Critical care management of cancer patients

The case of cancer patients in a critical care set up is a challenging task.These patients 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 eg DM, IHD, COPD & HT and their complications. Patients are also admitted for alleviation of pain and physical distress associated with end of life care .

Oncology Patients in ICU

Some of the special considerations for oncology patients in ICU are –

Chemotherapy induced complications

(a) Nausea/Vomiting- worst after cisplatin, cyclophosphamide,

Doxonibicin and Carboplatin.

Treatment –

Prochlorperazine, Ondansetron, Granisetron,

Metochlorpromide, Dexamethasone.

(b) Infusion Reaction- common with new monoclonal antibody agents eg.

Rituximab and presents with fever/hypertension/asthama like symptoms/pain.

(c) Oral Complications/ Mucositis –

(d) Diarrhoea – risk factors are elderly , 5FU,k/c/o colitis , GI tumors, concomitant irradiation and irinotecan.

Treatment would include:-

• Hydration
• Loperamide
• Octreotide 100 mcg in severe cases SC TID.
• Oral Metrogyl/Vancomycin/Ciprofloxacin in CDIFF positive cases.

(e) Anemia – ( BM Suppression )

Packed RBCs if Hb< 7.0 g/dl

Erythropoetin.

(f) Cardiac Adverse Effects- acute/ subacute cardiotoxicity

• Arrythmia(tachycardia, conduction blocks).
• Pericarditis/Pericardial effusion.
• Myocarditis.
• Cardiomyopathy with decrease in EF.
• CCF.

(g) Pulmonary Complications – ( Bleomycin,Busulfan,
Cyclophosphamide , Paclitaxel)

• Interstitial pneumonitis progresses to chronic fibrosis.
• Exertional dyspnoea/ non productive cough/ fever.CXR shows diffused interstitial changes and fine crackles are heard on examination.
• Patient may present with hypersensitivity reaction and pneumonitis. ( seen with Methotrexate,Procarbazine, B CNU, Paclitaxel and Bleomycin).

Radiotherapy induced Complications

• Mucositis.
• Xerostomia and restricted mouth opening
• Cardiac complications
  • constrictive pericarditis
  • myocardial fibrosis (arrhythmias/conduction defects)
• pulmonary complications
• acute pneumonitis and/ or late lung fibrosis.

Acute Tumor Lysis Syndrome (ATLS)

ATLS is seen in patients with extensive,rapidly growing chemosensitive tumors eg high grade NHL/AML & 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

Cardinal biochemical features

• Hyperkalaemia
• Hyperuricemia
• Hyperphosphataemia
• Hypocalcaemia

Risk Factors

Bulky disease

Marked Treatment sensitivity

Previous Renal impairment

High LDH > 600 IU

High serum uric acid

S/S-

• paresthesia ,weakness , arrhythmias (hyperkalemia)
• tetany , bronchospasm (hypocalcemia),
• malaise, vomiting, hiccups, neuromuscular irritability, pruritus, pericarditis, Features of volume overload, dyspnea, pulmonary rales, edema, hypertension (uremia)
• arthralgia , renal colic ( increasing uric acid levels)

Management of ATLS

Hydration

4-5 L/d (3 L/m2/d) yielding urine volumes of at least 3 L/d + NaHCO3 50 meq/l ( Maintain urine specific gravity < 1010)

Alkalinisation

Maintain urine pH 7-7.5

Acetazolamide 5 mg/kg/d

Uric acid reduction

Allopurinol 600 mg/d – prophylaxis and 600-900 mg/d (maximum of 500 mg/m2/d) – treatment

Rasburicase (recombinant urate oxidase) 50-100 U/kg/d

Diuretics

Furosemide 1 mg/kg q 6 hrs

Mannitol 0.5 g/kg q 6 hrs

Phosphate reduction

Aluminium hydroxide 50 mg/kg p.o. q 8 hrs

• Treatment of electrolyte distubances
• If (Ca)x (Ph)>4.6 despite the treatment use Renal Replacement Therapy.
• extended daily dialysis or isolated sequential dialysis followed by continuous hemofilteration.

