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1
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Mutlu YG, Aydin BB, Erdogan C, Kizilaslan D, Beköz HS, Gemici A, Kaynar L, Sevindik ÖG. Prognostic Factors and Intensive Care Outcome in Post-Transplant Phase of Hematopoietic Stem Cell Transplantation: Intensive Care Outcome in Hematopoietic Stem Cell Transplantation. Indian J Hematol Blood Transfus 2023; 39:167-172. [PMID: 37006979 PMCID: PMC10064358 DOI: 10.1007/s12288-022-01575-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/30/2022] [Indexed: 04/04/2023] Open
Abstract
Introduction To identify new clinical and biologic parameters associated with short-term survival in allogeneic or autologous hematopoietic stem cell transplantation (HSCT) patients who were admitted to the intensive care unit (ICU) during their post-transplant period. Materials and methods 40 patients who were admitted to the ICU in our center during their post-transplant period were evaluated retrospectively between Jan 2014 - Jun 2021. Baseline patient characteristics before the transplant, reasons for ICU admissions, laboratory and clinical findings, supportive treatment in ICU and short-term survival were analyzed. Results We found 8.8% ICU admission rate in all patient group (n = 450). Mortality rate of the patients who were admitted to ICU was 75%. Invasive mechanic ventilation, need for vasopressor, heart rate was significantly different between survivor and non-survivor group (p = 0.001, p = 0.001, p = 0.004). Elevated INR was associated with poor survival on ICU (p = 0.033). APACHE II score was an independent predictor of ICU mortality (p = 0.045). Conclusion Despite the recent advances in transplant conditioning protocols, prophylaxis strategies and improvements of management in ICU, overall survival for HSCT patients in ICU is still poor. In this study INR level was described as a new prognostic factor in ICU for first time in the literature.
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Affiliation(s)
- Yaşa Gül Mutlu
- Department of Hematology, Istanbul Medipol University, Istanbul, Turkey
| | | | - Cem Erdogan
- Department of Anesthesiology, Istanbul Medipol University, Istanbul, Turkey
| | - Deniz Kizilaslan
- Department of Anesthesiology, Istanbul Medipol University, Istanbul, Turkey
| | | | - Aliihsan Gemici
- Department of Hematology, Istanbul Medipol University, Istanbul, Turkey
| | - Leylagül Kaynar
- Department of Hematology, Istanbul Medipol University, Istanbul, Turkey
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2
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Leung KKY, Hon KL, Hui WF, Leung AK, Li CK. Therapeutics for paediatric oncological emergencies. Drugs Context 2021; 10:dic-2020-11-5. [PMID: 34234831 PMCID: PMC8232653 DOI: 10.7573/dic.2020-11-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/20/2021] [Indexed: 12/19/2022] Open
Abstract
Background With advancements in the field of oncology, cancer survival rates have improved dramatically but modern cancer treatments also come with an increasing number of disease and treatment-associated complications. This article provides an updated narrative review on the pathophysiology, clinical presentations and latest management strategies for common paediatric oncological emergencies. Methods An extensive PubMed® search of all human studies in the English literature was performed in Clinical Queries for different oncology syndromes and conditions using the following Medical Subject Headings: “tumour lysis syndrome”, “hyperleukocytosis”, “disseminated intravascular coagulation”, “superior mediastinal syndrome”, “superior vena cava syndrome”, “sepsis”, “severe inflammatory response syndrome”, “acute respiratory distress syndrome”, “posterior reversible encephalopathy syndrome” and “reversible posterior leukoencephalopathy syndrome”. Categories were limited to clinical trials and reviews for ages from birth to 18 years. Results The general description, presentation and management of these oncologic emergencies are systematically described. Early recognition along with prompt and proactive treatment can reduce the chances of potential complications and improve the clinical outcomes, thereby improving not only survival rates in oncology patients but also their clinical outcomes and quality of life. Conclusions Oncologic emergencies are associated with significant mortality and morbidity. Healthcare professionals involved with the care of oncology patients must be vigilant of these emergencies.
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Affiliation(s)
- Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Kam Lun Hon
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Wun Fung Hui
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Alexander Kc Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Chi Kong Li
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong.,Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong
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Barlas T, İnci K, Aygencel G, Türkoğlu M, Tunçcan ÖG, Can F, Aydın Kaynar L, Özkurt ZN, Yeğin ZA, Yağcı M. Infections in hematopoietic stem cell transplant patients admitted to Hematology intensive care unit: a single-center study. ACTA ACUST UNITED AC 2021; 26:328-339. [PMID: 33818297 DOI: 10.1080/16078454.2021.1905355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the data of HSCT patients who were admitted to our Hematology ICU due to infections or infectious complications. MATERIALS AND METHODS HSCT patients who were admitted to our Hematology ICU between 01 January 2014 and 01 September 2017 were analyzed retrospectively. RESULTS 62 HSCT patients were included in this study. The median age was 55.5 years and 58% of the patients were allogeneic HSCT patients. Major underlying hematologic disorders were multiple myeloma (29%) and lymphoma (27.4%). The most common reasons for ICU admission were sepsis/septic shock (61.3%) and acute respiratory failure (54.8%). Overall ICU mortality rate was 45.2%. However, a lot of factors were related with ICU mortality of HSCT patients in univariate analysis, only APACHE II score was found to be an independent risk factor for ICU mortality. While there was infection in 58 patients at ICU admission, new infections developed in 38 patients during ICU stay. The most common new infection was pneumonia/VAP, while the most frequently isolated bacteria were Acinetobacter baumannii. Length of ICU stay, sepsis/septic shock as a reason for ICU admission and the presence of urinary catheter at ICU admission were determined factors for ICU-acquired infections. There was no difference between autologous and allogeneic stem cell transplant patients in terms of ICU morbidities and mortality. However, pneumonia/VAP developed in the ICU was higher in autologous HSCT patients, while bloodstream/catheter-related bloodstream infection was higher in allogeneic HSCT patients. CONCLUSION It was concluded that early or late post-HSCT infections and related complications (sepsis, organ failure, etc.) constituted a major part of the reasons for ICU admission, ICU mortality and ICU morbidities.
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Affiliation(s)
- Tuğba Barlas
- Department of Internal Medicine, Division of Intensive Care Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Kamil İnci
- Department of Internal Medicine, Division of Intensive Care Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Gulbin Aygencel
- Department of Internal Medicine, Division of Intensive Care Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Melda Türkoğlu
- Department of Internal Medicine, Division of Intensive Care Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Özlem Güzel Tunçcan
- Department of Infectious Diseases and Clinical Microbiology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ferda Can
- Department of Internal Medicine, Division of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Lale Aydın Kaynar
- Department of Internal Medicine, Division of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Zübeyde Nur Özkurt
- Department of Internal Medicine, Division of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Arzu Yeğin
- Department of Internal Medicine, Division of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Münci Yağcı
- Department of Internal Medicine, Division of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
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El Cheikh J, Cheaito R, Abdul-Nabi SS, Cheaito MA, Mufarrij AJ, Tamim H, Makki M, El Majzoub I. Predictors of a short hospitalization in bone marrow transplantation patients presenting to the emergency department. Am J Emerg Med 2021; 45:117-123. [PMID: 33684868 DOI: 10.1016/j.ajem.2021.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Despite the advantages of bone marrow transplantation (BMT), patients receiving this intervention visit the emergency department (ED) frequently and for various reasons. Many of those ED visits result in hospitalization, and the length of stay varies. OBJECTIVES The objective of our study was to identify the patients who were only briefly hospitalized and were thus eligible for safe discharge from the ED. METHODS This was a retrospective cohort study conducted on all adult patients who have completed a successful BMT and had an ED visit that resulted in hospitalization. RESULTS Our study included 115 unique BMT with a total number of 357 ED visits. Around half of those visits resulted in a short hospitalization. We found higher odds of a short hospitalization among those who have undergone autologous BMT (95%CI [1.14-2.65]). Analysis of the discharge diagnoses showed that patients with gastroenteritis were more likely to have a shorter hospitalization in comparison to those diagnosed with others (95%CI [1.10-3.81]). Furthermore, we showed that patients who presented after a month from their procedure were more likely to have a short hospitalization (95%CI [1.04-4.87]). Another significant predictor of a short of hospitalization was the absence of Graft versus Host Disease (GvHD) (95%CI [2.53-12.28]). Additionally, patients with normal and high systolic blood pressure (95%CI [2.22-6.73] and 95%CI [2.81-13.05]; respectively), normal respiratory rate (95%CI [2.79-10.17]) and temperature (95%CI [2.91-7.44]) were more likely to have a shorter hospitalization, compared to those presenting with abnormal vitals. Likewise, we proved higher odds of a short hospitalization in patients with a quick Sepsis Related Organ Failure Assessment score of 1-2 (95%CI [1.29-5.20]). Moreover, we demonstrated higher odds of a short hospitalization in patients with a normal platelet count (95%CI [1.39-3.36]) and creatinine level (95%CI [1.30-6.18]). CONCLUSION In our study, we have shown that BMT patients visit the ED frequently and many of those visits result in a short hospitalization. Our study showed that patients presenting with fever/chills are less likely to have a short hospitalization. We also showed a significant association between a short hospitalization and BMT patients without GvHD, with normal RR, normal T °C and a normal platelet count.
