Patients withPatients with
haematological malignancyhaematological malignancy
should not be deniedshould not be denied
int...
IntroductionIntroduction
 I will argue that patients with haematological malignancyI will argue that patients with haemat...
Survival of cancer patients in NorthernSurvival of cancer patients in Northern
Ireland: 1993-2004Ireland: 1993-2004
 An o...
Relative survival from Hodgkin’s diseaseRelative survival from Hodgkin’s disease
(1993-2003)(1993-2003)
Relative survival form NHL by sex andRelative survival form NHL by sex and
period of diagnosis (1993-2003)period of diagno...
Relative survival from NHL by sex and periodRelative survival from NHL by sex and period
of diagnosis (1993-2000)of diagno...
Relative survival from multiple myelomaRelative survival from multiple myeloma
(1993-2000)(1993-2000)
Relative survival of all patients withRelative survival of all patients with
leukaemia (1993-2003)leukaemia (1993-2003)
Five year survival of
all patients
diagnosed with
cancer in Northern
Ireland (1996-2000)
Survival of cancer patients in
No...
The ICU Trial: A new admission policy forThe ICU Trial: A new admission policy for
cancer patients requiring mechanicalcan...
Impact of recent intravenous chemo onImpact of recent intravenous chemo on
outcome in severe sepsis and septic shockoutcom...
 Mortality rates appear better in those with recent chemoMortality rates appear better in those with recent chemo
compare...
Temporal changes in the management andTemporal changes in the management and
outcomes of septic shock in patients withoutc...
Outcome in critically ill medical patients treatedOutcome in critically ill medical patients treated
with renal replacemen...
 Those with haematological malignancy and RRT hadThose with haematological malignancy and RRT had
higher mortality rates:...
ConclusionConclusion
 Patients with haematological malignancies should not bePatients with haematological malignancies sh...
Upcoming SlideShare
Loading in...5
×

Patients with haematological malignancy should not be denied ...

252
-1

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
252
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
5
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Patients with haematological malignancy should not be denied ...

