DataSheet_2_Extracorporeal Membrane Oxygenation Candidacy in Pediatric Patients Treated With Hematopoietic Stem Cell Transplant and Chimeric Antigen Receptor T-Cell Therapy: An International Survey.pdf

IntroductionPediatric patients who undergo hematopoietic cell transplant (HCT) or chimeric antigen receptor T-cell (CAR-T) therapy are at high risk for complications leading to organ failure and the need for critical care resources. Extracorporeal membrane oxygenation (ECMO) is a supportive modality that is used for cardiac and respiratory failure refractory to conventional therapies. While the use of ECMO is increasing for patients who receive HCT, candidacy for these patients remains controversial. We therefore surveyed pediatric critical care and HCT providers across North America and Europe to evaluate current provider opinions and decision-making and institutional practices regarding ECMO use for patients treated with HCT or CAR-T.
MethodsAn electronic twenty-eight question survey was distributed to pediatric critical care and HCT providers practicing in North America (United States and Canada) and Europe through the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network and individual emails. Responses to the survey were recorded in a REDCap® database.
ResultsTwo-hundred and ten participants completed the survey. Of these, 159 (76%) identified themselves as pediatric critical care physicians and 47 (22%) as pediatric HCT physicians or oncologists. The majority (99.5%) of survey respondents stated that they would consider patients treated with HCT or CAR-T therapy as candidates for ECMO support. However, pediatric critical care physicians identified more absolute and relative contraindications for ECMO than non-pediatric critical care physicians. While only 0.5% of respondents reported that they consider HCT as an absolute contraindication for ECMO, 6% of respondents stated that ECMO is contraindicated in HCT patients within their institution and only 23% have an institutional protocol or policy to guide the evaluation for ECMO candidacy of these patients. Almost half (49.1%) of respondents would accept a survival to hospital discharge of 20-30% for pediatric HCT patients requiring ECMO as adequate.
ConclusionsECMO use for pediatric patients treated with HCT and CAR-T therapy is generally acceptable amongst physicians. However, there are differences in the evaluation and decision-making regarding ECMO candidacy amongst providers across medical specialties and institutions. Therefore, multidisciplinary collaboration is an essential component in establishing practice guidelines and advancing ECMO outcomes for these patients.

引言
接受造血干细胞移植（hematopoietic cell transplant, HCT）或嵌合抗原受体T细胞（chimeric antigen receptor T-cell, CAR-T）疗法的儿科患者，发生并发症进而导致器官衰竭并需重症监护资源支持的风险极高。体外膜肺氧合（extracorporeal membrane oxygenation, ECMO）是一种支持性治疗手段，用于经传统治疗无效的心脏和呼吸衰竭患者。尽管接受HCT治疗的患者使用ECMO的比例不断上升，但此类患者的ECMO应用指征仍存在争议。为此，我们对北美及欧洲的儿科重症监护与HCT医护人员开展了一项调查，以评估当前医护人员对于HCT或CAR-T疗法患者使用ECMO的观点、决策流程及机构实践规范。

方法
我们通过儿科急性肺损伤与脓毒症研究者（Pediatric Acute Lung Injury and Sepsis Investigators, PALISI）网络及个人邮件，向在北美（美国与加拿大）及欧洲执业的儿科重症监护与HCT医护人员发放了一份包含28个问题的电子调查问卷。所有问卷回复均录入REDCap®数据库中。

结果
共有210名参与者完成了本次调查。其中159名（76%）为儿科重症监护医师，47名（22%）为儿科HCT医师或肿瘤医师。绝大多数（99.5%）受访者表示，他们会将接受HCT或CAR-T疗法的患者视为ECMO支持的适用对象。但儿科重症监护医师相较于非儿科重症监护医师，列出了更多ECMO的绝对与相对禁忌证。尽管仅有0.5%的受访者表示，他们将HCT视为ECMO的绝对禁忌证，但有6%的受访者称，其所在机构认为HCT患者禁用ECMO，且仅23%的机构拥有针对此类患者ECMO指征评估的标准化流程或政策。近半数（49.1%）受访者认为，需接受ECMO治疗的儿科HCT患者，若能达到20%~30%的出院存活率即可接受。

结论
临床医师普遍认可对接受HCT与CAR-T疗法的儿科患者使用ECMO。但不同医学专科及机构的医护人员，在ECMO指征评估与决策流程方面仍存在差异。因此，多学科协作是制定实践指南、改善此类患者ECMO治疗结局的核心要素。