Outcome in Noninvasively and Invasively Ventilated Hematologic Patients With Acute Respiratory Failure

Mortality rate analysis of patients on invasive mechanical ventilation in the intensive care unit on day 28

Outcomes in patients receiving invasive mechanical ventilation (IMV) are currently unclear. The present study aimed to explore the prognostic factors of the mortality rate on day 28 in patients treated in the intensive care unit (ICU) and undergoing IMV. The IMV Mortality Prediction Score (IMPRES) of 129 patients in the ICU receiving IMV after emergency (or selective) endotracheal intubation from March 2018 to August 2020 was calculated. The patients were divided into survival (n=73) and death groups (n=56) on day 28. The predictive factors of independent and combined mortality rates were determined using a receiver operating characteristic (ROC) curve and the area under the ROC curve (AUC). The AUC of the IMPRES for predicting patient death on day 28 was 0.785 (95% confidence interval (CI): 0.704-0.864, P<0.01). When the IMPRES cut-off was 4.50, the Youden index was at its maximum (0.487) with a sensitivity of 85.7% and a specificity of 63.0%. The AUC of the ventilator use time (days) at 12.5 days cut-off was 0.653 (95% CI: 0.56-0.746, P<0.01), the Youden index was 0.235 with a sensitivity of 52.1% and a specificity of 71.4%. The AUC of the IMPRES combined with the duration of ventilator use was 0.856 (95% CI: 0.789-0.922, P<0.001), the Youden index was 0.635 with a sensitivity of 84.9% and a specificity of 78.6%. The IMPRES was observed to be the main factor influencing the mortality rate of patients receiving IMV at the ICU on day 28, and the IMPRES combined with the duration of ventilator use had a significant predictive value for the 28-day mortality rates of these patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Non-invasive ventilation in acute respiratory failure of oncology-hematology patients: What are its current benefits and limitations?]

Acute respiratory failure (ARF) is a leading cause, along with sepsis, of admission to the intensive care unit (ICU) of patients with active cancer. Presenting variable clinical severity, ARF in onco-hematological patients has differing etiologies, primarily represented by possibly opportunistic acute infectious pneumonia (de novo hypoxemic ARF), and decompensation in chronic cardiac or respiratory diseases (e.g., acute pulmonary edema or exacerbated chronic obstructive pulmonary disease). In these patients, orotracheal intubation is associated with a doubled risk of in-hospital mortality. Consequently, over the last three decades, numerous researchers have attempted to demonstrate and pinpoint the precise role of non-invasive ventilation (NIV) in the specific context of ARF in onco-hematological patients. While the benefits of NIV in the management of acute pulmonary edema or alveolar hypoventilation (hypercapnic ARF) are well-demonstrated, its positioning in de novo hypoxemic ARF is debatable, and has recently been called into question. In the early 2000s, based on randomized controlled trials, NIV was recommended as first-line treatment, one reason being that it allowed significantly reduced use of orotracheal intubation. In the latest randomized studies, however, the benefits of NIV in terms of survival orotracheal intubation have not been observed; as a result, it is no longer recommended in the management of de novo hypoxemic ARF in onco-haematological patients.

Lactate level is an independent predictor of mortality in patients with hematologic malignancy receiving urgent chemotherapy in intensive care unit

BACKGROUND

Intensive care unit (ICU) survival of cancer patients has improved. Urgent chemotherapy has become feasible in critically ill patients with specific organ dysfunction due to hematological malignancies.

OBJECTIVE

The aim of the study was to assess ICU mortality rates and the factors associated with mortality in patients with hematologic malignancies receiving urgent chemotherapy in the ICU.

METHODS

We retrospectively included all patients admitted to the ICU who received chemotherapy due to hematologic malignancy in 2012-2022.

RESULTS

Of the 129 patients undergoing chemotherapy in the ICU, 50 (38.7 %) died during the ICU follow-up. The following conditions were significantly more common among nonsurvivors: presence of infection at the time of ICU admission (p < 0.001), the requirement for mechanical ventilation during ICU stay (p < 0.001), the need for noninvasive mechanical ventilation during ICU stay (p = 0.014), vasopressor support (p < 0.001), and sepsis (p < 0.001). Logistic regression analysis revealed that among laboratory parameters on ICU admission, lactate (p = 0.008), albumin (p = 0.022), C-reactive protein (p = 0.046), baseline sequential organ failure assessment (SOFA) score (p < 0.001), newly developed heart failure (p = 0.006), and the requirement for vasopressor agents during ICU stay (p < 0.001) significantly influenced the risk of mortality in the univariate analysis. The multivariate analysis revealed lactate levels (p = 0.047) on ICU admission as an independent predictor of mortality.

CONCLUSION

The development of heart failure and lactate levels on admission were the main predictors of mortality. Additionally, higher SOFA scores revealed that illness severity was closely associated with mortality. Future studies should focus on strategies to further reduce these risks and achieve the best outcomes for these patients.

Prognostic and risk factor analysis of cancer patients after unplanned ICU admission: a real-world multicenter study

To investigate the occurrence and 90-day mortality of cancer patients following unplanned admission to the intensive care unit (ICU), as well as to develop a risk prediction model for their 90-day prognosis. We prospectively analyzed data from cancer patients who were admitted to the ICU without prior planning within the past 7 days, specifically between May 12, 2021, and July 12, 2021. The patients were grouped based on their 90-day survival status, and the aim was to identify the risk factors influencing their survival status. A total of 1488 cases were included in the study, with an average age of 63.2 ± 12.4 years. The most common reason for ICU admission was sepsis (n = 940, 63.2%). During their ICU stay, 29.7% of patients required vasoactive drug support (n = 442), 39.8% needed invasive mechanical ventilation support (n = 592), and 82 patients (5.5%) received renal replacement therapy. We conducted a multivariate COX proportional hazards model analysis, which revealed that BMI and a history of hypertension were protective factors. On the other hand, antitumor treatment within the 3 months prior to admission, transfer from the emergency department, general ward, or external hospital, high APACHE score, diagnosis of shock and respiratory failure, receiving invasive ventilation, and experiencing acute kidney injury (AKI) were identified as risk factors for poor prognosis within 90 days after ICU admission. The average length of stay in the ICU was 4 days, while the hospital stay duration was 18 days. A total of 415 patients died within 90 days after ICU admission, resulting in a mortality rate of 27.9%. We selected 8 indicators to construct the predictive model, which demonstrated good discrimination and calibration. The prognosis of cancer patients who are unplanned transferred to the ICU is generally poor. Assessing the risk factors and developing a risk prediction model for these patients can play a significant role in evaluating their prognosis.

