Intensive care of the cancer patient: recent achievements and remaining challenges

Diagnosis and outcome of acute respiratory failure in immunocompromised patients after bronchoscopy

OBJECTIVE

We wished to explore the use, diagnostic capability and outcomes of bronchoscopy added to noninvasive testing in immunocompromised patients. In this setting, an inability to identify the cause of acute hypoxaemic respiratory failure is associated with worse outcome. Every effort should be made to obtain a diagnosis, either with noninvasive testing alone or combined with bronchoscopy. However, our understanding of the risks and benefits of bronchoscopy remains uncertain.

PATIENTS AND METHODS

This was a pre-planned secondary analysis of Efraim, a prospective, multinational, observational study of 1611 immunocompromised patients with acute respiratory failure admitted to the intensive care unit (ICU). We compared patients with noninvasive testing only to those who had also received bronchoscopy by bivariate analysis and after propensity score matching.

RESULTS

Bronchoscopy was performed in 618 (39%) patients who were more likely to have haematological malignancy and a higher severity of illness score. Bronchoscopy alone achieved a diagnosis in 165 patients (27% adjusted diagnostic yield). Bronchoscopy resulted in a management change in 236 patients (38% therapeutic yield). Bronchoscopy was associated with worsening of respiratory status in 69 (11%) patients. Bronchoscopy was associated with higher ICU (40% versus 28%; p<0.0001) and hospital mortality (49% versus 41%; p=0.003). The overall rate of undiagnosed causes was 13%. After propensity score matching, bronchoscopy remained associated with increased risk of hospital mortality (OR 1.41, 95% CI 1.08-1.81).

CONCLUSIONS

Bronchoscopy was associated with improved diagnosis and changes in management, but also increased hospital mortality. Balancing risk and benefit in individualised cases should be investigated further.

Outcomes for older adults with acute myeloid leukemia after an intensive care unit admission

BACKGROUND

Older adults with acute myeloid leukemia (AML) are often assumed to have poor outcomes after admission to the intensive care unit (ICU). However, little is known about ICU utilization and post-ICU outcomes in this population.

METHODS

The authors conducted a retrospective analysis for 330 patients who were 60 years old or older and were diagnosed with AML between 2005 and 2013 at 2 hospitals in Boston.They used descriptive statistics to examine the proportion of patients admitted to the ICU as well as their mortality and functional recovery. They used logistic regression to identify risk factors for in-hospital mortality.

RESULTS

Ninety-six patients (29%) were admitted to the ICU, primarily because of respiratory failure (39%), septic shock (28%), and neurological compromise (9%). The proportions of patients who survived to hospital discharge, 90 days, and 1 year were 47% (45 of 96), 35% (34 of 96), and 30% (29 of 96), respectively. At 90 days, 76% of the patients had an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0 or 1, and 86% were in complete remission (CR) and/or continued to receive AML-directed therapy. In a multivariate analysis, a poorer baseline ECOG PS score (odds ratio, 2.76; P = .013) and the need for 2 or more life-sustaining therapies (ie, vasopressors, invasive ventilation, and/or renal replacement therapy; odds ratio, 12.4; P < .001) were associated with increased odds of in-hospital mortality.

CONCLUSIONS

Although almost one-third of older patients with AML are admitted to an ICU, nearly half survive to hospital discharge with good functional outcomes. The baseline performance status and the need for 2 or more life-sustaining therapies predict hospital mortality. These data support the judicious use of ICU resources for older patients with AML.

Long-term prognosis of septic shock in cancer patients

OBJECTIVES

In the last decades, the number of cancer patients admitted in intensive care units (ICUs) for septic shock has dramatically increased. However, prognosis data remain scarce.

METHODS

To assess the 180-day mortality rate in cancer patients admitted to the ICU for septic shock, a 5-year prospective study was performed. All adult patients admitted for septic shock were included and categorized into the following two groups and four subgroups: cancer patients (solid tumor or hematological malignancy) and non-cancer patients (immunocompromised or not). Data were collected and compared between the groups. Upon early ICU admission, the decision to forgo life-sustaining therapy (DFLST) or not was made by consultation among hematologists, oncologists, and the patients or their relatives.

RESULTS

During the study period, 496 patients were admitted for septic shock: 252 cancer patients (119 hematological malignancies and 133 solid tumors) and 244 non-cancer patients. A DFLST was made for 39% of the non-cancer patients and 52% of the cancer patients. The 180-day mortality rate among the cancer patients was 51% and 68% for those with hematological malignancies and solid cancers, respectively. The mortality rate among the non-cancer patients was 44%. In a multivariate analysis, the performance status, Charlson comorbidity index, simplified acute physiology score 2, sequential organ failure assessment score, and DFLST were independent predictors of 180-day mortality.

CONCLUSIONS

Despite early admission to the ICU, the 180-day mortality rate due to septic shock was higher in cancer patients compared with non-cancer patients, due to excess mortality in the patients with solid tumors. The long-term prognosis of cancer patients with septic shock is modulated by their general state, severity of organ failure, and DFLST.

Variability in triage practices for critically ill cancer patients: A randomized controlled trial

PURPOSE

Intensive care triage practices and end-user interpretation of triage guidelines have rarely been assessed. We evaluated agreement between providers on the prioritization of patients for ICU admission using different triage guidelines.

MATERIALS AND METHODS

A multi-centered randomized study on providers from 18 different countries was conducted using clinical vignettes of oncological patients. The level of agreement between providers was measured using two different guidelines, with one being cancer specific.

RESULTS

Amongst 257 providers, 52.5% randomly received the Society of Critical Care Prioritization Model, and 47.5% received a cancer specific flowchart as a guide. In the Prioritization Model arm the average entropy was 1.193, versus 1.153 in the flowchart arm (P = .095) indicating similarly poor agreement. The Fleiss' kappa coefficients were estimated to be 0.2136 for the SCCMPM arm and 0.2457 for the flowchart arm, also similarly implying poor agreement.

CONCLUSIONS

The low agreement amongst practitioners on the prioritization of cancer patient cases for ICU admission existed using both general triage guidelines and guidelines tailored only to cancer patients. The lack of consensus on intensive care unit triage practices in the oncological population exposes a potential barrier to appropriate resource allocation that needs to be addressed.

Management of sepsis in neutropenic cancer patients: 2018 guidelines from the Infectious Diseases Working Party (AGIHO) and Intensive Care Working Party (iCHOP) of the German Society of Hematology and Medical Oncology (DGHO)

Sepsis and septic shock are major causes of mortality during chemotherapy-induced neutropenia for malignancies requiring urgent treatment. Thus, awareness of the presenting characteristics and prompt management is most important. Improved management of sepsis during neutropenia may reduce the mortality of cancer therapies. However, optimal management may differ between neutropenic and non-neutropenic patients. The aim of the current guideline is to give evidence-based recommendations for hematologists, oncologists, and intensive care physicians on how to manage adult patients with neutropenia and sepsis.

Ventilator-associated pneumonia and bloodstream infections in intensive care unit cancer patients: a retrospective 12-year study on 3388 prospectively monitored patients

Purpose

Some publications suggest high rates of healthcare-associated infections (HAIs) and of nosocomial pneumonia portending a poor prognosis in ICU cancer patients. A better understanding of the epidemiology of HAIs in these patients is needed.

