1
|
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.
Collapse
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
| |
Collapse
|
2
|
Cennamo F, Masetti R, Largo P, Argentiero A, Pession A, Esposito S. Update on Febrile Neutropenia in Pediatric Oncological Patients Undergoing Chemotherapy. CHILDREN 2021; 8:children8121086. [PMID: 34943282 PMCID: PMC8700030 DOI: 10.3390/children8121086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
Febrile neutropenia (FN) is a common complication of chemotherapy in oncological children and one of the most important causes of morbidity and mortality in these patients. The early detection of a bacteremia and the rapid therapeutic intervention are crucial to improve the outcome. We analyzed the literature in order to clarify the epidemiology of FN in children undergoing chemotherapy, the specific factors associated with a negative outcome, the most common etiology, and the value of biological markers as a tool to make an early diagnosis or to monitor the evolution of the infection. Several studies have tried to identify specific factors that could help the clinician in the detection of an infection and in its microbiological identification. However, due to the heterogenicity of the available studies, sufficient evidence is lacking to establish the role of these risk factors in clinical practice and future research on this topic appear mandatory. Determinations of risk factors, etiology, and markers of febrile episodes in these patients are complicated by the characteristics of the underlying illness and the effects of treatments received. Although some studies have tried to develop an evidence-based guideline for the empiric management of FN in pediatrics, validated predictive scores and algorithms are still lacking and urgently needed.
Collapse
Affiliation(s)
- Federica Cennamo
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Riccardo Masetti
- Pediatric Oncology and Hematology Unit “Lalla Seragnoli”, Pediatric Unit-IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.M.); (A.P.)
| | - Prisca Largo
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Andrea Pession
- Pediatric Oncology and Hematology Unit “Lalla Seragnoli”, Pediatric Unit-IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.M.); (A.P.)
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
- Correspondence: ; Tel.: +39-0521-704-790
| |
Collapse
|
3
|
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.
Collapse
|
4
|
Jhang WK, Park SJ. Evaluation of Disseminated Intravascular Coagulation in Critically Ill Pediatric Hemato-oncology Patients with Septic Shock. Thromb Haemost 2020; 120:1505-1511. [PMID: 32772349 DOI: 10.1055/s-0040-1714737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) is a serious complication in septic shock. This study aimed to evaluate DIC and associated clinical outcomes using the International Society on Thrombosis and Hemostasis (ISTH) and modified ISTH overt DIC scores in critically ill pediatric hemato-oncology patients with septic shock. METHODS Pediatric hemato-oncology patients with septic shock admitted to the pediatric intensive care unit (PICU) of a tertiary children's hospital between January 2013 and February 2020 were included. We modified the ISTH overt DIC score by eliminating the platelet domain and compared the performances of the ISTH and the modified ISTH overt DIC scores in DIC diagnosis and PICU mortality prediction of these patients. RESULTS DIC was diagnosed in 56.4 and 38.5% of patients by ISTH and modified ISTH overt DIC scores, respectively. Patients with DIC showed a higher pediatric risk of mortality (PRISM) III, pediatric sequential organ failure assessment (pSOFA) scores, and PICU mortality than those without DIC (p < 0.05). The modified ISTH overt DIC score was an independent prognostic factor for PICU mortality and showed a larger area under the receiver operating characteristic curve than the ISTH overt DIC score (0.687 vs. 0.695). Addition of the DIC diagnosis improved the performance of PRISM III in predicting PICU mortality. CONCLUSION Critically ill pediatric hemato-oncology patients with septic shock frequently experience DIC, which was adequately evaluated by both ISTH and modified ISTH overt DIC scores. Considering the characteristics of these patients, the modified ISTH overt DIC score may be a promising prognostic factor for clinical outcomes in these critically ill pediatric patients.
