Characteristics and outcomes of patients with cancer requiring admission to intensive care units: A prospective multicenter study*:

Clinical characteristics and prognostic factors of sepsis in patients with malignancy

Sepsis is a severe complication in patients with malignant tumors, leading to high mortality and increased need for intensive care. This study aimed to investigate the clinical characteristics and prognostic factors influencing sepsis outcomes in patients with malignant tumors. We included 4,858 patients with cancer diagnosed with sepsis between September 2019 and February 2020 whose data were collected from the Korean Sepsis Alliance, a nationwide multicenter cohort study. Cox regression analysis was used to identify predictors of 30-day and in-hospital mortality. In total, 65% of the patients survived, whereas 35% did not. Non-survivors were more likely to require intensive care, including mechanical ventilation and continuous renal replacement therapy. Key predictors of mortality included renal dysfunction, higher Sequential Organ Failure Assessment scores, and reliance on life-sustaining treatments. Non-survivors exhibited lower adherence to the implementation of sepsis care bundles, particularly to later-stage interventions. Gram-negative bacterial infections and multidrug resistance were more prevalent in non-survivors, complicating treatment efficacy. In conclusion, tailored treatment strategies that consider specific patient characteristics and disease dynamics are needed in managing sepsis with malignancy. Early identification and treatment of organ dysfunction, coupled with strict adherence to sepsis treatment protocols, are critical to improving survival in this population.

Outcome of critically ill patients receiving systemic chemotherapy on the intensive care unit

Objective

Analyze the outcomes of critically ill patients who developed new-onset organ dysfunction and received systemic chemotherapy during their ICU stay.

Design

Retrospective cohort study.

Setting

A tertiary medical center in Germany with an Intensive Care Medicine department consists of 11 intensive care units comprising 140 beds, serving all subspecialties of adult intensive care medicine.

Patients

167 patients receiving systemic oncological treatment from January 1st, 2015 to December 31st, 2021, with a data cut-off on December 31st, 2022.

Interventions

None.

Measurements and main results

A total of 167 patients were included. The primary reasons for ICU admission were respiratory failure and shock/sepsis, each accounting for 34% of cases, while complications associated with oncological therapy accounted for less than 8%. The median age of hematological patients (n = 129) was 62 years (IQR 50-70), and for solid tumor patients (n = 38), it was 60 years (IQR 52-65). Predominant disease entities included lymphoma (43%) and acute myeloid leukemia (29%) among hematological patients, and lung cancer (47%) and gastrointestinal malignancies (17%) among solid tumor patients. Hematological patients had a significantly higher median Simplified Acute Physiology Score II (47 vs. 39 points; p=0.013), a higher need for invasive mechanical ventilation (59% vs. 50%; p=0.3), renal replacement therapy (54% vs. 24%; p < 0.001), and a higher 1-year mortality rate (64% vs. 53%; p=0.2) compared to solid tumor patients. The hazard ratio for 1 year survival for male sex was 2.34 (1.31-3.49), for mechanical ventilation 2.01 (1.33-3.04), for vasopressor therapy 1.98 (1.27-3.10), and for renal replacement therapy 1.51 (1.03-2.23), respectively.

Conclusion

Administering intravenous chemotherapy in an ICU setting remains challenging, and the experience to establish an indication for systemic chemotherapy is still challenging. However, the study demonstrates that, after careful interdisciplinary decision-making, a substantial number of patients can benefit from it.

Causes, management, and prognosis of severe gastrointestinal bleedings in critically ill patients with pancreatic cancer: A retrospective multicenter study

BACKGROUND

Gastrointestinal (GI) bleeding is a leading cause of intensive care unit (ICU) admission in pancreatic cancer patients.

AIMS

To analyze causes, ICU mortality and hemostatic treatment success rates of GI bleeding in pancreatic cancer patients requiring ICU admission.

METHODS

Retrospective multicenter cohort study between 2009 and 2021. Patients with a recent pancreatic resection surgery were excluded.

RESULTS

Ninety-five patients were included (62 % males, 67 years-old). Fifty-one percent presented hemorrhagic shock, 41 % required mechanical ventilation. Main GI bleeding causes were gastroduodenal tumor invasion (32 %), gastroesophageal varices (21 %) and arterial aneurysm (12 %). Arterial aneurysms were more frequent in patients with previous pancreatic resection (36 % vs 2 %, p < 0.001). Hemostatic procedures included gastroduodenal endoscopy in 81 % patients and arterial embolization in 28 % patients. ICU mortality was 19 %. Multivariate analysis identified four variables associated with mortality: performance status >2 (OR 9.34, p = 0.026), mechanical ventilation (OR 14.14, p = 0.003), treatment success (OR 0.09, p = 0.010), hemorrhagic shock (OR 11.24, p = 0.010). Treatment success was 46 % and was associated with aneurysmal bleeding (OR 29.89, p = 0.005), ongoing chemotherapy (OR 0.22, p = 0.016), and prothrombin time ratio (OR 1.05, p = 0.001).

CONCLUSION

In pancreatic cancer patients with severe GI bleeding, early identification of aneurysmal bleeding (particularly in case of previous resection surgery) and coagulopathy management may increase the treatment success and reduce mortality.

Differences in the relative importance of predictors of short- and long-term mortality among critically ill patients with cancer

OBJECTIVE

To identify the relative importance of several clinical variables present at intensive care unit admission on the short- and long-term mortality of critically ill patients with cancer after unplanned intensive care unit admission.

METHODS

This was a retrospective cohort study of patients with cancer with unplanned intensive care unit admission from January 2017 to December 2018. We developed models to analyze the relative importance of well-known predictors of mortality in patients with cancer admitted to the intensive care unit compared with mortality at 28, 90, and 360 days after intensive care unit admission, both in the full cohort and stratified by the type of cancer when the patient was admitted to the intensive care unit.

RESULTS

Among 3,592 patients, 3,136 (87.3%) had solid tumors, and metastatic disease was observed in 60.8% of those patients. A total of 1,196 (33.3%), 1,738 (48.4%), and 2,435 patients (67.8%) died at 28, 90, and 360 days, respectively. An impaired functional status was the greatest contribution to mortality in the short term for all patients and in the short and long term for the subgroups of patients with solid tumors. For patients with hematologic malignancies, the use of mechanical ventilation was the most important variable associated with mortality in all study periods. The SOFA score at admission was important for mortality prediction only for patients with solid metastatic tumors and hematological malignancies. The use of vasopressors and renal replacement therapy had a small importance in predicting mortality at every time point analyzed after the SOFA score was accounted for.

CONCLUSION

Healthcare providers must consider performance status, the use of mechanical ventilation, and the severity of illness when discussing prognosis, preferences for care, and end-of-life care planning with patients or their families during intensive care unit stays.

Prevalence and associated factors of cancer-related fatigue among adult patients with cancer attending oncology units: an institution-based cross-sectional study design in the Amhara region, Ethiopia, 2022

Introduction

Cancer-related fatigue (CRF) continues to be a common problem among most patients with cancer. It is a subjective feeling of tiredness, weakness or lack of energy. CRF has a significant impact on social interactions, everyday activities and the general quality of life of patients with cancer worldwide. However, little is known about CRF in Ethiopia as well as in the current study area. Therefore, the aim of this study was to assess the prevalence and associated factors of CRF among adult patients attending oncology units at the comprehensive specialised hospitals in the Amhara regional state of Ethiopia.

Methods

An institution-based cross-sectional study was conducted among adult patients with cancer undergoing treatment. A systematic random sampling technique was employed to select the study participants. An interviewer-administered questionnaire and participants' medical charts were used to collect the data. The questionnaire consisted of eight subsections, including sociodemographic characteristics, behavioural characteristics, Brief Fatigue Inventory, Performance Status Scale, Oslo Social Support Status, Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index, and clinical and medical factors. The data were entered into EpiData V.4.6 and exported into SPSS V.26 for analysis. The participants' characteristics were compiled using descriptive statics. Bivariable and multivariable logistic regressions were used to identify associations between dependent and independent variables. Variables with a value of p<0.05 were considered statistically significant.

Result

A total of 326 randomly selected patients with cancer, undergoing treatment, participated in this study; the response rate was 94%. The prevalence of CRF was found to be 63.93% (95% CI 58.5% to 69.25%). Depression (adjusted OR (AOR) 1.975, 95% CI 1.009 to 3.865), poor sleep quality (AOR 3.309, 95% CI 1.057 to 10.345), poor performance status (AOR 1.983, 95% CI 1.176 to 4.70), cancer stage (AOR 3.242, 95% CI 1.016 to 10.342) and admitted patients with cancer (AOR 2.047, 95% CI 1.122 to 3.734) were associated with CRF.

Conclusion and recommendation

The prevalence of CRF was found to be high. Stage of cancer, poor sleep quality, poor performance status, depression and hospital admission were significant factors. The results show that healthcare providers should focus on risk factors as well as CRF through early screening and management.

Predicting Reprisal of Solid Cancer Treatment and 60-Month Survival after Medical Intensive Care: A Single-Centre Cohort Study

INTRODUCTION

Our study aimed to identify relevant features associated with the reprisal of antineoplastic treatment in patients with solid cancers after unplanned admittance to the intensive care unit (ICU) and to assess 60th-month survival in patients with solid neoplasms admitted to the ICU.

METHODS

This single-centre retrospective study of critically ill patients with active cancers was performed over a 13-year period (2005-2018). Patients' characteristics, overall survival, and antineoplastic treatment reprisal were extracted from digital medical files and compared.

