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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] [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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2
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Azoulay E, Mokart D, Kouatchet A, Demoule A, Lemiale V. Acute respiratory failure in immunocompromised adults. THE LANCET. RESPIRATORY MEDICINE 2019; 7:173-186. [PMID: 30529232 PMCID: PMC7185453 DOI: 10.1016/s2213-2600(18)30345-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 12/12/2022]
Abstract
Acute respiratory failure occurs in up to half of patients with haematological malignancies and 15% of those with solid tumours or solid organ transplantation. Mortality remains high. Factors associated with mortality include a need for invasive mechanical ventilation, organ dysfunction, older age, frailty or poor performance status, delayed intensive care unit admission, and acute respiratory failure due to an invasive fungal infection or unknown cause. In addition to appropriate antibacterial therapy, initial clinical management aims to restore oxygenation and predict the most probable cause based on variables related to the underlying disease, acute respiratory failure characteristics, and radiographic findings. The cause of acute respiratory failure must then be confirmed using the most efficient, least invasive, and safest diagnostic tests. In patients with acute respiratory failure of undetermined cause, a standardised diagnostic investigation should be done immediately at admission before deciding whether to perform more invasive diagnostic procedures or to start empirical treatments. Collaborative and multidisciplinary clinical and research networks are crucial to improve our understanding of disease pathogenesis and causation and to develop less invasive diagnostic strategies and more targeted treatment options.
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Affiliation(s)
- Elie Azoulay
- Assistance Publique Hôpitaux de Paris, Service de Médecine Intensive et Réanimation, Hôpital Saint-Louis, Paris, France; ECSTRA Team, Biostatistics and Clinical Epidemiology, Center of Epidemiology and Biostatistics Sorbonne Paris Cité, Institut national de la santé et de la recherche médicale, Paris Diderot Sorbonne University, Paris, France.
| | - Djamel Mokart
- Medical Surgical Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | - Achille Kouatchet
- Medical Intensive Care Unit, Centre hospitalier universitaire d'Angers, Angers, France
| | - Alexandre Demoule
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France; Neurophysiologie respiratoire expérimentale et clinique, Institut national de la santé et de la recherche médicale, Sorbonne Universités, Paris, France
| | - Virginie Lemiale
- Assistance Publique Hôpitaux de Paris, Service de Médecine Intensive et Réanimation, Hôpital Saint-Louis, Paris, France; ECSTRA Team, Biostatistics and Clinical Epidemiology, Center of Epidemiology and Biostatistics Sorbonne Paris Cité, Institut national de la santé et de la recherche médicale, Paris Diderot Sorbonne University, Paris, France
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3
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Influence of neutropenia on mortality of critically ill cancer patients: results of a meta-analysis on individual data. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:326. [PMID: 30514339 PMCID: PMC6280476 DOI: 10.1186/s13054-018-2076-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/21/2018] [Indexed: 12/13/2022]
Abstract
Background The study objective was to assess the influence of neutropenia on outcome of critically ill cancer patients by meta-analysis of individual data. Secondary objectives were to assess the influence of neutropenia on outcome of critically ill patients in prespecified subgroups (according to underlying tumor, period of admission, need for mechanical ventilation and use of granulocyte colony stimulating factor (G-CSF)). Methods Data sources were PubMed and the Cochrane database. Study selection included articles focusing on critically ill cancer patients published in English and studies in humans from May 2005 to May 2015. For study selection, the study eligibility was assessed by two investigators. Individual data from selected studies were obtained from corresponding authors. Results Overall, 114 studies were identified and authors of 30 studies (26.3% of selected studies) agreed to participate in this study. Of the 7515 included patients, three were excluded due to a missing major variable (neutropenia or mortality) leading to analysis of 7512 patients, including 1702 neutropenic patients (22.6%). After adjustment for confounders, and taking study effect into account, neutropenia was independently associated with mortality (OR 1.41; 95% CI 1.23–1.62; P = 0.03). When analyzed separately, neither admission period, underlying malignancy nor need for mechanical ventilation modified the prognostic influence of neutropenia on outcome. However, among patients for whom data on G-CSF administration were available (n = 1949; 25.9%), neutropenia was no longer associated with outcome in patients receiving G-CSF (OR 1.03; 95% CI 0.70–1.51; P = 0.90). Conclusion Among 7512 critically ill cancer patients included in this systematic review, neutropenia was independently associated with poor outcome despite a meaningful survival. Neutropenia was no longer significantly associated with outcome in patients treated by G-CSF, which may suggest a beneficial effect of G-CSF in neutropenic critically ill cancer patients. Systematic review registration PROSPERO CRD42015026347. Date of registration: Sept 18 2015 Electronic supplementary material The online version of this article (10.1186/s13054-018-2076-z) contains supplementary material, which is available to authorized users.
