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Use of the APACHE II scoring system to determine mortality of gynecologic oncology patients in the intensive care unit
Use of the APACHE II Scoring System to Determine Mortality of Gynecologic Oncology Patients in the Intensive Care Unit L. V A N LE, S. FAKHRY, L. A. WALTON, D. H. MOORE, W. C. FOWLER, A N D R. RUTLEDGE Objective: To determine if an elevated score on the Acute P h y s i o l o g y and Chronic Health Evaluation II (APACHE II) scoring s y s t e m is associated w i t h mortality of acutely ill g y n e c o l o g i c o n c o l o g y patients. Methods: G y n e c o l o g i c o n c o l o g y patients admitted to the surgical i n t e n s i v e care unit (ICU) were identified from the ICU data base. Their a d m i s s i o n A P A C H E II score and type of g y n e c o l o g i c cancer were also extracted from the data base. Charts were r e v i e w e d to determine the disease status and reason for a d m i s s i o n to the surgical ICU. Patient mortality w a s correlated w i t h A P A C H E II scores. Results: Forty-five g y n e c o l o g i c o n c o l o g y patients were admitted to the surgical ICU from June 1988 to January 1992. T h e y had a mean age of 62 years and various cancers: ovarian (24), cervical (16), and e n d o m e t r i a l (five). T h e m e a n A P A C H E II score w a s 12 (range 2-26). Eight of 45 (18%) patients died. There w a s a significant correlation b e t w e e n A P A C H E II scores and mortality; patients w i t h an A P A C H E lI score of 20 or greater had a 78% risk of death compared to a 3% risk if the score w a s less than 20 (P < .001, ~2 test). Conclusion: Elevated A P A C H E II scores are associated w i t h mortality in acutely ill g y n e c o l o g i c o n c o l o g y patients.
been shown to correlate the severity of illness or injury with mortality and ultimate patient outcome. 2 Given the poor treatment outcome of m a n y gynecologic malignancies and the advanced age of most gynecologic oncology patients, m a n y cancer patients require intensive care in the course of disease management. To date, the use of a scoring system to assess the severity of illness in surgical patients admitted for intensive care has been evaluated mainly in general surgical and trauma patients; the usefulness of such a scoring system has not been studied in gynecologic oncology patients, and few studies ~5 have evaluated the use of these scores in patients with solid tumors. To determine if a scoring system that assesses severity of illness in an ICU can predict the mortality of gynecologic oncology patients, we reviewed APACHE scores and correlated these indices with the outcomes of patients with gynecologic cancers.
(Obstet Gynecol 1995;85:53-6)
Materials and Methods
Several scoring systems developed to assess the severity of injury and disease in critically ill patients have been used in a variety of situations, including patient care and triage, resource use, quality assurance, and research. The Acute Physiology and Chronic Health Evaluation (APACHE) classification system was developed to assess the severity of illness of patients admitted to intensive care units (ICU)] It includes 12 characteristics of physiologic aberrations and integrates chronic health status and patient age to arrive at a score; in studies of large groups of surgical ICU patients, these scores have From the Division qf Gynecologic Oncology, Departments of Obstetrics and Gynecology and Surgery, University of North Carolina, Chapel Hill, North Carolina.
