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Mauz N, Bouisse M, Cahn JY, Kaphan E, Truche AS, Thiebaut-Bertrand A, Carré M, Bulabois CE, Hamidfar-Roy R, Schwebel C, Park S, Labarere J, Terzi N. Rapid response system for critically ill patients with haematological malignancies: A pre- and post-intervention study. Eur J Haematol 2024; 113:330-339. [PMID: 38780264 DOI: 10.1111/ejh.14228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND This study aimed to determine whether implementing a rapid response system (RRS) is associated with improved short-term outcomes in critically ill patients with haematological malignancies. METHODS Our monocentric pre- versus post-intervention study was conducted between January 2012 and April 2020. RRS was activated at early signs of haemodynamic or respiratory failure. The primary outcome was the reduction in Sequential Organ Failure Assessment (SOFA) score on Day 3 after intensive care unit (ICU) admission. Secondary outcomes included time to ICU admission and mortality. RESULTS A total of 209 patients with a median age of 59 years were enrolled (108 in the pre-intervention period and 101 in the post-intervention period). 22% of them had received an allogeneic transplant. The post-intervention period was associated with a shorter time to ICU admission (195 vs. 390 min, p < .001), a more frequent favourable trend in SOFA score (57% vs. 42%, adjusted odds ratio, 2.02, 95% confidence interval, 1.09 to 3.76), no significant changes in ICU (22% vs. 26%, p = .48) and 1-year (62% vs. 58%, p = .62) mortality rates. CONCLUSION Detection of early organ failure and activation of an RRS was associated with faster ICU admission and lower SOFA scores on Day 3 of admission in critically ill patients with haematological malignancies.
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Affiliation(s)
- N Mauz
- Haematology Department, Annecy Hospital, Epagny-Metz-Tessy, France
- Intensive Care Unit, Annecy Hospital, Epagny-Metz-Tessy, France
| | - M Bouisse
- Clinical Epidemiology Unit, Grenoble Alpes Hospital, University Grenoble Alpes, TIMC-UMR 5525 CNRS, Grenoble, France
| | - J Y Cahn
- Haematology Department, Grenoble Alpes Hospital, University Grenoble Alpes, Grenoble, France
| | - E Kaphan
- Haematology Department, Saint Louis Hospital, Paris, France
| | - A-S Truche
- Medical Intensive Care Unit, Grenoble Alpes Hospital, Grenoble, France
| | - A Thiebaut-Bertrand
- Haematology Department, Grenoble Alpes Hospital, University Grenoble Alpes, Grenoble, France
| | - M Carré
- Haematology Department, Grenoble Alpes Hospital, University Grenoble Alpes, Grenoble, France
| | - C-E Bulabois
- Haematology Department, Grenoble Alpes Hospital, University Grenoble Alpes, Grenoble, France
| | - R Hamidfar-Roy
- Pneumology Department, Grenoble Alpes Hospital, Grenoble, France
| | - C Schwebel
- Medical Intensive Care Unit, Grenoble Alpes Hospital, Grenoble, France
| | - S Park
- Haematology Department, Grenoble Alpes Hospital, University Grenoble Alpes, Grenoble, France
- Inserm U 1209, CNRS UMR 5309, Team Epigenetics Regulation, Institute for Advanced Biosciences, University Grenoble Alpes, Grenoble, France
| | - J Labarere
- Clinical Epidemiology Unit, Grenoble Alpes Hospital, University Grenoble Alpes, TIMC-UMR 5525 CNRS, Grenoble, France
| | - N Terzi
- Medical Intensive Care Unit, Rennes University Hospital, Rennes, France
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Benguerfi S, Messéant O, Painvin B, Camus C, Maamar A, Gacouin A, Ricordel C, Reignier J, Canet E, Edeline J, Tadié JM. Factors associated with cancer treatment resumption after ICU stay in patients with solid tumors. Ann Intensive Care 2024; 14:135. [PMID: 39215851 PMCID: PMC11365869 DOI: 10.1186/s13613-024-01366-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 08/09/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Post-intensive care syndrome could be responsible for inability to receive proper cancer treatment after ICU stay in patients with solid tumors (ST). Our purpose was to determine the factors associated with cancer treatment resumption and the impact of cancer treatment on the outcome of patients with ST after ICU stay. METHODS We conducted a retrospective study including all patients with ST admitted to the ICU between 2014 and 2019 in a French University-affiliated Hospital. RESULTS A total of 219 patients were included. Median SAPS II at ICU admission was 44.0 [IQR 32.8, 66.3]. Among the 136 patients who survived the ICU stay, 81 (59.6%) received cancer treatment after ICU discharge. There was an important increase in patients with poor performance status (PS) of 3 or 4 after ICU stay (16.2% at admission vs. 44.5% of patients who survived), with significant PS decline following the ICU stay (median difference - 1.5, 95% confidence interval [-1.5-1.0], p < 0.001). The difference between the PS after and before ICU stay (delta PS) was independently associated with inability to receive cancer treatment (Odds ratio OR 0.34, 95%CI 0.18-0.56, p value < 0.001) and with 1-year mortality in patients who survived at ICU discharge (Hazard ratio HR 1.76, 95%CI 1.34-2.31, p value < 0.001). PS before ICU stay (OR 3.73, 95%IC 2.01-7.82, p value < 0.001) and length of stay (OR 1.23, 95%CI 1.06-1.49, p value 0.018) were independently associated with poor PS after ICU stay. Survival rates at ICU discharge, at 1 and 3 years were 62.3% (n = 136), 27.3% (n = 59) and 17.1% (n = 37), respectively. The median survival for patients who resumed cancer treatment after ICU stay was 771 days (95%CI 376-1058), compared to 29 days (95%CI 15-49) for those who did not resume treatment (p < 0.001). CONCLUSION Delta PS, before and after ICU stay, stands out as a critical determinant of cancer treatment resumption and survival after ICU stay. Multidisciplinary intervention to improve the general condition of these patients, in ICU and after ICU stay, may improve access to cancer treatment and long-term survival.
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Affiliation(s)
- Soraya Benguerfi
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, Rennes cedex 9, 35033, France.
- Laboratory "Movement, Interactions, Performance" (EA 4334), Faculty of Sport Sciences, University of Nantes, 25 Bis Boulevard Guy Mollet, BP 72206, Nantes Cedex 3, 44322, France.
| | - Ondine Messéant
- Service d'Hématologie Clinique, Hôpital Pontchaillou, CHU Rennes, Université de Rennes 1, 2, rue Henri Le Guilloux, Rennes cedex 9, 35033, France
| | - Benoit Painvin
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, Rennes cedex 9, 35033, France
| | - Christophe Camus
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, Rennes cedex 9, 35033, France
| | - Adel Maamar
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, Rennes cedex 9, 35033, France
| | - Arnaud Gacouin
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, Rennes cedex 9, 35033, France
| | - Charles Ricordel
- CHU Rennes, Service de Pneumologie, 2 Rue Henri Le Guilloux, Rennes, 35033, France
- INSERM, OSS (Oncogenesis Stress Signaling), UMR_S 1242, CLCC Eugene Marquis, Univ Rennes 1, Rennes, 35000, France
| | - Jean Reignier
- Laboratory "Movement, Interactions, Performance" (EA 4334), Faculty of Sport Sciences, University of Nantes, 25 Bis Boulevard Guy Mollet, BP 72206, Nantes Cedex 3, 44322, France
- CHU Nantes, Service de Médecine Intensive Réanimation, Nantes Université, 1 Place Alexis Ricordeau, Nantes Cedex 01, 44093, France
| | - Emmanuel Canet
- CHU Nantes, Service de Médecine Intensive Réanimation, Nantes Université, 1 Place Alexis Ricordeau, Nantes Cedex 01, 44093, France
| | - Julien Edeline
- CLCC Eugène Marquis, Service d'Oncologie Médicale, Université de Rennes 1, COSS (Chemistry Oncogenesis Stress Signaling), UMR_S 1242, Rennes, France
| | - Jean-Marc Tadié
- CHU Rennes, Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, Rennes cedex 9, 35033, France
- INSERM, Microenvironment, Cell Differentiation, Immunology, and Cancer-UMR_S1236, Établissement française du sang Bretagne, Université de Rennes 2, Rennes, F-35000, France
- CIC 1414, Rennes, France
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Singh S, Sharma R, Singh J, Jain K, Kaur G, Gupta V, Gautam PL. Clinical Outcomes and Determinants of Survival in Patients with Hematologic Malignancies Admitted to Intensive Care Units with Critical Illness. Indian J Hematol Blood Transfus 2024; 40:423-431. [PMID: 39011248 PMCID: PMC11246339 DOI: 10.1007/s12288-024-01757-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 03/15/2024] [Indexed: 07/17/2024] Open
Abstract
Outcomes of patients with hematologic malignancies requiring ICU care for critical illness are suboptimal and represent a major unmet need in this population. We present data from a dedicated haematology oncology setting including 63 patients with a median age of 60 years admitted to the ICU for critical illness with organ dysfunction. The most common underlying diagnosis was multiple myeloma (30%) followed by acute myeloid leukemia (25%). Chemotherapy had been initiated for 90.7% patients before ICU admission. The most common indication for ICU care was respiratory failure (36.5%) and shock (17.5%) patients. Evidence of sepsis was present in 44 (69%) patients. After shifting to ICU, 32 (50%) patients required inotropic support and 18 (28%) required invasive mechanical ventilation. After a median of 5 days of ICU stay, 43.1% patients had died, most commonly due to multiorgan dysfunction. Risk of mortality was higher with involvement of more than two major organs (p = .001), underlying AML (p = .001), need for mechanical ventilation (p = .001) and high inotrope usage (p = .004). Neutropenia was not associated with mortality. Our study indicates high rates of short term mortality and defines prognostic factors which can be used to prognosticate patients and establish goals of care. Supplementary Information The online version contains supplementary material available at 10.1007/s12288-024-01757-3.
