Original research paper
Hematologic malignancies in the medical intensive care unit – Outcomes and prognostic factors Marijana Grgić Medić 1 , Ivan Gornik 1,2, Vladimir Gašparović 1,2 1
Pro of
Department of Medicine, University Hospital Centre Zagreb, Intensive Care Unit, Zagreb, Croatia, University of Zagreb School of Medicine, Zagreb, Croatia
2
cor rec t
ed
Objectives: To analyze clinical characteristics, treatment, outcomes of critically ill patients with hematologic malignancies (HM) admitted to the medical intensive care unit (ICU) and to identify predictors of adverse outcome. Methods: We analyzed prospectively 170 patients. Data included: demographic characteristics, hematologic diagnosis, reasons for ICU admission, transplant status, the presence of neutropenia, acute physiology and chronic health evaluation-II and sequential organ failure assessment scores, and level of organ support. Predictors of ICU mortality were evaluated using univariate and multivariate analysis. Results: In total, 73% of patients had high-grade malignancy, 47.6% received intensive chemotherapy before admission, and 30% underwent hematologic stem cell transplantation procedure. In total, 116 (68.2%) of patients were mechanically ventilated; 88 (51.8%) required invasive mechanical ventilation (MV). Noninvasive ventilation started in 28 (16.5%) patients and was successful in 11 (6.5%). The ICU mortality rate was 53.5%, and the mortality of MV patients was 75.9%. Need for vasopressors at admission and MV were identified as independent predictors of fatal outcome. Conclusion: The ICU mortality of critically ill patients with HM is high, particularly in the group of MV. Need for vasopressors at admission and MV were independent predictors of ICU mortality. Majority of patients required invasive MV due to severe respiratory failure and non-invasive MV was sufficient only in small number of cases with favorable outcome. Keywords: Hematologic malignancies, ICU, Mechanical ventilation, Mortality
Introduction
Un
Hematologic malignancies (HM) and the complications related to their treatment cause substantial morbidity and mortality with poor prognosis.1–3 In recent years, intensified chemotherapy, monoclonal antibodies, autologous and allogenic bone marrow transplantation (BMT) have improved the survival rate. However, application of aggressive therapeutic protocols, toxicity of chemotherapeutic agents, as well as profound or chronic immnosuppression, and graft-versus host disease (GVHD) can lead to serious complications requiring the treatment in the intensive care units (ICU). The main reasons for ICU admission are: acute respiratory distress syndrome (ARDS), sepsis or septic shock, and postoperative care.4 Mechanical ventilation Correspondence to: Marijana Grgic Medic, Department of Medicine, University Hospital Centre Zagreb, Intensive Care Unit, Kisˇ patic´eva 12, Zagreb 10000, Croatia. Email: [email protected]
© W. S. Maney & Son Ltd 2014 DOI 10.1179/1607845414Y.0000000206
(MV) largely deteriorates outcome in HM patients,4–6 particularly in those who received allogenic or autologous BMT, and in majority of cases it has a fatal effect.7–12 Various factors have been associated with poor prognosis among critically ill patients with HM admitted to the ICU, including high acute physiology and chronic health evaluation-II (APACHE II) scores,1,13–15 invasive MV,13–16 neutropenia,2 sepsis,1 but the results of the published studies have been contradictory. The clear definition of parameters associated with fatal outcome would help hematologists and critical care specialists in recognizing the patients who could have benefited from ICU treatment and in decision making regarding treatment options. The objective of this study was to evaluate the clinical characteristics, treatment modalities, and outcomes of critically ill patients with HM admitted to a medical ICU, and to identify potential predictors of adverse outcome.
Hematology
2014
VOL.
0
NO.
