Association of Early vs Late Tracheostomy Placement With Pneumonia and Ventilator Days in Critically Ill Patients: A Meta-analysis.

Importance: The timing of tracheostomy placement in adult patients undergoing critical care remains unestablished. Previous meta-analyses have reported mixed findings regarding early vs late tracheostomy placement for ventilator-associated pneumonia (VAP), ventilator days, mortality, and length of intensive care unit (ICU) hospitalization. Objective: To compare the association of early (≤7 days) vs late tracheotomy with VAP and ventilator days in critically ill adults. Data Sources: A search of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, references of relevant articles, previous meta-analyses, and gray literature from inception to March 31, 2020, was performed. Study Selection: Randomized clinical trials comparing early and late tracheotomy with any of our primary outcomes, VAP or ventilator days, were included. Data Extraction and Synthesis: Two independent reviewers conducted all stages of the review. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Pooled odds ratios (ORs) or the mean difference (MD) with 95% CIs were calculated using a random-effects model. Main Outcomes and Measures: Primary outcomes included VAP and duration of mechanical ventilation. Intensive care unit days and mortality (within the first 30 days of hospitalization) constituted secondary outcomes. Results: Seventeen unique trials with a cumulative 3145 patients (mean [SD] age range, 32.9 [12.7] to 67.9 [17.6] years) were included in this review. Individuals undergoing early tracheotomy had a decrease in the occurrence of VAP (OR, 0.59 [95% CI, 0.35-0.99]; 1894 patients) and experienced more ventilator-free days (MD, 1.74 [95% CI, 0.48-3.00] days; 1243 patients). Early tracheotomy also resulted in fewer ICU days (MD, -6.25 [95% CI, -11.22 to -1.28] days; 2042 patients). Mortality was reported for 2445 patients and was comparable between groups (OR, 0.66 [95% CI, 0.38-1.15]). Conclusions and Relevance: Compared with late tracheotomy, early intervention was associated with lower VAP rates and shorter durations of mechanical ventilation and ICU stay, but not with reduced short-term, all-cause mortality. These findings have substantial clinical implications and may result in practice changes regarding the timing of tracheotomy in severely ill adults requiring mechanical ventilation.

Multisystem inflammatory syndrome in children: A systematic review.

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C), also known as pediatric inflammatory multisystem syndrome, is a new dangerous childhood disease that is temporally associated with coronavirus disease 2019 (COVID-19). We aimed to describe the typical presentation and outcomes of children diagnosed with this hyperinflammatory condition. METHODS: We conducted a systematic review to communicate the clinical signs and symptoms, laboratory findings, imaging results, and outcomes of individuals with MIS-C. We searched four medical databases to encompass studies characterizing MIS-C from January 1st, 2020 to July 25th, 2020. Two independent authors screened articles, extracted data, and assessed risk of bias. This review was registered with PROSPERO CRD42020191515. FINDINGS: Our search yielded 39 observational studies (n = 662 patients). While 71·0% of children (n = 470) were admitted to the intensive care unit, only 11 deaths (1·7%) were reported. Average length of hospital stay was 7·9 ± 0·6 days. Fever (100%, n = 662), abdominal pain or diarrhea (73·7%, n = 488), and vomiting (68·3%, n = 452) were the most common clinical presentation. Serum inflammatory, coagulative, and cardiac markers were considerably abnormal. Mechanical ventilation and extracorporeal membrane oxygenation were necessary in 22·2% (n = 147) and 4·4% (n = 29) of patients, respectively. An abnormal echocardiograph was observed in 314 of 581 individuals (54·0%) with depressed ejection fraction (45·1%, n = 262 of 581) comprising the most common aberrancy. INTERPRETATION: Multisystem inflammatory syndrome is a new pediatric disease associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that is dangerous and potentially lethal. With prompt recognition and medical attention, most children will survive but the long-term outcomes from this condition are presently unknown. FUNDING: Parker B. Francis and pilot grant from 2R25-HL126140. Funding agencies had no involvement in the study.

COVID-19 in 7780 pediatric patients: A systematic review.

BACKGROUND: Studies summarizing the clinical picture of COVID-19 in children are lacking. This review characterizes clinical symptoms, laboratory, and imaging findings, as well as therapies provided to confirmed pediatric cases of COVID-19. METHODS: Adhering to PRISMA guidelines, we searched four medical databases (PubMed, LitCovid, Scopus, WHO COVID-19 database) between December 1, 2019 to May 14, 2020 using the keywords "novel coronavirus", "COVID-19" or "SARS-CoV-2". We included published or in press peer-reviewed cross-sectional, case series, and case reports providing clinical signs, imaging findings, and/or laboratory results of pediatric patients who were positive for COVID-19. Risk of bias was appraised through the quality assessment tool published by the National Institutes of Health. PROSPERO registration # CRD42020182261. FINDINGS: We identified 131 studies across 26 countries comprising 7780 pediatric patients. Although fever (59·1%) and cough (55·9%) were the most frequent symptoms 19·3% of children were asymptomatic. Patchy lesions (21·0%) and ground-glass opacities (32·9%) depicted lung radiograph and computed tomography findings, respectively. Immunocompromised children or those with respiratory/cardiac disease comprised the largest subset of COVID-19 children with underlying medical conditions (152 of 233 individuals). Coinfections were observed in 5.6% of children and abnormal laboratory markers included serum D-dimer, procalcitonin, creatine kinase, and interleukin-6. Seven deaths were reported (0·09%) and 11 children (0·14%) met inclusion for multisystem inflammatory syndrome in children. INTERPRETATION: This review provides evidence that children diagnosed with COVID-19 have an overall excellent prognosis. Future longitudinal studies are needed to confirm our findings and better understand which patients are at increased risk for developing severe inflammation and multiorgan failure. FUNDING: Parker B. Francis and pilot grant from 2R25-HL126140. Funding agencies had no involvement in the study.