scholarly journals The Intensive Care Trial for Critically Ill Onco-Haematologic Patients: The Need for Response Criteria at 5 Days of Full Treatment to Separate Good Risk Patients and Avoid Futile Intensive Care Interventions

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 5987-5987
Author(s):  
Silvia Monsalvo ◽  
Belen Sevillano ◽  
Andrew Innes ◽  
Maialen Lasa ◽  
Laura Skinner ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Overall Survival ◽  
Intensive Care ◽  
Respiratory Failure ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Icu Admission ◽  
Organ Failures ◽  
Reason For Admission

Abstract Introduction: Critically ill onco-hematology patients (pts) admitted to intensive care units (ICU) have poor prognosis. Mechanical ventilation, multiple organ failures and severe sepsis are factors associated with high mortality. Current literature identifies day 5 in ICU as a specific time point at which ceilings of care should be re-addressed. Patients and methods: We retrospectively reviewed all consecutive onco-haematology patients admitted to the ICU between October 2010 and December 2015. We classified pts according to the reason for ICU admission in 5 groups: a) respiratory failure without mechanical ventilation during the first 24h; b) respiratory failure and mechanical ventilation in the first 24h; c) sepsis without respiratory failure and without renal replacement therapy in the first 24h; d) renal replacement therapy without respiratory failure regardless of septic status; and e) needing hemodynamic support without respiratory failure, sepsis or renal replacement therapy in the first 24h. After 5 days of full intensive therapy we defined a successful 5-day ICU trial for each of the five groups as follows: a) no mechanical ventilation during 5 days; b) neutrophils > 1.0 or ² 2 organ failures by day 5; c) C-reactive protein decreased by 50% or normalised lactate by day 5; d) off renal replacement therapy by day 5; and e) no inotropic support on day 5. Patients who died during the first 5 days of ICU admission were considered failures and pts who were discharged from the ICU before day 5 were considered successes. Results: 166 pts were identified, with 202 ICU admissions. The median number of ICU admissions was 1 (1-4), with 138 (84%) having 1 admission, 20 (12%) 2 admissions, 4 (2.4%) had 3 admissions and 3 (2%) 4 admissions respectively. The median length of stay in ICU was 6 days (1-95). The median duration of hospital stay prior to ICU admission was 14 days (0-104). The diagnoses were: AML 28% (n= 57), ALL 8% (n=16), CML 8% (n=16), myelofibrosis 4% (n=7), MDS 4% (n=7), myeloma 11% (n=23), NHL 30% (n=61) and Hodgkin's lymphoma 2% (n=4). Regarding pre ICU treatment, 44% (n=88) received chemotherapy, 11% (n=22) underwent autologous stem cell transplantation and 40% (n=81) allogeneic stem cell transplantation. Of those, 30% had myeloablative and 70% reduced intensity conditioning and 29 (35%) were from HLA identical sibling, 47 (58%) unrelated and 6 (7%) haplo-identical donors. The disease status was complete remission (n=77, 38%), partial remission (n=28, 14%) and stable disease (n=96, 48%). The reason for admission to ICU was respiratory failure in 53% (n=107), 19% sepsis (n=39), 16% renal failure (n=32) and 11% hemodynamic failure (n=22). The median APACHE II score was 24 (10-51), the median SOFA score was 10 (2-21) and the median SAPS-II score was 45 (0-100). APACHE II and SOFA scores were significantly greater in non-survivors vs survivors (p<0.0001). Overall 101(50%) pts survived their ICU admission and were discharged to the hematology ward. Of these, 31 (30%) died in hospital and 70 (70%) were discharged home. Estimated overall survival was 15% (95% CI 10-23) at 3 years post ICU admission. For the 5-day ICU trial we selected 138 pts with one admission. The distribution according to the different groups was: a) 56; b) 34; c) 17; d) 17 and e) 14. Overall 58 (42%) successfully passed the trial: a) 30 (53%); b) 14 (41%); c) 4 (23%); d) 7 (41%) and e) 3 (21%). Overall 41 (30%) pts failed the trial and were alive on day 5 and 39 (28%) died before day 5. The overall survival (Figure 1) for the 58 pts who passed the trial was 28% at 3 years. The overall mortality in ICU was 33% (19/58) for those who successfully passed the 5-day ICU trial, and was 71% (29/41) for those who failed. The overall survival for pts that successfully completed the 5-day ICU trial and were discharged to the hematology ward (n=39), was 49% at 3 years. Conclusions: In this study, 50% of onco-hematologic patients survived their ICU admission. The long-term overall survival was 15% at 3 years. Patients could be stratified according to the reason for admission and given an individualised 5-day trial: those who successfully completed their trial (42%) had a low ICU mortality (33%) and those who were subsequently discharged home had a long-term survival of 49% at 3 years. This study raises the possibility of offering a short-term ICU trial to onco-hematologic patients and perhaps allows for the ceiling of intensive care for those who fail the trial. Figure Figure. Disclosures MacDonald: Gilead Sciences: Speakers Bureau. Milojkovic:Ariad: Honoraria; Novartis: Honoraria; BMS: Honoraria; Pfizer: Honoraria. Apperley:Incyte: Speakers Bureau; Pfizer: Honoraria, Speakers Bureau; Novartis: Honoraria, Speakers Bureau; Ariad: Honoraria, Speakers Bureau; Bristol Myers Squibb: Honoraria, Speakers Bureau.

