Predictive factors of death in primary lung cancer patients on admission to the intensive care unit

Characteristics, management, and outcomes of patients with lung cancer admitted to a tertiary care intensive care unit over more than 20 years

RATIONALE

The prognosis of patients with lung cancer admitted to the intensive care unit (ICU) is often perceived as poor. We described the characteristics, management, and outcomes of critically ill patients with lung cancer and determined the predictors of mortality.

METHODS

We retrospectively studied patients with lung cancer who were admitted to the ICU of a tertiary care hospital between 1999 and 2021 for the reasons other than routine postoperative care. We noted their characteristics, ICU management, and outcomes. We performed the multivariable logistic regression analysis to determine the predictors of hospital mortality.

RESULTS

In the 23-year period, 306 patients with lung cancer were admitted to the ICU (median age = 63.0 years, 68.3% males, 45.6% with moderate/severe functional disability, most had advanced lung cancer, and median Acute Physiology and Chronic Health Evaluation II score = 24.0). Life support measures included invasive mechanical ventilation (47.1%), vasopressors (34.0%), and new renal replacement therapy (8.8%). Do-Not-Resuscitate orders were implemented during ICU stay in 30.1%. The hospital mortality was 43.8% with a significantly lower rate in patients admitted after 2015 (28.0%). The predictors of mortality were moderate/severe baseline disability (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.22, 5.78), advanced lung cancer (OR 8.36, 95% CI 1.81, 38.58), lactate level (OR 1.45, 95% CI 1.12, 1.88, invasive mechanical ventilation (OR 10.92, 95% CI 4.98, 23.95), and admission period after 2015 (OR 0.37, 95% CI 0.16, 0.85).

CONCLUSIONS

The mortality rates in patients with lung cancer admitted to the ICU during a 23-year period decreased after 2015. Functional disability, advanced lung cancer stage, vasopressor use, and invasive mechanical ventilation predicted mortality.

Factors associated with short- and long-term outcomes in lung cancer patients requiring unplanned invasive mechanical ventilation

OBJECTIVE

Unplanned invasive mechanical ventilation (IMV) is associated with high mortality in lung cancer patients. We aimed to identify factors associated with weaning from IMV, intensive care unit (ICU) survival and 1-year survival in lung cancer patients requiring unplanned IMV.

DESIGN

Retrospective observational study (2007-2017).

SETTING

University-affiliated ICU.

PATIENTS

Lung cancer patients requiring unplanned IMV.

INTERVENTION

None.

MAIN VARIABLES OF INTEREST

Weaning from IMV, ICU and 1-year survival.

RESULTS

Of the 136 patients included in the analysis (age 64 (9) years, male 110 (81%), metastatic disease 97 (62%)), 52 (38%) were weaned from IMV, 51 (38%) were discharged from ICU and 22 (16%) were alive at 1year. The main indication for intubation was acute respiratory failure. In multivariate analysis, PaO2/FiO2 >175mmHg at ICU admission and intubation before ICU admission were associated with successful weaning from IMV while intubation for cardiac arrest was associated with weaning failure. Same factors were associated with ICU survival. Absence of metastasis at ICU admission and lung resection surgery were independently associated with 1-year survival.

CONCLUSIONS

A significant proportion of patients with lung cancer treated with unplanned IMV could be weaned from IMV and survived to ICU discharge, especially in the absence of severe hypoxemia at ICU admission. The low one-year survival was mostly driven by metastatic status.

[Prognosis of lung cancer patients followed in the intensive care unit: A cross-sectional study]

Introduction

Lung cancer is the most common solid organ malignancy requiring intensive care unit (ICU) admission. For many years, lung cancer patients were not considered in the priority patient category for admission to ICU because of their high mortality rate and poor response to therapy. Considering the developments in treatment modalities, we aimed to reevaluate the prognosis of patients with lung cancer in the ICU.

Materials and Methods

Patients characteristics, date of diagnosis, the reason for ICU admission, the stage of cancer, histopathological type, history of chemotherapy, radiotherapy, or surgery for cancer, and APACHE-II and Charlson comorbidity index (CCI) were recorded retrospectively.

Result

A total of 100 patients had a mean age of 69.7 ± 9.0 years. Among these patients, 18% had small cell lung cancer, while 82% had non-small cell lung cancer. The in-hospital mortality rate was 69% for all patients, while among those discharged from the ICU, the first 6-month mortality rate was 58.1%. The median survival time was 8.2 months. Advanced age, the need for mechanical ventilation, the need for vasopressors, a high APACHE -II, and the CCI all reduced survival in multivariate analysis, whereas chemotherapy and surgical history improved survival.

Conclusions

Patients admitted to the ICU with lung cancer continue to experience a high mortality rate. However, identifying the factors that are associated with survival can be crucial in establishing care plans and prioritizing ICU admission for further therapy.

Validation of a palliative care outcome measurement tool supplemented by neurological symptoms (HOPE+): Identification of palliative concerns of neurological patients

BACKGROUND

There is growing interest to integrate palliative care and its structures into the care of neurological patients. However, in Germany there is no comprehensive assessment tool capturing the symptoms of patients with advanced neurological diseases.

AIM

To validate a newly developed palliative care measurement tool based on an extension of the validated core documentation system Hospice and Palliative Care Evaluation considering additional neurological issues (HOPE+).

DESIGN

Prospective, observational study using HOPE+ and as external criteria, the Eastern Cooperative Oncology Group (ECOG) performance status and the 12 months "surprise" question (12-SQ) in a neurological population, and assessment for its construct validity and diagnostic accuracy.

SETTING/PARTICIPANTS

All newly admitted patients to the Department of Neurorehabilitation, Dr. Becker Rhein-Sieg-Clinic aged 18-100 years (#DRKS00010947).

RESULTS

Data from 263 patients (63 ± 14 years of age) were analyzed. HOPE+ revealed a moderately correlated six-factor structure (r = -0.543-0.525). Correlation analysis to evaluate discriminant validity using ECOG as external criterion was high (rs(261) = 0.724, p < 0.001) and confirmed for severely affected patients by adding the 12-SQ ("No"-group: 48.00 ± 14.92 vs "Yes"-group: 18.67 ± 7.57, p < 0.009). Operating characteristics show satisfactory diagnostic accuracy (area under the curve: 0.746 ± 0.049, 95% confidence interval = 0.650-0.842).

