Pedro Caruso

Characteristics and outcomes of patients with cancer requiring admission to intensive care units: A prospective multicenter study*

Objective:To evaluate the characteristics and outcomes of patients with cancer admitted to several intensive care units. Knowledge on patients with cancer requiring intensive care is mostly restricted to single-center studies. Design:Prospective, multicenter, cohort study. Setting:Intensive care units from 28 hospitals in Brazil. Patients:A total of 717 consecutive patients included over a 2-mo period. Interventions:None. Measurements and Main Results:There were 667 (93%) patients with solid tumors and 50 (7%) patients had hematologic malignancies. The main reasons for intensive care unit admission were postoperative care (57%), sepsis (15%), and respiratory failure (10%). Overall hospital mortality rate was 30% and was higher in patients admitted because of medical complications (58%) than in emergency (37%) and scheduled (11%) surgical patients (p < .001). Adjusting for covariates other than the type of admission, the number of hospital days before intensive care unit admission (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.01–1.37), higher Sequential Organ Failure Assessment scores (OR, 1.25; 95% CI, 1.17–1.34), poor performance status (OR, 3.40; 95% CI, 2.19 –5.26), the need for mechanical ventilation (OR, 2.42; 95% CI, 1.51–3.87), and active underlying malignancy in recurrence or progression (OR, 2.42; 95% CI, 1.51–3.87) were associated with increased hospital mortality in multivariate analysis. Conclusions:This large multicenter study reports encouraging survival rates for patients with cancer requiring intensive care. In these patients, mortality was mostly dependent on the severity of organ failures, performance status, and need for mechanical ventilation rather than cancer-related characteristics, such as the type of malignancy or the presence of neutropenia.

Effect of acute kidney injury on weaning from mechanical ventilation in critically ill patients.

Objectives: Acute kidney injury (AKI) worsens outcome in various scenarios. We sought to investigate whether the occurrence of AKI has any effect on weaning from mechanical ventilation. Design and Setting: Observational, retrospective study in a 23‐bed medical/surgical intensive care unit (ICU) in a cancer hospital from January to December 2003. Patients: The inclusion criterion was invasive mechanical ventilation for ≥48 hrs. AKI was defined as at least one measurement of serum creatinine of ≥1.5 mg/dL during the ICU stay. Patients were then separated into AKI and non‐AKI patients (control group). The criterion for weaning was the combination of positive end‐expiratory pressure of ≤8 cm H2O, pressure support of ≤10 cm H2O, and Fio2 of ≤0.4, with spontaneous breathing. The primary end point was duration of weaning and the secondary end points were rate of weaning failure, total length of mechanical ventilation, length of stay in the ICU, and ICU mortality. Results: A total of 140 patients were studied: 93 with AKI and 47 controls. The groups were similar in regard to age, sex, and type of tumor. Diagnosis of acute lung injury/acute respiratory distress syndrome as cause of respiratory failure and Simplified Acute Physiology Score II at admission did not differ between groups. During ICU stay, AKI patients had markers of more severe disease: increased occurrence of severe sepsis or septic shock, higher number of antibiotics, and longer use of vasoactive drugs. The median (interquartile range) duration of mechanical ventilation (10 [6–17] vs. 7 [2–12] days, p = .017) and duration of weaning from mechanical ventilation (41 [16–97] vs. 21 [7–33.5] hrs, p = .018) were longer in AKI patients compared with control patients. Cox regression analysis demonstrated that a ≥85% increase in baseline serum creatinine (hazard rate, 2.30; 95% confidence interval, 1.30–4.08), oliguria (hazard rate, 2.51; 95% confidence interval, 1.24–5.08), and the number of antibiotics (hazard rate, 2.64; 95% confidence interval, 1.51–4.63) predicted longer duration of weaning. The length of ICU stay and ICU mortality rate were significantly greater in the AKI patients. After adjusting for Simplified Acute Physiology Score II, oliguria (odds ratio, 30.8; 95% confidence interval, 7.7–123.0) remained as a strong risk factor for mortality. Conclusion: This study shows that renal dysfunction has serious consequences in the duration of mechanical ventilation, weaning from mechanical ventilation, and mortality in critically ill cancer patients.

