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Schober S, Huber S, Braun N, Döring M, Lang P, Hofbeck M, Neunhoeffer F, Renk H. Prognostic factors and predictive scores for 6-months mortality of hematopoietic stem cell transplantation recipients admitted to the pediatric intensive care unit. Front Oncol 2023; 13:1161573. [PMID: 37810960 PMCID: PMC10552149 DOI: 10.3389/fonc.2023.1161573] [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: 02/08/2023] [Accepted: 08/28/2023] [Indexed: 10/10/2023] Open
Abstract
Objective Despite advances in hematopoietic stem cell transplantation (HSCT), a considerable number of pediatric HSCT patients develops post-transplant complications requiring admission to the pediatric intensive care unit (PICU). The objective of this study was to evaluate clinical findings, PICU supportive therapy and outcome as well as predictive factors for 6-months survival after discharge of HSCT patients from PICU. Study design This retrospective single-center analysis investigated patient characteristics, microbiological findings, reasons for admission and death of 54 cases accounting for 94 admissions to the PICU of the University Children's Hospital Tuebingen from 2002 to 2017. We compared clinical characteristics between children with and without 6-months survival after discharge from PICU following HSCT. Finally, we assessed the potential prognostic value of the oncological Pediatric Risk of Mortality Score (O-PRISM), the Pediatric Sequential Organ Failure Assessment Score (pSOFA) and the pRIFLE Criteria for Acute Kidney Injury for 6-months survival using Generalized Estimating Equations (GEE) and Receiver Operating Characteristic curves. Results Respiratory insufficiency, gastroenterological problems and sepsis were the most common reasons for PICU admission. Out of 54 patients, 38 (70%) died during or after their last PICU admission, 30% survived for at least six months. When considering only first PICU admissions, we could not determine prognostic factors for 6-months mortality. In contrast, under consideration of all PICU admissions in the GEE model, ventilation (p=0.03) and dialysis (p=0.007) were prognostic factors for 6-months mortality. Furthermore, pSOFA (p=0.04) and O-PRISM (p=0.02) were independent risk factors for 6-months mortality considering all PICU admissions. Conclusion Admission of HSCT patients to PICU is still associated with poor outcome and 69% of patients died within 6 months. Need for respiratory support and dialysis are associated with poor outcome. Prediction of 6-months survival is difficult, especially during a first PICU admission. However, on subsequent PICU admissions pSOFA and O-PRISM scores might be useful to predict mortality. These scores should be prospectively evaluated in further studies to verify whether they can identify pediatric HSCT recipients profiting most from transferal to the PICU.
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Affiliation(s)
- Sarah Schober
- University Children’s Hospital Tuebingen, Department I – General Pediatrics, Hematology/Oncology, Tuebingen, Germany
| | - Silke Huber
- University Children’s Hospital Tuebingen, Department II – Pediatric Cardiology, Pulmonology and Intensive Care Medicine, Tuebingen, Germany
| | - Norbert Braun
- University Children’s Hospital Tuebingen, Department II – Pediatric Cardiology, Pulmonology and Intensive Care Medicine, Tuebingen, Germany
| | - Michaela Döring
- University Children’s Hospital Tuebingen, Department I – General Pediatrics, Hematology/Oncology, Tuebingen, Germany
| | - Peter Lang
- University Children’s Hospital Tuebingen, Department I – General Pediatrics, Hematology/Oncology, Tuebingen, Germany
| | - Michael Hofbeck
- University Children’s Hospital Tuebingen, Department II – Pediatric Cardiology, Pulmonology and Intensive Care Medicine, Tuebingen, Germany
| | - Felix Neunhoeffer
- University Children’s Hospital Tuebingen, Department II – Pediatric Cardiology, Pulmonology and Intensive Care Medicine, Tuebingen, Germany
| | - Hanna Renk
- University Children’s Hospital Tuebingen, Department I – General Pediatrics, Hematology/Oncology, Tuebingen, Germany
- University Children’s Hospital Tuebingen, Department II – Pediatric Cardiology, Pulmonology and Intensive Care Medicine, Tuebingen, Germany
