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ICU and Critically Ill Cancer
         Patients
                    Dr Paul Lane
   Senior Staff Specialist, The Townsville Hospital

  VMO, The Mater Misericordae Hospital, Townsville
Declaration….

•   I really struggle with this!!
•   …nails in coffins…
•   Good opportunity to review the literature
•   Tell you what I do….
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.
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
Rituximab

• Chimeric monoclonal Ab against CD20
  protein.
• Destroys naughty B cells
• Lymhoma, leukemia and others
• Eg. CHOP+R better the CHOP alone
Velcade….great names

• Bortezomide
• Protease inhibitor for myeloma cells
• Changing face of disease…even in
  relapse
• Thalidomide for MM…better survival
• VIPER
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
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
Traditional…No longer relevant

•   Neutropenia
•   Physiological severity
•   Stem cell transplant


• No specific cancer prognosis systems
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)
Neutropenia

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

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Lane on Haem Malignancies in ICU

  • 1. ICU and Critically Ill Cancer Patients Dr Paul Lane Senior Staff Specialist, The Townsville Hospital VMO, The Mater Misericordae Hospital, Townsville
  • 2. Declaration…. • I really struggle with this!! • …nails in coffins… • Good opportunity to review the literature • Tell you what I do….
  • 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. 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. Rituximab • Chimeric monoclonal Ab against CD20 protein. • Destroys naughty B cells • Lymhoma, leukemia and others • Eg. CHOP+R better the CHOP alone
  • 6. Velcade….great names • Bortezomide • Protease inhibitor for myeloma cells • Changing face of disease…even in relapse • Thalidomide for MM…better survival • VIPER
  • 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. 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. Traditional…No longer relevant • Neutropenia • Physiological severity • Stem cell transplant • No specific cancer prognosis systems
  • 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. Neutropenia • Regazzoni etal 2004 / Blot et al … outcome based on severity and number of organ failures not neutrophil count or duration of neutropenia.
  • 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. 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. 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. 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. 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…