Dr Zuhal Karakurt Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital,
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Transcript of Dr Zuhal Karakurt Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital,
Management of the end stage Management of the end stage lung cancer patients:lung cancer patients:What would the politics be on What would the politics be on the intensive care support?the intensive care support?
Dr Zuhal KarakurtSüreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital,
Respiratory Intensive Care Unit
Admission for ICU: ATS 1999 GuidelinesAdmission for ICU: ATS 1999 Guidelines
Priority 1Priority 1 Priority 2Priority 2 Priority 3Priority 3 Priority 4Priority 4 Category ACategory A Category BCategory B
3. Patients with ARF but have a reduced likelihood of recovery due to underlying diseases.
metastatic malignancy complicated by infection, crdiac tamponade,or airwayobstruction
4. Generally not appropriate for ICU admission
Category A:Too well to benefit from ICU care
Category B: Too sick to benefit from ICU care (severe irreversible: brain damage,organ failure, metastatic cancer unresponsive to CTx& RTx, persistant vegetative state
SOFASOFAOrgansOrgans FindingsFindings
CardiovascularCardiovascular Blood pressure Blood pressure (Sistolic&diastolic), (Sistolic&diastolic), dopamine, dopamine, doputamine, doputamine, NE,AdrenalineNE,Adrenaline
RespiratoryRespiratory PaO2, FiO2PaO2, FiO2
CoagulationCoagulation Platalet countPlatalet count
HepaticHepatic Serum bilirubineSerum bilirubine
RenalRenal Serum creatinine, urine Serum creatinine, urine output/ houtput/ h
NeurologicalNeurological GCSGCS
MODSMODSOrgansOrgans FindingsFindings
CardiovascularCardiovascular
Blood pressure Blood pressure (sistolic&diastolic),heart (sistolic&diastolic),heart rate/min, CVPrate/min, CVP
RespiratoryRespiratory PaO2, FiO2PaO2, FiO2
RenalRenal Serum creatinineSerum creatinine
CoagulationCoagulation Platalet countPlatalet count
HepaticHepatic Serum bilirubineSerum bilirubine
NeurologicalNeurological GCSGCS
MODS score estimate the ICU mortality, hosp. Mortality & MODS score estimate the ICU mortality, hosp. Mortality & lenght of ICU stay.lenght of ICU stay.
www.ICU scores
Multi Organ Disfunctions:Criterias
MildMild SevereSevere
RespiratoryRespiratory MV requirment MV requirment hypoxia & hypoxia & hypercapnia> 3 dayhypercapnia> 3 day
FiO2>0.5, PEEP 8FiO2>0.5, PEEP 8
ARDS ARDS
HepaticHepatic Bilirubine 2-3Bilirubine 2-3 Bilirubine 8-10Bilirubine 8-10
RenalRenal Urine output<35cc/h Urine output<35cc/h DialysisDialysis
CardiovasculCardiovascularar
Reduced EF,Reduced EF,
Capillary leakCapillary leakDopa., doputamine,Dopa., doputamine,
Adrenaline, NEAdrenaline, NE
GISGIS > 5days intolerance > 5days intolerance to gastric feedingto gastric feeding
Stress ulcer, blood Stress ulcer, blood transfusiontransfusion
CogulationCogulation PLT< 100, PLT< 100,
aPTT > N %125aPTT > N %125DICDIC
NeurologicNeurologic Confusion, GKS 8-11Confusion, GKS 8-11 Coma, GKS< 7Coma, GKS< 7
Patients with Cancer:Common reasons of Patients with Cancer:Common reasons of ICU admissionICU admission
Respiratory failure due to CancerRespiratory failure due to Cancer After CTx & bone marrow transplantAfter CTx & bone marrow transplant SepsisSepsis Electrolite disorders (hyponatremia)Electrolite disorders (hyponatremia) Pulmonary edemaPulmonary edema Changes mental statatusChanges mental statatus Acute airway obstructionsAcute airway obstructions Side effects of medical treatmentSide effects of medical treatment Postoperative observationPostoperative observation
Paz H, Chest, 1993
Thomas A Br Med J 1988
Soares, M Chest 2007
Adam AK. ERJ, 2008
Cancer patients with high mortality Cancer patients with high mortality raterate
Bed restricted patientsBed restricted patients Patients with paliative cancer Patients with paliative cancer
teraphyteraphy Mechanical ventilation requirment Mechanical ventilation requirment High SOFA scoresHigh SOFA scores Late stage lung cancerLate stage lung cancer
Lung Cancer: Admission of ICU
ICU admission of patients with ICU admission of patients with newly diagnosed cancernewly diagnosed cancer
Specific organ failure & need Specific organ failure & need for administration of CT.for administration of CT.
