Effect of Flexible Family Visitation on Delirium Among Patients in the Intensive Care Unit: The ICU Visits Randomized Clinical Trial.

Importance: The effects of intensive care unit (ICU) visiting hours remain uncertain. Objective: To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium. Design, Setting and Participants: Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018. Interventions: Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation. Main Outcomes and Measures: Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory). Results: Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation. Conclusions and Relevance: Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium. Trial Registration: ClinicalTrials.gov Identifier: NCT02932358.

Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study.

INTRODUCTION: Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. The aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV). METHODS: A secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality. RESULTS: A total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P = 0.001) despite similar PaO2/FiO2 ratios and acute respiratory distress syndrome (ARDS) severity. In a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% CI, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; CI 95%, 1.00 to 1.04), severe ARDS (OR 1.44; CI 95%, 1.09 to 1.91) and deep sedation (OR 2.36; CI 95%, 1.31 to 4.25) were independently associated with increased hospital mortality. CONCLUSIONS: Early deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.

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.

Characteristics and outcomes of patients with cancer requiring admission to intensive care units: a prospective multicenter study.

OBJECTIVE: To evaluate the characteristics and outcomes of patients with cancer admitted to several intensive care units. Knowledge on patients with cancer requiring intensive care is mostly restricted to single-center studies. DESIGN: : Prospective, multicenter, cohort study. SETTING: Intensive care units from 28 hospitals in Brazil. PATIENTS: A total of 717 consecutive patients included over a 2-mo period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 667 (93%) patients with solid tumors and 50 (7%) patients had hematologic malignancies. The main reasons for intensive care unit admission were postoperative care (57%), sepsis (15%), and respiratory failure (10%). Overall hospital mortality rate was 30% and was higher in patients admitted because of medical complications (58%) than in emergency (37%) and scheduled (11%) surgical patients (p < .001). Adjusting for covariates other than the type of admission, the number of hospital days before intensive care unit admission (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.01-1.37), higher Sequential Organ Failure Assessment scores (OR, 1.25; 95% CI, 1.17-1.34), poor performance status (OR, 3.40; 95% CI, 2.19 -5.26), the need for mechanical ventilation (OR, 2.42; 95% CI, 1.51-3.87), and active underlying malignancy in recurrence or progression (OR, 2.42; 95% CI, 1.51-3.87) were associated with increased hospital mortality in multivariate analysis. CONCLUSIONS: This large multicenter study reports encouraging survival rates for patients with cancer requiring intensive care. In these patients, mortality was mostly dependent on the severity of organ failures, performance status, and need for mechanical ventilation rather than cancer-related characteristics, such as the type of malignancy or the presence of neutropenia.

High-value care for critically ill oncohematological patients: what do we know thus far? / Cuidados de alto valor para pacientes oncohematológicos graves: o que sabemos até agora?

ABSTRACT 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.

RESUMO O número de pacientes oncológicos com necessidade de internação em unidades de terapia intensiva está aumentando em todo o mundo. A maior compreensão fisiopatológica desse grupo de pacientes, bem como opções de tratamento cada vez melhores e mais direcionadas à doença subjacente, tem levado a um aumento significativo da sobrevida nas últimas três décadas. Dentro dos conceitos organizacionais é necessário saber o que agrega valor ao cuidado de pacientes onco-hematológicos graves. As práticas terapêuticas não benéficas aos pacientes e possivelmente causadoras de danos são chamadas práticas de baixo valor, enquanto as práticas de alto valor são definidas como cuidados de alta qualidade a um custo relativamente baixo. Neste artigo discutimos dez domínios com evidências de alto valor no cuidado de pacientes com câncer: (1) políticas de internação na unidade de terapia intensiva; (2) organização da unidade de terapia intensiva; (3) investigação etiológica da hipoxemia; (4) manejo da insuficiência respiratória aguda; (5) manejo da neutropenia febril; (6) tratamento quimioterápico de urgência em pacientes graves; (7) experiência do paciente e da família; (8) cuidados paliativos; (9) cuidados com a equipe da unidade de terapia intensiva; e (10) impacto a longo prazo da doença grave na população oncológica. Esperase que a divulgação dessas políticas traga mudanças aos padrões atuais do cuidado em saúde. Entendemos que é um processo longo, e iniciativas como o presente artigo são um dos primeiros passos para aumentar a conscientização e possibilitar discussão sobre cuidados de alto valor em vários cenários de saúde.

Outcomes in Critically Ill Patients with Cancer-Related Complications.