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Affiliation(s)
- Jean El Cheikh
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Rola Cheaito
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Sarah S Abdul-Nabi
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Mohamad Ali Cheaito
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Afif Jean Mufarrij
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Hani Tamim
- Biostatistics Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Maha Makki
- Biostatistics Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Imad El Majzoub
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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5
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[Bone marrow transplantation patients in the intensive care unit]. Med Klin Intensivmed Notfmed 2021; 116:111-120. [PMID: 33564899 PMCID: PMC7871956 DOI: 10.1007/s00063-021-00782-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/20/2020] [Accepted: 01/08/2021] [Indexed: 10/31/2022]
Abstract
Allogeneic hematopoetic stem cell transplantation yields improved long-term survival for patients with high-risk malignant and non-malignant hematologic disease. However, it is associated with high morbidity and mortality. A proportion of patients need intensive care due to infectious, immunological and/or toxic complications. The utility of intensive care unit (ICU) treatments as mechanical ventilation and renal replacement therapy for these patients is uncertain since mortality is high. We describe the most frequent complications and the treatment options concerning the ICU in recipients of allogeneic hematopoetic stem cells.
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6
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Hiong A, Thursky KA, Venn G, Teh BW, Haeusler GM, Crane M, Slavin MA, Worth LJ. Impact of a hospital-wide sepsis pathway on improved quality of care and clinical outcomes in surgical patients at a comprehensive cancer centre. Eur J Cancer Care (Engl) 2019; 28:e13018. [PMID: 30761632 DOI: 10.1111/ecc.13018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 09/12/2018] [Accepted: 12/18/2018] [Indexed: 01/25/2023]
Abstract
PURPOSE Sepsis is a significant complication following cancer surgery. Although standardised care bundles improve sepsis outcomes in other populations, the benefits in cancer patients are unclear. The objectives of this study were to describe the epidemiology of sepsis in cancer patients post-surgery, and to evaluate the impact of a clinical sepsis pathway on management and clinical outcomes. METHODS A standardised hospital-wide sepsis pathway was developed in 2013, and all cases of sepsis at the Peter MacCallum Cancer Centre in 2014 were retrospectively evaluated. Inclusion criteria were sepsis onset during the 100-day period following a surgical procedure for cancer diagnosis. Patients were identified using ICD-10-AM sepsis discharge codes, audit documentation and the hospital's antimicrobial approval system. Sepsis episodes were classified as managed on- or off-pathway. RESULTS A total of 119 sepsis episodes were identified. Of these, 71 (59.7%) were managed on the sepsis pathway. Episodes managed on-pathway resulted more frequently in administration of appropriate antibiotics compared to those off-pathway (94.4% vs. 66.7%, p < 0.001), and had shorter time to first-dose antibiotics (median 85 vs. 315 min, p < 0.001). Pathway utilisation was associated with significant reductions in need for inotropes (7% vs. 13%, p = 0.023), ventilation (3% vs. 10%, p = 0.006) and length of hospitalisation (median 15 vs. 30 days, p = 0.008). The most frequent source of infection was organ-space surgical site infection (24.4% of instances). CONCLUSIONS A dedicated hospital-wide sepsis pathway had significant impact on the quality of care and clinical outcomes of sepsis in cancer surgery patients. Cost-benefit analysis of sepsis pathways for cancer patients is required.
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Affiliation(s)
- Alison Hiong
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia.,National Health and Medical Research Council Centre for Research Excellence, National Centre for Antimicrobial Stewardship, Doherty Institute, Melbourne, Victoria, Australia
| | - Georgina Venn
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Benjamin W Teh
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia
| | - Megan Crane
- The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia
| | - Leon J Worth
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia.,Victorian Healthcare Associated Infection Surveillance System (VICNISS), Doherty Institute, Melbourne, Victoria, Australia
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7
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Al-Zubaidi N, Shehada E, Alshabani K, ZazaDitYafawi J, Kingah P, Soubani AO. Predictors of outcome in patients with hematologic malignancies admitted to the intensive care unit. Hematol Oncol Stem Cell Ther 2018; 11:206-218. [PMID: 29684341 DOI: 10.1016/j.hemonc.2018.03.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 01/02/2018] [Accepted: 03/10/2018] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Nassar Al-Zubaidi
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, United States
| | - Emad Shehada
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, United States
| | - Khaled Alshabani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, United States
| | - Jihane ZazaDitYafawi
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, United States
| | - Pascal Kingah
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, United States
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, United States.
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Na SJ, Ha TS, Koh Y, Suh GY, Koh SO, Lim CM, Choi WI, Lee YJ, Kim SC, Chon GR, Kim JH, Kim JY, Lim J, Park S, Kim HC, Lee JH, Lee JH, Park J, Cho J, Jeon K. Characteristics and Clinical Outcomes of Critically Ill Cancer Patients Admitted to Korean Intensive Care Units. Acute Crit Care 2018; 33:121-129. [PMID: 31723875 PMCID: PMC6786698 DOI: 10.4266/acc.2018.00143] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/16/2018] [Accepted: 07/17/2018] [Indexed: 11/30/2022] Open
Abstract
Background The objective of this study was to investigate the characteristics and clinical outcomes of critically ill cancer patients admitted to intensive care units (ICUs) in Korea. Methods This was a retrospective cohort study that analyzed prospective collected data from the Validation of Simplified Acute Physiology Score 3 (SAPS3) in Korean ICU (VSKI) study, which is a nationwide, multicenter, and prospective study that considered 5,063 patients from 22 ICUs in Korea over a period of 7 months. Among them, patients older than 18 years of age who were diagnosed with solid or hematologic malignancies prior to admission to the ICU were included in the present study. Results During the study period, a total of 1,762 cancer patients were admitted to the ICUs and 833 of them were deemed eligible for analysis. Six hundred fifty-eight (79%) had solid tumors and 175 (21%) had hematologic malignancies, respectively. Respiratory problems (30.1%) was the most common reason leading to ICU admission. Patients with hematologic malignancies had higher Sequential Organ Failure Assessment (12 vs. 8, P<0.001) and SAPS3 (71 vs. 69, P<0.001) values and were more likely to be associated with chemotherapy, steroid therapy, and immunocompromised status versus patients with solid tumors. The use of inotropes/vasopressors, mechanical ventilation, and/or continuous renal replacement therapy was more frequently required in hematologic malignancy patients. Mortality rates in the ICU (41.7% vs. 24.6%, P<0.001) and hospital (53.1% vs. 38.6%, P=0.002) were higher in hematologic malignancy patients than in solid tumor patients. Conclusions Cancer patients accounted for one-third of all patients admitted to the studied ICUs in Korea. Clinical characteristics were different according to the type of malignancy. Patients with hematologic malignancies had a worse prognosis than did patients with solid tumor.
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Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Sun Ha
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Younsuck Koh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin Ok Koh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won-Il Choi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Dongsan Hospital, Keimyung University, Daegu, Korea
| | - Young-Joo Lee
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Seok Chan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Gyu Rak Chon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Chungju Hospital, Konkuk University School of Medicine, Chungju, Korea
| | - Je Hyeong Kim
- Department of Critical Care Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jae Yeol Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jaemin Lim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Gangneung Asan Hospital, University of Ulsan Medical College of Medicine, Gangneung, Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ho Cheol Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, College of Medicine, Gyeongsang Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
| | - Jin Hwa Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Ji Hyun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, CHA Bundang Hospital, CHA University, Seongnam, Korea
| | - Jisook Park
- Department of Multimedia, Seoul Women's University, Seoul, Korea
| | - Juhee Cho
- Samsung Advanced Institute of Health Science and Technology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Improved short- and long-term outcome of allogeneic stem cell recipients admitted to the intensive care unit: a retrospective longitudinal analysis of 942 patients. Intensive Care Med 2018; 44:1483-1492. [PMID: 30141173 DOI: 10.1007/s00134-018-5347-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/10/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE Intensive care unit (ICU) admission of allogeneic hematopoietic stem cell transplant (HSCT) recipients is associated with relatively poor outcome. Since longitudinal data on this topic remains scarce, we analyzed reasons for ICU admission as well as short- and long-term outcome of critically ill HSCT recipients. METHODS A total of 942 consecutive adult patients were transplanted at Hannover Medical School from 2000 to 2013. Of those, 330 patients were at least admitted once to the ICU and included in this retrospective study. To analyze time-dependent improvements, we separately compared patient characteristics as well as reasons and outcome of ICU admission for the periods 2000-2006 and 2007-2013. RESULTS The main reasons for ICU admission were acute respiratory failure (ARF) in 35%, severe sepsis/septic shock in 23%, and cardiac problems in 18%. ICU admission was clearly associated with shortened survival (p < 0.001), but survival of ICU patients after hospital discharge reached 44% up to 5 years and was comparable to that of non-ICU HSCT patients. When ICU admission periods were compared, patients were older (48 vs. 52 years; p < 0.005) and the percentage of ARF as leading cause for ICU admission decreased from 43% in the first to 30% in the second period. Over time ICU and hospital survival improved from 44 to 60% (p < 0.01) and from 26 to 43% (p < 0.01), respectively. The 1- and 3-year survival rate after ICU admission increased significantly from 14 to 32% and from 11 to 23% (p < 0.01). CONCLUSIONS Besides ARF and septic shock, cardiac events were especially a major reason for ICU admission. Both short- and long-term survival of critically ill HSCT patients has improved significantly in recent years, and survival of HSCT recipients discharged from hospital is not significantly affected by a former ICU stay.
