Patients Admitted to Pediatric Intensive Care with Sars-Cov2: Results from a Nationwide Multicentre Study

BACKGROUND AND AIM: Admission to PICU due to SARS-CoV2 infection in children is unfrequent. However there are few pediatric patients who may require intensive care management. The aim of our study was to describe characteristics and evolution of those patients admitted to Spanish PICUs due to SARS-CoV2 infection. METHOD(S): A multicentre nationwide prospective registry involving all Spanish PICUs was carried out between 1st of march 2020 and 30 November 2021. RESULT(S): During the study period 299 patients where admitted to the participating units. Median age was 8.9 years (IQR 4.4 -12.2). 208 patients (69,6%) where diagnosed of Multisystem Inflamatory Syndrome associated to SARS-CoV2 (MIS-C). 225 patients (75.3%) where previously healthy. Main reason for admission was shock (which was present in 55.9% of patients). Respiratory difficulty was present only in 40.8% of patients. 50.5% of patients required vasoactive drugs, which was more frequent among those presenting with MIS-C (66.5% vs 20.9%, p<0.001). Only 17.4% of patients required mechanical ventilation, which was less frequent in patients with MIS-C (11.1% vs 34.1% p<0.001). 9 patients (3%) included in the registry died. Death was more frequent among patients with previous diseases (9.6% vs 0.9%, p<0.001) and less frequent in those admitted due to MIS-C (0.5% vs 9.3%, p<0.001). CONCLUSION(S): MIS-C was the most frequent cause of admission to PICU in Spain related to SARS-CoV2 infection. Most patients were admitted presenting shock and required vasoactive drugs, but only a few mechanical ventilation. Mortality rate was low. Prognosis was more favourable in those admitted due to MIS-C.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure.

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Children requiring intensive care with SARS-CoV-2 infection during the first wave of pandemic in spain: A multi-centre national registry

AIMS & OBJECTIVES: Describe the characteristics of children admitted to Pediatric Intensive Care Units (PICUs) with SARS-COV-2 infection during the first wave of pandemic in Spain. METHODS: A Multicentric prospective national registry was carried out. 47 Spanish PICUs participated in the study. Features from children admitted to PICUs with confirmed SARS-COV-2 infection or fulfilling multisystem inflammatory syndrome temporally associated with COVID-19 (MIS-C) criteria were collected. RESULTS: 74 patients were included in the registry. 61% of them presented with MIS-C features. Patients not presenting with MIS-C features presented more frequently with respiratory distress (60.7% vs 13.3%, p<0.001) and less frequently with shock (13.8% vs 84.4%, p<0.001) or cardiac dysfunction (10.3% vs 53.3%, p=0.001) and usually had previous health conditions (48.3% vs 11.8%, p=0.005) and were younger ((3.4 years (IQR 0.4-9.4) vs. 9.4 years (IQR 5.5-11.8), p=0.002). Three patients included in the registry died, they all had previous health conditions and none presented with MIS-C features. The group presenting with MIS-C had lower mortality (0% vs 10.3%, p=0.056) and needed less frequently invasive ventilation (13.3% vs 41.4% p=0.005) than patients not presenting with MIS-C. CONCLUSIONS: Although SARS-COV-2 severe infection is much more infrequent in children than in adults, some children present with severe disease requiring PICU admission. In Spain, MIS-C was the most frequent presentation. The course in this group of patients is usually more favorable compared to those patients without MIS-C.

Covid-19 in a pediatric intensive care unit

AIMS & OBJECTIVES: Describe the clinical features and management in the pediatric patient with SARS-CoV-2 infection. METHODS: Retrospective study. Patients admitted at pediatric intensive care between March-May 2020 with confirmed or suggestive infection by SARS-CoV-2 were included. Patients without microbiological confirmation were entered into the study given the clinical similarity and the epidemiological context. Descriptive analysis of the most relevant variables was performed. RESULTS: A total of 24 patients were included. Median age was 9.2 years (16 days-16 years). The diagnosis was confirmed in 22 patients (17 by PCR technique, 5 by serology (positive IgG). The remaining 2 were not confirmed, however, given the similarities in the diagnostic tests performed and clinic features, they were treated as positive cases. The main reason for admission was hemodynamic instability (13/24). Fever was the most frequently symptom (22/24). Chest radiography was performed observing alterations in 17/22 patients. A subgroup of 16 patients who presented a picture of systemic inflammatory response stood out. In this group, fever was a common finding (16/16), followed by abdominal pain (15/16). Hemodynamic lability stood out, showing myocardial dysfunction (echocardiography). They showed a greater lymphopenia, elevated ferritin, IL-6, D-dimer, C-reactive protein and procalcitonin. Given the abdominal symptoms, ultrasound was requested in 11/15 and computed tomography in 3/15, showing nonspecific inflammation, ascites, ileitis, and colitis. Regarding treatment, the recommendations established by official organisms were followed. Corticosteroids were used in 22/24 patients. CONCLUSIONS: The pediatric patient with SARS-CoV-2 infection can develop severe symptoms, and a systemic inflammatory response. It is essential to know clinical features in order to optimize management.

