Abstract
IntroductionPediatric patients who undergo hematopoietic cell transplant (HCT) or chimeric antigen receptor T-cell (CAR-T) therapy are at high risk for complications leading to organ failure and the need for critical care resources. Extracorporeal membrane oxygenation (ECMO) is a supportive modality that is used for cardiac and respiratory failure refractory to conventional therapies. While the use of ECMO is increasing for patients who receive HCT, candidacy for these patients remains controversial. We therefore surveyed pediatric critical care and HCT providers across North America and Europe to evaluate current provider opinions and decision-making and institutional practices regarding ECMO use for patients treated with HCT or CAR-T.MethodsAn electronic twenty-eight question survey was distributed to pediatric critical care and HCT providers practicing in North America (United States and Canada) and Europe through the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network and individual emails. Responses to the survey were recorded in a REDCap® database.ResultsTwo-hundred and ten participants completed the survey. Of these, 159 (76%) identified themselves as pediatric critical care physicians and 47 (22%) as pediatric HCT physicians or oncologists. The majority (99.5%) of survey respondents stated that they would consider patients treated with HCT or CAR-T therapy as candidates for ECMO support. However, pediatric critical care physicians identified more absolute and relative contraindications for ECMO than non-pediatric critical care physicians. While only 0.5% of respondents reported that they consider HCT as an absolute contraindication for ECMO, 6% of respondents stated that ECMO is contraindicated in HCT patients within their institution and only 23% have an institutional protocol or policy to guide the evaluation for ECMO candidacy of these patients. Almost half (49.1%) of respondents would accept a survival to hospital discharge of 20-30% for pediatric HCT patients requiring ECMO as adequate.ConclusionsECMO use for pediatric patients treated with HCT and CAR-T therapy is generally acceptable amongst physicians. However, there are differences in the evaluation and decision-making regarding ECMO candidacy amongst providers across medical specialties and institutions. Therefore, multidisciplinary collaboration is an essential component in establishing practice guidelines and advancing ECMO outcomes for these patients.
Highlights
Pediatric patients who undergo hematopoietic cell transplant (HCT) or chimeric antigen receptor T-cell (CAR-T) therapy are at high risk for complications leading to organ failure and the need for critical care resources
Given the global improvements in the care of pediatric HCT patients and increasing use of CAR-T therapy, we surveyed providers across North America and Europe to evaluate the current opinions and practice regarding Extracorporeal membrane oxygenation (ECMO) use for pediatric patients treated with HCT and CAR-T therapy
We formed a multidisciplinary committee consisting of seven pediatric critical care physicians, including one extracorporeal life support program director, and two bone marrow transplant/ cellular therapy physicians to develop a 28-question survey to evaluate three major content areas: [1] physician and institutional experience in caring for pediatric HCT and ECMO patients; [2] provider opinions and institutional practices regarding the use of ECMO support for pediatric HCT patients; and [3] provider opinions and institutional practices regarding the use of ECMO support for pediatric CAR-T patients (Supplemental Figure 1)
Summary
Pediatric patients who undergo hematopoietic cell transplant (HCT) or chimeric antigen receptor T-cell (CAR-T) therapy are at high risk for complications leading to organ failure and the need for critical care resources. Pediatric and young adult patients who receive hematopoietic cell transplant (HCT) are at high risk for multi-organ dysfunction and need for critical care support. Over the last decade, recognizing these advances and the knowledge gained from the care of critically ill pediatric HCT patients, some centers have reported successful ECMO use in a certain HCT patients [15,16,17,18,19]. These reports have led to a renewal of interest and suggest improving outcomes for pediatric HCT patients supported with ECMO. This is supported by recent reports that demonstrate improved survival of 26-50% for pediatric HCT patients supported with ECMO since 2010 [20, 21]
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