Methods

A retrospective analysis of all the patients hospitalized for ≥ 48 h during a 12-year period in the 12-bed ICU of the Gustave Roussy hospital, monitored prospectively for ventilator-associated pneumonia (VAP) and bloodstream infection (BSI) and for use of medical devices.

Results

During 3388 first stays in the ICU, 198 cases of VAP and 103 primary, 213 secondary, and 77 catheter-related BSIs were recorded. The VAP rate was 24.5/1000 ventilator days (95% confidence interval [CI] 21.2–28.0); the catheter-related BSI rate was 2.3/1000 catheter days (95% CI 1.8–2.8). The cumulative incidence during the first 25 days of exposure was 58.8% (95% CI 49.1–66.6%) for VAP, 8.9% (95% CI, 6.2–11.5%) for primary, 15.1% (95% CI 11.6–18.5%) for secondary and 5.0% (95% CI 3.2–6.8%) for catheter-related BSIs. VAP or BSIs were not associated with a higher risk of ICU mortality.

Conclusions

This is the first study to report HAI rates in a large cohort of critically ill cancer patients. Although both the incidence of VAP and the rate of BSI are higher than in general ICU populations, this does not impact patient outcomes. The occurrence of device-associated infections is essentially due to severe medical conditions in patients and to the characteristics of malignancy.

Electronic supplementary material

The online version of this article (10.1007/s00520-019-04800-6) contains supplementary material, which is available to authorized users.

Improved survival rates of AML patients following admission to the intensive care unit

Induction chemotherapy in AML patients may have life-threatening side effects requiring intensive care unit (ICU) treatment. We analyzed all AML patients receiving intensive chemotherapy at a single academic center between 01/2006-12/2016. At least one ICU admission was observed in 32% (76/240) patients, and 33% of those died following ICU admission. Whereas the ICU admission proportion remained stable, mortality after ICU admission decreased from 14% (2006-2008) to 3% (2014-2016; p = .056). The number of failing organ systems inversely correlated with surviving ICU admission (p < .001). Sepsis and renal, cardiac and pulmonary failure were each associated with higher mortality. With increasing ICU duration, survival probability decreased (p < .001), but remained >50% even after 14 days of ICU treatment. Progression-free and overall survival were comparable between ICU surviving patients and patients never needing ICU support. In conclusion, outcome after ICU admission of AML patients has substantially improved in recent years.

Choosing Wisely India: ten low-value or harmful practices that should be avoided in cancer care

The Choosing Wisely India campaign was an initiative that was established to identify low-value or potentially harmful practices that are relevant to the Indian cancer health-care system. We undertook a multidisciplinary framework-driven consensus process to identify a list of low-value or harmful cancer practices that are frequently undertaken in India. A task force convened by the National Cancer Grid of India included Indian representatives from surgical, medical, and radiation oncology. Each specialty had representation from the private and public sectors. The task force included two representatives from national patient and patient advocacy groups. Of the ten practices that were identified, four are completely new recommendations, and six are revisions or adaptations from previous Choosing Wisely USA and Canada lists. Recommendations in the final list pertain to diagnosis and treatment (five practices), palliative care (two practices), imaging (two practices), and system-level delivery of care (two practices). Implementation of this list and reporting of concordance with its recommendations will facilitate the delivery of high-quality, value-based cancer care in India.

Weaning outcome of solid cancer patients requiring mechanical ventilation in the intensive care unit

BACKGROUND

Whether the weaning outcome of solid cancer patients receiving mechanical ventilation (MV) in the intensive care unit (ICU) is comparable to that in non-cancer patients is unknown. The aim of this study was to compare the weaning outcomes between non-cancer patients and patients with different types of cancer.

METHODS

We studied patients requiring MV during ICU stay for medical reasons between 2012 and 2014. Cancer patients were grouped into those with lung cancer (LC), head and neck cancer (HNC), hepatocellular carcinoma (HCC), and other cancers (OC). The primary endpoint was successful weaning at day 90 after the initiation of MV, and the main secondary endpoints were 28-day and 90-day mortality after ICU admission.

RESULTS

Five hundred and eighteen patients with solid cancers and 1362 non-cancer patients were recruited. The rate of successful weaning at day 90 was 57.9% in cancer patients, which was lower than 68.9% in non-cancer patients (p < 0.001). Compared to non-cancer patients, LC was associated with a lower probability of weaning at day 90 (hazard ratio 0.565, 95% CI 0.446 to 0.715), while HNC, HCC, and OC had similar probabilities. The 28-day and 90-day mortality rates were higher in cancer patients than in non-cancer patients (45.2% vs. 29.4%, and 65.6% vs. 37.7%, respectively, both p < 0.001).

CONCLUSION

Among mechanically ventilated patients in the ICU, those with LC were associated with a lower probability of weaning at day 90 compared to non-cancer patients.

Effect of intensivist involvement on clinical outcomes in patients with advanced lung cancer admitted to the intensive care unit

Purpose

Intensive care unit (ICU)-related mortality for lung cancer is ranked highest among the solid tumors and little information exists on the role of intensivists on clinical outcomes. This study aimed to elucidate the intensivist’s contribution toward clinical outcomes.

Materials and methods

Data of advanced lung cancer patients, including stage IIIB or IV non-small cell lung cancer and extensive-stage small cell lung cancer, admitted to the ICU from 2005 to 2016 were analyzed. Multivariate logistic regression was performed to determine variables associated with ICU and in-hospital mortality. Autoregressive integrated moving average (ARIMA) for time-series was used to assess the intensivist’s impact.

Results

Of 264 patients, 85 (32.2%) were admitted to the ICU before and 179 (67.8%) after organized intensive care introduction in 2011. Before and after 2011, the changes observed were as follows: ICU mortality rate, 43.5% to 40.2%, respectively (p = 0.610); hospital mortality rate, 82.4% to 65. 9% (p = 0.006). The duration of ICU and hospital stay decreased after 2011 (14.5±16.5 vs. 8.3 ± 8.6, p < 0.001; 36.6 ± 37.2 vs. 22.0 ± 19.6, p < 0.001). On multivariate analysis, admission after 2011 was independently associated with decreased hospital mortality (Odds ratio 0.42, 95% confidence interval 0.21–0.77, p = 0.006). In ARIMA models, intensivist involvement was associated with significantly reduced hospital mortality. (Estimate -17.95, standard error 5.31, p = 0.001)

Conclusion

In patients with advanced lung cancer, organized intensive care could contribute to improved clinical outcomes.

[Hematological-oncological intensive care patients : Treatment without borders]

The number of treatment options and success of treating patients with cancer have both significantly increased in recent years. However, many of these patients require intensive care due to comorbidities, treatment-associated complications, or severe infections. At the same time, the boundaries between what is feasible and sensible are difficult to draw. Over the past few years, awareness of the problems these cancer patients may have in the intensive care unit has increased and discussions have begun. This article intends to offer a discussion basis and also possible solution strategies.

