Acute Physiology and Chronic Health Evaluation (APACHE II) Calculator

The Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system is a widely utilized tool in critical care medicine to assess the severity of illness and predict patient outcomes. It was developed to provide an objective and standardized method for evaluating the physiological derangements of critically ill patients. The APACHE II score takes into account several physiological variables and chronic health conditions to generate a numerical score that correlates with the patient's risk of mortality.

In critical care settings, accurately assessing the severity of illness is crucial for appropriate allocation of resources, decision-making, and prognostication. The APACHE II scoring system aids healthcare professionals in stratifying patients, identifying those at higher risk, and guiding clinical management strategies.

What is APACHE II?

The APACHE II scoring system takes into account multiple physiological variables, including temperature, heart rate, mean arterial pressure, respiratory rate, arterial pH, sodium, potassium, creatinine, hematocrit, white blood cell count, and Glasgow Coma Scale score. It also considers age and the presence of chronic health conditions such as AIDS, metastatic cancer, and end-stage liver disease.

Each variable is assigned a score based on its deviation from normal ranges or the presence of specific conditions. The scores are then summed to calculate the APACHE II score, which ranges from 0 to 71. A higher score indicates a more severe illness and is associated with increased mortality risk.

The APACHE II score provides clinicians with a standardized and objective measure to assess the severity of illness in critically ill patients. It helps in risk stratification, prognostication, and clinical decision-making. By considering multiple physiological parameters and chronic health conditions, the APACHE II score provides a comprehensive assessment of disease severity, enabling healthcare professionals to allocate appropriate resources, monitor patients' progress, and evaluate the effectiveness of interventions.

However, it is important to note that the APACHE II score is just one tool among many in critical care medicine. Clinical judgment and consideration of other factors, such as the underlying etiology of the illness and response to treatment, are also essential for optimal patient management. The APACHE II score should be used as part of a comprehensive assessment and in conjunction with clinical expertise to guide patient care in the ICU setting.

Components of the APACHE II Scoring System

The specific components of the APACHE II scoring system include:

Age: The patient's age in years is recorded.
Physiological Variables: These variables include the measurement of vital signs such as heart rate, mean arterial pressure, respiratory rate, and body temperature. Additionally, arterial blood gas values, including pH and partial pressure of oxygen, are assessed. Other laboratory values, such as serum sodium, potassium, creatinine, and hematocrit, are also recorded.
Chronic Health Conditions: The presence or absence of certain chronic health conditions is documented, including AIDS, metastatic cancer, hematologic malignancy, cirrhosis, and immunosuppression.
Glasgow Coma Scale (GCS) Score: The GCS is used to assess the patient's level of consciousness and neurological status.

For each component, specific criteria or values are assigned scores. The scoring system varies for each component, with higher scores indicating more severe abnormalities. The scores from all the components are then summed to calculate the total APACHE II score.

Calculating the APACHE II Score

To calculate the APACHE II score, follow these steps:

Assign points for age:
- Age less than 45 years: 0 points
- Age between 45 and 54 years: 2 points
- Age between 55 and 64 years: 3 points
- Age between 65 and 74 years: 5 points
- Age 75 years or older: 6 points
Assess physiological variables: For each physiological variable, assign points based on the severity of abnormality. The points are assigned as follows:

Vital Signs:
- Temperature (°C):
  - Less than 39°C: 0 points
  - 39-40°C: 1 point
  - Greater than 40°C: 3 points
- Mean Arterial Pressure (mmHg):
  - Greater than 70 mmHg: 0 points
  - 50-69 mmHg: 4 points
  - Less than 50 mmHg: 7 points
- Heart Rate (beats per minute):
  - Less than 100 bpm: 0 points
  - 100-119 bpm: 1 point
  - 120-139 bpm: 3 points
  - 140-159 bpm: 5 points
  - 160 bpm or higher: 7 points
- Respiratory Rate (breaths per minute):
  - Less than 12 bpm: 0 points
  - 12-24 bpm: 2 points
  - Greater than 24 bpm: 4 points
Arterial Blood Gas Values:
- Arterial pH:
  - Greater than 7.15: 0 points
  - 7.00-7.14: 3 points
  - Less than 7.00: 7 points
- Partial Pressure of Oxygen (mmHg):
  - Greater than 60 mmHg: 0 points
  - 40-59 mmHg: 1 point
  - Less than 40 mmHg: 3 points
Laboratory Values:
- Sodium (mEq/L):
  - 135-144 mEq/L: 0 points
  - Less than 135 mEq/L: 2 points
- Potassium (mEq/L):
  - 3.5-5.0 mEq/L: 0 points
  - Less than 3.5 mEq/L: 3 points
  - Greater than 5.0 mEq/L: 1 point
- Creatinine (mg/dL):
  - Less than 2.0 mg/dL: 0 points
  - 2.0-3.4 mg/dL: 2 points
  - Greater than 3.4 mg/dL: 4 points
- Hematocrit (%):
  - 30-45%: 0 points
  - Less than 30%: 4 points
Assess chronic health conditions: Assign points based on the presence or absence of chronic health conditions. The points are as follows:
- AIDS: 17 points
- Metastatic Cancer: 6 points
- Hematologic Malignancy: 10 points
- Cirrhosis: 4 points
- Immunosuppression: 10 points
Evaluate the Glasgow Coma Scale (GCS) score: The GCS score ranges from 3 to 15. The GCS score itself is not directly added to the APACHE II score but is recorded for documentation purposes.
Sum the points from each component to obtain the APACHE II score.

