scholarly journals Multicenter Interim Guidance on Use of Antivirals for Children With Coronavirus Disease 2019/Severe Acute Respiratory Syndrome Coronavirus 2

2020 ◽  
Author(s):  
Kathleen Chiotos ◽  
Molly Hayes ◽  
David W Kimberlin ◽  
Sarah B Jones ◽  
Scott H James ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Pediatric Patients ◽  
Invasive Mechanical Ventilation ◽  
Great Majority ◽  
Supplemental Oxygen ◽  
Critically Ill Children ◽  
Severe Illness ◽  
Noninvasive Mechanical Ventilation ◽  
Oxygen Requirement ◽  
Web Based

Abstract Background Although coronavirus disease 2019 (COVID-19) is a mild infection in most children, a small proportion develop severe or critical illness. Data describing agents with potential antiviral activity continue to expand such that updated guidance is needed regarding use of these agents in children. Methods A panel of pediatric infectious diseases physicians and pharmacists from 20 geographically diverse North American institutions was convened. Through a series of teleconferences and web-based surveys, a set of guidance statements was developed and refined based on review of the best available evidence and expert opinion. Results Given the typically mild course of COVID-19 in children, supportive care alone is suggested for most cases. For children with severe illness, defined as a supplemental oxygen requirement without need for noninvasive or invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO), remdesivir is suggested, preferably as part of a clinical trial if available. Remdesivir should also be considered for critically ill children requiring invasive or noninvasive mechanical ventilation or ECMO. A duration of 5 days is appropriate for most patients. The panel recommends against the use of hydroxychloroquine or lopinavir-ritonavir (or other protease inhibitors) for COVID-19 in children. Conclusions Antiviral therapy for COVID-19 is not necessary for the great majority of pediatric patients. For children with severe or critical disease, this guidance offers an approach for decision-making regarding use of remdesivir.

scholarly journals Intensive care resources required to care for critically ill children with focal intracranial infections

2018 ◽  
Vol 22 (4) ◽  
pp. 453-461 ◽  
Author(s):  
Marlina E. Lovett ◽  
Zubin S. Shah ◽  
Melissa Moore-Clingenpeel ◽  
Eric Sribnick ◽  
Adam Ostendorf ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Chart Review ◽  
Sinus Thrombosis ◽  
Invasive Mechanical Ventilation ◽  
Retrospective Chart Review ◽  
Cerebral Venous Sinus Thrombosis ◽  
Critically Ill Children ◽  
Venous Sinus Thrombosis ◽  
Intracranial Infections ◽  
Vasoactive Medications

OBJECTIVEFocal intracranial infections such as intraparenchymal abscesses or localized infections in the epidural or subdural spaces are relatively rare infections associated with both morbidity and mortality in children. Although children with these infections frequently require surgical intervention, there is a paucity of literature describing the critical care resources required to manage these cases. This retrospective chart review was performed to evaluate the resources necessary to care for critically ill children with focal intracranial infections at the authors’ institution.METHODSThe authors performed a retrospective chart review of cases at their institution by using ICD-9/10 codes to identify children admitted to the pediatric intensive care unit (PICU) for either intracranial abscess or extradural and subdural abscess between 2006 and 2016. All notes, medication administration records, laboratory/imaging results, vital signs, microbiological data, and electroencephalogram results were reviewed. Data were extracted to determine the utilization of the following resources: mechanical ventilation, vasoactive medications, and intracranial pressure (ICP) monitoring. The presence of intracranial hypertension, cerebral edema, seizure, and cerebral venous sinus thrombosis were noted. Pediatric cerebral performance category (PCPC) score was determined based upon the neurological exam at discharge.RESULTSA total of 45 children met the inclusion criteria. Their median age was 9 years (IQR 3–14 years). The incidence of focal intracranial infections in children admitted to the PICU was 0.68/1000 PICU admissions in 2006 and 2.81/1000 admissions in 2016. Thirty-nine children (86.7%) underwent neurosurgical intervention. Twenty patients (44%) required invasive mechanical ventilation, 7 (15.6%) received vasoactive medications, and 11 (24%) had an ICP monitor. Clinical seizures were detected in 12 children, including 2 who had both clinical and subclinical seizures; 1 child had subclinical seizures only. Eight children (17.8%) developed cerebral venous sinus thrombosis. The median PCPC score was 1 (interquartile range [IQR] 1–3). The median PICU length of stay was 6.4 days (IQR 2.2–10.2 days). Children with seizures had a significantly longer hospital LOS than children without seizure.CONCLUSIONSIn this single-center, retrospective study, critical care needs for children with focal intracranial infections varied. Most frequently, patients required close neurological monitoring, and almost half required invasive mechanical ventilation. Future studies should focus on further elucidating the resources required to care for these children as well as detecting factors to identify those children most at risk for complications.

