Acute kidney injury in pediatric toxic shock syndrome is associated with worse clinical course in the intensive care unit.

To explore the prevalence, severity, nature, and significance of acute kidney injury (AKI) among children admitted to the pediatric intensive care unit (PICU) with toxic shock syndrome (TSS). Bi-center, retrospective observational study. Children admitted for TSS to two intensive care units from 2009-2022 were included. We identified 41 children (median age 5 years, 46% females) who met the Centers for Disease Control and Prevention (CDC) definitions of TSS. Staphylococcal TSS accounted for 63% of the patients and Streptococcal TSS accounted for the remaining 37%. AKI was diagnosed in 24 (59%) (stage 1: n = 6 [15% of total], stage 2: n = 10 [24%], and stage 3: n = 8 [20%]). The worst creatinine level was measured during the first day of admission in 34 (83%) patients. The median duration of AKI was 2 days. Creatinine normalized by hospital discharge in all cases. Patients with AKI had a longer intensive care unit stay than those without AKI (6 vs. 3 days, respectively, p = 0.01), needed more respiratory support (87% vs. 47%, p = 0.002), had fewer 28 ventilation-free days (25 vs. 28, p = 0.01), fewer vasopressor-free days (25 vs. 28, p = 0.001), and received more blood products (p = 0.03).    Conclusion: Children admitted to the PICU with TSS, show a high prevalence of AKI at presentation. Creatinine levels and clearance normalize by hospital discharge in most cases. AKI in the setting of TSS could be used as an early marker for illness severity and a predictor of a more complex course. What is Known: • TSS is characterized according to the CDC by specific sets of clinical signs and symptoms in conjunction with specific laboratory findings one of which is AKI. • AKI is associated with worse outcomes in critically ill patients in general and in septic patients in particular. What is New: • AKI is found in about 60% of all patients admitted to the PICU with a diagnosis of TSS and hence is an important defining criteria. • AKI in the setting of TSS is associated with a more complex illness course and can serve as an early marker predicting such a course.

Postoperative coagulopathy among otherwise healthy pediatric patients undergoing open craniosynostosis repair: a retrospective study.

Significant blood loss and resultant transfusion may lead to coagulopathy. The need for routine transfusion of non-RBC blood products in healthy pediatric patients suffering significant, yet controlled, intra-operative blood loss is controversial. Open craniosynostosis surgery is often associated with significant intra-operative blood loss and transfusion, and routinely preformed on otherwise healthy pediatric patients. Therefore, we found it as a useful model for our study, which aimed to assess the need for routine transfusion of non-RBC blood products in healthy pediatric patients suffering significant intra-operative blood loss. We conducted a retrospective cohort study of otherwise healthy pediatric patients, undergoing open craniosynostosis surgery and transfused solely with packed red blood cells (pRBCs) in a single large-volume tertiary surgical center, between January 2010 and December 2021. Among 457 eligible patients, 34 (7.4%) developed significant postoperative coagulopathy. Median [IQR] intra-operative pRBC transfusion volume was 17.4 ml kg-1 [13.3, 23.1]. Patients who developed coagulopathy did not have higher postoperative pRBC transfusion rate (8.8% vs 3.8%, P = 0.16) or volume (median [IQR], 0 [0, 0] vs 0 [0, 0] ml, P = 0.15), nor higher hospital LOS (5 [4, 5] vs 5 [4, 5] days, P = 0.66). ICU LOS was 0.8 [0.7, 1] vs 0.7 [0.6, 0.8] days (P = 0.02), a difference of no clinical significance.  Conclusions: The incidence of significant coagulopathy after craniosynostosis surgery was low, and not associated with clinically important complications. In otherwise healthy pediatric patients, even significant intra-operative blood loss can be safely managed solely with intravenous fluids and pRBC transfusion. What is Known: • Significant intra-operative blood loss and resultant transfusion may lead to postoperative coagulopathy. • There are potential deleterious effects from both coagulopathy and administration of blood products. What is New: • Open craniosynostosis corrective surgery is a useful model for studying coagulopathy after significant intra-operative blood loss and transfusion in otherwise healthy children. • Under certain conditions, in otherwise healthy pediatric patients, even significant intra-operative blood loss can be safely treated with intravenous fluids and pRBC transfusion alone, with no clinically significant postoperative coagulopathy or its complications.

