J. Scott Baird

Novel Influenza A(H1N1) in a Pediatric Health Care Facility in New York City During the First Wave of the 2009 Pandemic

OBJECTIVE To describe the burden of care experienced by our pediatric health care facility in New York, New York, from May 3, 2009, to July 31, 2009, during the novel influenza A(H1N1) pandemic that began in spring 2009. DESIGN Retrospective case series. SETTING Pediatric emergency departments and inpatient facilities of New York-Presbyterian Hospital. Patients Children presenting to the emergency departments with influenza-like illness (ILI) and children aged 18 years or younger hospitalized with positive laboratory test results for influenza A from May 3, 2009, to July 31, 2009. MAIN OUTCOME MEASURES Proportion of children with ILI who were hospitalized and proportion of hospitalized children with influenza A with respiratory failure, bacterial superinfection, and mortality. RESULTS When compared with the same period in 2008, the pediatric emergency departments experienced an excess of 3750 visits (19.9% increase). Overall, 27.7% of visits were for ILI; 2.5% of patients with ILI were hospitalized. Of the 115 hospitalized subjects with confirmed influenza A (median age, 4.3 years), 93 (80.9%) had underlying conditions. Four (3.5%) had identified bacterial superinfection, 1 (0.9%) died, and 35 (30.4%) were admitted to a pediatric intensive care unit; of these 35 patients, 11 had pneumonia and required mechanical ventilation, including high-frequency oscillatory ventilation (n = 3). CONCLUSIONS At our center, 2.5% of children with ILI presenting to the emergency departments during the first wave of the 2009 novel influenza A(H1N1) pandemic were hospitalized. Of the 115 hospitalized children with confirmed influenza A, 9.6% had respiratory failure and 0.9% died. These findings can be compared with the disease severity of subsequent waves of the 2009 novel influenza A(H1N1) pandemic.

Massive Pulmonary Embolism in Children

We present 3 children with massive pulmonary embolism and review 17 recent pediatric reports. Malignancies were a frequent cause (40%), and sudden death was common (60%). Compared with adults, diagnosis was more likely to be made at autopsy (P < .0001), more children were treated with embolectomy/thrombectomy (P = .0006), and mortality was greater (P = .03).

Noninvasive ventilation during pediatric interhospital ground transport.

Objective. We report our use of noninvasive ventilation (NIV) during pediatric interhospital ground transport. Methods. We retrospectively reviewed transport andhospital records for nonneonatal patients ≤ 18 years old transferred into or out of our childrens hospital between January 2005 andJune 2006 while receiving continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP). Transport paramedics have extensive experience andsupplemental training in NIV andadvanced pediatric airway skills. Results. NIV was used during 31 transports of 25 patients (CPAP: 18 transports for 16 patients; BiPAP: 13 transports for nine patients). Nine patients (36%) were NIV-dependent prior to transport. Diagnoses included neurologic disease (n = 10), pulmonary disease (n = 10), congenital heart disease (n = 4), andother (n = 1). Oxygen saturation (SpO2) improved to or remained greater than 93% during all transports. Neither tracheal intubation nor cardiopulmonary resuscitation was required during or for one hour following any transport—though airway suctioning and/or bag–valve–mask ventilation was required during eight of 31 (26%) transports. Six of 17 patients transferred into our hospital while receiving NIV required tracheal intubation at three to 84 hours after transport; none of these patients developed aspiration pneumonia. Conclusions. Though the use of NIV during pediatric interhospital gound transports was not associated with serious out-of-hospital complications, advanced pediatric airway skills were frequently required

Comparing the clinical severity of the first versus second wave of 2009 Influenza A (h1n1) in a New York City pediatric healthcare facility

