Introduction and background
Methods
Strength | Recommendation |
A | Strong recommendation for use |
B | Moderate recommendation for use |
C | Marginal recommendation for use |
D | Recommendation against use |
Quality of evidence | |
I | Evidence from at least 1 properly designed randomized, controlled trial |
IIa | Evidence from at least 1 well-designed clinical trial, without randomization; from cohort or case-controlled analytic studies (preferably from > 1 center); from multiple time series; or from dramatic results of uncontrolled experiments |
III | Evidence from opinions of respected authorities, based on clinical experience, descriptive case studies |
Prognosis and ICU admission criteria
Whom to admit to the ICU/eligibility and goals of therapy
Full-code ICU management (without limitations of ICU resources) should be offered to all critically ill cancer patients if long-term survival may be compatible with the general prognosis of the underlying malignancy (A-IIu)
Patients with poor performance status not eligible for further anti-cancer therapy, dying patients, as well as those rejecting critical care treatment should not be admitted to the ICU in general (A-III)
For patients not fulfilling the above-described criteria for full-code ICU management or ICU refusal, time-limited ICU trials or pre-defined do-not-escalate decisions (e.g., do-not-intubate or do-not-attempt-resuscitation) may be adequate options (B-IIu)
When to admit to the ICU, indications and screening for organ dysfunction
Cancer patients should be considered for ICU admission in case of manifest or incipient acute organ dysfunction(s) (A-IIu)
Cancer ward patients at risk should be screened for the presence of sepsis daily (A-IIt)
Cancer ward patients at risk should be screened for the presence of acute organ dysfunction(s) daily (A-IIu)
Recommendations for local structures and educational matters
Centers should establish local admission criteria for critically ill cancer patients as well as standardized admission procedures, such as joint assessment by cancer specialists and intensivists, if available (A-III)
Centers should establish daily joint rounds of cancer specialists and intensivists as well as standard-operating procedures for the management of frequent medical conditions of critically ill cancer patients (A-IIu)
Centers should establish joint continuous medical education of cancer specialists and intensivists (A-III)
Basic concepts of the care of critically ill cancer patients should be included into the curricula of both cancer specialists and intensivists (A-III)
Intention | Clinical situation/intervention | SoR/QoE | Reference | |
---|---|---|---|---|
I. | Defining ICU eligibility criteria and goals of therapy | Full-code ICU management in all critically ill cancer patients with prospect of long-term survival | A-IIu | [3] |
II. | Defining ICU eligibility criteria and goals of therapy | ICU refusal in patients with poor performance status not eligible for further anti-cancer therapy, dying patients, as well as those rejecting critical care | A-III | |
III. | Defining ICU eligibility criteria and goals of therapy | Time-limited ICU trial and/or do-not-escalate decisions in patients neither fulfilling full code nor refusal criteria | B-IIu | |
IV. | Reducing mortality; indications for ICU admission | Early admission of patients with manifest or incipient acute organ dysfunction(s) to the ICU | A-IIu | |
V. | Reducing mortality; early identification of ICU candidates | Daily sepsis screening in cancer ward patients at risk | A-IIt | |
VI. | Reducing mortality; early identification of ICU candidates | Daily screening for acute organ dysfunctions in cancer ward patients at risk | A-IIu | |
VII. | Facilitating ICU admission decisions | Local ICU admission criteria and joint assessment by cancer specialists and intensivists | A-III | |
VIII. | Reducing mortality; local structures | Establish daily rounds of cancer specialists and intensivists | A-IIu | [20] |
IX. | Reducing mortality; local structures | Establish standard-operating procedures for frequent medical conditions of critically ill ICU cancer patients | A-IIu | [20] |
X. | Reducing mortality; local structures | Admit critically ill cancer patients to experienced ICUs | A-IIu | |
XI. | Continuous medical education | Establish joint continuous medical education of cancer specialist and intensivists | A-III | |
XII. | Basic medical education/training | Include basic concepts on critically ill cancer patients into cancer specialists’ and intensivists’ curricula | A-III |
Acute respiratory failure (ARF)
Diagnostic work-up
Independent of the clinical presentation, chest computed tomography is recommended (A-IIt)
Bronchoscopy and a BAL-based diagnostic work-up including a broad range of both culture- and non-culture-based diagnostic methods should be added to noninvasive tests depending on pretest probabilities of clinical etiologies (if clinically feasible early after ICU admission and without causing clinical worsening) (A-I)
Blood cultures | |
Multislice or high-resolution computed tomography (CT) scan of the lungs (in most cases without contrast media), (MRI of the lungs, if a pulmonary CT scan is not feasible) | |
Echocardiography (cardiac status) | |
