Characteristics and outcomes of haematology patients admitted to the intensive care unit

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<ul><li><p>AUDIT</p><p>doi: 10.1111/nicc.12005</p><p>Characteristics and outcomesof haematology patients admittedto the intensive care unitCaroline McCaughey, Bronagh Blackwood, Marie Glackin, Michele Bradyand Mary Frances McMullin</p><p>ABSTRACTAim: To profile the characteristics and outcomes of adult haematology patients admitted to the intensive care unit (ICU).Background: The role of intensive care support for haematology patients is contentious due to high mortality rates thus generating debateregarding the inappropriate use of limited resources versus denial of effective care.Methods: Medical notes, laboratory records and Intensive Care National Audit and Research Centre (ICNARC) data for all adult haematologypatients admitted to Belfast City Hospital ICU in 2009 were analysed.Results: Twenty one patients were admitted to the ICU; mean age was 56 years (SD 125), 52% were male and 82% (n=19) had amalignant diagnosis. The main indication for admission was neutropenic sepsis with associated organ impairment (n=18, 85%). ICU mortalitywas 43%. Three-month and six-month mortality rates were 62% and 67%, respectively. ICU survivors had lower acute physiology and chronichealth evaluation (APACHE II) scores, and decreased requirements for invasive ventilation and inotropic support. Of the post-six-month survivors,one had a relapse, one had responding disease and five remained in remission. Two patients have subsequently undergone a reduced intensityconditioning transplant.Conclusion: One third of patients survived for &gt;6 months indicating that critically ill haematology patients can benefit from ICU admission,allowing progression to potentially curative therapies.Relevance to clinical practice: This study highlights the necessity of individualized assessment regarding patient suitability for admissionto a critical care facility, incorporating the perspective of both the haematologist and the intensivist.</p><p>Key words: Critical care Haematology Intensive care Long-term outcome Short-term outcome Survival</p><p>INTRODUCTIONOverall survival for patients with haematologicalmalignancies is improving (Cuthbertson et al., 2008),with survival rates for some malignancies nowexceeding 80% (Gates et al., 2009). The progressin survival rates has been achieved by the useof intensified treatment protocols and advances in</p><p>Authors: C McCaughey, Practice Educator, Belfast Health and SocialCare Trust and School of Nursing and Midwifery, Queens UniversityBelfast, Belfast, UK; B Blackwood, Lecturer, School of Nursing andMidwifery, Queens University Belfast, Belfast, UK; M Glackin, NurseLecturer, School of Nursing and Midwifery, Queens University Belfast,Belfast, UK; MF McMullin, Professor of Haematology, Belfast Health andSocial Care Trust, Belfast, UK, Centre for Cancer Research and Cell Biology,Queens University Belfast, Belfast, UK; M Brady, Consultant Anaesthetist,Belfast Health and Social Care Trust, Belfast, UKAddress for correspondence: C McCaughey, Practice Educator,Belfast Health and Social Care Trust and School of Nursing and Midwifery,Queens University Belfast, Belfast, UK.E-mail:</p><p>supportive care. However, these improvements haveled to an increased occurrence of therapy-relatedcomplications in the immune-compromised patients,necessitating emergency admission to an intensive careunit (ICU) (Staudinger et al., 2000; Benoit et al., 2003;Cuthbertson et al., 2008).</p><p>In the past two decades, mortality rates forhaematology patients admitted to ICU in an emergencyranged from 54% to 98%; mortality is higher ifpatients require mechanical ventilation or renalreplacement therapy or if they develop multi-organ failure (Maschmeyer et al., 2003; McGrathet al., 2010; Soares et al., 2010). Furthermore, post-allogeneic transplantation patients are particularly atrisk (Maschmeyer et al., 2003). However, over the pastfew years several centres have reported improvingsurvival rates in haematology patients admitted toICU despite increased intensity of treatments (Soareset al., 2005, Cuthbertson et al., 2008, McGrath et al.,2010). Indeed, the largest data set study in this field</p><p> 2013 The Authors. Nursing in Critical Care 2013 British Association of Critical Care Nurses Vol 18 No 4 193</p></li><li><p>Characteristics and outcomes of haematology patients</p><p>(Hampshire et al., 2009) report an ICU mortality rateof 431%. Nevertheless, controversy still surrounds thebenefit versus futility of providing critical care forthis patient group, with an ongoing preconception thatICU resources for cancer patients may be less justifiable(Hill, 2010; Soares et al., 2010).</p><p>This study was conducted to profile patientcharacteristics and assess outcomes of haematologypatients admitted to the Belfast City Hospital ICUin order to establish a baseline, to identify areas forimprovement so that resources can be utilised mosteffectively and to compare outcomes against nationalstatistics.