VOL. 85, NO. 1, JANUARY 1995
All patients requiring intensive care on the gynecologic oncology service of the University of North Carolina Hospitals were admitted to the surgical ICU. Patients were cared for primarily by the gynecologic oncology service staff and followed by the critical care service. The APACHE II score, a revised scoring variant of the original APACHE system, was calculated within the first 24 hours of admission to the surgical [CU. 2 The score was determined from physiologic measurements and reflected chronic health status, patient age, and 12 health characteristics (Table 1). Data were recorded by the admitting surgical ICU physician and reviewed for accuracy by the critical care service fellow. All information was entered into a microcomputer data base system developed by the critical care service. We identified gynecologic oncology patients admit-
0029-7844/95/$9.50 53 0029-7844(94)00308-Z
Table 1. Scoring for the Acute Physiology and Chronic Health Evaluation II (APACHE II) Classification System No. of points Acute physiology* Temperature Mean arterial pressure Heart rate Respiratory rate Oxygenation Arterial pH Serum sodium Serum potassium Hematocrit White blood cell count Serum creatinine Glasgow Coma Scale Age (y) <44 45-54
0-4 0-4 0-4 0-4 0-4 0-4 0-4 0-4 0- 4 0-4 0-8 0-12 0 2
55-64 65-74 >75 Chronic health Nonoperative or emergency operative admission Elective postoperative admission Total
3 5 6 5 2 71
* There are specific criteria for the assignment of points for each physiologic abnormality.2
ted to the surgical ICU by their service code from the data base. Their admission A P A C H E II scores and type of gynecologic cancer were extracted from the data base. Hospital charts were reviewed to determine disease status, reason for admission to the surgical ICU, and patient outcome; in cases where mortality occurred, the reason for ICU admission and mortality were identified. Scores were reviewed to determine if an elevated A P A C H E II score correlated with patient mortality; specifically, we sought to determine if scores above a critical level predicted higher mortality rates. The mortality of patients with scores above and below a critical level were c o m p a r e d using X2 analysis.
years. A l t h o u g h m e a n A P A C H E II scores were comparable, gynecologic o n c o l o g y patients had a higher mortality rate than general surgical ICU patients; eight of 45 (18%) gynecologic o n c o l o g y patients died in the surgical ICU, whereas the mortality rate for all surgical ICU patients was only 7%. There w a s a significant correlation between A P A C H E II scores and mortality. O n l y one of 37 patients with an A P A C H E II score less than 20 died; in contrast, seven of eight patients with a score of 20 or greater died in the surgical ICU. The m e a n A P A C H E II score for the eight patients w h o died w a s 22. Patients with an A P A C H E II score of 20 or greater had a 78% risk of death c o m p a r e d to a 3% risk if the A P A C H E II score was less than 20 (P < .001, )(2 analysis). Half of the gynecologic oncology patients w h o died in the surgical ICU were admitted for specific cardiovascular disorders, and the remaining deaths occurred from sepsis and p u l m o n a r y complications. Seven of the eight patients w h o died had active disease (four had ovarian and three had cervical cancer). Gynecologic oncology patients were admitted to the surgical ICU for various reasons. Forty-nine percent of the patients required critical care services for specific cardiovascular complications (eg, arrhythmias, congestive heart failure, myocardial infarction) either postoperatively or unrelated to surgery. P u l m o n a r y complications (eg, p u l m o n a r y effusions, p u l m o n a r y embolism or pneumonia) and postoperative fluid m a n a g e m e n t accounted for 16 and 20% of surgical ICU admissions, respectively. The remaining patients were admitted for sepsis management. Of the 45 patients admitted, 30 (67%) were admitted postoperatively. Four patients died in the immediate postoperative period from pulm o n a r y and cardiovascular complications, and one patient died of p u l m o n a r y disease w i t h o u t residual cancer; only three patients admitted to the surgical ICU died of malignancies.
