A large prospective multicenter cohort study in France and Belgium, reported by the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique, has shown that critically ill patients with hematologic malignancies admitted to the intensive care unit (ICU) have good survival, disease control, and post-ICU health-related quality of life. Earlier admission to the ICU, a potentially modifiable risk factor, was associated with better survival.
The study involved 1,011 patients with life-threatening events hospitalized at 17 centers. Of these patients, 38.2% had newly diagnosed malignancies, 23.1% were in remission, and 24.9% had received bone marrow transplantation or hematopoietic stem cell transplantation, including allogeneic transplantation in 14.3%. Patients with non-Hodgkin lymphoma (31.6%), acute myeloid leukemia (27.2%), and myeloma (12.5%) accounted for the majority of the cohort.
On day 1, 72.5% of patients received life-supporting interventions. The primary reasons for ICU admission were acute respiratory failure (62.5%) or shock (42.3%). Neutropenia was present in 28.6% of patients at ICU admission and developed in the ICU in an additional 9%. The median time from hospital admission to ICU admission was 4 days, with ICU admission occurring within 1 day in 44.6% of patients and 26% being admitted directly to the ICU.
Characteristics of Patients with Earlier ICU Admission
Patients admitted to the ICU within 1 day after hospital admission had similar Sepsis-related Organ Failure Assessment (SOFA) scores on day 1 compared with those admitted later, but were less likely to have life supporting intervention (67.7% vs 74.2%).
These patients also had shorter times since malignancy diagnosis (median 153 vs 173.5 days), were more likely to have good performance status (86.6% vs 75.5%), and were less likely to have their primary hematologist in the same hospital as the ICU (57.6% vs 96.7%), history of allogeneic bone marrow transplantation or hematopoietic stem cell transplantation (11% vs 17%), neutropenia (19.6% vs 35.8%), and treatment with antifungal (27% vs 47%) or antiviral agents (36% vs 48%) during the first 3 days in the ICU. These patients were also significantly less likely to require more than one call to the ICU physician for admission than those admitted after 1 day (5.9% vs 18%).
Predictors of Mortality
Overall hospital, 90-day, and 1-year survival rates were 60.7%, 52.5%, and 43.3%, respectively. On multivariate analysis (using a model without imputation of missing data from the SOFA score), 10 variables were independently associated with hospital mortality. Time from hospital to ICU admission of < 24 hours (odds ratio = 0.7) and complete or partial remission status (odds ratio = 0.63) were associated with significantly reduced risk of mortality.
Poor performance status (odds ratio = 1.58), higher Charlson comorbidity index (odds ratio = 1.13/point), receipt of allogeneic bone marrow transplantation or hematopoietic stem cell transplantation (odds ratio = 2.18), higher SOFA score on admission (odds ratio = 1.21/point), admission after cardiac arrest (odds ratio = 2.63), admission with acute respiratory failure (odds ratio = 1.34), organ infiltration by malignancy (odds ratio = 1.89), and invasive pulmonary aspergillosis (odds ratio = 1.97) were associated with significantly increased risk of mortality.
Overall, mechanical ventilation was used in 47.9% of patients, vasoactive drugs in 51.2%, and dialysis in 25.9%. Mortality rates in these patients were 60.5%, 57.5%, and 59.2%, respectively.
Survivors Have Good Disease Control and Quality of Life
Assessment of health-related quality of life with the short-form 36 questionnaire on day 90 indicated no difference between survivors on physical and mental health measures compared with age- and gender-matched cancer patients not admitted to the ICU. At 6 months, hematologists reported that all but 7 of the ICU survivors were continuing their cancer treatment, that ICU admission did not alter therapeutic intensity in 80% of patients, and that 80% were in complete or partial remission.
The investigators concluded, “…ICU admission prolonged survival with good quality of life. ICU admission within 24 hours of hospital admission was identified as a variable significantly associated with better survival and possibly amenable to modification.”
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