Faculty Bibliography

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

INTRODUCTION: A very small proportion of children who get infected with the novel coronavirus (COVID-19) have a severe disease requiring ICU care. Little is known about what risk factors are associated with severe disease in children. The purpose of this study was to compare characteristics of children with ?severe? disease defined as those requiring ICU admission vs. ?moderate? disease (hospital but not ICU admission) using the VIRUS: COVID 19 registry.
METHOD(S): Retrospective analysis of the Society of Critical Care Medicine VIRUS: COVID-19 registry encompassing children hospitalized at 49 participating sites between 02/20 to 07/20. Patient demographics and clinical presentations were compared among patients who required ICU admission vs. those who did not. Univariate and Multivariate logistic regression was performed using JMP.
RESULT(S): Data was available for 398 children, of which 181 (45.4%) were admitted to ICU. Children who required ICU admission were older (10 years vs. 3.67 years, p<0.01) and were more likely to be African American (28.8% versus 17.8%, p= 0.02). A higher proportion of patients who required ICU admission have pre-existing conditions (58.2% vs. 44.3%, p= 0.01). Asthma was the most common pre-existing condition; but, a higher proportion of ICU admits had a diagnosis of asthma (14.2% vs. 7.52%, p= 0.01). The most common presenting symptom was fever; however, this did not differ between groups. Nausea/vomiting (38.4% vs. 22.1%, p<0.01), dyspnea (31.8% vs 17.7%, p<0.01) and abdominal pain (25.2% vs. 14.1%, p<0.01) were more common in patients requiring ICU admission. A significantly higher proportion of patients who required ICU had multisystem inflammatory syndrome of childhood [MIS-C (45.9% vs. 6.8%, p<0.01)] and acute kidney injury (9.34% vs. 1.7%, p<0.01). Race (AA vs white, odds ratio 1.9, p = 0.02) and age (p <0.01) were associated with the risk of ICU admission on multi variate logistic regression. Presence of preexisting conditions was not significant after accounting for age and race (p=0.07).
CONCLUSION(S): Preliminary data suggest that children requiring ICU admissions for severe COVID-19 infections are more likely to be older and from African American race. Asthma is the most common preexisting condition. Gastrointestinal complains are more likely in severe COVID infections

Infants with meconium aspiration syndrome (MAS) and/or persistent pulmonary hypertension of newborn (PPHN) have the most favorable outcomes among infants requiring extracorporeal membrane oxygenation (ECMO). Early term (ET) infants have been shown to have higher morbidities when compared with term infants. It is not known if ET infants requiring ECMO for MAS and/or PPHN have higher morbidities and mortality than term infants. Objective of our study was to compare morbidity and mortality in ET infants with MAS and/or PPHN requiring ECMO in comparison to their term counterparts. A total of 3831 neonatal ECMO runs for MAS and/or PPHN were reviewed from the de-identified ELSO registry patient dataset from 2007- 2017. Neonates born at ET (37+0/7 - 38+6/7 weeks) and term (39+0/7 - 40+6/7 weeks) were further classified as two study groups. Both groups were compared using chi-square test. Of 2529 infants who were included in the study, there were 799 ET and 1730 term infants. ET infants when compared with term infants had higher mortality (9.6% vs 6%, P=0.002), lower survival to discharge (80.4% vs 87.7%, P<0.001), higher neurologic complications (14.8% vs 11.5%, P=0.024), and increased need for hemofiltration (32.9% vs 28.7%, P=0.033). There were no statistically significant differences between both groups in hemorrhagic, infectious, metabolic and cardiovascular complications. ET infants with MAS and/or PPHN have higher morbidities and mortality than term infants on ECMO. Caregivers should be informed of higher risks associated with use of ECMO in ET infants when compared to full term newborns

