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Background and Aims

Fluid resuscitation remains the first line of dengue shock treatment. However, aggressive fluid loading may result in overload and its associated harm. Cardiac involvement in pediatric dengue has previously been described using echocardiography. This study aims to investigate cardiac performance using bedside hemodynamic monitoring in patients with dengue shock syndrome.

Methods

A cross-sectional study involving 17 pediatric patient diagnosed with dengue shock syndrome in an emergency room of a tertiary referral hospital in Jakarta, Indonesia. Dengue cases were serologically confirmed. Serum NTproBNP and cardiac performance monitoring were performed prior to fluid administration using ultrasound cardiac output monitoring (USCOM). Smith-Madigan inotropic index (SMII) and systemic vascular resistance (SVRI) were defined using cut-off according to age. Left ventricular end diastolic volume index (LVEDVI) was calculated using Inotropy v 7.2 ©BE Smith 2016.

Results

Median age was 48(5-67) months. Mean Hemoglobin level was 14.02±2.7 g/dL, mean Hematocrit of 40.2±9.63 % and median thrombocyte count of 15000(12000—89000)/μl. All patients had low SMII (0.69±0.18) and high SVRI (3848±1872). There was a moderate correlation between SMII and SVRI (r=-0.521, p=0.032). Median LVEDVI was 63.4(54.4—67.9) and median calculated ejection fraction was 63.4(54.4—67.9)%. NTproBNP levels was normal in 15(88.24%) with median of 131(88—1472)pg/mL. Eleven (64.7%) subjects received inotropic support and one did not survive.

Conclusions

Pediatric dengue shock syndrome demonstrates low SMII and compensatory high SVRI. The use of bedside cardiac monitoring is beneficial for judicial fluid and inotropic titration in dengue shock.

Background and Aims

Simulation-based medical education (SBME) has a crucial role in the preparedness for public-health emergencies. COVID-19 outbreak brings many modifications to the conditions of life and healthcare including SBME. The aim of the study was to explore preparedness, methods and maintenance of simulation activities and to match pandemic peaks and valleys with simulation activities of each center.

Methods

International multicentre survey study with questionnaire sent to ESPNIC, SECIP, SLACIP and GISP members.

Results

Fifty-one centers completed the survey from 18 countries. Major results about differences between countries are summed up in tables 1 and 2, showing significant dissimilarities in time to train in advanced and technology availability. Training was most often delivered in situ and the most common scenario was PPE training (88.2%) followed by airway management/intubation (62.7%), CPR (43.1%), transport (35.3%) and initial assessment of COVID patients (33%). 82.4% conducted multidisciplinary simulation-training. Main issues related to team dynamics were anxiety of the team (62.74%) and communication trough the PPE (60.78%). The engagement of the team was more than usual. Non-COVID simulation-based activities continued in the 70.6% but with less frequency, less participants and changes on training modes. Remote-simulation was used in the 17.6% for COVID training and in the 23.5% for non-COVID activities.

Conclusions

SBME remains essential, also in extraordinary times, but must be adapted. The “new normal” in medical education includes remote learning tools and telesimulation as effective solutions to support educational activities despite social distancing.

Background and Aims

At the end of March the first cases of an unknown syndrome with the features of a myocarditis, or Kawasaki, or toxic shock syndrome appeared in our city. With no references to therapy, we applied standard Kawasaki treatment. As a second wave of patients was expected in autumn, a protocol was prepared according to proposed literature. Treatment included steroids according to degree of left ventricular dysfunction, beside immunoglobulins, and low molecular weight heparin. Aim of the study is to describe patients’ characteristics among the two waves.

Methods

Retrospective observational study.

Results

Patients admitted for MIS-C have been 12 (Mean age 5.8 yrs - Picu 50%) in the first wave and 27 (mean age 8.9 yrs - PICU 74%) in the second wave; among PICU patients, in the first wave ventilatory support was needed in 33% (mean duration: 96 hrs); mean EF was 49%, inotrope use 66% (mean duration 75 hrs); in the second wave 50% required ventilatory support (mean duration 60 hrs), mean EF was 44.5%, inotrope use 50%, (mean duration 51 hrs). IVIG use 83% first wave, 100% second; steroids 16% first wave, 88% second. Mean PICU and hospital stay have been 4.2 and 10.75 days and 4.4 and 12 days in first and second wave respectively; one death in the first wave.

Conclusions

We observed a bigger number of MIS-C in autumn due to a rise in cases in our city. Creation of a shared protocol helped diagnosis and treatment at all levels.

Background and Aims

To evaluate the concordance between clinical diagnoses and postmortem pathological findings and utility of autopsies in critical ill children in the current era.

Methods

This is a retrospective observational study over a 6 years period. The setting is a single university tertiary hospital, 16-bed mixed medical-surgical PICU. Modified Goldman criteria were used to define diagnostic pre and postmortem concordance.

Results

From January 2015 to December 2020 a total of 3459 children were admitted to PICU and 122 died (3,5 %). 44 deceased patients (36%) underwent autopsy exam (as per attending physician criteria).

In 33 patients (75%) there was concordance between clinical pre and postmortem diagnosis of death. There were 2 patients (4,5%) with missed diagnosis with available in life treatment and potential different outcome if known, both of them opportunistic infectious (CMV disseminated disease and toxoplasmosis). There were 9 patients (20%) with major missed diagnosis that did not have impact on survival (5 infectious diseases and 4 vascular events)

Complete concordance between clinical diagnoses and postmortem findings was observed in 17 patients (39%). In 16 patients (36%) unknown minor diagnosis (not related to the cause of death) were found in postmortem exams.

Conclusions

The rate of complete concordance between pre and postmortem diagnosis is low. Autopsy findings were necessary to correctly state the cause of death in one out of four patients and showed unknown diagnosis in one out of three. These results remark the importance of autopsy to improve quality team performance.

Background and Aims

To investigate longitudinal functional and neuropsychological outcomes 3-6 and 24 months after pediatric OHCA. Furthermore, the association between pediatric cerebral performance category (PCPC) and neuropsychological outcome was explored.

Methods

Included were children (0-18 years) who experienced OHCA and were admitted to the pediatric intensive care unit (PICU) of a tertiary university hospital between 2012 and 2017. Survivors were assessed during an outpatient multidisciplinary follow-up program 3-6 and 24 months post-OHCA. Outcomes were assessed through interviews, neurologic exam, and validated neuropsychological testing.

Results

One-hundred-thirteen children were admitted to the PICU following return of circulation after OHCA. The most common cause of OHCA was near-drowning (21%). Median age at time of OHCA was 53 months, 64% were male. Fifty-one (45%) survived to hospital discharge. Three to six and 24 months post-OHCA, respectively 74 and 73% had a good PCPC score (1-2). Compared with normative data, lower scores were found on sustained attention and processing speed both at 3-6 (n=26) and at 24 months (n=27) post-OHCA. At 24 months, lower scores were also found on intelligence, selective attention, and cognitive flexibility. In children tested at both time-points (n=19), no significant changes in neuropsychological outcome were found over time. Intelligence scores did not correlate with PCPC.

Conclusions

In the majority of pediatric OHCA survivors PCPC was good 3-6 and 24 months post-arrest. Neuropsychological assessment showed adverse outcome at 3-6 and 24 months. PCPC scores were not associated with intelligence scores. Follow-up should be standardized and continued into adulthood