Outcomes in Critically Ill Patients With Systemic Rheumatic Disease: A Multicenter Study

Guillaume Dumas, MD; Guillaume Géri, MD; Claire Montlahuc, MD; Sarah Chemam, MD; Laurence Dangers, MD; Claire Pichereau, MD; Nicolas Brechot, MD; Matthieu Duprey, MD; Julien Mayaux, MD; Maleka Schenck, MD; Julie Boisramé-Helms, MD, PhD; Guillemette Thomas, MD; Loredana Baboi, PhD; Luc Mouthon, MD, PhD; Zair Amoura, MD, PhD; Thomas Papo, MD, PhD; Alfred Mahr, MD, PhD; Sylvie Chevret, MD, PhD; Jean-Daniel Chiche, MD, PhD; Elie Azoulay, MD, PhD

BACKGROUND: Patients with systemic rheumatic diseases (SRDs) may require ICU management for SRD exacerbation or treatment-related infections or toxicities.

METHODS: This was an observational study at 10 university-affiliated ICUs in France. Consecutive patients with SRDs were included. Determinants of ICU mortality were identified through multivariable logistic analysis.

RESULTS: Three hundred sixty-three patients (65.3% women; median age, 59 years [interquartile range, 42-70 years]) accounted for 381 admissions. Connective tissue disease (primarily systemic lupus erythematosus) accounted for 66.1% of SRDs and systemic vasculitides for 26.2% (chiefly antineutrophil cytoplasm antibodies-associated vasculitides). SRDs were newly diagnosed in 43 cases (11.3%). Direct admission to the ICU occurred in 143 cases (37.9%). Reasons for ICU admissions were infection (39.9%), SRD exacerbation (34.4%), toxicity (5.8%), or miscellaneous (19.9%). Respiratory involvement was the leading cause of admission (56.8%), followed by shock (41.5%) and acute kidney injury (42.2%). Median Sequential Organ Failure Assessment (SOFA) score on day 1 was 5 (3-8). Mechanical ventilation was required in 57% of cases, vasopressors in 33.9%, and renal replacement therapy in 28.1%. ICU mortality rate was 21.0% (80 deaths). Factors associated with ICU mortality were shock (OR, 3.77; 95% CI, 1.93-7.36), SOFA score at day 1 (OR, 1.19; 95% CI, 1.10-1.30), and direct admission (OR, 0.52; 95% CI, 0.28-0.97). Neither comorbidities nor SRD characteristics were associated with survival.

CONCLUSIONS: In patients with SRDs, critical care management is mostly needed only in patients with a previously known SRD; however, diagnosis can be made in the ICU for 12% of patients. Infection and SRD exacerbation account for more than two-thirds of these situations, both targeting chiefly the lungs. Direct admission to the ICU may improve outcomes.

Chest. 2015;148(4):927-935. doi:10.1378/chest.14-3098