Analyzing the Efficacy of Apache III versus Apache II on Duration of Mechanical Ventilation and ICU Stay
This study have been designed to compare Apache II and Apache III scores as a predictor factors for mechanical ventilation, mortality rate, duration of mechanical ventilation and ICU stay. This is a prospective study conducted in Alzahra General Hospital, Isfahan-Iran University of medical sciences, from September 2005 to September 2006. All patients with respiratory failure due to COPD, Bronchectasis, Asthma, pulmonary edema and pulmonary emboli admitted to ICU, were evaluated. The Apache II and Apache III scores obtained were calculated at admission. Other variables recorded were clinical outcome (dead/survival), mandatory intubation and mechanical ventilation, duration of mechanical ventilation and ICU stay. Correlation between Apache II and Apache III with duration of mechanical ventilation and ICU stay analyzed by Pearson correlation coefficient and p<0.05 considered meaningful. One hundred eighty patients were enrolled, that 38 % were women and 62% men. Of the 180 patients 52 (28.9%) died and 128 (71.1%) survived. Correlation between duration of ventilation and Apache II and III were, respectively p = 0.09 and p = 0.019 and correlation between of ICU stay and Apache II and III were p = 0.09 and p = 0.019. Apache III and Apache II both were used to predict outcome and necessity of intubation and mechanical ventilation but Apache III was more significant predictive factor for ICU stay and duration of mechanical ventilation.
Mechanical ventilation is an essential life support mode of treatment given
to many patients in Intensive Care Unit (ICU) (Debidas et
al., 1997; Eapen et al., 1997). Different
scoring systems have been developed to help the physician to determine the severity
of medical conditions and prediction of mortality and mobility (Eapen
et al., 1997; Listello and Sessler, 1994).
Although ICU stay is an important predictive factor and indirectly related to
weaning time (Woods et al., 2000; Sudarsanam et
al., 2005; Menzies et al., 1989) but
duration of mechanical ventilation is not almost always as necessary as the
patients condition (Listello and Sessler, 1994).
It other studies the relationship of Aphacy II Score with ICU stay and duration
of mechanical ventilation had been shown (Debidas et
al., 1997; Eapen et al., 1997). Because
Apache III score is easier to use and it is clinically more practical but still
it have not been tried to show that if Apache III is as useful as Apache II
(Ludwigs et al., 1991; Jeffrey
et al., 1992; Portier et al., 1992;
Miller et al., 1992). Therefore, we prospectively
compared the two scoring systems to predict during of mechanical ventilation
and ICU stay.
MATERIALS AND METHODS
This prospective study which had been conducted in Alzahra General Hospital
at Isfahan University of medical sciences from September 2007 to September 2008.
All patients with respiratory failure due to COPD, bronchectasia, asthma, pulmonary
edema and pulmonary emboli that needed ICU were evaluated. The patients with
age under 18 years, burns, mortality at the first 24 h, pelvic fracture, cardiopulmonary
arrest, cardiac disease and postoperative condition, were excluded. Respiratory
failure was defined as PaO2<55 mmHg and PaCO2 >50
mm Hg. Indications of endotracheal intubation (ET) were respiratory arrest,
unconsciousness, increasing PaCO2 and base acid disorder. The scores
obtained in Apache II (Woods et al., 2000) and
Apache III (Listello and Sessler, 1994) was calculated
at admission. Other variables recorded included clinical outcome (dead/survival),
necessity of intubation and mechanical ventilation, duration of mechanical ventilation
and ICU stay. Other parameters such as temperature, pulse and respiratory rate,
blood pressure, hematocrite, liver and renal function test, serum electrolytes,
base acid balance and oxygenation were aggregated during study.
Apache II and Apache III scores based on the need to intubation and mechanical ventilation and mortality rate were analyzed. Correlation between Apache II and Apache III with duration of mechanical ventilation and ICU stay analyzed by Pearson correlation coefficient and p<0.05 considered meaningful.
