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Moyon Q, Triboulet F, Reuter J, Lebreton G, Dorget A, Para M, Chommeloux J, Stern J, Pineton de Chambrun M, Hékimian G, Luyt CE, Combes A, Sonneville R, Schmidt M. Venoarterial extracorporeal membrane oxygenation in immunocompromised patients with cardiogenic shock: a cohort study and propensity-weighted analysis. Intensive Care Med 2024; 50:406-417. [PMID: 38436727 DOI: 10.1007/s00134-024-07354-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/11/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The outcomes of immunocompromised patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are seldom documented, making ECMO candidacy decisions challenging. This study aims (1) to report outcomes of immunocompromised patients treated with VA-ECMO, (2) to identify pre-ECMO predictors of 90-day mortality, (3) to assess the impact of immunodepression on 90-day mortality, and (4) to describe the main ECMO-related complications. METHODS This is a retrospective, propensity-weighted study conducted in two French experienced ECMO centers. RESULTS From January 2006 to January 2022, 177 critically ill immunocompromised patients (median (interquartile range, IQR) age 49 (32-60) years) received VA-ECMO. The main causes of immunosuppression were long-term corticosteroids/immunosuppressant treatment (29%), hematological malignancy (26%), solid organ transplant (20%), and solid tumor (13%). Overall 90-day and 1-year mortality were 70% (95% confidence interval (CI) 63-77%) and 75% (95% CI 65-79%), respectively. Older age and higher pre-ECMO lactate were independently associated with 90-day mortality. Across immunodepression causes, 1-year mortality ranged from 58% for patients with infection by human immunodeficiency virus (HIV) or asplenia, to 89% for solid organ transplant recipients. Hemorrhagic and infectious complications affected 39% and 54% of patients, while more than half the stay in intensive care unit (ICU) was spent on antibiotics. In a propensity score-weighted model comparing the 177 patients with 942 non-immunocompromised patients experiencing cardiogenic shock on VA-ECMO, immunocompromised status was independently associated with a higher 90-day mortality (odds ratio 2.53, 95% CI 1.72-3.79). CONCLUSION Immunocompromised patients undergoing VA-ECMO treatment face an unfavorable prognosis, with higher 90-day mortality compared to non-immunocompromised patients. This underscores the necessity for thorough evaluation and careful selection of ECMO candidates within this frail population.
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Affiliation(s)
- Quentin Moyon
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Félicien Triboulet
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Jean Reuter
- Assistance Publique des Hopitaux de Paris, Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Guillaume Lebreton
- Assistance Publique des Hopitaux de Paris, Service de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Amandine Dorget
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Marylou Para
- Assistance Publique Des Hopitaux de Paris, Bichat Hospital, Service de Chirurgie Cardiaque, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Juliette Chommeloux
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Jules Stern
- Assistance Publique Des Hopitaux de Paris, Department of Anesthesiology and Critical Care Medicine, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Marc Pineton de Chambrun
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Guillaume Hékimian
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Charles-Edouard Luyt
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, GRC 30, RESPIRE, Paris, France
| | - Alain Combes
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
- Sorbonne Université, GRC 30, RESPIRE, Paris, France
| | - Romain Sonneville
- Assistance Publique des Hopitaux de Paris, Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Matthieu Schmidt
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France.
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France.
- Sorbonne Université, GRC 30, RESPIRE, Paris, France.
- Service de Médecine Intensive-Réanimation Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition 47, Boulevard de L'Hôpital, 75013, Paris, France.
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Kang C, Choi S, Jang EJ, Joo S, Jeong JH, Oh SY, Ryu HG, Lee H. Prevalence and outcomes of chronic comorbid conditions in patients with sepsis in Korea: a nationwide cohort study from 2011 to 2016. BMC Infect Dis 2024; 24:184. [PMID: 38347513 PMCID: PMC10860243 DOI: 10.1186/s12879-024-09081-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/01/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Chronic comorbid conditions are common in patients with sepsis and may affect the outcomes. This study aimed to evaluate the prevalence and outcomes of common comorbidities in patients with sepsis. METHODS We conducted a nationwide retrospective cohort study. Using data from the National Health Insurance Service of Korea. Adult patients (age ≥ 18 years) who were hospitalized in tertiary or general hospitals with a diagnosis of sepsis between 2011 and 2016 were analyzed. After screening of all International Classification of Diseases 10th revision codes for comorbidities, we identified hypertension, diabetes mellitus (DM), liver cirrhosis (LC), chronic kidney disease (CKD), and malignancy as prevalent comorbidities. RESULTS Overall, 373,539 patients diagnosed with sepsis were hospitalized in Korea between 2011 and 2016. Among them, 46.7% had hypertension, 23.6% had DM, 7.4% had LC, 13.7% had CKD, and 30.7% had malignancy. In-hospital mortality rates for patients with hypertension, DM, LC, CKD, and malignancy were 25.5%, 25.2%, 34.5%, 28.0%, and 33.3%, respectively, showing a decreasing trend over time (P < 0.001). After adjusting for baseline characteristics, male sex, older age, use of mechanical ventilation, and continuous renal replacement therapy, LC, CKD, and malignancy were significantly associated with in-hospital mortality. CONCLUSIONS Hypertension is the most prevalent comorbidity in patients with sepsis, and it is associated with an increased survival rate. Additionally, liver cirrhosis, chronic kidney disease, and malignancy result in higher mortality rates than hypertension and DM, and are significant risk factors for in-hospital mortality in patients with sepsis.
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Affiliation(s)
- Christine Kang
- Departments of Critical Care Medicine, Seoul National University Hospital, Seoul, South Korea
| | | | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, South Korea
| | - Somin Joo
- Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jae Hoon Jeong
- Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Seung-Young Oh
- Departments of Critical Care Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ho Geol Ryu
- Departments of Critical Care Medicine, Seoul National University Hospital, Seoul, South Korea
- Departments of Anesthesiology and Pain Medicine, Seoul National University, College of Medicine, Seoul, South Korea
| | - Hannah Lee
- Departments of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea.
- Departments of Anesthesiology and Pain Medicine, Seoul National University, College of Medicine, Seoul, South Korea.
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Bernard J, Vacheron CH, Vantard N, Bachy E, Richard JC, Aubrun F, Cour M, Lukaszewicz AC, Bohe J, Allaouchiche B, Friggeri A, Wallet F. Outcome and factors associated with mortality in patients receiving urgent chemotherapy in the ICU: A retrospective study. J Crit Care 2023; 78:154399. [PMID: 37556968 DOI: 10.1016/j.jcrc.2023.154399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/24/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE This study aimed to assess the outcome and factors associated with mortality in patients who received urgent chemotherapy (CT) in the intensive care unit (ICU) in Lyon, France. MATERIAL AND METHODS A total of 147 adult patients diagnosed with cancer and requiring urgent CT during ICU stay between October 2014 and December 2019 were included in this retrospective study. RESULTS Hematological cancer was found in 77% of patients, and acute respiratory failure was the leading cause of ICU admission (46.3%). The 6-month mortality rate was 69.4%; patients with solid cancer had a higher risk of mortality. Patients who died within 6 months had a poor performance score and a higher SOFA score at admission. The multivariate analysis showed that solid tumors, sepsis on the day of CT, and SOFA score on the day of CT were associated with 6-month mortality. Additionally, 95% of patients who survived the ICU resumed conventional CT, with a higher likelihood of resuming CT among those with hematological cancer. CONCLUSION Urgent CT in the ICU is feasible in a specific subset of patients, mainly those with hematological cancer, with resumption of the curative treatment regimen after ICU discharge.
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Affiliation(s)
- Jean Bernard
- Service de Médecine Intensive Réanimation Anesthésie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Charles-Hervé Vacheron
- Service de Médecine Intensive Réanimation Anesthésie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Service de Bio statistique - Bio-informatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Nicolas Vantard
- Service de Pharmacie, Hôpital Lyon sud, Hospices Civils de Lyon, Lyon, France
| | - Emmanuel Bachy
- Service d'hématologie clinique, Hôpital Lyon sud, Hospices Civils de Lyon, Lyon, France
| | - Jean Christophe Richard
- Service de Médecine Intensive Réanimation, Hôpital De La Croix Rousse, Hospices Civils de Lyon, Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, F-69621 Lyon, France
| | - Frédéric Aubrun
- Service d'Anesthésie réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Martin Cour
- Service de Médecine Intensive Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Anne Claire Lukaszewicz
- Service d'Anesthésie réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Julien Bohe
- Service de Médecine Intensive Réanimation Anesthésie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Bernard Allaouchiche
- Service de Médecine Intensive Réanimation Anesthésie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Pulmonary and Cardiovascular Agression in Sepsis (APCSe), Université de Lyon, VetAgro Sup, Campus Vétérinaire de Lyon, UPSP 2016.A101, Marcy l'Étoile, France
| | - Arnaud Friggeri
- Service de Médecine Intensive Réanimation Anesthésie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Centre international de recherche en infectiologie (CIRI) - PHE3ID - Université claude bernard Lyon 1, faculté de médecine de Lyon, France
| | - Florent Wallet
- Service de Médecine Intensive Réanimation Anesthésie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France; Health Services and Performance Research - HESPER, Université Claude Bernard Lyon 1, Faculté de Médecine, Lyon, France.
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Patnaik S, Nathan S, Kar B, Gregoric ID, Li YP. The Role of Extracellular Heat Shock Proteins in Cardiovascular Diseases. Biomedicines 2023; 11:1557. [PMID: 37371652 DOI: 10.3390/biomedicines11061557] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
In the early 1960s, heat shock proteins (HSPs) were first identified as vital intracellular proteinaceous components that help in stress physiology and reprogram the cellular responses to enable the organism's survival. By the early 1990s, HSPs were detected in extracellular spaces and found to activate gamma-delta T-lymphocytes. Subsequent investigations identified their association with varied disease conditions, including autoimmune disorders, diabetes, cancer, hepatic, pancreatic, and renal disorders, and cachexia. In cardiology, extracellular HSPs play a definite, but still unclear, role in atherosclerosis, acute coronary syndromes, and heart failure. The possibility of HSP-targeted novel molecular therapeutics has generated much interest and hope in recent years. In this review, we discuss the role of Extracellular Heat Shock Proteins (Ec-HSPs) in various disease states, with a particular focus on cardiovascular diseases.
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Affiliation(s)
- Soumya Patnaik
- Division of Cardiology, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Sriram Nathan
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Biswajit Kar
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Yi-Ping Li
- Division of Integrative Biology and Pharmacology, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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Comparison of Short- and Long-Term Mortality in Patients with or without Cancer Admitted to the ICU for Septic Shock: A Retrospective Observational Study. Cancers (Basel) 2022; 14:cancers14133196. [PMID: 35804966 PMCID: PMC9264783 DOI: 10.3390/cancers14133196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 12/10/2022] Open
Abstract
Introduction: Cancer patients are at high risk of developing septic shock (SSh) and are increasingly admitted to ICU given their improved long-term prognosis. We, therefore, compared the prognosis of cancer and non-cancer patients with SSh. Methods: We conducted a monocentric, retrospective cohort study (2013−2019) on patients admitted to ICU for SSh. We compared the clinical characteristics and management and studied short- and long-term mortality with ICU and in-hospital mortality and 1-year survival according to cancer status. Results: We analyzed 239 ICU stays in 210 patients, 59.5% of whom were men (n = 125), with a median age of 66.5 (IQR 56.3−77.0). Of the 121 cancer patients (57.6% of all patients), 70 had solid tumors (33.3%), and 51 had hematological malignancies (24.3%). When comparing ICU stays of patients with versus without cancer (n = 148 vs. n = 91 stays, respectively), mortality reached 30.4% (n = 45) vs. 30.0% (n = 27) in the ICU (p = 0.95), and 41.6% (n = 59) vs. 35.6% (n = 32) in hospital (p = 0.36), respectively. ICU length of stay (LOS) was 5.0 (2.0−11.3) vs. 6.0 (3.0−15.0) days (p = 0.27), whereas in-hospital LOS was 25.5 (13.8−42.0) vs. 19.5 (10.8−41.0) days (p = 0.33). Upon multivariate analysis, renal replacement therapy (OR = 2.29, CI95%: 1.06−4.93, p = 0.03), disseminated intravascular coagulation (OR = 5.89, CI95%: 2.49−13.92, p < 0.01), and mechanical ventilation (OR = 7.85, CI95%: 2.90−21.20, p < 0.01) were associated with ICU mortality, whereas malignancy, hematological, or solid tumors were not (OR = 1.41, CI95%: 0.65−3.04; p = 0.38). Similarly, overall cancer status was not associated with in-hospital mortality (OR = 1.99, CI95%: 0.98−4.03, p = 0.06); however, solid cancers were associated with increased in-hospital mortality (OR = 2.52, CI95%: 1.12−5.67, p = 0.03). Lastly, mortality was not significantly different at 365-day follow-up between patients with and without cancer. Conclusions: In-hospital and ICU mortality, as well as LOS, were not different in SSh patients with and without cancer, suggesting that malignancies should no longer be considered a barrier to ICU admission.