Objective: We previously reported the epidemiology of 2009 Influenza A (H1N1) in our pediatric healthcare facility in New York City during the first wave of illness (May–July 2009). We hypothesized that compared with the first wave, the second wave would be characterized by increased severity of illness and mortality. Design: Case series conducted from May 2009 to April 2010. Setting: Pediatric emergency departments and inpatient facilities of New York-Presbyterian Hospital. Patients: All hospitalized patients ÷18 yrs of age with positive laboratory tests for influenza A. Measurements and Main Results: We compared severity of illness during the first and second wave assessed by the number of hospitalized children, including those in the pediatric intensive care unit, bacterial superinfections, and mortality rate. Compared to the first wave, fewer children were hospitalized during the second wave (n = 115 vs. 76), but a comparable portion were admitted to the pediatric intensive care unit (30.4% vs. 19.7%; p = .10). Pediatric Risk of Mortality III scores, length of hospitalization in the pediatric intensive care unit, incidence of respiratory failure and pneumonia, and peak oxygenation indices were similar during both waves. Bacterial superinfections were comparable in the first vs. second wave (3.5% vs. 1.3%). During the first wave, no child received extracorporeal membrane oxygenation and one died, while during the second wave, one child received extracorporeal membrane oxygenation and there were no deaths. Conclusions: At our pediatric healthcare facility in New York City, fewer children were hospitalized with 2009 Influenza A (H1N1) during the second wave, but both waves had a similar spectrum of illness severity and low mortality rate.

The sieving coefficient and clearance of vasopressin during continuous renal replacement therapy in critically ill children

HYPOTHESIS As vasopressin is a small peptide, its sieving coefficient (SC) and clearance (CL) during continuous renal replacement therapy may be intermediate to those for urea and β2 microglobulin (commonly used markers for small- and middle-molecular weight solutes, respectively). METHODS A prospective, minimal-risk study was undertaken of the SC and CL of vasopressin in critically ill children on the first day of continuous renal replacement therapy using AN69 membrane filters and prefilter replacement fluid. All prefilter plasma (vasopressin) samples were drawn from the arterial port after predilution. RESULTS Nine patients with fluid overload, renal failure, or both were recruited (median age, 14 years) during the first day of either continuous venovenous hemofiltration (n = 3) or hemodiafiltration (n = 6). Multiorgan dysfunction syndrome was present in 8 patients, and 3 were in shock (2 were receiving a vasopressin infusion). Median prefilter plasma (vasopressin) was 1.7 pg/mL, although data points were skewed: 5 patients had a low prefilter plasma (vasopressin) (<2 pg/mL), and 4 patients (including 2 receiving a continuous vasopressin infusion) had a prefilter plasma (vasopressin) between 4.2 and 56.4 pg/mL. All those with low prefilter plasma (vasopressin) had an effluent (vasopressin) less than the detection limit (0.6 pg/mL). The median SC was 1 in the 4 patients with a measurable effluent (vasopressin), and their median filter CL was 48 mL/min or 39 mL/(min 1.73 m(2)). CONCLUSIONS The SC and CL of vasopressin by continuous venovenous hemofiltration or hemodiafiltration in these critically ill children were similar to values for urea.

Long-duration (>4 weeks) continuous renal replacement therapy in critical illness

INTRODUCTION Decreased pediatric survival has been reported with long-duration (>4 weeks) continuous renal replacement therapy (CRRT), though the practice has not been well-described. METHODS Retrospective chart review in a childrens hospital of all patients treated with CRRT over 2 years (2003-4), including those who underwent long (group 1) and shorter duration (group 2) therapy. RESULTS We identified 39 patients: median age was 6 years (range: 0.3-23; 7 were infants), median PRISM III score was 16 (range: 4-35), and the most frequent primary diagnosis was a stem cell transplant (in 12 out of 39). At continuous renal replacement therapy initiation, almost all patients (38 out of 39) had multiorgan dysfunction syndrome, most (35 out of 39) were being treated with at least one inotrope or vasopressor, and median fluid overload was 18% (range: 1-43%). Survival was poor (38%). Groups 1 (n = 7) and 2 (n = 32) had similar age (p = 0.44), PRISM III score (p = 0.61), and stem cell transplant diagnosis (p = 0.65). At CRRT initiation, the incidence of multiorgan dysfunction syndrome (p=0.18), inotrope or vasopressor treatment (p = 0.56), and fluid overload severity (p = 0.71) were similar. Those in group 1 had a longer mean CRRT as well as persistent cardiovascular dysfunction limiting the utility of intermittent dialysis. Survival was similar between groups (p = 1). CONCLUSIONS Critically-ill patients treated with long and shorter duration CRRT had a similar survival rate.

