Marion Faucher

N-terminal pro-brain natriuretic peptide as an early prognostic factor in cancer patients developing septic shock

IntroductionThe overall prognosis of critically ill patients with cancer has improved during the past decade. The aim of this study was to identify early prognostic factors of intensive care unit (ICU) mortality in patients with cancer.MethodsWe designed a prospective, consecutive, observational study over a one-year period. Fifty-one cancer patients with septic shock were enrolled.ResultsThe ICU mortality rate was 51% (26 deaths). Among the 45 patients who benefited from transthoracic echocardiography evaluation, 17 showed right ventricular dysfunction, 18 showed left ventricular diastolic dysfunction, 18 showed left ventricular systolic dysfunction, and 11 did not show any cardiac dysfunction. During the first three days of ICU course, N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were significantly higher in patients presenting cardiac dysfunctions compared to patients without any cardiac dysfunction. Multivariate analysis discriminated early prognostic factors (within the first 24 hours after the septic shock diagnosis). ICU mortality was independently associated with NT-proBNP levels at day 2 (odds ratio, 1.2; 95% confidence interval, 1.004 to 1.32; p = 0.022). An NT-proBNP level of more than 6,624 pg/ml predicted ICU mortality with a sensitivity of 86%, a specificity of 77%, a positive predictive value of 79%, a negative predictive value of 85%, and an accuracy of 81%.ConclusionWe observed that critically ill cancer patients with septic shock have an approximately 50% chance of survival to ICU discharge. NT-proBNP was independently associated with ICU mortality within the first 24 hours. NT-proBNP could be a useful tool for detecting high-risk cancer patients within the first 24 hours after septic shock diagnosis.

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.

Initial Experience With Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND Until 2004, we treated peritoneal carcinomatosis with cytoreductive surgery accompanied by perioperative systemic chemotherapy. From October 2004, we decided to initiate a hyperthermic intraperitoneal chemotherapy (HIPEC) program for this condition. OBJECTIVE To determine the effect of HIPEC on postoperative outcomes at a single institution performing a high volume of cancer operations. METHOD Sixty consecutive patients underwent cytoreductive surgery plus HIPEC (oxaliplatin; 460 mg/m2 in 2 L/m2) from October 1, 2004, through December 31, 2010. Usual perioperative factors were studied for 3 groups of patients who underwent HIPEC: 0 to 20 HIPEC procedures (period 1), 21 to 40 HIPEC procedures (period 2), and 41 to 60 HIPEC procedures (period 3). RESULTS The mean peritoneal carcinomatosis index was 9.6, the mean duration of surgery was 410.7 minutes, and the mean blood loss was 450.2 mL/L. Mortality and morbidity were 0% and 33%, respectively. Grade III/IV morbidity (P = .02), transfusion (P < .01), and reintervention rate (P = .04) significantly decreased during the 3 periods. No difference was seen between the 3 periods with regard to mean peritoneal carcinomatosis index, operative duration, blood loss, mortality, overall morbidity, length of hospital stay, and readmission. The overall 1-, 3-, and 5-year survival rates of 26 patients with peritoneal carcinomatosis originating from colorectal cancer were 100%, 51%, and 37%, respectively. The overall median survival was 39 months. CONCLUSIONS We observed a significant reduction of grade III/IV morbidity, perioperative transfusion, and reintervention rate after 20 procedures. The introduction of the HIPEC program was successful because of the surgical teams prior experience in cytoreductive and cancer operations.

Neutropenic cancer patients with severe sepsis: need for antibiotics in the first hour

Dear Editor, Neutropenic cancer patients are at high risk of sepsis [1]. The delay and adequacy of antimicrobial treatment are likely to influence the outcomes of such patients. From 2008 to 2010, all neutropenic cancer patients admitted to our intensive care unit (ICU) for severe sepsis (n = 48) and septic shock (n = 70) were prospectively included in the present study. Our goal was to identify at ICU admission predictive factors associated with ICU mortality. Briefly, our methodological design was similar to that reported in a previous study [2]. Patient features were collected at ICU admission. In the ICU, antibiotics were initiated, continued, or adapted according to microbial documentation. The first antimicrobial treatment initiated in the ICU was a beta-lactam directed against Gram-negative bacilli in all patients. A combined regimen was administered to 69 (58 %) patients, consisting of addition of aminoglycosides (n = 34) or fluoroquinolones (n = 35). Moreover, 54 (46 %) patients received vancomycin (n = 42) or linezolid (n = 12). Our strategy was in compliance with the published guidelines [2]. The ICU and 1-year mortality rates were 34 and 63 %, respectively. In the univariate analysis, we confirmed predictive factors such as severity scores at admission, organ failure at the sepsis onset, and need for invasive mechanical ventilation (p \ 0.05). In the multivariate analysis (Table 1), during the ICU stay, the major predictive factor for ICU mortality was the interval ([1 h) between the first sign of sepsis and the initiation of antimicrobial treatment. In addition, we identified three independent predictors: inappropriate antimicrobials in the ICU, severity score at admission, and non-fermenting Gram-negative bacilli infection. Age, comorbidity, status of malignancy, and hematopoietic stem cell transplantation did not affect ICU mortality. Hence, those criteria are irrelevant for the decision of ICU admission. Our data underline the need for a prompt initiation of an appropriate antimicrobial treatment in neutropenic cancer patients admitted to ICU for severe sepsis. This finding was clearly shown in non-neutropenic patients. An early appropriate antimicrobial therapy in non-neutropenic patients is associated with better survival, although pathogen species are not associated with mortality [3]. In a large cohort of 28,150 non-neutropenic patients with severe sepsis, delay in the first antibiotic administration was associated with increased hospital mortality. A linear relationship was found between the mortality and each hour delay in antibiotic administration [4]. Previously, a retrospective study analyzed the impact of time before antibiotic administration in a cohort of cancer patients, including 53 % of neutropenic patients. A 2-h delay between ICU admission and the first antibiotic treatment administration was associated with increased mortality [5]. Within the limitations of our study due to the study design and sample size, our findings suggest that, in the ICU, a 1-h delay between the antimicrobial treatment initiation and the first sign of sepsis was the strongest predictor of ICU mortality in neutropenic cancer patients. Thereafter,

