Feasibility and Utility of the Venous Excess Ultrasound Score to Detect and Grade Central Venous Pressure Elevation in Critically Ill Children.

OBJECTIVES: The Venous Excess Ultrasound (VExUS) score has been described as a useful tool to estimate the degree of venous congestion in adult patients. The present study aimed to analyze the feasibility and usefulness of the VExUS score to detect and grade central venous pressure (CVP) elevation in critically ill children. METHODS: A cross-sectional pilot study was conducted in a tertiary-care pediatric intensive care unit between November 2020 and June 2021. All children in whom CVP was monitored, were enrolled. At the time of central venous catheter placement, CVP and VExUS score grade were determined, analyzing the inferior vena cava (IVC) diameter and the hepatic (HVD), portal (PVD), and intrarenal (IRVD) venous Doppler waveforms. RESULTS: A total of 33 children were studied (median age 12.2 [interquartile range (IQR) 4.1-100.6] months old; median weight 8.5 [IQR 5.6-35] kg; 20 [60.6%] males). The VExUS score was successfully obtained in 100% of the patients and its severity was strongly associated with the CVP levels (P < .001). Analyzing the VExUS score components separately, IVC dilation (P < .001) and severe HVD (P = .026), mild IRVD (P = .005), and severe IRVD (P = .025) patterns were associated with elevated CVP. After adjustment for confounding factors, IRVD pattern remained the only independent variable associated with elevated CVP. CONCLUSIONS: The VExUS score appears to be a feasible and potentially useful bedside noninvasive monitoring tool for the detection and grading of CVP elevation in critically ill children. Among all its components, IRVD assessment seems most associated with high CVP in this population.

Cytokine Profile in Children with Severe Multisystem Inflammatory Syndrome Related to the Coronavirus Disease 2019.

The multisystem inflammatory syndrome in children (MIS-C) is a novel and concerning entity related to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection. Although MIS-C has been the subject of intensive research efforts, its pathophysiology and optimal treatment remain elusive. We studied the clinical features, laboratory findings, and immunoinflammatory profiles of seven children prospectively admitted to a pediatric intensive care unit (PICU) during the first wave of the pandemic. All patients had immunoglobulin (Ig)-G against SARS-CoV-2, four of seven patients had both IgM and IgG, and in one of the 7 SARS-CoV-2 was detected in a respiratory sample. All patients received intravenous fluid boluses (median: 15 mL/kg) and norepinephrine. The most common form of respiratory support was supplemental oxygen via nasal cannula. None of the patients needed mechanical ventilation. The cardiovascular system was frequently involved. All patients had an elevated troponin-I (median: 107.3 ng/L). Four out of seven patients had coronary artery abnormalities, and two of seven had both abnormal electrocardiogram (EKG) findings and evidence of left ventricular dysfunction on echocardiogram. Ig levels and complement function were normal. Peripheral blood phenotyping with flow cytometry showed decreased T-cell numbers at the expense of CD8+ T-cells. Cytokine profiling showed a heterogeneous increase in interleukin (IL)-6, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, IL-18, IL-2Ra, IL-10, and IL-1Ra that tended to normalize after treatment. Our study shows that children with MIS-C have elevated plasma levels of pro- and anti-inflammatory cytokines in the acute phase of the disease without other relevant immunologic disturbances. These findings suggest the presence of a mixed antagonist response syndrome (MARS) similar to that present in pediatric sepsis. Combining a meticulous differential diagnosis with cautiously coordinated immunomodulatory therapy and high-quality supportive care can help clinicians avoid causing iatrogenic harm in patients with MIS-C.

Molecular diagnosis of bacteremia in a pediatric intensive care unit: a step forward.

Aim: T2Bacteria® Panel detects six ESKAPE pathogens in around 3.5 h directly in whole blood. Our aim was to compare T2Bacteria with simultaneous blood culture in critically ill children with suspected bloodstream infection. Materials & methods: Retrospective study of critically ill children admitted to our tertiary-care center (2018-2020). Results: A total of 60 patients were recruited, including 63 episodes and 75 T2Bacteria/blood cultures were performed. Overall agreement between T2Bacteria and blood culture was 78.7% with a discordance of 21.3% (16/75 samples). Conclusion: T2Bacteria Panel may be useful in critically ill children providing an accurate and fast diagnosis of bacteremia directly from blood sample and detecting pathogens not recovered in blood cultures.

Presenting Features and Prognosis of Ischemic and Nonischemic Neonatal Liver Failure.

OBJECTIVES: To describe the epidemiological features, clinical characteristics and outcomes of neonates diagnosed with liver failure, as well as determine prognostic factors. METHODS: Cohort study conducted at a single tertiary referral and university-affiliated pediatric center. Hospital records of all neonates diagnosed with liver failure between January 2003 and December 2015 were retrospectively reviewed, and data on clinical and laboratory findings, treatment, and outcomes were collected. Survival analysis (Kaplan-Meier) and Cox regression were performed to identify prognostic factors at diagnosis. Liver failure diagnosis was established using the pediatric acute liver failure study group's diagnostic criteria for every patient with coagulopathy and biochemical pattern of liver disease. RESULTS: Forty-five patients were included. In our series, most cases were secondary to ischemia (28.9%). Other causes were neonatal hemochromatosis (17.8%), viral infections (13.3%), and inborn errors of metabolism (13.3%). A total 55.6% (25/45) of the patients died (median age: 16 days; range 1-235 days). Alanine aminotransferase (ALT) at diagnosis was associated with higher mortality or the need for liver transplantation on day 21 after diagnosis (P = .006). For every 500 IU/L increase in ALT serum levels, the mortality/liver transplantation rate increased 1.3 times (hazard ratio 95% confidence interval: 1.1-1.6). Although ischemic neonatal acute liver failure presents with higher ALT levels, these cases appear to have better outcomes. Higher international normalized ratio tended to increase mortality/transplantation (hazard ratio 1.02; 95% confidence interval 0.91-1.2). CONCLUSIONS: Neonatal liver failure should perhaps be considered in the differential diagnoses of any coagulopathy. ALT and international normalized ratio levels at diagnosis could predict prognosis in the short term. Ischemic liver failure appears to have a better prognosis.

Cardiac preload responsiveness in children with cardiovascular dysfunction or dilated cardiomyopathy: a multicenter observational study.

OBJECTIVES: To characterize cardiac preload responsiveness in pediatric patients with cardiovascular dysfunction and dilated cardiomyopathy using global end-diastolic volume index, stroke volume index, cardiac index, and extravascular lung water index. DESIGN: Prospective multicenter observational study. SETTING: Medical/surgical PICUs of seven Spanish University Medical Centers. PATIENTS: Seventy-five pediatric patients (42 male, 33 female), median age 36 months (range, 1-207 mo), were divided into three groups: normal cardiovascular status, cardiovascular dysfunction, and dilated cardiomyopathy. INTERVENTIONS: All patients received hemodynamic monitoring with PiCCO2 (Pulsion Medical System SE, Munich, Germany). We evaluated 598 transpulmonary thermodilution sets of measurements. In 40 patients, stroke volume index, cardiac index, and global end-diastolic volume index were measured before and after 66 fluid challenges and loadings to test fluid responsiveness at different preload levels. MEASUREMENTS AND MAIN RESULTS: Global end-diastolic volume versus predicted body surface area exhibits a power-law relationship: Global end-diastolic volume = 488.8·predicted body surface area (r = 0.93). Four levels of cardiac preload were established from the resulting "normal" global end-diastolic volume index (= 488.8·predicted body surface area). Stroke volume index and cardiac index versus global end-diastolic volume index/normal global end-diastolic volume index built using a linear mixed model analysis emulated Frank-Starling curves: in cardiovascular dysfunction group, stroke volume index (geometric mean [95% CI]) was 27 mL/m (24-31 mL/m) at "≤ 0.67 times normal global end-diastolic volume index," 37 mL/m (35-40 mL/m) at "> 0.67 ≤ 1.33 times normal global end-diastolic volume index" (Δ stroke volume index = 35%; p < 0.0001; area under the receiver-operating characteristic curve = 75%), 45 mL/ m (41-49 mL/m) at "> 1.33 ≤ 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = 21%; p < 0.0001; area under the receiver-operating characteristic curve = 73%), and 47 mL/m (43-51 mL/m) at "> 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = 4%; p = 1; area under the receiver-operating characteristic curve = 54%). In dilated cardiomyopathy group, stroke volume index was 21 mL/m (17-26 mL/m) at "> 0.67 ≤ 1.33 times normal global end-diastolic volume index," 27 mL/m (21-34 mL/ m) at "> 1.33 ≤ 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = 29%; p = 0.005; area under the receiver-operating characteristic curve = 64%), and 25 mL/m (20-32 mL/m) at "> 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = -8%; p = 1; area under the receiver-operating characteristic curve = 54%). CONCLUSIONS: This study provides "normal" values for global end-diastolic volume index and limits of cardiac preload responsiveness in pediatric patients with cardiovascular dysfunction and dilated cardiomyopathy: 1.33 times normal global end-diastolic volume index represents the upper limit of patent cardiac preload responsiveness, with the highest expected responsiveness being below 0.67 times normal global end-diastolic volume index. The maximum response of the Frank-Starling relationship and therefore the level of no additional preload reserve is 1.33 to 1.51 times normal global end-diastolic volume index. Above 1.51 times normal global end-diastolic volume index preload responsiveness is unlikely, and the risk of pulmonary edema is maximal.