[Invasive mechanical ventilation in patients with solid tumor or hematological malignancy]

Invasive mechanical ventilation in onco-hematology patients has become relatively routine, and is now part and parcel of their care pathway. Nevertheless, specific complications and subsequent therapeutic possibilities require discussion. To a greater extent than with regard to other patient populations, cooperation between specialist and ICU physician is mandatory, the objective being to more comprehensively assess a therapeutic project before or during the period of invasive mechanical ventilation. After an overview of recent results concerning ventilated patients in intensive care, this review aims to describe the specific complications and factors associated with mortality in this population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Comparação da Mortalidade entre Pacientes com Neoplasias submetidos à Ventilação Invasiva e não Invasiva: Estudo de Coorte Retrospectiva

Introdução: O paciente com câncer apresenta alta prevalência de insuficiência respiratória aguda (IRpA) relacionada a complicações do tratamento oncológico. O suporte ventilatório mecânico e a principal terapêutica para resolução dessas complicações. No entanto, tal recurso pode aumentar a mortalidade. Objetivo: Verificar a taxa de mortalidade e os fatores intervenientes de pacientes oncológicos com IRpA expostos a ventilação mecânica invasiva (VMI) e não invasiva (VNI). Método: Estudo de coorte retrospectiva. Foram incluídos 121 pacientes oncológicos em ventilação mecânica separados em grupos: neoplasias hematológicas em VMI (HVMI, n=17), neoplasias hematológicas em VNI (HVNI, n=36), neoplasias solidas em VMI (SVMI, n=39) e neoplasias solidas em VNI (SVNI, n=29). Os desfechos avaliados foram: taxa de mortalidade, tempo de internamento, tempo de exposição a ventilação mecânica, taxa de falha da VNI e fatores relacionados a falha da VNI. Resultados: A taxa de mortalidade geral foi de 47,9%, distribuídos em HVMI (82,4%), HVNI (27,8%), SVMI (69,2%) e SVNI (24,1%). O escore APACHE III elevado foi associado a uma maior taxa de mortalidade. A taxa de mortalidade associada a falha da VNI foi de 71,4% HVNI e 77,8% SVNI. As variáveis associadas a maior taxa de falha da VNI foram o APACHE III>7 e o tempo de exposição a VNI>72 horas. Conclusão: A taxa de mortalidade de pacientes com neoplasia hematológica e solida em IRpA mostrou-se menor em pacientes expostos a VNI.

Oxygenation strategy during acute respiratory failure in immunocompromised patients

Acute respiratory failure (ARF) in immunocompromised patients remains challenging to treat. A large number of case require admission to intensive care unit (ICU) where mortality remains high. Oxygenation without intubation is important in this setting. This review summarizes recent studies assessing oxygenation devices for immunocompromised patients. Previous studies showed that non-invasive ventilation (NIV) has been associated with lower intubation and mortality rates. Indeed, in recent years, the outcomes of immunocompromised patients admitted to the ICU have improved. In the most recent randomized controlled trials, including immunocompromised patients admitted to the ICU with ARF, neither NIV nor high-flow nasal oxygen (HFNO) could reduce the mortality rate. In this setting, other strategies need to be tested to decrease the mortality rate. Early admission strategy and avoiding late failure of oxygenation strategy have been assessed in retrospective studies. However, objective criteria are still lacking to clearly discriminate time to admission or time to intubation. Also, diagnosis strategy may have an impact on intubation or mortality rates. On the other hand, lack of diagnosis has been associated with a higher mortality rate. In conclusion, improving outcomes in immunocompromised patients with ARF may include strategies other than the oxygenation strategy alone. This review discusses other unresolved questions to decrease mortality after ICU admission in such patients.

Bronchoscopy in intubated and non-intubated intensive care unit patients with respiratory failure

Bronchoscopy is one of the important tool for the pulmonary and critical care physicians to diagnose and treat various pulmonary conditions. It is increasingly being used by the intensivist due to its safety and portability. The utilization of bronchoscopy in the intensive care unit (ICU) has made the diagnosis and treatment of many conditions more feasible to intensivists. Sedation, topical or intravenous, usually helps better tolerate the procedure. However, the risks and benefits of bronchoscopy should be carefully considered in critically ill patients. The hypoxic patients in ICU pose a challenge as hypoxemia is one of the known complications of bronchoscopy, and this risk is exacerbated in patients with hypoxic respiratory failure. Bronchoscopy is relatively contraindicated in patients with severe hypoxemia and coagulopathy. However, bronchoscopy in hypoxic patients can have diagnostic as well as therapeutic implications. In patients with hypoxic respiratory failure, the use of non-invasive ventilation (NIV) during bronchoscopy has been shown to reduce the risk of intubation. On the other hand, bronchoscopy in mechanically ventilated patients is not contraindicated and has been widely used. Staying focused, monitoring vital signs closely, limiting the scope time in the airway, and understanding patient’s physiology may help decrease risk of complications. In this review, we discuss indications, techniques, complications, and yield associated with bronchoscopy in critically ill hypoxic patients.

Management strategy for hematological malignancy patients with acute respiratory failure

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

Risk factors of non-invasive ventilation failure in hematopoietic stem-cell transplantation patients with acute respiratory distress syndrome

Background:

Non-invasive ventilation (NIV) was one of the first-line ventilation supports for hematopoietic stem-cell transplantation (HSCT) patients with acute respiratory distress syndrome (ARDS). Successful NIV may avoid need for intubation. However, the influence NIV failure had on patients’ outcome and its risk factors were hardly known.

Methods:

In this retrospective observational study, we reported risk factors and incidence of NIV failure in HSCT patients who were admitted to the Intensive Care Unit (ICU) with a diagnosis of ARDS and supported with mechanical ventilation, in a 5-year period. Patient outcomes, such as ventilator-free days, ICU-free days, and ICU mortality were also reported.

Results:

Of all the 94 patients included, 70 patients were initially supported with NIV. NIV failure occurred in 44 (63%) patients. Male sex, elevated serum galactomannan (GM) test, (1-3)-β-D-glucan (BG) assay, or elevated serum creatinine level were risk factors for NIV failure. When compared with the NIV success group, failure of NIV was associated with much fewer ICU-free days (22 versus 0, p < 0.001, Cohen’s d = 0.62) and higher ICU mortality (9.5% versus 75.5%, p < 0.001, Pearson’s r = 0.75). There was no difference in ICU-free days, ventilator-free days and ICU mortality between NIV failure and initial invasive mechanical ventilation (IMV) groups. Patients who failed in NIV support had a higher ICU mortality (75.5%) than those who succeeded (9.5%).

Conclusion:

In a small cohort of HSCT patients with mainly moderate severity of ARDS, male patients with elevated serum GM/BG test or serum creatinine level had a higher risk of NIV failure. Both NIV failure and initial IMV groups were characterized by high mortality rate and extremely low ICU-free days and ventilator-free days; failure of NIV support may further aggravate patient prognosis.

The reviews of this paper are available via the supplemental material section.

Bacteremia in critically ill immunocompromised patients with acute hypoxic respiratory failure: A post-hoc analysis of a prospective multicenter multinational cohort

PURPOSE

The characteristics and impact of bacteremia have not been widely investigated in immunocompromised patients with acute respiratory failure (ARF).

