Haemodynamic support for paediatric septic shock: a global perspective

Septic shock is a leading cause of hospitalisation, morbidity, and mortality for children worldwide. In 2020, the paediatric Surviving Sepsis Campaign (SSC) issued evidence-based recommendations for clinicians caring for children with septic shock and sepsis-associated organ dysfunction based on the evidence available at the time. There are now more trials from multiple settings, including low-income and middle-income countries (LMICs), addressing optimal fluid choice and amount, selection and timing of vasoactive infusions, and optimal monitoring and therapeutic endpoints. In response to developments in adult critical care to trial personalised haemodynamic management algorithms, it is timely to critically reassess the current state of applying SSC guidelines in LMIC settings. In this Viewpoint, we briefly outline the challenges to improve sepsis care in LMICs and then discuss three key concepts that are relevant to management of children with septic shock around the world, especially in LMICs. These concepts include uncertainties surrounding the early recognition of paediatric septic shock, choices for initial haemodynamic support, and titration of ongoing resuscitation to therapeutic endpoints. Specifically, given the evolving understanding of clinical phenotypes, we focus on the controversies surrounding the concepts of early fluid resuscitation and vasoactive agent use, including insights gained from experience in LMICs and high-income countries. We outline the key components of sepsis management that are both globally relevant and translatable to low-resource settings, with a view to open the conversation to the large variety of treatment pathways, especially in LMICs. We emphasise the role of simple and easily available monitoring tools to apply the SSC guidelines and to tailor individualised support to the patient's cardiovascular physiology.

Corrigendum: Epidemiology, risk factors and outcomes of prolonged mechanical ventilation with different cut-points in a PICU

[This corrects the article DOI: 10.3389/fped.2023.1167595.].

The Role of Blood Purification by HA330 as Adjunctive Treatment in Children with Septic Shock

INTRODUCTION

Despite advances in supportive care for critically ill patients, sepsis remains an important cause of death worldwide in the PICU. One of the hallmarks of sepsis is hyperinflammation due to the excessive release of inflammatory mediators. Recently, new therapeutic approaches, such as immune modulation and blood purification, have been tried to improve outcomes in patients with septic shock.

METHODS

This study is a prospective observational study composed of children with septic shock and the PELOD-2 score ≥10 or the PRISM-3 score ≥15. All received 2-4 h of HA330 treatment on 2 consecutive days, used as adjunctive therapy. The effectiveness of HA330 hemoperfusion was evaluated by improving the PELOD-2 and PRISM-3 scores, the vasoactive inotropic score (VIS), and inflammatory markers from baseline to 72 h after the use of HA330 hemoperfusion.

RESULTS

Twelve patients hospitalized in the PICU and diagnosed with septic shock between July 2021 and May 2022 were included in this study and received hemoperfusion with HA330. The average PELOD-2 and PRISM-3 scores decreased significantly from 9.5 (IQR: 6.5-13.0) at baseline to 2.0 (IQR: 0-6.5) at 72 h (p = 0.002) and from 16.5 (IQR: 15.0-20.5) at baseline to 5.5 (IQR: 2.0-9.5) at 72 h (p = 0.002), respectively. The VIS decreased significantly from baseline to 72 h (p = 0.003). IL-6, procalcitonin, and lactate levels also decreased significantly from baseline to 72 h (p = 0.005, 0.03, and 0.03, respectively). Two of 12 patients expired due to their underlying condition (2/12, 16.7%). Device-related adverse events did not occur in this study.

CONCLUSIONS

Our observational case series suggests a possible role for HA330 hemoperfusion as an adjunctive treatment of refractory septic shock in children with high severity scores in the context of rapid improvement in organ dysfunction, without serious adverse effects.

Sepsis-related pediatric acute respiratory distress syndrome: A multicenter prospective cohort study

OBJECTIVES

This study aimed to compare the risk factors and outcomes for organ dysfunction between sepsis-related Pediatric acute respiratory distress syndrome (PARDS) and nonsepsis PARDS.

METHODS

We prospective cohort recruited intubated patients with PARDS at four tertiary care centers in Thailand. The baseline characteristics, mechanical ventilation, fluid balance, and clinical outcomes were collected. The primary outcome was organ dysfunction.

RESULTS

One hundred and thirty-two mechanically ventilated children with PARDS were included in the study. The median age was 29 months and 53.8% were male. The mortality rate was 22.7% and organ dysfunction was 45.4%. There were 26 (19.7%) and 106 (80.3%) patients who were classified into sepsis-related PARDS and nonsepsis PARDS, respectively. Sepsis-related PARDS patients had a significantly higher incidence of acute kidney injury (30.8% vs. 13.2%, P = 0.041), septic shock (88.5% vs. 32.1%, P < 0.001), organ dysfunction (84.6% vs. 35.8%, P < 0.001), and death (42.3% vs. 17.9%, P = 0.016) than nonsepsis PARDS group. Multivariate analysis adjusted for clinical variables showed that sepsis-related PARDS and percentage of fluid overload were significantly associated with organ dysfunction (odds ratio [OR] 11.414; 95% confidence interval [CI] 1.40892.557, P = 0.023 and OR 1.169; 95% CI 1.0121.352, P = 0.034).

CONCLUSIONS

Sepsis-related PARDS patients had more severe illness, organ dysfunction, and mortality than nonsepsis PARDS patients. The higher percentage of fluid overload and presentation of sepsis was the independent risk factor of organ dysfunction in PARDS patients.

Epidemiology, risk factors and outcomes of prolonged mechanical ventilation with different cut-points in a PICU

Background

A consensus on the definition of prolonged mechanical ventilation (PMV) for children does not exist. There is still lack of published work presenting the epidemiology, risk factors and outcomes at different cut-points for PMV patients. These are important for planning the goals of treatment and counseling of the prognosis for patient families. We aimed to determine the incidence, baseline characteristics, risk factors and outcomes of PMV in pediatric patients at various cut-points (>14, >21 or >30days).

Methods

A retrospective cohort study among children <18-years-old who were PMV > 14 days in the PICU of King Chulalongkorn Memorial Hospital was conducted. The primary outcomes were incidence of PMV with various cut-points. We stratified patients into three groups (Group 1; PMV > 14-21, Group 2; >21-30, Group 3; >30 days) for evaluating the baseline characteristics, risk factors, and outcomes of PMV (extubation success, tracheostomy status and death). Factors associated with PMV and deaths were analyzed using univariate and multivariate logistic regression.

Results

From January 2018 to August 2022, 1,050 patients were screened. Of these, 114 patients were enrolled. The incidence of PMV > 14, >21 and >30 days were 10.9%, 7.3% and 5.0% respectively. Extubation success was significantly lower in Group 3 than in Groups 1 & 2 (15.4% vs. 62.2% & 56.0%, P < 0.001). Consequently, the tracheostomy rate (63.5% vs. 16.2% & 12.0%, P < 0.001), VAP rate (98.1% vs. 59.5% & 80.0%, P < 0.001), mortality rate by disease (34.6% vs. 5.4% & 20.0%, P = 0.003), median PICU LOS (50.5 vs. 22.0 & 28.0 days, P < 0.001) and median hospital LOS (124.5 vs. 55.0 & 62.0 days, P < 0.001) were also significantly higher for Group 3 compared with Groups 1 & 2. The factor associated with PMV > 30 days was VAP (aOR: 19.53, 95% CI: 2.38-160.34, P = 0.01). Factors associated with non-surviving patients were 3rd degree PEM (aOR: 5.14, 95% CI: 1.57-16.88, P = 0.01), PIM3 score ≥14 (aOR: 6.75, 95% CI: 2.26-20.15, P < 0.001) and muscle relaxant usage (aOR: 5.58, 95% CI: 1.65-18.86, P = 0.01).

Conclusion

Extubation failure, tracheostomy rate, VAP rate, mortality rate by disease, PICU LOS and hospital LOS were significantly higher for PMV >30 days. Consequently, we suggest that a 30-day duration as a cut-point for PMV in PICUs might be more appropriate.

