Panama 1 PICU-COV Portugal 1 Katri Typpo, Guillaume … · Portugal 1 Japan 1 Brazil 1 Ghana 1 Saudi Arabia 1 Uruguay 1 Thailand 1 Not Provided 2 Sites by Country (n=91) PICU-COV

PICU-COV – Week 4 Results April 10th 2020 Katri Typpo, Guillaume Emeriaud, Akira Nishisaki, Ann-Marie Brown, Sharon Irving, Vijay Srinivasan, Mary Gaspers, Yolanda Margarita Lopez Fernandez, Robinder Khemani, & Connor Kelley

United States 55

Spain 5

United Kingdom 4

Colombia 4

Canada 3

Argentina 2

Italy 2

Turkey 2

Ecuador 2

Chile 2

Panama 1

Portugal 1

Japan 1

Brazil 1

Ghana 1

Saudi Arabia 1

Uruguay 1

Thailand 1

Not Provided 2

Sites by Country (n=91)

PICU-COV is a weekly survey to understand current clinical practices in pediatric intensive care during the COVID-19 pandemic. Weekly surveys are sent to

one identified participant per site, representing one PICU. Survey questions may change weekly based on participant feedback. The Week 4 Survey was

available to participants during April 8th – April 10th and results were shared on April 10th. The first page is a snapshot of results. Full text and results are on

subsequent pages. This is not an epidemiologic study; the purpose of this project is to share clinical practices only.

65, 71%

20, 22%

5, 6%1, 1%

Likelihood of NIV Use

Equal Less Not Used More

64, 76%

12, 14%

7, 8%

1, 1% 1, 1%

Likely First NIV Mode

HFNC CPAP BiPAP NPV Other

50, 55%41, 45%

Timing of Intubation

Earlier Unchanged

Suspected Proven

No 33 65

Yes 58 26

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PICUs with Pediatric Patients Under Investigation

for COVID-19

2 Responses to all questions are voluntary and may result in differences in sample sizes.

61.8%, 55

5.6%, 5

4.5%, 4

4.5%, 4

3.4%, 3

2.2%, 2

2.2%, 2

2.2%, 2

2.2%, 2

2.2%, 2

1.1%, 1

1.1%, 1

1.1%, 1

1.1%, 1

1.1%, 1

1.1%, 1

1.1%, 1

1.1%, 1

0 10 20 30 40 50 60

United States

Spain

United Kingdom

Colombia

Canada

Argentina

Italy

Turkey

Ecuador

Chile

Panama

Portugal

Japan

Brazil

Ghana

Saudi Arabia

Uruguay

Thailand

Q1: "In what country is your pediatric intensive care unit (PICU)?" (n=89)

65, 71%

20, 22%

5, 6% 1, 1%

Q2: "For children admitted to the PICU or wards with acute respiratory distress or failure, how has your site changed practice for NIV use since COVID-19 pandemic began in your community?" (n=91)

Equally likely to use NIV

Less likely to use NIV

Not using NIV

More likely to use NIV

Questions 1 & 2


Question 3 & 4

64, 76%

12, 14%

7, 8%

1, 1% 1, 1%

Q3: "If you are continuing to use NIV as initial respiratory support for children admitted to the PICU or wards with acute respiratory distress or failure, please indicate the mode you are most likely to use first."(n=83)

HFNC

CPAP

BiPAP

Negative PressureVentilation

Other

Branch: Q3 was only presented to participants who indicated the following options in Q2: "More likely to use NIV"; "Equally likely to use NIV"; or "Less likely to use NIV". "Other" option: Not described.

