The incidence of cancer following hospitalisation for a burn injury in Scotland 2009-2019: A retrospective cohort study

BACKGROUND

Studies suggest increased occurrence of cancer in persons who have experienced a burn injury with hospital admission.

OBJECTIVE

To determine the incidence of cancer among those hospitalised for burn injuries in Scotland compared with a similar group without a history of burn injury hospitalisation.

METHOD

A retrospective cohort design was used to compare cancer (ICD10 C00-97, excluding C44) incidence in two groups: 6805 burn injury patients discharged from Scottish hospitals between 2009 and 2019, and 25,946 subjects from the general population who were matched to burn patients by sex, year of birth, and degree of social deprivation. Cancer incidence was identified from the Scottish cancer registry. Cox proportional hazard regression was used to model time to cancer incidence adjusting for age, sex, degree of deprivation and presence of a comorbidity. Cancer risk was presented as standardised incidence ratios (SIRs) and hazard ratios (HR).

RESULTS

We found a higher prevalence of pre-existing conditions, particularly alcohol abuse among patients with burns. Pre-existing cancers were more common in the burn cohort (3.5%) than the comparison group (1.7%) and were excluded from further analysis. Over a median follow-up of 4-5 years, a total of 236 (3.5%) burn patients and 969 (3.7%) persons in the comparison group were diagnosed with cancer. At 0-6 months the cancer SIR for burn patients was 1.88 95% CI (1.40-2.52). After excluding the first six months of follow-up, the overall incidence of cancer was marginally elevated in burn patients (SIR 1.04, 95% CI 0.90-1.19, p = 0.62) and not statistically different from the incidence in comparison subjects (adjusted HR 1.03, 95% CI 0.88-1.21, p = 0.71).

CONCLUSIONS

Patients that suffer burn injury have a higher incidence of cancer than the general population and a group matched by age, sex and degree of deprivation. A higher incidence of adverse health-related behaviours such as smoking, alcohol use and pre-existing health conditions among many patients that suffer a burn most likely explain this observed increase. Any persisting inflammatory or immune dysfunction following burn injury is unlikely to account for the increase in cancers in this study.

Long term opioid use after burn injury: a retrospective cohort study

BACKGROUND

Patients who have survive a burn injury might be at risk of opioid dependence after discharge. This study examined the use of opioids in patients who suffer burn injury and explored factors associated with persistent opioid use after hospital discharge.

METHODS

This retrospective cohort study compared adults admitted with a burn injury from 2009 to 2019 with two matched comparison cohorts from the general population and adults with a diagnosis of acute pancreatitis. Pre-admission prescription opioid use was determined, and a multivariable negative binomial regression analysis used to explore post-discharge opioid use.

RESULTS

A total of 7147 burn patients were matched with 6810 pancreatitis patients and with 28 184 individuals from the general population. Pre-admission opioid use was higher in the burn and pancreatitis cohorts (29% and 40%, respectively) compared with the general population (17%). Opioid use increased in both burn and pancreatitis cohorts after discharge (41% and 53%, respectively), although patients with pancreatitis were at even higher risk of increased opioid use in an adjusted analysis (incidence rate ratio 1.43). Female sex, lower socioeconomic status, ICU admission, pre-injury opioid use, and a history of excess alcohol use were all associated with an increase in opioid prescriptions after discharge.

CONCLUSIONS

Opioid use is high in those admitted with a burn injury or acute pancreatitis when compared with the general population, increasing further after hospital discharge. Female sex and socioeconomic deprivation are among factors that make increased opioid use more likely, although this phenomenon seems even more pronounced in those with acute pancreatitis compared with burn injuries.

Platelet transfusions in adult thrombocytopenic ICU patients: Protocol for a sub-study of the PLOT-ICU cohort

INTRODUCTION

Platelet transfusions are frequently used in intensive care unit (ICU) patients, but contemporary epidemiological data are sparse. We aim to present contemporary international data on the use of platelet transfusions in adult ICU patients with thrombocytopenia.

METHODS

This is a protocol and statistical analysis plan for a post hoc sub-study of 504 thrombocytopenic patients from the 'Thrombocytopenia and platelet transfusions in ICU patients: an international inception cohort study (PLOT-ICU)'. The primary outcome will be the number of patients receiving platelet transfusion in the ICU reported according to the type of product received (apheresis-derived versus pooled whole-blood-derived transfusions). Secondary platelet transfusion outcomes will include platelet transfusion volumes; timing of platelet transfusion; approach to platelet transfusion dosing (fixed dosing versus weight-based dosing) and platelet count increments for prophylactic transfusions. Secondary clinical outcomes will include the number of patients receiving red blood cell- and plasma transfusions during ICU stay; the number of patients who bled in the ICU, the number of patients who had a new thrombosis in the ICU, and the number of patients who died. The duration of follow-up was 90 days. Baseline characteristics and secondary clinical outcomes will be stratified according to platelet transfusion status in the ICU and severity of thrombocytopenia. Data will be presented descriptively.