CONCLUSION

HOPE+ demonstrates promising psychometric properties. It helps to assess palliative care issues of patients in neurological settings and, in combination with the 12-SQ, conceivably conditions when to initiate the palliative care approach in a population underrepresented in palliative care structures so far.

[Emergency room management of patients with lung cancer and organ failure]

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.

Twenty-eight-day mortality in lung cancer patients with metastasis who initiated mechanical ventilation in the emergency department

Few data are available regarding treatment outcomes in lung cancer patients with metastasis who initiated mechanical ventilation in the emergency department (ED). We aimed to evaluate 28-day mortality in lung cancer patients with metastasis who initiated mechanical ventilation in the ED. Patients with solid malignancy who initiated mechanical ventilation in the ED of a tertiary hospital were retrospectively identified and stratified into four groups according to the presence of lung cancer and metastasis. Among 212 included patients, the mortality rates by the 28^th hospital day were as follows: 44.2% (19/43) in non-lung cancer patients without metastasis, 63.2% (43/68) in non-lung cancer patients with metastasis, 52.4% (11/21) in lung cancer patients without metastasis, and 66.2% (53/80) in lung cancer patients with metastasis. In multivariable analysis, lung cancer patients with metastasis had significantly higher odds ratio for 28-day mortality than non-lung cancer patients without metastasis (adjusted odds ratio [OR] = 7.17, 95% confidence interval [CI] = 2.14-24.01). Sepsis-related respiratory failure (adjusted OR = 2.60, 95% CI = 1.16-5.84) and cardiopulmonary resuscitation (adjusted OR = 13.34, 95% CI = 4.45-39.95) over respiratory failure without sepsis and acute organ dysfunction process measured by sequential organ failure assessment (SOFA) score (adjusted OR = 1.15, 95% CI = 1.05-12.6) were independently associated with an increase in mortality rate. In conclusion, the treatment outcomes in lung cancer patients with metastasis who initiated mechanical ventilation in the ED were poor. Aggressive resuscitation versus end-of-life care in advance of an unexpected medical crisis should be considered in lung cancer patients with metastasis via a multidisciplinary approach with a consideration of underlying comorbid illnesses in the acute organ dysfunction processes.

Risk factors and mortality of adults with lung cancer admitted to the intensive care unit

Background

This study aims to investigate lung cancer patients' risk factors for: intensive care unit (ICU) admission, infectious complications and organ dysfunction in the ICU, and prognosis after ICU admission.

Methods

The records of all patients with lung-cancer catastrophic-illness cards admitted to the ICU between 2003 and 2012 were reviewed. The primary endpoint was 1-year mortality.

Results

We finally analyzed the records of index-date-, age-, and sex-matched ICU-admitted (ICU⁺) lung cancer patients (n=17,687) and ICU-non-admitted (ICU^-) lung cancer patients (n=35,374). The overall 1-year mortality rate was significantly (P<0.0001) higher for ICU⁺ patients (49.91%) than for ICU^- patients (44.86%). Most ICU⁺ patients (56.16%) had infectious complications and organ dysfunction (52.33%), and overall, 6,893 (38.97%) had sepsis. Independent mortality risk factors were age (≥75 years) [adjusted hazard ratio (AHR), 1.22; 95% confidence interval (CI), 1.16-1.29], male sex: (AHR, 1.18; 95% CI, 1.13-1.23), recent radiotherapy (AHR, 1.09; 95% CI, 1.04-1.15), infectious complications (AHR: 1.23; 95% CI: 1.17-1.29), organ dysfunction (AHR, 1.57; 95% CI, 1.50-1.65), and hospital level (regional hospital: AHR, 1.11; 95% CI, 1.06-1.16; local hospital: AHR, 1.28; 95% CI, 1.18-1.37).

Conclusions

ICU admission for lung cancer patients is associated with higher mortality. Several risk factors of mortality for ICU⁺ patients should help physicians provide patients personalized and better-informed lung cancer therapy decisions.

Outcomes of cancer therapy administered to treatment-naïve lung cancer patients in the intensive care unit

Objectives: Therapy outcomes for newly diagnosed, critically ill lung cancer patients have seldom been evaluated. This study evaluated therapy outcomes for treatment-naïve lung cancer patients in the intensive care unit (ICU). Materials and Methods: Patients were excluded if they had previously received lung cancer treatment, such as systemic chemotherapy, targeted therapy, radiotherapy, or surgical lung resection before ICU admission. The therapeutic strategies for the treatment-naïve patients were determined while they were in the ICU. The patients' demographic data, clinical outcomes, and treatment-related toxicities were analyzed. Results: Newly diagnosed lung cancer patients (n = 72) who did not receive any anticancer treatment before ICU admission were included. Most patients had locally advanced disease, and 61 (84.7%) required intensive care due to cancer-related events. In the ICU, 24 (33.3%) patients received chemotherapy, 24 (33.3%) received epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) therapy and 24 (33.3%) received best supportive care (BSC). Patients receiving chemotherapy or EGFR-TKIs in the ICU demonstrated better ICU (p = 0.011) and in-hospital (p = 0.034) survival than those receiving BSC only. Among patients requiring mechanical ventilation, those receiving chemotherapy had higher weaning rates than those receiving EGFR-TKIs or BSC (p = 0.002). In multivariate analysis, receipt of chemotherapy (hazard ratio [HR], 0.443; p = 0.083) and mechanical ventilation (HR, 0.270; p = 0.022) were significantly associated with longer ICU survival after adjusting for clinical factors. Conclusions: Anticancer therapy in the ICU might provide better short-term ICU survival for treatment-naïve, critically ill lung cancer patients.

