Extracorporeal membrane oxygenation(ECMO)is a salvage treatment for severe respiratory or circulatory failure, which is refractory to conventional management.Critical care ultrasound can be used in each phase of pediatric ECMO treatment, such as ECMO initiation, cannulation, complications management, weaning and so on, which may provide valuable information for pediatricians.

As a kind of effective treatment,continuous blood purification (CBP),still left some risk factors in critically ill children.The risk factors include catheter-related complications such as bleeding and mispractice at the acute phase,long-term complications such as catheter infections,tube jam;complications occurred in the process of CBP such as low blood pressure,hypothermia and abnormal coagulation;metabolic complications such as lost syndrome and imbalance syndrome.CBP should be implemented safely and effectively in pediatric field by mastering the skill proficiently,continuously monitoring vital signs,tackling complications and accidental episodes.

Sepsis is a complex systemic inflammatory response syndrome caused by invasion of a varie-ty of pathogenic bacteria. The disease spectrum includes sepsis, severe sepsis, septic shock and multiple organ failure. Mitochondria are referred to as “power plants”, providing energy for viscera to maintain normal func-tion. Immune disorders,the activation and release of a series of inflammatory factors,anomalies of intracellular signal transmission and oxidative stress in sepsis can induce mitochondrial dysfunction. Recent research suggests that mitochondrial autophagy also plays a certain role in mitochondrial dysfunction. This article reviews the mechanism of mitochondrial functional damage during the pathogenesis of sepsis.

Objective Radiological grade of splenic injury was seldomly used in China trauma center now,though it had been established in 1994 by American Association for Surgery of Trauma (AAST) and widely used.The present study is aimed to analyze the imaging grade and clinical characteristics of traumatic splenic rupture in children,discuss the feasibility of conservative treatment,and the role of radiographic grading during clinical treatment.Methods Information (including age,gender,severity based on radiological findings,treatment strategies,and clinical outcome) regarding 59 hospitalized splenic injury patients whose injuries occurred between 2008 and 2014 was retrospectively analyzed.Results Between 2008 and 2014,59 pediatric patients with splenic injury were treated in our institution.Median age was 9.5 years (range,3 months to 16 years).Of all patients,41 (69.5%) were male.The injuries were primarily caused by traffic crash (45.7%),stumbling/falling from a height (38.9%).According to AAST,5 cases were grade Ⅰ,26 patients grade Ⅱ (44.1%),and 21 cases grade Ⅲ (35.6%),6 over grade Ⅳ,and only one was unclear.Of all patients,25 cases were with the other organs complications.All patients underwent fasting,bed rest,and antibiotics.Only 1 case was transferred to operation during the conservative treatment.Forty-nine patients underwent with CT scan over 2 times.Conclusion Imaging classification helps guide clinical treatment.Conservative treatment is feasible for traumatic splenic injury in children.Early imaging classification of splenic injury may be helpful in clinical judgment,and reduce children radiation exposure.

Cardiogenic pulmonary edema(CPE)is the serious stage of acute or chronic heart failure, due to the increasing pulmonary capillary hydrostatic pressure.CPE is one of the common causes of acute hypoxic respiratory failure,which is characterized by dyspnea,wheezing,cyanosis,and pink foaming sputum. Early identification and proper intervention can reduce the length of mechanical ventilation and improve the prognosis.This article reviewed its etiology,pathology,physiology,clinical symptoms,focused on monitoring and diagnosis methods,including chest auscultation,X-ray,transpulmonary thermodilution,and so on,espe-cially in critical care ultrasound.The advantages and limitations of above methods in the intensive care unit were compared.

To introduce the technical process,manpower,equipment preparation and attentions of children's emergency triage system,and briefly introduce the common triage system at home and abroad,and the new technology and development in this field.

Virtual reality (VR) is a technology, which can simulate human vision, touch, hearing and other sensory functions, and it synthesizes a computer-generated 3D world to provide immersive experiences.VR technology has the characteristics of interactivity, immersion and imagination, and its application in medical education and simulation training improves the quality and efficiency of learning.At the same time, VR technology also plays a certain role in clinical treatment such as surgery, rehabilitation, psychology, sedation and analgesia.With the development of VR technology, its application in pediatric medicine field is expected to solve some difficulties of pediatric practitioners.For example, the application of virtual standard patient in pediatric training, and VR technology relieving pain and anxiety.

