Der chronisch kritisch kranke Patient aus der Perspektive des Hämatoonkologen

T. Staudinger1, P. Schellongowski1
1Universitätsklinik für Innere Medizin I, Intensivstation 13.i2, Medizinische Universität Wien, Allgemeines Krankenhaus der Stadt Wien, Wien, Österreich

Tóm tắt

Etliche Faktoren machen kritisch kranke Patienten mit hämatologischer oder onkologischer Grunderkrankung zu einem besonderen Kollektiv auf der Intensivstation: eine häufig nicht oder zumindest fraglich „heilbare“ Grunderkrankung, therapieassoziierte Komplikationen sowie wie eine häufig bestehende Immunsuppression. Die Prognose dieser Patienten hat sich in den vergangenen Jahren deutlich verbessert, sodass sich eine grundsätzliche Zurückhaltung bei der Entscheidung, diese Patienten auf einer Intensivstation zu behandeln, definitiv nicht mehr rechtfertigen lässt. Eine umfassende infektiologische Diagnostik sowie eine leitliniengerechte, sowohl kausale als auch supportive Behandlung können die Prognose einer Sepsis auch bei hämatoonkologischen Patienten verbessern. In der Therapie des respiratorischen Versagens kommt der nichtinvasiven Beatmung ein hoher Stellenwert zur Reduktion der Mortalität zu, wenn sie früh einsetzt und Kontraindikationen sowie Abbruchskriterien berücksichtigt werden. Überlegungen zu Langzeitprognose, Lebensqualität und Palliation werden zunehmend auch zu intensivmedizinischen Themen.

