Prognostic factors in children requiring admission to an intensive care unit after hematopoietic stem cell transplant

Abstract

The objectives of this study are to identify prognostic factors of survival to discharge in pediatric hematopoietic stem cell transplant (HSCT) recipients requiring intensive care unit (ICU) admission, and to determine the utility of the Oncological Pediatric Risk of Mortality (O-PRISM) in predicting death of these patients. A retrospective cohort of 125 pediatric HSCT recipients from October 1992 to September 2002 was analysed to evaluate risk factors of mortality in those admitted to ICU after HSCT. Nineteen patients (median age 7.8 years, 14 boys) required 24 ICU admissions post-HSCT. The most frequent underlying diseases were acute myeloid leukemia (n=5). The survival rate on discharge from ICU was 54%. In univariate analysis, risk factors of mortality included earlier requirement of ICU admission post-HSCT (median 34 versus 166 days, p=0.002), a longer delay before ICU admission (median 12 versus 5 h, p=0.02), lack of neutrophil (p=0.011) or platelet engraftment (p=0.008), macroscopic hemorrhage (p<0.001), tachypnoea (p=0.033), hypoxemia (p=0.031), renal impairment (p=0.011), coagulopathy (p=0.012), mechanical ventilation (p<0.001), and an increasing number of organ failures (p=0.003). Macroscopic hemorrhage and mechanical ventilation remained significant in multivariate analysis. Both PRISM and O-PRISM scores were significant composite prognosticators. It was concluded that mortality of post-HSCT children requiring ICU admission is high, especially in those with poor prognosticators.

Outcome of adult umbilical cord blood transplant patients admitted to a medical intensive care unit

“…Platelet engraftment status on ICU admission and bleeding complications are known significant predictors of ICU survival in HSCT. 5,6,24 In the UCBT population, thrombocytopenia may reflect incomplete or slower stem cell engraftment and its association with mortality. A shorter time period between UCBT and ICU transfer trended toward statistical significance as a predictor of ICU mortality, and has also been recognized in prior analyses.…”

“…A shorter time period between UCBT and ICU transfer trended toward statistical significance as a predictor of ICU mortality, and has also been recognized in prior analyses. 22,24 The frequent pancytopenia that occurs in the early post-UCBT period with impaired oxygen delivery, infectious complications, sepsis and multi-organ system failure, puts patients at significant risk of mortality.…”

“…Several other reports in BMT and PBSCT patients also have identified higher APACHE II and III scores as a significant predictor of mortality. 6,21,[23][24][25][26] In the current analysis, no patient survived with an APACHE III score on ICU admission 489. This suggests that patients may be transferred to the ICU late in their clinical course with severe physiologic derangement and raises the question of whether these patients would benefit from early ICU transfer, even with signs of minimal organ dysfunction.…”

Transfer of the hematopoietic stem cell transplant patient to the intensive care unit: does it really matter?

“…The pediatric UCBT patient Three reports have described ICU transfer in the pediatric UCBT recipient, 36,39,41 although two provide very limited information on a small number of patients. 36, 41 Hagen et al 39 described the clinical course for 98 ICU admissions over a 9-year period; 52 of their subjects received an UCBT and 34 underwent BMT.…”

“…As a result, wherever possible, we separate these studies from those which consider the entire population requiring intensive care in our tabular summaries (Tables 3, 4 and 5). Table 1 The most frequent reasons for hematopoietic stem cell transplant recipients to experience ICU admission Respiratory failure and/or mechanical ventilation 6,8,9,11,12,14,16,17,18,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41 Sepsis 6,9,11,12,16,17,18,20,22,26,27,29,30,31,33,34,37,38 Cardiac dysfunction including arrhythmia, pericardial effusion, myocardial infarction and cardiac arrest 8,11,12,…”