Outcome of respiratory failure in hematologic malignancy

Association between serum calcium and in-hospital mortality in critical patients with multiple myeloma: a cohort study

BACKGROUND

Elevated serum calcium levels may serve as a useful clinical biomarker of mortality in patients with multiple myeloma(MM). However, the clinical significance of the relationship between serum calcium levels and in-hospital mortality in MM patients admitted to the Intensive Care Unit (ICU) remains unclear.

OBJECTIVES

This study aimed to explore the association between serum calcium levels and in-hospital mortality in patients with MM in the ICU.

METHODS

Patients with MM were identified from the Medical Information Mart for Intensive Care IV(MIMIC-IV) database. The outcome was in-hospital mortality. Multivariable-adjusted Cox regression analysis, curve fitting, and threshold effects analysis were used to assess the relationship between serum calcium levels and in-hospital mortality in patients with MM in the ICU.

RESULTS

Our study included 262 patients with MM with a mean age of 72.3 ± 11.0 years, 63.4% of whom were male. The in-hospital mortality was 19.5% (51/262). The relationship between serum calcium levels and in-hospital mortality was nonlinear. The effect size on the left and right sides of the inflection point, were 0.270 (HR: 0.270, 95% CI 0.106-0.687, P < 0.05) and 2.104 (HR: 2.104, 95% CI 1.069-4.142, P < 0.05), respectively. The results of the sensitivity analysis remained stable.

CONCLUSION

Our findings show that a nonlinear relationship exists between serum calcium levels and in-hospital mortality in critically ill patients with MM. A serum calcium level of approximately 8.40 mg/dL was associated with the lowest risk of in-hospital mortality, which increases with rising serum calcium levels, and should be of concern to ICU physicians.

Outcome Prediction of Hematologic Malignancy in Critically Sick People

People with hematologic malignancies (HM) frequently postulate intensive care unit (ICU) hospitalization due to organ damage caused by the disease process or treatment-related consequences. This study is aimed at looking at mortality and sign factors in adult patients with hematologic malignancy (HM) who have been hospitalized in the ICU. Death was one quality indicator; researchers used a machine learning approach to find determinants of death. As per the study, there have been 206 patients hospitalized in the ICU (mean age: 51.3 ± 13.6 years; 60% male). The average length of stay was three days, with 14.1% requiring extended ICU commitment. ICU death was 45.6% at 30 days, 62.6% at sixty days, and 74.3% at twelve months, rising to 59.2% at thirty days, 62.6% at sixty days, and 74.3% at twelve months. Ventilation systems and vasodilating medication were linked to higher ICU death, but admission to the ICU surgically and experiencing malignancies are linked with lower death rates. Patients with HM who are hospitalized in the ICU have a high mortality rate (45.6%), which rises to 74.3% after a year. Serious illness, postsurgical hospitalization, and malignancy were revealed as determinants of patient outcomes in multivariate analyses.

Clinical outcomes of immunocompromised patients on extracorporeal membrane oxygenation support for severe acute respiratory failure

OBJECTIVES

There are limited data regarding extracorporeal membrane oxygenation (ECMO) support in immunocompromised patients, despite an increase in ECMO use in patients with respiratory failure. The aim of this study was to investigate the clinical characteristics and outcomes of immunocompromised patients requiring ECMO support for severe acute respiratory failure.

METHODS

Between January 2012 and December 2015, all consecutive adult patients with severe acute respiratory failure who underwent ECMO for respiratory support at 16 tertiary or university-affiliated hospitals in South Korea were enrolled retrospectively. The patients were divided into 2 groups based on the immunocompromised status at the time of ECMO initiation. In-hospital and 6-month mortalities were compared between the 2 groups. In addition, association of immunocompromised status with 6-month mortality was evaluated with logistic regression analysis.

RESULTS

Among 461 patients, 118 (25.6%) were immunocompromised. Immunocompromised patients were younger and had lower haemoglobin and platelet counts than immunocompetent patients. Ventilatory parameters and the use of adjunctive/rescue therapies were similar between the 2 groups, but prone positioning was more commonly used in immunocompetent patients. Successful weaning rates from ECMO (46.6% vs 58.9%; P = 0.021) was lower and hospital mortality (66.1% vs 59.8%; P = 0.22) was higher in immunocompromised patients. In addition, immunocompromised status was associated with higher 6-month mortality (74.6% vs 64.7%, adjusted odds ratio 2.10, 95% confidence interval 1.02-4.35; P = 0.045).

CONCLUSIONS

Immunocompromised patients treated with ECMO support for severe acute respiratory failure had poorer short- and long-term prognoses than did immunocompetent patients.

[Cancer patients in operative intensive care medicine]

Die Prävalenz onkologischer Erkrankungen ist in den vergangenen Jahrzehnten stetig angestiegen. Durch neue Therapieoptionen können immer mehr Patienten mit einem kurativen Therapieansatz behandelt werden. Diese individualisierten und teilweise sehr aggressiven Therapien können jedoch auch zu schweren Nebenwirkungen führen. Diese sollten als wichtige Differenzialdiagnosen zu anderen vitalbedrohlichen Krankheitsbildern auch dem im OP und als Intensivmediziner tätigen Anästhesisten bekannt sein. Krebspatienten werden häufig auf operativen Intensivstationen aufgenommen, um Komplikationen der malignen Grunderkrankung oder auch Nebenwirkungen einer operativen oder konservativen Therapie zu behandeln. Aktuelle Untersuchungen zeigen, dass die maligne Grunderkrankung entgegen bisheriger Annahme keinen wesentlichen Einfluss auf das Intensivüberleben hat. Bei der Aufnahme eines onkologischen Patienten sollte daher die akut vorliegende Organdysfunktion zunächst im Vordergrund stehen. Bei der Therapiezielplanung gilt es, nicht zu übersehen, wann ein kuratives in ein palliatives Konzept übergehen muss. Hierfür müssen neue Aufnahmestrategien und -kriterien entwickelt und evaluiert werden. In diesem Übersichtsartikel werden Diagnosen und Therapien häufiger intensivmedizinischer Krankheitsbilder von onkologischen Patienten sowie Nebenwirkungen moderner onkologischer Therapien dargelegt und Aufnahmestrategien für Patienten mit malignen Erkrankungen vorgestellt.

Assessment of Outcome over a 10-year Period of Patients Admitted to a Multidisciplinary Adult Intensive Care Unit with Haematological and Solid Tumours

The risk factors for time to mortality, censored at 30 days, of patients admitted to an adult teaching hospital ICU with haematological and solid malignancies were assessed in a retrospective cohort study.

Patients, demographics and daily ICU patient data, from admission to day 8, were identified from a prospective computerized database and casenote review in consecutive admissions to ICU with haematological and solid tumours over a 10-year period (1989–99). The cohort, 108 ICU admissions in 89 patients was of mean age (±SD) 55±14 years; 43% were female. Patient diagnoses were leukaemia (35%), lymphoma (38%) and solid tumours (27%). Median time from hospital to ICU admission was five days (range 0–67). On ICU admission, 50% had septic shock and first day APACHE II score was 28±9. Forty-six per cent of patients were ventilated. ICU and 30-day mortality were 39% and 54% respectively. Multivariate Cox model predictors (P<0.05), using only ICU admission day data were: Charlson comorbidity index (CCI), time to ICU admission (days) and mechanical ventilation. For daily data (admission through day 8), predictors were: cohort effect (2nd vs 1st five-year period); CCI; time to ICU admission (days); APACHE II score and mechanical ventilation.

Outcomes were considered appropriate for severity of illness and demonstrated improvement over time. Ventilation was an independent outcome determinant. Controlling for other factors, mortality has improved over time (1st vs 2nd five year period). Analysis restricted to admission data alone may be insensitive to particular covariate effects.

Predictors of outcome in patients with hematologic malignancies admitted to the intensive care unit

PURPOSE

Several studies showed conflicting results about prognosis and predictors of outcome of critically ill patients with hematological malignancies (HM). The aim of this study is to determine the hospital outcome of critically ill patients with HM and the factors predicting the outcome.