METHODS

We performed a secondary analysis of a prospective cohort of immunocompromised patients with ARF (EFRAIM study). After exclusion of blood cultures positive for coagulase negative Staphylococci, we compared patients with (n = 236) and without (n = 1127) bacteremia.

RESULTS

The incidence of bacteremia was 17%. Bacterial pneumonia and extra-pulmonary ARDS were the main causes of ARF in bacteremic patients. Bacteremia involved gram negative rods (48%), gram positive cocci (40%) or were polymicrobial (10%). Bacteremic patients had more hematological malignancy, higher SOFA scores and increased organ support within 7 days. Bacteremia was associated with higher crude ICU mortality (40% versus 32%, p = 0.02), but neither hospital (49% versus 44%, p = 0.17) nor 90-day mortality (60% versus 56%, p = 0.25) were different from non-bacteremic patients. After propensity score matching based on baseline characteristics, the difference in ICU mortality lost statistical significance (p = 0.06), including in a sensitivity analysis restricted to patients with pneumonia.

CONCLUSIONS

We analyzed a large population of immunocompromised patients with ARF and an incidence of bacteremia of 17%. We could not demonstrate an impact of bacteremia on mortality after adjusting for baseline characteristics.

Reduce Mortality and Morbidity in Acute Myeloid Leukemia With Hyperleukocytosis With Early Admission in Intensive Care Unit: A Retrospective Analysis

Background

Patients presenting with acute myeloid leukemia (AML) at diagnosis are at high risk of severe complications and death, particularly with high white blood cell (WBC) count. In this retrospective study, we evaluate interest of early and systematic support in the intensive care unit (ICU) for AML with hyperleukocytosis (AML-HL) at diagnosis.

Methods

Patients with AML-HL, defined by WBC > 50 × 10⁹/L, primary referred in ICU (“Early ICU”) without organ failure and before initiating chemotherapy induction were compared to patients first admitted in the Hematology Department who required a secondary transfer in ICU (“Late ICU”) or not (“No ICU”). Primary end point was mortality during the first month, and secondary end points were the use of life-sustaining therapies in ICU and risk factors for ICU transfer and mortality.

Results

One hundred fifty-four patients were included: 77 (50%) to the group “No ICU”, 18 (12%) to “Late ICU” and 59 (38%) to “Early ICU”. Mortality at day 30 was higher in “Late ICU” than in “Early ICU” and “No ICU”, with 27.8%; 16.9% and 2.6% respectively (P < 0.001). “Late ICU” patients had an increased use of life-sustaining therapy comparing to “Early ICU” patients (56% vs. 29%, P = 0.04).

Conclusions

Early referral to ICU reduces morbidity and seems an effective strategy to reduce short-term mortality in AML-HL at diagnosis.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Can we predict patients that will not benefit from invasive mechanical ventilation? A novel scoring system in intensive care: the IMV Mortality Prediction Score (IMPRES)

Background/aim

The present study aimed to define the clinical and laboratory criteria for predicting patients that will not benefit from invasive mechanical ventilation (IMV) treatment and determine the prediction of mortality and prognosis of these critical ill patients.

Materials and methods

The study was designed as an observational, multicenter, prospective, and cross-sectional clinical study. It was conducted by 75 researchers at 41 centers in intensive care units (ICUs) located in various geographical areas of Turkey. It included a total of 1463 ICU patients who were receiving invasive mechanical ventilation (IMV) treatment. A total of 158 parameters were examined via logistic regression analysis to identify independent risk factors for mortality; using these data, the IMV Mortality Prediction Score (IMPRES) scoring system was developed.

Results

The following cut-off scores were used to indicate mortality risk: <2, low risk; 2–5, moderate risk; 5.1–8, high risk; >8, very high risk. There was a 26.8% mortality rate among the 254 patients who had a total IMPRES score of lower than 2. The mortality rate was 93.3% for patients with total IMPRES scores of greater than 8 (P < 0.001).

Conclusion

The present study included a large number of patients from various geographical areas of the country who were admitted to various types of ICUs, had diverse diagnoses and comorbidities, were intubated with various indications in either urgent or elective settings, and were followed by physicians from various specialties. Therefore, our data are more general and can be applied to a broader population. This study devised a new scoring system for decision-making for critically ill patients as to whether they need to be intubated or not and presents a rapid and accurate prediction of mortality and prognosis prior to ICU admission using simple clinical data.

[Cancer patients in operative intensive care medicine]

Die Prävalenz onkologischer Erkrankungen ist in den vergangenen Jahrzehnten stetig angestiegen. Durch neue Therapieoptionen können immer mehr Patienten mit einem kurativen Therapieansatz behandelt werden. Diese individualisierten und teilweise sehr aggressiven Therapien können jedoch auch zu schweren Nebenwirkungen führen. Diese sollten als wichtige Differenzialdiagnosen zu anderen vitalbedrohlichen Krankheitsbildern auch dem im OP und als Intensivmediziner tätigen Anästhesisten bekannt sein. Krebspatienten werden häufig auf operativen Intensivstationen aufgenommen, um Komplikationen der malignen Grunderkrankung oder auch Nebenwirkungen einer operativen oder konservativen Therapie zu behandeln. Aktuelle Untersuchungen zeigen, dass die maligne Grunderkrankung entgegen bisheriger Annahme keinen wesentlichen Einfluss auf das Intensivüberleben hat. Bei der Aufnahme eines onkologischen Patienten sollte daher die akut vorliegende Organdysfunktion zunächst im Vordergrund stehen. Bei der Therapiezielplanung gilt es, nicht zu übersehen, wann ein kuratives in ein palliatives Konzept übergehen muss. Hierfür müssen neue Aufnahmestrategien und -kriterien entwickelt und evaluiert werden. In diesem Übersichtsartikel werden Diagnosen und Therapien häufiger intensivmedizinischer Krankheitsbilder von onkologischen Patienten sowie Nebenwirkungen moderner onkologischer Therapien dargelegt und Aufnahmestrategien für Patienten mit malignen Erkrankungen vorgestellt.

[Role of the intensive care in treatment of patients with acute myeloid leukemia]

AIM

Remission induction can be associate, with the life threatening complications and transfer to ICU of de novo acute myeloid leukemia (AML) patients (pts). We evaluate influence of transfer to ICU and life threatening complication on early mortality and long - tram survival of de novo AML pts.

MATERIALS AND METHODS

Retrospective study. All de novo AML pts younger than 60 years old admitted in the National Research Center for Hematology from 2013 to 2016 years were enrolled in the study. Patients were divided into 2 groups: pts who were required ICU admission during remission induction (ICU-pts) and pts who did not require ICU admission and received chemotherapy only in hematology ward (non-ICU pts). The reasons for ICU admissions and results of life support were analyzed. Overall survival (OS) were assessed by the Kaplan-Meier method, long rank value p.

