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Cuenca JA, Nates JL, Laserna A, Heatter AJ, Manjappachar N, Martin P, Reyes MP, Hernandez M, Hall J, Ramirez CM, de Villalobos DH. Long-Term Survival of Patients With Cancer, Sepsis, and Vasopressor Requirements Based on Lactate Levels. Crit Care Explor 2024; 6:e1070. [PMID: 38572448 PMCID: PMC10990307 DOI: 10.1097/cce.0000000000001070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
A prospective cohort study was conducted to evaluate the 1-year survival of cancer patients with sepsis and vasopressor requirements. Eligible patients were admitted a Comprehensive Cancer Center's ICU and were compared based on their admission lactate levels. Of the 132 included patients, 87 (66%) had high lactate (HL; > 2.0 mmol/L), and 45 (34%) had normal lactate (NL; ≤ 2.0 mmol/L). The 1-year survival rates of the two groups were similar (HL 16% vs. NL 18%; p = 0.0921). After adjustment for ICU baseline characteristics, HL was not significantly associated with a 1-year survival (Hazards ratio, 1.39; 95% CI, 0.94-2.05). Critically ill cancer patients with sepsis and vasopressor requirements, regardless of the lactate level, had 1-year survival of less than 20%. Large multicenter cancer registries would enable to confirm our findings and better understand the long-term trajectories of sepsis in this vulnerable population.
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Affiliation(s)
- John A Cuenca
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
- Internal Medicine residency, Texas Institute of Graduate Medical Education and Research (TIGMER), University of Incarnate Word, San Antonio, TX
| | - 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
| | - Andres Laserna
- Department of Anesthesia and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY
| | - Alba J Heatter
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nirmala Manjappachar
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Peyton Martin
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maria P Reyes
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mike Hernandez
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jacob Hall
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claudia M Ramirez
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Diego H de Villalobos
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Cuenca JA, Hanmandlu A, Wegner R, Botdorf J, Tummala S, Iliescu CA, Nates JL, Reddy DR. Management of respiratory failure in immune checkpoint inhibitors-induced overlap syndrome: a case series and review of the literature. BMC Anesthesiol 2023; 23:310. [PMID: 37700240 PMCID: PMC10496364 DOI: 10.1186/s12871-023-02257-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 08/24/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Checkpoint inhibitor-induced overlap syndrome ([OS] myocarditis, and myositis with or without myasthenia gravis) is rare but life-threatening. CASES PRESENTATION Here we present a case series of four cancer patients that developed OS. High troponinemia raised the concern for myocarditis in all the cases. However, the predominant clinical feature differed among the cases. Two patients showed marked myocarditis with a shorter hospital stay. The other two patients had a prolonged ICU stay due to severe neuromuscular involvement secondary to myositis and myasthenia gravis. Treatment was based on steroids, plasmapheresis, intravenous immunoglobulin, and immunosuppressive biological agents. CONCLUSION The management of respiratory failure is challenging, particularly in those patients with predominant MG. Along with intensive clinical monitoring, bedside respiratory mechanics can guide the decision-making process of selecting a respiratory support method, the timing of elective intubation and extubation.
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Affiliation(s)
- John A Cuenca
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Ankit Hanmandlu
- McGovern School of Medicine, University of Texas, Houston, TX, USA
| | - Robert Wegner
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Joshua Botdorf
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Sudhakar Tummala
- Department of Neuro-oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cezar A Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph L Nates
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Dereddi R Reddy
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
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Cuenca JA, Casal RF, Ahrar K, Nates JL. Where did the line go? A case of a duplicated left superior vena cava. Oxf Med Case Reports 2023; 2023:omad035. [PMID: 37377723 PMCID: PMC10292635 DOI: 10.1093/omcr/omad035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/14/2023] [Accepted: 03/15/2023] [Indexed: 06/29/2023] Open
Affiliation(s)
- John A Cuenca
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kamran Ahrar
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph L Nates
- Correspondence address. Department of Critical Care Medicine, Unit 112, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, USA. Tel: 713-792-5040; E-mail:
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Gonzalez-Mosquera LF, Moscoso B, Tobar P, Cardenas-Maldonado D, Podrumar AI, Mesa R, Cuenca JA. Sepsis-Related Outcomes of Patients with Philadelphia-Negative Myeloproliferative Neoplasms. Cancer Invest 2023:1-9. [PMID: 36883674 DOI: 10.1080/07357907.2023.2187059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
We analyzed the National Inpatient Sample (NIS) database to study the sepsis-related outcomes in patients with Philadelphia negative myeloproliferative neoplasms (MPN). A total of 82,087 patients were included, most had essential thrombocytosis (83.7%), followed by polycythemia vera (13.7%), and primary myelofibrosis (2.6%). Sepsis was diagnosed in 15,789 (19.2%) patients and their mortality rate was higher than nonseptic patients (7.5% vs 1.8%; p < .001). Sepsis was the most significant risk factor of mortality (aOR, 3.84; 95% CI, 3.51-4.21), others included liver disease (aOR, 2.42; 95% CI, 2.11-2.78), pulmonary embolism (aOR, 2.26; 95% CI, 1.83-2.80), cerebrovascular disease (aOR, 2.05; 95% CI, 1.81-2.33), and myocardial infarction (aOR, 1.73; 95% CI, 1.52-1.96).
