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Lafarge A, Chean D, Whiting L, Clere-Jehl R. Management of hematological patients requiring emergency chemotherapy in the intensive care unit. Intensive Care Med 2024:10.1007/s00134-024-07454-z. [PMID: 38748265 DOI: 10.1007/s00134-024-07454-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
Hematological malignancies may require rapid-onset treatment because of their short doubling time, notably observed in acute leukemias and specific high-grade lymphomas. Furthermore, in targeted onco-hematological scenarios, chemotherapy is deemed necessary as an emergency measure when facing short-term, life-threatening complications associated with highly chemosensitive hematological malignancies. The risks inherent in the disease itself, or in the initiation of treatment, may then require admission to the intensive care unit (ICU) to optimize monitoring and initial management protocols. Hyperleukocytosis and leukostasis in acute leukemias, tumor lysis syndrome, and disseminated intravascular coagulation are the most frequent onco-hematological complications requiring the implementation of emergency chemotherapy in the ICU. Chemotherapy must also be started urgently in secondary hemophagocytic lymphohistiocytosis. Tumor-induced microangiopathic hemolytic anemia and plasma hyperviscosity due to malignant monoclonal gammopathy represent infrequent yet substantial indications for emergency chemotherapy. In all cases, the administration of emergency chemotherapy in the ICU requires close collaboration between intensivists and hematology specialists. In this review, we provide valuable insights that aid in the identification and treatment of patients requiring emergency chemotherapy in the ICU, offering diagnostic tools and guidance for their overall initial management.
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Affiliation(s)
- Antoine Lafarge
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France.
| | - Dara Chean
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Livia Whiting
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Raphaël Clere-Jehl
- Médecine Intensive et Réanimation, Hôpital de Hautepierre, University Hospital of Strasbourg, Strasbourg, France
- Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM (French National Institute of Health and Medical Research), UMR_S1109, Centre de Recherche d'Immunologie et d'Hématologie, University of Strasbourg, Strasbourg, France
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2
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Bozgul SMK, Kurtulmus IA, Gunes A, Koymen G, Bozkurt D, Karaman ZT, Islamoglu K, Ozkilic B, Barutcuoglu B, Cilli FF, Soyer NA. Lactate level is an independent predictor of mortality in patients with hematologic malignancy receiving urgent chemotherapy in intensive care unit. Curr Res Transl Med 2024; 72:103451. [PMID: 38677199 DOI: 10.1016/j.retram.2024.103451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/16/2024] [Accepted: 04/21/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Intensive care unit (ICU) survival of cancer patients has improved. Urgent chemotherapy has become feasible in critically ill patients with specific organ dysfunction due to hematological malignancies. OBJECTIVE The aim of the study was to assess ICU mortality rates and the factors associated with mortality in patients with hematologic malignancies receiving urgent chemotherapy in the ICU. METHODS We retrospectively included all patients admitted to the ICU who received chemotherapy due to hematologic malignancy in 2012-2022. RESULTS Of the 129 patients undergoing chemotherapy in the ICU, 50 (38.7 %) died during the ICU follow-up. The following conditions were significantly more common among nonsurvivors: presence of infection at the time of ICU admission (p < 0.001), the requirement for mechanical ventilation during ICU stay (p < 0.001), the need for noninvasive mechanical ventilation during ICU stay (p = 0.014), vasopressor support (p < 0.001), and sepsis (p < 0.001). Logistic regression analysis revealed that among laboratory parameters on ICU admission, lactate (p = 0.008), albumin (p = 0.022), C-reactive protein (p = 0.046), baseline sequential organ failure assessment (SOFA) score (p < 0.001), newly developed heart failure (p = 0.006), and the requirement for vasopressor agents during ICU stay (p < 0.001) significantly influenced the risk of mortality in the univariate analysis. The multivariate analysis revealed lactate levels (p = 0.047) on ICU admission as an independent predictor of mortality. CONCLUSION The development of heart failure and lactate levels on admission were the main predictors of mortality. Additionally, higher SOFA scores revealed that illness severity was closely associated with mortality. Future studies should focus on strategies to further reduce these risks and achieve the best outcomes for these patients.
