Risks of mortality in children admitted to the paediatric intensive care unit after haematopoietic stem cell transplantation

The risk of mortality in children admitted to the paediatric intensive care unit (PICU) after haematopoietic stem cell transplantation is felt to be very high. Life-threatening complications leading to PICU admission are due to organ toxicity caused by conditioning regimes and graft-versus-host disease (GVHD), systemic infections and other organ dysfunctions. Data collected between October 1998 and December 2001 of paediatric patients undergoing haematopoietic stem cell transplantation and thereafter admitted to the PICU were retrospectively analysed in order to reveal the possible causes and risk factors related to death while in the PICU. Twenty-six PICU admissions were recorded. We found a mortality rate of 57.7% and a 6-month survival rate of 23.1%. Univariate analysis identified an oncological paediatric risk of mortality (O-PRISM) score above 10 points, sustained renal failure and a failed negative fluid balance as significant predictors to non-survival.     

Predictors of outcome in patients with hematologic malignancies admitted to the intensive care unit

Purpose

Several studies showed conflicting results about prognosis and predictors of outcome of critically ill patients with hematological malignancies (HM). The aim of this study is to determine the hospital outcome of critically ill patients with HM and the factors predicting the outcome.

Transplant-related mortality in patients older than 60 years undergoing autologous hematopoietic stem cell transplantation

Although high-dose therapy with autologous hematopoietic stem cell transplantation (ASCT) is a widely used method of dose intensification in patients with hematological malignancies, patients aged over 60 are generally excluded. We evaluated high-dose therapy and ASCT in 29 cases involving 27 such patients (median age 63 years; range 61-68) with different malignancies. Patients were eligible if they had a good performance status, normal cardiac, respiratory, and hepatic function and a serum creatinine concentration of less than 2 mg/dl (<5 mg/dl in myeloma patients). Engraftment was assessable in 27 procedures. The median time to attain 0.5 and 1 x 10(9) PMN/l was 13 days (range 9-30) and 14 days (range 10-66), respectively. The median time taken to reach a platelet count greater than 50 x 10(9)/l was 14 days (range 8-223). Five patients (17%) died in the first 100 days after transplant, in two cases due to disease progression. The remaining three patients died as a consequence of transplant-related complications, with an overall transplant-related mortality of 10%. Five patients relapsed and died between 5 and 36 months after transplant. The remaining 17 patients are still alive without disease progression, with an actuarial overall survival of 47% at 42 months (95% CI 33-61). We consider that high-dose therapy with ASCT should be considered in those elderly patients with good performance status and without general organ impairment.     

Predictive factors of in-hospital mortality in older patients admitted to a medical intensive care unit

OBJECTIVES: To identify prognostic factors that are independently predictive of in-hospital mortality in older patients hospitalized in a medical intensive care unit (MICU). DESIGN: Prospective cohort study. SETTING: A MICU in an Italian university hospital. PARTICIPANTS: Patients aged 65 and older consecutively admitted to the MICU directly from the first-aid unit. MEASUREMENTS: Upon admission, the following variables were examined: demographics, clinical history (diabetes mellitus, active neoplasm, cognitive impairment, immobilization, pressure ulcers, use of nutritional support, home oxygen therapy), physiopathology (Acute Physiology and Chronic Health Evaluation (APACHE) II), and cognition/function (activity of daily living (ADL), instrumental activity of daily living (IADL), Short Portable Mental Status Questionnaire (SPMSQ)). The vital status of the patient at the end of hospitalization was recorded. RESULTS: Over a period of 10 months, 659 patients were recruited (mean age +/- standard deviation = 76.6 +/- 7.5; 352 men and 307 women). There were 97 deaths (14.71%). The following factors proved to be significantly associated with in-hospital mortality: old age, low body mass index (BMI) values, low values of albumin, high scores on APACHE II, functional impairment (ADL, IADL), cognitive impairment (SPMSQ), history of cognitive deterioration, history of confinement to bed, and presence of pressure ulcers. Using multivariate analysis, the following variables were independently predictive of in-hospital mortality: lack of independence in ADLs (P <.001), moderate-to-severe cognitive impairment on SPMSQ (P <.001), score on APACHE II (P =.002), and low BMI values (P =.031). CONCLUSION: The prognosis of older patients hospitalized in medical intensive care units depends not only on the acute physiological impairments, but also on a series of preexisting conditions, such as loss of functional independence, severe and moderate cognitive impairment, and low BMI.     

