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Table of Contents
LETTER TO EDITOR
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 189-190

Organizational aspects of critical care in patients with hematologic malignancies and those undergoing stem cell transplantation


1 Department of Clinical Haematology and Stem Cell Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Cardiac Anaesthesia and Critical Care, Hero DMC Heart Institute, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission06-Jan-2022
Date of Decision13-Jan-2022
Date of Acceptance19-Jan-2022
Date of Web Publication24-Feb-2022

Correspondence Address:
Suvir Singh
Department of Clinical Hematology, and Stem Cell Transplantation, Dayanand Medical College and Hospital, Ludhiana - 141 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_5_22

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How to cite this article:
Singh S, Gupta VK, Kaur G. Organizational aspects of critical care in patients with hematologic malignancies and those undergoing stem cell transplantation. Cancer Res Stat Treat 2022;5:189-90

How to cite this URL:
Singh S, Gupta VK, Kaur G. Organizational aspects of critical care in patients with hematologic malignancies and those undergoing stem cell transplantation. Cancer Res Stat Treat [serial online] 2022 [cited 2022 May 21];5:189-90. Available from: https://www.crstonline.com/text.asp?2022/5/1/189/342420



In the recent issue of Critical Care Clinics, Fornwalt et al. described key features of critical care requirements for patients undergoing hematopoietic stem cell transplantation in their review article.[1] This review describes an approach to specific situations that are unique to patients receiving a transplant, and an overview of organizational planning for critical care in these patients. Considering the comparable pathologic and physiologic changes, a similar approach is justified for other patients with hematologic malignancies, especially those with acute leukemia and severe neutropenia.

Conventionally, patients with hematologic malignancies who require critical care have been observed to have very poor rates of recovery with a high short-term mortality.[2],[3] Several datasets have reported in-hospital mortality of over 80% for patients with acute myeloid leukemia (AML) requiring mechanical ventilation.[4] Often, this leads to a pessimistic approach when managing critically ill patients with hematologic cancers, especially those with active leukemia, neutropenia, or organ dysfunction. However, the outcome for this subgroup of patients is improving, and the presence of neutropenia or active disease is no longer considered an exclusion criterion for admission to the intensive care unit (ICU).[5]

Selection of patients who are likely to benefit from ICU admission is one of the most important steps in ensuring that non-beneficial ICU admissions are avoided and patients likely to benefit are not denied intensive care. The most important predictors of survival in ICU traditionally include the extent of organ dysfunction, neutropenia, active disease, and scoring on critical illness severity scores (Acute Physiology and Chronic Health Evaluation-II and Simplified Acute Physiology Score). With advances in critical care science and more informed patient selection, the last few indicators are now less important, with the most important predictor being the extent of organ dysfunction.[6] Sequential end-organ involvement portends worse survival in ICU, as evidenced by a large cohort study of 1097 patients, in which the survival rate decreased from 38% for those with single-organ failure to <8% for those with failure of 4 organs.[7] This has, in fact, encouraged ICU admission for patients with dysfunction in up to 2 organs, with survival rates ranging from 15% to 40%.[8] It is essential to note that there is no specific prognostic scoring system for this group of patients.

This makes it essential to optimize resources for patients with hematologic malignancies and for those undergoing transplantation. With few exceptions, the few exceptions a few days continues to be a major challenge. As the majority of ICU expenses are out of pocket, a single ICU admission can disrupt individual finances and has been shown to amount to almost 50% of the per capita expenditure for an individual.[9]

First, a combined hematology/oncology/transplant-critical care team can be envisioned, with specific expertise in the above situations. Optimal management of patients in this setting requires proficiency in early identification of infections and sepsis in neutropenic patients, which are different from those seen in patients with normal immunity. As neutropenia is no longer an adverse prognostic factor for ICU admission, overcoming this barrier is expected to lead to better results.

Second, liaison between the ICU team and primary managing team in the wards/low dependency areas is vital. The Intensive Care National Audit and Research Centre study, including over 7600 patients, demonstrated that the care received in the ward before ICU admission is a significant determinant of survival.[10] This includes timely management of sepsis and respiratory failure and reducing delays in critical care transfer for patients who are likely to benefit.

The use of early warning systems, which document changes in physiological variables, is shown to objectively identify patients who need critical care support.[11] These can be calculated at the bedside and identify critical patients much earlier, translating into a reduced in-hospital mortality.[12] For cases in which an objective consensus to shift to the ICU cannot be reached, the concept of ICU “time trials” has been found to be useful. Full code management for at least 5 days in the ICU is identified as a pragmatic cut-off before reassessment and resetting of treatment goals.[13] Despite these approaches, identification of patients likely to benefit from ICU admission remains imprecise, and establishing a dedicated team could enable the development of specific proficiency.

