Role of the intensive care unit in children undergoing bone marrow transplantation with life-threatening complications

The role of support measures in the Intensive Care Unit for bone marrow tra nsplant recipients has been controversial. Data from 176 pediatric bone mar row transplants were retrospectively analyzed to ascertain the probability, causes, risk factors and survival for life-threatening complications requi ring intensive care. Ninety-two patients underwent allogeneic BMT and 84 au tologous BMT between January 1991 and December 1995. Thirty-one ICU admissi ons were recorded. The most frequent causes mere acute respiratory failure (n = 15, mostly interstitial pneumopathies), septic shock (n = 5) neurologi cal disorders (n = 5) and heart failure (n = 2). The cumulative incidence o f an ICU admission at 20 months post-transplant in patients with an allogen eic BMT was 25.7% (CI: 16.4-35.1), compared with 10.8% (CI: 4.2-17.5) in th ose with an autologous graft (P = 0.04). ICU admission frequency was maximu m during the first 2 months post-transplant. All complications in patients with autologous transplants appeared during the first 5 months post-transpl ant. Among patients with allogeneic grafts, four were later admitted to the ICU, at 7, 9, 12 and 20 months post-transplant, respectively. The main ris k factor for ICU admission was acute GVHD grades III-IV. No differences wer e found between patients with allogeneic transplants with GVHD grades 0-II and those undergoing autologous transplant. In contrast, differences were h ighly significant between patients undergoing allogeneic transplants with G VHD grades III-IV and those with GVHD grades 0-II, or autologous transplant s. No differences were observed between allogeneic and autologous transplan ts in terms of causes for ICU admission, duration of stay, hours on mechani cal ventilation, hours on inotropic drug therapy and numbers of organs fail ing. Neither were differences found in ICU discharge survival between patie nts with allogeneic (50%, CI: 29.1-70.9) and autologous (66.7%, CI: 29.9-89 .1) transplants. ICU discharge survival in patients admitted for lung disea se was 28.6% (CI: 12.1-65.6) but 76.5% (CI: 41.9-87.8) in patients admitted for other causes (P = 0.007). ICU discharge survival in mechanically venti lated patients was 46.2% (CI: 27.0-65.4), significantly lower than nonventi lated patients (100%). Three-year survival in all transplanted patients adm itted to the ICU was 29.7% (CI: 13.1-45.0) compared with 70.2% (CI: 62.7-77 .6) in patients not requiring ICU admission (P < 0.001). Although a complic ation requiring admission to the ICU is, as confirmed by multivariate analy sis, an unfavorable factor in long-term survival of transplanted patients, it must be emphasized that three of every 10 patients admitted to the ICU w ere alive and well at 3 years. Intensive care support in these patients can be life-saving.