Platelet number and graft function predict intensive care survival in allogeneic stem cell transplantation patients

Despite significant advances in the treatment of complications requiring intensive care unit (ICU) admission, ICU mortality remains high for patients after allogeneic stem cell transplantation. We evaluated the role of thrombocytopenia and poor graft function in allogeneic stem cell recipients receiving ICU treatments along with established prognostic ICU markers in order to identify patients at risk for severe complications. At ICU admission, clinical and laboratory data of 108 allogeneic stem cell transplanted ICU patients were collected and retrospectively analyzed. Platelet counts (≤ 50,000/μl, p < 0.0005), hemoglobin levels (≤ 8.5 mg/dl, p = 0.019), and leukocyte count (≤ 1500/μl, p = 0.025) along with sepsis (p = 0.002) and acute myeloid leukemia (p < 0.0005) correlated significantly with survival. Multivariate analysis confirmed thrombocytopenia (hazard ratio (HR) 2.79 (1.58-4.92, 95% confidence interval (CI)) and anemia (HR 1.82, 1.06-3.11, 95% CI) as independent mortality risk factors. Predominant ICU diagnoses were acute respiratory failure (75%), acute kidney injury (47%), and septic shock (30%). Acute graft versus host disease was diagnosed in 42% of patients, and 47% required vasopressors. Low platelet (≤ 50,000/μl) and poor graft function are independent prognostic factors for impaired survival in critically ill stem cell transplanted patients. The underlying pathophysiology of poor graft function is not fully understood and currently under investigation. High-risk patients may be identified and ICU treatments stratified according to allogeneic stem cell patients' individual risk profiles. In contrast to previous studies involving medical or surgical ICU patients, the fraction of thrombocytopenic patients was larger and low platelets were a better differentiating factor in multivariate analysis than any other parameter.

Outcomes for haematological cancer patients admitted to an intensive care unit in a university hospital

BACKGROUND

Haematological cancer (HC) patients are increasingly requiring intensive care (ICUs). The aim of this study was to investigate the outcome of HC patients in our ICU and evaluate 5 days-full support as a breakpoint for patients' re-assessment for support.

METHODS

Retrospective study enrolling 112 consecutive HC adults, requiring ICU in January-December 2015. Patients' data were collected from medical records and Infection Control Committee surveillance reports. Logistic regression analysis was performed to identify independent risk factors for ICU mortality.

RESULTS

Sixty-one were neutropenic, and 99 (88%) had infection at ICU admission. Acute myeloid leukaemia was diagnosed in 43%. Thirty-five (31%) were hematopoietic stem cell transplant recipients. Only 17 (15%) were in remission. Eighty-nine underwent mechanical ventilation on admission. Fifty-three patients acquired ICU-infection (35 bacteremia) being gram negative bacteria (Klebsiella pneumoniae and non-fermenters) the top pathogens. However, ICU-acquired infection had no impact on mortality. The overall ICU and 1-year survival rate was 27% (30 patients) and 7% (8 patients), respectively. Moreover, only 2/62 patients survived with APACHE II score ≥25. The median time for death was 4 days. APACHE II score ≥25 [OR:35.20], septic shock [OR:8.71] and respiratory failure on admission [OR:10.55] were independent risk factors for mortality in multivariate analysis. APACHE II score ≥25 was a strong indicator for poor outcome (ROC under curve 0.889).

CONCLUSIONS

APACHE II score ≥25 and septic shock were criteria of ICU futility. Our findings support the full support of patients for 5 days and the need to implement a therapeutic limitations protocol.

The challenge of avoiding intubation in immunocompromised patients with acute respiratory failure

INTRODUCTION

A growing number of immunocompromised (IC) patients with acute hypoxemic respiratory failure (ARF) is admitted to the intensive care unit (ICU) worldwide. Areas covered: This review provides an overview of the current knowledge of the ways to prevent intubation in IC patients with ARF. Expert commentary: Striking differences oppose ARF incidence, characteristics, etiologies and management between IC and non-IC patients. Survival benefits have been reported with early admission to ICU in IC patients. Then, while managing hypoxemia and associated organ dysfunction, the identification of the cause of ARF will be guided by a rigorous clinical assessment at the bedside, further assisted by an invasive or noninvasive diagnostic strategy based on clinical probability for each etiology. Finally, the initial respiratory support aims to avoid mechanical ventilation for the many yet recognizing those patients for whom delaying intubation expose them to suboptimal management. We advocate for not using noninvasive ventilation (NIV) in this setting. A proper evaluation of High-flow nasal cannula oxygen (HFNC)  is required in IC patients as to demonstrate its superiority compared to standard oxygen therapy. Day-to-day decisions must strive to avoid delayed intubation, and make every effort to identify ARF etiology.

Improved short- and long-term outcome of allogeneic stem cell recipients admitted to the intensive care unit: a retrospective longitudinal analysis of 942 patients

PURPOSE

Intensive care unit (ICU) admission of allogeneic hematopoietic stem cell transplant (HSCT) recipients is associated with relatively poor outcome. Since longitudinal data on this topic remains scarce, we analyzed reasons for ICU admission as well as short- and long-term outcome of critically ill HSCT recipients.

METHODS

A total of 942 consecutive adult patients were transplanted at Hannover Medical School from 2000 to 2013. Of those, 330 patients were at least admitted once to the ICU and included in this retrospective study. To analyze time-dependent improvements, we separately compared patient characteristics as well as reasons and outcome of ICU admission for the periods 2000-2006 and 2007-2013.

RESULTS

The main reasons for ICU admission were acute respiratory failure (ARF) in 35%, severe sepsis/septic shock in 23%, and cardiac problems in 18%. ICU admission was clearly associated with shortened survival (p < 0.001), but survival of ICU patients after hospital discharge reached 44% up to 5 years and was comparable to that of non-ICU HSCT patients. When ICU admission periods were compared, patients were older (48 vs. 52 years; p < 0.005) and the percentage of ARF as leading cause for ICU admission decreased from 43% in the first to 30% in the second period. Over time ICU and hospital survival improved from 44 to 60% (p < 0.01) and from 26 to 43% (p < 0.01), respectively. The 1- and 3-year survival rate after ICU admission increased significantly from 14 to 32% and from 11 to 23% (p < 0.01).

CONCLUSIONS

Besides ARF and septic shock, cardiac events were especially a major reason for ICU admission. Both short- and long-term survival of critically ill HSCT patients has improved significantly in recent years, and survival of HSCT recipients discharged from hospital is not significantly affected by a former ICU stay.

Characteristics and outcome of patients with newly diagnosed advanced or metastatic lung cancer admitted to intensive care units (ICUs)

Background

Although patients with advanced or metastatic lung cancer have poor prognosis, admission to the ICU for management of life-threatening complications has increased over the years. Patients with newly diagnosed lung cancer appear as good candidates for ICU admission, but more robust information to assist decisions is lacking. The aim of our study was to evaluate the prognosis of newly diagnosed unresectable lung cancer patients.

Methods

A retrospective multicentric study analyzed the outcome of patients admitted to the ICU with a newly diagnosed lung cancer (diagnosis within the month) between 2010 and 2013.

