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Systematic Guide to Taking ICU Rounds in Oncology Critical Care

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Preamble: Why Oncology ICU Rounds Are Different

• Standard critical care physiology
• Disease-specific oncological emergencies
• Treatment toxicities (chemotherapy, targeted therapy, immunotherapy, radiation)
• Immunosuppression and its infectious consequences
• Unique haematological derangements
• Goals of care and prognosis communication in the context of malignancy

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PART I: PRE-ROUND PREPARATION (Before Entering the Unit)

1.1 Situational Awareness

• New admissions overnight - confirm reason for admission, admitting team's initial assessment
• Deteriorating patients - any who triggered rapid response, needed code or intubation overnight
• Patients pending discharge/step-down - review stability criteria
• Active crises - bleeding, septic shock, respiratory failure requiring immediate attention

1.2 Overnight Nursing Handoff Summary

• Haemodynamic trends and any vasopressor changes
• Ventilator changes and tolerance
• Urine output trends (especially relevant post-op or in TLS risk)
• Any new labs, cultures, or imaging results
• Medication issues or refusals

1.3 Review Key Labs and Vitals Before Entering the Room

• Complete blood count with differential (ANC focus)
• Comprehensive metabolic panel (creatinine, LFTs, phosphorus, uric acid, potassium, calcium)
• Coagulation panel (PT/INR, aPTT, fibrinogen, D-dimer in DIC-risk patients)
• Blood cultures (dates collected, any preliminary results)
• Lactate (trend)
• Arterial blood gas if ventilated
• Overnight vital sign trends

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PART II: THE ROUNDS STRUCTURE - SYSTEMATIC HEAD-TO-TOE SYSTEMS REVIEW

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PART III: DOMAIN-BY-DOMAIN ASSESSMENT

3.1 Neurological Assessment

• GCS trend and pupil response
• Is there a structural CNS reason for altered mental status? (brain metastases, leptomeningeal disease, cerebral oedema from WBRT)
• CAM-ICU score for delirium - distinguish from metabolic encephalopathy
• Seizure activity - paraneoplastic, metabolic, drug-related
• New focal deficits? - Consider metastatic cord compression, intracranial bleed (especially in thrombocytopenic patients), posterior reversible encephalopathy syndrome (PRES - seen with bevacizumab, tacrolimus, cyclosporine, cisplatin, hypertension)

• Steroid-induced psychosis/agitation - common on high-dose dexamethasone
• ICI (immune checkpoint inhibitor) encephalitis - autoimmune, check for recent nivolumab/pembrolizumab/ipilimumab; CSF pleocytosis, check anti-neural antibodies
• CAR-T related CRS and ICANS - Immune Effector Cell-Associated Neurotoxicity Syndrome; grade and treat (dexamethasone for ICANS Grade 2+)
• Methotrexate neurotoxicity - leukoencephalopathy on MRI
• Posterior cord compromise - is the patient able to move all four limbs? Any bowel/bladder dysfunction?

• Order MRI brain/spine urgently for new deficits
• Neurosurgery consult for space-occupying lesions with mass effect
• Dexamethasone 8-16mg IV for cord compression or significant cerebral oedema pending definitive therapy
• Neurology for paraneoplastic/ICI encephalitis

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3.2 Cardiovascular Assessment

• MAP target (typically ≥65 mmHg; higher if baseline hypertensive or cerebral autoregulation concern)
• Vasopressor type, dose, and trend
• HR and rhythm - is the patient in AF? Flutter? QTc prolongation?
• Volume status: CVP trend, clinical exam (JVP, peripheral oedema), daily fluid balance, weight trend

