The prognostic factors for patients with hematological malignancies admitted to the intensive care unit
© The Author(s) 2016
Received: 5 June 2016
Accepted: 21 November 2016
Published: 29 November 2016
Owing to the nature of acute illness and adverse effects derived from intensive chemotherapy, patients with hematological malignancies (HM) who are admitted to the Intensive Care Unit (ICU) often present with poor prognosis. However, with advances in life-sustaining therapies and close collaborations between hematologists and intensive care specialists, the prognosis for these patients has improved substantially. Many studies from different countries have examined the prognostic factors of these critically ill HM patients. However, there has not been an up-to-date review on this subject, and very few studies have focused on the prognosis of patients with HM admitted to the ICU in Asian countries. Herein, we aim to explore the current situation and prognostic factors in patients with HM admitted to ICU, mainly focusing on studies published in the last 10 years.
The triage and management of patients with hematological malignancies (HM) in life-threatening situations presents a paradox for clinicians (Hill 2010). Historical research established more than 25 years ago found that HM patients admitted to the intensive care unit (ICU) have poor prognosis due to their acute illness and adverse effects resulting from intensive chemotherapy (Lloyd-Thomas et al. 1988; Yau et al. 1991; Brunet et al. 1990). Undeniably, recent advances in life-sustaining therapies and close collaborations between hematologists and intensive care specialists have resulted in a paradigm shift and in the improvement of the prognosis of patients with HM admitted to the ICU (Hampshire et al. 2009; Azoulay et al. 2013; Bird et al. 2012; Hill et al. 2012). In Western countries, the ICU mortality rate of patients with HM has abated from 65 to 80% in the 1980s (Lloyd-Thomas et al. 1988; Yau et al. 1991; Schuster and Marion 1983) to 34–56% today (Hampshire et al. 2009; Bird et al. 2012; Geerse et al. 2011). A large prospective trial performed by Azoulay et al. (2013) noted that the hospital, day-90, and 1-year survival rates for patients with HM admitted to ICU were 60.7, 52.5, and 43.3%, respectively. Additionally, while many studies from different countries have examined the prognostic factors of these critically ill HM patients, the relative significance of many factors remains controversial, as many of them have not been confirmed in multicenter prospective studies (Hampshire et al. 2009; Lamia et al. 2006; Gordon et al. 2005; Evison et al. 2001; Benoit et al. 2003; Liu et al. 2015). To the best of our knowledge, there has been no up-to-date review on this subject since 2010 (Hill 2010). Accordingly, we might ask, has the value of some classical prognostic factors changed? Furthermore, most of the earlier studies were mainly focused on Western countries, while an increasing number of Asian countries have published studies that have shown different results regarding this subgroup of patients. For example, in some retrospective study in China (Evison et al. 2001; Benoit et al. 2003; Liu et al. 2015), HM patients had higher mortality rate and less access to the ICU, as compared to reports published by Western countries (Azoulay et al. 2013; Bird et al. 2012; Merz et al. 2008). Considering this point of view, whether Asian countries will compare with each other remains elusive, and it is unclear what factors might contribute to the different prognosis observed in these countries. We aim to explore these questions in this review article, with a particular focus on studies published in the last 10 years.
Factors predictive of prognosis for HM patients admitted to the ICU
Use of mechanical ventilation
Most studies have shown that acute respiratory failure is one of the primary reasons for ICU admission for critically ill HM patients (Bird et al. 2012; Geerse et al. 2011; Merz et al. 2008). Generally, there are three ways to improve respiratory failure: supplemental oxygen (e.g., nasal cannula or face mask), invasive mechanical ventilation (IMV, e.g., via an endotracheal tube or tracheostomy), or noninvasive mechanical ventilation (NIMV, e.g., bilevel or continuous positive airway pressure). A large retrospective study in 2000 was the first to identify IMV as strong prognostic factor in critically ill patients with HM (Staudinger et al. 2000), and this was later proved to be the case in nearly all studies (Lloyd-Thomas et al. 1988; Geerse et al. 2011; Lamia et al. 2006; Evison et al. 2001; Turkoglu et al. 2011; Kroschinsky et al. 2002; Owczuk et al. 2005; Rabbat et al. 2005; Namendys-Silva et al. 2013; Yeo et al. 2012). Generally, more than half of the critically ill HM patients need IMV to improve respiratory failure, and most of them eventually died in the hospital or ICU (Geerse et al. 2011; Liu 2015; Turkoglu et al. 2011). An explanation for the high mortality rate in this subgroup of patients may attribute to the co-occurrence of severe pulmonary dysfunction and nosocomial infections, such as ventilator-associated pneumonia (Kwak et al. 2010). The results of previous studies also showed that noninvasive mechanical ventilation could significantly reduce the rates of endotracheal intubation and serious complications, and thus plays a protective role, especially in immunosuppressed hosts (Hilbert et al. 2001a; Azoulay et al. 2001). Moreover, the improvement in NIMV significantly decreases the overall mortality rate of critically ill patients with HM (Liu et al. 2015; Belenguer-Muncharaz et al. 2013). In a multicenter, ten-year retrospective observational study, Belenguer-Muncharaz et al. (2013) compared both IMV and noninvasive positive pressure ventilation (NPPV) in patients with HM admitted to the ICU. Their results revealed that the ICU mortality rate in the IMV group was three times as high as that in the NPPV group (100 vs. 37%). Overall, NIMV has significantly decreased the risk of death by obviating the need for endotracheal MV in critically ill HM patients. On the other hand, the higher mortality after NIMV failure is in line with studies of patients with HMs (Molina et al. 2012; Gristina et al. 2011; Azoulay et al. 2014), which calls for a more pragmatic approach towards the use of NIMV (Soares et al. 2010a). According to a previous study, first-line NIMV might be deleterious in patients in which the ARDS criteria has been met (Adda et al. 2008). The timely and earlier utilization of NIMV has been recommended, as it can reduce the likelihood of intubation (Hilbert et al. 2001b), ventilator-associated lung injury (Azoulay et al. 2001), and pneumonia or sepsis (Rabbat et al. 2005). In addition, the trials using high-flow nasal oxygen therapy (Mokart et al. 2015a) and extracorporeal gas exchange (Mokart et al. 2015b) have shown that these modalities could be promising alternative approaches to mechanical ventilation in HM patients who also have severe acute respiratory failure.