Acute respiratory failure in immunocompromised adults

Acute respiratory failure occurs in up to half of patients with haematological malignancies and 15% of those with solid tumours or solid organ transplantation. Mortality remains high. Factors associated with mortality include a need for invasive mechanical ventilation, organ dysfunction, older age, frailty or poor performance status, delayed intensive care unit admission, and acute respiratory failure due to an invasive fungal infection or unknown cause. In addition to appropriate antibacterial therapy, initial clinical management aims to restore oxygenation and predict the most probable cause based on variables related to the underlying disease, acute respiratory failure characteristics, and radiographic findings. The cause of acute respiratory failure must then be confirmed using the most efficient, least invasive, and safest diagnostic tests. In patients with acute respiratory failure of undetermined cause, a standardised diagnostic investigation should be done immediately at admission before deciding whether to perform more invasive diagnostic procedures or to start empirical treatments. Collaborative and multidisciplinary clinical and research networks are crucial to improve our understanding of disease pathogenesis and causation and to develop less invasive diagnostic strategies and more targeted treatment options.

Characteristics and Clinical Outcomes of Critically Ill Cancer Patients Admitted to Korean Intensive Care Units

Background

The objective of this study was to investigate the characteristics and clinical outcomes of critically ill cancer patients admitted to intensive care units (ICUs) in Korea.

Methods

This was a retrospective cohort study that analyzed prospective collected data from the Validation of Simplified Acute Physiology Score 3 (SAPS3) in Korean ICU (VSKI) study, which is a nationwide, multicenter, and prospective study that considered 5,063 patients from 22 ICUs in Korea over a period of 7 months. Among them, patients older than 18 years of age who were diagnosed with solid or hematologic malignancies prior to admission to the ICU were included in the present study.

Results

During the study period, a total of 1,762 cancer patients were admitted to the ICUs and 833 of them were deemed eligible for analysis. Six hundred fifty-eight (79%) had solid tumors and 175 (21%) had hematologic malignancies, respectively. Respiratory problems (30.1%) was the most common reason leading to ICU admission. Patients with hematologic malignancies had higher Sequential Organ Failure Assessment (12 vs. 8, P<0.001) and SAPS3 (71 vs. 69, P<0.001) values and were more likely to be associated with chemotherapy, steroid therapy, and immunocompromised status versus patients with solid tumors. The use of inotropes/vasopressors, mechanical ventilation, and/or continuous renal replacement therapy was more frequently required in hematologic malignancy patients. Mortality rates in the ICU (41.7% vs. 24.6%, P<0.001) and hospital (53.1% vs. 38.6%, P=0.002) were higher in hematologic malignancy patients than in solid tumor patients.

Conclusions

Cancer patients accounted for one-third of all patients admitted to the studied ICUs in Korea. Clinical characteristics were different according to the type of malignancy. Patients with hematologic malignancies had a worse prognosis than did patients with solid tumor.

Immunocompromised patients with acute respiratory distress syndrome: secondary analysis of the LUNG SAFE database

Background

The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients.

Methods

We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents.

Results

Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p < 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27.1% vs 18.6%; p < 0.0001). Use of noninvasive ventilation (NIV) as first-line treatment was higher in immunocompromised patients (20.9% vs 15.9%; p = 0.0048), and immunodeficiency remained independently associated with the use of NIV after adjustment for confounders. Forty-eight percent of the patients treated with NIV were intubated, and their mortality was not different from that of the patients invasively ventilated ab initio.

Conclusions

Immunosuppression is frequent in patients with ARDS, and infections are the main risk factors for ARDS in these immunocompromised patients. Their management differs from that of immunocompetent patients, particularly the greater use of NIV as first-line ventilation strategy. Compared with immunocompetent subjects, they have higher mortality regardless of ARDS severity as well as a higher frequency of limitation of life-sustaining measures. Nonetheless, nearly half of these patients survive to hospital discharge.

Trial registration

ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2079-9) contains supplementary material, which is available to authorized users.

Management and outcomes of acute respiratory distress syndrome patients with and without comorbid conditions

Rationale

The standard of care for patients with acute respiratory distress syndrome (ARDS) has been developed based on studies that usually excluded patients with major comorbidities.

Objectives

To describe treatments and outcomes according to comorbidities in patients with ARDS admitted to 19 ICUs (1997–2014).

Methods

Patients were grouped based on comorbidities. Determinants of day-28 mortality were identified by multivariable Cox analysis stratified on center.

Measurements and main results

Among 4953 ARDS patients, 2545 (51.4%) had major comorbidities; the proportion with major comorbidities increased after 2008. Hematological malignancy was associated with severe ARDS and rescue therapies for refractory hypoxemia. COPD, HIV infection, and hematological malignancy were associated with a lower likelihood of invasive mechanical ventilation on the admission day. Admission-day SOFA score was higher in patients with major comorbidities, who more often received vasopressors, dialysis, or treatment-limitation decisions. Day-28 mortality was 33.7% overall, 27.2% in patients without major comorbidities, and 31.1% (COPD) to 56% (hematological malignancy) in patients with major comorbidities. By multivariable analysis, mortality was lower in patients with COPD and higher in those with chronic heart failure, solid tumors, or hematological malignancies. Mortality was independently associated with P_aO₂/F_iO₂ and PaCO₂ on day 1, ARDS of pulmonary origin, worse SOFA score, and ICU-acquired events.

Conclusions

Half the patients with ARDS had major comorbidities, which were associated with severe ARDS, multiple organ dysfunction, and day-28 mortality. These findings do not support the exclusion of ARDS patients with severe comorbidities from randomized clinical trials. Trials in ARDS patients with whatever comorbidities are warranted.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5209-6) contains supplementary material, which is available to authorized users.

Predictors of outcome in patients with hematologic malignancies admitted to the intensive care unit

PURPOSE

Several studies showed conflicting results about prognosis and predictors of outcome of critically ill patients with hematological malignancies (HM). The aim of this study is to determine the hospital outcome of critically ill patients with HM and the factors predicting the outcome.

METHODS AND MATERIALS

All patients with HM admitted to MICU at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and 6 months outcomes were documented.

RESULTS

There were 130 HM patients during the study period. Acute Leukemia was the most common malignancy (31.5%) followed by Non-Hodgkin's Lymphoma (28.5%). About 12.5% patients had autologous HSCT and 51.5% had allogeneic HSCT. Sepsis was the most common ICU diagnosis (25.9%). ICU mortality and hospital mortality were 24.8% and 45.3%, respectively. Six months mortality (available on 80% of patients) was 56.7%. Hospital mortality was higher among mechanically ventilated patients (75%). Using multivariate analysis, only mechanical ventilation (OR of 19.0, CI: 3.1-117.4, P: 0.001) and allogeneic HSCT (OR of 10.9, CI: 1.8-66.9, P: 0.01) predicted hospital mortality.

CONCLUSION

Overall hospital outcome of critically ill patients with HM is improving. However those who require mechanical ventilation or underwent allogeneic HSCT continue to have poor outcome.

