To stop or not to stop: how much support should be provided to mechanically ventilated pediatric bone marrow and stem cell transplant patients?
Every publication to date reporting the outcome of intensive care support for pediatric SCT patients must be viewed with caution because all are single-institution, retrospective reports. Nevertheless, some of the conclusions made by these investigators appear to be clinically relevant. First, an SCT patient who requires intensive care support does not automatically have a dismal chance of survival. Survival rates in recent reports range from 15% to 36%, which is reasonable when the overall post-transplant survival rate for non-ICU patients may be only 50%. Second, adverse risk factors differ from center to center, likely due to the wide variation in patient populations, donor source, and transplant preparation regimens. Third, MSOF is a consistent adverse risk factor for survival. An additional conclusion that can be drawn from the data presented in this article is that patients who do not show significant, objective improvement by the second week of PICU care are unlikely to survive. The limitation or withdrawal of life-sustaining medical support should be recommended to the patient, the patient's family, and the patient's doctors. Although there are no predictive models that are 100% reliable for these clinical situations, in the author's experience, most families and physicians view critical care support beyond 2 weeks, in the absence of clinical improvement, as futile care. It is clear that better data are needed in the form of prospective, multi-institutional studies that include the therapeutic efficacy of interventions such as high-frequency oscillatory ventilation, continuous venovenous hemodialysis, early use of noninvasive ventilation (ie, noninvasive positive pressure ventilation), the use of biologic agents to decrease inflammation, the impact of new antifungal medications, and lung-protective ventilation with permissive hypercapnia. Of these potential therapies, the author is aware of only one multi-institutional study involving continuous venovenous hemodialysis at this time.
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