Boris Böll

Critical care of patients with cancer

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Characteristics and Outcome of Patients After Allogeneic Hematopoietic Stem Cell Transplantation Treated With Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome.

Objectives: The acute respiratory distress syndrome is a frequent condition following allogeneic hematopoietic stem cell transplantation. Extracorporeal membrane oxygenation may serve as rescue therapy in refractory acute respiratory distress syndrome but has not been assessed in allogeneic hematopoietic stem cell transplantation recipients. Design: Multicenter, retrospective, observational study. Setting: ICUs in 12 European tertiary care centers (Austria, Germany, France, and Belgium). Patients: All allogeneic hematopoietic stem cell transplantation recipients treated with venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome between 2010 and 2015. Interventions: None. Measurements and Main Results: Thirty-seven patients, nine of whom underwent noninvasive ventilation at the time of extracorporeal membrane oxygenation initiation, were analyzed. ICU admission occurred at a median of 146 (interquartile range, 27–321) days after allogeneic hematopoietic stem cell transplantation. The main reason for acute respiratory distress syndrome was pneumonia in 81% of patients. All but one patient undergoing noninvasive ventilation at extracorporeal membrane oxygenation initiation had to be intubated thereafter. Overall, seven patients (19%) survived to hospital discharge and were alive and in remission of their hematologic disease after a follow-up of 18 (range, 5–30) months. Only one of 24 patients (4%) initiated on extracorporeal membrane oxygenation within 240 days after allogeneic hematopoietic stem cell transplantation survived compared to six of 13 (46%) of those treated thereafter (p < 0.01). Fourteen patients (38%) experienced bleeding events, of which six (16%) were associated with fatal outcomes. Conclusions: Discouraging survival rates in patients treated early after allogeneic hematopoietic stem cell transplantation do not support the use of extracorporeal membrane oxygenation for acute respiratory distress syndrome in this group. On the contrary, long-term allogeneic hematopoietic stem cell transplantation recipients otherwise eligible for full-code ICU management may be potential candidates for extracorporeal membrane oxygenation therapy in case of severe acute respiratory distress syndrome failing conventional measures.