RESULTS

134 patients were included in the study. Solid neoplasms were mostly localised to the head and neck (n = 53) followed by lung cancers (n = 29). Sepsis was the leading cause of ICU admission (62.1%) with 41/82 patients presenting with septic shock. Antineoplastic treatments were resumed in 40 patients. An age ≤60 years and an Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≤1 were found to be predictors for treatment reprisal, with odd ratios of, respectively, 2.83 (95% CI, 1.15-6.99) and 5.45 (95% CI, 2.01-14.82); area under the ROC curve of 72% (95% CI, 63-81%). Survival after the immediate discharge from the ICU was 101/134 (75%) and the 60-month survival rate was 29% and significantly higher in the treatment-reprisal group.

CONCLUSIONS

Age and ECOG PS were found to be predictors for treatment reprisal in patients with solid neoplasms admitted to the ICU. The latter benefits from better long-term survival.

Effects of closed- versus open-system intensive care units on mortality rates in patients with cancer requiring emergent surgical intervention for acute abdominal complications: a single-center retrospective study in Korea

BACKGROUND

In this study, we aimed to compare the in-hospital mortality of patients with cancer who experienced acute abdominal complications that required emergent surgery in open (treatment decisions made by the primary attending physician of the patient's admission department) versus closed (treatment decisions made by intensive care unit [ICU] intensivists) ICUs.

METHODS

This retrospective, single-center study enrolled patients with cancer admitted to the ICU before or after emergency surgery between November 2020 and September 2023. Univariate and logistic regression analyses were conducted to explore the associations between patient characteristics in the open and closed ICUs and in-hospital mortality.

RESULTS

Among the 100 patients (open ICU, 49; closed ICU, 51), 23 died during hospitalization. The closed ICU group had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, vasopressor use, mechanical ventilation, and preoperative lactate levels and a shorter duration from diagnosis to ICU admission, surgery, and antibiotic administration than the open ICU group. Univariate analysis linked in-hospital mortality and APACHE II score, postoperative lactate levels, continuous renal replacement therapy (CRRT), and mechanical ventilation. Multivariate analysis revealed that in-hospital mortality rate increased with CRRT use and was lower in the closed ICU.

CONCLUSIONS

Compared to an open ICU, a closed ICU was an independent factor in reducing in-hospital mortality through prompt and appropriate treatment.

Intra-abdominal infection and sepsis in immunocompromised intensive care unit patients: Disease expression, microbial aetiology, and clinical outcomes

We compared epidemiology of intra-abdominal infection (IAI) between immunocompromised and non-immunocompromised ICU patients and identified risk factors for mortality. We performed a secondary analysis on the "AbSeS" database, a prospective, observational study with IAI patients from 309 ICUs in 42 countries. Immunocompromised status was defined as either neutropenia or prolonged corticosteroids use, chemotherapy or radiotherapy in the past year, bone marrow or solid organ transplantation, congenital immunodeficiency, or immunosuppressive drugs use. Mortality was defined as ICU mortality at any time or 28-day mortality for those discharged earlier. Associations with mortality were assessed by logistic regression. The cohort included 2589 patients of which 239 immunocompromised (9.2 %), most with secondary peritonitis. Among immunocompromised patients, biliary tract infections were less frequent, typhlitis more frequent, and IAIs were more frequently healthcare-associated or early-onset hospital-acquired compared with immunocompetent patients. No difference existed in grade of anatomical disruption, disease severity, organ failure, pathogens, and resistance patterns. Septic shock was significantly more frequent in the immunocompromised population. Mortality was similar in both groups (31.1% vs. 28.9 %; p = 0.468). Immunocompromise was not a risk factor for mortality (OR 0.98, 95 % CI 0.66-1.43). Independent risk factors for mortality among immunocompromised patients included septic shock at presentation (OR 6.64, 95 % CI 1.27-55.72), and unsuccessful source control with persistent inflammation (OR 5.48, 95 % CI 2.29-12.57). In immunocompromised ICU patients with IAI, short-term mortality was similar to immunocompetent patients, despite the former presented more frequently with septic shock, and septic shock and persistent inflammation after source control were independent risk factors for death.

The role of colonization with resistant Gram-negative bacteria in the treatment of febrile neutropenia after stem cell transplantation

BACKGROUND

Febrile neutropenia (FN) is a common complication of stem cell transplantation.

AIM

To evaluate the frequency of sepsis in patients with FN colonized with resistant Gram-negative bacteria (extended-spectrum β-lactamase (ESBL)-positive, multidrug-resistant (MDR) Pseudomonas aeruginosa) and the choice of primary antibiotic in colonized patients.

METHODS

This retrospective study analysed data from patients undergoing haematopoietic stem cell transplantation from January 2018 to September 2022. Data were extracted from the hospital information system.

FINDINGS

Carbapenem as the primary antibiotic of choice was chosen in 10.9% of non-colonized +/-AmpC patients, 31.5% of ESBL+ patients, and 0% of MDR P. aeruginosa patients. Patients with FN and MDR P. aeruginosa colonization had a high prevalence of sepsis (namely 100%, P = 0.0197). The spectrum of sepsis appeared to be different, with Gram-negative bacilli predominating in the ESBL+ group (OR: 5.39; 95% CI: 1.55-18.76; P = 0.0123). Colonizer sepsis was present in 100% of sepsis with MDR P. aeruginosa colonization (P = 0.002), all in allogeneic transplantation (P = 0.0003), with a mortality rate of 33.3% (P = 0.0384). The incidence of sepsis in patients with ESBL+ colonization was 25.9% (P = 0.0197), with colonizer sepsis in 50% of sepsis cases (P = 0.0002), most in allogeneic transplantation (P = 0.0003).

CONCLUSION

The results show a significant risk of sepsis in FN with MDR P. aeruginosa colonization, a condition almost exclusively caused by the colonizer. At the same time, a higher risk of Gram-negative sepsis has been demonstrated in patients colonized with ESBL+ bacteria.

Cancer and sepsis: future challenges for long-term outcome

PURPOSE OF REVIEW

The purpose of this review is to investigate the long-term outcomes of cancer patients who experience sepsis or septic shock.

RECENT FINDINGS

Sepsis is a frequent cause of ICU admission in cancer patients, accounting for approximately 15% of such cases. Short-term mortality rates among these patients vary widely across studies, but they are consistently found to be slightly higher than those of noncancer patients. However, there is a lack of evidence regarding the long-term outcomes of cancer patients who have experienced sepsis or septic shock. The few available studies have reported relatively high mortality rates, reaching around 80% in a few cohort studies. Although several observational studies have noted a decrease in 1-year mortality rates over time, observational data also suggest that sepsis may increase the risk of cancer in the long run.

SUMMARY

As cancer is becoming a chronic disease, there is an urgent need for studies on the quality of life of cancer patients who have experienced sepsis. The relationship between sepsis and cancer extends beyond its impact on the progression of cancer, as sepsis might also contribute to the development of cancer.

Procalcitonin-Guided Management and Duration of Antibiotic Therapy in Critically Ill Cancer Patients With Sepsis (Pro-Can Study): A Randomized Controlled Trial

OBJECTIVES

To evaluate the effect of procalcitonin-guided management on the duration of antibiotic therapy in critically ill cancer patients with sepsis.

DESIGN

Randomized, controlled, single-blinded trial.

SETTING

A comprehensive multidisciplinary cancer hospital in Jordan.

PATIENTS

Adults with cancer treated in the ICU who were started on antibiotics for suspected infection, met the SEPSIS-3 criteria, and were expected to stay in the ICU greater than or equal to 48 hours.

INTERVENTIONS

Patients were randomized to the procalcitonin-guided or standard care (SC) arms. All patients had procalcitonin measured daily, up to 5 days or until ICU discharge or death. For the procalcitonin arm, a procalcitonin-guided algorithm was provided to guide antibiotic management, but clinicians were allowed to override the algorithm, if clinically indicated. In the SC arm, ICU clinicians were blinded to the procalcitonin levels.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was time to antibiotic cessation. We also evaluated the number of antibiotic-free days at 28 days, hospital discharge, or death, whichever came first, and antibiotic defined daily doses (DDDs). We enrolled 77 patients in the procalcitonin arm and 76 in the SC arm. Mean age was 58 ± 14 (sd) years, 67% were males, 74% had solid tumors, and 13% were neutropenic. Median (interquartile range [IQR]) Sequential Organ Failure Assessment scores were 7 (6-10) and 7 (5-9) and procalcitonin concentrations (ng/mL) at baseline were 3.4 (0.8-16) and 3.4 (0.5-26), in the procalcitonin and SC arms, respectively. There was no difference in the median (IQR) time to antibiotic cessation in the procalcitonin and SC arms, 8 (4-11) and 8 (5-13), respectively (p = 0.463). Median (IQR) number of antibiotic-free days were 20 (17-24) and 20 (16-23), (p = 0.484) and total DDDs were 1541.4 and 2050.4 in the procalcitonin and SC arms, respectively.

CONCLUSIONS

In critically ill cancer patients with sepsis, procalcitonin-guided management did not reduce the duration of antibiotic treatment.

Decreased Long-Term Survival of Patients With Newly Diagnosed Cancer Discharged Home After Unplanned ICU Admission: A Prospective Observational Study

IMPORTANCE AND OBJECTIVES

To compare the 18-month survival between patients with newly diagnosed cancer discharged home after early unplanned ICU admission and those without early unplanned ICU admission; we also evaluated the frequency and risk factors for early unplanned ICU admission.