50, 55%

41, 45%

Q4: "For children admitted to the PICU with acute respiratory distress or failure, has your site changed practice for timing of invasive mechanical ventilation (intubation) in relation to NIV usage since COVID-19 pandemic began in your community?" (n=83)

Earlier timing forintubation

Unchanged timingfor intubation

Later timing forintubation


Questions 5 & 6

Branch: Q6 was presented only to participants who indicated "Yes" in Q5. "Other" responses, Q6: "Anesthesiology or the most experienced provider (attending and informally senior fellow)"; "For patients with COVID+ or PUI admitted to the COVID unit, ENT is doing all of our intubations. In all other non-COVID PICUs, senior fellow or attending intubates."; "Most experienced clinician present should intubate"; "most experienced physician available"; "only attendings intubate"; "Only for PUIs. rest still PICU team"; "Only physician (that is intensivist and anesthesiologist) covers PICU 24 hrs/day"; "PCCM Faculty only with Pedi Anesthesia back up"; "Person intubating for day is designated at morning signout"; "picu attending"; "PICU attendings or anesthesia can intubate CoVID + child"; "Two most experienced practitioners so could be junior ICU fellow".

37

16

13

10

54

75

78

81

0% 20% 40% 60% 80% 100%

We limit intubation to seniorPICU fellows or attending only

We limit intubation toanesthesiology service

Other

We have a separate intubation team who is called to intubate (no longer using

usual PICU team to intubate

Q6: "How has your site changed who performs intubation in the PICU?" (n=91)

Yes No

No 26

Yes 65

0%

20%

40%

60%

80%

100%

Q5: "Has your site changed who performs intubation in the PICU?" (n=91)


Questions 7 & 8

Branch: Q8 was presented only to participants who indicated "Yes" in Q7. "Other" responses, Q8: "addition of viral filter to ventilation bag; advoid use of bag ventilation; intubation with PPE;"; "attempt to avoid BMV; no bagged breaths until cuff up on ett; clamping for all planned ett disconnections"; "clamp ett before putting on vent from bagging"; "increased use of in-line capnography"; "intubation in a protective box that we designed specifically. Would be happy to share. And larger dose of paralytic agents."; "Only for PUIs"; "Protection barrier"; "Try to avoid positive pressure ventilation and we are trying to get barrier enclosure devices "; "Use of N95 mask for intubation"; "use of plastic barrier".

76

62

54

54

20

12

12

10

15

29

37

37

71

79

79

81

0% 20% 40% 60% 80% 100%

Limit the number of personnelin the room present during intubation

Increased use of rapid sequence intubation(defined as simultaneous administration…

Increased use of videolaryngoscopy

Addition of viral filter to the endof an endotracheal tube

Increased use of pre-oxygenation

Increased use of cuffed endotracheal tubes

Increased use of supraglottic airway(e.g., LMA) to minimize aerosolization

Other

Q8: "How has your site changed how intubation is perfomed in your PICU?" (n=91)

Yes No

Count

No 9

Yes 82

0%

20%

40%

60%

80%

100%

Q7: "Has your site changed how intubation is performed in your PICU?" (n=91)


Questions 9 & 10

Suspected Proven

No 33 65

Yes 58 26

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q9 & Q10: "In the previous 24 hours, did you have pediatric patients with [Q9: suspected; Q10: proven] COVID-19 in your PICU?" (n=91)


Questions 11 & 12

"Other" responses: "


Questions 13 & 14

"Other" responses: "all patients with symptoms, travel history and all patients before surgery"; "any and all patients pre

procedure"; "Only patients with symptoms, regardless of contact or travel history AND all patients undergoing a surgical

procedure requiring intubation"; "patients with respiratory failure and other who begin with respiratory symptoms"; "Patients

with symptoms and those undergoing high risk surgeries (ie laparoscopy)".

64, 70%

15, 16%

7, 8%

5, 6%

Q13: "Among pediatric patients admitted to the PICU, who is tested for COVID-19 at your site?" (n=91)

Only patients with symptoms, regardlessof contact or travel history

All patients admitted, with or withoutsymptoms of COVID19

Only patients with symptoms andcontact or travel history

Other

Only patients with contact or travelhistory, regardless of symptoms

Not testing patients for COVID-19

"Other" responses: "High level If suspicion"; "If symptoms or analysis are suspicious"; "Immunocompromised patients require 2 tests 12 hours apart"; "neonates re tested"; "No defined"; "Re-testing if no alternative diagnosis with initial test is negative".