The utilization of IMV is one of the most powerful predictors for predicting the outcome for patients with HM admitted to the ICU. The timely and appropriate use of NIMV can prevent the deterioration of respiratory failure, thus avoiding the need for patient intubation.
Organ failure is a powerful prognostic factor in non-cancer patients admitted to the ICU (Namendys-Silva et al. 2015; Leone et al. 2015). Similarly, critically ill patients with HM admitted to ICU often suffer from multi-organ failure, which also plays an important role in their prognosis (Hampshire et al. 2009; Bird et al. 2012; Gordon et al. 2005; Azoulay et al. 1999; Afessa et al. 1992). In an earlier study, only 1 of the 12 HM patients admitted to the ICU with multi-organ failure survived to discharge, and the authors proposed that HM patients with inadequate function in two or more organs are unable to benefit from intensive care (Brunet et al. 1990). A more recent prospective, multicenter cohort study confirmed that poor outcome was significantly associated with organ failure (Azoulay et al. 2013). Moreover, the number of dysfunctional organs appears to have even more powerful predictive value (Hampshire et al. 2009; Bird et al. 2012; Evison et al. 2001; Namendys-Silva et al. 2013). In another retrospective study performed in Switzerland, the mortality rates of HM patients by day 60 after ICU admission were 16, 36, 64, and 83% for zero, one, two, or three failing organs, respectively (P < 0.0002) (Evison et al. 2001).
These data suggest that the early recognition and management of organ failure can lead to more prompt ICU admission and therefore, better survival for patients with HM.
Scoring systems for overall wellness
Scoring systems have been proven to be of important value for estimating the risk of death and for evaluating the severity of the acute organ failure, especially in patients with HM, but were of less useful for predicting individual prognosis (Schellongowski et al. 2004). There is consensus that severity-of-illness scoring systems perform equal or even better than some other prognostic factors, such as underlying malignancies or disease status. Geerse et al. (2011) showed that the ICU mortality of critically ill HM patients was related to multiple organ failure and the need for mechanical ventilation or inotropic/vasopressor therapy. Therefore, the scoring systems should be considered as useful measures of the patient’s severity of acute illness.
Commonly used scoring systems include the following: Acute Physiology and Chronic Health Evaluation (APACHE and APACHE II), Sequential Organ Failure Assessment (SOFA), and Simplified Acute Physiology Score (SAPS) (Schellongowski et al. 2004; Sawicka et al. 2014). Among these, SOFA is deemed to be the most frequently used system in HM patients admitted to the ICU (Geerse et al. 2011; Lamia et al. 2006; Merz et al. 2008). SOFA was initially devised in 1994 to assess the prognosis of patients with sepsis and septic shock (Vincent et al. 1996), and it has been widely used in ICU patients in recent years. Various forms of SOFA scores, which are taken at different points during the admission or ICU stay, have been used (Cornet et al. 2005; Soares et al. 2010b). In one study, SOFA score ≥15 was associated with 100% ICU mortality in HM patients (Cornet et al. 2005). Additionally, another large prospective multicenter study that included 50 HM patients (7% of all subjects) showed that high SOFA scores (OR 1.25; 95% CI 1.17–1.34) were associated with severe organ failure and increased hospital mortality (Soares et al. 2010b).
Several other studies assessed the utility of monitoring the trend of SOFA scores over time to predict the mortality of HM patients admitted to ICU (Geerse et al. 2011; Liu et al. 2015). For example, Geerse et al. (2011) reported that patients with decreased SOFA scores through the course of ICU admission had significantly better prognosis than patients with unchanged or increasing SOFA scores. Our group replicated this result, and showed that the trend of the SOFA scores within the first 48 h of ICU admission had the most significant prognostic power (Liu et al. 2015).
The usefulness of APACHE II in HM patients is more controversial among the research literature. Some results have found its value for predicting mortality (Hampshire et al. 2009; Owczuk et al. 2005; Rabbat et al. 2005; Yeo et al. 2012; Parakh et al. 2014), while others have not (Lloyd-Thomas et al. 1988; Hampshire et al. 2009; Afessa et al. 1992; Sawicka et al. 2014). Our previous study confirmed the important value of APACHE II, suggesting that this score system may aid in evaluating HM patients before and after ICU transfer in China (Liu et al. 2015).
The SAPS II scoring system was developed to gauge the risk of hospital mortality for ICU patients (Minne et al. 2012; Vosylius et al. 2004). Sawicka et al. (2014) evaluated different scoring systems, including APACHE II, SAPS II and SOFA. Their statistical analysis showed SAPS II score was the only independent risk factor of patient death in multivariate analysis (Sawicka et al. 2014).
