Benoit Dominique D, Vandewoude Koenraad H, Decruyenaere Johan M, Hoste Eric A, Colardyn Francis A
Department of Intensive Care, Ghent University Hospital, Gent, Belgium.
Crit Care Med. 2003 Jan;31(1):104-12. doi: 10.1097/00003246-200301000-00017.
To assess the outcome and to identify early prognostic indicators in a global population of patients with hematologic malignancy admitted to the intensive care unit for a life-threatening complication.
Retrospective observational study.
Medical intensive care unit at a tertiary university hospital.
A total of 124 consecutive critically ill patients with a hematologic malignancy admitted to the intensive care unit during a 3.5-yr period. MEASUREMENTS We collected variables at admission and during admission and identified predictors of in-hospital mortality by stepwise logistic regression analysis.
Mean Acute Physiology and Chronic Health Evaluation II score was 26 +/- 7.7. Sixty-one percent had a high-grade malignancy, and 27% had active disease. Thirty-five percent were leukopenic (leukocyte count, <1.0 x 10(9)/L) at admission. Respiratory failure (48%), sepsis (18.5%), and neurologic impairment (17%) were the major reasons for admission at the intensive care unit. Seventy-one percent of the patients required ventilatory support for a median duration of 6 (3-17) days, 46% received vasopressors at admission, and 26.6% needed renal replacement therapy during their intensive care unit stay. A recent bacteremia precipitating intensive care unit admission was found in 21.8% of the patients. Crude intensive care unit, in-hospital, and 6-month mortality rates were 42%, 54%, and 66%, respectively. Four variables were independently associated with outcome in a multivariate logistic regression analysis: leukopenia (odds ratio, 2.9; 95% confidence interval, 1.1-7.7), vasopressors (odds ratio, 3.74; 95% confidence interval, 1.4-9.8), and urea of >0.75 g/L (>12 mmol/L) (odds ratio, 9.4; 95% confidence interval, 4.2-26) at admission were associated with poor outcome, whereas recent bacteremia (odds ratio, 0.17; 95% confidence interval, 0.05-0.58) was associated with better prognosis. Using these variables, we arbitrarily categorized our population into three groups for survival analysis: a low-risk group (low urea with or without either leukopenia or vasopressors, n = 60), an intermediate-risk group (high urea or a combination of leukopenia and vasopressors, n = 34), and a high-risk group (high urea in combination with leukopenia or vasopressors, n = 27). Patients with a bacteremia prompting intensive care unit admission were allocated to a one-step-lower risk group. Survival probabilities at 30 days and 6 months were 75% and 55% in the first group, 35% and 21% in the second group, and 4% and 0%, respectively, in the third group ( <.001).
The general reluctance to admit patients with a hematologic malignancy to the intensive care unit, even with severe critical illness, is unjustified. However, we identified four early predictors of outcome that may be of value in deciding in which patients advanced or prolonged support should not be continued.
评估入住重症监护病房（ICU）并出现危及生命并发症的全球血液系统恶性肿瘤患者的预后，并确定早期预后指标。
回顾性观察性研究。
一所三级大学医院的内科重症监护病房。
在3.5年期间，共有124例连续入住重症监护病房的血液系统恶性肿瘤危重症患者。测量：我们收集了入院时及住院期间的变量，并通过逐步逻辑回归分析确定院内死亡的预测因素。
急性生理与慢性健康状况评估II（APACHE II）评分的平均值为26±7.7。61%为高级别恶性肿瘤，27%为活动性疾病。35%的患者入院时白细胞减少（白细胞计数<1.0×10⁹/L）。呼吸衰竭（48%）、脓毒症（18.5%）和神经功能障碍（17%）是入住重症监护病房的主要原因。71%的患者需要机械通气支持，中位持续时间为6（3 - 17）天，46%的患者入院时接受血管升压药治疗，26.6%的患者在重症监护病房住院期间需要肾脏替代治疗。21.8%的患者因近期菌血症而入住重症监护病房。重症监护病房的粗死亡率、院内死亡率和6个月死亡率分别为42%、54%和66%。在多因素逻辑回归分析中，有4个变量与预后独立相关：入院时白细胞减少（比值比，2.9；95%置信区间，1.1 - 7.7）、血管升压药治疗（比值比，3.74；95%置信区间，1.4 - 9.8）以及尿素>0.75 g/L（>12 mmol/L）（比值比，9.4；95%置信区间，4.2 - 26）与预后不良相关，而近期菌血症（比值比，0.17；95%置信区间，0.05 - 0.58）与较好的预后相关。利用这些变量，我们将患者任意分为三组进行生存分析：低风险组（尿素水平低，伴有或不伴有白细胞减少或血管升压药治疗，n = 60）、中风险组（尿素水平高或白细胞减少与血管升压药治疗同时存在，n = 34）和高风险组（尿素水平高且伴有白细胞减少或血管升压药治疗，n = 27）。因菌血症而入住重症监护病房的患者被分配到低一级风险组。第一组30天和6个月的生存概率分别为75%和55%，第二组分别为35%和21%，第三组分别为4%和0%（P<0.001）。
即使患者患有严重危重症，普遍不愿将血液系统恶性肿瘤患者收入重症监护病房的做法是不合理的。然而，我们确定了4个早期预后预测因素，这可能有助于决定哪些患者不应继续进行强化或延长治疗。