• Cardiotoxic chemotherapy - anthracyclines (doxorubicin, epirubicin), trastuzumab, 5-FU (coronary vasospasm), cisplatin (vascular injury), VEGF inhibitors (hypertension, thrombosis). Review prior echo; check if LVEF monitoring is overdue
• ICI myocarditis - life-threatening; troponin rise + ECG changes + echo findings. Treat with high-dose methylprednisolone 1-2 mg/kg/day; cardiology input mandatory. (PMID 41123622)
• Pericardial effusion/tamponade - malignant effusion (breast, lung, lymphoma); check for pulsus paradoxus, echo ASAP, pericardiocentesis if haemodynamically significant
• Superior vena cava (SVC) syndrome - facial/neck swelling, plethora, arm oedema; semi-upright position, stenting or radiation/chemotherapy depending on histology
• Hypovolaemia vs. distributive shock - critical distinction; post-operative hypovolaemia vs. neutropenic septic shock require different approaches
• QTc prolongation - many antiemetics (ondansetron, haloperidol), antifungals (fluconazole, voriconazole), antibiotics (fluoroquinolones) prolong QT; review medication list; threshold for stopping if QTc >500ms

• Echo if new murmur, haemodynamic instability, or ICI exposure
• Daily ECG if QTc concern
• Troponin if ICI myocarditis suspected
• For septic shock: initiate Surviving Sepsis Bundle within 1 hour - cultures, broad-spectrum antibiotics, 30 mL/kg crystalloid bolus if not contraindicated

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3.3 Respiratory Assessment

• Ventilator mode, FiO2, PEEP, tidal volume (confirm 6 mL/kg IBW, plateau pressure <30 cmH2O)
• ABG: pH, PaO2, PaCO2, P/F ratio
• Is this ARDS? (Berlin criteria: bilateral infiltrates, P/F <300, not explained by heart failure, within 1 week of clinical insult)
• Spontaneous breathing trial (SBT) eligibility today?
• Secretion management, chest physiotherapy

• Causes of respiratory failure in cancer patients (prioritised approach):
  • Infection: bacterial (gram-negative organisms dominate in neutropenia), Pneumocystis jirovecii (PCP - diffuse ground-glass on CT, LDH elevated, β-D-glucan positive), invasive aspergillosis (tree-in-bud, halo sign on CT), cytomegalovirus pneumonitis (post-BMT), RSV/influenza
  • Drug-induced pneumonitis: bleomycin, methotrexate, cyclophosphamide, checkpoint inhibitors (ICI pneumonitis - bilateral infiltrates, usually 2-3 months into therapy), targeted agents (erlotinib, osimertinib, everolimus)
  • Disease related: lymphangitic carcinomatosis, massive pleural effusion, intrapulmonary tumour burden, haemoptysis
  • Post-BMT: engraftment syndrome, diffuse alveolar haemorrhage (DAH - bloody BAL, thrombocytopenia), bronchiolitis obliterans
  • Radiation pneumonitis: 4-12 weeks post-RT to thorax; ground-glass in radiation field
• High-flow nasal cannula (HFNC) vs. non-invasive ventilation (NIV): In immunocompromised patients with hypoxaemic failure, HFNC is preferred over NIV for most scenarios. Early intubation is better than prolonged failed NIV. Evidence suggests invasive ventilation outcomes are improving but still poor in hematologic malignancies (PMID 33751920)
• Bronchoscopy with BAL: strongly consider in neutropenic/immunocompromised patients with new infiltrates; yield for PCP, fungi, CMV, atypicals is high and guides targeted therapy
• Haemoptysis: quantify (massive = >100-600 mL/24h); interventional radiology for bronchial artery embolisation; hold anticoagulation; coagulopathy correction

• Daily assessment for SBT
• BAL for unexplained infiltrates in immunocompromised patients
• Beta-glucan, galactomannan, CMV PCR if fungal/viral pneumonitis suspected
• Consider withholding or holding ICI if grade ≥2 pneumonitis; steroids 1-2 mg/kg prednisolone equivalent

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3.4 Haematological Assessment

• Today's CBC: WBC, ANC, Hb, platelets
• Transfusion thresholds met?
• Coagulation status: PT/aPTT/fibrinogen/D-dimer
• Is there active bleeding?
• Any new petechiae, purpura, mucosal bleeding?

