Prognosis of hematologic malignancies does not predict intensive care unit mortality

Microbiological risk factors, ICU survival, and 1-year survival in hematological patients with pneumonia requiring invasive mechanical ventilation

PURPOSE

To identify pathogenic microorganisms and microbiological risk factors causing high morbidity and mortality in immunocompromised patients requiring invasive mechanical ventilation due to pneumonia.

METHODS

A retrospective single-center study was performed at the intensive care unit (ICU) of the Department of Internal Medicine at Heidelberg University Hospital (Germany) including 246 consecutive patients with hematological malignancies requiring invasive mechanical ventilation due to pneumonia from 08/2004 to 07/2016. Microbiological and radiological data were collected and statistically analyzed for risk factors for ICU and 1-year mortality.

RESULTS

ICU and 1-year mortality were 63.0% (155/246) and 81.0% (196/242), respectively. Pneumonia causing pathogens were identified in 143 (58.1%) patients, multimicrobial infections were present in 51 (20.7%) patients. Fungal, bacterial and viral pathogens were detected in 89 (36.2%), 55 (22.4%) and 41 (16.7%) patients, respectively. Human herpesviruses were concomitantly reactivated in 85 (34.6%) patients. As significant microbiological risk factors for ICU mortality probable invasive Aspergillus disease with positive serum-Galactomannan (odds ratio 3.1 (1.2-8.0), p = 0.021,) and pulmonary Cytomegalovirus reactivation at intubation (odds ratio 5.3 (1.1-26.8), p = 0.043,) were identified. 1-year mortality was not significantly associated with type of infection. Of interest, 19 patients had infections with various respiratory viruses and Aspergillus spp. superinfections and experienced high ICU and 1-year mortality of 78.9% (15/19) and 89.5% (17/19), respectively.

CONCLUSIONS

Patients with hematological malignancies requiring invasive mechanical ventilation due to pneumonia showed high ICU and 1-year mortality. Pulmonary Aspergillosis and pulmonary reactivation of Cytomegalovirus at intubation were significantly associated with negative outcome.

Outcome and factors associated with mortality in patients receiving urgent chemotherapy in the ICU: A retrospective study

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.

Risk factors for ICU mortality in patients with hematological malignancies: a singlecenter, retrospective cohort study from Turkey

BACKGROUND

Patients with hematological malignancies (HM) often require admission to the intensive care unit (ICU) due to organ failure, disease progression or treatment-related complications, and they generally have a poor prognosis. Therefore, understanding the factors affecting ICU mortality in HM patients is important. In this study, we aimed to identify the risk factors for ICU mortality in our critically ill HM patients.

METHODS

We retrospectively reviewed the medical records of HM patients who were hospitalized in our medical ICU between January 1, 2010 and December 31, 2018. We recorded some parameters of these patients and compared these parameters by statistically between survivors and nonsurvivors to determine the risk factors for ICU mortality.

RESULTS

The study included 368 critically ill HM patients who were admitted to our medical ICU during a 9-year period. The median age was 58 (49-67) years and 63.3% of the patients were male. Most of the patients (43.2%) had acute leukemia. Hematopoietic stem cell transplantation (HSCT) was performed in 153 (41.6%) patients. The ICU mortality rate was 51.4%. According to univariable analyses, a lot of parameters (e.g., admission APACHE II and SOFA scores, length of ICU stay, some laboratory parameters at the ICU admission, the reason for ICU admission, comorbidities, type of HM, type of HSCT, infections on ICU admission and during ICU stay, etc.) were significantly different between survivors and nonsurvivors. However, only high SOFA scores at ICU admission (OR:1.281, p = 0.004), presence of septic shock (OR:17.123, p = 0.0001), acute kidney injury (OR:48.284, p = 0.0001), and requirement of invasive mechanical ventilation support during ICU stay (OR:23.118, p = 0.0001) were independent risk factors for ICU mortality.

DISCUSSION

In our cohort, critically ill HM patients had high ICU mortality. We found four independent predictors for ICU mortality. Yet, there is still a need for further research to better understand poor outcome predictors in critically ill HM patients.

Outcomes and Prognostic Factors in Critical Patients with Hematologic Malignancies

Patients with hematologic malignancies (HMs) have a significantly elevated risk of mortality compared to other cancer patients treated in the intensive care unit (ICU). The prognostic impact of numerous poor outcome indicators has changed, and research has yielded conflicting results. This study aims to determine the ICU and hospital outcomes and risk factors that predict the prognosis of critically ill patients with HMs. In this retrospective study, conducted at a referral hospital in Taiwan, 213 adult patients with HMs who were admitted to the medical ICU were evaluated. We collected clinical data upon hospital and ICU admission. Using a multivariate regression analysis, the predictors of ICU and hospital mortality were assessed. Then, a scoring system (Hospital outcome of critically ill patients with Hematological Malignancies (HHM)) was built to predict hospital outcomes. Most HMs (76.1%) were classified as high grade, and more than one-third of patients experienced a relapsed or refractory disease. The ICU and hospital mortality rates were 55.9% and 71.8%, respectively. Moreover, the disease severity was high (median Sequential Organ Failure Assessment (SOFA) score: 11 and Acute Physiology and Chronic Health Evaluation (APACHE II) score: 28). The multivariate analysis revealed that high-grade HMs, invasive mechanical ventilation requirement, renal replacement therapy initiation in the ICU, and a high SOFA score correlated with ICU mortality. Furthermore, a higher HHM score predicted hospital mortality. This study demonstrates that ICU mortality primarily correlates with the severity of organ dysfunction, whereas the disease status markedly influences hospital outcomes. Furthermore, the HHM score significantly predicts hospital mortality.

Critical care for multimorbid patients

Multimorbidity - the simultaneous presence of several chronic diseases - is very common in the critically ill patients. Its prevalence is roughly 40-85 % and continues to increase further. Certain chronic diseases such as diabetes, obesity, chronic heart, pulmonary, liver or kidney disease and malignancy are associated with higher risk of developing serious acute complications and therefore the possible need for intensive care. This review summarizes and discusses selected specifics of critical care for multimorbid patients.

