Corrado Cecchetti

Relationship between global end-diastolic volume and cardiac output in critically ill infants and children

Objective:The objective of this study was to investigate possible correlations between the preload index global end-diastolic volume (GEDV) and the indexes of cardiac function, cardiac index, and stroke volume index in critically ill pediatric patients. The aim was to evaluate whether GEDV may help in the decision-making process concerning volume loading. Design:Prospective clinical study. Setting:Pediatric intensive care unit of the Bambino Gesù Children’s Research Hospital. Patients:Seventy patients, 40 male and 30 female, mean age 62 ± 41 months (range 5–156 months), divided into six groups: group A, hemorrhagic shock, ten cases; group B, head injury, 21 cases; group C, septic shock, ten cases; group D, encephalitis, ten cases; group E, respiratory failure, nine cases; group F, cardiogenic shock, ten cases. Interventions:All patients received volumetric hemodynamic monitoring following initial resuscitation and every 4 hrs thereafter or whenever a hemodynamic deterioration was suspected. During the cumulative in-hospital stay, a total 1,184 sets of measurements were done. Measurements and Main Results:Findings are consistent with a statistically significant linear correlation of GEDV with cardiac index and stroke volume index in hemorrhagic shock (group A) (R2 = .647, p < .0001; R2 = .738, p < .0001) and cardiogenic shock (group F) (R2 = .645, p < .0001; R2 = .841, p < .0001). Conclusions:GEDV may potentially be a useful guide to treatment in preload-dependent conditions, such as hemorrhagic and cardiogenic shock. In the other groups where there is little relationship between preload and cardiac function indexes, the influence of non-preload-dependent mechanisms on cardiac output is certainly more significant.

Ultrasound-guided central venous cannulation in infants weighing less than 5 kilograms

Purpose Recent reports suggest that ultrasound-guided central venous cannulation may also be safe and effective in infants. This study aimed to evaluate the success and complications rate of this technique in infants weighing less than 5 kg. Methods We studied 45 infants, weighing less than 5 kg (mean weight: 2.9 ± 1.1 kg, median: 3.1) needing a central venous access for intensive care treatment. In all patients, venous access was obtained by ultrasound-guided cannulation of the internal jugular vein (IJV). Results Central venous cannulation was successful in all 45 infants. The right internal jugular vein (IJV) was used in most cases (92%). The IJV was antero-lateral to the carotid artery in 66% of patients, lateral in 28% and anterior in 6%. Although we recorded 10 complications (22.2%), only one was clinically relevant (one pneumothorax). The other complications were repeated venipunctures (n=4), kinking of the guidewire (n=3) and local venous hematomas (n=2). The time required for completing the procedure was 7 ± 4.3 min, while the mean time of central venous catheter permanence was 5.5 ± 8 days. There was a negative correlation between the patients weight and the time needed for cannulation (p<0.01). Complications occurred in infants with a lower body weight (p<0.01). Conclusions Our experience suggests that ultrasound-guided central vein cannulation can be performed by well-trained physicians in infants weighing less than 5 kg without relevant risks.

Adoptive immunotherapy with antigen-specific T cells during extracorporeal membrane oxygenation (ECMO) for adenovirus-related respiratory failure in a child given haploidentical stem cell transplantation.

We report on the successful infusion of human adenovirus (HAdV)‐specific T cells in a child with congenital amegakaryocytic thrombocytopenia, given T‐cell‐depleted hematopoietic stem cell transplantation (HSCT) from the HLA‐haploidentical mother during extracorporeal membrane oxygenation (ECMO) for severe HAdV‐related respiratory failure. Donor‐derived, interferon (IFN)‐γ‐secreting HAdV‐specific T cells were enriched using the cytokine capture assay, after in vitro stimulation with overlapping peptides from the immunodominant HAdV5 hexon protein. Two weeks after T‐cell transfer, viral load decreased and ECMO was discontinued. T‐cell responses to HAdV antigens were documented after four weeks and were associated with viral clearance, immune reconstitution and clinical amelioration. Pediatr Blood Cancer 2014;61:376–379.

