Reason For Intensive Care Unit Admission Research Articles

Poor Prognosis for Patients after Myelo- and Non-Myeloablative Conditioning Therapy Followed by Allogeneic Peripheral Blood Stem Cell Transplantation Admitted to Intensive Care Unit.

Background and Aims: The role of intensive care unit (ICU) support for patients following allogeneic peripheral blood stem cell transplantation (PBSCT) is controversial. In an era of constrained resources, we assessed prognostic factors predictive for survival in patients after myeloablative (MAC) and non-myeloablative allogeneic (non-MAC) PBSCT over a period of seven years.Patients: Between January 1999 and February 2006 three-hundred and one patients with various hematological malignancies underwent allogeneic stem cell tranplantation in our institution (MAC 196, non-MAC 105). Of these, sixty-four patients (21,3%) with a median age of 47 years (range 18–64 years; female 24, male 40; MAC 49, non-MAC 15) were admitted to the ICU during the first two years following PBSCT (median 55 days, range 1–631 days). We looked for variables defining the SOFA (Sequential Organ Failure Assessment) and the SAPS (Simplified Acute Physiology Score) score on the day of ICU admission and five days later to discriminate patients with poor and good prognosis with regard to survival. We also looked for variables such as age of patients, diagnosis, disease status, donor type, time between transplantation and ICU admission, reason for ICU admission and occurrence of veno-occlusive disease and GVHD.Results: Mechanical ventilation was required by all patients admitted to the ICU. Median survival following referral to ICU was 22 days (range 0 – 959 days). The main reason for death was sepsis (56%). Among 49 patients who had received MAC 19 (39%) survived the ICU stay with a median survival time of 11 months (range 0–29 months). In the group of patients who had received non-MAC 3 out of 15 patients (20%) could be discharged from the ICU with a median survival time of 5 months (range 4–12 months). Looking at the twenty-two ICU survivors there were seven patients who survived the following year resulting in an overall survival of 11% one year after ICU admission. Only the SOFA score (p = 0.002) on the day of ICU admission was of prognostic relevance for survival.Conclusion: ICU admission and respiratory failure are associated with poor prognosis after allogeneic stem cell transplantation The probability of survival is independent from the type of conditioning therapy. The SOFA score is a predictor for short term survival but fails to identify long term survivors.

Prognostic factors for patients with lymphoma requiring intensive care

17519 Background: Prognosis of patients (pts) with hematological malignancies (HM) in the intensive care unit (ICU) seems to be improving, despite different biological behaviors and outcomes. The study of homogenous groups of pts might provide useful clinical insights. The aim of this study was to evaluate the outcomes of critically ill patients with lymphomas (CIPL). Methods: During 66 months, all consecutive CIPL admitted to an oncologic ICU were studied. Variables collected were: age, gender, performance status, type and status of lymphoma, neutropenia, infection at admission, use of mechanical ventilation (MV), the Acute Physiology and Chronic Health Evaluation (APACHE) II score, comorbidities and number of acute organ failures (AOF). Variables selected in the univariate analysis (p < 0.25) and those clinically relevant were entered in a multivariable logistic regression analysis [results expressed as odds-ratios (OR), 95% confidence interval (CI)]. The end-point was hospital mortality. Results: A total of 120 CIPL were studied. Mean age was 51 ± 20 years and 54% were males. APACHE II was 19 ± 7 points. Diagnoses were High Grade Non-Hodgkin’s Lymphoma (77.5%), Hodgkin’s disease (17.5%) and Low Grade Non-Hodgkin’s Lymphoma (5%). Reasons for ICU admission were severe sepsis (62%) and acute respiratory failure (22%). During ICU stay 90% pts received MV, 71% vasopressors and 27.5% dialysis. Twenty-three (19%) pts had neutropenia. End-of-life decisions were implemented in 31% pts and all of them died at the ICU. The ICU and hospital mortality rates were 53% and 67% respectively, with no difference among the groups of lymphomas (p = 0.877). Variables identified in the multivariate analysis were: age [OR = 1.03 (95% CI = 1.01–1.06)], male gender [3.72 (1.27–10.90)], uncontrolled disease [OR = 6.28 (1.80–21.95), for pts with newly diagnosed disease and OR = 5.33 (1.45–19.47), for those with recurrence/progression, sepsis [OR = 5.31 (1.62–17.37)] and AOF [OR = 2.35 (1.53–3.61)]. Conclusions: Higher age, male gender, the severity of organ failures, sepsis and disease status were the main adverse factors. Type of lymphoma and neutropenia had no impact in the outcome. The appropriate use of such easily available clinical characteristics may avoid forgoing intensive care for lymphoma pts with a chance of survival. No significant financial relationships to disclose.

Outcomes of critically ill patients with lung cancer

16001 Background: Recent advances in oncology and critical care have resulted in improved survival in critically ill cancer patients. An appraisal of the prognosis of critically ill patients with lung cancer is timely. Methods: The aim of this study was to evaluate the outcomes and prognostic factors of critically ill cancer patients with lung cancer. From 2000 to 2005, patients with either small-cell (SCLC) or non-small-cell lung cancer (NSCLC) admitted at two intensive care units (ICU) in Brazil and France were included. Patients with postoperative care, ICU stay <24 h and readmissions were excluded. Demographics, clinical, cancer related and outcome variables were collected. Hospital mortality was the outcome variable of interest. Variables selected in the univariate analysis (p < 0.25) and those considered clinically relevant were entered in a multivariable logistic regression analysis [results were expressed as odds-ratios (OR), 95% confidence interval (CI)]. Results: A total of 132 patients were studied (INCA = 87, St Louis Hospital = 45). Their mean age was 61 ± 10 years and 73% were males. Twenty-five (19%) had SCLC and 107 (81%), NSCLC. The SAPS II score was 48 ± 21 points. The main reasons for ICU admission were severe sepsis (45%) and acute respiratory failure (33%). During ICU stay, 96 (73%) patients received mechanical ventilation, 76 (58%) vasopressors and 11 (8%) dialysis; 15 (11%) patients were treated with chemotherapy and 6 (5%), radiation therapy. Thirty-eight (29%) patients had end-of-life decisions. ICU and hospital mortality were 43% and 60%, respectively. Multivariable analysis identified three independent determinants of hospital mortality: airway obstruction/infiltration by cancer [OR = 2.87 (1.34–8.13), p < 0.001], number of organ failures [OR = 1.91 (1.01–2.74), p = 0.047] and performance status 3–4 before admission [OR = 2.90 (0.94–8.95), p = 0.065]. Conclusions: Improved survival in overall ICU cancer patients extends to patients with lung cancer, including those needing mechanical ventilation. Interestingly, the characteristics of the cancer are not associated with the outcome and should not be the grounds for the ICU decision making. Mortality is increased with the number of organ dysfunctions, in particular when respiratory failure is due to cancer progression. No significant financial relationships to disclose.

Methicillin-resistant Staphylococcus aureus prolongs intensive care unit stay in ventilator-associated pneumonia, despite initially appropriate antibiotic therapy

To determine the impact of methicillin-resistant Staphylococcus aureus (MRSA) on length of stay in the intensive care unit (ICU) for patients with ventilator-associated pneumonia (VAP) and to control for the effect of initially inappropriate antibiotic treatment on outcomes by focusing only on persons who were given appropriate antibiotic therapy for their infection. Retrospective analysis of pooled, patient-level data from multiple clinical trials in VAP. Multiple ICUs in France. Persons with bronchoscopically confirmed VAP due to either MRSA or methicillin-susceptible S. aureus (MSSA) and who received initially appropriate antibiotic treatment. All persons with MRSA VAP received vancomycin (15 mg/kg intravenously, twice daily). None. We compared patients with MRSA VAP to persons with MSSA VAP. ICU length of stay represented the primary end point and ICU-free days served as a secondary end point. We recorded information regarding multiple confounders, including demographics, reasons for ICU admission and mechanical ventilation (MV), severity of illness at both ICU admission and time of diagnosis of VAP, and duration of mechanical ventilation before and following the onset of VAP. The final cohort included 107 patients, and one third of cases were due to MRSA. Despite receiving initially appropriate antibiotic treatment, median ICU length of stay was significantly longer for persons with MRSA infection (33 days vs. 22 days; p=.047). The median number of ICU-free days was concomitantly lower in MRSA VAP (0 days vs. 5 days; p=.011). Survival analysis employing a Cox proportional hazards model identified several predictors of remaining in the ICU: Pao2/Fio2 ratio at diagnosis of VAP, duration of MV before VAP, duration of MV after diagnosis of VAP, and reason for MV. Additionally, infection with MRSA as opposed MSSA doubled the probability of needing continued ICU care (hazard ratio, 2.08; 95% confidence interval, 1.09-3.95; p=.025). MRSA VAP independently prolongs the duration of ICU hospitalization, and in turn, increases overall costs, even for patients initially given appropriate antibiotic treatment. Confronting the adverse impact of MRSA will require efforts that address more than the initial antibiotic prescription.

Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death.

More than one-half the deaths of patients admitted to intensive care units (ICUs) occur after a decision to forgo life-sustaining therapy (DFLST). Although DFLSTs typically occur in patients with severe comorbidities and intractable acute medical disorders, other factors may influence the likelihood of DFLSTs. The objectives of this study were to describe the factors and mortality associated with DFLSTs and to evaluate the potential independent impact of DFLSTs on hospital mortality. Prospective multicenter 2-year study in six ICUs in France. The 1,698 patients admitted to the participating ICUs during the study period, including 295 (17.4%) with DFLSTs. The impact of DFLSTs on hospital mortality was evaluated using a model that incorporates changes in daily logistic organ dysfunction scores during the first ICU week. Univariate predictors of death included demographic factors (age, gender), comorbidities, reasons for ICU admission, severity scores at ICU admission, and DFLSTs. In a stepwise Cox model five variables independently predicted mortality: good chronic health status (hazard ratio, 0.479), SAPS II score higher than 39 (2.05), chronic liver disease (1.463), daily logistic organ dysfunction score (1.357 per point), and DFLSTs (1.887). DFLSTs remain independently associated with death after adjusting on comorbidities and severity at ICU admission and within the first ICU week. This highlights the need for further clarifying the many determinants of DFLSTs and for routinely collecting DFLSTs in studies with survival as the outcome variable of interest.

Prognosis and outcome of 26 patients with systemic necrotizing vasculitis admitted to the intensive care unit.

To investigate presenting features, prognostic factors and outcomes of patients with systemic necrotizing vasculitis (SNV) admitted to the intensive care unit (ICU). We retrospectively reviewed the medical records of all 210 SNV patients followed in our university hospital and admitted to the ICU between 1982 and 2001, with respect to clinical features, ICU disease severity scores (APACHE II and SAPS II), the Birmingham vasculitis activity score (BVAS), the five-factors score (FFS) and outcomes. Twenty-six patients (16 men, 10 women) with a mean age of 46.3+/-16.5 yr were included. The reasons for ICU admission were: active SNV, 20 (77%); infection, 3 (12%); others, 3 (12%). SNV was diagnosed in 11 (42%) patients in the ICU. The mean APACHE II and SAPS II scores were significantly higher for patients who died in the ICU (P = 0.01 and P = 0.01 respectively). After a mean follow-up of 31.4+/-29.2 months, the overall mortality rate was 39% (10 patients). Among patients admitted to the ICU with active SNV, BVAS calculated at ICU admission was significantly higher for non-survivors at the end of follow-up (26.9+/-13.0 vs 14.7+/-4.6, P = 0.02). The main reason for admitting SNV patients to the ICU was active vasculitis, which was often the first manifestation of SNV and led to its diagnosis. ICU disease severity scores at admission were associated with mortality in the ICU but did not predict long-term outcome, unlike BVAS, which accurately predicted long-term outcome but not ICU prognosis for patients admitted to the ICU with active SNV.

Impact of neutropenia duration on short-term mortality in neutropenic critically ill cancer patients.

To identify predictors of 30-day mortality and to assess the impact of neutropenia recovery (NR) on 30-day mortality in critically ill cancer patients (CICPs). Retrospective review of the medical records of the 102 neutropenic CICPs admitted to a medical intensive care unit (ICU) over a 10-year period. None. Malignancies consisted of acute leukemia (n=42), lymphoma (n=23), myeloma (n=28), and solid tumors (n=9). Reasons for ICU admission were acute respiratory failure (n=81), shock (n=58), acute renal failure (n=33), and coma (n=13). Seventy patients needed conventional mechanical ventilation (MV) and 21 noninvasive MV, 67 vasopressor agents, and 28 dialysis. Sixty-two patients experienced NR during their ICU stay. In a multivariate logistic regression model, 30-day mortality was higher in patients with acute respiratory or renal failure and lower in patients with NR (OR, 0.09 [0.01-0.86]). This model assumed that patients who experienced NR in the ICU were merely these who did not die early in the ICU. To take into account the effect of time to occurrence of NR on time to death we secondarily used a Cox model including neutropenia duration and NR as time-dependent variables. In this second model, the only significant predictors of 30-day mortality were age, respiratory failure, renal failure, and coma. Organ failure but not disease progression or neutropenia duration affect 30-day mortality in neutropenic CICPs. ICU-acquired events might be modeled as time-dependent variables in a Cox model, rather than standard covariates in logistic regression models.