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10
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Modification and Assessment of the Bedside Pediatric Early Warning Score in the Pediatric Allogeneic Hematopoietic Cell Transplant Population. Pediatr Crit Care Med 2018; 19. [PMID: 29521817 PMCID: PMC5935581 DOI: 10.1097/pcc.0000000000001521] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the validity of the Bedside Pediatric Early Warning Score system in the hematopoietic cell transplant population, and to determine if the addition of weight gain further strengthens the association with need for PICU admission. DESIGN Retrospective cohort study of pediatric allogeneic hematopoietic cell transplant patients from 2009 to 2016. Daily Pediatric Early Warning Score and weights were collected during hospitalization. Logistic regression was used to identify associations between maximum Pediatric Early Warning Score or Pediatric Early Warning Score plus weight gain and the need for PICU intervention. The primary outcome was need for PICU intervention; secondary outcomes included mortality and intubation. SETTING A large quaternary free-standing children's hospital. PATIENTS One-hundred two pediatric allogeneic hematopoietic cell transplant recipients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 102 hematopoietic cell transplant patients included in the study, 29 were admitted to the PICU. The median peak Pediatric Early Warning Score was 11 (interquartile range, 8-13) in the PICU admission cohort, compared with 4 (interquartile range, 3-5) in the cohort without a PICU admission (p < 0.0001). Pediatric Early Warning Score greater than or equal to 8 had a sensitivity of 76% and a specificity of 90%. The area under the receiver operating characteristics curve was 0.83. There was a high negative predictive value at this Pediatric Early Warning Score of 90%. When Pediatric Early Warning Score greater than or equal to 8 and weight gain greater than or equal to 7% were compared together, the area under the receiver operating characteristic curve increased to 0.88. CONCLUSIONS In this study, a Pediatric Early Warning Score greater than or equal to 8 was associated with PICU admission, having a moderately high sensitivity and high specificity. This study adds to literature supporting Pediatric Early Warning Score monitoring for hematopoietic cell transplant patients. Combining weight gain with Pediatric Early Warning Score improved the discriminative ability of the model to predict the need for critical care, suggesting that incorporation of weight gain into Pediatric Early Warning Score may be beneficial for monitoring of hematopoietic cell transplant patients.
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Abstract
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.
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Affiliation(s)
- Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, 3990 John R- 3 Hudson, Detroit, MI 48201, USA.
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Bayraktar UD, Milton DR, Shpall EJ, Rondon G, Price KJ, Champlin RE, Nates JL. Prognostic Index for Critically Ill Allogeneic Transplantation Patients. Biol Blood Marrow Transplant 2017; 23:991-996. [DOI: 10.1016/j.bbmt.2017.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 03/01/2017] [Indexed: 12/13/2022]
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Lee OJ, Jung M, Kim M, Yang HK, Cho J. Validation of the Pediatric Index of Mortality 3 in a Single Pediatric Intensive Care Unit in Korea. J Korean Med Sci 2017; 32:365-370. [PMID: 28049251 PMCID: PMC5220006 DOI: 10.3346/jkms.2017.32.2.365] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/16/2016] [Indexed: 11/20/2022] Open
Abstract
To compare mortality rate, the adjustment of case-mix variables is needed. The Pediatric Index of Mortality (PIM) 3 score is a widely used case-mix adjustment system of a pediatric intensive care unit (ICU), but there has been no validation study of it in Korea. We aim to validate the PIM3 in a Korean pediatric ICU, and extend the validation of the score from those aged 0-16 to 0-18 years, as patients aged 16-18 years are admitted to pediatric ICU in Korea. A retrospective cohort study of 1,710 patients was conducted in a tertiary pediatric ICU. To validate the score, the discriminatory power was assessed by calculating the area under the receiver-operating characteristic (ROC) curve, and calibration was evaluated by the Hosmer-Lemeshow goodness-of-fit (GOF) test. The observed mortality rate was 8.47%, and the predicted mortality rate was 6.57%. For patients aged < 18 years, the discrimination was acceptable (c-index = 0.76) and the calibration was good, with a χ² of 9.4 in the GOF test (P = 0.313). The observed mortality rate in the hemato-oncological subgroup was high (18.73%), as compared to the predicted mortality rate (7.13%), and the discrimination was unacceptable (c-index = 0.66). In conclusion, the PIM3 performed well in a Korean pediatric ICU. However, the application of the PIM3 to a hemato-oncological subgroup needs to be cautioned. Further studies on the performance of PIM3 in pediatric patients in adult ICUs and pediatric ICUs of primary and secondary hospitals are needed.
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Affiliation(s)
- Ok Jeong Lee
- Department of Pediatrics, Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Minyoung Jung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Minji Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hae Kyoung Yang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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An K, Wang Y, Li B, Luo C, Wang J, Luo C, Chen J. Prognostic factors and outcome of patients undergoing hematopoietic stem cell transplantation who are admitted to pediatric intensive care unit. BMC Pediatr 2016; 16:138. [PMID: 27544347 PMCID: PMC4992291 DOI: 10.1186/s12887-016-0669-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 08/09/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There are many studies about the prognosis and possible predictive factors of mortality for pediatric allogeneic hematopoietic stem cell transplantation (HSCT) recipients requiring pediatric intensive care unit (PICU) treatment, but the related study in China is lacking. This study investigates the data of these special patients in our center. METHODS This retrospective analysis is based on data from bone marrow center and PICU of our hospital. A total of 302 patients received allogeneic HSCT from January 2000 to December 2012, 29 of them were admitted to PICU because of various complications developed after transplantation. We collected the clinical data, identified the reasons why the patients to PICU, analyzed the mortality of these patients in PICU, and the prognostic factors of these patients. RESULTS The main reasons for admission were: respiratory failure (62.07 %), neurological abnormities (13.79 %), renal failure (13.79 %) and others (10.35 %). Twenty-one cases (72.41 %) died. Compared with survivors, the deaths cases had lower pediatric critical illness score (77 vs. 88, p = 0.004); higher levels of lactic acid and serum urea nitrogen (4.02 vs. 1.19 mmol/L, P = 0.008;11.56 vs. 7.13 m moll /L, P = 0.045); more organs damaged (2.05 vs. 1.38, P = 0.01), and required more supportive treatments (1.52 vs. 0.63, P = 0.02). Univariate analysis identified pediatric critical illness score, use of mechanical ventilation, and the number of supportive treatment as the significant predictors to prognosis. Multivariate analysis by regression showed that pediatric critical illness score was the only independent prognostic factor (P = 0.035). CONCLUSIONS In our study, pediatric allogeneic HSCT recipients who had PICU care had a high rate of mortality. Pediatric critical illness score was the independent prognostic factor for these patients.
