Extracorporeal Membrane Oxygenation Candidacy in Pediatric Patients Treated With Hematopoietic Stem Cell Transplant and Chimeric Antigen Receptor T-Cell Therapy: An International Survey

Abstract

IntroductionPediatric patients who undergo hematopoietic cell transplant (HCT) or chimeric antigen receptor T-cell (CAR-T) therapy are at high risk for complications leading to organ failure and the need for critical care resources. Extracorporeal membrane oxygenation (ECMO) is a supportive modality that is used for cardiac and respiratory failure refractory to conventional therapies. While the use of ECMO is increasing for patients who receive HCT, candidacy for these patients remains controversial. We therefore surveyed pediatric critical care and HCT providers across North America and Europe to evaluate current provider opinions and decision-making and institutional practices regarding ECMO use for patients treated with HCT or CAR-T.MethodsAn electronic twenty-eight question survey was distributed to pediatric critical care and HCT providers practicing in North America (United States and Canada) and Europe through the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network and individual emails. Responses to the survey were recorded in a REDCap® database.ResultsTwo-hundred and ten participants completed the survey. Of these, 159 (76%) identified themselves as pediatric critical care physicians and 47 (22%) as pediatric HCT physicians or oncologists. The majority (99.5%) of survey respondents stated that they would consider patients treated with HCT or CAR-T therapy as candidates for ECMO support. However, pediatric critical care physicians identified more absolute and relative contraindications for ECMO than non-pediatric critical care physicians. While only 0.5% of respondents reported that they consider HCT as an absolute contraindication for ECMO, 6% of respondents stated that ECMO is contraindicated in HCT patients within their institution and only 23% have an institutional protocol or policy to guide the evaluation for ECMO candidacy of these patients. Almost half (49.1%) of respondents would accept a survival to hospital discharge of 20-30% for pediatric HCT patients requiring ECMO as adequate.ConclusionsECMO use for pediatric patients treated with HCT and CAR-T therapy is generally acceptable amongst physicians. However, there are differences in the evaluation and decision-making regarding ECMO candidacy amongst providers across medical specialties and institutions. Therefore, multidisciplinary collaboration is an essential component in establishing practice guidelines and advancing ECMO outcomes for these patients.

Outcomes of Critically Ill Children With Acute Lymphoblastic Leukemia and Cytokine Release Syndrome Due to Chimeric Antigen Receptor T Cell Therapy: US, Multicenter PICU, Cohort Database Study

“…As PICU practitioners gain experience managing children with critical illness due to CRS, our ability to risk-stratify patients and identify those likely to benefit from advanced life support will improve. Specifically, the consideration to initiate ECMO is a complex clinical decision informed by incomplete evidence (18). Recent publications have emphasized the importance of instituting robust decision-making processes to determine ECMO candidacy and, specifically for patients who have had a hematopoietic cell transplantation, candidacy should be considered in the context of patient and family preferences, comorbidities, and reversibility of underlying organ failure(s) (19, 20).…”

Organ Donation From Patients on Extracorporeal Membrane Oxygenation at the Time of Death

“…Determining ECMO candidacy is provider- and institution-dependent. Different guidelines exist for distinct patient populations, but there are no universal recommendations ( 45 – 47 ). The decision to cannulate ECMO often occurs emergently, where the calculated risk-benefit ratio may be influenced by stress and other psychoemotional factors ( 48 ).…”

Extracorporeal membrane oxygenation in children with oncohematological diseases

“…Проведенный в 2021 г. опрос специалистов США, Канады и Европы, в котором приняли участие 210 врачей из отделений детской интенсивной терапии и онкогематологии, показал, что 99,5% участников рассматривают детей с онкогематологическими заболеваниями, после ТГСК и иммунной терапии в качестве кандидатов на ЭКМО и только 0,5% специалистов считают ТГСК абсолютным противопоказанием к ЭКМО. На вопрос, связанный с отбором кандидатов, 23% ответили, что имеют локальные протоколы по подбору кандидатов на ЭКМО в этой группе пациентов [45].…”