Improving Goal-Concordant Care in Intensive Care Unit Admissions from the Emergency Department in a Comprehensive Cancer Center.

CONTEXT: As patients approach the end of life, discussion of their treatment goals is essential to avoid unnecessary suffering and deliver care in a manner consistent with their overall values. OBJECTIVES: Implement a multipronged approach to improve the rates of advance care planning (ACP) documentation among providers admitting patients with cancer to the intensive care unit (ICU) from the emergency department (ED). METHODS: We developed multiple interventions including the development of a best-practice advisory to alert providers when patients had previous do-not-resuscitate orders; standardization of ACP documentation; early oncologist involvement in goals-of-care conversations with patients; a survey of ED providers to identify barriers to success; and positive reinforcement strategies aimed at improving the rates of ACP documentation in patients admitted from the ED to the ICU. RESULTS: Prior to our interventions, only 13% of patients admitted to the ICU from the ED had ACP notes. This percentage increased to 90% by the last month of our project. CONCLUSION: Through our multipronged approach, we significantly improved the rates of ACP documentation among providers admitting patients from the ED to the ICU.

Variability in triage practices for critically ill cancer patients: A randomized controlled trial.

PURPOSE: Intensive care triage practices and end-user interpretation of triage guidelines have rarely been assessed. We evaluated agreement between providers on the prioritization of patients for ICU admission using different triage guidelines. MATERIALS AND METHODS: A multi-centered randomized study on providers from 18 different countries was conducted using clinical vignettes of oncological patients. The level of agreement between providers was measured using two different guidelines, with one being cancer specific. RESULTS: Amongst 257 providers, 52.5% randomly received the Society of Critical Care Prioritization Model, and 47.5% received a cancer specific flowchart as a guide. In the Prioritization Model arm the average entropy was 1.193, versus 1.153 in the flowchart arm (P = .095) indicating similarly poor agreement. The Fleiss' kappa coefficients were estimated to be 0.2136 for the SCCMPM arm and 0.2457 for the flowchart arm, also similarly implying poor agreement. CONCLUSIONS: The low agreement amongst practitioners on the prioritization of cancer patient cases for ICU admission existed using both general triage guidelines and guidelines tailored only to cancer patients. The lack of consensus on intensive care unit triage practices in the oncological population exposes a potential barrier to appropriate resource allocation that needs to be addressed.

Incidence of Bleeding Complications With Flexible Bronchoscopy in Cancer Patients With Thrombocytopenia.

BACKGROUND: Bronchoscopy is a safe procedure, but current guidelines recommend transfusion for platelets <20 K/µL. Studies of bronchoscopy in thrombocytopenia are limited. OBJECTIVES: Our objective was to evaluate the incidence of bleeding with flexible bronchoscopy in those with thrombocytopenia especially those <20 K/µL. METHOD: We performed a retrospective review of all flexible bronchoscopies between June 1, 2008 and December 31, 2010. Biopsies and therapeutic procedures were excluded. The χ, Fisher exact, and Rank-sum test were conducted to evaluate associations of clinically significant bleeding. RESULTS: There were 1711 patients who underwent 2053 flexible bronchoscopies. Cancer diagnosis included hematologic (61.3%) and solid organ malignancy (34.9%). Half of the bronchoscopies had moderate to severe thrombocytopenia (<100 K/µL) with the following ranges: 14.7% with 50 to <100 K/µL, 20.6% with 20 to <50 K/µL, 10.6% with 10 to <20 K/µL, 4.1% with <10 K/µL. Platelet transfusion was given in 90.6% of those with platelets <10 K/µL and 55.5% of those with platelets 10 to <20 K/µL. The nasal route for bronchoscopy was used in 92.4%. Bleeding complication rate however was 1.1% (0.2% major) and not affected by platelets. CONCLUSION: Bronchoscopy with lavage can be safely performed without platelet transfusion in those with platelets of ≥10 K/µL. In the absence of nasal bleeding, trauma, or deformity, the nasal route can be used for bronchoscopy.

Noninvasivepositive pressure ventilation vsinvasive mechanical ventilation as first-line therapy for acute hypoxemic respiratory failure in cancer patients.

