Association between pediatric intensive care mortality and mechanical ventilation settings during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome.

The main objective of this study was to describe the current mechanical ventilation (MV) settings during extracorporeal membrane oxygenation (ECMO) for pediatric acute respiratory distress syndrome (P-ARDS) in six European centers. This is a retrospective observational cohort study performed in six European centers from January 2009 to December 2019. Children > 1 month to 18 years supported with ECMO for refractory P-ARDS were included. Collected data were as follows: patients' pre-ECMO medical condition, pre-ECMO adjunctive therapies for P-ARDS, pre-ECMO and during ECMO MV settings on day (D) 1, D3, D7, and D14 of ECMO, use of adjunctive therapies during ECMO, duration of ECMO, pediatric intensive care unit length of stay, and survival. A total of 255 patients with P-ARDS were included. The multivariate analysis showed that PEEP on D1 (OR = 1.13, 95% CI [1.03-1.24], p = 0.01); D3 (OR = 1.17, 95% CI [1.06-1.29], p = 0.001); and D14 (OR = 1.21, 95% CI [1.05-1.43], p = 0.02) and DP on D7 were significantly associated with higher odds of mortality (OR = 0.82, 95% CI [0.71-0.92], p = 0.001). Moreover, DP on D1 above 15 cmH2O (OR 2.23, 95% CI (1.09-4.71), p = 0.03) and native lung FiO2 above 60% on D14 (OR 10.36, 95% CI (1.51-116.15), p = 0.03) were significantly associated with higher odds of mortality.   Conclusion: MV settings during ECMO for P-ARDS varied among centers; however, use of high PEEP levels during ECMO was associated with higher odds of mortality as well as a DP above 15 cmH2O and a native lung FiO2 above 60% on D14 of ECMO. What is Known: • Invasive ventilation settings are well defined for pediatric acute respiratory distress syndrome; however, once the children required an extracorporeal respiratory support, there is no recommendation how to set the mechanical ventilator. • Impact of invasive ventilator during extracorporeal respiratory support ad only been during the first days of this support but the effects of these settings later in the assistance are not described. What is New: • It seems to be essential to early decrease FiO2 on native lung once the ECMO flow allows an efficient oxygenation. • Tight control to limit the driving pressure at 15 cmH20 during ECMO run seems to be associated with better survival rate.

Usefulness of implementation of a protective mechanical ventilation bundle during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome.

OBJECTIVE: Defining the best ventilatory settings under ECMO remains a challenging question. Despite a well-defined ARDS treatment before ECMO initiation, there is no recommendation on how to ventilate a patient under ECMO for P-ARDS. Only a few descriptive studies are available on ventilatory settings during respiratory ECMO. We aim at evaluating the usefulness of a protective ventilation bundle under ECMO and its capacity to reduce the ventilatory pressure in our ECMO center. METHODS: We performed a monocentric retrospective study from January 2007 to December 2018. All children aged from 1 month to 18 years old and requiring an extracorporeal membrane oxygenation for a refractory acute respiratory distress syndrome were included. A protective mechanical ventilation under ECMO bundle has been developed in 2014. We compare the period 1 (before 2014) to the period 2 (after 2014). RESULTS: Eighty-three patient had been included during the study. We reported a significant increase of PEEP and mean pressure respectively at day 3, day 7 and day 14 of ECMO during the period 2. Conversely, the driving pressure were significantly lower in the period 2 at day 3 (p: 0.009), day 7 (p:0.001) and day 14 (p: 0.001). We also shown a strong increase in the use of prone positioning during ECMO in the period 2 (p: 0.01). There was no significant effect of our bundle on the length of mechanical ventilation, of hospitalization and on the survival rate. CONCLUSIONS: The implementation of a protective mechanical ventilation bundle during ECMO is usefulness to apply for lower ventilatory pressure and higher use of prone positioning. Nonetheless, the lack of power of our study prevents us from showing its efficacy on outcome criteria.