Febrile Neutropenia

• neutrophil count< 1000/mm3.
• seen in patients on chemotherapy 7-14 days post chemotherapy
• 65 to 75 % cultures reveal gram +ve 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.
• Monotherapy in patients with solid tumours (if not in septic shock and or unlikely pseudomonas) with Meropenam
• Duotherapy – antipseudomonal penicillin (Piper/Tazo) with aminoglycoside. If a gram positive organism other than staph aureus is found it is advisable to add glycopeptide (Vancomycin) and Teicoplanin.

Metabolic Emergencies

Hypercalcaemia

• S/S nausea,thirst,vomiting,polyuria,lethargy,weakness or confusion
• seen in carcinoma of breast, bronchus, kidney or due to myeloma or lymphoma

pathogenesis –

• Local osteolytic hypercalcaemia
• Humoral hypercalcaemia
• Impaired renal calcium excretion
• Management includes measures to improve renal calcium clearance and those to decrease osteoclastic bone resorption
• Fluid replacement–hydration with 4-6 litre/24 hr of isotonic saline infusion , add 40-80 mmol of potassium to each litre of NS.
• Diuretic – furosemide 40-80 mg I.V. every 12 to 24 hrs
  If serum calcium is > 14mg/dl then forced diuresis with normal saline (2-3 times the maintenance fluid volume) and high dose I.V. furosemide (1mg/kg every hr).
• Calcitonin– 400 IU subcutaneously 8 hourly
• Corticosteroids : multiple myeloma, lymphoma or carcinoma of breast, i.e.,those tumours that cause hypercalcaemia by secretion of cytokines having osteoclastic activity
• Bisphosphonates– inhibit the release of bone calcium

Hyponatraemia

Salient Features of SIADH like sydrome

Clinical

• Drowsiness
• Confusion
• Lethargy
• Seizure

Biochemical

• Hyponatraemia
• Normovolaemia
• Normal renal and adrenal function
• Urinary osmolality > plasma
• Increased urinary sodium excretion

• Bronchogenic carcinoma (small cell lung cancer, carcinoid tumours,leukaemias and lymphomas,cyclophosphamide in high doses > 50 mg/kg, ifosfamide and vincristine)
• Control of underlying tumour and fluid restriction 500 ml to1litre/day.
• demeclocycline 0.6 to 1.2 g/d (blocks the effect of vasopressin on renal tubules)
• hypertonic saline-correction is restricted to 0.5 -1meq/l/hr.

Neurological emergencies

• Spinal cord compression—causes paraplegia and incontinence
• Cerebral metastasis
• Neuropathy – seen with Vincristine, Vinblastin, Cisplatin. It manifests as numbness, tingling of fingers and toes and jaw pain/seizure in severe cases.

Treatment-

• Laminectomy decompression
• Corticosteroids
• Radiotherapy
• Emergency chemotherapy( lymphomas, neuroblastomas and Ewing’s sarcomas)
• Antiepileptics

Superior Vena Caval Syndrome (SVCS)

• 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
• May be the invasive disease process in the superior mediastinum including extrinsic compression, invasion and thrombosis.
• S/S- facial swelling, chest pain, cough ,dysphagia,distension of neck, superficial thoracic veins and conjunctival oedema.In extreme cases – proptosis with cerebral oedema with altered consciousness
• small cell cancer commonest (38%)
• objectives of treatment – to provide symptomatic relief and to attempt to cure the underlying cancer.
• Diuretics decrease venous pressure but increase risk of thrombosis
• Corticosteroids decrease peritumor and periirradiation inflammation
• Radiotherapy where histological diagnosis is not established
• extreme cases – surgical bypass graft , venesection, reconstruction of SVC, angioplasty and stenting.

