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      Clinical Approach to the Patient in Critical State Following Immunotherapy and/or Stem Cell Transplantation: Guideline for the On-Call Physician

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          Abstract

          The initial management of the hematology patient in a critical state is crucial and poses a great challenge both for the hematologist and the intensive care unit (ICU) physician. After years of clinical practice, there is still a delay in the proper recognition and treatment of critical situations, which leads to late admission to the ICU. There is a much-needed systematic ABC (Airway, Breathing, Circulation) approach for the patients being treated on the wards as well as in the high dependency units because the underlying hematological disorder, as well as disease-related complications, have an increasing frequency. Focusing on score-based decision-making on the wards (Modified Early Warning Score (MEWS), together with Quick Sofa score), active sepsis screening with inflammation markers (C-reactive protein, procalcitonin, and presepsin), and assessment of microcirculation, organ perfusion, and oxygen supply by using paraclinical parameters from the ICU setting (lactate, central venous oxygen saturation (ScVO 2), and venous-to-arterial carbon dioxide difference), hematologists can manage the immediate critical patient and improve the overall outcome.

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          Sepsis and septic shock.

          For more than two decades, sepsis was defined as a microbial infection that produces fever (or hypothermia), tachycardia, tachypnoea and blood leukocyte changes. Sepsis is now increasingly being considered a dysregulated systemic inflammatory and immune response to microbial invasion that produces organ injury for which mortality rates are declining to 15-25%. Septic shock remains defined as sepsis with hyperlactataemia and concurrent hypotension requiring vasopressor therapy, with in-hospital mortality rates approaching 30-50%. With earlier recognition and more compliance to best practices, sepsis has become less of an immediate life-threatening disorder and more of a long-term chronic critical illness, often associated with prolonged inflammation, immune suppression, organ injury and lean tissue wasting. Furthermore, patients who survive sepsis have continuing risk of mortality after discharge, as well as long-term cognitive and functional deficits. Earlier recognition and improved implementation of best practices have reduced in-hospital mortality, but results from the use of immunomodulatory agents to date have been disappointing. Similarly, no biomarker can definitely diagnose sepsis or predict its clinical outcome. Because of its complexity, improvements in sepsis outcomes are likely to continue to be slow and incremental.
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            A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom--the ACADEMIA study.

            Many patients have physiological deterioration prior to cardiac arrest, death and intensive care unit (ICU) admission, that are detected and documented by medical and nursing staff. Appropriate early response to detected deterioration is likely to benefit patients. In a multi-centre, prospective, observational study over three consecutive days, we studied the incidence of antecedents (serious physiological abnormalities) preceding primary events (defined as in-hospital deaths, cardiac arrests, and unanticipated ICU admissions) in 90 hospitals (69 United Kingdom [UK]; 19 Australia and 2 New Zealand [ANZ]). 68 hospitals reported primary events during the three-day study period (50 United Kingdom, 16 Australia and 2 New Zealand). Data on the availability of ICU/HDU beds and cardiac arrest teams and Medical Emergency Teams were also collected. Of 638 primary events, there were 308 (48.3%) deaths, 141 (22.1%) cardiac arrests, and 189 (29.6%) unplanned ICU admissions. There were differences in the pattern of primary events between the UK and ANZ (P < 0.001). There were proportionally more deaths in the UK (52.3% versus 35.3%) and a higher number of unplanned ICU admissions in ANZ (47.3% versus 24.2%). Sixty percent (383) of primary events had a total of 1032 documented antecedents. The most common antecedents were hypotension and a fall in Glasgow Coma Scale. The proportion of ICU/HDU to general hospital beds was greater in ANZ (0.034 versus 0.016, P < 0.001) and medical emergency teams were more common in ANZ (70.0% versus 27.5%, P = 0.001). The data confirm antecedents are common before death, cardiac arrest, and unanticipated ICU admission. The study also shows differences in patterns of primary events, the provision of ICU/HDU beds and resuscitation teams, between the UK and ANZ. Future research, focusing upon the relationship between service provision and the pattern of primary events, is suggested.
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              Associations between end-of-life discussion characteristics and care received near death: a prospective cohort study.

              National guidelines recommend that discussions about end-of-life (EOL) care planning happen early for patients with incurable cancer. We do not know whether earlier EOL discussions lead to less aggressive care near death. We sought to evaluate the extent to which EOL discussion characteristics, such as timing, involved providers, and location, are associated with the aggressiveness of care received near death.
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                Author and article information

                Journal
                J Clin Med
                J Clin Med
                jcm
                Journal of Clinical Medicine
                MDPI
                2077-0383
                20 June 2019
                June 2019
                : 8
                : 6
                : 884
                Affiliations
                [1 ]Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania; constantinescu.catalin@ 123456ymail.com (C.C.); pasca.sergiu123@ 123456gmail.com (S.P.); patric_te@ 123456yahoo.com (P.T.)
                [2 ]Intensive Care Unit, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania
                [3 ]Department of Anesthesia, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania; cbodolea@ 123456gmail.com
                [4 ]Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400005 Cluj Napoca, Romania; deli_dima@ 123456yahoo.com (D.D.); codruta_21@ 123456yahoo.com (I.R.); dr_tibi@ 123456yahoo.com (T.T.)
                [5 ]Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400124 Cluj Napoca, Romania; patric_te@ 123456yahoo.com
                [6 ]Department of Stem Cell Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania; alinadanielatanase@ 123456yahoo.com
                [7 ]Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Victor Babes Street, 400124 Cluj Napoca, Romania
                [8 ]Department of Internal Medicine II, University Hospital Wuerzburg, 97070 Wuerzburg, Germany; Einsele_H@ 123456ukw.de
                Author notes
                Author information
                https://orcid.org/0000-0001-8292-911X
                https://orcid.org/0000-0002-4129-8478
                https://orcid.org/0000-0003-3075-499X
                https://orcid.org/0000-0001-5500-1519
                Article
                jcm-08-00884
                10.3390/jcm8060884
                6616972
                31226876
                ddb664ea-0332-49d4-955c-338c02de083d
                © 2019 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 02 May 2019
                : 18 June 2019
                Categories
                Review

                hematology patient,mews-based clinical approach,abcde approach,sepsis screening,cytokine release syndrome

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