Abstract 11597: Characterization of Epinephrine Use During Extracorporeal Cardiopulmonary Resuscitation

Introduction: Guidelines recommend dosing Epinephrine (Epi) at regular intervals during pediatric cardiac arrest, including patients requiring extracorporeal membrane oxygenation (ECMO). The impact of Epi-induced vasoconstriction on systemic afterload and veno-arterial ECMO support is poorly understood. Hypothesis: Higher total dose of Epi and shorter interval between Epi dose and ECMO flow during cardiac arrest will increase systemic afterload and interfere with ECMO support. Methods: This is an ancillary study to a single-center, retrospective observational study of patients 0-18 years old who required ECMO cannulation during resuscitation over a six-year period. Patients were excluded if ECMO was initiated prior to arrest or if the resuscitation record was incomplete. The primary exposure was time from last dose of Epi to initiation of ECMO flows; secondary exposures included cumulative Epi dose delivered and indexed to arrest time. Mean arterial pressure (MAP) and systemic vasodilator therapy were used as surrogates for systemic afterload; ECMO pump speed and vasoactive-inotrope score (VIS) were used as measures of ECMO support. Results: A total 92 events in 87 patients analyzed. The patient cohort was 53% female with median (IQR) age of 122 (30-478) days, weight 4.4 (3.3 - 8.7) kg, and 43% single ventricle physiology. On average, Epi was given 7 (4 - 10) times during a 35 (27 - 44) min arrest, for a total dose of 65 (37 - 101) mcg/kg; the last dose was given 6 (2 -16) min prior to the initiation of ECMO flows. In the 6 hours following initiation of ECMO, MAP increased from 42 (36 - 56) mmHg to 57 (47 - 70) mmHg, (p<0.0001). Shorter interval between last Epi dose and ECMO initiation trended with higher MAP after 1 hour of support (estimate -0.43, p=0.06) and associated with increased of vasodilators within 6 hours of ECMO (vasodilators used (1 - 6) vs not used 9 (3 - 16) min, p=0.05). No other associations were found between Epi delivery, MAP, vasodilator use, pump speed or VIS. Conclusion: There is limited evidence to support that regular dosing of Epi throughout a cardiac arrest is associated with clinically significant increases in afterload after ECMO cannulation. Additional studies are needed to validate findings against ECMO flows and clinically relevant outcomes.

Clinical Profile and Predictors of Outcome in Children with Acute Fulminant Myocarditis Receiving Intensive Care: A Single Center Experience

Acute myocarditis in children is associated with high morbidity and mortality, with limited data on intravenous immunoglobulin (IVIG) treatment and outcome. Our goal was to describe clinical, treatment profile, and predictors of outcome in children with acute fulminant myocarditis (AFM) receiving intensive care. Case records of 120 children with clinical diagnosis of acute myocarditis from January 2008 to December 2018 were analyzed retrospectively. AFM was seen in 89 (74.2%) children of which nearly two-thirds (54 [60.7%]) were hypotensive at admission. The median (interquartile range [IQR]) ejection fraction on echocardiography was 25 (18.5–36%). Eighty-two children (68.3%) received IVIG. Intensive care needs were mechanical ventilation (n = 71; 59.2%) and inotrope support (n = 89; 74.2%); median inotrope score being 30 (IQR: 20–55). Twenty-one children died (17.5%). Fever (p = 0.004), arrhythmia (p = 0.03), shock (p = 0.015), higher inotrope score (p = 0.0001), need for ventilation (p = 0.025), acidosis (p = 0.013), AKI (p = 0.0001), transaminitis (p = 0.0001), and multiorgan dysfunction (p = 0.0001) were associated with mortality. The mortality was significantly less in IVIG treated group (12.1 vs. 28.9%; p = 0.02). On multiple logistic regression, MODS (p = 0.002) was independent predictor of mortality while IVIG treatment (p = 0.004) was favorably associated with survival. AFM complicated by multiorgan dysfunction carried a poor prognosis. IVIG was associated with survival benefit.