50

31

8

6

41

60

83

85

0% 20% 40% 60% 80% 100%

Re-testing if patient has a declinein clinical status

We are not re-testing patients forCOVID-19 if initial test is negative

Re-testing at routine interval,irrespective of patient clinical status

Other

Q14: "How are patients in your PICU re-tested for COVID-19 if an initial test is negative?" (n=91)

Yes No


Question 15

50, 56%27, 30%

8, 9%

3, 3%2, 2%

Q15: "How are healthcare workers at your site screened for COVID-19?"(n=90)

Screened for symptoms of COVID-19with a test sent if symptomatic

Screening for symptoms of COVID-19

Not screened for COVID-19

Other

Routine testing for COVID-19 at aregular intervals, even ifasymptomatic

"Other" responses: "Temperature screening once daily at start of shift."; "Self screening for symptoms"; "Phisicians: Routine

testing for covid-19 at once, even if asymptmatic. Nurses:Testing for covid -19 if symptoms e".


Question 16

Note: "Other" medications and "Other" uses for listed medications can be found in Appendix A.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Chloroquine or Hydroxychloroquine

Azithromycin

Remdesivir

Lopinavir/Ritonavir

Other Medication

Tocilizumab

Vitamin C

Anakinra

IVIG

Convalescent Patient Plasma

Chloroquine orHydroxychloroq

uineAzithromycin Remdesivir

Lopinavir/Ritonavir

OtherMedication

Tocilizumab Vitamin C Anakinra IVIGConvalescent

Patient Plasma

First line treatment 58 26 20 15 5 3 3 1 1 0

Second line treatment 14 16 28 8 1 27 3 5 5 3

Third line treatment 2 8 8 3 2 18 1 6 12 7

Fourth line treatment 0 1 1 5 1 4 5 6 5 6

Other 5 6 7 5 6 8 7 8 6 10

Not using this treatment 15 35 29 53 74 32 70 63 61 64

Q16: "What COVID-19 targeted medications does your site plan to use for pediatric patients with suspected or proven COVID-19 with severe disease (intubated, severe ARDS)?" (n=91)


Question 17, Part 1

Note: Full descriptions of PPE options are available in Appendix B. "Other" PPE for patients with low or no suspicion: "All patients with influenza like illness are tested for placed on contact & Droplet including goggles or face shield with use of N95 for Aerosolized treatments until test comes back negative"; "All providers in our unit are wearing surgical masks- so there won't ever be a patient who is intubated without masked providers, independent of concern for COVID"; "Community mask"; "depends on whether the patient otherwise qualifies for contact or droplet isolation"; "droplet (surgical mask)"; "PPE based on non-COVID indications per routine."; "Surgical mask"; "Surgical masks are to be worn at all times and for all patients, regardless of CoVID status". "Other" PPE for untested patients: "All patients with influenza like illness are tested for placed on contact & Droplet including goggles or face shield with use of N95 for Aerosolized treatments until test comes back negative"; "Community mask"; "PPE based on non-COVID indications per routine."; "testing all pts with resp distress"; "they all are tested". "Other" PPE for postive or pending patients: "-".

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Admitted to the PICU with low or no suspicion of COVID-19

With acute respiratory distress or failure admitted to the PICU who are nottested for COVID-19

With acute respiratory distress or failure admitted to the PICU who are positiveor have a test pending for COVID-19

Admitted to the PICU with low or no suspicion ofCOVID-19

With acute respiratory distress or failure admittedto the PICU who are not tested for COVID-19