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Hong Y, Kim WJ, Hong JY, Jeong YJ, Park J. A comprehensive analysis of 5-year outcomes in patients with cancer admitted to intensive care units. Tuberc Respir Dis (Seoul) 2022; 85:195-201. [PMID: 35045687 PMCID: PMC8987664 DOI: 10.4046/trd.2021.0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 01/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background The aim of this study was to evaluate the long-term (5-year) clinical outcomes of patients who received intensive care unit (ICU) treatment using Korean nationwide data. Methods All patients aged >18 years with ICU admission according to Korean claims data from January 2008 to December 2010 were enrolled. These enrolled patients were followed up until December 2015. The primary outcome was ICU mortality. Results Among all critically ill patients admitted to the ICU (n=323,765), patients with cancer showed higher ICU mortality (18.6%) than those without cancer (13.2%, p<0.001). However, there was no significant difference in ICU mortality at day 28 among patients without cancer (14.5%) and those with cancer (lung cancer or hematologic malignancies) (14.3%). Compared to patients without cancer, hazard ratios of those with cancer for ICU mortality at 5 years were: 1.90 (1.87–1.94) for lung cancer; 1.44 (1.43–1.46) for other solid cancers; and 3.05 (2.95–3.16) for hematologic malignancies. Conclusion This study showed that the long-term survival rate of patients with cancer was significantly worse than that of general critically ill patients. However, short term outcomes of critically ill patients with cancer were not significantly different from those of general patients, except for those with lung cancer or hematologic malignancies.
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Affiliation(s)
- Yoonki Hong
- Department of Internal Medicine, School of Medicine, Kangwon National University, Kangwon National University Hospital, Chuncheon 24289, Republic of Korea
| | - Woo Jin Kim
- Department of Internal Medicine, School of Medicine, Kangwon National University, Kangwon National University Hospital, Chuncheon 24289, Republic of Korea
| | - Ji Young Hong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Chuncheon Sacred Heart Hospital, Hallym University Medical Center, Chuncheon 24253, Republic of Korea
| | - Yun-Jeong Jeong
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang 10326, Republic of Korea
| | - Jinkyeong Park
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang 10326, Republic of Korea
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Dessie AS, Lanning M, Nichols T, Delgado EM, Hart LS, Agrawal AK. Patient Outcomes With Febrile Neutropenia Based on Time to Antibiotics in the Emergency Department. Pediatr Emerg Care 2022; 38:e259-e263. [PMID: 32941363 DOI: 10.1097/pec.0000000000002241] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Although bacteremia in pediatric oncology patients with febrile neutropenia (FN) is not uncommon, sepsis and mortality are rare. Because of the lack of clinically meaningful decision tools to identify high-risk patients with bacteremia, time to antibiotic administration (TTA) is increasingly considered an important quality and safety measure in the emergency department. Because little evidence exists suggesting that this benchmark is beneficial, we sought to determine whether TTA of 60 minutes or less is associated with improved outcomes. METHODS We retrospectively reviewed patients presenting to a pediatric emergency department with FN from November 2013 to June 2016. Clinical outcomes including mortality, pediatric intensive care unit admission, imaging, fluid resuscitation of 40 mL/kg or greater in the first 24 hours, and length of stay were compared between TTA of 60 minutes or less and more than 60 minutes. RESULTS One hundred seventy-nine episodes of FN were analyzed. The median TTA was 76 minutes (interquartile range, 58-105). The incidence of bacteremia was higher in patients with TTA of more than 60 minutes (12% vs 2%, P = 0.04), but without impact on mortality, pediatric intensive care unit admission, fluid resuscitation, or median length of stay. The median TTA was not different for those who were and were not bacteremic (91 vs 73 minutes, P = 0.11). CONCLUSIONS Time to antibiotic administration of more than 60 minutes did not increase mortality in pediatric oncology patients with FN. Our study adds to the existing literature that TTA of 60 minutes or less does not seem to improve outcomes in pediatric FN. Further larger studies are required to confirm these findings and determine which features predispose pediatric FN patients to morbidity and mortality.
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Affiliation(s)
| | - Miranda Lanning
- New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Tristan Nichols
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | | | | | - Anurag K Agrawal
- Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, CA
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İleri İ, Özsürekci C, Halil MG, Gündoğan K. NRS-2002 and mNUTRIC score: Could we predict mortality of hematological malignancy patients in the ICU? Nutr Clin Pract 2021; 37:1199-1205. [PMID: 34587327 DOI: 10.1002/ncp.10783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Malnutrition is a problem that greatly affects patients with hematological malignancy (HM) throughout the course of illness. Intensity of the malignancy treatment, inadequate energy intake, complex procedures such as hematopoietic stem cell transplantation, and treatment side effects are contributing factors for malnutrition in HM patients. The aim of this study was to compare the accuracy of the modified Nutrition Risk in Critically Ill (mNUTRIC) score and Nutrition Risk Screening 2002 (NRS-2002) in predicting hospital and long-term mortality of HM patients in the intensive care unit (ICU) and to identify effects of malnutrition on ICU mortality. METHODS This prospective observational cohort study was conducted in a university teaching hospital tertiary ICU service. During the study period, 112 HM patients who were >18 years old were admitted to the ICU. We excluded the patients who were discharged or died within 24 h from the statistical analysis. The patients were followed for 3 years after discharge for long-term mortality. RESULTS Twenty-nine patients died within 24 h of admission and were excluded from the study; therefore, statistical analysis was done for 81 patients. Logistic regression analysis demonstrated that high malnutrition risk, according to the NRS-2002 score, was associated with greater odds of ICU mortality (P = 0.002, odds ratio = 19.16). CONCLUSION In this study, we showed that NRS-2002 is superior to mNUTRIC score in predicting ICU mortality in patients with HMs. mNUTRIC score and NRS-2002 were not superior to each other in predicting long-term mortality.
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Affiliation(s)
- İbrahim İleri
- Internal Medicine Department, Division of Geriatrics, Hacettepe University School of Medicine, Ankara, Turkey
| | - Cemile Özsürekci
- Internal Medicine Department, Division of Geriatrics, Hacettepe University School of Medicine, Ankara, Turkey
| | - Meltem Gülhan Halil
- Internal Medicine Department, Division of Geriatrics, Hacettepe University School of Medicine, Ankara, Turkey
| | - Kürşat Gündoğan
- Internal Medicine Department, Division of Medical Intensive Care, Erciyes University School of Medicine, Kayseri, Turkey
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Leung KKY, Hon KL, Hui WF, Leung AK, Li CK. Therapeutics for paediatric oncological emergencies. Drugs Context 2021; 10:dic-2020-11-5. [PMID: 34234831 PMCID: PMC8232653 DOI: 10.7573/dic.2020-11-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/20/2021] [Indexed: 12/19/2022] Open
Abstract
Background With advancements in the field of oncology, cancer survival rates have improved dramatically but modern cancer treatments also come with an increasing number of disease and treatment-associated complications. This article provides an updated narrative review on the pathophysiology, clinical presentations and latest management strategies for common paediatric oncological emergencies. Methods An extensive PubMed® search of all human studies in the English literature was performed in Clinical Queries for different oncology syndromes and conditions using the following Medical Subject Headings: “tumour lysis syndrome”, “hyperleukocytosis”, “disseminated intravascular coagulation”, “superior mediastinal syndrome”, “superior vena cava syndrome”, “sepsis”, “severe inflammatory response syndrome”, “acute respiratory distress syndrome”, “posterior reversible encephalopathy syndrome” and “reversible posterior leukoencephalopathy syndrome”. Categories were limited to clinical trials and reviews for ages from birth to 18 years. Results The general description, presentation and management of these oncologic emergencies are systematically described. Early recognition along with prompt and proactive treatment can reduce the chances of potential complications and improve the clinical outcomes, thereby improving not only survival rates in oncology patients but also their clinical outcomes and quality of life. Conclusions Oncologic emergencies are associated with significant mortality and morbidity. Healthcare professionals involved with the care of oncology patients must be vigilant of these emergencies.
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Affiliation(s)
- Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Kam Lun Hon
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Wun Fung Hui
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Alexander Kc Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Chi Kong Li
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong.,Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong
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Shen J, Hu Y, Zhao H, Xiao Z, Zhao L, Du A, An Y. Risk factors of non-invasive ventilation failure in hematopoietic stem-cell transplantation patients with acute respiratory distress syndrome. Ther Adv Respir Dis 2021; 14:1753466620914220. [PMID: 32345137 PMCID: PMC7225805 DOI: 10.1177/1753466620914220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Non-invasive ventilation (NIV) was one of the first-line ventilation supports for hematopoietic stem-cell transplantation (HSCT) patients with acute respiratory distress syndrome (ARDS). Successful NIV may avoid need for intubation. However, the influence NIV failure had on patients’ outcome and its risk factors were hardly known. Methods: In this retrospective observational study, we reported risk factors and incidence of NIV failure in HSCT patients who were admitted to the Intensive Care Unit (ICU) with a diagnosis of ARDS and supported with mechanical ventilation, in a 5-year period. Patient outcomes, such as ventilator-free days, ICU-free days, and ICU mortality were also reported. Results: Of all the 94 patients included, 70 patients were initially supported with NIV. NIV failure occurred in 44 (63%) patients. Male sex, elevated serum galactomannan (GM) test, (1-3)-β-D-glucan (BG) assay, or elevated serum creatinine level were risk factors for NIV failure. When compared with the NIV success group, failure of NIV was associated with much fewer ICU-free days (22 versus 0, p < 0.001, Cohen’s d = 0.62) and higher ICU mortality (9.5% versus 75.5%, p < 0.001, Pearson’s r = 0.75). There was no difference in ICU-free days, ventilator-free days and ICU mortality between NIV failure and initial invasive mechanical ventilation (IMV) groups. Patients who failed in NIV support had a higher ICU mortality (75.5%) than those who succeeded (9.5%). Conclusion: In a small cohort of HSCT patients with mainly moderate severity of ARDS, male patients with elevated serum GM/BG test or serum creatinine level had a higher risk of NIV failure. Both NIV failure and initial IMV groups were characterized by high mortality rate and extremely low ICU-free days and ventilator-free days; failure of NIV support may further aggravate patient prognosis. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Jiawei Shen
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China
| | - Yan Hu
- Department of Respiratory and Critical Care Medicine, Peking University International Hospital, Beijing, People's Republic of China
| | - Huiying Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China
| | - Zengli Xiao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China
| | - Lianze Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China
| | - Anqi Du
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China
| | - Youzhong An
- Department of Critical Care Medicine, Peking Univeristy People's Hospital, Beijing 100044, People's Republic of China
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Sepsis and Septic Shock in Patients With Malignancies: A Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique Study. Crit Care Med 2021; 48:822-829. [PMID: 32317596 DOI: 10.1097/ccm.0000000000004322] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Cancer affects up to 20% of critically ill patients, and sepsis is one of the leading reasons for ICU admission in this setting. Early signals suggested that survival might be increasing in this population. However, confirmation studies have been lacking. The goal of this study was to assess trends in survival rates over time in cancer patients admitted to the ICU for sepsis or septic shock over the last 2 decades. DATA SOURCE Seven European ICUs. STUDY SELECTION A hierarchical model taking into account the year of admission and the source dataset as random variables was used to identify risk factors for day 30 mortality. DATA EXTRACTION Data from cancer patients admitted to ICUs for sepsis or septic shock were extracted from the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique database (1994-2015). DATA SYNTHESIS Overall, 2,062 patients (62% men, median [interquartile range] age 59 yr [48-67 yr]) were included in the study. Underlying malignancies were solid tumors (n = 362; 17.6%) or hematologic malignancies (n = 1,700; 82.4%), including acute leukemia (n = 591; 28.7%), non-Hodgkin lymphoma (n = 461; 22.3%), and myeloma (n = 244; 11.8%). Two-hundred fifty patients (12%) underwent allogeneic hematopoietic stem cell transplantation and 640 (31.0%) were neutropenic at ICU admission. Day 30 mortality was 39.9% (823 deaths). The year of ICU admission was associated with significant decrease in day 30 mortality over time (odds ratio, 0.96; 95% CI, 0.93-0.98; p = 0.001). Mechanical ventilation (odds ratio, 3.25; 95% CI, 2.52-4.19; p < 0.01) and vasopressors use (odds ratio, 1.42; 95% CI, 1.10-1.83; p < 0.01) were independently associated with day 30 mortality, whereas underlying malignancy, allogeneic hematopoietic stem cell transplantation, and neutropenia were not. CONCLUSIONS Survival in critically ill oncology and hematology patients with sepsis improved significantly over time. As outcomes improve, clinicians should consider updating admission policies and goals of care in this population.
