PICU-COV – Week 6 Results April 24th 2020 Katri Typpo, Guillaume Emeriaud, Akira Nishisaki, Ann-Marie Brown, Sharon Irving, Vijay Srinivasan, Mary Gaspers, Yolanda Margarita Lopez Fernandez, Robinder Khemani, & Connor Kelley

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 6 Survey was available to participants during

April 22nd – April 24th and results were shared on April 24h. 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.

United States 49 Uruguay 1

Spain 7 Peru 1

Colombia 4 China 1

Canada 3 Portugal 1

France 3 Ghana 1

Japan 2 Puerto Rico 1

Argentina 2 Chile 1

United Kingdom 2 Saudi Arabia 1

Australia 2 Brazil 1

India 2 South Africa 1

Ecuador 2 Czechia 1

Italy 1 Turkey 1

Pakistan 1 Not Reported 1

Participating PICUs by Country (n=93)

71, 77%

17, 18%

3, 3% 2, 2%

Likelihood of NIV Use

Equally Less More Not Used

54, 60%35, 39%

1, 1%

Escalation from Initial NIV

Intubate Second NIV Other

48, 52%

43, 46%

2, 2%

Timing of Intubation

Earlier Unchanged Later

Suspected Proven

No 41 67

Yes 52 26

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PICUs with Patients Under Investigation for

COVID-19

50, 54%22, 24%

10, 11%

7, 7% 4, 4%

Adult Admissions Allowed

None COV- Any COV+, Susp. Other

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

Question 1

53.3%, 49

7.6%, 7

4.3%, 4

3.3%, 3

3.3%, 3

2.2%, 2

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

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

Colombia

Canada

France

Japan

Argentina

United Kingdom

Australia

India

Ecuador

Italy

Pakistan

Uruguay

Peru

China

Portugal

Ghana

Puerto Rico

Chile

Saudi Arabia

Brazil

South Africa

Czechia

Turkey

Q1: "In what country is your pediatric intensive care unit (PICU)?" (n=92)

3 Responses to all questions are voluntary and may result in differing sample sizes.

Questions 2, 3, & 4

71, 77%

17, 18%

3, 3% 2, 2%

Q2: "For children admitted to the PICU with acute respiratory distress or failure, how has your site changed practice for NIV use since COVID-19 pandemic began in your community?" (n=93)

Equally likely to use NIV

Less likely to use NIV

More likely to use NIV

Not using NIV

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

Pro

ne o

nN

IV

Prone on NIV

Yes 54

No 37

Q3: "For children with acute respiratory distress or failure with proven or suspected COVID-19 on NIV, does your site plan to use early (within 24 hours) prone positioning as part of treatment?" (n=91)

54, 60%35, 39%

1, 1%

Q4: "If you are continuing to use NIV as initial respiratory support for children admitted to the PICU with acute respiratory distress or failure and they fail the initial NIV mode with worsened clinical status, would you most likely:" (n=90)

Proceed directly to intubate forinvasive mechanical

Escalate or switch to second NIVmode

Other

Branch: Q3 was presented only to participants who indicated any NIV use in Q2.

Branch: Q4 was presented only to participants who indicated any NIV use in Q2.

4 Responses to all questions are voluntary and may result in differing sample sizes.

Questions 5, 6, 7, & 8

48, 52%

43, 46%

2, 2%

Q5: "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=93)

Earlier timing for intubation

Unchanged timing for intubation

Later timing for intubation

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

Pro

ne o

n IV

Prone on IV

Yes 76

No 17

Q6: "For children with acute respiratory distress or failure with proven or suspected COVID-19 on invasive ventilation (intubated), does your site plan to use early (within 24 hours) prone positioning as part of treatment?" (n=93)