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Affiliation(s)
| | - Ilkce Akgun Kurtulmus
- Faculty of Medicine, Department of Internal Medicine, Ege University, İzmir, Türkiye
| | - Ajda Gunes
- Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Ege University, İzmir, Türkiye.
| | - Gorkem Koymen
- Faculty of Medicine, Department of Internal Medicine, Ege University, İzmir, Türkiye
| | - Devrim Bozkurt
- Faculty of Medicine, Department of Internal Medicine, Ege University, İzmir, Türkiye
| | - Zehra Tuba Karaman
- Faculty of Medicine, Department of Internal Medicine, Ege University, İzmir, Türkiye
| | | | | | - Burcu Barutcuoglu
- Faculty of Medicine, Department of Clinical Biochemistry, Ege University, İzmir, Türkiye
| | - Fatma Feriha Cilli
- Faculty of Medicine, Department of Medical Microbiology, Ege University, İzmir, Türkiye
| | - Nur Akad Soyer
- Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Ege University, İzmir, Türkiye
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3
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Sljivic S, Nam J, Matthews R, Agala CB, Hollowell J, Nizamani R, King B, Williams FN. Does A History of Malignancy Lead to Worse Outcomes in a Single-center Burn Unit? J Burn Care Res 2023; 44:274-279. [PMID: 36617221 DOI: 10.1093/jbcr/irad002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Indexed: 01/09/2023]
Abstract
A history of malignancy is associated with worse outcomes in cardiac disease and trauma. Our objective was to determine if a past medical history or comorbid condition of cancer portends an increased morbidity or mortality in burns or skin-sloughing disorders at our institution. Patients were identified using our Institutional Burn Center registry and linked to the clinical and administrative data. All patients admitted between January 1, 2014 and June 30, 2021 were eligible for inclusion. Demographics, length of stay, comorbid conditions and mortality were evaluated. Statistical analysis was performed with Kruskal-Wallis, chi-square, and Fisher's exact tests. Seven thousand three hundred seventy-two patients were admitted during this time period. Three hundred eighty-six patients had a history of cancer (5%). Patients with a history of cancer were older (56 vs 44 years, P < .0001). They had a significantly longer length of stay (16 vs 10 days, P < .0001). They also had larger burns and higher hospital costs ($147,021 versus $83,788, P < .0001), were more likely to be male and more likely to have a skin-sloughing disorder. A history of cancer was not associated with increased odds of burn mortality. Thus, a history of cancer is associated with increased lengths of stay and costs in patients admitted for burn injury or skin-sloughing disorders, but not associated with increased mortality. Further study is warranted to investigate and mitigate what aspects of their care could be adjusted to improve outcomes.
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Affiliation(s)
- Sanja Sljivic
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA.,North Carolina Jaycee Burn Center, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Jason Nam
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, 2301 Erwin Road Durham, North Carolina 27710, USA
| | - Robert Matthews
- Department of Anesthesiology, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Chris B Agala
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Jamie Hollowell
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA.,North Carolina Jaycee Burn Center, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Rabia Nizamani
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA.,North Carolina Jaycee Burn Center, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Booker King
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA.,North Carolina Jaycee Burn Center, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Felicia N Williams
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA.,North Carolina Jaycee Burn Center, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
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4
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Silva IL, Ribeiro TG, Borges KWC. Análise de Força Muscular e Mobilidade de Pacientes com Câncer Hematológico Atendidos pela Fisioterapia em um Centro de Assistência de Alta Complexidade em Oncologia. REVISTA BRASILEIRA DE CANCEROLOGIA 2022. [DOI: 10.32635/2176-9745.rbc.2022v68n4.2548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introdução: Câncer é o nome dado a um conjunto de mais de 100 doenças, caracterizado pelo crescimento anormal e acelerado de células, podendo ser considerado sólido ou hematológico. As neoplasias hematológicas levam a alterações específicas que podem contribuir para a inatividade, principalmente pelo alto risco de sangramento, induzindo perdas funcionais, tornando importante a realização da fisioterapia para prevenir ou minimizar essas perdas. Objetivo: Analisar a força muscular e a mobilidade de pacientes com câncer hematológico internados em um hospital de referência do Distrito Federal. Método: Estudo quantitativo, retrospectivo e longitudinal. A coleta foi realizada a partir de dados secundários de prontuários eletrônicos e planilhas de acompanhamento da fisioterapia, abrangendo o período de junho a dezembro de 2020. Foram analisadas a força muscular, por meio da dinamometria manual e da escala Medical Research Council (MRC), e a mobilidade, por meio da ICU Mobility Scale (IMS). Resultados: Dos 86 indivíduos rastreados, 43 foram elegíveis para a pesquisa. A análise entre a admissão e a alta hospitalar não revelou diferenças significativas na força muscular e mobilidade. Houve associação moderada e significativa entre MRC e IMS na admissão (r=0,575 e p<0,001) e na alta (r=0,481 e p=0,001). Não houve associações significativas entre dinamometria e mobilidade. Conclusão: Este estudo permitiu identificar o perfil dos pacientes onco-hematológicos em acompanhamento, sugerindo que a fisioterapia contribuiu para a manutenção da funcionalidade desses doentes.
