Open Access Intensive care outcomes in bone marrow

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Critical Care Vol 12 No 3 Scales et al, Authorities suggest that ICU admission following bone mar identified ICU admissions diagnosed as a complication of. row transplantation is associated with a poor prognosis bone marrow transplant using the corresponding International. 17 18 No study however has examined whether the poor Classification of Diseases Ninth Revision Clinical Modifica. prognosis extends to subsequent hospitalizations Further tion Code 996 8 this code does not distinguish between. more greater knowledge of long term outcomes would be graft versus host disease and other complications of bone. useful to policymakers ethicists and other stakeholders marrow transplant Similarly we identified the diagnoses of. 19 20 The universal healthcare system in Ontario provides a acute renal failure Codes 584 5 584 6 584 7 584 8 and. unique opportunity to study long term outcomes of unusual 584 9 and acute hepatic failure Codes 570 573 3 572 2. conditions across multiple study centers and for an entire pop 572 4 782 4 and 286 7 during the hospital stay using previ. ulation We therefore used the Ontario health databases to ously described code combinations 28 29. evaluate survival of bone marrow transplant patients admitted. to the ICU Whereas previous research focused on outcomes We identified common procedures using codes available in. of patients requiring ICU at the time of transplant we exam the Ontario Health Insurance Plan database Mechanical ven. ined the ICU stay during subsequent hospital admissions tilation was identified using a previously described algorithm. 27 We defined pulmonary artery catheter use by the pres. Methods ence of the specific code for this procedure during the ICU. Identification of bone marrow transplant admission Similarly patients who had codes for acute hemo. We identified all adults age 18 years who underwent bone dialysis were defined as receiving renal replacement therapy. marrow transplant in the province of Ontario using the Ontario. Health Insurance Plan database This database contains fee Analysis. for service claims for services provided by physicians to The primary outcome was mortality at 1 year The end of the. Ontario residents 21 22 The study period spanned 1 Janu observation period was 31 March 2003 so that all patients. ary 1992 to 31 March 2002 representing all years for which were followed for at least 1 year We analyzed the frequency. data were available There were no exclusion criteria for the of death using the chi square test Odds ratios and 95 con. present study fidence intervals CIs were estimated using univariate logistic. regression We decided in advance to stratify patients into cat. Bone marrow transplant recipients were linked to the Cana egories based on the following characteristics autologous. dian Institute for Health Information Discharge Abstract Data versus allogeneic bone marrow transplant need for mechani. base which contains demographic data administrative data cal ventilation provision of mechanical ventilation for 10. and clinical data for hospital discharges and day surgeries in days receipt of hemodialysis and insertion of a pulmonary. Canada Individuals were also linked to the Registered Per artery catheter. sons Database which contains vital statistics on Ontario citi. zens These databases have been used extensively in past Life tables were constructed to create Kaplan Meier curves. research 23 26 for survival and for ICU free survival For the Kaplan Meier. analysis of ICU free survival we considered the event to be. The admission containing the most recent discharge date was admission to the ICU following hospitalization for bone marrow. retained when multiple records had the same unique patient transplant Patients were censored at the end of follow up or. identifier admission date and date of birth If multiple bone at death All P values were two tailed and analyses were con. marrow transplants were performed on the same patient we ducted using SAS software version 9 13 SAS Institute Inc. only considered the first procedure If duplicate records were Cary NC USA. identical for unique patient identifier and admission date the. record associated with the most recent discharge date was Ethics. retained If discharge dates were also identical one of the The need for informed consent was waived for this analysis of. records was randomly deleted administrative health data The