Pediatric extracorporeal life support for refractory status asthmaticus: ELSO Registry trends from the past decade.

BACKGROUND: Extracorporeal life support (ECLS) for status asthmaticus (SA) is rare. Increased safety and experience may increase utilization of ECLS for SA. METHODS: We reviewed pediatric (<18 years old) patients requiring ECLS for SA between 1998 and 2019 within the Extracorporeal Life Support Organization (ELSO) Registry and Nemours Children's Health (NCH) system. We compared patient characteristics, pre-ECLS medications, clinical data, complications, and survival to discharge between Early (1988-2008) and Late (2009-2019) eras. RESULTS: From the ELSO Registry, we identified 173 children, 53 in Early and 120 in Late eras, with primary diagnosis of SA. Pre-ECLS hypercarbic respiratory failure was similar between eras (median pH 7.0 and pCO2 111 mm Hg). Venovenous mode (79% vs. 82%), median ECLS time (116 vs. 99 h), time to extubation (53 vs. 62 h), and hospital survival (89% vs. 88%) also remained similar. Intubation to cannulation time significantly decreased (20 vs. 10 h, p = 0.01). ECLS without complication occurred more in the Late era (19% vs. 39%, p < 0.01), with decreased hemorrhagic (24% vs. 12%, p = 0.05) and noncannula-related mechanical (19% vs. 6%, p = 0.008) complications. Within NCH, we identified six Late era patients. Pre-ECLS medication favored intravenous beta agonists, bronchodilators, magnesium sulfate, and steroids. One patient died from neurological complications following pre-ECLS cardiac arrest. CONCLUSIONS: Collective experience supports ECLS as a rescue therapy for pediatric SA. Survival to discharge remains good, and complication rates have improved. Pre-ECLS cardiac arrest may potentiate neurologic injury and impact survival. Further study is needed to evaluate causal relationships between complications and outcomes.

A Prospective Assessment of Optimal Mechanical Ventilation Parameters for Pediatric Catheter Ablation.

Catheter stability, an important factor in ablation success, is affected by ventilation. Optimal ventilation strategies for pediatric catheter ablation are not known. We hypothesized that small tidal volume and positive end-expiratory pressure are associated with reduced ablation catheter movement at annular positions. Subjects aged 5-25 years undergoing ablation for supraventricular tachycardia (SVT) or WPW at two centers from March 2015 to September 2016 were prospectively enrolled and randomized to receive mechanical ventilation with either positive end-expiratory pressure of 5 cm H2O (PEEP) or 0 cm H2O (ZEEP). Movement of the ablation catheter tip at standard annular positions was measured using 3D electroanatomic mapping systems under two conditions: small tidal volume (STV) (3-5 mL/kg) or large TV (LTV) (6-8 mL/kg). 58 subjects (mean age 13.8 years) were enrolled for a total of 266 separate observations of catheter movement. STV ventilation was associated with significantly reduced catheter movement, compared to LTV at all positions (right posteroseptal: 2.5 ± 1.4 vs. 5.2 ± 3.1 mm, p < 0.0001; right lateral: 2.7 ± 1.6 vs. 6.3 ± 3.5 mm, p < 0.0001; left lateral: 1.8 ± 1.0 vs. 4.3 ± 1.9 mm, p < 0.0001). The presence or absence of PEEP had no effect on catheter movement. In multivariable analysis, STV was associated with a 3.1-mm reduction in movement (95% CI 2.6-3.5, p < 0.0001), adjusting for end-expiratory pressure, annular location, and patient size. We conclude that STV ventilation is associated with reduced ablation catheter movement compared to a LTV strategy, independent of PEEP and annular position.

Neuraxial Anesthesia in Parturients with Low Platelet Counts.

The obstetric anesthesiologist must consider the risk of spinal-epidural hematoma in patients with thrombocytopenia when choosing to provide neuraxial anesthesia. There are little data exploring this complication in the parturient. In this single-center retrospective study of 20,244 obstetric patients, the incidence of peripartum thrombocytopenia (platelet count <100,000/mm) was 1.8% (368 patients). Of these patients, 69% (256) received neuraxial anesthesia. No neuraxial hematoma occurred in any of our patients. The upper 95% confidence limit for spinal-epidural hematoma in patients who received neuraxial anesthesia with a platelet count of <100,000/mm was 1.2%.

