The APSY-SED study: protocol of an observational, longitudinal, mixed methods and multicenter study exploring the psychological adjustment of relatives and healthcare providers of patients with cancer with continuous deep sedation until death.

BACKGROUND: Since 2016, France is the only country in the World where continuous deep sedation until death (CDSUD) is regulated by law. CDSUD serves as a response to refractory suffering in palliative situations where the patients' death is expected to occur in the following hours or days. Little is known on the psychological adjustment surrounding a CDSUD procedure for healthcare providers (HCPs) and relatives. Our study aims to gather qualitative and quantitative data on the specific processes behind the psychological adjustment of both relatives and HCPs, after the administration of CDSUD for patients with cancer. METHODS: The APSY-SED study is a prospective, longitudinal, mixed-methods and multicenter study. Recruitment will involve any French-speaking adult cancer patient for who a CDSUD is discussed, their relatives and HCPs. We plan to include 150 patients, 150 relatives, and 50 HCPs. The evaluation criteria of this research are: 1/ Primary criterion: Psychological adjustment of relatives and HCPs 6 and 13 months after the death of the patient with cancer (psychological adjustment = intensity of anxiety, depression and grief reactions, CDSUD-related distress, job satisfaction, Professional Stress and Professional experience). Secondary criteria: a)occurrence of wish for a CDSUD in patients in palliative phase; b)occurrence of wish for hastened death in patients in palliative phase; c)potential predictors of adjustment assessed after the discussion concerning CDSUD as an option and before the setting of the CDSUD; d) Thematic analysis and narrative account of meaning-making process concerning the grief experience. DISCUSSION: The APSY-SED study will be the first to investigate the psychological adjustment of HCPs and relatives in the context of a CDSUD procedure implemented according to French law. Gathering data on the grief process for relatives can help understand bereavement after CDSUD, and participate in the elaboration of specific tailored interventions to support HCPs and relatives. Empirical findings on CDSUD among patients with cancer in France could be compared with existing data in other countries and with results related to other medical fields where CDSUD is also conducted. TRIAL REGISTRATION: This protocol received the National Registration Number: ID-RCB2021-A03042-39 on 14/12/2021.

Ventilator-associated pneumonia and bloodstream infections in intensive care unit cancer patients: a retrospective 12-year study on 3388 prospectively monitored patients.

PURPOSE: Some publications suggest high rates of healthcare-associated infections (HAIs) and of nosocomial pneumonia portending a poor prognosis in ICU cancer patients. A better understanding of the epidemiology of HAIs in these patients is needed. METHODS: A retrospective analysis of all the patients hospitalized for ≥ 48 h during a 12-year period in the 12-bed ICU of the Gustave Roussy hospital, monitored prospectively for ventilator-associated pneumonia (VAP) and bloodstream infection (BSI) and for use of medical devices. RESULTS: During 3388 first stays in the ICU, 198 cases of VAP and 103 primary, 213 secondary, and 77 catheter-related BSIs were recorded. The VAP rate was 24.5/1000 ventilator days (95% confidence interval [CI] 21.2-28.0); the catheter-related BSI rate was 2.3/1000 catheter days (95% CI 1.8-2.8). The cumulative incidence during the first 25 days of exposure was 58.8% (95% CI 49.1-66.6%) for VAP, 8.9% (95% CI, 6.2-11.5%) for primary, 15.1% (95% CI 11.6-18.5%) for secondary and 5.0% (95% CI 3.2-6.8%) for catheter-related BSIs. VAP or BSIs were not associated with a higher risk of ICU mortality. CONCLUSIONS: This is the first study to report HAI rates in a large cohort of critically ill cancer patients. Although both the incidence of VAP and the rate of BSI are higher than in general ICU populations, this does not impact patient outcomes. The occurrence of device-associated infections is essentially due to severe medical conditions in patients and to the characteristics of malignancy.

Characteristics and outcome of patients with newly diagnosed advanced or metastatic lung cancer admitted to intensive care units (ICUs).

