Magali Bisbal

Postoperative sepsis in cancer patients undergoing major elective digestive surgery is associated with increased long-term mortality

BACKGROUND Major postoperative events (acute respiratory failure, sepsis, and surgical complications) are frequent early after elective gastroesophageal and pancreatic surgery. It is unclear whether these complications impact equally on long-term outcome. METHODS Prospective observational study including the patients admitted to the surgical intensive care unit between January 2009 and October 2011 after elective gastroesophageal and pancreatic surgery. Risk factors for 30-day major postoperative events and long-term outcome were evaluated. RESULTS During the study period, 259 patients were consecutively included. Among them, 166 (64%), 54 (21%), and 39 (15%) patients underwent pancreatic surgery, gastric surgery, and esophageal surgery, respectively. Using the Clavien-Dindo classification, 117 patients (45%) developed at least 1 postoperative complication, including 60 (23%) patients with acute respiratory failure, 77 (30%) with sepsis, and 89 (34%) with surgical complications. The median follow-up from the time of intensive care unit admission was 34 months (95% confidence interval, 30-37 months). The 1-year survival was 95% (95% confidence interval, 92-98). Among the perioperative variables, postoperative sepsis and an American Society of Anesthesiologists score higher than 2 were independently associated with long-term mortality. In septic patients, death (n = 16) was significantly associated with cancer recurrence (n = 10; P < .0001). Independent factors associated with postoperative sepsis were a Sequential Organ Failure Assessment score on day 1, a systemic inflammatory response syndrome on day 3, positive intraoperative microbiological samples, Simplified Acute Physiology Score II and an American Society of Anesthesiologists score higher than 2 (P < .005). CONCLUSIONS Postoperative sepsis was the only major postoperative event associated with long-term mortality. Postoperative sepsis may reflect a deep impairment of immune response, which is potentially associated with cancer recurrence and mortality.

Effectiveness of SAPS III to predict hospital mortality for post-cardiac arrest patients

PURPOSE The mortality for patients admitted to intensive care unit (ICU) after cardiac arrest (CA) remains high despite advances in resuscitation and post-resuscitation care. The Simplified Acute Physiology Score (SAPS) III is the only score that can predict hospital mortality within an hour of admission to ICU. The objective was to evaluate the performance of SAPS III to predict mortality for post-CA patients. METHODS This retrospective single-center observational study included all patients admitted to ICU after CA between August 2010 and March 2013. The calibration (standardized mortality ratio [SMR]) and the discrimination of SAPS III (area under the curve [AUC] for receiver operating characteristic [ROC]) were measured. Univariate logistic regression tested the relationship between death and scores for SAPS III, SAPS II, Sequential Organ Failure Assessment (SOFA) Score and Out-of-Hospital Cardiac Arrests (OHCA) score. Independent factors associated with mortality were determined. RESULTS One-hundred twenty-four patients including 97 out-of-hospital CA were included. In-hospital mortality was 69%. The SAPS III was unable to predict mortality (SMRSAPS III: 1.26) and was less discriminating than other scores (AUCSAPSIII: 0.62 [0.51, 0.73] vs. AUCSAPSII 0.75 [0.66, 0.84], AUCSOFA: 0.72 [0.63, 0.81], AUCOHCA: 0.84 [0.77, 0.91]). An early return of spontaneous circulation, early resuscitation care and initial ventricular arrhythmia were associated with a better prognosis. CONCLUSIONS The SAPS III did not predict mortality in patients admitted to ICU after CA. The amount of time before specialized CPR, the low-flow interval and the absence of an initial ventricular arrhythmia appeared to be independently associated with mortality and these factors should be used to predict mortality for these patients.

Does Admission During Morning Rounds Increase the Mortality of Patients in the Medical ICU

BACKGROUND Early optimization of treatment is crucial when admitting patients to the ICU and could depend on the organization of the medical team. The aim of this retrospective observational study was to determine whether admissions during morning rounds are independently associated with hospital mortality in a medical ICU. METHODS The 3,540 patients admitted from May 2000 to April 2010 to the medical ICU of Sainte Marguerite Hospital in Marseille, France, were divided into two groups based on the time of admission.The non-morning rounds group was admitted between 1:00 PM and 7:59 AM , and the morningrounds group was admitted between 8:00 AM and 12:59 PM . Hospital mortality (crude and adjusted)was compared between the two groups. RESULTS The 583 patients (16.5%) admitted during morning rounds were older and sicker upon admission compared with those patients admitted during non-morning rounds. The crude hospital mortality was 35.2% (95% CI , 31.4-39.1) in the group of patients admitted during morning rounds and 28.0% (95% CI, 26.4-29.7) in the other group ( P < .001). An admission during morning rounds was not independently associated with hospital death (adjusted hazard ratio, 1.10; 95% CI,0.94-1.28; P 5=.24). CONCLUSIONS Being admitted to the medical ICU during morning rounds is not associated with a poorer outcome than afternoon and night admissions. The conditions of the patients admitted during morning rounds were more severe, which underlines the importance of the ICU team’s availability during this time. Further studies are needed to evaluate if the presence of a specific medical team overnight in the wards would be able to improve patients’ outcome by preventing delayed ICU admission.