Prognosis of Allogeneic Haematopoietic Stem Cell Recipients Admitted to the Intensive Care Unit: A Retrospective, Single-Centre Study

2015 ◽  
Vol 135 (2) ◽  
pp. 72-78 ◽  
Author(s):  
Sidsel Christy Lindgaard ◽  
Jonas Nielsen ◽  
Anders Lindmark ◽  
Henrik Sengeløv
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Stem Cell ◽  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Scoring Systems ◽  
University Hospital ◽  
Haematopoietic Stem Cell ◽  
Icu Admission

Background: Allogeneic haematopoietic stem cell transplantation (HSCT) is a procedure with inherent complications and intensive care may be necessary. We evaluated the short- and long-term outcomes of the HSCT recipients requiring admission to the intensive care unit (ICU). Methods: We retrospectively examined the outcome of 54 adult haematological HSCT recipients admitted to the ICU at the University Hospital Rigshospitalet between January 2007 and March 2012. Results: The overall in-ICU, in-hospital, 6-month and 1-year mortality rates were 46.3, 75.9, 79.6 and 86.5%, respectively. Mechanical ventilation had a statistically significant effect on in-ICU (p = 0.02), 6-month (p = 0.049) and 1-year (p = 0.014) mortality. Renal replacement therapy also had a statistically significant effect on in-hospital (p = 0.038) and 6-month (p = 0.026) mortality. Short ICU admissions, i.e. <10 days, had a statistically significant positive effect on in-hospital, 6-month and 1-year mortality (all p < 0.001). The SAPS II, APACHE II and SOFA scoring systems grossly underestimated the actual in-hospital mortality observed for these patients. Conclusion: The poor prognosis of critically ill HSCT recipients admitted to the ICU was confirmed in our study. Mechanical ventilation, renal replacement therapy and an ICU admission of ≥10 days were each risk factors for mortality in the first year after ICU admission.