Early Palliative Care Reduces End-of-Life Intensive Care Unit (ICU) Use but Not ICU Course in Patients with Advanced Cancer

BACKGROUND

Early palliative care for advanced cancer patients improves quality of life and survival, but less is known about its effect on intensive care unit (ICU) use at the end of life. This analysis assessed the effect of a comprehensive early palliative care program on ICU use and other outcomes among patients with advanced cancer.

PATIENTS AND METHODS

A retrospective cohort of patients with advanced cancer enrolled in an early palliative care program (n = 275) was compared with a concurrent control group of patients receiving standard care (n = 195) during the same time period by using multivariable logistic regression analysis. The multidisciplinary outpatient palliative care program used early end-of-life care planning, weekly interdisciplinary meetings to discuss patient status, and patient-reported outcomes assessment integrated within the electronic health record.

RESULTS

Patients in the control group had statistically significantly higher likelihood of ICU admission at the end of life (odds ratios [ORs]: last 6 months, 3.07; last month, 3.59; terminal admission, 4.69), higher likelihood of death in the hospital (OR, 4.14) or ICU (OR, 5.57), and lower likelihood of hospice enrollment (OR, 0.13). Use of chemotherapy or radiation did not significantly differ between groups, nor did length of ICU stay, code status, ICU procedures (other than cardiopulmonary resuscitation), disposition location, and outcomes after ICU admission.

CONCLUSION

Early palliative care significantly reduced ICU use at the end of life but did not change ICU events. This study supports early initiation of palliative care for advanced cancer patients before hospitalizations and intensive care. The Oncologist 2017;22:318-323 IMPLICATIONS FOR PRACTICE: Palliative care has shown clear benefit in quality of life and survival in advanced cancer patients, but less is known about its effect on intensive care. This retrospective cohort study at a university hospital showed that in the last 6 months of life, palliative care significantly reduced intensive care unit (ICU) and hospital admissions, reduced deaths in the hospital, and increased hospice enrollment. It did not, however, change patients' experiences within the ICU, such as number of procedures, code status, length of stay, or disposition. The findings further support that palliative care exerts its benefit before, rather than during, the ICU setting.

[Limitations of active therapeutic and palliative care in chronic respiratory disease]

The issue of intensive and palliative care in patients with chronic disease frequently arises. This review aims to describe the prognostic factors of chronic respiratory diseases in stable and in acute situations in order to improve the management of these complex situations. The various laws on patients' rights provide a legal framework and define the concept of unreasonable obstinacy. For patients with chronic obstructive pulmonary disease, the most robust decision factors are good knowledge of the respiratory disease, the comorbidities, the history of previous exacerbations and patient preferences. In the case of idiopathic pulmonary fibrosis, it is necessary to know if there is a prospect of transplantation and to assess the reversibility of the respiratory distress. In the case of amyotrophic lateral sclerosis, treatment decisions depend on the presence of advance directives about the use of intubation and tracheostomy. For lung cancer patients, general condition, cancer history and the tumor treatment plan are important factors. A multidisciplinary discussion that takes into account the patient's medical history, wishes and the current state of knowledge permits the taking of a coherent decision.

Rate and patterns of ICU admission among colorectal cancer patients: a single-center experience

PURPOSE

The purposes of this study were to evaluate, in colorectal cancer patients, the cause of ICU admission and to find predictors of death during and after hospitalization.

METHODS

This is a retrospective study including all patients with colorectal cancer admitted in the ICU of a cancer hospital from January 1st 2003 to December 31 2012.

RESULTS

Among 3721 ICU admissions occurring during the study period, 119 (3.2 %) admissions dealt with colorectal cancer, of whom 89 were eligible and assessable. The main reasons for admission were of metabolic (24 %), hemodynamic (19 %), cardiovascular (18 %), gastrointestinal (16 %), respiratory (13 %), or neurologic (6 %) origin. These complications were due to cancer in 43 %, to the antineoplastic treatment in 25 %, or were unrelated to the cancer or its treatment in 33 %. A quarter of the patients died during hospitalization. Independent predictors of death were the Sequential Organ Failure Assessment (SOFA) score (with risk of dying increasing by 42 % per unit of SOFA score), fever (with risk of dying multiplied by three per °C), and high values of GOT (with risk of dying multiplied by 1 % per unit increase), while cancer control (i.e., stage progression or not), compliance to the initial cancer treatment plan, and LDH ≤ median levels had prognostic significance for further longer survival after hospital discharge.

CONCLUSION

This is the first study looking at specific causes for unplanned ICU admission of patients with colorectal cancer. Hospital mortality was influenced by the characteristics of the complication that entailed the ICU admission while cancer characteristics retained their prognostic influence on survival after hospital discharge.

[The patient with lung cancer in intensive care]

In Western countries, lung cancer (LC) is the most common cause of cancer death. It is present in 15-20% of patients admitted to the ICU with a neoplastic condition. The purpose of this article is to review the causes of admission to ICU of patients with LC, their prognosis and the results of different life-support techniques. Most studies include mixed populations of non-small cell (NSCLC) and small-cell lung cancers (SCLC). However, there is preponderance of NSCLC (70%) and LC of advanced or metastatic stages, reflecting the distribution in the general population of LC. The cause of admission of LC patients to ICU is most often of respiratory origin. The ICU mortality rate currently ranges from 13 to 47% and the hospital mortality rate from 24 to 65%. The predictors of in-hospital mortality are mainly severity scores, organ dysfunction, general condition (performance status), respiratory distress and the need for mechanical ventilation or vasopressor drugs. When considering the long-term mortality, it is the features of the cancer (presence of metastases, cancer progression) that are important predictive factors.

Outcomes and prognostic factors of patients with lung cancer and pneumonia-induced respiratory failure in a medical intensive care unit: a single-center study

PURPOSE

To evaluate the outcomes and prognostic factors of 28-day mortality following medical intensive care unit (MICU) admission of patients with lung cancer and pneumonia-induced respiratory failure.

MATERIALS AND METHODS

Patients admitted to the MICU of a tertiary referral hospital between 2000 and 2009 were retrospectively studied.