BACKGROUND: Although patients with advanced or metastatic lung cancer have poor prognosis, admission to the ICU for management of life-threatening complications has increased over the years. Patients with newly diagnosed lung cancer appear as good candidates for ICU admission, but more robust information to assist decisions is lacking. The aim of our study was to evaluate the prognosis of newly diagnosed unresectable lung cancer patients. METHODS: A retrospective multicentric study analyzed the outcome of patients admitted to the ICU with a newly diagnosed lung cancer (diagnosis within the month) between 2010 and 2013. RESULTS: Out of the 100 patients, 30 had small cell lung cancer (SCLC) and 70 had non-small cell lung cancer. (Thirty patients had already been treated with oncologic treatments.) Mechanical ventilation (MV) was performed for 81 patients. Seventeen patients received emergency chemotherapy during their ICU stay. ICU, hospital, 3- and 6-month mortality were, respectively, 47, 60, 67 and 71%. Hospital mortality was 60% when invasive MV was used alone, 71% when MV and vasopressors were needed and 83% when MV, vasopressors and hemodialysis were required. In multivariate analysis, hospital mortality was associated with metastatic disease (OR 4.22 [1.4-12.4]; p = 0.008), need for invasive MV (OR 4.20 [1.11-16.2]; p = 0.030), while chemotherapy in ICU was associated with survival (OR 0.23, [0.07-0.81]; p = 0.020). CONCLUSION: This study shows that ICU management can be appropriate for selected newly diagnosed patients with advanced lung cancer, and chemotherapy might improve outcome for patients with SCLC admitted for cancer-related complications. Nevertheless, tumors' characteristics, numbers and types of organ dysfunction should be taken into account in the decisional process before admitting these patients in ICU.

Differential time to positivity of central and peripheral blood cultures is inaccurate for the diagnosis of Staphylococcus aureus long-term catheter-related sepsis.

OBJECTIVES: Differential time to positivity of cultures of blood drawn simultaneously from central venous catheter and peripheral sites is widely used to diagnose catheter-related bloodstream infections without removing the catheter. However, the accuracy of this technique for some pathogens, such as Staphylococcus aureus, is debated in routine practice. METHODS: In a 320-bed reference cancer centre, the charts of patients with at least one blood culture positive for S. aureus among paired blood cultures drawn over a six-year period were studied retrospectively. Microbiological data were extracted from the prospectively compiled database of the microbiology unit. Data concerning the 149 patients included were reviewed retrospectively by independent physicians blinded to the absolute and differential times to positivity, in order to establish or refute the diagnosis of catheter-related sepsis. Due to missing data, 48 charts were excluded, so 101 cases were actually analysed. The diagnosis was established in 62 cases, refuted in 15 cases and inconclusive in the remaining 24 cases. RESULTS: For the 64 patients with both central and peripheral positive blood cultures, the differential positivity time was significantly greater for patients with catheter-related bloodstream infections due to S. aureus (P<0.02). However, because of the high number of false-negative cases, the classic cut-off limit of 120 min showed 100% specificity but only 42% sensitivity for the diagnosis of catheter-related bloodstream infection due to S. aureus. CONCLUSIONS: These results strongly suggest that despite its high specificity, the differential time to positivity may not be reliable to rule out catheter-related bloodstream infection due to S. aureus.

Changes in intensive care for allogeneic hematopoietic stem cell transplant recipients.

Intensive care unit (ICU) admission is associated with high mortality in allogeneic hematopoietic stem cell transplant (HSCT) recipients. Whether mortality has decreased recently is unknown. The 497 adult allogeneic HSCT recipients admitted to three ICUs between 1997 and 2011 were evaluated retrospectively. Two hundred and nine patients admitted between 1997 and 2003 were compared with the 288 patients admitted from 2004 to 2011. Factors associated with 90-day mortality were identified. The recent cohort was characterized by older age, lower conditioning intensity, and greater use of peripheral blood or unrelated-donor graft. In the recent cohort, ICU was used more often for patients in hematological remission (67% vs 44%; P<0.0001) and without GVHD (73% vs 48%; P<0.0001) or invasive fungal infection (85% vs 73%; P=0.0003) despite a stable admission rate (21.7%). These changes were associated with significantly better 90-day survival (49% vs 31%). Independent predictors of hospital mortality were GVHD, mechanical ventilation (MV) and renal replacement therapy (RRT). Among patients who required MV or RRT, survival was 29% and 18%, respectively, but dropped to 18% and 6% in those with GVHD. The use of ICU admission has changed and translated into improved survival, but advanced life support in patients with GVHD usually provides no benefits.