Collapse
Affiliation(s)
- Won Kyoung Jhang
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Jong Park
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
5
|
Al Haj Moussa A, Maaz AUR, Faqih N, Sundaram M. Critically Ill Pediatric Oncology Patients: What the Intensivist Needs to Know? Pediatric Critical Care Medicine. Indian J Crit Care Med 2020; 24:1256-1263. [PMID: 33446982 PMCID: PMC7775926 DOI: 10.5005/jp-journals-10071-23693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Cancer is an evolving cause of morbidity and mortality in children worldwide. In recent decades, there has been a significant increase in the survival of children with cancer, after applying new methods and treatment protocols in practice. However, the complexity of the disease itself, as well as the intensity and toxicity of treatment is such that many children require admission to the pediatric intensive care unit (PICU) which should be well equipped and led by personnel who have adequate training and expertise to provide optimum care to these complex patients. Most oncology patients who require PICU admission categorized into oncological emergencies, and/or decompensation from treatment and its side effects. In this study, we provide a summary of the essential and most recent evidence-based recommendations from published reviews and articles to aid PICU physicians and to ensure the best treatment and outcome possible for the children with such disease. How to cite this article: Al Haj Moussa A, Maaz AUR, Faqih N, Sundaram M. Critically Ill Pediatric Oncology Patients: What the Intensivist Needs to Know? Pediatric Critical Care Medicine. Indian J Crit Care Med 2020;24(12):1256-1263.
Collapse
|
6
|
Critical Care Management: Sepsis and Disseminated and Local Infections. CRITICAL CARE OF THE PEDIATRIC IMMUNOCOMPROMISED HEMATOLOGY/ONCOLOGY PATIENT 2019. [PMCID: PMC7123939 DOI: 10.1007/978-3-030-01322-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Local and systemic infections are a significant cause of morbidity and mortality among immunocompromised children, including but not limited to patients with hematologic and solid malignancies, congenital or acquired immunodeficiencies, or hematopoietic cell or solid organ transplantation patients. Progression to septic shock can be rapid and profound and thus requires specific diagnostic and treatment approaches. This chapter will discuss the diagnosis and the initial hemodynamic management strategies of septic shock in immunocompromised children, including strategies to improve oxygen delivery, reduce metabolic demand, and monitor hemodynamic response to resuscitation. This chapter also discusses strategies to reverse septic shock pathobiology, including the use of both empiric and targeted anti-infective strategies and pharmacologic and cell therapy-based immunomodulation. Specific consideration is also paid to the management of high-risk subpopulations and the care of septic shock patients with resolving injury.
Collapse
|
7
|
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).
Collapse
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
| |
Collapse
|
8
|
Zinter MS, DuBois SG, Spicer A, Matthay K, Sapru A. Pediatric cancer type predicts infection rate, need for critical care intervention, and mortality in the pediatric intensive care unit. Intensive Care Med 2014; 40:1536-44. [PMID: 25023526 PMCID: PMC4177269 DOI: 10.1007/s00134-014-3389-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/27/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE Up to 38 % of children with cancer require pediatric intensive care unit (PICU) admission within 3 years of diagnosis, with reported PICU mortality of 13-27 % far exceeding that of the general PICU population. PICU outcomes data for individual cancer types are lacking and may help identify patients at risk for poor clinical outcomes. METHODS We performed a retrospective multicenter analysis of 10,365 PICU admissions of cancer patients no greater than 21 years old among 112 PICUs between 1 January 2009 and 30 June 2012. We evaluated the effect of cancer type, age, gender, genetic syndrome, stem cell transplantation, PRISM3 score, infections, and critical care interventions on PICU mortality. RESULTS After excluding scheduled perioperative admissions, cancer patients represented 4.2 % of all PICU admissions (10,365/246,346), had overall mortality of 6.8 % (708/10,365) vs. 2.4 % (5,485/230,548) in the general PICU population (RR = 2.9, 95 % CI 2.7-3.1, p < 0.001), and accounted for 11.4 % of all PICU deaths (708/6,215). Hematologic cancer patients had greater median PRISM3 score (8 vs 2, p < 0.001), rates of sepsis (27 vs 9 %, RR = 2.9, 95 % CI 2.6-3.1, p < 0.001), and mortality (9.6 vs 4.5 %, RR = 2.1, 95 % CI 1.8-2.5, p < 0.001) compared to solid cancer patients. Among hematologic cancer patients, stem cell transplantation, diagnosis of acute myeloid leukemia, PRISM3 score, and infection were all independently associated with PICU mortality. CONCLUSIONS Children with cancer account for 4.2 % of PICU admissions and 11.4 % of PICU deaths. Hematologic cancer patients have significantly higher admission illness severity, rates of infections, and PICU mortality than solid cancer patients. These data may be useful in risk stratification for closer monitoring and patient counseling.
