Diapositiva 1 - Terapia Intensiva dell`età Pediatrica (0

Dipartimento di oncoematologia pediatrica e medicina
trasfusionale
Il ruolo dell’intesivista pediatrico nella gestione dei
pazienti sottoposti a trapianto di cellule staminali
ematopoietiche
Pietro Merli
Pietro Merli
Indications for HSCT
Introduction
Complications
ICU admission for HSCT patients
Neither disease status at transplantation
nor transplantation-related characteristics
influenced the in-hospital outcome in
allogeneic HSCT recipients
- 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
ICU admission for HSCT patients
Far from 60-70% of
general ICU population
ICU admission for HSCT patients
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
Van Gestel et al, Crit Care Med2008
PICU hospitalization for Pediatric HSCT patients
McArthur et al, BMT 2011
Intensive Care for Pediatric HSCT patients
Intensive Care for Pediatric HSCT patients
Indications for PCCM physician consultation
McArthur et al, BMT 2011
ECMO for Pediatric HSCT patients
29 patients (ELSO registry between
1991-2012):
-23 (79%) died during ECMO
- 6 (21%) survived ECMO
- 3 (10%) discharged
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
PICU for HSCT patients: OPBG experience
Study period: 01/06/2015-30/11/2015
Number/
median
Percentage/
range
54
100%
32/22
59%/41%
8.5
0.6-23
Malignant/Non-Malignant
28/26
52%/48%
MAC/RIC*
34/20
63%/37%
Total number of patients
Male/Female
Age at diagnosis (years)
* MAC, MyeloAblativeConditioning; RIC, Reduced-Intensity
Conditioning
Update 15/12/2015
PICU for HSCT patients: OPBG experience
Type of Donor
N=27
N=13
N=13
N=1
MUD, Matched Unrelated Donor
UDCB, Unrelated Donor Cord Blood
Update 15/12/2015
PICU for HSCT patients: OPBG experience
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%
5 admitted to PICU
PICU admission rate = 9%
Intervention
rate = 20%
PICU for HSCT patients: OPBG experience
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%)
PICU for HSCT patients: OPBG experience
TRM by type of transplant (only AL patients)
PICU for HSCT patients: OPBG experience
Intervention
Indication
- 2 CPAP
- 2 MV
Respiratory failure
4
Cardiac failure
3
ARF
2
Septic shock
2
Vasoactive support
Hypovolemic/
hemorrhagic shock
1
Replacement therapy
Vasoactive support
HFNC
Inotropic support
- 1 CRRT
- 1 fenoldopam
PICU in HSCT patients: OPBG experience
OS of patients requiring PICU admission
PICU in HSCT patients: OPBG experience
OS of patients receiving PCCM physician evaluation
PICU in HSCT patients: OPBG experience
OS of patients receiving PCCM physician
evaluation, adjusted for indication
Patients censored if:
- Palliative care
- Salvage therapy
PICU for HSCT patients: OPBG experience
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
54
53
32/22
34/19
0.69
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
Total number of patients
Male/Female
Age at diagnosis (years)
P-value
* MAC, MyeloAblativeConditioning; RIC, Reduced-Intensity
Conditioning
Update 15/12/2015
PICU for HSCT patients: OPBG experience
Type of Donor
N=27
p=n.s.
N=13 N=13
N=24
N=15
N=13
N=1
MUD, Matched Unrelated Donor
UDCB, Unrelated Donor Cord Blood
N=1
Update 15/12/2015
PICU for HSCT patients: OPBG experience
OS of patients receiving PCCM physician evaluation,
adjusted for indication, comparison
intensity of care
Proposal for new Intensive Care approach for
Pediatric HSCT patients requirind PICU admission
OLD model (“progressive intensity”)
Intubation
NIV
BMT unit
Example: HFNC
PICU
time
NEW model (“top-down”)
Intubation
NIV
Example: HFNC
time
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.