Multisystem inflammatory syndrome in children (MIS-C) showing disseminated aspergillosis, cytomegalovirus reactivation and persistent SARS-COV-2: Case report with autopsy review

Multisystem inflammatory syndrome in children (MIS-C) is an emerging phenomenon associated with SARS-COV-2 infection (COVID-19) occurring in < 1 % of infected children. MIS-C is characterized by a hyperinflammatory state with excessive cytokine release ('storm') leading to hemodynamic compromise and multiorgan failure, with a death rate of ∼2 %. Autopsy examination can play a particularly important role in helping to understand the pathogenesis of MIS-C. Yet, only five autopsy studies have been reported to date. We report a fatal case of MIS-C involving a previously healthy, 5-year-old Thai boy admitted with MIS-C, one month after exposure to SARS-COV-2. While in intensive care, he was found to have a hypertrophic cardiomyopathy, and despite immunosuppressive treatment for MIS-C, developed shock and died. Multiorgan inflammation was not found at autopsy, implying that the MIS-C had responded to treatment. However, there was disseminated aspergillosis and cytomegalovirus reactivation, attributed to the immunosuppression. SARS-COV-2 virus was also found in multiple organs. To the best of our knowledge, this is the first reported autopsy of an MIS-C patient from Asia, and the first report of aspergillosis in MIS-C. This case underscores that the risks of immunosuppression are also a concern in MIS-C. Although MIS-C is generally considered to be a post-infectious hyperimmune reaction, persistence of SARS-COV-2 is a feature in all autopsies of MIS-C patients reported to date, suggesting a possible role in the pathogenesis, at least in fatal cases.

Polymyxin B Hemoperfusion in Pediatric Septic Shock: Single-Center Observational Case Series

OBJECTIVES

To evaluate the use of direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) as adjunctive therapy during pediatric patients with septic shock.

DESIGN

Prospective observational study.

SETTING

Nine-bed PICUs at university referral hospital.

PATIENTS

Children (30 d to 15 yr) with septic shock and Pediatric Logistic Organ Dysfunction (PELOD)-2 score greater than or equal to 10 or Pediatric Risk of Mortality (PRISM) 3 score greater than or equal to 15, who were also receiving at least one inotrope.

INTERVENTION

Patients received 2-4 hour treatment with PMX-DHP 20R column on 2 consecutive days.

MEASUREMENTS AND MAIN RESULTS

We enrolled six children aged 21-167 months old (median, 99-mo old), with a body weight of 10-50 kg (median, 28 kg). All six patients had both PELOD-2 greater than or equal to 10 and PRISM-3 greater than or equal to 15, required invasive mechanical ventilation, and received standard treatment for septic shock before enrollment. We observed significant improvement in PELOD-2 score from baseline to 72 hours after the start of PMX-DHP (mean [95% CI] from 14.3 [12.2-16.5] to 6.0 [0.3-11.7]; p = 0.006). The vasoactive inotropic score (VIS) and lactate concentration also significantly decreased from baseline to 72 hours (VIS, 60 mmol/L [25-95 mmol/L] to 4.0 mmol/L [44.1-12 mmol/L]; p = 0.003; lactate, 2.4 mmol/L [1.0-3.8 mmol/L] to 1.0 mmol/L [0.5-1.5 mmol/L]; p = 0.01). Five of six patients survived. There was no device-related adverse event in these patients.

CONCLUSIONS

In this case series of treatment with PMX-DHP as adjunctive therapy in children with refractory septic shock and high baseline severity, we have shown that patient recruitment is feasible. We have also found that clinical hemodynamic and severity of illness scores at 72 hours may be potential end points for testing in future randomized controlled trials.

Balanced Salt Solution Versus Normal Saline in Resuscitation of Pediatric Sepsis: A Randomized, Controlled Trial

Current evidences in resuscitation of adult sepsis have pointed to the importance of types of crystalloid fluid-related complications on resuscitation outcomes, but evidences are lacking in pediatric populations. In this study, the authors aimed to compare outcomes of pediatric sepsis resuscitation with different types of crystalloid. They randomly assigned pediatric sepsis patients requiring fluid bolus into three groups to receive either normal saline solution (NSS), Ringer lactate solution (RLS), or Sterofundin as fluid bolus therapy. Forty-two patients were included in the study. Median age was 29 mo and, weight 13 kg. After fluid bolus, the complications were not different among groups. However, in the RLS group, the patients who received large dose of the fluid showed significant reduction in urinary neutrophil gelatinase-associated lipocalin (uNGAL) level. It is concluded that fluid bolus therapy with different types of crystalloid solution did not result in different outcomes but large dose of RLS was associated with greater reduction of uNGAL level, compared to other fluids.Trial Registration: Thai Clinical Trial Registry (TCTR) identification number TCTR20170605001 (retrospectively registered on 1st June 2017). https://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task20=search&task2=view1&id=2576.

Changes Adopted in Asian Pediatric Hospitals during the COVID-19 Pandemic: A Report from the Pediatric Acute and Critical Care COVID-19 Registry of Asia

There is wide variation in the overall clinical impact of novel coronavirus disease 2019 (COVID-19) across countries worldwide. Changes adopted pertaining to the management of pediatric patients, in particular, the provision of respiratory support during the COVID-19 pandemic is poorly described in Asia. We performed a multicenter survey of 20 Asian pediatric hospitals to determine workflow changes adopted during the pandemic. Data from centers of high-income (HIC), upper middle income (UMIC), and lower middle income (LMIC) countries were compared. All 20 sites over nine countries (HIC: Japan [4] and Singapore [2]; UMIC: China [3], Malaysia [3] and Thailand [2]; and LMIC: India [1], Indonesia [2], Pakistan [1], and Philippines [2]) responded to this survey. This survey demonstrated substantial outbreak adaptability. The major differences between the three income categories were that HICs were (1) more able/willing to minimize use of noninvasive ventilation or high-flow nasal cannula therapy in favor of early intubation, and (2) had greater availability of negative-pressure rooms and powered air-purifying respirators. Further research into the best practices for respiratory support are warranted. In particular, innovation on cost-effective measures in infection control and respiratory support in the LMIC setting should be considered in preparation for future waves of COVID-19 infection.

Therapeutic Plasma Exchange with Continuous Renal Replacement Therapy for Pediatric Acute Liver Failure: A Case Series from Thailand

Aim and objective

Pediatric acute liver failure (PALF) is a life-threatening condition. Extracorporeal support has been applied for toxic metabolite clearance and serves as a bridging therapy to liver transplantation (LT) or to the regeneration of the liver, but evidence for treatment approaches is still lacking in the pediatric population. We aim to report our experience on therapeutic plasma exchange with high-volume continuous renal replacement therapy (TPE + HV-CRRT) as a promising supportive treatment for PALF.

Materials and methods

A total of eight PALF cases aged 9 months to 14 years, weighing 10–50 kg., who were admitted to PICU King Chulalongkorn Memorial Hospital, Thailand and treated with TPE + HV-CRRT from January 2016 to September 2019 were reviewed. Patient demographic data, indications, technical aspects, and clinical outcomes were recorded.

Results

All patients who underwent TPE + HV-CRRT showed clinical improvement regarding serum bilirubin levels and coagulation studies after the therapy. Complications from the therapy were hemodynamic instability, symptomatic fluid overload, and bleeding from catheter sites. Among these, 6 (75%) patients survived with 4 (50%) successful LTs and 2 (25%) spontaneous recovery. Two children (25%) died while on the transplantation list.

Conclusion

TPE + HV-CRRT can be used safely as a bridging therapy in children with PALF. As opposed to the adult population, higher volume of TPE or higher blood flow rate in pediatric patients might associate with hemodynamic instability during the procedure.

How to cite this article

Trepatchayakorn S, Chaijitraruch N, Chongsrisawat V, Chanakul A, Kongkiattikul L, Samransamruajkit R. Therapeutic Plasma Exchange with Continuous Renal Replacement Therapy for Pediatric Acute Liver Failure: A Case Series from Thailand. Indian J Crit Care Med 2021;25(7):812–816.

Endotoxemia and circulating bacteriome in severe COVID-19 patients

BACKGROUND

When severe, COVID-19 shares many clinical features with bacterial sepsis. Yet, secondary bacterial infection is uncommon. However, as epithelium is injured and barrier function is lost, bacterial products entering the circulation might contribute to the pathophysiology of COVID-19.

