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Huang H, Zhang R, Chen J, Dang H, Liu C, Lu S, Fu YQ. Comparing the clinical characteristics and outcomes of septic shock children with and without malignancies: a retrospective cohort study. J Pediatr (Rio J) 2024:S0021-7557(24)00075-5. [PMID: 38968957 DOI: 10.1016/j.jped.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/03/2024] [Accepted: 06/03/2024] [Indexed: 07/07/2024] Open
Abstract
OBJECTIVE There is an amelioration in mortality rates of septic shock patients with malignancies over time, but it remains uncertain in children. Therefore, the authors endeavored to compare the clinical characteristics, treatment needs, and outcomes of septic shock children with or without malignancies. METHODS The authors retrospectively analyzed the data of children admitted to the PICU due to septic shock from January 2015 to December 2022 in a tertiary pediatric hospital. The main outcome was in-hospital mortality. RESULTS A total of 508 patients were enrolled. The proportion of Gram-negative bacteria and fungal infections in children with malignancies was significantly higher than those without malignancies. Septic shock children with malignancies had a longer length of stay (LOS) in the hospital (21 vs. 11 days, p<0.001). However, there were no statistically significant differences in the LOS of PICU (5 vs. 5 days, p = 0.591), in-hospital mortality (43.0 % vs. 49.4 %, p = 0.276), and 28-day mortality (49.2 % vs. 44.7 %, p = 0.452). The 28-day survival analysis (p = 0.314) also showed no significant differences. CONCLUSION Although there are significant differences in the bacterial spectrum of infections, the septic shock children with or without malignancies showed a similar mortality rate. The septic shock children with malignancies had longer LOS of the hospital.
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Affiliation(s)
- Haixin Huang
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Ruichen Zhang
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Jian Chen
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Hongxing Dang
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Chengjun Liu
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Siwei Lu
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Yue-Qiang Fu
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China.
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Lucey K, Jones RC, Watson JA, Malakooti M, Stephen RJ. Risk Factors for Deterioration Events in the Pediatric Acute Care Setting. Hosp Pediatr 2024; 14:e260-e266. [PMID: 38784994 DOI: 10.1542/hpeds.2023-007426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 01/23/2024] [Accepted: 01/28/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Rapid response system (RRS) activations resulting in emergency transfers (ETs) and codes outside the ICU are associated with increased mortality and length of stay. We aimed to evaluate the patient and care team characteristics of RRS activations resulting in ETs and codes outside the ICU (together classified as "deterioration events") versus those that did not result in a deterioration event. METHODS For each RRS activation at our institution from 2019 to 2021, data were gathered on patient demographics and medical diagnoses, care team and treatment factors, and ICU transfer. Descriptive statistics, bivariate analyses, and multivariable logistic regression using a backward elimination model selection method were performed to assess potential risk factors for deterioration events. RESULTS Over the 3-year period, 1765 RRS activations were identified. Fifty-three (3%) activations were deemed acute care codes, 64 (4%) were noncode ETs, 921 (52%) resulted in nonemergent transfers to an ICU, and 727 (41%) patients remained in an acute care unit. In a multivariable model, any complex chronic condition (adjusted odds ratio, 6.26; 95% confidence interval, 2.83-16.60) and hematology/oncology service (adjusted odds ratio, 2.19; 95% confidence interval, 1.28-3.74) were independent risk factors for a deterioration event. CONCLUSIONS Patients with medical complexity and patients on the hematology/oncology service had a higher risk of deterioration events than other patients with RRS activations. Further analyzing how our hospital evaluates and treats these specific patient populations is critical as we develop targeted interventions to reduce deterioration events.
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Affiliation(s)
- Kate Lucey
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Hospital Based Medicine
- Center for Quality and Safety
| | | | - J Andrew Watson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Hospital Based Medicine
| | - Marcelo Malakooti
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Rebecca J Stephen
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Hospital Based Medicine
- Center for Quality and Safety
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Wittmann Dayagi T, Nirel R, Avrahami G, Amar S, Elitzur S, Fisher S, Gilead G, Gilad O, Goldberg T, Izraeli S, Kadmon G, Kaplan E, Krauss A, Michaeli O, Stein J, Steinberg-Shemer O, Tamary H, Tausky O, Toledano H, Weissbach A, Yacobovich J, Yanir AD, Zon J, Nahum E, Barzilai-Birenboim S. A Need for a Novel Survival Risk Scoring System for Intensive Care Admissions Due to Sepsis in Pediatric Hematology/Oncology Patients. J Intensive Care Med 2024; 39:484-492. [PMID: 37981801 DOI: 10.1177/08850666231216362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Background: Children with hemato-oncological diseases or following stem cell transplantation (SCT) are at high risk for life-threatening infections; sepsis in this population constitutes a substantial proportion of pediatric intensive care unit (PICU) admissions. The current pediatric prognostic scoring tools to evaluate illness severity and mortality risk are designed for the general pediatric population and may not be adequate for this vulnerable subpopulation. Methods: Retrospective analysis was performed on all PICU admissions for sepsis in children with hemato-oncological diseases or post-SCT, in a single tertiary pediatric hospital between 2008 and 2021 (n = 233). We collected and analyzed demographic, clinical, and laboratory data and outcomes for all patients, and evaluated the accuracy of two major prognostic scoring tools, the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) and the Pediatric Risk of Mortality III (PRISM III). Furthermore, we created a new risk-assessment model that contains additional parameters uniquely relevant to this population. Results: The survival rate for the cohort was 83%. The predictive accuracies of PELOD-2 and PRISM III, as determined by the area under the curve (AUC), were 83% and 78%, respectively. Nine new parameters were identified as clinically significant: age, SCT, viral infection, fungal infection, central venous line removal, vasoactive inotropic score, bilirubin level, C-reactive protein level, and prolonged neutropenia. Unique scoring systems were established by the integration of these new parameters into the algorithm; the new systems significantly improved their predictive accuracy to 91% (p = 0.01) and 89% (p < 0.001), respectively. Conclusions: The predictive accuracies (AUC) of the PELOD-2 and PRISM III scores are limited in children with hemato-oncological diseases admitted to PICU with sepsis. These results highlight the need to develop a risk-assessment tool adjusted to this special population. Such new scoring should represent their unique characteristics including their degree of immunosuppression and be validated in a large multi-center prospective study.
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Affiliation(s)
- Talya Wittmann Dayagi
- Division of Haematology and Oncology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Nirel
- Department of Statistics and Data Science, Hebrew University, Jerusalem, Israel
| | - Galia Avrahami
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shira Amar
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sarah Elitzur
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Salvador Fisher
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Gilead
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Gilad
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tracie Goldberg
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Izraeli
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kadmon
- Department of pediatric intensive care unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eytan Kaplan
- Department of pediatric intensive care unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviva Krauss
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orli Michaeli
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jerry Stein
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orna Steinberg-Shemer
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hannah Tamary
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Osnat Tausky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatrics, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Helen Toledano
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avichai Weissbach
- Department of pediatric intensive care unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joanne Yacobovich
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf D Yanir
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jessica Zon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elhanan Nahum
- Department of pediatric intensive care unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomit Barzilai-Birenboim
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Asif H, McNeer JL, Ghanayem NS, Cursio JF, Kane JM. First-Line Respiratory Support for Children With Hematologic Malignancy and Acute Respiratory Failure. Crit Care Explor 2024; 6:e1076. [PMID: 38601458 PMCID: PMC11005899 DOI: 10.1097/cce.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVES To characterize trends in noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) use over time in children with hematologic malignancy admitted to the PICU with acute respiratory failure (ARF), and to identify risk factors associated with NIV failure requiring transition to IMV. DESIGN Retrospective cohort analysis using the Virtual Pediatric Systems (VPS, LLC) between January 1, 2010 and December 31, 2019. SETTING One hundred thirteen North American PICUs participating in VPS. PATIENTS Two thousand four hundred eighty children 0-21 years old with hematologic malignancy admitted to participating PICUs for ARF requiring respiratory support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 3013 total encounters, of which 868 (28.8%) received first-line NIV alone (NIV only), 1544 (51.2%) received first-line IMV (IMV only), and 601 (19.9%) required IMV after a failed NIV trial (NIV failure). From 2010 to 2019, the NIV only group increased from 9.6% to 43.1% and the IMV only group decreased from 80.1% to 34.2% (p < 0.001). The NIV failure group had the highest mortality compared with NIV only and IMV only (36.6% vs. 8.1%, vs. 30.5%, p < 0.001). However, risk-of-mortality (ROM) was highest in the IMV only group compared with NIV only and NIV failure (median Pediatric Risk of Mortality III ROM 8.1% vs. 2.8% vs. 5.5%, p < 0.001). NIV failure patients also had the longest median PICU length of stay compared with the other two study groups (15.2 d vs. 6.1 and 9.0 d, p < 0.001). Higher age was associated with significantly decreased odds of NIV failure, and diagnosis of non-Hodgkin lymphoma was associated with significantly increased odds of NIV failure compared with acute lymphoid leukemia. CONCLUSIONS For children with hematologic malignancy admitted to the PICU with ARF, NIV has replaced IMV as the most common initial therapy. NIV failure rate remains high with high-observed mortality despite lower PICU admission ROM.
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Affiliation(s)
- Hassaan Asif
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Jennifer L McNeer
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Nancy S Ghanayem
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, University of Chicago, Comer Children's Hospital, Chicago, IL
| | - John F Cursio
- Department of Public Health Sciences, University of Chicago, Chicago, IL
| | - Jason M Kane
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, University of Chicago, Comer Children's Hospital, Chicago, IL
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Wösten-van Asperen RM, la Roi-Teeuw HM, van Amstel RBE, Bos LDJ, Tissing WJE, Jordan I, Dohna-Schwake C, Bottari G, Pappachan J, Crazzolara R, Comoretto RI, Mizia-Malarz A, Moscatelli A, Sánchez-Martín M, Willems J, Rogerson CM, Bennett TD, Luo Y, Atreya MR, Faustino ES, Geva A, Weiss SL, Schlapbach LJ, Sanchez-Pinto LN. Distinct clinical phenotypes in paediatric cancer patients with sepsis are associated with different outcomes-an international multicentre retrospective study. EClinicalMedicine 2023; 65:102252. [PMID: 37842550 PMCID: PMC10570699 DOI: 10.1016/j.eclinm.2023.102252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023] Open
Abstract
Background Identifying phenotypes in sepsis patients may enable precision medicine approaches. However, the generalisability of these phenotypes to specific patient populations is unclear. Given that paediatric cancer patients with sepsis have different host response and pathogen profiles and higher mortality rates when compared to non-cancer patients, we determined whether unique, reproducible, and clinically-relevant sepsis phenotypes exist in this specific patient population. Methods We studied patients with underlying malignancies admitted with sepsis to one of 25 paediatric intensive care units (PICUs) participating in two large, multi-centre, observational cohorts from the European SCOTER study (n = 383 patients; study period between January 1, 2018 and January 1, 2020) and the U.S. Novel Data-Driven Sepsis Phenotypes in Children study (n = 1898 patients; study period between January 1, 2012 and January 1, 2018). We independently used latent class analysis (LCA) in both cohorts to identify phenotypes using demographic, clinical, and laboratory data from the first 24 h of PICU admission. We then tested the association of the phenotypes with clinical outcomes in both cohorts. Findings LCA identified two distinct phenotypes that were comparable across both cohorts. Phenotype 1 was characterised by lower serum bicarbonate and albumin, markedly increased lactate and hepatic, renal, and coagulation abnormalities when compared to phenotype 2. Patients with phenotype 1 had a higher 90-day mortality (European cohort 29.2% versus 13.4%, U.S. cohort 27.3% versus 11.4%, p < 0.001) and received more vasopressor and renal replacement therapy than patients with phenotype 2. After adjusting for severity of organ dysfunction, haematological cancer, prior stem cell transplantation and age, phenotype 1 was associated with an adjusted OR of death at 90-day of 1.9 (1.04-3.34) in the European cohort and 1.6 (1.2-2.2) in the U.S. cohort. Interpretation We identified two clinically-relevant sepsis phenotypes in paediatric cancer patients that are reproducible across two international, multicentre cohorts with prognostic implications. These results may guide further research regarding therapeutic approaches for these specific phenotypes. Funding Part of this study is funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
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Affiliation(s)
- Roelie M. Wösten-van Asperen
- Department of Paediatric Intensive Care, University Medical Centre Utrecht/Wilhelmina Children’s Hospital, Utrecht, the Netherlands
| | - Hannah M. la Roi-Teeuw
- Department of Paediatric Intensive Care, University Medical Centre Utrecht/Wilhelmina Children’s Hospital, Utrecht, the Netherlands
| | - Rombout BE. van Amstel
- Intensive Care, Amsterdam UMC—location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lieuwe DJ. Bos
- Intensive Care, Amsterdam UMC—location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Wim JE. Tissing
- Princess Máxima Centre for Pediatric Oncology, Utrecht, the Netherlands
- Department of Paediatric Oncology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Iolanda Jordan
- Department of Paediatric Intensive Care and Institut de Recerca, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
| | - Christian Dohna-Schwake
- Department of Paediatrics I, Paediatric Intensive Care, Children’s Hospital Essen, Germany
- West German Centre for Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Gabriella Bottari
- Paediatric Intensive Care Unit, Children’s Hospital Bambino Gesù, IRCSS, Rome, Italy
| | - John Pappachan
- Department of Paediatric Intensive Care, Southampton Children’s Hospital, UK
| | - Roman Crazzolara
- Department of Paediatrics, Paediatric Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Rosanna I. Comoretto
- Department of Paediatric Intensive Care, Department of Woman's and Child's Health, Padua University Hospital, Padua, Italy
| | - Agniezka Mizia-Malarz
- Department of Paediatric Oncology, Haematology and Chemotherapy Unit, Medical University of Silesia, Katowice, Poland
| | - Andrea Moscatelli
- Neonatal and Paediatric Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - María Sánchez-Martín
- Department of Paediatric Intensive Care, Hospital Universitario La Paz, Madrid, Spain
| | - Jef Willems
- Department of Paediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Colin M. Rogerson
- Department of Paediatrics, Division of Critical Care, Indianapolis University School of Medicine, Indianapolis, IN, USA
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Paediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Yuan Luo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mihir R. Atreya
- Department of Paediatrics (Critical Care), University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Centre, Cincinnati, OH, USA
| | | | - Alon Geva
- Department of Anaesthesiology, Critical Care, and Pain Medicine and Computational Health Informatics Program, Boston Children's Hospital, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Scott L. Weiss
- Division of Critical Care, Department of Paediatrics, Nemours Children’s Health, Delaware, USA
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology and Children’s Research Centre, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - L Nelson Sanchez-Pinto
- Department of Paediatrics (Critical Care) and Preventive Medicine (Health & Biomedical Informatics), Northwestern University Feinberg School of Medicine and Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, USA
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Flerlage T, Fan K, Qin Y, Agulnik A, Arias AV, Cheng C, Elbahlawan L, Ghafoor S, Hurley C, McArthur J, Morrison RR, Zhou Y, Park HJ, Carcillo JA, Hines MR. Mortality Risk Factors in Pediatric Onco-Critical Care Patients and Machine Learning Derived Early Onco-Critical Care Phenotypes in a Retrospective Cohort. Crit Care Explor 2023; 5:e0976. [PMID: 37780176 PMCID: PMC10538916 DOI: 10.1097/cce.0000000000000976] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVES To use supervised and unsupervised statistical methodology to determine risk factors associated with mortality in critically ill pediatric oncology patients to identify patient phenotypes of interest for future prospective study. DESIGN This retrospective cohort study included nonsurgical pediatric critical care admissions from January 2017 to December 2018. We determined the prevalence of multiple organ failure (MOF), ICU mortality, and associated factors. Consensus k-means clustering analysis was performed using 35 bedside admission variables for early, onco-critical care phenotype development. SETTING Single critical care unit in a subspeciality pediatric hospital. INTERVENTION None. PATIENTS There were 364 critical care admissions in 324 patients with underlying malignancy, hematopoietic cell transplant, or immunodeficiency reviewed. MEASUREMENTS Prevalence of multiple organ failure, ICU mortality, determination of early onco-critical care phenotypes. MAIN RESULTS ICU mortality was 5.2% and was increased in those with MOF (18.4% MOF, 1.7% single organ failure [SOF], 0.6% no organ failure; p ≤ 0.0001). Prevalence of MOF was 23.9%. Significantly increased ICU mortality risk was associated with day 1 MOF (hazards ratio [HR] 2.27; 95% CI, 1.10-6.82; p = 0.03), MOF during ICU admission (HR 4.16; 95% CI, 1.09-15.86; p = 0.037), and with invasive mechanical ventilation requirement (IMV; HR 5.12; 95% CI, 1.31-19.94; p = 0.018). Four phenotypes were derived (PedOnc1-4). PedOnc1 and 2 represented patient groups with low mortality and SOF. PedOnc3 was enriched in patients with sepsis and MOF with mortality associated with liver and renal dysfunction. PedOnc4 had the highest frequency of ICU mortality and MOF characterized by acute respiratory failure requiring invasive mechanical ventilation at admission with neurologic dysfunction and/or severe sepsis. Notably, most of the mortality in PedOnc4 was early (i.e., within 72 hr of ICU admission). CONCLUSIONS Mortality was lower than previously reported in critically ill pediatric oncology patients and was associated with MOF and IMV. These findings were further validated and expanded by the four derived nonsynonymous computable phenotypes. Of particular interest for future prospective validation and correlative biological study was the PedOnc4 phenotype, which was composed of patients with hypoxic respiratory failure requiring IMV with sepsis and/or neurologic dysfunction at ICU admission.
