[Major therapeutic advances and new perspectives in onco-hematology]

Extracorporeal membrane oxygenation in critically ill patients with active hematologic and non-hematologic malignancy: a literature review

Combined progress in oncology and critical care medicine has led to new aspirations and discussions in advanced life support modalities in the intensive care unit. Over the last decade, extracorporeal membrane oxygenation, previously considered unsuitable for oncologic patients, has become increasingly popular, with more diverse applications. Nevertheless, mortality remains high in critically ill cancer patients, and eligibility for extracorporeal membrane oxygenation can be extremely challenging. This scenario is even more difficult due to the uncertain prognosis regarding the underlying malignancy, the increased rate of infections related to intensive care unit admission, and the high risk of adverse events during extracorporeal membrane oxygenation support. With advances in technology and better management involving extracorporeal membrane oxygenation, new data on clinical outcomes can be found. Therefore, this review article evaluates the indicators for extracorporeal membrane oxygenation in different types of oncology patients and the possible subgroups that could benefit from it. Furthermore, we highlight the prognosis, the risk factors for complications during this support, and the importance of decision-making based on a multidisciplinary team in the extracorporeal membrane oxygenation indication.

Advances in the use of ECMO in oncology patient

BACKGROUND

Over the past decade, ECMO has provided temporary cardiopulmonary support to an increasing number of patients, but the use of extracorporeal membrane oxygenation (ECMO) to provide temporary respiratory and circulatory support to adult patients with malignancy remains controversial.

OBJECTIVES

This paper reviews the specific use of extracorporeal membrane oxygenation (ECMO) in oncology patients.

METHODS

We searched PubMed, CINAHL, Cochrane Library, and Embase databases for studies on the use of ECMO in cancer patients between 1998 and 2022. Twenty-four retrospective, prospective, and case reports were included. The primary outcome was survival during extracorporeal membrane oxygenation.

RESULTS

Most studies suggest that ECMO can be used in oncology patients requiring life support during surgery, solid tumor patients with respiratory failure, and hematological tumor patients requiring ECOM as a supportive means of chemotherapy; however, in patients with hematologic oncology undergoing hematopoietic stem cell transplantation, there was no clear benefit after the use of ECMO.

CONCLUSION

Current research suggests that ECMO may be considered as a salvage support in specific cancer patients. Future studies should include larger sample sizes than those already conducted, including studies on efficacy, adverse events, and health.

Impact of clinical pharmacy in oncology and hematology centers: A systematic review

BACKGROUND

Oncology and hematology is a complex and specific area that requires monitoring by a multidisciplinary team capable of personalizing the treatment of each patient. Clinical pharmacy services have the potential to contribute significantly to the effective and economical care of cancer patients.

OBJECTIVE

To evaluate, synthesize and critically present the available evidence on the impact of the Clinical Pharmacy in the treatment of patients with hematological cancer.

METHOD

A review was carried out on the bases PubMed/MEDLINE, LILACS and Google Scholar. The included studies were: studies that evaluated the effects of pharmaceutical interventions in clinical in oncology and hematology services and having as a population patient with hematological cancer.

RESULTS

17 studies were selected among 745 identified. 4.771 patients were included, with an average follow-up time of 15.3 months. Patients affected by some type of hematological cancer, undergoing chemotherapy treatment, showed better adherence and continuity when accompanied by a clinical pharmacist, added to this professional in carrying out interventions, provides control of symptoms such as cancer pain, nausea and constipation and, thus, contributes to decrease the length of hospital stay.

CONCLUSION

The implementation of a Clinical Pharmacy service in oncology and hematology centers contributes significantly to the effectiveness of pharmacotherapeutic treatment, treatment costs reduction, safety increase in the use of medications and the patient's quality of life.

The Utility of Extracorporeal Membrane Oxygenation in Patients With Hematologic Malignancies: A Literature Review

Extracorporeal membrane oxygenation (ECMO) is used to provide respiratory and/or circulatory support for critically ill patients. In people suffering from hematologic malignancies (HMs), acute respiratory failure often necessitates intensive care. Whereas initial studies reported that these patients generally have poor outcomes, studies conducted within the last 10 years have shown that ECMO is quite beneficial for patients with HMs. This review showcases data from 2010 to 2019 demonstrating the utility of ECMO in cancer patients. Retrospective studies revealed long-term disease-free survival, particularly when ECMO served as a bridge through chemotherapy. Case reports suggested strong evidence of mortality benefit from ECMO, especially in patients with aggressive lymphomas. However, a systematic approach is needed to better quantify and validate these findings. Studies with larger sample size and prospective cohorts are needed to help create well-defined guidelines for physicians approaching the treatment of cancer patients on ECMO.

Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis

The outcome of allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients has significantly improved over the past decade. Still, a significant number of patients require intensive care unit (ICU) management because of life-threatening complications. Literature from the 1990s reported extremely poor prognosis for critically ill allo-HSCT patients requiring ICU management. Recent data justify the use of ICU resources in hematologic patients. Yet, allo-HSCT remains an independent variable associated with mortality. However, outcomes in allo-HSCT patients have improved over time and many classic determinants of mortality have become irrelevant. The main actual prognostic factors are the need for mechanical ventilation, the presence of GvHD and the number of organ failures at ICU admission. Recently, the development of reduced-intensity conditioning regimens, early ICU admission and the increased use of noninvasive ventilation, combined with time effect and general advances in hematology, in allo-HSCT procedures and in ICU management have contributed to improve general outcome. A rational policy of ICU admission triage in these patients is very hard to define, as each decision for ICU admission is a case-by-case decision at patient bedside. The collaboration between hematologists and intensivists is crucial in this context.

Clinical outcomes of extracorporeal membrane oxygenation support in patients with hematologic malignancies

BACKGROUND/AIMS

The clinical outcomes of patients with hematologic malignancies who were treated with extracorporeal membrane oxygenation (ECMO) after the failu re of optimal conventional therapy were determined.

METHODS

The medical records of all patients administered ECMO during their stay in a medical intensive care unit of Seoul St. Mary's Hospital between February 2010 and July 2013 were reviewed retrospectively.

RESULTS

In total, 15 patients with hematologic malignancies were compared to 33 immunocompetent patients with documented cardiorespiratory failure. Underlying hematologic malignancies were significantly associated with lower overall survival (0.0% vs. 24.2%, p = 0.044). Mortality was significantly associated with a higher 24 hours ECMO inspired fraction of oxygen (0.71 ± 0.24 vs. 0.47 ± 0.13, p = 0.015), the development of infection after ECMO (87.5% vs. 25.0%, p = 0.001), and the presence of hyperbilirubinemia (70.0% vs. 0.0%, p < 0.001). Matching of the patients based on their Acute Physiology and Chronic Health Evaluation II scores confirmed the greater risk of mortality in patients with hematologic malignancies (survival: 0.0% vs. 40.0%, p = 0.017). The mean difference in inotropic-equivalent scores after ECMO was significantly lower in the immunocompetent patients than in those with hematologic malignancies (-59.22 ± 97.83 vs. 53.87 ± 164.46, p = 0.026).

CONCLUSIONS

Patients with hematologic malignancies who require ECMO for respiratory support have poor outcomes. The incidence of complications in these patients did not significantly differ from that in immunocompetent patients.