DESIGN

Observational study with prospectively collected data from September 2019 to June 2021 and 18 months follow-up.

SETTING

Single dedicated cancer center in São Paulo, Brazil.

PARTICIPANTS

We screened consecutive adults with suspected cancer and included those with histologically proven cancer from among 20 highly prevalent cancers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The exposure was early unplanned ICU admission, defined as admission for medical reasons or urgent surgery during the first 6 months after cancer diagnosis. The main outcome was 18-month survival after cancer diagnosis, and the main analysis was Cox's proportional hazards model adjusted for confounders and immortal time bias. Propensity score matching was used in the sensitivity analysis. We screened 4738 consecutive adults with suspected cancer and included 3348 patients. Three hundred twelve (9.3%) had early unplanned ICU admission, which was associated with decreased 18-month survival both in the unadjusted (hazard ratio, 4.03; 95% CI, 2.89-5.62) and adjusted (hazard ratio, 1.84; 95% CI, 1.29-2.64) models. The sensitivity analysis confirmed the results because the groups were balanced after matching, and the 18-month survival of patients with early ICU admission was lower compared with patients without early ICU admission (87.0% vs. 93.9%; p = 0.01 log-rank test). Risk factors for early unplanned ICU admission were advanced age, comorbidities, worse performance status, socioeconomic deprivation, metastatic tumors, and hematologic malignancies.

CONCLUSIONS

Patients with newly diagnosed cancer discharged home after early unplanned ICU admission have decreased 18-month survival compared with patients without early unplanned ICU admission.

Oncology and intensive care doctors' perception of intensive care admission of cancer patients: A cross-sectional national survey

INTRODUCTION

Prognosis in oncology has improved with early diagnosis and novel therapies. However, critical illness continues to trigger clinical and ethical dilemmas for the treating oncology and intensive care unit (ICU) doctors.

OBJECTIVES

The objective of this study was to investigate the perceptions of oncology and ICU doctors in managing critically ill cancer patients.

METHODS

A cross-sectional web-based survey exploring the management of a fictitious acutely deteriorating case vignette with solid-organ malignancy. The survey weblink was distributed between May and July 2022 to all Australian oncology and ICU doctors via newsletters to the members of the Medical Oncology Group of Australia, the Australian and New Zealand Intensive Care Society, and the College of Intensive Care Medicine inviting them to participate. The weblink was active till August 2022. The six domains included patient prognostication, advanced care plan, collaborative management, legal/ethical/moral challenges, ICU referral, and protocol-based ICU admission. The outcomes were reported as the level of agreement between oncology and ICU doctors for each domain/question.

RESULTS

184 responses (64 oncology and 120 ICU doctors) were analysed. Most respondents were specialists (78.1% [n = 50] oncology, 78.3% [n = 94] ICU doctors). Oncology doctors more commonly reported managing cancer patients with poor prognosis than ICU doctors (p < 0.001). Oncology doctors less commonly referred such patients for ICU admission (29.7% [n = 19] vs. 80.8% [n = 97], p < 0.001; odds ratio [OR] = 0.07; 95% confidence interval [CI]: 0.03-0.16) and infrequently encountered patients with prior goals of care (GOC) in medical emergency team escalations (40.6% [n = 26] vs. 86.7% [n = 104]; p < 0.001; OR = 0.06; 95% CI: 0.02-0.15; p < 0.001). Oncology doctors were less likely to discuss GOC during medical emergency team calls or within 24 h of ICU admission. More oncology doctors than ICU doctors thought that training rotation in the corresponding speciality group was beneficial (56.3% [n = 36] vs. 31.7% [n = 38]; p = 0.012; OR = 2.07; 95% CI: 1.02-4.23; p = 0.045).

CONCLUSION

Oncology doctors were less likely to encounter acute patient deterioration or establish timely GOC for such patients. Oncology doctors believed that an ICU rotation during their training may have helped manage challenging situations.

Peritoneal Lymphomatosis in a Pediatric Patient: A Peruvian Case Report

While NHL commonly affects lymph nodes, peritoneal lymphomatosis causing ascites is rare in pediatric patients. We present a unique case of DLBC lymphoma in a Peruvian child presenting as ascites associated with peritoneal lymphomatosis. The 11-year-old boy was admitted with ascites and dyspnea. Physical examination revealed collateral circulation, abdominal distension, and diminished breath sounds. Investigations led to a suspected diagnosis of peritoneal tuberculosis; however, a laparoscopic biopsy showed granulomatous infiltration consistent with high-grade diffuse B-cell lymphoma. The peritoneal lymphomatosis causing ascites is uncommon, and its initial presentation as peritoneal symptoms is even rarer. Differential diagnosis between peritoneal tuberculosis and DLBCL involvement can be challenging due to both shared signs and symptoms. Staging systems, such as the International Pediatric NHL Staging System, aid in determining the extent of the disease. DLBCL has a good prognosis, with treatment regimens such as the LMB-89 protocol showing high overall survival rates. Awareness of DLBCL's atypical presentations is crucial for timely diagnosis and management in the pediatric population. To conclude, children with ascites represent a diagnostic challenge posed by overlapping symptoms with other conditions, such as tuberculosis, and the need for a comprehensive approach to rule out different etiologies. Additionally, it is important the prompt treatment to avoid complications.

Development of a nomogram to predict the prognosis of patients with secondary bone tumors in the intensive care unit: a retrospective analysis based on the MIMIC IV database

PURPOSE

The present study aimed to develop a nomogram to predict the prognosis of patients with secondary bone tumors in the intensive care unit to facilitate risk stratification and treatment planning.

METHODS

We used the MIMIC IV 2.0 (the Medical Information Mart for Intensive Care IV) to retrieve patients with secondary bone tumors as a study cohort. To evaluate the predictive ability of each characteristic on patient mortality, stepwise Cox regression was used to screen variables, and the selected variables were included in the final Cox proportional hazard model. Finally, the performance of the model was tested using the decision curve, calibration curve, and receiver operating characteristic (ROC) curve.

RESULTS

A total of 1028 patients were enrolled after excluding cases with missing information. In the training cohort, albumin, APSIII (Acute Physiology Score III), chemotherapy, lactate, chloride, hepatic metastases, respiratory failure, SAPSII (Simplified Acute Physiology Score II), and total protein were identified as independent risk factors for patient death and then incorporated into the final model. The model showed good and robust prediction performance.

CONCLUSION

We developed a nomogram prognostic model for patients with secondary bone tumors in the intensive care unit, which provides effective survival prediction information.

Characteristics of critically ill patients with cancer associated with intensivist's perception of inappropriateness of ICU admission: A retrospective cohort study

PURPOSE

Although admitting cancer patients to the ICU is no longer an issue, it may be valuable to identify patients perceived least likely to benefit from admission. Our objective was to investigate factors associated with potentially inappropriate ICU admission.

METHODS

Retrospective cohort study of patients with cancer with unplanned ICU admission. We classified admissions as appropriate or potentially inappropriate according to Society of Critical Care Medicine guidelines. We used logistic regression model to assess factors associated with inappropriateness for ICU admission.

RESULTS

From 3384 patients, 663 (19.6%) were classified as potentially inappropriate. They received more invasive mechanical ventilation (25.3% vs 12.5%, P < 0.001) and vasopressors (34.4% vs 30.1%, P = 0.034), had higher ICU [3 (2,6) vs 2 (1,4), P < 0.001] length-of-stay, higher ICU (32.7% vs 8.4%, P < 0.001), hospital (71.9% vs 21.3%, P < 0.001), and one-year mortality (97.6% vs 54.7%, P < 0.001) compared with those considered appropriate. Performance status impairment, more severe organ dysfunctions at admission, metastatic disease, and source of ICU admission were the characteristics associated with intensivist's perception of inappropriateness of ICU admission.

CONCLUSIONS

These findings may help guide ICU admission policies and triage criteria for end-of-life discussions among hospitalized patients with cancer.

Prognostic and risk factor analysis of cancer patients after unplanned ICU admission: a real-world multicenter study

To investigate the occurrence and 90-day mortality of cancer patients following unplanned admission to the intensive care unit (ICU), as well as to develop a risk prediction model for their 90-day prognosis. We prospectively analyzed data from cancer patients who were admitted to the ICU without prior planning within the past 7 days, specifically between May 12, 2021, and July 12, 2021. The patients were grouped based on their 90-day survival status, and the aim was to identify the risk factors influencing their survival status. A total of 1488 cases were included in the study, with an average age of 63.2 ± 12.4 years. The most common reason for ICU admission was sepsis (n = 940, 63.2%). During their ICU stay, 29.7% of patients required vasoactive drug support (n = 442), 39.8% needed invasive mechanical ventilation support (n = 592), and 82 patients (5.5%) received renal replacement therapy. We conducted a multivariate COX proportional hazards model analysis, which revealed that BMI and a history of hypertension were protective factors. On the other hand, antitumor treatment within the 3 months prior to admission, transfer from the emergency department, general ward, or external hospital, high APACHE score, diagnosis of shock and respiratory failure, receiving invasive ventilation, and experiencing acute kidney injury (AKI) were identified as risk factors for poor prognosis within 90 days after ICU admission. The average length of stay in the ICU was 4 days, while the hospital stay duration was 18 days. A total of 415 patients died within 90 days after ICU admission, resulting in a mortality rate of 27.9%. We selected 8 indicators to construct the predictive model, which demonstrated good discrimination and calibration. The prognosis of cancer patients who are unplanned transferred to the ICU is generally poor. Assessing the risk factors and developing a risk prediction model for these patients can play a significant role in evaluating their prognosis.