METHODS AND MATERIALS

All patients with HM admitted to MICU at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and 6 months outcomes were documented.

RESULTS

There were 130 HM patients during the study period. Acute Leukemia was the most common malignancy (31.5%) followed by Non-Hodgkin's Lymphoma (28.5%). About 12.5% patients had autologous HSCT and 51.5% had allogeneic HSCT. Sepsis was the most common ICU diagnosis (25.9%). ICU mortality and hospital mortality were 24.8% and 45.3%, respectively. Six months mortality (available on 80% of patients) was 56.7%. Hospital mortality was higher among mechanically ventilated patients (75%). Using multivariate analysis, only mechanical ventilation (OR of 19.0, CI: 3.1-117.4, P: 0.001) and allogeneic HSCT (OR of 10.9, CI: 1.8-66.9, P: 0.01) predicted hospital mortality.

CONCLUSION

Overall hospital outcome of critically ill patients with HM is improving. However those who require mechanical ventilation or underwent allogeneic HSCT continue to have poor outcome.

Outcome of invasive mechanical ventilation in cancer patients: Intubate or not to intubate a patient with cancer

PURPOSE

The outcome of cancer patients who undergo mechanical ventilation has been grim. However, it has lately become more promising, creating hesitation when approaching the decision to intubate a cancer patient. Therefore, the main goal was to find some factors that could predict mortality.

MATERIAL AND METHODS

Studies were selected on the basis of their information wholeness, the year done, patients' number, participating country, underlying hematological or nonhematological malignancies, ventilation duration, ICU survival, hospital survival, long term survival, disease activity, and other contributing factors.

RESULTS

Twenty-two studies were included which accrued 3115 patients. The average ICU survival was 32.4%, and long-term survival was 10.2%. Over the years, the outcome of cancer patients undergoing mechanical ventilation has improved. The most important predicting factors are: The respiratory failure etiology, the performance status, the disease activity, and the SOFA score.

CONCLUSIONS

The aforementioned predicting factors could be used when approaching the decision to intubate. When in doubt, we should give the benefit to the patient, proceed to intubate and reevaluate progress daily and in doing so, we would suggest to use the trends in SOFA score and weaning index to assess success or failure of invasive mechanical ventilation.

[Cancer patients in operative intensive care medicine]

Die Prävalenz onkologischer Erkrankungen ist in den vergangenen Jahrzehnten stetig angestiegen. Durch neue Therapieoptionen können immer mehr Patienten mit einem kurativen Therapieansatz behandelt werden. Diese individualisierten und teilweise sehr aggressiven Therapien können jedoch auch zu schweren Nebenwirkungen führen. Diese sollten als wichtige Differenzialdiagnosen zu anderen vitalbedrohlichen Krankheitsbildern auch dem im OP und als Intensivmediziner tätigen Anästhesisten bekannt sein. Krebspatienten werden häufig auf operativen Intensivstationen aufgenommen, um Komplikationen der malignen Grunderkrankung oder auch Nebenwirkungen einer operativen oder konservativen Therapie zu behandeln. Aktuelle Untersuchungen zeigen, dass die maligne Grunderkrankung entgegen bisheriger Annahme keinen wesentlichen Einfluss auf das Intensivüberleben hat. Bei der Aufnahme eines onkologischen Patienten sollte daher die akut vorliegende Organdysfunktion zunächst im Vordergrund stehen. Bei der Therapiezielplanung gilt es, nicht zu übersehen, wann ein kuratives in ein palliatives Konzept übergehen muss. Hierfür müssen neue Aufnahmestrategien und -kriterien entwickelt und evaluiert werden. In diesem Übersichtsartikel werden Diagnosen und Therapien häufiger intensivmedizinischer Krankheitsbilder von onkologischen Patienten sowie Nebenwirkungen moderner onkologischer Therapien dargelegt und Aufnahmestrategien für Patienten mit malignen Erkrankungen vorgestellt.

Critical Care Prognosis and Outcomes in Patients with Cancer

Advances in cancer treatment and patient survival are associated with increasing number of these patients requiring intensive care. Over the last 2 decades, there has been a steady improvement in the outcomes of critically ill patients with cancer. This review provides data on the use of the intensive care unit (ICU) and short and long-term outcomes of critically ill patients with cancer, the ICU system practices that influence patients outcomes, and the role of the different clinical variables in predicting the prognosis of these patients.

Characteristics and predictors of mortality of patients with hematologic malignancies requiring invasive mechanical ventilation

RATIONALE:

Acute respiratory failure (ARF) may complicate the course of hematologic malignancies (HMs). Our objective was to study the characteristics, outcomes and predictors of mortality of patients with HMs who required intubation for ARF.

METHODS:

This retrospective cohort study evaluated all patients with HMs who were admitted to the Intensive Care Unit (ICU) of King Abdul-Aziz Medical City-Riyadh between 2008 and 2013 and required invasive mechanical ventilation. We noted their baseline characteristics, treatments and different outcomes. Multivariable logistic regression analysis was performed to evaluate predictors of hospital mortality.

RESULTS:

During the 6-year period, 190 patients with HMs were admitted to the ICU and 122 (64.2%) required intubation for ARF. These patients had mean age of 57.2 ± 19.3 years and Acute Physiology and Chronic Health Evaluation II score of 28.0 ± 7.8 and were predominantly males (63.4%). Lymphoma (44.3%) and acute leukemia (38.5%) were the most common hematologic malignancy. Noninvasive ventilation (NIV) was tried in 22 patients (18.0%) but failed. The code status was changed to “Do-Not-Resuscitate” for 39 patients (32.0%) during ICU stay. Hospital mortality was 70.5% and most deaths (81.4%) occurred in the ICU. The mortality of patients with “Do-Not-Resuscitate” status was 97.4%. On multivariable logistic regression analysis, male gender (odds ratio (OR), 6.74; 95% confidence interval (CI), 2.24–20.30), septic shock (OR, 6.61; 95% CI, 1.93–22.66) were independent mortality predictors. Remission status, non-NIV failure and chemotherapy during ICU stay were not associated with mortality.

CONCLUSIONS:

Patients with HMs requiring intubation had high mortality (70.5%). Male gender and presence of septic shock were independent predictors of mortality.

Determinants of 6-month survival of critically ill patients with an active hematologic malignancy

PURPOSE

This study assessed the determinants of 6-month survival of critically ill patients with an active hematologic malignancy (HM).

METHODS

All patients with an active HM defined by either receiving ongoing or due to receive antineoplastic therapy, admitted to 2 tertiary intensive care units between 2010 and 2015, were included in this retrospective cohort study.

RESULTS

Of the 273 patients included in the study (median age, 63[interquartile range, 54-71] years; 40.7% female), 116 (42.5%; 95% confidence interval, 36.8-48.4) died in hospital. The 6-month mortality was 56.4% (95% confidence interval, 50.5-62.2). Mechanical ventilation, intensive care unit admission source, and the type of active HM were significantly associated with hospital mortality and 6-month survival, after adjusting for severity of acute illness. The type of active HM was the most important prognostic factor, with over a 10-fold difference in 6-month survival between HM with the best and worst prognosis. In addition, recent hematopoietic stem cell transplant (<30 days) was associated with a better 6-month survival.

CONCLUSION

Differences in 6-month survival between critically ill patients with different types of active HM were substantial. Recent hematopoietic stem cell transplant, severity of illness, and use of mechanical ventilation were additional important determinants of 6-month survival in patients with an active HM.

Predictors of ICU Admission in Patients With Cancer and the Related Characteristics and Outcomes: A 5-Year Registry-Based Study

OBJECTIVE

To identify factors predictive of admission of patients with cancer to an ICU. In addition, the study aimed to describe the characteristics and outcomes, both short-term and long-term, of patients with cancer admitted to the ICU.

DESIGN

Retrospective case-control study, utilizing the institution's cancer registry.

SETTING

Comprehensive cancer center.