Discussion Results Forty-five gynecologic oncology patients were admitted to the surgical ICU from June 1988 to January 1992. Patients had a m e a n age of 62 years and were diagnosed with several different cancers: ovarian (24), cervical (16), and endometrial (five). The m e a n admission A P A C H E II score for gynecologic oncology patients was 12 (range 2-26). In comparison, the m e a n A P A C H E II score for all surgical ICU patients was 11 and their m e a n age was 57
54 Van Le et al
APACHE in Gynecologic Oncology
Various scoring systems have been developed to aid in the assessment and m a n a g e m e n t of critically ill patients. Physiologic scoring systems such as the T r a u m a Score and Pediatric T r a u m a Score have been used to determine the severity of injury and t r a u m a in select groups. 6 A n o t h e r prognostic physiologic scoring system, A P A C H E , was developed in the 1970s. 1 Unlike scores designed to assess the severity of trauma and injury, A P A C H E was designed to p r o v i d e an estimation of the risk of mortality for critically ill patients in an
Obstetrics & Gynecology
ICU. In a large r e v i e w of 5815 g e n e r a l surgical l C U a d m i s s i o n s , a direct r e l a t i o n s h i p w a s f o u n d b e t w e e n the A P A C H E score a n d d e a t h rate. 2 The first A P A C H E s y s t e m i n c o r p o r a t e d 33 p h y s i o l o g i c characteristics b u t w a s felt to b e too c o m p l e x , so a r e v i s e d s y s t e m e v o l v e d . 7 The revision, A P A C H E II, i n c o r p o r a t e s 12 p h y s i o l o g i c m e a s u r e m e n t s of illness a n d p a t i e n t age, a n d e m p h a s i z e s chronic h e a l t h status, w h i c h is a reflection of p a t i e n t reserve. 2 The presence of renal failure is also e m p h a s i z e d in A P A C H E II, a n d the G l a s g o w C o m a Scale, u s e d to assess n e u r o l o g i c alterations from traumatic b r a i n injury, contributes g r e a t l y to the final score. A t h i r d version, A P A C H E III, has b e e n d e v e l o p e d a n d is u n d e r g o i n g evaluation; it i n c l u d e s six a d d i t i o n a l physiologic measurements. 8 For o u r g y n e c o l o g i c o n c o l o g y patients, there w a s a significant correlation b e t w e e n A P A C H E II scores a n d mortality; p a t i e n t s w i t h a n A P A C H E II score of 20 or greater h a d a 25-fold increased risk of d y i n g c o m p a r e d to p a t i e n t s w i t h a score of less than 20. These findings are similar to those f o u n d in a s t u d y 3 of A P A C H E scores in b r e a s t cancer p a t i e n t s a d m i t t e d to ICUs. The m e a n A P A C H E II score for b r e a s t cancer patients ( a d m i t t e d for similar p u l m o n a r y a n d c a r d i o v a s c u l a r p r o b l e m s ) w a s 20 a n d s u r v i v o r s h a d a score of 17, w h e r e a s those w h o d i e d h a d scores of 24. In a n o t h e r s t u d y 4 of n o n - g y n e c o l o g i c o n c o l o g y p a t i e n t s r e q u i r i n g intensive care, A P A C H E scores h a d a p o s i t i v e predictive v a l u e for d e a t h of 79%. M o r t a l i t y rates in o u r p o p u l a t i o n w e r e l o w c o m p a r e d to o t h e r studies of o n c o l o g y patients; m o r t a l i t y rates for cancer patients a d m i t t e d to ICUs h a v e b e e n r e p o r t e d to r a n g e from 4 0 - 8 0 % for solid tumors. 9 In o u r s t u d y g r o u p , o n l y 18% of p a t i e n t s d i e d in the ICU. O n the g y n e c o l o g i c o n c o l o g y service, those w i t h p r o g r e s s i v e t e r m i n a l d i s e a s e d o not, in general, p u r s u e a g g r e s s i v e m a n a g e m e n t ; thus, r e l a t i v e l y few p a t i e n t s w i t h p r o g r e s sive cancer are a d m i t t e d to the surgical ICU. H o w e v e r , the m o r t a l i t y rate for gynecologic o n c o l o g y p a t i e n t s in the surgical ICU w a s a l m o s t d o u b l e the rate of all p a t i e n t s a d m i t t e d to this unit. The presence of m a l i g nancies m a y c o n t r i b u t e to d e a t h in a w a y not m e a s u r able b y A P A C H E II score. O t h e r i n v e s t i g a t o r s 4 h a v e also n o t e d a h i g h e r m o r t a l i t y rate for o n c o l o g y patients c o m p a r e d to n o n - o n c o l o g y patients; the h i g h e r rate has b e e n a t t r i b u t e d to the d e b i l i t a t i v e n a t u r e of cancer a n d the s u g g e s t i o n that cancer p a t i e n t s are m o r e p r o n e to o r g a n d y s f u n c t i o n t h a n those w i t h o u t m a l i g n a n c y . A l t h o u g h it w o u l d s e e m to be fairly s i m p l e to assign a p a t i e n t an A P A C H E II score a n d then d e c i d e on a p p r o p r i a t e care, several i n v e s t i g a t o r s h a v e s u g g e s t e d that scores c a n n o t be u s e d on an i n d i v i d u a l basis. Two studies 1°'11 h a v e s h o w n that p h y s i c i a n a s s e s s m e n t w a s a better p r e d i c t o r of o u t c o m e t h a n A P A C H E II scoring.
