Association of Fluid Overload with Escalation of Respiratory Support and Endotracheal Intubation in Acute Bronchiolitis Patients.

Fluid overload has been associated with increased oxygen requirement, prolonged duration of mechanical ventilation, and longer length of hospital stay in children hospitalized with pulmonary diseases. Critically ill infants with bronchiolitis admitted to the pediatric intensive care unit (PICU) also tend to develop fluid overload and there is limited information of its role on noninvasive respiratory support. Thus, our primary objective was to study the association of fluid overload in patients with bronchiolitis admitted to the PICU with respiratory support escalation (RSE) and need for endotracheal intubation (ETI). Infants ≤24 months of age with bronchiolitis and admitted to the PICU between 9/2009 and 6/2015 were retrospectively studied. Demographic variables, clinical characteristics including type of respiratory support and need for ETI were evaluated. Fluid overload as assessed by net fluid intake and output (net fluid balance), cumulative fluid balance (CFB) (mL/kg), and percentage fluid overload (FO%), was compared between patients requiring and not requiring RSE and among patients requiring ETI and not requiring ETI at 0 (PICU admission), 12, 24, 36, 48, 72, 96, and 120 hours. One-hundred sixty four of 283 patients with bronchiolitis admitted to the PICU qualified for our study. Thirty-four of 164 (21%) patients required escalation of respiratory support within 5 days of PICU admission and of these 34 patients, 11 patients required ETI. Univariate analysis by Kruskal-Wallis test of fluid overload as assessed by net fluid balance, CFB, and FO% between 34 patients requiring and 130 patients not requiring RSE and among 11 patients requiring ETI and 153 patients not requiring ETI, at 0, 12, 24, 36, 48, 72, 96 and 120 hours did not reveal any significant difference ( p >0.05) at any time interval. Multivariable logistic regression analysis revealed higher PRISM score (odds ratio [OR]: 4.95, 95% confidence interval [95% CI]: 1.79-13.66; p = 0.002), longer hours on high flow nasal cannula (OR: 4.86, 95% CI: 1.68-14.03; p = 0.003) and longer hours on noninvasive ventilation (OR: 11.16, 95% CI: 3.36-36.98; p < 0.001) were associated with RSE. Fluid overload as assessed by net fluid balance, CFB, and FO% was not associated with RSE or need for ETI in critically ill bronchiolitis patients admitted to the PICU. Further prospective studies involving larger number of patients with bronchiolitis are needed to corroborate our findings.

Association of enteral feeds in critically ill bronchiolitis patients supported by high-flow nasal cannula with adverse events and outcomes.

To study association of enteral feeds in bronchiolitis patients supported by different levels of high flow nasal cannula (HFNC) with adverse events, nutritional goals, and clinical outcomes. Bronchiolitis patients ≤ 24 months of age treated with < 1 L/kg/min, 1-2 L/kg/min and > 2 L/kg/min of HFNC between January 2014 and December 2021 were studied retrospectively at a tertiary care children's hospital. Adverse events (aspiration pneumonia, emesis, and respiratory support escalation), nutritional goals (initiation of enteral feeds, achievement of nutritional goal volume and goal calories, percentage weight change during hospital stay) and clinical outcomes (HFNC duration, oxygen supplementation duration after HFNC, length of hospital stay following HFNC support, total length of hospital stay and follow-up for 1 month after hospital discharge) were compared between fed and non-fed patients on HFNC. Six hundred thirty-six (489 fed and 147 not-fed) bronchiolitis patients on HFNC studied. 260 patients, 317 patients and 59 patients were supported by < 1 L/kg/min, 1-2 L/kg/min and > 2 L/kg/min of HFNC, respectively. Enterally fed patients had significantly less adverse events (OR = 0.14, 95% CI 0.083 - 0.23, p < 0.001), significantly better nutritional goals: earlier initiation of enteral feeds by 65% in time (mean ratio = 0.35, 95% CI 0.28 - 0.43, p < 0.001), earlier achievement of goal volume and goal calorie needs by 14% in time (mean ratio = 0.86, 95% CI 0.78 to 0.96, p = 0.005) and significantly better clinical outcomes: shorter HFNC duration by 29.75 h (95% CI 20.19 -39.31, p < 0.001), shorter oxygen supplementation duration after HFNC by 12.14 h (95% CI 6.70 -17.59, p < 0.001), shorter length of hospital stay after HFNC support by 21.35 h (95% CI 14.71-27.98, p < 0.001) and shorter total length of hospital stay by 51.10 h (95% CI 38.65 -63.55, p < 0.001), as compared to non-fed patients, after adjusting for age, weight, prematurity, comorbidities, admission time, admission bronchiolitis score, admission respiratory rate, and HFNC levels. The number of revisits and readmissions at 7 and 30 days after hospital discharge were not significantly different (p > 0.05) between the fed and non-fed groups.    Conclusion: Enteral feeding of bronchiolitis patients supported by different levels of HFNC is associated with less adverse events and better nutrition goals and clinical outcomes. What is Known: •There is general apprehension to feed critically ill bronchiolitis patients supported by high flow nasal cannula. What is New: •Our study reveals that enteral feeding of critically ill bronchiolitis patients supported by different levels of high flow nasal cannula is associated with minimal adverse events, better nutritional goals and improved clinical outcomes as compared to non-fed patients.

