Bilateral Pneumothoraces in a 3-Month-Old Infant During an Apnea Test in the Diagnosis of Brain Death

We present the case of a 3-month-old boy who suffered bilateral pneumothoraces secondary to insufflation of oxygen into the endotracheal tube during the apnea test as part of brain death testing. Although rare, awareness of this potential complication of the apnea test is of particular importance in pediatric patients who have narrow endotracheal tubes because resistance to expiratory flow increases exponentially as lumen diameter decreases.

Multisystem inflammatory syndrome in children (MIS-C) and retropharyngeal edema: A case series

Multisystem inflammatory syndrome in children (MIS-C) is thought to follow SARS-CoV-2 infection and presents with fever and multisystem dysfunction. We report three children with suspected MIS-C found to have retropharyngeal edema without evidence of a bacterial etiology. We raise the possibility that an association between MIS-C and retropharyngeal edema exists.

Multisystem Inflammatory Syndrome in U.S. Children and Adolescents

BACKGROUND

Understanding the epidemiology and clinical course of multisystem inflammatory syndrome in children (MIS-C) and its temporal association with coronavirus disease 2019 (Covid-19) is important, given the clinical and public health implications of the syndrome.

METHODS

We conducted targeted surveillance for MIS-C from March 15 to May 20, 2020, in pediatric health centers across the United States. The case definition included six criteria: serious illness leading to hospitalization, an age of less than 21 years, fever that lasted for at least 24 hours, laboratory evidence of inflammation, multisystem organ involvement, and evidence of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) based on reverse-transcriptase polymerase chain reaction (RT-PCR), antibody testing, or exposure to persons with Covid-19 in the past month. Clinicians abstracted the data onto standardized forms.

RESULTS

We report on 186 patients with MIS-C in 26 states. The median age was 8.3 years, 115 patients (62%) were male, 135 (73%) had previously been healthy, 131 (70%) were positive for SARS-CoV-2 by RT-PCR or antibody testing, and 164 (88%) were hospitalized after April 16, 2020. Organ-system involvement included the gastrointestinal system in 171 patients (92%), cardiovascular in 149 (80%), hematologic in 142 (76%), mucocutaneous in 137 (74%), and respiratory in 131 (70%). The median duration of hospitalization was 7 days (interquartile range, 4 to 10); 148 patients (80%) received intensive care, 37 (20%) received mechanical ventilation, 90 (48%) received vasoactive support, and 4 (2%) died. Coronary-artery aneurysms (z scores ≥2.5) were documented in 15 patients (8%), and Kawasaki's disease-like features were documented in 74 (40%). Most patients (171 [92%]) had elevations in at least four biomarkers indicating inflammation. The use of immunomodulating therapies was common: intravenous immune globulin was used in 144 (77%), glucocorticoids in 91 (49%), and interleukin-6 or 1RA inhibitors in 38 (20%).

CONCLUSIONS

Multisystem inflammatory syndrome in children associated with SARS-CoV-2 led to serious and life-threatening illness in previously healthy children and adolescents. (Funded by the Centers for Disease Control and Prevention.).

The impact of a fellow-driven debriefing program after pediatric cardiac arrests

BACKGROUND

In the United States, post-cardiac arrest debriefing has increased, but historically it has occurred rarely in our pediatric intensive care unit (PICU). A fellow-led debriefing tool was developed as a tool for fellow development, as well as to enhance communication amongst a multidisciplinary team.

METHODS

A curriculum and debriefing tool for fellow facilitators was developed and introduced in a 41-bed cardiac and medical PICU. Pre- and post-intervention surveys were sent to multidisciplinary PICU providers to assess effectiveness of debriefings using newly-trained leaders, as well as changes in team communication.

RESULTS

Debriefing occurred after 84% (63/75) of cardiac arrests post-intervention. Providers in various team roles participated in pre-intervention (129 respondents/236 invitations) and post-intervention (96 respondents /232 invitations) surveys. Providers reported that frequently occurring debriefings increased from 9 to 58%, pre- and post-intervention respectively (p < .0001). Providers reported frequent identification and discussion of learning points increased from 32% pre- to 63% post-intervention. In the 12 months post-intervention, 62% of providers agreed that the overall quality of communication during arrests had improved, and 61% would be more likely to request a debriefing after cardiac arrest.

CONCLUSION

The introduction of a fellow-led debriefing tool resulted in regularly performed debriefings after arrests. Despite post-intervention debriefings being led by newly-trained facilitators, the majority of PICU staff expressed satisfaction with the quality of debriefing and improvement in communication during arrests, suggesting that fellow facilitators can be effective debrief leaders.

Venous return by the paraumbilical and hepatic veins in case of superior vena cava obstruction

Pseudolesion in segment IV of the liver is a well-known diagnostic pitfall during arterial portography or even spiral computed tomography (CT) of the liver. It has suggested that this pseudolesion is the result of an abnormality in subsegmental perfusion. We report a case of an early dense contrast enhancement of segment IV of the liver by epigastric and paraumbilical veins in a patient with a superior vena cava obstruction. A pseudolesion in segment IV was observed in this patient on a spiral CT of the liver obtained during the portal phase.

Differential diagnosis and repair of femoral artery pseudoaneurysms: report of clinical experience using color Doppler imaging

Sixty-two sonograms of the groin in 58 patients referred after cardiac catheterization (n = 45) or local surgical by-pass (n = 13) were reviewed retrospectively to determine the accuracy of color Doppler imaging in distinguishing femoral artery pseudoaneurysms from other causes of groin masses (e.g. hematomas) and to evaluate the therapeutical impact of US-guided compression. Thirty-seven cases of pseudoaneurysm, three arteriovenous fistulae (one isolated and two associated with a pseudoaneurysm), sixteen hematomas and eight other conditions were studied; US-guided compression repair was considered to treat thirteen pseudoaneurysms. The sensitivity and specificity of color Doppler imaging by comparison with angiography and/or surgery in the detection of femoral artery pseudoaneurysm was 100% and 94% respectively. US-guided compression repair was not attempted in 2/13 cases (one critical leg ischemia and one unsuitable anatomy) and successful in 7/11 cases. We conclude that color Doppler imaging is of great value in the differential diagnosis of groin masses, reducing the number of diagnostic and pretherapeutic angiographies. However, in our experience, US-guided compression repair is effective in the treatment of no more than 54% (7/13 cases) of nonselected femoral pseudoaneurysms.