• Red cells: transfuse for Hb <7 g/dL (restrictive) unless active bleeding, symptomatic anaemia, ACS - then <8 g/dL; haematologic malignancy post-induction may warrant higher threshold
• Platelets: transfuse for:
  • Plt <10,000 (prophylactic, stable)
  • Plt <20,000 if febrile or coagulopathic
  • Plt <50,000 for invasive procedures
  • Plt <100,000 for CNS surgery or active intracranial bleed
• FFP: for active bleeding with coagulopathy, not prophylactically
• Cryoprecipitate: fibrinogen <100-150 mg/dL with active bleeding
• Irradiated, leukodepleted products mandatory in BMT patients and for cellular immunodeficiency

• DIC - sepsis, AML-M3 (APML), mucin-secreting adenocarcinomas; prolonged PT/aPTT, low fibrinogen, elevated D-dimer, thrombocytopenia, microangiopathic haemolysis
• TTP/TMA - gemcitabine, mitomycin-C, post-SCT; MAHA + thrombocytopenia ± neurological + renal involvement; ADAMTS13 activity, plasma exchange
• Heparin-induced thrombocytopenia (HIT) - 4T score, anti-PF4 antibodies; stop heparin, switch to argatroban or fondaparinux
• Cancer-associated thrombosis (CAT) - DVT/PE; LMWH preferred over DOAC for most malignancies (rivaroxaban/apixaban now guideline options for some cancers); hold anticoagulation if Plt <50,000

• DIC is present in ~90% at diagnosis
• Start ATRA (all-trans retinoic acid) immediately before confirmatory genetics
• Aggressive coagulopathy correction: FFP, cryoprecipitate, platelets
• Watch for ATRA syndrome (differentiation syndrome): fever, respiratory distress, pulmonary infiltrates - treat with dexamethasone 10mg IV BD

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3.5 Infectious Disease and Antimicrobial Stewardship

1. Blood cultures x2 sets (peripheral + central line if present)
2. Urine cultures, throat swab, any wound swabs
3. Chest X-ray (CT chest preferred if CXR unremarkable and clinical suspicion high)
4. Empirical broad-spectrum antibiotics:
   • Low-risk (MASCC score ≥21, solid tumour, no comorbidities): oral ciprofloxacin + amoxicillin-clavulanate as outpatient
   • High-risk ICU patients: Piperacillin-tazobactam 4.5g IV 8-hourly OR cefepime 2g IV 8-hourly OR meropenem 1g IV 8-hourly (if prior ESBL colonisation, carbapenem-resistant history, or haemodynamic instability)
   • Add vancomycin/linezolid if: suspected line infection, skin/soft tissue infection, haemodynamic instability, mucositis, recent quinolone prophylaxis
   • Add antifungal (micafungin 100mg daily or liposomal amphotericin B) if: fever persists >96 hours on antibiotics, prolonged neutropenia expected >7 days, high-risk haematological malignancy
5. G-CSF: consider in high-risk febrile neutropenia; generally avoid if on active chemotherapy causing neutropenia (risk of stimulating malignant clone in MDS/AML)

• Day of cultures: review preliminary results, narrow if organism isolated
• Day 3-4: review clinical response; if improving and ANC recovering, oral step-down possible for low-risk patients
• Day 7: re-assess need for antifungal; consider CT chest for occult fungal infection if persistent fever
• De-escalation is mandatory - prolonged broad-spectrum coverage drives resistance and C. difficile

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3.6 Renal Assessment

• Urine output (target ≥0.5 mL/kg/hr)
• Creatinine trend
• BUN/creatinine ratio
• Electrolytes - potassium, phosphorus, calcium, magnesium, bicarbonate
• Is CRRT (continuous renal replacement therapy) running? Goals met?
• Bladder pressure if abdominal compartment syndrome suspected