RIFLE classification as predictive factor of mortality in patients with cirrhosis admitted to intensive care unit

Background and Aim:  To evaluate the association of the Risk, Injury, Failure, Loss and End-stage renal failure (RIFLE) score on mortality in patients with decompensated cirrhosis admitted to intensive care unit (ICU).
Methods:  A cohort of 412 patients with cirrhosis consecutively admitted to ICU was classified according to the RIFLE score. Multivariable logistic regression analysis was used to evaluate the factors associated with mortality. Liver-specific, Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA) and RIFLE scores on admission, were compared by receiver–operator characteristic curves.
Results:  The overall mortality during ICU stay or within 6 weeks after discharge from ICU was 61.2%, but decreased over time (76% during first interval, 1989–1992 vs 50% during the last, 2005–2006, P  < 0.001). Multivariate analysis showed that RIFLE score (odds ratio: 2.1, P  < 0.001) was an independent factor significantly associated with mortality. Although SOFA had the best discrimination (area under receiver–operator characteristic curve = 0.84), and the APACHE II had the best calibration, the RIFLE score had the best sensitivity (90%) to predict death in patients during follow up.
Conclusions:  RIFLE score was significantly associated with mortality, confirming the importance of renal failure in this large cohort of patients with cirrhosis admitted to ICU, but it is less useful than other scores.     

Prognostic factors of mortality in Iranian patients with systemic lupus erythematosus admitted to intensive care unit

The aim was to determine the course, outcome, and determinants of mortality in patients with systemic lupus erythematosus (SLE) in intensive care unit (ICU). SLE patients admitted to ICU from 2004 to 2015 were recruited retrospectively. Demographic data, disease characteristics, causes of admission, baseline SLE disease activity index-2K (SLEDAI-2K) and Acute Physiologic and Chronic Health Evaluation II (APACHE) score, the outcome, and the causes of death were recorded. Predictors of mortality were compared between alive and dead patients by Cox regression analysis. Ninety-four patients with SLE were enrolled. Mean age at the time of ICU admission was 29.6 years. Average scores of SLEDAI and APACHE II were 11.3 and 19.8, respectively. The most common causes of ICU admission were pneumonia, diffuse alveolar hemorrhage (DAH), and seizure. Forty-seven patients (50%) died in ICU. The principal causes of death were septic shock (25.5%), multi-organ failure (12.5%), DAH (10.6%), and pneumonia (10.6%). After multivariate analysis, high APACHE II, septic shock, and duration of mechanical ventilation were indicators of survival outcome. Mean (95% CI) survival days in ICU in patients with and without respiratory failure were 14.6 (10.4–18.9) and 28.7 (17.9–39.5) days, respectively (P = 0.001). This figure for those with and without septic shock was 13.5 (4.9–11.1) and 22.3 (9.3–24.7) days, respectively (P = 0.016). High APACHE II, septic shock, and duration of mechanical ventilation were the main predictors of death in patients with SLE in ICU. Multicenter studies are needed to draw a fine picture of SLE behavior in ICU.     