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Ho K, Gordon J, Litzenberg KT, Exline MC, Englert JA, Herman DD. Cancer Is an Independent Risk Factor for Acute Respiratory Distress Syndrome in Critically Ill Patients: A Single Center Retrospective Cohort Study. J Intensive Care Med 2021; 37:385-392. [PMID: 33779386 DOI: 10.1177/08850666211005422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute Respiratory Distress Syndrome (ARDS) is a frequent cause of respiratory failure in intensive care unit (ICU) patients and results in significant morbidity and mortality. ARDS often develops as a result of a local or systemic inflammatory insult. Cancer can lead to systemic inflammation but whether cancer is an independent risk factor for developing ARDS is unknown. We hypothesized that critically ill cancer patients admitted to the ICU were at increased risk for the diagnosis of ARDS. METHODS Retrospective cohort study of critically ill patients admitted between July 2017 and December 2018 at an academic medical center in Columbus, Ohio. The primary outcome was the association of patients with malignancy and the diagnosis of ARDS in a multivariable logistic regression model with covariables selected a priori informed through the construction of a directed acyclic graph. RESULTS 412 ARDS cases were identified with 166 of those patients having active cancer. There was an association between cancer and ARDS, with an odds ratio (OR) of 1.55 (95% CI 1.26-1.92, P < 0.001). When adjusted for our pre-specified confounding variables, the association remained statistically significant (OR 1.57, 95% CI 1.15-2.13, P = 0.004). In an unadjusted pre-specified subgroup analysis, hematologic malignancy (OR 1.81, 95% CI 1.30-2.53, P < 0.001) was associated with increased odds of developing ARDS while non-metastatic solid tumors (OR 0.51, 95% CI 0.31-0.85, P = 0.01) had statistically significant negative association. Cancer patients with ARDS had a significantly higher ICU (70.5% vs 39.8%, P < 0.001) and hospital (72.9% vs 40.7%, P < 0.001) mortality compared to ARDS patients without active malignancy. CONCLUSION In this single center retrospective cohort study, cancer was found to be an independent risk factor for the diagnosis of ARDS in critically ill patients. To our knowledge, we are the first report an independent association between cancer and ARDS in critically ill patients.
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Affiliation(s)
- Kevin Ho
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua Gordon
- Division of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kevin T Litzenberg
- Division of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Matthew C Exline
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua A Englert
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Derrick D Herman
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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13
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Kim YJ, Seo DW, Kim WY. Types of cancer and outcomes in patients with cancer requiring admission from the emergency department: A nationwide, population-based study, 2016-2017. Cancer 2021; 127:2553-2561. [PMID: 33740270 DOI: 10.1002/cncr.33534] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Emergency department (ED) utilization and emergency admissions by patients with cancer have increased. The authors aimed to evaluate the characteristics of patients with cancer admitted through the ED and determine whether cancer types are related to in-hospital mortality. METHODS The National Emergency Department Information System database of patients visiting EDs in South Korea between 2016 and 2017 was analyzed. Among 6,179,088 adult patients who presented to an ED with nontraumatic medical illness, patients with cancer were identified. The primary outcome was in-hospital mortality. RESULTS Patients with cancer accounted for 6.8% of ED visits, and 239,630 patients (57.0%) were admitted to the hospital (intensive care unit [ICU], 9.5%; others, 90.5%). The prevalent cancers requiring hospitalization were lung cancer (15.7%), liver cancer (14.2%), and colon cancer (11.6%). The commonest reasons for admission other than cancer-related medical problems (41.4%) were pneumonia (4.8%) and hepatobiliary infection (2.8%). Overall in-hospital mortality was 16.1% (ICU, 28.3%; general wards, 14.8%); lung cancer (22.9%), liver cancer (19.7%), and leukemia/multiple myeloma (17.8%) showed the highest mortality rates. The highest odds for mortality were for lung cancer (adjusted odds ratio [OR], 2.227; 95% confidence interval [CI], 2.124-2.335; P < .001) and liver cancer (adjusted OR, 1.839; 95% CI, 1.751-1.930; P < .001), which were referenced to genitourinary cancer by multivariable logistic regression analysis. CONCLUSIONS More than half of the patients with cancer visiting EDs were admitted to the hospital with a mortality rate of 16.1%. Physicians treating patients with cancer and policymakers and planners designing health systems should understand the different prevalences and outcomes of oncological emergencies by cancer type to improve patient care.
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Affiliation(s)
- Youn-Jung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Woo Seo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Weinberger J, Rhee C, Klompas M. A Critical Analysis of the Literature on Time-to-Antibiotics in Suspected Sepsis. J Infect Dis 2021; 222:S110-S118. [PMID: 32691835 DOI: 10.1093/infdis/jiaa146] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The Surviving Sepsis Campaign recommends immediate antibiotics for all patients with suspected sepsis and septic shock, ideally within 1 hour of recognition. Immediate antibiotic treatment is lifesaving for some patients, but a substantial fraction of patients initially diagnosed with sepsis have noninfectious conditions. Aggressive time-to-antibiotic targets risk promoting antibiotic overuse and antibiotic-associated harms for this subset of the population. An accurate understanding of the precise relationship between time-to-antibiotics and mortality for patients with possible sepsis is therefore critical to finding the best balance between assuring immediate antibiotics for those patients who truly need them versus allowing clinicians some time for rapid investigation to minimize the risk of overtreatment and antibiotic-associated harms for patients who are not infected. More than 30 papers have been published assessing the relationship between time-to-antibiotics and outcomes, almost all of which are observational cohort studies. Most report significant associations but all have important limitations. Key limitations include focusing just on the sickest subset of patients (only patients requiring intensive care and/or patients with septic shock), blending together mortality estimates from patients with very long intervals until antibiotics with patients with shorter intervals and reporting a single blended (and thus inflated) estimate for the average increase in mortality associated with each hour until antibiotics, and failure to control for large potential confounders including patients' presenting signs and symptoms and granular measures of comorbidities and severity of illness. In this study, we elaborate on these potential sources of bias and try to distill a better understanding of what the true relationship between time-to-antibiotics and mortality may be for patients with suspected sepsis or septic shock.
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Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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15
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Diao X, Cai R, Luo J, Zheng Z, Zhan H. Prognostic factors for patients with multiple myeloma admitted to the intensive care unit. ACTA ACUST UNITED AC 2021; 25:433-437. [PMID: 33210963 DOI: 10.1080/16078454.2020.1845502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objectives: This study aimed to analyze clinical characteristics and outcomes of critically ill patients with multiple myeloma (MM) admitted to the intensive care unit (ICU) and identify predictors of poor short-term prognosis. Methods: Data for patients with MM admitted to the ICU were extracted from the Medical Information Mart for Intensive Care III database. The risk factors leading to the ICU and hospital mortality were evaluated using logistic regression analysis. Results: Of 126 patients identified, 17 (13.5%) and 37 (29.4%) died in the ICU and hospital, respectively. Patients with ICU mortality showed higher median blood urea nitrogen (57.0 vs. 29.0) and poorer Acute Physiology Scores (APS, 70.0 vs. 46.0) than did surviving patients on the day of ICU admission. In-ICU deceased patients had higher proportion of mechanical ventilation (64.7% vs. 26.6%) and vasopressor use (64.7% vs. 17.4%) at admission and positive pathogenic culture during ICU stay (58.8% vs. 19.3%). The APS and positive pathogenic culture were independent prognostic factors for ICU mortality, while risk factors for hospital mortality included higher APS and relapsed/refractory disease. Conclusion: The short-term prognoses for patients with MM admitted to the ICU were mainly determined by the severity of organ failure, infection, and disease status.
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Affiliation(s)
- Xiangwen Diao
- Department of Emergency, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Ruibin Cai
- Department of Emergency, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Jieyu Luo
- Department of Emergency, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Zhiwei Zheng
- Ping An Life Insurance of China, Shenzhen, Guangdong, People's Republic of China
| | - Hong Zhan
- Department of Emergency, Sun Yat-Sen University, Guangzhou, People's Republic of China
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Atis S, Cekmen B, Koylu R, Akilli N, Gunaydin Y, Koylu O, Cander B. Ionized calcium level predicts in-hospital mortality of severe sepsis patients: A retrospective cross-sectional study. JOURNAL OF ACUTE DISEASE 2021. [DOI: 10.4103/2221-6189.330743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Kim YJ, Kang J, Kim MJ, Ryoo SM, Kang GH, Shin TG, Park YS, Choi SH, Kwon WY, Chung SP, Kim WY. Development and validation of the VitaL CLASS score to predict mortality in stage IV solid cancer patients with septic shock in the emergency department: a multi-center, prospective cohort study. BMC Med 2020; 18:390. [PMID: 33308206 PMCID: PMC7733739 DOI: 10.1186/s12916-020-01875-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/26/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinical decision-making of invasive high-intensity care for critically ill stage IV cancer patients in the emergency department (ED) is challenging. A reliable and clinically available prognostic score for advanced cancer patients with septic shock presented at ED is essential to improve the quality of intensive care unit care. This study aimed to develop a new prognostic score for advanced solid cancer patients with septic shock available early in the ED and to compare the performance to the previous severity scores. METHODS This multi-center, prospective cohort study included consecutive adult septic shock patients with stage IV solid cancer. A new scoring system for 28-day mortality was developed and validated using the data of development (January 2016 to December 2017; n = 469) and validation sets (January 2018 to June 2019; n = 428). The developed score's performance was compared to that of the previous severity scores. RESULTS New scoring system for 28-day mortality was based on six variables (score range, 0-8): vital signs at ED presentation (respiratory rate, body temperature, and altered mentation), lung cancer type, and two laboratory values (lactate and albumin) in septic shock (VitaL CLASS). The C-statistic of the VitaL CLASS score was 0.808 in the development set and 0.736 in the validation set, that is superior to that of the Sequential Organ Failure Assessment score (0.656, p = 0.01) and similar to that of the Acute Physiology and Chronic Health Evaluation II score (0.682, p = 0.08). This score could identify 41% of patients with a low-risk group (observed 28-day mortality, 10.3%) and 7% of patients with a high-risk group (observed 28-day mortality, 73.3%). CONCLUSIONS The VitaL CLASS score could be used for both risk stratification and as part of a shared clinical decision-making strategy for stage IV solid cancer patients with septic shock admitting at ED within several hours.
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Affiliation(s)
- Youn-Jung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Jihoon Kang
- Department of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, South Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Gu Hyun Kang
- Department of Emergency Medicine, Hallym University College of Medicine, Seoul, South Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Guro Hospital, Korea University Medical Center, Seoul, South Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olimpic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
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Platelet-lymphocyte Ratio After Granulocyte Colony Stimulating Factor Administration: an Early Prognostic Marker in Septic Shock Patients With Chemotherapy-Induced Febrile Neutropenia. Shock 2020; 52:160-165. [PMID: 30148761 DOI: 10.1097/shk.0000000000001256] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Chemotherapy-induced febrile neutropenia (FN) causes life-threatening complications, but little is known in septic shock patients with FN. The aim of this study was to investigate the prognostic value of inflammatory markers, including C-reactive protein level, immature granulocyte count, white blood cell (WBC) count, absolute neutrophil count (ANC), neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR), in septic shock patients with FN at admission and after granulocyte colony-stimulating factor (G-CSF) administration. METHODS Data on consecutive adult septic shock patients with FN treated with G-CSF between June 2012 and June 2017 were extracted from a prospectively compiled septic shock registry. Clinical and serial laboratory data at admission and <24 h after G-CSF administration were compared between nonsurvivor and 1-month survivor groups. RESULTS Of 1,671 septic shock patients, 158 FN patients were treated with G-CSF and 114 (72.2%) survived for 1 month. At admission, no clinical and serial laboratory data were significant to predict survival. After G-CSF administration, PLR and APACHE II were independent predictors for 1-month survival. PLR after administration of G-CSF >100 (adjusted odds ratio [aOR], 9.394; 95% CI, 2.821-31.285, P < 0.001) showed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 89.4%, 46.2%, 82.9%, and 60.0%, respectively, and APACHE II <28 (aOR, 6.944; 95% CI, 2.351-20.511, P < 0.001) showed sensitivity, specificity, PPV, and NPV of 86.8%, 63.6%, 86.1%, and 65.1%, respectively. CONCLUSIONS After G-CSF administration in septic shock patients with chemotherapy-induced FN, PLR may be used as an early prognostic marker for mortality.
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Intensive Care Outcomes of Patients after High Dose Chemotherapy and Subsequent Autologous Stem Cell Transplantation: A Retrospective, Single Centre Analysis. Cancers (Basel) 2020; 12:cancers12061678. [PMID: 32599837 PMCID: PMC7352739 DOI: 10.3390/cancers12061678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/17/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022] Open
Abstract
High dose chemotherapy (HDT) followed by autologous peripheral blood stem cell transplantation (ASCT) is standard of care including a curative treatment option for several cancers. While much is known about the management of patients with allogenic SCT at the intensive care unit (ICU), data regarding incidence, clinical impact, and outcome of critical illness following ASCT are less reported. This study included 256 patients with different cancer entities. Median age was 56 years (interquartile ranges (IQR): 45–64), and 67% were male. One-year survival was 89%; 15 patients (6%) required treatment at the ICU following HDT. The main reason for ICU admission was septic shock (80%) with the predominant focus being the respiratory tract (53%). Three patients died, twelve recovered, and six (40%) were alive at one-year, resulting in an immediate treatment-related mortality of 1.2%. Independent risk factors for ICU admission were age (odds ratio (OR) 1.05; 95% confidence interval (CI) 1.00–1.09; p = 0.043), duration of aplasia (OR: 1.37; CI: 1.07–1.75; p = 0.013), and Charlson comorbidity score (OR: 1.64; CI: 1.20–2.23; p = 0.002). HDT followed by ASCT performed at an experienced centre is generally associated with a low risk for treatment related mortality. ICU treatment is warranted mainly due to infectious complications and has a strong positive impact on intermediate-term survival.