METHODS

We studied 19 adults, severely ill patients with COVID-19 infection, who were admitted to King Chulalongkorn Memorial Hospital, Bangkok, Thailand, between 13th March and 17th April 2020. Blood samples on days 1, 3, and 7 of enrollment were analyzed for endotoxin activity assay (EAA), (1 → 3)-β-D-glucan (BG), and 16S rRNA gene sequencing to determine the circulating bacteriome.

RESULTS

Of the 19 patients, 13 were in intensive care and 10 patients received mechanical ventilation. We found 8 patients with high EAA (≥ 0.6) and about half of the patients had high serum BG levels which tended to be higher in later in the illness. Although only 1 patient had a positive blood culture, 18 of 19 patients were positive for 16S rRNA gene amplification. Proteobacteria was the most abundant phylum. The diversity of bacterial genera was decreased overtime.

CONCLUSIONS

Bacterial DNA and toxins were discovered in virtually all severely ill COVID-19 pneumonia patients. This raises a previously unrecognized concern for significant contribution of bacterial products in the pathogenesis of this disease.

The impact of high frequency oscillatory ventilation on mortality in paediatric acute respiratory distress syndrome

BACKGROUND

High-frequency oscillatory ventilation (HFOV) use was associated with greater mortality in adult acute respiratory distress syndrome (ARDS). Nevertheless, HFOV is still frequently used as rescue therapy in paediatric acute respiratory distress syndrome (PARDS). In view of the limited evidence for HFOV in PARDS and evidence demonstrating harm in adult patients with ARDS, we hypothesized that HFOV use compared to other modes of mechanical ventilation is associated with increased mortality in PARDS.

METHODS

Patients with PARDS from 10 paediatric intensive care units across Asia from 2009 to 2015 were identified. Data on epidemiology and clinical outcomes were collected. Patients on HFOV were compared to patients on other modes of ventilation. The primary outcome was 28-day mortality and secondary outcomes were 28-day ventilator- (VFD) and intensive care unit- (IFD) free days. Genetic matching (GM) method was used to analyse the association between HFOV treatment with the primary outcome. Additionally, we performed a sensitivity analysis, including propensity score (PS) matching, inverse probability of treatment weighting (IPTW) and marginal structural modelling (MSM) to estimate the treatment effect.

RESULTS

A total of 328 patients were included. In the first 7 days of PARDS, 122/328 (37.2%) patients were supported with HFOV. There were significant differences in baseline oxygenation index (OI) between the HFOV and non-HFOV groups (18.8 [12.0, 30.2] vs. 7.7 [5.1, 13.1] respectively; p < 0.001). A total of 118 pairs were matched in the GM method which found a significant association between HFOV with 28-day mortality in PARDS [odds ratio 2.3, 95% confidence interval (CI) 1.3, 4.4, p value 0.01]. VFD was indifferent between the HFOV and non-HFOV group [mean difference - 1.3 (95%CI - 3.4, 0.9); p = 0.29] but IFD was significantly lower in the HFOV group [- 2.5 (95%CI - 4.9, - 0.5); p = 0.03]. From the sensitivity analysis, PS matching, IPTW and MSM all showed consistent direction of HFOV treatment effect in PARDS.

CONCLUSION

The use of HFOV was associated with increased 28-day mortality in PARDS. This study suggests caution but does not eliminate equivocality and a randomized controlled trial is justified to examine the true association.

Non-Invasive Ventilation in Children with Paediatric Acute Respiratory Distress Syndrome

Introduction: Evidence supporting non-invasive ventilation (NIV) in paediatric acute respiratory distress syndrome (PARDS) remains sparse. We aimed to describe characteristics of patients with PARDS supported with NIV and risk factors for NIV failure. Materials and Methods: This is a multicentre retrospective study. Only patients supported on NIV with PARDS were included. Data on epidemiology and clinical outcomes were collected. Primary outcome was NIV failure which was defined as escalation to invasive mechanical ventilation within the first 7 days of PARDS. Patients in the NIV success and failure groups were compared. Results: There were 303 patients with PARDS; 53/303 (17.5%) patients were supported with NIV. The median age was 50.7 (interquartile range: 15.7-111.9) months. The Paediatric Logistic Organ Dysfunction score and oxygen saturation/fraction of inspired oxygen (SF) ratio were 2.0 (1.0-10.0) and 155.0 (119.4-187.3), respectively. Indications for NIV use were increased work of breathing (26/53 [49.1%]) and hypoxia (22/53 [41.5%]). Overall NIV failure rate was 77.4% (41/53). All patients with sepsis who developed PARDS experienced NIV failure. NIV failure was associated with an increased median paediatric intensive care unit stay (15.0 [9.5-26.5] vs 4.5 [3.0-6.8] days; P <0.001) and hospital length of stay (26.0 [17.0-39.0] days vs 10.5 [5.5-22.3] days; P = 0.004). Overall mortality rate was 32.1% (17/53). Conclusion: The use of NIV in children with PARDS was associated with high failure rate. As such, future studies should examine the optimal selection criteria for NIV use in these children. Key words: Bi-level positive airway pressure, Continuous positive airway pressure, Non-invasive ventilation

Non-Invasive Ventilation in Children with Paediatric Acute Respiratory Distress Syndrome

INTRODUCTION

Evidence supporting non-invasive ventilation (NIV) in paediatric acute respiratory distress syndrome (PARDS) remains sparse. We aimed to describe characteristics of patients with PARDS supported with NIV and risk factors for NIV failure.

MATERIALS AND METHODS

This is a multicentre retrospective study. Only patients supported on NIV with PARDS were included. Data on epidemiology and clinical outcomes were collected. Primary outcome was NIV failure which was defined as escalation to invasive mechanical ventilation within the first 7 days of PARDS. Patients in the NIV success and failure groups were compared.

RESULTS

There were 303 patients with PARDS; 53/303 (17.5%) patients were supported with NIV. The median age was 50.7 (interquartile range: 15.7-111.9) months. The Paediatric Logistic Organ Dysfunction score and oxygen saturation/fraction of inspired oxygen (SF) ratio were 2.0 (1.0-10.0) and 155.0 (119.4- 187.3), respectively. Indications for NIV use were increased work of breathing (26/53 [49.1%]) and hypoxia (22/53 [41.5%]). Overall NIV failure rate was 77.4% (41/53). All patients with sepsis who developed PARDS experienced NIV failure. NIV failure was associated with an increased median paediatric intensive care unit stay (15.0 [9.5-26.5] vs 4.5 [3.0-6.8] days; P <0.001) and hospital length of stay (26.0 [17.0-39.0] days vs 10.5 [5.5-22.3] days; P = 0.004). Overall mortality rate was 32.1% (17/53).

CONCLUSION

The use of NIV in children with PARDS was associated with high failure rate. As such, future studies should examine the optimal selection criteria for NIV use in these children.

Assessment of early goal-directed therapy guideline adherence: Balancing clinical importance and feasibility

BACKGROUND

Assessing adherence to Early goal-directed therapy (EGDT) is challenging and might account for the negative findings and generalisability of the major trials to a real-life setting. This study was aimed (1) to extract key components of pediatric EGDT guidelines potentially becoming adherence criteria; (2) to classify adherence criteria into complete, clinically important, and feasible; and (3) to compare percent adherence to selected guidelines using the three approaches.

METHODS

This study started with review of existing evidence to extract key components of pediatric EGDT guidelines. Modified Delphi method was then conducted in two rounds among national experts to identify feasible and/or clinically important criteria. Data from the national prospective multicenter study "Clinical Effectiveness of the Utilization of Bundled Care for Severe Sepsis and Septicemia Children" at King Chulalongkorn Memorial Hospital (KCMH) during 1 June 2012 and 28 February 2014 was used to compare percentage of adherence across the three approaches.