Inspiratory muscle training is ineffective in mechanically ventilated critically ill patients

PURPOSE Invasive mechanical ventilation is associated with complications, and its abbreviation is desirable. The imbalance between increased workload, decreased inspiratory muscle strength and endurance is an important determinant of ventilator dependence. Low endurance may be present due to respiratory muscle atrophy, critical illness, or steroid use. Specific inspiratory muscle training may increase or preserve endurance. The objective of the study was to test the hypothesis that inspiratory muscle training from the beginning of mechanical ventilation would abbreviate the weaning duration and decrease reintubation rate. As a secondary objective, we described the evolution of inspiratory muscle strength with and without inspiratory muscle training. METHODS Prospective, randomized clinical trial in an adult clinical-surgical intensive care unit. Twelve patients trained the inspiratory muscles twice a day, and 13 patients did not (control). Training was performed adjusting the sensitivity of the ventilator based on the maximal inspiratory pressure. Patients underwent daily surveillance of the maximal inspiratory pressure. RESULTS The weaning duration (31 +/- 22 hr, control and 23 +/- 11 hr, training group; P = .24) and reintubation rate (5 control and 3 training group; P = .39) were not statistically different. The maximal inspiratory pressure of the control group showed a trend toward a modest increase. In contrast, the training group showed a small decrease (P = .34). CONCLUSIONS In acute critically ill patients, inspiratory muscle training from the beginning of mechanical ventilation neither abbreviated the weaning duration, nor decreased the reintubation rate. Inspiratory muscle strength tended to stay constant, along the mechanical ventilation, with or without this specific inspiratory muscle training.

Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia

Objectives:To compare the incidence of ventilator-associated pneumonia (VAP) with or without isotonic saline instillation before tracheal suctioning. As a secondary objective, we compared the incidence of endotracheal tube occlusion and atelectasis. Design:Randomized clinical trial. Setting and Patients:The study was conducted in a medical surgical intensive care unit of an oncologic hospital. We selected consecutive patients needing mechanical ventilation for >72 hrs. Patients were allocated into two groups: a saline group that received instillation of 8 mL of saline before tracheal suctioning and a control group which did not. VAP was diagnosed based on clinical suspicion and confirmed by bronchoalveolar lavage quantitative culture. The incidence of atelectasis on daily chest radiography and endotracheal tube occlusions were recorded. The sample size was calculated to a power of 80% and a type I error probability of 5%. Measurements and Main Results:One hundred thirty patients were assigned to the saline group and 132 to the control group. The baseline demographic variables were similar between groups. The rate of clinically suspected VAP was similar in both groups. The incidence of microbiological proven VAP was significantly lower in the saline group (23.5% × 10.8%; p = 0.008) (incidence density/1.000 days of ventilation 21.22 × 9.62; p < 0.01). Using the Kaplan-Meier curve analysis, the proportion of patients remaining without VAP was higher in the saline group (p = 0.02, log-rank test). The relative risk reduction of VAP in the saline instillation group was 54% (95% confidence interval, 18%–74%) and the number needed to treat was eight (95% confidence interval, 5–27). The incidence of atelectases and endotracheal tube occlusion were similar between groups. Conclusions:Instillation of isotonic saline before tracheal suctioning decreases the incidence of microbiological proven VAP.

Outcomes for Patients With Cancer Admitted to the ICU Requiring Ventilatory Support: Results From a Prospective Multicenter Study

