Microsoft word - epicii_codes3.doc
EPIC II DIAGNOSES
101- Cerebrovascular accident: Recent stroke, by ischemic or hemorrhagic mechanism (non-
traumatic), documented by CT scan and/or lumbar puncture or only by history and physical symptoms.
102- Intracranial tumor: tumor documented by CT scan or MRI, malignant (primary or secondary)
103- Degenerative disease: includes Alzheimer’s disease, Huntington’s chorea, amyotrophic
lateral sclerosis, multiple sclerosis, Parkinson’s disease .
104- Idiopathic epilepsy: history of recurrent seizures with primary lesion not detected. 105- Myopathia, myasthenia gravis: acute exacerbation or progressive evolution of polymyositis,
dermatomyositis, progressive muscular dystrophy, myasthenia.
106- Polyneuritis and polyradiculoneuritis: includes polyneuritis due to infection, inflammation,
107- Post-anoxic coma: cerebral damage from hypoxia induced by several clinical situations, e.g.,
respiratory-cardiac arrest, cardiac disease with arrest, central nervous system diseases that lead to respiratory arrest (epilepsy, trauma, stroke), CO poisoning, profound hypotension.
108- Delirium tremens: acute encephalopathy due to alcohol withdrawal. 109- Other
201- Exacerbation of chronic pulmonary disease: exacerbation of respiratory failure in chronic
pulmonary disease (either obstructive or non obstructive) due to progressive evolution.
202- Asthma attack: acute exacerbation inducing paroxysms of dyspnea, cough and wheezing. 203- Pulmonary embolism: partial or complete obstruction of the pulmonary arterial blood flow by
a thrombus documented by pulmonary scintigraphy and/or pulmonary angiography.
204- Pleural effusion: air, blood, liquid, chyle in the pleural cavity documented by pleural tap,
205- Obstruction: obstruction of the upper or lower airways by a foreign body. Includes obstruction
206- Inhalation pneumonitis: induced by gastrointestinal contents, blood, smoke, and/or gases. 207- Tumor: Benign or malignant. 208- Other
301- Acute myocardial infarction. 302- Unstable angina, myocardial ischemia induced by crescendo angina, repeated attacks of
severe angina, recent onset angina or early return of angina after infarction.
303- Cardiopathy: includes ischemic, valvular, hypertensive, alcoholic and other, non infectious
400 Renal/genito-urinary tract:
401- Acute tubular necrosis: sudden onset of renal failure during or following an acute severe
402- Acute glomerulopathy: acute renal failure resulting from lesions in the glomeruli. 403- Interstitial nephropathy: renal failure resulting from lesions in the interstitium. 404- Vascular nephropathy: renal failure resulting from lesions in the arteries (intra or extra-renal). 405- Renal neoplasia 406- Gynecological diseases, non malignant: lesions of ovary, uterus, cervix, vulvae, vagina not
407- Gynecological diseases, malignant: lesions of ovary, uterus, cervix, vulvae, vagina due to
501- Transfusion reaction: includes all types of accident with transfusion of blood products. 502- Drug toxicity and secondary effects: includes toxicity or secondary effects of chemotherapy
and/or immunosuppressant agents and hematological toxicity of any other drugs (inducing neutropenia, thrombocytopenia.).
503- Non malignant disease: includes anemia (acquired or congenital), aplastic anemia,
methemoglobinemia, thrombocytopenia, congenital disorders of blood coagulation factors, hypersplenism (primary), sickle cell crisis.
504- Malignant disease: includes lymphoma, acute leukemia and multiple myeloma 505- Other
601- Cholecystitis, acute or chronic, with or without cholangitis. 602- Acute alcoholic hepatitis: with or without liver failure 603- Acute toxic, drug hepatitis: induced by drug (e.g., paracetamol/acetaminophen) or gas (e.g.,
604- Pancreatitis: includes acute or recurrent acute pancreatitis, from pancreatic edema, to
edema with fat necrosis, to necrosis with variable degrees of hemorrhage documented by laboratory data and abdominal CT scan.
605- Esophageal, gastric varices: documented by endoscopy or surgery. 606- Esophageal, gastric, duodenal ulcer: documented by endoscopy or surgery 607- Neoplasia of the upper digestive tract (esophageal, gastric or duodenal). 608- Neoplasia of the lower digestive tract (colon and rectum). 609- Other
701- Drug overdose: includes all accidental or intentional drug intoxication (including overdose),
702- Other intoxication, acute: by alcohol, CO inhalation, industrial, domestic, vegetable, animal
703- Adverse effects of medication: acute disease due to a drug given in normal dosage (Lyell’s
and Stevens-Johnson syndromes, malignant syndrome of neuroleptics).