Engaging Pediatric Resident Physicians in Quality Improvement Through Resident-Led Morbidity and Mortality Conferences.

BACKGROUND: Increasingly, medical disciplines have used morbidity and mortality conferences (MMCs) to address quality improvement and patient safety (QI/PS), as well as teach systems-based improvement to graduate trainees. The goal of this educational intervention was to establish a pediatric resident physician­led MMC that not only focused on QI/PS principles but also engaged resident physicians in QI/ PS endeavors in their clinical learning environments. METHODS: Following a needs assessment, pediatric resident physicians at the Stanford University School of Medicine (Stanford, California) established a new MMC model in February 2010 as part of a required QI rotation. Cases were identified, explored, analyzed, and presented by resident physicians using the Johns Hopkins Learning from Defects tool. Discussions during the MMCs were resident physician­ directed and systems-based, and resulted in projects to address care delivery. Faculty advisors assessed resident physician comprehension of QI/PS. Conferences were evaluated through the end of the 2012­2013 academic year and outcomes tracked through the 2013­2014 academic year to determine trainee involvement in systems change resulting from the MMCs. RESULTS: The MMC was well received and the number of MMCs increased over time. By the end of the 2013­2014 academic year, resident physicians were involved in address ing 14 systems-based issues resulting from 25 MMCs. Examples of the resident physician­initiated improvement work included increasing use of the rapid response team, institution of a gastrostomy (g)-tube order set, and establishing a face-to-face provider handoff for pediatric ICU­to-acute-care-floor transfers. CONCLUSION: A resident physician­run MMC exposes resident physicians to QI/PS concepts and principles, enables direct faculty assessment of QI/PS knowledge, and can propel resident physicians into real-time engagement in the culture of safety in a complex hospital environment.

Effects of ventilation and catheter position on catheter movement on the tricuspid annulus during ablation in children.

INTRODUCTION: There are little data on the effect of catheter position and mechanical ventilation on ablation catheter stability during electrophysiology study in children. We sought to determine the magnitude of catheter movement with mechanical ventilation, the effect of ventilation maneuvers on catheter movement, and to compare the degree of movement observed between the right lateral (RL) and right posteroseptal (RPS) regions. METHODS: From June 2012 to June 2013, patients ≤ 21 years of age undergoing ablation for supraventricular tachycardia with CARTO® 3 (Biosense Webster, Diamond Bar, CA, USA) were included. During mapping the ablation catheter was placed in the RPS and RL regions and the magnitude of catheter movement (mm) was measured using CARTO® 3. Measurements were made during routine ventilation and with a maximal inspiration maneuver between end-expiration (ENDEX) and peak-inspiration (PEAKINS). RESULTS: Twenty-one patients were included: 12 males (57%), age 13 ± 3 years, weight 55 ± 14 kg. Indications for ablation were: 10 Wolff-Parkinson-White, seven atrioventricular node re-entry tachycardia, four concealed accessory pathway. Mechanical ventilation was used in all cases. The magnitude of catheter movement was 3.6 ± 1.7 mm with routine ventilation and 6.2 ± 4.1 mm between ENDEX and PEAKINS (P ≤ 0.01). Catheter movement was greater in the RL compared to the RPS region with routine ventilation (RL 4.3 ± 1.6 vs RPS 3.0 ± 1.5; P < 0.01) and between ENDEX and PEAKINS (RL 8.3 ± 4.7 vs RPS 4.0 ± 1.7; P < 0.01). CONCLUSIONS: Ventilation and catheter position both have significant impact on the degree of catheter movement during ablation. Movement was greatest in the RL position. This may partially explain the lower success rates of ablation in the RL region.

Reframing morning report: Cognitive simulation in a safe space.

