SCCM Resource Library-60-Extracorporeal Membrane Support for Pediatric Multisystem Inflammatory Syndrome in Children

Video Transcription

Hi, I'm Jordan Schneider, a Pediatric Critical Care Medicine Fellow at Children's Hospital of Michigan in Detroit, Michigan.  And today I'm going to discuss a case series of extracorporeal membrane support for multisystem inflammatory syndrome in children.  Basic criteria for MIS-C include fever, evidence of inflammation, severe illness requiring hospitalization, and multisystem involvement with no alternative diagnoses in a patient  less than 21 years of age who has a current or recent COVID-19 infection or exposure within the last four weeks.  Reported treatment for this new condition has been variable with some more recent reports of extracorporeal use.  We report three cases of MIS-C with cardiogenic shock supported with VA ECMO. The first two cases occurred just weeks after the spring surge of COVID among the adult  population in Detroit and prior to the NHS or CDC reports warning of a new post-infectious systemic inflammatory syndrome in children.  All three patients survived with excellent outcomes. Here you can see a graph of daily new cases of COVID-19 in Michigan during the first surge in the spring of 2020.  Most of these cases were concentrated in the metro Detroit area. Our first patient presented here in late April, the day before the National Health Service  in England released their first warning about a coronavirus-linked illness emerging in children. Patient two presented two days later, while patient three presented in early July.  Patient one is a six-year-old female who presented with six days of fever, abdominal pain, and rash along with vital signs and exam findings consistent with cardiogenic shock.  Her initial COVID-19 PCR was positive. Her COVID serology was positive for antibodies and her inflammatory markers were significantly elevated.  EKG on presentation showed low voltage and first degree AV block and echo showed moderately depressed function with septal hypokinesia and prominent coronaries.  Despite treatment with IVIG and high-dose aspirin, she developed arrhythmia with poor perfusion leading to a short cardiac arrest.  Subsequently, she developed ventricular tachycardia, so she was cannulated to VA ECMO. Here you can see her elevated inflammatory markers on presentation with a gradual trend  towards normal levels over the course of her admission. She was treated with infliximab, methylprednisolone, and remdesivir.  She was anticoagulated with unfractionated heparin and had no bleeding or thrombotic complications.  She was decannulated after four days on ECMO and eventually discharged from the hospital.  Her most recent follow-up echo shows normal cardiac function and she has no residual symptoms.  Patient two is a 17-year-old male who presented with fever, abdominal pain, and rash as well as cervical lymphadenopathy and conjunctival injection. His COVID-19 PCR was positive.  His serology was antibody positive and his inflammatory markers were significantly elevated. His initial echo showed normal function with dilation of the left main coronary artery.  He was treated with IVIG and high-dose aspirin. He was then transferred to the ICU after developing dizziness and hypotension on the ward.  EKG at this time showed tachycardia with first-degree AV block and incomplete right bundle branch  block, while repeat echo showed moderately depressed ventricular function and increased dilation of the left coronary artery.  Similar to patient one, he developed refractory cardiogenic shock with accelerated idioventricular rhythm seen here and was cannulated to VA ECMO.  He was treated with infliximab, methylprednisolone, and remdesivir and was successfully decannulated after four days on ECMO.  While on ECMO, he was anticoagulated with unfractionated heparin with no bleeding or thrombotic complications. On the right is his echo showing the dilated left coronary artery.  Discharge echo showed return of normal ventricular function and resolution of coronary dilation.  Subsequent follow-up echoes remained normal and against our recommendation, he was playing high school football this fall without any symptoms.  Patient three is a 15-year-old male with insulin-dependent diabetes who was transferred to our hospital from an outside PICU after experiencing seven days of fever, rash, abdominal  pain, and vomiting and diarrhea. He is the only patient of the three to have had a known COVID infection diagnosed by PCR three weeks prior to presentation.  His initial echo showed mildly reduced left ventricular function with normal coronaries.  He was treated with IVIG but was not started on aspirin due to the finding of normal coronaries by echo.  When he arrived to our unit, he was hypoxic and poorly perfused with refractory cardiogenic shock. Repeat echo showed severely depressed biventricular function.  He then developed ventricular tachycardia and was cannulated to VA ECMO. Here you can see the trend of his inflammatory markers with significant initial elevation  and a gradual trend towards normal. He was treated with methylprednisolone, remdesivir, and tocilizumab.  While on ECMO, he was anticoagulated with unfractionated heparin, but he had circuit thrombosis and heparin resistance, so was changed to bivalorudin for anticoagulation  with no subsequent issues. While his inflammatory markers were similar to the previous two patients, this patient  had not been treated with high-dose aspirin prior to cannulation, and we believe this  was a major factor in his thrombotic complications, which were more similar to the reported adult difficulties with anticoagulation.  He was decannulated after four days of ECMO support, and follow-up echoes as well as a cardiac MRI showed no residual abnormalities.  On this slide, you can see that all patients had elevated troponin levels, but patient two in red had the largest increase in troponin levels.  As noted previously, this patient had severely decreased biventricular function as well as a dilated coronary artery.  His peak troponin level was associated with his clinical deterioration on hospital day four. This table summarizes the therapeutic medications received by our patients.  All patients were treated with IVIG, methobrenisolone, and remdesivir. In conclusion, these cases highlight severe presentations of children with MIS-C, two  of which occurred prior to national health organizations identifying MIS-C as a novel presentation of disease associated with COVID-19.  In these cases, VA ECMO was used as a bridge to recovery to allow time for treatments targeting the underlying inflammation to work.  The indication for ECMO in these patients was refractory cardiogenic shock with arrhythmia. All children survived and continue to have normal echocardiograms in outpatient follow-up  visits. Thank you for listening, and I'll be happy to answer any questions.

