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Massive Bleeding in Children With Cancer or Hematopoietic Cell Transplant: International, Multicenter Retrospective
Marianne E Nellis1, Marie E Steiner2, Saleh Bhar3
1Division of Pediatric Critical Care, Department of Pediatrics, Weill Cornell Medicine, New York, NY.
Insights
Children with cancer or hematopoietic cell transplant (HCT) experience high hemorrhage mortality. Most received balanced resuscitation, but outcomes remain poor, necessitating further research into optimal hemostatic practices.
Area of Science:
- Pediatric Hematology/Oncology
- Critical Care Medicine
- Transfusion Medicine
Background:
- Massive bleeding is a critical complication in pediatric patients with cancer and/or undergoing hematopoietic cell transplant (HCT).
- Understanding the epidemiology and management of these events is crucial for improving patient outcomes.
Purpose of the Study:
- To characterize the epidemiology of massive bleeding events in pediatric oncology and HCT patients.
- To analyze the management strategies and outcomes associated with massive bleeding in this vulnerable population.
Main Methods:
- A multicenter, retrospective cohort study was conducted across 19 pediatric hospitals in Europe and the United States.
- Data were collected for 135 children (ages 0-21) with malignancy and/or HCT experiencing massive bleeding between January 2017 and December 2021.
- Demographics, oncologic history, laboratory values, interventions, and pediatric intensive care unit (PICU) outcomes were analyzed.
Main Results:
- 152 bleeding episodes were analyzed; 19% of patients died due to hemorrhage.
- Common bleeding sites included pulmonary and oral/nasal regions; patients often had solid tumors or prior HCT.
- While most patients received balanced resuscitation with red blood cells, plasma, and platelets, specific interventions like pulmonary bleeding, oral/nasal bleeding, and receipt of prothrombin complex concentrate were associated with increased mortality.
Conclusions:
- Pediatric patients with malignancy and/or HCT face a high mortality rate from hemorrhage, even with hospitalization.
- Current resuscitation practices appear balanced but are insufficient to overcome the high risk of death.
- Further clinical trials are essential to establish optimal hemostatic resuscitation strategies for this population.
Objectives:
To characterize the epidemiology and management of massive bleeding events in children with cancer and/or hematopoietic cell transplant (HCT).
Design:
Multicenter, retrospective cohort study.
Setting:
Nineteen pediatric hospitals in Europe and United States.
Subjects:
Children ages 0-21 years old with malignancy and/or HCT and massive bleeding admitted from January 1, 2017, to December 31, 2021.
Interventions:
None.
Measurements And Main Results:
Demographics, oncologic history, laboratory values, interventions, and PICU outcomes were collected. One hundred fifty-two bleeding episodes from 135 patients were analyzed. The median (interquartile range [IQR]) age was 7 years (2-14 yr). Forty-three percent (58/135) were female sex. Nineteen percent of children (26/135) had death attributable to hemorrhage. Forty percent had solid tumors and one-third had undergone at least one HCT. The majority of bleeding events occurred in the PICU (81/152, 53%). The median (IQR) platelet count at time of bleeding was 52 × 10 9 /L (24-115 × 10 9 /L), prothrombin time 18.5 seconds (15.2-24.8 s), activated partial thromboplastin time 42.2 seconds (33.2-56.0 s), and international normalized ratio 1.51 (1.21-2.11). To treat these bleeding events, 99% (148/152) of the time children received RBC transfusions, 84% (126/152) of the time plasma transfusions, 88% (132/152) of the time platelet transfusions, and less than one-fifth hemostatic medications. Half (77/152, 52%) of the time the children received high plasma ratios and half (73/152, 49%) received high platelet ratios. Pulmonary bleeding, oral/nasal bleeding, and receipt of prothrombin complex concentrate were each associated with greater odds of death attributed to hemorrhage: odds ratio (95% CI), respectively: 5.44 (2.250-13.171; p < 0.001); 3.30 (1.20-9.09; p = 0.021); and 3.24 (1.18-8.93; p = 0.023).
Conclusions:
Children with malignancy and/or HCT have a high mortality rate from hemorrhage despite being hospitalized at the time of their bleeding event. The majority of children received balanced resuscitation. Definitive trials are needed to determine optimal hemostatic resuscitation practice in this population.
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