mercredi 5 février 2020 

14h10 - 15h10


 
Espace Poster 6

Pronostic en Onco-Hématologie

MODÉRATEUR(S) :  Michaël DARMON (Paris), Anne-Sophie MOREAU (Lille)  
  

The Use of ICU Resources in Metastatic Breast Cancer

Orateur(s) :   Guillaume BEINSE (Paris) 

Auteur(s) :  Jean jacques TUDESQ (Paris)   Luis TEIXEIRA (Paris)   Edith BORCOMAN (Paris)   Adrien MIROUSE (Paris)   Yannick HOURMANT (Paris)   Asma MABROUKI (Paris)   Michaël DARMON (Paris)   Virginie LEMIALE (Paris)   Elie AZOULAY (Paris)  

14h10 - 14h17
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
The Use of ICU Resources in Metastatic Breast Cancer

Introduction / Rationale :
Life expectancy in patients with metastatic breast cancer (MBC) has substantially improved over the last decade. Life threatening complications result from advanced diseases, infection and treatment-related toxicity. Only few studies have assessed outcomes in this setting. We performed a hospital-wide study to investigate how ICU resources are needed in patients with MBC.

Méthodes / Patients and Methods :
All patients with MBC managed at our hospital between 2010 and 2019 were retrospectively included. The primary outcome was overall survival (OS). Factors associated with ICU mortality were identified using a multivariable Cox proportional hazard model with sensitivity analysis. Results are expressed as median [interquartile range] unless stated otherwise.

Résultats / Results :
Among the 1128 patients managed at our hospital, 68 (6%, including 1 male) were admitted to the ICU (8 [2-15] patients per year). Age was 55 [49-67] years. Patients were receiving their 2nd [1st-3rd] line of treatment and had 3 [2-3] metastatic sites. SOFA score at admission was 3 [1-8]. Main reason for ICU admission was sepsis (n=23, 34%), acute respiratory failure (n=22, 32%), coma (n=9, 13%) and metabolic disorder (n=7, 10%). Invasive mechanical ventilation was required for 18 patients (26%) and renal replacement therapy for 10 (15%). Sixteen (24%) patients died in ICU. Following ICU discharge, median OS was 6.4 months (95% CI [1.7-17.9]) and 22/52 (42.3%) patients died within 3 months. An antineoplastic treatment was resumed for 33/52 (62%) patients alive after ICU discharge. Factors independently associated with mortality were performance status ≥ 2 (HR 1.85, 95%CI [1.01-3.40]) and SOFA score at day 1 (HR 1.19 per point, 95%CI [1.11-1.27]). After sensitivity analysis, the number of treatment lines at ICU admission was not associated with mortality.

Discussion / Discussion :


Conclusion / Conclusion :
ICU admission is required in the course of the MBC disease for 6% of the patients. Determinants of short term outcomes rely on performance status and disease severity but not on the characteristics of the underlying disease. Ongoing analyses will assess whether ICU survivors reach life expectancy of patients never admitted to the ICU.
 

Factors associated with survival of patients with solid cancer alive after intensive care unit (ICU) discharge between 2005 and 2013

Orateur(s) :   Hubert GHEERBRANT (Grenoble) 

Auteur(s) :  Jean-François TIMSIT (Paris)   Nicolas TERZI (Grenoble)   Stephane RUCKLY (Bobigny)   Mathieu LARAMAS (Grenoble)   Matteo GIAJ LEVRA (Grenoble)   Emmanuelle JACQUET (Grenoble)   Loic FALQUE (Grenoble)   Denis MORO-SIBILOT (Grenoble)   Anne claire TOFFART (Grenoble)  

14h17 - 14h24
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Factors associated with survival of patients with solid cancer alive after intensive care unit (ICU) discharge between 2005 and 2013

Introduction / Rationale :
At intensive care unit (ICU) admission, the issue about prognosis of critically ill cancer patients is of clinical interest, especially after ICU discharge. Our objective was to assess the factors associated with 3- and 6-month survival of ICU cancer survivors.

