Development of multiple organ dysfunction syndrome in critically ill patients with perforated viscus. Predictive value of APACHE severity scoring
P. S. Barie, L. J. Hydo and E. Fischer
Department of Surgery, Cornell University Medical College, New York, NY, USA.
OBJECTIVE: To determine whether scoring on the Acute Physiology and Chronic
Health Evaluation (APACHE) III at admission can predict the development of
multiple organ dysfunction syndrome and mortality in critically ill
surgical patients. DESIGN: Prospective, inception-cohort study. SETTING:
Surgical intensive care unit of an urban, tertiary-care hospital. PATIENTS:
One hundred fourteen critically ill patients with surgically treated
perforated gastrointestinal viscus. INTERVENTIONS: Calculation of APACHE II
and APACHE III scores 24 hours after admission to the surgical intensive
care unit and serial quantitation of organ dysfunction for the duration of
critical care according to two different predefined scoring systems.
Patients were stratified by survival, the development of organ dysfunction,
and colon vs noncolonic perforation. MAIN OUTCOME MEASURES: Hospital
mortality, length of stay in the surgical intensive care unit, and the
development of organ dysfunction or overt organ failure. RESULTS: The mean
(+/- SEM) APACHE II and APACHE III scores were 17.4 +/- 0.6 (range, 6 to
37) and 59.0 +/- 2.2 (range, 15 to 141), respectively. The incidence of
organ dysfunction was 73% (64% in survivors). All severity scores were
identical for colon perforation and noncolonic perforation subgroups.
Nonsurvivors invariably had organ dysfunction. Overall length of stay in
the intensive care unit was 12.0 +/- 1.6 days (8.7 +/- 1.2 days for
survivors and 22.7 +/- 5.0 days for nonsurvivors). The APACHE scores and
organ dysfunction or failure scores were significantly higher in
nonsurvivors, and APACHE scores were higher in survivors with organ
dysfunction than in those without it. Significant linear relationships were
identified for APACHE II vs APACHE III scores (R2 = .66) and for all four
combinations of APACHE scores and organ dysfunction or failure scores (R2 =
.43 to .52). By multivariate analysis of variance, independent predictors
of organ dysfunction or failure were APACHE III, increased age, and a
prolonged stay in the surgical intensive care unit, but not the type of
perforation. Neither APACHE II or APACHE III predicted mortality
independently. CONCLUSIONS: The development of multiple organ dysfunction
syndrome correlated with higher APACHE III scores but was independent of
the type of perforation. Only the development of overt multiple organ
failure predicted death. Combined use of APACHE III and the multiple organ
dysfunction score provides improved prediction of multiple organ
dysfunction syndrome, but further enhancements are needed before prediction
of outcome in individual patients is reliable.
