Condition of moderate severity: assessment of the patient's condition, criteria and indicators. Evaluation of the patient's condition Change, for example, the patient's condition over time

Practical lesson number 11.

Topic. Assessment of the functional state of the patient.

In modern conditions, the quality of the work of a nurse is becoming increasingly important, and the requirements for her professional training are increasing.

The success of the treatment of patients largely depends on the correct, continuous monitoring and quality care for them.

Constant monitoring of patients is necessary in order to notice changes in their state of health in a timely manner, to ensure proper care and, if necessary, to provide emergency medical care.

Patient monitoring includes:

general examination, which in essence begins from the moment of the first meeting with the patient;

· grade general condition, which can be satisfactory, moderate, severe and extremely severe.

However, it is not always possible to correctly assess the general condition of the patient only according to the examination data. For this it is necessary to take into account:

What consciousness is the patient in;

His position in bed;

Facial expression;

The condition of the skin;

The presence of edema;

Objective indicators (body temperature, frequency and nature of breathing, pulse rate, blood pressure).

The patient may develop various degrees of disorder of consciousness, which is manifested by its oppression (stupor, stupor, coma) or excitation of the central nervous system (delusions, hallucinations).

Assessment of the severity of the patient's condition

The severity of the patient's condition is assessed according to the algorithm:

1. Assessment of the state of consciousness.

2. Assessment of position in bed.

3. Evaluation of facial expressions.

4. Evaluation of the severity of symptoms of the disease.

Distinguish:

satisfactory condition

moderate condition

serious condition

Satisfactory condition:

1. Consciousness is clear.

2. Can serve himself, actively talks with medical staff.

3. Facial expression without features.

4. Many symptoms of the disease can be detected, but their presence does not prevent the patient from showing his activity.

Moderate condition:

1. The patient's consciousness is usually clear.

2. The patient prefers to stay in bed most of the time, since active actions increase general weakness and painful symptoms, often takes a forced position.

3. Painful facial expression.

4. During direct examination of the patient, the severity of pathological changes in internal organs and systems.

Severe condition:

Consciousness may be absent, confused, but often remains clear.

The patient is almost constantly in bed, active actions are performed with difficulty.

1. The facial expression is suffering.

2. Complaints and symptoms of the disease are expressed significantly.

Determination of the general condition of the patient

The general condition of the patient is assessed on the basis of his consciousness, position in bed, facial expressions and symptoms of the disease.

The general condition of the patient can be satisfactory, moderate and severe.

At satisfactory condition the patient's position is active, facial expression without features, consciousness is clear. The patient is active, can serve himself, actively talks with his roommates. Many symptoms of the disease can be determined, but they do not prevent the patient from being active.

At moderate condition the patient's consciousness is clear, the facial expression is painful. Most of the time he is in bed, as active activities increase the general weakness and painful symptoms. The symptoms of the underlying disease and pathological changes in internal organs and systems are more pronounced.

At serious condition the patient's position in bed is passive, various degrees of depression of consciousness are possible, complaints and symptoms of the disease are pronounced, the facial expression is suffering.

Definition of consciousness of the patient.

In therapeutic departments, nurses mainly deal with patients in clear consciousness. At the same time, the patient is fully oriented in the environment, clearly answers the questions posed.

Darkened (unclear) consciousness manifests itself in the patient's indifferent, indifferent attitude to his condition, he answers questions correctly, but with some delay.

Stupor(stunning) - the patient is poorly oriented in the environment, sluggishly, slowly answers questions, sometimes not to the point, and immediately begins to doze off, falls into a state of stupor.

Sopor- deep stupefaction of consciousness. With this type of disturbance of consciousness, the patient is in a state of “hibernation”. Only a loud cry, a painful impact (prick, pinches, etc.) can bring him out of this state, but for a very short time, then he “falls asleep” again.

Coma - complete loss of consciousness. The patient does not respond to pain and sound stimuli, there are no reflexes. Coma indicates a significant severity of the disease. It develops, for example, in severe diabetes mellitus, with renal and hepatic insufficiency, with alcohol poisoning.

Rave- this is a false, absolutely uncorrected judgment. Distinguish between quiet and violent delirium. In violent delirium, patients are extremely agitated, jump out of bed, and in this state can harm both themselves and those around them. An individual nursing post is organized for the care and observation of such patients.

hallucinations auditory, visual, olfactory, tactile. With auditory hallucinations, the patient talks to himself or to an imaginary interlocutor. With visual hallucinations, patients see something that is not really there. This kind of hallucination often occurs in patients suffering from chronic alcoholism. Olfactory hallucinations are accompanied in the patient by a sensation of unpleasant odors, a change in taste. Tactile hallucinations are the sensation of insects, microbes, etc. crawling over the body.

Facial expression

the patient reflects his condition, experience, suffering. Facial expression is an important diagnostic feature in a number of diseases.