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Affiliation(s)
| | - Bernard Moscoso
- Escuela Superior Politécnica del Litoral, ESPOL, Centro de Investigaciones Economicas, ESPOL Polytechnic University, Guayaquil, Ecuador
| | - Pool Tobar
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | | | - Alida I Podrumar
- Department of Hematology and Oncology, Nassau University Medical Center, East Meadow, NY, USA
| | - Ruben Mesa
- Mays Cancer Center, UT Health San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - John A Cuenca
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Gonzalez-Mosquera LF, Moscoso B, Tobar P, Cardenas-Maldonado D, Podrumar AI, Mesa R, Cuenca JA. Sepsis-related outcomes of patients with Philadelphia-negative myeloproliferative neoplasms. Cancer Invest 2023:1-20. [PMID: 36862101 DOI: 10.1080/07357907.2023.2187225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/23/2023] [Accepted: 02/28/2023] [Indexed: 03/03/2023]
Abstract
We analyzed the National Inpatient Sample (NIS) database to study the sepsis-related outcomes in patients with Philadelphia negative myeloproliferative neoplasms (MPN). A total of 82,087 patients were included, most had essential thrombocytosis (83.7%), followed by polycythemia vera (13.7%), and primary myelofibrosis (2.6%). Sepsis was diagnosed in 15,789 (19.2%) patients and their mortality rate was higher than non-septic patients (7.5% vs 1.8%; P<.001). Sepsis was the most significant risk factor of mortality (aOR, 3.84; 95% CI, 3.51-4.21), others included liver disease (aOR, 2.42; 95% CI, 2.11-2.78), pulmonary embolism (aOR, 2.26; 95% CI, 1.83-2.80), cerebrovascular disease (aOR, 2.05; 95% CI, 1.81-2.33), and myocardial infarction (aOR, 1.73; 95% CI, 1.52-1.96).
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Affiliation(s)
| | - Bernard Moscoso
- ESPOL Polytechnic University, Escuela Superior Politécnica del Litoral, ESPOL, Centro de Investigaciones Economicas, Guayaquil, Ecuador
| | - Pool Tobar
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | | | - Alida I Podrumar
- Department of Hematology and Oncology, Nassau University Medical Center, East Meadow, NY, USA
| | - Ruben Mesa
- Mays Cancer Center, UT Health San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - John A Cuenca
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Reddy DR, Cuenca JA, Botdorf J, Muthu M, Hanmandlu A, Wegner R, Crommett J, Gutierrez C, Rathi N, Sajith B, Knafl M, Abbas HA, Woodman SE, Nates JL. Clinical Characteristics and Cause of Death Among Hospitalized Decedents With Cancer and COVID-19. Mayo Clin Proc 2023; 98:451-457. [PMID: 36868753 PMCID: PMC9794478 DOI: 10.1016/j.mayocp.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/06/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
There is scant information on the clinical progression, end-of-life decisions, and cause of death of patients with cancer diagnosed with COVID-19. Therefore, we conducted a case series of patients admitted to a comprehensive cancer center who did not survive their hospitalization. To determine the cause of death, 3 board-certified intensivists reviewed the electronic medical records. Concordance regarding cause of death was calculated. Discrepancies were resolved through a joint case-by-case review and discussion among the 3 reviewers. During the study period, 551 patients with cancer and COVID-19 were admitted to a dedicated specialty unit; among them, 61 (11.6%) were nonsurvivors. Among nonsurvivors, 31 (51%) patients had hematologic cancers, and 29 (48%) had undergone cancer-directed chemotherapy within 3 months before admission. The median time to death was 15 days (95% confidence interval [CI], 11.8 to 18.2). There were no differences in time to death by cancer category or cancer treatment intent. The majority of decedents (84%) had full code status at admission; however, 53 (87%) had do-not-resuscitate orders at the time of death. Most deaths were deemed to be COVID-19 related (88.5%). The concordance between the reviewers for the cause of death was 78.7%. In contrast to the belief that COVID-19 decedents die because of their comorbidities, in our study only 1 of every 10 patients died of cancer-related causes. Full-scale interventions were offered to all patients irrespective of oncologic treatment intent. However, most decedents in this population preferred care with nonresuscitative measures rather than full support at the end of life.
