Severe acute respiratory syndrome coronavirus-2-related and imputable deaths in children: results from the French pediatric national registry.

BACKGROUND: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is responsible for an important mortality rate worldwide. We aimed to evaluate the actual imputability of SARS-CoV-2 on the mortality rate associated with SARS-CoV-2-related illnesses in the pediatric intensive care unit (PICU). Secondary objectives were to identify risk factors for death. METHODS: This national multicenter comparative study comprised all patients under 18 years old with positive SARS-CoV-2 polymerase chain reactions (PCRs) [acute corona virus disease 2019 (COVID-19) or incidental SARS-CoV-2 infection] and/or pediatric inflammatory multisystem syndrome (PIMS) recorded in the French PICU registry (PICURe) between September 1, 2021, and August 31, 2022. Included patients were classified and compared according to their living status at the end of their PICU stay. Deceased patients were evaluated by four experts in the field of pediatric infectiology and/or pediatric intensive care. The imputability of SARS-CoV-2 as the cause of death was classified into four categories: certain, very probable, possible, or unlikely, and was defined by any of the first three categories. RESULTS: There were 948 patients included of which 43 died (4.5%). From this, 26 deaths (67%) could be attributed to SARS-CoV-2 infection, with an overall mortality rate of 2.8%. The imputability of death to SARS-CoV-2 was considered certain in only one case (0.1%). Deceased patients suffered more often from comorbidities, especially heart disease, neurological disorders, hematological disease, cancer, and obesity. None of the deceased patients were admitted for pediatric inflammatory multisystem syndrome (PIMS). Mortality risk factors were male gender, cardiac comorbidities, cancer, and acute respiratory distress syndrome. CONCLUSIONS: SARS-CoV-2 mortality in the French pediatric population was low. Even though the imputability of SARS-CoV-2 on mortality was considered in almost two-thirds of cases, this imputability was considered certain in only one case.

High-dose intravenous immunoglobulin versus albumin 4% in paediatric toxic shock syndrome: a randomised controlled feasibility study.

PURPOSE: Toxic shock syndrome (TSS) is a rare disease responsible for significant morbidity and mortality. Intravenous immunoglobulin (IG) therapy in paediatric TSS could improve shock and organ failure, but more consistent efficacy and safety data are needed. Our objective was to determine whether a randomised clinical trial (RCT) assessing intravenous IG in TSS in children is feasible. METHODS: We performed a multicentre, feasibility, double-blind RCT assessing efficacy of high-dose intravenous IG versus albumin 4% (control group) within the first 12 hours of shock onset. Included patients were aged above 1 month and below 18 years with suspected TSS and septic shock. Feasibility was assessed by measuring inclusion rate, protocol compliance and missing data regarding death and the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) Score. Other secondary clinical outcomes were evaluated during hospital stay, at 60 day and 1 year. RESULTS: 28 patients, admitted in 6 paediatric intensive care units during 36 consecutive months and followed for 1 year, received the allocated treatment: 13 in intravenous IG group, 15 in control group. The median age was 10.6 years and the sex ratio was 1. Inclusion rate was above 50%, protocol deviations were below 30% and missing data regarding death and PELOD-2 Score below 10%. No difference concerning secondary clinical outcomes between groups was observed, and more adverse events were reported in the control group. CONCLUSION: It seems to be feasible to conduct an RCT assessing intravenous IG efficacy and safety in paediatric TSS but must be realised internationally, with choice of a clinically relevant endpoint and a specific design in order to be realistic. TRIAL REGISTRATION NUMBER: NCT02219165.

Patient Characteristics and Severity Trajectories in a Pediatric Intermediate Care Unit.

