Factores de mal pronostico en pacientes internados con neutropenia al inicio del episodio febril / Prognostic risk factors for serious complications in an inpatient population with neutropenia at the onset of a febrile episode

RESUMEN

Los pacientes con neutropenia y fiebre constituyen una población heterogénea con riesgo variable para el desarrollo de complicaciones serias y mortalidad. El objetivo de este trabajo es identificarfactores que, presentes al ingreso, estuvieran asociados a mayor riesgo de complicaciones graves en pacientesque se internan por neutropenia y fiebre. Se trata de un estudio de seguimiento de una cohorte de 238 episodios de neutropenia y fiebre (neutrófilos <1000/mm3 y T>38.3 °C) en 167 pacientes internados en sala general en nuestra institución desde 1997 a 2004. Ochenta y dos por ciento de los pacientes tenían enfermedad hematológica, 14% tumores sólidos y 4% no asociados a quimioterapia. Se registraron 67 eventos adversos (46% de insuficiencia renal, 27% de hipotensión refractaria, 15% de insuficiencia respiratoria y 12% con sangrado mayor). Se hallaron diferencias significativas en presencia de comorbilidades previas, temperatura mayor a 39 °C, frecuencia cardíaca mayor a 120 latidos por minuto, frecuencia respiratoria mayor a 24 por minuto, tensión arterial sistólica menor a 90 mm Hg, presencia de 3 o más valores de laboratorio alterados al ingreso, presencia de foco clínico y hemocultivos positivos. En el análisis multivariado de regresión logística mantuvieron asociación independiente con mayor riesgo de eventos graves hipotensión arterial sistólica (OR=7, p<0.01), comorbilidades (OR=8.5, p=0.02), taquipnea (OR=2.8, p=0.01), y presencia de foco clínico (OR=2.1, p=0.03)

ABSTRACT

Patients with neutropenia and fever conform a heterogeneouspopulation with a variable risk of serious complications and mortality. The goal of this study was to identifyprognostic risk factors present at the beginning of the episode, for adverse events and serious complications inpatients admitted in a general ward with fever and neutropenia. A cohort of 238 episodes with neutropenia andfever (neutrophils <1000/mm3 and T>38.3 °C) in 167 patients admitted to our general hospital between 1997and 2004 was followed. Eighty two percent of the patients had hematologic malignancies, 14% solid tumors and4% were not associated with chemotherapy. Sixty seven adverse events were registered (46% renal insufficiency, 27% refractory hypotension, 15% respiratory insufficiency and 12% major bleeding). Significant differences werefound in presence of current co-morbidities, body temperature >39 °C, heart rate >120 beats per minute, respiratory rate >24 per minute, systolic blood pressure <90 mm Hg, presence of 3 or more altered laboratory values, presenceof a clinical site of infection and positive blood cultures. The logistic regression multivariate analysis showedthat the following characteristics were independently associated with adverse events systolic blood pressure<90 mm Hg (OR=7, p<0.01), current co-morbidities (OR=8.5, p=0.02), respiratory rate >24 per minute (OR=2.8, p=0.01), and the presence of a clinical site of infection (OR=2.1, p=0.03). The presence of systolic hypotension, high respiratory rate, current co-morbidities and a clinical site of infection at the time of admission were identified predictors of subsequent serious complications in patients admitted with fever and neutropenia in a general ward