AJTCCM VOL. 29 NO. 1 2023 4
EDITORIAL
Critical care beds in South Africa (SA) are a scarce and precious
resource.[1] Allocation of resources to patients with the highest
likelihood of survival is a common practice with severity of disease
and likelihood of a successful ICU outcome, being carefully weighed
up.[1-3]Patients with solid organ-malignancies are oen excluded from
ICU except in rare acute life prolonging situations, for example bowel
obstruction surgery. Patients with haematological malignancies have
traditionally had very poor ICU outcomes, if needing admission for
organ support.[4] e outcomes depend on the type of malignancy
and requirement for organ support, such as dialysis or ventilation,
particularly if neutropenic sepsis or chemotherapy complications are
present.
The Critical care unit at the Universitas Academic Hospital –
University of Free State in Bloemfontein, conducted a review of
haematological patients requiring admission to their ICU. is study
provides important information to assist clinicians in the triage
process for a very scarce resource.[5]
Over a 10-year period, 182 patients were admitted with a
haematological malignancy: ~one and a half per month. The
researchers specically looked at those with neutropenic fever as a
result of their underlying treatment. What is not known is how many
were referred and not admitted, nor the criteria that the attending
ICU consultant on duty used to make the decision to admit or not.
It requires, in my experience, oen a lengthy discussion between the
oncologist/haematologist and the intensivist, in order to understand
the underlying malignancy, the medium-to-long-term prognosis
(oen a point of contention), and the specic needs of organ support
in the ICU.
A third of admissions had neutropenic sepsis, >86% needing
vasopressors with a median SOFA score of 10. Twelve of the 51
patients survived the ICU admission but only 9 (17.6%) were
discharged home, alive. In this very ill group of patients with high
organ failure scores, the outcomes would be considered dismal in any
general ICU. Arecent multicentre study evaluating ICU outcomes in
KwaZulu-Natal reported an overall ICU outcome of 19.7% mortality.[6]
erefore, we have to balance an expected outcome of ~20% chance of
mortality v. 20% chance of survival. In the COVID-ICU the survival-
to-hospital discharge was 30%, but the competition for beds/triage
system was not with those with an expected higher survival chance,
but among those with the same disease.[7]
ere are many challenges in the decision process of ‘to admit or
not: e ‘average’ or ‘median’ survival of 17.6% applies to the whole
group, and not the 9 individual patients who did survive, any of whom
may be standing in front of the attending doctor. On any given day, the
doctor may have no other admissions competing for the same bed; but
once the resource has been used, it can not be used for anyone else.
e challenge remains that without guidelines or national consensus
triage agreements, each patient is at the mercy of the day, the clinician
and the centre that they present to.
ere is no quick solution to these challenges, but ‘giving a patient
a chance’ today with an 80% chance of death, even if only for a short
stay, may preclude someone tomorrow who has an 80% chance of
survival if admitted to the ICU. Rational, consultative decision-
making, and guideline-based triage is required to assist clinicians
who make these life-and-death decisions, oen in the face of family
and referring clinician pressure. However, if the chance of survival
is low, as in the data presented, the cold light of day reality is that
precious resource allocation should trump personal/clinician feelings
and vested interest.
Richard van Zyl-Smit, MB ChB, FRCP(UK), Dip HIV(Man),
MMED, FCP(SA), Cert Pulm(SA), PhD, ATSF
Division of Pulmonology and Department of Medicine, University of Cape
Town and Groote Schuur Hospital, Cape Town, South Africa
richard.vanzyl-smit@uct.ac.za
1. Naidoo R, K Naidoo. Prioritising ‘already-scarce’ intensive care unit resources in the
midst of COVID-19: A call for regional triage committees in South Africa. BMC
Medical Ethics. 2021;22(1):28. https://doi.org/10.1186/s12910-021-00596-5
2. Joynt GM, Gopalan DP, Argent AA, etal. e Critical Care Society of Southern
Africa Consensus Statement on ICU Triage and Rationing (ConICTri). S Afr Med J
2019;109(8b):613-629. https://doi.org/10.7196/SAMJ.2019.v109i8b.13947.
3. van Zyl-Smit R, Burch V, Wilcox P. e need for appropriate critical care service
provision at non-tertiary hospitals in South Africa. South Afr Med J 2007;97(4):268-272.
4. Darmon M, Bourmaud A, Georges Q, etal., Changes in critically ill cancer patients’
short-term outcome over the last decades: results of systematic review with meta-
analysis on individual data. Intensive Care Med 2019;45(7):977-987. https://doi.
org/10.1007/s00134-019-05653-7
5. Martin CDS, Maasdorp SD Outcomes of patients with haematological malignancies
and febrile neutropenia in the Universitas Academic Hospital multidisciplinary
intensive care unit, Free State Province, South Africa. Afr J oracic Crit Care Med
2023;29(1):e263. https://doi.org/10.7196/AJTCCM.2023.v29i1.263
6. Wise R, de Vasconcellos K, Skinner D, etal., Outcomes 30 days aer ICU admission:
the 30DOS study. Southern Afr J Anaesth Anal 2017;23(6):139-144.
7. Arnold-Day C, van Zyl-Smit RN, Joubert IA, et al., Outcomes of patients with
COVID-19 acute respiratory distress syndrome requiring invasive mechanical
ventilation admitted to an intensive care unit in South Africa. S Afr Med J
2022;112(1):34-39. https://doi.org/10.7196/SAMJ.2022.v112i1.16115
Afr J Thoracic Crit Care Med 2023;29(1):e891. https://doi.
org/10.7196/AJTCCM.2023.v29i1.891
Critical care for patients with potentially fatal haematological
disorders