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Affiliation(s)
- Kang An
- Department of PICU, Shanghai Childrenʼs Medical Center, Pudong, Shanghai China
| | - Ying Wang
- Department of PICU, Shanghai Childrenʼs Medical Center, Pudong, Shanghai China
| | - Biru Li
- Department of PICU, Shanghai Childrenʼs Medical Center, Pudong, Shanghai China
| | - Changying Luo
- Department of Hematology and Oncology, Shanghai Childrenʼs Medical Center, 1678 Dongfang Road, Pudong, Shanghai China
| | - Jianmin Wang
- Department of Hematology and Oncology, Shanghai Childrenʼs Medical Center, 1678 Dongfang Road, Pudong, Shanghai China
| | - Chengjuan Luo
- Department of Hematology and Oncology, Shanghai Childrenʼs Medical Center, 1678 Dongfang Road, Pudong, Shanghai China
| | - Jing Chen
- Department of Hematology and Oncology, Shanghai Childrenʼs Medical Center, 1678 Dongfang Road, Pudong, Shanghai China
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Adaptive Immune Response Impairs the Efficacy of Autologous Transplantation of Engineered Stem Cells in Dystrophic Dogs. Mol Ther 2016; 24:1949-1964. [PMID: 27506452 DOI: 10.1038/mt.2016.163] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 08/03/2016] [Indexed: 12/27/2022] Open
Abstract
Duchenne muscular dystrophy is the most common genetic muscular dystrophy. It is caused by mutations in the dystrophin gene, leading to absence of muscular dystrophin and to progressive degeneration of skeletal muscle. We have demonstrated that the exon skipping method safely and efficiently brings to the expression of a functional dystrophin in dystrophic CD133+ cells injected scid/mdx mice. Golden Retriever muscular dystrophic (GRMD) dogs represent the best preclinical model of Duchenne muscular dystrophy, mimicking the human pathology in genotypic and phenotypic aspects. Here, we assess the capacity of intra-arterial delivered autologous engineered canine CD133+ cells of restoring dystrophin expression in Golden Retriever muscular dystrophy. This is the first demonstration of five-year follow up study, showing initial clinical amelioration followed by stabilization in mild and severe affected Golden Retriever muscular dystrophy dogs. The occurrence of T-cell response in three Golden Retriever muscular dystrophy dogs, consistent with a memory response boosted by the exon skipped-dystrophin protein, suggests an adaptive immune response against dystrophin.
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Mayer S, Pastores SM, Riedel E, Maloy M, Jakubowski AA. Short- and long-term outcomes of adult allogeneic hematopoietic stem cell transplant patients admitted to the intensive care unit in the peritransplant period. Leuk Lymphoma 2016; 58:382-390. [PMID: 27347608 DOI: 10.1080/10428194.2016.1195499] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Survival of allogeneic hematopoietic stem cell transplant (aHSCT) recipients in the intensive care unit (ICU) has been poor. We retrospectively analyzed the short- and long-term outcomes of aHSCT patients admitted to the ICU over a 12-year period. Of 1235 adult patients who had aHSCT between 2002 and 2013, 161 (13%) were admitted to the ICU. The impact of clinical parameters was assessed and outcomes were compared for the periods 2002-2007 and 2008-2013. The ICU, in-hospital, 1- and 5-year survival rates were 64.6%, 46%, 33% and 20%, respectively. Mechanical ventilation and vasopressor use predicted for worse hospital- and overall survival (OS). After 2008, the requirement for mechanical ventilation and vasopressors, and the diagnosis of sepsis were reduced. While hospital mortality decreased from 69% to 44%, long-term survival (LTS) remained unchanged. Late deaths, due to causes not associated with the ICU such as relapse and graft-versus-host disease, increased. As thresholds for transplant are lowered, improvements in ICU outcomes for aHSCT recipients may be limited.
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Affiliation(s)
- Sebastian Mayer
- a Department of Medicine , New York Presbyterian Hospital, Joan and Sanford I Weill Medical College, Cornell University , New York , USA
| | - Stephen M Pastores
- a Department of Medicine , New York Presbyterian Hospital, Joan and Sanford I Weill Medical College, Cornell University , New York , USA.,b Departments of Anesthesiology and Critical Care Medicine , Memorial Sloan-Kettering Cancer Center , New York , USA
| | - Elyn Riedel
- c Epidemiology and Biostatistics , Memorial Sloan-Kettering Cancer Center , New York , USA
| | - Molly Maloy
- d Memorial Sloan Kettering Cancer Center , New York , USA
| | - Ann A Jakubowski
- e Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , USA.,f Joan and Sanford I Weill Cornell Medical College, Cornell University , New York , New York , USA
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Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis. Bone Marrow Transplant 2016; 51:1050-61. [PMID: 27042832 DOI: 10.1038/bmt.2016.72] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 12/16/2022]
Abstract
The outcome of allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients has significantly improved over the past decade. Still, a significant number of patients require intensive care unit (ICU) management because of life-threatening complications. Literature from the 1990s reported extremely poor prognosis for critically ill allo-HSCT patients requiring ICU management. Recent data justify the use of ICU resources in hematologic patients. Yet, allo-HSCT remains an independent variable associated with mortality. However, outcomes in allo-HSCT patients have improved over time and many classic determinants of mortality have become irrelevant. The main actual prognostic factors are the need for mechanical ventilation, the presence of GvHD and the number of organ failures at ICU admission. Recently, the development of reduced-intensity conditioning regimens, early ICU admission and the increased use of noninvasive ventilation, combined with time effect and general advances in hematology, in allo-HSCT procedures and in ICU management have contributed to improve general outcome. A rational policy of ICU admission triage in these patients is very hard to define, as each decision for ICU admission is a case-by-case decision at patient bedside. The collaboration between hematologists and intensivists is crucial in this context.
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Bayraktar UD, Nates JL. Intensive care outcomes in adult hematopoietic stem cell transplantation patients. World J Clin Oncol 2016; 7:98-105. [PMID: 26862493 PMCID: PMC4734941 DOI: 10.5306/wjco.v7.i1.98] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/29/2015] [Accepted: 11/17/2015] [Indexed: 02/06/2023] Open
Abstract
Although outcomes of intensive care for patients undergoing hematopoietic stem cell transplantation (HSCT) have improved in the last two decades, the short-term mortality still remains above 50% among allogeneic HSCT patients. Better selection of HSCT patients for intensive care, and consequently reduction of non-beneficial care, may reduce financial costs and alleviate patient suffering. We reviewed the studies on intensive care outcomes of patients undergoing HSCT published since 2000. The risk factors for intensive care unit (ICU) admission identified in this report were primarily patient and transplant related: HSCT type (autologous vs allogeneic), conditioning intensity, HLA mismatch, and graft-versus-host disease (GVHD). At the same time, most of the factors associated with ICU outcomes reported were related to the patients’ functional status upon development of critical illness and interventions in ICU. Among the many possible interventions, the initiation of mechanical ventilation was the most consistently reported factor affecting ICU survival. As a consequence, our current ability to assess the benefit or futility of intensive care is limited. Until better ICU or hospital mortality prediction models are available, based on the available evidence, we recommend practitioners to base their ICU admission decisions on: Patient pre-transplant comorbidities, underlying disease status, GVHD diagnosis/grade, and patients’ functional status at the time of critical illness.
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Platon L, Amigues L, Ceballos P, Fegueux N, Daubin D, Besnard N, Larcher R, Landreau L, Agostini C, Machado S, Jonquet O, Klouche K. A reappraisal of ICU and long-term outcome of allogeneic hematopoietic stem cell transplantation patients and reassessment of prognosis factors: results of a 5-year cohort study (2009–2013). Bone Marrow Transplant 2015; 51:256-61. [DOI: 10.1038/bmt.2015.269] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/08/2015] [Accepted: 10/01/2015] [Indexed: 11/09/2022]
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Intensive Care Utilization for Hematopoietic Cell Transplant Recipients. Biol Blood Marrow Transplant 2015; 21:2023-7. [PMID: 26238809 DOI: 10.1016/j.bbmt.2015.07.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/24/2015] [Indexed: 11/24/2022]
Abstract
Blood and marrow transplantation (BMT) is a potentially curative therapy for a number of malignant and nonmalignant diseases. Multiple variables, including age, comorbid conditions, disease, disease stage, prior therapies, degree of donor-recipient matching, type of transplantation, and dose intensity of the preparative regimen, affect both morbidity and mortality. Despite tremendous gains in supportive care, BMT remains a high-risk medical therapy. A critically ill BMT recipient may require transfer to an intensive care unit (ICU) and the specialized medical and nursing care that can be provided, such as mechanical ventilation and vasopressor support. Mortality for BMT recipients requiring care in an ICU is high. This paper will describe the experience of the Stanford Blood and Marrow Transplant Program in developing and implementing guidelines to maximize the benefit of intensive care for critically ill BMT recipients.