Frailty and long-term survival among patients in Australian intensive care units with metastatic cancer (FRAIL-CANCER study): a retrospective registry-based cohort study

BACKGROUND

Recent advances in cancer therapeutics have improved outcomes, resulting in increasing candidacy of patients with metastatic cancer being admitted to intensive care units (ICUs). A large proportion of patients also have frailty, predisposing them to poor outcomes, yet the literature reporting on this is scarce. We aimed to assess the impact of frailty on survival in patients with metastatic cancer admitted to the ICU.

METHODS

In this retrospective registry-based cohort study, we used data from the Australia and New Zealand Intensive Care Society Adult Patient (age ≥16 years) database to identify patients with advanced (solid and haematological cancer) and a documented Clinical Frailty scale (CFS) admitted to 166 Australian ICUs. Patients without metastatic cancer were excluded. We analysed the effect of frailty (CFS 5-8) on long-term survival, and how this effect changed in specific subgroups (cancer subtypes, age [<65 years or ≥65 years], and those who survived hospitalisation). Because estimates tend to cluster within centres and vary between them, we used Cox proportional hazards regression models with robust sandwich variance estimators to assess the effect of frailty on survival time up to 4 years after ICU admission between groups.

FINDINGS

Between Jan 1, 2018, and March 31, 2022, 30 026 patients were eligible, and after exclusions 21 174 patients were included in the analysis; of these, 6806 (32·1%) had frailty, and 11 662 (55·1%) were male, 9489 (44·8%) were female, and 23 (0·1%) were intersex or self-reported indeterminate sex. The overall survival was lower for patients with frailty at 4 years compared with patients without frailty (29·5% vs 10·9%; p<0·0001). Frailty was associated with shorter 4-year survival times (adjusted hazard ratio 1·52 [95% CI 1·43-1·60]), and this effect was seen across all cancer subtypes. Frailty was associated with shorter survival times in patients younger than 65 years (1·66 [1·51-1·83]) and aged 65 years or older (1·40 [1·38-1·56]), but its effects were larger in patients younger than 65 years (pinteraction<0·0001). Frailty was also associated with shorter survival times in patients who survived hospitalisation (1·49 [1·40-1·59]).

INTERPRETATION

In patients with metastatic cancer admitted to the ICU, frailty was associated with poorer long-term survival. Patients with frailty might benefit from a goal-concordant time-limited trial in the ICU and will need suitable post-intensive care supportive management.

FUNDING

None.

Clinical course and outcomes of cancer patients admitted in medical ICU with sepsis

BACKGROUND AND AIMS

Sepsis is not only a leading cause of intensive care unit (ICU) admission but also one of the variables which affect outcomes of cancer patients. We aimed to assess the clinical characteristics, clinical course, mortality and risk factors associated with 30-day mortality in medical oncology patients admitted in a multi-disciplinary medical ICU.

METHODS

We conducted a retrospective analysis of 435 consecutive cancer patients admitted in medical ICU over a 28 months period. Patients were divided into two groups based on the presence of sepsis at the time of ICU admission. Data regarding baseline patient characteristics, clinical and laboratory data, need for organ support and 30-day mortality were collected. Sepsis patients were further classified as 30-day survivors and non-survivors and risk factors for mortality in these patients were determined.

RESULTS

Overall 30-day mortality was 57.8%. It was significantly higher in sepsis group patients (73.9%) as compared to non-sepsis patients (46.6%) (p < 0.001). Most common reason for ICU admission in non-sepsis group was respiratory distress (51.4%) followed by altered sensorium (28.4%). Presence of metastasis [odds ratio, OR: 3.89 (95% confidence interval, CI: 1.536-9.901)], high lactate [OR: 1.374 (95% CI: 1.024-1.843)] and need of invasive mechanical ventilator (IMV) support [OR: 7.634 (95% CI: 2.519-23.256)] or vasopressor support [OR: 3.268 (95% CI: 1.179-9.090)] were directly associated with 30-day mortality.

CONCLUSION

Critically ill cancer patients admitted with sepsis had high mortality. Presence of metastasis, high lactate and need of IMV or vasopressor support was associated with worse prognosis in cancer patients admitted with sepsis in ICU.

Sepsis and acute respiratory failure in patients with cancer: how can we improve care and outcomes even further?

PURPOSE OF REVIEW

Care and outcomes of critically ill patients with cancer have improved over the past decade. This selective review will discuss recent updates in sepsis and acute respiratory failure among patients with cancer, with particular focus on important opportunities to improve outcomes further through attention to phenotyping, predictive analytics, and improved outcome measures.

RECENT FINDINGS

The prevalence of cancer diagnoses in intensive care units (ICUs) is nontrivial and increasing. Sepsis and acute respiratory failure remain the most common critical illness syndromes affecting these patients, although other complications are also frequent. Recent research in oncologic sepsis has described outcome variation - including ICU, hospital, and 28-day mortality - across different types of cancer (e.g., solid vs. hematologic malignancies) and different sepsis definitions (e.g., Sepsis-3 vs. prior definitions). Research in acute respiratory failure in oncology patients has highlighted continued uncertainty in the value of diagnostic bronchoscopy for some patients and in the optimal respiratory support strategy. For both of these syndromes, specific challenges include multifactorial heterogeneity (e.g. in etiology and/or underlying cancer), delayed recognition of clinical deterioration, and complex outcomes measurement.

SUMMARY

Improving outcomes in oncologic critical care requires attention to the heterogeneity of cancer diagnoses, timely recognition and management of critical illness, and defining appropriate ICU outcomes.

Critically ill metastatic cancer patients returning home after unplanned ICU stay: an observational, multicentre retrospective study

BACKGROUND

Data about critically ill metastatic cancer patients functional outcome after unplanned admission to the ICU are scarce. The aim of this study was to assess factors associated with 90-day return home and 1-year survival in this population.

STUDY DESIGN AND METHODS

A multicenter retrospective study included all consecutive metastatic cancer patients admitted to the ICU for unplanned reason between 2017 and 2020.

RESULTS

Among 253 included metastatic cancer patients, mainly with lung cancer, 94 patients (37.2%) could return home on day 90. One-year survival rate was 28.5%. Performance status 0 or 1 (OR, 2.18; 95% CI 1.21-3.93; P = 0.010), no malnutrition (OR, 2.90; 95% CI 1.61-5.24; P < 0.001), female gender (OR, 2.39; 95% CI 1.33-4.29; P = 0.004), recent chemotherapy (OR, 2.62; 95% CI 1.40-4.90; P = 0.003), SOFA score ≤ 5 on admission (OR, 2.62; 95% CI 1.41-4.90; P = 0.002) were significantly predictive for 90-day return home. Malnutrition (HR, 1.66; 95% CI 1.18-2.22; P = 0.003), acute respiratory failure (ARF) as reason for admission (HR, 1.40; 95% CI 1.10-1.95; P = 0.043), SAPS II on admission (HR, 1.03; 95% CI 1.02-1.05; P < 0.001) and decisions to forgo life-sustaining therapies (DFLST) (HR, 2.80; 95% CI 2.04-3.84; P < 0.001) were independently associated with 1-year mortality.

CONCLUSIONS

More than one out of three metastatic cancer patients could return home within 3 months after an unplanned admission to the ICU. Previous performance and nutritional status, ongoing specific treatment and low severity of the acute illness were found to be predictive for return home. Such encouraging findings should help change the dismal perception of critically ill metastatic cancer patients.

The Effects of a Simulation-Based Experience with Standardized Participants on Learning and Clinical Decision-Making Related to Nursing Management of Oncologic Emergencies

Upon entry-to-practice, graduate nurses must be able to effectively manage oncologic emergencies to ensure best patient and family outcomes. Thus, nurse educators must develop active teaching strategies to prepare prelicensure nursing students with appropriate nursing oncology knowledge and skills. The purposes of this study were to determine the effect of simulation-based experiences (SBEs) with standardized participants (SPs) involving a patient and family member on baccalaureate nursing students' confidence and competence, anxiety and self-confidence with clinical decision-making, and satisfaction and self-confidence in learning using SBEs related to management of oncologic emergencies within a seminar-style course. A longitudinal, one-group, convergent mixed-methods design was used. Baccalaureate nursing students enrolled in a senior seminar participated in two SBEs. Study data were collected pre-seminar, pre-SBE, and post-SBE. Twenty-five senior nursing students participated in this study. There was a significant increase in students' confidence and self-perceived competence, and a significant decrease in anxiety and increase in self-confidence with clinical decision-making related to the nursing management of oncologic emergencies over time. All seven student groups in the hypercalcemia SBE, and five student groups in the hypersensitivity reaction SBE demonstrated objective competence. Qualitative themes identified included: realism, critical thinking, and benefits for professional practice. Study findings support the use of SBEs with SPs to enhance nursing students' confidence and competence, and to increase self-confidence and reduce anxiety with clinical decision-making related to the management of oncologic emergencies in a seminar-style course. The inclusion of a family member enhanced the realism of complex SBEs.

In-hospital mortality and one-year survival of critically ill patients with cancer colonized or not with carbapenem-resistant gram-negative bacteria or vancomycin-resistant enterococci: an observational study

BACKGROUND

Patients with cancer are at risk of multidrug-resistant bacteria colonization, but association of colonization with in-hospital mortality and one-year survival has not been established in critically ill patients with cancer.

