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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 15  |  Issue : 4  |  Page : 172-178

Evaluation of acute physiology and chronic health evaluation IV score and sequential organ failure assessment score in predicting outcome of patients in respiratory intensive care unit


Chest Department, Faculty of Medicine, Al Azhar University, Cairo, Egypt

Date of Submission09-May-2017
Date of Acceptance06-Feb-2018
Date of Web Publication19-Jul-2018

Correspondence Address:
Ahmad A Naglh
Professor of Chest Disease, Professor of Chest Disease.
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_25_17

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  Abstract 


Background Scoring systems in ICU allow assessment of severity of the disease and provide an estimate of in-hospital mortality. And they quantify the severity of illness for hospital and health care system administration.
Objective The objective of this study was to detect the ability of acute physiology and chronic health evaluation (APACHE) IV score and sequential organ failure assessment (SOFA) score in predicting outcome of patients in respiratory intensive care unit (RICU).
Patients and methods A prospective observational cohort study was performed at the RICU of Bab El-Sha’eria and Al-Hussein Al-Azhar University hospitals. The study includes all critically ill patients admitted to the RICU between November 2014 and November 2016. Data were collected from 100 patients (42 female and 58 male) consecutively admitted to the RICU (aged ≥18 years and ICU stay of ≤24 h). Mean of APACHE IV score, length of stay, and predicted mortality rate were calculated during the first 24 h. Mean of SOFA score and length of stay were calculated during the admission. Data were analyzed with SPSS versus version 15.
Results In 100 patients, the observed mortality rate was 49%. The mean age in survived patients was 57.216±12.588 years and in nonsurvived patients was 62.694±10.304 years. APACHE IV score more than 81 was kept as cutoff point, with sensitivity of 81.6% and specificity of 80.4% with area under receiver operating characteristic curve of 0.841. SOFA score more than 7 was kept as cutoff point, with sensitivity of 95.9% and specificity of 100% with area under receiver operating characteristic curve of 0.997.
Conclusion The mortality prediction by APACHE IV and SOFA scoring systems performs acceptably in our patients, and they can be used as performance assessment tools in our RICUs. Both scores showed good discrimination between survived and nonsurvived patients, with SOFA score being more accurate in predicting mortality than APACHE IV.

Keywords: acute physiology and chronic health evaluation IV score, respiratory intensive care unit, sequential organ failure assessment score


How to cite this article:
Naglh AA, Zedan M, Arafa M, Alzeftawy M. Evaluation of acute physiology and chronic health evaluation IV score and sequential organ failure assessment score in predicting outcome of patients in respiratory intensive care unit. Al-Azhar Assiut Med J 2017;15:172-8

How to cite this URL:
Naglh AA, Zedan M, Arafa M, Alzeftawy M. Evaluation of acute physiology and chronic health evaluation IV score and sequential organ failure assessment score in predicting outcome of patients in respiratory intensive care unit. Al-Azhar Assiut Med J [serial online] 2017 [cited 2018 Oct 22];15:172-8. Available from: http://www.azmj.eg.net/text.asp?2017/15/4/172/237129




  Introduction Top


The severity scoring systems were introduced for critically ill patients in ICUs in 1980 [1]. Acute physiology and chronic health evaluation (APACHE) IV scoring systems have been designed for making quantitative statements regarding the severity of a disease, its course, and its prognosis [2]. APACHE IV system predicts hospital mortality and provides useful marks for evaluating efficiency in ICUs [3]. The sequential organ failure assessment (SOFA) score has been developed by European Society of Critical Care Medicine in 1994 [4],[5].


  Objective Top


The objective of this study is to detect the ability of APACHE IV score and SOFA score in predicting outcome of patients in respiratory intensive care unit (RICU).


  Patients and methods Top


A prospective observational cohort study was performed at the RICU of Bab El-Sha’eria and Al-Hussein University Hospitals. The study included all critically ill patients admitted to the RICU between November 2014 and November 2016, and they underwent randomized selection. Ethical approval was taken from the Research Ethical Committee at Al-Azhar university hospital and consent was taken from the patient or his relatives. Critically ill patients are defined as those patients who are at a high risk for actual or potential life-threatening health problems. Critical illness is the impairment of vital organ function or the presence of instability, or the risk of serious and potentially preventable complications [6]. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable, and complex, thereby requiring intense and vigilant nursing care. Data were analyzed with SPSS version 15 (SPSS Inc., Chicago, Illinois, USA).

