Acute COVID-19 Infection in a Pediatric Patient with ROHHAD.

The novel coronavirus (severe acute respiratory syndrome coronavirus-2) has led to a global pandemic. In the adult population, coronavirus disease 2019 (COVID-19) has been found to cause multiorgan system damage with predicted long-term sequelae. We present a case of a 10-year-old boy with a history of ROHHAD (rapid-onset obesity with hypothalamic dysregulation, hypoventilation, and autonomic dysregulation) who presented with hypoxia, emesis, and abdominal pain. Imaging found bilateral ground glass opacities in the lungs and a pericardial effusion. Laboratory evaluation was concerning for elevated inflammatory markers. Remdesivir, hydroxychloroquine, and anticoagulation (heparin and enoxaparin) were utilized. The patient's severe respiratory failure was managed with conventional mechanical ventilation, inhaled nitric oxide, and airway pressure release ventilation. We hope that this report provides insight into the course and management of the severe acute pediatric COVID-19 patient, specifically with underlying comorbidities such as ROHHAD. Clinical trial registration is none.

Impacting Satisfaction, Learning, and Efficiency Through Structured Interdisciplinary Rounding in a Pediatric Intensive Care Unit: A Quality Improvement Project.

BACKGROUND: Daily rounds in many pediatric intensive care units (PICUs) vary in quality, duration, and participation. We hypothesized that implementing structured interdisciplinary bedside rounds (SIBR®) would improve our rounding process. METHODS: This was a quality improvement initiative in a 25-bed multidisciplinary PICU in a tertiary children's hospital. Baseline data included rounding duration; participation of nurses, respiratory care practitioners (RCP), parents; and physician order read-back practices. Interventions were implementing pre-rounding huddles, changing the start of the rounding week, and instituting a SIBR model. All staff, consecutive patients and parents participated over 18 months. We used Mann-Whitney, z-test, and t-tests for statistical analysis with a significance level of 0.05. We tracked data with a statistical process control chart. RESULTS: Rounds participation increased for nurses (88% to 100%), RCPs (13% to 61%), and families (24% to 49%) (all p <0.001). Physician order read-back increased (41% to 79%) (p<0.001). The median length of stay (LOS) decreased from 2.1 to 1.9 days (p=0.004) with no changes in mortality or readmissions. The proportion of top responses from family surveys increased from 0.69 to 0.76 (p<0.001). PICU rounding duration (minutes/patient) decreased from 17.1 to 11.3. Most resident physicians felt SIBR positively impacted their education (70%), was more effective than rounds without structure (97%), and that family presence positively impacted learning (70%). CONCLUSIONS: Implementing a SIBR process in our PICU resulted in greater family and staff satisfaction, improved workflow and decreased rounding time by 34% without compromising education. LOS decreased significantly with no increases in mortality or readmissions.

Effect of high-dose continuous albuterol nebulization on clinical variables in children with status asthmaticus.

OBJECTIVES: Continuous albuterol nebulization is generally administered at 2.5-20 mg/hr at most centers. We examined the effect of high-dose (75 or 150 mg/hr) albuterol on clinical variables in children with status asthmaticus. DESIGN: Retrospective analysis of inpatient medical records and prospectively collected computerized PICU respiratory therapy database. SETTING: Twenty-five-bed multidisciplinary PICU in a tertiary care children's hospital. PATIENTS: Children admitted to the PICU between January 2006 and December 2007 with status asthmaticus receiving high-dose continuous albuterol nebulization. (Those with cerebral palsy, cardiac pathology, and ventilator dependence were excluded.) INTERVENTIONS: : Chart review for PICU length of stay, albuterol dose, duration of nebulization, occurrence of chest pain, vomiting, tremors, hypokalemia (serum potassium < 3.0 mEq/L), and cardiac arrhythmia. Maximal heart rate, lowest diastolic blood pressure, and mean arterial pressure were compared to the variables at initiation of therapy and at hospital discharge. MEASUREMENTS AND MAIN RESULTS: Forty-two patients (22 boys and 20 girls) received high-dose continuous albuterol nebulization. Twenty-three received 75 mg/hr and 19 received 150 mg/hr (3.7 mg/kg/hr [interquartile range, 2.4-5.8 mg/kg/hr]) for a duration of 22.3 hours (interquartile range, 6.6-31.7 hr). Heart rate increased and diastolic blood pressure and mean arterial pressure were significantly lower during nebulization compared to initiation of therapy or at hospital discharge (p < 0.05). No patient required fluid resuscitation or inotropic support, and one had self-limited premature ventricular contractions. Hypokalemia occurred in five of 33 patients who had serum electrolytes measured but did not require supplementation. One patient required endotracheal intubation after initiation of nebulization, and seven patients (16.7%) received noninvasive ventilation. PICU length of stay was 2.3 ± 1.7 days; there were no deaths. CONCLUSIONS: High-dose continuous albuterol nebulization is associated with a low rate of subsequent mechanical ventilation and fairly short PICU length of stay without significant toxicity. Prospective studies comparing conventional and high-dose albuterol nebulization are needed to determine the optimum dose providing maximum efficacy with the least adverse effects.