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Lactated Ringer's Versus 4% Albumin on Lactated Ringer's in Early Sepsis Therapy in Cancer Patients: A Pilot Single-Center Randomized Trial. Crit Care Med 2020; 47:e798-e805. [PMID: 31356475 DOI: 10.1097/ccm.0000000000003900] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate the effects of the administration of 4% albumin on lactated Ringer's, when compared with lactated Ringer's alone, in the early phase of sepsis in cancer patients. DESIGN Single-center, randomized, double-blind, controlled-parallel trial. SETTING A tertiary care university cancer hospital. PATIENTS Cancer patients with severe sepsis or septic shock. INTERVENTIONS Between October 2014 and December 2016, patients were randomly assigned to receive either bolus of albumin in a lactated Ringer's solution or lactated Ringer's solution alone during the first 6 hours of fluid resuscitation after intensive care medicine (ICU) admission. Primary outcome was defined as death from any cause at 7 days. Secondary outcomes were defined as death from any cause within 28 days, change in Sequence Organ Failure Assessment scores from baseline to day 7, days alive and free of mechanical ventilation, days alive and free of vasopressor, renal replacement therapy during ICU stay, and length of ICU and hospital stay. MEASUREMENTS AND MAIN RESULTS A total of 360 patients were enrolled in the trial. At 7 days, 46 of 180 patients (26%) died in the albumin group and 40 of 180 (22%) died in the lactated Ringer's group (p = 0.5). At 28 days, 96 of 180 patients (53%) died in the albumin group and 83 of 180 (46%) died in the lactated Ringer's group (p = 0.2). No significant differences in secondary outcomes were observed. CONCLUSIONS Adding albumin to early standard resuscitation with lactated Ringer's in cancer patients with sepsis did not improve 7-day survival.
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Epidemiology and Outcomes of Cancer-Related Versus Non-Cancer-Related Sepsis Hospitalizations. Crit Care Med 2020; 47:1310-1316. [PMID: 31356477 DOI: 10.1097/ccm.0000000000003896] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Cancer and its treatment are known to be important risk factors for sepsis, contributing to an estimated 12% of U.S. sepsis admissions in the 1990s. However, cancer treatment has evolved markedly over the past 2 decades. We sought to examine how cancer-related sepsis differs from non-cancer-related sepsis. DESIGN Observational cohort. SETTING National Readmissions Database (2013-2014), containing all-payer claims for 49% of U.S. POPULATION PATIENTS A total of 1,104,363 sepsis hospitalizations. INTERVENTIONS We identified sepsis hospitalizations in the U.S. National Readmissions Database using explicit codes for severe sepsis, septic shock, or Dombrovskiy criteria (concomitant codes for infection and organ dysfunction). We classified hospitalizations as cancer-related versus non-cancer-related sepsis based on the presence of secondary diagnosis codes for malignancy. We compared characteristics (site of infection and organ dysfunction) and outcomes (in-hospital mortality and 30-d readmissions) of cancer-related versus non-cancer-related sepsis hospitalizations. We also completed subgroup analyses by age, cancer types, and specific cancer diagnoses. MEASUREMENTS AND MAIN RESULTS There were 27,481,517 hospitalizations in National Readmissions Database 2013-2014, of which 1,104,363 (4.0%) were for sepsis and 4,150,998 (15.1%) were cancer related. In-hospital mortality in cancer-related sepsis was 27.9% versus 19.5% in non-cancer-related sepsis. The median count of organ dysfunctions was indistinguishable, but the rate of specific organ dysfunctions differed by small amounts (e.g., hematologic dysfunction 20.1% in cancer-related sepsis vs 16.6% in non-cancer-related sepsis; p < 0.001). Cancer-related sepsis was associated with an adjusted absolute increase in in-hospital mortality ranging from 2.2% to 15.2% compared with non-cancer-related sepsis. The mortality difference was greatest in younger adults and waned with age. Patients (23.2%) discharged from cancer-related sepsis were rehospitalized within 30 days, compared with 20.1% in non-cancer-related sepsis (p < 0.001). CONCLUSIONS In this cohort of over 1 million U.S. sepsis hospitalizations, more than one in five were cancer related. The difference in mortality varies substantially across age spectrum and is greatest in younger adults. Readmissions were more common after cancer-related sepsis.
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Antibiotic prescribing and outcomes in cancer patients with febrile neutropenia in the emergency department. PLoS One 2020; 15:e0229828. [PMID: 32109264 PMCID: PMC7048306 DOI: 10.1371/journal.pone.0229828] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 02/16/2020] [Indexed: 01/26/2023] Open
Abstract
Introduction The benefit of reducing the time of antibiotic initiation in the emergency department (ED) for neutropenic patients is controversial and the research on the impact of antibiotic adherence to international guidelines in the ED is scarce. We aimed to investigate the effect of antibiotic timing and appropriateness on outcomes in patients with febrile neutropenia (FN) and to assess the performance of the MASCC risk-index to risk-stratify such patients in the ED. Methods We prospectively identified patients with FN who presented to our ED and assessed their Multinational Association of Supportive Care in Cancer (MASCC) risk-index. The time to parenteral antibiotic initiation and the appropriateness of the antibiotic regimen according to international guidelines were retrospectively abstracted. The performance of the MASCC risk-index in predicting the absence of complication was assessed with sensitivity, specificity and the area under the receiver operating characteristics curve (AUC). We investigated the effect of the time to antibiotic initiation and the appropriateness of the antibiotic regimen on the outcome (ICU admission or death) by logistic regression analyses. Results We included 249 patients. Median age was 60 years and 67.9% had hematological malignancies, 26 (10.4%) were admitted to the ICU and 23 (9.8%) died during hospital stay. Among the 173 patients at low risk according to the MASCC risk-index, 56 (32.4%) presented at least one complication including 11 deaths. The MASCC risk-index had a sensitivity and a specificity of 0.78% and 0.43%, respectively, in predicting the absence of complication and the AUC was 0.67. The time to antibiotic initiation in the ED was not associated with the outcome after adjusting for performance status and shock-index. Conversely, an inadequate ED antibiotic regimen was associated with higher ICU admission or death during hospital stay (OR = 3.50; 95% CI = 1.49 to 8.28). Conclusion An inadequate ED antibiotic regimen in patients with FN was significantly associated with higher ICU admission or death during hospital stay.
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Cherkaoui A, Renzi G, Azam N, Schorderet D, Vuilleumier N, Schrenzel J. Rapid identification by MALDI-TOF/MS and antimicrobial disk diffusion susceptibility testing for positive blood cultures after a short incubation on the WASPLab. Eur J Clin Microbiol Infect Dis 2020; 39:1063-1070. [PMID: 31965365 DOI: 10.1007/s10096-020-03817-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/12/2020] [Indexed: 12/19/2022]
Abstract
The objectives of this study were to define the shortest incubation times on the WASPLab for reliable MALDI-TOF/MS-based species identification and for the preparation of a 0.5 McFarland suspension for antimicrobial disk diffusion susceptibility testing using short subcultures growing on solid culture media inoculated by positive blood cultures spiked with a wide range of pathogens associated with bloodstream infections. The 520 clinical strains (20 × 26 different species) included in this study were obtained from a collection of non-consecutive and non-duplicate pathogens identified at Geneva University Hospitals. After 4 h of incubation on the WASPLab, microorganisms' growth allowed accurate identification of 73% (380/520) (95% CI, 69.1-76.7%) of the strains included in this study. The identification rate increased to 85% (440/520) (95% CI, 81.3-87.5%) after 6-h incubation. When excluding Corynebacterium and Candida spp., the microbial growth was sufficient to permit accurate identification of all tested species (100%, 460/460) (95% CI, 99.2-100%) after 8-h incubation. With the exception of Burkholderia cepacia and Haemophilus influenzae, AST by disk diffusion could be performed for Enterobacterales and non-fermenting Gram-negative bacilli after only 4 h of growth in the WASPLab. The preparation of a 0.5 McFarland suspension for Gram-positive bacteria required incubation times ranging between 3 and 8 h according to the bacterial species. Only Corynebacterium spp. required incubation times as long as 16 h. The WASPLab enables rapid pathogen identification as well as swift comprehensive AST from positive blood cultures that can be implemented without additional costs nor hands-on time by defining optimal time points for image acquisition.
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Affiliation(s)
- Abdessalam Cherkaoui
- Department of Diagnostics, Bacteriology Laboratory, Division of Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland.
| | - Gesuele Renzi
- Department of Diagnostics, Bacteriology Laboratory, Division of Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Nouria Azam
- Department of Diagnostics, Bacteriology Laboratory, Division of Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Didier Schorderet
- Department of Diagnostics, Bacteriology Laboratory, Division of Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
| | - Nicolas Vuilleumier
- Department of Diagnostics, Division of Laboratory Medicine, Geneva University Hospitals, Geneva, Switzerland.,Department of Medical Specialities, Division of Laboratory Medicine, Faculty of Medicine, Geneva, Switzerland
| | - Jacques Schrenzel
- Department of Diagnostics, Bacteriology Laboratory, Division of Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland.,Department of Medicine, Genomic Research Laboratory, Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Siddiqui SS, Narkhede AM, Kulkarni AP, Prabu NR, Chaudhari HK, Sarode SV, Divatia JV. Evaluation and Validation of Four Scoring Systems: the APACHE IV, SAPS III, MPM0 II, and ICMM in Critically Ill Cancer Patients. Indian J Crit Care Med 2020; 24:263-269. [PMID: 32565637 PMCID: PMC7297244 DOI: 10.5005/jp-journals-10071-23407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and aims To evaluate and validate four severity-of-illness scores, acute physiology and chronic health evaluation IV (APACHE IV), simplified acute physiology score III (SAPS III), mortality probability models II at 0 hours (MPM0 II), and ICU cancer mortality model (ICMM), in a prospective cohort of critically ill cancer patients. Materials and methods Single-center, prospective observational study performed in a 14-bedded combined medical–surgical ICU of a tertiary care cancer center of India, from July 2014 to November 2015. Score performance was judged by discrimination and calibration, using the area under receiver–operating characteristics (ROC) curve and Hosmer–Lemeshow goodness-of-fit test, respectively. Results A total of 431 patients were included in the study. Intensive care unit (ICU) and hospital mortality were 37.4% and 41.1%, respectively. The area under ROC curve for APACHE IV, SAPS III, MPM0 II, and ICMM were 0.73, 0.70, 0.67, and 0.67, respectively. Calibration as calculated by Hosmer–Lemeshow analysis type C statistics for APACHE IV, SAPS III, MPM0 II, and ICMM shows good calibration with Chi-square values of 5.32, 9.285, 9.873, and 9.855 and p values of 0.723, 0.319, 0.274, and 0.275, respectively. Conclusion All the four models had moderate discrimination and good calibration. However, none of the mortality prediction models could accurately discriminate between survivors and nonsurvivors in our patients. How to cite this article Siddiqui SS, Narkhede AM, Kulkarni AP, Prabu NR, Chaudhari HK, Divatia JV, et al. Evaluation and Validation of Four Scoring Systems: the APACHE IV, SAPS III, MPM0 II, and ICMM in Critically Ill Cancer Patients. Indian J Crit Care Med 2020;24(4):263–269.
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Affiliation(s)
- Suhail S Siddiqui
- Department of Critical Care Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Amit M Narkhede
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Natesh R Prabu
- Department of Critical Care Medicine, St John's Medical College, Bengaluru, Karnataka, India
| | - Harish K Chaudhari
- Department of Critical Care, Arneja Heart and Multispeciality Hospital, Nagpur, Maharashtra, India
| | - Satish V Sarode
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jigeeshu V Divatia
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Rasheed M, Khan YH, Mujtaba G, Mallhi TH, Saadullah M, Saifullah A. Assessment of clinical features and determinants of mortality among cancer patients with septic shock of pulmonary origin: a prospective analysis. Postgrad Med J 2019; 96:277-285. [PMID: 31685679 DOI: 10.1136/postgradmedj-2019-136987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/04/2019] [Accepted: 10/11/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pneumonia-associated septic shock (PASS) in patients with cancer inflicts healthcare burden attributed to high morbidity and mortality. Current study was aimed to evaluate the clinical outcomes, microbiological characteristics, risk factors and impact of life-support interventions on 28-day mortality among cancer patients with PASS. METHODS A prospective observational study was conducted among cancer patients with PASS admitted to intensive care unit (ICU) of 'Shaukat Khanum Memorial Cancer Hospital'. Data were analysed using appropriate statistical methods. RESULTS Out of 100 patients who sought medical care during the study period, 59 (59%) were male and majority had solid tumour than haematological malignancies (68% vs 32%). Nosocomial pneumonia was most frequent (90%) followed by healthcare-associated pneumonia (HCAP) (9%) and community-acquired pneumonia (CAP) (1%). The most common causative pathogen was Pseudomonas aeruginosa, 21 (32%). Overall mortality rate was 76% including 15% hospital and 61% ICU mortality. Sequential Organ Failure Assessment (SOFA) score at first day (HR 3.8; 95% CI 1.7 to 8.9; p=0.002), SOFA score at seventh day (HR 8.9; 95% CI 3.6 to 22.7; p=<0.001), invasive mechanical ventilation (HR 8.0; 95% CI 3.2 to 20; p<0.001) and performance status (HR 5.4; 95% CI 2.5 to 11.3; p<0.001) were found to be independently associated with 28-day mortality. Receiver operating characteristic curve analysis accentuates the excellent predictive accuracy of Cox regression model for mortality indicated by area under the curve of 0.892 (95% CI 0.801 to 0.983, p<0.001). CONCLUSION Our analysis demonstrates substantial mortality associated with PASS among patients with cancer. Timely recognition of patients with high predilection of increased mortality could be of value in improving the disease burden.