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Affiliation(s)
- Dereddi Raja Reddy
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John A Cuenca
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Data-Driven Determinants for COVID-19 Oncology Discovery Effort (D3CODE) Team, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joshua Botdorf
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mayoora Muthu
- Department of Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ankit Hanmandlu
- McGovern School of Medicine, The University of Texas Health Science Center, Houston, TX
| | - Robert Wegner
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John Crommett
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cristina Gutierrez
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nisha Rathi
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bilja Sajith
- Acute Care Services, The University of Texas MD Anderson Cancer Center, Houston, TX; Data-Driven Determinants for COVID-19 Oncology Discovery Effort (D3CODE) Team, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mark Knafl
- Data-Driven Determinants for COVID-19 Oncology Discovery Effort (D3CODE) Team, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hussein A Abbas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Scott E Woodman
- Data-Driven Determinants for COVID-19 Oncology Discovery Effort (D3CODE) Team, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Genomics Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Joseph L Nates
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Data-Driven Determinants for COVID-19 Oncology Discovery Effort (D3CODE) Team, The University of Texas MD Anderson Cancer Center, Houston, TX.
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7
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Cuenca JA, Manjappachar N, Nates J, Mundie T, Beil L, Christensen E, Martin P, Diaz N, Layton LS, Plexman K, Nates JL, Price KJ, Idowu O. Humanizing the intensive care unit experience in a comprehensive cancer center: A patient- and family-centered improvement study. Palliat Support Care 2022; 20:794-800. [PMID: 36942585 PMCID: PMC10030873 DOI: 10.1017/s1478951521001838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Improving family-centered outcomes is a priority in oncologic critical care. As part of the Intensive Care Unit (ICU) Patient-Centered Outcomes Research Collaborative, we implemented patient- and family-centered initiatives in a comprehensive cancer center. METHODS A multidisciplinary team was created to implement the initiatives. We instituted an open visitation policy (OVP) that revamped the use of the two-way communication boards and enhanced the waiting room experience by hosting ICU family-centered events. To assess the initiatives' effects, we carried out pre-intervention (PRE) and post-intervention (POST) family/caregiver and ICU practitioner surveys. RESULTS A total of 159 (PRE = 79, POST = 80) family members and 147 (PRE = 95, POST = 52) ICU practitioners participated. Regarding the decision-making process, family members felt more included (40.5% vs. 68.8%, p < 0.001) and more supported (29.1% vs. 48.8%, p = 0.011) after the implementation of the initiatives. The caregivers also felt more control over the decision-making process in the POST survey (34.2% vs. 56.3%, p = 0.005). Although 33% of the ICU staff considered OVP was beneficial for the ICU, 41% disagreed and 26% were neutral. Only half of them responded that OVP was beneficial for patients and 63% agreed that OVP was beneficial for families. Half of the practitioners agreed that OVP resulted in additional work for staff. SIGNIFICANCE OF RESULTS Our project effectively promoted patient- and family-centered care. The families expressed satisfaction with the communication of information and the decision-making process. However, the ICU staff felt that the initiatives increased their work load. Further research is needed to understand whether making this project universal or introducing additional novel practices would significantly benefit patients admitted to the ICU and their family.
