Impact of organ dysfunction on mortality in ICU patients with hematologic malignancies.

PURPOSE: To compare evolution in organ dysfunction (OD) between hematologic malignancy patients with and without bacterial infection (BI) precipitating intensive care unit (ICU) admission, and to assess its impact on mortality. METHODS: Retrospective analysis of prospectively collected data was performed. Sequential Organ Failure Assessment (SOFA) scores from day 1 to 5 were calculated in all consecutive hematologic malignancy patients admitted to the ICU (2000-2006). Patients were categorized according to the presence or absence, the diagnostic certainty, and the site of BI. RESULTS: Of the 344 patients admitted, 258 were still in the ICU at day 3 and 164 at day 5. Patients admitted because of BI had more severe OD on day 1 (SOFA 9.7 ± 4.0 vs. 8.4 ± 4.0, p = 0.008) but a more rapidly reversible OD within the first 3 days (ΔSOFA -1.12 ± 3.10 vs. 0.03 ± 3.40, p = 0.013) and a lower in-hospital (43.2% vs. 62.9%, p < 0.001) and 6-month mortality (52.1% vs. 71.7%, p < 0.001) than patients with other complications. In a multivariate analysis, BI remained associated with a lower risk of death (OR 0.20, 95% CI 0.1-0.4, p < 0.001) even after adjustment for the SOFA on day 1 (OR 1.36, 95% CI 1.22-1.52, p < 0.001) and the ΔSOFA (OR 1.48, 95% CI 1.29-1.68, p < 0.001). These findings remained significant regardless of the site and the diagnostic certainty of BI. CONCLUSION: BI is associated with a more severe initial but a more rapidly reversible OD and a subsequent lower mortality compared to other complications in ICU patients with hematologic malignancies. These findings further support the recommendation that these patients should certainly benefit from advanced life support, and in the case of an uncertain long-term prognosis due to the underlying malignancy, at least from a 3-day ICU trial.

The impact of the initial ventilatory strategy on survival in hematological patients with acute hypoxemic respiratory failure.

PURPOSE: The aim of this study was to assess the impact of the 3 types of initial respiratory support (noninvasive positive pressure ventilation vs invasive positive pressure ventilation vs supplemental oxygen only) in hematological patients with acute hypoxemic respiratory failure (ARF). MATERIALS AND METHODS: This study is a retrospective analysis of a cohort of hematological patients admitted to the intensive care unit (ICU) of a tertiary care hospital between January 1, 2002, and June 30, 2006. RESULTS: One hundred thirty-seven hematological patients were admitted at the ICU with ARF (defined as Pao(2)/Fio(2) <200): within the first 24 hours, 24 and 67 patients received noninvasive positive pressure ventilation and invasive positive pressure ventilation, respectively, and 46 received supplemental oxygen only. Intensive care unit mortality in the 3 patient categories was 71%, 63%, and 32%, respectively (P = .001), and in-hospital mortality was 75%, 80%, and 47%, respectively (P = .001). In multivariate regression analysis, increasing cancer-specific severity-of-illness score upon admission and more organ failure after 24 hours of ICU admission, but not the type of initial respiratory support, were significantly associated with ICU or in-hospital mortality. CONCLUSIONS: Intensive care unit and in-hospital mortality in our population of hematological patients with hypoxemic ARF was determined by severity of illness and not by the type of initial respiratory support.

Impact of recent intravenous chemotherapy on outcome in severe sepsis and septic shock patients with hematological malignancies.

OBJECTIVE: To compare the characteristics and outcome of patients with hematological malignancies referred to the ICU with severe sepsis and septic shock who had or had not received recent intravenous chemotherapy, defined as within 3 weeks prior to ICU admission. DESIGN AND SETTING: Retrospective observational cohort study on prospectively collected data in a medical ICU of a university hospital. PATIENTS: 186 ICU patients with hematological malignancies with severe sepsis or septic shock (2000-2006). MEASUREMENTS AND RESULTS: There were 77 patients admitted with severe sepsis and 109 with septic shock; 91 (49%) had received recent intravenous chemotherapy. Patients with recent chemotherapy more often had a high-grade malignancy and were more often neutropenic, less often had pulmonary infiltrates, and less often required mechanical ventilation. ICU, 28-day, in-hospital, and 6-month mortality rates were 33% vs. 48.4%, 40.7% vs. 57.4%, 45.1% vs. 58.9%, and 50.5% vs. 63.2% in patients with and without recent chemotherapy, respectively. Logistic regression identified four variables independently associated with 28-day mortality: SOFA score at ICU admission, pulmonary site of infection, and fungal infection were associated with worse outcome whereas previous intravenous chemotherapy was protective at borderline significance. After adjustment with a propensity score for recent chemotherapy, chemotherapy was not associated with outcome. CONCLUSIONS: Patients referred to the ICU with severe sepsis and septic shock complicating active chemotherapeutic treatment have better prognosis than commonly perceived.

Outcome in severely ill patients with hematological malignancies who received intravenous chemotherapy in the intensive care unit.

