Objective:To evaluate the effectiveness of integrated pediatric training course of extracorporeal membrane oxygenation(ECMO)based on simulation teaching.Methods:The instructors of ECMO team of Children′s Hospital of Fudan University developed the teaching curriculum.Team members as a unit were recruited to study simulation-based courses, whose theoretical knowledge, skills and teamwork were assessed, and feedback from the trainees were gathered.Results:Since May 2018, 22 teams of pediatric specialized hospitals or general hospitals have taken part in our ECMO simulation, with totally 132 participants, including 45 ICU doctors(34.1%), 60 ICU nurses(45.5%), 23 thoracic surgeons(17.4%) and four anesthesiologists(3.0%). Twelve of them(9.1%)had a little ECMO experience.After training, the trainees had a high evaluation on each part of the course, with average score more than four, of which the theoretical score was lowest.Their self-evaluation on the theory, skills, teamwork and confidence in the implementation of ECMO had been significantly improved.Most(80.3%)of the trainees were confident to carry out ECMO in their local hospitals.The trainees′ baseline score of theoretical knowledge was 55.2±7.6, and increased to 67.1±7.3 after training( P<0.001). The average teamwork score of the 22 teams was 70.2±8.2, and the qualified rate was up to 86.4%.The most prominent skill problems in operation assessment were no albumin and blood priming(90.9%), non-skill problems were extremely anxious during the overall assessment(84.8%)of the participants, poor team work(74.2%), poor leadership(68.2%). For the feedback of the whole course, 97.0% and 94.7% of the trainees thought that integrated training and simulation teaching were the highlights of the course.At present, 13(59.1%)units have successfully developed ECMO technology after the course, and the number of children treated has been up to 83, with a survival rate of discharge of 54.2%.However, it was found that the skill level of some participants decreased about 2 weeks after the course. Conclusion:As a new attempt of ECMO teaching, this curriculum has achieved certain efficiency in both teaching and clinical practice.At the same time, our study also plays a role in promoting the development of ECMO in pediatrics.

Objective To understand the changes of the levels of serum cortisol,pro‐B‐type natri‐uretic peptide(Pro‐BNP) and interleukin‐6(IL‐6) in the critical stress children. Methods The experimental group enrolled the children with severe infection,polytrauma and cardiopulmonary resuscitation admitted in PICU of Children′s Hospital of Fudan University from May 2015 to December 2015. The children admitted to the surgical ward during the same period without trauma,infection,heart,kidney and adrenal diseases or dys‐function,and without a long history of glucocorticoid use were selected as the control group. According to the pediatric critical illness score(PCIS),the experimental group was divided into 3 subgroups:severe critically ill group(PCIS≤70,n＝17),critically ill group(PCIS 71‐89,n＝26),and non‐critically ill group( PCIS≥90,n＝15). What′s more,the experimental cases were divided into survival group (n＝39) and death group ( n＝19) according to the prognosis. On the day of admission and during the period with stable condition,the peripheral blood sample were collected to detect serum cortisol,Pro‐BNP and IL‐6. While the control cases were detected the same items on the day of admission or pre‐operation. Results The concentrations of serum cortisol,Pro‐BNP and IL‐6 on the day of admission in severe critically ill group,critically ill group and non‐critically ill group were higher than those in the period with stable condition (P<0. 05). The concentrations of serum cortisol, Pro‐BNP and IL‐6 on the day of admission in control group, non‐critically ill group, critically ill group and severe critically ill group increased in sequence (P<0. 05). While in stable condition, there were no statistically significant differences among severe critically ill group,critically ill group and non‐critically ill group( P >0. 05). The concentrations of Pro‐BNP and IL‐6 in death group were significantly higher than those in survival group(P<0. 05). While the level of cortisol showed no statistically significant difference between death group and survival group( P>0. 05). PCIS was negatively correlated with serum cortisol,Pro‐BNP and IL‐6 (r＝ －0. 571,－0. 661 and －0. 504,P<0. 05,respectively). Conclusion The levels of serum cortisol,Pro‐BNP and IL‐6 in critically ill children all significantly increase in acute critically ill period,which are all negatively correlated with PCIS. They can be used as the indicators of severity of ill‐ness. Pro‐BNP and IL‐6 also can be used as the indicators of the prognosis of disease.

