The Intensive Care Medicine research agenda on critically ill oncology and hematology patients

Azoulay, Élie; Schellongowski, Peter; Darmon, Michaël; Bauer, Philippe R.; Benoît, Dominique; Depuydt, Pieter; Divatia, Jigeeshu V.; Lemiale, Virginie; Vliet, Mario van; Meert, Anne-Pascale; Mokart, Djamel; Pastores, Stephen M.; Perner, Anders; Pène, Frédéric; Pickkers, Peter; Puxty, Kathryn; Vincent, François; Salluh, Jorge I.; Soubani, Ayman O.; Antonelli, Massimo; Staudinger, Thomas; Bergwelt‐Baildon, Michael von; Soares, Márcio

doi:10.1007/s00134-017-4884-z

Cited by 144 publications

(130 citation statements)

References 149 publications

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“…Non-invasive ventilation (NIV) is frequently used as firstline respiratory support in HSCT patients [46]. However, early studies which showed a mortality benefit in immunosuppressed patients with using NIV compared to invasive mechanical ventilation were limited by relatively few numbers of HSCT patients and extremely high mortality in the control groups [47,48]. It is nearly impossible to control delivered tidal volume with NIV and high delivered noninvasive tidal volumes are linked to higher rates of NIV failure [49].…”

Section: Respiratory Viral Infection Is Common Aftermentioning

confidence: 99%

“…The presence of respiratory failure, respiratory symptoms, or abnormalities on chest imaging should prompt evaluation for a respiratory infection. In many cases a non-invasive evaluation is appropriate, but bronchoscopy may be indicated in some patients [48,54,55], and bronchoscopic findings that lead to a change in management are associated with improved outcomes [55].…”

Section: Respiratory Viral Infection Is Common Aftermentioning

confidence: 99%

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ICU Complications of Hematopoietic Stem Cell Transplant, Including Graft vs Host Disease

Stephens

2020

Evidence-Based Critical Care

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A 44 year-old woman with a history of acute myeloid leukemia (AML) underwent a non-myeloablative haploidentical peripheral blood hematopoietic stem cell transplant (HSCT) 10 days ago. She was admitted to the hospital with fevers to 39 °C. On examination, she is anxious-appearing, with a temperature of 38.9 °C, a heart rate of 120 beats/min, a respiratory rate of 28 breaths/min, a blood pressure of 98/64 mmHg, and an oxygen saturation of 94% on 4 L/min oxygen via nasal cannula. A tunneled central venous catheter is in situ in her right internal jugular vein. Her total white blood cell (WBC) count is <0.5 cells/mm 3 and platelet count is 8000 cells/mm 3 . A chest CT scan shows diffuse patchy bilateral infiltrates (Figure). She is started on empiric antibiotic coverage with piperacillin/tazobactam, and 3 L of crystalloid are administered. Several hours later, she is more hypotensive, with nadir systolic pressures of 80-88 mmHg, and is more hypoxic, now saturating 85% on 6 L/min nasal cannula oxygen. QuestionHow should this patient be managed?Answer Broad spectrum antibiotics and lung-protective respiratory support.All patients after HSCT are immunosuppressed, profoundly so in the early post-transplant period before engraftment has occurred. This patient is likely to have a pneumonia with secondary septic shock, but a central line-associated infection from her tunneled central line is possible, as are non-infectious complications of HSCT. Respiratory failure is the most frequent cause of intensive care unit (ICU) admission after HSCT, most frequently from an infectious cause. The patient was placed on high-flow nasal cannula (HFNC) for oxygenation support and started on a norepinephrine infusion for hemodynamic support. Antibacterial coverage was changed to meropenem, levofloxacin, and vancomycin, and voriconazole was added for antifungal coverage. Her central line was removed. Her respiratory status continued to decline, and endotracheal intubation and mechanical ventilation were required 24 h after admission. She was placed on volume assist-control with a tidal volume of 6 mL/kg predicted body weight, and bronchoscopy with bronchoalveolar lavage (BAL) was performed. The BAL fluid was initially bloody, but cleared with sequential aliquots. Microbiologic studies of the BAL fluid were positive for respiratory syncytial virus and Pseudomonas aeruginosa. She was maintained on low tidal-volume ventilation and vasopressors were weaned off. Her white blood cell count slowly began to recover, and her respiratory status began to improve. She was extubated on hospital day 12 and was discharged from the ICU on hospital day 14. Principles of ManagementHematopoietic stem cell transplant (HSCT) has become an essential therapeutic modality in the treatment of malignant and non-malignant hematologic disease. In 2016, more than 23,000 HSCTs were performed in the United States, including approximately 15,000 autologous HSCTs and more than 8500 allogeneic transplants [1]. Allogeneic transplants are associated with more morbidity and m...

