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Management of the Critically Ill Adult Chimeric Antigen Receptor-T Cell Therapy Patient: A Critical Care Perspective

Gutierrez, Cristina, MD1; McEvoy, Colleen, MD2; Mead, Elena, MD3; Stephens, R. Scott, MD4; Munshi, Laveena, MD, MSc, FRCPC5; Detsky, Michael E., MD6; Pastores, Stephen M., MD, FCCM7; Nates, Joseph L., MD, MBA, MCCM8

doi: 10.1097/CCM.0000000000003258
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Objectives: Chimeric antigen receptor T-cell therapy, a type of immune effector therapy for cancer, has demonstrated encouraging results in clinical trials for the treatment of patients with refractory hematologic malignancies. Nevertheless, there are toxicities specific to these treatments that, if not recognized and treated appropriately, can lead to multiple organ failure and death. This article is a comprehensive review of the available literature and provides, from a critical care perspective, recommendations by experienced intensivists in the care of critically ill adult chimeric antigen receptor T-cell patients.

Data Sources: PubMed and Medline search of articles published from 2006 to date.

Study Selection: Clinical studies, reviews, or guidelines were selected and reviewed by the authors.

Data Extraction: Not available.

Data Synthesis: Not available.

Conclusions: Until modifications in chimeric antigen receptor T-cell therapy decrease their toxicities, the intensivist will play a leading role in the management of critically ill chimeric antigen receptor T-cell patients. As this novel immunotherapeutic approach becomes widely available, all critical care clinicians need to be familiar with the recognition and management of complications associated with this treatment.

1Department of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX.

2Stem Cell Transplant and Oncology Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO.

3Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY.

4Oncology and Bone Marrow Transplant Critical Care, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.

5Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, ON, Canada.

6Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, Toronto, ON, Canada.

7Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.

8Weill Cornell Medical College, New York, NY.

9Surgical and Medical Intensive Care Units, Division of Anesthesiology and Critical Care, Department of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX.

Drs. Gutierrez, McEvoy, Mead, Stephens, and Pastores disclosed off-label product use of siltuximab for use in cytokine release syndrome and neurotoxicity related to chimeric antigen receptor T cells. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: cgutierrez4@mdanderson.org

Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.