Coronavirus disease 2019 (COVID-19) in adults has been associated with thrombosis. Multisystem inflammatory syndrome in children (MIS-C) with COVID-19 case series have reported high fibrinogen levels, but it is not known whether this causes thrombophilia. We report two patients needing extracorporeal membrane oxygenation (ECMO) who both suffered thrombotic complications. We retrospectively reviewed patients with MIS-C needing ECMO support admitted to a single Paediatric and Cardiac Intensive Care Unit within a regional center for MIS-C in South East England. Two children required ECMO for cardiovascular support. Both developed thrombotic events despite receiving heparin infusions at dosing higher than the interquartile range for our ECMO population. Case 1 developed a right anterior and middle cerebral artery infarct, which led to his death. Case 2 had a right atrial thrombus, which resolved without complication. When compared with patients undergoing ECMO in the same institution in pre-MIS-C era, fibrinogen levels were consistently higher before and during ECMO therapy. MIS-C patients presenting with hyperfibrinogenemia are likely to have a propensity toward thrombotic complications; this must be considered when optimizing the anticoagulation strategy on ECMO.
OBJECTIVES:Neonates with respiratory failure are ideally supported with veno-venous rather than veno-arterial extracorporeal membrane oxygenation due to the reduced rate of neurologic complications. However, the proportion of neonates supported with veno-venous extracorporeal membrane oxygenation is declining. We report multisite veno-venous extracorporeal membrane oxygenation, accessing the neck, returning to the inferior vena cava via the common femoral vein in neonates and children less than 10 kg. DESIGN:Retrospective case series with 1 year minimum follow-up.PATIENTS: Patients less than 10 kg supported with veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein SETTING: A 30-bed pediatric intensive care delivering extracorporeal membrane oxygenation to approximately 20 children annually. INTERVENTIONS:Veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein was delivered using two single lumen cannulae. MEASUREMENTS AND MAIN RESULTS:January 2015 to August 2019, 11 patients underwent veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein with median weight of 3.6 kg (interquartile range 2.8-6.1 kg), and median corrected gestational age of 13 days (interquartile range, 2-175 d). The smallest patient weighed 2.1 kg. Seven patients had comorbidities. Extracorporeal membrane oxygenation was technically successful in all patients with median flows of 126 mL/kg/min (interquartile range, 120-138 mL/kg/min) and median arterial oxygenation saturation of 94% (interquartile range, 91-98%) at 24 hours. Nine survived to home discharge, and two were palliated. Common femoral vein occlusion was observed in all patients on ultrasound post decannulation. There was no clinical or functional deficit in the cannulated limb at follow-up, a minimum of 1 year post extracorporeal membrane oxygenation. CONCLUSIONS:Veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein was performed safely in patients under 10 kg with the smallest patient weighing 2.1 kg. Although occlusion of the common femoral vein was observed in patients post decannulation, subsequent follow-up demonstrated no clinical implications. We challenge current practice that veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein cannot be performed in nonambulatory patients and suggest that this strategy is preferred over veno-arterial extracorporeal membrane oxygenation in infants requiring extracorporeal membrane oxygenation for respiratory failure.
Workload was most intense for the in-house team at night, in terms of sicker admissions, ECMOs and cardiac arrests. Conventional roster patterns may not offer ideal matching between staffing and workload. Data analysis of variable and urgent workload may be used to inform medical rosters.
AimsUp to 3% of hospitalised paediatric patients are at risk of sudden deterioration. Paediatric early warning systems (PEWS) aim to identify at-risk patients to assist clinical decision-making. Although many UK hospitals use PEWS, there is no national standard. Our hospital introduced a new PEWS in August 2015, based on the Australian ‘Between the Flags’ system. Each physiological parameter is graphed in colour coded bands (red – severely deranged; amber – very deranged; blue – moderately deranged; white – normal), with no numerical scoring. In Australia, ‘Between the Flags’ decreased the proportion of deteriorating patients who were not appropriately escalated and admitted to paediatric intensive care (PICU)1 – an improvement we have also seen in our hospital, after applying a PEWS within inpatient areas. We undertook a study to assess the suitability of this PEWS to recognising deterioration in children who were referred from regional hospitals to our PICU.MethodWe retrospectively analysed referral records from our intensive care transport service to assess the sensitivity of PEWS. We hypothesised that PEWS would be sensitive enough to detect deterioration in regional hospitals, as defined by the need for PICU admission, using a threshold of one red event or three or more amber events. Clinical observations at the time of transfer request were recorded according to age-specific charts. Transfer requests from other PICUs, step-down units, and emergency departments were excluded.Results100 patient records fulfilling inclusion criteria were randomly selected from January and July 2016. 146 red triggers were identified. Our PEWS would have been activated in 97 out of 100 patients who were subsequently admitted to PICU – 97% sensitivity, based on a threshold of one red event or three or more amber events. With threshold of only one red event, our PEWS is 91% sensitive.ConclusionOur PEWS is sensitive as a trigger tool for regional referring hospitals. Further study on specificity is required to identify its wider utility.ReferenceAkre, M. et al. ‘Sensitivity Of The Paediatric Early Warning Score To Identify Patient Deterioration’. PAEDIATRICSPEDIATRICS 125.4 (2010): e763–e769.
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