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de Almeida MJ, Camandaroba MPG, Nassar AP, de Jesus VHF. Short-term survival of patients with advanced pancreatic cancer admitted to intensive care unit: a retrospective cohort study. Ecancermedicalscience 2022; 16:1475. [PMID: 36819828 PMCID: PMC9934886 DOI: 10.3332/ecancer.2022.1475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Indexed: 11/24/2022] Open
Abstract
Background Little is known about the outcomes of patients with advanced pancreatic cancer admitted to the intensive care unit (ICU) due to medical complications. We designed a study to evaluate their short-term (30-day) survival, predictors of short-term survival and chances of additional chemotherapy. Methods We reviewed all patients with advanced (stage III or IV) pancreatic adenocarcinoma admitted to an ICU in a dedicated Brazilian cancer centre from 2009 to 2018 due to medical reasons. We fitted multivariate regression models to identify predictors of 30-day survival and additional systemic chemotherapy. Results The study population consisted of 171 patients. Ninety-four patients (55.0%) had Eastern Cooperative Oncology Group (ECOG) performance status 2-4 and 146 (85.4%) had metastatic disease. Most patients (N = 75; 43.9%) were admitted to the ICU during first-line treatment. Median overall survival was 32 days (95% confidence interval (95% CI): 20-49). Survival rate at 30 days was 50.6%. ECOG performance status 2-4 was the only variable associated with lower probability of survival at 30 days in multivariate analysis (odds ratio: 0.28; 95% CI: 0.14-0.54; p < 0.001). Overall, 58 patients (33.9%) received additional chemotherapy and among all patients, 13.5% experienced clinical benefit from this treatment. Conclusion Patients with advanced pancreatic cancer admitted to the ICU for medical reasons have a dismal prognosis. Early palliative care and refined tools to establish those who would benefit from an ICU trial could help improve patients' care.
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Affiliation(s)
- Marina Junqueira de Almeida
- Medical Oncology Department, A.C. Camargo Cancer Center, Rua Prof. Antônio Prudente, 211, São Paulo, SP 01509-010, Brazil
| | | | - Antonio Paulo Nassar
- Intensive Care Medicine Department, A.C. Camargo Cancer Center, Rua Prof. Antônio Prudente, 211, São Paulo, SP 01509-010, Brazil
| | - Victor Hugo Fonseca de Jesus
- Medical Oncology Department, A.C. Camargo Cancer Center, Rua Prof. Antônio Prudente, 211, São Paulo, SP 01509-010, Brazil,https://orcid.org/0000-0003-4702-116X
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Cooksley T, Weaver JMJ, Haji-Michael P. Intensive Care Unit requirements in patients treated with immune checkpoint inhibitors. QJM 2022; 116:285-287. [PMID: 36377790 DOI: 10.1093/qjmed/hcac258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/06/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine the proportion of emergency patients treated with immune checkpoint inhibitors (ICIs) that require critical care admission and their requirements. DESIGN Prospective case series. METHODS Analysis of acutely unwell patients treated with ICIs attending a tertiary UK cancer hospital between May 2018 and May 2022. The primary outcome measure was the percentage of patients treated with ICI therapy requiring ICU admission. The secondary outcome measure was whether this need was driven by an immune-mediated toxicity. RESULTS Eighteen (1.2%) patients of the 1561 acutely admitted patients treated with ICI therapy required an admission to ICU. Ten (55.5%) patients were admitted due to an immune-mediated toxicity; 4 due to pneumonitis and 4 due to myasthenia gravis. Seven of 10 survived their ICU admission with 6 surviving at least 6 month post ICU discharge. CONCLUSIONS Only a small minority of emergency admissions in patients treated with ICIs require admission to ICU. This series adds further evidence that patients with organ failure due to immune-mediated toxicity may achieve good outcomes from ICU admission.
