A New Algorithm for Preventing Morbidity and Mortality Associated with Inflammation and Third Spacing in Pediatric HSCT Patients

Introduction Many HSCT patients experience severe vital sign changes during their hospital stay often requiring a higher level of service. Treatment historically uses fluid boluses, antibiotics, and vasopressors. However, inflammation places HSCT patients at risk of third spacing and fluid overload, prompting the need for targeted resuscitative efforts dependent on the etiology of the patientOs vital sign abnormalities. Objective We propose a novel treatment algorithm for patients receiving HSCT created in collaboration with the pediatric intensive care unit (PICU) at Texas ChildrenOs Hospital to provide targeted resuscitation for HSCT patients. The overarching goal is to limit morbidities associated with resuscitation and minimize differences in management across PICU and HSCT teams. Methods Our center is employing a grading system from 1 to 4 based on hemodynamics at various phases of HSCT (Figure A). This system will identify what we are characterizing as cytokine shock syndrome (CSS). Once they reach a grade of 1, they will receive antibiotics, albumin, hydrocortisone, and blood products as needed. There will be a maximum of 20 ml/kg of colloids given before starting pressors to avoid further fluid overload. Blood transfusions and albumin will be used as the fluids of choice. For worsening scores, they will receive additional targeted cardiac and respiratory interventions (Figure B). Echocardiogram and central venous pressure will provide additional resources for targeted management. Results Four patients to date have been managed according to this algorithm. All patients responded to therapy and received antibiotics, albumin, hydrocortisone, and TNF antibody without the need of further escalation of care. Conclusions We demonstrate that providing targeted therapy to HSCT patients has the potential to identify and treat HSCT patients early and prevent morbidity and mortality due to aggressive nonspecific treatment efforts when rapidly deteriorating. With further validation, this poses a promising alternative to existing supportive care measures.