Advertisement

Intensive Care Medicine

, Volume 29, Issue 10, pp 1688–1695 | Cite as

Improved survival of critically ill cancer patients with septic shock

  • Jérôme Larché
  • Élie AzoulayEmail author
  • Fabienne Fieux
  • Laurent Mesnard
  • Delphine Moreau
  • Guillaume Thiery
  • Michaël Darmon
  • Jean-Roger Le Gall
  • Benoît Schlemmer
Original

Abstract

Objective

To identify predictors of 30-day mortality in critically ill cancer patients with septic shock.

Design

Retrospective study over a 6-year period.

Setting

Twelve-bed medical intensive care unit (ICU).

Patients

Eighty-eight patients (55 men, 33 women) aged 55 (43.5–63) years admitted to the ICU for septic shock.

Interventions

None.

Measurements and main results

Eighty (90.9%) patients had hematological malignancies and eight (9.1%) had solid tumors; 47 patients (53.4%) were neutropenic, 19 (21.6%) were hematopoietic stem cell transplantation (HSCT) recipients, and 27 (30.7%) were in remission. Microbiologically documented infections were found in 60 (68.2%) patients. The Simplified Acute Physiologic Score II (SAPS II) and Logistic Organ Dysfunction (LOD) scores at ICU admission were 66 (47–89) and 7 (5–10), respectively, and the LOD score on day 3 was 8 (4–10). Sixty-eight (78.1%) patients received invasive mechanical ventilation (MV), 12 (13.6%) noninvasive MV, 22 (25%) dialysis. Thirty-day mortality was 65.5% (57/88). By multivariable analysis, mortality was higher when time to antibiotic treatment was >2 h [odds ratio (OR), 7.05; 95% confidence interval (95% CI), 1.17–42.21] and when DLOD (day 3−day 1 LOD score/day 3 LOD score) was high (OR, 3.47; 95% CI, 1.44–8.39); mortality was lower when admission occurred between 1998 and 2000 (OR, 0.23; 95% CI, 0.05–0.98) and when initial antibiotics were adapted (OR, 0.24; 95% CI, 0.06–0.09).

Conclusions

Earlier ICU admission and antibiotic treatment of critically ill cancer patients with septic shock is associated with higher 30-day survival. The LOD score change on day 3 as compared to admission is useful for predicting survival.

Keywords

Critically ill cancer patients Septic shock LOD score Mortality Treatment delays Antibiotics 

