Outcome of patients with hematologic malignancy admitted to the ICU

Transcription

1 Outcome of patients with hematologic malignancy admitted to the ICU Geeta Mehta MD, FRCPC Mount Sinai Hospital Toronto, Canada CCCF November 2, 2016

2 Disclosures

3 Hematologic Malignancy Advances in diagnostics, risk stratification and treatment regimens including hematopoietic cell transplantation (HCT) Aggressive treatment has been extended to higher risk candidates: older, more comorbid illness, receiving salvage chemotherapy More dose-intensive regimens, or novel approaches to HCT (mismatched, haploidentical, cord blood transplant ) As a consequence, there has been an increased risk of serious complications and need for ICU care.

4 Complications Infectious Chemotherapy related HCT related Bleeding Acute respiratory failure GVHD Sinusoidal Obstructive syndrome etc

5 ICU survival has improved In 1999, the American College of Critical Care Medicine stated: patients with HM are poor candidates for ICU admission with a mortality rate of up to 90%. Immediate treatment limitation/refusal of ICU admission is advocated (Crit Care Med 1999) Recent reports showing improved ICU survival rates challenge this perception Mount Sinai Hospital Between 2012 and 2015, 420 patients from Princess Margaret Hospital were admitted to ICU ICU mortality 32% > 500 ICU admissions annually in Canada

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7 We need more data More multi-center and population studies are needed to evaluate outcomes and predictors Functional outcomes Patient and family perspectives Advance Care Planning Clinical Practice Guidelines

8 AJRCCM 2016 age > 66 yr ICU LOS >2 wk

9 Retrospective chart review 151 consecutive patients with AML and ALL admitted to Mount Sinai Hospital Medical-Surgical ICU, a 16- bed ICU affiliated with the University of Toronto 2009 to 2012 Objective: to describe ICU interventions, short and long-term outcomes, and predictors of outcome

10 Patient Characteristics Age, years 54 (15) Female 76 (50%) APACHE II 27 (22-33) SOFA 10 (8-13) MODS 7 (6-10) Neutropenia (<500) 84 (74) Thrombocytopenia (<50) 126 (86) Admission Diagnosis Sepsis 74 (49) Respiratory 46 (31) Cardiovascular Failure 14 (10) Gastrointestinal Bleed 3 (2) Neurological Dysfunction 8 (5)

11 Leukemia Characteristics (N=151) Leukemia Type Acute Myeloid Leukemia Acute Lymphoblastic Leukemia Chemotherapy Stage Induction Consolidation Intensification Phase Reinduction for Relapse Reinduction for Non-response Not Provided Chemotherapy within 40 days No Pharmacy Records Leukemia Factors CNS Infiltration HCT before ICU Allogeneic Autologous GVHD N (%) 118 (78) 33 (22) 55 (36) 9 (6) 5 (3) 29 (20) 12 (8) 33 (22) 3 (2) 9 (6) 20 (13) (7)

12 Outcomes ICU stay 4 days (2-8) Survival ICU 62% 30-day 49% 90-day 40% 6 months 34% 12 months 25%

13 Characteristics of ICU survivors and non-survivors at ICU discharge and 1-year post ICU admission

14 Characteristics of ICU survivors and non-survivors at ICU discharge and 1-year post ICU admission

15 Multivariable analysis of independent predictors of ICU mortality Variable Odds Ratio Estimates (95% CI) P Value SOFA Induction Stage at ICU admission Relapse Stage at ICU admission Age Septic Shock Invasive Ventilation 1.18 ( ) 0.43 ( ) 0.49 ( ) 1.01 ( ) 4.06 ( ) 9.64 ( ) <0.001

16 Other Canadian studies Study Patients N ICU Mortality 1 year mortality Krajuljak AML/ALL % 75% Cornish 2016 HM % 74% Roze des Ordons 2010 AML 45 44% 71% Trinkaus 2009 Auto-SCT 34 38% Scales 2008 HCT %

17 Crit Care 2008 OHIP database Adults (>18 years) who underwent BMT1992 to 2002

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19 Internationally - Single center studies Study Country Patients N ICU Mortality 1 year mortality Kroschinsky 2002 Germany HCT % 71% Massion 2002 Belgium HM % Afessa 2003 US HCT Rabbat 2005 France AML % Bruennler 2007 Germany HM Ferra 2007 Spain HM Thakkar 2008 US AL Silva 2013 Mexico HM Bird 2012 UK HM Hill 2012 UK HM Hampshire 2014 UK 3 centers HM Medic 2015 Croatia HM

20 Grrr-OH: Groupe de recherche respiratoire en réanimation onco-hématologique 17 centers in France and Belgium Study Patients N ICU Mortality Hospital Mortality Azoulay 2013 HM % Lengline 2015 Allo-HCT % 90-day Mokart 2015 Neutropenic % 75% Lemiale 2015 HM - ARF % Darmon 2015 HM - AKI %

21 Independent Predictors of Mortality Azoulay 2013: Poor performance status, Charlson comorbidity index, allogeneic HSCT, organ dysfunction score, cardiac arrest, acute respiratory failure, malignant organ infiltration, and invasive aspergillosis Mokart 2015: allogeneic HCT (OR 3.83; 95 % CI ), MV (OR 6.57; 95 % CI ), microbiological documentation (OR 2.33; CI ), RRT (OR 2.77; 95 %CI ) Lengline 2015: GVHD, MV, RRT Darmon 2015: AKI (OR 1.65, 95% CI )

22 Summary Patients with hematologic malignancy ICU mortality 40%; 1 year mortality as high as 75% Not possible to predict outcome with 100% certainty Cannot justify denying these patients ICU admission Independent predictors of mortality vary Pre-morbid functional status may be as important as HM and acute illness variables

23 Urgently needed Multicenter outcome studies on patients with HM who require ICU admission Population based data on survival and functional outcomes Comprehensive evaluation of the factors contributing to long term morbidity in patients who survive their critical illness Patients, families, and clinicians will benefit from knowing which patients survive, and the challenges faced by survivors and their families

24 JAMA 2016

25 COHO Critical Care Outcomes of Patients with Hematologic Malignancy or Hematopoietic Cell Transplant

26 Quality Improvement Initiative Critical Care Oncologic Investigative Network (COIN) Vision: To become a world class centre in providing critical care services to oncological patients Mission: To provide the best critical care for oncological patients by having optimal knowledge, communication, and research development through collaborations of all stakeholders Focus on: 1. Clinical Knowledge 2. Education 3. Research 4. Quality Improvement AFI Examples of Projects by COIN Members TOPIC 1 Acute Promyelocytic Leukemia Outcomes Study 2 Interhospital Transfer 3 Intrahospital Transfer 4 Data Mapping 5 Medications (Tumor Lysis Mgt) 6 Education 7 Advance Care Planning 8 Blood Bank 9 Hickman Line 10 Hypoxia post BMT

27 Intensivists Patients Hematologists Pharmacists Palliative care Transplant physicians Spiritual Care Dieticians Family Members Rehab specialists

28 Thank-you!