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Bredin S, Decroocq J, Devautour C, Charpentier J, Vigneron C, Pène F. Impact of critical illness on continuation of anticancer treatment and prognosis of patients with aggressive hematological malignancies. Ann Intensive Care 2024; 14:143. [PMID: 39259434 PMCID: PMC11390996 DOI: 10.1186/s13613-024-01372-5] [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: 05/31/2024] [Accepted: 08/23/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND Maintaining the dose-intensity of cancer treatment is an important prognostic factor of aggressive hematological malignancies. The objective of this study was to assess the long-term outcomes of intensive care unit (ICU) survivors with acute myeloid leukemia (AML) or aggressive B-cell non-Hodgkin lymphoma (B-NHL) with emphasis on the resumption of the intended optimal regimen of cancer treatment. PATIENTS AND METHODS We conducted a retrospective (2013-2021) single-center observational study where we included patients with AML and B-NHL discharged alive from the ICU after an unplanned admission. The primary endpoint was the change in the intended optimal cancer treatment following ICU discharge. Secondary endpoints were 1-year progression-free survival and overall survival rates. Determinants associated with modifications in cancer treatment were assessed through multivariate logistic regression. RESULTS Over the study period, 366 patients with AML or B-NHL were admitted to the ICU, of whom 170 survivors with AML (n = 92) and B-NHL (n = 78) formed the cohort of interest. The hematological malignancy was recently diagnosed in 68% of patients. The admission Sequential Organ Failure Assessment (SOFA) score was 5 (interquartile range 4-8). During the ICU stay, 30 patients (17.6%) required invasive mechanical ventilation, 29 (17.0%) vasopressor support, and 16 (9.4%) renal replacement therapy. The one-year survival rate following ICU discharge was 59.5%. Further modifications in hematologic treatment regimens were required in 72 patients (42%). In multivariate analysis, age > 65 years (odds ratio (OR) 3.54 [95%-confidence interval 1.67-7.50], p < 0.001), ICU-discharge hyperbilirubinemia > 20 µmol/L (OR 3.01 [1.10-8.15], p = 0.031), and therapeutic limitations (OR 16.5 [1.83-149.7], p = 0.012) were independently associated with modifications in cancer treatment. Post-ICU modifications of cancer treatment had significant impact on in-hospital, 1-year overall survival and progression-free survival. CONCLUSION The intended cancer treatment could be resumed in 58% of ICU survivors with aggressive hematological malignancies. At the time of ICU discharge, advanced age, persistent liver dysfunction and decisions to limit further life-support therapies were independent determinants of cancer treatment modifications. These modifications were associated with worsened one-year outcomes.
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Affiliation(s)
- Swann Bredin
- Service de médecine intensive-réanimation, hôpital Cochin, Assistance Publique-Hôpitaux de Paris. Centre, Université Paris-Cité, Paris, France
| | - Justine Decroocq
- Service d'hématologie clinique, hôpital Cochin, Assistance Publique-Hôpitaux de Paris. Centre, Université Paris-Cité, Paris, France
| | - Clément Devautour
- Service de médecine intensive-réanimation, hôpital Cochin, Assistance Publique-Hôpitaux de Paris. Centre, Université Paris-Cité, Paris, France
| | - Julien Charpentier
- Service de médecine intensive-réanimation, hôpital Cochin, Assistance Publique-Hôpitaux de Paris. Centre, Université Paris-Cité, Paris, France
| | - Clara Vigneron
- Service de médecine intensive-réanimation, hôpital Cochin, Assistance Publique-Hôpitaux de Paris. Centre, Université Paris-Cité, Paris, France
| | - Frédéric Pène
- Service de médecine intensive-réanimation, hôpital Cochin, Assistance Publique-Hôpitaux de Paris. Centre, Université Paris-Cité, Paris, France.
- Institut Cochin, INSERM U1016, CNRS UMR8104, Université Paris-Cité, Paris, France.