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Affiliation(s)
- Tim Flerlage
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN
| | - Kimberly Fan
- Division of Critical Care, Department of Pediatrics, MD Anderson Cancer Center, Houston, TX
| | - Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Asya Agulnik
- Department of Global Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Anita V Arias
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Cheng Cheng
- Division of Critical Care, Department Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Lama Elbahlawan
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Saad Ghafoor
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Caitlin Hurley
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Jennifer McArthur
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - R Ray Morrison
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Yinmei Zhou
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - H J Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Melissa R Hines
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
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7
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Wraight TI, Namachivayam SP, Maiden MJ, Erickson SJ, Oberender F, Singh P, Gard J, Ganeshalingham A, Millar J. Trends in Childhood Oncology Admissions to ICUs in Australia and New Zealand. Pediatr Crit Care Med 2023; 24:e487-e497. [PMID: 37133322 DOI: 10.1097/pcc.0000000000003268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVES There are few robust, national-level reports of contemporary trends in pediatric oncology admissions, resource use, and mortality. We aimed to describe national-level data on trends in intensive care admissions, interventions, and survival for children with cancer. DESIGN Cohort study using a binational pediatric intensive care registry. SETTING Australia and New Zealand. PATIENTS Patients younger than 16 years, admitted to an ICU in Australia or New Zealand with an oncology diagnosis between January 1, 2003, and December 31, 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We examined trends in oncology admissions, ICU interventions, and both crude and risk-adjusted patient-level mortality. Eight thousand four hundred ninety admissions were identified for 5,747 patients, accounting for 5.8% of PICU admissions. Absolute and population-indexed oncology admissions increased from 2003 to 2018, and median length of stay increased from 23.2 hours (interquartile range [IQR], 16.8-62 hr) to 38.8 hours (IQR, 20.9-81.1 hr) ( p < 0.001). Three hundred fifty-seven of 5,747 patients died (6.2%). There was a 45% reduction in risk-adjusted ICU mortality, which reduced from 3.3% (95% CI, 2.1-4.4) in 2003-2004 to 1.8% (95% CI, 1.1-2.5%) in 2017-2018 ( p trend = 0.02). The greatest reduction in mortality seen in hematological cancers and in nonelective admissions. Mechanical ventilation rates were unchanged from 2003 to 2018, while the use of high-flow nasal prong oxygen increased (incidence rate ratio, 2.43; 95% CI, 1.61-3.67 per 2 yr). CONCLUSIONS In Australian and New Zealand PICUs, pediatric oncology admissions are increasing steadily and such admissions are staying longer, representing a considerable proportion of ICU activity. The mortality of children with cancer who are admitted to ICU is low and falling.
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Affiliation(s)
- Tracey I Wraight
- Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Siva P Namachivayam
- Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Intensive Care Unit, Barwon Health, Geelong, VIC, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Paediatric Critical Care, Perth Children's Hospital, Perth, WA, Australia
- Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Sydney Children's Hospital, Randwick, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- Clinical Haematology Department, The Royal Children's Hospital, Melbourne, VIC, Australia
- Monash Simulation, Monash Health, Clayton, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
| | - Matthew J Maiden
- Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Intensive Care Unit, Barwon Health, Geelong, VIC, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Paediatric Critical Care, Perth Children's Hospital, Perth, WA, Australia
- Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Sydney Children's Hospital, Randwick, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- Clinical Haematology Department, The Royal Children's Hospital, Melbourne, VIC, Australia
- Monash Simulation, Monash Health, Clayton, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
| | - Simon J Erickson
- Paediatric Critical Care, Perth Children's Hospital, Perth, WA, Australia
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Puneet Singh
- Intensive Care Unit, Sydney Children's Hospital, Randwick, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Jye Gard
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | | | - Johnny Millar
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
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8
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Afungchwi GM, Kiteni E, Ndagire M, Maliti B, Kunkel R, Challinor JM, Hollis R. Current status and priorities of paediatric oncology nursing in Africa: a synthesis of perspectives from SIOP Africa nurses. Ecancermedicalscience 2023; 17:1585. [PMID: 37799941 PMCID: PMC10550298 DOI: 10.3332/ecancer.2023.1585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Indexed: 10/07/2023] Open
Abstract
Introduction As African countries adopt the global goal of improving childhood cancer survival to 60% by 2030, intentional actions are required to improve nursing. This report aims to describe the current status of paediatric oncology nursing in Africa. Methods We report on nursing-related aspects of a survey to map paediatric oncology services in Africa (2018-2019), document perceived nursing strengths and weaknesses (2017) and share nurses' research priorities (2019). Additionally, we report on a survey to identify topics for a foundation course (2019) and the expressed perspective of African nurses about the status of paediatric oncology nursing across the continent (2022). Results Only 21% of respondents in the African mapping survey reported having nurses who care for children with cancer at least 75% of the time. Many centres do not have allied health workers like dieticians and play therapists, thus contributing to the nursing burden of care. The main strength of African paediatric oncology nurses was the humanisation of care, while the major weakness was the lack of training follow-up. The top research priorities focused on professional practice and psychosocial support. The Delphi survey identified 57 topic areas grouped into a 12-module curriculum for nurses new to paediatric oncology. The nurses affirmed their dedication to providing compassionate care, however, noted their vulnerability to harm and called for better specialisation, recognition and remuneration. Conclusion This paper amplifies the voice of African paediatric oncology nurses. It illuminates the room for improvement and provides a reference point for future comparison.
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Affiliation(s)
| | | | | | | | - Rachael Kunkel
- Arkansas Children's Hospital, Little Rock, AR 72202, USA
| | - Julia M Challinor
- University of California San Francisco, 2 Koret Way, San Francisco, CA 94143, USA
| | - Rachel Hollis
- Leeds Children's Hospital, Clarendon Wing, LS1 3EX Leeds, UK
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9
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Soeteman M, Fiocco MF, Nijman J, Bollen CW, Marcelis MM, Kilsdonk E, Nieuwenhuis EES, Kappen TH, Tissing WJE, Wösten-van Asperen RM. Prognostic factors for multi-organ dysfunction in pediatric oncology patients admitted to the pediatric intensive care unit. Front Oncol 2023; 13:1192806. [PMID: 37503310 PMCID: PMC10369184 DOI: 10.3389/fonc.2023.1192806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
Background Pediatric oncology patients who require admission to the pediatric intensive care unit (PICU) have worse outcomes compared to their non-cancer peers. Although multi-organ dysfunction (MOD) plays a pivotal role in PICU mortality and morbidity, risk factors for MOD have not yet been identified. We aimed to identify risk factors at PICU admission for new or progressive MOD (NPMOD) during the first week of PICU stay. Methods This retrospective cohort study included all pediatric oncology patients aged 0 to 18 years admitted to the PICU between June 2018 and June 2021. We used the recently published PODIUM criteria for defining multi-organ dysfunction and estimated the association between covariates at PICU baseline and the outcome NPMOD using a multivariable logistic regression model, with PICU admission as unit of study. To study the predictive performance, the model was internally validated by using bootstrap. Results A total of 761 PICU admissions of 571 patients were included. NPMOD was present in 154 PICU admissions (20%). Patients with NPMOD had a high mortality compared to patients without NPMOD, 14% and 1.0% respectively. Hemato-oncological diagnosis, number of failing organs and unplanned admission were independent risk factors for NPMOD. The prognostic model had an overall good discrimination and calibration. Conclusion The risk factors at PICU admission for NPMOD may help to identify patients who may benefit from closer monitoring and early interventions. When applying the PODIUM criteria, we found some opportunities for fine-tuning these criteria for pediatric oncology patients, that need to be validated in future studies.
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Affiliation(s)
- Marijn Soeteman
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Marta F. Fiocco
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Mathematical Institute, Leiden University, Leiden, Netherlands
| | - Joppe Nijman
- Department of Pediatric Intensive Care, Wilhelmina Children’s Hospital/University Medical Center Utrecht, Utrecht, Netherlands
| | - Casper W. Bollen
- Department of Pediatric Intensive Care, Wilhelmina Children’s Hospital/University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Ellen Kilsdonk
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Edward E. S. Nieuwenhuis
- Department of Pediatrics, Wilhelmina Children’s Hospital/University Medical Center Utrecht, Utrecht, Netherlands
| | - Teus H. Kappen
- Department of Anesthesiology, Wilhelmina Children’s Hospital/University Medical Center Utrecht, Utrecht, Netherlands
| | - Wim J. E. Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Department of Pediatric Oncology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Roelie M. Wösten-van Asperen
- Department of Pediatric Intensive Care, Wilhelmina Children’s Hospital/University Medical Center Utrecht, Utrecht, Netherlands
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10
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Marwah H, Tripathi R, Saikia B, Anand P, Arora RS. ICU Admissions and Outcomes of Childhood Cancer Patients in Single Tertiary Hospital in the Private Sector in India. South Asian J Cancer 2023; 12:286-289. [PMID: 38047049 PMCID: PMC10691912 DOI: 10.1055/s-0042-1756283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Ramandeep Singh AroraBackground Modern-day treatment of childhood cancer is punctuated by the necessary need for intensive care. This study was performed to understand the intensive care unit (ICU) admission rates and factors associated with ICU admission in a cohort of newly diagnosed childhood cancer patients in India. Materials and Methods All childhood (age <18 years) patients in the hospital-based cancer registry who had registered between March 1, 2013, and May 31, 2018, formed the cohort. ICU admissions were recorded and demographic and clinical factors associated with ICU admission were investigated. ICU admission rates were the primary outcome of interest and secondary outcomes were ICU admission rates for sick/supportive reasons, ICU admission rates for surgical/procedural reasons and mortality during ICU admission. Results In a cohort of 258 children (66% males, 61% from India, and median age 7 years), 149 (58%) patients needed one or more ICU admission (median one with range of one to five) with total 204 ICU admission episodes. While age group, gender, and nationality were not significantly associated with ICU admission, cancer type was (highest in neuroblastoma (82%) and central nervous system (CNS) tumors (71%)). Sick/supportive care ICU admissions were significantly higher in patients of younger age, Indian origin, and certain cancers (leukemias, lymphomas). Surgical/procedural ICU admissions were significantly higher in international patients and certain cancers (CNS tumors, neuroblastomas, and soft tissue sarcomas). There were 17 ICU deaths (11% of patients admitted to ICU) and all but one were from sick/supportive care ICU admissions. Conclusion Our study highlights higher than reported ICU admission rates and lower than reported mortality in children with cancer in low- and middle-income countries. We next plan to develop more specific ICU admission criteria, prospectively evaluating severity metrics in these patients, and explore the development of a high dependency unit.