Early removal of a permanent catheter during the acute management of the unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection: a multi-disciplinary survey and review of the literature.

There are no guidelines for the optimal manner and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infections (CRBSI). Our goals were to examine current practices of permanent central catheter management and choice of removal in the hemodynamically unstable pediatric patient with suspected CRBSI among practitioners in diverse subspecialties. We performed a literature review on the subject, and conducted a multi-disciplinary survey included pediatric oncologists, pediatric emergency medicine physicians, and pediatric intensive care physicians whom we queried about their choice of permanent central catheter management and removal while treating the hemodynamically unstable pediatric patient with suspected CRBSI. Most of the 78 responders (n = 47, 59%) preferred to utilize the existing permanent central catheter for initial intravenous access rather than an alternative access. There were no significant differences between physician subspecialties (p = 0.29) or training levels (p = 0.14). Significantly more pediatric emergency medicine physicians preferred not to remove the permanent central catheter at any time point compared to the pediatric hemato-oncologists, who preferred to remove it at some point during the acute presentation (44.4% vs. 9.4%, respectively, p = 0.02). CONCLUSION: Our study findings reflect the need for uniform guidelines on permanent central catheter use and indications for its removal in the hemodynamically unstable pediatric patient. We suggest that permanent central catheter removal should be urgently considered in a deteriorating patient who failed to be stabilized with medical treatment. WHAT IS KNOWN: • There are no guidelines for the optimal choice and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection (CRBSI). WHAT IS NEW: • We found variations in practices among pediatricians from diverse subspecialties and conflicting data in the literature. • There is a need for prospective studies to provide uniform guidelines for optimal management of suspected CRBSI in the hemodynamically unstable pediatric patient.

Cardiorespiratory Abnormalities in Patients Recovering from Coronavirus Disease 2019.

BACKGROUND: A large number of patients around the world are recovering from coronavirus disease 2019 (COVID-19); many of them report persistence of symptoms. The aim of this study was to test pulmonary, cardiovascular, and peripheral responses to exercise in patients recovering from COVID-19. METHODS: Patients who recovered from COVID-19 were prospectively evaluated using a combined anatomic and functional assessment. All patients underwent clinical examination, laboratory tests, and combined stress echocardiography and cardiopulmonary exercise testing. Left ventricular volumes, ejection fraction, stroke volume, heart rate, E/e' ratio, right ventricular function, oxygen consumption (Vo2), lung volumes, ventilatory efficiency, oxygen saturation, and muscle oxygen extraction were measured in all effort stages and compared with values in historical control subjects. RESULTS: A total of 71 patients were assessed 90.6 ± 26 days after the onset of COVID-19 symptoms. Only 23 (33%) were asymptomatic. The most common symptoms were fatigue (34%), muscle weakness or pain (27%), and dyspnea (22%). Vo2 was lower among post-COVID-19 patients compared with control subjects (P = .03, group-by-time interaction P = .007). Reduction in peak Vo2 was due to a combination of chronotropic incompetence (75% of post-COVID-19 patients vs 8% of control subjects, P < .0001) and an insufficient increase in stroke volume during exercise (P = .0007, group-by-time interaction P = .03). Stroke volume limitation was mostly explained by diminished increase in left ventricular end-diastolic volume (P = .10, group-by-time interaction P = .03) and insufficient increase in ejection fraction (P = .01, group-by-time interaction P = .01). Post-COVID-19 patients had higher peripheral oxygen extraction (P = .004) and did not have significantly different respiratory and gas exchange parameters compared with control subjects. CONCLUSIONS: Patients recovering from COVID-19 have symptoms associated with objective reduction in peak Vo2. The mechanism of this reduction is complex and mainly involves a combination of attenuated heart rate and stroke volume reserve.

Correction to: Lung ultrasound predicts clinical course and outcomes in COVID-19 patients.

