Lane on Haem Malignancies in ICU

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Paul Lane is an intensivist from Townsville, in the tropical north of Queensland, Australia. He gave this talk at last year's bedside critical care conference straight after Ed Morris' talk on the same subject. In this talk, Paul brings the intensivist's perspective. Not too late to join the 550 others coming to SMACC - see the website for details and see ICN for Paul's slides that go with this talk.

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Lane on Haem Malignancies in ICU

  1. 1. ICU and Critically Ill Cancer Patients Dr Paul Lane Senior Staff Specialist, The Townsville Hospital VMO, The Mater Misericordae Hospital, Townsville
  2. 2. Declaration….• I really struggle with this!!• …nails in coffins…• Good opportunity to review the literature• Tell you what I do….
  3. 3. History• High mortality, high costs, high burden for patients and families.• General mortality ~90% …blower or post transplant.• 1995 European Cancer Registry….100% mortality at 12months if 4 organ systems supported.
  4. 4. And now…• Experts are saying that prognosis has improved in last decade.• Potential benefits of early ICU care• Better chemo…new drugs, intensified treatment protocols, better supportive care
  5. 5. Rituximab• Chimeric monoclonal Ab against CD20 protein.• Destroys naughty B cells• Lymhoma, leukemia and others• Eg. CHOP+R better the CHOP alone
  6. 6. Velcade….great names• Bortezomide• Protease inhibitor for myeloma cells• Changing face of disease…even in relapse• Thalidomide for MM…better survival• VIPER
  7. 7. Supportive• Better sepsis treatment• Brief post op support good• NIV for cancer patients• Early vs Late RRT for cancer patients• Soares etal 2006 J Clin Onc 300 patients• No survivors with late RRT (>4days)• Ho KM etal Chest 2011 improved survival with VTE prophylaxis
  8. 8. Ethics and cost• Health budgets under fire• QLD over $85billion debt• I think we now need to consider this• Hippocrates vs Social Justice• Billions spent taking life span from 78 to 81
  9. 9. Traditional…No longer relevant• Neutropenia• Physiological severity• Stem cell transplant• No specific cancer prognosis systems
  10. 10. Traditional• Uncontrolled cancer remains bad• Prolonged ICU admission remains bad• In responding patients (3yr survival), outlook more guided by performance status and number of organ systems down. (Massion et al)
  11. 11. Neutropenia• Regazzoni etal 2004 / Blot et al … outcome based on severity and number of organ failures not neutrophil count or duration of neutropenia.
  12. 12. Allogeneic HSCT• Mortality historically 100%• Autologous vs Allogeneic (GVHD)• Early Allo HSCT much better then late• No longer dreadful prognosis, but late allo HSCT with GVHD is Bad!!
  13. 13. Chemo in ICU• Darmon et al 2005• 100 preselected patients• Cancer chemotherapy for newly diagnosed malignancies• 50% 6 month survival• 30% at 30days if ETT
  14. 14. So….• 1 is 30%, 2 is 60% and 3 is 90%• The course of organ dysfunction is the key• Late presentation, particularly RRT initiation is lethal
  15. 15. What do I do…• Biases and heuristics…Framing Effect, Selective recall.• Talk to Haem-Onc Consultant (key)• Cancer state and functional status• ARP prior to ICU admission• ‘trial’ of ICU…try and keep patient comfortable, serial evaluation of status
  16. 16. So….to sum up• Prognosis is better• Usual culprits for bad outlook are severity and number of organ system failures, poor functional status and uncontrolled cancer.• Early admission better…
  17. 17. Questions?

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