Changing use of intensive care for hematological patients: the example of multiple myeloma

Intensivists generally view patients with hematological malignancies as poor candidates for intensive care. Nevertheless, hematologists have recently developed more aggressive treatment protocols capable of achieving prolonged complete remissions in many of these patients. This change mandates a reappraisal of indications for ICU admission in each type of hematological disease. Improved knowledge of the prognosis is of assistance in making treatment decisions.

The records of 75 myeloma patients consecutively admitted to our ICU between 1992 and 1998 were reviewed retrospectively and predictors of 30-day mortality were identified using stepwise logistic regression.

The median age was 56 years (37-84). Chronic health status (Knaus scale) was C or D in 39 cases. Fifty-five patients (73%) had stage III disease and 17 had a complete or partial remission. Autologous bone marrow transplantation had been performed in 28 patients (37%). ICU admission occurred between 1992 and 1995 in 41 patients (54.7%), and between 1996 and 1998 in 34 patients (45.3%). The median SAPS II and LOD scores were 60 (23-107) and 7 (0-21), respectively. Reasons for ICU admission were acute respiratory failure in 39 patients (52%) and shock in 31 (41%). Forty-six patients (61%) required mechanical ventilation. Fifty patients (66%) received vasopressors and 24 dialysis. Thirty-day mortality was 57%. Only five parameters were independently associated with 30-day mortality in the multivariate model: female gender (OR = 5.12), mechanical ventilation (OR = 16.7) and use of vasopressor agents (OR = 5.67) were associated with a higher mortality rate, whereas disease remission (OR = 0.16) and ICU admission between 1996 and 1998 (OR = 0.09) were associated with a lower one.

The prognosis for myeloma patients in the ICU is improving over time. This may reflect either recent therapeutic changes in hematological departments and ICUs or changes in patient selection for ICU admission. Hematologists and intensivists should work closely together to select hematological patients likely to benefit from ICU admission.