References

  1. 1.
    Bodey GP (2000) Unusual presentations of infection in neutropenic patients. Int J Antimicrob Agents 16:93–95CrossRefPubMedGoogle Scholar
  2. 2.
    Azoulay E, Recher C, Alberti C, Soufir L, Leleu G, Le Gall JR, Fermand JP, Schlemmer B (1999) Changing use of intensive care for hematological patients: the example of multiple myeloma. Intensive Care Med 25:1395–1401PubMedGoogle Scholar
  3. 3.
    Azoulay E, Moreau D, Alberti C, Leleu G, Adrie C, Barboteu M, Cottu P, Levy V, Le Gall JR, Schlemmer B (2000) Predictors of short-term mortality in critically ill patients with solid malignancies. Intensive Care Med 26:1817–1823CrossRefPubMedGoogle Scholar
  4. 4.
    Blot F, Guiguet M, Nitenberg G, Leclercq B, Gachot B, Escudier B (1997) Prognostic factors for neutropenic patients in an intensive care unit: respective roles of underlying malignancies and acute organ failures. Eur J Cancer 33:1031–1037PubMedGoogle Scholar
  5. 5.
    Kress JP, Christenson J, Pohlman AS, Linkin DR, Hall JB (1999) Outcomes of critically ill cancer patients in a university hospital setting. Am J Respir Crit Care Med 160:1957–1961PubMedGoogle Scholar
  6. 6.
    Staudinger T, Stoiser B, Mullner M, Locker GJ, Laczika K, Knapp S, Burgmann H, Wilfing A, Kofler J, Thalhammer F, Frass M (2000) Outcome and prognostic factors in critically ill cancer patients admitted to the intensive care unit. Crit Care Med 28:1322–1328PubMedGoogle Scholar
  7. 7.
    Crawford SW, Schwartz DA, Petersen FB, Clark JG (1988) Mechanical ventilation after marrow transplantation. Risk factors and clinical outcome. Am Rev Respir Dis 137:682–687PubMedGoogle Scholar
  8. 8.
    Epner DE, White P, Krasnoff M, Khanduja S, Kimball KT, Knaus WA (1996) Outcome of mechanical ventilation for adults with hematologic malignancy. J Investig Med 44:254–260PubMedGoogle Scholar
  9. 9.
    Kongsgaard UE, Meidell NK (1999) Mechanical ventilation in critically ill cancer patients: outcome and utilisation of resources. Support Care Cancer 7:95–99CrossRefGoogle Scholar
  10. 10.
    Azoulay E, Alberti C, Bornstain C, Leleu G, Moreau D, Recher C, Chevret S, Le Gall JR, Brochard L, Schlemmer B (2001) Improved survival in cancer patients requiring mechanical ventilatory support: impact of noninvasive mechanical ventilatory support. Crit Care Med 29:519–525PubMedGoogle Scholar
  11. 11.
    Hilbert G, Gruson D, Vargas F, Valentino R, Gbikpi-Benissan G, Dupon M, Reiffers J, Cardinaud JP (2001) Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 344:481–487PubMedGoogle Scholar
  12. 12.
    American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference (1992) American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 20:864–874PubMedGoogle Scholar
  13. 13.
    Alberti C, Brun-Buisson C, Burchardi H, Martin C, Goodman S, Artigas A, Sicignano A, Palazzo M, Moreno R, Boulme R, Lepage E, Le Gall R (2002) Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study. Intensive Care Med 28:108–121PubMedGoogle Scholar
  14. 14.
    Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE (1981) APACHE-acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 9:591–597PubMedGoogle Scholar
  15. 15.
    Darmon M, Azoulay E, Alberti C, Fieux F, Moreau D, Gall JR, Schlemmer B (2002) Impact of neutropenia duration on short-term mortality in neutropenic critically ill cancer patients. Intensive Care Med 28:1775–1780CrossRefPubMedGoogle Scholar
  16. 16.
    Gruson D, Hilbert G, Bebear C, Allery A, Boiron JM, Pigneux A, Vargas F, Reiffers J, Gbikpi-Benissan G, Cardinaud JP (1998) Early infectious complications after bone marrow transplantation requiring medical ICU admission. Hematol Cell Ther 40:269–274PubMedGoogle Scholar
  17. 17.
    Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963PubMedGoogle Scholar
  18. 18.
    Le Gall JR, Klar J, Lemeshow S, Saulnier F, Alberti C, Artigas A, Teres D (1996) The Logistic Organ Dysfunction system. A new way to assess organ dysfunction in the intensive care unit. ICU Scoring Group. JAMA 276:802–810PubMedGoogle Scholar
  19. 19.