Outcome Prediction of Hematologic Malignancy in Critically Sick People

People with hematologic malignancies (HM) frequently postulate intensive care unit (ICU) hospitalization due to organ damage caused by the disease process or treatment-related consequences. This study is aimed at looking at mortality and sign factors in adult patients with hematologic malignancy (HM) who have been hospitalized in the ICU. Death was one quality indicator; researchers used a machine learning approach to find determinants of death. As per the study, there have been 206 patients hospitalized in the ICU (mean age: 51.3 ± 13.6 years; 60% male). The average length of stay was three days, with 14.1% requiring extended ICU commitment. ICU death was 45.6% at 30 days, 62.6% at sixty days, and 74.3% at twelve months, rising to 59.2% at thirty days, 62.6% at sixty days, and 74.3% at twelve months. Ventilation systems and vasodilating medication were linked to higher ICU death, but admission to the ICU surgically and experiencing malignancies are linked with lower death rates. Patients with HM who are hospitalized in the ICU have a high mortality rate (45.6%), which rises to 74.3% after a year. Serious illness, postsurgical hospitalization, and malignancy were revealed as determinants of patient outcomes in multivariate analyses.

Critical care management of chimeric antigen receptor T-cell therapy recipients

Chimeric antigen receptor (CAR) T-cell therapy is a promising immunotherapeutic treatment concept that is changing the treatment approach to hematologic malignancies. The development of CAR T-cell therapy represents a prime example for the successful bench-to-bedside translation of advances in immunology and cellular therapy into clinical practice. The currently available CAR T-cell products have shown high response rates and long-term remissions in patients with relapsed/refractory acute lymphoblastic leukemia and relapsed/refractory lymphoma. However, CAR T-cell therapy can induce severe life-threatening toxicities such as cytokine release syndrome, neurotoxicity, or infection, which require rapid and aggressive medical treatment in the intensive care unit setting. In this review, the authors provide an overview of the state-of-the-art in the clinical management of severe life-threatening events in CAR T-cell recipients. Furthermore, key challenges that have to be overcome to maximize the safety of CAR T cells are discussed.

Critically ill cancer patient's resuscitation: a Belgian/French societies' consensus conference

To respond to the legitimate questions raised by the application of invasive methods of monitoring and life-support techniques in cancer patients admitted in the ICU, the European Lung Cancer Working Party and the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique, set up a consensus conference. The methodology involved a systematic literature review, experts' opinion and a final consensus conference about nine predefined questions1. Which triage criteria, in terms of complications and considering the underlying neoplastic disease and possible therapeutic limitations, should be used to guide admission of cancer patient to intensive care units?2. Which ventilatory support [High Flow Oxygenation, Non-invasive Ventilation (NIV), Invasive Mechanical Ventilation (IMV), Extra-Corporeal Membrane Oxygenation (ECMO)] should be used, for which complications and in which environment?3. Which support should be used for extra-renal purification, in which conditions and environment?4. Which haemodynamic support should be used, for which complications, and in which environment?5. Which benefit of cardiopulmonary resuscitation in cancer patients and for which complications?6. Which intensive monitoring in the context of oncologic treatment (surgery, anti-cancer treatment …)?7. What specific considerations should be taken into account in the intensive care unit?8. Based on which criteria, in terms of benefit and complications and taking into account the neoplastic disease, patients hospitalized in an intensive care unit (or equivalent) should receive cellular elements derived from the blood (red blood cells, white blood cells and platelets)?9. Which training is required for critical care doctors in charge of cancer patients?

Prognostic factors for patients with multiple myeloma admitted to the intensive care unit

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.

Determination of the relationship between mortality and SOFA, qSOFA, MASCC scores in febrile neutropenic patients monitored in the intensive care unit

PURPOSE

Febrile neutropenia (FN) is a hematological emergency. It is challenging and confusing for the clinicians to make the decision of the febrile neutropenic patients under chemotherapy to be monitored at intensive care unit (ICU). The aim of this study was to define the factors supporting decision-making for the critical patients with febrile neutropenia.

METHODS

The data of 60 patients, who were taken to the ICU while they were under treatment in the Hematology Clinic with a diagnosis of febrile neutropenia, were analyzed retrospectively, in order to identify clinically useful prognostic parameters.

RESULTS

The ICU mortality rate was 80%. Mortality was significantly associated with higher sequential organ failure assessment score (SOFA), quick sequential organ failure assessment score (qSOFA), and hematological SOFA (SOFAhem) scores on admission. All cases having SOFA score 10 and above and qSOFA score 2 and above died. In multivariate analysis, qSOFA score was found to be statistically significant in predicting mortality in regard to ICU admission (p = 0.004).

CONCLUSION

Mortality of febrile neutropenic patients admitted to ICU is high. It would be appropriate to determine the extent of organ dysfunction instead of underlying disease, for making the decision of ICU admission. It should be noticed that the risk mortality is high for the FN cases with SOFA score 10 or above, qSOFA score 2 or above, and in need of mechanical ventilation and positive inotropic support; hence, early intervention is recommended. In our study, the most significant parameter in predicting ICU mortality was found to be qSOFA.