Third, the use of equipment and structural modifications may be justified for these patients and is best guided by the local pattern of infections. For instance, physical isolation is shown to reduce the incidence of nosocomial infections in these patients, and although the evidence is challenged, it may be warranted based on local infection rates.[14] This fact is much more relevant for India, as infections continue to be the most common cause of mortality in patients with AML or those undergoing stem cell transplantation.[15],[16]

Therefore, ICU admission for patients undergoing treatment for hematologic cancers or stem cell transplantation is no longer associated with adverse outcomes by default. This is relevant in the Indian setting as well, where several innovations are contributing to improving outcomes with acute leukemia.[17] Careful selection of patients and close collaboration between the hematology/oncology and critical care teams can improve the outcomes in this high-risk group of patients and reduce non-beneficial admissions to the critical care setting. Regardless of the data, the decision to shift to the ICU should be guided by detailed communication between the patient's family, the critical care team, and the primary hematologist/oncologist. The prognosis of the primary malignancy and the patient's wishes for the extent of care must be kept at the forefront.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fornwalt RA, Brigham EP, Scott Stephens R. Critical care of hematopoietic stem cell transplant patients. Crit Care Clin 2021;37:29-46.  Back to cited text no. 1
    
2.
Groeger JS, Lemeshow S, Price K, Nierman DM, White P Jr., Klar J, et al. Multicenter outcome study of cancer patients admitted to the intensive care unit: A probability of mortality model. J Clin Oncol 1998;16:761-70.  Back to cited text no. 2
    
3.
Hill QA, Kelly RJ, Patalappa C, Whittle AM, Scally AJ, Hughes A, et al. Survival of patients with hematological malignancy admitted to the intensive care unit: Prognostic factors and outcome compared to unselected medical intensive care unit admissions, a parallel group study. Leuk Lymphoma 2012;53:282-8.  Back to cited text no. 3
    
4.
Tremblay LN, Hyland RH, Schouten BD, Hanly PJ. Survival of acute myelogenous leukemia patients requiring intubation/ventilatory support. Clin Invest Med 1995;18:19-24.  Back to cited text no. 4
    
5.
Thakkar SG, Fu AZ, Sweetenham JW, Mciver ZA, Mohan SR, Ramsingh G, et al. Survival and predictors of outcome in patients with acute leukemia admitted to the intensive care unit. Cancer 2008;112:2233-40.  Back to cited text no. 5
    
6.
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;108:452-9.  Back to cited text no. 6
    
7.
de Vries VA, Müller MC, Arbous MS, Biemond BJ, Blijlevens NM, Kusadasi N, et al. Long-term outcome of patients with a hematologic malignancy and multiple organ failure admitted at the intensive care. Crit Care Med 2019;47:e120-8.  Back to cited text no. 7
    
8.
Kroschinsky F, Weise M, Illmer T, Haenel M, Bornhaeuser M, Hoeffken G, et al. Outcome and prognostic features of intensive care unit treatment in patients with hematological malignancies. Intensive Care Med 2002;28:1294-300.  Back to cited text no. 8
    
9.
Jayaram R, Ramakrishnan N. Cost of intensive care in India. Indian J Crit Care Med 2008;12:55-61.  Back to cited text no. 9
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10.
Hampshire PA, Welch CA, McCrossan LA, Francis K, Harrison DA. Admission factors associated with hospital mortality in patients with haematological malignancy admitted to UK adult, general critical care units: A secondary analysis of the ICNARC Case Mix Programme Database. Crit Care 2009;13:R137.  Back to cited text no. 10
    
11.
Wise MP, Barnes RA, Baudouin SV, Howell D, Lyttelton M, Marks DI, et al. Guidelines on the management and admission to intensive care of critically ill adult patients with haematological malignancy in the UK. Br J Haematol 2015;171:179-88.  Back to cited text no. 11
    
12.
Bokhari SW, Munir T, Memon S, Byrne JL, Russell NH, Beed M. Impact of critical care reconfiguration and track-and-trigger outreach team intervention on outcomes of haematology patients requiring intensive care admission. Ann Hematol 2010;89:505-12.  Back to cited text no. 12
    
13.
Lecuyer L, Chevret S, Thiery G, Darmon M, Schlemmer B, Azoulay E. The ICU trial: A new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med 2007;35:808-14.  Back to cited text no. 13
    
14.
Klein BS, Perloff WH, Maki DG. Reduction of nosocomial infection during pediatric intensive care by protective isolation. N Engl J Med 1989;320:1714-21.  Back to cited text no. 14
    
15.
Shah CA, Karanwal A, Desai M, Pandya M, Shah R, Shah R. Hematopoietic stem-cell transplantation in the developing world: Experience from a center in Western India. J Oncol 2015;2015:710543.  Back to cited text no. 15
    
16.
Philip C, George B, Ganapule A, Korula A, Jain P, Alex AA, et al. Acute myeloid leukaemia: challenges and real world data from India. Br J Haematol 2015;170:110-7.  Back to cited text no. 16
    
17.
Nayak L. Optimizing acute leukemia treatment in resource-constrained settings. Cancer Res Stat Treat 2020;3:287-9.  Back to cited text no. 17
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