Results

Out of the 100 patients, 30 had small cell lung cancer (SCLC) and 70 had non-small cell lung cancer. (Thirty patients had already been treated with oncologic treatments.) Mechanical ventilation (MV) was performed for 81 patients. Seventeen patients received emergency chemotherapy during their ICU stay. ICU, hospital, 3- and 6-month mortality were, respectively, 47, 60, 67 and 71%. Hospital mortality was 60% when invasive MV was used alone, 71% when MV and vasopressors were needed and 83% when MV, vasopressors and hemodialysis were required. In multivariate analysis, hospital mortality was associated with metastatic disease (OR 4.22 [1.4–12.4]; p = 0.008), need for invasive MV (OR 4.20 [1.11–16.2]; p = 0.030), while chemotherapy in ICU was associated with survival (OR 0.23, [0.07–0.81]; p = 0.020).

Conclusion

This study shows that ICU management can be appropriate for selected newly diagnosed patients with advanced lung cancer, and chemotherapy might improve outcome for patients with SCLC admitted for cancer-related complications. Nevertheless, tumors’ characteristics, numbers and types of organ dysfunction should be taken into account in the decisional process before admitting these patients in ICU.

Practical Management of Epileptic Seizures and Status Epilepticus in Adult Palliative Care Patients

In terminally ill patients, paroxysmal or episodic changes of consciousness, movements and behavior are frequent. Due to ambiguous appearance, the correct diagnosis of epileptic seizures (ES) and non-epileptic events (NEE) is often difficult. Treatment is frequently complicated by the underlying condition, and an approach indicated in healthier patients may not always be appropriate in the palliative care setting. This article provides recommendations for diagnosis of ES and NEE and treatment options for ES in adult palliative care patients, including aspects of alternative administration routes for antiepileptic drugs such as intranasal, subcutaneous, or rectal application.

Evaluating the Predictive Value of Lactate in Patients With Cancer Having Septic Shock

PURPOSE

Limited studies evaluated the predictive value of serum lactate (LA) in critically ill patients with cancer. The main objective of this study was to evaluate the predictive validity of LA single measurements as well as LA clearance in predicting mortality in patients with cancer having septic shock. The study also aimed to determine the LA measurement over the first 24 hours with the highest predictability for hospital mortality.

MATERIALS AND METHODS

A retrospective cohort study of adult patients with cancer having septic shock and LA measurements during the first 24 hours. Three receiver-operating characteristic (ROC) curves were constructed to evaluate the predictive validity for hospital mortality of LA at baseline, at 6 hours and at 24 hours after identifying septic shock. The ROC with the largest area under the curve was analyzed to determine LA level with the highest predictability for hospital mortality. In addition, the ability of LA normalization (LA <2 mmol/L at 6 hours and at 24 hours) and the degree of LA elimination (>10% and >20% at 24 hours) to predict hospital mortality were evaluated by determining the predictive values for each clearance end point.

RESULTS

The study included 401 patients. LA >2.5 mmol/L at 24 hours showed the largest area under the ROC curve to predict hospital mortality (ROC area: 0.648; 95% confidence interval: 0.585-0.711) with a sensitivity of 58.4% and specificity of 62.8%. The LA normalization, LA clearance >10%, and LA clearance >20% were also predictors of hospital mortality, with the highest sensitivity for LA normalization at 6 hours (74%) and LA normalization at 24 hours (73.4%).

CONCLUSION

In patients with cancer having septic shock, LA >2.5 mmol/L at 24 hours of septic shock had the highest predictability for hospital mortality. The LA normalization and clearance were also predictors of hospital mortality. However, all LA end points were not strong predictors.

Characteristics and outcomes of patients with hematologic malignancies receiving chemotherapy in the intensive care unit

BACKGROUND

The objective of this study was to evaluate the short-term and long-term outcomes of adult patients with hematologic malignancies who received chemotherapy in the intensive care unit (ICU).

METHODS

This was a retrospective, single-center study comparing the outcomes of patients with hematologic malignancies who received chemotherapy in the ICU with a matched cohort of ICU patients who did not receive chemotherapy. Conditional logistic regression and shared-frailty Cox regression were used to assess short-term (ICU and hospital) mortality and death by 12 months after hospital discharge, respectively.

RESULTS

One hundred eighty-one patients with hematologic malignancies received chemotherapy in the ICU. The ICU and hospital mortality rates were 25% and 42% for chemotherapy patients and 22% and 33% for non-chemotherapy patients, respectively. Higher severity of illness scores on ICU admission were significantly associated with higher ICU mortality (odds ratio, 1.07; P < .001) and hospital mortality (odds ratio, 1.05; P ≤ .001). Six-month and 12-month survival estimates posthospital discharge were 58% and 50%, respectively. Compared with the matched cohort of patients who did not receive chemotherapy, those who did receive chemotherapy had a significantly longer length of stay in the ICU (median, 6 vs 3 days; P < .001) and in the hospital (median, 22 vs 14 days; P = .024). In multivariable analysis, the patients who received chemotherapy in the ICU had a trend toward a higher risk of dying by 12 months (hazard ratio, 1.45; P = .08).

CONCLUSIONS

Short-term mortality was similar among patients with hematologic malignancies who did and did not receive chemotherapy in the ICU, although patients who received chemotherapy had increased resource utilization. These results may inform ICU triage and goals-of-care discussions with patients and their families regarding outcomes after receiving chemotherapy in the ICU. Cancer 2018;124:3025-36. © 2018 American Cancer Society.

Consensus statement for cancer patients requiring intensive care support

This consensus statement is directed to intensivists, hematologists, and oncologists caring for critically ill cancer patients and focuses on the management of these patients.

Use of regional citrate anticoagulation for continuous venovenous hemodialysis in critically ill cancer patients with acute kidney injury

PURPOSE

This study aimed to evaluate the safety and efficacy of a regional citrate anticoagulation (RCA) protocol for continuous venovenous hemodialysis (CVVHD) in cancer patients with acute kidney injury (AKI) in the intensive care unit (ICU) setting.

MATERIAL AND METHODS

One hundred twenty two consecutive ICU cancer patients with AKI treated with citrate-based CVVHD were prospectively evaluated in this prospective observational study.

RESULTS

A total of 7198 h of CVVHD therapy (250 filters) were performed. Patients were 61.3 ± 15.7 years old, 78% had solid cancer and the main AKI cause was sepsis (50%). The in-hospital mortality was 78.7%. Systemic ionized calcium (SCai) was 4.35 (4.10-4.60) mg/dL, severe hypocalcemia (SCai <3.6 mg/dL) was observed in 4.3% of procedures and post-filter ionized calcium was 1.60 (1.40-1.80) mg/dL. Median filter patency was 24.8 (11-43) hours. Factors related to filter clotting were: no tumor evidence (OR 0.44, CI 0.18-0.99); genitourinary tumor (OR 1.83, CI 1.18-2.81); platelets number (each 10,000/mm³) (OR 1.02, CI 1.00-1.04); International Normatized Ratio (INR) (OR 0.59, CI 0.41-0.85) and citrate dose (each 10 mL/h) (OR 0.88, CI 0.82-0.95).

CONCLUSION

Filter patency was relatively short and clotting was associated with active cancer disease, genitourinary tumor, lower citrate dose and lower INR.

