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Epidemiology of Bleeding in Critically Ill Children With an Underlying Oncologic Diagnosis
Juliana Romano1, Mario Martinez1, Julie Levasseur1
1Department of Pediatrics, New York-Presbyterian/Weill Cornell Medicine, New York, NY.
Insights
Severe bleeding affects nearly 10% of critically ill children with cancer, often without low platelets or coagulopathy. Most received blood products, but few got medications, highlighting a need for better treatment guidelines for pediatric oncology patients.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Oncology
- Hematology
Background:
- Critically ill children with cancer face a high risk of bleeding.
- The precise epidemiology of severe bleeding in this population is not well-defined.
Purpose of the Study:
- To describe the occurrence of severe bleeding events in critically ill pediatric cancer patients.
- To identify risk factors associated with severe bleeding in this cohort.
- To utilize the Bleeding Assessment Scale in Critically Ill Children (BASIC) definition.
Main Methods:
- Retrospective cohort study design.
- Inclusion of pediatric patients (28 days to 18 years) admitted to a pediatric intensive care unit (PICU) at a comprehensive cancer center in 2018.
- Analysis of demographic data, oncologic diagnosis, and bleeding events.
Main Results:
- Nine percent (23/267) of admissions experienced at least one severe bleeding event.
- Severe bleeding frequency varied significantly by underlying oncologic diagnosis (p = 0.009).
- Patients with severe bleeding had fewer PICU-free days, fewer ventilator-free days, and higher 28-day mortality.
Conclusions:
- Severe bleeding occurs in a significant minority of critically ill pediatric cancer patients, even without severe thrombocytopenia or coagulopathy.
- Blood component therapy was common, but hemostatic medications were infrequently used.
- Further research is essential to establish optimal management strategies for severe bleeding in this vulnerable group.
Objectives:
Critically ill children with malignancy have significant risk of bleeding but the exact epidemiology is unknown. We sought to describe severe bleeding events and associated risk factors in critically ill pediatric patients with an underlying oncologic diagnosis using the newly developed Bleeding Assessment Scale in Critically Ill Children definition.
Design:
Retrospective cohort study.
Setting:
PICU in comprehensive cancer center.
Patients:
Children ages 28 days to 18 years with an underlying oncologic diagnosis admitted to the PICU during 2018.
Interventions:
None.
Measurements And Main Results:
Two-hundred sixty-seven admissions met inclusion criteria. Sixty-four percent (171/267) were male, with a median (interquartile range) age of 6.3 years (3.1-12.1 yr). Nine percent (23/267) had at least one severe bleeding event during their PICU admission. There were no significant differences between those with severe bleeding and those without, with respect to gender (p = 0.07), age (p = 0.66), weight (p = 0.76), or transplant status (p = 0.18). There was a difference in the frequency of severe bleeding based on underlying oncologic diagnosis (p = 0.009). For patients with severe bleeding, the median (interquartile range) platelet count and international normalized ratio on the day of bleeding were 102 × 109/L (40-181 × 109/L) and 1.36 (1.26-1.51), respectively. Eighty-seven percent patients (20/23) with severe bleeding received at least one blood component in response to bleeding. Two patients received antifibrinolytics. Patients with severe bleeding had significantly fewer PICU-free days (p = 0.001), fewer ventilator-free days (p < 0.001), and higher 28-day mortality (p = 0.003).
Conclusions:
Severe bleeding occurred in nearly one-tenth of critically ill children with an underlying oncologic diagnosis without severe thrombocytopenia or coagulopathy. The vast majority received blood component therapy, but few received hemostatic medication. Studies are needed to guide the treatment of severe bleeding in this vulnerable patient population.
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