Ethical and clinical aspects of intensive care unit admission in patients with hematological malignancies: guidelines of the ethics commission of the French society of hematology

Trends and outcomes of chemotherapy timing in critically ill patients with hematologic malignancies using a Japanese national database

Hematologic malignancies are a global public health concern, with high mortality rates in patients requiring critical care. The role of chemotherapy during intensive care unit (ICU) admission in this context remains unclear. This study aimed to analyze trends in survival rates based on chemotherapy timing and examine patient characteristics, ICU treatments, and clinical outcomes in each group. Using the Japanese Diagnosis Procedure Combination inpatient database, data from 21,837 patients aged ≥ 18 years who were hospitalized for hematologic malignancies and admitted to ICUs between April 1, 2012, and March 31, 2022, were analyzed. Patients were categorized based on chemotherapy timing as follows: no chemotherapy (NC), chemotherapy before ICU admission (CB), chemotherapy during ICU admission (CD), and chemotherapy after ICU discharge (CA). Mortality trends were assessed, with in-hospital mortality as the primary outcome variable. The CB group had the highest mortality rate, which decreased over time (61.2% in 2012 to 46.2% in 2021). The CD group had stable mortality rates (24.2% in 2012 and 22.6% in 2021), with a notable proportion of patients (55.4%) discharged home. These findings highlight the need for further investigation into the factors influencing ICU outcomes in patients receiving chemotherapy.

Developing Organizational Requirements to Standardize Delivery and Improve Quality of Acute Leukemia Care in Ontario

Acute leukemia is a rapidly progressive cancer of the blood and bone marrow that requires a high degree of complex, specialized, resource-intensive clinical and supportive care. The aging Canadian population has introduced an unprecedented demand on the health care system for a variety of illnesses, including acute leukemia. The purpose of this work was to develop organizational requirements for service providers delivering care for patients aged 18 years and older with acute leukemia within a single-payer health care system in Ontario. This initiative was intended to support streamlining high-quality health care across Ontario. We worked collaboratively with an expert panel to conduct a review of the literature to synthesize the organizational requirements for delivering acute leukemia care. A total of 229 requirements were developed. The requirements were categorized into themes including (1) facility requirements, including infrastructure, data management, safety, policies and procedures; (2) availability of clinical services and service complexity; (3) personnel, including roles, responsibilities, and ongoing education; (4) patient care; (5) quality management; (6) clinical research; and (7) laboratory services. These requirements will act as a framework for the provision of service, complexity of care, safety, accessibility, and quality care across all levels from the patient, organization, and system perspectives. This framework will help support person-centred care, emphasizing providing care close to home, while optimizing the use of specialized resources. Moving forward, Ontario Health (Cancer Care Ontario) will continue to work with acute leukemia service providers in the province to determine compliance and focus improvement efforts in priority areas.

Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria

OBJECTIVES

To identify and appraise articles describing criteria used to prioritize or withhold a critical care admission.

DATA SOURCES

PubMed, Embase, Medline, EBM Reviews, and CINAHL Complete databases. Gray literature searches and a manual review of references were also performed. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed.

STUDY SELECTION

We sought all articles and abstracts of original research as well as local, provincial, or national policies on the topic of ICU resource allocation. We excluded studies whose population of interest was neonatal, pediatric, trauma, or noncritically ill. Screening of 6,633 citations was conducted.

DATA EXTRACTION

Triage and/or transport criteria were extracted, based on type of article, methodology, publication year, and country. An appraisal scale was developed to assess the quality of identified articles. We also developed a robustness score to further appraise the robustness of the evidence supporting each criterion. Finally, all criteria were extracted, evaluated, and grouped by theme.

DATA SYNTHESIS

One-hundred twenty-nine articles were included. These were mainly original research (34%), guidelines (26%), and reviews (21%). Among them, we identified 200 unique triage and transport criteria. Most articles highlighted an exclusion (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). Criteria were classified in one of four emerging themes: patient, condition, physician, and context. The majority of criteria used were nonspecific. No study prospectively evaluated the implementation of its cited criteria.