• Uric acid ≥8 mg/dL or 25% increase from baseline
• Potassium ≥6.0 mEq/L or 25% increase
• Phosphorus ≥4.5 mg/dL (adults) or 25% increase
• Calcium ≤7 mg/dL or 25% decrease

• Prevention (high-risk): allopurinol 300mg PO daily x5-7 days; rasburicase 0.2 mg/kg IV (contraindicated in G6PD deficiency) for high-risk; aggressive hydration (3 L/m²/day or 200 mL/hr in adults without cardiac compromise)
• Established TLS: aggressive IV hydration; rasburicase; discontinue any potassium supplements; treat hyperkalaemia (calcium gluconate for cardiac protection, insulin-glucose, resonium); correct symptomatic hypocalcaemia cautiously (IV calcium may worsen nephrocalcinosis); treat hyperphosphataemia with dietary restriction and phosphate binders
• Dialysis indications: refractory hyperkalaemia, severe oliguria, symptomatic uraemia, acidosis

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3.7 Gastrointestinal and Nutritional Assessment

• Is the patient enterally fed? Tolerance? Rate?
• Bowel sounds, bowel opening, abdominal distension
• Mucositis grade (WHO scale 0-4): impacts oral intake, risk of bacteraemia
• Nausea/vomiting control: chemotherapy-induced (CINV) vs. ileus vs. bowel obstruction

• Nutrition in oncology ICU: early enteral nutrition (within 24-48 hours) is preferred unless haemodynamically unstable. Cancer patients are often catabolic - protein targets higher (1.2-1.5 g/kg/day). Avoid parenteral nutrition unless gut non-functional.
• Mucositis: meticulous oral hygiene; magic mouthwash (viscous lidocaine/antacid/diphenhydramine); analgesia; watch for secondary candidiasis (nystatin or fluconazole) and herpes simplex (acyclovir)
• Neutropenic enterocolitis (typhlitis): right lower quadrant pain, fever, diarrhoea with mucosal thickening on CT; bowel rest, IV antibiotics covering gram-negatives and anaerobes; surgical consult for perforation/peritonitis
• Graft-versus-host disease (GVHD) - GI: watery/bloody diarrhoea, nausea, ileus; confirm with endoscopic biopsy; treat with steroids; rule out CMV colitis concurrently
• C. difficile: high index of suspicion with any diarrhoea in antibiotic-treated cancer patients; stool PCR; oral vancomycin 125mg QID or fidaxomicin for severe/fulminant cases; faecal microbiota transplant after treatment
• Post-operative ileus (surgical oncology): nasogastric tube decompression, early mobilisation, correct electrolytes (especially K+ and Mg²+), prokinetics if appropriate, avoid prolonged NPO

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3.8 Hepatic Assessment

• LFT trend: bilirubin, AST, ALT, ALP, GGT
• Albumin (nutritional marker and synthetic function)
• Coagulation (PT/INR as synthetic function marker)
• Any jaundice on exam? RUQ tenderness?

• Chemotherapy-induced hepatotoxicity: direct hepatocyte damage (methotrexate, oxaliplatin - sinusoidal obstruction syndrome/VOD), cholestatic picture (checkpoint inhibitors, capecitabine)
• Veno-occlusive disease (VOD/SOS): post-HSCT; hepatomegaly, RUQ pain, jaundice, fluid retention; Seattle or Baltimore criteria for diagnosis; defibrotide treatment
• Hepatic metastases/tumour infiltration: elevated ALP/GGT, bilirubin; assess for biliary obstruction (ERCP/stenting)
• ICI hepatitis: grade hepatitis; hold ICI; steroids 1-2 mg/kg for grade 2+; mycophenolate for steroid-refractory cases
• Sepsis-associated cholestasis: rule out primary hepatic pathology
• Drug interactions via CYP450: voriconazole + vincristine (increased neurotoxicity), many targeted agents via CYP3A4

