Safety of Pleural and Peritoneal Drain Placement in Pediatric Hematopoietic Cell Transplant Recipients with Veno-Occlusive Disease

Background: Thoracentesis and or paracentesis via pleural or peritoneal drains (PD) are often needed in hematopoietic cell transplant (HCT) patients with veno-occlusive disease (VOD) to relieve intra-abdominal pressure, improve respiratory mechanics and renal perfusion. However, these may increase the risk of infection in immunosuppressed patients. Methods: A retrospective study of HCT patients who developed VOD during the study period from January 1995 – May 2017 was conducted to analyze the safety of these procedures. Results: Thirty-nine (39) HCT patients developed VOD at a median of 12 days (range 3-29) post-HCT. Median age at transplant was 2 years (range 1 month-17 years). Thirty-six (36, 93%) patients received myeloablative conditioning, including 25 with busulfan-based conditioning. Peritoneal drain (PD) was placed in 22 (56%) patients, including 11 HCT recipients with severe VOD, at a median of 3 days (range 0-31) from the day of VOD diagnosis. Seven (18%) patients also had a chest tube (CT) placed at a median of 12.5 days (range 7-33) from VOD diagnosis. Ten (26%) patients were neutropenic at the time of PD or CT placement. Hypoxia or tense ascites were common indications for PD placement. Drains were placed by interventional radiologists (n = 12) or intensivists (n = 10). Five of the 22 (23%) patients developed hypotension requiring fluid resuscitation. Seven (32%) patients with PD experienced drain obstruction requiring intervention, 6 (86%) were replaced. Obstruction and dislodgement (one each) were encountered with CTs. Median duration of PDs and CTs were 17 (range 4-55) and 6 (range 0-12) days, respectively. Two cases of peritonitis due to gram-negative rods (by gram stain only) occurred and both responded to treatment. Overall mortality was 46% (18/39 patients), but no deaths were directly attributed to drain placement. Conclusion: Paracentesis and thoracentesis with drain placement were found to be safe in most patients who developed VOD.