Propofol Infusion Is a Feasible Bridge to Extubation in General Pediatric Intensive Care Unit.

Objective: The current literature on propofol infusion as a bridge to extubation in critically ill children is limited to children with burns and congenital cardiac disease. We hypothesize that propofol infusion is a feasible bridge to extubation in mechanically ventilated, critically ill children. Design: Retrospective chart review. Setting: Pediatric intensive care unit of a tertiary care teaching hospital. Patients: Children < 21 years, admitted to our Pediatric intensive care unit (PICU), requiring mechanical ventilation (MV) for at least 48 h and at least two sedative infusions and who received propofol infusion for 4 to 24 h during anticipated extubation from January 2014 to May 2017. Interventions: None. Measurements and Main Results: We assessed extubation success as primary outcome. We defined extubation success as no re-intubation within 24 h after extubation. We also assessed for occurrence of adverse effects of propofol infusion (1) hemodynamic instability [more than 10% change from pre-propofol baseline heart rate (HR) and mean arterial pressure (MAP) measured 4 h before and during propofol infusion, need for any inotrope and/or fluid bolus] and (2) occurrence of lactic acidosis in absence of any documented sepsis. We compared hemodynamic parameters before and during infusion using Wilcoxon Rank Sum Test (significant p-value ≤ 0.05). We evaluated 35 critically ill, mechanically ventilated children. The median age, weight and duration of MV were 3.8 (IQR: 1.25-10.5) years, 12 (IQR: 6-16.2) kilograms and 111 (IQR: 78-212) h, respectively. Of the 35 patients, 15 (43%) were post-surgical (10 general and 5 cardiac) and the remaining 20 (57%) were non-surgical respiratory failure cases. The median (IQR) propofol infusion dose and duration were 64.7 (53.2-81.1) mcg/kg/min and 7.8 h respectively. Only one patient got re-intubated within 24 h of extubation and was later diagnosed with vascular ring. During propofol infusion, 7/35 (20%) patients exhibited transient drop in MAP > 10% from baseline, but none had lactic acidosis or required an inotrope or fluid bolus. Conclusions: In critically ill, mechanically ventilated patients, propofol infusion used over a short duration (<12 h) was found to be a feasible bridge to extubation. No patient had significant hypotension or lactic acidosis during the infusion.

Thoracic Fluid Content (TFC) Measurement Using Impedance Cardiography Predicts Outcomes in Critically Ill Children.

Objective: Conventional methods of fluid assessment in critically ill children are difficult and/or inaccurate. Impedance cardiography has capability of measuring thoracic fluid content (TFC). There is an insufficient literature reporting correlation between TFC and conventional methods of fluid balance and whether TFC predicts outcomes in critically ill children. We hypothesized that TFC correlates with indices of fluid balance [FIMO (Fluid Intake Minus Output) and AFIMO (Adjusted Fluid Intake Minus Output)] and is a predictor of outcomes in critically ill children. Design: Retrospective chart review. Setting: Pediatric intensive care unit of a tertiary care teaching hospital. Patients: Children <21 years, admitted to our Pediatric Intensive Care Unit (PICU) between July- November 2018 with acute respiratory failure and/or shock and who were monitored for fluid status using ICON® monitor. Interventions: None. Measurements and Main Results: We collected demographic information, data on daily and cumulative fluid balance (CFB), ventilator, PICU and hospital days, occurrence of multi-organ dysfunction syndrome (MODS), and mortality. We calculated AFIMO using insensible fluid loss. We analyzed data using correlation coefficient, chi-square test and multiple linear regression analysis. We analyzed a total 327 recordings of TFC, FIMO and AFIMO as daily records of fluid balance in 61 critically ill children during the study period. The initial TFC, FIMO, and AFIMO in ml [median (IQR)] were 30(23, 44), 300(268, 325), and 21.05(-171.3, 240.2), respectively. The peak TFC, FIMO, and AFIMO in ml were 36(26, 24), 322(286, 334), and 108.8(-143.6, 324.4) respectively. The initial CFB was 1134.2(325.6, 2774.4). TFC did not correlate well with FIMO or AFIMO (correlation coefficient of 0.02 and -0.03, respectively), but a significant proportion of patients with high TFC exhibited pulmonary plethora on x-ray chest (as defined by increased bronchovascular markings and/or presence of pleural effusion) (p = 0.015). The multiple linear regression analysis revealed that initial and peak TFC and peak and mean FIMO and AFIMO predicted outcomes (ventilator days, length of PICU, and hospital days) in critically ill children (p < 0.05). Conclusions: In our cohort of critically ill children with respiratory failure and/or shock, TFC did not correlate with conventional measures of fluid balance (FIMO/AFIMO), but a significant proportion of patients with high TFC had pulmonary plethora on chest x-ray. Both initial and peak TFC predicted outcomes in critically ill children.