Intensive care in cancer patients in the age of immunotherapy and molecular therapies: Commitment of the SEOM-SEMICYUC

Cancer patients are a vulnerable group exposed to numerous and serious risks beyond cancer itself. In recent years, the prognosis of these individuals has improved substantially thanks to several advances such as immunotherapy, targeted molecular therapies, surgical techniques, or developments in support treatment. This coincides with the prolonged survival of oncological patients admitted to the ICU due to critical complications, and under the supervision of intensivists. The time has therefore come to revisit the intensive care support of these patients, which poses new professional as well as organizational challenges. An agreement was signed in 2017 between the SEOM and SEMICYUC with the aim of improving the quality of care of cancer patients with critical complications. The initiative seeks to aid in decision-making, standardize criteria, decrease subjectivity, generate channels of communication, and delve deeper into the ethical and scientific aspects of these situations. This document sets forth the most important reasons that have led us to undertake this initiative.

Extremely Low-Frequency Magnetic Fields and Redox-Responsive Pathways Linked to Cancer Drug Resistance: Insights from Co-Exposure-Based In Vitro Studies

Electrical devices currently used in clinical practice and common household equipments generate extremely low-frequency magnetic fields (ELF-MF) that were classified by the International Agency for Research on Cancer as “possible carcinogenic.” Assuming that ELF-MF plays a role in the carcinogenic process without inducing direct genomic alterations, ELF-MF may be involved in the promotion or progression of cancers. In particular, ELF-MF-induced responses are suspected to activate redox-responsive intracellular signaling or detoxification scavenging systems. In fact, improved protection against oxidative stress and redox-active xenobiotics is thought to provide critical proliferative and survival advantage in tumors. On this basis, an ever-growing research activity worldwide is attempting to establish whether tumor cells may develop multidrug resistance through the activation of essential cytoprotective networks in the presence of ELF fields, and how this might trigger relevant changes in tumor phenotype. This review builds a framework around how the activity of redox-responsive mediators may be controlled by co-exposure to ELF-MF and reactive oxygen species-generating agents in tumor and cancer cells, in order to clarify whether and how such potential molecular targets could help to minimize or neutralize the functional interaction between ELF-MF and malignancies.

Causes of death in hospitalized children younger than 12 years of age in a Chinese hospital: a 10 year study

Background

In China, the majority (77%) of urban children die in hospitals. Hospital-based review could provide insight leading to improvements in clinical practice and increase the survival of critically ill children. The aim of the present study is to identify the trends of immediate causes and chronic underlying diseases associated with deaths of children at one of the largest teaching hospitals in China over a period of 10 years (2006–2015).

Methods

A retrospective analysis of data of all children aged 1 month to 11 years who died at Xinhua Hospital between 2006 and 2015. Demographic details, main causes of deaths, and chronic underlying diseases were reviewed.

Results

Case fatality rate was 0.55% (510/93,443) and it represented 0.41–0.80% deaths per year. Overall, the most common immediate causes of deaths in hospitalized children were pneumonia (36.7%), sepsis (13.5%), tumour (11.4%), followed by nontraumatic intracranial or gastrointestinal hemorrhage (10.6%) and cardiac shock (9.6%). Over 70% of the deaths in children were complicated with chronic underlying diseases. Congenital abnormality was the most frequent chronic underlying disease observed in infants (60.3%) and tumour was the main chronic underlying disease in toddlers (31.1%) and older children (44%).

Conclusions

Infectious diseases, especially pneumonia, were the major immediate causes of deaths, and the mortality in the study population decreased with age. Tumour and other noninfectious disease accounted for more deaths in older children. Chronic underlying diseases were found in most deaths of children.

Electronic supplementary material

The online version of this article (10.1186/s12887-017-0981-y) contains supplementary material, which is available to authorized users.

Evolution of Intensive Care Unit Nursing

The specialties of critical care medicine and critical care nursing arose to provide special treatment and care to the most severely ill hospital patients. However, critical care medicine does not seem to have made any major therapeutic progress in the past 30 years. The reduction of mortality in intensive care units (ICUs) is due essentially to improvements in both supportive care and the relevant technologies. In future, increases in the number of ICU beds relative to bed numbers in other hospital wards will probably be contemplated, even in a scenario of decreasing costs; clinical protocols will be computerized and/or nurse-driven; more multicenter and international trials will be performed; and organizational strategies will concentrate ICU personnel in a few large units, to promote the flexible management of these healthcare workers. Moreover, extracorporeal organ support technologies will be improved; technology informatics will cover all the bureaucratic aspects of healthcare work, aiding the staff in workload assessment; and critical care multidisciplinary rounds and follow-up services for post-ICU patients will be implemented. Lastly, a better continuum of care between the pre-hospital phase, the emergency care phase, the ICU phase, and the post-ICU phase should be achieved.

Also, policies should be drafted to manage sudden large demands for critical care beds in mega-emergencies.

The main lines of discussion in critical care nursing research should include nursing research priorities in critical care patients, holistic approaches to the patient, the humanization of care, special populations of ICU patients, and challenges related to critical care nursing during emerging outbreaks of infectious diseases.

[Cancer patients in operative intensive care medicine]

Die Prävalenz onkologischer Erkrankungen ist in den vergangenen Jahrzehnten stetig angestiegen. Durch neue Therapieoptionen können immer mehr Patienten mit einem kurativen Therapieansatz behandelt werden. Diese individualisierten und teilweise sehr aggressiven Therapien können jedoch auch zu schweren Nebenwirkungen führen. Diese sollten als wichtige Differenzialdiagnosen zu anderen vitalbedrohlichen Krankheitsbildern auch dem im OP und als Intensivmediziner tätigen Anästhesisten bekannt sein. Krebspatienten werden häufig auf operativen Intensivstationen aufgenommen, um Komplikationen der malignen Grunderkrankung oder auch Nebenwirkungen einer operativen oder konservativen Therapie zu behandeln. Aktuelle Untersuchungen zeigen, dass die maligne Grunderkrankung entgegen bisheriger Annahme keinen wesentlichen Einfluss auf das Intensivüberleben hat. Bei der Aufnahme eines onkologischen Patienten sollte daher die akut vorliegende Organdysfunktion zunächst im Vordergrund stehen. Bei der Therapiezielplanung gilt es, nicht zu übersehen, wann ein kuratives in ein palliatives Konzept übergehen muss. Hierfür müssen neue Aufnahmestrategien und -kriterien entwickelt und evaluiert werden. In diesem Übersichtsartikel werden Diagnosen und Therapien häufiger intensivmedizinischer Krankheitsbilder von onkologischen Patienten sowie Nebenwirkungen moderner onkologischer Therapien dargelegt und Aufnahmestrategien für Patienten mit malignen Erkrankungen vorgestellt.

Short- and long-term outcomes in onco-hematological patients admitted to the intensive care unit with classic factors of poor prognosis

Although the overall mortality of patients admitted to intensive care units (ICU) with hematological malignancy has decreased over the years, some groups of patients still have low survival rates. We performed a monocentric retrospective study including all patients with hematological malignancy in a ten-year period, to identify factors related to the outcome for the whole cohort and for patients with allogeneic hematopoietic stem cell transplantation (HSCT), neutropenia, or those requiring invasive mechanical ventilation (IMV). A total of 418 patients with acute leukemia (n=239; 57%), myeloma (n=69; 17%), and lymphoma (n=53; 13%) were studied. Day-28 and 1-year mortality were 49% and 72%, respectively. The type of disease was not associated with outcome. The disease status was independentlty associated with 1-year mortality only. Independent predictors of day-28 mortality were IMV, renal replacement therapy (RRT), and performance status. For allogeneic HSCT recipients (n=116), neutropenic patients (n=124) and patients requiring IMV (n=196), day-28 and 1-year mortality were 52%, 54%, 74% and 81%, 78%, 87%, respectively. Multivariate analysis showed that IMV and RRT for allogeneic HSCT recipients, performance status and IMV for neutropenic patients, and RRT for patients requiring IMV were independently associated with short-term mortality (p<0.05).These results suggest that IMV is the strongest predictor of mortality in hematological patients admitted to ICUs, whereas allogeneic HSCT and neutropenia do not worsen their short-term outcome.

