New Insights Into Multicenter PICU Mortality Among Pediatric Hematopoietic Stem Cell Transplant Patients
New Insights Into Multicenter PICU Mortality Among Pediatric Hematopoietic Stem Cell Transplant Patients
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DOI：
10.1097/ccm.0000000000001085
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发表时间：
2015-09-01
影响因子：
8.8
通讯作者：
Sapru, Anil
中科院分区：
文献类型：
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作者：
Zinter, Matt S.;Dvorak, Christopher C.;Sapru, Anil
目的：在美国，每年有超过2500名儿童接受造血干细胞移植，其中高达35%的儿童因危及生命的并发症而需要PICU的支持。PICU死亡率已从85%降至44%，但显著的队列异质性使解释变得混乱。关于具有不同潜在造血干细胞移植适应证的患者的结果报告相互矛盾，并且这些患者的感染并发症的负担尚未评估。我们的目标是描述需要PICU入院的儿童造血干细胞移植患者的感染、危重护理干预措施和死亡率。设计：一项回顾性多中心队列分析。地点：虚拟PICU系统数据库中的112个中心，从2009年1月1日到2012年6月30日。患者：21岁或以下的既往有造血干细胞移植的患者共有1,782人入院。干预：无。测量和主要结果：儿科死亡指数-2，儿科死亡风险-3，移植适应症，感染，干预和死亡。儿童造血干细胞移植患者占所有PICU住院患者的0.7%(1,782/246,346例)，死亡率为16.2%，而非造血干细胞移植入院患者的死亡率为2.4%(优势比7.8；95%可信区间6.8-8.8；p<；0.001)。基础恶性血液病患者的死亡率(22.7%)与原发免疫缺陷患者(19.4%)相似，但显著高于基础非恶性非原发免疫缺陷血液疾病患者(15.4%；p=0.020)、代谢紊乱患者(8.1%；p<；0.001)或实体恶性肿瘤患者(5.7%；p<；0.001)。45.7%的住院患者有感染记录，死亡率为22.2%；病毒和真菌的死亡率分别为28.5%和33.7%。有创正压呼吸机和肾脏替代疗法的应用比例分别为34.6%和11.9%，病死率分别为42.5%和51.9%。结论：儿童造血干细胞移植患者的PICU病死率可能低至16.2%，而插管者(42.5%)和替代疗法(51.9%)的病死率较高。与其他移植适应症相比，血液系统恶性肿瘤和原发免疫缺陷的死亡风险更大。需要更多地了解影响死亡率的其他风险因素以及对危重护理支持的需求。
Objectives: Over 2,500 children undergo hematopoietic stem cell transplantation in the United States each year, and up to 35% require PICU support for life-threatening complications. PICU mortality has dropped from 85% to 44%, but interpretation is confounded by significant cohort heterogeneity. Reports conflict regarding outcomes for patients with different underlying hematopoietic stem cell transplantation indications, and the burden of infectious complications for these patients has not been evaluated. We aim to describe infections, critical care interventions, and mortality for pediatric hematopoietic stem cell transplantation patients requiring PICU admission.Design: A retrospective multicenter cohort analysis.Setting: One hundred twelve centers in the Virtual PICU Systems database, January 1, 2009, to June 30, 2012.Patients: A total of 1,782 admissions for patients who are 21 years old or younger with prior hematopoietic stem cell transplantation.Interventions: None.Measurements and Main Results: Pediatric Index of Mortality-2, Pediatric Risk of Mortality-3, transplant indication, infections, interventions, and mortality were recorded from admission through PICU death or discharge. Pediatric hematopoietic stem cell transplantation patients comprised 0.7% of all PICU admissions (1,782/246,346), which resulted in 16.2% mortality compared with 2.4% mortality for non-hematopoietic stem cell transplantation admissions (odds ratio, 7.8; 95% CI, 6.8-8.8; p < 0.001). Mortality for admissions with underlying hematologic malignancy (22.7%) was similar to that of admissions with primary immunodeficiency (19.4%; p = 0.41) but significantly greater than admissions with underlying nonmalignant non-primary immunodeficiency hematologic disease (15.4%; p = 0.020), metabolic disorder (8.1%; p < 0.001), or solid malignancy (5.7%; p < 0.001). Infection was documented in 45.7% of admissions with 22.2% mortality; viral and fungal mortality were 28.5% and 33.7%, respectively. Invasive positive pressure ventilation and renal replacement therapy were used in only 34.6% and 11.9% of admissions, with mortality of 42.5% and 51.9%, respectively.Conclusions: PICU mortality for pediatric hematopoietic stem cell transplantation patients may be as low as 16.2% but higher for those receiving intubation (42.5%) or replacement therapy (51.9%). Hematologic malignancy and primary immunodeficiency had greater risk for mortality than other transplant indications. Greater understanding of other risk factors affecting mortality and the need for critical care support is needed.