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Affiliation(s)
- John A Cuenca
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nirmala Manjappachar
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joel Nates
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tiffany Mundie
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lisa Beil
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eric Christensen
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Peyton Martin
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nancy Diaz
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lorraine S Layton
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Karen Plexman
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - 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
| | - Kristen J Price
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Olakunle Idowu
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Cuenca JA, Manjappachar NK, Ramírez CM, Hernandez M, Martin P, Gutierrez C, Rathi N, Sprung CL, Price KJ, Nates JL. Outcomes and Predictors of 28-Day Mortality in Patients With Solid Tumors and Septic Shock Defined by Third International Consensus Definitions for Sepsis and Septic Shock Criteria. Chest 2022; 162:1063-1073. [PMID: 35644244 PMCID: PMC9808606 DOI: 10.1016/j.chest.2022.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/27/2022] [Accepted: 05/16/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Data assessing outcomes of patients with solid tumors demonstrating septic shock using the Third International Consensus Definitions for Sepsis and Septic Shock are scarce. RESEARCH QUESTION What are the independent predictors of 28-day mortality in critically ill adults with solid tumors and septic shock? STUDY DESIGN AND METHODS Cohort of solid tumor patients admitted to the ICU with septic shock. Demographic and clinical characteristics were gathered from the electronic health records. We developed a reduced multivariate logistics regression model to identify independent predictors of 28-day mortality and used Kaplan-Meier plots to assess survival. RESULTS A total of 271 patients were included. The median age was 62 years (range, 19-94 years); 57.2% were men and 53.5% were White. The most common underlying malignancies were lung (19.2%), breast (7.7%), pancreatic (7.7%), and colorectal (7.4%) cancers. Most patients (84.5%) harbored metastatic disease. Twenty-eight days after ICU admission, 188 patients (69.4%) had died. Nonsurvivors showed a higher rate of advanced cancer, longer hospital stays before ICU admission, and higher Sequential Organ Failure Assessment scores at admission and throughout the ICU stay (P < .001 for all). The multivariate analysis identified metastatic disease (OR, 3.17; 95% CI, 1.43-7.03), respiratory failure (OR, 2.34; 95% CI, 1.15-4.74), elevated lactate levels (OR, 3.19; 95% CI, 1.90-5.36), and Eastern Cooperative Oncology Group performance scores of 3 or 4 (OR, 2.72; 95% CI, 1.33-5.57) as independent predictors of 28-day mortality. Only 38 patients (14%) were discharged home without medical assistance. INTERPRETATION The 28-day mortality rate of patients with solid tumors and septic shock was considerably high. Factors associated with worse survival included advanced oncologic disease, poor performance status, high lactate level, and concomitant acute respiratory failure. Early goals-of-care discussions should be considered for frail patients with septic shock and advanced metastatic disease without denying access to the appropriate level of care.
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Affiliation(s)
- John A Cuenca
- Division of Anesthesiology, Critical Care, and Pain Medicine, Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nirmala K Manjappachar
- Division of Anesthesiology, Critical Care, and Pain Medicine, Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claudia M Ramírez
- Division of Anesthesiology, Critical Care, and Pain Medicine, Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mike Hernandez
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Peyton Martin
- Division of Anesthesiology, Critical Care, and Pain Medicine, Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cristina Gutierrez
- Division of Anesthesiology, Critical Care, and Pain Medicine, Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nisha Rathi
- Division of Anesthesiology, Critical Care, and Pain Medicine, Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care Medicine and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Kristen J Price
- Division of Anesthesiology, Critical Care, and Pain Medicine, Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joseph L Nates
- Division of Anesthesiology, Critical Care, and Pain Medicine, Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Nazer L, Lopez-Olivo MA, Cuenca JA, Awad W, Brown AR, Abusara A, Sirimaturos M, Hicklen RS, Nates JL. All-cause mortality in cancer patients treated for sepsis in intensive care units: a systematic review and meta-analysis. Support Care Cancer 2022; 30:10099-10109. [PMID: 36214879 PMCID: PMC9549043 DOI: 10.1007/s00520-022-07392-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/03/2022] [Indexed: 11/28/2022]
Abstract
Purpose Sepsis is a common complication in patients with cancer, but studies evaluating the outcomes of critically ill cancer patients with sepsis on a global scale are limited. We aimed to summarize the existing evidence on mortality rates in this patient population. Methods Prospective and retrospective observational studies evaluating critically ill adult cancer patients with sepsis, severe sepsis, and/or septic shock were included. Studies published from January 2010 to September 2021 that reported at least one mortality outcome were retrieved from MEDLINE (Ovid), Embase (Ovid), and Cochrane databases. Study selection, bias assessment, and data collection were performed independently by two reviewers, and any discrepancies were resolved by a third reviewer. The risk of bias was assessed using the Newcastle–Ottawa scale. We calculated pooled intensive care unit (ICU), hospital, and 28/30-day mortality rates. The heterogeneity of the data was tested using the chi-square test, with a P value < 0.10 indicating significant heterogeneity. Results A total of 5464 citations were reviewed, of which 10 studies met the inclusion criteria; these studies included 6605 patients. All studies had a Newcastle–Ottawa scale score of 7 or higher. The mean patient age ranged from 51.4 to 64.9 years. The pooled ICU, hospital, and 28/30 day mortality rates were 48% (95% CI, 43– 53%; I2 = 80.6%), 62% (95% CI, 58–67%; I2 = 0%), and 50% (95% CI, 38– 62%; I2 = 98%), respectively. Substantial between-study heterogeneity was observed. Conclusion Critically ill cancer patients with sepsis had poor survival, with a hospital mortality rate of about two-thirds. The substantial observed heterogeneity among studies could be attributed to variability in the criteria used to define sepsis as well as variability in treatment, the severity of illness, and care across settings. Our results are a call to action to identify strategies that improve outcomes for cancer patients with sepsis. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-022-07392-w.
