Prophylactic versus restrictive platelet transfusion strategy in patients with haematological malignancies in the ICU setting, a propensity-score analysis.

PURPOSE: Prophylactic platelet transfusions (PT) aim to reduce bleeding. We assessed whether restrictive PT compared to prophylactic strategy could apply in ICU. MATERIAL AND METHODS: We conducted a retrospective monocentric study including patients >18 yo with haematological malignancy admitted to the ICU with thrombocytopenia <20 G/L between 2018 and 2021. Patients were classified in 2 groups according transfusion strategy applied during the first 3 days: prophylactic or restrictive transfusion. RESULTS: 180 patients were included, 87 and 93 in the restrictive and prophylactic groups respectively. After propensity-score analysis, 2 groups of 54 matched patients were analyzed. Restrictive strategy led to a significant reduction in PT with incidence rate for 100-ICU-patients-days of 34.9 and 49.9, incidence rate ratio = 0.699 [0.5-0.9], p = 0.006, representing a 31% decrease. Decreased PT persisted until day 28 with platelet concentrates transfusions-free days at day 28 of 21 [13-25] and 16.5 [10.2-21] in the 2 groups (p = 0.04). Restrictive strategy did not result in higher grade ≥ 2 bleeding. Transfusion efficiency was low with similar number of days with platelet <10 or < 20 G/L regardless of strategy. Platelet transfusion strategy was not associated with 28-day mortality. Platelet nadir <5G/L was associated with day-28 mortality with HR = 1.882 [1.011-3.055], p = 0.046. CONCLUSION: A restrictive PT strategy appears feasible in the ICU.

Septic shock and biliary sepsis: 90-day mortality and associated risk factors.

BACKGROUND: Biliary sepsis is common in patients with digestive cancer. Recommendations call for antibiotic de-escalation (ADE) as a strategy for antibiotic treatment of sepsis or septic shock. The aim of this study was to identify factors influencing 90-day mortality and to evaluate the impact of ADE. METHODS: This retrospective study was conducted between November 2008 and December 2019 in a referral cancer center. Adults with biliary sepsis or septic shock admitted to the ICU were included. Variables associated with 90-day mortality were identified using univariate and multivariate Cox proportional hazards models. RESULTS: 122 patients were included. The 90-day mortality was 30.3% (n = 37). After multivariate analysis, the factors independently associated 90-day mortality were metastatic stage (p = 0.004), biliary tract tumour compression (p = 0.001), multi drug resistant (MDR) bacteria carriage on intensive care unit (ICU)admission (p = 0.048), serum lactate on ICU admission (p < 0.001), the use of extra-renal replacement (p = 0.008), factor V < 50% (p = 0.009) and performance status (ECOG-PS) > 2 (p < 0.001). ADE of the pivotal antibiotic (p = 0.041) and recent cancer surgery (p < 0.001) appeared to be associated with survival. CONCLUSION: The 90-day mortality of biliary sepsis seems to be favourable. The 90-day mortality is associated with organ dysfunctions, but also with ECOG-PS, cancer stage, MDR bacteria colonisation. ADE seems to be safe.

Factors Associated with 1-Year Mortality in Elderly Patients (Age ≥ 80 Years) with Cancer Undergoing Major Abdominal Surgery: A Retrospective Cohort Study.

BACKGROUND: The number of elderly patients undergoing major abdominal surgery is increasing, but the factors affecting their postoperative outcomes remain unclear. This study aimed to identify the factors associated with 1-year mortality among elderly patients (age ≥ 80 years) with cancer undergoing major abdominal surgery. METHODS: This retrospective cohort study was conducted from March 2009 to December 2020. The study enrolled 378 patients 80 years old or older who underwent major abdominal surgery. The main outcome was 1-year mortality, and the factors associated with mortality were analyzed. RESULTS: Of the 378 patients, 92 died at 1 year (24.3%), whereas the 30-day mortality rate was 4% (n = 15). In the multivariate analysis, the factors independently associated with 1-year mortality were preoperative Eastern Cooperative Oncology Group (ECOG) performance status (PS) score higher than 1 (odds ratio [OR], 3.189; 95% confidence interval [CI], 1.595-6.377; p = 0.001), preoperative weight loss greater than 3 kg (OR, 2.145; 95% CI, 1.044-4.404; p = 0.038), use of an intraoperative vasopressor (OR, 3.090; 95% CI, 1.188-8.042; p = 0.021), and postoperative red blood cell units (OR, 1.212; 95% CI, 1.045-1.405; p = 0.011). Survival was associated with perioperative management according to an enhanced recovery after surgery (ERAS) protocol (OR, 0.370; 95% CI, 0.160-0.854; p = 0.006) and supramesocolic surgery (OR, 0.371; 95% CI, 0.158-0.871; p = 0.023). CONCLUSION: The study identified several factors associated with an encouraging 1-year mortality rate in this setting. These results highlight the need for identification of suitable targets to optimize pre-, intra-, and postoperative management in order to improve outcomes for this vulnerable population.