[Cancer patients in operative intensive care medicine]

Die Prävalenz onkologischer Erkrankungen ist in den vergangenen Jahrzehnten stetig angestiegen. Durch neue Therapieoptionen können immer mehr Patienten mit einem kurativen Therapieansatz behandelt werden. Diese individualisierten und teilweise sehr aggressiven Therapien können jedoch auch zu schweren Nebenwirkungen führen. Diese sollten als wichtige Differenzialdiagnosen zu anderen vitalbedrohlichen Krankheitsbildern auch dem im OP und als Intensivmediziner tätigen Anästhesisten bekannt sein. Krebspatienten werden häufig auf operativen Intensivstationen aufgenommen, um Komplikationen der malignen Grunderkrankung oder auch Nebenwirkungen einer operativen oder konservativen Therapie zu behandeln. Aktuelle Untersuchungen zeigen, dass die maligne Grunderkrankung entgegen bisheriger Annahme keinen wesentlichen Einfluss auf das Intensivüberleben hat. Bei der Aufnahme eines onkologischen Patienten sollte daher die akut vorliegende Organdysfunktion zunächst im Vordergrund stehen. Bei der Therapiezielplanung gilt es, nicht zu übersehen, wann ein kuratives in ein palliatives Konzept übergehen muss. Hierfür müssen neue Aufnahmestrategien und -kriterien entwickelt und evaluiert werden. In diesem Übersichtsartikel werden Diagnosen und Therapien häufiger intensivmedizinischer Krankheitsbilder von onkologischen Patienten sowie Nebenwirkungen moderner onkologischer Therapien dargelegt und Aufnahmestrategien für Patienten mit malignen Erkrankungen vorgestellt.

The efficacy of initial ventilation strategy for adult immunocompromised patients with severe acute hypoxemic respiratory failure: study protocol for a multicentre randomized controlled trial (VENIM)

Background

Acute respiratory failure (ARF) is still one of the most severe complications in immunocompromised patients. Our previous systematic review showed noninvasive mechanical ventilation (NIV) reduced mortality, length of hospitalization and ICU stay in AIDS/hematological malignancy patients with relatively less severe ARF, compared to invasive mechanical ventilation (IMV). However, this systematic review was based on 13 observational studies and the quality of evidence was low to moderate. The efficacy of NIV in more severe ARF and in patients with other causes of immunodeficiency is still unclear. We aim to determine the efficacy of the initial ventilation strategy in managing ARF in immunocompromised patients stratified by different disease severity and causes of immunodeficiency, and explore predictors for failure of NIV.

Methods and analysis

The VENIM is a multicentre randomized controlled trial (RCT) comparing the effects of NIV compared with IMV in adult immunocompromised patients with severe hypoxemic ARF. Patients who meet the indications for both forms of ventilatory support will be included. Primary outcome will be 30-day all-cause mortality. Secondary outcomes will include in-hospital mortality, length of stay in hospital, improvement of oxygenation, nosocomial infections, seven-day organ failure, adverse events of intervention, et al. Subgroups with different disease severity and causes of immunodeficiency will also be analyzed.

Discussion

VENIM is the first randomized controlled trial aiming at assessing the efficacy of initial ventilation strategy in treating moderate and severe acute respiratory failure in immunocompromised patients. The result of this RCT may help doctors with their ventilation decisions.

Trial registration

ClinicalTrials.gov NCT02983851. Registered 2 September 2016.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

High-flow Nasal Cannula Versus Noninvasive Ventilation for Treatment of Acute Hypoxemic Respiratory Failure in Renal Transplant Recipients

OBJECTIVE

This study aimed to evaluate the outcomes of high-flow nasal cannula (HFNC) oxygen therapy compared with noninvasive ventilation (NIV) for the treatment of acute hypoxemic respiratory failure in renal transplant recipients.

METHODS

Data were retrospectively collected from a tertiary intensive care unit (ICU) from July 1, 2011, to September 31, 2015. All renal recipients who had acute respiratory failure at that period of time were classified into the HFNC or NIV group depending on the initial form of respiratory support.

RESULTS

A total of 38 patients were enrolled in this study. Twenty patients received HFNC and the other 18 received NIV as the initial respiratory support. The ICU mortality in the HFNC group was 5% (1 patient), compared with 22.2% (4 patients) in the NIV group (P = .083). The median length of the ICU stay was 12 days in the HFNC group, compared with 14 days in the NIV group (P = .297). The number of ventilator-free days at day 28 was significantly higher in the HFNC group than in the NIV group (26 ± 3 vs 21 ± 3; P < .001). The incidences of both pneumothorax (0% vs 22.2%; P = .042) and skin breakdown (0% vs 22.2%; P = .042) were significantly lower in the HFNC group.

CONCLUSIONS

In renal transplant recipients with acute hypoxemic respiratory failure secondary to severe pneumonia, HFNC achieved outcomes similar to NIV. In addition, HFNC was associated with an increased number of ventilator-free days at day 28 and fewer complications.

Impact of Initial Ventilatory Strategy in Hematological Patients With Acute Respiratory Failure: A Systematic Review and Meta-Analysis

OBJECTIVE

Acute respiratory failure in hematological patients is related to a high mortality. Noninvasive mechanical ventilation may benefit a subset of these patients, but the overall effect on mortality and the risks derived from its failure are unclear. Our objective was to review the impact of initial ventilatory strategy on mortality and the risks related to noninvasive mechanical ventilation failure in this group of patients.

DATA SOURCES

Data sources, including PubMed and conference proceedings, were searched from the year 2000 to January 2015.

STUDY SELECTION

We selected studies reporting mortality and the need for mechanical ventilation in hematological patients with acute respiratory failure.

DATA EXTRACTION

Two trained reviewers independently conducted study selection, abstracted data, and assessed the risk of bias. Discrepancies between reviewers were resolved through discussion and consensus. The outcomes explored were all-cause mortality after mechanical ventilation and incidence of noninvasive mechanical ventilation failure.

DATA SYNTHESIS

A random-effects model was used in all the analysis. Thirteen studies, involving 2,380 patients, were included. Use of noninvasive mechanical ventilation was related to a better outcome than initial intubation (risk ratio, 0.74; 95% CI, 0.65-0.84). Failure of noninvasive mechanical ventilation did not increase the overall risk of death (risk ratio, 1.02; 95% CI, 0.93-1.13). There were signs of publication bias and substantial heterogeneity among the studies. Compensation of this bias by using the trim-and-fill method showed a significant risk of death after noninvasive mechanical ventilation failure (risk ratio, 1.07; 95% CI, 1.00-1.14). Meta-regression analysis showed that the predicted risk of death for the noninvasive mechanical ventilation group acted as a significant moderator, with a higher risk of death after noninvasive mechanical ventilation failure in those studies reporting lower predicted mortality.