PATIENTS

Patients with cancer. The case group consisted of patients who required ICU admission during the study period, whereas the control group consisted of patients who did not require ICU admission.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The patient characteristics and outcomes were recorded. Univariate and multivariate analyses were conducted to determine factors associated with ICU admission. The registry included 10,792 patients, and among those, 2,439 patients (22.6%) required ICU admission after a median of 10.1 months (interquartile range, 3.28-25.2). The following factors were associated with ICU admission: hematologic malignancy (odds ratio, 1.51; 95% CI, 1.26-1.81), chemotherapy (odds ratio, 1.74; 95% CI, 1.48-2.03), advanced cancer (odds ratio, 2.57; 95% CI, 1.44-4.60), and smoking (odds ratio, 1.38; 95% CI, 1.20-1.61). The most common ICU admission diagnoses were sepsis (21.5%) and respiratory insufficiency/failure (25.7%). The ICU mortality was 36.5%, whereas the 1-year and 5-year survival rates were 22.8% and 14.2%, respectively.

CONCLUSION

In a comprehensive cancer center, about one fourth of the patients required ICU admission. Addressing modifiable risk factors associated with ICU admission is essential to potentially reduce ICU admissions and improve long-term survival.

AML versus ICU: outcome of septic AML patients in an intensive care setting

PURPOSE

Intensive therapy regimens in patients with acute myeloid leukemia (AML) frequently result in sepsis and septic shock. In this study, we investigated the prognostic outcome of AML patients requiring intensive care treatment due to severe sepsis or septic shock.

DESIGN

We present a retrospective cohort study in a medical intensive care unit (ICU) of a university hospital that serves as a tertiary care center.

MATERIALS AND METHODS

Here we present data from 44 AML patients of our ICU with 29 requiring invasive mechanical ventilation due to sepsis and compared multiple clinical and laboratory parameters of ICU survivors and non-survivors.

RESULTS

Mean age was 59.5 years, the overall mortality rate was 41% (18/44), and the mortality rate among patients who received mechanical ventilation was 55% (16/29). The mortality rate among younger patients (aged 60 years or less) was 17% (3/18), while 58% of the older patients died (15/26). The mortality rate among younger patients who received mechanical ventilation was 23% (3/13) compared with 81% (13/16) of the older patients. The mean invasive ventilation time was 415 h in non-survivors compared with 667 h in survivors. No differences could be identified between survivors and non-survivors, concerning multiple laboratory parameters or AML prognostic and therapeutic parameters; our analysis, however, confirmed a statistically significant difference in the patients' age.

CONCLUSIONS

In previous studies, age was one of the most important prognostic factors in AML patients receiving mechanical ventilation due to severe sepsis or septic shock. In spite of improvements in diagnostic and treatment over the last couple of years, our study indicates that this fact still is true. However, the overall outcome has improved over the years due to improvements in intensive care medicine.

Outcomes in critically ill chronic lymphocytic leukemia patients

BACKGROUND

Although recent studies have demonstrated an improvement in the prognosis of critically ill cancer patients, little is known regarding the prognosis of patients with non-aggressive underlying malignancies. The aims of this study were to assess the prognosis of critically ill patients with chronic lymphocytic leukemia (CLL) and to evaluate risk factors for hospital mortality.

METHODS

In retrospective mono-center cohort study, consecutive adult patients with CLL requiring ICU admission from 1997 to 2008 were included.

RESULTS

Sixty-two patients of 67 years (62-75) were included. Median time interval between CLL diagnosis and ICU admission was 6.7 years (2.6-10.8). Nine patients (15 %) had stage C disease at the time of ICU admission, and seven patients (11 %) had Richter syndrome. Most ICU admissions were related to bacterial or fungal pulmonary infections (n = 47; 76 %). ICU, in-hospital, and 90-day mortality were 35 % (n = 22), 42 % (n = 26), and 58 % (n = 36), respectively. Only three factors were independently associated with in-hospital mortality: oxygen saturation lower than 95 % when breathing room air (odds ratio (OR) 5.80; 95 % confidence interval (CI) 1.23-27.33), need for vasopressors (OR 27.94; 95 % CI 5.37-145.4), and past history of infection (OR 6.62; 95 % CI 1.34-32.68). The final model did not change when disease-related variables (Binet classification, Richter syndrome, long-term steroids) or treatment-related variables (fludarabine, rituximab, or alemtuzumab) were included.

CONCLUSION

Acute pulmonary infections remain the leading cause of ICU admission in patients with CLL. The severity at ICU admission and past history of infection were the only factors associated with hospital mortality. Neither disease characteristics nor previous cancer treatments were associated with outcome.

Clinical characteristics and outcomes of patients with acute myelogenous leukemia admitted to intensive care: a case-control study

Background

There is limited epidemiologic data on patients with acute myelogenous (myeloid) leukemia (AML) requiring life-sustaining therapies in the intensive care unit (ICU). Our objectives were to describe the clinical characteristics and outcomes in critically ill AML patients.

Methods

This was a retrospective case-control study. Cases were defined as adult patients with a primary diagnosis of AML admitted to ICU at the University of Alberta Hospital between January 1^st 2002 and June 30^th 2008. Each case was matched by age, sex, and illness severity (ICU only) to two control groups: hospitalized AML controls, and non-AML ICU controls. Data were extracted on demographics, course of hospitalization, and clinical outcomes.

Results

In total, 45 AML patients with available data were admitted to ICU. Mean (SD) age was 54.8 (13.1) years and 28.9% were female. Primary diagnoses were sepsis (32.6%) and respiratory failure (37.3%). Mean (SD) APACHE II score was 30.3 (10.3), SOFA score 12.6 (4.0) with 62.2% receiving mechanical ventilation, 55.6% vasoactive therapy, and 26.7% renal replacement therapy. Crude in-hospital, 90-day and 1-year mortality was 44.4%, 51.1% and 71.1%, respectively. AML cases had significantly higher adjusted-hazards of death (HR 2.23; 95% CI, 1.38-3.60, p = 0.001) compared to both non-AML ICU controls (HR 1.69; 95% CI, 1.11-2.58, p = 0.02) and hospitalized AML controls (OR 1.0, reference variable). Factors associated with ICU mortality by univariate analysis included older age, AML subtype, higher baseline SOFA score, no change or an increase in early SOFA score, shock, vasoactive therapy and mechanical ventilation. Active chemotherapy in ICU was associated with lower mortality.

Conclusions

AML patients may represent a minority of all critically ill admissions; however, are not uncommonly supported in ICU. These AML patients are characterized by high illness severity, multi-organ dysfunction, and high treatment intensity and have a higher risk of death when compared with matched hospitalized AML or non-AML ICU controls. The absence of early improvement in organ failure may be a useful predictor for mortality for AML patients admitted to ICU.

Mechanical ventilation in cancer patients: clinical characteristics and outcomes

Acute respiratory failure with the need for mechanical ventilation is a severe and frequent complication, and a leading reason for admission to the intensive care unit (ICU) in patients with malignancies. Nevertheless, improvements in patient survival have been observed over the last decade. This article reviews the epidemiology of adult patients with malignancies requiring ventilatory support. Criteria used to assist decisions to admit a patient to the ICU and to select the initial ventilatory strategy are discussed.

Acute respiratory failure in the patient with cancer: diagnostic and management strategies

Acute respiratory failure (ARF) remains the major reason for admission to the intensive care unit (ICU) in patients with cancer and is often associated with high mortality, especially in those who require mechanical ventilation. The diagnosis and management of ARF in patients who have cancer pose unique challenges to the intensivist. This article reviews the most common causes of ARF in patients with cancer and discusses recent advances in the diagnostic and management approaches of these disorders. Timely diagnosis and treatment of reversible causes of respiratory failure, including earlier use of noninvasive ventilation and judicious ventilator and fluid management in patients with acute lung injury, are essential to achieve an optimal outcome. Close collaboration between oncologists and intensivists helps ensure that clear goals, including direction of treatment and quality of life, are established for every patient with cancer who requires mechanical ventilation for ARF.