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Affiliation(s)
- Suvir Singh
- Department of Clinical Hematology and Stem Cell Transplantation, Bone Marrow Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab 141001 India
| | - Rintu Sharma
- Department of Clinical Hematology and Stem Cell Transplantation, Bone Marrow Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab 141001 India
| | - Jagdeep Singh
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Kunal Jain
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Gurkirat Kaur
- Department of Cardiac Anaesthesia, Hero DMC Heart Institute, Dayanand Medical College and Hospital, Ludhiana, India
| | - Vivek Gupta
- Department of Cardiac Anaesthesia, Hero DMC Heart Institute, Dayanand Medical College and Hospital, Ludhiana, India
| | - P. L. Gautam
- Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, India
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Boldingh JWHL, Arbous MS, Biemond BJ, Blijlevens NMA, van Bommel J, Hilkens MGEC, Kusadasi N, Muller MCA, de Vries VA, Steyerberg EW, van den Bergh WM. Development and Validation of a Prediction Model for 1-Year Mortality in Patients With a Hematologic Malignancy Admitted to the ICU. Crit Care Explor 2024; 6:e1093. [PMID: 38813435 PMCID: PMC11132307 DOI: 10.1097/cce.0000000000001093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
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.
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Affiliation(s)
- Jan-Willem H L Boldingh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M Sesmu Arbous
- Department of Critical Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam University Medical Center (location AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Jasper van Bommel
- Department of Critical Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Murielle G E C Hilkens
- Department of Critical Care, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Nuray Kusadasi
- Department of Critical Care, Erasmus Medical Center, Rotterdam, The Netherlands
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcella C A Muller
- Department of Critical Care, Amsterdam University Medical Center (location AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Vera A de Vries
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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MacPhail A, Dendle C, Slavin M, Weinkove R, Bailey M, Pilcher D, McQuilten Z. Sepsis mortality among patients with haematological malignancy admitted to intensive care 2000-2022: a binational cohort study. Crit Care 2024; 28:148. [PMID: 38711155 DOI: 10.1186/s13054-024-04932-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/27/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Sepsis occurs in 12-27% of patients with haematological malignancy within a year of diagnosis. Sepsis mortality has improved in non-cancer patients in the last two decades, but longitudinal trends in patients with haematological malignancy are not well characterised. We aimed to compare outcomes, including temporal changes, in patients with and without a haematological malignancy admitted to ICU with a primary diagnosis of sepsis in Australia and New Zealand over the past two decades. METHODS We performed a retrospective cohort study of 282,627 patients with a primary intensive care unit (ICU) admission diagnosis of sepsis including 17,313 patients with haematological malignancy, admitted to 216 intensive care units (ICUs) in Australia or New Zealand between January 2000 and December 2022. Annual crude and adjusted in-hospital mortality were reported. Risk factors for in-hospital mortality were determined using a mixed methods logistic regression model and were used to calculate annual changes in mortality. RESULTS In-hospital sepsis mortality decreased in patients with haematological malignancy, from 55.6% (95% CI 46.5-64.6%) in 2000 to 23.1% (95% CI 20.8-25.5%) in 2021. In patients without haematological malignancy mortality decreased from 33.1% (95% CI 31.3-35.1%) to 14.4% (95% CI 13.8-14.8%). This decrease remained significant after adjusting for mortality predictors including age, SOFA score and comorbidities, as estimated by adjusted annual odds of in-hospital death. The reduction in odds of death was of greater magnitude in patients with haematological malignancy than those without (OR 0.954, 95% CI 0.947-0.961 vs. OR 0.968, 95% CI 0.966-0.971, p < 0.001). However, absolute risk of in-hospital mortality remained higher in patients with haematological malignancy. Older age, higher SOFA score, presence of comorbidities, and mechanical ventilation were associated with increased mortality. Leukopenia (white cell count < 1.0 × 109 cells/L) was not associated with increased mortality in patients with haematological malignancy (p = 0.60). CONCLUSIONS Sepsis mortality has improved in patients with haematological malignancy admitted to ICU. However, mortality remains higher in patients with haematological malignancy than those without.
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Affiliation(s)
- Aleece MacPhail
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Infectious Diseases, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Claire Dendle
- Department of Infectious Diseases, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, 246 Clayton Road, Clayton, VIC, 3004, Australia
| | - Monica Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Robert Weinkove
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Te Rerenga Ora Wellington Blood and Cancer Centre, Wellington Hospital, Te Whatu Ora Health New Zealand Capital Coast & Hutt Valley, Wellington, 6021, New Zealand
| | - Michael Bailey
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - David Pilcher
- Department of Intensive Care, Alfred Health, 55 Commercial Road, Prahran, VIC, 3004, Australia
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS-CORE), 101 High St Prahran, Victoria, 3001, Australia
- The Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, 553 St Kilda Rd, Prahran, VIC, 3004, Australia
| | - Zoe McQuilten
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
- Department of Haematology, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia.
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van Mourik N, Oomen JJ, van Vught LA, Biemond BJ, van den Bergh WM, Blijlevens NMA, Vlaar APJ, Müller MCA. The predictive value of the modified early warning score for admission to the intensive care unit in patients with a hematologic malignancy - A multicenter observational study. Intensive Crit Care Nurs 2023; 79:103486. [PMID: 37441816 DOI: 10.1016/j.iccn.2023.103486] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES The modified early warning score (MEWS) is used to detect clinical deterioration of hospitalized patients. We aimed to investigate the predictive value of MEWS and derived quick Sequential Organ Failure Assessment (qSOFA) scores for intensive care unit admission in patients with a hematologic malignancy admitted to the ward. DESIGN Retrospective, observational study in two Dutch university hospitals. SETTING Data from adult patients with a hematologic malignancy, admitted to the ward over a 2-year period, were extracted from electronic patient files. MAIN OUTCOME MEASURES Intensive care admission. RESULTS We included 395 patients with 736 hospital admissions; 2% (n = 15) of admissions resulted in admission to the intensive care unit. A higher MEWS (OR 1.5; 95 %CI 1.3-1.80) and qSOFA (OR 4.4; 95 %CI 2.1-9.3) were associated with admission. Using restricted cubic splines, a rise in the probability of admission for a MEWS ≥ 6 was observed. The AUC of MEWS for predicting admission was 0.830, the AUC of qSOFA was 0.752. MEWS was indicative for intensive care unit admission two days before admission. CONCLUSIONS MEWS was a sensitive predictor of ICU admission in patients with a hematologic malignancy, superior to qSOFA. Future studies should confirm cut-off values and identify potential additional characteristics, to further enhance identification of critically ill hemato-oncology patients. IMPLICATIONS FOR CLINICAL PRACTICE The Modified Early Warning Score (MEWS) can be used as a tool for healthcare providers to monitor clinical deterioration and predict the need for intensive care unit admission in patients with a hematologic malignancy. Yet, consistent application and potential reevaluation of current thresholds is crucial. This will enable bedside nurses to more effectively identify patients needing adjunctive care, facilitating timely interventions and improved outcome.
