Patients with hematological malignancies admitted to intensive care units: new challenges for the intensivist

Advances in treatment of cancer patients and improved understanding of pathophysiological mechanisms behind malignant diseases contribute to increased survival and, consequently, increasing needs of intensive care support for this population.⁽¹⁾ It should be highlighted that ‘cancer’ is a name generically given to a widely heterogeneous group of diseases; in comparison to solid tumors, hematological neoplasms show a number peculiar features. Among the most relevant, it should be emphasized the urgency of starting anti-cancer therapy, as often required in high-grade hematological neoplasms as acute leukemia and aggressive lymphomas. Specific research on this subgroup is warranted, considering the potential prognostic impact of the underlying neoplasm behavior and center-specific features (such as volume of cases, availability of anti-cancer agents and specific diagnosis techniques).⁽²⁾

In the past two decades, intensive care units (ICU) increasingly played a relevant role, both treating infective intercurrences and severe complications related to the cancer itself and its therapy; and preventive admissions of high-risk patients undergoing chemotherapy.⁽³⁾Currently, refusing ICU admissions based only on the type of hematological cancer is no longer justifiable. Therefore, the intensive care specialty faces new challenges represented by severely ill patients with malignant underlying diseases requiring, in addition to traditional intensive care, progressively more specific knowledge on oncology.⁽⁴⁾

These new and progressive challenges require the intensivist to be capable of offering both the best clinical care and appropriate advice for patient and family members regarding prognosis, therapeutic options and preferences. Therefore, some behavioral changes are required, particularly regarding improved cooperation between intensivists and oncologists/hematologists. In addition to influencing the clinical practice and decision making on anti-cancer therapy, this interaction may contribute to appropriately select patients who may better benefit from intensive care.⁽⁴⁾ A suitable example of such cooperation is giving urgent intravenous chemotherapy to hematological patients during their ICU stay. This cooperation has been shown feasible, adding a positive impact on selected patients’ prognosis, including for those with highly severe diseases.^(3,5)

Some independent aspects associated to poor prognosis in severely ill hematological cancer patients have been identified, such as the need of invasive respiratory support, more organ dysfunctions, poor performance status and neoplasm organ infiltrations.^(6,7) Now, the challenge is to evaluate if these findings translate into bedside benefits in different scenarios.⁽⁸⁾ So far, most of the studies assessing this population outcomes in Brazilian ICUs have included solid tumors, rendering difficult interpreting the results.⁽⁹⁾

In this issue of RBTI, Barreto et al. report on the two-year assessment of 157 hematological disease adult patients admitted to a general ICU in a Brazilian university hospital.⁽¹⁰⁾ Although conducted in one single center, this study adds relevant information on the scenario of hematological patients in Brazilian ICUs. The authors observed a high prevalence of cancer, 81.6% of this hematological patients’ sample. This translated into one out every six ICU admissions in this timeframe. The reported ICU and hospital mortality rates were 47.8% and 73.2%, respectively. Multiple factors may have contributed to such high rates. Among them, the disease severity upon ICU admission, assessed by SAPS 3 score, was shown to be an independent mortality predictor. These findings highlight the results of recent studies stressing the relevance of early intensive care in severely ill patients. Expert recommendations for widening criteria for admitting hematological cancer patients to the ICU and full intensive care within the first days should be aligned with identifying early stage of critical diseases. Ideally, before organ dysfunctions are installed.⁽¹¹⁾ Thus, a possible intervention target is apparent, particularly in Brazil, where the access to intensive care is jeopardized by system ineffectiveness and/or shortness of intensive care beds.⁽¹²⁾ Recently a European study including hematological cancer patients in 17 ICUs located in France and Belgium identified that ICU admission within the first 24 hours after hospital admission is associated to better survival rates in comparison to the a priori anticipated. The reported hospital mortality was 39%, and both cancer disease control and health-related quality of life following discharge were considered satisfactory, suggesting that appropriate cost-benefit ratio was achieved.⁽⁷⁾

Respiratory failure is known to be the main cause leading hematological patients to intensive care admission; another relevant contribution by Barreto et al.⁽¹⁰⁾ regards the encouraging hospital survival rates found in patients undergoing noninvasive mechanic ventilation (NIMV). These rates were similar to those found in patients requiring no respiratory support at all. Yet in patients failing to NIMV, the mortality rate was high, even above the rate observed in patients whose first respiratory support option was invasive mechanic ventilation. These results confirm previous results^(13,14) supporting both decisions for electing invasive respiratory support in selected patients and the importance of early identification of NIMV failure associated features. In the study by Barreto et al. the subgroup failing to NIMV had more severe respiratory dysfunction and increased use of hemodynamic support within the first 24 hours following ICU admission; this agrees with the literature.⁽¹⁵⁾According to the current knowledge, upon identification of these features, invasive respiratory support would be the preferable starting strategy.

