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Abstract Body

Background:

Congenital Diaphragmatic Hernia (CDH) is a congenital malformation with herniation of abdominal contents through the diaphragmatic defect into the thorax, often associated with pulmonary hypoplasia and pulmonary hypertension. The incidence is 1/3000 live births and postnatal survival ranges from 50 to 70%. A European consensus guideline on the management of CDH has been published to enable standardised postnatal management of these neonates (1).

Aims:

Using the 2015 European Consensus Guideline to identify local practice in relation to postnatal CDH management with following outcomes:

Primary outcome: mortality

Secondary outcomes:

Length of PICU stay

Readmission

Days to discharge home

Methods:

A retrospective review of all CDH admissions to PICU over a 2-year period (January 2018 –December 2019). Data collection was undertaken using the electronic patient record (Badgernet, Clevermed) to include: stabilisation, PICU and surgical management, and final outcome.

Results:

28 patients were identified and 26 patients included in the review. 77%(20/26) were diagnosed antenatally and 92%(24/26) were left-sided. Mortality was 15%(4/26). 5/26 required ECMO with repair undertaken on ECMO. Mean age of surgical repair was 6.5 days(2-20days).

Mean age of discharge from PICU was day 14.6 of life (5-40days), and discharge from hospital on day 25.3 of life (9-92days). The readmission rate for associated complications was 19% (5/26).

Conclusion:

This review provides useful data relating to outcomes of all neonates admitted to our PICU with CDH. Further work needs to be undertaken on the predictive models for prognostication which will include setting up a prospective regional database.

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Background

Haemophagocytic lymphohistocystosis (HLH) is a severe systemic inflammatory response syndrome, which can be familial or sporadic, with a reported mortality of >50%. HLH presents in a diverse manner which may mimic other conditions including severe sepsis. A delayed or missed diagnosis, therefore, remains of great concern. In 2014, the ‘H-Score’ was developed to provide a probability of HLH with weighted points for the following: immunosuppression, temperature, organomegaly, blood parameters and bone marrow evidence.

Methods

A retrospective review of the Nottingham Paediatric Intensive Care (PICU) discharge database from March 2019-2020, identified 642 children admitted to the unit of which 19 died. A keyword search identified four suspected and subsequently diagnosed HLH cases.

Results

Conclusions

All four children had varying presentations and alternative initial diagnoses, highlighting the importance of maintaining a high index of suspicion of HLH. Using the H score as a valid assessment and treatment decision tool is simple and effective. Although many of the criteria for HLH diagnosis overlap with other clinical presentations, the H score can help prevent missed opportunities for immunosuppressive treatment, especially important due to the reported HLH mortality rate.

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UNUSUAL HIPOXEMIA IN A BONE MARROW TRANSPLANT RECIPIENT:

BACKGROUND:

Acute Respiratory Distress Syndrome (ARDS) can be caused by multiple etiologies such as infections, trauma or extracorporeal circulation, all of whom may trigger an inflammatory systemic response. The aim of this case report is to emphasize the importance of considering unusual etiologies of ARDS in immunocompromised patients.

CASE REPORT:

We present the case of a 6-year old patient, born in Honduras and diagnosed of Pro-B Acute Limphoblastic Leukemia. On day 35 after receiving a bone marrow transplant, she developed fever, cough, diarrhea and a lumbar subcutaneous node. Broad spectrum antibiotic therapy was started. However, her clinical status worsened with respiratory failure, hypotension and oliguria. She was transferred to the Pediatric Intensive Care Unit (PICU) where a chest radiography showed bilateral interstitial infiltrates. She was intubated and mechanical ventilation was started. Due to refractory hypoxemia, she required lung protective ventilation, deep sedation, neuromuscular blockade, prone position, inhaled nitric oxide and high-frequency oscillatory ventilation (HFOV).

Etiological study showed a positive Toxoplasma gondii polymerase chain reaction (PCR) in tracheal aspirate, blood, urine and the subcutaneous node biopsy. The patient was diagnosed with disseminated toxoplasmosis and treatment with pyrimethamine, sulfadiazine and folinic acid was started. The patient improved significantly and was extubated after 36 days of admission.

CONCLUSIONS:

ARDS in immunocompromised patients can be triggered by multiple etiologies, such as pulmonary and disseminated toxoplasmosis. Differential diagnosis should consider the less common infectious causes, especially in patients from endemic regions.

Figure1: Chest radiography on PICU admission

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BACKGROUND AND AIMS

Neonatal and paediatric specialty transport services (NPSTS) remain exceptional in Spain. Lack of quality standards difficulties its progress and implementation. A list of 15 quality indicators (QI) was elaborated in 2018 by different NPSTS nationwide (including air and ground transport). Our aim was to analyse our performance and use benchmarking to improve our transfers.

METHODS

5 mixed NPSTS collected data monthly and prospectively along 2019. A descriptive analysis was performed afterwards.

RESULTS

1521 transfers were registered. 80% were performed by 2 of the units.

We found good overall results regarding patient safety with 86.8% use of appropriate restraint systems, 0.26% of accidental extubations, 1.3% of unplanned devices dislodgments, 0.9% emptied gas tanks, 0.13% transport-related patient injuries, 0.33% serious reportable events and 0.2% medication errors. 86.3% had standardised patient care hand-off. 89.9% of ventilated patients had a confirmed ETT position.

We identified several weak points. Only in 67% of cases pain assessment was documented. Neonatal temperature management showed a 20.2% of unintended hypothermia and only 55% of neonates requiring passive cooling achieved the target temperature. Finally, one of the units had a significant delay in mobilization, probably related to its organisation model

CONCLUSIONS

Our QI have been a useful tool to depict and evaluate transport quality and represent a good starting point towards improvement. We have already spotted obvious difficulties we need to work on. Spreading its use to other transport teams would make data more representative and rewarding and could help us promoting NPSTS.

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Background:

Children’s Medical Emergency Transport (CoMET) is the dedicated PCCTS provider in East Midlands. CoMET offers critical care advice and serves critically ill children in the region requiring interhospital transfer. SE is one of the main reasons for referral to CoMET.

Aim:

Detail analysis of all referrals with SE made to CoMET and looking at factors / identifiers that might help managing patients closer to home.

Methods:

Data was collected retrospectively from CoMET’s central database between June 2018 and May 2020 with a diagnosis of SE or seizure; repatriation requests and bed requests from other regions were excluded.

Results:

Total 104 referrals over two years period with SE or seizures needing retrievals and / or advices - constitutes 7.26 % of total referrals. 43/104 (41%) required invasive ventilation and retrieved to PICU; a large portion got extubated in the first 24 hours. 3/104 were self-ventilating but still needed retrieval because of complexity. 58/104 (55%) were self-ventilating and managed locally with telephonic triage, assessment, advice and subsequent support from CoMET team. 12/58 patients were initially referred for retrieval to tertiary center however they were managed locally with advice and support from CoMET team.

Conclusions:

The resources distribution is different at different DGHs. Regular teaching sessions and support from CoMET as outreach will enable management of many such children at established local HDUs, where available thereby reducing cost of transport, PICU beds and help families of these children to avail services locally and stay close to home.

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Background and Aim:

This study reviews clinical presentation, management and outcomes of children with acute upper airway obstruction referred to the largest regional Paediatric transport service in the UK.

Methods:

2 year retrospective review of CATS database for all referrals for acute upper airway obstruction.

Results:

149 cases were included. 63 (42.2%) were ventilated (61 endotracheal tube (ETT); 1 tracheostomy and 1 laryngeal mask airway (LMA)) for transfer. Of these, 16 (25%) were preterm (24-35 weeks gestation), 27 (42.8%) were female, 21 (33.3%) had known airway disorders, 17 (26.9%) had co-morbidities.

