Kathryn Puxty

Risk of Critical Illness Among Patients With Solid Cancers: A Population-Based Observational Study

IMPORTANCE Critical illness may be a potential determinant of cancer outcomes and geographic variations, but its role has not been described before. OBJECTIVE To determine the incidence of admission to intensive care units (ICUs) within 2 years following cancer diagnosis. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective observational study using cancer registry data in 4 datasets from 2000 to 2009 with linked ICU admission data from 2000 to 2011, in the West of Scotland region of the United Kingdom (population, 2.4 million; all 16 ICUs within the region). All 118,541 patients (≥16 years) diagnosed as having solid (nonhematological) cancers. Their median age was 69 years, and 52.0% were women. MAIN OUTCOMES AND MEASURES Demographic and clinical variables associated with admission to an ICU and death in an ICU. RESULTS A total of 118,541 patients met the study criteria. Overall, 6116 patients (5.2% [95% CI, 5.0%-5.3%]) developed a critical illness and were admitted to an ICU within 2 years. Risk of critical illness was highest at ages 60 to 69 years and higher in men. The cumulative incidence of critical illness was greatest for small intestinal (17.2% [95% CI, 13.3%-21.8%]) and colorectal cancers (16.5% [95% CI, 15.9%-17.1%]). The risk following breast cancer was low (0.8% [95% CI, 0.7%-1.0%]). The percentage who died in ICUs was 14.1% (95% CI, 13.3%-15.0%), and during the hospital stay, 24.6% (95% CI, 23.5%-25.7%). Mortality was greatest among emergency medical admissions and lowest among elective surgical patients. The risk of critical illness did not vary by socioeconomic circumstances, but mortality was higher among patients from deprived areas. CONCLUSIONS AND RELEVANCE In this study, about 1 in 20 patients experienced a critical illness resulting in ICU admission within 2 years of cancer diagnosis. The associated high mortality rate may make a significant contribution to overall cancer outcomes.

A randomised, controlled, double blind, non‐inferiority trial of ultrasound‐guided fascia iliaca block vs. spinal morphine for analgesia after primary hip arthroplasty

We performed a single centre, double blind, randomised, controlled, non‐inferiority study comparing ultrasound‐guided fascia iliaca block with spinal morphine for the primary outcome of 24‐h postoperative morphine consumption in patients undergoing primary total hip arthroplasty under spinal anaesthesia with levobupivacaine. One hundred and eight patients were randomly allocated to receive either ultrasound‐guided fascia iliaca block with 2 mg.kg−1 levobupivacaine (fascia iliaca group) or spinal morphine 100 μg plus a sham ultrasound‐guided fascia iliaca block using saline (spinal morphine group). The pre‐defined non‐inferiority margin was a median difference between the groups of 10 mg in cumulative intravenous morphine use in the first 24 h postoperatively. Patients in the fascia iliaca group received 25 mg more intravenous morphine than patients in the spinal morphine group (95% CI 9.0–30.5 mg, p < 0.001). Ultrasound‐guided fascia iliaca block was significantly worse than spinal morphine in the provision of analgesia in the first 24 h after total hip arthroplasty. No increase in side‐effects was noted in the spinal morphine group but the study was not powered to investigate all secondary outcomes.

The Intensive Care Medicine research agenda on critically ill oncology and hematology patients

Over the coming years, accelerating progress against cancer will be associated with an increased number of patients who require life-sustaining therapies for infectious or toxic chemotherapy-related events. Major changes include increased number of cancer patients admitted to the ICU with full-code status or for time-limited trials, increased survival and quality of life in ICU survivors, changing prognostic factors, early ICU admission for optimal monitoring, and use of noninvasive diagnostic and therapeutic strategies. In this review, experts in the management of critically ill cancer patients highlight recent changes in the use and the results of intensive care in patients with malignancies. They seek to put forward a standard of care for the management of these patients and highlight important updates that are required to care for them. The research agenda they suggest includes important studies to be conducted in the next few years to increase our understanding of organ dysfunction in this population and to improve our ability to appropriately use life-saving therapies or select new therapeutic approaches that are likely to improve outcomes. This review aims to provide more guidance for the daily management of patients with cancer, in whom outcomes are constantly improving, as is our global ability to fight against what is becoming the leading cause of mortality in industrialized and non-industrialized countries.

