Inotropic Score Research Articles

The evaluation of the burden of multisystem inflammatory syndrome in children on health economics.

This study aimed to evaluate the diagnostic tests and treatments applied in patients with multisystem inflammatory syndrome in children (MIS-C) and to determine the effect of the disease on health costs. This retrospective cohort study included 59 MIS-C patients (40 males, 19 females; mean age: 7.7±4.2 years; range, 4 months to 16.5 years) who were admitted and treated between April 1, 2020, and November 1, 2021. Demographic and clinical features with hospital costs and length of stay were retrospectively reviewed from the medical files and computerized system of the hospital. Direct medical care costs of items were calculated with the hospital perspective using a combination of microcosting technique (resource-based accounting method) and hospital list data. Cases were classified as mild, moderate, or severe, and the patients were divided into two groups: the mild group and the moderate-severe group. Classification was determined by the vasoactive inotropic score (VIS), degree of respiratory support, and evidence of organ damage. The mean age of the cases in the mild group was 6.5±3.7 years, and the mean age of the cases in the moderate-severe group was 9.2±4.3 years. Of 59 patients, 19 (32.2%) were followed up in the pediatric intensive care unit. The median duration of hospitalization in the hospital was 8 (interquartile range: 7-12) days. The total cost of the patients hospitalized with the diagnosis of MIS-C during the study period was 849,242.93$, and the mean cost per patient was 14,393.94±9,631.92$. In the distribution of the total cost of hospitalization according to expenses, the highest rate was pharmacy and blood products (51.99%) and IVIG costs (43.99%). While the mean total cost per person was 13,682.87±8,799.63$ in mild cases, it was 16,433.82±9,440.02$ in moderate-severe cases, and no statistically significant relationship was found between the two groups (p>0.05). There was no difference in the mean cost per patient between the cases with and without heart, lung, kidney, or neurologic involvement and advanced respiratory support (p>0.05). There was a strong positive correlation between the total costs and age (r=0.883, n=59, p<0.0001), with increased amount of costs with increased age. In the study, no statistically significant correlation was found between the total cost of per person in the mild group and the moderate-severe group (p>0.05). This finding may be due to the wide use of IVIG in MIS-C treatment, in addition to low transfer rates to pediatric intensive care units due to high-flow nasal cannula usage.

Association Between High Sensitivity Troponin Levels Following Pediatric Orthotopic Heart Transplantation and Intensive Care Unit Resource Utilization.

The utility of troponin levels, including high sensitivity troponin T (hs-TnT), after orthotopic heart transplant (OHT) is controversial. Conflicting data exist regarding its use as a marker of acute rejection. Few studies have examined possible associations of hs-TnT levels immediately after OHT with metrics of intensive care unit (ICU) resource utilization or risk of acute rejection. We performed a retrospective cohort chart review including all OHT recipients < 20years of age at our center between June 2019 and December 2022. Patients were divided into two groups based on supra- or sub-median initial hs-TnT levels (median 3462.5ng/L). Primary outcome was days requiring ICU-level care, secondary outcomes included days intubated, days requiring positive pressure ventilation (PPV), days on inotropic medications, actual ICU length of stay, Vasoactive Inotrope Scores (VIS) on postoperative days (POD) 0 through 7, and acute rejection at 30days and one year after OHT. Patients with higher hs-TnT required ICU level care for longer [13.5 (10-17.5) vs. 9.5 (8-12) days, p = 0.01] and spent more days intubated [6 (4-7) vs. 3 (3-5) days, p < 0.001], on PPV [9 (6-15) vs. 6 (5-8.5) days, p = 0.02], and on inotropes [11 (9-14) vs. 8 (7-11) days, p = 0.025]. VIS was only different between groups on POD7 [5 (3-7) vs. 3 (0-5), p = 0.04]. There was no difference in rejection between the groups. Higher hs-TnT immediately following pediatric OHT may predict higher ICU resource utilization, despite no difference in VIS, although it does not predict acute rejection in the first year after OHT.

Physiologic benefits of veno-pulmonary extracorporeal membrane oxygenation for COVID-19 ARDS: A single center experience.

