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DeCoy M, Page-Goertz C, Nofziger R, Besunder J, Raimer P, Gothard D, Brown M, Stewart R, Ruggles C, Breedlove K, Clark J. Hemodynamic profile effects of PM101 amiodarone formulation in patients with post-operative tachyarrhythmias. Cardiol Young 2023; 33:1643-1648. [PMID: 36124626 DOI: 10.1017/s1047951122002888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Amiodarone may be considered for patients with junctional ectopic tachycardia refractory to treatment with sedation, analgesia, cooling, and electrolyte replacements. There are currently no published pediatric data regarding the hemodynamic effects of the newer amiodarone formulation, PM101, devoid of hypotensive agents used in the original amiodarone formulation. We performed a single-center, retrospective, descriptive study from January 2012 to December 2020 in a pediatric ICU. Thirty-three patients were included (22 male and 11 female) between the ages of 1.1 and 1,460 days who developed post-operative junctional ectopic tachycardia or other tachyarrhythmias requiring PM101. Data analysis was performed on hemodynamic parameters (mean arterial pressures and heart rate) and total PM101 (mg/kg) from hour 0 of amiodarone administration to hour 72. Adverse outcomes were defined as Vasoactive-Inotropic Score >20, patients requiring ECMO or CPR, or patient death. There was no statistically significant decrease in mean arterial pressures within the 6 hours of PM101 administration (p > 0.05), but there was a statistically significant therapeutic decrease in heart rate for resolution of tachyarrhythmia (p < 0.05). Patients received up to 25 mg/kg in an 8-hour time for rate control. Average rate control was achieved within 11.91 hours and average rhythm control within 62 hours. There were four adverse events around the time of PM101 administration, with three determined to not be associated with the medication. PM101 is safe and effective in the pediatric cardiac surgical population. Our study demonstrated that PM101 can be used in a more aggressive dosing regimen than previously reported in pediatric literature with the prior formulation.
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Affiliation(s)
- Meredith DeCoy
- Akron Children's Hospital, Department of Medical Education, Akron, OH, USA
| | | | - Ryan Nofziger
- Akron Children's Hospital, Division of Critical Care, Akron, OH, USA
| | - James Besunder
- Akron Children's Hospital, Division of Critical Care, Akron, OH, USA
| | - Patricia Raimer
- Akron Children's Hospital, Division of Critical Care, Akron, OH, USA
| | - David Gothard
- Biostats, Inc: Data Analysis for Clinical Research Studies, East Canton, OH, USA
| | | | | | - Cassandra Ruggles
- Akron Children's Hospital, Division of Critical Care, Akron, OH, USA
| | | | - John Clark
- Akron Children's Hospital, Heart Center, Akron, OH, USA
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Bodansky A, Vazquez SE, Chou J, Novak T, Al-Musa A, Young C, Newhams M, Kucukak S, Zambrano LD, Mitchell A, Wang CY, Moffitt K, Halasa NB, Loftis LL, Schwartz SP, Walker TC, Mack EH, Fitzgerald JC, Gertz SJ, Rowan CM, Irby K, Sanders RC, Kong M, Schuster JE, Staat MA, Zinter MS, Cvijanovich NZ, Tarquinio KM, Coates BM, Flori HR, Dahmer MK, Crandall H, Cullimore ML, Levy ER, Chatani B, Nofziger R, Geha RS, DeRisi J, Campbell AP, Anderson M, Randolph AG. NFKB2 haploinsufficiency identified via screening for IFN-α2 autoantibodies in children and adolescents hospitalized with SARS-CoV-2-related complications. J Allergy Clin Immunol 2023; 151:926-930.e2. [PMID: 36509151 PMCID: PMC9733962 DOI: 10.1016/j.jaci.2022.11.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/21/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Autoantibodies against type I IFNs occur in approximately 10% of adults with life-threatening coronavirus disease 2019 (COVID-19). The frequency of anti-IFN autoantibodies in children with severe sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is unknown. OBJECTIVE We quantified anti-type I IFN autoantibodies in a multicenter cohort of children with severe COVID-19, multisystem inflammatory syndrome in children (MIS-C), and mild SARS-CoV-2 infections. METHODS Circulating anti-IFN-α2 antibodies were measured by a radioligand binding assay. Whole-exome sequencing, RNA sequencing, and functional studies of peripheral blood mononuclear cells were used to study any patients with levels of anti-IFN-α2 autoantibodies exceeding the assay's positive control. RESULTS Among 168 patients with severe COVID-19, 199 with MIS-C, and 45 with mild SARS-CoV-2 infections, only 1 had high levels of anti-IFN-α2 antibodies. Anti-IFN-α2 autoantibodies were not detected in patients treated with intravenous immunoglobulin before sample collection. Whole-exome sequencing identified a missense variant in the ankyrin domain of NFKB2, encoding the p100 subunit of nuclear factor kappa-light-chain enhancer of activated B cells, aka NF-κB, essential for noncanonical NF-κB signaling. The patient's peripheral blood mononuclear cells exhibited impaired cleavage of p100 characteristic of NFKB2 haploinsufficiency, an inborn error of immunity with a high prevalence of autoimmunity. CONCLUSIONS High levels of anti-IFN-α2 autoantibodies in children and adolescents with MIS-C, severe COVID-19, and mild SARS-CoV-2 infections are rare but can occur in patients with inborn errors of immunity.