Predictors of intensive care unit admission in patients with hematologic malignancy

Limited data exist on predictors of intensive care unit (ICU) admission in patients with hematologic malignancy. The objective of this study was to identify predictors of ICU admission in hospitalized patients with hematologic malignancies. A retrospective cohort study was conducted on 820 consecutive admissions of patients with a malignant hematology diagnosis at our institution between March 2009 and December 2015. Backward stepwise selection procedure was conducted for multivariable logistic regression analyses. 820 patients were included, of whom 179 (22%) were admitted to the ICU. Types of hematologic cancers included 71% (N = 578) lymphoid cancer, 18% (N = 151) myeloid cancer, and 10% (N = 80) plasma cell neoplasms. 14% (N = 111) of patients had acute leukemia. Six predictors of admission to ICU were found in multivariable analysis, including disease-related (acute leukemia, curative intent chemotherapy), laboratory-related (platelet count < 50 × 109/L, albumin below normal, LDH above normal at time of admission), and physician-related factors (having advanced directives discussion) (p < 0.0001). A significant proportion of patients with hematologic malignancies admitted to hospital are admitted to ICU. Utilizing the identified predictors of ICU admission may help guide timely informed goals of care discussions with patients before clinical deterioration occurs.

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.

Epidemiology, clinical features, and management of severe hypercalcemia in critically ill patients

BACKGROUND

Severe hypercalcemia (HCM) is a common reason for admission in intensive-care unit (ICU). This case series aims to describe the clinical and biological features, etiologies, treatments, and outcome associated with severe HCM. This study included all patients with a total calcemia above 12 mg/dL (3 mmol/L) admitted in two ICUs from January 2007 to February 2017.

RESULTS

131 patients with HCM were included. HCM was related to hematologic malignancy in 58 (44.3%), solid tumors in 29 (22.1%), endocrinopathies in 16 (12.2%), and other causes in 28 (21.3%) patients. 108 (82.4%) patients fulfilled acute kidney injury (AKI) criteria. Among them, 25 (19%) patients required renal replacement therapy (RRT). 51 (38.9%) patients presented with neurological symptoms, 73 (55.7%) patients had cardiovascular manifestations, and 50 (38.1%) patients had digestive manifestations. The use of bisphosphonates (HR, 0.42; 95% CI, 0.27-0.67; P < 0.001) was the only treatment significantly associated with a decrease of total calcemia below 12 mg/dL (3 mmol/L) at day 5. ICU and Hospital mortality rates were, respectively, 9.9% and 21.3%. Simplified Acute Physiologic Score (SAPS II) (OR, 1.05; 95% CI 1.01-1.1; P = 0.03) and an underlying solid tumor (OR, 13.83; 95% CI 2.24-141.25; P = 0.01) were two independent factors associated with hospital mortality in multivariate analysis.

CONCLUSIONS

HCM is associated with high mortality rates, mainly due to underlying malignancies. The course of HCM may be complicated by organ failures which are most of the time reversible with early ICU management. Early ICU admission and prompt HCM management are crucial, especially in patients with an underlying solid tumor presenting with neurological symptoms.

Long-Term Outcome of Patients With a Hematologic Malignancy and Multiple Organ Failure Admitted at the Intensive Care

Objectives:

Historically, patients with a hematologic malignancy have one of the highest mortality rates among cancer patients admitted to the ICU. Therefore, physicians are often reluctant to admit these patients to the ICU. The aim of our study was to examine the survival of patients who have a hematologic malignancy and multiple organ failure admitted to the ICU.

Design:

This retrospective cohort study, part of the HEMA-ICU study group, was designed to study the survival of patients with a hematologic malignancy and organ failure after admission to the ICU. Patients were followed for at least 1 year.

Setting:

Five university hospitals in the Netherlands.

Patients:

One-thousand ninety-seven patients with a hematologic malignancy who were admitted at the ICU.

Interventions:

None.

Measurements and Main Results:

Primary outcome was 1-year survival. Organ failure was categorized as acute kidney injury, respiratory failure, hepatic failure, and hemodynamic failure; multiple organ failure was defined as failure of two or more organs. The World Health Organization performance score measured 3 months after discharge from the ICU was used as a measure of functional outcome. The 1-year survival rate among these patients was 38%. Multiple organ failure was inversely associated with long-term survival, and an absence of respiratory failure was the strongest predictor of 1-year survival. The survival rate among patients with 2, 3, and 4 failing organs was 27%, 22%, and 8%, respectively. Among all surviving patients for which World Health Organization scores were available, 39% had a World Health Organization performance score of 0–1 3 months after ICU discharge. Functional outcome was not associated with the number of failing organs.

Conclusions:

Our results suggest that multiple organ failure should not be used as a criterion for excluding a patient with a hematologic malignancy from admission to the ICU.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Extracorporeal Life Support in Adult Patients with Hematologic Malignancies and Acute Circulatory and/or Respiratory Failure

Background

The primary goal of this study was to characterize the clinical outcomes of adult patients with hematologic malignancies (HM) who were treated with extracorporeal membrane oxygenation (ECMO) support when conventional treatments failed.

Methods

In this retrospective, observational study at a tertiary medical center, we reviewed the clinical course of 23 consecutive patients with HM requiring ECMO who were admitted to the intensive care unit at Asan Medical Center from March 2010 to April 2015.

Results

A total of 23 patients (8 female; median age, 44 years; range, 29-51 years) with HM and severe acute circulatory and/or respiratory failure received ECMO therapy during the study period. Fourteen patients received veno-arterial ECMO, while 9 patients received veno-venous ECMO. The median ECMO duration was 104.7 hours (range, 37.1-221 hours). Nine patients were successfully weaned from ECMO. The in-hospital mortality rate was 91.1% (21 of 23). There were complications in 3 patients (cannulation site bleeding, limb ischemia, and gastrointestinal bleeding).

Conclusion

ECMO is a useful treatment for patients with circulatory and/or pulmonary failure. However, in patients with HM, the outcomes of ECMO treatment results were very poor, so it is advisable to carefully decide whether to apply ECMO to these patients.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Renal recovery after severe acute kidney injury in critically ill myeloma patients: a retrospective study

Background

Despite substantial improvements in the management of multiple myeloma, renal failure remains an important burden that tremendously impairs prognosis. The purpose of this study was to describe the characteristics and to establish prognostic factors of renal recovery in myeloma patients admitted to the intensive care unit (ICU) for acute kidney injury (AKI) Stage 3 treated with renal replacement therapy (RRT).

