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

Published in ICU

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

Our findings support those of Crawford and Petersen reporting a mortality of 97 percent for nonsurgical patients with BMTs requiring mechanical ventilation. On the other hand, our results put into question the conclusion of these authors that mechanical ventilation is a precise surrogate for respiratory failure, as we found that 24 percent of patients admitted to the MICU with respiratory failure did not require mechanical ventilation. In expanding this study to include nonintubated medical patients, we found that these individuals do rather well with an overall survival of 81 percent. This finding may be due to selection bias and may reflect subjective differences in clinical decision-making regarding the necessity of MICU admission. However, given the substantially smaller percentage of patients with BMTs admitted to the MICU at our institution compared with other series, this seems unlikely. Given one report demonstrating that the effectiveness of ICU care is based on the coordination of its delivery and a second suggesting that direct admission of unstable moderately ill patients to critical care units seems to reduce mortality, it is possible that transfer of patients with BMTs from the controlled environmental oncology unit to the MICU at our institution may have averted further clinical deterioration and death. Further study will be necessary to investigate this possibility.
At the present time, in counseling patients with BMTs and their families regarding the benefits of MICU admission, the results of this study and those of the three other series in the literature may be utilized. Patients who become critically ill but do not require mechanical ventilation may benefit from admission to the MICU and have a reasonable chance for discharge. Alternatively, the option of mechanical ventilation should be carefully discussed, as it is unlikely these patients will benefit from this intervention but instead will have prolonged ICU hospitalization at considerable emotional and financial cost to the patient, family, and others. Despite this, as Crawford and Petersen point out, a 3 percent survival rate with confidence intervals of 2 to 6 percent is not equivalent to medical futility and thus, this argument should not be used to actively withhold mechanical ventilation from this population. Certainly, since the outcome for mechanically ventilated patients with BMTs has been replicated in two studies, these data should be used to counsel patients about their chances of survival with mechanical ventilation before BMT.