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Affiliation(s)
- Aaron Bodansky
- Department of Pediatric Critical Care Medicine, University of California, San Francisco, Calif
| | - Sara E Vazquez
- Department of Biochemistry and Biophysics, University of California, San Francisco, Calif; Diabetes Center, School of Medicine, University of California, San Francisco, Calif
| | - Janet Chou
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Mass.
| | - Tanya Novak
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Mass; Department of Anesthesia, Harvard Medical School, Boston, Mass
| | - Amer Al-Musa
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Cameron Young
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Margaret Newhams
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Suden Kucukak
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Laura D Zambrano
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Ga
| | - Anthea Mitchell
- Department of Biochemistry and Biophysics, University of California, San Francisco, Calif; Chan Zuckerberg Biohub, San Francisco, Calif
| | | | - Kristin Moffitt
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Mass; Division of Infectious Diseases, Boston Children's Hospital, Boston, Mass
| | - Natasha B Halasa
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tenn
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Tex
| | - Stephanie P Schwartz
- Department of Pediatrics, University of North Carolina at Chapel Hill Children's Hospital, Chapel Hill, NC
| | - Tracie C Walker
- Department of Pediatrics, University of North Carolina at Chapel Hill Children's Hospital, Chapel Hill, NC
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Division of Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Shira J Gertz
- Department of Pediatrics, Division of Pediatric Critical Care, Cooperman Barnabas Medical Center, Livingston, NJ
| | - Courtney M Rowan
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Ind
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Ark
| | - Ronald C Sanders
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Ark
| | - Michele Kong
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Jennifer E Schuster
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Children's Mercy Kansas City, Kansas City, Mo
| | - Mary A Staat
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matt S Zinter
- Department of Pediatrics, Divisions of Critical Care and Bone Marrow Transplantation, University of California, San Francisco, Calif
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital, Oakland, Calif
| | - Keiko M Tarquinio
- Department of Pediatrics, Division of Critical Care Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Bria M Coates
- Department of Pediatrics, Division of Critical Care Medicine, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Heidi R Flori
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Mott Children's Hospital and University of Michigan, Ann Arbor, Mich
| | - Mary K Dahmer
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Mott Children's Hospital and University of Michigan, Ann Arbor, Mich
| | - Hillary Crandall
- Department of Pediatrics, Division of Pediatric Critical Care, Primary Children's Hospital and University of Utah, Salt Lake City, Utah
| | - Melissa L Cullimore
- Department of Pediatrics, University of Nebraska Medical Center, College of Medicine, Children's Hospital and Medical Center, Omaha, Neb
| | - Emily R Levy
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minn
| | - Brandon Chatani
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Holtz Children's Hospital, University of Miami Miller School of Medicine, Miami, Fla
| | - Ryan Nofziger
- Department of Pediatrics, Division of Critical Care Medicine, Akron Children's Hospital, Akron, Ohio
| | - Raif S Geha
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Joseph DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, Calif; Chan Zuckerberg Biohub, San Francisco, Calif
