Caroline McCaughey - Haematology Association of Ireland

C McCaughey 1 , B Blackwood 2 , M Brady 3 , MF McMullin 1
1
Department of Haematology, Belfast City Hospital and Queen's University, Belfast
2
School of Nursing and Midwifery, Queen's University, Belfast,
3
Department of Anaesthetics, Belfast City Hospital, Belfast, N. Ireland

Background
• Controversy – inappropriate use of limited resources v denial of
effective care
• Studies in the 1980’s and 1990’s reported ICU mortality rates of
80% for patients with malignant disease requiring invasive
ventilation, and 90‐95% for those with multiorgan failure or
requiring renal replacement therapy (McGrath et al., 2010)
• Improving prognosis for patients with haematological
malignancies (NI Cancer Registry, 2010)
• Improvements in ICU outcomes for haematology patients over
last 5 years despite increased intensity treatments (Cuthbertson
et al., 2008)

Aims
• To profile patient characteristics and assess outcomes of
haematology patients admitted to the Belfast City
Hospital ICU
• To establish a baseline against which to re‐audit in the
future and compare against national statistics
• To identify areas for improvement
• To establish trends of ICU admission with a view to
developing and refining research question(s) for future
study.

Setting
• Haematology Unit
• 29 beds (incorporating 6 transplant beds)
• Total admissions for 2009 = 829
• Intensive Care Unit
• 9 beds (12 up until September 2009)
• Total admissions for 2009 = 660
• Haematology ICU admissions in 2009
• 21/829 (2.5%) of all haematology admissions
• 21/660 (3.2%) of all ICU admissions

Methods
• Audit team – clinical, academic, ICU, Haematology
• Audit proposal accepted and registered by Trust Audit
Department
• Retrospective audit of medical notes; laboratory
records; Intensive Care National Audit and Research
Centre (ICNARC) data
• Population – all adults admitted to Belfast City
Hospital ICU from 1 st January – 31 st December 2009

Results
• 21 adult patients admitted to ICU in 2009
• Mean age 56 years (range 22 – 71 years)
• Male n=11, female n=10

Diagnoses
29%
82% (n=19) had a
malignant diagnosis.
No. Patients
24%

Treatment history prior to current
haematology admission and ICU transfer
At ICU admission 71% (n=15) were post chemo (median 9.9 days, range 1-22 days,
n=1 was day 4 post autograft)

Reasons for admission to ICU
Neutropaenic sepsis (n=18, 85%)
No. Patients

Outcomes –ICU mortality
89% deaths sepsis related

Haematological status on admission to ICU
Haematological status Frequency Percentage
Newly diagnosed malignant disease n=6 28.6%
Newly diagnosed non malignant disease n=2 9.5%
Remission / stable disease n=9 42.9%
Active disease n=1 4.8%
Relapsed disease n=2 9.5%
Refractory disease n=1 4.8%
TOTAL n=21 100%

Haematological status and outcomes
Should patients with active malignant disease be admitted to ICU?
Haematological status Frequency Outcome
Active disease n=1 >6 month survival
Relapsed disease n=2 • Deceased in ICU
• Deceased 67
days
Refractory disease n=1 Deceased 112 days

On admission to ICU ICU survivors (n = 12) ICU non‐survivors (n = 9)
APACHE II score, (mean, SD) 20 (5) 28 (6.6)
No of pt’s with neutropenia ≥ grade
3 (n %)
6 (50%) 6 (66.7%)
No of pt’s with pancytopaenia ≥
grade 3 (n %)
6 (50%) 6 (66.7%)
No of pt’s with liver toxicity ≥ grade
3 (n %)
3 (25%) 7 (78%)

Throughout ICU admission ICU survivors (n = 12) ICU non‐survivors (n = 9)
No of pt’s requiring invasive
ventilation (n %)
No of pt’s requiring inotropic
support (n %)
No of pt’s requiring continuous
renal replacement therapy
Maximum no. of organs supported
(mean, SD)
6 (50%) 8 (90%)
3 (25%) 7 (78%)
4 (33%) 3 (33%)
2.25 (1.1) 3 (0.7)
Days in ICU (median, IQR) 4.3 (2, 8) 4 (1, 7)

Mortality
Alive
Deceased
ICU 12 (57%) 9 (43%)
3 months 8 (48%) 13 (62%)
6 months 7 (33%) 14 (67%)
3 months
n=2 died 1-day post ICU (sepsis related multi organ failure; non ICU related death)
n=1 died 2-days post ICU (PE)
n=1 died 67-days post ICU (refractory disease)
6 months
n=1 died 112-days post ICU (refractory disease)

6month survivors ‐ present
haematological status
Haematological status
Frequency
Remission 5
Responding 1
Relapsed 1
TOTAL 7
Two of the patients who survived > 6months have progressed to a
potentially curative RIC transplant.

Conclusions
• Most common reason for admission to ICU was
neutropaenic sepsis associated respiratory failure (n=10,
48%)
• Median length of stay was 4 days (SD 4.7)
• A third of patients survived >6months indicating that
critically ill haematology patients may benefit from ICU
admission, allowing progression to potentially curative
therapies

• The benefit of ICU for patients with relapsed or refractory
disease remains ambiguous, however McGrath et al.,
(2010) contend that long term prognosis has minimal
effect on short term prognosis during acute critical illness
• ICU mortality in BCH is identical to ICNARC national
statistics for haematology patients

Recommendations
• Decision to admit haematology patients to ICU should depend
on severity of critical illness rather than underlying malignancy
(note non malignant outcomes)
• ICNARC –number of failed organs is main prognostic factor for
cancer patients admitted to ICU. Therefore early referral and
prompt admission is critical and careful review of the
appropriateness of admissions
• Of the 2 BCH patients with multi‐organ failure at time of
admission to ICU, one died in ICU, and the other one day 1 post
ICU discharge

Recommendations
Areas for future study.
• Most appropriate/preferred place of death
• Patient and family experience of ICU admission
• Staff attitudes to ICU admissions
• QOL post ICU

Acknowledgements
• Tanya Longmuir, BCH critical care secretary, for her
invaluable help in accessing data from the ICNARC
database

References
• Cuthbertson, B.H., Rajalingham, Y. Harrison, S. and McKirdy, F. (2008) The
outcome of haematological malignancy in Scottish intensive care units. Journal
of the Intensive Care Society, 9, pp. 135‐140
• Guidelines and audit implementation network (GAIN) http://www.gain‐ni.org/
Accessed September 2010.
• McGrath, S., Chatterjee, F. Whiteley, C. and Ostermann, M. (2010) ICU and 6‐
month outcome of oncology patients in the intensive care unit. Quarterly Journal
of Medicine, 103, pp. 397‐403
• Northern Ireland Cancer Registry (2010) http://www.qub.ac.uk/researchcentres/nicr/Data/OnlineStatistics/
(internet) Accessed September 2010.
• Perry, A.R., Rivlin, M.M., Goldstone, A.H. (1999) BMT patients with lifethreatening
organ failure: when should treatment stop? Journal of Clinical
Oncology, 17, pp.298‐303
• Principles for Best Practice in Clinical Audit (NICE/CHI/RCN, 2002). Available
from: http://www.uhbristol.nhs.uk/documents/best_practice_clinical_audit.pdf
(internet) Accessed September 2010.