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Chicoisneau M, Paesmans M, Ameye L, Sculier JP, Meert AP. Initiation of a new anti-cancer medical treatment in ICU: a retrospective study. Acta Clin Belg 2022; 77:337-345. [PMID: 33416021 DOI: 10.1080/17843286.2020.1870854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of our study is to evaluate the characteristics of patients whose medical anti-cancer treatment has been initiated at the ICU and to release prognostic factors for hospital mortality in these patients. MATERIAL AND METHODS We analyzed retrospectively all the records of cancer patients admitted between 01/01/2007 and 31/12/2017 in our ICU and for whom a new anti-cancer medical treatment was initiated during their ICU stay. RESULTS Our study includes 147 patients, 78 men (53%) and 69 women (47%), with a median age of 58 years. Eighty patients (54%) had a solid tumor and 67 (46%) a hematological malignancy. ICU mortality was 23% and hospital mortality 32%. The poor prognostic factors for hospital mortality were: higher SOFA, higher Charslon comorbidity index and the presence of a therapeutic limitation (introduced at the time of admission or within 24 hours of admission to the ICU). One-year survival for patients who survived hospital stay was 37% (17% for those with a solid tumor and 61% for the ones with a hematological malignancy). CONCLUSION Initiation of an anti-cancer medical treatment is feasible and can lead to good 1 year survival rate, especially for those with a hematological tumor.
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Affiliation(s)
- Maxence Chicoisneau
- Service de médecine interne, Soins intensifs et urgences oncologiques, Institut Jules Bordet, Université libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Lieveke Ameye
- Data Centre, Institut Jules Bordet, Brussels, Belgium
| | - Jean-Paul Sculier
- Service de médecine interne, Soins intensifs et urgences oncologiques, Institut Jules Bordet, Université libre de Bruxelles (ULB), Brussels, Belgium
| | - Anne-Pascale Meert
- Service de médecine interne, Soins intensifs et urgences oncologiques, Institut Jules Bordet, Université libre de Bruxelles (ULB), Brussels, Belgium
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6
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Shaz D, Pastores SM, Dayal L, Berkowitz J, Kostelecky N, Tan KS, Halpern N. Analysis of Intent and Reason for Oncologic Therapy Administration in Cancer Patients Admitted to the Intensive Care Unit. J Intensive Care Med 2021; 37:1305-1311. [PMID: 34898322 DOI: 10.1177/08850666211065993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To investigate the intent of, and reason for, administration of oncologic therapies in the intensive care unit (ICU). METHODS Single center, retrospective, cohort study of patients with cancer who received oncologic therapies at a tertiary cancer center ICU between April 1, 2019 and March 31, 2020. Oncologic therapies included traditional cytotoxic chemotherapy, targeted therapy, immunotherapy, hormonal or biologic therapy directed at a malignancy and were characterized as initiation (initial administration) or continuation (part of an ongoing regimen). RESULTS 84 unique patients (6.8% of total ICU admissions) received oncologic therapies in the ICU; 43 (51%) had hematologic malignancies and 41 (49%) had solid tumors. The intent of oncologic therapy was palliative in 63% and curative in 27%. Twenty-two (26%) patients received initiation and 62 (74%) received continuation oncologic therapies. The intent of oncologic therapy was significantly different by regimen type (initiation vs. continuation, p = <0.0001). Initiation therapy was more commonly prescribed with curative intent and continuation therapy was more commonly administered with palliative intent (p = <0.0001). Oncologic therapies were given in the ICU mainly for an oncologic emergency (56%) and because the patients happened to be in the ICU for a non-oncologic critical illness when their oncologic therapy was due (34.5%). CONCLUSION Our study provides intensivists with a better understanding of the context and intent of oncologic therapies and why these therapies are administered in the ICU.