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Affiliation(s)
- Maria Rasheed
- Institute of Pharmacy, Lahore College for Women University, Lahore, Punjab, Pakistan
| | - Yusra Habib Khan
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka, Al-Jouf, Kingdom of Saudi Arabia
| | - Ghulam Mujtaba
- Department of Pharmacy, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan
| | - Tauqeer Hussain Mallhi
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka, Al-Jouf, Kingdom of Saudi Arabia
| | - Malik Saadullah
- Department of Pharmaceutical Chemistry, Faculty of Pharmaceutical Sciences, Government College University Faisalabad, Faisalabad, Punjab, Pakistan
| | - Amna Saifullah
- Institute of Pharmacy, Lahore College for Women University, Lahore, Punjab, Pakistan
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Cheepcharoenrat C. The Result of Treatment of Deep Neck Infection in Patients Referred According to Public Health System. EAR, NOSE & THROAT JOURNAL 2019; 99:627-632. [PMID: 31637950 DOI: 10.1177/0145561319881856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There are many factors that result in the treatment of deep neck infection (DNI). This study aims to compare the results of DNI treatment between referred and walk-in patients. This retrospective cohort study reviewed the data of 282 DNI patients. The peritonsillar abscesses and limited intraoral abscesses were excluded. The outcome of treatment such as duration of hospital stay, the expense of treatment, morbidity, and mortality were reviewed during staying in the hospital. A total of 282 patients were included in this study, there were 152 referred patients and 130 walk-in patients. Patients who were sent to have treatment results were not significantly different from those who had come directly to the hospital regardless of the length of stay, the cost of medical treatment, complications, and death due to complications with sepsis (P = .013). However, the referred patients exhibited a risk to have sepsis 1.1 times more than the patients who went straight to the medical specialists (univariate analysis risk ratio [RR]: 1.1, 95% confidence interval [CI]: 0.8-1.3; P = .620). The results were confirmed in the multivariate analysis after adjusting for age, gender, diabetes, chronic renal failure, cirrhosis, and dental care. It was found that the risk to have sepsis in the "refer in" group was 1.1 times more than the other group (multivariate analysis RR: 1.1, 95% CI: 0.8-1.3; P = .658). In conclusion, the results of treatment in referred patients were not different from walk-in patients. Deep neck infection patients at hospitals that do not have a specialized doctor will receive appropriate treatment because of the effective DNI referral system according to public health systems. However, in referred patients, sepsis should be maintained prior to delivery.
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Affiliation(s)
- Chuan Cheepcharoenrat
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Education Center 67968Chiangrai Prachnukroh Hospital, Chiang Rai, Thailand
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Pardo E, Lemiale V, Mokart D, Stoclin A, Moreau AS, Kerhuel L, Calvet L, Valade S, De Jong A, Darmon M, Azoulay E. Invasive pulmonary aspergillosis in critically ill patients with hematological malignancies. Intensive Care Med 2019; 45:1732-1741. [PMID: 31599334 DOI: 10.1007/s00134-019-05789-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 09/17/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE Invasive pulmonary aspergillosis (IPA) is a dreadful event in patients with hematological malignancies (HM). Recent advances have standardized diagnostic, prophylactic and curative therapeutic strategies. We sought to assess whether these advances actually translate into improved survival in critically ill patients with acute respiratory failure and IPA. METHODS This was a retrospective, multicenter study. Adult patients with HM, IPA, admitted to the ICU for acute respiratory failure over a 20-year period (January 1998-December 2017) were included. A cox regression model was used to identify variables independently associated with day-90 survival. RESULTS Overall, 219 patients were included [138 (63%) men, median age 55 (IQR 44-64)]. Acute myeloid leukemia (30.1%) and non-Hodgkin lymphoma (22.8%) were the most frequent malignancies, and 53 (24.2%) were allogeneic stem cell recipients. Day-1 SOFA score was 9 [7-12]. Most patients presented with probable IPA, whereas 15 (7%) underwent lung biopsies or pleurocentesis and met criteria for proven IPA. Overall ICU and day-90 mortality were, respectively, 58.4% and 75.2% (80.4% if invasive mechanical ventilation) without any significant improvement over time. By multivariable analysis adjusted on day-1 SOFA score and ventilation strategies, voriconazole use (HR 0.49, CI 95 0.34-0.73, p < 0.001) and an ICU admission after 2010 (HR 0.67, 0.45-0.99, p = 0.042) were associated with increased survival, whereas a diffuse radiologic pattern (HR 2.07, CI 95 1.33-3.24, p = 0.001) and delayed admission to the ICU (HR 1.51, CI 95 1.05-2.16, p = 0.026) were independently associated with increased mortality. CONCLUSIONS IPA is associated with high mortality rates in critically ill patients with acute respiratory failure. Routine voriconazole and prompt ICU admission are warranted.
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Affiliation(s)
- Emmanuel Pardo
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Virginie Lemiale
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France
| | | | | | | | - Lionel Kerhuel
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Laure Calvet
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Sandrine Valade
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Audrey De Jong
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Michael Darmon
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153, (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris, France
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France. .,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France. .,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153, (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris, France.
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Bazhenov AV, Galstyan GM, Parovichnikova EN, Troitskaya VV, Kuzmina LA, Fidarova ZT, Gribanova EO, Makhinya SA, Latyshkevich OA, Chabaeva UA, Kulikov SM, Savchenko VG. [Role of the intensive care in treatment of patients with acute myeloid leukemia]. TERAPEVT ARKH 2019; 91:14-24. [PMID: 32598731 DOI: 10.26442/00403660.2019.07.000321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
AIM Remission induction can be associate, with the life threatening complications and transfer to ICU of de novo acute myeloid leukemia (AML) patients (pts). We evaluate influence of transfer to ICU and life threatening complication on early mortality and long - tram survival of de novo AML pts. MATERIALS AND METHODS Retrospective study. All de novo AML pts younger than 60 years old admitted in the National Research Center for Hematology from 2013 to 2016 years were enrolled in the study. Patients were divided into 2 groups: pts who were required ICU admission during remission induction (ICU-pts) and pts who did not require ICU admission and received chemotherapy only in hematology ward (non-ICU pts). The reasons for ICU admissions and results of life support were analyzed. Overall survival (OS) were assessed by the Kaplan-Meier method, long rank value p.
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Collart C, Moro-Sibilot D, Maignan M, Schwebel C, Giaj Levra M, Ferrer L, Paquier C, Viglino D, Toffart AC. [Emergency room management of patients with lung cancer and organ failure]. Rev Mal Respir 2019; 36:672-678. [PMID: 31255316 DOI: 10.1016/j.rmr.2019.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 03/23/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND When patients with lung cancer present to the emergency department with organ failure the question of admission to intensive care has to be considered. Our aim is to describe the process leading to the proposed management. METHODS Retrospectively, all patients admitted to the emergency room between December 2010 and January 2015 with a diagnosis of ICD-10 C34.9 (lung cancer) were reviewed. Those with at least one organ failure were included. RESULTS The records of 561 patients were reviewed, 79 (14%) had at least one organ failure. The majority of these patients received maximal medical care (59%), 25% exclusive palliative care, and 15% intensive care. Performance status, metastatic status and efficacy of anti-tumor treatment were recorded in the emergency medical record in 20%, 66% and 74% of cases, respectively. An opinion was obtained from the oncologist in 44% of cases and from the intensivist in 41% of cases. No external advice was provided in 27% of cases. CONCLUSION In the majority of cases, the decision on the intensity of care to be provided to patients with lung cancer and organ failure was made in a collective manner.
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Affiliation(s)
- C Collart
- Service d'accueil des urgences, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - D Moro-Sibilot
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - M Maignan
- Service d'accueil des urgences, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France; Inserm U1042, laboratoire hypoxie physiopathologie, université Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - C Schwebel
- Clinique universitaire de médecine intensive et réanimation, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France; Inserm U1039, biocliniques radiopharmaceutiques, université Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - M Giaj Levra
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - L Ferrer
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - C Paquier
- Service d'accueil des urgences, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - D Viglino
- Service d'accueil des urgences, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France; Inserm U1042, laboratoire hypoxie physiopathologie, université Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - A-C Toffart
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France; Inserm U 1209, CNRS UMR 5309, centre de recherche UGA, institut pour l'avancée des biosciences, 38700 La Tronche, France.
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Camou F, Didier M, Leguay T, Milpied N, Daste A, Ravaud A, Mourissoux G, Guisset O, Issa N. Long-term prognosis of septic shock in cancer patients. Support Care Cancer 2019; 28:1325-1333. [PMID: 31243586 DOI: 10.1007/s00520-019-04937-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 06/11/2019] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Fabrice Camou
- Intensive Care and Infectious Disease Unit, CHU Bordeaux, 33000, Bordeaux, France
| | - Marion Didier
- Intensive Care and Infectious Disease Unit, CHU Bordeaux, 33000, Bordeaux, France
| | | | - Noël Milpied
- Hematology, CHU Bordeaux, 33000, Bordeaux, France
| | | | | | - Gaëlle Mourissoux
- Intensive Care and Infectious Disease Unit, CHU Bordeaux, 33000, Bordeaux, France
| | - Olivier Guisset
- Intensive Care and Infectious Disease Unit, CHU Bordeaux, 33000, Bordeaux, France
| | - Nahéma Issa
- Intensive Care and Infectious Disease Unit, CHU Bordeaux, 33000, Bordeaux, France. .,Hôpital Saint-André, 1 rue Jean Burguet, 33075, Bordeaux, France.
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Constantinescu C, Bodolea C, Pasca S, Teodorescu P, Dima D, Rus I, Tat T, Achimas-Cadariu P, Tanase A, Tomuleasa C, Einsele H. Clinical Approach to the Patient in Critical State Following Immunotherapy and/or Stem Cell Transplantation: Guideline for the On-Call Physician. J Clin Med 2019; 8:jcm8060884. [PMID: 31226876 PMCID: PMC6616972 DOI: 10.3390/jcm8060884] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 12/11/2022] Open
Abstract
The initial management of the hematology patient in a critical state is crucial and poses a great challenge both for the hematologist and the intensive care unit (ICU) physician. After years of clinical practice, there is still a delay in the proper recognition and treatment of critical situations, which leads to late admission to the ICU. There is a much-needed systematic ABC (Airway, Breathing, Circulation) approach for the patients being treated on the wards as well as in the high dependency units because the underlying hematological disorder, as well as disease-related complications, have an increasing frequency. Focusing on score-based decision-making on the wards (Modified Early Warning Score (MEWS), together with Quick Sofa score), active sepsis screening with inflammation markers (C-reactive protein, procalcitonin, and presepsin), and assessment of microcirculation, organ perfusion, and oxygen supply by using paraclinical parameters from the ICU setting (lactate, central venous oxygen saturation (ScVO2), and venous-to-arterial carbon dioxide difference), hematologists can manage the immediate critical patient and improve the overall outcome.
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Affiliation(s)
- Catalin Constantinescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
- Intensive Care Unit, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
| | - Constantin Bodolea
- Department of Anesthesia, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
| | - Sergiu Pasca
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
| | - Patric Teodorescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
| | - Ioana Rus
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
| | - Tiberiu Tat
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
| | - Patriciu Achimas-Cadariu
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
| | - Alina Tanase
- Department of Stem Cell Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania.
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania.
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania.
- Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Victor Babes Street, 400124 Cluj Napoca, Romania.
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Wuerzburg, 97070 Wuerzburg, Germany.