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Affiliation(s)
- Tim Cooksley
- Departments of Acute Medicine, Medical Oncology and Critical Care, The Christie, Wilmslow Road, Manchester, UK
| | - Jamie M J Weaver
- Departments of Acute Medicine, Medical Oncology and Critical Care, The Christie, Wilmslow Road, Manchester, UK
| | - Phil Haji-Michael
- Departments of Acute Medicine, Medical Oncology and Critical Care, The Christie, Wilmslow Road, Manchester, UK
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Nazer LH, Lopez-olivo MA, Brown AR, Cuenca JA, Sirimaturos M, Habash K, Alqadheeb N, May H, Milano V, Taylor A, Nates JL. A Systematic Review and Meta-Analysis Evaluating Geographical Variation in Outcomes of Cancer Patients Treated in ICUs. Crit Care Explor 2022; 4:e0757. [PMID: 36119395 PMCID: PMC9473777 DOI: 10.1097/cce.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The reported mortality rates of cancer patients admitted to ICUs vary widely. In addition, there are no studies that examined the outcomes of critically ill cancer patients based on the geographical regions. Therefore, we aimed to evaluate the mortality rates among critically ill cancer patients and provide a comparison based on geography.
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Hautecloque-Rayz S, Albert-Thananayagam M, Martignene N, Le Deley MC, Carbonnelle G, Penel N, Carnot A. Long-Term Outcomes and Prognostic Factors of Patients with Metastatic Solid Tumors Admitted to the Intensive Care Unit. Oncology 2022; 100:173-181. [PMID: 35051928 DOI: 10.1159/000520097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Admission of metastatic cancer patients to the intensive care unit (ICU) poses medical and ethical challenges in the absence of reliable prognostic tools to guide decision-making. MATERIAL AND METHODS We retrospectively analyzed the medical charts of 129 consecutive patients with metastatic solid tumors admitted to the ICU between January and September 2014 and identified prognostic factors (PFs) using Cox models. RESULTS The mean patient age at ICU admission was 58.9 years (range, 25-81 years; males, 51%). Performance status (PS) was 0-1 and 2-3 in 61% and 39% of the patients, respectively. The most prevalent cancers were lung cancer (20%), sarcoma (17%), and breast cancer (16%). ICU admission was attributable to the cancer itself (53%), cancer treatment toxicity (43%), and comorbidities (37%). The median overall survival (OS) after ICU admission was 2.6 months; 15% of the patients died during the ICU stay. Poor PFs for OS were PS >1 before ICU admission (p = 0.007) and ICU admission for the cancer itself (p < 10-3). After ICU discharge, 58% and 42% of the patients received systemic treatment within 12 months and showed good PS recovery, respectively. Multiple organ failure and a multidisciplinary decision to limit therapeutic efforts were poor PFs for reinitiation of systemic treatment (p = 0.2 and 0.006, respectively), and the latter was also a poor PF for PS recovery (p = 0.004). DISCUSSION In the ICU, the OS of adult patients with solid tumors was similar to that of the noncancer population. For ICU admissions related to the cancer itself, the prognosis is poor.
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Affiliation(s)
- Ségolène Hautecloque-Rayz
- Department of Medical Oncology, Centre Oscar Lambret, Lille, France.,Medical School, Lille University, Lille, France.,Department of Medical Oncology, Hôpital Duchesne de Boulogne, Boulogne-sur-mer, France
| | | | - Niels Martignene
- Department of Medical Oncology, Hôpital Duchesne de Boulogne, Boulogne-sur-mer, France.,Methology and Biostatistics Unit, Centre Oscar Lambret, Lille, France.,Medical Information Unit, Centre Oscar Lambret, Lille, France
| | - Marie-Cécile Le Deley
- Methology and Biostatistics Unit, Centre Oscar Lambret, Lille, France.,CESP, INSERM, Paris-Saclay University, Paris-Sud University, UVSQ, Villejuif, France
| | - Guillaume Carbonnelle
- Department of Medical Oncology, Centre Oscar Lambret, Lille, France.,Supportive Care Unit, Centre Oscar Lambret, Lille, France
| | - Nicolas Penel
- Department of Medical Oncology, Centre Oscar Lambret, Lille, France.,Medical School, Lille University, Lille, France
| | - Aurélien Carnot
- Department of Medical Oncology, Centre Oscar Lambret, Lille, France