OCOSO2: study protocol for a single-blinded, multicentre, randomised controlled trial assessing a central venous oxygen saturation-based goal-directed therapy to reduce postoperative complications in high-risk patients after elective major surgery.

BACKGROUND: Fluid loading-based goal-directed therapy is a cornerstone of anaesthesia management in major surgery. Its widespread application has contributed to a significant improvement in perioperative morbidity and mortality. In theory, only hypovolemic patients should receive fluid therapy. However, to achieve such a diagnosis, a surrogate marker of cardiac output adequacy must be used. Current methods of fluid loading-based goal-directed therapy do not assess cardiac output adequacy. Nowadays, new devices make it possible to continuously monitor central venous oxygen saturation (ScvO2) and therefore, to assess the adequacy of perioperative cardiac output during surgery. In major surgery, ScvO2-based goal-directed therapy can be used to enhance fluid therapy and improve patient outcomes. METHODS: We designed a prospective, randomised, single-blinded, multicentre controlled superiority study with a 1:1 allocation ratio. Patients to be included will be high-risk major surgery patients (> 50 years old, ASA score > 2, major intra-abdominal or intra-thoracic surgery > 90 min). Patients in the control group will undergo standard fluid loading-based goal-directed therapy, as recommended by the guidelines. Patients in the intervention group will have ScvO2-based goal-directed therapy and receive fluid loading only if fluid responsiveness and cardiac output inadequacy are present. The primary outcome will be the Comprehensive Complication Index on day five postoperatively. DISCUSSION: This study is the first to address the issue of cardiac output adequacy in goal-directed therapy. Our hypothesis is that cardiac output optimisation during major surgery achieved by continuous monitoring of the ScvO2 to guide fluid therapy will result in a reduction of postoperative complications as compared with current goal-directed fluid therapy practices. TRIAL REGISTRATION: ClinicalTrials.gov. NCT03828565. Registered on February 4, 2019.

Critically ill metastatic cancer patients returning home after unplanned ICU stay: an observational, multicentre retrospective study.

BACKGROUND: Data about critically ill metastatic cancer patients functional outcome after unplanned admission to the ICU are scarce. The aim of this study was to assess factors associated with 90-day return home and 1-year survival in this population. STUDY DESIGN AND METHODS: A multicenter retrospective study included all consecutive metastatic cancer patients admitted to the ICU for unplanned reason between 2017 and 2020. RESULTS: Among 253 included metastatic cancer patients, mainly with lung cancer, 94 patients (37.2%) could return home on day 90. One-year survival rate was 28.5%. Performance status 0 or 1 (OR, 2.18; 95% CI 1.21-3.93; P = 0.010), no malnutrition (OR, 2.90; 95% CI 1.61-5.24; P < 0.001), female gender (OR, 2.39; 95% CI 1.33-4.29; P = 0.004), recent chemotherapy (OR, 2.62; 95% CI 1.40-4.90; P = 0.003), SOFA score ≤ 5 on admission (OR, 2.62; 95% CI 1.41-4.90; P = 0.002) were significantly predictive for 90-day return home. Malnutrition (HR, 1.66; 95% CI 1.18-2.22; P = 0.003), acute respiratory failure (ARF) as reason for admission (HR, 1.40; 95% CI 1.10-1.95; P = 0.043), SAPS II on admission (HR, 1.03; 95% CI 1.02-1.05; P < 0.001) and decisions to forgo life-sustaining therapies (DFLST) (HR, 2.80; 95% CI 2.04-3.84; P < 0.001) were independently associated with 1-year mortality. CONCLUSIONS: More than one out of three metastatic cancer patients could return home within 3 months after an unplanned admission to the ICU. Previous performance and nutritional status, ongoing specific treatment and low severity of the acute illness were found to be predictive for return home. Such encouraging findings should help change the dismal perception of critically ill metastatic cancer patients.

LATE POSTPANCREATICODUODENECTOMY HEMORRHAGE: INCIDENCE, RISK FACTORS, MANAGEMENT AND OUTCOME.