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

Q7: Suspected

Q8: Proven

Q7: Suspected Q8: Proven

Yes 52 26

No 41 67

Q7: "In the previous 24 hours, did you have pediatric patients with suspected COVID-19 in your PICU?" (n=93); Q8: "In the previous 24 hours, did you have pediatric patients with proven COVID-19 in your PICU?" (n=93)

5 Responses to all questions are voluntary and may result in differing sample sizes.

Questions 9 & 10

50, 54%

22, 24%

10, 11%

7, 7%4, 4%

Q9: "What type of adult patients are you accepting as overflow from adult ICU's into your PICU?" (n=94)

We are not accepting adult patients asoverflow in our PICU

COVID-19 negative patients only

Any adult patient, regardless of COVID-19 status

COVID-19 positive and suspected only

Other

“Other” Responses: “adults are not accepted”; “No conclusion has been made”; “Plan in place but no patients admitted”; “we

would accept adult pt if needed but none now”.

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

Pro

ven

Proven

Yes 4

No 17

Q10: "Did you have adult patients with proven COVID-19 in your PICU in the previous 24 hours?" (n=21)

Branch: Q10 was presented only to participants who responded with the following in Q9: “COVID-19 positive and suspected

only”; “Any Adult patient, regardless of COVID-19 status”; or “Other”.

6 Responses to all questions are voluntary and may result in differing sample sizes.

Questions 11 & 12

57, 61%

22, 24%

7, 8%

6, 6% 1, 1%

Q11: "Among pediatric patients admitted to the PICU, who is tested for COVID-19 at your site?" (n=93)

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

“Other” Responses: “any patients with symptoms, contact or travel history, or preoperatively”; “Only patients with lower

respiratory tract infection”; “Patients with symptoms + weekly point prevalence testing of all PICU patients irrespective of

symptoms or contact/travel history”; “Patients with symptoms and any pre-op patients or pre-procedure if sedation to be

used.”; “Symptoms, contact or travel history OR aerosol-generating procedure planned/likely”; “with symptoms, or with contact

or travel history”.

66.67%, 62

26.88%, 25

9.68%, 9

8.60%, 8

0 10 20 30 40 50 60 70

Re-testing if patient has a decline in clinical status

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

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

Other

Q12: "How are patients in your PICU re-tested for COVID-19 if an initial test is negative?: (n=93)

“Other” Responses: “dependent on the symptoms, disease progression ,and timing of the test”; “For Anethesia/surgery

Immunosuppressant patients are tested twice”; “in surgery planned”; “Re testing if strong clinical suspicion”; “Rechecking as part

of process to allow clearance from isolation precautions.”; “retesting at symptom resolution”; “will do a second test prior to

planned aerosol generating procedure if it has been >72 hrs since last test. with max of 2 tests, unless new symptoms/risks”.

7 Responses to all questions are voluntary and may result in differing sample sizes.

Questions 13 & 14

Count

No 34

Yes 59

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q13: "Is your site testing asymptomatic pediatric patients who are scheduled for a procedure (OR, brochoscopy, endoscopy) for COVID-19?" (n=93)

64.4%, 53

21.1%, 52

10.0%, 45

6.7%, 24

6.7%, 5

0 10 20 30 40 50 60

We test asymptomatic pediatric patients who are scheduled for asurgery

We test asymptomatic pediatric patients who are scheduled forbronchoscopy

We test asymptomatic pediatric patients who are scheduled forendoscopy

We test asymptomatic pediatric patients who are scheduled forsedation for diagnostic imaging

Other

Q14: "How is your site testing asymptomatic pediatric patients who are scheduled for a procedure for COVID-19?" (n=59)

Branch: Q14 was presented only to participants who responded “Yes” in Q13.

“Other” Responses: “Anybody with symptoms or procedures that may potentially lead to aerosolization”; “practice is not uniform”; “We are not having any scheduled

procedures/surgeries”; “we are testing all patients”; “We have planned. SOP yet to be approved”.