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Gutierrez C, Brown ART, May HP, Beitinjaneh A, Stephens RS, Rajendram P, Nates JL, Pastores SM, Dharshan A, de Moraes AG, Hensley MK, Feng L, Brudno JN, Athale J, Ghosh M, Kochenderfer JN, Arias AS, Lin Y, McEvoy C, Mead E, Westin J, Kostelecky N, Mian A, Herr MM. Critically Ill Patients Treated for Chimeric Antigen Receptor-Related Toxicity: A Multicenter Study. Crit Care Med 2022; 50:81-92. [PMID: 34259446 DOI: 10.1097/CCM.0000000000005149] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To report the epidemiology, treatments, and outcomes of adult patients admitted to the ICU after cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome. DESIGN Retrospective cohort study. SETTING Nine centers across the U.S. part of the chimeric antigen receptor-ICU initiative. PATIENTS Adult patients treated with chimeric antigen receptor T-cell therapy who required ICU admission between November 2017 and May 2019. INTERVENTIONS Demographics, toxicities, specific interventions, and outcomes were collected. RESULTS One-hundred five patients treated with axicabtagene ciloleucel required ICU admission for cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome during the study period. At the time of ICU admission, the majority of patients had grade 3-4 toxicities (66.7%); 15.2% had grade 3-4 cytokine release syndrome and 64% grade 3-4 immune effector cell-associated neurotoxicity syndrome. During ICU stay, cytokine release syndrome was observed in 77.1% patients and immune effector cell-associated neurotoxicity syndrome in 84.8% of patients; 61.9% patients experienced both toxicities. Seventy-nine percent of patients developed greater than or equal to grade 3 toxicities during ICU stay, however, need for vasopressors (18.1%), mechanical ventilation (10.5%), and dialysis (2.9%) was uncommon. Immune Effector Cell-Associated Encephalopathy score less than 3 (69.7%), seizures (20.2%), status epilepticus (5.7%), motor deficits (12.4%), and cerebral edema (7.9%) were more prevalent. ICU mortality was 8.6%, with only three deaths related to cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome. Median overall survival time was 10.4 months (95% CI, 6.64-not available mo). Toxicity grade or organ support had no impact on overall survival; higher cumulative corticosteroid doses were associated to decreased overall and progression-free survival. CONCLUSIONS This is the first study to describe a multicenter cohort of patients requiring ICU admission with cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome after chimeric antigen receptor T-cell therapy. Despite severe toxicities, organ support and in-hospital mortality were low in this patient population.
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van der Zee EN, Noordhuis LM, Epker JL, van Leeuwen N, Wijnhoven BPL, Benoit DD, Bakker J, Kompanje EJO. Assessment of mortality and performance status in critically ill cancer patients: A retrospective cohort study. PLoS One 2021; 16:e0252771. [PMID: 34115771 PMCID: PMC8195393 DOI: 10.1371/journal.pone.0252771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 05/22/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Given clinicians' frequent concerns about unfavourable outcomes, Intensive Care Unit (ICU) triage decisions in acutely ill cancer patients can be difficult, as clinicians may have doubts about the appropriateness of an ICU admission. To aid to this decision making, we studied the survival and performance status of cancer patients 2 years following an unplanned ICU admission. MATERIALS AND METHODS This was a retrospective cohort study in a large tertiary referral university hospital in the Netherlands. We categorized all adult patients with an unplanned ICU admission in 2017 into two groups: patients with or without an active malignancy. Descriptive statistics, Pearson's Chi-square tests and the Mann-Whitney U tests were used to evaluate the primary objective 2-year mortality and performance status. A good performance status was defined as ECOG performance status 0 (fully active) or 1 (restricted in physically strenuous activity but ambulatory and able to carry out light work). A multivariable binary logistic regression analysis was used to identify factors associated with 2-year mortality within cancer patients. RESULTS Of the 1046 unplanned ICU admissions, 125 (12%) patients had cancer. The 2-year mortality in patients with cancer was significantly higher than in patients without cancer (72% and 42.5%, P <0.001). The median performance status at 2 years in cancer patients was 1 (IQR 0-2). Only an ECOG performance status of 2 (OR 8.94; 95% CI 1.21-65.89) was independently associated with 2-year mortality. CONCLUSIONS In our study, the majority of the survivors have a good performance status 2 years after ICU admission. However, at that point, three-quarter of these cancer patients had died, and mortality in cancer patients was significantly higher than in patients without cancer. ICU admission decisions in acutely ill cancer patients should be based on performance status, severity of illness and long-term prognosis, and this should be communicated in the shared decision making. An ICU admission decision should not solely be based on the presence of a malignancy.
