B. Leclercq

Prognostic factors for neutropenic patients in an intensive care unit : Respective roles of underlying malignancies and acute organ failures

The admission of neutropenic patients to an intensive care unit (ICU) is still controversial, especially if mechanical ventilation is required. To avoid useless stays in ICU, the evaluation of the respective role of the underlying malignancy and acute organ failures might be useful for better definition of the categories of patients who could benefit from aggressive ICU support. For this purpose, we carried out a retrospective study of the charts of 107 consecutive neutropenic patients admitted to an ICU in a comprehensive cancer centre over a four-year period. The following characteristics were recorded within 24 h of admission: patient data, characteristics of neutropenia and the underlying malignancy, the type and number of organ system failures (OSFs) and simplified acute physiological scores (SAPS and SAPS II). The impact of each variable on outcome in the ICU was studied by univariate and multivariate (logistic regression) analysis. 59 patients died in the ICU (mortality rate: 55%). Patients with a haematological malignancy (n = 57, 53%) were more likely to experience respiratory failure, an underlying malignancy deemed rapidly fatal, and to have longer lasting neutropenia than patients with a solid tumour (n = 50, 47%). However, the mortality rate did not differ in the two groups (haematological malignancy 61% versus solid tumour 48%, p = 0.16). Respiratory and cardiovascular organ failure (p < 0.001 for both) correlated with mortality in the ICU. In the multiple logistic regression model, only the number of organ system failures and respiratory failure remained predictive of ICU mortality. In conclusion, the characteristics of the underlying malignancy are not relevant when deciding whether or not neutropenic patients should be admitted to an ICU. The main risk factors for death in an ICU are the number of organ failures on admission, and among them the presence of respiratory failure.

Severity-of-illness scores for neutropenic cancer patients in an intensive care unit: Which is the best predictor? Do multiple assessment times improve the predictive value

OBJECTIVES To use three severity of illness scores to estimate the probability of hospital mortality among patients with cancer and neutropenia; to compare the performance of these scores, calculated at admission to an intensive care unit (ICU); and to test the improvement in estimation obtained by taking into account the first 72-hr period. DESIGN Collection of data for every neutropenic patient hospitalized in the ICU during a 4-yr period. SETTING A comprehensive cancer center. PATIENTS Ninety-four patients were neutropenic at ICU admission. Their vital status was measured at hospital discharge. MEASUREMENTS AND MAIN RESULTS The new Simplified Acute Physiology Score (SAPS) II improved the estimation of hospital mortality compared with the original SAPS score. Using a simple score based on the number of acute organ system failures (OSFs) to classify the patients, good discrimination between survivors and nonsurvivors was observed (area under the receiver operating characteristic curves, 79 +/- 5 [SD] %). The relationship between successive scores and outcome was explored using recursive partitioning. Patients were first classified according to their OSF value on the first day of hospitalization in the ICU with a cutoff of two organ failures, and classification was then improved by taking into account the OSF score on the third day. CONCLUSIONS For cancer patients hospitalized in an ICU for a neutropenic episode, the severity of illness and the risk of death can be accurately assessed by the SAPS II score and the number of acute organ failures at admission. The OSF values on the first and third days of hospitalization both provided information, allowing the classification of patients into groups with different probabilities of hospital mortality.

Early tracheotomy in neutropenic, mechanically ventilated patients: rationale and results of a pilot study

Despite substantial advances in the management of such patients, the prognosis of ventilated neutropenic patients remains grim. The objective of our study was to evaluate the benefit of tracheotomy in this category of patients, in terms of mortality while they were in the intensive-care unit and nosocomial pneumonias. The charts of 53 consecutive, ventilated, neutropenic patients, or those destined to be imminently neutropenic, admitted to our intensive-care unit during a 4-year period, have been retrospectively reviewed. Tracheotomy was performed at the bedside or in the operating room: 20 patients underwent tracheotomy within 48 h of mechanical ventilation (ET group), while 33 were tracheotomized later or remained intubated (INT group). The two groups were comparable with regard to the underlying disease, respiratory failure, mechanical ventilation patterns and severity scores, but neutropenia was more profound in the ET group. Mortality while in the intensivecare unit was similar (ET:70%; INT:78.8%). However, the survival curves showed a trend towards longer survival in the ET group, even after adjustment for the degree of neutropenia (log-rank test: P=0.07). The incidence of pneumonias was similar in both groups. No major complications of tracheotomy were reported. These findings suggest that a tracheotomy could be proposed for neutropenic patients requiring mechanical ventilation, in order to prologn their survival beyond the end of the neutropenic period. A prospective study is underway to confirm these preliminary results.

Effects of Infused Intralipids on Neutrophil Chemotaxis during Total Parenteral Nutrition

A number of previous studies have suggested that the fat emulsion, Intralipid, might compromise human host defenses, due mainly to impairment of neutrophil functions. The aim of this study was to evaluate the effects of Intralipid on neutrophil chemotaxis in cancer patients receiving total parenteral nutrition including 500 ml of 20% Intralipid over 6 hours (83 ml/hr). No impairment of neutrophil chemotaxis was found during or after lipid infusion. Further investigations are necessary to determine whether, in routine clinical practice, intralipids are responsible for impairment of other neutrophil functions and whether side treatments have a protective effect for neutrophil functions.

Safety of tracheotomy in neutropenic patients: A retrospective study of 26 consecutive cases

ObjectiveTo evaluate the safety of tracheotomy in neutropenic ventilated cancer patients, in terms of infectious and haemorrhagic complications.DesignRetrospective study.SettingA medical-surgical intensive care unit in a Cancer-hospital.Patients and participants: 26 consecutive patients undergoing a tracheotomy in neutropenic period, from 1987 to 1990.InterventionsTracheotomy, performed at the bedside or in operating, room.Measurements and resultsIn all neutropenic patients undergoing a tracheotomy, the characteristics and duration of both neutropenia and mechanical ventilation have been recorded. Stomal bleeding and infection, and infectious pneumonias and alveolar haemorrhage have been carefully reviewed. Platelets were transfused in 23 of the 26 patients at the time of the procedure; no local haemorrhage was observed. Neither stomal nor pulmonary infections secondary to traceotomy were noted. No respiratory worsening was attributable to the tracheotomy. Nineteen patients (73%) died in ICU, without direct link between tracheotomy and death.ConclusionsThese findings suggest that a tracheotomy can be safely performed in neutropenic patients requiring mechanical ventilation.

Super-high-risk germ-cell tumors: a clinical entity

Among patients suffering from nonseminomatous germ-cell tumor, with a poor prognosis, a subset underwent respiratory failure and died very early in the course of their treatment. Between 1982 and 1989, 11 out of 56 such patients (20%) died within the first 5 weeks of chemotherapy. The clinical, radiological, biological and infectious characteristics of these patients were analyzed. Nine patients had extensive pulmonary metastases and the 2 others presented a bulky mediastinal mass with pleural effusion. All patients experienced acute respiratory distress during chemotherapy and underwent mechanical ventilation. All patients were febrile, and septicemia was documented in 7 cases. WHO grade 4 and grade 1–2 renal toxicities occurred in 3 and 4 patients respectively. There was no tumor lysis syndrome. All patients died within 35 days from the start of therapy; 4 were autopsied. These 11 patients represent a clinical entity, having what we called super-high-risk germ cell tumors. Early death is related to pulmonary distress within the first 5 weeks of therapy. The origin of the pulmonary distress is multifactorial: bulky disease of the chest, infection, and interstitial fibrosis. Immediate full-dose standard chemotherapy in association with intensive supportive care is recommended in the management of these patients.

Wegener's granulomatosis presenting as diffuse pulmonary hemorrhage

A 35-year-old woman experienced diffuse intraalveolar haemorrhage with respiratory distress and acute renal failure. Renal histology and evolution confirmed Wegeners granulomatosis. Early use of immunosuppressive drugs allowed weaning from mechanical ventilation and temporary improvement of the renal failure. A review of the literature emphazises the rarity of alveolar hemorrhage as an initial symptom of Wegeners granulomatosis and the necessity of aggressive management.

Lithium concentrations during cisplatin-based chemotherapy: evidence for renal interaction

We read with interest the report of J. H. Beijnen etal . [1] concerning lithium pharmacokinetics during cisplatin-based chemotherapy [1]. However, we do not agree with their interpretation of the transient decrease in serum lithium concentration. Lithium clearance is widely used in view of estimating the distal tubular sodium delivery, because of its absorption at the same rate as sodium in the proximal tubule and, normally, no more beyond the thick ascending limb [2]. This is true only in normovolemic states. In case of water and/or sodium depletion, some lithium is reabsorbed in the thick ascending limb and the collecting duct. Under osmotic diuresis as usually done during cisplatin-based chemotherapy, these phenomena do not occur [3]. Therefore, the two major factors influencing renal lithium clearance include not only the glomerular filtration rate but also variations in the tubular reabsorption of sodium and water. It cannot be interpreted at face value because of its variation with creatinine clearance and sodium intake. The necessity of correction for total sodium excretion and creatinine clearance so as to obtain the true value has been established [4]. Large variations in sodium loading before, during, and after treatment of the patient as reported by Beijnen et al. [1] may account for variation in lithium concentrations without a significant difference in noncorrected lithium clearance. As for sodimn, the transport of lithium along the proximal tubule is due mainly to an active phenomenon [5]. The mechanism of renal dysfunction during cisplatin therapy remains unclear. In a recent report suggesting a protective effect of glycine [6], it has been proven that toxic intracellular platinum species are formed early after injection. The main site of such formation is the

Totally implanted catheters to reduce catheter-related infections in patients receiving interleukin-2: a 2-year experience

3 part of the

Predicting infection in critically ill surgical patients: usefulness of bacteriuria

A high incidence of bacterial infections has been previously reported during interleukin-2 (IL-2) treatment, mainly due to catheter-related infections. Antibiotic prophylaxis has been successfully used to decrease such infections. The goal of this study was to evaluate an alternative way to reduce catheter-related infections in IL-2-treated patients by the use of totally implanted catheters. A total of 74 patients with metastatic renal cell carcinoma, referred to our institution to receive IL-2 from March 1989 to July 1991, were included in this prospective study. IL-2 was given on a 2-days-a-week schedule (24x106 IU m-2 day-1) either alone (41 patients) or in association with interferon γ (33 patients). All these patients were prospectively evaluated for fever, bacteremia and line-site infection. Seven patients (9.5%) had one (2 patients) or more (5 patients) positive blood cultures with Staphylococcus aureus. Antibiotics were used only in 5 patients, and the catheter had to be removed in only 2 of these patients. In the other patients, no further infection developed despite the lack of antibiotics. Moreover, 9 patients had positive blood cultures with Staphylococcus epidermidis (1.9% of total number of blood cultures). In conclusion, a totally implanted catheter appears to reduce the incidence of infections in IL-2-treated patients, at least on a 2-days-a-week schedule.