Adverse Tracheal Intubation Events in Critically Ill Underweight and Obese Children: Retrospective Study of the National Emergency Airway for Children Registry (2013-2020).

OBJECTIVES: Extremes of patient body mass index are associated with difficult intubation and increased morbidity in adults. We aimed to determine the association between being underweight or obese with adverse airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe peri-intubation hypoxemia (pulse oximetry oxygen saturation < 80%) in critically ill children. DESIGN/SETTING: Retrospective cohort using the National Emergency Airway for Children registry dataset of 2013-2020. PATIENTS: Critically ill children, 0 to 17 years old, undergoing TI in PICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Registry data from 24,342 patients who underwent TI between 2013 and 2020 were analyzed. Patients were categorized using the Centers for Disease Control and Prevention weight-for-age chart: normal weight (5th-84th percentile) 57.1%, underweight (< 5th percentile) 27.5%, overweight (85th to < 95th percentile) 7.2%, and obese (≥ 95th percentile) 8.2%. Underweight was most common in infants (34%); obesity was most common in children older than 8 years old (15.1%). Underweight patients more often had oxygenation and ventilation failure (34.0%, 36.2%, respectively) as the indication for TI and a history of difficult airway (16.7%). Apneic oxygenation was used more often in overweight and obese patients (19.1%, 19.6%) than in underweight or normal weight patients (14.1%, 17.1%; p < 0.001). TIAEs and/or hypoxemia occurred more often in underweight (27.1%) and obese (24.3%) patients ( p < 0.001). TI in underweight children was associated with greater odds of adverse airway outcome compared with normal weight children after adjusting for potential confounders (underweight: adjusted odds ratio [aOR], 1.09; 95% CI, 1.01-1.18; p = 0.016). Both underweight and obesity were associated with hypoxemia after adjusting for covariates and site clustering (underweight: aOR, 1.11; 95% CI, 1.02-1.21; p = 0.01 and obesity: aOR, 1.22; 95% CI, 1.07-1.39; p = 0.002). CONCLUSIONS: In underweight and obese children compared with normal weight children, procedures around the timing of TI are associated with greater odds of adverse airway events.

Perioperative Mobile Telehealth Program for Post-Prostatectomy Incontinence: A Randomized Clinical Trial.

PURPOSE: Perioperative pelvic floor muscle training can hasten recovery of bladder control and reduce severity of urinary incontinence following radical prostatectomy. Nevertheless, most men undergoing prostatectomy do not receive this training. The purpose of this trial was to test the effectiveness of interactive mobile telehealth (mHealth) to deliver an evidence-based perioperative behavioral training program for post-prostatectomy incontinence. MATERIALS AND METHODS: This was a 3-site, 2-arm, randomized trial (2014-2019). Men with prostate cancer scheduled to undergo radical prostatectomy were randomized to a perioperative behavioral program (education, pelvic floor muscle training, progressive exercises, bladder control techniques) or a general prostate cancer education control condition, both delivered by mHealth for 1-4 weeks preoperatively and 8 weeks postoperatively. The primary outcome was time to continence following surgery measured by the ICIQ (International Consultation on Incontinence Questionnaire) Short-Form. Secondary outcomes measured at 6, 9 and 12 months included Urinary Incontinence Subscale of Expanded Prostate Cancer Index Composite; pad use; International Prostate Symptom Score QoL Question and Global Perception of Improvement. RESULTS: A total of 245 men (ages 42-78 years; mean=61.7) were randomized. Survival analysis using the Kaplan-Meier estimate showed no statistically significant between-group differences in time to continence. Analyses at 6 months indicated no statistically significant between-group differences in ICIQ scores (mean=7.1 vs 7.0, p=0.7) or other secondary outcomes. CONCLUSIONS: mHealth delivery of a perioperative program to reduce post-prostatectomy incontinence was not more effective than an mHealth education program. More research is needed to assess whether perioperative mHealth programs can be a helpful addition to standard prostate cancer care.

Friend or Foe? Venoarterial ECMO via Carotid Artery "Jump Graft": A Case Series.

Extracorporeal life support is used in adult and pediatric patients for refractory cardiac and respiratory failure. The great arteries and veins of the neck and groin are often used for cannulation to extracorporeal membrane oxygenation (ECMO). Newer cannulation techniques use the subclavian or axillary arteries, in addition to synthetic grafts anastomosed in end-to-side fashion, from which the cannula is positioned. These newer techniques can prevent need for ligation and sacrifice of important major vessels that is often undertaken in "traditional" direct surgical cannulation strategies. To our knowledge this graft technique has not been performed in pediatric ECMO patients. We describe a case series of nine patients from 2012 to 2017 supported with venoarterial (V-A) ECMO utilizing a synthetic Gore-Tex® "jump graft" sewn in an end-to-side fashion to the right carotid artery, for the arterial cannula insertion. Each patient's hospital course was reviewed with particular consideration given to disease process, site of cannulation, neurologic examination abnormalities noted during ECMO, computed tomography (CT) or magnetic resonance imaging (MRI) evidence of intracranial hemorrhage, and outcomes. Eight of nine patients were successfully cannulated utilizing this technique without neurologic complication. One suffered catastrophic intracerebral hemorrhage. This series is limited by small sample size and single center experience. Further work is needed to determine the advantages and disadvantages of utilizing a synthetic graft in pediatric V-A ECMO.