The study by Barreto et al.⁽¹⁰⁾ reports on relevant information about features of hematological diseases in severely ill patients. However, additional research is warranted to better understand the profile of this population of patients, increasingly admitted to Brazilian ICUs. New data on long-term mortality, health-related quality of life following ICU discharge and characterization of possibly outcome-related ICU issues are necessary for better assessing the care provided to these patients.

REFERÊNCIAS

• ¹
  Azoulay E, Pène F, Darmon M, Lengliné E, Benoit D, Soares M, Vincent F, Bruneel F, Perez P, Lemiale V, Mokart D; Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique (Grrr-OH). Managing critically Ill hematology patients: Time to think differently. Blood Rev. 2015. [Epub ahead of print]
• ²
  Bird GT, Farquhar-Smith P, Wigmore T, Potter M, Gruber PC. Outcomes and prognostic factors in patients with haematological malignancy admitted to a specialist cancer intensive care unit: a 5 yr study. Br J Anaesth. 2012;108(3):452-9.
• ³
  Benoit DD, Depuydt PO, Vandewoude KH, Offner FC, Boterberg T, De Cock CA, et al. Outcome in severely ill patients with hematological malignancies who received intravenous chemotherapy in the intensive care unit. Intensive Care Med. 2006;32(1):93-9.
• ⁴
  Azoulay E, Soares M, Darmon M, Benoit D, Pastores S, Afessa B. Intensive care of the cancer patient: recent achievements and remaining challenges. Ann Intensive Care. 2011;1(1):5.
• ⁵
  Darmon M, Thiery G, Ciroldi M, de Miranda S, Galicier L, Raffoux E, et al. Intensive care in patients with newly diagnosed malignancies and a need for cancer chemotherapy. Crit Care Med. 2005;33(11):2488-93.
• ⁶
  Benoit DD, Vandewoude KH, Decruyenaere JM, Hoste EA, Colardyn FA. Outcome and early prognostic indicators in patients with a hematologic malignancy admitted to the intensive care unit for a life-threatening complication. Crit Care Med. 2003;31(1):104-12.
• ⁷
  Azoulay E, Mokart D, Pène F, Lambert J, Kouatchet A, Mayaux J, et al. Outcomes of critically ill patients with hematologic malignancies: prospective multicenter data from France and Belgium-a groupe de recherche respiratoire en réanimation onco-hématologique study. J Clin Oncol. 2013;31(22):2810-8.
• ⁸
  Benoit DD, Soares M, Azoulay E. Has survival increased in cancer patients admitted to the ICU? We are not sure. Intensive Care Med. 2014;40(10):1576-9.
• ⁹
  Soares M, Caruso P, Silva E, Teles JM, Lobo SM, Friedman G, Dal Pizzol F, Mello PV, Bozza FA, Silva UV, Torelly AP, Knibel MF, Rezende E, Netto JJ, Piras C, Castro A, Ferreira BS, Réa-Neto A, Olmedo PB, Salluh JI; Brazilian Research in Intensive Care Network (BRICNet). Characteristics and outcomes of patients with cancer requiring admission to intensive care units: a prospective multicenter study. Crit Care Med. 2010;38(1):9-15.
• ¹⁰
  Barreto LM, Torga JP, Coelho SV, Nobre V. Principais características observadas em pacientes com doenças hematológicas admitidos em unidade de terapia intensiva de um hospital universitário. Rev Bras Ter Intensiva. 2015;27(3):212-9.
• ¹¹
  Mokart D, Lambert J, Schnell D, Fouché L, Rabbat A, Kouatchet A, et al. Delayed intensive care unit admission is associated with increased mortality in patients with cancer with acute respiratory failure. Leuk Lymphoma. 2013;54(8):1724-9.
• ¹²
  Soares M, Salluh JI, Sullah JI. Advanced supportive care for patients with cancer in Latin America. Lancet Oncol. 2013;14(9):e337. Erratum in: Lancet Oncol. 2013;14(12):e493. Sullah, Jorge I F [corrected to Salluh, Jorge I F].
• ¹³
  Azoulay E, Attalah H, Harf A, Schlemmer B, Delclaux C. Granulocyte colony-stimulating factor or neutrophil-induced pulmonary toxicity: myth or reality? Systematic review of clinical case reports and experimental data. Chest. 2001;120(5):1695-701.
• ¹⁴
  Depuydt PO, Benoit DD, Roosens CD, Offner FC, Noens LA, Decruyenaere JM. The impact of the initial ventilatory strategy on survival in hematological patients with acute hypoxemic respiratory failure. J Crit Care. 2010;25(1):30-6.
• ¹⁵
  Adda M, Coquet I, Darmon M, Thiery G, Schlemmer B, Azoulay E. Predictors of noninvasive ventilation failure in patients with hematologic malignancy and acute respiratory failure. Crit Care Med. 2008;36(10):2766-72.

Publication Dates

• Publication in this collection
  Sept 2015