CONCLUSIONS

The outlined study will provide detailed epidemiological data on the use of platelet transfusions in adult ICU patients with thrombocytopenia using data from the large international PLOT-ICU cohort study. The findings will inform the design of future randomised trials evaluating platelet transfusions in ICU patients.

Predicting time to asystole following withdrawal of life-sustaining treatment: a systematic review

The planned withdrawal of life-sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life-sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life-sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty-three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole (<60 min) included: deteriorating oxygenation; absence of corneal reflexes; absence of a cough reflex; blood pressure; use of vasopressors; and use of comfort medications. We identified a total of 20 unique predictive models using a wide range of variables and techniques. Many of these models also underwent secondary validation in further studies or were adapted to develop new models. This review identifies variables associated with time to asystole following withdrawal of life-sustaining treatment and summarises existing predictive models. Although several predictive models have been developed, their generalisability and performance varied. Further research and validation are needed to improve the accuracy and widespread adoption of predictive models for patients managed in intensive care units who may be eligible to donate organs following their diagnosis of death by circulatory criteria.

Thrombocytopenia and platelet transfusions in ICU patients: an international inception cohort study (PLOT-ICU)

PURPOSE

Thrombocytopenia (platelet count < 150 × 109/L) is common in intensive care unit (ICU) patients and is likely associated with worse outcomes. In this study we present international contemporary data on thrombocytopenia in ICU patients.

METHODS

We conducted a prospective cohort study in adult ICU patients in 52 ICUs across 10 countries. We assessed frequencies of thrombocytopenia, use of platelet transfusions and clinical outcomes including mortality. We evaluated pre-selected potential risk factors for the development of thrombocytopenia during ICU stay and associations between thrombocytopenia at ICU admission and 90-day mortality using pre-specified logistic regression analyses.

RESULTS

We analysed 1166 ICU patients; the median age was 63 years and 39.5% were female. Overall, 43.2% (95% confidence interval (CI) 40.4-46.1) had thrombocytopenia; 23.4% (20-26) had thrombocytopenia at ICU admission, and 19.8% (17.6-22.2) developed thrombocytopenia during their ICU stay. Absence of acquired immune deficiency syndrome (AIDS), non-cancer-related immune deficiency, liver failure, male sex, septic shock, and bleeding at ICU admission were associated with the development of thrombocytopenia during ICU stay. Among patients with thrombocytopenia, 22.6% received platelet transfusion(s), and 64.3% of in-ICU transfusions were prophylactic. Patients with thrombocytopenia had higher occurrences of bleeding and death, fewer days alive without the use of life-support, and fewer days alive and out of hospital. Thrombocytopenia at ICU admission was associated with 90-day mortality (adjusted odds ratio 1.7; 95% CI 1.19-2.42).

CONCLUSION

Thrombocytopenia occurred in 43% of critically ill patients and was associated with worse outcomes including increased mortality. Platelet transfusions were given to 23% of patients with thrombocytopenia and most were prophylactic.

Post-hospital recovery trajectories of family members of critically ill COVID-19 survivors: an international qualitative investigation

PURPOSE

The immediate impact of coronavirus disease 2019 (COVID-19) visiting restrictions for family members has been well-documented. However, the longer-term trajectory, including mechanisms for support, is less well-known. To address this knowledge gap, we aimed to explore the post-hospital recovery trajectory of family members of patients hospitalised with a critical care COVID-19 admission. We also sought to understand any differences across international contexts.

METHODS

We undertook semi-structured interviews with family members of patients who had survived a COVID-19 critical care admission. Family members were recruited from Spain and the United Kingdom (UK) and telephone interviews were undertaken. Interviews were analysed using a thematic content analysis.

RESULTS

Across the international sites, 19 family members were interviewed. Four themes were identified: changing relationships and carer burden; family health and trauma; social support and networks and differences in lived experience. We found differences in the social support and networks theme across international contexts, with Spanish participants more frequently discussing religion as a form of support.

CONCLUSIONS

This international qualitative investigation has demonstrated the challenges which family members of patients hospitalised with a critical care COVID-19 admission experience following hospital discharge. Specific support mechanisms which could include peer support networks, should be implemented for family members to ensure ongoing needs are met.

