Determinants of mortality in cancer patients with unscheduled admission to the Intensive Care Unit: A prospective multicenter study.

OBJECTIVES: To analyze clinical features associated to mortality in oncological patients with unplanned admission to the Intensive Care Unit (ICU), and to determine whether such risk factors differ between patients with solid tumors and those with hematological malignancies. DESIGN: An observational study was carried out. SETTING: A total of 123 Intensive Care Units across Spain. PATIENTS: All cancer patients with unscheduled admission due to acute illness related to the background oncological disease. INTERVENTIONS: None. MAIN VARIABLES: Demographic parameters, severity scores and clinical condition were assessed, and mortality was analyzed. Multivariate binary logistic regression analysis was performed. RESULTS: A total of 482 patients were included: solid cancer (n=311) and hematological malignancy (n=171). Multivariate regression analysis showed the factors independently associated to ICU mortality to be the APACHE II score (OR 1.102; 95% CI 1.064-1.143), medical admission (OR 3.587; 95% CI 1.327-9.701), lung cancer (OR 2.98; 95% CI 1.48-5.99) and mechanical ventilation after the first 24h of ICU stay (OR 2.27; 95% CI 1.09-4.73), whereas no need for mechanical ventilation was identified as a protective factor (OR 0.15; 95% CI 0.09-0.28). In solid cancer patients, the APACHE II score, medical admission, antibiotics in the previous 48h and lung cancer were identified as independent mortality indicators, while no need for mechanical ventilation was identified as a protective factor. In the multivariate analysis, the APACHE II score and mechanical ventilation after 24h of ICU stay were independently associated to mortality in hematological cancer patients, while no need for mechanical ventilation was identified as a protective factor. Neutropenia was not identified as an independent mortality predictor in either the total cohort or in the two subgroups. CONCLUSIONS: The risk factors associated to mortality did not differ significantly between patients with solid cancers and those with hematological malignancies. Delayed intubation in patients requiring mechanical ventilation might be associated to ICU mortality.

Clinical impact of procalcitonin-based algorithms for duration of antibiotic treatment in critically ill adult patients with sepsis: a meta-analysis of randomized clinical trials.

BACKGROUND: Our objective was to assess the impact on mortality, antibacterial therapy duration, and length of stay of using PCT to guide antibiotic cessation in critically ill patients with sepsis or septic shock. RESEARCH DESIGN AND METHODS: A systematic literature search was performed in PubMed, Embase, ISI Web of Knowledge, BioMed Central, ScienceDirect and the Cochrane Central Register of Controlled Trials, of clinical trials published in English before December 31, 2019. Eligible studies should be carried out in adults at ICU with sepsis, comparing the PCT-guided antimicrobial therapy with standard of care. A random effects model was used. RESULTS: Twelve studies were eligible with a total of 4292 patients included. The combined relative risk for 28-day mortality was 0.89 (95% CI: 0.79; 0.99), for the duration of antimicrobial therapy was -1.98 days (95% CI: -2.76, -1.21) and for ICU- length of stay was-1.21 days (95% CI: -4.16, 1.74). CONCLUSIONS: In critically ill adults with sepsis, a procalcitonin-guided strategy is associated with a significant shorter duration of antimicrobial therapy. This reduction was associated with a significant decrease in mortality although the length of ICU stay was not affected.

Epidemiology and prognosis of patients with a history of cancer admitted to intensive care. A multicenter observational study.

OBJECTIVE: To assess the epidemiology and outcome at discharge of cancer patients requiring admission to the Intensive Care Unit (ICU). DESIGN: A descriptive observational study was made of data from the ENVIN-HELICS registry, combined with specifically compiled variables. Comparisons were made between patients with and without neoplastic disease, and groups of cancer patients with a poorer outcome were identified. SETTING: Intensive Care Units participating in ENVIN-HELICS 2018, with voluntary participation in the oncological registry. PATIENTS: Subjects admitted during over 24 h and diagnosed with cancer in the last 5 years. PRIMARY ENDPOINTS: The general epidemiological endpoints of the ENVIN-HELICS registry and cancer-related variables. RESULTS: Of the 92 ICUs with full data, a total of 11,796 patients were selected, of which 1786 (15.1%) were cancer patients. The proportion of cancer patients per Unit proved highly variable (1%-48%). In-ICU mortality was higher among the cancer patients than in the non-oncological subjects (12.3% versus 8.9%; p < .001). Elective postoperative (46.7%) or emergency admission (15.3%) predominated in the cancer patients. Patients with medical disease were in more serious condition, with longer stay and greater mortality (27.5%). The patients admitted to the ICU due to nonsurgical disease related to cancer exhibited the highest mortality rate (31.4%). CONCLUSIONS: Great variability was recorded in the percentage of cancer patients in the different ICUs. A total of 46.7% of the patients were admitted after undergoing scheduled surgery. The highest mortality rate corresponded to patients with medical disease (27.5%), and to those admitted due to cancer-related complications (31.4%).