| | - Angela P Campbell
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Ga
| | - Mark Anderson
- Diabetes Center, School of Medicine, University of California, San Francisco, Calif
| | - Adrienne G Randolph
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Mass; Department of Anesthesia, Harvard Medical School, Boston, Mass
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Bhalla AK, Klein MJ, Emeriaud G, Lopez-Fernandez YM, Napolitano N, Fernandez A, Al-Subu AM, Gedeit R, Shein SL, Nofziger R, Hsing DD, Briassoulis G, Ilia S, Baudin F, Piñeres-Olave BE, Maria Izquierdo L, Lin JC, Cheifetz IM, Kneyber MCJ, Smith L, Khemani RG, Newth CJL. Adherence to Lung-Protective Ventilation Principles in Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study. Crit Care Med 2021; 49:1779-1789. [PMID: 34259438 PMCID: PMC8448899 DOI: 10.1097/ccm.0000000000005060] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe mechanical ventilation management and factors associated with nonadherence to lung-protective ventilation principles in pediatric acute respiratory distress syndrome. DESIGN A planned ancillary study to a prospective international observational study. Mechanical ventilation management (every 6 hr measurements) during pediatric acute respiratory distress syndrome days 0-3 was described and compared with Pediatric Acute Lung Injury Consensus Conference tidal volume recommendations (< 7 mL/kg in children with impaired respiratory system compliance, < 9 mL/kg in all other children) and the Acute Respiratory Distress Syndrome Network lower positive end-expiratory pressure/higher Fio2 grid recommendations. SETTING Seventy-one international PICUs. PATIENTS Children with pediatric acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Analyses included 422 children. On pediatric acute respiratory distress syndrome day 0, median tidal volume was 7.6 mL/kg (interquartile range, 6.3-8.9 mL/kg) and did not differ by pediatric acute respiratory distress syndrome severity. Plateau pressure was not recorded in 97% of measurements. Using delta pressure (peak inspiratory pressure - positive end-expiratory pressure), median tidal volume increased over quartiles of median delta pressure (p = 0.007). Median delta pressure was greater than or equal to 18 cm H2O for all pediatric acute respiratory distress syndrome severity levels. In severe pediatric acute respiratory distress syndrome, tidal volume was greater than or equal to 7 mL/kg 62% of the time, and positive end-expiratory pressure was lower than recommended by the positive end-expiratory pressure/Fio2 grid 70% of the time. In multivariable analysis, tidal volume nonadherence was more common with severe pediatric acute respiratory distress syndrome, fewer PICU admissions/yr, non-European PICUs, higher delta pressure, corticosteroid use, and pressure control mode. Adherence was associated with underweight stature and cuffed endotracheal tubes. In multivariable analysis, positive end-expiratory pressure/Fio2 grid nonadherence was more common with higher pediatric acute respiratory distress syndrome severity, ventilator decisions made primarily by the attending physician, pre-ICU cardiopulmonary resuscitation, underweight stature, and age less than 2 years. Adherence was associated with respiratory therapist involvement in ventilator management and longer time from pediatric acute respiratory distress syndrome diagnosis. Higher nonadherence to tidal volume and positive end-expiratory pressure recommendations were independently associated with higher mortality and longer duration of ventilation after adjustment for confounding variables. In stratified analyses, these associations were primarily influenced by children with severe pediatric acute respiratory distress syndrome. CONCLUSIONS Nonadherence to lung-protective ventilation principles is common in pediatric acute respiratory distress syndrome and may impact outcome. Modifiable factors exist that may improve adherence.