A subset of patients with COVID-19 acute respiratory distress syndrome (ARDS) require extracorporeal membrane oxygenation (ECMO). Veno-pulmonary (VP) ECMO provides support to the right ventricle and decreased risk of recirculation. A retrospective analysis of patients with COVID-19 ARDS and VP ECMO was performed. Patients were separated into groups by indication (1) "right ventricular (RV) failure," (2) "refractory hypoxemia," and (3) "recurrent suck-down events (SDEs)." Pre- and post-configuration vasoactive inotropic scores (VIS), fraction of inspired oxygen (FIO2), and resolution of SDEs were reported. A 90-day mortality was computed for all groups. Patients were also compared to those who underwent conventional venovenous (VV) ECMO. Forty-seven patients underwent VP ECMO configuration, 18 in group 1, 16 in group 2, and 8 in group 3. Ninety-day mortality was 66% for the entire cohort and was 77.8%, 81.3% and 37.5% for groups 1, 2, and 3, respectively. Mean VIS decreased in group 1 (8.3 vs 2.9, p = 0.005), while mean FIO2 decreased in the group 2 and was sustained at 72 h (82.5% vs 52.5% and 47.5%, p < 0.001). Six of the eight (75%) of patients with recurrent SDEs had resolution of these events after configuration to VP ECMO. Patients with VP ECMO spent more days on ECMO (33 days compared to 18 days, p = 0.004) with no difference in mortality (66% compared to 55.1%, p = 0.28). VP ECMO in COVID-19 ARDS improves hemodynamics in patients with RV failure, improves oxygenation in patients with refractory hypoxemia and improves the frequency of SDEs.

Effects of Early Initiation of Polymyxin B Hemoperfusion Therapy in Patients with Cancer with Refractory Septic Shock.

Background: We aimed to analyze the correlation between in-hospital mortality and hemodynamic changes, using polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) initiation time in patients with cancer with refractory septic shock. Methods: Forty-six patients with cancer who received PMX-DHP for refractory septic shock were retrospectively analyzed and classified into early (≤3 h between refractory septic shock and PMX-DHP; n = 17) and late (>3 h; n = 29) initiation groups. The vasopressor inotropic score (VIS), sequential organ failure assessment (SOFA) score, and lactate clearance before and 24 h post-PMX-DHP were compared. Results: Overall, 52.17% died from multiple organ dysfunction, with a lower mortality rate in the early initiation group. The VIS and SOFA score decreased in both groups, but the magnitude of decrease was not significant. Lactate clearance improved in both groups, with greater improvement in the early initiation group. Univariable analysis identified associations of in-hospital mortality with early initiation, ΔC-reactive protein, lactate clearance, ΔSOFA score, and ΔVIS. Multivariable analysis demonstrated associations of in-hospital mortality risk with ΔSOFA score and early PMX-DHP initiation. Overall survival was higher in the early initiation group. Early initiation of PMX-DHP in patients with cancer with refractory septic shock reduced in-hospital mortality and improved lactate clearance.

Prognostic implication of Vasoactive Inotropic Score in adult patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation.

Vasopressors and inotropes are crucial in managing cardiogenic shock (CS) as they enhance microcirculation in patients. Numerous studies have demonstrated the adverse outcomes associated with excessive use of vasoactive drugs and the vasoactive drug scoring system has emerged as a valuable prognostic tool, particularly in pediatric patients. This study aimed to examine the prognostic significance of the Vasoactive Inotropic Score (VIS) in adult patients with CS receiving veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment. This retrospective multi-center study involved 2,453 adult patients who underwent VA-ECMO in China between 2015 and 2021. Among them, 1,742 adult patients with CS following VA-ECMO were finally included. The maximum VIS (VISmax) was determined by considering the highest doses of vasoactive and inotropic drugs administered within the first 6 hours before ECMO initiation. Based on the VISmax, patients were classified into two groups: 0-20 and >20. The primary outcome of this study was in-hospital mortality. A total of 1,146 patients were included in the high VISmax group, while 596 patients were assigned to the low VISmax group. Overall, 882 (50.6%) patients experienced in-hospital mortality, with significantly higher rates observed among those with higher VISmax scores (41.4% for VIS ≤20 versus 68.3% for VIS >20; P<0.001). Similar trends were observed for 30-day mortality (40.7% for VIS ≤20 versus 64.9% for VIS >20; P<0.001). Multivariable regression analysis demonstrated that a VIS score exceeding 20 independently predicted in-hospital mortality [odds ratio (OR) 2.64; 95% confidence interval (CI): 2.10-3.33; P<0.001]. The receiver operating characteristic (ROC) analysis revealed that VIS had an area under the curve (AUC) of 0.65 (95% CI: 0.63-0.68; P<0.001) as a predictor of in-hospital mortality, with an optimal cutoff value of 20.1. Moreover, the VIS exhibited good predictive ability for in-hospital mortality in patients with acute myocarditis (AUC 0.70; 95% CI: 0.63-0.78; P<0.001). Firstly, higher maximum level of VIS within the first 6 hours before ECMO initiation independently predicted poorer clinical outcomes in patients supported with ECMO for CS. Secondly, VIS exceeding 20 was significantly associated with increased risks of in-hospital mortality and 30-day mortality. Thirdly, when categorized by the cause of CS, a high VIS exhibited good predictive ability in patients with acute myocardial infarction, heart failure, and acute myocarditis.