RESULTS

In total, 143 patients were included. Their mean age was 65±8 years and 94% were male. The 28-day mortality rate was 57%. Multivariate analysis was performed to identify variables associated with 28-day mortality. At 72 hours after admission, a history of radiotherapy (OR=2.80, 95% CI: 1.15-6.78), PaO2/FiO2 (P/F) ratio at admission of <100 mmHg (OR=5.62, 95% CI: 2.10-15.07), P/F ratio after 72 hours of <100 mmHg (OR=4.61, 95% CI: 1.24-17.15), and arterial pH after 72 hours of <7.30 (OR=5.78, 95% CI: 1.15-28.89) were associated with increased mortality.

CONCLUSIONS

The prognosis of patients with lung cancer and severe pneumonia after 72 hours of MICU management mainly depends on the severity of the underlying lung injury, which is reflected by a history of radiotherapy and a low P/F ratio, rather than on cancer stage or disease status.

The prognosis of patients with lung cancer admitted to the medical intensive care unit

AIMS

Lung cancer remains the leading cause of cancer mortality worldwide. Despite their poor prognosis, patients with lung cancer are increasingly being admitted to the medical intensive care unit (MICU) for treatment of critical illnesses. The aim of this study was to assess the outcome of patients with lung cancer who are admitted to an MICU and to identify the measurable predictors of their MICU outcome.

METHODS

We conducted retrospective analysis on 97 patients with lung cancer admitted to the MICU between 2007 and 2011.

RESULTS

The mean age ± standard deviation was 71.8 ± 6.8 years. Of the 97 patients (82 male), 73 patients (75%) had non-small cell lung cancer stage IIIB, IV and 24 patients (25%) had small cell lung cancer. The intensive care unit mortality and in-hospital mortality rates were 53.6 and 61.8%. The main reasons for MICU admission were pneumonia (n = 51) and complication of cancer management (n = 45). The predictors of poor MICU outcome were history of diabetes mellitus (P = 0.028), Acute Physiology and Chronic Health Evaluation II score (P = 0.018), need for mechanical ventilation (P = 0.014), use of vasoactive agents (P < 0.0001), the presence of acute renal failure (P < 0.0001) and presence of multiorgan failure (P < 0.0001).

CONCLUSIONS

We found that in-hospital mortality was not influenced by age, sex or performance status score of patients with lung cancer but increased with the severity of organ failure at MICU admission.

Outcome of lung cancer patients admitted to the intensive care unit with acute respiratory failure

BACKGROUND

Previous studies have shown that the outcome of lung cancer patients who were admitted to the Intensive Care Unit (ICU), especially those requiring mechanical ventilation, is extremely poor. The present study was conducted in order to assess the outcome of a recent cohort of lung cancer patients admitted to the ICU with acute respiratory failure.

METHODS

A retrospective analysis of the medical records of 105 lung cancer patients who were admitted to the ICU between January 2008 and January 2011 was performed. Severity of illness on the first day of ICU admission was assessed using the acute physiology and chronic health evaluation (APACHE) II and the sequential organ failure assessment (SOFA) scoring systems. Associated organ failure was determined according to the Knaus criteria.

RESULTS

Eighty four (80%) patients were diagnosed with non-small cell lung cancer, 14 (13.3%) with small cell lung cancer, one patient with mesothelioma, and in the remaining 6 patients, the type of lung cancer could not be determined. Significant factors on admission were APACHE II and SOFA scores, poor performance status and severe comorbidity. During ICU stay, the main risk factors for poor outcome were the long term mechanical ventilation duration, use of vasopressors, more than two organ system failures and septic condition. The overall ICU, hospital and 6-month mortality rates were 44.7% (47/105), 56.1% (59/105) and 77.1% (81/105) respectively.

CONCLUSIONS

The present data show that the medical intensive care unit outcome of lung cancer patients is improving. Further studies of patients selected to ICU admission are needed to assess long-term mortality, quality of life, ability to continue chemotherapy and economic cost.

Intensive care unit outcomes among patients with lung cancer in the surveillance, epidemiology, and end results-medicare registry

PURPOSE

Lung cancer is the leading cause of cancer-related mortality. Intensive care unit (ICU) use among patients with cancer is increasing, but data regarding ICU outcomes for patients with lung cancer are limited.

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare registry (1992 to 2007) to conduct a retrospective cohort study of patients with lung cancer who were admitted to an ICU for reasons other than surgical resection of their tumor. We used logistic and Cox regression to evaluate associations of patient characteristics and hospital mortality and 6-month mortality, respectively. We calculated adjusted associations for mechanical ventilation receipt with hospital and 6-month mortality.

RESULTS

Of the 49,373 patients with lung cancer admitted to an ICU for reasons other than surgical resection, 76% of patients survived the hospitalization, and 35% of patients were alive 6 months after discharge. Receipt of mechanical ventilation was associated with increased hospital mortality (adjusted odds ratio, 6.95; 95% CI, 6.89 to 7.01; P < .001), and only 15% of these patients were alive 6 months after discharge. Of all ICU patients with lung cancer, the percentage of patients who survived 6 months from discharge was 36% for patients diagnosed in 1992 and 32% for patients diagnosed in 2005, whereas it was 16% and 11% for patients who received mechanical ventilation, respectively.

CONCLUSION

Most patients with lung cancer enrolled in Medicare who are admitted to an ICU die within 6 months of admission. To improve patient-centered care, these results should guide shared decision making between patients with lung cancer and their clinicians before an ICU admission.

Integrating palliative care with intensive care for critically ill patients with lung cancer

With newer information indicating more favorable outcomes of intensive care therapy for lung cancer patients, intensivists increasingly are willing to initiate an aggressive trial of this therapy. Concerns remain, however, that the experience of the intensive care unit for patients with lung cancer and their families often may be distressing. Regardless of prognosis, all patients with critical illness should receive high-quality palliative care, including symptom control, communication about appropriate care goals, and support for both patient and family throughout the illness trajectory. In this article, we suggest strategies for integrating palliative care with intensive care for critically ill lung cancer patients. We address assessment and management of symptoms, knowledge and skill needed for effective communication, and interdisciplinary collaboration for patient and family support. We review the role of expert consultants in providing palliative care in the intensive care unit, while highlighting the responsibility of all critical care clinicians to address basic palliative care needs of patients and their families.