Sputum examination for | Bacteria Fungi Mycobacteria |
Induced sputum |
Pneumocystis jiroveci
|
Nasopharyngeal aspirates | RSV, influenza |
Polymerase chain reaction blood test for | Herpesviridae Cytomegalovirus Epstein-Barr virus |
Circulating Aspergillus galactomannan | |
Serologic tests for |
Chlamydia pneumoniae
Mycoplasma pneumoniae
Legionella pneumophila
|
Urine antigen for |
Legionella pneumophila
Streptococcus pneumoniae
|
BAL (samples should include by default) | • Cytospin preparation including Giemsa stain for cytological diagnostics and Gram stain • Bacteriological cultures (quantitative or semi-quantitative) including culture media to detect Legionella spp., mycobacteria and fungi • Calcofluor white or equivalent stain (assessment of fungi) • (quantitative, if possible) PCR for Pneumocystis jirovecii • direct immunofluorescence test for Pneumocystis jirovecii • Aspergillus antigen (Galactomannan ELISA) • Mycobacterium tuberculosis PCR, atypical mycobacteria |
BAL (optional) | • PCR for cytomegalovirus, respiratory syncytial virus, influenza A/B virus, parainfluenza virus, human metapneumovirus, adenovirus, varicella zoster virus, and Pneumocystis jirovecii (quantitative) [34] • Aspergillus antigen (Galactomannan ELISA; ODI (optical density index): 1.0) Panfungal or Aspergillus/mucormycetes PCR |
Transbronchial biopsies | Not recommended in general in febrile neutropenic and/or thrombocytopenic patients as a first line procedure. |
Ventilatory strategies
Prior to NIV | Vasopressor need Multiple organ failure Airway involvement by malignancy Acute respiratory distress syndrome Unknown etiology of ARF Delayed onset of ARF |
During NIV | Patient not tolerating NIV No improvement of ABG within 6 h Respiratory rate > 30/min NIV dependency ≥ 3 days Clinical or respiratory deterioration Unknown etiology of ARF |
In case a NIV or HFNO trial is initiated in cancer patients with hypoxic ARF, common contraindications and/or the occurrence of pre-specified intubation criteria should lead to intubation and invasive mechanical ventilation without delay (A-IIu)
Given the considerable failure rates of NIV and HFNO in hypoxic ARF and the lack of sufficient data on the safety of such therapies in regular wards, NIV and HFNO should not be attempted in this indication on a regular ward (B-III)
End-of-life, palliative care
Special situations
Anticancer therapy during ICU
Prevention and treatment of infections in critically ill cancer patients
Intention | Clinical situation/Intervention | SoR/QoE | Reference | |
---|---|---|---|---|
I. | Reducing mortality | Treatment in close collaboration of intensivist with cancer specialist and ID specialist | AIIt | |
II. | Prevention of infections | Continuation of prophylactic antiviral, antibacterial and antifungal treatment upon ICU-admission, unless switch to therapeutic treatment or excessive organ toxicity | AIIt | |
III. | Prevention of infections | Immunization only according to specific guidelines for patients with cancer | BIII | [58] |
IV. | Treatment | Treatment of critically ill patients with infections including neutropenic sepsis according to current guidelines for the treatment of sepsis and septic shock | AIIt | [59] |
V. | Anti-infective treatment | Anti-infective treatment according to recommendations for treatment of bacterial, fungal and viral infections in cancer patients | AIIr | |
VI. | Reducing mortality | Recommendation against routine use of GCSF in neutropenic patients with pulmonary infiltrates | AIIr | |
VII | Reducing mortality | Use of GCSF only in selected cancer patients according to current recommendations. | AIIt | [68] |
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Management of neutropenic patients in the intensive care unit [69]
-
Unexplained fever in neutropenic patients [60] (new version in progress)
-
Diagnosis of invasive fungal infections [70] (new version in progress)
-
Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients [63]
-
Community-acquired respiratory viral infections [72]
-
Management of central venous catheter-related infections [73]
-
Gastrointestinal complications including neutropenic enterocolitis [74] (new version in progress).
-
Infections of the central nervous system in patients with hematological disorders [75]
-
IDSA guidelines on immunization in patients with cancer [58]; guidelines on immunization by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) are under progress.
-
Prophylaxis of infectious complications with colony-stimulating factors in adult cancer patients undergoing chemotherapy [68].
Allogeneic stem cell transplant setting
Criteria for ICU admission
Coagulation
Complications after new cancer drugs or cellular immunotherapy
VAIA
Transfusions
Cytokine storm disease/Sepsis-like syndromes
HLH-2004 diagnostic criteria: ≥ 5 must be fulfilled |
---|
- Fever (≥ 38.3 °C) |
- Splenomegaly |
- Cytopenias in ≥ 2 lines (hb < 9 g/dL, plt < 100 /nL, neutrophils < 1.0/nL) |
- Ferritin ≥ 500 μg/L |
- Hypertriglyceridemia and/or hypofibrinogenemia (fasting triglycerides ≥ 265 mg/dL, fibrinogen < 1.5 g/L) |
- Hemophagocytosis in bone marrow or spleen or lymph nodes |
- Low or absent NK activity |
- Soluble CD25 (soluble IL-2 receptor) ≥ 2400 U/mL |