SYNOPSIS OF DISSERTATION
DR.HARIPRASAD KV
PG in EMERGENCY MEDICINE
VIMS & RC
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR SYNOPSIS
1. / a. Name of the Candidate/ Dr. HARIPRASAD KV
2. / Name of the Institution / VYDEHI INSTITUTE OF MEDICAL SCIENCES,
EPIP AREA, #82, NALLURHALLI, WHITEFIELD
BANGALORE- 560066
3. / Course of Study and Subject / M.D EMERGENCY MEDICINE
4. / Date of Admission to Course / 28/05/2013
5. / Title of the Topic / “COMPARISON OF APACHE II SCORE AND SOFA SCORE TO PREDICT OUTCOME IN ICU PATIENTS”
Brief resume of intended work
6.1 Need for the study:
In a developing country like ours, concerns about the high costs in the ICU are increasing.Thus illness severity scoring systems have been devised depending on therapeutic,anatomical and physiological basis.
If ICU admissions could be prioritized based on scoring systems, the use of limited financial, medical and human resources can be optimized and will allow the best usage in the ICU. Such studies are very few in the developing countries.
Severity scoring systems in the intensive care unit have been developed in response to an increased emphasis on the evaluation and monitoring of health care
services.
There are three major purposes of severity-of-illness scoring systems:
1. Scoring systems are used to assess the prognosis of individual patients
2. Scoring systems are used to quantify severity of illness for resource allocation.
3. Scoring systems assess ICU performance and compare the quality of care.
Currently the APACHE II scoring system is widely used.A controversy exists as to which is an ideal scoring system. Limitations of APACHE II are :
1. Failure to compensate for lead time bias
2. Requirement to choose on disease
3. Poor inter-observer reliability
6.2Review of literature
Scoring systems for use in intensive care unit (ICU) patients have been introduced and developed over the last 30 years. They allow an assessment of the severity of disease and provide an estimate of in-hospital mortality. This estimate is achieved by collating routinely measured data specific to a patient . A weighting is applied to each variable, and the sum of the weighted individual scores produces the severity score. Various factors have been shown to increase the risk of in-hospital mortality after admission to ICU, including increasing age and severity of acute illness, certain pre-existing medical conditions (e.g.malignancy,immunosuppression, and requirement for renal replacement therapy), and emergency admission to ICU
Physiology-based scoring systems are applied to critically ill patients and have a number of advantages over diagnosis-based systems that may be used in other patient groups. Any patient admitted to ICU can have single or multiple organ failure and therefore will not fit a clearly defined diagnostic group. Sometimes, no diagnosis can be made, either on admission or retrospectively. A diagnosis-based scoring system will therefore be inapplicable.
The ideal scoring system would have the following characteristics:
1. On the basis of easily/routinely recordable variables
2. Well calibrated
3. A high level of discrimination
4. Applicable to all patient populations
5. Can be used in different countries
6. The ability to predict functional status or quality of life after ICU discharge.
The APACHE II is measured during the first 24 h of ICU admission; the maximum score is 71. For example,A score of 25 represents a predicted mortality of 50% and a score of over 35 represents a predicted mortality of 80%.(1) The APACHE II severity score has shown a good calibration and discriminatory value across a range of disease processes, and remains the most commonly used international severity scoring system worldwide.
The SOFA was produced by a group from the European Society of Intensive Care Medicine to describe the degree of organ dysfunction associated with sepsis. However, it has since been validated to describe the degree of organ dysfunction in patient groups with organ dysfunctions not due to sepsis.
} Six organ systems—respiratory, cardiovascular, central nervous systems, renal, coagulation, and liver—are weighted (each 1–4) to give a final score [6–24 (maximum)]. For example, a maximal SOFA score >15 is associated with 90% mortality (2)
· A study was done by Acharya et al (3) where Fifty patients admitted with SIRS were consecutively enrolled in the study and SOFA scores were calculated at zero hour, after 48 hrs, and after 96 hrs and patients followed till discharge from hospital.
· When compared to outcome, the non survivors had high initial, mean and highest SOFA scores as compared to survivors. (p value = 0.002, <0.001, <0.001 respectively). Delta SOFA was not significantly associated with outcome. (p value= 0.117). The initial SOFA score > 11 predicted a mortality of 90%. (OR 23.72, 95%CI2.68-209.78, p=0.004). Similarly, mean SOFA score of > 7 predicted a mortality of 73.9% (OR 22.7, 95%CI 5.0 – 103.5, p<0.001) and high SOFA score > 11 predicted a mortality of 87.5% (OR 32.66, 95%CI 5.82-183.179, p< 0.001).Area under receiver operating characteristic (ROC) curve for mean SOFA was 0.825, for high SOFA was 0.817 and for initial SOFA was 0.708. Thus mean, high and initial SOFA scores were helpful in predicting between the survivors and the non survivors.
· It was concluded that the SOFA scoring system is useful in predicting outcomes in ICU and thus help in proper utilization of ICU resources.