Early prediction of in-hospital mortality of patients with hemoptysis: an approach to defining severe hemoptysis

BACKGROUND

The severity of hemoptysis is usually assessed on the amount of blood expectorated, although no threshold has been agreed upon. Respiratory or hemodynamic failures are additional severity criteria but occur in few cases.

OBJECTIVES

Early identification of the in-hospital mortality determinants might be helpful to best characterize severe hemoptysis.

METHODS

This is a retrospective cohort study of consecutive patients with hemoptysis admitted to the ICU of a teaching hospital during a 14-year period. The model for early prediction of in-hospital mortality was developed on a derivation sample (67% of patients) using multiple logistic regression. Calibration and discrimination of the model were tested using the remaining validation sample. A scoring system was developed for clinical use.

RESULTS

The in-hospital mortality of the 1,087 patients (age 54 years, 71% male) was 6.5% (95% CI 5-8). Chronic alcoholism, cancer or aspergillosis, pulmonary artery involvement, infiltrates involving two quadrants or more on the admission radiograph, and mechanical ventilation at referral predicted independently mortality. The model showed good concordance between predicted and observed probabilities of death and good discrimination (receiver operating characteristic curve area 0.87; 95% CI 0.82-0.92). The model-based score (chronic alcoholism, pulmonary artery involvement, and radiographic patterns, 1 point each; cancer, aspergillosis, and mechanical ventilation, 2 points each) predicted the probability of death as follows: score 0, 1%; score 1, 2%; score 2, 6%; score 3, 16%; score 4, 34%; score 5, 58%; score 6, 79%, and score 7, 91%.

CONCLUSIONS

Our results provide useful information about the short-term prognosis of patients with hemoptysis, which could help design therapeutic approaches and management plans according to the risk of in-hospital mortality.

Clinical characteristics and outcomes of critically ill cancer patients with septic shock

OBJECTIVE

To evaluate the clinical characteristics and outcomes of critically ill cancer patients with septic shock.

DESIGN

Prospective, observational cohort study.

METHODS

Medical-surgical intensive care unit (ICU) at the Instituto Nacional de Cancerología located in Mexico City from January 2008 to February 2010. There were no interventions. Eighty-two consecutive cancer patients with septic shock aged over 18 years were prospectively included and evaluated.

RESULTS

During the study period, 620 critically ill cancer patients were admitted to ICU. Ninety-four patients were evaluated for septic shock at the request of ward onco-hematologists or surgeon oncologist responsible for the patient. After being evaluated by the intensivists, 82 patients were admitted to the ICU. Of the 82 patients, 56 (68.3%) had solid tumours and 26 (31.7%) had hematological malignancy. The most frequent sites of infection were: abdominal (57.3%) and respiratory (35.8%). Cultures were positive in 41 (50%) patients. The 63.4% of the patients had three or more organ dysfunctions on the day of their admission to the ICU. Cox multivariate analysis identified the Sequential Organ Failure Assessment (SOFA) score [hazard ratio (HR): 1.11; 95% confidence interval (95% CI): 1.02-1.19, P=0.008) and performance status (PS)≥2 (HR: 1.84; 95% CI: 1.03-3.29, P=0.040) as independent predictors of death to 3 months. The ICU mortality rate was 41.5% (95% CI: 31-52%).

CONCLUSION

The variables associated with increased mortality were the degree of organ dysfunction determined by SOFA score at ICU admission and PS≥2.

Admission of advanced lung cancer patients to intensive care unit: a retrospective study of 76 patients

BACKGROUND

Criteria for admitting patients with incurable diseases to the medical intensive care unit (MICU) remain unclear and have ethical implications.

METHODS

We retrospectively evaluated MICU outcomes and identified risk factors for MICU mortality in consecutive patients with advanced lung cancer admitted to two university-hospital MICUs in France between 1996 and 2006.

RESULTS

Of 76 included patients, 49 had non-small cell lung cancer (stage IIIB n = 20; stage IV n = 29). In 60 patients, MICU admission was directly related to the lung cancer (complication of cancer management, n = 30; cancer progression, n = 14; and lung-cancer-induced diseases, n = 17). Mechanical ventilation was required during the MICU stay in 57 patients. Thirty-six (47.4%) patients died in the MICU. Three factors were independently associated with MICU mortality: use of vasoactive agents (odds ratio [OR] 6.81 95% confidence interval [95%CI] [1.77-26.26], p = 0.005), mechanical ventilation (OR 6.61 95%CI [1.44-30.5], p = 0.015) and thrombocytopenia (OR 5.13; 95%CI [1.17-22.5], p = 0.030). In contrast, mortality was lower in patients admitted for a complication of cancer management (OR 0.206; 95%CI [0.058-0.738], p = 0.015). Of the 27 patients who returned home, four received specific lung cancer treatment after the MICU stay.

CONCLUSIONS

Patients with acute complications of treatment for advanced lung cancer may benefit from MCIU admission. Further studies are necessary to assess outcomes such as quality of life after MICU discharge.

Prognosis and Resuscitation Status of Critically Ill Patients with Lung Cancer Admitted to the Intensive Care Unit

The aims of the study were to assess the intensive care unit (ICU) outcome for critically ill patients with lung cancer, to determine the risk factors for mortality and to examine the resuscitation status on admission and during their ICU course. Data was collected from May 1999 to March 2009 for patients with lung cancer admitted to the ICU. During the study period, 51 patients with lung cancer were admitted to our ICU. The ICU and hospital mortality rates were 49 and 60%, respectively. The majority of patients were full resuscitation on admission to ICU. The resuscitation status was changed in 56% of patients during the ICU course. It is suggested that end-of-life decisions should be addressed earlier in these patients’ illnesses.

Use of intensive care in patients with nonresectable lung cancer

BACKGROUND

Admission of patients with lung cancer to the ICU has been criticized. We evaluated whether ICU admission improved 3-month survival in patients with nonresectable lung cancer. Factors associated with survival were identified.