RESULTS

Of 28 components extracted from the review, 10 were identified by the national experts through the Modified Delphi as feasible whereas 8 were identified as clinically important. Thirty-one severe sepsis patients (48.39% male, median age 3.4 years) were reviewed. Sepsis mortality was 9.7%, a significant reduction from 19% and 42% in 2010 and 2007, respectively. Based on the complete adherence criteria, the percent adherence varied from 60.71% to 89.29% (overall mean 76.84%), with lower adherence in the dead than the survived cases (73.81% vs 77.17%; p = 0.55). The percent adherence varied by criteria used: 69.35%, 76.84%, and 84.52% for clinical importance, complete, and feasibility criteria, respectively.

CONCLUSION

Adherence determination based on selected clinical importance alone might result in an incorrectly estimated clinical benefit of EGDT guidelines, especially in a resource-limited setting. Both clinical importance and feasibility should be integrated into the development of adherence assessment criteria.

Prognostic value of continuous electroencephalography in children undergoing therapeutic hypothermia after cardiac arrest: A pilot study

OBJECTIVE

To determine the prognostic value of continuous electroencephalography (EEG) in children undergoing therapeutic hypothermia after cardiac arrest.

METHOD

We retrospectively reviewed medical records and continuous EEG of all patients undergoing therapeutic hypothermia after cardiac arrest from November 2013 to September 2016. Demographic, clinical data and immediate complications were collected. Characteristics of continuous EEG including EEG background, time to normal trace (TTNT) and electrographic seizures were reviewed by investigators. Cerebral performance category scales at 6 months' follow up were evaluated and divided into good (grade 1-2) and poor (grade 3-5) outcome groups.

RESULT

Six patients were included (two boys and four girls) with median age of 19.5 months (range13-128 months). Five patients (83.3%) presented with cardiac arrest from near-drowning and one patient with underlying acute lymphocytic leukemia presented an in-hospital cardiac arrest. Initial EKG rhythm was asystole in 3 patients (50%), pulseless activity in 1 patient (16.7%) and initially unknown in 2 patients (33.3%). Two patients (33.3%) who had EEG reactivity and TTNT within 5minutes and 2.5hours had good neurological outcome (CPC1). Four patients (66.7%) with absent EEG reactivity had poor neurological outcome (CPC4, 5 in 3 and 1 children respectively). Three patients from the poor outcome group had electrographic seizures, of whom 2/3 progressed to status epilepticus. Three out of four patients in the poor outcome group had the following complications: pneumonia, bleeding and pancreatitis.

CONCLUSION

Early TTNT and EEG reactivity help to predict good neurological outcome in children undergoing therapeutic hypothermia after cardiac arrest. Seizures and status epilepticus may predict poor neurological outcome.

The Utilization of the Surviving Sepsis Campaign Care Bundles in the Treatment of Pediatric Patients with Severe Sepsis or Septic Shock in a Resource-Limited Environment: A Prospective Multicenter Trial

Background:

Sepsis is a common condition affecting the lives of infants and children worldwide. Although implementation of the surviving sepsis campaign (SSC) care bundles was once believed to be effective in reducing sepsis mortality rates, the approach has recently been questioned.

Methods:

The study was a prospective, interventional, multicenter trial. Infants and children aged 1 month to 15 years in seven different large academic centers in Thailand who had been diagnosed with severe sepsis or septic shock. They were given treatment based on the SSC care bundles.

Results:

A total of 519 children with severe sepsis or septic shock were enrolled in the study. Among these, 188 were assigned to the intervention group and 331 were recruited to the historical case–control group. There were no significant differences in the baseline clinical characteristics. The intervention group was administered a significantly higher fluid bolus than was the control group (28.3 ± 17.2 cc/kg vs. 17.7 ± 10.6 cc/kg; P = 0.02) with early vasopressor used (1.5 ± 0.7 h) compared to control group (7.4 ± 2.4 h, P < 0.05). More importantly, our sepsis mortality reduced significantly from 37% ± 20.7% during the preintervention period to 19.4% ± 14.3% during the postintervention period (P < 0.001).

Conclusion:

Our study demonstrated a significant reduction in sepsis mortality after the implementation of the SSC care bundles. Early diagnosis of the disease, optimum hemodynamic resuscitation, and timely antibiotic administration are the key elements of sepsis management.

High-Flow Nasal Cannula versus Conventional Oxygen Therapy in Children with Respiratory Distress

Purpose:

The aim of this study is to determine the clinical efficacy of high-flow nasal cannula (HFNC) therapy compared with conventional oxygen therapy in children presented with respiratory distress.

Study Design:

This was a randomized controlled study.

Materials and Methods:

Infants and children aged between 1 month to 5 years who were admitted to our tertiary referral center for respiratory distress (July 1, 2014 to March 31, 2015) and met the inclusion criteria were recruited.

Interventions:

Infants and children hospitalized with respiratory distress were randomized into two groups of interventions. All clinical data, for example, respiratory score, pulse rate, and respiratory rate were recorded. The results were subsequently analyzed.

Results:

A total of 98 respiratory distress children were enrolled during the study period. Only 4 children (8.2%) failed in HFNC therapy, compared with 10 children (20.4%) in conventional oxygen therapy group (P = 0.09). After adjusted for body weight, underlying diseases, and respiratory distress score, there was an 85% reduction in the odds of treatment failure in HFNC therapy group (adjusted odds ratio 0.15, 95% confidence interval 0.03–0.66, P = 0.01). Most children in HFNC therapy group had significant improvement in clinical respiratory score, heart rate, and respiratory rate at 240, 360, and 120 min compared with conventional oxygen therapy (P = 0.03, 0.04, and 0.03).

Conclusion:

HFNC therapy revealed a potential clinical advantage in management children hospitalized with respiratory distress compared with conventional respiratory therapy. The early use of HFNC in children with moderate-to-severe respiratory distress may prevent endotracheal tube intubation.

Trial Register:

TCTR 20170222007.

Exhaled nitric oxide, pulmonary function, and disease activity in children with systemic lupus erythematosus

AIM

To determine the association among fractional exhaled nitric oxide (FENO), pulmonary function, and disease activity in children with systemic lupus erythematosus (SLE).

METHODS

Children aged 7-18 years, diagnosed with SLE under the criteria of the American Rheumatism Association (revised 2012), were enrolled. All eligible participants had disease activity, FENO, and pulmonary function evaluated and re-evaluated at 6-month follow-up.

RESULTS

Twenty-four children (95.8% female; mean age 15.2 ± 2 years; median disease duration 2.4 years) were studied. The mean FENO₁ and FENO₂ were 19.6 ± 7.2 parts per billion (ppb) and 17.4 ± 4.5 ppb, respectively. At baseline, 20.8% had abnormal pulmonary functions (all restrictive defects) and increased to 29.2% at follow-up (isolated restrictive defect 25% and restrictive with diffusion defect 4.2%). Most of their disease activities at baseline and second assessment were non-active (58.3%, 70.8%) or mild disease activities (20.8% both). There was significant correlation between FENO and disease activity (r = 0.49; P-value = 0.02). The significant negative correlation between total lung capacity (TLC) and disease activity was detected in children with active SLE (r = -0.71; P-value = 0.02).

CONCLUSION

Decreased TLC and high FENO were common in SLE children who had no respiratory symptoms and correlated with disease activity. FENO should be considered as an additional pulmonary function to evaluate disease activity in children with SLE.

Optimal nutrition therapy in paediatric critical care in the Asia-Pacific and Middle East: a consensus

BACKGROUND AND OBJECTIVES

Current practices and available resources for nutrition therapy in paediatric intensive care units (PICUs) in the Asia Pacific-Middle East region are expected to differ from western countries. Existing guidelines for nutrition management in critically ill children may not be directly applicable in this region. This paper outlines consensus statements developed by the Asia Pacific-Middle East Consensus Working Group on Nutrition Therapy in the Paediatric Critical Care Environment. Challenges and recommendations unique to the region are described.

METHODS AND STUDY DESIGN

Following a systematic literature search from 2004-2014, consensus statements were developed for key areas of nutrient delivery in the PICU. This review focused on evidence applicable to the Asia Pacific-Middle East region. Quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach.

RESULTS

Enteral nutrition (EN) is the preferred mode of nutritional support. Feeding algorithms that optimize EN should be encouraged and must include: assessment and monitoring of nutritional status, selection of feeding route, time to initiate and advance EN, management strategies for EN intolerance and indications for using parenteral nutrition (PN). Despite heterogeneity in nutritional status of patients, availability of resources and diversity of cultures, PICUs in the region should consider involvement of dieticians and/or nutritional support teams.