Although all scoring systems provide an estimate of the severity of organ failure and acute illness in HM patients, none yields adequately comprehensive and reliable information to be used alone. In addition, the scoring systems have only been used in retrospective or cohort studies with relatively small numbers of HM patients and were conducted at single academic institutions. Their usefulness needs to be yet confirmed in large prospective studies.
Hematopoietic stem cell transplantation (HSCT)
For selected patients with HM, stem cell transplant can provide long-lasting remission. After allogeneic HSCT, some patients inevitably require intensive care. However, the treatment and health care of general HM patients deviates significantly from HSCT patients, due to high doses of chemotherapy, severe immunosuppression, and isolation. The ICU mortality for HSCT patients is generally high, at 33–65% (Soubani et al. 2004; Bruennler et al. 2007; Afessa et al. 2003; Pene et al. 2006). In recent years, the development of targeted therapy, careful patient selection, and more attentive post-transplant nursing, has substantially improved the outcome of these patients (Bird et al. 2012). A large retrospective cohort study performed by Huynh et al. (2009) showed that the outcome of HSCT patients who required ICU-level care was not as poor as previously described, and the authors observed an improvement in the survival of HSCT patients who required mechanical ventilation. However, the outcome still remains poor for HSCT recipients who develop severe graft versus host disease (GVHD) or other severe complications (Schellongowski et al. 2004; Sawicka et al. 2014). One study noted high mortality rates of up to 100% in ICU patients who developed multiple organ failures after bone marrow transplantation. However, the size of the subgroup in this study was too small for this observation to reach significance (Afessa et al. 1992). In a large study of 398 patients of HM admitted to ICU after HSCT, the morality rate was observed to be 100% if the patients developed acute lung injury, received more than 4 h of pressors, or had sustained hepatic and renal failure (Rubenfeld and Crawford 1996). On the other hand, HSCT patients who do not have uncontrolled GVHD and remain on functional mechanical ventilation have been shown to have more optimistic survival rates (Pene et al. 2006; Gooley et al. 2010; Price et al. 1998). Thus, HSCT recipients without severe organ failure or GVHD would likely benefit from intensive care. Knowledge deficits among ICU physicians on the caring of HSCT recipients may negatively affect the outcome as well. Accordingly, timely communication and close collaboration between hematologists and intensivists could improve patient care. In addition, future studies should compare the prognosis of patients who had undergone different types of HSCT.
Controversial prognostic factors
Type and disease status of HM
HM is a broad category of diagnoses, which include both acute and chronic leukemias, various types of lymphomas, and dysfunctional hematopoiesis such as aplastic anemia. The disease statuses include newly diagnosed, remission, and relapsed or progression. Some previous studies have noted that both the type and status of disease were independent prognostic factors for survival. For instance, the ICU mortality rate was lower for HM patients who were in remission status than those with progressive disease (Azoulay et al. 2013; Aygencel et al. 2014). Moreover, ICU mortality was significantly higher in patients diagnosed with acute leukemia (Yeo et al. 2012; Groeger et al. 1999). For example, in one study, the ICU mortality rate of patients diagnosed with acute lymphatic leukemia (ALL) was as high as 100%, although the sample size was too small to make a scientific conclusion (Geerse et al. 2011).
With improvements in supportive care and unbiased patient selection, an increasing number of publications have revealed that the nature of HM does not influence patient prognosis (Lamia et al. 2006; Benoit et al. 2003; Merz et al. 2008; Bruennler et al. 2007). Some studies have demonstrated that patients with de novo acute myeloid leukemia or diffuse large B cell lymphoma show good long term prognosis if they survive the acute disease leading to ICU admission (Schellongowski et al. 2011; Wohlfarth et al. 2016). In a retrospective study, the rate of ICU discharge was 48.8% in remission patients and 38.2% in active/progressive patients, which was not statistically significant (Benoit et al. 2003). A separate study showed that underlying malignancies determined long-term survival, but did not predict ICU or hospital mortality (Massion et al. 2002). Thus, whether the nature of the disease can significantly affect the prognosis of HM patients admitted to the ICU remains debatable. In clinical practice, type and status of HM should not preclude ICU admission in patients who may otherwise benefit from intensive care.
Infection is a common reason for ICU admission, especially for critically ill patients (Schuster and Marion 1983; Schellongowski et al. 2004). HM patients are more vulnerable to infection than other patients because of the nature of immunosuppression, medications, particularly steroids, chemotherapy, and stem cell transplant (Hollis 1996). It was previously observed that the incidence of Gram-negative sepsis increased annually in patients with HM (Soubani et al. 2004). The study performed by Hampshire et al. showed that the ICU mortality rate for HM patients suffering from severe infection reached 66.6%, and infection was independently associated with high hospital mortality. The ICU mortality rate was even higher in HM patients with invasive fungal infection (Bird et al. 2012; Sipsas and Kontoyiannis 2012), and reached 79% in a longitudinal observation study (Bird et al. 2012).