PURPOSE: The objective was to describe the characteristics and outcomes of critically ill cancer patients who received noninvasive positive pressure ventilation (NIPPV) vs invasive mechanical ventilation as first-line therapy for acute hypoxemic respiratory failure. MATERIAL AND METHODS: A retrospective cohort study of consecutive adult intensive care unit (ICU) cancer patients who received either conventional invasive mechanical ventilation or NIPPV as first-line therapy for hypoxemic respiratory failure. RESULTS: Of the 1614 patients included, the NIPPV failure group had the greatest hospital length of stay, ICU length of stay, ICU mortality (71.3%), and hospital mortality (79.5%) as compared with the other 2 groups (P < .0001). The variables independently associated with NIPPV failure included younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-0.99; P=.031), non-Caucasian race (OR, 1.61; 95% CI, 1.14-2.26; P=.006), presence of a hematologic malignancy (OR, 1.87; 95% CI, 1.33-2.64; P=.0003), and a higher Sequential Organ Failure Assessment score (OR, 1.12; 95% CI, 1.08-1.17; P < .0001). There was no difference in mortality when comparing early vs late intubation (less than or greater than 24 or 48 hours) for the NIPPV failure group. CONCLUSION: Noninvasive positive pressure ventilation failure is an independent risk factor for ICU mortality, but NIPPV patients who avoided intubation had the best outcomes compared with the other groups. Early vs late intubation did not have a significant impact on outcomes.

Two Decades of ICU Utilization and Hospital Outcomes in a Comprehensive Cancer Center.

OBJECTIVE: To investigate ICU utilization and hospital outcomes of oncological patients admitted to a comprehensive cancer center. DESIGN: Observational cohort study. SETTING: The University of Texas MD Anderson Cancer Center. PATIENTS: Consecutive adults with cancer discharged over a 20-year period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The Cochran-Armitage test for trend was used to evaluate ICU utilization and hospital mortality rates by primary service over time. A negative binomial log linear regression model was fitted to the data to investigate length of stay over time. Among 387,306 adult hospitalized patients, the ICU utilization rate was 12.9%. The overall hospital mortality rate was 3.6%: 16.2% among patients with an ICU stay and 1.8% among non-ICU patients. Among those admitted to the ICU, the mean (SD) admission Sequential Organ Failure Assessment score was 6.1 (3.8) for all ICU patients: 7.3 (4.4) for medical ICU patients and 4.9 (2.8) for surgical ICU patients. Hematologic disorders were associated with the highest hospital mortality rate in ICU patients (42.8%); metastatic disease had the highest mortality rate in non-ICU patients (4.2%); sepsis, pneumonia, and other infections had the highest mortality rate for all inpatients (8.5%). CONCLUSIONS: This study provides a longitudinal view of ICU utilization rates, hospital and ICU length of stay, and severity-adjusted mortality rates. Although the data arise from a single institution, it encompasses a large number of hospital admissions over two decades and can serve as a point of comparison for future oncological studies at similar institutions. More studies of this nature are needed to determine whether consolidation of cancer care into specialized large-volume facilities may improve outcomes, while simultaneously sustaining appropriate resource utilization and reducing unnecessary healthcare costs.

Does Thrombolysis Have a Place in the Cardiopulmonary Resuscitation of Patients With Acute Pulmonary Embolism? A Case of Successful Thrombolysis During Pulmonary Embolism Induced Cardiopulmonary Arrest.

OBJECTIVE: Pulmonary embolism often causes cardiac arrest. When this occurs, thrombolytic therapy is not routinely administered. There are multiple reasons for this, including difficulty with rapidly adequately diagnosing the embolus, the lack of good data supporting the use of thrombolytics during resuscitation, the belief that thrombolytic therapy is ineffective once a patient has already arrested, the difficulty of obtaining thrombolytics at the bedside rapidly enough to administer during a code, and the increased risks of bleeding, particularly with ongoing chest compressions. In this case report, we present a patient who was successfully treated with thrombolytic therapy during pulmonary embolism-induced cardiopulmonary arrest and discuss the role of thrombolytics in cardiopulmonary resuscitation. DESIGN: Case report. SETTING: Surgical ICU in a comprehensive cancer center. PATIENT: A 56-year-old man who developed hypotension, dyspnea, hypoxia, and pulseless electrical activity 10 days after resection of a benign colon lesion with a right hemicolectomy and primary end-to-end anastomosis. INTERVENTIONS: After a rapid bedside echocardiogram suggesting pulmonary embolus, thrombolytic therapy was administered during cardiopulmonary resuscitative efforts. MEASUREMENTS AND MAIN RESULTS: The patient had a return of spontaneous circulation and showed improvement in repeat echocardiographic imaging. He had a prolonged course in the ICU and hospital, but eventually made an essentially complete clinical recovery. CONCLUSION: As bedside echocardiographic technology becomes more rapidly and readily available, the rapid diagnosis of pulmonary embolism and use of thrombolytics during cardiopulmonary resuscitation may need to be more routinely considered a potential therapeutic adjunctive measure.

