Critical care considerations of hematopoietic stem cell transplantation

It Takes a Team to Make It Through: The Role of Social Support for Survival and Self-Care After Allogeneic Hematopoietic Stem Cell Transplant

Background

Social support plays an important role for health outcomes. Support for those living with chronic conditions may be particularly important for their health, and even for their survival. The role of support for the survival of cancer patients after receiving an allogeneic hematopoietic cell transplant (alloHCT) is understudied. To better understand the link between survival and support, as well as different sources and functions of support, we conducted two studies in alloHCT patients. First, we examined whether social support is related to survival (Study 1). Second, we examined who provides which support and which specific support-related functions and tasks are fulfilled by lay caregivers and healthcare professionals (Study 2).

Methods

In Study 1, we conducted a retrospective chart review of alloHCT patients (N = 173, 42.8% female, age: M = 49.88) and registered availability of a dedicated lay caregiver and survival. In Study 2, we prospectively followed patients after alloHCT (N = 28, 46.4% female, age: M = 53.97, 46.4% ethnic minority) from the same hospital, partly overlapping from Study 1, who shared their experiences of support from lay caregivers and healthcare providers in semi-structured in-depth interviews 3 to 6 months after their first hospital discharge.

Results

Patients with a dedicated caregiver had a higher probability of surviving to 100 days (86.7%) than patients without a caregiver (69.6%), OR = 2.84, p = 0.042. Study 2 demonstrated the importance of post-transplant support due to patients’ emotional needs and complex self-care regimen. The role of lay caregivers extended to many areas of patients’ daily lives, including support for attending doctor’s appointments, managing medications and financial tasks, physical distancing, and maintaining strict dietary requirements. Healthcare providers mainly fulfilled medical needs and provided informational support, while lay caregivers were the main source of emotional and practical support.

Conclusion

The findings highlight the importance of studying support from lay caregivers as well as healthcare providers, to better understand how they work together to support patients’ adherence to recommended self-care and survival.

Pulmonary Manifestations of Hematologic and Oncologic Diseases in Children

Pulmonary complications are common in children with hematologic or oncologic diseases, and many experience long-term effects even after the primary disease has been cured. This article reviews pulmonary complications in children with cancer, after hematopoietic stem cell transplant, and caused by sickle cell disease and discusses their management.

[Transfer of allogeneic stem cell transplant recipients to the intensive care unit: Guidelines from the Francophone society of marrow transplantation and cellular therapy (SFGM-TC)]

Transferring a patient undergoing an allogeneic stem cell transplantation to the intensive care unit (ICU) is always a challenging situation on a medical and psychological point of view for the patient and his relatives as well as for the medical staff. Despite the progress in hematology and intensive care during the last decade, the prognosis of these patients admitted to the ICU remains poor and mortality is around 50 %. The harmonization working party of the SFGM-TC assembled hematologists and intensive care specialist in order to improve conditions and modalities of the transfer of a patient after allogeneic stem cell transplantation to the ICU. We propose a structured medical form comprising all essential information necessary for optimal medical care on ICU.

[Infections in hemato-oncology patients in intensive care. An interdisciplinary challenge]

Infections are among the most common complications in patients with hematologic neoplasms. Due to changes in demographics, the number of hematologic patients with severe infections who require intensive care is expected to increase. Treatment of these patients requires knowledge of multiple specialties. This review summarizes key aspects for the optimal management of infections in critical care patients with hematologic malignancies.

Characteristics and outcomes of haematology patients admitted to the intensive care unit

AIM

To profile the characteristics and outcomes of adult haematology patients admitted to the intensive care unit (ICU).

BACKGROUND

The role of intensive care support for haematology patients is contentious due to high mortality rates thus generating debate regarding the inappropriate use of limited resources versus denial of effective care.

METHODS

Medical notes, laboratory records and Intensive Care National Audit and Research Centre (ICNARC) data for all adult haematology patients admitted to Belfast City Hospital ICU in 2009 were analysed.

RESULTS

Twenty one patients were admitted to the ICU; mean age was 56 years (SD 12·5), 52% were male and 82% (n=19) had a malignant diagnosis. The main indication for admission was neutropenic sepsis with associated organ impairment (n=18, 85%). ICU mortality was 43%. Three-month and six-month mortality rates were 62% and 67%, respectively. ICU survivors had lower acute physiology and chronic health evaluation (APACHE II) scores, and decreased requirements for invasive ventilation and inotropic support. Of the post-six-month survivors, one had a relapse, one had responding disease and five remained in remission. Two patients have subsequently undergone a reduced intensity conditioning transplant.

