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New Insights Into Multicenter PICU Mortality Among Pediatric Hematopoietic Stem Cell Transplant Patients
Matt S Zinter1, Christopher C Dvorak, Aaron Spicer
11Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco-School of Medicine, San Francisco, CA. 2UCSF Benioff Children's Hospital, San Francisco, CA. 3Division of Allergy, Immunology, and Blood and Marrow Transplantation, Department of Pediatrics, University of California, San Francisco-School of Medicine, San Francisco, CA.
Insights
Pediatric hematopoietic stem cell transplantation (HSCT) patients admitted to the pediatric intensive care unit (PICU) have a 16.2% mortality rate. Mortality is higher for patients requiring mechanical ventilation or renal replacement therapy, particularly those with hematologic malignancy.
Area of Science:
- Pediatric critical care medicine
- Hematopoietic stem cell transplantation (HSCT)
- Pediatric intensive care unit (PICU) outcomes
Background:
- Hematopoietic stem cell transplantation (HSCT) is a critical treatment for pediatric patients, with a significant portion requiring intensive care due to life-threatening complications.
- While overall PICU mortality has decreased, there's a need to understand outcomes and infectious burdens specific to pediatric HSCT patients, considering heterogeneity in transplant indications.
Purpose of the Study:
- To describe infection rates, critical care interventions, and mortality among pediatric patients undergoing hematopoietic stem cell transplantation (HSCT) and requiring admission to the pediatric intensive care unit (PICU).
- To evaluate the impact of different transplant indications on mortality risk in the PICU setting.
Main Methods:
- Retrospective multicenter cohort analysis utilizing data from the Virtual PICU Systems database.
- Inclusion of 1,782 admissions for patients aged 21 years or younger with prior HSCT, spanning January 1, 2009, to June 30, 2012.
- Data collected included mortality, transplant indication, infections, and interventions such as invasive positive pressure ventilation and renal replacement therapy.
Main Results:
- Pediatric HSCT admissions represented 0.7% of all PICU admissions, with an overall mortality of 16.2%, significantly higher than non-HSCT admissions (2.4%).
- Mortality was highest for patients with underlying hematologic malignancy (22.7%) and primary immunodeficiency (19.4%) compared to other indications.
- Infections were present in 45.7% of admissions, with viral and fungal infections carrying mortality rates of 28.5% and 33.7%, respectively. Mechanical ventilation and renal replacement therapy were associated with high mortality (42.5% and 51.9%).
Conclusions:
- Pediatric HSCT patients admitted to the PICU have a substantial mortality risk, particularly those requiring advanced life support like mechanical ventilation or renal replacement therapy.
- Hematologic malignancy and primary immunodeficiency are associated with increased mortality risk in this population.
- Further research is needed to identify additional risk factors and optimize critical care support for pediatric HSCT patients.
Objectives:
Over 2,500 children undergo hematopoietic stem cell transplantation in the United States each year, and up to 35% require PICU support for life-threatening complications. PICU mortality has dropped from 85% to 44%, but interpretation is confounded by significant cohort heterogeneity. Reports conflict regarding outcomes for patients with different underlying hematopoietic stem cell transplantation indications, and the burden of infectious complications for these patients has not been evaluated. We aim to describe infections, critical care interventions, and mortality for pediatric hematopoietic stem cell transplantation patients requiring PICU admission.
Design:
A retrospective multicenter cohort analysis.
Setting:
One hundred twelve centers in the Virtual PICU Systems database, January 1, 2009, to June 30, 2012.
Patients:
A total of 1,782 admissions for patients who are 21 years old or younger with prior hematopoietic stem cell transplantation.
Interventions:
None.
Measurements And Main Results:
Pediatric Index of Mortality-2, Pediatric Risk of Mortality-3, transplant indication, infections, interventions, and mortality were recorded from admission through PICU death or discharge. Pediatric hematopoietic stem cell transplantation patients comprised 0.7% of all PICU admissions (1,782/246,346), which resulted in 16.2% mortality compared with 2.4% mortality for non-hematopoietic stem cell transplantation admissions (odds ratio, 7.8; 95% CI, 6.8-8.8; p < 0.001). Mortality for admissions with underlying hematologic malignancy (22.7%) was similar to that of admissions with primary immunodeficiency (19.4%; p = 0.41) but significantly greater than admissions with underlying nonmalignant non-primary immunodeficiency hematologic disease (15.4%; p = 0.020), metabolic disorder (8.1%; p < 0.001), or solid malignancy (5.7%; p < 0.001). Infection was documented in 45.7% of admissions with 22.2% mortality; viral and fungal mortality were 28.5% and 33.7%, respectively. Invasive positive pressure ventilation and renal replacement therapy were used in only 34.6% and 11.9% of admissions, with mortality of 42.5% and 51.9%, respectively.
Conclusions:
PICU mortality for pediatric hematopoietic stem cell transplantation patients may be as low as 16.2% but higher for those receiving intubation (42.5%) or replacement therapy (51.9%). Hematologic malignancy and primary immunodeficiency had greater risk for mortality than other transplant indications. Greater understanding of other risk factors affecting mortality and the need for critical care support is needed.
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