The original article can be found online.

Lung ultrasound predicts clinical course and outcomes in COVID-19 patients.

PURPOSE: Information regarding the use of lung ultrasound (LUS) in patients with Coronavirus disease 2019 (COVID-19) is quickly accumulating, but its use for risk stratification and outcome prediction has yet to be described. We performed the first systematic and comprehensive LUS evaluation of consecutive patients hospitalized with COVID-19 infection, in order to describe LUS findings and their association with clinical course and outcome. METHODS: Between 21/03/2020 and 04/05/2020, 120 consecutive patients admitted to the Tel Aviv Medical Center due to COVID-19, underwent complete LUS within 24 h of admission. A second exam was performed in case of clinical deterioration. LUS score of 0 (best)-36 (worst) was assigned to each patient. LUS findings were compared with clinical data. RESULTS: The median baseline total LUS score was 15, IQR [7-20]. Baseline LUS score was 0-18 in 80 (67%) patients, and 19-36 in 40 (33%) patients. The majority had patchy pleural thickening (n = 100; 83%), or patchy subpleural consolidations (n = 93; 78%) in at least one zone. The prevalence of pleural thickening, subpleural consolidations and the total LUS score were all correlated with severity of illness on admission. Clinical deterioration was associated with increased follow-up LUS scores (p = 0.0009), mostly due to loss of aeration in anterior lung segments. The optimal cutoff point for LUS score was 18 (sensitivity = 62%, specificity = 74%). Both mortality and need for invasive mechanical ventilation were increased with baseline LUS score > 18 compared to baseline LUS score 0-18. Unadjusted hazard ratio of death for LUS score was 1.08 per point [1.02-1.16], p = 0.008; Unadjusted hazard ratio of the composite endpoint (death or need for invasive mechanical ventilation) for LUS score was 1.12 per point [1.05-1.2], p = 0.0008. CONCLUSION: Hospitalized patients with COVID-19, at all clinical grades, present with pathological LUS findings. Baseline LUS score strongly correlates with the eventual need for invasive mechanical ventilation and is a strong predictor of mortality. Routine use of LUS may guide patients' management strategies, as well as resource allocation in case of surge capacity.

A Case of Methotrexate Neurotoxicity Presented as Status Epilepticus, Encephalopathy, and High Fever.

High-dose methotrexate is used to treat a range of adult and childhood cancers including osteosarcoma. Significant neurotoxicity is reported in 1% to 4.5% of patients treated with high-dose methotrexate and can present in a wide variety of symptoms. We present a case of a 14-year-old boy with a recent diagnosis of osteosarcoma who presented to the emergency department with status epilepticus, altered mental status, and very high fever secondary to methotrexate neurotoxicity. We review current literature and discuss some controversies related to this state. We also describe high fever as one of the possible symptoms associated with this condition and suggest using specific magnetic resonance imaging sequence to uncover abnormal findings related to this state. Since high-dose methotrexate is not a rare treatment in this era, we believe that in addition to oncologists, emergency department and intensive care providers should be aware of the potential role of methotrexate in causing significant neurotoxicity and include it in the differential diagnosis when treating a patient presenting with new neurological symptoms in the setting of recent high-dose methotrexate treatment.

Severe disseminated intravascular coagulation in a child envenomated by Echis coloratus and successful treatment with monovalent equine immunoglobulin G antivenom.

BACKGROUND: Echis coloratus (Burton Carpet viper), a highly venomous snake belonging to the family Viperidae, is responsible for a large proportion of the venomous snakebites in Israel and Palestinian Authority. Procoagulant enzymes are present in Echis coloratus venom and significant coagulopathy is typical after envenomation. Here we report a case of envenomation by Echis coloratus that involved severe coagulopathy as the main systemic manifestation with severe bleeding after fasciotomy. CASE DETAILS: A 3-year-old boy was admitted to our pediatric critical care unit after a snakebite to his left hand, 2-3 hours post-bite. Based on the possibility of compartment syndrome, a fasciotomy was performed before administration of antivenom. At our hospital, he had altered prothrombin time (PT) and activated partial thromboplastin time (aPTT), with low fibrinogen levels. The snake responsible for the bite was later identified as a 38-cm long Echis coloratus. Five vials of Israeli monovalent antivenom were subsequently administered with step-wise improvement in hematological abnormalities. Other treatments included massive blood products transfusion (packed RBC, FFP, cryoprecipitate, PLT), inotropes and ventilatory support. After a prolonged hospital course the patient had a positive outcome.