Méthodes / Patients and Methods :
Based on the French OutcomeRea™ database, we included solid cancer patients discharged alive, between December 2005 and November 2013, from the medical ICUof the university hospital in Grenoble, France. Patient characteristics and outcome at 3 and 6 months following ICU discharge were extracted from available database.

Résultats / Results :
Of the 361 cancer patients with unscheduled admissions, 253 (70%) were discharged alive from ICU. The main primary cancer sites were digestive (31%) and thoracic (26%). The 3- and 6-month mortality rates were 33% and 41%, respectively. Factors independently associated with 6-month mortality included ECOG performance status (ECOG-PS) of 3–4 (OR, 3.71; 95%CI: 1.67–8.23), metastatic disease (OR, 2.24; 95%CI: 1.22–4.09), admission for cancer progression (OR, 2.64; 95%CI: 1.32–5.30), SAPS II of 45 to 58 (OR, 4.41; 95%CI: 1.85–10.53), and treatment limitation decision at ICU admission (OR, 3.89; 95%CI: 1.60–9.43). Interestingly, previous cancer chemotherapy prior to ICU admission was independently associated with lower 3-month mortality (OR, 0.38; 95%CI: 0.2–0.75). Among patients with an ECOG-PS 0–1 at admission, 70% (n=66) and 61% (n=57) displayed an ECOG-PS 0–2 at 3 and 6 months, respectively. At 3 months, 74 (55%) patients received anticancer treatment, 13 (8%) were given exclusive palliative care.

Discussion / Discussion :
Factors associated with 6-month mortality are almost the same as those known to be associated with ICU mortality. We highlight that most patients recovered an ECOG-PS of 0–2 at 3 and 6 months, in particular those with a good ECOG-PS at ICU admission, and could benefit from an anticancer treatment following ICU discharge.

Conclusion / Conclusion :
These results should be taken into account when deciding upon ICU admission. At that particular time, it is paramount to have a sound concept concerning the patient’s general condition and his/her anticancer treatment opportunities following ICU discharge.
 

Inititation of chemotherapy within ICU: a retrospective study.

Orateur(s) :   Maxence CHICOISNEAU (Bruxelles, BELGIQUE) 

Auteur(s) :  Lieveke AMEYE (Brussels, BELGIQUE)   Marianne PAESMANS (Brussels, BELGIQUE)   Jean-Paul SCULIER (Brussels, BELGIQUE)   Anne-Pascale MEERT (Brussels, BELGIQUE)  

14h24 - 14h31
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Inititation of chemotherapy within ICU: a retrospective study.

Introduction / Rationale :
The decision to urgently initiate medical anti-cancer treatment in cancer patients admitted to intensive care for cancer-related organ failure is complex. We currently lack criteria to select patients for whom this initiation will be beneficial. The purpose of our exploratory study was therefore to evaluate the characteristics of patients whose medical anti-cancer treatment is initiated at the ICU and to try to release prognostic factors for hospital mortality in these patients

Méthodes / Patients and Methods :
We analyzed retrospectively, over a period of 11 years (1/1/2007 to 31/12/2017), the files of cancer patients over 18 years old admitted to our intensive care unit Bordet and in whose anti-cancer medical treatment was initiated during their stay in the intensive care unit.
In an attempt to identify prognostic factors for hospital mortality, we carried out a multivariate analysis of the factors influencing this mortality, considered as a binary.
We also analyzed the overall survival of patients who survived their hospital stay (from the day of going out of hospital).

Résultats / Results :
Our study consists of 147 patients, 78 men (53%) and 69 women (47%), with a median age of 58 years (18-86). Of these, 79 patients (54%) had a solid tumor and 68 (46%) had a hematological tumor. ICU mortality is 23% (95% CI: 17%-31%) and hospital mortality 32% (95% CI: 25%-40%). The poor prognostic factors for hospital mortality were a high age (mean 61 vs 54 in those who survived), the SOFA score (median 6 vs 2), the SAPS II score (mean 41 vs 31), the Charlson score (mean 8 vs. 6.5) , the number of organ failures (mean 2.5 vs 1.4) and the presence of a therapeutic limitation (NTBR stated within 24h: 68% vs 16%). Survival at 1 year of patients who survived the hospital stay was 37% and median survival time was estimated to be 0.5 year (95% CI: 0.4-0.9). In those with a solid tumor, it was 17% and 61% in those with a hematological tumor (p<0.001).