  1. 1. Patients withPatients with haematological malignancyhaematological malignancy should not be deniedshould not be denied intensive careintensive care Dr Sharon McCulloughDr Sharon McCullough StR 2 ICUStR 2 ICU
  2. 2. IntroductionIntroduction  I will argue that patients with haematological malignancyI will argue that patients with haematological malignancy should not be excluded from ICU just because they haveshould not be excluded from ICU just because they have a haematological malignancya haematological malignancy  Every patient has the right to be considered for ICUEvery patient has the right to be considered for ICU treatment in the event of life threatening acute illness, ittreatment in the event of life threatening acute illness, it is the role of the ICU consultant to consider all aspects ofis the role of the ICU consultant to consider all aspects of the patient’s case including co-morbid conditions andthe patient’s case including co-morbid conditions and pre-morbid statuspre-morbid status  I will give examples showing that while the mortality ofI will give examples showing that while the mortality of patients with haematological malignancies is notpatients with haematological malignancies is not insignificant, it is improving and haematologicalinsignificant, it is improving and haematological malignancy in itself should not be a barrier to ICUmalignancy in itself should not be a barrier to ICU
  3. 3. Survival of cancer patients in NorthernSurvival of cancer patients in Northern Ireland: 1993-2004Ireland: 1993-2004  An overall increase in the number of cancer cases eachAn overall increase in the number of cancer cases each year, relatively static incidence when European ageyear, relatively static incidence when European age standardisation used for comparisonstandardisation used for comparison  Overall improvement in the survival rates includingOverall improvement in the survival rates including haematological malignancies, except leukaemia (static)haematological malignancies, except leukaemia (static)
  4. 4. Relative survival from Hodgkin’s diseaseRelative survival from Hodgkin’s disease (1993-2003)(1993-2003)
  5. 5. Relative survival form NHL by sex andRelative survival form NHL by sex and period of diagnosis (1993-2003)period of diagnosis (1993-2003)
  6. 6. Relative survival from NHL by sex and periodRelative survival from NHL by sex and period of diagnosis (1993-2000)of diagnosis (1993-2000)
  7. 7. Relative survival from multiple myelomaRelative survival from multiple myeloma (1993-2000)(1993-2000)
  8. 8. Relative survival of all patients withRelative survival of all patients with leukaemia (1993-2003)leukaemia (1993-2003)
  9. 9. Five year survival of all patients diagnosed with cancer in Northern Ireland (1996-2000) Survival of cancer patients in Northern Ireland, N. Ireland Cancer Registry, Oct 2007
  10. 10. The ICU Trial: A new admission policy forThe ICU Trial: A new admission policy for cancer patients requiring mechanicalcancer patients requiring mechanical ventilationventilation  Crit Care MedCrit Care Med 2007 Mar;35(3):808-142007 Mar;35(3):808-14  188 patients with solid tumour or haematological188 patients with solid tumour or haematological malignancy requiring mechanical ventilation and at leastmalignancy requiring mechanical ventilation and at least one other organ failureone other organ failure  Bedridden patients or those on palliative treatment wereBedridden patients or those on palliative treatment were not admitted to ICUnot admitted to ICU  Survival was 40% inSurvival was 40% in mechanically ventilated cancer patients who survived tomechanically ventilated cancer patients who survived to day 5 and 21.8% overallday 5 and 21.8% overall
  11. 11. Impact of recent intravenous chemo onImpact of recent intravenous chemo on outcome in severe sepsis and septic shockoutcome in severe sepsis and septic shock patients with haematological malignanciespatients with haematological malignancies  Intensive Care MedIntensive Care Med 2008;34:847-8552008;34:847-855  Retrospective cohort study of 186 patients withRetrospective cohort study of 186 patients with haematological malignancy and sepsis (77) or septichaematological malignancy and sepsis (77) or septic shock (109).shock (109).  49% had received iv chemo49% had received iv chemo  They were more likely to have high grade malignancyThey were more likely to have high grade malignancy  More likely to be neutropenicMore likely to be neutropenic  Less likely to have pulmonary infiltratesLess likely to have pulmonary infiltrates  Less often required mechanical ventilationLess often required mechanical ventilation
  12. 12.  Mortality rates appear better in those with recent chemoMortality rates appear better in those with recent chemo compared to those without:compared to those without:  ICU mortality rate 33% vs 48.3%ICU mortality rate 33% vs 48.3%  28 day mortality rate 40.7% vs 57.4%28 day mortality rate 40.7% vs 57.4%  Hospital mortality rate 45.1% vs 58.8%Hospital mortality rate 45.1% vs 58.8%  6 month mortality rate 50.5% vs 63.2%6 month mortality rate 50.5% vs 63.2%  After adjustment with a propensity score for recentAfter adjustment with a propensity score for recent chemo, chemo was not associated with outcomechemo, chemo was not associated with outcome  Three independent variables associated with higher 28Three independent variables associated with higher 28 day mortality:day mortality:  SOFA score on ICU admission, pulmonary site of infection,SOFA score on ICU admission, pulmonary site of infection, fungal infectionfungal infection
  13. 13. Temporal changes in the management andTemporal changes in the management and outcomes of septic shock in patients withoutcomes of septic shock in patients with haematological malignancies in the ICU.haematological malignancies in the ICU.  Crit Care MedCrit Care Med 2008;36(6):690-6962008;36(6):690-696  8 year retrospective study (1998-2001 and 2002-2005)8 year retrospective study (1998-2001 and 2002-2005)  238 consecutive patients with cancer and septic shock238 consecutive patients with cancer and septic shock  Improvement in survival outcomes:Improvement in survival outcomes:  28 day survival rate 47.3% vs 27.8% (p=0.003)28 day survival rate 47.3% vs 27.8% (p=0.003)  ICU survival rate 41.2% vs 26.7% (p=0.02)ICU survival rate 41.2% vs 26.7% (p=0.02)  Hospital survival rate 36.5% vs 21.1% (p=0.01)Hospital survival rate 36.5% vs 21.1% (p=0.01)  Potential reasons: the use of adjuvant therapies such asPotential reasons: the use of adjuvant therapies such as steroids, insulin, CRRT, surviving sepsis campaign,steroids, insulin, CRRT, surviving sepsis campaign, better patient selectionbetter patient selection
  14. 14. Outcome in critically ill medical patients treatedOutcome in critically ill medical patients treated with renal replacement therapy for acute renalwith renal replacement therapy for acute renal failure: comparison between patients with andfailure: comparison between patients with and those without haematological malignanciesthose without haematological malignancies  Nephrol Dial TransplantNephrol Dial Transplant 2005;20:552-5582005;20:552-558  Retrospective data collection of all consecutive patients inRetrospective data collection of all consecutive patients in a medical IUC requiring RRT for ARF.a medical IUC requiring RRT for ARF.  22.5% of those admitted to the ICU with haematological22.5% of those admitted to the ICU with haematological malignancy required RRT vs 5.8% of those admittedmalignancy required RRT vs 5.8% of those admitted without haematological malignancywithout haematological malignancy
  15. 15.  Those with haematological malignancy and RRT hadThose with haematological malignancy and RRT had higher mortality rates:higher mortality rates:  ICU mortality rate 79.6% vs 55.7% (p=0.002)ICU mortality rate 79.6% vs 55.7% (p=0.002)  Hospital mortality rate 83.7 vs 66.1% (0.016)Hospital mortality rate 83.7 vs 66.1% (0.016)  6 month mortality rate 85% vs 72% (p=0.018)6 month mortality rate 85% vs 72% (p=0.018)  When adjusted for severity of illness and duration ofWhen adjusted for severity of illness and duration of hospitalisation before ICU admission, haematologicalhospitalisation before ICU admission, haematological malignancy was no longer associated with a higher riskmalignancy was no longer associated with a higher risk of death.of death.  Concluded therefore that the presence of haematologicalConcluded therefore that the presence of haematological malignancy was not a reason to withhold RRT in patientsmalignancy was not a reason to withhold RRT in patients with ARF.with ARF.
  16. 16. ConclusionConclusion  Patients with haematological malignancies should not bePatients with haematological malignancies should not be denied the consideration of ICU treatment for lifedenied the consideration of ICU treatment for life threatening acute illnessthreatening acute illness  Survival rates of haematological malignancies haveSurvival rates of haematological malignancies have improved in recent years and will likely to continue to doimproved in recent years and will likely to continue to do soso  Most patients present with sepsis or septic shock andMost patients present with sepsis or septic shock and the advancements of treatment of this have dramaticallythe advancements of treatment of this have dramatically improved survival ratesimproved survival rates  Studies show that those requiring mechanical ventilationStudies show that those requiring mechanical ventilation or RRT survive ICU management better than previouslyor RRT survive ICU management better than previously thoughtthought  It is unethical to withhold a treatment that may benefitIt is unethical to withhold a treatment that may benefit the patient.the patient.
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×