Objective: Hemolytic uremic syndrome (HUS) is a triad of hemolytic anemia, thrombocytopenia, and acute renal failure. In critically ill children with HUS, extra-renal manifestations may require intensive care unit admission and extracorporeal membrane oxygenation (ECMO) support. Outcomes specific to HUS and ECMO in children have not been well investigated. The primary aim of this project was to query a multicenter database to identify risk factors associated with mortality in HUS patients supported on ECMO. A secondary aim was to identify factors associated with ECMO utilization in children with HUS. Methods: Utilizing the Pediatric Health Information System (PHIS (R)) database (January 2004 and September 2018), this retrospective, multicenter cohort study identified the index HUS hospitalization among children aged 0-18 years. Univariate analysis was used to compare demographics, clinical characteristics, and procedures to identify risk factors associated with adverse outcomes. Results: Among 4,144 subjects, 37 were supported on ECMO. Survival for those on ECMO support was 54%. Among non-survivors, 59% of deaths occurred within 14 days of hospitalization. The mean hospital LOS was 15.9 days in non-survivors vs 53.9 days for survivors (p<0.001). When comparing subjects supported on ECMO to those who were not, patients with ECMO support had statistically longer hospital length of stay (LOS) and higher rates of extra-renal involvement (p<0.001). Conclusion: This study found a mortality rate of 46% among HUS patients requiring ECMO. The investigated clinical risk factors were not associated with mortality amongst the ECMO population. The study identifies risk factors associated with ECMO utilization in children with HUS.
Objective: Extracorporeal Membrane Oxygenation (ECMO) support is increasingly used for refractory septic shock. There is lack of data on the outcomes of children requiring ECMO support for refractory septic shock. Our study objective was to describe the variables associated with survival, risk factors for mortality and outcomes of children requiring ECMO support for refractory shock. Materials and Methods: Retrospective registry study of 340 international centers contributing data to the ELSO Registry, analyzing children <18 years who received ECMO with septic shock, severe sepsis, sepsis, SIRS, toxic shock syndrome, shock associated with infection and septicemia from any organism from 1990 to 2015. Outcomes were analyzed by categorizing the data into survivors and non-survivors. Logistic regression models were used to describe the association of dependent variable and multiple independent variables. Results: A total of 1928 patients were identified which met the inclusion criteria. 744 (38.5%) of the cohort survived. Survivors in this cohort tend to have longer duration of ECMO (230 hrs vs 201 hrs, p =0.005) and shorter time from intubation to ECMO cannulation (87 hrs vs 116 hrs, p =0.0033) when compared to non-survivors. Survivors were also noted to have higher pH, higher serum bicarbonate, higher saturations, and higher systolic, diastolic, and mean arterial pressures compared to non-survivors. Conclusions: These results suggest that early initiation of ECMO therapy for refractory sepsis is associated with better patient outcomes. ECMO is unlikely to recover patients once circulatory and metabolic collapse has developed.
Background: Tracheal intubation in critically ill children is a life-saving, but high-risk procedure that involves multiple team members with diverse clinical skills. We aim to examine the association between the provider-reported teamwork rating and the occurrence of adverse tracheal intubation-associated events (TIAEs). Methods: A retrospective analysis of prospectively collected data from 45 pediatric intensive care units (PICUs) in the National Emergency Airway Registry for Children (NEAR4KIDS) database from January 2013 to March 2018 was performed. A composite teamwork score was generated using the average of each of five (7-point Likert scale) domains in the teamwork assessment tool. Poor teamwork was defined as an average score of 4 or lower. Team provider stress data were also recorded with each intubation. Results: 12,536 tracheal intubations (TIs) were reported from 2013 to 2018. Approximately 4.1% (n=520) rated a poor teamwork score. TIs indicated for shock were more commonly associated with a poor teamwork score, while those indicated for procedures and those utilizing neuromuscular blockade were less commonly associated with a poor teamwork score. TIs with poor teamwork were associated with a higher occurrence of adverse TIAE (24.4% vs. 14.4%, p<0.001), severe TIAE (13.7% vs. 5.9%, p<0.001), and peri-intubation hypoxemia < 80% (26.4% vs. 17.9%, p<0.001). After adjusting for indication, provider type, and neuromuscular blockade use, poor teamwork was associated with higher odds of adverse TIAEs (OR 1.77, 95% CI 1.35-2.34), severe TIAEs (OR 2.23, 95% CI 1.47-3.37) and hypoxemia (OR 1.63, 95% CI 1.25-2.03). Conclusion: TIs with poor teamwork were independently associated with a higher occurrence of TIAEs, severe TIAEs, and hypoxemia.
Background: Metabolic disturbances frequently occur in neonatal seizures either as an underlying cause or as an associated abnormality. A prompt recognition of metabolic abnormalities and early therapy are necessary to avoid poor neurological outcome. Methods: Neonates with clinical seizures were enrolled in the study. Diagnostic evaluation included complete blood count, sepsis screen, and estimation of blood glucose, serum sodium, calcium and magnesium before instituting any specific treatment. Metabolic abnormalities, were considered as isolated when hypoxicischemic encephalopathy (HIE), sepsis, intracranial hemorrhage and polycythemia were ruled out. Results: Among 80 newborns with clinical seizures, one metabolic abnormality was detected in 46 (57.5%). The commonest metabolic abnormality observed was hypoglycemia; noted in 22/80 (27.5%). Hypocalcemia was the second common abnormality; noted in 10/80 (12.5%). Isolated metabolic abnormalities were observed in 23.8% (19/80) of neonates with seizures. Associated morbidities with seizures included HIE in 21 (26.3%) and sepsis in 28 (35%). Hypoglycemia was the commonest isolated metabolic abnormality (12.5%). Metabolic abnormalities coexisted with HIE in 9 out of 21 neonates and with sepsis in 8 of 28 neonates. Hypoglycemia was the common abnormality associated with both the conditions. Inborn errors of metabolism constituted 8.8% of the cohort studied (7 of 80 patients). Conclusions: A metabolic abnormality was detected in more than of 50% neonates with clinical seizures enrolled in our study. Metabolic abnormality also co-exists in neonates with HIE as well as sepsis related seizures.
Objectives: We aim to determine if there is a difference in length of respiratory support between nasoduodenal (NDT) and nasogastric tube (NGT) feedings in patients with bronchiolitis on high flow nasal cannula (HFNC). Methods: A single-center non-blinded parallel randomized control trial at a tertiary care hospital was designed. Pediatric patients ≤ 12 months old with bronchiolitis, on HFNC, requiring nutrition via a feeding tube were eligible. Patients were randomized to NGT or NDT and stratified into low- and high-risk groups. Length of respiratory support was the primary outcome. Secondary outcomes included length of stay, number of emesis events, maximum level of respiratory support, number of x-rays to confirm tube placement, number of attempts to place the tube by staff, adverse events during placement, instances of PICU admission, and emergency room visits and hospital readmissions within 7 and 30 days after discharge. Results: Forty patients were randomized, 20 in each arm. There were no significant differences in baseline characteristics. We found no significant difference in length of respiratory support between the two groups (NGT 0.84 IRR, [0.58, 1.2], p = 0.34). None of the secondary outcomes showed significant differences. Each arm reported one adverse event: nasal trauma in the NGT group and pneumothorax in the NDT group. Conclusions: For infants with bronchiolitis on HFNC that need enteric tube feedings, we find no difference in duration of respiratory support or other clinically relevant outcomes for those with NGT or NDTs. These results should be interpreted in the context of a limited sample size and an indirect primary outcome of length of respiratory support that may be influenced by other factors besides aspiration events.