METHODS

Using logistic and Cox-regression analyses adjusted for confounders, in adult patients admitted at intensive care unit (ICU) with active cancer, we evaluate the association of colonization by carbapenem-resistant Gram-negative bacteria or vancomycin-resistant enterococci with in-hospital mortality and one-year survival.

RESULTS

We included 714 patients and among them 140 were colonized (19.6%). Colonized patients more frequently came from ward, had longer hospital length of stay before ICU admission, had unplanned ICU admission, had worse performance status, higher predicted mortality upon ICU admission, and more hematological malignancies than patients without colonization. None of the patients presented conversion of colonization to infection by the same bacteria during hospital stay, but 20.7% presented conversion to infection after hospital discharge. Colonized patients had a higher in-hospital mortality compared to patients without colonization (44.3 vs. 33.4%; p < 0.01), but adjusting for confounders, colonization was not associated with in-hospital mortality [Odds ratio = 1.03 (0.77-1.99)]. Additionally, adjusting for confounders, colonization was not associated with one-year survival [Hazard ratio = 1.10 (0.87-1.40)].

CONCLUSIONS

Adult critically ill patients with active cancer and colonized by carbapenem-resistant Gram-negative bacteria or vancomycin-resistant enterococci active cancer have a worse health status compared to patients without colonization. However, adjusting for confounders, colonization by carbapenem-resistant Gram-negative bacteria or vancomycin-resistant enterococci are not associated with in-hospital mortality and one-year survival.

A prediction model for in-hospital mortality in intensive care unit patients with metastatic cancer

Aim

To identify predictors for in-hospital mortality in patients with metastatic cancer in intensive care units (ICUs) and established a prediction model for in-hospital mortality in those patients.

Methods

In this cohort study, the data of 2,462 patients with metastatic cancer in ICUs were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Least absolute shrinkage and selection operator (LASSO) regression analysis was applied to identify the predictors for in-hospital mortality in metastatic cancer patients. Participants were randomly divided into the training set (n = 1,723) and the testing set (n = 739). Patients with metastatic cancer in ICUs from MIMIC-IV were used as the validation set (n = 1,726). The prediction model was constructed in the training set. The area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were employed for measuring the predictive performance of the model. The predictive performance of the model was validated in the testing set and external validation was performed in the validation set.

Results

In total, 656 (26.65%) metastatic cancer patients were dead in hospital. Age, respiratory failure, the sequential organ failure assessment (SOFA) score, the Simplified Acute Physiology Score II (SAPS II) score, glucose, red cell distribution width (RDW) and lactate were predictors for the in-hospital mortality in patients with metastatic cancer in ICUs. The equation of the prediction model was ln(P/(1 + P)) = -5.9830 + 0.0174 × age + 1.3686 × respiratory failure + 0.0537 × SAPS II + 0.0312 × SOFA + 0.1278 × lactate - 0.0026 × glucose + 0.0772 × RDW. The AUCs of the prediction model was 0.797 (95% CI,0.776-0.825) in the training set, 0.778 (95% CI, 0.740-0.817) in the testing set and 0.811 (95% CI, 0.789-0.833) in the validation set. The predictive values of the model in lymphoma, myeloma, brain/spinal cord, lung, liver, peritoneum/pleura, enteroncus and other cancer populations were also assessed.

Conclusion

The prediction model for in-hospital mortality in ICU patients with metastatic cancer exhibited good predictive ability, which might help identify patients with high risk of in-hospital death and provide timely interventions to those patients.

Machine Learning-Based Mortality Prediction Model for Critically Ill Cancer Patients Admitted to the Intensive Care Unit (CanICU)

BACKGROUND

Although cancer patients are increasingly admitted to the intensive care unit (ICU) for cancer- or treatment-related complications, improved mortality prediction remains a big challenge. This study describes a new ML-based mortality prediction model for critically ill cancer patients admitted to ICU.

PATIENTS AND METHODS

We developed CanICU, a machine learning-based 28-day mortality prediction model for adult cancer patients admitted to ICU from Medical Information Mart for Intensive Care (MIMIC) database in the USA (n = 766), Yonsei Cancer Center (YCC, n = 3571), and Samsung Medical Center in Korea (SMC, n = 2563) from 2 January 2008 to 31 December 2017. The accuracy of CanICU was measured using sensitivity, specificity, and area under the receiver operating curve (AUROC).

RESULTS

A total of 6900 patients were included, with a 28-day mortality of 10.2%/12.7%/36.6% and a 1-year mortality of 30.0%/36.6%/58.5% in the YCC, SMC, and MIMIC-III cohort. Nine clinical and laboratory factors were used to construct the classifier using a random forest machine-learning algorithm. CanICU had 96% sensitivity/73% specificity with the area under the receiver operating characteristic (AUROC) of 0.94 for 28-day, showing better performance than current prognostic models, including the Acute Physiology and Chronic Health Evaluation (APACHE) or Sequential Organ Failure Assessment (SOFA) score. Application of CanICU in two external data sets across the countries yielded 79-89% sensitivity, 58-59% specificity, and 0.75-0.78 AUROC for 28-day mortality. The CanICU score was also correlated with one-year mortality with 88-93% specificity.

CONCLUSION

CanICU offers improved performance for predicting mortality in critically ill cancer patients admitted to ICU. A user-friendly online implementation is available and should be valuable for better mortality risk stratification to allocate ICU care for cancer patients.

Analysis of physical function, muscle strength, and pulmonary function in surgical cancer patients: a prospective cohort study

The aim of this study was to investigate mobility, physical functioning, peripheral muscle strength, inspiratory muscle strength and pulmonary function in surgical cancer patients admitted to an intensive care unit (ICU). We conducted a prospective cohort study with 85 patients. Mobility, physical functioning, peripheral muscle strength, inspiratory muscle strength, and pulmonary function were assessed using the following tests: ICU Mobility Scale (IMS); Chelsea Critical Care Physical Assessment (CPAx); handgrip strength and Medical Research Council Sum-Score (MRC-SS); maximal inspiratory pressure (MIP) and S-Index; and peak inspiratory flow, respectively. The assessments were undertaken at ICU admission and discharge. The data were analyzed using the Shapiro-Wilk and Wilcoxon tests and Spearman's correlation coefficient. Significant differences in inspiratory muscle strength, CPAx, grip strength, MRC-SS, MIP, S-Index, and peak inspiratory flow scores were observed between ICU admission and discharge. Grip strength showed a moderate correlation with MIP at admission and discharge. The findings also show a moderate correlation between S-Index scores and both MIP and peak inspiratory flow scores at admission and a strong correlation at discharge. Patients showed a gradual improvement in mobility, physical functioning, peripheral and inspiratory muscle strength, and inspiratory flow during their stay in the ICU.

Quality of life of patients with solid malignancies at 3 months after unplanned admission in the intensive care unit: A prospective case-control study

BACKGROUND

Although short- and long-term survival in critically ill patients with cancer has been described, data on their quality of life (QoL) after an intensive care unit (ICU) stay are scarce. This study aimed to determine the impact of an ICU stay on QoL assessed at 3 months in patients with solid malignancies.

METHODS

A prospective case-control study was conducted in three French ICUs between February 2020 and February 2021. Adult patients with lung, colorectal, or head and neck cancer who were admitted in the ICU were matched in a 1:2 ratio with patients who were not admitted in the ICU regarding their type of cancer, curative or palliative anticancer treatment, and treatment line. The primary endpoint was the QoL assessed at 3 months from inclusion using the mental and physical components of the Short Form 36 (SF-36) Health Survey. The use of anticancer therapies at 3 months was also evaluated.

RESULTS

In total, 23 surviving ICU cancer patients were matched with 46 non-ICU cancer patients. Four patients in the ICU group did not respond to the questionnaire. The mental component score of the SF-36 was higher in ICU patients than in non-ICU patients: median of 54 (interquartile range: 42-57) vs. 47 (37-52), respectively (p = 0.01). The physical component score of the SF-36 did not differ between groups: 35 (31-47) vs. 42 (34-47) (p = 0.24). In multivariate analysis, no association was found between patient QoL and an ICU stay. A good performance status and a non-metastatic cancer at baseline were independently associated with a higher physical component score. The use of anticancer therapies at 3 months was comparable between the two groups.

CONCLUSION

In patients with solid malignancies, an ICU stay had no negative impact on QoL at 3 months after discharge when compared with matched non-ICU patients.

Machine Learning Model Development and Validation for Predicting Outcome in Stage 4 Solid Cancer Patients with Septic Shock Visiting the Emergency Department: A Multi-Center, Prospective Cohort Study

A reliable prognostic score for minimizing futile treatments in advanced cancer patients with septic shock is rare. A machine learning (ML) model to classify the risk of advanced cancer patients with septic shock is proposed and compared with the existing scoring systems. A multi-center, retrospective, observational study of the septic shock registry in patients with stage 4 cancer was divided into a training set and a test set in a 7:3 ratio. The primary outcome was 28-day mortality. The best ML model was determined using a stratified 10-fold cross-validation in the training set. A total of 897 patients were included, and the 28-day mortality was 26.4%. The best ML model in the training set was balanced random forest (BRF), with an area under the curve (AUC) of 0.821 to predict 28-day mortality. The AUC of the BRF to predict the 28-day mortality in the test set was 0.859. The AUC of the BRF was significantly higher than those of the Sequential Organ Failure Assessment score and the Acute Physiology and Chronic Health Evaluation II score (both p < 0.001). The ML model outperformed the existing scores for predicting 28-day mortality in stage 4 cancer patients with septic shock. However, further studies are needed to improve the prediction algorithm and to validate it in various countries. This model might support clinicians in real-time to adopt appropriate levels of care.