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Nates JL, Pène F, Darmon M, Mokart D, Castro P, David S, Povoa P, Russell L, Nielsen ND, Gorecki GP, Gradel KO, Azoulay E, Bauer PR. Septic shock in the immunocompromised cancer patient: a narrative review. Crit Care 2024; 28:285. [PMID: 39215292 PMCID: PMC11363658 DOI: 10.1186/s13054-024-05073-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024] Open
Abstract
Immunosuppressed patients, particularly those with cancer, represent a momentous and increasing portion of the population, especially as cancer incidence rises with population growth and aging. These patients are at a heightened risk of developing severe infections, including sepsis and septic shock, due to multiple immunologic defects such as neutropenia, lymphopenia, and T and B-cell impairment. The diverse and complex nature of these immunologic profiles, compounded by the concomitant use of immunosuppressive therapies (e.g., corticosteroids, cytotoxic drugs, and immunotherapy), superimposed by the breakage of natural protective barriers (e.g., mucosal damage, chronic indwelling catheters, and alterations of anatomical structures), increases the risk of various infections. These and other conditions that mimic sepsis pose substantial diagnostic and therapeutic challenges. Factors that elevate the risk of progression to septic shock in these patients include advanced age, pre-existing comorbidities, frailty, type of cancer, the severity of immunosuppression, hypoalbuminemia, hypophosphatemia, Gram-negative bacteremia, and type and timing of responses to initial treatment. The management of vulnerable cancer patients with sepsis or septic shock varies due to biased clinical practices that may result in delayed access to intensive care and worse outcomes. While septic shock is typically associated with poor outcomes in patients with malignancies, survival has significantly improved over time. Therefore, understanding and addressing the unique needs of cancer patients through a new paradigm, which includes the integration of innovative technologies into our healthcare system (e.g., wireless technologies, medical informatics, precision medicine), targeted management strategies, and robust clinical practices, including early identification and diagnosis, coupled with prompt admission to high-level care facilities that promote a multidisciplinary approach, is crucial for improving their prognosis and overall survival rates.
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Affiliation(s)
- Joseph L Nates
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Frédéric Pène
- Médecine Intensive et Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Institut Cochin, INSERM U1016, CNRS UMR8104, Université Paris Cité, Paris, France
| | - Michael Darmon
- Médecine Intensive et Réanimation, Assistance Publique-Hôpitaux de Paris, Saint-Louis Hospital and Paris University, Paris, France
| | - Djamel Mokart
- Critical Care Department, Institut Paoli Calmettes, Marseille, France
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Pedro Povoa
- Intensive Care Unit 4, Dept of Intensive Care, Hospital de São Francisco Xavier, ULSLO, Lisbon, Portugal
- NOVA Medical School, NOVA University of Lisbon, Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, Odense University Hospital, Odense, Denmark
| | - Lene Russell
- Dept. of Intensive Care Medicine, Copenhagen University Hospital Gentofte, Hellerup, Denmark
- Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nathan D Nielsen
- University of New Mexico Hospital, Lomas Ave, Albuquerque, NM, USA
| | | | - Kim O Gradel
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, Odense University Hospital, Odense, Denmark
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Assistance Publique-Hôpitaux de Paris, Saint-Louis Hospital and Paris University, Paris, France
| | - Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, 200 First Street S.W., Rochester, MN, 55905, USA.
