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Clinical Outcomes of Children Receiving Intensive Cardiopulmonary Support During Hematopoietic Stem Cell Transplant*

Duncan, Christine N. MD1; Lehmann, Leslie E. MD1; Cheifetz, Ira M. MD, FCCM2; Greathouse, Kristin RN3; Haight, Ann E. MD4; Hall, Mark W. MD3; Herschberger, Amber RN, BSN, CCRP5; Hill, Katherine S. MD4; Moffet, Jerelyn R. PNP2; Morrison, R. Ray MD6; Norris, Angela L. RN6; Petrovic, Aleksandra MD7; Spear, Debra A. RN, CCRN8; Steiner, Marie E. MD9; Talano, Julie-An M. MD10; Tamburro, Robert F. MD8; Wagner, John MD9; McArthur, Jennifer DO10; for the Pediatric Acute Lung Injury and Sepsis (PALISI) Network

Pediatric Critical Care Medicine:
doi: 10.1097/PCC.0b013e3182720601
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Abstract

Objective: We investigated the short-term and 1-year clinical outcomes of 129 children who received intensive cardiopulmonary support during hematopoietic stem cell transplant. Intensive cardiopulmonary support was defined as receiving at least one of the following interventions: continuous positive pressure ventilation, dopamine infusion greater than or equal to 10 mcg/kg/minute, or the use of any other vasoactive infusion. Duration of intensive cardiopulmonary support, survival to hospital discharge, and predictors of these outcome variables were compared with 387 hematopoietic stem cell transplant patients who did not receive intensive support during the same period. We also report the 1-year survival; presence of chronic graft-versus-host disease; and renal, cardiac, and pulmonary function for all patients.

Design: A multicenter retrospective cohort study.

Setting: The ICU and hematopoietic stem cell transplant unit of nine pediatric tertiary care centers.

Patients: Children undergoing hematopoietic stem cell transplant who required intensive cardiopulmonary support.

Interventions: None.

Results: Predictors of the need for intensive support included unrelated donor allogeneic transplant, glomerular filtration rate less than 85 mL/minute/1.73 m2, and nonmalignant disease as the indication for transplant. The survival to discontinuation of intensive support for all patients was 62% and 58% for patients who received invasive mechanical ventilatory support. The duration of mechanical ventilation was not predictive of survival. Predictors of intensive support mortality included macroscopic bleeding, engraftment, and pediatric logistic organ dysfunction score greater than one in two domains. Survival to hospital discharge was 50% for the intensive support group and 99% for the nonintensive support group. Overall 1-year survival was 40% in the intensive support population and 65% in the nonintensive support group. There were no significant differences in the survival, rates of chronic graft-versus-host disease, creatinine, forced expiratory volume in 1-minute, cardiac shortening fraction, or performance status in intensive and nonintensive support patients who survived to hospital discharge.

Conclusion: Intensive cardiopulmonary support plays an important and potentially life-saving role in the care of pediatric stem cell transplant patients. Survivors of intensive support do not have compromised 1-year survival or organ function compared with children who did not receive intensive support.

Author Information

1Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA.

2Department of Pediatrics, Duke Children’s Hospital, Durham, NC.

3Department of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, OH.

4Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, GA.

5Department of Oncology, Moffitt Cancer Center, Tampa, FL.

6Department of Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN.

7Department of Pediatrics, All Children’s Hospital, St. Petersburg, FL.

8Department of Medicine, Penn State Hershey Children’s Hospital, Hershey, PA.

9Department of Pediatrics, University of Minnesota Children’s Hospital, Minneapolis, MN.

10Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.

*See also p. 326.

Supported, in part, by donation to the Dana-Farber Cancer Institution and the Medical College of Wisconsin institutional funds.

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The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: christine_duncan@dfci.harvard.edu

©2013The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies