Association between pediatric intensive care mortality and mechanical ventilation settings during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome.

The main objective of this study was to describe the current mechanical ventilation (MV) settings during extracorporeal membrane oxygenation (ECMO) for pediatric acute respiratory distress syndrome (P-ARDS) in six European centers. This is a retrospective observational cohort study performed in six European centers from January 2009 to December 2019. Children > 1 month to 18 years supported with ECMO for refractory P-ARDS were included. Collected data were as follows: patients' pre-ECMO medical condition, pre-ECMO adjunctive therapies for P-ARDS, pre-ECMO and during ECMO MV settings on day (D) 1, D3, D7, and D14 of ECMO, use of adjunctive therapies during ECMO, duration of ECMO, pediatric intensive care unit length of stay, and survival. A total of 255 patients with P-ARDS were included. The multivariate analysis showed that PEEP on D1 (OR = 1.13, 95% CI [1.03-1.24], p = 0.01); D3 (OR = 1.17, 95% CI [1.06-1.29], p = 0.001); and D14 (OR = 1.21, 95% CI [1.05-1.43], p = 0.02) and DP on D7 were significantly associated with higher odds of mortality (OR = 0.82, 95% CI [0.71-0.92], p = 0.001). Moreover, DP on D1 above 15 cmH2O (OR 2.23, 95% CI (1.09-4.71), p = 0.03) and native lung FiO2 above 60% on D14 (OR 10.36, 95% CI (1.51-116.15), p = 0.03) were significantly associated with higher odds of mortality.   Conclusion: MV settings during ECMO for P-ARDS varied among centers; however, use of high PEEP levels during ECMO was associated with higher odds of mortality as well as a DP above 15 cmH2O and a native lung FiO2 above 60% on D14 of ECMO. What is Known: • Invasive ventilation settings are well defined for pediatric acute respiratory distress syndrome; however, once the children required an extracorporeal respiratory support, there is no recommendation how to set the mechanical ventilator. • Impact of invasive ventilator during extracorporeal respiratory support ad only been during the first days of this support but the effects of these settings later in the assistance are not described. What is New: • It seems to be essential to early decrease FiO2 on native lung once the ECMO flow allows an efficient oxygenation. • Tight control to limit the driving pressure at 15 cmH20 during ECMO run seems to be associated with better survival rate.

Multisystemic involvement of post-traumatic fat embolism at a Pediatric Trauma Center: a clinical series and literature review.

Post-traumatic fat embolism syndrome (FES) is a severe complication consequent to bone fractures. The authors describe its clinical features and management in a population of teenagers by detailing demographics, organ involvement, laboratory, and imaging findings, as well as outcome. Moreover, a systematic review of pediatric published case reports of post-traumatic FES is provided. First, a series of eight episodes of post-traumatic FES that occurred in seven patients (median age 16.0 years, IQR 16.0-17.5) admitted to a pediatric intensive care unit (PICU) in an 8-year period was analyzed through a retrospective chart review. Secondly, a systematic research was performed on PUBMED database. Trauma patients ≤ 18 years without comorbidities in a 20-year period (2002-2022) were included in the review. Neurological impairment was present in five out of seven patients, and a patent foramen ovale was found in four cases. Hemodynamic instability requiring vasoactive drugs was recorded in four patients. A severe form of acute respiratory distress syndrome (ARDS) occurred in five cases, with the evidence of hemorrhagic alveolitis in three of them. In the literature review, eighteen cases were examined. Most cases refer to adolescents (median age 17.0 years). More than half of patients experienced two or more long bone fractures (median: 2 fractures). Both respiratory and neurological impairment were common (77.8% and 83.3%, respectively). 88.9% of patients underwent invasive mechanical ventilation and 33.3% of them required vasoactive drugs support. Neurological sequelae were reported in 22.2% of patients. CONCLUSION: Post-traumatic FES is an uncommon multi-faceted condition even in pediatric trauma patients, requiring a high level of suspicion. Prognosis of patients who receive prompt support in an intensive care setting is generally favorable. WHAT IS KNOWN: •Post-traumatic fat embolism syndrome is a severe condition complicating long bone or pelvic fractures. •Little is known about clinical features and management in pediatric age. WHAT IS NEW: •Post-traumatic fat embolism syndrome can cause multiple organ failure, often requiring an intensive care management. •Prompt supportive care contributes to a favorable prognosis.

Coronavirus disease 2019 in critically ill patients: can we re-program the immune system? A primer for Intensivists.

In December 2019, Coronavirus disease 2019 (COVID-19) emerged in Wuhan and rapidly spread around the word. The immune response is essential to control and eliminate CoV infections, however, multiorgan damage might be due to direct SARS-CoV2 action against the infected organ cells, as well as an imbalanced host immune response. In effect, a "cytokines storm" and an impaired innate immunity were found in the COVID-19 critically ill patients. In this review, we summarized the virus immune response steps, underlying the relevance of introducing the measurement of plasma cytokine levels and of circulating lymphocyte subsets in clinical practice for the follow-up of critically ill COVID-19 patients and support new therapy.

Clinical Outcomes and Prognostic Factors for Spontaneous Intracerebral Hemorrhage in Pediatric ICU: A 12-Year Experience.

