Transforming a paediatric ICU to an adult ICU for severe Covid-19: lessons learned.

During the first Covid-19 wave, our paediatric intensive care unit (PICU), like many others across the globe, was transformed into an adult ICU for patients with severe Covid-19, due to a shortage of adult ICU beds. Here, we provide a comprehensive description of all the conditions that must be fulfilled to successfully accomplish this transformation. Strong support from all hospital departments was crucial, as their activity was modified by the change. Healthcare workers from various units, notably the paediatric anaesthesiology department, worked in the adult ICU to ensure sufficient staffing. The number of physiotherapists and psychologists was increased. A support system for both healthcare workers and patients' relatives was set up with the help of the mobile paediatric palliative care and support team. Supplies suitable for adults were ordered. Protocols for numerous procedures were written within a few days. Video tutorials, checklists, and simulation sessions were circulated to the entire staff. The head nurses guided and supported the new staff and usual PICU staff. The transformation was achieved within a week. The main difficulties were healthcare worker stress, changes in recommendations over time, absence of visits from relatives, and specific adult issues that paediatricians are unfamiliar with.Conclusion: For the staff, caring for adult patients was made easier by working in their familiar unit instead of being moved to an adult hospital with unfamiliar staff members and equipment. Strong support from the hospital and the assistance of consultants from adult hospital departments were crucial. What is Known: • The dramatic spread across the world of coronavirus disease 2019 generated critical care needs that drastically exceeded resources in many countries worldwide. • Paediatric ICU activity during this period decreased due to lockdown measures and the fact that children rarely required ICU for coronavirus disease 2019. What is New: • We describe how an 18-bed adult Covid-19 ICU was successfully set up in a paediatric hospital during the first wave of the Covid-19 pandemic. • Specific requirements regarding supply, human resources, and procedures, as well as difficulties encountered, are described.

Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 mimicking Kawasaki disease (Kawa-COVID-19): a multicentre cohort.

BACKGROUND: Current data suggest that COVID-19 is less frequent in children, with a milder course. However, over the past weeks, an increase in the number of children presenting to hospitals in the greater Paris region with a phenotype resembling Kawasaki disease (KD) has led to an alert by the French national health authorities. METHODS: Multicentre compilation of patients with KD in Paris region since April 2020, associated with the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ('Kawa-COVID-19'). A historical cohort of 'classical' KD served as a comparator. RESULTS: Sixteen patients were included (sex ratio=1, median age 10 years IQR (4·7 to 12.5)). SARS-CoV-2 was detected in 12 cases (69%), while a further three cases had documented recent contact with a quantitative PCR-positive individual (19%). Cardiac involvement included myocarditis in 44% (n=7). Factors prognostic for the development of severe disease (ie, requiring intensive care, n=7) were age over 5 years and ferritinaemia >1400 µg/L. Only five patients (31%) were successfully treated with a single intravenous immunoglobulin (IVIg) infusion, while 10 patients (62%) required a second line of treatment. The Kawa-COVID-19 cohort differed from a comparator group of 'classical' KD by older age at onset 10 vs 2 years (p<0.0001), lower platelet count (188 vs 383 G/L (p<0.0001)), a higher rate of myocarditis 7/16 vs 3/220 (p=0.0001) and resistance to first IVIg treatment 10/16 vs 45/220 (p=0.004). CONCLUSION: Kawa-COVID-19 likely represents a new systemic inflammatory syndrome temporally associated with SARS-CoV-2 infection in children. Further prospective international studies are necessary to confirm these findings and better understand the pathophysiology of Kawa-COVID-19. Trial registration number NCT02377245.

Successful extracorporeal membrane oxygenation transport of a 4-month-old brain-dead infant for organ donation: A case report.

A 4-month-old infant was declared brain-dead 2 days after being initiated on venoarterial ECMO for a refractory septic shock. All brain death diagnostic criteria were fulfilled according to French law, and parental consent was given for organ donation. The hospital where ECMO was initiated had no authorization for organ procurement, and the donor was then transferred to the local referral center for child organ recovery with our mobile ECMO team to maintain organ perfusion. The kidneys were recovered and successfully transplanted to a child who is now well and alive. Although the transport elements of this case report are of limited relevance to an international audience as no other country, to our knowledge, has this particular organization, it does show excellent collaboration between teams to realize the goal of organ donation for this family. This is the first case describing a successful inter-hospital transport for organ procurement of a brain-dead infant on ECMO. Brain-dead pediatric patients undergoing ECMO can be considered as potential organ donors to expand the donor pool.

Factors associated with adverse outcome among children with sickle cell disease admitted to the pediatric intensive care unit: an observational cohort.