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Affiliation(s)
- Esther N. van der Zee
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | - Lianne M. Noordhuis
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jelle L. Epker
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nikki van Leeuwen
- Department of Public Health, Center for Medical Decision Making, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bas P. L. Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Jan Bakker
- Department of Pulmonology and Critical Care, New York University NYU Langone Medical Center, New York, NY, United States of America
- Department of Pulmonology and Critical Care Columbia University Irvine Medical Center, New York, NY, United States of America
- Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Erwin J. O. Kompanje
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
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8
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Rapoport BL, Cooksley T, Johnson DB, Anderson R, Shannon VR. Treatment of infections in cancer patients: an update from the neutropenia, infection and myelosuppression study group of the Multinational Association for Supportive Care in Cancer (MASCC). Expert Rev Clin Pharmacol 2021; 14:295-313. [PMID: 33517803 DOI: 10.1080/17512433.2021.1884067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients with hematological and advanced solid malignancies have acquired immune dysfunction, often exacerbated by treatment, posing a significant risk for the development of infections. This review evaluates the utility of current clinical and treatment guidelines, in the setting of management of infections in cancer patients. AREAS COVERED These include causes of infection in cancer patients, management of patients with high-risk and low-risk febrile neutropenia, management of low-risk patients in an outpatient setting, the role of granulocyte colony-stimulating factor (G-CSF) in the prevention and treatment of neutropenia-related infections, management of lung infections in various clinical settings, and emerging challenges surrounding the risk of infection in cancer patients treated with novel treatments. The literature search was performed by accessing PubMed and other databases, focusing on published clinical trials of relevant anti-cancer agents and diseases, primarily covering the recent past, but also including several key studies published during the last decade and, somewhat earlier in a few cases. EXPERT REVIEW Notwithstanding the promise of gene therapy/gene editing in hematological malignancies and some types of solid cancers, innovations introduced in clinical practice include more discerning clinical management such as the generalized use of biosimilar formulations of G-CSF and the implementation of novel, innovative immunotherapies.
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Affiliation(s)
- Bernardo L Rapoport
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,The Medical Oncology Centre of Rosebank, Saxonwold, Johannesburg, South Africa.,The Multinational Association for Supportive Care in Cancer (MASCC), Chair of the Neutropenia, Infection and Myelosuppression Study Group
| | - Tim Cooksley
- Manchester University Foundation Trust, Manchester, United Kingdom. The Christie, University of Manchester, Manchester, UK.,The Multinational Association for Supportive Care in Cancer (MASCC), Infection and Myelosuppression Study Group
| | - Douglas B Johnson
- Douglas B. Johnson, Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, Tennessee, USA
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Vickie R Shannon
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
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Kim YJ, Kim MJ, Kim YJ, Kim WY. Short and Long-Term Mortality Trends for Cancer Patients with Septic Shock Stratified by Cancer Type from 2009 to 2017: A Population-Based Cohort Study. Cancers (Basel) 2021; 13:cancers13040657. [PMID: 33562125 PMCID: PMC7931033 DOI: 10.3390/cancers13040657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 01/22/2023] Open
Abstract
Simple Summary This study aimed to assess short and long-term mortality trends in cancer patients with septic shock from 2009 to 2017. Among 43,466 adult cancer patients with septic shock (90% solid and 10% hematologic cancer cases) who presented at an emergency department (ED) in Korea between 2009 and 2017, the 30-day and 1-year mortality rates were 52.1% and 81.3%, respectively. The overall 30-day mortality decreased by 4.8% annually from 2013 to 2017, whereas the 1-year mortality only showed a 1.9% annual decrease over this same period. Pancreatic cancer cases showed the most significant improvement in the 30-day mortality since 2014, and lung and stomach cancer showed a sustained decrease in this metric during the whole study period. The outcomes of cancer patients with septic shock have improved in recent years across most cancer types. Physicians should have expectations of improved prognoses in cancer patients admitted to the ED with septic shock. Abstract There have been recent advances in both cancer and sepsis management. This study aimed to assess short and long-term mortality trends in cancer patients with septic shock from 2009 to 2017 by cancer type. This nationwide population-based cohort study using data from the National Health Insurance Service of Korea included adult cancer patients who presented to an emergency department (ED) with septic shock from 2009 to 2017. Among 43,466 adult cancer patients with septic shock (90% solid and 10% hematologic cancer cases), the 30-day and 1-year mortality rates were 52.1% and 81.3%, respectively. The overall 30-day mortality showed a marked decrease of 4.8% annually from 2013 to 2017, but the annual decrease in the 1-year mortality over the same period was only 1.9%. Pancreatic cancer cases showed the most significant improvement in 30-day mortality between 2014 and 2019 (11.0% decrease/year). Lung and stomach cancers showed a sustained decrease in 30-day mortality during the whole study period (1.7% and 2.0% decrease/year, respectively). The outcomes of cancer patients with septic shock have improved in recent years across most cancer types. Physicians should have expectations of an improved prognosis in cancer patients admitted to the ED with septic shock.