OBJECTIVES: To describe the characteristics of patients admitted to Pediatric Intermediate Care Units (PImCU) and to assess their illness severity trajectories. METHODS: This prospective, observational, multicentre cohort study was conducted in seven French PImCUs between September 2012 and January 2014. All consecutive patients aged under 18 were included. The severity of illness was evaluated through the Paediatric Advanced Warning Score (PAWS), measured every 8 h for each patient. A latent class mixed model was used to identify severity trajectory classes. RESULTS: A total of 2868 patients were included. The median [interquartile range] age was 29 [5-103] mo and the median length of stay was 1 [1-3] d. The primary indication for admission was respiratory (44%). Almost 3% of the patients were subsequently transferred to a pediatric intensive care unit. Three severity trajectory classes were identified. In one class, comprising the largest proportion of patients, the PAWS was low on admission and did not change markedly over time. In this class, patients were older and had a shorter length of stay. The other two classes were characterized by a higher PAWS on admission and rapid or slow improvement. These patients were more severely ill, mostly due to respiratory failure. CONCLUSIONS: A large proportion of patients had a stable profile and no signs of severity which suggests that the stay in PImCU was not indicated but a part of these patients have remained stable perhaps because of the advanced monitoring and intensive nursing in these units. CLINICAL TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov Protocol, Identifier: NCT02304341, ClinicalTrials.gov .

Anti-infective prescribing practices in critically ill children on continuous renal replacement therapy: a multicenter survey of French-speaking countries.

BACKGROUND: Use of continuous renal replacement therapy in children receiving anti-infective drugs may lead to inappropriate concentrations with risks related to treatment failure, toxicity and emergence of multidrug-resistant bacteria. We aimed to describe anti-infective prescribing practices in critically ill children undergoing continuous renal replacement therapy. METHODS: An online survey to assess continuous renal replacement therapy, anti-infective prescribing and therapeutic drug monitoring practices was sent by e-mail to physicians working in pediatric intensive care units through the French-speaking Group of Pediatric Intensive Care and Emergency medicine (GFRUP). RESULTS: From April 1st, 2021 to May 1st, 2021, 26/40 pediatric intensive care units participated in the survey, corresponding to a response rate of 65%. Twenty-one were located in France and five abroad. All pediatric intensive care units administered continuous renal replacement therapy, primarily with Prismaflex™ System. Anti-infective prescriptions were adjusted to the presence of continuous renal replacement therapy in 23 (88%) pediatric intensive care units mainly according to molecular weight in 6 (23%), molecule protein binding in 6 (23%) and elimination routes in 15 (58%) including residual diuresis in 9 (35%), to the continuous renal replacement therapy flow in 6 (23%) and to the modality of continuous renal replacement therapy used in 15 (58%), pediatric intensive care units. There was broad variability among pediatric intensive care units and among physicians within the same unit. Barriers to therapeutic drug monitoring were mainly an excessive delay in obtaining results in 11 (42%) and the lack of an on-site laboratory in 8 (31%) pediatric intensive care units. CONCLUSIONS: Our survey reported wide variability in anti-infective prescribing practices in children undergoing continuous renal replacement therapy, thus highlighting a gap in knowledge and the need for education and recommendations.

Severe post-pyloric injury after button battery ingestion: Systematic literature review and case report.

BACKGROUND: The health and safety hazards related to button batteries (BB) have been extensively studied, highlighting that the presence of a button battery in the esophagus is a life-threatening emergency. However, complications related to bowel BB are poorly evaluated and not well known. The objective of this review of the literature was to describe severe cases of BB that have passed the pylorus. CASE REPORT: This case, from the PilBouTox cohort, is the first report of small-bowel occlusion following ingestion of an LR44 BB (diameter: 11.4 mm) by a 7-month-old infant with a history of intestinal resections. In this case, the BB was ingested without a witness. The initial presentation mimicked acute gastroenteritis evolving into hypovolemic shock. An X-ray revealed a foreign body stuck in the small bowel causing an intestinal occlusion and local necrosis without perforation. The patient's history of intestinal stenosis and intestinal surgery were the contributing factor of impaction. SYSTEMATIC LITERATURE REVIEW: The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The research was conducted on September 12, 2022 through five database and the U.S. Poison Control Center website. An additional 12 severe cases of intestinal or colonic injury after ingestion of a single BB were identified. Of these, 11 were related to small BBs (< 15 mm) that impacted Meckel's diverticulum and one was related to postoperative stenosis. CONCLUSION: In view of the findings, the indications for digestive endoscopy for extraction of a BB in the stomach should include a history of intestinal stenosis or intestinal surgery so as to avoid delayed intestinal perforation or occlusion and prolonged hospitalization.

Out-of-hospital cardiac arrests occurring at school in France: A nation-wide retrospective cohort study from the RéAC registry.