ECMO Support in Pre-B-Cell ALL for Disseminated Legionnaire's Disease.

Legionella pneumophila is a common cause of community- and hospital-acquired pneumonia. Its increasing frequency and reemergence as a pathogen of interest in the intensive care unit is likely due to increased awareness, recognition, and diagnostic test availability (1). Extracorporeal Membrane Oxygenation (ECMO) is increasingly used in the pediatric intensive care unit (PICU) for refractory cardiopulmonary failure and acute respiratory distress syndrome (ARDS) in concert with conventional modalities or when these have failed to adequately support the patient. The breadth of applications for this technology are ever-expanding as our collective knowledge and experience grows. With a particularly high mortality rate among immunocompromised patients, Legionnaires' disease should be considered early in the differential diagnosis and appropriate antimicrobials initiated (1). We present the case of an adolescent patient with pre-B-cell acute lymphoblastic leukemia (pre-B ALL) requiring ECMO support for septic shock and ARDS due to disseminated Legionella. To our knowledge, this is the first case describing an immunocompromised pediatric patient supported with ECMO for Legionnaires' disease.

Seizures, Meds, and Vtach: A Journey to a Brugada Diagnosis.

ABSTRACT: Sudden cardiac arrest of cardiac etiology is rare in children and adolescents and most often occurs with exertion. Conversely, syncope is a common pediatric emergency department complaint but rarely is associated with a serious underlying cardiac disorder. This report describes a case of the channelopathy Brugada syndrome (BrS) as a cause of sudden cardiac arrest in a febrile preadolescent child taking medications known to affect cardiac conduction. The patient received cardiopulmonary resuscitation and was successfully defibrillated. Initial electrocardiogram (ECG) demonstrated findings consistent with BrS. Confirmatory electrophysiologic testing was performed, and an implantable cardiac defibrillator was placed. Pediatric emergency specialists must recognize both the importance of ECG in the workup of syncope and be familiar with the specific ECG findings suggestive of BrS. Ventricular arrhythmias that occur at rest should raise the suspicion of this genetic cardiac channelopathy, regardless of age.

Methicillin-Sensitive Staphylococcus aureus Co-infection in Adolescent Patients With Delta-Variant SARS-CoV-2 Acute Respiratory Failure.

We report a series of five pediatric patients admitted with acute respiratory failure due to delta-variant SARS-CoV-2, found to have a methicillin-sensitive Staphylococcus aureus (MSSA) co-infection. All five patients required escalation of their respiratory support within 24 hours of discovering the MSSA infections. Four out of the five patients received immune-modulating therapies. Four patients required extracorporeal membrane oxygenation support. One patient died, and the other four survived until hospital discharge. Clinicians should consider secondary bacterial infections in patients with COVID-19 treated with immune modulators. MSSA co-infection can lead to increased morbidity and mortality in patients with COVID-19.

Safety of primary nasotracheal intubation in the pediatric intensive care unit (PICU).

Background: Nasal tracheal intubation (TI) represents a minority of all TI in the pediatric intensive care unit (PICU). The risks and benefits of nasal TI are not well quantified. As such, safety and descriptive data regarding this practice are warranted. Methods: We evaluated the association between TI route and safety outcomes in a prospectively collected quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013 to 2020. The primary outcome was severe desaturation (SpO2 > 20% from baseline) and/or severe adverse TI-associated events (TIAEs), using NEAR4KIDS definitions. To balance patient, provider, and practice covariates, we utilized propensity score (PS) matching to compare the outcomes of nasal vs. oral TI. Results: A total of 22,741 TIs [nasal 870 (3.8%), oral 21,871 (96.2%)] were reported from 60 PICUs. Infants were represented in higher proportion in the nasal TI than the oral TI (75.9%, vs 46.2%), as well as children with cardiac conditions (46.9% vs. 14.4%), both p < 0.001. Severe desaturation or severe TIAE occurred in 23.7% of nasal and 22.5% of oral TI (non-adjusted p = 0.408). With PS matching, the prevalence of severe desaturation and or severe adverse TIAEs was 23.6% of nasal vs. 19.8% of oral TI (absolute difference 3.8%, 95% confidence interval (CI): - 0.07, 7.7%), p = 0.055. First attempt success rate was 72.1% of nasal TI versus 69.2% of oral TI, p = 0.072. With PS matching, the success rate was not different between two groups (nasal 72.2% vs. oral 71.5%, p = 0.759). Conclusion: In this large international prospective cohort study, the risk of severe peri-intubation complications was not significantly higher. Nasal TI is used in a minority of TI in PICUs, with substantial differences in patient, provider, and practice compared to oral TI.A prospective multicenter trial may be warranted to address the potential selection bias and to confirm the safety of nasal TI.