NMBA could exert beneficial effects in patients with moderate ARDS, at least in part, by limiting expiratory efforts.

Objectives: Cancer affects up to 20% of critically ill patients, and sepsis is one of the leading reasons for ICU admission in this setting. Early signals suggested that survival might be increasing in this population. However, confirmation studies have been lacking. The goal of this study was to assess trends in survival rates over time in cancer patients admitted to the ICU for sepsis or septic shock over the last 2 decades. Data Source: Seven European ICUs. Study Selection: A hierarchical model taking into account the year of admission and the source dataset as random variables was used to identify risk factors for day 30 mortality. Data Extraction: Data from cancer patients admitted to ICUs for sepsis or septic shock were extracted from the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique database (1994–2015). Data Synthesis: Overall, 2,062 patients (62% men, median [interquartile range] age 59 yr [48–67 yr]) were included in the study. Underlying malignancies were solid tumors (n = 362; 17.6%) or hematologic malignancies (n = 1,700; 82.4%), including acute leukemia (n = 591; 28.7%), non-Hodgkin lymphoma (n = 461; 22.3%), and myeloma (n = 244; 11.8%). Two-hundred fifty patients (12%) underwent allogeneic hematopoietic stem cell transplantation and 640 (31.0%) were neutropenic at ICU admission. Day 30 mortality was 39.9% (823 deaths). The year of ICU admission was associated with significant decrease in day 30 mortality over time (odds ratio, 0.96; 95% CI, 0.93–0.98; p = 0.001). Mechanical ventilation (odds ratio, 3.25; 95% CI, 2.52–4.19; p < 0.01) and vasopressors use (odds ratio, 1.42; 95% CI, 1.10–1.83; p < 0.01) were independently associated with day 30 mortality, whereas underlying malignancy, allogeneic hematopoietic stem cell transplantation, and neutropenia were not. Conclusions: Survival in critically ill oncology and hematology patients with sepsis improved significantly over time. As outcomes improve, clinicians should consider updating admission policies and goals of care in this population.

Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-015-3994-8) contains supplementary material, which is available to authorized users.Dear Editor, Acute respiratory failure is a dramatic event and remains a major cause of ICU admission in cancer patients [1]. It has been recently shown that highflow oxygen therapy through a nasal cannula in association with noninvasive ventilation (HFNC-NIV) during acute respiratory failure is associated with high mortality in unselected patients with hypoxemic acute respiratory failure (FLORALI study) [2]. We retrospectively analyzed 178 cancer patients admitted to the ICU for severe acute respiratory failure (O 2 delivery [9 L/min). We computed a propensity score to predict HFNC-NIV treatment based on specific characteristics at ICU admission. The primary outcome was all-causes mortality at day 28; secondary outcomes included the number of ventilator-free days at day 28 and long-term mortality. The study was approved by our institutional review board. For the initial population (n = 178), pulmonary infection (any pathogen) was present in 116 patients (65 %). At ICU admission the median SAPS II was 47 (IQR 38-57), SOFA score 6 (4-9), and PaO 2 /FiO 2 ratio 123 (87-158). A total of 150 patients (84 %) were treated with NIV, 84 (47 %) with HFNC, and 94 (53 %) with standard oxygen. Among these patients, 76 (43 %) were treated with HFNC-NIV, 74 (42 %) with standard O 2 -NIV, 8 (5 %) with standard O 2 alone, and 20 (11 %) with HFNC alone. As compared to the others patients, HFNC-NIV patients presented a lower day-28 mortality rate, 37 % (n = 28) vs 52 % (n = 53), p = 0.045; a longer time from ICU admission to intubation 34 h (18-72) vs 16 h (7-45), p = 0.01; and a higher but not significant number of ventilator-free days, 24 (2-28) vs 8 (1-28), p = 0.06.

Outcome of patients undergoing allogenic hematopoietic stem cell transplantation (allo-HSCT) has improved. To investigate if this improvement can be transposed to the ICU setting, we conducted a systematic review and meta-analysis to assess short-term mortality of critically ill allo-HSCT patients admitted to the ICU and to identify prognostic factors of mortality. Public-domain electronic databases, including Medline via PubMed and the Cochrane Library were searched. All full-text articles written-English studies published from 2006 to 2016, including allo-HSCT adults transferred to the ICU were included. Eighteen studies were selected, including 2342 patients. Overall estimated ICU mortality was 51.7%. Prognostic factors associated with an increased ICU mortality were mechanical ventilation (OR = 12.2, 95% CI = 6.2-23.7), vasopressors (OR = 6.3, 95% CI = 3.6-11.1), renal replacement therapy (OR = 4.2, 95% CI = 2.8-6.2), ICU admission for acute respiratory failure (OR = 2.2, 95% CI = 1.1-4.4), acute kidney injury (OR = 2.2, 95% CI = 1.3-4), and acute graft-versus-host disease (OR = 1.6, 95% CI = 1.1-2.3). Factors associated with an increased ICU survival were a single-organ failure (OR = 0.2, 95% CI = 0.1-0.4), neurological failure (OR = 0.4, 95% CI = 0.2-0.8), and reduced-intensity conditioning regimens (OR = 0.7, 95% CI = 0.5-0.9). Septic shock, underlying malignancy, disease status, donor, and graft source did not impact prognosis. Outcome has improved, supporting the usefulness of ICU management. Organ failures at ICU admission, organ support requirement, and GVHD are the main prognostic factors.

Background Delayed intubation is associated with high mortality. There is a lack of objective criteria to decide the time of intubation. We assessed a recently described combined oxygenation index (ROX index) to predict intubation in immunocompromised patients. The study is a secondary analysis of randomized trials in immunocompromised patients, including all patients who received high-flow nasal cannula (HFNC). The first objective was to evaluate the accuracy of the ROX index to predict intubation for patients with acute respiratory failure. Results In the study, 302 patients received HFNC. Acute respiratory failure was mostly related to pneumonia (n = 150, 49.7%). Within 2 (1–3) days, 115 (38.1%) patients were intubated. The ICU mortality rate was 27.4% (n = 83). At 6 h, the ROX index was lower for patients who needed intubation compared with those who did not [4.79 (3.69–7.01) vs. 6.10 (4.48–8.68), p < 0.001]. The accuracy of the ROX index to predict intubation was poor [AUC = 0.623 (0.557–0.689)], with low performance using the threshold previously found (4.88). In multivariate analysis, a higher ROX index was still independently associated with a lower intubation rate (OR = 0.89 [0.82–0.96], p = 0.04). Conclusion A ROX index greater than 4.88 appears to have a poor ability to predict intubation in immunocompromised patients with acute respiratory failure, although it remains highly associated with the risk of intubation and may be useful to stratify such risk in future studies.