With acute respiratory distress or failure admittedto the PICU who are positive or have a test pending

for COVID-19

Contact only 13 3 0

Droplet & Contact 28 35 6

Enhanced Droplet 15 16 15

Further Enhanced Droplet 1 6 14

Aerosol 1 19 46

Enhanced Aerosol 3 5 9

Other 8 5 1

No precautions 22 2 0

Q17, Part 1: "At your site, what personal protective equipment (PPE) do healthcare workers in the PICU wear in the routine care of patients..." (n=91)


Question 17, Part 2

Note: Full descriptions of PPE options are available in Appendix B. "Other" PPE for patients who previously tested negative: "All patients with influenza like illness are tested for placed on contact & Droplet including goggles or face shield with use of N95 for Aerosolized treatments until test comes back negative". "Other" PPE for untested patients: "testing all pts with resp distress"; "All patients with influenza like illness are tested for placed on contact & Droplet including goggles or face shield with use of N95 for Aerosolized treatments until test comes back negative". "testing all pts with resp distress"; "All patients with influenza like illness are tested for placed on contact & Droplet including goggles or face shield with use of N95 for Aerosolized treatments until test comes back negative". "Other" PPE for patient with low or no suspicion: "-".

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Admitted to the PICU with low or no suspicion of COVID-19

With acute respiratory distress or failure admitted to the PICU who is nottested for COVID-19

With acute respiratory distress who tested negative for COVID-19 during sameadmission, 48 hours ago

Who is positive or has a pending test for COVID-19

Admitted to the PICU with low or nosuspicion of COVID-19

With acute respiratory distress orfailure admitted to the PICU who is not

tested for COVID-19

With acute respiratory distress whotested negative for COVID-19 during

same admission, 48 hours ago

Who is positive or has a pending testfor COVID-19

Contact only 2 1 1 0

Droplet & Contact 12 6 13 0

Enhanced Droplet 10 6 9 1

Further Enhanced Droplet 7 8 7 4

Aerosol 43 52 44 59

Enhanced Aerosol 13 15 15 27

Other 1 2 1 0

No precautions 3 1 1 0

Q17, Part 2: "At your site, what personal protective equipment (PPE) do healthcare workers in the PICU wear when performing intuation in a patient..." (n=91)


8

Question 18, 19, 20, & 21

Have HFOV Use HFOV

No 3 37

Yes 88 51

-5

5

15

25

35

45

55

65

75

85

95

Q21: "Does your site have high frequency oscillatory ventilation (HFOV)?" (n=91)Q22: "Does your site plan to offer HFOV to pediatric patients with COVID-19?" (n=88)

Have ECMO Use ECMO

No 26 5

Yes 65 60

-5

5

15

25

35

45

55

65

75

85

95

Q18: "Does your site have extracorporeal membrane oxygenation (ECMO)?" (n=91)Q19: "Does your site plan to offer ECMO to pediatric patients with COVID-19?" (n=65)

Branch: Q19 was presented to participants who

responded "Yes" in Q18. Branch: Q21 was presented to participants who

responded "Yes" in Q20.


Questions 22 & 23

1

No 47

Yes 44

0%

20%

40%

60%

80%

100%

Q22: "Does your site have bioethics team or policy to determine allocation of PICU beds or resources if PICU beds or resources are of insufficient supply to treat all patients?" (n=91)

37

23

18

14

14

6

7

21

26

30

30

38

0% 20% 40% 60% 80% 100%

Likelihood to survive theacute episode with PICU care

Likelihood to survive on alonger term (years)

Likelihood to have independencefor life care/activities of

daily living after the episode

Likelihood to survive the acuteepisode without PICU care

Likelihood to stay dependenton technology to survive

Other

Q23: "According to your specific bioethics committee or policies for resource allocation during the COVID-19 pandemic, which of the following factors are considered for PICU bed and PICU resource allocation?" (n=44)

Yes No

Branch: Q23 was presented only to participants who indicated "Yes" in Q22. "Other" responses, Q23: "age


