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Introduction: Given clinicians' frequent concerns about unfavourable outcomes, Intensive Care Unit (ICU) triage decisions in acutely ill cancer patients can be difficult, as clinicians may have doubts about the appropriateness of an ICU admission. To aid to this decision making, we studied the survival and performance status of cancer patients 2 years following an unplanned ICU admission., Materials and Methods: This was a retrospective cohort study in a large tertiary referral university hospital in the Netherlands. We categorized all adult patients with an unplanned ICU admission in 2017 into two groups: patients with or without an active malignancy. Descriptive statistics, Pearson's Chi-square tests and the Mann-Whitney U tests were used to evaluate the primary objective 2-year mortality and performance status. A good performance status was defined as ECOG performance status 0 (fully active) or 1 (restricted in physically strenuous activity but ambulatory and able to carry out light work). A multivariable binary logistic regression analysis was used to identify factors associated with 2-year mortality within cancer patients., Results: Of the 1046 unplanned ICU admissions, 125 (12%) patients had cancer. The 2-year mortality in patients with cancer was significantly higher than in patients without cancer (72% and 42.5%, P <0.001). The median performance status at 2 years in cancer patients was 1 (IQR 0-2). Only an ECOG performance status of 2 (OR 8.94; 95% CI 1.21-65.89) was independently associated with 2-year mortality., Conclusions: In our study, the majority of the survivors have a good performance status 2 years after ICU admission. However, at that point, three-quarter of these cancer patients had died, and mortality in cancer patients was significantly higher than in patients without cancer. ICU admission decisions in acutely ill cancer patients should be based on performance status, severity of illness and long-term prognosis, and this should be communicated in the shared decision making. An ICU admission decision should not solely be based on the presence of a malignancy., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Patients with hematological malignancies are at high risk for life-threatening complications. To date, little attention has been paid to the impact of hyperoxemia and excess oxygen use on mortality. The aim of this study was to investigate the association between partial pressure of arterial oxygen (PaO2) and 28-day mortality in critically ill patients with hematologic malignancies. Methods: Data from three international cohorts (Europe, Canada, Oceania) of patients who received respiratory support (noninvasive ventilation, high-flow nasal cannula, invasive mechanical ventilation) were obtained. We used mixed-effect Cox models to investigate the association between day one PaO2 or excess oxygen use (inspired fraction of oxygen ≥ 0.6 with PaO2 > 100 mmHg) on day-28 mortality. Results: 11,249 patients were included. On day one, 5716 patients (50.8%) had normoxemia (60 ≤ PaO2 ≤ 100 mmHg), 1454 (12.9%) hypoxemia (PaO2 < 60 mmHg), and 4079 patients (36.3%) hyperoxemia (PaO2 > 100 mmHg). Excess oxygen was used in 2201 patients (20%). Crude day-28 mortality rate was 40.6%. There was a significant association between PaO2 and day-28 mortality with a U-shaped relationship (p < 0.001). Higher PaO2 levels (> 100 mmHg) were associated with day-28 mortality with a dose–effect relationship. Subgroup analyses showed an association between hyperoxemia and mortality in patients admitted with neurological disorders; however, the opposite relationship was seen across those admitted with sepsis and neutropenia. Excess oxygen use was also associated with subsequent day-28 mortality (adjusted hazard ratio (aHR) [95% confidence interval (CI)]: 1.11[1.04–1.19]). This result persisted after propensity score analysis (matched HR associated with excess oxygen:1.31 [1.20–1.1.44]). Conclusion: In critically-ill patients with hematological malignancies, exposure to hyperoxemia and excess oxygen use were associated with increased mortality, with variable magnitude across subgroups. This might be a modifiable factor to improve mortality. [ABSTRACT FROM AUTHOR]