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Affiliation(s)
- Harleen Marwah
- School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia, United States
| | - Rashi Tripathi
- Quality Care, Research and Impact, Cankids, New Delhi, India
| | - Bhaskar Saikia
- Pediatric Intensive Care, Max Smart Super Specialty Hospital, New Delhi, India
| | - Preeti Anand
- Pediatric Intensive Care, Max Smart Super Specialty Hospital, New Delhi, India
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Gaugler M, Swinger N, Rahrig AL, Skiles J, Rowan CM. Multiple Organ Dysfunction and Critically Ill Children With Acute Myeloid Leukemia: Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2023; 24:e170-e178. [PMID: 36728709 PMCID: PMC10081947 DOI: 10.1097/pcc.0000000000003153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To describe the prevalence of multiple organ dysfunction syndrome (MODS) and critical care utilization in children and young adults with acute myeloid leukemia (AML) who have not undergone hematopoietic cell transplantation (HCT). DESIGN Retrospective cohort study of MODS (defined as dysfunction of two or more organ systems) occurring any day within the first 72 hours of PICU admission. SETTING Large, quaternary-care children's hospital. PATIENTS Patients 1 month through 26 years old who were treated for AML from 2011-2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighty patients with AML were included. These 80 patients had a total of 409 total non-HCT-related hospital and 71 PICU admissions. The majority 53 of 71 of PICU admissions (75%) were associated with MODS within the first 72 hours. MODS was present in 49 of 71 of PICU admissions (69%) on day 1, 29 of 52 (56%) on day 2, and 25 of 32 (78%) on day 3. The organ systems most often involved were hematologic, respiratory, and cardiovascular. There was an increasing proportion of renal failure (8/71 [11%] on day 1 to 8/32 [25%] on day 3; p = 0.02) and respiratory failure (33/71 [47%] to 24/32 [75%]; p = 0.001) as PICU stay progressed. The presence of MODS on day 1 was associated with a longer PICU length of stay (LOS) (β = 5.4 [95% CI, 0.7-10.2]; p = 0.024) and over a six-fold increased risk of an LOS over 2 days (odds ratio, 6.08 [95% CI, 1.59-23.23]; p = 0.008). Respiratory failure on admission was associated with higher risk of increased LOS. CONCLUSIONS AML patients frequently require intensive care. In this cohort, MODS occurred in over half of PICU admissions and was associated with longer PICU LOS. Respiratory failure was associated with the development of MODS and progressive MODS, as well as prolonged LOS.
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Affiliation(s)
- Mary Gaugler
- Department of Pediatrics, Division of General Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Nathan Swinger
- Department of Pediatrics, Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - April L Rahrig
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Jodi Skiles
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Courtney M Rowan
- Department of Pediatrics, Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
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12
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Willis DN, McGlynn MC, Reich PJ, Hayashi RJ. Mortality in pediatric oncology and stem cell transplant patients with bloodstream infections. Front Oncol 2023; 12:1063253. [PMID: 36713545 PMCID: PMC9874914 DOI: 10.3389/fonc.2022.1063253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023] Open
Abstract
Background Bloodstream infections (BSI) continue to represent a significant source of morbidity for pediatric oncology patients, however less is known regarding this population's risk of death. We sought to evaluate the risk of BSI and death at a large pediatric cancer center. Methods We retrospectively collected inpatient data from pediatric oncology and hematopoietic stem cell transplant (HSCT) patients over a 9-year period. We performed univariate and multivariable modeling to assess risk of BSI and mortality examining the following variables: demographics, underlying malignancy, history of HSCT, central line type, and febrile neutropenia (FN). Results During the study period, 6763 admissions from 952 patients met inclusion criteria. BSI occurred in 367 admissions (5.4%) from 231 unique individuals. Risk factors for BSI include younger age, diagnoses of hemophagocytic lymphohistiocytosis or acute myeloid leukemia, ethnicity, and history of HSCT. Mortality for those with BSI was 6.5%, compared to 0.7% without (OR 7.2, CI 4.1 - 12.7, p<0.0001). In patients with BSI, admissions with FN were associated with reduced mortality compared to admissions without FN (OR 0.21, CI 0.05 - 0.94, p=0.04). In both univariate and multivariable analysis, no other risk factor was significantly associated with mortality in patients with BSI. Conclusion BSI is a significant source of mortality in pediatric oncology and HSCT patients. While demographic variables contribute to the risk of BSI, they did not influence mortality. These findings highlight the importance of BSI prevention to reduce the risk of death in pediatric oncology patients. Future studies should focus on comprehensive BSI prevention.
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Affiliation(s)
- Daniel N. Willis
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO, United States,*Correspondence: Daniel N. Willis,
| | - Mary Claire McGlynn
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO, United States
| | - Patrick J. Reich
- Department of Pediatrics, Division of Infectious Diseases, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO, United States
| | - Robert J. Hayashi
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO, United States
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13
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Soeteman M, Kappen TH, van Engelen M, Marcelis M, Kilsdonk E, van den Heuvel-Eibrink MM, Nieuwenhuis EES, Tissing WJE, Fiocco M, van Asperen RMW. Validation of a modified bedside Pediatric Early Warning System score for detection of clinical deterioration in hospitalized pediatric oncology patients: A prospective cohort study. Pediatr Blood Cancer 2023; 70:e30036. [PMID: 36316817 DOI: 10.1002/pbc.30036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/19/2022] [Accepted: 09/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hospitalized pediatric oncology patients are at risk of severe clinical deterioration. Yet Pediatric Early Warning System (PEWS) scores have not been prospectively validated in these patients. We aimed to determine the predictive performance of the modified BedsidePEWS score for unplanned pediatric intensive care unit (PICU) admission and cardiopulmonary resuscitation (CPR) in this patient population. METHODS We performed a prospective cohort study in an 80-bed pediatric oncology hospital in the Netherlands, where care has been nationally centralized. All hospitalized pediatric oncology patients aged 0-18 years were eligible for inclusion. A Cox proportional hazard model was estimated to study the association between BedsidePEWS score and unplanned PICU admissions or CPR. The predictive performance of the model was internally validated by bootstrapping. RESULTS A total of 1137 patients were included. During the study, 103 patients experienced 127 unplanned PICU admissions and three CPRs. The hazard ratio for unplanned PICU admission or CPR was 1.65 (95% confidence interval [CI]: 1.59-1.72) for each point increase in the modified BedsidePEWS score. The discriminative ability was moderate (D-index close to 0 and a C-index of 0.83 [95% CI: 0.79-0.90]). Positive and negative predictive values of modified BedsidePEWS score at the widely used cutoff of 8, at which escalation of care is required, were 1.4% and 99.9%, respectively. CONCLUSION The modified BedsidePEWS score is significantly associated with requirement of PICU transfer or CPR. In pediatric oncology patients, this PEWS score may aid in clinical decision-making for timing of PICU transfer.
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Affiliation(s)
- Marijn Soeteman
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Teus H Kappen
- Department of Anesthesiology, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Maartje Marcelis
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Ellen Kilsdonk
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Edward E S Nieuwenhuis
- Department of Pediatrics, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wim J E Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Mathematical Institute, Leiden University, Leiden, The Netherlands
| | - Roelie M Wösten- van Asperen
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht, The Netherlands
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14
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Cardenas-Aguirre A, Hernandez-Garcia M, Lira-De-Leon B, Munoz-Brugal YL, Wang H, Villanueva-Diaz I, Ruiz-Perez E, Mijares-Tobias JM, Giles-Gonzalez AO, McArthur J, Escamilla-Aisan G, Arias A, Devidas M, Agulnik A. Outcomes for critical illness in children with cancer: Analysis of risk factors for adverse outcome and resource utilization from a specialized center in Mexico. Front Oncol 2022; 12:1038879. [DOI: 10.3389/fonc.2022.1038879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/03/2022] [Indexed: 12/02/2022] Open
Abstract
IntroductionChildren with cancer have a higher risk of adverse outcomes during critical illness than general pediatric populations. In Low- and middle-income countries, lack of resources can further negatively impact outcomes in critically ill children with cancer.MethodsIn this study, we describe the outcomes of a large cohort of children with cancer including mortality and resource utilization. We performed a retrospective review of all patients admitted to our PICU between December 12th, 2013 and December 31st, 2019. Outcomes were defined as recovery or death and resource utilization was described via use of critical care interventions, Length of stay as well as PICU- and Mechanical Ventilation- free days.ResultsOverall mortality was 6.9% while mortality in the unplanned admissions was 9.1%. This remained lower than expected mortality based on PIM2 scoring. Type of PICU admission, Neurological Deterioration as a cause of PICU admission, and PIM2 were significant as risk factors in univariate analysis, but only PIM2 remained significant in the multivariate analysis.DiscussionOur Study shows that high survival rates are achievable for children with cancer with critical illness in resource-limited settings with provision of high-quality critical care. Organizational and clinical practice facilitating quality improvement and early identification and management of critical illness may attenuate the impact of known risk factors for mortality in this population.
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15
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Reschke A, Richards RM, Smith SM, Long AH, Marks LJ, Schultz L, Kamens JL, Aftandilian C, Davis KL, Gruber T, Sakamoto KM. Development of clinical pathways to improve multidisciplinary care of high-risk pediatric oncology patients. Front Oncol 2022; 12:1033993. [PMID: 36523979 PMCID: PMC9744920 DOI: 10.3389/fonc.2022.1033993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/31/2022] [Indexed: 11/30/2022] Open
Abstract
Clinical pathways are evidence-based tools that have been integrated into many aspects of pediatric hospital medicine and have proven effective at reducing in-hospital complications from a variety of diseases. Adaptation of similar tools for specific, high-risk patient populations in pediatric oncology has been slower, in part due to patient complexities and variations in management strategies. There are few published studies of clinical pathways for pediatric oncology patients. Pediatric patients with a new diagnosis of leukemia or lymphoma often present with one or more “oncologic emergencies” that require urgent intervention and deliberate multidisciplinary care to prevent significant consequences. Here, we present two clinical pathways that have recently been developed using a multidisciplinary approach at a single institution, intended for the care of patients who present with hyperleukocytosis or an anterior mediastinal mass. These clinical care pathways have provided a critical framework for the immediate care of these patients who are often admitted to the pediatric intensive care unit for initial management. The goal of the pathways is to facilitate multidisciplinary collaborations, expedite diagnosis, and streamline timely treatment initiation. Standardizing the care of high-risk pediatric oncology patients will ultimately decrease morbidity and mortality associated with these diseases to increase the potential for excellent outcomes.
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Leung KKY, Ray S, Chan GCF, Hon KL. Functional outcomes at PICU discharge in hemato-oncology children at a tertiary oncology center in Hong Kong. Int J Clin Oncol 2022; 27:1904-1915. [PMID: 36149516 DOI: 10.1007/s10147-022-02244-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/03/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Advancements in cancer treatment have resulted in longer survival but often at the expense of new therapy-associated morbidities. The aim of this study is to evaluate functional outcomes of hemato-oncology patients at PICU discharge, and to identify associated risk factors. METHODS A single-center retrospective observational study. All children (< 19 years) with a hemato-oncology diagnosis admitted to the Hong Kong Children's Hospital PICU over a 2-year period were included. Functional status upon admission and discharge were compared. Univariable and multi-variable analyses were employed to identify risk factors associated with new morbidities. RESULTS Out of 288 PICU admissions, there were 277 live discharges (mortality 4%), of which 52 (18.8%) developed new morbidities. Emergency admission, severity of illness at admission, organ dysfunction and support were associated with new morbidities (OR 1.08-11.96; p < 0.05). Adjusting for confounding factors, higher Pediatric Logistic Organ Dysfunction 2 score at admission was significantly associated with development of new morbidities (OR 1.34; 95% CI 1.18-1.54; p < 0.001). CONCLUSION Critically ill children with hemato-oncological diseases had a higher rate of developing new morbidities (18.8%) compared with the general PICU population (4-8%). This was associated with severity of illness at admission. Further work is warranted to understand the lasting effects of these new morbidities and mitigating interventions.
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Affiliation(s)
- Karen K Y Leung
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China.
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China.
| | - Samiran Ray
- Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Godfrey C F Chan
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
| | - Kam Lun Hon
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
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17
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Should We Intubate Pediatric Hematopoietic Cell Transplant Patients With Respiratory Failure Sooner? Crit Care Med 2022; 50:1163-1167. [PMID: 35726983 PMCID: PMC9219038 DOI: 10.1097/ccm.0000000000005548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Suzuki Y, Cass SH, Kugelmann A, Mobli K, Taylor WP, Radhakrishnan RS. Outcome of Extracorporeal Membrane Oxygenation for Pediatric Patients With Neoplasm: An Extracorporeal Life Support Organization Database Study (2000-2019). Pediatr Crit Care Med 2022; 23:e240-e248. [PMID: 35220342 DOI: 10.1097/pcc.0000000000002915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study update in usage and outcomes of pediatric extracorporeal membrane oxygenation (ECMO) for patients with neoplasm analyzed according to demographics, clinical variables, and complications. DESIGN Retrospective database review of the Extracorporeal Life Support Organization registry from the last 2 decades (2000-2019). The data were divided between two decades in order to compare patients' backgrounds and outcomes over time. SETTING ECMO centers reporting to Extracorporeal Life Support Organization. PATIENTS Patients equal to or younger than 18 years old with International Classification of Diseases, 9th Revision and International Classification of Diseases, 10th Revision codes that referred to neoplasms who were managed with ECMO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographics, cancer subtype, clinical variables, and ECMO complications were assessed in relation to the primary study outcome of survival to hospital discharge. Nine-hundred two patients met inclusion criteria; 699 patients were in the latest decade, which is more than three times the number from the previous decade (203 patients). On univariate analysis, compared with the previous decade, in the later decade, ECMO was more frequently applied in patients with pre-ECMO cardiac arrest (31.3% vs 17.1%; p < 0.001), and/or lower oxygenation index (38.0 vs 48.1; p < 0.001). We failed to identify a difference in survival between the 2 decades (42.8% vs 37.9%; p = 0.218). On multivariable analysis, diagnosis of hematologic malignancy, post-cardiopulmonary resuscitation support type, hematopoietic stem cell transplant, and age older than seven were each associated with greater odds of mortality. CONCLUSIONS The use of ECMO in children with neoplasm has expanded over the latest decade with changes in patient selection. Mortality remains unchanged. Hence, although the clinician still should stay cautious in its application, ECMO can be considered as an option to rescue pediatric oncologic patients in the setting of worsening cardiopulmonary status in the PICU.
