SLIDE 1
CSIM 2018 Banff AB Scott McKee MD MPH FACP -Basic elements of - - PowerPoint PPT Presentation
CSIM 2018 Banff AB Scott McKee MD MPH FACP -Basic elements of - - PowerPoint PPT Presentation
CSIM 2018 Banff AB Scott McKee MD MPH FACP -Basic elements of Scoring Systems -Widely used ICU scoring systems and relative performance data -Examples of 2 special cases outside of the ICU -SOFA data support for 2016 Sepsis
SLIDE 2
SLIDE 3
Scoring systems are widely used in critical care
- medicine. A few are used widely for ICU
predictions and infinite others for selected disease states and outcomes
Usually quantify severity of illness (the Score) used
to assign probability of mortality (the Prediction)
Should always be used with an understanding of
their limitations
Some systems have been compared but there is no
- ne “best” model
SLIDE 4
Infinite variables available, no universal
approach
May be single set or repeated over time:
First day: APACHE, SAPS, MPM Repetitive: SOFA, OSF, MODS
SLIDE 5
- Assemble the scoring components
- Validation
- Discrimination
- Calibration
SLIDE 6
APACHE (II-IV)
Acute Physiology and Chronic Health Evaluation
MPM (1-3)
Mortality Prediction Model
SOFA
Sequential Organ Failure Assessment
SAPS (1-3)
Simplified Acute Physiology Score
SLIDE 7
SLIDE 8
SLIDE 9
Crit Care Med. 2011 Jan;39(1):163-9. doi:
10.1097/CCM.0b013e3181f96f81.
Severity of illness scoring systems in the
intensive care unit.
Keegan MT1, Gajic O, Afessa B.
Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.
SLIDE 10
“The areas under the receiver operating
characteristic curve of SAPS 3, Acute Physiology and Chronic Health Evaluation IV, and Mortality Probability Model0 III were 0.85, 0.88, and 0.82, respectively.”
“All three fourth-generation models had good
calibration.”
SLIDE 11
Comparison of newer scoring systems with the
conventional scoring systems in general intensive care population.
Aujuneja D, Singh O, Nasa P, Dang R SO. Minerva Anestesiol. 2012 Feb;78(2):194-200.
Epub 2011 Nov 18
SLIDE 12
“Overall, the newer scoring systems
performed better than their older counterparts and were more accurate.”
“Nevertheless, the difference in efficacy
was not statistically significant and the choice of scoring system may depend on the ease of use and local preferences.”
SLIDE 13
Early Warning System Scoring
SLIDE 14
Derivation of a PIRO Score for Prediction of Mortality in Surgical Patients With Intra-Abdominal Sepsis
Juan G. Posadas-Calleja, MD, MSc,
Henry T. Stelfox, MD, PhD, FRCPC,
Andre Ferland, MD, FRCPC,
Danny J. Zuege, MD, MSc, FRCPC,
Daniel J. Niven, MD, PhD, FRCPC,
Luc Berthiaume, MD, MSc, FRCPC and
Christopher James Doig, MD, MSc, FRCPC⇑
+Author Affiliations
All authors are at the University of Calgary, Calgary, Alberta, Canada. Juan G. Posadas-Calleja is a clinical assistant professor, Department of Critical Care Medicine. Henry T. Stelfox is a professor, Departments of Critical Care Medicine, Community Health Sciences, and Medicine. Andre Ferland is a clinical associate professor, Departments of Critical Care Medicine and Medicine. Danny J. Zuege is a clinical professor, Department of Critical Care Medicine and Division of Respiratory Medicine. Daniel J. Niven is an assistant professor, Departments of Critical Care Medicine and Community Health Sciences. Luc Berthiaume is a clinical associate professor, Departments of Critical Care Medicine and Community Health Sciences and Division of Respiratory Medicine. Christopher James Doig is a professor and head, Department of Critical Care Medicine, and a professor, Departments of Community Health Sciences and Medicine.
Corresponding author: Christopher James Doig, MD, MSc, FRCPC, Foothills Medical Centre, ICU Administration McCaig Tower, Room 0449, 3134 Hospital Dr NW, Calgary, AB T2N 5A1 (e-mail: cdoig@ucalgary.ca).
