In 1989, Denardo and associates reported the results of intensive care unit (ICU) therapy in a series of patients who developed acute respiratory failure and required mechanical ventilation after bone marrow transplantation. Of those on mechanical ventilatory support longer than 4 days, not one survived.1 The editorial that accompanied the study publication was titled, “Just Say No.”2
Over the ensuing decades, our understanding of the cellular etiology of hematologic malignancies has deepened, targeted therapies have been developed, and we have seen great advances in the management of therapy-related toxicities. This has culminated in the ability to more safely widen therapeutic options offered to patients with hematologic malignancies.
As demonstrated in the publication of a report by Azoulay et al,3 ICU management should now be seen as a reasonable intervention in an extraordinarily ill population, leading not only to a greater probability of survival than in the past, but also to a survival associated with a reasonable quality of life. Appropriate initiation of ICU management in patients with hematologic cancers offers a good chance of leaving the patient with physiology that permits ongoing attempts at disease management and possible cure.
While the combination of respiratory failure, circulatory compromise requiring vasopressors, and renal replacement therapy is extremely ominous, the presence of a single–organ system failure is not. The earlier patients enter the ICU, the less likely their chance of dying.
Advances in Critical Care Management
Independent of the remarkable inroads in the treatment of liquid tumors, advances in critical care management likely contribute to this beneficial trend. Salient examples include the implementation of low–tidal volume mechanical ventilation in patients with respiratory failure,4 fluid restriction in acute lung injury,5 the understanding that there is no advantage of use of pulmonary artery catheters,6 the use of protocols to prevent catheter-related bacteremia and ventilator-associated pneumonia, as well as management of hypotension with norepinephrine rather than dopamine.7
What is of striking importance in the study of Azoulay et al is the collaboration between oncologist and intensivist. Management of the complexity of ICU care in the setting of coagulopathy, neutropenia, and immunosuppression can be daunting and requires multidisciplinary interaction.
Understanding the disease status, comorbid conditions, and organ function status should improve the ability of health-care providers to present probability-of-survival data to patients and family members and allow for reasoned end-of-life discussions when appropriate. Thus, the observations of Azoulay and colleagues strongly suggest that this contemporary editorial should be titled “Just Say ‘Know.’” ■
Dr. Groeger is Chief, Urgent Care Service, Attending Critical Care Physician, and Dr. Cathcart, is Associate Attending Hematologist-Oncologist, Memorial Sloan-Kettering Cancer Center, New York.
Disclosure: Drs. Groeger and Cathcart reported no potential conflicts of interest.
References
1. Denardo SJ, Oye RK, Bellamy PE: Efficacy of intensive care for bone marrow transplant patients with respiratory failure. Crit Care Med 14:4-6, 1989.
2. Carlon GC: Just say no. Crit Care Med 7:106-107, 1989.
3. Azoulay E, Mokart D, Pène F, et al: Outcomes of critically ill patients with hematologic malignancies: Prospective multicenter data from France and Belgium—a Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique study. J Clin Oncol. June 10, 2013 (early release online).
4. The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301-1308, 2000.
5. National Heart, Lung and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network: Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 354:2564-2575, 2006.
6. Shah MR, Hasselblad V, Stevenson LW, et al: Impact of the pulmonary artery catheter in critically ill patients: Meta-analysis of randomized clinical trials. JAMA 294:1664-1670, 2005.
7. De Backer D, Biston P, Devriendt J, et al, for the SOAP II Investigators: Comparison of dopamine and norepinephrine in the treatment of septic shock. N Engl J Med 362:779-789, 2010.