Scoring systems used in ICU for critically ill patients are the APACHE [7] and the SOFA scoring systems. The SOFA score basically evaluates the six different organ systems separately. Different variables and parameters are included in each of the organ system, and a definite score is given to that state varying from 0 to 4, all of which is later added to calculate the SOFA score (maximum of 24). The score increases as the organ system functioning worsens; thus, the assessment of individual organ dysfunction or failure can be done along with evaluation of patient as a whole [4],[8]. Data were collected on 100 patients (42 female and 58 male) consecutively admitted to the RICU (aged ≥18 years and ICU stay ≤24 h).

All patients were subjected to the followings:
  1. Complete history taking.
  2. General examination including recording blood pressure, heart rate, body temperature, and respiratory rate.
  3. Local chest examination.
  4. Laboratory investigation including complete blood count, erythrocyte sedimentation rate, serum glucose, renal and hepatic profile, and serum sodium and potassium levels.
  5. Arterial blood gases.
  6. Recording urine output (ml/24 h).
  7. Length of stay in hospital from admission to discharge.
  8. Outcome of patients (cured or died).


Exclusion criteria

Patients who were excluded from the present study include those who were younger than 18 years, had coronary artery bypass grafting surgery, and died or discharged within 4 h of admission to the RICU.

The predictive capability of the APACHE IV and SOFA scores at the best cutoffs was assessed using the receiver operating characteristic (ROC) curve. Discrimination was tested using the ROC curves and by evaluating areas under the curve.

Admission criteria to intensive care unit

Admission to the RICU will be based on the nature and severity of the patient’s acute medical illness, their need for ICU intervention(s) or monitoring, and the likelihood that such interventions and ICU management will improve outcome. And patient admitted with one of the following indication for ICU admission
  1. Acute respiratory failure requiring mechanical ventilation (MV).
  2. Shock requiring vasopressors, aggressive fluid resuscitation, and/or invasive monitoring.
  3. Post cardiopulmonary arrest.
  4. Pulmonary emboli with hemodynamic instability.
  5. Patients in an intermediate care unit who are demonstrating respiratory deterioration.
  6. Respiratory distress or insufficiency requiring intensive therapy and observation.
  7. Massive hemoptysis.
  8. Cardiopulmonary conditions that require invasive hemodynamic monitoring.
  9. Chronic respiratory failure requiring MV [9].


Discharge criteria from intensive care unit

Patients are discharged to various sites with different levels of care provided. These include to another ICU, to the operating room, to a step-down or intermediate care unit, to a standard hospital ward, to a nursing home, or to an extended care facility. In general, patients being transferred to a lower level of care should have the following characteristics listed [9]:
  1. Stabilization of the patient’s condition such that vasopressors and MV with an artificial airway are not needed.
  2. Absence of a large bore single lumen, central venous, pulmonary artery, or arterial catheter.
  3. Absence of active, inadequately corrected conditions such as electrolyte disturbances, cardiac arrhythmias, or other serious medical illness.
  4. Oxygen requirements not more than 60% [9].



  Results Top


In the present study, the mean age in survived patients was 57.21±12.58 years and in nonsurvived patients was 62.69±10.30 years, so there is significant difference between survived and nonsurvived patients regarding age distribution with p value = 0.019 .

In the present study, there were 26 female and 25 male survived patients, and there were 16 female and 33 male nonsurvived patients, so there is insignificant difference among studied patients regarding sex distribution (P=0.062) ([Table 1]). In this study, the cause of admission was acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome with infective exacerbation, severe community acquired pneumonia (CAP), interstitial lung diseases with infective bronchitis, AE of bronchiectasis, aspiration pneumonia, and acute severe asthma, and all patients were complicated by respiratory failure before admission to RICU ([Table 1]). The study showed extremely significant difference between survived and nonsurvived patients regarding the presence of comorbidities ([Table 1]).
Table 1 Characteristics of patients in the study group

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In the present study, there is insignificant difference between survived and nonsurvived patients regarding receiving MV during the first 24 h ([Table 1]).

