Short- and long-term outcomes of patients with solid tumours following non-surgical intensive care admission.

BACKGROUND: There has been a significant increase in the number of patients presenting with cancer related emergencies and potentially requiring critical care admission. AIM: To analyse the short and long-term outcomes of patients with solid tumours requiring unplanned medical admission to a specialist cancer intensive care unit (ICU). DESIGN: An unplanned cohort study. METHODS: A retrospective analysis of patients admitted to a UK specialist tertiary oncology CCU between September 2009 and September 2015. The primary outcome measures were survival to CCU discharge and 1-year survival. RESULTS: 687 patients had an unplanned medical admission. The most frequent primary tumours were lymphoma (22.1%), lung (15.2%) and colorectal (13.0%), and 181 (44.4%) were known to have metastases. The median Acute Physiology and Chronic Health Evaluation (APACHE) II and Intensive Care National Audit and Research Centre (ICNARC) scores were 21 and 17, respectively. ICU mortality was 26.7%, with total hospital mortality of 41.9%. The median survival of the total cohort was 56 days after ICU admission, with 107 patients surviving 365 days. Patients with metastatic disease were almost twice as likely to die within the year following ICU admission compared with their counterparts without metastases. Only pancreatic and lung primaries were shown to have a statistically significant impact on survival at 1 year. Pneumonia carried with it the worst prognosis (cumulative survival 0.11), followed by sepsis (0.25) and non-infective respiratory disease (0.26). CONCLUSIONS: The stage and type of cancer appear to have minimal impact on short-term ICU outcomes and only confer poorer long-term prognosis related to the disease.

Effectiveness of early antibiotic administration in septic patients with cancer.

INTRODUCTION: First dose intravenous antimicrobial therapy should be administered within 1 hour of admission but this is achieved in a minority of patients. METHODS: We performed a retrospective analysis at the largest Oncology hospital in Europe. Nurse-led administration of initial antibiotic therapy was introduced to the admissions unit. RESULTS: The nurse led protocol increased compliance with the 1 hour target from 40% to 88.6%. There was a statistically significant decrease in the mean length of stay (p=0.045) which was more pronounced in the neutropenic population (p=0.006). There was a trend to improved 30 day mortality. CONCLUSIONS: A nurse led protocol can be effective in improving compliance with the 1 hour target. Early administration of intravenous antibiotics in cancer patients with sepsis is associated with a shorter length of inpatient stay and a trend to decreased mortality.

Posterior reversible encephalopathy syndrome associated with deoxycoformycin and alemtuzumab.

Posterior reversible encephalopathy syndrome (PRES) is a combined clinical and radiological syndrome characterised by headaches, encephalopathy, seizures and visual loss. We present the case of a 55-year-old male who developed this condition following treatment with deoxycoformycin and alemtuzumab. We review the literature considering diagnosis, pathophysiology and optimal strategies for treatment of this condition.

Ruptured abdominal aortic aneurysm. Is it possible to predict outcome?

AIM: Mortality after ruptured abdominal aortic aneurysm (rAAA) remains high. Hardman et al. suggested that the following factors predict perioperative death: age >76 years, loss of consciousness, ECG confirmed ischemia, creatinine over 180 micromol/l and hemoglobin below 9 g/dl. A score of 3 or more had 100% mortality. A retrospective study was performed to validate this and determine if modification is required. METHODS: Retrospective analysis of the 5 Hardman Index factors along with preoperative systolic blood pressure at presentation, after resuscitation and during surgery was performed. RESULTS: A total of 137 cases were reviewed with overall mortality of 56.2%. Of Hardman's criteria: age, ECG ischemic changes, creatinine and hemoglobin levels were significant in predicting outcome (p=0.0007, 0.0152, 0.0001 and 0.0213, respectively). Loss of consciousness was not significant (p=0.9054). Hardman scores of 0, 1, 2, 3, and 4 scored mortality percentages of 40.4%, 46.4%, 76.7%, 91.7% and 100%, respectively. Systolic blood pressure was significantly predictive at 100 mmHg and 120 mmHg on presentation (p=0.0008 and 0.0017, respectively) and 100 mmHg and 120 mmHg after resuscitation (p=0.0001 and 0.0510, respectively). A modified score replaced loss of consciousness with systolic blood pressure below 100 mmHg with scores of 0, 1, 2, 3, and 4 had mortality of 22.2%, 46.8%, 66.7%, 83.9% and 100%, respectively. CONCLUSION: Our data supports the effectiveness of the Hardman Index in predicting successful surgery. However loss of consciousness was not a significant predictor. We proposed review of predictive indices, but resources should be channelled into screening to prevent rAAA.

Data collection in the emergency setting.

This is the ninth article in the research series and focuses on the collection of data.

Power spectral analysis of cardiovascular variability in critically ill neurosurgical patients.

