IMPORTANCEThe recent and ongoing coronavirus disease 2019 (COVID-19) pandemic has taken an unprecedented toll on adults critically ill with COVID-19 infection. While there is evidence that the burden of COVID-19 infection in hospitalized children is lesser than in their adult counterparts, to date, there are only limited reports describing COVID-19 in pediatric intensive care units (PICUs).OBJECTIVE To provide an early description and characterization of COVID-19 infection in North American PICUs, focusing on mode of presentation, presence of comorbidities, severity of disease, therapeutic interventions, clinical trajectory, and early outcomes. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included children positive for COVID-19 admitted to 46 North American PICUs between March 14 and April 3, 2020. with follow-up to April 10, 2020. MAIN OUTCOMES AND MEASURES Prehospital characteristics, clinical trajectory, and hospital outcomes of children admitted to PICUs with confirmed COVID-19 infection.RESULTS Of the 48 children with COVID-19 admitted to participating PICUs, 25 (52%) were male, and the median (range) age was 13 (4.2-16.6) years. Forty patients (83%) had significant preexisting comorbidities; 35 (73%) presented with respiratory symptoms and 18 (38%) required invasive ventilation. Eleven patients (23%) had failure of 2 or more organ systems. Extracorporeal membrane oxygenation was required for 1 patient (2%). Targeted therapies were used in 28 patients (61%), with hydroxychloroquine being the most commonly used agent either alone (11 patients) or in combination (10 patients). At the completion of the follow-up period, 2 patients (4%) had died and 15 (31%) were still hospitalized, with 3 still requiring ventilatory support and 1 receiving extracorporeal membrane oxygenation. The median (range) PICU and hospital lengths of stay for those who had been discharged were 5 (3-9) days and 7 (4-13) days, respectively.CONCLUSIONS AND RELEVANCE This early report describes the burden of COVID-19 infection in North American PICUs and confirms that severe illness in children is significant but far less frequent than in adults. Prehospital comorbidities appear to be an important factor in children. These preliminary observations provide an important platform for larger and more extensive studies of children with COVID-19 infection.
Ipratropium and magnesium were both often used in children with severe asthma hospitalizations that required continuous albuterol therapy. Magnesium use was associated with unfavorable outcomes, possibly reflecting preferential treatment to patients with more severe cases and differing practices between centers. Given the high prevalence of asthma, wide variations in practice, and the potential to improve outcomes and costs, prospective trials of these adjunctive therapies are needed.
Objective To test the effects of inhaled ipratropium on clinical outcomes of critical asthma in the first randomized trial of this adjunctive therapy in critically ill children. Design Pilot, placebo‐controlled, double‐blinded, and randomized‐controlled trial Patients Thirty children (15 per group) with critical asthma receiving high‐intensity albuterol per a standardized pathway utilizing objective assessments to wean patients to less frequent albuterol administration. Interventions Subjects were randomized to receive either nebulized ipratropium bromide (500 µg in 0.9% saline per dose) or an equivalent volume of nebulized 0.9% saline every 6 h until the patient was successfully weaned to albuterol doses every 2 h (“q2 albuterol”). Measurements and Main Results Demographics, initial clinical severity score, and asthma histories were similar between groups. There was no significant difference in the median duration of high‐intensity albuterol between the treatment group (17.5 [10.3–22.1] h) and placebo group (14.6 [12.7–24.5] days; p = .56). Similarly, there was no significant difference in pediatric intensive care unit length of stay (22.6 [21.1–33.6] vs. 21.4 [16.1–35.8] h; p = .74) or hospital length of stay (48.0 [41.8–59.8] vs. 47.3 [37.2–63.1] h; p = .67). In multivariate linear regression adjusting for identified confounders, treatment with ipratropium was not significantly associated with any of the three outcomes. Side effects were rare and occurred with equally between both groups Conclusions Adjunctive therapy with ipratropium was not associated with decreased duration of high‐intensity albuterol or shortened length of stay when compared to placebo. A larger, multicenter trial is warranted to confirm that ipratropium does not improve clinical outcomes.
We studied the effect of a single analgesic regime for outpatient lithotripsy on the patient's perception of pain and the disruption of their normal activities by sending a postal questionnaire to 200 patients. Results showed that 15% of patients received insufficient analgesia during ESWL, 25% considered treatment painful, 6.8% had side effects from analgesia, 18% had delayed return to their normal activities and 33% contacted their doctor within a week of lithotripsy with problems related to it. This study shows that analgesic requirements of patients treated with modern lithotriptors are underestimated. This can be avoided by tailoring analgesia to individual needs and better patient communication.
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