The ICU Trial: A new admission policy for cancer patients requiring mechanical ventilation* Lucien Lecuyer, MD; Sylvie Chevret, MD, PhD; Guillaume Thiery, MD; Michael Darmon, MD; Benoît Schlemmer, MD; Élie Azoulay, MD, PhD O ver the last 2 decades, the management of critically ill cancer patients has changed dramatically. Dismally low survival rates in cancer patients requiring life-sustaining treatment were reported in the 1980s, leading experts to discour- age intensive care unit (ICU) admission of cancer patients (1–3). In addition, pro- longed mechanical ventilation was con- sidered inappropriate in recipients of bone marrow transplantation (4 – 8). Consequently, procedures for triaging cancer patients to the ICU have been de- veloped (9, 10). However, the perfor- mance of the selection criteria used for triage has not been fully evaluated. The limited performance of ICU ad- mission criteria for predicting outcomes (11) prompted us to broaden our ICU admission policy for critically ill cancer patients (3). The ICU Trial strategy is designed to improve the chances of sur- vival in critically ill cancer patients who could receive life-extending cancer treat- ment provided they survive an episode of very severe acute disease. According to our new policy, patients who are bedrid- den, or for whom no lifespan-extending cancer treatment is available, are not ad- mitted to the ICU. Patients scheduled for cancer treatment or having a good chronic performance status are admitted for a trial of ICU management (Fig. 1) (12). This ICU trial consists of full-code treatment for 4 days followed, on day 5, by a reappraisal of the appropriate level of care. The rationale for this ICU trial strat- egy is based on five facts that have emerged from recent studies: a) survival has improved in critically ill cancer pa- tients, including those who need ventila- tory support (10, 13–15), vasopressors (16), or renal replacement therapy (17, 18); b) classic predictors of mortality may have lost much of their value (14, 19 –21); c) because of patient selection, the char- acteristics of the malignancy are not as- sociated with ICU survival (22, 23); d) physiologic scores do not perform well enough to assist in ICU triage (24) and the use of specific scores (25) remains controversial (26, 27); and e) mortality in critically ill patients depends on the nature and number of organ failures (16, 28 –30). This is true not only at ICU admission but even more so 3 days (16, 28, 29) to 5 days (4, 22) after ICU ad- mission. We conducted a prospective study to evaluate survival in cancer patients ad- mitted for an ICU trial, requiring me- chanical ventilation during the ICU stay, and having at least one other organ dys- function. In addition, we sought to iden- tify criteria for deciding when to withhold or withdraw life-sustaining treatment on *See also p. 965. From the AP-HP, Saint Louis Hospital, Medical ICU; Paris 7 University, Paris, France. Supported, in part, by a grant from the Assistance- Publique Hôpitaux de Paris, a nonprofit institution. The authors have not disclosed any potential con- flicts of interest. Copyright © 2007 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01.CCM.0000256846.27192.7A Objective: Cancer patients requiring mechanical ventilation are widely viewed as poor candidates for intensive care unit (ICU) admission. We designed a prospective study evaluating a new admission policy titled The ICU Trial. Design: Prospective study. Setting: Intensive care unit. Patients: One hundred eighty-eight patients requiring mechan- ical ventilation and having at least one other organ failure. Interventions: Over a 3-yr period, all patients with hematologic malignancies or solid tumors proposed for ICU admission under- went a triage procedure. Bedridden patients and patients in whom palliative care was the only cancer treatment option were not admitted to the ICU. Patients at earliest phase of the malignancy (diagnosis <30 days) were admitted without any restriction. All other patients were prospectively included in The ICU Trial, con- sisting of a full-code ICU admission followed by reappraisal of the level of care on day 5. Measurements and Main Results: Among the 188 patients, 103 survived the first 4 ICU days and 85 died from the acute illness. Hospital survival was 21.8% overall. Among the 103 survivors on day 5, none of the characteristics of the malignancy were signif- icantly different between the 62 patients who died and the 41 who survived. Time course of organ dysfunction over the first 6 ICU days differed significantly between survivors and nonsurvivors. Organ failure scores were more accurate on day 6 than at admis- sion or on day 3 for predicting survival. All patients who required initiation of mechanical ventilation, vasopressors, or dialysis after 3 days in the ICU died. Conclusions: Survival was 40% in mechanically ventilated cancer patients who survived to day 5 and 21.8% overall. If these results are confirmed in future interventional studies, we recom- mend ICU admission with full-code management followed by reappraisal on day 6 in all nonbedridden cancer patients for whom lifespan-extending cancer treatment is available. (Crit Care Med 2007; 35:808–814) KEY WORDS: mechanical ventilation; cancer; neutropenia; septic shock; dialysis; organ failure 808 Crit Care Med 2007 Vol. 35, No. 3