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Affiliation(s)
- Niels van Mourik
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands.
| | - Jesse J Oomen
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lonneke A van Vught
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
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Zhou Y, Mu W, Wang C, Zhuo Z, Xin Y, Li H, Wang C. Ray of dawn: Anti-PD-1 immunotherapy enhances the chimeric antigen receptor T-cell therapy in Lymphoma patients. BMC Cancer 2023; 23:1019. [PMID: 37872514 PMCID: PMC10591343 DOI: 10.1186/s12885-023-11536-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/17/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Chimeric antigen receptor T (CAR-T) cell therapy, a new adoptive cell therapy, has been widely used to treat lymphoma patients. Immune checkpoint blockade may improve the cytotoxicity of CAR-T cells by reducing the failure of CAR-T cells and improving antitumor activity. It has shown promising efficacy. METHOD We searched PubMed, the Cochrane Library, Embase and Web of Science from January 2012 to August 2022 to find data reporting the results of CAR-T cells therapy combined with PD-1 in tumor patients. An updated search was conducted in October 2023. The partial response rate (PR), complete response rate (CR), objective response rate (ORR), mortality rate, and incidence of adverse reactions were calculated. RESULTS We analyzed 57 lymphoma patients from 5 clinical trials. The pooled partial, complete and overall response rates were 21% (95% CI 0.06-0.39, I2 = 0.37%), 27% (95% CI 0.03-0.60, I2 = 60.43%) and 65% (95% CI 0.23-0.98, I2 = 76.31%), respectively. The pooled incidence of cytokine release syndrome, neutropenia, fever, and fatigue was estimated to be 57% (95% CI 0.08-0.99, I2 = 85.20%), 47% (95% CI 0.14-0.81, I2 = 74.17%), 59% (95% CI 0.27-0.89, I2 = 60.23%), and 50% (95% CI 0.13-0.87, I2 = 73.89%), respectively. CONCLUSION CAR-T-cell therapy combined with anti-PD-1 immunotherapy in the treatment of lymphoma patients has efficacy, and the most common adverse effect is fever. REGISTRATION The protocol was registered in prospero, with the registration number CRD42022342647.
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Affiliation(s)
- Yuxin Zhou
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, 150001, China
| | - Wenjing Mu
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangdong, Guangzhou Province, 510280, China
- Department of Critical Care Medicine, the Cancer Hospital of Harbin Medical University, Harbin, Heilongjiang Province, 150081, China
| | - Chen Wang
- Department of Digestive medicine center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518017, China
| | - Zipeng Zhuo
- Department of Critical Care Medicine, the Cancer Hospital of Harbin Medical University, Harbin, Heilongjiang Province, 150081, China
| | - Yu Xin
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, 150001, China
| | - Hongxu Li
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, 150001, China
| | - Changsong Wang
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, 150001, China.
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Constantinescu C, Moisoiu V, Tigu B, Kegyes D, Tomuleasa C. Outcomes of CAR-T Cell Therapy Recipients Admitted to the ICU: In Search for a Standard of Care-A Brief Overview and Meta-Analysis of Proportions. J Clin Med 2023; 12:6098. [PMID: 37763039 PMCID: PMC10531736 DOI: 10.3390/jcm12186098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE Our primary objective was to describe the baseline characteristics, main reasons for intensive care unit (ICU) admission, and interventions required in the ICU across patients who received CAR-T cell immunotherapy. The secondary objectives were to evaluate different outcomes (ICU mortality) across patients admitted to the ICU after having received CAR-T cell therapy. MATERIALS AND METHODS We performed a medical literature review, which included MEDLINE, Embase, and Cochrane Library, of studies published from the inception of the databases until 2022. We conducted a systematic review with meta-analyses of proportions of several studies, including CAR-T cell-treated patients who required ICU admission. Outcomes in the meta-analysis were evaluated using the random-effects model. RESULTS We included four studies and analyzed several outcomes, including baseline characteristics and ICU-related findings. CAR-T cell recipients admitted to the ICU are predominantly males (62% CI-95% (57-66)). Of the total CAR-T cell recipients, 4% CI-95% (3-5) die in the hospital, and 6% CI-95% (4-9) of those admitted to the ICU subsequently die. One of the main reasons for ICU admission is acute kidney injury (AKI) in 15% CI-95% (10-19) of cases and acute respiratory failure in 10% CI-95% (6-13) of cases. Regarding the interventions initiated in the ICU, 18% CI-95% (13-22) of the CAR-T recipients required invasive mechanical ventilation during their ICU stay, 23% CI-95% (16-30) required infusion of vasoactive drugs, and 1% CI-95% (0.1-3) required renal replacement therapy (RRT). 18% CI-95% (13-22) of the initially discharged patients were readmitted to the ICU within 30 days, and the mean length of hospital stay is 22 days CI-95% (19-25). The results paint a current state of matter in CAR-T cell recipients admitted to the ICU. CONCLUSIONS To better understand immunotherapy-related complications from an ICU standpoint, acknowledge the deteriorating patient on the ward, reduce the ICU admission rate, advance ICU care, and improve the outcomes of these patients, a standard of care and research regarding CAR-T cell-based immunotherapies should be created. Studies that are looking from the perspective of intensive care are highly warranted because the available literature regarding this area is scarce.
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Affiliation(s)
- Catalin Constantinescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania; (C.C.); (C.T.)
- Department of Anesthesia and Intensive Care, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania
- Intensive Care Unit, Emergency Hospital, 400006 Cluj-Napoca, Romania
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
| | - Vlad Moisoiu
- Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
| | - Bogdan Tigu
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
| | - David Kegyes
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania; (C.C.); (C.T.)
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
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9
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Grünewaldt A, Peiffer KH, Bojunga J, Rohde GGU. Characteristics, clinical course and outcome of ventilated patients at a non-surgical intensive care unit in Germany: a single-centre, retrospective observational cohort analysis. BMJ Open 2023; 13:e069834. [PMID: 37423629 DOI: 10.1136/bmjopen-2022-069834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
OBJECTIVES The objective of this study was to evaluate epidemiological characteristics, clinical course and outcome of mechanically ventilated non-surgical intensive care unit (ICU) patients, with the aim of improving the strategic planning of ICU capacities. DESIGN We conducted a retrospective observational cohort analysis. Data from mechanically ventilated intensive care patients were obtained by investigating electronic health records. The association between clinical parameters and ordinal scale data of clinical course was evaluated using Spearman correlation and Mann-Whitney U test. Relations between clinical parameters and in-hospital mortality rates were examined using binary logistic regression analysis. SETTING A single-centre study at the non-surgical ICU of the University Hospital of Frankfurt, Germany (tertiary care-level centre). PARTICIPANTS All cases of critically ill adult patients in need of mechanical ventilation during the years 2013-2015 were included. In total, 932 cases were analysed. RESULTS From a total of 932 cases, 260 patients (27.9%) were transferred from peripheral ward, 224 patients (24.1%) were hospitalised via emergency rescue services, 211 patients (22.7%) were admitted via emergency room and 236 patients (25.3%) via various transfers. In 266 cases (28.5%), respiratory failure was the reason for ICU admission. The length of stay was higher in non-geriatric patients, patients with immunosuppression and haemato-oncological disease or those in need of renal replacement therapy. 431 patients died, which corresponds to an all-cause in-hospital mortality rate of 46.2%. 92 of 172 patients with presence of immunosuppression (53.5%), 111 of 186 patients (59.7%) with pre-existing haemato-oncological disease, 27 of 36 patients (75.0%) under extracorporeal membrane oxygenation (ECMO) therapy, and 182 of 246 patients (74.0%) undergoing renal replacement therapy died. In logistic regression analysis, these subgroups and older age were significantly associated with higher mortality rates. CONCLUSIONS Respiratory failure was the main reason for ventilatory support at this non-surgical ICU. Immunosuppression, haemato-oncological diseases, the need for ECMO or renal replacement therapy and older age were associated with higher mortality.
