Impact of the COVID-19 Pandemic on the Outcomes of Patients Undergoing Oncological Surgeries: CORONAL Study.

BACKGROUND: The impact of coronavirus disease 2019 (COVID-19) on postoperative recovery from oncology surgeries should be understood for the clinical decision-making. Therefore, this study was designed to evaluate the postoperative cumulative 28-day mortality and the morbidity of surgical oncology patients during the COVID-19 pandemic. METHODS: This retrospective cohort study included patients consecutively admitted to intensive care units (ICU) of three centres for postoperative care of oncologic surgeries between March to June 2019 (first phase) and March to June 2020 (second phase). The primary outcome was cumulative 28-day postoperative mortality. Secondary outcomes were postoperative organic dysfunction and the incidence of clinical complications. Because of the possibility of imbalance between groups, adjusted analyses were performed: Cox proportional hazards model (primary outcome) and multiple logistic regression model (secondary outcomes). RESULTS: After screening 328 patients, 291 were included. The proportional hazard of cumulative 28-day mortality was higher in the second phase than that in the first phase in the Cox model, with the adjusted hazard ratio of 4.35 (95% confidence interval [CI] 2.15-8.82). The adjusted incidences of respiratory complications (odds ratio [OR] 5.35; 95% CI 1.42-20.11) and pulmonary infections (OR 1.53; 95% CI 1.08-2.17) were higher in the second phase. However, the adjusted incidence of other infections was lower in the second phase (OR 0.78; 95% CI 0.67-0.91). CONCLUSIONS: Surgical oncology patients who underwent postoperative care in the intensive care unit during the COVID-19 pandemic had higher hazard of 28-day mortality. Furthermore, these patients had higher odds of respiratory complications and pulmonary infections. Trials registration The study is registered in the Brazilian Registry of Clinical Trials under the code RBR-8ygjpqm, UTN code U1111-1293-5414.

Characteristics of critically ill patients with cancer associated with intensivist's perception of inappropriateness of ICU admission: A retrospective cohort study.

PURPOSE: Although admitting cancer patients to the ICU is no longer an issue, it may be valuable to identify patients perceived least likely to benefit from admission. Our objective was to investigate factors associated with potentially inappropriate ICU admission. METHODS: Retrospective cohort study of patients with cancer with unplanned ICU admission. We classified admissions as appropriate or potentially inappropriate according to Society of Critical Care Medicine guidelines. We used logistic regression model to assess factors associated with inappropriateness for ICU admission. RESULTS: From 3384 patients, 663 (19.6%) were classified as potentially inappropriate. They received more invasive mechanical ventilation (25.3% vs 12.5%, P < 0.001) and vasopressors (34.4% vs 30.1%, P = 0.034), had higher ICU [3 (2,6) vs 2 (1,4), P < 0.001] length-of-stay, higher ICU (32.7% vs 8.4%, P < 0.001), hospital (71.9% vs 21.3%, P < 0.001), and one-year mortality (97.6% vs 54.7%, P < 0.001) compared with those considered appropriate. Performance status impairment, more severe organ dysfunctions at admission, metastatic disease, and source of ICU admission were the characteristics associated with intensivist's perception of inappropriateness of ICU admission. CONCLUSIONS: These findings may help guide ICU admission policies and triage criteria for end-of-life discussions among hospitalized patients with cancer.

High-value care for critically ill oncohematological patients: what do we know thus far?

The number of patients with cancer requiring intensive care unit admission is increasing around the world. The improvement in the pathophysiological understanding of this group of patients, as well as the increasingly better and more targeted treatment options for their underlying disease, has led to a significant increase in their survival over the past three decades. Within the organizational concepts, it is necessary to know what adds value in the care of critical oncohematological patients. Practices in medicine that do not benefit patients and possibly cause harm are called low-value practices, while high-value practices are defined as high-quality care at relatively low cost. In this article, we discuss ten domains with high-value evidence in the care of cancer patients: (1) intensive care unit admission policies; (2) intensive care unit organization; (3) etiological investigation of hypoxemia; (4) management of acute respiratory failure; (5) management of febrile neutropenia; (6) urgent chemotherapy treatment in critically ill patients; (7) patient and family experience; (8) palliative care; (9) care of intensive care unit staff; and (10) long-term impact of critical disease on the cancer population. The disclosure of such policies is expected to have the potential to change health care standards. We understand that it is a lengthy process, and initiatives such as this paper are one of the first steps in raising awareness and beginning a discussion about high-value care in various health scenarios.

Long-term mortality of critically ill patients with cancer and delirium who survived to discharge: a retrospective cohort study.

PURPOSE: Delirium is common in critically ill patients and has been associated with lower short-term survival; however, its association with long-term survival has been scarcely evaluated and few studies have shown divergent results. METHODS: We conducted a retrospective cohort study of adult patients with cancer admitted to the intensive care unit (ICU) and discharged from hospital from January 2015 to December 2018. We considered delirium present if the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) result was positive. We assessed the association between delirium during ICU stay and long-term mortality (up to three years after discharge). We also assessed the association between delirium type (hypoactive, hyperactive, and mixed) with long-term mortality. RESULTS: We included 3,079 patients. Of these, 430 (14%) were considered delirious at some point during their ICU stay. Delirium was associated with one-year mortality after hospital discharge (hazard ratio [HR], 1.58; 95% confidence interval [CI], 1.36 to 1.83) after adjustment for potential confounders, but not with one to three year-mortality (HR, 0.92; 95% CI, 0.61 to 1.39). Hypoactive and mixed delirium were associated with one-year mortality (HR, 1.77; 95% CI, 1.46 to 2.14 and HR, 1.56; 95% CI, 1.21 to 2.00, respectively), but none of the delirium motor types was associated with one to three-year mortality. CONCLUSIONS: We observed that delirium during ICU stay was associated with increased one-year mortality, but was not with mortality after one year. This association was observed in hypoactive and mixed delirium types but not with hyperactive delirium.

RéSUMé: OBJECTIF: Le delirium est fréquent chez la patientèle gravement malade et a été associé à une survie réduite à court terme; son association avec la survie à long terme n'a cependant que très peu été évaluée et les rares études ont affiché des résultats divergents. MéTHODE: Nous avons mené une étude de cohorte rétrospective de patient·es adultes atteint·es de cancer admis·es à l'unité de soins intensifs (USI) et ayant reçu leur congé de l'hôpital entre janvier 2015 et décembre 2018. Nous avons considéré qu'un delirium était présent si le résultat de la Méthode d'évaluation de la confusion pour l'unité de soins intensifs (CAM-USI) était positif. Nous avons évalué l'association entre le delirium pendant le séjour aux soins intensifs et la mortalité à long terme (jusqu'à trois ans après le congé). Nous avons également évalué l'association entre le type de delirium (hypoactif, hyperactif et mixte) et la mortalité à long terme. RéSULTATS: Nous avons inclus 3079 patient·es. De ce nombre, 430 (14 %) personnes ont été considérées comme en delirium à un moment donné pendant leur séjour à l'USI. Le delirium était associé à la mortalité à un an après le congé de l'hôpital (rapport de risque [RR], 1,58; intervalle de confiance [IC] à 95%, 1,36 à 1,83) et après ajustement des données pour tenir compte des facteurs de confusion potentiels, mais pas à la mortalité d'un à trois ans après le congé (RR, 0,92; IC 95%, 0,61 à 1,39). Les deliriums hypoactif et mixte étaient associés à la mortalité à un an (RR, 1,77; IC 95 %, 1,46 à 2,14 et RR, 1,56; IC 95 %, 1,21 à 2,00, respectivement), mais aucun des types moteurs de delirium n'était associé à la mortalité d'un à trois ans. CONCLUSION: Nous avons observé qu'un delirium pendant le séjour à l'USI était associé à une augmentation de la mortalité à un an, mais pas à la mortalité après un an. Cette association a été observée dans les types de delirium hypoactif et mixte, mais pas avec le type hyperactif.

Attributable mortality due to nosocomial sepsis in Brazilian hospitals: a case-control study.