Characteristics and Outcomes of Surgical Patients With Solid Cancers Admitted to the Intensive Care Unit

Importance Within the surgical population admitted to intensive care units (ICUs), cancer is a common condition. However, clinicians can be reluctant to admit patients with cancer to ICUs owing to concerns about survival. Objective To compare the clinical characteristics and outcomes of surgical patients with and without cancer who are admitted to ICUs. Design, Setting, and Participants An observational retrospective cohort study using ICU audit records linked to hospitalization discharge summaries, cancer registrations, and death records of all 16 general adult ICUs in the West of Scotland was conducted. All 25 017 surgical ICU admissions between January 1, 2000, and December 31, 2011, were included, and data analysis was conducted during that time. Exposures Patients were dichotomized based on a diagnosis of a solid malignant tumor as determined by its documentation in the Scottish Cancer Registry within the 2 years prior to ICU admission. Main Outcomes and Measures Intensive care unit patients with cancer were compared with ICU patients without cancer in terms of patient characteristics (age, sex, severity of illness, reason for admission, and organ support) and survival (ICU, hospital, 6 months, and 4 years). Results Within the 25 017 surgical ICU patients, 13 684 (54.7%) were male, the median (interquartile range [IQR]) age was 64 (50-74), and 5462 (21.8%) had an underlying solid tumor diagnosis. Patients with cancer were older (median [IQR] age, 68 [60-76] vs 62 [45-74] years; P < .001) with a higher proportion of elective hospitalizations (60.5% vs 19.8%; P < .001), similar Acute Physiology and Chronic Health Evaluation II scores (median for both, 17), but lower use of multiorgan support (57.9% vs 66.7%; P < .001). Intensive care unit and hospital mortality were lower for the cancer group, at 12.2% (95% CI, 11.3%-13.1%) vs 16.8% (95% CI, 16.3%-17.4%) (P < .001) and 22.9% (95% CI, 21.8%-24.1%) vs 28.1% (27.4%-28.7%) (P < .001). Patients with cancer had an adjusted odds ratio for hospital mortality of 1.09 (95% CI, 1.00-1.19). By 6 months, mortality in the cancer group was higher than that in the noncancer group at 31.3% compared with 28.2% (P < .001). Four years after ICU admission, mortality for those with and without cancer was 60.9% vs 39.7% (P < .001) respectively. Conclusions and Relevance Cancer is a common diagnosis among surgical ICU patients and this study suggests that initial outcomes compare favorably with those of ICU patients with other conditions. Consideration that a diagnosis of cancer should not preclude admission to the ICU in patients with surgical disease is suggested.

Unsolved questions in solid tumor patients and intensive care: response to Vincent et al.

Dear Editor, We thank Vincent et al. [1] for their interest in our work. They suggest that three additional papers should be considered in our systematic review of survival in solid cancer patients following intensive care admission [2]. Two of the papers suggested indeed meet the inclusion criteria. The paper by Kim et al. [3] was published in print the same week as our literature search was performed, and as a consequence did not appear in our search results. The paper by Hwang et al. [4] was not identified by our search strategy. Both papers report survival outcomes for patients with lung cancer who were admitted to the ICU, the first in a cohort of 97 patients with stage IIIB/IV lung cancer and the second in a cohort of 95 patients with lung cancer (of whom 75 % had stage IIIB/IV disease). ICU mortality was reported in 57 and 53.6 %, respectively. While these figures are higher than the 40.1 % average pooled mortality for ICU patients with lung cancer reported in our systematic review, it is likely that this reflects the advanced disease present in those patients included in these studies. The paper by Sharma et al. [5] was reviewed, and was considered of interest; however, this study assessed a cohort of patients that was predefined by their survival (patients that died within 1 year of diagnosis). We believed that inclusion of these patients in a review aimed at assessing survival would introduce bias and therefore we opted to exclude the paper. We agree with Vincent et al. that there is considerable variation in short-term survival dependant on the nature of ICU admission (i.e., elective surgery, emergency surgery, or medical). Unfortunately, many of the historical papers that studied survival of tumour patients do not provide outcome data for these subgroups of patients and thus exclusion would involve a significant reduction in included studies. It was felt that to restrict the number of studies further would be to discount much of the valuable literature to date. In general, the more recent studies provide greater detail in terms of patient subgroups with outcomes reported for each group. We would be keen to see this trend continue to allow future reviews to provide additional accuracy for the individual patient. As with any systematic review, the conclusions are limited by the published literature available. We concur that the literature does not yet answer many of the important questions pertaining to the ICU patient with a solid tumour. Furthermore, it was never our intention to examine outcomes beyond survival, such as quality of life or post-ICU chemotherapy use. However, we accept that these are important issues and would be eager to see publications addressing these subjects in the future. Conflicts of interest None declared.

