Background Infants undergoing ECMO may have elevated serum ferritin and iron levels, raising concerns about iron overload. Recent studies question the utility of these markers for acute vs. chronic iron overload during ECMO. This study evaluates iron content and localization in autopsy tissues from deceased infants who received or were considered for ECMO. Methods This retrospective single-center case-control study analyzed paraffin-embedded tissues from the basal ganglia, liver, spleen, pancreas, and kidney. Tissue sections were stained to quantify iron deposition and an independent pathologist reviewed samples for iron accumulation. Results Eighteen deceased infants' tissues were analyzed: nine underwent ECMO, and nine were considered for it. Both groups showed multi-organ iron accumulation with no significant difference between ECMO and non-ECMO cohorts. Red blood cell transfusions were linked to increased iron content in adrenal ( p = 0.004), hepatic ( p = 0.042), and splenic ( p = 0.013) tissues. Conclusions ECMO exposure alone does not independently increase iron content in infants' organs. Multi-organ iron accumulation in both groups suggests iron deposition in critically ill pediatric patients irrespective of ECMO exposure. Further research is needed to understand the mechanisms and implications.

Introduction: Elevations in serum ferritin and serum iron occur during pediatric extracorporeal membrane oxygenation (ECMO). Previous reports attribute the elevation to frequent red blood cell transfusions and/or hemolysis. Chronic transfusion can cause iron deposition in tissues leading to multisystem organ dysfunction. This study aims identify clinical factors associated with elevated ferritin and iron in pediatric ECMO patients, along with post-decannulation magnetic resonance imaging (MRI) assessment of iron deposition in liver and brain. Methods: Prospective, pilot study, using descriptive statistics to investigate potential associations between patient characteristics, serum ferritin and iron levels, and post-decannulation hepatic and basal ganglia iron deposition. Results: In this study, nine patients (100%) had elevated serum ferritin levels during ECMO. High ferritin levels were more common with veno-arterial than with veno-venous cannulation ( p = 0.026) and were also associated with high plasma free hemoglobin levels ( p < 0.001). Five patients presented with elevated serum iron levels. High serum iron levels were associated with higher daily ( p = 0.016) and cumulative transfusion volumes ( p = 0.013) as well ECMO duration beyond 7 days. MRI scans were performed on three patients with no evidence of abnormal iron deposition detected in the liver or brain. Conclusions: This pilot study shows that during pediatric ECMO, elevations in serum ferritin and serum iron occur and those elevations may be related to the cannulation modality, ECMO duration, amount of hemolysis, and volume of red blood cell transfusions. Further investigation is warranted to fully understand the implications of elevated serum iron and ferritin in pediatric ECMO.

Background: The U.S. Indo-Pacific Command (INDOPACOM) has over 375,000 military personnel, civilian employees, and their dependents. Routine pediatric care is available in theater, but pediatric subspecialty, surgical, and intensive care often require patient movement. Transfer is frequently performed by military air evacuation teams and intermittently augmented by civilian services. Pediatric care requires special training and equipment, yet most transports are staffed by non-pediatric specialists. We seek to describe the epidemiology of pediatric transport missions in INDOPACOM. Methods: A retrospective review of all patients less than 18 years old transported within INDOPACOM and logged into the Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from June 2008 through June 2018 was conducted. Data are reported using descriptive statistics. Patients were categorized into four age groups: neonatal (<31 days), infant (31-364 days), young children (1 to<8 years), and older children (8-17 years). Results: During the study period, 687 out of 4,217 (16.3%) transports were children. Median age was 4 years (interquartile range 6 months to 8 years) and 654 patients (95.2%) were transported via military fixed-wing aircraft. There were 219 (31.9%) neonates, 162 (23.6%) infants, 133 (19.4%) young children, and 173 (25.2%) older children. Most common diagnoses encountered were respiratory, cardiac, or abdominal, although older children had a higher percentage of psychiatric diagnoses (28%). Mechanical ventilation was used in 118 (17.2%) patients, and 75 (63.6%) of these patients were neonates. Conclusions: Within TRAC2ES, nearly one in six encounters were patients aged <18 years, with neonates or infants representing nearly one of three pediatric encounters. Slightly more than one in six pediatric patients required intubation for transport. The data suggest the need for appropriately trained transport teams and equipment be provided to support these missions.

Abnormally high serum ferritin levels have been reported during pediatric ECMO, attributed to frequent red blood cell transfusion and suggestive of iron overload. However, the utility of ferritin for diagnosing iron overload is complicated by its response as an acute-phase reactant. In this study, we aimed to assess the utility of ferritin for diagnosing ECMO-related iron overload, with secondary aims of understanding its relationship with inflammation and erythropoiesis. Ferritin was elevated in all pediatric ECMO runs (median 459 ng/ml, IQR = 327.3-694.4). While intermittent elevations in serum iron were observed, all normalized prior to decannulation. Unreported previously, erythropoietin (EPO) remained well above normative values prior to and throughout ECMO runs, despite frequent transfusion and exposure to hyperoxia. Ferritin correlated poorly with serum iron [r (80) = 0.05, p = 0.65], but correlated well with IL-6 [r(76) = 0.48, p < 0.001] and EPO [r(81) = 0.55, p < 0.001]. We suggest that serum ferritin is a poor biomarker of iron overload in ECMO patients, and that future investigation into its relationship with EPO is warranted.

OBJECTIVES: The Pediatric Early Warning Score (PEWS) is an evidence-based tool that allows early collaborative assessment and intervention for a rapid response team (RRT) activation. The goal of our quality improvement initiative was to reduce the percentage of unnecessary RRT activations by 50% over 2 years without increasing PICU transfers or compromising patient safety and timely evaluation. METHODS: A PEWS system replaced preexisting vital signs-based pediatric RRT criteria and was modified through plan-do-study-act cycles. Unnecessary RRT activations, total RRT activation rate, transfers to the PICU, total clinical interventions performed per RRT, and missed RRT activation rate were compared between intervention periods. Likert scale surveys were administered to measure satisfaction with each modification. RESULTS: There was a significant decrease in the percentage of unnecessary RRT activations from 33% to 3.5% after the implementation of the PEWS and modified-PEWS systems (P < .05). The RRT activation rate decreased from 22.6 to 13.3 RRT activations per 1000 patient care days after implementation of the PEWS and modified-PEWS systems (P < .05), without changes in PICU transfer rates. Physicians reported that the PEWS system improved nursing communication and accuracy of RRT criteria (P < .05). Nursing reported that the PEWS system improved patient management and clinical autonomy (P < .05). CONCLUSIONS: The PEWS systems have been an effective means of identifying deteriorating pediatric patients and reducing unnecessary RRT activations. The new system fosters collaboration and communication at the bedside to prevent acute deterioration, perform timely interventions, and ultimately improve patient safety and outcomes.

Elevated serum ferritin, or hyperferritinemia, is frequently used as a surrogate to represent iron overload in patients who undergo chronic transfusions. Recently, increased ferritin and iron levels have been found in pediatric Extracorporeal Life Support (ECLS) patients. While elevated ferritin may represent an acute inflammatory phase reactant alone, it can also represent both acute or chronic iron overload due to large volume or chronic transfusion. Recognition of iron overload is crucial because when untreated it …