure use and on patient outcome. JAMA 1984;252:2023-7.  Back to cited text no. 6
    
7.
Wagner DP, Knaus WA, Draper EA. Statistical validation of a severity of illness measure. Am J Public Health 1983;73:878-84.  Back to cited text no. 7
    
8.
Kenney RA, editor. Physiology of Aging: A Synopsis. Chicago: Year Book Medical Publishers, Inc.; 1982.  Back to cited text no. 8
    
9.
Lee KH, Hui KP, Lim TK, Tan WC. Acute physiology and chronic health evaluation (APACHE II) scoring in the Medical Intensive Care Unit, National University Hospital, Singapore. Singapore Med J 1993;34:41-4.  Back to cited text no. 9
    
10.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985;13:818-29.  Back to cited text no. 10
    
11.
Jordan DA, Miller CF, Kubos KL, Rogers MC. Evaluation of sepsis in a critically ill surgical population. Crit Care Med 1987;15:897-904.  Back to cited text no. 11
    
12.
Purdie JA, Ridley SA, Wallace PG. Effective use of regional Intensive Therapy Units. BMJ 1990;300:79-81.  Back to cited text no. 12
    
13.
Marks RJ, Simons RS, Blizzard RA, Browne DR. Predicting outcome in intensive therapy units – A comparison of APACHE II with subjective assessments. Intensive Care Med 1991;17:159-63.  Back to cited text no. 13
    
14.
Brown PE, McClave SA, Hoy NW, Short AF, Sexton LK, Meyer KL. The acute physiology and chronic health evaluation II classification system is a valid marker for physiologic stress in the critically ill patient. Crit Care Med 1993;21:363-7.  Back to cited text no. 14
    
15.
Van Le L, Fakhry S, Walton LA, Moore DH, Fowler WC, Rutledge R. Use of the APACHE II scoring system to determine mortality of gynecologic oncology patients in the Intensive Care Unit. Obstet Gynecol 1995;85:53-6.  Back to cited text no. 15
    
16.
Wang BW, Mok KT, Chang HT, Liu SI, Chou NH, Tsai CC, et al. APACHE II score: A useful tool for risk assessment and an aid to decision-making in emergency operation for bleeding gastric ulcer. J Am Coll Surg 1998;187:287-94.  Back to cited text no. 16
    
17.
Markgraf R, Deutschinoff G, Pientka L, Scholten T. Comparison of acute physiology and chronic health evaluations II and III and simplified acute physiology score II: A prospective cohort study evaluating these methods to predict outcome in a German interdisciplinary Intensive Care Unit. Crit Care Med 2000;28:26-33.  Back to cited text no. 17
    
18.
Ridley S, Jackson R, Findlay J, Wallace P. Long term survival after intensive care. Br Med J 1990;301:1127-30.  Back to cited text no. 18
    
19.
Giangiuliani G, Mancini A, Gui D. Validation of a severity of illness score (APACHE II) in a surgical Intensive Care Unit. Intensive Care Med 1989;15:519-22.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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