0
1
Hematologic malignancies in the medical ICU
Methods
Un
cor rec t
ed
This prospective, observational study included patients with HM treated in the medical ICU of the Department of Internal Medicine, University Hospital Centre Zagreb from January 2011 to December 2013. Our ICU is a ward with 12 beds that admits patients with acute medical conditions, and HM constitutes 9% of admittances. The study included patients >18 years admitted to the ICU, with HM as a primary diagnosis or a concurrent comorbidity over a 5-year period. These patients were included regardless of the duration of the ICU treatment. The decision to admit the patient to the ICU was made by the intensivist, following the consultations with the attending hematologist. The patients with advanced disease or repeated relapses, who received intensive and potentially curable chemotherapeutic regime, as assessed by the attending hematologist, were also admitted. None of the patients had signed do not resuscitate or do not intubate consent. The institutional Committee of Clinical Research approved the collection of patients data for the purpose of this study. Demographic, clinical, and laboratory data from the first day of ICU treatment were used for statistical analysis and included: HM type; disease status; reasons for admission; treatment modalities in the ICU (MV and type of ventilation, use of vasopressors, renal replacement therapy (RRT), and plasmapheresis); length of stay; ICU mortality; and mortality within 1 month following the discharge from the ICU. APACHE II score and sequential organ failure assessment (SOFA) score were calculated during the first 24 hours after admission to the ICU. Organ dysfunction was defined by a SOFA score ≥1 point for any organ system. Neutropenia was defined as absolute neutrophil count 30 breaths per minute with respiratory distress symptoms, PaO2 on room air 70 mmHg), who were awake and cooperative, able to clear their secretions adequately, and showed no signs of imminent respiratory arrest. It was delivered via face mask or Helmet system, and resumed when the arterial O2 saturation was 35 breaths per minute and respiratory distress symptoms during NIV. Criteria for orotracheal intubation were conditions necessitating endotracheal intubation to protect the airways (a seizure disorder or severe encephalopathy with a score on the Glasgow Coma Scale of ≤8); agitation requiring sedation; the development of copious tracheal secretions; an increase in the partial pressure of arterial CO2 accompanied by a pH≤7.30; severe hemodynamic instability (SBP of 6.0 mEq/l; volume overload; severe hyperphosphatemia or dysnatremia; oligo/ anuria; and uremia. Furthermore, RRT modes were daily conventional dialysis and continuous RRT. Patients receiving vasopressors with potential for hemodynamic instability were treated with continuous RRT.18 Decisions regarding initiation, termination, or selection of the mode of RRT were made by the intensivist. Plasmapheresis was used in patients with hyperleukocytary and hyperviscosity syndrome. The primary outcome was ICU mortality and secondary outcome was mortality 1 month following the discharge from ICU.
Pro of
Grgić Medić et al.
2
Hematology
2014
VOL.
0
NO.
0
Statistical analysis All analyses were performed using the SPSS Statistics, V.17.0 (SPSS Inc., Chicago, USA). Categorical data
Grgić Medić et al.
Results
Indication for admission to the ICU Shock Septic shock Respiratory tract infection Gastrointestinal infection Urinary tract infection Skin infection Unknown source of infection Cardiogenic shock Cardiac arrest/resuscitation at ward Acute respiratory failure Pneumonia Malignant lung infiltration Pneumothorax Hyperviscosity syndrome Congestive heart failure Acute renal failure Malignant infiltration Hypercalcemia Sepsis Toxic nephropathy Disturbed consciousness Intracranial bleeding Malignant CNS infiltration Toxic encephalopathy Monitoring only
n (%)
MV n (%)
80 (47.1) 76 (44.7) 44 (25.9) 15 (8.8) 2 (1.2) 3 (1.8) 12 (7.1) 4 (2.4) 4 (2.4) 63 (37.1) 20 (11.8) 4 (2.4) 1 (0.6) 2 (1.2) 3 (1.8) 8 (4.7) 3 (1.8) 1 (0.6) 2 (1.2) 2 (1.2) 9 (5.3) 2 (1.2) 3 (1.8) 4 (2.4) 10 (5.9)
63 (37.1)
46 (27.1)
5 (2.9)
2 (1.2)
0 (0)
ed
Overall, there were 1769 admissions to the medical ICU and 170 admissions (9.6%) of patients with HM. Their general characteristics are given in Table 1. There were 82 (48.2%) women and 88 (51.8%) men. In total, 73% had a high-grade malignancy, the most frequent diagnoses being the acute leukemia and high-grade lymphoma. Eighty-one patients (45.8%) were treated by intensive chemotherapy regimen in weeks prior to admission to the ICU, and 52 (30.6%) underwent allogenic or autologous BMT. Furthermore, 86 (50.6%) were neutropenic at admission. Shock and ARF were the most frequent indications for admission, in 80 (47.1%) and 63 (37.1%) patients, respectively (Table 2). Pulmonary infections were the most common underlying disease in patients with ARF, and septic shock was most common form of shock. Sixty-three patients (37.1%)
Table 2 The reasons for admission to the ICU, underlying pathology and proportion of mechanically ventilated patients in each group of patients with HM
Pro of
were presented with absolute and relative frequencies, continuous data with mean and standard deviation or median with interquartile range as appropriate. Chi-square test was used for group comparisons and analyses of categorical variables. Mann–Whitney test and t-test were used for comparisons of continuous variables as appropriate. The logistic regression of the variables that were in univariate analyses associated with an outcome was performed using stepwise approach. Statistical significance was set at P = 0.05.