The effect of histidine-tryptophan-ketoglutarate cardioplegia alone or combined with preoperative infusion of levosimendan on vasoactive inotropic score in patients with poor cardiac function undergoing coronary artery bypass grafting

ABSTRACT Background: Patients with poor left ventricular function undergoing cardiac surgery frequently require inotropic drug support immediately after cardiopulmonary bypass. Levosimendan is an effective agent that acts via two complementary mechanisms. It enhances cardiac contractility and reduces cardiac workload. Aim: to assess the effect of histidine-tryptophan-ketoglutarate cardioplegia (HTK cardioplegia) alone or combined with preoperative infusion of levosimendan on the vasoactive inotropic score in patients with poor left ventricular function undergoing coronary artery bypass grafting. Material and method: this double-blinded randomized controlled trial was carried on 100 patients, divided into two groups; Levosimendan group (n = 49): patients received 0.1ug/kg/min levosimendan without loading, 12 hours preoperatively and continued for a total of 24 hours. Control group (n = 51): patients received a placebo 12 hours before surgery and continued for a total 24 hours. Both groups received HTK cardioplegia after cross-clamping of the aorta approximately 20 ml/kg into the ascending aorta over 6–8 minutes at a temperature of 4−10°C. Results: Levosimendan group was superior to control group with statistical significance regarding the need of intraaortic balloon pump (IABP), vasoactive inotropic score over the first 24 hours, troponin levels over the first 72 hours, ICU stays, hospital stay, and cumulative hospital costs. Although the incidence of postoperative low Cardiac output syndrome (LCOS), atrial fibrillation (AF), acute kidney injury (AKI), and overall mortality was lower in levosimendan group, but all were not statistically significant. Conclusion: Preoperative infusion of levosimendan combined with HTK cardioplegia in patients with poor cardiac function decreased vasoactive inotropic score and lowered the costs of hospital stay.

Frequency domain analysis of photoplethysmographic and arterial pressure waveforms for assessing hemodynamics in children with congenital heart surgery.

Time-domain parameters are less reliable in children due to increased arterial and chest wall compliance. We assessed the ability of indices derived from frequency analysis of photoplethysmography (PPG) and arterial blood pressure (ABP) waveforms to predict the hemodynamic state in children undergoing congenital heart surgery. We analyzed waveforms after cardiopulmonary bypass period in 76 children who underwent total repair of congenital heart disease. Amplitude density of baseline and amplitude modulation in PPG and ABP by respiratory frequency were obtained using fast Fourier transform analysis and normalized by cardiac pulse height (representing respiratory modulations in venous blood [PPG-DC%] and in amplitude [PPG-AC%] at respiratory frequency). The ratio of amplitude density of PPG at the cardiac frequency (CF) to ABP-CF was used to assess vascular compliance. We assessed volume replacement (ml/kg) and vasoactive inotropic score (VIS). Children requiring volume replacement > 10 ml/kg (15.8%) showed higher PPG-DC% than those not requiring it (median: 52.4%, 95% CI [24.8, 295.1] vs. 36.7% [10.7, 125.7], P = 0.017). In addition, children with a VIS > 7 (22.4%) showed higher PPG-CF/ABP-CF (3.6 [0.91, 10.8] vs. 1.2 [0.27, 5.5], P = 0.008). On receiver operating characteristic curve analysis, PPG-DC% predicted a higher fluid requirement (area under the curve: 0.71, 95% CI [0.604, 0.816], P = 0.009), while PPG-CF/ABP-CF predicted a higher VIS (0.714, [0.599, 0.812], P = 0.004). Frequency domain analysis of PPG and ABP may assess hemodynamic status requiring fluid or vasoactive inotropic therapy after congenital heart surgery.

