REVIEW Managing critically Ill hematology patients: Time to think differently Elie Azoulay c, ⁎, Frédéric Pène a , Michael Darmon b , Etienne Lengliné c , Dominique Benoit d , Marcio Soares e , Francois Vincent f , Fabrice Bruneel g , Pierre Perez h , Virginie Lemiale c , Djamel Mokart i , Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique (Grrr-OH) 1 a AP-HP Cochin, Paris, France b CHU Saint Etienne, France c AP-HP Saint Louis, Paris, France d Universitair ziekenhuis Gent, Belgium e Instituto Nacional de Câncer, Rio de Janeiro, Brazil f Monfermeil Hospital, France g Andre Mignot Hospital, Versailles, France h CHU Nancy, France i Paoli Calmette Institute, Marseilles, France abstract article info Available online xxxx Keywords: Acute respiratory failure Mechanical ventilation Outcomes Leukemia Bone marrow transplantation The number of patients living with hematological malignancies (HMs) has increased steadily over time. This is the result of intensive and effective treatments that also increase the probability of infiltrative, infectious or toxic life threatening event. Over the last two decades, the number of patients with HMs admitted to the ICU in- creased and their mortality has dropped sharply. ICU patients with HMs require an extensive diagnostic workup and the optimal use of ICU treatments to identify the reason for ICU admission and the nature of the complication that explains organ dysfunctions. Mortality of ARDS or septic shock is up to 50%, respectively. In this review, the authors share their experience with managing critically ill patients with HMs. They discuss the main aspects of the diagnostic and therapeutic management of critically ill patients with HMs and argue that outcomes have im- proved over time and that many classic determinants of mortality have become irrelevant. © 2015 Elsevier Ltd. All rights reserved. 1. Background In most industrialized countries, the number of patients living with hematological malignancies (HMs) has increased steadily over the last two decades, for several reasons [1]. The diagnosis is made earlier, when treatments are more effective, and molecular biology advances help to recognize low-grade malignancies consistent with normal life for many years [2]. Effective high-dose treatment regimens and targeted treatments have been introduced. These changes have considerably increased survival with good quality of life [3–5]. Patients with HMs increasingly require admission to the intensive care unit (ICU) for life-threatening events related to the malignancy and/or treatments, with immunosuppression being a major contributor [6,7]. Also, the aging of the population and development of specific treatment strategies for elderly patients [5,8,9] have increased the pro- portion of ICU admissions for comorbidity decompensation to about 20% among patients with HMs [10]. ICU patients with HMs require an extensive diagnostic workup [11] and the optimal use of available treatments [12]. Only close collabora- tion among hematologists, intensivists, and other specialists can meet these requirements [12]. The diagnosis and treatment of acute respira- tory failure has been the most controversial issue over the past two decades [13–15]. Research fueled by this controversy has resulted in a sharp drop in mortality, from nearly 100% to about 40% [16]. Lung biop- sies are now rarely needed, and bronchoscopy with bronchoalveolar lavage (BAL) is deemed useful only in selected patients [11]. In patients receiving mechanical ventilation (MV), mortality ranges from 35% to 70% depending on the associated organ dysfunctions and presence of graft versus host disease (GVHD) [17]. Mortality in patients with HMs and septic shock has fallen by 30% [18,19]. Non-bone marrow transplant (BMT) recipients with HMs requiring renal replacement therapy (RRT) have the same long-term outcomes as do patients without malignancies [20,21]. However, these data come from high-volume centers [22]. Moreover, they are probably influenced by selection bias, as up to 50% of patients referred for ICU admission are not admitted [10,23]. Al- though the current literature strongly suggests improved survival of Blood Reviews xxx (2015) xxx–xxx ⁎ Corresponding author at: Medical Intensive Care Unit, Hôpital Saint-Louis, ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, France. Tel.: +33 142 499 421; fax: +33 142 499 426. E-mail address: elie.azoulay@sls.aphp.fr (E. Azoulay). 1 This review article was written on behalf of the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique (Grrr-OH). YBLRE-00391; No of Pages 9 http://dx.doi.org/10.1016/j.blre.2015.04.002 0268-960X/© 2015 Elsevier Ltd. All rights reserved. Contents lists available at ScienceDirect Blood Reviews journal homepage: www.elsevier.com/locate/blre Please cite this article as: Azoulay E, et al, Managing critically Ill hematology patients: Time to think differently, Blood Rev (2015), http://dx.doi.org/10.1016/j.blre.2015.04.002