With pulmonary tuberculosis, the face is pale, with bright spots of blush on the cheeks, with chronic alcoholism - reddened, with dilated veins on the cheeks and nose, at elevated temperature - feverish (shiny eyes, hyperemic skin).

In patients suffering from myxedema (decrease in thyroid function), the face is puffy, with narrow palpebral fissures, with sluggish facial expressions and an indifferent look.

In diseases of the kidneys, the face is pale, inexpressive, swollen, especially in the upper and lower eyelids.

Treatment in intensive care is a very stressful situation for the patient. Indeed, in many intensive care centers there are no separate wards for men and women. Often patients lie naked, with open wounds. Yes, and you have to cope with the need without getting out of bed. The intensive care unit is represented by a highly specialized unit of the hospital. Patients are referred to the intensive care unit:

Intensive care unit, its features

Due to the severity of the condition of patients in the intensive care unit, round-the-clock monitoring is carried out. Specialists monitor the functioning of all vital organs and systems. The following indicators are monitored:

• blood pressure level;
• blood oxygen saturation;
• breathing rate;
• heart rate.

To determine all these indicators, a lot of special equipment is connected to the patient. To stabilize the condition of patients, the administration of medicines is provided around the clock (24 hours). The introduction of drugs occurs through vascular access (veins of the arms, neck, subclavian region of the chest).

Patients who are in the intensive care unit after the operation have temporary drainage tubes. They are needed to monitor the wound healing process after surgery.

The extremely serious condition of patients means the need to attach to the patient a large amount of special equipment necessary to monitor vital signs. Various medical devices are also used (urinary catheter, dropper, oxygen mask).

All these devices significantly limit the patient's motor activity, he is unable to get out of bed. Excessive activity may cause critical equipment to become disconnected. So, as a result of removing the dropper, bleeding may open, and the disconnection of the pacemaker will cause cardiac arrest.

Determination of the patient's condition

Experts determine the severity of the patient's condition depending on the decompensation of vital functions in the body, their presence, and severity. Depending on these indicators, the doctor prescribes diagnostic and therapeutic measures. The specialist establishes the indications for hospitalization, determines the transportability, the probable outcome of the disease.

The general condition of the patient has the following classification:

1. Satisfactory.
2. Medium severity.
3. Severe condition.
4. Extremely heavy.
5. Terminal.
6. clinical death.

One of these conditions in intensive care is determined by the doctor depending on such factors:

• examination of the patient (general, local);
• familiarization with his complaints;
• examination of internal organs.

When examining a patient, a specialist gets acquainted with the existing symptoms of diseases, injuries: the appearance of the patient, fatness, his state of consciousness, body temperature, the presence of edema, foci of inflammation, the color of the epithelium, mucosa. Especially important are indicators of the functioning of the cardiovascular system, respiratory organs.

In some cases, an accurate determination of the patient's condition is possible only after obtaining the results of additional laboratory, instrumental studies: the presence of a bleeding ulcer after gastroscopy, the detection of signs of acute leukemia in blood tests, the visualization of cancerous liver metastases through ultrasound diagnostics.

serious condition

A serious condition means a situation in which the patient develops decompensation of the activity of vital systems and organs. The development of this decompensation poses a danger to the patient's life, and can also lead to his deep disability.

Usually, a serious condition is observed in case of a complication of the current disease, which is characterized by pronounced, rapidly progressive clinical manifestations. Patients in this condition are characterized by the following complaints:

• for frequent pain in the heart;
• manifestation of shortness of breath at rest;
• the presence of prolonged anuria.

The patient may become delirious, ask for help, moan, his facial features become sharper, and the patient's consciousness is depressed. In some cases, there are states of psychomotor agitation, general convulsions.

Usually, the following symptoms indicate a serious condition of the patient:

• increase in cachexia;
• anasarka;
• dropsy of cavities;
• rapid dehydration of the body, in which there is dryness of the mucous membranes, a decrease in epidermal turgor;
• the skin becomes pale;
• hyperpyretic fever.

When diagnosing the cardiovascular system, the following are found:

• thready pulse;
• arterial hypo-, hypertension;
• weakening of the tone above the apex;
• expansion of cardiac boundaries;
• deterioration of patency inside large vascular trunks (arterial, venous).

When diagnosing the organs of the respiratory system, experts note:

• tachypnea more than 40 per minute;
• the presence of obstruction of the upper respiratory tract;
• pulmonary edema;
• attacks of bronchial asthma.

All these indicators indicate a very serious condition of the patient. In addition to the listed symptoms, the patient has vomiting, symptoms of diffuse peritonitis, profuse diarrhea, nasal, uterine, gastric bleeding.

All patients with a very serious condition are subject to mandatory hospitalization. And this means that their treatment is carried out in the intensive care unit.

Stable serious condition

This term is often used by emergency room physicians. Many relatives of patients are interested in the question: Stably serious condition in intensive care, what does this mean?