However, existing research has not reached a definitive conclusion on how infection affects survival. Some studies actually showed that HM patients had better outcomes if the ICU admission was precipitated by bacteremia (Benoit et al. 2003, 2005; Depuydt et al. 2004, 2010). One explanation may be that bacteremia leads to prompt ICU admission and prevents the development of severe sepsis or septic shock. Variations in the definition of infection may also change its association with prognosis. Confirmed infection is usually defined as positive culture from a sterile site, but the diagnosis of some infections, such as pneumonia, often depends on clinical signs and radiologic judgments, which may not be accurate (Benoit et al. 2003; Reyes et al. 1999). Nevertheless, a broader ICU admission policy may be beneficial to patients with bacteremia.
Neutropenia is generally defined as an absolute neutrophil count less than 1000/μL. The significance of neutropenia as a risk factor for HM patients at the time of admission to ICU or during the ICU stay remains controversial. Some publications have reported higher mortality in neutropenic patients, especially when mechanical ventilation is essential (Khwankeaw and Bhurayanontachai 2014). In a retrospective observational study, neutropenia was independently associated with poor outcomes (Benoit et al. 2003). The higher mortality in this subgroup may be attributed to an increased susceptibility to nosocomial infections and severe sepsis (Benoit et al. 2003).
On the contrary, other researchers reported that neutropenia was not independently associated with higher mortality in HM patients admitted to the ICU (Liu et al. 2015). In our previous analysis, neutropenia at the time of admission was not a prognostic factor for ICU mortality (Liu et al. 2015). Interestingly, in another retrospective cohort study, mortality was not significantly higher, even when it persisted throughout the ICU stay or had been present for more than 21 days prior to admission (Geerse et al. 2011). In these cases, the contribution of neutropenia may have been masked by the severe multi-organ failure these patients also suffered from (Blot et al. 1997).
Studies on HM patients from Asian countries
In the last decade, the ICU mortality rates for HM patients dropped to 26–56% in most of the western countries (Geerse et al. 2011; Evison et al. 2001; Benoit et al. 2003; Kroschinsky et al. 2002; Rabbat et al. 2005; McCaughey et al. 2013), although the mortality still remained higher for post HSCT patients (Townsend et al. 2013). A study from Poland reported an ICU mortality of 75.7%, which was much higher than the overall Western standard, and may be attributed to a comparably higher proportion of patients with mechanical ventilation (Sawicka et al. 2014). Presently, we could not find any studies published from African countries. Of most importance, studies published from Asian countries (China, Korean, India and so on) have revealed that the ICU mortality rate in these countries is higher than that in most western countries, ranging from 55.2 to 84.1% (Liu et al. 2015; Khwankeaw and Bhurayanontachai 2014; Metan et al. 2013; Bahammam et al. 2005; Park et al. 2011; Bajwa et al. 2010). More surprisingly, the highest hospital mortality was shown to be in Korea (84.1%), where the access to advanced medical technology is relatively unrestricted (Yeo et al. 2012).
How can we explain the comparably high mortality rate in Asian countries? First, patients with HM admitted to the ICU in Asian countries may severely suffer from more organ failure and acute illness. For instance, the Asian studies had higher proportions of patients who required IMV or vasopressors (64% required IMV in Turkey and 64.5% required IMV and 67.8% required vasopressors in China). A greater number of patients also had acute leukemia and other acute malignancies, which are associated with a high risk for treatment-related complications (Liu et al. 2015; Yeo et al. 2012). Second, due to insufficient intensive care resources and high population densities, the more stringent ICU admission policies in these countries may have resulted in delayed care (Murthy et al. 2015). For instance, only 0.61% of patients with HM were transferred to the ICU in our previous study involving a three-hospital academic center in China, which is much lower than what was reported in a study from Brazil (5.9%) (Liu et al. 2015; Lecuyer et al. 2007). Additionally, the occupancy of ICU beds in Asian countries is far less than that of western countries (Liu et al. 2015). Previous studies have also shown that ICU centers with high volumes of patients with HM had significantly decreased mortality (Zuber et al. 2012; Lecuyer et al. 2008). Many researchers have suggested that a more reasonable goal is the early identification of the subgroup of patients whose probability of survival is very low despite advanced ICU support (Khwankeaw and Bhurayanontachai 2014). Moreover, the relatively high ratio of mortality to incidence in Asian countries may reflect different cultural beliefs. According to a large scale statistical analysis, 19% of patients in China who would otherwise deteriorate in the ICU were likely to be discharged home near the end of life, while in Brazil, this ratio was as high as 75% (Broad et al. 2013).
Therefore, the high ICU mortality rate may be stem from a combination of the study population characteristics, the distribution of medical resources, and cultural differences on the end of life care. Most of the current data has come from early or retrospective studies, and further prospective and large multi-centered studies should test these hypotheses in Asian regions.