Extracorporeal membrane oxygenation in adults receiving haematopoietic cell transplantation: an international expert statement

Combined advances in haematopoietic cell transplantation (HCT) and intensive care management have improved the survival of patients with haematological malignancies admitted to the intensive care unit. In cases of refractory respiratory failure or refractory cardiac failure, these advances have led to a renewed interest in advanced life support therapies, such as extracorporeal membrane oxygenation (ECMO), previously considered inappropriate for these patients due to their poor prognosis. Given the scarcity of evidence-based guidelines on the use of ECMO in patients receiving HCT and the need to provide equitable and sustainable access to ECMO, the European Society of Intensive Care Medicine, the Extracorporeal Life Support Organization, and the International ECMO Network aimed to develop an expert consensus statement on the use of ECMO in adult patients receiving HCT. A steering committee with expertise in ECMO and HCT searched the literature for relevant articles on ECMO, HCT, and immune effector cell therapy, and developed opinion statements through discussions following a Quaker-based consensus approach. An international panel of experts was convened to vote on these expert opinion statements following the Research and Development/University of California, Los Angeles Appropriateness Method. The Appraisal of Guidelines for Research and Evaluation statement was followed to prepare this Position Paper. 36 statements were drafted by the steering committee, 33 of which reached strong agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and expert panel, and rephrased before an additional round of voting. At the conclusion of the process, 33 statements received strong agreement and three weak agreement. This Position Paper could help to guide intensivists and haematologists during the difficult decision-making process regarding ECMO candidacy in adult patients receiving HCT. The statements could also serve as a basis for future research focused on ECMO selection criteria and bedside management.

COVID-19 infection and maternal morbidity in critical care units in Scotland: a national cohort study

BACKGROUND

Previous research has shown that, in comparison with non-pregnant women of reproductive age, pregnant women with COVID-19 are more likely to be admitted to critical care, receive invasive ventilation, and die. At present there are limited data in relation to outcomes and healthcare utilisation following hospital discharge of pregnant and recently pregnant women admitted to critical care.

METHODS

A national cohort study of pregnant and recently pregnant women who were admitted to critical care in Scotland with confirmed or suspected COVID-19. We examined hospital outcomes as well as hospital re-admission rates.

RESULTS

Between March 2020 and March 2022, 75 pregnant or recently pregnant women with laboratory-confirmed COVID-19 were admitted to 24 Intensive Care Units across Scotland. Almost two thirds (n=49, 65%) were from the most deprived socio-economic areas. Complete 90-day acute hospital re-admission data were available for 74 (99%) patients. Nine (12%) women required an emergency non-obstetric hospital re-admission within 90 days. Less than 5% of the cohort had received any form of vaccination.

CONCLUSIONS

This national cohort study has demonstrated that pregnant or recently pregnant women admitted to critical care with COVID-19 were more likely to reside in areas of socio-economic deprivation, and fewer than 5% of the cohort had received any form of vaccination. More targeted public health campaigning across the socio-economic gradient is urgently required.

Clinician perceptions of the impact of ICU family visiting restrictions during the COVID-19 pandemic: an international investigation

PURPOSE

To guarantee the safety of the public, clinicians and patients during the COVID-19 pandemic, hospital visits were severely restricted internationally. There are limited data on the precise impact of these visiting restrictions on Intensive Care Unit clinicians. Our objectives therefore were to explore the impact of family visitation restrictions on clinicians and care delivery and describe innovation alongside areas for potential improvement.

METHODS

A qualitative approach using focus groups was employed. We recruited members of the multi-disciplinary team from Spain, France and the UK. Framework analysis was used to synthesize and interpret data.

RESULTS

In total, 28 staff from multiple international sites contributed to data across six focus groups: 12 from the UK, 9 from France and 7 from Spain. In relation to the key aims, we derived four themes: the emergence of new technologies, relationships and rapport establishment, communication challenges and end-of-life care provision. Across each theme, the overarching concepts of clinician emotional exhaustion and emotional distress emerged alongside the negative impact on job satisfaction.

CONCLUSION

The impact of COVID-19 family visitation restrictions is far reaching. Future research should examine the wider impact of family presence in the ICU.

SARS-CoV-2 Omicron is an immune escape variant with an altered cell entry pathway

Vaccines based on the spike protein of SARS-CoV-2 are a cornerstone of the public health response to COVID-19. The emergence of hypermutated, increasingly transmissible variants of concern (VOCs) threaten this strategy. Omicron (B.1.1.529), the fifth VOC to be described, harbours multiple amino acid mutations in spike, half of which lie within the receptor-binding domain. Here we demonstrate substantial evasion of neutralization by Omicron BA.1 and BA.2 variants in vitro using sera from individuals vaccinated with ChAdOx1, BNT162b2 and mRNA-1273. These data were mirrored by a substantial reduction in real-world vaccine effectiveness that was partially restored by booster vaccination. The Omicron variants BA.1 and BA.2 did not induce cell syncytia in vitro and favoured a TMPRSS2-independent endosomal entry pathway, these phenotypes mapping to distinct regions of the spike protein. Impaired cell fusion was determined by the receptor-binding domain, while endosomal entry mapped to the S2 domain. Such marked changes in antigenicity and replicative biology may underlie the rapid global spread and altered pathogenicity of the Omicron variant.

Platelet transfusions and thrombocytopenia in intensive care units: protocol for an international inception cohort study (PLOT‐ICU)

Introduction

Thrombocytopenia is frequent in intensive care unit (ICU) patients and has been associated with worse outcome. Platelet transfusions are often used in the management of ICU patients with severe thrombocytopenia. However, the reported frequencies of thrombocytopenia and platelet transfusion practices in the ICU vary considerably. Therefore, we aim to provide contemporary epidemiological data on thrombocytopenia and platelet transfusion practices in the ICU.