Modified selection criteria for complete cytoreductive surgery plus HIPEC based on peritoneal cancer index and small bowel involvement for peritoneal carcinomatosis of colorectal origin.

BACKGROUND: Complete cytoreductive surgery (CCRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is on the verge of becoming the gold standard treatment for selected patients presenting peritoneal metastases (PM) of colorectal origin. PM is scored with the peritoneal cancer index (PCI), which is the main prognostic factor. However, small bowel (SB) involvement could exert an independent prognostic impact. AIM: To define an adequate cut-off for the PCI and to appraise whether SB involvement exerts an impact on this cut-off. PATIENTS AND METHODS: Patients (n = 139) treated with CCRS plus HIPEC were prospectively verified and retrospectively analyzed. One hundred presented with SB involvement of different extents and at different locations. RESULTS: All the patients with a PCI ≥ 15 exhibited SB involvement. Five-year overall survival was 48% when the PCI was <15 vs 12% when it was ≥ 15 (p < 0.0001. The multivariate analysis retained two prognostic factors: PCI ≥ 15 (p = 0.02, HR = 1.8), and the involvement of area 12 (lower ileum) (p = 0.001, HR = 3.1). When area 12 was invaded, it significantly worsened the prognosis: 5-year overall survival of patients with a PCI <15 and area 12 involved was 15%, close to that of patients with a PCI ≥ 15 (12%) and far lower than that of patients with a PCI <15 and no area 12 involvement (70%). CONCLUSION: A PCI greater than 15 appears to be a relative contraindication for treatment of colorectal PM with CCRS + HIPEC. Involvement of the lower ileum is also a negative prognostic factor to be taken into consideration.

Intensive care in patients with lung cancer: a multinational study.

BACKGROUND: Detailed information about lung cancer patients requiring admission to intensive care units (ICUs) is mostly restricted to single-center studies. Our aim was to evaluate the clinical characteristics and outcomes of lung cancer patients admitted to ICUs. PATIENTS AND METHODS: Prospective multicenter study in 449 patients with lung cancer (small cell, n = 55; non-small cell, n = 394) admitted to 22 ICUs in six countries in Europe and South America during 2011. Multivariate Cox proportional hazards frailty models were built to identify characteristics associated with 30-day and 6-month mortality. RESULTS: Most of the patients (71%) had newly diagnosed cancer. Cancer-related complications occurred in 56% of patients; the most common was tumoral airway involvement (26%). Ventilatory support was required in 53% of patients. Overall hospital, 30-day, and 6-month mortality rates were 39%, 41%, and 55%, respectively. After adjustment for type of admission and early treatment-limitation decisions, determinants of mortality were organ dysfunction severity, poor performance status (PS), recurrent/progressive cancer, and cancer-related complications. Mortality rates were far lower in the patient subset with nonrecurrent/progressive cancer and a good PS, even those with sepsis, multiple organ dysfunctions, and need for ventilatory support. Mortality was also lower in high-volume centers. Poor PS predicted failure to receive the initially planned cancer treatment after hospital discharge. CONCLUSIONS: ICU admission was associated with meaningful survival in lung cancer patients with good PS and non-recurrent/progressive disease. Conversely, mortality rates were very high in patients not fit for anticancer treatment and poor PS. In this subgroup, palliative care may be the best option.

Airway fire during tracheostomy.

