Invasive versus conservative waiting strategy in complicated acute pediatric leukemia patients

Introduction

The outcome for children with acute lymphoblastic leukemia (ALL) has improved dramatically with current therapy resulting in an event-free survival exceeding 75% for most patients over the past four decades. Modern child leukemia treatment requires an interdisciplinary cooperation – PICU interventions demand serious pathological cases with immediate life exposure originated from long-term haematological treatment: (1) patient's clinical status impairment related to aggressive cytostatic therapy (febrile neutropenia, sepsis, pneumonia, respiratory failure, ARDS, hemodynamic instability, MODS, MOF, life-threatening bleeding, neurological alterations in the course of toxic encephalopathy, etc.), (2) postanesthesia intensive care for complications due to invasive procedures (CVC implantations) or vital sign decompensation after anaesthesia.

Objective

To assess the benefit of early invasive (transfer from standard hematology to PICU, respiratory and circulation support, invasive arterial blood pressure and central venous pressure [CVP] measurement, continuous hemodynamic monitoring [PICO, NICO], permanent urinary catheter and nasogastric tube insertion) versus a conservative waiting strategy without invasive procedures when complications appear during hematology leukemia treatment.

Design

Retrospective analysis, n = 29 patients with acute leukaemia admitted to the PICU because of life-threatening complications during their hematological treatment, within the years 2000–2004.

Patients and methods

Critically ill patients admitted to the PICU. Twenty-nine children with leukemia, 20 × ALL, 8 × acute myeloid leukaemia, 1 × chronic myeloid leukaemia, average age 8.7 years (from 5 months to 18 years), 21 boys, eight girls. All patients were hospitalized at the PICU 45 times altogether within the period under consideration (2000–2004) regarding life-threatening events: postanesthesia care (complicated CVC implantation – haemothorax, pneumothorax), febrile neutropenia, sepsis, septic shock, respiratory failure, hemodynamic instability, acute neurological deterioration.

Results

Twenty-two children (76%) from 29 patients with leukemia admitted to the PICU survived. Seven children (24%) died (6 × MOF and septic shock, 1 × fatal intracerebral hemorrhage) – in three of them (42% mortality rate) it was hesitated for invasive treatment initiation (conservative waiting strategy). The authors detail the monitored parameters, clinical patient's status (PRISM), laboratory findings, and at the conclusion illustrate the casual report of a 15-year-old boy with ALL, MODS and septic shock with good outcome thanks to early invasive treatment and adequate therapy (mechanical ventilation, invasive arterial blood pressure monitoring, CVP monitoring, continuous cardiac output measurement from the PICO).

Conclusion

Although pediatric leukemic patients with severe sepsis remain at very high risk, recent findings suggest that their outcomes may be better, as previously reported, using aggressive and early ICU interventions.