INTRODUCTION: Cancer patients are at risk for severe complications related to the underlying malignancy or its treatment and, therefore, usually require admission to intensive care units (ICU). Here, we evaluated the clinical characteristics and outcomes in this subgroup of patients. MATERIALS AND METHODS: Secondary analysis of two prospective cohorts of cancer patients admitted to ICUs. We used multivariable logistic regression to identify variables associated with hospital mortality. RESULTS: Out of 2,028 patients, 456 (23%) had cancer-related complications. Compared to those without cancer-related complications, they more frequently had worse performance status (PS) (57% vs 36% with PS≥2), active malignancy (95% vs 58%), need for vasopressors (45% vs 34%), mechanical ventilation (70% vs 51%) and dialysis (12% vs 8%) (P<0.001 for all analyses). ICU (47% vs. 27%) and hospital (63% vs. 38%) mortality rates were also higher in patients with cancer-related complications (P<0.001). Chemo/radiation therapy-induced toxicity (6%), venous thromboembolism (5%), respiratory failure (4%), gastrointestinal involvement (3%) and vena cava syndrome (VCS) (2%) were the most frequent cancer-related complications. In multivariable analysis, the presence of cancer-related complications per se was not associated with mortality [odds ratio (OR) = 1.25 (95% confidence interval, 0.94-1.66), P = 0.131]. However, among the individual cancer-related complications, VCS [OR = 3.79 (1.11-12.92), P = 0.033], gastrointestinal involvement [OR = 3.05 (1.57-5.91), P = <0.001] and respiratory failure [OR = 1.96(1.04-3.71), P = 0.038] were independently associated with in-hospital mortality. CONCLUSIONS: The prognostic impact of cancer-related complications was variable. Although some complications were associated with worse outcomes, the presence of an acute cancer-related complication per se should not guide decisions to admit a patient to ICU.

Effects of Organizational Characteristics on Outcomes and Resource Use in Patients With Cancer Admitted to Intensive Care Units.

PURPOSE: To investigate the impact of organizational characteristics and processes of care on hospital mortality and resource use in patients with cancer admitted to intensive care units (ICUs). PATIENTS AND METHODS: We performed a retrospective cohort study of 9,946 patients with cancer (solid, n = 8,956; hematologic, n = 990) admitted to 70 ICUs (51 located in general hospitals and 19 in cancer centers) during 2013. We retrieved patients' clinical and outcome data from an electronic ICU quality registry. We surveyed ICUs regarding structure, organization, staffing patterns, and processes of care. We used mixed multivariable logistic regression analysis to identify characteristics associated with hospital mortality and efficient resource use in the ICU. RESULTS: Median number of patients with cancer per center was 110 (interquartile range, 58 to 154), corresponding to 17.9% of all ICU admissions. ICU and hospital mortality rates were 15.9% and 25.4%, respectively. After adjusting for relevant patient characteristics, presence of clinical pharmacists in the ICU (odds ratio [OR], 0.67; 95% CI, 0.49 to 0.90), number of protocols (OR, 0.92; 95% CI, 0.87 to 0.98), and daily meetings between oncologists and intensivists for care planning (OR, 0.69; 95% CI, 0.52 to 0.91) were associated with lower mortality. Implementation of protocols (OR, 1.52; 95% CI, 1.11 to 2.07) and meetings between oncologists and intensivists (OR, 4.70; 95% CI, 1.15 to 19.22) were also independently associated with more efficient resource use. Neither admission to ICUs in cancer centers compared with general hospitals nor annual case volume had an impact on mortality or resource use. CONCLUSION: Organizational aspects, namely the implementation of protocols and presence of clinical pharmacists in the ICU, and close collaboration between oncologists and ICU teams are targets to improve mortality and resource use in critically ill patients with cancer.

The reality of patients requiring prolonged mechanical ventilation: a multicenter study.

