基本评分系统ppt课件

ICU基本评分系统,“Its more important to know what sort of person this disease has, than what sort of disease this person has.” William Osler 1849-1919,ICU评分的目的,ICU评分系统可帮助我们？,Case-mix adjustment for evaluative research A tool for comparative audit SMR 评估医护工作的效果 standardized mortality ratio:1.0 or 1.0 A mechanism to decide resource allocation An aid for the clinical management of patients,评分基础,Physiologic parameter Anatomic injury Combined Organ function Therapeutic Intervention,ICU评分的种类,Specific or generic Anatomical or physiological Anatomical systems assess extent of injury (eg injury severity score) Physiological systems assess impact of injury on function (eg GCS) Measuring severity by treatment- TISS Measuring severity by patient characteristics and physiological measurements-APACHE ,SAPS,MPM,评分系统的选择标准,Proposed use Validity of score Reliability of score Discrimination of scoring system Calibration of scoring system,APACHE I,APACHE I=APS（ acute physiology score ）+CPS（ chronic health points） APS= 34 physiological variables（04scores） CPS=AD Total scores=0A to 128D,APACHE II,APACHE II = APS + Age + CPS APS= 12 variables(04 scores,060) Age = 06 scores CPS = 25 scores Total scores = 071 scores Predicted death rate Logit = -3.517+( Apache II) * 0.146 Predicted Death Rate =eLogit/(1+eLogit),APACHE III,APACHE = APS +Age +CPS APS = 0252 CPS = 023 Age = 024 Total scores = 0299 Predicted death rate(AIII) is more accuracy than AII,APACHE IV,New variables (mechanical ventilation, thrombolysis, the impact of sedation on Glasgow Coma Score (GCS), and a rescaled GCS and PaO2:FIO2) were added,APACHE II,APS（ acute physiology score ） GCS Age CPS（ chronic health points）,APACHE II,APS（ acute physiology score ）,APS-Pulmonary Condition,Respiratory rate non-ventilated or ventilated Oxygenation a.FiO2 0.5 record A-aDO2 b.FiO2 0.5 record PaO2 Arterial pH,(A-a)O2 Gradient =(760-47)*FIO2 - PaCO2 - Pa02,Serum Creatinine： Without Acute Renal Failure With Acute Renal Failure Double Serum HCO3： not preferred, use if no ABGs,APS-Renal Condition,APS- Glasgow Coma Score,Glasgow Coma Score,Used as part of several ICU scoring system, including APACHE,SAPS and SOFA, as a contribution for the status of the central nervous system. Classified as: severe, with GCS8 moderate, GCS 9-12 minor, GCS13,Glasgow Coma Score,Neurological scale after head trauma Limited to body trauma and children, especially below the age of 36 months Correlates well with outcome following severe brain injury One determines the best eye opening response, the best verbal response, and the best motor response. Scores = 15 actual GCS,Age,CPS（ chronic health points）,指住院前患者具有严重器官功能障碍或免疫功能受损病史 评分标准： 择期手术后患者（2 分） 非手术或急诊手术后患者（5 分） 因全身性感染或呼吸心跳骤停入ICU，纳入非手术组,CPS评估项目,Cardiovascular Respiratory Liver insufficiency Renal Immuno-depression,CPS- Cardiovascular,NYHA Class IV,Class I 日常活动无症状 Class II 日常活动有症状 Class III 轻微活动就会有明显症状 Class IV 休息时也出现症状,CPS- Respiratory,慢性限制性、阻塞性或血管性疾病导致的严重活动受限：无法爬楼梯、处理家务 慢性低氧血症(hypoxia) 高碳酸血症(hypercapnia) 继发性红细胞增多症（polycythemia） 严重肺动脉高压(PAP40 mmHg) 高度依赖呼吸机,CPS- Liver insufficiency,-活检诊断肝硬化 -门静脉高压(portal hypertension) -门脉高压导致上消血病史 -肝功能衰竭/肝性脑病/肝昏迷病史,CPS- Renal,Receiving chronic dialysis,CPS- Immuno-depression,接受抑制抗感染能力的治疗：免疫抑制药、放化疗、长期或近期是用大剂量类固醇 免疫性疾病：白血病，淋巴瘤，AIDS,APACHE II,AII Predicted death rate,Logit = -3.517+( Apache II) * 0.146 Predicted Death Rate =eLogit/(1+eLogit),1Kpa=7.5 mmHg,APACHEII局限性,群体敏感度好，个体预测准确率较低 联合应用其他评价系统，提高预测准确性 采样时间点选择？是否有最佳时间点？ 对PHM（pridict hospital mortality)的预测值偏高 APS未考虑血管活性药物、呼吸机、非甾体类药物对各项参数影响 老年患者计分比重偏高 营养状态未列入计分考虑 对创伤患者考虑不充分,SAPS (Simplified Acute Physiology Score),发展历史,In 1984, Le Gall reduced former 34-variable APACHE score to 14 parameters,SAPS I In 1994,SAPS II(SAPS II score + PHM) In 2008,SAPS III,SAPS II,构成：0163 scores Physiological variable:12 variable (026 scores/v),include GCS Age(0712151618score) Type of admission(内科0、择期6、急诊8） 3 chronic disease(AIDS18,Hematologic malignancy10,Meta-static cancer9) PHM,SAPS II Data,Data are collected during the first 24 hours after ICU admission Age Use the patients age in years at last birthday Heart rate Use the worst value in 24 hours, either low or high rate; if it varied from cardiac arrest (11pts) to extreme tachycardia (7pts), assign 11points. SBP Use the same method as for hearth rate : eg, if it varied from 60 mmHg to 205 mmHg, assign 13 Points. Body temperature Use the highest temperature in C or F PaO2/FiO2 ratio If ventilated or CPAP, use the lowest value of the ratio.,SAPS II Data,Urinary output if the patient is in the intensive care unit for less than 24 hours, make the calculation for 24 hours. Serum urea or BUN Use the highest value in mmol/ or g/L for serum urea, in mg/dL for the serum urea nitrogen. WBC count Use the worst (high or low) WBC count. Serum potassium level Use the worst (high or low) value. Serum Sodium level Use the worst (high or low) value. Serum bicarbonate level Use the lowest value. Bilirubin Use the highest value in micromol/L or mg/dL Glasgow coma score Use the lowest value. If the patient is sedated, record the estimated Glasgow coma score before sedation.,SAPS II Predicted death rate,Logit = -7.7631+0.0737*(SAPS II)+0.9971*ln(SAPS II)+1) Predicted Death Rate =e(Logit)/(1+e(Logit),SAPS,24小時為緊急與否分界點；一週以上視為medical,AIDS,Hematologic malignancy,Meta-static cancer,以未被sedation之前的GCS為基準,沒有呼吸器之病患則以0分記,Patients excluded :Coronary care, cardiac surgery, burn patients, age 15 years,SAPS ,Very Simple and quick. (一个病