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Background and Aims

Lung Ultrasound is a well-established diagnostic tool in neonates as its capability to evaluate pulmonary aeration has been successfully applied for tailored surfactant administration and respiratory support in the first hours of life, as well as for later BPD diagnosis. Recently, Lung Ultrasound has been studied to predict BPD. Thus, we performed a meta-analysis of these data to evaluate the diagnostic accuracy of Lung Ultrasound Score (LUS) for the early prediction of BPD in very and extremely preterm neonates.

Methods

All studies performed on this field were searched on PUBMED database by matching the terms “bpd”, “bronchopulmonary dysplasia”, “predicting”, “Lung Ultrasound Score”. Four studies published between 2018 and 2020 were found and meta-analysis was performed according with PRISMA guidelines.

Results

In the whole population LUS (on 6 chest areas) performed at 1-week post-natal age predicted BPD with an AUC: 0.81, pooled sensitivity: 71% (95%CI:0.62-0.79), I²= 0%, pooled specificity: 80% (95%CI:0.74-0.85), I²= 0%. At 2- weeks post-natal age LUS (on 6 chest areas) showed an AUC: 0.77, pooled sensitivity: 72% (95%CI:0.64-0.80), I²= 0%, pooled specificity 74% (95%CI:0.68-0.79), I²= 91.8%.

Conclusions

While further research is needed, these preliminary findings show that LUS has satisfactory diagnostic accuracy for the early prediction of BPD in very and extremely preterm neonates. Diagnostic accuracy of extended LUS (on more chest areas) needs to be investigated.

Background and Aims

An appropriate interface is essential to the success of non-invasive ventilation (NIV). Total facial mask (TFM) has been approved for children older than 1 year. However, in many units it is used for younger children due to the lack of appropriate interface for this age group. The objective of this study is to assess the comfort level of children undergoing NIV with TFM by age group (<6 months vs >6 months).

Methods

An observational prospective study including children with acute respiratory failure subjected to NIV with total face mask as first-line therapy was performed (December-2019 to December-2020). Demographic and clinical data were collected, and tolerance was evaluated using the COMFORT scale.

Results

Twenty-eight children undergoing NIV with TFM were included. The median weight was 9.8 Kg [range 5-15] and 39.3% were younger than 6 months; 57.1% were male. Bi-level pressure was used in 85.7% and 10.7% were intubated. Sedation was administered in 50%. The COMFORT score decreased from 25 to 19 points at 3 hours after the start of NIV (p= <0.001). This trend continued over time with a mean comfort score of 19 points being observed during the first 24 hours of NIV therapy (adequate comfort range: 17-26). No significant differences were observed in the COMFORT score between age groups (<6 months vs >6 months; p>0.1). Figure 1. No adverse effects were observed with total face mask.

Conclusions

COMFORT score results indicated that TFM was well tolerated overall, including those under 6 months, with no adverse effects observed.

Background and Aims

Noninvasive ventilation (NIV) is the first-line therapy in infants with bronchiolitis-related acute respiratory failure. However, there is a lack of data regarding weaning from NIV in this setting. This study aims to evaluate a nurse-driven weaning protocol in this homogenous population.

Methods

A retrospective single-center study with pre-versus-post comparative design in a tertiary center. Data from all infants aged ≤ 6 months admitted to the PICU during 2 seasons with a clinical diagnosis of bronchiolitis and requiring any type of noninvasive ventilatory support on admission, were analyzed.

Results

In total, 187 infants (95 with standard and 92 with nurse-driven protocols) were included; the median age was 47 (IQR 24-75) and 31 days (19-58) in patients at baseline and after the protocol implementation, respectively. There was no difference in terms of weaning failure between the two periods (11 (12%) versus 14 (15%), p=0.46). At baseline, the ventilatory support duration was 70 hours (IQR 54-104) versus 56 hours (IQR 29-83) during the nurse-driven protocol period (p=0.29). The PICU and hospital lengths of stay did not differ between the two periods. No complication related to NIV occurred in the two periods.

Conclusions

In patients with bronchiolitis supported by NIV, the nurse-driven weaning management - as opposed to physician-driven - was not associated with a significantly higher proportion of weaning failure cases.

Background and Aims

During the COVID-19 pandemic, a new syndrome called Multisystem Inflammatory Syndrome associated with COVID-19 (MIS-C) emerged in pediatric age and was described by Centre of Disease Control and Prevention as Kawasaki-like or toxic shock syndrome. We hypothesized that lung ultrasound (LUS) findings of these patients would be associated with illness severity and need of respiratory support.

Methods

Retrospective observational cohort study. All patients admitted to Pediatric Intensive Care Unit (PICU) with diagnosis of MIS-C underwent a LUS within 6 hours from admission. Four LUS patterns were considered: >3 B lines for field in posterior fields, comet-tail artifacts, subpleural consolidations and pleural effusion.