VOL. 85, NO. 1, JANUARY 1995
Scores for b r e a s t cancer p a t i e n t s w e r e 87% specific for d e a t h in the hospital; h o w e v e r , sensitivity w a s o n l y 54%. 3 O t h e r i n v e s t i g a t o r s 4 h a v e also o b s e r v e d h i g h specificity (83%) a n d l o w sensitivity (48%) for A P A C H E II scores in a v a r i e t y of o n c o l o g y patients. In o u r p a t i e n t p o p u l a t i o n , one of eight p a t i e n t s w i t h an A P A C H E II score o v e r 20 d i d not d i e in the surgical ICU; e v e n t h o u g h o u r results s t r o n g l y s u g g e s t e d that this p a t i e n t s h o u l d h a v e died, d i s c o n t i n u a t i o n of s u p p o r t i v e care w o u l d h a v e b e e n incorrect. A P A C H E II scores are associated w i t h the m o r t a l i t y rate for g y n e c o l o g i c o n c o l o g y patients w h o r e q u i r e intensive care. H o w e v e r , the use of the A P A C H E II scoring s y s t e m to d e t e r m i n e the limits of a g g r e s s i v e intensive care for all a c u t e l y ill p a t i e n t s will r e q u i r e a d d i t i o n a l s t u d y . A l t e r n a t i v e l y , a scoring s y s t e m tail o r e d for o n c o l o g y patients, w h i c h w o u l d take u n i q u e aspects r e g a r d i n g cancer p a t i e n t s into c o n s i d e r a t i o n , m i g h t be u s e f u l for correlating d i s e a s e a n d mortality. Such a scoring s y s t e m m i g h t i n c o r p o r a t e d u r a t i o n of disease, intensity of p r e v i o u s t h e r a p y , stage of disease, a n d p r o g n o s i s . In the interim, a c c e p t a b l e uses for A P A C H E II a s s e s s m e n t i n c l u d e quality a s s u r a n c e issues in the surgical ICU, resource allocation, a n d p o p u l a t i o n c o m p a r i s o n s in clinical studies. 6'7"12
References 1. Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE--acute physiology and chronic health evaluation: A physiologically based disease classification system. Crit Care Med 1981;9:591-7. 2. Knaus WA, Draper EA, Wagner DP, Zirnmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985;13: 818-28. 3. Headley J, Teriault R, Smith TL. Independent validation of APACHE II severity of illness score for predicting mortality in patients with breast cancer admitted to the intensive care unit. Cancer 1992;70:497-503. 4. Dart R, Bhavdipkumar P, Prez-Alard ], Vaswani S, Yanamadala S. Prognosis of oncology patients receiving intensive care using the APACHE II scoring system. Md Med J 1991;40:273-6. 5. Giangiuliani G, Gui D, Bonatti P, Tozzi P, Caracciolo F. APACHE II in surgical lung carcinoma patients. Chest 1990;98:627-30. 6. Fakhry SM, Rutledge R, Meyer AA. Severity of illness indices. In: Weigelt JA, Lewis FR, eds. Surgical critical care. Philadelphia: WB Saunders (in press). 7. Wong DT, Knaus WA. Predicting outcome in critical care: The current status of the APACHE prognostic scoring system. Can J Anaesth 1991;38:374-83. 8. Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991;100:1619-36. 9. Schapira DV, Studnicki J, Bradham DD, Wolff P, Jarrett A. Inten-
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APACHE in Gynecologic Oncology
55
sive care, survival, and expense of treating critically ill cancer patients. JAMA 1993;269:783-6. 10. Marks RJ, Simons RS, Blizzard RA, Browne DRG. Predicting outcome in intensive therapy units--a comparison of APACHE II with subjective assessments. Intensive Care Med 1991;17:159-63. 11. Meyer AA, Messick WJ, Young P, et al. Prospective comparison of clinical judgment and APACHE II score in predicting the outcome in critically ill surgical patients. J Trauma 1992;32:747-54. 12. Rutledge R, Fakhry SM, Rutherford EJ, et al. Acute Physiology and Chronic Health Evaluation (APACHE II) score and outcome in the surgical intensive care unit: An analysis of multiple intervention and outcome variables in 1,238 patients. Crit Care Med 1991;19: 1048-53.