CONCLUSIONS

This systematic review identified 200 criteria classified within four themes that may be included when devising triage programs including the coronavirus disease 2019 pandemic. We identified significant knowledge gaps where research would assist in improving existing triage criteria and guidelines, aiming to decrease arbitrary decisions and variability.

Palliative, Ethics, and End-of-Life Care Issues in the Cancer Patient

End-of-life care of critically ill adult patients with advanced or incurable cancers is imbued with major ethical challenges. Oncologists, hospitalists, and intensivists can inadvertently subjugate themselves to the perceived powers of autonomous patients. Therapeutic illusion and poor insight by surrogates in physicians' ability to offer accurate prognosis, missed opportunities and miscommunication by clinicians, and lack of systematic or protocolized approach represent important barriers to high-quality palliative care. Enhanced collaboration, models that allow clinicians and surrogates to share the burdens of decision, and institutional support for early integration of palliative care can foster an ethical climate.

Antimicrobial Stewardship in Hematological Patients at the intensive care unit: a global cross-sectional survey from the Nine-i Investigators Network

A global cross-sectional survey was performed to gather data on the current treatment of infections caused by multidrug-resistant (MDR) bacteria among hematological patients admitted to ICUs worldwide. The survey was performed in April 2019 using an electronic platform (SurveyMonkey®) being distributed among 83 physicians and completed by 48 (57.8%) responders. ESBL Enterobacteriaceae, carbapenem-resistant K. pneumoniae and carbapenem-resistant P. aeruginosa were the main concerns. Previous MDR infection (34% of responders), MDR colonization (20%) and previous antibiotic exposure within the last 3 months (20.5%) were considered the most relevant risk factors of bloodstream infection (BSI) due to MDR bacteria. In 48.8% of the ICUs, there was no antimicrobial stewardship (AMS) team focused on hematological patients. Updates on local epidemiology of MDR pathogens were provided in 98% of the centers, using phone or verbal communications (56.1% and 53.7%, respectively). In presence of febrile neutropenia, initial therapy consisted of anti-Gram-negative plus anti-Gram-positive antibiotics for 41% of participants. Antibiotic de-escalation and/or discontinuation of therapy were considered as a promising strategy for the prevention of MDR development (32.4%). Factors associated with antibiotic de-escalation were clinical improvement (43.6%) and neutrophil count recovery (12.8%). Infectious Disease consultation and AMS interventions were not determining factors for de-escalation decisions (more than 50% of responders). Infection control and educational programs were valued as necessary measures for implementation by ICU practitioners. These findings should guide future efforts on collaborative team working, improving compliance with adequate treatment protocols, implementing antimicrobial stewardship programs in critically ill hematological patients, and educational activities.

Clinical Approach to the Patient in Critical State Following Immunotherapy and/or Stem Cell Transplantation: Guideline for the On-Call Physician

: The initial management of the hematology patient in a critical state is crucial and poses a great challenge both for the hematologist and the intensive care unit (ICU) physician. After years of clinical practice, there is still a delay in the proper recognition and treatment of critical situations, which leads to late admission to the ICU. There is a much-needed systematic ABC (Airway, Breathing, Circulation) approach for the patients being treated on the wards as well as in the high dependency units because the underlying hematological disorder, as well as disease-related complications, have an increasing frequency. Focusing on score-based decision-making on the wards (Modified Early Warning Score (MEWS), together with Quick Sofa score), active sepsis screening with inflammation markers (C-reactive protein, procalcitonin, and presepsin), and assessment of microcirculation, organ perfusion, and oxygen supply by using paraclinical parameters from the ICU setting (lactate, central venous oxygen saturation (ScVO2), and venous-to-arterial carbon dioxide difference), hematologists can manage the immediate critical patient and improve the overall outcome.