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Vergnano B, Signori D, Benini A, Calcinati S, Bettini F, Verga L, Borin LM, Cavalca F, Gambacorti-Passerini C, Bellani G, Foti G. Safety and Effectiveness of Intensive Treatments Administered Outside the Intensive Care Unit to Hematological Critically Ill Patients: An Intensive Care without Walls Trial. J Clin Med 2023; 12:6281. [PMID: 37834926 PMCID: PMC10573388 DOI: 10.3390/jcm12196281] [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: 09/02/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Historically, the admission of hematological patients in the ICU shortly after the start of a critical illness is associated with better survival rates. Early intensive interventions administered by MET could play a role in the management of hematological critically ill patients, eventually reducing the ICU admission rate. In this retrospective and monocentric study, we evaluate the safety and effectiveness of intensive treatments administered by the MET in a medical ward frame. The administered interventions were mainly helmet CPAP and pharmacological cardiovascular support. Frequent reassessment by the MET at least every 8 to 12 h was guaranteed. We analyzed data from 133 hematological patients who required MET intervention. In-hospital mortality was 38%; mortality does not increase in patients not immediately transferred to the ICU. Only three patients died without a former admission to the ICU; in these cases, mortality was not related to the acute illness. Moreover, 37% of patients overcame the critical episode in the hematological ward. Higher SOFA and MEWS scores were associated with a worse survival rate, while neutropenia and pharmacological immunosuppression were not. The MET approach seems to be safe and effective. SOFA and MEWS were confirmed to be effective tools for prognostication.
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Affiliation(s)
- Beatrice Vergnano
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Davide Signori
- Department of Medicine and Surgery, University of Milan-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| | - Annalisa Benini
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Serena Calcinati
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Francesca Bettini
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Luisa Verga
- Department of Hematology, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Lorenza Maria Borin
- Department of Hematology, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Fabrizio Cavalca
- Department of Medicine and Surgery, University of Milan-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| | - Carlo Gambacorti-Passerini
- Department of Medicine and Surgery, University of Milan-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
- Department of Hematology, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Giacomo Bellani
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| | - Giuseppe Foti
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
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Bıkmaz ŞGA, Gökçe O, Haşimoğlu MM, Boyacı N, Türkoğlu M, Yeğin ZA, Özkurt ZN, Yağcı AM. Risk factors for ICU mortality in patients with hematological malignancies: a singlecenter, retrospective cohort study from Turkey. Turk J Med Sci 2023; 53:340-351. [PMID: 36945922 PMCID: PMC10387870 DOI: 10.55730/1300-0144.5590] [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: 06/29/2022] [Accepted: 11/01/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Patients with hematological malignancies (HM) often require admission to the intensive care unit (ICU) due to organ failure, disease progression or treatment-related complications, and they generally have a poor prognosis. Therefore, understanding the factors affecting ICU mortality in HM patients is important. In this study, we aimed to identify the risk factors for ICU mortality in our critically ill HM patients. METHODS We retrospectively reviewed the medical records of HM patients who were hospitalized in our medical ICU between January 1, 2010 and December 31, 2018. We recorded some parameters of these patients and compared these parameters by statistically between survivors and nonsurvivors to determine the risk factors for ICU mortality. RESULTS The study included 368 critically ill HM patients who were admitted to our medical ICU during a 9-year period. The median age was 58 (49-67) years and 63.3% of the patients were male. Most of the patients (43.2%) had acute leukemia. Hematopoietic stem cell transplantation (HSCT) was performed in 153 (41.6%) patients. The ICU mortality rate was 51.4%. According to univariable analyses, a lot of parameters (e.g., admission APACHE II and SOFA scores, length of ICU stay, some laboratory parameters at the ICU admission, the reason for ICU admission, comorbidities, type of HM, type of HSCT, infections on ICU admission and during ICU stay, etc.) were significantly different between survivors and nonsurvivors. However, only high SOFA scores at ICU admission (OR:1.281, p = 0.004), presence of septic shock (OR:17.123, p = 0.0001), acute kidney injury (OR:48.284, p = 0.0001), and requirement of invasive mechanical ventilation support during ICU stay (OR:23.118, p = 0.0001) were independent risk factors for ICU mortality. DISCUSSION In our cohort, critically ill HM patients had high ICU mortality. We found four independent predictors for ICU mortality. Yet, there is still a need for further research to better understand poor outcome predictors in critically ill HM patients.
