The Role of Critical Care for Non-Haematological Malignancy

1. The Role of Critical Care for Non-Haematological Malignancy Dr Phil Haji-Michael

2. Mr Heam. Mr Onc.

3. Long time to an anticipated poor outcome Relatively well until a final decline May well have discussed last wishes with their family Palliative care planning and hospice care The “patient journey” & Cancer Murray SA et al. BMJ 2005;330:1007-11.

4. Conflict with oncologists

5. Changing outcomes for cancer

7. For some cancers the natural history is becoming more like a chronic relapsing remitting disease

8. For some cancers things are little changed

9. Is survival alone the most important issue?

10. Issues for oncology patients in critical care • The individual patient’s journey not the cohort • How reversible is the acute condition • Is the current problem treatment related? • How much benefit for how much harm? • Decision making and who to talk to

11. Changes in critical care • The impact of outreach (“upstream triage”) • Newer technologies available Ventilators, NIV & cardiovascular monitoring • Standardisation of care Sepsis & ventilator care bundles

12. Bigger issues….. • Availability of beds • Who do you pick & how do you judge? Metastatic cancer vs emergency AAA • Financial austerity & the NHS • Cancer drugs versus hip replacements • Demographics • Ageing population & they are not dying from myocardial infarcts anymore • Acute Oncology • Only 10% of “acute oncology” is treatment related

13. Scenarios

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17. What did you think of Lunch? • Good • Poor • Fantastic • Unedible

18. Case 1: 57yr woman with Myeloma Disease for 4 yr, now on 3rd line treatment Known recent vertebral fracture Now increasingly short of breath & febrile over past 3 days Seen by oncology registrar in clinic and admitted to the ward. He writes “For everything” in the notes.

19. Case 1: 57yr woman with Myeloma Breathless at rest T 38.5˚C RR 25 BVM@ 15 l/min SaO2 85% Crepitataions in both bases HR120 BP 90/50 CRT 4 sec PU’d 8hr ago, ABG pH 7.3 PO2 6 kPa PCO2 3.3 kPa BE -6 Urea 15 Creat 200

20. Q1. Would you… Admit for full level 3 care? Admit for level 2 care only? Limit to ward care only (level 1)? Put on the end of life pathway? Ring up, berate the Oncology SpR and refuse to come and see the patient?

21. Q2. Likely mortality? (hospital discharge) 100% 80% 60% 40% 20%

22. Case 2: 64yr woman with NHL Stage IV B cell lymphoma 2yr ago In remission but recently noticed parotid lump MRI scan - tumor in parotid infiltrating left temporal lobe Attended for chemo, SpR noticed AF. Echo shows “thrombus in RA”. Admitted from clinic. Now (18:00 Friday) sudden deterioration & a call to outreach…

23. Case 2: 64yr woman with NHL Acutely unwell, clammy, breathless RR 30 SaO2 83% on air Chest clear HR 65 BP 90/50 CRT 3 sec New systolic murmur 3/6 ABG pH 7.48 pO2 8.55kPa pCO2 3.5kPa BE -2

24. Q3. The immediate plan would be.. Chemotherapy Thrombolysis Anticoagulation Surgery (Thrombectomy) More imaging (e.g. CT scan chest)

25. Q4. Would you… Admit for full level 3 care? Admit for level 2 care only? Limit to ward care only (level 1)? Put on the end of life pathway?

27. Case 3: 43yr woman Breast CA Lumpectomy 5yr, Local recurrence 4yr, mastectomy, node clearance & local radiotherapy, and chemo (FEC)x6 1yr boney mets, now on Herceptin Last 24hrs, developed fever, cough & felt unwell. Presented to local A&E

28. Case 3: 43yr woman Breast CA In resus: Given O2 & 2 litres saline Flushed and unwell. T 39˚C RR 20 SaO2 95% 35%FiO2 Right basal signs HR120 BP 75/40 CRT <2secs feels warm Hickman in situ ABG pH 7.3 pO2 9.6kPa pCO2 3.3kPa BE -6

29. Q5. What would you give for initial management of the circulation No drugs, just more fluids Norepinephrine Epinephrine Dobutamine Cardiac output monitoring & then decide

30. Q6. Would you… Admit for full level 3 care? Admit for level 2 care only? Limit to ward care only (level 1)? Put on the end of life pathway?

31. Q7. Likely mortality? (hospital discharge) 100% 80% 60% 40% 20%

32. Case 4: 74 yr man with Lung CA Non-small cell lung cancer diagnosed 5months ago. Smoker 40 pack years. On radical radiotherapy (now at 16/20) Admitted to the ward not coping, difficulty swallowing & productive cough Increasingly short of breath On fentanyl patches for pain, increased on admission Deteriorates over 48hr, now drowsy and low sats..

33. Case 4: 74 yr man with Lung CA Unwell T37.5˚C RR 30 SaO2 85% on 24% Oxygen Bronchial breathing and crepitations on right base HR 120 BP 110/60 CRT < 2 secs Drowsy and only responsive to pain. Small pupils. Already on antibiotics for his “chest” ABG pH 7.28 pCO2 7.8kPa pO2 8.8kPa BE -1

34. Q8. Would you… Admit for full level 3 care? Admit for level 2 care only? Limit to ward care only (level 1)? Put on the end of life pathway?

35. Summary Cancer is a very heterogeneous group of diseases Outcome has changed radically for some over the past few decades Equally critical care has undergone a similar transformation Open and honest dialogue between Oncology and Critical Care is essential Upstream/ward assessment and triage is also key “How much harm for how much benefit”

36. Thank you