Extracorporeal membrane oxygenation for immunocompromised children with acute respiratory distress syndrome: a French referral center cohort.

BACKGROUND: Immunocompromised children are likely to develop a refractory acute respiratory distress syndrome (ARDS). The usefulness of providing extracorporeal life support (ECLS) to these patients is a subject of debate. The aim of our study was to report the outcomes and to compare factors associated with mortality between immunocompromised and non-immunocompromised children supported with veno-venous ECMO. METHODS: We performed a retrospective monocentric study in the French pediatric ECMO center of Armand Trousseau Hospital, including all pediatric patients aged from 1 month to 18 years requiring ECLS for ARDS. RESULTS: Between 2007 and 2018, one hundred and eleven (111) patients underwent ECMO for respiratory failure; among them twenty-five (25) were immunocompromised. Survival rate at 6 months after intensive care discharge was significantly lower for immunocompromised patients compared to non-immunocompromised ones (41.7% vs. 62.8%; P=0.0.04). ARDS severity was similar between the 2 groups. Fungal pneumonias were reported only in immunocompromised patients (12.5% versus 0% in the control group; P=0.0.001). Bleeding complications were significantly more frequent in the immunocompromised group and blood product transfusions were also more frequently required in this group. CONCLUSIONS: Six months after intensive care discharge, survival rate of immunocompromised children supported with ECMO for pediatric ARDS is lower than for non-immunocompromised patients. But the expectation for a favorable outcome is real and it is worth it if their condition is likely to be compatible with a good long-term quality of life.

Myeloid phenotypes in severe COVID-19 predict secondary infection and mortality: a pilot study.

BACKGROUND: De-regulated host response to severe coronavirus disease 2019 (COVID-19), directly referring to the concept of sepsis-associated immunological dysregulation, seems to be a strong signature of severe COVID-19. Myeloid cells phenotyping is well recognized to diagnose critical illness-induced immunodepression in sepsis and has not been well characterized in COVID-19. The aim of this study is to review phenotypic characteristics of myeloid cells and evaluate their relations with the occurrence of secondary infection and mortality in patients with COVID-19 admitted in an intensive care unit. METHODS: Retrospective analysis of the circulating myeloid cells phenotypes of adult COVID-19 critically ill patients. Phenotyping circulating immune cells was performed by flow cytometry daily for routine analysis and twice weekly for lymphocytes and monocytes subpopulations analysis, as well as monocyte human leukocyte antigen (mHLA)-DR expression. RESULTS: Out of the 29 critically ill adult patients with severe COVID-19 analyzed, 12 (41.4%) developed secondary infection and six patients died during their stay. Monocyte HLA-DR kinetics was significantly different between patients developing secondary infection and those without, respectively, at day 5-7 and 8-10 following admission. The monocytes myeloid-derived suppressor cells to total monocytes ratio was associated with 28- and 60-day mortality. Those myeloid characteristics suggest three phenotypes: hyperactivated monocyte/macrophage is significantly associated with mortality, whereas persistent immunodepression is associated with secondary infection occurrence compared to transient immunodepression. CONCLUSIONS: Myeloid phenotypes of critically ill COVID-19 patients may be associated with development of secondary infection, 28- and 60-day mortality.

A twelve-year neonatal and pediatric high-frequency oscillatory ventilation transport experience.