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Affiliation(s)
- Yota Suzuki
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Samuel H Cass
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - Keyan Mobli
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Williams P Taylor
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Ravi S Radhakrishnan
- Division of Pediatric Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
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19
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Outcomes of Pediatric Oncology Patients Admitted to An Intensive Care Unit in a Resource-limited Setting. J Pediatr Hematol Oncol 2022; 44:89-97. [PMID: 34654757 DOI: 10.1097/mph.0000000000002345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 09/09/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Improved survival and intensified treatment protocols in pediatric oncology have resulted in an increased need for intensive care. However, in resource-constrained settings, the higher morbidity and mortality of these patients raises sensitive issues around the optimal use of limited critical care resources. METHODS Single-center, 10-year retrospective review of pediatric oncology patients admitted to the pediatric intensive care unit (PICU). RESULTS Of the 117 admissions, 70.1% had solid tumors, 61.5% were admitted electively, and 76.1% were admitted for noninfective indications. PICU mortality of oncology patients was 18.8% relative to the PICU mortality of all patients in the same period of 10.5%. In a multivariable analysis, factors shown to be independently associated with PICU mortality were infective indications for admission (relative risk=3.83, confidence interval: 1.16; 12.6, P=0.028) and vasoactive support (relative risk=7.50, confidence interval: 1.72; 32.8, P=0.0074). CONCLUSION The increased mortality associated with sepsis, organ dysfunction and need for organ support underscores the need for earlier recognition of and intervention in pediatric oncology patients requiring intensive care. Further prospective studies are needed to identify the most critical areas for improvement in the referral of these children to PICU, to optimize care and improve outcomes.
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20
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Outcomes for paediatric acute leukaemia patients admitted to the paediatric intensive care unit. Eur J Pediatr 2022; 181:1037-1045. [PMID: 34694507 DOI: 10.1007/s00431-021-04292-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/29/2021] [Accepted: 10/08/2021] [Indexed: 10/20/2022]
Abstract
Children with acute leukaemia (AL) are a high-risk population for infections and life-threatening conditions requiring paediatric intensive care unit (PICU) admission, presenting an increased mortality rate. A few literature exists about PICU outcomes in this kind of patients, especially with haematopoietic stem cell transplant (HSCT) background. We investigated the clinical and epidemiological characteristics of these patients as well as their outcomes. A retrospective, single-centre analytical/observational study was conducted from January 2011 to December 2018 in the PICU of a tertiary care hospital. AL patients from 28 days to 18 years old admitted to the PICU were included, excluding those with histories of HSCT or CAR T-cell therapy. We collected epidemiological and clinical characteristics, laboratory and microbiology results and outcomes. Forty-three patients with AL required urgent admission (35 lymphoblastic and 8 myeloblastic) for 63 different episodes. The main reasons were sepsis (21, 33.3%), hyperleukocytosis (12, 19%), respiratory failure (11, 17.5%) and seizures (8, 12.7%). Nineteen (30.2%) required inotropic support, and fifteen (23.8%) required mechanical ventilation. Three patients died at the hospital (3/43, 6.9%). Sixty-day mortality was 9.3%, and 1-year mortality was 13.9%. There was no differences regarding the type of AL and 60-day mortality (log-rank 2.652, p = 0.103).Conclusion: In our study, the main cause of admission for AL patients was infection, which was associated to more severity and longer hospital admission. What is Known: • Acute leukaemia is the most common childhood cancer. Admission to a paediatric intensive care unit is required in 30% of children with acute leukaemia. • Regarding the outcomes of children with acute leukaemia that require admission to the intensive care unit data are scarce. What is New: • Mortality in acute leukaemia patients admitted to the paediatric intensive care unit is lower than that of patients with a history of stem cell therapy but higher than that of patients with solid tumours. • The main reason for admission was sepsis, which is related in literature to more severity and long length of stay.
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21
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Zaidman I, Mohamad H, Shalom L, Ben Arush M, Even-Or E, Averbuch D, Zilkha A, Braun J, Mandel A, Kleid D, Attias O, Ben-Ari J, Brooks R, Gefen A, Stepensky P. Survival of pediatric patients requiring admission in the intensive care unit post hematopoietic stem cell transplantation: Prognostic factors associated with mortality. Pediatr Blood Cancer 2022; 69:e29549. [PMID: 34968007 DOI: 10.1002/pbc.29549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/18/2021] [Accepted: 12/03/2021] [Indexed: 11/06/2022]
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.
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Affiliation(s)
- Irina Zaidman
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hadhud Mohamad
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Lidor Shalom
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Myriam Ben Arush
- Division of Pediatric Hematology Oncology and Bone Marrow Transplantation, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Ehud Even-Or
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Dina Averbuch
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Amir Zilkha
- Pediatric Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Jacques Braun
- Pediatric Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Asaf Mandel
- Pediatric Intensive Care Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - David Kleid
- Pediatric Intensive Care Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ori Attias
- Pediatric Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Josef Ben-Ari
- Pediatric Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Rebecca Brooks
- Pediatric Intensive Care Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Aharon Gefen
- Division of Pediatric Hematology Oncology and Bone Marrow Transplantation, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Polina Stepensky
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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22
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A Single-center Report of the Admission to Intensive Care Unit Effectiveness on Treatment and Survival of Children Diagnosed with Cancer in Iran. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2022. [DOI: 10.5812/ijcm.117517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Childhood cancer is the second leading cause of death in children. Approximately, 40% of children with cancer need to be admitted to the intensive care unit (ICU), which plays a key role in their treatment procedure and overall survival. Objectives: In this study, we aimed at evaluating the impact of ICU admission on pediatric patients’ survival and prognosis at Mahak Pediatric Cancer Treatment and Research Center (MPCTRC), Tehran, Iran. Methods: Amongst a total number of 2693 hospitalized patients who were referred to our center from March 2014 to September 2019, 674 patients younger than 14 years of age who were at least admitted once to the ICU were included in this study. All the collected data were analyzed using IBM-SPSS software version 22. Results: Totally, 48.96% of patients were female and 51.03% of them were male. The most frequent types of cancer were central nervous system tumors (33.23%) and Leukemia (18.99%). Additionally, 43.62% of admitted patients were in the 1 - 4 age group, with the mean age of 1.5 ± 0.30. The mortality rate in ICU was 40.20% and the overall survival (OS) rate was 29.5% ± 2.6. Moreover, the OS in children with solid tumors and non-solid tumors were 27.1% ± 5.5 and 32.6% ± 3.1, respectively. Conclusions: The results of this conducted study provide a complete report on the status of children admitted to the ICU ward in Mahak Hospital. Because of this fact that the most frequent type of cancer was CNS tumors and children with CNS tumors are usually admitted to the ICU in the late stages of their disease, the overall survival rate in our study was 29.80%, which is lower than other studies.
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23
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Bhosale SJ, Joshi M, Patil VP, Kothekar AT, Myatra SN, Divatia JV, Kulkarni AP. Epidemiology and Predictors of Hospital Outcomes of Critically Ill Pediatric Oncology Patients: A Retrospective Study. Indian J Crit Care Med 2021; 25:1183-1188. [PMID: 34916753 PMCID: PMC8645808 DOI: 10.5005/jp-journals-10071-23984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The number of pediatric oncology patients admitted to the intensive care unit (ICU) has increased, and their hospital outcomes are improving. Since scarce data are available about this patient population, we conducted this retrospective study to evaluate the epidemiology and predictors of hospital outcomes. Materials and methods We included all children with cancers who were admitted to our ICU over 1 year. We excluded children admitted after elective surgery and those following bone marrow transplant. We collected data about demographics, admission diagnosis, type of malignancies, and ICU interventions. The primary outcome was the hospital outcome. The secondary outcomes were ICU length of stay (LOS), and ICU and hospital mortality. We analyzed the predictors of hospital outcome. Results Two hundred pediatric oncology patients were admitted from November 1, 2014 to October 30, 2015. Seventy-eight children had solid organ malignancies, and the rest had hematological malignancies. Hematooncology malignancy patients had significantly higher hospital mortality than those with solid organ malignancies. (61.5 vs 34.6%, p = 0.015). On multivariate regression analysis, mechanical ventilation [odds ratio (OR), 14.64; 95% confidence interval (CI): 1.23–165.05; p <0.030], inotropes (OR, 9.81; 95% CI: 1.222–78.66; p <0.032), and the presence of coagulopathy (OR, 3.86; 95% CI: 1.568–9.514; p <0.003) were independent predictors of hospital mortality. Conclusion In this retrospective cohort of 200 children with malignancies, we found that children with hematologic cancer had significantly higher hospital mortality as compared to those with solid tumors. The need for mechanical ventilation, use of inotrope infusion, and coagulopathy were independent predictors of mortality. How to cite this article Bhosale SJ, Joshi M, Patil VP, Kothekar AT, Myatra SN, Divatia JV, et al. Epidemiology and Predictors of Hospital Outcomes of Critically Ill Pediatric Oncology Patients: A Retrospective Study. Indian J Crit Care Med 2021;25(10):1183–1188.
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Affiliation(s)
- Shilpushp J Bhosale
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Malini Joshi
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vijaya P Patil
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Amol T Kothekar
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sheila Nainan Myatra
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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24
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Ranta S, Broman LM, Abrahamsson J, Berner J, Fläring U, Hed Myrberg I, Kalzén H, Karlsson L, Mellgren K, Nilsson A, Norén-Nyström U, Palle J, von Schewelov K, Svahn JE, Törnudd L, Heyman M, Harila-Saari A. ICU Admission in Children With Acute Lymphoblastic Leukemia in Sweden: Prevalence, Outcome, and Risk Factors. Pediatr Crit Care Med 2021; 22:1050-1060. [PMID: 34074998 DOI: 10.1097/pcc.0000000000002787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Despite progress in the treatment of childhood acute lymphoblastic leukemia, severe complications are common, and the need of supportive care is high. We explored the cumulative prevalence, clinical risk factors, and outcomes of children with acute lymphoblastic leukemia, on first-line leukemia treatment in the ICUs in Sweden. DESIGN A nationwide prospective register and retrospective chart review study. SETTING Children with acute lymphoblastic leukemia were identified, and demographic and clinical data were obtained from the Swedish Childhood Cancer Registry. Data on intensive care were collected from the Swedish Intensive Care Registry. Data on patients with registered ICU admission in the Swedish Childhood Cancer Registry were supplemented through questionnaires to the pediatric oncology centers. PATIENTS All 637 children 0-17.9 years old with acute lymphoblastic leukemia diagnosed between June 2008 and December 2016 in Sweden were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty-eight percent of the children (178/637) were admitted to an ICU at least once. The Swedish Intensive Care Registry data were available for 96% of admissions (241/252). An ICU admission was associated with poor overall survival (hazard ratio, 3.25; 95% CI, 1.97-5.36; p ≤ 0.0001). ICU admissions occurred often during early treatment; 48% (85/178) were admitted to the ICU before the end of the first month of acute lymphoblastic leukemia treatment (induction therapy). Children with T-cell acute lymphoblastic leukemia or CNS leukemia had a higher risk of being admitted to the ICU in multivariable analyses, both for early admissions before the end of induction therapy and for all admissions during the study period. CONCLUSIONS The need for intensive care in children with acute lymphoblastic leukemia, especially for children with T cell acute lymphoblastic leukemia and CNS leukemia, is high with most admissions occurring during early treatment.
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Affiliation(s)
- Susanna Ranta
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Abrahamsson
- Institution of Clinical Sciences, Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonas Berner
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Urban Fläring
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Ida Hed Myrberg
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Kalzén
- Department of Anesthesia, Södertälje Hospital, Södertälje, Sweden
- Department of Anaesthesia and Intensive Care, Karolinska Institutet at Danderyd Hospital (KIDS), Danderyd, Sweden
| | - Lene Karlsson
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Institution of Clinical Sciences, Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Anesthesia, Södertälje Hospital, Södertälje, Sweden
- Department of Anaesthesia and Intensive Care, Karolinska Institutet at Danderyd Hospital (KIDS), Danderyd, Sweden
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
- Department of Women's and Children's Health, Uppsala University and Pediatric Oncology, Uppsala University Hospital, Uppsala, Sweden
- Department of Pediatric Oncology, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Pediatrics, Linköping University Hospital, Linköping, Sweden
| | - Karin Mellgren
- Institution of Clinical Sciences, Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Nilsson
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | | | - Josefine Palle
- Department of Women's and Children's Health, Uppsala University and Pediatric Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Katarina von Schewelov
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Johan E Svahn
- Department of Pediatric Oncology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Lisa Törnudd
- Department of Pediatrics, Linköping University Hospital, Linköping, Sweden
| | - Mats Heyman
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Arja Harila-Saari
- Department of Women's and Children's Health, Uppsala University and Pediatric Oncology, Uppsala University Hospital, Uppsala, Sweden
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Abstract
OBJECTIVES To assess the prevalence of immunocompromised diagnoses among children with severe sepsis and septic shock, and to determine the association between immunocompromised diagnoses and clinical outcomes after adjustment for demographics and illness severity. DESIGN Retrospective multicenter cohort study. SETTING Eighty-three centers in the Virtual Pediatric Systems database. PATIENTS Children with severe sepsis or septic shock admitted to a participating PICU between January 1, 2012, and December 31, 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Across 83 centers, we identified 10,768 PICU admissions with an International Classification of Diseases, 9th Revision, Clinical Modification code for severe sepsis or septic shock; 3,021 of these patients (28%) had an immunocompromised diagnosis. To evaluate variation across centers and determine factors associated with PICU mortality, we used mixed-effect logistic regression models. Among patients without hematopoietic cell transplant, congenital immunodeficiency (adjusted odds ratio, 1.90; 95% CI, 1.24-2.92), multiple prior malignancies (adjusted odds ratio, 1.86; 95% CI, 1.15-2.99), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 3.09; 95% CI, 1.91-4.98) were associated with an increased odds of PICU mortality. Among patients with prior hematopoietic cell transplant, liquid malignancy (adjusted odds ratio, 3.15; 95% CI, 2.09-4.74), congenital immunodeficiency (adjusted odds ratio, 6.94; 95% CI, 3.84-12.53), multiple prior malignancies (adjusted odds ratio, 3.54; 95% CI, 1.80-6.95), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 2.79; 95% CI, 1.36-5.71) were associated with an increased odds of PICU mortality. PICU mortality varied significantly by center, and a higher mean number of sepsis patients per month in a center was associated with lower PICU mortality (adjusted odds ratio, 0.94; 95% CI, 0.90-0.98). PICU resource utilization varied by immunocompromised diagnosis and history of hematopoietic cell transplant, and among survivors immunocompromised patients have shorter median PICU length of stay compared with patients without immunocompromised diagnoses (p < 0.001). CONCLUSIONS Immunocompromised diagnoses are present in 28% of children with severe sepsis or septic shock. Multiple prior malignancies, hemophagocytic lymphohistiocytosis, congenital immunodeficiency, and hematopoietic cell transplant are independently associated with an increased odds of PICU mortality in children with severe sepsis or septic shock. Significant variation exists in PICU mortality among centers despite adjustment for immunocompromised diagnoses, known risk factors for sepsis-related mortality, and center-level sepsis volume.