Methods

We will conduct an international inception cohort, including at least 1000 acutely admitted adult ICU patients. Routinely available data will be collected at baseline (ICU admission), and daily during ICU stay up to a maximum of 90 days. The primary outcome will be the number of patients with thrombocytopenia (a recorded platelet count < 150 × 10⁹/L) at baseline and/or during ICU stay. Secondary outcomes include mortality, days alive and out of hospital, days alive without life‐support, the number of patients with at least one bleeding episode, at least one thromboembolic event and at least one platelet transfusion in the ICU, the number of platelet transfusions and the indications for transfusion. The primary and secondary outcomes will be presented descriptively. In addition, we will assess risk factors for developing thrombocytopenia during ICU stay and the association between thrombocytopenia at baseline and 90‐day mortality using logistic regression analyses.

Conclusion

The outlined international PLOT‐ICU cohort study will provide contemporary epidemiological data on the burden and clinical significance of thrombocytopenia in adult ICU patients and describe the current platelet transfusion practice.

Prevalence, characteristics, and longer-term outcomes of patients with persistent critical illness attributable to COVID-19 in Scotland: a national cohort study

BACKGROUND

Patients with COVID-19 can require critical care for prolonged periods. Patients with persistent critical Illness can have complex recovery trajectories, but this has not been studied for patients with COVID-19. We examined the prevalence, risk factors, and long-term outcomes of critically ill patients with COVID-19 and persistent critical illness.

METHODS

This was a national cohort study of all adults admitted to Scottish critical care units with COVID-19 from March 1, 2020 to September 4, 20. Persistent critical illness was defined as a critical care length of stay (LOS) of ≥10 days. Outcomes included 1-yr mortality and hospital readmission after critical care discharge. Fine and Gray competing risk analysis was used to identify factors associated with persistent critical Illness with death as a competing risk.

RESULTS

A total of 2236 patients with COVID-19 were admitted to critical care; 1045 patients were identified as developing persistent critical Illness, comprising 46.7% of the cohort but using 80.6% of bed-days. Patients with persistent critical illness used more organ support, had longer post-critical care LOS, and longer total hospital LOS. Persistent critical illness was not significantly associated with long-term mortality or hospital readmission. Risk factors associated with increased hazard of persistent critical illness included age, illness severity, organ support on admission, and fewer comorbidities.

CONCLUSIONS

Almost half of all patients with COVID-19 admitted to critical care developed persistent critical illness, with high resource use in critical care and beyond. However, persistent critical illness was not associated with significantly worse long-term outcomes compared with patients who were critically ill for shorter periods.

Long-term outcomes following severe COVID-19 infection: a propensity matched cohort study

BACKGROUND

There are limited data describing the long-term outcomes of severe COVID-19. We aimed to evaluate the long-term psychosocial and physical consequences of severe COVID-19 for patients.

METHODS

We conducted a multicentre observational cohort study; between 3 and 7 months posthospital discharge, patients who had been admitted to critical care due to severe COVID-19 were invited to an established recovery service. Standardised questionnaires concerning emotional, physical and social recovery, including information on employment, were completed by patients. Using propensity score matching, we explored outcomes between patients admitted to critical care with and without COVID-19, using data from the same recovery programme.

RESULTS

Between July 2020 and December 2020, 93 patients who had been admitted to critical with COVID-19 participated. Emotional dysfunction was common: 46.2% of patients had symptoms of anxiety and 34.4% symptoms of depression. At follow-up 53.7% of previously employed patients had returned to employment; there was a significant difference in return to employment across the socio-economic gradient, with lower numbers of patients from the most deprived areas returning to employment (p=0.03). 91 (97.8%) COVID-19 patients were matched with 91 non-COVID-19 patients. There were no significant differences in any measured outcomes between the two cohorts.

INTERPRETATION

Emotional and social problems are common in survivors of severe COVID-19 infection. Coordinated rehabilitation is required to ensure patients make an optimal recovery.

Neuropathic agents in the management of pruritus in burn injuries: a systematic review and meta-analysis

Objectives

Pruritus is a common and often distressing complication after a burn injury. The purpose of this review is to explore the efficacy of drugs classically used to treat neuropathic pain in the management of pruritus after burn injury.

Methods

A systematic literature search of medical databases was conducted to find studies investigating drugs listed in the National Institute for Health and Care Excellence (NICE) guideline (CG173, "neuropathic pain in adults") for the management of pruritus after burn injury in patients of any age. Controlled studies were stratified by the drug class studied and their risk of bias before conducting meta-analysis. A narrative review of case series or observational studies was presented. Severity of pruritus at any time point, with all quantitative and qualitative measures, was included.