CONCLUSIONS

Noninvasive mechanical ventilation is associated with a lower risk of death in hematological patients with respiratory failure. Noninvasive mechanical ventilation failure may worsen the prognosis, mainly in less severe patients.

Critical Care Prognosis and Outcomes in Patients with Cancer

Advances in cancer treatment and patient survival are associated with increasing number of these patients requiring intensive care. Over the last 2 decades, there has been a steady improvement in the outcomes of critically ill patients with cancer. This review provides data on the use of the intensive care unit (ICU) and short and long-term outcomes of critically ill patients with cancer, the ICU system practices that influence patients outcomes, and the role of the different clinical variables in predicting the prognosis of these patients.

Characteristics and predictors of mortality of patients with hematologic malignancies requiring invasive mechanical ventilation

RATIONALE:

Acute respiratory failure (ARF) may complicate the course of hematologic malignancies (HMs). Our objective was to study the characteristics, outcomes and predictors of mortality of patients with HMs who required intubation for ARF.

METHODS:

This retrospective cohort study evaluated all patients with HMs who were admitted to the Intensive Care Unit (ICU) of King Abdul-Aziz Medical City-Riyadh between 2008 and 2013 and required invasive mechanical ventilation. We noted their baseline characteristics, treatments and different outcomes. Multivariable logistic regression analysis was performed to evaluate predictors of hospital mortality.

RESULTS:

During the 6-year period, 190 patients with HMs were admitted to the ICU and 122 (64.2%) required intubation for ARF. These patients had mean age of 57.2 ± 19.3 years and Acute Physiology and Chronic Health Evaluation II score of 28.0 ± 7.8 and were predominantly males (63.4%). Lymphoma (44.3%) and acute leukemia (38.5%) were the most common hematologic malignancy. Noninvasive ventilation (NIV) was tried in 22 patients (18.0%) but failed. The code status was changed to “Do-Not-Resuscitate” for 39 patients (32.0%) during ICU stay. Hospital mortality was 70.5% and most deaths (81.4%) occurred in the ICU. The mortality of patients with “Do-Not-Resuscitate” status was 97.4%. On multivariable logistic regression analysis, male gender (odds ratio (OR), 6.74; 95% confidence interval (CI), 2.24–20.30), septic shock (OR, 6.61; 95% CI, 1.93–22.66) were independent mortality predictors. Remission status, non-NIV failure and chemotherapy during ICU stay were not associated with mortality.

CONCLUSIONS:

Patients with HMs requiring intubation had high mortality (70.5%). Male gender and presence of septic shock were independent predictors of mortality.

Noninvasive Ventilation in Patients With Hematologic Malignancy

INTRODUCTION

Noninvasive ventilation (NIV) is commonly used as first-line therapy for immunocompromised patients with acute respiratory failure. However, it may not be appropriate for all patients, as failure of NIV and delayed endotracheal intubation (ETI) may increase mortality. We report our center's experience and outcomes for patients with active hematologic malignancy (HM) treated with NIV.

METHODS

We conducted a retrospective study of consecutive patients with HM who were admitted to the intensive care unit (ICU) of Mount Sinai Hospital for acute respiratory failure between January 1, 2010, and May 31, 2015, and were initially treated with NIV. We compared the characteristics of patients who were successfully treated with NIV and avoided intubation and those who failed NIV.

RESULTS

Seventy-nine patients (mean age 56 ± 14 years, mean Acute Physiology and Chronic Health Evaluation II score 27 ± 5) with HM were treated with NIV for acute respiratory failure. The etiology of respiratory failure was multifactorial in 31 (39%) patients, with features of pneumonia in 61 (77%) patients, severe sepsis or septic shock in 33 (42%) patients, and pulmonary edema in 24 (30%) patients. The majority of patients were admitted with acute leukemia (n = 60, 76%), 8 (10%) with lymphoma, and 11 (14%) with chronic leukemia, multiple myeloma, or myelodysplastic syndrome. Of the 79 patients treated with NIV, 44 (56%) failed NIV and required ETI, 7 (9%) had a do-not-intubate (DNI) order and died, and 28 (35%) avoided ETI. Compared with patients who avoided ETI, those who failed NIV or had a DNI order and died were more likely to have acute leukemia (84% vs 61%; P = .02) and at baseline had higher Paco2 (39 vs 30; P = .038), higher fraction of inspired oxygen (Fio2) requirements (0.6 vs 0.4; P = .002), and more vasopressor use (31% vs 11%; P = .059). The ICU mortality was 42%; 3-month mortality was 57% overall and was significantly lower in the NIV success patients compared with the NIV failure group (21% vs 74%; P < .001).

CONCLUSION

Two-thirds of patients with HM and respiratory failure failed NIV and required ETI, and had high subsequent mortality. Patients who failed NIV had higher Paco2, higher Fio2, and a trend toward more vasopressor use.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Critical care of patients with cancer

Answer questions and earn CME/CNE The increasing prevalence of patients living with cancer in conjunction with the rapid progress in cancer therapy will lead to a growing number of patients with cancer who will require intensive care treatment. Fortunately, the development of more effective oncologic therapies, advances in critical care, and improvements in patient selection have led to an increased survival of critically ill patients with cancer. As a consequence, critical care has become an important cornerstone in the continuum of modern cancer care. Although, in many aspects, critical care for patients with cancer does not differ from intensive care for other seriously ill patients, there are several challenging issues that are unique to this patient population and require special knowledge and skills. The optimal management of critically ill patients with cancer necessitates expertise in oncology, critical care, and palliative medicine. Cancer specialists therefore have to be familiar with key principles of intensive care for critically ill patients with cancer. This review provides an overview of the state-of-the-art in the individualized management of critically ill patients with cancer. CA Cancer J Clin 2016;66:496-517. © 2016 American Cancer Society.

Management of neutropenic patients in the intensive care unit (NEWBORNS EXCLUDED) recommendations from an expert panel from the French Intensive Care Society (SRLF) with the French Group for Pediatric Intensive Care Emergencies (GFRUP), the French Society of Anesthesia and Intensive Care (SFAR), the French Society of Hematology (SFH), the French Society for Hospital Hygiene (SF2H), and the French Infectious Diseases Society (SPILF)

Neutropenia is defined by either an absolute or functional defect (acute myeloid leukemia or myelodysplastic syndrome) of polymorphonuclear neutrophils and is associated with high risk of specific complications that may require intensive care unit (ICU) admission. Specificities in the management of critically ill neutropenic patients prompted the establishment of guidelines dedicated to intensivists. These recommendations were drawn up by a panel of experts brought together by the French Intensive Care Society in collaboration with the French Group for Pediatric Intensive Care Emergencies, the French Society of Anesthesia and Intensive Care, the French Society of Hematology, the French Society for Hospital Hygiene, and the French Infectious Diseases Society. Literature review and formulation of recommendations were performed using the Grading of Recommendations Assessment, Development and Evaluation system. Each recommendation was then evaluated and rated by each expert using a methodology derived from the RAND/UCLA Appropriateness Method. Six fields are covered by the provided recommendations: (1) ICU admission and prognosis, (2) protective isolation and prophylaxis, (3) management of acute respiratory failure, (4) organ failure and organ support, (5) antibiotic management and source control, and (6) hematological management. Most of the provided recommendations are obtained from low levels of evidence, however, suggesting a need for additional studies. Seven recommendations were, however, associated with high level of evidences and are related to protective isolation, diagnostic workup of acute respiratory failure, medical management, and timing surgery in patients with typhlitis.

