Impacto da fonte pagadora e do local de residência na sobrevida de pacientes com tumores hematológicos e sólidos, admissões planejadas e não planejadas em unidade de terapia intensiva: Um estudo de coorte retrospectiva / Impact of payer source and distance from place of residence on survival of patients with hematologic and solid tumors, planned and unplanned intensive care unit admissions: A retrospective cohort study

INTRODUÇÃO: Sobrevida de longo prazo e local de residência e fonte pagadora em pacientes com câncer que são internados em unidades de terapia intensiva (UTI) na América Latina são raramente descritas. OBJETIVO: Descrever sobrevida de longo prazo e avaliar se fatores sociais de pacientes com câncer internados em uma UTI estão associados com esta. MÉTODOS: Coorte retrospectiva em um centro oncológico, em São Paulo, Brasil. Iniciado no primeiro dia de internação na UTI e a data final de seguimento é a última consulta ambulatorial ou óbito, feito censuramento máximo em 5 anos. Foram incluídos pacientes internados na UTI de 2012 a 2017. Foram excluídos menores de 18 anos e pacientes sem câncer ativo. Foram coletados dados clínicos, demográficos e sociais dos pacientes. Foram construídas curvas de sobrevida pelo método de Kaplan-Meier. Foram feitas 3 estratificações da população total de pacientes com câncer orientadas pela análise de resíduos Schoenfeld nas covariáveis para ajuste no modelo de prejuízos proporcionais de Cox. Desta forma, 4 populações de pacientes com câncer na UTI foram definidas: pós-operatório eletivo em pacientes com tumor sólido, admissões não-planejadas em pacientes com tumor sólido loco regional, admissões não-planejadas em pacientes com tumor sólido metastático e admissões não-planejadas em pacientes com tumor hematológico). Foi estimada causa específicas de razão de prejuízos (Hazard Ratio - HR) ajustado para potenciais fatores de confusão nas 4 populações definidas. RESULTADOS: No período de 2012 a 2017, foram incluídos 10085 pacientes com câncer que necessitaram de UTI. Foram 5014 (49,7%) tumores sólidos e admissões planejadas; 4414 (43,7%) pacientes com tumores sólidos e admissões não planejadas, neste grupo houve uma nova estratificação em tumores localizados 1575 (15,6%), tumores metastáticos 2839 (28,1%) e 657 (6,5%) hematológicos. A mortalidade no período de seguimento das 4 populações foi de 28,3% em tumores sólidos e admissões planejadas, 58,7% em tumores sólidos localizados e admissões não planejadas, 78,6% em tumores hematológicos e 89,1% em tumores sólidos com metástase e motivo de admissão não planejado. Corrigindo para idade, gênero, comorbidades e funcionalidade ,em 5 anos, em tumores sólidos metastáticos e admissões não planejadas, ser admitido via SUS associou-se a prejuízo: [HR=1,14(IC 95%,1,04 1,25)] e de tumores hematológicos [HR=1,29( IC 95%,1,06-1,58 )] mas não nas populações de tumores sólidos com câncer localizado e admissões não planejadas [HR=1,08(IC 95%,0,94-1,25 )]. Pacientes com tumores sólidos e admissões planejadas, na variável fonte pagadora, tiveram o fenômeno da tempo dependência e não foi possível ajustá-la no modelo de prejuízos proporcionais de Cox. O local de moradia não apresentou qualquer fator de proteção ou prejuízo nas 4 populações estudadas. CONCLUSÃO: Ser admitido via SUS (vs. Sistema privado) associouse a maior mortalidade em 5 anos na população tumores sólidos metastáticos e admissões não planejadas ,tumores hematológicos e admissões não planejadas, mas não na população de tumores sólidos localizados e admissões não planejadas. O local de moradia em relação ao hospital não mostrou associação com mortalidade nos quatro grupos de pacientes analisados.