BACKGROUND: In the pediatric population, spontaneous intracerebral hemorrhage (sICH) is as common as ischemic stroke and accounts for significant mortality and morbidity. Differently from the ischemic stroke, there are few guidelines for directing management of sICH. This article aims to analyze both clinical outcomes and prognostic factors in order to produce tools for the design of prospective randomized studies addressed to implement treatment of pediatric sICH. METHODS: Twelve-year retrospective review of a single-center consecutivesICH pediatric cases admitted to the pediatric intensive care unit (PICU). Selected end points were survival, PICU stay, and dichotomized Glasgow Outcome Score (GOS), with recovery and moderate disability (GOS 4-5) classified as favorable outcome and vegetative state or severe disability (GOS 2-3) classified as unfavorable. RESULTS: Data of 107 children younger than 14 years admitted to our PICU due to sICH were analyzed. Overall PICU mortality was 24.2%. On multivariate analysis, the single factor markedly influencing survival was the presence of midline shift (P = .002). In PICU survivors, there were 42 GOS 2-3 and 39 GOS 4-5. A low Glasgow Coma Scale (GCS) on PICU admission was predictive of severe neurological impairment in survivors (P = .003). Intraventricular hemorrhage and infratentorial origin did not influence outcome in this series. CONCLUSION: The severity of presentation of sICH expressed by the midline shift and the GCS at PICU admission are significant prognostic factors for survival and neurological outcome. Some prognostic factors of the adult population have not been confirmed.

Oscillation transmission and volume delivery during face mask-delivered HFOV in infants: Bench and in vivo study.

OBJECTIVE: Noninvasive high frequency oscillatory ventilation (NHFOV) has not been studied beyond neonatal age and with interfaces other than nasal prongs. We set up a preliminary study to investigate feasibility, oscillation transmission, and volume delivery of face mask-delivered NHFOV in a bench model mimicking a normal 1-year infant without any lung disease and then in vivo in a series of infants with same characteristics. DESIGN: A mannequin with upper airways was connected to an electronic active lung simulator ventilated through NHFOV with varying parameters. Volume delivered by oscillations (oTv), oscillatory pressure ratio, and estimation of ventilation (DCO2) were measured at the lung simulator. Four infants were ventilated with face mask-delivered NHFOV for 2 hr and monitored with respiratory inductance plethismography. Vital parameters, oscillatory pressure ratio, oscillatory (RIPo), and spontaneous cage/abdomen displacement (RIPs) were recorded. RESULTS: There was a dampening of oscillation amplitude both on the bench model and in vivo: oscillatory pressure ratios at the mask were 80% and 17%, respectively. Significant correlations exist between oscillatory pressure ratio (only when this latter was <0.038) and oTv (r = 0.48; P < 0.001) or DCO2 (r = 0.47; P < 0.001). At multivariate analysis, oscillatory pressure ratio was a main determinant of oTv and DCO2. Oscillations were slightly visible on the chest in vivo and RIPo was about 5% of RIPs. NHFOV did not change vital parameters and did not cause discomfort. CONCLUSIONS: Face mask-delivered NHFOV is feasible in a model of 1-year infant. No major complications occurred in vivo. Oscillations are superimposed to the spontaneous breathing and are significantly dampened. Pediatr Pulmonol. Pediatr Pulmonol. 2016;51:705-712. © 2016 Wiley Periodicals, Inc.

Neurally adjusted ventilatory assist vs pressure support ventilation in infants recovering from severe acute respiratory distress syndrome: nested study.

OBJECTIVE: Neurally adjusted ventilatory assist (NAVA) is a new ventilator modality with an innovative synchronization technique. Our aim is to verify if NAVA is feasible and safe in terms of physiological and clinical variables in infants recovering from severe acute respiratory distress syndrome (ARDS). DESIGN: This is a pilot nested study to help future trial design. SETTING: The study was performed in third-level academic pediatric intensive care units. PATIENTS: Infants affected by severe ARDS requiring high-frequency ventilation and weaned with NAVA during 2010 were included. Controls (2:1 ratio) were ARDS infants weaned with pressure support ventilation (PSV) during 2008-2009 matched for age, gas exchange impairment, and weight. MAIN OUTCOME MEASURES: The main outcome measures were the physiological and ventilator parameters and the duration of ventilator support in PSV or NAVA. RESULTS: Ten infants treated with NAVA and 20 with PSV were studied. Heart rate (P < .001) and mean arterial pressure (P < .001) increased less during NAVA than during PSV. Similarly, Pao2/Fio2 ratio decreased less in NAVA than in PSV (P < .001). Neurally adjusted ventilatory assist also resulted in lower Paco2 (P < .001) and peak pressure (P = .001), as well as higher minute ventilation (P = .013). COMFORT score (P = .004) and duration of support were lower in NAVA than in PSV (P = .011). CONCLUSIONS: Neurally adjusted ventilatory assist is safe and suitable in infants recovering from severe ARDS. It could provide better results than PSV and is worth to be investigated in a multicenter randomized trial.

Inotropic and vasoactive drugs in pediatric ICU.

Circulatory failure recognition and treatment represents an important issue in critically ill infants and children. Early diagnosis and prompt institution of adequate treatment may be life-saving for pediatric patients with cardiocirculatory instability in the setting of intensive care. However, the hemodynamic status of the critically ill child is poorly reflected by baseline vital parameters or laboratory blood tests. A reliable tool for diagnosis and monitoring of evolution of both heart performance and vascular status is strictly needed. Advanced hemodynamic monitoring consists - among others - of measuring cardiac output, predicting fluid responsiveness and calculating systemic oxygen delivery. Identification and quantifying of pulmonary edema has also been recently appreciated in pediatric critical care. In the last decade, the number of vasoactive drugs has increased, together with a better understanding of clinical application of both different monitoring devices and treatment strategies.