INTRODUCTION: Twenty-five cases of airway fire during tracheostomy have been reported in the literature. The authors describe a case observed in their centre 3 years ago, discuss the causes and preventive management and propose guidelines for prevention of this complication. CASE REPORT: A 66-year-old woman was intubated and ventilated with 100% oxygen during general anaesthesia for tracheostomy. On opening the trachea by monopolar diathermy, the oxygen present in the endotracheal tube caught fire, inducing combustion of the tube spreading to the lower airways. This airway fire was responsible for severe acute respiratory failure and the formation of multiple laryngotracheal stenoses. DISCUSSION: Combustion of the endotracheal tube due to ignition of anaesthetic gases induced by the heat generated by diathermy is responsible for airway fire. These various phenomena are discussed. Prevention is based on safety measures and coordination of surgical and anaesthetic teams.

Discontinuation of empirical antibiotic therapy in neutropenic acute myeloid leukaemia patients with fever of unknown origin: is it ethical?

Based on recommendations of the ECIL-4, we prospectively evaluated discontinuation of empirical antibiotic therapy in high-risk neutropenic acute myeloid leukaemia patients with fever of unknown origin. Seven patients (median neutropenia duration 30 days) were included. Four of them remained afebrile but quickly recovered from neutropenia. The other three had rapid recurrent fever. Two of these three patients had bacteraemia with susceptible strains and one of them was transferred to the ICU for septic shock. Median duration of sparing of antibiotics for the seven patients was 3 days (2-4). Because of these limited results the study was stopped.

Diagnostic strategy for oncology patients with acute respiratory failure.

Acute respiratory failure (ARF) is frequent and often fatal in patients with a malignancy. However, there is not one type of "oncology patient", and it's high time that both clinical management and further studies consider specific populations rather than the heterogeneous and artificial group of "cancer patients". This individual-based approach will allow a relevant use of the numerous non invasive diagnostic tools developed during the past years: high resolution tomodensitometry, echocardiography, urine or serum antigen assays, polymerase chain reaction, serum biomarkers etc. These non invasive tools have reduced but not weakened the value of fiberoptic bronchoscopy and bronchoalveolar lavage: some subsets of patients may always benefit from this technique, particularly when new protective strategies such as non invasive mechanical ventilation and target-controlled infusion of sedative drugs are used. The present review focuses on the personalised approach required in "oncology patients" with ARF, based on first identifying the pattern of immunodeficiency, then listing the most probable hypotheses in the light of clinical and radiological findings in order to, finally, select the most accurate diagnostic tools.

[Treatment of infected breast implant in reconstructive surgery]. / Complication infectieuse sur prothèse en chirurgie reconstructrice mammaire : quelle attitude thérapeutique adopter ?

OBJECTIVE OF THE STUDY: Immediate failure in breast surgery with implant is a serious medical complication with negative ramifications for both the patient and the health care system. The classical treatment is removal of the breast implant and delay reconstruction. Our objective is to show that this standard treatment is not the good one in many cases, and abundant irrigation with implant salvage is a sure and effective alternative. PATIENTS AND METHODS: Between January 2001 and December 2009, among the 680 patients who had a breast reconstruction, 18 were operated using the same protocol treatment by the same surgeon: implant removal, irrigation, implant replacement, antibiotic treatment. RESULTS: After a median month follow-up period of 30 months, definitive conservation of the breast implant was obtained in all of the cases. CONCLUSION: This preliminary study provides encouraging results in a selected patient population improving the possibility of a conservative treatment according to a precise and rigourous protocol.

Poor prognosis nonseminomatous germ-cell tumours (NSGCTs): should chemotherapy doses be reduced at first cycle to prevent acute respiratory distress syndrome in patients with multiple lung metastases?

