Louis Voigt

Premortem clinical diagnoses and postmortem autopsy findings: discrepancies in critically ill cancer patients

IntroductionLimited data are available regarding the relationship of premortem clinical diagnoses and postmortem autopsy findings in cancer patients who die in an oncologic intensive care unit (ICU). The purposes of this study were to compare the premortem clinical and postmortem diagnoses of cancer patients who died in the ICU and to analyze any discrepancies between them.MethodsThis is a retrospective review of medical records and autopsy reports of all cancer patients who died in a medical-surgical ICU and had an autopsy performed between 1 January 1999 and 30 September 2005 at a tertiary care cancer center. Premortem clinical diagnoses were compared with the postmortem findings. Major missed diagnoses were identified and classified, according to the Goldman criteria, into class I and class II discrepancies.ResultsOf 658 deaths in the ICU during the study period, 86 (13%) autopsies were performed. Of the 86 patients, 22 (26%) had 25 major missed diagnoses, 12 (54%) patients had class I discrepancies, 7 (32%) had class II discrepancies, and 3 (14%) had both class I and class II discrepancies. Class I discrepancies were due to opportunistic infections (67%) and cardiac complications (33%), whereas class II discrepancies were due to cardiopulmonary complications (70%) and opportunistic infections (30%).ConclusionThere was a discrepancy rate of 26% between premortem clinical diagnoses and postmortem findings in cancer patients who died in a medical-surgical ICU at a tertiary care cancer center. Our findings underscore the need for enhanced surveillance, monitoring, and treatment of infections and cardiopulmonary disorders in critically ill cancer patients.

Review of A Large Clinical Series: Intrahospital Transport of Critically Ill Patients: Outcomes, Timing, and Patterns

The purpose of this study was to analyze the relationship of intrahospital transport patterns with patient throughput and outcomes in an oncological intensive care unit. We retrospectively reviewed all patients admitted to a closed medical-surgical intensive care unit at a cancer center between January 1, 2004 and December 31, 2005. We compared the clinical characteristics and outcomes of patients with and without transport and analyzed all intrahospital transports in relation to intensive care unit occupancy, length of stay, and intensive care unit and hospital outcomes. Transport patterns were also assessed by day of week, time of day, timing of the first transport to intensive care unit admission, and destination. Transported patients (n = 413, 43.5%) had significantly higher severity of illness scores on intensive care unit admission, greater use of vasopressors and mechanical ventilation, and longer intensive care unit and hospital length of stay and higher hospital mortality than nontransported patients (n = 535, 56.5%). Multiple transports (!2) occurred in 45% of the transported patients. The number of transports was directly proportional to intensive care unit length of stay. The highest transport rates and nearly half of all first transports occurred during the first 24 hours of intensive care unit admission. Transports were most common during weekdays and on afternoon and evening hours and most frequently to the computed tomography suite. Our study shows that intrahospital transport of the critically ill is a multifaceted process with important implications for intensive care unit resource analysis, workload and throughput.

Humidified high-flow nasal oxygen utilization in patients with cancer at Memorial Sloan-Kettering Cancer Center.

BACKGROUND Respiratory signs and symptoms are commonly encountered by physicians who care for cancer patients. Supplemental oxygen (SOx) has long been used for treatment of hypoxic respiratory insufficiency, but data reveal mixed efficacy results. The use and outcome patterns of technologically advanced oxygen delivery devices, such as humidified high-flow nasal oxygen (HHFNOx), are incompletely understood. METHODS Institutional database search of the number of patient cases in which the current HHFNOx device was used, and abstraction of 183 patient medical records for usage characteristics. RESULTS Patients have been treated with HHFNOx at Memorial Sloan Kettering Cancer Center (MSKCC) since 2008. Of the 183 patients randomly selected for our study, 72% received HHFNOx in the intensive care unit (ICU) because of hypoxia. Patients usually improved (41%) or remained stable (44%) while on the device, whereas 15% declined. At study completion, 45% of patients were living, and 55% had died. The median time on HHFNOx was 3 days (range: 1-27). A do not resuscitate (DNR) order was present in 101 (55%) patients, either before (12%) or after (43%) device utilization. The majority (78%) of these 101 patients died at MSKCC. CONCLUSION Dyspnea is a common and important symptom in cancer patients for which SOx traditionally has had no clear basis except in select cases of hypoxia and patient preference. Our institutional experience with HHFNOx contributes to the understanding of the applications and challenges surrounding the use of new medical devices in the cancer population. Physiologic and quality-of-life benefits of HHFNOx compared with traditional oxygen delivery methods should be studied prospectively.