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Affiliation(s)
- Achim Grünewaldt
- Department of Respiratory Medicine and Allergology, Goethe University, Frankfurt, Germany
| | | | - Jörg Bojunga
- Department of Endocrinology, Goethe University, Frankfurt, Germany
| | - Gernot G U Rohde
- Department of Respiratory Medicine and Allergology, Goethe University, Frankfurt, Germany
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10
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Martins CDS, Maasdorp SD. Outcomes of patients with haematological malignancies and febrile neutropenia at the Universitas Academic Hospital multidisciplinary intensive care unit, Free State Province, South Africa. Afr J Thorac Crit Care Med 2023; 29:10.7196/AJTCCM.2023.v29i1.263. [PMID: 37476654 PMCID: PMC10354873 DOI: 10.7196/ajtccm.2023.v29i1.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 01/17/2023] [Indexed: 07/22/2023] Open
Abstract
Background Mortality rates in patients with haematological malignancies who required intensive care unit (ICU) admission have in the past been high. More recently, however, improved outcomes for critically ill haematological patients have been reported. Objectives To determine outcomes, average length of ICU stay, and factors associated with mortality in patients with haematological malignancies and neutropenic fever in the multidisciplinary ICU (MICU) at Universitas Academic Hospital (UAH), Bloemfontein, Free State Province, South Africa. Methods We conducted a retrospective review of medical and laboratory records of all patients admitted to the UAH MICU with haematological malignancies and febrile neutropenia between 2010 and 2019. Results A total of 182 patients with haematological malignancies were admitted to the MICU between 1 January 2010 and 31 December 2019, of whom 51 (28.0%) fulfilled the inclusion criteria for the study. The median age was 33 years, and 29 patients (56.9%) were female. Most patients had either acute myeloid leukaemia (n=22; 43.1%) or acute lymphocytic leukaemia (n=16; 31.4%), while B-cell lymphoma (n=12; 23.5%) and multiple myeloma (n=1; 2%) were less frequent. The median length of stay in the ICU was 3 days. ICU mortality was 76.5% and hospital mortality 82.4%. Factors associated with mortality included septic shock, vasoactive agent use and mechanical ventilation. Conclusion Patients with haematological malignancies and febrile neutropenia in the UAH MICU have high ICU and hospital mortality rates. More needs to be done with regard to timeous management of patients with haematological malignancies and septic shock in our setting to improve survival. Study synopsis This is the first study to report on ICU mortality of adult patients with haematological malignancies and neutropenic sepsis in a tertiary hospital ICU in the Free State. These patients had a high mortality rate. What the study adds. Our study shows that septic shock, vasoactive agent use and mechanical ventilation were associated with increased ICU mortality.Implications of the findings. Strict adherence to infection prevention and control measures in haematology wards is required. Early recognition and treatment of sepsis before it progresses to septic shock is important. ICUs must be designed so that isolation cubicles are readily available to prevent cross-infection of patients.
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Affiliation(s)
- C D S Martins
- Division of Critical Care, Department of Surgery, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - S D Maasdorp
- Division of Critical Care, Department of Surgery, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
- Division of Pulmonology, Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
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11
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Friend BD, Broglie L, Logan BR, Chhabra S, Bupp C, Schiller G, Beitinjaneh A, Perez MAD, Guilcher GMT, Hashem H, Hildebrandt GC, Krem MM, Lazarus HM, Nishihori T, Nusrat R, Rotz SJ, Wirk B, Wieduwilt M, Pasquini M, Savani BN, Stadtmauer EA, Sorror ML, Thakar MS. Adapting the HCT-CI Definitions for Children, Adolescents, and Young Adults with Hematologic Malignancies Undergoing Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:123.e1-123.e10. [PMID: 36442769 PMCID: PMC9911376 DOI: 10.1016/j.jtct.2022.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/08/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
Allogeneic hematopoietic cell transplantation is a curative procedure for hematologic malignancies but is associated with a significant risk of non-relapse mortality (NRM). The Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI) is a prognostic tool that discriminates this risk in all age groups. A recent survey of transplant physicians demonstrated that 79% of pediatric providers used the HCT-CI infrequently, and most reported concerns about its applicability in the younger population. We conducted a retrospective study using the Center for International Blood and Marrow Transplant Research database to examine the impact of expanded HCT-CI definitions on NRM in pediatric and young adult patients with hematologic malignancies. We included 5790 patients <40 years old receiving allogeneic transplants between 2008 and 2017 to examine broader definitions of comorbidities in the HCT-CI, including history of mechanical ventilation and fungal infection, estimated glomerular filtration rate, and body mass index (BMI) percentiles. Multivariable Fine-Gray models were created to determine the effect of each HCT-CI defining comorbidity and its modification on NRM and were used to develop 2 novel risk scores. We next developed the expanded HCT-CI for children and young adults (youth with malignancies; expanded ymHCT-CI), where 23% patients had an increased comorbidity score, compared to the HCT-CI. Comorbidities with hazard ratio < 1.2 were then removed to create the simplified HCT-CI for children and young adults (youth with malignancies; simplified ymHCT-CI), which demonstrated higher scores corresponded to a greater risk of NRM (P < .001). These novel comorbidity indexes with broader definitions are more relevant to pediatric and young adult patients, and prospective studies are needed to validate these in the younger patient population. It remains to be seen whether the development of these pediatric-specific and practical risk indexes increases their use by the pediatric transplant community.
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Affiliation(s)
- Brian D Friend
- Baylor College of Medicine Center for Cell and Gene Therapy, Houston, Texas
| | - Larisa Broglie
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brent R Logan
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin; CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Saurabh Chhabra
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Hematology/Oncology, Department of Medicine, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Caitrin Bupp
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Gary Schiller
- Hematological Malignancy/Stem Cell Transplant Program, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Miguel Angel Diaz Perez
- Department of Hematology/Oncology, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
| | - Gregory M T Guilcher
- Section of Pediatric Oncology/Cellular Therapy, Alberta Children's Hospital, Departments of Oncology and Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | | | | | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI), Moffitt Cancer Center, Tampa, Florida
| | | | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Matthew Wieduwilt
- Department of Medicine, University of Oklahoma, Stephenson Cancer Center, Oklahoma City, Oklahoma
| | - Marcelo Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edward A Stadtmauer
- University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Monica S Thakar
- Clinical Research Division, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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12
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Chen CL, Wang ST, Cheng WC, Wu BR, Liao WC, Hsu WH. Outcomes and Prognostic Factors in Critical Patients with Hematologic Malignancies. J Clin Med 2023; 12:jcm12030958. [PMID: 36769606 PMCID: PMC9918099 DOI: 10.3390/jcm12030958] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/17/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Chieh-Lung Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 404, Taiwan
| | - Sing-Ting Wang
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung 404, Taiwan
| | - Wen-Chien Cheng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 404, Taiwan
- School of Medicine, China Medical University, Taichung 404, Taiwan
- Department of Life Science, National Chung Hsing University, Taichung 402, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Biing-Ru Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 404, Taiwan
- Department of Respiratory Therapy, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence: (B.-R.W.); (W.-C.L.)
| | - Wei-Chih Liao
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 404, Taiwan
- School of Medicine, China Medical University, Taichung 404, Taiwan
- Center for Hyperbaric Oxygenation Therapy, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence: (B.-R.W.); (W.-C.L.)
| | - Wu-Huei Hsu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 404, Taiwan
- Critical Medical Center, China Medical University Hospital, Taichung 404, Taiwan
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13
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Fizza Haider S, Sloss R, Jhanji S, Nicholson E, Creagh-Brown B. Management of adult patients with haematological malignancies in critical care. Anaesthesia 2023. [PMID: 36658786 DOI: 10.1111/anae.15955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2022] [Indexed: 01/21/2023]
Abstract
There are a diverse range of haematological malignancies with varying clinical presentations and prognoses. Patients with haematological malignancy may require admission to critical care at the time of diagnosis or due to treatment related effects and complications. Although the prognosis for such patients requiring critical care has improved, there remain uncertainties in optimal clinical management. Identification of patients who will benefit from critical care admission is challenging and selective involvement of palliative care may help to reduce unnecessary and non-beneficial treatments. While patients with haematological malignancy can present a challenge to critical care physicians, good outcomes can be achieved. In this narrative review, we provide a brief overview of relevant haematological malignancies for the critical care physician and a summary of recent treatment advances. Subsequently, we focus on critical care management for the patient with haematological malignancy including sepsis; acute respiratory failure; prevention and treatment of tumour lysis syndrome; thrombocytopaenia; and venous thromboembolism. We also discuss immunotherapeutic-specific related complications and their management, including cytokine release syndrome and immune effector cell associated neurotoxicity syndrome associated with chimeric antigen receptor T-cell therapy. While the management of haematological malignancies is highly specialised and increasingly centralised, acutely unwell patients often present to their local hospital with complications requiring critical care expertise. The aim of this review is to provide a contemporary overview of disease and management principles for non-specialist critical care teams.