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Reich-Slotky R, Makhani SS, Vasovic LV, Pearse RN, Rossi A, Philips A, Cushing MM, Singh AD, van Besien K. Comparison of time to engraftment between autologous patients receiving washed versus non-washed cryopreserved peripheral blood stem cell products. Leuk Lymphoma 2018; 59:2829-2835. [PMID: 29790808 DOI: 10.1080/10428194.2018.1455975] [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: 10/16/2022]
Abstract
Washing cryopreserved peripheral blood stem cell (PBSC) products can decrease infusion-related adverse reactions but can also result in cell loss and reduced cell viability. To assess the risk and benefit of washing products, we compared the time to neutrophil and platelet engraftment between autologous patients that received washed products (n = 201) and non-washed products (n = 89). The effect of the other variables, including age, gender, diagnosis, transplant dose, method of stem cell mobilization, and growth factor support regimen post-transplant, was assessed. In multivariate analysis, direct thaw and infusion of non-washed products resulted in significantly faster neutrophil engraftment (p = .003) and platelet engraftment (p = .017) than washed products. The mean neutrophil and platelet engraftment times were 1.07 days faster and 2.27 days faster, respectively. In conclusion, direct thaw and infusion of cryopreserved PBSC without washing results in significantly shorter time to recovery of neutrophils and platelets after autologous transplantation.
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Affiliation(s)
- Ronit Reich-Slotky
- a Department of Transfusion Medicine and Cellular Therapy , New York Presbyterian Hospital , New York , NY , USA
| | - Sarah S Makhani
- a Department of Transfusion Medicine and Cellular Therapy , New York Presbyterian Hospital , New York , NY , USA
| | - Ljiljana V Vasovic
- b Department of Pathology , Weill Cornell Medical College , New York , NY , USA
| | - Roger N Pearse
- c Department of Medicine , Weill Cornell Medical College , New York , NY , USA
| | - Adriana Rossi
- c Department of Medicine , Weill Cornell Medical College , New York , NY , USA
| | - Adrianne Philips
- c Department of Medicine , Weill Cornell Medical College , New York , NY , USA
| | - Melissa M Cushing
- b Department of Pathology , Weill Cornell Medical College , New York , NY , USA
| | - Amrita D Singh
- d Department of Pharmacy , New York Presbyterian Hospital , New York , NY , USA
| | - Koen van Besien
- c Department of Medicine , Weill Cornell Medical College , New York , NY , USA
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5
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Progression of the Radiologic Severity Index predicts mortality in patients with parainfluenza virus-associated lower respiratory infections. PLoS One 2018; 13:e0197418. [PMID: 29771962 PMCID: PMC5957350 DOI: 10.1371/journal.pone.0197418] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 05/02/2018] [Indexed: 01/29/2023] Open
Abstract
Background Radiologic severity may predict adverse outcomes after lower respiratory tract infection (LRI). However, few studies have quantified radiologic severity of LRIs. We sought to evaluate whether a semi-quantitative scoring tool, the Radiologic Severity Index (RSI), predicted mortality after parainfluenza virus (PIV)-associated LRI. Methods We conducted a retrospective review of consecutively-enrolled adult patients with hematologic malignancy or hematopoietic stem cell transplantation and with PIV detected in nasal wash who subsequently developed radiologically-confirmed LRI. We measured RSI (range 0–72) in each chest radiograph during the first 30 days after LRI diagnosis. We used extended Cox proportional hazards models to identify factors associated with mortality after onset of LRI with all-cause mortality as our failure event. Results After adjustment for patient characteristics, each 1-point increase in RSI was associated with an increased hazard of death (HR 1.13, 95% confidence interval [CI] 1.05–1.21, p = 0.0008). Baseline RSI was not predictive of death, but both peak RSI and the change from baseline to peak RSI (delta-RSI) predicted mortality (odds ratio for mortality, peak: 1.11 [95%CI 1.04–1.18], delta-RSI: 1.14 [95%CI 1.06–1.22]). A delta-RSI of ≥19.5 was 89% sensitive and 91% specific in predicting 30-day mortality. Conclusions We conclude that the RSI offers precise, informative and reliable assessments of LRI severity. Progression of RSI predicts 30-day mortality after LRI, but baseline RSI does not. Our results were derived from a cohort of patients with PIV-associated LRI, but can be applied in validated in other populations of patients with LRI.