Methods

A retrospective single-centre cohort study was performed, including consecutive myeloma patients admitted to one medical ICU between 1 January 2007 and 1 September 2015 and treated with RRT. Patients were evaluated 60 days after initiation of RRT and divided into three groups: alive without dialysis, alive and dialysis-dependent or deceased. A univariate analysis was performed to identify factors associated with renal recovery (alive without dialysis 60 days after initiation of RRT).

Results

Fifty patients were included in the study. Mean age was 63 (interquartile range: 58–70) years and 32 (64%) were male. Patients were admitted to the ICU 4 (1–7) years after the diagnosis of myeloma. Twenty-one (42%) had already been treated with high-dose therapy combined with autologous stem cell transplantation. Baseline renal function evaluated by estimated glomerular filtration rate (GFR) before ICU admission was 63 (44–90) mL/min/1.73 m². The mean SOFA score at Day 1 was 7 (4–8). The three main reasons for ICU admission were AKI (n = 31, 62%), acute pulmonary oedema (n = 17, 32%) and sepsis (n = 10, 20%). During ICU stay, RRT was implemented in all patients, 16 (32%) patients required invasive mechanical ventilation and 12 (24%) received vasopressors. The mean ICU and hospital length of stay were 6 (1–7) and 28 (13–34) days, respectively. At Day 60, 23 (46%) patients were alive without dialysis, 17 (32%) had died and 10 (20%) were still undergoing dialysis. Among the 23 patients who recovered, the mean duration of dialysis was 6 (2–18) days and renal function was not significantly different from baseline [estimated GFR at baseline = 65 (25–74) mL/min/1.73 m² versus 63 (56–70) mL/min/1.73 m² at Day 60, P = 0.70]. By univariate analysis, two factors were associated with nonrecovery of renal function at Day 60: a history of high-dose therapy combined with autologous stem cell transplantation [odds ratio (OR) = 6.1, 95% confidence interval (CI) 1.7–21.6; P = 0.008] and a proteinuria at ICU admission >370 mg/mmol creatinine (OR = 4.2, 95% CI 1.1–17; P = 0.02). None of the other variables related to the haematological malignancy or to the ICU stay was associated with renal recovery at Day 60.

Conclusions

AKI Stage 3 in critically ill myeloma patients was associated with a lower than expected hospital mortality. Patients with a high level of proteinuria and a history of high-dose therapy combined with autologous stem cell transplantation were less likely to recover their renal function at Day 60.

Key words

dialysis, intensive care, multiple myeloma, prognosis, proteinuria

Neurological failure in ICU patients with hematological malignancies: A prospective cohort study

Background

Epidemiological studies of neurological complications in patients with hematological malignancies are scant. The objective of the study was to identify determinants of survival in patients with hematological malignancy and neurological failure.

Methods

Post hoc analysis of a prospective study of adults with hematological malignancies admitted for any reason to one of 17 university or university-affiliated participating ICUs in France and Belgium (2010–2012). The primary outcome was vital status at hospital discharge.

Results

Of the 1011 patients enrolled initially, 226 (22.4%) had neurological failure. Presenting manifestations were dominated by drowsiness or stupor (65%), coma (32%), weakness (26%), and seizures (19%). Neuroimaging, lumbar puncture, and electroencephalography were performed in 113 (50%), 73 (32%), and 63 (28%) patients, respectively. A neurosurgical biopsy was done in 1 patient. Hospital mortality was 50%. By multivariate analysis, factors independently associated with higher hospital mortality were poor performance status (odds ratio [OR], 3.99; 95%CI, 1.82–9.39; P = 0.0009), non-Hodgkin’s lymphoma (OR, 2.60; 95%CI, 1.35–5.15; P = 0.005), shock (OR, 1.95; 95%CI, 1.04–3.72; P = 0.04), and respiratory failure (OR, 2.18; 95%CI, 1.14–4.25; P = 0.02); and factors independently associated with lower hospital mortality were GCS score on day 1 (OR, 0.88/point; 95%CI, 0.81–0.95; P = 0.0009) and autologous stem cell transplantation (OR, 0.25; 95%CI, 0.07–0.75; P = 0.02).

Conclusions

In ICU patients with hematological malignancies, neurological failure is common and often fatal. Independent predictors of higher hospital mortality were type of underlying hematological malignancy, poor performance status, hemodynamic and respiratory failures, and severity of consciousness impairment. Knowledge of these risk factors might help to optimize management strategies.

Critical Care Prognosis and Outcomes in Patients with Cancer

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.

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

PURPOSE

This study assessed the determinants of 6-month survival of critically ill patients with an active hematologic malignancy (HM).

METHODS

All patients with an active HM defined by either receiving ongoing or due to receive antineoplastic therapy, admitted to 2 tertiary intensive care units between 2010 and 2015, were included in this retrospective cohort study.

RESULTS

Of the 273 patients included in the study (median age, 63[interquartile range, 54-71] years; 40.7% female), 116 (42.5%; 95% confidence interval, 36.8-48.4) died in hospital. The 6-month mortality was 56.4% (95% confidence interval, 50.5-62.2). Mechanical ventilation, intensive care unit admission source, and the type of active HM were significantly associated with hospital mortality and 6-month survival, after adjusting for severity of acute illness. The type of active HM was the most important prognostic factor, with over a 10-fold difference in 6-month survival between HM with the best and worst prognosis. In addition, recent hematopoietic stem cell transplant (<30 days) was associated with a better 6-month survival.

CONCLUSION

Differences in 6-month survival between critically ill patients with different types of active HM were substantial. Recent hematopoietic stem cell transplant, severity of illness, and use of mechanical ventilation were additional important determinants of 6-month survival in patients with an active HM.

