Abstract P-394: BETWEEN A ROCK AND A HARD PLACE- IS A SECOND BONE MARROW TRANSPLANTATION A SUITABLE TREATMENT OPTION IN UNWELL CHILDREN ON PICU?

Abstract

Aims & Objectives: Bone marrow transplantation (BMT) is standard curative treatment for a variety of life-limiting conditions, but it remains a much-debated topic owning to associated life-threatening complications, ethical and psychological burdens on all parties involved. Whilst current evidence supports its efficacy as a curative measure in life-limiting illnesses; re-transplant in severely unwell post BMT children on PICU for the management of failed graft or graft versus host disease (GVHD) raises new ethical dilemmas. Methods I report one of such cases treated in a tertiary UK PICU and the ethical dilemmas posed. An 18-month-old boy was admitted onto PICU with respiratory, intestinal and skin failure 110 days post his first BMT for Juvenile myelomonocytic Leukaemia. He required prolonged ventilatory support for presumed GVHD-related idiopathic pneumonia, subsequent ventilator associated pneumonia and acquired critical illness myopathy. Results Skin and bowel GVHD proved resistant to all treatment including extracorporeal photophresis. Immunosuppressive therapy was complicated by multiresistant infections resulting in liver and renal impairment. Daily blood product requirement suggested engraftment failure. A second BMT on PICU was carried out as the last available option. Unfortunately, he deteriorated rapidly after the second BMT and died with multi-organ failure secondary to Stenotrophamonas sepsis. Conclusions Failure of BMT or GVHD requiring prolonged PICU admission will invariably result in mortality, but re-transplant is not without risk. There is little evidence for the outcome of re-transplantation in severely unwell children and local experience suggests poor outcome is likely. Although re-transplant may be the only curative option; the question remains- Does the benefit outweigh the risk?