The Christie NHS Foundation Trust The Role of Critical Care for Non-Haematological Malignancy Dr Phil Haji-Michael
The Christie NHS Foundation Trust
The Role of Critical Care for Non-Haematological
Malignancy
Dr Phil Haji-Michael
The Christie NHS Foundation Trust
The “patient journey” & Cancer
1) Long time to an anticipated poor outcome
2) Relatively well until a final decline
3) May well have discussed last wishes with their family
4) Palliative care planning and hospice care
Murray SA et al. BMJ 2005;330:1007-11.
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For some cancers the natural history is becoming more like a chronic relapsing remitting disease
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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
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Changes in critical care
• The impact of outreach (“upstream triage”)
• Newer technologies available
Ventilators, NIV & cardiovascular monitoring
• Standardisation of care
Sepsis & ventilator care bundles
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Bigger issues…..
1) Availability of beds• Who do you pick & how do you judge?
Metastatic cancer vs emergency AAA
2) Financial austerity & the NHS• Cancer drugs versus hip replacements
3) Demographics• Ageing population & they are not dying from
myocardial infarcts anymore
4) Acute Oncology• Only 10% of “acute oncology” is treatment related
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What did you think of Lunch?
1) Good
2) Poor
3) Fantastic
4) Unedible
83%
10%2
17%
30%4
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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.
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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
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Q1. Would you…
1) Admit for full level 3 care?
2) Admit for level 2 care only?
3) Limit to ward care only (level 1)?
4) Put on the end of life pathway?
5) Ring up, berate the Oncology
SpR and refuse to come and see
the patient?
40%
1
52%
20%3
2%
4
5%
5
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Q2. Likely mortality? (hospital discharge)
1) 100%
2) 80%
3) 60%
4) 40%
5) 20%
0%1
41%
2
30%
3
23%
4
7%
5
The Christie NHS Foundation Trust
Case 2: 64yr woman with NHL
Stage IV B cell lymphoma 2yr agoIn remission but recently noticed parotid lumpMRI scan - tumor in parotid infiltrating left temporallobe
Attended for chemo, SpR noticed AF. Echo shows“thrombus in RA”. Admitted from clinic. Now (18:00 Friday) sudden deterioration & a call tooutreach…
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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
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Q3. The immediate plan would be..
1) Chemotherapy
2) Thrombolysis
3) Anticoagulation
4) Surgery (Thrombectomy)
5) More imaging (e.g. CT scan
chest)
5%
1
24%
2
29%
3
14%
4
29%
5
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Q4. Would you…
1) Admit for full level 3 care?
2) Admit for level 2 care only?
3) Limit to ward care only (level 1)?
4) Put on the end of life pathway?
1 47.6%
2 31.0%
3 14.3%
4 7.1%
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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
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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
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Q5. What would you give for initial management of the circulation
1) No drugs, just more fluids
2) Norepinephrine
3) Epinephrine
4) Dobutamine
5) Cardiac output monitoring & then
decide
39%
1
27%
20%3
2%
4
32%
5
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Q6. Would you…
1) Admit for full level 3 care?
2) Admit for level 2 care only?
3) Limit to ward care only (level 1)?
4) Put on the end of life pathway?
1 65.9%
2 27.3%
3 4.6%
4 2.3%
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Q7. Likely mortality? (hospital discharge)1) 100%
2) 80%
3) 60%
4) 40%
5) 20%
0%1
9%
2
26%
3
53%
4
12%
5
The Christie NHS Foundation Trust
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..
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Case 4: 74 yr man with Lung CA
Unwell T37.5˚CRR 30 SaO2 85% on 24% OxygenBronchial breathing and crepitations on right baseHR 120 BP 110/60 CRT < 2 secsDrowsy 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
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Q8. Would you…
1) Admit for full level 3 care?
2) Admit for level 2 care only?
3) Limit to ward care only (level 1)?
4) Put on the end of life pathway?
1 14.0%
2 16.3%
3 32.6%
4 37.2%
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Summary
Cancer is a very heterogeneous group of diseasesOutcome has changed radically for some over thepast few decadesEqually critical care has undergone a similartransformationOpen and honest dialogue between Oncology andCritical Care is essentialUpstream/ward assessment and triage is also key“How much harm for how much benefit”