Hematologic malignancies in the medical ICU
MV, mechanical ventilation; CNS, central nervous system.
cor rec t
admitted with shock and 46 (27.1%) admitted with ARF required some form of MV within the first 24 hours of ICU treatment. Moreover, MV was also started in seven patients (4.1%) admitted for other reasons (acute renal failure or disturbed consciousness) (Table 2). Totally, 116 patients (68.2%) required MV, NIV was started in 28 (26.6%) patients, and was successful in 11. Nine out of 11 patients treated only with NIV survived (9/11), and in the group of 17 patients who required orotracheal intubation and invasive MV following NIV, 6 patients (6/17) survived and were successfully weaned from the ventilator. Major
Table 1 Characteristics of patients with hematological malignancies admitted to medical ICU
Un
Age (year) (mean ± SD) Female sex (n (%)) Hematological malignancy (n (%)) Acute leukemia Chronic leukemia Aggressive lymphoma Indolent lymphoma Multiple myeloma Other Disease stage (n (%)) Disease presentation (no treatment) Initial intensive chemotherapy Intensive chemotherapy for relapse or BMT procedure Remission Transformation or repeated relapse or refractory disease Neutropenia (n (%)) Stem cell transplantation (n (%)) Allogenic Autologous No transplantation Allogenic after autologous transplant Source of admission (n (%)) Ward Emergency department Another hospital APACHE II score (mean ± SD) SOFA score (mean ± SD) BMT, bone marrow transplantation.
50 ± 16 82 (48.2)
71 (41.8) 16 (9.4) 53 (31.2) 1 (0.6) 23 (13.5) 6 (3.5)
38 (22.4) 29 (17.1) 52 (30.5) 25 (15.3) 25 (14.7) 86 (50.6) 31 (18.2) 20 (11.8) 118 (69.4) 1 (0.6) 148 (87.1) 17 (10.0) 5 (82.9) 25 ± 9 8±5
Table 3 Major ICU treatment and outcomes of patients with hematological malignancies Mechanical ventilation (n (%)) Invasive (endotracheal intubation) Non-invasive ventilation Invasive following non-invasive None Dialysis (n (%)) Plasmapheresis (n (%)) Vasoactive treatment at admission (n (%)) Noradrenalin or dopamine Noradrenalin and dopamine None Morality Overall Ventilated patients (N = 116) Dialyzed patients (N = 40) Survivors LOS (days) (mean ± SD) Non-survivors LOS (days) (mean ± SD) 28-day survival (N = 163)
88 (51.8) 11 (6.5) 17 (10.0) 54 (31.8) 40 (23.5) 7 (4.2) 85 (50.0) 12 (7.1) 73 (42.9) 91 (53.5) 88 (75.9) 26 (65) 7±6 5±6 31.3
LOS, length of stay.
Hematology
2014
VOL.
0
NO.
0
3
Grgić Medić et al.