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Labudde EJ, DeGroote NP, Smith S, Ebelhar J, Allen KE, Castellino SM, Wasilewski‐Masker K, Brock KE. Evaluating palliative opportunities in pediatric patients with leukemia and lymphoma. Cancer Med 2021; 10:2714-2722. [PMID: 33754498 PMCID: PMC8026931 DOI: 10.1002/cam4.3862] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/05/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Despite favorable prognoses, pediatric patients with hematologic malignancies experience significant challenges that may lead to diminished quality of life or family stress. They are less likely to receive subspecialty palliative care (PC) consultation and often undergo intensive end-of-life (EOL) care. We examined "palliative opportunities," or events when the integration of PC would have the greatest impact, present during a patient's hematologic malignancy course and relevant associations. METHODS A single-center retrospective review was conducted on patients aged 0-18 years with a hematologic malignancy who died between 1/1/12 and 11/30/17. Demographic, disease, and treatment data were collected. A priori, nine palliative opportunity categories were defined. Descriptive statistics were performed. Palliative opportunities were evaluated over temporal quartiles from diagnosis to death. Timing and rationale of pediatric PC consultation were evaluated. RESULTS Patients (n = 92) had a median of 5.0 (interquartile range [IQR] 6.0) palliative opportunities, incurring 522 total opportunities, increasing toward the EOL. Number and type of opportunities did not differ by demographics. PC consultation was most common in patients with lymphoid leukemia (50.9%, 28/55) and myeloid leukemia (48.5%, 16/33) versus lymphoma (0%, 0/4, p = 0.14). Forty-four of ninety-two patients (47.8%) received PC consultation a median of 1.8 months (IQR 4.1) prior to death. Receipt of PC was associated with transplant status (p = 0.0018) and a higher number of prior palliative opportunities (p = 0.0005); 70.3% (367/522) of palliative opportunities occurred without PC. CONCLUSION Patients with hematologic malignancies experience many opportunities warranting PC support. Identifying opportunities for ideal timing of PC involvement may benefit patients with hematologic cancers and their caregivers.
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Affiliation(s)
| | - Nicholas P. DeGroote
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
| | - Susie Smith
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
| | - Jonathan Ebelhar
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
- Department of PediatricsDivision of Pediatric Hematology/OncologyEmory UniversityAtlantaGAUSA
| | - Kristen E. Allen
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
| | - Sharon M. Castellino
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
- Department of PediatricsDivision of Pediatric Hematology/OncologyEmory UniversityAtlantaGAUSA
| | - Karen Wasilewski‐Masker
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
- Department of PediatricsDivision of Pediatric Hematology/OncologyEmory UniversityAtlantaGAUSA
| | - Katharine E. Brock
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
- Department of PediatricsDivision of Pediatric Hematology/OncologyEmory UniversityAtlantaGAUSA
- Department of PediatricsDivision of Pediatric Palliative CareEmory UniversityAtlantaGAUSA
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27
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Agulnik A, Cárdenas A, Carrillo AK, Bulsara P, Garza M, Alfonso Carreras Y, Alvarado M, Calderón P, Díaz R, de León C, Del Real C, Huitz T, Martínez A, Miralda S, Montalvo E, Negrín O, Osuna A, Perez Fermin CK, Pineda E, Soberanis D, Juárez Tobias MS, Lu Z, Rodriguez-Galindo C. Clinical and organizational risk factors for mortality during deterioration events among pediatric oncology patients in Latin America: A multicenter prospective cohort. Cancer 2021; 127:1668-1678. [PMID: 33524166 PMCID: PMC8248122 DOI: 10.1002/cncr.33411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hospitalized pediatric hematology-oncology (PHO) patients have frequent clinical deterioration events (CDE) requiring intensive care unit (ICU) admission, particularly in resource-limited settings. The objective of this study was to describe CDEs in hospitalized PHO patients in Latin America and to identify event-level and center-level risk factors for mortality. METHODS In 2017, the authors implemented a prospective registry of CDEs, defined as unplanned transfers to a higher level of care, use of ICU-level interventions on the floor, or nonpalliative floor deaths, in 16 PHO centers in 10 countries. PHO hospital admissions and hospital inpatient days were also reported. This study analyzes the first year of registry data (June 2017 to May 2018). RESULTS Among 16 centers, 553 CDEs were reported in PHO patients during 11,536 admissions and 119,414 inpatient days (4.63 per 1000 inpatient days). Event mortality was 29% (1.33 per 1000 inpatient days) but ranged widely across centers (11%-79% or 0.36-5.80 per 1000 inpatient days). Significant risk factors for event mortality included requiring any ICU-level intervention on the floor and not being transferred to a higher level of care. Events with organ dysfunction, a higher severity of illness, and a requirement for ICU intervention had higher mortality. In center-level analysis, hospitals with a higher volume of PHO patients, less floor use of ICU intervention, lower severity of illness on transfer, and lower rates of floor cardiopulmonary arrest had lower event mortality. CONCLUSIONS Hospitalized PHO patients who experience CDEs in resource-limited settings frequently require floor-based ICU interventions and have high mortality. Modifiable hospital practices around the escalation of care for these high-risk patients may contribute to poor outcomes. Earlier recognition of critical illness and timely ICU transfer may improve survival in hospitalized children with cancer.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee.,Division of Critical Care, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Adolfo Cárdenas
- Critical Care Medicine, Hospital Infantil Teletón de Oncología, Queretaro, Mexico
| | - Angela K Carrillo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Purva Bulsara
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Marcela Garza
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Manuel Alvarado
- Critical Care, Hospital del Niño Dr. José Renán Esquivel, Panama City, Panama
| | - Patricia Calderón
- Oncology, Hospital Infantil Manuel de Jesús Rivera, Managua, Nicaragua
| | - Rosdali Díaz
- Pediatric Oncology, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Claudia de León
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Claudia Del Real
- Pediatric Oncology, Benemérito Hospital General con Especialidades ¨Juan María de Salvatierra", La Paz, Mexico
| | - Tania Huitz
- Pediatric Oncology, Centro Estatal de Oncología de Campeche, Campeche, Mexico
| | | | - Scheybi Miralda
- Pediatric Critical Care, Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Erika Montalvo
- Pediatric Critical Care, Sociedad de Lucha contra el Cáncer Núcleo de Quito, Quito, Ecuador
| | - Octavia Negrín
- Hematology, Hospital Infantil Dr. Robert Reid Cabral, Santo Domingo, Dominican Republic
| | - Alejandra Osuna
- Hematology/Oncology, Hospital Pediátrico de Sinaloa, Sinaloa, Mexico
| | - Clara Krystal Perez Fermin
- Hematology/Oncology, Hospital Infantil Regional Universitario Dr. Arturo Guillón, Santiago, Dominican Republic.,Biomedical and Clinical Research Center, Santiago, Dominican Republic
| | - Estuardo Pineda
- Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Dora Soberanis
- Hematology/Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | - Zhaohua Lu
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
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Treatment of Children With Cancer and/or Hematopoietic Stem Cell Transplantation in the Intensive Care Unit: Experience at a Large European Pediatric Cancer Center. J Pediatr Hematol Oncol 2020; 42:e583-e588. [PMID: 31985550 DOI: 10.1097/mph.0000000000001718] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Pediatric cancer treatment and hematopoietic stem cell transplantation (HSCT) carry considerable risks of morbidity. We conducted a single-center retrospective analysis of intensive care unit (ICU) admissions in unselected children and adolescents treated for cancer or undergoing HSCT. In a 10-year time period, 140 patients had 188 ICU admissions for a life-threatening condition. Main reasons for ICU admission were respiratory or cardiovascular insufficiency and sepsis. Mortality in the ICU was 19.1% and related to organ failure or acute complications in 77.8% and progress of the underlying malignancy in 22.2%. Mortality rates at 30, 100, and 365 days after discharge from the ICU were 24.5%, 30.9%, and 39.9%. Kaplan-Meier survival probabilities at 5 and 10 years were 46.4% and 39.8%, respectively. Multivariable analysis revealed the number of failed organ systems, the number of prior ICU stays, and days spent in the ICU as parameters independently associated with death. Taken together, the outcome of pediatric cancer and/or HSCT patients admitted to the ICU for life-threatening conditions was not as dismal as reported elsewhere. Most patients benefitted from ICU care, and survival was predominantly compromised by the evolution of complications.
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Leimanis Laurens M, Snyder K, Davis AT, Fitzgerald RK, Hackbarth R, Rajasekaran S. Racial/Ethnic Minority Children With Cancer Experience Higher Mortality on Admission to the ICU in the United States. Pediatr Crit Care Med 2020; 21:859-868. [PMID: 33017127 DOI: 10.1097/pcc.0000000000002375] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We investigated whether differences in survival exist between children of various racial/ethnic groups with cancer admitted to the PICU. DESIGN A retrospective multicenter analysis was conducted using Virtual Pediatric Systems data from reporting centers. Demographic information, Pediatric Risk for Mortality III score, and outcome variables were analyzed using mixed-effects logistic regression modeling to assess for differences in mortality. SETTING One hundred thirty-five PICUs in the United States. PATIENTS Pediatric patients with cancer admitted to PICUs in the United States. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS This study details the analysis of 23,128 PICU admissions of 12,232 unique oncology patients representing 3% of all PICU admissions with 1,610 deaths (7.0% case fatality). African American (8.5%) and Hispanic children (8.1%) had significantly higher mortality (p < 0.05) compared with Caucasian children (6.3%). Regional analysis showed Hispanic patients to have higher mortality in the West in the United States, whereas African American patients in the South in the United States had higher mortality. A pulmonary disease diagnosis in Hispanics increased odds of mortality (odds ratio, 1.39; 95% CI, 1.13-1.70), whereas a diagnosis of shock/sepsis increased risk for mortality in African Americans (odds ratio, 1.56; 95% CI, 1.11-2.20) compared with Caucasians. There were no differences between races/ethnic groups in the rates of limitations of care. After controlling for Pediatric Risk of Mortality III, PICU length of stay, stem cell transplant status, readmissions, cancer type (solid, brain, hematologic), mechanical ventilation days, and sex, Hispanic (odds ratio, 1.24; 95% CI, 1.05-1.47) and African Americans (odds ratio, 1.37; 95% CI, 1.14-1.66) had significantly higher odds of mortality compared with Caucasians. CONCLUSIONS The results show that after controlling for severity and cancer type, a child's race, ethnicity, and region of presentation influence mortality in the PICU. This suggests that additional investigation is warranted along with a need to rethink our approach to the evaluation and treatment of critically ill African American and Hispanic children with cancer.
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Affiliation(s)
- Mara Leimanis Laurens
- Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, Grand Rapids, MI.,Department of Pediatric and Human Development, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Kristen Snyder
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alan T Davis
- Spectrum Health, Office of Research and Education, Grand Rapids, MI.,Department of Surgery, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Robert K Fitzgerald
- Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, Grand Rapids, MI.,Department of Pediatric and Human Development, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Richard Hackbarth
- Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, Grand Rapids, MI.,Department of Pediatric and Human Development, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Surender Rajasekaran
- Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, Grand Rapids, MI.,Department of Pediatric and Human Development, College of Human Medicine, Michigan State University, East Lansing, MI
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Steppan DA, Coleman RD, Viamonte HK, Hanson SJ, Carroll MK, Klein OR, Cooke KR, Spinella PC, Steiner ME, Loftis LL, Bembea MM. Outcomes of pediatric patients with oncologic disease or following hematopoietic stem cell transplant supported on extracorporeal membrane oxygenation: The PEDECOR experience. Pediatr Blood Cancer 2020; 67:e28403. [PMID: 32519430 DOI: 10.1002/pbc.28403] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/10/2020] [Accepted: 04/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Outcomes for patients with oncologic disease and/or after hematopoietic stem cell transplant (HSCT) requiring intensive care unit admission have improved, but indications for and outcomes after extracorporeal membrane oxygenation (ECMO) support in this population are poorly characterized. PROCEDURE We analyzed data from consecutive patients < 18 years with oncologic disease and/or after HSCT reported to a pediatric ECMO registry by nine pediatric centers in the United States between 2011 and 2018. RESULTS We identified 18 ECMO patients with oncologic disease and/or HSCT, and 415 ECMO controls matched with a propensity score algorithm based on age, gender, race, severity of illness at admission, and reason for ECMO. The primary indication for ECMO was respiratory failure in 66.7% in the oncologic disease and/or HSCT group, and in 70.7% in the matched ECMO control group. Eleven of 18 patients survived to hospital discharge (61.1%), similar to the matched control group (60.8%), P = 0.979. Children with oncologic disease and/or HSCT had lower mean platelet counts during ECMO and received higher volumes of platelets compared with the control group, mean 14.6 mL/kg/day (standard deviations [SD], 9.8) versus mean 9.3 mL/kg/day (SD, 10.4), P = 0.001. Of the 11 surviving children with oncologic disease and/or HSCT, five sustained new neurologic disorders (45.5%) versus 45 of 222 (20.3%) in the control group, P = 0.061. Bleeding complications were similar in the two groups. CONCLUSIONS Outcomes of patients with oncologic disease and/or HSCT supported on ECMO in the current era are not significantly different compared with matched ECMO controls and are improved from previously published reports.