Results

Fifteen studies were included in the final analysis, 10 investigated the use of gabapentinoids, 4 studied doxepin, and 1 local anesthetic agents. Meta-analysis of three randomized controlled trials (RCTs) demonstrated that the use of gabapentinoids was associated with an improvement in mean VAS (Visual Analog Scale) 0-10 scores of 2.96 (95% confidence interval (95% CI) 1.20 to 4.73, p<0.001) when compared with placebo or antihistamine. A meta-analysis of four RCTs investigating topical doxepin showed an improvement in mean VAS scores of 1.82 (95% CI 0.55 to 3.09, p<0.001). However, when excluding two studies found to be at high risk of bias, no such improvement was found (-0.32, 95% CI -1.64 to -0.99, p=0.83).

Conclusion

This study suggests that gabapentinoids are beneficial in the management of burn-related pruritus. There is a lack of evidence to suggest that doxepin is an effective treatment. Topical local anesthetic agents may be safe and beneficial, but studies are scarce.

Level of evidence

Systematic review, level II.

Postoperative C-reactive protein concentrations to predict infective complications following gastrectomy for cancer

BACKGROUND AND OBJECTIVES

Gastrectomy for gastric cancer is associated with significant infective postoperative complications. C-reactive protein (CRP) is a useful biomarker in the early detection of infective complications following major abdominal surgery. This single-centre retrospective study aimed to determine the relationship between postoperative CRP levels and development of postoperative infective complications after gastrectomy.

METHODS

Daily postoperative CRP levels were analyzed to determine a CRP threshold associated with infective complications. ROC curve analysis was used to determine which postoperative day (POD) gave the optimal cutoff. Multivariate analysis was performed to determine significant factors associated with complications.

RESULTS

One hundred and forty-four patients were included. A total of 61 patients (42%) had at least one infective complication. A CRP level of 220 mg/L was associated with the highest AUC (0.765) with a sensitivity of 70% and specificity of 76% (positive predictive value, 67%; negative predictive value, 78%). More patients with a CRP > 220 mg/L on POD 3 developed infective complications (67% vs. 21%, p < 0.001).

CONCLUSIONS

A CRP of more than 220 mg/L on POD 3 may be useful to alert clinicians to the increased risk of a postoperative infective complication or enable earlier safe discharge from critical care for those with a lower value.

Prophylactic platelet transfusions in hospitalised patients with thrombocytopenia-Protocol for a systematic review with meta-analysis

BACKGROUND

Prophylactic platelet transfusions are frequently used to prevent bleeding in hospitalised patients with thrombocytopenia. Recommendations regarding the use of prophylactic platelet transfusions in non-haematological patients are based on extrapolations, observational studies, and expert opinions, and transfusion with platelets has been associated with adverse effects. We aim to assess the overall benefits and harms of prophylactic platelet transfusions in hospitalised patients with thrombocytopenia.

METHODS/DESIGN

We will conduct a systematic review with meta-analyses and trial sequential analyses in compliance with the recommendations by the Cochrane Collaboration and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We will prepare the manuscript in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. We will include randomised clinical trials assessing prophylactic platelet transfusion versus no prophylaxis or placebo in hospitalised patients with thrombocytopenia. The primary outcome is mortality at longest follow-up. Secondary outcomes include episodes of clinically important bleeding, nosocomial infections, transfusion-related adverse events, thromboembolic events, length of hospital stay, quality of life, and days alive without the use of life support. We will conduct prespecified subgroup analyses and sensitivity analyses and assess the risk of random errors by trial sequential analyses.

DISCUSSION

The proposed systematic review will provide an overview of the certainty of evidence for the benefits and harms of prophylactic platelet transfusion in hospitalised patients with thrombocytopenia.

Association Between Anesthetic Dose and Technique and Oncologic Outcomes After Surgical Resection of Non-Small Cell Lung Cancer

OBJECTIVES

Because of the biologic effects of volatile anesthetics on the immune system and cancer cells, it has been hypothesized that their use during non-small cell lung cancer (NSCLC) surgery may negatively affect cancer outcomes compared with total intravenous anesthesia (TIVA) with propofol. The present study evaluated the relationship between anesthetic technique and dose and oncologic outcome in NSCLC surgery.

DESIGN

Retrospective cohort study.

SETTING

Surgical records collated from a single, tertiary care hospital and combined with the Scottish Cancer Registry and continuously recorded electronic anesthetic data.

PARTICIPANTS

Patients undergoing elective lung resection for NSCLC between January 2010 and December 2014.

INTERVENTIONS

The cohort was divided into patients receiving TIVA only and patients exposed to volatile anesthetics.

MEASUREMENTS AND MAIN RESULTS

Final analysis included 746 patients (342 received TIVA and 404 volatile anesthetic). Kaplan-Meier survival curves with log-rank testing were drawn for cancer-specific and overall survival. No significant differences were demonstrated for either cancer-specific (p = 0.802) or overall survival (p = 0.736). Factors influencing survival were analyzed using Cox proportional hazards modeling. Anesthetic type was not a significant predictor for cancer-specific or overall survival in univariate or multivariate Cox analysis. Volatile anesthetic exposure was quantified using area under the end-tidal expired anesthetic agent versus time curves. This was not significantly associated with cancer-specific survival on univariate (p = 0.357) or multivariate (p = 0.673) modeling.

