Outcome of children requiring admission to an intensive care unit after bone marrow transplantation

Stephen J Jacobe, Amal Hassan, Paul Veys, Quen Mok
Critical Care Medicine 2003, 31 (5): 1299-305

OBJECTIVE: To review the outcome of bone marrow transplant (BMT) recipients admitted to a pediatric intensive care unit (ICU) and attempt to identify admission characteristics that might accurately predict a poor outcome.

DESIGN: Retrospective case-note review.

SETTING: Pediatric ICU of a tertiary teaching hospital.

PATIENTS: A total of 40 BMT recipients, accounting for 57 admissions to the ICU, in the 5 yrs between 1994 and 1998 were identified.

MEASUREMENTS AND MAIN RESULTS: Median time to ICU admission after BMT was 42 days. Of the 40 patients admitted to ICU, 11 (22.5%) are still alive, with a median time of follow-up since their most recent ICU admission of 587 days (absolute range, 308-1803 days). A total of 32 of 57 admissions (56.1%) resulted in the patient's discharge from the ICU, and 21 admissions (36.8%) resulted in survival to at least 30 days after discharge. There was no difference between the survivors and nonsurvivors in terms of underlying diagnoses, age at BMT, or time to ICU admission after BMT. Type of BMT, conditioning regimen, and presence of significant graft vs. host disease was not found to influence outcome. Although patients who died in the ICU had a significantly longer length of stay compared with the survivors (median, 7.9 days, vs. 2.1 days, p =.02), 11 of 21 admissions (52.4%) associated with survival to 30 days post-ICU discharge were of >or=2 days of duration, the longest being 22.8 days. Thirty-one of 40 patients (77.5%) required intubation and mechanical ventilation during 36 of the 57 admissions, and 15 of these episodes (41.6%) ended with the patient's discharge from the ICU. Of ten patients with respiratory failure associated with pulmonary infection, there were no survivors among those who remained ventilated at 48 hrs (n = 8). Four patients who required mechanical ventilation (12.9%) were alive at the 6-month follow-up. The majority of patients who died in the ICU did so after either withdrawal (65%) or limitation (22%) of treatment.

CONCLUSIONS: Despite the generally poor prognosis for pediatric patients admitted to the ICU after BMT, intensive care continues to play an important role in the care of these patients. Although it is clear that patients who require mechanical ventilation have a worse prognosis, we were unable to identify factors that accurately predict with 100% sensitivity which patients will not survive. Those patients requiring mechanical ventilation due to pneumonitis have a particularly poor outcome, and our findings support the limitation of intensive care in certain circumstances. Decisions regarding treatment options and limitation of care in this group of patients should be based on ongoing outcome research in this field.

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