In the present study, the mean APACHE IV score in survived patients was 72.0±13.08 and in nonsurvived patients was 105.2±29.9, so there is a highly significant difference between survived and nonsurvived patients regarding values of APACHE IV score (P<0.001) ([Table 2]). In the present study, the mean SOFA score in survived patients was 5.0±1.48 and in nonsurvived patients was 12.5±2.45, so there is highly significant difference between survived and nonsurvived patients regarding values of mean SOFA score (P<0.001) ([Table 2]).
Table 2 Mean±SD and rang of APACHE, acute physiology and chronic health evaluation and SOFA, sequential organ failure assessment among studied patients

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In the present study, the mean predicted mortality rate (MR) in survived patients was 27.16±15.91 and in nonsurvived patients was 52.27±22.83, so there is highly significant difference between survived and nonsurvived patients regarding predicted MR by APACHE IV score (P<0.001) ([Table 3]). In the present study, there is highly significant difference between survived and nonsurvived patients regarding predicted MR by SOFA score ([Table 3]). The Mean±SD predicted MR for all patients was 39.4±23.23, and observed mortality was 49% ([Table 4]).
Table 3 Predicted mortality rate (MR) range, Mean±SD by APACHE IV and SOFA scores for patients

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Table 4 Comparison of Predicted mortality rate for all patients by APACHE IV acute physiology and chronic health evaluation IV to observed mortality

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In the present study, the mean predicted LOS at ICU in survived patients was 5.6±1.17 and in nonsurvived patients was 5.4±1.44 (P=0.434), and the mean observed LOS at ICU in survived patients was 5.1±1.7 and in nonsurvived patients was 6.6±4.79 (P=0.032) ([Table 5]). There were significant positive correlation between predicted LOS and observed LOS, where r is 0.301 and P value of 0.002.
Table 5 Comparison between Predicted and Observed Length of stay (LOS) at ICU

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In the present study, the cutoff point of APACHE IV score between survived and nonsurvived patients was more than 81, with sensitivity of 81.6% and specificity of 80.4%, and area under receiver operating characteristic curve (AUROC) was 0.81, and it showed good discrimination between survived and nonsurvived patients ([Table 6]). The cutoff point of SOFA score between survived and nonsurvived patients was more than 7, with sensitivity 95.9% and specificity 100% and AUROC was 0.997, and it showed good discrimination between survived and nonsurvived patients ([Table 6]). In this study, the accuracy in predicting mortality by SOFA score was more than by APACH IV score.
Table 6 Comparison between APACHE IV and SOFA scores in predicting outcomes in respiratory ICU as regard cutoff value and accuracy

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  Discussion Top


In this study, we determined the APACHE IV score and mean SOFA score for every case during the first 24 h and during the period of admission to the RICU. The outcome measure was ICU mortality or improvement and discharge from ICU. The observed MR in this study was 49%.

In the present study, the mean age in survived patients was 57.2±12.58 years and in nonsurvived patients was 62.6±10.30 years, so there is a significant difference between survived and nonsurvived patients regarding age distribution (P=0.019). This is in agreement with Kamal et al. [5] who reported that mean age for survived was 28.8 years and for nonsurvived was 47.9 years (P=0.000). Moreover, in the study by Moses et al. [10] the mean age for survived patients was 31.6±11.99 years and for nonsurvived patients was 38.8±16.18 years.

In the present study, 26 female and 25 male patients survived, whereas 16 female and 33 male patients did not survive. There was an insignificant difference among studied patients regarding sex distribution (P=0.062) ([Table 1]). This in agreement with the study by Ayazoglu [11] who found that 10 female and 26 male patients survived and nine female and 10 male patients did not survive (P=0.146), and the study by Kamal et al. [5] who found that nine female and 23 male patients survived and seven female and eight male patients did not survive (P=0.127).

The admission diagnoses at ICU were AE chronic obstructive pulmonary disease with respiratory failure in 45 cases, severe CAP with respiratory failure in 30 cases, obesity hypoventilation syndrome with respiratory failure in nine cases, AE of bronchiectasis with respiratory failure in eight cases, interstitial lung disease with respiratory failure in four cases, aspiration pneumonia with respiratory failure in two cases, and acute severe asthma with respiratory failure in two cases ([Table 1]).

In this study, the presence of comorbidities had a reflection on the survival status of patients. Comorbidities were present in 25 patients, with the survival status distributed as follows: hepatic failure in 15 cases − two survived and 13 nonsurvived; non-Hodgkin lymphoma in three cases − all did not survive; metastatic carcinoma in two cases − all did not survive; and chronic renal failure in five cases − four survived and one did not survive ([Table 1]).

In this study, there was insignificant relation between early need for MV in first 24 h following RICU admission and the survival status of patients (P=0.571). A total of 34 patients received early MV, among them 16 survived and 18 did not survive ([Table 1]).

In the present study, the mean value of APACHE IV in survived patients was 72.0±13.08 and in nonsurvived patients was 105.2±29.95, so there is highly significant difference between survived and nonsurvived patients regarding values of APACHE IV score (P<0.001) ([Table 2]). This in agreement with study by Yamin et al. [12], who found that the mean APACHE IV score in survived patients was 54.5±25.32 and in nonsurvived patients was 85.0±30.39; the results by Moses et al. [10], who found that mean APACHE IV score in survived patients was 32.7±11.11 and in nonsurvived patients was 76.7±10.75 (P<0.0001); and the results by Kamal et al. [5], who reported that the mean APACHE IV score in survived patients was 78.9±12.6 and in nonsurvived patients was 106.4±2.9 (P=0.000).

In the present study, the mean value of SOFA in survived patients was 5.0±1.48 and in nonsurvived patients was 12.5±2.45, so there is highly significant difference between survived and nonsurvived patients (P<0.001) ([Table 2]). This is in agreement with results obtained by Acharya et al. [13], who found that the nonsurvived patients had a higher mean SOFA score as compared with survived patients (P<0.001); the results by Yıldız et al. [14], who found that the mean SOFA score in survived patients was 3.8±2.21 and in nonsurvived patients was 6.1±3.27 (P=0.004); the results obtained by Mansour et al. [15], who found that mean SOFA score in survived patients was 4.9±2.49 and in nonsurvived patients was 6.1±2.76 (P=0.028); and the results by Shrestha et al. [16], who found that mean SOFA score in survived patients was 6.3±3.15 and in nonsurvived patients was 11.8±3.64 (P<0.001).

In the present study, the mean predicted MR by APACHE IV score in survived patients was 27.1%±15.91 and in nonsurvived patients was 52.2%±22.833. There is a highly significant difference between survived and nonsurvived patients (P<0.001) ([Table 3]). These results agree with those obtained by Kamal et al. [5] who found that predicted MR in survived patients was 0.38±0.11 and in nonsurvived patients was 0.66±0.12 (P=0.000) and those by Ayazoglu [11] who found that predicted MR in survived patients was 0.38±0.09 and in nonsurvived patients was 0.65±0.11 (P=0.000).

In the present study, the predicted MR in survived patients by SOFA score was 18.6%±5.52 and in nonsurvived patients was 73.3%±24.96. There is a highly significant difference between survived and nonsurvived patients (P<0.001) ([Table 3]). These results agree with those obtained by Acharya et al. [13] who found that the mean SOFA score when more than 7, with predicted mortality of 73.9% (P=0.00002).

In the present study, the predicted MR by APACHE IV in all patients was 39.46% ([Table 4]). This is in agreement with Mansour et al. [15], who found the predicted MR to be 59%; the results by Yıldız et al. [14], who found the predicted MR to be 49.7%, the results by Ayazoglu [11], who found the predicted MR to be 36.3%; and the results obtained by Kamal et al. [5], who found the predicted MR to be 34.04%; however, it disagrees with the results obtained by Zimmerman et al. [17], who conducted a study on 131 615 patients at 104 ICUs including medical, surgical, neurological, coronary, cardiothoracic, and trauma ICU and found the predicted MR to be 13.55%. Moreover, our results disagrees with those obtained by Moses et al. [10], who conducted a study on 107 patients who were admitted to the surgical ICU and found the predicted MR to be 17.75%.