Simulation-based medical education（SBME）is an important model in international medical education.With the development of SBME domestically,various forms such as in-situ simulation,team simulation,interdisciplinary simulation,and hybrid simulation are gradually emerging.While post-graduate education and competency receive more attention,SBME has shown its value in areas including education and training,clinical thinking,assessment,and evaluation,as well as improving medical quality and patients safety,especially in the management of emergency and critical care crisis resources.However,the progress of pediatric SBME has been slow despite attracting significant attention within the field of pediatric critical care.The establishment of pediatric critical care skills simulation,scenario simulation,in-situ simulation and other training methods can not only enable clinicians to achieve“standardized operation” and “team collaboration”,but also promote“system transformation”,greatly improving the medical quality of pediatric critical care while ensuring patients safety.

Objective:To prospectively investigate the prevalence of heparin-induced thrombocytopenia (HIT) in critically ill children during extracorporeal membrane oxygenation(ECMO) and explore the clinical characteristics and prognosis of HIT during ECMO.Methods:A total of 22 critically ill children, who had received ECMO support for more than 96 hours in the Intensive Care Unit at the Children′s Hospital of Fudan University from March 2019 to December 2020, were enrolled.According to the 4T score and the heparin/platelet factor 4(PF4) antibody, children whose 4T scores were not less than 6 and heparin/ PF4 antibodies were positive, were classified into HIT group ( n=6), and non-HIT group ( n=16). The clinical outcomes and the incidence of thrombotic events were compared between two groups. Results:The incidence of HIT during ECMO in critically ill children was 27% in this study.The incidence of thrombosis in the ECMO circuit in the HIT group was higher (100% vs.63%, P=0.133), and the average time to the first thrombosis in ECMO circuit in the HIT group was shorter than that in the non-HIT group (3.70 d vs.5.44 d, P=0.06). During the first 14 days of ECMO, the proportion of children with thrombotic events no less than twice was higher in the HIT group (67% vs.19%, P=0.054). There was no significant difference regarding the survival rate at 28 days after ECMO withdrawal between two groups (33% vs.50%, P=0.664). Conclusion:The prevalence of HIT during ECMO in critically ill children is high.Thrombosis events tend to occur earlier and more extensively in children with HIT during ECMO.No significant effect of HIT on the survival rate of children during ECMO is found.Whether HIT has effect on the survival rate of children with ECMO requires a prospective and large clinical study.

Objective:To analyze the effects of microvascular invasion (MVI) and anatomical hepatectomy on early recurrence and survival of patients with hepatocellular carcinoma (HCC).Methods:The data of 246 patients with HCC admitted to 215 Hospital of Shaanxi Nuclear Industry, Chinese PLA General Hospital and Beijing Tsinghua Chang Gung Hospital from July 2008 to June 2019 were retrospectively analyzed, including 208 males and 38 females, aged (53.8±9.6) years. According to the occurrence of MVI, 246 patients were divided into the MVI group ( n=83) and control group ( n=163, without MVI). Hepatitis B virus (HBV) infection, preoperative alpha-fetoprotein (AFP), maximum tumor diameter, intraoperative blood loss were compared between the two groups. The recurrence-free survival and cumulative survival were compared between the two groups before and after the inverse probability weighted correction for propensity score. Results:The propensity score was calculated by logistic regression model. After inverse probability weighted correction, the virtual sample size was 247 cases (82 cases in MVI group and 165 cases in control group). The proportion of HBV infection, with a serum level of AFP > 200 μg/L, the maximum diameter of tumor and the intraoperative blood loss were higher in MVI group (all P<0.05). The risk of early recurrence in patients undergoing anatomical hepatectomy ( n=107) was lower than that in patients undergoing non-anatomical hepatectomy ( n=139) (univariate Cox regression analysis of HR=1.60, 95% CI: 1.06 to 2.42, P=0.020), but the overall survival was comparable (univariate Cox regression analysis of HR=1.66, 95% CI: 0.80 to 3.42, P=0.200). The recurrence-free survival (RFS) of MVI group was lower than that of the control group, and the postoperative cumulative survival rate was also lower before the inverse probability weighted correction of the tendency score. The RFS in MVI group was lower than that in control group after the tendency score was adjusted by inverse probability weighting ( HR=2.62, 95% CI: 1.61 to 4.27, P<0.001). There was no significant difference in the cumulative survival between the MVI and control group ( HR=2.09, 95% CI: 0.89 to 4.93, P=0.050). Conclusion:MVI is associated with early postoperative recurrence in patients with HCC, and the early recurrence rate after anatomical hepatectomy is lower than that after non-anatomical hepatectomy.