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Affiliation(s)
- Lama Nazer
- Department of Pharmacy, King Hussein Cancer Center, Queen Rania Al-Abdallah StreetPO Box 1269, Amman, 11941, Jordan.
| | - Maria A Lopez-Olivo
- Department of Health Services Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John A Cuenca
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wedad Awad
- Department of Pharmacy, King Hussein Cancer Center, Queen Rania Al-Abdallah StreetPO Box 1269, Amman, 11941, Jordan
| | - Anne Rain Brown
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aseel Abusara
- Department of Pharmacy, King Hussein Cancer Center, Queen Rania Al-Abdallah StreetPO Box 1269, Amman, 11941, Jordan
| | | | - Rachel S Hicklen
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph L Nates
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Reyes MP, Cuenca JA, Heatter J, Martin PR, Villalobos DHD, Nates JL. Tribulations of conducting critically ill cancer patients research: Lessons from a failed septic shock trial and Murphy's law. Med Intensiva 2022; 46:582-585. [PMID: 36155682 DOI: 10.1016/j.medine.2021.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/31/2021] [Indexed: 06/16/2023]
Affiliation(s)
- M P Reyes
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J A Cuenca
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Heatter
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P R Martin
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D H D Villalobos
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J 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.
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11
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Manjappachar NK, Cuenca JA, Ramírez CM, Hernandez M, Martin P, Reyes MP, Heatter AJ, Gutierrez C, Rathi N, Sprung CL, Price KJ, Nates JL. Outcomes and Predictors of 28-Day Mortality in Patients With Hematologic Malignancies and Septic Shock Defined by Sepsis-3 Criteria. J Natl Compr Canc Netw 2022; 20:45-53. [PMID: 34991066 DOI: 10.6004/jnccn.2021.7046] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/15/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND To describe short-term outcomes and independent predictors of 28-dayx mortality in adult patients with hematologic malignancies and septic shock defined by the new Third International Consensus Definitions (Sepsis-3) criteria. METHODS We performed a retrospective cohort study of patients admitted to the medical ICU with septic shock from April 2016 to March 2019. Demographic and clinical features and short-term outcomes were collected. We used descriptive statistics to summarize patient characteristics, logistic regression to identify predictors of 28-day mortality, and Kaplan-Meier plots to assess survival. RESULTS Among the 459 hematologic patients with septic shock admitted to the ICU, 109 (23.7%) had received hematopoietic stem cell transplant. The median age was 63 years (range, 18-89 years), and 179 (39%) were women. Nonsurvivors had a higher Charlson comorbidity index (P=.007), longer length of stay before ICU admission (P=.01), and greater illness severity at diagnosis and throughout the hospital course (P<.001). The mortality rate at 28 days was 67.8% and increased with increasing sequential organ failure assessment score on admission (odds ratio [OR], 1.11; 95% CI, 1.03-1.20), respiratory failure (OR, 3.12; 95% CI, 1.49-6.51), and maximum lactate level (OR, 1.16; 95% CI, 1.10-1.22). Aminoglycosides administration (OR, 0.42; 95% CI, 0.26-0.69), serum albumin (OR, 0.51; 95% CI, 0.31-0.86), and granulocyte colony-stimulating factor (G-CSF) (OR, 0.40; 95% CI, 0.24-0.65) were associated with lower 28-day mortality. Life support limitations were present in 81.6% of patients at death. At 90 days, 19.4% of the patients were alive. CONCLUSIONS Despite efforts to enhance survival, septic shock in patients with hematologic malignancies is still associated with high mortality rates and poor 90-day survival. These results demonstrate the need for an urgent call to action with higher awareness, including the further evaluation of interventions such as earlier ICU admission, aminoglycosides administration, and G-CSF treatment.