Table 4
Hematologic malignancies in the medical ICU
Association of ICU mortality with hematological and intensive care factors Survivors (n (%))
Non-survivors (n (%))
71 (41.8) 16 (9.4) 53 (31.2) 1 (0.6) 23 (13.5) 6 (3.5)
31 (43.7) 7 (43.8) 25 (47.2) 0 (0.0) 14 (60.9) 2 (33.3)
40 (56.3) 9 (56.2) 28 (52.8) 1 (100) 9 (39.1) 4 (66.7)
0.625
38 (22.4) 29 (17.1) 52 (30.5) 25 (14.7) 26 (15.3)
18 (47.4) 15 (51.7) 35 (67.3) 13 (52) 10 (38.5)
20 (52.6) 14 (48.3) 17 (32.7) 12 (48) 16 (61.5)
0.112
ed
80 (47.1) 63 (37.1) 8 (4.7) 9 (5.3%) 10 (5.9) 86 (50.6) 52 (30.6) 148 (87.1) 116 (68.2) 40 (23.5) 97 (57.1) 25 ± 9 8±5
cor rec t
Hematological malignancy Acute leukemia Chronic leukemia Aggressive lymphoma Indolent lymphoma Multiple myeloma Other Disease stage Disease presentation (no treatment) Initial intensive chemotherapy Intensive chemotherapy for relapse or transplantation Remission Transformation or repeated relapse or refractory disease Primary reason for ICU admission Shock Respiratory failure Renal failure Disturbed consciousness Monitoring only Neutropenia Bone marrow transplantation Admission from hematology ward Mechanical ventilation Renal replacement therapy Vasoactive treatment ICU admission data APACHE II SOFA
All patients (n (%)) N = 170
Pro of
Factor
Un
treatment modalities and outcomes are given in Table 3. Furthermore, RRT was required in 40 (23.5%) patients, and 65% died. Plasmapheresis was performed in 7 (4.2%). Ninety-seven (57.1%) patients required vasopressors at admission. The ICU mortality was 53.5%, and the mortality of MV patients was 75.9%. The 28-day survival rate was 31.3%. In the univariate analysis, mortality was significantly associated with factors such as neutropenia at admission, need for vasopressors on the day of admission to the ICU, primary reason for ICU admission, MV within 24 hours of ICU treatment, and severity Table 5 Multivariate analysis of factors associated with mortal outcome Variable
OR (95% CI)
Primary reason for admission (shock) Mechanical ventilation APACHE II SOFA Vasoactive treatment Neutropenia
0.713 (0.299–1.696) 2.710 (1.433–5.128) 1.090 (0.969–1.226) 1.024 (0.867–1.210) 6.289 (2.689–14.705) 0.415 (0.096–1.780)
OR, odds ratio; CI, confidence interval.
4
Hematology
2014
VOL.
0
NO.
0
P value 0.445 0.002 0.149 0.777
Hematologic malignancies in the medical intensive care unit – Outcomes and prognostic factors Marijana Grgić Medić 1 , Ivan Gornik 1,2, Vladimir Gašparović 1,2 1
Pro of
Department of Medicine, University Hospital Centre Zagreb, Intensive Care Unit, Zagreb, Croatia, University of Zagreb School of Medicine, Zagreb, Croatia
2
cor rec t
ed
Objectives: To analyze clinical characteristics, treatment, outcomes of critically ill patients with hematologic malignancies (HM) admitted to the medical intensive care unit (ICU) and to identify predictors of adverse outcome. Methods: We analyzed prospectively 170 patients. Data included: demographic characteristics, hematologic diagnosis, reasons for ICU admission, transplant status, the presence of neutropenia, acute physiology and chronic health evaluation-II and sequential organ failure assessment scores, and level of organ support. Predictors of ICU mortality were evaluated using univariate and multivariate analysis. Results: In total, 73% of patients had high-grade malignancy, 47.6% received intensive chemotherapy before admission, and 30% underwent hematologic stem cell transplantation procedure. In total, 116 (68.2%) of patients were mechanically ventilated; 88 (51.8%) required invasive mechanical ventilation (MV). Noninvasive ventilation started in 28 (16.5%) patients and was successful in 11 (6.5%). The ICU mortality rate was 53.5%, and the mortality of MV patients was 75.9%. Need for vasopressors at admission and MV were identified as independent predictors of fatal outcome. Conclusion: The ICU mortality of critically ill patients with HM is high, particularly in the group of MV. Need for vasopressors at admission and MV were independent predictors of ICU mortality. Majority of patients required invasive MV due to severe respiratory failure and non-invasive MV was sufficient only in small number of cases with favorable outcome. Keywords: Hematologic malignancies, ICU, Mechanical ventilation, Mortality
Introduction
Un