Outcome of patients having dermatomyositis admitted to the intensive care unit

Patients having systemic rheumatic diseases constitute a small percentage of admissions to the medical intensive care units (ICUs). Dermatomyositis (DM) is one of the rheumatic diseases that have secondary complications that may lead to a critical illness requiring hospitalization in the ICU. Herein, we present the features, clinical course, and outcome of critically ill patients having DM who were admitted to the ICU. The medical records of six DM patients admitted to the ICU in a large tertiary hospital in a 12-year period were reviewed. The mean age of patients at time of admission to the ICU was 38 (range 16–37). Mean disease duration from diagnosis to admission to the ICU was 1.6 years (range 1 month–8 years), while the main reason for admission to the ICU was acute respiratory failure. Two of six patients died during the hospitalization. The main causes of death were respiratory complications and sepsis. The outcome of DM patients admitted to the ICU was generally not different from the outcome of other patients hospitalized in the ICU. The main reason for hospitalization was acute respiratory failure. As there are many reasons for respiratory failure in DM, an early diagnosis and aggressive appropriate treatment may help to further reduce the mortality in these patients.     

Outcome predictors of cirrhosis patients admitted to the intensive care unit

OBJECTIVE: To evaluate outcome predictors of patients with cirrhosis admitted to an intensive care unit (ICU). METHODS: One hundred and twenty-nine consecutive patients with cirrhosis admitted to the ICU at a tertiary care transplant centre in Saudi Arabia between March 1999 and December 2000 were entered prospectively in an ICU database. Liver transplantation patients and readmissions to the ICU were excluded. The following data were documented: demographic features, severity of illness measures, parameters of organ failure, presence of gastrointestinal bleeding, and sepsis. The need for mechanical ventilation, renal replacement therapy and pulmonary artery catheter placement was recorded. The primary endpoint was hospital outcome. RESULTS: Cirrhotic patients admitted to the ICU had high hospital mortality (73.6%). However, the actual mortality was not significantly different from the predicted mortality using prediction systems. There was an association between the number of organs failing and mortality. Coma and acute renal failure emerged as independent predictors of mortality. All patients who were monitored with pulmonary artery catheterisation in this study died. Patients requiring mechanical ventilation and renal replacement therapy had very high mortalities (84% and 89%, respectively). All 13 cirrhotic patients admitted to ICU immediately post-cardiac arrest in this study died. CONCLUSIONS: Cirrhotic patients admitted to ICU have a poor prognosis, especially when admitted with coma, acute renal failure or post-cardiac arrest. The consistently poor prognosis associated with certain ICU interventions should raise new awareness regarding limitations of medical therapy. These mortality statistics compel a critical re-examination of uniformly aggressive life support for the critically ill cirrhotic patient, a percentage of whom will not benefit from invasive measures.     

Determinants of outcome in elderly patients admitted to the intensive care unit

BACKGROUND: Age is thought to be strongly associated with intensive care outcomes, but this relationship may be confounded by many clinical variables. OBJECTIVES: To compare clinical characteristics of elderly patients (> or = 65 years) admitted to the intensive care unit (ICU) with those in younger patients and to identify the risk factors which independently could predict mortality in patients aged > or = 75 years. DESIGN: Prospective observational cohort study. SETTING: Medical-surgical ICU in a university hospital. SUBJECTS: 2,067 adult patients admitted to the ICU. METHODS: Comparison of clinical characteristics of patients divided into groups according to their age. RESULTS: Elderly patients comprised 51% of the study population. Compared with younger patients, elderly patients were more severely ill on admission, had shock and renal dysfunction. The presence of infection on admission and the incidence rate of infection acquired during stay in the ICU also significantly increased with age. Hospital mortality increased with age: for patients aged > or = 75 years, it was more than double that of patients aged <65 years (39% versus 19%, P < 0.001). Using multivariate logistic regression analysis we determined the independent risk factors of hospital mortality for the patients aged > or = 75 years: impaired level of consciousness, infection on admission, ICU-acquired infection and severity of illness score. CONCLUSIONS: Morbidity and mortality in elderly patients admitted to the ICU are higher than in younger patients. The most important factors independently associated with the highest risk of death are the severity of illness, impaired level of consciousness and infection.     