56
V a n Le et al
APACHE in Gynecologic Oncology
A d d r e s s r e p r i n t r e q u e s t s to:
L. Van Le Department of Obstetrics and Gynecology CB 7570, MacNider Building University of North Carolina Chapel Hill, NC 27599 Received April 13, 1994. Received in revisedform July 28, 1994. Accepted August 8, 1994. Copyright © 1995 by The American College of Obstetricians and Gynecologists.
Obstetrics & Gynecology
been shown to correlate the severity of illness or injury with mortality and ultimate patient outcome. 2 Given the poor treatment outcome of m a n y gynecologic malignancies and the advanced age of most gynecologic oncology patients, m a n y cancer patients require intensive care in the course of disease management. To date, the use of a scoring system to assess the severity of illness in surgical patients admitted for intensive care has been evaluated mainly in general surgical and trauma patients; the usefulness of such a scoring system has not been studied in gynecologic oncology patients, and few studies ~5 have evaluated the use of these scores in patients with solid tumors. To determine if a scoring system that assesses severity of illness in an ICU can predict the mortality of gynecologic oncology patients, we reviewed APACHE scores and correlated these indices with the outcomes of patients with gynecologic cancers.
(Obstet Gynecol 1995;85:53-6)
Materials and Methods
Several scoring systems developed to assess the severity of injury and disease in critically ill patients have been used in a variety of situations, including patient care and triage, resource use, quality assurance, and research. The Acute Physiology and Chronic Health Evaluation (APACHE) classification system was developed to assess the severity of illness of patients admitted to intensive care units (ICU)] It includes 12 characteristics of physiologic aberrations and integrates chronic health status and patient age to arrive at a score; in studies of large groups of surgical ICU patients, these scores have From the Division qf Gynecologic Oncology, Departments of Obstetrics and Gynecology and Surgery, University of North Carolina, Chapel Hill, North Carolina.
VOL. 85, NO. 1, JANUARY 1995
All patients requiring intensive care on the gynecologic oncology service of the University of North Carolina Hospitals were admitted to the surgical ICU. Patients were cared for primarily by the gynecologic oncology service staff and followed by the critical care service. The APACHE II score, a revised scoring variant of the original APACHE system, was calculated within the first 24 hours of admission to the surgical [CU. 2 The score was determined from physiologic measurements and reflected chronic health status, patient age, and 12 health characteristics (Table 1). Data were recorded by the admitting surgical ICU physician and reviewed for accuracy by the critical care service fellow. All information was entered into a microcomputer data base system developed by the critical care service. We identified gynecologic oncology patients admit-
0029-7844/95/$9.50 53 0029-7844(94)00308-Z
Table 1. Scoring for the Acute Physiology and Chronic Health Evaluation II (APACHE II) Classification System No. of points Acute physiology* Temperature Mean arterial pressure Heart rate Respiratory rate Oxygenation Arterial pH Serum sodium Serum potassium Hematocrit White blood cell count Serum creatinine Glasgow Coma Scale Age (y) <44 45-54
0-4 0-4 0-4 0-4 0-4 0-4 0-4 0-4 0- 4 0-4 0-8 0-12 0 2
55-64 65-74 >75 Chronic health Nonoperative or emergency operative admission Elective postoperative admission Total
3 5 6 5 2 71
* There are specific criteria for the assignment of points for each physiologic abnormality.2
ted to the surgical ICU by their service code from the data base. Their admission A P A C H E II scores and type of gynecologic cancer were extracted from the data base. Hospital charts were reviewed to determine disease status, reason for admission to the surgical ICU, and patient outcome; in cases where mortality occurred, the reason for ICU admission and mortality were identified. Scores were reviewed to determine if an elevated A P A C H E II score correlated with patient mortality; specifically, we sought to determine if scores above a critical level predicted higher mortality rates. The mortality of patients with scores above and below a critical level were c o m p a r e d using X2 analysis.