Oral, jaw, and neck injury in infants and children: from abusive trauma or intubation?

OBJECTIVES: The objective of this study was to identify the incidence of oral, jaw, and neck injury secondary to endotracheal intubation in young children. METHODS: This prospective observational study was conducted in the pediatric intensive care unit at a level 1 trauma center. From October 1998 to January 1999 and November 2007 to April 2008, all intubated patients younger than 3 years with no prior oral procedures were examined within 24 hours of intubation. A standardized form was used to record injuries. Separately, medical records were reviewed for prior injuries. Chi-square/Fisher exact test was used for statistical analysis. RESULTS: Of 105 patients included in the study, 12 had oral, jaw, or neck injury. One patient had a hard palate injury from a pen cap in his mouth during a seizure. Another broke a tooth biting the laryngoscope blade (the only injury directly attributable to intubation). The remaining 10 patients were determined to be those who experienced abusive trauma. The overall incidence of injury directly from intubation was 0.9%. Oral, jaw, and neck injuries were all significantly associated with abusive trauma (P < 0.001). Eleven patients had difficult intubations: 9 had no injuries, 1 experienced abusive trauma and the second was the patient who broke his tooth during intubation. CONCLUSIONS: Oral, jaw, or neck injury in young children is rarely caused by endotracheal intubation, regardless of difficulty during the procedure.

Three-percent saline administration during pediatric critical care transport.

OBJECTIVES: The purpose of this study was to describe the administration of 3% saline (3%S) during pediatric critical care transport. METHODS: A retrospective study was performed on pediatric patients who underwent critical transport to Loma Linda University Children's Hospital from January 1, 2003, to June 30, 2007, and were given 3%S. Patients' demographics, admission diagnosis, route and amount of 3%S administration, serum electrolytes, vital signs, radiographic data, and Glasgow Coma Scale scores were collected and analyzed. RESULTS: A total of 101 children who received 3%S infusions during pediatric critical care transport were identified. Mean patient age was 5.9 years, and mean patient weight was 27.6 kg. The main indications for infusing 3%S were suspected cerebral edema (41%), intracranial bleed with edema (51%), and symptomatic hyponatremia (6%). The amount of 3%S bolus ranged from 1.2 to 24 mL/kg, with a mean of 5.4 mL/kg. Serum electrolytes before and after 3%S infusion demonstrated significant increases in sodium, chloride, and bicarbonate levels (P < 0.05). A significant reduction was also seen in serum urea nitrogen levels and anion gap. Radiographic imaging performed before 3%S infusion demonstrated findings consistent with concerns of increased intracranial pressure such as intracranial bleed and cerebral edema. The route of initial 3%S infusions was mainly through peripheral intravenous lines (96%). No complications related to the 3%S delivery such as local reactions, renal abnormalities, or central pontine myelinolysis were observed. CONCLUSIONS: It seems 3%S may be administered safely during pediatric critical transport and administration routes can include peripheral lines. With the importance of initiating therapy early to improve patient outcomes, the use of 3%S may benefit transported children with brain injury and suspected intracranial hypertension.

Experience of families during cardiopulmonary resuscitation in a pediatric intensive care unit.

OBJECTIVES: Having parents present during cardiopulmonary resuscitation is becoming a common practice in pediatrics. This study aimed to determine parents' perception of the effects of their presence during the resuscitation efforts of their child and whether they would recommend the experience to other families. METHODS: This study included parents or guardians of children who underwent cardiopulmonary resuscitation, and died at least 6 months before the interview. After telephone consent was obtained, a survey questionnaire was completed. The interviewees answered whether they were asked to be present, whether they had physical contact with their child, and whether the experience frightened them or gave them and their child comfort. The interviewees were asked to express their feelings about what was helpful to them and what could be done to improve the experience. RESULTS: A total of 41 interviews were conducted, and responders were divided into 2 groups: 21 in the present group and 20 in the not-present group for cardiopulmonary resuscitation. Twelve (60%) of those in the not-present group believed that their presence would have comforted the child, and 50% (10 of 20) believed that it would have helped them accept the child's death. Of those in the present group, 67% (8 of 12) believed that touching their child brought comfort, 29% (6 of 21) felt scared during cardiopulmonary resuscitation, 71% (15 of 21) believed that their presence comforted their child, and 67% (14 of 21) believed that their presence helped them adjust to the loss of the child. The majority in both groups (63% [26 of 41]) would recommend being present during cardiopulmonary resuscitation. CONCLUSIONS: This study supports encouraging family presence during cardiopulmonary resuscitation. The majority of parents who had been present and those who had not been present believed that all families should be given the option to be present.

