Shivanand Medar

Serial Measurement of Amino-Terminal Pro-B-Type Natriuretic Peptide Predicts Adverse Cardiovascular Outcome in Children With Primary Myocardial Dysfunction and Acute Decompensated Heart Failure.

Objectives: In children, elevated amino-terminal pro-B-type natriuretic peptide levels are associated with impaired heart function. The predictive value of serial monitoring of amino-terminal pro-B-type natriuretic peptide levels in acute decompensated heart failure is unclear. Design: Prospective observational study. Setting: Single, tertiary referral pediatric critical care unit. Patients: Patients aged 0-21 years with primary myocardial dysfunction and acute decompensated heart failure. Interventions: Amino-terminal pro-B-type natriuretic peptide levels were obtained on enrollment, day 2, and day 7. Clinical, laboratory, and imaging data were collected on enrollment. Adverse cardiovascular outcome was defined as heart transplant, ventricular assist device placement, extracorporeal membrane oxygenation, or death at 1 year after admission. Aminoterminal pro-B-type natriuretic peptide levels and the percent change from day 0 to day 2 and day 0 to day 7 were calculated and compared between those with and without adverse cardiovascular outcome. Measurements and Main Results: Sixteen consecutive patients were enrolled. Adverse cardiovascular outcome occurred in six patients (37.5%, four heart transplant and two ventricular assist device). In patients with an adverse cardiovascular outcome, median amino-terminal pro-B-type natriuretic peptide levels at day 7 were significantly higher (7,365 vs 1,196 pg/mL; p = 0.02) and the percent decline in amino-terminal pro-B-type natriuretic peptide was significantly smaller (28% vs 73%; p = 0.02) compared with those without an adverse cardiovascular outcome. Receiver operating curve analysis revealed that a less than 55% decline in amino-terminal pro-B-type natriuretic peptide levels at day 7 had a sensitivity and specificity of 83% and 90%, respectively, in predicting an adverse cardiovascular (area under the curve, 0.86; 95% CI, 0.68–1.0; p = 0.02). Conclusions: In conclusion, children with primary myocardial dysfunction and acute decompensated heart failure, a persistently elevated amino-terminal pro-B-type natriuretic peptide, and/or a lesser degree of decline in amino-terminal pro-B-type natriuretic peptide during the first week of presentation were strongly associated with adverse cardiovascular outcome. Serial amino-terminal pro-B-type natriuretic peptide monitoring may allow the early identification of children at risk for worse outcome.

235: THE CLINICAL ROLE AND PROGNOSTIC VALUE OF ECHOCARDIOGRAPHY IN PEDIATRIC ARDS

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: We conducted a descriptive retrospective study of echocardiographic findings in Pediatric Acute Respiratory Distress Syndrome (PARDS) patients, aiming to assess whether pulmonary hypertension and Right Ventricle (RV) dysfunction were associated with PARDS severity and inferior outcome compared to PARDS patients with normal echocardiography studies. Methods: We retrospectively evaluated clinical and echocardiographic data of 34 PARDS patients receiving invasive mechanical ventilation, admitted to a single center Pediatric Critical Care Unit from January 2011 to June 2016. Factors associated with mortality, ventilator free days at 28 days and length of stay were identified using multivariate regression. Results: Twenty-nine patients (29/34, 85%) had mildly elevated systolic pulmonary arterial pressure (Acceleration Time of 80–100 msec) and 5/34 (14%) patients had severe pulmonary hypertension (Acceleration Time < 80 msec). Twelve patients (12/31, 38.7%) had RV dysfunction defined by RV Fractional Area Change (RVFAC) %≤ 45%. Compered to Patients with normal RV function, patients with RV dysfunction had significantly higher Oxygenation Index: 37.2 ± 9.35 Vs 16.15 ± 2.88 p = 0.02, less ventilator free days on 28 days: 4.08 ± 2.44 days Vs 12.37 ± 2.42 days p = 0.03 and higher mortality rate:50% (6/12) Vs 5% (1/19) in the RVFAC > 45% group (p = 0.003). Mechanical ventilation parameters including tidal volume, Positive End Expiratory Pressure and Peak Inspiratory Pressure did not differ significantly between the groups. Conclusions: RV dysfunction was found in almost 40% of the study patients, paralleled disease severity and its presence correlated with worse outcome. Further prospective studies with a standardized echocardiography protocol should be conducted to accurately determine the incidence of RV dysfunction in PARDS and whether the routine use of echocardiography to guide ventilation management in patients with RV dysfunction has impact on outcome.