Everyone knows what a very serious condition means, we examined it in the previous paragraph. But the expression "stable heavy" often scares people.

Patients in this condition are under the constant supervision of specialists. Doctors, nurses monitor all vital signs of the body. What is most pleasing about this expression is the stability of the state. Despite the lack of improvement in the patient, there is still no deterioration in the patient's condition.

A stably serious condition can last from several days to weeks. It differs from the usual serious condition in the absence of dynamics, any changes. Most often, this condition occurs after major operations. The vital processes of the body are supported by special equipment. After turning off the equipment, the patient will be under the close supervision of medical staff.

Extremely serious condition

In this condition, there is a sharp violation of all vital functions of the body. Without prompt treatment, the patient may die. This state is noted:

• sharp oppression of the patient;
• general convulsions;
• face pale, pointed;
• heart sounds are weakly audible;
• respiratory failure;
• wheezing is heard in the lungs;
• blood pressure cannot be determined.

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Treatment in intensive care

It is not uncommon for patients to misunderstand the features of the treatment regimen of the intensive care unit as a cause of serious complications, sometimes representing a great danger to their lives. In addition, treatment in intensive care is a great psychological stress for patients. Reducing the level of anxiety and anxiety, as well as preventing the development of severe complications associated with violation of the resuscitation treatment regimen by patients are the main goals of this educational article. This article will be especially useful for patients who are expected to undergo further treatment in the intensive care unit.

The intensive care unit is a highly specialized unit of the hospital. The main contingent of intensive care patients are critically ill patients with serious illnesses and injuries, as well as severe patients after complex surgical interventions and.

The severity of the condition of patients in the intensive care unit necessitates round-the-clock monitoring (observation) of the work of vital organs and body systems - blood pressure, heart rate, respiratory rate, blood oxygen saturation, etc. For these purposes, a large number of special equipment is used in intensive care, directly connected to the patient. In addition, patients in resuscitation are constantly administered drugs through a vascular access for 24 hours a day, for which the veins of the arm, neck or subclavian region of the chest are used. Also, quite often, special drainage tubes are temporarily left in patients in the area of ​​the surgical intervention, which are necessary to monitor the healing process of the postoperative wound.

The extremely serious condition of patients in intensive care is the reason for attaching to them a large number of tracking equipment, as well as other medical devices that are essential components of intensive care performed in intensive care (“droppers”, urinary catheter, oxygen mask, etc.). All this sharply limits the amount of motor activity of intensive care patients, makes it impossible for them to get out of bed. On the other hand, excessive motor activity of the patient can cause a critical condition and catastrophe (for example, "disconnection of the IV", causing bleeding or "displacement" of the pacemaker, leading to cardiac arrest).

Given all the above reasons, patients in intensive care must comply with strict bed rest. Compliance with strict bed rest is one of the most important conditions for a safe stay in the intensive care unit.

In intensive care, it is possible to fulfill a physiological need (need) only within the limits of the bed. If the patient cannot relieve himself “in a small way”, then to facilitate urination, a thin tube is installed in the bladder - a urinary catheter. If there is a difficulty with coping with the need "for the most part", then laxative drugs or an enema are used. In fact, these seemingly intimate moments of a person’s life, in the work of the intensive care unit, are routine everyday procedures, as natural as, for example, the installation of a “dropper” by a nurse, so they should by no means be a reason for your anxiety and excitement.

Resuscitation medical personnel should always have quick access to the entire body of the patient in case of cardiac or respiratory arrest. Resuscitators should be able to quickly and easily initiate cardiopulmonary resuscitation. This is one of the reasons why intensive care patients are without underwear. On the other hand, the presence of clothing on the patient significantly complicates the hygienic treatment of the skin, thereby increasing the risk of developing infectious complications.

Taking into account certain features of the organization of the treatment process, one of the specifics of placing patients in intensive care is the presence of joint wards, that is, both men and women are located in the same ward. This fact should also not be a cause for concern, since in case of any need (for example, to relieve yourself), you can always ask the medical staff to put a separating screen between the beds.

All of the above features of the resuscitation treatment regimen are certainly not psychologically and physically comfortable, but they all pursue one noble goal - to achieve a speedy recovery of our patients.

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The severity of the condition of the victims (TSP), unified criteria. It is necessary to distinguish between "severity of TBI" and "severity of the victim's condition". The concept of the severity of the condition of the victims, although it is largely derived from the concept of "injury severity", is nevertheless much more dynamic than the latter. Within each clinical form of TBI, depending on the period and direction of its course, conditions of varying severity can be observed.

The assessment of the severity of the injury and the assessment of the severity of the condition of the victims coincide in most cases upon admission of the patient. But situations are often possible when these estimates diverge. For example, with subacute development of a shell hematoma against a background of a slight bruise of the brain; with moderate or even severe brain contusions, with depressed fractures, when the “silent” zones of the hemispheres selectively suffer, etc.

