RBC transfusion in pediatric patients supported with extracorporeal membrane oxygenation: is there an impact on tissue oxygenation?

OBJECTIVE: To examine first the RBC transfusion practice in pediatric patients supported with extracorporeal membrane oxygenation and second the relationship between transfusion of RBCs and changes in mixed venous saturation (SvO2) and cerebral regional tissue oxygenation, as measured by near-infrared spectroscopy in patients supported with extracorporeal membrane oxygenation. DESIGN: Retrospective observational study. SETTING: Pediatric, cardiovascular, and neonatal ICUs of a tertiary care children's hospital. PATIENTS: All pediatric patients supported with extracorporeal membrane oxygenation between January 1, 2010, and December 31, 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 45 patients supported with extracorporeal membrane oxygenation. The median (interquartile range) phlebotomy during extracorporeal membrane oxygenation was 75 mL/kg (33, 149 mL/kg). A total of 617 transfusions were administered (median, 9 per patient; range = 1-57). RBC volumes transfused during extracorporeal membrane oxygenation support were 254 mL/kg (136, 557) and 267 mL/kg (187, 393; p = 0.82) for cardiac and noncardiac patients, respectively. Subtracting the volume of RBCs used for extracorporeal membrane oxygenation circuit priming, median RBC transfusion volumes were 131 and 80 mL/kg for cardiac and noncardiac patients, respectively (p = 0.26). The cardiac surgical patients received the most RBCs (529 vs 74 mL/kg for nonsurgical cardiac patients). The median hematocrit maintained during extracorporeal membrane oxygenation support was 37%, with no difference between cardiac and noncardiac patients. Patients supported with extracorporeal membrane oxygenation were exposed to a median of 10.9 (range, 3-43) individual donor RBC units. Most transfusions resulted in no significant change in either SvO2 or cerebral near-infrared spectroscopy. Only 5% of transfusions administered (31/617) resulted in an increase in SvO2 of more than 5%, whereas an increase in cerebral near-infrared spectroscopy of more than 5 was only observed in 9% of transfusions (53/617). Most transfusions (73%) were administered at a time when the pretransfusion SvO2 was more than 70%. CONCLUSIONS: Patients supported with extracorporeal membrane oxygenation were exposed to large RBC transfusion volumes for treatment of mild anemia resulting from blood loss, particularly phlebotomy. In the majority of events, RBC transfusion did not significantly alter global tissue oxygenation, as assessed by changes in SvO2 and cerebral near-infrared spectroscopy. Most transfusions were administered at a time at which the patient did not appear to be oxygen delivery dependent according to global measures of tissue oxygenation.

von Willebrand factor multimers in pediatric extracorporeal membrane oxygenation support.

Acquired von Willebrand factor (vWF) disease is associated with a decrease in the amount of circulating high molecular weight (HMW) vWF multimers. vWF has not been previously investigated in children on extracorporeal membrane oxygenation (ECMO) support. We hypothesized that HMW vWF multimers and vWF activity decrease over the course of ECMO support in these patients. This prospective, single center, observational, cohort pilot study was carried out between December 2010 and April 2011 and included patients 0 to 18 years old requiring ECMO support at our institution. Blood samples were tested for various aspects of vWF. Mean and standard deviation were estimated for vWF activity and multimers, whereas a generalized linear model was developed to estimate multimer changes over time.The study included six pediatric patients. The mean age of the patients was 54.9 ± 55.3 (mean ± standard deviation) months. The mean HMW vWF multimer percentage was 23.4 ± 7.3 in the pre-ECMO samples and significantly decreased over time (p<0.003). There was no significant change in low molecular weight vWF multimer percentage. An immediate decrease in vWF HMW multimers as a percentage of all multimers once ECMO is initiated was noted and persisted across the study period.

Extracorporeal membrane oxygenation support among children with adenovirus infection: a review of the Extracorporeal Life Support Organization registry.