CONCLUSION

One third of patients survived for >6 months indicating that critically ill haematology patients can benefit from ICU admission, allowing progression to potentially curative therapies.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the necessity of individualized assessment regarding patient suitability for admission to a critical care facility, incorporating the perspective of both the haematologist and the intensivist.

Invasive fungal infection among hematopoietic stem cell transplantation patients with mechanical ventilation in the intensive care unit

Background

Invasive fungal infection (IFI) is associated with high morbidity and high mortality in hematopoietic stem cell transplantation (HSCT) patientsThe purpose of this study was to assess the characteristics and outcomes of HSCT patients with IFIs who are undergoing MV at a single institution in Taiwan.

Methods

We performed an observational retrospective analysis of IFIs in HSCT patients undergoing mechanical ventilation (MV) in an intensive care unit (ICU) from the year 2000 to 2009. The characteristics of these HSCT patients and risk factors related to IFIs were evaluated. The status of discharge, length of ICU stay, date of death and cause of death were also recorded.

Results

There were 326 HSCT patients at the Linkou Chang-Gung Memorial Hospital (Taipei, Taiwan) during the study period. Sixty of these patients (18%) were transferred to the ICU and placed on mechanical ventilators. A total of 20 of these 60 patients (33%) had IFIs. Multivariate analysis indicated that independent risk factors for IFI were admission to an ICU more than 40 days after HSCT, graft versus host disease (GVHD), and high dose corticosteroid (p < 0.01 for all). The overall ICU mortality rate was 88% (53 of 60 patients), and was not significantly different for patients with IFIs (85%) and those without IFIs (90%, p = 0.676).

Conclusion

There was a high incidence of IFIs in HSCT patients requiring MV in the ICU in our study cohort. The independent risk factors for IFI are ICU admission more than 40 days after HSCT, GVHD, and use of high-dose corticosteroid.

Drug interactions of anti-microbial agents used in hematopoietic stem cell transplantation

This study analyzed potential drug interactions (PDIs) of antimicrobials used in patients of hematopoietic stem cell transplantation and identified associated factors. The sample consisted of 70 patients admitted to a hospital in São Paulo. The PDIs were analyzed through the consultation of the Drug Interactions Facts and Drug Interactions Handbook. Descriptive statistics and logistic regression were used. Half of the sample was exposed to 13 PDIs, which occurred with fluconazole (53.8%), ciprofloxacin (30.8%) and sulfamethoxazole-trimethoprim (15.4%). Most (92.3%) were of moderate severity, with good evidence (61.6%), early delayed effect (61.5%) and need to have their therapy monitored (76.9%). Patients with four or more medications (p<0.001), aged between 40-49 years of age (p <0.001), and being male (p<0.001) were associated with PDIs. A PDI may result in adverse outcomes, impacting patients' morbidity and mortality. Combination regimens can be safe, provided there is careful monitoring by professionals involved in care delivery.

How I manage haematology patients with septic shock

Patients with a variety of haematological conditions are at risk of infection and its most serious complication: septic shock. Mortality for septic shock remains high and especially so in patients with haematological malignancy and following bone marrow transplantation. However, advances in the treatment of severe sepsis have improved mortality rates even though evidence for the management of severe sepsis in haematology patients is limited. Wherever possible this review will concentrate on evidence directly applicable to haematology patients but inevitably will have to extrapolate evidence from other patient groups. The Surviving Sepsis Guidelines 2008 provide information on best practice in the management of patients with severe sepsis and septic shock and are broadly applicable though not specific to haematology patients. This review summarizes a practical approach to the management of severe sepsis in haematology patients and highlights areas of research which may bring new treatments in the future. The review is limited to the management and initial resuscitation of septic shock in adult haematology patients and will not address the detailed intensive care management of these patients or the management of severe sepsis in children.

Impact of critical care outreach on hematopoietic stem cell transplant recipients: a cohort study

Serious morbidity and mortality can occur after hematopoietic SCT (HSCT). Critical care outreach (CCO) can provide timely access to intensive care for hospitalized patients in need of urgent stabilization but has not been examined in HSCT. Rapid Assessment of Critical Events (RACE) team was introduced at our centre January 1, 2005. A retrospective cohort study was performed. Patients undergoing HSCT between January 1, 2000 and December 31, 2004 (n=520) formed the 'before' cohort and patients transplanted between January 1, 2005 and December 31, 2007 (n=294) formed the 'after' cohort. Non-relapse mortality at day 100 after transplant was not different in the two cohorts (26 (8.8%) post-RACE vs 53 (10.2%) pre-RACE, P=0.62). The number of failed organs at time of transfer to intensive care unit (ICU) was reduced in the post-RACE cohort (1.9 ± 0.8 vs 2.3 ± 1.0, P=0.04) and the incidence of cardiovascular failure was lower (23.8 vs 43.8%, P=0.04). Other secondary outcomes were not different, including the frequency of ICU admission. RACE may contribute to earlier stabilization during critical illness in patients undergoing HSCT but does not reduce non-relapse mortality. CCO should be studied prospectively in patients undergoing HSCT to better evaluate its role.