ICU admission policy
Summary of selected studies mentioned in this article
Patients and sample size
Significant prognostic factors
ICU mortality (%)
Hospital mortality (%)
6-month mortality (%)
Lloyd-Thomas et al. (1988)
N = 60
The dysfunction of an increasing number of organ systems, an APACHE II score of greater than 30, failure of the malignancy to respond to chemotherapy, and persistent leucopenia all
Yau et al. (1991)
N = 92
The nature and progress of the underlying malignancy
APACHE II: 25.9
Evison et al.(2001)
N = 78
Multi-organ failure and evidence of liver damage
47% required vasopressors; 43% required MV
Kroschinsky et al. (2002)
N = 104
mechanical ventilation, SAPS II
52% required MV
SAPS II: 46
Benoit et al. (2003)
N = 124
Leukopenia, vasopressors, urea of >0.75 g/L at admission, recent bacteremia
54% required ventilation; 54% required pressors
APACHE II: 26 ± 7.7; SAPS II: 53 ± 17.8
Rabbat et al. (2005)
N = 83
Simplified acute physiology score II and need for IMV
47% required IMV
SAPS II 54.9 ± 26.7
Lamia et al. (2006)
N = 92
Severity and three organ failure scores on day 1 and Delta scores
41% required IMV; 50% required pressors
SOFA: 9 ± 5
SAPS II:60 ± 22
Verplancke et al. (2008)
N = 352
49% Required IMV; 41% required pressors
APACHE II: 24.5 ± 7.4
Ferrà et al. (2008)
N = 116
Need of mechanical ventilation, cardiovascular vasoactive drugs
Merz et al. (2008)
N = 101
SAPS II at ICU admission, Mechanical ventilation, Renal replacement therapy, ICU length of stay
55.3% required MV
Hampshire et al. (2009)
N = 7689
Bone marrow transplant, Hodgkin’s lymphoma, severe sepsis, age, length of hospital stay prior to intensive care admission, tachycardia, low systolic blood pressuretachypnoea, low Glasgow Coma Score, sedation, PaO2:FiO2, acidaemia, alkalaemia, oliguria, hyponatraemia, hypernatraemia, low haematocrit, and uraemia
APACHE II: 24.4 ± 7.9
Geerse et al. (2011)
N = 86
Organ failure, a need for mechanical ventilation or inotropic/vasopressor therapy
52% required IMV, 52% required pressors
APACHE II:28.8 ± 7.9
SOFA:10.1 ± 3.4
Turkoglu et al. (2011)
N = 128
Low Glasgow coma scale, prior immunosuppressive treatment, neutropenia, IMV, and severe sepsis
64% required IMV
Bird et al. (2012)
N = 199
Mechanical ventilation;≥2 organ failures
51.9% required IMV; 51.5% required pressors
Yeo et al. (2012)
N = 227
Acute leukemia, need for invasive mechanical ventilator, use of inotropic/vasopressor agents, and Acute Physiology, Chronic Health Evaluation II scores
48% required IMV; 54.6% required inotropes
APACHE II: 19.4 ± 0.5
Namendys-Silva et al. (2013)
N = 102
Neutropenia at the time of ICU admission, the need for vasopressors, need for invasive mechanical ventilation, serum creatinine > 106 μmol/L
85.3% required IMV; 77.5% required pressors
SOFA: 9.8 ± 4;
APACHE:17.5 ± 6;
SAPS II: 42.5 ± 15.3
Hill et al. (2013)
N = 147
Culture proven infection, age, MV and inotropes
McCaughey et al. (2013)
N = 21
(APACHE II) scores, and decreased requirements for invasive ventilation and inotropic support
Azoulay et al. (2013)
N = 1011
Cancer remission; time to ICU admission less than 24 h, poor performance status, Charlson comorbidity index, allogeneic HSCT, organ dysfunction score, cardiac arrest, acute respiratory failure, malignant organ infiltration, invasive aspergillosis
47.9% required IMV, 51.2% required pressors
Townsend et al. (2013)
N = 213
The need for ventilation
50% required MV;45% required pressors
APACHE II: 23
Sawicka et al. (2014)
N = 99
Khwankeaw and Bhurayanontachai (2014)
N = 145
Mechanical ventilation, the use of vasopressors and the APACHE II scores
Liu et al. (2015)
Liu and Cheng
N = 121
The use of IMV, APACH II at admission, SOFA trend
64.5% required IMV, 67.8% required pressors
APACHE II:20.84 ± 0.89
SOFA:10.75 ± 0.48
Many studies have investigated the prognostic factors for HM patients admitted to the ICU. Some factors identified in the earlier studies, such as age, underlying diagnosis of malignancy, and disease status, were proven to be irrelevant in more recent studies. The role of other clinical factors, such as infection and neutropenia, remain controversial. Although the incorporation of comprehensive scoring systems for assessing overall health and organ failure status have helped clinicians to estimate prognosis, none is specific enough for predicting mortality in critically ill patients with HM.
The overall ICU mortality rate for HM patients ranges between 26 and 84.1%, and differs by study population and region. The mortality rate is comparably higher in Asian countries (Yeo et al. 2012). Broader ICU admission policies are recommended to ensure earlier treatment and for improving mortality. The admission of HM patients to the ICU raises ethical concerns for both the hematological and intensive care teams. The decision of transfer to the ICU has major consequences on end of life care for both the patients and their relatives. It affects the distribution of medical resources, human resources, and the organizational and economic aspects for the ICU and global health policy. A guiding principle for ICU admission is that it should be reserved for patients with reversible medical conditions and a reasonable chance of substantial recovery. Thus, the basis of intensive care medicine is optimizing the patient’s physiology by delivering supportive therapy, while attempting to treat the underlying disease. With more scientific patient selection and unbiased judgment, the prognosis of HM patients admitted to the ICU may improve.
XL conceived the study, participated in its design and coordination, and helped in drafting the manuscript. QC and YST performed majority of the study and wrote this manuscript. QY, EW and JL participated in the editing of proper English language. All authors read and approved the final manuscript.
This study was funded by the Education Reform Program for Central South University, No. 2016JGB20 for Xin Li and the Innovative Research Funds For the Central South University, No. 2016zzts151 for Qian Cheng and 2016zzts567 for Yishu Tang. This review has been copy edited for proper English language related to grammar, syntax, word choice, and sentence construction by American Journal Experts.
