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Munshi L, Dumas G, Rochwerg B, Shoukat F, Detsky M, Fergusson DA, Ferreyro BL, Heffernan P, Herridge M, Magder S, Minden M, Patel R, Qureshi S, Schimmer A, Thyagu S, Wang HT, Mehta S. Long-term survival and functional outcomes of critically ill patients with hematologic malignancies: a Canadian multicenter prospective study. Intensive Care Med 2024; 50:561-572. [PMID: 38466402 DOI: 10.1007/s00134-024-07349-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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/05/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE Patients with hematologic malignancy (HM) commonly develop critical illness. Their long-term survival and functional outcomes have not been well described. METHODS We conducted a prospective, observational study of HM patients admitted to seven Canadian intensive care units (ICUs) (2018-2020). We followed survivors at 7 days, 6 months and 12 months following ICU discharge. The primary outcome was 12-month survival. We evaluated functional outcomes at 6 and 12 months using the functional independent measure (FIM) and short form (SF)-36 as well as variables associated with 12-month survival. RESULTS We enrolled 414 patients including 35% women. The median age was 61 (interquartile range, IQR: 52-69), median Sequential Organ Failure Assessment (SOFA) score was 9 (IQR: 6-12), and 22% had moderate-severe frailty (clinical frailty scale [CFS] ≥ 6). 51% had acute leukemia, 38% lymphoma/multiple myeloma, and 40% had received a hematopoietic stem cell transplant (HCT). The most common reasons for ICU admission were acute respiratory failure (50%) and sepsis (40%). Overall, 203 (49%) were alive 7 days post-ICU discharge (ICU survivors). Twelve-month survival of the entire cohort was 21% (43% across ICU survivors). The proportion of survivors with moderate-severe frailty was 42% (at 7 days), 14% (6 months), and 8% (12 months). Median FIM at 7 days was 80 (IQR: 50-109). Physical function, pain, social function, mental health, and emotional well-being were below age- and sex-matched population scores at 6 and 12 months. Frailty, allogeneic HCT, kidney injury, and cardiac complications during ICU were associated with lower 12- month survival. CONCLUSIONS 49% of all HM patients were alive at 7 days post-ICU discharge, and 21% at 12 months. Survival varied based upon hematologic diagnosis and frailty status. Survivors had important functional disability and impairment in emotional, physical, and general well-being.
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Affiliation(s)
- Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Guillaume Dumas
- Service de Médecine Intensive-Réanimation, CHU Grenoble-Alpes, Université Grenoble-Alpes, INSERM U1042-HP2, Grenoble, France
| | - Bram Rochwerg
- Department of Medicine, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Farah Shoukat
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Michael Detsky
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Paul Heffernan
- Department of Medicine at Queen's University, Kingston General Health Research Institute, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Margaret Herridge
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Sheldon Magder
- Department of Medicine, Royal Victoria Hospital, The Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
- Critical Care Department, Royal Victoria Hospital, The Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Mark Minden
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Rakesh Patel
- Department of Medicine, Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Department of Critical Care Medicine, Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Salman Qureshi
- Department of Medicine, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Aaron Schimmer
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Santhosh Thyagu
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Han Ting Wang
- Division of Critical Care MedicineDepartment of Medicine at Hopital Maisonneuve-Rosemont, University of Montreal, Montreal, QC, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
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Sehgal P, Piquette D, Detsky M, Maham N, Jogova M, Hall D, Wozniak H, Herridge M. Critical Care Education and the ICU Care Continuum. Am J Respir Crit Care Med 2024; 209:360-361. [PMID: 37824734 PMCID: PMC10878382 DOI: 10.1164/rccm.202310-1734vp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/12/2023] [Indexed: 10/14/2023] Open
Affiliation(s)
