Creatinine correction to account for fluid overload in children with acute respiratory distress syndrome treated with extracorporeal membrane oxygenation: an initial exploratory report.

BACKGROUND: Creatinine is distributed between the intracellular and extracellular compartments, and as a result, the measurement of its concentration is strongly related to the fluid status of the patient. An interest has been shown in correcting measured serum creatinine levels according to the fluid balance in order to better specify the degree of acute kidney injury (AKI). METHODS: We conducted a retrospective observational study of 33 children, aged 0 to 5 years, admitted to the pediatric intensive care unit for acute respiratory distress syndrome treated by extracorporeal membrane oxygenation. We compared measured and corrected creatinine and assessed the degree of agreement between these values using both Cohen's kappa and Krippendorff's alpha coefficient. RESULTS: In our cohort, 37% of the classifications made according to measured creatinine levels were erroneous and, in the majority of cases, the degree of AKI was underestimated. CONCLUSION: Correction of the measured creatinine value according to the degree of fluid overload may result in more accurate diagnosis of AKI. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.

[Paediatric Life Support]. / Lebensrettende Maßnahmen bei Kindern (Paediatric Life Support, PLS): Leitlinien des European Resuscitation Council 2021.

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

Is a semi-elemental diet better than a polymeric diet after congenital heart surgery?

A retrospective observational study has been set up in order to compare feeding tolerance and energy delivery in children fed with a semi-elemental diet or a polymeric diet after congenital heart surgery. The study took place in the intensive care unit of a tertiary children's hospital. One hundred children were included: 56 received a semi-elemental diet and 44 received a polymeric diet. Patients were aged between 2 days and 6 years. Data from patients were obtained from medical files between February 2014 and May 2016. The feeding protocol was changed in March 2015 when a semi-elemental diet was substituted for the polymeric diet. Primary outcome was the feeding tolerance. Feeding intolerance occurs if the patient has more than two episodes of emesis or more than four liquid stools per day. Feeding tolerance in the semi-elemental and polymeric diet groups was comparable: emesis occurred in 14.3% versus 6.8% of patients, respectively (p = 0.338); diarrhea occurred in 3.6% versus 4.5% (p = 1000); post-pyloric feeding was necessary in 14% versus 9% (p = 0.542). Energy delivery was also comparable in the two groups: on postoperative day 2, the semi-elemental diet group reached 50% of the caloric target versus 52% in the polymeric diet group (p = 0.283); on day 5, 76% versus 85% (p = 0.429); and on day 10, 105% versus 125% (p = 0.397). Energy delivery was insufficient on postoperative days 2 and 5, but nutritional goals were achieved by day 10. No patient developed necrotizing enterocolitis in our population.Conclusion: the present study suggests that the feeding tolerance to a semi-elemental or a polymeric diet is similar after CHS.What is Known:•Nutrition can modify prognosis in PICU•Different types of diet have been tested in children with intestinal disorders or with congenital heart disease. None of these diets have shown to be superior in terms of feeding tolerance.What is New:•Semi elemental and polymeric diets seem to have the same feeding tolerance in PICU after cardiac surgery for congenital heart disease.

Impact of vancomycin protein binding on target attainment in critically ill children: back to the drawing board?

Objectives: The objectives of this observational study were to investigate plasma protein binding and to evaluate target attainment rates of vancomycin therapy in critically ill children. Patients and methods: Paediatric ICU patients, in whom intravenous intermittent dosing (ID) or continuous dosing (CD) with vancomycin was indicated, were included. Covariates on unbound vancomycin fraction and concentration were tested using a linear mixed model analysis and attainment of currently used pharmacokinetic/pharmacodynamic (PK/PD) targets was evaluated. Clinicaltrials.gov: NCT02456974. Results: One hundred and eighty-eight plasma samples were collected from 32 patients. The unbound vancomycin fraction (median = 71.1%; IQR = 65.4%-79.7%) was highly variable within and between patients and significantly correlated with total protein and albumin concentration, which were both decreased in our population. Total trough concentration (ID) and total concentration (CD) were within the aimed target concentrations in 8% of patients. The targets of AUC/MIC ≥400 and f AUC/MIC ≥200 were achieved in 54% and 83% of patients, respectively. Unbound vancomycin concentrations were adequately predicted using the following equation: unbound vancomycin concentration (mg/L) = 5.38 + [0.71 × total vancomycin concentration (mg/L)] - [0.085 × total protein concentration (g/L)]. This final model was externally validated using 51 samples from another six patients. Conclusions: The protein binding of vancomycin in our paediatric population was lower than reported in non-critically ill adults and exhibited large variability. Higher target attainment rates were achieved when using PK/PD indices based on unbound concentrations, when compared with total concentrations. These results highlight the need for protein binding assessment in future vancomycin PK/PD research.

Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.

Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation science, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the International Liaison Committee on Resuscitation developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/postresuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondents' assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system-treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome.

Managing Ventricular Septal Defect with Associated Aortic Regurgitation: Two Decades of Experience.

BACKGROUND AND AIM OF THE STUDY: Ventricular septal defect (VSD) with aortic regurgitation (AR) is a well-known association. However, there is still no agreement about its management, particularly regarding the technical details of its operative treatment. The study aim was to describe all components of the syndrome and to evaluate the various techniques used with regards to its anatomical and functional features. METHODS: A total of 31 patients (mean age 7.4 years; range: 1.0-14.3 years) who underwent repair of VSD and AR between 1990 and 2013 was reviewed. The VSD was perimembranous in 22 patients, and subarterial in nine. Trusler's valvuloplasty technique was used in 15 patients, Yacoub's technique in seven, and Carpentier's technique (triangular resection) in four. Two patients underwent aortic valve replacement (AVR), and three patients with no significant aortic valve lesions underwent a simple patch repair of the VSD. RESULTS: The aortic valvuloplasty results were generally good, with an initial aortic valvuloplasty avoiding AVR. During the immediate postoperative period, valvuloplasty failure occurred in three patients, regardless of the technique used, and all three patients were reoperated on. The mean duration of follow up was 8.5 years (range: 3.2-20.6 years). The initial result was maintained in all patients, except for four who underwent late AVR. CONCLUSION: The study findings contributed to an analysis of VSD and AR, and helped to clarify the best surgical strategy. The results obtained suggest that adequacy of the initial repair is the most important determinant of subsequent evolution.

Severe Staphylococcus aureus infections in children: Case reports and management of positive Panton-Valentine leucocidin cases.

Background: Staphylococcus aureus is a well-known bacterium associated with carriage and responsible for different types of infections. The Panton-Valentine leucocidin (PVL) is a key virulence factor causing tissue necrosis. PVL can, however, be present in both benign and life-threatening infections. Case reports and management: We present three pediatric severe infections occurring over a period of only three weeks, in February 2021, and caused by genetically unrelated methicillin-sensitive Staphylococcus aureus producing PVL in a tertiary children's hospital in Belgium. The first one presented with necrotizing pneumonia, the second one with a neck abscess extended to the mediastinum, and the last one had sacral osteomyelitis complicated by endocarditis. The management of these infections is mostly based on expert opinions. The most appropriate treatment seems to be the combination of early surgical drainage of infected collections with an antibiotic regimen associating two antibiotics; beta-lactams and either clindamycin or linezolid. Human immunoglobulins also appear to be useful as adjunctive therapy. Conclusion: PVL-producing Staphylococcus aureus is associated with life-threatening infections in children. Prompt management is needed including surgery and appropriate antibiotic regimens.

Increasing burden of viral bronchiolitis in the pediatric intensive care unit; an observational study.

PURPOSE: Viral bronchiolitis is a major cause of pediatric intensive care unit (PICU) admission. Insight in the trends of bronchiolitis-associated PICU admissions is limited, but imperative for future PICU resource and capacity planning. MATERIALS AND METHODS: We retrospectively studied trends in PICU admissions for bronchiolitis in six European sites, including three full national registries, between 2000 and 2019 and calculated population-based estimates per 100,000 children where appropriate. Information concerning risk factors for severe disease and use of invasive mechanical ventilation was also collected when available. RESULTS: In total, there were 15,606 PICU admissions for bronchiolitis. We observed an increase in the annual number, rate and estimates per 100,000 children of PICU admissions for bronchiolitis at all sites over the last two decades, while the proportion of patients at high risk for severe disease remained relatively stable. CONCLUSIONS: The international increased burden of bronchiolitis for the PICU is concerning, and warrants further international attention and investigation.