METHODS

A retrospective study was conducted in consecutive nonsurgical patients with lung cancer admitted to three ICUs in France between 2000 and 2007, 2005 and 2007, and 2005 and 2006.

RESULTS

We included 103 patients with a median (interquartile range) Simplified Acute Physiology Score II of 33 (25-46) and logistic organ dysfunction (LOD) score of 3 (1-4). Invasive mechanical ventilation was required in 41 (40%) patients. Sixty-three (61%) patients had metastasis and 26 (25%) an Eastern Cooperative Oncology Group performance status (ECOG-PS) > 2. The reason for ICU admission was acute respiratory failure in 58 (56%) patients. Three-month survival rate was 37% (95% CI, 28%-46%). By multivariate analysis, variables associated with mortality were ECOG-PS > 2 (hazard ratio [HR], 2.65; 95% CI, 1.43-4.88), metastasis at admission (HR, 1.90; 95% CI, 1.08-3.33), and worse LOD score (HR, 1.19; 95% CI, 1.08-1.32). An LOD score decrease over the first 72 h was associated with survival.

CONCLUSIONS

Survival in nonsurgical patients with lung cancer requiring ICU admission was 37% after 90 days. Our results provide additional evidence that ICU management may be appropriate in patients with nonresectable lung cancer and organ failure.

Mechanical ventilation in cancer patients: clinical characteristics and outcomes

Acute respiratory failure with the need for mechanical ventilation is a severe and frequent complication, and a leading reason for admission to the intensive care unit (ICU) in patients with malignancies. Nevertheless, improvements in patient survival have been observed over the last decade. This article reviews the epidemiology of adult patients with malignancies requiring ventilatory support. Criteria used to assist decisions to admit a patient to the ICU and to select the initial ventilatory strategy are discussed.

Admission criteria and prognostication in patients with cancer admitted to the intensive care unit

Critical care for patients with cancer was once considered inappropriate because of a perceived poor prognosis for their long-term survival. Three decades of research has yielded evidence to support the use of critical care resources for many patients with cancer. A methodical approach to triage and evaluation of critically ill patients regardless of baseline medical diagnosis, coupled with an appreciation for the likely prognosis of their current cancer, is most likely to yield the fairest and most accurate appropriation of care. No clinical scoring system has emerged that accurately defines the severity of illness and likelihood for survival in patients with cancer. This article reviews the studies that have attempted to apply mortality prediction scales or scoring systems to these patients. Clinical judgment with incorporation of consensus opinions from the literature should be used to develop admission or restriction criteria for intensive care of patients with cancer.

Six-month prognosis of patients with lung cancer admitted to the intensive care unit

BACKGROUND

Intensive care unit (ICU) admission of patients with lung cancer remains debated because of the poor short-term prognosis. However, ICU admission of such patients should also be assessed on the possibility to administer specific anticancer treatment and the long-term outcome thereafter.

OBJECTIVES

To identify predictive factors of hospital and 6-month mortality in critically ill lung-cancer patients.

DESIGN AND SETTING

Retrospective study conducted in the ICU of a university hospital.

PATIENTS

One hundred five consecutive lung-cancer patients included between 1 January 1997 and 31 December 2006.

INTERVENTIONS

None.

RESULTS

Of the 105 patients (mean age 64.8 years), 87 (83%) had a non-small cell lung cancer (NSCLC). Extensive disease was diagnosed in 85 patients (83%) (NSCLC stages IIIB and IV or disseminated small cell lung cancer). The main reasons for ICU admission were acute respiratory failure (59%) and/or hemoptysis (45%). Forty-three patients (41%) needed mechanical ventilation (MV). The ICU, hospital and 6-month mortality rates were 43, 54 and 73%, respectively. A performance status (PS) >or=2 [odds ratio OR = 3.6 (95% confidence interval CI (1.5-8.7)] and acute respiratory failure [OR = 3.5 (95% CI (1.5-8.4)] predicted hospital mortality. In a multivariate Cox model, the cancer progression [hazard ratio HR = 6.1 (95% CI 2.2-17)] and the need for MV [HR = 3.6 (95% CI 1.35-9.4)] were independently associated with 6-month mortality. Two-thirds of the ICU survivors were able to receive anticancer treatment.

CONCLUSIONS

ICU admission should be considered in selected patients with lung cancer (PS <2, no cancer disease progression).

Critical care management of cancer patients: cause for optimism and need for objectivity

PURPOSE OF REVIEW

In the 1990s, cancer patients were described as poor candidates for ICU admission on the basis of high mortality rates and management costs. Over the last decade, however, advances in the management of malignancies and organ failures have led to substantial increases in survival. This review discusses current outcomes of critically ill cancer patients and recent insights into prognostic factors. Persistent areas of uncertainty are emphasized.

RECENT FINDINGS

New drugs, diagnostic tools, and management strategies are available for malignancies and organ failures. Survival after ICU admission has increased in patients with solid tumors, hematological malignancies, or autologous hematopoietic cell transplantation. A few patient subgroups remain poor candidates for ICU management (i.e., allogeneic hematopoietic cell transplantation recipients and patients with advanced lung cancer). Careful evaluation of potential benefits from ICU admission is crucial to limit inappropriate ICU admission, nonbeneficial care, and suboptimal resource utilization.

SUMMARY

ICU admission of selected cancer patients leads to meaningful survival. The optimal time of ICU admission needs to be determined, and patient selection criteria by both hemato-oncologists and intensivists should be improved. Long-term studies of overall survival, disease-free survival, and quality of life are needed.

[Bronchial carcinoma and intensive care]

INTRODUCTION

Lung cancer is a disease with a poor prognosis. Therapeutic innovations in oncology and the optimisation of intensive care patient management have improved the prognosis of lung cancer presenting with acute life-threatening respiratory or cardiac emergencies.

OBSERVATION

We reported on the case of a patient with lung cancer presenting with mildly abundant haemoptysis, who was hospitalised in intensive care. After multidisciplinary discussion, the patient was intubated following recurrent haemorrhage that resulted in respiratory failure. The outcome was favourable. Four months later, this patient was still alive and autonomous.