Discussion / Discussion :


Conclusion / Conclusion :
We have observed that, in selected cancer patients admitted to the intensive care unit for a cancer-related complication, the initiation of an anti-cancer medical treatment is feasible and can lead to interesting results, particularly in patients with a hematological tumor.
 

Adequacy and prognosis of ICU admission or denial in critically ill onco-hematology patients.

Orateur(s) :   Wafa ZARROUGUI (Sousse, TUNISIE) 

Auteur(s) :  Emna ENNOURI (Sousse, TUNISIE)   Tarek BEN AHMED (Sousse)   Khaoula MEDDEB (Sousse)   Radhouane TOUMI (Sousse, TUNISIE)   Amal BACCARI (Sousse, TUNISIE)   Imen BEN SAIDA (Sousse, TUNISIE)   Mohamed BOUSSARSAR (Sousse, TUNISIE)  

14h31 - 14h38
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Adequacy and prognosis of ICU admission or denial in critically ill onco-hematology patients.

Introduction / Rationale :
Considerable progress in management of onco-hematology (OH) malignancies led to an increase in the number of patients proposed for Intensive Care Unit (ICU) admission. Several guidelines offer decision models forICU transfer of these patients.
Aim
To determine prognosis and adequacy of ICU admission and denial in onco-hematology patients.

Méthodes / Patients and Methods :
Were included all OH patients proposed for ICU admission in a Tunisian medical ICU, between January 2016 and July2019. From an admission proposal registry, were collected patient underlying condition, functional status, malignancy and predicted prognosis, acute critical illness and its reversibility, adequacy of ICU admission approval or denial according to the 2016 AFSOS guidelines, and patients outcomes.

Résultats / Results :
During the study period, 173 patients were proposed for ICU admission, only 8(4.6%) were admitted. They were 96(55%) male; 44.6±15.6 mean aged; 3.6±2.3, mean Charlson Index; 49(28.3%) had World Health Organisation (WHO) score ≥ 3. Underlying Malignancy were; 23(13.3%) non metastatic cancer; 43(24.9%), metastatic cancer; 103(59.5%), haematological malignancy. Predicted prognosis was estimated at under 3 months for 68(39.3%) of patients. Acute critical illness were mainly acute circulatory failure, 66(38.2%) and acute respiratory failure, 52(30.1%) with 99(57.2%) considered reversible. Mortality was, 7(87.5%) for admitted and 83(50.3%) for denied patients. Decision of ICU admission was adequate with guidelines in 5(62.5%) and 139(84.2%) in denials.

Discussion / Discussion :


Conclusion / Conclusion :
Physicians’ clinical judgement regarding ICU admission of OH patients seems satisfying. However, a subset of patients could benefit from ICU but are denied admission due to ICU beds unavailability and misuse.
 

Characteristics and Outcomes of Critically Ill Cancer Patients admitted to a Tunisian Intensive Care Unit

Orateur(s) :   Imen BEN SAIDA (Sousse, TUNISIE) 

Auteur(s) :  Hela KALLAL (Sousse)   Yosri BEN ALI (Sousse, TUNISIE)   Nesrine FRAJ (Sousse)   Wafa ZARROUGUI (Sousse)   Imtinene BELAID (Sousse)   Mohamed BOUSSARSAR (Sousse, TUNISIE)  

14h38 - 14h45
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Characteristics and Outcomes of Critically Ill Cancer Patients admitted to a Tunisian Intensive Care Unit

Introduction / Rationale :
Cancer patients frequently need intensive care support for a life-threatening condition due to the underlying neoplasm or an adverse event of the therapy. However, there are poor data on their characteristics and outcomes in the intensive care setting. The aim of the present study was to describe clinical characteristics and identify factors associated with ICU mortality in critically ill cancer patients.