AIM: We sought to describe the characteristics of at-school out-of-hospital cardiac arrests cases, subsequent basic life support, as well as ultimate patient outcomes. METHODS: This was a nation-wide, multicentre, retrospective cohort study from the French national population-based RéAC out-of-hospital cardiac arrest registry (July 2011 - March 2023). We compared the characteristics and outcomes of cases occurring at schools vs. in other public places. RESULTS: Of the 149,088 national out-of-hospital cardiac arrests, 25,071 were public: 86 (0.3%) and 24,985 (99.7%) in schools and other public places, respectively. At-school out-of-hospital cardiac arrests, in comparison to other public places, were: significantly younger (median: 42.5 vs. 58 years, p < 0.001); more commonly of a medical cause (90.7% vs. 63.8%, p < 0.001), more commonly bystander-witnessed (93.0% vs. 73.4%, p < 0.001) and recipients of bystander cardiopulmonary resuscitation (78.8% vs. 60.6%, p = 0.001) with shorter median no-flow durations (2 min. vs. 7 min.); with greater bystander automated external defibrillator application (38.9% vs. 18.4%) and defibrillation (23.6%, vs. 7.9%; all p < 0.001). At-school patients had greater rates of return of spontaneous circulation than out-of-school ones (47.7%, vs. 31.8%; p = 0.002), higher rates of survival at arrival at hospital (60.5% vs. 30.7%; p < 0.001) and at 30-days (34.9% vs. 11.6%; p < 0.001), and survival with favourable neurological outcomes at 30 days (25.9% vs. 9.2%; p < 0.001). CONCLUSION: At-school out-of-hospital cardiac arrests were rare in France, however demonstrated favourable prognostic features and outcomes. The use of automated external defibrillators in at-school cases, while more common than cases occurring elsewhere, should be improved.

Visiting Policies and Parental Presence During PICU Admission: A Survey in French Units.

OBJECTIVES: To describe the policies about parent visiting and involvement in care during admission to French PICUs. DESIGN: A structured questionnaire was emailed to the chief of each of 35 French PICUs. Data about visiting policies, involvement in care, evolution of policies, and general characteristics were collected from April 2021 to May 2021. A descriptive analysis was conducted. SETTING: Thirty-five PICUs in France. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twenty-nine of 35 (83%) PICUs replied. Twenty-four-hour access for parents was reported for all PICUs responding. Other allowed visitors were grandparents (21/29, 72%) and siblings (19/29, 66%) with professional support. Simultaneous visits were restricted to two visitors in 83% (24/29) of PICUs. Family presence was always permitted during medical rounds for 20 of 29 (69%) PICUs. Most of the units rarely or never allowed parental presence during the most invasive procedures, such as central venous catheter placement (18/29, 62%) and intubation (22/29, 76%). CONCLUSIONS: Unrestricted access to the PICU, for both parents, was available in all responding French units. There were, however, restrictions on the number of visitors and the presence of other family members at the bedside. Moreover, permission for parental presence during care procedures was heterogenous, and mainly restricted. National guidelines and educational programs are needed to support family wishes and promote acceptance by healthcare providers in French PICUs.

Association between out-of-hospital cardiac arrest and survival in paediatric traumatic population: results from the French national registry.

BACKGROUND AND IMPORTANCE: Trauma is an important cause of paediatric out-of-hospital cardiac arrest (OHCA) with a high mortality rate. OBJECTIVES: The first aim of this study was to compare the survival rate at day 30 and at hospital discharge following paediatric traumatic and medical OHCA. The second aim was to compare the rates of return of spontaneous circulation and survival rates at hospital admission (Day 0). SETTING AND PARTICIPANTS: This multicentre comparative post-hoc study was conducted between July 2011 and February 2022 based on the French National Cardiac Arrest Registry data. All patients aged <18 years with OHCA were included in the study. OUTCOME MEASURES AND ANALYSIS: Patients with traumatic aetiology were matched with those with medical aetiology using propensity score matching. Endpoint was the survival rate at day 30. MAIN RESULTS: There were 398 traumatic and 1061 medical OHCAs. Matching yielded 227 pairs. In non-adjusted comparisons, days 0 and 30 survival rates were lower in the traumatic aetiology group than in the medical aetiology group [19.1% vs. 24.0%, odds ratio (OR) 0.75, 95% confidence interval (CI) 0.56-0.99, and 2.0% vs. 4.5%, OR 0.43, 95% CI, 0.20-0.92, respectively]. In adjusted comparisons, day 30 survival rate was lower in the traumatic aetiology group than in the medical aetiology group (2.2% vs. 6.2%, OR 0.36, 95% CI, 0.13-0.99). CONCLUSION: In this post-hoc analysis, paediatric traumatic OHCA was associated with a lower survival rate than medical cardiac arrest.