8 Responses to all questions are voluntary and may result in differing sample sizes.

Question 15

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

Chloroquine or Hydroxychloroquine

Remdesivir

Tocilizumab

Anakinra

Lopinavir/Ritonavir

Convalescent patient plasma

IVIG

Azithromycin

Intravenous steroids

Anticoagulation, prophylaxis

Anticoagulation, treatment

Other

Chloroquineor

Hydroxychloroquine

Remdesivir Tocilizumab AnakinraLopinavir/Rit

onavir

Convalescent patientplasma

IVIG AzithromycinIntravenous

steroids

Anticoagulation,

prophylaxis

Anticoagulation,

treatmentOther

First line treatment 44 40 26 20 12 11 4 3 2 2 1 1

Second line treatment 20 11 20 16 20 8 19 19 6 7 6 2

Third line treatment 3 5 11 4 11 9 19 10 18 6 10 0

Fourth line treatment 1 2 0 2 6 1 10 5 12 10 1 2

Other 3 6 4 4 5 3 5 12 9 5 4 12

Not using this treatment 22 28 30 46 38 57 34 41 44 61 68 71

Q15: "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=93)

“Other” Responses: Other medications and other uses for medications are provided on Pages 9-14.

9 Responses to all questions are voluntary and may result in differing sample sizes.

Questions 16, Chloroquine or Hydroxychloroquine & Remdesivir

38.6%, 27

31.4%, 22

28.6%, 20

22.9%, 16

17.1%, 12

11.4%, 8

10.0%, 7

0 5 10 15 20 25 30

In patient with severe ARDS

In patients with moderate ARDS

In all patients admitted to the PICU

In patients with mild ARDS

Only in the context of research or clinical trial enrollment

In all patients admitted to the hospital

Other

Q16, Option 1: "At your site, which of the following are indications to start 'Chloroquine or Hydroxychloroquine' in children with symptomatic COVID-19 even if in consultation with another medical service?" (n=70)

Branch: Q16:1 was presented only to participants who indicated the use of Chloroquine or Hydroxychloroquine in Q15.

“Other” Indications: “case by case discussion with pediatric infectious diseases”; “No formal decision plan”; “Patients admitted

to PICU, but must have approval from ID”; “patients mechanically ventilated who can't get remdesevir”; “plan to consider in the

above context”; “recommendation from ID, which means that we are not using”; “with ID consultation; anticipate starting until

Remdesivir arrives”.

“Other” Uses: “none”; ”plan to consider in the above context”; “you mean for Paludisme treatment for example ?”.

39.3%, 27

36.1%, 22

31.1%, 20

16.4%, 16

11.5%, 12

6.6%, 8

3.3%, 7

0 5 10 15 20 25 30

In patient with severe ARDS

In patients with moderate ARDS

In all patients admitted to the PICU

In patients with mild ARDS

Only in the context of research or clinical trial enrollment

In all patients admitted to the hospital

Other

Q16, Option 2: "At your site, which of the following are indications to start 'Remdesivir' in children with symptomatic COVID-19 even if in consultation with another medical service?" (n=61)

Branch: Q16:2 was presented only to participants who indicated the use of Remdesivir in Q15.

“Other” Indications: “case by case discussion with pediatric infectious diseases”; “discussion with infectologyst”; “intubated with

COVID-19”; “No formal decision plan”; “Not using Remdesevir”; “severe ARDS without response to first line treatments

with ID consultation”.

“Other” Uses: “in trial”; “NA”; “none”; “RCT only”.

10 Responses to all questions are voluntary and may result in differing sample sizes.

Question 16, Tocilizumab & Anakinra

57.1%, 32

41.1%, 23

23.2%, 13

10.7%, 6

10.7%, 6

3.6%, 2

1.8%, 1

0 5 10 15 20 25 30 35

In patients with clinical and laboratory evidence of cytokine storm

In patient with severe ARDS

In patients with moderate ARDS

Only in the context of research or clinical trial enrollment

Other

In all patients admitted to the PICU

In patients with mild ARDS

Q16, Option 3: "At your site, which of the following are indications to start 'Tocilizumab' in children with symptomatic COVID-19 even if in consultation with another medical service?" (n=56)

Branch: Q16:3 was presented only to participants who indicated the use of Tocilizumab in Q15.