Admission criteria and prognostication in patients with cancer admitted to the intensive care unit

Critical care for patients with cancer was once considered inappropriate because of a perceived poor prognosis for their long-term survival. Three decades of research has yielded evidence to support the use of critical care resources for many patients with cancer. A methodical approach to triage and evaluation of critically ill patients regardless of baseline medical diagnosis, coupled with an appreciation for the likely prognosis of their current cancer, is most likely to yield the fairest and most accurate appropriation of care. No clinical scoring system has emerged that accurately defines the severity of illness and likelihood for survival in patients with cancer. This article reviews the studies that have attempted to apply mortality prediction scales or scoring systems to these patients. Clinical judgment with incorporation of consensus opinions from the literature should be used to develop admission or restriction criteria for intensive care of patients with cancer.

Admission factors associated with hospital mortality in patients with haematological malignancy admitted to UK adult, general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database

Introduction

Patients with haematological malignancy admitted to intensive care have a high mortality. Adverse prognostic factors include the number of organ failures, invasive mechanical ventilation and previous bone marrow transplantation. Severity-of-illness scores may underestimate the mortality of critically ill patients with haematological malignancy. This study investigates the relationship between admission characteristics and outcome in patients with haematological malignancies admitted to intensive care units (ICUs) in England, Wales and Northern Ireland, and assesses the performance of three severity-of-illness scores in this population.

Methods

A secondary analysis of the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database was conducted on admissions to 178 adult, general ICUs in England, Wales and Northern Ireland between 1995 and 2007. Multivariate logistic regression analysis was used to identify factors associated with hospital mortality. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II and ICNARC score were evaluated for discrimination (the ability to distinguish survivors from nonsurvivors); and the APACHE II, SAPS II and ICNARC mortality probabilities were evaluated for calibration (the accuracy of the estimated probability of survival).

Results

There were 7,689 eligible admissions. ICU mortality was 43.1% (3,312 deaths) and acute hospital mortality was 59.2% (4,239 deaths). ICU and hospital mortality increased with the number of organ failures on admission. Admission factors associated with an increased risk of death were bone marrow transplant, Hodgkin's lymphoma, severe sepsis, age, length of hospital stay prior to intensive care admission, tachycardia, low systolic blood pressure, tachypnoea, low Glasgow Coma Score, sedation, PaO₂:FiO₂, acidaemia, alkalaemia, oliguria, hyponatraemia, hypernatraemia, low haematocrit, and uraemia. The ICNARC model had the best discrimination of the three scores analysed, as assessed by the area under the receiver operating characteristic curve of 0.78, but all scores were poorly calibrated. APACHE II had the highest accuracy at predicting hospital mortality, with a standardised mortality ratio of 1.01. SAPS II and the ICNARC score both underestimated hospital mortality.

Conclusions

Increased hospital mortality is associated with the length of hospital stay prior to ICU admission and with severe sepsis, suggesting that, if appropriate, such patients should be treated aggressively with early ICU admission. A low haematocrit was associated with higher mortality and this relationship requires further investigation. The severity-of-illness scores assessed in this study had reasonable discriminative power, but none showed good calibration.

The effect of implementing high-intensity intensive care unit staffing model on outcome of critically ill oncology patients

OBJECTIVE

Implementing high-intensity staffing model improves outcome in general intensive care units (ICUs). We studied the effect of implementing such a model on the outcome of critically ill medical patients in an oncology ICU.

DESIGN

We compared admission rates, ICU mortality rates (MRs), 28-day MRs, length of stay (LOS) for patients discharged alive, and bed turnover rates of medical patients admitted to the ICU in the year 2004 (before an intensivist model was established) with those in the years 2006 and 2007 (after the model was established). We allowed for 1 year of transition to implement the changes required including the transformation of the ICU to a closed ICU with daily multidisciplinary rounds led by an intensivist as described in the Leapfrog model.

RESULTS

ICU admissions increased from 236 patients (2004) to 388 (2006) and 446 (2007). There was no significant difference in the disease severity of illness when compared by Acute Physiology and Chronic Health Evaluation II scores, 20.6 (before) vs. 20.9 (after) (p = 0.386). ICU MR for the consecutive years decreased from 35.17% (95% confidence interval [CI]: 29.08-41.26) to 23.97% (95% CI: 19.72-28.22) and 22.87% (95% CI: 18.97-26.77), and 28-day MRs decreased from 47.69% (95% CI: 40.68-54.7) to 38.24% (95% CI: 32.91-43.58) and 29.84% (95% CI: 24.79-34.89). LOS (for patients who survived) decreased from a mean of 4.26 days (95% CI: 3.19-5.33) to 2.63 (95% CI: 2.4-2.86) and 2.63 (95% CI: 2.4-2.86). Bed turnover rates increased from 5.0 patient/bed (95% CI: 4.22-5.78) to 6.9 patient/bed (95% CI: 6.04-7.77) and 7.56 patient/bed (95% CI: 6.67-8.44).

CONCLUSION

Implementing a high-intensity staffing model is associated with significant improvements in MRs, LOS, and bed utilization of critically ill oncology patients.

The Outcome of Haematological Malignancy in Scottish Intensive Care Units

To study the prognostic indicators and outcome in patients with haematological malignancy requiring intensive care, we identified 714 adult patients and analysed their clinical audit data. Mean APACHE II score was 24. Main admitting diagnoses were acute lymphoma (43%) and acute leukaemia (28%). There was a high requirement for acute organ support. Intensive care unit (ICU) mortality was 39% and hospital mortality 55%, with a standardised mortality rate of 1.05 (0.98–1.13). Factors predictive of outcome after multivariate analysis were: cardiopulmonary resuscitation (CPR) in the 24-hours before ICU admission, inotropic support in the first 24-hours, APACHE II score and requirement for ventilatory support immediately prior to, or at admission to the ICU. Neutropaenia was not an independent predictor. Patients with neutropaenic septic shock and multiorgan failure left hospital. Hospital mortality for this group is comparable to that of non-cancer patients admitted with multi-organ system failure. The reluctance to admit such patients to ICU may be unjustified.

Epidemiology of Acute Respiratory Failure and Mechanical Ventilation

Acute respiratory failure, and the need for mechanical ventilation, remains one of the most common reasons for admission to the intensive care unit (ICU). The burden of acute respiratory failure is high in terms of mortality and morbidity as well as the cost of its principal treatment, mechanical ventilation. Very few epidemiologic studies have evaluated the prevalence and outcome of acute respiratory failure and mechanical ventilation in general. Most of the published literature has focused on specific forms of acute respiratory failure, particularly acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). In this chapter, we provide a brief review of the pathophysiology of acute respiratory failure, its definition and classification, and then present the incidence and outcomes of specific forms of acute respiratory failure from epidemiologic studies.

Epidemiology of Acute Respiratory Failure and Mechanical Ventilation

Acute respiratory failure, and the need for mechanical ventilation, remains one of the most common reasons for admission to the intensive care unit (ICU). The burden of acute respiratory failure is high in terms of mortality and morbidity as well as the cost of its principal treatment, mechanical ventilation. Very few epidemiologic studies have evaluated the prevalence and outcome of acute respiratory failure and mechanical ventilation in general. Most of the published literature has focused on specific forms of acute respiratory failure, particularly acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). In this chapter, we provide a brief review of the pathophysiology of acute respiratory failure, its definition and classification, and then present the incidence and outcomes of specific forms of acute respiratory failure from epidemiologic studies.

Predictors of short and long-term outcome in patients with hematological disorders admitted to the intensive care unit for a life-threatening complication

GOAL OF WORK

The admission of patients with hematological disorders to the intensive care unit (ICU) involves a complex resource usage and may be associated with high mortality. The decision making to transfer a severely ill patient to the ICU, therefore, presents an ethical dilemma. We assessed both early and long-term outcomes in relation to clinical characteristics with the aim to facilitate clinical decision making.

MATERIALS AND METHODS

We performed a cohort study of hematological patients admitted to ICU at a university hospital.