Objective To investigate the clinical manifestations, treatment and prognosis of streptococcal toxic shock syndrome (STSS) in children. Methods One case of STSS was reported in a child who was admitted to Children's Hospital of Fudan University. Search terms such as "streptococcal toxic shock syndrome", "children" and "case report" were used to identify relevant reports from PubMed database, as well as Chinese databases including Chongqing VIP, Wanfang, and China National Knowledge Infrastructure for further review. Results The patient in this report was a 11-year-old female. The main clinical manifestations were fever, red, swelling, and pain in the right lower extremity, associated with impaired walking and hypotension. Imaging examination suggested diffuse abnormal signals in the soft tissue of right thigh. Group A Streptococcus (namely Streptococcus pyogenes) was isolated from the puncture fluid. The patient was improved after active shock-correcting and anti-infective treatment. A total of 6 STSS cases were identified from Chinese databases between January 1, 1996 and May 1, 2017. All the 7 cases (including this one, 4 males and 3 females, 15 months to 13 years of age) reported fever and skin rashes, and rapidly progressed to shock. Respiratory failure was reported in 4 cases and supported with a ventilator. Three patients died, including 2 within 24 hours after hospitaladmission. A total of 38 STSS cases (40 days to 18 years of age) were identified from PubMed database. The main clinical manifestations of these cases were respiratory tract or digestive tract symptoms, and skin and soft tissue infection. In addition, chickenpox was found in 3 cases, Kawasaki disease in 2 cases, neonatal bullous impetigo, pancreatitis, infectious mononucleosis, and lymphohistiocytosis in one case each. Of the 38 patients, 22 survived and 16 died. Conclusions STSS is a rare and severe form of invasive streptococcal infection in children. The early manifestations are not specific, which may be mistaken for upper respiratory tract infection, gastrointestinal dysfunction symptoms, skin and soft tissue infection, or muscle and joint disorder, or even similar to or associated with Kawasaki disease. But rapid progression to shock and multiple organ failure of STSS pose a serious threat to children. Pediatricians should keep alert on STSS. Early identification, timely diagnosis, and adequate treatment are key to improving patient outcome.

Objective We tried to develop a reliable,stable and effective customized ECLS system through a well designed in vitro and in vivo study.Methods An in vitro test model of the ECLS system,mainly consisting of a pseudo-patient (a blood reservoir),bladder,oxygenator,pump tube (outer diameter:1/4 inch),roller pump and the heater,was built.Performances of the pump,monitors,and the heater were observed every day.The precision of the pump flow (pressure monitor or the heater) was compared with a transonic flow-meter (Medtronic ECMO system or thermometer).The monitors were tested to see if they could meet the requirements.Four healthy and two mild ARDS piglets were supported with the customized ECLS system for 24 hours.Hemodynamics,lung mechanics,gas change and hematological parameters of the piglets and performances of the machine were recorded.Agreement between the customized ECLS system and other devices including the transonic flow-meter,Medtronic ECMO system and thermometer was evaluated by the Bland-Altman method.Results The pump,the monitors,and the heater functioned well without accidently stopping working.The 95％ limits of agreement of pump flow,pre-pump pressure,post-pump pressure,post-membrane pressure,and temperature were (-0.04 L/min,0.03 L/min),(-3 mmHg,3 mmHg),(-5 mmHg,6 mmHg),(-6 mmHg,6 mmHg),(0.1 ℃,0.3 ℃).The pressure monitors and the bladder could alarm and stop the pump fast during a 100 times trail.The bubble detector could respond well (alarm and stop the pump) to 60 of the 100 bubbles injected into the circuit.The alarming temperature of the heater was (42.3±0.2) ℃.The customized ECLS worked well without complications throughout the in vivo test.A temporary decrease of Cdyn and increase of A-aDO2 and OI were observed in healthy piglets while an escalating trend of Cdyn and a downtrend of A-aDO2 and OI in ARDS piglets.Mean arterial blood pressure of the piglets supported with the customized ECLS system maintained stable while the Hb and PLT decreased.Conclusion In vitro and in vivo test showed the pump,pressure monitors and the heater of the customized ECLS system functioned well,and the feasibility,safety and stability of the system were preliminarily verified from the cytosol of the cell to the lumen of the sarcoplasmic reticulum.

