Early Consults, Timely Patient Histories Aid Rheumatologists Treating Patients in the ICU

Illnesses involving the lung are among the most common reasons for rheumatology consults in the ICU.
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CHICAGO—When it comes to treating patients with rheumatic diseases who are in the intensive care unit (ICU), there are so many complications and considerations that few rules exist as a guide. But Paul Dellaripa, MD, associate professor at Harvard Medical School, said at the ACR’s State-of-the-Art Clinical Symposium that there are basic steps a rheumatologist can take to give themselves the best chance at effective treatment. And he walked through difficult cases to give attendees a sense of his approach.

In some cases, earlier consults and quick action to get a history from a patient before they become unable to help are two ways to try to get a leg up on a tough ICU case.

“It’s important that we ask those acute clinical questions,” he said. “Try to get the patient before they are intubated. … And even when they are intubated, they can still offer you key history and physical exam findings that other people may not have asked.”

According to an informal poll of his colleagues at Brigham and Women’s Hospital, Boston, the main reasons for rheumatology consults in the ICU are vasculitis, interstitial lung disease due to a confirmed or suspected case of connective tissue disease and systemic lupus erythematosus (SLE).

“The problem with understanding how our patients do in the ICU is there’s not a lot of data, and gathering this data can be challenging,” he said.

But according to the small amount of data available, the short answer is: They often don’t do very well. Those with vasculitis in the ICU have been found to have a 39% mortality rate after 31 months of follow-up. And among SLE patients, one 61-patient cohort out of Thailand had a mortality rate of 57%.^1,2

Example 1

He recounted the case of a 55-year-old woman who presented with skin lesions and progressive interstitial lung disease. She had been tired recently, with a dry cough, prominent lesions on her forehead and back that were red and slightly raised, and some periungual erythema.

Her aldolase was slightly elevated, her creatinine kinase was normal, but C-reactive protein was high, as expected. Her kidney and liver function were normal.

The woman soon fell into respiratory failure, with an X-ray showing diffuse bilateral infiltrates. Then she developed adenopathy with pulmonary hypertension.

Dr. Dellaripa