Enteroviral infection of a cardiac prosthetic device.

BACKGROUND: Identification of the causative pathogen may be challenging in culture negative infective endocarditis (IE). METHODS: A 4 month-old 21-trisomic boy with congenital atrioventricular septal defect presented 3 episodes of dehiscence of his prosthetic patch, attributed to IE. He presented heart failure, but neither fever, nor inflammatory syndrome. RESULTS: Surgical and histopathological findings confirmed the diagnosis of IE, but blood cultures remained sterile. Extensive work up failed to demonstrate bacterial or fungal etiology. Coxsackie B2 virus was cultured from the excised patch, nasopharyngeal secretions and stools. CONCLUSIONS: Viral IE has only been described in animal models. This case is the first reported probable human viral IE. We suggest that a viral etiology should be considered in case of culture negative IE.

Complicated forms of tachycardia-mediated cardiomyopathy associated with idiopathic left ventricular tachycardia.

Idiopathic left ventricular tachycardia is an infrequent form of ventricular tachycardia associated with a structurally normal heart. The prognosis is usually benign; however, sustained cases have been reported. In this report, we describe two cases of persistent idiopathic left ventricular tachycardia complicated by tachycardia-mediated cardiomyopathy. In the first case, the patient developed a right ventricular thrombus with subsequent pulmonary embolism. In the second case, the patient developed acute pulmonary edema. Both cases were cured by catheter ablation.

The European Paediatric Life Support course improves assessment and care of dehydrated children in the emergency department.

We tested the hypothesis that application of the principles learned from the European Paediatric Life Support (EPLS) course improves child health assessment and care. In a retrospective study, residents from five paediatric emergency departments were included. For each of them, we analysed five medical records of infants and children suffering from diarrhoea; three were in ambulatory care and two were in-hospital care with IV hydration. Two independent observers analysed the records using a standardized checklist of 14 clinical points, as well as three items to evaluate the adequacy of treatment according to hydration status. Agreement between readers was evaluated the kappa coefficient of concordance. Statistical associations between each item and the EPLS course status was assessed by logistic regression taking into account the clustered data structure. Fifty residents and 240 medical records were included. Twenty-six residents were EPLS trained (intervention group) and 24 residents were not (control group). The results of the analyses of the medical records by the observers were concordant (kappa >0.91). Medical records in the intervention group contained more clinical information on circulatory status (P < 0.0001). Residents in the intervention group prescribed goal-directed therapy more often (P = 0.006). For children with shock, they administered volume resuscitation (P = 0.01) with goal-directed therapy more often (P = 0.003). This is the first evaluation of an educational program focusing on the actions of "learners" in the clinical environment. Our findings highlight that the EPLS course is associated with a better clinical analysis of hydration and circulation status as well as with goal-directed therapy.

Impact of CRRT in Patients with PARDS Treated with VV-ECMO.

The high mortality of pediatric acute respiratory distress syndrome (PARDS) is partly related to fluid overload. Extracorporeal membrane oxygenation (ECMO) is used to treat pediatric patients with severe PARDS, but can result in acute kidney injury (AKI) and worsening fluid overload. The objective of this study was to determine whether the addition of CRRT to ECMO in patients with PARDS is associated with increased mortality. METHODS: We conducted a retrospective 7-year study of patients with PARDS requiring ECMO and divided them into those requiring CRRT and those not requiring CRRT. We calculated severity of illness scores, the amount of blood products administered to both groups, and determined the impact of CRRT on mortality and morbidity. RESULTS: We found no significant difference in severity of illness scores except the vasoactive inotropic score (VIS, 45 ± 71 vs. 139 ± 251, p = 0.042), which was significantly elevated during the initiation and the first three days of ECMO. CRRT was associated with an increase in the use of blood products and noradrenaline (p < 0.01) without changing ECMO duration, length of PICU stay or mortality. CONCLUSION: The addition of CRRT to ECMO is associated with a greater consumption of blood products but no increase in mortality.

Acute Bronchiolitis: Why Put an IV Line?

BACKGROUND: Acute bronchiolitis is the most frequent cause of respiratory distress in pediatric emergency medicine. The risk of respiratory failure is frequently over evaluated, and results in systematic vascular access. METHODS: We conducted a prospective observational study in children under 18 months of age hospitalized for bronchiolitis. The aim of the study was to evaluate whether catheter insertion was useful for management. We monitored the number of catheters inserted in the emergency department and their subsequent use for rapid sequence intubation, adrenaline administration, or antimicrobial therapy. We recorded the number of secondary pediatric intensive care unit (ICU) admissions. RESULTS: We followed 162 patients and compared two populations, children with (population A, n = 35) and without (population B, n = 127) catheter insertion. There were no significant differences in age, oxygen saturation, heart rate, c-reactive protein, neutrophil count and the number of times nebulization was conducted at admission. Population A compared to B had a significantly higher temperature (38.1 ± 0.9 vs. 37.6 ± 0.7°C, P = 0.004) and respiratory rate (64 ±13 vs. 59 ±17, P = 0.033). Twelve patients were secondarily transferred to pediatric ICU, 3 from population A and 9 from B (NS). In a multivariate analysis, no significant relationship was found between ICU admission, venous access placement and potential confounding factors (pneumonia, age < 6 months, age < 3 months, food intake < 60%, temperature > 38° C, heart rate > 180 bpm, respiratory rate > 60/min, SpO2 < 95%, Spo2 < 90%, oxygen therapy, positive respiratory syncytial virus [RSV] sampling). Except for antimicrobial therapy (n = 32), catheters inserted in the emergency department were used in 5 patients for intravenous rehydration and in one patient in pediatric ICU for rapid sequence intubation. CONCLUSIONS: There were no life-threatening events that required immediate venous access for cardiopulmonary resuscitation. Medical treatment could be administered orally or via nasogastric tube in most cases. Peripheral catheterization was useless in immediate emergency management and only one child required a differed rapid sequence intubation.

Hyperoxaluria: An early diagnosis will allow a timely combined renal and liver transplantations to avoid irreversible damages to all other organs.

A 4-month-old patient was admitted to the emergency room for vomiting, weight gain, food refusal and hypertension. Blood gases showed a metabolic acidosis with increased anion gap. Laboratory finding revealed severe renal failure (creatinine 8 mg/dL). Renal ultrasound showed an important hyperechogenicity of the parenchyma with loss of cortico-medullar differentiation suggesting a nephronophytosis. Genetic testing was negative. Urine oxalate levels were increased to 140 µmol/L. New genetic tests were positive for type I hyperoxaluria. The authors discuss the management of hyperoxaluria.

European Resuscitation Council Guidelines 2021: Paediatric Life Support.

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Transfusion strategies for patients in pediatric intensive care units.

BACKGROUND: The optimal hemoglobin threshold for erythrocyte transfusions in critically ill children is unknown. We hypothesized that a restrictive transfusion strategy of using packed red cells that were leukocyte-reduced before storage would be as safe as a liberal transfusion strategy, as judged by the outcome of multiple-organ dysfunction. METHODS: In this noninferiority trial, we enrolled 637 stable, critically ill children who had hemoglobin concentrations below 9.5 g per deciliter within 7 days after admission to an intensive care unit. We randomly assigned 320 patients to a hemoglobin threshold of 7 g per deciliter for red-cell transfusion (restrictive-strategy group) and 317 patients to a threshold of 9.5 g per deciliter (liberal-strategy group). RESULTS: Hemoglobin concentrations were maintained at a mean (+/-SD) level that was 2.1+/-0.2 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group (lowest average levels, 8.7+/-0.4 and 10.8+/-0.5 g per deciliter, respectively; P<0.001). Patients in the restrictive-strategy group received 44% fewer transfusions; 174 patients (54%) in that group did not receive any transfusions, as compared with 7 patients (2%) in the liberal-strategy group (P<0.001). New or progressive multiple-organ dysfunction syndrome (the primary outcome) developed in 38 patients in the restrictive-strategy group, as compared with 39 in the liberal-strategy group (12% in both groups) (absolute risk reduction with the restrictive strategy, 0.4%; 95% confidence interval, -4.6 to 5.4). There were 14 deaths in each group within 28 days after randomization. No significant differences were found in other outcomes, including adverse events. CONCLUSIONS: In stable, critically ill children a hemoglobin threshold of 7 g per deciliter for red-cell transfusion can decrease transfusion requirements without increasing adverse outcomes. (Controlled-trials.com number, ISRCTN37246456 [controlled-trials.com].).