BACKGROUND: Various purposes for morning report (MR), in addition to education, have been cited in the literature. Learners can find traditional MR challenging secondary to a perceived lack of psychological safety, the sense that they are being evaluated. Despite the recognition of unsafe learning environments, there is a paucity of literature on how to promote psychological safety in the MR setting. APPROACH: Our aim was to create an MR format utilizing scientifically proven teaching strategies to enhance its educational value. The creation of a safe learning environment was at the forefront of this initiative. Using Kern's six steps of curriculum development, we describe one institution's experience in reframing the morning report experience. RESULTS: We conducted a pilot trial of the new MR with 35 paediatric residents beginning in July 2020 and followed the resident experience over 2 years. The primary outcome was attitudinal data as measured via a Likert scale. We found that by the second-year post-curricular implementation, greater than 50% of residents were less hesitant to participate in conference, increased their practice of retrieval and perceived feeling more prepared for examinations as the curriculum progressed. IMPLICATIONS: We believe the use of proven teaching strategies based in the cognitive psychology of learning can enhance the quality of education. Furthermore, we believe that central to the success of learning is the perception that the classroom is a safe space to be wrong. This model can serve as a steppingstone for institutions that look to improve their MR series.

Association between maintenance fluid tonicity and hospital-acquired hyponatremia.

OBJECTIVE: To evaluate whether the administration of hypotonic fluids compared with isotonic fluids is associated with a greater risk for hyponatremia in hospitalized children. STUDY DESIGN: Informatics-enabled cohort study of all hospitalizations at Lucile Packard Children's Hospital between April 2009 and March 2011. Extraction and analysis of electronic medical record data identified normonatremic hospitalized children who received either hypotonic or isotonic intravenous maintenance fluids upon admission. The primary exposure was the administration of hypotonic maintenance fluids, and the primary outcome was the development of hyponatremia (serum sodium <135 mEq/L). RESULTS: A total of 1048 normonatremic children received either hypotonic (n = 674) or isotonic (n = 374) maintenance fluids upon admission. Hyponatremia developed in 260 (38.6%) children who received hypotonic fluids and 104 (27.8%) of those who received isotonic fluids (unadjusted OR 1.63; 95% CI 1.24-2.15, P < .001). After we controlled for intergroup differences and potential confounders, patients receiving hypotonic fluids remained more likely to develop hyponatremia (aOR 1.37, 95% CI 1.03-1.84). Multivariable analysis identified additional factors associated with the development of hyponatremia, including surgical admission (aOR 1.44, 95% CI 1.09-1.91), cardiac admitting diagnosis (aOR 2.08, 95% CI 1.34-3.20), and hematology/oncology admitting diagnosis (aOR 2.37, 95% CI 1.74-3.25). CONCLUSIONS: Hyponatremia was common regardless of maintenance fluid tonicity; however, the administration of hypotonic maintenance fluids compared with isotonic fluids was associated with a greater risk of developing hospital-acquired hyponatremia. Additional clinical characteristics modified the hyponatremic effect of hypotonic fluid, and it is possible that optimal maintenance fluid therapy now requires a more individualized approach.

Correction: Mycoplasma pneumoniae Associated Acute Transverse Myelitis: An Atypical Clinical Presentation in an Adolescent Child.

[This corrects the article DOI: 10.7759/cureus.17259.].

Mycoplasma pneumoniae Associated Acute Transverse Myelitis: An Atypical Clinical Presentation in an Adolescent Child.

We report an atypical case of a 15-year-old pediatric patient diagnosed with Mycoplasma pneumoniae associated acute transverse myelitis (ATM). The patient had no prodromal or pulmonary symptoms that are commonly associated with mycoplasma infection. Yet, the patient exhibited acute bilateral lower extremity paralysis, paresthesia, decreased sensation at the level of T11 and below, bowel and bladder dysfunction, and thrombocytopenia. Magnetic resonance imaging of the spinal cord revealed transverse myelitis from T10 to the end of the conus medullaris. The patient showed only slow clinical improvement despite therapy consisting of azithromycin, high-dose intravenous methylprednisolone, intravenous immunoglobulin, and plasmapheresis. This report calls attention to the importance of early identification of mycoplasma as an underlying cause of ATM and the potential consequences of delayed detection and treatment: more severe neurologic complications, prolonged hospitalization, and unfavorable clinical outcomes.

Altered Mental Status and Respiratory Failure in an 11-Year-Old Female.

Congenital central hypoventilation syndrome (CCHS) is a rare disorder that results in profound hypoventilation that is most prominent during periods of sleep. Caused by a genetic mutation in the PHOX2B gene, CCHS typically presents in the newborn period with symptoms of hypoventilation. However, there is a subset of patients with the same genetic mutation who present much later in life, which is termed late-onset congenital central hypoventilation syndrome (LO-CCHS). The reason for its late presentation is unclear but is often dramatic. Given its rarity, the diagnosis can be difficult to establish but can be accomplished by using a systematic approach. Here, we present a case of LO-CCHS in an 11-year-old female who presented with respiratory failure and altered mental status.

