� APACHE II�� !"#$��%&'Taiwan Crit. Care Med.2010;11:1-7

1

APACHE II�� !"#$%&'(

�� 1I=�� 1I=�� 2I=�� 1I=�� 1I

�� 1I=�� 1I=�� 1I=�� 1I=�� 1I

��

�� �� !"#$%&"'()*+,�Acute Physiology and

Chronic Health Evaluation II� APACHE II�� 1985�� !"#$%&'

�� !"#$%&'()*+,-./0123456789:;<=&>

�� !"#$%&'()*+,$-./�0123456789:;<=

��APACHE II�� !"#$%&'()*+,# !-.'/0123

�� !"#$%&'APACHE II�� !"#$%&'()%*+,��

�� !"

�� �� !"#$�%&'()*+,-./0122005�1�1�

�2008�12�31�� !"#$%&'()*+APACHE II�� !"#

� 15�� !"#�$%& APACHE II�� 10�� !"�#$%&'

�� APACHE II �� !"#$%&'$()*+,'-.�/01

APACHE II�� !"#$%&'()*+,-./0�12

�� �� !"884�� !"#$%&'()'*+,-.542��

�� !"APACHE II�� !"#$%&'()*+,-./0$123

��P� 0.001��� !"#$%&'()*�+,-./01234-5

�P� 0.05�� APACHE II�� !"#$%&'(#$�� !"# 54�

���� !"# 75�� !"#$! 2.42-2.57��P<0.05��

�� APACHE II�� !"#$%&'!()*+,-./0123

�� !"#$%&'()*+APACHE II�� !"#$%&'()*+

�� !"#$%&'()*+,-./0123&456789:;<='

�� !"#$%&'()*+,"-$%./0123456&178,9

�� !"#$%&'()* +,-./01234+56

�� ! �� !"#�$%&'()*+,-*./01

�� !�� !"

500�� ��!"#$ 135�� !"#$%&'()*+%,( 1

�� 04-723-8595 � 1371�E-mail�54407@cch.org.tw

�� !"#$ �� !"#$%& 2

�� !Taiwan Crit. Care Med.2010;11:1-7

2

��

�� !"#$%&'()*�+,-!

�� !"#$%&'()*+,-./0

�� !"#$%&'()*+',-./0

�� !"#$%&'()*+,!-.Acute

Physiology and Chronic Health Evaluation

�APACHE�� Mortality Predictor Model

�MPM��Simplified Acute Physiology Score

�SAPS�� Therapeutic Intervention Scoring

System�TISS��Multiple Organ Dysfunction

Score�MODS� � Trauma Injury Severity

Score��� !"#$%&'()*+,-

�� !"#$%&'()*+,-.(/0

�� !"#$%&'(�)*+,-./0

�� !"#$%&'()*+,-./0'

�� �!"�#$%&'()*+,-./

�� !"�#$%&'(�Acute Physiology

and Chronic Health Evaluation�� !"

APACHE��1,2 �� !"#�$%&'()

�APACHE�� 1981�� !"#$%&'(

�� !"#$%& APACHE II� APACHE

III �� APACHE IV�� !"#$%&'(

�� !"#$%&'() 1985�� !"

APACHE II�� !"#$%�2 �� !"

�� !"#$ Kanus�� 1985�� !

APACHE II�� !"#$%&'(�)*+

�� !"#$%&'( APACHE II��

�� !"#$%&'()*+,-./01

�� !"#$ APACHE II�� !"#$

���3 APACHE II�� !"#$%&�'

�� !"#$%&'()*+#,-.

�� !"#$%&'()*+#%,-

�� !"#$%&'()*$+,-.'/

�� !"# APACHE II�� !"#$%

�� !"#$%&'()*+,-./!0

�� !"#$%&'()*+,-./01

�� !"#$ APACHE II�� !"#$

�� !"#$%&'()*+,-!./0

�� !"#$%&'()*+,-./

�2005-2008��� !"#$%&'()*(

�� !"#$% APACHE II�� !"�

��

��

�� !"#$�%&'()*+,-.

�� ! 2005� 1� 1�� 2008� 12� 31

�� !"#$%&'()*+,APACHE II

�� !� 15�� !"#�� $%&'(

�� 24�� !"#$ APACHE II��

�� !"#$%&'( )*+,%&'-

�� !"#$%� !&'$%� !()

�� !"#$%!"&'()*+#$,-

�� !"#$%&' APACHE II�� !

