Determinants of 6-month survival of critically ill patients with an active hematologic malignancy

Development and Validation of a Prediction Model for 1-Year Mortality in Patients With a Hematologic Malignancy Admitted to the ICU

OBJECTIVES

To develop and validate a prediction model for 1-year mortality in patients with a hematologic malignancy acutely admitted to the ICU.

DESIGN

A retrospective cohort study.

SETTING

Five university hospitals in the Netherlands between 2002 and 2015.

PATIENTS

A total of 1097 consecutive patients with a hematologic malignancy were acutely admitted to the ICU for at least 24 h.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We created a 13-variable model from 22 potential predictors. Key predictors included active disease, age, previous hematopoietic stem cell transplantation, mechanical ventilation, lowest platelet count, acute kidney injury, maximum heart rate, and type of malignancy. A bootstrap procedure reduced overfitting and improved the model's generalizability. This involved estimating the optimism in the initial model and shrinking the regression coefficients accordingly in the final model. We assessed performance using internal-external cross-validation by center and compared it with the Acute Physiology and Chronic Health Evaluation II model. Additionally, we evaluated clinical usefulness through decision curve analysis. The overall 1-year mortality rate observed in the study was 62% (95% CI, 59-65). Our 13-variable prediction model demonstrated acceptable calibration and discrimination at internal-external validation across centers (C-statistic 0.70; 95% CI, 0.63-0.77), outperforming the Acute Physiology and Chronic Health Evaluation II model (C-statistic 0.61; 95% CI, 0.57-0.65). Decision curve analysis indicated overall net benefit within a clinically relevant threshold probability range of 60-100% predicted 1-year mortality.

CONCLUSIONS

Our newly developed 13-variable prediction model predicts 1-year mortality in hematologic malignancy patients admitted to the ICU more accurately than the Acute Physiology and Chronic Health Evaluation II model. This model may aid in shared decision-making regarding the continuation of ICU care and end-of-life considerations.

A Systematic Review and Meta-Analysis Evaluating Geographical Variation in Outcomes of Cancer Patients Treated in ICUs

The reported mortality rates of cancer patients admitted to ICUs vary widely. In addition, there are no studies that examined the outcomes of critically ill cancer patients based on the geographical regions. Therefore, we aimed to evaluate the mortality rates among critically ill cancer patients and provide a comparison based on geography.

DATA SOURCES

PubMed, EMBASE, and Web of Science.

STUDY SELECTION

We included observational studies evaluating adult patients with cancer treated in ICUs. We excluded non-English studies, those with greater than 30% hematopoietic stem cell transplant or postsurgical patients, and those that evaluated a specific type of critical illness, stage of malignancy, or age group.

DATA EXTRACTION

Two reviewers independently applied eligibility criteria, assessed quality, and extracted data. Studies were classified based on the continent in which they were conducted. Primary outcomes were ICU and hospital mortality. We pooled effect sizes by geographical region.

DATA SYNTHESIS

Forty-six studies were included (n = 110,366). The overall quality of studies was moderate. Most of the published literature was from Europe (n = 22), followed by North America (n = 9), Asia (n = 8), South America (n = 5), and Oceania (n = 2). Pooled ICU mortality rate was 38% (95% CI, 33-43%); the lowest mortality rate was in Oceania (26%; 95% CI, 22-30%) and highest in Asia (51%; 95% CI, 44-57%). Pooled hospital mortality rate was 45% (95% CI, 41-49%), with the lowest in North America (37%; 95% CI, 31-43%) and highest in Asia (54%; 95% CI, 37-71%).

CONCLUSIONS

More than half of cancer patients admitted to ICUs survived hospitalization. However, there was wide variability in the mortality rates, as well as the number of available studies among geographical regions. This variability suggests an opportunity to improve outcomes worldwide, through optimizing practice and research.

Management strategy for hematological malignancy patients with acute respiratory failure

Acute respiratory failure (ARF) is still the major cause of intensive care unit (ICU) admission for hematological malignancy (HM) patients although the advance in hematology and supportive care has greatly improved the prognosis. Clinicians have to make decisions whether the HM patients with ARF should be sent to ICU and which ventilation support should be administered. Based on the reported investigations related to management of HM patients with ARF, we propose a selection procedure to manage this population and recommend hematological ICU as the optimal setting to recuse these patients, where hematologists and intensivists can collaborate closely and improve the outcomes. Moreover, noninvasive ventilation (NIV) still has its own place for selected HM patients with ARF who have mild hypoxemia and reversible causes. It is also crucial to monitor the efficacy of NIV closely and switch to invasive mechanical ventilation at appropriate timing when NIV shows no apparent improvement. Otherwise, early IMV should be initiated to HM with ARF who have moderate and severe hypoxemia, adult respiratory distress syndrome, multiple organ dysfunction, and unstable hemodynamic. More studies are needed to elucidate the predictors of ICU mortality and ventilatory mode for HM patients with ARF.

Short- and long-term outcomes of neutropenic cancer patients in intensive care according to requirement for invasive ventilation

BACKGROUND

Neutropenic fever is a frequently encountered complication when caring for cancer patients and can lead to intensive care admission, with high mortality rates in those patients who require invasive mechanical ventilation (IMV). Although hospital survival in this population has improved, long-term outcomes of critically ill neutropenic cancer patients have not been well defined.

