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Identifying early predictors of mortality in pediatric patients with acute leukemia and pneumonia
C J Randle1, L R Frankel, M D Amylon
1Department of Pediatrics, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, USA.
Insights
In children with acute leukemia, increased oxygen needs during pneumonia predict respiratory failure. Monitoring oxygen saturation (SO2) and requirements can identify high-risk patients early, even before mechanical ventilation is needed.
Area of Science:
- Pediatric Oncology
- Pediatric Critical Care
- Pulmonology
Background:
- Children with acute leukemia are susceptible to pneumonia.
- Pneumonia in this population can lead to severe complications like respiratory failure and mortality.
Purpose of the Study:
- To identify clinical variables predicting respiratory failure and mortality in pediatric acute leukemia patients with pneumonia.
- To evaluate the utility of oxygen requirements and pulmonary infiltrates in predicting outcomes.
Main Methods:
- Retrospective chart review of children with acute leukemia and pneumonia or ARDS.
- Analysis of clinical data including oxygen requirements, sepsis, shock, and chest x-ray findings.
Main Results:
- Pulmonary infiltrates in more than one quadrant (53%), sepsis (70%), and shock (75%) were associated with increased mortality.
- Children requiring > 3 L/min oxygen to maintain SO2 > 95% had a 79% mortality rate.
- Mechanical ventilation was required by all children who previously needed > 3 L/min oxygen, with 90% mortality.
Conclusions:
- Oxygen requirement (> 3 L/min to maintain SO2 > 95%) is a sensitive predictor of respiratory failure in children with acute leukemia and pneumonia.
- Combining oxygen requirements with extent of pulmonary infiltrates does not improve prediction accuracy.
- Survival rates are very low for children requiring mechanical ventilation for respiratory failure.
Study Objective:
To identify clinical variables of pneumonia in children with acute leukemia that predicted respiratory failure and mortality.
Design:
A retrospective chart review of children with acute leukemia admitted to the hospital with the diagnosis of pneumonia or ARDS from March 1991 to April 1994.
Setting:
Lucile Salter Packard Children's Hospital at Stanford, a 168-bed teaching hospital and regional tertiary referral center for children in northern California.
Patients:
During this study period, 20% of the 174 admissions of children with acute leukemia had pneumonia at the time of admission or during the course of the hospitalization for a total of 36 admissions. The mean age of these children was 9.2 +/- 1.1 years.
Results:
Eleven percent of the children with pulmonary infiltrates in one quadrant on the chest x-ray film at the onset of pneumonia and 53% of the children with pulmonary infiltrates in more than one quadrant at the onset of pneumonia died. Fifteen percent of the children without sepsis at the onset of pneumonia and 70% of the children with sepsis at onset died. Eighteen percent of the children without shock at the onset of pneumonia and 75% of the children with shock at the onset died. None of the children died who required < or = 3L/min of O2 to maintain SO2 > or = 95%, but 79% of the children who required > 3L/min O2 died. Using the criteria "> 3 L/min O2 by nasal cannula to maintain SO2 > or = 95%" to identify the nonsurvivors had a sensitivity of 100% and specificity of 88%. This specificity was not increased by combining the criteria "O2 requirements at any time" and "the extent of pulmonary infiltrates at the onset of pneumonia." All children who required mechanical ventilatory support for respiratory failure had previously received > 3 L/min O2 by nasal cannula to maintain SO2 > or = 95% for 37.8 +/- 12.9 h (range 3 to 96 h). Nine of the 10 children in our study who received mechanical ventilation died.
Conclusion:
In children with acute leukemia and pneumonia, the amount of O2 required to maintain SO2 > or = 95% may identify those who are likely to develop respiratory failure hours before mechanical ventilatory support is needed. The ability to identify children at risk for respiratory failure is not increased by combining the risk factors "oxygen requirements" and "extent of pulmonary infiltrates at the onset of pneumonia". Finally, only 10% of the children who required mechanical ventilatory support survived.