CONCLUSIONS

Robust evidence for several aspects of optimal nutrition therapy in PICUs is lacking. Nutritional assessment must be implemented to document prevalence and impact of malnutrition. Nutritional support must be given greater priority in PICUs, with particular emphasis in optimizing EN delivery.

A comparison of clinical efficacy between high frequency oscillatory ventilation and conventional ventilation with lung volume recruitment in pediatric acute respiratory distress syndrome: A randomized controlled trial

PURPOSE

To determine the efficacy of lung volume recruitment maneuver (LVRM) with high frequency oscillatory ventilation (HFOV) on oxygenation, hemodynamic alteration, and clinical outcomes when compared to conventional mechanical ventilation (CV) in children with severe acute respiratory distress syndrome (ARDS).

MATERIALS

We performed a randomized controlled trial and enrolled pediatric patients who were diagnosed to have severe ARDS upon pediatric intensive care unit (PICU) admission. LVRM protocol combined with HFOV or conventional mechanical ventilation was used. Baseline characteristic data, oxygenation, hemodynamic parameters, and clinical outcomes were recorded.

RESULTS

Eighteen children with severe ARDS were enrolled in our study. The primary cause of ARDS was pneumonia (91.7%). Their mean age was 47.7 ± 61.2 (m) and body weight was 25.3 ± 27.1 (kg). Their initial pediatric risk of mortality score 3 and pediatric logistic organ dysfunction were 12 ± 9.2 and 15.9 ± 12.8, respectively. The initial mean oxygen index was 24.5 ± 10.4, and mean PaO2/FiO2 was 80.6 ± 25. There was no difference in oxygen parameters at baseline the between two groups. There was a significant increase in PaO2/FiO2 (119.2 ± 41.1, 49.6 ± 30.6, P = 0.01*) response after 1 h of LVRM with HFOV compare to CV. Hemodynamic and serious complications were not significantly affected after LVRM. The overall PICU mortality of our severe ARDS at 28 days was 16.7%. Three patients in CV with LVRM group failed to wean oxygen requirement and were cross-over to HFOV group.

CONCLUSIONS

HFOV combined with LVRM in severe pediatric ARDS had superior oxygenation and tended to have better clinical effect over CV. There is no significant effect on hemodynamic parameters. Moreover, no serious complication was noted.

CAUSATIVE AGENTS OF SEVERE COMMUNITY ACQUIRED VIRAL PNEUMONIA AMONG CHILDREN IN EASTERN THAILAND

Pneumonia is a leading cause of morbidity and mortality among infants and young children. The most common causes of pneumonia in children are respiratory viruses. In Thailand, the epidemiology of the viruses causing community-acquired pneumonia (CAP) among children is poorly defined. In this cross sectional study we used nasopharyngeal samples collected from hospitalized children diagnosed with severe CAP in accordance with WHO criteria between June 2013 and May 2014 to determine the causes of infection. The samples were analyzed for respiratory syncytial virus (RSV), parainfluenza viruses (PIV) types 1,2 and 3, adenovirus, rhinovirus, influenza viruses types A and B and coronavirus by polymerase chain reaction (PCR) and reverse transcriptase-polymerase chain reaction (RT-PCR). Of 102 cases of severe CAP, samples were obtained in 91 cases and 48 (52.7%) were positive for respiratory viruses. The most common viruses were RSV (n = 22; 45.8%), rhinovirus (n = 11; 22.9%) and adenovirus (n = 9; 18.7%). Patients were aged 1 month to 4 years 5 months, with a median age of 1 year 1 month. Thirty-seven (77.1%) were male. Asthma was the most common co-morbidity affecting 5 (10.4%) of the 48 cases with an identified virus. The peak prevalence occurred during October (n = 17). All patients required oxygen therapy and 17 (35.4%) required mechanical ventilation. The median length of hospitalization was 11 days. Preterm infants had a significantly higher rate of RSV infection than other respiratory viruses (8 of 21; 38% vs 3 of 27; 11.1%) (p = 0.02). Viruses were most commonly associated with severe CAP among children aged less than 1 year. The peak prevalence occurred during the rainy season. Our findings suggest that young and preterm infants with CAP should be monitored closely due to their high risk for developing serious complications.

Human parainfluenza virus infection in Thai children with lower respiratory tract infection from 2010 to 2013

Human parainfluenza virus (HPIV) is a common cause of upper and lower respiratory illness in infants and young children. In order to classify the HPIV isolates circulating in the central part of Thailand, 650 samples obtained from the lower respiratory tract of patients from two hospital pediatric wards during 2010 to 2013, were analyzed for the presence and types of HPIVs by multiplex semi-nested PCR of hemagglutinin-neuraminidase (HN) gene. The results showed that 4.8% of the samples were positive for HPIV, among which 0.5%, 2.5% and 1.5% were positive for HPIV-1, HPIV-3, and HPIV-4, respectively, and none were positive for HPIV-2. A phylogenetic tree constructed from 31 HPIV HN gene sequences compared to those in GenBank showed greater than 80% identity to other reference strains. Prevalence of HPIV infection and phylogenetic characteristics of the circulating HPIVs may help explain the impact of HPIVs infection in Thai children.

Clinical outcomes after utilizing surviving sepsis campaign in children with septic shock and prognostic value of initial plasma NT-proBNP

BACKGROUND AND OBJECTIVE

The surviving sepsis campaign treatment guideline (SSC) implementation is associated with improved outcome in adults with severe sepsis. The effect on outcome of pediatric sepsis is less clear.

PURPOSE

To determine the clinical outcomes of SSC implementation and to investigate the prognostic value of initial plasma NT-proBNP and procalcitonin in children.

MATERIALS AND METHODS

Infants and children (aged 1month/0-15 years with severe sepsis or septic shock) were prospectively enrolled and treated according to the guidelines. Initial blood drawn was saved for NT-pro-BNP, procalcitonin measurements and clinical data were also recorded.

RESULTS

A total of 47 subjects were recruited. Since the application of the SSC, our mortality rate had significantly decreased from 42-19% (P = 0.003) as compared to the data in the previous 3 years. Clinical factors that significantly increased the mortality rate were: Initial central venous oxygen saturation < 7 0% after fluid resuscitation [odds ratio (OR) = 23.3; 95% confidence interval (CI) 3.7-143; P = 0.001], and initial albumin level (≤ 3 g/dl, OR = 6.7; 95% CI 1.2-37.5, P = 0.03). There was asignificant difference between the initial NT-proBNP levels between survivors and non survivors, (6280.3 ± 9597 ng/L, P < 0.001), but not for procalcitonin (12.7 ± 24.8, 29.3 ± 46 μg/L, P = 0.1), respectively. An initial NT-proBNP level of more than 11,200 pg/ml predicted Pediatric Intensive Care Unit (PICU) mortality with a sensitivity of 85.7% and a specificity of 90%.

CONCLUSIONS

A modified SSC for severe sepsis and septic shock significantly reduced the mortality rate in our PICU. High initial NT-ProBNP level was associated with mortality.

Incidence of recurrent wheezing in under 5-year-old human bocavirus infection during one year follow-up

BACKGROUND

Human bocavirus (HBoV) is a newly identified virus that can cause acute wheezing in young children. The present study aimed to evaluate the incidence and factors associated with recurrent wheezing during 1 year after HBoV lower respiratory tract infection (LRI).

MATERIAL AND METHOD

Children younger than 5 years old who were admitted to King Chulalongkorn Memorial Hospital between February 1, 2006 and September 30, 2008 due to LRI were recruited. Their nasopharyngeal aspirates were evaluated for respiratory virus by polymerase chain reaction (PCR) assays. Those who had positive PCR for HBoV and had no underlying diseases were studied. Their clinical presentations were evaluated and their clinical data about recurrent wheezing as well as pulmonary function tests were followed-up for 1 year.

