DIREKTORAT KESEHATAN ANGKATAN DARAT

RSPAD GATOT SOEBROTO

Nama :
APACHE II SCORE AND PREDICTED HOSPITAL DEATH No. RM :
(Ruang ICU - IMCU - ISOLASI - PERAWATAN) Tgl Lahir : ☐Laki-laki ☐Perempuan
Diagnosa : Hari Rawat : Ruangan :
APACHE II SCORE AND PREDICTED
THE APACHE II SEVERITY OF DISEASE CLASSIFICATION SYSTEM
HOSPITAL DEATH
High Abnormal Range Low Abnormal Range Apache Apache
Physiologic Variable PHD PHD
+4 +3 +2 +1 0 +1 +2 +3 +4 II II
Temperature - rectal (C°) ≥ 41° 39° - 40.9° 38.5° - 38.9° 36° - 38.4° 34° - 35.9° 32° - 33.9° 30° - 31.9° ≤ 29.9° 1 3.3 41 92.2
Mean Arterial Pressure (mmHg) ≥ 160 130 - 159 110 -129 70 - 109 50 - 69 ≤ 49 2 3.8 42 93.2
Heart Rate (Ventricular Response) ≥ 180 140 - 179 110 - 139 70 - 109 55 - 69 40 - 54 ≤ 39 3 4.4 43 94.1
Respiratory Rate (non ventilated or ventilated) ≥ 50 35 - 49 25 - 34 12 - 24 10 - 11 6-9 ≤5 4 5.1 44 94.8
Oxygenation : a. O₂ or PaO₂ (mmHg) ≥ 500 350 - 499 200 - 349 < 200 5 5.8 45 95.5
b. FiO₂ < 0,5 record only PaO₂ PO₂ > 70 PO₂ 61 - 70 PO₂ 55 - 60 PO₂ < 55 6 6.7 46 96.1
Arterial pH ≥ 7.7 7.6 - 7.69 7.5 - 7.59 7.33 - 7.49 7.25 - 7.32 7.15 - 7.24 < 7.15 7 7.6 47 96.6
Serum Sodium (mMol/L) ≥ 180 160 - 179 155 - 159 150 - 154 130 - 149 120 - 129 111 - 119 ≤ 110 8 8.7 48 97
Serum Potassium (mMol/L) ≥7 6 - 6.9 5.5 - 5.9 3.5 - 5.4 3 - 3.4 2.5 - 2.9 < 2.5 9 9.9 49 97.4
Serum Creatinine (mg/100ml) (Double point score for 10 11.3 50 97.8
≥ 3.5 2 - 3.4 1.5 - 1.9 0.6 - 1.4 < 0.6
ACUTE renal failure) 11 12.9 51 98.1
Hematocrit ( % ) ≥ 60 50 - 59.9 46 - 49.9 30 - 45.9 20 - 29.9 < 20 12 14.6 52 98.3
White Blood Count (total/mm³) (in 1.000s) ≥ 40 20 - 39.9 15 - 19.9 3 - 14.9 1 - 2.9 <1 13 16.5 53 98.6
Glascow Coma Score : Score = 15 - Actual GCS 14 18.6 54 98.7
A : Total ACUTE PHYSIOLOGY 15 21 55 98.9
SCORE ( APS ) : Sum of the 12 individual variable point 16 23.5 56 99.1
Serum HCO₃ (venous - mMol/L) (*NOT preferred, use 17 26.2 57 99.2
≥ 52 41* - 51.9 32 - 40.9 22 - 31.9 18 - 21.9 15 - 17.9 < 15
if no ABG's) 18 29.1 58 99.3
B : AGE POINT : Assign point to age as follows : C : CHRONIC HEALTH POINT - if the pateint has a history of servere organ system, insulfficiency or is immuno- 19 32.2 59 99.4
Age (years) points compromised, assign point as follows : 20 35.5 60 99.5
≤ 44 = 0 a. for non-operative or emergency post-operative patients : 5 point 21 38.9 61 99.5
b. for elective post-operative patient : 2 point
45 - 54 = 2 22 42.4 62 99.6
55 - 64 = 3 DEFINITIONS : 23 46 63 99.7
Organ insulfficiency or immuno-compromised state must have been evident prior to this hospital adminission and
65 - 74 = 5 conform to the following criteria : 24 49.7 64 99.7
≥ 75 = 6 25 53.3 65 99.7
LIVER : Biopsy proven cirrhosis and documented portal hypertensions; episodes of past upper GI bleeding
attributed to portal hypertension; or prior episodes of hepatic failure / encephalopathy / coma. 26 56.9 66 99.8
APACHE II Score = Sum of A + B + C CARDIOVASCULAR : NYHA Class IV. 27 60.5 67 99.8
A. APS point : ………………………………………………… 28 63.9 68 99.8
RESPIRATORY : Chronic restrictive, obstructive, or vascular disease resulting in severe exercise restriction, i.e.
B. Age point : ………………………………………………… unable to climb stairs or perform household duties; or documented chronic hypoxia, hypercapnia, secondary 29 67.2 69 99.9
C. Chronic Health pint : ……………………………………... polycythemia, severe pulmonary hypertension (> 40 mmHg), or respiratory dependency. 30 70.3 70 99.9
RENAL : Receiving chronic dialysis. 31 73.3 71 99.9
Total APACHE II Score IMMUNO-COMPROMISED : The patient has received therapy that suppressed resistance to infection, e.g. 32 76 72 99.9
= ……………………………………… (document immuno-suppresion, chemotherapy, radiation, long term or recent high dose glarolds, or has a disease that is 33 78.6 73 99.9
calculated score on Page 2 of drotrecogin alfa sufficiently advanced to suppress resistance to infection, e.g. leukemia, lymphoma, AIDS. 34 81 74 99.9
assessment worksheet) 35 83.1 75 99.9
Reference : 36 85.1 76 99.9
37 86.8 77 100
38 88.4 78
39 89.8 79
40 91.1 80
Rev.I/IV/2014/RM-006d.3/RI