Fabienne Fieux

Outcome of Cancer Patients Considered for Intensive Care Unit Admission: A Hospital-Wide Prospective Study

PURPOSE To evaluate the outcome of cancer patients considered for admission to the intensive care unit (ICU). PATIENTS AND METHODS Prospective, one-year hospital-wide study of all cancer and hematology patients, including bone marrow transplantation patients, for whom admission to the ICU was requested. RESULTS Of the 206 patients considered for ICU admission, 105 patients (51%) were admitted. Of the 101 patients who were not admitted, 54 patients (26.2%) were considered too sick to benefit, and 47 patients (22.8%) were considered to be too well to benefit from the ICU. Of these 47 patients, 13 patients were admitted later. Survival rates after 30 and 180 days were significantly associated with admission status (P < .0001). Remission of the malignancy (odds ratio [OR], 3.37; 95% CI, 1.25 to 9.07) was independently associated with ICU admission, whereas poor chronic health status (OR, 0.38; 95% CI, 0.16 to 0.74) and solid tumor (OR, 0.43; 95% CI, 0.24 to 0.78) were associated with ICU refusal. In admitted patients, 30-day and 6-month survival rates were 54.3% and 32.4%, respectively. Of the patients considered too sick to benefit from ICU admission, 26% were alive on day 30 and 16.7% on day 180. Among patients considered too well to benefit, the 30-day survival rate was a worrisome 78.7%. Calibration of the Mortality Probability Model (the only score available at triage) was of limited value for predicting 30-day survival (area under the curve, 0.62). CONCLUSION Both the excess mortality in too-well patients later admitted to the ICU and the relatively good survival in too-sick patients suggest the need for a broader admission policy.

Deterioration of previous acute lung injury during neutropenia recovery

DesignAlthough neutropenia recovery is associated with a high risk of deterioration of respiratory condition, no studies designed to identify risk factors for acute respiratory distress syndrome (ARDS) in this situation have been published. SettingMedical ICU in a French teaching hospital. Subjects We conducted a study to describe critically ill cancer patients with ARDS during neutropenia recovery (defined as the 7-day period centered on the day the neutrophil count rose above 1000/mm3 [day 0]) and to compare them with critically ill cancer patients without ARDS during neutropenia recovery. InterventionsNone. Measurements and Main ResultsDuring a 10-yr period, 62 critically ill cancer patients recovered from neutropenia, of whom 21 experienced ARDS during neutropenia recovery, with a median time of −1 days (−2.5–1) between day 0 and ARDS. In-ICU mortality in these 21 patients was 61.9%. As compared with non-ARDS patients, ARDS patients were less likely to have myeloma and more likely to have leukemia/lymphoma treated with adriamycin, a history of pneumonia before neutropenia, and a neutropenia duration >10 days; they had a shorter time since malignancy diagnosis and a longer time from chemotherapy to neutropenia. Neither the leukocyte counts on day 0 nor those during the 6-day neutropenia recovery period were predictive of ARDS. ConclusionsPatients with acute respiratory failure after prolonged neutropenia complicated by pneumonia are at increased risk for ARDS.

Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II.

RATIONALE Although intensive care units (ICUs) were created for patients with life-threatening illnesses, the ICU environment generates a high risk of iatrogenic events. Identifying medical errors (MEs) that serve as indicators for iatrogenic risk is crucial for purposes of reporting and prevention. OBJECTIVES We describe the selection of indicator MEs, the incidence of such MEs, and their relationship with mortality. METHODS We selected indicator MEs using Delphi techniques. An observational prospective multicenter cohort study of these MEs was conducted from March 27 to April 3, 2006, in 70 ICUs; 16 (23%) centers were audited. Harm from MEs was collected using specific scales. MEASUREMENTS AND MAIN RESULTS Fourteen types of MEs were selected as indicators; 1,192 MEs were reported for 1,369 patients, and 367 (26.8%) patients experienced at least 1 ME (2.1/1,000 patient-days). The most common MEs were insulin administration errors (185.9/1,000 d of insulin treatment). Of the 1,192 medical errors, 183 (15.4%) in 128 (9.3%) patients were adverse events that were followed by one or more clinical consequences (n = 163) or that required one or more procedures or treatments (n = 58). By multivariable analysis, having two or more adverse events was an independent risk factor for ICU mortality (odds ratio, 3.09; 95% confidence interval, 1.30-7.36; P = 0.039). CONCLUSIONS The impact of medical errors on mortality indicates an urgent need to develop prevention programs. We have planned a study to assess a program based on our results.

Important questions asked by family members of intensive care unit patients.