BACKGROUND: Patients with extensive lung metastases from nonseminomatous germ-cell tumours (NSGCTs) and dyspnoea at presentation are at high risk of acute respiratory distress syndrome (ARDS) and death within the first weeks after chemotherapy induction. This syndrome is linked to acute intra-alveolar haemorrhage related to early tumour necrosis, which in turn, can be complicated by pulmonary infection promoted by neutropenia. The management of these patients was modified at Institut Gustave Roussy in 1997 to try to avoid this complication. PATIENTS AND METHODS: Data concerning all patients with lung metastases from NSGCT and dyspnoea or a partial pressure of oxygen (pO(2)) <80 mmHg treated from 1980 to 2006 in our institution were collected. Patients were treated in a specialised intensive care unit. From 1980 to 1997, the first chemotherapy cycle consisted in a full-dose regimen. After 1997, a 3-day reduced induction regimen of EP (cisplatin 20 mg/m(2)/day and etoposide 100 mg/m(2)/day) was used, with bleomycin and two additional days of EP being postponed to day 15, with the regular BEP regimen being started at day 21. RESULTS: Twenty-five patients with poor-risk disseminated NSGCT according to the International Germ Cell Consensus Classification Group had extensive lung metastases plus dyspnoea at presentation (n = 6), a pO(2) <80 mmHg (n = 2), or both criteria (n = 17). Median human chorionic gonadotrophin was 200 000 UI (range 11-8 920 000), and 18 of 25 (72%) patients also had nonpulmonary visceral metastases. During the 1980-1997 period, 13 of 15 patients (87%) developed ARDS, 10 of whom died, and only 4 of 15 (27%) patients were long-term survivors. In contrast, during the 1997-2006 period, only 3 of 10 patients (30%) developed ARDS (P = 0.01), 2 of whom died, and 4 of 10 (40%) eventually survived. CONCLUSION: Initial reduction of chemotherapy doses during the first cycle of chemotherapy for poor prognosis NSGCT with extensive lung metastases seems to prevent the risk of early death due to ARDS.

Is routine changing of peripheral arterial catheters justified?

Although peripheral arterial catheters (pACs) are used extensively, disagreement persists concerning the practice of scheduled replacement to prevent catheter-related infections. Despite recommendations and no proof of benefit, pAC replacement continues to be scheduled as a routine practice in many intensive care units (ICUs) worldwide. Our own experience in an oncology ICU, based on a 217-device database, confirms that the risk for pAC-related infections is stable over time, arguing against scheduled replacement. The low rate and stability of the risk of pAC-related infections supports the rationale for conservative management in accordance with expert recommendations.

[Stomach rupture after nasal oxygen administration]. / Rupture gastrique après oxygénothérapie par voie nasale.

We report a case of a spontaneous rupture of a normal stomach after therapeutic oxygen administration. In this case, early treatment precluded the need for a laparotomy. This rare complication highlights the importance of the right positioning of a nasal catheter and leads us to question its role compared to other means of oxygen delivery (nasal cannulae, Hudson mask, Venturi mask).

Isospora belli infection in a patient with non-Hodgkin's lymphoma.

Isospora belli infection is frequent in patients with acquired immunodeficiency syndrome in tropical areas. It has also been reported in other immunodepressive diseases, such as lymphoblastic leukemia, adult T-cell leukemia, and Hodgkin's disease. To date, no case of non-Hodgkin's lymphoma-related isosporiasis has been reported in a non-HIV-infected patient. We describe a case of non-Hodgkin's lymphoma with chronic diarrhea due to I. belli. In Europe, I. belli can cause severe chronic diarrhea in patients with malignancies whose country of origin is in an endemic area. Trimethoprim-sulfamethoxazole can provide rapid and prolonged clinical and parasitologic cure.

[A study of early tracheostomy in patients undergoing prolonged mechanical ventilation]. / Etude de l'intérêt de la trachéotomie précoce chez les malades sous ventilation mécanique prolongée.

BACKGROUND: Several complications are associated to mechanical ventilation (MV), especially if the duration of MV is prolonged: nosocomial pneumonias and sinusitis, laryngeal and tracheal complications (such as stenosis or granuloma). Pneumonias, en particular, seem to be associated to an increased mortality risk. Overall, the hospital mortality rate of patients undergoing MV for more than 7 days is 45%. Early tracheostomy could allow to reduce some of these complications; however, the actual value of this procedure has never been proven. AIM OF THE STUDY: The aim of this multicenter randomized trial is to assess the potential interest of early tracheostomy (before the 4th day of MV) compared to translaryngeal intubation, in critically ill patients undergoing MV for more than 7 days, in reducing mortality rate, incidence of pneumonias, and duration of MV. METHODS: Inclusion criteria are: MV since<4 days, forseable duration of MV>7 days, age>18-yr, and informed consent obtained. Exclusion criteria are: MV since > 4 days, presence of tracheostomy, major risk of bleeding, cervical infectious disease, "moribund" state (according to SAPS II and OSF scores), MV or CPAP at home, non reversible neurologic disease, intracranial hypertension. The randomization is performed before the end of the 4th day of MV. EXPECTED RESULTS: A decrease of mortality rate on d.28 from 45% to 32% is expected (two-sided test, alpha=0.05, B=0.80); overall, 468 patients should be included over a 3-yr period in at least 50 centers. In addition, a decrease of the incidence of pneumonias and of duration of MV during the first 28 days is expected. Secondary endpoints are mortality rate on d.60, hospital mortality, total duration of MV, infectious complications (other than pneumonias), laryngeal and tracheal complications, duration of sedation, duration of stay in intensive care unit, hospital costs, and comfort of patients.