Hematologic malignancies (HM) and the complications related to their treatment cause substantial morbidity and mortality with poor prognosis.1–3 In recent years, intensified chemotherapy, monoclonal antibodies, autologous and allogenic bone marrow transplantation (BMT) have improved the survival rate. However, application of aggressive therapeutic protocols, toxicity of chemotherapeutic agents, as well as profound or chronic immnosuppression, and graft-versus host disease (GVHD) can lead to serious complications requiring the treatment in the intensive care units (ICU). The main reasons for ICU admission are: acute respiratory distress syndrome (ARDS), sepsis or septic shock, and postoperative care.4 Mechanical ventilation Correspondence to: Marijana Grgic Medic, Department of Medicine, University Hospital Centre Zagreb, Intensive Care Unit, Kisˇ patic´eva 12, Zagreb 10000, Croatia. Email: [email protected]
© W. S. Maney & Son Ltd 2014 DOI 10.1179/1607845414Y.0000000206
(MV) largely deteriorates outcome in HM patients,4–6 particularly in those who received allogenic or autologous BMT, and in majority of cases it has a fatal effect.7–12 Various factors have been associated with poor prognosis among critically ill patients with HM admitted to the ICU, including high acute physiology and chronic health evaluation-II (APACHE II) scores,1,13–15 invasive MV,13–16 neutropenia,2 sepsis,1 but the results of the published studies have been contradictory. The clear definition of parameters associated with fatal outcome would help hematologists and critical care specialists in recognizing the patients who could have benefited from ICU treatment and in decision making regarding treatment options. The objective of this study was to evaluate the clinical characteristics, treatment modalities, and outcomes of critically ill patients with HM admitted to a medical ICU, and to identify potential predictors of adverse outcome.
Hematology
2014
VOL.
0
NO.
0
1
Hematologic malignancies in the medical ICU
Methods
Un
cor rec t
ed
This prospective, observational study included patients with HM treated in the medical ICU of the Department of Internal Medicine, University Hospital Centre Zagreb from January 2011 to December 2013. Our ICU is a ward with 12 beds that admits patients with acute medical conditions, and HM constitutes 9% of admittances. The study included patients >18 years admitted to the ICU, with HM as a primary diagnosis or a concurrent comorbidity over a 5-year period. These patients were included regardless of the duration of the ICU treatment. The decision to admit the patient to the ICU was made by the intensivist, following the consultations with the attending hematologist. The patients with advanced disease or repeated relapses, who received intensive and potentially curable chemotherapeutic regime, as assessed by the attending hematologist, were also admitted. None of the patients had signed do not resuscitate or do not intubate consent. The institutional Committee of Clinical Research approved the collection of patients data for the purpose of this study. Demographic, clinical, and laboratory data from the first day of ICU treatment were used for statistical analysis and included: HM type; disease status; reasons for admission; treatment modalities in the ICU (MV and type of ventilation, use of vasopressors, renal replacement therapy (RRT), and plasmapheresis); length of stay; ICU mortality; and mortality within 1 month following the discharge from the ICU. APACHE II score and sequential organ failure assessment (SOFA) score were calculated during the first 24 hours after admission to the ICU. Organ dysfunction was defined by a SOFA score ≥1 point for any organ system. Neutropenia was defined as absolute neutrophil count 30 breaths per minute with respiratory distress symptoms, PaO2 on room air 70 mmHg), who were awake and cooperative, able to clear their secretions adequately, and showed no signs of imminent respiratory arrest. It was delivered via face mask or Helmet system, and resumed when the arterial O2 saturation was 35 breaths per minute and respiratory distress symptoms during NIV. Criteria for orotracheal intubation were conditions necessitating endotracheal intubation to protect the airways (a seizure disorder or severe encephalopathy with a score on the Glasgow Coma Scale of ≤8); agitation requiring sedation; the development of copious tracheal secretions; an increase in the partial pressure of arterial CO2 accompanied by a pH≤7.30; severe hemodynamic instability (SBP of 6.0 mEq/l; volume overload; severe hyperphosphatemia or dysnatremia; oligo/ anuria; and uremia. Furthermore, RRT modes were daily conventional dialysis and continuous RRT. Patients receiving vasopressors with potential for hemodynamic instability were treated with continuous RRT.18 Decisions regarding initiation, termination, or selection of the mode of RRT were made by the intensivist. Plasmapheresis was used in patients with hyperleukocytary and hyperviscosity syndrome. The primary outcome was ICU mortality and secondary outcome was mortality 1 month following the discharge from ICU.