CONCLUSIONS

No significant relationship was demonstrated between anesthetic technique and NSCLC survival. Whether a causal relationship exists between anesthetic technique during NSCLC surgery and oncologic outcome warrants definitive investigation in a prospective, randomized trial.

Influence of socioeconomic deprivation on interventions and outcomes for patients admitted with COVID-19 to critical care units in Scotland: A national cohort study

Background

Coronavirus disease 2019 (COVID-19) can lead to significant respiratory failure with between 14% and 18% of hospitalised patients requiring critical care admission. This study describes the impact of socioeconomic deprivation on 30-day survival following critical care admission for COVID-19, and the impact of the COVID-19 pandemic on critical care capacity in Scotland.

Methods

This cohort study used linked national hospital records including ICU, virology testing and national death records to identify and describe patients with COVID-19 admitted to critical care units in Scotland. Multivariable logistic regression was used to assess the impact of deprivation on 30-day mortality. Critical care capacity was described by reporting the percentage of baseline ICU bed utilisation required.

Findings

There were 735 patients with COVID-19 admitted to critical care units across Scotland from 1/3/2020 to 20/6/2020. There was a higher proportion of patients from more deprived areas, with 183 admissions (24.9%) from the most deprived quintile and 100 (13.6%) from the least deprived quintile. Overall, 30-day mortality was 34.8%. After adjusting for age, sex and ethnicity, mortality was significantly higher in patients from the most deprived quintile (OR 1.97, 95%CI 1.13, 3.41, p=0.016). ICUs serving populations with higher levels of deprivation spent a greater amount of time over their baseline ICU bed capacity.

Interpretation

Patients with COVID-19 living in areas with greatest socioeconomic deprivation had a higher frequency of critical care admission and a higher adjusted 30-day mortality. ICUs in health boards with higher levels of socioeconomic deprivation had both higher peak occupancy and longer duration of occupancy over normal maximum capacity.

Funding

None.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Comorbidity and survival after admission to the intensive care unit: A population-based study of 41,230 patients

Purpose

To describe the relationship between comorbidities and survival following admission to the intensive care unit.

Methods

Retrospective observational study using several linked routinely collected databases from 16 general intensive care units between 2002 and 2011. Comorbidities identified from hospitalisation in the five years prior to intensive care unit admission. Odds ratios for survival in intensive care unit, hospital and at 30 days, 180 days and 12 months after intensive care unit admission derived from multiple logistic regression models.

Results

There were 41,230 admissions to intensive care units between 2002 and 2011. Forty-one percent had at least one comorbidity - 24% had one, 17% had more than one. Patients with comorbidities were significantly older, had higher Acute Physiology and Chronic Health Evaluation II scores and were more likely to have received elective rather than emergency surgery compared with those without comorbidities. After excluding elective hospitalisations, intensive care unit and hospital mortality for the cohort were 24% and 29%, respectively. Asthma (odds ratio 0.79, 95% confidence interval 0.63-0.99) and solid tumours (odds ratio 0.74, 0.67-0.83) were associated with lower odds of intensive care unit mortality than no comorbidity. Intensive care unit mortality was raised for liver disease (odds ratio 2.98, 2.43-3.65), cirrhosis (odds ratio 2.61, 1.9-3.61), haematological malignancy (odds ratio 2.29, 1.85-2.83), chronic ischaemic heart disease (odds ratio 1.53, 1.19-1.98), heart failure (odds ratio 1.79, 1.35-2.39) and rheumatological disease (odds ratio 1.53, 1.18-1.98).

Conclusions

Comorbidities affect two-fifths of intensive care unit admission and have highly variable effects on subsequent outcomes. Information on the differential effects of comorbidities will be helpful in making better decisions about intensive care unit support and understanding outcomes beyond surviving intensive care unit.

Factors associated with intensive care admission in patients with lung cancer: a population-based observational study of 26, 731 patients

BACKGROUND

Lung cancer is the most common cause of cancer related death worldwide and survival is poor. Patients with lung cancer may develop a critical illness, but it is unclear what features are associated with an Intensive Care Unit (ICU) admission.

METHODS

This retrospective, observational, population-based study of linked cancer registration, ICU, hospital discharge and mortality data described the factors associated with ICU admission in patients with lung cancer. The cohort comprised all incident cases of adult lung cancer diagnosed between 1st January 2000 and 31st December 2009 in the West of Scotland, UK, who were subsequently admitted to an ICU within 2 years of cancer diagnosis. Multiple logistic regression was used to determine factors associated with admission.