The higher the APACHE II score, the greater the severity of illness and the higher the predicted mortality risk. The APACHE II score provides clinicians with an objective measure to assess the severity of illness and helps guide treatment decisions and resource allocation in the critical care setting.

Interpreting the APACHE II Score

Interpreting the APACHE II score involves understanding the relationship between the score and the predicted mortality risk. The score is an indicator of the severity of illness and provides an estimate of the likelihood of mortality for a patient in the ICU. The higher the APACHE II score, the higher the predicted mortality risk.

The predicted mortality risk associated with a specific APACHE II score can be calculated using mortality risk equations derived from large patient databases. These equations estimate the probability of mortality based on the patient's APACHE II score and other factors.

For example, an APACHE II score of 0-4 is associated with a predicted mortality risk of less than 1%, while a score of 40 or higher indicates a predicted mortality risk of around 90% or higher.

It is important to note that the APACHE II score is not intended to predict individual outcomes with certainty, as there can be considerable variability among patients with the same score. The score should be used as part of a comprehensive assessment and in conjunction with clinical judgment and other factors, such as the patient's underlying condition, response to treatment, and comorbidities.

Limitations and Criticisms of the APACHE II Scoring System

One limitation of the APACHE II scoring system is the potential for subjective interpretation, which can introduce variability in scoring. Different healthcare providers may assign different scores for the same physiological variables or chronic health conditions, leading to inconsistencies in the overall APACHE II score.

Another limitation is that the scoring system does not account for all comorbidities that may impact disease severity. The inclusion of only specific chronic health conditions in the scoring system may not capture the full spectrum of a patient's comorbidities, potentially underestimating or overestimating their overall risk.

There is also criticism regarding the assignment of points to certain variables, as the choice of cut-off values and point assignments may be arbitrary. This can introduce bias and impact the accuracy of the APACHE II score in predicting outcomes.

Furthermore, the APACHE II score primarily focuses on physiological variables and does not consider important non-physiological factors, such as psychological factors or functional status, which can also influence prognosis and treatment outcomes.

Lastly, the APACHE II scoring system was developed several decades ago and may not fully capture advances in critical care practices and evolving patient populations. Newer scoring systems, such as APACHE IV or SAPS II, have been developed to address some of these limitations and offer improved accuracy in predicting outcomes.

Despite these limitations, the APACHE II scoring system remains a valuable tool for assessing severity of illness and predicting mortality risk in the ICU. However, it should be used alongside clinical judgment, taking into account individual patient characteristics, and considering other relevant factors for a comprehensive evaluation of the patient's condition.

In conclusion, the APACHE II scoring system is a valuable tool in critical care medicine for assessing disease severity and predicting outcomes. Despite its limitations, the APACHE II score provides a standardized and objective measure of illness severity, assisting healthcare professionals in making informed decisions and providing tailored care to critically ill patients. It continues to be a widely used tool in research, quality improvement efforts, and patient care planning in the ICU setting.

