Critical care clinics
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This article discusses end-of-life issues in critically ill cancer patients. Since the majority of deaths will occur after limiting or withdrawing life support, focus should be given to ensuring that multidisciplinary family meetings are convened to discuss end-of-life decision making. ⋯ The use of protocols facilitates a smooth transition and potentially reduces variability between health care providers. Integrating measures into the ICU routine that will help health care providers cope with the care of a dying patient is recommended to avoid moral distress or emotional burnout.
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Critical care clinics · Jan 2010
ReviewHematological issues in critically ill patients with cancer.
Patients with solid and hematologic malignancies presenting with major bleeding or thrombotic complications, potentially life-ending events in a cancer patient's clinical course, usually require admission to an intensive care unit (ICU), making their diagnosis and management even more important for the intensivist. Given the significant advances in the diagnosis and treatment of almost all types of cancers in recent years, the intensivist is likely to encounter an ever-increasing number of cancer patients in the ICU setting with these complications. Abnormal hemostasis can occur as a consequence of both the pathology and treatment of cancer. ⋯ This article reviews the physiology of coagulation and fibrinolysis, with special attention to those aspects that are most frequently altered in the setting of malignancy. The pathophysiology of bleeding and thrombotic complications specific to critically ill cancer patients are then detailed, and the diagnostic and therapeutic strategies are discussed. Special emphasis is placed on new cancer medications that have an effect on hemostasis, and on novel clotting and anticoagulant agents that are available to the intensivist for the management of these patients.
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Critical care clinics · Jan 2010
ReviewMechanical ventilation in cancer patients: clinical characteristics and outcomes.
Acute respiratory failure with the need for mechanical ventilation is a severe and frequent complication, and a leading reason for admission to the intensive care unit (ICU) in patients with malignancies. Nevertheless, improvements in patient survival have been observed over the last decade. This article reviews the epidemiology of adult patients with malignancies requiring ventilatory support. Criteria used to assist decisions to admit a patient to the ICU and to select the initial ventilatory strategy are discussed.
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Critical care clinics · Jan 2010
ReviewDiagnosis and management of infectious complications in critically ill patients with cancer.
Cancer and its treatments lead to profound suppression of innate and acquired immune function. In this population, bacterial infections are common and may rapidly lead to overwhelming sepsis and death. ⋯ Despite improvements in long-term survival, infections remain a common complication of cancer therapy and accounts for the majority of chemotherapy-associated deaths. By understanding the host defense impairments and likely pathogens clinicians will be better able to guide diagnosis and management of this unique population.
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Critically ill cancer patients have a higher incidence of acute kidney injury treated with renal replacement therapy than critically ill patients without cancer. Acute kidney injury may occur as a direct or indirect consequence of the cancer itself, its treatment, or associated complications. ⋯ However, these relatively good results should not be used to justify unrealistic therapeutic perseverance or to withhold palliative care in cancer patients who are in a desperate situation. Similar to that for any other critically ill patient, the decision to initiate advanced life-supportive therapy as well as its duration should be in proportion with the patient's expected long-term prognosis and quality of life.