What are the ethical aspects surrounding intensive care unit admission in patients with cancer?

Improvements in living conditions and increasing life expectancy have combined to result in ever older patients being admitted to hospital. In parallel, the increasing incidence of cancer, along with the improved efficacy of anti-cancer therapies has led to greater needs for intensive care among cancer patients. The objectives underpinning the management of cancer patients in the intensive care unit (ICU) are to achieve a return to a clinical status that would allow the patient to be either, transferred back to the original unit, or discharged from the hospital with an acceptable quality of life, and where warranted, pursuit of cancer therapy. The relevance of ICU admission should be assessed systematically for patients with active cancer. The decision needs to be made taking into account the expected benefit for the patient, the life-support therapies that are possible with discussion about a care project, and also considering the future quality of life and the short and long-term prognosis. Anticipating the question of potential ICU admission should help protect the patient against both inappropriate refusal of intensive care, and inappropriate admission to the ICU that might only lead to unreasonable therapeutic obstinacy. The intensive care physician has a major role to play in helping the cancer patient to develop an appropriate and flexible healthcare project. Anticipating the question of ICU admission in advance, as well as a close alliance between the oncologist and the intensive care physician are the two keys to the success of a healthcare project focused on the patient.

Predictors of In-Hospital Mortality in Patients With Metastatic Cancer Receiving Specific Critical Care Therapies

BACKGROUND

In-hospital mortality is high for critically ill patients with metastatic cancer. To help patients, families, and clinicians make an informed decision about invasive medical treatments, we examined predictors of in-hospital mortality among patients with metastatic cancer who received critical care therapies (CCTs).

PATIENTS AND METHODS

We used the 2010 California Healthcare Cost and Utilization Project: State Inpatient Databases to identify admissions of patients with metastatic cancer (age ≥18 years) who received CCTs, including invasive mechanical ventilation (IMV), tracheostomy, percutaneous endoscopic gastrostomy (PEG) tube, acute use of dialysis, and total parenteral nutrition (TPN). We first described the characteristics and outcomes of patients who received any CCTs. We then used multivariable logistic regression models with generalized estimating equations (to account for clustering within hospitals) to identify predictors of in-hospital mortality among patients who received any CCTs.

RESULTS

For 2010, we identified 99,085 admissions among patients with metastatic cancer. Of these, 9,348 (9.4%) received any CCT during hospitalization; 50% received IMV, 15% PEG tube, 8% tracheostomy, 40% TPN, and 8% acute dialysis. Inpatient mortality was 30%. Of patients who received any CCT and survived to discharge, 27% were discharged to a skilled nursing facility. Compared with patients who died, costs of care were $3,019 higher for admissions in which patients survived the hospitalization. Predictors of in-hospital mortality included non-white race (vs whites), lack of insurance (vs Medicare), unscheduled admissions, principal diagnosis of infections (vs cancer-related), greater burden of comorbidities, end-stage renal disease, liver disease and lung cancer (vs other cancers).

CONCLUSIONS

Although more studies are needed to better understand risks and benefits of specific treatments in the setting of specific cancer types, these data will help to inform decision-making for patients with metastatic cancer who become critically ill.

Haemato-oncology patients' perceptions of health-related quality of life after critical illness: A qualitative phenomenological study

INTRODUCTION

Haemato-oncology patients often require critical care support due to side-effects of treatment. Discharge can mark the start of an uncertain journey due to the impact of critical illness on health-related quality of life. Qualitatively establishing needs is a priority as current evidence is limited.

AIMS

To qualitatively explore perceptions of haemato-oncology patients' health-related quality of life after critical illness and explore how healthcare professionals can provide long-term support.

METHODS

Nine in-depth interviews were conducted three to eighteen months post-discharge from critical care. Phenomenology was used to gain deeper understanding of the patients' lived experience.

SETTING

A 19-bedded Intensive Care Unit in a specialist cancer centre.

FINDINGS

Five major themes emerged: Intensive care as a means to an end; Rollercoaster of illness; Reliance on hospital; Having a realistic/sanguine approach; Living in the moment. Haemato-oncology patients who experience critical illness may view it as a small part of a larger treatment pathway, thus health-related quality of life is impacted by this rather than the acute episode.

CONCLUSIONS

Discharge from the intensive care unit can be seen as a positive end-point, allowing personal growth in areas such as relationships and living life to the full. The contribution of health-care professionals and support of significant others is regarded as critical to the recovery experience.

Prognosis of patients with primary malignant brain tumors admitted to the intensive care unit: a two-decade experience

The purpose of this study is to describe the reasons for ICU admission and to evaluate the outcome and prognostic factors of patients with primary malignant brain tumors (PMBT) admitted to the intensive care unit (ICU). This is a retrospective observational cohort study of 196 PMBT patients admitted to two ICUs over a 19-year period. Acute respiratory failure was the main reason for ICU admission (45%) followed by seizures (25%) and non-epileptic coma (14%). Seizures were more common in patients with glial lesions (84 vs. 67%), whereas patients with primary brain lymphoma were more frequently admitted for shock (42 vs. 18%). Overall ICU and 90-day mortality rates were 23 and 50%, respectively. Admission for seizures was independently associated with lower ICU mortality [odds ratio (OR) 0.06], whereas the need for mechanical ventilation (OR 6.85), cancer progression (OR 7.84), respiratory rate (OR 1.11) and Glasgow coma scale (OR 0.85) were associated with higher ICU mortality. Among the 95 patients who received invasive mechanical ventilation, ICU mortality was 37% (n = 35). For these patients, admission for seizures was associated with lower ICU mortality (OR 0.050) whereas cancer progression (OR 7.49) and respiratory rate (OR 1.08) were associated with higher ICU mortality. The prognosis of PMBT patients admitted to the ICU appears relatively favorable compared to that of hematologic malignancies or solid tumors, especially when the patient is admitted for seizures. The presence of a PMBT, therefore, does not appear to be sufficient for refusal of ICU admission. Predictive factors of mortality may help clinicians make optimal triage decisions.