Overwhelming adenovirus infection requiring extracorporeal membrane oxygenation (ECMO) support carries a high mortality in pediatric patients. The objective of this study was to retrospectively review data from the Extracorporeal Life Support Organization (ELSO) registry for pediatric patients with adenovirus infection and define for this patient cohort: 1) clinical characteristics, 2) survival to hospital discharge, and 3) factors associated with mortality before hospital discharge. In this retrospective registry study, pediatric patients with adenovirus infection requiring ECMO support identified in an international ECMO registry from 1998 to 2009 were compared for clinical characteristics (demographics, pre-ECMO variables, and complications on ECMO) between survivors and nonsurvivors to hospital discharge. Descriptive statistics and univariate and multivariate logistic analysis were used to compare clinical characteristics among survivors and nonsurvivors. For children requiring ECMO support for adenovirus, the survival at hospital discharge is 38% (62/163). Among neonates (<31 days of age), the survival at hospital discharge was only 11% (6/54). Among patient factors, neonatal age (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.62-10.87), a decrease of 0.1 unit in pre-ECMO pH (OR, 1.77; 95% CI, 1.3-2.42), the presence of sepsis (OR, 4.55; 95% CI, 1.47-14.15), and increased peak inspiratory pressures (OR, 1.04; 95% CI, 1.01-1.08) were all independently associated with in-hospital mortality. ECMO complications independently associated with in-hospital mortality were presence of pneumothorax (OR, 3.57; 95% CI, 1.19-10.7), pH less than 7.2 (OR, 5.94; 95% CI, 1.04-34.1), and central nervous system hemorrhage (OR, 25.36; 95% CI, 1.47-436.7). In this retrospective cohort study of pediatric patients with adenovirus infection supported on ECMO, survival to hospital discharge was 38% but was much lower in neonates. Neonatal presentation, degree of acidosis, sepsis, and increased PIP are factors present before decisions are made regarding a trial of ECMO, whereas pneumothorax and brain hemorrhage were ECMO-related complications independently associated with mortality.

Fungal infections and antifungal prophylaxis in pediatric cardiac extracorporeal life support.

OBJECTIVE: Infections acquired by children during extracorporeal membrane oxygenation (ECMO) increase mortality. Our aim was to evaluate the effectiveness of prophylactic fluconazole on the incidence of fungal infections and to assess whether hospital-acquired fungal infection is associated with increased in-hospital mortality in pediatric cardiac patients requiring ECMO. METHODS: We retrospectively reviewed a prospectively maintained database and collected data on all hospital-acquired infections in patients supported for cardiac indications at a tertiary children's hospital from 1989 to 2008. RESULTS: ECMO was deployed 801 times in 767 patients. After exclusion criteria were applied, 261 pediatric patients supported for cardiac indications were studied. Fungal infection (blood, urine, or surgical site) occurred in 12% (31/261) of patients, 9 (7%) of 127 patients receiving fluconazole prophylaxis versus 22 (16.4%) of 134 without antifungal prophylaxis (P = .02). Using a multivariable logistic regression model, the absence of fluconazole prophylaxis was associated with an increased risk of fungal infection (odds ratio [OR] = 2.8; 95% confidence intervals [CI], 1.2, 6.7; P = .016). In a multivariable logistic regression model for in-hospital mortality, the presence of fungal infection was associated with increased odds (OR = 3.8; 95% CI, 1.5, 9.6; P = .005) of in-hospital mortality among cardiac patients requiring ECMO, and the absence of antifungal prophylaxis showed a trend toward the same (OR = 1.6; 95% CI, 0.96, 2.8; P = .072). CONCLUSIONS: Children with cardiac disease supported with ECMO who acquire fungal infections have increased mortality. Routine fluconazole prophylaxis is associated with lower rates of fungal infections in these patients.

Impact of neutrophil recovery on oxygenation in pediatric oncology patients with acute hypoxemic respiratory failure.

