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

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.

Figure 1. Multivariate Predictors of PICU Mortality

Model (a) refers to solid cancers only. Model (b) refers to hematologic cancers only. ^a reference group for solid cancers ^b reference group for hematologic cancers ^c OR refers to each additional year of age ^d OR refers to each additional PRISM3 point. See eTables 5 and 6 for complete model results.

Figure 2. PICU Mortality by Infection Type

For each type of infection, hematologic cancer patients with HSCT have greater mortality than those without HSCT. For each type of infection, solid cancer patients with and without HSCT have similar mortality. ** refers to non-significant p-values (>0.05). See Table1 and eTable4 for complete results.

Figure 3. PICU Mortality by Intervention Type

Among those receiving IPPV and RRT, hematologic cancer patients with history of HSCT have greater mortality than those without HSCT. There was a trend towards significance for greater mortality among solid cancer patients with HSCT receiving IPPV compared to solid cancer patients without HSCT. ** refers to non-significant p-values (>0.05). See Table1 and eTable5 for complete results.