Outcomes of Patients with Hematological Malignancies Admitted to Critical Care.

INTRODUCTION

Advent of lung protective ventilatory modes, non invasive ventilation, superior renal filtration modalities, better antifungals, better antivirals, antibacterials represent significant advances in intensive care medicine. This coupled with reduced intensity conditioning protocols and T cell depletion transplantation strategies, have translated to improved overall survival outcomes for patients with haematological malignancies undergoing intensive chemotherapy and haematopoietic stem cell transplants.

METHODS

We report 43 consecutive admissions (41 patients) to our critical care unit over a 22 month period. Data was collected from the Electronic Patient Record System, patient notes and ICU databases.

FINDINGS

19 out of 43 (44.18%) admissions to critical care were due to sepsis. [Bacterial sepsis (n=6) [CNS (n=1), Serratia (n=1), Staph (n=1), Gram+ cocci (n=1), MRSA (n=1), Enterococci (n=1) ], viral sepsis(n=4) [(CMV (n=1), VZV (n=1), RSV(n=2) ], fungal sepsis (n=4), neutropenic sepsis without any positive blood cultures (n=5)]. Sepsis was associated with concomitant respiratory failure in 5 patients and renal failure in 3 patients.

Respiratory failure accounted for 12 admissions [ARDS/ALI (n=10), Pleural effusions (n=1), T-cell lymphoma involving lungs (n=1)]. Renal failure (n=8) and other causes (n=4) included gastrointestinal [GI hemorrhage (n=1), splenic rupture (n=1)], Steven Johnson syndrome (n=1) and tumor lysis syndrome (n=1)]

Of the patients who had been transplanted, there were 15 (34.88 %) admissions to critical care. (282 autologous and unrelated haematopoietic stem cell transplants were performed in the same period). 6 (37.5%) patients underwent autologous transplants [high dose Melphalan (n=3), BEAM (n=3)], 1 underwent a sibling allogeneic transplant, 2 patients underwent full intensity unrelated donor transplant [(Cyclo/TBI/Campath (n=1) and Melphalan/ TBI (n=1)] and the remaining 6 patients underwent reduced intensity transplants [ FMC conditioning (n=4), FM conditioning (n=1), Fludarabine/ Busulphan (n=1)].

Among the patients receiving intensive chemotherapy there were 28 (65.11 %) admissions to critical care [AML (n=7), ALL (n=6), CLL (n=1), MM (n=1), NHL (n=10) Sezary syndrome (n=1) Amyloidosis (n=1) and TPLL (n=1)]

Survival from the critical care unit, survival from the hospital admission, survival at 3 months and survival at 6 months were 26/ 43 (60.4%), 20/43 (46.5 %), 18/ 43 (41.8%) and 15/43 (34.88%) respectively.

CONCLUSION

Our findings justify early availability of facilities for single organ support (Level 2/HDU care) and timely transfer to level 3 care (more than one organ support) for patients undergoing treatment with intensive chemotherapy for haematological malignancies. Haemato - oncologists, transplant physicians and intensivists need to do combined assessments of the critically ill haemato oncology patient at an early stage to decide who will benefit from escalation of care. As haematological malignancies are heterogeneous in nature, the current ICU scoring systems need to be modified according to disease type to prognosticate outcomes more effectively.