Management

Management of Cancer Patients in ICU

The management of cancer patients in surgical ICU is quite a challenging task

"End-of-Life Care is an important aspect of a cancer ICU where patients may come to ICU in the terminal stage where there is no useful treatment or palliation" - Dr Surabhi Awasthi Consultant and Head- Critical Care Dharamshila Hospital & Research Centre New Delhi

Management of cancer patients in a critical care set-up is a challenging task. These patients are different from our regular ICU patients such that they may have undergone chemotherapy and/ or radiotherapy or a major debilitating surgery. ICU care is given to all those patients who have a good chance of cure, palliation of disease or for correction of emergency/ acute problem in an otherwise advanced disease. Some of the patients come up for treatment of co-existent medical disease like diabetes, cardiac disease, COPD & hypertension and their complications.

Chemotherapy Induced Complications

Many of the patients would be suffering from nausea/ vomiting, infusion reaction (common with new monoclonal antibody agents eg. Rituximab) with fever/ hypertension/ asthma like symptoms/pain, oral mucositis, diarrhoea (treatment would include hydration, diet, loperamide, octreotide in severe cases and oral Metrogyl/ Vancomycin/ Ciprofloxacin in CDIFF positive cases), anemia and thrombocytopenia.

The other adverse effects of chemotherapeutic agents are acute/ sub-acute cardiotoxicity (presenting as arrhythmia, conduction blocks, pericarditis/ pericardial effusion, cardiomyopathy with decrease in ejection fraction and congestive cardiac failure and pulmonary complications like interstitial pneumonitis with exertional dyspnoea/ non-productive cough/ fever or patient may present with hypersensitivity reaction (Methotrexate, Procarbazine, B CNU, Paclitaxel and Bleomycin).

Radiotherapy Induced Complications

Some patients would have undergone radiotherapy and would be suffering from mucositis, xerostomia, restricted mouth opening, cardiac complications like constrictive pericarditis, myocardial fibrosis with arrhythmias and conduction defects. Patient may also present with acute pneumonitis or late lung fibrosis.

Acute Tumour Lysis Syndrome (ATLS)

Collapse consolidation of Lung (due to mucus plug)with chest physiotherapy esophagectomy, dilated stomach tube and surgical emphysema

Re-expansion of lung after bronchoscopic suction and pnemothorax in post op

ATLS is seen in patients with extensive, rapidly growing chemo-sensitive tumours (high grade NHL/AML and ALL). It is seen after treatment like chemotherapy or radiotherapy, steroid therapy, cytokine or hormonal therapy, but also may develop spontaneously due to tumour necrosis or fulminant apoptosis.

The cardinal biochemical features are hyperkalaemia, hyperuricemia, hyperphosphataemia and hypocalcaemia.

The risk factors for development of ATLS are bulky disease, marked treatment sensitivity, previous renal impairment, LDH > 600 IU and high serum uric acid levels.

Management of ATLS is with the following:

• Hydration with dextrose saline (3 litres/ m2/ day) yielding urine volumes of at least 3 litres/ day with added NaHCO3 to maintain urine specific gravity < 1010)
• Alkalinisation to maintain urine pH 7-7.5 and acetazolamide.
• Uric acid reduction with Allopurinol and Rasburicase (recombinant urate oxidase).
• Diuretics like Furosemide and Mannitol.
• Phosphate reduction with aluminium hydroxide.
• Treatment of electrolyte disturbances.
• Renal replacement therapy.
• Hemodialyses.

Febrile Neutropenia

It is seen with neutrophil count < 1,000/mm3 and is seen in patients on chemotherapy 7-14 days post chemotherapy. 65 to 75 per cent cultures reveal Gram positive organism (coagulase negative staph, Staph aureus, Visidans streptococci) or Gram negative bacilli (E. coli, Klebsiella, Pseudomonas aeruginosa) or a fungal infection if patient already on antibiotics.

Metabolic Emergencies

Certain metabolic emergencies seen in the cancer ICU are hypercalcaemia which presents as nausea, thirst, vomiting, polyuria, lethargy, weakness, confusion. It is seen in carcinoma of breast, bronchus, kidney or due to myeloma or lymphoma. Management includes measures to improve renal calcium clearance and those to decrease osteoclastic bone resorption (hydration with added potassium, diuretics, calcitonin, corticosteroids and bisphosphonates).

Hyponatraemia

Hyponatraemia presents as drowsiness, confusion, seizures. Laboratory reports reveal hyponatremia, normovolemia, urinary osmolality greater than plasma osmolality, normal renal and adrenal function, increased urinary sodium. It is seen in bronchogenic carcinoma (small cell lung cancer, carcinoid tumours, leukaemias and lymphomas, cyclophosphamide in high doses > 50 mg/kg, ifosfamide and vincristine). Treatment is control of underlying tumour and fluid restriction 500 ml to1litre/ day along with demeclocycline and slow hypertonic saline correction.

Neurological Emergencies

In oncology patients it is in the form of spinal cord compression with paraplegia and incontinence, cerebral metastasis with convulsions and altered sensorium and neuropathy which manifests as numbness, tingling of fingers and toes and jaw pain/ seizure in severe cases. The treatment of these is with corticosteroids, radiotherapy, emergency chemotherapy in lymphomas, neuroblastomas and Ewing's sarcomas, and finally de-compression laminectomy.

