Background In April, 2020, clinicians in the UK observed a cluster of children with unexplained inflammation requiring admission to paediatric intensive care units (PICUs). We aimed to describe the clinical characteristics, course, management, and outcomes of patients admitted to PICUs with this condition, which is now known as paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS). MethodsWe did a multicentre observational study of children (aged <18 years), admitted to PICUs in the UK between April 1 and May 10, 2020, fulfilling the case definition of PIMS-TS published by the Royal College of Paediatrics and Child Health. We analysed routinely collected, de-identified data, including demographic details, presenting clinical features, underlying comorbidities, laboratory markers, echocardiographic findings, interventions, treatments, and outcomes; serology information was collected if available. PICU admission rates of PIMS-TS were compared with historical trends of PICU admissions for four similar inflammatory conditions (Kawasaki disease, toxic shock syndrome, haemophagocytic lymphohistiocytosis, and macrophage activation syndrome). Findings 78 cases of PIMS-TS were reported by 21 of 23 PICUs in the UK. Historical data for similar inflammatory conditions showed a mean of one (95% CI 0•85-1•22) admission per week, compared to an average of 14 admissions per week for PIMS-TS and a peak of 32 admissions per week during the study period. The median age of patients was 11 years (IQR 8-14). Male patients (52 [67%] of 78) and those from ethnic minority backgrounds (61 [78%] of 78) were over-represented. Fever (78 [100%] patients), shock (68 [87%]), abdominal pain (48 [62%]), vomiting (49 [63%]), and diarrhoea (50 [64%]) were common presenting features. Longitudinal data over the first 4 days of admission showed a serial reduction in C-reactive protein (from a median of 264 mg/L on day 1 to 96 mg/L on day 4), D-dimer (4030 µg/L to 1659 µg/L), and ferritin (1042 μg/L to 757 μg/L), whereas the lymphocyte count increased to more than 1•0 × 10⁹ cells per L by day 3 and troponin increased over the 4 days (from a median of 157 ng/mL to 358 ng/mL). 36 (46%) of 78 patients were invasively ventilated and 65 (83%) needed vasoactive infusions; 57 (73%) received steroids, 59 (76%) received intravenous immunoglobulin, and 17 (22%) received biologic therapies. 28 (36%) had evidence of coronary artery abnormalities (18 aneurysms and ten echogenicity). Three children needed extracorporeal membrane oxygenation, and two children died.Interpretation During the study period, the rate of PICU admissions for PIMS-TS was at least 11-fold higher than historical trends for similar inflammatory conditions. Clinical presentations and treatments varied. Coronary artery aneurysms appear to be an important complication. Although immediate survival is high, the long-term outcomes of children with PIMS-TS are unknown.Funding None.

Measurements and Main Results: De-identified data collected as part of routine clinical care was analysed. All children were diagnosed and staged for AKI based on the level of serum creatinine above the upper limit of reference interval (ULRI) values according to published guidance. Severe AKI was defined as stage 2/3 AKI. Uni-and multi-variable analyses were performed to study the association between demographic data, clinical features, markers of inflammation and cardiac injury, and severe AKI. Over the study period, 116 patients with PIMS-TS were admitted to 15 UK PICUs. Any-stage AKI occurred in 48/116 patients (41.4%), and severe AKI in 32/116 (27.6%) patients, which was mostly evident at admission (24/32, 75%). In univariable analysis, body mass index, hyperferritinemia, high C-reactive protein (CRP), Pediatric Index of Mortality 3 (PIM3) score, vasoactive medication and invasive mechanical ventilation (IMV) were associated with severe AKI. In multivariable logistic regression, hyperferritinemia was associated with severe AKI (compared to non-severe AKI, adjusted odds ratio 1.04, 95% CI 1.01-1.08, p=0.04). Severe AKI was associated with longer PICU stay (median 5 days [IQR 4,7] vs 3 days [IQR 1.5,5], p<0.001) and increased duration of IMV (median 4 days [IQR 2,6] vs 2 days [IQR 1,3], p=0.04). Conclusions: Severe AKI occurred in just over a quarter of children admitted to UK PICUs with PIMS-TS. Hyperferritinemia was significantly associated with severe AKI. Severe AKI was associated with increased duration of stay and ventilation. Although short-term outcomes for AKI in PIMS-TS appear good, long-term outcomes are unknown.

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General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/ probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m -2 ); low BMI (<18.5 kg.m -2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.

Aims: To assess the technical performance of spirometry in one general practice, and then to deliver in-house education to effect change.Methods: Retrospective audit of 45 spirometry reports assessed against possible alternative quality criteria. Three subsequent educational interventions for those clinicians performing and interpreting spirometry. Re-audit of 45 spirometry report sheets four months later against the same criteria.Results: 38% of the initial post-bronchodilator spirometries were technically flawed. Post-education, 2% of spirometries were technically flawed and respiratory referrals fell by 50%. Conclusion:The technical quality of practice spirometry can be audited. In-house education significantly reduced spirometry errors and was associated with a 50% reduction in respiratory referrals.