Objective To review multi-center experience on rescue use of extracorporeal membrane oxygenation(ECMO) in pediatric patients with acute fulminant myocarditis and to investigate its short-term outcome in China.Methods The survey was conducted in 28 tertiary hospitals in China mainland.All children<18 years who had been supported with non-open chest ECMO to rescue acute fulminant myocarditis in PICU were reviewed.Results Twenty-three of 63 patients with ECMO support were diagnosed acute fulminant myocarditis.Their mean age was(86.3±48.8)months,mean weight was(25.8±12.1)kg,and mean left ventricular ejection fraction was(39.5±15.6)%.Eighteen patients(78.3%) survived to discharge and 5 cases(21.7%) died.The average length of ECMO was(119.1±57.3)h,(110.6±42.7)h for survival,(150.0±93.8)h for nonsurvival.There was no statistically difference between survival and death in ECMO support time(P=0.41).The mean arterial pressure increased from(60.7±23.7)mmHg(1mmHg=0.113kPa) of the beginning to(72.1±9.8)mmHg at 24h after ECMO treatment,and increase of mean arterial pressure was higher in the survival compared with the nonsurvival(P=0.04).The mean serum lactate decreased from(6.8±5.1)mmol/L at ECMO initiation to(2.9±2.6)mmol/L at 24h after ECMO treatment,and decrease of serum lactate was higher in survival group compared to nonsurvival group(P<0.001).Twenty-one patients(91.3%) were decanulated from ECMO successfully.Three patients died within 30 days after ECMO support,and eighteen patients survived to hospital discharge.The overall survival rate was 78.3%.There were no significant difference between the death and the survival in ECMO support time(P=0.41) and medical cost(P=0.24).The most common complications during ECMO were bleeding and disfunction of oxygenator.Of the 18 survivors,15 were followed up,4 experienced obvious sequelae,and 2 had neurologic issues.Conclusion ECMO is an effective hemodynamic support treatment that confers better clinical outcome for pediatric patients with acute fulminant myocarditis.

Patients with respiratory crisis occupied a large numbers in extracorporeal membrane oxy-genation(ECMO) group. ECMO is able to give a plenty amount of gas exchange for body essential metabolic needs by ECMO oxygenator whoever the lungs are of function or not. The key indications for respiratory ECMO are that the patient had no response to all medical treatment except ECMO,and the origin cause of the disease is potentially recoverable. Besides the contraindications and accessibility, ECMO has no special settings among the different ages or cause of diseases. The VV-ECMO is preferred for respiratory support. VA-ECMO should be considered if cardiovascular failure exists. ECMO may offer a powerful respiratory support to patient with critically ill conditions until recovery. The outcomes are influenced by some factors including the reversibility and the cause of diseases.

Objective: To compare the effects of high-volume hemofiltration (HVHF) and continuous veno-venous hemofiltration (CVVH) on cardiopulmonary functions, lung fluid balance, lung damage and cytokine expression in endotoxin-induced acute lung injury piglet model, and to further evaluate the value of high-volume hemofiltration in acute lung injury. Method: Eighteen piglets were randomly divided into the control group (6 piglets), the CVVH group (6 piglets) and the HVHF group (6 piglets). By general anesthesia, the intravenous infusion of 0.15 mg/kg endotoxin were received in all the animals and induced acute lung injury.High-volume hemofiltration and continuous veno-venous hemofiltration were addressed to different groups.Subsequently, hemodynamic parameters (heart rate, mean arterial blood pressure, central venous pressure, pulse contour cardiac index, systemic venous resistance index and extravascular lung water index) as well as gas exchange and lung mechanics parameters (respiratory rate, partial pressure of carbon dioxide, partial pressure of oxygen/fraction of inspired oxygen, dynamic lung compliance and airway resistance) were intermittently measured.Lung tissues were collected for further analysis (the lung wet-to-dry weight ratio, lung injury scoring). The plasma protein levels of cytokines (interleukin(IL) -6, 10 and tumor necrosis factors alpha(TNF-α)) were also assessed.Two-way analysis of variance (ANOVA) and Bonferroni post-test were conducted to identify significant differences among the control, CVVH and HVHF group. Result: Compared with CVVH, HVHF had the capacity to improve significantly the index of Cdyn(HVHF (2.3±0.5) vs. CVVH (1.5±0.5) ml/(cmH₂O·kg), 1 cmH₂O=0.098 kPa, P<0.05)and Rrs(HVHF (22.0±1.9) vs.CVVH (29.5±1.5) cmH₂O/(L·s), P<0.05)at the time of 6 h, and decreased lung water accumulation(index of EVLWI in HVHF (22.7±2.1) vs.CVVH (39.5±2.6) ml/m^2, P<0.01) at the time of 6 h, and the plasma concentration of cytokines(IL-6, IL-10, TNF-α)in the HVHF group had an obvious decline compared with those in the CVVH group at the time of 6 h( (200±55) vs. (280±61), (74±17) vs. (102±21), (54±13) vs. (73±21) pg/ml, all P<0.05). The lung injury scoring of HVHF group was significantly lower than those of CVVH group((7.8±1.9) vs. (11.3±2.2) scores, P<0.05). Although the plasma concentration of cytokines(IL-6, IL-10, TNF-α) in the CVVH group were lower than those in the control group at the time of 6 h((374±55), (137±25), (98±17) pg/ml, all P<0.05), the indexes of respiratory function were not improved (all P<0.05). Conclusion Different doses hemofiltration can reduce plasma inflammatory mediators indicators in piglets.Early high volume hemofiltration can improve respiratory function of piglets with endotoxin-induced acute lung injury and reduce lung injury pathological score.