“Other” Indications: “56”; “At discretion of primary team.”; “its use has not been considered”; “moderare/severe ARDS or shock

& highly inflammatory blood test data.”; “No formal decision plan”; “Reserved for adults”; “with ID and heme consultation”.

“Other” Uses: “Case by case discussion with multidisciplinary team”; “NA”; “none”; “only elevated IL-6>150”; “plan to consider

in the above context”.

45.5%, 10

27.3%, 6

22.7%, 5

18.2%, 4

18.2%, 4

13.6%, 3

0 2 4 6 8 10 12

In patients with clinical and laboratory evidence of cytokine storm

Other

In patient with severe ARDS

In all patients admitted to the PICU

Only in the context of research or clinical trial enrollment

In patients with moderate ARDS

Q16, Option 4: "At your site, which of the following are indications to start 'Anakinra' in children with symptomatic COVID-19 even if in consultation with another medical service?" (n=22)

Branch: Q16:4 was presented only to participants who indicated the use of Anakinra in Q15.

“Other” Indications: “At discretion of primary team.”; “Availability”; “if Tocilizumab fails”; “NA”; “No formal decision plan”;

“severe ARDS & highly inflammatory blood test data without response to tocilizumab .”.

“Other” Uses: “if Tocilizumab fails”; “NA”; “No formal decision plan”; “none”.

11 Responses to all questions are voluntary and may result in differing sample sizes.

Question 16, Lopinavir/Ritonavir & Convalescent Patient Plasma

46.8%, 22

40.4%, 19

21.3%, 10

19.1%, 9

17.0%, 8

2.1%, 1

2.1%, 1

0 5 10 15 20 25

In patient with severe ARDS

Only in the context of research or clinical trial enrollment

In patients with clinical and laboratory evidence of cytokine storm

Other

In patients with moderate ARDS

In all patients admitted to the PICU

In patients with mild ARDS

Q16, Option 6: "At your site, which of the following are indications to start 'Convalescent patient plasma' in children with symptomatic COVID-19 even if in consultation with another medical service?" (n=47)

Branch: Q16:5 was presented only to participants who indicated the use of Lopinavir/Ritonavir in Q15.

“Other” Indications: “shock”; “patient's unable to get hydroxychlorquinone due to prolonged QTC etc”; “No formal decision

plan”.

“Other” Uses: “NA”; “No formal decision plan”; “none”.

45.2%, 14

35.5%, 11

25.8%, 8

22.6%, 7

12.9%, 4

9.7%, 3

3.2%, 1

0 2 4 6 8 10 12 14 16

In patient with severe ARDS

In patients with moderate ARDS

In all patients admitted to the PICU

In patients with mild ARDS

Only in the context of research or clinical trial enrollment

Other

In all patients admitted to the hospital

Q16, Option 5: "At your site, which of the following are indications to start 'Lopinavir/Ritonavir' in children with symptomatic COVID-19 even if in consultation with another medical service?" (n=31)

Branch: Q16:6 was presented only to participants who indicated the use of Lopinavir/Ritonavir in Q15.

“Other” Indications: “case by case discussion b/w PICU and ID”; “case by case discussion with pediatric infectious disease team”;

“Early phase of the disease when is technicaly possible”; “guideline for use in development”; “NA”; “Need to discuss with ID

team”; “No formal decision plan”; “not avalillable yet”; “with ID and heme consultation”.

“Other” Uses: “as above”; “case by case discussion with pediatric infectious disease te”; “in trial” ; “NA”; “No formal decision”;

“plan”; “none”; “none”; “Plan to give if part of national protocol then”.