Surgical treatment of acute abdominal complications in hematology patients: outcomes and prognostic factors

Abstract The decision to operate on hematology patients with abdominal emergencies can be difficult, as neutropenia and thrombocytopenia are common and the usual causes of abdominal pain are broad. We conducted a retrospective observational study including all hematology patients undergoing emergency abdominal surgery between January 1998 and January 2013. Of the fifty-eight consecutive patients included in the study, nineteen (33%) underwent an operation during the neutropenia period. In the multivariate analysis, a laparotomy after 2002 was protective (HR: 0.05; 95%CI: 0.001–0.24), whereas preoperative septic shock (HR: 8.58; 95%CI: 2.25–32.63) and use of dialysis (HR: 6.67; 95%CI: 2.11–21.07) were independently associated with hospital mortality. Surgery during neutropenia or thrombocytopenia was not associated with prognosis. In hematology patients, emergency abdominal surgery is associated with encouraging hospital survival rates. Surgery should be performed prior to septic shock, regardless of whether neutropenia or thrombocytopenia is present.

The prognostic impact of abdominal surgery in cancer patients with neutropenic enterocolitis: a systematic review and meta-analysis, on behalf the Groupe de Recherche en Réanimation Respiratoire du patient d’Onco-Hématologie (GRRR-OH)

Neutropenic enterocolitis (NE) is a diagnostic and therapeutic challenge associated with high mortality rates, with controversial opinions on its optimal management. Physicians are usually reluctant to select surgery as the first-choice treatment, concerns being raised regarding the potential risks associated with abdominal surgery during neutropenia. Nevertheless, no published studies comforted this idea, literature is scarce and surgery has never been compared to medical treatment. This review and meta-analysis aimed to determine the prognostic impact of abdominal surgery on outcome of neutropenic cancer patients presenting with NE, versus medical conservative treatment. This meta-analysis included studies analyzing cancer patients presenting with NE, treated with surgical or medical treatment, searched by PubMed and Cochrane databases (1983–2016), according to PRISMA recommendations. The endpoint was hospital mortality. Fixed-effects models were used. The meta-analysis included 20 studies (385 patients). Overall estimated mortality was 42.2% (95% CI = 40.2–44.2). Abdominal surgery was associated with a favorable outcome with an OR of 0.41 (95% CI = 0.23–0.74; p = 0.003). Pre-defined subgroups analysis showed that neither period of admission, underlying malignancy nor neutropenia during the surgical procedure, influenced this result. Surgery was not associated with an excess risk of mortality compared to medical treatment. Defining the optimal indications of surgical treatment is needed.Trial registration PROSPERO CRD42016048952

Critically ill allogenic HSCT patients in the intensive care unit: a systematic review and meta-analysis of prognostic factors of mortality

Outcome of patients undergoing allogenic hematopoietic stem cell transplantation (allo-HSCT) has improved. To investigate if this improvement can be transposed to the ICU setting, we conducted a systematic review and meta-analysis to assess short-term mortality of critically ill allo-HSCT patients admitted to the ICU and to identify prognostic factors of mortality. Public-domain electronic databases, including Medline via PubMed and the Cochrane Library were searched. All full-text articles written-English studies published from 2006 to 2016, including allo-HSCT adults transferred to the ICU were included. Eighteen studies were selected, including 2342 patients. Overall estimated ICU mortality was 51.7%. Prognostic factors associated with an increased ICU mortality were mechanical ventilation (OR = 12.2, 95% CI = 6.2–23.7), vasopressors (OR = 6.3, 95% CI = 3.6–11.1), renal replacement therapy (OR = 4.2, 95% CI = 2.8–6.2), ICU admission for acute respiratory failure (OR = 2.2, 95% CI = 1.1–4.4), acute kidney injury (OR = 2.2, 95% CI = 1.3–4), and acute graft-versus-host disease (OR = 1.6, 95% CI = 1.1–2.3). Factors associated with an increased ICU survival were a single-organ failure (OR = 0.2, 95% CI = 0.1–0.4), neurological failure (OR = 0.4, 95% CI = 0.2–0.8), and reduced-intensity conditioning regimens (OR = 0.7, 95% CI = 0.5–0.9). Septic shock, underlying malignancy, disease status, donor, and graft source did not impact prognosis. Outcome has improved, supporting the usefulness of ICU management. Organ failures at ICU admission, organ support requirement, and GVHD are the main prognostic factors.

Respiratory events in ward are associated with later intensive care unit (ICU) admission and hospital mortality in onco-hematology patients not admitted to ICU after a first request

Introduction Prognostic impact of delayed intensive care unit(ICU) admission in critically ill cancer patients remains debatable. We determined predictive factors for later ICU admission and mortality in cancer patients initially not admitted after their first ICU request. Methods All cancer patients referred for an emergency ICU admission between 1 January 2012 and 31 August 2013 were included. Results Totally, 246(54.8%) patients were immediately admitted. Among 203(45.2%) patients denied at the first request, 54(26.6%) were admitted later. A former ICU stay [OR: 2.75(1.12–6.75)], a request based on a clinical respiratory event[OR: 2.6(1.35–5.02)] and neutropenia[OR: 2.25(1.06–4.8)] were independently associated with later ICU admission. Survival of patients admitted immediately and later did not differ at ICU(78.5% and 70.4%, respectively; p = 0.2) or hospital(74% and 66%, respectively; p = 0.24) discharge. Hospital mortality of patients initially not admitted was 29.7% and independently associated with malignancy progression[OR: 3.15(1.6–6.19)], allogeneic hematopoietic stem cell transplantation[OR: 2.5(1.06–5.89)], a request based on a clinical respiratory event[OR: 2.36(1.22–4.56)] and severe sepsis[OR: 0.27(0.08–0.99)]. Conclusion Compared with immediate ICU admission, later ICU admission was not associated with hospital mortality. Clinical respiratory events were independently associated with both later ICU admission and hospital mortality.