The authors declare that they have no competing interests.
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- Adda M et al (2008) Predictors of noninvasive ventilation failure in patients with hematologic malignancy and acute respiratory failure. Crit Care Med 36(10):2766–2772View ArticleGoogle Scholar
- Afessa B et al (1992) Outcome of recipients of bone marrow transplants who require intensive-care unit support. Mayo Clin Proc 67(2):117–122View ArticleGoogle Scholar
- Afessa B et al (2003) Intensive care unit support and Acute Physiology and Chronic Health Evaluation III performance in hematopoietic stem cell transplant recipients. Crit Care Med 31(6):1715–1721View ArticleGoogle Scholar
- Aygencel G et al (2014) Prognostic factors in critically ill cancer patients admitted to the intensive care unit. J Crit Care 29(4):618–626View ArticleGoogle Scholar
- Azoulay E et al (1999) Changing use of intensive care for hematological patients: the example of multiple myeloma. Intensive Care Med 25(12):1395–1401View ArticleGoogle Scholar
- Azoulay E et al (2001) Improved survival in cancer patients requiring mechanical ventilatory support: impact of noninvasive mechanical ventilatory support. Crit Care Med 29(3):519–525View ArticleGoogle Scholar
- Azoulay E et al (2011) Intensive care of the cancer patient: recent achievements and remaining challenges. Ann Intensive Care 1(1):5View ArticleGoogle Scholar
- Azoulay E et al (2013) Outcomes of critically ill patients with hematologic malignancies: prospective multicenter data from France and Belgium–a groupe de recherche respiratoire en reanimation onco-hematologique study. J Clin Oncol 31(22):2810–2818View ArticleGoogle Scholar
- Azoulay E et al (2014) Acute respiratory distress syndrome in patients with malignancies. Intensive Care Med 40(8):1106–1114View ArticleGoogle Scholar
- Bahammam AS et al (2005) Outcome of patients with hematological malignancies admitted to the intensive care unit with life-threatening complications. Saudi Med J 26(2):246–250Google Scholar
- Bajwa SJ, Bajwa SK, Kaur J (2010) Care of terminally Ill cancer patients: an intensivist’s dilemma. Indian J Palliat Care 16(2):83–89View ArticleGoogle Scholar
- Belenguer-Muncharaz A et al (2013) Ten-year evolution of mechanical ventilation in acute respiratory failure in the hematogical patient admitted to the intensive care unit. Med Intensiva 37(7):452–460View ArticleGoogle Scholar
- Benoit DD et al (2003) Outcome and early prognostic indicators in patients with a hematologic malignancy admitted to the intensive care unit for a life-threatening complication. Crit Care Med 31(1):104–112View ArticleGoogle Scholar
- Benoit DD et al (2005) Documented and clinically suspected bacterial infection precipitating intensive care unit admission in patients with hematological malignancies: impact on outcome. Intensive Care Med 31(7):934–942View ArticleGoogle Scholar
- Bird GT et al (2012) Outcomes and prognostic factors in patients with haematological malignancy admitted to a specialist cancer intensive care unit: a 5 yr study. Br J Anaesth 108(3):452–459View ArticleGoogle Scholar
- Blot F et al (1997) Prognostic factors for neutropenic patients in an intensive care unit: respective roles of underlying malignancies and acute organ failures. Eur J Cancer 33(7):1031–1037View ArticleGoogle Scholar
- Broad JB et al (2013) Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. Int J Public Health 58(2):257–267View ArticleGoogle Scholar
- Bruennler T et al (2007) Outcome of hemato-oncologic patients with and without stem cell transplantation in a medical ICU. Eur J Med Res 12(8):323–330Google Scholar
- Brunet F et al (1990) Is intensive care justified for patients with haematological malignancies? Intensive Care Med 16(5):291–297View ArticleGoogle Scholar
- Cornet AD et al (2005) Sequential organ failure predicts mortality of patients with a haematological malignancy needing intensive care. Eur J Haematol 74(6):511–516View ArticleGoogle Scholar
- Depuydt PO et al (2004) Outcome in noninvasively and invasively ventilated hematologic patients with acute respiratory failure. Chest 126(4):1299–1306View ArticleGoogle Scholar
- Depuydt PO et al (2010) The impact of the initial ventilatory strategy on survival in hematological patients with acute hypoxemic respiratory failure. J Crit Care 25(1):30–36View ArticleGoogle Scholar
- Evison J et al (2001) Intensive care unit admission in patients with haematological disease: incidence, outcome and prognostic factors. Swiss Med Wkly 131(47–48):681–686Google Scholar
- Ferrà C et al (2008) Similar prognosis for transplanted and non-transplanted patients with hematological malignancy admitted to the intensive care unit. Med Clin (Barc) 130(15):573–575View ArticleGoogle Scholar
- Geerse DA et al (2011) Prognosis of patients with haematological malignancies admitted to the intensive care unit: Sequential Organ Failure Assessment (SOFA) trend is a powerful predictor of mortality. Eur J Intern Med 22(1):57–61View ArticleGoogle Scholar
- Gooley TA et al (2010) Reduced mortality after allogeneic hematopoietic-cell transplantation. N Engl J Med 363(22):2091–2101View ArticleGoogle Scholar
- Gordon AC et al (2005) Incidence and outcome of critical illness amongst hospitalised patients with haematological malignancy: a prospective observational study of ward and intensive care unit based care. Anaesthesia 60(4):340–347View ArticleGoogle Scholar
