Characteristics and predictors of outcomes of critically Ill children with SARS-CoV-2 infection - the PICU experience

Abstract Objective To describe the clinical characteristics, laboratory parameters, treatment, and predictors of an unfavorable outcome of critically ill children with SARS-CoV-2 infection. Method This was a prospective observational study performed in a pediatric intensive care unit (PICU) of a tertiary care COVID referral hospital among critically ill children in the age group 1 month - 12 years admitted due to SARS-CoV-2 infection from June to December 2020. Demographic, clinical profile, pSOFA and PRISM III scores, laboratory parameters, treatment, and outcomes of the patients were recorded. Children who had a prolonged PICU stay (>14 days) or died were compared with those who were discharged from PICU within 14 days to assess predictors of unfavorable outcomes. Results PICU admission rate among hospitalized SARS-CoV-2 infected children was 22.1% (92/416). Infants comprised the majority of the ICU population. Invasive mechanical ventilation and inotropic support were required for 28.3% and 37% of patients, respectively. Remdesivir, IVIg, and steroids were administered to 15.2%, 26.1%, and 54.3% of the subjects, respectively. The mortality rate was 7.6 %. MIS-C patients were older, less comorbid, and required less ventilator support but more inotrope support than acute severe COVID-19 patients. Predictors of unfavorable outcomes were age < 1 year, fever duration > 5 days, respiratory distress, shock, comorbidity, elevated CRP (> 50 mg/L), procalcitonin (> 6 ng/L), D-dimer (> 6 µg/L) and arterial lactate (> 2 mmol/L). Conclusion Critically ill children with unfavorable outcomes were predominantly infants, comorbid, prolonged fever, respiratory distress, shock and elevated inflammatory markers, D-dimer and lactate. These factors may be useful for watchful monitoring and early intervention.

Factores de riesgo de evolución desfavorable en niños con plástica de la válvula mitral / Risk Factors of Unfavorable Outcome in Children with Mitral Valve Repair

RESUMEN Objetivo: Analizar los factores de riesgo de evolución desfavorable (ED) en niños con insuficiencia mitral (IM) sometidos a plástica mitral (PM). Métodos: Se analizaron pacientes con IM sometidos a PM entre los años 2004 y 2014. Se definió ED como la reoperación o la IM significativa (3+, moderada a grave, o 4+, grave) durante el seguimiento. Las variables se expresaron como mediana. Se realizó el análisis univariado y el de regresión logística multivariado de los factores predictores de ED. Resultados: Se sometieron a PM 65 pacientes con IM 3+ e IM 4+. La etiología incluyó displasia (44,6%), endocarditis infecciosa (13,8%), fiebre reumática (18,4%), anomalía coronaria (7,7%) y otras (13,8%). La mediana del tiempo de seguimiento fue 26,5 meses (52 pacientes se encuentran aún en seguimiento). El 44,6% presentó disfunción ventricular y el 46,1% hipertensión pulmonar. La cantidad de pacientes con ED fue de 15: 9 fueron reoperados (7 reemplazos valvulares y 2 replástica). El análisis univariado demostró asociación significativa entre ED y las siguientes condiciones: fiebre reumática (p = 0,005), anillo mitral preoperatorio ≥+5 DS (p = 0,002), diámetro sistólico del ventrículo izquierdo (DSVI) ≥ +4 DS (p = 0,022), hipertensión pulmonar (p = 0,024) e IM residual posoperatoria inmediata ≥ moderada (p = 0,021). El análisis multivariado demostró como variables independientes de ED el diámetro del anillo mitral (p = 0,012), la fiebre reumática (p = 0,026) y la IM residual temprana (p = 0,042). No se produjo mortalidad. Conclusiones: La plástica mitral en niños con IM grave demostró resultados favorables a mediano plazo. La fiebre reumática, el diámetro del anillo mitral ≥ +5 DS y la IM residual ≥ 2+ fueron factores predictores de ED. No se hallaron diferencias estadísticamente significativas durante el seguimiento en relación con la edad ni con la presencia de disfunción ventricular.

ABSTRACT Objective: The aim of this study was to analyze risk factors of unfavorable outcome (UO) in patients with mitral regurgitation (MR) undergoing mitral valve repair (MVR). Methods: Patients with MR who had undergone MVR from 2004 to 2014 were retrospectively analyzed. Unfavorable outcome was defined as reoperation or significant MR [moderate to severe (3+) or severe MR (4+)] during follow-up. Variables were expressed as median. Univariate and multivariate logistic regression analyses were performed to identify predictive factors of UO. Results: Sixty five patients with MR3+ and MR4+ underwent MVR. Etiology was dysplasia in 44.6% of cases, infective endocarditis in 13.8%, rheumatic fever in 18.4%, abnormal coronary origin in 7.7% and other disorders in 13.8%. Median follow-up time was 26.5 months (52 patients are still being followed-up).Ventricular dysfunction was documented in 44.6% of cases and 46.1% had pulmonary hypertension. Fifteen patients presented UO and 9 were reoperated (7 valve replacements and 2 re-repairs). Univariate analysis demonstrated a significant association between UO and the following conditions: rheumatic fever (p=0.005), preoperative mitral annulus ≥+5 SD (p=0.002), left ventricular end-systolic diameter ≥+4 SD (p=0.022), pulmonary hypertension (p=0.024) and immediate postoperative residual MR ≥ moderate (p=0.021). Multivariate analysis demonstrated mitral annulus diameter (p=0.012), rheumatic fever (p=0.026) and early residual MR (p=0.042) as independent variables of UO. No deaths occurred in this series. Conclusions: Mitral valve repair in children with severe MR demonstrated mid-term favourable results. Rheumatic fever, mitral annulus diameter ≥+5 SD and immediate postoperative residual MR ≥2+ were predictive factors of UO. Neither age at surgery nor ventricular dysfunction showed statistically significant differences during follow-up.