ABSTRACT: Background:Postpancreaticoduodenectomy (PD) hemorrhage (PPH) is a life-threatening complication after PD. The main objective of this study was to evaluate incidence and factors associated with late PPH as well as the management strategy and outcomes. Methods: Between May 2017 and March 2020, clinical data from 192 patients undergoing PD were collected prospectively in the CHIRPAN Database (NCT02871336) and retrospectively analyzed. In our institution, all patients scheduled for a PD are routinely admitted for monitoring and management in intensive/intermediate care unit (ICU/IMC). Results: The incidence of late PPH was 17% (32 of 192), whereas the 90-day mortality rate of late PPH was 19% (6 of 32). Late PPH was associated with 90-day mortality (P = 0.001). Using multivariate analysis, independent risk factors for late PPH were postoperative sepsis (P = 0.036), and on day 3, creatinine (P = 0.025), drain fluid amylase concentration (P = 0.023), lipase concentration (P < 0.001), and C-reactive protein (CRP) concentration (P < 0.001). We developed two predictive scores for PPH occurrence, the PANCRHEMO scores. Score 1 was associated with 68.8% sensitivity, 85.6% specificity, 48.8% predictive positive value, 93.2% negative predictive value, and an area under the receiver operating characteristic curves of 0.841. Score 2 was associated with 81.2% sensitivity, 76.9% specificity, 41.3% predictive positive value, 95.3% negative predictive value, and an area under the receiver operating characteristic curve of 0.859. Conclusions: Routine ICU/IMC monitoring might contribute to a better management of these complications. Some predicting factors such as postoperative sepsis and biological markers on day 3 should help physicians to determine patients requiring a prolonged ICU/IMC monitoring.

High-flow nasal cannula failure in critically ill cancer patients with acute respiratory failure: Moving from avoiding intubation to avoiding delayed intubation.

BACKGROUND: High-flow nasal cannula (HFNC) is increasingly used in critically ill cancer patients with acute respiratory failure (ARF) to avoid mechanical ventilation (MV). The objective was to assess prognostic factors associated with mortality in ICU cancer patients requiring MV after HFNC failure, and to identify predictive factors of intubation. METHODS: We conducted a retrospective study from 2012-2016 in a cancer referral center. All consecutive onco-hematology adult patients admitted to the ICU treated with HFNC were included. HFNC failure was defined by intubation requirement. RESULTS: 202 patients were included, 104 successfully treated with HFNC and 98 requiring intubation. ICU and hospital mortality rates were 26.2% (n = 53) and 42.1% (n = 85) respectively, and 53.1% (n = 52) and 68.4% (n = 67) in patients requiring MV. Multivariate analysis identified 4 prognostic factors of hospital mortality after HFNC failure: complete/partial remission (OR = 0.2, 95%CI = 0.04-0.98, p<0.001) compared to patients with refractory/relapse disease (OR = 3.73, 95%CI = 1.08-12.86), intubation after day 3 (OR = 7.78, 95%CI = 1.44-41.96), number of pulmonary quadrants involved on chest X-ray (OR = 1.93, 95%CI = 1.14-3.26, p = 0.01) and SAPSII at ICU admission (OR = 1.06, 95%CI = 1-1.12, p = 0.019). Predictive factors of intubation were the absence of sepsis (sHR = 0.32, 95%CI = 0.12-0.74, p = 0.0087), Sp02<95% 15 minutes after HFNC initiation (sHR = 2.05, 95%CI = 1.32-3.18, p = 0.0014), number of quadrants on X-ray (sHR = 1.73, 95%CI = 1.46-2.06, p<0.001), Fi02>60% at HFNC initiation (sHR = 3.12, 95%CI = 2.06-4.74, p<0.001) and SAPSII at ICU admission (sHR = 1.03, 95%CI = 1.02-1.05, p<0.01). CONCLUSION: Duration of HFNC may be predictive of an excess mortality in ARF cancer patients. Early warning scores to predict HFNC failure are needed to identify patients who would benefit from early intubation.

Herpesviridae in critically ill hematology patients: HHV-6 is associated with worse clinical outcome.