The majority of neonatal and pediatric patients require emergent cannulations at the bedside in the intensive care unit (ICU). To accomplish a bedside cannulation, multidisciplinary teams need to work together and perform tasks that may be different from the usual practices in the ICU. The complexity of the many tasks that need to be completed can lead to significant delay if not well choreographed. Our project goal was to streamline the pre-cannulation process to decrease the time from ECMO mobilization to procedure start. The initiative was implemented in September 2016. Interventions included formalization of ECMO Program policies & procedures and multidisciplinary education, as well as implementation of formal patient case reviews & quality assurance meetings. Our team collaborated with ancillary departments to ensure timeliness and efficiency with orders & processes related to ECMO initiation. We also created a detailed precannulation checklist which defines each team members' role and their responsibilities in the pre-cannulation process. The checklist is reviewed prior to the procedure time out as a final check to ensure all required tasks are completed. Upon retrospective chart review, the pre- & post-initiative data revealed a 54% decrease in time from ECMO mobilization to cannulation procedure start. The post-initiative average time of 65 minutes showed successful improvement from the pre-initiative average time of 136 minutes. We concluded that a structured process for pre-cannulation preparedness, role definition, multidisciplinary education, and team debriefs maximize efficiency in team readiness for a bedside ECMO cannulation procedure

Since March 2015, our Pediatric ECMO team has cared for 31 patients. Of these, 16 patients are still living today (53%). Patient & family support are necessary during ECMO, as well as post-ECMO and hospital discharge. Recent studies show that not only patients who required ECMO fulfill post-traumatic stress disorder diagnostic criteria, but also their close relatives are at risk to develop PTSD. Minimal peer to peer resources exist in the community for these patients and families. We found this to be a gap in ECMO care and an area of opportunity for us to provide additional support to this patient population. Our team explored options for engaging and decided to host our first Pediatric ECMO Reunion. The reunion included both patients & families and multidisciplinary staff members who cared for our prior ECMO patients. This venue provided an opportunity for sharing patient stories, for ECMO providers to reconnect with survivors and staff to experience the positive outcomes from their work. This allowed for a first step for families to understand their experience and help decrease burnout in providers and staff. We provided families the option to stay in touch with the ECMO Program through different family work groups. We also interviewed families and distributed surveys for direct feedback on their experience working with our team while their child was on ECMO. Next steps include creating an ECMO Family Work Group by partnering with families to develop new ways to support future ECMO families and improve the ECMO family experience

Introduction/Aim: NYU Langone Health's first neonatal ECMO patient was in March 2015, marking the start of the Pediatric and Neonatal ECMO Program within the institution. Since then, our program averages 5 ECMO patients per fiscal year (September 1 to August 31). A core ECMO Team, consisting of a Medical Director, a Surgical Director, an ECMO coordinator, 2 Chiefs of Perfusion, and 3 ECMO Intensivists, was identified to establish a reservoir of ECMO expertise within our new, low volume ECMO program. When a patient requires ECMO support, the core ECMO Team collaborates with the multidisciplinary ICU team to optimize both patient and circuit management. The teams provide concurrent care with the ECMO Team overseeing all ECMO-related decision making. Despite having the core ECMO Team as a resource during each ECMO case, a low volume of ECMO patients per year augments slower institutional learning and highlights the need for more frequent educational opportunities. The core ECMO Team worked together to create a recurring multidisciplinary Pediatric ECMO In-situ Simulation to bridge the educational gap in a new, low volume ECMO center. Material and Methods: The goal of establishing Pediatric ECMO In-Situ Simulation was to have either a real life patient on ECMO support or have a simulated ECMO patient once a month to establish routine ECMO exposure and promote multidisciplinary learning and competency. The first simulation session took place in September 2017. For 9 consecutive months, we achieved this goal with 4 real life ECMO patients and 5 simulated ECMO patients. Each simulation session took place over 4 hours and included a complete critical care team, consisting of an ICU Attending Physician, an Advanced Practice Provider, a Resident, 2 Critical Care Nurses, a Perfusionist, and a Respiratory Therapist. Pre-and postsimulation, participants completed self-assessments and knowledge tests, which were then, analyzed using the Wilcoxon Signed-rank test. Simulation logistics included a high fidelity simulation mannequin that was connected to a running ECMO circuit, as well as IV infusions and a mechanical ventilator. Simulation medications, fluids, blood products, and bedside supplies were readily available for the participants. Contact information to simulated ancillary departments, such as Inpatient STAT Lab, Blood Bank and Radiology, was distributed. We also collaborated with Hospital Informatics to create a virtual medical record for the simulated patient, which allowed the participants to view the ECMO order set, lab values, imaging results, vital signs, etc. The participants could also place orders in real time and document in the "patient's" medical record. The primary learning objective of the simulation was to improve competency in the daily management of an ECMO patient with less emphasis on ECMO circuit troubleshooting and emergency management. Scenarios included routine ECMO practices, such as conducting multidisciplinary ECMO rounds, adhering to programmatic processes, completing hourly patient assessments and documentation requirements, and monitoring patient fluid volume status. Results: 27 participants took pre-and post-course tests to assess their ECMO knowledge. They also filled out pre-and post-course selfassessments to determine their level of self-confidence in caring for an ECMO patient. One participant was excluded from the data analysis due to incomplete test scores and survey responses. Using the Wilcoxon Signed-rank test, we found a statistically significant improvement in the self-assessment scores (p=0.00001284). There was also a trend towards improvement in the knowledge scores (p=0.09). Conclusions: High fidelity in-situ simulation targeting various learner groups is effective with improvement in self-confidence and written knowledge. Recurring simulation opportunities in a new, low volume ECMO Center promotes continued familiarity and experience in caring for ECMO patients. Next steps include conducting multiple simulation sessions throughout a longer time span, such as over a 12 to 24 hour period