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Affiliation(s)
| | - Onur Gökçe
- Division of Intensive Care Medicine, Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Meryem Merve Haşimoğlu
- Division of Intensive Care Medicine, Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Nazlıhan Boyacı
- Division of Intensive Care Medicine, Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Melda Türkoğlu
- Division of Intensive Care Medicine, Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Zeynep Arzu Yeğin
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Zübeyde Nur Özkurt
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Abdullah Münci Yağcı
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
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Lucet A, Franchitti J, Legay L, Milacic H, Fontaine JP, Ellouze S, Peyrony O. Effect of a delayed admission to the intensive care unit on survival after emergency department visit in patients with cancer: a retrospective observational study. Eur J Emerg Med 2022; 29:221-226. [PMID: 35297386 DOI: 10.1097/mej.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND IMPORTANCE Delayed admission to the ICU is reported to be associated with worse outcomes in cancer patients. OBJECTIVE The main objective of this study was to compare the 180-day survival of cancer patients whether they were directly admitted to the ICU from the emergency department (ED) or secondarily from the wards after the ED visit. DESIGN, SETTINGS AND PARTICIPANTS This was a retrospective observational study including all adult cancer patients that visited the ED in 2018 and that were admitted to the ICU at some point within 7 days from the ED visit. EXPOSURE Delayed ICU admission. OUTCOME MEASURE AND ANALYSIS Survival at day 180 was plotted using Kaplan-Meier curves, and hazard ratio (HR) from Cox proportional-hazard models was used to quantify the association between admission modality (directly from the ED or later from wards) and survival at day 180, after adjustment to baseline characteristics. RESULTS During the study period, 4560 patients were admitted to the hospital following an ED visit, among whom 136 (3%) patients had cancer and were admitted to the ICU, either directly from the ED in 101 (74%) cases or secondarily from the wards in 35 (26%) cases. Patients admitted to the ICU from the ED had a better 180-day survival than those admitted secondarily from wards (log-rank P = 0.006). After adjustment to disease status (remission or uncontrolled malignancy), survival at day 180 was significantly improved in the case of admission to the ICU directly from the ED with an adjusted HR of 0.50 (95% confidence interval, 0.26-0.95), P = 0.03. CONCLUSION In ED patients with cancer, a direct admission to the ICU was associated with better 180-day survival compared with patients with a delayed ICU admission secondary from the wards. However, several confounders were not taken into account, which limits the validity of this result.
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Affiliation(s)
- Aude Lucet
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
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6
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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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Hourmant Y, Mailloux A, Valade S, Lemiale V, Azoulay E, Darmon M. Impact of early ICU admission on outcome of critically ill and critically ill cancer patients: A systematic review and meta-analysis. J Crit Care 2020; 61:82-88. [PMID: 33157309 DOI: 10.1016/j.jcrc.2020.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/22/2020] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Prognostic impact of early ICU admission remains controversial. The aim of this review was to investigate the impact of early ICU admission in the general ICU population and in critically ill cancer patients and to report level of evidences of this later. METHODS Systematic review and meta-analysis performed on articles published between 1970 and 2017. Two authors extracted data. Influence of early ICU admission on mortality is reported as Risk Ratio (95%CI) using both fixed and random-effects model. DATA SYNTHESIS For general ICU population, 31 studies reporting on 73,213 patients were included (including 66,797 patients with early ICU admission) and for critically ill cancer patients 14 studies reporting on 2414 patients (including 1272 with early ICU admission) were included. Early ICU admission was associated with decreased mortality using a random effect model (RR 0.65; 95% confidence interval 0.58-0.73; I2 = 66%) in overall ICU population as in critically ill cancer patients (RR 0.69; 95% confidence interval 0.52-0.90; I2 = 85%). To explore heterogeneity, a meta-regression was performed. Characteristics of the trials (prospective vs. retrospective, monocenter vs. multicenter) had no impact on findings. Publication after 2010 (median publication period) was associated with a lower effect of early ICU admission (estimate 0.37; 95%CI 0.14-0.60; P = 0.002) in the general ICU population. A significant publication bias was observed. CONCLUSION Theses results suggest that early ICU admission is associated with decreased mortality in the general ICU population and in CICP. These results were however obtained from high risk of bias studies and a high heterogeneity was noted. Systematic review registration: PROSPERO 2018 CRD42018094828.
