Implementing a physician-driven feeding protocol is not sufficient to achieve adequate caloric and protein delivery in a paediatric intensive care unit: A retrospective cohort study.

BACKGROUND AND AIMS: Daily caloric and protein intake is crucial for the management of critically ill children. The benefit of feeding protocols in improving daily nutritional intake in children remains controversial. This study aimed to assess whether the introduction of an enteral feeding protocol in a paediatric intensive care unit (PICU) improves daily caloric and protein delivery on day 5 after admission and the accuracy of the medical prescription. METHODS: Children admitted to our PICU for a minimum of 5 days who received enteral feeding were included. Daily caloric and protein intake were recorded and retrospectively compared before and after the introduction of the feeding protocol. RESULTS: Caloric and protein intake was similar before and after introduction of the feeding protocol. The prescribed caloric target was significantly lower than the theoretical target. The children who received less than 50% of the caloric and protein targets were significantly heavier and taller than those who received more than 50%; the patients who received more than 100% of the caloric and protein aims on day 5 after admission had a decreased PICU length of stay and decreased duration of invasive ventilation. CONCLUSION: The introduction of a physician-driven feeding protocol was not associated with an increase in the daily caloric or protein intake in our cohort. Other methods of improving nutritional delivery and patient outcomes need to be explored.

Intra-arterial vasodilators infusion for management of reversible cerebral vasoconstriction syndrome in a 12-year-old girl: A case report.

Reversible cerebral vasoconstriction syndrome (RCVS) is a vascular disease characterized by diffuse transient vasoconstriction and vasodilatation of the cerebral arteries. It is commonly associated with recurrent severe acute headaches with or without focal neurological deficits due to hemorrhages, infarcts, and even posterior reversible encephalopathy syndrome. The optimal management of acute neurologic deficits caused by RCVS is still uncertain. Calcium channel blockers (CCBs) such as nimodipine or verapamil have been reported to be effective in adult series. Intra-arterial injection of nimodipine, verapamil, and milrinone has recently been demonstrated to be safe and effective for treating severe segmental vasoconstriction in adults. CCBs are the most used treatment in the available pediatric literature. Intra-arterial vasodilators have been reported in some rare pediatric reports with more severe diseases, but their utility is still under investigation. We report a case of a 12-year-old girl who underwent a severe course of RCVS complicated by multiple cerebral infarcts, treated by several sessions of intra-arterial vasodilators infusion.

Suspected Case of Drug-Induced Acute Respiratory Distress Syndrome following Trimethoprim-Sulfamethoxazole Treatment.

In this article, we reported the case of a child patient who was admitted to our PICU for severe acute respiratory distress syndrome (ARDS) while being treated with trimethoprim-sulfamethoxazole (TMP-SMX) for osteomyelitis. Based on the timing of exposure, lack of alternative explanations, and clinical course similar to previously described cases, we suspect that TMP-SMX may have triggered ARDS. Despite meeting criteria for extracorporeal membrane oxygenation cannulation, conservative management and lung recruitment with high-frequency percussive ventilation could avoid the latter.

Severe Lactic Acidosis in a Critically Ill Child: Think About Thiamine! A Case Report.

In this article, we presented a teenager, in maintenance chemotherapy for leukemia, who was admitted for digestive symptoms related to a parasitic infection and required nutritional support with parenteral nutrition. After 6 weeks, his condition worsened with refractory shock of presumed septic origin, necessitating extracorporeal membrane oxygenation. Despite hemodynamic stabilization, his lactic acidosis worsened until thiamine supplementation was started. Lactate normalized within 12 hours. Thiamine is an essential coenzyme in aerobic glycolysis, and deficiency leads to lactate accumulation through anaerobic glycolysis. Thiamine deficiency is uncommon in the pediatric population. However, it should be considered in patients at risk of nutritional deficiencies with lactic acidosis of unknown origin.

Case Report: Colchicine Toxicokinetic Analysis in a Poisoned Child Requiring Extracorporeal Life Support.