Long-term evolution after in-hospital cardiac arrest in children: Prospective multicenter multinational study☆

OBJECTIVE The main objective was to study survival and neurologic evolution of children who suffered in-hospital pediatric cardiac arrest (CA). The secondary objective was to analyze the influence of risk factors on the long term outcome after CA. METHODS prospective, international, observational, multicentric study in 48 hospitals of 12 countries. CA in children between 1 month and 18 years were analyzed using the Utstein template. Survival and neurological state measured by Pediatric Cerebral Performance Category (PCPC) scale one year after hospital discharge was evaluated. RESULTS 502 patients with in-hospital CA were evaluated. 197 of them (39.2%) survived to hospital discharge. PCPC at hospital discharge was available in 156 of survivors (79.2%). 76.9% had good neurologic state (PCPC 1-2) and 23.1% poor PCPC values (3-6). One year after cardiac arrest we could obtain data from 144 patients (28.6%). PCPC was available in 116 patients. 88 (75.9%) had a good neurologic evaluation and 28 (24.1%) a poor one. A neurological deterioration evaluated by PCPC scale was observed in 40 patients (7.9%). One year after cardiac arrest PCPC scores compared to hospital discharge had worsen in 7 patients (6%), remained constant in 103 patients (88.8%) and had improved in 6 patients (5.2%). CONCLUSION Survival one year after cardiac arrest in children after in-hospital cardiac arrest is high. Neurologic outcome of these children a year after cardiac arrest is mostly the same as after hospital discharge. The factors associated with a worst long-term neurological outcome are the etiology of arrest being a traumatic or neurologic illness, and the persistency of higher lactic acid values 24h after ROSC. A standardised basic protocol even practicable for lower developed countries would be a first step for the new multicenter studies.

Extracorporeal membrane oxygenation as a bridge to allogeneic T-cell depleted hematopoietic stem cell transplantation in infants with severe combined immune deficiency: is it feasible?

Dear Editor, Because severe combined immunodeficiency (SCID) is usually lethal within the first year of life [1], diagnosis and treatment must be established rapidly. Although gene therapy is currently investigated for some SCID variants, the most widely employed treatment is still represented by allogeneic hematopoietic stem cell transplantation (allo-HSCT) [2]. The therapeutic benefit of alloHSCT is frequently offset by respiratory failure (RF) due to opportunistic infections occurring both before and after transplantation. Few attempts have been made to manage RF with extracorporeal membrane oxygenation (ECMO) during the aplastic phase following allo-HSCT. Leahey et al. [3] reported successful use of ECMO post-transplant in SCID patients with bronchiolitis; however, a recent review of 29 cases of ECMO posttransplant indicates that patient outcome is dismal [4]. To the best of our knowledge, no one has reported ECMO as a ‘‘bridge to allo-HSCT’’ in SCID patients. We describe the case of a 6-month-old boy with c-chain deficiency SCID, supported with ECMO before and after T cell depleted allo-HSCT from his HLAhaploidentical mother for RF. This child was referred to our hospital for diarrhea, dehydration, and RF [pH 7.48, PaO2/FiO2 280, PaCO2 4 kPa (30 mmHg)]. Chest X-ray showed bilateral consolidations. He was immediately admitted to the pediatric intensive care unit (PICU), where helmet continuous positive-airway pressure [0.5 kPa (5 cmH2O), FiO2 0.6] was started. However, as a result of respiratory fatigue, we decided to intubate the patient. Bronchoalveolar lavage (BAL) was positive for cytomegalovirus (CMV) and Pneumocystis jirovecii (PJ); thus, intravenous ganciclovir and trimethoprim were started. Although on mechanical ventilation, gas exchange worsened (Fig. 1) and ECMO was started. The child was supported with VV-ECMO using a double-lumen 16-F Avalon cannula (Maquet, Getinge Group, Germany), inserted percutaneously from the right jugular vein. A centrifugal pump (Pedivas, Levitronix, Thoratec, UK) with a phosphorylcholine fully coated oxygenator (Pediatric ECMO A.L. ONE, Eurosets Medolla, Italy) and a phosphorylcholine fully coated 1/4 circuit (Eurosets, Medolla, Italy) were used. The patient received reducedintensity regimen including treosulfan and fludarabine. A novel graft manipulation with a/b T and CD19? B cell depletion (Miltenyi

The Importance of Mortality Risk Assessment: Validation of the Pediatric Index of Mortality 3 Score.