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Affiliation(s)
- Yannick Hourmant
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Arnaud Mailloux
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Sandrine Valade
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Virginie Lemiale
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Elie Azoulay
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France; Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France; ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris, France
| | - Michael Darmon
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France; Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France; ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris, France.
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Effect of Delayed Admission to Intensive Care Units from the Emergency Department on the Mortality of Critically Ill Patients. IRANIAN RED CRESCENT MEDICAL JOURNAL 2020. [DOI: 10.5812/ircmj.102425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Increasing in emergency department need to critical care, the number of intensive care unit bed worldwide is inadequate to meet these applies. Objectives: The aim of this study was to investigate the effect of waiting for admission to the Intensive Care Unit (ICU) in the Emergency Department (ED) on the length of stay in the ICU and the mortality of critically ill patients. Methods: This retrospective cohort study carried out between January 2012 - 2019 patients admitted to the ICU of a training and research hospital. The data of 1297 adult patients were obtained by searching the Clinical Decision Support System. Results: The data of the patients were evaluated in two groups as those considered to be delayed and non-delayed. It was determined that the delay of two hours increased the risk of mortality 1.5 times. Hazard Ratios (HR) was 1.548 (1.077 - 2.224). Patients whose ICU admission was delayed by 5 - 6 hours were found to have the highest risk in terms of mortality (HR = 2.291 [1.503 - 3.493]). A statistically significant difference was found in the ICU mortality, 28-day and, 90-day mortality between the two groups. ICU mortality for all patients’ general was 25.2% (327/1297). This rate was 11.4% (55/481) in the non-delayed group and 33.3% (272/816) in the delayed group (P < 0.001). The 28-day mortality rate for all patients’ general was 26.9% (349/1297). This rate was found to be 13.5% (65/481) in the non-delayed group and 34.8% (284/816) in the delayed group (P < 0.001). The 90-day mortality for all patients’ general was 28.4% (368/1297). This rate was 14.1% (68/481) in the non-delayed group and 36.8% (300/816) in the delayed group (P < 0.001). Conclusions: Prolonged stay in the ED before admission to the ICU is associated with worse consequences, and increased mortality.
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Peyrony O, Fontaine JP, Beaune S, Khoury A, Truchot J, Balen F, Vally R, Schmitt J, Ben Hammouda K, Roussel M, Borzymowski C, Vallot C, Sanh V, Azoulay E, Chevret S. EPICANCER-Cancer Patients Presenting to the Emergency Departments in France: A Prospective Nationwide Study. J Clin Med 2020; 9:jcm9051505. [PMID: 32429507 PMCID: PMC7291158 DOI: 10.3390/jcm9051505] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 01/20/2023] Open
Abstract
Background: We aimed to estimate the prevalence of cancer patients who presented to Emergency Departments (EDs), report their chief complaint and identify the predictors of 30-day all-cause mortality. Patients and methods: we undertook a prospective, cross-sectional study during three consecutive days in 138 EDs and performed a logistic regression to identify the predictors of 30-day mortality in hospitalized patients. Results: A total of 1380 cancer patients were included. The prevalence of cancer patients among ED patients was 2.8%. The most frequent reasons patients sought ED care were fatigue (16.6%), dyspnea (16.3%), gastro-intestinal disorders (15.1%), trauma (13.0%), fever (12.5%) and neurological disorders (12.5%). Patients were admitted to the hospital in 64.9% of cases, of which 13.4% died at day 30. Variables independently associated with a higher mortality at day 30 were male gender (Odds Ratio (OR), 1.63; 95% CI, 1.04–2.56), fatigue (OR, 1.65; 95% CI, 1.01–2.67), poor performance status (OR, 3.00; 95% CI, 1.87–4.80), solid malignancy (OR, 3.05; 95% CI, 1.26–7.40), uncontrolled malignancy (OR, 2.27; 95% CI, 1.36–3.80), ED attendance for a neurological disorder (OR, 2.38; 95% CI, 1.36–4.19), high shock-index (OR, 1.80; 95% CI, 1.03–3.13) and oxygen therapy (OR, 2.68; 95% CI, 1.68–4.29). Conclusion: Cancer patients showed heterogeneity among their reasons for ED attendance and a high need for hospitalization and case fatality. Malignancy and general health status played a major role in the patient outcomes. This study suggests that the emergency care of cancer patients may be complex. Thus, studies to assess the impact of a dedicated oncology curriculum for ED physicians are warranted.