study was approved by the eth. ics committee of the Sunnybrook Health Sciences Centre and. Identification of subsequent ICU admission was conducted using confidentiality safeguards at the Institute. We identified admissions to the ICU using codes in the for Clinical Evaluative Sciences in Ontario. Ontario Health Insurance Plan database according to a previ. ously described algorithm 27 The Ontario Health Insurance Results. Plan database contains all claims submitted to the single We identified 2 653 patients who underwent a first bone mar. payer healthcare system for reimbursement for physician serv row transplant during the study of whom 60 received allo. ices We focused on the first ICU admission following the hos geneic transplants Table 1 The underlying diagnosis was. pital discharge for bone marrow transplantation When ICU malignancy in most cases Almost all of the procedures n. codes were interrupted by 1 day we assumed the patient 2 631 99 were performed at seven different centers. had been discharged and then readmitted to the ICU We range 45 to 1 543 transplants per center and no. Page 2 of 9,page number not for citation purposes,Edited by Foxit Reader. Copyright C by Foxit Software Company 2005 2007, For Evaluation Only online http ccforum com content 12 3 R77. association was apparent between 1 year mortality and the in five patients n 97 whereas acute hepatic failure was rare. bone marrow transplant procedure volume Spearman s rank n 17 Few of the patients n 66 received a second bone. correlation 0 14 P 0 76 Only 175 6 6 patients died marrow transplant during this subsequent hospitalization. during the initial bone marrow transplant hospitalization On. average survivors required hospitalization 1 2 times median Specific procedures. 1 0 interquartile range 0 to 2 during the first year following Mechanical ventilation at any time during subsequent hospital. transplant and 2 2 times during the entire study period izations was provided to about one half n 258 of 504 bone. median 1 0 range 0 to 20 interquartile range 0 to 3 Dur marrow transplant recipients admitted to the ICU but was. ing these subsequent hospital admissions 504 20 rarely continued for 10 days n 67 Table 3 Hemodialysis. patients received ICU care typically 351 patients 70 during the ICU stay was provided to 35 6 9 patients and. during the first year following the original transplant procedure pulmonary artery catheterization to 94 19 patients Multiple. Figure 1 procedures were frequently performed for example 86 33. mechanically ventilated patients also received pulmonary. The median time from the original transplant discharge to sub artery catheterization and 29 11 mechanically ventilated. sequent ICU admission was 124 days interquartile range 24 patients also received hemodialysis. to 584 days The frequencies of ICU admission comparing. autologous bone marrow transplant recipients with allogeneic Outcomes following ICU admission. recipients were similar in the long run Figure 1 The mean age Mortality 1 year following ICU admission Table 4 was not sig. was 43 years standard deviation 11 years and the median nificantly related to the type of transplant autologous 70. length of the first ICU stay was 4 days interquartile range 2 versus allogeneic 66 P 0 33 and was similar comparing. to 10 days The main reasons for hospital admission varied early study years January 1992 to March 1998 69 with. but included infection n 82 16 respiratory failure n later years April 1998 to March 2002 66 P 0 59. 72 14 and cardiac failure 49 patients 9 7 Table 2 Longer intervals between bone marrow transplant and ICU. One third of patients n 154 were admitted with a compli admission decreased the 1 year risk of dying odds ratio 0 73. cation of the bone marrow transplant including graft versus 95 confidence interval 0 65 to 0 83 for each additional year. host disease although this was rarely the most responsible between hospitalizations P 0 0001 The mean years from. diagnosis n 30 Acute renal failure developed in about one transplant to subsequent ICU admission was two times longer. Characteristics of patients with and without intensive care unit admission following bone marrow transplant hospitalization. All patients No ICU admission following BMT ICU admission during P valueb. n 2 653 hospitalization subsequent hospitalizations. n 1 974 a n 504, Age standard deviation at BMT years 44 12 44 12 43 11 0 04. Female gender 1 221 46 907 46 217 43 0 24,Allogeneic BMT 1 583 60 1 215 62 264 52 0 0002.