OBJECTIVE: To assess the outcome in severely ill patients with hematological malignancies who receive intravenous chemotherapy in an intensive care unit (ICU) for a life-threatening malignancy-related complication. DESIGN: Retrospective observational study of prospectively collected data. PATIENTS: All 37 critically ill patients with hematological malignancies who received intravenous chemotherapy in the ICU between January 1997 and March 2005 (mean age 46+/-19 years; mean APACHE II 23+/-7). MEASUREMENTS AND RESULTS: Thirty-seven (69%) patients received chemotherapy because of extensive disease with organ involvement (54%), extensive disease without organ involvement (19%), severe disseminated intravascular coagulation (11%), and other reasons (16%). In 41% there was concomitant infection when chemotherapy was initiated, in 86% a high-grade malignancy, and 30% relapsing disease. Twenty-three (62%) patients received mechanical ventilation at the moment of or soon after initiation of chemotherapy for a median duration of 5 days (1-67), and 24% underwent renal replacement therapy during ICU stay. Only ventilation was associated with in-hospital mortality (odds ratio 9.3). ICU, in-hospital, and 6-month mortality rates in nonventilated vs. ventilated patients were 7% and 48%, 14% and 61%, and 54% and 74%, respectively. CONCLUSIONS: Starting chemotherapy in the ICU for a life-threatening malignancy related complication can be lifesaving even when infection or organ failure is present.

Documented and clinically suspected bacterial infection precipitating intensive care unit admission in patients with hematological malignancies: impact on outcome.

OBJECTIVE: To assess the impact of documented and clinically suspected bacterial infection precipitating ICU admission on in-hospital mortality in patients with hematological malignancies. DESIGN AND SETTING: Prospective observational study in a 14-bed medical ICU at a tertiary university hospital. PATIENTS: A total of 172 consecutive patients with hematological malignancies admitted to the ICU for a life-threatening complication over a 4-year period were categorized into three main groups according to their admission diagnosis (documented bacterial infection, clinically suspected bacterial infection, nonbacterial complications) by an independent panel of three physicians blinded to the patient's outcome and C-reactive protein levels. RESULTS: In-hospital and 6-months mortality rates in documented bacterial infection (n=42), clinically suspected bacterial infection (n=40) vs. nonbacterial complications (n=90) were 50.0% and 42.5% vs. 65.6% (p=0.09 and 0.02) and 56.1% and 48.7% vs. 72.1% (p=0.11 and 0.02), respectively. Median baseline C-reactive protein levels in the first two groups were 23 mg/dl and 21.5 mg/dl vs. 10.7 mg/dl (p<0.001 and p=0.001) respectively. After adjustment for the severity of critical and underlying hematological illness and the duration of hospitalization before admission documented (OR 0.20; 95% CI 0.06-0.62, p=0.006) and clinically suspected bacterial infection (OR 0.18; 95% CI 0.06-0.53, p=0.002) were associated with a more favorable outcome than nonbacterial complications. CONCLUSIONS: Severely ill patients with hematological malignancies admitted to the ICU because of documented or clinically suspected bacterial infection have a better outcome than those admitted with nonbacterial complications. These patients should receive advanced life-supporting therapy for an appropriate period of time.

Outcome in critically ill medical patients treated with renal replacement therapy for acute renal failure: comparison between patients with and those without haematological malignancies.

BACKGROUND: Starting renal replacement therapy (RRT) for acute renal failure in critically ill patients with haematological malignancies is controversial because of the poor outcome and high costs. The aim of this study was to compare the outcome between critically ill medical patients with and without haematological malignancies who received RRT for acute renal failure. METHODS: We retrospectively collected data on all consecutive patients who received RRT for acute renal failure at the Medical Intensive Care Unit (ICU) of a University Hospital between 1997 and 2002, and assessed the impact of the presence of a haematological malignancy on the survival within 6 months after ICU admission by Cox proportional hazard models. RESULTS: Fifty of the 222 (22.5%) consecutive patients with haematological malignancies admitted to the ICU over the study period received RRT for acute renal failure compared with 248 of the 4293 (5.8%) patients without haematological malignancies (P<0.001). Among patients who received RRT, those with haematological malignancies had higher crude ICU (79.6 vs 55.7%, P=0.002) and in-hospital (83.7 vs 66.1%, P=0.016) mortality rates, and a higher mortality at 6 months (86 vs 72%, P=0.018) by Kaplan-Meier estimates compared with those without haematological malignancies. However, after adjustment for the severity of illness and the duration of hospitalization before ICU admission, haematological malignancy by itself was no longer associated with a higher risk of death (hazard ratio 1.04; 95% confidence interval, 0.73-1.54, P=0.78). CONCLUSIONS: Medical ICU patients with haematological malignancies have a higher rate of occurrence of acute renal failure treated with RRT and a higher mortality, compared with those without haematological malignancies. However, the presence of a haematological malignancy by itself is not a reason to withhold RRT in medical ICU patients with acute renal failure.