Collapse
Affiliation(s)
- Matt S Zinter
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco-School of Medicine, 505 Parnassus Ave, M680, San Francisco, 94143-0106, CA, USA,
| | | | | | | | | |
Collapse
|
9
|
Kirby J, Dolendo M, Guimera D, Castillo C, Johnson KM, Mzayek F, Nolan VG, Relyea G, Caniza MA. Predictors of wait-time for antibiotic initiation and association of wait-time with hospital length of stay and ICU admission among children with cancer at the Southern Philippines Medical Center. Pediatr Blood Cancer 2014; 61:680-6. [PMID: 24660227 DOI: 10.1002/pbc.24836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Expedited antibiotic administration improves the survival of children with cancer and infection. A 1-hour antibiotic wait-time (AWT) post-hospital arrival is a quality-of-care bench mark in healthcare. However, multiple factors preclude achieving this goal in developing countries. Predictors of AWT and its association with hospital length of stay (LOS) and intensive care unit (ICU) admission at the Southern Philippines Medical Center (SPMC) were identified. PROCEDURES Health and socioeconomic characteristics of 55 children in 92 admissions who required antibiotics were reviewed;and SPMC care providers about institutional capacity and response to suspected infection were surveyed. RESULTS The mean total AWT was 3 days and 15 hours. For admissions of established patients, mean total AWT and mean LOS were approximately half that for new patients. Admissions from high-income households waited an average 44% less for antibiotics and were discharged 43% sooner than those from medium-income households. Admissions from residence owner families waited 31% less to receive antibiotics, and total AWT for admissions of patients with no insurance was 32% less than for those with insurance. The likelihood of ICU admission increased 20% with every 1-day increase in total AWT (95% CI: 1.021.42). Only 59% of nurses recognized fever as an emergency. CONCLUSIONS AWT is complex and multifactorial; it may be reduced by educating parents and care providers about infection and infection control and improving the availability of antibiotics and associated supplies. These interventions will most likely reduce ICU admissions and possibly LOS and increase the survival of pediatric oncology patients at SPMC.
Collapse
Affiliation(s)
- Jeannette Kirby
- School of Public Health; University of Memphis; Memphis Tennessee
| | - Mae Dolendo
- Children's Cancer and Blood Disease Unit of the Southern Philippines Medical Center; Davao City Philippines
| | - Don Guimera
- Department of Infectious Diseases; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Czarina Castillo
- Children's Cancer and Blood Disease Unit of the Southern Philippines Medical Center; Davao City Philippines
| | - Kyle M. Johnson
- Department of Infectious Diseases; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Fawaz Mzayek
- School of Public Health; University of Memphis; Memphis Tennessee
| | - Vikki G. Nolan
- School of Public Health; University of Memphis; Memphis Tennessee
| | - George Relyea
- School of Public Health; University of Memphis; Memphis Tennessee
| | - Miguela A. Caniza
- Department of Infectious Diseases; St. Jude Children's Research Hospital; Memphis Tennessee
- International Outreach Program; St. Jude Children's Research Hospital; Memphis TN
- Department of Pediatrics; College of Medicine; University of Tennessee Health Science Center; Memphis Tennessee
| |
Collapse
|
10
|
Standardized process used in the emergency department for pediatric oncology patients with fever and neutropenia improves time to the first dose of antibiotics. Pediatr Emerg Care 2014; 30:91-3. [PMID: 24457498 DOI: 10.1097/pec.0000000000000077] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aimed to evaluate the effect of a standardized process on time to the first dose of antibiotics in pediatric oncology patients presenting to the emergency department (ED) with fever and neutropenia (F-N). METHODS A standardized process and order set were created to be used on all pediatric febrile neutropenic patients who presented to the ED of a large academic children's hospital. The order set was used for patients with a known oncologic diagnosis, a fever greater than 38.3°C, and who were presumed or known to be neutropenic. A retrospective chart review was then performed for the 18 months before and the 6 months after implementation of the new process to evaluate if the time to the first dose of antibiotics was significantly reduced. RESULTS A total of 130 occurrences of F-N were analyzed. This included 100 episodes before the implementation of the new process and 30 episodes afterward. The time to antibiotics being ordered was reduced by over half, with a median time of 72 minutes preprocess and 27 minutes postprocess implementation (P = 0.04). Median time from the arrival in the ED to the administration of the first dose of antibiotics was reduced by almost an hour, taking 154 minutes before the new process compared with 95 minutes after its implementation (P = 0.0001). CONCLUSIONS The use of a standardized process that uses a standardized order set can reduce the time to the first dose of antibiotics in pediatric oncology patients with F-N.