BACKGROUND: Sickle cell disease (SCD) is one of the most frequent inherited diseases in the world. Over the last decades, in high-income countries, an important decrease in mortality have been observed due to the improvement of care. However, children with SCD can become critically ill and require admission in Pediatric Intensive Care Units (PICU). The purpose of this study was to describe the epidemiology of children with SCD admitted to PICU for acute crisis and to identify factors associated with adverse outcome (AO). METHODS: We conducted a retrospective study in a Tertiary Hospital in France including all consecutive children with SCD admitted to PICU between January 1st, 2009 and December 31, 2019. We collected baseline patient's characteristics, clinical and biological data as well as treatments and life sustaining therapies used in the PICU. Patients were defined as experiencing AO in case of death during stay and/or need for invasive mechanical ventilation (MV) and/or for non-invasive ventilation (NIV) for more than 3 days and/or need for vasopressors and/or need for renal replacement therapy. RESULTS: We included 579 admissions in 395 patients, mainly of SS genotype (90%) with a median age of 9.2 years [5.5-13.4] and a median baseline hemoglobin of 8.0 g/dl (7.5-8.8). The two main reasons for admission were acute chest syndrome (ACS) (n = 331, 57%) and vaso-occlusive crisis refractory to first line therapy (n = 99, 17%). Half of patients required NIV and 47 (8%) required MV. The overall length of stay was 3 days [1-4] and seven (1%) patients died during PICU stay.There was a total of 113 (20%) admissions with AO and on multivariable analysis, baseline hemoglobin < 8 g/dL, history of bronchial obstruction and admission for ACS were associated with AO. There was no difference in the proportion of hydroxyurea treatment or exchange transfusion program between patients with AO and the other patients. CONCLUSIONS: Baseline hemoglobin < 8 g/dL, history of bronchial obstruction and admission for ACS were the strongest risk factors for severe evolution in SCD children admitted to PICU. These factors could be taken into consideration when choosing the adequate therapeutic options.

Emergency management of children with acute severe asthma requiring transfer to intensive care.

PURPOSE: Children presenting to emergency departments (ED) with acute severe asthma unresponsive to initial medical therapy may require endotracheal intubation and mechanical ventilation. There is little data on complications during the acute management of children with life-threatening asthma, particularly at hospitals where specialist paediatric staff are lacking. It was hypothesised that a better understanding of complications, particularly associated with intubation and mechanical ventilation, would improve acute management in ED, aid quality improvement initiatives at district general hospitals (DGH) and form the basis for educational interventions from regional paediatric critical care units. METHODS: A retrospective case note review was performed for all children referred to a regional intensive care retrieval service with status asthmaticus over a 2-year period. Initial treatment, patient-related factors, indication for endotracheal intubation and the type and occurrence of adverse events during acute management at the DGH were studied. Bivariate and multivariate analyses were undertaken to identify factors associated with the occurrence of complications. RESULTS: 51 (85%) of the 60 children transferred to a paediatric intensive care unit for acute severe asthma required intubation. 36 (70.5%) experienced one or more complications during intubation and in the early phase of mechanical ventilation. The most common complications were hypotension (requiring fluid resuscitation and/or inotropic support) and severe bronchospasm with acute hypercarbia. The indication for intubation significantly affected the chances of a complication occurring during stabilisation. CONCLUSIONS: There is considerable morbidity in asthmatic children who are referred to paediatric intensive care. The majority of complications may be anticipated and prevented resulting in improved management at DGH.

Varicella zoster in sudden infant death.

A 2-month-old girl with normal development and no previous physical illnesses was resuscitated having been found lifeless on her back at home. On admission to Paediatric Intensive Care, she had severe metabolic disturbance, associated with an extremely troubling neurological signs. She died 2 hours later. A full body CT scan did not reveal injury and her parents declined an autopsy. Peripheral blood and cerebrospinal fluid samples were sterile. However, a broad-range PCR coupled with electrospray-ionisation mass spectrometry onto the PLEX-ID automat of peripheral blood revealed the presence of varicella zoster virus. There was a specific viral load in whole blood of 20 542 copies/ml. It is presumed that Varicella myocarditis was the likely cause of death. Our case illustrates the potential usefulness of a broad range PCR strategy in determining infectious causes of death in sudden infant death. Varicella is a potential cause of sudden infant death.

A multicenter randomized controlled trial of a 3-L/kg/min versus 2-L/kg/min high-flow nasal cannula flow rate in young infants with severe viral bronchiolitis (TRAMONTANE 2).