Acute Respiratory Failure in the Patient with Cancer: Diagnostic and Management Strategies

Acute respiratory failure (ARF) remains the major reason for admission to the intensive care unit (ICU) in patients with cancer and is often associated with high mortality, especially in those who require mechanical ventilation. The diagnosis and management of ARF in patients who have cancer pose unique challenges to the intensivist. This article reviews the most common causes of ARF in patients with cancer and discusses recent advances in the diagnostic and management approaches of these disorders. Timely diagnosis and treatment of reversible causes of respiratory failure, including earlier use of noninvasive ventilation and judicious ventilator and fluid management in patients with acute lung injury, are essential to achieve an optimal outcome. Close collaboration between oncologists and intensivists helps ensure that clear goals, including direction of treatment and quality of life, are established for every patient with cancer who requires mechanical ventilation for ARF.

Effect of obstructive sleep apnea on QT dispersion: a potential mechanism of sudden cardiac death.

Objectives: QT dispersion (QT_d) measures the variability of the ventricular recovery time. QT_d may identify patients at risk for ventricular arrhythmias and sudden cardiac death (SCD). The purpose of our study was to determine the effect of obstructive sleep apnea (OSA) on QT_d. Methods: There were 199 patients studied: 101 patients (28 women, 73 men) with OSA diagnosed in our sleep center and 98 patients (49 women, 49 men) without OSA from the outpatient clinic, representing the control group. QT intervals (milliseconds) were measured in each of the 12 leads of a standard surface electrocardiogram during wakefulness and QT_d calculated (QT_max – QT_min). QT^c_d, which corrects for heart rate, was also calculated. Results: Mean age and heart rate were similar in men and women with or without OSA. Control patients exhibited a significant difference (p < 0.001) in QT_d between men (48 ± 19) and women (31 ± 13). Men and women with OSA had similar QT_d (56 ± 35 vs. 54 ± 21) but higher QT_d compared to the control group. QT^c_d results were similar to QT_d. Conclusions: Patients with OSA and no structural heart disease have a higher QT_d/QT^c_d compared to an overtly healthy patient population, possibly serving as a marker for an increased risk of SCD.

Brugada electrocardiographic pattern in a postoperative patient.

Objective:To report the development of the Brugada electrocardiographic (ECG) pattern in the immediate postoperative setting. Design:Case report. Setting:Postanesthesia care unit at Memorial Sloan-Kettering Cancer Center. Patient:A 51-yr-old white male who developed new ST-segment elevation in leads V1–V3 typical of the ECG changes of the Brugada syndrome immediately after undergoing head and neck surgery for cancer. The patient was asymptomatic, and the cardiac enzymes and echocardiogram were normal; therefore, electrophysiologic study was not performed. Conclusions:We postulated that the Brugada ECG abnormalities were induced primarily by an increase in parasympathetic tone resulting from vagal nerve manipulation during deep neck dissection and partially by the fever he developed during the postoperative period. In addition to the more common causes of ST-segment elevation, the Brugada ECG pattern or syndrome should be considered in patients undergoing deep neck dissection who develop characteristic ECG changes in association with normal cardiac enzymes and echocardiogram.

Ten key points about ICU palliative care.

Introduction Palliative care is a core component of comprehensive care for patients facing critical illness, regardless of age, diagnosis, or prognosis. Key domains of intensive care unit (ICU) palliative care include relief of distressing symptoms, effective communication about care goals, patient-focused decision-making, caregiver support, and continuity across care settings. In this article, we highlight ten evidence-based principles of palliative care that help support optimal critical care practice.

