Epidemiology and Predictors of Hospital Outcomes of Critically Ill Pediatric Oncology Patients: A Retrospective Study

A Need for a Novel Survival Risk Scoring System for Intensive Care Admissions Due to Sepsis in Pediatric Hematology/Oncology Patients

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.

Non-thyroidal illness syndrome and its relationship with mortality risk in critically ill children

Introduction

Non-thyroidal illness syndrome (NTIS) is considered to be associated with adverse outcomes in critically ill children.The hypothesis that thyroid hormones and inflammatory markers are associated with increased prediction of mortality risk scores is tested in this paper.

Methods

A prospective observational study was set up in a pediatric intensive care unit (PICU). One hundred and three patients were included. NTIS was defined as a low free triiodothyronine (FT3) value for the patient's age. Thyroid hormones levels and inflammatory markers were determined at admission: FT3, FT4 (free thyroxine), TSH (thyroid-stimulating hormone), rT3 (reverse triiodothyronine), CRP (C-reactive protein) and PCT (Procalcitonin). They were compared between children with a pediatric risk of mortality score PRISM-III >75th percentile (group A, n= 25) and the rest (group B, n = 78).

Results

A FT4 value lower than 16.6 pmol/L showed an area under the curve (AUC) of 0.655 (0.56-0.78, p = 0.02), with 76% sensitivity and 61.5% specificity to detect a high risk of mortality. A multiple regression analysis revealed that a FT4 lower than 16.6 pmol/L [OR: 4.92 (1.60-18.19), p = 0.009] and having NTIS [OR: 6.04 (1.45-27.93), p = 0.016] could predict a high risk of mortality.

Conclusions

In unselected critically ill children, FT4 and FT3 values at admission could be used as a good predictor of a high mortality risk. We have not achieved a predictive model that combines hormones with inflammatory markers.

Factores clínicos asociados a extubación fallida y a estridor laríngeo post-extubación en pacientes adultos con ventilación mecánica invasiva

Introducción. La intubación orotraqueal es un procedimiento que conlleva riesgos como la extubación fallida y el estridor laríngeo, los cuales aumentan el riesgo de morbilidad. Objetivo. Identificar los factores asociados a extubación fallida temprana (≤24 horas) y al desarrollo de estridor laríngeo post-extubación en pacientes adultos con ventilación mecánica invasiva (VMI). Materiales y métodos. Estudio de casos y controles con recolección prospectiva de información realizado en la unidad de cuidados intensivos (UCI) de un hospital de IV nivel de Bogotá, Colombia, entre abril de 2019 y febrero de 2020. Se incluyeron 180 pacientes con VMI ≥24 horas y al menos ≥1 intento de extubación: 30 casos, definidos como pacientes con extubación fallida temprana (≤24 horas a la extubación) y 150 controles. Las diferencias en las variables consideradas entre casos y controles se determinaron mediante las pruebas t de Student y Chi 2 o exacta de Fisher. Además, se realizó un análisis multivariado (modelo de regresión logística no condicional) para determinar los factores asociados con extubación fallida y estridor laríngeo post-extubación, calculando los Odds ratio (OR) con sus respectivos intervalos de confianza al 95% (IC95%). Se consideró un nivel de significancia de p<0.05. Resultados. La extubación fallida temprana y el estridor laríngeo tuvieron una prevalencia de 16.66% (n=30) y 3.89% (n=7), respectivamente. En el análisis multivariado, el antecedente de intubación (OR=4.27, IC95%=1.44-12.66), la presencia de cáncer activo (OR= 2.92, IC95%=1.08-7.90) y ser diagnosticado con neumonía (OR=2.84, IC95%=1.15-6.99) se asociaron significativamente con extubación fallida, mientras que la duración de la VMI (OR=1.53, IC95%=1.18-1.99) y el antecedente de intubación (OR=37.9, IC95%=2.22-650.8), con estridor laríngeo post-extubación. Conclusiones. Con base en los resultados aquí obtenidos, se sugiere considerar factores como antecedente de intubación previa, comorbilidad con cáncer y diagnóstico de neumonía en la estratificación de estos pacientes críticos para aumentar la probabilidad de una extubación exitosa.

Critically Ill Pediatric Oncology Patients: A Difficult-to-treat Population

How to cite this article: Poddar B. Critically Ill Pediatric Oncology Patients: A Difficult-to-treat Population. Indian J Crit Care Med 2021;25(10):1091–1092.