OBJECTIVE: The number of patients who require prolonged mechanical ventilation increased during the last decade, which generated a large population of chronically ill patients. This study established the incidence of prolonged mechanical ventilation in four intensive care units and reported different characteristics, hospital outcomes, and the impact of costs and services of prolonged mechanical ventilation patients (mechanical ventilation dependency ≥ 21 days) compared with non-prolonged mechanical ventilation patients (mechanical ventilation dependency < 21 days). METHODS: This study was a multicenter cohort study of all patients who were admitted to four intensive care units. The main outcome measures were length of stay in the intensive care unit, hospital, complications during intensive care unit stay, and intensive care unit and hospital mortality. RESULTS: There were 5,287 admissions to the intensive care units during study period. Some of these patients (41.5%) needed ventilatory support (n = 2,197), and 218 of the patients met criteria for prolonged mechanical ventilation (9.9%). Some complications developed during intensive care unit stay, such as muscle weakness, pressure ulcers, bacterial nosocomial sepsis, candidemia, pulmonary embolism, and hyperactive delirium, were associated with a significantly higher risk of prolonged mechanical ventilation. Prolonged mechanical ventilation patients had a significant increase in intensive care unit mortality (absolute difference = 14.2%, p < 0.001) and hospital mortality (absolute difference = 19.1%, p < 0.001). The prolonged mechanical ventilation group spent more days in the hospital after intensive care unit discharge (26.9 ± 29.3 versus 10.3 ± 20.4 days, p < 0.001) with higher costs. CONCLUSION: The classification of chronically critically ill patients according to the definition of prolonged mechanical ventilation adopted by our study (mechanical ventilation dependency ≥ 21 days) identified patients with a high risk for complications during intensive care unit stay, longer intensive care unit and hospital stays, high death rates, and higher costs.

Sepsis-Associated Outcomes in Critically Ill Patients with Malignancies.

RATIONALE: Sepsis is a major cause of mortality among critically ill patients with cancer. Information about clinical outcomes and factors associated with increased risk of death in these patients is necessary to help physicians recognize those patients who are most likely to benefit from ICU therapy and identify possible targets for intervention. OBJECTIVES: In this study, we evaluated cancer patients with sepsis chosen from a multicenter prospective study to characterize their clinical characteristics and to identify independent risk factors associated with hospital mortality. METHODS: Subgroup analysis of a multicenter prospective cohort study conducted in 28 Brazilian intensive care units (ICUs) to evaluate adult cancer patients with severe sepsis and septic shock. We used logistic regression to identify variables associated with hospital mortality. MEASUREMENTS AND MAIN RESULTS: Of the 717 patients admitted to the participating ICUs, 268 (37%) had severe sepsis (n = 142, 53%) or septic shock (n = 126, 47%). These patients comprised the population of the present study. The mean score on the third version of the Simplified Acute Physiology Score was 62.9 ± 17.7 points, and the median Sequential Organ Failure Assessment score was 9 (7-12) points. The most frequent sites of infection were the lungs (48%), intraabdominal region (25%), bloodstream as primary infection (19%), and urinary tract (17%). Half of the patients had microbiologically proven infections, and Gram-negative bacteria were the most common pathogens causing sepsis (31%). ICU and hospital mortality rates were 42% and 56%, respectively. In multivariable analysis, the number of acute organ dysfunctions (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.16-1.87), hematological malignancies (OR, 2.57; 95% CI, 1.05-6.27), performance status 2-4 (OR, 2.53; 95% CI, 1.44-4.43), and polymicrobial infections (OR, 3.74; 95% CI, 1.52-9.21) were associated with hospital mortality. CONCLUSIONS: Sepsis is a common cause of critical illness in patients with cancer and remains associated with high mortality. Variables related to underlying malignancy, sepsis severity, and characteristics of infection are associated with a grim prognosis.

Outcomes for patients with cancer admitted to the ICU requiring ventilatory support: results from a prospective multicenter study.

BACKGROUND: This study was undertaken to evaluate the clinical characteristics and outcomes of patients with cancer requiring nonpalliative ventilatory support. METHODS: This was a secondary analysis of a prospective cohort study conducted in 28 Brazilian ICUs evaluating adult patients with cancer requiring invasive mechanical ventilation (MV) or noninvasive ventilation (NIV) during the first 48 h of their ICU stay. We used logistic regression to identify the variables associated with hospital mortality. RESULTS: Of 717 patients, 263 (37%) (solid tumors = 227; hematologic malignancies = 36) received ventilatory support. NIV was initially used in 85 patients (32%), and 178 (68%) received MV. Additionally, NIV followed by MV occurred in 45 patients (53%). Hospital mortality rates were 67% in all patients, 40% in patients receiving NIV only, 69% when NIV was followed by MV, and 73% in patients receiving MV only (P < .001). Adjusting for the type of admission, newly diagnosed malignancy (OR, 3.59; 95% CI, 1.28-10.10), recurrent or progressive malignancy (OR, 3.67; 95% CI, 1.25-10.81), tumoral airway involvement (OR, 4.04; 95% CI, 1.30-12.56), performance status (PS) 2 to 4 (OR, 2.39; 95% CI, 1.24-4.59), NIV followed by MV (OR, 3.00; 95% CI, 1.09-8.18), MV as initial ventilatory strategy (OR, 3.53; 95% CI, 1.45-8.60), and Sequential Organ Failure Assessment score (each point except the respiratory domain) (OR, 1.15; 95% CI, 1.03-1.29) were associated with hospital mortality. Hospital survival in patients with good PS and nonprogressive malignancy and without tumoral airway involvement was 53%. Conversely, patients with poor functional capacity and cancer progression had unfavorable outcomes. CONCLUSIONS: Patients with cancer with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care, because one-half of these patients survive. On the other hand, provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy.