Superior Vena Caval Syndrome (SVCS)

SVCS is impedance of venous return from the head, upper extremities and upper thorax to the heart as a consequence of obstruction of blood flow through superior vena cava. It may be the invasive disease process in the superior mediastinum including extrinsic compression, invasion and thrombosis. It presents as facial swelling, chest pain, cough, dysphagia, distension of neck, superficial thoracic veins and conjunctival oedema and in extreme cases proptosis with cerebral oedema and altered consciousness. It is seen most often with small cell cancer. The objectives of treatment are to provide symptomatic relief with diuretics, corticosteroids, radiotherapy and to attempt to cure the underlying cancer. In extreme cases surgical bypass graft, venesection, reconstruction of SVC, angioplasty and stenting may be required.

Leukostasis

This happens with leukocyte counts > 100,000/ml resulting in obstruction to circulation in brain and lungs by forming aggregates and thrombi in small veins. The leukocytes compete for oxygen and damage vessel walls with subsequent bleeding. Patient presents with altered sensorium, frontal headache, seizures, papilloedema, dyspnoea, hypoxaemia, cardiac failure. Chest X-ray reveals diffuse interstitial infiltrates. Treatment is with prompt hydration, alkalinisation, allopurinol, platelet transfusion to maintain count > 20,000/mm3 to avoid intracranial haemorrhage and finally exchange transfusions and leukopheresis.

DVT Prophylaxis

LMWH/ LDUH is used for prophylaxis of DVT. In high risk cases- pharmacologic prophylaxis along with mechanical devices are used.

Nutrition Recommendations

• Enteral nutrition is preferred over parenteral nutrition.
• Early enteral nutrition (within one to two days of ICU admission) with use of prokinetics (metoclorpromide, domeperidone) is recommended.
• Nutritional supplements containing fish oils Omega-3 polyunsaturated fatty acids act as immune modulators and anti-inflammatory agents (especially in ARDS).
• Small bowel feeding is initiated in patients with risk of intolerance to enteral feeds (patients on sedatives/paralytics/ agents/ inotropes) or at high risk of regurgitation and aspiration.
• Patient is nursed at 45 degrees head elevation.
• Parenteral nutrition is started if patient not tolerating enteral nutrition and Glutamine supplementation in parenteral nutrition is useful.
• Test for nutritional deficit used in ICU are body weight deviations, anthropometry, plasma proteins like albumin, transferrin, retinol binding protein and prealbumin.

Surgical Oncology

The management of cancer patients in surgical ICU is also a challenging task. In addition to the above mentioned problems typical to a cancer patient, they also have the following considerations to be kept in mind.

Post Oesophagectomy

Pre-operatively the patient is cachexix, hypovolemic, dehydrated. There is high risk of post-operative pulmonary complications like atelectasis due to hypoventilation due to pain, collapse consolidation due to mucous plug, pleural effusion, pneumonia, pulmonary edema due to interruptions of lymphatic channels, dilated stomach tube in mediastinum which occupies space in thorax, leak at anastomotic site which causes mediastinitis which presents as tachycardia, arrhythmias, bronchospasm, respiratory distress. We should not move or manipulate nasogastric tubes. Most surgeons begin early jejunostomy tube feedings. It is important to maintain adequate oxygenation, perfusion which is judged by monitoring of mixed venous oxygen saturation, DaO2, CVP, Urine output, ABG the target of which would be absence of metabolic acidosis, base deficit < 3, normal bicarbonates.

Head, Neck & Face Surgeries

Patient may have a difficult airway with difficult intubation due to tumour, fibrosis, radiation, or previous surgery . Endotrachial tube may be kept overnight to maintain airway, prevent aspiration of blood , saliva , secretions as patient is unable to swallow. There is danger of blocked tubes with respiratory distress due drying of secretions and blood. It is therefore important to keep patient well hydrated with regular tube suctioning.

Others

Post-surgical oncology patients may need care ranging from only monitoring in supra-major surgery (gastro intestinal, genito- urinary, thoracic lung, mediastinal tumours ,breast and neurological surgeries) in some patients; to fully aggressive ICU management for post-surgical complications like anastomotic dehiscence, septic shock, ARDS, multi-organ dysfunction, control of medical problems which are co-existing in an oncosurgery patient.

End-of-Life Care

End-of-Life Care is an important aspect of a cancer ICU where patients may come to ICU in the terminal stage where there is no useful treatment or palliation. The patient is in distress, both emotional and physical and often in severe pain, breathless and may be delirious. After a consensual agreement with the patient, his or her relatives, all concerned physicians the decision for terminal care is taken. The focus now shifts from curative treatment to that which gives comfort to the patient. Communication with family and preparing them for the same is needed. It is advisable to discontinue investigations and invasive hemohydanamic monitoring. Decision to stop antibiotics, vasopressors, dialyses may be taken. Patient may refuse intubation, ventilation but may request other treatment. 'Terminal Weaning' may be tried. Artificial airways may be removed. Use of non-invasive ventilation should be evaluated as it may minimise dyspnoea and avoids intubation. Neuromuscular blockade is avoided or weaned off as it masks patient discomfort. Pain management is of utmost importance and usually Opioids like Morphine, Fentanyl are used. Patient may be sedated with Benzodiazepines like Midazolam and Lorazepam. Delirium is managed with Haloperidol. Treatment of dyspnoea is controversial and steroids, bronchodilators , oxygen , diuretics may be used. It is necessary to remove restraints and permit family member . One must also respect religious feelings of the patients and his attendants.

Alleviating pain, physical and emotional discomfort is also an important role of an intensivists in 'End-of-Life' care setting which requires communication, humane handling of patients and their relatives and an inter-disciplinary approach.

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