In the present study, the observed MR was 49% ([Table 4]). In comparison with other studies, the observed MR in the study by Mansour et al. [15], was 55.2%; Acharya et al. [13] was 40%; Yıldız et al. [14], was 39.6%; Shrestha et al. [16], was 37.6%; Ayazoglu [11] was 34.54%; Kamal et al. [5], was 32%; Yamin et al. [12] was 28.4%; Moses et al. [10], was 15.88%; Zimmerman et al. [17], was 13.51%; Namendys et al. [18], was 20.25%; and Vincent et al. [19], was 22%.

The Observed Mortality Rate (MR) was high in our study because of the following factors:
  1. There are other comorbidities in the patients, as 15 cases had hepatic failure, five cases had chronic renal failure, and five cases had malignancy.
  2. The cases were complicated by severe bronchitis or pneumonia beside the underlying cause of admission, and all of them were experiencing respiratory failure at the same time.
  3. Most studies with low MR were done in general ICUs, including postoperative surgical patients who were already fit and noncomplicated.


In the present study, the predicted LOS at ICU in survived patients was 5.6±1.17 and in nonsurvived patients was 5.4±1.44 (P=0.434), with no statistically significant difference ([Table 5]). Moreover, in the present study, the observed LOS at ICU in survived patients was 5.1±1.71 and in nonsurvived patients was 6.6±4.79 (P=0.032), with statistically significant difference ([Table 5]). Therefore, there is significant difference between predicted LOS at ICU and observed LOS at ICU between survived and nonsurvived patients (P=0.002). The observed LOS at ICU (5.1±1.71) days in survived patients was less than the predicted LOS at ICU (5.6±1.17) days in survived patients (the same group) because there is rapid removal of patients to the intermediate care when the patients fulfill the discharge criteria due to rapid turnover in our ICU.

This is not in agreement with study by Moses et al. [10] who found that the mean predicted LOS in ICU for survived patients was 3.06±1.42 and mean observed LOS in ICU was 3.81±2.01 (P<0.0001). Mean predicted LOS for nonsurvived patients was 8.87±1.31 and mean observed LOS in ICU was 4.59±3.39 (P<0.0001) [10]. It is also in disagreement with Ayazoglu [11] who found that the mean predicted LOS in survived patients was 6±0.8 and in nonsurvived was 5.5±0.8 (P=0.021) and the mean observed LOS in survived patients was 16±6 and in nonsurvived was 19±8 (P=0.037) and Yıldız et al. [14], who found that the median observed LOS was 11.5 days for survived and 5 days for nonsurvived patients (P<0.01).

In the present study, the cutoff point of APACHE IV score between survived and nonsurvived patients was more than 81, with sensitivity 81.6% and specificity 80.4% and AUROC was 0.81, which showed good discrimination between survived and nonsurvived patients ([Table 6]). These results agree with those obtained by Kamal et al. [5], who conducted a study on comparison between APACHE II and APACHE IV scoring systems in predicting outcome in patients with acute lung injury and the adult respiratory distress syndrome; they found that the cutoff point of APACHE IV score was more than 90, and it gives a prediction of high possibility of death with sensitivity 94.73% and specificity 93.74%, and the AUROC curve was 0.92.

In the study by Ayazoglu [11], who compared between APACHE II and APACHE IV scoring systems in predicting outcome in patients admitted with stroke to an ICU, the author found that the cutoff point of APACHE IV score was more than 84, and it gives a prediction of high possibility of death with sensitivity 94.7% and specificity 94. 4% and the AUROC curve was 0.93. Moreover, in the study by Moses et al. [10], who conducted a study on APACHE IV score in 107 critically ill patients with abdominal trauma, patients with an APACHE IV score more than 60 had very high chances of mortality. Based on this assumption, 19 patients had high chances of death. However, on observation, 17 died and two patients who had high APACHE IV score did not die and were discharged [10]. Moreover, in the study by Yamin et al. [12], who analyzed the predictive efficacy of APACHE IV score at different ICUs, the authors showed that at APACHE IV scores more than 81, length of stay decreases and the MR increases. In addition, in the study by Zimmerman et al. [17], who assessed the APACHE IV score on hospital mortality, the area under the ROC curve was 0.88.