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Rathi NK, Haque SA, Morales F, Kaul B, Ramirez R, Ovu S, Feng L, Dong W, Price KJ, Ugarte S, Raimondi N, Quintero A, Cardenas YR, Nates JL. Variability in triage practices for critically ill cancer patients: A randomized controlled trial. J Crit Care 2019; 53:18-24. [PMID: 31174172 DOI: 10.1016/j.jcrc.2019.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 05/10/2019] [Accepted: 05/27/2019] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Nisha K Rathi
- Department of Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 112, Houston, TX 77030, United States of America.
| | - Sajid A Haque
- Department of Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 112, Houston, TX 77030, United States of America.
| | - Freddy Morales
- Hospital Oncológico "Dr. Julio Villacreses Colmont" SOLCA Manabí, Núcleo de Portoviejo, Autopista del Valle Manabí Guillen en Portoviejo, Manibi, Ecuador
| | - Bhavika Kaul
- Department of Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 112, Houston, TX 77030, United States of America.
| | - Rafael Ramirez
- Department of Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 112, Houston, TX 77030, United States of America.
| | - Steven Ovu
- Department of Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 112, Houston, TX 77030, United States of America.
| | - Lei Feng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America.
| | - Wenli Dong
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America.
| | - Kristen J Price
- Department of Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 112, Houston, TX 77030, United States of America.
| | - Sebastian Ugarte
- INDISA Clinic, Salvador's Hospital, Avenida Santa Maria 1810, Providencia Region Metropolitana, Santiago, Chile
| | - Nestor Raimondi
- Juan A. Fernandez Hospital, Cervino 3356, C1425AGP CABA, Buenos Aires, Argentina
| | | | - Yenny R Cardenas
- Critical Care Department, Universidad del Rosario, Hospital Universitario Fundacion Santa Fe de Bogota, Carrera 7 No. 117 - 15, Bogota DC, Colombia
| | - Joseph L Nates
- Department of Critical Care, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 112, Houston, TX 77030, United States of America.
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Peltan ID, Brown SM, Bledsoe JR, Sorensen J, Samore MH, Allen TL, Hough CL. ED Door-to-Antibiotic Time and Long-term Mortality in Sepsis. Chest 2019; 155:938-946. [PMID: 30779916 DOI: 10.1016/j.chest.2019.02.008] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 01/28/2019] [Accepted: 02/01/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The impact of antibiotic timing on sepsis outcomes remains controversial due to conflicting results from previous studies. OBJECTIVES This study investigated the association of door-to-antibiotic time with long-term mortality in ED patients with sepsis. METHODS This retrospective cohort study included nontrauma adult ED patients with clinical sepsis admitted to four hospitals from 2013 to 2017. Only patients' first eligible encounter was included. Multivariable logistic regression was used to measure the adjusted association between door-to-antibiotic time and 1-year mortality. Secondary analyses used alternative antibiotic timing measures (antibiotic initiation within 1 or 3 h and separate comparison of antibiotic exposure at each hour up to hour 6), alternative outcomes (hospital, 30-day, and 90-day mortality), and alternative statistical methods to mitigate indication bias. RESULTS Among 10,811 eligible patients, median door-to-antibiotic time was 166 min (interquartile range, 115-230 min), and 1-year mortality was 19%. After adjustment, each additional hour from ED arrival to antibiotic initiation was associated with a 10% (95% CI, 5-14; P < .001) increased odds of 1-year mortality. The association remained linear when each 1-h interval of door-to-antibiotic time was independently compared with door-to-antibiotic time ≤ 1 h and was similar for hospital, 30-day, and 90-day mortality. Mortality at 1 year was higher when door-to-antibiotic times were > 3 h vs ≤ 3 h (adjusted OR, 1.27; 95% CI, 1.13-1.43) but not > 1 h vs ≤ 1 h (adjusted OR, 1.26; 95% CI, 0.98-1.62). CONCLUSIONS Delays in ED antibiotic initiation time are associated with clinically important increases in long-term, risk-adjusted sepsis mortality.
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Affiliation(s)
- Ithan D Peltan
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT.
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Joseph R Bledsoe
- Departments of Medicine and Emergency Medicine, Intermountain Medical Center, Murray, UT
| | - Jeffrey Sorensen
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Matthew H Samore
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Todd L Allen
- Departments of Medicine and Emergency Medicine, Intermountain Medical Center, Murray, UT
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA
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Outcomes for Critically Ill Cancer Patients in the ICU: Current Trends and Prediction. Int Anesthesiol Clin 2018; 54:e62-75. [PMID: 27623129 DOI: 10.1097/aia.0000000000000121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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One more lesson from a great man! The intensive care ethical dilemma exposed. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Robineau O, Robert J, Rabaud C, Bedos JP, Varon E, Péan Y, Gauzit R, Alfandari S. Management and outcome of bloodstream infections: a prospective survey in 121 French hospitals (SPA-BACT survey). Infect Drug Resist 2018; 11:1359-1368. [PMID: 30214256 PMCID: PMC6124465 DOI: 10.2147/idr.s165877] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Bloodstream infections (BSIs) are severe infections that can be community or hospital acquired. Effects of time to appropriate treatment and impact of antimicrobial management team are discussed in terms of outcome of BSI. We sought to evaluate the impact of initial BSI management on short-term mortality. Patients and methods A prospective, multicenter survey was conducted in 121 French hospitals. Participants declaring BSI during a 1-month period were included consecutively. Data on patient comorbidities, illness severity, BSI management, and resistance profile of bacterial strains were collected. Predictors of 10-day mortality were identified by multivariate regression for overall BSI, health care-related and hospital-acquired BSI. Results We included 1,952 BSIs. More than a third of them were hospital acquired (39%). Multidrug resistance was identified in 10% of cases, mainly in health care-related BSI. Empirical therapy and targeted therapy were appropriate for 61% and 94% of cases, respectively. Increased 10-day mortality was associated with severe sepsis, septic shock, increasing age, and any focus other than the urinary tract. Decreased mortality was associated with receiving at least one active antibiotic within the first 48 hours. Intervention of antimicrobial management team during the acute phase of BSI was associated with a decreased mortality at day 10 in the overall population and in health care-related BSI. Conclusion Optimizing BSI management by increasing rapidity of appropriate treatment initiation may decrease short-term mortality, even in countries with low rate of multidrug-resistant organisms. Early intervention of antimicrobial management team is crucial in terms of mortality.
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Affiliation(s)
- Oliver Robineau
- Infectious Disease Department, Dron Hospital, Univ Lille, Tourcoing,
| | - Jérome Robert
- Sorbonne University, UPMC Univ Paris 06, CR7, CIMI, Team E13 (Bacteriology), Paris
| | | | | | | | - Yves Péan
- Observatoire National de L'epidémiologie de la Résistance Bactérienne aux Antibiotiques (OneRBa)
| | - Rémy Gauzit
- Intensive Care Unit, Cochin Hospital, APHP, Paris
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Saillard C, Darmon M, Bisbal M, Sannini A, Chow-Chine L, Faucher M, Lengline E, Vey N, Blaise D, Azoulay E, Mokart D. Critically ill allogenic HSCT patients in the intensive care unit: a systematic review and meta-analysis of prognostic factors of mortality. Bone Marrow Transplant 2018; 53:1233-1241. [DOI: 10.1038/s41409-018-0181-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/08/2018] [Accepted: 03/25/2018] [Indexed: 12/13/2022]
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Predictors of outcome in patients with hematologic malignancies admitted to the intensive care unit. Hematol Oncol Stem Cell Ther 2018; 11:206-218. [PMID: 29684341 DOI: 10.1016/j.hemonc.2018.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 01/02/2018] [Accepted: 03/10/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Several studies showed conflicting results about prognosis and predictors of outcome of critically ill patients with hematological malignancies (HM). The aim of this study is to determine the hospital outcome of critically ill patients with HM and the factors predicting the outcome. METHODS AND MATERIALS All patients with HM admitted to MICU at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and 6 months outcomes were documented. RESULTS There were 130 HM patients during the study period. Acute Leukemia was the most common malignancy (31.5%) followed by Non-Hodgkin's Lymphoma (28.5%). About 12.5% patients had autologous HSCT and 51.5% had allogeneic HSCT. Sepsis was the most common ICU diagnosis (25.9%). ICU mortality and hospital mortality were 24.8% and 45.3%, respectively. Six months mortality (available on 80% of patients) was 56.7%. Hospital mortality was higher among mechanically ventilated patients (75%). Using multivariate analysis, only mechanical ventilation (OR of 19.0, CI: 3.1-117.4, P: 0.001) and allogeneic HSCT (OR of 10.9, CI: 1.8-66.9, P: 0.01) predicted hospital mortality. CONCLUSION Overall hospital outcome of critically ill patients with HM is improving. However those who require mechanical ventilation or underwent allogeneic HSCT continue to have poor outcome.
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Mokart D, Saillard C, Zemmour C, Bisbal M, Sannini A, Chow-Chine L, Brun JP, Faucher M, Boher JM, Toiron Y, Chabannon C, Borg JP, Gonçalves A, Camoin L. Early prognostic factors in septic shock cancer patients: a prospective study with a proteomic approach. Acta Anaesthesiol Scand 2018; 62:493-503. [PMID: 29315472 DOI: 10.1111/aas.13060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 11/24/2017] [Accepted: 11/29/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Organ failures are the main prognostic factors in septic shock. The aim was to assess classical clinico-biological parameters evaluating organ dysfunctions at intensive care unit admission, combined with proteomics, on day-30 mortality in critically ill onco-hematology patients admitted to the intensive care unit for septic shock. METHODS This was a prospective monocenter cohort study. Clinico-biological parameters were collected at admission. Plasma proteomics analyses were performed, including protein profiling using isobaric Tag for Relative and Absolute Quantification (iTRAQ) and subsequent validation by ELISA. RESULTS Sixty consecutive patients were included. Day-30 mortality was 47%. All required vasopressors, 32% mechanical ventilation, 33% non-invasive ventilation and 13% renal-replacement therapy. iTRAQ-based proteomics identified von Willebrand factor as a protein of interest. Multivariate analysis identified four factors independently associated with day-30 mortality: positive fluid balance in the first 24 h (odds ratio = 1.06, 95% CI = 1.01-1.12, P = 0.02), severe acute respiratory failure (odds ratio = 6.14, 95% CI = 1.04-36.15, P = 0.04), von Willebrand factor plasma level > 439 ng/ml (odds ratio = 9.7, 95% CI = 1.52-61.98, P = 0.02), and bacteremia (odds ratio = 6.98, 95% CI = 1.17-41.6, P = 0.03). CONCLUSION Endothelial dysfunction, revealed by proteomics, appears as an independent prognostic factor on day-30 mortality, as well as hydric balance, acute respiratory failure and bacteremia, in critically ill cancer patients admitted to the intensive care unit. Endothelial failure is underestimated in clinical practice and represents an innovative therapeutic target.
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Affiliation(s)
- D. Mokart
- Polyvalent Intensive Care Unit; Department of Anesthesiology and Critical Care; Institut Paoli Calmettes; Marseille France
- Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologie (GRRROH); Paris France
| | - C. Saillard
- Hematology Department; Institut Paoli Calmettes; Marseille France
| | - C. Zemmour
- Departement of Clinical Research and Innovation; Institut Paoli-Calmettes; Marseille France
| | - M. Bisbal
- Polyvalent Intensive Care Unit; Department of Anesthesiology and Critical Care; Institut Paoli Calmettes; Marseille France
- Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologie (GRRROH); Paris France
| | - A. Sannini
- Polyvalent Intensive Care Unit; Department of Anesthesiology and Critical Care; Institut Paoli Calmettes; Marseille France
| | - L. Chow-Chine
- Polyvalent Intensive Care Unit; Department of Anesthesiology and Critical Care; Institut Paoli Calmettes; Marseille France
| | - J.-P. Brun
- Polyvalent Intensive Care Unit; Department of Anesthesiology and Critical Care; Institut Paoli Calmettes; Marseille France
| | - M. Faucher
- Polyvalent Intensive Care Unit; Department of Anesthesiology and Critical Care; Institut Paoli Calmettes; Marseille France
| | - J.-M. Boher
- Departement of Clinical Research and Innovation; Institut Paoli-Calmettes; Marseille France
| | - Y. Toiron
- Inserm, U1068; Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
- Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
| | - C. Chabannon
- Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
- CNRS, UMR7258; Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
- Aix-Marseille Medical University; Marseille France
- Cell Therapy Department; Institut Paoli Calmettes; Marseille France
| | - J.-P. Borg
- Inserm, U1068; Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
- Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
- CNRS, UMR7258; Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
- UM105; Aix-Marseille Université; Marseille France
| | - A. Gonçalves
- Inserm, U1068; Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
- Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
- CNRS, UMR7258; Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
- Aix-Marseille Medical University; Marseille France
- Department of Medical Oncology; Institut Paoli Calmettes; Marseille France
| | - L. Camoin
- Inserm, U1068; Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
- Centre de Recherche en Cancérologie de Marseille (CRCM); Marseille France
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Mirouse A, Resche-Rigon M, Lemiale V, Mokart D, Kouatchet A, Mayaux J, Vincent F, Nyunga M, Bruneel F, Rabbat A, Lebert C, Perez P, Renault A, Meert AP, Benoit D, Hamidfar R, Jourdain M, Darmon M, Azoulay E, Pène F. Red blood cell transfusion in the resuscitation of septic patients with hematological malignancies. Ann Intensive Care 2017; 7:62. [PMID: 28608137 PMCID: PMC5468360 DOI: 10.1186/s13613-017-0292-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 06/02/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Indications for red blood cell (RBC) transfusion in septic acute circulatory failure remain unclear. We addressed the practices and the prognostic impact of RBC transfusion in the early resuscitation of severe sepsis and septic shock in patients with hematological malignancies. METHODS We performed a retrospective analysis of a prospectively collected database of patients with hematological malignancies who required intensive care unit (ICU) admission in 2010-2011. Patients with a main admission diagnosis of severe sepsis or septic shock were included in the present study. We assessed RBC transfusion during the first two days as part of initial resuscitation. RESULTS Among the 1011 patients of the primary cohort, 631 (62.4%) were admitted to the ICU for severe sepsis (55%) or septic shock (45%). Among them, 210 (33.3%) patients received a median of 2 [interquartile 1-3] packed red cells during the first 48 h. Hemoglobin levels were lower in transfused patients at days 1 and 2 and became similar to those of non-transfused patients at day 3. Early RBC transfusion was more likely in patients with myeloid neoplasms and neutropenia. Transfused patients displayed more severe presentations as assessed by higher admission SOFA scores and blood lactate levels and the further requirements for organ failure supports. RBC transfusion within the first two days was associated with higher day 7 (20.5 vs. 13.3%, p = 0.02), in-ICU (39 vs. 25.2%, p < 0.001) and in-hospital (51 vs. 36.6%, p < 0.001) mortality rates. RBC transfusion remained independently associated with increased in-hospital mortality in multivariate logistic regression (OR 1.52 [1.03-2.26], p = 0.03) and propensity score-adjusted (OR 1.64 [1.05-2.57], p = 0.03) analysis. CONCLUSIONS RBC transfusion is commonly used in the early resuscitation of septic patients with hematological malignancies. Although it was preferentially provided to the most severe patients, we found it possibly associated with an increased risk of death.