Hyperammonemic Encephalopathy due to Ureaplasma parvum Infection in an Immunocompromised Child.

Idiopathic hyperammonemia is a rare complication with a high mortality rate that occurs in persons with hematologic malignancies or hematopoietic stem cell or solid organ transplant. Patients present with encephalopathy and hyperammonemia in the absence of liver disease or inborn errors of metabolism. Several etiologies have been proposed, including chemotherapeutic agents, medications, and a catabolic state with an elevated nitrogen load in the setting of acute illness. Recently, cases of hyperammonemia in adult lung transplant recipients have been attributed to infection from Ureaplasma parvum or U urealyticum Herein, we report a 12-year-old girl with acute myeloid leukemia and neutropenic fever who developed acute encephalopathy. Laboratory testing revealed severe hyperammonemia (blood ammonia level >1609 µmol/L) with normal liver function studies. U parvum was detected in blood, urine, and respiratory specimens by polymerase chain reaction testing. After antibiotic therapy directed against U parvum, blood ammonia levels normalized, the infection was eradicated, and the patient recovered. We propose that clinicians should test for invasive infection from Ureaplasma species in immunocompromised children with unexplained hyperammonemia.

Hands-On Defibrillation Skills of Pediatric Acute Care Providers During a Simulated Ventricular Fibrillation Cardiac Arrest Scenario.

Introduction: Timely defibrillation in ventricular fibrillation cardiac arrest (VFCA) is associated with good outcome. While defibrillation skills of pediatric providers have been reported to be poor, the factors related to poor hands-on defibrillation skills of pediatric providers are largely unknown. The aim of our study was to evaluate delay in individual steps of the defibrillation and human and non-human factors associated with poor hands-on defibrillation skills among pediatric acute care providers during a simulated VFCA scenario. Methods: We conducted a prospective observational study of video evaluation of hands-on defibrillation skills of pediatric providers in a simulated VFCA in our children's hospital. Each provider was asked to use pads followed by paddles to provide 2 J/kg shock to an infant mannequin in VFCA. The hands-on skills were evaluated for struggle with any step of defibrillation, defined a priori as >10 s delay with particular step. The data was analyzed using chi-square test with significant p-value < 0.05. Results: A total of 68 acute care providers were evaluated. Median time to first shock was 97 s (IQR: 60-122.5 s) and did not correlate with provider factors, except previous experience with the defibrillator used in study. The number of providers who struggled (>10 s delay) with each of connecting the pads/paddles to the device, using pads/paddles on the mannequin and using buttons on the machine was 34 (50%), 26 (38%), and 31 (46%), respectively. Conclusions: The defibrillation skills of providers in a tertiary care children's hospital are poor. Both human and machine-related factors are associated with delay in defibrillation. Prior use of the study defibrillator is associated with a significantly shorter time-to-first shock as compared to prior use of any other defibrillator or no prior use of any defibrillator.

Neurologic Injury Associated with Rewarming from Hypothermia: Is Mild Hypothermia on Bypass Better than Deep Hypothermic Circulatory Arrest?

Many known risk factors for adverse cardiovascular and neurological outcomes in children with congenital heart defects (CHD) are not modifiable; however, the temperature and blood flow during cardiopulmonary bypass (CPB), are two risk factors, which may be altered in an attempt to improve long-term neurological outcomes. Deep hypothermic circulatory arrest, traditionally used for aortic arch repair, has been associated with short-term and long-term neurologic sequelae. Therefore, there is a rising interest in using moderate hypothermia with selective antegrade cerebral blood flow on CPB during aortic arch repair. Rewarming from moderate-to-deep hypothermia has been shown to be associated with neuronal injury, neuroinflammation, and loss of cerebrovascular autoregulation. A significantly lesser degree of rewarming is required following mild (33-35°C) hypothermia as compared with moderate (28-32°C), deep (21-27°C), and profound (less than 20°C) hypothermia. Therefore, we believe that mild hypothermia is associated with a lower risk of rewarming-induced neurologic injury. We hypothesize that mild hypothermia with selective antegrade cerebral perfusion during CPB for neonatal aortic arch repair would be associated with improved neurologic outcome.

