ABSTRACT
Background: Since the emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a new multisystem inflammatory syndrome in children (MIS-C) has been described amongst patients with recent past SARS-CoV-2 infection. The primary objective of this study is to describe a single center experience in relation to cardiac manifestations of MIS-C in an ethnically diverse pediatric population. Methods: We conducted a retrospective chart review of pediatric patients less than 21 of age meeting MIS-C criteria who presented to a tertiary care children's hospital from May 2020 to March 2021. Results: Seventy-eight patients diagnosed with MIS-C (average age 9.7 +/- 4.6 years, 57% male) were included in this study (60 Hispanic, 9 non-Hispanic White, 7 Black, and 1 American Indian). The most common presenting symptoms were nausea and vomiting (76%), abdominal pain (71%), appetite changes (69%), fatigue (64%), and conjunctivitis (63%). The average length of intensive care unit stay was 2.5 days while average total hospitalization was 7.3 days. Forty-nine patients (62%) underwent echocardiography. Of those evaluated, there was systolic dysfunction in 45% with an average ejection fraction of 48%, diastolic dysfunction in 14%, valvular disease in 53%, coronary involvement in 16%, and pericardial effusion in 22%. Electrocardiogram was completed on 37 patients (47%) which revealed heart block in 23% and arrhythmia in 3%. Troponin T was elevated in 32% and pro-BNP was elevated in 89%. Ninety-five percent of patients received immunomodulators during their hospitalization, while 94% received methylprednisolone, 59% received intravenous immunoglobulin, and 19% received Anakinra. There was one mortality. Conclusion: The results of this retrospective study contribute to a growing knowledge base in the literature that MIS-C can exhibit a wide spectrum of cardiac manifestations further underscoring the importance of thorough cardiac workup and regular outpatient follow-up in patients diagnosed with MIS-C.
ABSTRACT
TOPIC: Palliative Care and End of Life Issues TYPE: Original Investigations PURPOSE: The end-of-life resuscitation status and therapeutic interventions in critically ill Muslim patients who succumb to their illness is not well reported. We describe our experience in such patients who were admitted to our tertiary care hospital Intensive Care Unit (ICU). METHODS: Our hospital is a tertiary care center accredited by Joint Commission International and Nurses Magnet Programs and runs active organ transplantation services. The patient population and treating ICU physicians are all Muslim. We collected twelve-month data from the year 2020 of patients who died in our ICU. Coronavirus Disease 2019 infected patients were treated separately and were not included in the study to give true reflection of the end-of-life care in Muslim patients under ordinary circumstances. Patient demographics, characteristics before and at ICU admission, cardiopulmonary resuscitation and DNAR details in ICU, and therapies administered in last 24 hours before death were recorded. Descriptive statistics were used to organize the collected data. Continuous variables were described as median with Interquartile Range Q1-Q3 (IQR), and categorical variables were described as number and percentages, as appropriate. RESULTS: 104 Muslim patients died during the study period. Their median age was 64 years and 51% were male. These patients had a median of 5 underlying comorbidities and a Charlson Comorbidity Index of 6 at baseline, highlighting their moribund status. 56% had underlying illness that would have qualified them for hospice before admission. Patients spent a median of 10 days (IQR 6-15) in the ward before ICU admission, had a high APACHE II score of 23 (IQR 20-33) and lactic acid of 3.7 (IQR 2.2-4.8) upon ICU admission. Their duration of mechanical ventilation (6 days;IQR 4-9), ICU stay (6 days;IQR 2-13) and hospital length of stay (10 days;IQR 6-15) were relatively long. 92% were "Full Code" at ICU admission and the status was changed to 'do-not-attempt resuscitation' (DNAR) in about 67% of the cohort before death. 42 patients had CPR done and 8 were made DNAR after one CPR. DNAR decision was made after median of 13 days (IQR 7-22 days) of hospital admission and 5 days (IQR 2.5-9 days) before death. DNAR discussions were led by Intensivists in 89% of the cases. Until the very end, patients in both groups were on tube feeds, underwent blood draws, had few limitations on therapy or withdrawal of care. There was hardly any involvement of Muslim chaplain and palliative care service. CONCLUSIONS: The concept of DNAR is accepted in Muslim patients even though decision is made near end of life. Many patients with terminal disease ended up in the ICU and role of hospice and palliative care needs to be increased in this population. CLINICAL IMPLICATIONS: DNAR is acceptable in Muslim patients, however, active mechanisms need to be developed to avoid terminal patients suffering undue ICU course at end of life. DISCLOSURES: No relevant relationships by Azhar Alharbi, source=Web Response No relevant relationships by Mohammed Alzahrani, source=Web Response No relevant relationships by MANSOR BINHASHR, source=Web Response No relevant relationships by Maryam Imran, source=Web Response No relevant relationships by Manahil Imran, source=Web Response No relevant relationships by Imran Khalid, source=Web Response No relevant relationships by Tabindeh Khalid, source=Web Response No relevant relationships by Murad Mawlawi, source=Web Response No relevant relationships by Nahid Mulla, source=Web Response No relevant relationships by Renad Nadhreen, source=Web Response No relevant relationships by Ahmed Qadah, source=Web Response No relevant relationships by Romaysaa Yamani, source=Web Response