OBJECTIVE: To describe the evolution over a 12-year period of a pediatric intensive care unit transport team's (PICU-TT) experience of pediatric and neonatal interhospital transportation on high-frequency oscillation ventilation (HFOV). METHODS: This was a monocentric retrospective observational study from January 2006 to December 2017. All patients aged under 18 years old who were transported on HFOV by the Robert Debré Hospital PICU-TT were included. RESULTS: Over a 12-year period, 125 patients were transported on HFOV, including 107 newborns and 18 children. Median (range) age and weight were 9 days (1 h-9 years) and 3.3 (0.6-39) kg, respectively. Initial median oxygenation index, SpO2 /FiO2 ratio and mean airway pressure were 32, 91, and 18 cmH2 O, respectively, without significant difference between values before and after transport. Adverse events occurred during 28 transportations (22%) including three recovered cardiac arrests and one death. Overall survival rate at discharge was 74%, 78% in neonates and 56% in pediatrics, respectively. HFOV transportation rate increased over the last four years of the study for neonates and remained stable for older children. Extra-corporeal membrane oxygenation (ECMO) initiation rate on arrival decreased and survival rate increased significantly during the last four years of the study (p < .05). CONCLUSION: This study showed the feasibility of HFOV transportation by a PICU-TT, despite some challenges. A trend towards using ECMO more than HFOV for the most severe respiratory and/or circulatory failures was seen over the 12-year period. The HFOV transportation rate has increased for less severe neonatal patients.

Childhood Langerhans cell histiocytosis with severe lung involvement: a nationwide cohort study.

BACKGROUND: Lung involvement in childhood Langerhans cell histiocytosis (LCH) is infrequent and rarely life threatening, but occasionally, severe presentations are observed. METHODS: Among 1482 children (< 15 years) registered in the French LCH registry (1994-2018), 111 (7.4%) had lung involvement. This retrospective study included data for 17 (1.1%) patients that required one or more intensive care unit (ICU) admissions for respiratory failure. RESULTS: The median age was 1.3 years at the first ICU hospitalization. Of the 17 patients, 14 presented with lung involvement at the LCH diagnosis, and 7 patients (41%) had concomitant involvement of risk-organ (hematologic, spleen, or liver). Thirty-five ICU hospitalizations were analysed. Among these, 22 (63%) were secondary to a pneumothorax, 5 (14%) were associated with important cystic lesions without pneumothorax, and 8 (23%) included a diffuse micronodular lung infiltration in the context of multisystem disease. First-line vinblastine-corticosteroid combination therapy was administered to 16 patients; 12 patients required a second-line therapy (cladribine: n = 7; etoposide-aracytine: n = 3; targeted therapy n = 2). A total of 6 children (35%) died (repeated pneumothorax: n = 3; diffuse micronodular lung infiltration in the context of multisystem disease: n = 2; following lung transplantation: n = 1). For survivors, the median follow-up after ICU was 11.2 years. Among these, 9 patients remain asymptomatic despite abnormal chest imaging. CONCLUSIONS: Severe lung involvement is unusual in childhood LCH, but it is associated with high mortality. Treatment guidelines should be improved for this group of patients: viral infection prophylaxis and early administration of a new LCH therapy, such as targeted therapy.

Sevoflurane Sedation with AnaConDa-S Device for a Child Undergoing Extracorporeal Membrane Oxygenation.

BACKGROUND: Deep sedation in critically ill children undergoing extracorporeal membrane oxygenation (ECMO) can be challenging. Volatile anesthetics like sevoflurane can be a good alternative for patients hospitalized in pediatric intensive care units, in whom adequate sedation is difficult to obtain. CASE DESCRIPTION: We report here the first pediatric case of a patient under extracorporeal membrane oxygenation receiving sedation by sevoflurane using the AnaConDa-S device. This 2-year-old girl, suffering from congenital diaphragmatic hernia, was put on extracorporeal membrane oxygenation due to a persistent pulmonary hypertension following metapneumovirus infection. Despite high doses of drugs, neither satisfactory sedation nor analgesia could be reached. Sevoflurane allowed her to be released and we were able to wean her from certain drugs. Her physiological parameters and the indicators of pain and sedation improved. CONCLUSION: Anesthesia using sevoflurane with the AnaConDa-S device is efficient for children under ECMO. CLINICAL SIGNIFICANCE: This is the first pediatric report on anesthesia with sevoflurane under ECMO. HOW TO CITE THIS ARTICLE: Soreze Y, Piloquet J-E, Amblard A, Constan I, Rambaud J, Leger P-L. Sevoflurane Sedation with AnaConDa-S Device for a Child Undergoing Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020;24(7):596-598.