ICU stay during BMT admission 2 544 96 1 877 95 496 98 0 013. Mechanical ventilation during BMT admission 181 7 1 31 2 0 54 11 0 0001. Length of hospital stay standard deviation during 32 21 31 20 33 19 0 0028. BMT admission days, Physician claims standard deviation during 3 years 151 83 145 74 172 107 0 0001. preceding BMT admission, Charlson score 2 during BMT hospitalization 150 5 6 128 6 0 12 2 0 0 0004. Malignancy 2 582 97 1 920 97 492 98 0 66,Leukemia 948 36 620 31 227 45 0 0001c. Lymphoma 831 31 666 34 125 25,Multiple myeloma 461 17 364 18 86 17. Breast cancer 151 5 7 131 6 6 15 3 0, aExcludes the 175 patients who died during bone marrow transplant BMT admission.
bFor comparison of patients with versus patients without intensive care unit ICU admission following bone marrow transplantation hospitalization. cFor comparison of patients with versus patients without ICU admission following bone marrow transplantation across subtypes of malignancy. Page 3 of 9,page number not for citation purposes,Critical Care Vol 12 No 3 Scales et al. Time frombone,bonemarrow,marrowtransplant,transplant. to intensive,to intensive, 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 inten. sive 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. for survivors than for decedents 1 6 versus 0 8 P 0 0001 16 mechanically ventilated patients who received multiple ICU. Patients admitted to hospital for complications of the bone admissions during the same hospitalization died Exactly eight. marrow transplant including graft versus host disease had patients receiving hemodialysis during their ICU stay required. particularly high mortality at 1 year 81 95 confidence chronic hemodialysis during the subsequent year The strong. interval 73 to 86 As expected mortality at 1 year was est independent predictors of death were mechanical ventila. also high for patients who developed acute renal failure 89 tion and hemodialysis Table 5 Multivariable regression. 95 confidence interval 81 to 94 or acute hepatic failure analysis could not be completed because of the small number. 71 95 confidence interval 44 to 90 of survivors in each stratum. Most patients died within the first year after ICU admission We further examined survivors of multiple procedures during. whereas survival declined only modestly during subsequent ICU admission Eight survivors received mechanical ventilation. years Figure 2 Patients receiving any ICU procedure had plus either pulmonary artery catheterization or hemodialysis In. higher 1 year mortality than those patients not receiving a pro this subgroup the median time interval between bone marrow. cedure 87 versus 44 P 0 0001 Death at 1 year was transplant and ICU admission was 1 3 years interquartile. specifically more frequent if patients required mechanical ven range 0 36 to 4 5 years The median ICU length of stay was. tilation 87 95 confidence interval 82 to 91 pulmo 6 5 days interquartile range 2 0 to 31 days The survivors. nary artery catheterization 91 95 confidence interval mean age was 45 years standard deviation 7 3 years and. 84 to 96 or hemodialysis 94 95 confidence inter most survivors n 7 were male. val 81 to 99 Only about 7 of patients who were, mechanically ventilated for 10 days or longer survived and all. Page 4 of 9,page number not for citation purposes,Edited by Foxit Reader.
Copyright C by Foxit Software Company 2005 2007, For Evaluation Only online http ccforum com content 12 3 R77. Table 2 Outcomes following ICU procedures in our study are similar to. those previously reported for the early post transplant period. Most responsible diagnosis for bone marrow transplant. recipients requiring intensive care unit during subsequent the pooled mortality in 21 studies of mechanical ventilation. hospitalizations during the early post transplant period was 90 1 974 of. 2 183 patients range 55 to 100 in four studies of acute. Most responsible diagnosis n renal failure was 78 104 of 134 patients range 69 to. Hematological lymphatic malignancy 186 37 100 and in one study reporting pulmonary artery catheter. Intensive care outcomes in bone marrow transplant recipients a population based cohort analysis Damon C Scales1 2 3 4 Deva Thiruchelvam3 Alexander Kiss3 William J Sibbald1 2 4 and Donald A Redelmeier3 4 1Department of Critical Care Sunnybrook Health Sciences Centre 2075 Bayview Avenue Room D108 Toronto Ontario Canada M4N 3M5

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