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Öztürk M, Botan E, Gün E, Baskin AK, İslamoğlu C, Erkol GH, Havan M, Çakmak FH, Haskoloğlu Ş, İleri T, İnce E, Doğu F, Ertem M, İkinciogullari A, Kendirli T. The Determining Factors for Outcome of Pediatric Intensive Care Admitted Children After Stem Cell Transplantation. J Pediatr Hematol Oncol 2023; 45:e768-e772. [PMID: 36706283 DOI: 10.1097/mph.0000000000002610] [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] [Received: 05/24/2022] [Accepted: 11/07/2022] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Requiring pediatric intensive care unit (PICU) admission relates to high mortality and morbidity in patients who received hematopoietic stem cell transplantation (HSCT). In this study, we aimed to evaluate the indications for PICU admission, treatments, and the determining risk factors for morbidity and mortality in patients who had allogeneic HSCT from various donors. MATERIALS AND METHODS In this retrospective study, we enrolled to patients who required the PICU after receiving allogeneic HSCT at our Pediatric Bone Marrow Transplantation Unit between 2005 and 2020. We evaluated to indication to PICU admission, applications, mortality rate, and the determining factors to outcomes. RESULTS Thirty-three (7%) patients had 47 PICU admissions and 471 patients underwent bone marrow transplantation during 16-year study period. Also, 14 repeated episodes were registered in 9 different patients. The median age of PICU admitted patients was 4 (0.3 to 18) years and 29 (62%) were male. The main reasons for PICU admission were a respiratory failure, sepsis, and neurological event in 20, 8, and 7 patients, respectively. The average length of PICU stay was 14.5 (1 to 80) days, 14 (43%) of patients survived and the mortality rate was 57%. Multiple organ failure ( P =0.001), need for respiratory support ( P =0.007), inotrope agents ( P =0.001), and renal replacement therapy ( P =0.013) were found as significant risk factors for mortality. CONCLUSIONS Allogeneic HSCT recipients need PICU admission because of its related different life-threatening complications. But there is a good chance of survival with quality PICU care and different advanced organ support methods.
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Affiliation(s)
| | - Edin Botan
- Division of Pediatric Critical Care Medicine
| | - Emrah Gün
- Division of Pediatric Critical Care Medicine
| | | | | | - Gül Hatice Erkol
- Department of Pediatric Hematology and Oncology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Merve Havan
- Division of Pediatric Critical Care Medicine
| | - Fatih Hasan Çakmak
- Department of Pediatric Hematology and Oncology, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Talia İleri
- Department of Pediatric Hematology and Oncology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Elif İnce
- Department of Pediatric Hematology and Oncology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Figen Doğu
- Department of Pediatric Allergy and Immunology
| | - Mehmet Ertem
- Department of Pediatric Hematology and Oncology, Ankara University Faculty of Medicine, Ankara, Turkey
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Pathobiology, Severity, and Risk Stratification of Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S12-S27. [PMID: 36661433 DOI: 10.1097/pcc.0000000000003156] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To review the literature for studies published in children on the pathobiology, severity, and risk stratification of pediatric acute respiratory distress syndrome (PARDS) with the intent of guiding current medical practice and identifying important areas for future research related to severity and risk stratification. DATA SOURCES Electronic searches of PubMed and Embase were conducted from 2013 to March 2022 by using a combination of medical subject heading terms and text words to capture the pathobiology, severity, and comorbidities of PARDS. STUDY SELECTION We included studies of critically ill patients with PARDS that related to the severity and risk stratification of PARDS using characteristics other than the oxygenation defect. Studies using animal models, adult only, and studies with 10 or fewer children were excluded from our review. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize relevant evidence and develop recommendations for clinical practice. There were 192 studies identified for full-text extraction to address the relevant Patient/Intervention/Comparator/Outcome questions. One clinical recommendation was generated related to the use of dead space fraction for risk stratification. In addition, six research statements were generated about the impact of age on acute respiratory distress syndrome pathobiology and outcomes, addressing PARDS heterogeneity using biomarkers to identify subphenotypes and endotypes, and use of standardized ventilator, physiologic, and nonpulmonary organ failure measurements for future research. CONCLUSIONS Based on an extensive literature review, we propose clinical management and research recommendations related to characterization and risk stratification of PARDS severity.
