Abstract
Background: The landscape of paediatric oncology has undergone a remarkable transformation over recent decades. Advances in both oncological and supportive therapies have dramatically improved survival in children with haematological malignancies and solid tumours, with current survival rates exceeding 80% for many childhood cancers. However, this therapeutic success has brought with it an unexpected consequence: the intensification of treatment protocols has led to a parallel increase in life-threatening complications requiring intensive care support. Current evidence indicates that up to 40% of paediatric oncology patients will require admission to a Paediatric Intensive Care Unit (PICU) at some point during their disease trajectory. Objectives: This comprehensive review synthesises current evidence to provide an updated framework for PICU admission decision-making in oncology haematology patients. We have integrated the most recently published international guidelines, including the groundbreaking Phoenix 2024 sepsis criteria and the updated PALICC-2 2023 recommendations for paediatric acute respiratory distress syndrome. Beyond establishing admission criteria, we critically analyse the efficacy of advanced support strategies and examine emerging therapeutic approaches in this uniquely vulnerable population. Methods: Our methodology encompassed a systematic review of the literature published between 2011 and 2024, complemented by a detailed analysis of current international guidelines and expert consensus statements. We included randomised controlled trials, observational studies, meta-analyses, and consensus conference proceedings specifically addressing the intensive care management of paediatric patients with oncological or haematological conditions. Main Results: Several key findings emerge from our analysis. The Phoenix 2024 criteria represent a fundamental reconceptualisation of paediatric sepsis diagnosis, validated through an unprecedented dataset encompassing more than 3 million paediatric encounters. In the realm of respiratory support, early implementation of non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP) has demonstrated remarkable efficacy, reducing the need for invasive mechanical ventilation by 45% (RR 0.45, 95% CI 0.26-0.78) when applied to appropriately selected patients. Extracorporeal membrane oxygenation (ECMO), whilst increasingly utilised, shows survival to decannulation ranging from 52% to 64%, though survival to hospital discharge remains less encouraging at 36-42%. Continuous renal replacement therapy (CRRT) has proven highly effective for tumour lysis syndrome, achieving metabolic correction in 90% of severe cases. Perhaps most promisingly, emerging biomarkers-particularly interleukin-6, interleukin-10, and procalcitonin-have substantially enhanced our ability to stratify infection risk, demonstrating sensitivity exceeding 85% for bacteraemia detection. Conclusions: The evidence unequivocally supports several core principles for optimising outcomes in this population. Early identification of deterioration through validated scoring systems enables timely intervention before irreversible organ failure develops. Prompt implementation of non-invasive respiratory support, when appropriately applied, can obviate the need for mechanical ventilation with its attendant complications. Perhaps most critically, centralisation of care in centres with dedicated expertise and comprehensive support capabilities fundamentally improves survival. These findings argue compellingly for the establishment of a formal national network of reference centres, implementing standardised protocols and structured care pathways specifically designed for critically ill paediatric oncology haematology patients.