scholarly journals Anti-COVID property of subcutaneous ivermectin in synergy with zinc among midlife moderately symptomatic patients: a structured summary of a study protocol for a randomised controlled trial

Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Shoaib Ashraf ◽  
Sohaib Ashraf ◽  
Iqra Farooq ◽  
Sidra Ashraf ◽  
Moneeb Ashraf ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Mechanical Ventilation ◽  
Study Protocol ◽  
Primary Care Physicians ◽  
Invasive Mechanical Ventilation ◽  
Supplemental Oxygen ◽  
Study Objective ◽  
Link Type ◽  
High Flow Oxygen ◽  
Full Protocol

Abstract Objectives The study objective is to quantify the effectiveness of ivermectin (subcutaneous/oral IVM) in the presence or absence of zinc (Zn) for clinical and radiological improvement in coronavirus disease 2019 (COVID-19) patients with moderate severity. Trial design This quadruple-blinded, placebo-controlled randomized clinical trial will be a multiarmed multi-centered study with superiority framework. Participants Quinquagenarian and sexagenarian patients with moderate COVID-19 symptoms and positive severe respiratory syndrome coronavirus -2 (SARS-CoV-2) PCR will be included. Participants with co-morbidities and pregnant women will be excluded. Patient recruitment will be done in Shaikh Zayed Medical Complex, Doctors Lounge and Ali Clinic in Lahore (Pakistan). Intervention and comparator The registered patients will be allocated in 6 groups (30 participants each). Patients will be taking subcutaneous IVM at 200 μg/kg/48 h (Arm A) or subcutaneous IVM at 200 μg/kg/48 h and oral Zn 20mg/8 h (Arm B) or oral IVM at 0.2 mg/kg/day (Arm C) or oral IVM at 0.2 mg/kg/day and oral Zn 20mg/8 h (Arm D) or alone oral Zn 20mg/8 h (Arm E) or placebo alone (Arm X). Patients in all arms will receive standard care and respective placebo (empty capsule 8 hourly and/or subcutaneous normal saline 2ml/48 h). Main outcomes Primary endpoints will be duration of symptomatic phase and SARS-CoV-2 clearance along with high resolution CT (HRCT) chest score and clinical grade scale (CGS) on day 6. 30-day mortality will be documented as a secondary endpoint. SARS-CoV-2 clearance will be calculated by second PCR on day 7. HRCT chest score will be measured by the percentage and lung lobes involvement on day 6 with a maximum score of 25. CGS will be recorded on a seven-point scale; grade 1 (not hospitalized, no evidence of infection and resumption of normal activities), grade 2 (not hospitalized, but unable to resume normal activities), grade 3 (hospitalized, not requiring supplemental oxygen), grade 4 (hospitalized, requiring supplemental oxygen), grade 5 (hospitalized, requiring nasal high-flow oxygen therapy and/or noninvasive mechanical ventilation), grade 6 (hospitalized, requiring ECMO and/or invasive mechanical ventilation) and grade 7 (death). Randomisation A simple lottery method will be used to randomly allocate scrutinized patients in 1:1:1:1:1:1 ratio in 6 groups. Blinding (masking) Patients, primary care physicians, outcome assessors and the data collection team will be blinded. Numbers to be randomised (sample size) 180 participants will be randomized into six arms with five investigational and one placebo group. Trial Status Institutional Review Board Shaikh Zayed Post-Graduate Medical Complex, Lahore, Pakistan has approved the protocol (version 2.3) with ID SZMC/IRB/Internal0056/2020. The trial was approved on July 14, 2020, and enrolment started on July 30, 2020. The estimated completion date is October 30, 2021. Trial registration Clinical Trial has been retrospectively registered on www.clinicaltrials.gov with registration ID NCT04472585 dated July 16, 2020. Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). With the intention of expediting dissemination of this trial, the conventional formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines.

Lost in Transition: Is Early Respiratory Support in Newborn Infants the Best Option?