Pediatric critical care nurses' perceptions, knowledge, and attitudes regarding organ donation after cardiac death.

OBJECTIVE: Donation after cardiac death (DCD) is being implemented nationwide in the United States to increase the number of organ donors. Pediatric critical care nurses (PCRNs) are key facilitators in the organ donation process. This study assesses their perception, level of knowledge, and understanding of DCD and the effect of an educational intervention. DESIGN: Anonymous questionnaire administered before and after an educational intervention. SETTING: Children's hospital with 39 pediatric and cardiac/transplant intensive care unit beds. SUBJECTS: PCRNs in these intensive care units. INTERVENTIONS: DCD education. MEASUREMENTS AND MAIN RESULTS: Response to the initial questionnaire was 93 of 123 (76%): 63% of PCRNs supported organ donation, 69% felt it gives meaning and worth to death, and 76% felt that it contributes positively to the donating family's grieving process. Ninety-five percent agreed that DCD patients have a right to pain medications, and 92% supported such medications even if they hasten death. However, 11% feared that the DCD donor feels pain and suffering. Fourteen percent felt that a 5-min observation period after asystole is insufficient to pronounce death, and 8% feared legal repercussions. PCRNs scored lower on questions assessing their knowledge (p < .01), their comfort answering family questions (p < .05), and their comfort in calling the organ procurement agency about DCD donors compared with similar questions about brain-dead donors. One month after 104 PCRNs attended the educational intervention, 64 (62%) completed a follow-up survey. Correct identification of the DCD process improved from 20% to 79%. Confidence with knowledge, comfort answering family questions, and comfort in calling the organ procurement agency about DCD donors improved by 41%, 25%, and 18%, respectively. CONCLUSIONS: PCRNs are generally supportive of organ donation but have a self-perceived and objectively identified knowledge deficit regarding DCD, resulting in their being unprepared to identify potential DCD donors or handle family questions. A simple educational intervention can improve PCRNs' knowledge of the DCD process and their confidence and comfort with this process. As DCD policies are implemented, specific interventions should target these key members of the intensive care unit team.

Drotrecogin alfa (activated) in children with severe sepsis: a multicentre phase III randomised controlled trial.

BACKGROUND: Drotrecogin alfa (activated) (DrotAA) is used for the treatment of adults with severe sepsis who have a high risk of dying. A phase 1b open-label study has indicated that the pharmacokinetics and pharmacodynamics of DrotAA are similar in children and adults. We initiated the RESOLVE (REsearching severe Sepsis and Organ dysfunction in children: a gLobal perspectiVE) trial to investigate the efficacy and safety of the drug in children. METHODS: Children aged between 38 weeks' corrected gestational age and 17 years with sepsis-induced cardiovascular and respiratory failure were randomly assigned to receive placebo or DrotAA (24 microg/kg/h) for 96 h. We used a prospectively defined, novel primary endpoint of Composite Time to Complete Organ Failure Resolution (CTCOFR) score. Secondary endpoints were 28-day mortality, major amputations, and safety. Analysis was by intention-to-treat. This trial is registered with clinicaltrials.gov, number NCT00049764. FINDINGS: 477 patients were enrolled; 237 received placebo, and 240 DrotAA. Our results showed no significant difference between groups in CTCOFR score (p=0.72) or in 28-day mortality (placebo 17.5%; DrotAA, 17.2%; p=0.93). Although there was no difference in overall serious bleeding events during the 28-day study period (placebo 6.8%; DrotAA 6.7%; p=0.97), there were numerically more instances of CNS bleeding in the DrotAA group (11 [4.6%], vs 5 [2.1%] in placebo, p=0.13), particularly in children younger than 60 days. For CTCOFR score days 1-14, correlation coefficient was -0.016 (95% CI -0.106 to 0.74); relative risk for 28-day mortality was 1.06 (95% CI 0.66 to 1.46) for DrotAA compared with placebo. INTERPRETATION: Although we did not record any efficacy of DrotAA in children with severe sepsis, serious bleeding events were similar between groups and the overall safety profile acceptable, except in children younger than 60 days. However, we gained important insights into clinical and laboratory characteristics of childhood severe sepsis, and have identified issues that need to be addressed in future trials in critically ill children.

Magnetic resonance spectroscopy and electroencephalography in baclofen coma.