The care of critically ill children after hematopoietic SCT: a North American survey

Although potentially curative, hematopoietic SCT (HSCT) is associated with significant morbidity. To improve outcomes, multicenter studies of critical illness in this patient population appear needed. To assist in the design of such studies, a survey was conducted to identify variations in care provided to critically ill pediatric HSCT patients. A survey was conducted of the highest volume pediatric HSCT centers in the United States (n=30) and Canada (n=4). One pediatric critical care medicine (PCCM) physician and one pediatric HSCT physician were surveyed at each institution. Analysis consisted of descriptive statistics. Thirty-three (29 United States/4 Canada) of 34 institutions responded. Although most HSCT units permit fluid boluses and nearly half permit some dose of dopamine, high-dose dopamine and other vasoactive infusions are rarely allowed there. Six institutions (21%) permit non-invasive ventilation on the HSCT unit. Criterion for PCCM consultation and therapies implemented before intubation vary significantly. High-frequency oscillatory ventilation and renal replacement therapy are commonly used for lung injury in patients failing conventional therapy. Variability exists in the location and type of therapy critically ill pediatric HSCT patients receive. Understanding this variability will help facilitate the design of clinical trials.

Approach to the immunocompromised host with infection in the intensive care unit

Despite significant advances in the prevention, diagnosis, and treatment of infection in the immunocompromised host, it remains a major cause of morbidity, increased length of stay, total costs, and of course mortality. Intensive care mortality rates are significantly higher among immunocompromised hosts in part due to the higher incidence of infection severity. The superimposition of the compromised host defenses and critical illness makes the detection and management of infections in such patients more difficult, but crucial toward salvaging patient outcome. Moreover, although there is a rapidly increasing evidence base in intensive care medicine, many interventional trials for the management of severe sepsis (activated protein C, adjunctive corticosteroids, goal-based resuscitation), acute lung injury (low stretch ventilation), and other organ failures have excluded immunocompromised hosts.

Outcome and prognostic indicators of patients with hematopoietic stem cell transplants admitted to the intensive care unit

The prognosis of patients with hematopoietic stem cell transplants (HSCTs) who require admission to the intensive care unit (ICU) has been regarded as extremely poor. We sought to re-evaluate recent outcomes and predictive factors in a retrospective cohort study. Among the 605 adult patients that received an HSCT between 2001 and 2006, 154 required admission to the ICU. Of these, 47% were discharged from the ICU, 36% were discharged from the hospital, and 19% survived 6 months. Allogeneic transplant, mechanical ventilation, vasopressor-use, and neutropenia were each associated with increased mortality, and the mortality of patients with all four characteristics was 100%. Hemodialysis was also associated with increased mortality in a Kaplan-Meier analysis but did not appear important in a multivariate tree analysis. A final Cox model confirmed that allogeneic transplant, mechanical ventilation, and vasopressor-use were each independent risk factors for mortality in the 6 months following ICU admission.

Mesenchymal stem cell: present challenges and prospective cellular cardiomyoplasty approaches for myocardial regeneration

Myocardial ischemia and cardiac dysfunction have been known to follow ischemic heart diseases (IHDs). Despite a plethora of conventional treatment options, their efficacies are associated with skepticism. Cell therapies harbor a promising potential for vascular and cardiac repair, which is corroborated by adequate preclinical evidence. The underlying objectives behind cardiac regenerative therapies subsume enhancing angiomyogenesis in the ischemic myocardium, ameliorating cellular apoptosis, regenerating the damaged myocardium, repopulating the lost resident myocardial cells (smooth muscle, cardiomyocyte, and endothelial cells), and finally, decreasing fibrosis with a consequent reduction in ventricular remodeling. Although-cell based cardiomyoplasty approaches have an immense potential, their clinical utilization is limited owing to the increased need for better candidates for cellular cardiomyoplasty, better routes of delivery, appropriate dose for efficient engraftment, and better preconditioning or genetic-modification strategies for the progenitor and stem cells. Mesenchymal stem cells (MSCs) have emerged as powerful candidates in mediating myocardial repair owing to their unique properties of multipotency, transdifferentiation, intercellular connection with the resident cardiomyocytes via connexin 43 (Cx43)-positive gap junctions in the myocardium, and most important, immunomodulation. In this review, we present an in-depth discussion on the complexities associated with stem and progenitor cell therapies, the potential of preclinical approaches involving MSCs for myocardial repair, and an account of the past milestones and ongoing MSC-based trials in humans.