RESULTS

Fifteen patients with HBoV-LRI were regularly followed-up. Seven patients (47%) had co-infection with other respiratory viruses. Generalized wheezing was the most common lung sign detected in 73% of cases (11 cases) and 36% (4 cases) of them responded well to bronchodilators. During one year follow-up, serial pulmonary function tests were normal in all cases and most patients were doing well. However 27% of HBoV infected patients (4 cases) developed recurrent wheezing associated with respiratory tract infections. Two of them had to be re-hospitalized. Compared to patients without recurrent wheezing, eosinophil count tended to be higher in those with recurrent wheezing and isolated HBoV infected patients tended to develop recurrent wheezing more than those with co-infection.

CONCLUSION

Acute wheezing is a common presenting lung sign in HBo V-LRI. Although the pulmonary function tests of all patients were normal, more than a quarter of patients suffered from recurrent wheezing during one-year follow-up.

Potent inflammatory cytokine response following lung volume recruitment maneuvers with HFOV in pediatric acute respiratory distress syndrome

OBJECTIVE

Lung volume recruitment maneuver (LVRM) may improve gas exchange but inflating the lungs to nearly vital capacity may cause further lung injuries. Our aim was to determine the potent inflammatory cytokine response following lung volume recruitment (LVRM) with high frequency oscillator ventilation (HFOV) in pediatric acute respiratory distress syndrome (ARDS).

METHODS

We prospectively recruited pediatric patients (age >1 month - <15 year old) with a diagnosis of ARDS within 72 hrs of PICU admission. They underwent the LVRM protocol combined with HFOV. Any enrolled subject who had a 20% improvement in PaO2/FiO2 (PF ratio) 1 hr after the LVRM we classified as a responder. Baseline clinical data were recorded. Blood was also drawn at baseline, 1 & 24 hrs after LVRM and kept for further sICAM-1, IL-6 & IL-8 analysis.

RESULTS

Eighteen children with ARDS were enrolled. Their mean age was at 6.8 +/- 6.1 years (mean +/- SD). The initial oxygen index (iOI) was at 26.8 +/- 17.8 (11.5-84.9). There was no significant differences in sICAM-1, IL-6 and IL-8 levels at baseline; (34 +/- 17.5, 121.7 +/- 115.15, 601.5 +/- 675 pg/ml); 1 hr (39.6 +/- 28.7, 99.8 +/- 75.5, 617.4 +/- 692.5 pg/ml) and at 24 hrs (44.23 +/- 34.4, 109.4 +/- 63.9, 737.6 +/- 922.3 pg/ml) following LVRMs, respectively. However, there was significant difference in the elevation of sICAM-1 levels (%change) from baseline in responders (-1.8 +/- 12.2%) vs. non-responders (47.65 +/- 43.5%) at 1 hr. Additionally, sICAM-1 levels were also significantly higher at baseline, 1 hr and 24 hrs in non-survivors as compared with survivors.

CONCLUSION

There was no significant elevation of potent inflammatory cytokines that may indicate further lung injuries in the majority of our patients. However, there was significant elevation of sICAM-1 levels in non-responders and in those who did not survive that may indicate more lung injuries in these individuals.

The long duration of extracorporeal membrane oxygenation in a child with acute severe hypoxic respiratory failure treated in a resource-limited center

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been indicated in patients with severe refractory respiratory failure from various causes for more than 30 years, even for the small infant.(1) Improved outcome from using ECMO for respiratory failure has been reported worldwide, ranging from 15% to over 50% in recent reviews.(1,2) The rationale of this therapy is to allow time for the lungs to heal, minimizing further lung injury from positive pressure ventilation.(3,4) We describe a case of severe acute respiratory distress syndrome (ARDS) with extensive barotrauma supported by VV-ECMO for 96 days in a resource-limited center. This is likely the longest ECMO support ever reported in a child.

Gas exchange abnormality during sleep in non-snoring severe thalassemia children

OBJECTIVE

To study the prevalence and associated factors of gas exchange abnormality during sleep in non-snoring severe thalassemia children.

MATERIAL AND METHOD

Non-snoring severe thalassemia children aged 6 to 15 years who had been followed up at King Chulalongkorn Memorial Hospital between June 2009 and March 2010 were studied. Overnight pulse oximetry and end-tidal carbon dioxide tension (P(ET)CO2) monitoring as well as pulmonary function tests were evaluated.

RESULTS

Fifty-eight non-snoring severe thalassemia children (aged 10.5 +/- 2.6 years, 43% male) were studied. 67.2% showed abnormal gas exchange during sleep. All of them had nocturnal desaturation (nadir SpO2 87 +/- 6.9%; range 65 to 94%). 33.3% of those who had nocturnal desaturation had associated lung function abnormality. Abnormal lung function was found in 32.8% of the present study patients. Of these, 68.4% had associated nocturnal desaturation. Age, gender nutritional status, size of liver and spleen, history of splenectomy, hemoglobin and serum ferritin level, and lung function were not associated with abnormal gas exchange during sleep.

CONCLUSION

Nocturnal desaturation was demonstrated in more than a half of non-snoring severe thalassemia children. Normal lung function did not guarantee normal gas exchange during sleep. However, more than a half of those who had lung function abnormality had associated nocturnal desaturation. Evaluation of gas exchange during sleep would be merited in this group of patients.

High prevalence of human rhinovirus C infection in Thai children with acute lower respiratory tract disease

Objective

To determine the prevalence of human rhinoviruses (HRV) infections in children with lower respiratory disease in Thailand and monitor the association between species of HRV and clinical presentation in hospitalized paediatric patients.

Method

Two hundred and eighty-nine nasopharyngeal (NP) suction specimens were collected from hospitalized paediatric patients admitted to King Chulalongkorn Memorial Hospital, Thailand during February 2006–2007. Nucleic acids were extracted from each sample with subsequent amplification of VP4/2 by semi-nested RT-PCR for HRV detection. Other viral respiratory pathogens were also detected by PCR, RT-PCR or real time PCR. Nucleotide sequences of the VP4 region were used for genotyping and phylogenetic tree construction.

Result

In total, 87 of 289 specimens were positive for HRV indicating an annual prevalence of 30%. Wheezing or asthma exacerbation was the most common clinical presentation observed in infected patients. Sequence analysis and phylogenetic tree showed that 29 (33%) and 8 (9%) specimens belonged to HRV-A and HRV-B, respectively. Most of the HRV positive samples were HRV-C (58%). Moreover, species C was predominantly found in the paediatric population of Thailand in raining season (p < 0.05). The frequency of co-infection of HRV-C with other respiratory viral pathogens was approximately 40%.

Conclusion

HRV-C represents the predominant species and is one of the etiologic agents in acute lower respiratory tract infection, causes of wheezing and asthma exacerbation in infants and young children in Thailand.

Multidrug-resistant hospital-associated infections in a pediatric intensive care unit: a cross-sectional survey in a Thai university hospital

OBJECTIVE

To determine the incidence and associated factors of multidrug-resistant hospital-associated infections (MDR-HAI) in a pediatric intensive care unit (PICU) of a university hospital in Thailand.

METHOD

A prospective study was performed in the PICU of King Chulalongkorn Memorial Hospital during the period May-December 2005. Children aged < or = 15 years who developed a PICU-related HAI were studied.

RESULTS

Forty-four patients (median age 6 months; male:female = 1.4:1) developed 58 episodes of PICU-related HAI. The HAI rate was 28.3 per 1000 patient-days. Thirty episodes (52%) were MDR-HAI. The following were found more frequently in MDR-HAI when compared to non-MDR-HAI: Acinetobacter baumannii (50% vs. 23%, p = 0.04), female sex (60% vs. 29%, p = 0.02), admission to the PICU with a medical condition (90% vs. 64%, p = 0.03), PICU stay longer than 7 days prior to the development of HAI (67% vs. 36%, p = 0.03), and previous use of broad-spectrum antibiotics (83% vs. 43%, p = 0.002). Independent risk factors for MDR-HAI included female sex (OR = 5.5, p = 0.03) and previous use of a broad-spectrum antibiotic (OR = 9.7, p = 0.01).

CONCLUSION

The incidence of MDR-HAI was high in the PICU. Female sex and previous use of a broad-spectrum antibiotic were independent risk factors for MDR-HAI.