The value of cerebrospinal fluid lactate levels in diagnosing CSF infections in pediatric neurosurgical patients.

PURPOSE: Diagnosis of cerebrospinal fluid (CSF) infections in patients following neurosurgical procedures can be challenging. CSF lactate (LCSF) has been shown to assist in differentiating bacterial from non-bacterial meningitis in non-neurosurgical patients. The use of lactate in diagnosing CSF-related infections following neurosurgical procedures has been described in adults. The goal of this study was to describe the role of LCSF levels in diagnosing CSF-related infections among neurosurgical children. METHODS: We retrospectively collected data for all pediatric patients treated at a large tertiary pediatric neurosurgical department, for whom CSF samples were collected over a 2-year period. Lactate levels were correlated with other CSF parameters, surgical parameters, presence of CSF infection, and source of CSF sample (lumbar, ventricular, or pseudomeningocele). RESULTS: A total of 215 CSF samples from 162 patients were analyzed. We found a correlation between lactate levels and other CSF parameters. Lactate levels displayed an inconsistent correlation with infection depending on sample origin. Irrespective of the CSF source, lactate levels could not sufficiently discriminate between those with or without infection. Lactate levels were correlated with recent surgery, and, in some of the subgroups, to the extent of blood in CSF. CONCLUSIONS: LCSF levels are influenced by many factors, including the source of sample, recent surgery, and the presence of subarachnoid or ventricular blood secondary to surgery. The added value of LCSF for diagnosing CSF infections in children with a history of neurosurgical procedures is unclear and may be influenced by the extent of blood in the CSF.

Value of Cerebrospinal Fluid Lactate Levels in Diagnosing Shunt Infections in Pediatric Patients.

OBJECTIVE: The diagnosis and timely treatment of shunt infections (SI) in children is of paramount importance. In some cases, the standard cerebrospinal fluid (CSF) variables will not be sufficient for an accurate diagnosis of SI. CSF lactate (LCSF) has been found to assist in differentiating bacterial from nonbacterial meningitis in non-neurosurgical patients. To the best of our knowledge, the use of lactate in diagnosing or confirming the presence of SI has not yet been discussed. The goal of the present study was to describe the role of LCSF levels in children with shunts and Ommaya reservoirs and to evaluate its role in the accurate diagnosis of shunt-related infection. METHODS: We retrospectively collected data for a consecutive series of pediatric patients treated at a large tertiary pediatric neurosurgical department, for whom CSF samples from shunts had been collected during a 2-year period (2016-2017). The lactate levels were correlated with the presence of SI. RESULTS: A total of 61 CSF samples were analyzed, with 6 SIs found. The LCSF levels and white blood cell count were both found to correlate with the presence of CSF infections. A cutoff value of ≥2.95 mmol/L reached a sensitivity of 83%, specificity of 83%, and positive predictive value of 50%. LCSF <2.95 mmol/L had a negative predictive value of 96%. CONCLUSIONS: LCSF levels can be used as an additional chemical marker for the diagnosis and confirmation of SIs. An LCSF value of <2.95 mmol/L had a high negative predictive value.

Hyperchloremia and Diuresis in Children Undergoing Scoliosis Surgery: A Retrospective Cohort Study.

