Introduction of the oncological pediatric risk of mortality score (O-PRISM) for ICU support following stem cell transplantation in children.

Prognostic scoring systems based on physiological parameters have been established in order to predict the outcome of ICU patients. It has been demonstrated that the predictive value of these scores is limited in patients following hematopoietic stem cell transplantation (HSCT). Therefore, we evaluated patients from the Düsseldorf pediatric stem cell transplantation center with regard to predisposing factors and prognostic variables for ICU treatment and outcome. Between January 1989 and December 1998, 180 HSCT have been performed. The clinical, laboratory and HSCT-related parameters such as conditioning treatment, engraftment, GVHD, infections and HSCT toxicity were prospectively recorded and retrospectively analyzed. Established pediatric scoring systems (PRISM, TISS, P-TISS) were applied. Twenty-eight patients required intensive care (16 male, 12 female, median age: 10.9 years (range: 0.4 to 18.9 years), five autologous, 13 allogeneic-related and 10 unrelated transplanted patients). Ventilator-dependent respiratory failure was the most frequent cause of admission to the ICU (n = 23). Fourteen of 28 patients were discharged from ICU, and six of 28 patients achieved a long-term survival (110 to 396 weeks). At admission to the ICU, impaired cardiovascular status, high CRP levels and presence of macroscopic bleeding were each associated with fatal outcome (P < 0.05). The Pediatric Risk of Mortality (PRISM) score was not prognostically significant at the 0.05 level. Long-term survival after discharge from the ICU correlated with HSCT-related parameters such as the type of transplant and severity of GVHD (P = 0.002). By introduction of HSCT related parameters such as severity of GVHD (grade 2: 2 points; grade >2: 4 points), CRP-level (>10 mg/dl: 4 points), and presence of macroscopic bleeding (4 points) into the PRISM score a new oncological PRISM ('O-PRISM') score was established. This score significantly correlated with the risk of mortality in the ICU (P = 0.01). In conclusion, the new O-PRISM score accurately characterizes the clinical situation of children requiring ICU treatment following HSCT. It distinguishes more appropriately between success and failure of ICU treatment following HSCT than the standard prognostic scores. It needs to be evaluated in future prospective studies of critically ill children after HSCT. Bone Marrow Transplantation (2000).

'Sepsis' and multi-organ failure: predictors of poor outcome after hematopoietic stem cell transplantation in children.

Prognostic scores, such as the PRISM and APACHE II, have been established, predicting with reasonable accuracy the outcome of patients admitted to intensive care units (ICU). In keeping with previous reports, we found, however, that these scores failed to perform in a series of 28 recipients of hematopoietic auto- or allografts (BMT) who required ICU admission for reasons including respiratory (82%) and multi-organ (36%) failure. We therefore retrospectively analyzed the charts of these patients, evaluating predisposing factors and prognostic variables which might confound the validity of these ICU tools which in other clinical scenarios have proven so valuable. Of all the parameters tested, logistic analysis established the following as predictors for poor outcome: increased C-reactive protein (CRP) to > 10 mg/dl (P = 0.04), macroscopic hemorrhage (P = 0.04), hypotension (mean arterial pressure < normal) (P = 0.04) and GVHD > or = III (P = 0.002). Most of these factors are not accounted for by the standard prognostic questionnaires. The development of an 'oncological' or 'post-BMT' risk of mortality score, taking into account these patients' specific clinical problems, might improve the risk assessment for this patient group, and might thus facilitate the timely recognition of those patients most in need of more intensive therapeutic measures.

[Early diagnosis of severe brain damage of premature and newborn infants under intensive care. A polygraphic study (author's transl)]. / Früherkennung schwerer Cerebralschäden bei Früh- und Neugeborenen unter Intensivtherapie. Eine polygraphische Untersuchung.

24 premature and newborn infants under intensive care (intubation and artificial respiration) were subjected to a polygraphic examination in order to diagnose severe brain damage already in the acute stage of a disease. The results collected in the polygraphic recording were correlated to the further development and progress of the infant. Nine infants die within one week--all of these underwent a post-Mortem examination. Diagnosis of brain damage was confirmed by post-mortem examination or by a clinical neurological follow-up examination. All infants with severe brain damage showed pathological polygraphic recordings. In contrast to this, clinical neurological examination at the time of the polygraphic recording did not reveal such pathological results in all of these infants. Important was the EEG, supplemented by determining the bioelectric brain maturation, the differentiation of sleep states and the correlation of these derived parameter to the behavior pattern of the infant. The heart rate frequency and variability could not be used to make an useful diagnostic statement.

Perinatal hypoxia and bioelectric brain maturation of the newborn infant.

Bioelectric brain maturation of twenty infants who had suffered acute perinatal hypoxia (patients) was compared with that of twenty healthy newborns (controls). None of the patients had suffered any other pre- or perinatal complications that could have influenced the bioelectric brain maturation. All infants (postmenstrual age: 40--42 weeks) were subjected to a polygraphic recording. The patients were examined after the acute phase of their disease; all were in good clinical condition at the time of recording. Statistic evaluation revealed significantly retarded bioelectric brain maturation in the patient group. Furthermore, a more immature EEG pattern was found to correspond to greater extent of oxygen deprivation. The study shows: determination of bioelectric brain maturation can be used to obtain information about suffered hypoxia and extent of oxygen deprivation.

[Partial tracheal rupture in a newborn infant. A rare traumatic birth complication or intubation sequela?]. / Tracheateilabriss bei einem Neugeborenen. Seltene geburtstraumatische Komplikation oder Intubationsfolge?

The neonate was born with the help of vacuum extraction because of difficult delivery of the shoulders. After birth respiratory distress developed and endotracheal intubation and artificial ventilation became necessary. When the tube was changed in the intensive care unit the infant's clinical status suddenly deteriorated. A rupture of the trachea was diagnosed immediately followed by surgery. The child survived without neurological sequelae. The chronological sequence of symptoms after birth suggests that the rupture of the trachea primarily developed during delivery and was secondarily enlarged by repeated endotracheal intubation.

Efficiency of heparin in the treatment of newborn infants with respiratory distress syndrome and disseminated intravascular coagulation.

Forty newborns with severe shock and disseminated intravascular coagulation were randomized for treatment with heparin or placebo. Mortality was equal in both groups. The heparin group required significantly shorter periods of artificial ventilation. The coagulation system improved faster, and the coagulation pattern showed normal values in the treatment group. Due to the low number of cases, these differences could not be statistically confirmed.