Letalität hämatoonkologischer Patienten in Neutropenie auf der Intensivstation

ZusammenfassungHintergrundDie febrile Neutropenie ist weiterhin einer der häufigsten Gründe für die stationäre Aufnahme von Patienten mit hämatoonkologischer Grunderkrankung. Diese Patienten haben ein bis zu 10-fach erhöhtes Risiko, eine Sepsis und andere schwere Komplikationen zu erleiden, die wiederum häufig zur Verlegung auf eine Intensivstation führen.Aktuelle Untersuchungen zeigen, dass sich das Überleben neutropenischer Patienten, insbesondere mit Sepsis, innerhalb der letzten Jahre verbessert hat, jedoch gibt es zu neutropenischen Krebspatienten auf der Intensivstation bisher keine größeren systematischen Untersuchungen.MethodeRetrospektiv wurden innerhalb eines Zeitraums von 24 Monaten 59 Episoden von Patienten mit Leukopenie bzw. Neutropenie auf einer internistischen Intensivstation erfasst.ErgebnissePneumonie und Sepsis sind die Hauptaufnahmediagnosen von neutropenischen Krebspatienten auf der Intensivstation. Die Gesamtmortalität dieses Patientenkollektivs ist hierbei mit 50,8u2009% sehr hoch. Pneumonie und Sepsis, Stammzelltransplantation in der Vorgeschichte, maschinelle Beatmung und ein akutes Nierenversagen kommen signifikant häufiger bei letalen Verläufen vor.SchlussfolgerungenKrebspatienten sollte eine intensivmedizinische Behandlung nicht vorenthalten werden. Die Einrichtung einer Intermediate-Care-Station zur frühzeitigen Überwachung kritisch kranker Patienten in Aplasie könnte die Mortalität reduzieren.AbstractBackgroundFebrile neutropenia remains one of the most common reasons for hospital admission of patients with underlying oncologic disease. These patients have an up to 10-fold increased risk of developing sepsis, which often leads to these patients being transferred to the intensive care unit (ICU). The survival of neutropenic patients with sepsis in particular has improved in recent years, due to advanced therapy in intensive care (surviving sepsis campaign); however few large international studies of neutropenic cancer patients in the ICU are available.MethodsIn a retrospective study, 59xa0episodes of neutropenic cancer patients in the internal medicine ICU at the University Hospital of Cologne over a period of 2xa0years were analyzed.ResultsPneumonia with or without sepsis are the main admission diagnoses of neutropenic cancer patients in the ICU. The mortality rate of these patients is very high (50.8u2009%). Pneumonia and sepsis, stem cell transplantation, mechanical ventilation, and acute renal failure with or without dialysis are correlated with mortality.ConclusionCancer patients should be admitted immediately to the ICU if they have signs of sepsis for early monitoring and treatment. Neutropenic patients have an increased risk for infectious complications and a risk for sepsis with higher mortality rates.BACKGROUNDnFebrile neutropenia remains one of the most common reasons for hospital admission of patients with underlying oncologic disease. These patients have an up to 10-fold increased risk of developing sepsis, which often leads to these patients being transferred to the intensive care unit (ICU). The survival of neutropenic patients with sepsis in particular has improved in recent years, due to advanced therapy in intensive care (surviving sepsis campaign); however few large international studies of neutropenic cancer patients in the ICU are available.nnnMETHODSnIn a retrospective study, 59xa0episodes of neutropenic cancer patients in the internal medicine ICU at the University Hospital of Cologne over a period of 2xa0years were analyzed.nnnRESULTSnPneumonia with or without sepsis are the main admission diagnoses of neutropenic cancer patients in the ICU. The mortality rate of these patients is very high (50.8u2009%). Pneumonia and sepsis, stem cell transplantation, mechanical ventilation, and acute renal failure with or without dialysis are correlated with mortality.nnnCONCLUSIONnCancer patients should be admitted immediately to the ICU if they have signs of sepsis for early monitoring and treatment. Neutropenic patients have an increased risk for infectious complications and a risk for sepsis with higher mortality rates.

Hematologic and oncologic emergencies

The rapid development of novel, targeted drugs in cancer medicine has led to an increase in chronically ill cancer patients and hematology patients, who are being treated aggressively despite significant comorbidities and higher age. This development will lead to an increase in the number of hematologic and oncologic emergencies, and these patients will be seen by various specialties. This review article, therefore, aims at providing clinical management algorithms for the most frequent emergencies.ZusammenfassungDie rasante Entwicklung neuer, spezifischer Medikamente in der Krebsmedizin führt zu einer Zunahme sowohl chronisch kranker onkologischer Patienten als auch hämatologischer Patienten, die trotz signifikanter Komorbiditäten und höheren Alters zunehmend aggressiv behandelt werden. Deshalb wird es mittelfristig zu einer Zunahme an hämatolgischen und onkologischen Notfallpatienten kommen, die multidisziplinär und kompetent versorgt werden müssen. Der Übersichtsartikel stellt einen Leitfaden für das Management einiger häufiger Krankheitsbildern dar.AbstractThe rapid development of novel, targeted drugs in cancer medicine has led to an increase in chronically ill cancer patients and hematology patients, who are being treated aggressively despite significant comorbidities and higher age. This development will lead to an increase in the number of hematologic and oncologic emergencies, and these patients will be seen by various specialties. This review article, therefore, aims at providing clinical management algorithms for the most frequent emergencies.

Neutropenia and sepsis

ZusammenfassungDas klinische Management von Infektionen während einer Neutropenie stellt eine große diagnostische und therapeutische Herausforderung dar. Die etablierten Sepsiskriterien sind nur bedingt anwendbar. Die Diagnostik wird durch eine begleitende Thrombopenie und die häufige respiratorische Insuffizienz erschwert. Fulminante Verläufe, eine Blutungsneigung und das „engraftment“ erschweren z.xa0T. die Therapie. Wichtig sind klare und gut kommunizierte Diagnostik- und Therapiealgorithmen, schnelles Handeln sowie eine enge Zusammenarbeit von Intensivmedizinern und hämatologisch bzw. onkologisch tätigen Ärzten.AbstractThe clinical management of neutropenic infections represents a great diagnostic and therapeutic challenge. Established sepsis criteria only partially reflect the neutropenic setting. Diagnostic procedures are frequently impaired by thrombocytopenia and progressive respiratory insufficiency. Increased tendency to bleed, engraftment, and fulminant progression represent major therapeutic challenges. Thus, crucial for the diagnosis and therapy of neutropenic sepsis are clear and well-communicated algorithms, rapid action, and close collaboration between oncologists and intensivists.