Cd64, cd11a, and cd18 leukocytes expression in a case series of children with SARS-CoV-2 multisystem inflammatory syndrome and kawasaki disease: Similar but not the same

AIMS & OBJECTIVES: A new paediatric inflammatory syndrome named as "pediatric multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS)" has been described. It has been compared to Kawasaki Disease. The aim of this report is adding to the PIMS-TS clinical and analytical description the application of immunophenotyping by flow cytometry (FC). We describe CD64, CD18, and CD11a leukocytes expression in three children with SARSCoV2 infection and compare it with three cases of Kawasaki Disease. METHODS: Three children were studied after informed consent obtained from their parents or legal guardians. Their blood samples were collected in sterile EDTA at room temperature or refrigerated at 4°C and analyzed within 24 hours. Expressions were measured in monocytes, neutrophils, and lymphocytes. At least 10 000 events were recorded for each sample. The intensity of CD64, CD18, and CD11a surface expression were measured as mean fluorescence intensity in arbitrary units (MFI). They were compared with three previous cases of KD. RESULTS: The median CD64, CD18 and CD11a MFI expression in PIMS-TS versus KD cases are described in Figure 1. The CD64 and the CD11a expression on neutrophils and monocytes are higher. The CD11a in CD8 Lymphocytes is higher too. CONCLUSIONS: We compare for the first time the immunophenotype of children with PIMS-TS infection versus KD. We observed significant but higher upregulation of CD64, CD18, and CD11a expression. This response appears to be similar but different than in KD. Prospective studies with a higher number of cases should be conducted to confirm this observation.

Preliminary study of cd64 on monocytes and neutrophils in children with severe SARS-CoV-2 infection: Comparison with other viruses and bacteria

AIMS & OBJECTIVES: The immune response to SARSCoV-2 is not completely understood. The flow cytometry (FC) allows measuring leukocyte populations instantaneously. One of the better-studied molecules is the immunoglobulin-Fc fragment receptor I (FcγRI) or CD64. Its expression informs about the patient immune status. The aim of this study was to describe the CD64 expression in healthy children requiring pediatric intensive care unit (PICU) admission because of SARS-COV-2 infection. Later, we compare it to previous viral or bacterial infections that caused PICU admission in our centre. METHODS: Prospective observational study (March 2020 to May 2020). The percentage of CD64-positive cells and the CD64 mean fluorescence intensity (MFI) on monocytes (mCD64) and neutrophils (nCD64) were determined. The FC was done on a blood sample obtained at PICU admission. Healthy children with positive serology (IgM) or nasopharyngeal swab using real-time reverse transcriptasepolymerase chain reaction were included. The values are expressed as median and range, p < 0.05 was considered statistically significant. RESULTS: Children from the SARS-CoV-2 group were older (p= 0,000), there were no other baseline differences. CONCLUSIONS: The CD64 expression was higher compared to other causes of PICU admission. It could be linked to immune dysregulation. Prospective observational studies are needed.

Live-tweeting the discovery of the new multisystem inflammatory syndrome in children (MIS-C)

INTRODUCTION: In April 2020, the COVID-19 pandemic saw a rise in the number of children with a multi-system hyperinflammatory disease with myocardial involvement and characteristics of toxic shock syndrome, Kawasaki Disease Shock Syndrome, atypical Kawasaki disease. Clinicians turned to social media to discuss what they were seeing and several names for this new syndrome were used, including Paediatric Multisystem Inflammatory Syndrome - Temporally Associated with SARSCoV- 2 and MIS-C. The use of these different names and hashtags may have affected the discussion and ability to share information. Our goal was to examine the real-time conversation on Twitter related to the discovery of this new syndrome. METHODS: We examined conversations occurring on Twitter in the pediatric critical care (PCC) community by examining hashtags associated with #PedsICU. Symplur Signals was used to identify the MIS-C related hashtags. We examined the digital footprint containing those hashtags including stakeholders, frequency of use, and the most commonly tweeted links. RESULTS: Between April 1st and July 21st 2020, there were 50,628 tweets by 13,411 users in the #PedsICU dataset resulting in 128,609,673 impressions. Thirteen new hashtags were identified related to MIS-C in 3664 tweets by 1391 users;#PIMSTS and #MISC were the most commonly used in 3085 (84%) of these tweets. Although #PIMSTS was promoted more in the UK and #MISC in the US, there were no significant differences in usage by country. Of the users tweeting with these MIS-C related hashtags, 39% were healthcare providers, 23% were physicians, and 6% were healthcare organizations. The five most commonly shared links were shared 248 times and included links to research articles, government guidelines, news articles, and a review blog. Peaks of usage of these hashtags coincided with the publication of research articles. CONCLUSIONS: New hashtags like #PIMSTS and #MISC have been used in the PCC community to focus and disseminate contents related to a novel pediatric syndrome related to COVID19. The evolving definitions and names used for this new entity are converging, but early confusion in names may have hampered discussion on Twitter and curation of reliable content.