No abstract

Multisystem inflammatory syndrome in children (MIS-C) is characterized by fever and multiorgan system dysfunction. Neurologic complications of MIS-C are not well described. We present 4 patients with MIS-C who had intracranial hypertension and discuss the unique management considerations when this occurs concurrently with significant myocardial dysfunction.

Background The effect of various sedatives and anesthetics on vasopressor modulation of cerebral blood flow (CBF) in children is unclear. In adults, isoflurane has been described to decrease CBF to a lesser extent than fentanyl and midazolam. Most large animal models of neurocritical care use inhaled anesthetics for anesthesia. Investigations involving modulations of CBF would have improved translatability within a model that more closely approximates the current practice in the pediatric intensive care unit. Methods Fifteen (15) four-week-old piglets were given one of 2 anesthetic protocols: total IV anesthesia (TIVA) (midazolam 1 mg/kg/hr and fentanyl 100 mcg/kg/hr, N=8) or ISO (isoflurane 1.5–2% and fentanyl 100 mcg/kg/hr, N=7). Mean arterial blood pressure, intracranial pressure (ICP), CBF, and brain tissue oxygen tension were measured continuously as piglets were exposed to escalating doses of arginine vasopressin, norepinephrine (NE) and phenylephrine (PE). Results Baseline CBF was similar in two groups (ISO 38±10 vs. TIVA 35±26 ml/100gm/min) despite lower baseline cerebral perfusion pressure in the ISO group, 45±11 vs. 71±11 mmHg (p< 0.0005). Piglets in ISO group displayed increases in ICP with PE and NE (11±4 vs. 16±4 mmHg and 11±8 vs. 18±5 mmHg; p< 0.05), but in the TIVA group only exposure to PE resulted in increases in ICP when comparing maximal dose values to baseline data (11±4 vs. 15±5 mmHg; p < 0.05). Normalized CBF displayed statistically significant increases with regards to anesthetic group and vasopressor dose when piglets were exposed to NE and PE (p < 0.05), suggesting an impairment of autoregulation within ISO, but not TIVA. Conclusion The vasopressor effect on CBF was limited when using a narcotic-benzodiazepine-based anesthetic protocol compared to volatile anesthetics, consistent with a preservation of autoregulation. Selection of anesthetic drugs is critical to investigate mechanisms of cerebrovascular hemodynamics, and in translating critical care investigations between the laboratory and bedside.

Low cerebral blood flow (CBF) states have been demonstrated in children early after traumatic brain injury (TBI), and have been correlated with poorer outcomes. Cerebral perfusion pressure (CPP) support following severe TBI is commonly implemented to correct cerebral hypoperfusion, but the efficacy of various vasopressors has not been determined. Sixteen 4-week-old female swine underwent nonimpact inertial brain injury in the sagittal plane. Intraparenchymal monitors were placed to measure intracranial pressure (ICP), CBF, brain tissue oxygen tension (PbtO2), and cerebral microdialysis 30 min to 6 h post-injury. One hour after injury, animals were randomized to receive either phenylephrine (PE) or norepinephrine (NE) infusions titrated to a CPP>70 mm Hg for 5 h. Animals were euthanized 6 h post-TBI, and brains were fixed and stained to assess regions of cell and axonal injury. After initiation of CPP augmentation with NE or PE infusions, there were no differences in ICP between the groups or over time. Animals receiving NE had higher PbtO2 than those receiving PE (29.6±10.2 vs. 19.6±6.4 torr at 6 h post-injury, p<0.05). CBF increased similarly in both the NE and PE groups. CPP support with PE resulted in a greater reduction in metabolic crisis than with NE (lactate/pyruvate ratio 16.7±2.4 vs. 42.7±10.2 at 6 h post-injury, p<0.05). Augmentation of CPP to 70 mm Hg with PE resulted in significantly smaller cell injury volumes at 6 h post-injury than CPP support with NE (0.4% vs. 1.4%, p<0.05). Despite similar increases in CBF, CPP support with NE resulted in greater brain tissue oxygenation and hypoxic-ischemic injury than CPP support with PE. Future clinical studies comparing the effectiveness of various vasopressors for CPP support are warranted.

No abstract

Aberrant or anomalous anatomy is an under appreciated risk for venous thromboembolic events (VTE). Five adolescents with VTE and predisposing anatomic abnormalities are presented. In three cases, knowledge of the underlying anatomic abnormalities resulted in changes in treatment and management. In two other cases, failure to consider or correct the underlying defect resulted in recurrent thrombosis or post-thrombotic complications. Few case reports are found in the pediatric literature, but a MEDLINE search across all age groups suggests these anomalies are frequently found when appropriate radiological imaging is obtained.

Objectives: Capillary refill time (CRT) is a non-invasive method to assess tissue perfusion to determine shock status. CRT is defined as the time required to regain skin color after blanching pressure is applied. While common methods to measure CRT depend on clinicians' visual assessment, a new approach using a pulse oximeter waveform analysis exists, referred to as full finger reperfusion time (FFRT). We aim to evaluate reproducibility and validity of the novel FFRT measurement using clinicians' visual CRT assessment as a reference standard.Design: Prospective observational study.Setting: Pediatric Intensive Care Units (PICUs) and Operating Suites at a large academic children's hospital.Patients: 99 children aged 1-12 years old with various skin color tones.Interventions: Each child had 10 measurements, including 5 FFRT and 5 clinician CRT, alternating 2 nd and 3 rd digits.

Objectives: Bag-mask ventilation is commonly used prior to tracheal intubation; however, the epidemiology, risk factors, and clinical implications of difficult bag-mask ventilation among critically ill children are not well studied. This study aims to describe prevalence and risk factors for pediatric difficult bag-mask ventilation as well as its association with adverse tracheal intubation–associated events and oxygen desaturation in PICU patients. Design: A retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from January 2013 to December 2018. Setting: Forty-six international PICUs. Patients: Children receiving bag-mask ventilation as a part of tracheal intubation in a PICU. Interventions: None. Measurements and Main Results: The primary outcome is the occurrence of either specific tracheal intubation–associated events (hemodynamic tracheal intubation–associated events, emesis with/without aspiration) and/or oxygen desaturation (< 80%). Factors associated with perceived difficult bag-mask ventilation were found using univariate analyses, and multivariable logistic regression identified an independent association between bag-mask ventilation difficulty and the primary outcome. Difficult bag-mask ventilation is reported in 9.5% (n = 1,501) of 15,810 patients undergoing tracheal intubation with bag-mask ventilation during the study period. Difficult bag-mask ventilation is more commonly reported with increasing age, those with a primary respiratory diagnosis/indication for tracheal intubation, presence of difficult airway features, more experienced provider level, and tracheal intubations without use of neuromuscular blockade (p < 0.001). Specific tracheal intubation–associated events or oxygen desaturation events occurred in 40.2% of patients with reported difficult bag-mask ventilation versus 19.8% in patients without perceived difficult bag-mask ventilation (p < 0.001). The presence of difficult bag-mask ventilation is independently associated with an increased risk of the primary outcome: odds ratio, 2.28 (95% CI, 2.03–2.57; p < 0.001). Conclusions: Difficult bag-mask ventilation is reported in approximately one in 10 PICU patients undergoing tracheal intubation. Given its association with adverse procedure–related events and oxygen desaturation, future study is warranted to improve preprocedural planning and real-time management strategies.