Improving Outcomes for Children Requiring Extracorporeal Membrane Oxygenation Therapy Following Hematopoietic Stem Cell Transplantation

Abstract

OBJECTIVES: The objective of this study was to provide an updated review of survival for pediatric hematopoietic stem cell transplantation patients requiring extracorporeal membrane oxygenation therapy as well as characterize the demographics, clinical variables, and complications associated with mortality. DESIGN: Retrospective database review of the Extracorporeal Life Support Organization Registry from 1990 to 2019. SETTING: Extracorporeal membrane oxygenation centers reporting to Extracorporeal Life Support Organization. PATIENTS: Patients treated with extracorporeal membrane oxygenation greater than 28 days to 18 years old with International Classification of Diseases Ninth Revision, International Classification of Diseases Tenth Revision, and current procedural terminology codes consistent with hematopoietic stem cell transplantation were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics, year of extracorporeal membrane oxygenation run, clinical variables, comorbid diagnoses, and extracorporeal membrane oxygenation complications were assessed in relation to the primary study outcome of survival to hospital discharge. Ninety patients were included in the final analysis. The overall survival rate for the study period was 19%. However, the survival rate in the last decade (2010–2019) improved to 26% (p = 0.01; odds ratio 9.4 [1.2–74.8]). Factors associated with decreased survival included comorbid malignancy, elevated peak inspiratory pressure in conventionally ventilated patients, and pulmonary and metabolic complications on extracorporeal membrane oxygenation. CONCLUSIONS: Pediatric patients posthematopoietic stem cell transplantation supported with extracorporeal membrane oxygenation have improving survival rates over time. With 26% of patients (16/62) surviving to hospital discharge in the last decade (2010–2019), history of hematopoietic stem cell transplantation may no longer be considered an absolute contraindication to extracorporeal membrane oxygenation. As advancements are made in hematopoietic stem cell transplantation therapies and extracorporeal membrane oxygenation management, the indications for life-saving extracorporeal membrane oxygenation support among patients posthematopoietic stem cell transplantation may expand accordingly.

Extracorporeal Membrane Oxygenation Candidacy in Pediatric Patients Treated With Hematopoietic Stem Cell Transplant and Chimeric Antigen Receptor T-Cell Therapy: An International Survey

“…These reports have led to a renewal of interest and suggest improving outcomes for pediatric HCT patients supported with ECMO. This is also supported by recent reports that demonstrate improved survival of 26-50% for pediatric HCT patients supported with ECMO since 2010 (20,21).…”

“…Interval advancements in both peri-HCT support and critical care therapies have resulted in improved patient outcomes for pediatric HCT patients who require intensive care and critical care resources ( 13 , 14 , 32 ). This is supported by a recent report of the ELSO database by Olson, et al, which showed an improvement in survival to hospital discharge in pediatric HCT patient requiring ECMO from 3% between 1991 and 2009 to 26% between 2010 and 2019 ( 21 ).…”

“…When asked to identify an acceptable rate to hospital survival for HCT patients supported with ECMO, the majority (95.7%) of respondents selected a survival range ≤50%, which is lower than that of the overall pediatric ECMO population ( 33 ) and 49.1% responded that they would accept a rate of hospital survival between 20-30% for these patients. Interestingly, over the last decade, the survival to hospital discharge for pediatric HCT patients supported with ECMO has already achieved this level with 26% survival ( 21 ). This suggests that survival for these patients is at a generally acceptable level.…”

Extracorporeal Membrane Oxygenation in Children With Cancer or Hematopoietic Cell Transplantation: Single-Center Experience in 20 Consecutive Patients

“…In patients post allogeneic HCT, the use of ECMO at our center was approximately two-fold higher than in patients with hematological malignancies (3.5%). Two of nine patients (22%) survived to discharge, which is within the range of data from the U.S. Pediatric Health Information System database and the Extracorporeal Life Support Organization (ELSO) registry (4,6,11). The fact that all seven patients surviving to discharge also are long-term survivors is notable considering the high rates of mortality reported within the first 90 days post ECMO treatment (12,13).…”

“…The fact that all seven patients surviving to discharge also are long-term survivors is notable considering the high rates of mortality reported within the first 90 days post ECMO treatment (12,13). While, despite signals for improved survival of ECMO in more recent years (10,11), status post allogeneic HCT, a diagnosis of leukemia, and granulocytopenia remain to be generally associated with higher odds of mortality relative to non-immunocompromised patients (4), clinical variables in our patients at initiation and during ECMO do not show any evidence for additional differences between patients post allogeneic HCT and those receiving chemotherapy for hematological malignancies. Indeed, although not reaching statistical significance, exploration of differences between survivors and non-survivors suggest a low vasoactive inotrope score (VIS) at initiation of ECMO, shorter duration of granulocytopenia, absence of emerging infections and bleeding complications, and absence of non-pulmonary organ failure during ECMO as being associated with survival.…”