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Outcome of Patients Requiring Medical ICU Admission Following Bone Marrow Transplantation: Conclusion

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While clearly related to prognostic score at the time of admission, the development of MOF during MICU hospitalization was also an important predictor of death. A number of studies have demonstrated a relationship between MOF and death in the ICU. Of the 24 nonsurvivors, all but 4 developed MOF during their MICU stay. All three of the patients who developed MOF on their first MICU admission and survived were later readmitted to the MICU and died. Of note, in a larger series, a small number of patients were identified who survived ICU admission after developing MOF along with requiring mechanical ventilation. Given these findings, important predictors of outcome in the MICU include the presence of respiratory failure requiring mechanical ventilation, APACHE II score, and the development of MOF during the MICU stay. We did not find age or disease state to be reliable predictors of outcome in our study.
These data differ from those of other centers in that we looked specifically at patients with BMTs admitted to a MICU for nonsurgical problems, and as such, postoperative surgical patients with brief periods of mechanical ventilation were not included. In addition, this analysis is not limited to only medical patients requiring ICU admission for respiratory failure as in other series. canadian family pharmacy online

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Outcome of Patients Requiring Medical ICU Admission Following Bone Marrow Transplantation: Discussion

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Outcome of Patients Requiring Medical ICU Admission Following Bone Marrow Transplantation: DiscussionWe conclude that while the mortality rate for patients requiring mechanical ventilation after BMT is more than 96 percent for those patients without significant respiratory failure, there is a reasonable chance of MICU survival. Overall, 16 percent of patients required admission to the MICU after BMT. This figure varied from others reported in the literature; for example, Afessa and colleagues found that 24 percent of patients at their institution required ICU care after BMT. Other series have reported that 30 to 40 percent of patients with BMTs required ICU admission. It is unlikely that the patients studied had a lower premorbid risk to account for this difference. The lower rate of MICU admission at our institution may be due to the impact of the controlled environmental oncology unit, which is an intermediate care unit with laminar air flow; this unit can care for patients with increased levels of acuity. Since most patients with BMTs at our institution are referred locally, it is unlikely that their posttransplant critical care took place at other institutions and was not recorded.
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Outcome of Patients Requiring Medical ICU Admission Following Bone Marrow Transplantation: Results

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There were 229 BMTs performed at our institution (129 allogeneic transplants and 100 autologous transplants) between March 3, 1984 and March 26, 1991. During this period 36 of these patients (15.7 percent) had 43 admissions to the MICU. The admission data for these patients in terms of outcome are summarized in Table 1.
There was no statistically significant difference in age between the survivors and nonsurvivors, 34.4 years vs 37.6 years of age, respectively. Of these patients, 19 were male and 17 were female. The indications for BMT included acute myeloid leukemia in 14, lymphoma in 10, chronic myelogenous leukemia in 6, acute lymphocytic leukemia in 4, aplastic anemia in 1, and small-cell carcinoma of the lung in 1. There was no statistically significant difference in outcome with regard to the patients indication for BMT. A larger percentage of nonsurvivors had disease in remission, but this trend was not statistically different. Similarly, there was no statistically significant difference in outcome between the 28 patients who had allogeneic transplants and the 8 patients who had autologous transplants. Furthermore, we did not determine a difference in outcome with regard to a patients conditioning regimen. Of those patients with GVHD, 82 percent did not survive, but this difference was not statistically different when compared with those without GVHD.
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Outcome of Patients Requiring Medical ICU Admission Following Bone Marrow Transplantation: Methods

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Outcome of Patients Requiring Medical ICU Admission Following Bone Marrow Transplantation: MethodsOver the past two decades, bone marrow transplantation (BMT) has become accepted as a standard treatment modality in adults with aplastic anemia (AA), acute lymphocytic leukemia (ALL), acute myeloid leukemia (AML), chronic myelogenous leukemia (CML), lymphoma, and certain solid tumors. Prior to BMT, patients receive conditioning regimens that include myeloablative chemotherapy often accompanied by total-body irradiation. For at least 2 weeks after BMT, patients will experience profound leuko-cytopenia and thrombocytopenia. This and the additional use of immunosuppressive therapy place these patients at increased risk for numerous complications, including opportunistic infections, bleeding, and graft-vs-host disease (GVHD).
Pulmonary complications have been observed in 40 to 60 percent of patients with BMTs. These include interstitial pneumonitis in up to 40 percent of allogeneic BMT recipients, bacterial, viral, and fungal pneumonias, cardiogenic and noncardiogenic pulmonary edema, bronchiolitis obliterans, and alveolar hemorrhage syndrome. With these severe acute complications, it has been estimated that 30 to 40 percent of BMT recipients require treatment.
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