Prognostic Indicators for Blood and Marrow Transplant Patients Admitted to an Intensive Care Unit

Abstract

Although hematopoietic stem cell transplantation (HSCT) can be curative in patients with certain malignancies, survival is poor if the recipient becomes critically ill. This prospective study examined the outcomes of 115 consecutive HSCT patients admitted to the medical intensive care unit (MICU) of a tertiary cancer center and identified variables associated with survival. The need for endotracheal intubation and mechanical ventilation ("intubation") had a profound adverse effect on survival. Overall, 9 of 48 (18.8%) intubated patients survived compared with a survival rate of 44 of 67 (65.7%) among patients not intubated (p < 0.001). This pattern persisted for nearly all patient subgroups. Among intubated patients, those receiving peripheral blood stem cell transplant (PBSCT) had significantly better survival than bone marrow transplant (BMT) patients (8 of 26, 31% versus 1 of 22, 4%; p = 0.028). Multiple logistic regression analyses indicated that the probability a patient admitted to the MICU survived decreased significantly if the patient was intubated, had an allogeneic rather than autologous transplant, had an infection or gastrointestinal bleeding, and also decreased with higher respiratory rate, higher heart rate, longer time from transplant to MICU admission or higher bilirubin. These results may be of value in deciding which critically ill patients will benefit from intubation following major complications after HSCT transplantation.

Outcome in critically ill cancer patients: past and present

“…For instance, of the 112 patients with hematological malignancies ventilated in our centre > 7 days between 1997 and 2007, 26% survived to hospital discharge and 20% were still alive at 6 months (unpublished data). However, the survival of ventilated allogeneic bone marrow or peripheral stem cell transplantation recipients remains particularly poor [19][20][21] although some improvement has been achieved [36][37][38] . Encouraging results have also been obtained in cancer patients requiring renal replacement therapy for acute renal failure, even in case of multiple organ failure or in combination with ventilatory support [33][34][35][36] .…”

“…However, the survival of ventilated allogeneic bone marrow or peripheral stem cell transplantation recipients remains particularly poor [19][20][21] although some improvement has been achieved [36][37][38] . Encouraging results have also been obtained in cancer patients requiring renal replacement therapy for acute renal failure, even in case of multiple organ failure or in combination with ventilatory support [33][34][35][36] . While renal replacement therapy was unequivocally associated with a 90-95% ICU mortality in case of multiple organ failure two decades ago 12,18 , Soares et al 31 recently reported 65% six month mortality in patients with one or two associated organ failures and a 93% six month mortality in case of 3 associated organ failures, again similar to general ICU patients 32 .…”

“…Although clearly, these patients were highly selected, meaningful long-term survival was observed despite the need for advanced life-supporting therapy during ICU stay in patients with hematological malignancies or chemo-sensible solid tumors at first presentation of their disease, a finding that no one could have been thought of being possible a few years ago. These improvements in outcome can been attributed to a better selection of patients with respect to their underlying malignancy and subsequent expected longterm prognosis 22,28,31,40 , the increasing use of peripheral blood stem cell transplantation 36 , the availability of better supportive measures in the subgroup of immunocompromised patients such as of non-invasive ventilation 22,41 and last but not least the advances in the treatment of sepsis and in ICU support in general 42,43 .…”

Suporte de terapia intensiva no paciente oncológico

“…Gastrointestinal (venoocclusive hepatic insufficiency, gastric bleeding), neurological (metabolic encephalopathy, hemorrhages), and cardiac disorders (drug toxicity, pericardial effusion), in addition to coagulopathies and renal insufficiency are the most common complications in transplant recipients that might need intensive care. 50 …”

Mortalidade relacionada ao transplante e fatores associados em pacientes submetidos ao transplante de células tronco hematopoiéticas: estudo de coorte

“…Nas UTI em que o uso do SAPSII é frequente, estima-se que 20 a 40% dos pacientes submetidos a TCTH autólogo e alogênico necessitem de cuidados intensivos (63) e cuja taxa de mortalidade hospitalar varia de 54-96% (55,64) .…”