The prognostic factors for patients with hematological malignancies admitted to the intensive care unit

Owing to the nature of acute illness and adverse effects derived from intensive chemotherapy, patients with hematological malignancies (HM) who are admitted to the Intensive Care Unit (ICU) often present with poor prognosis. However, with advances in life-sustaining therapies and close collaborations between hematologists and intensive care specialists, the prognosis for these patients has improved substantially. Many studies from different countries have examined the prognostic factors of these critically ill HM patients. However, there has not been an up-to-date review on this subject, and very few studies have focused on the prognosis of patients with HM admitted to the ICU in Asian countries. Herein, we aim to explore the current situation and prognostic factors in patients with HM admitted to ICU, mainly focusing on studies published in the last 10 years.

Critical care of patients with cancer

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.

Critically ill patients with cancer: chances and limitations of intensive care medicine-a narrative review

This narrative review deals with the challenge of defining adequate therapy goals and intensive care unit (ICU) admission criteria for critically ill patients with cancer. Several specific complications of critically ill patients with cancer require close collaborations of intensive care and cancer specialists. Intensivists require a basic understanding of the pathophysiology, diagnosis and therapy of common cancer-specific problems. Cancer specialists must be knowledgeable in preventing, detecting and treating imminent or manifest organ failures. In case of one or more organ dysfunctions, ICU admissions must be evaluated early. In order to properly define the therapy goals for critically ill patients with cancer, decision-makers must be aware of the short-term intensive care prognosis as well as the long-term oncological options and perspectives. Multidisciplinary teamwork is key when it comes down to decisions on ICU admission, planning of therapeutic aims, patient management in the ICU and tailored therapy limiting with smooth transition into a palliative care (PC) setting, whenever appropriate.

Sequential Organ Failure Assessment Score Modified for Recent Infection in Patients With Hematologic Malignant Tumors and Severe Sepsis

BACKGROUND

Baseline health status influences outcomes of severe sepsis.

OBJECTIVE

To determine if recent infection is a marker of poor health in patients with hematologic malignant tumors and severe sepsis by modifying the Sequential Organ Failure Assessment (SOFA) score to account for infection.

METHODS

Medical records of the first 50 patients with hematologic malignant tumors and severe sepsis admitted from September 1, 2009 to September 1, 2014, were reviewed to derive a modified SOFA score. The predictive accuracy of the modified score was compared with that of the unmodified score and the Acute Physiology and Chronic Health Evaluation (APACHE) II score for the 196 subsequent patients.

RESULTS

The area under the receiver operator characteristic curve was 0.73 (95% CI, 0.66-0.80) for the modified score, 0.68 (95% CI, 0.61-0.76) for the unmodified score, and 0.65 (95% CI, 0.58-0.73) for the APACHE II score. The modified score was better for discriminating survivors from nonsurvivors than the unmodified score (P = .005) and the APACHE II score (P = .04). After adjustments for the modified score and age, only increased days from hospital to intensive care unit admission was significantly associated with 30-day mortality.

CONCLUSION

Modifying the SOFA score to account for infections before admission to the intensive care unit improved the prognostic usefulness of the scores for patients with hematologic malignant tumors and severe sepsis.

Management of Acute Respiratory Failure in Patients With Hematological Malignancy

Acute respiratory failure (ARF) is the leading cause of intensive care unit admission in patients with hematologic malignancies and is associated with a high mortality. The main causes of ARF are bacterial and opportunistic pulmonary infections and noninfectious lung disorders. Management consists of a systematic clinical evaluation aimed at identifying the most likely cause, which in turn determines the best first-line empirical treatments. The need for mechanical ventilation is a major determinant of prognosis. Beneficial outcomes have been demonstrated with early use of noninvasive ventilation (NIV) in selected patients with hematologic malignancies. However, most of these studies did not control the time between onset of ARF to NIV implementation nor accounted for the etiology of ARF or the presence of associated organ dysfunction at the time of NIV initiation. Moreover, the benefits demonstrated with NIV in these patients were derived from studies with high mortality rates of intubated patients. Additional studies are therefore warranted to determine the appropriate patients with hematologic malignancy and ARF who may benefit from prophylactic or curative NIV.

Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis

The outcome of allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients has significantly improved over the past decade. Still, a significant number of patients require intensive care unit (ICU) management because of life-threatening complications. Literature from the 1990s reported extremely poor prognosis for critically ill allo-HSCT patients requiring ICU management. Recent data justify the use of ICU resources in hematologic patients. Yet, allo-HSCT remains an independent variable associated with mortality. However, outcomes in allo-HSCT patients have improved over time and many classic determinants of mortality have become irrelevant. The main actual prognostic factors are the need for mechanical ventilation, the presence of GvHD and the number of organ failures at ICU admission. Recently, the development of reduced-intensity conditioning regimens, early ICU admission and the increased use of noninvasive ventilation, combined with time effect and general advances in hematology, in allo-HSCT procedures and in ICU management have contributed to improve general outcome. A rational policy of ICU admission triage in these patients is very hard to define, as each decision for ICU admission is a case-by-case decision at patient bedside. The collaboration between hematologists and intensivists is crucial in this context.

Predictors of Poor Outcomes in Critically Ill Adults with Hematologic Malignancy

Background. Patients with hematologic malignancy (HM) often require intensive care unit (ICU) admission due to organ failure through disease progression or treatment-related complications. Objective. To determine mortality and prognostic variables in adult patients with HM who were admitted to ICU. Methods. Structured chart review of all adult patients (age ≥ 18 years) with HM admitted to ICU of a Canadian tertiary care hospital between 2004 and 2014. Outcome measures included mortality (ICU, 30-day, 60-day, and 12-month). Logistic regression was performed to determine predictors of mortality. Results. Overall, there were 206 cases of HM admitted to the ICU during the study (mean age: 51.3 ± 13.6 years; 60% male). Median stay was 3 days, with 14.1% requiring prolonged ICU admission. ICU mortality was 45.6% and increased to 59.2% at 30 days, 62.6% at 60 days, and 74.3% at 12 months. Predictors of increased ICU mortality included mechanical ventilation requirement and vasopressor therapy requirement, while admission to ICU postoperatively and having myeloma were associated with decreased mortality. Conclusions. Patients admitted to ICU with HM have high mortality (45.6%), which increased to 74.3% at 1 year. Analysis of multiple variables identified critical illness, postsurgical admission, and myeloma as predictors of patient outcomes.