In the present study, the cutoff point of SOFA score between survived and nonsurvived patients was more than 7, with sensitivity 95.9% and specificity 100% and AUROC was 0.997, which showed good discrimination between survived and nonsurvived patients ([Table 6]).

These results are in agreement with those obtained by Mansour et al. [15], who found that the cutoff obtained by the ROC curve for SOFA score was 7.5; Shrestha et al. [16], who showed that the cutoff point for SOFA score between survived and nonsurvived patients was 8, with sensitivity 90.91% and specificity 65.75%; and Acharya et al. [13], who showed that the cutoff obtained by the ROC curve for SOFA score was 7, and area under ROC curve was 0.825.

In the present study, comparison between APACHE IV and SOFA scores shows that the SOFA score was more accurate than APACHE IV score (P<0.001) ([Table 6]).


  Conclusion Top


The present study demonstrates that the mortality prediction by APACHE IV and ASOFA scoring systems performs acceptably in our RICU patients and can be used as performance assessment tools in our RICU. Both scores showed good discrimination between survived and nonsurvived patients, with SOFA score being more accurate in predicting mortality than APACHE IV.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Zimmerman JE, Kramer AA, McNair AA, Douglas S, Andrew A, Fern R. Acute Physiology and Chronic Health Evaluation [APACHE) IV: ICU length of stay benchmarks for today’s critically ill patients. Crit Care Med 2006; 34:1297–1310.  Back to cited text no. 3
    
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Ferreira FL, Bota DP, Bross A, Melot C, Vincent JL. Serial evaluation of the SOFA scores to predict outcome in critically ill patients. JAMA 2001; 286:1754–1758.  Back to cited text no. 4
    
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Moses S, Gautam A, Shukla S, Mathur RK. Evaluation of predictive efficacy of APACH IV score in abdominal trauma patients. J Evol Med Den Sci 2015; 4:4834–4843.  Back to cited text no. 10
    
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Ayazoglu TA. Validation of the APACHE IV scoring system in patients with stroke: a comparison with the APACHE II system. Anaesth Pain Intensive Care 2011; 15:7–12.  Back to cited text no. 11
    
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Yamin S, Vaswani A, Afreedi M. Predictive efficacy of APACHE IV at ICU’s of civil hospital Karachi. Pak J Med 2011; 17:1–14.  Back to cited text no. 12
    
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Acharya SP, Pradhan B, Marhatta MN. Application of ‘the Sequential Organ Failure Assessment (SOFA) score’ in predicting outcome in ICU patients with SIRS Kathmandu University. Med J 2007; 5:475–83.  Back to cited text no. 13
    
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Yıldız T, Gündoğuş B, Ateş G, Akyıldız L, Çelik Y, Topçu F. The effectiveness of scoring systems and various biochemical parameters in predicting survival in a respiratory intensive care unit. Turk Biochem 2010; 35:128–132.  Back to cited text no. 14
    
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Mansour M, Galal I, Kassem E. Study of the role of different severity scores in respiratory ICU. Egypt J Bronchol 2013; 7:55–59  Back to cited text no. 15
    
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Shrestha GS, Gurung R, Amatya R. Comparison of acute physiology, age, chronic health evaluation III score with initial sequential organ failure assessment score to predict ICU mortality. Nepal Med Coll J 2011; 13:50–54.  Back to cited text no. 16
    
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Zimmerman JE, Kramer AA, McNair AA, Douglas S, Fern R. Acute Physiology and Chronic Health Evaluation (APACHE) IV: ICU length of stay benchmarks for today’s critically ill patients. Crit Care Med 2006; 34:2517–2529.  Back to cited text no. 17
    
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Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 2006; 34:344–353.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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