Characteristics and outcomes of lung cancer patients after intensive care admission

Lung cancer is the leading cause of cancer-related deaths accounting for 27.5% of cancer deaths in Scotland.1 Lung cancer patients sometimes require ventilatory support for respiratory complications; however, admission to intensive care unit (ICU) is restricted due to a perception that lung cancer patients have universally poor outcomes. Methods We performed a multicentre retrospective observational study using linked data from west of Scotland ICUs. Data from ICU were matched to cancer registry, hospitalisation and death records between 1 January 2000 and 31 December 2011. From this population, we selected patients with diagnosis of lung cancer by ICD- 10 coding. These patients were then matched to lung cancer patients who were not admitted to ICU. Statistical analyses were performed using StataCorp 2011(Stata Statistical Software: Release 12). Results A total of 538 patients had lung cancer and were admitted to ICU; 311 (57.8%) of ICU lung cancer patients were male, the average age was 66.9 years and APACHE-II score was 21.9 (7.1). Hospital and six-month mortality were 51.9% and 68.7%, respectively. Although the initial rates of mortality in ICU patients are high, survival of matched ICU and non-ICU groups was similar when measured from 30 days after hospital discharge (Figure 1). Factors associated with hospital mortality on multivariate analysis were surgical admission (HR: 0.57, P ¼ <0.001), APACHE-II score 518 (HR: 1.90, P ¼ 0.001), 52 organs supported (HR: 2.86, P ¼ <0.001) and pre-ICU chemotherapy (HR: 0.49, P ¼ 0.003). These factors were still significantly related to mortality at six months with the addition of lung resection surgery which conferred a strong survival advantage (HR: 0.42, P ¼ <0.001) Discussion This study confirms that mortality rates for lung cancer patients in ICU remain high and are associated with severity of illness whilst short-term outcomes in this cohort of patients remain poor, and it is interesting to note that longer term survival in lung cancer ICU survivors does not appear to be influenced by their critical illness as mortality follows the same trajectory as a matched non-ICU cohort.

Does the risk of critical illness among cancer patients make a significant contribution to cancer outcomes? A population-based observational study of 118,571 adults from the Scottish cancer registry

Background: Survival from cancer is poorer in the UK than other European countries. Critical illness may be a potential determinant of cancer outcomes but its role has not been described before. We assessed the incidence of admission to intensive care units (ICU) following cancer diagnosis to quantify the risk of critical illness among cancer patients. Method: We took data for solid cancer registrations in the West of Scotland region, UK, between 2000–2009 from the Scottish Cancer Registry. Linked hospital, ICU, and mortality records provided details of hospital admissions, deaths, sociodemographics and comorbidities. We assessed the incidence of admission to ICU within two years of cancer diagnosis and explored differences in hospital mortality by patient characteristics. Results: 6,121 (5.2%,95% CI 5.0–5.3%) out of 118,571 incident cancer patients developed a critical illness and were admitted to ICU within 2 years. Risk of critical illness was highest at ages 60–69 and higher in men. The cumulative inci-dence of critical illness was greatest for small intestinal (17.2%,95% CI 13.3–21.8%) and colorectal cancers (16.5%,15.9–17.1%). The risk following breast cancer was low (0.8%,95% CI 0.7–1.0%). Mortality in ICU was 14.1% (95% CI 13.3–15.0%), and during the hospital stay 24.6% (23.5– 25.7%). Mortality was greatest among emergency medical admissions and lowest among elective surgical patients. The risk of critical illness did not vary by socio-economic circumstances but mortality was higher among patients from deprived areas. Conclusions: About one in 20 cancer patients experiences a critical illness resulting in ICU admission within two years of cancer diagnosis. They experience high mortality which may make a significant contribution to cancer outcomes. The UK has lower provision of ICU than countries in which cancer survival is better. It is important to determine whether provision of ICU resources might reduce critical illness mortality among cancer patients.Aim: To explore the experience of serious mental illness and cancer from the perspective of patients, significant others and health care professionals involved in their care. Background: Serious mental illness is associated with poorer cancer outcomes. Those suffering from this comorbidity receive fewer specialist interventions and die earlier than the general population. Prior qualitative research in this area has comprised of a single study focussing on healthcare professionals, and there is little evidence regarding the experiences of patients and caregivers. Design: A qualitative exploration using approximately 36 semi-structured interviews. Methods: Semi-structured digitally recorded interviews conducted with: adults living with serious mental illness and diagnosed with cancer; those providing them with informal support and care; and healthcare professionals. Questions will focus on the experience of having cancer and serious mental illness or caring for someone with this comorbidity, experiences of healthcare, and priorities for patients and carers. Framework analysis will be used. Research Ethics Committee and Trust Research & Development approval was obtained. A steering group comprising six people with experience of either cancer or mental illness provided feedback and ratified the patient information sheets and interview schedules. Discussion: There is a paucity of research addressing stakeholder perspectives on the experience of cancer and of cancer services for people with serious mental illness. Dissemination of findings will inform practice relating to the care of an often neglected population, informing better support for their significant others and the professionals involved in their care. Summary Statement Why this study is needed: • People with serious mental illness experience poorer cancer outcomes than the general population, with mortality rates around double those for patients without mental illness. There are indications that this is linked to service-related factors. • There has been no research that directly consults patients with comorbid cancer and serious mental illness, or their informal caregivers, about their experiences of cancer and of cancer care. There has only been one study directly consulting healthcare professionals about this issue.

