What factors should be considered when deciding on the next stages of treatment?
New data over the past 15 years shows that with better supportive care mortality has improved in haematology malignancy patients.2 Changes in chemotherapy protocols, reduced intensity transplants compared to myeloablative transplants, and the recognition of the importance of early consultant involvement has contributed to this. This is in keeping with the NICE 2007 guidance relating to recognition and response to the deteriorating adult inpatient4: the referral should be consultant to consultant where possible, taking into account the status of the underlying malignancy, the treatment the patient has received prior to referral, any pre-morbid performance status, and the patient’s wishes. If any disagreement occurs, the patient should be considered for admission to ICU for a limited trial of Critical Care support.2
Following discussion between the haematology consultant looking after the patient and the intensive care consultant, a decision is made to admit the patient to intensive care. He is started on high flow nasal oxygen, a CXR is arranged, and an arterial line is inserted. He is placed in a side room in order to reverse-barrier nurse him even though he is not currently neutropenic. A full septic screen is undertaken including MSU and blood cultures are taken and, following discussion with the on-call microbiology consultant he is started on broad spectrum antibiotics that include anti-pseudomonal cover.
CXR shows diffuse bilateral pulmonary infiltrates. He is able to remain on HFNO, maintaining saturations of 92% on 50% FiO2. However, he is advised that if he requires mechanical ventilation his outcome is likely to be very poor. Later, CMV serology proves to be negative. No fungal markers are found in his sputum. The septic screen is negative.
After 48 hours, the patient is making limited progress and his clinical condition remains static. He is started on high dose steroids to treat suspected pulmonary haemorrhage. He had a positive response and was discharged from intensive care 7 days later.