A realidade dos pacientes que necessitam de ventilação mecânica prolongada: um estudo multicêntrico / The reality of patients requiring prolonged mechanical ventilation: a multicenter study

Objetivo: Na última década ocorreu um aumento no número de pacientes que necessitam manutenção de ventilação mecânica prolongada, resultando no surgimento de uma grande população de pacientes crônicos criticamente enfermos. Este estudo estabeleceu a incidência de ventilação mecânica prolongada em quatro unidades de terapia intensiva e relatou as diferentes características, desfechos hospitalares e impacto nos custos e serviços de pacientes com ventilação mecânica prolongada (dependência de ventilação mecânica por 21 dias ou mais) em comparação a pacientes sem ventilação mecânica prolongada (dependência de ventilação mecânica inferior a 21 dias). Métodos: Este foi um estudo multicêntrico de coorte que envolveu todos os pacientes admitidos em quatro unidades de terapia intensiva. As principais avaliações de desfechos incluíram o tempo de permanência na unidade de terapia intensiva e no hospital, a incidência de complicações durante a permanência na unidade de terapia intensiva, e a mortalidade na unidade de terapia intensiva e no hospital. Resultados: Durante o período do estudo, ocorreram 5.287 admissões às unidades de terapia intensiva. Alguns desses pacientes (41,5%) necessitaram de suporte ventilatório (n = 2.197), e 218 dos pacientes (9,9%) cumpriram os critérios de ventilação mecânica prolongada. Algumas complicações se desenvolveram durante a permanência na unidade de terapia intensiva como fraqueza muscular, úlceras de pressão, sepse nosocomial bacteriana, candidemia, embolia pulmonar, e delirium hiperativo; estas se associaram com um risco significantemente maior de ventilação mecânica prolongada. Os pacientes de ventilação mecânica prolongada tiveram um aumento significante da mortalidade na unidade de terapia intensiva (diferença absoluta = 14,2%; p < 0,001) e da mortalidade hospitalar (diferença absoluta = 19,1%; p < 0,001). O grupo com ventilação mecânica prolongada permaneceu mais dias no hospital após receber alta ...

Objective: The number of patients who require prolonged mechanical ventilation increased during the last decade, which generated a large population of chronically ill patients. This study established the incidence of prolonged mechanical ventilation in four intensive care units and reported different characteristics, hospital outcomes, and the impact of costs and services of prolonged mechanical ventilation patients (mechanical ventilation dependency ≥ 21 days) compared with non-prolonged mechanical ventilation patients (mechanical ventilation dependency < 21 days). Methods: This study was a multicenter cohort study of all patients who were admitted to four intensive care units. The main outcome measures were length of stay in the intensive care unit, hospital, complications during intensive care unit stay, and intensive care unit and hospital mortality. Results: There were 5,287 admissions to the intensive care units during study period. Some of these patients (41.5%) needed ventilatory support (n = 2,197), and 218 of the patients met criteria for prolonged mechanical ventilation (9.9%). Some complications developed during intensive care unit stay, such as muscle weakness, pressure ulcers, bacterial nosocomial sepsis, candidemia, pulmonary embolism, and hyperactive delirium, were associated with a significantly higher risk of prolonged mechanical ventilation. Prolonged mechanical ventilation patients had a significant increase in intensive care unit mortality (absolute difference = 14.2%, p < 0.001) and hospital mortality (absolute difference = 19.1%, p < 0.001). The prolonged mechanical ventilation group spent more days in the hospital after intensive care unit discharge (26.9 ± 29.3 versus 10.3 ± 20.4 days, p < 0.001) with higher costs. Conclusion: The classification of chronically critically ill patients according to the definition of prolonged mechanical ventilation adopted by our study (mechanical ventilation ...

Outcomes of cancer patients admitted to Brazilian intensive care units with severe acute kidney injury. / Desfecho de pacientes com câncer internados em unidades de terapia intensiva brasileiras com lesão renal aguda.