Bystander basic life support and survival after out-of-hospital cardiac arrest: A propensity score matching analysis.

INTRODUCTION AND OBJECTIVES: In out-of-hospital cardiac arrest, early recognition, calling for emergency medical assistance, and early cardiopulmonary resuscitation are acknowledged to be the three most important components in the chain of survival. However, bystander basic life support (BLS) initiation rates remain low. The objective of the present study was to evaluate the association between bystander BLS and survival after an out-of-hospital cardiac arrest (OHCA). METHODS: We conducted a retrospective cohort study of all patients with OHCA with a medical etiology treated by a mobile intensive care unit (MICU) in France from July 2011 to September 2021, as recorded in the French National OHCA Registry (RéAC). Cases in which the bystander was an on-duty fire fighter, paramedic, or emergency physician were excluded. We assessed the characteristics of patients who received bystander BLS vs. those who did not. The two classes of patient were then matched 1:1, using a propensity score. Conditional logistic regression was then used to probe the putative association between bystander BLS and survival. RESULTS: During the study, 52,303 patients were included; BLS was provided by a bystander in 29,412 of these cases (56.2%). The 30-day survival rates were 7.6% in the BLS group and 2.5% in the no-BLS group (p < 0.001). After matching, bystander BLS was associated with a greater 30-day survival rate (odds ratio (OR) [95% confidence interval (CI)] = 1.77 [1.58-1.98]). Bystander BLS was also associated with greater short-term survival (alive on hospital admission; OR [95%CI] = 1.29 [1.23-1.36]). CONCLUSIONS: The provision of bystander BLS was associated with a 77% greater likelihood of 30-day survival after OHCA. Given than only one in two OHCA bystanders provides BLS, a greater focus on life saving training for laypeople is essential.

Risk of Admission to the Pediatric Intensive Care Unit for SARS-CoV-2 Delta and Omicron Infections.

BACKGROUND: The severity of SARS-CoV-2-related diseases in children remains unclear. This study aimed to describe the incidence of French pediatric intensive care units (PICUs) admissions with acute COVID-19, incidental positive SARS-CoV-2 test result, and multisystem inflammatory syndrome in children (MIS-C) during the delta and omicron variant periods. METHODS: This study used the French PICU registry to obtain data on all patients admitted to 41 French PICUs diagnosed with acute COVID-19, incidental positive SARS-CoV-2 test result, or MIS-C between August 30, 2021 and April 20, 2022. Data regarding the total number of positive SARS-CoV-2 polymerase chain reaction results according to the type of variants were obtained from the French National Public Health Agency. RESULTS: Of 745 children, 244 (32.8%) were admitted for acute COVID-19, 246 (33.0%) for incidental positive SARS-CoV-2 test results, and 255 (34.2%) for MIS-C. The incidence of each group was higher with delta than with omicron. The incidence rate ratios with the delta variant were 7.47 (95% CI, 4.22-13.26) for acute COVID-19, 4·78 (95% CI, 2.30-9.94) for incidental positive SARS-CoV-2 test results, and 10.46 (95% CI, 5.98-18.31) for MIS-C compared to the omicron variant. The median age was 66 (7.7-126.8) months; 314 (42%) patients had comorbidities. Patients with acute COVID-19 and incidental positive SARS-CoV-2 test results had similar proportions of comorbidities. No patient with MIS-C died, whereas the mortality rates in the acute COVID-19 and incidental positive SARS-CoV-2 test results groups were 6.8% and 3.8%, respectively. CONCLUSIONS: The incidence of acute COVID-19, incidental positive SARS-CoV-2 test results, and MIS-C admitted to the PICU were significantly higher with the delta variant than with the omicron variant.

Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit.

PURPOSE: We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines. METHODS: Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology. RESULTS: This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting. CONCLUSION: These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

Impact of time to diagnosis on the occurrence of cardiogenic shock in MIS-C post-COVID-19 infection.

BACKGROUND: In multisystem inflammatory syndrome in children (MIS-C), diagnostic delay could be associated with severity. This study aims to measure the time to diagnosis in MIS-C, assess its impact on the occurrence of cardiogenic shock, and specify its determinants. METHODS: A single-center prospective cohort observational study was conducted between May 2020 and July 2022 at a tertiary care hospital. Children meeting the World Health Organization MIS-C criteria were included. A long time to diagnosis was defined as six days or more. Data on time to diagnosis were collected by two independent physicians. The primary outcome was the occurrence of cardiogenic shock. Logistic regression and receiver operating characteristic curve analysis were used for outcomes, and a Cox proportional hazards model was used for determinants. RESULTS: Totally 60 children were assessed for inclusion, and 31 were finally analyzed [52% males, median age 8.8 (5.7-10.7) years]. The median time to diagnosis was 5.3 (4.2-6.2) days. In univariable analysis, age above the median, time to diagnosis, high C-reactive protein, and high N-terminal pro-B-type natriuretic peptide (NT-proBNP) were associated with cardiogenic shock [odds ratio (OR) 6.13 (1.02-36.9), 2.79 (1.15-6.74), 2.08 (1.05-4.12), and 1.70 (1.04-2.78), respectively]. In multivariable analysis, time to diagnosis ≥ 6 days was associated with cardiogenic shock [adjusted OR (aOR) 21.2 (1.98-227)]. Time to diagnosis ≥ 6 days had a sensitivity of 89% and a specificity of 77% in predicting cardiogenic shock; the addition of age > 8 years and NT-proBNP at diagnosis ≥ 11,254 ng/L increased the specificity to 91%. Independent determinants of short time to diagnosis were age < 8.8 years [aHR 0.34 (0.13-0.88)], short distance to tertiary care hospital [aHR 0.27 (0.08-0.92)], and the late period of the COVID-19 pandemic [aHR 2.48 (1.05-5.85)]. CONCLUSIONS: Time to diagnosis ≥ 6 days was independently associated with cardiogenic shock in MIS-C. Early diagnosis and treatment are crucial to avoid the use of inotropes and limit morbidity, especially in older children.

Severity of illness and organ dysfunction scoring systems in pediatric critical care: The impacts on clinician's practices and the future.

Severity and organ dysfunction (OD) scores are increasingly used in pediatric intensive care units (PICU). Therefore, this review aims to provide 1/ an updated state-of-the-art of severity scoring systems and OD scores in pediatric critical care, which explains 2/ the performance measurement tools and the significance of each tool in clinical practice and provides 3/ the usefulness, limits, and impact on future scores in PICU. The following two pediatric systems have been proposed: the PRISMIV, is used to collect data between 2 h before PICU admission and the first 4 h after PICU admission; the PIM3, is used to collect data during the first hour after PICU admission. The PELOD-2 and SOFApediatric scores were the most common OD scores available. Scores used in the PICU should help clinicians answer the following three questions: 1/ Are the most severely ill patients dying in my service: a good discrimination allow us to interpret that there are the most severe patients who died in my service. 2/ Does the overall number of deaths observed in my department consistent with the severity of patients? The standard mortality ratio allow us to determine whether the total number of deaths observed in our service over a given period is in adequacy with the number of deaths predicted, by considering the severity of patients on admission? 3/ Does the number of deaths observed by severity level in my department consistent with the severity of patients? The calibration enabled us to determine whether the number of deaths observed according to the severity of patients at PICU admission in a department over a given period is in adequacy with the number of deaths predicted, according to the severity of the patients at PICU admission. These scoring systems are not interpretable at the patient level. Scoring systems are used to describe patients with PICU in research and evaluate the service's case mix and performance. Therefore, the prospect of automated data collection, which permits their calculation, facilitated by the computerization of services, is a necessity that manufacturers should consider.

High dose of epinephrine does not improve survival of children with out-of-hospital cardiac arrest: Results from the French National Cardiac Arrest Registry.