Colchicine poisoning is associated with a poor prognosis, especially when leading to shock and multi-organ failure, and management is limited to supportive care, including multiple-dose activated charcoal. At therapeutic concentrations, colchicine elimination occurs mainly through hepatic metabolism and involves an enterohepatic circulation, with a small contribution of renal elimination (10-30%). Colchicine toxicokinetics is however rarely described, especially in children. We present the case of a 4-year-old patient who survived a severe iatrogenic colchicine intoxication with a dose of 0.5 mg/kg. She developed multi-organ failure and shock, but recovered after receiving aggressive resuscitation, including extracorporeal life support. Close monitoring of colchicine blood levels showed a plateau for 6 days, indicating impeded elimination resulting from liver failure. We observed no significant clearance from renal replacement therapy, nor activated charcoal, during this period. Extracorporeal life support may play a supportive role in the management of severe colchicine poisoning. However, extracorporeal techniques do not seem to improve colchicine elimination.

Extracorporeal cardiopulmonary resuscitation for severe chloroquine intoxication in a child - a case report.

BACKGROUND: Chloroquine use has increased worldwide recently in the setting of experimental treatment for the novel coronavirus disease (Covid-19). Nevertheless, in case of chloroquine intoxication, it can be life threatening, with cardiac arrest, due to its cardiac toxicity. CASE PRESENTATION: This case study reports on a 14-years-old girl who presented in cardiac arrest after an uncommon suicide attempt by ingesting 3 g of chloroquine. After 66 min of cardio-pulmonary resuscitation (CPR), extracorporeal cardiopulmonary resuscitation (ECPR) was initiated, allowing cardiac function to recover. CONCLUSIONS: Chloroquine intoxication is a rare but serious condition due to its cardiac toxicity. Use of ECPR in this case of transient toxicity allowed a favorable evolution with little neurological impairment.

Point-of-care hemostasis in children with congenital heart disease, the POCHEMO study: baseline reference values of thromboelastometry and impedance aggregometry.

: Viscoelastic tests and impedance aggregometry allow coagulation evaluation at the bedside, but reference values are scarce in pediatrics. The aim of this study was to establish reference values of thromboelastometry and impedance aggregometry for this population and compare it between age groups. This prospective, single-center, observational study evaluates viscoelastic tests and impedance aggregometry in children with congenital heart disease. A total of 204 children were included with a median age of 3.6 years old. We provide references values for this population with median, percentile 2.5 and percentile 97.5. Infants demonstrate for extrinsic activity a shorter coagulation time (52 [49-55] vs. 56 [51-62] s, P = 0.007) and clot formation time (90 [71-118] vs. 113 [93-146] s, P < 0.0001) so as for intrinsic activity a shorter clot formation time (53 [44-69] vs. 75 [59-92] s, P < 0.0001). The maximal clot firmness was significantly stronger in infants for extrinsic (65 [61-69] vs. 59 [54-63] mm, P < 0.0001), intrinsic (68 [64-70] vs. 61 [57-65] mm, P < 0.0001), and fibrinogen (12 [9-16] vs. 10 [8-13] mm, P = 0.02) activities. Platelet aggregation was significantly higher in infants with an amplitude at 6 min of 28 [23-34] vs. 22 [15-27] Ω, P less than 0.0001, a maximum speed of 11 [9-13] vs. 7 [5-10] Ω/min, P less than 0.0001, and an area under the curve of 120 [92-135] vs. 86 [59-112] Ω min, P less than 0.0001. We provided the first reference values for impedance aggregometry and thromboelastometry in children with congenital heart disease. We showed that these infants tend to have accelerated coagulation and stronger clot firmness compared with older children, but this finding may have only minimal relevance when treating a bleeding child. Trial registration number: ClinicalTrials.gov (clinicaltrials.gov/ct2/show/NCT02387944).

CytoSorb® hemoadsorption and mechanical circulatory support in a newborn with refractory shock after congenital heart surgery.

