|LETTER TO EDITOR
|Year : 2022 | Volume
| Issue : 1 | Page : 189-190
Organizational aspects of critical care in patients with hematologic malignancies and those undergoing stem cell transplantation
Suvir Singh1, Vivek K Gupta2, Gurkirat Kaur2
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 Submission||06-Jan-2022|
|Date of Decision||13-Jan-2022|
|Date of Acceptance||19-Jan-2022|
|Date of Web Publication||24-Feb-2022|
Department of Clinical Hematology, and Stem Cell Transplantation, Dayanand Medical College and Hospital, Ludhiana - 141 001, Punjab
Source of Support: None, Conflict of Interest: None
|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. 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., Several datasets have reported in-hospital mortality of over 80% for patients with acute myeloid leukemia (AML) requiring mechanical ventilation. 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).
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. 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. This has, in fact, encouraged ICU admission for patients with dysfunction in up to 2 organs, with survival rates ranging from 15% to 40%. 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.
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. 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. These can be calculated at the bedside and identify critical patients much earlier, translating into a reduced in-hospital mortality. 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. 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. 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.,
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. 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
Conflicts of interest
There are no conflicts of interest.
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