Allogeneic hematopoietic stem cell transplantation after reduced intensity conditioning regimen: Outcomes of patients admitted to intensive care unit

PURPOSE The prognosis of allogeneic hematopoietic stem cell transplantation (HSCT) patients admitted to the intensive care unit (ICU) is still poor. Overall, when these patients receive reduced intensity conditioning (RIC) regimens, the survival is better. To date, no study has specifically evaluated the outcome of RIC allogeneic HSCT admitted to the ICU. METHODS We realized a retrospective study of 102 patients admitted to the ICU among a cohort of 601 consecutive patients receiving RIC regimens. The primary objective of the study was to assess in-ICU and inhospital mortality rates. RESULTS The ICU mortality was 39.2%, and the hospital mortality was 59.8%. The median overall survival of ICU patients was 8.2 months (95% confidence interval [CI], 5.7-10.6) vs 75 (95% CI, 63-87) in non-ICU patients (P < .0001). During hospital stay, an ICU admission for neurologic dysfunction was independently associated with hospital survival (P = .012). The use of invasive mechanical ventilation (IMV; P = .011), Simplified Acute Physiology Score II (P = .003), and longer time between diagnosis of malignancy and HSCT (P = .012) were associated with hospital mortality. The overall survival of the ICU survivors was significantly lower than that of non-ICU patients (hazard ratio, 3.61 [95% CI, 2.18-4.59]; P < .001). The median survival of ICU survivors was 9 months (95% CI, 4-14) vs 75 (95% CI, 63-87) in non-ICU patients (P < .0001). Noninvasive ventilation (NIV) was successful (not followed by IMV in 61% of cases [25/41 NIV patients]), and failure of NIV was not associated with hospital mortality in patients treated with subsequent IMV. CONCLUSION From our study, short-term survival rates of ICU patients receiving RIC regimens justify a broad ICU admission policy. The use of IMV is associated with hospital mortality, whereas the use of NIV is frequently successful. Long-term outcome remains poor after ICU discharge.

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.

Enhanced recovery after surgery program in older patients undergoing gynaecologic oncological surgery is feasible and safe

BACKGROUND Enhanced Recovery After Surgery Programs (ERP) include multimodal approaches of perioperative patients clinical pathways designed to achieve early recovery after surgery and a decreased length of hospital stay (LOS). By allowing patients to return rapidly to their everyday surroundings, older patients are those who could take the greatest benefit from ERP. This is the first study to date to assess feasibility and safety of ERP on older patients undergoing gynaecologic oncological surgery. METHODS Data were prospectively collected between December 2015 and September 2017 at the Institut Paoli-Calmettes, a French comprehensive cancer centre. All the patients included in the study were referred for hysterectomy and/or pelvic or para-aortic lymphadenectomy for gynaecological cancer. The primary objective was to achieve similar LOS in patients ≥70 years old compared to younger patients without increasing the proportion of complications and readmission rates. A binary (LOS < or ≥ 2 days) logistic regression was built, including age, Charlson score, BMI, ASA score, oncological indication, surgical procedures and surgical approaches. G8 score was estimated for all the ≥70 years old patients. RESULTS Of a total of 329 patients, 75 were ≥70 years old and 254 were <70. Except a disparity in oncological indications with a higher proportion of endometrial cancer in the ≥70 years old group (56% vs. 27%; p < 0.01), there were no differences in patients characteristics and surgical procedures. Age ≥ 70 years was associated with a longer LOS (means, 3.88 vs. 3.11 days; p = 0.024) only in univariate analysis. Considering the logistic regression, age was no longer associated with LOS. Total hysterectomy with pelvic lymphadenectomy and ASA score ≥ 3 were independently associated with longer LOS while mini-invasive techniques were associated with a shorter LOS. Morbidities and readmissions occurred respectively in 23% and 8% of the total population without any difference between the two groups. In the ≥70 years old population, G8 score was not predictive of LOS, morbidities or readmissions. CONCLUSION Although it is already widely accepted that ERP improves early recovery, our study shows that ERP for patients over 70 years of age undergoing gynaecologic oncological surgery is as safe and feasible as on younger patients.

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.