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Miśkiewicz-Bujna J, Miśkiewicz-Migoń I, Szmit Z, Przystupski D, Rosa M, Król A, Kałwak K, Ussowicz M, Gorczyńska E. Short- and long-term outcome of allogeneic stem cell transplantation in infants: A single-center experience over 20 years. Front Pediatr 2022; 10:956108. [PMID: 36071886 PMCID: PMC9441786 DOI: 10.3389/fped.2022.956108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a treatment method for a wide range of malignant and non-malignant diseases. Infants constitute a distinct patient group, especially due to their organ immaturity and differences in drug metabolism. The present paper aims to analyse the short- and long-term outcomes after allo-HSCT in infants. MATERIAL AND METHODS In the study period, 67 patients under 12 months of age underwent allo-HSCT. This study is a retrospective analysis of patient medical records, in the form of paper and electronic documentation. RESULTS The probability of 5-year OS was 69% and 72% in patients with malignant and non-malignant diseases, respectively. The allo-HSCT from a matched donor was associated with improved OS in comparison to haploidentical donor (0.8 vs. 0.58%, p = 0.0425). The overall incidence of acute graft-vs.-host disease (aGVHD) was 59.3%, and grade III-IV aGVHD was diagnosed in 23% of patients. The 100-day non-relapse mortality (NRM) in the study cohort was 17.9%, while the 5-year NRM was 26.9%. Among the causes of NRM, infections occurred in 83.3% of patients, and aGVHD in 16.3% of individuals. Twenty-two children (32.8%) required hospitalization in the pediatric intensive care unit (PICU). The median length of PICU hospitalization was 6 days (range 1 to 12 days). Late sequelae diagnosed during post-transplant surveillance included ocular disorders in 26.8% of patients, cardiac complications in 4.4%, as well as endocrinopathy with short stature (<3rd percentile) in 37.2% and overt hypothyroidism in 35.4%. In the long-term perspective, 83.3% of survivors were able to attend a regular school. CONCLUSIONS Improvements in unrelated donor availability, and better supportive care resulted in better outcomes. Management of infant allo-HSCT recipients requires the formation of multi-disciplinary specialist teams. In addition, the role of parental empowerment must be acknowledged; for example, in speech therapy and rehabilitation.
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Affiliation(s)
- Justyna Miśkiewicz-Bujna
- Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Izabella Miśkiewicz-Migoń
- Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Zofia Szmit
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Dawid Przystupski
- Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Monika Rosa
- Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Anna Król
- Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Kałwak
- Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Marek Ussowicz
- Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Ewa Gorczyńska
- Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland
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Specialized Pediatric Palliative Care Services in Pediatric Hematopoietic Stem Cell Transplant Centers. CHILDREN-BASEL 2021; 8:children8080615. [PMID: 34438506 PMCID: PMC8393700 DOI: 10.3390/children8080615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/15/2021] [Accepted: 07/18/2021] [Indexed: 01/04/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is widely used in pediatric patients as a successful curative therapy for life-threatening conditions. The treatment is intensive, with risks of serious complications and lethal outcomes. This study aimed to provide insight into current data on the place and cause of death of transplanted children, the available specialized pediatric palliative care services (SPPCS), and what services HSCT professionals feel the SPPCS team should provide. First, a retrospective database analysis on the place and cause of death of transplanted pediatric HSCT patients was performed. Second, a survey was performed addressing the availability of and views on SPPCS among HSCT professionals. Database analysis included 233 patients of whom the majority died in-hospital: 38% in the pediatric intensive care unit, 20% in HSCT units, 17% in other hospitals, and 14% at home or in a hospice (11% unknown). For the survey, 98 HSCT professionals from 54 centers participated. Nearly all professionals indicated that HSCT patients should have access to SPPCS, especially for pain management, but less than half routinely referred to this service at an early stage. We, therefore, advise HSCT teams to integrate advance care planning for pediatric HSCT patients actively, ideally from diagnosis, to ensure timely SPPCS involvement and maximize end-of-life preparation.
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