Cardiopulmonary Protection of Modified Remote Ischemic Preconditioning in Mitral Valve Replacement Surgery: A Randomized Controlled Trial

Background: Remote ischemic preconditioning (RIPC) is reported to have early‐phase and delayed‐phase organ‐protective effects. Previous studies have focused on the organ protection of a single RIPC protocol, and the clinical outcomes remain uncertain. Whether the modified RIPC (mRIPC) protocol performed repeatedly provides cardiopulmonary protection is still uncertain.Methods: In this single‐center, randomized, controlled trial, 86 patients undergoing elective mitral valve replacement (MVR) surgery were randomized 1:1 to receive either mRIPC or no ischemic preconditioning (control). Three cycles of 5 min ischemia and 5 min reperfusion induced by a blood pressure cuff served as the RIPC stimulus. mRIPC was induced at the following three time points: 24 h, 12 h, and 1 h before surgery. Blood samples were withdrawn at 10 min after intubation (T0), at 1 h after aortic declamping (T1), and at 6 h (T2), 12 h (T3), and 24 h (T4) after surgery to measure the serum concentrations of myocardial enzymes and other biomarkers, including cardiac troponin I (cTnI), which was the primary endpoint of this study. Creatine kinase isoenzyme (CK‐MB), lactate dehydrogenase (LDH), inotropic score (IS), and inflammatory mediators were also measured. Blood gas analysis was conducted to calculate the PaO2/FiO2 ratio and A‐aDO2, and the incidence of acute lung injury (ALI) was also recorded.Results: mRIPC significantly decreased the serum concentrations of cTnI, CK‐MB, and LDH at T2, T3, and T4 (p &lt; 0.01), and the IS decreased compared with that in the control group (12.0 ± 1.0 vs. 14.2 ± 1.1, p &lt; 0.01). In addition, the incidence of ALI in the mRIPC group was decreased (32.6% vs. 51.2%, p = 0.039), and the PaO2/FiO2 was higher at T4 (p &lt; 0.05). Compared with those in the control group, the levels of interleukin‐6 (IL‐6) and tumor necrosis factor‐α (TNF‐α) were decreased at T1, T2, T3, and T4 (p &lt; 0.05) in the mRIPC group, and the level of IL‐10 increased at the same time.Conclusions: mRIPC decreased the incidence of myocardial and lung injury in MVR surgery, providing new evidence for the clinical application of RIPC in valve surgery.Trial Registration: ClinicalTrials.gov (NCT01406678).

Assessment of timing of hydrocortisone treatment and vasoactive inotrope scores in pediatric septic shock cases

Assessment of timing of hydrocortisone treatment and vasoactive inotrope scores in pediatric septic shock cases

Perioperative Challenges and Outcome After Surgical Correction of Post-myocardial Infarction Ventricular Septal Rupture: A Retrospective Single Center Study.

Ventricular septal rupture (VSR) is a rare but grave complication of acute myocardial infarction (AMI). It is a mechanical complication of myocardial infarction where patients may present either in a compensated state or in cardiogenic shock. The aim of the study is to determine the in-hospital mortality. The study also aims to identify the predictors of outcomes (in-hospital mortality, vasoactive inotrope score (VIS), duration of ICU stay and mechanical ventilation in the postoperative period) and compare the clinical and surgical parameters between survivors and non-survivors. This is a retrospective study. The data of 90 patients was collected from the medical records and the data comprising of 13 patients who underwent VSR closure by single patch technique, or septal occluder, and those who expired before receiving the treatment, was excluded. The data of 77 patients diagnosed with post-AMI VSR and who underwent surgical closure of VSR by double patch technique was included in this study. Clinical findings and echocardiography parameters were recorded from the perioperative period. The statistical software used was SPSS version 27. The primary outcome was determining the in-hospital mortality. The secondary outcome was identifying the clinical parameters that are significantly more in the non-survivors, and the factors predicting the in-hopsital mortality and morbidity (increased duration of ICU stay, and of mechanical ventilation, postoperative requirement of high doses of vasopressors and inotropes). Subgroup analysis was done to identify the relation of various clinical parameters with the postoperative complications. The factors predicting the in-hospital mortality were illustrated by a forest plot. The mean age of the patients was 60.35 (±9.9) years, 56 (72.7%) were males, and 21 (27.3%) were females. Requirement of mechanical ventilation preoperatively (OR 3.92 [CI 2.91-6.96]), cardiogenic shock at presentation (OR 4 [CI 2.33 - 6.85]), requirement of IABP (OR 2.05 [CI 1.38-3.94]), were predictors of mortality. The apical location of VSR had been favorable for survival. The EUROScore II at presentation correlated with the postoperative VIS (level of significance [LS] 0.0011, R 0.36. The in-hospital mortality in this study was 33.76%. The in-hospital mortality of VSR is 33.76%. Cardiogenic shock at presentation, non-apical site of VSR, preoperative requirement of mechanical ventilation, high VIS preoperatively, perioperative utilization of IABP, prolonged CPB time, postoperative duration of mechanical ventilation, and high postoperative VIS were the factors associated with increased odds of in-hospital mortality.

Use of intraaortic balloon pump in cardiogenic shock patients.

The relevance of the use of intra-aortic balloon pump (IABP) in cardiogenic shock (CS) has been discussed over the past years. The aim of this study is to describe asingle-centre 10-year experience with IABP and analyse the risk factors for 30-day mortality. The data for this single-centre, observational, retrospective study were drawn from records dated from January 2012 to May 2022 pertaining to patients presenting with CS, treated with IABP and hospitalised at the Department of Acute Cardiology, Institute for Clinical and Experimental Medicine, Prague. Among the patients included in the study, 87% patients presented with newly developed heart failure. The leading cause of CS was acute myocardial infarction accounting for 86% of cases. Hospital mortality was recorded at 39% and the 30-day mortality reached 43%. Upon multi-variable analysis, only the vasoactive inotropic score on day 5 emerged as astatistically significant predictor for 30-day mortality (p=0.0055). Cox regression analysis revealed that the presence of mechanical complications was the only variable identified as yielding astatistically significant impact on the 30-day survival (Log-rank p=0.014, HR 2.19, 95% CI: 1.15‒4.15). There was no statistically significant difference in the 30-day mortality across the SCAI classes. The main cause of CS was anewly developed acute heart failure secondary to acute myocardial infarction. Despite the implementation of mechanical circulatory support, both in-hospital and 30-day mortality rates remained high. Increased vasoactive inotropic score and presence of mechanical complications were identified as significant predictors the 30-day survival (Tab. 6, Fig. 1, Ref. 36). Text in PDF www.elis.sk Keywords: cardiogenic shock, IABP, risk factors, mortality, Czech Republic, AMICS.

When is the Ideal Time to Calculate the Vasoactive Inotropic Score as a Predictor of Mortality and Morbidity in Cardiac Surgery? A Retrospective Study.

The aim of this study was to evaluate the prediction of vasoactive inotropic score (VIS) on early mortality and morbidity after coronary artery bypass grafting (CABG) and to determine the ideal time for score calculation. The study included patients who underwent isolated on-pump CABG surgery between November 2021 and November 2022. Pre, intra, and postoperative data were obtained by retrospective chart review. The final VIS value in the operating room (VISintra) and the highest VIS value in the first 24 hours in the intensive care unit (VISmax) were calculated. The patients were divided into two groups; Group 1 who developed early postoperative morbidity and mortality and Group 2 who did not. And the data were analyzed by groups. A total of 221 patients with a mean age of 63.49 ± 9.96 years were evaluated and 73 (33%) were in Group 1. The cut-off value for VISintra was determined to be 6.20, VISmax was 6,05. VISintra and VISmax values were significantly higher in the poor outcome group. Multivariate analysis showed that only VISmax value was an independent variable on mortality-morbidity. Our results imply that the vasoactive inotropic score is an easy and inexpensive score to calculate and can be used as a specific scoring system to predict poor early outcomes in CABG patients. According to statistical analyses, the most predictive time among VIS measurements was VISmax, the highest value calculated in the ICU in the first 24 hours postoperatively.

Prevalence and risk factors for prolonged mechanical ventilation in patients with congenital heart diseases undergoing cardiac surgery at a tertiary care center.