Outcome of patients with solid tumours admitted to intensive care with a medical diagnosis

ESICM LIVES 2013 26th Annual Congress Paris, France 5–9 October This supplement issue of the official ESICM/ESPNIC journal Intensive Care Medicine contains abstracts of scientific papers presented at the 26th Annual Congress of the European Society of Intensive Care Medicine. The abstracts appear in order of presentation from Monday 7 October to Wednesday 9 October 2013. The same abstract numbering is used in the Congress Final Programme. This supplement was not sponsored by outside commercial interests; it was funded entirely by the society’s own resources. DOI:10.1007/s00134-013-3095-5 123 26th ANNUAL CONGRESS—PARIS, FRANCE—5–9 OCTOBER 2013 26th ANNUAL CONGRESS—PARIS, FRANCE—5–9 OCTOBER 2013

Characteristics and outcomes of ICU patients with lung cancer

ESICM LIVES 2013 26th Annual Congress Paris, France 5–9 October This supplement issue of the official ESICM/ESPNIC journal Intensive Care Medicine contains abstracts of scientific papers presented at the 26th Annual Congress of the European Society of Intensive Care Medicine. The abstracts appear in order of presentation from Monday 7 October to Wednesday 9 October 2013. The same abstract numbering is used in the Congress Final Programme. This supplement was not sponsored by outside commercial interests; it was funded entirely by the society’s own resources. DOI:10.1007/s00134-013-3095-5 123 26th ANNUAL CONGRESS—PARIS, FRANCE—5–9 OCTOBER 2013 26th ANNUAL CONGRESS—PARIS, FRANCE—5–9 OCTOBER 2013

643: Factors associated with Icu mortality among critically ill patients with colorectal cancer

Introduction: Most admissions to Intensive Care (ICU) are unplanned and associated with acute illness, however, co-morbidities also have an impact on survival. Patients with colorectal cancer represent the largest group of cancer patients admitted to ICU. It is unknown which factors are important at determining survival, and whether it is the features associated with the underlying malignancy or the acute illness that has the largest impact upon prognosis. Methods: We used routinely collected data from West of Scotland ICUs linked to Scottish Cancer registry data to identify patients (aged 16 and over) who had been admitted to ICU between 1st January 2000 and 31st December 2011 and who had a diagnosis of colorectal cancer (ICD10 coding C18-C20) within the previous five years. We used multivariable logistic regression analysis to identify factors associated with ICU outcome. Results: During the study period 3650 patients with colorectal cancer were admitted to ICU. Thirteen percent had two or more admissions. The majority of patients (93%) were admitted from surgical specialties with 78% admitted immediately post-operatively. Of those who had undergone a surgical procedure, 34% were performed as an emergency. Median time from diagnosis to ICU admission was 43 (IQR 14-104) days. Median age 71 (IQR 64-78) years; APACHE II score 13 (IQR 0-19); 59% were men. Dukes tumour staging was 12% A, 34% B, 32% C and 10% D with 12% unknown. Organ support was provided by invasive mechanical ventilation (51% of patients), vasoactive drug therapy (51%), and renal replacement therapy (9%). The proportion of patients receiving no, one, two, or three organ support were 35%, 26%, 31%, and 8%. Mortality in ICU was 14.8% (13.0 to 16.7%) among emergency patients, 3.1% (2.3 to 4.0%) among elective patients and 27.1% (24.2 to 30.0%) among non-surgical patients. ICU mortality among Dukes stage A was 9.1% (6.7 to 11.9%), B 11.1% (9.5 to 12.8%), C 11.4% (9.7 to 13.2%), and D 13.9% (10.7 to 17.5%). Mortality was 21.6% (18.0 to 25.5%) among patients with unknown stage. ICU mortality by the number of organs supported was 0.9% (0.1 to 3.2%) for no organ support, 4.8% (2.1 to 9.2%) for one organ support, 20.3% (14.9 to 26.6%) for two organ support, and 39.6% (25.8 to 54.7%) for three organ support. Age, severity score, tumor stage, emergency surgery, being a non-surgical patient and organ support were each independently associated with mortality during ICU when modeled by multivariable logistic regression. Conclusions: Mortality among colorectal cancer patients admitted to ICU was most strongly associated with severity of illness, admitting specialty (surgical or medical), nature of surgery, and number of organs supported during the stay. Tumor stage was independently associated with mortality during ICU stay but showed a smaller differential across stage categories compared to other patient characteristics.