dipartimento di oncoematologia pediatrica e medicina ... · il ruolo dell’intesivista pediatrico...

Il ruolo dell’intesivista pediatrico nella gestione dei

pazienti sottoposti a trapianto di cellule staminali

ematopoietiche

Dipartimento di oncoematologia pediatrica e medicina

trasfusionale

Pietro Merli

Pietro Merli

Indications for HSCT

Introduction

Complications

ICU admission for HSCT patients

- The overall in-ICU, in-hospital, 6-month, and 1-year survival rates were 48.3%, 32.5%, 27.2%, and 21%, respectively; - Mechanical ventilation, elevated bilirubin level (and corticosteroid treatment for the indication of active graft-versus-host disease (GVHD)) were independent predictors of death in the whole cohort; - In the subgroup of patients requiring mechanical ventilation, associated organ failures, such as shock and liver dysfunction, were independent predictors of death; - ICU admission during engraftment period was associated with acceptable outcome in mechanically ventilated patients, whereas patients with late complications of HSCT in the setting of active GVHD had a poor outcome

Neither disease status at transplantation nor transplantation-related characteristics influenced the in-hospital outcome in allogeneic HSCT recipients


Far from 60-70% of general ICU population


Legline et al, BMT 2015

PICU admission for Pediatric HSCT patients

- Admission rate ̴ 23% [Platon et al, BMT 2015]

- Mortality decresing over time?

Van Gestel et al, BBMT 2008

Mortality during PICU permanence for HSCT patients

Van Gestel et al, Crit Care Med2008

PICU hospitalization for Pediatric HSCT patients

Van

Ge

stel

et

al, C

rit

Car

e M

ed2

00

8

Intensive Care for Pediatric HSCT patients

McA

rth

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et a

l, B

MT

20

11

Intensive Care for Pediatric HSCT patients

McArthur et al, BMT 2011

Indications for PCCM physician consultation

ECMO for Pediatric HSCT patients

ECMO should be considered in: 1) HSCT patients with either nonmalignant disorders or with malignancies at low risk of recurrence 2) when engraftment is acquired 3) when an effective etiologically targeted treatment of the HSCT complications is available

29 patients (ELSO registry between 1991-2012): -23 (79%) died during ECMO - 6 (21%) survived ECMO - 3 (10%) discharged

PICU for HSCT patients: OPBG experience

Study period: 01/06/2015-30/11/2015

Number/ median

Percentage/ range

Total number of patients 54 100%

Male/Female 32/22 59%/41%

Age at diagnosis (years) 8.5 0.6-23

Malignant/Non-Malignant 28/26 52%/48%

MAC/RIC* 34/20 63%/37%

* MAC, MyeloAblativeConditioning; RIC, Reduced-Intensity Conditioning

Update 15/12/2015


Type of Donor

N=13 N=13

N=27

N=1

MUD, Matched Unrelated Donor UDCB, Unrelated Donor Cord Blood

Update 15/12/2015


Reason for PCCM physician consultation

Total: 11 pts

Respiratory failure 4 36%

Cardiac failure 3 27%

ARF 2 18%

Septic shock 2 18%

Ipovolemic shock 1 9%

PICU admission rate = 9%

5 admitted to PICU

Intervention rate = 20%


Intervention by type of transplant

Total 11 intervention

Sibling 3/13 23%

MUD 5/13 38%

Haplo 2/27 7.4%

UDCB 1/1 (100%)


TRM by type of transplant (only AL patients)


Intervention

Indication

Respiratory failure

4

Cardiac failure

3

ARF

2

Septic shock

2

Hypovolemic/ hemorrhagic shock

1

HFNC - 2 CPAP - 2 MV

Inotropic support

- 1 CRRT - 1 fenoldopam

Vasoactive support

Replacement therapy Vasoactive support

PICU in HSCT patients: OPBG experience

OS of patients requiring PICU admission


OS of patients receiving PCCM physician evaluation


OS of patients receiving PCCM physician evaluation, adjusted for indication

Patients censored if: - Palliative care - Salvage therapy


Comparison with historical cohort Study period: 01/06-30/11/2015 vs 01/06-30/11/2014

Number/ Median yr 2015

Number/ Median yr 2014

P-value

Total number of patients 54 53

Male/Female 32/22 34/19 0.69

Age at diagnosis (years) 8.5 (0.6-23) 10.1 (0.7-22.2) 0.09

Malignant/Non-Malignant 28/26 32/21 0.43

MAC/RIC* 34/20 24/29 0.08

* MAC, MyeloAblativeConditioning; RIC, Reduced-Intensity Conditioning

Update 15/12/2015


Type of Donor

N=13

MUD, Matched Unrelated Donor UDCB, Unrelated Donor Cord Blood

Update 15/12/2015

N=13 N=13

N=15

N=1 N=1

N=27

N=24 p=n.s.


OS of patients receiving PCCM physician evaluation, adjusted for indication, comparison

Proposal for new Intensive Care approach for

Pediatric HSCT patients requirind PICU admission

time

time

inte

nsi

ty o

f ca

re OLD model (“progressive intensity”)

NEW model (“top-down”)

Example: HFNC

Intubation

BMT unit

PICU Example: HFNC

NIV

Intubation

NIV

Conclusions

- PCCM physician plays an important role in the management of pediatric patients undergoing HSCT;

- A tight cooperation between PCCM and BMT physician seems to ameliorate the outcome of children who received an HSCT;

- Despite improvements in supportive care, mortality remains high; thus, new approaches/treatment strategies are desirable;

- Since robust data on PICU admission for pediatric patients undergoing HSCT are lacking, well-designed studies will clarify indications to (and timing for) PICU admission, prognostic factors and optimal treatment program in this setting.

dipartimento di oncoematologia pediatrica e medicina ... · il ruolo dell’intesivista pediatrico...

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