OBJECTIVES: Critically ill cancer patients are at increased risk for acute kidney injury, but studies on these patients are scarce and were all single centered conducted in specialized intensive care units. The objective was to evaluate the characteristics and outcomes in a prospective cohort of cancer patients admitted to several intensive care units with acute kidney injury. METHODS: Prospective multicenter cohort study conducted in intensive care units from 28 hospitals in Brazil over a two-month period. Univariate and multivariate logistic regression were used to identify factors associated with hospital mortality. RESULTS: Out of all 717 intensive care unit admissions, 87 (12%) had acute kidney injury and 36% of them received renal replacement therapy. Kidney injury developed more frequently in patients with hematological malignancies than in patients with solid tumors (26% vs. 11%, P=0.003). Ischemia/shock (76%) and sepsis (67%) were the main contributing factor for and kidney injury was multifactorial in 79% of the patients. Hospital mortality was 71%. General and renal-specific severity-of-illness scores were inaccurate in predicting outcomes for these patients. In a multivariate analysis, length of hospital stay prior to intensive care unit, acute organ dysfunctions, need for mechanical ventilation and a poor performance status were associated with increased mortality. Moreover, cancer-related characteristics were not associated with outcomes. CONCLUSIONS: The present study demonstrates that intensive care units admission and advanced life-support should be considered in selected critically ill cancer patients with kidney injury.

Desfecho de pacientes com câncer internados em unidades de terapia intensiva brasileiras com lesão renal aguda / Outcomes of cancer patients admitted to Brazilian intensive care units with severe acute kidney injury

OBJETIVOS: Pacientes com câncer criticamente enfermos têm maior risco de lesão renal aguda, mas estudos envolvendo estes pacientes são escassos, e todos em centros únicos e realizados em unidades de terapia intensiva especializadas. O objetivo deste estudo foi avaliar as características e desfechos em uma coorte prospectiva de pacientes de câncer internados em diversas unidades de terapia intensiva com lesão renal aguda. MÉTODOS: Estudo prospectivo multicêntrico de coorte realizado em unidades de terapia intensiva de 28 hospitais brasileiros em um período de dois meses. Foram utilizadas regressões logísticas univariada e multivariada para identificar os fatores associados a mortalidade hospitalar. RESULTADOS: Dentre todas as 717 internações a unidades de terapia intensiva, 87 (12 por cento) tiveram lesão renal aguda e 36 por cento deles receberam terapia de substituição renal. A lesão renal se desenvolveu mais frequentemente em pacientes com neoplasias hematológicas do que em pacientes com tumores sólidos (26 por cento x 11 por cento; p=0,003). Isquemia/choque (76 por cento) e sepse (67 por cento) foram os principais fatores associados à lesão renal, e esta foi multifatorial em 79 por cento dos pacientes. A letalidade hospitalar foi de 71 por cento. Os escores de gravidade gerais e específicos para pacientes com lesão renal, foram imprecisos para predizer o prognóstico nestes pacientes. Na análise multivariada, a duração da internação hospitalar antes da unidade de terapia intensiva, disfunções orgânicas agudas, necessidade de ventilação mecânica e um performance status comprometido associaram-se à maior letalidade. Mais ainda, características relacionadas ao câncer não se associaram com os desfechos. CONCLUSÕES: O presente estudo demonstra que internação na unidade de terapia intensiva e suporte avançado à vida devem ser considerados em pacientes selecionados de câncer criticamente enfermos com lesão renal.

OBJECTIVES: Critically ill cancer patients are at increased risk for acute kidney injury, but studies on these patients are scarce and were all single centered conducted in specialized intensive care units. The objective was to evaluate the characteristics and outcomes in a prospective cohort of cancer patients admitted to several intensive care units with acute kidney injury. METHODS: Prospective multicenter cohort study conducted in intensive care units from 28 hospitals in Brazil over a two-month period. Univariate and multivariate logistic regression were used to identify factors associated with hospital mortality. RESULTS: Out of all 717 intensive care unit admissions, 87 (12 percent) had acute kidney injury and 36 percent of them received renal replacement therapy. Kidney injury developed more frequently in patients with hematological malignancies than in patients with solid tumors (26 percent vs. 11 percent, P=0.003). Ischemia/shock (76 percent) and sepsis (67 percent) were the main contributing factor for and kidney injury was multifactorial in 79 percent of the patients. Hospital mortality was 71 percent. General and renal-specific severity-of-illness scores were inaccurate in predicting outcomes for these patients. In a multivariate analysis, length of hospital stay prior to intensive care unit, acute organ dysfunctions, need for mechanical ventilation and a poor performance status were associated with increased mortality. Moreover, cancer-related characteristics were not associated with outcomes. CONCLUSIONS: The present study demonstrates that intensive care units admission and advanced life-support should be considered in selected critically ill cancer patients with kidney injury.