Dynamic Prediction of ICU Transfer and Critical Interventions After Pediatric Allogeneic HSCT

Authors

Taylor L. Olson, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA. Electronic address: tolson@childrensnational.org.
Eduardo A. Rivera, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
Blachy J. Saldaña, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA.
Maryanne C. Odinakachukwu, Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA.
Anita K. Patel, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
Murray M. Pollack, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.

Document Type

Journal Article

Publication Date

1-23-2026

Journal

Transplantation and cellular therapy

DOI

10.1016/j.jtct.2026.01.030

Keywords

child; critical care; early warning systems; hematopoietic stem cell transplantation; intensive care units; physiologic monitoring; proportional hazards models; risk assessment; treatment outcome

Abstract

BACKGROUND: National and international hematopoietic stem cell transplantation (HSCT) societies recommend the use of early warning systems to detect clinical deterioration after pediatric HSCT. Commonly utilized tools, such as vital-sign-based early warning scores, do not incorporate pre-transplant risk factors, rely on categorization of vital sign ranges, and generate static scores applicable to single points in time. OBJECTIVE: To predict the future need for 1) ICU transfer and 2) ICU transfer with critical intervention following pediatric allogeneic HSCT by integrating baseline demographic and transplant characteristics with dynamic changes in post-transplant physiologic variables. STUDY DESIGN: Retrospective observational cohort study of patients admitted for first allogeneic HSCT at Children's National Hospital from January 1, 2012, through December 31, 2022. Patients were observed for ICU outcomes from transplant to day 100 or hospital discharge. Statistical analyses included Kaplan-Meier survival analysis and time-dependent univariate and multivariate Cox proportional hazards regression. We also report 100-day and 1-year mortality. RESULTS: Among 307 pediatric HSCT recipients, 73 (24%) required ICU transfer and 37 (12%) received ≥ 1 critical intervention (invasive mechanical ventilation, vasoactive medication administration, and/or renal replacement therapy). The cumulative incidence of both outcomes plateaued by day 45 post-HSCT, with 65% of at-risk patients remaining free of ICU transfer and 81% free of ICU critical interventions. The final multivariate Cox proportional hazards models incorporated pre-transplant variables and dynamic post-transplant physiologic changes, demonstrating excellent performance with daily C-statistics ranging from 0.83 to 0.86 for ICU transfer and 0.89 to 0.93 for ICU transfer with critical intervention. Overall mortality was 6% at 100 days and 15% at 1 year, but was higher among patients requiring ICU transfer (22% at 100 days, 37% at 1 year) and highest among those requiring critical interventions (38% at 100 days, 65% at 1 year). CONCLUSION: Dynamic modelling of pre-transplant factors and evolving post-transplant physiologic trajectories can quantify the changing risk of clinical deterioration over time after pediatric HSCT. The performance of our models is appropriate for implementation, meeting the recommendations of national and international societies for the use of early warning systems. Implementation of dynamic early warning systems such as this may enable earlier recognition, enhanced surveillance, and potentially improved outcomes for high-risk patients.

APA Citation

Olson, Taylor L.; Rivera, Eduardo A.; Saldaña, Blachy J.; Odinakachukwu, Maryanne C.; Patel, Anita K.; and Pollack, Murray M., "Dynamic Prediction of ICU Transfer and Critical Interventions After Pediatric Allogeneic HSCT" (2026). GW Authored Works. Paper 8533.
https://hsrc.himmelfarb.gwu.edu/gwhpubs/8533

Department

Pediatrics