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Bouteloup M, Perinel S, Bourmaud A, Azoulay E, Mokart D, Darmon M. Outcomes in adult critically ill cancer patients with and without neutropenia: a systematic review and meta-analysis of the Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie (GRRR-OH). Oncotarget 2018; 8:1860-1870. [PMID: 27661125 PMCID: PMC5352103 DOI: 10.18632/oncotarget.12165] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 09/14/2016] [Indexed: 01/24/2023] Open
Abstract
PURPOSE Whether neutropenia has an impact on the mortality of critically ill cancer patients remains controversial, yet it is widely used as an admission criterion and prognostic factor. METHODS Systematic review and meta-analysis. Studies on adult cancer patients and intensive care units were searched on PubMed and Cochrane databases (2005-2015). Summary estimates of mortality risk differences were calculated using the random-effects model. RESULTS Among the 1,528 citations identified, 38 studies reporting on 6,054 patients (2,097 neutropenic patients) were included. Median mortality across the studies was 54% [45–64], with unadjusted mortality in neutropenic and non-neutropenic critically ill patients of 60% [53–74] and 47% [41–68], respectively. Overall, neutropenia was associated with a 10% increased mortality risk (6%-14%; I2 = 50%). The admission period was not associated with how neutropenia affected mortality. Mortality significantly dropped throughout the study decade [−11% (−13.5 to −8.4)]. This mortality drop was observed in non-neutropenic patients [−12.1% (−15.2 to −9.0)] but not in neutropenic patients [−3.8% (−8.1 to +5.6)]. Sensitivity analyses disclosed no differences in underlying malignancy, mechanical ventilation use, or Granulocyte-colony stimulating factor use. Seven studies allowed the adjustment of severity results (1,350 patients). Although pooled risk difference estimates were similar to non-adjusted results, there was no significant impact of neutropenia on mortality (risk difference of mortality, 9%; 95% CI, −15 to +33) CONCLUSION Although the unadjusted mortality of neutropenic patients was 11% higher, this effect disappeared when adjusted for severity. Therefore, when cancer patients become critically ill, neutropenia cannot be considered as a decision-making criterion.
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Affiliation(s)
- Marie Bouteloup
- Medical-Surgical ICU, Hôpital Nord, Université Jean Monnet, Saint-Etienne, France
| | - Sophie Perinel
- Medical-Surgical ICU, Hôpital Nord, Université Jean Monnet, Saint-Etienne, France
| | - Aurélie Bourmaud
- Department of Public Health, Hygée Centre, Lucien Neuwirth Cancer Institut, Saint Priest en Jarez, France
| | - Elie Azoulay
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France
| | - Djamel Mokart
- Anesthesiology and Intensive Care Unit, Institut Paoli Calmette, Marseille Cedex 9, France
| | - Michael Darmon
- Medical-Surgical ICU, Hôpital Nord, Université Jean Monnet, Saint-Etienne, France.,Thrombosis Research Group, EA 3065, Saint-Etienne University Hospital and Saint-Etienne Medical School, Saint-Etienne, France
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Ljungman P, Snydman D, Boeckh M. Pneumonia After Hematopoietic Stem Cell Transplantation. TRANSPLANT INFECTIONS 2016. [PMCID: PMC7153442 DOI: 10.1007/978-3-319-28797-3_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pneumonia is the main cause of morbidity and mortality after hematopoietic stem cell transplantation. Two thirds of pneumonias observed after both autologous and allogeneic stem cell transplantations are of infectious origin, and coinfections are frequent. One third is due to noninfectious process, such as alveolar hemorrhage, alveolar proteinosis, or alloimmune pulmonary complications such as bronchiolitis obliterans or idiopathic interstitial pneumonitis. Most of these noninfectious complications may require treatment with corticosteroids which may be deleterious in infection. On the other hand, these complications either mimic or may be complicated with infections. Therefore, a precise diagnosis of pneumonia is of crucial importance to decide of the optimal treatment. CT scan is the best procedure for imaging of the lung. Although several indirect biomarkers, such as serum or plasma galactomannan or (1-3) β(beta)-G-glucan, can help in the etiological diagnosis, only direct invasive investigations provide the best chance to identify the cause(s) of pneumonia. Bronchoalveolar lavage (BAL) under fiberoptic bronchoscopy is the procedure of choice to identify the cause of pulmonary infection. It is safe and reproducible, and its diagnostic yield is around 50 % if the BAL fluid is processed at the laboratory according to a prespecified protocol established between the transplanter, the infectious diseases’ specialist, the pneumologist, and the laboratory, allowing the identification of the most likely hypotheses. Transbronchial biopsy does not provide significant additional information to BAL in most cases and more often complicates with bleeding and pneumothorax. In case of a noncontributory BAL, the decision to proceed to a second BAL, a transthoracic biopsy, or a surgical biopsy should be cautiously weighted in a multidisciplinary approach in regard to the benefits and risks of invasive procedures versus empirical treatment.
