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Should the pre-sedation Glasgow Coma Scale value be used when calculating Acute Physiology and Chronic Health Evaluation scores for sedated patients?

Livingston, Brian Mark BA, MSc, RGN; Mackenzie, Simon James MB, ChB, FRCA; MacKirdy, Fiona Nancy BSc, MN, RGN; Howie, John Cameron BSc, MB ChB, FRCA on behalf of the Scottish Intensive Care Society Audit Group

Clinical Investigations
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Objective: To assess the effect on the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III of two different approaches to scoring the Glasgow Coma Scale (GCS) in sedated patients. The first approach was to assume that the GCS score was normal, and the second was to use the GCS value recorded before the patient was sedated.

Design: Prospective cohort study over 2 yrs.

Setting: Twenty-two general adult intensive care units in Scotland.

Patients: 13,291 consecutive admissions to the participating intensive care units.

Measurements and Main Results: After exclusion of patients according to standard, predefined criteria, the Acute Physiology and Chronic Health Evaluation II and III systems were used to calculate the probability of hospital mortality for patients included in the study. In patients whose GCS scores could not be assessed accurately during the first 24 hrs, the APACHE II and III predictions were calculated twice: first, assuming that the GCS score was normal; and second, substituting the GCS score recorded before sedation. This generated two different databases for each system, and the predictions for both were compared with the observed hospital mortality rate. The effect of the two different approaches to the GCS on the performance of both APACHE II and APACHE III was assessed using measures of discrimination (area under the receiver operating characteristic curve) and goodness of fit (calibration curves and the Hosmer-Lemeshow statistic). Analysis was undertaken for both the entire cohort and for the group of patients whose APACHE scores were altered.

There was a wide variation in the number of patients who had their scores altered between participating units. There were also differences between diagnostic groups. Overall, however, 50% of the patients were sedated and 22% had their scores altered. Using the presedation GCS score increased the discrimination of both APACHE II and APACHE III. The calibration of APACHE III was also improved but that of APACHE II deteriorated. The calibration improved, however, in those patients with altered scores, suggesting that the overall deterioration is attributable to other limitations in the fit of the model to these data. Although changes had the greatest effect in patients with a neurologic or trauma diagnosis, the changes were important in most diagnostic groups.

Conclusions: The GCS is an important component of both APACHE II and APACHE III. It should be assessed directly whenever possible. When patients are sedated, using the GCS score recorded before sedation is preferable to the assumption of normality. The variations between different units and different diagnostic groups highlight the possible effects of case mix on the performance of prognostic scoring systems.

From the Department of Public Health, University of Glasgow (Mr. Livingston), the Intensive Care Unit, Royal Infirmary, Edinburgh (Dr. Mackenzie), and the Scottish Intensive Care Society Audit Group (Ms. MacKirdy) and the Department of Anaesthetics (Dr. Howie), Victoria Infirmary, Glasgow, Scotland.

Funded, in part, by the Clinical Resource and Audit Group of the Scottish Office.

Address requests for reprints to: Simon Mackenzie, MB ChB, FRCA, Intensive Care Unit, Royal Infirmary, Lauriston Place, Edinburgh EH3 9YW, UK.

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