PURPOSE: Although viral infections are frequent among patients with hematological malignancies (HM), data about herpesviridae in critically ill hematology patients are scarce. We aimed at determining the impact of herpesviridae reactivation/infection in this population. MATERIAL AND METHODS: We performed a single center retrospective study including all consecutive adult hematology patients admitted to our comprehensive cancer center ICU on a 6-year period. Clinical characteristics, microbiological findings, especially virus detection and outcome were recorded. RESULTS: Among the 364 included patients, HHV-6 was the predominant retrieved herpesviridae (66 patients, 17.9%), followed by HSV1/2 (41 patients, 11.3%), CMV (38 patients, 10.4%), EBV (24 patients, 6.6%) and VZV (3 patients). By multivariable analysis, HHV-6 reactivation was independently associated with hospital mortality (OR, 2.35; 95% CI, 1.03-5.34; P = 0.042), whereas antiviral prophylaxis during ICU stay had a protective effect (OR, 0.41; 95% CI, 0.18-0.95; P = 0.037). HHV-6 pneumonitis was independently associated with 1-year mortality (OR, 6.87; 95% CI, 1.09-43.3; P = 0.04). CONCLUSIONS: Among critically ill hematology patients, HHV-6 reactivation and pneumonitis are independent risk factors for hospital and 1-year mortality, respectively. Impact of prevention and treatment using agents active against HHV-6 should be assessed to define a consensual diagnostic and therapeutic strategy.

Prognostic impact of early adjunctive corticosteroid therapy in non-HIV oncology or haematology patients with Pneumocystis jirovecii pneumonia: A propensity score analysis.

PURPOSE: While early adjunctive corticosteroid therapy (EACST) has been proven effective in HIV patients with Pneumocystis Jirovecii Pneumonia (PJP), data remains controversial concerning non-HIV oncology or haematology patients. METHODS: This retrospective study included cancer patients without HIV and with diagnosis of PJP admitted in a cancer referral centre, from January-1-2010 to March-31-2017. We compared 30-day and 1-year mortality rate, change in the respiratory item of the Sequential Organ Failure Assessment score(SOFA-resp worsening), use of tracheal intubation between day-1 and day-5 of anti-pneumocystis therapy and occurrence of coinfections between patients with EACST and those with no or late corticosteroid therapy, using an inverse probability weighting propensity score-based (IPW) analysis. RESULTS: 133 non-HIV oncology or haematology PJP patients were included (EACST n = 58, others n = 75). The main underlying conditions were haematological malignancies (n = 107, 80,5%), solid tumour (n = 27, 20,3%) and allogeneic stem cell transplantation (n = 17, 12,8%). Overall 30-day and 1-year mortality rate was 24,1% and 56,4%, respectively. IPW analysis found no difference on 30-day (HR = 1.45, 95% CI [0.7-3.04], p = 0.321) and 1-year (HR = 1.25, CI 95% [0.75-2.09], p = 0.39) mortality rate between groups. CONCLUSION: No difference in SOFA-resp worsening, tracheal intubation and coinfections was found between groups. Combination of EACST with anti-pneumocystis therapy in non-HIV onco-haematology PJP-patients was not associated with clinical improvement.

Impact of a computer-assisted decision support system (CDSS) on nutrition management in critically ill hematology patients: the NUTCHOCO study (nutritional care in hematology oncologic patients and critical outcome).

BACKGROUND: Mortality of critically ill hematology (HM) patients has improved over time. Thus, those patients require an extensive diagnostic workup and the optimal use of available treatments. There are no data regarding nutrition strategy for critically ill HM patients, while nutritional support is crucial for both HM and critically ill patients. We hypothesized that the implementation of a computer-assisted decision support system (CDSS), designed to supervise a nutritional intervention by a multidisciplinary team, would be able to increase guidelines adherence and outcomes. RESULTS: In this before/after study, 275 critically ill hematology patients admitted to the ICU over 5-year period were included. Energy and protein intakes were delivered using standard protocol in the 147 patients (53%) of the 'before group' and using a CDSS in order to reach every day predefined caloric and protein targets accordingly to the catabolic or anabolic status in the 128 patients (47%) of the 'after group.' Using a Poisson regression, we showed that the use of CDSS allowed to reach a relative increase in the rate of days in compliance with caloric (1.57; 95% confidence interval (CI), [1.17-2.10], p = 0.0025) and protein targets (3.86 [2.21-6.73], p < 0.0001) in the 'after group' by more than 50% as compared with the 'before group.' Interestingly, compliance rates were low and only reached 30% after intervention. Hospital mortality, ICU-acquired infection, and hospital, and ICU length of stay were similar in the two groups of patients. Importantly, exploratory analysis showed that hospital mortality was lower in the 'after group' for neutropenic and severely ill patients. CONCLUSION: For critically ill hematology patients, the use of a nutritional CDSS allowed to increase the days in compliance with caloric and protein targets as compared with no CDSS use. In this context, overall hospital mortality was not affected.