儿科异基因造血干细胞移植中的小儿急性呼吸窘迫综合征：一项多中心研究
Pediatric Acute Respiratory Distress Syndrome in Pediatric Allogeneic Hematopoietic Stem Cell Transplants: A Multicenter Study.
作者信息
Rowan Courtney M, Smith Lincoln S, Loomis Ashley, McArthur Jennifer, Gertz Shira J, Fitzgerald Julie C, Nitu Mara E, Moser Elizabeth A S, Hsing Deyin D, Duncan Christine N, Mahadeo Kris M, Moffet Jerelyn, Hall Mark W, Pinos Emily L, Tamburro Robert F, Cheifetz Ira M
机构信息
1Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis IN. 2Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA. 3Division of Critical Care, Department of Pediatrics, Masonic Children's Hospital, University of Minnesota, Minneapolis, MN. 4Division of Critical Care, Department of Pediatrics, St. Jude's Children's Research Hospital, Memphis, TN. 5Division of Critical Care, Department of Pediatrics, Joseph M Sanzari Children's Hospital at Hackensack University Medical Center, Bergen County, NJ. 6Division of Critical Care, Department of Anesthesia, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 7Department of Biostatistics, Indiana University, Indianapolis IN. 8Division of Critical Care, Department of Pediatrics, Weil Cornell Medical College, New York Presbyterian Hospital, New York City, NY. 9Division of Oncology, Department of Pediatrics, Dana-Farber Cancer Institute Harvard University, Boston, MA. 10Division of Oncology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY. 11Division of Blood and Marrow Transplant, Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC. 12Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH. 13Division of Critical Care, Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey, PA. 14Division of Critical Care, Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC.
出版信息
Pediatr Crit Care Med. 2017 Apr;18(4):304-309. doi: 10.1097/PCC.0000000000001061.
OBJECTIVE
Immunodeficiency is both a preexisting condition and a risk factor for mortality in pediatric acute respiratory distress syndrome. We describe a series of pediatric allogeneic hematopoietic stem cell transplant patients with pediatric acute respiratory distress syndrome based on the recent Pediatric Acute Lung Injury Consensus Conference guidelines with the objective to better define survival of this population.
DESIGN
Secondary analysis of a retrospective database.
SETTING
Twelve U.S. pediatric centers.
PATIENTS
Pediatric allogeneic hematopoietic stem cell transplant recipients requiring mechanical ventilation.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
During the first week of mechanical ventilation, patients were categorized as: no pediatric acute respiratory distress syndrome or mild, moderate, or severe pediatric acute respiratory distress syndrome based on oxygenation index or oxygen saturation index. Univariable logistic regression evaluated the association between pediatric acute respiratory distress syndrome and PICU mortality. A total of 91.5% of the 211 patients met criteria for pediatric acute respiratory distress syndrome using the Pediatric Acute Lung Injury Consensus Conference definition: 61.1% were severe, 27.5% moderate, and 11.4% mild. Overall survival was 39.3%. Survival decreased with worsening pediatric acute respiratory distress syndrome: no pediatric acute respiratory distress syndrome 66.7%, mild 63.6%, odds ratio = 1.1 (95% CI, 0.3-4.2; p = 0.84), moderate 52.8%, odds ratio = 1.8 (95% CI, 0.6-5.5; p = 0.31), and severe 24.6%, odds ratio = 6.1 (95% CI, 2.1-17.8; p < 0.001). Nonsurvivors were more likely to have multiple consecutive days at moderate and severe pediatric acute respiratory distress syndrome (p < 0.001). Moderate and severe patients had longer PICU length of stay (p = 0.01) and longer mechanical ventilation course (p = 0.02) when compared with those with mild or no pediatric acute respiratory distress syndrome. Nonsurvivors had a higher median maximum oxygenation index than survivors at 28.6 (interquartile range, 15.5-49.9) versus 15.0 (interquartile range, 8.4-29.6) (p < 0.0001).
CONCLUSION
In this multicenter cohort, the majority of pediatric allogeneic hematopoietic stem cell transplant patients with respiratory failure met oxygenation criteria for pediatric acute respiratory distress syndrome based on the Pediatric Acute Lung Injury Consensus Conference definition within the first week of invasive mechanical ventilation. Length of invasive mechanical ventilation, length of PICU stay, and mortality increased as the severity of pediatric acute respiratory distress syndrome worsened.
目的
免疫缺陷既是小儿急性呼吸窘迫综合征的一种既存状况，也是导致其死亡的一个风险因素。我们依据近期的《小儿急性肺损伤共识会议》指南，描述了一系列患有小儿急性呼吸窘迫综合征的小儿异基因造血干细胞移植患者，目的是更好地界定这一人群的生存率。
设计
对一个回顾性数据库进行二次分析。
地点
美国的12家儿科中心。
患者
需要机械通气的小儿异基因造血干细胞移植受者。
干预措施
无。
测量指标及主要结果
在机械通气的第一周，根据氧合指数或氧饱和度指数，将患者分为：无小儿急性呼吸窘迫综合征或轻度、中度或重度小儿急性呼吸窘迫综合征。单变量逻辑回归分析评估小儿急性呼吸窘迫综合征与儿科重症监护病房（PICU）死亡率之间的关联。根据《小儿急性肺损伤共识会议》的定义，211例患者中有91.5%符合小儿急性呼吸窘迫综合征的标准：61.1%为重度，27.5%为中度，11.4%为轻度。总体生存率为39.3%。随着小儿急性呼吸窘迫综合征病情恶化，生存率下降：无小儿急性呼吸窘迫综合征为66.7%，轻度为63.6%，比值比=1.1（95%置信区间，0.3 - 4.2；p = 0.84），中度为52.8%，比值比=1.8（95%置信区间，0.6 - 5.5；p = 0.31），重度为24.6%，比值比=6.1（95%置信区间，2.1 - 17.8；p < 0.001）。非幸存者更有可能连续多日处于中度和重度小儿急性呼吸窘迫综合征状态（p < 0.001）。与轻度或无小儿急性呼吸窘迫综合征的患者相比，中度和重度患者的PICU住院时间更长（p = 0.01），机械通气疗程更长（p = 0.02）。非幸存者的最大氧合指数中位数高于幸存者，分别为28.6（四分位间距，15.5 - 49.9）和15.0（四分位间距，8.4 - 29.6）（p < 0.0001）。
结论
在这个多中心队列中，大多数患有呼吸衰竭的小儿异基因造血干细胞移植患者在有创机械通气的第一周内，根据《小儿急性肺损伤共识会议》定义符合小儿急性呼吸窘迫综合征的氧合标准。随着小儿急性呼吸窘迫综合征严重程度的加重，有创机械通气时间、PICU住院时间和死亡率均增加。
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