Alicia Teagarden

Thiamine Deficiency Leading to Refractory Lactic Acidosis in a Pediatric Patient

Thiamine plays a critical role in energy metabolism. Critically ill children and adults may develop thiamine deficiency with ultimately increased mortality due to potentially irreversible consequences of severe type B lactic acidosis. We report a case of an unvaccinated term neonate with malignant pertussis requiring extracorporeal membrane oxygenation and continuous renal replacement therapy, who developed profound lactic acidosis of unknown etiology. After countless evaluations for likely causes, the patient was ultimately determined to have thiamine deficiency and her acidosis resolved rapidly with vitamin supplementation.

Clinical significance of serum cortisol levels following surgery for congenital heart disease.

OBJECTIVE Use of hydrocortisone to treat refractory haemodynamic instability in patients recovering from surgery for congenital heart disease is common practice at many centres. We aimed to determine whether there is a relationship between total serum cortisol concentrations and haemodynamic response to this therapy. Material and methods We retrospectively reviewed patients <21 years who underwent cardiac surgery from 2011 to 2013, received hydrocortisone within 72 hours postoperatively, and had total serum cortisol measurements contemporaneous with its administration. Favourable responders were defined as patients in whom, at 24 hours after hydrocortisone initiation, either (1) systolic blood pressure was increased or unchanged and vasoactive-inotrope score was decreased or (2) systolic blood pressure increased by ⩾10% of baseline and vasoactive-inotrope score was unchanged. Variables were compared using t-tests or Mann-Whitney U tests as appropriate. RESULTS In total, 24 patients were reviewed, with a median age of 1.4 months and range of 0.1-232 months. Among them, 14 (58%) patients responded favourably to hydrocortisone. At 24 hours, the median change in vasoactive-inotrope score was -18% in favourable responders and +31% in those who did not respond favourably, p=0.001. The mean pre-hydrocortisone total serum cortisol in favourable responders was 17.4±10.9 µg/dl compared with 46.1±44.7 µg/dl in those who did not respond favourably, p=0.03. CONCLUSION Total serum cortisol obtained before initiation of hydrocortisone was significantly lower in patients who responded favourably to this therapy. Total serum cortisol may therefore be helpful in identifying children recovering from cardiac surgery who may or may not haemodynamically improve with hydrocortisone.

Devastating Ischemic Stroke Following Selective Arterial Embolization of a Large Chest Wall Aneurysmal Bone Cyst.

Aneurysmal bone cysts (ABC) are benign bone lesions found in children and young adults. Rarely, these lesions can arise from ribs, and there is disagreement on the best treatment because of proximity to vital structures. Frequently, surgeons remove ABC with en bloc resection. Selective arterial embolization has been used as an adjunct to surgery, or rarely as the primary treatment. We report a case of embolic stroke complicating embolization of a rib ABC, likely from the presence of collateral circulation between the mass and vertebral artery. Caution should be taken when performing embolization of lesions in this location because of potential complications.

Food Protein-Induced Enterocolitis Syndrome Causing Hypovolemic Shock and Methemoglobinemia

A 5-week-old previously healthy male presented with vomiting and diarrhea leading to hypovolemic shock and profound metabolic acidosis. He was subsequently found to have severe methemoglobinemia. The acidosis and shock improved with fluid resuscitation and methemoglobinemia was successfully treated with methylene blue. An extensive workup, including evaluations for infectious and metabolic etiologies, was unremarkable. However, a detailed dietary history revealed a recent change in diet, supporting a diagnosis of food protein-induced enterocolitis syndrome (FPIES). We present this case to highlight the importance of considering FPIES in an infant with vomiting and diarrhea, in the setting of a recent dietary change, leading to profound dehydration, metabolic acidosis, and methemoglobinemia. Diagnosis of FPIES, although difficult to make and one of exclusion, can be potentially life-saving.

Low serum albumin levels prior to pediatric allogeneic HCT are associated with increased need for critical care interventions and increased 6-month mortality

Poor nutritional status in HCT patients is a negative prognostic factor. There are no pediatric studies evaluating albumin levels prior to HCT and need for critical care interventions. We hypothesized that pediatric patients with low albumin levels, routinely measured 30 days (±10 days) prior to allogeneic HCT, have a higher risk of critical care interventions in the post‐transplant period. We performed a 5‐year retrospective study of pediatric patients who underwent allogeneic HCT for any indication. Patients were categorized based on albumin level. Hypoalbuminemia was defined as <3.1 g/dL. A total of 73 patients were included, with a median age of 7.4 years (IQR 3.3, 13.2). Patients with hypoalbuminemia had higher needs for critical care interventions including non‐invasive ventilation (44% vs 8%, P=.01), mechanical ventilation (67% vs 17%, P<.01), and vasoactive therapy (56% vs 16%, P=.01). Patients with hypoalbuminemia also had a higher 6‐month mortality (56% vs 17%, P=.02). Our data demonstrate that children undergoing allogeneic HCT with hypoalbuminemia in the pretransplant period are more likely to require critical care interventions and have higher 6‐month mortality. These findings identify an at‐risk population in which nutritional improvements may be instituted prior to HCT in hopes of improving outcomes.

1224: TARGETED TEMPERATURE MANAGEMENT REDUCES FEVER INCIDENCE IN PEDIATRIC TBI AND CARDIAC ARREST

Learning Objectives: In critically ill children who suffer from cerebral ischemia and brain trauma, elevated body temperature is common and associated with neurologic deterioration and poor outcomes. Recent studies have failed to show benefit of hypothermia over targeted normothermia (TN) in this patient population. We developed a proactive targeted temperature management protocol at our institution with the goal of maintaining normothermia in pediatric patients post-cardiac arrest or traumatic brain injury (TBI). We hypothesized that this protocol would decrease the incidence of fever in our targeted patient population. Methods: This study was conducted as a quality improvement project in a busy level 1 trauma center children’s hospital. A retrospective chart review of patients who sustained a severe TBI or cardiac arrest was conducted. We compared the incidence of fever after the implementation of our protocol to a similar control group from the two years prior to protocol implementation as part of a PDSA cycle. We collected basic patient demographics, incidence of fever within the first 72 hours of admission, PICU length of stay (LOS), hospital LOS, and in-hospital mortality. Variables were compared using Chi-squared or Mann-Whitney U test, as appropriate. Results: In the year after protocol implementation, 26 patients met criteria for TN. We used a comparison group of 47 patients from the two years prior to implementation. Patient populations were similar with regard to age, gender, and race. There was a higher proportion of TBI patients in the control group vs the TN group (66% vs 27%, p=0.001). There was a significant decrease in fever incidence in the TN group vs controls (23% vs 47%, p=0.046). There was no significant difference in any other collected outcome. Conclusions: We found that a proactive temperature management protocol decreases the incidence of fever in pediatric patients post TBI and cardiac arrest. Further PDSA cycles will need to focus on more rapid initiation of the protocol to further reduce fever incidence in this population.

1159: RISK FACTORS, OUTCOMES, AND TIMING OF VENTILATOR-ASSOCIATED INFECTIONS IN PEDIATRIC TRAUMA PATIENTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) expected response to successful SBT in an already established, structured handoff tool as a contingency plan; and designation of a MICU provider to respond to notices of successful SBTs occurring during work rounds, allowing assessment of the patient and order entry without interruption. An uncontrolled beforeafter study design was employed, and medical records were reviewed from two cohorts: six months preand post-intervention. Results: Early post-intervention analysis was conducted at four months. The pre(n=59) and post-intervention (n=33) cohorts were not statistically different in baseline characteristics except for prevalence of obstructive sleep apnea. The percentage of patients extubated within 45 minutes of successful completion of a SBT increased significantly from 33.9% to 51.5% (RR = 1.52, p < 0.05). The mean time to extubation after successful completion of SBT decreased significantly from 86.9 to 57.1 minutes (p = 0.02). Conclusions: Improving communication regarding extubation of patients who have passed a SBT can lead to early liberation from MV. This initiative suggests, with limitation, that a bundled intervention that formalizes communication about extubation plans through development of a new system is a possible solution to this issue.