Results

26 patients were admitted to PICU in 2020 with a diagnosis of MIS-C. The mean age was 8.6 ys, 58% had respiratory symptoms (tachipnea or respiratory distress), 46% needed non invasive or invasive respiratory support and 54% inotropic support. None had a normal LUS: 70% showed >3 B lines for field in posteriore fields, 57% had supleural consolidations, 35% pleural effusion and 27% comet-tail artifacts. Two thirds of patients with respiratory support had >/= 2 positive signs at LUS. Subpleural consolidation is the most common sign in patients with respiratory support.

Conclusions

LUS is a noninvasive, safe and useful tool to evaluate lung involvement in children with MIS-C and to decide the need of respiratory support.

Background and Aims

Respiratory problems are the most common cause of emergency room admission in infants. Bronchiolitis is the most common cause of respiratory distress under one year of age. Approximetately one-third of infants suffer from bronchiolitis, and in winter months18% of all pediatric emergency admissions are due to bronchiolitis. The diagnosis of bronchiolitis is clinical and no laboratory and radiological imaging is required in otherwise healthy infants. The treatment is supportive with oxygen support and hydration if needed. This study was planned to investigate the diagnostic work-up and treatment methods of bronchiolitis in the emergency department of our teaching hospital.

Methods

This study was an observational retrospective study. Infants who present to our emergency department due to respiratory distress, and fit into AAP bronchiolitis criteria were included. Patients’ data were retrieved from emergency room files and hospital electronic patient database.

Results

147 subject were included. Mean age was 3,68+2,6 months. 53,7% were male and 46,3% were female. Diagnostic studies and their respective frequencies were, nasopharyngeal aspirate for viral antigens (97.3%), blood gas (96.6%), CRP (95.2%) blood count (93.9%) and chest radiograph, (91.2%). Inhaled salbutamol therapies were the most common treatment modality (93.2%) followed by inhaled ipratropium (60.5%), inhaled corticosteroid (81%), iv antibiotic (62.6%) and iv corticosteroid (55.8%).

Conclusions

Many diagnostic and treatment methods that are not routinely recommended in bronchiolitis guidelines are in common use. Evidence from the literature does not support their cost-effectiveness. Prospective multicenter studies could be helpfulin this regard

Background and Aims

Dengue remains a major global health burden with about half the world's population at risk of infection. CBC is universally monitored in dengue. Unlocking its potential to predict severity progression would greatly improve outcomes in dengue management, especially in limited-resource settings. This study aimed to explore CBC indices across days of illness that may predict progression to severe dengue in children. It also aimed to determine optimal cutoff values of CBC indices predictive of severity.

Methods

A retrospective, analytical, observational, cohort study was conducted through chart review of cases admitted as Dengue in the Philippine Children’s Medical Center from 2016 to 2019. Daily CBC indices were analyzed. Optimum cutoff values were determined using area under the receiver operating characteristic curve.

Results

Two-hundred eighty seven laboratory-confirmed dengue with warning signs (DWS) patients were included, 22% progressed to severe dengue (DS). DS had significantly higher values of leucocyte count on Days 3 and 4 of illness, neutrophil-lymphocyte ratio (NLR) on Days 5 to 7, monocyte-lymphocyte ratio (MLR) on Day 7, and lower platelet-lymphocyte ratio (PLR) on Day 3. Platelet, hematocrit, and monocyte levels were not significantly different. Optimal cutoff values predictive of severe dengue were leucocyte count of 3.33×10⁹/L (AUC of 0.67) and NLR of 0.93 (AUC of 0.63) on Day 4 of illness. Other indices had poor discriminative power.

Conclusions

High leucocyte and NLR values in the early phase may predict progression to severe dengue. However, recommendation to use these indices as predictors of dengue severity remains weak. Future prospective studies with larger sample sizes are recommended for more robust findings.

Background and Aims

Objectives: To analyze the clinical characteristics of 86 neonates with enterovirus infection.

Methods

Methods: From May 2019 to July 2019,a retrospective analysis was performed in neonates with enterovirus infection in our hospital.Clinical characteristics and laboratory examinations of the patients were collected for statistical analysis.

Results

Results：1. 86 neonates with neonatal enterovirus infection were included in the study.Among them, 59 were males and 27 were females.75 were full-term infants and 11 were premature infants.17 infants were early-onset infants, 69 infants were later-onset infants. 82 cases were cured and discharged,4 cases died. 2. Common clinic symptoms included fever (75 / 86,87.2%); jaundice (50 / 86,8,51%); dyspnea (17 / 86,19.8%); rash (9 / 86,10.5%); diarrhea (9 / 86,10.5%); abdominal distention (8 / 86,9.3%); vomiting (5 / 86,5.8%); convulsion (2 / 86,2.3%). Coagulation dysfunction (17 / 86,19.8%), liver dysfunction (11 / 86,12.8%), and myocardial damage (9 / 86,10.5%) were founded in severe cases. 3. 6 infants had hepatic necrosis with coagulopathy (HNC). 4 of them died. Compared with the general group, earlier age of onset(<7 days), dyspnea, abdominal distention, coagulation dysfunction, liver function damage, myocardial damage, hypoproteinemia, PCT increase, PLT decrease and death rate were significantly higher in the group infants with HNC(p< 0.05).

