Extracorporeal membrane oxygenation in pediatric recipients of hematopoietic stem cell transplantation: an updated analysis of the Extracorporeal Life Support Organization experience

Nardo, Matteo Di; Locatelli, Franco; Palmér, Kenneth; Amodeo, Antonio; Lorusso, Roberto; Belliato, Mirko; Cecchetti, Corrado; Perrotta, Daniela; Picardo, Sergio; Bertaina, Alice; Rutella, Sergio; Rycus, Peter; Ciommo, Vincenzo Di; Holzgraefe, Bernhard

doi:10.1007/s00134-014-3240-9

Cited by 40 publications

(65 citation statements)

References 6 publications

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“…This may be due to increased immunodeficiency in hematologic cancers, related to both underlying malignancy as well as more aggressive treatments such as glucocorticoid-based regimens and allogeneic HSCT, although these parameters could not be analyzed in our dataset. Interestingly, our finding of 50% survival in both solid and hematologic cancer patients requiring ECMO is encouraging and consistent with a recent case series suggesting that at least some critically ill children may be suitable candidates for this intervention [37, 38]. …”

Section: Discussionsupporting

confidence: 90%

Pediatric cancer type predicts infection rate, need for critical care intervention, and mortality in the pediatric intensive care unit

et al. 2014

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PURPOSE Up to 38% of children with cancer require PICU admission within three years of diagnosis, with reported PICU mortality of 13–27% far exceeding that of the general PICU population. PICU outcomes data for individual cancer types are lacking and may help identify patients at risk for poor clinical outcomes. METHODS We performed a retrospective multi-center analysis of 10,365 PICU admissions of cancer patients ≤ 21 years old among 112 PICUs between 1/1/2009 and 6/30/2012. We evaluated the effect of cancer type, age, gender, genetic syndrome, stem cell transplantation, PRISM3 score, infections, and critical care interventions on PICU mortality. RESULTS After excluding scheduled perioperative admissions, cancer patients represented 4.2% of all PICU admissions (10,365/246,346), had overall mortality of 6.8% (708/10,365) vs. 2.4% (5,485/230,548) in the general PICU population (RR=2.9, 95% CI 2.7–3.1, p<0.001), and accounted for 11.4% of all PICU deaths (708/6,215). Hematologic cancer patients had greater median PRISM3 score (8 vs 2, p<0.001), rates of sepsis (27% vs 9%, RR=2.9, 95% CI 2.6–3.1, p<0.001), and mortality (9.6% vs 4.5%, RR=2.1, 95% CI 1.8–2.5, p<0.001) compared to solid cancer patients. Among hematologic cancer patients, stem cell transplantation, diagnosis of acute myeloid leukemia, PRISM3 score, and infection were all independently associated with PICU mortality. CONCLUSIONS Children with cancer account for 4.2% of PICU admissions and 11.4% of PICU deaths. Hematologic cancer patients have significantly higher admission illness severity, rates of infections, and PICU mortality than solid cancer patients. These data may be useful in risk-stratification for closer monitoring and patient counseling.

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Section: Discussionsupporting

confidence: 90%

Pediatric cancer type predicts infection rate, need for critical care intervention, and mortality in the pediatric intensive care unit

et al. 2014

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“…If true, this may have also contributed to our overall low mortality data by shunting HSCT patient deaths out of the PICU. Unfortunately, our finding of four of 1,782 admissions using ECMO with 100% mortality is discouraging and emphasizes the need for ECMO-use guidelines in this population, especially as outcomes appear to be dismal (54, 55). …”

Section: Discussionmentioning

confidence: 81%

New Insights Into Multicenter PICU Mortality Among Pediatric Hematopoietic Stem Cell Transplant Patients*