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3.9 Endocrine and Metabolic Assessment

• Steroid-induced hyperglycaemia: very common on dexamethasone/methylprednisolone; target glucose 140-180 mg/dL (7.8-10 mmol/L) in ICU; insulin sliding scale + basal insulin often required; peaks typically 4-8 hours after AM steroid dose
• Adrenal insufficiency: prior steroid therapy, bilateral adrenal metastases (lung cancer), adrenalectomy; low cortisol, hyponatraemia, hyperkalemia; empirical hydrocortisone 100mg IV TDS in suspected adrenal crisis
• SIADH: ectopic ADH production (SCLC, CNS tumours, various chemo agents - vincristine, cyclophosphamide); hyponatraemia with urine osmolality >100 mOsm/kg and urine Na >40; water restriction; treat underlying cause; tolvaptan for severe/refractory cases
• Hypercalcaemia of malignancy: most common metabolic emergency in cancer; PTHrP-mediated (squamous cell, renal cell, breast), osteolytic metastases (myeloma, breast), ectopic PTH/1,25-OH Vit D (lymphoma)
  • Presentation: "stones, bones, groans, psychic moans" - nephrolithiasis, bone pain, constipation/ileus, confusion
  • Treatment: IV fluid resuscitation 200-300 mL/hr; zoledronic acid 4mg IV over 15 min (most potent bisphosphonate; avoid if CrCl <35); denosumab 120mg SC if bisphosphonate-refractory or severe renal impairment; calcitonin 4 IU/kg IM/SC 12-hourly for rapid initial effect (tachyphylaxis after 48h); haemodialysis for severe/refractory cases
  • Treat underlying malignancy if feasible (PMID 35379468)
• Thyroid dysfunction from ICI: hypothyroidism (most common), hyperthyroidism/thyroiditis; check TSH weekly during ICI-related admissions

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3.10 Lines, Devices, and Wound Assessment

• Central venous catheter (CVC/PICC/Port): insertion date, site inspection (erythema, discharge, tenderness), necessity (remove when no longer needed); if tunnelled port accessed - assess for pocket infection; blood cultures from line AND peripheral simultaneously to calculate differential time to positivity (DTTP ≥2 hours from line = line-related bacteraemia)
• Arterial line: site check, calibration, necessity
• Urinary catheter: days in situ, necessity - remove as soon as able (target <48-72 hours post-op)
• Drains (surgical patients): character and volume of output (serous, serosanguinous, bile, chyle, pus), any sudden change in output
• Surgical wounds: for post-operative oncology patients - dehiscence, infection, haematoma, seroma
• Ostomies: output, character, any retraction or necrosis of stoma
• Epidural/regional blocks: sensory level, motor function, local anaesthetic dosing

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PART IV: SURGICAL ONCOLOGY-SPECIFIC ASSESSMENT

4.1 Common Surgical Oncology Procedures and ICU Considerations

4.2 Post-Operative Systems Assessment

• Anticipated difficult extubation? (head/neck, oropharyngeal surgery)
• Epidural/PCA effectiveness - pain is the number one barrier to effective breathing and coughing
• Incentive spirometry, chest physio
• Pleural effusion/haemothorax on CXR in thoracic/upper abdominal cases

• Fluid balance: aim for euvolaemia to slight negative balance post Day 1-2 after major abdominal surgery (oedematous bowel anastomosis heals poorly in a flooded patient)
• AF is particularly common after oesophagectomy and thoracic procedures - rate control first (amiodarone IV 300mg then 900mg/24h infusion; metoprolol); anticoagulation decision based on duration and bleeding risk
• Post-op hypertension: pain, bladder distension, catecholamine surge - treat the cause before antihypertensives

• Classic signs: fever Day 5-7, tachycardia, rising CRP, increasing drain amylase (if pancreatic), turbid/faeculent drain output, clinical peritonism
• CT with oral/rectal/IV contrast to confirm
• Management: drainage (percutaneous/surgical), antibiotics, nutritional support; anastomotic leak is the most dreaded surgical complication and has high mortality