BACKGROUND This study was undertaken to evaluate the clinical characteristics and outcomes of patients with cancer requiring nonpalliative ventilatory support. METHODS This was a secondary analysis of a prospective cohort study conducted in 28 Brazilian ICUs evaluating adult patients with cancer requiring invasive mechanical ventilation (MV) or noninvasive ventilation (NIV) during the first 48 h of their ICU stay. We used logistic regression to identify the variables associated with hospital mortality. RESULTS Of 717 patients, 263 (37%) (solid tumors = 227; hematologic malignancies = 36) received ventilatory support. NIV was initially used in 85 patients (32%), and 178 (68%) received MV. Additionally, NIV followed by MV occurred in 45 patients (53%). Hospital mortality rates were 67% in all patients, 40% in patients receiving NIV only, 69% when NIV was followed by MV, and 73% in patients receiving MV only (P < .001). Adjusting for the type of admission, newly diagnosed malignancy (OR, 3.59; 95% CI, 1.28-10.10), recurrent or progressive malignancy (OR, 3.67; 95% CI, 1.25-10.81), tumoral airway involvement (OR, 4.04; 95% CI, 1.30-12.56), performance status (PS) 2 to 4 (OR, 2.39; 95% CI, 1.24-4.59), NIV followed by MV (OR, 3.00; 95% CI, 1.09-8.18), MV as initial ventilatory strategy (OR, 3.53; 95% CI, 1.45-8.60), and Sequential Organ Failure Assessment score (each point except the respiratory domain) (OR, 1.15; 95% CI, 1.03-1.29) were associated with hospital mortality. Hospital survival in patients with good PS and nonprogressive malignancy and without tumoral airway involvement was 53%. Conversely, patients with poor functional capacity and cancer progression had unfavorable outcomes. CONCLUSIONS Patients with cancer with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care, because one-half of these patients survive. On the other hand, provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy.

Original ResearchCritical CareFeaturedOutcomes for Patients With Cancer Admitted to the ICU Requiring Ventilatory Support: Results From a Prospective Multicenter Study

BACKGROUND This study was undertaken to evaluate the clinical characteristics and outcomes of patients with cancer requiring nonpalliative ventilatory support. METHODS This was a secondary analysis of a prospective cohort study conducted in 28 Brazilian ICUs evaluating adult patients with cancer requiring invasive mechanical ventilation (MV) or noninvasive ventilation (NIV) during the first 48 h of their ICU stay. We used logistic regression to identify the variables associated with hospital mortality. RESULTS Of 717 patients, 263 (37%) (solid tumors = 227; hematologic malignancies = 36) received ventilatory support. NIV was initially used in 85 patients (32%), and 178 (68%) received MV. Additionally, NIV followed by MV occurred in 45 patients (53%). Hospital mortality rates were 67% in all patients, 40% in patients receiving NIV only, 69% when NIV was followed by MV, and 73% in patients receiving MV only (P < .001). Adjusting for the type of admission, newly diagnosed malignancy (OR, 3.59; 95% CI, 1.28-10.10), recurrent or progressive malignancy (OR, 3.67; 95% CI, 1.25-10.81), tumoral airway involvement (OR, 4.04; 95% CI, 1.30-12.56), performance status (PS) 2 to 4 (OR, 2.39; 95% CI, 1.24-4.59), NIV followed by MV (OR, 3.00; 95% CI, 1.09-8.18), MV as initial ventilatory strategy (OR, 3.53; 95% CI, 1.45-8.60), and Sequential Organ Failure Assessment score (each point except the respiratory domain) (OR, 1.15; 95% CI, 1.03-1.29) were associated with hospital mortality. Hospital survival in patients with good PS and nonprogressive malignancy and without tumoral airway involvement was 53%. Conversely, patients with poor functional capacity and cancer progression had unfavorable outcomes. CONCLUSIONS Patients with cancer with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care, because one-half of these patients survive. On the other hand, provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy.

Critically ill patients with cancer and sepsis: Clinical course and prognostic factors ☆ ☆☆ ★

PURPOSE The purposes of this study were to evaluate the clinical course and to identify independent predictors of mortality in patients with cancer with sepsis. MATERIALS AND METHODS This is a secondary analysis of a prospective cohort study conducted at an oncological medical-surgical intensive care unit. Logistic regression was used to identify predictors of hospital mortality. RESULTS A total of 563 patients (77% solid tumor, 23% hematologic malignancies) were included over a 55-month period. The most frequent sites of infection were the lung, abdomen, and urinary tract; 91% patients had severe sepsis/septic shock. Gram-negative bacteria were responsible for more than half of the episodes of infection; 38% of patients had polymicrobial infections. Intensive care unit, hospital, and 6-month mortality rates were 51%, 65%, and 72%, respectively. In multivariate analyses, sepsis in the context of medical complications; active disease; compromised performance status; presence of 3 to 4 systemic inflammatory response syndrome criteria; and the presence of respiratory, renal, and cardiovascular failures were associated with increased mortality. Adjusting for other covariates, patients with non-urinary tract infections, mostly represented by patients with pneumonia and abdominal infections, had worse outcomes. CONCLUSIONS Sepsis remains a frequent complication in patients with cancer and associated with high mortality. Our results can be of help to assist intensivists in clinical decisions and to improve characterization and risk stratification in these patients.

