Log in | Register

Pediatric cancer type predicts infection rate, need for critical care intervention, and mortality in the pediatric intensive care unit

Matt S. Zinter| Steven G. DuBois| Aaron Spicer| Katherine Matthay| Anil Sapru
Pediatric Original
Volume 40, Issue 10 / October , 2014

Pages 1536 - 1544

Abstract

Purpose

Up to 38 % of children with cancer require pediatric intensive care unit (PICU) admission within 3 years of diagnosis, with reported PICU mortality of 13–27 % far exceeding that of the general PICU population. PICU outcomes data for individual cancer types are lacking and may help identify patients at risk for poor clinical outcomes.

Methods

We performed a retrospective multicenter analysis of 10,365 PICU admissions of cancer patients no greater than 21 years old among 112 PICUs between 1 January 2009 and 30 June 2012. We evaluated the effect of cancer type, age, gender, genetic syndrome, stem cell transplantation, PRISM3 score, infections, and critical care interventions on PICU mortality.

Results

After excluding scheduled perioperative admissions, cancer patients represented 4.2 % of all PICU admissions (10,365/246,346), had overall mortality of 6.8 % (708/10,365) vs. 2.4 % (5,485/230,548) in the general PICU population (RR = 2.9, 95 % CI 2.7–3.1, p < 0.001), and accounted for 11.4 % of all PICU deaths (708/6,215). Hematologic cancer patients had greater median PRISM3 score (8 vs 2, p < 0.001), rates of sepsis (27 vs 9 %, RR = 2.9, 95 % CI 2.6–3.1, p < 0.001), and mortality (9.6 vs 4.5 %, RR = 2.1, 95 % CI 1.8–2.5, p < 0.001) compared to solid cancer patients. Among hematologic cancer patients, stem cell transplantation, diagnosis of acute myeloid leukemia, PRISM3 score, and infection were all independently associated with PICU mortality.

Conclusions

Children with cancer account for 4.2 % of PICU admissions and 11.4 % of PICU deaths. Hematologic cancer patients have significantly higher admission illness severity, rates of infections, and PICU mortality than solid cancer patients. These data may be useful in risk stratification for closer monitoring and patient counseling.