Single Centre Experience of Patients with Haematological Malignancies Admitted to Intensive Care Unit: A Comparative Review of Allogenic Bone Marrow Transplant Data.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1830-1830
Author(s):  
Zi Yi Lim ◽  
Jane Graham ◽  
Sylvia Simpson ◽  
Stephen Devereux ◽  
Antonio Pagliuca ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Overall Survival ◽  
Intensive Care ◽  
Inotropic Support ◽  
Haematological Malignancies ◽  
Term Survival ◽  
Icu Admission ◽  
Icu Outcome ◽  
Reduced Intensity

Abstract Introduction: Previous studies have indicated that the prognosis of patients with haematological malignancies who are admitted to intensive care unit (ICU) is poor. In particular, it has been suggested that the mortality for allogenic BMT patients requiring ICU admission is particularly high. The recent increased usage of reduced intensity conditioning has allowed allogenic transplantation of older patients who would previously be unsuitable for BMT. It is however unclear as to whether these patients may have a better ICU outcome. Methods: A retrospective review was performed of all haemato-oncology admissions to Kings College Hospital from May 2000 to Apr 2004 who were subsequently admitted to ICU. Information was collected from all patients for demographic factors, haematological status, APACHE score, organ dysfunction, microbiological data, and supportive organ therapy at point of admission to and during ICU stay. All variables were evaluated for prognostic relevance by univariate and multivariate analyses. Post-ICU survival was examined at day 30 and 1 year. Results: There were a total of 1249 admissions during the study period, of which 330(26.4%) were BMT patients. 57 ICU admissions (55 patients) were documented, 31 non-BMT (3.3%) vs 26 BMT (8.5%). The diagnoses were AML/MDS 26 (47.3%), ALL 6 (10.9%), NHL/HD 14 (25.5%), myeloma 5 (9.1%), others 4 (7.2%). Amongst post BMT patients, type of conditioning received was: reduced intensity 50%(13), standard myeloablative 34.6%(9), autologous 15.3%(4). 14 patients were early admissions within 6 months of BMT. The main cause of admission to ICU was due to chest sepsis with acute hypoxaemia. Conventional mechanical ventilation (MV) was used in 43(72.9%) of patients, and non-invasive MV in 16(27.1%). 30(50.8%) of patients received inotropic support during their ICU admission. Main cause of death was due to acute respiratory distress syndrome. There was no significant difference in age, duration of ICU admission and mechanical ventilation between non-BMT and BMT patients. However, the BMT group had higher numbers of myeloid malignancies, neutropenia, and intropic support. Overall ICU survival for the entire group, non-BMT, allogenic BMT (myeloablative + RIC) patients was 29.8%, 32.3% and 27.3% respectively. Kaplan-Meier estimation of longer term survival for these three groups at 30 day and 12 months was 23.7% and 14.6%, 20.1% and 10.9%, 24.3% and 19.5% respectively. The overall survival between these patient groups was not significant (p-value 0.757). Sub-analysis of RIC BMT data for 30 day and 1 year outcome was 35.8% and 29.3%, none of the 9 myeloablative patients survived beyond day 30. Univariate analysis identified intropic support, renal failure (creatinine >150), thrombocytopenia (platelet < 50) as significant variables for increased mortality (p-values 0.005, 0.012, 0.007 respectively). Results of multivariate analysis showed that inotropic support, was the only independant factor associated with increased ICU mortality. Estimated 30 day and 1 year survival for patients receiving vs not receiving inotropic support was 8% vs 39% and 6% vs 24%. Conclusion: Our data demonstrates that the admission of haemato-oncology patients to ICU can be associated with a favourable outcome. Significantly, in our cohort the overall survival of allogenic BMT patients was comparable with non-BMT patients. In addition, RIC patients appear to have a good ICU outcome and longer term survival.

Acute Myeloid Leukemia and Survival on the Intensive Care Unit (ICU) - Biology- and Treatment-Related Determinants of Outcome - An Analysis of the AML-CG

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 2166-2166
Author(s):  
Bernhard Heilmeier ◽  
Johannes Thudium ◽  
Matthias Kochanek ◽  
Christoph Schmid ◽  
Joachim Stemmler ◽  
...  
Keyword(s):  
Risk Factors ◽  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Univariate Analysis ◽  
Primary Diagnosis ◽  
Induction Phase ◽  
Icu Admission ◽  
Saps Ii ◽  
Icu Outcome

Abstract Abstract 2166 Background: An established factor for predicting the mortality of patients admitted to an ICU is the Severe Acute Physiology Score (SAPS) II. However, for patients with acute myeloid leukemia (AML) it is uncertain whether factors beyond SAPS II do influence the ICU outcome. Therefore we examined additional factors including age and factors related to AML biology and its treatment in the so far largest cohort of patients with AML worldwide regarding their ICU outcome. Methods: Retrospective analysis of 256 patients with 366 admissions to medical ICU between 2004 and 2009 in 3 large German hematologic centers. Patient age and gender, reason for ICU admission, duration of intensive care, SAPSII, need for invasive mechanical ventilation (IMV), renal replacement therapy and/or vasopressors, laboratory values at ICU admission for creatinine, bilirubin and C-reactive protein, AML karyotype, presence of FLT3-ITD and/or NPM1-mutation, FAB classification, last AML treatment, AML status and allogeneic transplant status were evaluated as potential risk factors. Correlations were analyzed using the Mann-Whitney U test. Univariate analysis was performed using the log rank test for the time until death on ICU occurred. Significant risk factors were studied in multivariate analysis (Cox regression). Results: At the time of analysis (08/2010) the median age of patients was 55.3 (range 19.7–84.9) years, and 47.5% were female. 46% of ICU admissions were due to infectious complications. A respiratory problem was present in 60% of the ICU transfers. IMV, vasopressors and renal replacement therapy were necessary in 51.3%, 42.6% and 22.7%, respectively, of the ICU courses. ICU survival was 64.8%. AML status was primary diagnosis/induction phase in 53.3%, postremission phase in 15.8% and relapse/refractory in 27.6% of ICU courses. 66.4% of admissions to ICU had conservative treatment (no transplant), 15.8% underwent allogeneic hematopoietic stem cell transplantation (allo SCT) in the same hospital stay (peritransplant status) and 14.5% had had allo SCT in a former hospital stay (posttransplant status). AML karyotype was favourable in 7.1%, intermediate in 47.8% and unfavourable in 20.2%. SAPS II was available in 208 ICU transfers. Duration of intensive care was 8.1 (mean)/3.0 (median) days with a range from 0.5–76 days. In univariate analysis risk factors predicting diminished ICU survival were high SAPS II (p=0.008), sepsis as reason for ICU admission (p=0.007), need for IMV (p<0.001), use of vasopressors (p<0.001), renal replacement therapy (p=0.002), intermediate or unfavourable AML karyotype (p=0.027), FAB classification other than AML M3 (p=0.012), postremission or relapse/refractory status of AML (p=0.029) and posttransplant status of AML (p=0.002). ICU mortality was lower in primary diagnosis/induction phase and higher in posttransplant phase of AML than predicted by the median SAPS II of these cohorts. In multivariate analysis the only significant predictor of inferior ICU survival was the extent of vasopressor treatment (hazard ratio (hr) 1.83, 95% CI 1.09–3.08; p=0.022), whereas high SAPS II was of borderline significance (hr 1.02, 95% CI 1.00– 1.03; p=0.064). Conclusions: In contrast to the broad majority of ICU patients, SAPS II is not an optimal predictor of ICU survival in patients with AML. Disease status was of high relevance with an AML status of primary diagnosis/induction phase indicating a better and posttransplant (but not peritransplant) status a worse ICU survival than predicted by SAPS II. The strongest predictor for ICU mortality was the extent of vasopressor use. In contrast age up to the 8th decade had no impact on ICU survival. These results may help to better define ICU admission and treatment policies for patients with AML. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Long-term renal and survival outcomes in acute kidney injury patients receiving renal replacement therapy in intensive care