- Prateek Sehgal
- Department of Critical Care Medicine, William Osler Health System, Brampton, Ontario, Canada
| | - Dominique Piquette
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Michael Detsky
- Department of Critical Care Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Nava Maham
- Department of Critical Care Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada; and
| | - Maria Jogova
- Department of Critical Care Medicine, University Health Network, Toronto, Ontario, Canada
| | - David Hall
- Department of Critical Care Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada; and
| | - Hannah Wozniak
- Department of Critical Care Medicine, University Health Network, Toronto, Ontario, Canada
| | - Margaret Herridge
- Department of Critical Care Medicine, University Health Network, Toronto, Ontario, Canada
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Barua R, Ferreyro B, Detsky M, Thyagu S, Law A, Munshi L. Clinical diagnostic accuracy of respiratory failure in critically ill hematopoietic stem cell transplant patients. Int J Hematol 2022; 116:929-936. [PMID: 35962275 DOI: 10.1007/s12185-022-03429-2] [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: 03/11/2022] [Revised: 07/05/2022] [Accepted: 07/21/2022] [Indexed: 11/25/2022]
Abstract
RATIONALE Acute respiratory failure (ARF) is a frequent complication following hematopoietic cell transplantation (HCT). We aimed to characterize the etiologies of ARF in patients who died in the intensive care unit following HCT based on autopsy findings. We then evaluated agreement between the clinical and pathologic diagnosis. METHODS We performed a chart review of all HCT patients who died and underwent autopsy in our ICU between 2006-2016. We evaluated the presumed clinical diagnosis and confidence in the diagnosis by chart review, the pathologic diagnosis on autopsy, and whether the clinical-pathologic diagnoses were concordant. When there was discordance, we evaluated whether knowledge of the pathology could have changed management. RESULTS Thirteen patients underwent autopsy after dying. Infection was the presumed cause in 11/13 cases. The clinical and pathologic diagnoses were concordant in 6/13(46%). In the seven discordant cases (all clinically diagnosed as infection), autopsy revealed two non-infectious inflammatory causes, one post-transplant lymphoproliferative disorder, and three non-bacterial infectious etiology. Pathologic findings may have changed management in 7/13(54%) cases. CONCLUSIONS In a subset of HCT-recipients who died from respiratory failure, discordance was frequent between clinical and pathologic diagnoses. The risks and benefits of obtaining tissue to improve our diagnostic accuracy requires further evaluation.
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Affiliation(s)
- Reeta Barua
- Division of Medical Oncology, University of Toronto, Toronto, Canada
| | - Bruno Ferreyro
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Mount Sinai Hospital, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Michael Detsky
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Mount Sinai Hospital, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada
| | - Santhosh Thyagu
- Division of Medical Oncology/Malignant Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Arjun Law
- Division of Medical Oncology/Malignant Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Mount Sinai Hospital, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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Alibhai N, Detsky M, Wunsch H, Teja B. Severe Hyponatremia and Seizure From Peripheral Infusion of Norepinephrine Diluted in Dextrose 5% in Water: A Case Report. A A Pract 2021; 15:e01479. [PMID: 33988526 DOI: 10.1213/xaa.0000000000001479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recent studies have demonstrated that vasopressors can be delivered safely through peripheral intravenous lines. While norepinephrine is usually delivered at a concentration of 16 to 32 μg/mL, out of concern for extravasation and interstitial necrosis, some patients receive more dilute norepinephrine solutions through peripheral intravenous catheters. We describe a case of severe hyponatremia and seizure resulting from administration of norepinephrine concentrated at 4 μg/mL in dextrose 5% in water. After the incident, the institutional policy changed to recommend normal saline as the default diluent for peripheral norepinephrine, with a more concentrated option available. The incident also informed similar guidelines at other hospitals.