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Kerhuel L, Amorim S, Azoulay E, Thiéblemont C, Canet E. Clinical features of life-threatening complications following autologous stem cell transplantation in patients with lymphoma. Leuk Lymphoma 2015; 56:3090-5. [DOI: 10.3109/10428194.2015.1034700] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Escobar K, Rojas P, Ernst D, Bertin P, Nervi B, Jara V, Garcia MJ, Ocqueteau M, Sarmiento M, Ramirez P. Admission of Hematopoietic Cell Transplantation Patients to the Intensive Care Unit at the Pontificia Universidad Católica de Chile Hospital. Biol Blood Marrow Transplant 2015; 21:176-9. [DOI: 10.1016/j.bbmt.2014.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 08/12/2014] [Indexed: 11/16/2022]
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Ethical and clinical aspects of intensive care unit admission in patients with hematological malignancies: guidelines of the ethics commission of the French society of hematology. Adv Hematol 2014; 2014:704318. [PMID: 25349612 PMCID: PMC4199072 DOI: 10.1155/2014/704318] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 09/22/2014] [Accepted: 09/22/2014] [Indexed: 11/26/2022] Open
Abstract
Admission of patients with hematological malignancies to intensive care unit (ICU) raises recurrent ethical issues for both hematological and intensivist teams. The decision of transfer to ICU has major consequences for end of life care for patients and their relatives. It also impacts organizational human and economic aspects for the ICU and global health policy. In light of the recent advances in hematology and critical care medicine, a wide multidisciplinary debate has been conducted resulting in guidelines approved by consensus by both disciplines. The main aspects developed were (i) clarification of the clinical situations that could lead to a transfer to ICU taking into account the severity criteria of both hematological malignancy and clinical distress, (ii) understanding the process of decision-making in a context of regular interdisciplinary concertation involving the patient and his relatives, (iii) organization of a collegial concertation at the time of the initial decision of transfer to ICU and throughout and beyond the stay in ICU. The aim of this work is to propose suggestions to strengthen the collaboration between the different teams involved, to facilitate the daily decision-making process, and to allow improvement of clinical practice.
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Boyacı N, Aygencel G, Turkoglu M, Yegin ZA, Acar K, Sucak GT. The intensive care management process in patients with hematopoietic stem cell transplantation and factors affecting their prognosis. ACTA ACUST UNITED AC 2014; 19:338-45. [PMID: 24620953 DOI: 10.1179/1607845413y.0000000130] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Hematopoietic stem cell transplantation (HSCT) recipients may require further management in intensive care unit (ICU). The ICU outcome of the HSCT recipients is claimed to have improved significantly over the last two decades. Our aim was to investigate the ICU outcome of the HSCT recipients who required management in ICU, together with the factors that are likely to affect the results. MATERIALS AND METHODS We retrospectively investigated the ICU outcome of 48 adults (≥18 years of age) who received HSCT in the bone marrow transplant unit of our hospital and required admission to ICU between 01 January 2007 and 31 December 2010. The data were retrieved from the databases of the adult bone marrow transplantation unit and the ICU. RESULTS Sixty-one percent of the patients were male with a median age of 39 years (28-46.75) in the study cohort. Leukemia (54%) and lymphoma (27%) were the leading underlying disorders. The type of HSCT was autologous in 14.6% and allogeneic in 85.4% of the patients. The reason for admission to ICU was acute respiratory failure in 85.5% of the HSCT recipients and 75% had sepsis/septic shock. The mean duration of ICU stay was 104.5 (48-168) hours. Sixty-nine percent of the patients died during their ICU stay while 31% survived. Besides the several statistically significant differences between the patients who survived or died in ICU in univariate analysis, baseline Acute Physiology and Chronic Health Evaluation (APACHE II) score (odds ratio 1.38, 95% confidence interval: 1.06-1.79) and requirement of vasopressors in the ICU (odds ratio 72.29, 95% confidence interval:4.47-1169.91) were found to be independent risk factors for mortality in multivariate analysis. CONCLUSION Baseline APACHE II score and requirement of vasopressors during ICU stay were the most significant independent risk factors for mortality in HSCT recipients who required ICU management in our center.
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Bayraktar UD, Shpall EJ, Liu P, Ciurea SO, Rondon G, de Lima M, Cardenas-Turanzas M, Price KJ, Champlin RE, Nates JL. Hematopoietic cell transplantation-specific comorbidity index predicts inpatient mortality and survival in patients who received allogeneic transplantation admitted to the intensive care unit. J Clin Oncol 2013; 31:4207-14. [PMID: 24127454 DOI: 10.1200/jco.2013.50.5867] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To investigate the prognostic value of the Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI) in patients who received transplantation admitted to the intensive care unit (ICU). PATIENTS AND METHODS We investigated the association of HCT-CI with inpatient mortality and overall survival (OS) among 377 patients who were admitted to the ICU within 100 days of allogeneic stem-cell transplantation (ASCT) at our institution. HCT-CI scores were collapsed into four groups and were evaluated in univariate and multivariate analyses using logistic regression and Cox proportional hazards models. RESULTS The most common pretransplantation comorbidities were pulmonary and cardiac diseases, and respiratory failure was the primary reason for ICU admission. We observed a strong trend for higher inpatient mortality and shorter OS among patients with HCT-CI values ≥ 2 compared with patients with values of 0 to 1 in all patient subsets studied. Multivariate analysis showed that patients with HCT-CI values ≥ 2 had significantly higher inpatient mortality than patients with values of 0 to 1 and that HCT-CI values ≥ 4 were significantly associated with shorter OS compared with values of 0 to 1 (hazard ratio, 1.74; 95% CI, 1.23 to 2.47). The factors associated with lower inpatient mortality were ICU admission during the ASCT conditioning phase or the use of reduced-intensity conditioning regimens. The overall inpatient mortality rate was 64%, and the 1-year OS rate was 15%. Among patients with HCT-CI scores of 0 to 1, 2, 3, and ≥ 4, the 1-year OS rates were 22%, 17%, 18%, and 9%, respectively. CONCLUSION HCT-CI is a valuable predictor of mortality and survival in critically ill patients after ASCT.
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Affiliation(s)
- Ulas D Bayraktar
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
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Wigmore TJ, Farquhar-Smith P, Lawson A. Intensive care for the cancer patient - unique clinical and ethical challenges and outcome prediction in the critically ill cancer patient. Best Pract Res Clin Anaesthesiol 2013; 27:527-43. [PMID: 24267556 DOI: 10.1016/j.bpa.2013.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/04/2013] [Indexed: 10/26/2022]
Abstract
With the rising number of cancer cases and increasing survival times, cancer patients with critical illness are increasingly presenting to the intensive care unit. This article considers the unique challenges they pose in terms of oncological-specific disease processes and treatment and reviews current trends in outcome prediction. We also consider the ethical standpoints surrounding the treatment of patients for whom there may be no cure and their subsequent transition to palliative care, should it become necessary.
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Risk factors for ICU admission and ICU survival after allogeneic hematopoietic SCT. Bone Marrow Transplant 2013; 49:62-5. [PMID: 24056739 DOI: 10.1038/bmt.2013.141] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 07/31/2013] [Accepted: 08/06/2013] [Indexed: 01/08/2023]
Abstract
A considerable number of patients undergoing allogeneic hematopoietic SCT (HSCT) develop post-transplant complications requiring intensive care unit (ICU) treatment. Whereas the indications and the outcome of ICU admission are well known, the risk factors leading to ICU admission are less well understood. We performed a retrospective single-center study on 250 consecutive HSCT patients analyzing the indications, risk factors and outcome of ICU admission. Of these 250 patients, 33 (13%) were admitted to the ICU. The most common indications for admission to the ICU were pulmonary complications (11, 33%), sepsis (8, 24%), neurological disorders (6, 18%) and cardiovascular problems (2, 6%). Acute GvHD and HLA mismatch were the only significant risk factors for ICU admission in multivariate analysis. Among patients admitted to the ICU, the number of organ failures correlated negatively with survival. Twenty-one (64%) patients died during the ICU stay and the 6-month mortality was 85% (27 out of 33). SAPS II score underestimated the mortality rate. In conclusion, acute GvHD and HLA mismatch were identified as risk factors for ICU admission following allogeneic HSCT. Both, short- and long-term survival of patients admitted to the ICU remains dismal and depends on the number of organ failures.
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Agarwal S, O'Donoghue S, Gowardman J, Kennedy G, Bandeshe H, Boots R. Intensive care unit experience of haemopoietic stem cell transplant patients. Intern Med J 2013; 42:748-54. [PMID: 21627739 DOI: 10.1111/j.1445-5994.2011.02533.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Previous research at our institution (1988-1998) established an intensive care unit (ICU) and hospital mortality between 70% and 80% in haemopoietic stem cell transplant (HSCT) patients requiring ICU admission. AIMS This study explored mortality in a more contemporary cohort while comparing outcomes to published literature and our previous experience. METHODS Retrospective chart review of HSCT patients admitted to ICU between December 1998 and June 2008. RESULTS Of 146 admissions, 53% were male, with a mean age of 44 years, an Acute Physiologic and Chronic Health Evaluation II score of 28 and Sepsis Organ Failure Assessment score of 11. Fifty-six per cent had graft versus host disease (GVHD), with respiratory failure (67%) being the most common admission diagnosis. All but one received mechanical ventilation. The ICU and hospital mortality were 42% (72% 1988-1998 cohort) and 64% (82% 1998-1998 cohort) respectively. The 6- and 12-month survivals were 29% and 24% respectively for the 1998-2008 cohort. Dying in ICU was independently predicted by fungal infection (P= 0.02) and early onset of organ failure (P < 0.001), while GVHD (P= 0.04) predicted survival. Mortality at 12 months was independently predicted by the acute physiology score (P= 0.002), increasing number of organ failures (P= 0.001), and cytomegalovirus positive serology (P= 0.005), while blood stream infection (P= 0.003), an antibiotic change on admission to the ICU (P= 0.007) and a diagnosis of non-Hodgkin lymphoma (P= 0.02) predicted survival. CONCLUSION Our study found that acute admission of HSCT patients to the ICU is associated with improved survival compared to our previous experience, with organ failure progression a strong predictor of ICU outcome, and specific disease characteristics contributing to long-term survival.