Predictive factors for 28-day mortality in acute-on-chronic liver failure patients admitted to the intensive care unit

BackgroundAcute-on-chronic liver failure (ACLF) is an entity comprising an acute deterioration of liver function in cirrhotic patients, associated with organ failure(s) and high short-term mortality. We aimed to identify predictive factors for short-term mortality in patients admitted with ACLF that may benefit most from liver transplantation.MethodsRetrospective analysis of patients admitted in ACLF to a tertiary intensive care unit between 2013 and 2017 was performed. The EASL-CLIF acute-on-chronic liver failure in cirrhosis (CANONIC) criteria were used to define ACLF grade. Multivariable analysis using 28-day mortality as an end-point was performed, including severity-of-disease scores and clinical parameters.ResultsSeventy-seven patients were admitted in ACLF over the study period. The commonest aetiology of liver disease was alcohol related 52/77(68%) and the commonest precipitant of ACLF was variceal haemorrhage 38/77(49%). Overall 28-day mortality was 42/77(55%) [ACLF-(grade)1:3/42(7%); ACLF-2:10/42(24%); and, ACLF-3:29/42(69%);p = 0.002]. On multivariable analysis MELD ≥ 26 [odds ratio(OR) = 11.559; 95% confidence interval(CI):2.820–47.382;p = 0.001], ACLF-3 (OR = 3.287; 95%CI:1.047–10.325;p = 0.042) at admission and requirement for renal replacement therapy (OR = 5.348; 95%CI:1.385–20.645;p = 0.015) were independently associated with 28-day mortality.ConclusionPatients admitted with ACLF to intensive care have a high mortality rate. Defined early thresholds at admission can identify patients at the highest risk that may benefit most from liver transplantation.     

Predictors of non-compliance in autologous hematopoietic SCT patients undergoing out-patient transplants

Non-compliance has received significant attention in medicine, yet few studies have examined its correlates in autologous hematopoietic SCT (AHSCT) patients. This study examined predictors of non-compliance in a sample of 151 AHSCT patients treated in an outpatient setting. Before AHSCT, participants completed a validated measure of mood and retrospective chart reviews were conducted to assess non-compliance during AHSCT, defined as refusal of oral hygiene, prescribed exercise programs, oral nutrition and/or prescribed medications. We found 121 patients (80%) were non-compliant with an aspect of the AHSCT regimen on 1 or more days; mean percentage of non-compliant days was 16.6 (s.d. 15.6). Men were more likely than women to be non-compliant (P<0.05); as were participants with an elevated depression score (P<0.05). Stepwise regression models identified significant predictors of non-compliance: gender, depression, global distress and nausea and vomiting severity (P-values all <0.01). Further analysis revealed that the interaction of the psychological variables with gender was a more robust predictor of non-compliance (P<0.001). For outpatient AHSCT, our findings suggest the need to broaden conceptualizations of risk factors for non-compliance and the importance of assessing patient barriers to compliance to ensure optimal treatment outcome.     

Outcome of patients with idiopathic pulmonary fibrosis admitted to the intensive care unit

This retrospective study describes the clinical course of 38 patients with idiopathic pulmonary fibrosis (IPF) admitted to the intensive care unit (ICU). There were 25 males and 13 females who were the mean age of 68.3 +/- 11.5 years. Twenty patients were on corticosteroids at the time of admission to the hospital, and 24 had been on home oxygen therapy. The most common reason for ICU admission was respiratory failure. The Acute Physiology and Chronic Health Evaluation III-predicted ICU and hospital mortality rates were 12% and 26%, whereas the actual ICU and hospital mortality rates were 45% and 61%, respectively. We did not find significant differences in pulmonary function or echocardiogram findings between survivors and nonsurvivors. Mechanical ventilation was used in 19 patients (50%). Sepsis developed in nine patients. Multiple organ failure developed in 14% of the survivors and in 43% of the nonsurvivors (p = 0.14). Ninety-two percent of the hospital survivors died at a median of 2 months after discharge. These findings suggest that patients with IPF admitted to the ICU have poor short- and long-term prognosis. Patients with IPF and their families should be informed about the overall outlook when they make decisions about life support and ICU care.     

