Hinds C J, Martin R, Quinton P
Department of Intensive Care, St. Bartholomew's Hospital, Smithfield, London, England.
Schweiz Med Wochenschr. 1998 Sep 26;128(39):1467-73.
Appropriately aggressive treatment of haematological malignancies can be complicated by a variety of life threatening events. Usually such acute events are, at least theoretically, potentially reversible and in view of the much improved prognosis of the underlying malignancy it is now generally considered to be appropriate to offer intensive care to selected cases, provided there is a reasonable prospect of cure or at least worthwhile palliation. A few remain concerned, however, and question whether the provision of intensive care for such patients is worthwhile. Hospital mortality rates of between 69-80% have been reported for patients admitted to intensive care with medical complications of haematological malignancy and this rises to 80-90% in those with respiratory failure. Overall mortality rates are generally even higher (87-95%) in those who have received a bone marrow transplant (BMT). The median duration of survival following discharge from hospital is in the region of 12-23 months, but a few survive much longer, a number must be presumed cured and their quality of life is good. These disappointing short- and long-term survival rates are achieved at considerable cost and, as is the case in many other categories of critically ill patients, expense and utilisation of resources is much higher in non-survivors than in survivors. Factors associated with a poor short-term outcome include the need for mechanical ventilation, hypotension, the administration of inotropes or vasopressors, an increasing number of failed organs, relapsed or unresponsive malignancy and persistent neutropenia. A poor prognosis may also be associated with increasing age, time on the ventilator and time in intensive care. BMT recipients have a particularly poor prognosis, especially when they require mechanical ventilation, and survival is unprecedented when ventilated BMT recipients either receive vasopressors or develop hepatic and renal insufficiency. It has not been possible to identify any features of the acute illness which influence the duration of long-term survival: this seems to depend solely on the progress of the underlying malignancy, something which is often difficult to predict before or during intensive care. In our view patients with life threatening complications of haematological malignancy should be offered intensive care unless or until it is clear that there is no prospect of recovery from the acute illness or that the underlying malignancy cannot be controlled.
对血液系统恶性肿瘤进行适当积极的治疗可能会因各种危及生命的事件而变得复杂。通常，这些急性事件至少在理论上是有可能逆转的，而且鉴于潜在恶性肿瘤的预后有了很大改善，现在一般认为，对选定的病例提供重症监护是合适的，前提是有合理的治愈前景或至少有值得的姑息治疗效果。然而，仍有一些人对此表示担忧，并质疑为这类患者提供重症监护是否值得。据报道，因血液系统恶性肿瘤的医疗并发症而入住重症监护病房的患者，医院死亡率在69%至80%之间，而呼吸衰竭患者的死亡率则升至80%至90%。接受骨髓移植（BMT）的患者总体死亡率通常更高（87%至95%）。出院后的中位生存期约为12至23个月，但有少数患者存活时间更长，一定数量的患者可被认为已治愈且生活质量良好。这些令人失望的短期和长期生存率是以相当高的成本实现的，而且与许多其他危重症患者的情况一样，非幸存者的费用和资源利用率比幸存者高得多。与短期预后不良相关的因素包括需要机械通气、低血压、使用血管活性药物或血管加压药、器官功能衰竭数量增加、恶性肿瘤复发或无反应以及持续中性粒细胞减少。预后不良也可能与年龄增加、呼吸机使用时间和重症监护时间有关。骨髓移植受者的预后特别差，尤其是当他们需要机械通气时，接受血管加压药或出现肝肾功能不全的接受机械通气的骨髓移植受者的生存率极低。目前还无法确定急性疾病的任何特征会影响长期生存时间：这似乎仅取决于潜在恶性肿瘤的进展情况，而这在重症监护之前或期间通常很难预测。我们认为，除非或直到明确急性疾病没有恢复的希望或潜在恶性肿瘤无法控制，否则应为患有危及生命的血液系统恶性肿瘤并发症的患者提供重症监护。