Pulmonary and cardiovascular complications of obesity: an autopsy study of 76 obese subjects.

CONTEXT: Obesity is associated with sleep disordered breathing and cardiovascular morbidity, but the relationship between pulmonary hypertension, heart disease, and obesity is unknown. OBJECTIVE: To determine the prevalence of pulmonary and cardiovascular disease in obese subjects undergoing autopsy at a large medical center. DESIGN: A search through autopsy records from an 11-year period identified 76 subjects with a body mass index greater than 30 kg/m(2) and 46 age-matched, nonobese controls. Clinical data were collected from medical charts and autopsy records. Formalin-fixed, paraffin-embedded sections of lungs and heart were reviewed for each subject. The presence of pulmonary edema, hemorrhage, diffuse alveolar damage, thrombi, and pulmonary hypertensive changes, including intimal fibrosis, medial hypertrophy, muscularization of arterioles, alveolar capillary hemangiomatosis, hemosiderosis, and iron encrustation were documented. Hearts were examined for the presence of cardiomegaly, ventricular hypertrophy, coronary artery atherosclerosis, acute infarction, fibrosis, and inflammation. Differences between the obese and control groups were compared using a statistical software program. RESULTS: The obese group demonstrated a greater occurrence of diabetes mellitus, systemic hypertension, pulmonary edema, hemorrhage, and pulmonary hypertensive changes compared with the control group. Alveolar capillary hemangiomatosis was exclusively observed in the obese subjects. Cardiomegaly and left ventricular hypertrophy were present in all obese subjects; approximately one third of the obese subjects had no coronary atherosclerosis. CONCLUSIONS: Pulmonary hypertensive changes, including venous hypertension and capillary hemangiomatosis, were observed in 72% of obese subjects. Cardiomegaly with biventricular hypertrophy was present in all obese subjects and was suggestive of obesity cardiomyopathy.

Body position and obstructive sleep apnea in 8-12-month-old infants.

AIM: To determine the association between body position and obstructive events during sleep as determined by polysomnography (PSG) in infants of ages 8-12 months with obstructive sleep apnea (OSA). METHODS: Consecutive nocturnal polysomnograms (NPSGs) of 50 children ages 8-12 months old referred to the sleep disorders center between 1 January 2003 and 1 June 2006 for possible sleep-disordered breathing were retrospectively reviewed. Data on total obstructive apnea index (AI), total obstructive apnea-hypopnea index (AHI), AI by body position, AHI by body position, rapid eye movement (REM) and non-REM sleep AHI and REM and non-REM AI were recorded. RESULTS: The mean age was 9.5+/-1.9S.D. months and 46% of the patients were females. There were no significant differences between the mean non-supine AHI (2.0+/-5.1) and supine AHI (2.5+/-5.4), p=0.63. When comparing specific body positions, there were also no significant differences between the mean supine AHI (2.5+/-5.4), prone AHI (2.9+/-7.3), left-lateral decubitus AHI (1.1+/-6.1), or the right-lateral decubitus AHI (2.5+/-7.6), p=0.71. Additionally, there were also no significant differences between the mean non-supine AI (0.7+/-2.9) and supine AI (1.4+/-3.0), p=0.23, and no differences between the supine AI (0.7+/-2.9), prone AI (1.0+/-2.9), left-lateral decubitus AI (0.3+/-2.9) or the right-lateral decubitus AI (1.1+/-3.0), p=0.44. Children spent an average of 50% of their total sleep time supine. OSA was significantly worse in REM sleep as compared to non-REM sleep (REM AHI 4.3+/-7.3 versus non-REM AHI 1.4+/-3.9, p=0.015; REM AI 5.1+/-4.9 versus non-REM AI 1.5+/-4.9, p<0.001). Mean time in REM sleep was 26% (range 5-42%). CONCLUSIONS: There was no significant effect of body position on sleep-disordered breathing in 8-12 months old infants, although REM sleep represented a significant risk factor for OSA.