Intravenous Lipid Emulsion Rescue Therapy in a Child with Carisoprodol Overdose.

The use of intravenous lipid emulsion (ILE) therapy in children with carisoprodol toxicity was not described previously. We report the case of an adolescent female who presented to our pediatric intensive care unit with unresponsiveness and respiratory depression. The patient recovered immediately following ILE therapy and subsequently admitted having carisoprodol overdose.

Severe eczema vaccinatum in a household contact of a smallpox vaccinee.

BACKGROUND: We report the first confirmed case of eczema vaccinatum in the United States related to smallpox vaccination since routine vaccination was discontinued in 1972. A 28-month-old child with refractory atopic dermatitis developed eczema vaccinatum after exposure to his father, a member of the US military who had recently received smallpox vaccine. The father had a history of inactive eczema but reportedly reacted normally to the vaccine. The child's mother also developed contact vaccinia infection. METHODS: Treatment of the child included vaccinia immune globulin administered intravenously, used for the first time in a pediatric patient; cidofovir, never previously used for human vaccinia infection; and ST-246, an investigational agent being studied for the treatment of orthopoxvirus infection. Serological response to vaccinia virus and viral DNA levels, correlated with clinical events, were utilized to monitor the course of disease and to guide therapy. Burn patient-type management was required, including skin grafts. RESULTS: The child was discharged from the hospital after 48 days and has recovered with no apparent systemic sequelae or significant scarring. CONCLUSION: This case illustrates the need for careful screening prior to administration of smallpox vaccine and awareness by clinicians of the ongoing vaccination program and the potential risk for severe adverse events related to vaccinia virus.

Anesthetic Management of a Pediatric Patient With Pelizaeus-Merzbacher Syndrome: A Case Report.

A 3-year-old pediatric patient with previously diagnosed Pelizaeus-Merzbacher syndrome presented for outpatient dental restoration. Given the infrequency of this demyelinating disorder, an anesthetic plan was tailored to address the patient's hypotonia and aspiration risk, as well as minimize potential complications including seizures, hemodynamic instability, and postoperative respiratory support. Multimodal analgesia, along with an appropriate ventilation strategy and normothermia, allowed the patient to successfully undergo a general anesthetic and be safely discharged home the same day.

Extracorporeal membrane oxygenation after stem cell transplant: clinical decision-making in the absence of evidence.

OBJECTIVE: To discuss the ethical dilemmas that arise in considering innovative therapies for critically ill children when there is little data to support their use. DESIGN: Case report of a 13-yr-old patient after autologous peripheral blood stem cell transplant for stage III neuroblastoma with sepsis and hemodynamic instability who survived to discharge after a 6-day course of extracorporeal membrane oxygenation (ECMO) support. The case serves as a source of discussion of the following: the use of available data in deciding to proceed with an unproved therapy, the approach to conversations to obtain informed consent, and the need for institutional oversight and hypothesis-driven data collection to advance pediatric critical care. SETTING: Pediatric intensive care unit at a university hospital. PATIENT: One adolescent with stage III neuroblastoma. RESULTS: Despite a lack of data to support the use of ECMO in a neutropenic oncology patient after autologous peripheral blood stem cell transplant, our patient had clinical features that suggested he was a reasonable ECMO candidate. His family gave informed consent to use ECMO and he survived. It is ethical to consider and use innovative therapies when patient characteristics are suggestive that the therapy may be successful even in the absence of evidence. This requires physicians' attention to the best interest of the patient and should occur in the setting of informed consent and rigorous data collection. CONCLUSIONS: The boundaries among standard therapy, innovative therapy, and research can be quite fluid. This case illustrates the ethical imperative to consider therapies that may be appropriate for a critically ill child even without evidence predictive of success, to have entry criteria and treatment protocols for such therapies, and to collect data from such experiences to advance the standard of care.

The uncomfortable reality We simply do not know if general anesthesia negatively impacts the neurocognitive development of our small children.