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Affiliation(s)
| | - John A Cuenca
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Claudia M Ramírez
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Mike Hernandez
- 2Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Peyton Martin
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Maria P Reyes
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Alba J Heatter
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Cristina Gutierrez
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Nisha Rathi
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Charles L Sprung
- 3Department of Anesthesiology, Critical Care Medicine and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Kristen J Price
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Joseph L Nates
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
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12
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Gonzalez Mosquera LF, Tobar P, Cardenas Maldonado DD, Moscoso B, Podrumar AI, Cuenca JA. Outcomes and predictors of hospital mortality of patients with Philadelphia-negative myeloproliferative neoplasms and sepsis: A Nationwide Inpatient Sample Database analysis. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e19038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e19038 Background: Sepsis is associated with increased mortality in patients with hematologic malignancies, especially in those receiving cytotoxic chemotherapy. The development of new therapies also increases the risk of infections in Philadelphia negative myeloproliferative neoplasms (MPN). However, the clinical implications and costs of sepsis in patients with polycythemia vera (PV), essential thrombocytosis (ET), and primary myelofibrosis (PMF) have not been reported at a national level. Therefore, we aimed to determine the outcomes, hospitalization costs, and predictors of mortality in patients with MPN and sepsis. Methods: We retrieved adult patients with MPN from the Nationwide Inpatient Sample database from 2016-2018. We used the ICD-10 codes to identify and compare patients with and without sepsis. The main outcomes were hospital mortality and predictors of mortality. We computed the chi-squared test and the Mann-Whitney U-test. Mortality predictors are estimated using multivariate logistic regression and logistic fixed-effect methods to control for admission cohort and hospital time invariant characteristics. All analyses were performed using Stata Statistical Software version 14 (StataCorp, College Station, TX). Results: A total of 86,723 patients with MPN were identified. The majority of them were white (66.9%), female (54.3%), with a median age of 62 (IQR 47-76). The most common MPN was ET (84.3%), followed by PV (14.2%). Sepsis was diagnosed in 16,146 (18.6%) of the MPN patients. There was a significantly higher mortality in the sepsis group vs. the non-sepsis group (7.4% vs. 1.8%; p < 0.001), longer LOS (8 vs. 4 days; p < 0.001), and higher median hospitalization cost (US$74,128 vs. US$39,987; p < 0.001). In the multivariable analysis, sepsis was associated with higher mortality (OR: 4.74; CI 95%: 4.33-5.18; p < 0.001). Among the MPN, those with PMF and sepsis had a higher risk of death (OR: 2.21; CI 95%: 1.72-2.82; p < 0.001). Other significant variables associated with mortality were age > 65 (OR: 2.51; CI 95%: 2.14-2.95; p < 0.001), concomitant chronic heart failure (CHF) (OR: 1.57; CI 95%: 1.39-1.77; p < 0.001), chronic kidney disease (CKD) (OR: 1.22; CI 95%: 1.10-1.35; p < 0.001), and weight loss (OR: 2.12; CI 95%: 1.79-2.51; p < 0.001). There was no significant association with sex and race/ethinicity. Conclusions: On patients with MPN, sepsis was associated with higher mortality, hospitalization costs, and LOS. Additionally, those with increased age, CHF, CKD, weight loss, and PMF were also at increased risk of death. There should be more emphasis on assessing the risk of sepsis on MPN to prevent worse outcomes and higher costs. Further studies should focus on identifying the specific causes of sepsis in MPN and promoting early recognition.
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Affiliation(s)
| | - Pool Tobar
- Advocate Illinois Masonic Medical Center, Chicago, IL
| | | | | | | | - John A. Cuenca
- The University of Texas MD Anderson Cancer Center, Houston, TX
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13
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Tobar P, Gonzalez Mosquera LF, Cardenas Maldonado DD, Moscoso B, Podrumar AI, Cuenca JA. Clinical and financial implications of central venous catheters bloodstream infections in patients with multiple myeloma in the United States. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e20033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e20033 Background: Multiple Myeloma(MM) has an increased exposure to intravascular catheters due to the increased risk of severe infections and due to the route of treatment administration. Central Venous Catheter Bloodstream Infections(CVCBI) have significant mortality, imply a delay in treatment and increased cost as well. There is no prior report on the risk factors for poor outcome in MM patients that develop this complication. We aim to describe the predictors of mortality as well as the changes in cost that CVCBI implies. Methods: We retrieved adult patients with MM from the Nationwide Inpatient Sample database from 2016-2018. We used the ICD-10 codes to identify and compare patients who developed CVCBI with those that did not developed it. The main outcomes were hospital mortality and predictors of mortality. We computed the chi-squared test and the Mann-Whitney U-test. Mortality predictors are estimated using multivariate logistic regression and logistic fixed-effect methods to control for admission cohort and hospital time invariant characteristics. All analyses were performed using Stata Statistical Software version 14 (StataCorp, College Station, TX). Results: A total of 58,838 patients with MM were identified. The majority were white (63.5%), male (55.3%), with a median age of 70 (IQR 62-78). Most MM were not in remission (99.1%), followed by those in remission (1.3%) and relapse (0.3%). CVCBI was diagnosed in 264 (0.4%) of the MM patients. There was significantly higher mortality in the CVCBI group vs. the non-CVCBI group (8.7% vs. 5%; p < 0.01), longer LOS (10 vs. 5 days; p < 0.001), and higher median hospitalization cost (US$86,168 vs. US$43,511; p < 0.001). In the multivariable analysis, CVCBI was associated with higher mortality (OR: 1.69; CI 95%: 1.14-2.52; p < 0.001). Among patients with MM and CVCBI those that had achieved remission had a higher risk of death (OR: 2.87; CI 95%: 2.17-3.8; p < 0.001). Other variables associated with mortality were age > 65 (OR: 1.84; CI 95%: 1.59-2.15; p < 0.001), concomitant chronic heart failure (CHF) (OR: 1.46; CI 95%: 1.29-1.65; p < 0.001), chronic kidney disease (CKD) (OR: 1.43; CI 95%: 1.32-1.56; p < 0.001), and weight loss (OR: 2.31; CI 95%: 1.91-2.8; p < 0.001). When compared to medicare patients with higher mortality were more likely to be under medicaid(OR: 1.25; CI 95%: 1.02-1.55; p < 0.05) and private insurances(OR: 1.31; CI 95%: 1.15-1.49; p < 0.001). There was no significant association with sex, race/ethinicity or household income. Conclusions: In patients with Multiple Myeloma the development of Central Venous Catheter Bloodstream Infections was associated with a higher overall mortality, length of stay and cost of hospitalization. Age, CHF, CKD and weight loss were independent risk factors for poor outcome in this patient population. Further studies are required on developing strategies for the prevention of this complication.
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Affiliation(s)
- Pool Tobar
- Advocate Illinois Masonic Medical Center, Chicago, IL
| | | | | | | | | | - John A. Cuenca
- The University of Texas MD Anderson Cancer Center, Houston, TX
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14
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Laserna A, Cuenca JA, Fowler C, Duran-Crane A. Pain management during the withholding and withdrawal of life support in critically ill patients at the end of life: a response to a comment. Intensive Care Med 2021; 47:491-492. [PMID: 33635354 DOI: 10.1007/s00134-020-06344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Andres Laserna
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY, USA.
| | - John A Cuenca
- Department of Critical Care, Division of Anesthesiology, Critical Care and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cosmo Fowler
- Department of Medicine, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, USA
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15
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Laserna A, Durán-Crane A, López-Olivo MA, Cuenca JA, Fowler C, Díaz DP, Cardenas YR, Urso C, O'Connell K, Fowler C, Price KJ, Sprung CL, Nates JL. Pain management during the withholding and withdrawal of life support in critically ill patients at the end-of-life: a systematic review and meta-analysis. Intensive Care Med 2020; 46:1671-1682. [PMID: 32833041 PMCID: PMC7444163 DOI: 10.1007/s00134-020-06139-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/26/2020] [Indexed: 01/08/2023]
Abstract
Purpose To review and summarize the most frequent medications and dosages used during withholding and withdrawal of life-prolonging measures in critically ill patients in the intensive care unit. Methods We searched PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Virtual Health Library from inception through March 2019. We considered any study evaluating pharmaceutical interventions for pain management during the withholding or withdrawing of life support in adult critically ill patients at the end-of-life. Two independent investigators performed the screening and data extraction. We pooled data on utilization rate of analgesic and sedative drugs and summarized the dosing between the moment prior to withholding or withdrawal of life support and the moment before death. Results Thirteen studies met inclusion criteria. Studies were conducted in the United States (38%), Canada (31%), and the Netherlands (31%). Eleven studies were single-cohort and twelve had a Newcastle–Ottawa Scale score of less than 7. The mean age of the patients ranged from 59 to 71 years, 59–100% were mechanically ventilated, and 47–100% of the patients underwent life support withdrawal. The most commonly used opioid and sedative were morphine [utilization rate 60% (95% CI 48–71%)] and midazolam [utilization rate 28% (95% CI 23–32%)], respectively. Doses increased during the end-of-life process (pooled mean increase in the dose of morphine: 2.6 mg/h, 95% CI 1.2–4). Conclusions Pain control is centered on opioids and adjunctive benzodiazepines, with dosages exceeding those recommended by guidelines. Despite consistency among guidelines, there is significant heterogeneity among practices in end-of-life care. Electronic supplementary material The online version of this article (10.1007/s00134-020-06139-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andres Laserna