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Affiliation(s)
- Olivier Peyrony
- Department of Emergency Medicine, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, 1 avenue Claude Vellefaux, 75010 Paris, France;
- Correspondence: ; Tel.: +33-1-42-49-84-04
| | - Jean-Paul Fontaine
- Department of Emergency Medicine, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, 1 avenue Claude Vellefaux, 75010 Paris, France;
| | - Sébastien Beaune
- Department of Emergency Medicine, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, 92100 Boulogne-Billancourt, France;
- INSERM UMRS 1144, Paris-Descartes University, 75006 Paris, France
- Initiatives de Recherche aux Urgences (IRU) Research Network, Société Française de Médecine d’Urgence (SFMU), 75010 Paris, France; (A.K.); (J.T.)
| | - Abdo Khoury
- Initiatives de Recherche aux Urgences (IRU) Research Network, Société Française de Médecine d’Urgence (SFMU), 75010 Paris, France; (A.K.); (J.T.)
- Department of Emergency Medicine & Critical Care, Besançon University Hospital, 25000 Besançon, France
| | - Jennifer Truchot
- Initiatives de Recherche aux Urgences (IRU) Research Network, Société Française de Médecine d’Urgence (SFMU), 75010 Paris, France; (A.K.); (J.T.)
- Department of Emergency Medicine, SMUR, Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, 75010 Paris, France
- Faculty of Medicine, Paris Diderot University, 75010 Paris, France
| | - Frédéric Balen
- Department of Emergency Medicine, Toulouse University Hospital, 31059 Toulouse, France;
- Faculty of Medicine, Toulouse III—Paul Sabatier University, 31330 Toulouse, France
| | - Rishad Vally
- Department of Emergency Medicine, SAMU 33, Pellegrin University Hospital, 33000 Bordeaux, France;
| | - Jacques Schmitt
- Department of Emergency Medicine, SAMU 68, Mulhouse Hospital, 68100 Mulhouse, France;
| | | | - Mélanie Roussel
- Department of Emergency Medicine, Rouen University Hospital, F-76031 Rouen, France;
| | - Céline Borzymowski
- Department of Emergency Médicine, Jean Bernard Hospital, 59322 Valenciennes, France;
| | - Cécile Vallot
- Department of Emergency Medicine, Annecy Genevois Hospital, 74370 Annecy, France;
| | - Veronique Sanh
- Department of Emergency Medicine, SAMU 95, René Dubos Hospital, 95300 Pontoise, France;
| | - Elie Azoulay
- Intensive Care Unit, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, 75010 Paris, France;
- Centre of Research in Epidemiology and StatisticS (CRESS), INSERM, UMR 1153, Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments (ECSTRRA) Team. University of Paris, 75010 Paris, France;
| | - Sylvie Chevret
- Centre of Research in Epidemiology and StatisticS (CRESS), INSERM, UMR 1153, Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments (ECSTRRA) Team. University of Paris, 75010 Paris, France;
- Department of Biostatistics and Medical Information, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, 75004 Paris, France
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10
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Peyrony O, Chevret S, Meert AP, Perez P, Kouatchet A, Pène F, Mokart D, Lemiale V, Demoule A, Nyunga M, Bruneel F, Lebert C, Benoit D, Mirouse A, Azoulay E. Direct admission to the intensive care unit from the emergency department and mortality in critically ill hematology patients. Ann Intensive Care 2019; 9:110. [PMID: 31578641 PMCID: PMC6775178 DOI: 10.1186/s13613-019-0587-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/21/2019] [Indexed: 01/06/2023] Open
Abstract
