Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited.
We conducted this trial of two ...targeted temperature interventions at 38 children's hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest.
A total of 295 patients underwent randomization. Among the 260 patients with data that could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval CI, 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality.
In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; THAPCA-OH ClinicalTrials.gov number, NCT00878644.).
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.
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•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.
Pulmonary hypertension causes increased morbidity and mortality in adults after heart transplantation. The effect of markedly elevated pulmonary vascular resistance (PVR) on post-transplant outcomes ...in children has not been well described.
Outcomes were compared in a retrospective study between 58 children with an elevated PVR index (PVRI) ≥ 6 U/m(2) and 205 children with a PVRI < 6 U/m(2). Patients who did and did not respond to acute vasodilator testing and patients who underwent transplant before (pre-1995) and after (post-1995) the availability of inhaled nitric oxide (iNO) were compared.
The pre-transplant diagnoses, and cardiopulmonary bypass and donor ischemic times were similar between the high and low PVRI groups. High PVRI patients were older at transplant (12 ± 6.2 vs 8 ± 7.1 years, p = 0.002). The post-transplant inotrope score was higher in the high PVRI group (12 ± 12 vs 2 ± 2, p = 0.0001) and 1-year survival was worse (76% vs 81%, p = 0.03). The PVRI fell to < 6 U/m(2) with acute vasodilator testing in 21 of 49 (42%) high PVRI patients. RV failure occurred in 4 (19%) of the responders and in 14 (50%) of the non-responders (p = 0.037). One responder (5%) and 4 non-responders (14%) died of RV failure. In the period after 1995, the year iNO became clinically available, the select group of high PVRI patients who received iNO preemptively had a lower incidence of post-transplant RV failure than the group that did not receive preemptive iNO (13% vs 54%, p = 0.04).
Pre-transplant vasodilator testing identified patients at higher risk for RV failure. Patients who did not respond to vasodilator testing had an increased incidence of RV failure and death from RV failure. Preemptive use of iNO was associated with a decreased incidence of RV failure.
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