Cytokine release syndrome

During the last decade the field of cancer immunotherapy has witnessed impressive progress. Highly effective immunotherapies such as immune checkpoint inhibition, and T-cell engaging therapies like bispecific T-cell engaging (BiTE) single-chain antibody constructs and chimeric antigen receptor (CAR) T cells have shown remarkable efficacy in clinical trials and some of these agents have already received regulatory approval. However, along with growing experience in the clinical application of these potent immunotherapeutic agents comes the increasing awareness of their inherent and potentially fatal adverse effects, most notably the cytokine release syndrome (CRS). This review provides a comprehensive overview of the mechanisms underlying CRS pathophysiology, risk factors, clinical presentation, differential diagnoses, and prognostic factors. In addition, based on the current evidence we give practical guidance to the management of the cytokine release syndrome.

Neutropenie und Sepsis

ZusammenfassungDas klinische Management von Infektionen während einer Neutropenie stellt eine große diagnostische und therapeutische Herausforderung dar. Die etablierten Sepsiskriterien sind nur bedingt anwendbar. Die Diagnostik wird durch eine begleitende Thrombopenie und die häufige respiratorische Insuffizienz erschwert. Fulminante Verläufe, eine Blutungsneigung und das „engraftment“ erschweren z.xa0T. die Therapie. Wichtig sind klare und gut kommunizierte Diagnostik- und Therapiealgorithmen, schnelles Handeln sowie eine enge Zusammenarbeit von Intensivmedizinern und hämatologisch bzw. onkologisch tätigen Ärzten.AbstractThe clinical management of neutropenic infections represents a great diagnostic and therapeutic challenge. Established sepsis criteria only partially reflect the neutropenic setting. Diagnostic procedures are frequently impaired by thrombocytopenia and progressive respiratory insufficiency. Increased tendency to bleed, engraftment, and fulminant progression represent major therapeutic challenges. Thus, crucial for the diagnosis and therapy of neutropenic sepsis are clear and well-communicated algorithms, rapid action, and close collaboration between oncologists and intensivists.