One hundred eighty patients were enrolled that 38 % were women and 62% were men. Of the 180 patients 52 (28.9%) died and 128 (71.1%) survived. The mean of Apache II was 21.41+2.81 and Apache III was 63.97+11.2. 146 (81.1%) of patients were intubated. Of one hundred eighty patients, 137 (76.11%) of patients needed mechanical ventilation.The mean duration of intubation and mechanical ventilation and ICU stay were subsequently; 19.97+2.31, 11.17+1.19 and 31.62+8.14 days.
The average score of the Apache II and the Apache III based on necessity of intubation and mechanical ventilation and mortality rate are shown in Table 1.
Among 137 patients that needed mechanical ventilation, analysis of correlation was preformed between duration of ventilation and Apache II and III (Table 2).
The mean of duration of ICU stay was 31.62 days: (min: 6 max: 122 days) correlation
between of ICU stay and two scores of Apache are shown in Table
3 (Woods et al., 2000).
average score of the Apache II and Apache III based on the need to intubation
and mechanical ventilation and mortality rate|
||Correlation between duration of ventilation and Apache II
and III score
= 0.019, p = 0.091|
|| Correlation between of ICU stay and two scores of apache
= 0.019, p = 0.091|
Scoring systems primarily developed for estimating prognosis in critically
ill patients have not been well validated in mechanically ventilated patients.
Modified Organ System Failure (OSF) score had been shown that be superior to
the Apache score in predicting mortality (Eapen et al.,
So, suggested that Apache II score measured at admission is significant independent predictor of mortality in the patients on mechanical ventilation (Sudarsanam et al., 2005). This study was done on patients to compare Apache II and Apache III scores as predictor factors for mechanical ventilation and mortality rate and duration of mechanical ventilation and remaining in ICU.
The data show that 76.11% of patients admitted to ICU needed mechanical ventilation
that is more than sudarsanam study (Sudarsanam et al.,
2005) (76.11% vs. 41%) Our patients had more critical conditions. Patients
with respiratory failure and lower mean arterial pressure, comorbid condition
(Spicher and White, 1987; Menzies
et al., 1989), high blood urea (Ludwigs et
al., 1991) and requiring ventilation within first 24 h (Portier
et al., 1992). Lower serum albumin and lower FEV1, had been found
to have poorer prognosis but were not shown to independently predict outcome
(Sudarsanam et al., 2005). Among patients with
type I respiratory failure, sepsis, multi-organ system failure, cardiac failure,
higher bronchoalveolar fluid interleukin 8 concentrations (Miller
et al., 1992), worsening renal function (Sloane
et al., 1992), a longer duration of mechanical ventilation, medically
ill patients with sepsis and multiple transfusions as compared with trauma patients
with the above comorbidities (Hudson, 1989) were all
found to have an adverse affect on outcome. (Sudarsanam
et al., 2005). Present study showed that Apache III as compared with
Apache II causes significant longer duration of mechanical ventilation (Spicher
and White, 1987). Then patients with higher Apache III will had more poor
prognosis compared with others and could be consider as a predictive factor
for prognosis (Suchyta et al., 1992). Gupta
et al. (2001) had shown an Apache III score of >57 predicted a
poor outcome but Sudarsanam et al. (2005) believed
that Apache II score is a factor that had prognostic significance on out come
Nevins and Epstein (2001) have also shown that the Apache
II associated comorbidities predicted a poorer outcome for COPD patients requiring
mechanical ventilation (Menzies et al., 1989).
Present study showed that Apache III is more important predictive factor in
ICU stay and duration of mechanical ventilation than Apache II (Ludwigs
et al., 1991). Some other studies shown that Apache III score couldnt
be used as well as the Apache II for predict outcome because arterial PH, as
a significant predictive value (Diener and Burrows, 2001),
is not included in the Apache III scoring system and additional variables in
the Apache III such as billirubin and glucose may not have any bearing on the
population (Sudarsanam et al., 2005). However
our study had shown that Apache III is more significant to predict ICU stay
as an important predictive factor to weaning time (Woods
et al., 2000).
In conclusion, we have noted that Apache III and Apache II both could be used to predict outcome and need to intubation and mechanical ventilation but Apache III is more significant index as a predictive factor for ICU stay and duration of mechanical ventilation.
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