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Affiliation(s)
- S Agarwal
- Department of Intensive Care Medicine, Haematology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Townsend WM, Holroyd A, Pearce R, Mackinnon S, Naik P, Goldstone AH, Linch DC, Peggs KS, Thomson KJ, Singer M, Howell DCJ, Morris EC. Improved intensive care unit survival for critically ill allogeneic haematopoietic stem cell transplant recipients following reduced intensity conditioning. Br J Haematol 2013; 161:578-86. [PMID: 23496350 PMCID: PMC4296346 DOI: 10.1111/bjh.12294] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 02/04/2013] [Indexed: 01/20/2023]
Abstract
The use of allogeneic haematopoietic stem cell transplantation (Allo-HSCT) is a standard treatment option for many patients with haematological malignancies. Historically, patients requiring intensive care unit (ICU) admission for transplant-related toxicities have fared extremely poorly, with high ICU mortality rates. Little is known about the impact of reduced intensity Allo-HSCT conditioning regimens in older patients on the ICU and subsequent long-term outcomes. A retrospective analysis of data collected from 164 consecutive Allo-HSCT recipients admitted to ICU for a total of 213 admissions, at a single centre over an 11·5-year study period was performed. Follow-up was recorded until 31 March 2011. Autologous HSCT recipients were excluded. In this study we report favourable ICU survival following Allo-HSCT and, for the first time, demonstrate significantly better survival for patients who underwent Allo-HSCT with reduced intensity conditioning compared to those treated with myeloablative conditioning regimens. In addition, we identified the need for ventilation (invasive or non-invasive) as an independently significant adverse factor affecting short-term ICU outcome. For patients surviving ICU admission, subsequent long-term overall survival was excellent; 61% and 51% at 1 and 5 years, respectively. Reduced intensity Allo-HSCT patients admitted to ICU with critical illness have improved survival compared to myeloablative Allo-HSCT recipients.
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Affiliation(s)
- William M Townsend
- Department of Haematology, University College London Hospitals NHS Foundation Trust and UCL Medical School, London, UK
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Jannone Forés R, Botella de Maglia J, Bonastre Mora J. [Survival of haematologic patients admitted to an Intensive Care Unit. A 16 years study]. Med Clin (Barc) 2012; 139:607-12. [PMID: 22995845 DOI: 10.1016/j.medcli.2012.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 02/13/2012] [Accepted: 02/23/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE The survival of haematologic patients admitted to Intensive Care units (ICU) is so poor, that it is debatable whether they should be admitted or not to them. We aimed to find out the survival of these patients in an ICU to know if their admission is justified. PATIENTS AND METHOD Retrospective study of 600 haematologic patients (49.4 ± 16.4 years, 58.3% male) representing a total of 660 different admissions to the ICU of a university hospital, with a 6 months follow-up. Haematologic diseases were: leukaemia (50.5%), lymphoma (18.7%), myeloma (10.0%), myelodysplasic syndromes (4.2%), aplastic anaemia or bone marrow aplasia (3.3%), thrombotic microangiopathies and HELLP syndrome (7.4%), and others. RESULTS A total of 37.5% of patients survived. Survival of thrombotic microangiopathies and HELLP syndrome was higher (81.8% of patients) than that of leukaemias (26.6%) and lymphomas (49.1%). When the reason for ICU admission was respiratory failure with or without septic shock, the survival was lower (20 and 27% of admissions respectively) than when it was septic shock alone (58.7%). Survival of mechanically ventilated patients was 14.6%, that of those treated with any renal replacement therapy 32.4% and that of patients with both treatments 13.8%. From all mechanically ventilated leukaemia or lymphoma patients, 10.3% survived (93 days in the ICU per life saved) but only 7.7% were alive 6 months later. CONCLUSIONS Considering that the ICU survival was higher than 10% for all the groups studied, we conclude that admission of haematologic patients to the ICU is appropriate.
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Affiliation(s)
- Rosa Jannone Forés
- Servicio de Medicina Intensiva, Hospital Universitario y Politécnico La Fe, Valencia, España.
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Ferrà C, Ribera JM. [Prognosis of the hematologic patients admitted to an Intensive Care Unit]. Med Clin (Barc) 2012; 139:631-3. [PMID: 22944211 DOI: 10.1016/j.medcli.2012.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 06/28/2012] [Indexed: 11/24/2022]
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Gilbert C, Vasu TS, Baram M. Use of mechanical ventilation and renal replacement therapy in critically ill hematopoietic stem cell transplant recipients. Biol Blood Marrow Transplant 2012; 19:321-4. [PMID: 23025989 DOI: 10.1016/j.bbmt.2012.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 09/15/2012] [Indexed: 12/13/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is a treatment option for both malignant and nonmalignant disorders. HSCT patients remain at high risk for multiorgan failure, with previous studies noting mortality rates exceeding 90% when mechanical ventilation (MV) is required. We propose that advancements in critical care management and HSCT practices have improved these dismal outcomes. We performed a retrospective review of admissions to our bone marrow transplant unit between 2006 and 2010. All HSCT recipients requiring admission to the bone marrow transplant unit who received MV or renal replacement therapy (RRT) were evaluated. A total of 68 patients required MV. Twenty patients required RRT, all of whom required MV. Fifty-nine of the 68 ventilated patients died, for an overall mortality rate of 86.8%. The presence of renal failure and concomitant respiratory or liver dysfunction at the time of intubation was associated with a mortality rate of 100%. High mortality persists in our HSCT population requiring artificial support despite overall advances in critical care and HSCT practices. Critical care triage and management decisions in this high-risk population remain challenging.
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Affiliation(s)
- Christopher Gilbert
- Division of Pulmonary and Critical Care Medicine, Pennsylvania State University School of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, USA.
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Epstein AS, Goldberg GR, Meier DE. Palliative care and hematologic oncology: the promise of collaboration. Blood Rev 2012; 26:233-9. [PMID: 22874874 DOI: 10.1016/j.blre.2012.07.001] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Palliative medicine provides active evaluation and treatment of the physical, psychosocial and spiritual needs of patients and families with serious illnesses, regardless of curability or stage of illness. The hematologic malignancies comprise diverse clinical presentations, evolutions, treatment strategies and clinical and quality of life outcomes with dual potential for rapid clinical decline and ultimate improvement. While recent medical advances have led to cure, remission or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses and all are associated with significant symptom and quality of life burden for patients and families. The gravity of a diagnosis of a hematologic malignancy also weighs heavily on the medical team, who typically develop close and long-term relationships with their patients. Palliative care teams provide an additional layer of support to patients, family caregivers, and the primary medical team through close attention to symptoms and emotional, practical, and spiritual needs. Barriers to routine palliative care co-management in hematologic malignancies include persistent health professional confusion about the role of palliative care and its distinction from hospice; inadequate availability of palliative care provider capacity; and widespread lack of physician training in communicating about achievable goals of care with patients, family caregivers, and colleagues. We herein review the evidence of need for palliative care services in hematologic malignancy patients in the context of a growing body of evidence demonstrating the beneficial outcomes of such care when provided simultaneously with curative or life-prolonging treatment.
