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The prognosis of oncologic patients in the pediatric intensive care unit
A van Veen1, A Karstens, A C van der Hoek
1Department of Pediatrics, Sophia Children's Hospital, Rotterdam, The Netherlands.
Insights
The Pediatric Index of Mortality (PIM) score is not ideal for predicting outcomes in pediatric oncology patients admitted to the Pediatric Intensive Care Unit (PICU). Oncologic patients benefit from PICU care, but factors beyond PIM scores influence survival.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Oncology
- Clinical Outcomes Research
Background:
- Pediatric oncology patients admitted to the Pediatric Intensive Care Unit (PICU) have a higher mortality rate (32%) compared to the general PICU population (8%).
- Accurate prediction of mortality is crucial for resource allocation and treatment decisions in critically ill pediatric cancer patients.
Purpose of the Study:
- To evaluate the predictive accuracy of the Pediatric Index of Mortality (PIM) score for oncologic patients in the PICU.
- To identify factors influencing short-term outcomes and mortality in this vulnerable patient group.
Main Methods:
- Retrospective study analyzing medical charts of oncologic patients admitted to a university hospital's PICU between January 1983 and December 1992.
- Comparison of observed mortality with PIM score-predicted mortality using chi-square goodness-of-fit tests.
- Analysis of factors including circulatory failure, respiratory failure, central nervous system deterioration, mechanical ventilation, and inotropic support.
Main Results:
- The PIM score significantly underestimated observed mortality in pediatric oncology patients (P < 0.01).
- Highest mortality rates were associated with circulatory failure (47%), followed by respiratory failure (36%), CNS deterioration (27%), and airway obstruction (25%).
- Mechanical ventilation and inotropic support increased mortality, with 100% mortality in cases of septic shock requiring both.
Conclusions:
- The PIM score is not a suitable predictor for pediatric oncology patients in the PICU.
- Oncologic patients benefit from PICU admission, but treatment decisions require individualized assessment.
- Factors such as neutropenia, septic shock, and the need for mechanical ventilation/inotropic support are critical determinants of outcome.
Objective:
To evaluate the predicted mortality rate of oncologic patients in the PICU using the PRISM score and factors that might influence short-term outcomes.
Design:
Retrospective study.
Setting:
Pediatric ICU in a university hospital.
Patients And Methods:
The medical charts of all oncologic patients admitted to the PICU during the period from January 1983 to December 1992 were reviewed.
Main Results:
Over a period of 10 years, 51 oncologic patients were admitted on 57 occasions to the PICU. The mortality was 32%. This is significantly higher than the overall mortality in the PICU (8%). Comparison of observed and predicted mortality, derived from the PRISM score, using chi square goodness-of-fit tests showed a significantly higher observed mortality (x2(5) = 20.1, P < 0.01). Patients admitted for circulatory failure had the highest mortality (47%), followed by those with respiratory failure due to tachypnea/cyanosis (36%), central nervous system deterioration (27%), respiratory failure due to airway obstruction (25%), and metabolic disorders (20%). Of the 31 patients who needed mechanical ventilation, 17 died (55%), and when they needed inotropic support as well, the mortality increased to 69%. The mortality rose to 100% when the patient was admitted with a septic shock, necessitating mechanical ventilation and inotropic support. The median PRISM score was 5 in the survivor group and 18.5 in the non-survivor group; this difference was found to be significant using the Wilcoxon test (P = 0.01). However, some patients with high scores were found in the survivor group, as well as some with low scores in the non-survivor group.
Conclusion:
The decision to treat oncologic patients in a PICU remains difficult and has to be considered on an individual basis. However, oncologic patients do benefit from admission to the PICU. The PRISM score is not suitable for oncologic patients in the PICU, because it underestimates the observed mortality. Other factors like neutropenia, septic shock, the need for mechanical ventilation, and inotropic support should be taken into consideration.