Méthodes / Patients and Methods :
It is a retrospective study conducted in the medical ICU of Farhat Hached teaching hospital between January 2007 and December 2018. All cancer patients with complete records were included. Baseline characteristics, clinical parameters, severity of illness, primary tumor location and outcomes were collected. Univariate and multivariate regression analyses were carried out to identify factors independently associated to poor prognosis.

Résultats / Results :
During the study period, 3569 patients were admitted, 59(1.65%) had a malignancy. Among these, 27(45.8%) had hematological malignancies and 32(54.2%) had solid tumors, of whom 15(25.4%) had evidence of metastases. Clinical characteristics were : mean age, 55.3±14.7years ; male, 38(64.4%) ; WHO Performance status 0 to 1, 55(93.2%) ; median SAPSII, 53[41-67] ; invasive mechanical ventilation (IMV), 45(76.6%) ; median duration of IMV, 2[1-5]days ; vasopressors use, 43(72.9%). The main reasons for admission were: septic shock, 21(35.6%) ; coma, 11(16.9%) ; pneumonia 9(15.3%) ; pulmonary edema, 8(13.6%) and miscellaneous 11(18.6%). Median length of ICU stay was 3[2-8]days and mortality rate was 67.8%.
On univariate analysis, the factors associated with mortality were, IMV on admission (26.3% vs 80% ; p<0.001) ; vasopressors use (26.3% vs 95% ;p<0.001) and septic shock (45% vs 15.8% ; p=0.029). Multivariate regression model identified two factors as independently associated to mortality : IMV on admission (OR, 9.4 ; 95%CI, [1.6-55.1] ; p=0.013) and vasopressors use (OR, 46.5 ; 95%CI, [6.5-330.3] ; p<0.001).

Discussion / Discussion :


Conclusion / Conclusion :
In the present study, invasive mechanical ventilation and vasopressors use on ICU admission were the independent predictive factors of mortality in critically ill cancer patients.
 

Prognosis and mortality risk factors of denied onco-hematology patients for ICU admission.

Orateur(s) :   Emna ENNOURI (Sousse, TUNISIE) 

Auteur(s) :  Wafa ZARROUGUI (Sousse)   Tarek BEN AHMED (Sousse)   Khaoula MEDDEB (Sousse)   Radhouane TOUMI (Sousse, TUNISIE)   Amal TRIKI (Sousse)   Imen BEN SAIDA (Sousse, TUNISIE)   Mohamed BOUSSARSAR (Sousse, TUNISIE)  

14h45 - 14h52
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Prognosis and mortality risk factors of denied onco-hematology patients for ICU admission.

Introduction / Rationale :
Since the advances in specific therapies, prognosis of patients with malignancies improved significantly last decades. However, occurrence of life-threatening condition could be a turning point in those patients evolution, especially when ICU facilities are not available.
Aim
To determine prognosis and risk factors of mortality of denied onco-hematology patients for ICU admission.

Méthodes / Patients and Methods :
A retrospective study was conducted in a Tunisian medical ICU between January 2016 and July 2019. Were included all consecutive denied onco-hematology patients proposed for ICU admission. Patients baseline characteristics, underlying malignancy and its 3 months prognosis, severity of illness and its reversibility and outcome were collected. Univariate and multivariate regression analysis were used to identify factors independently associated to mortality.