Short-term survival of patients with advanced pancreatic cancer admitted to intensive care unit: a retrospective cohort study

Background

Little is known about the outcomes of patients with advanced pancreatic cancer admitted to the intensive care unit (ICU) due to medical complications. We designed a study to evaluate their short-term (30-day) survival, predictors of short-term survival and chances of additional chemotherapy.

Methods

We reviewed all patients with advanced (stage III or IV) pancreatic adenocarcinoma admitted to an ICU in a dedicated Brazilian cancer centre from 2009 to 2018 due to medical reasons. We fitted multivariate regression models to identify predictors of 30-day survival and additional systemic chemotherapy.

Results

The study population consisted of 171 patients. Ninety-four patients (55.0%) had Eastern Cooperative Oncology Group (ECOG) performance status 2-4 and 146 (85.4%) had metastatic disease. Most patients (N = 75; 43.9%) were admitted to the ICU during first-line treatment. Median overall survival was 32 days (95% confidence interval (95% CI): 20-49). Survival rate at 30 days was 50.6%. ECOG performance status 2-4 was the only variable associated with lower probability of survival at 30 days in multivariate analysis (odds ratio: 0.28; 95% CI: 0.14-0.54; p < 0.001). Overall, 58 patients (33.9%) received additional chemotherapy and among all patients, 13.5% experienced clinical benefit from this treatment.

Conclusion

Patients with advanced pancreatic cancer admitted to the ICU for medical reasons have a dismal prognosis. Early palliative care and refined tools to establish those who would benefit from an ICU trial could help improve patients' care.

A Systematic Review and Meta-Analysis Evaluating Geographical Variation in Outcomes of Cancer Patients Treated in ICUs

The reported mortality rates of cancer patients admitted to ICUs vary widely. In addition, there are no studies that examined the outcomes of critically ill cancer patients based on the geographical regions. Therefore, we aimed to evaluate the mortality rates among critically ill cancer patients and provide a comparison based on geography.

DATA SOURCES

PubMed, EMBASE, and Web of Science.

STUDY SELECTION

We included observational studies evaluating adult patients with cancer treated in ICUs. We excluded non-English studies, those with greater than 30% hematopoietic stem cell transplant or postsurgical patients, and those that evaluated a specific type of critical illness, stage of malignancy, or age group.

DATA EXTRACTION

Two reviewers independently applied eligibility criteria, assessed quality, and extracted data. Studies were classified based on the continent in which they were conducted. Primary outcomes were ICU and hospital mortality. We pooled effect sizes by geographical region.

DATA SYNTHESIS

Forty-six studies were included (n = 110,366). The overall quality of studies was moderate. Most of the published literature was from Europe (n = 22), followed by North America (n = 9), Asia (n = 8), South America (n = 5), and Oceania (n = 2). Pooled ICU mortality rate was 38% (95% CI, 33-43%); the lowest mortality rate was in Oceania (26%; 95% CI, 22-30%) and highest in Asia (51%; 95% CI, 44-57%). Pooled hospital mortality rate was 45% (95% CI, 41-49%), with the lowest in North America (37%; 95% CI, 31-43%) and highest in Asia (54%; 95% CI, 37-71%).

CONCLUSIONS

More than half of cancer patients admitted to ICUs survived hospitalization. However, there was wide variability in the mortality rates, as well as the number of available studies among geographical regions. This variability suggests an opportunity to improve outcomes worldwide, through optimizing practice and research.

A nationwide study on characteristics and outcome of cancer patients with sepsis requiring intensive care

BACKGROUND

Sepsis is the leading cause of admission to the intensive care unit (ICU) for cancer patients and survival rates have historically been low. The aims of this nationwide cohort study were to describe the characteristics and outcomes of cancer patients admitted to the ICU with sepsis compared with other sepsis patients requiring ICU admission.

MATERIAL AND METHODS

This was a retrospective, observational study. All adult admissions to Icelandic ICUs during years 2006, 2008, 2010, 2012, 2014 and 2016 were screened for severe sepsis or septic shock by ACCP/SCCM criteria. Clinical characteristics and outcomes of sepsis patients with cancer were compared to those without cancer.

RESULTS

In the study period, 235 of 971 (24%) patients admitted to Icelandic ICUs because of sepsis had cancer, most often a solid tumour (100), followed by metastatic tumours (69) and haematological malignancies (66). Infections were more often hospital-acquired in cancer patients (52%) than other sepsis patients (18%, p < 0.001) and sites of infections differed, with abdominal infections being most common in patients with solid and metastatic tumours but lungs and bloodstream infections in haematological malignancies. The length of stay in the ICU was shorter for sepsis patients with metastatic disease than other sepsis patients (2 vs. 4 days, p < 0.001) and they were more likely to have treatment limitations (52 vs. 19%, p < 0.05). Median survival of patients with metastatic disease was 19 days from ICU admission. The 28-day mortality (25%) of solid tumour patients was comparable to that of sepsis patients without cancer (20%, p < 0.001).

CONCLUSIONS

Cancer is a common comorbidity in patients admitted to the ICU with sepsis. The clinical presentation and outcome differs between cancer types. Individuals with metastatic cancer were unlikely to receive prolonged invasive ICU care treatment. Comparable short-term outcome was found for patients with solid tumours and no cancer.

Long-Term Outcome of Critically Ill Advanced Cancer Patients Managed in an Intermediate Care Unit

Background: To analyze the long-term outcomes for advanced cancer patients admitted to an intermediate care unit (ImCU), an analysis of a do not resuscitate orders (DNR) subgroup was made. Methods: A retrospective observational study was conducted from 2006 to January 2019 in a single academic medical center of cancer patients with stage IV disease who suffered acute severe complications. The Simplified Acute Physiology Score 3 (SAPS 3) was used as a prognostic and severity score. In-hospital mortality, 30-day mortality and survival after hospital discharge were calculated. Results: Two hundred and forty patients with stage IV cancer who attended at an ImCU were included. In total, 47.5% of the cohort had DNR orders. The two most frequent reasons for admission were sepsis (32.1%) and acute respiratory failure (excluding sepsis) (38.7%). Mortality in the ImCU was 10.8%. The mean predicted in-hospital mortality according to SAPS 3 was 51.9%. The observed in-hospital mortality was 37.5% (standard mortality ratio of 0.72). Patients discharged from hospital had a median survival of 81 (30.75−391.25) days (patients with DNR orders 46 days (19.5−92.25), patients without DNR orders 162 days (39.5−632)). The observed mortality was higher in patients with DNR orders: 52.6% vs. 23.8%, p 0 < 0.001. By multivariate logistic regression, a worse ECOG performance status (3−4 vs. 0−2), a higher SAPS 3 Score and DNR orders were associated with a higher in-hospital mortality. By multivariate analysis, non-invasive mechanical ventilation, higher bilirubin levels and DNR orders were significantly associated with 30-day mortality. Conclusion: For patients with advanced cancer disease, even those with DNR orders, who suffer from acute complications or require continuous monitoring, an ImCU-centered multidisciplinary management shows encouraging results in terms of observed-to-expected mortality ratios.

Outcomes of Patients With Active Cancer and COVID-19 in the Intensive-Care Unit: A Multicenter Ambispective Study

Background

Several studies report an increased susceptibility to SARS-CoV-2 infection in cancer patients. However, data in the intensive care unit (ICU) are scarce.

Research Question

We aimed to investigate the association between active cancer and mortality among patients requiring organ support in the ICU.

Study Design and Methods

In this ambispective study encompassing 17 hospitals in France, we included all adult active cancer patients with SARS-CoV-2 infection requiring organ support and admitted in ICU. For each cancer patient, we included 3 non cancer patients as controls. Patients were matched at the same ratio using the inverse probability weighting approach based on a propensity score assessing the probability of cancer at admission. Mortality at day 60 after ICU admission was compared between cancer patients and non-cancer patients using primary logistic regression analysis and secondary multivariable analyses.

Results

Between March 12, 2020 and March 8, 2021, 2608 patients were admitted with SARS-CoV-2 infection in our study, accounting for 2.8% of the total population of patients with SARS-CoV-2 admitted in all French ICUs within the same period. Among them, 105 (n=4%) presented with cancer (51 patients had hematological malignancy and 54 patients had solid tumors). 409 of 420 patients were included in the propensity score matching process, of whom 307 patients in the non-cancer group and 102 patients in the cancer group. 145 patients (35%) died in the ICU at day 60, 59 (56%) with cancer and 86 (27%) without cancer. In the primary logistic regression analysis, the odds ratio for death associated to cancer was 2.3 (95%CI 1.24 - 4.28, p=0.0082) higher for cancer patients than for a non-cancer patient at ICU admission. Exploratory multivariable analyses showed that solid tumor (OR: 2.344 (0.87-6.31), p=0.062) and hematological malignancies (OR: 4.144 (1.24-13.83), p=0.062) were independently associated with mortality.

Interpretation

Patients with cancer and requiring ICU admission for SARS-CoV-2 infection had an increased mortality, hematological malignancy harboring the higher risk in comparison to solid tumors.

