Prolonged Unconsciousness is Common in COVID-19 and Associated with Hypoxemia.

OBJECTIVE: The purpose of this study was to estimate the time to recovery of command-following and associations between hypoxemia with time to recovery of command-following. METHODS: In this multicenter, retrospective, cohort study during the initial surge of the United States' pandemic (March-July 2020) we estimate the time from intubation to recovery of command-following, using Kaplan Meier cumulative-incidence curves and Cox proportional hazard models. Patients were included if they were admitted to 1 of 3 hospitals because of severe coronavirus disease 2019 (COVID-19), required endotracheal intubation for at least 7 days, and experienced impairment of consciousness (Glasgow Coma Scale motor score <6). RESULTS: Five hundred seventy-one patients of the 795 patients recovered command-following. The median time to recovery of command-following was 30 days (95% confidence interval [CI] = 27-32 days). Median time to recovery of command-following increased by 16 days for patients with at least one episode of an arterial partial pressure of oxygen (PaO2 ) value ≤55 mmHg (p < 0.001), and 25% recovered ≥10 days after cessation of mechanical ventilation. The time to recovery of command-following  was associated with hypoxemia (PaO2 ≤55 mmHg hazard ratio [HR] = 0.56, 95% CI = 0.46-0.68; PaO2 ≤70 HR = 0.88, 95% CI = 0.85-0.91), and each additional day of hypoxemia decreased the likelihood of recovery, accounting for confounders including sedation. These findings were confirmed among patients without any imagining evidence of structural brain injury (n = 199), and in a non-overlapping second surge cohort (N = 427, October 2020 to April 2021). INTERPRETATION: Survivors of severe COVID-19 commonly recover consciousness weeks after cessation of mechanical ventilation. Long recovery periods are associated with more severe hypoxemia. This relationship is not explained by sedation or brain injury identified on clinical imaging and should inform decisions about life-sustaining therapies. ANN NEUROL 2022;91:740-755.

The Use of Hemostatic Blood Products in Children Following Cardiopulmonary Bypass and Associated Outcomes.

To describe the use of hemostatic transfusions in children following cardiac surgery with cardiopulmonary bypass and the association of hemostatic transfusions postoperatively with clinical outcomes. DESIGN: A retrospective cohort study. SETTING: PICU of a tertiary care center from 2011 to 2017. PATIENTS: Children 0-18 years old undergoing cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four-hundred twenty children underwent cardiac surgery with cardiopulmonary bypass. The median (interquartile range) age was 0.8 years (0.3-5 yr) and 243 (58%) were male. The majority of cases were classified as Risk Adjustment for Congenital Heart Surgery 2 (223, 54%) or Risk Adjustment for Congenital Heart Surgery 3 (124, 30%). Twenty-four percent of children (102/420) received at least one hemostatic transfusion with the most common first product being platelet transfusions (47/102), followed by plasma (44/102), and cryoprecipitate (11/102). The children who received hemostatic transfusions were younger (p = 0.006), had lower body weights (p = 0.004), less likely to be their initial operation with cardiopulmonary bypass (p = 0.003), underwent more complex surgeries (p = 0.001) with longer bypass runs (p < 0.001), and had more use of hypothermic circulatory arrest (p = 0.014). The receipt of hemostatic blood products postoperatively was independently associated with more days of mechanical ventilation (p < 0.001) and longer PICU lengths of stay (p = 0.001) but not with time receiving vasoactive mediations (p = 0.113) or nosocomial infections (p = 0.299). CONCLUSIONS: Nearly one-quarter of children undergoing cardiac repair with cardiopulmonary bypass receive hemostatic transfusions postoperatively. These blood products are independently associated with worse clinical outcomes. Larger studies should be performed to determine the hemostatic efficacy of these products, as well as to clarify associated morbidities, in order to inform proper blood management.

Hemodynamic Changes Associated with Mydriatic Eye Drop Administration in Anesthetized Pediatric Patients.

BACKGROUND: Dilating eye drops are routinely used in pediatric retinoblastoma patients during anesthetized ophthalmologic exams. Information on the systemic effects of ocular mydriatics, especially in anesthetized pediatric patients, is limited. OBJECTIVE: The primary aim of this study was to analyze hemodynamic changes during mydriatic eye drop administration in anesthetized pediatric patients. METHODS: A retrospective chart review was performed for pediatric retinoblastoma patients who underwent MRI with anesthesia. Baseline blood pressure (BP) and heart rate (HR) were charted for each patient at induction. HR and mean arterial pressure (MAP) measurements were recorded at 5, 10, 15, 30, and 45 min after eye drop administration. Secondarily, we included data from 15 patients who received dilating eye drops while under sevoflurane general anesthetic. All patients were dilated with phenylephrine 2.5 or 10% (depending on age) and tropicamide 1%. RESULTS: The final analysis included 176 anesthesia encounters. The results demonstrate no statistically significant deviation of more than 20% from baseline for either HR or MAP. Additionally, we did not detect any difference between patients who were anesthetized with propofol versus sevoflurane. CONCLUSIONS: We did not observe significant hemodynamic instability with administration of dilating eye drops during propofol anesthesia.