1、A-aDO2 = FiO2 x (PB-PH2O) PaCO2/RQ = FiO2 x (760 74) PaCO2/ = 713 x FiO2 PaCO2/其中:A-aDO2:肺泡动脉氧分压差,FiO2:吸入氧浓度,PB:大气压,PH2O:水蒸气压,RQ:呼吸熵鼻导管面罩氧流量(lpm)123456815重复吸入FiO2注:利用鼻导管时氧流量应 6 lpm。动脉血pH:同时记录最高值和最低值后别离评分,并取分值高者血钠:血钾:血肌酐:注意肌酐太低也有分(SCr mg/dL或53 mol/L时为2分)急性肾功能衰竭时,应依照肌酐先行评分后将分值x 2,而非将肌酐数值x 2后再进行评分急性肾功能
2、衰竭的概念为:每日尿量 mg/dL或 mol/L,且未同意长期透析(腹膜透析或血液透析)血球压积:白细胞计数:格拉斯哥昏迷评分(GCS)利用镇定和(或)肌松药物时应遵循best guess的原那么进行判定评分,即依照临床表现及药物利用情形,估量在没有药物阻碍时的GCS。(这固然并非容易,且容易致使不同评分者之间的不同,但没有更好的解决方式。)双侧肢体活动不对称时,应依照病情较轻侧的情形进行评分。有人工气道的患者进行语言评分时应采用5-3-1评分(见下表)。应计算15 GCS的结果后与其他急性生理评分相加最佳语言反应插管患者“语言”最佳运动反应最佳睁眼定向力好遵嘱活动自主言语错乱介于两者之间疼痛
3、定位命令只能说出单词无反应屈曲: 收回疼痛只能发音气管插管或气管切开患者语言评分应使用此列 去皮层伸展血HCO3:当没有血气结果时利用此项(不建议不查血气,因为这将没有氧合及pH两项评分结果)急性生理评分应为各项评分的总和如有缺项,应视为正常,即评0分三、年龄评分年龄(岁) 4445 5455 6465 74 75分值四、慢性健康评分入院前须知足慢性器官功能不全或免疫功能抑制状态的诊断相关诊断标准见下表符合慢性器官功能不全或免疫功能抑制的患者才有慢性健康评分择期手术后入ICU,为2分急诊手术或非手术后入ICU,为5分假设不符合慢性器官功能不全或免疫功能抑制的诊断,无论入院情形如何,均没有慢性健
4、康评分(即慢性健康评分为0)肝脏活检证实的肝硬化及明确的门脉高压;既往因门脉高压引起的上消化道出血;或既往发生肝功能衰竭 / 肝性脑病 / 肝昏迷心血管纽约心脏病协会心功能IV级呼吸慢性阻塞性、梗阻性或血管性肺疾病导致活动重度受限,即不能上楼或不能做家务;或明确的慢性低氧、CO2潴留、继发性真红细胞增多症、重度肺动脉高压( 40 mmHg)或呼吸肌依赖肾脏接受长期透析治疗免疫功能抑制应用治疗影响感染的抵抗力,如免疫功能抑制治疗,化疗,放疗,长期或近期使用大剂量激素,或罹患疾病影响感染的抵抗力,如白血病、淋巴瘤和AIDS最终APACHE II评分 = 急性生理评分 + 年龄评分 + 慢性健康评分
5、APACHE II评分的理论最高值为71分五、预期病死率的计算计算APACHE II评分判定是不是为急诊手术急诊手术概念为由打算手术开始24小时内进行的手术确信入ICU的诊断分类系数(或权重)见附录中相应表格依照患者入ICU的要紧缘故此非基础疾病确信系数。例如,择期消化道肿瘤切除手术患者因有慢性肾衰病史,术后返回ICU。此刻,诊断分类系数应选择手术栏目中的admission due to chronic cardiovascular disease ,而非GI surgery for neoplasm 。如列举项目均与患者情形不符合,应依照致使患者入ICU的要紧罹患器官或系统确信系数(在表格的
6、下部)。例如,患者因急性肾功能衰竭致使的高钾血症入ICU,应选择表格左半部份下方的Metabolic/renal 。依照以下公式计算预期病死率病死率指住院病死率而非ICU病死率ln(R/1-R) = + (APACHE II评分 x + , 若为急诊手术) + (诊断分类系数)其中,R为预期病死率The APACHE II Severity of Disease Classification SystemPhysiologic Variable+4+3+2+1ScoreTemperature rectal (C) 41 39 30 32 34 36 MAP mmHg 160 49130 159
7、110 12950 6970 109HR (ventricular response) 180 39140 17940 54110 13955 69RR (non-ventilated or ventilated) 50 535 496 925 3410 1112 24Oxygenation: A-aDO2 or PaO2 (mmHg):a. FiO2 : A-aDO2 500350 499200 349 200b. FiO2 70Arterial pH Serum Na (mmol/L) 110160 179111 119155 159120 129150 154130 149Serum K
8、 (mmol/L) 76 3 Serum Cr (mg/dL)2 (double point score for ARF)Hct (%) 60 2050 20 46 30 WCC (x 109/L) 40 11 15 GCS (Score = 15 actual GCS)A Acute physiology score (APS)Serum HCO3 (venous, mmol/L) (not preferred, use if no ABGs) 52 1541 18 32 22 B Age PointsAssign points to age as follows:Age (yrs)Poin
9、tsC Chronic Health PointsIf the patient has a history of severe organ system insufficiency or is immunocompromised assign points as follows:a. for nonoperative or emergency postoperative patients 5 pointsb. for elective postoperative patients 2 pointsDefinitions:Organ insufficiency or immunocompromi
