This study of targeted temperature interventions in 295 children who were comatose after cardiac arrest showed no significant difference between the hypothermia group (33.0°C) and the normothermia ...group (36.8°C) with respect to 1-year survival with a good functional outcome.
Out-of-hospital cardiac arrest in children often results in death or in poor long-term functional outcome in survivors.
1
–
3
In 2002, two trials involving adults showed that therapeutic hypothermia improved neurologic outcomes in comatose survivors after out-of-hospital cardiac arrest with ventricular fibrillation or ventricular tachycardia.
4
,
5
International guidelines recommend therapeutic hypothermia for adults with out-of-hospital cardiac arrest who have similar characteristics.
6
,
7
Recently, another trial involving adults after out-of-hospital cardiac arrest showed that therapeutic hypothermia with the use of a target temperature of 33°C, as compared with actively maintained therapeutic normothermia (36°C), did not improve outcomes.
8
The fundamental difference between this . . .
Initially, children were thought to be spared from disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, a month into the epidemic, a novel multisystem inflammatory ...syndrome in children (MIS-C) emerged. Herein, we report on the immune profiles of nine MIS-C cases. All MIS-C patients had evidence of prior SARS-CoV-2 exposure, mounting an antibody response with intact neutralization capability. Cytokine profiling identified elevated signatures of inflammation (IL-18 and IL-6), lymphocytic and myeloid chemotaxis and activation (CCL3, CCL4, and CDCP1), and mucosal immune dysregulation (IL-17A, CCL20, and CCL28). Immunophenotyping of peripheral blood revealed reductions of non-classical monocytes, and subsets of NK and T lymphocytes, suggesting extravasation to affected tissues. Finally, profiling the autoantigen reactivity of MIS-C plasma revealed both known disease-associated autoantibodies (anti-La) and novel candidates that recognize endothelial, gastrointestinal, and immune-cell antigens. All patients were treated with anti-IL-6R antibody and/or IVIG, which led to rapid disease resolution.
Display omitted
•The MIS-C anti-SARS-CoV-2 antibody repertoire resembles a convalescent response•Cytokine profiling indicates myeloid cell chemotaxis and mucosal inflammation•Mass cytometry uncovers immune cell activation and egress to the periphery•MIS-C autoantibodies target organ systems central to MIS-C pathology
Insights into the cellular and serological immune dysfunction underlying MIS-C, a novel pediatric inflammatory syndrome associated with SARS-CoV-2 infection, reveal potential autoantibodies that may link organ systems relevant to pathology.
In this report, we describe the case of a 5-year-old male with SARS-CoV-2 associated MIS-C with progressive respiratory failure and vasoplegic shock requiring extracorporeal support. At presentation, ...reverse transcription-polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 was negative, however, SARS-CoV2 antibody testing was positive. Multiple inflammatory markers and cardiac biomarkers were elevated. Echocardiogram demonstrated mildly depressed left ventricular function and no coronary anomalies noted. The patient required mechanical ventilation, vasopressors, and eventually extracorporeal membrane oxygenation (ECMO) for profound circulatory shock and progressive respiratory failure. During his clinical course, recovery of cardiac function was demonstrated however, a middle cerebral artery infarct and left frontal subarachnoid hemorrhage was suffered which ultimately the patient succumbed to. To the best of our knowledge, this is the youngest previously healthy child who had multi-system hyperinflammatory syndrome requiring ECMO support and the first case of SARS-CoV-2 related pediatric stroke.
Clinical Trial Registration: None
Summary
Background
Assessment of pulmonary blood flow and cardiac output is critical in the postoperative management of patients with single‐ventricle physiology or 2‐ventricle physiology with ...intracardiac shunting. Currently, such hemodynamic data are only obtainable by invasive procedures, such as cardiac catheterization or the use of a pulmonary artery catheter. Ready availability of such information, especially if attainable noninvasively, could be a valuable addition to postoperative management.
Aims
The aim of this study was to assess the correlation between volume of CO2 elimination obtained by volumetric capnography and pulmonary blood flow in pediatric patients with single‐ventricle physiology after stage 1 palliation as well as in patients with other cardiac lesions associated with intracardiac shunting.
Methods
This prospective cohort study included children with congenital or acquired heart disease who underwent cardiac catheterization as part of clinical care. Cardiac output, pulmonary blood flow, and volume of CO2 elimination were simultaneously collected. Spearman's rank correlation coefficients were used to assess correlation between measurements after controlling for minute ventilation.
Results
Thirty‐five patients were enrolled and divided into 3 groups. Group 1 (n = 8) included single‐ventricle patients after stage 1 palliation. Group 2 (n = 10) patients had structural heart disease with 2 ventricles and intracardiac shunting. Group 3 (n = 17) had structurally normal hearts. Among Group 1 patients, the correlation coefficients (R2) between volume of CO2 elimination and pulmonary blood flow and volume of CO2 elimination and cardiac output were 0.60 (P = .02) 95% CI 0.01‐0.79 and 0.29 (P = .74) 95% CI −0.91 ‐ 0.86, respectively. In patients with 2 ventricles associated with intracardiac shunts (Group 2), the correlation coefficients between volume of CO2 elimination and pulmonary blood flow and volume of CO2 elimination and cardiac output were 0.86 (P = .001) 95% CI 0.53 ‐ 0.97 and 0.73 (P = .001) 95% CI 0.29 ‐ 0.95, respectively. Among Group 3 patients, the correlation coefficient between volume of CO2 elimination and pulmonary blood flow was 0.66 (P = .038) 95% CI 0.29 ‐ 0.87.
Conclusion
Volume of CO2 elimination may be a surrogate marker of pulmonary blood flow in single‐ventricle patients and patients with biventricular physiology with intracardiac shunting. Also, among patients with normal cardiac anatomy, volume of CO2 elimination may be a marker of cardiac output.