Perioperative serum interleukins in neonates with hypoplastic left-heart syndrome and transposition of the great arteries.

OBJECTIVE: The primary study objective was to examine the impact of diagnosis on the inflammatory response in neonates with congenital heart disease undergoing cardiac surgery. The secondary objective was to study the impact of the inflammatory response on postoperative outcome in these neonates. DESIGN: Observational study. SETTING: Tertiary care children's hospital heart center. PATIENTS: Neonates with hypoplastic left-heart syndrome (HLHS) undergoing stage I repair and patients with transposition of the great arteries (TGA) undergoing arterial switch operation. MEASUREMENTS AND MAIN RESULTS: There were 24 neonates with HLHS and 21 neonates with TGA. Serum samples to measure interleukin (IL)-6 and -10 were obtained before and after CPB at 1, 3, 6, and 24 hours postoperatively. Time to extubation, intensive care unit (ICU) length of stay, and peritoneal fluid drainage were compared between the groups. Serum IL-6 and IL-10 concentrations increased after CPB when compared to the preoperative concentration. Preoperative concentrations of IL-6 were significantly elevated in the HLHS group (HLHS: 32 [21.1, 69.6] pg/mL v TGA: 7.2 [3.6, 22.5] pg/mL [median, 25th, and 75th percentile], p = 0.003) and remained elevated immediately after CPB, and at 3 and 6 hours postoperatively. The IL-10 to IL-6 ratio was lower in the HLHS group preoperatively and immediately after CPB. ICU length of stay was significantly longer in the HLHS group (TGA 4 [3-6] days v HLHS 6 [5-8] days, p = 0.031). Mortality in the HLHS group (4/24) was associated with significantly higher IL-6 postoperatively (IL-6 immediately postoperatively: HLHS survivors 59.9 [34.3, 65.7] pg/mL v nonsurvivors 98.7 [94.4, 104.5] pg/mL, p < 0.011). CONCLUSIONS: All neonates with TGA or HLHS have a significant inflammatory response after CPB. Neonates with HLHS have evidence of an activated inflammatory response before CPB, which remains significant in the postoperative period. Accelerated interleukin expression and an abnormal cytokine balance correlate with longer time to extubation, longer ICU length of stay, and increased peritoneal fluid volume.

Acute pancreatitis after anesthesia with propofol in a child with glycogen storage disease type IA.

Glycogen storage disorder type 1A (GSD 1A) is an inherited disorder of glycogen metabolism characterized by fasting hypoglycemia, lactic acidosis, hyperuricemia, and hyperlipidemia. These children have a higher risk of developing pancreatitis because of hypertriglyceridemia. Drug-induced pancreatitis accounts for a small proportion of cases of pancreatitis. The mechanism of drug-induced pancreatitis include hypersensitivity, direct toxic injury or indirectly by inducing hypertriglyceridemia. Propofol is often the drug of choice for induction of anesthesia in ambulatory surgical procedures. There are various reports in the literature describing pancreatitis induced by propofol. We present a 4-year-old girl with GSD 1A, who required tonsillectomy and adenoidectomy under general anesthesia. She developed acute pancreatitis in the postoperative period. Propofol was used as a general anesthetic and the postoperative incidence of pancreatitis is discussed.

Quantitative analysis of procalcitonin after pediatric cardiothoracic surgery.