Early Stepdown From Echinocandin to Fluconazole Treatment in Candidemia: A Post Hoc Analysis of Three Cohort Studies.

BACKGROUND: There are no clear criteria for antifungal de-escalation after initial empirical treatments. We hypothesized that early de-escalation (ED) (within 5 days) to fluconazole is safe in fluconazole-susceptible candidemia with controlled source of infection. METHODS: This is a multicenter post hoc study that included consecutive patients from 3 prospective candidemia cohorts (2007-2016). The impact of ED and factors associated with mortality were assessed. RESULTS: Of 1023 candidemia episodes, 235 met inclusion criteria. Of these, 54 (23%) were classified as the ED group and 181 (77%) were classified as the non-ED group. ED was more common in catheter-related candidemia (51.9% vs 31.5%; P = .006) and episodes caused by Candida parapsilosis, yet it was less frequent in patients in the intensive care unit (24.1% vs 39.2%; P = .043), infections caused by Nakaseomyces glabrata (0% vs 9.9%; P = .016), and candidemia from an unknown source (24.1% vs 47%; P = .003). In the ED and non-ED groups, 30-day mortality was 11.1% and 29.8% (P = .006), respectively. Chronic obstructive pulmonary disease (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.48-10.61), Pitt score > 2 (OR, 4.39; 95% CI, 1.94-9.20), unknown source of candidemia (OR, 2.59; 95% CI, 1.14-5.86), candidemia caused by Candida albicans (OR, 3.92; 95% CI, 1.48-10.61), and prior surgery (OR, 0.29; 95% CI, 0.08-0.97) were independent predictors of mortality. Similar results were found when a propensity score for receiving ED was incorporated into the model. ED had no significant impact on mortality (OR, 0.50; 95% CI, 0.16-1.53). CONCLUSIONS: Early de-escalation is a safe strategy in patients with candidemia caused by fluconazole-susceptible strains with controlled source of bloodstream infection and hemodynamic stability. These results are important to apply antifungal stewardship strategies.

Intensive care in cancer patients in the age of immunotherapy and molecular therapies: Commitment of the SEOM-SEMICYUC.

Cancer patients are a vulnerable group exposed to numerous and serious risks beyond cancer itself. In recent years, the prognosis of these individuals has improved substantially thanks to several advances such as immunotherapy, targeted molecular therapies, surgical techniques, or developments in support treatment. This coincides with the prolonged survival of oncological patients admitted to the ICU due to critical complications, and under the supervision of intensivists. The time has therefore come to revisit the intensive care support of these patients, which poses new professional as well as organizational challenges. An agreement was signed in 2017 between the SEOM and SEMICYUC with the aim of improving the quality of care of cancer patients with critical complications. The initiative seeks to aid in decision-making, standardize criteria, decrease subjectivity, generate channels of communication, and delve deeper into the ethical and scientific aspects of these situations. This document sets forth the most important reasons that have led us to undertake this initiative.

Mortality of Oncohematological Patients Undergoing Hematopoietic Stem Cell Transplantation Admitted to the Intensive Care Unit.