Age
	0 - Age ≤ 44 years.
	2 - Age ≥ 45 years and ≤ 54 years.
	3 - Age ≥ 55 years and ≤ 64 years.
	5 - Age ≥ 65 years and ≤ 74 years.
	6 - Age ≥ 75 years.
Rectal temperature
	4 - Temperature < 30°C.
	3 - Temperature ≥ 30°C and < 32°C.
	2 - Temperature ≥ 32°C and < 34°C.
	1 - Temperature ≥ 34°C and < 36°C.
	0 - Temperature ≥ 36°C and < 38,5°C.
	1 - Temperature ≥ 38,5°C and < 39°C.
	3 - Temperature ≥ 39°C and < 41°C.
	4 - Temperature ≥ 41°C.
Mean Arterial Pressure
	4 - MAP < 50 mmHg.
	2 - MAP ≥ 50 mmHg and < 70 mmHg.
	0 - MAP ≥ 70 mmHg and < 110 mmHg.
	2 - MAP ≥ 110 mmHg and < 130 mmHg.
	3 - MAP ≥ 130 mmHg and < 160 mmHg.
	4 - MAP ≥ 60 mmHg.
Heart rate
	4 - rate < 40/mn.
	3 - rate ≥ 40/mn and < 55/mn.
	2 - rate ≥ 55/mn and < 70/mn.
	0 - rate ≥ 70/mn and < 110/mn.
	2 - rate ≥ 110/mn and < 140/mn.
	3 - rate ≥ 140/mn and < 180/mn.
	4 - rate ≥ 180/mn.
Respiratory rate
	4 - rate ≤ 5/mn.
	2 - rate ≥ 6/mn and ≤ 9/mn.
	1 - rate ≥ 10/mn and ≤ 11/mn.
	0 - rate ≥ 12/mn and ≤ 24/mn.
	1 - rate ≥ 25/mn and ≤ 34/mn.
	3 - rate ≥ 35/mn and ≤ 49/mn.
	4 - rate ≥ 50/mn.
Oxygen saturation
If FiO₂ < 50%, use PaO₂:
	4 - PaO₂ < 55 mmHg.
	3 - PaO₂ ≥ 55 mmHg and ≤ 60 mmHg.
	1 - PaO₂ > 60 mmHg and ≤ 70 mmHg.
	0 - PaO₂ > 70 mmHg.
If FiO₂ ≥ 50%, use Gradient A-a en O₂:
	0 - Gradient < 200.
	2 - Gradient ≥ 200 et ≤ 350.
	3 - Gradient ≥ 350 et ≤ 500.
	4 - Gradient ≥ 500.
arterial pH
	4 - pH < 7,15.
	3 - pH ≥ 7,15 and < 7,25.
	2 - pH ≥ 7,25 and < 7,33.
	0 - pH ≥ 7,33 and < 7,50.
	1 - pH ≥ 7,50 and < 7,60.
	3 - pH ≥ 7,60 and < 7,70.
	4 - pH ≥ 7,70.
Natremia
	4 - Natremia ≤ 110 mmol/l.
	3 - Natremia ≥ 111 mmol/l and ≤ 119 mmol/l.
	2 - Natremia ≥ 120 mmol/l and ≤ 129 mmol/l.
	0 - Natremia ≥ 130 mmol/l and ≤ 149 mmol/l.
	1 - Natremia ≥ 150 mmol/l and ≤ 154 mmol/l.
	2 - Natremia ≥ 155 mmol/l and ≤ 159 mmol/l.
	3 - Natremia ≥ 160 mmol/l and ≤ 179 mmol/l.
	4 - Natremia ≥ 180 mmol/l.
Kalemia
	4 - Kalemia < 2,5 mmol/l.
	2 - Kalemia ≥ 2,5 mmol/l and < 3 mmol/l.
	1 - Kalemia ≥ 3 mmol/l and < 3,5 mmol/l.
	0 - Kalemia ≥ 3,5 mmol/l and < 5,5 mmol/l.
	1 - Kalemia ≥ 5,5 mmol/l and < 6 mmol/l.
	3 - Kalemia ≥ 6 mmol/l and < 7 mmol/l.
	4 - Kalemia ≥ 7 mmol/l.
Blood creatinine
	2 - creatinine < 54 µmol/l (6 mg/l).
	0 - creatinine ≥ 54 mmol/l (6 mg/l) and ≤ 129 mmol/l (14 mg/l).
	2 - creatinine ≥ 130 mmol/l (15 mg/l) and ≤ 169 mmol/l (19 mg/l).
	3 - creatinine ≥ 170 mmol/l (20 mg/l) and ≤ 304 mmol/l (304 mg/l).
	4 - creatinine ≥ 305 mmol/l (35 mg/l).
	Acute renal failure
Hematocrit
	4 - Hematocrit < 20 %.
	2 - Hematocrit ≥ 20 % and ≤ 30 %.
	0 - Hematocrit ≥ 30 % and ≤ 46 %.
	1 - Hematocrit ≥ 46 % and ≤ 50 %.
	2 - Hematocrit ≥ 50 % and ≤ 60 %.
	4 - Hematocrit > 60 %.
Leukocytes
	4 - Leukocytes < 1 000 / mm³.
	2 - Leukocytes ≥ 1 000 / mm³ and < 3 000 / mm³.
	0 - Leukocytes ≥ 3 000 / mm³ and < 15 000 / mm³.
	1 - Leukocytes ≥ 15 000 / mm³ and < 20 000 / mm³.
	2 - Leukocytes ≥ 20 000 / mm³ and < 40 000 / mm³.
	4 - Leukocytes ≥ 40 000 / mm³.
Awareness
Glasgow score:
*Severe organ dysfunction or Immunodepression**
	0 - None
	2 - Attendance, patient admitted post scheduled surgery
	5 - Attendance, patient admitted post-surgery in emergency.
	5 - Attendance, patient admitted without surgical reason.
* Liver disease: Cirrhosis proven by biopsy, documented portal hypertension, episodes of upper gastrointestinal bleeding from Portal Hypertension, episodes of encephalopathy or hepatic coma. * Heart disease: NYHA Class 4 disease. * Respiratory disease: Restrictive, obstructive or vascular disease severely reducing physical activity; Documented chronic hypoxia or hypercapnia, secondary polycythaemia, severe pulmonary hypertension or respiratory dependence. * Renal disease: Chronic hemodialysis. * Immunodepression:Patient under immunosuppressive treatment, chemotherapy, radiotherapy, long-term high-dose steroids, prior disease such as leukemia, lymphoma, AIDS.