A case report of leukemoid reaction in a child with severe diabetic ketoacidosis (DKA) and cerebral edema: When rarity and complexity meet.

Key Clinical Message: In pediatrics, a leukemoid reaction in severe DKA cases with cerebral edema has never been reported. The fluid management was challenging as it required balancing rates to ensure improvement of the condition while preventing neurological sequelae. Abstract: The combination of diabetic ketoacidosis (DKA), cerebral edema, and leukemoid reaction in pediatrics has never been reported before in the literature. It may lead to significant morbidity and high mortality. Here, we report a case of DKA-induced cerebral edema associated with severe leukocytosis (WBC 98 × 109/L), which had many challenges in fluid therapy.

The effect of Telehealth Antimicrobial Stewardship Program (Tele-ASP) on antimicrobial use in a pediatric intensive care unit: Pre- and post-implementation single center study.

BACKGROUND: Overuse or misuse of antimicrobials is common in pediatric intensive care units (PICU) and may be associated with poor clinical outcomes. Although an antimicrobial stewardship program (ASP) has been found to improve this practice, the required expertise in infectious diseases may be limited in some centers. We aimed to evaluate the effect of telehealth ASP on the rate of PICU antimicrobial use in a center without a local Infectious Diseases consultation service. METHODS: A retrospective cohort study was performed between October 1st, 2018, and October 31st, 2020, in Farwaniya Hospital PICU, a 20-bed unit. All pediatric patients who were admitted to PICU and received systemic antimicrobials during the study period were included and followed until hospital discharge. The ASP team provided weekly prospective audit and feedback on antimicrobial use starting October 8th, 2019. A pediatric infectious diseases specialist joined the ASP rounds remotely. Descriptive analyses and a pre-post intervention comparison of days of therapy (DOT) were used to assess the effectiveness of the ASP intervention. RESULTS: There were 272 and 156 PICU admissions received systemic antimicrobial before and after the initiation of ASP, respectively. Bronchiolitis and pneumonia were the most common admission diagnoses, together compromising 60.7% and 61.2% of cases pre- and post-ASP. The requirement for respiratory support was higher post-ASP (76.5% vs. 91.5%, p < 0.001). Average monthly antimicrobial use decreased from 922 (95%CI 745-1000) to 485 DOT/1000 patient-days (95%CI 246-722, P < 0.05). A decline in DOT was observed across most antibiotic classes, except for ceftriaxone. No effect on the length of PICU stay, length of hospitalization, or mortality was observed. Most (89.7%) ASP recommendations were followed either fully or partially. CONCLUSION: In settings where Infectious Diseases consultation services are unavailable, PICU telehealth ASP can be effectively implemented and associated with significantly reducing antimicrobial use.

Adult-size interface during non-invasive ventilation for a child with pediatric acute respiratory distress syndrome: Maintaining principle on a different population.

Acute respiratory failure is a common pediatric condition requiring respiratory support invasively or non-invasively. Limited access to proper size interface in pediatrics causes a significant drawback from using non-invasive ventilation. We report a successful use of an adult-size nasal interface by fitting a child's oro-nasal area to ventilate him non-invasively.

Whole-Cell and Acellular Pertussis Vaccine: Reflections on Efficacy.

Pertussis is a common respiratory infection caused by the bacterium Bordetella pertussis. Although most cases occur in developing countries, it is considered endemic globally. The World Health Organization estimates there are 20-40 million cases of pertussis annually. Pertussis vaccines played a pivotal role in reducing the burden of pertussis disease as well as infant morbidity and mortality. Although the two forms of pertussis vaccine are effective, each has its advantages and drawbacks. This review aims to review the current knowledge on pertussis vaccines, emphasizing vaccine effectiveness in different populations within a community. Clinical trials have shown favorable vaccine efficacy with acellular pertussis (aP)vaccine. However, observational and population-level studies showed that introducing at least a single dose of whole-cell pertussis (wP) vaccine within the routine immunization schedule is associated with better disease protection and a longer duration of immunity. On the other hand, wP vaccine is more reactogenic and associated with higher adverse events. Therefore, the selection of vaccine should be weighed against the effectiveness, reactogenicity, and cost-effectiveness. Due to its safety profile, aP vaccine can be offered to wider population groups. Booster adolescent and pregnant immunization programs have been implemented globally to control outbreaks and protect vulnerable infants. Due to the variable effectiveness performance of both vaccines, different countries adopted distinctive immunization programs. Determining the right vaccination approach depends on financial consideration, immunization program infrastructure, adverse event monitoring, and pertussis surveillance in the community.

The Pediatric COVID-19 Registry in Kuwait: Methodology and Results of Pilot Phase.

OBJECTIVE: Establishing a pediatric COVID-19 registry in Kuwait (PCR-Q8) was deemed imperative during the pandemic to study children infected with severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) focusing on mode of presentation, therapeutic interventions, disease severity, and early outcomes. This manuscript describes the rapid establishment of the PCR-Q8 registry showcasing an infrastructure of the development process and presents the results of the pilot phase. SUBJECT AND METHODS: The registry was developed and implemented using the general key steps from a resource titled "Registries for Evaluating Patient Outcomes: A User's Guide" as a guide for best practice, experience from a previously established pediatric diabetes registry in Kuwait and several other COVID-19 registries developed globally. During the pilot phase, a convenience sample of 120 children was included, of whom 66 (55%) were male. RESULTS: Experience and expertise from other COVID-19 registries; guidance provided by the World Health Organization; and effective collaboration and cooperation between the stakeholders, study group, and data enterers during these challenging times were critical for the development and implementation of the registry. Our results were similar to international reports which showed that most children presented with mild disease (69.2%), majority (70.2%) had normal chest X-ray, and the most common symptom at presentation was fever (77%). CONCLUSION: We anticipate the development of PCR-Q8 to be a stepping-stone for more in-depth investigation of SARS-CoV-2 infection in children in Kuwait and for the establishment of other registries.

The effect of topical nitroglycerin on symmetrical peripheral gangrene in a pediatric patient.

Symmetrical peripheral gangrene is a rare condition associated with significant morbidity and mortality. The use of topical nitroglycerin may have a role in improving patient outcomes and opens a new area for future research regarding the use of topical nitroglycerin in SPG.

Characteristics and outcomes of coronavirus disease 2019 (COVID-19) in critically ill pediatric patients admitted to the intensive care unit: A multicenter retrospective cohort study.

BACKGROUND: Characteristics of critical Severe Acute Respiratory Syndrome-related Coronavirus 2 (SARS-CoV-2) infection in children is not well understood. This study described the clinical characteristics of children admitted to intensive care units (ICU) and explored factors associated with the need for invasive ventilation or mortality. METHODS: A multicenter, retrospective, cohort study was conducted over eight medical centers, including all patients younger than 18 years of age and admitted to the ICU due to a direct consequence of coronavirus disease 2019 (COVID-19). Patients who were admitted to the ICU for any alternate reason and tested positive for SARS-CoV-2 by screening test, and patients who were admitted due to multi-inflammatory syndrome in children, were excluded. Demographic, laboratory, imaging, and clinical data were collected. Descriptive statistics were used to compare survivors and non-survivors. Fine and Gray's hazard model was used to estimate the association between clinical variables and ICU death. RESULTS: During the study period, 25 pediatric COVID-19 patients received care in the ICUs. The median age was 2.78 years (IQR 0.21-8.51), and 60% were male. Only three patients were reported to be previously healthy at admission. Nine (36%) patients required invasive mechanical ventilation, including two were on extracorporeal membrane oxygenation. Four (16%) patients died during ICU care. In univariate analysis, the presence of comorbidity (HR 0.0001; 95%CI 0.00001-0.00016), platelets count (HR 0.99; 95% CI 0.98-0.99), elevated procalcitonin (HR 1.05; 95%CI 1.016-1.09), and circulatory compromise (HR 16.34; 95%CI 1.99-134.35), all at the time of ICU admission, were associated with in-ICU mortality. CONCLUSION: Our findings suggest that children admitted to the ICU with SARS-CoV-2 infection, generally, have a favorable outcome. Low platelets count, elevated procalcitonin, presence of comorbidity, and shock at the time of ICU admission were associated with death. This study may shed more light on the disease dynamics of critical pediatric COVID-19.