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Affiliation(s)
- Youn-Jung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea;
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul 05505, Korea; (M.-J.K.); (Y.-J.K.)
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul 05505, Korea; (M.-J.K.); (Y.-J.K.)
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea;
- Correspondence: ; Tel.: +82-2-3010-3350
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Gheerbrant H, Timsit JF, Terzi N, Ruckly S, Laramas M, Levra MG, Jacquet E, Falque L, Moro-Sibilot D, Toffart AC. Factors associated with survival of patients with solid Cancer alive after intensive care unit discharge between 2005 and 2013. BMC Cancer 2021; 21:9. [PMID: 33402107 DOI: 10.1186/s12885-020-07706-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/01/2020] [Indexed: 12/24/2022] Open
Abstract
Background At intensive care unit (ICU) admission, the issue about prognosis of critically ill cancer patients is of clinical interest, especially after ICU discharge. Our objective was to assess the factors associated with 3- and 6-month survival of ICU cancer survivors. Methods Based on the French OutcomeRea™ database, we included solid cancer patients discharged alive, between December 2005 and November 2013, from the medical ICU of the university hospital in Grenoble, France. Patient characteristics and outcome at 3 and 6 months following ICU discharge were extracted from available database. Results Of the 361 cancer patients with unscheduled admissions, 253 (70%) were discharged alive from ICU. The main primary cancer sites were digestive (31%) and thoracic (26%). The 3- and 6-month mortality rates were 33 and 41%, respectively. Factors independently associated with 6-month mortality included ECOG performance status (ECOG-PS) of 3–4 (OR,3.74; 95%CI: 1.67–8.37), metastatic disease (OR,2.56; 95%CI: 1.34–4.90), admission for cancer progression (OR,2.31; 95%CI: 1.14–4.68), SAPS II of 45 to 58 (OR,4.19; 95%CI: 1.76–9.97), and treatment limitation decision at ICU admission (OR,4.00; 95%CI: 1.64–9.77). Interestingly, previous cancer chemotherapy prior to ICU admission was independently associated with lower 3-month mortality (OR, 0.38; 95%CI: 0.19–0.75). Among patients with an ECOG-PS 0–1 at admission, 70% (n = 66) and 61% (n = 57) displayed an ECOG-PS 0–2 at 3- and 6-months, respectively. At 3 months, 74 (55%) patients received anticancer treatment, 13 (8%) were given exclusive palliative care. Conclusions Factors associated with 6-month mortality are almost the same as those known to be associated with ICU mortality. We highlight that most patients recovered an ECOG-PS of 0–2 at 3 and 6 months, in particular those with a good ECOG-PS at ICU admission and could benefit from an anticancer treatment following ICU discharge. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-020-07706-3.
