1. De-escalation of Intensive Therapies

De-escalation relies on objective clinical and laboratory criteria to safely discontinue or taper high-intensity interventions, preventing rebound complications and promoting recovery.

A. Criteria for Discontinuing Rasburicase

Rasburicase is indicated for tumor lysis syndrome (TLS) with hyperuricemia refractory to standard care. Discontinuation is guided by resolution of the acute metabolic crisis.

• Clinical Triggers for Discontinuation:
  • Serum uric acid < 7 mg/dL for ≥ 24 hours.
  • Stable urine output (> 0.5 mL/kg/h) and creatinine trending downward.
  • No new or worsening electrolyte derangements (e.g., hyperkalemia, hyperphosphatemia).
• Transition Plan:
  • Initiate oral allopurinol 300 mg once daily (adjust for renal impairment).
  • Monitor uric acid every 24 hours for 48 hours post-discontinuation to ensure stability.

B. Corticosteroid Tapering and Adrenal Support

High-dose corticosteroids, such as dexamethasone for spinal cord compression, require a careful taper to prevent adrenal insufficiency.

• Taper Protocol: Begin taper after a stable neurologic exam (usually day 7–10). A common approach is to reduce the total daily dexamethasone dose by 2 mg every 48 hours until reaching 4 mg daily, then transition to an equivalent oral prednisone dose.
• Adrenal Support Triggers: Monitor for symptoms of adrenal insufficiency (fatigue, refractory hypotension, hypoglycemia). If suspected, consider stress-dose hydrocortisone (e.g., 50 mg IV q6–8h) during the taper.

C. Vasopressor Weaning Strategies

The goal is to maintain a mean arterial pressure (MAP) ≥ 65 mm Hg while demonstrating improved tissue perfusion (e.g., lactate clearance, warming extremities, adequate urine output).

• Weaning Steps: Reduce norepinephrine by 0.01–0.03 µg/kg/min every 1–2 hours. Before each reduction, assess hemodynamics and perfusion markers. Dynamic tests like passive leg raise or POCUS can help predict tolerance.
• Adjuncts: Vasopressin at a fixed low dose (e.g., 0.03 units/min) can facilitate weaning of catecholamines. Low-dose hydrocortisone should be considered in cases of suspected septic shock-related adrenal insufficiency.

2. Pharmacotherapy Transition and IV-to-Enteral Conversion

Early conversion to enteral therapy reduces IV line complications, lowers costs, and facilitates a smoother transition to outpatient management once GI function and clinical stability permit.

A. Allopurinol vs. Rasburicase

Allopurinol, a xanthine oxidase inhibitor, prevents new uric acid formation and is the standard for oral management after the acute phase of TLS is controlled with rasburicase.

• Dosing: Standard dose is 300 mg PO once daily. Reduce to 100–200 mg daily for CrCl < 20 mL/min.
• Conversion Criteria: Patient must be tolerating enteral intake without severe mucositis or ileus, and serum uric acid should be stable (< 7 mg/dL) under rasburicase therapy.

B. Anticoagulation Transition

Transitioning from inpatient parenteral anticoagulation to an outpatient regimen requires careful consideration of drug interactions, organ function, and patient factors.

C. Antimicrobial Prophylaxis

Prophylaxis is crucial during periods of profound neutropenia to prevent life-threatening infections.

• Bacterial: Fluoroquinolones (e.g., levofloxacin 500 mg PO daily) are standard for patients with expected prolonged neutropenia (ANC < 500 cells/µL).
• Fungal: Mold-active azoles (e.g., posaconazole) are used for high-risk patients. IV echinocandins are an alternative if severe mucositis precludes oral intake.

3. Mitigating Post-ICU Syndrome (PICS)

Early rehabilitation and structured delirium prevention are essential to minimizing the long-term physical, cognitive, and psychological deficits common in survivors of critical illness.

A. Early Mobilization & The ABCDEF Bundle

The ABCDEF bundle is a proven, evidence-based framework for improving ICU outcomes and reducing the incidence and severity of PICS.

B. Cognitive & Functional Screening

Systematic screening helps identify deficits early, allowing for timely intervention.

• Delirium: Assess with the Confusion Assessment Method for the ICU (CAM-ICU) every 8–12 hours.
• Mobility: Track progress with the ICU Mobility Scale daily. A 6-minute walk test at ICU discharge can establish a functional baseline.
• Referral: Patients with persistent deficits should be referred to neuropsychology or a dedicated cancer survivorship clinic.

4. Medication Reconciliation and Discharge Planning

A comprehensive reconciliation process and patient-centered education are critical to bridging the gap from ICU to outpatient care and preventing readmissions.

A. Medication Review

The clinical pharmacist should lead a meticulous review, comparing pre-admission, ICU-initiated, and newly prescribed discharge therapies. Pay special attention to high-risk medication classes: anticoagulants, antimicrobials, corticosteroids, and targeted cancer agents. All taper schedules and drug indications must be explicitly confirmed and documented.

B. Patient & Caregiver Education

Effective education empowers patients and caregivers to manage complex regimens and recognize warning signs. The teach-back method should be used to confirm understanding.

C. Outpatient Follow-Up Coordination

A safe transition requires a well-coordinated follow-up plan communicated to all care teams via a detailed discharge summary.

• Timeline: Schedule follow-up visits within 7–14 days post-discharge with key services (oncology, pharmacy, nephrology, rehab).
• Lab Monitoring: Arrange for frequent lab draws (e.g., twice weekly) to monitor electrolytes, renal function, CBC, and coagulation profiles until stable.