The intensive care support of patients with malignancy: do everything that can be done

Excerpt

Over the last 20 years several advances have been made in the early diagnosis and aggressive management of patients with various types of malignancies, resulting in a decrease in overall mortality by about 20% [1]. As a consequence of aggressive and effective surgery, chemotherapy and radiation therapy, and longer overall survival the number of patients admitted to the intensive care unit (ICU) either for malignancy-related complications or treatment-associated side effects (chemotherapy-related organ toxicities and immunosuppression-related infection) has increased. In parallel with the overall improved survival, the recent literature has highlighted a reduced mortality rate in critically ill cancer patients [2, 3, 4, 5, 6], including autologous hematopoietic stem cell transplant recipients [2, 7], and those requiring life sustaining therapies for the management of acute respiratory failure, acute renal failure, or shock [8, 9, 10]. These improvements may be attributable to the following three factors: (a) Based on current recommendations [11], patients with poor functional status and underlying comorbidities as well as those with no available treatment for their underlying medical conditions may be denied admission to the ICU [8, 12]. Although these triage criteria lack sensitivity and specificity, they may lead to improved survival as the result of selection bias [13]. (b) Advances in the understanding of the pathophysiology of certain complications that develop in critically ill patients with malignancy have led to effective treatment and improved survival [7, 14, 15]. (c) The use of noninvasive mechanical ventilation in patients with acute respiratory failure has reduced the endotracheal intubation rate and subsequent mortality [8, 16]. These results provide evidence that ICU management would benefit cancer patients referred earlier to the ICU for noninvasive diagnostic and therapeutic strategies, providing these strategies do not delay intubation and optimal management [17, 18]. …