PURPOSE: High-flow nasal cannula (HFNC) therapy is increasingly proposed as first-line respiratory support for infants with acute viral bronchiolitis (AVB). Most teams use 2 L/kg/min, but no study compared different flow rates in this setting. We hypothesized that 3 L/kg/min would be more efficient for the initial management of these patients. METHODS: A randomized controlled trial was performed in 16 pediatric intensive care units (PICUs) to compare these two flow rates in infants up to 6 months old with moderate to severe AVB and treated with HFNC. The primary endpoint was the percentage of failure within 48 h of randomization, using prespecified criteria of worsening respiratory distress and discomfort. RESULTS: From November 2016 to March 2017, 142 infants were allocated to the 2-L/kg/min (2L) flow rate and 144 to the 3-L/kg/min (3L) flow rate. Failure rate was comparable between groups: 38.7% (2L) vs. 38.9% (3L; p = 0.98). Worsening respiratory distress was the most common cause of failure in both groups: 49% (2L) vs. 39% (3L; p = 0.45). In the 3L group, discomfort was more frequent (43% vs. 16%, p = 0.002) and PICU stays were longer (6.4 vs. 5.3 days, p = 0.048). The intubation rates [2.8% (2L) vs. 6.9% (3L), p = 0.17] and durations of invasive [0.2 (2L) vs. 0.5 (3L) days, p = 0.10] and noninvasive [1.4 (2L) vs. 1.6 (3L) days, p = 0.97] ventilation were comparable. No patient had air leak syndrome or died. CONCLUSION: In young infants with AVB supported with HFNC, 3 L/kg/min did not reduce the risk of failure compared with 2 L/kg/min. This clinical trial was recorded on the National Library of Medicine registry (NCT02824744).

Gaslini's tracheal team: preliminary experience after one year of paediatric airway reconstructive surgery.

BACKGROUND: Congenital and acquired airway anomalies represent a relatively common albeit challenging problem in a national tertiary care hospital. In the past, most of these patients were sent to foreign Centres because of the lack of local experience in reconstructive surgery of the paediatric airway. In 2009, a dedicated team was established at our Institute. Gaslini's Tracheal Team includes different professionals, namely anaesthetists, intensive care specialists, neonatologists, pulmonologists, radiologists, and ENT, paediatric, and cardiovascular surgeons. The aim of this project was to provide these multidisciplinary patients, at any time, with intensive care, radiological investigations, diagnostic and operative endoscopy, reconstructive surgery, ECMO or cardiopulmonary bypass. Aim of this study is to present the results of the first year of airway reconstructive surgery activity of the Tracheal Team. METHODS: Between September 2009 and December 2010, 97 patients were evaluated or treated by our Gaslini Tracheal Team. Most of them were evaluated by both rigid and flexible endoscopy. In this study we included 8 patients who underwent reconstructive surgery of the airways. Four of them were referred to our centre or previously treated surgically or endoscopically without success in other Centres. RESULTS: Eight patients required 9 surgical procedures on the airway: 4 cricotracheal resections, 2 laryngotracheoplasties, 1 tracheal resection, 1 repair of laryngeal cleft and 1 foreign body removal with cardiopulmonary bypass through anterior tracheal opening. Moreover, in 1 case secondary aortopexy was performed. All patients achieved finally good results, but two of them required two surgeries and most required endoscopic manoeuvres after surgery. The most complex cases were the ones who had already been previously treated. CONCLUSIONS: The treatment of paediatric airway anomalies requires a dedicated multidisciplinary approach and a single tertiary care Centre providing rapid access to endoscopic and surgical manoeuvres on upper and lower airways and the possibility to start immediately cardiopulmonary bypass or ECMO.The preliminary experience of the Tracheal Team shows that good results can be obtained with this multidisciplinary approach in the treatment of complicated cases. The centralization of all the cases in one or few national Centres should be considered.

Reconstitution dynamics of plasmacytoid and myeloid dendritic cell precursors after allogeneic myeloablative hematopoietic stem cell transplantation.

Dendritic cells (DCs) are fundamental for immunity. We investigated reconstitution of plasmacytoid DC (PDC) and myeloid DC (My-DC) precursors in the first 2 months after allogeneic hematopoietic stem cell transplantation (Allo-HSCT). Circulating DCs were monitored from the earliest phase of hematopoietic reconstitution in 43 children given standard therapy to prevent graft-versus-host disease (GVHD) and either treated or untreated with granulocyte colony-stimulating factor (G-CSF) after HSCT. In patients without GVHD, both My-DCs and PDCs reached consistently high absolute values during the initial phase. Time of engraftment did not differ between My-DCs and PDCs, regardless of administration of G-CSF. Treatment with G-CSF (1) accelerated early recovery of My-DC absolute numbers; (2) was associated with lower numbers of both My-DCs and PDCs in the later phase; and (3) significantly reduced the proportion of interleukin-12 (IL-12)-secreting cells. In some patients who developed acute GVHD, we found high numbers of circulating DC precursors during the early phase of this complication. However, treatment with steroids invariably induced rapid decrease of PDCs. Altogether, these data provide an evaluation of DC release after Allo-HSCT, indicate that postgrafting administration of G-CSF impairs the appearance of IL-12-producing DCs, and suggest that DC homeostasis may be disrupted at onset of GVHD.