</p><p>METHODSSettingThe Belfast City Hospital haematology service isa regional tertiary referral centre for NorthernIreland and acts as a haematology unit to its localpopulation. It has a 29 bedded in-patient unit,incorporating six transplant beds designated for theprovision of autografts and sibling allografts. Inaddition to the management of patients with ahaematological malignancy, the service covers non-malignant haematological disorders and incorporatesa haemostasis and thrombosis comprehensive carecentre. In 2009, there were 829 admissions to the in-patient haematology unit.</p><p>The ICU had 12 beds up until September 2009,which was then reduced to 9 as part of the Belfast,Health and Social Care Trust (HSCT) reconfiguration.The ICU is staffed by a full-time team of intensivists(n= 8) with 24-h multidisciplinary support, offeringlevel 3 critical care, including invasive mechanicalventilation. In 2009, there were 660 admissionsto the ICU.</p><p>DesignRetrospective data were collected from medical notes,laboratory records and the Intensive Care NationalAudit and Research Centre (ICNARC) database for alladult haematology patients admitted to the ICU from1 January to 31 December 2009.</p><p>Data collectionData were collected on the following availablevariables: patient characteristics; APACHE II scores;requirement for invasive mechanical ventilation, renalreplacement therapy and inotropic support; ICU lengthof stay; mortality (ICU, 3 and 6 months); neutropaenia;pancytopaenia and liver toxicity.</p><p>Data analysisData were analysed using the SPSS software (SPSS,version 17.0). Descriptive statistics were used andresults were reported as mean SD or median andIQR.</p><p>ETHICAL APPROVALA sub-panel of the Northern Ireland Research EthicsCommittee reviewed the protocol. Approval was notrequired, and the study was registered with the BelfastHSCT Audit Department.</p><p>RESULTSPatient characteristicsFrom 1 January 2009 to 31 December 2009, therewere 829 admissions to the in-patient haematologyunit. Twenty-one adult patients were admitted tothe ICU. This constituted 25% of all haematologyadmissions in that year and 32% of all ICU admissions.Demographics, baseline data and ICU mortality arepresented in Table 1.</p><p>Eighty two percent (n= 19) had a malignantdiagnosis, with the majority having an acuteleukaemia (n= 8, 38%) or an aggressive lymphoma(n= 6, 285%). Table 2 categorizes the haematologydiagnoses.</p><p>Treatment historyBefore the haematology admission during which theywere transferred to ICU, 38% (n= 8) of patients hadnot been previously treated with chemotherapy: twohad a non-malignant diagnosis and six were newlydiagnosed with a haematological malignancy. Sevenpatients had been pre-treated with chemotherapy,four patients had a previous autograft, one hada previous sibling myeloablative allograft and onehad a previous sibling reduced intensity conditioning(RIC) allograft. At the point of ICU admission, 71%(n= 15) were post-chemotherapy patients (median99 days, range 122 days) and one was at day 4 postautograft.</p><p>At the time of ICU admission, nine patients (429%)were in remission or had stable disease, six (286%)had newly diagnosed malignant disease, two (95%)had newly diagnosed non-malignant disease and one(48%) had active, relapsed (n= 2, 95%) or refractorydisease (n= 1, 48%).</p><p>Reason for ICU admissionThe most prevalent reason for emergency admissionto the ICU was neutropenic sepsis and associated</p><p>194 2013 The Authors. Nursing in Critical Care 2013 British Association of Critical Care Nurses</p></li><li><p>Characteristics and outcomes of haematology patients</p><p>Table 1 Demographics and outcomes of patients admitted to ICU in 2009</p><p>Total ICU admissionsin 2009</p><p>Haematology admissionsin 2009</p><p>Admissions 660 21Male 395 (358%) 11 (52%)Age (mean) 60 56APACHE II 12 23ICU length of stay 4 days 4 daysICU mortality 115% 43%</p><p>Table 2 ICU mortality according to haematology diagnoses</p><p>Number admittedto ICU ICU mortality (%)</p><p>Acute leukaemia N= 8 N= 6 (75)Chronic leukaemia N= 1 N= 0 (0)High-risk myleodysplastic syndrome N= 2 N= 0 (0)Lymphoma N= 6 N= 3 (50)Myeloma N= 2 N= 0 (0)Non-malignant N= 2 N= 2 (100)Total 21</p><p>organ impairment (85%, n= 18), with respiratoryfailure being the most common complication of sepsis.Two patients had multi-organ failure at the point ofadmission, with neither surviving. In patients with anon-malignant diagnosis (n= 2), reasons for admissionwere acute haemolysis (Hb 28 on presentation) leadingto loss of consciousness, and seizures secondary tothrombotic thrombocytopaenia purpura.