Inhaled nitric oxide therapy for severe hypoxemia in hyperinflated mechanically ventilated bronchiolitis patient.

Management of hospitalized bronchiolitis patients comprises supportive care including non-invasive and invasive mechanical ventilation. Inhaled nitric oxide (iNO) therapy has been used in bronchiolitis patients to manage pulmonary hypertension, acute respiratory distress syndrome, bronchoconstriction or inflammation. We report the role of iNO in management of severe hypoxemia in a 7-month-old mechanically ventilated bronchiolitis patient on 100% oxygen and high ventilator settings who had hyperinflation on chest x-ray, and diffuse bronchospasm on clinical assessment. We believe iNO improved hypoxemia in our patient by optimizing the ventilation/perfusion mismatch, decreasing dead space ventilation and relieving elevated pulmonary vascular resistance associated with alveolar overdistention. Inhaled nitric oxide therapy for severe hypoxemia in hyperinflated mechanically ventilated bronchiolitis patient.

Streptococcus Pneumoniae-Associated Hemolytic Uremic Syndrome in the Era of Pneumococcal Vaccine.

Streptococcus pneumoniae-associated hemolytic uremic syndrome (Sp-HUS) is a serious complication of invasive pneumococcal disease that is associated with increased mortality in the acute phase and morbidity in the long term. Recently, Sp-HUS definition has undergone revision and cases are categorized as definite, probable, and possible, based on less invasive serological investigations that evaluate Thomsen-Friedenreich crypt antigen (T-antigen) activation. In comparison to the pre-vaccine era, Sp-HUS incidence seems to be decreasing after the introduction of 7-serotype valence and 13-serotype valence pneumococcal vaccines in 2000 and 2010, respectively. However, Sp-HUS cases continue to occur secondary to vaccine failure and emergence of non-vaccine/replacement serotypes. No single hypothesis elucidates the molecular basis for Sp-HUS occurrence, although pneumococcal neuraminidase production and formation of T-antigen antibody complexes on susceptible endothelial and red blood cells continues to remain the most acceptable explanation. Management of Sp-HUS patients remains supportive in nature and better outcomes are being reported secondary to earlier recognition, better diagnostic tools and improved medical care. Recently, the addition of eculizumab therapy in the management of Sp-HUS for control of dysregulated complement activity has demonstrated good outcomes, although randomized clinical trials are awaited. A sustained pneumococcal vaccination program and vigilance for replacement serotypes will be the key for persistent reduction in Sp-HUS cases worldwide.

Acute Tracheal Necrosis After Intubation in a Childhood Onset Systemic Lupus Erythematosus.

Upper airway involvement in systemic lupus erythematosus (SLE) disease process is uncommon. A 15-year-old girl, a known patient with class IVA lupus nephritis, presented in acute renal failure due to flare-up of SLE. She underwent an uneventful elective intubation procedure for placement of a hemodialysis catheter. After 36 hours of extubation, she developed biphasic stridor and severe shortness of breath that was unresponsive to multiple medications. Prompt airway evaluation by laryngoscopy and confirmation of acute tracheal necrosis by histopathology along with reintubation and high-dose steroid therapy resulted in good outcome and recovery.