BACKGROUND: Hyperchloremia is frequent in adult surgical patients and is associated with renal dysfunction. Studies in surgical pediatric patients are lacking. OBJECTIVES: To identify both the incidence of postoperative hyperchloremia in children undergoing surgery for idiopathic and non-idiopathic scoliosis, and the association of postoperative hyperchloremia with intraoperative fluid management and postoperative diuresis. METHODS: The records of 74 children and adolescents who underwent elective scoliosis surgery were retrospectively evaluated. The primary endpoint was the incidence of serum chloride level ≥ 110 mEq/L at the end of surgery and 12 hours postoperatively. Secondary endpoints were the type and volume of administered fluids, 12 hours postoperative diuresis, and the incidence of postoperative oliguria. RESULTS: Hyperchloremia occurred in 55% of the patients at the end of surgery and in 52% 12 hours postoperatively. Hyperchloremic patients received larger intraoperative volume of 0.9% NaCl diluted cell-saver blood and 10% HAES than did normochloremic patients [median (interquartile range) 6.8 (2.5-11.0) ml/kg vs. 0 (0-7.3), P = 0.003 and 10.0 (0-12.8) vs. 4.4 (0-9.8), P = 0.02, respectively]. Additionally, when compared with normochloremic patients, diuresis during the first 12 hours postoperatively was lower in hyperchloremic patients. Postoperative oliguria (urine output < 0.5 ml/kg/hr for 12 hours) was diagnosed in 7 children (9%), of whom 6 were hyperchloremic at the end of surgery. CONCLUSIONS: Early postoperative hyperchloremia is common in children undergoing scoliosis repair surgery and may be attributed to the administration of 0.9% NaCl diluted cell-saver blood and 10% HAES. Postoperative hyperchloremia might be associated with postoperative oliguria.

Laryngeal ultrasound for the diagnosis of laryngomalacia in infants.

INTRODUCTION: Laryngomalacia is the most prevalent cause of congenital stridor. Flexible laryngobronchoscopy (FLB) is the gold standard for diagnosis. However, FLB requires venous access, deep sedation or general anesthesia, and is associated with patient's and parental discomfort and a considerable cost. Laryngeal ultrasound (LUS) has been shown to provide good evaluation of the normal anatomy and the dynamic motion of laryngeal structures. We investigated the yield of LUS in the diagnosis of laryngomalacia in infants with congenital stridor compared to FLB. METHODS: A prospective blind study of consecutive infants referred for FLB due to congenital stridor with unknown cause. The presence of arytenoids adduction on LUS during inspiration was used to diagnose laryngomalacia. LUS was followed by FLB under anesthesia. The physician performing the FLB was blinded to the LUS results. RESULTS: Twenty-four patients participated in the study (54% males). Median (IQR) age and weight were 3.5 (1-7.7) months and 5.1 (4-8.4) kg, respectively. LUS was well tolerated in all infants. Compared to FLB, LUS correctly diagnosed laryngomalacia in 11/14 (78.6%) infants. In 10 infants FLB ruled out laryngomalacia of whom LUS concurred in 9 infants and one was falsely diagnosed with laryngomalacia. LUS had a sensitivity of 78.5% (CI 52-95%), specificity of 90% (CI 49-94%), NPV of 75%, and PPV of 92%. ROC analysis demonstrated AUC of 0.84 (P < 0.01, 95%CI: 0.67-1.0). CONCLUSION: We suggest that LUS has a role in screening congenital stridor in otherwise healthy infants when laryngomalacia is highly probable.

Combined plerixafor and granulocyte colony-stimulating factor for harvesting high-dose hematopoietic stem cells: Possible niche for plerixafor use in pediatric patients.

PB is a source of HSC, especially for autologous HCT in solid tumors. However, there is a risk of failing to achieve the target number of SC after mobilization with growth factors alone in patients who were heavily pretreated with chemotherapy or those in need for tandem transplants. SC were harvested from seven pediatric patients with solid tumors who were in need of autologous HCT following combination GCSF and plerixafor. Six of them received plerixafor after failing to achieve enough SC with GCSF only, while the seventh patient received the combined protocol upfront. All seven patients achieved the target number of SC according to their treatment protocol. There were no adverse events. All patients underwent autologous HCT using the harvested HSC and achieved full engraftment. A protocol for harvesting autologous HCT using GCSF and plerixafor is feasible and safe in children with solid tumors who had been heavily pretreated with chemotherapy or needed tandem transplants.