Résultats / Results :
During the study period, 165 onco-hematology patients were denied to ICU admission out of 173 proposed patients. Mean age, 45.1±15.6 years; sex ratio 1; mean Charlson Index, 3.6±2.4; median[IQR] World Health Organisation (WHO) score, 2[0-2]. Underlying malignancies were: non metastatic cancer, 21(12.5%); metastatic cancer, 42(25.5%) and haematological malignancies, 98(59.4%). Mortality rate was 83(50.3%).
Univariate analysis yielded the following as factors associated with mortality: 3 months malignancy prognosis (p=0.000), predicted reversibility of critical illness (p=0.000), WHO score≥2(p=0.005), acute neurological impairment (p=0.006) and pulmonary embolism (p=0.008).
Multivariate regression model identified 3 factors to be independently associated to mortality: reversibility of critical illness (OR, 7.4 ; 95%CI, [2.5-22.9] ; p=0.000); WHO score≥2 (OR, 0.44 ; 95%CI, [0.19-0.99] ; p=0.048) and acute neurological impairment (OR, 0.3 ; 95%CI, [0.1-0.9] ; p=0.035).

Discussion / Discussion :


Conclusion / Conclusion :
The present study among onco-hematological patients denied for ICU admission, identified, underlying condition, neurological impairment and predicted reversibility of critical illness, as factors associated to short term hospital mortality
 

Influence of underlying hematological malignancy grade on outcome of critically ill hematological patients

Orateur(s) :   Vincent REBIERE (Paris) 

Auteur(s) :  Pablo PAGLIARANI (Paris)   Lara ZAFRANI (Paris)   Virginie LEMIALE (Paris)   djamel MOKART (Paris)   Alexandre DEMOULE (Paris)   Martine NYUNGA (Paris)   achille KOUATCHET (Paris)   Frédéric PENE (Paris)   Michaël DARMON (Paris)   Elie AZOULAY (Paris)  

14h52 - 14h59
Durée de la présentation : 4 min
Durée de la discussion : 3 min


Abstract : 
Influence of underlying hematological malignancy grade on outcome of critically ill hematological patients

Introduction / Rationale :
Prognostic impact of underlying malignancy seems limited in most studies assessing outcome of critically ill cancer patients [1]. However, only limited number of characteristics, namely disease progression status and preexisting stem cell transplantation, were usually assessed [1]. Primary objective of this study was to assess influence of hematological malignancy aggressiveness on hospital outcome. Secondary objective was to assess influence hematological malignancy aggressiveness on type of infection.

Méthodes / Patients and Methods :
Post-hoc analysis of prospective multicenter cohort performed in 17 hospitals in France and Belgium and including critically ill adults with underlying hematological malignancy admitted in ICU from Jan 2010 to May 2011. A cox model was used to adjust for confounding variables then a propensity score matching on characteristics associated with underlying malignancy aggressiveness was performed.

Résultats / Results :
Of the 1011 included patients, 300 (29.7%) had low grade malignancy (LG), the most frequent being myeloma (n=126), chronic lymphocytic leukemia (n=76), and myelodysplasia (n=46). Patients with LG malignancy were older, underwent more frequently autologous stem cell transplantation (SCT) and had less frequently altered performans status. They were also more severe at ICU admission (SOFA score 6 [4-9] vs. 5 [3-8], P=0.03).
Before adjustment, mortality was 36% (n=108) and 39.9% (n=284) respectively in patients with and without LG malignancy (P=0.27).
After adjustment for confounder using a Cox model, a higher mortality was associated with non-low grade malignancy (OR 1.49; 95%CI 1.17-1.9).
A propensity score then allowed a 1:1 matching upon variable associated with malignancy aggressiveness. After matching unadjusted mortality was 36% (n=108) in patients with LG malignancy and 48.8% (n=146) in patients with high grade malignancy (P=0.002) (figure).
In the matched cohort and after adjustment for confounder, high grade malignancies were associated with lower mortality (OR 1.42; 95%CI 1.10-1.84).
Risk of fungal infection was unchanged by underlying malignancy before adjustment (6% vs. 8.6% of patients with and without LG malignancy; P=0.26) or after adjustment (HR 1.29; 95%CI 0.71-2.41).

Discussion / Discussion :


Conclusion / Conclusion :
Despite anti-cancer advances, aggressiveness of hematological malignancies is associated with overall survival in ICU, Low-grade malignancies displaying a better prognosis than
non-low grade. Aggressiveness of the underlying malignancy is not associated with risk of fungal infection.