Mobile Extracorporeal Membrane Oxygenation: 5-Year Experience of a French Pediatric and Neonatal Center.

OBJECTIVES: Extracorporeal membrane oxygenation is an established therapy for refractory cardiac and/or pulmonary failure that is not available in all centers. When infants and children require extracorporeal membrane oxygenation, they are sometimes placed on extracorporeal membrane oxygenation support in peripheral centers where extracorporeal membrane oxygenation is not available and then transferred on extracorporeal membrane oxygenation to specialized centers. The objective of this study is to first describe one of the largest cohorts of infants and children transported by a mobile unit while on extracorporeal membrane oxygenation. DESIGN: We undertook a single-center retrospective study that included patients transported while on extracorporeal membrane oxygenation between November 1, 2014, and May 31, 2019. PATIENTS: All patients transported by our mobile extracorporeal membrane oxygenation unit during the study period were included. Computerized data collection was approved by the French Data Protection Authority (Commission nationale de l'informatique et des libertés n° 2121127V0). MAIN RESULTS: Over the study period, our extracorporeal membrane oxygenation mobile team transported 80 patients on extracorporeal membrane oxygenation among which 20 were newborns (25%) and 60 were children of 1 month to 17 years old (75%); 57 patients were on venoarterial-extracorporeal membrane oxygenation (71%) and 23 on venovenous-extracorporeal membrane oxygenation (29%). The average duration of transport was 8.4 hours with a median of 8 hours; the average distance travelled was 189 ± 140 km. Transport was by air and then ground for 50% of the patients and by ground for 42%. We observed a significant decrease in the Vasoactive-Inotropic Score (125 vs 99; p = 0.005) and PaCO2 levels (67 vs 49 mm Hg; p = 0.0005) after arrival in our unit. Survival rate 6 months after PICU discharge was 46% (37). There was a statistically significant relationship between initial lactate level and mortality (p = 0.02). We observed minor adverse events in 39% of the transports and had no mortality during transport. CONCLUSIONS: We describe one of the largest cohorts of infants and children transported by a mobile unit while on extracorporeal membrane oxygenation. Our findings confirm that it is safe to start extracorporeal membrane oxygenation in a referring center and to transport patients using an extracorporeal membrane oxygenation mobile team. The only risk factor associated with higher mortality was an initially elevated lactate level.

First Evidence of Angiostrongyliasis Caused by Angiostrongylus cantonensis in Guadeloupe, Lesser Antilles.

Infection by the rat lungworm Angiostrongylus cantonensis represents the most common cause of infectious eosinophilic meningitis in humans, causing central nervous system (CNS) angiostrongyliasis. Most of CNS angiostrongyliasis cases were described in Asia, Pacific Basin, Australia, and some limited parts of Africa and America. CNS angiostrongyliasis has been reported in the Caribbean but never in the Lesser Antilles. The primary objectives of this study were to depict the first case of CNS angiostrongyliasis in the Lesser Antilles and investigate the environmental presence of A. cantonensis in Guadeloupe, Lesser Antilles. In December 2013, a suspected case of CNS angiostrongyliasis in an 8-month-old infant in Guadeloupe was investigated by real-time polymerase chain reaction (PCR) testing on cerebral spinal fluid (CSF). The environmental investigation was performed by collecting Achatina fulica molluscs from different parts of Guadeloupe and testing the occurrence of A. cantonensis by real-time PCR. CSF from the suspected case of angiostrongyliasis was positive for A. cantonensis by real-time PCR. Among 34 collected snails for environmental investigation, 32.4% were positive for A. cantonensis. In conclusion, we report the first laboratory-confirmed case of CNS-angiostrongyliasis in the Lesser Antilles. We identified the presence and high prevalence of A. cantonensis in A. fulica in Guadeloupe. These results highlight the need to increase awareness of this disease and implement public health programs in the region to prevent human cases of angiostrongyliasis and improve management of eosinophilic meningitis patients.