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Affiliation(s)
- Adrien Mirouse
- Réanimation médicale, hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP) and Université Paris Descartes, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Matthieu Resche-Rigon
- Département de biostatistiques, Hôpital Saint-Louis, AP-HP and Université Paris Diderot, Paris, France
| | - Virginie Lemiale
- Réanimation médicale, Hôpital Saint-Louis, AP-HP and Université Paris Diderot, Paris, France
| | - Djamel Mokart
- Département d’anesthésie-réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Achille Kouatchet
- Réanimation médicale et médecine hyperbare, CHU d’Angers, Angers, France
| | - Julien Mayaux
- Réanimation médicale, Hôpital de la Pitié-Salpêtrière, AP-HP and Université Pierre et Marie Curie, Paris, France
| | - François Vincent
- Réanimation polyvalente, Centre Hospitalier Intercommunal, Montfermeil, France
| | | | - Fabrice Bruneel
- Réanimation polyvalente, Hôpital André Mignot, Le Chesnay, France
| | - Antoine Rabbat
- Unité de soins intensifs respiratoires, Hôpital Cochin, AP-HP and Université Paris Descartes, Paris, France
| | - Christine Lebert
- Réanimation polyvalente, Centre Hospitalier Départemental, La Roche-sur-Yon, France
| | - Pierre Perez
- Réanimation médicale, Hôpital Brabois, Nancy, France
| | - Anne Renault
- Réanimation médicale, Centre Hospitalier de Brest, Brest, France
| | - Anne-Pascale Meert
- Service des soins intensifs et urgences oncologiques, Institut Jules Bordet, Brussels, Belgium
| | | | | | - Mercé Jourdain
- Université de Lille and Réanimation Polyvalente, CHU de Lille, Lille, France
| | - Michaël Darmon
- Réanimation médicale, Centre Hospitalier de Saint-Etienne, Saint-Etienne, France
| | - Elie Azoulay
- Réanimation médicale, Hôpital Saint-Louis, AP-HP and Université Paris Diderot, Paris, France
| | - Frédéric Pène
- Réanimation médicale, hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP) and Université Paris Descartes, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - on behalf of the Groupe de Recherche sur la Réanimation Respiratoire en Onco-Hématologie (Grrr-OH)
- Réanimation médicale, hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP) and Université Paris Descartes, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
- Département de biostatistiques, Hôpital Saint-Louis, AP-HP and Université Paris Diderot, Paris, France
- Réanimation médicale, Hôpital Saint-Louis, AP-HP and Université Paris Diderot, Paris, France
- Département d’anesthésie-réanimation, Institut Paoli-Calmettes, Marseille, France
- Réanimation médicale et médecine hyperbare, CHU d’Angers, Angers, France
- Réanimation médicale, Hôpital de la Pitié-Salpêtrière, AP-HP and Université Pierre et Marie Curie, Paris, France
- Réanimation polyvalente, Centre Hospitalier Intercommunal, Montfermeil, France
- Centre Hospitalier de Roubaix, Roubaix, France
- Réanimation polyvalente, Hôpital André Mignot, Le Chesnay, France
- Unité de soins intensifs respiratoires, Hôpital Cochin, AP-HP and Université Paris Descartes, Paris, France
- Réanimation polyvalente, Centre Hospitalier Départemental, La Roche-sur-Yon, France
- Réanimation médicale, Hôpital Brabois, Nancy, France
- Réanimation médicale, Centre Hospitalier de Brest, Brest, France
- Service des soins intensifs et urgences oncologiques, Institut Jules Bordet, Brussels, Belgium
- Ghent University Hospital, Ghent, Belgium
- Réanimation médicale, CHU Grenoble-Alpes, Grenoble, France
- Université de Lille and Réanimation Polyvalente, CHU de Lille, Lille, France
- Réanimation médicale, Centre Hospitalier de Saint-Etienne, Saint-Etienne, France
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Liu VX, Fielding-Singh V, Greene JD, Baker JM, Iwashyna TJ, Bhattacharya J, Escobar GJ. The Timing of Early Antibiotics and Hospital Mortality in Sepsis. Am J Respir Crit Care Med 2017; 196:856-863. [PMID: 28345952 PMCID: PMC5649973 DOI: 10.1164/rccm.201609-1848oc] [Citation(s) in RCA: 508] [Impact Index Per Article: 72.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 03/24/2017] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Prior sepsis studies evaluating antibiotic timing have shown mixed results. OBJECTIVES To evaluate the association between antibiotic timing and mortality among patients with sepsis receiving antibiotics within 6 hours of emergency department registration. METHODS Retrospective study of 35,000 randomly selected inpatients with sepsis treated at 21 emergency departments between 2010 and 2013 in Northern California. The primary exposure was antibiotics given within 6 hours of emergency department registration. The primary outcome was adjusted in-hospital mortality. We used detailed physiologic data to quantify severity of illness within 1 hour of registration and logistic regression to estimate the odds of hospital mortality based on antibiotic timing and patient factors. MEASUREMENTS AND MAIN RESULTS The median time to antibiotic administration was 2.1 hours (interquartile range, 1.4-3.1 h). The adjusted odds ratio for hospital mortality based on each hour of delay in antibiotics after registration was 1.09 (95% confidence interval [CI], 1.05-1.13) for each elapsed hour between registration and antibiotic administration. The increase in absolute mortality associated with an hour's delay in antibiotic administration was 0.3% (95% CI, 0.01-0.6%; P = 0.04) for sepsis, 0.4% (95% CI, 0.1-0.8%; P = 0.02) for severe sepsis, and 1.8% (95% CI, 0.8-3.0%; P = 0.001) for shock. CONCLUSIONS In a large, contemporary, and multicenter sample of patients with sepsis in the emergency department, hourly delays in antibiotic administration were associated with increased odds of hospital mortality even among patients who received antibiotics within 6 hours. The odds increased within each sepsis severity strata, and the increased odds of mortality were greatest in septic shock.
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Affiliation(s)
- Vincent X. Liu
- Kaiser Permanente Division of Research, Oakland, California
| | - Vikram Fielding-Singh
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - John D. Greene
- Kaiser Permanente Division of Research, Oakland, California
| | | | - Theodore J. Iwashyna
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; and
| | - Jay Bhattacharya
- Primary Care and Outcomes Research, Stanford University, Stanford, California
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Goldman JD, Gallaher A, Jain R, Stednick Z, Menon M, Boeckh MJ, Pottinger PS, Schwartz SM, Casper C. Infusion-Compatible Antibiotic Formulations for Rapid Administration to Improve Outcomes in Cancer Outpatients With Severe Sepsis and Septic Shock: The Sepsis STAT Pack. J Natl Compr Canc Netw 2017; 15:457-464. [PMID: 28404756 DOI: 10.6004/jnccn.2017.0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 12/08/2016] [Indexed: 02/07/2023]
Abstract
Background: Patients with cancer are at high risk for severe sepsis and septic shock (SS/SSh), and a delay in receiving effective antibiotics is strongly associated with mortality. Delays are due to logistics of clinic flow and drug delivery. In an era of increasing antimicrobial resistance, combination therapy may be superior to monotherapy for patients with SS/SSh. Patients and Methods: At the Seattle Cancer Care Alliance, we implemented the Sepsis STAT Pack (SSP) program to simplify timely and effective provision of empiric antibiotics and other resuscitative care to outpatients with cancer with suspected SS/SSh before hospitalization. Over a 49-month period from January 1, 2008, through January 31, 2012, a total of 162 outpatients with cancer received the intervention. A retrospective cohort study was conducted to determine outcomes, including mortality and adverse events associated with the use of a novel care bundle designed for compatibility of broad-spectrum antibiotics and other supportive care administered concurrently via rapid infusion at fixed doses. Results: Of 162 sequential patients with cancer and suspected SS/SSh who received the SSP, 71 (44%) were diagnosed with SS/SSh. Median age was 53 years and 65% were men; 141 (87%) had hematologic malignancies, 77 (48%) were transplant recipients, and 80 (49%) were neutropenic. Median time to completion of antibiotics was 111 minutes (interquartile range, 60-178 minutes). A total of 71 patients (44%) had bacteremia and 17% of 93 isolates were multidrug-resistant. Possibly related nephrotoxicity occurred in 7 patients, and 30-day mortality occured in 6 of 160 patients (4%), including 3 of 71 (4%) with SS/SSh. Risk of developing SSh or death within 30 days increased 18% (95% CI, 4%-34%) for each hour delay to completion of antibiotics (P=.01). Conclusions: Rapidly administered combination antibiotics and supportive care delivered emergently to ambulatory patients with cancer with suspected SS/SSh was well-tolerated and associated with excellent short-term survival.
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Affiliation(s)
- Jason D Goldman
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center,Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington,Seattle Cancer Care Alliance;,Department of Epidemiology, School of Public Health, University of Washington
| | | | - Rupali Jain
- School of Pharmacy, University of Washington
| | - Zach Stednick
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center
| | - Manoj Menon
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center,Seattle Cancer Care Alliance;,Division of Hematology, Department of Medicine, University of Washington
| | - Michael J Boeckh
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center,Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington,Seattle Cancer Care Alliance
| | - Paul S Pottinger
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington,Seattle Cancer Care Alliance
| | - Stephen M Schwartz
- Department of Epidemiology, School of Public Health, University of Washington,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Corey Casper
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center,Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington,Seattle Cancer Care Alliance;,Department of Epidemiology, School of Public Health, University of Washington,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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43
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Morneau K, Chisholm GB, Tverdek F, Bruno J, Toale KM. Timing to antibiotic therapy in septic oncologic patients presenting without hypotension. Support Care Cancer 2017; 25:3357-3363. [DOI: 10.1007/s00520-017-3754-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 05/16/2017] [Indexed: 01/29/2023]
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Lee CC, Lee CH, Hong MY, Tang HJ, Ko WC. Timing of appropriate empirical antimicrobial administration and outcome of adults with community-onset bacteremia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:119. [PMID: 28545484 PMCID: PMC5445436 DOI: 10.1186/s13054-017-1696-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 05/02/2017] [Indexed: 12/29/2022]
Abstract
Background Early administration of appropriate antimicrobials has been correlated with a better prognosis in patients with bacteremia, but the optimum timing of early antibiotic administration as one of the resuscitation strategies for severe bacterial infections remains unclear. Methods In a retrospective cohort study, adults with community-onset bacteremia at the emergency department (ED) were analyzed. Effects of different cutoffs of time to appropriate antibiotic (TtAa) administration after arrival at the ED on 28-day mortality were examined, after adjustment for independent predictors of mortality identified by multivariate regression analysis. Results Among 2349 patients, the mean (interquartile range) TtAa was 2.0 (<1 to 12) hours. All selected cutoffs of TtAa, ranging from 1 to 96 hours, were significantly associated with 28-day mortality (adjusted odds ratio (AOR), 0.54–0.65, all P < 0.001), after adjustment of the following prognostic factors: fatal comorbidities (McCabe classification), critical illness (Pitt bacteremia score (PBS) ≥4) on arrival at the ED, polymicrobial bacteremia, extended-spectrum beta-lactamase-producer bacteremia, underlying malignancies or liver cirrhosis, and bacteremia caused by pneumonia or urinary tract infections. The adverse impact of TtAa on 28-day mortality was most evident at the cutoff of 48 hours, as the lowest AOR was identified (0.54, P < 0.001). In subgroup analyses, the most evident TtAa cutoff (i.e., the lowest AOR) remained at 48 hours in mildly ill (PBS = 0; AOR 0.47; P = 0.04) and moderately ill (PBS = 1–3; AOR 0.55; P = 0.02) patients, but shifted to 1 hour in critically ill patients (PBS ≥4; AOR 0.56; P < 0.001). Conclusions The time from triage to administration of appropriate antimicrobials is one of the primary determinants of mortality. The optimum timing of appropriate antimicrobial administration is the first 48 hours after non-critically ill patients arrive at the ED. As bacteremia severity increases, effective antimicrobial therapy should be empirically prescribed within 1 hour after critically ill patients arrive at the ED.