Collapse
|
11
|
Mian A, Becton D, Saylors R, James L, Tang X, Bhutta A, Prodhan P. Biomarkers for risk stratification of febrile neutropenia among children with malignancy: a pilot study. Pediatr Blood Cancer 2012; 59:238-45. [PMID: 22535591 DOI: 10.1002/pbc.24158] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 03/09/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients receiving myelosuppressive chemotherapy remain at increased risk for developing febrile neutropenia (FN). For this heterogeneous population, a biomarker based risk stratification of FN patients may be a useful clinical tool. We hypothesized that serum biomarkers during initial presentation of an FN event could be predictive of subsequent clinical outcome. PROCEDURE Eighty-nine FN events from 36 non-consecutive subjects were analyzed. "High-risk" FN criteria included prolonged hospitalization (≥ 7 days), admission to pediatric intensive care unit (PICU) or a microbiology confirmed bacteremia. Patients with "low risk" FN had none of the above. Biomarkers measured during the first 2 days of FN hospitalization were analyzed and correlated with respective clinical outcome. RESULTS Of the 89 FN events, 44 (49%) fulfilled pre-defined high-risk criteria and 45 (51%) were low-risk. Procalcitonin level (>0.11 ng/ml) was found to be associated with the high-risk FN outcome with sensitivity of 97%. With an increase in log scale by 1, the odds of being high-risk FN increased twofold. Hs-CRP >100 mg/L had sensitivity of 88% in predicting high-risk FN. The odds of a high-risk FN event increased by approximately 1.8-fold with an increase in the log scale of hs-CRP by 1 (10-fold). In univariate analysis, IL-6, IL-8, and IL-10 were statistically significant and associated with high-risk FN. However, no statistically significant difference was found for IL-1α, sIL-2Ra, IL-3, or TNF-α. CONCLUSIONS Biomarkers with appropriate critical threshold values may be a useful clinical tool for appropriate risk stratification of children with FN.
Collapse
Affiliation(s)
- Amir Mian
- Department of Pediatric Hematology-Oncology, College of Medicine, University of Arkansas Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas 72205, USA.
| | | | | | | | | | | | | |
Collapse
|
12
|
Hospital charges and length of stay associated with septicemia among children hospitalized for leukemia treatment in the United States. World J Pediatr 2012; 8:222-8. [PMID: 22886194 DOI: 10.1007/s12519-012-0361-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 12/07/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND This study examines hospital charges and length of stay (LOS) associated with septicemia during hospitalization for leukemia treatment among children aged ≤18 years. METHODS Nationwide Inpatient Sample (year 2008) was used. All hospitalizations (regardless of their discharge status following hospitalization) among children aged ≤18 years with a primary diagnosis of leukemia were selected. Leukemia was identified using ICD-9-CM codes in the primary diagnosis field. The presence of septicemia during hospitalization was identified using ICD-9-CM codes in the secondary diagnosis field. Multivariable linear regression analyses were made to examine the effect of septicemia on hospitalization charges and LOS. RESULTS Totally 6220 hospitalizations were attributed to leukemia treatment. Among these, 787 had septicemia. The mean hospitalization charge for those with septicemia was $279,137 and for those without septicemia was $113,530. The average LOS for those with septicemia was 33.18 days while the LOS for those without septicemia was 13.79 days. Septicemia was associated with increased hospitalization charges and a prolonged duration of stay in hospital after adjustments for confounders (P<0.0001). CONCLUSIONS Septicemia is associated with adverse outcomes among children hospitalized for leukemia treatment.
Collapse
|
13
|
Demaret P, Pettersen G, Hubert P, Teira P, Emeriaud G. The critically-ill pediatric hemato-oncology patient: epidemiology, management, and strategy of transfer to the pediatric intensive care unit. Ann Intensive Care 2012; 2:14. [PMID: 22691690 PMCID: PMC3423066 DOI: 10.1186/2110-5820-2-14] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 06/12/2012] [Indexed: 12/13/2022] Open
Abstract
Cancer is a leading cause of death in children. In the past decades, there has been a marked increase in overall survival of children with cancer. However, children whose treatment includes hematopoietic stem cell transplantation still represent a subpopulation with a higher risk of mortality. These improvements in mortality are accompanied by an increase in complications, such as respiratory and cardiovascular insufficiencies as well as neurological problems that may require an admission to the pediatric intensive care unit where most supportive therapies can be provided. It has been shown that ventilatory and cardiovascular support along with renal replacement therapy can benefit pediatric hemato-oncology patients if promptly established. Even if admissions of these patients are not considered futile anymore, they still raise sensitive questions, including ethical issues. To support the discussion and potentially facilitate the decision-making process, we propose an algorithm that takes into account the reason for admission (surgical versus medical) and the hemato-oncological prognosis. The algorithm then leads to different types of admission: full-support admission, "pediatric intensive care unit trial" admission, intensive care with adapted level of support, and palliative intensive care. Throughout the process, maintaining a dialogue between the treating physicians, the paramedical staff, the child, and his parents is of paramount importance to optimize the care of these children with complex disease and evolving medical status.
