An increased proportion of deaths occur in the intensive care unit (ICU). We performed this prospective study in 41 ICUs to determine the prevalence and determinants of complicated grief after death ...of a loved one in the ICU. Relatives of 475 adult patients were followed up. Complicated grief was assessed at 6 and 12 months using the Inventory of Complicated Grief (cut-off score >25). Relatives also completed the Hospital Anxiety and Depression Scale at 3 months, and the Revised Impact of Event Scale for post-traumatic stress disorder symptoms at 3, 6 and 12 months. We used a mixed multivariate logistic regression model to identify determinants of complicated grief after 6 months. Among the 475 patients, 282 (59.4%) had a relative evaluated at 6 months. Complicated grief symptoms were identified in 147 (52%) relatives. Independent determinants of complicated grief symptoms were either not amenable to changes (relative of female sex, relative living alone and intensivist board certification before 2009) or potential targets for improvements (refusal of treatment by the patient, patient died while intubated, relatives present at the time of death, relatives did not say goodbye to the patient, and poor communication between physicians and relatives). End-of-life practices, communication and loneliness in bereaved relatives may be amenable to improvements.
PURPOSE Patients with hematologic malignancies are increasingly admitted to the intensive care unit (ICU) when life-threatening events occur. We sought to report outcomes and prognostic factors in ...these patients. PATIENTS AND METHODS Ours was a prospective, multicenter cohort study of critically ill patients with hematologic malignancies. Health-related quality of life (HRQOL) and disease status were collected after 3 to 6 months. Results Of the 1,011 patients, 38.2% had newly diagnosed malignancies, 23.1% were in remission, and 24.9% had received hematopoietic stem-cell transplantations (HSCT, including 145 allogeneic). ICU admission was mostly required for acute respiratory failure (62.5%) and/or shock (42.3%). On day1, 733 patients (72.5%) received life-supporting interventions. Hospital, day-90, and 1-year survival rates were 60.7%, 52.5%, and 43.3%, respectively. By multivariate analysis, cancer remission and time to ICU admission less than 24 hours were associated with better hospital survival. Poor performance status, Charlson comorbidity index, allogeneic HSCT, organ dysfunction score, cardiac arrest, acute respiratory failure, malignant organ infiltration, and invasive aspergillosis were associated with higher hospital mortality. Mechanical ventilation (47.9% of patients), vasoactive drugs (51.2%), and dialysis (25.9%) were associated with mortality rates of 60.5%, 57.5%, and 59.2%, respectively. On day 90, 80% of survivors had no HRQOL alterations (physical and mental health similar to that of the overall cancer population). After 6 months, 80% of survivors had no change in treatment intensity compared with similar patients not admitted to the ICU, and 80% were in remission. CONCLUSION Critically ill patients with hematologic malignancies have good survival, disease control, and post-ICU HRQOL. Earlier ICU admission is associated with better survival.
OBJECTIVES:The current trend to manage critically ill hematologic patients admitted with acute respiratory failure is to perform noninvasive ventilation to avoid endotracheal intubation. However, ...failure of noninvasive ventilation may lead to an increased mortality.
DESIGN:Retrospective study to determine the frequency of noninvasive ventilation failure and identify its determinants.
SETTING:Medical intensive care unit in a University hospital.
PATIENTS:All consecutive patients with hematologic malignancies admitted to the intensive care unit over a 10-yr period who received noninvasive ventilation.
RESULTS:A total of 99 patients were studied. Simplified Acute Physiology Score II at admission was 49 (median, interquartile range, 39–57). Fifty-three patients (54%) failed noninvasive ventilation and required endotracheal intubation. Their Pao2/Fio2 ratio was significantly lower (175 101–236 vs. 248 134–337) and their respiratory rate under noninvasive ventilation was significantly higher (32 breaths/min 30–36 vs. 28 27–30). Forty-seven patients (89%) who failed noninvasive ventilation required vasopressors. Hospital mortality was 79% in those who failed noninvasive ventilation, and 41% in those who succeeded. Patients who failed noninvasive ventilation had a significantly longer intensive care unit stay (13 days 8–23 vs. 5 2–8) and a significantly higher rate of intensive care unit-acquired infections (32% compared with 7%). Factors independently associated with noninvasive ventilation failure by multivariate analysis were respiratory rate under noninvasive ventilation, longer delay between admission and noninvasive ventilation first use, need for vasopressors or renal replacement therapy, and acute respiratory distress syndrome.
CONCLUSIONS:Failure of noninvasive ventilation occurs in half the critically ill hematologic patients and is associated with an increased mortality. Predictors of noninvasive ventilation failure might be used to guide decisions regarding intubation.