Appendix A: "Other" medications and "Other" uses for specified medications

"Other" medication responses: "antibioticotherapy empiric"; "Clexane"; "Corticoides. Checking IL- 6 before Tocilizumab;convalescent patient plasma still is not available."; "Corticosteroides"; "corticosteroids"; "do not know the order of treatment strategies"; "Favipiravir"; "Have not yet discussed as a group."; "NA"; "Na"; "No formal decision"; "None"; "Ribavirin"; "steroid"; "Systemic steroids". "Other" use of Convalescent Patient Plasma: "based on clinical team decision"; "do not know the order of treatment strategies"; "Have not yet discussed as a group."; "in a research project"; "No formal decision"; "Not using"; "not yet discussed"; "To be considered"; "Waiting for case series"; "working on getting running - paperwork in the works". "Other" use of IVIG: "do not know the order of treatment strategies"; "Have not yet discussed as a group."; "Needs approbal from Health ministery"; "No formal decision"; "Not using"; "With signs of cytokine storm". "Other" use of Anakinra: "All COVID need ID consult for medication use."; "Artritis"; "based on clinical team decision"; "do not know the order of treatment strategies"; "Have not yet discussed as a group."; "if cytokine release synrome. Tocilizumab will be used prior"; "Implied during discussions"; "With signs of cytokine storm". "Other" use of Vitamin C: "based on clinical team decision"; "depend on attendings"; "do not know the order of treatment strategies"; "Don't use"; "Have not yet discussed as a group."; "No formal decision"; "Not using". "Other" use of Tocilizumab: "All COVID need ID consult for medication use."; "case-by-case "; "do not know the order of treatment strategies"; "Have not yet discussed as a group."; "if cytokine release syndrome"; "Implied during discussions"; "Only used when IL-6 level is above threshold"; "With signs of cytokine storm". "Other" use of Lopinavir/Ritonavir: "specific management of ARDS in children with COVID-19 will be assessed on a case-by-case basis under the direction of critical care and respiratory teams when appropriate. "; "do not know the order of treatment strategies"; "Have not yet discussed as a group."; "No formal decision"; "Not using". "Other" use of Remdesivir: "specific management of ARDS in children with COVID-19 will be assessed on a case-by-case basis under the direction of critical care and respiratory teams when appropriate."; "All COVID need ID consult for medication use."; "by trial only, in teens"; "do not know the order of treatment strategies"; "Have not yet discussed as a group."; "Implied during discussions"; "RCT trial". "Other" use of Azithromycin: "specific management of ARDS in children with COVID-19 will be assessed on a case-by-case basis under the direction of critical care and respiratory teams when appropriate."; "At discretion of provider"; "based on clinical team decision"; "do not know the order of treatment strategies"; "Have not yet discussed as a group."; "Not using". "Other use of Chloroquine or Hydroxychloroquine: "specific management of ARDS in children with COVID-19 will be assessed on a case-by-case basis under the direction of critical care and respiratory teams when appropriate."; "All COVID need ID consult for medication use."; "do not know the order of treatment strategies"; "Have not yet discussed as a group."; "Implied during discussions ".

Experiences to Share Appendix A


Appendix B: Personal Protective Equipment Descriptions

• Contact precautions only: gown and gloves.

• Droplet & Contact precautions: surgical mask, gown, and gloves.

• Enhanced Droplet precautions: as above with face shield, shielded face mask or face mask with goggles.

• Further Enhanced Droplet precautions: as above, with bonnet or hair cover.

• Aerosol precautions: gown, gloves, N95 or equivalent mask, shielded face mask or goggles, with bonnet or hair cover, or powered air purifying respirator.

• Enhanced Aerosol precautions: hazardous materials or isolation suit with powered air purifying respirator or equivalent.

Appendix B

Documents

Panama 1 PICU-COV Portugal 1 Katri Typpo, Guillaume … · Portugal 1 Japan 1 Brazil 1 Ghana 1 Saudi Arabia 1 Uruguay 1 Thailand 1 Not Provided 2 Sites by Country (n=91) PICU-COV