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Affiliation(s)
- S Fizza Haider
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - R Sloss
- Department of Peri-Operative Medicine (Critical Care), St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - S Jhanji
- Department of Critical Care, Royal Marsden Hospital, London, UK.,Division of Cancer Biology, Institute of Cancer Research, London, UK
| | - E Nicholson
- Department of Haematology, Royal Marsden Hospital, London, UK.,Division of Cancer Therapeutics, Institute of Cancer Research, London, UK
| | - B Creagh-Brown
- Intensive Care Unit, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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14
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Prognostic Impact of Neutropenia in Cancer Patients with Septic Shock: A 2009–2017 Nationwide Cohort Study. Cancers (Basel) 2022; 14:cancers14153601. [PMID: 35892860 PMCID: PMC9332608 DOI: 10.3390/cancers14153601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary The prognostic impact of neutropenia on mortality in cancer patients with septic shock remains controversial despite recent advances in cancer and sepsis management. This study aimed to determine whether neutropenia could be related to an increase in short-term and long-term mortality. This population-based, case–control study used data from the National Health Insurance Service of Korea. Adult cancer patients who presented to the emergency department with septic shock from 2009 to 2017 were analyzed. The 30-day and 1-year mortality rates were evaluated as short-term and long-term outcomes. After adjustment for confounders, neutropenia was independently associated with decreased 30-day and 1-year mortality rates. Neutropenia did not increase mortality in cancer patients with septic shock, suggesting that neutropenia may not be used as a single triage criterion for withholding intensive care in cancer patients presenting to the emergency department with septic shock. Abstract (1) Background: Neutropenia’s prognostic impact on mortality in cancer patients with septic shock remains controversial despite recent advances in cancer and sepsis management. This population-based, case–control study aimed to determine whether neutropenia could be related to an increase in short-term and long-term mortality. (2) Methods: This population-based, case–control study used data from the National Health Insurance Service of Korea. Adult cancer patients who presented to the emergency department with septic shock from 2009 to 2017 were included. The 30-day and 1-year mortality rates were evaluated as short-term and long-term outcomes. Cox proportional hazard regression was performed after adjusting for age, sex, Charlson comorbidity index, and neutropenia. (3) Results: In 43,466 adult cancer patients with septic shock, the 30-day and 1-year mortality rates were 52.1% and 81.3%, respectively. In total, 6391 patients had neutropenic septic shock, and the prevalent cancer type was lung cancer, followed by leukemia, non-Hodgkin’s lymphoma, stomach cancer, and colon cancer. Furthermore, 30-day and 1-year mortality was lower in patients with neutropenia than in those without neutropenia. After adjustment for confounders, neutropenia was independently associated with decreased 30-day and 1-year mortality rates. (4) Conclusions: In cancer patients presenting to the emergency department with septic shock, the presence of neutropenia did not increase mortality. This suggests that neutropenia may not be used as a single triage criterion for withholding intensive care in cancer patients presenting to the emergency department with septic shock.
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15
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Papakonstantinou E, Dragoumani K, Efthimiadou A, Palaiogeorgou AM, Pierouli K, Mitsis T, Chrousos GP, Bacopoulou F, Vlachakis D. Haematological malignancies implications during the times of the COVID-19 pandemic. Oncol Lett 2021; 22:856. [PMID: 34777590 PMCID: PMC8581473 DOI: 10.3892/ol.2021.13117] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/18/2021] [Indexed: 12/13/2022] Open
Abstract
The COVID-19 pandemic has complicated current healthcare services for cancer patients. Patients with haematological malignancies specifically seem vulnerable to SARS-CoV-2 infection due to their immunosuppressed status. The COVID-19 pandemic influences every step of the assessment and treatment of a haematological malignancy. Clinicians must adhere to strict policies to not spread the virus to their patients while they must also adjust their workflow for maximum productivity. These difficulties accentuate the ever-present need to improve the healthcare services for cancer patients. This improvement is needed not only to combat the problems that arose from the COVID-19 pandemic but also to establish a framework for the management of patients with haematological malignancies in potential future pandemics.
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Affiliation(s)
- Eleni Papakonstantinou
- Laboratory of Genetics, Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 11855 Athens, Greece
| | - Konstantina Dragoumani
- Laboratory of Genetics, Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 11855 Athens, Greece
| | - Aspasia Efthimiadou
- Hellenic Agricultural Organization-Demeter, Institute of Soil and Water Resources, Department of Soil Science of Athens, 14123 Lycovrisi, Greece
| | - Anastasia Marina Palaiogeorgou
- Laboratory of Genetics, Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 11855 Athens, Greece
| | - Katerina Pierouli
- Laboratory of Genetics, Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 11855 Athens, Greece
| | - Thanasis Mitsis
- Laboratory of Genetics, Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 11855 Athens, Greece
| | - George P. Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, 11527 Athens, Greece
- Division of Endocrinology and Metabolism, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, 11527 Athens, Greece
| | - Flora Bacopoulou
- University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, 11527 Athens, Greece
| | - Dimitrios Vlachakis
- Laboratory of Genetics, Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 11855 Athens, Greece
- University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, 11527 Athens, Greece
- Division of Endocrinology and Metabolism, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, 11527 Athens, Greece
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16
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Warren ML, Schneider VV, Qing Y, Feng L, Campbell JY, Myers JW, Von-Maszewski M, Gutierrez C. Short- and Long-Term Outcomes of Hematologic Malignancy Patients After Cardiopulmonary Resuscitation: Experience of a Large Oncology Center. J Adv Pract Oncol 2021; 12:705-714. [PMID: 34671500 PMCID: PMC8504933 DOI: 10.6004/jadpro.2021.12.7.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose The objective of this study is to describe characteristics and short- and long-term outcomes of patients with hematologic malignancies who received cardiopulmonary resuscitation (CPR). Methods A retrospective review was conducted of all Code Blues at a large comprehensive cancer center. Demographic, clinical, and outcome variables were analyzed for patients with a hematologic malignancy who underwent CPR. Results Of 258 patients, 60.1% had leukemia. Outcomes included return of spontaneous circulation (70.2%), hospital survival (12%), and 90-day, 6-month, and 1-year survival rates of 9.8%, 8.2%, and 5.9%, respectively. Factors associated with hospital mortality included establishing a do not resuscitate order after CPR (p < .0001), location of CPR (p = .0004), cause of arrest (p = .0019), requiring vasopressors (p = .0130), mechanical ventilation (p = .0423), and acute renal failure post CPR (p = .0006). Although no difference in hospital survival between leukemia and non-leukemia patients was found, more non-leukemia patients were alive at 90 days (p = .0099), 6 months (p = .0023), and 1 year (p = .0119). Conclusions Factors including organ dysfunction, location of CPR, and cause of arrest are associated with hospital mortality post CPR. However, immediate survival post CPR does not seem to be affected by a diagnosis of leukemia. These data should assist health care providers with discussions regarding advance care planning and goals of care after cardiac arrest.
