Hematological issues in critically ill patients with cancer

Patients with solid and hematologic malignancies presenting with major bleeding or thrombotic complications, potentially life-ending events in a cancer patient's clinical course, usually require admission to an intensive care unit (ICU), making their diagnosis and management even more important for the intensivist. Given the significant advances in the diagnosis and treatment of almost all types of cancers in recent years, the intensivist is likely to encounter an ever-increasing number of cancer patients in the ICU setting with these complications. Abnormal hemostasis can occur as a consequence of both the pathology and treatment of cancer. Because cancer can have multiple effects on hemostatic equilibrium, treatment of these complications can be more complex than in the general population. This article reviews the physiology of coagulation and fibrinolysis, with special attention to those aspects that are most frequently altered in the setting of malignancy. The pathophysiology of bleeding and thrombotic complications specific to critically ill cancer patients are then detailed, and the diagnostic and therapeutic strategies are discussed. Special emphasis is placed on new cancer medications that have an effect on hemostasis, and on novel clotting and anticoagulant agents that are available to the intensivist for the management of these patients.