Nearly 15% of cancer patients experience acute respiratory failure (ARF) requiring admission to the intensive care unit, where their mortality is about 50%. This review focuses on ARF in cancer ...patients. The most recent literature is reviewed, and emphasis is placed on current controversies, most notably the risk/benefit ratio of fiberoptic bronchoscopy and BAL in patients with severe hypoxemia.
Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is the cornerstone of the causal diagnosis. However, the low diagnostic yield of about 50%, related to the widespread use of broad-spectrum antimicrobial therapy in cancer patients, has generated interest in high-resolution computed tomography (HRCT) and primary surgical lung biopsy. In patients with hypoxemia, bronchoscopy and BAL may trigger a need for invasive mechanical ventilation, thus considerably decreasing the chances of survival.
The place for recently developed, effective, noninvasive diagnostic tools (tests on sputum, blood, urine, and nasopharyngeal aspirates) needs to be determined. The prognosis is not markedly influenced by cancer characteristics; it is determined chiefly by the cause of ARF, need for mechanical ventilation, and presence of other organ failures. Although noninvasive ventilation reduces the need for endotracheal intubation and diminishes mortality rate, its prolonged use in patients with severe disease may preclude optimal diagnostic and therapeutic management. The appropriateness of switching to endotracheal mechanical ventilation in patients who fail noninvasive ventilation warrants evaluation.
This review discusses risks and benefits from invasive and non invasive diagnostic and therapeutic strategies in critically ill cancer patients with acute respiratory failure. Avenues for research are also suggested in order to improve survival in these very high risk patients.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The death of a loved one in an intensive care unit is an emotionally trying experience. These investigators compared a proactive end-of-life conference with family members, including the provision of ...an informational brochure, with a customary conference; outcomes were reported by family members 90 days after the loved one's death. Family members who participated in the intervention conference had improved outcomes, as compared with those who participated in the standard conference.
These investigators compared a proactive end-of-life conference with a customary conference. Family members who participated in the proactive conference had improved outcomes.
Having a loved one die in the intensive care unit (ICU) is an extraordinarily stressful event.
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The patient is usually unable to communicate with the family or with ICU staff. Qualitative and quantitative studies of families in this situation
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have identified effective communication between caregivers and families and support from caregivers throughout the decision-making process as important to family members.
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In many ICUs, an end-of-life family conference, which is rooted in findings from epidemiologic and interventional studies on communicating with families of dying patients, is an important part of ICU practice.
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In these conferences, family members and ICU staff . . .
Background Acute kidney injury (AKI) in the setting of hemophagocytic lymphohistiocytosis (HLH) is poorly characterized. This study aims to describe the incidence, clinical and biological features, ...and outcome associated with AKI in this population. Study Design Case series. Setting & Participants Patients with secondary HLH admitted to a single center from February 2007 through January 2013. 95 patients were included in the study. Predictor AKI. Outcomes Recovery of kidney function, 6-month mortality, and complete remission of the underlying disease. Measurements AKI was defined according to the KDIGO 2012 guideline. Recovery of kidney function was defined as improvement in serum creatinine level, with return to baseline serum creatinine level ±26.5 μmol/L. Results HLH was related to hematologic malignancy in 73 (77%), infectious disease in 21 (22%), and autoimmune disease in 9 (10%) patients and was multifactorial in 10 (11%) patients. The cause was undetermined in 2 (2%) patients. The incidence of AKI during HLH is high (62%), and 59% of the AKI population required renal replacement therapy. Main causes of AKI were acute tubular necrosis (49%), hypoperfusion (46%), tumor lysis syndrome (29%), or HLH-associated glomerulopathies (17%). At 6 months, 32% of the patients with AKI had chronic kidney disease. Two factors were associated independently with 6-month mortality by multivariable analysis: AKI stage ≥ 2 (OR, 2.61; 95% CI, 1.08-6.29; P = 0.03) and an underlying hematologic malignancy (OR, 3.1; 95% CI, 1.05-9.14; P = 0.04). In patients with hematologic malignancy, AKI was associated with lower 6-month complete remission (non-AKI, 25%; AKI patients, 5%; P = 0.05). Limitations Retrospective study, lack of histologic data. Conclusions AKI in patients with HLH is frequent and adversely affects remission and survival. Early intensive management, including administration of etoposide, nephrotoxic drug withdrawal, prevention of tumor lysis syndrome, or aggressive supportive care, might improve kidney function and survival.
