Role of the intensive care unit in children undergoing bone marrow transplantation with life-threatening complications

Abstract

Summary:The role of support measures in the Intensive Care Unit for bone marrow transplant recipients has been controversial. Data from 176 pediatric bone marrow transplants were retrospectively analyzed to ascertain the probability, causes, risk factors and survival for lifethreatening complications requiring intensive care. Ninety-two patients underwent allogeneic BMT and 84 autologous BMT between January 1991 and December 1995. Thirty-one ICU admissions were recorded. The most frequent causes were acute respiratory failure (n = 15, mostly interstitial pneumopathies), septic shock (n = 5) neurological disorders (n = 5) and heart failure (n = 2). The cumulative incidence of an ICU admission at 20 months post-transplant in patients with an allogeneic BMT was 25.7% (CI: 16.4-35.1), compared with 10.8% (CI: 4.2-17.5) in those with an autologous graft (P = 0.04). ICU admission frequency was maximum during the first 2 months post-transplant. All complications in patients with autologous transplants appeared during the first 5 months post-transplant. Among patients with allogeneic grafts, four were later admitted to the ICU, at 7, 9, 12 and 20 months post-transplant, respectively. The main risk factor for ICU admission was acute GVHD grades III-IV. No differences were found between patients with allogeneic transplants with GVHD grades 0-II and those undergoing autologous transplant. In contrast, differences were highly significant between patients undergoing allogeneic transplants with GVHD grades III-IV and those with GVHD grades 0-II or autologous transplants. No differences were observed between allogeneic and autologous transplants in terms of causes for ICU admission, duration of stay, hours on mechanical ventilation, hours on inotropic drug therapy and numbers of organs failing. Neither were differences found in ICU discharge survival between patients with allogeneic (50%, CI: 29.1-70.9) and autologous (66.7%, CI: 29.9-89.1) transplants. ICU discharge survival in patients admitted for lung disease was 28.6% (CI: 12.1-65.6) but 76.5% (CI: 41.9-87.8) in patients admitted for other causes (P = 0.007). ICU Although a complication requiring admission to the ICU is, as confirmed by multivariate analysis, an unfavorable factor in long-term survival of transplanted patients, it must be emphasized that three of every 10 patients admitted to the ICU were alive and well at 3 years. Intensive care support in these patients can be life-saving.

Prognosis of child recipients of hematopoietic stem cell transplantation requiring intensive care

“…It has been estimated that 11-40% of BMT recipients, adults or children, require critical care because of the severity of the complications developing after BMT [4,6,7,8,9,10,11]. Given the high mortality rate of these patients, particularly those receiving MV, and the large amount of resources they need, the determination of mortality risk factors is of great clinical relevance.…”

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

“…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,…”

Outcome of children requiring intensive care following haematopoietic SCT for primary immunodeficiency and other non-malignant disorders

“…Post transplant grade III-IV GVHD has been shown to be associated with increased risk of ICU admission. 3 A number of predictors of poor outcome for those admitted to ICU have been identified, including the need for mechanical ventilation. [10][11][12] In one early study from 1993, only 3% of those requiring mechanical ventilation survived beyond 6 months after extubation.…”

“…Recipients of allogeneic transplants are more at risk than those undergoing autologous HSCT. 3 Rates of admission to ICUs for adults and children vary between centres, but range from 11 to 44% of HSCT recipients. [4][5][6][7] The reasons for ICU admission relate to well-recognised post-HSCT complications, including respiratory failure, neurological deterioration, cardiac dysfunction, sepsis and gastrointestinal bleeding.…”