DISCUSSION

After years of pessimism, the medical literature has revealed an improvement in lung cancer patients' survival. Respiratory failure and shock are the main reasons for admission to the intensive care unit. The mortality risk factors depend more on acute conditions than on the underlying lung cancer. The patient's admission must be made before multiorgan failure occurs, along with the implementation of non invasive therapies. The use of intensive care as a bridge to overcome an acute event is a possible means of caring for the patient.

CONCLUSION

Consideration of the acute event is important when deciding whether to hospitalise a patient with lung cancer in intensive care. An early admission, if indicated, is desirable. The course in the first 72hours provides a good estimation of the patient's prognosis and helps to achieve better treatment.

Long-term functional outcome and performance status after intensive care unit re-admission: a prospective survey

BACKGROUND

Intensive care unit (ICU) re-admission identifies a high-risk group in terms of hospital mortality, length of stay, and resource utilization. Only hospital and ICU mortality are well described in the literature on critically ill patients needing re-admission.

METHODS

With ethical committee approval, from a prospectively collected database of all admissions to a combined medical and surgical ICU from January 1 to December 31, 2004, we identified all ICU re-admissions from within the hospital and analysed the factors associated with increased incidence of re-admission. At 2-3 yr after discharge, we evaluated the functional outcome of the surviving re-admitted patients as Glasgow Outcome Score (GOS) and Karnofsky index and identified determinants of both mortality and good functional outcome.

RESULTS

Seventy-three (7.4%) of the 1061 patients who survived their first ICU stay were re-admitted during the study period. Of the 73 re-admitted patients, 14 died in ICU, 17 died later in the same hospital stay, and 10 died in the interim. Thus, 32 (43.8%) were alive 2-3 yr after discharge. The median [IQR] GOS of the survivors was 4 (see Mackle and colleagues in One year outcome of intensive care patients with decompensated alcoholic liver disease.

CONCLUSIONS

Although the ICU, hospital, and subsequent mortalities are high in patients after ICU re-admission, most survivors at 2-3 yr had by then made a good functional recovery and were independent.

Trends in end-of-life ICU use among older adults with advanced lung cancer

BACKGROUND

There is increasing concern about the appropriateness of intensive medical care near the end of life in ICUs throughout the United States. As a result of hospice expansion in the 1990s, we hypothesized that ICU use decreased over time in older adults with advanced lung cancer.

METHODS

Retrospective analysis using the linked Surveillance, Epidemiology and End Results Medicare database. There were 45,627 Medicare beneficiaries > or = 66 years of age with confirmed stage IIIB or IV lung cancer between January 1, 1992, and December 31, 2002, who died within a year of their cancer diagnosis from 1993 through 2002.

RESULTS

ICU use in the last 6 months of life increased from 17.5% in 1993 to 24.7% in 2002 (p < 0.001). After adjusting for patient characteristics, there was a 6.6% annual increase in ICU use from 1993 to 2002. During the same period, hospice use had risen from 28.8 to 49.9% (p < 0.001). A total of 6.2% of patients received both end-of-life ICU care and hospice care, a percentage that increased over time. The total health-care cost for Medicare fee-for-service patients during last 6 months was $40,929 for ICU users and $27,160 for non-ICU users (p < 0.001).

CONCLUSION

Despite increasing hospice use, ICU utilization among older adults dying with advanced lung cancer continued to rise in the United States during the 1990s.

Prognosis of lung cancer patients with life-threatening complications

BACKGROUND

The management of patients with lung cancer has improved recently, and many of them will require admission to the ICU. The aims of this study were to determine hospital mortality and to identify risk factors for death in a large cohort of critically ill patients.

METHODS

Cohort study in two ICUs specialized in the management of patients with cancer, in France and Brazil.

RESULTS

Of the 143 patients (mean age, 61.6 +/- 9.9 years [+/- SD]), 25 patients (17%) had small cell lung cancer and 118 patients (83%) had non-small cell lung cancer. The main reasons for ICU admission were sepsis (44%) and acute respiratory failure (31%). Mechanical ventilation (MV) was used in 100 patients (70%), including 38 patients in whom lung cancer was considered a reason for MV. Hospital mortality was 59% overall and 69% in patients receiving MV. By multivariate logistic regression, airway infiltration or obstruction by cancer, number of organ failures, cancer recurrence or progression, and severity of comorbidities were associated with increased mortality.

CONCLUSIONS

The improved survival previously reported in patients with cancer admitted to the ICU seems to extend to patients with lung cancer, including those who need MV. Mortality increased with the number of organ failures, severity of comorbidities, and presence of respiratory failure due to cancer progression. The type of the cancer per se was not associated with mortality and, therefore, should not be factored into ICU triage decisions.

Long-term outcomes and clinical predictors of hospital mortality in very long stay intensive care unit patients: a cohort study

Introduction

Little information is available on prognosis and outcomes of very long stay intensive care unit (ICU) patients. The purpose of this study was to identify long-term outcomes after hospital discharge and readily available clinical predictors of hospital mortality for patients requiring prolonged care in the ICU.

Method

Clinical data were collected from consecutive patients requiring at least 30 days of ICU care admitted over 3 calendar years (2001 to 2003) to a medical/surgical ICU in a university-affiliated tertiary care centre.

Results

A total of 182 patients met the inclusion criteria, with a mean age of 63 years, median ICU stay of 48.5 days (interquartile range 36–78 days) and ICU mortality of 32%. They accounted for 8% of total admissions and 48% of total occupied beds. Of these patients, 42% died in hospital, 44% returned to their previous place of residence, and 14% were transferred to long-term care institutions. By 6 months after hospital discharge a further 8% of the patients had died, 40% remained at their previous place of residence, and 10% were in long-term care. Predictors of hospital mortality, identified using multivariate logistic regression, included age (odds ratio [OR] 1.45 per additional decade, 95% confidence interval [CI] 1.10–1.91), any immunosuppression (OR 5.2, 95% CI 1.7–15.5), mechanical ventilation for longer than 90 days (OR 4.0, 95% CI 1.3–12.0), treatment with inotropes or vasopressors for more than 3 days at or after day 30 in the ICU (OR 7.1, 95% CI 2.6–19.3), and acute renal failure requiring dialysis at or after day 30 in the ICU (OR 6.3, 95% CI 2.0–19.7).