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Affiliation(s)
- Ching-Chi Lee
- Division of Critical Care Medicine, Department of Internal Medicine, Madou Sin-Lau Hospital, No. 20, Lingzilin, 72152, Madou Dist, Tainan City, Taiwan.,Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chung-Hsun Lee
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Ming-Yuan Hong
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Hung-Jen Tang
- Department of Medicine, Chi-Mei Medical Center, Tainan, Taiwan. .,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan. .,Division of Infectious Disease, Department of Medicine, Chi-Mei Medical Center, No. 901, Chung-Hwa Road, Yung-Kang City, 710, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan. .,Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan. .,Division of Infectious Disease, Department of Internal Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
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45
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Bloos F, Rüddel H, Thomas-Rüddel D, Schwarzkopf D, Pausch C, Harbarth S, Schreiber T, Gründling M, Marshall J, Simon P, Levy MM, Weiss M, Weyland A, Gerlach H, Schürholz T, Engel C, Matthäus-Krämer C, Scheer C, Bach F, Riessen R, Poidinger B, Dey K, Weiler N, Meier-Hellmann A, Häberle HH, Wöbker G, Kaisers UX, Reinhart K. Effect of a multifaceted educational intervention for anti-infectious measures on sepsis mortality: a cluster randomized trial. Intensive Care Med 2017; 43:1602-1612. [PMID: 28466151 DOI: 10.1007/s00134-017-4782-4] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 03/21/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Guidelines recommend administering antibiotics within 1 h of sepsis recognition but this recommendation remains untested by randomized trials. This trial was set up to investigate whether survival is improved by reducing the time before initiation of antimicrobial therapy by means of a multifaceted intervention in compliance with guideline recommendations. METHODS The MEDUSA study, a prospective multicenter cluster-randomized trial, was conducted from July 2011 to July 2013 in 40 German hospitals. Hospitals were randomly allocated to receive conventional continuous medical education (CME) measures (control group) or multifaceted interventions including local quality improvement teams, educational outreach, audit, feedback, and reminders. We included 4183 patients with severe sepsis or septic shock in an intention-to-treat analysis comparing the multifaceted intervention (n = 2596) with conventional CME (n = 1587). The primary outcome was 28-day mortality. RESULTS The 28-day mortality was 35.1% (883 of 2596 patients) in the intervention group and 26.7% (403 of 1587 patients; p = 0.01) in the control group. The intervention was not a risk factor for mortality, since this difference was present from the beginning of the study and remained unaffected by the intervention. Median time to antimicrobial therapy was 1.5 h (interquartile range 0.1-4.9 h) in the intervention group and 2.0 h (0.4-5.9 h; p = 0.41) in the control group. The risk of death increased by 2% per hour delay of antimicrobial therapy and 1% per hour delay of source control, independent of group assignment. CONCLUSIONS Delay in antimicrobial therapy and source control was associated with increased mortality but the multifaceted approach was unable to change time to antimicrobial therapy in this setting and did not affect survival.
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Affiliation(s)
- Frank Bloos
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Hendrik Rüddel
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Daniel Thomas-Rüddel
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Daniel Schwarzkopf
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - Christine Pausch
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Stephan Harbarth
- Service Prévention et Contrôle de l'Infection, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Torsten Schreiber
- Department of Anaesthesia and Intensive Care Medicine, Zentralklinik Bad Berka GmbH, Bad Berka, Germany
| | - Matthias Gründling
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Greifswald, Greifswald, Germany
| | - John Marshall
- Department of Surgery and the Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Ontario, Canada
| | - Philipp Simon
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Mitchell M Levy
- Division of Pulmonary and Critical Care Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Manfred Weiss
- Department of Anesthesiology, University Hospital Ulm, Ulm, Germany
| | - Andreas Weyland
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Oldenburg, Oldenburg, Germany
| | - Herwig Gerlach
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Therapy, Vivantes Hospital Neukölln, Berlin, Germany
| | - Tobias Schürholz
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany.,Department of Anesthesiology and Intensive Care Medicine, University Hospital Rostock, Rostock, Germany
| | - Christoph Engel
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | | | - Christian Scheer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Greifswald, Greifswald, Germany
| | - Friedhelm Bach
- Department of Anesthesiology, Intensive Care, Transfusion and Emergency Medicine and Pain Therapy, Bethel Hospital Bielefeld, Bielefeld, Germany
| | - Reimer Riessen
- Department of Internal Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Bernhard Poidinger
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Karin Dey
- Department of Anesthesiology and Intensive Care Medicine, Hospital of the Bundeswehr Berlin, Berlin, Germany
| | - Norbert Weiler
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Kiel, Kiel, Germany
| | - Andreas Meier-Hellmann
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Helios Hospital Erfurt, Erfurt, Germany
| | - Helene H Häberle
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Gabriele Wöbker
- Department of Intensive Care Medicine, Helios Hospital Wuppertal, Wuppertal, Germany
| | - Udo X Kaisers
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany.,University Hospital Ulm, Ulm, Germany
| | - Konrad Reinhart
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany. .,Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
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Abstract
Advances in cancer treatment and patient survival are associated with increasing number of these patients requiring intensive care. Over the last 2 decades, there has been a steady improvement in the outcomes of critically ill patients with cancer. This review provides data on the use of the intensive care unit (ICU) and short and long-term outcomes of critically ill patients with cancer, the ICU system practices that influence patients outcomes, and the role of the different clinical variables in predicting the prognosis of these patients.
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Affiliation(s)
- Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, 3990 John R- 3 Hudson, Detroit, MI 48201, USA.
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47
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Waszczuk-Gajda A, Wiktor Jedrzejczak W. Prognostic factors in the survival of patients with blood disorders recovering from septic shock. Hematology 2016; 22:292-298. [DOI: 10.1080/10245332.2016.1253521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Anna Waszczuk-Gajda
- Department of Hematology, Oncology and Internal Medicine, Warsaw Medical University, Warsaw, Poland
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48
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Shimabukuro-Vornhagen A, Böll B, Kochanek M, Azoulay É, von Bergwelt-Baildon MS. Critical care of patients with cancer. CA Cancer J Clin 2016; 66:496-517. [PMID: 27348695 DOI: 10.3322/caac.21351] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Answer questions and earn CME/CNE The increasing prevalence of patients living with cancer in conjunction with the rapid progress in cancer therapy will lead to a growing number of patients with cancer who will require intensive care treatment. Fortunately, the development of more effective oncologic therapies, advances in critical care, and improvements in patient selection have led to an increased survival of critically ill patients with cancer. As a consequence, critical care has become an important cornerstone in the continuum of modern cancer care. Although, in many aspects, critical care for patients with cancer does not differ from intensive care for other seriously ill patients, there are several challenging issues that are unique to this patient population and require special knowledge and skills. The optimal management of critically ill patients with cancer necessitates expertise in oncology, critical care, and palliative medicine. Cancer specialists therefore have to be familiar with key principles of intensive care for critically ill patients with cancer. This review provides an overview of the state-of-the-art in the individualized management of critically ill patients with cancer. CA Cancer J Clin 2016;66:496-517. © 2016 American Cancer Society.
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Affiliation(s)
- Alexander Shimabukuro-Vornhagen
- Consultant, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Boris Böll
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Head of Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Matthias Kochanek
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Program Director, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Éli Azoulay
- Director, Medical Intensive Care Unit, St. Louis Hospital, Paris, France
- Professor of Medicine, Teaching and Research Unit, Department of Medicine, Paris Diderot University, Paris, France
- Chair, Study Group for Respiratory Intensive Care in Malignancies, St. Louis Hospital, Paris, France
| | - Michael S von Bergwelt-Baildon
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Program Director, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Professor, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
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49
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Long B, Koyfman A, Modisett KL, Woods CJ. Practical Considerations in Sepsis Resuscitation. J Emerg Med 2016; 52:472-483. [PMID: 27823892 DOI: 10.1016/j.jemermed.2016.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/27/2016] [Accepted: 10/03/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Sepsis is a common condition managed in the emergency department, and the majority of patients respond to resuscitation measures, including antibiotics and i.v. fluids. However, a proportion of patients will fail to respond to standard treatment. OBJECTIVE This review elucidates practical considerations for management of sepsis in patients who fail to respond to standard treatment. DISCUSSION Early goal-directed therapy revolutionized sepsis management. However, there is a paucity of literature that provides a well-defined treatment algorithm for patients who fail to improve with therapy. Refractory shock can be defined as continued patient hemodynamic instability (mean arterial pressure, ≤ 65 mm Hg, lactate ≥ 4 mmol/L, altered mental status) after adequate fluid loading (at least 30 mL/kg i.v.), the use of two vasopressors (with one as norepinephrine), and provision of antibiotics. When a lack of improvement is evident in the early stages of resuscitation, systematically considering source control, appropriate volume resuscitation, adequate antimicrobial coverage, vasopressor selection, presence of metabolic pathology, and complications of resuscitation, such as abdominal compartment syndrome and respiratory failure, allow emergency physicians to address the entire clinical scenario. CONCLUSIONS The care of sepsis has experienced many changes in recent years. Care of the patient with sepsis who is not responding appropriately to initial resuscitation is troublesome for emergency physicians. This review provides practical considerations for resuscitation of the patient with septic shock. When a septic patient is refractory to standard therapy, systematically evaluating the patient and clinical course may lead to improved outcomes.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katharine L Modisett
- Department of Pulmonary and Critical Care Medicine, MedStar Georgetown University/MedStar Washington Hospital Center, Washington, District of Columbia
| | - Christian J Woods
- Sections of Infectious Diseases and Pulmonary Critical Care, MedStar Washington Hospital Center, Washington, District of Columbia
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50
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Dekter HE, Orelio CC, Morsink MC, Tektas S, Vis B, Te Witt R, van Leeuwen WB. Antimicrobial susceptibility testing of Gram-positive and -negative bacterial isolates directly from spiked blood culture media with Raman spectroscopy. Eur J Clin Microbiol Infect Dis 2016; 36:81-89. [PMID: 27638006 DOI: 10.1007/s10096-016-2773-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/30/2016] [Indexed: 11/24/2022]
Abstract
Patients suffering from bacterial bloodstream infections have an increased risk of developing systematic inflammatory response syndrome (SIRS), which can result in rapid deterioration of the patients' health. Diagnostic methods for bacterial identification and antimicrobial susceptibility tests are time-consuming. The aim of this study was to investigate whether Raman spectroscopy would be able to rapidly provide an antimicrobial susceptibility profile from bacteria isolated directly from positive blood cultures. First, bacterial strains (n = 133) were inoculated in tryptic soy broth and incubated in the presence or absence of antibiotics for 5 h. Antimicrobial susceptibility profiles were analyzed by Raman spectroscopy. Subsequently, a selection of strains was isolated from blood cultures and analyzed similarly. VITEK®2 technology and broth dilution were used as the reference methods. Raman spectra from 67 antibiotic-susceptible strains showed discriminatory spectra in the absence or at low concentrations of antibiotics as compared to high antibiotic concentrations. For 66 antibiotic-resistant strains, no antimicrobial effect was observed on the bacterial Raman spectra. Full concordance with VITEK®2 data and broth dilution was obtained for the antibiotic-susceptible strains, 68 % and 98 %, respectively, for the resistant strains. Discriminative antimicrobial susceptibility testing (AST) profiles were obtained for all bacterial strains isolated from blood cultures, resulting in full concordance with the VITEK®2 data. It can be concluded that Raman spectroscopy is able to detect the antimicrobial susceptibility of bacterial species isolated from a positive blood culture bottle within 5 h. Although Raman spectroscopy is cheap and rapid, further optimization is required, to fulfill a great promise for future AST profiling technology development.
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Affiliation(s)
- H E Dekter
- Research Department of Innovative Molecular Diagnostics, University of Applied Sciences Leiden, J. H. Oortweg 21, 2333 CH, Leiden, The Netherlands
| | - C C Orelio
- Research Department of Innovative Molecular Diagnostics, University of Applied Sciences Leiden, J. H. Oortweg 21, 2333 CH, Leiden, The Netherlands
| | - M C Morsink
- Research Department of Innovative Molecular Diagnostics, University of Applied Sciences Leiden, J. H. Oortweg 21, 2333 CH, Leiden, The Netherlands
| | - S Tektas
- Research Department of Innovative Molecular Diagnostics, University of Applied Sciences Leiden, J. H. Oortweg 21, 2333 CH, Leiden, The Netherlands
| | - B Vis
- Research Department of Innovative Molecular Diagnostics, University of Applied Sciences Leiden, J. H. Oortweg 21, 2333 CH, Leiden, The Netherlands
| | - R Te Witt
- Netherlands Molecular Diagnostic Laboratory B.V. (NMDL), Visseringlaan 25, 2288 ER, Rijswijk, The Netherlands
| | - W B van Leeuwen
- Research Department of Innovative Molecular Diagnostics, University of Applied Sciences Leiden, J. H. Oortweg 21, 2333 CH, Leiden, The Netherlands.
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