Objective: To determine the prevalence and risk factors for prolonged mechanical ventilation (PMV) in patients with CHDs undergoing cardiac surgery at a tertiary care center of Karachi, Pakistan. Study Design: Cross-sectional study. Setting: Paediatric Cardiac Intensive Care Unit (PCICU) at National Institute of Cardiovascular Diseases, Karachi, Pakistan. Period: July 2022 to June 2023. Material &amp; Methods: We analyzed patients who underwent open or closed heart surgery for CHDs. PMV was defined as duration of mechanical ventilation &gt; 72 hours from the time of arrival to PCICU until extubation after cardiac surgery. Peri-operative factors were noted and their association with PMV was documented. Results: In a total of 184 patients who underwent surgeries for CHD, 105 (57.1%) were male while the overall mean age was 7.23±6.49 years. Post-surgery, PMV was documented in 17 (9.2%) patients. PMV was significantly associated with age (p=0.001), weight (p&lt;0.001), cyanosis (p=0.005), TAPSE (p=0.011), and CPB time (p=0.003). Post-surgery, PMV was linked with metabolic acidosis (p=0.003), lactate (p=0.001), AVDO2 (p&lt;0.001), inotropic score (p=0.002), low cardiac output (p=0.005), LV dysfunction (p&lt;0.001), acute kidney injury (p=0.002), sepsis (p&lt;0.001), pneumonia (p=0.004), mortality (p=0.045), and PCICU stay (p&lt;0.001). Conclusion: PMV was documented in 9.2% patients who underwent CHD repair. Age, weight, cyanosis, TAPSE, CPB time, metabolic acidosis, lactate, AVDO2, inotropic score, low cardiac output, LV dysfunction, acute kidney injury, sepsis, and pneumonia were noted to be significant risk factors for PMV.

Additional Bicarbonate Infusion Complements WHO Rehydration Therapy in Children with Acute Diarrhea and Severe Dehydration Presenting with Severe Non-anion Gap Metabolic Acidemia: An Open Label Randomized Trial.

To assess the efficacy and safety of bicarbonate infusion in children with Acute Diarrhea and Severe Dehydration (ADSD) having severe Non-Anion Gap Metabolic Acidemia (sNAGMA). Children (aged 1-144 mo) with ADSD and sNAGMA (pH ≤7.2 and/or serum bicarbonate ≤15mEq/L) were enrolled in an open-label randomized design. Controls (n = 25) received WHO-recommended rehydration therapy with Ringer Lactate, while intervention group (n = 25) received additional bicarbonate deficit correction. Primary outcome was time taken to resolve metabolic acidemia (pH >7.30 and/or bicarbonate >15mEq/L). Secondary outcome measures were adverse outcome [composite of pediatric intensive care unit (PICU) transfer and deaths], acute care area free days in 5 d (ACAFD5), hospital stay, and adverse effects. Time taken to resolve metabolic acidemia was significantly lesser with intervention [median (IQR); 8h (4, 12) vs. 12h (8, 24); p = 0.0067]. Intervention led to acidemia resolution in significantly more children by 8h and 16h (17/25 vs. 9/25, p = 0.035 and 23/25 vs. 17/24, p = 0.018, respectively). Patients with fluid refractory shock needed lesser inotropes in intervention group [median Vasoactive Inotrope Score (VIS), 10.5 vs. 34]. Intervention led to significantly lesser adverse outcome (0/25 vs. 5/25, p = 0.049), and noticeably more ACAFD5 [median (IQR); 2 (1, 2) vs. 1 (1, 2); p = 0.12]. Two patients died in the control group while none in the intervention group. No adverse effect was documented. Additional calculated dose of bicarbonate infusion led to significantly early resolution of metabolic acidemia, lesser utilization of critical care facilities, and lesser adverse outcome in children with ADSD and sNAGMA, compared to standard therapy, with no adverse effect.

Tei Index and its Relation to Outcome of Critically Ill Children on Continuous Renal Replacement Therapy.

To evaluate echocardiographic parameters, especially the Tei index as a predictor of outcome in critically ill children on continuous renal replacement therapy (CRRT). This cohort study included all critically ill patients admitted at the Pediatric intensive care unit (PICU) and underwent CRRT. Functional echocardiography and Pediatric Risk of Mortality Index (PRISM) III were used to evaluate the participants. Both the Tei index and the Vasoactive inotropic score (VIS) were estimated. The study included 35 patients with an age range of 6 mo to 14 y. The Tei indexes, VIS, and PRISM III were reported as predictors of mortality with a sensitivity of 88%, 83%, and 94% and a specificity of 73%, 79%, and 89% respectively. In survivors, the mean Tei index score, median VIS, and mean PRISM values were 0.44 ± 0.1, 3.8 (0-40), and 12.06 ± 3.35, respectively. However, in non-survivors, the mean Tei index, median VIS, and mean PRISM score were 0.59 ± 0.16, 0.60 (0-342.5), and 22.94 ± 8.93, respectively. The Tei index could be used as a predictor for poor outcomes in children receiving CRRT. It is correlated to the PRISM score and VIS.