Outcomes for haematological cancer patients admitted to an intensive care unit in a university hospital

BACKGROUND

Haematological cancer (HC) patients are increasingly requiring intensive care (ICUs). The aim of this study was to investigate the outcome of HC patients in our ICU and evaluate 5 days-full support as a breakpoint for patients' re-assessment for support.

METHODS

Retrospective study enrolling 112 consecutive HC adults, requiring ICU in January-December 2015. Patients' data were collected from medical records and Infection Control Committee surveillance reports. Logistic regression analysis was performed to identify independent risk factors for ICU mortality.

RESULTS

Sixty-one were neutropenic, and 99 (88%) had infection at ICU admission. Acute myeloid leukaemia was diagnosed in 43%. Thirty-five (31%) were hematopoietic stem cell transplant recipients. Only 17 (15%) were in remission. Eighty-nine underwent mechanical ventilation on admission. Fifty-three patients acquired ICU-infection (35 bacteremia) being gram negative bacteria (Klebsiella pneumoniae and non-fermenters) the top pathogens. However, ICU-acquired infection had no impact on mortality. The overall ICU and 1-year survival rate was 27% (30 patients) and 7% (8 patients), respectively. Moreover, only 2/62 patients survived with APACHE II score ≥25. The median time for death was 4 days. APACHE II score ≥25 [OR:35.20], septic shock [OR:8.71] and respiratory failure on admission [OR:10.55] were independent risk factors for mortality in multivariate analysis. APACHE II score ≥25 was a strong indicator for poor outcome (ROC under curve 0.889).

CONCLUSIONS

APACHE II score ≥25 and septic shock were criteria of ICU futility. Our findings support the full support of patients for 5 days and the need to implement a therapeutic limitations protocol.

Admission to intensive care: A qualitative study of triage and its determinants

OBJECTIVE

To examine physicians' decision making and its determinants about admission to intensive care.

DATA SOURCES/STUDY SETTING

ICU physicians (n = 12) and internists (n = 12) working in a Swiss tertiary care hospital.

STUDY DESIGN

We conducted in-depth interviews.

DATA COLLECTION/EXTRACTION METHODS

Interviews were analyzed using an inductive thematic approach.

PRINCIPAL FINDINGS

Admission decisions regarding seriously ill or elderly patients with comorbidities are complex. Nonmedical factors such as ICU beds availability, health care resources on the ward, information about patient preferences, and family behavior determine the decision. Code status and the quality of interaction between physicians are key determinants. The absence of code status or poor documentation of code status discussions makes decisions more difficult and laden emotionally, as physicians feel they are making a life-death decision. Mutual respect and collaborative decision making facilitate the decision. Tensions arise due to ICU physicians' postponing the decision because of lack of beds, ICU physicians' dismissive attitudes, perceived shortcomings in the other physician's completion of expected tasks, and preconceptions about the other physician.

CONCLUSIONS

Systematic documentation of code status, and fostering collaboration between ICU physicians and internists would facilitate ICU admission decisions in complex clinical situations.

The prognostic factors for patients with hematological malignancies admitted to the intensive care unit

Owing to the nature of acute illness and adverse effects derived from intensive chemotherapy, patients with hematological malignancies (HM) who are admitted to the Intensive Care Unit (ICU) often present with poor prognosis. However, with advances in life-sustaining therapies and close collaborations between hematologists and intensive care specialists, the prognosis for these patients has improved substantially. Many studies from different countries have examined the prognostic factors of these critically ill HM patients. However, there has not been an up-to-date review on this subject, and very few studies have focused on the prognosis of patients with HM admitted to the ICU in Asian countries. Herein, we aim to explore the current situation and prognostic factors in patients with HM admitted to ICU, mainly focusing on studies published in the last 10 years.

Withdrawing and Withholding Life Support in Patients With Cancer in an ICU Setting: A 5-Year Experience at a European Cancer Center

OBJECTIVE

This was an observational retrospective study aimed to examine the frequency and associated factors of withdrawing or withholding life support (WWLS) in the intensive care unit (ICU) of a comprehensive cancer center.