The severity of the condition of the victims is a reflection of the severity of the injury at the moment; it may or may not correspond to the morphological substrate of the brain injury. At the same time, an objective assessment of the severity of the condition of victims upon admission is the first and most important stage in diagnosing a specific clinical form of TBI, which significantly affects the correct sorting of victims, treatment tactics and prognosis (not only in terms of survival, but also recovery). The role of the evaluation of the TSP is similar in the further observation of the victim.

Assessment of the severity of the condition of victims in the acute period of TBI, including the prognosis for both life and recovery, can be complete only when using at least three terms, namely the condition:

1. consciousness,
2. vital functions,
3. focal neurological functions.

The following 5 gradations of the state of patients with TBI are distinguished:

1. satisfactory,
2. moderate,
3. heavy
4. extremely heavy
5. terminal.

Satisfactory condition.

Criteria:

1. clear consciousness;
2. lack of violations of vital functions;
3. absence of secondary (dislocation) neurological symptoms; absence or mild severity of primary hemispheric and craniobasal symptoms (for example, motor disorders do not reach the degree of paresis).

When qualifying the condition as satisfactory, it is permissible to take into account, along with objective indicators, the complaints of the victim. There is no threat to life (with adequate treatment); the prognosis for recovery is usually good.

Moderate condition.

1. state of consciousness - clear or moderate stunning;
2. vital functions are not impaired (only bradycardia is possible),
3. focal symptoms - certain hemispheric and craniobasal symptoms can be expressed, which are more often selective: mono- or hemiparesis of the extremities; insufficiency from individual cranial nerves; decreased vision in one eye, sensory or motor aphasia, etc.). There may be single stem symptoms (spontaneous nystagmus, etc.).

To state a state of moderate severity, it is sufficient to have the indicated violations in at least one of the parameters. For example, the detection of moderate stunning in the absence of severe focal symptoms is sufficient to determine the patient's condition as moderate. When qualifying the patient's condition as moderate, along with the objective, it is permissible to take into account the severity of subjective signs (primarily headache).

The threat to life (with adequate treatment) is insignificant: the prognosis for recovery is often favorable.

Severe condition.

Criteria (limits of violations for each parameter are given):

1. state of consciousness - deep stupor or stupor;
2. vital functions - violated, mostly moderately in 1-2 indicators;
3. focal symptoms:

• stem - moderately expressed (anisocoria, decreased pupillary reactions, upward gaze restriction, homolateral pyramidal insufficiency, dissociation of meningeal symptoms along the axis of the body, etc.);
• hemispheric and craniobasal - are clearly expressed both in the form of symptoms of irritation (epileptic seizures) and prolapse (motor disorders can reach the degree of plegia).

To ascertain the serious condition of the patient, it is permissible to have these violations in at least one of the parameters. Identification of violations of vital functions by 2 or more indicators, regardless of the severity of depression of consciousness and focal symptoms, is sufficient to qualify the condition as severe.

The threat to life is significant, largely depends on the duration of the serious condition. The prognosis for recovery of working capacity is sometimes unfavorable.

Extremely serious condition.

Criteria (limits of violations for each parameter are given):

1. state of consciousness - moderate or deep coma;
2. vital functions - gross violations simultaneously in several parameters;
3. focal symptoms:

• stem - expressed roughly (reflex paresis or plegia of upward gaze, gross anisocoria, divergence of the eyes along the vertical or horizontal axis, tonic spontaneous nystagmus, a sharp weakening of the pupils' reactions to light, bilateral pathological signs, hormetonia, etc.);
• hemispheric and craniobasal - pronounced sharply (up to bilateral and multiple paresis). Threat to life - maximum; largely depends on the duration of the extremely serious condition. The prognosis for recovery is often poor.

terminal state.

Criteria:

1. state of consciousness - terminal coma;
2. vital functions - critical disorders;
3. focal symptoms:

• stem - bilateral fixed mydriasis, absence of pupillary and corneal reflexes;
• hemispheric and craniobasal - blocked by cerebral and stem disorders.

Prediction: Survival is usually impossible.

When using the scale for assessing the severity of the condition of the victims for diagnostic and especially prognostic judgments, one should take into account the time factor - the duration of the patient's stay in a particular state. A serious condition within 15-60 minutes after the injury can also be observed in victims with concussion and mild contusion of the brain, but it has little effect on a favorable prognosis of life and recovery. If the patient stays in a serious and extremely serious condition for more than 6-12 hours, then this usually excludes the leading role of many concomitant factors, such as alcohol intoxication, and indicates a severe TBI.

When it should be taken into account that, along with the cerebral component, the leading causes of a protracted severe and extremely severe condition may be extracranial factors (traumatic shock, internal bleeding, fat embolism, intoxication, etc.).

