ICU SCORING SYSTEM

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
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 assumptation that very ill
patients require more complex interventions and procedures than
patients who are less ill eg; the therapeutic intervention scoring
system(TISS)
CLASSIFICATION OF SCORING SYSTEM
• Organ specific score; sirmilar 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)
CLADDIFICATION 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
TYPES OF SCORING SYSTEM
• First day scoring systems;
• APACHE scoring system
• SAPS (simplified acute physiology score)
• MPM ( mortality prediction model)
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)
THE IDEAL SCORING SYSTEM
1. On the basic of easily/routinely recordable variables
2. Well caliberated
3. A high level of discrimination
4. Applicable to all patient population
5. Can be used in different countries
6. The ability to predict functional status or quality of life after ICU
discharge
No scoring system currently incorporates all these features
SEVERITY SCORE IN MEDICAL AND
SURGICAL ICU
 COMMON SCORING SYSTEMS

Acute Physiology and Chronic Health

Evaluation (APACHE)
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
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)
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
APACHE II SCORE
• The APACHE II score (0-71)
• Total APACHE = A+B+C
• A – APS points
• B – Age points
• C – Chronic Health Points
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
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)
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
 COMMON SCORING SYSTEM

SIMPLIFIED ACUTE PHYSIOLOGY

SCORE (SAPS)
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
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
SAPS III
• Scores based on data collected within 1st 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
COMMON SCORING SYSTEM

SEQUENTIAL ORGAN FAILURE

ASSESSMENT(SOFA)
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
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)
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
 COMMON SCORING SYSTEM

MULTIPLE ORGAN DYSFUNCTION

SCORE (MODS)
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
 COMMON SCORING SYSTEMS

LOGISTIC ORGAN DYSFUNCTION

SYSTEM (LODS)
LOGISTIC ORGAN DYSFUNCTION
SYSTEM (LODS)
• Worst values in 1st 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)
 COMMON SCORING SYSTEMS

CLINICAL PULMONARY INFECTION

SCORE (CPIS)
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.
 COMMON SCORING SYSTEMS

MORTALITY PROBABILITY MODEL

(MPM)
MORTALITY PROBABILITY MODEL
(MPM)
COMMON SCORING SYSTEMS

THERAPEUTIC INTERVENTION
SCORING SYSTEM (TISS)
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
 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
 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
 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
 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 )
 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)