Neonatology ◽  
2020 ◽  
Vol 117 (4) ◽  
pp. 517-521
Author(s):  
Adam Buckmaster ◽  
Gaston Arnolda ◽  
Louise Owen ◽  
Calum Roberts ◽  
Peter Davis ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Distress ◽  
Treatment Failure ◽  
Newborn Infants ◽  
Supplemental Oxygen ◽  
Late Preterm ◽  
Respiratory Support ◽  
Severe Illness ◽  
Intravenous Fluids ◽  
Using Data

<b><i>Background:</i></b> Late preterm and term newborns with respiratory distress are increasingly treated with non-invasive ventilation (NIV) including nasal high-flow or continuous positive airway pressure. For infants with mild distress, NIV may be unnecessary. <b><i>Objectives:</i></b> We speculated that treatment with supplemental oxygen (SO) prior to NIV could help clinicians select infants for NIV treatment, and examined this hypothesis using data from a recently completed trial. <b><i>Method:</i></b> Post hoc analysis of data from a subset of infants enrolled in the HUNTER trial. Infants born at ≥36 weeks’ gestation were categorized by whether they were receiving SO prior to randomization. The 2 groups were compared for illness severity (indicated by treatment failure at 72 h, mechanical ventilation, need for up-transfer, SO requirement post-randomization, and length of time receiving respiratory support), use of selected medical interventions (antibiotics, intravenous fluids), and breastfeeding at discharge. <b><i>Results:</i></b> Analysis included 380 infants. Infants not receiving SO had less severe illness; lower rates of treatment failure (7.3 vs. 17.2%), mechanical ventilation (0.6 vs. 5.9%), need for transfer (6.8 vs. 13.8%), and more often did not receive any SO post-randomization (75.1 vs. 3.0%). Most infants in both groups received intravenous fluids (93 and 98%) and antibiotics (81 and 93%); the rate of full breastfeeding was low in both groups (51 and 45%). <b><i>Conclusions:</i></b> Late preterm and term newborn infants without SO requirement at the time of commencing NIV for respiratory distress are at lower risk of requiring treatment escalation. Close observation of these infants (watch and wait strategy) may avoid unnecessary treatment.

Point-of-Care Ultrasound Measurement of Diaphragm Thickening Fraction as a Predictor of Successful Extubation in Critically Ill Children

2021 ◽  
Author(s):  
Swathy Subhash ◽  
Vasanth Kumar
Keyword(s):  
Mechanical Ventilation ◽  
Point Of Care ◽  
Neuromuscular Disorders ◽  
Spontaneous Breathing Trial ◽  
Invasive Mechanical Ventilation ◽  
Tertiary Care ◽  
Critically Ill Children ◽  
Ultrasound Measurement ◽  
Point Of Care Ultrasound ◽  
Diaphragm Function

AbstractVentilation-induced diaphragm dysfunction can delay weaning from mechanical ventilation. Identifying the optimal time for extubation has always been a challenge for intensivists. Diaphragm ultrasound is gaining immense popularity as a surrogate to measure diaphragm function. We attempted to assess the utility of diaphragm function in predicting extubation success using point-of-care ultrasound examination. We conducted a prospective observational study in a single-center tertiary care pediatric intensive care unit (PICU). All children aged between 1 month and 16 years admitted to the PICU and who underwent invasive mechanical ventilation for more than 24 hours were included in the study. Children who died during mechanical ventilation and those with conditions affecting diaphragm function like neuromuscular disorders, pneumothorax, chronic respiratory diseases, and intraabdominal hypertension were excluded from the study. Diaphragm thickening fraction (DTf) was measured during spontaneous breathing trial and correlated to predict extubation success. We found that DTf is an independent predictor of extubation success. DTf more than or equal to 20% was associated with extubation success with a positive predictive value of 85%. The area under the curve for DTf showed good accuracy.

scholarly journals Respiratory Care in Children with COVID-19

2021 ◽  
Author(s):  
Shalu Gupta ◽  
Suresh K. Angurana ◽  
Virendra Kumar
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Distress ◽  
Health Care Providers ◽  
Respiratory System ◽  
Oxygen Delivery ◽  
Invasive Mechanical Ventilation ◽  
Respiratory Support ◽  
Critically Ill Children ◽  
Care Providers ◽  
Novel Coronavirus

AbstractThe novel coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) is causing significant morbidity and mortality worldwide. The common presentations in children include involvement of respiratory system leading to pneumonia and acute respiratory distress syndrome, as well as multiorgan dysfunction syndrome and multisystem inflammatory syndrome in children (MIS-C). Pediatric COVID-19 is a milder disease as compared with the adults. Also, there is rise in MIS-C cases which is a hyperinflammatory condition temporally associated with SARS-CoV-2. Since respiratory system is predominantly involved, few of these critically ill children often require respiratory support which can range from simple oxygen delivery devices, high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), invasive mechanical ventilation, and extracorporeal membrane oxygenation (ECMO). Most of the oxygen delivery devices and respiratory interventions generate aerosols and pose risk of transmission of virus to health care providers (HCPs). The use of HFNC and NIV should be limited to children with mild respiratory distress preferably in negative pressure rooms and with adequate personnel protective equipments (PPEs). However, there should be low thresholds for intubation and invasive mechanical ventilation in the event of clinical deterioration while on any respiratory support. The principle of providing respiratory support requires special droplet and air-borne precautions to limit exposure or transmission of virus to HCPs and at the same time ensuring safety of the patient.