BACKGROUND: Both autologous and allogenic hematopoietic stem cell transplantation (HSCT) are potentially curative treatments for hematological malignancies. Patients with related complications may need admission to the intensive care unit (ICU) for specific therapy and organ support. A consensus on treatment between hematologists and intensive care specialists is essential. METHODS: This observasional, retrospective study included all recipients of HSCT in a third-level hospital during 2013 and 2014. Certain parameters were taken into account for patients who needed to be admitted to the ICU, evolution, and ICU and hospital mortality. RESULTS: A total of 228 HSCT were carried out: 127 autologous (55.7%) and 101 allogenic (44.3%). Twenty-four patients were admitted to the ICU; 22 had received allogenic HSCT and 2 autologous. The main underlying conditions were acute leukemias (41.6%) and myelodysplastic syndromes (20.8%). Of these patients, 45.8% were in complete remission and 33.3% were in relapse or progression. Causes of admission to the ICU were mainly respiratory failure (70.8%) followed by shock requiring vasoactive drugs. High values for severity scores were observed for APACHE II 25 (19-28) and SOFA 10 (8-14). During hospitalization, a high percentage of patients had hemodynamic (91.7%), renal (87.5%), hepatic (79.2%), and respiratory (87.5%) failure. Mortality in the ICU was 83.3% and hospitalary, 91.7%. All patients requiring invasive mechanical ventilation died in the ICU. CONCLUSIONS: Of recipient patients of allogenic HSCT, 21.8% were admitted to the ICU, presenting a mortality rate of >95%. The main reason for admission was respiratory failure with requirement of invasive mechanical ventilation. Patients with autologous HSCT presented very few complications needing organ support.

[Neuromuscular abnormalities in critical illness]. / Patología neuromuscular en cuidados intensivos.

The spectrum of neuromuscular disease encountered in today's intensive care units (ICU) has evolved over the last few decades. However, in spite of many studies on neuromuscular disorders complicating critical illness as well as its epidemiology, etiology, treatment and prognosis, several key areas remain unclear. Two main groups are found among these neuromuscular abnormalities. The first group includes primary neuromuscular disorders present on admission to the ICU in which a possible etiology can be identified. Guillain-Barré syndrome and myasthenia gravis are two of the most common diseases admitted to ours units. In the second group, weakness is acquired in the ICU in the absence of preexisting neuromuscular disease. It is believed to reflect illnesses or treatments occurring in the ICU. Critical illness polyneuropathy (CIP) is the most clearly defined neuromuscular complication in this group. However, although we have better knowledge of its clinical, diagnosis, and prognosis features, its pathophysiological substrate has not been fully elucidated. Neuromuscular junction defects and specially myopathies, that frequently coexist with CIP, are the others main causes of acquired weakness in critically ill patients. Advances in understanding of these neuromuscular disorders could have an important impact in terms of developing effective preventive and therapeutic interventions that could help to improve the poor prognosis of these patients.

Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery.

OBJECTIVE: To investigate the influence of blood derivatives on the acquisition of severe postoperative infection (SPI) in patients undergoing heart surgery. SETTING: The postoperative ICUs of a tertiary-level university hospital. DESIGN: A cohort study. METHODS: During a 4-year period, 738 patients, classified as patients with SPIs and patients without SPIs (non-SPI patients), were included in the study. We studied the influence of 36 variables on the development of SPI in general and individually for pneumonia, mediastinitis, and/or septicemia. The influence of the blood derivatives on infections was assessed for RBC concentrates, RBC and plasma, and RBC and platelets. RESULTS: Seventy patients (9.4%) were classified as having SPIs, and 668 (90.6%) were classified as not having SPIs. After multivariate analysis, the variables associated with SPI (incidence, 9.4%) were reintubation, sternal dehiscence, mechanical ventilation (MV) for > or = 48 h, reintervention, neurologic dysfunction, transfusion of > or = 4 U RBCs, and systemic arterial hypotension. The variables associated with nosocomial pneumonia (incidence, 5.9%) were reintubation, MV for > or = 48 h, neurologic dysfunction, transfusion of > or = 4 U blood components, and arterial hypotension. The variables associated with mediastinitis (incidence, 2.3%) were reintervention and sternal dehiscence, and those associated with sepsis (incidence, 1.6%) were reintubation, time of bypass > or = 110 min, and MV for > or = 48 h. The mortality rate (patients with SPI, 52.8%; non-SPI patients, 8.2%; p < 0.001) and mean (+/- SD) length of stay in the ICU (patients with SPI, 15.8 +/- 12.9 days; non-SPI patients, 4.5 +/- 4.4 days; p < 0.001) were greater for the infected patients. The transfused patients also had a greater mortality rate (13.3% vs 8.9%, respectively; p < 0.001) and a longer mean stay in the ICU (6.1 +/- 7.2 days vs 3.7 +/- 2.8 days, respectively; p < 0.01) than those not transfused. CONCLUSION: The administration of blood derivatives, mainly RBCs, was associated in a dose-dependent manner with the development of SPIs, primarily nosocomial pneumonia.