MAIN RESULTS

During a 6-year period (1996-2001), 85 patients with a median age of 59 years were admitted to ICU. The majority of patients (88%) suffered from hematological malignancies. Major reasons for ICU admission were respiratory failure (41%) and septic shock/pre-shock (24%). The median duration of ICU admission was 2 (1-67) days. Crude in-ICU, 30-day, and 6-month mortality rates were 30, 49, and 62%, respectively. Overall 5-year survival rate was 20%, and 13 (15%) patients were alive at time of follow-up (median 7.4 years). Respiratory failure requiring ventilatory support and a high Acute Physiology and Chronic Health Evaluation II score was significantly correlated to high in-ICU mortality, but not to long-term outcome. Type of hematological malignancy, neutropenia, thrombocytopenia, bacteremia, prior administration of chemotherapy, age, or gender was not significantly associated with outcome.

CONCLUSIONS

The current study provides encouraging results on long-term post-ICU outcome also in elderly patients with hematological diseases. For a substantial proportion of critically ill hematological patients, a short time care at an ICU is lifesaving. These patients should be offered intensive care unless or until it is clear that there is little prospect of recovery from the acute illness or that the underlying malignancy cannot be controlled.

Incidence and outcome of critical illness amongst hospitalised patients with haematological malignancy: a prospective observational study of ward and intensive care unit based care

To determine the incidence and outcome of critical illness amongst the total population of hospital patients with haematological malignancy (including patients treated on the ward as well as those admitted to the intensive care unit), consecutive patients with haematological malignancy were prospectively studied. One hundred and one of the 1437 haemato-oncology admissions (7%) in 2001 were complicated by critical illness (26% of all new referrals). Fifty-four (53%) of these critically ill patients survived to leave hospital and 33 (34%) were still alive after 6 months. The majority (77/101) were not admitted to the intensive care unit but were managed on the ward, often with the assistance of the intensive care team. Independent risk factors for dying in hospital included hepatic failure (odds ratio 5.3, 95% confidence intervals 1.3-21.2) and central nervous system failure (odds ratio 14.5, 95% confidence intervals 1.7-120.5). No patient with four or more organ failures or a Simplified Acute Physiology Score II >/= 65 survived to leave hospital. There was close agreement between actual and predicted mortality with increasing Simplified Acute Physiology Score II for all patients, including those not admitted to intensive care.

Patients with haematological malignancies requiring invasive mechanical ventilation: differences between survivors and non-survivors in intensive care unit

BACKGROUND

Mortality of patients with haematological malignancies requiring intensive therapy is high. We wanted to establish reasons for intensive care unit (ICU) admission and treatment as well as outcome in subjects who required invasive mechanical ventilation. We were also interested in differences between ICU survivors and non-survivors at the moment of admission.

PATIENTS AND METHODS

Forty patients (21 women and 19 men) were included in the study. Median of age was 42 (range 16-73) years. All patients required mechanical ventilation. We analysed age, gender, disease character (acute/chronic), diagnosed pneumonia, multiple organ failure (MOF), history of bone marrow transplantation, peripheral blood parameters (leukocyte, neutrocyte, erythrocyte and thrombocyte counts, haemoglobin level and haematocrit), mean arterial pressure (obtained through direct measurement), necessity of catecholamine administration and symptoms of the acute renal insufficiency at the moment of ICU admission.

MAIN RESULTS

Sixty-five percent of patients died in ICU. Intergroup comparisons between survivors and non-survivors revealed statistically significant differences in the presence of neutropenia, thrombocyte count, mean arterial pressure and the necessity of catecholamines administration, as well as scores obtained through patient evaluation according to the Acute Physiology and Chronic Health Evaluation (APACHE II), the Sequential Organ Failure Assessment (SOFA) and the New Simplified Acute Physiology Score (SAPS II) scales. Multivariate logistic regression revealed only one independent risk factor for ICU mortality in the analysed group--SAPS II score (p=0.009). Calculated value of the unitary odds ratio was 1.065 (95% confidence interval 1.017-1.116).

CONCLUSIONS

Mortality of patients with haematological malignancies requiring intensive mechanical ventilation remains high. Scoring with the SAPS II system was a useful tool for determination of ICU mortality risk in those patients.

Outcome in Noninvasively and Invasively Ventilated Hematologic Patients With Acute Respiratory Failure

STUDY OBJECTIVES

The survival rate of patients with a hematologic malignancy requiring mechanical ventilation (MV) in the ICU has improved over the last few decades. The objective of this study was to identify the factors affecting the in-hospital mortality of these particular patients, and to assess whether the use of noninvasive positive pressure ventilation (NPPV) was protective in our study population.

DESIGN

We retrospectively collected variables in 166 consecutive patients with hematologic malignancies who had acute respiratory failure (ARF) requiring MV, and identified factors obtained within 24 h of ICU admission affecting in-hospital mortality in univariate and multivariate stepwise logistic regression analyses. The effect of NPPV on mortality was assessed using a pair-wise matched exposed-unexposed analysis.

RESULTS

The mean simplified acute physiology score (SAPS) II was 58.9. The in-hospital mortality rate was 71%. In a multivariate logistic regression analysis, the in-hospital mortality rate was predicted by increasing severity of illness, as measured by SAPS II (odds ratio [OR] per point of increase, 1.07; 95% confidence interval [CI], 1.04 to 1.11) and a diagnosis of acute myelogenous leukemia (OR, 2.73; 95% CI, 1.05 to 7.11). Female sex (OR, 0.36; 95% CI, 0.16 to 0.82), endotracheal intubation (ETI) within 24 h of ICU admission (OR, 0.29; 95% CI, 0.11 to 0.78), and recent bacteremia (defined as blood cultures positive for bacteria < 48h before or < 24h after ICU admission) [OR, 0.22; 95% CI, 0.08 to 0.61] were associated with a lower mortality rate. Twenty-seven patients who received NPPV were matched for SAPS II (+/- 3) with 52 patients who required immediate ETI on a 1:2 basis. The crude in-hospital mortality rate was 65.4% in both groups.

CONCLUSION

Although the in-hospital mortality rate in hematologic patients who develop ARF remains high, the reluctance to intubate and start treatment with invasive MV in this population is unjustified, especially when bacteremia has precipitated ICU admission.

Outcome of lung cancer patients with acute respiratory failure requiring mechanical ventilation

To assess the weaning outcome of lung cancer patients with acute respiratory failure (ARF) requiring mechanical ventilation, we retrospectively analyzed the database of the respiratory intensive care unit at a university-affiliated tertiary care hospital. Charts were reviewed for cancer status, biochemistries before respiratory failure, causes of respiratory failure, acute physiology and chronic health evaluation (APACHE) III score, ventilatory settings, data recorded during spontaneous breathing, duration of ventilator days, and weaning outcome. Ninety-five consecutive respiratory failure events in 81 patients were recorded from January 1, 1995 through June 30, 1999. Twenty-six episodes ended with successful weaning (27.4%). Age, gender, and cancer status did not affect the weaning outcome. Serum albumin level, APACHE III score, highest fractional inspired O2 (FiO2) and highest positive end-expiratory pressure, organ failure, ability to shift to partial ventilatory support, and duration of mechanical ventilation could significantly influence the weaning outcome statistically. The overall hospital mortality rate was 85.2%. Our results suggested that lung cancer patients with ARF will have a better chance to wean if the initial APACHE III score was less than 70, use of FiO2 never exceeded 0.6, or less than 2 additional organ systems failed during the treatment course.

Treatment of acute respiratory failure by helmet-delivered non-invasive pressure support ventilation in children with acute leukemia: a pilot study

OBJECTIVE

To evaluate the feasibility of non-invasive ventilation (NIV) through a new interface-the helmet-in the treatment of acute respiratory failure (ARF) in hematologic children.

DESIGN AND SETTING

Observational, non-randomized report of four consecutive cases. Pediatric Intensive Care Unit in a university hospital.

PATIENTS AND METHODS

Four consecutive females (aged 9-17 years) affected by acute leukemia (3 acute lymphocytic leukemia [ALL], 1 acute myeloid leukemia [AML]) and with hypoxemic ARF (defined by severe dyspnea at rest, respiratory rate >30 breaths/min, PaO2:FiO2 <200 and active contraction of the accessory muscles). Pressure support ventilation was delivered via a helmet (CaStar,Starmed, Italy) by means of an ICU ventilator (Servo 300, Siemens Elema, Sweden).