BACKGROUND: Nosocomial sepsis is a major healthcare issue, but there are few data on estimates of its attributable mortality. We aimed to estimate attributable mortality fraction (AF) due to nosocomial sepsis. METHODS: Matched 1:1 case-control study in 37 hospitals in Brazil. Hospitalized patients in participating hospitals were included. Cases were hospital non-survivors and controls were hospital survivors, which were matched by admission type and date of discharge. Exposure was defined as occurrence of nosocomial sepsis, defined as antibiotic prescription plus presence of organ dysfunction attributed to sepsis without an alternative reason for organ failure; alternative definitions were explored. Main outcome measurement was nosocomial sepsis-attributable fractions, estimated using inversed-weight probabilities methods using generalized mixed model considering time-dependency of sepsis occurrence. RESULTS: 3588 patients from 37 hospitals were included. Mean age was 63 years and 48.8% were female at birth. 470 sepsis episodes occurred in 388 patients (311 in cases and 77 in control group), with pneumonia being the most common source of infection (44.3%). Average AF for sepsis mortality was 0.076 (95% CI 0.068-0.084) for medical admissions; 0.043 (95% CI 0.032-0.055) for elective surgical admissions; and 0.036 (95% CI 0.017-0.055) for emergency surgeries. In a time-dependent analysis, AF for sepsis rose linearly for medical admissions, reaching close to 0.12 on day 28; AF plateaued earlier for other admission types (0.04 for elective surgery and 0.07 for urgent surgery). Alternative sepsis definitions yield different estimates. CONCLUSION: The impact of nosocomial sepsis on outcome is more pronounced in medical admissions and tends to increase over time. The results, however, are sensitive to sepsis definitions.

Association of appropriateness for ICU admission with resource use, organ support and long-term survival in critically ill cancer patients.

We aimed to evaluate the characteristics, resource use and outcomes of critically ill patients with cancer according to appropriateness of ICU admission. This was a retrospective cohort study of patients with cancer admitted to ICU from January 2017 to December 2018. Patients were classified as appropriate, potentially inappropriate, or inappropriate for ICU admission according to the Society of Critical Care Medicine guidelines. The primary outcome was ICU length of stay (LOS). Secondary outcomes were one-year, ICU, and hospital mortality, hospital LOS and utilization of ICU organ support. We used logistic regression and competing risk models accounting for relevant confounders in primary outcome analyses. From 6700 admitted patients, 5803 (86.6%) were classified as appropriate, 683 (10.2%) as potentially inappropriate and 214 (3.2%) as inappropriate for ICU admission. Potentially inappropriate and inappropriate ICU admissions had lower likelihood of being discharged from the ICU than patients with appropriate ICU admission (sHR 0.55, 95% CI 0.49-0.61 and sHR 0.65, 95% CI 0.53-0.81, respectively), and were associated with higher 1-year mortality (OR 6.39, 95% CI 5.60-7.29 and OR 11.12, 95% CI 8.33-14.83, respectively). Among patients with appropriate, potentially inappropriate, and inappropriate ICU admissions, ICU mortality was 4.8%, 32.6% and 35.0%, and in-hospital mortality was 12.2%, 71.6% and 81.3%, respectively (p < 0.01). Use of organ support was more common and longer among patients with potentially inappropriate ICU admission. The findings of our study suggest that inappropriateness for ICU admission among patients with cancer was associated with higher resource use in ICU and higher one-year mortality among ICU survivors.

Short-term survival of patients with advanced pancreatic cancer admitted to intensive care unit: a retrospective cohort study.