Leukostasis

• Leukocyte count > 100,000/ml
• Obstruct circulation in brain and lungs by forming aggregates and thrombi in small veins. They compete for oxygen and damage vessel walls with subsequent bleeding.
• Altered sensorium, frontal headache, seizures, papilloedema, dyspnoea, hypoxaemia , cardiac failure.
• Chest X-ray reveals diffuse interstitial infiltrates
• Prompt hydration, alkalinisation and allopurinol needed.
• Platelets transfused to maintain count > 20,000/mm3 (avoid intracranial haemorrhage)
• Rise in haematocrit avoided.
• Exchange transfusions and leukopheresis

SURGICAL ONCOLOGY

(Few cases seen in surgical ICU)

ESOPHAGECTOMY

• Pre Operatively – Patient is cachexix, hypovolemic, dehydrated.
• High risk of pulmonary complications like-
• Atelectasis(hypoventilation due to pain.)
• Collapse consolidation (mucus plug- treated with chest physiotherapy/bed side bronchoscopy)
• Pleural effusion
• Pneumonia
• Pulmonary edema(interruptions of lymphatic channels)
• Dilated stomach tube in mediastinum-occupies space in thorax
• Leak at anastomotic site causes mediastinitis-(S/S- tachycardia,arrhythmias,bronchospasm,respiratory distress)
• Nasogastric tubes – Do not move / manipulate.
• Jejunostomy tube –most surgeons begin tube feedings at 10cc/hr on day 2 (do not need bowel sounds)
• Important to maintain adequate oxygenation , perfusion (monitoring by mixed venous oxygen saturation,DaO2,CVP,Urine Output,ABG-Absence of metabolic acidosis,base deficit < 3,normal bicarbonates.)

Collapse consolidation with Re-expansion of lung after
pnemothorax in post op esophagectomybronchoscopy and lavage
(due to mucus plug) , dilated stomach tube
and surgical emphysema.

HEAD NECK FACE ONCOSURGERIES

• Difficult airway (difficult intubation) – due totumour/ fibrosis/ radiation/ previous surgery
• Endotrachial tube (nasal most often) is kept overnight to maintain airway,prevent aspiration of blood,mucus/saliva/secretions as patient is unable to swallow. There is danger of blocked tubes with respiratory distress due drying of secretions/blood.It is important to keep patient well hydrated with regular suctioning
• Tracheostomy tube is done in patients with extensive surgeries especially those crossing midline.

COMPLICATIONS OF SUGERY

Some patients are admitted with complications of the procedures/post op infection / sepsis / control of medical problems which are co existing in an oncosurgery patient.

Pulmonary air embolism during Same patient after its successful
chemoport insertion. treatment.

DVT PROPHYLAXIS

• LMWH/LDUH is used for prophylaxis of DVT
• Neuraxial anaesthesia with pharmacologic prophylaxis is allowed in post op patients with proper patient selection,removing epidural catheter 2 hrs prior to next scheduled heparin inj and waiting 2 hrs after removal to resume injections.
• In high risk cases-pharmacologic prophylaxis along with mechanical devices are used.

NUTRITION RECOMMENDATIONS

• Enteral nutrition over parenteral nutrition
• Early enteral nutrition (within 1-2 days of ICU admission)
• Use of prokinetics(metoclorpromide,domeperidone )
• nutritional supplements containing fish oils (esp in ARDS)
• Small bowel feeding in patients with risk of intolerance to enteral feeds(patients on sedatives/paralytics agents/inotropes) or at high risk of regurgitation and aspiration (supine)
• Patient nursed at 45 degrees head elevation
• Parenteral nutrition started if patient not tolerating enteral nutrition.
• Glutamine supplementation in parenteral nutrition .

End Of Life Care

• Focus shifts from curative to that which gives comfort.
• Communication with family and preparing them for the same is needed.
• Discontinue investigations and invasive hemohydanamic monitoring.
• May stop antibiotics,vasopressors,dialyses.
• Patient may refuse intubation,ventilation but may request other treatment.
• `Terminal Weaning’ may be tried.Artificial airways may be removed.
• Use of NIV should be evaluated (minimize dyspnoea,no intubation)
• Neuromuscular blockade avoided or weaned off as it masks discomfort.
• Pain Management (Opioids – Morphine,Fentanyl infusion)
• Sedation- Benzodiazepines ( Midazolam/Lorazepam)
• Delirium – Haloperidol
• Treatment of dyspnoea ( steroids / bronchodilators / oxygen / diuretics ? )
• Remove restraints / allow to sleep/permit family member

Alleviating pain, physical discomfort is an important role of an intensivist. End Of Life Care requires communication , humane handling of patients and their relatives.