RESULTS

We evaluated the effect of pressure support ventilation delivered by helmet on blood gases, respiratory rate, hemodynamics, patient tolerance, complication rate and outcome. An improvement of oxygenation was uniformly observed within the first 3 h after admission. The helmet was well tolerated by all children. No complication was observed. Two patients were discharged from the PICU in stable clinical conditions, whereas the remaining two children overcame the respiratory distress but had non-respiratory complications and eventually died.

CONCLUSION

Non-invasive ventilation via the helmet can offer effective ventilatory support and improve gas exchange in the treatment of ARF in pediatric hematologic patients. As already shown in adults, NIV may decrease the risk of life-threatening complications associated with invasive mechanical ventilation (MV), also in children with hematologic malignancies; moreover, it offers the possibility of an earlier approach to respiratory failure in this patient subset.

Outcome of patients with acute myeloid leukemia and pulmonary infiltrates requiring invasive mechanical ventilation—a retrospective analysis

PURPOSE

To assess the prognosis of patients with acute myeloid leukemia (AML) and pulmonary infiltrates requiring mechanical ventilation.

DESIGN

A retrospective cohort study.

SETTING

A medical intensive care unit (ICU) in an academic tertiary care center.

PATIENTS AND METHODS

We identified 30 consecutive patients with acute myeloid leukemia and pulmonary infiltrates who received invasive mechanical ventilation and compared clinical and laboratory parameters between ICU survivors and ICU non-survivors using non-parametric statistics.

RESULTS

The overall mortality rate was 87% (26/30). The survival was 40 % (4/10) for patients aged 50 years or less while none (0/20) of the patients older than 50 years survived (P <.02). The median time of mechanical ventilation in survivors was 23.5 (3-45) days. No differences between survivors and non-survivors were observed for the APACHE II score, oxygenation quotient, liver function tests, creatinine, blood urea nitrogen, or prognostic parameters of acute myeloid leukemia (presence of blasts on bone marrow aspirate, cytogenetic studies, and intensity of the chemotherapy regimen).

CONCLUSIONS

Age seems to be an important prognostic parameter in our cohort of 30 consecutive patients with acute myeloid leukemia and pulmonary infiltrates requiring mechanical ventilation. Prolonged ventilation does not preclude survival.

Intensive care unit outcomes in elderly cancer patients

As the number of elderly patients receiving oncologic therapies increases, the need for better outcome predictors for the critically ill elderly with cancer increases. Physicians should not view age as an indicator of poor ICU outcome, as many elderly patients with cancer will derive the same benefit from intensive care as their younger counterparts. Such a gain can be accomplished without overuse of valuable resources. Similar prognostic factors that are applied to the younger cancer patients should also be applied to the elderly. These parameters, in addition to clinical judgment, can be helpful in deciding who will benefit from ICU care regardless of age. Oncologists and critical care physicians will need to collaborate and change the paradigm of ICU care for the elderly.

Outcome analysis of 189 consecutive cancer patients referred to the intensive care unit as emergencies during a 2-year period

The referral of critically ill cancer patients to an intensive care unit (ICU) is a matter of controversial debate. This study was conducted by an interdisciplinary clinical group to evaluate the outcome of ICU treatment in cancer patients according to their characteristics at the time of referral. A retrospective analysis was used to identify relevant subgroups among 189 consecutive cancer patients referred as emergencies to one of four ICUs during a 2-year period. Reasons for ICU referral were pneumonia (29.6%), sepsis (27.0%), fungal infection (11.1%), another infection (9.5%), gastrointestinal emergency (16.9%), treatment-related organ toxicity (6.9%), or other, non-infectious complications (43.9%). Vasopressor support was required in 50.3%, mechanical ventilation in 49.7%, and haemodialysis/-filtration in 26.5% of the patients. Overall, 41.3% died during ICU treatment, 12.2% died after transfer from ICU to a non-ICU ward, and 35.4% were discharged alive. Sepsis, mechanical ventilation, vasopressor support, renal replacement therapy and neutropenia were independent risk factors for fatal outcome, but no single risk factor unequivocally predicted death. All patients with fungal infection who required vasopressor support and either had sepsis (n=13) or needed mechanical ventilation (n=14) died during ICU treatment, while all non-septic patients. who did not require mechanical ventilation, were younger than 74 years of age and had a non-infectious underlying complication (n=29), survived. This analysis may help to early identify relevant subgroups of cancer patients with different prognoses under ICU treatment. A prospective study to confirm the predictive usefulness of this approach is needed. Cancer patients should not be excluded from referral to the intensive care unit in an emergency solely due to their underlying malignant disease or a single unfavourable prognostic factor.

Prospective evaluation of the epidemiology, microbiology, and outcome of bloodstream infections in hematologic patients in a single cancer center

Bloodstream infections (BSIs) have an important impact on the outcome of cancer patients. A prospective cohort study was undertaken at a referral cancer center in order to describe the clinical and microbiological characteristics of patients with hematologic malignancies and BSIs and to identify independent predictors associated with mortality. The study enrolled 110 consecutive BSI episodes during an 18-month period. Patients were monitored for 30 days after the last positive blood culture. There were 10.24 BSI episodes per 1,000 patient-days. The median age of the patients was 25 years. Most patients had acute leukemia ( n=72). The origin of the BSI was unknown in 43.6% of the episodes and was associated with known sites in 32.7%. There were 58 concomitant infectious sites (lungs, 43%, and soft tissue, 22.4%) and 195 noninfectious comorbid factors (poor performance status, 30.2%; undernourishment, 14.3%). The median neutrophil count was 215 cells/mm(3). Indwelling catheters were present in 70% of the episodes. The majority of isolates obtained within the first 48 h of the BSI episode (61%) were gram-negative rods. Overall mortality was 24.5%. Multivariate analysis using logistic regression showed relapsed leukemia, poor performance status, recent weight loss, and ventilatory failure requiring ventilatory support as independent predictors of mortality. Hematologic cancer patients with BSIs should be regarded as a distinct group of patients at high risk of death. The knowledge of variables amenable to intervention would help diminish or prevent serious medical complications.

Multiple organ failure and outcome of critically ill patients with haematological malignancy

BACKGROUND

The number of failing organs systems in ICU patients with haematological malignancy is associated with outcome. The objective of this study was to assess short and long-term survival in these patients with special reference to multiple organ failure reflected by the SOFA (Sequential Organ Failure Assessment) score.

METHODS

Retrospective chart review of haematological patients admitted to the 10-bed intensive care unit (ICU) of a tertiary level academic teaching hospital from 1994 to 1998. Of 31 admitted patients with the diagnosis of haematological malignancy, the charts of 30 were available for analysis.

RESULTS

Univariate logistic regression analysis of factors previously shown to influence survival revealed that only admission SOFA score and untreated status of haematological disease were significantly associated with survival (P < 0.05). ICU, 3-month and one-year survival rates were 57% (17/30), 23% (7/30) and 20% (6/30), respectively. If maximal SOFA score during the ICU stay was included in a multivariate model comprising treatment status and effect, admission day SOFA and APACHE II scores, mechanical ventilation, renal replacement therapy and neutropenia, the maximal SOFA score became the only independent variable. All patients with an admission SOFA score exceeding 11 died in hospital. Leave-one-out method revealed that admission SOFA scores and the status of haematological disease (untreated or not) correctly classified 83% (25 of 30) of patients to survivors or non-survivors.

CONCLUSIONS

Multiple organ failure assessed as SOFA score on admission and status of disease were associated with outcome in critically ill patients with haematological malignancy.

Outcome and early prognostic indicators in patients with a hematologic malignancy admitted to the intensive care unit for a life-threatening complication

OBJECTIVES

To assess the outcome and to identify early prognostic indicators in a global population of patients with hematologic malignancy admitted to the intensive care unit for a life-threatening complication.

DESIGN

Retrospective observational study.

SETTING

Medical intensive care unit at a tertiary university hospital.