Acute respiratory distress syndrome after chemotherapy for lung metastases from non-seminomatous germ-cell tumors.

GOALS: To describe an acute respiratory distress syndrome (ARDS) occurring after chemotherapy for non-seminomatous germ-cell tumors (NSGCT) with diffuse lung metastases, we conducted a retrospective study in a 15-bed intensive care unit (ICU) in a comprehensive cancer center. PATIENTS AND METHODS: During a 10-year period, 16 consecutive patients with diffuse lung metastases from a NSGCT were admitted to the ICU for respiratory distress and high-risk chemotherapy. MAIN RESULTS: Nine patients developed acute respiratory failure requiring mechanical ventilation (MV) within 3 days of the initiation of chemotherapy, while the respiratory status of the seven other patients improved. The evolution was independent of tumor marker levels and the type of chemotherapy regimen. The SAPS II score did not accurately describe the severity of this population. The only predictor of intubation was the initial PaO2/FiO2 ratio upon admission to the ICU. Six out of seven patients who did not require MV were discharged alive from the hospital, whereas all but one patient requiring MV died. Refractory hypoxemia and ventilator-associated pneumonia were the leading causes of death. CONCLUSIONS: Acute respiratory distress in patients with lung metastases from NSGCT is a rare cause of ARDS. Chemotherapy could be responsible for triggering the respiratory worsening. Patients with severe respiratory insufficiency (PaO2 <70 mmHg on room air) on admission to hospital should be promptly transferred to the ICU for the first chemotherapy course.

Severity of illness scores: are they useful in febrile neutropenic adult patients in hematology wards? A prospective multicenter study.

OBJECTIVE: To assess the prognostic value of two severity of illness scores, commonly used for critically ill patients, Simplified Acute Physiology Score (SAPS II) and Organ Dysfunctions and Infection (ODIN), in predicting mortality in febrile neutropenic patients in hematology wards. DESIGN: A 2-month prospective multicenter study. SETTING: Thirty-six hematologic and/or stem cell transplant units in France. PATIENTS: All adult patients with a first febrile neutropenic episode (polymorphonuclear cells <500/mm(3)) were included. INTERVENTIONS: SAPS II was calculated on day 1 of fever, and ODIN on days 1 and 8. The end point was the mortality rate on day 28. MEASUREMENTS AND MAIN RESULTS: Twenty-eight (6.6%) of the 421 patients included died before day 28. The mortality rate predicted by SAPS II was 23.8%, indicating a poor calibration. The SAPS II score at day 1 was greater in nonsurvivors than in survivors (44 +/- 11 vs. 38 +/- 7, p <.0001), as was the number of patients with one or more organ failures at day 1 (14 vs. 2%, p <.0001), and day 8 (42 vs. 3%, p <.0001). The pattern of change in the scores over the first 8 days differed significantly between survivors and nonsurvivors. In multivariate analysis, only ODIN on day 1 and day 8, and spontaneous neutropenia were independent predictors for death. CONCLUSIONS: SAPS II and ODIN scores are inaccurate for predicting individual outcome of febrile neutropenic patients in hematology wards. Serial measurements of these scores during the first week of hospitalization could be more accurate than a single measurement. Besides severity scores and organ failures, the type of neutropenia is at least as important in assessing the prognosis.