Surgical Complications of Cerebral Arteriovenous Malformation: A Retrospective Analysis of 297 Consecutive Cases / 대한뇌혈관외과학회지

To analyze the complications following surgical resection of cerebral arteriovenous malformations (AVMs) and to improve the surgical outcomes, we reviewed 297 consecutive patients who had undergone surgical excision of AVM at Yonsei University between June 1975 and July 2004. The patients' ages ranged from 2 to 68 with a mean age of 29 years. The series included 182 males (61.3%) and 115 females (38.5%). The most common presenting symptom was hemorrhage (228 patients, 76.8%). And others were seizure (45 patients, 15.2%), hemorrhage with seizure (12 patients, 4.1%), focal deficit (3 patients, 1.0%), headache (4 patients, 1.3%) and incidental (5 patients, 1.6%). The locations of AVMs were cerebral convexity (220 patients, 74%;46 frontal, 68 parietal, 77 temporal, 29 occipital), callosal (28 patients, 9.4%), sylvian (11 patients, 3.7%), rolandic (8 patients, 2.7%), basal ganglia and thalamus (11patients, 3.7%), cerebellum (18 patients, 6.1%) and one patient had brain stem lesion (0.3%). Postoperative rebleeding and the incomplete excision (12 and 9 patients each) were the major surgical complications, followed by postoperative epilepsy (5 patients), normal perfusion pressure breakthrough (3 patients), and infection (2 patients). The outcome was classified into good for the patients who returned to their previous jobs with or without neurological deficits, fair for the patients who were unable to return to work but performed daily activities independently with minor deficits, and poor for the patients who were performing dependent daily activities with major deficits. The average follow-up period was 4.2 years. The overall outcome of surgery was considered good in 233 patients (75.0%), fair in 51 patients (17.2%), poor in 15 patients (5.1%) and 8 patients (2.7%) were died. The Spetzler-Martin grading system correlated well with the difficulty of surgery. No morbidity resulted from resection of Grade I AVMs;the percentage with unfavorable outcome was 8.1% in Grade II, 9.6% in Grade III, and 28.6% for those with Grade IV. Initial insult (14 patients) and rebleeding (4 patients) were the major causes of unfavorable outcome. Prevention of postoperative hemorrhage following meticulous hemostasis and complete excision and prevention of hemodynamic complications would result in a favorable outcome after surgery for cerebral AVM.

Causes of Unfavorable Surgical Outcome in Cases of Preoperative Good-grade Aneurysm (Grades I, II)

The authors anaylzed 244 cases of good grade(Hunt-Hess I or II) intracranial aneurysm patients who underwent surgery between January 1984 to May 1995. Unfavorable outcome according to the Sundt scale, included surgical results which were fair or poor, and also patients who died, and was more prevalent in patients aged over 60, those with a history of hypertension, or in whom a basal blood clot thicker than 3mm, as seen on brain CT scan, or intraventricular hemorrhage was present. The main cause of unfavorable surgical outcome was technical failure(47%), and the other causes were delayed vasospasm, cerebrovascular accident(CVA) and hydrocephalus. The results suggest that in good-grade aneurysm(grade I or II), prudent surgical techniques, aggressive early treatment for vasospasm, the prevention of perioperative CVA, and proper management of hydrocephalus lead to a better outcome.

Overall Surgical Results and Causes of Unfavorable Outcome in Good Grade Patients with Intracranial Aneurysm

We analyzed the overall surgical results in 100 patients with intracranial aneurysms operated in Presbyterian Medical Center during the period from June 1990 to December 1993. Preoperatively, all patients were in Hunt and Hess grades I-III. Overall outcomes revealed 83 patients(83%) of good outcome, 10 patients(0%) of fair outcome. 3 patients(3%) of poor outcome, and 4 patients(4%) of dead outcome. The outcome was worse if surgery was performed in the 4 to 10 day post- bleed interval(P<0.05) and there was no statistical difference of the rate of good outcome between the parients operated at 0 to 3 days, and 11 day more after subarachnoid hemorrhage. In good grade patients, surgical trauma rather than delayed ischemic deficit was considered as the major cause of unfavorable outcome of aneurysm surgery. Intermedia to period operation increased the chance of postoperative delayed ischemic deficit. Systemic complications and vasospasm were the major causes of dead outcome in the oldaged patients.

Effect of Cryotherapy for Retinopathy of Prematurity

Cryotherapy or photocoagulation is indicated for threshcld stage 3+ retinopathy of prematurity. Twenty-three infants with threshold stage 3+ retinopathy of prematurity were treated with cryotherapy and were analyzed from June 1988 10 December 1991. In patient with cryotherapy, mean gestational age was 30.0 weeks, mean birth weight was 1281gm, and mean number of cryoapplications was 45.4. 32 of 44 eyes (72.7%) had favorable outcomes, and 12 of 44 eyes (27.3%) had unfavorable outcomes.