Conclusion

Patients with very long stays in the ICU appear to have a reasonable chance of survival, with most survivors in our cohort residing at their previous place of residence 6 months after hospital discharge. Prolonged requirement for life support therapies (ventilation, vasoactive agents, or acute dialysis) and a limited number of pre-existing co-morbidities (immunosuppression and, to a lesser extent, patient age) were predictors of increased hospital mortality. These predictors may assist in clinical decision making for this resource intensive patient population, and their reproducibility in other very long stay patient populations should be explored.

Outcome and Code Status of Lung Cancer Patients Admitted to the Medical ICU

OBJECTIVES

To determine the outcome of lung cancer patients admitted to the medical ICU (MICU), to examine their code status at MICU admission and prior to death, and to determine which subspecialty physician was responsible for the change in code status.

DESIGN

Retrospective chart review study.

SETTING

A 19-bed MICU in a tertiary-care university hospital.

PATIENTS

Consecutive patients with a diagnosis of lung cancer admitted to the MICU from July 2002 to June 2004.

MEASUREMENTS AND MAIN RESULTS

Forty-seven patients with a diagnosis of lung cancer accounted for 53 MICU admissions. Mean (+/- SD) age at MICU admission was 65 +/- 10 years. Sixty-six percent were male. Eighty-three percent had non-small cell lung cancer (NSCLC); 64% of these were stage IV NSCLC. The most common organ system implicated on MICU admission was pulmonary, with 38% of patients presenting with pneumonia. Overall MICU mortality was 43%, and in-hospital mortality was 60%. Patients who required mechanical ventilation or had more advanced lung cancer stage had the worst prognosis, with mortality rates of 74% and 68%, respectively. Seventy-four percent of patients were "full code" at MICU admission. Subsequently, the code status was changed to "do not resuscitate" in 49% of these cases. The pulmonary/critical care physician was involved in this change 96% of the time and was the sole physician in 65% of cases.

CONCLUSIONS

This study confirms that patients with lung cancer admitted to the MICU have a high mortality. Despite this, the majority of patients are full code on MICU admission. Pulmonary/critical care physicians play an important role in the end-of-life decision making of lung cancer patients admitted to the MICU, perhaps because of their availability in the MICU and also because of their sense of responsibility in maintaining and withdrawing life support.

Management of infections in critically ill neutropenic cancer patients

Because of improving antineoplastic treatment options with increasing cure rates, prolonging survival, and improving quality of life, the reluctance to admit patients with malignant disease to an intensive care unit is not justified; thus, the number of patients with malignancies treated in intensive care units rises. The use of more aggressive anticancer regimens leads to an increase of attendant infections, which are the most frequent and often life-threatening complications in cancer patients. A multidisciplinary practical approach to evaluation and treatment is needed to optimize treatment results and to meet the various diagnostic and therapeutic challenges in this subset of patients on an intensive care unit.

Cancer patients with septic shock: mortality predictors and neutropenia

GOALS OF WORK

To study outcome and its predictive factors in cancer patients admitted to the ICU with septic shock, and the implications of neutropenia as a risk factor in this advanced stage of systemic inflammatory response.

PATIENTS AND METHODS

A prospective consecutive observational cohort study was conducted in 73 adults with cancer and septic shock admitted to the ICU at the Cancer Medical Center associated with the University of Buenos Aires.

MAIN RESULTS

The mortality rate from septic shock was 53.4% (95%CI 41.9 to 64.8%). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission, the mean number of organ dysfunctions on admission or during the ICU stay, liver dysfunction, respiratory dysfunction, and the need for mechanical ventilation were predictive of mortality in a univariate analysis. Neutropenia was not associated with a worse prognosis in terms of mortality (56%) or mean days of ICU stay (6.64 days) in comparison with nonneutropenic patients (52.1% and 6.8 days) in the univariate analysis. In the logistic regression model only the need for mechanical ventilation and liver dysfunction remained independent predictors of mortality.

CONCLUSIONS

Septic shock among cancer patients admitted to the ICU has a mortality rate similar to that reported for mixed populations, and it is particularly increased when hepatic or respiratory dysfunction develop. Neutropenia on admission does not seem to modify outcome.

[High and low-risk febrile neutropenic patients]

IDENTIFICATION OF LOW-RISK PATIENTS: These patients exhibit a low probability of dying (risk equal or lesser than 1%) and of developing major complications (risk to the order of 5%). A clinical model developed by Talcott et al. considers at low risk patients at home when the fever starts, without severe co-morbidity and in whom the neoplasia is under control. A prognostic score was established by the MASCC (Multinational Association for Supportive Care in Cancer); it is based on objectively weighted and selected variables. In comparison, the Talcott's classification appears more restrictive (2.5-fold less patients at low risk) but also that it supplies greater safety. IDENTIFICATION OF HIGH-RISK PATIENTS: All the severity scores used in intensive care have their limits. However, the repeated calculation of severity scores (at 48 and 72 hours) might lead to an improvement in their predictive value. The number of organ dysfunction could also be used because the latter provides supplementary clinical information and hence the development of organ dysfunction scores over the past few Years. For febrile neutropenic patients other than in intensive care, the interest of the severity scores and organ dysfunction scores appears limited.

Intensive care unit outcomes in elderly cancer patients

As the number of elderly patients receiving oncologic therapies increases, the need for better outcome predictors for the critically ill elderly with cancer increases. Physicians should not view age as an indicator of poor ICU outcome, as many elderly patients with cancer will derive the same benefit from intensive care as their younger counterparts. Such a gain can be accomplished without overuse of valuable resources. Similar prognostic factors that are applied to the younger cancer patients should also be applied to the elderly. These parameters, in addition to clinical judgment, can be helpful in deciding who will benefit from ICU care regardless of age. Oncologists and critical care physicians will need to collaborate and change the paradigm of ICU care for the elderly.