INTRODUCTION: Long-term survival and place of residence and payer source in cancer patients who are admitted to intensive care units (ICU) in Latin America have been rarely described. OBJECTIVE: To describe long-term survival and to assess whether social factors in cancer patients who were admitted to an ICU are associated with long-term survival. METHODS: This was a retrospective cohort study in an oncology center in São Paulo, Brazil. The initial date was the first day of ICU admission and the final date of follow-up as the last outpatient visit or death, with maximum censoring at 5 years. Patients admitted to the ICU from 2012 to 2017 were included; patients under 18 years of age and patients without active cancer were excluded. Clinical, demographic, and social data were collected. Survival curves were constructed by the KaplanMeier method. We performed 3 stratifications of the total population of cancer patients guided by Schoenfeld residual analysis on the covariates for adjustment in the Cox proportional hazards model. Thus, 4 populations of cancer patients in the ICU were defined: elective postoperative in solid tumor patients, unplanned admissions in locoregional solid tumor patients, unplanned admissions in metastatic solid tumor patients, and unplanned admissions in hematologic tumor patients). Specific cause of harzard ratio (HR) was estimated adjusted for potential confounding factors in the 4 defined populations. RESULTS: In the period from 2012 to 2017, 10085 cancer patients requiring ICU were included. There were 5014 (49.7%) patients with solid tumors and planned admissions; 4414 (43.7%) patients with solid tumors and unplanned admissions, in this group there was further stratification into patients with localized tumors 1575 (15.6%), metastatic tumors 2839 (28.1%) and 657 (6.5%) patients with hematologic tumors. Mortality over the follow-up period for the 4 populations was 28.3% for solid tumor group and planned admissions, 58.7% for patients with localized solid tumors and unplanned admissions, 78.6% for patients with hematologic tumors, and 89.1% for patients with solid tumors with metastasis and unplanned reason for admission. Correcting for age, gender, comorbidities and functionality, at 5 years, in metastatic solid tumor patients and unplanned admissions, being admitted via SUS was associated with hazard: [HR=1.14(95% CI,1.04-1.25)] and hematologic tumors [HR=1.29( 95% CI,1.06-1.58 )] but not in the populations of solid tumor patients with localized cancer and unplanned admissions [HR=1.08(95% CI,0.94-1.25 )]. Patients with solid tumors and planned admissions in the payer source variable had the phenomenon of time dependence and it was not possible to fit it in the Cox proportional hazards model. Place of residence did not show any protective or detrimental factor in the 4 populations studied. CONCLUSION: Being admitted via SUS (vs. private system) was associated with higher 5-year mortality in the population of patients with metastatic solid tumors and unplanned admissions, patients with hematologic tumors and unplanned admissions, but not in the population of patients with localized solid tumors and unplanned admissions. The patient's place of residence in relation to the hospital showed no association with mortality in the four patient groups analyzed.

Cancer-Related Characteristics Associated With Invasive Mechanical Ventilation or In-Hospital Mortality in Patients With COVID-19 Admitted to ICU: A Cohort Multicenter Study.

BACKGROUND: Coexistence of cancer and COVID-19 is associated with worse outcomes. However, the studies on cancer-related characteristics associated with worse COVID-19 outcomes have shown controversial results. The objective of the study was to evaluate cancer-related characteristics associated with invasive mechanical ventilation use or in-hospital mortality in patients with COVID-19 admitted to intensive care unit (ICU). METHODS: We designed a cohort multicenter study including adults with active cancer admitted to ICU due to COVID-19. Seven cancer-related characteristics (cancer status, type of cancer, metastasis occurrence, recent chemotherapy, recent immunotherapy, lung tumor, and performance status) were introduced in a multilevel logistic regression model as first-level variables and hospital was introduced as second-level variable (random effect). Confounders were identified using directed acyclic graphs. RESULTS: We included 274 patients. Required to undergo invasive mechanical ventilation were 176 patients (64.2%) and none of the cancer-related characteristics were associated with mechanical ventilation use. Approximately 155 patients died in hospital (56.6%) and poor performance status, measured with the Eastern Cooperative Oncology Group (ECOG) score was associated with increased in-hospital mortality, with odds ratio = 3.54 (1.60-7.88, 95% CI) for ECOG =2 and odds ratio = 3.40 (1.60-7.22, 95% CI) for ECOG = 3 to 4. Cancer status, cancer type, metastatic tumor, lung cancer, and recent chemotherapy or immunotherapy were not associated with in-hospital mortality. CONCLUSIONS: In patients with active cancer and COVID-19 admitted to ICU, poor performance status was associated with in-hospital mortality but not with mechanical ventilation use. Cancer status, cancer type, metastatic tumor, lung cancer, and recent chemotherapy or immunotherapy were not associated with invasive mechanical ventilation use or in-hospital mortality.