Prevalence, clinical presentations and complications among hospitalized children with influenza pneumonia

Viral respiratory tract infections are a major cause of hospitalization in children. Influenza is common but often not laboratory proven. We report a prospective study of children admitted with a clinical diagnosis of pneumonia. Infants and children (ages 1 month-15 years) who were hospitalized with community-acquired pneumonia were enrolled in the study. Their nasopharyngeal aspirated samples were analyzed for common respiratory viruses, including influenza virus, by reverse transcription-polymerase chain reaction (RT-PCR) or PCR. Out of 257 patients, we identified 127 (49.4%) cases with respiratory viruses, and influenza was found in 32 of these cases (12.5%). Other common respiratory viruses included respiratory syncytial virus in 42 (16.3%), human metapneumovirus in 24 (9.3%), adenovirus in 17 (6.6%) and parainfluenza virus in 12 (4.7%). The median age of the influenza group was 2 years and 3 months, and 27 (84%) of children in this group were under the age of 5. Asthma was the most common co-morbidity (4/32, 12.5%). Common clinical presentations were fever and cough (100%) with crepitations (90%). The median length of hospitalization was 6 days. Three patients developed respiratory failure, with one mortality (3.1%). One child developed infection-associated hemophagocytic syndrome. Our study demonstrated that young children had a high risk of hospitalization due to influenza pneumonia, which contributed to a significant morbidity.

Optimal level of physical activity in children with chronic lung diseases

AIM

To determine the optimal level of physical activity and its relationship with disease severity in children with chronic lung diseases (CLD).

METHODS

Pulmonary function and exercise tests were compared between 18 CLD children (aged 13.5 +/- 2.4 years, 33% male) and 18 healthy controls without any history of lung diseases (age and sex matched).

RESULTS

CLD children had lower forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV)(1), forced expiratory flow rate between 25% and 75% of vital capacity (FEF)(25-75%) and total lung capacity (TLC) and higher residual volume (RV)/TLC ratio than controls (77.3 +/- 22.6 vs. 97.9 +/- 12.5%pred; p = 0.002, 74.3 +/- 17.6 vs. 104.0 +/- 12.6%pred; p < 0.001, 49.9 +/- 23.1 vs. 75.6 +/- 18.6%pred; p < 0.001, 82.8 +/- 18.6 vs. 95.6 +/- 9.8%pred; p = 0.04, 30.8 +/- 10.2 vs. 24.4 +/- 5.9%; p = 0.04, respectively). Oxygen consumption at anaerobic threshold (AT) and optimal level of physical activity (metabolic equivalents [METs] at AT) were not different between the two groups and between mild and moderate to severe CLD. However, when the exercise was continued beyond the AT, CLD children demonstrated poorer exercise performance than normal controls.

CONCLUSION

Children with CLD demonstrated the same level of optimal physical activity as normal children despite their lower lung function. The optimal level of physical activity was not related to disease severity. The exercise test and exercise should not be performed beyond the AT by the CLD children. Proper exercise test should be done to determine their optimal exercise activity.

Detection of influenza virus types A and B and type A subtypes (H1, H3, and H5) by multiplex polymerase chain reaction

Infections with influenza virus type A and B present serious public health problems on a global scale. However, only influenza A virus has been reported to cause fatal pandemic in many species. To provide suitable clinical management and prevent further virus transmission, efficient and effective clinical diagnosis is essential. Therefore, we developed multiplex PCR assays for detecting influenza types A and B and the subtypes of influenza A virus (H1, H3 and H5). Upon performing multiplex PCR assays with type-specific primer sets, the clearly distinguishable products representing influenza A and B virus were separated by agarose gel electrophoresis. In addition, the subtypes of influenza A virus (H1, H3 and H5), which are most common in humans, can be readily distinguished by PCR with subtype-specific primer sets, yielding PCR products of different sizes depending on which subtype has been amplified. This method was tested on 46 influenza virus positive specimens of avian and mammalian (dog and human) origins collected between 2006 and 2008. The sensitivity of this method, tested against known concentrations of each type and subtype specific plasmid, was established to detect 10(3) copies/microl. The method's specificity was determined by testing against other subtypes of influenza A virus (H2, H4 and H6-H15) and respiratory pathogens commonly found in humans. None of them could be amplified, thus excluding cross reactivity. In conclusion, the multiplex PCR assays developed are advantageous as to rapidity, specificity, and cost effectiveness.

Detection and discrimination of WU/KI polyomaviruses by real-time PCR with melting curve analysis

WU and KI polyomaviruses are novel viruses of the Polyomaviridae family, which have been identified recently in respiratory secretions from patients with acute respiratory tract infection. Their potential role in respiratory disease is still unclear and requires additional investigation. To facilitate further studies and diagnosis, a real-time PCR with melting curve analysis was optimized and evaluated to detect WU and KI polyomaviruses. Primers specific for the VP1 gene were designed from regions conserved among WU and KI polyomaviruses which provided amplification products of 198 and 231bp corresponding to WU and KI, respectively and thus yielded a difference in melting temperature (Tm) between WU and KI polyomaviruses. The assay proved highly specific for WU and KI polyomaviruses as no cross amplification was detected with other respiratory viruses or human genomic DNA. The assay was also highly sensitive with a detection limit as low as 10copies/microL for both WU and KI polyomaviruses. The performance of the real-time PCR assay was evaluated in terms of amplification efficiency (92%). Finally, the assay was validated using DNA extracted from clinical respiratory specimens for WU and KI polyomaviruses and the results were confirmed by direct nucleotide sequencing. The results obtained by melting curve analysis were in perfect agreement with nucleotide sequencing. In conclusion, this method is advantageous because it is rapid, specific, sensitive, reproducible, accurate, cost-effective and thus, would be feasible and attractive for large-scale analysis aimed at investigating the clinical role of WU and KI polyomaviruses.

Typing (A/B) and subtyping (H1/H3/H5) of influenza A viruses by multiplex real-time RT-PCR assays

In this study, a specific and sensitive one-step multiplex real-time RT-PCR was developed in two assays by using primers and a number of specific locked nucleic acid (LNA)-mediated TaqMan probes which increase the thermal stability of oligonucleotides. The first assay consisted of primers and probes specific to the matrix (M1) gene of influenza A virus, matrix (M1) gene of influenza B virus and GAPDH gene of host cells for typing of influenza virus and verification by an internal control, respectively. The other assay employed primers and probes specific to the hemagglutinin gene of H1, H3 and H5 subtypes in order to identify the three most prominent subtypes of influenza A capable of infecting humans. The specificity results did not produce any cross reactivity with other respiratory viruses or other subtypes of influenza A viruses (H2, H4 and H6-H15), indicating the high specificity of the primers and probes used. The sensitivity of the assays which depend on the type or subtype being detected was approximately 10 to 10(3)copies/microl that depended on the types or subtypes being detected. Furthermore, the assays demonstrated 100% concordance with 35 specimens infected with influenza A viruses and 34 specimens infected with other respiratory viruses, which were identified by direct nucleotide sequencing. In conclusion, the multiplex real-time RT-PCR assays have proven advantageous in terms of rapidity, specificity and sensitivity for human specimens and thus present a feasible and attractive method for large-scale detection aimed at controlling influenza outbreaks.

Prevalence and molecular characterization of WU/KI polyomaviruses isolated from pediatric patients with respiratory disease in Thailand

WU and KI polyomaviruses represent novel viruses discovered in respiratory secretions from human patients with acute respiratory tract infection. However, the association between WU/KI polyomaviruses and human disease has remained unclear. In this study, the prevalence of these two novel viruses and occurrence of co-infection with other respiratory viruses were determined in Thai pediatric patients with respiratory disease. Previously described PCR assays were applied to detect WU/KI polyomaviruses as well as other respiratory viruses in 302 nasopharyngeal suction specimens collected from February 2006 through February 2007. The results revealed the anneal prevalence of WU and KI polyomaviruses in the Thai population was 6.29% and 1.99%, respectively. The frequency of co-detection of WU and KI polyomaviruses with other respiratory viral pathogens was 42.11% and 33.33%, respectively. Moreover, each of the two complete genome sequences of WU (CU_295 and CU_302) and KI (CU_255 and CU_258) polyomaviruses were genetically and phylogenetically characterized. Sequence analysis showed that they contained features common to those found in previous studies. However, there were several nucleotide variations within the non-coding regulatory regions and various non-synonymous mutations within the coding regions which may influence virulence and pathogenesis of these viruses. Nevertheless, it is still possible that these viruses are not the causative agents of clinical respiratory disease. Therefore, judging the association of WU/KI polyomavirus infections with a particular disease will be challenging and require more comprehensive case control investigations.