    Timsit JF, Misset B, Azoulay E, Renaud B, Garrouste-Orgeas M, Carlet J (1996) Usefulness of airway visualization in the diagnosis of nosocomial pneumonia in ventilated patients. Chest 110:172–179PubMedGoogle Scholar
  20. 20.
    Barnes RA, Stallard N (2001) Severe infections after bone marrow transplantation. Curr Opin Crit Care 7:362–366CrossRefPubMedGoogle Scholar
  21. 21.
    Elting LS, Rubenstein EB, Rolston KV, Bodey GP (1997) Outcomes of bacteremia in patients with cancer and neutropenia: observations from two decades of epidemiological and clinical trials. Clin Infect Dis 25:247–259PubMedGoogle Scholar
  22. 22.
    Uzun O, Ascioglu S, Anaissie EJ, Rex JH (2001) Risk factors and predictors of outcome in patients with cancer and breakthrough candidemia. Clin Infect Dis 32:1713–1717PubMedGoogle Scholar
  23. 23.
    Anderson KC, Soiffer R, DeLage R, Takvorian T, Freedman AS, Rabinowe SL, Nadler LM, Dear K, Heflin L, Mauch P, et al. (1990) T-cell-depleted autologous bone marrow transplantation therapy: analysis of immune deficiency and late complications. Blood 76:235–244PubMedGoogle Scholar
  24. 24.
    Campbell JH, Blessing N, Burnett AK, Stevenson RD (1993) Investigation and management of pulmonary infiltrates following bone marrow transplantation: an eight year review. Thorax 48:1248–1251PubMedGoogle Scholar
  25. 25.
    Meletis J, Arlet G, Dournon E, Pol S, Devergie A, Sportes C, Peraldi MN, Mayaud C, Perol Y, Gluckman E (1987) Legionnaires' disease after bone marrow transplantation. Bone Marrow Transplant 2:307–313PubMedGoogle Scholar
  26. 26.
    Khassawneh BY, White P, Jr., Anaissie EJ, Barlogie B, Hiller FC (2002) Outcome from mechanical ventilation after autologous peripheral blood stem cell transplantation. Chest 121:185–188CrossRefPubMedGoogle Scholar
  27. 27.
    Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M, Early Goal-Directed Therapy Collaborative Group (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377PubMedGoogle Scholar
  28. 28.
    Bellomo R (2002) Fluid resuscitation: colloids vs. crystalloids. Blood Purif 20:239–242CrossRefPubMedGoogle Scholar
  29. 29.
    Guiguet M, Blot F, Escudier B, Antoun S, Leclercq B, Nitenberg G (1998) Severity-of-illness scores for neutropenic cancer patients in an intensive care unit: which is the best predictor? Do multiple assessment times improve the predictive value? Crit Care Med 26:488–493PubMedGoogle Scholar
  30. 30.
    Timsit JF, Fosse JP, Troche G, De Lassence A, Alberti C, Garrouste-Orgeas M, Azoulay E, Chevret S, Moine P, Cohen Y (2001) Accuracy of a composite score using daily SAPS II and LOD scores for predicting hospital mortality in ICU patients hospitalized for more than 72 h. Intensive Care Med 27:1012–1021PubMedGoogle Scholar
  31. 31.
    Rubenfeld GD, Crawford SW (1996) Withdrawing life support from mechanically ventilated recipients of bone marrow transplants: a case for evidence-based guidelines. Ann Intern Med 125:625–633PubMedGoogle Scholar
  32. 32.
    Natsch S, Kullberg BJ, Meis JF, van der Meer JW (2000) Earlier initiation of antibiotic treatment for severe infections after interventions to improve the organization and specific guidelines in the emergency department. Arch Intern Med 160:1317–1320CrossRefPubMedGoogle Scholar
  33. 33.
    Natsch S, Kullberg BJ, van der Meer JW, Meis JF (1998) Delay in administering the first dose of antibiotics in patients admitted to hospital with serious infections. Eur J Clin Microbiol Infect Dis 17:681–684CrossRefPubMedGoogle Scholar
  34. 34.
    Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ, Jr (2001) Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 344:699–709PubMedGoogle Scholar
  35. 35.
    Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2003

Authors and Affiliations

  • Jérôme Larché
    • 1
  • Élie Azoulay
    • 1
    Email author
  • Fabienne Fieux
    • 1
  • Laurent Mesnard
    • 1
  • Delphine Moreau
    • 1
  • Guillaume Thiery
    • 1
  • Michaël Darmon
    • 1
  • Jean-Roger Le Gall
    • 1
  • Benoît Schlemmer
    • 1
  1. 1.Medical ICU of the Saint-Louis Teaching Hospital and Paris 7 UniversityAssistance Publique-Hôpitaux de ParisParisFrance

Personalised recommendations