Critical illness epidemiology and mortality risk in pediatric oncology

Abstract

Objective: Pediatric oncology patients admitted to the pediatric intensive care unit (PICU) are at high risk of mortality. This study aims to describe the epidemiology of and the risk factors for mortality in these patients. Study design:This is a retrospective cohort study including all consecutive PICU oncology admissions from 2011 to 2017. Demographic and clinical risk factors between survivors and nonsurvivors were compared. Both univariate and multivariate Cox proportional hazard regression models were used to quantify the association between 60-day mortality and admission categories, accounting for other covariates (Pediatric Risk Of Mortality [PRISM] III score and previous bacteremia). Main outcome measures:The primary outcome was 60-day mortality. Results:The median (interquartile range) age and PRISM III scores of pediatric oncology patients admitted to the PICU were 7 (3, 12) years and 3 (0, 5), respectively. The most common underlying oncological diagnoses were brain tumors (73/200 [36.5%]) and acute lymphoblastic leukemia (36/200 [18.0%]). Emergency admissions accounted for approximately half of all admissions (108/200 [54.0%]), including cardiovascular (24/108 [22.2%]), neurology (24/108 [22.2%]), respiratory (22/108 [20.4%]), and "other" indications (38/108 [35.2%]). The overall 60-day mortality was 35 of 200 (17.5%). Independent risk factors for mortality were emergency respiratory and neurology categories of admission (adjusted hazard ratio[aHR]: 5.62, 95% confidence interval [95% CI]: 1. 57, 20.19; P = .008 and aHR: 6.96, 95% CI: 2.04, 23.75; P = .002, respectively) and previous bacteremia (aHR: 3.37, 95% CI: 1.57, 7.20; P = .002). Conclusion:Emergency respiratory and neurology admissions and previous bacteremia were independent risk factors for 60-day mortality for pediatric oncological patients admitted to the PICU. K E Y W O R D Sepidemiology, intensive care,

Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit

“…In addition to the common risk factors for developing PICS-p, critically ill pediatric patients with underlying oncologic and hematologic disorders have additional risk factors, such as glucocorticoid-related immunosuppression, myopathy, and neurocognitive changes; high acuity of disease; chronic organ dysfunction; and high rates of critical care resource utilization (6,7,11,22,(42)(43)(44). These factors highlight the need for interventions to recognize and address PICS-p in this vulnerable patient population.…”

“…However, up to 40% of these children still require critical care therapies for factors specific to their oncologic disease (6). These factors include immunosuppression and a dysregulated inflammatory response secondary to malignant bone marrow infiltration and chronic glucocorticoid use, infection from long-term indwelling central venous catheters, and acute and chronic organ toxicity from chemotherapy agents (7). Additionally, patients who undergo hematopoietic cell transplant (HCT) are subject to unique complications such as graft-versus-host disease, idiopathic pneumonia syndrome, diffuse alveolar hemorrhage, and sinusoidal obstruction syndrome, which further increases critical care utilization, intensive care unit (ICU) morbidity, and mortality in these patients (7)(8)(9)(10)(11)(12).…”

“…These factors include immunosuppression and a dysregulated inflammatory response secondary to malignant bone marrow infiltration and chronic glucocorticoid use, infection from long-term indwelling central venous catheters, and acute and chronic organ toxicity from chemotherapy agents (7). Additionally, patients who undergo hematopoietic cell transplant (HCT) are subject to unique complications such as graft-versus-host disease, idiopathic pneumonia syndrome, diffuse alveolar hemorrhage, and sinusoidal obstruction syndrome, which further increases critical care utilization, intensive care unit (ICU) morbidity, and mortality in these patients (7)(8)(9)(10)(11)(12). Furthermore, post-HCT patients and those with underlying malignancies who require critical care have higher rates of resource utilization, such as invasive mechanical ventilation, vasoactive infusions, and continuous renal replacement therapy, as well as higher mortality, when compared to the general inpatient pediatric population (6).…”

Chronic Illness in Pediatric Critical Care

“…CMC specifically accounted for nearly 50% of unscheduled PICU admissions (21). When considering both scheduled and unplanned PICU admissions, CMC represent the vast majority of all PICU days (78.8%), therapies including mechanical ventilation days (86.1%), and PICU costs (80.5%) (22). Patients without chronic illness received <10% of all PICU therapies (22).…”

“…When considering both scheduled and unplanned PICU admissions, CMC represent the vast majority of all PICU days (78.8%), therapies including mechanical ventilation days (86.1%), and PICU costs (80.5%) (22). Patients without chronic illness received <10% of all PICU therapies (22). CYSHCN are at higher risk for prolonged length of stay ( 23), both early and late readmission (24,25), medical errors ( 26), as well as in hospital mortality ( 27), compared to the general pediatric population.…”