Keywords

PediatricPICUCancerNeoplasmMalignancyMortality

References

  1. National Cancer Institute (2014) Surveillance, epidemiology, and end results (SEER) program research data (1973-2011). DCCPS, Surveillance Res Prog, Surveillance Sys Branch. http://www.seer.cancer.gov
  2. Dalton HJ, Slonim AD, Pollack MM (2003) Multicenter outcome of pediatric oncology patients requiring intensive care. Pediatr Hematol Oncol 20:643–649
    • View reference on PubMed
    • View reference on publisher's website
  3. Rosenman MB, Vik T, Hui SL, Breitfeld PP (2005) Hospital resource utilization in childhood cancer. J Pediatr Hematol Oncol 27:295–300
    • View reference on PubMed
    • View reference on publisher's website
  4. Pollack MM, Patel KM, Ruttimann UE (1996) PRISM III: an updated pediatric risk of mortality score. Crit Care Med 24:743–752
    • View reference on PubMed
    • View reference on publisher's website
  5. Tilford JM, Roberson PK, Lensing S, Fiser DH (1998) Differences in pediatric ICU mortality risk over time. Crit Care Med 26:1737–1743
    • View reference on PubMed
    • View reference on publisher's website
  6. Pound CM, Johnston DL, Armstrong R, Gaboury I, Menon K (2008) The morbidity and mortality of pediatric oncology patients presenting to the intensive care unit with septic shock. Pediatr Blood Cancer 51:584–588. doi:10.1002/pbc.21670
    • View reference on PubMed
    • View reference on publisher's website
  7. Haase R, Lieser U, Kramm C et al (2011) Management of oncology patients admitted to the paediatric intensive care unit of a general children’s hospital—a single center analysis. Klin Padiatr 223:142–146. doi:10.1055/s-0031-1275291
    • View reference on PubMed
    • View reference on publisher's website
  8. Meyer S, Gottschling S, Biran T, Georg T, Ehlayil K, Graf N, Gortner L (2005) Assessing the risk of mortality in paediatric cancer patients admitted to the paediatric intensive care unit: a novel risk score? Eur J Pediatr 164:563–567. doi:10.1007/s00431-005-1695-y
    • View reference on PubMed
    • View reference on publisher's website
  9. Owens C, Mannion D, O’Marcaigh A, Waldron M, Butler K, O’Meara A (2011) Indications for admission, treatment and improved outcome of paediatric haematology/oncology patients admitted to a tertiary paediatric ICU. Ir J Med Sci 180:85–89. doi:10.1007/s11845-010-0634-8
    • View reference on PubMed
    • View reference on publisher's website
  10. Hallahan AR, Shaw PJ, Rowell G, O’Connell A, Schell D, Gillis J (2000) Improved outcomes of children with malignancy admitted to a pediatric intensive care unit. Crit Care Med 28:3718–3721
    • View reference on PubMed
    • View reference on publisher's website
  11. van Veen A, Karstens A, van der Hoek AC, Tibboel D, Hahlen K, van der Voort E (1996) The prognosis of oncologic patients in the pediatric intensive care unit. Intensive Care Med 22:237–241
  12. Sivan Y, Schwartz PH, Schonfeld T, Cohen IJ, Newth CJ (1991) Outcome of oncology patients in the pediatric intensive care unit. Intensive Care Med 17:11–15
  13. Ha EJ, Kim S, Jin HS, Bae KW, Lim HJ, Seo JJ, Park SJ (2010) Early changes in SOFA score as a prognostic factor in pediatric oncology patients requiring mechanical ventilatory support. J Pediatr Hematol Oncol 32:e308–e313. doi:10.1097/MPH.0b013e3181e51338
    • View reference on PubMed
    • View reference on publisher's website
  14. Heying R, Schneider DT, Korholz D, Stannigel H, Lemburg P, Gobel U (2001) Efficacy and outcome of intensive care in pediatric oncologic patients. Crit Care Med 29:2276–2280
    • View reference on PubMed
    • View reference on publisher's website
  15. Heney D, Lewis IJ, Lockwood L, Cohen AT, Bailey CC (1992) The intensive care unit in paediatric oncology. Arch Dis Child 67:294–298
    • View reference on PubMed
    • View reference on publisher's website
  16. Tamburro R (2005) Pediatric cancer patients in clinical trials of sepsis: factors that predispose to sepsis and stratify outcome. Pediatr Crit Care Med 6:S87–S91. doi:10.1097/01.PCC.0000161288.00396.49
    • View reference on PubMed
    • View reference on publisher's website
  17. Tamburro RF, Barfield RC, Shaffer ML et al (2008) Changes in outcomes (1996–2004) for pediatric oncology and hematopoietic stem cell transplant patients requiring invasive mechanical ventilation. Pediatr Crit Care Med 9:270–277. doi:10.1097/PCC.0b013e31816c7260
    • View reference on PubMed
    • View reference on publisher's website
  18. Fiser RT, West NK, Bush AJ, Sillos EM, Schmidt JE, Tamburro RF (2005) Outcome of severe sepsis in pediatric oncology patients. Pediatr Crit Care Med 6:531–536
    • View reference on PubMed
    • View reference on publisher's website
  19. Baden L, Bensinger W, Casper C et al (2012) NCCN clinical practice guidelines in oncology: prevention and treatment of cancer-related infections. J Natl Compr Canc Netw 10:1412–1445
  20. Haase R, Mathony U, Lieser U, Nagel F, Sitka U, Burdach S (2003) Oncology patients in a pediatric intensive care unit—a 7-year experience. Klin Padiatr 215:234–240. doi:10.1055/s-2003-41399
    • View reference on PubMed
    • View reference on publisher's website
  21. Dursun O, Hazar V, Karasu GT, Uygun V, Tosun O, Yesilipek A (2009) Prognostic factors in pediatric cancer patients admitted to the pediatric intensive care unit. J Pediatr Hematol Oncol 31:481–484. doi:10.1097/MPH.0b013e3181a330ef
    • View reference on PubMed
    • View reference on publisher's website