years. A l t h o u g h m e a n A P A C H E II scores were comparable, gynecologic o n c o l o g y patients had a higher mortality rate than general surgical ICU patients; eight of 45 (18%) gynecologic o n c o l o g y patients died in the surgical ICU, whereas the mortality rate for all surgical ICU patients was only 7%. There w a s a significant correlation between A P A C H E II scores and mortality. O n l y one of 37 patients with an A P A C H E II score less than 20 died; in contrast, seven of eight patients with a score of 20 or greater died in the surgical ICU. The m e a n A P A C H E II score for the eight patients w h o died w a s 22. Patients with an A P A C H E II score of 20 or greater had a 78% risk of death c o m p a r e d to a 3% risk if the A P A C H E II score was less than 20 (P < .001, )(2 analysis). Half of the gynecologic oncology patients w h o died in the surgical ICU were admitted for specific cardiovascular disorders, and the remaining deaths occurred from sepsis and p u l m o n a r y complications. Seven of the eight patients w h o died had active disease (four had ovarian and three had cervical cancer). Gynecologic oncology patients were admitted to the surgical ICU for various reasons. Forty-nine percent of the patients required critical care services for specific cardiovascular complications (eg, arrhythmias, congestive heart failure, myocardial infarction) either postoperatively or unrelated to surgery. P u l m o n a r y complications (eg, p u l m o n a r y effusions, p u l m o n a r y embolism or pneumonia) and postoperative fluid m a n a g e m e n t accounted for 16 and 20% of surgical ICU admissions, respectively. The remaining patients were admitted for sepsis management. Of the 45 patients admitted, 30 (67%) were admitted postoperatively. Four patients died in the immediate postoperative period from pulm o n a r y and cardiovascular complications, and one patient died of p u l m o n a r y disease w i t h o u t residual cancer; only three patients admitted to the surgical ICU died of malignancies.
Discussion Results Forty-five gynecologic oncology patients were admitted to the surgical ICU from June 1988 to January 1992. Patients had a m e a n age of 62 years and were diagnosed with several different cancers: ovarian (24), cervical (16), and endometrial (five). The m e a n admission A P A C H E II score for gynecologic oncology patients was 12 (range 2-26). In comparison, the m e a n A P A C H E II score for all surgical ICU patients was 11 and their m e a n age was 57
54 Van Le et al
APACHE in Gynecologic Oncology
Various scoring systems have been developed to aid in the assessment and m a n a g e m e n t of critically ill patients. Physiologic scoring systems such as the T r a u m a Score and Pediatric T r a u m a Score have been used to determine the severity of injury and t r a u m a in select groups. 6 A n o t h e r prognostic physiologic scoring system, A P A C H E , was developed in the 1970s. 1 Unlike scores designed to assess the severity of trauma and injury, A P A C H E was designed to p r o v i d e an estimation of the risk of mortality for critically ill patients in an
Obstetrics & Gynecology