METHODS

Medical records of adult patients with cancer admitted to the ICU between January 2010 and December 2014 were reviewed. Patients who died during that period were classified into 2 groups: full life support and withdrawing and withholding life support. The relative impact of demographic and clinical factors was assessed using logistic regression.

RESULTS

A total of 247 patients died in our unit (mortality rate of 16.3%). Their median age was 62 (interquartile range [IQR] 51-73) years, there were 142 (57.5%) male patients, and they had predominantly solid malignancies (62.3%). The median Simplified Acute Physiology Score II and Acute Physiology and Chronic Health Evaluation scores were 67 (IQR 54-80) and 29 (IQR 23-55), respectively. Ninety-six (38.9%) patients died after WWLS with no statistically significant differences in decisions to limit therapy during the study period. Patients with advanced age, solid malignancies, nonneutropenic, and longer duration of mechanical ventilation were more likely to die after WWLS. In multivariate analysis, presenting with neutropenia was independently associated with a lower likelihood of dying after WWLS (odds ratio: 0.34, 95% confidence interval: 0.15-0.80).

CONCLUSION

Limitation of therapy has been a common practice in oncologic ICUs over recent years. Neutropenia is an independent predictor of limitation of therapy.

Short- and long-term outcomes of AL amyloidosis patients admitted into intensive care units

Amyloidosis is a rare and threatening condition that may require intensive care because of amyloid deposit-related organ dysfunction or therapy-related adverse events. Although new multiple myeloma drugs have dramatically improved outcomes in AL amyloidosis, the outcomes of AL patients admitted into intensive care units (ICUs) remain largely unknown. Admission has been often restricted to patients with low Mayo Clinic staging and/or with a complete or very good immunological response at admission. In a retrospective multicentre cohort of 66 adult AL (n = 52) or AA (n = 14) amyloidosis patients, with similar causes of admission to an ICU, the 28-d and 6-month survival rates of AA patients were significantly higher compared to AL patients (93% vs. 60%, P = 0·03; 71% vs. 45%, P = 0·02, respectively). In AL patients, the simplified Index of Gravity Score (IGS2) was the only independent predictive factor for death by day 28, whereas the Mayo-Clinic classification stage had no influence. In Cox's multivariate regression model, only cardiac arrest and on-going chemotherapy at ICU admission significantly predicted death at 6 months. Short-term outcomes of AL patients admitted into an ICU were mainly related to the severity of the acute medical condition, whereas on-going chemotherapy for active amyloidosis impacted on long-term outcomes.

Predictors of Poor Outcomes in Critically Ill Adults with Hematologic Malignancy

Background. Patients with hematologic malignancy (HM) often require intensive care unit (ICU) admission due to organ failure through disease progression or treatment-related complications. Objective. To determine mortality and prognostic variables in adult patients with HM who were admitted to ICU. Methods. Structured chart review of all adult patients (age ≥ 18 years) with HM admitted to ICU of a Canadian tertiary care hospital between 2004 and 2014. Outcome measures included mortality (ICU, 30-day, 60-day, and 12-month). Logistic regression was performed to determine predictors of mortality. Results. Overall, there were 206 cases of HM admitted to the ICU during the study (mean age: 51.3 ± 13.6 years; 60% male). Median stay was 3 days, with 14.1% requiring prolonged ICU admission. ICU mortality was 45.6% and increased to 59.2% at 30 days, 62.6% at 60 days, and 74.3% at 12 months. Predictors of increased ICU mortality included mechanical ventilation requirement and vasopressor therapy requirement, while admission to ICU postoperatively and having myeloma were associated with decreased mortality. Conclusions. Patients admitted to ICU with HM have high mortality (45.6%), which increased to 74.3% at 1 year. Analysis of multiple variables identified critical illness, postsurgical admission, and myeloma as predictors of patient outcomes.