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Lenz KB, Nishisaki A, Lindell RB, Yehya N, Laverriere EK, Bruins BB, Napolitano N, Traynor DM, Rowan CM, Fitzgerald JC. Peri-Intubation Adverse Events in the Critically Ill Child After Hematopoietic Cell Transplant. Pediatr Crit Care Med 2023; 24:584-593. [PMID: 37098779 PMCID: PMC10330041 DOI: 10.1097/pcc.0000000000003243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
OBJECTIVES Mechanically ventilated children post-hematopoietic cell transplant (HCT) have increased morbidity and mortality compared with other mechanically ventilated critically ill children. Tracheal intubation-associated adverse events (TIAEs) and peri-intubation hypoxemia universally portend worse outcomes. We investigated whether adverse peri-intubation associated events occur at increased frequency in patients with HCT compared with non-HCT oncologic or other PICU patients and therefore might contribute to increased mortality. DESIGN Retrospective cohort between 2014 and 2019. SETTING Single-center academic noncardiac PICU. PATIENTS Critically ill children who underwent tracheal intubation (TI). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data from the local airway management quality improvement databases and Virtual Pediatric Systems were merged. These data were supplemented with a retrospective chart review for HCT-related data, including HCT indication, transplant-related comorbidity status, and patient condition at the time of TI procedure. The primary outcome was defined as the composite of hemodynamic TIAE (hypo/hypertension, arrhythmia, cardiac arrest) and/or peri-intubation hypoxemia (oxygen saturation < 80%) events. One thousand nine hundred thirty-one encounters underwent TI, of which 92 (4.8%) were post-HCT, while 319 (16.5%) had history of malignancy without HCT, and 1,520 (78.7%) had neither HCT nor malignancy. Children post-HCT were older more often had respiratory failure as an indication for intubation, use of catecholamine infusions peri-intubation, and use of noninvasive ventilation prior to intubation. Hemodynamic TIAE or peri-intubation hypoxemia were not different across three groups (HCT 16%, non-HCT with malignancy 10%, other 15). After adjusting for age, difficult airway feature, provider type, device, apneic oxygenation use, and indication for intubation, we did not identify an association between HCT status and the adverse TI outcome (odds ratio, 1.32 for HCT status vs other; 95% CI, 0.72-2.41; p = 0.37). CONCLUSIONS In this single-center study, we did not identify an association between HCT status and hemodynamic TIAE or peri-intubation hypoxemia during TI.
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Affiliation(s)
- Kyle B. Lenz
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Akira Nishisaki
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert B. Lindell
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nadir Yehya
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Elizabeth K. Laverriere
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of General Anesthesiology, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Benjamin B. Bruins
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of General Anesthesiology, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Natalie Napolitano
- Respiratory Therapy Department, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Danielle M. Traynor
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Courtney M. Rowan
- Division of Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Julie C. Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Lindell RB, Fitzgerald JC, Rowan CM, Flori HR, Di Nardo M, Napolitano N, Traynor DM, Lenz KB, Emeriaud G, Jeyapalan A, Nishisaki A. The Use and Duration of Preintubation Respiratory Support Is Associated With Increased Mortality in Immunocompromised Children With Acute Respiratory Failure. Crit Care Med 2022; 50:1127-1137. [PMID: 35275593 PMCID: PMC9707852 DOI: 10.1097/ccm.0000000000005535] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the association between preintubation respiratory support and outcomes in patients with acute respiratory failure and to determine the impact of immunocompromised (IC) diagnoses on outcomes after adjustment for illness severity. DESIGN Retrospective multicenter cohort study. SETTING Eighty-two centers in the Virtual Pediatric Systems database. PATIENTS Children 1 month to 17 years old intubated in the PICU who received invasive mechanical ventilation (IMV) for greater than or equal to 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS High-flow nasal cannula (HFNC) or noninvasive positive-pressure ventilation (NIPPV) or both were used prior to intubation in 1,825 (34%) of 5,348 PICU intubations across 82 centers. When stratified by IC status, 50% of patients had no IC diagnosis, whereas 41% were IC without prior hematopoietic cell transplant (HCT) and 9% had prior HCT. Compared with patients intubated without prior support, preintubation exposure to HFNC (adjusted odds ratio [aOR], 1.33; 95% CI, 1.10-1.62) or NIPPV (aOR, 1.44; 95% CI, 1.20-1.74) was associated with increased odds of PICU mortality. Within subgroups of IC status, preintubation respiratory support was associated with increased odds of PICU mortality in IC patients (HFNC: aOR, 1.50; 95% CI, 1.11-2.03; NIPPV: aOR, 1.76; 95% CI, 1.31-2.35) and HCT patients (HFNC: aOR, 1.75; 95% CI, 1.07-2.86; NIPPV: aOR, 1.85; 95% CI, 1.12-3.02) compared with IC/HCT patients intubated without prior respiratory support. Preintubation exposure to HFNC/NIPPV was not associated with mortality in patients without an IC diagnosis. Duration of HFNC/NIPPV greater than 6 hours was associated with increased mortality in IC HCT patients (HFNC: aOR, 2.41; 95% CI, 1.05-5.55; NIPPV: aOR, 2.53; 95% CI, 1.04-6.15) and patients compared HCT patients with less than 6-hour HFNC/NIPPV exposure. After adjustment for patient and center characteristics, both preintubation HFNC/NIPPV use (median, 15%; range, 0-63%) and PICU mortality varied by center. CONCLUSIONS In IC pediatric patients, preintubation exposure to HFNC and/or NIPPV is associated with increased odds of PICU mortality, independent of illness severity. Longer duration of exposure to HFNC/NIPPV prior to IMV is associated with increased mortality in HCT patients.