Introduction/Aim: Our Pediatric ECMO Program was launched in March of 2015. Based on historical volumes and projections we anticipated a low volume center. Per ELSO Guidelines, ECMO centers require institutional structure and organization for effective use of ECMO therapy. Also, literature review of pediatric ECMO patient outcomes imply that high volume ECMO centers are associated with improved survival rates in pediatric ECMO patients. Our goal was to implement a formal Pediatric ECMO Program, along with a structured educational course, to demonstrate that successful patient survival rates are obtainable in a low volume ECMO center. Material and Methods: A comprehensive review was completed to identify gaps and areas for improvement within the current state of ECMO at the institution with the goal of establishing an ECMO Program, per ELSO Guidelines, that ensures safe use of ECMO, improved patient outcomes, and optimized programmatic processes. Interventions implemented to formalize the ECMO Program included establishment of clinical practice guidelines and protocols, creation of an ECMO credentialing process, standardization of intrahospital processes related to ECMO, and organization of patient data collection. To assure reasonable use of this resource all cannulation and decannulation decisions required agreement of both the Medical and Surgical ECMO Directors. Formalization of the interprofessional collaboration with the critical care teams and ancillary departments was established with structured morning and evening rounds. Collaboration continued through implementation of formal multidisciplinary team meetings, including patient case reviews and quality assurance meetings. Last, a primary intervention in formalization of an ECMO Program was the establishment of an ECMO education course that was required for all providers who would be involved in the care of ECMO patients. The course was geared towards frontline critical care physicians and advanced practice providers caring for pediatric ECMO patients. The course included didactic learning and simulation training with a high fidelity simulation mannequin and a running ECMO circuit. Pre-and postcourse, participants completed self-assessments and knowledge tests. Results: Since March 2015, our Pediatric ECMO Program averages 5 ECMO patients per fiscal year (September 1 to August 31). In the first fiscal year (FY) 2015, our survival from ECMO rate was 33% with 0% of our patients surviving to discharge. Our hemorrhagic and neurologic complication rates were 67%. The formalization of our ECMO Program and implementation of ECMO education occurred in April 2016, mid FY 2016. Our survival from ECMO rate for FY 2016 improved from 33% to 86%, showing a 160.6% increase. Subsequently, our survival from ECMO rates continued to improve with FY 2017 having 100% survival rate and FY 2018 having 80% survival rate. We also observed a notable decrease in hemorrhagic and neurologic complications per FY. These complications decreased by 40.3% and 70.1%, respectively. Along with tracking our ECMO patient outcomes and complications, our program closely monitors our ECMO consults. Since March 2015, we average 23 ECMO consults per FY with an average of 5 patients (20%) placed on ECMO and 18 patients (80%) denied from ECMO. Out of the patients who were denied ECMO support, 30% of patients expired and 70% of patients recovered and survived to discharge, emphasizing the importance of strict patient selection criteria and centralized ECMO decision-making. For our ECMO course results, our team has held seven courses since August 2016. Among the first time participants (n=82), 84% showed improvement, 10% did worse, and 6% had incomplete data in their post-test written knowledge test. Conclusions: Despite a low institutional case volume of ECMO patients, creation of a structured ECMO Program with a recurring comprehensive ECMO course, promotes both self-confidence and clinical abilities of the multidisciplinary critical care team, as well as improves patient outcomes. Ongoing data collection and quality improvement will be essential to maintain this high level of performance