Abstarct
To investigate the use of two-site regional oxygen saturations (rSO
2
) and end tidal carbon dioxide (EtCO
2
) to assess the effectiveness of resuscitation and return of spontaneous ...circulation (ROSC). Eight mechanically ventilated juvenile swine underwent 28 ventricular fibrillatory arrests with open cardiac massage. Cardiac massage was administered to achieve target pulmonary blood flow (PBF) as a percentage of pre-cardiac arrest baseline. Non-invasive data, including, EtCO
2
, cerebral rSO
2
(C-rSO
2
) and renal rSO
2
(R-rSO
2
) were collected continuously. Our data demonstrate the ability to measure both rSO
2
and EtCO
2
during CPR and after ROSC. During resuscitation EtCO
2
had a strong correlation with goal CO with r = 0.83 (p < 0.001) 95% CI 0.67–0.92. Both C-rSO
2
and R-rSO
2
had moderate and statistically significant correlation with CO with r = 0.52 (p = 0.003) 95% CI (0.19–0.74) and 0.50 (p = 0.004) 95% CI 0.16–0.73. The AUCs for sudden increase of EtCO
2
, C-rSO
2
, and R-rSO
2
at ROSC were 0.86 95% CI, 0.77–0.94, 0.87 95% CI, 0.8–0.94, and 0.98 95% CI, 0.96–1.00 respectively. Measurement of continuous EtCO
2
and rSO
2
may be used during CPR to ensure effective chest compressions. Moreover, both rSO
2
and EtCO
2
may be used to detect ROSC in a swine pediatric ventricular fibrillatory arrest model.
Summary
Objective
Thrombocytopenia and acute kidney injury (AKI) are common following pediatric cardiac surgery with cardiopulmonary bypass (CPB). However, the relationship between postoperative ...nadir platelet counts and AKI has not been investigated in the pediatric population. Our objective was to investigate this relationship and examine independent predictors of AKI.
Design
After IRB approval, we performed a retrospective review of the institution's medical records and database. Setting: This study was performed at a single institution over a 5‐year period. Patients: We included patients <21 years of age undergoing cardiac surgery with CPB. Interventions: Demographics, laboratory, and surgical characteristics were captured, and clinical event rates were recorded. Measurements: Descriptive statistics were used to evaluate platelet and creatinine distributions. T‐tests and chi‐squared tests were used to compare characteristics among Acute Kidney Injury Network groups. Multivariable logistic and ordinal logistic regression models were used to determine the association of our predictor of interest, postoperative nadir platelet count and AKI.
Results
Eight hundred and fourteen patients (23% infants and 23% neonates) were included in the analysis. Postoperative platelet counts decreased 48% from baseline reaching a mean nadir value of 150 × 109·l−1 on postoperative day 3. AKI occurred in 37% of patients including 13%, 17%, and 6% with Acute Kidney Injury Network stages 1, 2, and 3, respectively. The magnitude of nadir platelet counts correlated with the severity of AKI. Independent predictors of severity of AKI include nadir platelet counts, CPB time, Aristotle score, patient weight, intra‐operative packed red blood cell transfusion, and having a heart transplant procedure.
Conclusions
In pediatric open‐heart surgery, thrombocytopenia and AKI occur commonly following CPB. Our findings show a strong association between nadir platelet counts and the severity of AKI.
Pediatric postoperative cardiac care Ofori-Amanfo, George; Cheifetz, Ira M
Critical care clinics,
04/2013, Letnik:
29, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Postoperative care of cardiac patients requires a comprehensive and multidisciplinary approach to critically ill patients with cardiac disease whose care requires a clear understanding of ...cardiovascular physiology. When a patient fails to progress along the projected course or decompensates acutely, prompt evaluation with bedside assessment, laboratory evaluation, and echocardiography is essential. When things do not add up, cardiac catheterization must be seriously considered. With continued advancements in the field of neonatal and pediatric postoperative cardiac care, continued improvements in overall outcomes for this specialized population are anticipated.
To assess clinical characteristics and outcomes of severe acute respiratory syndrome coronavirus 2-associated multisystem inflammatory syndrome in children (MIS-C).
Children with MIS-C admitted to ...pediatric intensive care units in New York City between April 23 and May 23, 2020, were included. Demographic and clinical data were collected.
Of 33 children with MIS-C, the median age was 10 years; 61% were male; 45% were Hispanic/Latino; and 39% were black. Comorbidities were present in 45%. Fever (93%) and vomiting (69%) were the most common presenting symptoms. Depressed left ventricular ejection fraction was found in 63% of patients with median ejection fraction of 46.6% (IQR, 39.5-52.8). C-reactive protein, procalcitonin, d-dimer, and pro-B-type natriuretic peptide levels were elevated in all patients. For treatment, intravenous immunoglobulin was used in 18 (54%), corticosteroids in 17 (51%), tocilizumab in 12 (36%), remdesivir in 7 (21%), vasopressors in 17 (51%), mechanical ventilation in 5 (15%), extracorporeal membrane oxygenation in 1 (3%), and intra-aortic balloon pump in 1 (3%). The left ventricular ejection fraction normalized in 95% of those with a depressed ejection fraction. All patients were discharged home with median duration of pediatric intensive care unit stay of 4.7 days (IQR, 4-8 days) and a hospital stay of 7.8 days (IQR, 6.0-10.1 days). One patient (3%) died after withdrawal of care secondary to stroke while on extracorporeal membrane oxygenation.
Critically ill children with coronavirus disease-2019-associated MIS-C have a spectrum of severity broader than described previously but still require careful supportive intensive care. Rapid, complete clinical and myocardial recovery was almost universal.
PDF