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Ashana DC, Umscheid CA, Stephens-Shields AJ, Kohn R, Madden V, Harhay MO, Chen Y, Kerlin MP. Determining the Association Between End-of-Life Care Resources and Patient Outcomes in Pennsylvania ICUs. Crit Care Med 2019; 47:1591-8. [PMID: 31464767 DOI: 10.1097/CCM.0000000000003969] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES As ICUs are increasingly a site of end-of-life care, many have adopted end-of-life care resources. We sought to determine the association of such resources with outcomes of ICU patients. DESIGN Retrospective cohort study. SETTING Pennsylvania ICUs. PATIENTS Medicare fee-for-service beneficiaries. INTERVENTIONS Availability of any of one hospital-based resource (palliative care consultants) or four ICU-based resources (protocol for withdrawal of life-sustaining therapy, triggers for automated palliative care consultation, protocol for family meetings, and palliative care clinicians embedded in ICU rounds). MEASUREMENTS AND MAIN RESULTS In mixed-effects regression analyses, admission to a hospital with end-of-life resources was not associated with mortality, length of stay, or treatment intensity (mechanical ventilation, hemodialysis, tracheostomy, gastrostomy, artificial nutrition, or cardiopulmonary resuscitation); however, it was associated with a higher likelihood of discharge to hospice (odds ratio, 1.58; 95% CI, 1.11-2.24), an effect that was driven by ICU-based resources (odds ratio, 1.37; 95% CI, 1.04-1.81) rather than hospital-based resources (odds ratio, 1.19; 95% CI, 0.83-1.71). Instrumental variable analysis using differential distance (defined as the additional travel distance beyond the hospital closest to a patient's home needed to reach a hospital with end-of-life resources) demonstrated that among those for whom differential distance would influence receipt of end-of-life resources, admission to a hospital with such resources was not associated with any outcome. CONCLUSIONS ICU-based end-of-life care resources do not appear to change mortality but are associated with increased hospice utilization. Given that this finding was not confirmed by the instrumental variable analysis, future studies should attempt to verify this finding, and identify specific resources or processes of care that impact the care of ICU patients at the end of life.
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Cooksley T. The Disappearing Dichotomy Between Critical Care and Palliative Care: Integration Will Enhance Patient Outcomes. Crit Care Med 2019; 47:1667-8. [PMID: 31609267 DOI: 10.1097/CCM.0000000000003994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Praça APA, Nassar AP, Caruso P. Outcomes of Cancer Patients Discharged From ICU After a Decision to Forgo Life-Sustaining Therapies: . Crit Care Med 2019; 47:e454-60. [DOI: 10.1097/ccm.0000000000003729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Siegrist V, Eken C, Nickel CH, Mata R, Hertwig R, Bingisser R. End-of-life decisions in emergency patients: prevalence, outcome and physician effect. QJM 2018; 111:549-554. [PMID: 29860409 DOI: 10.1093/qjmed/hcy112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/08/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND End-of-life decisions (EOLD) represent potentially highly consequential decisions often made in acute situations, such as 'do not attempt resuscitation' (DNAR) choices at emergency presentation. AIM We investigated DNAR decisions in an emergency department (ED) to assess prevalence, associated patient characteristics, potential medical and economic consequences and estimate contributions of patients and physicians to DNAR decisions. DESIGN Single-centre retrospective observation, including ED patients with subsequent hospitalization between 2012 and 2016. Primary outcome was a DNAR decision and associated patient characteristics. Secondary outcomes were mortality, admission to intensive care unit and use of resources. METHODS Associations between DNAR and patient characteristics were analysed using logistic mixed effects models, results were reported as odds ratios (OR). Median odds ratios (MOR) were used to estimate patient and physician contributions to variability in DNAR. RESULTS Patients of 10 458 were attended by 315 physicians. DNAR was the choice in 23.3% of patients. Patients' characteristics highly associated with DNAR were age (OR = 4.0, 95% CI = 3.6-4.3) and non-trauma presentation (OR = 2.3, 95% CI = 1.9-2.9). In-hospital mortality was significantly higher (OR = 5.4, CI = 4.0-7.3), and use of resources was significantly lower (OR = 0.7, CI = 0.6-0.8) in patients choosing DNAR. There was a significant effect on DNAR by both patient (MOR = 1.8) and physician (MOR = 2.0). CONCLUSIONS DNAR choices are common in emergency patients and closely associated with age and non-trauma presentation. Mortality was significantly higher, and use of resources significantly lower in DNAR patients. Evidence of a physician effect raises questions about the choice autonomy of emergency patients in the process of EOLD.
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Affiliation(s)
- V Siegrist
- Emergency Department, University Hospital Basel
- Center for Cognitive and Decision Sciences, University of Basel, Basel, Switzerland
| | - C Eken
- Emergency Department, University Hospital Basel
| | - C H Nickel
- Emergency Department, University Hospital Basel
| | - R Mata
- Center for Cognitive and Decision Sciences, University of Basel, Basel, Switzerland
| | - R Hertwig
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
| | - R Bingisser
- Emergency Department, University Hospital Basel
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