Introduction: A decrease in short-term mortality of critically ill cancer patients with an unplanned intensive care unit (ICU) admission has been described. Few studies describe a change over time of 1-year mortality. Therefore, we examined the 1-year mortality of cancer patients (hematological or solid) with an unplanned ICU admission and we described whether the mortality changed over time. Methods: We used the National Intensive Care Evaluation (NICE) registry and extracted all patients with an unplanned ICU admission in the Netherlands between 2008 and 2017. The primary outcome was 1-year mortality, analyzed with a mixed-effects Cox proportional hazard regression. We compared the 1-year mortality of cancer patients to that of patients without cancer. Furthermore, we examined changes in mortality over the study period. Results: We included 470,305 patients: 10,401 with hematological cancer, 35,920 with solid cancer, and 423,984 without cancer. The 1-year mortality rates were 60.1%, 46.2%, and 28.3% respectively (P< .01). Approximately 30% of the cancer patients surviving their hospital admission died within 1 year, this was 12% in patients without cancer. In hematological patients, 1-year mortality decreased between 2008 and 2011, after which it stabilized. In solid cancer patients, inspection showed neither an increasing nor decreasing trend over the inclusion period. For patients without cancer, 1-year mortality decreased between 2008 and 2013, after which it stabilized. A clear decrease in hospital mortality was seen within all three groups. Conclusion: The 1-year mortality of cancer patients with an unplanned ICU admission (hematological and solid) was higher than that of patients without cancer. About one-third of the cancer patients surviving their hospital admission died within 1 year after ICU admission. We found a decrease in 1-year mortality until 2011 in hematology patients and no decrease in solid cancer patients. Our results suggest that for many cancer patients, an unplanned ICU admission is still a way to recover from critical illness, and it does not necessarily lead to success in long-term survival. The underlying type of malignancy is an important factor for long-term outcomes in patients recovering from critical illness. [ABSTRACT FROM AUTHOR]

The article offers information on understanding of adequate antimicrobial treatment as important to reduce mortality in critically ill patients with infection. Topics discussed include combination antibiotic treatment recommended for non-neutropenic and neutropenic patients with sepsis, issues concerning with β-lactam antibiotics concentrations in critically ill patients and role of rapid diagnostic systems in delaying in microbiological identification of pathogens and susceptibility testing.

Background: Acute respiratory failure (ARF) is the most frequent complication in patients with hematological malignancies and is associated with high morbidity and mortality. ARF etiologies are numerous, and despite extensive diagnostic workflow, some patients remain with undetermined ARF etiology. Methods: This is a post-hoc study of a prospective multicenter cohort performed on 1011 critically ill hematological patients. Relationship between ARF etiology and hospital mortality was assessed using a multivariable regression model adjusting for confounders. Results: This study included 604 patients with ARF. All patients underwent noninvasive diagnostic tests, and a bronchoscopy and bronchoalveolar lavage (BAL) was performed in 155 (25.6%). Definite diagnoses were classified into four exclusive etiological categories: pneumonia (44.4%), non-infectious diagnoses (32.6%), opportunistic infection (10.1%) and undetermined (12.9%), with corresponding hospital mortality rates of 40, 35, 55 and 59%, respectively. Overall hospital mortality was 42%. By multivariable analysis, factors associated with hospital mortality were invasive pulmonary aspergillosis (OR 7.57 (95% CI 3.06-21.62); p < 0.005), use of invasive mechanical ventilation (OR 1.65 (95% CI 1.07-2.55); p = 0.02), a SOFA score >7 (OR 3.32 (95% CI 2.15-5.15); p < 0.005) and an undetermined ARF etiology (OR 2.92 (95% CI 1.71-5.07); p < 0.005). Conclusions: In patients with hematological malignancies and ARF, up to 13% remain with undetermined ARF etiology despite comprehensive diagnostic workup. Undetermined ARF etiology is independently associated with hospital mortality. Studies to guide second-line diagnostic strategies are warranted. ClinicalTrials.Gov NCT01172132 [ABSTRACT FROM AUTHOR]