At intubation 15 (24%) had ENT present. Gas induction was used in 19 cases (30.1%).

Croup was the predominant diagnosis, 73 (48.9%), 25 (34.2%) were intubated for transfer, 48 (65.7%) were not transferred. Average size of ETT used was smaller by 0.85mm (compared to APLS guidelines) (p= 0.03).

In croup, 13 (52%) required 3 or more intubation attempts although 23 (92%) were grade 1 laryngoscopy. 18 had complications with too large an ETT at initial attempt. 5 had other complications, 9 (36%) had no peri-intubation problems.

Conclusion:

Repeated attempts at intubation are common in upper airway obstruction requiring PICU in children.

Our review suggests children are likely to have a grade 1 laryngoscopy but require a smaller ETT than calculated. APLS guidelines overestimate ETT requirement for children with Croup by 0.5 – 1mm.

We recommend ENT presence when intubating a child with upper airways obstruction although current practice suggests 24% presence at these intubations.

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Introduction

Flu is generally benign, although it can sometimes cause serious complications. The goal of the study was to describe the frequency, clinical evolution and complications of influenza in a PICU during five epidemic seasons.

Methods

Retrospective observational study of patients with influenza diagnosis admitted to PICU between 2015 and 2020. Demographic variables, morbidity, virus serotype, treatments, mortality and length of the PICU stay, were collected.

Results

Twenty-four patients were admitted into the PICU for influenza, with a median age of 3.4 years; 52.4% were male and 42% had associated morbidity. Influenza infection was responsible for 5.2% of paediatric inpatients (excluding surgical and neonatal admission); with an increase in the number of cases and complications in the last epidemic season (Figure 1). Influenza A accounted for 79.2%, influenza B 12.5% and co-infection influenza A+B 8.3%. Bacterial co-infection was present in 20.8%, with the most common organisms being streptococcus pneumoniae and streptococcus pyogenes. We observed complications in 79.2% (sepsis/septic shock, bacterial pneumonia, pleural effusion, myocarditis and seizures); 66.7% received antibiotherapy and 38% Oseltamivir. Non-invasive respiratory support was required in 41.8%, mechanical ventilation in 29.2% and inotropic-vasopressor drugs in 20.8%. The average stay in PICU was 4.9 days (IC95% 2.8–7.2) and mortality was 12.5% (3 patients).

Conclusions

We observed a high rate of complications and mortality especially during the last epidemic season, probably due to the high number of patients with associated morbidity. It is important to ensure specialized care in PICU in patients with moderate-severe course of the disease.

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Introduction: Pediatric C.N.S. tumors are the most common solid tumors in children and
comprise 15% to 20% of all malignancies in children. The majority of these children will
undergo neurosurgery and some will require hospitalization in a pediatric I.C.U.

Methods: This is a retrospective study of the registry of children with CNS operated tumors,
who have been treated in our unit from 2016.

Results: 28 children were hospitalized during this period. 18 of them were male (64%) and
10 were female (36%). Their ages ranged from 5 months to 14 years. The total days of
hospitalization were 770. The days of mechanical ventilation were 658. 18 children had a
posterior cranial fossa tumor. Ιn 7 children the tumor was located supratentorially. 2
children were found with optic nerve glioma and 1 child had neuroblastoma. CSF drainage
was placed in 21 children. 12 of them were external and 9 were ventriculoperitoneal shunts.
Various complications occurred in 12 of the 28 children. The main ones were tumor
recurrence, hydrocephalus, complications from drainages and seizures. Emergency and
scheduled readmissions amounted to 6. 8 children underwent tracheostomy. Finally,
mortality rate was approximately 21,4% (6/28 children).

Conclusion: For modern clinicians charged with the care of critically-ill children, the
protection and restoration of neurologic function involves increasingly sophisticated
management strategies and technologies. For this reason, the collaboration of
neurosurgeons, pediatric oncologists and pediatric intensivists is essential for the best
possible outcome for children with CNS tumors.