Collapse
Affiliation(s)
- Pierre Demaret
- Division of pediatric critical care medicine, Department of Pediatrics, Sainte-Justine Hospital, Chemin de la Côte-Sainte-Catherine, Montreal, H2J3V6, Canada
| | - Geraldine Pettersen
- Division of pediatric critical care medicine, Department of Pediatrics, Sainte-Justine Hospital, Chemin de la Côte-Sainte-Catherine, Montreal, H2J3V6, Canada
| | - Philippe Hubert
- Division of pediatric critical care medicine, Hôpital Necker-Enfants Malades, Rue de Sèvres, 75007, Paris, France
| | - Pierre Teira
- Division of pediatric hemato-oncology, Department of Pediatrics, Sainte-Justine Hospital, Chemin de la Côte-Sainte-Catherine, Montreal, H2J3V6, Canada
| | - Guillaume Emeriaud
- Division of pediatric critical care medicine, Department of Pediatrics, Sainte-Justine Hospital, Chemin de la Côte-Sainte-Catherine, Montreal, H2J3V6, Canada
| |
Collapse
|
14
|
Etiological Agents in Bacteremia of Children with Hemato-oncologic Diseases (2006-2010): A Single Center Study. ACTA ACUST UNITED AC 2012. [DOI: 10.14776/kjpid.2012.19.3.131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
15
|
Infections in the Immunocompromised Host. TEXTBOOK OF CLINICAL PEDIATRICS 2012. [PMCID: PMC7123909 DOI: 10.1007/978-3-642-02202-9_68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
16
|
Asturias EJ, Corral JE, Quezada J. Evaluation of six risk factors for the development of bacteremia in children with cancer and febrile neutropenia. ACTA ACUST UNITED AC 2011; 17:59-63. [PMID: 20404980 DOI: 10.3747/co.v17i2.453] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Febrile neutropenia is a well-known entity in children with cancer, being responsible for the high risk for infection that characterizes this population. For this reason, cancer patients are hospitalized so that they can receive prophylactic care. Risk factors have been used to classify patients at a high risk for developing bacteremia. The present study evaluates whether those risk factors (C-reactive protein, hypotension, leukemia as the cancer type, thrombocytopenia, recent chemotherapy, and acute malnutrition) apply to patients at the Unidad Nacional de Oncología Pediátrica. We evaluated 102 episodes in 88 patients, in whom risk factors and blood cultures were tested. We observed no statistical relationship between the six risk factors and bacteremia. There was also no relationship between bacteremia and the simultaneous presence of two, three, or more risk factors. A significant relationship of C-reactive protein and platelet count with other outcome factors was observed.
Collapse
Affiliation(s)
- E J Asturias
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | |
Collapse
|
17
|
Demmel KM, Williams L, Flesch L. Implementation of the Pediatric Early Warning Scoring System on a Pediatric Hematology/Oncology Unit. J Pediatr Oncol Nurs 2010; 27:229-40. [DOI: 10.1177/1043454209358410] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Despite improved outcomes for pediatric Hematology/Oncology patients over the past 15-20 years, sepsis and other acute events continue to cause serious illness in these children. Implementing a pediatric early warning scoring tool (PEWS) with an associated multi-disciplinary action algorithm in a pediatric Hematology/Oncology unit helped to remove barriers that prevented timely referral of children who are clinically deteriorating and requiring immediate help, enhanced multi-disciplinary team communication, and has led to a more than 3-fold increase in days between codes on the Hematology/Oncology unit.