- Gristina GR et al (2011) Noninvasive versus invasive ventilation for acute respiratory failure in patients with hematologic malignancies: a 5-year multicenter observational survey. Crit Care Med 39(10):2232–2239View ArticleGoogle Scholar
- Groeger JS et al (1999) Outcome for cancer patients requiring mechanical ventilation. J Clin Oncol 17(3):991–997Google Scholar
- Hampshire PA et al (2009) Admission factors associated with hospital mortality in patients with haematological malignancy admitted to UK adult, general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database. Crit Care 13(4):R137View ArticleGoogle Scholar
- Hilbert G et al (2001) Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 344(7):481–487View ArticleGoogle Scholar
- Hill QA (2010) Intensify, resuscitate or palliate: decision making in the critically ill patient with haematological malignancy. Blood Rev 24(1):17–25View ArticleGoogle Scholar
- Hill QA et al (2012) Survival of patients with hematological malignancy admitted to the intensive care unit: prognostic factors and outcome compared to unselected medical intensive care unit admissions, a parallel group study. Leuk Lymphoma 53(2):282–288View ArticleGoogle Scholar
- Hollis H (1996) Haematological patients transferred to the intensive care unit: what ICU nurses need to know. Intensive Crit Care Nurs 12(5):272–276View ArticleGoogle Scholar
- Huynh TN et al (2009) Outcome and prognostic indicators of patients with hematopoietic stem cell transplants admitted to the intensive care unit. J Transpl 2009:917294Google Scholar
- Khwankeaw J, Bhurayanontachai R (2014) Mortality correlation factors in patients with lymphoma and acute myeloid leukemia admitted into the intensive care unit at a referral center in the south of Thailand. J Med Assoc Thai 97(Suppl 1):S77–S83Google Scholar
- Kroschinsky F et al (2002) Outcome and prognostic features of intensive care unit treatment in patients with hematological malignancies. Intensive Care Med 28(9):1294–1300View ArticleGoogle Scholar
- Kwak YG et al (2010) Risk factors for device-associated infection related to organisational characteristics of intensive care units: findings from the Korean Nosocomial Infections Surveillance System. J Hosp Infect 75(3):195–199View ArticleGoogle Scholar
- Lamia B et al (2006) Changes in severity and organ failure scores as prognostic factors in onco-hematological malignancy patients admitted to the ICU. Intensive Care Med 32(10):1560–1568View ArticleGoogle Scholar
- Lecuyer L et al (2007) The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med 35(3):808–814View ArticleGoogle Scholar
- Lecuyer L et al (2008) Case volume and mortality in haematological patients with acute respiratory failure. Eur Respir J 32(3):748–754View ArticleGoogle Scholar
- Leone M et al (2015) Outcome of acute mesenteric ischemia in the intensive care unit: a retrospective, multicenter study of 780 cases. Intensive Care Med 41(4):667–676View ArticleGoogle Scholar
- Liu J et al (2015) Prognosis-related factors in intensive care unit (ICU) patients with hematological malignancies: a retrospective cohort analysis in a Chinese population. Hematology 20(9):494–503View ArticleGoogle Scholar
- Lloyd-Thomas AR et al (1988) Prognosis of patients receiving intensive care for lifethreatening medical complications of haematological malignancy. Br Med J (Clin Res Ed) 296(6628):1025–1029View ArticleGoogle Scholar
- Malak S et al (2014) Ethical and clinical aspects of intensive care unit admission in patients with hematological malignancies: guidelines of the ethics commission of the French society of hematology. Adv Hematol 2014:704318View ArticleGoogle Scholar
- Massion PB et al (2002) Prognosis of hematologic malignancies does not predict intensive care unit mortality. Crit Care Med 30(10):2260–2270View ArticleGoogle Scholar
- McCaughey C et al (2013) Characteristics and outcomes of haematology patients admitted to the intensive care unit. Nurs Crit Care 18(4):193–199View ArticleGoogle Scholar
- Merz TM et al (2008) Resource use and outcome in critically ill patients with hematological malignancy: a retrospective cohort study. Crit Care 12(3):R75View ArticleGoogle Scholar
- Metan G et al (2013) Factors influencing the early mortality in haematological malignancy patients with nosocomial Gram negative bacilli bacteraemia: a retrospective analysis of 154 cases. Braz J Infect Dis 17(2):143–149View ArticleGoogle Scholar
- Minne L et al (2012) Effect of changes over time in the performance of a customized SAPS-II model on the quality of care assessment. Intensive Care Med 38(1):40–46View ArticleGoogle Scholar
- Mokart D et al (2015) High-flow oxygen therapy in cancer patients with acute respiratory failure. Intensive Care Med 41(11):2008–2010View ArticleGoogle Scholar
- Molina R et al (2012) Ventilatory support in critically ill hematology patients with respiratory failure. Crit Care 16(4):R133View ArticleGoogle Scholar
- Murthy S, Leligdowicz A, Adhikari NK (2015) Intensive care unit capacity in low-income countries: a systematic review. PLoS ONE 10(1):e0116949View ArticleGoogle Scholar
- Namendys-Silva SA et al (2013) Outcome of critically ill patients with hematological malignancies. Ann Hematol 92(5):699–705View ArticleGoogle Scholar
