Introduction of the oncological pediatric risk of mortality scare (O-PRISM) for ICU support following stem cell transplantation in children

Prognostic scoring systems based on physiological parameters have been esta blished in order to predict the outcome of ICU patients. It has been demons trated that the predictive value of these scores is limited in patients fol lowing hematopoietic stem cell transplantation (HSCT). Therefore, we evalua ted patients from the Dusseldorf pediatric stem cell transplantation center with regard to predisposing factors and prognostic variables for ICU treat ment and outcome. Between January 1989 and December 1998, 180 HSCT have bee n performed. The clinical, laboratory and HSCT-related parameters such as c onditioning treatment, engraftment, GVHD, infections and HSCT toxicity were prospectively recorded and retrospectively analyzed. Established pediatric scoring systems (PRISM, TISS, P-TISS) were applied. Twenty-eight patients required intensive care (16 male, 12 female, median age: 10.9 years (range: 0.4 to 18.9 years), five autologous, 13 allogeneic-related and 10 unrelate d transplanted patients). Ventilator-dependent respiratory failure was the most frequent cause of admission to the ICU (n = 23), Fourteen of 28 patien ts were discharged from ICU, and six of 28 patients achieved a long-term su rvival (110 to 396 weeks). At admission to the ICU, impaired cardiovascular status, high CRP levels and presence of macroscopic bleeding were each ass ociated with fatal outcome (P < 0.05). The Pediatric Risk of Mortality (PRI SM) score was not prognostically significant at the 0.05 level. Long-term s urvival after discharge from the ICU correlated with HSCT-related parameter s such as the type of transplant and severity of GVHD (P = 0.002). By intro duction of HSCT related parameters such as severity of GVHD (grade 2: 2 poi nts; grade >2: 4 points), CRP-level (>10 mg/dl: 4 points), and presence of macroscopic bleeding (4 points) into the PRISM score a new oncological PRIS M ('O-PRISM') score was established. This score significantly correlated wi th the risk of mortality in the ICU (P = 0.01). In conclusion, the new O-PR ISM score accurately characterizes the clinical situation of children requi ring ICU treatment following HSCT. It distinguishes more appropriately betw een success and failure of ICU treatment following HSCT than the standard p rognostic scores. It needs to be evaluated in future prospective studies of critically ill children after HSCT.