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Affiliation(s)
- Mary Lou Warren
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Yun Qing
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lei Feng
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Jason W Myers
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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van der Zee EN, Benoit DD, Hazenbroek M, Bakker J, Kompanje EJO, Kusadasi N, Epker JL. Outcome of cancer patients considered for intensive care unit admission in two university hospitals in the Netherlands: the danger of delayed ICU admissions and off-hour triage decisions. Ann Intensive Care 2021; 11:125. [PMID: 34379217 PMCID: PMC8357904 DOI: 10.1186/s13613-021-00898-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/29/2021] [Indexed: 12/12/2022] Open
Abstract
Background Very few studies assessed the association between Intensive Care Unit (ICU) triage decisions and mortality. The aim of this study was to assess whether an association could be found between 30-day mortality, and ICU admission consultation conditions and triage decisions. Methods We conducted a retrospective cohort study in two large referral university hospitals in the Netherlands. We identified all adult cancer patients for whom ICU admission was requested from 2016 to 2019. Via a multivariable logistic regression analysis, we assessed the association between 30-day mortality, and ICU admission consultation conditions and triage decisions. Results Of the 780 cancer patients for whom ICU admission was requested, 332 patients (42.6%) were considered ‘too well to benefit’ from ICU admission, 382 (49%) patients were immediately admitted to the ICU and 66 patients (8.4%) were considered ‘too sick to benefit’ according to the consulting intensivist(s). The 30-day mortality in these subgroups was 30.1%, 36.9% and 81.8%, respectively. In the patient group considered ‘too well to benefit’, 258 patients were never admitted to the ICU and 74 patients (9.5% of the overall study population, 22.3% of the patients ‘too well to benefit’) were admitted to the ICU after a second ICU admission request (delayed ICU admission). Thirty-day mortality in these groups was 25.6% and 45.9%. After adjustment for confounders, ICU consultations during off-hours (OR 1.61, 95% CI 1.09–2.38, p-value 0.02) and delayed ICU admission (OR 1.83, 95% CI 1.00–3.33, p-value 0.048 compared to “ICU admission”) were independently associated with 30-day mortality. Conclusion The ICU denial rate in our study was high (51%). Sixty percent of the ICU triage decisions in cancer patients were made during off-hours, and 22.3% of the patients initially considered “too well to benefit” from ICU admission were subsequently admitted to the ICU. Both decisions during off-hours and a delayed ICU admission were associated with an increased risk of death at 30 days. Our study suggests that in cancer patients, ICU triage decisions should be discussed during on-hours, and ICU admission policy should be broadened, with a lower admission threshold for critically ill cancer patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00898-2.
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Affiliation(s)
- Esther N van der Zee
- Department of Intensive Care, Erasmus MC University Medical Center, Room Ne-403, Doctor molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | | | - Marinus Hazenbroek
- Department of Intensive Care, Erasmus MC University Medical Center, Room Ne-403, Doctor molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Jan Bakker
- Department of Intensive Care, Erasmus MC University Medical Center, Room Ne-403, Doctor molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Department of Pulmonology and Critical Care, New York University, New York, USA.,Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, USA.,Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center, Room Ne-403, Doctor molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Nuray Kusadasi
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jelle L Epker
- Department of Intensive Care, Erasmus MC University Medical Center, Room Ne-403, Doctor molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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Association of Acute Kidney Injury Receiving Kidney Replacement Therapy With Prognosis of Critically Ill Patients With and Without Cancer: A Retrospective Study. Crit Care Med 2021; 49:1932-1942. [PMID: 34166290 DOI: 10.1097/ccm.0000000000005102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess outcomes of cancer patients receiving kidney replacement therapy due to acute kidney injury in ICUs and compare these with other patient groups receiving kidney replacement therapy in ICUs. DESIGN Retrospective registry analysis. SETTING Prospectively collected database of 296,424 ICU patients. PATIENTS Patients with and without solid cancer with acute kidney injury necessitating kidney replacement therapy were identified and compared with those without acute kidney injury necessitating kidney replacement therapy. INTERVENTIONS Descriptive statistics were used to ascertain prevalence of acute kidney injury necessitating kidney replacement therapy and solid cancer in ICU patients. Association of acute kidney injury necessitating kidney replacement therapy and cancer with prognosis was assessed using logistic regression analysis. To compare the attributable mortality of acute kidney injury necessitating kidney replacement therapy, 20,154 noncancer patients and 2,411 cancer patients without acute kidney injury necessitating kidney replacement therapy were matched with 12,827 noncancer patients and 1,079 cancer patients with acute kidney injury necessitating kidney replacement therapy. MEASUREMENTS AND MAIN RESULTS Thirty-five thousand three hundred fifty-six ICU patients (11.9%) had solid cancer. Acute kidney injury necessitating kidney replacement therapy was present in 1,408 (4.0%) cancer patients and 13,637 (5.2%) noncancer patients. Crude ICU and hospital mortality was higher in the cancer group (646 [45.9%] vs 4,674 [34.3%], p < 0.001, and 787 [55.9%] vs 5,935 [43.5%], p < 0.001). In multivariable logistic regression analyses, odds ratio (95% CI) for hospital mortality was 1.73 (1.62-1.85) for cancer compared with no cancer 3.57 (3.32-3.83) for acute kidney injury necessitating kidney replacement therapy and 1.07 (0.86-1.33) for their interaction. In the matched subcohort, attributable hospital mortality of acute kidney injury necessitating kidney replacement therapy was 56.7% in noncancer patients and 48.0% in cancer patients. CONCLUSIONS Occurrence rate of acute kidney injury necessitating kidney replacement therapy and prognosis in ICU patients with solid cancer are comparable with other ICU patient groups. In cancer, acute kidney injury necessitating kidney replacement therapy is associated with higher crude hospital mortality. However, the specific attributable mortality conveyed by acute kidney injury necessitating kidney replacement therapy is actually lower in cancer patients than in noncancer patients. Diagnosis of cancer per se does not justify withholding kidney replacement therapy.
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Sepsis and Septic Shock in Patients With Malignancies: A Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique Study. Crit Care Med 2021; 48:822-829. [PMID: 32317596 DOI: 10.1097/ccm.0000000000004322] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Cancer affects up to 20% of critically ill patients, and sepsis is one of the leading reasons for ICU admission in this setting. Early signals suggested that survival might be increasing in this population. However, confirmation studies have been lacking. The goal of this study was to assess trends in survival rates over time in cancer patients admitted to the ICU for sepsis or septic shock over the last 2 decades. DATA SOURCE Seven European ICUs. STUDY SELECTION A hierarchical model taking into account the year of admission and the source dataset as random variables was used to identify risk factors for day 30 mortality. DATA EXTRACTION Data from cancer patients admitted to ICUs for sepsis or septic shock were extracted from the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique database (1994-2015). DATA SYNTHESIS Overall, 2,062 patients (62% men, median [interquartile range] age 59 yr [48-67 yr]) were included in the study. Underlying malignancies were solid tumors (n = 362; 17.6%) or hematologic malignancies (n = 1,700; 82.4%), including acute leukemia (n = 591; 28.7%), non-Hodgkin lymphoma (n = 461; 22.3%), and myeloma (n = 244; 11.8%). Two-hundred fifty patients (12%) underwent allogeneic hematopoietic stem cell transplantation and 640 (31.0%) were neutropenic at ICU admission. Day 30 mortality was 39.9% (823 deaths). The year of ICU admission was associated with significant decrease in day 30 mortality over time (odds ratio, 0.96; 95% CI, 0.93-0.98; p = 0.001). Mechanical ventilation (odds ratio, 3.25; 95% CI, 2.52-4.19; p < 0.01) and vasopressors use (odds ratio, 1.42; 95% CI, 1.10-1.83; p < 0.01) were independently associated with day 30 mortality, whereas underlying malignancy, allogeneic hematopoietic stem cell transplantation, and neutropenia were not. CONCLUSIONS Survival in critically ill oncology and hematology patients with sepsis improved significantly over time. As outcomes improve, clinicians should consider updating admission policies and goals of care in this population.
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20
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Lueck C, Beutel G. [Cancer patients in the intensive care unit]. Med Klin Intensivmed Notfmed 2021; 116:104-110. [PMID: 33591384 DOI: 10.1007/s00063-021-00795-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 01/19/2021] [Indexed: 11/24/2022]
Abstract
Over the past 20 years, demographic changes and a longer life expectancy of cancer patients has significantly increased the prevalence of this patient group in the intensive care unit (ICU). A fundamental finding is that acute organ dysfunction, rather than the underlying malignancy, determines the prognosis of ICU patients. While hematologic patients often suffer from a more severe disease course, patients with solid tumors do not present an increased hospital mortality compared to the normal population. As with other indications, the decision to transfer a cancer patient to an ICU should be made as soon as possible. While early transfer is associated with reduced hospital mortality, the presence of multiorgan failure on ICU admission is associated with increased mortality. Overall, the intensive care and hospital survival of critically ill hematologic or oncologic patients has improved over the last two decades and is now as high as 50 to 60%. After surviving an intensive care stay, one fifth of all patients have a good long-term prognosis. Thus, the former paradigm of general rejection of cancer patients for ICU care is no longer justified. For optimal care of cancer patients requiring intensive care, close cooperation between hematologists/oncologists and intensive care physicians is essential.