• Milky pleural drain output (especially after first enteral feeding)
• Triglycerides in drain fluid >110 mg/dL confirms
• Initial management: NPO + parenteral nutrition or MCT-rich enteral feeds; octreotide 100-300 mcg SC TDS; surgical ligation if output >1 L/day for 5 days

• Cytopenia: myelosuppression from systemic absorption of intraperitoneal chemotherapy typically Day 7-14
• Nephrotoxicity: cisplatin-based HIPEC requires hydration protocol, monitoring Cr/eGFR, avoid nephrotoxins
• Prolonged ileus is the norm - aggressive bowel regimen, early mobilisation

4.3 Enhanced Recovery After Surgery (ERAS) in Oncology ICU

• Early oral feeding (typically Day 1 post major abdominal surgery)
• Epidural analgesia or TAP block for abdominal cases
• Targeted fluid therapy - avoid crystalloid overload
• Early mobilisation - physiotherapy from Day 1 post-operatively
• DVT prophylaxis (LMWH + TED stockings + pneumatic sequential compression devices)
• Urinary catheter removal by Day 1-2 post pelvic surgery if possible
• Avoid routine NGT use

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PART V: IMMUNOTHERAPY AND TARGETED THERAPY TOXICITIES IN THE ICU

5.1 Immune Checkpoint Inhibitor (ICI) Toxicities (irAEs)

5.2 CAR-T Cell Therapy Toxicities

• Cytokine Release Syndrome (CRS): fever, hypotension, hypoxia; grade using ASTCT criteria; tocilizumab 8mg/kg IV (first-line for Grade 2+); dexamethasone for Grade 3-4
• ICANS: encephalopathy, seizures, aphasia, motor deficits; grade by ICE score; dexamethasone 10mg IV QID for Grade 2+; levetiracetam prophylaxis recommended by most centres
• Haemophagocytic lymphohistiocytosis (HLH): fever, cytopenias, ferritin >10,000, splenomegaly, haemophagocytosis on bone marrow biopsy; etoposide-based regimen; consider in any critically ill haematology patient with high ferritin

5.3 Targeted Therapy Toxicities to Know

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PART VI: SPECIFIC ONCOLOGICAL EMERGENCIES - RAPID ASSESSMENT GUIDE

6.1 Superior Vena Cava (SVC) Syndrome

• Sit upright
• Obtain tissue diagnosis BEFORE starting treatment if possible (unless respiratory compromise is imminent)
• NSCLC (most common cause): systemic chemotherapy or EGFR/ALK targeted therapy if driver mutation; radiotherapy for SCLC
• Endovascular stenting: fastest symptom relief, preferred for severe/emergent presentations
• Dexamethasone 8-16mg IV: reduces oedema, useful for lymphoma

6.2 Malignant Spinal Cord Compression (MSCC)

• Dexamethasone 16mg IV stat, then 8mg BD
• Urgent MRI whole spine (not just symptomatic level - skip lesions common)
• Neurosurgical consult immediately if: potentially operable, single site, good functional status, radioresistant histology (renal cell, sarcoma)
• Radiotherapy: definitive for radiosensitive tumours (myeloma, lymphoma, SCLC, prostate); post-decompression adjuvant for others
• Bladder catheterisation if urinary retention
• Prognosis: ambulation at time of treatment is the single strongest predictor of outcome - treat within 24 hours

6.3 Raised Intracranial Pressure (ICP)

• HOB 30 degrees
• Dexamethasone 8-16mg daily for vasogenic oedema from metastases
• Mannitol 0.5-1 g/kg IV for acute herniation
• Neurosurgical consult for single/resectable lesion with mass effect
• Whole brain radiotherapy or stereotactic radiosurgery (SRS) depending on number/size of metastases