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Affiliation(s)
- Diana A Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ryan D Coleman
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - Sheila J Hanson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Megan K Carroll
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Orly R Klein
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kenneth R Cooke
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Philip C Spinella
- Department of Pediatrics, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Laura L Loftis
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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McCormick M, Friehling E, Kalpatthi R, Siripong N, Smith K. Cost-effectiveness of levofloxacin prophylaxis against bacterial infection in pediatric patients with acute myeloid leukemia. Pediatr Blood Cancer 2020; 67:e28469. [PMID: 32710709 PMCID: PMC7722035 DOI: 10.1002/pbc.28469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/08/2020] [Accepted: 05/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infections are the leading cause of therapy-related mortality in pediatric patients with acute myeloid leukemia (AML). Although effectiveness of levofloxacin antibacterial prophylaxis in oncology patients is recognized, its cost-effectiveness is unknown. This study evaluated epidemiologic data regarding levofloxacin use and the cost-effectiveness of this strategy as the cost per bacteremia episode, intensive care unit (ICU) admission, and death avoided in children with AML. PROCEDURE A retrospective cohort study using the Pediatric Health Information System (PHIS) database compared demographic and clinical characteristics and receipt of levofloxacin prophylaxis in children with AML admitted for chemotherapy from January 1, 2014, through December 31, 2018. We then developed a decision analysis model in this population that compared costs associated with bacteremia, ICU admission, or death secondary to bacteremia to levofloxacin prophylaxis cost from a healthcare perspective. Time horizon is one chemotherapy cycle. Probabilistic and one-way sensitivity analyses evaluated model uncertainty. RESULTS Prophylaxis cost $8491 per bacteremia episode prevented compared with an average added hospital cost of $119 478. Prophylaxis cost $81 609 per ICU admission avoided, compared with an average added hospital cost of $94 181. Prophylaxis cost $220 457 per death avoided. In sensitivity analysis, at a willingness-to-pay threshold of $100 000 per bacteremia episode avoided, prophylaxis remained cost-effective in 94.6% of simulations. Prophylaxis use was more common in recent years in patients with relapsed disease and with chemotherapy regimens considered more intensive. CONCLUSION Prophylaxis is cost-effective in preventing bacterial infections in patients with AML. Findings support increased use in patients considered at high risk of bacterial infection secondary to myelosuppression.
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Affiliation(s)
- Meghan McCormick
- Division of Pediatric Hematology-Oncology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erika Friehling
- Division of Pediatric Hematology-Oncology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ramasubramanian Kalpatthi
- Division of Pediatric Hematology-Oncology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nalyn Siripong
- The Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kenneth Smith
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Abstract
We evaluated the performance of PRISM IV for pediatric cancer patients, and adapted and calibrated the algorithm to calculate mortality probabilities for these patients. An ambidirectional cohort was used, and data were collected from March 2017 prospectively to April 2019, and retrospectively to November 2014. The derivation set for model building contained 500 patients, and a validation set of 503 patients. Risk variables for hospital death were tested in logistic regression models encompassing PRISM IV components. There were 128 deaths (12.7%), being 65 deaths in the validation set. In the validation set, the PRISM IV algorithm had an area under the receiver operating characteristic curve of 0.89, with P=0.13 by Hosmer-Lemeshow test, and predicted 33 of the 65 deaths for a standardized mortality rate of 1.8 (95% confidence interval, 1.4-2.9; P<0.001 by Mid-P test). Our modified algorithm had an area under the receiver operating characteristic curve of 0.93, with P=0.3 by Hosmer-Lemeshow test and an standardized mortality rate of 1.02 (95% confidence interval, 0.79-1.19). The modified algorithm predicted 63.7 of 65 deaths. The PRISM IV algorithm was a poor predictor of mortality in children with cancer. The modified algorithm improved the predictive performance.
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Arias AV, Garza M, Murthy S, Cardenas A, Diaz F, Montalvo E, Nielsen KR, Kortz T, Sharara-Chami R, Friedrich P, McArthur J, Agulnik A. Quality and capacity indicators for hospitalized pediatric oncology patients with critical illness: A modified delphi consensus. Cancer Med 2020; 9:6984-6995. [PMID: 32777172 PMCID: PMC7541142 DOI: 10.1002/cam4.3351] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/21/2020] [Accepted: 07/14/2020] [Indexed: 01/09/2023] Open
Abstract
Background Hospitalized pediatric hematology‐oncology (PHO) patients are at high risk for critical illness, especially in resource‐limited settings. Unfortunately, there are no established quality indicators to guide institutional improvement for these patients. The objective of this study was to identify quality indicators to include in PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), an assessment tool to evaluate the capacity and quality of pediatric critical care services offered to PHO patients. Methods A comprehensive literature review identified relevant indicators in the areas of structure, performance, and outcomes. An international focus group sorted potential indicators using the framework of domains and subdomains. A modified, three‐round Delphi was conducted among 36 international experts with diverse experience in PHO and critical care in high‐resource and resource‐limited settings. Quality indicators were ranked on relevance and actionability via electronically distributed surveys. Results PROACTIVE contains 119 indicators among eight domains and 22 subdomains, with high‐median importance (≥7) in both relevance and actionability, and ≥80% evaluator agreement. The top five indicators were: (a) A designated PICU area; (b) Availability of a pediatric intensivist; (c) A PHO physician as part of the primary team caring for critically ill PHO patients; (d) Trained nursing staff in pediatric critical care; and (e) Timely PICU transfer of hospitalized PHO patients requiring escalation of care. Conclusions PROACTIVE is a consensus‐derived tool to assess the capacity and quality of pediatric onco‐critical care in resource‐limited settings. Future endeavors include validation of PROACTIVE by correlating the proposed indicators to clinical outcomes and its implementation to identify service delivery gaps amenable to improvement.
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Affiliation(s)
- Anita V Arias
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Marcela Garza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Adolfo Cardenas
- Hospital Infantil Teletón de Oncología (HITO), Querétaro, México
| | - Franco Diaz
- Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Erika Montalvo
- Pediatric Critical Care Unit, SOLCA Quito, Quito, Ecuador
| | - Katie R Nielsen
- Division of Pediatric Critical Care, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Teresa Kortz
- Division of Pediatric Critical Care, University of California San Francisco, San Francisco, CA, USA
| | - Rana Sharara-Chami
- Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jennifer McArthur
- Division of Pediatric Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA.,Division of Pediatric Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA
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Extracorporeal Membrane Oxygenation as a Bridge to Chimeric Antigen Receptor T-cell Therapy for Severe Refractory Sepsis in the Setting of Relapsed Refractory Pediatric Acute Lymphoblastic Leukemia: A Case Report. Crit Care Explor 2020; 2:e0093. [PMID: 32426735 PMCID: PMC7188439 DOI: 10.1097/cce.0000000000000093] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Pediatric oncology patients with sepsis are at higher risk of morbidity and mortality compared with pediatric patients without malignancy. Historically, patients with relapsed and/or refractory disease were not considered candidates for aggressive life support strategies including extracorporeal membrane oxygenation support.
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Pillon M, Sperotto F, Zattarin E, Cattelan M, Carraro E, Contin AE, Massano D, Pece F, Putti MC, Messina C, Pettenazzo A, Amigoni A. Predictors of mortality after admission to pediatric intensive care unit in oncohematologic patients without history of hematopoietic stem cell transplantation: A single-center experience. Pediatr Blood Cancer 2019; 66:e27892. [PMID: 31250548 DOI: 10.1002/pbc.27892] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/24/2019] [Accepted: 06/01/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pediatric oncohematologic patients are a high-risk population for clinical deterioration that might require pediatric intensive care unit (PICU) admission. Several studies have described outcomes and mortality predictors for patients post hematopoietic stem cell transplantation (HSCT), but fewer data exist regarding the category of non-HSCT patients. PROCEDURE All oncohematologic non-HSCT patients ≤18 years requiring PICU admission from 1998 to 2015 in our tertiary-care academic hospital were retrospectively evaluated by means of the pediatric hematology-oncology unit database and the Italian PICUs data network database. We assessed the relation between demographic and clinical characteristics and 90-day mortality after PICU admission. RESULTS Of 3750 hospitalized oncohematologic patients, 3238 were non-HSCT and 63 (2%) of them were admitted to the PICU. Patients were mainly affected by hematological malignancies (70%) and mostly were in the induction-therapy phase. The main reasons for admission were respiratory failure (40%), sepsis (25%), and seizures (16%). The median PICU stay was 5 days (range 1-107). The mortality rate at PICU discharge was 30%, and at 90 days it was 35%. Fifty-five percent of deaths happened in the first 2 days of the PICU stay. Cardiac arrest (P = .007), presence of disseminated intravascular coagulation (DIC, P = .007), and acute kidney injury (AKI) at PICU admission (P < .001) and during PICU stay (P = .021) were significant predictors of mortality in the multivariate analysis. Respiratory failure and mechanical ventilation were not associated with mortality. CONCLUSIONS A relatively small percentage of non-HSCT patients required PICU admission, but the mortality rate was still high. Hemodynamic instability, DIC, and AKI, but not respiratory failure, were significant predictors of mortality.
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Affiliation(s)
- Marta Pillon
- Pediatric Hematology and Oncology, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Francesca Sperotto
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Emma Zattarin
- Pediatric Hematology and Oncology, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Manuela Cattelan
- Department of Statistical Sciences, University of Padua, Padua, Italy
| | - Elisa Carraro
- Pediatric Hematology and Oncology, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Anna E Contin
- Pediatric Hematology and Oncology, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Davide Massano
- Pediatric Hematology and Oncology, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Federico Pece
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Maria C Putti
- Pediatric Hematology and Oncology, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Chiara Messina
- Pediatric Hematology and Oncology, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Andrea Pettenazzo
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
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Comprehensive Prognostication in Critically Ill Pediatric Hematopoietic Cell Transplant Patients: Results from Merging the Center for International Blood and Marrow Transplant Research (CIBMTR) and Virtual Pediatric Systems (VPS) Registries. Biol Blood Marrow Transplant 2019; 26:333-342. [PMID: 31563573 DOI: 10.1016/j.bbmt.2019.09.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/29/2019] [Accepted: 09/23/2019] [Indexed: 12/26/2022]
Abstract
Critically ill pediatric allogeneic hematopoietic cell transplant (HCT) patients may benefit from early and aggressive interventions aimed at reversing the progression of multiorgan dysfunction. Therefore, we evaluated 25 early risk factors for pediatric intensive care unit (PICU) mortality to improve mortality prognostication. We merged the Virtual Pediatric Systems and Center for International Blood and Marrow Transplant Research databases and analyzed 936 critically ill patients ≤21 years of age who had undergone allogeneic HCT and subsequently required PICU admission between January 1, 2009, and December 31, 2014. Of 1532 PICU admissions, the overall PICU mortality rate was 17.4% (95% confidence interval [CI], 15.6% to 19.4%) but was significantly higher for patients requiring mechanical ventilation (44.0%), renal replacement therapy (56.1%), or extracorporeal life support (77.8%). Mortality estimates increased significantly the longer that patients remained in the PICU. Of 25 HCT- and PICU-specific characteristics available at or near the time of PICU admission, moderate/severe pre-HCT renal injury, pre-HCT recipient cytomegalovirus seropositivity, <100-day interval between HCT and PICU admission, HCT for underlying acute myeloid leukemia, and greater admission organ dysfunction as approximated by the Pediatric Risk of Mortality 3 score were each independently associated with PICU mortality. A multivariable model using these components identified that patients in the top quartile of risk had 3 times greater mortality than other patients (35.1% versus 11.5%, P < .001, classification accuracy 75.2%; 95% CI, 73.0% to 77.4%). These data improve our working knowledge of the factors influencing the progression of critical illness in pediatric allogeneic HCT patients. Future investigation aimed at mitigating the effect of these risk factors is warranted.
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Wösten-van Asperen RM, van Gestel JPJ, van Grotel M, Tschiedel E, Dohna-Schwake C, Valla FV, Willems J, Angaard Nielsen JS, Krause MF, Potratz J, van den Heuvel-Eibrink MM, Brierley J. PICU mortality of children with cancer admitted to pediatric intensive care unit a systematic review and meta-analysis. Crit Rev Oncol Hematol 2019; 142:153-163. [PMID: 31404827 DOI: 10.1016/j.critrevonc.2019.07.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 03/27/2019] [Accepted: 07/17/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Outcomes for children diagnosed with cancer have improved dramatically over the past 20 years. However, although 40% of pediatric cancer patients require at least one intensive care admission throughout their disease course, PICU outcomes and resource utilization by this population have not been rigorously studied in this specific group. METHODS Using a systematic strategy, we searched Medline, Embase, and CINAHL databases for articles describing PICU mortality of pediatric cancer patients admitted to PICU. Two investigators independently applied eligibility criteria, assessed data quality, and extracted data. We pooled PICU mortality estimates using random-effects models and examined mortality trends over time using meta-regression models. RESULTS Out of 1218 identified manuscripts, 31 studies were included covering 16,853 PICU admissions with the majority being retrospective in nature. Overall pooled weighted mortality was 27.8% (95% confidence interval (CI), 23.7-31.9%). Mortality decreased slightly over time when post-operative patients were excluded. The use of mechanical ventilation (odds ratio (OR): 18.49 [95% CI 13.79-24.78], p < 0.001), inotropic support (OR: 14.05 [95% CI 9.16-21.57], p < 0.001), or continuous renal replacement therapy (OR: 3.24 [95% CI 1.31-8.04], p = 0.01) was significantly associated with PICU mortality. CONCLUSIONS PICU mortality rates of pediatric cancer patients are far higher when compared to current mortality rates of the general PICU population. PICU mortality has remained relatively unchanged over the past decades, a slight decrease was only seen when post-operative patients were excluded. This compared infavorably with the improved mortality seen in adults with cancer admitted to ICU, where research-led improvements have led to the paradigm of unlimited, aggressive ICU management without any limitations on resuscitations status, for a time-limited trial.