Zinter

Dvorak

Spicer

et al. 2015

Critical Care Medicine

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Objectives Over 2,500 children undergo hematopoietic stem cell transplantation in the United States each year, and up to 35% require PICU support for life-threatening complications. PICU mortality has dropped from 85% to 44%, but interpretation is confounded by significant cohort heterogeneity. Reports conflict regarding outcomes for patients with different underlying hematopoietic stem cell transplantation indications, and the burden of infectious complications for these patients has not been evaluated. We aim to describe infections, critical care interventions, and mortality for pediatric hematopoietic stem cell transplantation patients requiring PICU admission. Design A retrospective multicenter cohort analysis. Setting One hundred twelve centers in the Virtual PICU Systems database, January 1, 2009, to June 30, 2012. Patients A total of 1,782 admissions for patients who are 21 years old or younger with prior hematopoietic stem cell transplantation. Interventions None. Measurements and Main Results Pediatric Index of Mortality-2, Pediatric Risk of Mortality-3, transplant indication, infections, interventions, and mortality were recorded from admission through PICU death or discharge. Pediatric hematopoietic stem cell transplantation patients comprised 0.7% of all PICU admissions (1,782/246,346), which resulted in 16.2% mortality compared with 2.4% mortality for non-hematopoietic stem cell transplantation admissions (odds ratio, 7.8; 95% CI, 6.8–8.8; p < 0.001). Mortality for admissions with underlying hematologic malignancy (22.7%) was similar to that of admissions with primary immunodeficiency (19.4%; p = 0.41) but significantly greater than admissions with underlying nonmalignant non-primary immunodeficiency hematologic disease (15.4%; p = 0.020), metabolic disorder (8.1%; p < 0.001), or solid malignancy (5.7%; p < 0.001). Infection was documented in 45.7% of admissions with 22.2% mortality; viral and fungal mortality were 28.5% and 33.7%, respectively. Invasive positive pressure ventilation and renal replacement therapy were used in only 34.6% and 11.9% of admissions, with mortality of 42.5% and 51.9%, respectively. Conclusions PICU mortality for pediatric hematopoietic stem cell transplantation patients may be as low as 16.2% but higher for those receiving intubation (42.5%) or replacement therapy (51.9%). Hematologic malignancy and primary immunodeficiency had greater risk for mortality than other transplant indications. Greater understanding of other risk factors affecting mortality and the need for critical care support is needed.

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“…None of the publications we reviewed above reported any HSCT patients requiring support with extracorporeal membrane oxygenation (ECMO). Published reviews of patients in the extracorporeal life support organization registry found overall poor outcomes for pediatric HSCT patients receiving ECMO support [46,47]. However, there are isolated case reports describing successful use of ECMO and survival in pediatric patients undergoing HSCT for various non-malignant diagnoses [48][49][50].…”

Section: Unanswered Questionsmentioning

confidence: 99%

“…However, there are isolated case reports describing successful use of ECMO and survival in pediatric patients undergoing HSCT for various non-malignant diagnoses [48][49][50]. Ongoing improvements in ECMO technology, including advances in cannula development, circuit technology and homeostasis management, along with refinement in patient selection, raise the possibility of ECMO successes in selected HSCT populations [46]. Since the number of HSCT patients amenable to ECMO is likely to be small, collaborative efforts are warranted for ongoing studies to optimize implementation of ECMO following HSCT.…”

Section: Unanswered Questionsmentioning

confidence: 99%

Historical outcomes of pediatric hematopoietic stem cell transplantation patients requiring critical care

Hume

Gupta

Steiner

2015

J Pediatr Intensive Care

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Hematopoietic stem cell transplantation (HSCT) is being used to treat numerous malignant and non-malignant medical conditions in pediatric patients, but frequently is associated with severe medical complications. We review the outcomes of HSCT patients who developed complications requiring pediatric intensive care unit (PICU) care. The earliest reported patient cohorts, who were transplanted prior to 1990, had high PICU mortality rates, exceeding 80%. Patients transplanted from the 1980s-1990s varied more widely in mortality rates, with mortalities of 56-88% reported for mechanically ventilated patients and rates of 44-50% reported for studies including both mechanically ventilated and non-mechanically ventilated patients in PICU. The patient group transplanted from the 1990s to the early 2000s had reported mortalities of 46-60%. For patients transplanted after 2000, mortality rates were reported ranging from 37-69%. Two centers reported a significant improvement in mortality over time at their centers, although other institutions did not find similar changes. Factors associated with increased mortality included the need for mechanical ventilation, pulmonary pathology as a cause for intubation, severity of lung disease, multiorgan failure, and severe graft versus host disease. The Pediatric Risk of Mortality scoring system has not been consistently predictive of mortality; the modified Oncological Pediatric Risk of Mortality system was more predictive of mortality in several studies. Overall, the mortality of pediatric HSCT patients requiring PICU care has decreased, but remains substantial. Further study is needed to define clinical factors that affect outcome, so that treatments might be modified to improve survival.

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Extracorporeal membrane oxygenation in pediatric recipients of hematopoietic stem cell transplantation: an updated analysis of the Extracorporeal Life Support Organization experience

Cited by 40 publications

References 6 publications

Pediatric cancer type predicts infection rate, need for critical care intervention, and mortality in the pediatric intensive care unit

Pediatric cancer type predicts infection rate, need for critical care intervention, and mortality in the pediatric intensive care unit

New Insights Into Multicenter PICU Mortality Among Pediatric Hematopoietic Stem Cell Transplant Patients*

Historical outcomes of pediatric hematopoietic stem cell transplantation patients requiring critical care

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