Collapse
Affiliation(s)
| | | | - Laura Flesch
- Cincinnati Children's Hospital, Cincinnati, OH, USA
| |
Collapse
|
18
|
da Silva ED, Koch Nogueira PC, Russo Zamataro TM, de Carvalho WB, Petrilli AS. Risk factors for death in children and adolescents with cancer and sepsis/septic shock. J Pediatr Hematol Oncol 2008; 30:513-8. [PMID: 18797197 DOI: 10.1097/mph.0b013e31815acae0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess risk factors for mortality in children and adolescents with cancer and sepsis/septic shock, admitted to intensive care unit. PATIENTS AND METHODS Retrospective study of a cohort of cancer and sepsis/septic shock patients (n=155) admitted to Oncological Pediatric Intensive Care Unit, between October 1998 and October 2001, with assessment of 12 potential risk factors for mortality by univariate analysis, followed by multivariable analysis. RESULTS Forty-seven out of 155 patients died (30.3%). In the present sample, after multivariable analysis, 3/12 variables proved to be statistically significant: respiratory infection [hazard ratio (HR)=2.3 and 95% confidence interval (CI)=1.3-4.2], duration of granulocytopenia (HR=2.4 and 95% CI=1.2-4.9), and number of organ dysfunction (HR=7.4 and 95% CI=2.6-21.3). CONCLUSIONS Our data suggest that mortality in Oncological Pediatric Intensive Care Unit is high and the main factors involved in prognosis are number of dysfunctional organs, respiratory infections, and duration of granulocytopenia; the mortality rises 7.4 times for each dysfunctional organ. We believe that prospective and multicenter studies are necessary to better characterize risk factors that are specific for cancer patients to produce a particular score to predict severity of complications and mortality of children with cancer.
Collapse
Affiliation(s)
- Elenice Domingos da Silva
- Oncologic Pediatric Intensive Care Unit, Instituto de Oncologia Pediátrica, Grupo de Apoio ao Adolescente e à Criança com Câncer, Universidade Federal de São Paulo, Sao Paulo, Brazil.
| | | | | | | | | |
Collapse
|
19
|
Predictors of severe sepsis not clinically apparent during the first twenty-four hours of hospitalization in children with cancer, neutropenia, and fever: a prospective, multicenter trial. Pediatr Infect Dis J 2008; 27:538-43. [PMID: 18458649 DOI: 10.1097/inf.0b013e3181673c3c] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Severe sepsis is not clinically apparent during the first 24 hours of hospitalization in most children with cancer and febrile neutropenia (FN), delaying targeted interventions that could impact mortality. The aim of this study was to prospectively evaluate biomarkers obtained within 24 hours of hospitalization as predictors of severe sepsis before it becomes clinically evident. METHODS Children with cancer, admitted with FN at high risk for an invasive bacterial infection in 6 public hospitals in Santiago, Chile, were monitored throughout their clinical course for occurrence of severe sepsis. Clinical, demographic and 6 biomarkers [eg, blood urea nitrogen, serum glucose, lactic dehydrogenase, serum C-reactive protein (CRP), interleukin (IL)-8, and procalcitonin] were obtained at the time of admission and after 24 hours. Biomarkers independently associated with severe sepsis diagnosed after the first 24 hours of hospitalization were identified by logistic regression analysis. RESULTS A total of 601 high risk FN episodes were enrolled between June 2004 and October 2006; 151 (25%) developed severe sepsis of which 116 (77%) were not clinically apparent during the first 24 hours of hospitalization. Risk factors for severe sepsis were age > or =12 years [odds ratio (OR): 3.85; 95% confidence interval (CI): 2.41-6.15], admission CRP > or =90 mg/L (OR: 2.03; 95% CI: 1.32-3.14), admission IL-8 > or =200 pg/mL (OR: 2.39; 95% CI: 1.51-3.78), 24-hour CRP > or =100 mg/L (OR: 3.06; 95% CI: 1.94-4.85), and 24-hour IL-8 > or =300 pg/mL (OR: 3.13; 95% CI 1.92-5.08). CONCLUSIONS Age > or =12 years and admission or 24-hour values of CRP > or =90/100 mg/L and IL-8 > or =200/300 pg/mL are predictors of sepsis not clinically apparent during the first 24 hours of hospitalization.
Collapse
|
20
|
Kim SH, Lee YA, Eun BW, Kim NH, Lee JA, Kang HJ, Choi EH, Shin HY, Lee HJ, Ahn HS. Etiological agents isolated from blood in children with hemato-oncologic diseases (2002-2005). KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.1.56] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- So-Hee Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Ah Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Byung-Wook Eun
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Hee Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-A Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoung Jin Kang
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Eun-Hwa Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Young Shin
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hoan-Jong Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo Seop Ahn
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|