Acute Kidney Injury in Children With Acute Respiratory Failure

Background. Acute kidney injury (AKI) is common in critically ill children and develops in association with organ system dysfunction, with acute respiratory failure (ARF) one of the most common. We aim to study AKI in the pediatric ARF population. Methods. Data were retrospectively collected on children aged 1 day to 18 years admitted to the pediatric intensive care unit (PICU) with ARF between 2010 and 2013. Descriptive statistics and multivariate analyses utilizing Mann-Whitney U, Wilcoxon signed rank, χ2, or Fisher’s exact tests were performed to identify risk factors associated with AKI. Results. A total of 186 patients, with median age of 36 months (interquartile range 4-120 months) met the inclusion criteria. ARF was related to pulmonary disease in 49%. AKI was noted in 53% of patients. Patients with AKI had significantly higher serum creatinine (P < .001) and lower estimated creatinine clearance (P < .001) compared with those without AKI. Among patients with moderate and severe acute respiratory distress syndrome (ARDS), 64% had AKI versus 46% with mild or no ARDS (P = .02). Patients with AKI had significantly lower PaO2/FiO2 ratio (P = .03), longer PICU (P = .03), and longer hospital length of stay (P = .01). ARDS patients were less likely to be AKI free on day 7 of hospitalization, as compared with those without ARDS. Multivariate analysis revealed positive end expiratory pressure (odds ratio [OR] = 1.2, confidence interval [CI] = 1.0-1.4; P = .03) and admission serum creatinine (OR = 27.9, CI = 5.2-148.5; P < .001) to be independently associated with AKI. Conclusions. AKI is common in children with ARF. In patients with ARF and AKI, AKI is associated with ARDS and longer PICU and hospital length of stay. Positive end expiratory pressure and serum creatinine are independently associated with AKI.

Failure to Thrive and Respiratory Failure in an Adolescent Male

A 14-year-old boy with a 5-month history of progressive weight loss presented with a cough and sore throat for 2 days as well as 1 day of increased respiratory effort. On the morning of admission, the patient stayed home from school, due to worsening of his sore throat. Notably, the patient, who was always a slim child, had lost 8 to 10 pounds of weight over the course of 5 months. He once was an active baseball player, and now he no longer possessed the energy to compete in athletics. Due to progressive weight loss, the patient’s primary care physician referred the patient to a pediatric gastroenterologist, 1 month prior to our admission, who performed an initial workup, which was unremarkable. The patient denied fevers, vomiting, diarrhea, bone pain, night sweats, sick contacts, joint pain, rashes, illicit drugs, purging, or recent travel. Also of note, the patient was admitted to another hospital 2 months prior, where he presented with similar complaints of sore throat, cough, and respiratory distress. The patient was diagnosed with clinical pneumonia and was discharged with a 5-day course of azithromycin. On our admission, the patient’s initial vital signs were the following: temperature 37.6°C, pulse 110, blood pressure 122/89, respiratory rate 40, oxygen saturation 95% on room air, and weight 31 kg. On examination, the patient was a cachectic appearing boy in moderate respiratory distress with suprasternal, intercostal, and subcostal retractions. The patient had decreased breath sounds throughout, without wheezes, rales, or rhonchi. His cardiovascular exam was significant for tachycardia, though with a normal rhythm. His oropharynx was unremarkable. The remainder of the exam was within normal limits. Initial lab work revealed a white blood cell count of 11.8, C-reactive protein 27.2 (normal range = 0-5), erythrocyte sedimentation rate 9 (normal range = 0-15), and an otherwise normal comprehensive metabolic panel. A chest X-ray and neck soft tissue film were both within normal limits. The patient was admitted for a presumed viral illness and to provide respiratory support with bronchodilators and oxygen as needed. Hospital Course

1288: Transfusion Related Acute Lung Injury after Scoliosis Surgery

complication of PCC, ventricular tachycardia (VT) is rare and torsades de pointes (TdP) yet more rare. We report a previously healthy 12 yo boy who developed VT and TdP in the context of PCC. He presented with history of chronic headaches, acutely altered mental status, diaphoresis, blood pressure (BP) of 220/110mmHg and heart rate of 108bpm. Empiric intravenous (IV) labetalol lead to initial improvement, but 6h later, he developed multiple episodes of non-sustained VT, including one of TdP. Electrolytes were normal. QTc was prolonged to 510ms. After improvement in BP, QTc normalized, and arrhythmias did not recur. Urine normetanephrine/creatinine was 6883 (normal < 278). I-123 Metaiodobenzylguanidine (MIBG) scinitgraphy demonstrated significant uptake in the right adrenal gland with small uptake in the left adrenal gland. A right-sided adrenal PCC was confirmed by magnetic resonance imaging of the abdomen. Following prolonged alpha-blockade, the PCC was resected uneventfully; however, he remained persistently tachycardic with frequent premature ventricular contractions (PVCs), and 12h after surgery, he developed short monomorphic VT with new troponin elevation to 1.89ng/ml. His BP, QTc, and echocardiogram remained normal. VT did not recur after restarting IV labetalol, but PVCs persisted. Six weeks after surgery, his urine catecholamines normalized, and PVCs were decreasing in frequency allowing for a reduction in labetalol dose. VT and TdP in the context of PCC as experienced by our patient are very rare. Acquired long QTc and TdP (reported with hypertensive encephalopathy) and hypertensive coronary insufficiency may have contributed to their pathogenesis. Persistent ventricular arrhythmia despite BP control and tumor resection is concerning for malignant PCC. However, normal urine catecholamines make this unlikely, even with the above MIBG findings. No single factor explains the persistence of this patients arrhythmias, which suggests that their etiology in PCC may be multifactorial and underscores the importance of close follow-up.