Table 1.

Considerations when Discussing ECLS Candidacy in Pediatric HCT Patients

Considerations when Discussing ECLS Candidacy in Pediatric HCT Patients
Factor 1) Current Comorbidities • What current infections are present or suspected and how have they responded to therapy? What is their prognosis in light of forecasted immune reconstitution? • What end-organ toxicities exist (including significant neurological injury)? Can these be quantified/staged? What available therapies exist to address these toxicities and what is the ultimate prognosis? Is the cardiac and/or respiratory failure which requires ECLS potentially reversible? • What bleeding & hemostatic complications are present? Can these be corrected with transfusional/other support? Are there deep venous thromboses complicating cannulation?
Factor 2) Underlying Disease and Prognosis • If the underlying disease is malignant, what is the chance of post-HCT relapse? (This is affected by disease status, remission, and other characteristics at the time of HCT) • If the underlying disease is non-malignant, what is the chance of cure due to HCT? • What disease specific toxicities were present prior to HCT? (i.e.: chronic transfusion related iron overload, chemotherapy-related toxicities, chronic infections, chronic cardiac dysfunction, etc)
Factor 3) HCT-Specific Comorbidities • What is the current graft function? Has the patient achieved neutrophil/platelet engraftment? Have T-cells reconstituted? What is the donor chimerism? (These can inform the prognosis for immune reconstitution) • Does the patient have acute or chronic GVHD? What organs are involved and of what severity? Has the patient been responsive to therapy, and if not, what additional therapies are available? • Has the patient developed an endothelial injury syndrome such as VOD/SOS, TMA, or IPS? How has this responded to therapy? • Has the patient developed other HCT-specific comorbidities?
Factor 4) Family and patient desires and expectations • What are the expectations regarding ongoing maximally intensive care in the setting of severe critical illness? • What are the cares desired vs. declined? • Has an advance directive been discussed with the patient? • Are those who provided longitudinal care and the psychosocial and palliative care teams involved?
Factor 5) HCT Conditioning Regimen • What conditioning regimen was used and what toxicities were caused by it? (This is particularly relevant for TBI and myeloablative conditioning regimens) • How will the conditioning regimen affect the rate of immune reconstitution (Use of serotherapy such as ATG, alemtuzumab)
Factor 6) HCT Graft Characteristics • Was the graft from the patient (autologous) or a donor (allogeneic)? • Was the graft HLA-matched? • Was the graft modified, depleted, or enriched in certain cell types that might affect the patient’s immune reconstitution? (The restoration of the patient’s immune system is key for short-term survival)