Background: Little is known about the outcomes of patients with advanced pancreatic cancer admitted to the intensive care unit (ICU) due to medical complications. We designed a study to evaluate their short-term (30-day) survival, predictors of short-term survival and chances of additional chemotherapy. Methods: We reviewed all patients with advanced (stage III or IV) pancreatic adenocarcinoma admitted to an ICU in a dedicated Brazilian cancer centre from 2009 to 2018 due to medical reasons. We fitted multivariate regression models to identify predictors of 30-day survival and additional systemic chemotherapy. Results: The study population consisted of 171 patients. Ninety-four patients (55.0%) had Eastern Cooperative Oncology Group (ECOG) performance status 2-4 and 146 (85.4%) had metastatic disease. Most patients (N = 75; 43.9%) were admitted to the ICU during first-line treatment. Median overall survival was 32 days (95% confidence interval (95% CI): 20-49). Survival rate at 30 days was 50.6%. ECOG performance status 2-4 was the only variable associated with lower probability of survival at 30 days in multivariate analysis (odds ratio: 0.28; 95% CI: 0.14-0.54; p < 0.001). Overall, 58 patients (33.9%) received additional chemotherapy and among all patients, 13.5% experienced clinical benefit from this treatment. Conclusion: Patients with advanced pancreatic cancer admitted to the ICU for medical reasons have a dismal prognosis. Early palliative care and refined tools to establish those who would benefit from an ICU trial could help improve patients' care.

IMPACTO-MR: a Brazilian nationwide platform study to assess infections and multidrug resistance in intensive care units. / IMPACTO-MR: um estudo brasileiro de plataforma nacional para avaliar infecções e multirresistência em unidades de terapia intensiva.

OBJECTIVE: To describe the IMPACTO-MR, a Brazilian nationwide intensive care unit platform study focused on the impact of health care-associated infections due to multidrug-resistant bacteria. METHODS: We described the IMPACTO-MR platform, its development, criteria for intensive care unit selection, characterization of core data collection, objectives, and future research projects to be held within the platform. RESULTS: The core data were collected using the Epimed Monitor System® and consisted of demographic data, comorbidity data, functional status, clinical scores, admission diagnosis and secondary diagnoses, laboratory, clinical, and microbiological data, and organ support during intensive care unit stay, among others. From October 2019 to December 2020, 33,983 patients from 51 intensive care units were included in the core database. CONCLUSION: The IMPACTO-MR platform is a nationwide Brazilian intensive care unit clinical database focused on researching the impact of health care-associated infections due to multidrug-resistant bacteria. This platform provides data for individual intensive care unit development and research and multicenter observational and prospective trials.

OBJETIVO: Descrever o IMPACTO-MR, um estudo brasileiro de plataforma nacional em unidades de terapia intensiva focado no impacto das infecções por bactérias multirresistentes relacionadas à assistência à saúde. MÉTODOS: Descrevemos a plataforma IMPACTO-MR, seu desenvolvimento, critérios para seleção das unidades de terapia intensiva, caracterização da coleta de dados, objetivos e projetos de pesquisa futuros a serem realizados na plataforma. RESULTADOS: Os dados principais foram coletados por meio do Epimed Monitor System® e consistiram em dados demográficos, dados de comorbidades, estado funcional, escores clínicos, diagnóstico de internação e diagnósticos secundários, dados laboratoriais, clínicos e microbiológicos e suporte de órgãos durante a internação na unidade de terapia intensiva, entre outros. De outubro de 2019 a dezembro de 2020, 33.983 pacientes de 51 unidades de terapia intensiva foram incluídos no banco de dados principal. CONCLUSÃO: A plataforma IMPACTO-MR é um banco de dados clínico brasileiro de unidades de terapia intensiva focado na pesquisa do impacto das infecções por bactérias multirresistentes relacionadas à assistência à saúde. Essa plataforma fornece dados para o desenvolvimento e pesquisa de unidades de terapia intensiva individuais e ensaios clínicos observacionais e prospectivos multicêntricos.

Impact of intensive care unit admission during handover on mortality: propensity matched cohort study.

OBJECTIVE: To investigate the impact of intensive care unit admission during medical handover on mortality. METHODS: Post-hoc analysis of data extracted from a prior study aimed at addressing the impacts of intensive care unit readmission on clinical outcomes. This retrospective, single-center, propensity-matched cohort study was conducted in a 41-bed general open-model intensive care unit. Patients were assigned to one of two cohorts according to time of intensive care unit admission: Handover Group (intensive care unit admission between 6:30 am and 7:30 am or 6:30 pm and 7:30 pm) or Control Group (intensive care unit admission between 7:31 am and 6:29 pm or 7:31 pm and 6:29 am). Patients in the Handover Group were propensity-matched to patients in the Control Group at a 1:2 ratio. RESULTS: A total of 6,650 adult patients were admitted to the intensive care unit between June 1st 2013 and May 31st 2015. Following exclusion of non-eligible participants, 5,779 patients (389; 6.7% and 5,390; 93.3%, Handover and Control Group) were deemed eligible for propensity score matching. Of these, 1,166 were successfully matched (389; 33.4% and 777; 66.6%, Handover and Control Group). Following propensity-score matching, intensive care unit admission during handover was not associated with increased risk of intensive care unit (OR: 1.40; 95%CI: 0.92-2.11; p=0.113) or in-hospital (OR: 1.23; 95%CI: 0.85-1.75; p=0.265) mortality. CONCLUSION: Intensive care unit admission during medical handover did not affect in-hospital mortality in this propensity-matched, single-center cohort study.

Organizational factors associated with adherence to low tidal volume ventilation: a secondary analysis of the CHECKLIST-ICU database.

BACKGROUND: Survival benefit from low tidal volume (VT) ventilation (LTVV) has been demonstrated for patients with acute respiratory distress syndrome (ARDS), and patients not having ARDS could also benefit from this strategy. Organizational factors may play a role on adherence to LTVV. The present study aimed to identify organizational factors with an independent association with adherence to LTVV. METHODS: Secondary analysis of the database of a multicenter two-phase study (prospective cohort followed by a cluster-randomized trial) performed in 118 Brazilian intensive care units. Patients under mechanical ventilation at day 2 were included. LTVV was defined as a VT ≤ 8 ml/kg PBW on the second day of ventilation. Data on the type and number of beds of the hospital, teaching status, nursing, respiratory therapists and physician staffing, use of structured checklist, and presence of protocols were tested. A multivariable mixed-effect model was used to assess the association between organizational factors and adherence to LTVV. RESULTS: The study included 5719 patients; 3340 (58%) patients received LTVV. A greater number of hospital beds (absolute difference 7.43% [95% confidence interval 0.61-14.24%]; p = 0.038), use of structured checklist during multidisciplinary rounds (5.10% [0.55-9.81%]; p = 0.030), and presence of at least one nurse per 10 patients during all shifts (17.24% [0.85-33.60%]; p = 0.045) were the only three factors that had an independent association with adherence to LTVV. CONCLUSIONS: Number of hospital beds, use of a structured checklist during multidisciplinary rounds, and nurse staffing are organizational factors associated with adherence to LTVV. These findings shed light on organizational factors that may improve ventilation in critically ill patients.

Bundle of Coated Devices to Reduce Nosocomial Infections in the Intensive Care Unit. CRITIC Pilot Randomized Controlled Trial.

Rationale: Coated devices may reduce biofilm formation and reduce the occurrence of device-related infections in critically ill patients. A bundle of coated devices (an endotracheal tube [ETT], central venous catheter [CVC], and urinary catheter [UC]) simultaneously inserted may optimize benefits of coated devices in patients with the most severe illness.Objectives: To assess the feasibility of a randomized controlled trial on simultaneous insertion of gold/silver/palladium-coated devices versus uncoated devices in severely ill patients, which required sequential insertion of all three devices (an ETT, CVC, and UC) for support in the intensive care unit (ICU).Methods: This was a multicenter randomized controlled pilot trial. Patients who required simultaneous insertion of an ETT, CVC, and UC were randomized to treatment with coated versus uncoated devices, which were used as necessary for up to 28 days. The primary endpoint was feasibility, defined as the trial being able to enroll enough participants to have the sample size necessary for its secondary primary endpoint (estimating sepsis incidence in this population) in less than 1 year and for estimating the number of admitted patients who require simultaneous insertion of all three devices. Secondary endpoints included the incidence of sepsis and device-associated infections (ventilator-associated pneumonia, catheter-related bloodstream infection, and catheter-related urinary-tract infection) within each group as well as the number of days alive and free of antibiotics during the ICU stay. All events were adjudicated.Results: One hundred and three patients (48 in the coated-device group and 55 in the uncoated-device group) were included in the per-protocol analysis. The inclusion period was 8 months. There were 13 septic events in each group (26 in total), with an approximate incidence of sepsis of 32.3 (95% credible interval [CrI], 22.4-44.9) per 100 patient-days. The overall incidences of ventilator-associated pneumonia, catheter-related urinary-tract infection, and catheter-related bloodstream infection were 15.2 (95% CrI, 7.8-26.4), 6.3 (95% CrI, 2.4-13.7), and 7.9 (95% CrI, 3.6-15.1) per 1,000 patient-days, and incidence rates were not statistically different between groups. Patients in the coated-device group had more days alive and free of antibiotics in the ICU (28.97 d vs. 19.62 d per 100 patient-days; mean ratio, 1.48; 95% CrI, 1.16-1.89).Conclusions: Use of a bundle of coated devices as the initial treatment for of severely ill patients is feasible. Coated devices may be associated with more days alive and free of antibiotics.Clinical trial registered with www.clinicaltrials.gov (NCT03868241).