Cortisol levels associated with mortality in children with critical illness: a systematic review

Background Critically ill patients, including those with sepsis, have increased cortisol levels due to activation of the hypothalamic-pituitary-adrenal (HPA) axis or critical illness-related corticosteroid insufficiency (CIRCI).&#x0D; Objective To evaluate for a possible association between cortisol levels and mortality from sepsis in pediatric patients by systematic review of the literature.&#x0D; Methods A systematic review was conducted on studies involving critically ill children, including those with sepsis. We included studies published between 2011-2020 analyzing data on cortisol levels (total serum cortisol, serum-free cortisol, salivary cortisol, real-time free cortisol, basal serum cortisol and post-adrenocorticotropin hormone (ACTH) stimulation test, or basal salivary cortisol and post-ACTH stimulation test), the predictive score for mortality (Pediatric Logistic Organ Dysfunction/PELOD), Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality (PIM), Vasotropic Inotropic Score (VIS), or Pediatric Critical Illness Score (PCIS)], mortality (non-survivor percentage), and CIRCI percentage as an outcome in patients with critical illness, sepsis, and septic shock.&#x0D; Results Twenty-one observational studies were included in our systematic review, with a total of 2,212 subjects, 916 of whom had sepsis. Nineteen studies indicated a positive association between elevated cortisol levels and mortality in critically ill children, but 2 studies stated that there was no association with the CIRCI percentage of 32.3 and 84.3% respectively. The mortality percentage of critically ill patients with elevated cortisol levels and sepsis were 25.81 (2.7-60)% and 35.31 (6-60)%, respectively. The percentages of CIRCI in critically ill and sepsis patients were 21.91 (0-84.3)% and 21.35 (0-84.3)%, respectively.&#x0D; Conclusion Cortisol levels may increase or decrease in critically ill children. Elevated cortisol levels are associated with mortality in septic children. The effect of CIRCI on mortality in critically ill children cannot be concluded.

Myeloid-derived suppressor cells and T cell populations in children with Multisystem Inflammatory Syndrome.

Multisystem inflammatory syndrome in children (MIS-C) represents a hyperinflammatory state that can result in multi-organ dysfunction and death. Myeloid-derived suppressor cells (MDSC) are an immunosuppressive cell population that expands under inflammatory conditions and suppresses T cell function. We hypothesized that MDSC would be increased in children with MIS-C and that MDSC expansion would be associated with T cell lymphopenia. We conducted a prospective, observational study. Initial blood samples were collected within 48 h of admission. Age-matched healthy controls underwent sampling once. MDSC and T cell populations were identified by flow cytometric methods. We enrolled 22 children with MIS-C (12 ICU, 10 ward) and 21 healthy controls (HC). Children with MIS-C demonstrated significantly higher MDSC compared to HC, and MDSC expansion persisted for >3 weeks in the ICU group. Children with MIS-C admitted to the ICU demonstrated significantly lower absolute numbers of T cells and natural killer cells. There were no significant associations between MDSC and cardiac dysfunction, duration of hospitalization, or vasoactive inotrope score. Our study suggests that children critically ill with MIS-C have expansion of MDSC and associated decreased T cell and NK cell populations. Our results did not demonstrate associations between MDSC and clinical outcomes. Multisystem inflammatory syndrome in children (MIS-C) is a dysregulated immune response occurring several weeks after SARS-CoV-2 infection that can result in multi-organ dysfunction and death. Children severely ill with MIS-C demonstrated increased myeloid-derived suppressor cells and decreased absolute numbers of CD4+ and CD8 + T cells and NK cells compared to healthy controls. There was no significant association between MDSC numbers and clinical outcomes; including cardiac dysfunction, length of stay, or requirement of vasoactive support, in children with MIS-C.

Should the Vasoactive Inotropic Score be a Determinant for Early Initiation of VA ECMO in Postcardiotomy Cardiogenic Shock?

The authors investigated the role of early venoarterial extracorporeal membrane oxygenation (VA ECMO) implantation in patients with postcardiotomy cardiogenic shock (PCS) on mortality and morbidity when integrating vasoactive-inotropic score (VIS) and type of catecholamine support. A retrospective, multicenter, observational study with propensity-weight matching. Four university-affiliated intensive care units. Patients with PCS in the operating room. Early VA ECMO support. Of 2,742 patients screened during the study period, 424 (16%) patients were treated with inotropic drugs, and 75 (3%) patients were supported by VA ECMO in the operating room. Patients supported by VA ECMO had a higher use of vasopressor and inotropic drugs, with a higher VIS score. After propensity matching (integrating VIS and catecholamines type), mortality (56% v 20%, p < 0.001) and morbidity (cardiac, renal, transfusion) were higher in patients supported by VA ECMO than in a matched control group. When matching integrated the pre-ECMO VIS and the type of catecholamines, VA ECMO remained associated with high mortality and morbidity, suggesting that VIS alone should not be used as a main determinant of VA ECMO implantation.

Incidence and risk factors for acute kidney injury in children with congenital heart disease undergoing cardiac surgery in a tertiary care center.

Objective: To determine the incidence and risk factors associated with acute kidney injury (AKI) in children with congenital heart diseases (CHDs) who underwent cardiac surgery in a tertiary care center. Study Design: Cross-sectional study. Setting: Paediatric Cardiac Intensive Care Unit (PCICU) of National Institute of Cardiovascular diseases, Karachi, Pakistan. Period: November 2022 to May 2023. Material &amp; Methods: We included patients of both genders and any age who underwent open or closed heart surgery for congenital heart defects. All patients undergoing CHD repairs were monitored for the total duration of PCICU stay. The development of AKI was labeled as per RIFLE criteria, and management thereafter was performed as per standard institutional protocols. Results: In a total of 93 patients with CHD, there were 50 (53.8%) males and 43 (46.2%) females. The mean age was 9.71±9.14 year ranging between 3 months to 60 years. There were 6 (6.5%) patients who developed AKI post-surgery. Overall, mortality was noted in 7 (7.5%) patients. Cardiopulmonary bypass (CPB) time and aortic cross-clamp (ACC) time were significantly higher among patients who developed post-surgery AKI (&lt;0.001). Moreover, post-surgery AKI was significantly associated with intra-operative hypotension (p&lt;0.001), post-operative hypotension (p&lt;0.001), and post-operative sepsis (p&lt;0.001). It was also found that AKI had significant association with higher post-operative inotropic scores (p&lt;0.001), prolonged duration of mechanical ventilation (p&lt;0.001), and length of PCICU stay (p&lt;0.001). Mortality had significant association with AKI (33.3% vs. 5.7%, p=0.013). Conclusion: We noted the incidence of AKI among patient who underwent cardiac repairs to be 6.5%. CPB time and ACC time were significantly higher among patients who developed post-surgery AKI. Post-surgery AKI was significantly associated with intra-operative hypotension, post-operative hypotension, and post-operative sepsis. Mortality was significant high among cases that had AKI.

Acute kidney injury and renal recovery following Fontan surgery

ObjectivesAcute kidney injury has been described after Fontan surgery, but the duration and outcomes are unknown. We sought to describe the incidence of and risk factors for acute kidney injury and the phenotype of renal recovery, and evaluate the impact of renal recovery phenotype on outcomes. MethodsAll children who underwent a Fontan operation at a single center between 2009 and 2022 were included. Data collected included Fontan characteristics, vasopressor use, all measures of creatinine, and postoperative outcomes. Logistic regression models were used to assess predictors of acute kidney injury and the association between acute kidney injury and outcomes. ResultsWe enrolled 141 children (45% female). Acute kidney injury occurred in 100 patients (71%). Acute kidney injury duration was transient (<48 hours) in 77 patients (55%), persistent (2-7 days) in 15 patients (11%), more than 7 days in 4 patients (3%), and unknown in 4 patients (3%). Risk factors for acute kidney injury included higher preoperative indexed pulmonary vascular resistance (odds ratio, 3.90; P = .004) and higher postoperative inotrope score on day 0 (odds ratio, 1.13, P = .047). Risk factors for acute kidney injury duration more than 48 hours included absence of a fenestration (odds ratio, 3.43, P = .03) and longer duration of cardiopulmonary bypass (odds ratio, 1.22 per 15-minute interval, P = .01). Acute kidney injury duration more than 48 hours was associated with longer length of stay compared with transient acute kidney injury (median 18 days [interquartile range, 9-62] vs 10 days [interquartile range, 8-16], P = .006) and more sternal wound infections (17% vs 4%, P = .049). ConclusionsAcute kidney injury after the Fontan operation is common. The occurrence and duration of acute kidney injury have significant implications for postoperative outcomes.