Cancer patients with community-acquired pneumonia treated in intensive care have poorer outcomes associated with increased illness severity and septic shock at admission to intensive care: a retrospective cohort study

Patients with community-acquired pneumonia (CAP) and an underlying diagnosis of cancer have worse outcomes. However, the characteristics of cancer patients with CAP admitted to intensive care units (ICUs) are not well established. In a retrospective observational study, patients admitted to a London university hospital ICU between January 2006 and October 2011 with a primary diagnosis of CAP were included. Demographic, clinical, laboratory, and outcome data were collected from the ICU and hospital pathology databases. The analysis included 96 patients with CAP, 19 of whom had an existing diagnosis of cancer. Patients with cancer had a longer median time interval between hospital and ICU admission (1 vs 2 days, p = 0.049). On admission to ICU, there were no differences in white cell count, C-reactive protein, clotting, renal function, liver function, heart rate, temperature, systolic blood pressure or oxygenation index between patients with or without cancer. However, patients with cancer had significantly lower haemoglobin levels (median 8.6 vs 10.0 g/dl, p = 0.010) and lowest diastolic blood pressure (median 40 vs 50 mmHg, p = 0.026), and higher sodium levels (median 142 vs 139 mmol/l), p = 0.020), APACHE II (median 25 vs 20, p = 0.009), SAPS II (median 51 vs 43, p = 0.039) and SOFA (median 12 vs 9, p = 0.018) scores. There were no statistically significant differences in the proportion of patients receiving mechanical ventilation or renal support, the duration of mechanical ventilation or ICU or hospital length of stay. Patients with cancer were more likely to receive vasopressors (89.5% vs 63.6%, p = 0.030) and had increased ICU (68.4% vs 31.2%, p = 0.004) and hospital (78.9% vs 33.8%, p = 0.001) mortality. The limitations of this study are its relatively small sample size and those associated with the retrospective study design. In conclusion, cancer patients with CAP had an increased risk of death that was associated with increased illness severity and prevalence of septic shock at the time of ICU admission, suggesting there may be a delay in recognition for the need for intensive care support in these patients.

Quality of transition to end-of-life care for cancer patients in the intensive care unit

Background

There have been few studies that have evaluated the quality of end-of-life care (EOLC) for cancer patients in the ICU. The aim of this study was to explore the quality of transition to EOLC for cancer patients in ICU.

Methods

The study was undertaken on medical patients admitted to a specialist cancer hospital ICU over 6 months. Quantitative and qualitative methods were used to explore quality of transition to EOLC using documentary evidence. Clinical parameters on ICU admission were reviewed to determine if they could be used to identify patients who were likely to transition to EOLC during their ICU stay.

Results

Of 85 patients, 44.7% transitioned to EOLC during their ICU stay. Qualitative and quantitative analysis of the patients’ records demonstrated that there was collaborative decision-making between teams, patients and families during transition to EOLC. However, 51.4 and 40.5% of patients were too unwell to discuss transition to EOLC and DNACPR respectively. In the EOLC cohort, 76.3% died in ICU, but preferred place of death known in only 10%. Age, APACHE II score, and organ support, but not cancer diagnosis, were identified as associated with transition to EOLC (p = 0.017, p < 0.0001 and p = 0.001).

Conclusions

Advanced EOLC planning in patients with progressive disease prior to acute deterioration is warranted to enable patients’ wishes to be fulfilled and ceiling of treatments agreed. Better documentation and development of validated tools to measure the quality EOLC transition on the ICU are needed.

Prognosis-related factors in intensive care unit (ICU) patients with hematological malignancies: A retrospective cohort analysis in a Chinese population

OBJECTIVES

This study investigates the link between patient characteristics and mortality in patients with hematological malignancies (HM) in three university-affiliated hospitals in Hunan, China.

METHODS

We conducted a detailed retrospective chart review of 121 sequential intensive care unit (ICU) admissions with HM over a 5-year period. Outcome measures were short- and long-term mortality rates and were correlated with physiologic and therapeutic factors. We also evaluate the performance of two severity-of-illness scoring systems in this population, particularly the value and trend of the sequential organ failure assessment (SOFA).

RESULTS

The rates for ICU, 1-month and 6-month mortalities were 60.3, 85.9, and 90.9%, respectively. Invasive mechanical ventilation (IMV) was associated with worse outcomes at all time points. Both acute physiology and chronic health evaluation and SOFA scores had positive correlation with ICU mortality. An increase or no change in SOFA over the course of the admission or during the first 48 hours after admission was the most powerful adverse predictor. IMV use and renal dysfunction had a negative effect on the 1-month survival.

CONCLUSION

Patients with HM have less access to intensive care resources in Hunan, China. The use of IMV, APACHII at admission, and SOFA trend have a strong predictive value in this population. Based on our results, we propose a panel of parameters for use when considering ICU transfer to guide patient management.

The impact of hospital-acquired infections with multidrug-resistant bacteria in an oncology intensive care unit

OBJECTIVE

To describe overall site-specific hospital-acquired infection (HAI) rates and to describe the microbiological and antibiotic resistance profiles of infecting pathogens, together with their impact on multidrug-resistant (MDR) bacteria-associated mortality.

METHODS

We conducted a 5-year retrospective descriptive study of HAI in patients in the intensive care unit (ICU) of a cancer center in Mexico from January 2007 to December 2011. The following information was collected: patient characteristics and comorbidities, data related to the neoplasm and its treatment, microbiology, and the resistance pattern of all isolates.

