Massive Bleeding in Children With Cancer or Hematopoietic Cell Transplant: International, Multicenter Retrospective Study, 2017-2021

Marianne E. Nellis, Division of Pediatric Critical Care, Department of Pediatrics, Weill Cornell Medicine, New York, NY.
Marie E. Steiner, Divisions of Hematology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN.
Saleh Bhar, Pediatric Critical Care Medicine and Hematology Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX.
Jennifer McArthur, Department of Pediatric Critical Care Medicine, St Jude Children's Research Hospital, Memphis, TN.
Ali McMichael, Phoenix Children's, Division of Pediatric Critical Care, Department of Child Health, University of Arizona College of Medicine, Phoenix, AZ.
April L. Rahrig, Department of Pediatrics, Division of Hematology/Oncology/Stem Cell Transplant, Indiana University School of Medicine, Indianapolis, IN.
Christine Leeper, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
Salvatore Perdichizzi, Anesthesia and Critical Care Medicine, Department of Pediatric Critical Care, Bambino Gesù Children's Hospital, Rome, Italy.
Fabrizio Chiusolo, Anesthesia and Critical Care Medicine, Department of Pediatric Critical Care, Bambino Gesù Children's Hospital, Rome, Italy.
Jacob Shamash, Division of Pediatric Critical Care, Department of Pediatrics, Weill Cornell Medicine, New York, NY.
Nora Bruns, Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
Hilary Schreiber, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
Matthew P. Sharron, Pediatric Critical Care Medicine, Department of Pediatrics, Children's National Hospital/George Washington University School of Medicine, Washington, DC.
Laura Butragueño-Laiseca, Pediatric Intensive Care Unit, Department of Pediatric Critical Care, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
James S. Killinger, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY.
Charlene P. Pringle, Department of Pediatrics, Critical Care Medicine, University of Florida, Gainesville, FL.
Samantha M. Koenig, Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL.
Cassandra Josephson, Departments of Oncology, Pediatrics, and Pathology, Johns Hopkins University School of Medicine, Baltimore, MD.
David Crawford, Department of Pediatrics, Division of Hematology and Oncology, University of Miami Miller School of Medicine, Miami, FL.
Briana L. Scott, Division of Critical Care Medicine, University of Rochester Medical Center, Rochester, NY.
Kenneth E. Remy, Departments of Internal Medicine and Pediatrics, Case Western University School of Medicine, University Hospitals of Cleveland, Cleveland, OH.
Christine Puthawala, Pediatric Critical Care Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT.
Philip C. Spinella, Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA.

Document Type

Journal Article

Publication Date

4-25-2025

Journal

Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

DOI

10.1097/PCC.0000000000003751

Keywords

bleeding; cancer; children; critical illness; hematopoietic cell transplant; hemorrhage

Abstract

OBJECTIVES: To characterize the epidemiology and management of massive bleeding events in children with cancer and/or hematopoietic cell transplant (HCT). DESIGN: Multicenter, retrospective cohort study. SETTING: Nineteen pediatric hospitals in Europe and United States. SUBJECTS: Children ages 0-21 years old with malignancy and/or HCT and massive bleeding admitted from January 1, 2017, to December 31, 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics, oncologic history, laboratory values, interventions, and PICU outcomes were collected. One hundred fifty-two bleeding episodes from 135 patients were analyzed. The median (interquartile range [IQR]) age was 7 years (2-14 yr). Forty-three percent (58/135) were female sex. Nineteen percent of children (26/135) had death attributable to hemorrhage. Forty percent had solid tumors and one-third had undergone at least one HCT. The majority of bleeding events occurred in the PICU (81/152, 53%). The median (IQR) platelet count at time of bleeding was 52 × 109/L (24-115 × 109/L), prothrombin time 18.5 seconds (15.2-24.8 s), activated partial thromboplastin time 42.2 seconds (33.2-56.0 s), and international normalized ratio 1.51 (1.21-2.11). To treat these bleeding events, 99% (148/152) of the time children received RBC transfusions, 84% (126/152) of the time plasma transfusions, 88% (132/152) of the time platelet transfusions, and less than one-fifth hemostatic medications. Half (77/152, 52%) of the time the children received high plasma ratios and half (73/152, 49%) received high platelet ratios. Pulmonary bleeding, oral/nasal bleeding, and receipt of prothrombin complex concentrate were each associated with greater odds of death attributed to hemorrhage: odds ratio (95% CI), respectively: 5.44 (2.250-13.171; p < 0.001); 3.30 (1.20-9.09; p = 0.021); and 3.24 (1.18-8.93; p = 0.023). CONCLUSIONS: Children with malignancy and/or HCT have a high mortality rate from hemorrhage despite being hospitalized at the time of their bleeding event. The majority of children received balanced resuscitation. Definitive trials are needed to determine optimal hemostatic resuscitation practice in this population.

Department

Pediatrics

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