scholarly journals Hospital saturation and risk of death without receiving mechanical ventilation in hospitalized COVID-19 patients: a city-wide analysis

2021 ◽  
Author(s):  
Isaac Núñez ◽  
Adrian Soto-Mota
Keyword(s):  
Mechanical Ventilation ◽  
Mexico City ◽  
Protective Factor ◽  
Invasive Mechanical Ventilation ◽  
Binary Logistic Regression ◽  
Supplemental Oxygen ◽  
Risk Of Death ◽  
Private Healthcare ◽  
Refractory Hypoxemia ◽  
High Disease Burden

Background: Pneumonia is the hallmark of severe COVID-19, with supplemental oxygen requirement being the main indication for hospitalization. Refractory hypoxemia in these patients requires invasive mechanical ventilation (IMV) otherwise, death is imminent. In places with a high disease burden, availability of critical care experts, beds, or resources is challenged and many patients could die without receiving them. Methods: We performed a retrospective cohort study using open databases from Mexico City about suspected or confirmed COVID-19 patients, health system saturation, and deaths between May 8th, 2020, and January 5th, 2021. After building a directed acyclic graph, we performed a binary logistic regression to identify the association between proposed causal variables and dying without receiving IMV (the outcome). Results: We included 33 805 hospitalized patients with suspected or confirmed COVID-19, of which 19 820 (58.6%) did not require IMV and survived, 5416 (16.1%) required and received IMV, and 8569 (25.3%) required IMV but died without receiving it. Saturation of IMV-capable beds did not increase the odds of the outcome (odds ratio 1.07, 95% confidence interval 0.94-1.22 of 90%vs50% occupancy), while general bed saturation (2, 1.86-2.14 of 90%vs50% occupancy) and IMV-capable to general bed ratio (1.64, 1.52-1.77 for a ratio of 2vs0.5) did. Private healthcare decreased the odds of the outcome (0.12, 0.08-0.17) and dyspnea increased them (1.33, 1.19-1.9). Conclusions: In Mexico City, increased general hospital bed saturation and IMV-capable to general bed ratio were associated with a higher risk of dying without receiving IMV. Private healthcare was the most protective factor.

scholarly journals Sublingual Atropine Sulfate Use for Sialorrhea in Pediatric Patients

2020 ◽  
Vol 09 (03) ◽  
pp. 196-200
Author(s):  
Ebru Azapağası ◽  
Tanıl Kendirli ◽  
Oktay Perk ◽  
Gültekin Kutluk ◽  
Gökçen Öz Tunçer ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Pediatric Patients ◽  
Neurodevelopmental Disorder ◽  
Invasive Mechanical Ventilation ◽  
Atropine Sulfate ◽  
Term Treatment ◽  
Short Term Treatment ◽  
Swallowing Dysfunction ◽  
Long Term Follow Up

AbstractSialorrhea is a frequent problem and may lead to aspiration in patients with swallowing dysfunction. We aimed to assess the effectiveness and safety of sublingual atropine sulfate treatment in pediatric patients with sialorrhea. The medical records of patients who had received sublingual atropine sulfate between January 2015 and January 2016 were reviewed retrospectively. The demographic properties, diagnosis, invasive or noninvasive mechanical ventilation need, and the presence of tracheotomy were assessed. Response rates to sublingual atropine were measured using the Teacher Drooling Scale (TDS). Pre and post-treatment drooling scores were compared. Atropine sulfate ampoule was administered at 20 µg/kg/dose. Minimum dose was 0.25 mg, while maximum dose was 0.03 mg/kg.Thirty-five pediatric patients with sialorrhea who had received sublingual atropine sulfate were identified; however, TDS scores had been recorded in only 20 of them. The median age of the patients was 25 months (3–78 months; 7 girls, 13 boys). Sixteen (80%) patients were on invasive mechanical ventilation and seven (30%) had tracheotomy. Nineteen patients had a neurodevelopmental disorder and only one patient had oral and esophageal lesions due to corrosive material intake. The median TDS score prior to sublingual atropine sulfate treatment was 5, and it decreased to 3 on the second day of treatment, a change that was statistically significant (p < 0.001). No side effects were observed. Sublingual atropine sulfate is safe and effective in the short-term treatment of sialorrhea; however, randomized placebo controlled and long-term follow-up studies are necessary.

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