Pro of
Grgić Medić et al.
2
Hematology
2014
VOL.
0
NO.
0
Statistical analysis All analyses were performed using the SPSS Statistics, V.17.0 (SPSS Inc., Chicago, USA). Categorical data
Grgić Medić et al.
Results
Indication for admission to the ICU Shock Septic shock Respiratory tract infection Gastrointestinal infection Urinary tract infection Skin infection Unknown source of infection Cardiogenic shock Cardiac arrest/resuscitation at ward Acute respiratory failure Pneumonia Malignant lung infiltration Pneumothorax Hyperviscosity syndrome Congestive heart failure Acute renal failure Malignant infiltration Hypercalcemia Sepsis Toxic nephropathy Disturbed consciousness Intracranial bleeding Malignant CNS infiltration Toxic encephalopathy Monitoring only
n (%)
MV n (%)
80 (47.1) 76 (44.7) 44 (25.9) 15 (8.8) 2 (1.2) 3 (1.8) 12 (7.1) 4 (2.4) 4 (2.4) 63 (37.1) 20 (11.8) 4 (2.4) 1 (0.6) 2 (1.2) 3 (1.8) 8 (4.7) 3 (1.8) 1 (0.6) 2 (1.2) 2 (1.2) 9 (5.3) 2 (1.2) 3 (1.8) 4 (2.4) 10 (5.9)
63 (37.1)
46 (27.1)
5 (2.9)
2 (1.2)
0 (0)
ed
Overall, there were 1769 admissions to the medical ICU and 170 admissions (9.6%) of patients with HM. Their general characteristics are given in Table 1. There were 82 (48.2%) women and 88 (51.8%) men. In total, 73% had a high-grade malignancy, the most frequent diagnoses being the acute leukemia and high-grade lymphoma. Eighty-one patients (45.8%) were treated by intensive chemotherapy regimen in weeks prior to admission to the ICU, and 52 (30.6%) underwent allogenic or autologous BMT. Furthermore, 86 (50.6%) were neutropenic at admission. Shock and ARF were the most frequent indications for admission, in 80 (47.1%) and 63 (37.1%) patients, respectively (Table 2). Pulmonary infections were the most common underlying disease in patients with ARF, and septic shock was most common form of shock. Sixty-three patients (37.1%)
Table 2 The reasons for admission to the ICU, underlying pathology and proportion of mechanically ventilated patients in each group of patients with HM
Pro of
were presented with absolute and relative frequencies, continuous data with mean and standard deviation or median with interquartile range as appropriate. Chi-square test was used for group comparisons and analyses of categorical variables. Mann–Whitney test and t-test were used for comparisons of continuous variables as appropriate. The logistic regression of the variables that were in univariate analyses associated with an outcome was performed using stepwise approach. Statistical significance was set at P = 0.05.
Hematologic malignancies in the medical ICU
MV, mechanical ventilation; CNS, central nervous system.
cor rec t
admitted with shock and 46 (27.1%) admitted with ARF required some form of MV within the first 24 hours of ICU treatment. Moreover, MV was also started in seven patients (4.1%) admitted for other reasons (acute renal failure or disturbed consciousness) (Table 2). Totally, 116 patients (68.2%) required MV, NIV was started in 28 (26.6%) patients, and was successful in 11. Nine out of 11 patients treated only with NIV survived (9/11), and in the group of 17 patients who required orotracheal intubation and invasive MV following NIV, 6 patients (6/17) survived and were successfully weaned from the ventilator. Major
Table 1 Characteristics of patients with hematological malignancies admitted to medical ICU
Un
Age (year) (mean ± SD) Female sex (n (%)) Hematological malignancy (n (%)) Acute leukemia Chronic leukemia Aggressive lymphoma Indolent lymphoma Multiple myeloma Other Disease stage (n (%)) Disease presentation (no treatment) Initial intensive chemotherapy Intensive chemotherapy for relapse or BMT procedure Remission Transformation or repeated relapse or refractory disease Neutropenia (n (%)) Stem cell transplantation (n (%)) Allogenic Autologous No transplantation Allogenic after autologous transplant Source of admission (n (%)) Ward Emergency department Another hospital APACHE II score (mean ± SD) SOFA score (mean ± SD) BMT, bone marrow transplantation.
