The pillars of managing critically ill patients with acute respiratory failure owing to coronavirus disease 2019 (COVID-19) are mechanical ventilation and extracorporeal membrane oxygenation (ECMO) as supportive therapies for impaired respiratory function. Given the increasing number of patients with COVID-19, a summary of standardized care regarding ECMO that can serve as a reference in clinical practice is proposed as an expert consensus statement. Indications, management practices, and caveats for ECMO management are described, including those in the presence of resource constraints.

Objective: Laryngeal ultrasonography has gradually been gaining popularity as a screening tool for vocal cord paralysis in children. The aim of this study is to evaluate the diagnostic accuracy of pediatric laryngeal ultrasonography by pediatric intensivists in identifying postoperative vocal cord paralysis in PICU. Methods: Thirty patients who had hoarseness or inspiratory stridor after postoperative tracheal extubation in PICU at Kobe Children’s Hospital from October 2017 to July 2019 were enrolled in this retrospective study. They underwent bedside laryngeal ultrasonography by two pediatric intensivists for the assessment of vocal cord movement. Subsequently, flexible nasolaryngoscopy was performed to confirm the ultrasonographic findings. Results: The median age of the study group was 2.5 [interquartile range (IQR) 1-6] months, and the median body weight was 5.1 [IQR 3.4-6.5] kg. Hoarseness was observed in 23 of 30 patients (77%) after postoperative tracheal extubation, and inspiratory stridor in 15 of 30 patients (50%). The median duration between extubation and laryngeal ultrasonography was 2 [IQR 1-3] days, and between extubation and nasolaryngoscopy was 4 [IQR 3-6] days. Vocal cord movement was visualized by ultrasonography in all patients. It revealed vocal cord paralysis in 19 patients and normal vocal cords in 11 patients. In 26 out of 30 patients, the ultrasonographic findings corresponded with the results of flexible nasolaryngoscopy. The sensitivity and specificity of laryngeal ultrasonography was 86% and 89%, respectively. Conclusions: Laryngeal ultrasonography by pediatric intensivists is a reliable method of screening of postoperative vocal cord paralysis in children. It can be used as an initial assessment tool for pediatric vocal cord paralysis in PICU.

Objective: To describe current management and the differences of high flow nasal therapy (HFNT) in pediatric intensivists between Japan and European/North America. Methods: A multinational cross-sectional questionnaire survey conducted in 2018. The sample in the main study included pediatric intensive care physicians in North and South America, Asia, Europe, and Australia/New Zealand. For this post-hoc study, we analyzed the responses from Japan, compared with the responses from North America and Europe. Survey questions consisted of 1) characteristics of intensivists and hospital, 2) practice of HFNC, 3) supportive treatment, and 4) research of HFNT. Results: We analyzed 547 responses (51 in Japan, 215 in North America, 281 in Europe). The response rate for the Japanese cohort was 42% (51/121). Seventy-four percent of the respondents used HFNT in non-PICU settings in their institutions in Japan. For a case scenario of an infant with bronchiolitis/pneumonia, 87% of the respondents in Japan used 2 L/kg/min as an initial flow rate. For a scenario of a child with pneumonia of 30kg weight, 62% of the respondents in Japan used 2 L/kg/min as a maximum flow rate. Noninvasive ventilation (NIV) was considered as a next step when the patient failed HFNT, in a smaller proportion of Japanese respondents compared to other cohorts. Significant practice variations were observed in the flow weaning strategy and supportive practices. Conclusions: Significant practice variations, including opinions of high flow nasal therapy (HFNT) compared to continuous positive airway pressure (CPAP) was found among pediatric intensive care physicians in Japan. There were specific trends and variations observed in the Japanese cohort compared to the others.

In children with severe subglottic stenosis, decannulation of tracheostomy tube is desired. Laryngotracheal reconstruction, however, can lead to various severe complications: restenosis and potential for dehiscence. Partial cricotracheal resection (PCTR) is another method, but complications have also been reported. For that reason, we provide postoperative management in PICU to decrease complications. We assessed the postoperative management of 15 patients who underwent PCTR between July 2016 and June 2019. Median age at the time of surgery was 8 years old. We used sedative management with fentanyl, midazolam, and muscle relaxation by rocuronium in all patients. Dexmedetomidine supplementation was used for patients in whom sedation was difficult. Median ventilation duration was nine days, and the median length of PICU management was 12 days. All patients had full removal of tubes. Minor complications included mild atelectasis in six cases and suspected drug withdrawal symptoms or delirium in five cases. There was no unplanned extubation, restenosis, or anastomotic dehiscence. Absolute rest by sedation and careful postoperative management in PICU effectively avoided severe complications in children with severe subglottic stenosis.

Pulmonary hemorrhage and hemoptysis are well-known complications in patients with congenital heart disease and are commonly associated with aorto-pulmonary collateral arteries (APCA). We report a rare case of idiopathic pulmonary hemosiderosis in a patient with pulmonary hemorrhage who underwent pediatric cardiac surgery. A child with tetralogy of Fallot presented with recurrent pulmonary hemorrhage before and after intracardiac repair. Coil embolization for APCA was not effective against the pulmonary hemorrhage. Although her symptoms were improved by administration of recombinant activated factor VII and blood transfusion, the cause of the pulmonary hemorrhage was still obscure. She was admitted to our hospital urgently at 4 years of age with severe anemia and hypoxemia secondary to diffuse alveolar hemorrhage. Histopathological examination of bronchoalveolar lavage fluid revealed hemosiderin-laden macrophages. We diagnosed her with idiopathic pulmonary hemosiderosis after excluding all other sources of hemorrhage. She was treated with oral corticosteroids and immunosuppressants and showed a good clinical response. This case highlights that clinicians must consider rare conditions such as idiopathic pulmonary hemosiderosis as a cause of pulmonary hemorrhage even without evidence of APCA in patients with congenital heart disease showing recurrent symptoms.

Introduction: Irregular antibodies are non-ABO alloantibodies that can cause hemolytic disease in fetuses and newborns, reduced red cell survival, and delayed hemolytic transfusion reaction (DHTR). DHTR may present with intravascular hemolysis and associated findings, including death. However, little is known about the frequency of irregular antibodies in critically ill patients. Methods: We used an electronic clinical transfusion management system to retrospectively assess all patients who underwent irregular antibody screening between January 2012 and November 2015. We collected information about age, sex, transfusion history, and type of irregular antibodies. Results: Screening for irregular antibodies revealed that 14 (1.8%) of 770 patients (male, n=11; female, n=3; mean age [±SD], 64.0±14.7 years) harbored irregular antibodies. Ten patients (1.3%) had clinically significant warm antibodies. Five patients had a history of transfusion and four did not. Information about transfusion was unavailable for the remaining five due to varying circumstances such as patient unconsciousness. Conclusion: Patients with irregular antibodies are not rare, and 14 (1.8%) of 770 patients in our ICU had them. As the history of transfusion in critically ill patients is often unknown, side effects of transfusion can be serious. Therefore, repeating irregular antibodies tests proactively may prevent side effects of transfusion, including DHTR.

We conducted a survey to investigate whether nurses had difficulties in activating the rapid response system (RRS) and to explore the factors affecting its activation. We found that 80% of the 381 nurses experienced difficulties with RRS activation. Three factors were found to account for these difficulties: (1) “the heavy responsibility of activating the RRS” (56%), (2) “not knowing the right timing to activate the RRS” (41%), and (3) “lack of confidence in one’s ability to determine whether something is wrong with a patient” (this is one of the RRS activation standards) (40%).