1. Respiratory and Hemodynamic Support

Respiratory failure and shock are common life-threatening conditions in critically ill oncology patients. Prompt, evidence-based interventions focusing on early lung-protective ventilation, targeted sedation, and judicious vasopressor use are essential to reduce morbidity and mortality.

A. Mechanical Ventilation Strategies

The primary goal is to maintain gas exchange while minimizing ventilator-induced lung injury (VILI).

• Tidal Volume: 4–8 mL/kg of predicted body weight.
• Plateau Pressure (Pplat): Maintain < 30 cm H₂O.
• PEEP: Use 5–15 cm H₂O to maintain alveolar recruitment and improve oxygenation.
• FiO₂: Titrate to the lowest level to maintain SpO₂ of 88–95%, avoiding hyperoxia.
• Permissive Hypercapnia: Acceptable (PaCO₂ up to 60 mm Hg) provided the pH remains ≥ 7.20.

B. Sedation and Analgesia Protocols

An “analgesia-first” approach is recommended, prioritizing pain control before adding sedatives. The goal is a calm, comfortable patient who is synchronous with the ventilator.

• Regimen: Fentanyl infusion (1–5 µg/kg/h) for analgesia, with propofol (5–50 µg/kg/min) added for sedation.
• Monitoring: Target a Richmond Agitation Sedation Scale (RASS) of –2 (light sedation) to 0 (alert and calm). Perform daily sedation interruptions (“sedation vacations”) to assess neurologic status and facilitate weaning.
• Induction: In patients with hemodynamic instability, etomidate (0.2–0.3 mg/kg) is a preferred induction agent due to its cardiovascular stability.

C. Vasopressor Selection and Titration

The goal is to restore adequate tissue perfusion, typically targeting a Mean Arterial Pressure (MAP) of ≥ 65 mm Hg.

• First-Line: Norepinephrine (0.05–0.2 µg/kg/min) is the preferred agent due to its potent alpha- and modest beta-adrenergic effects.
• Adjunct: Vasopressin (0.03 units/min) can be added to decrease the required norepinephrine dose (a “catecholamine-sparing” effect).
• Refractory Shock: Epinephrine or phenylephrine may be considered if goals are not met.
• Monitoring: An arterial line is essential for continuous, accurate blood pressure monitoring. Point-of-care ultrasound can help assess volume status and cardiac function to guide therapy.

2. Renal Replacement Therapy (RRT)

Acute kidney injury (AKI) is a frequent complication in oncologic emergencies, often resulting from tumor lysis syndrome, nephrotoxic agents, or sepsis. Continuous Renal Replacement Therapy (CRRT) is often preferred over intermittent hemodialysis in hemodynamically unstable patients.

A. CRRT Modalities and Indications

• CVVH (Continuous Veno-Venous Hemofiltration): Primarily uses convective clearance. Ideal for removing middle- to large-sized molecules (e.g., myoglobin, inflammatory cytokines).
• CVVHDF (Continuous Veno-Venous Hemodiafiltration): Combines convective and diffusive clearance, providing efficient removal of a broad spectrum of solutes, from small (urea) to large.
• Indications for Initiation:
  • Severe oliguria (< 0.3 mL/kg/h for > 6 hours)
  • Life-threatening hyperkalemia (K⁺ > 6.5 mEq/L)
  • Severe metabolic acidosis (pH < 7.15)
  • Refractory volume overload causing respiratory compromise

B. Anticoagulation Management During RRT

Anticoagulation is necessary to prevent clotting of the extracorporeal circuit. Regional citrate is the recommended first-line strategy.

3. ICU Complication Prevention

Critically ill oncology patients face a high risk of preventable complications, including venous thromboembolism (VTE), stress ulcers, and nosocomial infections. Implementing standardized prophylaxis bundles is a cornerstone of patient safety in the ICU.

Nosocomial Infection Prevention Bundles

Strict adherence to care bundles is proven to reduce infection rates.

• CLABSI Bundle (Central Line-Associated Bloodstream Infection):
  • Hand hygiene before any line manipulation.
  • Chlorhexidine skin preparation.
  • Use of maximal sterile barriers during insertion.
  • Daily assessment of line necessity.
• VAP Bundle (Ventilator-Associated Pneumonia):
  • Head-of-bed elevation to 30–45 degrees.
  • Daily sedation vacations and assessment of readiness to extubate.
  • Regular oral care with chlorhexidine.
  • VTE and stress ulcer prophylaxis.
• CAUTI Prevention (Catheter-Associated Urinary Tract Infection):
  • Avoid unnecessary catheterization.
  • Use aseptic technique for insertion.
  • Maintain a closed drainage system.
  • Remove the catheter as soon as it is no longer indicated.

4. Management of Iatrogenic Complications

Aggressive treatments for oncologic emergencies can themselves cause significant toxicity. Proactive screening and supportive measures are critical to mitigate harm from these life-saving therapies.

A. Nephrotoxicity from Rasburicase

Rasburicase is highly effective for tumor lysis syndrome but carries a risk of severe hemolysis and methemoglobinemia in patients with Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency.

• Prevention: Mandatory G6PD screening is required before administration.
• Alternative: If a patient is G6PD deficient or screening is unavailable, use allopurinol (300 mg PO daily) with aggressive hydration for hyperuricemia prophylaxis.
• Monitoring: If rasburicase is given, monitor hemoglobin, LDH, and methemoglobin levels daily.

B. Cardiotoxicity from High-Dose Corticosteroids

High-dose steroids (e.g., for spinal cord compression or superior vena cava syndrome) can cause significant metabolic and cardiovascular side effects.

• Risks: Hypertension, fluid retention, severe hypokalemia, and arrhythmias.
• Monitoring: Check blood pressure at least every 4 hours. Monitor electrolytes, particularly potassium and magnesium, daily.
• Management: Treat hypertension as needed. Administer loop diuretics (e.g., furosemide 20–40 mg IV) for fluid overload and aggressively replete potassium.
• Tapering: Always taper steroids gradually after prolonged use to prevent acute adrenal insufficiency.

5. Goals-of-Care Conversations

Effective and compassionate communication is a core competency in critical care oncology. Structured, multidisciplinary discussions are essential to ensure that the intensive care provided aligns with the patient’s values, goals, and prognosis.

A. Multidisciplinary Framework and Communication

A team-based approach facilitates comprehensive and consistent communication.

• Team: Should include oncology, critical care, palliative care, nursing, and pharmacy.
• Timing: Initiate a formal goals-of-care discussion within 48 hours of ICU admission.
• Framework: The SPIKES protocol provides a useful structure for these conversations:
  1. Setting: Ensure a private, quiet, and uninterrupted environment.
  2. Perception: Ask the patient/family what they understand about the current situation.
  3. Invitation: Ask for permission to discuss prognostic information and goals.
  4. Knowledge: Deliver information clearly and concisely, avoiding medical jargon.
  5. Empathy: Acknowledge and validate emotional responses with statements like, “This must be very difficult to hear.”
  6. Strategy/Summary: Outline a plan that aligns with the established goals and summarize the conversation.