Objective: To evaluate the performance of the newest version of the Pediatric Index of Mortality 3 score and compare it with the Pediatric Index of Mortality 2 in a multicenter national cohort of children admitted to PICU. Design: Retrospective, prospective cohort study. Setting: Seventeen Italian PICUs. Patients: All children 0 to 15 years old admitted in PICU from January 2010 to October 2014. Interventions: None. Measurement and Main Results: Eleven thousand one hundred nine children were enrolled in the study. The mean Pediatric Index of Mortality 2 and 3 values of 4.9 and 3.9, respectively, differed significantly (p < 0.05). Overall mortality rate was 3.9%, and the standardized mortality ratio was 0.80 for Pediatric Index of Mortality 2 and 0.98 for Pediatric Index of Mortality 3 (p < 0.05). The area under the curve of the receiver operating characteristic curves was similar for Pediatric Index of Mortality 2 and Pediatric Index of Mortality 3. The Hosmer-Lemeshow test was not significant for Pediatric Index of Mortality 3 (p = 0.21) but was highly significant for Pediatric Index of Mortality 2 (p < 0.001), which overestimated death mainly in high-risk categories. Conclusions: Mortality indices require validation in each country where it is used. The new Pediatric Index of Mortality 3 score performed well in an Italian population. Both calibration and discrimination were appropriate, and the score more accurately predicted the mortality risk than Pediatric Index of Mortality 2.

ECLS in Pediatric Cardiac Patients

Extracorporeal life support (ECLS) is an important device in the management of children with severe refractory cardiac and or pulmonary failure. Actually, two forms of ECLS are available for neonates and children: extracorporeal membrane oxygenation (ECMO) and use of a ventricular assist device (VAD). Both these techniques have their own advantages and disadvantages. The intra-aortic balloon pump is another ECLS device that has been successfully used in larger children, adolescents, and adults, but has found limited applicability in smaller children. In this review, we will present the “state of art” of ECMO in neonate and children with heart failure. ECMO is commonly used in a variety of settings to provide support to critically ill patients with cardiac disease. However, a strict selection of patients and timing of intervention should be performed to avoid the increase in mortality and morbidity of these patients. Therefore, every attempt should be done to start ECLS “urgently” rather than “emergently,” before the presence of dysfunction of end organs or circulatory collapse. Even though exciting progress is being made in the development of VADs for long-term mechanical support in children, ECMO remains the mainstay of mechanical circulatory support in children with complex anatomy, particularly those needing rapid resuscitation and those with a functionally univentricular circulation. With the increase in familiarity with ECMO, new indications have been added, such as extracorporeal cardiopulmonary resuscitation (ECPR). The literature supporting ECPR is increasing in children. Reasonable survival rates have been achieved after initiation of support during active compressions of the chest following in-hospital cardiac arrest. Contraindications to ECLS have reduced in the last 5 years and many centers support patients with functionally univentricular circulations. Improved results have been recently achieved in this complex subset of patients.

