Increase in Pediatric Intensive Care Unit Hospitalizations Due to Toxic Ingestions during the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic and related community mitigation measures had a significant psychosocial impact. We suspected that more patients were admitted to our pediatric intensive care unit (PICU) for toxic ingestions since the start of the pandemic. We therefore investigated if PICU admissions related to toxic ingestions were higher in 2020 as a result of COVID-19 compared with previous years. We completed a cross-sectional study at a tertiary children's hospital comparing admissions to our PICU between April 2020 and October 2020, during which COVID-19 and community mitigation measures were in place, to those during the same 7-month period in the previous 3 years. Total PICU admissions, admissions for all toxic ingestions (intentional ingestions and accidental ingestions), and demographic and clinical characteristics of patients were compared. Total PICU admissions in 2020 during COVID-19 pandemic months were lower compared with the same months in the preceding 3 years (-16%, p < 0.001), however, admissions for toxic ingestions were higher during COVID-19 (+64%, p < 0.001). When separated by type, intentional (+55%, p = 0.012) and accidental ingestions (+94%, p = 0.021) were higher during COVID-19. COVID-19 with community mitigation measures has led to an increase in PICU admissions for intentional and accidental ingestions, indicating an increase in severity of toxic ingestions in children associated with the pandemic. Mental health of adolescents, and safety of infants and toddlers in their home environment, should be targeted with specific interventions in the ongoing COVID-19 pandemic.

Relationship between alveolar functional fraction and clinical outcomes in children during postoperative care after surgery for single-ventricular heart.

Background: Optimization of pulmonary to systemic blood flow (Qp: Qs) is the key to postoperative care of children with a single-ventricular heart. The ratio of end-tidal CO2 to partial pressure of CO2 called alveolar functional fraction (AFF) has shown a strong relationship with Qp: Qs in the catheterization lab in this population (with Qp: Qs of 1 correlating with AFF of 0.7). As there are no studies to understand the relationship between AFF and clinical outcomes in the postoperative care of these children, this study was carried out. Methodology and Results: This retrospective cohort study included 29 postoperative periods of children who underwent surgery for a single-ventricular heart. The average AFF was calculated for each early postoperative period. The primary clinical outcome was time in hours to normalize lactate. Other clinical outcomes included duration of mechanical ventilation, duration of milrinone infusion; presence of acute kidney injury (AKI), seizures and necrotizing enterocolitis (NEC); need for tracheostomy, need for extra-corporeal support, and mortality in the first 60 days postoperatively. The study population was divided into Group 1 with AFF ≤0.7 and Group 2 with AFF >0.7, to compare the outcome differences between the groups. Time to normalize the lactate had a modest negative correlation with the AFF, with Pearson's r = -0.49 (P = 0.007) for the entire cohort. The clinical outcomes were not statistically different for groups with AFF ≤0.7 and with AFF >0.7, although the group with AFF ≤0.7 had a higher incidence of NEC and higher mortality, whereas the group with AFF >0.7 had a higher incidence of AKI. Conclusions: In this small study, the AFF showed a modest negative correlation with the time to normalize lactate in postoperative care after surgery for a single-ventricle heart. There were the trends with some other important clinical outcomes but not statistically significant. A larger, multi-center study is needed to delineate these relationships further.

The Use of Diuretic in Mechanically Ventilated Children with Viral Bronchiolitis: a Cohort Study.

INTRODUCTION: Viral bronchiolitis is a leading cause of admissions to pediatric intensive care unit (PICU). A literature review indicates that there is limited information on fluid overload and the use of diuretics in mechanically ventilated children with viral bronchiolitis. This study was conducted to understand diuretic use concerning fluid overload in this population. MATERIAL AND METHODS: A retrospective cohort study performed at a quaternary children's hospital. The study population consisted of mechanically ventilated children with bronchiolitis, with a confirmed viral diagnosis on polymerase chain reaction (PCR) testing. Children with co-morbidities were excluded. Data collected included demographics, fluid status, diuretic use, morbidity and outcomes. The data were compared between groups that received or did not receive diuretics. RESULT: Of the 224 mechanically ventilated children with confirmed bronchiolitis, 179 (79%) received furosemide on Day 2 of invasive ventilation. Out of these, 72% of the patients received intermittent intravenous furosemide, whereas 28% received continuous infusion. It was used more commonly in patients who had a higher fluid overload. Initial fluid overload was associated with longer duration of mechanical ventilation (median days 6 vs 4, p<0.001) and length of stay (median days 10 vs 6, p<0.001) even with the use of furosemide. Superimposed bacterial pneumonia was seen in 60% of cases and was associated with a higher per cent fluid overload at 24 hours (9.1 vs 6.3, p = 0.003). CONCLUSION: Diuretics are frequently used in mechanically ventilated children with bronchiolitis and fluid overload, with intermittent dosing of furosemide being the commonest treatment. There is a potential benefit of improved oxygenation in these children, though further research is needed to quantify this benefit and any potential harm. Due to potential harm with fluid overload, restrictive fluid strategies may have a potential benefit.

Thyroid storm with encephalopathy and cardiovascular symptoms refractory to medical management in an adolescent.