Objectives: The pediatric resuscitation guidelines recommend the use of 0. 01 mg kg-1 epinephrine during a cardiac arrest; an epinephrine dose higher than that is not recommended. The first aim of this study was to determine the administration rate of high epinephrine dose during pediatric out-of-hospital cardiac arrest. The second aim was to compare the survival status in patients who received high or standard doses of epinephrine. Methods: This was a multicenter comparative post-hoc study conducted between January 2011 and July 2021 based on the French National Cardiac Arrest Registry data. All prepubescent (boys < 12 years old, girls < 10 years old) victims of an out-of-hospital cardiac arrest were included. To compare survival status and control bias, patients who received a high epinephrine dose were matched with those who received a standard epinephrine dose using propensity score matching. Results: The analysis included 755 patients; 400 (53%) received a high dose and 355 (47%) received a standard dose of epinephrine. The median dose (mg kg-1) per bolus was higher in the high-dose group than that in the standard dose group (0.04 vs. 0.01 mg kg-1, P < 0.001). Before matching, there was no between-group difference in the 30-day survival rate or survival status at hospital discharge. Matching yielded 288 pairs; there was no between-group difference in the 30-day survival rate or survival at hospital discharge (High dose, n = 5; standard dose, n = 12; Odds ratios: 2.40, 95% confidence interval: 0.85-6.81). Only 2 patients in the standard dose group had a good neurological outcome. Conclusion: More than 50% of the patients did not receive the recommended epinephrine dose during resuscitation. There was no association between patients receiving a high dose or standard dose of epinephrine with the 30-day survival or survival status at hospital discharge. Collaboration across multiple cardiac arrest registries is needed to study the application of pediatric guidelines.

Out-of-hospital cardiac arrest in pregnant women: A 55-patient French cohort study.

AIM: To describe a cohort of pregnant women having suffered an out-of-hospital cardiac arrest (OHCA) and to compare them with nonpregnant women of childbearing age having suffered OHCA. METHODS: Study data were extracted from the French National OHCA Registry between 2011 and 2021. We compared patients in terms of characteristics, care and survival. RESULTS: We included 3,645 women of childbearing age (15-44) who had suffered an OHCA; 55 of the women were pregnant. Pregnant women were younger than nonpregnant victims (30 vs. 35 years, p = 0.006) and were more likely to have a medical history (76.4% vs. 50.5%, p < 0.001) and a medical cause of the OHCA (85.5% vs. 57.2%, p < 0.001). Advanced Life Support was more frequently administered to pregnant women (98.2%, vs. 72.0%; p < 0.001). In pregnant women, the median time of MICU arrival was 20 minutes for the Medical Intensive Care Unit with no difference with nonpregnant women. Survival rate on admission to hospital was higher among pregnant women (43.6% vs. 27.3%; p = 0.009). There was no difference in 30-day survival between pregnant and nonpregnant groups (14.5% vs. 7.3%; p = 0.061). Fetal survival was only observed for OHCAs that occurred during the pregnancy second or third trimester (survival rates: 10.0% and 23.5%, respectively). CONCLUSIONS: Our results show that resuscitation performance does not meet European Resuscitation Council's specific guidelines on OHCA in pregnant women. Although OHCA in pregnancy is rare, the associated prognosis is poor for both woman and fetus. Preventive measures should be reinforced, especially when pregnant women have medical history.

Cardiac involvement in pediatric hemolytic uremic syndrome.

BACKGROUND: Cardiac involvement is a known but rare complication of pediatric hemolytic uremic syndrome (HUS). We conducted a nationwide observational, retrospective case-control study describing factors associated with the occurrence of myocarditis among HUS patients. METHODS: Cases were defined as hospitalized children affected by any form of HUS with co-existent myocarditis in 8 French Pediatric Intensive Care Units (PICU) between January 2007 and December 2018. Control subjects were children, consecutively admitted with any form of HUS without coexistent myocarditis, at a single PICU in Lyon, France, during the same time period. RESULTS: A total of 20 cases of myocarditis were reported among 8 PICUs, with a mean age of 34.3 ± 31.9 months; 66 controls were identified. There were no differences between the two groups concerning the season and the typical, Shiga toxin-producing Escherichia coli (STEC-HUS), or atypical HUS (aHUS). Maximal leukocyte count was higher in the myocarditis group (29.1 ± 16.3G/L versus 21.0 ± 9.9G/L, p = 0.04). The median time between admission and first cardiac symptoms was of 3 days (range 0-19 days), and 4 patients displayed myocarditis at admission. The fatality rate in the myocarditis group was higher than in the control group (40.0% versus 1.5%, p < 0.001). Thirteen (65%) children from the myocarditis group received platelet transfusion compared to 19 (29%) in the control group (p = 0.03). CONCLUSION: Our study confirms that myocarditis is potentially lethal and identifies higher leukocyte count and platelet transfusion as possible risk factors of myocarditis. A higher resolution version of the Graphical abstract is available as Supplementary information.