</p><p>Characteristics and outcomes of survivorsand non-survivorsICU mortality was 43% (n= 9), and 89% (n= 8) of thesedeaths were sepsis related. To contextualize this figure,throughout the same time period the crude mortalityrate for the Belfast HSCT was 2%. Non-survivors hadhigher admission APACHE II scores, and were moreinclined to have grade 3 or more bone marrow andliver toxicity (using the NCI Common TerminologyCriteria for Adverse Events (CTCAE) Version 4.02). Agreater percentage of non-survivors required invasiveventilation and inotropic support. Both survivors andnon-survivors had similar requirements for continuousrenal replacement therapy and had similar lengths ofstay in the ICU (see Table 3)</p><p>The 3-month mortality rate was 62%. Three ofthe four deaths within this time period occurredwithin 2 days of ICU discharge. The 6-month mortalityrate was 67%. Seven patients were alive more thansix months: one had relapsed disease; one had</p><p>Table 3 Characteristics and support requirements of survivors andnon-survivors</p><p>Survivors(n= 12)</p><p>Non-survivors(n= 9)</p><p>APACHE II score, (mean, SD) 20 (5) 28 (66)Neutropaenia grade 3 (n%) 6 (50%) 6 (667%)Pancytopaenia grade 3 (n %) 6 (50%) 6 (667%)Liver toxicity grade 3 (n %) 3 (25%) 7 (78%)Invasive ventilation (n %) 6 (50%) 8 (90%)Inotropic support (n %) 3 (25%) 7 (78%)Continuous renal replacement therapy 4 (33%) 3 (33%)Maximum no. of organs supported (mean, SD) 225 (11) 3 (07)Days in ICU (median, IQR) 43 (2, 8) 4 (1, 7)</p><p>Table 4 Disease status of patients admitted to ICU</p><p>Haematological status Frequency Percentage</p><p>Newly diagnosed malignant disease n= 6 28.6Newly diagnosed non-malignant disease n= 2 95Remission/stable disease n= 9 429Active disease n= 1 48Relapsed disease n= 2 95Refractory disease n= 1 48Total n= 21 100</p><p>responding disease; and five were in remission, twoof whom have progressed to a potentially curativeRIC transplant.</p><p>Haematological status and outcomesOwing to the controversies associated with access tocritical care facilities for patients with malignant dis-ease, disease status and outcome were recorded. Whilstthe patient with active disease survived&gt;6 months,those with relapsed or refractory disease had a maxi-mum survival of 112 days (Table 4).</p><p>DISCUSSIONMany studies have examined the characteristicsand outcomes of patients with solid tumours andhaematological malignancies in the ICU context(Staudinger et al., 2000; Benoit et al., 2003; Maschmeyeret al., 2003; Gruson et al., 2004; Darmon et al., 2005;Thiery et al., 2005; Ferra et al., 2007; McGrath et al.,2010; Soares et al., 2010; Schellongowski et al., 2011).This study is unique in that it addresses the specialityof haematology, incorporating both malignant andnon-malignant conditions; however, as there wereonly two patients with a non-malignant diagnosisadmitted to ICU in the audit timeframe, a review</p><p> 2013 The Authors. Nursing in Critical Care 2013 British Association of Critical Care Nurses 195</p></li><li><p>Characteristics and outcomes of haematology patients</p><p>spanning a longer time period would have been moreinsightful. Our study showed a trend towards betteroutcomes for patients with active malignant diseasethan non-malignant disease and thus tentativelysupports the view that the severity of the acute illnessrather than malignancy-specific parameters determinepatient outcome from ICU (Staudinger et al., 2000;Massion et al., 2002; Maschmeyer et al., 2003; Darmonet al., 2005; Hill, 2010; Soares et al., 2010; Schellongowskiet al., 2011).</p><p>Our most common reason for ICU admission wasacute respiratory failure (secondary to sepsis), whichwas similarly reported by Ferra et al. (2007), Limet al. (2006), Soubani (2006), Azoulay et al. (2010) andSchellongowski et al. (2011). Additionally, 24% of ourpopulation were chemotherapy naive, emphasizingthe impact of disease-related as well as treatment-related acute complications in the haemato-oncologycontext, also reflected in Thiery et al. (2005) andSchellongowski et al.s (2011) experience. Molina et al.(2012) conducted a large prospective, multicentreobservational study to clarify the role of differentventilatory strategies, given the high mortality ratesassociated with intubation. They found that whilst non-invasive mechanical ventilation (NIMV) can improveoutcomes in haematology patients admitted to the ICU,patients with NIMV failure experience a more severerespiratory impairment than those electively intubated.Their results suggest that diseases that may have a fastresponse to therapy, such as diuretics and inotropes forcardiogenic pulmonary oedema, or directed antibiotictherapy for a documented infection may benefit fromNIMV. However, in other causes of lung injury, NIMVmay not be effective for a prolonged time, thusincreasing the risk of failure and intubation. Molinaet al. therefore concluded that it appears critical tocarefully select candidates for NIMV, identifying thosewith rapidly reversible causes of respiratory failure, asin other cases, the delay in optimal respiratory supportwith invasive mechanical ventilation may increasethe risk of death. Furthermore, a randomized trialconducted by Wermke et al. (2012), recruiting a cohortof allogeneic transplant recipients, found an earlyinterventional strategy using NIMV (versus oxygenonly) was not associated with improved prognosis.However, it is acknowledged that the limited influenceof NIMV may be related to their modest samplesize and cross-over study design. They would concurwith Molina et al. that whilst early application ofNIMV may be of help, it must be combined withother modern treatment modalities for respira...</p></li></ul>


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