· A study conducted by Innocenti F (4) et al where prognostic scores were used for early stratification of septic patients admitted to an emergency department-high dependency unit MEDS, APACHEII, SAPS II, SOFAscore were compared.SOFAscoreis a feasible and accurate tool for an early risk stratification of septic patients admitted to the ED-HDU
· In a study done by GS Shrestha et al in 2011(5). APACHE III score was compared with initial SOFA score to predict ICU mortality ;Scoring done in 117 patients,APACHE III and initial SOFA score of individual patients calculated based on worst values in the first 24 hours .It was concluded that initial SOFA score is comparable to APACHE III for mortality prediction
6.3 Objectives of the study:
1.To assess the performance of the currently used APACHE II score
2.Compare the performance of the APACHE II score with that of SOFA score for the same patients
7.Materials andMethods
SOFA SCORE
7.1Source of Data
All the patients admitted in the acute care unit of the department of emergency medicine and the Multi-disciplinary ICU at Vydehi Institute of Medical Sciences and Research Centre,Bangalore
7.2 Method of collection data :
Duration of study:18 months (Nov 2013-May 2015)
Sample size : Patients admitted in acute care unit of department of emergency medicine and MICU during the study period with a minimum of 90 patients
Inclusion Criteria :
1. All patients presenting to emergency department and admitted in the acute care unit or MICU with evidence of organ dysfunction.
2. Patients with SIRS
3. Patients with sepsis and septic shock
4. Age > 16 years
5. Patients with cardiogenic shock
6. Polytrauma requiring ICU/HDU admission
Exclusion criteria :
1. Age < 16 years
2. Patients who get discharged against medical advice which prevents follow up on outcome
3. Post-op patients
4. Patients whose duration of stay less than 24 hours
5. Patients in whom any of the 12 physiological variables are missing
Methodology:
This prospective study will be undertaken over a18 month period includes all the admissions which fit the inclusion criteria.
APACHE II SCORE is calculated at 24 hours of admission to ICU using the worst values of the 12 varibles
SOFA SCORE is calculated at 24 hours after admission to the ICU and every 48 hours thereafter.The mean and highest scores are calculated
Outcome measures:
Statistical analysis:
· Descriptive statistics and frequency distribution will be used
· Data will be analysed using student t test and Spearman’s correlation
7.3 Does the study require any investigations or interventions to be conducted on patients or other animals?
NO
7.4 Has ethical clearance been obtained from your institution?
yes
REFERENCES
1. Wong DT,Knaus WA .“Predicting outcome in critical care: The current status of the APACHE prognostic scoring system. Can J Anesth 1991;38:374-83
2. Flavio Lopes Ferreira, Daliana Peres Bota,Annette Bross, Christian Mélot, J ean-Louis Vincent, “Serial Evaluation of the SOFA Score to Predict Outcome in Critically Ill Patients” JAMA.2001;286(14):1754-1758
3. Acharya SP,Pradhan B,Marhatta MN. “Application of the SOFA score in predicting outcome in ICU patients with SIRS;Kathmandu university medical journal(2007),vol.5,no.4,issue 20,475-483.
4. Innocenti F,Bianchi S,Guerrini E,Vicidomini S,Conti A,Zanobetti M ” Prognostic scores for early stratification of septic patients admitted to an emergency department-high dependency unit” . Eur j of emergency med 2013 Aug 21.
5. GS Shrestha,R Gurung and R Amatya. ”Comparison of APACHE III score with initial SOFA score to predict ICU mortality”.Nepal med coll J 2011;13(1) : 50-54
6. Thanapaisal C, Saksaen P .“A comparison of the Acute Physiology and Chronic Health Evaluation (APACHE)IIscore and the Trauma-Injury Severity Score (TRISS) for outcome assessment in ICU trauma patients” 2012 Nov;95 Suppl 11:S25-33. Pubmed ID:23961616
7. Jalili M,Barzegari H,Pourtabatabaei N,Honarmand AR,Boreiri M,Mehrvarz A et al . “Effect of door-to-antibiotic time on mortality of patients with sepsis in emergency department: a prospective cohort study” ; 2013 Aug 7;51(7):454-60.
8. Mhamed S. Mebazaa . “Individual Organ SOFA Score and Prediction of Mortality in ICU” Anesthesiology 2004; 101:A408
9. / Signature of candidate10. / Remarks of the Guide / This study will help the PG understand the value of scoring system in predicting outcome in the ER
11. / Name and Designation
11.1 Guide
11.2 Signature of Guide
11.3 Co-Guide(if any)
11.4 Remarks and
Signature
11.5 Head of Department
11.6 Remarks and
Signature / DR. MURALI MOHAN NT
Professor& HOD
Department of Emergency Medicine
Vydehi Institute Medical Sciences &Research Centre, Bangalore- 560066
DR.GAGANAM TRIMURTY
ASSOCIATE PROFESSOR
DEPARTMENT OF EMERGENCY MEDICINE
VIMS &RC
This study would help focus on a single scoring system to prognosticate the death rate in ICU patients and guide the team as a quality indicator
DR. MURALI MOHAN N T
Professor& HOD
Department of Emergency Medicine
Vydehi Institute Medical Sciences & Research Centre, Bangalore- 560066
This study will help the PG understand the value of scoring system in predicting outcome in the ER
12. / 12.1 Principal
12.2 Remarks and
Signature
/ Dr. GURUMURTHY
Principal
Vydehi Institute of Medical Sciences &
Research Centre, Bangalore- 560066