Noninvasive versus invasive mechanical ventilation for immunocompromised patients with acute respiratory failure: a systematic review and meta-analysis

Background

To determine the effects of noninvasive mechanical ventilation (NIV) compared with invasive mechanical ventilation (IMV) as the initial mechanical ventilation on clinical outcomes when used for treatment of acute respiratory failure (ARF) in immunocompromised patients.

Methods

We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Chinese Biomedical Literature Database (CBM) and other databases. Subgroup analyses by disease severity and causes of immunodeficiency were also conducted.

Results

Thirteen observational studies with a total of 2552 patients were included. Compared to IMV, NIV was shown to significantly reduce in-hospital mortality (OR 0.43, 95 % CI 0.23 to 0.80, P value = 0.007) and 30-day mortality (OR 0.34, 95 % CI 0.20 to 0.61, P value < 0.0001) in overall analysis. Subgroup analysis showed NIV had great advantage over IMV for less severe, AIDS, BMT and hematological malignancies patients in reducing mortality and duration of ICU stay.

Conclusions

The overall evidence we obtained shows NIV does more benefits or at least no harm to ARF patients with certain causes of immunodeficiency or who are less severe.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0289-y) contains supplementary material, which is available to authorized users.

Can fiberoptic bronchoscopy be applied to critically ill patients treated with noninvasive ventilation for acute respiratory distress syndrome? Prospective observational study

Background

Noninvasive ventilation (NIV) is a cornerstone for the treatment of acute respiratory failure of various etiologies. Using NIV is discussed in mild-to-moderate acute respiratory distress syndrome (ARDS) patients (PaO₂/FiO₂ > 150). These patients often have comorbidities that increase the risk for bronchoscopy related complications. The primary outcome of this prospective observational study was to evaluate the feasibility, safety and contribution in diagnosis and/or modification of the ongoing treatment of fiberoptic bronchoscopy (FOB) in patients with ARDS treated with NIV.

Methods

ARDS patients treated with NIV and who require FOB as the diagnostic or therapeutic procedure were included the study. Intensive care ventilators or other dedicated NIV ventilators were used. NIV was applied via simple oro-nasal mask or full-face mask. Pressure support or inspiratory positive airway pressure (IPAP), external positive end expiratory pressure (PEEP) or expiratory positive airway pressure (EPAP) levels were titrated to achieve an expiratory tidal volume of 8 to 10 ml/kg according to ideal body weight, SpO₂ > 90 % and respiratory rate below 25/min.

Results

Twenty eight subjects (mean age 63.3 ± 15.9 years, 15 men, 13 women, PaO₂/FiO₂ rate 145 ± 50.1 at admission) were included the study. Overall the procedure was well tolerated with only 5 (17.9 %) patients showing minor complications. There was no impairment in arterial blood gas and cardiopulmonary parameters after FOB. PaO₂/FiO₂ rate increased from 132.2 ± 49.8 to 172.9 ± 63.2 (p = 0.001). No patient was intubated within 2 h after the bronchoscopy. 10.7, 32.1 and 39.3 % of the patients required invasive mechanical ventilation after 8 h, 24 h and 48 h, respectively. Bronchoscopy provided diagnosis in 27 (96.4 %) patients. Appropriate treatment was decided according to the results of the bronchoscopic sampling in 20 (71.4 %) patients.

Conclusion

FOB under NIV could be considered as a feasible tool for diagnosis and guide for treatment of patients with ARDS treated via NIV in intensive care units. However, FOB-correlated life-treathening complications in severe hypoxemia should not be forgotten. Furthermore, further controlled studies involving a larger series of homogeneous ARDS patients undergoing FOB under NIV are needed to confirm these preliminary findings.

ECIL guidelines for treatment of Pneumocystis jirovecii pneumonia in non-HIV-infected haematology patients

The initiation of systemic antimicrobial treatment of Pneumocystis jirovecii pneumonia (PCP) is triggered by clinical signs and symptoms, typical radiological and occasionally laboratory findings in patients at risk of this infection. Diagnostic proof by bronchoalveolar lavage should not delay the start of treatment. Most patients with haematological malignancies present with a severe PCP; therefore, antimicrobial therapy should be started intravenously. High-dose trimethoprim/sulfamethoxazole is the treatment of choice. In patients with documented intolerance to this regimen, the preferred alternative is the combination of primaquine plus clindamycin. Treatment success should be first evaluated after 1 week, and in case of clinical non-response, pulmonary CT scan and bronchoalveolar lavage should be repeated to look for secondary or co-infections. Treatment duration typically is 3 weeks and secondary anti-PCP prophylaxis is indicated in all patients thereafter. In patients with critical respiratory failure, non-invasive ventilation is not significantly superior to intubation and mechanical ventilation. The administration of glucocorticoids must be decided on a case-by-case basis.

Clinical utility of high-flow nasal cannula oxygen therapy for acute respiratory failure in patients with hematological disease

A high-flow nasal cannula (HFNC) is a newly developed device that enables high-flow oxygen therapy for patients with serious cardiopulmonary problems, but there are few data regarding its use in patients with hematological disease. The efficacy and tolerability of HFNCs for patients who developed ARF during the treatment of various hematological diseases was evaluated. Fifty-six patients underwent HFNC therapy during the last 2 years, and the causes of ARF were mainly pneumonia (n = 37) or acute congestive heart failure (n = 7). Only 11 patients (20 %) showed a good response to HFNC therapy, and remaining 45 patients (80 %) failed to respond to the initial HFNC therapy and, therefore, underwent second-line therapy including endotracheal intubation with mechanical ventilation (n = 15), non-invasive positive pressure ventilation (n = 1), or narcotic palliation alone (n = 29). Thus, HFNC appear not to be a viable treatment option in 4 out of 5 patients in this cohort of patients with hematological disease, but it was well tolerated in most patients (96 %); no major complications except for nasal soreness (n = 2) were observed. Multivariate analysis showed that the cause of ARF (pneumonia, odds ratio 11.2, 95 % CI 1.76–71.5, p = 0.01) was the only risk factor for treatment failure.

