Changes in outcomes (1996 –2004) for pediatric oncology and
hematopoietic stem cell transplant patients requiring invasive
mechanical ventilation
Robert F. Tamburro, MD; Raymond C. Barfield, MD; Michele L. Shaffer, PhD; Surender Rajasekaran, MD;
Paul Woodard, MD; R. Ray Morrison, MD; Scott C. Howard, MD; Richard T. Fiser, MD;
Jeffrey C. Schmidt, MD; Elaine M. Sillos, MD
A
lthough cancer is responsible
for more deaths in children 1
yr of age than any other dis-
ease, outcomes are improving
(1, 2). Over the past 4 decades in the
United States, outcomes for children di-
agnosed with cancer have progressed
from an estimated 80% mortality to an
80% survival (2). Moreover, hematopoi-
etic stem cell transplantation (HSCT) is
being employed for an ever-expanding list
of malignant and nonmalignant diseases
(3). These advancements have resulted in
an increased need for critical care ser-
vices for these children. In fact, nearly
40% of pediatric cancer patients require
intensive care services, accounting for
approximately 3% of all pediatric inten-
sive care unit (PICU) admissions (4, 5).
Additionally, 10% to 25% of allogeneic
pediatric HSCT patients require mechan-
ical ventilation (6 –11).
Historically, these children have been
considered poor candidates for intensive
care interventions, most notably those re-
quiring mechanical ventilation due to re-
spiratory failure. Data from the 1980s sug-
gested that mortality rates for pediatric
oncology patients requiring mechanical
ventilation approached 75% (12, 13), with
mortality rates approximating 90% for
HSCT patients (14 –19). Over time, how-
ever, outcomes have improved, particularly
Objective: To assess the following hypotheses regarding me-
chanically ventilated pediatric oncology patients, including those
receiving hematopoietic stem cell transplant (HSCT) and those not
receiving HSCT: 1) outcomes are more favorable for nontransplant
oncology patients than for those requiring HSCT; 2) outcomes
have improved for both populations over time; and 3) there are
factors available during the time of mechanical ventilation that
identify patients with a higher likelihood of dying.
Design: Retrospective review.
Setting: Free-standing, tertiary care, pediatric hematology on-
cology hospital.
Patients: All patients requiring invasive mechanical ventilation
with a diagnosis of cancer or following HSCT from January 1996
to December 2004.
Interventions: Bivariate and multivariate analysis. Dates of
admission were grouped into time periods for analysis: 1996 –
1998, 1999 –2001, and 2002–2004.
Measurements and Main Results: There were 401 courses of
mechanical ventilation (329 patients) analyzed. Forty-five percent
of HSCT admissions (92 of 206) vs. 75% of non-HSCT oncology
admissions (146 of 195) were extubated and discharged from the
pediatric intensive care unit (p < .0001). Twenty-five percent of
HSCT vs. 60% of non-HSCT admissions survived 6 months ( p < .0001).
Among admissions with an abnormal chest radiograph and a
PaO
2
/FIO
2
ratio <200, pediatric intensive care unit survival in-
creased for each successive time period, with 45% of HSCT and
83% of non-HSCT admissions surviving during 2002–2004. In
multivariate analysis of all study patients, Pediatric Risk of Mor-
tality scores on the day of intubation, allogeneic HSCT, cardio-
vascular failure, hepatic failure, neurologic failure, a previous
course of mechanical ventilation within 6 months, and the time
period intubated were associated with mortality. With the excep-
tion of time period, these same variables were associated with
mortality in multivariate analysis of only HSCT patients.
Conclusions: HSCT patients who require mechanical ventila-
tion have worse outcomes than non-HSCT oncology patients.
Outcomes for both groups have improved over time. Allogeneic
transplant, higher Pediatric Risk of Mortality scores, need for
repeated mechanical ventilation, and concomitant organ system
dysfunction are risk factors for death. (Pediatr Crit Care Med
2008; 9:●●●–●●●)
KEY WORDS: hematopoietic stem cell transplantation; cancer;
critically ill; mechanical ventilation; respiratory failure; pediatrics;
mortality
From Penn State Children’s Hospital, Pediatrics,
Division of Critical Care Medicine (RFT); St. Jude
Children’s Research Hospital, Division of Bone Mar-
row Transplantation (RCB, PW), Division of Critical
Care Medicine (SR, RRM), and Department of He-
matology Oncology (SCH); Penn State College of
Medicine, Departments of Health Evaluation Sci-
ences and Pediatrics (MLS); University of Arkansas
for Medical Sciences, Pediatrics, Division of Critical
Care Medicine (RTF); Pediatrix Medical Group of
Colorado (JCS); and Baylor College of Medicine,
Department of Pediatrics (EMS).
Supported, in part, by the National Institutes of Health
Cancer Center Support Core Grant CA 21765 and by the
American Lebanese Syrian Associated Charities (ALSAC).
The authors have not disclosed any potential con-
flicts of interest.
For information regarding this article, E-mail:
rtamburro@psu.edu
Copyright © 2008 by the Society of Critical Care
Medicine and the World Federation of Pediatric Inten-
sive and Critical Care Societies
DOI: 10.1097/PCC.0b013e31816c7260
1 Pediatr Crit Care Med 2008 Vol. 9, No. 3
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