Objectives: Relatives often lack important information about intensive care unit patients. High-quality information is crucial to help relatives overcome the often considerable situational stress and to acquire the ability to participate in the decision-making process, most notably regarding the appropriate level of care. We aimed to develop a list of questions important for relatives of patients in the intensive care unit. Design, Setting, and Participants: This was a multicenter study. Questions asked by relatives of intensive care unit patients were collected from five different sources (literature, panel of 28 intensive care unit nurses and physicians, 1-wk survey of nurses and 1-wk survey of physicians in 14 intensive care units, and in-depth interviews with 14 families). After a qualitative analysis (framework approach and thematic analysis), questions were rated by 22 relatives and 14 intensive care unit physicians, and the ratings were analyzed using principal component analysis and hierarchical clustering. Results: The five sources produced 2,135 questions. Removal of duplicates and redundancies left 443 questions, which were distributed among nine predefined domains using a framework approach (“diagnosis,” “treatment,” “prognosis,” “comfort,” “interaction,” “communication,” “family,” “end of life,” and “postintensive care unit management”). Thematic analysis in each domain led to the identification of 46 themes, which were reworded as 46 different questions. Ratings by relatives and physicians showed that 21 of these questions were particularly important for relatives of intensive care unit patients. Conclusion: This study increases knowledge about the informational needs of relatives of intensive care unit patients. This list of questions may prove valuable for both relatives and intensive care unit physicians as a tool for improving communication in the intensive care unit.

Pulsatile perfusion preservation for expanded-criteria donors kidneys: Impact on delayed graft function rate

Purpose Expanded criteria donors (ECD) kidneys are a potential solution to organ shortage, but exhibit more delayed graft function (DGF). We conducted a prospective controlled study aiming to evaluate the impact of Pulsatile Perfusion Preservation (PPP) on DGF rate. Methods Inclusion criteria were: 1) ECD definition (any brain-dead donor aged > 60 years or aged 50-60 years with at least 2 of the following: history of hypertension, terminal serum creatinin level ≥ 1.5 mg/dL, death resulting from a cerebrovascular accident; 2) Donor prolonged circulatory arrest (> 20 mn); 3) previsible cold ischemia time longer than 24 hours. In each pair of kidneys, one organ was preserved with PPP and the other organ was preserved in static cold storage. Results From February 2007 to September 2009, a total of 22 donors (44 recipients) were included. Recipients were comparable in the two groups with respect to demographic and immunological data. The rate of DGF was significantly lower (9% vs. 31.8%, p=0.021) in the PPP group. At 1, 3, and 12 months, renal function was comparable in the two groups. Conclusions Pulsatile Perfusion Preservation significantly reduced DGF rate in ECD kidney transplantation.

Kidney allograft fibrosis after transplantation from uncontrolled circulatory death donors.

Background Existing data suggest that increased interstitial fibrosis may occur abnormally in renal transplants from donations after uncontrolled circulatory death (uDCD). Methods To evaluate the factors that are associated with the progression of fibrosis and its functional impact on renal grafts, we compared 76 uDCD recipients with 86 recipients of kidney donations after brain death at 1-year after transplantation. Groups were matched for donor age, rank of transplantation, and absence of human leukocyte antigen sensitization. Histology was performed on sequential biopsies in uDCD recipients. Associations between variables were analyzed using linear mixed models and univariate analyses. Results In the uDCD group, increased fibrosis was detected 3 months after transplantation compared to before implantation. After 1 year, interstitial fibrosis and tubular atrophy score was significantly greater (1.5 ± 0.7 vs. 1.0 ± 0.9; P = 0.003) and estimated glomerular filtration rate (49.5 ± 17.4 vs. 60.6 ± 19.1 mL/min/1.73 m2; P = 0.0003) was significantly lower in the uDCD group than in the donations after brain death group. No flow duration and donor age were significantly associated with accelerated fibrosis. Interstitial fibrosis and tubular atrophy score, interstitial inflammation score, and estimated glomerular filtration rate were significantly worse in uDCD patients with no flow longer than 10 min. Conclusion Donations after uncontrolled circulatory death grafts show more fibrosis after transplantation. No flow duration is associated with accelerated fibrosis and should be considered during uDCD graft allocation.

Informing Family Members of Critically Ill Patients

Delivering honest information to families in easily understandable words and in an empathic manner is an integral part of high-quality care in the intensive care unit (ICU). Findings from studies of the quality of information given to the families of ICU patients have been used by the Société de Réanimation de Langue Française to establish 10 recommendations designed to increase the chances of achieving the following key goals: good comprehension of the information by families, good family satisfaction with the information received, and minimization of anxiety and depression among family members (23). Additional evaluations are needed to improve family information in the ICU and to determine the extent to which well-informed families can accurately communicate patient values and effectively participate in decision making.