Fever without a source in children with congenital heart disease.

Two paediatric congenital heart disease patients presented with a brief history of low-grade fever without any focal symptoms. Their clinical features and laboratory tests were unremarkable; however, their blood cultures were positive that prompted further work-up. Infective endocarditis should be considered in any paediatric congenital heart disease patient who presents with fever without any other associated clinical features.

Eutectic mixture of lidocaine and prilocaine versus 1% lidocaine injection for lumbar punctures in pediatric oncology patients.

BACKGROUND: The role of local analgesics for lumbar punctures (LPs) in pediatric oncology patients has not been specifically studied. AIM: To compare the efficacy of eutectic mixture of local anesthetics (EMLA) cream to 1% lidocaine injection for LPs. METHOD: This was a retrospective observational study of all patients receiving either EMLA cream (EMLA group) or 1% lidocaine subcutaneous injection (lidocaine group) in addition to fentanyl and propofol for LPs over 18 months. Demographics, vital parameters, procedural and recovery times, propofol and fentanyl doses, and adverse events were studied. RESULTS: Two hundred ninety LPs in 49 children were studied: 148 in the EMLA group and 142 in the lidocaine group. There was no difference in demographics or preprocedural parameters between the two groups. LPs in the EMLA group were completed in a shorter time (7.5 minutes [CI 7.0-8.1] vs 9.4 minutes [CI 8.9-9.9]) with a faster recovery time (38.7 minutes [CI 36.9-40.9] vs 43.9 minutes. [CI 41.9-45.9]) as compared with the lidocaine group (P < 0.001). The EMLA group required less maintenance doses (0.54 mg/kg [CI 0.47-0.62] vs 1.14 mg/kg [CI 1.06-1.21]) and total doses (2.58 mg/kg [CI 2.42-2.75] vs 3.12 mg/kg [CI 2.95-3.29]) of propofol as compared with the lidocaine group (P < 0.0001). Adverse events in the EMLA group were less (19% vs 41%) as compared with the lidocaine group (P < 0.0001). CONCLUSION: The addition of EMLA cream for procedural sedation for LPs in pediatric oncology patients significantly improves pain management in comparison with 1% lidocaine injection.

Conversion Disorder Manifesting as Functional Visual Loss.

BACKGROUND: Children with conversion disorder experience neurological symptoms without a definable organic cause. Clinical presentation of conversion disorders is uncommon in the emergency department (ED). CASE REPORT: An 11-year-old previously healthy girl presented to the ED for management of lobar pneumonia. She developed acute visual loss subsequent to accidental placement of an intra-arterial cannula in her arm. Clinical assessments by the emergency physician, neurology, ophthalmology, and psychiatry services, and negative neuroimaging studies established the diagnosis of functional visual loss as a manifestation of conversion disorder. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Conversion disorder symptoms are often without any specific markers and do not fit standard clinical guidelines. A comprehensive and step-wise evaluation of unusual clinical presentation by multiple specialties and ancillary test results should be considered to rule out organic causes and establish the diagnosis of conversion disorder, as seen in our patient.

Subclinical cerebral edema in diabetic ketoacidosis in children.

Subclinical cerebral edema in diabetic ketoacidosis tends to manifest with subtle neurological symptoms including headache, lethargy, or disorientation and a Glasgow Coma Scale of 14-15. Treatment of subclinical cerebral edema with hyperosmolar therapy for persistent symptoms is associated with good outcomes.

Early Testing of Serum Ferritin Facilitates Hemophagocytic Lymphohistiocytosis Diagnosis in Children.

The clinical and laboratory features of hemophagocytic lymphohistiocytosis (HLH) are nonspecific that makes the definitive diagnosis of HLH very challenging. The disease is almost universally fatal in the absence of early recognition and appropriate therapy. Elevated serum ferritin level is one of the diagnostic markers of HLH disease. We report the value of testing serum ferritin level early in the disease process in 3 pediatric patients who presented with persistent fever and sepsis-like features. Detection of elevated serum ferritin levels facilitated further testing to confirm the diagnosis of HLH and initiate early therapy with good outcomes.