Procalcitonin appears to be an early and sensitive marker of bacterial infection in a variety of clinical settings. The use of levels of procalcitonin to predict infection in children undergoing cardiac surgery, however, may be complicated by the systemic inflammatory response that normally accompanies cardiopulmonary bypass. The aim of our study was to estimate peri-operative concentrations of procalcitonin in non-infected children undergoing cardiac surgery. Samples of serum for assay of procalcitonin were obtained in 53 patients at baseline, 24, 48, and 72 hours following cardiac surgery. Concentrations were assessed using an immunoluminetric technique. Median concentrations were lowest at baseline at less than 0.5 nanograms per millilitre, increased at 24 hours to 1.8 nanograms per millilitre, maximized at 48 hours at 2.1 nanograms per millilitre, and decreased at 72 hours to 1.3 nanograms per millilitre, but did not return to baseline levels. Ratios of concentrations between 24, 48 and 72 hours after surgery as compared to baseline were 6.15, with 95 percent confidence intervals between 4.60 and 8.23, 6.49, with 95 percent confidence intervals from 4.55 to 9.27, and 4.26, with 95 percent confidence intervals between 2.78 and 6.51, respectively, with a p value less than 0.001. In 8 patients, who had no evidence of infection, concentrations during the period from 24 to 72 hours were well above the median for the group. We conclude that concentrations of procalcitonin in the serum increase significantly in children following cardiac surgery, with a peak at 48 hours, and do not return to baseline within 72 hours of surgery. A proportion of patients, in the absence of infection, had exaggerated elevations post-operatively.

Indications for tracheotomy in the pediatric intensive care unit population: a pilot study.

OBJECTIVE: To define the indications for tracheotomy in patients requiring prolonged intubation (>1 week) in the pediatric intensive care unit (PICU). DESIGN: Retrospective chart review and follow-up telephone survey. SETTING: A tertiary care center PICU. OUTCOME MEASURE: Tracheotomy or extubation. PATIENTS: All patients older than 30 days in the PICU intubated for longer than 1 week between 1997 and 1999. RESULTS: During the study, 63 total admissions required intubation for longer than 1 week. A tracheotomy was necessary in 14% of admissions (n = 9). The mean length of intubation before the tracheotomy was 424 hours, whereas the mean length of intubation without the need for tracheotomy was 386 hours. Length of intubation, age, and number of intubations did not increase the probability of having a tracheotomy. Of those requiring a tracheotomy, 2 had tracheomalacia, 1 had subglottic edema, 1 had plastic bronchitis, 1 had Down syndrome with apnea resulting in right heart failure, 3 required long-term ventilation after cardiopulmonary collapse, and 1 had mitochondrial cytopathy. Of these 9 children, 7 were successfully decannulated, 1 patient died of underlying disease, and 1 patient remained cannulated secondary to the mitochondrial cytopathy. Twenty families of the patients who did not undergo a tracheotomy were reached by telephone after discharge. Most of the families reported that their children were free of stridor and hoarseness after extubation. CONCLUSIONS: Children tolerate prolonged intubation without laryngeal complications. The consideration for tracheotomy in the PICU setting must be highly individualized for each child.

A glial-derived protein, S100B, in neonates and infants with congenital heart disease: evidence for preexisting neurologic injury.

UNLABELLED: The glial-derived protein S100B is a serum marker of cerebral ischemia and correlates with negative neurological outcome after cardiopulmonary bypass (CPB) in adults. We sought to characterize the S100B release pattern before and after CPB in neonates and infants with congenital heart disease and correlate it with surgical mortality. Serum was collected before surgery and at 24 postoperative h from 109 neonates and infants with congenital heart disease. All patients had presurgical transthoracic echocardiograms and CPB with or without hypothermic circulatory arrest. S100B concentrations were determined using a two-site immunoluminometric assay (Sangtec 100). Thirty-day surgical mortality was observed. All neonates had significantly increased S100B concentrations before surgery that decreased by 24 postoperative h. Preoperative S100B concentrations in 32 neonates with hypoplastic left heart syndrome correlated inversely with the forward flow and size of the ascending aorta and postoperative mortality (r(2) = -0.63; P = 0.03). Among infants, increased pulmonary blood flow was associated with higher S100B levels before surgery than cyanosis. There was no correlation with postoperative S100B and time on CPB, hypothermic circulatory arrest, or 30-day surgical mortality. In conclusion, preoperative S100B concentrations correlate inversely with the size of the ascending aorta in hypoplastic left heart syndrome and may serve as a marker for preexisting brain injury and mortality. IMPLICATIONS: Neonates with hypoplastic left heart syndrome and no forward flow in the ascending aorta may have brain injury at birth before heart surgery.