Video Summary

This video discusses a case series of extracorporeal membrane support for multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. Three cases of MIS-C with cardiogenic shock were treated with veno-arterial extracorporeal membrane oxygenation (VA ECMO). The patients received treatments including IVIG, high-dose aspirin, infliximab, methylprednisolone, remdesivir, and tocilizumab. Despite the severe presentations, all three patients survived and had normal cardiac function in follow-up visits. ECMO was used as a bridge to recovery in these cases. The findings emphasize the importance of early recognition and treatment of MIS-C in children.

Asset Subtitle

Pediatrics, Procedures, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Jordan Schneider

Introduction: Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 (SARS-CoV-2) has been described in the pediatric population. These children present with symptomatology similar to Kawasaki disease/toxic shock syndrome with tachycardia, fever, hypotension, rash, abdominal pain, and depressed myocardial function. Treatment varies, with most centers describing supportive care and isolated reports of extracorporeal support. We present three cases of severe MIS-C with cardiogenic shock treated with venoarterial ECMO with excellent results.

Description: We report three cases of MIS-C with myocardial involvement in previously healthy children, all of whom were SARS-CoV-2 IgG positive. Patient 1, a 6 year old female, suffered a cardiac arrest prior to cannulation. All three patients had severely depressed myocardial function and arrhythmia, as well as evidence of multiple organ failure with severely elevated systemic inflammatory markers. The children were treated with intravenous immunoglobulin (IVIG), remdesivir, and methylprednisolone. Two patients received infliximab, while the other received tocilizumab. Patients 1 and 2 had features of Kawasaki disease, with significant coronary artery dilatation on echocardiogram, so were treated with moderate dose aspirin. Of note, Patients 1 and 2 were treated with aspirin prior to cannulation and were successfully anticoagulated using unfractionated heparin without clotting issues. Patient 3 did not have coronary dilation on echocardiogram, so was not treated with aspirin. Patient 3 had heparin resistance and developed clots in the arterial cannula within hours of initiation, requiring a circuit change and transition to bivalirudin for anticoagulation. All three patients had significant improvement in cardiac function within 48 hours after ECMO initiation, and all were decannulated and discharged home without serious sequelae. All three patients now have normal cardiac function on echocardiography and no residual end organ effects.

Discussion: This case series highlights a novel severe clinical presentation of COVID-19 in pediatric patients. These cases describe the successful use of ECMO to support children with MIS-C and treat the underlying inflammatory response with complete symptom resolution and normalization of cardiac function

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Procedures

Knowledge Level Advanced

Membership Level Select

Tag Extracorporeal Membrane Oxygenation ECMO

Tag Cardiothoracic Critical Care

Year 2021

Keywords

extracorporeal membrane support

multisystem inflammatory syndrome in children

MIS-C

COVID-19

veno-arterial extracorporeal membrane oxygenation

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.