Septic shock linked to high mortality rates among patients with hematologic malignancies
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Septic shock remained significantly associated with increased 28-day mortality among patients with hematologic malignancies, according to study results published in Journal of the National Comprehensive Cancer Network.
The findings indicated the need for an urgent call to action and increased awareness of septic shock in this patient population, researchers noted.
Rationale
“Infections are among the most common noncancer causes of death among patients with hematologic malignancies,” Joseph L. Nates, MD, MBA, CMQ, MCCM, professor and deputy chair in the department of critical care at The University of Texas MD Anderson Cancer Center, told Healio. “Infections lead to sepsis, which is an exaggerated response of the body that causes organ injury, and it is the primary cause of death from infections.”
“If not recognized early, sepsis can progress to septic shock, leading to the failure of multiple organs and inability to maintain normal blood pressure,” he added. “Recently, a new definition of sepsis became available — the Third International Consensus Definitions criteria, or Sepsis-3 — and there was a need to investigate the outcomes associated with these criteria.”
Methodology
Nates and colleagues sought to describe the short-term outcomes and independent predictors of 28-day mortality among 459 patients (median age, 63 years; 61% men) with hematologic malignancies admitted to the ICU with septic shock — as defined by the new Sepsis-3 criteria — between April 2016 and March 2019.
Key findings
More than two-thirds (67.8%) of patients died within 28 days. Among them, 23.7% had received a hematopoietic stem cell transplant.
The 28-day mortality rate increased with increasing sequential organ failure assessment score on admission (OR = 1.11; 95% CI, 1.03-1.2), respiratory failure (OR = 3.12; 95% CI, 1.49-6.51) and maximum lactate level (OR = 1.16; 95% CI, 1.1-1.22).
Factors associated with higher 28-day mortality included higher Charlson comorbidity index (P = .007), longer length of hospital stay before ICU admission (P = .01) and greater illness severity at diagnosis and throughout hospital course (P < .001).
Conversely, factors associated with lower 28-day mortality included administration of aminoglycosides (OR = 0.42; 95% CI, 0.26-0.69), serum albumin (OR = 0.51; 95% CI, 0.31-0.86) and granulocyte colony-stimulating factor (OR = 0.4; 95% CI, 0.24-0.65).
“This information is crucial for clinicians to communicate realistic expectations when conducting goals-of-care conversations with their patients with hematologic malignancies and septic shock and their families,” Nates said.
Implications
“Our results highlight the opportunity to increase awareness regarding the lethality of septic shock among patients with cancer and how important it is to prevent it,” Nates said.
Preventive strategies are needed to reduce infection rates in patients with hematologic cancers, he added.
“There is also a need to promote the advancement of novel technologies to detect sepsis early in the disease course and to treat it before it progresses to septic shock,” Nates said. “We need to emphasize the early initiation of antibiotic therapy, appropriate monitoring techniques and rational fluid resuscitation in patients with cancer with suspected infections.”
For more information:
Joseph L. Nates, MD, MBA, CMQ, MCCM, can be reached at The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 112, Houston, TX 77030; email: jlnates@mdanderson.org.
Perspective
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Mikkael A. Sekeres, MD, MS
We have long suspected that patients with cancers of the blood and bone marrow have poor outcomes when they go to the ICU, particularly in the setting of septic shock.
This study by Manjappachar and colleagues includes a wonderful representative patient population of individuals with hematologic malignancies who develop septic shock and end up in an ICU. About one-fifth of patients had undergone a bone marrow transplant, which means this is a particularly vulnerable population with often severely compromised immune systems.
The 28-day mortality rate for patients was 67.8%, which is enormous, and the 90-day mortality rate was 80%. So, 3 months after developing septic shock and winding up in the ICU, only 20% of patients remained alive. Some of this was due to septic shock and some of it was probably due to the consequences of their cancer. Also, some factors appeared to be associated with worse outcome and some with a better outcome. Patients deemed sicker by a variety of measures did not do as well. In addition, the mortality rate was higher among those identified as having respiratory failure.
The researchers reported a number of surprising findings. For one, patients who received a specific antibiotic, an aminoglycoside, and those who received growth factor support had better outcomes. I would take the finding about growth factors with a grain of salt, as it needs to be sussed out in more detail before we adopt that as standard therapy. There are many reasons why patients may have received a growth factor — they may have been younger, potentially had a better outcome, or were more likely to receive a growth factor during their first treatment course compared with patients who were older or more likely to have a worse outcome. All these factors would confound the results of a certain growth factor. It may be that patients with certain hematologic malignancies — for example, lymphoid malignancies — were more likely to receive a growth factor than those with myeloid malignancies.
Years ago, my colleagues and I did a study looking at outcomes of patients diagnosed with cancer who go into the ICU, and we reported findings similar to those of the current study. One is important to pass on to our critical care colleagues: Just because a patient has a cancer diagnosis does not mean that person’s outcome in an ICU is much worse than that of someone else in an ICU. It is also so important to calculate the same outcome scores in patients who have blood and bone marrow cancers as patients who do not have cancer before declaring futility of an ICU stay.
When patients with blood and bone marrow cancers get sick from causes that may be related to their cancer or treatment, their outcome is poor because they are already starting the entire process of being sick with an immune system that is compromised. There is a cancer of the immune system in these patients. We should aggressively identify patients who are more likely to get sick early so that we can make appropriate interventions as quickly as possible and prevent poor outcomes.
University of Miami Health System
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