Appropriateness of admissions of children with cancer to intensive care facilities in a resource-limited setting

<strong>Background:</strong> The increasing intensity of treatment of paediatric malignancies has led to improved survival rates, but often necessitates intensive supportive care. The decision to admit a child to the paediatric intensive care unit (PICU) is based on the probability of both short-term and long-term survival in the context of severe resource constraints. Resource constraints in South Africa result in limited access of children with cancer to PICU facilities.<br /><strong>Objectives:</strong> The aim of this study was to determine whether referrals by paediatric oncologists to a PICU in Johannesburg were appropriate by analysing indications for admission, underlying diagnoses, duration and costs of admissions, and overall outcomes.<br /><strong>Methods:</strong> A retrospective review of consecutive PICU admissions over a 12-year period was performed. Data from all patients with histologically proven malignant conditions were included and analysed using descriptive statistical methods, Kaplan–Meier curves, log-rank analysis and Fisher’s exact test.<br /><strong>Results:</strong> There were 5704 recorded admissions to PICU in the study period. Of these admissions, 120 (2.1%) were for patients with malignancies. The majority of PICU oncology admissions were for post-operative care, and the median duration of stay was 1 day (interquartile range: 1–3 days). The short-term mortality rate of oncology patients in PICU was 13.3% in comparison with 16.2% in the overall PICU population. The 4-year overall survival rate post PICU discharge was 54%.<br /><strong>Conclusion:</strong> The documented short-term mortality rate indicates that referrals by paediatric oncologists are consistent with current PICU admission policies. Oncologists should assess the prognosis for survival before requesting admission to PICU, and, resources permitting, these patients should be accepted to PICU.

Characteristics and Outcome of Cancer Patients Admitted to the ICU in England, Wales, and Northern Ireland and National Trends Between 1997 and 2013

OBJECTIVE

To describe trends in outcomes of cancer patients with an unplanned admission to the ICU between 1997 and 2013 and to identify risk factors for mortality of those admitted between 2009 and 2013.

DESIGN

Retrospective analysis.

SETTING

Intensive Care National Audit & Research Centre Case Mix Programme Database including data of ICUs in England, Wales, and Northern Ireland.

PATIENTS

Patients (99,590) with a solid tumor and 13,538 patients with a hematological malignancy with an unplanned ICU admission between 1997 and 2013; 39,734 solid tumor patients and 6,652 patients with a hematological malignancy who were admitted between 2009 and 2013 were analyzed in depth.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In solid tumor patients admitted between 2009 and 2013, hospital mortality was 26.4%. Independent risk factors for hospital mortality were metastatic disease (odds ratio, 1.99), cardiopulmonary resuscitation before ICU admission (odds ratio, 1.63), Intensive Care National Audit & Research Centre Physiology score (odds ratio, 1.14), admission for gastrointestinal (odds ratio, 1.12), respiratory (odds ratio, 1.48) or neurological (odds ratio, 1.65) reasons, and previous ICU admission (odds ratio, 1.18). In patients with a hematological malignancy admitted between 2009 and 2013, hospital mortality was 53.6%. Independent risk factors for hospital mortality were age (odds ratio, 1.02), cardiopulmonary resuscitation before ICU admission (odds ratio, 1.90), Intensive Care National Audit & Research Centre Physiology Score (odds ratio, 1.12), admission for hematological (odds ratio, 1.48) or respiratory (odds ratio, 1.56) reasons, bone marrow transplant (odds ratio, 1.53), previous ICU admission (odds ratio, 1.43), and mechanical ventilation within 24 hours of admission (odds ratio, 1.33). Trend analysis showed a significant decrease in ICU and hospital mortality and length of stay between 1997 and 2013 despite little change in severity of illness during this time.

CONCLUSIONS

Between 1997 and 2013, the outcome of cancer patients with an unplanned admission to ICU improved significantly. Among those admitted between 2009 and 2013, independent risk factors for hospital mortality were age, severity of illness, previous cardiopulmonary resuscitation, previous ICU admission, metastatic disease, and admission for respiratory reasons.

Urgent Chemotherapy for Life-Threatening Complications Related to Solid Neoplasms

OBJECTIVES

Solid neoplasms can be directly responsible for organ failures at the time of diagnosis or relapse. The management of such specific complications relies on urgent chemotherapy and eventual instrumental or surgical procedures, combined with advanced life support. We conducted a multicenter study to address the prognosis of this condition.

DESIGN

A multicenter retrospective (2001-2015) chart review.

SETTING

Medical and respiratory ICUs.

PATIENTS

Adult patients who received urgent chemotherapy in the ICU for organ failure related to solid neoplasms were included. The modalities of chemotherapy, requirements of adjuvant instrumental or surgical procedures, and organ supports were collected. Endpoints were short- and long-term survival rates.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty-six patients were included. Lung cancer was the most common malignancy distributed into small cell lung cancer (n = 57) and non-small cell lung cancer (n = 33). The main reason for ICU admission was acute respiratory failure in 111 patients (81.6%), of whom 89 required invasive mechanical ventilation. Compression and tissue infiltration by tumor cells were the leading mechanisms resulting in organ involvement in 78 (57.4%) and 47 (34.6%) patients. The overall in-ICU, in-hospital, 6-month, and 1-year mortality rates were 37%, 58%, 74%, and 88%, respectively. Small cell lung cancer was identified as an independent predictor of hospital survival. However, this gain in survival was not sustained since the 1-year survival rates of small cell lung cancer, non-small cell lung cancer, and non-lung cancer patients all dropped below 20%.

CONCLUSIONS

Urgent chemotherapy along with aggressive management of organ failures in the ICU can be lifesaving in very selected cancer patients, most especially with small cell lung cancer, although the long-term survival is hardly sustainable.

The prognostic value of a trend in modified SOFA score for patients with hematological malignancies in the intensive care unit

BACKGROUND

Patients with hematological malignancies admitted to an intensive care unit (ICU) have a poor prognosis. The Sequential Organ Failure Assessment (SOFA) score is used to monitor patients on the ICU. Little is known about the value of this score in hematology patients. Therefore, the prognostic value of the SOFA score and a modified hematological SOFA score (SOFAhem) was studied.

METHODS

Patients with hematological malignancies admitted to the ICU between 1999 and 2009 were analyzed in a retrospective cohort study. The SOFAhem score was defined as the original SOFA score omitting the coagulation and neurological parameters.

RESULTS

In 149 admissions, ICU mortality was 52%. Mortality was significantly associated with higher SOFA and SOFAhem scores on admission, and trend in SOFAhem scores. An unchanged and increased SOFAhem score compared to decreasing SOFAhem scores was associated with a higher mortality rate (53% resp 67% resp 25%).

CONCLUSIONS

Trends in SOFA or SOFAhem score are both suitable as prognostic parameter. The trend in SOFAhem score seems to be independently related to mortality in hematological patients admitted to the ICU, and because of the higher odds ratios and lower P-values compared to the SOFA score, it is probably stronger related to mortality than the classical score, but its prognostic value should be tested in a larger cohort.

Respiratory events in ward are associated with later intensive care unit (ICU) admission and hospital mortality in onco-hematology patients not admitted to ICU after a first request

INTRODUCTION

Prognostic impact of delayed intensive care unit(ICU) admission in critically ill cancer patients remains debatable. We determined predictive factors for later ICU admission and mortality in cancer patients initially not admitted after their first ICU request.

METHODS

All cancer patients referred for an emergency ICU admission between 1 January 2012 and 31 August 2013 were included.