Background. Cancer patients are at high risk for acute kidney injury (AKI), which is associated with high morbidity and mortality. We sought to appraise the incidence, risk factors, and outcome of AKI in a large multicentre cohort study of critically ill patients with haematological malignancies. Methods. We used a retrospective analysis of a prospectively collected database. The study was carried out in 17 university or university-affiliated centres in France and Belgium between 2010 and 2012. AKI was defined according to the Acute Kidney Injury Network (AKIN) definition. Results. Of the 1011 patients admitted into the intensive care unit (ICU) during the study period, 1009 were included in this study. According to the AKIN definition, 671 patients (66.5%) developed an AKI during their ICU stay, of which 258 patients (38.4%) were AKI stage 1, 75 patients (11.2%) AKI stage 2 and 338 patients (50.4%) AKI stage 3. After adjustment for confounders, main adverse risk factors of AKI were older age, severity [non-renal Sequential Organ Failure Assessment (SOFA)], history of hypertension, tumour lysis syndrome, exposure to nephrotoxic agents and myeloma. Hospital mortality was 44.3% in patients with AKI and 25.4% in patients without AKI (P < 0.0001). After adjustment for confounders, AKI was independently associated with hospital mortality [OR 1.65 (95% CI 1.19-2.29)]. Overall, 271 patients required renal replacement therapy (RRT), of whom 57.2% died during their hospital stay as compared with 31.2% (P < 0.0001) in those not requiring RRT. Conclusion. Two-thirds of critically ill patients with haematological malignancies developed AKI. Hospital mortality in this population of patients developing AKI or requiring RRT is close to that in general ICU population. [ABSTRACT FROM AUTHOR]

The article discusses studies that argue for and against the claim that survival rates in critically ill patients with cancer increased. Topics discussed include a comparison in the survival rates of patients with cancer, severe sepsis and septic shock, argument that survival rates are based on studies performed in heterogeneous populations from different experiences and cultures and survival benefits from earlier and better supportive care provided to patients with less comorbidities.

The article discusses various studies which appeared in "Intensive Care Medicine" journal in 2013. Information is presented on the study in Malaysia which assessed whether early sedation depth was independently associated with delayed extubation and increased mortality. An overview of a review article about efficient weaning and automatic ventilation modes for failing patients.

Purpose: To compare evolution in organ dysfunction (OD) between hematologic malignancy patients with and without bacterial infection (BI) precipitating intensive care unit (ICU) admission, and to assess its impact on mortality. Methods: Retrospective analysis of prospectively collected data was performed. Sequential Organ Failure Assessment (SOFA) scores from day 1 to 5 were calculated in all consecutive hematologic malignancy patients admitted to the ICU (2000-2006). Patients were categorized according to the presence or absence, the diagnostic certainty, and the site of BI. Results: Of the 344 patients admitted, 258 were still in the ICU at day 3 and 164 at day 5. Patients admitted because of BI had more severe OD on day 1 (SOFA 9.7 ± 4.0 vs. 8.4 ± 4.0, p = 0.008) but a more rapidly reversible OD within the first 3 days (ΔSOFA −1.12 ± 3.10 vs. 0.03 ± 3.40, p = 0.013) and a lower in-hospital (43.2% vs. 62.9%, p < 0.001) and 6-month mortality (52.1% vs. 71.7%, p < 0.001) than patients with other complications. In a multivariate analysis, BI remained associated with a lower risk of death (OR 0.20, 95% CI 0.1-0.4, p < 0.001) even after adjustment for the SOFA on day 1 (OR 1.36, 95% CI 1.22-1.52, p < 0.001) and the ΔSOFA (OR 1.48, 95% CI 1.29-1.68, p < 0.001). These findings remained significant regardless of the site and the diagnostic certainty of BI. Conclusion: BI is associated with a more severe initial but a more rapidly reversible OD and a subsequent lower mortality compared to other complications in ICU patients with hematologic malignancies. These findings further support the recommendation that these patients should certainly benefit from advanced life support, and in the case of an uncertain long-term prognosis due to the underlying malignancy, at least from a 3-day ICU trial. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The aim of this study was to assess the impact of the 3 types of initial respiratory support (noninvasive positive pressure ventilation vs invasive positive pressure ventilation vs supplemental oxygen only) in hematological patients with acute hypoxemic respiratory failure (ARF). Materials and Methods: This study is a retrospective analysis of a cohort of hematological patients admitted to the intensive care unit (ICU) of a tertiary care hospital between January 1, 2002, and June 30, 2006. Results: One hundred thirty-seven hematological patients were admitted at the ICU with ARF (defined as Pao 2/Fio 2 <200): within the first 24 hours, 24 and 67 patients received noninvasive positive pressure ventilation and invasive positive pressure ventilation, respectively, and 46 received supplemental oxygen only. Intensive care unit mortality in the 3 patient categories was 71%, 63%, and 32%, respectively (P = .001), and in-hospital mortality was 75%, 80%, and 47%, respectively (P = .001). In multivariate regression analysis, increasing cancer-specific severity-of-illness score upon admission and more organ failure after 24 hours of ICU admission, but not the type of initial respiratory support, were significantly associated with ICU or in-hospital mortality. Conclusions: Intensive care unit and in-hospital mortality in our population of hematological patients with hypoxemic ARF was determined by severity of illness and not by the type of initial respiratory support. [Copyright &y& Elsevier]