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | | | - María A López-Olivo
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John A Cuenca
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cosmo Fowler
- Department of Medicine, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, USA
| | - Diana Paola Díaz
- Department of Critical Care, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Yenny R Cardenas
- Department of Critical Care, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Catherine Urso
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keara O'Connell
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Clara Fowler
- Research Services and Assessment, Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristen J Price
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joseph L Nates
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Abstract
Although aortoesophageal fistulas are rare, they can present as life-threatening emergencies. This condition can develop secondary to an aneurysm, foreign bodies, infiltrating tumors, and radiotherapy. We report a patient with hemorrhagic shock secondary to an aortoesophageal fistula. A 69-year-old male with squamous cell carcinoma of the esophagus treated with chemoradiation and metallic stent placement was admitted to the intensive care unit (ICU) after an episode of hematemesis. The patient was hemodynamically unstable, requiring fluid resuscitation, blood transfusions, and respiratory and vasopressor support. The patient developed electric pulseless activity, and cardiopulmonary resuscitation was performed for 40 minutes. An upper endoscopy showed the esophageal tumor infiltrating into the stent, and computed tomography (CT) angiogram showed leakage of contrast from the thoracic aorta to the esophagus. The diagnosis of aortoesophageal fistula was made. The patient underwent endovascular management for the fistula. However, his critical condition did not improve, and the patient perished.
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Affiliation(s)
- Ivan Guerrero
- Department of Surgery, San Ignacio Hospital-Pontificia Universidad Javeriana, Bogota, COL
| | - John A Cuenca
- Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Yenny R Cardenas
- Department of Critical and Intensive Care, Hospital Universitario Fundación Santa Fe De Bogotá, Bogota, COL
| | - Joseph L Nates
- Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, USA
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17
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Cuenca JA, Balda J, Palacio A, Young L, Pillinger MH, Tamariz L. Febuxostat and Cardiovascular Events: A Systematic Review and Meta-Analysis. Int J Rheumatol 2019; 2019:1076189. [PMID: 30863448 PMCID: PMC6378016 DOI: 10.1155/2019/1076189] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/03/2019] [Accepted: 01/16/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Febuxostat is approved in the United States for the management of hyperuricemia in patients with gout. In November 2017 the FDA released a warning alert on a possible link between febuxostat and cardiovascular disease (CVD) reported in a single clinical trial. OBJECTIVE To conduct a systematic review and meta-analysis and assess the risk of major adverse cardiovascular events (MACE) in patients receiving febuxostat compared to a control group. METHODS We searched the MEDLINE and EMBASE database for studies published up until March 2018. We included randomized clinical trials (RCTs) that compared febuxostat to control groups including placebo and allopurinol. We calculated the pooled relative risk (RR) of MACE and cardiovascular disease (CVD) mortality with the corresponding 95% confidence intervals (CI). RESULTS Our search yielded 374 potentially relevant studies. Among the 25 RCTs included in the systematic review, 10 qualified for the meta-analysis. Among the 14,402 subjects included, the median age was 54 years (IQR 52-67) and 90% were male (IQR 82-96); 8602 received febuxostat, 5118 allopurinol, and 643 placebo. The pooled RR of MACE for febuxostat was 0.9; 95% CI 0.6-1.5 (p= 0.96) compared to the control. The RR of CV-related death for febuxostat was 1.29; 95% CI 1.01-1.66 (p=0.03). CONCLUSIONS Compared with other SU-lowering treatments, febuxostat does not increase or decrease the risk of cardiovascular disease but may increase the risk of CVD death. More RCTs measuring cardiovascular safety as a primary outcome are needed to adequately evaluate the risk of CVD with febuxostat.
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Affiliation(s)
| | - Javier Balda
- Universidad Catolica de Santiago de Guayaquil, Ecuador
| | - Ana Palacio
- Division of Population Health and Computational Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
- Veterans Affairs Medical Center, Miami, FL, USA
| | - Larry Young
- Veterans Affairs Medical Center, Miami, FL, USA
- Division of Rheumatology, University of Miami, USA
| | - Michael H. Pillinger
- Division of Rheumatology, New York University School of Medicine, USA
- Veterans Affairs Medical Center, New York, NY, USA
| | - Leonardo Tamariz
- Division of Population Health and Computational Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
- Veterans Affairs Medical Center, Miami, FL, USA
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