Neutrophil recovery has been implicated in deterioration of oxygenation and exacerbation of lung injury in pediatric oncology patients. Our objectives were to determine the impact of neutrophil recovery on oxygenation in pediatric oncology patients with acute hypoxemic respiratory failure (AHRF) and to identify risk factors that result in oxygenation worsening. A cohort of 24 neutropenic pediatric oncology patients with AHRF in whom neutrophil recovery occurred during a course of mechanical ventilation was evaluated. Oxygenation index (OI) and PaO(2)/FiO(2) ratio showed a trend of improvement after neutrophil recovery. Mean PaO(2)/FiO(2) pre-recovery was 205±48.67 versus 225±72.24 postrecovery (P=0.08), whereas mean pre-recovery OI was 9.39±0.96 compared with 8.31±1.1 postrecovery (P=0.078). Seven episodes (24% of the total episodes) of recovery were characterized by worsening of oxygenation. Tripling absolute neutrophil count on Day+2 compared with Day+1 postrecovery was associated with 28-fold increase in risk of oxygenation worsening. In conclusion, resolution of neutropenia lead to significant deterioration of oxygenation in 24% of episodes of neutrophil recovery in a pediatric oncology cohort with AHRF. Our findings suggest that a faster ANC increment in the 2 days after recovery is associated with an increased risk of oxygenation worsening.

Interhospital transport of children requiring extracorporeal membrane oxygenation support for cardiac dysfunction.

OBJECTIVE: Many centers are able to emergently deploy extracorporeal membrane oxygenation (ECMO) as support in children with refractory hemodynamic instability, but may be limited in their ability to provide prolonged circulatory support or cardiac transplantation. Such patients may require interhospital transport while on ECMO (cardiac mobile [CM]-ECMO) for additional hemodynamic support or therapy. There are only three centers in the United States that routinely perform CM-ECMO. Our center has a 20-year experience in carrying out such transports. The purpose of this study was twofold: (1) to review our experience with pediatric cardiac patients undergoing CM-ECMO and (2) identify risk factors for a composite outcome (defined as either cardiac transplantation or death) among children undergoing CM-ECMO. DESIGN: Retrospective case series. SETTING: Cardiovascular intensive care and pediatric transport system. PATIENTS: Children (n = 37) from 0-18 years undergoing CM-ECMO transports (n = 38) between January 1990 and September 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 38 CM-ECMO transports were performed for congenital heart disease (n = 22), cardiomyopathy (n = 11), and sepsis with myocardial dysfunction (n = 4). There were 18 survivors to hospital discharge. Twenty-two patients were transported a distance of more than 300 miles from our institution. Ten patients were previously cannulated and on ECMO prior to transport. Thirty-five patients were transported by air and two by ground. Six patients underwent cardiac transplantation, all of whom survived to discharge. After adjusting for other covariates post-CM-ECMO renal support was the only variable associated with the composite outcome of death/need for cardiac transplant (odds ratio = 13.2; 95% confidence interval, 1.60--108.90; P = 0.003). There were two minor complications (equipment failure/dysfunction) and no major complications or deaths during transport. CONCLUSIONS: Air and ground CM-ECMO transport of pediatric patients with refractory myocardial dysfunction is safe and effective. In our study cohort, the need for post-CM-ECMO renal support was associated with the composite outcome of death/need for cardiac transplant.

Single-institution experience with interhospital extracorporeal membrane oxygenation transport: A descriptive study.

OBJECTIVE: Patients with refractory cardiopulmonary failure may benefit from extracorporeal membrane oxygenation, but extracorporeal membrane oxygenation is not available in all medical centers. We report our institution's nearly 20-yr experience with interhospital extracorporeal membrane oxygenation transport. DESIGN: Retrospective review. SETTING: Quaternary care children's hospital. PATIENTS: All patients undergoing interhospital extracorporeal membrane oxygenation transport by the Arkansas Children's Hospital extracorporeal membrane oxygenation team. INTERVENTIONS: Data (age, weight, diagnosis, extracorporeal membrane oxygenation course, hospital course, mode of transport, and outcome) were obtained and compared with the most recent Extracorporeal Life Support Organization Registry report. RESULTS: Interhospital extracorporeal membrane oxygenation transport was provided to 112 patients from 1990 to 2008. Eight were transferred between outside facilities (TAXI group); 104 were transported to our hospital (RETURN group). Transport was by helicopter (75%), ground (12.5%), and fixed wing (12.5%). No patient died during transport. Indications for extracorporeal membrane oxygenation in RETURN patients were cardiac failure in 46% (48 of 104), neonatal respiratory failure in 34% (35 of 104), and other respiratory failure in 20% (21 of 104). Overall survival from extracorporeal membrane oxygenation for the RETURN group was 71% (74 of 104); overall survival to discharge was 58% (61 of 104). Patients with cardiac failure had a 46% (22 of 48) rate of survival to discharge. Neonates with respiratory failure had an 80% (28 of 35) rate of survival to discharge. Other patients with respiratory failure had a 62% (13 of 21) rate of survival to discharge. None of these survival rates were statistically different from survival rates for in-house extracorporeal membrane oxygenation patients or for survival rates reported in the international Extracorporeal Life Support Organization Registry (p > .1 for all comparisons). CONCLUSIONS: Outcomes of patients transported by an experienced extracorporeal membrane oxygenation team to a busy extracorporeal membrane oxygenation center are very comparable to outcomes of nontransported extracorporeal membrane oxygenation patients as reported in the Extracorporeal Life Support Organization registry. As has been previously reported, interhospital extracorporeal membrane oxygenation transport is feasible and can be accomplished safely. Other experienced extracorporeal membrane oxygenation centers may want to consider developing interhospital extracorporeal membrane oxygenation transport capabilities to better serve patients in different geographic regions.

Neonatal herpes virus infection and extracorporeal life support.

OBJECTIVES: To investigate outcomes among neonates with herpes virus infection reported to the Extracorporeal Life Support Organization (ELSO) Registry and analyze factors associated with death before hospital discharge with this virus. Currently, scant data exist regarding extracorporeal membrane oxygenation support in neonates with herpes virus infection. DESIGN: Retrospective analysis of ELSO Registry data set from 1985 to 2005. SETTING: A total of 114 extracorporeal membrane oxygenation centers contributing data to the ELSO Registry. PATIENTS: Patients, 0 to 31 days of age, with herpes simplex virus infection supported with extracorporeal membrane oxygenation and reported to the ELSO Registry. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical characteristics, outcomes, and factors associated with death before hospital discharge were investigated for patients in the virus group. Kaplan-Meier estimates of survival to hospital discharge according to virus type were investigated. Newborns with herpes simplex virus infection requiring extracorporeal membrane oxygenation support demonstrated much lower hospital survival rates (25%). Clinical presentation with septicemia/shock was significantly associated with mortality for the herpes simplex virus group on multivariate analysis. There was no difference in herpes simplex virus mortality when comparing two eras (> or =2000 vs. <2000). CONCLUSIONS: In this cohort of neonatal patients with overwhelming infections due to herpes simplex virus who were supported with extracorporeal membrane oxygenation, survival was dismal. Patients with disseminated herpes simplex virus infection presenting with septicemia/shock are unlikely to survive, even with aggressive extracorporeal support.

Intrahospital transport of children on extracorporeal membrane oxygenation: indications, process, interventions, and effectiveness.

OBJECTIVE: To evaluate indications, process, interventions, and effectiveness of patients undergoing intrahospital transport. Critically ill patients supported with extracorporeal membrane oxygenation are transported within the hospital to the radiology suite, cardiac catheterization suite, operating room, and from one intensive care unit to another. No studies to date have systematically evaluated intrahospital transport for patients on extracorporeal membrane oxygenation. DESIGN: Retrospective cohort analysis. SETTING: Cardiac intensive care unit in a tertiary care children's hospital. PATIENTS: All patients on extracorporeal membrane oxygenation who required intrahospital transport between January 1996 and March 2007 were included and analyzed. MEASUREMENTS AND MAIN RESULTS: A total of 57 intrahospital transports for cardiac catheterization and head computed tomography scans were analyzed. In 14 (70%) of 20 of patients with cardiac catheterization, a management change occurred as a result of the diagnostic cardiac catheterization. In ten (59%) of 17 patients, bedside echocardiography was of limited value in defining the critical problem. In the interventional group, the majority of transports were for atrial septostomy. In the head computed tomography group, significant pathology was identified, which led to management change. No major complications occurred during these intrahospital transports. CONCLUSIONS: Although transporting patients on extracorporeal membrane oxygenation is labor intensive and requires extensive logistic support, it can be carried out safely in experienced hands and it can result in important therapeutic and diagnostic yields. To our knowledge, this is the first study designed to evaluate safety and efficacy of intrahospital transport for patients receiving extracorporeal membrane oxygenation support.

Outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) following refractory pediatric cardiac arrest in the intensive care unit.

AIM: To describe our experience using extracorporeal cardiopulmonary resuscitation (ECPR) in resuscitating children with refractory cardiac arrest in the intensive care unit (ICU) and to describe hospital survival and neurologic outcomes after ECPR. METHODS: A retrospective chart review of a consecutive case series of patients requiring ECPR from 2001 to 2006 at Arkansas Children's Hospital. Data from medical records was abstracted and reviewed. Primary study outcomes were survival to hospital discharge and neurological outcome at hospital discharge. RESULTS: During the 6-year study period, ECPR was deployed 34 times in 32 patients. 24 deployments (73%) resulted in survival to hospital discharge. Twenty-eight deployments (82%) were for underlying cardiac disease, 3 for neonatal non-cardiac (NICU) patients and 3 for paediatric non-cardiac (PICU) patients. On multivariate logistic regression analysis, only serum ALT (p-value=0.043; OR, 1.6; 95% confidence interval, 1.014-2.527) was significantly associated with risk of death prior to hospital discharge. Blood lactate at 24h post-ECPR showed a trend towards significance (p-value=0.059; OR, 1.27; 95% confidence interval, 0.991-1.627). The Hosmer-Lemeshow tests (p-value=0.178) suggested a good fit for the model. Neurological evaluation of the survivors revealed that there was no change in PCPC scores from a baseline of 1-2 in 18/24 (75%) survivors. CONCLUSIONS: ECPR can be used successfully to resuscitate children following refractory cardiac arrest in the ICU, and grossly intact neurologic outcomes can be achieved in a majority of cases.

Extracorporeal cardiopulmonary resuscitation in refractory pediatric cardiac arrest.

The purpose of this article is to discuss the indications for extracorporeal cardiopulmonary resuscitation (ECPR), physiologic and mechanical issues that arise in patients managed with ECPR, and optimal patient selection for ECPR. ECPR can provide very good outcomes for some children who, in all likelihood, would otherwise have died. Having the capability to routinely offer ECPR represents an enormous institutional commitment of people and resources. For ECPR to be successful, it must be rapidly deployed, patients must be selected with care, and consistently excellent conventional CPR must take place while awaiting ECPR.

Changes in outcomes (1996-2004) for pediatric oncology and hematopoietic stem cell transplant patients requiring invasive mechanical ventilation.

OBJECTIVE: To assess the following hypotheses regarding mechanically ventilated pediatric oncology patients, including those receiving hematopoietic stem cell transplant (HSCT) and those not receiving HSCT: 1) outcomes are more favorable for nontransplant oncology patients than for those requiring HSCT; 2) outcomes have improved for both populations over time; and 3) there are factors available during the time of mechanical ventilation that identify patients with a higher likelihood of dying. DESIGN: Retrospective review. SETTING: Free-standing, tertiary care, pediatric hematology oncology hospital. PATIENTS: All patients requiring invasive mechanical ventilation with a diagnosis of cancer or following HSCT from January 1996 to December 2004. INTERVENTIONS: Bivariate and multivariate analysis. Dates of admission were grouped into time periods for analysis: 1996-1998, 1999-2001, and 2002-2004. MEASUREMENTS AND MAIN RESULTS: There were 401 courses of mechanical ventilation (329 patients) analyzed. Forty-five percent of HSCT admissions (92 of 206) vs. 75% of non-HSCT oncology admissions (146 of 195) were extubated and discharged from the pediatric intensive care unit (p < .0001). Twenty-five percent of HSCT vs. 60% of non-HSCT admissions survived 6 months (p < .0001). Among admissions with an abnormal chest radiograph and a PaO2/FiO2 ratio <200, pediatric intensive care unit survival increased for each successive time period, with 45% of HSCT and 83% of non-HSCT admissions surviving during 2002-2004. In multivariate analysis of all study patients, Pediatric Risk of Mortality scores on the day of intubation, allogeneic HSCT, cardiovascular failure, hepatic failure, neurologic failure, a previous course of mechanical ventilation within 6 months, and the time period intubated were associated with mortality. With the exception of time period, these same variables were associated with mortality in multivariate analysis of only HSCT patients. CONCLUSIONS: HSCT patients who require mechanical ventilation have worse outcomes than non-HSCT oncology patients. Outcomes for both groups have improved over time. Allogeneic transplant, higher Pediatric Risk of Mortality scores, need for repeated mechanical ventilation, and concomitant organ system dysfunction are risk factors for death.

Successful use of extracorporeal membrane oxygenation in severe necrotizing pneumonia caused by Staphylococcus aureus.

OBJECTIVE: To report the successful use of extracorporeal membrane oxygenation (ECMO) as rescue therapy for severe necrotizing pneumonia secondary to infection by the Staphylococcus aureus species. DESIGN: Case series. SETTING: Pediatric intensive care unit at a freestanding tertiary care children's hospital. PATIENTS: Two pediatric patients with severe S. aureus-induced necrotizing pneumonia requiring rescue with ECMO. Both patients survived with good neurologic outcomes. One patient required the use of activated factor VII for severe bleeding while on ECMO, with no thrombotic effect on the ECMO circuit. CONCLUSION: ECMO as rescue support should be considered in a timely fashion for refractory hypoxemic respiratory failure resulting from S. aureus pneumonia, including patients with necrotizing pneumonia. Use of ECMO support in such cases, coupled with aggressive measures aimed at minimizing bleeding, such as the use of activated factor VII, may result in excellent short- and long-term outcomes for such patients.

Ruptured tricuspid valve papillary muscle: a treatable cause of neonatal cyanosis.

Severe tricuspid regurgitation resulting from a flail leaflet is a rare cause of neonatal cyanosis. We report two neonates with profound cyanosis and severe tricuspid regurgitation caused by rupture of the papillary muscle supporting the anterior leaflet, without other structural heart defects. Ductal patency could not be established. Repair of the tricuspid valve was performed by reimplantation of the ruptured papillary muscle head, after initial stabilization using extracorporeal membrane oxygenation. Early recognition and treatment of this otherwise fatal condition can be lifesaving.

Outcome of severe sepsis in pediatric oncology patients.

OBJECTIVE: To describe survival to intensive care unit (ICU) discharge and 6-month survival in a large cohort of pediatric oncology patients with severe sepsis. DESIGN: Retrospective analysis. SETTING: The ICU of a single pediatric oncology center. PATIENTS: Patients with cancer admitted to the ICU of St. Jude Children's Research Hospital between January 1, 1990, and December 31, 2002, who met the following criteria: 1) severe sepsis by ACCP/SCCM (American College of Chest Physicians/Society of Critical Care Medicine) Consensus Conference criteria and 2) receipt of fluid boluses of > or =30 mL/kg to correct hypoperfusion or receipt of a dopamine infusion of >5 microg.kg.min for inotropic support. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data evaluated were demographic variables, oncologic diagnosis and time from diagnosis to ICU admission, Pediatric Risk of Mortality III score and absolute neutrophil count at admission, use of inotropes or pressors, use of mechanical ventilation, maximum organ system failure score, blood culture results, survival to ICU discharge, and 6-month survival. We identified 446 ICU admissions of 359 eligible patients. Overall ICU mortality was 76 of 446 (17%): 40 of 132 (30%) in post-bone marrow transplant (BMT) admissions and 36 of 314 (12%) in non-BMT admissions (p < .0001). In the 106 admissions requiring both mechanical ventilation and inotropic support, ICU mortality was 68 of 106 (64%). Regarding individual patients, 6-month survival was 170 of 248 (69%) among non-BMT patients vs. 43 of 111 (39%) for BMT patients (p < .001). When the 38 patients who survived to ICU discharge after requiring both mechanical ventilation and inotropic/vasopressor support are considered, 27 (71%) were alive 6 months after ICU discharge (22 of 27 [81%] non-BMT vs. 5 of 27 BMT [19%; p < .001]). ICU mortality varied by causative pathogen, from 63% for fungal sepsis (12 of 19) to 9% (5 of 53) for Gram-negative sepsis. Logistic regression analysis of factors significantly associated with ICU mortality in admissions requiring both mechanical ventilation and inotropic support identified four variables: BMT (odds ratio, 2.9; 95% confidence interval, 1.1-7.4; p = .03); fungal sepsis (odds ratio, 10.7; 95% confidence interval, 1.2-94.4; p = .03); use of multiple inotropes (odds ratio, 4.1; 95% confidence interval, 1.4-11.8; p = .01); and Pediatric Risk of Mortality III score (odds ratio, 1.1; 95% confidence interval, 1.0-1.2; p = .04). CONCLUSIONS: In a large series of pediatric oncology patients with severe sepsis, ICU mortality was only 17% overall, although mortality remained quite high in the higher acuity patients. Mortality among the higher acuity patients was significantly associated with only a small number of variables. The number of patients alive at 6 months and the encouraging ICU survival rate further justifies the use of aggressive ICU interventions in this population.

Fibrosing mediastinitis secondary to zygomycosis in a twenty-two-month-old child.

We report the case of a 22-month-old immunocompetent male child with fibrosing mediastinitis secondary to zygomycosis, an unusual presentation of a rare fungal infection. This patient was successfully treated with amphotericin B and itraconazole for 20 weeks. Stenting of the superior vena cava was helpful in relieving the patient's superior vena cava syndrome.

Munchausen syndrome by proxy in the pediatric intensive care unit: An unusual mechanism.

OBJECTIVE: To present a case of Munchausen syndrome by proxy (MSbP) by a previously unreported mechanism, discussing the occurrence of MSbP in patients in the pediatric intensive care unit (PICU) and the use of covert video surveillance in the diagnosis of MSbP. DESIGN: Report of one case of a child who was proven to be the victim of MSbP while hospitalized in a PICU. SETTING: A six-bed PICU in a military teaching hospital. PATIENTS: One patient hospitalized for evaluation of confusing symptoms, later shown to be the victim of MSbP while on mechanical ventilation in the PICU. The mechanism of MSbP was intentional tracheal extubation by the patient's mother. INTERVENTIONS: Covert video surveillance. MEASUREMENTS AND MAIN RESULTS: After initiation of covert video surveillance in the PICU, the diagnosis of MSbP was confirmed. The patient recovered with some physical sequelae. CONCLUSIONS: Children can be victims of MSbP even in a closely monitored PICU. Covert video surveillance was crucial to confirming the diagnosis.