Hospital survival of older patients admitted to a medical intensive care unit

BACKGROUND AND AIMS: It is not well-known whether age or the severity of underlying conditions affects mortality in critically ill patients. The aim of this study was therefore to determine whether age is an independent predictor of hospital survival for critically ill patients. METHODS: Patients consecutively admitted to the intensive care unit from December 1 1999 to July 31 2001 were included in the study. Patients were stratified into 3 groups (< or = 65 years old, 66-75 years old, > 75 years old) and were compared, by both bivariate and multivariate analyses, to ascertain whether older critically ill patients had poorer hospital survival than younger patients. RESULTS: Of 331 patients, 178 (53.8%) patients were < or = 65 years old, 100 (30.2%) were 66-75 years old, and 53 (16%) were > 75 years old. Multivariate logistic regression analysis revealed that older age, presence of fatal comorbidities, mechanical ventilation, central venous catheterization, and higher acute physiology and chronic health evaluation score II (excluding the score obtained from age) were independent predictors of hospital mortality in the study population. Kaplan-Meier survival analysis revealed that patients < or = 65 years old had better hospital survival than older patients (p=0.02). CONCLUSIONS: Older critically ill patients have poorer hospital survival than patients < or = 65 years old, when other confounding factors such as disease severity score, invasive procedures and comorbidities were controlled for.     

Predicting factors for admission to an intensive care unit and clinical outcome in pediatric patients receiving hematopoietic stem cell transplantation

BACKGROUND AND OBJECTIVES. In children, hematopoietic stem cell transplantation (HSCT) implies life-threatening complications and some patients need admission to a pediatric intensive care unit (PICU). Few studies have been reported analyzing this issue in a pediatric population and most focused on risk factors predicting survival following PICU admission. DESIGN AND METHODS. We examined data of 240 pediatric patients who received HSCT (100 allogeneic and 140 autologous) in order to ascertain the incidence of life-threatening complications requiring PICU admission, the contributing risk factors and the patients' long-term survival. RESULTS. Forty-two (17.5%) (25 males and 17 females) of the transplanted children were admitted to the PICU. Twenty-nine of them (69%) had received an allogeneic transplant and thirteen (31%) an autologous transplant. Their median age was 7 years (range; 1-18). The most frequent reason for admission was respiratory failure (37 cases, 88%). The overall probability of developing complications requiring PICU admission was 21.2% (33.5% for allogeneic transplantation and 10.1% for patients receiving autologous grafts, p=0.0002). On univariate analysis, only the type of transplantation was significantly associated with PICU admission (allogeneic vs autologous RR 1.92, 95% CI: 1.46-2.53)(p = 0.0001). In allogeneic transplants, only the underlying disease (non-malignant) and the status of disease at transplantation within malignant diseases (advanced phase) were pretransplant variables associated with PICU admission. Post-transplantation risk factors were presence of graft-versus-host disease (GvHD) (p = 0.046) and its grade (II-IV) (p = 0.002), as well as the presence of multiorgan dysfunction during the early post-infusion phase especially when the lung was the first failing organ (p = 0.0001). However, on multivariate analysis, only severe GvHD was statistically significant. In the autologous transplantation group, the underlying disease (solid tumor, p = 0.07) and status at transplantation (advanced phase, p = 0.0029) were the only risk factors. In the post-transplant phase, patients who develop multiorgan dysfunction during the neutropenic period and those with engraftment syndrome had an increased risk of requiring critical care. The overall event-free survival (EFS) at 3 years was 15.3%, (18.4% for autologous transplant recipients and 13.7% for those receiving an allogeneic graft, p = 0.4). Using a Cox regression model, multiorgan failure (MOF) present at admission was the only variable that had a negative impact on EFS (4.28% vs 35.71% for patients with no MOF, p = 0.016). INTERPRETATION AND CONCLUSIONS. Despite high mortality, intensive care support can be beneficial for pediatric patients with life-threatening complications following HSCT. However, for patients with multiorgan failure involving the lungs, admission to the PICU should be avoided.