Haematological malignancy in ICU

Abstract

The admission of patients suffering haematological malignancy to the intensive care unit (ICU) is controversial due to their poor prognosis. The dilemma regarding admission has escalated with the development of more aggressive forms of chemotherapy. Whilst improving survival from primary disease these treatments also result in an increase in life-threatening complications requiring ICU admission.1 Analysis of patients admitted to a large ICU over a 3-yr period and data collected from surrounding regional hospitals has allowed determination of various prognostic factors that may assist in patient management. A retrospective observational study on patients with haematological malignancy admitted to ICU between January 1996 and July 1999 was conducted. Patients admitted from medical and haematological wards and a regional cancer centre were included, as were data from regional ICUs. Data included malignancy type, reason for admission, severity and duration of leucopenia, creatinine on admission, Logistic Organ Dysfunction (LOD) score, requirement for invasive ventilation and survival. Sixteen patients (8 male, 8 female) were admitted to the ICU within the specified time. An additional 13 patients were admitted to regional ICUs between January 1997 and July 1999. Haematological diagnoses: Hodgkin's lymphoma (7), non-Hodgkin's lymphoma (1), chronical lymphocytic leukaemia (3), chronic myeloid leukaemia (6), acute myelogenous leukaemia (6), acute lymphoblastic leukaemia (3), multiple myeloma (2). Admission to ICU was precipitated by pneumonia (35%), adult respiratory distress syndrome (15%), sepsis (15%), multi-organ failure (15%), bleeding (12%) and graft-versus-host disease (8%). On admission LOD scores ranged from 1–16 (average 6.5) and ICU mortality was 71%. Of the 30% surviving ICU, only 18% survived to long term (>6 months). Survival was associated with not requiring mechanical ventilation, a normal white cell count or brief period of neutropenia. A creatinine on admission of greater than 200 μmol litre−1 was noted to be associated with mortality (P = 0.05). In logistic regression analysis haematological malignancy is significantly associated with in hospital mortality (P In conclusion it can be shown that a high mortality is associated with admission of such patients to ICU. Prognosis is guided by several factors including the requirement for mechanical ventilation,2 LOD score >10 and severe prolonged neutropenia. Improved prognosis is associated with normal white cell count, rapid recovery of bone marow3, normal admission creatinine and avoidance of mechanical ventilation.