Procalcitonin Clearance at 24, 48, 72, and 96 Hours and Mortality in Patients With Cancer and Sepsis: A Retrospective Cohort Study.

INTRODUCTION: Previous studies have evaluated procalcitonin clearance (PCTc) as a marker of sepsis severity but at different time points and cutoffs. We aimed to assess the predictive performance of PCTc at different time points of sepsis management in patients with cancer. METHODS: This retrospective cohort study included patients with cancer admitted to an intensive care unit between 2013 and 2016. We calculated PCTc at 24, 48, 72, and 96 hours after admission. Its predictive performance for hospital and 90-day mortality was analyzed with receiver operating characteristic curves and areas under the curves (AUCs). Sensitivity and specificity were calculated for different time points using different cutoffs. RESULTS: We included 301 patients. Areas under the curves ranged from 0.62 for PCTc at 24 hours to 0.68 for PCTc at 72 and 96 hours for hospital mortality prediction, and from 0.61 for PCTc at 24 hours to 0.68 for PCTc at 72 hours for 90-day mortality prediction. For hospital mortality prediction, PCTc at 72 hours ≤80% showed the best sensitivity (96.0%; 95% confidence interval [CI]: 90.8%-98.7%), and PCTc at 96 hours ≤50% showed the best specificity (70.7%; 95% CI: 54.5%-83.9%). CONCLUSIONS: Procalcitonin clearance at 24, 48, 72, and 96 hours poorly predicted hospital and 90-day mortality. Therefore, daily PCT measurement should not be used to predict mortality for patients with cancer and sepsis.

Organizational factors associated with target sedation on the first 48 h of mechanical ventilation: an analysis of checklist-ICU database.

BACKGROUND: Although light sedation levels are associated with several beneficial outcomes for critically ill patients on mechanical ventilation, the majority of patients are still deeply sedated. Organizational factors may play a role on adherence to light sedation levels. We aimed to identify organizational factors associated with a moderate to light sedation target on the first 48 h of mechanical ventilation, as well as the association between early achievement of within-target sedation and mortality. METHODS: This study is a secondary analysis of a multicenter two-phase study (prospective cohort followed by a cluster-randomized controlled trial) performed in 118 Brazilian ICUs. We included all critically ill patients who were on mechanical ventilation 48 h after ICU admission. A moderate to light level of sedation or being alert and calm (i.e., the Richmond Agitation-Sedation Scale of - 3 to 0) was the target for all patients on mechanical ventilation during the study period. We collected data on the type of hospital (public, private, profit and private, nonprofit), hospital teaching status, nursing and physician staffing, and presence of sedation, analgesia, and weaning protocols. We used multivariate random-effects regression with ICU and study phase as random-effects and correction for patients' Simplified Acute Physiology Score 3 and Sequential Organ Failure Assessment. We also performed a mediation analysis to explore whether sedation level was just a mediator of the association between organizational factors and mortality. RESULTS: We included 5719 patients. Only 1710 (29.9%) were on target sedation levels on day 2. Board-certified intensivists on the morning and afternoon shifts were associated with an adequate sedation level on day 2 (OR = 2.43; CI 95%, 1.09-5.38). Target sedation levels were associated with reduced hospital mortality (OR = 0.63; CI 95%, 0.55-0.72). Mediation analysis also suggested such an association, but did not suggest a relationship between the physician staffing model and hospital mortality. CONCLUSIONS: Board-certified intensivists on morning and afternoon shifts were associated with an increased number of patients achieving lighter sedation goals. These findings reinforce the importance of organizational factors, such as intensivists' presence, as a modifiable quality improvement target.