Initiation of a new anti-cancer medical treatment in ICU: a retrospective study

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.

A Novel Nomogram for Predicting Morbidity Risk in Patients with Secondary Malignant Neoplasm of Bone and Bone Marrow: An Analysis Based on the Large MIMIC-III Clinical Database

Objective

Bone and bone marrow are the third most frequent sites of metastases from many cancers and are associated with low survival and high morbidity rates. Currently, there are no effective bedside tools to predict the morbidity risk of these patients in general intensive care units (ICUs). The main objective of this study was to establish and validate a nomogram to predict the morbidity risk of patients with bone and bone marrow metastases.

Methods

Data on patients with bone and bone marrow metastases were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The patients were divided into training and validation cohorts. The data were analyzed using univariate and multivariate Cox regression methods. Factors significantly and independently prognostic of survival were used to construct a nomogram predicting 30-day morbidity. The nomogram was validated by various methods, including Harrell’s concordance index (C-index), area under the receiver operating characteristic curve (AUC), calibration curve, integrated discrimination improvement (IDI), net reclassification index (NRI), and decision curve analysis (DCA).

Results

The study included 610 patients in the training cohort and 262 in the validation cohort. Multivariate Cox regression analysis showed that temperature, SpO₂, Sequential Organ Failure Assessment (SOFA) score, Oxford Acute Severity of Illness Score (OASIS), comorbidities with coagulopathy, white blood cell count, heart rate, and respiratory rate were independent predictors of patient survival. The resulting nomogram had good discriminative ability, as shown by high AUCs, and was well calibrated, as demonstrated by calibration curves. Improvements in NRI and IDI values suggested that the nomogram was superior to the SOFA scoring system. DCA curves revealed that the nomogram showed good value in clinical applications.

Conclusion

This prognostic nomogram, based on demographic and laboratory parameters, was predictive of the 30-day morbidity rate in patients with secondary malignant neoplasms of the bone and bone marrow, suggesting its applicability in clinical practice.

Advance Directives in Oncology and Haematology: A Long Way to Go-A Narrative Review

Patients living with cancer often experience serious adverse events due to their condition or its treatments. Those events may lead to a critical care unit admission or even result in death. One of the most important but challenging parts of care is to build a care plan according to the patient’s wishes, meeting their goals and values. Advance directives (ADs) allow everyone to give their preferences in advance regarding life sustaining treatments, continuation, and withdrawal or withholding of treatments in case one is not able to speak their mind anymore. While the absence of ADs is associated with a greater probability of receiving unwanted intensive care around the end of their life, their existence correlates with the respect of the patient’s desires and their greater satisfaction. Although progress has been made to promote ADs’ completion, they are still scarcely used among cancer patients in many countries. Several limitations to their acceptance and use can be detected. Efforts should be made to provide tailored solutions for the identified hindrances. This narrative review aims to depict the situation of ADs in the oncology context, and to highlight the future areas of improvement.

Smaller but more frequent dosing of cefepime in the treatment of febrile neutropenia

BACKGROUND

Generally national guidelines for febrile neutropenia recommend treatment with cefepime 2 g every 8 h. Due to beta-lactam's time dependent killing effects, it is hypothesized smaller doses given more frequently might be non-inferior. The objective of this study is to retrospectively evaluate the efficacy of cefepime 1 g every 6 h versus 2 g every 8 h in cancer patients with febrile neutropenia.

METHODS

This retrospective, single-center, cohort study included patients with a diagnosis of febrile neutropenia treated with cefepime during an inpatient encounter. Patients were grouped based on receipt of cefepime 2 g every 8 h (high dose cohort) versus cefepime 1 g every 6 h (low dose cohort). The primary outcome compared the time to defervescence after cefepime initiation between the two dosing strategies. A subgroup analysis of the primary endpoint was conducted in patients who received both cefepime and vancomycin.

RESULTS

Ninety-seven patients were included in the high dose cohort, and seventy-six patients were included in the low dose cohort. Baseline characteristics were similar between cohorts with the exception of race. The time to defervescence between the high dose cohort and low dose cohort were comparable between groups (49.2 vs. 46.7 h). The time to defervescence in subgroup analysis of patients who received empiric vancomycin and cefepime was 65.7 versus 59.7.

CONCLUSION

Patients who received cefepime 1 g every 6 h were found to have similar trends in achieving time to defervescence compared to 2 g every 8 h.

The pharmacoeconomic benefits of pemetrexed dose individualization in lung cancer patients

Neutropenia is a dose-related treatment-limiting and costly adverse event of pemetrexed. We postulate that individualized dosing reduces the incidence of neutropenia. The aims of this study were to 1) investigate the costs of pemetrexed-related neutropenia and 2) to determine the pharmacoeconomic benefits of individualized dosing of pemetrexed in terms of budget impact, yearly cost savings and reduction in severe neutropenia. Retrospective data on the treatment of ≥grade 3 neutropenia during pemetrexed-based chemotherapy were collected from three Dutch hospitals to determine the mean health care consumption during a neutropenic episode. Subsequently, Monte Carlo simulations were performed using a validated pharmacokinetic/pharmacodynamic (PK/PD) model to predict the neutropenia incidence during four cycles for standard dosing of pemetrexed and individualized dosing. The mean costs per neutropenia and the expected neutropenia incidence were combined to calculate the budget impact and cost savings. We found that the average costs per pemetrexed-associated neutropenic episode to be € 1,490. The neutropenia incidence for the standard and individualized pemetrexed dosing strategies were 12.7 and 9.9%, respectively. This resulted in total expected neutropenia-related costs of approximately € 3.0 million and €2.4 million, respectively. Taking the number of patients eligible for pemetrexed treatment into account, individualized dosing could result in saving €686,000 on a yearly basis in the Netherlands alone. Individualized dosing of pemetrexed can decrease the incidence of neutropenia and thus result in a significant decrease in neutropenia-related costs and decreased risk of hospitalization or even death while maintaining therapeutic exposure.

Long-Term Outcomes and Prognostic Factors of Patients with Metastatic Solid Tumors Admitted to the Intensive Care Unit

INTRODUCTION

Admission of metastatic cancer patients to the intensive care unit (ICU) poses medical and ethical challenges in the absence of reliable prognostic tools to guide decision-making.

MATERIAL AND METHODS

We retrospectively analyzed the medical charts of 129 consecutive patients with metastatic solid tumors admitted to the ICU between January and September 2014 and identified prognostic factors (PFs) using Cox models.

RESULTS

The mean patient age at ICU admission was 58.9 years (range, 25-81 years; males, 51%). Performance status (PS) was 0-1 and 2-3 in 61% and 39% of the patients, respectively. The most prevalent cancers were lung cancer (20%), sarcoma (17%), and breast cancer (16%). ICU admission was attributable to the cancer itself (53%), cancer treatment toxicity (43%), and comorbidities (37%). The median overall survival (OS) after ICU admission was 2.6 months; 15% of the patients died during the ICU stay. Poor PFs for OS were PS >1 before ICU admission (p = 0.007) and ICU admission for the cancer itself (p < 10-3). After ICU discharge, 58% and 42% of the patients received systemic treatment within 12 months and showed good PS recovery, respectively. Multiple organ failure and a multidisciplinary decision to limit therapeutic efforts were poor PFs for reinitiation of systemic treatment (p = 0.2 and 0.006, respectively), and the latter was also a poor PF for PS recovery (p = 0.004).

DISCUSSION

In the ICU, the OS of adult patients with solid tumors was similar to that of the noncancer population. For ICU admissions related to the cancer itself, the prognosis is poor.

Clinico-demographic and Outcome Predictors in Solid Tumor Patients with Unplanned Intensive Care Unit Admissions: An Observational Study

OBJECTIVES

Critically ill solid organ malignancy patients admitted to intensive care unit (ICU) as unplanned medical admissions behave differently from other subsets of cancer patients (hematolymphoid malignancies and cancer patients admitted for postoperative care). These patients if appropriately selected may benefit from the ICU care. There is paucity of data on critically ill unplanned admissions of solid organ malignancies from South Asia. We analyzed data of patients with solid tumors with unplanned admissions to the ICU to determine the clinical, epidemiological characteristics, and predictors of hospital mortality in an Indian ICU.

MATERIALS AND METHODS

This prospective, observational study was done in our 14-bedded mixed medical-surgical ICU from July 2014 to November 2015. We included all consecutive adult unplanned admissions with solid organ malignancies having ICU stay of >24 hours. Surgical admissions, hematolymphoid malignancies, advanced malignancy with no treatment options, and those cured of cancer >5 years were excluded.

RESULTS

Two hundred and thirty-five consecutive patients were included in this cohort. ICU and hospital mortalities were 36.6 and 40%, respectively. On multivariate analysis, cancer status [odds ratio (OR): 3.204; 95% confidence interval (CI): 1.271-8.078], invasive mechanical ventilation (OR: 5.940; 95% CI: 2.632-13.408), and sequential organ failure assessment (SOFA) score on the day of ICU admission (OR: 1.199; 95% CI: 1.042-1.379) were independent predictors of hospital mortality.

CONCLUSION

Acute respiratory failure and septic shock are the common reasons of unplanned ICU admission for patients with solid organ malignancies. With good patient selection, more than half of such patients are likely to be discharged alive from the hospital.