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Affiliation(s)
- C Lueck
- Klinik für Hämatologie, Hämostaseologie, Onkologie und Stammzelltransplantation, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - G Beutel
- Klinik für Hämatologie, Hämostaseologie, Onkologie und Stammzelltransplantation, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
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21
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Bourcier S, Villie P, Nguyen S, Hékimian G, Demondion P, Bréchot N, Luyt CE, Lebreton G, Combes A, Schmidt M. Venoarterial Extracorporeal Membrane Oxygenation Support Rescue of Obstructive Shock Caused by Bulky Compressive Mediastinal Cancer. Am J Respir Crit Care Med 2020; 202:1181-1184. [PMID: 32543883 DOI: 10.1164/rccm.202001-0193le] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | | | - Pierre Demondion
- Pitié-Salpêtrière Hospital Paris, France and.,Sorbonne Université Paris, France
| | | | | | - Guillaume Lebreton
- Pitié-Salpêtrière Hospital Paris, France and.,Sorbonne Université Paris, France
| | - Alain Combes
- Pitié-Salpêtrière Hospital Paris, France and.,Sorbonne Université Paris, France
| | - Matthieu Schmidt
- Pitié-Salpêtrière Hospital Paris, France and.,Sorbonne Université Paris, France
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Alobuia WM, Perrone K, Iberri DJ, Brar RS, Spain DA, Forrester JD. Splenectomy for benign and malignant hematologic pathology: Modern morbidity, mortality, and long-term outcomes. Surg Open Sci 2020; 2:19-24. [PMID: 32939448 PMCID: PMC7479208 DOI: 10.1016/j.sopen.2020.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/15/2020] [Accepted: 06/21/2020] [Indexed: 11/25/2022] Open
Abstract
Background The role of splenectomy to diagnose and treat hematologic disease continues to evolve. In this single-center retrospective review, we describe modern morbidity, mortality, and long-term outcomes associated with splenectomy for benign and malignant hematologic disorders. Methods We analyzed all nontrauma splenectomies performed for benign or malignant hematologic disorders from January 2009 to September 2018. Variables collected included demographics, preexisting comorbidities, laboratory results, intra- and postoperative features, and long-term follow-up. Outcomes of interest included postoperative complications, 30-day mortality, and overall mortality. Results We identified 161 patients who underwent splenectomy for hematologic disorders. Median age was 54 years (range 19–94), and 83 (52%) were female. Splenectomy was performed for 95 (59%) patients with benign hematologic disorders and for 66 (41%) with malignant conditions. Most splenectomies were laparoscopic (76%), followed by laparoscopic hand assisted (11%), open (8%), and laparoscopic converted to open (6%). Median follow-up was 761 days (interquartile range: 179–2025 days). Major complications occurred in 21 (13%) patients. Three (2%) patients died within 30 days; 16 (9%) died more than 30 days after operation, none from surgical complications, with median time to death of 438 days (interquartile range: 231–1497 days). Among malignant cases, only preoperative thrombocytopenia predicted death (odds ratio = 5.8, 95% confidence interval = 1.1–31.8, P = .04). For benign cases, increasing age was associated with inferior survival (odds ratio = 2.3, 95% confidence interval = 1.0–5.1, P = .05). Conclusion Splenectomy remains an important diagnostic and therapeutic option for patients with benign and malignant hematologic disorders and can be performed with a low complication rate. Despite considerable burden of comorbid disease in these patients, early postoperative mortality was uncommon.
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Affiliation(s)
| | | | - David J Iberri
- Department of Medicine-Hematology, Stanford University, Stanford, CA
| | - Rondeep S Brar
- Department of Medicine-Hematology, Stanford University, Stanford, CA
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, CA
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23
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Kalicińska E, Kuszczak B, Dębski J, Szukalski Ł, Wątek M, Strzała J, Rybka J, Czyż J, Lech-Marańda E, Zaucha J, Wróbel T. Hematological malignancies in Polish population: what are the predictors of outcome in patients admitted to Intensive Care Unit? Support Care Cancer 2020; 29:323-330. [PMID: 32361829 DOI: 10.1007/s00520-020-05480-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/17/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Patients with hematological malignancies (HM) require intensive chemotherapy with curative intent, especially in case of AML that results in more frequent admissions to Intensive Care Units (ICU). Due to our knowledge, this study is the first multicenter retrospective analysis in Polish population. METHODS A total of 200 patients with HM hospitalized in 4 Polish hematological centers. Data concerning clinical indices and outcomes during admission and ICU stay were collected retrospectively. RESULTS The most common hematological malignancy was acute leukemia (55%). The main cause of ICU admission was respiratory failure (88.5%), often accompanied by sepsis (58.5%) and acute renal failure (51.5%). In patients with hematological malignancies, the following factors were associated with ICU mortality: prolonged ICU stay (odd ratio [OR] = 6.98, 95% confidence interval [CI]: 1.38-35.33, χ2 = 5.61, p = 0.02), the presence of acute respiratory failure (odd ratio [OR] = 5.35, 95% confidence interval [CI]: 1.01-28.46, χ2 = 3.93, p = 0.04), and the need for renal replacement therapy (odd ratio [OR] = 8.75, 95% confidence interval [CI]: 1.23-62.11, χ2 = 4.78, p = 0.03). There were following associations with in-hospital mortality in patients with hematological malignancies: prolonged ICU stay (odd ratio [OR] = 10.12, 95% confidence interval [CI]: 1.85-55.37, χ2 = 7.21, p = 0.008), the presence of acute respiratory failure (odd ratio [OR] =5.24, 95% confidence interval [CI]: 1.36-20.16, χ2 = 5.87, p = 0.02), the need for catecholamine support (odd ratio [OR] =3.43, 95% confidence interval [CI]: 1.06-11.05, χ2 = 4.32, p = 0.04), and renal replacement therapy (odd ratio [OR] =5.55, 95% confidence interval [CI]: 1.14-26.92, χ2 = 4.59, p = 0.03). CONCLUSIONS We have demonstrated that ICU and in-hospital mortalities among patients with hematological malignancies are still poor, but easier access to the intensive care unit and close cooperation between hematologists and intensivists may improve outcomes. We have found that acute failure of key organs (acute respiratory failure, end-stage renal failure requires renal replacement therapy) and length of ICU stay (but probably no comorbidities and illness severity) may have impact on mortality (both ICU and in-hospital).
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Affiliation(s)
- Elżbieta Kalicińska
- Department and Clinic of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland.
| | - Bartłomiej Kuszczak
- Department and Clinic of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Jakub Dębski
- Department and Clinic of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Łukasz Szukalski
- Department of Hematology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Marzena Wątek
- Department of Hematology, Institute of Hematology and Transfusion Medicine in Warsaw, Warsaw, Poland
| | - Judyta Strzała
- Department of Hematology, Medical University of Gdańsk, Gdańsk, Poland
| | - Justyna Rybka
- Department and Clinic of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Jarosław Czyż
- Department of Hematology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Ewa Lech-Marańda
- Department of Hematology, Institute of Hematology and Transfusion Medicine in Warsaw, Warsaw, Poland
| | - Jan Zaucha
- Department of Hematology, Medical University of Gdańsk, Gdańsk, Poland
| | - Tomasz Wróbel
- Department and Clinic of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
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24
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The Conundrum of Septic Shock Imitators in Patients with Hematologic Cancers: Case Presentation and Possible Differential Diagnoses. Case Rep Crit Care 2019; 2019:6561018. [PMID: 31583137 PMCID: PMC6754887 DOI: 10.1155/2019/6561018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/04/2019] [Accepted: 07/15/2019] [Indexed: 11/27/2022] Open
Abstract
The authors describe the case of a patient treated with several cycles of chemotherapy due to an advanced stage non-Hodgkin lymphoma. One daafter the last cycle, he was admitted to our Intensive Care Unit with a septic shock-like clinical picture which didn't respond to the aggressive treatment and the patient died a few hours later. The autoptical findings cast some doubts on the diagnosis, and demonstrated the presence of other factors imitating its symptoms. In this article, the mimickers of septic shock are reviewed and discussed, as some of them require an aggressive immunosuppression instead of the recommended treatment for septic shock.