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Affiliation(s)
- Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, QC, Canada
- Department of Pediatrics, Université de Montréal, Montreal, QC, Canada
| | - Yolanda M Lopez-Fernandez
- Pediatric Intensive Care Unit, Department of Pediatrics, Biocruces-Bizkaia, Bizkaia, Spain
- Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Natalie Napolitano
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Analia Fernandez
- Pediatric Intensive Care Unit, Hospital General de Agudos "C. Durand", Buenos Aires, Argentina
| | - Awni M Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Rainer Gedeit
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
- Critical Care Section, Children's Wisconsin, Milwaukee, WI
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Ryan Nofziger
- Department of Pediatrics, Division of Critical Care Medicine, Akron Children's Hospital, Akron, OH
| | - Deyin Doreen Hsing
- Department of Pediatrics, Pediatric Critical Care Medicine, Weill Cornell Medicine, New York City, NY
| | - George Briassoulis
- Pediatric Intensive Care Unit, Medical School, University of Crete, Crete, Greece
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, Medical School, University of Crete, Crete, Greece
| | - Florent Baudin
- Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Réanimation Pédiatrique, Lyon, France
| | | | | | - John C Lin
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Ira M Cheifetz
- Division of Cardiac Critical Care, UH Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Critical Care, Anaesthesiology, Peri-operative and Emergency medicine (CAPE), University of Groningen, Groningen, the Netherlands
| | - Lincoln Smith
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Muszynski JA, Nofziger R, Moore-Clingenpeel M, Greathouse K, Anglim L, Steele L, Hensley J, Hanson-Huber L, Nateri J, Ramilo O, Hall MW. Early Immune Function and Duration of Organ Dysfunction in Critically III Children with Sepsis. Am J Respir Crit Care Med 2018; 198:361-369. [PMID: 29470918 PMCID: PMC6835060 DOI: 10.1164/rccm.201710-2006oc] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 02/21/2018] [Indexed: 12/22/2022] Open
Abstract
RATIONALE Late immune suppression is associated with nosocomial infection and mortality in adults and children with sepsis. Relationships between early immune suppression and outcomes in children with sepsis remain unclear. OBJECTIVES Prospective observational study to test the hypothesis that early innate and adaptive immune suppression are associated with longer duration of organ dysfunction in children with severe sepsis or septic shock. METHODS Children younger than 18 years of age meeting consensus criteria for severe sepsis or septic shock were sampled within 48 hours of sepsis onset. Healthy control subjects were sampled once. Innate immune function was quantified by whole blood ex vivo LPS-induced TNF-α (tumor necrosis factor-α) production capacity. Adaptive immune function was quantified by ex vivo phytohemagglutinin-induced IFN-γ production capacity. MEASUREMENTS AND MAIN RESULTS One hundred two children with sepsis and 35 healthy children were enrolled. Compared with healthy children, children with sepsis demonstrated lower LPS-induced TNF-α production (P < 0.0001) and lower phytohemagglutinin-induced IFN-γ production (P < 0.0001). Among children with sepsis, early innate and adaptive immune suppression were associated with greater number of days with multiple organ dysfunction syndrome and greater number of days with any organ dysfunction. On multivariable analyses, early innate immune suppression remained independently associated with increased multiple organ dysfunction syndrome days (adjusted relative risk, 1.2; 95% confidence interval, 1.03-1.5) and organ dysfunction days (adjusted relative risk, 1.2; 95% confidence interval, 1.1-1.3). CONCLUSIONS Critically ill children with severe sepsis or septic shock demonstrate early innate and adaptive immune suppression. Early innate and adaptive immune suppression are associated with longer durations of organ dysfunction and may be useful markers to help guide future investigations of immunomodulatory therapies in children with sepsis.