�� !"#$%&'()*+,-./

�� !"# APACHE II��� !"

10�� !"#$%�& 15-24�� 25-34

�� 35�� !"#$%� &'($%)

� APACHE II�� !"#$%$&'( 44

��� !"#$ 0�� 45� 54��� !

�� 2�� 55� 64��� !"#$ 3��

65� 74��� !"#$ 5��� !" 75

��� !"#$ 6��� !"#$%&'

�� APACHE II�� !"#$%&'()

�� ! Excel�� !"#$ SPSS 15.0�

�� !"#$%

��

�� !" 884�� !"#$%&!'

� 45�� 52�� 45�� 54�� 89��

55�� 64�� 103�� 65�� 74��

198��� !� 75��� 442����

APACHE II�� !"�#$ APACHE II 15-

24�� 325�� 25-34�� 409�� !

� APACHE II�� !"#$��%&'Taiwan Crit. Care Med.2010;11:1-7

3

�� 35�� 150�� !"#$%&%'(

�� !"#�APACHE II �� � 15�

���� !"�# APACHE II�� !"

�P� 0.001��� !"#$%&'()*+

��� !�

884�� !"#$%&"'()*+,-

�� ! 342�� !"# 542�� t ��

�� !"#$%&'()*+,-./%&

�� !"# 69.2�� !"#$%&'()

� 72.2��P� 0.004��� !�� !"#

�� !"#$% APACHE II Score �� !"#$

APACHE II Score

15-24 25-34 >=35 TotalP-value(n=325) (n=409) (n=150) (n=884)

Age N % N % N % N %

<45 022 06.8 020 04.9 10 06.7 052 05.9 0.001

45-54 046 14.2 036 08.8 07 04.7 089 10.1

55-64 045 13.8 040 09.8 18 12.0 103 11.7

65-74 073 22.5 093 22.7 32 21.3 198 22.4

>=75 139 42.8 220 53.8 83 55.3 442 50.0

P-value by Chi-square test for trend

�� !"#$%& APACHE II �� � 15�� !"#$%&'()*+' APACHE II�� !"�P� 0.01��

�� !"#$%&'()*+,-./012 APACHE II Score �� !"#

��

�� �� Total

(n=342) (n=542) (n=884)P-value

Age Mean 69.2 72.2 71.0 0.004

SD 15.5 13.6 14.4

Median 72.5 75.0 74.5

Min 21 20 20

Max 100 102 102

APACHE II Score Mean 29.8 25.8 27.4 <0.001

SD 7.6 6.8 7.4

Median 30.0 25.0 27.0

Min 15 15 15

Max 53 48 53

P-value by Student's t-test� APACHE II�� � 15�� !"#$%&�'()*+,-./0 t�� !"#$%&'()*+,%&-./0*

�P� 0.004��� APACHE II�� !"#$%&'#�P� 0.01��

�� !Taiwan Crit. Care Med.2010;11:1-7

4

� APACHE II�� !"#$%&�� 29.8

�� !"# 25.8�� !"#$%&'()

��P� 0.001��� !"

�� !"#$%&'()*+,-./

����� !���� !��P�0.001��

�� APACHE II�� �!�"#$%&

� APACHE II 25-34�� !"#$%&�P

�0.001��� APACHE II 15-24�� !

�� 35�� !"#$%&'()*+,-

��

�� !"#$%&'��Univariate

logistic regression��� !"#$%&'(

�� !"#$%&'()*+,-./ 45�

�� !"#$%&' 75�� !" 2.118�

�P� 0.011��� !"# 45-54�� !"

�� !"#$ 75�� !" 1.942�� !

�� !"#$%&�Multiple logistic regres-

sion��� ! APACHE II�� !"#$%

�� !"#$%&' 45�� 45-54�� !

�� !"#$%&'()%*+,-. 75�

�� ! 2.424��P� 0.004�� 2.57��P

� 0.001��� !"#$%&'(�)*+,

��

�� !"#$%&'()*+,-./

�� !" #$%&' APACHE II��

�� !"#$%&'()*+,-%

APACHE II�� !"#$%&'()*+,

�� !"#$%&$'�( APACHE II�

�� !"#$%&'()*+,-./01

�� !�� !" #$�� ! APACHE

II �� !"#$%&�� !"# 54��

�� !"# 75�� !"#$! 2.42-2.57

�� !"#$%&'()*+,-&.*/

�� !"#$%&'()*+,-!./0

�� !"#$$� !%&'()*+,-

�� !"#$%&'()*+,-./01

�� !"#$%&'()*+,-.&/0

�� !"#$%&'()"*+,-().

�� !"#$%&'()*+,-./$0

�� !"#$%&' APACHE II�� !

�� !"#$%&'()*+,-."/01

�� ! APACHE II�� !"#$%&'

�� ! APACHE II Score ��� !"#$%&'()*+,-./

Age

APACHE II <45 45-54 55-64 65-74 >=75 Total P-valueScore

�� N % N % N % N % N % N %

15-24 �� 09 40.9 16 34.8 11 24.4 016 21.9 34 24.5 086 26.5 <0.067

�� 13 59.1 30 65.2 34 75.6 057 78.1 105 75.5 239 73.5

25-34 �� 12 60.0 25 69.4 18 45.0 039 41.9 075 34.1 169 41.3 <0.001

�� 08 40.0 11 30.6 22 55.0 054 58.1 145 65.9 240 58.7

>=35 �� 07 70.0 05 71.4 12 66.7 015 46.9 048 57.8 087 58.0 <0.510

�� 03 30.0 02 28.6 06 33.3 017 53.1 035 42.2 063 42.0

Overall �� 28 53.8 46 51.7 41 39.8 070 35.4 157 35.5 342 38.7<0.001

�� 24 46.2 43 48.3 62 60.2 128 64.6 285 64.5 542 61.3

P-value by Chi-square test for trend

�� !"#$% APACHE II�� � 15�� !"#$%&'()*+,'-./*0�P� 0.01��

� APACHE II�� !"#$��%&'Taiwan Crit. Care Med.2010;11:1-7

5

�� !"#$%&'()*+,-. APACHE II Score �� !"#$%&'

����������������� !"#$%&'()*�������� !"#$%

Total N % OR 95% C.I. P-value OR 95% C.I. P-value

Age <45 52 28 53.8 2.118 1.187-3.779 0.011 2.424 1.326-4.429 0.004

45-54 89 46 51.7 1.942 1.227-3.073 0.005 2.570 1.589 -4.158 <0.001

55-64 103 41 39.8 1.200 0.773 -1.864 0.416 1.348 0.853 -2.130 0.201

65-74 198 70 35.4 0.993 0.699 -1.409 0.967 1.055 0.735 -1.514 0.772

>=75 442 157 35.5 1.000 1.000

APACHE II 15-24 325 86 26.5 1.000 1.000

25-34 409 169 41.3 1.957 1.428 -2.683 <0.001 2.171 1.569-3.005 <0.001

>=35 150 87 58.0 3.838 2.554-5.767 <0.001 4.393 2.889 -6.680 <0.001

OR: Odds ratio�� !"#$%&' APACHE II�� � 15�� !"#$%&'()*+, 54�� !"#$% 75�� !"#$!

2.42-2.57��

�� !"#$%&'()*+,-./01

�� !"#$��%&'()#*APACHE

II �� !"#$%&'()*+�,-+.

�� !"#$%&'()*+,-�./0

�� !"#$%&'( )*+,-./0

�� �!"#$%&'()*+,� -.

�� !"#$%&'!()*+,-./0

� APACHE III � APACHE IV�� !"#

�� !"#$%&'()!*+,-.

APACHE II�� 1985�� !"#$

�� !"#$%&'()*+,-'./0

�� !"#$%&'�the area under receiver

operating characteristic curve��0.863��

�� �4 �� !"#$%&'()*+,

�� !"#$%&'()*+,-./01

�� !"#$%&' APACHE II�� !

�� !"#$%$&'()%*+,-./

�� !"#$%&'(�2,3 �� !"#$%

�� APACHE II�� !"#$%&'(

�� !"#$%&'�()*+,-./0

�� !"#$ Glasgow Coma Scale��

�� !"#$%&'()*+&,-./0

�� !"#$%&'()*+,-./01

�� !"#$%&'(�)*+,-./0

�� !"#$%&'()*+,-./01

�� !"#$%&'()*+,-./�5 �

�� !"#$%&'()*+',-./0

�� !"�#$�6 �� !"#$%&'(

�� APACHE III � APACHE IV�� !

�� !"#$%&'()*+,-APACHE

III � APACHE IV�� !"#$%&'()

�� !"#$%&'()*+,-./01

�� !"#$%&'()*+,-./01

�� !"#$%&'()*+,-./

APACHE II�� !"#$%&'&()*+

�� !"#$%&'()*+,-./01

�� !"#$%&'()*+,-./01

�� !"#$%!&'()*+,-./0

�� !"#$%&'()*+,-./01

�� !"#$%&'()*+,-./0#

�� !" #$%&'( )*+,-./

�� �!"#$%&'()*+,-./0"

�� !"#$%&'()*+,-./01

�� !"#$%&'

�� !Taiwan Crit. Care Med.2010;11:1-7

6

�� !

1. Knaus WA, Zimmermann JE, Wagner DP, Draper EA,Lawrence DE, APACHE - acute physiology and chronichealth evaluation: a physiologically based classificationsystem. Crit Care Med 1981;9:591-597.

2. �� !"#$.�� !"#$%&�'()*+

��.�� ! 1999;14:44-58.3. Knaus, W. A., E. A. Draper, D. P. Wanger and J.E.

Zimmerman , APACHE-II : a severity of disease clas-sification system, Critical Care Medicine 1985;13,818-828.

4. Bekele Afessa, MD, Ognjen Gajic, MD, Mark T. Keegan,MB, MRCPI Severity of Illness and Organ FailureAssessment in Adult Intensive Care Units. Critical CareClinics 2007;23:639-658.

5. Paul L. Marino. The ICU Book. 3rd edition. Philadelphia,USA, Lippincott Williams&Wilkins 2007: 997-1001.

6. Knaus WA, Wagner DP, Draper EA, et al. The APACHEIII prognostic system. Risk prediction of hospital mortalityfor critically ill hospitalized adults. Chest 1991;100:1619-1636.

� APACHE II�� !"#$��%&'Taiwan Crit. Care Med.2010;11:1-7

7

Correspondence to: Dr. Kai-Huang LinDivision of Critical Care, Department of Internal Medicine, Changhua Christian Hospital; No. 135, Nan Hsiao St., Changhua,Taiwan1

Phone: 886-4-723-8595; Email: 54407@cch.org.twEpidemiology and Biometrics Center, Changhua Christian Hospital2

THE PITFALLS OF UTILIZING THE APACHE II SCORING SYSTEM

IN ASSESSING PATIENTS WITH SEPSIS

Hsin-Whae Hsu1, Kai-Huang Lin1, Yu-Jun Chang2, Chu-Hsien Wang1, Shin-Hwar Wu1,

Ming-Hwarng Horng1, Yu-Cheng Wu1, Ya-Pai Chen1, Yao-Chuan Hsiao1

Abstract

Introduction: Developed in 1985, the APACHE II scoring system was dem-onstrated to provide an accurate and reliable measure of the severity of illness andprobabilities of mortality. This scoring system soon became the most widely usedof the scoring systems. The APACHE II scoring system has been used in estimateand in the quality assessment of intensive care units. Although recent studies haveshown good discrimination and calibration for the APACHE II scoring system, it stillhas limitations in the clinic. This study will discuss and demonstrate the limitationsof APACHE II in predicting mortality in severe sepsis patients.

Methods: We collected the data of severe sepsis patients from January 2005to December 2008. All APACHE II scores on admission, age, and mortality resultsin the ICU were obtained from computer records. The patients were divided intofive groups, based on the age points in the APACHE II score. Their records wereanalyzed retrospectively, as well as the correlation between the APACHE II score,age, and mortality.

Results: Of the 884 patients with severe sepsis, 542 survived after critical caretreatment. The mean APACHE II scores of the survivors were higher than those ofthe non-survivors (P<0.001), but the mean age of the survivors was older (P=0.004).The younger severe sepsis patients (age < 54 years old) had 2.424-2.57 times themortality risk of the older severe sepsis patients (age >= 75 years old).

Discussion: Severity scoring systems play an important role in critical care.Our study revealed the limitations of the scoring system. The excessive age pointsof the APACHE II scoring system may cause us to neglect the mortality risk of patients.Even through the severity scoring system demonstrated good agreement in describingpatients in the aggregate, it did not perform as well for individual patients. Use ofprobabilities should not be employed for making clinical decisions regarding individualpatients.

Key words: Severity scoring system, Severe sepsis, APACHE II, Mortality risk