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Affiliation(s)
- Andrew S Epstein
- The Lilian and Benjamin Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics and Palliative Medicine, The Mount Sinai School of Medicine, New York, NY, United States
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Heslet L, Nielsen JD, Nepper-Christensen S. Local pulmonary administration of factor VIIa (rFVIIa) in diffuse alveolar hemorrhage (DAH) - a review of a new treatment paradigm. Biologics 2012; 6:37-46. [PMID: 22419859 PMCID: PMC3299534 DOI: 10.2147/btt.s25507] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Diffuse alveolar hemorrhage (DAH) is a clinical syndrome with typical symptoms dyspnea and hemoptysis. DAH is a complication of specific diseases, in some cases with acute catastrophic hemoptysis, while other patients present low grade alveolar bleeding with a need of chronic transfusion as in pulmonary hemosiderosis. Methods Current literature in the PubMed database and other sources was reviewed in order to evaluate the current treatment recommendations, efficacy of this treatment, and finally the risk of complications after off-label use of rFVIIa in respect to DAH. Objectives (i) To elucidate the clinical aspects of alveolar hemorrhage, (ii) to develop a simple diagnostic algorithm in order to separate DAH from other important pulmonary diseases with similar clinical picture and comparably high mortality. Such an algorithm has important therapeutic consequences because these diseases: acute lung injury (ALI), acute respiratory distress syndrome (ARDS) and bronchiolitis obliterans organizing pneumonia (BOOP) have different therapies, (iii) to evaluate and discuss whether local pulmonary administration may improve outcome and reduce mortality in DAH, and (iv) to suggest a treatment schedule. Results Hitherto the diagnosis and treatment of DAH has been based on anecdotal reports. The treatment has relied on different unspecific treatment modalities based on a mixture of treatment of the underlying disease and treatment without evidence targeted to stop the alveolar bleeding. However, recently a number of publications have advocated the use of intrapulmonary rFVIIa. Even in severe bleeding DAH has been shown to respond promptly without thromboembolic complication when FVIIa was administered locally via the air side, because the FVIIa does not penetrate the alveolo-capillary membrane to the blood-side. The incidence of DAH (in the US and Europe is 100,000–150,000, and 50,000 patients annually are at risk of developing DAH following hematopoietic stem cell transplant (HSCT) and autoimmune diseases. Finally 50,000–100,000 patients may be falsely categorized as having acute respiratory distress syndrome/acute lung injury (ARDS/ALI) because DAH and ARDS cannot be separated clinically. A new treatment paradigm of DAH is proposed as no other intervention has been able to ensure pulmonary hemostasis in DAH. The diagnosis of DAH is simple, a series of broncho-alveolar washes which become increasingly bloody. This test should be performed in all patients with pulmonary opacities in order to separate ARDS/ALI from DAH. FVIIa administrated via pulmonary route is “drug of choice”, because it stops bleeding in the life-threatening syndrome DAH. Hemostasis is obtained after only one to two small doses of FVIIa (50 μg/kg body weight per dose) and after hemostasis the oxygen transport quickly improves. Conclusion Intrapulmonary administration of rFVIIa is recommended as the treatment of choice for DAH and blast lung injury (BLI) because the treatment has been shown to be successful and uncomplicated in spite of the fact that only a small series of DAH has been documented.
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Affiliation(s)
- Lars Heslet
- Serendex ApS, Parkovsvej 20, Gentofte, DK 2820 Denmark
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Solh M, Oommen S, Vogel RI, Shanley R, Majhail NS, Burns LJ. A prognostic index for survival among mechanically ventilated hematopoietic cell transplant recipients. Biol Blood Marrow Transplant 2012; 18:1378-84. [PMID: 22387348 DOI: 10.1016/j.bbmt.2012.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 02/22/2012] [Indexed: 11/17/2022]
Abstract
The prognosis of recipients of allogeneic hematopoietic cell transplantation (HCT) who require mechanical ventilation (MV) has historically been poor. Of 883 adults undergoing allogeneic HCT at the University of Minnesota between 1998 and 2009, 179 (20%) required MV before day 100 posttransplantation. We evaluated the outcomes of these patients to develop a prognostic index to predict the 100-day post-MV overall survival (OS) based on factors present at the time of MV. The 179 patients were divided at random into a training set (n = 119) and a validation set (n = 60). The 100-day postventilation OS was 17% for the total population. Multivariate Cox regression on the training set identified creatinine <2 mg/dL and platelet count >20 × 10(9)/L as significant predictors of better OS. Recursive partitioning classified patients with these good prognostic criteria into class A (n = 76); all other patients were classified as class B (n = 103). Among class A patients, 100-day OS was 29% in the training set and 30% in the validation set. Corresponding OS in class B patients was 5% and 15%, respectively. This prognostic index should help guide physicians in counseling HCT patients and their families regarding the use of MV and potential outcomes.
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Affiliation(s)
- Melhem Solh
- Blood and Marrow Transplant Program, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, Minnesota 55455, USA
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Hill QA, Kelly RJ, Patalappa C, Whittle AM, Scally AJ, Hughes A, Ashcroft AJ, Hill A. Survival of patients with hematological malignancy admitted to the intensive care unit: prognostic factors and outcome compared to unselected medical intensive care unit admissions, a parallel group study. Leuk Lymphoma 2011; 53:282-8. [PMID: 21846185 DOI: 10.3109/10428194.2011.614705] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Improved survival in patients with hematological malignancy (HM) admitted to the intensive care unit (ICU) has largely been reported in uncontrolled cohorts from single academic institutions. We compared hospital mortality between 147 patients with HM and 147 general medical admissions to five non-specialist ICUs. The proportion of patients surviving to hospital discharge was significantly worse in patients with HM (27% vs. 56%; p < 0.001). Six-month and 1-year survival in patients with HM was 21% and 18%, respectively. HM, greater age, mechanical ventilation (MV) and acute physiology and chronic health evaluation (APACHE) II score were independent predictors of poor outcome. For patients with HM, culture proven infection, age, MV and inotropes were negative predictors. Disease-specific factors including hematological diagnosis, neutropenia, remission status, prior stem cell transplant, time from diagnosis to admission and degree of prior treatment were not predictive. Overall survival of patients with HM was worse than that recently reported from specialist units.
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Affiliation(s)
- Quentin A Hill
- Haematology Department, St James's Institute of Oncology, St James ’s University Hospital, Leeds, UK.
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Respiratory failure in patients undergoing allogeneic hematopoietic SCT--a randomized trial on early non-invasive ventilation based on standard care hematology wards. Bone Marrow Transplant 2011; 47:574-80. [PMID: 21927036 DOI: 10.1038/bmt.2011.160] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The prognosis of patients suffering from respiratory failure (RF) after allogeneic hematopoietic SCT (HSCT) is poor. However, early treatment for using non-invasive ventilation (NIV) may be of benefit. We conducted a randomized trial to prove the impact of early NIV in patients in the early post-transplant period. A total of 526 patients undergoing HSCT in a single center were monitored for signs of RF. Patients with RF were enrolled into either treatment arm A (oxygen supply only) or treatment arm B (oxygen+intermittent NIV). RF had to be diagnosed in 86 patients (16%). RF was an independent risk factor for both short-term (100 day mortality/ OR 2.76; P<0.001) and long-term survival (OR 1.57; P<0.01). Although early RF treatment with NIV was associated with a decreased rate of failure to achieve sufficient oxygenation (39% in arm A vs 24% in arm B, P=0.17), neither intensive care unit admission rate, nor need for intubation or survival parameters were affected by the treatment strategy. An early interventional strategy using NIV was not associated with improvement of the prognosis of the patients. The limited influence of NIV may be related to the study design allowing for switching of treatment in case of unsatisfactory efficacy.
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Boehm A, Rabitsch W, Locker GJ, Worel N, Robak O, Laczika KF, Staudinger T, Bojic A, Siersch V, Valent P, Sperr WR. Successful allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia during respiratory failure and invasive mechanical ventilation. Wien Klin Wochenschr 2011; 123:354-8. [DOI: 10.1007/s00508-011-1590-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 04/14/2011] [Indexed: 11/28/2022]
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Outcome of children requiring intensive care following haematopoietic SCT for primary immunodeficiency and other non-malignant disorders. Bone Marrow Transplant 2011; 47:40-5. [PMID: 21358684 DOI: 10.1038/bmt.2011.26] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Haematopoietic SCT (HSCT) is curative for many children with primary immunodeficiencies or other non-malignant conditions. Outcome for those admitted to intensive care following HSCT for oncology diagnoses has historically been very poor. There is no literature available specifically regarding the outcome for children with primary immunodeficiency requiring intensive care following HSCT. We reviewed our post-HSCT admission to intensive care over a 5-year period. A total of 111 children underwent HSCT. Median age at transplant was 1 year 4 months. The most common diagnosis was SCID. In all, 35% had at least one intensive care admission and 44% survived to be discharged from intensive care. Also, 73% of admission episodes requiring invasive ventilation but no inotropes or renal replacement therapy resulted in survival to discharge. Children undergoing HSCT for immunological diagnoses had a high rate of admission to intensive care. No factors were identified that could predict the need for admission. Invasive ventilation alone has a much better outcome than that in historical series. However, the need for multi-organ system support was still associated with a poor outcome. This information is useful when counselling families of children that have deteriorated and been admitted to intensive care during the HSCT procedure.
