Critical care in hematopoietic stem cell transplantation: Common complications and management

This narrative review synthesizes contemporary evidence regarding critical care complications following hematopoietic stem cell transplantation (HSCT) and evaluates management strategies for improving outcomes in this complex population. We conducted a comprehensive literature search of MEDLINE/PubMed databases from January 2014 to December 2024, focusing on critical care complications, prognostic factors, and therapeutic interventions in HSCT recipients. Intensive care unit (ICU) admission affects 8.8%-40% of HSCT recipients, with contemporary 30-day survival reaching 57.7% in specialized centers. Respiratory failure predominates as the primary indication for ICU support. The Lung Injury Prevention Score for Bone Marrow Transplant demonstrates strong predictive accuracy for acute respiratory distress syndrome development. Novel therapeutic approaches show promise, including inhaled tranexamic acid protocols for diffuse alveolar hemorrhage showing promising hemostasis rates in cohort studies, though randomized controlled trial data are lacking. JAK inhibitors achieve improved response rates compared to best available therapy for steroid-refractory graft-versus-host disease (GVHD). The Mount Sinai Acute GVHD International Consortium algorithm provides validated biomarker-based prognostication. Post-transplant cyclophosphamide reduces acute GVHD incidence, while complement inhibition improves outcomes in transplant-associated thrombotic. Early recognition using validated scoring systems and integration of standard ICU protocols with specialized HSCT expertise are essential for optimizing outcomes. Despite advances, significant knowledge gaps remain regarding optimal management strategies for many complications, with most evidence derived from retrospective cohort studies.