Krebspatienten in der operativen Intensivmedizin

ZusammenfassungDie Prävalenz onkologischer Erkrankungen ist in den vergangenen Jahrzehnten stetig angestiegen. Durch neue Therapieoptionen können immer mehr Patienten mit einem kurativen Therapieansatz behandelt werden. Diese individualisierten und teilweise sehr aggressiven Therapien können jedoch auch zu schweren Nebenwirkungen führen. Diese sollten als wichtige Differenzialdiagnosen zu anderen vitalbedrohlichen Krankheitsbildern auch dem im OP und als Intensivmediziner tätigen Anästhesisten bekannt sein. Krebspatienten werden häufig auf operativen Intensivstationen aufgenommen, um Komplikationen der malignen Grunderkrankung oder auch Nebenwirkungen einer operativen oder konservativen Therapie zu behandeln. Aktuelle Untersuchungen zeigen, dass die maligne Grunderkrankung entgegen bisheriger Annahme keinen wesentlichen Einfluss auf das Intensivüberleben hat. Bei der Aufnahme eines onkologischen Patienten sollte daher die akut vorliegende Organdysfunktion zunächst im Vordergrund stehen. Bei der Therapiezielplanung gilt es, nicht zu übersehen, wann ein kuratives in ein palliatives Konzept übergehen muss. Hierfür müssen neue Aufnahmestrategien und -kriterien entwickelt und evaluiert werden. In diesem Übersichtsartikel werden Diagnosen und Therapien häufiger intensivmedizinischer Krankheitsbilder von onkologischen Patienten sowie Nebenwirkungen moderner onkologischer Therapien dargelegt und Aufnahmestrategien für Patienten mit malignen Erkrankungen vorgestellt.AbstractCancer is one of the leading causes of death worldwide. New targeted and individualized therapies and drugs provide axa0survival benefit for an increasing number of patients, but can also cause severe side effects. An increasing number of oncology patients are admitted to intensive care units (ICU) because of cancer-related complications or treatment-associated side effects. Postoperative care, respiratory distress and sepsis are the leading causes for admission. Tumor mass syndromes and tumor lysis may require urgent treatment. Traditional anticancer chemotherapy is associated with infections and immunosuppression. Newer agents are generally well-tolerated and side effects are mild or moderate, but overwhelming inflammation and autoimmunity can also occur. Cellular treatment, such as with chimeric antigen receptor modified T‑cells, monoclonal and bispecific antibodies targeting immune effectors and tumor cells are associated with cytokine release syndrome (CRS) with hypotension, skin reactions and fever. It is related to excessively high levels of inflammatory cytokines. Immune checkpoint inhibitors can lead to immune-related adverse events (IRAEs), such as colitis and endocrine disorders. Noninfectious respiratory complications, such as pneumonitis can also occur. Recent studies revealed that short-term and medium-term survival of cancer patients is better than previously expected. In this review article we summarize diagnostic and treatment strategies for common life-threatening complications and emergencies requiring ICU admission. Furthermore, strategies for rational admission policies are presented.Cancer is one of the leading causes of death worldwide. New targeted and individualized therapies and drugs provide axa0survival benefit for an increasing number of patients, but can also cause severe side effects. An increasing number of oncology patients are admitted to intensive care units (ICU) because of cancer-related complications or treatment-associated side effects. Postoperative care, respiratory distress and sepsis are the leading causes for admission. Tumor mass syndromes and tumor lysis may require urgent treatment. Traditional anticancer chemotherapy is associated with infections and immunosuppression. Newer agents are generally well-tolerated and side effects are mild or moderate, but overwhelming inflammation and autoimmunity can also occur. Cellular treatment, such as with chimeric antigen receptor modified T‑cells, monoclonal and bispecific antibodies targeting immune effectors and tumor cells are associated with cytokine release syndrome (CRS) with hypotension, skin reactions and fever. It is related to excessively high levels of inflammatory cytokines. Immune checkpoint inhibitors can lead to immune-related adverse events (IRAEs), such as colitis and endocrine disorders. Noninfectious respiratory complications, such as pneumonitis can also occur. Recent studies revealed that short-term and medium-term survival of cancer patients is better than previously expected. In this review article we summarize diagnostic and treatment strategies for common life-threatening complications and emergencies requiring ICU admission. Furthermore, strategies for rational admission policies are presented.

‘Lost in Nasal Space’: Staphylococcus aureus sepsis associated with Nasal Handkerchief Packing

IntroductionStaphylococcus aureus frequently causes infections in outpatient and hospital settings and can present as a highly variable entity. Typical manifestations are endocarditis, osteoarticular infections or infection of implanted prostheses, intravascular devices or foreign bodies. A thorough diagnostic evaluation with early focus identification is mandatory to improve patient outcome.Case reportWe report a case of a 68-year old patient with a history of double allogeneic stem cell transplant for acute myeloid leukemia who developed a S. aureus bacteremia with dissemination, severe sepsis and lethal outcome due to nasal handkerchief packing after nose bleeding.ConclusionA thorough medical examination with further diagnostic work-up is most important in S. aureus blood stream infection to identify and eradicate the portal(s) of entry, to rule out endocarditis, to search for spinal abscesses, osteomyelitis or spondylodiscitis. Adherence to management guides for clinicians must be of major importance to achieve optimal quality of clinical care, and thus improve patient outcome.

Volumenmanagement bei Sepsis und septischer Schock

Sepsis and septic shock are common diseases with high mortality rates. Although volume therapy has been a central component of sepsis therapy for decades, the choice of optimal fluid and fluid intake is unclear. This paper summarizes findings on pathophysiology, clinical trial results, and current recommendations for optimal volume and fluid management in sepsis.