Impact of puberty as threshold to differentiate outcome of out-of-hospital cardiac arrest care groups: a nationwide observational study in France.

BACKGROUND: Since 2005, the international guidelines for out-of-hospital cardiac arrest (OHCA) use puberty to differentiate paediatric and adult care. This threshold is mainly relied on the more frequent respiratory aetiologies in children. Hitherto, to the best of our knowledge, no study has compared the characteristics and outcomes of non-pubescent children, adolescents and adult patients with OHCA. In this study, we intended to describe the characteristics, outcome and factors associated with survival of patients who experienced OHCA in the three groups: children, adolescents (pubescent<18 years) and adults (<65 years), to assess the pertinence of the guidelines. METHODS: Data from the French national cardiac arrest registry (2012-2017) were used in this nationwide observational study. Victims of OHCA who were <65 years old were included. The characteristics and outcomes of children and adolescents, and adolescents and adults were compared. Logistic regression was performed in each group to identify factors associated with survival at day 30. RESULTS: We included 934 children, 433 adolescents and 26 952 adults. Respiratory aetiology was more frequent and shockable rhythm less frequent in children compared with adolescents (25.5% vs 17.2%, p=0.025 and 2.4% vs 6.8%, p<0.001, respectively). However, these differences were not observed between adolescents and adults (17.2% vs 14.1%, p=0.266 and 6.8% vs 10%, p=0.055, respectively). Between children and adolescents, and adolescents and adults, there was no significant difference in survival at day 30 (8.6%vs 9.8% and 9.8% vs 8.5%, respectively). For all groups, shockable initial rhythm was a factor of survival. CONCLUSION: Frequency of respiratory aetiologies and shockable rhythm were common in adolescents and adults and different between children and adolescents. These results indicate that puberty as a threshold in international guidelines seems to be relevant.

Coronavirus Disease 2019 and Out-of-Hospital Cardiac Arrest: No Survivors.

OBJECTIVES: To describe and compare survival among patients with out-of-hospital cardiac arrest as a function of their status for coronavirus disease 2019. DESIGN: We performed an observational study of out-of-hospital cardiac arrest patients between March 2020 and December 2020. Coronavirus disease 2019 status (confirmed, suspected, or negative) was defined according to the World Health Organization's criteria. SETTING: Information on the patients and their care was extracted from the French national out-of-hospital cardiac arrest registry. The French prehospital emergency medical system has two tiers: the fire department intervenes rapidly to provide basic life support, and mobile ICUs provide advanced life support. The study data (including each patient's coronavirus disease 2019 status) were collected by 95 mobile ICUs throughout France. PATIENTS: We included 6,624 out-of-hospital cardiac arrest patients: 127 cases with confirmed coronavirus disease 2019, 473 with suspected coronavirus disease 2019, and 6,024 negative for coronavirus disease 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The "confirmed" and "suspected" groups of coronavirus disease 2019 patients had similar characteristics and were more likely to have suffered an out-of-hospital cardiac arrest with a respiratory cause (confirmed: 53.7%, suspected coronavirus disease 2019: 56.5%; p = 0.472) than noncoronavirus disease 2019 patients (14.0%; p < 0.001 vs confirmed coronavirus disease 2019 patients). Advanced life support was initiated for 57.5% of the confirmed coronavirus disease 2019 patients, compared with 64.5% of the suspected coronavirus disease 2019 patients (p = 0.149) and 70.6% of the noncoronavirus disease 2019 ones (p = 0.002). The survival rate at 30-day postout-of-hospital cardiac arrest was 0% in the confirmed coronavirus disease 2019 group, 0.9% in the suspected coronavirus disease 2019 group (p = 0.583 vs confirmed), and 3.5% (p = 0.023) in the noncoronavirus disease 2019 group. CONCLUSIONS: Our results highlighted a zero survival rate in out-of-hospital cardiac arrest patients with confirmed coronavirus disease 2019. This finding raises important questions with regard to the futility of resuscitation for coronavirus disease 2019 patients and the management of the associated risks.