AIMS

To evaluate short- and long-term outcomes of neutropenic cancer patients admitted to intensive care, according to requirement for invasive ventilation. Additionally, we aimed to determine predictors of poor clinical outcomes in this group.

METHODS

A retrospective cohort study of neutropenic cancer patients admitted to our intensive care unit (ICU) from 2008 to 2016.

RESULTS

We included 192 cancer patients of whom 100 (52.1%) required IMV. Overall ICU mortality was 29.7% and 12-month post-ICU mortality was 61.5%. Patients requiring IMV had significantly higher short- and long-term mortality (P < 0.001). Multivariate analysis determined three variables to be predictors of mortality at ICU discharge in the whole cohort: IMV (OR 13.52), renal replacement therapy (RRT, OR 2.37) and higher APACHE II scores (OR 1.1 for each unit increase). These variables were identical in the subgroup requiring invasive ventilation, with RRT (OR 2.76) and APACHE II scores (OR 1.1 for each unit increase) predicting short-term mortality.

CONCLUSION

Neutropenic cancer patients admitted to ICU have lower short-term mortality than previously reported in cohort studies, however their mortality rises significantly following discharge from ICU. Those patients who require IMV are at significantly increased risk of both short- and long-term mortality.

Factors associated with non-invasive mechanical ventilation failure in patients with hematological neoplasia and their association with outcomes

BACKGROUND

The usefulness of non-invasive mechanical ventilation (NIMV) in oncohematological patients is still a matter of debate.

AIM

To analyze the rate of noninvasive ventilation failure and the main characteristics associated with this endpoint in oncohematological patients with acute respiratory failure (ARF).

METHODS

A ventilatory support protocol was developed and implemented before the onset of the study. According to the PaO2/FiO2 (P/F) ratio and clinical judgment, patients received supplementary oxygen therapy, NIMV, or invasive mechanical ventilation (IMV).

RESULTS

Eighty-two patients were included, average age between 52.1 ± 16 years old; 44 (53.6%) were male. The tested protocol was followed in 95.1% of cases. Six patients (7.3%) received IMV, 59 (89.7%) received NIMV, and 17 (20.7%) received oxygen therapy. ICU mortality rates were significantly higher in the IMV (83.3%) than in the NIMV (49.2%) and oxygen therapy (5.9%) groups (P < 0.001). Among the 59 patients who initially received NIMV, 30 (50.8%) had to eventually be intubated. Higher SOFA score at baseline (1.35 [95% CI = 1.12-2.10], P = 0.007), higher respiratory rate (RR) (1.10 [95% CI = 1.00-1.22], P = 0.048), and sepsis on admission (16.9 [95% CI = 1.93-149.26], P = 0.011) were independently associated with the need of orotracheal intubation among patients initially treated with NIMV. Moreover, NIMV failure was independently associated with ICU (P < 0.001) and hospital mortality (P = 0.049), and mortality between 6 months and 1 year (P < 0.001).

CONCLUSION

The implementation of a NIMV protocol is feasible in patients with hematological neoplasia admitted to the ICU, even though its benefits still remain to be demonstrated. NIMV failure was associated with higher SOFA and RR and more frequent sepsis, and it was also related to poor prognosis.

Intensive care unit outcomes in patients with hematological malignancy

Hematological malignancies are usually life-limiting conditions. Limitations of care need to be decided early, based on acceptability to the patient, family, physician, and community. Inappropriate intensive care unit (ICU) admission is likely to result in significant physical, psychological, and economic burden. There is little published on the impact of non-acute preadmission disease factors on ICU outcomes in hematological malignancies.

Factors predicting long-term survival of patients with sepsis on arrival at the emergency department: A single-center, observational study

Predicting long-term outcomes after sepsis is important when caring for patients with this condition. The purpose of the present study was to develop models predicting long-term mortality of patients with sepsis, including septic shock.Retrospective data from 446 patients with sepsis (60.8% men; median age, 71 years) treated at a single university-affiliated tertiary care hospital over 3 years were reviewed. Binary logistic regression was used to identify factors predicting mortality at 180 and 365 days after arrival at the emergency department. Long-term prognosis scores for the 180- and 365-day models were calculated by assigning points to variables according to their β coefficients.The 180- and 365-day mortality rates were 40.6% and 47.8%, respectively. Multivariate analysis identified the following factors for inclusion in the 180- and 365-day models: age ≥65 years, body mass index ≤18.5 kg/m, hemato-oncologic diseases as comorbidities, and ventilator care. Patients with scores of 0 to ≥3 had 180-day survival rates of 83.8%, 70.8%, 42.3%, and 25.0%, respectively, and 365-day survival rates of 72.1%, 64.6%, 36.2%, and 15.9%, respectively (all differences P < .001; log-rank test). The areas under the receiver operating characteristic curves of the 180- and 365-day models were 0.713 (95% confidence interval [CI] 0.668-0.756, P < .001) and 0.697 (95% CI 0.650-0.740, P < .001), respectively.These long-term prognosis models based on baseline patient characteristics and treatments are useful for predicting the 6- and 12-month mortality rates of patients with sepsis.