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2007| January-March | Volume 11 | Issue 1
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Deciding intensive care unit-admission for critically ill cancer patients
Guillaume Thiery, Michael Darmon, Elie Azoulay
January-March 2007, 11(1):12-18
Over the last 15 years, the management of critically ill cancer patients requiring intensive care unit admission has substantially changed. High mortality rates (75-85%) were reported 10-20 years ago in cancer patients requiring life sustaining treatments. Because of these high mortality rates, the high costs, and the moral burden for patients and their families, ICU admission of cancer patients became controversial, or even clearly discouraged by some. As a result, the reluctance of intensivists regarding cancer patients has led to frequent refusal admission in the ICU. However, prognosis of critically ill cancer patients has been improved over the past 10 years leading to an urgent need to reappraise this reluctance. In this review, the authors sought to highlight that critical care management, including mechanical ventilation and other life sustaining therapies, may benefit to cancer patients. In addition, criteria for ICU admission are discussed, with a particular emphasis to potential benefits of early ICU-admission.
Preventing acute renal failure is crucial during acute tumor lysis syndrome
Michael Darmon, Guillaume Thiery, Elie Azoulay
January-March 2007, 11(1):29-35
Tumour Lysis syndrome (TLS) is characterized by the massive destruction of tumoral cells and the release in the extracellular space of their content. While TLS may occur spontaneously before treatment, it usually develops shortly after the initiation of cytotoxic chemotherapy. These metabolites can overwhelm the homeostatic mechanisms and cause hyperuricemia, hyperkalemia, hyperphosphatemia and hypocalcemia. Moreover, TLS may lead to an acute renal failure (ARF). In addition to the hospital mortality induced by the acute renal failure itself, development of an ARF may preclude optimal cancer treatment. Therefore, prevention of the acute renal failure during acute tumor lysis syndrome is mandatory. The objective of this review is to describe pathophysiological mechanisms leading to acute tumor lysis syndrome, clinical and biological consequences of this syndrome and to provide up-to-date guidelines to ensure prevention and prompt management of this syndrome.
Prognostic factors in cancer patients in the intensive care unit
Marcio Soares, Jorge I.F Salluh
January-March 2007, 11(1):19-24
Intensive care has become important for the treatment of patients with cancer. However, the prognosis of these patients is considered poor a priori and decisions to admit a patient with cancer to the intensive care unit (ICU) are still source of controversy between oncologists and intensivists. The outcome of severely ill cancer patients does not depend solely on the causes that determine the admission to the ICU, but it also depends on cancer- and anticancer-related characteristics, such as performance status and cancer status. The decision-making process of ICU admission and of the appropriateness of advanced life-support requires a thorough evaluation of these characteristics and of the expectancies and wishes of patients and family members. A better understanding of such parameters may be helpful to avoid forgoing intensive care to patients who can potentially benefit from it.
The role of noninvasive ventilation in cancer patients with acute respiratory failure
January-March 2007, 11(1):25-28
The poor prognosis of ventilated patients with cancers, especially hematological malignancies, has been a major incentive in the use non-invasive ventilation in such patients. With experience of more than a decade, a few recommendations can be made. While experience in non invasive ventilation is of prime importance, it is the early use especially in conditions requiring supplemental oxygen and a drop in SaO
of > 10% that the most benefit is expected. Use of the helmet to provide noninvasive ventilation (NIV) may improve patient compliance. With appropriate use during diagnostic bronchoscopy, NIV may prevent endotracheal intubation. NIV has also been shown to provide relief from dyspnoea to a select group of do-not-intubate patients. While outcome in this group of patients is poor, appropriate use of NIV has been shown to reduce mortality. The coming years and more experience will improve our understanding and refine the use of this modality in this critical condition.
Critical care for cancer patients
January-March 2007, 11(1):1-3
Airway emergencies in cancer
Vijaya P Patil
January-March 2007, 11(1):36-44
Management of airway obstruction is always challenging but more so in cancer setting, as obstruction can lie at any level right from pyriform fossa to low down in medistinum. Morbidity is significant but if not managed properly leads to frightful death by suffocation. These cases need to be evaluated, diagnosed and managed with care, skill, speed and appropriate intervention. With the advent of technology, it has become much easier to manage such situations with a team of specialists involving anesthetist, thoracic surgeon and intensivist.
An overview of critical care in cancer patients
Atul P Kulkarni
January-March 2007, 11(1):4-11
Intensivists often refuse admission to cancer patients needing critical care, which may result in denial of effective care for some deserving patients. A cancer patient may need admission to intensive care units for a variety of reasons. The outcomes of patients with hematological malignancies, previously dismal, have improved over last 10 years. The previously known indicators of poor outcome are no longer valid in view of recent advances in intensive care. A select group of patients with hematological malignancies may be offered aggressive therapy for a limited duration and then prognosis can be reassessed. Cancer chemotherapy can produce toxicities affecting all major organ systems. Such patients may be admitted with acute organ dysfunction or years afterwards for incidental illnesses. Knowledge of these toxicities is essential for early diagnosis, management and prognostication in such patients. The post-surgical cancer patient has unique problems, the problems of these groups are discussed. The post-surgical cancer patient may need care ranging from only monitoring; in view of supra-major surgery in some patients; to fully aggressive intensive care for post-surgical anastomotic dehiscence, mediastinitis, septic shock and multiorgan dysfunction in others. The metabolic and mechanical complications commonly seen in non-surgical cancer patients are also discussed. Intensive care should be offered to all cancer patients who have a reasonable chance of cure or palliation of their disease.
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