The Christie NHS Foundation Trust The Role of Critical Care for Non- Haematological Malignancy Dr Phil Haji-Michael

The Christie NHS Foundation Trust Mr Onc. Mr Heam.

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:

The Christie NHS Foundation Trust Conflict with oncologists

The Christie NHS Foundation Trust Changing outcomes for cancer

The Christie NHS Foundation Trust

For some cancers the natural history is becoming more like a chronic relapsing remitting disease

The Christie NHS Foundation Trust For some cancers things are little changed

The Christie NHS Foundation Trust Is survival alone the most important issue?

The Christie NHS Foundation Trust 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

The Christie NHS Foundation Trust Changes in critical care The impact of outreach (“upstream triage”) Newer technologies available Ventilators, NIV & cardiovascular monitoring Standardisation of care Sepsis & ventilator care bundles

The Christie NHS Foundation Trust 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

The Christie NHS Foundation Trust Scenarios

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The Christie NHS Foundation Trust What did you think of Lunch? 1)Good 2)Poor 3)Fantastic 4)Unedible

The Christie NHS Foundation Trust 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.

The Christie NHS Foundation Trust Case 1: 57yr woman with Myeloma Breathless at rest T 38.5˚C RR 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

The Christie NHS Foundation Trust 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?

The Christie NHS Foundation Trust Q2. Likely mortality? (hospital discharge) 1)100% 2) 80% 3) 60% 4) 40% 5) 20%

The Christie NHS Foundation Trust Case 2: 64yr woman with NHL Stage IV B cell lymphoma 2yr ago In remission but recently noticed parotid lump MRI scan - tumor in parotid infiltrating left temporal lobe Attended for chemo, SpR noticed AF. Echo shows “thrombus in RA”. Admitted from clinic. Now (18:00 Friday) sudden deterioration & a call to outreach…

The Christie NHS Foundation Trust 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

The Christie NHS Foundation Trust Q3. The immediate plan would be.. 1)Chemotherapy 2)Thrombolysis 3)Anticoagulation 4)Surgery (Thrombectomy) 5)More imaging (e.g. CT scan chest)

The Christie NHS Foundation Trust 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?

The Christie NHS Foundation Trust

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

The Christie NHS Foundation Trust 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

The Christie NHS Foundation Trust 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

The Christie NHS Foundation Trust 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?

The Christie NHS Foundation Trust Q7. Likely mortality? (hospital discharge) 1)100% 2) 80% 3) 60% 4) 40% 5) 20%

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..

The Christie NHS Foundation Trust Case 4: 74 yr man with Lung CA Unwell T37.5˚C RR 30 SaO2 85% on 24% Oxygen Bronchial breathing and crepitations on right base HR 120 BP 110/60 CRT < 2 secs Drowsy 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

The Christie NHS Foundation Trust 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?

The Christie NHS Foundation Trust Summary Cancer is a very heterogeneous group of diseases Outcome has changed radically for some over the past few decades Equally critical care has undergone a similar transformation Open and honest dialogue between Oncology and Critical Care is essential Upstream/ward assessment and triage is also key “How much harm for how much benefit”

The Christie NHS Foundation Trust Thank you