Outcome for immunocompromised pediatric critical patients

Introduction

The incidence and prevalence of immunocompromised patients has increased (higher number of transplantations and improved management of primary immunodeficiencies). Nevertheless, the management strategies of these patients in the pediatric ICU (PICU) remain a challenge because of their important death rate. The study objective was to analyse the morbimortality and prognosis of immunosuppressed patients requiring critical care due to a medical cause.

Methods

A retrospective study (January 2004–July 2007) in a 15-bed PICU at a university hospital. Chi-square and Fisher exact test analysis was performed.

Results

One hundred and thirty-nine immunocompromised patients were admitted 186 times, which comprised 10% of the total number of admissions to the PICU in this period. The median age was 63 months (range, 1 month-23 years); male predominance (60.2%). Cause of immunosuppression: postchemotherapy neutropenia or hematopoietic stem cell transplantation (HSCT; 65.1%), solid organ transplantation (15.6%), primary immunodeficiency (9.7%) and miscellany (8.6%). Initial problem: haemodynamic (43.5%), respiratory (34.4%), neurological (14.0%), other (8.1%). PRISM 24-hour score was 8 (0–40). Evolutive failures (% patients): hematologic (50.5%), respiratory (40.5%), cardiovascular (40.5%), renal (30.6%), hepatic (19.4%), neurological (14%), gastrointestinal (5.6%). Multisystem organ failure (MOF; ≥ 3 organs) in 32.2%. Critical care support (% patients): mechanical ventilation (50.5%), sympathicomimetic drugs (36.6%), renal depuration (12%), extracorporeal life support with membrane oxygenator (0.5%). Mean stay in the PICU was 7.3 days (median 3 (1–49)). Mortality was 22%; higher in HSCT (26.2%) but without significant differences among groups (P = 0.529). Mortality according to initial problem: respiratory (31.2%), neurological (23%), cardiovascular (17.5%), other (6.6%) (P = 0.012). Mortality of patients who underwent mechanical ventilation was 40.4%; if respiratory and haematologic failure association it was 63.8%; if MOF it was 55% (P > 0.0001).

Conclusion

Regarding immunocompromised patients in the PICU, respiratory failure at admission or during the evolution involves a high risk of death, especially when associated with haematological failure. The impact on the policy of admission in the PICU must be investigated in new studies.