Background

Few studies have evaluated whether levels of endothelial biomarkers are different between pulmonary and extrapulmonary acute respiratory distress syndrome (ARDS).

Objectives

To evaluate endothelial biomarkers in the prediction of pulmonary and extrapulmonary ARDS in children.

Methods

Cross-sectional study of 42 patients who developed pediatric ARDS from a cohort study involving 114 children with circulatory shock in Brazil. The plasma levels of sICAM-1, sVCAM-1, sP-selectin, and Endocan were measured at days 1, 2 and 3 after admission in PICU. According to the Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria, patients with ARDS were classified after discharge or death into two groups: “Pulmonary” (n=27) and “Extrapulmonary” (n=15). Age, C-Reactive protein (CRp), Procalcitonin (PCT), Lactate, Pediatric Index of Mortality 2 (PIM-2), ventilator-free time, PaO2/FiO2 ratio, and oxygenation index (IO) were compared between groups. Logistic regression models were fitted.

Results

“Extrapulmonary” group had significantly higher mean level of sICAM-1 in the plasma at day 1 compared with “Pulmonary” group (2165.3±316 vs 1454.7±132,2 pg/mL, p=0.001). The decrease of sICAM-1 during days 2 and 3 was higher in the “extrapulmonary” group (p=0.011). For each 100 pg/mL of circulanting sICAM-1 there was a 13% increase in the risk of children having extrapulmonary ARDS (β=0.0013, p=0.032) after adjusting by age, CRp and PCT (AUC=0.8942). The groups did not differ regarding PIM-2, ventilation-free time, PaO2/FiO2 ratio, IO, and others adhesion molecules.

Conclusion

sICAM levels potentially discriminate the extrapulmonary SDRA, supporting the decision making to manage this respiratory syndrome that are not explained by clinical factors alone

Background

Enterovirus D68 is a non-poliovirus, spread by respiratory droplets, which in rare circumstances has been associated with an acute flaccid paralysis (AFP). In 2014 there was an outbreak of this strain in the USA and Northern Europe, leading to five cases of AFP in Colorado and two cases in Norway.

Objectives

Following two recent cases of children admitted to PICU in Nottingham with AFP secondary to Enterovirus D68, it was decided to survey all of the UK Paediatric Intensive Care Units, to identify whether these were isolated incidents.

Methods

A survey was conducted amongst 24 PICUs in the UK confirming cases of AFP associated with Enterovirus D68 during 2018. They were asked about the patient’s age and whether or not the patient required tracheostomy ventilation long term.

Results

Of the 24 PICUs contacted, 21 responded to the survey. There were 10 cases of confirmed D68 AFP in 2018, with ages ranging from 8 months to 6 years. 40% of cases were located in the East Midlands and South Yorkshire, with 70% requiring long-term ventilation, and at least 50% of patients requiring tracheostomy.

Conclusion

Our experience in Nottingham has been reflected in other parts of the UK, and is suggestive of a possible outbreak of AFP associated with Enterovirus D68. This emerging problem is concerning, with significant long term implications for health and resource utilisation.

Background

In recent years, many studies have reported potential associations between cytokine gene polymorphisms and the development, course, and outcome of sepsis, often with apparently conflicting results.

Objectives

To investigate single nucleotide polymorphism (SNP) in the interleukin (IL)-1β –31 T/C, IL-6 –174 G/C, tumor necrosis factor α (TNF-α) –308 G/A, and interferon γ (IFN-γ) +874 A/T genes for their possible association with susceptibility to early onset sepsis (EOS) in Saudi newborn infants.

Methods

A total of 205 newborn infants aged 1-2 days were consecutively enrolled onto the study having met the inclusion criteria (as per the research protocol). DNA was extracted from filter papers using the Chelex-100 method. The cytokines SNP were genotyping using Taqman 5’ nuclease allelic discrimination. For cytokine measurements we used the commercially available Enzyme-Linked Immunosorbent Assay (ELISA) kit

Results

Circulating IL-1β, IL-6, TNF-α, and IFN-γ were significantly (p < 0.001) elevated in EOS patients compared to suspected and sepsis-free control groups; and IL-1β –31C, IL-6 –174G, TNF-α –308G, and IFN-γ +874A alleles were associated with EOS in Saudi infants.

Conclusion

Cytokines concentrations and SNP for the four tested genes can be used as a predictor of sepsis outcome in newborns.

Background

Despite widespread vaccination, pertussis continues to occur with significant incidence worldwide and causes morbidity and mortality⁽¹⁾. Few studies have reported risk factors associated with critical pertussis including age <6months, incomplete DTaP vaccination and hyperleukocytosis^(2,3). In the middle east,little has been published about critical pertussis.

Objectives

To describe demographics, outcomes and associated risk factors for critical pertussis in Oman.

Methods

In this retrospective study, we reviewed the Electronic Medical Records of all patients aged <13years who presented to the university-affiliated tertiary center in Oman with a positive PCR test for pertussis between January 2013 and June 2018. Data including demographics, possible risk factors of severity, and patient outcomes were recorded.

Results

A total of 69 children were enrolled, 34(49%) were aged <2months, 65(94%) aged <4months, 62(90%) received no or 1 DTaP vaccine and 40(58%) were male. 38(55%) patients had lymphocytosis and 7(10%) had WBC>50 000/mm³.

Of the total, 9(13%) were discharged from ER, 18(26%) required pediatric high dependency(PHDU) and 6(8.7%) required PICU care. Pulmonary complications were commonest 23(33). 9(13%) required assisted ventilation. Others included secondary bacterial infections 11(16%), seizures 3(4%), pulmonary hypertension 1(1%), and death 1(1%).

Factors associated with PICU/PHDU admission (p<0.05) were leukocytosis >50x10⁹/L, elevated C-Reactive Protein, development of secondary bacterial infection, infiltrates seen on chest-radiograph and seizures at presentation.

Conclusion

Similar to other countries worldwide, pertussis remains a significant cause of morbidity and mortality in Oman. The youngest age groups with incomplete vaccination especially with leukocytosis and elevated CRP are at highest risk. Therefore, protection of infants by vaccinating pregnant mothers is recommended.

Background

We have previously shown that Respiratory Syncytial Virus bronchiolitis is associated with lymphopenia and that the degree of lymphopenia reflects the severity of illness. C-Reactive Protein is often used in paediatric practice and its prognostic implications in bronchiolitis are unclear.

Objectives

We sought to understand whether the use of CRP at admission or at the peak of illness reflected which patients were sickest and offered useful additional clinical information.

Methods

We retrospectively identified admissions coded as bronchiolitis under a year of age admitted for the first time to PICU between autumn 2014 and 2018. Infants with underlying conditions such as chromosomal disorders, leukaemias and proven septicaemia were excluded. 146 children (57% male) with virus proven bronchiolitis between 9 and 339 days of age were identified of whom 63 were born preterm. We sub-divided the cohort by virus and into those who received invasive ventilation or non-invasive ventilation (NIV) as a surrogate for severity of illness.

Results

Lymphopenia on admission (p=0.028) and at its nadir was more pronounced in those children who required invasive ventilation compared with NIV. There was no difference in eosinophilia on admission to PICU but in those ventilated the value was significantly greater in those with more severe bronchiolitis (p= 0.0002).

Conclusion

Lymphopenia occurred in Rhinovirus infection as well as those with RSV. The degree of lymphopenia was not affected by prematurity or by age. C-Reactive Protein did not differ between groups and was of no prognostic value at admission or at its peak value.

Background

Acinetobacter baumannii and its antimicrobial resistance are serious emerging problem that cause high morbidity and mortality in critically ill patients.

Objectives

In our pediatric intensive care, an endemic situation with a single specific strain of carbapenem-resistant Acinetobacter baumannii (CRAB) occurred, and we investigated the effectiveness of comprehensive intensified infection control measures for controlling endemic CRAB.