RESULTS

Totally, 246(54.8%) patients were immediately admitted. Among 203(45.2%) patients denied at the first request, 54(26.6%) were admitted later. A former ICU stay [OR: 2.75(1.12-6.75)], a request based on a clinical respiratory event[OR: 2.6(1.35-5.02)] and neutropenia[OR: 2.25(1.06-4.8)] were independently associated with later ICU admission. Survival of patients admitted immediately and later did not differ at ICU(78.5% and 70.4%, respectively; p = 0.2) or hospital(74% and 66%, respectively; p = 0.24) discharge. Hospital mortality of patients initially not admitted was 29.7% and independently associated with malignancy progression[OR: 3.15(1.6-6.19)], allogeneic hematopoietic stem cell transplantation[OR: 2.5(1.06-5.89)], a request based on a clinical respiratory event[OR: 2.36(1.22-4.56)] and severe sepsis[OR: 0.27(0.08-0.99)].

CONCLUSION

Compared with immediate ICU admission, later ICU admission was not associated with hospital mortality. Clinical respiratory events were independently associated with both later ICU admission and hospital mortality.

The Intensive Care Medicine research agenda on critically ill oncology and hematology patients

Over the coming years, accelerating progress against cancer will be associated with an increased number of patients who require life-sustaining therapies for infectious or toxic chemotherapy-related events. Major changes include increased number of cancer patients admitted to the ICU with full-code status or for time-limited trials, increased survival and quality of life in ICU survivors, changing prognostic factors, early ICU admission for optimal monitoring, and use of noninvasive diagnostic and therapeutic strategies. In this review, experts in the management of critically ill cancer patients highlight recent changes in the use and the results of intensive care in patients with malignancies. They seek to put forward a standard of care for the management of these patients and highlight important updates that are required to care for them. The research agenda they suggest includes important studies to be conducted in the next few years to increase our understanding of organ dysfunction in this population and to improve our ability to appropriately use life-saving therapies or select new therapeutic approaches that are likely to improve outcomes. This review aims to provide more guidance for the daily management of patients with cancer, in whom outcomes are constantly improving, as is our global ability to fight against what is becoming the leading cause of mortality in industrialized and non-industrialized countries.

Patterns of C-reactive protein ratio predicts outcomes in healthcare-associated pneumonia in critically ill patients with cancer

PURPOSE

Describe the patterns of C-reactive protein relative changes in response to antibiotic therapy in critically ill cancer patients with healthcare-associated pneumonia (HCAP) and its ability to predict outcome.

METHODS

Secondary analysis of a prospective cohort of critically ill cancer patients with HCAP. CRP was sampled every other day from D0 to D6 of antibiotic therapy. Patients were classified according to an individual pattern of CRP-ratio response: fast - CRP at D4 of therapy was <0.4 of D0 CRP; slow - a continuous but slow decrease of CRP; non - CRP remained ≥0.8 of D0 CRP; biphasic - initial CRP decrease to levels <0.8 of the D0 CRP followed by a secondary rise ≥0.8.

RESULTS

129 patients were included and septic shock was present in 74% and invasive mechanical ventilation was used in 73%. Intensive care unit (ICU) and hospital mortality rates were 47% and 64%, respectively. By D4, both CRP and CRP-ratio of survivors were significantly lower than in nonsurvivors (p<0.001 and p=0.004, respectively). Both time-dependent analysis of CRP-ratio of the four previously defined patterns (p<0.001) as ICU mortality were consistently different [fast 12.9%, slow 43.2%, biphasic 66.7% and non 71.8% (p<0.001)].

CONCLUSION

CRP-ratio was useful in the early prediction of poor outcomes in cancer patients with HCAP.

Different Impact of the Number of Organ Failures and Graft-Versus-Host Disease on the Outcome of Allogeneic Stem Cell Transplantation Recipients Requiring Intensive Care

BACKGROUND

Admission of allogeneic stem cell transplantation (SCT) recipients to the intensive care unit (ICU) remains controversial, especially when graft-versus-host disease (GVHD) is present.

METHODS

We performed a retrospective study to assess prognostic factors of survival in all allogeneic SCT recipients admitted to the ICU between 2002 and 2013 in our center which has flexible admission criteria, especially regarding GVHD.

RESULTS

Of 349 patients who underwent allogeneic SCT during the study period, 92 patients (26%) were admitted to the ICU. Intensive care unit and hospital discharge rates were 66% and 46%, respectively, whereas 1 year survival was 24%. Acute GVHD, either grade III to IV (30 patients, 33%) or refractory (12 patients, 13%) had a nonsignificant impact on hospital mortality (odds ratio [OR], 2.1; P = 0.1; OR, 5, P = 0.05, respectively). Fifty percent of patients required invasive mechanical ventilation, 30% required vasopressors, 17% required renal replacement therapy, and 28% had liver impairment (bilirubin >34 μmol/L), each of these parameters defining organ failure. Mortality was closely associated with the number of organ failures as hospital discharge rates were 69%, 50%, 42%, and 0% among patients with 0 (26 patients), 1 (26 patients), 2 (26 patients), and 3 to 4 (14 patients) organ failures, respectively (OR, 2.7; 95% confidence interval, 1.6-4.6; P < 0.001 according to the number of organ failures).

CONCLUSIONS

Early mortality of allogeneic SCT recipients admitted to the ICU is especially influenced by the number of organ failures and therefore patients with 0 to 2 organ failures should be considered if required. Refractory GVHD affects survival but not within the confined ICU admission.

Long-Term Survival, Quality of Life, and Quality-Adjusted Survival in Critically Ill Patients With Cancer

OBJECTIVES

To assess the long-term survival, health-related quality of life, and quality-adjusted life years of cancer patients admitted to ICUs.

DESIGN

Prospective cohort.

SETTING

Two cancer specialized ICUs in Brazil.

PATIENTS

A total of 792 participants.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The health-related quality of life before ICU admission; at 15 days; and at 3, 6, 12, and 18 months was assessed with the EQ-5D-3L. In addition, the vital status was assessed at 24 months. The mean age of the subjects was 61.6 ± 14.3 years, 42.5% were female subjects and half were admitted after elective surgery. The mean Simplified Acute Physiology Score 3 was 47.4 ± 15.6. Survival at 12 and 18 months was 42.4% and 38.1%, respectively. The mean EQ-5D-3L utility measure before admission to the ICU was 0.47 ± 0.43, at 15 days it was 0.41 ± 0.44, at 90 days 0.56 ± 0.42, at 6 months 0.60 ± 0.41, at 12 months 0.67 ± 0.35, and at 18 months 0.67 ± 0.35. The probabilities for attaining 12 and 18 months of quality-adjusted survival were 30.1% and 19.1%, respectively. There were statistically significant differences in survival time and quality-adjusted life years according to all assessed baseline characteristics (ICU admission after elective surgery, emergency surgery, or medical admission; Simplified Acute Physiology Score 3; cancer extension; cancer status; previous surgery; previous chemotherapy; previous radiotherapy; performance status; and previous health-related quality of life). Only the previous health-related quality of life and performance status were associated with the health-related quality of life during the 18-month follow-up.

CONCLUSIONS

Long-term survival, health-related quality of life, and quality-adjusted life year expectancy of cancer patients admitted to the ICU are limited. Nevertheless, these clinical outcomes exhibit wide variability among patients and are associated with simple characteristics present at the time of ICU admission, which may help healthcare professionals estimate patients' prognoses.