RESULTS

26,731 incident cases of lung cancer were diagnosed with 398 (1.5%) patients admitted to an ICU. Patients were most commonly admitted with respiratory conditions and there was a high rate of invasive mechanical ventilation. ICU, in-hospital and six-month survival were 58.5, 42.0 and 31.2%, respectively. Surgical treatment of lung cancer increased the odds of ICU admission (OR 7.23 (5.14-10.2)). Odds of admission to ICU were reduced with older age (75-80 years OR 0.69 (0.49-0.94), > 80 years OR 0.21 (0.12-0.37)), female gender (OR 0.73 (0.59-0.90)) and radiotherapy (OR 0.54 (0.39-0.73)) or chemotherapy treatment (OR 0.52 (0.38-0.70)).

CONCLUSION

1.5% of patients diagnosed with lung cancer are admitted to an ICU but both short term and long term survival was poor. Factors associated with ICU admission included age < 75 years, male gender and surgical treatment of cancer.

Diagnosis of severe respiratory infections in immunocompromised patients

An increasing number of critically ill patients are immunocompromised. Acute hypoxemic respiratory failure (ARF), chiefly due to pulmonary infection, is the leading reason for ICU admission. Identifying the cause of ARF increases the chances of survival, but may be extremely challenging, as the underlying disease, treatments, and infection combine to create complex clinical pictures. In addition, there may be more than one infectious agent, and the pulmonary manifestations may be related to both infectious and non-infectious insults. Clinically or microbiologically documented bacterial pneumonia accounts for one-third of cases of ARF in immunocompromised patients. Early antibiotic therapy is recommended but decreases the chances of identifying the causative organism(s) to about 50%. Viruses are the second most common cause of severe respiratory infections. Positive tests for a virus in respiratory samples do not necessarily indicate a role for the virus in the current acute illness. Invasive fungal infections (Aspergillus, Mucorales, and Pneumocystis jirovecii) account for about 15% of severe respiratory infections, whereas parasites rarely cause severe acute infections in immunocompromised patients. This review focuses on the diagnosis of severe respiratory infections in immunocompromised patients. Special attention is given to newly validated diagnostic tests designed to be used on non-invasive samples or bronchoalveolar lavage fluid and capable of increasing the likelihood of an early etiological diagnosis.

Correction to: Expert statement on the ICU management of patients with thrombotic thrombocytopenic purpura

The original version of this article unfortunately contained a mistake. The penultimate row of Table 4 shows INR > 1.5 which is incorrect. The correct figure is INR < 1.5. The authors apologize for the mistake. The correct table is given below.

Expert statement on the ICU management of patients with thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is fatal in 90% of patients if left untreated and must be diagnosed early to optimize patient outcomes. However, the very low incidence of TTP is an obstacle to the development of evidence-based clinical practice recommendations, and the very wide variability in survival rates across centers may be partly ascribable to differences in management strategies due to insufficient guidance. We therefore developed an expert statement to provide trustworthy guidance about the management of critically ill patients with TTP. As strong evidence was difficult to find in the literature, consensus building among experts could not be reported for most of the items. This expert statement is timely given the recent advances in the treatment of TTP, such as the use of rituximab and of the recently licensed drug caplacizumab, whose benefits will be maximized if the other components of the management strategy follow a standardized pattern. Finally, unanswered questions are identified as topics of future research on TTP.

Characteristics and Outcomes of Surgical Patients With Solid Cancers Admitted to the Intensive Care Unit

Importance

Within the surgical population admitted to intensive care units (ICUs), cancer is a common condition. However, clinicians can be reluctant to admit patients with cancer to ICUs owing to concerns about survival.

Objective

To compare the clinical characteristics and outcomes of surgical patients with and without cancer who are admitted to ICUs.

Design, Setting, and Participants

An observational retrospective cohort study using ICU audit records linked to hospitalization discharge summaries, cancer registrations, and death records of all 16 general adult ICUs in the West of Scotland was conducted. All 25 017 surgical ICU admissions between January 1, 2000, and December 31, 2011, were included, and data analysis was conducted during that time.

Exposures

Patients were dichotomized based on a diagnosis of a solid malignant tumor as determined by its documentation in the Scottish Cancer Registry within the 2 years prior to ICU admission.

Main Outcomes and Measures

Intensive care unit patients with cancer were compared with ICU patients without cancer in terms of patient characteristics (age, sex, severity of illness, reason for admission, and organ support) and survival (ICU, hospital, 6 months, and 4 years).

Results

Within the 25 017 surgical ICU patients, 13 684 (54.7%) were male, the median (interquartile range [IQR]) age was 64 (50-74), and 5462 (21.8%) had an underlying solid tumor diagnosis. Patients with cancer were older (median [IQR] age, 68 [60-76] vs 62 [45-74] years; P < .001) with a higher proportion of elective hospitalizations (60.5% vs 19.8%; P < .001), similar Acute Physiology and Chronic Health Evaluation II scores (median for both, 17), but lower use of multiorgan support (57.9% vs 66.7%; P < .001). Intensive care unit and hospital mortality were lower for the cancer group, at 12.2% (95% CI, 11.3%-13.1%) vs 16.8% (95% CI, 16.3%-17.4%) (P < .001) and 22.9% (95% CI, 21.8%-24.1%) vs 28.1% (27.4%-28.7%) (P < .001). Patients with cancer had an adjusted odds ratio for hospital mortality of 1.09 (95% CI, 1.00-1.19). By 6 months, mortality in the cancer group was higher than that in the noncancer group at 31.3% compared with 28.2% (P < .001). Four years after ICU admission, mortality for those with and without cancer was 60.9% vs 39.7% (P < .001) respectively.

