Díaz de Heredia C, Moreno A, Olivé T, Iglesias J, Ortega J J
Department of Haematology-Oncology, Hospital Universitario Materno-Infantil Vall d'Hebron, Barcelona, Spain.
Bone Marrow Transplant. 1999 Jul;24(2):163-8. doi: 10.1038/sj.bmt.1701874.
The role of support measures in the Intensive Care Unit for bone marrow transplant recipients has been controversial. Data from 176 pediatric bone marrow transplants were retrospectively analyzed to ascertain the probability, causes, risk factors and survival for life-threatening complications requiring intensive care. Ninety-two patients underwent allogeneic BMT and 84 autologous BMT between January 1991 and December 1995. Thirty-one ICU admissions were recorded. The most frequent causes were acute respiratory failure (n = 15, mostly interstitial pneumopathies), septic shock (n = 5) neurological disorders (n = 5) and heart failure (n = 2). The cumulative incidence of an ICU admission at 20 months post-transplant in patients with an allogeneic BMT was 25.7% (CI: 16.4-35.1), compared with 10.8% (CI: 4.2-17.5) in those with an autologous graft (P = 0.04). ICU admission frequency was maximum during the first 2 months post-transplant. All complications in patients with autologous transplants appeared during the first 5 months post-transplant. Among patients with allogeneic grafts, four were later admitted to the ICU, at 7, 9, 12 and 20 months post-transplant, respectively. The main risk factor for ICU admission was acute GVHD grades III-IV. No differences were found between patients with allogeneic transplants with GVHD grades 0-II and those undergoing autologous transplant. In contrast, differences were highly significant between patients undergoing allogeneic transplants with GVHD grades III-IV and those with GVHD grades 0-II or autologous transplants. No differences were observed between allogeneic and autologous transplants in terms of causes for ICU admission, duration of stay, hours on mechanical ventilation, hours on inotropic drug therapy and numbers of organs failing. Neither were differences found in ICU discharge survival between patients 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 disease 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 ventilated patients was 46.2% (CI: 27.0-65.4), significantly lower than nonventilated patients (100%). Three-year survival in all transplanted patients admitted 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 complication requiring admission to the ICU is, as confirmed by multivariate analysis, an unfavorable factor in long-term survival of transplanted patients, it must be emphasized that three of every 10 patients admitted to the ICU were alive and well at 3 years. Intensive care support in these patients can be life-saving.
支持措施在重症监护病房对骨髓移植受者的作用一直存在争议。回顾性分析了176例儿科骨髓移植的数据，以确定需要重症监护的危及生命并发症的概率、原因、危险因素和生存率。1991年1月至1995年12月期间，92例患者接受了异基因骨髓移植，84例接受了自体骨髓移植。记录了31例入住重症监护病房的情况。最常见的原因是急性呼吸衰竭（n = 15，大多为间质性肺病）、感染性休克（n = 5）、神经系统疾病（n = 5）和心力衰竭（n = 2）。异基因骨髓移植患者移植后20个月入住重症监护病房的累积发生率为25.7%（置信区间：16.4 - 35.1），而自体移植患者为10.8%（置信区间：4.2 - 17.5）（P = 0.04）。入住重症监护病房的频率在移植后的前2个月最高。自体移植患者的所有并发症均出现在移植后的前5个月。在异基因移植患者中，分别有4例在移植后7、9、12和20个月后入住重症监护病房。入住重症监护病房的主要危险因素是急性移植物抗宿主病III - IV级。异基因移植GVHD 0 - II级患者与自体移植患者之间未发现差异。相比之下，异基因移植GVHD III - IV级患者与GVHD 0 - II级患者或自体移植患者之间差异非常显著。在入住重症监护病房的原因、住院时间、机械通气时间、使用血管活性药物治疗时间和衰竭器官数量方面，异基因移植和自体移植之间未观察到差异。异基因移植（50%，置信区间：29.1 - 70.9）和自体移植（66.7%，置信区间：29.9 - 89.1）患者的重症监护病房出院生存率也未发现差异。因肺部疾病入住的患者重症监护病房出院生存率为28.6%（置信区间：12.1 - 65.6），而因其他原因入住的患者为76.5%（置信区间：41.9 - 87.8）（P = 0.007）。接受机械通气患者的重症监护病房出院生存率为46.2%（置信区间：27.0 - 65.4），显著低于未接受通气的患者（100%）。入住重症监护病房的所有移植患者的三年生存率为29.7%（置信区间：13.1 - 45.0），而不需要入住重症监护病房的患者为70.2%（置信区间：62.7 - 77.6）（P < 0.001）。尽管多因素分析证实，需要入住重症监护病房的并发症是移植患者长期生存的不利因素，但必须强调的是，每10例入住重症监护病房的患者中有3例在3年后存活且状况良好。对这些患者的重症监护支持可以挽救生命。