- Namendys-Silva SA et al (2015) Organ dysfunction in critically ill cancer patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Oncol Lett 9(4):1873–1876Google Scholar
- Owczuk R et al (2005) Patients with haematological malignancies requiring invasive mechanical ventilation: differences between survivors and non-survivors in intensive care unit. Support Care Cancer 13(5):332–338View ArticleGoogle Scholar
- Parakh S et al (2014) Outcomes of haematology/oncology patients admitted to intensive care unit at The Canberra Hospital. Intern Med J 44(11):1087–1094View ArticleGoogle Scholar
- Park MR et al (2011) Outcomes in critically ill patients with hematologic malignancies who received renal replacement therapy for acute kidney injury in an intensive care unit. J Crit Care 26(1):107–126View ArticleGoogle Scholar
- Pene F et al (2006) Outcome of critically ill allogeneic hematopoietic stem-cell transplantation recipients: a reappraisal of indications for organ failure supports. J Clin Oncol 24(4):643–649View ArticleGoogle Scholar
- Price KJ et al (1998) Prognostic indicators for blood and marrow transplant patients admitted to an intensive care unit. Am J Respir Crit Care Med 158(3):876–884View ArticleGoogle Scholar
- Rabbat A et al (2005) Prognosis of patients with acute myeloid leukaemia admitted to intensive care. Br J Haematol 129(3):350–357View ArticleGoogle Scholar
- Reyes WJ, Brimioulle S, Vincent JL (1999) Septic shock without documented infection: an uncommon entity with a high mortality. Intensive Care Med 25(11):1267–1270View ArticleGoogle Scholar
- 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(8):625–633View ArticleGoogle Scholar
- Sawicka W et al (2014) The effectiveness of the APACHE II, SAPS II and SOFA prognostic scoring systems in patients with haematological malignancies in the intensive care unit. Anaesthesiol Intensive Ther 46(3):166–170View ArticleGoogle Scholar
- Schellongowski P et al (2004) Comparison of three severity scores for critically ill cancer patients. Intensive Care Med 30(3):430–436View ArticleGoogle Scholar
- Schellongowski P et al (2011) Prognostic factors for intensive care unit admission, intensive care outcome, and post-intensive care survival in patients with de novo acute myeloid leukemia: a single center experience. Haematologica 96(2):231–237View ArticleGoogle Scholar
- Schuster DP, Marion JM (1983) Precedents for meaningful recovery during treatment in a medical intensive care unit. Outcome in patients with hematologic malignancy. Am J Med 75(3):402–408View ArticleGoogle Scholar
- Sipsas NV, Kontoyiannis DP (2012) Invasive fungal infections in patients with cancer in the Intensive Care Unit. Int J Antimicrob Agents 39(6):464–471View ArticleGoogle Scholar
- Soares M, Depuydt PO, Salluh JI (2010a) Mechanical ventilation in cancer patients: clinical characteristics and outcomes. Crit Care Clin 26(1):41–58View ArticleGoogle Scholar
- Soares M et al (2010b) Characteristics and outcomes of patients with cancer requiring admission to intensive care units: a prospective multicenter study. Crit Care Med 38(1):9–15View ArticleGoogle Scholar
- Soubani AO et al (2004) Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a medical ICU. Chest 126(5):1604–1611View ArticleGoogle Scholar
- Staudinger T et al (2000) Outcome and prognostic factors in critically ill cancer patients admitted to the intensive care unit. Crit Care Med 28(5):1322–1328View ArticleGoogle Scholar
- Thiery G et al (2005) Outcome of cancer patients considered for intensive care unit admission: a hospital-wide prospective study. J Clin Oncol 23(19):4406–4413View ArticleGoogle Scholar
- Townsend WM et al (2013) Improved intensive care unit survival for critically ill allogeneic haematopoietic stem cell transplant recipients following reduced intensity conditioning. Br J Haematol 161(4):578–586View ArticleGoogle Scholar
- Turkoglu M et al (2011) Acinetobacter baumannii infection in patients with hematologic malignancies in intensive care unit: risk factors and impact on mortality. J Crit Care 26(5):460–467View ArticleGoogle Scholar
- Verplancke T et al (2008) Support vector machine versus logistic regression modeling for prediction of hospital mortality in critically ill patients with haematological malignancies. BMC Med Inform Decis Mak 8:56View ArticleGoogle Scholar
- Vincent JL et al (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22(7):707–710View ArticleGoogle Scholar
- Vosylius S, Sipylaite J, Ivaskevicius J (2004) Evaluation of intensive care unit performance in Lithuania using the SAPS II system. Eur J Anaesthesiol 21(8):619–624View ArticleGoogle Scholar
- Wohlfarth P et al (2016) Incidence of intensive care unit admission, outcome and post intensive care survival in patients with diffuse large B-cell lymphoma. Leuk Lymphoma 57(8):1831–1838View ArticleGoogle Scholar
- Yau E et al (1991) Long term prognosis and quality of life following intensive care for life-threatening complications of haematological malignancy. Br J Cancer 64(5):938–942View ArticleGoogle Scholar
- Yeo CD et al (2012) Prognostic factors in critically ill patients with hematologic malignancies admitted to the intensive care unit. J Crit Care 27(6):739.e1–739.e6View ArticleGoogle Scholar
- Zuber B et al (2012) Impact of case volume on survival of septic shock in patients with malignancies. Crit Care Med 40(1):55–62View ArticleGoogle Scholar