PATIENTS

A total of 124 consecutive critically ill patients with a hematologic malignancy admitted to the intensive care unit during a 3.5-yr period. MEASUREMENTS We collected variables at admission and during admission and identified predictors of in-hospital mortality by stepwise logistic regression analysis.

MAIN RESULTS

Mean Acute Physiology and Chronic Health Evaluation II score was 26 +/- 7.7. Sixty-one percent had a high-grade malignancy, and 27% had active disease. Thirty-five percent were leukopenic (leukocyte count, <1.0 x 10(9)/L) at admission. Respiratory failure (48%), sepsis (18.5%), and neurologic impairment (17%) were the major reasons for admission at the intensive care unit. Seventy-one percent of the patients required ventilatory support for a median duration of 6 (3-17) days, 46% received vasopressors at admission, and 26.6% needed renal replacement therapy during their intensive care unit stay. A recent bacteremia precipitating intensive care unit admission was found in 21.8% of the patients. Crude intensive care unit, in-hospital, and 6-month mortality rates were 42%, 54%, and 66%, respectively. Four variables were independently associated with outcome in a multivariate logistic regression analysis: leukopenia (odds ratio, 2.9; 95% confidence interval, 1.1-7.7), vasopressors (odds ratio, 3.74; 95% confidence interval, 1.4-9.8), and urea of >0.75 g/L (>12 mmol/L) (odds ratio, 9.4; 95% confidence interval, 4.2-26) at admission were associated with poor outcome, whereas recent bacteremia (odds ratio, 0.17; 95% confidence interval, 0.05-0.58) was associated with better prognosis. Using these variables, we arbitrarily categorized our population into three groups for survival analysis: a low-risk group (low urea with or without either leukopenia or vasopressors, n = 60), an intermediate-risk group (high urea or a combination of leukopenia and vasopressors, n = 34), and a high-risk group (high urea in combination with leukopenia or vasopressors, n = 27). Patients with a bacteremia prompting intensive care unit admission were allocated to a one-step-lower risk group. Survival probabilities at 30 days and 6 months were 75% and 55% in the first group, 35% and 21% in the second group, and 4% and 0%, respectively, in the third group ( <.001).

CONCLUSION

The general reluctance to admit patients with a hematologic malignancy to the intensive care unit, even with severe critical illness, is unjustified. However, we identified four early predictors of outcome that may be of value in deciding in which patients advanced or prolonged support should not be continued.

Prognosis of hematologic malignancies does not predict intensive care unit mortality

OBJECTIVE

To evaluate the correlation between specific prognosis of hematologic malignancies on the one hand and intensive care unit and hospital mortality in critically ill patients with hematologic malignancies on the other hand.

DESIGN

Observational study during a 10-yr period.

SETTING

A 22-bed medical-surgical intensive care unit.

PATIENTS

A total of 84 consecutive patients with nonterminal hematologic malignancies with medical complications requiring intensive care.

INTERVENTIONS

None.

MEASUREMENTS

Demographic factors, acute physiology and organ dysfunction scores, microbiology, therapeutic support, and hematologic factors data on admission and during the intensive care unit stay were collected, together with mortality follow-up. Based on specific-disease prognostic factors and related published survival curves, the prognosis of hematologic malignancies was assessed and defined as good, intermediate, or poor according to a 3-yr survival probability of >50%, 20-50%, or <20%, respectively.

MAIN RESULTS

Prognosis of hematologic malignancies does not predict intensive care unit or hospital mortality and almost reaches significance for 6-mo mortality (53%, 71%, and 84% rate for patients with good, intermediate, and poor prognosis, respectively, p =.058), but it determines long-term survival (p =.008). Intensive care unit, hospital, and 6-mo overall mortality rates were 38%, 61%, and 75%, respectively. Using multivariate analysis, intensive care unit mortality was best predicted on admission by respiratory failure and fungal infection, whereas hospital mortality was predicted by the number of organ failures, the bone marrow transplant status, and the presence of fungal infection. The Acute Physiology and Chronic Health Evaluation II and the Simplified Acute Physiology Score II had no prognostic value, whereas the difference of the Multiple Organ Dysfunction Score between at the time of admission and at day 5 allowed quick prediction of hospital mortality. Diseases with the poorest 6-mo prognosis were acute myeloid leukemia and non-Hodgkin lymphoma. CONCLUSION The severity of the underlying hematologic malignancies does not influence intensive care unit or hospital mortality. Short-term prognosis is exclusively predicted by acute organ dysfunctions and by a pathogen's aggressiveness. Therefore, reluctance to admit patients with nonterminal hematologic malignancies to the intensive care unit based only on the prognosis of their underlying hematologic malignancy does not seem justified.

Noninvasive ventilation in the treatment of acute respiratory failure induced by all-trans retinoic acid (retinoic acid syndrome) in children with acute promyelocytic leukemia

PURPOSE

To evaluate the feasibility of noninvasive ventilation through a nasal mask in the treatment of acute respiratory failure induced by all-trans retinoic acid.

DESIGN

Observational, nonrandomized report of two cases.

SETTING

Intensive care unit in a university hospital.

PATIENTS

Two pediatric patients (an 11-yr-old male and a 12-yr-old female) affected by acute promyelocytic leukemia.

INTERVENTIONS

Pressure support ventilation was delivered via a nasal mask by means of a bilevel positive pressure ventilator (Respironics, Murrysville, PA).

MEASUREMENTS AND MAIN RESULTS

We evaluated the effects of the bilevel positive pressure ventilator on blood gas analysis, respiratory rate, hemodynamics, patient tolerance, complications, and outcome. Patients showed an improvement of blood gas analysis and respiratory rate after 3-6 hrs of noninvasive ventilation. The nasal mask was well tolerated by the two patients. No complications were observed. Patients were discharged from the intensive care unit in stable clinical conditions after 3-4 days.

CONCLUSIONS

Noninvasive ventilation by a nasal mask can offer effective ventilatory support and improve gas exchange in the treatment of acute respiratory failure in pediatric hematologic patients. In addition, noninvasive ventilation may decrease the risk of life-threatening complications associated with endotracheal intubation and conventional mechanical ventilation in patients with hematologic malignancies.

Intensive care, mechanical ventilation, dialysis, and cardiopulmonary resuscitation. Implications for the patient with cancer

The broad range in mortality rates seen in the critically ill cancer population reflects the fact that cancer is a heterogeneous disease, affecting a heterogeneous population at different stages of care. Patients, families, and physicians frequently agonize about the utility of CPR and ICU care and whether this care should be offered. Understanding the goals of care, respecting autonomy, and knowing the likelihood of benefits and burdens of these interventions are critical in making these difficult decisions.

Acute respiratory failure in critically ill patients with cancer. Diagnosis and management

Respiratory failure remains a common cause of admission to the ICU for patients with cancer, regardless of the nature of malignancy. The diagnosis and management of ARF in patients with cancer poses special challenges to the intensivist. Depending on the type of cancer, the degree of immunosuppression, underlying comorbidities, the modality of cancer treatment, progression or spread of underlying cancer, and disease- or therapy-associated complications are the most common causes of ARF in these patients. Despite significant advances in antineoplastic therapies and supportive management in the ICU, the mortality rate of patients with cancer with ARF remains high. Severity-of-illness scoring systems and mortality probability models, although useful in discriminating between survivors and nonsurvivors in large groups of critically ill patients, should not be used alone to justify reluctance in admitting individual patients with cancer with potentially reversible respiratory failure to the ICU. Close collaboration between oncologists and intensivists will ensure the establishment of clear goals and direction of treatment for every patient with cancer who requires mechanical ventilation.

Improved survival in cancer patients requiring mechanical ventilatory support: Impact of noninvasive mechanical ventilatory support

OBJECTIVE

When a cancer patient becomes critically ill, mechanical ventilation (MV) is often considered futile. However, recent studies have found that outcomes of critically ill cancer patients have been improving over the years and that classic predictors of high mortality have lost their relevance.

DESIGN

We retrospectively determined outcomes and predictors of 30-day mortality in 237 mechanically-ventilated cancer patients admitted to the intensive care unit (ICU).

