ICU and Critically Ill ICU and Critically Ill Cancer PatientsCancer Patients

Dr Paul LaneDr Paul LaneSenior Staff Specialist, The Townsville HospitalSenior Staff Specialist, The Townsville Hospital

VMO, The Mater Misericordae Hospital, VMO, The Mater Misericordae Hospital, TownsvilleTownsville

Declaration….Declaration….

• I really struggle with this!!I really struggle with this!!

• ……nails in coffins…nails in coffins…

• Good opportunity to review the Good opportunity to review the literatureliterature

• Tell you what I do….Tell you what I do….

HistoryHistory

• High mortality, high costs, high High mortality, high costs, high burden for patients and families.burden for patients and families.

• General mortality ~90% …blower or General mortality ~90% …blower or post transplant.post transplant.

• 1995 European Cancer 1995 European Cancer Registry….100% mortality at Registry….100% mortality at 12months if 4 organ systems 12months if 4 organ systems supported.supported.

And now…And now…

• Experts are saying that prognosis Experts are saying that prognosis has improved in last decade.has improved in last decade.

• Potential benefits of early ICU carePotential benefits of early ICU care

• Better chemo…new drugs, intensified Better chemo…new drugs, intensified treatment protocols, better treatment protocols, better supportive caresupportive care

RituximabRituximab

• Chimeric monoclonal Ab against Chimeric monoclonal Ab against CD20 protein.CD20 protein.

• Destroys naughty B cellsDestroys naughty B cells

• Lymhoma, leukemia and othersLymhoma, leukemia and others

• Eg. CHOP+R better the CHOP aloneEg. CHOP+R better the CHOP alone

Velcade….great namesVelcade….great names

• BortezomideBortezomide

• Protease inhibitor for myeloma cellsProtease inhibitor for myeloma cells

• Changing face of disease…even in Changing face of disease…even in relapserelapse

• Thalidomide for MM…better survivalThalidomide for MM…better survival

• VIPERVIPER

SupportiveSupportive

• Better sepsis treatmentBetter sepsis treatment• Brief post op support goodBrief post op support good• NIV for cancer patientsNIV for cancer patients• Early vs Late RRT for cancer patientsEarly vs Late RRT for cancer patients• Soares etal 2006 J Clin Onc 300 patientsSoares etal 2006 J Clin Onc 300 patients• No survivors with late RRT (>4days)No survivors with late RRT (>4days)

• Ho KM etal Chest 2011 improved survival Ho KM etal Chest 2011 improved survival with VTE prophylaxiswith VTE prophylaxis

Ethics and costEthics and cost

• Health budgets under fireHealth budgets under fire

• QLD over $85billion debtQLD over $85billion debt

• I think we now need to consider thisI think we now need to consider this

• Hippocrates vs Social JusticeHippocrates vs Social Justice

• Billions spent taking life span from 78 Billions spent taking life span from 78 to 81to 81

Traditional…No longer Traditional…No longer relevantrelevant

• NeutropeniaNeutropenia

• Physiological severityPhysiological severity

• Stem cell transplantStem cell transplant

• No specific cancer prognosis systemsNo specific cancer prognosis systems

TraditionalTraditional

• Uncontrolled cancer remains badUncontrolled cancer remains bad

• Prolonged ICU admission remains Prolonged ICU admission remains badbad

• In responding patients (3yr survival), In responding patients (3yr survival), outlook more guided by performance outlook more guided by performance status and number of organ systems status and number of organ systems down. (Massion et al)down. (Massion et al)

NeutropeniaNeutropenia

• Regazzoni etal 2004 / Blot et al …Regazzoni etal 2004 / Blot et al …outcome based on severity and outcome based on severity and number of organ failures not number of organ failures not neutrophil count or duration of neutrophil count or duration of neutropenia.neutropenia.

Allogeneic HSCTAllogeneic HSCT

• Mortality historically 100%Mortality historically 100%

• Autologous vs Allogeneic (GVHD)Autologous vs Allogeneic (GVHD)

• Early Allo HSCT much better then Early Allo HSCT much better then latelate

• No longer dreadful prognosis, but No longer dreadful prognosis, but late allo HSCT with GVHD is Bad!!late allo HSCT with GVHD is Bad!!

Chemo in ICUChemo in ICU

• Darmon et al 2005Darmon et al 2005

• 100 preselected patients100 preselected patients

• Cancer chemotherapy for newly Cancer chemotherapy for newly diagnosed malignanciesdiagnosed malignancies

• 50% 6 month survival50% 6 month survival

• 30% at 30days if ETT30% at 30days if ETT

So….So….

• 1 is 30%, 2 is 60% and 3 is 90%1 is 30%, 2 is 60% and 3 is 90%

• The course of organ dysfunction is The course of organ dysfunction is the keythe key

• Late presentation, particularly RRT Late presentation, particularly RRT initiation is lethalinitiation is lethal

What do I do…What do I do…

• Biases and heuristics…Framing Effect, Biases and heuristics…Framing Effect, Selective recall.Selective recall.

• Talk to Haem-Onc Consultant (key)Talk to Haem-Onc Consultant (key)

• Cancer state and functional statusCancer state and functional status

• ARP prior to ICU admissionARP prior to ICU admission

• ‘‘trial’ of ICU…try and keep patient trial’ of ICU…try and keep patient comfortable, serial evaluation of comfortable, serial evaluation of status status

So….to sum upSo….to sum up

• Prognosis is betterPrognosis is better

• Usual culprits for bad outlook are Usual culprits for bad outlook are severity and number of organ system severity and number of organ system failures, poor functional status and failures, poor functional status and uncontrolled cancer.uncontrolled cancer.

• Early admission better…Early admission better…

Questions?Questions?