Outcomes in Critically Ill Cancer Patients: Impact on Admission Policies? Élie Azoulay, Réanimation Médicale Groupe de Recherche Respiratoire en Réanimation Onco- Hématologique (Grrr-OH) Université Paris 7, GHU Nord, Hôpital Saint-Louis, Paris, France, Europe [email protected] Imatinib vs. Interferon and Low-Dose Cytarabine for Newly Diagnosed ChronicPhase CML O ’Brien et al. N Engl J Med. 2003 13;348(11):994-1004 Trends in mortality across the last 25 years Mortality Darmon & Azoulay, Current Opnion in Oncology, 2009 428 patients with neutropenia and sepsis 1998-2003, N=184 Mortality: 57% 2004-2008, N=244 Mortality 43% Catheter withdrawal YES Aminiglycosides YES Catheter withdrawal YES Aminiglycosides YES Mortality: 41% Mortality: 33% Mortality – Patients with Sepsis Zuber et al. Crit Care Med, 2012 ARDS in 1004 patients with malignancies Hospital mortality 1 1 P<0.0001 0.8 0.8 0.6 0.6 Mild ARDS 0.4 0.4 0.2 Severe ARDS 0.2 0 0 0.0 20 40 60 Days 80 100 Azoulay et al. Submitted 2014 Cancer patients requiring admission to ICUs: a multicenter study. 717 patients, 28 centers, 93% oncology Mortality rate was 30%: Medical complications (58%) Emergency surgery (37%) Scheduled surgery (11%) Determinants of hospital mortality SOFA, Poor performance status, MV Number of days before ICU admission Active underlying cancer (recurrence or progression) Soares M, et al. Crit Care Med. 2010 Jan;38(1):9-15. 406 AML patients Decreased survival in patients requiring ICU admission (9% vs. 21% at 8y) ICU survivors have the same Hematology outcomes Prospective multicentre study in France and Belgium part of the GRRR-OH (Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique) The group is now recruiting all over Europe ICU mortality: 28% Hospital mortality: 39% D-90 mortality: 47% At 6m: 80% of complete remission At 6m: excellent QOL Trial-OH Poor performance status (bedridden/ completely disabled) Charlson Comorbidity Index Risk Factors Recipients of allogeneic BMT/HSCT Complete or Partial Remission Time from hospital to ICU admission < 24 hours SOFA score at admission Admission after cardiac arrest Admission for acute respiratory failure Organ infiltration by the malignancy Invasive Pulmonary Aspergillosis 0·89 1·00 1·12 1·26 1·41 E Azoulay, D Mokart, F Pene, et al. Journal of Clinical Oncology 2013 Assessing chances of survival No longer associated with mortality Characteristics of the malignancy Staging Neutropenia Auto-BMT Physiological scores Transfusions Chemotherapy Still associated with mortality Chronic health status, age, and comorbid conditions Therapeutic options Neutopenia recovery Allo-BMT Organ dysfunction scores … Why thinking differently? Impact of ICU denial overall Triage to ICU admission for hematology patients Need to develop new modalities for ICU admission Making the decision of ICU admission 57yoman Newly diagnosed AML Pulmonary infiltration NIV TLS / RRT Liver dysfunction Vasopressors Neutropenia FULL CODE 44yo man Diffuse B cell lymphoma Liver cirrhosis Ischemic heart failure Huge tumoral burden Impossible curative chemotherapy PALLIATIVE CARE NO ICU ADMISSION 27yo woman Allo BMT recipient Acute GVHD Refractory to steroids 3 IS agents Inv. Pulm. Aspergillosis MV EXCEPTIONAL ICU ADMISSION (denied by the patient) Terminal ICU Admission ? Palliative ICU Admission ? Prophylactic ICU Admission ? In-ICU non ICU care ? Early ICU Admission ? Heroic ICU status Exceptional ICU status ICU TRIAL FULL CODE ICU MANAGEMENT New Modalities of ICU admission for patients with malignancies Type of ICU admission 1. Full code ICU management 2. 3. 4. 5. a) Code status Full code Clinical situation Newly diagnosed malignancies Malignancies in complete remission Unlimited for a limited time period that Clinical response to therapy not available or undetermined ICU trial should last at least 3 to 5 days Same as ICU trial Newly available effective therapy that should be tested in a Exceptional ICU admission patient who becomes critically ill ICU management until conflict Both hematologists/oncologists and intensivists agree that Heroic ICU admission resolution ICU admission is not appropriate, but patients or relatives disagree with the appropriate level of care Other admission modalities that are performed but not yet formally evaluated Prophylactic ICU admission Full code. Intensive clinical and Earliest phase of high risk malignancies. Admission to the biological monitoring. Invasive ICU is warranted to avoid development of organ dysfunction procedures under safer conditions. (acute respiratory failure, tumor lysis syndrome, etc…). b) Early ICU admission Full code. Intensive clinical and Admission to the ICU in patients with no organ dysfunction biological monitoring. Invasive but physiological disturbances. ICU is warranted to avoid late procedures under safe conditions. ICU admission (a condition associated with higher mortality). c) Palliative ICU admission No life sustaining therapies. Non- Admission to the ICU for the purpose of undergoing invasive strategies only. noninvasive mechanical ventilation as the ceiling of therapy. d) In-ICU non ICU care No life sustaining therapies. Short ICU admission to help for optimal and prompt management (catheter withdrawal, early antibiotics etc…). e) Terminal ICU admission No life sustaining therapies. ICU admission is required to best provide palliative care and symptom control.. Controversial issue In the sickest ICU cancer patients, the impact of age on the outcome disappears behind organ dysfunctions Older age, Lower systolic blood pressure, Abnormal respiratory rate, Lower Glasgow Coma Scale Lower pulse oximetry, Nursing home residence 0.6 0.4 0.2 The MiniMax study, Azoulay et al. 2010 0.0 Cumulative Survival 0.8 1.0 Day-28 survival 0 5 10 15 20 Time (days) after ICU admission 25 28 N Engl J Med 2001 15;344:481-487 Noninvasive Conventional ventilation treatment Total 13/26 (50%) 21/26 (81%) 0.02 Oncology/hematology patients 8/15 (53%) 14/15 (93%) 0.02 Treatment-related immunosup. 4/9 (44%) 6/9 (67%) 0.32 HIV 1/2 (50%) 1/2 (50%) 0.83 P AVOID SURGERY? Tumor lysis syndrome: chemotherapy +MV + vasopressors + RRT Patients with newly diagnosed metastatic non–small-cell lung cancer were randomized to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood and the Hospital Anxiety and Depression Scale were better in the palliative care group than in the chemotherapy group NIV in DNI patients P<0.0001 Mortality (%) 60 Similar HRQOL 50 40 30 Similar post-ICU burden 20 10 0 Chronic Respiratory Insufficiency Heart Failure In patients and in relatives Pneumonia Cancer Azoulay et al. Intensive Care Medicine, 2013 Take-home Messages Making the decision to admit a cancer to the ICU relies on a good knowledge of both critical care and hematology (goals of care) Short and long term survival in Critically Ill Cancer patients increases. Classic predictors of death have lost much of their value. Our willingness of caring for cancer patients in the ICU needs to increase. Sometimes we may loose chance for survival.
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