Chapter 6 - Special Considerations for ICU Management of Patients Receiving CAR Therapy

Abstract

Chimeric antigen receptor (CAR) T-cells belong to the class of immune effector cell (IEC) therapies, which have been associated with striking clinical outcomes, particularly among patients with relapsed/refractory hematologic malignancies. Yet, they have also been associated with unique toxicities, which may lead to very rapid and life-threatening cardiorespiratory, neurological, and multiorgan dysfunction. Cytokine release syndrome (CRS) and immune effector cell–associated neurotoxicity syndrome (ICANS) are well-described complications associated with CAR and other immunotherapies. The constellation of signs and symptoms of CAR-associated toxicities may require critical care recognition and intervention that is independent of CRS- and ICANS-specific treatment. Prompt recognition and supportive management by trained critical care staff of CAR-associated toxicities, including, but not limited to, hypotension and shock, acute respiratory distress syndrome (ARDS and pediatric ARDS), acute kidney injury, arrhythmias, coagulopathy, status epilepticus, and intracranial hypertension, may be lifesaving and/or preserve long-term organ function.