50 ± 16 82 (48.2)
71 (41.8) 16 (9.4) 53 (31.2) 1 (0.6) 23 (13.5) 6 (3.5)
38 (22.4) 29 (17.1) 52 (30.5) 25 (15.3) 25 (14.7) 86 (50.6) 31 (18.2) 20 (11.8) 118 (69.4) 1 (0.6) 148 (87.1) 17 (10.0) 5 (82.9) 25 ± 9 8±5
Table 3 Major ICU treatment and outcomes of patients with hematological malignancies Mechanical ventilation (n (%)) Invasive (endotracheal intubation) Non-invasive ventilation Invasive following non-invasive None Dialysis (n (%)) Plasmapheresis (n (%)) Vasoactive treatment at admission (n (%)) Noradrenalin or dopamine Noradrenalin and dopamine None Morality Overall Ventilated patients (N = 116) Dialyzed patients (N = 40) Survivors LOS (days) (mean ± SD) Non-survivors LOS (days) (mean ± SD) 28-day survival (N = 163)
88 (51.8) 11 (6.5) 17 (10.0) 54 (31.8) 40 (23.5) 7 (4.2) 85 (50.0) 12 (7.1) 73 (42.9) 91 (53.5) 88 (75.9) 26 (65) 7±6 5±6 31.3
LOS, length of stay.
Hematology
2014
VOL.
0
NO.
0
3
Grgić Medić et al.
Table 4
Hematologic malignancies in the medical ICU
Association of ICU mortality with hematological and intensive care factors Survivors (n (%))
Non-survivors (n (%))
71 (41.8) 16 (9.4) 53 (31.2) 1 (0.6) 23 (13.5) 6 (3.5)
31 (43.7) 7 (43.8) 25 (47.2) 0 (0.0) 14 (60.9) 2 (33.3)
40 (56.3) 9 (56.2) 28 (52.8) 1 (100) 9 (39.1) 4 (66.7)
0.625
38 (22.4) 29 (17.1) 52 (30.5) 25 (14.7) 26 (15.3)
18 (47.4) 15 (51.7) 35 (67.3) 13 (52) 10 (38.5)
20 (52.6) 14 (48.3) 17 (32.7) 12 (48) 16 (61.5)
0.112
ed
80 (47.1) 63 (37.1) 8 (4.7) 9 (5.3%) 10 (5.9) 86 (50.6) 52 (30.6) 148 (87.1) 116 (68.2) 40 (23.5) 97 (57.1) 25 ± 9 8±5
cor rec t
Hematological malignancy Acute leukemia Chronic leukemia Aggressive lymphoma Indolent lymphoma Multiple myeloma Other Disease stage Disease presentation (no treatment) Initial intensive chemotherapy Intensive chemotherapy for relapse or transplantation Remission Transformation or repeated relapse or refractory disease Primary reason for ICU admission Shock Respiratory failure Renal failure Disturbed consciousness Monitoring only Neutropenia Bone marrow transplantation Admission from hematology ward Mechanical ventilation Renal replacement therapy Vasoactive treatment ICU admission data APACHE II SOFA
All patients (n (%)) N = 170
Pro of
Factor
Un
treatment modalities and outcomes are given in Table 3. Furthermore, RRT was required in 40 (23.5%) patients, and 65% died. Plasmapheresis was performed in 7 (4.2%). Ninety-seven (57.1%) patients required vasopressors at admission. The ICU mortality was 53.5%, and the mortality of MV patients was 75.9%. The 28-day survival rate was 31.3%. In the univariate analysis, mortality was significantly associated with factors such as neutropenia at admission, need for vasopressors on the day of admission to the ICU, primary reason for ICU admission, MV within 24 hours of ICU treatment, and severity Table 5 Multivariate analysis of factors associated with mortal outcome Variable
OR (95% CI)
Primary reason for admission (shock) Mechanical ventilation APACHE II SOFA Vasoactive treatment Neutropenia
0.713 (0.299–1.696) 2.710 (1.433–5.128) 1.090 (0.969–1.226) 1.024 (0.867–1.210) 6.289 (2.689–14.705) 0.415 (0.096–1.780)
OR, odds ratio; CI, confidence interval.
4
Hematology
2014
VOL.
0
NO.
0
P value 0.445 0.002 0.149 0.777