12 Responses to all questions are voluntary and may result in differing sample sizes.

Question 16, IVIG & Azithromycin

50.0%, 15

40.0%, 12

36.7%, 11

30.0%, 9

26.7%, 8

20.0%, 6

13.3%, 4

10.0%, 3

10.0%, 3

3.3%, 1

0 2 4 6 8 10 12 14 16

In patients with pre-existing immune deficiency

In patient with severe ARDS

In patients with myocardial dysfunction due to COVID-19

In patients with clinical and laboratory evidence of cytokine storm

In patients with moderate ARDS

Other

In patients with mild ARDS

In all patients admitted to the PICU

Only in the context of research or clinical trial enrollment

In all patients admitted to the hospital

Q16, Option 7: "At your site, which of the following are indications to start 'IVIG' in children with symptomatic COVID-19 even if in consultation with another medical service?" (n=30)

Branch: Q16:7 was presented only to participants who indicated the use of IVIG in Q15.

“Other” Indications: “After discussion with ID team,”; “based on individual case discussion”; “Case by case analysis”;

“encephalitis”; “NA”; “No formal decision plan”.

“Other” Uses: “encephalitis”; “hematological disease etc.”; “NA”; “No formal decision plan”; “none”.

37.0%, 17

32.6%, 15

30.4%, 14

28.3%, 13

8.7%, 4

8.7%, 4

6.5%, 3

0 2 4 6 8 10 12 14 16 18

In patient with severe ARDS

In patients with moderate ARDS

In patients with mild ARDS

In all patients admitted to the PICU

Only in the context of research or clinical trial enrollment

Other

In all patients admitted to the hospital

Q16, Option 8: "At your site, which of the following are indications to start 'Azithromycin' in children with symptomatic COVID-19 even if in consultation with another medical service?" (n=46)

Branch: Q16:8 was presented only to participants who indicated the use of Azithromycin in Q15.

“Other” Indications: “If concern for atypical PNa”; “NA”; “No formal decision plan”; “upon evidence or suspicion of co-infection”.

“Other” Uses: “If concern for atypical PNA”; “Mucyoplamsa and other bacteriological infections”; “NA”; “Plan to consider in the

above context”.

13 Responses to all questions are voluntary and may result in differing sample sizes.

Question 16, Intravenous Steroids & Anticoagulation, Prophylaxis

64.8%, 35

64.8%, 35

61.1%, 33

53.7%, 29

35.2%, 19

11.1%, 6

11.1%, 6

7.4%, 4

3.7%, 2

1.9%, 1

0 5 10 15 20 25 30 35 40

In patients with pre-existing adrenal insufficiency

In patients with refractory shock

In patient with severe ARDS

In patients with pre-existing chronic lung disease

In patients with moderate ARDS

In all patients admitted to the PICU

In patients with mild ARDS

Other

Only in the context of research or clinical trial enrollment

In all patients admitted to the hospital

Q16, Option 9: "At your site, which of the following are indications to start 'Intravenous steroids' in children with symptomatic COVID-19 even if in consultation with another medical service?" (n=54)

Branch: Q16:9 was presented only to participants who indicated the use of Intravenous Steroids in Q15.

“Other” Indications: “If concern for atypical PNa”; “NA”; “No formal decision plan”; “upon evidence or suspicion of co-infection”.

“Other” Uses: “If concern for atypical PNA”; “Mucyoplamsa and other bacteriological infections”; “NA”; “Plan to consider in the

above context”.