  22. Vogiatzi L, Ilia S, Sideri G et al (2013) Invasive candidiasis in pediatric intensive care in Greece: a nationwide study. Intensive Care Med 39:2188–2195. doi:10.1007/s00134-013-3057-y
  23. Ben Abraham R, Toren A, Ono N, Weinbroum AA, Vardi A, Barzilay Z, Paret G (2002) Predictors of outcome in the pediatric intensive care units of children with malignancies. J Pediatr Hematol Oncol 24:23–26
    • View reference on PubMed
    • View reference on publisher's website
  24. Akhtar N, Fadoo Z, Panju S, Haque A (2011) Outcome and prognostic factors seen in pediatric oncology patients admitted in PICU of a developing country. Indian J Pediatr 78:969–972. doi:10.1007/s12098-011-0391-3
    • View reference on PubMed
    • View reference on publisher's website
  25. Singer K, Subbaiah P, Hutchinson R, Odetola F, Shanley TP (2011) Clinical course of sepsis in children with acute leukemia admitted to the pediatric intensive care unit. Pediatr Crit Care Med 12:649–654. doi:10.1097/PCC.0b013e31821927f1
    • View reference on PubMed
    • View reference on publisher's website
  26. Gupta P, Green JW, Tang X et al (2014) Comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure. JAMA Pediatr 168:243–249. doi:10.1001/jamapediatrics.2013.4463
    • View reference on PubMed
    • View reference on publisher's website
  27. Typpo KV, Petersen NJ, Petersen LA, Mariscalco MM (2010) Children with chronic illness return to their baseline functional status after organ dysfunction on the first day of admission in the pediatric intensive care unit. J Pediatr 157(108–113):e1. doi:10.1016/j.jpeds.2009.12.029
    • View reference on PubMed
  28. Typpo KV, Petersen NJ, Hallman DM, Markovitz BP, Mariscalco MM (2009) Day 1 multiple organ dysfunction syndrome is associated with poor functional outcome and mortality in the pediatric intensive care unit. Pediatr Crit Care Med 10:562–570. doi:10.1097/PCC.0b013e3181a64be1
    • View reference on PubMed
    • View reference on publisher's website
  29. Steliarova-Foucher E, Stiller C, Lacour B, Kaatsch P (2005) International classification of childhood cancer, third edition. Cancer 103:1457–1467. doi:10.1002/cncr.20910
    • View reference on PubMed
    • View reference on publisher's website
  30. Weiss SL, Parker B, Bullock ME, Swartz S, Price C, Wainwright MS, Goodman DM (2012) Defining pediatric sepsis by different criteria: discrepancies in populations and implications for clinical practice. Pediatr Crit Care Med 13:e219–e226. doi:10.1097/PCC.0b013e31823c98da
    • View reference on PubMed
    • View reference on publisher's website
  31. Goldstein B, Giroir B, Randolph A, International Consensus Conference on Pediatric Sepsis (2005) International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 6:2–8. doi:10.1097/01.PCC.0000149131.72248.E6
    • View reference on PubMed
    • View reference on publisher's website
  32. Pollack MM, Ruttimann UE, Getson PR (1988) Pediatric risk of mortality (PRISM) score. Crit Care Med 16:1110–1116
    • View reference on PubMed
    • View reference on publisher's website
  33. Ludbrook J, Dudley H (1994) Issues in biomedical statistics: analysing 2 × 2 tables of frequencies. Aust N Z J Surg 64:780–787
    • View reference on PubMed
    • View reference on publisher's website
  34. Diggle PJ, Heagerty P, Liang K, Zeger SL (2002) Analysis of longitudinal data. Oxford Statistical Science Series. Oxford University Press, Oxford
  35. Hardin J, Hilbe J (2003) Generalized estimating equations. Chapman Hall/CRC, London
  36. Pancera CF, Hayashi M, Fregnani JH, Negri EM, Deheinzelin D, de Camargo B (2008) Noninvasive ventilation in immunocompromised pediatric patients: eight years of experience in a pediatric oncology intensive care unit. J Pediatr Hematol Oncol 30:533–538. doi:10.1097/MPH.0b013e3181754198
    • View reference on PubMed
    • View reference on publisher's website
  37. Gow KW, Heiss KF, Wulkan ML et al (2009) Extracorporeal life support for support of children with malignancy and respiratory or cardiac failure: the extracorporeal life support experience. Crit Care Med 37:1308–1316. doi:10.1097/CCM.0b013e31819cf01a
    • View reference on PubMed
    • View reference on publisher's website
  38. Di Nardo M, Locatelli F, Palmer K et al (2014) Extracorporeal membrane oxygenation in pediatric recipients of hematopoietic stem cell transplantation: an updated analysis of the Extracorporeal Life Support Organization experience. Intensive Care Med 40:754–756. doi:10.1007/s00134-014-3240-9
  39. Margolin JF (2011) Molecular diagnosis and risk-adjusted therapy in pediatric hematologic malignancies: a primer for pediatricians. Eur J Pediatr 170:419–425. doi:10.1007/s00431-011-1424-7
    • View reference on PubMed
    • View reference on publisher's website
  40. Demaret P, Pettersen G, Hubert P, Teira P, Emeriaud G (2012) The critically-ill pediatric hemato-oncology patient: epidemiology, management, and strategy of transfer to the pediatric intensive care unit. Ann Intensive Care 2:14. doi:10.1186/2110-5820-2-14
    • View reference on PubMed
    • View reference on publisher's website
  41. Piastra M, Fognani G, Franceschi A, “ICARO Italian Network For Intensive Care In Pediatric Oncology” (2011) Pediatric intensive care unit admission criteria for haemato-oncological patients: a basis for clinical guidelines implementation. Pediatr Rep 3:e13. doi:10.4081/pr.2011.e13
    • View reference on PubMed
    • View reference on publisher's website

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement