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Introduction: The SARS-CoV-2 pandemic has affected medical decision-making in all practice areas, including the pediatric cardiac intensive care unit (CICU), sometimes necessitating the use of innovative management strategies. Venovenous extracorporeal membrane oxygenation (VV-ECMO) and, particularly, late ductal stenting are infrequently applied interventions in the CICU. Here we present a critically ill infant with d-transposition of the great arteries (d-TGA), ventricular septal defect (VSD), pulmonary stenosis (PS), and patent ductus arteriosus (PDA), in which VV-ECMO and late ductal stenting were utilized successfully in the setting of active SARS-CoV-2 infection to treat worsening PS and pulmonary venous desaturation, thereby delaying surgical intervention and its associated risks during active infection. Case Description: A 3 month old male with d-TGA, VSD, and PS, initially managed with a balloon atrial septostomy at birth, was admitted to the CICU after presenting with respiratory distress and hypoxemia. He was found to be SARS-CoV-2 positive, requiring only nasal cannula initially. Admission echocardiogram demonstrated known d-TGA, VSD, severe pulmonary stenosis (peak gradient 95-110mmHg), unrestrictive atrial communication, and preserved systolic function. A tiny, hemodynamically insignificant PDA was also noted. While admitted, the patient exhibited intermittent, severe desaturations requiring escalating respiratory support. He was started on a prostaglandin infusion with aim to promote additional pulmonary blood flow through the PDA, thereby limiting the severity and frequency of desaturations. However, the patient ultimately became severely hypoxemic, despite multiple interventions to improve oxygenation. Echocardiogram at this time demonstrated preserved ventricular function, so the decision was made to escalate to VVECMO therapy. Following ECMO cannulation, the patient's hypoxemia quickly resolved, and he remained hemodynamically stable. Given the persistence of his PDA and the desire to avoid the risks of cardiac surgery in the setting of acute COVID infection, percutaneous intervention to augment pulmonary blood flow was attempted. Despite its diminutive size, his PDA was able to be successfully cannulated and stented the day after ECMO initiation. He was able to be quickly weaned from ECMO support and was decannulated the following day. He was subsequently extubated and ultimately discharged home with planning for definitive surgical intervention underway. Discussion(s): Here we present an interesting case of an infant with d-TGA, VSD, PS, and PDA in which VV-ECMO and PDA stenting were successfully applied to treat acute hypoxemia in the setting of SARS-CoV-2 infection and severe pulmonary stenosis. These therapies may be considered in appropriate patients for whom the risks of cardiac surgery are significant.
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Advances in neonatal medicine have progressively increased the survival of premature infants. Increased survival has however come at the cost of increased number of infants with prematurity-related complications. This is represented by high rates of respiratory distress syndrome, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), sepsis, periventricular leukomalacia (PVL), intraventricular haemorrhage (IVH), cerebral palsy, hypoxic ischaemic encephalopathy (HIE) and visual and hearing problems in survivors. In addition to prolonged hospital stay after birth, readmission to hospital in the first year of life is common if chronic lung disease exists. Around 3% of newborns have a congenital physical anomaly with 60% of congenital anomalies affecting the brain or heart and around 1% having multiple anomalies. Individual congenital conditions requiring surgical intervention in the neonatal period are rare. Neonates have a higher perioperative mortality risk largely due to the degree of prior illness, the complexity of their surgeries, and infant physiology. The maintenance of oxygenation and perfusion in the perioperative phase is critical as both affect cerebral perfusion and neurocognitive outcome but the triggers for intervention and the thresholds of physiological parameters during neonatal anaesthesia are not well described. After even minor surgical procedures, ex-premature infants are at higher risk for postoperative complications than infants born at term.Copyright © 2022
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Background: Multisystem inflammatory syndrome in children (MIS-C) is a post-infectious sequelae of acute COVID-19 infection affecting children. This study was done over a period of 12 months from December 2020 to November 2021 to describe the clinical presentation, laboratory abnormalities, and outcome of children with MIS-C. Method(s): Seventy-eight children below 12 years of age who satisfied the WHO diagnostic criteria for MIS-C were included in the study. Clinical parameters were recorded at admission. Relevant laboratory investigations, radiological studies, and outcome were documented. Result(s): The most commonly affected age group was 6-12 years with a female predominance. COVID RTPCR was negative in all patients. Most cases presented 2-6 weeks after the onset of acute COVID-19 infection. Lethargy, poor feeding, vomiting, abdominal pain, loose stools, cough, and cold are common symptoms of MIS-C syndrome in children and the common signs were rash, conjunctival congestion, hypotension, tachycardia, tachypnea, and hypoxemia. Gastrointestinal system was the commonly affected followed by the hepatic, renal, and cardiovascular systems. Coronary artery abnormalities were seen in 20% of cases. IVIg was the mainstay of therapy used in 95% of patients. Mortality was 1.3%. Cases responded well to IVIg and steroids. Conclusion(s): Overall, the short-term outcome was favorable with low mortality in our study cohort. One-fifth of children had coronary artery abnormalities during acute phase underscoring the need for long-term follow-up. Copyright © 2022, The Author(s).