Early Versus Late Initiation of Renal Replacement Therapy in Critically Ill Patients: Systematic Review and Meta-Analysis.

OBJECTIVE: Early initiation of renal replacement therapy (RRT) effect on survival and renal recovery of critically ill patients is still uncertain. We aimed to systematically review current evidence comparing outcomes of early versus late initiation of RRT in critically ill patients. METHODS: We searched the Medline (via Pubmed), LILACS, Science Direct, and CENTRAL databases from inception until November 2016 for randomized clinical trials (RCTs) or observational studies comparing early versus late initiation of RRT in critically ill patients. The primary outcome was mortality. Duration of mechanical ventilation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and renal function recovery were secondary outcomes. Meta-analysis and trial sequential analysis (TSA) were used for the primary outcome. RESULTS: Sixty-two studies were retrieved and analyzed, including 11 RCTs. There was no difference in mortality between early and late initiation of RRT among RCTs (odds ratio [OR] = 0.78; 95% confidence interval [CI]: 0.52-1.19; I2 = 63.1%). Trial sequential analysis of mortality across all RCTs achieved futility boundaries at both 1% and 5% type I error rates, although a subgroup analysis of studies including only acute kidney injury patients was not conclusive. There was also no difference in time on mechanical ventilation, ICU and hospital LOS, or renal recovery among studies. Early initiation of RRT was associated with reduced mortality among prospective (OR = 0.69; 95% CI: 0.49-0.96; I2 = 85.9%) and retrospective (OR = 0.61; 95% CI: 0.41-0.92; I2 = 90.9%) observational studies, both with substantial heterogeneity. However, subgroup analysis excluding low-quality observational studies did not achieve statistical significance. CONCLUSION: Pooled analysis of randomized trials indicates early initiation of RRT is not associated with lower mortality rates. The potential benefit of reduced mortality associated with early initiation of RRT was limited to low-quality observational studies.

Oncologists' and Intensivists' Attitudes Toward the Care of Critically Ill Patients with Cancer.

BACKGROUND: Patients with cancer represent an important proportion of intensive care unit (ICU) admissions. Oncologists and intensivists have distinct knowledge backgrounds, and conflicts about the appropriate management of these patients may emerge. METHODS: We surveyed oncologists and intensivists at 2 academic cancer centers regarding their management of 2 hypothetical patients with different cancer types (metastatic pancreatic cancer and metastatic breast cancer with positive receptors for estrogen, progesterone, and HER-2) who develop septic shock and multiple organ failure. RESULTS: Sixty intensivists and 46 oncologists responded to the survey. Oncologists and intensivists similarly favored withdrawal of life support measures for the patient with pancreatic cancer (33/46 [72%] vs 48/60 [80%], P = .45). On the other hand, intensivists favored more withdrawal of life support measures for the patient with breast cancer compared to oncologists (32/59 [54%] vs 9/44 [21%], P < .001). In the multinomial logistic regression, the oncology specialists were more likely to advocate for a full-code status for the patient with breast cancer (OR = 5.931; CI 95%, 1.762-19.956; P = .004). CONCLUSIONS: Oncologists and intensivists share different views regarding life support measures in critically ill patients with cancer. Oncologists tend to focus on the cancer characteristics, whereas intensivists focus on multiple organ failure when weighing in on the same decisions. Regular meetings between oncologists and intensivists may reduce possible conflicts regarding the critical care of patients with cancer.