The Therapeutic Outcomes of Mechanical Ventilation in Hematological Malignancy Patients with Respiratory Failure

Objective In hematological malignancy patients, the complication of acute respiratory failure often reaches a degree of severity that necessitates mechanical ventilation. The objective of the present study was to investigate the therapeutic outcomes of mechanical ventilation in hematological malignancy patients with respiratory failure and to analyze the factors that are associated with successful treatment in order to identify the issues that should be addressed in the future. Methods The present study was a retrospective analysis of 71 hematological malignancy patients with non-cardiogenic acute respiratory failure who were treated with mechanical ventilation at Nippon Medical School Hospital between 2003 and 2014. Results Twenty-six patients (36.6%) were treated with mechanical ventilation in an intensive care unit (ICU). Non-invasive positive pressure ventilation (NPPV) was applied in 29 cases (40.8%). The rate of successful mechanical ventilation treatment with NPPV alone was 13.8%. The rate of endotracheal extubation was 17.7%. A univariate analysis revealed that the following factors were associated with the successful extubation of patients who received invasive mechanical ventilation: respiratory management in an ICU (p=0.012); remission of the hematological disease (p=0.011); female gender (p=0.048); low levels of accompanying non-respiratory organ failure (p=0.041); and the non-use of extracorporeal circulation (p=0.005). A subsequent multivariate analysis revealed that respiratory management in an ICU was the only variable associated with successful extubation (p=0.030). Conclusion The outcomes of hematological malignancy patients who receive mechanical ventilation treatment for respiratory failure are very poor. Respiratory management in an ICU environment may be useful in improving the therapeutic outcomes of such patients.

Acute respiratory failure in patients with hematological malignancies: outcomes according to initial ventilation strategy. A groupe de recherche respiratoire en réanimation onco-hématologique (Grrr-OH) study

BACKGROUND

In patients with hematological malignancies and acute respiratory failure (ARF), noninvasive ventilation was associated with a decreased mortality in older studies. However, mortality of intubated patients decreased in the last years. In this study, we assess outcomes in those patients according to the initial ventilation strategy.

METHODS

We performed a post hoc analysis of a prospective multicentre study of critically ill hematology patients, in 17 intensive care units in France and Belgium. Patients with hematological malignancies admitted for ARF in 2010 and 2011 and who were not intubated at admission were included in the study. A propensity score-based approach was used to assess the impact of NIV compared to oxygen only on hospital mortality.

RESULTS

Among 1011 patients admitted to ICU during the study period, 380 met inclusion criteria. Underlying diseases included lymphoid (n = 162, 42.6 %) or myeloid (n = 141, 37.1 %) diseases. ARF etiologies were pulmonary infections (n = 161, 43 %), malignant infiltration (n = 65, 17 %) or cardiac pulmonary edema (n = 40, 10 %). Mechanical ventilation was ultimately needed in 94 (24.7 %) patients, within 3 [2-5] days of ICU admission. Hospital mortality was 32 % (123 deaths). At ICU admission, 142 patients received first-line noninvasive ventilation (NIV), whereas 238 received oxygen only. Fifty-five patients in each group (NIV or oxygen only) were matched according the propensity score. NIV was not associated with decreased hospital mortality [OR 1.5 (0.62-3.65)].

CONCLUSIONS

In hematology patients with acute respiratory failure, initial treatment with NIV did not improve survival compared to oxygen only.

CLINICAL TRIAL

gov number NCT 01172132.

Main characteristics observed in patients with hematologic diseases admitted to an intensive care unit of a Brazilian university hospital

Objective

To evaluate the clinical characteristics of patients with hematological disease admitted to the intensive care unit and the use of noninvasive mechanical ventilation in a subgroup with respiratory dysfunction.

Methods

A retrospective observational study from September 2011 to January 2014.

Results

Overall, 157 patients were included. The mean age was 45.13 (± 17.2) years and 46.5% of the patients were female. Sixty-seven (48.4%) patients had sepsis, and 90 (57.3%) patients required vasoactive vasopressors. The main cause for admission to the intensive care unit was acute respiratory failure (94.3%). Among the 157 studied patients, 47 (29.9%) were intubated within the first 24 hours, and 38 (24.2%) underwent noninvasive mechanical ventilation. Among the 38 patients who initially received noninvasive mechanical ventilation, 26 (68.4%) were subsequently intubated, and 12 (31.6%) responded to this mode of ventilation. Patients who failed to respond to noninvasive mechanical ventilation had higher intensive care unit mortality (66.7% versus 16.7%; p = 0.004) and a longer stay in the intensive care unit (9.6 days versus 4.6 days, p = 0.02) compared with the successful cases. Baseline severity scores (SOFA and SAPS 3) and the total leukocyte count were not significantly different between these two subgroups. In a multivariate logistic regression model including the 157 patients, intubation at any time during the stay in the intensive care unit and SAPS 3 were independently associated with intensive care unit mortality, while using noninvasive mechanical ventilation was not.

Conclusion

In this retrospective study with severely ill hematologic patients, those who underwent noninvasive mechanical ventilation at admission and failed to respond to it presented elevated intensive care unit mortality. However, only intubation during the intensive care unit stay was independently associated with a poor outcome. Further studies are needed to define predictors of noninvasive mechanical ventilation failure.

Outcomes for patients with cancer admitted to the ICU requiring ventilatory support: results from a prospective multicenter study

BACKGROUND

This study was undertaken to evaluate the clinical characteristics and outcomes of patients with cancer requiring nonpalliative ventilatory support.

METHODS

This was a secondary analysis of a prospective cohort study conducted in 28 Brazilian ICUs evaluating adult patients with cancer requiring invasive mechanical ventilation (MV) or noninvasive ventilation (NIV) during the first 48 h of their ICU stay. We used logistic regression to identify the variables associated with hospital mortality.

RESULTS

Of 717 patients, 263 (37%) (solid tumors = 227; hematologic malignancies = 36) received ventilatory support. NIV was initially used in 85 patients (32%), and 178 (68%) received MV. Additionally, NIV followed by MV occurred in 45 patients (53%). Hospital mortality rates were 67% in all patients, 40% in patients receiving NIV only, 69% when NIV was followed by MV, and 73% in patients receiving MV only (P < .001). Adjusting for the type of admission, newly diagnosed malignancy (OR, 3.59; 95% CI, 1.28-10.10), recurrent or progressive malignancy (OR, 3.67; 95% CI, 1.25-10.81), tumoral airway involvement (OR, 4.04; 95% CI, 1.30-12.56), performance status (PS) 2 to 4 (OR, 2.39; 95% CI, 1.24-4.59), NIV followed by MV (OR, 3.00; 95% CI, 1.09-8.18), MV as initial ventilatory strategy (OR, 3.53; 95% CI, 1.45-8.60), and Sequential Organ Failure Assessment score (each point except the respiratory domain) (OR, 1.15; 95% CI, 1.03-1.29) were associated with hospital mortality. Hospital survival in patients with good PS and nonprogressive malignancy and without tumoral airway involvement was 53%. Conversely, patients with poor functional capacity and cancer progression had unfavorable outcomes.

CONCLUSIONS

Patients with cancer with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care, because one-half of these patients survive. On the other hand, provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy.