ICU SCORING SYSTEM (1).pptx

For doctor of intensive care medicine

1. ICU SCORING SYSTEM

2. CONTENT Introduction Classification of scoring system Types of scoring system (time frame) Ideal scoring system Severity score in MICU and SICU Common scoring system and other scores Comparison of scoring system Which score to use? Reference

3. INTRODUCTION Severity of illness scoring system are developed to evaluate delivery of care and provide prediction of outcome of groups of critically ill patients who are admit to ICUs Scoring system consist of two parts; a severity score , which is a number( generally the higher this is, the more severe the condition) and a calculated probability of mortality

4. CLASSIFICATION OF SCORING SYSTEM Anatomical score ; depend on the anatomical are involved. mainly used for trauma patients ( eg ; injury score (AIS) a injury score (ISS) ) Therapeutic weighted score ; based on the assumption that very ill patients require more complex interventions and procedures than patients who are less ill eg ; the therapeutic intervention scoring system(TISS)

5. CLASSIFICATION OF SCORING SYSTEM Organ specific score ; similar to the therapeutic scoring; the sticker a patient the more organ system will be involved, ranging from organ dysfunction to failure ( eg ; sequential organ failure assessment score SOFA)

6. CLASSIFICATION OF SCORING SYSTEM Physiological assessment ; based on the degree of derangement of routinely measured physiological variables ( eg ; acute physiology and chronic health evaluation (APACHE) and simplified acute physiology score (SAPS) Simple scale ; based on clinical judgement ( eg ; survive or die ) Disease specific ; ( eg ; Ranson’s criteria for acute pancreatitis, subarachnoid hemorrhage assessment using the World Fedration of Neurosurgeon score and liver failure assessment using Child-Pugh or model for end stage liver disease (MELD) scoring

7. TYPES OF SCORING SYSTEM First day scoring systems ; APACHE scoring system SAPS (simplified acute physiology score) MPM ( mortality prediction model)

8. TYPES OF SCORING SYSTEM Repetitive scoring system ; OSF (organ system failure) SOFA ( sequential organ failure assessment) ODIN (organ dysfunction and infection system) MODS ( multiple organ dysfunction score) LOD ( logistic organ dysfunction)

9. THE IDEAL SCORING SYSTEM On the basic of easily/routinely recordable variables Well caliberated A high level of discrimination Applicable to all patient population Can be used in different countries The ability to predict functional status or quality of life after ICU discharge No scoring system currently incorporates all these features

10. Calibration? Predicted mortality Observed mortality Good calibration P value 0.25 mean 25% die 7 5 % survive

11. Discrimination? Using computerized statistics process to get AUC, ROC curve AUC 0.5 coin test ROC eg ; P value 0.7

12. SEVERITY SCORE IN MEDICAL AND SURGICAL ICU

13. COMMON SCORING SYSTEMS Acute Physiology and Chronic Health Evaluation (APACHE)

14. Acute Physiology and Chronic Health Evaluation (APACHE) The APACHE score is the best known and most widely used score with good calibration and discrimination The original APACHE score developed in 1981 to classify groups of patients according to severity of illness and was divided into 2 sections; physiology score to assess the degree of acute illness and preadmission evaluation to determine the chronic health status of the patients

15. ORIGINAL APACHE SCORE 34 physiologic measures (0-4) Sum of all acute physiology score (APS) Worst of the initial 24 hour after ICU admission Chronic health A (excellent health) B C D (severe chronic organ system insufficiency)

16. APACHE II SCORE The APACHE II score system was released in 1985 and included a reduction in the number of variables to 12 The APACHE II scoring system is measured during the first 24 hour of ICU admission with a maximum score 71. A score of 25 represents a predicted mortality of 50 % and a score of over 35 represents a predicted mortality of 80%. APACHE II score is sum of; Acute physiology score Age Chronic health score

17. APACHE II SCORE The APACHE II score (0-71) Total APACHE = A+B+C A – APS points B – Age points C – Chronic Health Points

18. APACHE II SCORE Predicted mortality = 3.517+ (score APACHE II) * 0.146 Predicted mortality (adjusted) = 3.517+( score APACHE II )* 0.146 + diagnostic category weight

19. APACHE III SCORE APACHE III , released in 1991, was developed with the objective of improved statistical power, ability to predict individual patient outcome and identify the factors in ICU that influence outcome variations but it is far more complex than the 2 previous scoring syatems 17 physiological variables and Total score (0-299) Acid-base disturbances GCS score- based on the worst Age score 7 co-morbidities (cardiac, respiratory, renal failure excluded)

20. APACHE IV SCORE The APACHE IV score system was published in 2006 Limitations; Complexity has 142 variables But wed-based can be done Developed and validated in ICUs of USA only

21. COMMON SCORING SYSTEM SIMPLIFIED ACUTE PHYSIOLOGY SCORE (SAPS)

22. SIMPLIFIED ACUTE PHYSIOLOGY SCORE (SAPS) The SAPS score was first released in 1984 as an alternative to APACHE scoring The original SAPS score is obtained in the first 24 hour of ICU admission by assessment of 14 physiological variables, but no input of pre-existing disease was included It has superseded by the SAPS II and SAPS III, both of which assess the 12 physiological variables in the first 24 hour of ICU admission and include weightings for pre-admission health status and age

23. SIMPLIFIED ACUTE PHYSIOLOGY SCORE (SAPS) Predicted mortality = 14.4761 + 0,0844 * SAPS II + 6.6158* log (SAPS II+1) Area under ROC for SAPS is 0.8 where as SAPS II has a better value of 0.86

24. SAPS III Scores based on data collected within 1 st hour of entry to ICU Allows predicting outcome before ICU intervention occurs Better evaluation of individual patient rather than an ICU Limitation Time for collecting data Can have greater missing information

25. COMMON SCORING SYSTEM SEQUENTIAL ORGAN FAILURE ASSESSMENT(SOFA)

26. SEQUENTIAL ORGAN FAILURE ASSESSMENT(SOFA) Previously known as sepsis-related organ failure assessment because it was initially developed in 1994 to describe the degree of organ dysfunction associated with sepsis in a mixed, medical-surgical ICU patients Nowadays, it has since been validated to describe the degree of organ dysfunction in various ICU patient groups with organ dysfunctions not due to sepsis

27. SEQUENTIAL ORGAN FAILURE ASSESSMENT(SOFA ) The SOFA score involves six organs systems (respiratory, cardiovascular, renal, hepatic, central nervous system, coagulation), and the function of each is scored from 0 (normal) to 4 (most abnormal) , giving a possible score of 0-24 Mortality rate increases as number of organs with dysfunction increase Unlike other scores, the worst value on each day is recorded A key difference is in the cardiovascular component; instead of the composite variable, the SOFA score uses a treatment-related variable ( dose of vasopressor agents)

28. SEQUENTIAL ORGAN FAILURE ASSESSMENT(SOFA) Maximal (highest total) SOFA score is the sum of highest score per individual during the entire ICU stay. SOFA for 1 st 10 days is significantly higher in non-survivors Delta SOFA score; maximum SOFA admission SOFA

29. COMMON SCORING SYSTEM MULTIPLE ORGAN DYSFUNCTION SCORE (MODS)

30. MULTIPLE ORGAN DYSFUNCTION SCORE (MODS ) The MODS score six organ system; respiratory (PaO2/FiO2 in arterial blood); renal (serum creatinine); hepatic (serum bilirubin); cardiovascular (pressure adjusted heart rate); hematological (platelet count) and CNS (Glasgow Coma Score) with weighted score (0-4) awarded for increasing abnormality of each organ system Scoring is performed on a daily basis Total score range from 0-24 Area under ROC 0.936 MODS predicts mortality to a greater extent than Admission MODS score

31. COMMON SCORING SYSTEMS LOGISTIC ORGAN DYSFUNCTION SYSTEM (LODS)

32. LOGISTIC ORGAN DYSFUNCTION SYSTEM (LODS ) Worst values in 1 st 24 hours of ICU stay Worst value in each of 6 organ system Total score ranges from 0-22 Good calibration and discrimination ( area under ROC 0.85)

33. COMMON SCORING SYSTEMS CLINICAL PULMONARY INFECTION SCORE (CPIS)

34. CLINICAL PULMONARY INFECTION SCORE A score developed to established a numerical value of clinical, radiographic, and laboratory markers of pneumonia Serial measurements of the CPIS could be used to identify survivors versus non-survivors as early as day 3 of therapy The CPIS correlated with mortality rate CPIS score 6 suggest pneumonia CPIS is an important variable to monitor during VAP therapy. Patient with VAP having CPIS 6 can safely discontinue antibiotics after 3 days.

35. COMMON SCORING SYSTEMS MORTALITY PROBABILITY MODEL (MPM)

36. MORTALITY PROBABILITY MODEL (MPM )

37. COMMON SCORING SYSTEMS THERAPEUTIC INTERVENTION SCORING SYSTEM (TISS)

38. THERAPEUTIC INTERVENTION SCORING SYSTEM (TISS ) Measuring sickness severity based on type and amount of treatment received Both clinical and administrative application; - assessing severity of illness - determining resource requirements - assessing use of critical care facilities and function - not standardized Daily data collected from each patient on 76 possible clinical interventions

39. EARLY WARNING SCORE (EWS) The Early Warning Score (EWS) born in the late 1990 in the UK, is simply a medical guide to quickly evaluate the level of a patient’s clinical deterioration in both emergency and general care conditions It is a physiological scoring system, based on the individual values of multiple vital signs For each vital signs, the deviation from its normal range is assessed and classified into threshold ranges, with individual score from 0 to 3, according to severity

40. EARLY WARNING SCORE (EWS) They are including, but not limited to; Core body temperature Heart rate Respiratory rate Blood oxygen saturation Blood pressure (systolic) Level of consciousness

41. MELD SCORE ( MODEL FOR END-STAGE LIVER DISEASE This provide a numerical calculation based on the following informations How effectively liver excrete bile(bilirubin). Patient with an elevated bilirubin may have jaundice, or the yellowing of the skin, due to inability to efficiently remove bile How well the liver can produce blood clotting factors (INR or Prothrombin ). Patient with altered INR often develop easy brusing and easy bleeding

42. MELD SCORE ( MODEL FOR END-STAGE LIVER DISEASE The current function of the kidney (creatinine) An electrolyte that is a marker for significant liver disease ( sodium )

43. MELD SCORE ( MODEL FOR END-STAGE LIVER DISEASE The MELD score range from 6 to 40 and is a measure of how severe a patient’s liver disease is. MELD can fluctuate based on your current condition, with variations from a few points as lab values vary to a larger increase if you have an infection or an acute decompensation ( worsening of your liver disease)

44. REFERENCE OH’s Intensive Care Manual, 8 th edition Scoring System in the critically ill, BJA, 19(7) Severity Scoring And Outcome Prediction (C.J Barlow,David Pilcher ) ICU Scoring Systems PPT, Dr. Iman Gilal , MD

45. THANK YOU