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Bleeding in Critically Ill Children With Malignancy or Hematopoietic Cell Transplant: A Single-Center Prospective
Julie Levasseur1, Lauren Fikse2, Audrey Mauguen3
1Department of Pediatrics, New York Presbyterian Hospital, New York, NY.
Insights
Critically ill children with cancer experienced a 20% daily bleeding incidence, with most cases being minimal. Low platelet counts and prior radiation therapy independently predicted severe bleeding events in pediatric oncology patients.
Area of Science:
- Pediatric Oncology
- Critical Care Medicine
- Hematology
Background:
- Bleeding complications are a significant concern in critically ill children with malignancy.
- Understanding the incidence and risk factors for bleeding is crucial for improving patient outcomes in pediatric intensive care units (PICUs).
Purpose of the Study:
- To determine the incidence of bleeding in critically ill children with malignancy.
- To describe patient characteristics, interventions, and clinical outcomes associated with bleeding events.
Main Methods:
- Prospective cohort study conducted in a specialized cancer hospital's PICU.
- Included children aged 0-18 years with malignancy or undergoing hematopoietic cell transplant.
- Bleeding classified using the Bleeding Assessment Scale in Critically Ill Children.
Main Results:
- A bleeding incidence rate of 20% per day was observed in 93 enrolled patients.
- Severe bleeding (2%) was independently associated with thrombocytopenia and prior radiation therapy.
- Severe bleeding correlated with longer mechanical ventilation, increased PICU length of stay, and higher PICU mortality.
Conclusions:
- The daily incidence of bleeding in critically ill children with cancer is substantial (20%).
- Thrombocytopenia and radiation therapy are key predictors of severe bleeding.
- Minimizing bleeding risk factors is essential for improving outcomes in this vulnerable population.
Objectives:
To determine the incidence of bleeding in critically ill children with malignancy and to describe associated patient characteristics, interventions, and clinical outcomes.
Design:
Prospective cohort study.
Setting:
PICU in a specialized cancer hospital.
Patients:
Children with malignancy or hematopoietic cell transplant 0-18 years of age were admitted to the PICU from November 2020 to November 2021.
Interventions:
None.
Measurements:
Patient demographic data, laboratory values, and PICU outcome data were collected. Bleeding was classified according to the Bleeding Assessment Scale in Critically Ill Children.
Main Results:
Ninety-three bleeding patients were enrolled, and a total of 322 bleeding days were recorded. The median (interquartile range [IQR]) age was 5.8 (2.9-11.8) years and 56% (52/93) of the patients were male. There were 121 new bleeding episodes, in 593 at-risk person-days, translating into a 20% incidence rate per day (95% CI, 17-24%). The incidence of severe, moderate, and minimal bleeding was 2% (95% CI, 1-3), 4% (95% CI, 3-6), and 14% (95% CI, 12-17), respectively. Of the new bleeding episodes, 9% were severe, 25% were moderate and 66% were minimal. Thrombocytopenia was the only laboratory value independently associated with severe bleeding ( p = 0.009), as compared to minimal and moderate bleeding episodes. History of radiation therapy was independently associated with severe bleeding ( p = 0.04). We failed to identify an association between a history of stem cell transplant ( p = 0.49) or tumor type ( p = 0.76), and bleeding severity. Patients were transfused any blood product on 28% (95% CI, 22-34) of the bleeding days. Severe bleeding was associated with increased length of mechanical ventilation ( p = 0.003), longer PICU stays ( p = 0.03), and higher PICU mortality ( p = 0.004).
Conclusions:
In this prospective cohort of children with malignancy, the incidence rate of bleeding was 20%. Most events were classified as minimal bleeding. Low platelet count and radiation therapy were variables independently associated with severe bleeding episodes.
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