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Affiliation(s)
- David Shaz
- 5803Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Lokesh Dayal
- 5803Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Kay See Tan
- 5803Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neil Halpern
- 5803Memorial Sloan Kettering Cancer Center, New York, NY, USA
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7
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Zhao J, Bewersdorf JP, Jaszczur S, Kowalski A, Perreault S, Schiffer M, Gore S, Podoltsev N, Prebet T, Shallis R, Zeidan AM. High dose cyclophosphamide for cytoreduction in patients with acute myeloid leukemia with hyperleukocytosis or leukostasis. Leuk Lymphoma 2020; 62:1195-1202. [PMID: 33325761 DOI: 10.1080/10428194.2020.1856835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Hyperleukocytosis may lead to multiple medical emergencies. Hydroxyurea, intensive chemotherapy, and leukapheresis are used for cytoreduction. However, there is little data regarding the best approach. Here, we report on the efficacy and safety of high dose cyclophosphamide (HDCy; 60 mg/kg). 27 patients with acute myeloid leukemia or blast phase chronic myeloid leukemia who presented with white blood cell count (WBC) of ≥50x109/L or symptoms of leukostasis were treated with HDCy. Primary endpoint was early mortality (death within seven days of admission). Median WBC was 107 × 109/L at time of HDCy; 74% had leukostasis symptoms at presentation. Eight (29.6%) patients died within seven days of admission. Sustained WBC reduction was achieved in 18/24 (75%) evaluable patients with median nadir of 0.25 × 109/L. Adverse effects attributed to HDCy included tumor lysis syndrome (n = 7; 25.9%), disseminated intravascular coagulopathy (n = 5; 18.5%), and hemorrhagic cystitis (n = 1; 3.7%). HDCy was effective for cytoreduction and adverse effects were acceptable.
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Affiliation(s)
- Jennifer Zhao
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | | | - Sara Jaszczur
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Andrew Kowalski
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Sarah Perreault
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Molly Schiffer
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Steven Gore
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Nikolai Podoltsev
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas Prebet
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Rory Shallis
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
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8
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Reddy DRS, Botz GH. Triage and Prognostication of Cancer Patients Admitted to the Intensive Care Unit. Crit Care Clin 2020; 37:1-18. [PMID: 33190763 DOI: 10.1016/j.ccc.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Cancer remains a leading cause of morbidity and mortality. Advances in cancer screening, early detection, targeted therapies, and supportive care have led to improvements in outcomes and quality of life. The rapid increase in novel cancer therapies can cause life-threatening adverse events. The need for intensive care unit (ICU) care is projected to increase. Until 2 decades ago, cancer diagnosis often precluded ICU admission. Recently, substantial cancer survival has been achieved; therefore, ICU denial is not recommended. ICU resources are limited and expensive; hence, appropriate utilization is needed. This review focuses on triage and prognosis in critically ill cancer patients requiring ICU admission.
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Affiliation(s)
- Dereddi Raja Shekar Reddy
- Department of Critical Care and Respiratory Care, Division of Anesthesiology, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 112, Houston, TX 77030, USA
| | - Gregory H Botz
- Department of Critical Care and Respiratory Care, Division of Anesthesiology, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 112, Houston, TX 77030, USA.
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9
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Shimabukuro-Vornhagen A. Intensive Care Unit Organization and Interdisciplinary Care for Critically Ill Patients with Cancer. Crit Care Clin 2020; 37:19-28. [PMID: 33190769 DOI: 10.1016/j.ccc.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Patients with cancer are at high risk of developing acute critical illness requiring intensive care unit (ICU) admission. Critically ill patients with cancer have complex medical needs that can best be served by a multidisciplinary ICU care team. This article provides an overview of the current state-of-the-art in multidisciplinary care for critically ill patients with cancer. Better integration of multidisciplinary critical care into the continuum of care for patients with cancer offers the prospect of further improvements in the outcomes of patients with cancer.