RESULTS

During the study period, 1418 patients were admitted to the ICU; 134 of them developed 159 infections, with an incidence of 11.2/100 hospitalized patients and 32.2/per 1000 patient-days. Two hundred sixty-six microorganisms were isolated. The overall prevalence of MDR-HAI was 39.5%. The most frequent organisms were as follows: 54 (20%) Escherichia coli (94.4% of these were extended-spectrum beta-lactamase producers), 32 (12%) Staphylococcus aureus (90.6% of these were methicillin-resistant), 32 (12%) Enterococcus faecium (18.7% of these were vancomycin-resistant), and 20 (6%) Acinetobacter baumannii (all were MDR). Among patients admitted to the ICU, 252 (17.8%) died. Death was related to the HAI in 58 (23%) of these patients (p<0.001) and 51 (88%) had a MDR organism isolated (p=0.05).

CONCLUSIONS

The emergence of MDR bacteria poses a difficult task for physicians, who have limited therapeutic options. Critically ill cancer patients admitted to the ICU are at major risk of a bacterial MDR-HAI that will impact adversely on mortality.

Ethical and clinical aspects of intensive care unit admission in patients with hematological malignancies: guidelines of the ethics commission of the French society of hematology

Admission of patients with hematological malignancies to intensive care unit (ICU) raises recurrent ethical issues for both hematological and intensivist teams. The decision of transfer to ICU has major consequences for end of life care for patients and their relatives. It also impacts organizational human and economic aspects for the ICU and global health policy. In light of the recent advances in hematology and critical care medicine, a wide multidisciplinary debate has been conducted resulting in guidelines approved by consensus by both disciplines. The main aspects developed were (i) clarification of the clinical situations that could lead to a transfer to ICU taking into account the severity criteria of both hematological malignancy and clinical distress, (ii) understanding the process of decision-making in a context of regular interdisciplinary concertation involving the patient and his relatives, (iii) organization of a collegial concertation at the time of the initial decision of transfer to ICU and throughout and beyond the stay in ICU. The aim of this work is to propose suggestions to strengthen the collaboration between the different teams involved, to facilitate the daily decision-making process, and to allow improvement of clinical practice.

Intensive Care: Who Benefits?

Intensive care has saved many lives but there are still those patients who are so ill at the time of presentation that the benefit of escalating intensive care support is not clear-cut. To be fair to these patients and the others who can benefit from our services, it is vital that decisions concerning how far organ supporting measures should be pursued are made as reliably and robustly as possible. This review describes some of the prognostic features available at presentation or shortly afterwards, pertaining to five clinical scenarios associated with a perceived poor survival rate (ie, acute-on-chronic liver failure, haematological malignancy, chronic lung disease, cardiac arrest and morbid obesity).

Trends in admission prevalence, illness severity and survival of haematological patients treated in Dutch intensive care units

PURPOSE

To explore trends over time in admission prevalence and (risk-adjusted) mortality of critically ill haematological patients and compare these trends to those of several subgroups of patients admitted to the medical intensive care unit (medical ICU patients).

METHODS

A total of 1,741 haematological and 60,954 non-haematological patients admitted to the medical ICU were analysed. Trends over time and differences between two subgroups of haematological medical ICU patients and four subgroups of non-haematological medical ICU patients were assessed, as well as the influence of leukocytopenia.

RESULTS

The proportion of haematological patients among all medical ICU patients increased over time [odds ratio (OR) 1.06; 95 % confidence interval (CI) 1.03-1.10 per year; p < 0.001]. Risk-adjusted mortality was significantly higher for haematological patients admitted to the ICU with white blood cell (WBC) counts of <1.0 × 10(9)/L (47 %; 95 % CI 41-54 %) and ≥1.0 × 10(9)/L (45 %; 95 % CI 42-49 %), respectively, than for patients admitted with chronic heart failure (27 %; 95 % CI 26-28 %) and with chronic liver cirrhosis (38 %; 95 % CI 35-42 %), but was not significantly different from patients admitted with solid tumours (40 %; 95 % CI 36-45 %). Over the years, the risk-adjusted hospital mortality rate significantly decreased in both the haematological and non-haematological group with an OR of 0.93 (95 % CI 0.92-0.95) per year. After correction for case-mix using the APACHE-II score (with WBC omitted), a WBC <1.0 × 10(9)/L was not a predictor of mortality in haematological patients (OR 0.86; 95 % CI 0.46-1.64; p = 0.65). We found no case-volume effect on mortality for haematological ICU patients.

CONCLUSIONS

An increasing number of haematological patients are being admitted to Dutch ICUs. While mortality is significantly higher in this group of medical ICU patients than in subgroups of non-haematological ones, the former show a similar decrease in raw and risk-adjusted mortality rate over time, while leukocytopenia is not a predictor of mortality. These results suggest that haematological ICU patients have benefitted from improved intensive care support during the last decade.

[Hematooncology patients in intensive care management]

Critically ill cancer patients on intensive units with hematological or oncological underlying diseases are a special situation: the underlying disease may be incurable, acute problems are often therapy associated and immunosuppression is regularly present. Due to evolving knowledge about special aspects of these patients and optimized supportive therapy, the prognosis has substantially improved during the last decades. General reluctance to admit cancer patients to an intensive care unit is therefore no longer justified. Reasons for admission are often infections and/or respiratory failure. Extensive diagnostic measures, causal and supportive therapy of sepsis according to current guidelines has led to improved outcome even in cancer patients. In respiratory failure, non-invasive ventilation is the key to improved prognosis if used early enough and indications, contraindications and break-off criteria are strictly followed. The prognosis of critically ill cancer patients is determined by the severity of the acute problem and not by the underlying disease.

Prognostic factors in critically ill cancer patients admitted to the intensive care unit

OBJECTIVE

The objective of this study is to identify factors predicting intensive care unit (ICU) mortality in cancer patients admitted to a medical ICU.