This report describes a 14-year-old female who presented with coma and seizures. Continuous electroencephalographic monitoring revealed suppression and semiperiodic sharp waves. Magnetic resonance spectroscopy performed 1 day after admission suggested a good outcome despite her clinical examination and electroencephalogram. She was subsequently found to have elevated serum baclofen levels after an intentional overdose. At the time of her discharge from the pediatric intensive care unit, she manifested no neurologic deficits, and on telephone follow-up 2 years after the ingestion the patient had no complaints of any cognitive problems or neurologic dysfunction.

Intraosseous access in the setting of pediatric critical care transport.

OBJECTIVE: To demonstrate safety and efficacy of intraosseous needle placement among health care provider groups in the setting of pediatric critical care transport. DESIGN: Retrospective chart review. SETTING: Pediatric critical care transports to a pediatric intensive care unit. PATIENTS: Children undergoing pediatric critical care transport between January 1, 2000, and March 31, 2002, requiring intraosseous access before arrival to the pediatric intensive care unit. INTERVENTIONS: Intraosseous access placed for emergent vascular access. MEASUREMENTS AND MAIN RESULTS: During the study period, the transport team performed 1,792 transports and identified 47 patients requiring 58 intraosseous placements. These were placed by emergency medical technician-paramedics (18%), referring emergency medicine physicians (42%), and the transport team members (40%). The intraosseous needles were placed with a mean of 1.2 attempts per placement and a first attempt success rate of 78%. Main site of placement was the proximal anterior tibia (95%). Access was maintained for a mean of 5.2 hrs. The intraosseous needle was used for fluids, medications, and laboratory studies. Admitting diagnoses included respiratory distress (28%), cardiopulmonary arrest (26%), neurologic insults (17%), dehydration (15%), sepsis (11%), and other (3%). Ages ranged from 3 wks to 14 yrs (mean 2.2 yrs) and weights from 2.1 to 60 kg (mean 12.3 kg). Complications were noted in seven of 58 (12%), all limited to local edema or infiltration. CONCLUSIONS: Intraosseous placement is frequently needed in the care of critically ill pediatric patients before they reach the pediatric intensive care unit. We have demonstrated that intraosseous needles can be placed safely with similar rates of success when comparing different provider groups. Emergency medical technician-paramedics, emergency medicine physicians, and pediatric critical care transport teams should be familiar with intraosseous placement.

Helium-oxygen therapy for pediatric acute severe asthma requiring mechanical ventilation.

OBJECTIVE: To illustrate the use of helium-oxygen gas mixtures as therapy for pediatric patients with acute severe asthma requiring conventional mechanical ventilation. DESIGN: Retrospective review. SETTING: Tertiary care children's teaching hospital. PATIENTS: All mechanically ventilated patients with severe asthma admitted to the pediatric intensive care unit from August 1994 to October 2000. INTERVENTIONS: Within 24 hrs of intubation or admission, patients were stabilized on volume ventilation, bronchodilator therapy, corticosteroids, and antibiotics when indicated. Hypercapnia was permitted while maintaining arterial blood gas pH > or =7.25. A helium-oxygen gas mixture then was begun with helium flow set at 5-7 L/min, and oxygen flow was titrated to maintain desired oxygen saturation. Only sedated, chemically paralyzed patients with adequate pre-helium-oxygen and post-helium-oxygen measurements were statistically analyzed. MEASUREMENTS AND MAIN RESULTS: Twenty-eight mechanically ventilated patients with severe asthma placed on helium-oxygen gas mixtures were identified who met study entry criteria. Mean patient age was 8.8 yrs (range, 1.1-14.6). Before helium-oxygen therapy began, mean peak inspiratory pressure was 40.5 +/- 4.2 cm H(2)O, mean arterial blood gas pH was 7.26 +/- 0.05, and mean CO(2) partial pressure was 58.2 +/- 8.5 torr. After patients were placed on helium-oxygen therapy, there was a significant decrease in mean peak inspiratory pressure to 35.3 +/- 3.0 cm H(2)O. Mean pH increased significantly to 7.32 +/- 0.06, and mean partial pressure CO(2) decreased significantly to 50.5 +/- 7.4 torr. Initial mean inspired helium was 57 +/- 4% (range, 32-74). Mechanical ventilation days ranged from 1 to 23 days (mean, 5.0). Hospital stay ranged from 4 to 29 days (mean, 10.1), with an average pediatric intensive care unit stay of 6.9 days (range, 2-24). There were two incidences of pneumothorax. CONCLUSIONS: In the pediatric patient with severe asthma requiring conventional mechanical ventilation, helium-oxygen administration appears to be a safe therapy and may assist in lowering peak inspiratory pressure and improving blood gas pH and partial pressure CO(2).