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25
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Gershkovich B, Fernando SM, Herritt B, Castellucci LA, Rochwerg B, Munshi L, Mehta S, Seely AJE, McIsaac DI, Tran A, Reardon PM, Tanuseputro P, Kyeremanteng K. Outcomes of hospitalized hematologic oncology patients receiving rapid response system activation for acute deterioration. Crit Care 2019; 23:286. [PMID: 31455376 PMCID: PMC6712869 DOI: 10.1186/s13054-019-2568-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/13/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with hematologic malignancies who are admitted to hospital are at increased risk of deterioration and death. Rapid response systems (RRSs) respond to hospitalized patients who clinically deteriorate. We sought to describe the characteristics and outcomes of hematologic oncology inpatients requiring rapid response system (RRS) activation, and to determine the prognostic accuracy of the SIRS and qSOFA criteria for in-hospital mortality of hematologic oncology patients with suspected infection. METHODS We used registry data from two hospitals within The Ottawa Hospital network, between 2012 and 2016. Consecutive hematologic oncology inpatients who experienced activation of the RRS were included in the study. Data was gathered at the time of RRS activation and assessment. The primary outcome was in-hospital mortality. Logistical regression was used to evaluate for predictors of in-hospital mortality. RESULTS We included 401 patients during the study period. In-hospital mortality for all included patients was 41.9% (168 patients), and 145 patients (45%) were admitted to ICU following RRS activation. Among patients with suspected infection at the time of RRS activation, Systemic Inflammatory Response Syndrome (SIRS) criteria had a sensitivity of 86.9% (95% CI 80.9-91.6) and a specificity of 38.2% (95% CI 31.9-44.8) for predicting in-hospital mortality, while Quick Sequential Organ Failure Assessment (qSOFA) criteria had a sensitivity of 61.9% (95% CI 54.1-69.3) and a specificity of 91.4% (95% CI 87.1-94.7). Factors associated with increased in-hospital mortality included transfer to ICU after RRS activation (adjusted odds ratio [OR] 3.56, 95% CI 2.12-5.97) and a higher number of RRS activations (OR 2.45, 95% CI 1.63-3.69). Factors associated with improved survival included active malignancy treatment at the time of RRS activation (OR 0.54, 95% CI 0.34-0.86) and longer hospital length of stay (OR 0.78, 95% CI 0.70-0.87). CONCLUSIONS Hematologic oncology inpatients requiring RRS activation have high rates of subsequent ICU admission and mortality. ICU admission and higher number of RRS activations are associated with increased risk of death, while active cancer treatment and longer hospital stay are associated with lower risk of mortality. Clinicians should consider these factors in risk-stratifying these patients during RRS assessment.
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Affiliation(s)
- Benjamin Gershkovich
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON K1H 8L6 Canada
| | - Shannon M. Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON Canada
| | - Brent Herritt
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Lana A. Castellucci
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
| | - Laveena Munshi
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
| | - Andrew J. E. Seely
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Department of Surgery, University of Ottawa, Ottawa, ON Canada
| | - Daniel I. McIsaac
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON Canada
| | - Alexandre Tran
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Department of Surgery, University of Ottawa, Ottawa, ON Canada
| | - Peter M. Reardon
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON Canada
| | - Peter Tanuseputro
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Institut du Savoir Montfort, Ottawa, ON Canada
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Lyons PG, Klaus J, McEvoy CA, Westervelt P, Gage BF, Kollef MH. Factors Associated With Clinical Deterioration Among Patients Hospitalized on the Wards at a Tertiary Cancer Hospital. J Oncol Pract 2019; 15:e652-e665. [PMID: 31306039 PMCID: PMC6694031 DOI: 10.1200/jop.18.00765] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2019] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Patients hospitalized outside the intensive care unit (ICU) frequently experience clinical deterioration. Little has been done to describe the landscape of clinical deterioration among inpatients with cancer. We aimed to describe the frequency of clinical deterioration among patients with cancer hospitalized on the wards at a major academic hospital and to identify independent risk factors for clinical deterioration among these patients. METHODS This was a retrospective cohort study at a 1,300-bed urban academic hospital with a 138-bed inpatient cancer center. We included consecutive admissions to the oncology wards between January 1, 2014, and June 30, 2017. We defined clinical deterioration as the composite of ward death and transfer to the ICU. RESULTS We evaluated 21,219 admissions from 9,058 patients. The composite outcome occurred during 1,945 admissions (9.2%): 1,365 (6.4%) had at least one ICU transfer, and 580 (2.7%) involved ward death. Logistic regression identified several independent risk factors for clinical deterioration, including the following: age (odds ratio [OR], 1.33 per decade; 95% CI, 1.07 to 1.67), male sex (OR, 1.15; 95% CI, 1.05 to 1.33), comorbidities, illness severity (OR, 1.11; 95% CI, 1.10 to 1.13), emergency admission (OR, 1.45; 95% CI, 1.26 to 1.67), hospitalization on particular wards (OR, 1.525; 95% CI, 1.326 to 1.67), bacteremia (OR, 1.24; 95% CI, 1.01 to 1.52), fungemia (OR, 3.76; 95% CI, 1.90 to 7.41), tumor lysis syndrome (OR, 3.01; 95% CI, 2.41 to 3.76), and receipt of antimicrobials (OR, 2.04; 95% CI, 1.72 to 2.42) and transfusions (OR, 1.65; 95% CI, 1.42 to 1.92). CONCLUSION Clinical deterioration was common; it occurred in more than 9% of admissions. Factors independently associated with deterioration included comorbidities, admission source, infections, and blood product transfusion.
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Affiliation(s)
| | | | | | - Peter Westervelt
- Washington University School of Medicine, St Louis, MO
- Siteman Cancer Center, St Louis, MO
| | - Brian F. Gage
- Washington University School of Medicine, St Louis, MO
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Hamidi M, Gossack-Keenan KL, Ferreyro BL, Angriman F, Rochwerg B, Mehta S. Outcomes of hematopoietic cell transplant recipients requiring invasive mechanical ventilation: a two-centre retrospective cohort study. Can J Anaesth 2019; 66:1450-1457. [PMID: 31290122 DOI: 10.1007/s12630-019-01439-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/16/2019] [Accepted: 05/19/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Outcomes of critically ill, hematopoietic cell transplant patients who require prolonged mechanical ventilation are not well studied. We describe the baseline characteristics, critical care management, and outcomes of this population and explore potential predictors of mortality. METHODS We performed a retrospective cohort study in two critical care units in Ontario. We included adult intensive care unit patients who required invasive mechanical ventilation within 90 days of receiving a hematopoietic cell transplant. The primary outcome was mortality at 90 days. Using logistic regression, we explored predictors of mortality including type of transplant (allogeneic vs autologous), severity of illness (assessed using the Sequential Organ Failure Assessment [SOFA] score), and baseline characteristics (such as age and sex). RESULTS We included 70 patients from two study sites. Ninety-day mortality was 73% (n = 51) in the entire cohort, 58% (15/26) in patients post-autologous transplant, and 82% (36/44) in those post-allogeneic transplant. Ninety-one percent (10/11) of patients who required invasive mechanical ventilation for more than 21 days died. Independent predictors of all-cause mortality included allogeneic transplant, higher SOFA score, the presence of acute hypoxemic respiratory failure, and a longer interval between receiving the transplant and initiation of mechanical ventilation. CONCLUSIONS Our study shows high rates of mortality among hematopoietic cell transplant recipients that require invasive mechanical ventilation, particularly in those post-allogeneic transplant and in those who require prolonged ventilation for more than 21 days.
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Affiliation(s)
- Mohammad Hamidi
- Intensive Care Unit, Westmead Hospital, Sydney, NSW, Australia
| | | | - Bruno L Ferreyro
- Department of Medicine, Sinai Health System, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Federico Angriman
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, Toronto, ON, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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[Hematological-oncological intensive care patients : Treatment without borders]. Med Klin Intensivmed Notfmed 2019; 114:214-221. [PMID: 30725269 DOI: 10.1007/s00063-019-0532-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 12/16/2018] [Accepted: 12/17/2018] [Indexed: 01/07/2023]
Abstract
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.
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