What increases type III procollagen mRNA levels in lung tissue: stress induced by changes in force or amplitude?

We hypothesized that stress determined by force could induce higher type III procollagen (PCIII) mRNA expression than the stress determined by amplitude. To that end, rat lung tissue strips were oscillated for 1h under different amplitudes [1, 5 and 10% of resting length (L(B)), at 0.5 x 10(-2) N] and forces (0.25 x 10(-2), 0.5 x 10(-2) and 10(-2)N, at 5% L(B)). Resistance (R), elastance (E) and hysteresivity (eta) were analysed during sinusoidal oscillations at 1Hz. After 1h of oscillation, PCIII mRNA expression was determined by Northern-blot and semiquantitative RT-PCR. Control value of PCIII mRNA was obtained from unstressed strips. E and R increased with augmenting force and decreased with increasing amplitude, while eta remained unaltered. PCIII mRNA expression increased significantly after 1h of oscillation at 10(-2)N and 5% L(B) and remained unchanged for 6h. In conclusion, the stress induced by force but not by amplitude led to the increment in PCIII mRNA expression.

Very Early Passive Cycling Exercise in Mechanically Ventilated Critically Ill Patients: Physiological and Safety Aspects - A Case Series

Introduction Early mobilization can be performed in critically ill patients and improves outcomes. A daily cycling exercise started from day 5 after ICU admission is feasible and can enhance functional capacity after hospital discharge. In the present study we verified the physiological changes and safety of an earlier cycling intervention (< 72 hrs of mechanical ventilation) in critical ill patients. Methods Nineteen hemodynamically stable and deeply sedated patients within the first 72 hrs of mechanical ventilation were enrolled in a single 20 minute passive leg cycling exercise using an electric cycle ergometer. A minute-by-minute evaluation of hemodynamic, respiratory and metabolic variables was undertaken before, during and after the exercise. Analyzed variables included the following: cardiac output, systemic vascular resistance, central venous blood oxygen saturation, respiratory rate and tidal volume, oxygen consumption, carbon dioxide production and blood lactate levels. Results We enrolled 19 patients (42% male, age 55±17 years, SOFA = 6 ± 3, SAPS3 score = 58 ± 13, PaO2/FIO2 = 223±75). The median time of mechanical ventilation was 1 day (02), and 68% (n=13) of our patients required norepinephrine (maximum concentration = 0.47 µg.kg -1.min-1). There were no clinically relevant changes in any of the analyzed variables during the exercise, and two minor adverse events unrelated to hemodynamic instability were observed. Conclusions In our study, this very early passive cycling exercise in sedated, critically ill, mechanically ventilated patients was considered safe and was not associated with significant alterations in hemodynamic, respiratory or metabolic variables even in those requiring vasoactive agents.

Diagnostic methods to assess inspiratory and expiratory muscle strength

Impairment of (inspiratory and expiratory) respiratory muscles is a common clinical finding, not only in patients with neuromuscular disease but also in patients with primary disease of the lung parenchyma or airways. Although such impairment is common, its recognition is usually delayed because its signs and symptoms are nonspecific and late. This delayed recognition, or even the lack thereof, occurs because the diagnostic tests used in the assessment of respiratory muscle strength are not widely known and available. There are various methods of assessing respiratory muscle strength during the inspiratory and expiratory phases. These methods are divided into two categories: volitional tests (which require patient understanding and cooperation); and non-volitional tests. Volitional tests, such as those that measure maximal inspiratory and expiratory pressures, are the most commonly used because they are readily available. Non-volitional tests depend on magnetic stimulation of the phrenic nerve accompanied by the measurement of inspiratory mouth pressure, inspiratory esophageal pressure, or inspiratory transdiaphragmatic pressure. Another method that has come to be widely used is ultrasound imaging of the diaphragm. We believe that pulmonologists involved in the care of patients with respiratory diseases should be familiar with the tests used in order to assess respiratory muscle function.Therefore, the aim of the present article is to describe the advantages, disadvantages, procedures, and clinical applicability of the main tests used in the assessment of respiratory muscle strength.