Refractory cardiogenic and vasoplegic shock after congenital heart surgery is a threatening condition leading to high morbidity and mortality. Control of hemodynamic and inflammatory response is fundamental in medical strategy. We report the case of a newborn with cardiogenic and vasoplegic shock secondary to cardiopulmonary bypass for atrioseptostomy and prostaglandin treatment in the context of hypoplastic left heart syndrome, successfully treated with a combination of mechanical circulatory support and cytokine hemoadsorption column (CytoSorb®). Vasopressor support was weaned during the time of treatment without multiple organ failure occurrence. The use of CytoSorb® cartridge inserted in an extra-corporeal circuit even in a newborn is easy and feasible, as long as some precautions are considered. Routine monitoring of drugs levels is mandatory during the use of the cartridge and immediately after.

Clindamycin clearance during Cytosorb® hemoadsorption: A case report and pharmacokinetic study.

Panton-Valentine leucocidin producing methicillin-resistant Staphylococcus aureus infections are rare but associated with very high mortality rates. We report the case of a 14-year-old patient with Panton-Valentine leucocidin producing methicillin-resistant Staphylococcus aureus infection and Influenza B pneumonia requiring veno-arterial extra-corporeal membrane oxygenator for refractory shock. In the absence of response to conventional therapy, we have inserted a Cytosorb® cartridge within the extra-corporeal membrane oxygenator circuit. A spectacular decrease in vasopressor requirements followed. Since clindamycin, a key component of Panton-Valentine leucocidin producing methicillin-resistant Staphylococcus aureus treatment, might be removed by Cytosorb® hemoadsorption, we have performed serial plasma concentrations measurements of the drug. Based on these measurements, we were able to develop a pharmacokinetic model incorporating variable plasma clearance. Patient's exposure was estimated before, during and after Cytosorb® hemoadsorption. According to this model, Cytosorb® hemoadsorption did not seem to result in significant clindamycin removal. Cytosorb® hemoadsorption during Panton-Valentine leucocidin producing methicillin-resistant Staphylococcus aureus infection appears safe and feasible and no adaptation of clindamycin dosage seems necessary.

Leukemoid Reaction in Infant Pertussis: Is There a Place for Hydroxyurea? A Case Report.

A 73-days old infant of 34 weeks' gestation was hospitalized with a co-infection of respiratory syncytial virus (RSV) and Bordetella pertussis (BP). She required invasive ventilation for 9 days in the context of malignant pertussis with persistent hypoxemia and hypercapnia secondary to a leukemoid reaction. Despite an increase of white blood cell (WBC) count up to 70 G/L and ensuing pulmonary hypertension, no hemodynamic compromise occurred. Without clear indication for leukapheresis nor exchange transfusion, an off-label treatment with hydroxyurea was given for 5 days with gradual decrease of WBC count, without any complication and hospital discharge on day 29. To our knowledge, no effective therapy for malignant pertussis has been described in the literature and complications are frequent with leukoreduction procedures. We discuss an alternative to invasive procedures in young infants to fulfill the need to decrease rapidly leukocyte counts in a leukemoid reaction associated with Bordetella pertussis infection. To our knowledge, hydroxyurea has never been used in malignant pertussis but is a well-known medication for oncologic and hematologic diseases such as acute myeloid leukemia or sickle cell anemia. Its effects in this setting are not well understood but the positive outcome in our patient supports the need for further studies.

Anesthetic Management for Concomitant Correction of Congenital Cardiac Defects and Long "O" Ring Tracheal Stenosis: A Role for Heliox?: Report of 2 Cases.

We present 2 infants with the rare association of long congenital tracheal stenosis, ventricular septal defect, and pulmonary hypertension. We describe a step-by-step assessment of the patients and the necessary procedures for a successful concomitant repair of both cardiac and tracheal malformations. The use of a helium-oxygen mixture (heliox) for the induction of anesthesia and pre-cardiopulmonary bypass is discussed.

Estimation of Resting Energy Expenditure Using Predictive Equations in Critically Ill Children: Results of a Systematic Review.

Provision of adequate energy intake to critically ill children is associated with improved prognosis, but resting energy expenditure (REE) is rarely determined by indirect calorimetry (IC) due to practical constraints. Some studies have tested the validity of various predictive equations that are routinely used for this purpose, but no systematic evaluation has been made. Therefore, we performed a systematic review of the literature to assess predictive equations of REE in critically ill children. We systematically searched the literature for eligible studies, and then we extracted data and assigned a quality grade to each article according to guidelines of the Academy of Nutrition and Dietetics. Accuracy was defined as the percentage of predicted REE values to fall within ±10% or ±15% of the measured energy expenditure (MEE) values, computed based on individual participant data. Of the 993 identified studies, 22 studies testing 21 equations using 2326 IC measurements in 1102 children were included in this review. Only 6 equations were evaluated by at least 3 studies in critically ill children. No equation predicted REE within ±10% of MEE in >50% of observations. The Harris-Benedict equation overestimated REE in two-thirds of patients, whereas the Schofield equations and Talbot tables predicted REE within ±15% of MEE in approximately 50% of observations. In summary, the Schofield equations and Talbot tables were the least inaccurate of the predictive equations. We conclude that a new validated indirect calorimeter is urgently needed in the critically ill pediatric population.).

Meningococcal serogroup W135 epiglottitis in an adolescent patient.

Acute epiglottitis is a severe and potentially life-threatening condition. Since the implementation of Haemophilus influenzae vaccination, the number of cases of epiglottitis has decreased and the proportion of other infectious causes has increased. We report a case of acute epiglottitis in a teenager caused by Neisseria meningitidis, an unusual pathogen.

Use of Levosimendan in Postoperative Setting After Surgical Repair of Congenital Heart Disease in Children.

Low cardiac output is one of the most common complications after cardiac surgery. Levosimendan, a new inotrope agent, has been demonstrated in adult patient to be an effective treatment for this purpose when classical therapy is not effective. The aim of this study was to evaluate the effect of Levosimendan on cardiac output parameters in cardiac children with low cardiac output syndrome (LCOS.). We carried out a retrospective analysis on 62 children hospitalized in our pediatric intensive care unit (PICU) after cardiac surgery, which demonstrated LCOS not responding to classical catecholamine therapy and who received levosimendan as rescue therapy. LCOS parameters like diuresis, central venous oxygen saturation (SvO2), venous-to-arterial CO2 difference (∆avCO2), and plasmatic lactate were compared before therapy and at 3, 6, 12, and 24 h after the beginning of the levosimendan infusion. We also analyzed the effect on the Vasoactive-inotropic score (VIS), adverse events, and mortality. After the beginning of levosimendan infusion, diuresis (1.1 vs. 3.5 ml/kg/h, p = 0.001) and SvO2 (59.5 vs. 63.3%, p = 0.026) increased significantly during the 24 h of infusion, and at the same time, plasmatic lactate (2.3 vs. 1.3 mmol/l, p < 0.001) decreased. ∆avCO2 (10.8 vs. 9.4 mmHg, p = 0.21) and the VIS (44.5 vs. 22.5, p = 0.143) also decreased, but not significantly. No side effects were noted. The mortality in this patient group was 16%. Levosimendan is an effective treatment in children presenting LCOS after congenital heart surgery. Our study confirms the improvement of cardiac output already shown in other pediatric studies, with no undesirable side effects.

Age is not a good predictor of irreversibility of pulmonary hypertension in congenital cardiac malformations with left-to-right shunt.

OBJECTIVE: Congenital cardiac malformations with high pulmonary blood flow and pressure due to left-to-right shunts are usually repaired in early infancy for both the benefits of early relief of heart failure and the fear that the concomitant pulmonary hypertension may become irreversible unless these defects are corrected at an early age. Age, however, has been a poor predictor of irreversibility of pulmonary hypertension in our experience, which is presented here. DESIGN: A retrospective observational study. We defined "late" as age ≥2 years. We examined clinical, echocardiographic, and hemodynamic data from all patients aged ≥2 years with such malformations referred to us from 2004 untill 2015. SETTING: Department of Pediatric Cardiology and Cardiac Surgery, University Hospital of Vaud, Lausanne, Switzerland. PATIENTS: There were 39 patients, aged 2-35 years (median: 5 years), without chromosomal abnormalities. All had malformations amenable to biventricular repair, and all had high systolic right ventricular pressures by echocardiography prior to referral. INTERVENTIONS: All patients underwent catheterization for assessment of pulmonary hypertension. If this was reversible, surgical correction was offered. OUTCOME MEASURES: (1) Operability based on reversibility of pulmonary hypertension. (2) When surgery was offered, mortality and evidence of persisting postoperative pulmonary hypertension were examined. RESULTS: Eighteen patients had no pulmonary hypertension, 5 of variable ages were inoperable due to irreversible pulmonary hypertension, and 16 had reversible pulmonary hypertension. Therefore, 34 patients underwent corrective surgery, with no immediate or late mortality. Pulmonary arterial and right ventricular pressures decreased noticeably in all operated patients. This is sustained to date; they are all asymptomatic with no echocardiographic evidence of pulmonary hypertension at a median follow-up of 7 years (range 2-13 years). CONCLUSIONS: Pulmonary hypertension may still be reversible in many surprisingly old patients with left-to-right shunt lesions, who may therefore still be operable.

Severe viral respiratory infections in children with IFIH1 loss-of-function mutations.

Viral respiratory infections are usually mild and self-limiting; still they exceptionally result in life-threatening infections in previously healthy children. To investigate a potential genetic cause, we recruited 120 previously healthy children requiring support in intensive care because of a severe illness caused by a respiratory virus. Using exome and transcriptome sequencing, we identified and characterized three rare loss-of-function variants in IFIH1, which encodes an RIG-I-like receptor involved in the sensing of viral RNA. Functional testing of the variants IFIH1 alleles demonstrated that the resulting proteins are unable to induce IFN-ß, are intrinsically less stable than wild-type IFIH1, and lack ATPase activity. In vitro assays showed that IFIH1 effectively restricts replication of human respiratory syncytial virus and rhinoviruses. We conclude that IFIH1 deficiency causes a primary immunodeficiency manifested in extreme susceptibility to common respiratory RNA viruses.

Improvement in perioperative care in pediatric cardiac surgery by shifting the primary focus of treatment from cardiac output to perfusion pressure: Are beta stimulants still needed?

OBJECTIVE: An important aspect of perioperative care in pediatric cardiac surgery is maintenance of optimal hemodynamic status using vasoactive/inotropic agents. Conventionally, this has focused on maintenance of cardiac output rather than perfusion pressure. However, this approach has been abandoned in our center in favor of one focusing primarily on perfusion pressure, which is presented here and compared to the conventional approach. DESIGN: A retrospective study. SETTING: Regional center for congenital heart disease. University Hospital of Lausanne, Switzerland. PATIENTS: All patients with Aristotle risk score ≥8 that underwent surgery from 1996 to 2012 were included. Patients operated between 1996 and 2005 (Group 1: 206 patients) were treated according to the conventional approach. Patients operated between 2006 and 2012 (Group 2: 217 patients) were treated according to our new approach. INTERVENTIONS: All patients had undergone surgery for correction or palliation of congenital cardiac defects. OUTCOME MEASUREMENTS: Mortality, duration of ventilation and inotropic treatment, use of ECMO, and complications of poor peripheral perfusion (need for hemofiltration, laparotomy for enterocolitis, amputation). RESULTS: The two groups were similar in age and complexity. Mortality was lower in group 2 (7.3% in group 1 vs 1.4% in group 2, P < .005). Ventilation times (hours) and number of days on inotropic/vasoactive treatment (all agents), expressed as median and interquartile range [Q1-Q3] were shorter in group 2: 69 [24-163] hours in group 1 vs 35 [22-120] hours in group 2 (P < .01) for ventilation, and 9 [3-5] days in group 1 vs 7 [2-5] days in group 2 (P < .05) for inotropic/vasoactive agents. There were no differences in ECMO usage or complications of peripheral perfusion. CONCLUSIONS: Results in pediatric cardiac surgery may be improved by shifting the primary focus of perioperative care from cardiac output to perfusion pressure.