Conclusions

Conclusions:Neonatal enterovirus infection have diverse manifestations. Infants with HNC had high mortality and needed to be monitored closely.

Background and Aims

Central line-associated bloodstream infections (CLABSIs) are currently the commonest type of nosocomial infection in neonates admitted to the neonatal intensive care unit (NICU), contributing substantially to neonatal morbidity and mortality. Reducing the burden of CLABSI requires the assessment of pathways of disease and associated risk factors, and identification of areas for quality improvement. We used data of preterm infants admitted to a NICU over an 8-year surveillance period to describe trends in annual CLABSI incidence rates, clinical characteristics and bacterial etiology.

Methods

All preterm neonates (<32 weeks gestational age) admitted to the NICU between January 1^st, 2012 and December 31^st, 2019 were included in the analysis. Annual incidence rates for CLABSI were calculated per 1,000 central-line days. U chart analysis was performed to determine special-cause variation in half-yearly CLABSI rates. Trends in CLABSI incidence were assessed using Poisson regression.

Results

Of 1,400 included infants, 894 (63.9%) received a central-line, of whom 83 (9.3%) acquired 85 CLABSIs. Statistically significant decreasing trends were found in the number of infants with a central-line (p<0.001) and median birth-weight (p=0.03), while an increasing trend was observed in median line-days per infant (p=0.01) (Table 1). Despite the substantial increase in CLABSI rate in 2015, U chart analysis did not reveal any potential sources of special-cause variation. Coagulase-negative staphylococci were the most frequently isolated pathogens (n=66, 78%).

Conclusions

Although no significant changes were found in annual CLABSI rates, fewer lines were placed with significantly longer dwell-times. Emphasis on optimizing catheter dwell-time and limiting line-use is warranted in CLABSI prevention efforts.

Background and Aims

Point of care lung ultrasound is recognized as a valid imaging technique for the diagnosis and follow-up of pneumonia in children and has been explored in the safe management of COVID-19 outbreaks. Our aim was to retrospectively analyze the LUS images obtained for clinical use in children with COVID-19 pneumonia and correlate and compare our findings with the severity of disease and findings reported by our adult critical care colleagues.

Methods

This is a retrospective observational analysis of LUS imaging performed during the patients’ admission to PICU. Fourteen children tested positive for SARS-Cov-2 by qualitative real-time RT-PCR targeting the RNA polymerase region admitted from March 2020 to March 2021. Eight of these were admitted to PICU for mechanical ventilatory support. Semiquantitative LUS scores were retrospectively analyzed for all obtained images.

Results

	Early	Established	Advanced
Clinical Findings	FiO2 60-80% OI=8.8-15, PF ratio 150-180 Increased WOB Patient requiring some support (invasive or noninvasive)	FiO2 70-100% OI=15-18.8; PF ratio 100-150 Proning Muscle relaxation Inotropic support	FiO2 80 – 100% OI 20-23.6, PF ratio 80-100 high PEEP HFOV Chest drain insertion
CXR
	Bilateral infiltrates	Confluent infiltrates	4 quadrant disease
LUS
USG finding description	Scattered B lines, with skip zones bilaterally Pleural thickening	Confluent B lines Subpleural consolidation Pleural thickening and irregularity	Lobar consolidation with dynamic air bronchograms Pleural effusion

Conclusions

In this case series, we have found that both qualitative and semi-quantitative LUS features of COVID-19 pneumonia in children correlates with the degree of severity of lung disease and are similar to those reported in adults

Background and Aims

Thrombocytopenia-Associated Multiple Organ Failure (TAMOF) is a clinical phenotype in sepsis. The pathophysiology of TAMOF is related to thrombotic microangiopathy. Mortality rates in children with TAMOF are higher than in children with other sepsis phenotypes. There is strong evidence that Therapeutic Plasma Exchange (TPE) reduces mortality. The aims of TPE are mainly to eliminate inflammatory mediators and antifibrinolytic molecules, to provide anticoagulant proteins and ADAMTS-13 activity. We retrospectively evaluated the data of 95 patients who were admitted to two pediatric intensive care units between 2014-2020. We aimed to show the effect of TPE and other immune-modulatory treatments on mortality and the length of intensive care unit stay.

Methods

TAMOF is defined as thrombocytopenia (<100,000/µL), new-onset organ failure in at least three systems and the etiology of organ failure was due to systemic infection and shock. We enrolled 95 patients who met these criteria. Demographic data, PRISM score, organ failure index (OFI) score of the patients and whether they received renal replacement, inotrope and mechanical ventilator supports were recorded. For the day of each TPE session, PELOD and OFI scores were calculated; laboratory parameters were recorded.

Results

The mean PRISM score was found to be 18.2. While 46% of patients required renal replacement therapy, three-quarters of the patients received support from invasive mechanical ventilation. Overall mortality was calculated as %33 in all patients.

Conclusions

Further studies are needed to determine the treatment regimen of TAMOF. Given the pathophysiology of the disease, TPE and other immunomodulatory treatments such as intravenous immunoglobulin and steroid seem promising.