6.4 Hyperleucocytosis and Leucostasis

• Avoid red cell transfusion (raises viscosity); treat thrombocytopenia if needed
• IV hydration
• Hydroxyurea 50-100 mg/kg/day to rapidly reduce WBC
• Leukapheresis: if severe symptoms, respiratory failure, CNS involvement
• Start definitive chemotherapy as soon as possible
• Do NOT administer allopurinol without hydration (TLS risk with rapid cell lysis)

6.5 Haemorrhagic Cystitis

• Vigorous IV hydration
• Bladder irrigation via 3-way catheter
• Mesna (prevention of drug-induced, not viral)
• Cidofovir for BK/adenoviral haemorrhagic cystitis
• Cystoscopy, fulguration, or intravesical formalin/alum for refractory cases
• Hyperbaric oxygen therapy for radiation-induced haemorrhagic cystitis

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PART VII: GOALS OF CARE AND PALLIATIVE INTEGRATION

7.1 Daily Goals of Care Assessment

1. What is the underlying oncological status? Active disease, remission, palliative/end-stage, bone marrow transplant candidate?
2. What is the ICU admission trajectory? Are they improving, stable, or deteriorating?
3. Has the patient expressed their wishes? Advance directives, health proxy, documented code status?
4. Is this ICU admission consistent with the patient's values and goals? Many cancer patients did not intend to spend end-of-life on mechanical ventilation.
5. Is treatment futile or disproportionate? Discuss with oncology team regarding underlying disease trajectory.

7.2 Family Meetings in Oncology ICU

• Should occur within 72 hours of admission for every high-acuity oncology patient
• Invite: patient (if competent), key family members/HCP, primary oncologist, ICU consultant, palliative care, nursing, social work
• Follow the VALUE framework:
  • Value and acknowledge what family members say
  • Acknowledge family emotions
  • Listen to the family
  • Understand the patient as a person (not just the disease)
  • Elicit family questions
• Communicate prognosis honestly but compassionately; the systematic review on ICU mortality in hematologic malignancies (PMID 40136336) can inform discussions - factors associated with high mortality include active disease at admission, MV ≥14 days, multi-organ failure, progressive disease on treatment.

7.3 Deciding on ICU Limitations

• Terminal malignancy with no disease-modifying options available
• Multi-organ failure without trajectory of improvement after 3-5 days of full ICU care
• Patient's documented wishes for no escalation
• Consensus of oncology and ICU teams that treatment is disproportionate

• Comfort measures: analgesia (morphine titration), anxiolytics (midazolam)
• Palliative care formal involvement
• Chaplaincy/spiritual support
• Communicate clearly with family what withdrawal means and what to expect
• Document every decision meticulously

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PART VIII: THE MULTIDISCIPLINARY TEAM (MDT) IN ONCOLOGY ICU

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PART IX: DAILY DOCUMENTATION TEMPLATE FOR ONCOLOGY ICU ROUNDS

Patient Summary Header

Name/ID | Age | Sex | Oncological Diagnosis | Current Treatment | Admission Date | Day of ICU Stay | Admitting Diagnosis

Systems-Based Daily Note Format

NEURO: GCS__, Pupils__, CAM-ICU__, Sedation agent/score__, Pain score/management__
RESPIRATORY: Mode__, FiO2__, PEEP__, TV__, Sats/ABG__, SBT candidate Y/N__, Plan__
CARDIAC: BP/MAP__, HR/rhythm__, Vasopressors__, Volume status__, Echo date__
HAEMATOLOGY: WBC__, ANC__, Hb__, Plt__, Coags__, Transfusions today__, Anticoag status__
INFECTION: Fever Y/N__, Cultures pending/resulted__, Antibiotics D__, De-escalation possible__
RENAL: UO__, Cr__, Electrolytes__, CRRT Y/N__, TLS risk__
GI/NUTRITION: Feeding route/rate__, Bowel activity__, Mucositis grade__, LFTs__
METABOLIC: Glucose__, Na__, Thyroid if relevant__, Steroids dose__
LINES/WOUNDS: Lines (date/site)__, Drains (character/volume)__, Wound status__
GOALS OF CARE: Advance directive Y/N__, Code status__, Family meeting date__, Palliation plan__

ACTIVE PROBLEM LIST:
1.
2.
3.

