Risks of bleeding and thrombosis in intensive care unit patients with haematological malignancies

Abstract

Background: Patients with malignant haematological disease and especially those who require intensive care have an increased risk of bleeding and thrombosis, but none of these data were obtained in ICU patients only. We assessed the incidence of bleeding and thrombotic complications, use of blood products and risk factors for bleeding in an adult population of ICU patients with haematological malignancies.

Methods: We screened all patients with acute leukaemia and myelodysplastic syndrome admitted to a university hospital ICU during 2008-2012. Bleeding in ICU was scored according to the WHO grading system, and risk factors were evaluated using unadjusted and adjusted analyses.

Results: In total, 116 of 129 ICU patients were included; their median length of stay was 7 (IQR 2-16) days. Of these, 66 patients (57%) had at least one bleeding episode in ICU; they bled for 3 (2-6) days and most often from lower and upper airways and upper GI tract. Thirty-nine (59%) of the 66 patients had severe or debilitating (WHO grade 3 or 4) bleeding. The median platelet count on the day of grade 3 or 4 bleeding was 23 × 10⁹ per litre (IQR 13-39). Nine patients (8%) died in ICU following a bleeding episode; five of these had intra-cerebral haemorrhage. Platelet count on admission was associated with subsequent bleeding (adjusted odds ratio 1.18 (95% CI 1.03-1.35) for every 10 × 10⁹ per litre drop in platelet count, p = 0.016). Eleven of the 116 patients (9%) developed a clinically significant thrombosis in ICU, which was the cause of death in four patients. The median platelet count was 20 × 10⁹ per litre (15-48) at the time of thrombosis. The patients received a median of 6 units of red blood cells, 1 unit of fresh frozen plasma and 8 units of platelet concentrates in ICU.

Conclusions: Severe and debilitating bleeding complications were frequent in our ICU patients with haematological malignancies, but thrombosis also occurred in spite of low platelet counts. Platelet count on ICU admission was associated with subsequent bleeding.

Keywords: Bleeding; Haematology; ICU; Intensive care; Leukaemia; Myelodysplastic syndrome; Sepsis; Thrombosis; Transfusion.

Fig. 1

Bleeding complications during ICU stay. No significant difference was seen in number of bleedings complications between the different diagnoses or in patients with haematopoietic stem cell transplantation (HSCT). ALL acute lymphoblastic leukaemia, MDS myelodysplastic syndrome, AML acute myeloid leukaemia

Fig. 2

Bleeding complications at different platelet levels. This figure shows the range of platelet level at ICU admission across our patient population and frequency of bleeding complications in ICU graded according to WHO, in which bleeding episodes are categorised as grade 1 (mild), grade 2 (moderate), grade 3 (severe; requiring red blood cell (RBC) transfusion within 24-h) or grade 4 (debilitating or life-threatening)

Fig. 3

Time to death showed as Kaplan–Meier survival curves in bleeding and non-bleeding patients. The log-rank score for bleeding was 1.74 (p = 0.19) and the hazard ratio (HR) for patients with bleeding as compared to non-bleeders was 1.37 (95% CI 0.86–2.19). Survival curves are presented with 95% confidential intervals

Fig. 4

Blood transfusions given the days before a WHO grade 3–4 bleeding episode. This figure shows the median amount of blood products given during the days leading up to a major bleeding. FFP fresh frozen plasma, RBC red blood cells, Plt platelet concentrate