Written by Clay Smith
This top 10 list may be life saving by helping us identify which cancer patients have a greater chance of becoming critically ill.
Why does this matter?
Patients with cancer are at greater risk of complications and have higher mortality. What are some other clues that may indicate greater illness severity in cancer patients?
Top 10: cancer, cancer, cancer, cancer…
The authors compiled a top 10 list of signs that may indicate that the patient with cancer in your ED is at greater risk of becoming critically ill.
Ignorance is not bliss. Knowing the, “underlying malignancy, comorbidities, autonomy, history of fungal or multiresistant bacterial infection,” is crucial. The patient or family is unlikely to know this key information.
Performance status – When you don’t have all the key information, yet have to make disposition decisions, consider calculating performance status (thanks MDCalc!). Poor performance status increases risk of critical illness.
Level of immunodepression – Be especially wary in patients with allogeneic bone marrow transplant, prolonged (>7 days), or profound neutropenia (< 100/mm3), as these can result in severe infection and increase risk of fungal disease. Immune checkpoint inhibitors cause immune enhancement but still may have profound toxicity.
Pulmonary involvement – Dyspnea from pneumonia, presence of hypoxia, or dyspnea from anemia, PE, heart failure, or chemo toxicity to heart or lung, are all markers of severe illness.
Sepsis – Cancer patients with sepsis need ICU care. Neutropenia alone doesn’t – unless septic.
Metabolic disturbance – Hyperkalemia, hyperphosphatemia, and hyperuricemia may all accompany tumor lysis. Induction chemo for some malignancies is often best started in the ICU. Don’t forget about the metabolic dangers from hyperglycemia, adrenal insufficiency, or hypercalcemia related to cancer.
Coagulation – DIC may accompany some promyelocytic leukemias. Hypercoagulability and venous thromboembolism is an ever-present risk in cancer patients.
Neurological signs – Tumor infiltration, edema, leptomeningeal spread, infection, or bleeding may all cause neurological emergencies. Emergent MRI or LP may be needed for some.
Absence of clear diagnosis – Don’t blow off cancer patients or skimp on the workup. Err on the side of being more thorough. Failing to find reversible causes of illness may cause rapid decompensation.
Delayed ICU admission – Many of our illness severity scoring systems don’t apply to cancer patients. Have a lower threshold to admit to the ICU if they have abnormal vital signs.
The 10 signs telling me that my cancer patient in the emergency department is at high risk of becoming critically ill. Intensive Care Med. 2018 Dec;44(12):2315-2318. doi: 10.1007/s00134-018-5449-5. Epub 2018 Nov 12.
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