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Affiliation(s)
- Per Ljungman
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - David Snydman
- Tufts University School of Medicine Tufts Medical Center, Boston, Massachusetts USA
| | - Michael Boeckh
- University of Washington Fred Hutchinson Cancer Research Center, Seattle, Washington USA
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Stiehl T, Ho AD, Marciniak-Czochra A. The impact of CD34+ cell dose on engraftment after SCTs: personalized estimates based on mathematical modeling. Bone Marrow Transplant 2013; 49:30-7. [DOI: 10.1038/bmt.2013.138] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 07/05/2013] [Accepted: 08/03/2013] [Indexed: 11/09/2022]
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Turkoglu M, Mirza E, Tunçcan ÖG, Erdem GU, Dizbay M, Yağcı M, Aygencel G, Türköz Sucak G. Acinetobacter baumannii infection in patients with hematologic malignancies in intensive care unit: risk factors and impact on mortality. J Crit Care 2011; 26:460-467. [PMID: 21715136 DOI: 10.1016/j.jcrc.2011.04.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 03/07/2011] [Accepted: 04/29/2011] [Indexed: 12/18/2022]
Abstract
PURPOSE We investigated the characteristics of Acinetobacter baumannii infection in critically ill patients with hematologic malignancies. MATERIALS AND METHODS The prospectively collected data of patients with hematologic malignancies admitted to a medical intensive care unit of a university hospital from 2007 through 2010 were reviewed retrospectively. RESULTS One hundred twenty-eight patients were included in the study, among whom 35 (27%) developed 39 A baumannii infections. Pneumonia was the most common infection site of A baumannii. Presence of neutropenia, underlying hematologic malignancy, and the disease status did not affect the acquisition of the infection. Advancing age, prior exposure to aminoglycosides, central venous catheterization, and presence of nasogastric tube were the independent risk factors for the development of A baumannii infections. The mortality rate was higher in patients with A baumannii infections compared with the ones without (P = .009). However, in multivariate analysis, low Glasgow coma scale, prior immunosuppressive treatment, neutropenia, invasive mechanical ventilation, and severe sepsis were independently associated with mortality, whereas presence of A baumannii infection was not. CONCLUSIONS Despite the high mortality rate in critically ill patients with hematologic malignancies, presence of A baumannii infection was not an independent risk factor for mortality.
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Affiliation(s)
- Melda Turkoglu
- Department of Medical Intensive Care Unit, Gazi University School of Medicine, Besevler 06510 Ankara, Turkey.
| | - Emel Mirza
- Department of Medical Intensive Care Unit, Gazi University School of Medicine, Besevler 06510 Ankara, Turkey
| | - Özlem Güzel Tunçcan
- Department of Clinical Microbiology and Infectious Diseases, Gazi University School of Medicine, Besevler 06510 Ankara, Turkey
| | - Gökmen Umut Erdem
- Department of Medical Intensive Care Unit, Gazi University School of Medicine, Besevler 06510 Ankara, Turkey
| | - Murat Dizbay
- Department of Clinical Microbiology and Infectious Diseases, Gazi University School of Medicine, Besevler 06510 Ankara, Turkey
| | - Münci Yağcı
- Department of Hematology, Gazi University School of Medicine,Gazi University School of Medicine, Besevler 06510 Ankara, Turkey
| | - Gülbin Aygencel
- Department of Medical Intensive Care Unit, Gazi University School of Medicine, Besevler 06510 Ankara, Turkey
| | - Gülsan Türköz Sucak
- Department of Hematology, Gazi University School of Medicine,Gazi University School of Medicine, Besevler 06510 Ankara, Turkey
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Azoulay E, Darmon M. Acute respiratory distress syndrome during neutropenia recovery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:114. [PMID: 20236481 PMCID: PMC2875486 DOI: 10.1186/cc8198] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Acute respiratory failure is a life-threatening complication in cancer patients. During neutropenia, patients are at high risk for bacterial pneumonia or invasive fungal infections, when neutropenia is prolonged. A high proportion of patients in whom neutropenia had been complicated by pneumonia will present with substantial respiratory deterioration during neutropenia recovery. Patients with fungal pneumonia and those receiving granulocyte colony-stimulating factor to shorten neutropenia duration may be at higher risk for this acute lung injury/acute respiratory distress syndrome during neutropenia recovery. Routine screening of patient's risk factors is crucial since first symptoms of acute respiratory distress syndrome may occur before biological leukocyte recovery.
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