PATIENTS AND METHODS

We conducted a retrospective study in 162 consecutive cancer patients admitted to the medical ICU of a 1000-bed university hospital between January 2009 and June 2012. Medical history, physical and laboratory findings on admission, and therapeutic interventions during ICU stay were recorded. The study end point was ICU mortality. Logistic regression analysis was performed to identify independent risk factors for ICU mortality.

RESULTS

The study cohort consisted of 104 (64.2%) patients with solid tumors and 58 patients (35.8%) with hematological malignancies. The major causes of ICU admission were sepsis/septic shock (66.7%) and respiratory failure (63.6%), respectively. Overall ICU mortality rate was 55 % (n=89). The ICU mortality rates were similar in patients with hematological malignancies and solid tumors (57% vs 53.8%; P=.744). Four variables were independent predictors for ICU mortality in cancer patients: the remission status of the underlying cancer on ICU admission (odds ratio [OR], 0.113; 95% confidence interval [CI], 0.027-0.48; P=.003), Acute Physiology and Chronic Health Evaluation II score (OR, 1.12; 95% CI, 1.032-1.215; P=.007), sepsis/septic shock during ICU stay (OR, 8.94; 95% CI, 2.28-35; P=.002), and vasopressor requirement (OR 16.84; 95% CI, 3.98-71.24; P=.0001). Although Acute Physiology and Chronic Health Evaluation II score (OR, 1.30; 95% CI, 1.054-1.61; P=.014), admission through emergency service (OR, 0.005; 95% CI, 0.00-0.69; P=.035), and vasopressor requirement during ICU stay (OR, 140.64; 95% CI, 3.59-5505.5; P=.008) were independent predictors for ICU mortality in patients with hematological malignancies, Sequential Organ Failure Assessment score (OR, 1.83; 95% CI, 1.29-2.6; P=.001), lactate dehydrogenase level on admission (OR, 1.002; 95% CI, 1-1.005; P=.028), sepsis/septic shock during ICU stay (OR, 138.4; 95% CI, 12.54-1528.4; P=.0001), and complete or partial remission of the underlying cancer (OR, 0.026; 95% CI, 0.002-0.3; P=.004) were the independent risk factors in patients with solid tumors.

CONCLUSION

Intensive care unit mortality rate was 55% in our cancer patients, which suggests that patients with cancer can benefit from ICU admission. We also found that ICU mortality rates of patients with hematological malignancies and solid tumors were similar.

Survival of hematological patients after discharge from the intensive care unit: a prospective observational study

Introduction

Although the survival rates of hematological patients admitted to the ICU are improving, little is known about the long-term outcome. Our objective was to identify factors related to long-term outcome in hematological patients after ICU discharge.

Methods

A prospective, observational study was carried out in seven centers in Spain. From an initial sample of 161 hematological patients admitted to one of the participating ICUs during the study period, 62 were discharged alive and followed for a median time of 23 (1 to 54) months. Univariate and multivariate analysis were performed to identify the factors related to long term-survival. Finally, variables that influence the continuation of the scheduled therapy for the hematological disease were studied.

Results

Mortality after ICU discharge was 61%, with a median survival of 18 (1 to 54) months. In the multivariate analysis, an Eastern Cooperative Oncology Group score (ECOG) >2 at ICU discharge (Hazard ratio 11.15 (4.626 to 26.872)), relapse of the hematological disease (Hazard ratio 9.738 (3.804 to 24.93)) and discontinuation of the planned treatment for the hematological disease (Hazard ratio 4.349 (1.286 to 14.705)) were independently related to mortality. Absence of stem cell transplantation, high ECOG and high Acute Physiology and Chronic Health Evaluation II (APACHE II) scores decreased the probability of receiving the planned therapy for the hematological malignancy.

Conclusions

Both ICU care and post-ICU management determine the long-term outcome of hematological patients who are discharged alive from the ICU.

Intensive care for the cancer patient - unique clinical and ethical challenges and outcome prediction in the critically ill cancer patient

With the rising number of cancer cases and increasing survival times, cancer patients with critical illness are increasingly presenting to the intensive care unit. This article considers the unique challenges they pose in terms of oncological-specific disease processes and treatment and reviews current trends in outcome prediction. We also consider the ethical standpoints surrounding the treatment of patients for whom there may be no cure and their subsequent transition to palliative care, should it become necessary.

Intensive care unit experience of haemopoietic stem cell transplant patients

BACKGROUND

Previous research at our institution (1988-1998) established an intensive care unit (ICU) and hospital mortality between 70% and 80% in haemopoietic stem cell transplant (HSCT) patients requiring ICU admission.

AIMS

This study explored mortality in a more contemporary cohort while comparing outcomes to published literature and our previous experience.

METHODS

Retrospective chart review of HSCT patients admitted to ICU between December 1998 and June 2008.

RESULTS

Of 146 admissions, 53% were male, with a mean age of 44 years, an Acute Physiologic and Chronic Health Evaluation II score of 28 and Sepsis Organ Failure Assessment score of 11. Fifty-six per cent had graft versus host disease (GVHD), with respiratory failure (67%) being the most common admission diagnosis. All but one received mechanical ventilation. The ICU and hospital mortality were 42% (72% 1988-1998 cohort) and 64% (82% 1998-1998 cohort) respectively. The 6- and 12-month survivals were 29% and 24% respectively for the 1998-2008 cohort. Dying in ICU was independently predicted by fungal infection (P= 0.02) and early onset of organ failure (P < 0.001), while GVHD (P= 0.04) predicted survival. Mortality at 12 months was independently predicted by the acute physiology score (P= 0.002), increasing number of organ failures (P= 0.001), and cytomegalovirus positive serology (P= 0.005), while blood stream infection (P= 0.003), an antibiotic change on admission to the ICU (P= 0.007) and a diagnosis of non-Hodgkin lymphoma (P= 0.02) predicted survival.

CONCLUSION

Our study found that acute admission of HSCT patients to the ICU is associated with improved survival compared to our previous experience, with organ failure progression a strong predictor of ICU outcome, and specific disease characteristics contributing to long-term survival.