Association of blood products administration during cardiopulmonary bypass and excessive post-operative bleeding in pediatric cardiac surgery.

Our objectives were to study risk factors and post-operative outcomes associated with excessive post-operative bleeding in pediatric cardiac surgeries performed using cardiopulmonary bypass (CPB) support. A retrospective observational study was undertaken, and all consecutive pediatric heart surgeries over 1 year period were studied. Excessive post-operative bleeding was defined as 10 ml/kg/h of chest tube output for 1 h or 5 ml/kg/h for three consecutive hours in the first 12 h of pediatric cardiac intensive care unit (PCICU) stay. Risk factors including demographics, complexity of cardiac defect, CPB parameters, hematological studies, and post-operative morbidity and mortality were evaluated for excessive bleeding. 253 patients were studied, and 107 (42 %) met the criteria for excessive bleeding. Bayesian model averaging revealed that greater volume of blood products transfusion during CPB was significantly associated with excessive bleeding. Multiple logistic regression analysis of blood products transfusion revealed that increased volume of packed red blood cells (PRBCs) administration for CPB prime and during CPB was significantly associated with excessive bleeding (p = 0.028 and p = 0.0012, respectively). Proportional odds logistic regression revealed that excessive bleeding was associated with greater time to achieve negative fluid balance, prolonged mechanical ventilation, and duration of PCICU stay (p < 0.001) after adjusting for multiple parameters. A greater volume of blood products administration, especially PRBCs transfusion for CPB prime, and during the CPB period is associated with excessive post-operative bleeding. Excessive bleeding is associated with worse post-operative outcomes.

Ceftriaxone-induced hemolytic anemia: case report and review of literature.

Ceftriaxone is a frequently used empiric antibiotic in children. Acute hemolysis is a rare side effect of ceftriaxone therapy associated with a high mortality rate. A 14-year-old boy suffering from Crohn disease developed bacterial pneumonia that was treated with ceftriaxone. We report successful management of ceftriaxone-induced hemolytic anemia (CIHA) in this patient and review the CIHA literature in pediatric patients. Early recognition of CIHA with prompt discontinuation of ceftriaxone therapy may have a beneficial role in reduction of high mortality seen in these patients.

Residual lesions in postoperative pediatric cardiac surgery patients receiving extracorporeal membrane oxygenation support.

OBJECTIVE: The objective of this study was to examine the incidence and clinical outcomes of residual lesions in postoperative pediatric cardiac surgery patients receiving extracorporeal membrane oxygenation (ECMO) support. METHODS: A retrospective observational study was undertaken at a pediatric heart institution. Postoperative pediatric cardiac surgery patients receiving ECMO support within 7 days of surgery during the past 7 years (2005-2011) were studied. A hemodynamically significant cardiac lesion on ECMO support that required intervention to decannulate successfully was defined as a residual lesion. Demographic data, complexity of cardiac defect, surgical data, indications for ECMO, echocardiographic findings, and cardiac catheterization results were studied. Evaluation of residual lesions based on duration of ECMO support, interventions undertaken, and clinical outcomes were also examined. RESULTS: Residual lesions were evaluated in 43 of 119 postoperative patients placed on ECMO support. Lesions were detected in 35 patients (28%), predominantly in branch pulmonary arteries (n = 10), shunts (n = 7), and ventricular outflow tracts (n = 9). Echocardiography detected 7 residual lesions (20%) and cardiac catheterization detected 28 residual lesions (80%). Earlier detection of residual lesions during the first 3 days of ECMO support in 24 patients improved their rate of decannulation significantly (P = .004) and survival to hospital discharge (P = .035), compared with later detection (after 3 days of ECMO support) in 11 patients. CONCLUSIONS: Residual lesions are present in approximately one-quarter of postoperative cardiac surgery patients requiring ECMO support. All postoperative pediatric cardiac surgery patients unable to be weaned off ECMO successfully should be evaluated actively for residual lesions, preferably by cardiac catheterization imaging. Earlier detection of residual lesions and reintervention are associated with improved clinical outcome.

Postoperative complications and association with outcomes in pediatric cardiac surgery.