Critical Care ◽  
2015 ◽  
Vol 19 (Suppl 1) ◽  
pp. P305
Author(s):  
I Elsayed ◽  
N Pawley ◽  
J Rosser ◽  
MJ Heap ◽  
GH Mills ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Kidney Injury ◽  
Survival Outcomes

scholarly journals Outcome of Patients Admitted to Intensive Care Unit for Acute Exacerbation of Idiopathic Pulmonary Fibrosis

2004 ◽  
Vol 11 (2) ◽  
pp. 117-122 ◽  
Author(s):  
Fahad M Al-hameed ◽  
Sat Sharma
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Respiratory Failure ◽  
Idiopathic Pulmonary Fibrosis ◽  
Pulmonary Fibrosis ◽  
Acute Respiratory Failure ◽  
Acute Exacerbation ◽  
Icu Admission ◽  
End Point

RATIONALE:The aim of this study was to evaluate the outcome of intensive care unit (ICU) admission in patients with idiopathic pulmonary fibrosis (IPF) who develop acute respiratory failure of unknown etiology.METHODS:A retrospective study at University of Manitoba hospitals reviewed all patients admitted to the ICU from November 1988 to December 2000 with IPF requiring mechanical ventilation for unknown causes of acute respiratory failure. Survival at hospital discharge was assessed as the primary end point and ICU length of stay as a secondary end point. In the absence of open lung biopsy, major and minor clinical criteria (as per American Thoracic Society statements) were used for the diagnosis of IPF. Infections were ruled out by extensive surveillance cultures and/or bronchoscopy with bronchoalveolar lavage.RESULTS:Eighty-eight charts were reviewed and 25 patients met the inclusion criteria. The mean (± SD) age was 69±11 years (range 42 to 96 years) and 23 patients were male. With the exception of one survivor who was discharged home, 21 patients died while receiving mechanical ventilation, and three patients died in hospital shortly after ICU discharge (one day, 22 days and 67 days). Intubation and mechanical ventilation were administered to 21 patients, with a mean duration of 11±6 days (range two to 27 days); the other four patients were treated with noninvasive ventilation. The average duration of symptoms before ICU admission was 22±26 days. All patients were treated with systemic corticosteroids, while eight patients received additional chemotherapy.CONCLUSIONS:In the absence of a reversible cause, patients with IPF who develop acute exacerbation of IPF may not benefit from ICU admission and mechanical ventilation. However, it is imperative that a diagnostic workup be performed to rule out an infectious or other reversible cause of respiratory failure before admission to the ICU is denied.

scholarly journals Bichat guidelines for the clinical management of botulism and bioterrorism-related botulism

2004 ◽  
Vol 9 (12) ◽  
pp. 31-32 ◽  
Author(s):  
P Bossi ◽  
A Tegnell ◽  
A Baka ◽  
A Werner ◽  
F van Loock ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Body Weight ◽  
Intensive Care ◽  
Botulinum Toxin ◽  
Respiratory Failure ◽  
Clinical Management ◽  
Clostridium Botulinum ◽  
Deliberate Release

Botulism is a rare but serious paralytic illness caused by botulinum toxin, which is produced by the Clostridium botulinum. This toxin is the most poisonous substance known. It 100 000 times more toxic than sarin gas. Eating or breathing this toxin causes illness in humans. Four distinct clinical forms are described: foodborne, wound, infant and intestinal botulism. The fifth form, inhalational botulism, is caused by aerosolised botulinum toxin that could be used as a biological weapon. A deliberate release may also involve contamination of food or water supplies with toxin or C. botulinum bacteria. By inhalation, the dose that would kill 50% of exposed persons (LD50) is 0.003 microgrammes/kg of body weight. Patients with respiratory failure must be admitted to an intensive care unit and require long-term mechanical ventilation. Trivalent equine antitoxins (A,B,E) must be given to patients as soon as possible after clinical diagnosis. Heptavalent human antitoxins (A-G) are available in certain countries.

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