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10
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Martos-Benítez FD, Soler-Morejón CDD, Lara-Ponce KX, Orama-Requejo V, Burgos-Aragüez D, Larrondo-Muguercia H, Lespoir RW. Critically ill patients with cancer: A clinical perspective. World J Clin Oncol 2020; 11:809-835. [PMID: 33200075 PMCID: PMC7643188 DOI: 10.5306/wjco.v11.i10.809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 08/09/2020] [Accepted: 09/14/2020] [Indexed: 02/06/2023] Open
Abstract
Cancer patients account for 15% of all admissions to intensive care unit (ICU) and 5% will experience a critical illness resulting in ICU admission. Mortality rates have decreased during the last decades because of new anticancer therapies and advanced organ support methods. Since early critical care and organ support is associated with improved survival, timely identification of the onset of clinical signs indicating critical illness is crucial to avoid delaying. This article focused on relevant and current information on epidemiology, diagnosis, and treatment of the main clinical disorders experienced by critically ill cancer patients.
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Affiliation(s)
| | | | | | | | | | | | - Rahim W Lespoir
- Intensive Care Unit 8B, Hermanos Ameijeiras Hospital, Havana 10300, Cuba
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11
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Shaz DJ, Pastores SM, Goldman DA, Kostelecky N, Tizon RF, Tan KS, Halpern NA. Characteristics and outcomes of patients with solid tumors receiving chemotherapy in the intensive care unit. Support Care Cancer 2019; 28:3855-3865. [PMID: 31836938 DOI: 10.1007/s00520-019-05226-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 11/28/2019] [Indexed: 01/16/2023]
Abstract
PURPOSE The objective of this study was to evaluate the short- and long-term outcomes of adult patients with solid tumors receiving chemotherapy in the intensive care unit (ICU). METHODS This was a retrospective single-center study comparing the outcomes of patients with solid tumors who received chemotherapy in the ICU with a matched cohort of ICU patients (by age, sex, and tumor type) who did not receive chemotherapy. Conditional logistic regression and shared frailty Cox regression were used to assess short-term (ICU and hospital) mortality and death by 12-month post-hospital discharge, respectively. RESULTS Seventy-three patients with solid tumors who received chemotherapy in the ICU were successfully matched. The most common solid tumors included thoracic (30%), genitourinary (26%), and breast (16%). The ICU, hospital, and 12-month (post discharge) mortality rates of patients who recieved chomtherapy in the ICU were 23%, 36%, and 43%, respectively. When compared to the matched cohort of patients who did not receive chemotherapy, patients who received chemotherapy had a significantly longer length of stay in the ICU (median 7 vs. 4 days, p < 0.001) and hospital (median 15 vs. 11 days, p = 0.011) but similar short-term ICU and hospital mortality rates (23% vs. 18% and 36% vs. 38%, respectively). Patients who received chemotherapy in the ICU were at a lower risk of death by 12 months (HR 0.31, p < 0.001) compared to the matched cohort on multivariable analysis. CONCLUSIONS Patients with solid tumors who received chemotherapy had increased ICU and hospital length of stay compared to patients who did not. Although short-term mortality did not differ, patients who received chemotherapy in the ICU had improved long-term survival. Our data can inform critical care triage decisions to include patients who are to receive chemotherapy in the ICU.
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Affiliation(s)
- David J Shaz
- Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue C-1179, New York, NY, 10065, USA.