Pulmonary microvascular fat

To determine the effects of fat emboli on cardiopulmonary function in critically ill patients. A prospective study. Tertiary referral medical/surgical shock/trauma intensive care unit (ICU). A total of 51 critically ill medical and surgical (including acute trauma) patients who required supplemental oxygen (FIO2 of > or = 0.35) to maintain arterial blood oxyhemoglobin saturation of > or = 90% and who had 62 pulmonary artery catheters placed for patient care reasons. Pulmonary capillary blood samples were obtained via the pulmonary artery catheters in the "wedged position" at insertion and postinsertion at 8, 24, 48, and 72 hrs. Cytospun smears of the buffy coat aspirates of these samples were made and were stained with Oil Red-O for fat. One investigator, without knowledge of the patients' cardiopulmonary function, examined all smears and graded them 0 to 4+ for amount of fat. Fat scores were correlated with chest radiograph appearance, hemodynamic and respiratory parameters, complete blood cell counts with differential white blood cell counts, whether the patient was receiving lipid-containing parenteral nutrition, principal organ system failure, and reason for ICU admission. Samples from 27 pulmonary artery catheter insertions had no fat, 13 samples had low-grade (1+) episodic fat, and 22 samples had repeated episodes of > or = 2+ fat or isolated episodes of 4+ fat. There was a significant association between the amount of pulmonary microvascular fat and trauma as the reason for ICU admission. Of the other parameters, only chest compliance and body temperature showed unequivocal significant associations. These associations were opposite to the expected findings, but would support a conclusion that fat emboli did not cause the observed cardiopulmonary dysfunction. The inconsistent associations for the FIO2, PCO2, and mixed venous blood oxyhemoglobin saturation may be random events. Cardiopulmonary dysfunction commonly attributed to fat emboli is likely due to other causes.

Independent validation of APACHE II severity of illness score for predicting mortality in patients with breast cancer admitted to the intensive care unit.

To determine the validity and predictive accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system for severity of illness by comparing the actual hospital mortality with the predicted mortality for patients with breast cancer admitted to the intensive care unit (ICU). APACHE II scores were calculated based on retrospective evaluation of the medical records of 52 patients with breast cancer who received ICU care. The relationships between hospital mortality and APACHE II scores, number of sites of metastatic disease, duration of metastatic disease, number of chemotherapeutic regimens given for metastatic disease, presence of neutropenia or thrombocytopenia, age, reason for ICU admission, and length of ICU stay were assessed. Twenty-two patients (42%) died during the hospital stay during in which they were admitted to the ICU. Predicted mortality based on a logistic regression model using APACHE II scores was 21 patients (40%). APACHE II specificity was 87%; sensitivity was 54%. There were significant relationships between presence of metastatic disease, number of metastatic sites, reason for ICU admission, and length of ICU stay. Patients with more than two sites of metastatic disease and those with respiratory failure had particularly poor chances of survival. Regression analysis incorporating the number of sites of metastatic disease, reason for ICU admission (whether for a pulmonary or a cardiovascular problem), and APACHE II score suggested that APACHE II could predict hospital survival. This retrospective study showed that APACHE II scores were associated with hospital mortality in patients with breast cancer who were admitted to ICU. The number of metastatic sites and the type of major organ system failure were also associated with outcome. Regression analysis suggested that APACHE II scores were independently associated with survival outcome.

On-site Physician Staffing in a Community Hospital Intensive Care Unit

To determine whether on-site physician staffing changed test and procedure use and improved patient outcome in a community hospital intensive care unit (ICU), we studied all ICU admissions for matched periods before and after the staffing change. Compared with the 463 year-1 patients, the 491 year-2 patients were no more likely to receive life-support interventions (respirators, dialysis, or pacemakers), but had substantially more monitoring interventions, such as pulmonary artery catheters (22% v 2%, P less than .0001) and arterial catheters (9% v 0%, P less than .0001). After controlling for factors that predicted death (age, mental status at time of admission, reason for ICU admission), year-2 patients were significantly more likely to survive the ICU and subsequent hospital stay (P = .01). Nearly all of the improvement of survival rate took place among patients with intermediate likelihoods of death; this improved survival rate persisted at the 12-month follow-up (P = .01).