OBJECTIVE: Patients with brain damage exhibit a number of changes in heart rate and cardiovascular control. The aim of this study was to relate changes in autonomic cardiovascular control seen in critically ill neurosurgical patients to the quality of subsequent outcome and survival. DESIGN: Prospective, longitudinal, outcome study. SETTING: Intensive care department of a university teaching hospital. PATIENTS: A total of 29 consecutive neurosurgical patients admitted for > or =2 days to the intensive care department with a Glasgow Coma Scale score < 13 who needed electrocardiographic and invasive arterial monitoring. INTERVENTIONS: Sampling of the electrocardiogram, respiratory rate, and arterial pressure into a personal computer was carried out for > or =60 mins. Power spectral analysis was then applied to the data by using a fast Fourier transformation. Arterial baroreflex sensitivity was determined as the gain of the transfer function between systolic arterial blood pressure and electrocardiograph R-R interval (RRI) variability. All surviving patients were followed up at 3 months postadmission to measure quality of outcome. MEASUREMENTS AND MAIN RESULTS: There were reductions in the total power (p < .01) of RRI variability in those who subsequently died compared with those who survived. This was significant for very low frequency (p < .001) and low-frequency (LF) (p < .05) but not high-frequency (HF) bands (p = .11). Blood pressure variability, however, did not change between groups. Baroreflex sensitivity was 8.7+/-2.2 msecs/mm Hg for patients with a good later outcome and 4.4+/-1.5 msecs/mm Hg for patients who subsequently died (p = .03). Patients who recovered to a good quality outcome also had a raised LF/HF ratio in RRI (p = .05). CONCLUSION: A reduction in the total power variability of RRI and a lowered LF/HF ratio of the RRI are associated with a poor quality recovery or death after neurosurgical illness. A reduction in the baroreflex was specifically associated with death in this patient group.

Strong vasopressor support may be futile in the intensive care unit patient with multiple organ failure.

OBJECTIVE: The aim of the study was to determine the prognosis in patients who needed norepinephrine treatment in our institution in relation to the degree of organ failure and the evolution of the disease process. DESIGN: Retrospective case note analysis of outcome of those patients who needed norepinephrine according to our institutional regimen. PATIENTS: A total of 100 consecutive patients admitted to our 31-bed medical-surgical intensive care unit (ICU) who were treated with norepinephrine for severe hypotension and evidence of end-organ hypoperfusion unresponsive to both fluid resuscitation and dopamine treatment at 20 microg/kg/min. MEASUREMENTS: The degree of organ dysfunction at the time of starting norepinephrine treatment was assessed by the sequential organ failure assessment (SOFA) score. The time before starting norepinephrine treatment was defined as the time elapsed between ICU admission and that of starting norepinephrine administration. The patients were defined as survivors or nonsurvivors according to their ICU outcome. RESULTS: There were relationships between mortality and the degree of organ dysfunction and mortality and the duration of ICU stay before starting norepinephrine treatment. The mortality rate was 100% in the 30 patients with a total SOFA score of >12 and a delay before starting norepinephrine treatment of >1 day. The mortality rate of the other patients was 63%. The lowest mortality was seen in patients with lower SOFA scores and early norepinephrine administration after admission. CONCLUSIONS: Both the time of starting norepinephrine treatment after admission to the ICU and the degree of organ dysfunction have an important bearing on subsequent outcome. Although norepinephrine may be a lifesaving catecholamine in some cases, its administration to patients who have already developed multiple organ failure during their stay in the ICU is associated with a poor outcome.

Leukocyte glycolysis and lactate output in animal sepsis and ex vivo human blood.

Lactate is released in large quantity from sites of sepsis and inflammation. We asked whether the increased lactate production found in sepsis can be explained by the augmented glycolysis of inflammatory cells. The glycolytic metabolism of rat peritoneal leukocytes was measured following cecal ligation and perforation (CLP) or sham laparotomy. CLP augmented glucose uptake, the pentose phosphate pathway, and glucose oxidation. Lactate output increased from 1.03 +/- 0.05 to 1.20 +/- 0.05 fmol x cell(-1) x min(-1) (P < .001). Total lactate output of peritoneal lavage fluid increased from 7.94 +/- 2.59 to 28.12 +/- 5.60 nmol L x min(-1) (P < .005). The effect of lipopolysaccharide (LPS) on the lactate output of whole blood from 31 critically ill patients was measured. Leukocyte lactate production was calculated by multiple linear regression analysis. Following exposure to LPS, human leukocyte lactate output increased from 0.20 +/- 0.09 to 1.22 +/- 0.14 fmol x cell(-1) x min(-1) (P < .001). This rate of production is so high that it suggests that the lactate output of different tissue beds in sepsis may be affected by their different cell populations and state of activation. This study supports the hypothesis that lactate may be more a product of inflammation than a marker of tissue hypoxia in sepsis.