The authors comment on research works on immunocompromised patients. They discuss the inability of immunocompromised patients to fight infection, a study on mortality in children with cancer compared to hematologic cancer patients and with solid cancer patients, studies on the outcomes in critically ill cancer patients, and the need for these studies to appraise beliefs on intensive care unit management of immunocompromised patients.

Objective: To assess the outcome in severely ill patients with hematological malignancies who receive intravenous chemotherapy in an intensive care unit (ICU) for a life-threatening malignancy-related complication.Design: Retrospective observational study of prospectively collected data.Patients: All 37 critically ill patients with hematological malignancies who received intravenous chemotherapy in the ICU between January 1997 and March 2005 (mean age 46+/-19 years; mean APACHE II 23+/-7).Measurements and Results: Thirty-seven (69%) patients received chemotherapy because of extensive disease with organ involvement (54%), extensive disease without organ involvement (19%), severe disseminated intravascular coagulation (11%), and other reasons (16%). In 41% there was concomitant infection when chemotherapy was initiated, in 86% a high-grade malignancy, and 30% relapsing disease. Twenty-three (62%) patients received mechanical ventilation at the moment of or soon after initiation of chemotherapy for a median duration of 5 days (1-67), and 24% underwent renal replacement therapy during ICU stay. Only ventilation was associated with in-hospital mortality (odds ratio 9.3). ICU, in-hospital, and 6-month mortality rates in nonventilated vs. ventilated patients were 7% and 48%, 14% and 61%, and 54% and 74%, respectively.Conclusions: Starting chemotherapy in the ICU for a life-threatening malignancy related complication can be lifesaving even when infection or organ failure is present. [ABSTRACT FROM AUTHOR]

Study objectives: The survival rate of patients with a hematologic malignancy requiring mechanical ventilation (MV) in the ICU has improved over the last few decades. The objective of this study was to identify the factors affecting the in-hospital mortality of these particular patients, and to assess whether the use of noninvasive positive pressure ventilation (NPPV) was protective in our study population. Design: We retrospectively collected variables in 166 consecutive patients with hematologic malignancies who had acute respiratory failure (ARF) requiring MV, and identified factors obtained within 24 h of KU admission affecting in-hospital mortality in univariate and multivariate stepwise logistic regression analyses. The effect of NPPV on mortality was assessed using a pair-wise matched exposed-unexposed analysis. Results: The mean simplified acute physiology score (SAPS) II was 58.9. The in-hospital mortality rate was 71%. In a multivariate logistic regression analysis, the in-hospital mortality rate was predicted by increasing severity of illness, as measured by SAPS II (odds ratio [OR] per point of increase, 1.07; 95% confidence interval [CI], 1.04 to 1.11) and a diagnosis of acute myelogenous leukemia (OR, 2.13; 95% CI, 1.05 to 1.11). Female sex (OR, 0.36; 95% CI, 0.16 to 0.82), endotracheal intubation (ETI) within 24 h of ICU admission (OR, 0.29; 95% CI, 0.11 to 0.78), and recent bacteremia (defined as blood cultures positive for bacteria < 48h before or < 24h after ICU admission) [OR, 0.22; 95% CI, 0.08 to 0.61] were associated with a lower mortality rate. Twenty-seven patients who received NPPV were matched for SAPS II (± 3) with 52 patients who required immediate ETI on a 1:2 basis. The crude in-hospital mortality rate was 65.4% in both groups. Conclusion: Although the in-hospital mortality rate in hematologic patients who develop ARF remains high, the reluctance to intubate and start treatment with invasive MV in this population is unjustified, especially when bacteremia has precipitated ICU admission. [ABSTRACT FROM AUTHOR]