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Affiliation(s)
- Robert B Lindell
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN. Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI. Pediatric Intensive Care Unit, Bambino Gesù, Children's Hospital, IRCCS, Rome, Italy. Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA. Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, QC. Division of Pediatric Critical Care Medicine, University of Miami Miller School of Medicine, Miami, FL
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Geng H, Hurtz C, Lenz KB, Chen Z, Baumjohann D, Thompson S, Goloviznina NA, Chen WY, Huan J, LaTocha D, Ballabio E, Xiao G, Lee JW, Deucher A, Qi Z, Park E, Huang C, Nahar R, Kweon SM, Shojaee S, Chan LN, Yu J, Kornblau SM, Bijl JJ, Ye BH, Ansel KM, Paietta E, Melnick A, Hunger SP, Kurre P, Tyner JW, Loh ML, Roeder RG, Druker BJ, Burger JA, Milne TA, Chang BH, Müschen M. Self-enforcing feedback activation between BCL6 and pre-B cell receptor signaling defines a distinct subtype of acute lymphoblastic leukemia. Cancer Cell 2015; 27:409-25. [PMID: 25759025 PMCID: PMC4618684 DOI: 10.1016/j.ccell.2015.02.003] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 12/22/2014] [Accepted: 02/10/2015] [Indexed: 10/23/2022]
Abstract
Studying 830 pre-B ALL cases from four clinical trials, we found that human ALL can be divided into two fundamentally distinct subtypes based on pre-BCR function. While absent in the majority of ALL cases, tonic pre-BCR signaling was found in 112 cases (13.5%). In these cases, tonic pre-BCR signaling induced activation of BCL6, which in turn increased pre-BCR signaling output at the transcriptional level. Interestingly, inhibition of pre-BCR-related tyrosine kinases reduced constitutive BCL6 expression and selectively killed patient-derived pre-BCR(+) ALL cells. These findings identify a genetically and phenotypically distinct subset of human ALL that critically depends on tonic pre-BCR signaling. In vivo treatment studies suggested that pre-BCR tyrosine kinase inhibitors are useful for the treatment of patients with pre-BCR(+) ALL.
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Affiliation(s)
- Huimin Geng
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Christian Hurtz
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Kyle B Lenz
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239, USA; Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Zhengshan Chen
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Dirk Baumjohann
- Microbiology and Immunology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Sarah Thompson
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239, USA; Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Natalya A Goloviznina
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239, USA; Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Wei-Yi Chen
- Laboratory of Biochemistry and Molecular Biology, Rockefeller University, New York, NY 10065, USA; Institute of Biochemistry and Molecular Biology, National Yang-Ming University, Taipei 11221, Taiwan
| | - Jianya Huan
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239, USA; Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Dorian LaTocha
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Erica Ballabio
- MRC Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, OX3 9DS, UK
| | - Gang Xiao
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Jae-Woong Lee
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Anne Deucher
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Zhongxia Qi
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Eugene Park
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Chuanxin Huang
- Departments of Medicine and Pharmacology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Rahul Nahar
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Soo-Mi Kweon
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Seyedmehdi Shojaee
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Lai N Chan
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Jingwei Yu
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Steven M Kornblau
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
| | - Janetta J Bijl
- Hôpital Maisonneuve-Rosemont, Montreal, QC H1T 2M4, Canada
| | - B Hilda Ye
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - K Mark Ansel
- Microbiology and Immunology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Elisabeth Paietta
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Ari Melnick
- Departments of Medicine and Pharmacology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Stephen P Hunger
- Division of Pediatric Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Peter Kurre
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239, USA; Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Jeffrey W Tyner
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA; Department of Cell & Developmental Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Mignon L Loh
- Pediatric Hematology-Oncology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Robert G Roeder
- Laboratory of Biochemistry and Molecular Biology, Rockefeller University, New York, NY 10065, USA
| | - Brian J Druker
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA; Howard Hughes Medical Institute, Portland, OR 97239, USA
| | - Jan A Burger
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
| | - Thomas A Milne
- MRC Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, OX3 9DS, UK
| | - Bill H Chang
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239, USA; Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Markus Müschen
- Departments of Laboratory Medicine, University of California, San Francisco, San Francisco, CA 94143, USA.
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