PATIENTS

The 132 (55.7%) patients who were admitted between 1990 and 1995 were compared with 105 (44.3%) patients who were admitted between 1996 and 1998. The malignancy was leukemia/lymphoma in 119 (50.3%) patients, myeloma in 50 (21%), and a solid tumor in 68 (28.7%). Forty-two (17.7%) patients had bone marrow transplantation, and 91 (38.4%) were neutropenic. Median Simplified Acute Physiology Score II (SAPS II) was 58 (range, 40-75). Reasons for MV were acute hypoxemic respiratory failure in 148 (62.5%) patients, coma in 54 (22.8%), and cardiogenic pulmonary edema in 35 (14.7%). Conventional MV was used first in 189 (79.8%) patients, and noninvasive MV (NIMV) was used in 48 (20.2%). Overall mortality rate was 72.5% (172 deaths).

RESULTS

Logistic regression identified three variables associated with mortality: ICU admission between 1996 and 1998 (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.12-0.50) and the use of NIMV (OR, 0.34; 95% CI, 0.16-0.73) were protective, and the SAPS II was aggravating (OR, 1.04 per point; 95% CI, 1.02-1.06). To better define the impact of NIMV, we performed a pairwise-matched exposed-unexposed analysis. Forty-eight patients who did and 48 who did not receive NIMV as the first ventilation method were matched for SAPS II, type of malignancy, and period of ICU admission. Crude ICU mortality rates from exposed patients and controls were 43.7% and 70.8%, respectively. NIMV remained protective from mortality after adjustment for matching variables (OR, 0.31; 95% CI, 0.12-0.82).

CONCLUSION

Our results confirm that mortality has improved over the past decade in critically ill cancer patients, even those who require MV, and suggest that this may be, in part, because of a protective effect of NIMV.

Outcome for cancer patients requiring mechanical ventilation

PURPOSE

To describe hospital survival for cancer patients who require mechanical ventilation.

MATERIALS AND METHODS

A prospective, multicenter observational study was performed at five academic tertiary care hospitals. Demographic and clinical variables were obtained on consecutive cancer patients at initiation of mechanical ventilation, and information on vital status at hospital discharge was acquired.

RESULTS

Our analysis was based on 782 adult cancer patients who met predetermined inclusion criteria. The overall observed hospital mortality was 76%, with no statistically significant differences among the five study centers. Seven variables (intubation after 24 hours, leukemia, progression or recurrence of cancer, allogeneic bone marrow transplantation, cardiac arrhythmias, presence of disseminated intravascular coagulation, and need for vasopressor therapy) were associated with an increased risk of death, whereas prior surgery with curative intent was protective. The predictive model based on these variables had an area under the receiver operating characteristic curve of 0.736, with Hosmer-Lemeshow goodness-of-fit statistics of 7.19; P = .52.

CONCLUSION

This model can be used to estimate the probability of hospital survival for classes of adult cancer patients who require mechanical ventilation and can help to guide physicians, patients, and families in deciding goals and direction of treatment. Prospective independent validation in different medical settings is warranted.

Pulmonary infiltrates in neutropenic patients with acute leukemia during chemotherapy: outcome and prognostic factors

STUDY OBJECTIVE

To determine predictors of mortality from pulmonary infiltrates in neutropenic patients with acute leukemia during chemotherapy, and the significance of those factors related to the underlying malignancy and its therapy as well as of those related to the severity of the illness associated with pulmonary infiltrates.

DESIGN

A historical cohort study.

SETTING

A university teaching hospital and tertiary referral center.

PATIENTS AND METHODS

Overall, 53 patients with neutropenia during chemotherapy and with first episodes of pulmonary infiltrates during a 4-year period were studied. Prognostic analysis included 38 variables. Multivariate analyses were performed by logistic regression.

RESULTS

The survival rate from pneumonia was 57% (30/53). The following eight parameters were significantly associated with death in univariate analysis: comorbidity present; development of "late" pulmonary infiltrates (> or = 14 days after hospital admission); heart rate > or = 100 beats/min; a ratio heart rate/systolic blood pressure (HR/SBP) > or = 1.2; urea nitrogen > 7 mmol/L; radiographic score > or = 3; neutropenia < 1.0x10(9)/L at the treatment end point; and failed complete remission. In a multivariate model including only parameters available at diagnosis of pulmonary infiltrates, the presence of a ratio HR/SBP > or = 1.2 and of a radiographic score > or = 3 remained independently associated with death. In a second model also including the evolutionary parameter neutropenia < or = 1.0x10(9)/L at the treatment end point, both parameters remained significant together with neutropenia <1.0x 10(9)/L at the treatment end point. The presence of a ratio HR/SBP > or = 1.2 was a strong marker of early death.

CONCLUSION

Both therapy- and malignancy-associated neutropenia as well as the severity of illness associated with pulmonary infiltrates are independent prognostic factors. Patients with a ratio HR/SBP > or = 1.2 at diagnosis of pulmonary infiltrates suffer from potentially reversible acute illness, are at risk for early death and, therefore, may be appropriate candidates for treatment in an ICU.

Feasibility of noninvasive mechanical ventilation in the treatment of acute respiratory failure in postoperative cancer patients

PURPOSE

Patients with cancer who require mechanical ventilation have high mortality rates. Although oncological patients have multiple clinical problems, including nutritional and immunological deficiencies, added complications from mechanical ventilation by themselves may be life-threatening and may further compromise the ability of these patients to recover from an episode of acute respiratory failure (ARF). Noninvasive mechanical ventilatory support (NIMV) using positive-pressure-ventilation delivered through a mask has gained popularity for the treatment of ARF and may limit some mechanical ventilation complications. The purpose of this study was to prospectively evaluate NIMV in cancer patients with ARF.

MATERIALS AND METHODS

All patients admitted to the surgical intensive care unit (SICU) at The University of Texas M.D. Anderson Cancer Center from August 1, 1994, to April 15, 1996, with hypoxemic or hypercapnic ARF were eligible for this study. NIMV was delivered with the BiPAP S/T-D (Respironics, Murrysville, PA) device. The initial settings were adjusted to achieve a tidal volume of 5 to 7 mL/kg and a SaO2 greater than 0.90. Demographic data, duration of therapy, and need for endotracheal intubation were recorded for each patient.

RESULTS

Sixty patients were included in this study. There were 21 women (35%) and 39 men. The primary cancer sites of these patients were gastrointestinal (25 patients), genitourinary (15), hematological (8), lung (6), sarcoma (4), and skin (2). Fifty-three patients (88%) had hypoxemic ARF and 7 had hypercapnic ARF. The mean duration of NIMV was 1.83 days (range, 1 to 5 days) with a median of 2 days. Forty-two patients (70%) were weaned from NIMV and were spared endotracheal intubation. The remaining 18 patients deteriorated and ultimately required intubation and assisted mechanical ventilation. No complications related to the use of NIMV were seen in this study population.

CONCLUSIONS

NIMV was effective in the treatment of ARF in cancer patients at our institution substantially decreasing the need for intubation. This ventilatory technique is a viable option for cancer patients with ARF.

Treatment of acute respiratory failure by prolonged non-invasive ventilation in a child

PURPOSE

To evaluate the feasibility and the efficacy of non-invasive ventilation (NIV) by nasal mask in a paediatric patient.

CLINICAL FEATURES

A four-year-old girl with acute lymphocytic leukaemia (ALL L1, pre-pre B) complicated by acute respiratory failure was treated with NIV. ON admission she exhibited hyperpyrexia (40C), pancytopaenia and severe hypoxia with hypocapnia (PaO2 = 45 mmHg; PaCO2 = 28.2 mmHG; pH = 7.30; SpO2 = 76%; ABE = -7.3 mmol.L-1. With NIV, PaO2 improved (PaO2 = 78 +/- 8 mmHG; SpO2 = 86 +/- 2; PaCO2 = 39 +/- 2) throughout the first day. Treatment was continued for six days until the patient was discharged. No complications were recorded.

CONCLUSION

Non-invasive ventilation by nasal mask may represent a choice in the treatment of acute respiratory failure of parenchymal origin in paediatric haematological patients.