OBJECTIVE: Our primary aim was to study postoperative complications in pediatric cardiac surgery patients and their association with cardiopulmonary bypass (CPB) use. The secondary aim was to evaluate the association of postoperative complications with established outcome measures. METHODS: A single-institution retrospective observational study was undertaken of consecutive pediatric cardiac surgery patients during a 1-year period. Five cardiac and 15 extracardiac complications were studied. CPB use, CPB parameters, demographics, and Risk Adjusted Classification for Congenital Heart Surgery (RACHS-1) levels were evaluated as risk factors for complications. Outcomes, including mechanical ventilation duration, pediatric cardiac intensive care unit stay, hospital stay, and mortality were studied. RESULTS: A total of 325 patients were studied: 271 with CPB and 54 without CPB. Of the 325 patients, 141 (43%) had ≥1 complication (95% confidence interval, 38%-49%). Of the 325 patients, 82 (25%) developed cardiac and 120 (37%) developed extracardiac complications. The evidence from logistic regression analysis was insufficient to suggest a relationship between CPB support and the incidence of cardiac or extracardiac complications after adjusting for age, gender, previous sternotomy, and RACHS-1 levels. For patients receiving CPB, longer CPB times, higher RACHS-1 levels, and a lower temperature with CPB were associated with a greater number of cardiac complications (P < .01). Longer CPB times and higher RACHS-1 levels were associated with a greater number of extracardiac complications (P = .006). Postoperative complications were significantly associated with an increased mechanical ventilation duration, pediatric cardiac intensive care unit stay, and hospital stay and mortality (P < .01). CONCLUSIONS: Postoperative complications occurred in 43% of pediatric cardiac surgeries performed both with and without CPB. The complications were associated with longer mechanical ventilation and pediatric cardiac intensive care unit and hospital stays, and increased mortality.

Template of patient-specific summaries facilitates education and outcomes in paediatric cardiac surgery units.

OBJECTIVES: Few educational opportunities exist in paediatric cardiac critical care units (PCCUs). We introduced a new educational activity in the PCCU in the form of of patient-specific summaries (TPSS). Our objective was to study the role of TPSS in the provision of a positive learning experience to the multidisciplinary clinical team of PCCUs and in improving patient-related clinical outcomes in the PCCU. METHODS: Prospective educational intervention with simultaneous clinical assessment was undertaken in PCCU in an academic children's hospital. TPSS was developed utilizing the case presentation format for upcoming week's surgical cases and delivered once every week to each PCCU clinical team member. Role of TPSS to provide clinical education was assessed using five-point Likert-style scale responses in an anonymous survey 1 year after TPSS provision. Paediatric cardiac surgery patients admitted to the PCCU were evaluated for postoperative outcomes for TPSS provision period of 1 year and compared with a preintervention period of 1 year. RESULTS: TPSS was delivered to 259 clinical team members including faculty, fellows, residents, nurse practitioners, nurses, respiratory therapists and others from the Divisions of Anesthesia, Cardiology, Cardio-Thoracic Surgery, Critical Care, and Pediatrics working in the PCCU. Two hundred and twenty-four (86%) members responded to the survey and assessed the role of TPSS in providing clinical education to be excellent based on mean Likert-style scores of 4.32 ± 0.71 in survey responses. Seven hundred patients were studied for the two time periods and there were no differences in patient demographics, complexity of cardiac defect and surgical details. The length of mechanical ventilation for the TPSS period (57.08 ± 141.44 h) was significantly less when compared with preintervention period (117.39 ± 433.81 h) (P < 0.001) with no differences in length of PCICU stay, hospital stay and mortality for the two time periods. CONCLUSIONS: Provision of TPSS in a paediatric cardiac surgery unit is perceived to be beneficial in providing clinical education to multidisciplinary clinical teams and may be associated with improved clinical outcome.

Perioperative management of pheochromocytoma and catecholamine-induced dilated cardiomyopathy in a pediatric patient.