Conclusions and Relevance

Cancer is a common diagnosis among surgical ICU patients and this study suggests that initial outcomes compare favorably with those of ICU patients with other conditions. Consideration that a diagnosis of cancer should not preclude admission to the ICU in patients with surgical disease is suggested.

Critical care provision after colorectal cancer surgery

BACKGROUND

Colorectal cancer (CRC) is the 2nd largest cause of cancer related mortality in the UK with 40 000 new patients being diagnosed each year. Complications of CRC surgery can occur in the perioperative period that leads to the requirement of organ support. The aim of this study was to identify pre-operative risk factors that increased the likelihood of this occurring.

METHODS

This is a retrospective observational study of all 6441 patients who underwent colorectal cancer surgery within the West of Scotland Region between 2005 and 2011. Logistic regression was employed to determine factors associated with receiving postoperative organ support.

RESULTS

A total of 610 (9 %) patients received organ support. Multivariate analysis identified age ≥65, male gender, emergency surgery, social deprivation, heart failure and type II diabetes as being independently associated with organ support postoperatively. After adjusting for demographic and clinical factors, patients with metastatic disease appeared less likely to receive organ support (p = 0.012).

CONCLUSIONS

Nearly one in ten patients undergoing CRC surgery receive organ support in the post operative period. We identified several risk factors which increase the likelihood of receiving organ support post operatively. This is relevant when consenting patients about the risks of CRC surgery.

Risk of Critical Illness Among Patients With Solid Cancers: A Population-Based Observational Study

IMPORTANCE

Critical illness may be a potential determinant of cancer outcomes and geographic variations, but its role has not been described before.

OBJECTIVE

To determine the incidence of admission to intensive care units (ICUs) within 2 years following cancer diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective observational study using cancer registry data in 4 datasets from 2000 to 2009 with linked ICU admission data from 2000 to 2011, in the West of Scotland region of the United Kingdom (population, 2.4 million; all 16 ICUs within the region). All 118,541 patients (≥16 years) diagnosed as having solid (nonhematological) cancers. Their median age was 69 years, and 52.0% were women.

MAIN OUTCOMES AND MEASURES

Demographic and clinical variables associated with admission to an ICU and death in an ICU.

RESULTS

A total of 118,541 patients met the study criteria. Overall, 6116 patients (5.2% [95% CI, 5.0%-5.3%]) developed a critical illness and were admitted to an ICU within 2 years. Risk of critical illness was highest at ages 60 to 69 years and higher in men. The cumulative incidence of critical illness was greatest for small intestinal (17.2% [95% CI, 13.3%-21.8%]) and colorectal cancers (16.5% [95% CI, 15.9%-17.1%]). The risk following breast cancer was low (0.8% [95% CI, 0.7%-1.0%]). The percentage who died in ICUs was 14.1% (95% CI, 13.3%-15.0%), and during the hospital stay, 24.6% (95% CI, 23.5%-25.7%). Mortality was greatest among emergency medical admissions and lowest among elective surgical patients. The risk of critical illness did not vary by socioeconomic circumstances, but mortality was higher among patients from deprived areas.

CONCLUSIONS AND RELEVANCE

In this study, about 1 in 20 patients experienced a critical illness resulting in ICU admission within 2 years of cancer diagnosis. The associated high mortality rate may make a significant contribution to overall cancer outcomes.

Survival in solid cancer patients following intensive care unit admission

PURPOSE

One in seven patients admitted to intensive care units (ICU) has a cancer diagnosis but evidence on their expected outcomes after admission has not been synthesised.

METHODS

Systematic literature review of solid cancer adult patients admitted to ICU from 2000 onwards using EMBASE and MEDLINE electronic databases.

RESULTS

There were 48 papers identified that reported survival in ICU patients with solid cancers. ICU mortality was reported in 35 studies comprising a total sample of 25,339 patients and ranging from 4.5 to 85 %. The average mortality of the distribution of reported mortality rates within ICU was 31.2 % (95 % CI 24.0-39.0 %). Hospital mortality was reported in 31 studies across a total sample of 74,061 patients. The average hospital mortality was 38.2 % (33.8-42.7 %) and ranged from 4.6 to 76.8 %. Poorer physiological score, invasive mechanical ventilation and poor functional status were associated with higher mortality.

CONCLUSIONS

Several factors have been associated with poor survival in ICU cancer patients; however, primary research is still needed to describe outcomes in cancer patients with sufficient case mix and treatment details to be of prognostic value to clinicians.