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Anderson WG, Arnold RM, Angus DC et al (2008) Posttraumatic stress and complicated grief in family members of patients in the intensive care unit. J Gen Intern Med 23:1871–1876 Azoulay E, Afessa B (2006) The intensive care support of patients with malignancy: do everything that can be done. Intensive Care Med 32:3–5 Azoulay E, Mokart D, Lambert J et al (2010) Diagnostic strategy for hematology and oncology patients with acute respiratory failure: randomized controlled trial. Am J Respir Crit Care Med 182:1038–1046 Azoulay E, Recher C, Alberti C et al (1999) Changing use of intensive care for hematological patients: the example of multiple myeloma. Intensive Care Med 25:1395–1401 Chaoui D, Legrand O, Roche N et al (2004) Incidence and prognostic value of respiratory events in acute leukemia. Leukemia 18:670–675 Darmon M, Azoulay E, Alberti C et al (2002) Impact of neutropenia duration on short-term mortality in neutropenic critically ill cancer patients. Intensive Care Med 28:1775–1780 Epner DE, White P, Krasnoff M et al (1996) Outcome of mechanical ventilation for adults with hematologic malignancy. J Investig Med 44:254–260 Gristina GR, Antonelli M, Conti G et al (2011) Noninvasive versus invasive ventilation for acute respiratory failure in patients with hematologic malignancies: a 5-year multicenter observational survey. Crit Care Med 39:2232–2239 Groeger JS, Lemeshow S, Price K et al (1998) Multicenter outcome study of cancer patients admitted to the intensive care unit: a probability mortality model. J Clin Oncol 16:761–770 Hilbert G, Gruson D, Vargas F et al (2001) Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 344:481–487 Huynh TN, Weigt SS, Belperio JA (2009) Outcome and prognostic indicators of patients with hematopoietic stem cell transplants admitted to the intensive care unit. J Transplant (Article ID 917294) Kress JP, Christenson J, Pohlman AS et al (1999) Outcomes of critically ill cancer patients in a university hospital setting. Am J Respir Crit Care Med 160:1957–1961 Kumar A, Zarychanski R, Light B et al (2010) Early combination antibiotic therapy yields improved survival compared with monotherapy in septic shock: a propensity-matched analysis. Crit Care Med 38:1773–1785 Lautrette A, Darmon M, Megarbane B et al (2007) A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 356:469–478 Lecuyer L, Chevret S, Thiery G et al (2007) The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med 35:808–814 Legrand M, Max A, Peigne V et al (2012) Survival in neutropenic patients with severe sepsis or septic shock. Crit Care Med 40:43–49 Massion PB, Dive AM, Doyen C et al (2002) Prognosis of hematologic malignancies does not predict intensive care unit mortality. Crit Care Med 30:2260–2270 McGrath S, Chatterjee F, Whiteley C et al (2010) ICU and 6-month outcome of oncology patients in the intensive care unit. QJM 103:397–403 Molina R, Bernal T, Borges M et al (2012) Ventilatory support in critically ill hematology patients with respiratory failure. Crit Care 16:R133 Nelson JE, Meier DE, Oei EJ et al (2001) Self-reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med 29:277–282 Norton SA, Hogan LA, Holloway RG et al (2007) Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med 35:1530–1535 Oeyen SG, Benoit DD, Annemans L et al (2012) Long-term outcomes and quality of life in critically ill patients with hematological or solid malignancies: a single center study. Intensive Care Med DOI 10.1007/s00134-012-2791-x Pène F, Aubron C, Azoulay E et al (2006) Outcome of critically ill allogeneic hematopoietic stem-cell transplantation recipients: a reappraisal of indications for organ failure supports. J Clin Oncol 24:643–649 Pène F, Percheron S, Lemiale V et al (2008) Temporal changes in management and outcome of septic shock in patients with malignancies in the intensive care unit. Crit Care Med 36:690–696 Puntillo KA, Arai S, Cohen NH et al (2010) Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med 38:2155–2160 Rubenfeld GD, Crawford SW (1996) Withdrawing life support from mechanically ventilated recipients of bone marrow transplants: a case for evidence-based guidelines. Ann Intern Med 125:625–633 Schellongowski P (2011) Onkologische Notfälle. Wien Klin Wochenschr Educ 6:113–129 Schellongowski P (2013) Der hämatologisch-onkologische Patient auf der Intensivstation: Therapieziele – Ethik – Palliation? Med Klin Intensivmed Notfmed DOI 10.1007/s00063-012-0177-z Schellongowski P, Benesch M, Lang T et al (2004) Comparison of three severity scores for critically ill cancer patients. Intensive Care Med 30:430–436 Schellongowski P, Staudinger T (2012) Intensivmedizinische Probleme des hämato-onkologischen Patienten. Med Klin Intensivmed Notfmed 107:386–390 Schellongowski P, Staudinger T, Kundi M et al (2011) Prognostic factors for intensive care unit admission, intensive care outcome, and post-intensive care survival in patients with de novo acute myeloid leukemia: a single center experience. Haematologica 96:231–237 Sculier JP (1991) Intensive care in the treatment of cancer patients. Curr Opin Oncol 3:656–662 Smith TJ, Temin S, Alesi ER et al (2012) American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol 30:880–887 Soares M, Caruso P, Silva E et al (2010) Characteristics and outcomes of patients with cancer requiring admission to intensive care units: a prospective multicenter study. Crit Care Med 38:9–15 Soares M, Salluh JI, Azoulay E (2010) Noninvasive ventilation in patients with malignancies and hypoxemic acute respiratory failure: a still pending question. J Crit Care 25:37–38 Soubani AO, Kseibi E, Bander JJ et al (2004) Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a medical ICU. Chest 126:1604–1611 Squadrone V, Massaia M, Bruno B et al (2010) Early CPAP prevents evolution of acute lung injury in patients with hematologic malignancy. Intensive Care Med 36:1666–1674 Staudinger T (2013) Der hämato-onkologische Patient im Intensivmanagement. Med Klin Intensivmed Notfmed DOI 10.1007/s00063-012-0178-y Staudinger T, Stoiser B, Mullner M et al (2000) Outcome and prognostic factors in critically ill cancer patients admitted to the intensive care unit. Crit Care Med 28:1322–1328 Taccone FS, Artigas AA, Sprung CL et al (2009) Characteristics and outcomes of cancer patients in European ICUs. Crit Care 13:R15 Thiery G, Azoulay E, Darmon M et al (2005) Outcome of cancer patients considered for intensive care unit admission: a hospital-wide prospective study. J Clin Oncol 23:4406–4413 Thirumala R, Ramaswamy M, Chawla S (2010) Diagnosis and management of infectious complications in critically ill patients with cancer. Crit Care Clin 26:59–91 Vandijck DM, Benoit DD, Depuydt PO et al (2008) Impact of recent intravenous chemotherapy on outcome in severe sepsis and septic shock patients with hematological malignancies. Intensive Care Med 34:847–855 Zuber B, Tran TC, Aegerter P et al (2012) Impact of case volume on survival of septic shock in patients with malignancies. Crit Care Med 40:55–62