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Background: The SARS-Cov-2 virus and the associated Multi-System Inflammatory Syndrome in Children (MIS-C) can cause myocardial injury, cardiac dysfunction, and coronary dilation. This makes echocardiography a key component during clinical evaluation. To improve technician safety, we implemented a protocol utilizing a tablet-based echocardiography (TBE) system to evaluate patients who had active COVID-19 or whose testing was pending. We hypothesized that appropriate clinical evaluations could be completed with TBE while having a shorter exposure time for personnel. Methods: We retrospectively evaluated 35 patients at a tertiary, pediatric hospital between March 2020 and May 2021 who underwent TBE. We compared the TBE findings and duration to comprehensive echocardiograms done on average two weeks later with a traditional machine. A complete study included evaluation of ventricular function, coronary artery diameter, and pericardial fluid assessment. Pro-brain natriuretic peptide (pro-BNP) and troponin-T levels were reviewed. Subjects were divided into two groups based on an elevation in troponin-T as a surrogate for myocardial injury (Trop and Trop ).Results: Eight subjects had cardiac dysfunction with 6/12 being from the Trop group and 2/23 in the Trop group. The mean troponin-T elevation was 0.32 ng/mL. Pro-BNP levels were elevated in all but 1 of the 35 subjects but were ten times higher in the trop group (mean 18,055 vs 1,888 pg/mL;p = 0.001). Three subjects with MIS-C had coronary dilation noted by TBE (2 in Trop and 1 in Trop ) with one persistently dilated at follow up. TBE findings such as coronary dilation or cardiac dysfunction guided medical therapies and no clinically relevant findings were missed when compared to studies at follow up. TBE was on average 29 minutes shorter (41 ± 18 vs 12 ± 5 min;p < 0.001). One patent ductus arteriosus was found by TBE and this was confirmed on repeat imaging. Conclusions: TBE allows for experienced sonographers to limit exposure time to potentially contagious patients and easier decontamination while not compromising essential clinical information. This study shows TBE is a useful tool to effectively evaluate patients during highly contagious viral respiratory outbreaks.
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The proceedings contain 122 papers. The topics discussed include: educational impact of targeted neonatal echocardiography (TNE) on neonatal-perinatal medicine (NPM) subspecialty residents;extremely low gestational age neonates and resuscitation: perspectives of Canadian neonatologists;neurodevelopmental outcomes of extremely preterm infants with late-onset bacterial sepsis according to type of bacteria;efficacy of pharmacologic therapy for patent ductus arteriosus closure in preterm newborns according to their gestational age-specific Z-score for birth weight;food insecurity during COVID-19 in a Canadian academic pediatric hospital;the burden of bronchopulmonary dysplasia and pulmonary vascular disease in premature infants;high spontaneous ductal closure even at the extreme of prematurity;exploring the impact of COVID-19 on families of children with developmental disabilities: a community-based formative study;a qualitative study of factors that helped prepare athletes for special Olympics sport programs;and impact of catheter choice on procedural success of minimally invasive surfactant therapy.
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INTRODUCTION AND IMPORTANCE: Conjoined twin is a rare congenital anomaly characterized by a fusion of certain anatomical structures. Coronavirus-19 (COVID-19) is a new emerging infectious respiratory disease affecting worldwide and potentially leads to acute respiratory distress (ARDS) in children. COVID-19 has reconstructed the healthcare system, including surgical care and decision-making. CASE PRESENTATION: Herein we describe a surgical separation of 2.5 months old omphalopagus conjoined twins, with one of them (Baby A) presenting COVID-19-associated respiratory distress, as well as the challenges faced during the preparation and the execution of the complex surgical procedure. CLINICAL DISCUSSION: Baby A underwent antiviral therapy, oxygen supplementation, and ventilation in the ICU, while baby B remained stable and confirmed negative for SARS-CoV-2. The separation surgery was conducted after baby A had become clinically stable. Defect closure and reconstruction were accomplished. At one week follow-up, Baby A died of lung infection, while baby B remained well after one year. CONCLUSION: The complexity of surgical separation requires careful planning by a multidisciplinary team. Surgical separation of conjoined twins during the pandemic era has not been reported much in the literature, more reports are required to provide further insight.