Posttraumatic Stress Among Pediatric Critical Care Physicians in the United States in Association with Corona virus Disease 2019 Patient Care Experiences

Background: Pediatric critical care physicians have played an active role in the care of critically ill patients including adults with coronavirus disease 2019 (COVID-19). Our objective was to assess the prevalence of posttraumatic stress (PTS) and its association with COVID-19 patient care experiences among pediatric critical care physicians during the SARS-CoV-2 pandemic. Methods: The study is a cross-sectional study of pediatric critical care physicians working in the US. The study was conducted from August 26, 2020 to October 26, 2020 using a web-based online survey platform (Qualtrics, Provo, Utah). Results: We measured PTS which included posttraumatic stress disorder (PTSD) and subthreshold posttraumatic stress disorder (SubPTSD) using validated PTSD Checklist- 5 survey tool. Association of PTS with COVID-19 patient care experiences was analyzed using regression analysis. Prevalence of PTS was noted in 120 among 294 pediatric critical care physicians (41%;95% CI, 35-47%) with predominance of hyperarousal symptoms and feelings of negative cognition and mood. Among our physicians with PTS, 19% had PTSD and 81% had SubPTSD. Female physicians and those with children had statistically significant increase in posttraumatic stress (p<0.05). Posttraumatic stress was significantly associated with physicians testing positive or taking time off for COVID-19 illness, self-isolation, fear of infecting their loved ones, families scared of being infected, feeling helpless, patients expressing fears of dying, having preexisting depression, anxiety or insomnia, working beyond comfort level of training and having thoughts of quitting (p<0.05). Thoughts of quitting was associated with the highest significant increase in PTS scores (coefficient:11.643;95% CI:8.551,14.735;P<0.01) followed by feeling of helplessness (coefficient:11.055;95% CI: 8.484,13.624;P<0.01) and need for additional medications for depression, anxiety and insomnia (coefficient: 10.980;95% CI: 4.970, 16.990;P<0.01). Conclusion: Posttraumatic stress is high in pediatric critical care physicians especially in female physicians and those with children and is associated with various COVID-19 patient care experiences. Thoughts of quitting was associated with highest increase in posttraumatic stress score and this could have major implications for the workforce in the future. Subthreshold posttraumatic stress disorder should be identified and mental health issues of pediatric critical care physicians addressed.

Abdominal imaging findings in critically ill children with mis-c

AIMS & OBJECTIVES: We sought to describe abdominal imaging findings on ultrasound and computed tomography on children presenting with abdominal symptoms and multisystem inflammatory syndrome (MIS-C) related to coronavirus disease (COVID-19). METHODS: We report findings on abdominal imaging in 7 critically ill children admitted with MIS-C to a tertiary, urban intensive care unit. All children had clinical and laboratory criteria of MIS-C including positive antibody testing to COVID-19. RESULTS: Of 23 children diagnosed with MIS-C, 7 children (30%) had abdominal imaging, including ultrasound (all 7) and CT (3/7). Indications for abdominal imaging included concern for acute abdomen, gall bladder inflammation and intestinal obstruction. Hepatomegaly was the most common finding, while nephromegaly, gall bladder wall edema, ascites, intestinal inflammation and mesenteric lymphadenopathy were also seen on ultrasound. Two children had incidental finding of bilateral lower lobe consolidations on CT abdomen. One child had a thickened, enlarged appendix with diffuse inflammation of intestinal wall of descending colon and ileum on CT. Another patient with severe MIS-C had fluidfilled small bowel loops, terminal ileal inflammation, diffuse lymphadenopathy and moderate ascites on abdominal CT. This patient also had large vessel vasculitis involving the junction of the aortic arch and brachiocephalic trunk. CONCLUSIONS: Common with abdominal imaging findings in Kawasaki disease, our patients had reactive lymphadenopathy, abdominal free fluid, bowel wall thickening and vasculitis. Gall bladder hydrops, intestinal pseudo-obstruction or dilated bowel loops, commonly found in Kawasaki disease with prominent abdominal symptoms were not seen in our patients.

Thromboelastography variables in critically ill children with COVID-19

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state in adults with significant mortality attributable to thrombotic complications. We report on the coagulation profiles of children admitted to the Intensive Care Unit with coronavirus related illness. METHODS: We describe a single-center retrospective cohort of 22 children admitted to the pediatric intensive care unit with SARS-CoV2 related illness. All children were admitted with PCR or antibody positive SARS-CoV2 related illness, or if antibody negative met CDC criteria for MIS-C including close family contact with COVID-19 positive patient. Thromboelastography was performed on all patients in addition to routine hematologic assays. RESULTS: Majority of patients (55%) were female, with median age of 6 years (IQR 2.3,14), with predominantly hispanic (59%) and black (27%) race/ethnicity. Three children had preexisting comorbidities. The most common clinical presentation was multisystem inflammatory syndrome (77 %). Two children, both adolescent females presented with extensive thrombotic complications- one with deep venous thrombosis and gangrene of leg, one with multiple pulmonary emboli. One-third (36%) of children had abnormal values on thromboelastography (TEG). Hypercoagulability on TEG was the most frequent finding, characterized by acceleration of clot formation and increase in maximal clot amplitude. Most children had minimal to no fibrinolysis on TEG suggestive of impaired fibrinolysis. Elevation in D-Dimer, IL-6 level, ferritin and CRP was universal, and 50% had associated hyperfibrinogenemia (>400 mg/dL). Platelet count, prothrombin time and activated thromboplastin values were normal for all children except the two who presented with thrombotic complications. CONCLUSIONS: We report abnormal coagulation profiles in one-third of critically ill children with coronavirus related illness detected by thromboelastography (TEG). Routine coagulation variables were within normal range for most patients, while TEG uncovered a pattern of accelerated clot formation and increased clot strength. Our findings suggest significant inflammation associated with a distinct hypercoagulable profile in a subset of children with SARSCoV2 related illness. Viscoelastic tests may be useful to characterize these abnormalities.