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Providing Palliative Care to Family Caregivers Throughout the Bone Marrow Transplantation Trajectory. J Hosp Palliat Nurs 2011. [DOI: 10.1097/njh.0b013e3181fce813] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Squadrone V, Massaia M, Bruno B, Marmont F, Falda M, Bagna C, Bertone S, Filippini C, Slutsky AS, Vitolo U, Boccadoro M, Ranieri VM. Early CPAP prevents evolution of acute lung injury in patients with hematologic malignancy. Intensive Care Med 2010; 36:1666-1674. [PMID: 20533022 DOI: 10.1007/s00134-010-1934-1] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 05/15/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE Although chemotherapy and transplantation improve outcome of patients with hematological malignancy, complications of these therapies are responsible for a 20-50% mortality rate that increases when respiratory symptoms evolve into acute lung injury (ALI). The aim of this study is to determine the effectiveness of early continuous positive airway pressure (CPAP) delivered in the ward to prevent occurrence of ALI requiring intensive care unit (ICU) admission for mechanical ventilation. METHODS Patients with hematological malignancy presenting in the hematological ward with early changes in respiratory variables were randomized to receive oxygen (N = 20) or oxygen plus CPAP (N = 20). Primary outcome variables were need of mechanical ventilation requiring ICU admission, and intubation rate among those patients who required ICU admission. RESULTS At randomization, arterial-to-inspiratory O(2) ratio in control and CPAP group was 282 ± 41 and 256 ± 52, respectively. Patients who received CPAP had less need of ICU admission for mechanical ventilation (4 versus 16 patients; P = 0.0002). CPAP reduced the relative risk for developing need of ventilatory support to 0.25 (95% confidence interval: 0.10-0.62). Among patients admitted to ICU, intubation rate was lower in the CPAP than in the control group (2 versus 14 patients; P = 0.0001). CPAP reduced the relative risk for intubation to 0.46 (95% confidence interval: 0.27-0.78). CONCLUSIONS This study suggests that early use of CPAP on the hematological ward in patients with early changes in respiratory variables prevents evolution to acute lung injury requiring mechanical ventilation and ICU admission.
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Affiliation(s)
- Vincenzo Squadrone
- Dipartimento di Anestesia e di Medicina degli Stati Critici, Azienda Ospedaliera S. Giovanni Battista-Molinette, Università di Torino, Corso Dogliotti 14, 10126 Turin, Italy
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Abstract
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.
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44
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Pastores SM, Voigt LP. Acute respiratory failure in the patient with cancer: diagnostic and management strategies. Crit Care Clin 2010; 26:21-40. [PMID: 19944274 DOI: 10.1016/j.ccc.2009.10.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue C1179, New York, NY 10065, USA.
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Abstract
An estimated 50,000 to 60,000 patients undergo hematopoietic stem cell transplantation (HSCT) worldwide annually, of which 15.7% are admitted to the intensive care unit (ICU). The most common reason for ICU admission is respiratory failure and almost all develop single or multiorgan failure. Most HSCT recipients admitted to ICU receive invasive mechanical ventilation (MV). The overall short-term mortality rate of HSCT recipients admitted to ICU is 65%, and 86.4% for those receiving MV. Patient outcome has improved over time. Poor prognostic indicators include advanced age, poor functional status, active disease at transplant, allogeneic transplant, the severity of acute illness, and the development of multiorgan failure. ICU resource limitations often lead to triage decisions for admission. For HSCT recipients, the authors recommend (1) ICU admission for full support during their pre-engraftment period and when there is no evidence of disease recurrence; (2) no ICU admission for patients who refuse it and those who are bedridden with disease recurrence and without treatment options except palliation; (3) a trial ICU admission for patients with unknown status of disease recurrence with available treatment options.
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Affiliation(s)
- Bekele Afessa
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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46
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Hill QA. Intensify, resuscitate or palliate: Decision making in the critically ill patient with haematological malignancy. Blood Rev 2010; 24:17-25. [DOI: 10.1016/j.blre.2009.10.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bokhari SWI, Munir T, Memon S, Byrne JL, Russell NH, Beed M. Impact of critical care reconfiguration and track-and-trigger outreach team intervention on outcomes of haematology patients requiring intensive care admission. Ann Hematol 2009; 89:505-12. [PMID: 19876629 DOI: 10.1007/s00277-009-0853-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Accepted: 10/11/2009] [Indexed: 01/04/2023]
Abstract
Patients with haematological disorders have previously been considered to have poor outcomes following admission to intensive care units. Although a number of haematology centres from outside the UK have now demonstrated improved outcomes, the continuing perception of poor outcomes in this patient group continues to adversely affect their chances of being admitted to some intensive care units (ICUs). Over the past 10 years, there have been many advances within the disciplines of both haematology and intensive care medicine. This study was done to assess outcomes and the impact of an early warning scoring system (EWS) and early involvement of ICU outreach teams. One hundred five haematology patients (haematopoietic stem cell transplant (HSCT) or non-HSCT) had 114 admissions to ICU between April 2006 and August 2008 which coincided with hospital-wide implementation of EWS. The survival to ICU discharge was 56 (53%). Thirty-three (33%) patients were alive at 6 months giving a 1-year survival of 31%. Of the 39 HSCT patients, nine were post-autologous and 30 post-allogeneic transplant. The survival to ICU discharge was 22 (56%) with 14 (36%) patients alive at 6 months. One year survival was 36%. Prior to the introduction of EWS and critical care outreach team (2004), survival to ICU discharge was 44% which has increased to 53% (2006-2008). This is despite an increase in mechanical ventilation in 2006-2008 (50%) as compared to 2004 (32%).The improvement in ICU survivorship was even more prominent in HSCT patients (37% in 2004 versus 56% in 2006-2008). There was a trend towards decreasing Acute Physiology and Chronic Health Evaluation scores with time, suggesting appropriate patients being identified earlier and having timely escalation of their treatment.
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Affiliation(s)
- Syed W I Bokhari
- Department of Clinical Haematology, Nottingham University Hospitals-City Campus, Nottingham, UK.
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Outcome and prognostic indicators of patients with hematopoietic stem cell transplants admitted to the intensive care unit. J Transplant 2009; 2009:917294. [PMID: 20130763 PMCID: PMC2809022 DOI: 10.1155/2009/917294] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2009] [Revised: 06/10/2009] [Accepted: 06/30/2009] [Indexed: 01/20/2023] Open
Abstract
The prognosis of patients with hematopoietic stem cell transplants (HSCTs) who require
admission to the intensive care unit (ICU) has been regarded as extremely poor. We sought to
re-evaluate recent outcomes and predictive factors in a retrospective cohort study. Among the
605 adult patients that received an HSCT between 2001 and 2006, 154 required admission to the
ICU. Of these, 47% were discharged from the ICU, 36% were discharged from the hospital, and
19% survived 6 months. Allogeneic transplant, mechanical ventilation, vasopressor-use, and
neutropenia were each associated with increased mortality, and the mortality of patients with all
four characteristics was 100%. Hemodialysis was also associated with increased mortality in a
Kaplan-Meier analysis but did not appear important in a multivariate tree analysis. A final Cox
model confirmed that allogeneic transplant, mechanical ventilation, and vasopressor-use were
each independent risk factors for mortality in the 6 months following ICU admission.
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Gilli K, Remberger M, Hjelmqvist H, Ringden O, Mattsson J. Sequential Organ Failure Assessment predicts the outcome of SCT recipients admitted to intensive care unit. Bone Marrow Transplant 2009; 45:682-8. [PMID: 19718056 DOI: 10.1038/bmt.2009.220] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We analyzed all patients undergoing allogeneic stem cell transplantation (ASCT) and transferred to the intensive care unit (ICU) from January 1995 to December 2005. During this period, 661 patients underwent ASCT at our center. A total of 91 patients were admitted to the ICU. Median time from ASCT to ICU admission was 69 days (-24 to 1572) and median stay at the ICU was 4 (1-60) days. The survival after transfer to the ICU at day 100 and at 1 year was 22 and 16%, respectively. Median Sequential Organ Failure Assessment (SOFA) score was 10 (1-17). Patients with SOFA score <8 (n=18) had a 44% survival compared with 17% with SOFA score 8-11 (n=30) and no survival with SOFA score >11 (n=20) (P=0.0002). None of the 14 retransplanted patients survived compared with 31% among patients after first ASCT (P=0.006). Patients receiving TBI had a lower survival compared with patients treated with chemotherapy only (14 vs 45%, P=0.02). Patients needing vasopressor support had a worse survival, 15 vs 41%, compared with patients without vasopressor treatment (P=0.01). In multivariate analysis of death, SOFA score was the only significant factor (P<0.001). In conclusion, SOFA score predicted prognosis in ASCT patients treated at the ICU.
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Affiliation(s)
- K Gilli
- Department for Anaesthesiology and Intensive Care Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
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Abstract
Critical illness is a dreaded complication in recipients of hematologic stem cell transplantation, with poor survival described in a number of early series. The perception of futility may impact the approach to therapy. Over the last 20 years, there have been significant advances in the application of intensive care, as well as changes in the management of patients before, during, and after transplantation. These advances and changes may have an impact on this traditionally poor survival. This article discusses the outcomes of critical illness in bone marrow and stem cell transplant recipients, and gives possible reasons for the apparent improvement in outcomes seen in more recent series.
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Affiliation(s)
- John R McArdle
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06073, USA.
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