W. A. ​​Knauss et al. (1981) developed and implemented a classification system based on the assessment of physiological parameters APACHE (Acute Physiology and Chronic Health Evaluation), applicable to adults and older children, which involves the use of routine parameters in the intensive care unit and is designed to evaluate all important physiological systems. A distinctive feature of this scale was that assessments that use specific parameters of organ system dysfunction are limited to diseases of these systems, while assessment of systems that could provide more extensive information about the patient's condition requires extensive invasive monitoring.

Initially, the APACHE scale contained 34 parameters, and the results obtained in the first 24 hours were used to determine the physiological status in the acute period. The parameters were assessed from 0 to 4 points, the health status was determined from A (complete health) to D (acute multiple organ failure). The likely outcome was not determined. In 1985, after revision (APACHE II), 12 main parameters remained in the scale that determine the main processes of life (Knaus W. A. ​​et al., 1985). In addition, it turned out that a number of indicators, such as plasma glucose and albumin concentrations, central venous pressure or diuresis, are of little significance in assessing the severity of the scale and more reflect the treatment process. The Glasgow score was rated from 0 to 12, and urea-replaced creatinine was 0 to 8.

Direct determination of oxygen in arterial blood began to be carried out only when Fi02 was less than 0.5. The remaining nine parameters did not change their assessment. The general state of health is assessed separately. Moreover, patients without surgery or with surgery for emergency indications were much less likely to survive compared to planned patients. The total assessment of age and general health cannot exceed 71 points; in persons with a score of up to 30-34 points, the probability of death is significantly higher than in patients with a higher score.

In general, the risk of death varied in different diseases. Thus, mortality in individuals with low ejection syndrome is higher than in patients with sepsis, with the same score on the scale. It turned out to be possible to introduce coefficients that take these changes into account. In the case of a relatively favorable outcome, the coefficient has a large negative value, and with an unfavorable prognosis, this coefficient is positive. In the case of pathology of an individual organ, a certain coefficient also takes place.

One of the main limitations of the APACHE II scale is that the mortality risk prediction is based on the outcomes of patients treated in the ICU during the period from 1979 to 1982. In addition, the scale was not originally designed to predict death for an individual patient and had a margin of error of approximately 15% when predicting in-hospital mortality. However, some researchers have used the APACHE II score to determine prognosis for each individual patient.

The APACHE II scale consists of three blocks:

1. assessment of acute physiological changes (acute physiology score-APS);
2. age assessment;
3. evaluation of chronic diseases.

Data on the block "Assessment of acute physiological changes" are collected during the first 24 hours of the patient's admission to the ICU. The worst variant of the estimate obtained during this time period is entered into the table.

Acute Physiological Disorders and Chronic Disorders Rating Scale

Acute Physiology and Chronic Health Evaluation II (APACHE II) (Knaus W. A., Draper E. A. et al., 1985)

Assessment of acute physiological changes - Acute Physiology Score, APS

Note: The estimate for serum creatinine is duplicated if the patient has acute renal failure (AKI). Mean arterial pressure \u003d ((BP system) + (2 (BP diast.)) / 3.

If no blood gas data are available, then serum bicarbonate can be used (the authors recommend using this indicator instead of arterial pH).

Estimating the patient's age

Assessment of comorbid chronic diseases

Note:

• An organ (or system) failure or immunodeficiency condition preceded the current hospitalization.
• An immunodeficiency state is defined if: (1) the patient has received therapy that reduces defenses (immunosuppressive
• therapy, chemotherapy, radiation therapy, long-term use of steroids or short-term use of high doses of steroids), or (2) has diseases that suppress immune function such as malignant lymphoma, leukemia, or AIDS.
• Liver failure if: there is cirrhosis of the liver, confirmed by biopsy, portal hypertension, episodes of bleeding from the upper digestive tract against the background of portal hypertension, previous episodes of liver failure, coma or encephalopathy.
• Cardiovascular insufficiency - class IV according to the New York classification.
• Respiratory failure: if there is respiratory limitation due to chronic restrictive, obstructive, or vascular disease, documented chronic hypoxia, hypercapnia, secondary polycythemia, severe pulmonary hypertension, respirator dependence.
• Renal failure: if the patient is on chronic dialysis.
• APACH EII score = (scores on the scale of acute physiological changes) + (scores for age) + (scores for chronic diseases).
• High scores on the APACHE II scale are associated with a high risk of mortality in the ICU.
• The scale is not recommended for use in patients with burns and after coronary artery bypass grafting.

Disadvantages of the APACHE II scale:

1. Cannot be used by under 18s.
2. General health should only be assessed in critically ill patients, otherwise the addition of this indicator would lead to an overestimation.
3. No score prior to admission to intensive care unit, (appeared in the APACHE III scale).
4. In case of death within the first 8 hours after admission, the evaluation of the data is meaningless.
5. In sedated, intubated patients, the Glasgow score should be 15 (normal), in the case of a history of neurological pathology, this score can be reduced.
6. With frequent reuse, the scale gives a slightly higher score.
7. A number of diagnostic categories are omitted (pre-eclampsia, burns, and other conditions), and the organ damage ratio does not always give an accurate picture of the condition.
8. With a lower diagnostic coefficient, the scale score is more significant.