SLIDE 15
Intensive Care Med. 1996 Jul;22(7):707-10. The SOFA (Sepsis-related Organ Failure
Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems
- f the European Society of Intensive Care
Medicine.
Vincent JL1, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, Reinhart CK, Suter PM, Thijs LG.
SLIDE 16
- JAMA. 2001 Oct 10;286(14):1754-8.
Serial evaluation of the SOFA score to predict
- utcome in critically ill patients.
Ferreira FL1, Bota DP, Bross A, Mélot C, Vincent JL.
CONCLUSIONS:
“Sequential assessment of organ dysfunction during the first few days of ICU admission is a good indicator of prognosis. Both the mean and highest SOFA scores are particularly useful predictors of outcome. Independent of the initial score, an increase in SOFA score during the first 48 hours in the ICU predicts a mortality rate of at least 50%.”
SLIDE 17
January 17, 2017
Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit
Eamon P. Raith, MBBS, MACCP1,2; Andrew A. Udy, MBChB, PhD, FCICM1,3; Michael Bailey, PhD3; et al CONCLUSIONS In this retrospective cohort analysis
- f 184 875 adults, SOFA (area under the receiver
- perating characteristic curve [AUROC], 0.753)
demonstrated significantly greater discrimination for in-hospital mortality than SIRS criteria (AUROC, 0.589)
- r qSOFA (AUROC, 0.607).
SLIDE 18
General ICU scoring systems have been developed
and updated over ~30 years and perform well at predicting mortality in populations.
Score should NOT be used in the management
decisions on individual patients
Scores most helpful in research and in QI projects. When choosing a system, factors that should be
taken in to consideration include performance in the population of interest, feasibility, ease of use, and availability
SLIDE 19
http://intensivecarenetwork.com/124-icu-calculators/ Scores : APACHE II
APACHE IV APGAR CHILD ISS - RTS - TRISS MPM II (Admission) MPM II (24-48-72h) MODS SAPS II SOFA
SLIDE 20
SLIDE 21
SLIDE 22
SLIDE 23
Mortality prediction model III (MPM0-III)
VariableResponsePointsPatient age* Medical or unscheduled surgical admission?Yes1No0Cardiopulmonary resuscitation prior to admission?Yes1No0Coma (Glasgow coma scale 3-5)?
(Does not include patients whose coma is due to overdose or who received neuromuscular blocking agents)Yes1No0Heart rate ≥150 bpm?Yes1No0Systolic blood pressure ≤90 mmHg?Yes1No0Mechanical ventilation?Yes1No0Acute renal failure?
(Does not include pre-renal azotemia)Yes1No0Cardiac dysrhythmias?Yes1No0Cerebrovascular accident?Yes1No0Intracranial mass effect?Yes1No0Gastrointestinal bleeding?Yes1No0Metastatic carcinoma?
(Distant metastases only; does not include local lymph node involvement)Yes1No0Cirrhosis?Yes1No0Chronic renal insufficiency?
(Creatinine >2 mg/dL chronically)Yes1No0In acute or chronic care facility before admission to ICUYes1No0Time between hospital and ICU admission >1 dayYes1No0Full resuscitation statusYes1No0
* Patient age does not receive points when calculating the severity score; however, it is used in the formula to calculate predicted mortality.
Source: Higgins TL, Teres D, Copes WS, et al. Assessing contemporary intensive care unit outcome: an updated Mortality Probability Admission Model (MPM0-III). Crit Care Med 2007; 35:827.
Graphic 106776 Version 1.0
SLIDE 24
“We recommend fluid resuscitation with either natural/artificial colloids
- r crystalloids. There is no evidence-based
support for one type of fluid
- ver another (grade 1B)”.
Dellinger RP, Levy MM, Carlet JM, et al.
Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296.
SLIDE 25
Anatomical: e.g. Trauma. Abbreviated Injury Score (AIS), Injury Severity Score (ISS).
Subjective: clinician judgement: e.g. live or die
Organ Specific: Assumes that sicker patients have more organ derangements (SOFA).
Physiologic Assessment: degree of derangement
- f routinely measured variables (APACHE,
SAPS).
Disease-specific:
Ranson’s criteria - pancreatitis
MELD – liver failure
WFNS – Subarachnoid hemorrhage
Bouch, et al Brit J Anest Educ Vol 8, No. 5, 2008
SLIDE 26