Flerlage Tim, Fan Kimberly, Qin Yidi, Agulnik Asya, Arias Anita V, Cheng Cheng, Elbahlawan Lama, Ghafoor Saad, Hurley Caitlin, McArthur Jennifer, Morrison R Ray, Zhou Yinmei, Park H J, Carcillo Joseph A, Hines Melissa R
Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN.
Division of Critical Care, Department of Pediatrics, MD Anderson Cancer Center, Houston, TX.
Crit Care Explor. 2023 Sep 27;5(10):e0976. doi: 10.1097/CCE.0000000000000976. eCollection 2023 Oct.
To use supervised and unsupervised statistical methodology to determine risk factors associated with mortality in critically ill pediatric oncology patients to identify patient phenotypes of interest for future prospective study.
This retrospective cohort study included nonsurgical pediatric critical care admissions from January 2017 to December 2018. We determined the prevalence of multiple organ failure (MOF), ICU mortality, and associated factors. Consensus -means clustering analysis was performed using 35 bedside admission variables for early, onco-critical care phenotype development.
Single critical care unit in a subspeciality pediatric hospital.
None.
There were 364 critical care admissions in 324 patients with underlying malignancy, hematopoietic cell transplant, or immunodeficiency reviewed.
Prevalence of multiple organ failure, ICU mortality, determination of early onco-critical care phenotypes.
ICU mortality was 5.2% and was increased in those with MOF (18.4% MOF, 1.7% single organ failure [SOF], 0.6% no organ failure; ≤ 0.0001). Prevalence of MOF was 23.9%. Significantly increased ICU mortality risk was associated with day 1 MOF (hazards ratio [HR] 2.27; 95% CI, 1.10-6.82; = 0.03), MOF during ICU admission (HR 4.16; 95% CI, 1.09-15.86; = 0.037), and with invasive mechanical ventilation requirement (IMV; HR 5.12; 95% CI, 1.31-19.94; = 0.018). Four phenotypes were derived (PedOnc1-4). PedOnc1 and 2 represented patient groups with low mortality and SOF. PedOnc3 was enriched in patients with sepsis and MOF with mortality associated with liver and renal dysfunction. PedOnc4 had the highest frequency of ICU mortality and MOF characterized by acute respiratory failure requiring invasive mechanical ventilation at admission with neurologic dysfunction and/or severe sepsis. Notably, most of the mortality in PedOnc4 was early (i.e., within 72 hr of ICU admission).
Mortality was lower than previously reported in critically ill pediatric oncology patients and was associated with MOF and IMV. These findings were further validated and expanded by the four derived nonsynonymous computable phenotypes. Of particular interest for future prospective validation and correlative biological study was the PedOnc4 phenotype, which was composed of patients with hypoxic respiratory failure requiring IMV with sepsis and/or neurologic dysfunction at ICU admission.
运用监督式和非监督式统计方法，确定危重症儿科肿瘤患者的死亡风险因素，以识别值得未来进行前瞻性研究的患者表型。
这项回顾性队列研究纳入了2017年1月至2018年12月非手术治疗的儿科重症监护病房收治病例。我们确定了多器官功能衰竭（MOF）的发生率、重症监护病房死亡率及相关因素。使用35项床边入院变量进行共识均值聚类分析，以确定早期肿瘤重症监护表型。
一家儿科专科医院的单一重症监护病房。
无。
对324例患有潜在恶性肿瘤、造血细胞移植或免疫缺陷的患者进行了364次重症监护病房收治病例回顾。
多器官功能衰竭的发生率、重症监护病房死亡率、早期肿瘤重症监护表型的确定。
重症监护病房死亡率为5.2%，多器官功能衰竭患者的死亡率更高（多器官功能衰竭患者为18.4%，单器官功能衰竭患者为1.7%，无器官功能衰竭患者为0.6%；P≤0.0001）。多器官功能衰竭的发生率为23.9%。重症监护病房死亡风险显著增加与第1天出现多器官功能衰竭（风险比[HR]2.27；95%置信区间[CI]，1.10 - 6. . . 82；P = 0.03）、重症监护病房住院期间出现多器官功能衰竭（HR 4.16；95% CI，1.09 - 15.86；P = 0.037）以及需要有创机械通气（IMV；HR 5.12；95% CI，1.31 - 19.9 . . . 4；P = 0.018）有关。得出了四种表型（PedOnc1 - 4）。PedOnc1和2代表死亡率低且为单器官功能衰竭的患者组。PedOnc3中脓毒症和多器官功能衰竭患者较多，其死亡率与肝肾功能障碍有关。PedOnc4的重症监护病房死亡率和多器官功能衰竭发生率最高，其特征为入院时因急性呼吸衰竭需要有创机械通气，伴有神经功能障碍和/或严重脓毒症。值得注意的是，PedOnc4中的大多数死亡发生在早期（即重症监护病房入院后72小时内）。
危重症儿科肿瘤患者的死亡率低于先前报道，且与多器官功能衰竭和有创机械通气有关。这四项得出的非同义可计算表型进一步验证并扩展了这些发现。未来进行前瞻性验证和相关生物学研究特别感兴趣的是PedOnc4表型，该表型由入住重症监护病房时因缺氧性呼吸衰竭需要有创机械通气且伴有脓毒症和/或神经功能障碍的患者组成。