Intensive care unit mortality trends in children after hematopoietic stem cell transplantation: a meta-regression analysis

BACKGROUND

There is ongoing discussion whether intensive care unit mortality has decreased over time for children after hematopoietic stem cell transplantation.

OBJECTIVE

To analyze intensive care unit mortality trends in children after hematopoietic stem cell transplantation.

DATA SOURCES

Search of MEDLINE, EMBASE, and Cochrane databases, and a manual review of reference lists.

STUDY SELECTION

Prospective and retrospective cohort studies containing intensive care unit mortality data of children after hematopoietic stem cell transplantation.

DATA EXTRACTION

Mortality statistics and features associated with mortality were abstracted from studies of interest. To assess mortality over time, the median years of inclusion in original studies were included as risk factor. A multiple random-effects meta-regression analysis was conducted to assess the independent contribution of prognostic factors on mortality.

DATA SYNTHESIS

Twenty-three studies were included, reporting on 1101 intensive care unit admissions. Overall intensive care unit mortality was 60% (range, 25%-91%). Once mechanical ventilation was necessary (n = 822), mean intensive care unit mortality was 71% (range, 25%-91%). Over the years, significantly fewer intensive care unit admitted patients received mechanical ventilation (p < 0.001). Univariable analysis in all intensive care unit admitted patients showed a significant decrease in mortality associated with year of inclusion. Mechanical ventilation and pulmonary disease were associated with increased mortality. In the multiple meta-regression analysis, only pulmonary disease remained significantly associated with mortality (odds ratio = 1.21, 95% confidence interval 1.01-1.46 per 10% increase in the number of patients with pulmonary disease in studies). The association between year of inclusion and intensive care unit mortality was less pronounced (odds ratio = 0.92, 95% confidence interval 0.84-1.01).

CONCLUSION

There is a widely held impression that intensive care unit mortality clearly decreased in children after hematopoietic stem cell transplantation. However, characteristics of intensive care unit admitted patients significantly changed over time. After correcting for this, an improvement in intensive care unit survival was less evident. More studies are needed before a true improvement in intensive care unit survival can be confirmed.

Causes and prognosis of diffuse alveolar damage diagnosed on surgical lung biopsy

BACKGROUND

Diffuse alveolar damage (DAD) is a relatively common histopathologic finding at autopsy, particularly in patients dying with ARDS, and can result from a variety of causes. The spectrum of causes and associated prognostic implications for DAD diagnosed by surgical lung biopsy are unclear.

METHODS

We identified 58 consecutive patients with DAD diagnosed by surgical lung biopsy over a 7-year period, January 1996 through December 2002. The presenting clinicoradiologic features, causes, and clinical course of these patients were studied.

RESULTS

The median age was 61 years, 48% were women, and 60% were immunocompromised. Ninety percent of patients fulfilled the criteria for ARDS at the time of surgical lung biopsy. Chest radiography demonstrated bilateral parenchymal infiltrates, while CT revealed predominantly ground-glass and consolidative opacities. Infections were the most common cause of DAD (22%). Other causes were noninfectious pulmonary complications of hematopoietic stem-cell or solid-organ transplantation (17%), connective tissue diseases (16%), acute exacerbation of idiopathic pulmonary fibrosis (12%), drugs (10%), and radiation therapy (2%). Twelve patients (21%) had acute interstitial pneumonia (ie, no identifiable cause or predisposing condition for DAD). Overall hospital mortality was 53%, with the highest mortality (86%) occurring among patients for whom DAD represented acute exacerbation of idiopathic pulmonary fibrosis.

CONCLUSION

Our study showed that infections and acute interstitial pneumonia are the most common causes of DAD diagnosed by surgical lung biopsy. Hospital mortality rate associated with DAD may vary depending on the underlying cause.

[Intensive care support of patients after stem cell transplantation]

Within the hematologic therapy procedures, stem cell transplantation (SCT) represents the most extensive and invasive intervention. Those patients have certain risks for several bacterial, viral, as well as fungal infections during the different stages of transplantation. Especially in allogenic transplantation, discrimination of non-infectious, mostly immunologic complications like graft-versus-host reactions or VOD (veno-occlusive disease) is crucial, and often represents a therapeutic challenge. An adequate intensive care therapy of these patients can only be achieved with the knowledge of the specific complications of SCT. This review starts with an overview of the SCT stages with their corresponding infectious and noninfectious complications, followed by the discussion of organ specific pulmonary, renal, cardiac, gastrointestinal, hepatic and neurological complications of stem cell transplantation.