Management of hematological patients in ICU: a retrospective study of 110 patients
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KeywordsMechanical Ventilation Severe Sepsis Septic Patient Acute Leukemia Acute Leukemia
Intensive care in hematological patients remains challenging. In despite of an agressive and sometimes prolonged treatment, outcome in ICU remains poor, particularly in septic patients.
A retrospective review of hematological patients suffering from acute leukemia (AL), non-Hodgkin's lymphoma (NHL) and Hodgkin's lymphoma (HL), hospitalized in our ICU from January 1995 to October 2000, has been performed. We studied demographic data, mortality rates and risk factors associated to mortality both for all patients (excepted allogeneic transplants patients) and for septic patients.
110 patients have been included in our study and 10 of them beneficiated from an allogeneic bone marrow transplantation. Mean age was 47.49 years (range 16-77), and sex-ratio male/female was 1.08. 58% suffered from AL, 36% from NHL and 6% from HL. Sepsis, respiratory and neurologic failures represented the most frequent causes of admission. Mean SAPS II, SOFA max and OSF scores were respectively 51.41, 9.07 and 2.40. Mean OSF decreased significantly between 1997 and 2000 (2.66 vs 1.90; P = 0.04). Mean mortality rate was 56%. In univariate analysis, SAPS II, SOFA max, OSF scores, mechanical ventilation, extrarenal replacement and use of amines were significantly associated with mortality. Renal, hepatic, neurologic and circulatory failures at admission were also significant.
Among the 110 patients, 53 (48.18%) had septic conditions (severe sepsis and septic shock). Mean age was 47.51 years. Mean SAPS II, SOFA max and OSF scores were respectively 59.11, 10.68 and 2.98. Mean mortality rate was 75.47%. Comparisons between septic patients during these 5 years showed no statistical differences, excepted for mean SAPS II which increased significantly between 1995 and 1999 (40.71 vs 77.63; P = 0.04). Severity-of-illness scores, use and duration of mechanical ventilation, extrarenal replacement (ERR) and amines were significantly associated with mortality. Interestingly, only hepatic, neurologic and circulatory failures at admission were also significantly associated to a poor outcome. Mortality rates in patients with no organ supply, with 1, 2 and 3 supplied organs were respectively 0%, 66.66%, 86.66% and 92.59%. Type of disease was not associated to an increased mortality rate. Performing chemotherapy in ICU, with ERR if necessary, seems possible with no harmful consequences.
These results could suggest that hematological underlying disease has no major influence on early outcome, but that prognosis is mainly determined by acute physiologic changes induced by sepsis, and reflected in severity-of-illness scores . New therapeutic strategies based on earlier referral in ICU, reliable markers of organ dysfunction and agressive treatment, should be tested prospectively to ensure an optimal management and a better prognosis for these patients.