Mortality and Life-Sustaining Therapy Decisions in Patients With Cancer and Acute Respiratory Failure Due to COVID-19 or Other Causes: An Observational Study.

It is unknown if patients with cancer and acute respiratory failure due to COVID-19 have different clinical or cancer-related characteristics, decisions to forgo life-sustaining therapies (LST), and mortality compared to patients with cancer and acute respiratory failure due to other causes. In a cohort study, we tested the hypothesis that COVID-19 was associated with increased in-hospital mortality and decreased decisions to forgo LST in patients with cancer and acute respiratory failure. We employed two multivariate logistic regression models. Propensity score matching was employed as sensitivity analysis. We compared 382 patients without COVID-19 with 65 with COVID-19. Patients with COVID-19 had better performance status, less metastatic tumors, and progressive cancer. In-hospital mortality of patients with COVID-19 was lower compared with patients without COVID-19 (46.2 vs. 74.6%; p < 0.01). However, the cause of acute respiratory failure (COVID-19 or other causes) was not associated with increased in-hospital mortality [adjusted odds ratio (OR) 1.27 (0.55-2.93; 95% confidence interval, CI)] in the adjusted model. The percentage of patients with a decision to forgo LST was lower in patients with COVID-19 (15.4 vs. 36.1%; p = 0.01). However, COVID-19 was not associated with decisions to forgo LST [adjusted OR 1.21 (0.44-3.28; 95% CI)] in the adjusted model. The sensitivity analysis confirmed the primary analysis. In conclusion, COVID-19 was not associated with increased in-hospital mortality or decreased decisions to forgo LST in patients with cancer and acute respiratory failure. These patients had better performance status, less progressive cancer, less metastatic tumors, and less organ dysfunctions upon intensive care unit (ICU) admission than patients with acute respiratory failure due to other causes.

Controle da pressão do cuff na unidade terapia intensiva: efeitos do treinamento / Cuff pressure control in intensive care unit: training effects

OBJETIVOS: A pressão do cuff é transmitida de forma direta na parede da traquéia e isto pode ocasionar lesões. O objetivo deste trabalho foi verificar a eficácia de um treinamento com a equipe de enfermagem no controle da pressão do cuff. MÉTODOS: Foi realizado um levantamento retrospectivo das mensurações da pressão de cuff de janeiro de 2007 a junho de 2008, verificando-se o percentual de inadequação. Posteriormente, foi elaborado um programa de treinamento da equipe de enfermagem durante o mês de Junho 2008 em todos os três turnos de trabalho. Após o encerramento dessa fase de treinamento, o percentual de adequação na pressão de cuff foi verificado prospectivamente durante os meses de Julho a Dezembro. Foi comparado o percentual de inadequação da pressão do cuff entre os turnos de trabalho (matutino, vespertino e noturno) e entre os períodos pré-treinamento e pós-treinamento pelo teste qualitativo de qui-quadrado, considerando-se como significativa diferença acima de 5 por cento (p<0,05). RESULTADOS: No período pré-treinamento as medidas inadequadas das pressões do cuff (acima de 30cmH2O) nos períodos matutino, vespertino e noturno foram respectivamente 9,2; 11,9 e 13,7 por cento. Após o treinamento foi verificada inadequação de 7,6; 4,1 e 5,2 por cento, nos mesmos períodos, observando-se diminuição significativa no tocante aos períodos vespertino e noturno pré e pós (p<0,001). CONCLUSÃO: O treinamento realizado com a equipe de enfermagem demonstrou-se efetivo na conscientização dos malefícios da pressão do cuff inadequada, acarretando na utilização de níveis de pressão mais seguros nos pacientes.