Annually in the United States more than one million children under the age of 5 years are exposed to anesthetics for therapeutic and diagnostic procedures. Pre-clinical data in animal models has consistently shown that anesthetic exposure to the developing brain results in long-term cognitive deficits. Current clinical data addressing the safety of these pharmaceutical agents on the developing human brain is limited. Recently, there has been an enormous amount of attention directed at this potential public health issue in both pre-clinical investigations and ongoing human research. A number of these studies should add to our understanding about the impact anesthetic exposure will have on the developing human brain. Until then, there is little data that absolutely reassures clinicians and parents that the pharmaceutical agents used are indeed safe for our children. The uncomfortable reality is that despite the fact that there are more than one million children younger than 5 years old who receive general anesthesia in the United States annually, and thousands more who are deeply sedated for imaging and diagnostic studies or as a necessary adjunct to care in the intensive care unit, there is little data that assures clinicians and parents that the pharmaceutical agents used are indeed safe for the developing brain. That said, there are no convincing human data to suggest that they are not.

Severe Staphylococcus aureus infections caused by clonally related community-acquired methicillin-susceptible and methicillin-resistant isolates.

We investigated the genetic relatedness of 5 community-acquired (CA) Staphylococcus aureus isolates obtained from 4 consecutive pediatric patients presenting with sepsis syndrome and severe pneumonia during a 3-week period in 2000. Two patients were infected with methicillin-susceptible S. aureus (MSSA), and 2 were infected with methicillin-resistant S. aureus (MRSA). The pulsed-field gel electrophoresis patterns for the 2 CA-MRSA isolates were identical to each other, as were the patterns for the 3 CA-MSSA isolates. A 2-band difference reflecting the presence of a staphylococcal cassette chromosome mec (SCCmec) element distinguished the CA-MRSA isolates from the CA-MSSA isolates. The small, mobile type IV SCCmec element was present in the CA-MRSA isolates. These data suggest that an insertion or, less likely, a deletion of the SCCmec type IV element occurred in a highly virulent S. aureus background. Staphylococcal toxin genes sea, seh, lukS-PV, and lukF-PV were detected in all isolates. Also, in all isolates, was a partial homolog of seo (seo'). The relationship among these patient isolates strengthens the assumption that CA-MRSA infections may be caused by isolates closely related to MSSA isolates.

Glutamine attenuates tumor necrosis factor-alpha release and enhances heat shock protein 72 in human peripheral blood mononuclear cells.

OBJECTIVE: Overexpression of pro-inflammatory cytokines such as tumor necrosis factor-alpha (TNF-alpha) can contribute to multiple organ dysfunction syndrome and septic shock in critically ill patients. We previously found that glutamine (GLN) can attenuate cytokine expression, induce heat shock protein 72 (HSP 72), and protect against endotoxin-induced mortality and organ injury in an in vivo rat model. However, data on the effect of GLN on direct attenuation of cytokine release and HSP 72 expression in human peripheral blood polymorphonuclear cells (PBMCs) is lacking. METHODS: In this study, we assessed the effect of GLN on TNF-alpha and HSP 72 expression in human PBMCs. After treating with various doses of GLN, human PBMCs were stimulated with lipopolysaccharide (LPS). TNF-alpha release was analyzed via enzyme-linked immunosorbent assay and HSP 72 via western blot. RESULTS: GLN at doses greater than 4 mM decreased TNF-alpha release at 4 and 24 h after LPS stimulation. Sublethal heating of PBMCs before LPS also markedly decreased TNF-alpha after LPS. Doses of GLN greater than 2 to 4 mM led to an increase in HSP 72 expression after LPS. CONCLUSION: These results indicate that GLN, which may improve outcomes in critically ill patients, can directly attenuate pro-inflammatory cytokine release in PBMCs. This effect may be related to enhanced HSP 72 expression.

Use of vasopressin in refractory hypotension in children with vasodilatory shock: five cases and a review of the literature.

This article describes case studies of five children treated with vasopressin for refractory hypotension. In addition, physiology and pharmacology of vasopressin are reviewed in a comprehensive survey of the literature from 1966 until the present. In all five children, blood pressure increased immediately after vasopressin administration. The preliminary success of vasopressin for hypotension the setting of vasodilatory shock is promising. This limited use of vasopressin in the setting of refractory hypotension in these patients appears to be safe; the appropriate patient population and dose regimen are not yet determined.