| | - Stephen M Pastores
- Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue C-1179, New York, NY, 10065, USA
| | - Debra A Goldman
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natalie Kostelecky
- Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue C-1179, New York, NY, 10065, USA
| | - Richard F Tizon
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kay See Tan
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neil A Halpern
- Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue C-1179, New York, NY, 10065, USA
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12
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Gershkovich B, Fernando SM, Herritt B, Castellucci LA, Rochwerg B, Munshi L, Mehta S, Seely AJE, McIsaac DI, Tran A, Reardon PM, Tanuseputro P, Kyeremanteng K. Outcomes of hospitalized hematologic oncology patients receiving rapid response system activation for acute deterioration. Crit Care 2019; 23:286. [PMID: 31455376 PMCID: PMC6712869 DOI: 10.1186/s13054-019-2568-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/13/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with hematologic malignancies who are admitted to hospital are at increased risk of deterioration and death. Rapid response systems (RRSs) respond to hospitalized patients who clinically deteriorate. We sought to describe the characteristics and outcomes of hematologic oncology inpatients requiring rapid response system (RRS) activation, and to determine the prognostic accuracy of the SIRS and qSOFA criteria for in-hospital mortality of hematologic oncology patients with suspected infection. METHODS We used registry data from two hospitals within The Ottawa Hospital network, between 2012 and 2016. Consecutive hematologic oncology inpatients who experienced activation of the RRS were included in the study. Data was gathered at the time of RRS activation and assessment. The primary outcome was in-hospital mortality. Logistical regression was used to evaluate for predictors of in-hospital mortality. RESULTS We included 401 patients during the study period. In-hospital mortality for all included patients was 41.9% (168 patients), and 145 patients (45%) were admitted to ICU following RRS activation. Among patients with suspected infection at the time of RRS activation, Systemic Inflammatory Response Syndrome (SIRS) criteria had a sensitivity of 86.9% (95% CI 80.9-91.6) and a specificity of 38.2% (95% CI 31.9-44.8) for predicting in-hospital mortality, while Quick Sequential Organ Failure Assessment (qSOFA) criteria had a sensitivity of 61.9% (95% CI 54.1-69.3) and a specificity of 91.4% (95% CI 87.1-94.7). Factors associated with increased in-hospital mortality included transfer to ICU after RRS activation (adjusted odds ratio [OR] 3.56, 95% CI 2.12-5.97) and a higher number of RRS activations (OR 2.45, 95% CI 1.63-3.69). Factors associated with improved survival included active malignancy treatment at the time of RRS activation (OR 0.54, 95% CI 0.34-0.86) and longer hospital length of stay (OR 0.78, 95% CI 0.70-0.87). CONCLUSIONS Hematologic oncology inpatients requiring RRS activation have high rates of subsequent ICU admission and mortality. ICU admission and higher number of RRS activations are associated with increased risk of death, while active cancer treatment and longer hospital stay are associated with lower risk of mortality. Clinicians should consider these factors in risk-stratifying these patients during RRS assessment.
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Affiliation(s)
- Benjamin Gershkovich
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON K1H 8L6 Canada
| | - Shannon M. Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON Canada
| | - Brent Herritt
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Lana A. Castellucci
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
| | - Laveena Munshi
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
| | - Andrew J. E. Seely
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Department of Surgery, University of Ottawa, Ottawa, ON Canada
| | - Daniel I. McIsaac
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON Canada
| | - Alexandre Tran
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Department of Surgery, University of Ottawa, Ottawa, ON Canada
| | - Peter M. Reardon
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON Canada
| | - Peter Tanuseputro
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Institut du Savoir Montfort, Ottawa, ON Canada
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13
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Acute Respiratory Failure in the Oncologic Patient: New Era, New Issues. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2019 2019. [PMCID: PMC7121650 DOI: 10.1007/978-3-030-06067-1_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Recent decades have seen an increase in the number of patients living with cancer. This trend has resulted in an increase in intensive care unit (ICU) utilization across this population [1]. Acute respiratory failure is the most frequent medical complication leading to critical illness in oncologic patients [2–4]. Historically, there had been a reluctance to admit cancer patients to the ICU given their poor outcomes, particularly in the setting of hematologic malignancy and invasive mechanical ventilation [5]. ICU treatment limitations or refusal of admission was advocated [6]. Major advances in oncologic care, critical care and more meticulous attention to where the conditions overlap, have resulted in marked improvement in short-term survival in this population [1, 7, 8]. Despite these major advances, acute respiratory failure in this population remains complex with unique challenges surrounding diagnosis and management compared to the general ICU population. This chapter provides a comprehensive overview of acute respiratory failure in the oncologic population and highlights specific considerations for the intensivist. We will focus on the important differences between the immunocompromised oncologic patient and general intensive care population, the spectrum of causes of acute respiratory failure with a specific focus on toxicities related to newer cancer therapies, diagnostic approach, management and an up-to-date overview of prognosis.
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