Dilated cardiomyopathy resulting from pheochromocytoma-mediated catecholamine excess poses a unique challenge to heart failure management. Although early screening of patients with familial neoplastic syndromes at risk for pheochromocytoma may facilitate early resection, the resultant manifestations of prolonged catecholamine excess among patients with undiagnosed pheochromocytoma may lead to myocardial fibrosis with both systolic and diastolic dysfunction. Furthermore, the hemodynamic effects of catecholamine excess exacerbate the risks of perioperative hemodynamic instability in the setting of such myocardial depression. This report describes an approach to the perioperative care of a child who had pheochromocytoma and catecholamine-induced cardiomyopathy with ventricular dysfunction refractory to medical management.

Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance*.

OBJECTIVE: To determine whether structured handover tool from operating room to pediatric cardiac intensive care unit following cardiac surgery is associated with a reduction in the loss of information transfer and an improvement in the quality of communication exchange. In addition, whether this tool is associated with a decrease in postoperative complications and an improvement in patient outcomes in the first 24 hrs of pediatric cardiac intensive care unit stay. DESIGN: Prospective observational clinical study. SETTING: Pediatric cardiac intensive care unit of an academic medical center. PATIENTS: Pediatric cardiac surgery patients over a 3-yr period. Evaluation of communication and patients studied for two time periods: verbal handover (July 2007-June 2009) and structured handover (July 2009-June 2010). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two anonymous surveys administered to the entire clinical team of the pediatric cardiac intensive care unit evaluated loss of information transfer for each of the two handover processes. Quality of structured handover tool was evaluated by Likert scale responses in the second survey. Patient complications including cardiopulmonary resuscitation, mediastinal reexploration, placement on extracorporeal membrane oxygenation, development of severe metabolic acidosis, and number of early extubations in the first 24-hr pediatric cardiac intensive care unit stay were compared for the two time periods. Survey results showed the general opinion that the structured handover tool was of excellent quality to enhance communication (Likert scale: 4.4 ± 0.7). In addition, the tool was associated with a significant reduction (p < .001) in loss of information for every category of patient clinical care including patient, preoperative, anesthesia, operative, and postoperative details and laboratory values. Patient data revealed significant decrease (p < .05) for three of the four major complications studied and a significant increase (p < .04) in the number of early extubations following introduction of our standardized handover tool. CONCLUSIONS: In this setting, a standardized handover tool is associated with a decrease in the loss of patient information, an improvement in the quality of communication during postoperative transfer, a decrease in postoperative complications, and an improvement in 24-hr patient outcomes.

Recombinant factor seven therapy for postoperative bleeding in neonatal and pediatric cardiac surgery.

BACKGROUND: Severe bleeding is a major complication in the postoperative pediatric cardiac surgery patients. We evaluated the efficacy and safety of recombinant factor seven (rFVIIa) therapy in this patient population. METHODS: A retrospective unmatched case-control study for the previous five years in a single institution was undertaken. Patients with severe bleeding treated with rFVIIa therapy (study group) were compared with patients treated with blood products only (control group) using analysis of variance. Mediastinal bleeding, blood products transfusion, and coagulation studies before and six hours after the first dose of rFVIIa therapy were analyzed using the Student paired t test. The dose, frequency, and side-effects of rFVIIa therapy were studied. RESULTS: Forty-six patients with severe bleeding were studied. Twenty-three of 24 patients in the study group, including 12 patients placed on extracorporeal membrane oxygenation (ECMO), responded to rFVIIa therapy (mean dose 43 +/- 22.9 microg/kg/dose). There was significant reduction in chest tube drainage (from 52.3 +/- 36.1 mL/kg/hour to 18.8 +/- 20.9 mL/kg/hour, p = 0.0003) along with significant reduction of blood products transfusion (p < 0.001) in the study group patients as compared with control group patients. One patient who failed to respond had surgical bleeding. Two patients developed major thrombotic complications that included clots in the ECMO circuit and thrombosis at bleeding arterial line site resulting in limb ischemia. Four additional patients in the study group developed mediastinal clots. Overall, 25% of patients developed thrombosis after rFVIIa therapy. CONCLUSIONS: The rFVIIa therapy seems to be an effective treatment for severe bleeding in postoperative pediatric cardiac surgery patients in the absence of surgical bleeding. It must be judiciously used in patients bleeding from multiple sites or having preexistent clots in the ECMO circuit to prevent major thrombotic complications.