ICU. In a large r e v i e w of 5815 g e n e r a l surgical l C U a d m i s s i o n s , a direct r e l a t i o n s h i p w a s f o u n d b e t w e e n the A P A C H E score a n d d e a t h rate. 2 The first A P A C H E s y s t e m i n c o r p o r a t e d 33 p h y s i o l o g i c characteristics b u t w a s felt to b e too c o m p l e x , so a r e v i s e d s y s t e m e v o l v e d . 7 The revision, A P A C H E II, i n c o r p o r a t e s 12 p h y s i o l o g i c m e a s u r e m e n t s of illness a n d p a t i e n t age, a n d e m p h a s i z e s chronic h e a l t h status, w h i c h is a reflection of p a t i e n t reserve. 2 The presence of renal failure is also e m p h a s i z e d in A P A C H E II, a n d the G l a s g o w C o m a Scale, u s e d to assess n e u r o l o g i c alterations from traumatic b r a i n injury, contributes g r e a t l y to the final score. A t h i r d version, A P A C H E III, has b e e n d e v e l o p e d a n d is u n d e r g o i n g evaluation; it i n c l u d e s six a d d i t i o n a l physiologic measurements. 8 For o u r g y n e c o l o g i c o n c o l o g y patients, there w a s a significant correlation b e t w e e n A P A C H E II scores a n d mortality; p a t i e n t s w i t h a n A P A C H E II score of 20 or greater h a d a 25-fold increased risk of d y i n g c o m p a r e d to p a t i e n t s w i t h a score of less than 20. These findings are similar to those f o u n d in a s t u d y 3 of A P A C H E scores in b r e a s t cancer p a t i e n t s a d m i t t e d to ICUs. The m e a n A P A C H E II score for b r e a s t cancer patients ( a d m i t t e d for similar p u l m o n a r y a n d c a r d i o v a s c u l a r p r o b l e m s ) w a s 20 a n d s u r v i v o r s h a d a score of 17, w h e r e a s those w h o d i e d h a d scores of 24. In a n o t h e r s t u d y 4 of n o n - g y n e c o l o g i c o n c o l o g y p a t i e n t s r e q u i r i n g intensive care, A P A C H E scores h a d a p o s i t i v e predictive v a l u e for d e a t h of 79%. M o r t a l i t y rates in o u r p o p u l a t i o n w e r e l o w c o m p a r e d to o t h e r studies of o n c o l o g y patients; m o r t a l i t y rates for cancer patients a d m i t t e d to ICUs h a v e b e e n r e p o r t e d to r a n g e from 4 0 - 8 0 % for solid tumors. 9 In o u r s t u d y g r o u p , o n l y 18% of p a t i e n t s d i e d in the ICU. O n the g y n e c o l o g i c o n c o l o g y service, those w i t h p r o g r e s s i v e t e r m i n a l d i s e a s e d o not, in general, p u r s u e a g g r e s s i v e m a n a g e m e n t ; thus, r e l a t i v e l y few p a t i e n t s w i t h p r o g r e s sive cancer are a d m i t t e d to the surgical ICU. H o w e v e r , the m o r t a l i t y rate for gynecologic o n c o l o g y p a t i e n t s in the surgical ICU w a s a l m o s t d o u b l e the rate of all p a t i e n t s a d m i t t e d to this unit. The presence of m a l i g nancies m a y c o n t r i b u t e to d e a t h in a w a y not m e a s u r able b y A P A C H E II score. O t h e r i n v e s t i g a t o r s 4 h a v e also n o t e d a h i g h e r m o r t a l i t y rate for o n c o l o g y patients c o m p a r e d to n o n - o n c o l o g y patients; the h i g h e r rate has b e e n a t t r i b u t e d to the d e b i l i t a t i v e n a t u r e of cancer a n d the s u g g e s t i o n that cancer p a t i e n t s are m o r e p r o n e to o r g a n d y s f u n c t i o n t h a n those w i t h o u t m a l i g n a n c y . A l t h o u g h it w o u l d s e e m to be fairly s i m p l e to assign a p a t i e n t an A P A C H E II score a n d then d e c i d e on a p p r o p r i a t e care, several i n v e s t i g a t o r s h a v e s u g g e s t e d that scores c a n n o t be u s e d on an i n d i v i d u a l basis. Two studies 1°'11 h a v e s h o w n that p h y s i c i a n a s s e s s m e n t w a s a better p r e d i c t o r of o u t c o m e t h a n A P A C H E II scoring.
