Development of pediatric surgical decision-making guidelines for COVID-19 in a New York City children's hospital.
- 作者列表："DeFazio JR","Kahan A","Fallon EM","Griggs C","Kabagambe S","Zitsman J","Middlesworth W","Stylianos S","Duron V
OBJECTIVE:During the COVID-19 pandemic, experience-based guidelines are needed in the pediatric population in order to deliver high quality care in a new way that keeps patients and healthcare workers safe and maximizes hospital resource utilization. BACKGROUND:The COVID-19 pandemic has created an unprecedented strain on national health care resources, particularly in New York City, the epicenter of the outbreak in the United States. Prudent allocation of surgical resources during the pandemic quickly became essential, and there is an unprecedented need to weigh the risks of operating versus delaying intervention in our pediatric patients. METHODS:Here we describe our experience in surgical decision-making in the pediatric surgical population at Morgan Stanley Children's Hospital of New York-Presbyterian (MSCHONY), which has served as a major urban catchment area for COVID-19 positive pediatric patients. We describe how we have adjusted our current treatment of multiple facets of pediatric surgery including oncology, trauma, minimally invasive procedures, and extracorporeal membrane oxygenation (ECMO). CONCLUSIONS:Our pediatric surgery department had to creatively and expeditiously adjust our protocols, guidelines, and workforce to not only serve our pediatric population but merge ourselves with our adult hospital system during the COVID pandemic. TYPE OF STUDY:Clinical research paper LEVEL OF EVIDENCE: Level V.
目标: 在新型冠状病毒肺炎大流行期间,在儿科人群中需要基于经验的指南，以便以一种新的方式提供高质量的护理，使患者和医护人员安全并最大限度地利用医院资源。 背景: 新型冠状病毒肺炎大流行给国家卫生保健资源造成了前所未有的压力，尤其是在美国爆发的中心纽约市。在大流行期间谨慎分配手术资源很快变得至关重要，前所未有地需要权衡我们儿科患者的手术与延迟干预风险。 方法: 在这里，我们描述了我们在纽约长老会 (MSCHONY) 摩根士丹利儿童医院儿科手术人群中的手术决策经验,这已作为一个主要的城市集水区新型冠状病毒肺炎阳性儿科患者。我们描述了我们如何调整目前儿科手术的多个方面的治疗，包括肿瘤学、创伤、微创手术和体外膜肺氧合 (ECMO)。 结论: 我们的小儿外科必须创造性地迅速调整我们的方案、指南和劳动力，不仅为我们的儿科人群服务，而且在 COVID 大流行期间将我们自己与我们的成人医院系统融合在一起。 研究类型: 临床研究论文证据等级: ⅴ 级。
METHODS:INTRODUCTION:Continuous albuterol is a mainstay in management of pediatric status asthmaticus. While the National Heart Lung and Blood Institute Asthma Guidelines suggest 0.5 mg/kg/hr as the recommended dosage, there is a paucity of evidence comparing different weight based rates on hospital outcomes. METHODS:Patients requiring continuous albuterol for asthma exacerbation from January 2015 to December 2016 were identified using ICD codes. The concentration of albuterol (5 mg/h - 20 mg/h) and the duration of treatment were used to determine total albuterol administration. After dividing by patient weight, average weight based doses were divided into equal quintiles. Unadjusted and length of stay adjusted for age, initial asthma severity score, and administration of magnesium were compared among the quintiles. The same multivariate analysis was used for duration of continuous albuterol. RESULTS:533 hospitalizations for asthma were identified of which 289 received continuous albuterol. Weight based dosage quintiles ranged from lowest (0.07 - 0.29 mg/kg/hr) to the highest (>0.76 - 3.2 mg/kg/hr). Baseline characteristics were similar aside from age, race, and magnesium administration. There was no difference in adjusted length of stay or adjusted duration of continuous albuterol therapy among the five quintiles. CONCLUSION:No optimal weight based dose of continuous albuterol was found. Further investigation is needed to see if lower amounts of continuous albuterol may be as efficacious as higher doses. This could improve cost of status asthmaticus management and limit the number of adverse events associated with high exposure to continuous albuterol.
METHODS:Abstract Background We investigated the association between a combination of two markers, peripheral (PEC) and bronchoalveolar lavage (BAL) eosinophil percentage (BEP), and oxygen requirements in patients with acute eosinophilic pneumonia (AEP). Methods We retrospectively reviewed the medical records of patients with AEP treated at the Armed Forces Capital Hospital between May 2012 and May 2017. We used correlation analyses to assess the association between PEC/BEP and clinical outcomes in AEP patients. Receiver operating characteristic (ROC) curve analyses were used to calculate the cut-off value for BEP that categorised patients requiring a significant oxygen supply. The BAL/blood eosinophil (BBE) score was introduced to stratify patients with peripheral eosinophilia and elevated BEP. Clinical characteristics and outcomes were compared between the different groups. Multiple logistic regression was performed for significant oxygen requirements using two different models using age, C-reactive protein (CRP), smoking duration, and BBE score (model 1) and age, CRP, BEP, and PEC (model 2). Results Among the 338 patients, 99.7% were male, and their mean age was 20.4 ± 1.4 years. Only 0.6% of patients were never smokers and the mean number of smoking days was 26.2 ± 25.4. Correlation analyses revealed that both the PaO2/FiO2 ratio and duration of oxygen supply were associated with BEP. ROC curve analyses indicated a cut-off level of 41.5%. Patients with a high BBE score had favourable outcomes in terms of hypoxemia, hospital days, intensive care unit admission, oxygen supply days, and steroid treatment days. Multiple logistic regression revealed that BEP and BBE score tended to be associated with significant oxygen requirements. Conclusions In this study, we revealed that both peripheral and BAL eosinophilia is associated with favourable outcomes in AEP patients.
METHODS:Background. Extensive studies have focused on the diagnosis and treatment of Mycoplasma pneumoniae infection; however, rare studies investigated the posttreatment conditions. We analyzed the carrying status of M. pneumoniae in the respiratory tract of children before and after treatment. Methods. Ninety-two children with M. pneumoniae pneumonia were included in this study. Clinical data were obtained from each patient, and pharyngeal swab sampling was performed at preliminary diagnosis and discharge. Real-time PCR and dilution quantitative culture were utilized to determine the DNA quantification and number of viable M. pneumoniae from samples collected upon preliminary diagnosis and discharge. Results. All the 92 cases showed DNA positivity upon preliminary diagnosis, serum IgM antibody was detected in 80 patients, and positivity of M. pneumoniae culture was observed in 82 cases. Upon discharge, the M. pneumoniae nucleotide and culture positivity were detected in 87 and 49 cases, respectively. The content of viable M. pneumoniae was 10–104 CCU/mL and 10–102 CCU/mL in the preliminary diagnosis samples and discharge samples, respectively. Conclusions. Real-time PCR was rapid and effective for the qualitative diagnosis of M. pneumoniae at the early stage, but it cannot be used to evaluate the prognosis of patients with M. pneumoniae infection. Quantitative analysis for M. pneumoniae DNA could not directly reflex the viable strain content.