Survival of pediatric patients requiring admission in the intensive care unit post hematopoietic stem cell transplantation: Prognostic factors associated with mortality

Abstract

Background Although hematopoietic stem cell transplantation (HSCT) is the only curative option for some children with malignant and nonmalignant disorders, the procedure itself carries a high risk of complications. A proportion of children undergoing HSCT develop severe transplant‐related complications requiring hospitalization in the pediatric intensive care unit (PICU). Methods A retrospective cohort study included 793 children with malignant and nonmalignant diseases that underwent 963 HSCTs in two large pediatric hospitals over 15 years. Ninety‐one patients needed 105 (11%) PICU admissions. The objective of the study was to analyze the risk factors associated with morbidity and mortality in children post HSCT who were admitted to the PICU. Results Survival rate of a single PICU hospitalization was 43%. Long‐term survival rate (classified as 1 year and 3 years) was 29.1% and 14.9% among PICU hospitalized patients compared with 74.6% and 53.3% among patients who had undergone HSCT and did not require PICU hospitalization. Factors found to have a significant negative association with PICU survival were respiratory failure as indication for PICU admission, neutropenia, graft‐versus‐host disease, mechanical ventilation, inotropic support, need for dialysis, and multiple‐organ failure (MOF) with more than one systemic intensive intervention. The strongest prognostic factors associated with mortality were MOF (p < .001) and the need for inotropic support (p = .004). Conclusions Neutropenia was found to be negatively associated with survival, suggesting non‐engraftment and late engraftment are important risk factors for HSCT patients hospitalized in PICU. MOF and inotropic support were found to be the main negatively associated predictive factors with survival.

Risk factors predicting need for the pediatric intensive care unit (PICU) post-hematopoietic cell transplant, PICU utilization, and outcomes following HCT: a single center retrospective analysis

“…Additionally, our institutional practice of allowing advanced respiratory support on the HCT unit (HFNC and some NIPPV) potentially led to PICU transfer later in the post-HCT course than in institutions with more restrictive policies. Post-HCT PICU 3-year overall survival from our cohort (52.0%) is higher in comparison to a recently published study (14.9%; 13 ) that evaluated post-HCT outcomes and is similar to another recent multi-center study’s 1-year survival post-ICU transfer (52.5%; 14 ). This discrepancy is at least partially due to improvement in supportive care over time.…”

“…Our study found that younger patients (and patients with lower weights) were more likely to need ICU care, which is not surprising given patients with smaller airways have a higher risk of increased respiratory needs and intubation post-HCT ( 17 ). Our cohort had a higher proportion of patients needing PICU care compared to previously reported retrospective cohorts (38.5% vs. 10%–15%; 3 – 5 , 13 , 14 ) and is likely the result of our patient cohort being younger, lower weight and having a high proportion of patients with underlying inborn errors of metabolism, who are also have a higher risk of complications peri-transplant ( 17 – 19 ). Further, when evaluating PICU care risk by multivariate logistic regression and adjusting for underlying disease, increasing age was found to have a lower odds of needing PICU care, which is in keeping with lower age (and likely smaller weight patients) experiencing higher risk of PICU need peri-HCT ( 17 ).…”

“…To date, some single-center retrospective studies of risk factors for PICU care post-HCT have been published ( 3 – 5 ) and multiple older prospective and multi-center studies also available ( 10 – 12 ). However, recent prospective and multi-center experiences are lacking aside from two recently published multi-center retrospective studies ( 13 , 14 ). Further, utilization of different supports in the PICU (e.g., types of respiratory support, types of dialysis) during HCT needs to be better described as HCT centers often have different approaches and institutional practices for interventions necessitating a PICU transfer and ongoing PICU care.…”

Organizational characteristics of European pediatric onco-critical care: An international cross-sectional survey

“…These treatment protocols are however, associated with severe side effects. Infections and treatment-related toxicity conditions are leading causes for of mortality and morbidity in cancer patients that require treatment in the intensive care unit and 2% to 28% of the pediatric cancer patients have been shown to require admission to the PICU during their disease course (2)(3)(4)(5)(6)(7)(8).…”

Organizational Characteristics of European Pediatric Onco-Critical Care: An International Cross-Sectional Survey.

“…Infections and treatment-related toxicity conditions are leading causes for of mortality and morbidity in cancer patients that require treatment in the intensive care unit and 2% to 28% of the pediatric cancer patients have been shown to require admission to the PICU during their disease course. [2][3][4][5][6][7][8] As cancer therapies improve and options evolve rapidly the knowledge, prompt recognition, and management of potentially life-threatening disease-and treatment-related complications is of utmost importance and requires close collaboration between the oncologists and PICU physicians. It has been shown in adult cancer patients that differences in ICU structure, organization, and collaboration between oncologists and the ICU team affects the quality of care and patient outcomes.…”