Characteristics and Outcomes of Ethics Consultations in an Oncologic Intensive Care Unit

Objective: To evaluate the frequency, characteristics, and outcomes of ethics consultations in critically ill patients with cancer. Design, Setting, and Methods: This is a retrospective analysis of all adult patients with cancer who were admitted to the intensive care unit (ICU) of a comprehensive cancer center and had an ethics consultation between September 2007 and December 2011. Demographic and clinical variables were abstracted along with the details and contexts of the ethics consultations. Main Results: Ethics consultations were obtained on 53 patients (representing 1% of all ICU admissions). The majority (90%) of patients had advanced-stage malignancies, had received oncologic therapies within the past 12 months, and required mechanical ventilation and/or vasopressor therapy for respiratory failure and/or severe sepsis. Two-thirds of the patients lacked decision-making capacity and nearly all had surrogates. The most common reasons for ethics consultations were disagreements between the patients/surrogates and the ICU team regarding end-of-life care. After ethics consultations, the surrogates agreed with the recommendations made by the ICU team on the goals of care in 85% of patients. Moreover, ethics consultations facilitated the provision of palliative medicine and chaplaincy services to several patients who did not have these services offered to them prior to the ethics consultations. Conclusion: Our study showed that ethics consultations were helpful in resolving seemingly irreconcilable differences between the ICU team and the patients’ surrogates in the majority of cases. Additionally, these consultations identified the need for an increased provision of palliative care and chaplaincy visits for patients and their surrogates at the end of life.

Monitoring sound and light continuously in an intensive care unit patient room: A pilot study

Purpose: To determine the feasibility of continuous recording of sound and light in the intensive care unit (ICU). Materials and methods: Four 1‐hour baseline scenarios in an empty ICU patient room by day and night (doors open or closed and maximal or minimal lighting) and two daytime scenarios simulating a stable and unstable patient (quiet or loud devices and staff) were conducted. Sound and light levels were continuously recorded using a commercially available multisensor monitor and transmitted via the hospitals network to a cloud‐based data storage and management system. Results: The empty ICU room was loud with similar mean sound levels of 45 to 46 dBA for the day and night simulations. Mean levels for maximal lighting during day and night ranged from 1306 to 1812 lux and mean levels for minimum lighting were 1 to 3 lux. The mean sound levels for the stable and unstable patient simulations were 61 and 81 dBA, respectively. The mean light levels were 349 lux for the stable patient and 1947 lux for the unstable patient. Conclusions: Combined sound and light can be continuously and easily monitored in the ICU setting. Incorporating sound and light monitors in ICU rooms may promote an enhanced patient‐ and staff‐centered healing environment. HighlightsSound and light levels in ICU patient rooms can be continuously recorded using a commercially available multisensor monitor.High sound levels can be present even in an empty ICU room.Light levels coincide with room occupancy and are much higher in rooms of unstable than stable patients.Incorporating sound and light monitors may promote an enhanced healing environment in the ICU.

ICU Admissions After Actual or Planned Hospital Discharge : Incidence, Clinical Characteristics, and Outcomes in Patients With Cancer

BACKGROUND Unexpected ICU admissions may result from early or premature discharge from the hospital. We sought to determine the incidence, clinical characteristics, and outcomes of patients admitted to the ICU after actual or planned hospital discharge and to analyze whether the need for ICU admission was related or unrelated to the associated hospitalization. METHODS We retrospectively reviewed all adult ICU admissions between January 2004 and December 2006 at a tertiary care cancer center and identified the following two groups of patients: those patients admitted directly to the ICU within 48 h of actual hospital discharge (group A); and those patients admitted to the ICU within 48 h of planned hospital discharge (group B). RESULTS Of 60,462 patients discharged from the hospital during the study period, 826 patients (1.4%) required readmission to the hospital within 48 h of discharge; of these, 13 patients (1.5%) were admitted directly to the ICU (group A). An additional 12 patients were admitted to the ICU within 48 h of a planned hospital discharge (group B). The majority of these 25 patients (68%) [groups A and B] required ICU admission for a condition that was related to the previous or current hospitalization. The overall hospital mortality rate for both groups was 16%. CONCLUSIONS A small, but unique group of patients is admitted to the ICU within 48 h of actual or planned hospital discharge. Worsening of the underlying condition that necessitated the previous or current hospitalization often is the reason for ICU admission. Whether ICU admission could have been prevented by continued hospital care or improved diagnostic evaluation during the prior or current hospitalization requires further study.