10、sed state must have been evident prior to this hospital admission and conform to the following criteria:LiverBiopsy proven cirrhosis and documented portal hypertension; episodes of past upper GI bleeding attributed to portal hypertension; or prior episodes of hepatic failure / encephalophathy / coma
11、CardiovascularNew York Heart Association Class IVRespiratoryChronic restrictive, obstructive, or vascular disease resulting in severe exercise restriction, ., unable to climb stairs or perform household duties; or documented chronic hypoxia, hypercapnia, secondary polycythemia, severe pulmonary hype
12、rtension ( 40 mmHg), or respiratory dependencyRenalreceiving chronic dialysisImmunocompromisedThe patient has received therapy that suppresses resistance to infection, ., immunosuppression, chemotherapy, radiation, long-term or recent high doses steroids, or has a disease that is sufficiently advanc
13、ed to suppress resistance to infection, ., leukemia, lymphoma, AIDSAPACHE II ScoreA APS pointsB Age pointsC Chronic health pointsTotal APACHE II score = A + B + C = Emergency surgery: c Yes c NoDiagnostic category weight:Probability of Death:Principal Diagnostic Categories Leading to ICU AdmissionNo
14、noperative patientsPostoperative patientsRespiratory failure or insufficiency from:Multiple traumaAsthma/allergyAdmission due to chronic cardiovascular dis.COPDPeripheral vascular surgeryPulmonary edema (noncardiogenic)Heart valve surgeryPostrespiratory arrestCraniotomy for neoplasmAspiration/poison
15、ing/toxicRenal surgery for neoplasmPulmonary embolusRenal transplantInfectionHead traumaNeoplasmThoracic surgery for neoplasmCardiovascular failure or insufficiency from:Craniotomy for ICH/SDH/SAHHypertensionLaminectomy and other spinal cord surgeryRhythm disturbanceHemorrhagic shockCongestive heart
16、 failureGI bleedingHemorrhagic shock/hypovolemiaGI surgery for neoplasmCoronary artery diseaseRespiratory insufficiency after surgerySepsisGI perforation/obstructionPostcardiac arrestCardiogenic shockDissecting thoracic/abdominal aneurysmTrauma:For postoperative patients admitted to the ICU for seps
17、is or postarrest, use the corresponding weights for nonoperative patients.Neurologic:Seizure disorderICH/SDH/SAHOther:Drug overdoseDiabetic ketoacidosisIf not in one of the specific groups above, then which major vital organ system was the principal reason for admission?If not in one of the above, w
18、hich major vital organ system led to ICU admission postsurgery?Metabolic/renalNeurologicGastrointestinalTo compute predicted death rates for groups of acutely ill patients, for each individual compute the risk (R) of hospital death with the following equation; then sum the individual risks and divide by the total number of patients.ln(R/1-R) = + (APACHE II score x + , only if postemergency surgery) + (Diagnostic category weight)
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