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Intensive care outcomes in bone marrow transplant recipients: a population-based cohort analysis.

Scales DC, Thiruchelvam D, Kiss A, Sibbald WJ, Redelmeier DA - Crit Care (2008)

Bottom Line: Patients receiving any major procedure during their ICU stay had higher 1-year mortality than those patients who received no ICU procedure (87% versus 44%, P < 0.0001).Death rates at 1 year were highest for those receiving mechanical ventilation (87%), pulmonary artery catheterization (91%), or hemodialysis (94%).In combination, the strongest independent predictors of death at 1 year were mechanical ventilation (odds ratio, 7.4; 95% confidence interval, 4.8 to 11.4) and hemodialysis (odds ratio, 8.7; 95% confidence interval, 2.1 to 36.7), yet no combination of procedures uniformly predicted 100% mortality.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Critical Care, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, Ontario, Canada, M4N 3M5. damon.scales@utoronto.ca

ABSTRACT

Introduction: Intensive care unit (ICU) admission for bone marrow transplant recipients immediately following transplantation is an ominous event, yet the survival of these patients with subsequent ICU admissions is unknown. Our objective was to determine the long-term outcome of bone marrow transplant recipients admitted to an ICU during subsequent hospitalizations.

Methods: We conducted a population-based cohort analysis of all adult bone marrow transplant recipients who received subsequent ICU care in Ontario, Canada from 1 January 1992 to 31 March 2002. The primary endpoint was mortality at 1 year.

Results: A total of 2,653 patients received bone marrow transplantation; 504 of which received ICU care during a subsequent hospitalization. Patients receiving any major procedure during their ICU stay had higher 1-year mortality than those patients who received no ICU procedure (87% versus 44%, P < 0.0001). Death rates at 1 year were highest for those receiving mechanical ventilation (87%), pulmonary artery catheterization (91%), or hemodialysis (94%). In combination, the strongest independent predictors of death at 1 year were mechanical ventilation (odds ratio, 7.4; 95% confidence interval, 4.8 to 11.4) and hemodialysis (odds ratio, 8.7; 95% confidence interval, 2.1 to 36.7), yet no combination of procedures uniformly predicted 100% mortality.

Conclusion: The prognosis of bone marrow transplant recipients receiving ICU care during subsequent hospitalizations is very poor but should not be considered futile.

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Time from bone marrow transplant to intensive care unit admission. Kaplan–Meier curves showing outcomes following bone marrow transplant (BMT) hospitalization. y axis, percentage of original cohort remaining event-free following discharge from BMT (n = 2,653); x axis, time in years from BMT discharge. Curves represent patients still alive following BMT hospitalization (no deaths, lower curves) and patients remaining free of the intensive care unit (ICU) following BMT hospitalization (censoring both deaths and patients lost to follow up) (no subsequent ICU, upper curves). Black lines, survival following autologous BMT; gray lines, survival following allogeneic BMT.
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Figure 1: Time from bone marrow transplant to intensive care unit admission. Kaplan–Meier curves showing outcomes following bone marrow transplant (BMT) hospitalization. y axis, percentage of original cohort remaining event-free following discharge from BMT (n = 2,653); x axis, time in years from BMT discharge. Curves represent patients still alive following BMT hospitalization (no deaths, lower curves) and patients remaining free of the intensive care unit (ICU) following BMT hospitalization (censoring both deaths and patients lost to follow up) (no subsequent ICU, upper curves). Black lines, survival following autologous BMT; gray lines, survival following allogeneic BMT.

Mentions: We identified 2,653 patients who underwent a first bone marrow transplant during the study, of whom 60% received allogeneic transplants (Table 1). The underlying diagnosis was malignancy in most cases. Almost all of the procedures (n = 2,631; 99%) were performed at seven different centers (range, 45 to 1,543 transplants per center), and no association was apparent between 1-year mortality and the bone marrow transplant procedure volume (Spearman's rank correlation ρ = 0.14, P = 0.76). Only 175 (6.6%) patients died during the initial bone marrow transplant hospitalization. On average, survivors required hospitalization 1.2 times (median, 1.0; interquartile range, 0 to 2) during the first year following transplant and 2.2 times during the entire study period (median, 1.0; range, 0 to 20; interquartile range, 0 to 3). During these subsequent hospital admissions, 504 (20%) patients received ICU care – typically (351 patients; 70%) during the first year following the original transplant procedure (Figure 1).


Intensive care outcomes in bone marrow transplant recipients: a population-based cohort analysis.

Scales DC, Thiruchelvam D, Kiss A, Sibbald WJ, Redelmeier DA - Crit Care (2008)

Time from bone marrow transplant to intensive care unit admission. Kaplan–Meier curves showing outcomes following bone marrow transplant (BMT) hospitalization. y axis, percentage of original cohort remaining event-free following discharge from BMT (n = 2,653); x axis, time in years from BMT discharge. Curves represent patients still alive following BMT hospitalization (no deaths, lower curves) and patients remaining free of the intensive care unit (ICU) following BMT hospitalization (censoring both deaths and patients lost to follow up) (no subsequent ICU, upper curves). Black lines, survival following autologous BMT; gray lines, survival following allogeneic BMT.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2481474&req=5

Figure 1: Time from bone marrow transplant to intensive care unit admission. Kaplan–Meier curves showing outcomes following bone marrow transplant (BMT) hospitalization. y axis, percentage of original cohort remaining event-free following discharge from BMT (n = 2,653); x axis, time in years from BMT discharge. Curves represent patients still alive following BMT hospitalization (no deaths, lower curves) and patients remaining free of the intensive care unit (ICU) following BMT hospitalization (censoring both deaths and patients lost to follow up) (no subsequent ICU, upper curves). Black lines, survival following autologous BMT; gray lines, survival following allogeneic BMT.
Mentions: We identified 2,653 patients who underwent a first bone marrow transplant during the study, of whom 60% received allogeneic transplants (Table 1). The underlying diagnosis was malignancy in most cases. Almost all of the procedures (n = 2,631; 99%) were performed at seven different centers (range, 45 to 1,543 transplants per center), and no association was apparent between 1-year mortality and the bone marrow transplant procedure volume (Spearman's rank correlation ρ = 0.14, P = 0.76). Only 175 (6.6%) patients died during the initial bone marrow transplant hospitalization. On average, survivors required hospitalization 1.2 times (median, 1.0; interquartile range, 0 to 2) during the first year following transplant and 2.2 times during the entire study period (median, 1.0; range, 0 to 20; interquartile range, 0 to 3). During these subsequent hospital admissions, 504 (20%) patients received ICU care – typically (351 patients; 70%) during the first year following the original transplant procedure (Figure 1).

Bottom Line: Patients receiving any major procedure during their ICU stay had higher 1-year mortality than those patients who received no ICU procedure (87% versus 44%, P < 0.0001).Death rates at 1 year were highest for those receiving mechanical ventilation (87%), pulmonary artery catheterization (91%), or hemodialysis (94%).In combination, the strongest independent predictors of death at 1 year were mechanical ventilation (odds ratio, 7.4; 95% confidence interval, 4.8 to 11.4) and hemodialysis (odds ratio, 8.7; 95% confidence interval, 2.1 to 36.7), yet no combination of procedures uniformly predicted 100% mortality.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Critical Care, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, Ontario, Canada, M4N 3M5. damon.scales@utoronto.ca

ABSTRACT

Introduction: Intensive care unit (ICU) admission for bone marrow transplant recipients immediately following transplantation is an ominous event, yet the survival of these patients with subsequent ICU admissions is unknown. Our objective was to determine the long-term outcome of bone marrow transplant recipients admitted to an ICU during subsequent hospitalizations.

Methods: We conducted a population-based cohort analysis of all adult bone marrow transplant recipients who received subsequent ICU care in Ontario, Canada from 1 January 1992 to 31 March 2002. The primary endpoint was mortality at 1 year.

Results: A total of 2,653 patients received bone marrow transplantation; 504 of which received ICU care during a subsequent hospitalization. Patients receiving any major procedure during their ICU stay had higher 1-year mortality than those patients who received no ICU procedure (87% versus 44%, P < 0.0001). Death rates at 1 year were highest for those receiving mechanical ventilation (87%), pulmonary artery catheterization (91%), or hemodialysis (94%). In combination, the strongest independent predictors of death at 1 year were mechanical ventilation (odds ratio, 7.4; 95% confidence interval, 4.8 to 11.4) and hemodialysis (odds ratio, 8.7; 95% confidence interval, 2.1 to 36.7), yet no combination of procedures uniformly predicted 100% mortality.

Conclusion: The prognosis of bone marrow transplant recipients receiving ICU care during subsequent hospitalizations is very poor but should not be considered futile.

Show MeSH
Related in: MedlinePlus