Wednesday, April 2, 2008
Cancer has a retrospective study looking at prognosis of patients with acute leukemia admitted to the ICU. It looks at all patients with acute leukemia (in any stage of their illness as long as it was pre-transplant) admitted to the ICU at a single institution over a 4 year period - 90 patients in all, mean age ~54 years, almost all had AML. Mortality up to 12 months was measured.
Major findings: ICU mortality was ~57% with another 11% dying that hospitalization prior to any treatment for leukemia (out of the ICU). A few percent recovered, were treated, then died. Only 27% survived to hospital discharge; 6 and 12 month survival was 18% and 16%. Having received a BMT preparative regimen and having a higher APACHE-II score were predictive of particularly bad outcomes. Of note, 2 month mortality was >90% for patients with AML, who needed inotropes and mechanical ventilation and stayed in the ICU at least 7 days.
The authors conclude, more or less, that everyone is wrong (wrong!) who ever suggested that ICU-level care is inappropriate for patients with acute leukemia because the outcomes aren't that bad. That seems like a bit of a straw-man argument to me - who are these people blocking admission to the nation's ICUs for leukemic patients? One could make an equally compelling argument that survival is so poor for these patients that a 'concurrent care model' (offering both curative and palliative-oriented care simultaneously) should be the standard of care, as well as having serious informed consent discussions with these incredibly ill patients & their families about treatment options (including limitations) given the likelihood of a poor outcome.
Thakkar, S.G., Fu, A.Z., Sweetenham, J.W., Mciver, Z.A., Mohan, S.R., Ramsingh, G., Advani, A.S., Sobecks, R., Rybicki, L., Kalaycio, M., Sekeres, M.A. (2008). Survival and predictors of outcome in patients with acute leukemia admitted to the intensive care unit. Cancer DOI: 10.1002/cncr.23394
Pain Practice has a critical, narrative review of sympathetic blocks for pain relief. Reviews the evidence (which is spotty, to be generous) and then endorses blocks heartily. That aside, it's a pretty good one for the teaching file, especially as an introduction to sympathetic ganglion blocks: it discusses the different blocks' techniques and indications, gives one a sense of their history, and has a good reference list
JCO's Art of Oncology section has a personal narrative about being confronted with a dying patient and struggling with what to say, being paralyzed by fear and heartache (written by a colleague of mine from my institution who is also a blogger). There's also an accompanying editorial about educating oncologists/oncology fellows about difficult communication.
The Journal of Health Psychology has published the best-titled paper I have seen in a while: Love Medicine for the Dying & Their Caregivers - The Body of Evidence.
Finally, and building on a conversation Tom & I had in the comments section of his last post, Palliative Medicine has published an editorial about the term 'palliative care' - in particularly lamenting language such as 'a palliative patient.'