Subsequently, the scale was transformed into the APACHE III scale.

APACHE III was developed in 1991 to extend and improve the APACHE II predictive scores. The database for creating the scale was collected from 1988 to 1990 and included data on 17,440 patients in intensive care units and intensive care units. The study included 42 departments in 40 different clinics. Urea, diuresis, glucose, albumin, bilirubin were added to the scale to improve the assessment of the prognosis. Added interaction parameters between various variables (serum creatinine and diuresis, pH and pCO2). In the APACHE III scale, more attention is paid to the state of immunity (Knaus W. A. ​​et al., 1991).

The development of APACHE III pursued the following goals:

1. Re-evaluate the sample and the significance of outliers using unbiased statistical models.
2. Update and increase the size and representativeness of the data under consideration.
3. Assess the relationship between the results on the scale and the time spent by the patient in the intensive care unit.
4. Distinguish between the use of prognostic estimates for groups of patients from the prognosis of a lethal outcome in each specific case.

The APACHE III system has three main benefits. The first is that it can be used to assess the severity of the disease and patients at risk within a single diagnostic category (group) or an independently selected group of patients. This is due to the fact that the increase in values ​​on the scale correlates with an increasing risk of hospital mortality. Secondly, the APACHE III scale is used to compare outcomes in patients in intensive care units and intensive care units, despite the fact that diagnostic and screening criteria are similar to those used in the development of the APACHE III system. Third, APACHE III can be used to predict treatment outcomes.

APACHE III predicts in-hospital mortality for groups of ICU patients by correlating patient characteristics on the first day of ICU stay with 17,440 patients initially entered in the database (between 1988 and 1990) and 37,000 patients admitted to the ICU resuscitation in the United States, which were included in the updated database (1993 and 1996).

Acute Physiological Disorders and Chronic Disorders Assessment Scale III

Acute Physiology and Chronic Health Evaluation III (APACHE III) (Knaus W. A. ​​et al., 1991)

The APACHE III score consists of assessments of several components - age, chronic diseases, physiological, acid-base and neurological condition. In addition, scores reflecting the patient's condition at the time of admission to the ICU and the category of the underlying disease are additionally taken into account.

Based on the assessment of the severity of the condition, the risk of death in the hospital is calculated.

Assessment of the patient's condition before admission to the ICU

Assessment of the state before admission to the ICU for patients of a therapeutic profile

ICU Admission Assessment for Surgical Patients

Category of the underlying disease for therapeutic patients

Underlying disease category for surgical patients

Physiological scale APACHE III

The physiological scale is based on a variety of physiological and biochemical parameters, with scores presented according to the severity of the pathological condition at the moment.

The calculation is made on the basis of the worst values ​​during the 24 h of observation.

If the indicator has not been studied, then its value is taken as normal.

Note.

1. Mean BP = Systolic BP + (2 x Diastolic BP)/3.
2. The Pa02 score is not used in intubated patients Fi02>0.5.
3. A-a D02, used only in intubated patients with Fi02 > 0.5.
4. AKI is diagnosed when creaginine > 1.5 mg/dl, urine output >410 ml/day, and no chronic dialysis.

Physiological Scale Score = (Pulse Score) + + (BPM Score) + (Temperature Score) + (RR Score) + (Pa02 or A-a D02 Score) + (Hematocrit Score) + (WBC Score) + (Creaginine Score) +/- ARF) + (Diuresis Score) + (Residual Azog Score) + (Sodium Score) + (Albumin Score) + (Bilirubin Score) + (Glucose Score).

Interpretation:

• Minimum rating: 0.
• Maximum score: 192 (due to limitations of Pa02, A-aD02 and creatinine). 2.5.

Assessment of the acid-base state

Evaluation of pathological conditions of CBS is based on the study of the content of pCO2 and pH of the patient's arterial blood.

The calculation is based on the worst values ​​within 24 hours. If the value is not available, it is considered normal.

Assessment of neurological status

Assessment of neurological status is based on the patient's ability to open his eyes, the presence of verbal contact and motor response. The calculation is based on the worst values ​​within 24 hours. If the value is not available, it is considered normal.

The APACHE III ICU Severity Scale can be used throughout the entire hospital stay to predict the likelihood of death in the hospital.

Each day of the patient's stay in the ICU, an APACHE III score is recorded. Based on the developed multivariate equations, using daily APACHE III scores, it is possible to predict the probability of a patient dying on the present day.

Daily Risk = (Acute Physiology Score on the first day of ICU stay) + (Acute Physiology Score during the current day) + (Change in Acute Physiology Score from the previous day).

Multivariate equations for estimating daily mortality risk are copyrighted. They are not published in the literature, but are available to subscribers of the commercial system.

