the role of critical care for non-haematological malignancy

The Christie NHS Foundation Trust

The Role of Critical Care for Non-Haematological

Malignancy

Dr Phil Haji-Michael


Mr Onc.

Mr Heam.


The “patient journey” & Cancer

1) Long time to an anticipated poor outcome

2) Relatively well until a final decline

3) May well have discussed last wishes with their family

4) Palliative care planning and hospice care

Murray SA et al. BMJ 2005;330:1007-11.


Conflict with oncologists


Changing outcomes for cancer


For some cancers the natural history is becoming more like a chronic relapsing remitting disease


For some cancers things are little changed


Is survival alone the most important issue?


Issues for oncology patients in critical care• The individual patient’s journey not the cohort• How reversible is the acute condition• Is the current problem treatment related?• How much benefit for how much harm?• Decision making and who to talk to


Changes in critical care

• The impact of outreach (“upstream triage”)

• Newer technologies availableVentilators, NIV & cardiovascular

monitoring

• Standardisation of careSepsis & ventilator care bundles


Bigger issues…..

1) Availability of beds• Who do you pick & how do you judge?

Metastatic cancer vs emergency AAA2) Financial austerity & the NHS

• Cancer drugs versus hip replacements3) Demographics• Ageing population & they are not dying from

myocardial infarcts anymore4) Acute Oncology• Only 10% of “acute oncology” is treatment related


Scenarios


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What did you think of Lunch?

1) Good2) Poor3) Fantastic4) Unedible

83%

10%2

17%

30%4


Case 1: 57yr woman with Myeloma

Disease for 4 yr, now on 3rd line treatmentKnown recent vertebral fractureNow increasingly short of breath & febrile overpast 3 days

Seen by oncology registrar in clinic and admittedto the ward. He writes “For everything” in the notes.


Case 1: 57yr woman with Myeloma

Breathless at rest T 38.5˚CRR 25 BVM@ 15 l/min SaO2 85%Crepitataions in both basesHR120 BP 90/50 CRT 4 secPU’d 8hr ago, ABG pH 7.3 PO2 6 kPa PCO2 3.3 kPa BE -6Urea 15 Creat 200


Q1. Would you…

1) Admit for full level 3 care?

2) Admit for level 2 care only?

3) Limit to ward care only (level 1)?

4) Put on the end of life pathway?

5) Ring up, berate the Oncology SpR and refuse to come and see the patient?

40%

1

52%

20%3

2%

4

5%

5


Q2. Likely mortality? (hospital discharge)1) 100%

2) 80%

3) 60%

4) 40%

5) 20%

0%1

41%

2

30%

3

23%

4

7%

5


Case 2: 64yr woman with NHL

Stage IV B cell lymphoma 2yr agoIn remission but recently noticed parotid lumpMRI scan - tumor in parotid infiltrating left temporallobe

Attended for chemo, SpR noticed AF. Echo shows“thrombus in RA”. Admitted from clinic. Now (18:00 Friday) sudden deterioration & a call tooutreach…


Case 2: 64yr woman with NHL

Acutely unwell, clammy, breathlessRR 30 SaO2 83% on air Chest clear HR 65 BP 90/50 CRT 3 secNew systolic murmur 3/6ABG pH 7.48 pO2 8.55kPa pCO2 3.5kPa BE -2


Q3. The immediate plan would be..

1) Chemotherapy

2) Thrombolysis

3) Anticoagulation

4) Surgery (Thrombectomy)

5) More imaging (e.g. CT scan chest)

5%

1

24%

2

29%

3

14%

4

29%

5


Q4. Would you…





1 47.6%

2 31.0%

3 14.3%

4 7.1%


Case 3: 43yr woman Breast CA

Lumpectomy 5yr,Local recurrence 4yr, mastectomy, node clearance& local radiotherapy, and chemo (FEC)x61yr boney mets, now on Herceptin

Last 24hrs, developed fever, cough & felt unwell.Presented to local A&E


Case 3: 43yr woman Breast CA

In resus: Given O2 & 2 litres saline

Flushed and unwell. T 39˚CRR 20 SaO2 95% 35%FiO2Right basal signsHR120 BP 75/40 CRT <2secs feels warmHickman in situABG pH 7.3 pO2 9.6kPa pCO2 3.3kPa BE -6


Q5. What would you give for initial management of the circulation1) No drugs, just more fluids

2) Norepinephrine

3) Epinephrine

4) Dobutamine

5) Cardiac output monitoring & then decide

39%

1

27%

20%3

2%

4

32%

5


Q6. Would you…





1 65.9%

2 27.3%

3 4.6%

4 2.3%


Q7. Likely mortality? (hospital discharge)1) 100%

2) 80%

3) 60%

4) 40%

5) 20%

0%1

9%

2

26%

3

53%

4

12%

5


Case 4: 74 yr man with Lung CA

Non-small cell lung cancer diagnosed 5monthsago. Smoker 40 pack years.On radical radiotherapy (now at 16/20)Admitted to the ward not coping, difficulty swallowing &productive coughIncreasingly short of breath

On fentanyl patches for pain, increased on admissionDeteriorates over 48hr, now drowsy and low sats..


Case 4: 74 yr man with Lung CA

Unwell T37.5˚CRR 30 SaO2 85% on 24% OxygenBronchial breathing and crepitations on right baseHR 120 BP 110/60 CRT < 2 secsDrowsy and only responsive to pain. Small pupils.

Already on antibiotics for his “chest”ABG pH 7.28 pCO2 7.8kPa pO2 8.8kPa BE -1


Q8. Would you…





1 14.0%

2 16.3%

3 32.6%

4 37.2%


Summary

Cancer is a very heterogeneous group of diseasesOutcome has changed radically for some over thepast few decadesEqually critical care has undergone a similartransformationOpen and honest dialogue between Oncology andCritical Care is essentialUpstream/ward assessment and triage is also key“How much harm for how much benefit”


Thank you

the role of critical care for non-haematological malignancy

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