704- Diabetic ketoacidosis. 705- Hyperosmolar diabetic coma. 706- Endocrinopathy: includes diseases of thyroid, pituitary gland, adrenal cortex, endocrine
801- Eclampsia, preeclampsia: Disorders encountered during the last trimester of pregnancy or
shortly after delivery which are characterized by hypertension, edema, proteinuria (preeclampsia), convulsions and coma (eclampsia).
802- HELLP syndrome 803- Delivery hemorrhage 804- Other
901- Isolated brain trauma 902- Monotrauma, without brain trauma 903- Polytrauma, without brain trauma 904- Polytrauma, with brain trauma 905- Burn 906- Near-drowning 907- Other
000 Other diseases
SITE OF SURGERY
No surgery in the current hospital stay.
101- Cerebrovascular accident: neurosurgery of intracranial hematoma or other non traumatic
102- Intracranial tumour: neurosurgery for any type of tumour primary or secondary 103-Spinal surgery 104-Ear, nose and throat surgery 105-Maxillo-facial surgery 106-Other
200 Thoracic surgery:
201- Pneumonectomy 202- Lobectomy 203- Pleural surgery: includes all surgery on pleura either for tumor or talcage/abrasion for
300 Cardiac surgery:
301- Valvular, without coronary artery by-pass graft (CABG): surgical treatment of valvulopathies
302- Valvular with CABG: valvular repair with coronary surgery. 303- CABG without valvular repair. 304- Other: pericardial effusion, congenital anomaly, ventricular aneurysm, neoplastic disease,
305- Heart transplantation 306- Heart & lung transplantation 307-Major aortic surgery: includes all surgery on aorta for dissection, atheroma, aneurysm. 308-Carotid endarterectomy: includes all surgery on the carotid artery 309-Other major vascular surgery: includes all surgery on intra thoracic or intra abdominal
310-Peripheral vascular surgery: includes all surgery on non-intracranial, non-intrathoracic, non-
intraabdominal vessels, either arteries or veins with or without by-pass graft.
400 Renal-urinary tract:
401- Renal surgery 402- Urologic surgery
- 500 Orthopedic (non trauma):
601- Upper gastro-intestinal surgery (up to and including the jejunum) 602- Lower gastrointesinal surgery 603- Biliary tract: surgery of gallbladder and/or biliary tract 604- Liver: partial hepatectomy, portal-systemic shunt surgery 605- Liver transplantation 606- Pancreas
701- Endocrine surgery (thyroid, adrenal, pancreas etc)
801- Obstetric surgery: Cesarean section, surgery for ectopic pregnancy, peri- or post-partum
802- Gynecological surgery: surgery of uterus, ovaries, cervix, genitalia.
901- Brain: surgery for subdural, epidural, intracerebral haematoma or skull fracture. 902- Thorax: surgery of intra-thoracic organs (either cardiac, respiratory or digestive tract) and
903- Abdomen 904- Limb 905- Multiple 906- Other
1000 Other surgery
For patients undergoing surgery the anatomical site of surgery should be indicated. Only one
selection is possible. Invasive radiological procedures or definitive pacemaker insertions should not be considered as surgical procedures.
REASON(S) FOR ICU ADMISSION
000 Surveillance/Monitoring only
101- Coma, stupor, obtunded patient, confusion, agitation, delirium 102- Seizures 103- Focal neurologic deficit (hemiplegia, paraplegia, tetraplegia) 104- Intracranial mass effect 105- Other
201- ALI and ARDS: Syndrome of inflammation and increased permeability associated with
clinical, radiological and physiologic abnormalities: arterial hypoxemia resistant to oxygen therapy (PaO2/FiO2 < 300 mmHg) and diffuse bilateral radiological infiltrates without signs of cardiac failure or pulmonary capillary hypertension (pulmonary artery occlusion pressure < 18 mmHg).
202- Acute respiratory failure on chronic pulmonary disease: Chronic pulmonary disease could be
203- Other: Impaired respiratory function less than that defined by ALI, due to pulmonary lesion or
pleuritis, necessitating oxygen or mechanical ventilation.
301- Cardiac arrest: Needing cardiopulmonary resuscitation (CPR) prior to admission to ICU.
CPR must include chest compression, defibrillation or cardiac massage.
302- Shock: Defined by a systolic blood pressure (SBP) less than 90 mmHg or a drop in SBP of >
40 mmHg from baseline with presence of clinical signs of peripheral circulatory insufficiency (cold, moist skin, cyanosis) and organ hypoperfusion (oliguria, encephalopathy, metabolic acidosis.) requiring the use of inotropic/vasopressor agents.
303- Chest pain (with electrocardiographic changes compatible with either angina or acute
304- Hypertensive crisis 305- Arrhythmia: (due to heart rate or heart conduction disturbances) 306- Cardiac failure without shock either left, right or global 307- Other
401- Pre-renal acute renal failure (induced by hypovolemia or shock.) 402- Obstructive acute renal failure (post-renal acute renal failure: obstruction of the urinary tract
403- Organic acute renal failure (resulting from lesions in the arteries (intra or extra-renal), in the
501- Hemorrhagic syndrome/disseminated intravascular coagulation: Induced by coagulation
disorders, like thrombocytopenia and/or increase in prothrombin time and/or congenital disorders of blood coagulation factors and/or acquired disorders of blood coagulation factors.
601- Bleeding: Either upper or lower gastrointestinal tract 602- Acute abdomen: Related to infection, ischemia, perforation, inflammation, either upper or
lower gastrointestinal tract. Excludes severe pancreatitis
603- Severe pancreatitis 604- Liver failure: hepatic failure inducing metabolic disturbances and/or encephalopathy. 605- Other
701- Acid-base and/or electrolyte disturbance 702- Hypo and hyperthermia 703- Hypo and hyperglycemia (includes diabetic comas) 704- Other
The reason of ICU admission should be recorded for all patients, independent of the surgical
status. It is the acute (or acute on chronic) disease that best explains the reason(s) for admission. It can be medical or surgical. Only one choice is possible.
101 Staphylococcus aureus sensitive to methicillin 102 Staphylococcus aureus resistant to methicillin 103 Staphylococcus coagulase negative (epidermidis, haemolyticus, hominis, …) sensitive to
104 Staphylococcus coagulase negative (epidermidis, haemolyticus, hominis, …) resistant to
105 Streptococcus D group (Entrococcus faecalis, faecium) sensitive to Vancomycin (see 115-) 106 Streptococcus, A, B, C, G group 107 Streptococcus pneumoniae 108 Streptococcus, others 109 Cocci Gram +ve, others 111 Moraxella (Moraxella catarrhalis, Moraxella spp) 112 Listeria monocytogenes 113 Neisseria gonorrhoeae 114 Bacillus Gram +ve, others (Bacillus cereus, Bacillus spp, Corynebacterium spp,
Lactobacillus, Rhodococcus equi, Nocardia spp, other)
115 Streptococcus D group (Entrococcus faecalis, faecium) resistant to Vancomycin (see 105-)
Gram negative (see 216)
201 Escherichia coli 202 Enterobacter (aerogenes, cloacae, agglomerans, .) 203 Klebsiella (Klebsiella pneumoniae or other) 204 Proteus (Proteus morganii, Morganella morganii, Proteus indole+, Proteus mirabilis,
205 Salmonella 206 Serratia (Serratia marcescens, Serratia spp) 207 Citrobacter (Citrobacter freundii, Citrobacter spp) 208 Pseudomonas aeruginosa 209 Pseudomonas, other 210 Stenotrophomonas maltophilia 211 Acinetobacter (baumannii or other) 212 Campylobacter (Helicobacter, Campylobacter spp, Brucella spp) 213 Haemophilus (influenzae or other) 214 Enterobacteria, other (Yersinia spp, Shigella spp, other) 215 Bacillus Gram -ve, other 216 (add this code if ESBL) 217 Neisseria meningitidis
301 Clostridium (Clostridium difficile, Clostridium perfringens, Clostridium spp, Actinomyces,
302 Anaerobe cocci (Peptococcus, Peptostreptoccus, Veillonella) 303 Bacteroides (Bacteroides fragilis, Bacteroides melaninogenicus, Capnocytophaga,
401 Mycobacteria (tuberculosis or others) 402 Chlamydia 403 Rickettsia 404 Mycoplasma (Mycoplasma pneumoniae or hominis, Rochalimeae spp, Bartonella spp) 405 Legionella pneumoniae
501 Candida albicans 502 Candida non-albicans 503 Aspergillus 504 Fungi, other (Cryptoccus neoformans, Histoplasma spp…)
701 Plasmodium falciparum, Pneumocystis jiroveci (carinii), Toxoplasma gondii.
11 cefazolin 12 cefuroxime 13 ceftazidime 14 cefepime/cefpirome 15 other cephalosporin
21 benzyl penicillin 22 ampicillin 23 amoxy + clavulanate 24 pipera + tazo 25 oxa/cloxa/flucloxacillin 26 other penicillin
3 Other beta-lactams
31 temocillin 32 (imi/mero) penem 33 aztreonam 34 other
71 erythromycin 72 other (clarithromycin, etc)
8 Other antibiotics
81 metronidazole 82 cotrimoxazole 83 oxazolidinone (Linezolid) 84 lipopeptide (Daptomycin) 85 tigecycline 86 other
91 fluconazole 92 amphotericin B 93 ampho lipid formulation 94 caspofungin 95 voriconazole 96 other
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