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Scores for b r e a s t cancer p a t i e n t s w e r e 87% specific for d e a t h in the hospital; h o w e v e r , sensitivity w a s o n l y 54%. 3 O t h e r i n v e s t i g a t o r s 4 h a v e also o b s e r v e d h i g h specificity (83%) a n d l o w sensitivity (48%) for A P A C H E II scores in a v a r i e t y of o n c o l o g y patients. In o u r p a t i e n t p o p u l a t i o n , one of eight p a t i e n t s w i t h an A P A C H E II score o v e r 20 d i d not d i e in the surgical ICU; e v e n t h o u g h o u r results s t r o n g l y s u g g e s t e d that this p a t i e n t s h o u l d h a v e died, d i s c o n t i n u a t i o n of s u p p o r t i v e care w o u l d h a v e b e e n incorrect. A P A C H E II scores are associated w i t h the m o r t a l i t y rate for g y n e c o l o g i c o n c o l o g y patients w h o r e q u i r e intensive care. H o w e v e r , the use of the A P A C H E II scoring s y s t e m to d e t e r m i n e the limits of a g g r e s s i v e intensive care for all a c u t e l y ill p a t i e n t s will r e q u i r e a d d i t i o n a l s t u d y . A l t e r n a t i v e l y , a scoring s y s t e m tail o r e d for o n c o l o g y patients, w h i c h w o u l d take u n i q u e aspects r e g a r d i n g cancer p a t i e n t s into c o n s i d e r a t i o n , m i g h t be u s e f u l for correlating d i s e a s e a n d mortality. Such a scoring s y s t e m m i g h t i n c o r p o r a t e d u r a t i o n of disease, intensity of p r e v i o u s t h e r a p y , stage of disease, a n d p r o g n o s i s . In the interim, a c c e p t a b l e uses for A P A C H E II a s s e s s m e n t i n c l u d e quality a s s u r a n c e issues in the surgical ICU, resource allocation, a n d p o p u l a t i o n c o m p a r i s o n s in clinical studies. 6'7"12
References 1. Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE--acute physiology and chronic health evaluation: A physiologically based disease classification system. Crit Care Med 1981;9:591-7. 2. Knaus WA, Draper EA, Wagner DP, Zirnmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985;13: 818-28. 3. Headley J, Teriault R, Smith TL. Independent validation of APACHE II severity of illness score for predicting mortality in patients with breast cancer admitted to the intensive care unit. Cancer 1992;70:497-503. 4. Dart R, Bhavdipkumar P, Prez-Alard ], Vaswani S, Yanamadala S. Prognosis of oncology patients receiving intensive care using the APACHE II scoring system. Md Med J 1991;40:273-6. 5. Giangiuliani G, Gui D, Bonatti P, Tozzi P, Caracciolo F. APACHE II in surgical lung carcinoma patients. Chest 1990;98:627-30. 6. Fakhry SM, Rutledge R, Meyer AA. Severity of illness indices. In: Weigelt JA, Lewis FR, eds. Surgical critical care. Philadelphia: WB Saunders (in press). 7. Wong DT, Knaus WA. Predicting outcome in critical care: The current status of the APACHE prognostic scoring system. Can J Anaesth 1991;38:374-83. 8. Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991;100:1619-36. 9. Schapira DV, Studnicki J, Bradham DD, Wolff P, Jarrett A. Inten-
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sive care, survival, and expense of treating critically ill cancer patients. JAMA 1993;269:783-6. 10. Marks RJ, Simons RS, Blizzard RA, Browne DRG. Predicting outcome in intensive therapy units--a comparison of APACHE II with subjective assessments. Intensive Care Med 1991;17:159-63. 11. Meyer AA, Messick WJ, Young P, et al. Prospective comparison of clinical judgment and APACHE II score in predicting the outcome in critically ill surgical patients. J Trauma 1992;32:747-54. 12. Rutledge R, Fakhry SM, Rutherford EJ, et al. Acute Physiology and Chronic Health Evaluation (APACHE II) score and outcome in the surgical intensive care unit: An analysis of multiple intervention and outcome variables in 1,238 patients. Crit Care Med 1991;19: 1048-53.
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V a n Le et al
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A d d r e s s r e p r i n t r e q u e s t s to:
L. Van Le Department of Obstetrics and Gynecology CB 7570, MacNider Building University of North Carolina Chapel Hill, NC 27599 Received April 13, 1994. Received in revisedform July 28, 1994. Accepted August 8, 1994. Copyright © 1995 by The American College of Obstetricians and Gynecologists.
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