Intensivmedizinische Versorgung des kritisch kranken Tumorpatienten – Status Quo 2019

Abstract

In Europe, up to 25 % of the ICU patients suffer from malignant diseases. Recent studies have shown that the short term prognosis of critically ill cancer patients is determined by the severity of the acute complication leading to ICU admission, but not by the underlying malignancy. Long-term prognosis of cancer patients surviving the ICU however is given by the underlying disease and comparable to cancer patients never admitted to the ICU. In particular, survival rates of tumor patients admitted after surgery are equal to those from surgical non-tumor patients. Despite this favorable trend the ICU admission of patients suffering from malignancy is still debatable.

To define admission criteria a triage system has been developed taking into account the prognosis of the underlying disease, the overall performance status, patient will and the severity of complications. Those criteria allow us to categorize patients and to grade the intensity of treatment into “full code” treatment, a limited “ICU trial”, or palliative care without ICU intervention. In addition to those, additional factors of adverse prognosis as low performance status, number of comorbidities, admission due to cardiorespiratory arrest, organ failure due to malignancy, aspergillosis or admission after allogeneic stem cell transplantation have been identified.

This complexity requires an interdisciplinary cooperation between oncologists/haematologists and intensive care specialists and seems to be an essential clue to successfully manage critically ill cancer patients. For the future the improvement of education and training, the development of individualized therapies, and to seize the opportunity to use modern tools of data analytics and machine learning are important goals in this field.

Einen Tumorpatienten intensivmedizinisch behandeln? Mancherorts löst dieses Ansinnen Kopfschütteln aus, genauso wie in den 1960er-Jahren, wenn man für über 50-jährige Patienten eine Dialyse plante (Durchschnittsalter bei Dialysebeginn liegt heute bei über 70 Jahren). Mittlerweile hat auch der Tumorpatient im Falle eines Organversagens deutlich bessere Überlebenschancen als früher. Der Beitrag erläutert aktuelle Entscheidungshilfen.

Schlüsselwörter

Krebs - Intensivstation - Aufnahmekriterien - Prognose

Key words

cancer - ICU - critical illness - admission criteria - prognosis

• Literatur

• 1 Jansen L, Castro FA, Gondos A. et al. Recent cancer survival in Germany: An analysis of common and less common cancers. Int J Cancer 2015; 136: 2649-2658
• 2 Puxty K, McLoone P, Quasim T. et al. Characteristics and Outcomes of Surgical Patients With Solid Cancers Admitted to the Intensive Care Unit. JAMA Surg 2018; 153: 834-840
• 3 Taccone FS, Artigas AA, Sprung CL. et al. Characteristics and outcomes of cancer patients in European ICUs. Crit Care 2009; 13: R15
• 4 Beutel G. Intensivtherapie bei hämatologischen Patienten. 124. Kongress der Deutschen Gesellschaft für Innere Medizin. 2018: 183
• 5 Azoulay E, Afessa B. The intensive care support of patients with malignancy: do everything that can be done. Intensive Care Med 2006; 32: 3-5
• 6 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 2013; 31: 2810-2818
• 7 Thiery G, Azoulay E, Darmon M. et al. Outcome of Cancer Patients Considered for Intensive Care Unit Admission: A Hospital-Wide Prospective Study. J Clin Oncol 2005; 23: 4406-4413
• 8 Lecuyer L, Chevret S, Thiery G. et al. The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med 2007; 35: 808-814
• 9 Beutel G, Schellongowski P, Kiehl M. et al. Intensive care of hematological and oncological patients: recent challenges. Dtsch Med Wochenschr 2017; 142: 500-505
• 10 Kiehl MG, Beutel G, Böll B. et al. Consensus statement for cancer patients requiring intensive care support. Ann Hematol 2018; 97: 1271-1282
• 11 Neitzke G, Böll B, Burchardi H. et al. Documentation of decisions to withhold or withdraw life-sustaining therapies: Recommendation of the Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) in collaboration with the Ethics Section of the German Society for Medical Intensive Care and Emergency Medicine (DGIIN). Med Klin Intensivmed Notfmed 2017; 112: 527-530
• 12 de Vries VA, Müller MCA, Arbous MS. et al. Long-Term Outcome of Patients With a Hematologic Malignancy and Multiple Organ Failure Admitted at the Intensive Care. Crit Care Med 2019; 47: e120-128
• 13 Mokart D, Lambert J, Schnell D. et al. Delayed intensive care unit admission is associated with increased mortality in patients with cancer with acute respiratory failure. Leuk Lymphoma 2013; 54: 1724-1729
• 14 Lee DS, Suh GY, Ryu JA. et al. Effect of Early Intervention on Long-Term Outcomes of Critically Ill Cancer Patients Admitted to ICUs. Care Med 2015; 43: 1439-1448
• 15 Bos MMEM, de Keizer NF, Meynaar IA. et al. Outcomes of cancer patients after unplanned admission to general intensive care units. Acta Oncol (Madr) 2012; 51: 897-905
• 16 Lueck C, Stadler M, Koenecke C. et al. Improved short- and long-term outcome of allogeneic stem cell recipients admitted to the intensive care unit: a retrospective longitudinal analysis of 942 patients. Intensive Care Med 2018; 44: 1483-1492
• 17 Shimabukuro-Vornhagen A, Böll B, Kochanek M. et al. Critical care of patients with cancer. CA Cancer J Clin 2016; 66: 496-517
• 18 Soares M, Bozza FA, Azevedo LCP. et al. Effects of Organizational Characteristics on Outcomes and Resource Use in Patients With Cancer Admitted to Intensive Care Units. J Clin Oncol 2016; 34: 3315-3324