Ultrasound-guided left brachiocephalic vein cannulation in children with underlying bleeding disorders: A retrospective analysis

Objectives: To evaluate the safety and effectiveness of ultrasound–guided left brachiocephalic vein cannulation in infants and children with underlying bleeding conditions. Design: Retrospective cohort. Setting: PICU of a tertiary pediatric hospital. Patients: Thirty-four patients requiring central venous catheterization from January 2011 to January 2012. Interventions: None. Measurements and Main Results: Two pediatric intensivists, experienced in ultrasound–guided vessel cannulation, performed the ultrasound catheterization of the left brachiocephalic vein. Ultrasound equipment consisted of a standard ultrasound monitor with a linear 6–13 MHz probe. The ultrasound monitor was set on a resolution with a depth of 1.8 cm for infants and 2.2 cm for children. The “in-plane” technique was used for all patients. Thirty-four catheterizations were performed. Patient median age was 12.5 months (5.75–63.5 mo) and median weight was 9.25 kg (7–16.25 kg). The population of infants and children analyzed was composed of 25 patients with hematologic disorder (73%) treated with hematopoietic stem cell transplantation, five patients (15%) supported with extracorporeal membrane oxygenation for viral pneumonias, and four patients (12%) with uremic hemolytic syndrome. A 4F catheter was used in 79% of cases. Left brachiocephalic vein cannulation was successful in all 34 patients. Median time needed for cannulation was 350 seconds (277.5–450 s). The overall complication rate was 9% (3 of 34) and consisted of difficulty in advancing the guidewire after having pierced the vein. The time required for catheter positioning and complications was not associated with both lower body weight and body surface area of the patients (p > 0.05). Mean central venous catheter duration was 32 ± 4 days. Conclusions: Data reported in this retrospective study confirm the safety and effectiveness of ultrasound–guided left brachiocephalic vein catheterization in infants and children with underlying bleeding disorders.

Independent lung ventilation in a newborn with asymmetric acute lung injury due to respiratory syncytial virus: A case report

IntroductionIndependent lung ventilation is a form of protective ventilation strategy used in adult asymmetric acute lung injury, where the application of conventional mechanical ventilation can produce ventilator-induced lung injury and ventilation-perfusion mismatch. Only a few experiences have been published on the use of independent lung ventilation in newborn patients.Case presentationWe present a case of independent lung ventilation in a 16-day-old infant of 3.5 kg body weight who had an asymmetric lung injury due to respiratory syncytial virus bronchiolitis. We used independent lung ventilation applying conventional protective pressure controlled ventilation to the less-compromised lung, with a respiratory frequency proportional to the age of the patient, and a pressure controlled high-frequency ventilation to the atelectatic lung. This was done because a single tube conventional ventilation protective strategy would have exposed the less-compromised lung to a high mean airways pressure. The target of independent lung ventilation is to provide adequate gas exchange at a safe mean airways pressure level and to expand the atelectatic lung. Independent lung ventilation was accomplished for 24 hours. Daily chest radiograph and gas exchange were used to evaluate the efficacy of independent lung ventilation. Extubation was performed after 48 hours of conventional single-tube mechanical ventilation following independent lung ventilation.ConclusionThis case report demonstrates the feasibility of independent lung ventilation with two separate tubes in neonates as a treatment of an asymmetric acute lung injury.

Accuracy of Bedside Paediatric Early Warning System (BedsidePEWS) in a Pediatric Stem Cell Transplant Unit

Hospital mortality in children who undergo stem cell transplant (SCT) is high. Early warning scores aim at identifying deteriorating patients and at preventing adverse outcomes. The bedside pediatric early warning system (BedsidePEWS) is a pediatric early warning score based on 7 clinical indicators, ranging from 0 (all indicators within normal ranges for age) to 26. The aim of this case-control study was to assess the performance of BedsidePEWS in identifying clinical deterioration events among children admitted to an SCT unit. Cases were defined as clinical deterioration events; controls were all the other patients hospitalized on the same ward at the time of case occurrence. BedsidePEWS was retrospectively measured at 4-hour intervals in cases and controls 24 hours before an event (T4-T24). We studied 19 cases and 80 controls. The score significantly increased in cases from a median of 4 at T24 to a median of 14 at T4. The proportion of correctly classified cases and controls was >90% since T8. The area under the curve receiver operating characteristic was 0.9. BedsidePEWS is an accurate screening tool to predict clinical deterioration in SCT patients.