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Affiliation(s)
- Roelie M Wösten-van Asperen
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital/University Medical Center Utrecht, the Netherlands.
| | - Josephus P J van Gestel
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital/University Medical Center Utrecht, the Netherlands
| | | | - Eva Tschiedel
- Department of Pediatric Intensive Care, Universitätsklinik Essen, Essen, Germany
| | | | - Frédéric V Valla
- Pediatric Intensive Care Unit, Hôpital Universitaire Femme Mère Enfant, Hospices Civils de Lyon, Lyon-Bron, France
| | - Jef Willems
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | | | - Martin F Krause
- Department of Pediatrics, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Jenny Potratz
- Department of General Pediatrics-Intensive Care Medicine, University Children's Hospital Münster, Münster, Germany
| | | | - Joe Brierley
- Department of Critical Care & Bioethics, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, UK
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Anthracycline Exposure and Subsequent Critical Illness: Getting to the Heart of the Problem. Pediatr Crit Care Med 2019; 20:672-673. [PMID: 31274791 DOI: 10.1097/pcc.0000000000001930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Positive Cumulative Fluid Balance Is Associated With Mortality in Pediatric Acute Respiratory Distress Syndrome in the Setting of Acute Kidney Injury. Pediatr Crit Care Med 2019; 20:323-331. [PMID: 30672838 PMCID: PMC6454886 DOI: 10.1097/pcc.0000000000001845] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES As acute kidney injury and elevated cumulative fluid balance commonly co-occur in pediatric acute respiratory distress syndrome, we aimed to identify risk factors for their development and evaluate their independent relationships with mortality. We hypothesized that acute kidney injury and elevated cumulative fluid balance would be associated with markers of inflammation and that children with elevated cumulative fluid balance and concomitant acute kidney injury would have worse outcomes than other children. DESIGN Prospective observational study using the pediatric Risk, Injury, Failure, Loss, End-Stage acute kidney injury classification. SETTING Five academic PICUs. PATIENTS Two-hundred sixty patients 1 month to 18 years old meeting the Berlin definition of acute respiratory distress syndrome between 2008 and 2014. INTERVENTIONS None. MEASUREMENTS AND RESULTS PICU mortality was 13% (34/260). Relative to survivors, nonsurvivors had greater cumulative fluid balance on day 3 of acute respiratory distress syndrome (+90.1 mL/kg; interquartile range 26.6-161.7 vs +44.9 mL/kg; interquartile range 10.0-111.3; p = 0.008) and also had higher prevalence of acute kidney injury on day 3 of acute respiratory distress syndrome (50% vs 23%; p = 0.001). On stratified analysis, greater cumulative fluid balance on day 3 of acute respiratory distress syndrome was associated with mortality among patients with concomitant acute kidney injury (+111.5 mL/kg for nonsurvivors; interquartile range 82.6-236.8 vs +58.5 mL/kg for survivors; interquartile range 0.9-176.2; p = 0.041) but not among patients without acute kidney injury (p = 0.308). The presence of acute kidney injury on acute respiratory distress syndrome day 3 was associated with mortality among patients with positive cumulative fluid balance (29.1% vs 10.4% mortality; p = 0.001) but not among patients with even or negative cumulative fluid balance (p = 0.430). Day 1 plasma interleukin-6 levels were associated with the development of day 3 positive cumulative fluid balance, day 3 acute kidney injury, and PICU mortality and the association between elevated day 1 interleukin-6 and PICU mortality was partially mediated by the interval development of day 3 positive cumulative fluid balance and day 3 acute kidney injury (p < 0.001). CONCLUSIONS In pediatric acute respiratory distress syndrome, elevated cumulative fluid balance on day 3 of acute respiratory distress syndrome is associated with mortality specifically in patients with concomitant acute kidney injury. Plasma interleukin-6 levels are associated with the development of positive cumulative fluid balance and acute kidney injury, suggesting a potential mechanism by which inflammation might predispose to mortality.
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Zinter MS, Delucchi KL, Kong MY, Orwoll BE, Spicer AS, Lim MJ, Alkhouli MF, Ratiu AE, McKenzie AV, McQuillen PS, Dvorak CC, Calfee CS, Matthay MA, Sapru A. Early Plasma Matrix Metalloproteinase Profiles. A Novel Pathway in Pediatric Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2019; 199:181-189. [PMID: 30114376 PMCID: PMC6353006 DOI: 10.1164/rccm.201804-0678oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 08/10/2018] [Indexed: 12/12/2022] Open
Abstract
RATIONALE MMPs (Matrix metalloproteinases) and their endogenous tissue inhibitors may contribute to lung injury through extracellular matrix degradation and modulation of inflammation and fibrosis. OBJECTIVES To test for an association between MMP pathway proteins and inflammation, endothelial dysfunction, and clinical outcomes. METHODS We measured MMPs in plasma collected on acute respiratory distress syndrome (ARDS) Day 1 from 235 children at five hospitals between 2008 and 2017. We used latent class analysis to identify patients with distinct MMP profiles and then associated those profiles with markers of inflammation (IL-1RA, -6, -8, -10, and -18; macrophage inflammatory protein-1α and -1β; tumor necrosis factor-α and -R2), endothelial injury (angiopoietin-2, von Willebrand factor, soluble thrombomodulin), impaired oxygenation (PaO2/FiO2 [P/F] ratio, oxygenation index), morbidity, and mortality. MEASUREMENTS AND MAIN RESULTS In geographically distinct derivation and validation cohorts, approximately one-third of patients demonstrated an MMP profile characterized by elevated MMP-1, -2, -3, -7, and -8 and tissue inhibitor of metalloproteinase-1 and -2; and depressed active and total MMP-9. This MMP profile was associated with multiple markers of inflammation, endothelial injury, and impaired oxygenation on Day 1 of ARDS, and conferred fourfold increased odds of mortality or severe morbidity independent of the P/F ratio and other confounders (95% confidence interval, 2.1-7.6; P < 0.001). Logistic regression using both the P/F ratio and MMP profiles was superior to the P/F ratio alone in prognosticating mortality or severe morbidity (area under the receiver operating characteristic curve, 0.75; 95% confidence interval, 0.68-0.82 vs. area under the receiver operating characteristic curve, 0.66; 95% confidence interval, 0.58-0.73; P = 0.009). CONCLUSIONS Pediatric patients with ARDS have specific plasma MMP profiles associated with inflammation, endothelial injury, morbidity, and mortality. MMPs may play a role in the pathobiology of children with ARDS.
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Affiliation(s)
| | | | - Michele Y. Kong
- Division of Critical Care Medicine, Department of Pediatrics, University of Alabama School of Medicine, Birmingham, Alabama; and
| | | | | | - Michelle J. Lim
- Division of Critical Care, Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles Geffen School of Medicine, Los Angeles, California
| | | | - Anna E. Ratiu
- Division of Critical Care, Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles Geffen School of Medicine, Los Angeles, California
| | | | | | - Christopher C. Dvorak
- Division of Allergy, Immunology, and Blood & Marrow Transplantation, Department of Pediatrics, Benioff Children’s Hospital
| | - Carolyn S. Calfee
- Department of Anesthesia and
- Department of Medicine, Cardiovascular Research Institute, University of California San Francisco School of Medicine, San Francisco, California
| | - Michael A. Matthay
- Department of Anesthesia and
- Department of Medicine, Cardiovascular Research Institute, University of California San Francisco School of Medicine, San Francisco, California
| | - Anil Sapru
- Division of Critical Care and
- Division of Critical Care, Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles Geffen School of Medicine, Los Angeles, California
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Aljabari S, Balch A, Larsen GY, Fluchel M, Workman JK. Severe Sepsis-Associated Morbidity and Mortality among Critically Ill Children with Cancer. J Pediatr Intensive Care 2018; 8:122-129. [PMID: 31404226 DOI: 10.1055/s-0038-1676658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/05/2018] [Indexed: 01/20/2023] Open
Abstract
Severe sepsis (SS) in pediatric oncology patients is a leading cause of morbidity and mortality. We investigated the incidence of and risk factors for morbidity and mortality among children diagnosed with cancer from 2008 to 2012, and admitted with SS during the 3 years following cancer diagnosis. A total of 1,002 children with cancer were included, 8% of whom required pediatric intensive care unit (PICU) admission with SS. Death and/or multiple organ dysfunction syndrome occurred in 34 out of 99 PICU encounters (34%). Lactate level and history of stem-cell transplantation were significantly associated with the development of death and/or organ dysfunction ( p < 0.05).
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Affiliation(s)
- Salim Aljabari
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Alfred Balch
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Gitte Y Larsen
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Mark Fluchel
- Division of Pediatric Hematology and Oncology, Department of pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Jennifer K Workman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
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Thomas NJ, Spear D, Wasserman E, Pon S, Markovitz B, Singh AR, Li S, Gertz SJ, Rowan CM, Kunselman A, Tamburro RF. CALIPSO: A Randomized Controlled Trial of Calfactant for Acute Lung Injury in Pediatric Stem Cell and Oncology Patients. Biol Blood Marrow Transplant 2018; 24:2479-2486. [PMID: 30059785 PMCID: PMC10479933 DOI: 10.1016/j.bbmt.2018.07.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/14/2018] [Indexed: 11/23/2022]
Abstract
To assess if calfactant reduces mortality among children with leukemia/lymphoma or after hematopoietic cell transplantation (HCT) with pediatric acute respiratory distress syndrome (PARDS), we conducted a multicenter, randomized, placebo-controlled, double-blinded trial in 17 pediatric intensive care units (PICUs) of tertiary care children's hospitals. Patients ages 18 months to 25 years with leukemia/lymphoma or having undergone HCT who required invasive mechanical ventilation for bilateral lung disease with an oxygenation index (OI) > 10 and <37 were studied. Interventions used were intratracheal instillation of either calfactant or air placebo (1 or 2 doses). Forty-three subjects were enrolled between November 2010 and June 2015: 26 assigned to calfactant and 17 to placebo. There were no significant differences in the primary outcome, which was survival to PICU discharge (adjusted hazard ratio of mortality for calfactant versus placebo, 1.78; 95% confidence interval, .53 to 6.05; P = .35), OI, functional outcomes, or ventilator-free days, adjusting for risk strata and Pediatric Risk of Mortality (PRISM) score. Despite the risk-stratified randomization, more allogeneic HCT patients received calfactant (76% and 39%, respectively) due to low recruitment at various sites. This imbalance is important because independent of treatment arm and while adjusting for PRISM score, those with allogeneic HCT had a nonsignificant higher likelihood of death at PICU discharge (adjusted odds ratio, 3.02; 95% confidence interval, .76 to 12.06; P = .12). Overall, 86% of the patients who survived to PICU discharge also were successfully discharged from the hospital. These data do not support the use of calfactant among this high mortality group of pediatric leukemia/lymphoma and/or HCT patients with PARDS to increase survival. In spite of poor enrollment, allogeneic HCT patients with PARDS appeared to be characterized by higher mortality than even other high-risk immunosuppressed groups. Conducting research among these children is challenging but necessary, because survival to PICU discharge usually results in successful discharge to home.
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Affiliation(s)
- Neal J Thomas
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania.
| | - Debbie Spear
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Emily Wasserman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Steven Pon
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Weill Cornell Medicine, New York, New York
| | - Barry Markovitz
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | - Aalok R Singh
- Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Simon Li
- Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Shira J Gertz
- Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey
| | - Courtney M Rowan
- Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Allen Kunselman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Robert F Tamburro
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
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The SCARF Trial: A Veiled Statement on the PICU? Pediatr Crit Care Med 2018; 19:995-996. [PMID: 30281567 DOI: 10.1097/pcc.0000000000001714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Prout AJ, Talisa VB, Carcillo JA, Mayr FB, Angus DC, Seymour CW, Chang CCH, Yende S. Children with Chronic Disease Bear the Highest Burden of Pediatric Sepsis. J Pediatr 2018; 199:194-199.e1. [PMID: 29753542 PMCID: PMC6063765 DOI: 10.1016/j.jpeds.2018.03.056] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/08/2018] [Accepted: 03/21/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To describe the contemporary epidemiology of pediatric sepsis in children with chronic disease, and the contribution of chronic diseases to mortality. We examined the incidence and hospital mortality of pediatric sepsis in a nationally representative sample and described the contribution of chronic diseases to hospital mortality. STUDY DESIGN We analyzed the 2013 Nationwide Readmissions Database using a retrospective cohort design. We included non-neonatal patients <19 years of age hospitalized with sepsis. We examined patient characteristics, the distribution of chronic disease, and the estimated national incidence, and described hospital mortality. We used mixed effects logistic regression to explore the association between chronic diseases and hospital mortality. RESULTS A total of 16 387 admissions, representing 14 243 unique patients, were for sepsis. The national incidence was 0.72 cases per 1000 per year (54 060 cases annually). Most (68.6%) had a chronic disease. The in-hospital mortality was 3.7% overall-0.7% for previously healthy patients and 5.1% for patients with chronic disease. In multivariable analysis, oncologic, hematologic, metabolic, neurologic, cardiac and renal disease, and solid organ transplantation were associated with increased in-hospital mortality. CONCLUSIONS More than 2 of 3 children admitted with sepsis have ≥1 chronic disease and these patients have a higher in-hospital mortality than previously healthy patients. The burden of sepsis in hospitalized children is greatest in pediatric patients with chronic disease.
