(814) Assessing Intubation Risk and Extubation Success in Hematopoietic Stem Cell Pediatric Recipients

Introduction: Although hematopoietic stem cell transplant (HSCT) is a potentially curative therapy for children with malignant and non-malignant disease, it is associated with significant complications. Mortality rates exceed 60% in those requiring intubation. The goal of this study is to describe risk factors for intubation, characteristics of extubation success, and outcomes of HSCT recipients admitted to the PICU.

Methods: An IRB approved retrospective chart analysis was conducted at a single quaternary care center. Patients with history of HSCT admitted to the PICU between November 2020 and August 2022 were captured. Patient demographics, transplant characteristics, indication for ICU admission, critical interventions, and outcomes were manually extracted from the health record. Comparisons of intubation status and extubation success were made using two-sample hypothesis tests with p-value of < 0.05 as significant.

Results: A total of 92 PICU admissions among 45 patients were included in this study, where 30 of the admissions required intubation. Transplant related complications associated with increased risk of intubation included thrombotic microangiopathy (67% vs. 39%, p= 0.012) and acute kidney injury (AKI) on or within 24 hours of PICU admission (50% vs. 23%, p=0.008). Lack of veno-occlusive disease was associated with decreased risk of intubation (82% vs. 57%, p=0.009). The use of high flow nasal cannula (HFNC) as respiratory support was also associated with increased need for intubation (57% vs. 27%, p= 0.006). There was no association with use of non-invasive positive pressure ventilation and intubation. Of patients requiring intubation, 50% were able to be successfully extubated on first attempt while 40% did not survive ICU admission. Risk factors associated with extubation failure included a diagnosis of AKI (85% vs. 24%, p< 0.001) and use of HFNC prior to intubation (85% vs. 35%, p=0.007). Of patients who required intubation and continuous renal replacement therapy, only 18% survived to hospital discharge and none remain alive.

Conclusions: HSCT recipients represent a complicated pediatric population with many risk factors for intubation. The use of HFNC and development of AKI are particularly concerning for intubation need and subsequent extubation failure, thus contributing to mortality.