Noninvasive Cardiac Output Monitoring Using Electrical Cardiometry and Outcomes in Critically Ill Children

Cardiac output (CO) measurement is an important element of hemodynamic assessment in critically ill children and existing methods are difficult and/or inaccurate. There is insufficient literature regarding CO as measured by noninvasive electrical cardiometry (EC) as a predictor of outcomes in critically ill children. We conducted a retrospective chart review in children <21 years, admitted to our pediatric intensive care unit (PICU) between July 2018 and November 2018 with acute respiratory failure and/or shock and who were monitored with EC (ICON monitor). We collected demographic information, data on CO measurements with EC and with transthoracic echocardiography (TTE), and data on ventilator days, PICU and hospital days, inotrope score, and mortality. We analyzed the data using Chi-square and multiple linear regression analysis. Among 327 recordings of CO as measured by EC in 61 critically ill children, the initial, nadir, and median CO (L/min; median [interquartile range (IQR)]) were 3.4 (1.15, 5.6), 2.39 (0.63, 4.4), and 2.74 (1.03, 5.2), respectively. Low CO as measured with EC did not correlate well with TTE (p = 0.9). Both nadir and mean CO predicted ventilator days (p = 0.05 and 0.01, respectively), and nadir CO was correlated with peak inotrope score (correlation coefficient of –0.3). In our cohort of critically ill children with respiratory failure and/or shock, CO measured with EC did not correlate with TTE. Both nadir and median CO measured with EC predicted outcomes in critically ill children.

Clinical Characteristics and Predictors of In-hospital Mortality in Patients with Cardiogenic Shock: Results from the RESCUE Registry

Background: In the current era of mechanical circulatory support, limited data are available on prognosis of cardiogenic shock (CS) caused by various diseases. We investigated the characteristics and predictors of in-hospital mortality in Korean CS patients.Methods: The RESCUE study is a multi-center, retrospective and prospective registry of patients that presented with CS. Between January 2014 and December 2018, 1,247 patients with CS were enrolled from 12 major centers in Korea. The primary outcome was in-hospital mortality. Results: In-hospital mortality rate was 33.6%. The main causes of shock were ischemic heart disease (80.7%), dilated cardiomyopathy (6.1%), myocarditis (3.2%), and non-ischemic ventricular arrhythmia (2.5%). Vasopressors were used in 1081 patients (86.7%). The most frequently used vasopressor was dopamine (63.4%) followed by norepinephrine (57.3%). An intra-aortic balloon pump was used in 314 patients (25.2%) and extracorporeal membrane oxygenator in 496 patients (39.8%). In multi-variable analysis, age ≥70 years, cardiac arrest at presentation, vasoactive-inotrope score >80, continuous renal replacement therapy, and mechanical ventilator were independent predictors for in-hospital mortality.Conclusions: The in-hospital mortality of CS patients remains high despite the high utilization of mechanical circulatory support. Age, cardiac arrest at presentation, amount of vasopressor, and advanced organ failure were poor prognostic factors for in-hospital mortality.Trial registration: RESCUE registry, Clinicaltrials.gov, NCT02985008, Registered 01 January 2014 - Retrospectively and Prospectively registered https://clinicaltrials.gov/ct2/show/NCT02985008.

Effects of Fenoldopam in the Pediatric Population: Fluid Status, Serum Biomarkers, and Hemodynamics. A Systematic Review and Meta-Analysis

Fluid overload is a frequent complication in children during critical illness. Fluid restriction and diuretic agents have been the mainstay therapies so far. Fenoldopam, a selective dopamine-1 receptor agonist, is a diuretic agent with promising effects in the pediatric population. The purpose of this meta-analysis is to evaluate the outcomes of pediatric patients who received fenoldopam. We hypothesized that the administration of fenoldopam will cause an increase in urine output and decrease in serum creatinine in this patient population. A comprehensive database search of PubMed, EMBASE, and Cochrane libraries from the databases' inception through December 2018 was undertaken. Independent reviewers selected appropriate studies and the reviewed data. A meta-analysis was then conducted to determine the effects of fenoldopam on hemodynamics, the amount of vasoactive support, and renal function in children under the critical care setting. The selected end points were measured prior to the administration of fenoldopam and 24 hours after the initiation of the infusion: urine output, serum creatinine, serum sodium, inotrope score, heart rate, central venous pressure, systolic blood pressure, and mean blood pressure. Forest plots were generated to demonstrate individual study data as well as pooled data for each end point. A total of five studies (three retrospective cohort studies, two randomized trials) with 121 patients were included for analysis. No significant difference was observed in urine output, inotrope score, systolic blood pressure, or mean blood pressure. There was a statistically significant increase in serum creatinine and central venous pressure. There was statistically significant decrease in serum sodium and heart rate, and central venous pressure. This meta-analysis did not identify significant renoprotective or vasodilator effects from fenoldopam in this patient population. Although mild electrolyte and hemodynamic changes were identified, larger studies are warranted to determine the clinical significance of fenoldopam in this patient population.