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Affiliation(s)
- Andrew J. Prout
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Victor B. Talisa
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Florian B. Mayr
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Derek C. Angus
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher W. Seymour
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chung-Chou H. Chang
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sachin Yende
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA.
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Mayampurath A, Volchenboum SL, Sanchez-Pinto LN. Using photoplethysmography data to estimate heart rate variability and its association with organ dysfunction in pediatric oncology patients. NPJ Digit Med 2018; 1:29. [PMID: 31304311 PMCID: PMC6550162 DOI: 10.1038/s41746-018-0038-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/27/2018] [Accepted: 06/28/2018] [Indexed: 11/10/2022] Open
Abstract
Pediatric oncology patients are at high risk of developing clinical deterioration and organ dysfunction during their illness. Heart rate variability (HRV) measured using electrocardiography waveforms is associated with increased organ dysfunction and clinical deterioration in adult and pediatric patients in the intensive care unit (ICU). Here, we explore the feasibility of using photoplethysmography (PPG)-derived integer pulse rate variability (PRVi) to estimate HRV and determine its association with organ dysfunction in pediatric oncology patients in the ward and pediatric ICU. The advantage of using PPG sensor data over electrocardiography is its higher availability in most healthcare settings and in wearable technology. In a cohort of 38 patients, reduced median daily PRVi was significantly associated with increase in two pediatric organ dysfunction scores after adjusting for confounders (p < 0.001). PRVi shows promise as a real-time physiologic marker of clinical deterioration using highly-available PPG data, but further research is warranted.
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Affiliation(s)
- Anoop Mayampurath
- Department of Pediatrics, The University of Chicago, Chicago, IL USA
- Center for Research Informatics, The University of Chicago, Chicago, IL USA
| | - Samuel L Volchenboum
- Department of Pediatrics, The University of Chicago, Chicago, IL USA
- Center for Research Informatics, The University of Chicago, Chicago, IL USA
| | - L. Nelson Sanchez-Pinto
- Division of Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA
- Departments of Pediatrics & Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
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Abstract
OBJECTIVES To evaluate hospital-level variability in resource utilization and mortality in children with new leukemia who require ICU support, and identify factors associated with variation. DESIGN Retrospective cohort study. SETTING Children's hospitals contributing to the Pediatric Health Information Systems administrative database from 1999 to 2011. PATIENTS Inpatients less than 25 years old with newly diagnosed acute lymphocytic leukemia or acute myeloid leukemia requiring ICU support (n = 1,754). INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS Evaluated exposures included leukemia type, year of diagnosis, and hospital-wide proportion of patients with public insurance. The main outcome was hospital mortality. Wide variability existed in the ICU resources used across hospitals. Combined acute lymphocytic leukemia and acute myeloid leukemia mortality varied by hospital from 0% (95% CI, 0-14.8%) to 42.9% (95% CI, 17.7-71.1%). A mixed-effects model with a hospital-level random effect suggests significant variation across hospitals in mortality (p = 0.007). When including patient and hospital factors as fixed effects into the model, younger age, acute myeloid leukemia versus acute lymphocytic leukemia diagnosis, leukemia diagnosis prior to 2005, hospital-wide proportion of public insurance patients, and hospital-level proportion of leukemia patients receiving ICU care are significantly associated with mortality. The variation across hospitals remains significant with all patient factors included (p = 0.021) but is no longer significant after adjusting for the hospital-level factors proportion of public insurance and proportion receiving ICU care (p = 0.48). CONCLUSIONS Wide hospital-level variability in ICU resource utilization and mortality exists in the care of children with leukemia requiring ICU support. Hospital payer mix is associated with some mortality variability. Additional study into how ICU support could be standardized through clinical practice guidelines, impact of payer mix on hospital resources allocation to the ICU, and subsequent impact on patient outcomes is warranted.
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High Levels of Morbidity and Mortality Among Pediatric Hematopoietic Cell Transplant Recipients With Severe Sepsis: Insights From the Sepsis PRevalence, OUtcomes, and Therapies International Point Prevalence Study. Pediatr Crit Care Med 2017; 18:1114-1125. [PMID: 28926489 PMCID: PMC7339740 DOI: 10.1097/pcc.0000000000001338] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Pediatric severe sepsis is a major cause of morbidity and mortality worldwide, and hematopoietic cell transplant patients represent a high-risk population. We assessed the epidemiology of severe sepsis in hematopoietic cell transplant patients, describing patient outcomes compared with children with no history of hematopoietic cell transplant. DESIGN Secondary analysis of the Sepsis PRevalence, OUtcomes, and Therapies point prevalence study, comparing demographics, sepsis etiology, illness severity, organ dysfunction, and sepsis-related treatments in patients with and without hematopoietic cell transplant. The primary outcome was hospital mortality. Multivariable logistic regression models were used to determine adjusted differences in mortality. SETTING International; 128 PICUs in 26 countries. PATIENTS Pediatric patients with severe sepsis prospectively identified over a 1-year period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In patients with severe sepsis, 37/567 (6.5%) had a history of hematopoietic cell transplant. Compared with patients without hematopoietic cell transplant, hematopoietic cell transplant patients had significantly higher hospital mortality (68% vs 23%; p < 0.001). Hematopoietic cell transplant patients were more likely to have hospital acquired sepsis and had more preexisting renal and hepatic dysfunction than non-hematopoietic cell transplant patients with severe sepsis. History of hematopoietic cell transplant, renal replacement therapy, admission from inpatient floor, and number of organ dysfunctions at severe sepsis recognition were independently associated with hospital mortality in multivariable analysis; hematopoietic cell transplant conferred the highest odds of mortality (odds ratio, 4.00; 95% CI, 1.78-8.98). In secondary analysis of hematopoietic cell transplant patients compared with other immunocompromised patients with severe sepsis, history of hematopoietic cell transplant remained independently associated with hospital mortality (odds ratio, 3.03; 95% CI, 1.11-8.27). CONCLUSIONS In an international study of pediatric severe sepsis, history of hematopoietic cell transplant is associated with a four-fold increased odds of hospital mortality after adjustment for potential measured confounders. Hematopoietic cell transplant patients more often originated from within the hospital compared to children with severe sepsis without hematopoietic cell transplant, possibly providing an earlier opportunity for sepsis recognition and intervention in this high-risk population.
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48
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Zinter MS, Holubkov R, Steurer MA, Dvorak CC, Duncan CN, Sapru A, Tamburro RF, McQuillen PS, Pollack MM. Pediatric Hematopoietic Cell Transplant Patients Who Survive Critical Illness Frequently Have Significant but Recoverable Decline in Functional Status. Biol Blood Marrow Transplant 2017; 24:330-336. [PMID: 29128553 DOI: 10.1016/j.bbmt.2017.10.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 10/31/2017] [Indexed: 12/28/2022]
Abstract
The number of pediatric hematopoietic cell transplant (HCT) patients who survive pediatric intensive care unit (PICU) admission is increasing, yet little is known about their functional morbidity after PICU discharge. We hypothesized that relative to control subjects, pediatric HCT patients who survive PICU admission would have greater rates of new functional morbidity at the time of PICU discharge and only some of these patients would return to their functional baseline by the end of the hospitalization. We performed a retrospective cohort study with secondary data analysis of the Trichotomous Outcomes in Pediatric Critical Care dataset. The pediatric HCT cohort was identified by querying International Classification of Diseases, 9th edition, diagnostic codes. A control group consisted of previously healthy patients matched 4:1 on age, sex, and illness severity, as estimated by the Pediatric Risk of Mortality (PRISM) score. We benchmarked our findings by comparing with a previously healthy group of children with lower respiratory tract infections. Functional impairment was measured by the Functional Status Scale, wherein new morbidity was defined as an increase of ≥3 points relative to the prehospital baseline. Relative to matched control subjects, HCT patients had similar admission PRISM scores (P = .516) but greater PICU mortality (12.9% [11/85] versus 6.2% [21/340], P = .035). However, among those who survived to PICU discharge, HCT patients had similar rates of new morbidity at PICU discharge (14.9% [11/74] versus 17.2% [55/319], P = .622) and similar rates of resolution of new morbidity by hospital discharge (54.5% [6/11] versus 60.0% [33/55], P = .737). Relative to the comparison group with lower respiratory tract infections, HCT patients had both greater admission PRISM scores (P < .001) and greater PICU mortality (12.9% [11/85] versus 1.6% [5/308], P < .001). However, among those who survived to PICU discharge, HCT patients again displayed similar rates of new morbidity at PICU discharge (14.9% [11/74] versus 22.1% [67/303], P = .168) as well as resolution of new morbidity by hospital discharge (54.5% [6/11] versus 71.6% [48/67], P = .299). For pediatric HCT patients PICU survival with new functional morbidity is as prevalent an outcome as PICU mortality. Although pediatric HCT patients have greater PICU mortality than age-, sex-, and PRISM-matched control subjects, they have similar rates of new functional morbidity at PICU discharge and similar resolution of new functional morbidity at hospital discharge. Future interventions focused on improving functional status in pediatric HCT survivors of critical illness are warranted.
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Affiliation(s)
- Matt S Zinter
- Department of Pediatrics, Division of Critical Care, Benioff Children's Hospital, University of California-San Francisco School of Medicine, San Francisco, California.
| | - Richard Holubkov
- Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah
| | - Martina A Steurer
- Department of Pediatrics, Division of Critical Care, Benioff Children's Hospital, University of California-San Francisco School of Medicine, San Francisco, California
| | - Christopher C Dvorak
- Department of Pediatrics, Division of Allergy, Immunology, and Blood & Marrow Transplantation, Benioff Children's Hospital, University of California-San Francisco School of Medicine, San Francisco, California
| | - Christine N Duncan
- Department of Pediatrics, Division of Stem Cell Transplantation, Boston Children's Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Anil Sapru
- Department of Pediatrics, Division of Critical Care, Mattel Children's Hospital, University of California-Los Angeles School of Medicine, San Francisco, California
| | | | - Patrick S McQuillen
- Department of Pediatrics, Division of Critical Care, Benioff Children's Hospital, University of California-San Francisco School of Medicine, San Francisco, California
| | - Murray M Pollack
- Department of Pediatrics, Division of Critical Care, Children's National Medical Center, George Washington University School of Medicine, Washington, DC
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Beringer N, Poole JE, Ballot DE, Geel JA. Appropriateness of admissions of children with cancer to intensive care facilities in a resource-limited setting. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2017. [DOI: 10.4102/sajo.v1i0.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
<strong>Background:</strong> The increasing intensity of treatment of paediatric malignancies has led to improved survival rates, but often necessitates intensive supportive care. The decision to admit a child to the paediatric intensive care unit (PICU) is based on the probability of both short-term and long-term survival in the context of severe resource constraints. Resource constraints in South Africa result in limited access of children with cancer to PICU facilities.<br /><strong>Objectives:</strong> The aim of this study was to determine whether referrals by paediatric oncologists to a PICU in Johannesburg were appropriate by analysing indications for admission, underlying diagnoses, duration and costs of admissions, and overall outcomes.<br /><strong>Methods:</strong> A retrospective review of consecutive PICU admissions over a 12-year period was performed. Data from all patients with histologically proven malignant conditions were included and analysed using descriptive statistical methods, Kaplan–Meier curves, log-rank analysis and Fisher’s exact test.<br /><strong>Results:</strong> There were 5704 recorded admissions to PICU in the study period. Of these admissions, 120 (2.1%) were for patients with malignancies. The majority of PICU oncology admissions were for post-operative care, and the median duration of stay was 1 day (interquartile range: 1–3 days). The short-term mortality rate of oncology patients in PICU was 13.3% in comparison with 16.2% in the overall PICU population. The 4-year overall survival rate post PICU discharge was 54%.<br /><strong>Conclusion:</strong> The documented short-term mortality rate indicates that referrals by paediatric oncologists are consistent with current PICU admission policies. Oncologists should assess the prognosis for survival before requesting admission to PICU, and, resources permitting, these patients should be accepted to PICU.
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Incorporating Inflammation into Mortality Risk in Pediatric Acute Respiratory Distress Syndrome. Crit Care Med 2017; 45:858-866. [PMID: 28248715 DOI: 10.1097/ccm.0000000000002370] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES In pediatric acute respiratory distress syndrome, lung injury is mediated by immune activation and severe inflammation. Therefore, we hypothesized that patients with elevated pro- and anti-inflammatory cytokines would have higher mortality rates and that these biomarkers could improve risk stratification of poor outcomes. DESIGN Multicenter prospective observational study. SETTING We enrolled patients from five academic PICUs between 2008 and 2015. PATIENTS Patients were 1 month to 18 years old, used noninvasive or invasive ventilation, and met the American European Consensus Conference definition of acute respiratory distress syndrome. INTERVENTIONS Eight proinflammatory and anti-inflammatory cytokines were measured on acute respiratory distress syndrome day 1 and correlated with mortality, ICU morbidity as measured by survivor Pediatric Logistic Organ Dysfunction score, and biomarkers of endothelial injury, including angiopoietin-2, von Willebrand Factor, and soluble thrombomodulin. MEASUREMENTS AND MAIN RESULTS We measured biomarker levels in 194 patients, including 38 acute respiratory distress syndrome nonsurvivors. Interleukin-6, interleukin-8, interleukin-10, interleukin-18, and tumor necrosis factor-R2 were each strongly associated with all-cause mortality, multiple markers of ICU morbidity, and endothelial injury. A multiple logistic regression model incorporating oxygenation index, interleukin-8, and tumor necrosis factor-R2 was superior to a model of oxygenation index alone in predicting the composite outcome of mortality or severe morbidity (area under the receiver operating characteristic, 0.77 [0.70-0.83] vs 0.70 [0.62-0.77]; p = 0.042). CONCLUSIONS In pediatric acute respiratory distress syndrome, pro- and anti-inflammatory cytokines are strongly associated with mortality, ICU morbidity, and biochemical evidence of endothelial injury. These cytokines significantly improve the ability of the oxygenation index to discriminate risk of mortality or severe morbidity and may allow for identification and enrollment of high-risk subgroups for future studies.
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