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Affiliation(s)
- Nafeesa Alibhai
- From the Department of Integrated Sciences: Genetics, Physiology, Neuroscience, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Detsky
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada.,Division of Critical Care Medicine, Department of Medicine and Interdepartmental University of Toronto, Toronto, Ontario, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bijan Teja
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Departments of Anesthesiology and Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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Burry L, Scales D, Williamson D, Foster J, Mehta S, Guenette M, Fan E, Detsky M, Azad A, Bernard F, Rose L. Feasibility of melatonin for prevention of delirium in critically ill patients: a protocol for a multicentre, randomised, placebo-controlled study. BMJ Open 2017; 7:e015420. [PMID: 28363933 PMCID: PMC5387939 DOI: 10.1136/bmjopen-2016-015420] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Delirium is highly prevalent in the intensive care unit (ICU) and is associated with adverse clinical outcomes. At this time, there is no drug that effectively prevents delirium in critically ill patients. Alterations in melatonin secretion and metabolism may contribute to the development of delirium. Administration of exogenous melatonin has been shown to prevent delirium in non-critically ill surgical and medical patients. This trial will demonstrate the feasibility of a planned multicentre, randomised controlled trial to test the hypothesis that melatonin can prevent delirium in critically ill patients compared with placebo. METHODS AND ANALYSIS This feasibility trial is a randomised, 3-arm, placebo-controlled study of melatonin (2 vs 0.5 mg vs placebo, administered for a maximum of 14 days) for the prevention of delirium in critically ill patients. A total of 69 patients aged 18 years and older with an expected ICU length of stay >48 hours will be recruited from 3 Canadian ICUs. The primary outcome is protocol adherence (ie, overall proportion of study drug doses administered in the prescribed administration window). Secondary outcomes include pharmacokinetic parameters, incidence, time to onset, duration of delirium, number of delirium-free days, adverse events, self-reported sleep quality, rest-activity cycles measured by wrist actigraphy, duration of mechanical ventilation, ICU length of stay and mortality. Data will be analysed using an intention-to-treat approach. ETHICS AND DISSEMINATION The study has been approved by Health Canada and the research ethics board of each study site. Trial results will be presented at international conferences and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02615340: Pre-results.
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Affiliation(s)
- Lisa Burry
- Department of Pharmacy, Mount Sinai Hospital, and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Damon Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - David Williamson
- Department of Pharmacy, Hôpital du Sacré-Coeur de Montréal, and Faculté de pharmacie, Université de Montréal, Montréal, Canada
| | - Jennifer Foster
- Department of Critical Care, IWK Health Centre, and Dalhousie University, Halifax, Canada
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Melanie Guenette
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Michael Detsky
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto and Department of Medicine, Mount Sinai Hospital, Toronto, Canada
| | - Azar Azad
- Mount Sinai Services, Mount Sinai Hospital, and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Francis Bernard
- Département de Médecine, Hôpital du Sacré-Cœur de Montréal, and Département de Médecine, Université de Montréal, Montreal, Canada
- Département de Médecine, Université de Montréal, Montreal, Quebec, Canada
| | - Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, and Lawrence S. Bloomberg Faculty of Nursing and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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Marhong JD, Munshi L, Detsky M, Telesnicki T, Fan E. Mechanical ventilation during extracorporeal life support (ECLS): a systematic review. Intensive Care Med 2015; 41:994-1003. [PMID: 25752302 DOI: 10.1007/s00134-015-3716-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/24/2015] [Indexed: 01/18/2023]
Abstract
PURPOSE In patients with acute respiratory distress syndrome (ARDS), extracorporeal life support (ECLS) has been utilized to support gas exchange and mitigate ventilator-induced lung injury (VILI). The optimal ventilation settings while on ECLS are unknown. The purpose of this systematic review is to describe the ventilation practices in patients with ARDS who require ECLS. METHODS We electronically searched MEDLINE, EMBASE, CENTRAL, AMED, and HAPI (inception to January 2015). Studies included were randomized controlled trials, observational studies, or case series (≥4 patients) of ARDS patients undergoing ECLS. Our review focused on studies describing ventilation practices employed during ECLS for ARDS. RESULTS Forty-nine studies (2,042 patients) met our inclusion criteria. Prior to initiation of ECLS, at least one parameter consistent with injurious ventilation [tidal volume >8 mL/kg predicted body weight (PBW), peak pressure >35 cmH2O (or plateau pressure >30 cmH2O), or FiO2 ≥0.8] was noted in 90% of studies. After initiation of ECLS, studies reported median [interquartile range (IQR)] reductions in: tidal volume [2.4 mL/kg PBW (2.2-2.9)], plateau pressure [4.3 cmH2O (3.5-5.8)], positive end-expiratory pressure (PEEP) [0.20 cmH2O (0-3.0)], and FiO2 [0.40 (0.30-0.60)]. Median (IQR) overall mortality was 41 % (31-51%). CONCLUSIONS Reduction in the intensity of mechanical ventilation in patients with ARDS supported by ECLS is common, suggesting that clinicians may be focused on reducing VILI after ECLS initiation. Future investigations should focus on establishing the optimal ventilatory strategy for patients with ARDS who require ECLS.
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Affiliation(s)
- Jonathan D Marhong
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada,
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