Background The aim of this study was to assess the benefit of direct ICU admission from the emergency department (ED) compared to admission from wards, in patients with hematological malignancies requiring critical care. Methods Post hoc analysis derived from a prospective, multicenter cohort study of 1011 critically ill adult patients with hematologic malignancies admitted to 17 ICU in Belgium and France from January 2010 to May 2011. The variable of interest was a direct ICU admission from the ED and the outcome was in-hospital mortality. The association between the variable of interest and the outcome was assessed by multivariable logistic regression after multiple imputation of missing data. Several sensitivity analyses were performed: complete case analysis, propensity score matching and multivariable Cox proportional-hazards analysis of 90-day survival. Results Direct ICU admission from the ED occurred in 266 (26.4%) cases, 84 of whom (31.6%) died in the hospital versus 311/742 (41.9%) in those who did not. After adjustment, direct ICU admission from the ED was associated with a decreased in-hospital mortality (adjusted OR: 0.63; 95% CI 0.45–0.88). This was confirmed in the complete cases analysis (adjusted OR: 0.64; 95% CI 0.45–0.92) as well as in terms of hazard of death within the 90 days after admission (adjusted HR: 0.77; 95% CI 0.60–0.99). By contrast, in the propensity score-matched sample of 402 patients, direct admission was not associated with in-hospital mortality (adjusted OR: 0.92; 95% CI 0.84–1.01). Conclusions In this study, patients with hematological malignancies admitted to the ICU were more likely to be alive at hospital discharge if they were directly admitted from the ED rather than from the wards. Assessment of early predictors of poor outcome in cancer patients admitted to the ED is crucial so as to allow early referral to the ICU and avoid delays in treatment initiation and mis-orientation.
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Affiliation(s)
- Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France.
| | - Sylvie Chevret
- Biostatistics and Medical Information Department, Hôpital Saint-Louis, Paris, France.,Centre de Recherche en Épidémiologie et Statistiques - Université de Paris (CRESS-INSERM-UMR1153), Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments (ECSTRRA) Team, Paris, France.,Université de Paris, Paris, France
| | - Anne-Pascale Meert
- Intensive Care Unit, Institut Jules Bordet, Université libre de Bruxelles (ULB), Brussels, Belgium
| | - Pierre Perez
- Intensive Care Unit, Hôpital Brabois, Vandoeuvre Les Nancy, France
| | - Achille Kouatchet
- Intensive Care Unit, Centre hospitalier régional universitaire, Angers, France
| | - Frédéric Pène
- Université de Paris, Paris, France.,Intensive Care Unit, Hôpital Cochin, Paris, France.,Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris, France
| | - Djamel Mokart
- Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | | | - Alexandre Demoule
- Intensive Care Unit, Hôpital Pitié-Salpêtrière, Paris, France.,INSERM, UMRS 1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France.,Université Paris Sorbonne, Paris, France
| | - Martine Nyunga
- Intensive Care Unit, Hôpital Victor Provo, Roubaix, France
| | - Fabrice Bruneel
- Intensive Care Unit, Hôpital André Mignot, Versailles, France
| | - Christine Lebert
- Intensive Care Unit, Centre hospitalier départemental Vendee, La Roche Sur Yon, France
| | - Dominique Benoit
- Intensive Care Unit, Hôpital universitaire de Ghent, Ghent, Belgium
| | | | - Elie Azoulay
- Centre de Recherche en Épidémiologie et Statistiques - Université de Paris (CRESS-INSERM-UMR1153), Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments (ECSTRRA) Team, Paris, France.,Université de Paris, Paris, France.,Intensive Care Unit, Hôpital Saint-Louis, Paris, France
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11
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The 10 signs telling me that my cancer patient in the emergency department is at high risk of becoming critically ill. Intensive Care Med 2018; 44:2315-2318. [PMID: 30421252 DOI: 10.1007/s00134-018-5449-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2018] [Indexed: 02/06/2023]
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