Once the parameters included in the APACHE III scale are tabulated, an estimate of the severity of the condition and the probability of death in the hospital can be calculated.

Data requirements:

• The assessment is made to determine the indications for hospitalization in the ICU.
• If the patient has a therapeutic pathology, select the appropriate assessment prior to admission to the ICU.
• If the patient has been operated on, select the type of surgery (emergency, elective).
• The assessment is made for the main disease category.
• If the patient is a therapeutic profile, select the main pathological condition that requires hospitalization in the ICU.
• If the patient has been operated on, select the main pathological condition among the surgical diseases requiring hospitalization in the ICU.

APACHE III overall score

APACHE III Total Score = (Age Score) + (Chronic Condition Score) + (Physical Status Score) + (Acid-Base Balance Score) + (Neurological Status Score)

APACHE III Minimum Overall Score = O

Maximum APACHE III total score = 299 (24 + 23 + 192 + 12 + 48)

APACHE III Severity Score = (Pre-ICU Score) + (Major Category Score) + + (0.0537(0 total APACHE III score)).

Probability of death in hospital = (exp (APACHE III Severity Score)) / ((exp (APACHE III Risk Equation)) + 1)

Again, we emphasize that prediction scales are not designed to predict the death of an individual patient with 100% accuracy. High scores on the scale do not mean complete hopelessness, just as low scores do not insure against the development of unforeseen complications or accidental death. Although the prediction of death using APACHE III scores obtained on the first day of ICU stay is reliable, it is rarely possible to determine an accurate prognosis for an individual patient after the first day of intensive care. The ability to predict a patient's individual likelihood of survival depends, among other things, on how he or she responds to therapy over time.

Clinicians using predictive models should be aware of the possibilities of modern therapy and understand that the confidence intervals for each value are expanding every day, increasing the number of positive results that are more important than absolute values, and also that some factors and response rates to therapy is not determined by acute physiological abnormalities.

In 1984, the SAPS scale (UFSHO) was proposed, the main purpose of which was to simplify the traditional methodology for assessing severely ill patients (APACHE). In this variant, 14 easily determined biological and clinical indicators are used, reflecting the risk of death to a fairly high degree in patients in intensive care units (Le Gall J. R. et al., 1984). Indicators are evaluated in the first 24 hours after admission. This scale correctly classified patients into groups with an increased likelihood of death, regardless of diagnosis, and was comparable with the physiological scale of acute conditions and other assessment systems used in intensive care units. The FSE turned out to be the simplest and took much less time to evaluate it. Furthermore, retrospective assessment appears to be possible, as all parameters used in this scale are routinely recorded in most intensive care units.

Original Simplified Physiological Disorder Scale

Original Simplified Acute Physiology Score (SAPS) (Le Gall J-R, 1984)

The Simplified Acute Physiological Conditions Scale (SAPS) is a simplified version of the APACHE Acute Physiological Conditions (APS). It allows easy scoring using available clinical information; scores correspond to the risk of patient mortality in the ICU.

• received in the first 24 hours of stay after admission to the ICU;
• 14 information values ​​versus 34 APACHE APS values.

Notes:

1. Glucose converted to mg/dL from mol/L (mol/L times 18.018).
2. Urea converted to mg/dL from mol/L (mol/L times 2.801). Overall score on the SAPS scale = The sum of the scores for all indicators of the scale. The minimum value is 0 points and the maximum is 56 points. The probability of developing a lethal outcome is presented below.

New Simplified Physiological Disorder Scale II

New Simplified Acute Physiology Score (SAPS II) (Le Gall J-R. et al., 1993; Lemeshow S. et al., 1994)

The New Simplified Acute Physiological Conditions Scale (SAPS II) is a modified simplified Acute Physiological Conditions Scale. It is used to evaluate ICU patients and can predict mortality risk based on 15 key variables.

Compared to SAPS:

• Excluded: glucose, hematocrit.
• Added: bilirubin, chronic diseases, reason for admission.
• Changed: Pa02/Fi02 (zero points if not on ventilator or CPAP).

The SAPS II score ranges from 0 to 26 versus 0 to 4 for SAPS.

>SAPS II = (Age Score) + (HR Score) + (Systolic BP Score) + (Body Temperature Score) + (Ventilation Score) + (Urine Score) + (Blood Urea Nitrogen Score) ) + (Leukocyte Score) + (Potassium Score) + (Sodium Score) + (Bicarbonate Score) + + (Bilirubin Score) + (Glasgow Score) + ( Points for chronic illness) + (Points for type of admission).