OBJECTIVES: Direct cuff pressure to the tracheal wall can cause damage. This paper aimed to verify the effectiveness of nursing team training on cuff pressure control. METHODS: A retrospective survey was initially made on the records of cuff pressure measurements from January 2007 to June 2008 and the inadequacy percent was verified. Next, a nursing team training program was provided involving all nursing shift teams during June 2008, and after the training the appropriate cuff pressures proportion was prospectively recorded between June and December 2008. The proportion of inappropriate cuff pressure was compared between the work shifts (morning, afternoon and evening-night) and between pre- and post-training, using the qualitative Chi-square test. The 5 percent limit (p<0.05) was considered for significant differences. RESULTS: For the pre-training period, inappropriate cuff pressure measures (over 30cmH2O) during morning, afternoon and evening-night shifts were 9.2 percent, 11.9 percent and 13.7 percent, respectively. For the post-training phase, 7.6 percent, 4.1 percent and 5.2 percent inappropriate cuff-pressures were identified for the morning, afternoon and evening-night shifts, respectively, with a significant reduction for the afternoon and evening-night shifts, respectively (p<0.001). CONCLUSION: Nursing team training was effective for inadequate cuff pressure harms awareness improvement, and resulted in safer pressure levels.

Cuff pressure control in intensive care unit: training effects. / Controle da pressão do cuff na unidade terapia intensiva: efeitos do treinamento.

OBJECTIVES: Direct cuff pressure to the tracheal wall can cause damage. This paper aimed to verify the effectiveness of nursing team training on cuff pressure control. METHODS: A retrospective survey was initially made on the records of cuff pressure measurements from January 2007 to June 2008 and the inadequacy percent was verified. Next, a nursing team training program was provided involving all nursing shift teams during June 2008, and after the training the appropriate cuff pressures proportion was prospectively recorded between June and December 2008. The proportion of inappropriate cuff pressure was compared between the work shifts (morning, afternoon and evening-night) and between pre- and post-training, using the qualitative Chi-square test. The 5% limit (p<0.05) was considered for significant differences. RESULTS: For the pre-training period, inappropriate cuff pressure measures (over 30cmH2O) during morning, afternoon and evening-night shifts were 9.2%, 11.9% and 13.7%, respectively. For the post-training phase, 7.6%, 4.1% and 5.2% inappropriate cuff-pressures were identified for the morning, afternoon and evening-night shifts, respectively, with a significant reduction for the afternoon and evening-night shifts, respectively (p<0.001). CONCLUSION: Nursing team training was effective for inadequate cuff pressure harms awareness improvement, and resulted in safer pressure levels.

Cervical necrotizing fasciitis due to bacterial tonsillitis.

Necrotizing fasciitis is a severe and potentially fatal soft tissue infection, but involvement of the head and neck is rare. We report on 4 cases of cervical necrotizing fasciitis arising from tonsillitis. One patient was diabetic and one had received steroids before disease development. One patient developed acute respiratory failure and died of septic shock. Three patients recovered, helped by early recognition, aggressive surgical intervention, appropriate broad-spectrum antibiotics, and supportive therapy. The common bacteria found in all abscess samples were Streptococcus sp., but mixed flora with anaerobic organisms was seen in all but 1 case. Tonsillitis and peritonsillar abscess must be suspected as a cause of cervical necrotizing fasciitis and a successful result can be achieved with immediate aggressive treatment.

Cervical necrotizing fasciitis due to bacterial tonsillitis

A fasceite necrotizante cervical é uma infecção grave de partes moles do pescoço. Trata-se de entidade rara, porém quando presente tem como principal origem um foco infeccioso odontogênico. São descritos 4 casos de fasceite necrotizante cervical a partir de tonsilites e abscesso peritonsilar, os quais, foram admitidos e tratados na unidade de terapia intensiva. Um dos pacientes era portador de Diabetes Melittus não insulino- dependente e outro paciente havia recebido corticoterapia antes do desenvolvimento da infecção. Em um dos casos ocorreu mediastinite, insuficiência respiratória e o paciente evolui para o óbito em decorrência de choque séptico. Durante o tratamento, 3 pacientes evoluíram satisfatoriamente devido ao diagnostico precoce, tratamento cirúrgico agressivo e utilização de antibiótico terapia de largo espectro. A bactéria mais comumente encontrada foi o Streptococcus sp, mas flora mista com germes anaeróbios foi encontrada em 3 dos casos descritos. CONCLUSÕES: Deve-se suspeitar de tonsilite e abscesso peritonsilar como causa de fasceite necrotizante cervical para que tratamento agressivo e precoce seja realizado.