Abstract
Patients with acute myeloid leukemia (AML) may present with early complications from sepsis or leukemic infiltration. Benefits from early in-intensive care unit (ICU) hematological ...management was evaluated in 42 adults with newly diagnosed AML with hematological risk of early death (age 46 years, French-American-British FAB M4/5 58%, leukocytes 103 × 109/L) first admitted to the ICU without immediate life support (early-ICU). Controls were 42 patients primarily admitted to hematology wards, matched for age, leukocytes and FAB subtype. Twenty (47.6%) control patients were subsequently admitted to the ICU (late-ICU). Late-ICU patients presented with increased respiratory and cardiac rates, decreased oxygen saturation (SpO2) and blood pressure, at hospital admission. Late-ICU admission resulted in increased use of mechanical ventilation (60% vs. 33%) and vasopressors (60% vs. 16%), longer ICU stay (9 6-25 vs. 5 2-9 days) and decreased ICU survival (65% vs. 79%). Direct admission to the ICU of patients with high-risk AML with physiological disturbances but no organ dysfunction is associated with improved outcomes.
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DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Objective
Therapeutic advances have improved survival in patients with myeloma (MM) over the past decade. We investigated whether survival has also improved in critically ill myeloma patients.
Design
...Retrospective study.
Setting
Intensive care unit.
Patient
Consecutive myeloma patients admitted to a teaching hospital ICU between 1990 and 2006. We compared three year-of-admission groups (1990–1995, 1996–2001, and 2002–2006) that matched changes in myeloma treatment (chemotherapy only, stem cell transplantation, and new molecules, respectively).
Intervention
None.
Measurements and main results
We included 196 patients. Reasons for ICU admission and patient characteristics were similar across groups; however, less use of conventional chemotherapy and radiotherapy and greater use of steroids were noted in the more recent periods. Over time, vasopressors and invasive mechanical ventilation were used decreasingly, and noninvasive ventilation increasingly, to treat acute respiratory failure. Hospital mortality decreased from 75% in 1990–1995 to 49% in 1996–2001 and 40% in 2002–2006 (
P
= 0.0007). Mortality was associated with poor performance status OR 2.27, 95% CI (1.04–4.99), need for mechanical ventilation OR 4.33, 95% CI (1.86–10.10), need for vasopressors OR 2.57, 95% CI (1.12–5.86), and admission for an event related to myeloma progression OR 2.77, 95% CI (1.13–6.79). ICU admission within 48 h after hospital admission was associated with lower mortality OR 0.28, 95% CI (0.19–0.89).
Conclusion
Hospital mortality decreased significantly over the last 15 years in myeloma patients admitted to the ICU. Risk factors for death were organ failure and poor chronic health status. Early ICU admission was associated with lower mortality, suggesting opportunities for further improving survival.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Acute renal failure (ARF) in cancer patients is a dreadful complication that causes substantial morbidity and mortality. Moreover, ARF may preclude optimal cancer treatment by requiring a decrease in ...chemotherapy dosage or by contraindicating potentially curative treatment. The pathways leading to ARF in cancer patients are common to the development of ARF in other conditions. However, ARF may also develop due to etiologies arising from cancer treatment, such as nephrotoxic chemotherapy agents or the disease itself, including post-renal obstruction, compression or infiltration, and metabolic or immunological mechanisms. This article reviews specific renal disease in cancer patients, providing a comprehensive overview of the causes of ARF in this setting, such as treatment toxicity, acute renal failure in the setting of myeloma or bone marrow transplantation.
Abstract
Acute myeloid leukemia (AML) can result in acute respiratory failure (ARF) during the first days, requiring intensive care unit (ICU) admission in half the cases. We describe three ...leukemia-specific syndromes responsible for ARF: leukostasis, pulmonary leukemic infiltration (PLI) and acute lysis pneumopathy (ALP). We retrospectively analyzed clinical and laboratory data from 114 patients admitted to a medical ICU within 10 days after a diagnosis of AML. Respiratory events (REs) occurred in 95 patients and were leukemia-specific in 58 patients (61%). Day-28 mortality was 34.5% in patients with leukemia-specific REs (leukostasis, 41%; PLI, 23%; and ALP, 31%) and 48.6% in patients with other REs. By multivariate analysis, independent risk factors for death were age > 50 (odds ratio, 13; 95% confidence interval, 3-51), Eastern Cooperative Oncology Group (ECOG) status ≥ 2 (5.4; 1.8-17) and need for invasive mechanical ventilation (19; 5-75). Dexamethasone therapy was protective (0.26; 0.09-0.8), suggesting a role as a preventive treatment in patients with AML-related non-infectious pulmonary involvement.
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DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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