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  • Untreated acute leukemia is rapidly fatal, but a percentage of patients can be cured. In the absence of cure, many can achieve a significant duration of high-quality life depending on preleukemia comorbidities, and should therefore be considered for therapy.

  • Medical complications of the acute leukemias are often reversed with treatment of the underlying disease.

  • Bleeding or infectious complications account for the majority of deaths in patients with acute leukemias.

  • Laboratory findings define and are prominent in tumor lysis syndrome and include hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia.

  • Rasburicase can be used to treat hyperuricemia, but must be avoided for patients with known hypersensitivity, methemoglobinemia, or G6PD deficiency.

  • Urinary alkalinization is not recommended for prevention of tumor lysis syndrome.

  • Cytogenetics and molecular studies are important prognostic indicators in AML and ALL.

  • Prophylactic platelet transfusion is indicated for thrombocytopenia associated with acute leukemia.

  • Disseminated intravascular coagulation (DIC) should be aggressively treated with transfusion support with fresh frozen plasma and cryoprecipitate during the initial treatment of acute leukemias.

  • Acute promyelocytic leukemia (APL) should be suspected in patients with pancytopenia and severe DIC.

  • All-trans retinoic acid (ATRA) therapy should be rapidly initiated if APL is suspected, and invasive procedures including placement of a central venous catheter should be avoided until the DIC has resolved.

  • Rapid cytoreduction by hydroxyurea and leukapheresis are mainstays of therapy for hyperleukocytosis.


Acute leukemias are a collection of bone marrow and lymphoid disorders that result from establishment of a malignant stem cell population. Presentation of a patient to medical care with a suspected acute leukemia should be considered a medical emergency, and rapidly involve a specialist in hematologic malignancies and referral to a tertiary care facility with expertise in treatment of patients with acute leukemia. Left untreated, acute leukemias are rapidly fatal within days to weeks of presentation, but with appropriate supportive measures and therapeutic interventions a significant number of patients are cured. For those in whom a cure cannot be achieved, there is still the potential for a substantial period of good quality life. Because of the acuity of these diseases and consequences of their treatment, it is not infrequent that patients with acute leukemias are seen in the setting of a medical ICU.45 It is especially important to understand that acute leukemias develop rapidly and the disease itself profoundly compromises an individual's performance status and comorbidities; however, with rapid and appropriate therapy, these leukemia-induced complications are often reversed. In order to appropriately target care from the perspective of the intensivist, it is important to understand the disease pathophysiology, overall prognostic evaluation, and complications unique to leukemia treatment regimens.

The goal of this chapter is to alert the intensivist to specific issues unique to the management of patients with acute leukemias that can directly impact the course of therapy in a medical ICU setting. We will focus on the diagnosis of leukemia and complications of patients with ...

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