Mortality:Mortality:
* need for vasopressor * need for vasopressor
* need for mechanical * need for mechanical
ventilationventilation
* hepatic failure* hepatic failure
Darmon M. Crit Care Med. 2005; 33:2488
Terminal Cancer & COPD Terminal Cancer & COPD patientspatients
NSCLC (939 pts)NSCLC (939 pts)
Severe dispnea %32Severe dispnea %32
Severe pain %28Severe pain %28
Short term effectiveness MVShort term effectiveness MV %19%19
Tube feeding %18Tube feeding %18
CPR %7.5CPR %7.5
COPD (1008 pts)COPD (1008 pts)
% 56% 56
%21%21
%70%70
%38%38
%25%25
Claessens MT .Dying with lung cancer or chronic obstructive pulmonary diseases: insights from SUPPORT.. J Am Geriatr Soc. 2000.:48 (5 Supp) 146
Metastatic colon cancer: 316 stage III-IV lung cancer: 7471. Severity of dieases (APACHE) 2. Activities of daily life (ADLs)
score,3. Physical and emotinal
symptoms (pain, depretion, anxiety)
4. Patients preference for care5. Financial impact on patient’s
families
3 days before death 4 or more impairments. More pain (%40) confusion, decrease
mood,anxiety. 2/3 patients forego
resuscitation.
3-6 month before death: 25% suffer pain, Families incurred significant
financial burdens
McCarthy EP. Dying with cancer:patient’s function, symptoms, and care preferences as
death approaches. JAm Geriatry Soc. 2000; 48 (5 Suppl): 110
Terminal colon & lung (NSCLC)cancer:three days before death
FindingsFindings Number of Number of ptspts
stagestage ICU etio?ICU etio?
(%)(%)MV MV
mortalitmortalityy
MortalityMortality
Our centerOur center
2001-2001-04.200804.2008
7272 %60%60
IVIVPulm (70)Pulm (70)
Postop Postop (30)(30)
%59%59 %50 ICU%50 ICU
Adam A.Adam A.
ERJ 2008ERJ 2008139139
(% 69 (% 69 NSCLC)NSCLC)
%62%62
IVIVPulm (49)Pulm (49)
Cardio Cardio (25)(25)
%38 ICU%38 ICU
%53 %53 HospHosp
% 22 ICU,% 22 ICU,
% 40 Hosp% 40 Hosp
Reicher A, Reicher A,
Chest 2006Chest 20064848
(%83 (%83 NSCLC)NSCLC)
%64 %64
IVIVPulm (57), Pulm (57),
Sepsis Sepsis (15)(15)
% 75% 75
(%86 )(%86 )%43 ICU%43 ICU
%60 Hosp%60 Hosp
Lin YCLin YC
Respir 2004Respir 20048181 ?? Pulm Pulm %85%85 %85 ICU%85 ICU
Jennens RRJennens RR
Lung C 2002Lung C 200220 , 20 ,
SCLC newSCLC new?? PulmPulm ------ 7 m 2 pts7 m 2 pts
4 m 17 pts4 m 17 pts
40 day 1 40 day 1 ptspts
Boussat SBoussat S
ICM 2000ICM 200056 56 ?? PulmPulm %66%66 %66 ICU%66 ICU
%75 Hosp%75 Hosp
Ewer MSEwer MS
JAMA 1986JAMA 19864646 IVIV Pulm (100)Pulm (100) %100%100 %100 ICU%100 ICU
Results of patients with lung cancer in the ICU
0102030405060708090100
%
1 2mortality in MV General Mortality
Mortality in ICU according to years
1986
2000
2002
2004
2008
Lung cancer casesLung cancer cases
Diagnosed in ICU: 59 y, F, NSCLC& invazive aspergillosis, MOF ( 31st day eksitus)
NSCLC, stageIV,entubated on admission: 49 y M, 6th.day exitus, hypoxic cardiac arrest
Acute respiratory failure due to lung cancer:
Cancer related Cancer related atelectasisatelectasis
Cardiac pulmonary Cardiac pulmonary edema,edema,
Pulmonary Pulmonary infection,infection,
COPD COPD exacerbation,exacerbation,Noninvasive mechanical
ventilation
19.04.08
WHERE ???
ICU indications for lung cancer ICU indications for lung cancer patientspatients
Endobronchial stent aplications and observations
Postop prolonged MV
September 07
April 08
NIMV on wardsNIMV on wards
Acute respiratory failure in 23 solid cancer
13 succesfull
10 failure
4 BİPAP
intolerance
6 rapidly detoriate
6 exitus3 exitus
13 alive 1 alive
Cuomo A. Palliative Med 2004: 18: 602.
Approachment for admission to ICUApproachment for admission to ICU
Newly diagnosed Newly diagnosed casescases
Presence of Presence of infectionsinfections
COPD acute COPD acute exacerbationsexacerbations
Post-op prolonged Post-op prolonged MVMV
Organ functions Organ functions failurefailure
( > 4 organs ( > 4 organs mortality % 100)mortality % 100)
high mortality for high mortality for unresponsive Ctx unresponsive Ctx ve RTx in ve RTx in metastatic cases.metastatic cases.
CONCLUSIONSCONCLUSIONS3 days left for end of life!3 days left for end of life!
Sign & symptomsSign & symptoms Increase the pain, Increase the pain, anxiety, anxiety, Fear from death, Fear from death, Respiratory Respiratory
distressdistress Rapidly Rapidly
detoriation in detoriation in general status general status
Unresponsive to Unresponsive to CTx ve RTx CTx ve RTx
What can we do?What can we do? OxygenOxygen NIMV **(wards)NIMV **(wards) Sedation Sedation Analgesia**Analgesia**
Place: ICU if patient Place: ICU if patient requestrequest
(priority 4, Category B)
McCarthy Ep. JAM Geriatry Soc. 2000:48 (Supp).:110
Stefano Nava, ERS 2007 Oral prentation)**
Thanks