Characteristics and predictors of outcomes of critically Ill children with SARS-CoV-2 infection - the PICU experience

Clinical characteristics of SARS-CoV-2 Omicron BA.2 infection and its impact on pediatric emergency care in northern Taiwan

BACKGROUND

The SARS-CoV-2 Omicron BA.2 outbreak started in Taiwan in April 2022. The pandemic posed a challenge to pediatric emergency departments (PEDs) because of increased PED visits and diverse clinical presentations.

METHODS

We analyzed the clinical characteristics and impact of the Omicron BA.2 pandemic in patients who visited our PED from April 2022 to July 2022. The data from the Alpha variant pandemic during the same period in 2021 were compared with these findings.

RESULTS

Overall, 10,878 children were enrolled, and 7047 (64.8%) children were positive for SARS-CoV-2 infection. They had a mean ± SD age of 5.3 ± 4.1 years. The rates of patients with Pediatric Taiwan Triage and Acuity Scale (Ped-TTAS) level 1 (most urgent) (12.3%) and level 2 (27.6%) increased. More children were triaged as most urgent during the Omicron BA.2 pandemic than during the Alpha variant pandemic (p < 0.001). Patients with SARS-CoV-2 infection were likely to present with high fever, croup, dyspnea, febrile seizures, headache, dizziness, and myalgia (all p < 0.001). Four hundred and eleven (5.8%) patients were admitted; 25 (0.4%) patients needed intensive care, including 11 (44.0%) with encephalopathy or encephalitis. Three (0.04%) patients died due to fulminant encephalitis, encephalitis with septic shock, and respiratory failure.

CONCLUSIONS

The number of PED visits and the Ped-TTAS level of disease severity significantly increased during the SARS-CoV-2 Omicron BA.2 outbreak. The most common symptom was fever, and high fever was more common in patients with SARS-CoV-2 Omicron BA.2 infection. The rates of patients with croup and febrile seizures also increased.

Associations Between Core Temperature Disorders and Outcomes of Pediatric Intensive Care Unit Patients

BACKGROUND

The few studies of associations between fever and outcomes in pediatric intensive care unit (PICU) patients have conflicting findings. Associations between hypothermia and patient outcomes have not been studied.

OBJECTIVE

To investigate the incidence and characteristics of fever and hypothermia and their associations with adverse outcomes among PICU patients.

METHODS

Patients consecutively admitted to 2 PICUs in a 2-year period were prospectively studied. Core temperature was mainly measured by rectal or axillary thermometry. Fever and hypothermia were defined as core temperatures of greater than 38.0 °C and less than 36.0 °C, respectively. Prolonged mechanical ventilation, prolonged PICU stay, and PICU mortality were the adverse patient outcomes studied. Associations between patient outcomes and core temperature disorders were evaluated with univariate comparisons and multivariate analyses.

RESULTS

Of 545 patients enrolled, fever occurred in 299 (54.9%) and hypothermia occurred in 161 (29.5%). Both temperature disorders were independently associated with prolonged mechanical ventilation and prolonged PICU stay (P < .001) but not with PICU mortality. Late onset of fever (P < .001) and hypothermia (P = .009) were independently associated with prolonged mechanical ventilation, fever magnitude and duration (both P < .001) were independently associated with prolonged PICU stay, and fever magnitude (P < .001) and infectious cause of hypothermia (P= .01) were independently associated with higher PICU mortality.

CONCLUSIONS

These findings provide evidence that the manifestation and characteristics of fever and hypothermia are independent predictors of adverse outcomes in PICU patients.

HMGB1: A Potential Target of Nervus Vagus Stimulation in Pediatric SARS-CoV-2-Induced ALI/ARDS

From the start of pandemics, children were described as the ones who were less affected by SARS-Cov-2 or COVID-19, which was mild in most of the cases. However, with the growing vaccination rate of the adult population, children became more exposed to the virus and more cases of severe SARS-CoV-2-induced ARDS are being diagnosed with the disabling consequences or lethal outcomes associated with the cytokine storm. Thus, we do hypothesize that some of the children could benefit from nervus vagus stimulation during COVID-19 ARDS through the inhibition of HMGB1 release and interaction with the receptor, resulting in decreased neutrophil accumulation, oxidative stress, and coagulopathy as well as lung vascular permeability. Moreover, stimulation through alpha-7 nicotinic acetylcholine receptors could boost macrophage phagocytosis and increase the clearance of DAMPs and PAMPs. Further rise of FGF10 could contribute to lung stem cell proliferation and potential regeneration of the injured lung. However, this stimulation should be very specific, timely, and of proper duration, as it could lead to such adverse effects as increased viral spread and systemic infection, especially in small children or infants due to specific pediatric immunity state and anatomical features of the respiratory system.