Interpretation:

• Minimum value: About
• Maximum value: 160
• logit = (-7.7631) + (0.0737 (SAPSII)) + ((0.9971(LN((SAPSII) + 1))),
], ,

Lung Injury Score (Murray J. F., 1988)

Assessed parameter	Index	Meaning
Chest radiograph	Alveolar consolidation	No alveolar consolidation
		Alveolar consolidation in one quadrant of the lungs
		Alveolar consolidation in two quadrants of the lungs
		Alveolar consolidation in the three quadrants of the lungs
		Alveolar consolidation in the four quadrants of the lungs
hypoxemia
Compliance of the respiratory system, ml/cm H20 (with mechanical ventilation)	Compliance
Positive end-expiratory pressure, cm H20 (with mechanical ventilation)
Total points	Availability damage lungs	No lung damage
		Acute lung injury
		Severe lung injury (ARDS)

RIFLE scale

(National Kidney Foundation: K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification and Stratification, 2002)

To unify approaches to the definition and stratification of the severity of acute renal failure, a group of experts from the Acute Dialysis Quality Initiative (ADQI) created the RIFLE scale (rifle - rifle, English), which includes the following stages of renal failure:

• Risk - risk.
• Injury - damage.
• Failure - insufficiency.
• Loss - loss of function.
• ESKD (end stage renal disease) - end stage kidney disease = terminal renal failure.

	Serum creatinine	Pace diuresis	Specificity/ sensitivity
	Increasing the concentration of serum creatine and by 1.5 times Decreased glomerular filtration rate (GFR) by more than 25%	More than 0.5ml/kg/h for 6 hours	high sensitivity
I (damage)	An increase in serum creatinine concentration by 2 times or. GFR reduction by more than 50%	More than 0.5 ml/kg/h for 12 hours
F(insufficiency)	Increase in serum creatinine concentration by 3 times GFR reduction by more than 75% An increase in serum creatinine to 4 mg/dL (>354 µmol/L) or more with a rapid increase in >0.5 mg/dL (>44 µmol/L)	More than 0.3 ml/kg/h within 24 hours or anuria within 12 hours	high specificity
L (loss of kidney function)	Persistent AKI (complete loss of kidney function) for 4 or more weeks
E (terminal renal failure)	Terminal renal failure for more than 3 months

This classification system includes criteria for assessing creatinine clearance and urine output. When examining a patient, only those scores are used that indicate that the patient has the most severe class of kidney damage.

It should be borne in mind that with an initially elevated serum creatinine concentration (Scr), renal failure (F) is diagnosed even in cases where the increase in Scr does not reach a three-fold excess over the initial level. This situation is characterized by a rapid increase in Scr by more than 44 µmol/l to a serum creatinine concentration above 354 µmol/l.

The designation RIFLE-FC is used when a patient with chronic renal failure has experienced an acute worsening of kidney function "ARF in CRF" and an increase in serum creatinine concentration compared to baseline. If renal failure is diagnosed on the basis of a decrease in the rate of hourly urine output (oliguria), the designation RIFLE-FO is used.

The “high sensitivity” of the scale means that the majority of patients with the presence of these features are diagnosed with moderately severe renal dysfunction even in the absence of true renal failure (low specificity).

With “high specificity”, there is little doubt that there is severe kidney damage, although in some patients it may not be diagnosed.

One disadvantage of the scale is that baseline renal function is required to stratify the severity of AKI, but this is usually unknown in patients admitted to the ICU. This was the basis for another study, "Modification of Diet in Rénal Disease (MDRD)", based on the results of which ADQI experts calculated estimates of "basal" values ​​of serum creatinine concentration at a given glomerular filtration rate of 75 ml / min / 1 .73 m2.

Estimation of "basal" values ​​of creatinine in blood serum (µmol/l), corresponding to the values ​​of the glomerular filtration rate of 75 mg/min/1.73 mg for Caucasians

Taking into account the obtained results, the Acute Kidney Injury Network (AKIN) experts subsequently proposed a stratification system for the severity of acute renal failure, which is a modification of the RIFLE system.

Kidney injury according to AKIN

	The concentration of creatinine in the patient's blood serum	Diuresis rate
	Serum creatinine concentration (Running)> 26.4 µmol/l or its increase by more than 150-200% of the initial level (1.5-2.0 times)	More than 0.5 ml/kg/h for six hours or more
	Increasing concentration Running more than 200% but less than 300% (more than 2 but less than 3 hours) of baseline	More than 0.5 ml/kg/h for 12 hours or more
	Increase in Run concentration by more than 300% (more than 3 times) of baseline or Run concentration >354 µmol/L with a rapid increase of more than 44 µmol/L	More than 0.3 ml/kg/h within 24 hours or anuria within 12 hours

The proposed system, based on changes in serum creatinine concentration and/or hourly urine output, is largely similar to the RIFLE system, but still has a number of differences.

In particular, classes L and E according to the RIFLE system are not used in this classification and are considered as outcomes of acute kidney injury. At the same time, category R in the RIFLE system is equivalent to the first stage of acute renal failure in the AKIN system, and classes I and F according to RIFLE correspond to the second and third stages according to the AKIN classification.