Faculty Bibliography

INTRODUCTION: Colchicine is a plant-derived alkaloid that exerts its effect by inhibiting microtubule polymerization. Due to its narrow therapeutic index, acute colchicine toxicity is considered a medical emergency, and is associated with high mortality rates. Treatment is limited to supportive care with scarce reports of extracorporeal membrane oxygenation (ECMO) and whole blood exchange transfusion as treatment modalities. DESCRIPTION: A 13 year old (55 kg) previously healthy male ingested 7 mg (0.13 mg/kg) of colchicine with the intent "to get high." He presented to the emergency department 36 hours after ingestion with vomiting, diarrhea, and fatigue. He was found to have tachycardia, elevated troponin, and an ejection fraction of 30%. He rapidly deteriorated, requiring intubation and vasoactive support shortly after admission. On hospital day (HD) 2 he suffered a three minute bradycardic arrest and was emergently cannulated onto veno-arterial ECMO due to the known risk of progressive cardiac depression and arrhythmia associated with colchicine toxicity. Renal function progressively worsened and continuous renal replacement therapy (CRRT) was started in tandem with the ECMO circuit. Filgastrim was started empirically due to the myelosuppressive effects of colchicine. On HD 4 the patient had a transient period of improvement in hyperlactatemia, followed by progressive decline in cardiac, renal, and liver function. Whole blood exchange was trialed on HD 6, but was aborted after 15% of planned volume exchange due to significant inflammatory response. He required continued fluid resuscitation due to worsening capillary leak and vasoplegia. Methylene blue was tried without improvement. On HD 8 the patient developed abdominal compartment syndrome. Decision was made by the parents to withdraw care. The patient died nine days following ingestion. DISCUSSION: Colchicine ingestion is a rare, but highly lethal toxicity that can lead to cardiovascular collapse. The early clinical presentation of colchicine poisoning includes nausea, vomiting, and diarrhea with multi-organ injury occurring within 24 hours post-ingestion. A high level of clinical suspicion is needed and immediate transfer to an ECMO-trained pediatric intensive care unit is warranted. Further studies are needed in researching the type and timing of interventions

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) 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.

INTRODUCTION: Multisystem Inflammatory Syndrome in Children (MIS-C) is a newly described inflammatory state that is thought to arise from immune dysregulation following SARS-CoV-2 infection. The Centers for Disease Control and Prevention criteria for diagnosis are: age less than 21-yearsold, fever, elevated inflammatory markers, multisystem organ involvement, absence of plausible alternative diagnosis, and current or prior SARS-CoV-2 infection. We report four patients with presumed MIS-C who were found to have retropharyngeal abscesses/fluid collections.
METHOD(S): The first is a 12-year-old male presenting with fevers, neck pain, rash, fluid-responsive shock, acute kidney injury, respiratory failure, and a CT scan showing a right-sided retropharyngeal abscess (0.8x3.0x6cm) with right cervical adenitis; he underwent incision and drainage of the retropharyngeal collection, which yielded no pus and grew S. parasanguinis. The second case is a 4-year-old male presenting with fevers, conjunctivitis, abdominal pain, sore throat, a negative rapid strep at urgent care, stridor, an elevated B-type natriuretic peptide, fluid-responsive shock, acute kidney injury, and a CT scan that showed a retropharyngeal effusion (1.5x0.6x5cm). The third case is a 13-year-old female presenting with fevers, cracked lips, sore throat, a negative throat culture, vasodilatory shock, a mildly dilated left main coronary artery, and a CT scan that showed a retropharyngeal abscess (0.7x2.9x7.8cm). The fourth case is a 6-month-old female presenting with fevers, an urticarial rash, lip redness, cervical lymphadenopathy, and a CT scan showing a right-sided retropharyngeal abscess (1.2x2.8x3.7cm) and right carotid arteritis; throat culture was not performed. All four patients had elevated inflammatory markers, SARS-CoV-2 IgG antibodies, and were treated with broad spectrum antibiotics. The first three patients received immunomodulatory treatment for presumed MIS-C.
RESULT(S): Based on these cases, we question whether an association between MIS-C and retropharyngeal fluid collections exists; epidemiological studies are warranted to investigate this possibility further. While the mechanism remains unclear, retropharyngeal fluid collections have been described in Kawasaki Disease, which is thought to share features with MIS-C

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.).

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/CONCLUSIONS: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.