Objective To determine the epidemiology of death in PICU in the past ten years.Meth-ods Retrospective cohort study was conducted in the PICU of Childrne ′s Hosip tal of Fud an University from January2005 to December 2014.Resulst The overall mortality rate of PICU was 8.5%overa 10-year peri-od for m January 2005 toD ecember 2014.Compared wti h the period from 2005 to 2009,the mortalti y rate in PICU decreasedf rom 9.7%to 8.0%during ht e period of 2010 to 2014.A totalo f 736 patients died over a 10-year pre iod,including 329(44.7%) infants,191(26.0%) toddlers,118(16.0%) preschoolers,and 98 (13.3%) school-age and adolsec ence.From 2005 to 2009,there were 269 deaths,of which 65.4% were infants and toddlers.From 2010 to 2014,there were 467 deaths,of which 73.7% were infants and toddlers. Among the diseases causing death,the severe pneumonia was the most common disease(21.6%),followed by malignant tumors ( 16.3%) , sepsis ( 15.4%) , accidental injury ( 13.7%) , and severe encephla itis (8.0%).In different age groups,the distribution of the diseases causing death was different,such as infants mainly with sevre e pneum onia(34.3%),t oddlers mainly with accidental injury(16.8%),preschoolers main-ly with accidental injury and malignant tumors(23.7%),school-age and adolescence mainly with malignant tumor(28.6%).From 2005 to 2009,77.5%deaths were critically and very critically ill patients,and the sep sis was the most common cause of death ( 27.6%) especially in very critically ill patients.From 2010 to 2014,83.0%deaths were critically and very critically ill patients,and the accidental injury was the most com-mon cause of death( 23.2%) especially in very critically ill patients, followed by sepsis ( 17.9%).There were 345 deaths ( 46.9%) occurred within the first week of admission, mainly with accidental injury (20.9%).There we re 391 deaths(53.1%) with the PICU stay for 7 or more days,and severe pneumonia (24.3%) was the most common cause of death.Modes of death were categorized as failed cardiopulmonary resuscitation(54.6%) adn forgoing life-sustaining treatme nt(45.4 %).Conclu sion Compared with the pe-riod from 2005 to 2009,the mortality rate in PICU decreaseds gi nificantly during the periodo f 2010 to 2014. The younger the patine t,the higher the mortality rate.Most deaths were attributed to severe pneumonia,fol-lowed by malignant tumors and sepsis.The causes of death also had relations with severity of diseases and lne gth of PICU stay.Failed cardiopulmonary resuscitation and forgoing life-sustaining treatment were still the mostc ommon mode of deaths.

Acute respiratory distress syndrome(ARDS) is a critical illness in children with high mortality.Extracorporeal membrane oxygenation (ECMO) is an effective rescue method for the severe ARDS,and is usually used in ARDS patient who does not respond to conventional respiratory support including mechanical ventilation.The principle of ECMO is to afford a cardiopulmonary bypass support and gives enough blood oxygen delivery.The effectiveness of ECMO on ARDS is influenced by the severity and causes of the sickness because of its respiratory support character.The reported survival rate of the ECMO children with ARDS ranged from 40％ to 78％.The traumatic procedure,need anticoagulation,noted complication and treatment cost are the important factors that restrain ECMO at the rescue role.

Objective To summarize the experience in applying a technique of inserting a cannula through right internal jugular vein and common carotid artery to build extracorporeal membrane oxygenation (ECMO) for critically ill children.Method The data of critically ill patients received ECMO support through right internal jugular vein and common carotid artery between December 2011 and December 2015 from Children's Hospital of Fudan University were analyzed retrospectively.The data included diagnosis,age,body weight,time of cannula and ECMO running,complication and prognosis.Result In total 28 patients received ECMO support,3 patients of post-cardiac surgery with transthoracic cannula were excluded.Twenty-five patients inserted cannula through neck vessels were enrolled,15 boys and 10 girls,the median age was 1.8 years (range,1 d-13 years),the median weight was 12.0 (2.8-50.0) kg.All the cannula sites were right internal jugular vein and right common carotid artery,before cannula use 5 patients had been inserted central vein tube and 3 patients with blood filter tube in right internal jugular vein,in one case cannula was applied during cardiopulmonary resuscitation.V-A ECMO had been built for all the cases successfully,the median operation time was (45 ± 26) min.The pump flow was 80-150 ml/(kg · min),the median duration of ECMO support was 153 (14-567) h.Sixteen (64％) patients weaned off ECMO successfully,15 (60％) survived to hospital discharge.About the complication of cannula,six patients developed cannula site bleeding,and two patients required re-fixation of cannula,one patient's external jugular vein had been hurt and sutured for bleeding.Conclusion Application of right jugular vessels to build ECMO is easy and safe for treating the sick children.The skill should be proficient to assure ECMO run and reduce the complications.