Prevalence of Mycoplasma and Chlamydia pneumonia in severe community-acquired pneumonia among hospitalized children in Thailand

Pneumonia is the leading cause of pediatric morbidity and mortality worldwide, and Mycoplasma pneumoniae and Chlamydia pneumoniae are the two most common atypical pathogens. This study was designed to determine the prevalence and clinical impact of mycoplasma and chlamydia pneumonia in children hospitalized with severe pneumonia. Children 1 month-15 years old with a diagnosis of severe pneumonia (WHO criteria) were recruited between March 2005 and March 2006. Serologic studies were performed for anti-M. pneumoniae and anti-C. pneumoniae IgG/M on admission and 2-4 weeks afterward using ELISA. Of 52 patients, 13 (25%) were positive for Mycoplasma, 8 (15%) were positive for Chlamydia, 4 (7.6%) were positive for a mixed infection and 27 (52%) were negative. The subjects' mean age was 23.8+/-4.1 months. The mean of initial oxygen saturation on admission was 87.5+/-1.2%. Fever and prolonged cough were the leading symptoms. The mean of hospitalization was 18.8+/-2.6 days, chlamydia pneumonia had the longest duration, 30+/-10.2 days and 13/52 (25%) study subjects developed respiratory failure. Only 10% were treated with adequate antibiotic prior to serologic results. There was one mortality (1/52, 2%). Our study suggests that mycoplasma and chlamydia infections are commonly found among children hospitalized with severe pneumonia. Coverage with an appropriate antibiotic should be considered to hasten recovery.

Human bocavirus (HBoV) in Thailand: clinical manifestations in a hospitalized pediatric patient and molecular virus characterization

Objective

Human bocavirus (HBoV), a novel virus, which based on molecular analysis has been associated with respiratory tract diseases in infants and children have recently been studied worldwide. To determine prevalence, clinical features and perform phylogenetic analysis in HBoV infected Thai pediatric patients.

Methods

HBoV was detected from 302 nasopharyngeal (NP) suctions of pediatric patients with acute lower respiratory tract illness and sequenced applying molecular techniques.

Results

The incidence of HBoV infection in pediatric patients amounted to 6.62% with 40% co-infected with other respiratory viruses. There were no clinical specific manifestations for HBoV; however, fever and productive cough were commonly found. Generalized rales and wheezing were detected in most of the patients as well as perihilar infiltrates. The alignment and phylogenetic analysis of partial VP1 genes showed minor variations.

Conclusion

Our results indicated that HBoV can be detected in nasopharyngeal aspirate specimens from infants and children with acute lower respiratory tract illness.

Levels of protein C activity and clinical factors in early phase of pediatric septic shock may be associated with the risk of death

Severe sepsis and septic shock are major causes of morbidity and mortality among children in pediatric intensive care units (PICUs) worldwide. Activated protein C (PC) is a critical endogenous regulator of coagulation and inflammation in patients with sepsis. However, the role of PC in pediatric sepsis is still obscure. We prospectively recruited infants and children aged between 1 month and 15 years old who were admitted to PICU with a clinical diagnosis of systemic inflammatory response syndrome, sepsis, or septic shock. Clinical data were recorded and blood samples kept for further analysis. We then measured the levels of PC activity. Of the approximately 1,100 pediatric patients admitted to PICU from January 1, 2004 to December 31, 2005, 75 were diagnosed with septic shock (6.8%), and 67 samples were available for analysis. Out of these, 41 (61%) were survivors, and 26 (39%) were nonsurvivors. The average plasma PC activity (%) was at 37.8 +/- 4.4. Plasma PC activity (%) was significantly lower in the nonsurvivors compared with the survivors at 23.6 +/- 4.3 and 46.8 +/- 6.3 (P = 0.002), respectively. D-Dimer levels were not significantly different between the survivors (1,461 +/- 266 ng/mL) and the nonsurvivors (1,989 +/- 489 ng/mL) (P = 0.68). Also, there was no correlation between plasma PC activity and D-dimer levels (r = -0.07; P = 0.6). Importantly, the odds of dying were significantly higher in patients whose level of PC activity was less than 25% (odds ratio = 5.6; P = 0.02). Pediatric patients with septic shock demonstrate very low levels of PC activity, and this may be associated with an increased risk of death.

Molecular characterization and phylogenetic analysis of H1N1 and H3N2 human influenza A viruses among infants and children in Thailand

The annual influenza outbreaks can cause a high mortality rate among infants and children. In the tropics, influenza shows no clear dependence on seasons. In the present study, we performed molecular and phylogenetic analysis of H1N1 and H3N2 influenza virus isolated from infants and children diagnosed with respiratory tract illness between February 2006 and February 2007. A total of 33 samples (10.92%) were found positive for human influenza virus infection. Characterization of the hemagglutinin gene revealed conserved sequences at the receptor-binding site as well as variations due to amino acid substitutions at the antigenic site, potentially resulting in an N-linked glycosylation site. As for the neuraminidase gene, amino acid substitutions were found in N1 and N2 but not directly at the catalytic or framework sites of this enzyme. Based on the phylogenetic tree, the hemagglutinin 1 (HA1) region and the neuraminidase (NA) gene of both H1N1 and H3N2 isolated subtypes clustered with the current vaccine strain for the Northern Hemisphere 2007-2008. This finding contributes to understanding the evolution of influenza A viruses in humans and is useful for surveillance and vaccine strain selection.

Adrenal insufficiency in early phase of pediatric acute lung injury/acute respiratory distress syndrome

INTRODUCTION

Adequate adrenal function is essential to survive critical illness. Several recent articles have reported the significant effect of adrenal insufficiency (AI) in patients with sepsis. However, the prevalence of AI in pediatric acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is so far still scanty. Thus, we elected to study its prevalence and its clinical outcome.

METHODS

This is a cross-sectional observational study. We enrolled eligible infants and children aged between 1 month and 15 years who were admitted to our tertiary pediatric intensive care unit from February 1, 2005, to December 31, 2005, with ALI or ARDS diagnosed by the American-European Consensus criteria. A short corticotropin stimulation test (250 microg) was done within 24 hours of enrollment, and all clinical data were also recorded. Cortisol levels were measured at baseline, 30 minutes, and 60 minutes posttest. Adrenal insufficiency was defined as a baseline cortisol level of less than 15.1 microg/dL or an increment of cortisol level of less than 9 microg/dL after the adrenocorticotropic hormone stimulation test.

RESULTS

Of 507 patients admitted to the pediatric intensive care unit, there were 20 diagnosed with ALI/ARDS. Of 20 children, 16 met the inclusion criteria and had none of the exclusion criteria. Of 16, there were 9 (56%) with ARDS, and 7 (44%) of 12 had ALI. The prevalence of AI was observed in 37.5% (6/16), diagnosed by baseline level criteria in 25% (4/16) and by incremental criteria in 12.5% (2/16). The Baseline level of the adrenocorticotropic hormone was 7.8 +/- 5 (nmol/L). The median age in the AI group was 2 months. Of 6 children, 5 (83.3%) were in the ARDS group. Pediatric Risk of Mortality III score was significantly higher in the AI group compared with that in the non-AI (P < .05). Initial Pao(2)/fraction of inspired oxygen ratio tended to be lower in the AI group (123.2 +/- 62.2) compared with that in the non-AI group (183.8 +/- 79.1), although not statistically significant (P = .1). The mortality was also not statistically different between the AI (1/6, 16.7%) and the non-AI groups (1/10, 10%).

CONCLUSIONS

Our study demonstrated that the prevalence of AI was common in pediatric ALI/ARDS. These results would be an initial step to further study the impact of AI on clinical outcomes of these children in a larger scale.