56.3%, 36

29.7%, 19

28.1%, 18

15.6%, 10

14.1%, 9

9.4%, 6

9.4%, 6

7.8%, 5

4.7%, 3

3.1%, 2

3.1%, 2

0 5 10 15 20 25 30 35 40

In patients based on our usual PICU venous thromboembolism guideline

In all patients admitted to the PICU

In patients with laboratory evidence of pro-thrombotic state

In patients with moderate ARDS

In patient with severe ARDS

In patients with mild ARDS

In patients with diagnosed clot

In all patients with central venous catheters

Other

In all patients admitted to the hospital

Only in the context of research or clinical trial enrollment

Q16, Option 10: "At your site, which of the following are indications to start 'Anticoagulation, prophylaxis' in children with symptomatic COVID-19 even if in consultation with another medical service?" (n=64)

Branch: Q16:10 was presented only to participants who indicated the use of Anticoagulation, prophylaxis in Q15.

“Other” Indications: “case by case basis in consultation with pediatric hematology”; “in older children, teens, and young adults

with COVID-19 or suspected”; “NA”.

“Other” Uses: “as above”; “case by case basis in consultation with pe”; “NA”; “none”; “Per ICU protocol”.

14 Responses to all questions are voluntary and may result in differing sample sizes.

Q16, Option 12: “Please specify other medication or therapy, along with the 'treatment-line' preference.” (n=6)

Treatment Indication

"ANTIBIOTICS: FIRST" Need for inpatient hospitalization, Moderate ARDS

"early prone positioning" Other: "Case by case basis in discussion with pediatric infectious disease team"

"favipiravir" Need for ICU hospitalization

"IL-7"

Need for HFNC, Need for BiPAP or CPAP, Need for ICU hospitalization, Need for

intubation, Mild ARDS, Moderate ARDS, Severe ARDS, Clinical decline after initial therapy,

Clinical trial enrollment

"Prono" Clinical decline after initial therapy

"Ribavirin" Need for ICU hospitalization

Question 16, Anticoagulation, Treatment & Other Medications

65.3%, 32

55.1%, 27

49.0%, 24

14.3%, 7

10.2%, 5

6.1%, 3

6.1%, 3

4.1%, 2

4.1%, 2

2.0%, 1

0 5 10 15 20 25 30 35

In patients with diagnosed clot

In patients based on our usual PICU venous thromboembolism guideline

In patients with laboratory evidence of pro-thrombotic state

In patient with severe ARDS

In patients with moderate ARDS

In all patients admitted to the PICU

Only in the context of research or clinical trial enrollment

In all patients with central venous catheters

Other

In patients with mild ARDS

Q16, Option 11: "At your site, which of the following are indications to start 'Anticoagulation, treatment' in children with symptomatic COVID-19 even if in consultation with another medical service?" (n=49)

Branch: Q16:11 was presented only to participants who indicated the use of Anticoagulation, treatment in Q15.

“Other” Indications: “At discretion of treating team”; “NA”.

“Other” Uses: “As indicated clinically”; “At discretion of treating team.”; “case by case basis in consultation with pe”; “diagnosed

thromboembolismo”; “NA”; “none”; “Per ICU protocol”; “PICU guidelines, if proven venous thromboembolism”; “planned in

above context”; “strong concern for DVT/PE without + labs”.

15 Responses to all questions are voluntary and may result in differing sample sizes.

Experiences to Share Questions 17, 18, 19, & 20

Q17: Have ECMO Q18: Use ECMO

No 28 6

Yes 64 58

0

10

20

30

40

50

60

70

80

90

100

Q17: "Does your site have extracorporeal membrane oxygenation

(ECMO)?" (n=92)Q18: "Does your site plan to offer ECMO

to pediatric patients with COVID-19?" (n=64)

Q19: Have HFOV Q20: Use HFOV

No 3 36

Yes 90 54

0

10

20

30

40

50

60

70

80

90

100

Q19: "Does your site have high frequency oscillatory ventilation

(HFOV)?" (n=93)Q20: "Does your site plan to offer HFOV to pediatric patients with COVID-19?"

(n=90)

Branch: Q18 was presented only to participants who

responded “Yes” in Q17.

Branch: Q20 was presented only to participants who

responded “Yes” in Q19.