Intensive care of the cancer patient: recent achievements and remaining challenges

A few decades have passed since intensive care unit (ICU) beds have been available for critically ill patients with cancer. Although the initial reports showed dismal prognosis, recent data suggest that an increased number of patients with solid and hematological malignancies benefit from intensive care support, with dramatically decreased mortality rates. Advances in the management of the underlying malignancies and support of organ dysfunctions have led to survival gains in patients with life-threatening complications from the malignancy itself, as well as infectious and toxic adverse effects related to the oncological treatments. In this review, we will appraise the prognostic factors and discuss the overall perspective related to the management of critically ill patients with cancer. The prognostic significance of certain factors has changed over time. For example, neutropenia or autologous bone marrow transplantation (BMT) have less adverse prognostic implications than two decades ago. Similarly, because hematologists and oncologists select patients for ICU admission based on the characteristics of the malignancy, the underlying malignancy rarely influences short-term survival after ICU admission. Since the recent data do not clearly support the benefit of ICU support to unselected critically ill allogeneic BMT recipients, more outcome research is needed in this subgroup. Because of the overall increased survival that has been reported in critically ill patients with cancer, we outline an easy-to-use and evidence-based ICU admission triage criteria that may help avoid depriving life support to patients with cancer who can benefit. Lastly, we propose a research agenda to address unanswered questions

Statin therapy for acute respiratory distress syndrome: an individual patient data meta-analysis of randomised clinical trials

Purpose We performed an individual patient data meta-analysis to assess the possible benefits and harms of statin therapy in adults with acute respiratory distress syndrome (ARDS) as well as investigate effects in specific ARDS subgroups. Methods We identified randomised clinical trials up to 31st October 2016 investigating statin therapy versus placebo in patients with ARDS. Individual patient data from each trial were compiled. Conventional two-stage meta-analyses were performed for primary and secondary outcomes and one-stage regression models with single treatment covariate interactions for subgroup analyses. Risk of bias was assessed using the Cochrane Risk of Bias tool. Results Six trials were included with a total of 1,755 patients. For the primary outcomes, there was no significant effect of statin therapy on 28-day mortality (relative risk (RR) 1.03, 95% CI 0.86 to 1.23), ventilator free days (mean difference 0.34 days, 95% CI -0.68 to 1.36) or serious adverse events (RR 1.14, 95% CI 0.84 to 1.53). There was a significantly increased incidence of raised serum creatine kinase or transaminase levels with statin therapy (106/879; 12.1%) versus control (78/876; 8.9%) (RR 1.40, 95% CI 1.07 to 1.83, p=0.015). There were no significant treatment covariate interactions in the pre-defined subgroups investigated. Conclusions We found no clinical benefit from initiation of statin therapy in adult patients with ARDS, either overall or in pre-defined subgroups. While there was an increased incidence of raised serum creatine kinase and transaminase levels, there was no difference in serious adverse events between groups. Therefore, we do not recommend initiation of statin therapy for the treatment of ARDS