Methods

The study period was divided into three periods, from the month of introduction of the single strain of CRAB to the implementation of the intervention (Period 1; Jun 2017 to Feb 2018), from the implementation until the end of the CRAB spread (Period 2; Mar to Aug 2018), and a follow-up phase (Sep to Dec 2018) of four months. A comprehensive intensified infection control strategy was implemented to prevent the new colonization of CRAB by a multidisciplinary team. All patients, as well as CRAB colonized patients, were isolated. And the strategy focused on environmental cleaning, disinfection enforcement, hand hygiene promotion through PICU staff education, and active surveillance.

Results

The incidence density rate of CRAB, defined as the number of new colonizations or infections per 1,000 patient-days, decreased from 9.10 ± 6.46 (median, 10.56; range, 0 to 18.09) to 5.76 ± 4.00 (median, 4.48; range, 0 to 11.68) after the interventions were implemented. No CRAB colonization or infection occurred during the 4-month follow-up period.

Conclusion

Comprehensive infection control measures effectively controlled endemic CRAB in our PICU. Universal contact precaution and environmental disinfection were crucial in controlling the horizontal spread of CRAB.

Background

Experimental studies have demonstrated a relationship between adhesion molecules as biomarkers of endothelial function and the selenium status under different conditions. However, there are few clinical studies to corroborate the hypothesis that selenium has an active role in endothelial function.

Objectives

To test if erythrocyte selenium and Selenoprotein P, as markers of selenium status, are associated with endothelial adaptative response during the acute phase of systemic inflammatory response in children.

Methods

Prospective cohort study of 109 children (median age: 22.4 months, interquartile range: 7-73.1) admitted with circulatory shock. Plasma levels of sICAM-1, sVCAM-1, P-selectin, and EndoCAM were measured at days 1, 2 and 3 of ICU stay. Selenium concentration in erythrocyte and plasma Selenoprotein P were measured on admission. Multivariable generalized estimating equations were adjusted for the covariables Pediatric Index of Mortality 2, procalcitonin and serum lactate concentrations.

Results

The mean erythrocyte selenium concentration was 75.8 (3.7) µmol/L. There were positive significant associations between erythrocyte selenium and P-selectin and EndoCAM plasma concentrations, and between Selenoprotein and P-selectin plasma concentration. The increase of 1.0 µmol/L/L in erythrocyte selenium resulted in increases of 4.7 nmol/L (95% CI: 2.6;6.9, p<0.001) in P-selectin and of 0.004 ng/mL (95% CI: 0.001;0.006, p=0.02) in EndoCAM. The increase of 1.0 nmol/L in plasma Selenoprotein P resulted in the increase of 1.5 nmol/L (95% CI: 0.24; 2.8, p=0.02) in P-selectin. There were no association between selenium status and sICAM-1 or sVCAM-1

Conclusion

Selenium nutritional status is potentially associated with the magnitude of endothelial activation during acute systemic inflammatory response.

Background

Treatment of neonates with renal ROH and complete “potter sequence” is challenging. Mortality remains high.

Objectives

Report BP requirements in neonates on VV-CRRT due to ROH during the first 16 days of life. Compare neonates < 3kg to > 3kg birth weight.

Methods

Retrospective data review of 5 patients with ROH. VV-CRRT was initiated between day 0 and 4 of life. Prismaflex with HF 20 Filter was used. Anticoagulation was accomplished with low dose citrate (2,5-3 mmol/l), Epoprostenol 4- 10 ng/kg/min) and Heparin 5- 10 IE/kg/h. Coagulation goals were defined as ACT 160- 180, fibrinogen > 150 mg/d, ATIII > 40 % Thrombocytes > 30000, HCT > 35 %. All administered, body weight adjusted, units of BP were noted.

Results

Pathologies were ARPKD (n=1), urethral valve (n=2), and renal dysplasia (n=2). Patients 2 < 3kg (2,2- 2,8), and 3 > 3kg (3 -3,8). No Bleeding episodes occurred. Filter running time < 3kg 32h (11- 109) > 3kg 58h (10- 124). Filter change, including planned down time 7 /6 in > 3 kg. Blood- products administered: Fibrinogen < 3kg 8,5 (7-10) opposed to 4 (1-4) > 3kg, ATIII 7 / 2(1-3) thrombocytes 7,5 (7-8) /2 (0-4) and packed red blood 6,5 (6-7)/ 3 (3-8). Most administrations occurred during blood prime after planned or unplanned filter change.

Conclusion

Neonates < 3kg had shorter filter running times and needed excessively more BPs. Longer filter running times seem to be associated with less BP requirements. There is a need for standardised management especially frugal laboratory testing.

Background

Children admitted to PICU are at risk of AKI. Few pediatric studies have focused on the identification of factors associated with the development of this condition.

Objectives

We assess the incidence rate of AKI, identify risk factors, and evaluate clinical outcome in a large sample of critically ill children.

Methods

This retrospective observational study was conducted including patients admitted to our PICU from Jan 2014 to Dec 2016. AKI was defined according to KDIGO criteria. A comparison between patients with and without AKI was carried out. Risk factors for AKI were analyzed by univariate and multivariate analysis.

Results

222 patients out of 811 (27.4%) had AKI. The most common PICU admission diagnoses in AKI cases were heart disease (38.6%) and respiratory failure (16.8%). Hypoxic-ischemic was the most frequent cause of AKI. Significant risk factors for AKI in multivariate analysis were age > 2 years (OR 2.27; 95% CI 1.06-4.90; p=0.035), inotrope exposure (OR 2.88; 95% CI 1.64-5.08 p<0.001), multiple organ dysfunction syndrome (OR 2.90; 95% CI 1.77-4.76; p<0.001), coagulopathy (OR 1.57; 95% CI 0.98-2.50, p=0.054) and thrombocytopenia (OR 2.54; 95% CI 1.34-4.79; p=0.004). AKI was associated with a longer PICU stay (median LOS of 8 days, vs. 4 days, in non-AKI patients; p <0.001). The mortality rate resulted ten-fold higher in AKI than non-AKI patients (12.6% vs.1.3%; p<0.001).

Conclusion

The incidence of AKI in critically ill children is high, with an associated increased LOS and mortality. In the PICU setting, risk factors of AKI are multiple and mainly associated with illness severity.

Background

Very low birth weight (VLBW) preterm neonates are at high risk of acute kidney injury (AKI). Urine output (UO) is part of the neonatal Kidney Disease Improving Global Outcomes (nKDIGO) definition, but datas are usually lacking.

Objectives

To identify risk factors and outcomes associated with neonatal AKI.

Methods

204 preterm neonates born before 30 weeks of gestational age (GA) were retrospectively enrolled between 2014 and 2018 in Geneva. AKI was defined according to the nKDIGO definition. Daily UO was recorded between day 1 and day 7. Exclusion criteria included death <24 hours and severe congenital malformations.

Results

Mean GA was 27.5 weeks and mean birth weight 1003 grams. AKI occurred in 59/204 (28.9%): 44 at stage I, 11 at stade II and 4 at stage III. Fifty percents of AKI were diagnosed exclusively on UO criteria, 32% on creatinine variation and 18% on both cumulated criterias. Significant risk factors for neonatal AKI included Apgar below 5 at 5 minutes, significant patent ductus arteriosus, necrotizing enterocolitis, late onset sepsis, exposure to dopamine, indomethacin, vancomycin and treatment with gentamycin ≥ 5 days. Infants with AKI had higher mortality compared to those without AKI (OR: 4.7 [1.45-16.55], p:0.003), a higher rate of moderate to severe bronchopulmonary dysplasia (OR: 2.5 [1.12-5.6], p:0.016) and a longer respiratory support (45.5 days [2-172] vs 33 days [0-342] p:0.022). Neurological outcome was not significantly impaired in case of AKI.

Conclusion

Neonatal AKI is common in VLBW preterm neonates and is associated with poor outcomes. Measuring urine output is highly relevant in this population.