PLAN:
1.
2.
3.

DAILY GOALS (communicated to nursing team):

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PART X: RAPID REFERENCE - ONCOLOGY ICU ANTIBIOTICS AND DOSING

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PART XI: CHECKLIST SUMMARY FOR DAILY ONCOLOGY ICU ROUNDS

• Overnight events and deteriorations reviewed
• Labs, cultures, imaging results reviewed
• Nurse handover received

• Neuro: GCS, delirium screen, focal deficits, ICP concerns
• Respiratory: vent settings, ABG, SBT eligibility, infiltrates cause identified
• CVS: MAP target met, vasopressors trend, rhythm, volume status, echo if needed
• Haematology: ANC/neutropenia, transfusion needs, coagulopathy, DIC screen, anticoagulation
• Infection: cultures resulted, antibiotics appropriate/narrow, antifungal needed
• Oncology-specific: TLS risk/treatment, hypercalcaemia, cord compression, ICI toxicity
• Renal: UO, creatinine, electrolytes, CRRT needs
• GI/nutrition: feeding, mucositis, ileus, C. diff risk
• Lines: all lines necessary? Site checks, culture strategy
• Surgical: drain outputs, anastomotic leak signs, wound status (surgical patients)
• Metabolic: glucose, electrolytes, steroid dose-related issues, thyroid
• Goals of care: code status confirmed, family meeting scheduled/completed
• Medications: renal/hepatic dose adjustments, drug interactions, QTc risk, de-escalation

• Daily goals communicated to nursing staff
• Multidisciplinary referrals placed (ID, palliative care, physiotherapy, nutrition)
• Family communication completed or planned
• Documentation complete

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Key References

1. Spring J, Munshi L. Hematology Emergencies in Adults with Critical Illness: Malignant Hematology. Chest. 2022;161(7):1790-1800. PMID 35167862
2. Dumas G, Lemiale V, et al. Survival in Immunocompromised Patients Ultimately Requiring Invasive Mechanical Ventilation: A Pooled Individual Patient Data Analysis. Am J Respir Crit Care Med. 2021;204(2):187-196. PMID 33751920
3. Pichon S, Zebian G, Bureau C, et al. Life-threatening immune-related adverse events in the intensive care unit: a narrative review. Intensive Care Med. 2025. PMID 41123622
4. Carter S, Wigmore T. Immunotherapy on ICU: a narrative review. Anaesthesia. 2025;80(3):271-282. PMID 39776055
5. Averbuch D, Vanbiervliet Y, et al. Empirical and targeted antimicrobial therapy in febrile neutropenia: ECIL-10 recommendations. Lancet Infect Dis. 2026. PMID 41314221
6. Quintana JH, Lopez-Vanegas CD, et al. Mortality-Related Risk Factors in Patients with Hematologic Neoplasm Admitted to the Intensive Care Unit: A Systematic Review. Curr Oncol. 2025. PMID 40136336
7. Issani A. An updated narrative review on the management of the most common oncological and hematological emergencies. Dis Mon. 2023;69(2):101442. PMID 35379468
8. Nguyen TAVT, Ng ZQ. Management of Perianal Sepsis in Neutropenic Patients with Haematological Malignancies. ANZ J Surg. 2026. PMID 41159400
9. Brenner and Rector's The Kidney, 2-Volume Set - Tumor Lysis Syndrome and AKI in Cancer (Cairo-Bishop Criteria, TLS management)
10. Gutierrez C, Rajendram P, Idowu O. Novel Cancer Therapeutics: Perioperative Implications and Challenges. Anesth Analg. 2025;140(4):766-779. PMID 39453847

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