Performance of Predictive Equations Specifically Developed to Estimate Resting Energy Expenditure in Ventilated Critically Ill Children.

OBJECTIVE: To determine, based on indirect calorimetry measurements, the biases of predictive equations specifically developed recently for estimating resting energy expenditure (REE) in ventilated critically ill children, or developed for healthy populations but used in critically ill children. STUDY DESIGN: A secondary analysis study was performed using our data on REE measured in a previous prospective study on protein and energy needs in pediatric intensive care unit. We included 75 ventilated critically ill children (median age, 21 months) in whom 407 indirect calorimetry measurements were performed. Fifteen predictive equations were used to estimate REE: the equations of White, Meyer, Mehta, Schofield, Henry, the World Health Organization, Fleisch, and Harris-Benedict and the tables of Talbot. Their differential and proportional biases (with 95% CIs) were computed and the bias plotted in graphs. The Bland-Altman method was also used. RESULTS: Most equations underestimated and overestimated REE between 200 and 1000 kcal/day. The equations of Mehta, Schofield, and Henry and the tables of Talbot had a bias ≤10%, but the 95% CI was large and contained values by far beyond ±10% for low REE values. Other specific equations for critically ill children had even wider biases. CONCLUSIONS: In ventilated critically ill children, none of the predictive equations tested met the performance criteria for the entire range of REE between 200 and 1000 kcal/day. Even the equations with the smallest bias may entail a risk of underfeeding or overfeeding, especially in the youngest children. Indirect calorimetry measurement must be preferred.

How much protein and energy are needed to equilibrate nitrogen and energy balances in ventilated critically ill children?

BACKGROUND & AIMS: Protein and energy requirements in critically ill children are currently based on insufficient data. Moreover, longitudinal measurements of both total urinary nitrogen (TUN) and resting energy expenditure (REE) are lacking. The aim of this study was to investigate how much protein and energy are needed to equilibrate nitrogen and energy balances in ventilated critically ill children on the basis of daily measurements of TUN, REE and protein and energy intakes. Comparisons were made with the guidelines of the American Society for Parenteral and Enteral Nutrition and the Dietary Reference Intakes. METHODS: Children with an expected duration of mechanical ventilation ≥72 h were prospectively recruited. TUN was measured by chemiluminescence, and REE was measured by indirect calorimetry. Generalised linear models for longitudinal data were used to study the relation between protein intake and nitrogen balance and to calculate the minimum intake of protein needed to achieve nitrogen equilibrium. A similar approach was used for energy. Results were compared to the recommended values. RESULTS: Based on 402 measurements performed in 74 children (median age: 21 months), the mean TUN was high at 0.20 (95% CI: 0.20, 0.22) g/kg/d and the REE was 55 (95% CI: 54, 57) kcal/kg/d. Nitrogen and energy balances were achieved with 1.5 (95% CI: 1.4, 1.6) g/kg/d of protein and 58 (95% CI: 53, 63) kcal/kg/d for the entire group, but there were differences among children of different ages. Children required more protein and less energy than the Dietary Reference Intakes. CONCLUSIONS: In critically ill children, TUN was elevated and REE was reduced during the entire period of mechanical ventilation. Minimum intakes of 1.5 g/kg/d of protein and 58 kcal/kg/d can equilibrate nitrogen and energy balances in children up to 4 years old. Older children require more protein.