Heart Failure and Hypothermia in an Infant: Pseudocyanide Syndrome?

Purpose Mixed or central venous oxygen saturation has not been described during concurrent heart failure and hypothermia in children, both of which may be associated with hyperlactatemia. This report of an infant with heart failure and hypothermia is significant for increased inferior vena cava (IVC) oxygen saturation and hyperlactatemia. Case Report A 36-day-old female was fussy for a day and then developed respiratory distress. In the Pediatric ER, she was tachycardic (260 beats/minute) and hypothermic (32.4 degrees C) with prolonged capillary refill and faint distal pulses. Adenosine was given twice via an intraosseous line for supraventricular tachycardia, with conversion to sinus rhythm. Blood drawn from an IVC catheter was significant for uncorrected (for temperature) oxygen saturation of 94% and lactate 18 mmol/L; corrected and uncorrected IVC oxygen saturation early during rewarming were >90%. During rewarming, declines in uncorrected IVC oxygen saturation and lactate correlated. Hypothermia and hyperlactatemia resolved after 10 and 12 hours. Conclusions Concurrent heart failure and hypothermia in an infant were associated with increased IVC oxygen saturation and hyperlactatemia, similar to lab findings associated with a mitochondrial toxin such as cyanide. Improvement of heart failure and hypothermia were associated with resolution of these lab abnormalities, thus helping to rule out mitochondrial toxins. Additional reports may help better define a pseudocyanide syndrome in this setting.

Polymyxin B and haemofiltration in an adolescent with leukaemia

respectively, relative to the S. maltophilia strain IAM 1566 protein) (Figure 1). S. maltophilia is a Gram-negative bacterium found in a variety of environments, including soil, water and plants, and is therefore a potential reservoir of the MBL gene. Similar to POM-1 and L1 MBLs, the ability of the PAM-1 enzyme to hydrolyse carbapenems might be relatively low; consequently, the PAM-1-positive MRY13-0052 strain was not categorized as carbapenem resistant. However, the combination of PAM-1-mediated b-lactam hydrolysis with genetic mutations that decrease outermembrane permeability could confer high-level carbapenem resistance, leading to major concern for the treatment of P. alcaligenes infection.

Pediatric respiratory syncytial virus infection and high frequency oscillatory ventilation

Study objectives — To report the results of treating respiratory syncytial virus-associated respiratory failure with high frequency oscillatory ventilation as rescue therapy.Design — Retrospective case series.Setting — A pediatric intensive care unit in a tertiary academic medical center.Patients or participants — Nineteen of 74 (26%) patients admitted to the pediatric intensive care unit over 3 years for respiratory syncytial virus respiratory tract infection developed respiratory failure. Eleven were treated with conventional ventilation only (group 1) and 8 were treated with high frequency oscillatory ventilation when conventional ventilation failed (group 2).Interventions — Medical records were reviewed to assess risk factors for severe disease, duration of mechanical ventilation and oxygen therapy, peak oxygenation index, length of stay, morbidities, and mortalities.Measurements and results — Group 2 had a longer duration of mechanical ventilation, oxygen therapy, length of stay, and a higher peak ox...

Trends in serum sodium concentration and effective osmolality during repair of paediatric diabetic ketoacidosis

Objective: To assess the effect of resuscitation fluid on trends in serum sodium and effective osmolality during repair of paediatric diabetic ketoacidosis. Design: Retrospective. Setting: A paediatric intensive care unit (PICU) in a tertiary academic medical centre. Subjects: Sixteen patients (age range: 7–20 years; mean: 14 +/− 3 years) admitted to the PICU over 19 months for 35 episodes of diabetic ketoacidosis. Interventions: We reviewed trends in serum sodium and effective osmolality as well as total fluid and sodium intake and mean resuscitation fluid sodium concentration (total sodium intake/total fluid intake) during the first day of therapy. Measurements and main results: Within the range of resuscitation fluid composition observed (mean resuscitation fluid [sodium]: 63–149 mmol/l), we noted a weak, positive correlation between trends in uncorrected serum [sodium] and mean resuscitation fluid [sodium]. No association was found between trends in corrected serum [sodium] or effective osmolality and...