[Prospective comparative study of different amino acid and lipid solutions in parenteral nutrition of patients undergoing bone marrow transplantation]. / Estudio prospectivo comparativo de diferentes soluciones de aminoácidos y lípidos, en la nutrición parenteral de pacientes sometidos a trasplante de médula ósea.

UNLABELLED: The patient who will undergo a bone marrow transplant (BMT) has a high protein catabolism in the time period after the infusion of the marrow, and therefore there is a need for an adequate nutritional support. The objective of our study is to analyze the behavior of nutritional assessment parameters, the lipid metabolism, the number of days of mucositis, the number of infections, the number of days to recovery, and the number of hospitalization days when using different parenteral nutrition solutions: 22.5% and 45% branched chain amino acid solutions, and lipid solutions with long chain triglycerides (LCT), vs. medium chain triglycerides (MCT). MATERIAL AND METHODS: We have carried out a prospective, randomized study in patients who underwent a BMT who received parenteral nutrition. The supply of nitrogen was 1.5 +/- 0.3 g of AA/kg/day (either in standard solution or in a 45% branched chain AA solution). The caloric supply was similar in all the groups, with a proportion of 60% coming from carbohydrates and 40% from lipids, either LCT or MCT/LCT. The nutritional assessment parameters were studied, as well as of the lipid metabolism, and also clinical evolutive data: number of days of mucositis, number of days of PN, number of days hospitalized, number of infections, rate of infection density. All the data were measured and/or quantified 4 times: pretransplant, on day--of the transplant, and after 7 and 14 days after the transplant. RESULTS: 62 patients were studied. Group A: 19 patients treated with 22.5% branched chain amino acids + 20% LCT. Group B: 26 patients (45% branched chain amino acids + 20% LCT). Group C: 17 patients, (45% branched chain amino acids + 20% MCT/LCT). There is a quicker recover of the marrow in groups B + C: 14.4 vs. 11.7 and 11.1, with a p < 0.05. The nitrogen balance improves significantly in groups B and C (p < 0.05). The retinol-binding protein increases significantly from day 0 to day 7 (p < 0.01) in the LCT group (Group B). The phospholipids decrease in group B after one day (p < 0.05), and after the 7th day (p < 0.05). The triglycerides increase in group C between 7 and 14 days. The LDL/HDL quotient increases in group B after 14 days (p < 0.05). The triglycerides increase in group C between 7 and 14 days. The LDL/HDL quotient will increase in the B group after 14 days (p < 0.05). There are no differences in the number of days of mucositis, the total number of infections, the number of infections per 100 days of hospitalization, or in the number of hospitalization days. CONCLUSIONS: In patients who are given parenteral nutrition in the period immediately after the BMT, we found an improvement in the catabolic metabolism parameters when using a solution with a high proportion of branched chain amino acids (45%) and a smaller alteration of the metabolism of the plasmatic lipoproteins when we use MCT/LCT enriched solutions.

Diagnostic value of the blind brush in mechanically ventilated patients with nosocomial pneumonia.

OBJECTIVES: To check on the accuracy of a new protected blind brush (BB) inserted through an endotracheal tube to collect respiratory secretions to be used in the diagnosis of nosocomial pneumonia (NP) in ventilated patients. DESIGN: Prospective study of patients who had undergone both BB and plugged telescoping catheter via fiberoptic bronchoscopy (PTC-FB) sample collection sessions. SETTING: Intensive Care Unit of a referral-based University Hospital. PATIENTS: All patients (n = 37) mechanically ventilated for more than 3 days with clinical and radiological criteria of NP between July 1990 and March 1991. INTERVENTIONS: Randomized BB and PTC-FB sample collection sessions carried out less than 30 min apart. MEASUREMENTS AND MAIN RESULTS: The two sampling procedures resulted in similar findings with both cultures either negative or positive and identified the same organism and colonies in 31 patients (83.7%). Agreement was 90% when the patients with right or bilateral pulmonary infiltrates were grouped together and 100% when only the right field was considered. Complications arising from BB sampling were much lower than those from the conventional PTC-FB technique. CONCLUSIONS: Our results, pending confirmation by other prospective studies, indicate that BB sampling is useful in the diagnosis of NP in ventilated patients with radiological evidence of either right or bilateral pulmonary infiltrates and that it could stand in for PTC-FB in ICU settings where this procedure is not available.