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Affiliation(s)
- Jennifer A. Muszynski
- Division of Critical Care Medicine and
- The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Ryan Nofziger
- Division of Critical Care Medicine, Akron Children’s Hospital, Akron, Ohio; and
| | - Melissa Moore-Clingenpeel
- Division of Critical Care Medicine and
- Biostatistics Core, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Kristin Greathouse
- The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Larissa Anglim
- The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Lisa Steele
- The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Josey Hensley
- The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Lisa Hanson-Huber
- The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Jyotsna Nateri
- The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Octavio Ramilo
- Division of Pediatric Infectious Diseases, Nationwide Children’s Hospital, Columbus, Ohio
- The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Mark W. Hall
- Division of Critical Care Medicine and
- The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
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Muszynski JA, Frazier E, Nofziger R, Nateri J, Hanson-Huber L, Steele L, Nicol K, Spinella PC, Hall MW. Red blood cell transfusion and immune function in critically ill children: a prospective observational study. Transfusion 2014; 55:766-74. [PMID: 25355535 DOI: 10.1111/trf.12896] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 08/25/2014] [Accepted: 08/29/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Our previous in vitro work showed that stored red blood cells (RBCs) increasingly suppress markers of innate immune function with increased storage time. This multicenter prospective observational study tests the hypothesis that a single RBC transfusion in critically ill children is associated with immune suppression as a function of storage time. STUDY DESIGN AND METHODS Blood samples were taken immediately before and 24 (±6) hours after a single RBC transfusion ordered as part of routine care. Innate and adaptive immune function was assessed by ex vivo whole blood stimulation with lipopolysaccharide (LPS) and phytohemagglutinin, respectively. Monocyte HLA-DR expression, regulatory T cells, plasma interleukin (IL)-6, and IL-8 levels were also measured. RESULTS Thirty-one transfused critically ill children and eight healthy controls were studied. Critically ill subjects had lower pretransfusion LPS-induced tumor necrosis factor-α production capacity compared to healthy controls, indicating innate immune suppression (p < 0.0002). Those who received RBCs stored for not more than 21 days demonstrated recovery of innate immune function (p = 0.02) and decreased plasma IL-6 levels (p = 0.002) over time compared to children transfused with older blood, who showed persistence of systemic inflammation and innate immune suppression. RBC storage time was not associated with changes in adaptive immune function. CONCLUSION In this pilot cohort of critically ill children, transfusion with older prestorage leukoreduced RBCs was associated with persistence of innate immune suppression and systemic inflammation. This was not seen with fresher RBCs. RBC transfusion had no short-term association with adaptive immune function. Further studies are warranted to confirm these findings in a larger cohort of patients.
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Affiliation(s)
- Jennifer A Muszynski
- Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio.,The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Elfaridah Frazier
- Pediatrics, Division of Critical Care Medicine, Washington University, St Louis, Missouri
| | - Ryan Nofziger
- Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, Ohio
| | - Jyotsna Nateri
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Lisa Hanson-Huber
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Lisa Steele
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Kathleen Nicol
- Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Philip C Spinella
- Pediatrics, Division of Critical Care Medicine, Washington University, St Louis, Missouri
| | - Mark W Hall
- Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio.,The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
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Muszynski JA, Nofziger R, Greathouse K, Steele L, Hanson-Huber L, Nateri J, Hall MW. Early adaptive immune suppression in children with septic shock: a prospective observational study. Crit Care 2014; 18:R145. [PMID: 25005517 PMCID: PMC4226962 DOI: 10.1186/cc13980] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/13/2014] [Indexed: 11/27/2022] Open
Abstract
Introduction Innate immune suppression occurs commonly in pediatric critical illness, in which it is associated with adverse outcomes. Less is known about the adaptive immune response in critically ill children with sepsis. We designed a single-center prospective, observational study to test the hypothesis that children with septic shock would have decreased adaptive immune function compared with healthy children and that among children with sepsis, lower adaptive immune function would be associated with the development of persistent infection or new nosocomial infection. Methods Children (18 years or younger) who were admitted to the pediatric intensive care unit with septic shock (by International Consensus Criteria) were enrolled in the study. Blood samples were taken within 48 hours of sepsis onset and again on Day 7 of illness. Adaptive immune function was assessed with ex vivo phytohemagglutinin (PHA)-induced cytokine production capacity of isolated CD4+ T cells. Percentage of regulatory T cells was measured with flow cytometry. Absolute lymphocyte counts were recorded when available. Results In total, 22 children with septic shock and eight healthy controls were enrolled. Compared with those from healthy children, CD4+ T cells isolated from septic shock children on Days 1 to 2 of illness and stimulated with PHA produced less of the pro-inflammatory cytokine interferon gamma (IFN-γ) (P = 0.002), and the antiinflammatory cytokines interleukin (IL)-4 (P = 0.03) and IL-10 (P = 0.02). Among septic shock children, those who went on to develop persistent or nosocomial infection had decreased T-cell ex vivo PHA-induced production of IFN-γ (P = 0.01), IL-2 (P = 0.01), IL-4 (P = 0.008), and IL-10 (P = 0.001) compared with septic shock children who did not. Percentage of regulatory T cells (CD4+CD25+CD127lo) did not differ among groups. Conclusions Adaptive immune suppression may occur early in the course of pediatric septic shock and is associated with adverse infection-related outcomes.
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