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Section: Respiratory Viral Infection Is Common Aftermentioning

confidence: 99%

Section: Respiratory Viral Infection Is Common Aftermentioning

confidence: 99%

ICU Complications of Hematopoietic Stem Cell Transplant, Including Graft vs Host Disease

Stephens

2020

Evidence-Based Critical Care

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“…Relevant information about this should be given to the patient early enough, so that taking note of the patient's wishes may contribute to meaningful decision-making at a later timepoint, as close as possible to the patient's values and preferences. It is essential that this approach be carried out in collaboration between the oncologist, the patient, the family, the palliative care team and the intensivist (11,26).…”

Section: In This Context How Is the Decision On Icu Admission Made?mentioning

confidence: 99%

“…It is likely that patients with cancer have yielded benefit from the technical progress in intensive care medicine in the same way as patients with other diseases. Conversely, admission to the ICU during an acute episode remains associated with a higher mortality rate than admissions arising from scheduled surgery (3,4,11,12).…”

Section: Introductionmentioning

confidence: 99%

What are the ethical aspects surrounding intensive care unit admission in patients with cancer?

Rigaud¹,

Large²,

Meunier-Beillard³

et al. 2017

Ann. Transl. Med.

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Improvements in living conditions and increasing life expectancy have combined to result in ever older patients being admitted to hospital. In parallel, the increasing incidence of cancer, along with the improved efficacy of anti-cancer therapies has led to greater needs for intensive care among cancer patients.The objectives underpinning the management of cancer patients in the intensive care unit (ICU) are to achieve a return to a clinical status that would allow the patient to be either, transferred back to the original unit, or discharged from the hospital with an acceptable quality of life, and where warranted, pursuit of cancer therapy. The relevance of ICU admission should be assessed systematically for patients with active cancer. The decision needs to be made taking into account the expected benefit for the patient, the lifesupport therapies that are possible with discussion about a care project, and also considering the future quality of life and the short and long-term prognosis. Anticipating the question of potential ICU admission should help protect the patient against both inappropriate refusal of intensive care, and inappropriate admission to the ICU that might only lead to unreasonable therapeutic obstinacy. The intensive care physician has a major role to play in helping the cancer patient to develop an appropriate and flexible healthcare project. Anticipating the question of ICU admission in advance, as well as a close alliance between the oncologist and the intensive care physician are the two keys to the success of a healthcare project focused on the patient.

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“…13,14 In a cohort of 5 000 cancer patients requiring ventilator support for more than 21 days, median 1-year survival was 14.3%. 15 Subgroup analysis of those with lung cancer revealed a dismal 1-year survival rate of 6.6%.…”

Section: Clinical Momentum As An Underappreciated Forcementioning

confidence: 99%

Should Physicians New to a Case Counsel Patients and Their Families to Change Course at the End of Life?

Honiden

Possick

2018

AMA Journal of Ethics

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The Intensive Care Medicine research agenda on critically ill oncology and hematology patients

Cited by 144 publications

References 149 publications

ICU Complications of Hematopoietic Stem Cell Transplant, Including Graft vs Host Disease

ICU Complications of Hematopoietic Stem Cell Transplant, Including Graft vs Host Disease

What are the ethical aspects surrounding intensive care unit admission in patients with cancer?

Should Physicians New to a Case Counsel Patients and Their Families to Change Course at the End of Life?

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