Thyroid storm (TS) is rare in pediatrics, most cases reported in literature responded well to medical therapy. We report the case of an adolescent female presented with TS refractory to anti-thyroid medical management. She had refractory hypertension, tachycardia, and progressive encephalopathy despite aggressive medical management. She underwent subtotal thyroidectomy after 2 weeks of failed medical management with a complete resolution of symptoms within days of surgery. We also learned sodium nitroprusside with its direct vasodilatory effect on conduit vessels, verapamil with its rate control properties, and labetalol with its dual sympathetic blockage property were beneficial in the management of this patient.

Tracheoinnominate Artery Fistula Formation in a Child with Long-Term Tracheostomy Dependence.

We report a fatal tracheoinnominate artery fistula (TIF) in a 13-year-old female patient with long-term tracheostomy tube dependence due to chronic respiratory failure. Thirteen years after placement of her tracheostomy tube, the patient experienced two separate episodes of sentinel bleeding prior to a fatal hemorrhagic event. Diagnostic evaluation after the sentinel events was mostly nonconclusive. This case highlights the risk of TIF in pediatric age group, even years after initial tracheostomy tube placement, and the need for a high index of suspicion for TIF when children present with unexplained tracheal bleeding.

Relationship Between Pulmonary-to-Systemic-Blood-Flow Ratio (Qp:Qs) Based on Cardiac Catheterization and Indices Derived from Simultaneously Measured End Tidal CO2 (EtCO2) in Children with Complex Congenital Heart Disease.

CO2 removal by the lungs depends upon ventilation and pulmonary blood flow, with end tidal CO2 (EtCO2) as surrogate for it. We studied indices based on EtCO2 measured routinely during anesthesia for cardiac catheterization, along with simultaneously calculated Qp:Qs (pulmonary-to-systemic-blood-flow ratio) in children with complex congenital heart disease to assess the relationship between these measures. A retrospective, single-center, correlational cohort study was conducted at a tertiary-care, free-standing children's hospital. All included subjects had Qp:Qs calculated as well as EtCO2 and PaCO2 documented during a single cardiac catheterization. Children with stage-1 single ventricle or complex biventricular repair with highly variable Qp:Qs were defined as Group 1, and Group 2 comprised those with stage 2 or 3 repairs with less variable Qp:Qs. Exclusion criteria were uncuffed artificial airway, EtCO2 > PaCO2, and abnormally high Qp:Qs. EtCO2 indices were defined as EtCO2:PaCO2 (alveolar functional fraction) and EtCO2 gap (PaCO2-EtCO2). Correlation coefficients were obtained between Qp:Qs and EtCO2 indices in both groups. A total of 29 patients in Group 1 and 24 in Group 2 underwent final analysis. Even with highly variable Qp:Qs, Group 1 showed a strong correlation between Qp:Qs and EtCO2:PaCO2 (r = 0.83, p < 0.0001). A similarly strong correlation was maintained in Group 2 (r = 0.79, p < 0.0001) and in both groups combined (r = 0.86, p < 0.0001). A very strong negative correlation was present between Qp:Qs and EtCO2 gap (r = - 0.77, p < 0.0001). EtCO2:PaCO2 has a very strong correlation with Qp:Qs simultaneously calculated during catheterization. It can be an additional parameter to estimate Qp:Qs in critical management of children with congenital heart disease. Our results also provide a basis for future prospective studies to assess dynamic changes in EtCO2-based indices and Qp:Qs.

The Impact of Multiple Viral Respiratory Infections on Outcomes for Critically Ill Children.

OBJECTIVE: Advances in molecular diagnosis have led to increased testing for single and multiviral respiratory infection in routine clinical practice. This study compares outcomes between single and multiviral respiratory infections in children younger than 5 years old admitted to the PICU with respiratory failure. DESIGN: Retrospective, single-center, cohort study. SETTING: Tertiary-care, freestanding children's hospital. PATIENTS: Children younger than 5 years old admitted to the PICU with respiratory failure and positive respiratory molecular panel. Children with comorbidity or history of similar infections were excluded. After exclusions, the children were divided into single or multiviral groups. Their demographics and PICU outcomes were compared and analyzed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four hundred seventy-seven children with respiratory failure tested positive on respiratory panel, out of which 432 had single and 45 had multiple viruses. Children with multiple viruses had a longer PICU stay (4.5 d) compared with the single viral group (3 d; p < 0.002). Multiviral infections were associated with higher utilization of central line (odds ratio, 2.4; 95% CI, 1.3-4.6; p = 0.008) but not with the need of invasive ventilation requirement or cardiovascular dysfunction. Further analysis among invasively ventilated patients showed multiviral infections resulted in higher association of prolonged ventilation (> 7 d) (odds ratio, 3.4; 95% CI, 1.2-9.4; p = 0.01) and bacterial lower respiratory tract infection confirmed by quantitative bronchoalveolar lavage (odds ratio, 2.1; 95% CI, 1.1-11.2; p = 0.03). Infections with human rhinovirus/Enterovirus, Adenovirus, parainfluenza, and influenza formed a significantly larger proportions of cases (p = 0.00089) as multiviral infections compared with individual infections. CONCLUSIONS: Multiviral infections were associated with longer PICU stay, with prolonged mechanical ventilation, with bacterial lower respiratory infections, and with central line requirement. Certain common viruses resulted in higher percentages of PICU admission as multiviral infections.