HOW TO CITE THIS ARTICLE

Siddiqui SS, Narkhede AM, Chaudhari HK, Ravisankar NP, Dhundi U, Sarode S, et al. Clinico-demographic and Outcome Predictors in Solid Tumor Patients with Unplanned Intensive Care Unit Admissions: An Observational Study. Indian J Crit Care Med 2021;25(12):1421-1426.

[The role of the intensive care unit after thoracic surgery]

Lung (bronchial) cancer is the leading cause of cancer-related death in Western countries today. Thoracic surgery represents a major therapeutic strategy and the various advances made in recent years have made it possible to develop less and less invasive techniques. That said, the postoperative period may be lengthy, post-surgical approaches need to be more precisely codified, and it matters that the different interventions involved be supported by sound scientific evidence. To date, however, there exists no evidence that preventive postoperative admission to intensive care is beneficial for patients having undergone lung resection surgery without immediate complications. A stratification of the risk of complications taking into consideration the patient's general state of health (e.g., nutritional status, degree of autonomy, etc.), comorbidities and type of surgery could be a useful predictive tool regarding the need for postoperative intensive care. However, serious post-operative complications remain relatively frequent and post-operative management of these intensive care patients is liable to become complex and long-lasting. In the aftermath of the validation of "enhanced recovery after surgery" (ERAS) in thoracic surgery, new protocols are needed to optimize management of patients having undergone pulmonary resection. This article focuses on the main postoperative complications and more broadly on intensive care patient management following thoracic surgery.

Critically Ill Patients Treated for Chimeric Antigen Receptor-Related Toxicity: A Multicenter Study

OBJECTIVES

To report the epidemiology, treatments, and outcomes of adult patients admitted to the ICU after cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome.

DESIGN

Retrospective cohort study.

SETTING

Nine centers across the U.S. part of the chimeric antigen receptor-ICU initiative.

PATIENTS

Adult patients treated with chimeric antigen receptor T-cell therapy who required ICU admission between November 2017 and May 2019.

INTERVENTIONS

Demographics, toxicities, specific interventions, and outcomes were collected.

RESULTS

One-hundred five patients treated with axicabtagene ciloleucel required ICU admission for cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome during the study period. At the time of ICU admission, the majority of patients had grade 3-4 toxicities (66.7%); 15.2% had grade 3-4 cytokine release syndrome and 64% grade 3-4 immune effector cell-associated neurotoxicity syndrome. During ICU stay, cytokine release syndrome was observed in 77.1% patients and immune effector cell-associated neurotoxicity syndrome in 84.8% of patients; 61.9% patients experienced both toxicities. Seventy-nine percent of patients developed greater than or equal to grade 3 toxicities during ICU stay, however, need for vasopressors (18.1%), mechanical ventilation (10.5%), and dialysis (2.9%) was uncommon. Immune Effector Cell-Associated Encephalopathy score less than 3 (69.7%), seizures (20.2%), status epilepticus (5.7%), motor deficits (12.4%), and cerebral edema (7.9%) were more prevalent. ICU mortality was 8.6%, with only three deaths related to cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome. Median overall survival time was 10.4 months (95% CI, 6.64-not available mo). Toxicity grade or organ support had no impact on overall survival; higher cumulative corticosteroid doses were associated to decreased overall and progression-free survival.

CONCLUSIONS

This is the first study to describe a multicenter cohort of patients requiring ICU admission with cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome after chimeric antigen receptor T-cell therapy. Despite severe toxicities, organ support and in-hospital mortality were low in this patient population.

Impact of empirical antibiotic regimens on mortality in neutropenic patients with bloodstream infection presenting with septic shock

Objectives: We analyzed risk factors for mortality in febrile neutropenic patients with bloodstream infections (BSI) presenting with septic shock and assessed the impact of empirical antibiotic regimens. Methods: Multicenter retrospective study (2010-2019) of two prospective cohorts comparing BSI episodes in patients with or without septic shock. Multivariate analysis was performed to identify independent risk factors for mortality in episodes with septic shock. Results: Of 1563 patients with BSI, 257 (16%) presented with septic shock. Those patients with septic shock had higher mortality than those without septic shock (55% vs 15%, p<0.001). Gram-negative bacilli caused 81% of episodes with septic shock; gram-positive cocci, 22%; and Candida species 5%. Inappropriate empirical antibiotic treatment (IEAT) was administered in 17.5% of septic shock episodes. Empirical β-lactam combined with other active antibiotics was associated with the lowest mortality observed. When amikacin was the only active antibiotic, mortality was 90%. Addition of empirical specific gram-positive coverage had no impact on mortality. Mortality was higher when IEAT was administered (76% vs 51%, p=0.002). Age >70 years (OR 2.3, 95% CI 1.2-4.7), IEAT for Candida spp. or gram-negative bacilli (OR 3.8, 1.3-11.1), acute kidney injury (OR 2.6, 1.4-4.9) and amikacin as the only active antibiotic (OR 15.2, 1.7-134.5) were independent risk factors for mortality, while combination of β-lactam and amikacin was protective (OR 0.32, 0.18-0.57). Conclusions: Septic shock in febrile neutropenic patients with BSI is associated with extremely high mortality, especially when IEAT is administered. Combination therapy including an active β-lactam and amikacin results in the best outcomes.

Improving Outcomes for Elderly Patients Following Emergency Surgery: a Cutting-edge Review

Purpose of Review

The aim of this review is to explore the consequence of emergency general surgery in the elderly, and to summarise recent developments in the pre-, peri- and postoperative management of these patients, in order to improve outcomes.

Recent Findings

Preoperatively, accurate risk assessment is vital to ensure the right patients undergo emergency surgery. Perioperatively, there are multiple interventions specific to elderly patients that have been shown to improve outcomes. Postoperatively, elderly patients must be cared more in an appropriate setting in order to avoid failure to rescue and promote return to function.

Summary

This review of contemporary evidence identifies multiple pre-, peri- and postoperative interventions that can improve outcomes for elderly patients after emergency general surgery. These evidence-based recommendations should help direct care of elderly patients undergoing emergency surgery and foster further quality improvement measures and research investigations.

One-year Mortality of Cancer Patients with an Unplanned ICU Admission: A Cohort Analysis Between 2008 and 2017 in the Netherlands

Introduction: A decrease in short-term mortality of critically ill cancer patients with an unplanned intensive care unit (ICU) admission has been described. Few studies describe a change over time of 1-year mortality. Therefore, we examined the 1-year mortality of cancer patients (hematological or solid) with an unplanned ICU admission and we described whether the mortality changed over time. Methods: We used the National Intensive Care Evaluation (NICE) registry and extracted all patients with an unplanned ICU admission in the Netherlands between 2008 and 2017. The primary outcome was 1-year mortality, analyzed with a mixed-effects Cox proportional hazard regression. We compared the 1-year mortality of cancer patients to that of patients without cancer. Furthermore, we examined changes in mortality over the study period. Results: We included 470,305 patients: 10,401 with hematological cancer, 35,920 with solid cancer, and 423,984 without cancer. The 1-year mortality rates were 60.1%, 46.2%, and 28.3% respectively (P< .01). Approximately 30% of the cancer patients surviving their hospital admission died within 1 year, this was 12% in patients without cancer. In hematological patients, 1-year mortality decreased between 2008 and 2011, after which it stabilized. In solid cancer patients, inspection showed neither an increasing nor decreasing trend over the inclusion period. For patients without cancer, 1-year mortality decreased between 2008 and 2013, after which it stabilized. A clear decrease in hospital mortality was seen within all three groups. Conclusion: The 1-year mortality of cancer patients with an unplanned ICU admission (hematological and solid) was higher than that of patients without cancer. About one-third of the cancer patients surviving their hospital admission died within 1 year after ICU admission. We found a decrease in 1-year mortality until 2011 in hematology patients and no decrease in solid cancer patients. Our results suggest that for many cancer patients, an unplanned ICU admission is still a way to recover from critical illness, and it does not necessarily lead to success in long-term survival. The underlying type of malignancy is an important factor for long-term outcomes in patients recovering from critical illness.

Integrated palliative care: triggers for referral to palliative care in ICU patients

INTRODUCTION

Palliative care within intensive care units (ICU) benefits decision-making, symptom control, and end-of-life care. It has been shown to reduce the length of ICU stay and the use of non-beneficial and unwanted life-sustaining therapies. However, it is often initiated late or not at all. There is increasing evidence to support screening ICU patients using palliative care referral criteria or "triggers". The aim of the project was to assess the need for palliative care referral during ICU admission using "trigger" tools.

METHODS

Electronic record review of cancer patients who died in or within 30 days of discharge from oncology ICU, between 2016 and 2018. Patients referred to palliative care before or during ICU admission were identified. Three sets of palliative care referral "triggers" were applied: one that is being tested locally and two internationally derived tools. The proportion of patients who met any of these triggers during their final ICU admission was calculated.

RESULTS

Records of 149 patients were reviewed: median age 65 (range 20-83). Most admissions (89%) were unplanned, with the most common diagnoses being haemato-oncology (31%) and gastrointestinal (16%) cancers. Most (73%) were unknown to palliative care pre-ICU admission; 44% were referred between admission and death. The median time from referral to death was 0 day (range 0-19). On ICU admission, 97-99% warranted referral to palliative care using locally and internationally derived triggers.

CONCLUSION

All "trigger" tools identified a high proportion of patients who may have warranted a palliative care referral either before or during admission to ICU. The routine use of trigger tools could help streamline referral pathways and underpin the development of an effective consultative model of palliative care within the ICU setting to enhance decision-making about appropriate treatment and patient-centred care.