Emily Levy, MD1; Jennifer Blumenthal, MD2; Kathleen Chiotos, MD, MSCE3
1Divisions of Pediatric Infectious Diseases and Pediatric Critical Care Medicine, Mayo Clinic, Rochester, MN, 2Divisions of Infectious Disease and Critical Care Medicine, Boston Children’s Hospital, Boston, MA, 3Divisions of Infectious Diseases and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
1. What is the role of nasal swab versus serum testing in a child needing heart surgery?
The best test for SARS-CoV2 in the peri-operative setting is a PCR of respiratory secretions. These samples may be from a nasopharyngeal swab, oropharyngeal swab, or sample from the lower respiratory tract (e.g., tracheal aspirate or BAL), if available at your center. PCR testing sensitivity is dependent on viral SARS-CoV2 concentrations at the site of the sample, thus it may be affected by sampling technique, by progression of the disease, and by the test itself. As the disease progresses, viral load tends to decrease in the upper respiratory tract. Serology serum testing for antibodies (IgG) may be available in some centers. However, positive serology will demonstrate prior exposure (or maternal status for neonates) rather than active illness, so is less useful in a peri-operative setting.
2. What is the optimal preoperative testing? Is there a role for CT chest scan to look at lungs the day before surgery?
There are reports demonstrating chest CT abnormalities in adults during asymptomatic/pre-symptomatic disease; however, the role of chest CT in relation to COVID-19 in children remains undifferentiated at this time. Given lack of evidence, it should be reserved for clinical indication based on symptoms. If preoperative testing is required, PCR-based testing of respiratory secretions is the most widely accepted approach.
Fu L, et al. Clinical characteristics of coronavirus disease 2019 (COVID-19) in China: a systematic review and meta-analysis. J Infect. 2020 Apr 10
3. Should parents of pediatric cardiac patients be screened?
All parents entering the hospital or clinic should be screened for symptoms suggesting SARS-CoV-2 (including cough or fever) as well as for contact with known positive cases. Whether microbiologic test screening is performed routinely depends on a multitude of factors, including local prevalence, whether parents are required to mask in the hospital, and testing availability at that center. Parents of cardiac patients should follow local guidance in accordance with the CDC guidance.
4. What is the best approach for a newborn of COVID positive mother who will need heart surgery in the first 1-2 weeks of life (e.g., arterial switch, Norwood, etc.)?
Consensus guidelines for infants born to mothers with COVID-19 are not yet finalized though are in process. There is minimal evidence of placental vertical transmission, so we suspect most maternal to neonatal transmission occurs at birth or shortly after via droplet contamination. All infants born to COVID positive mothers should be considered persons under investigation (PUI). It may be reasonable to separate the infant from the mother if the infant will need cardiac surgery in order to try and avoid post-natal infection. It may also be reasonable to do serial testing on the infant, some experts recommend at 2, 4, and 6 days of life while others recommend at 24-48 hours of life and then again at 14 days of life. This should be done in conjunction with consultation from local experts.
Schwartz D. An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes. Arch Pathol Lab Med. Mar 2020.
5. What factors determine optimal timing of surgery in patients who have been COVID positive?
There is no evidence to suggest optimal timing of surgery in COVID positive patients. Surgery should be scheduled with advice from a multidisciplinary team of experts including cardiac medical, cardiac surgical, and infectious diseases as indicated. If prudent, surgery should be delayed until a test has been repeated (typically after 14 days) and is negative.
6. Can an asymptomatic COVID +child transmit the virus?
Yes, asymptomatic patients may shed virus and may transmit virus.
7. Which CHD population should we worry about most? Which pediatric patients are at highest risk?
Teenagers are the most likely to develop symptomatic or severe disease, particularly those who are obese, have type 2 diabetes, or hypertension. Thus, the post-repair cardiac population may be at risk of severe disease. Children have had mild disease in general, though we do not yet have data about infants with congenital heart disease. There are some case series to suggest more significant disease in infants <1 year of life compared with other younger children, again data is sparse.
Cruz AT, et al. COVID-19 in Children: Initial Characterization of the Pediatric Disease. Pediatrics. 2020 Mar 16.
8. Is there a role for antiviral therapy?
In some critically ill children there may be a role for specific antiviral therapy. Remdesivir is an antiviral being studied in adults in several RCTs and may be used in children through single patient expanded access requests. There may also be a role for convalescent serum (plasma from patients who have had COVID-19 and now have antibodies) during pediatric critical illness. Additionally, Hydroxychloroquine can be considered in some situations, though extreme care should be considered in patients at increased risk of prolonged QTc. The use of corticosteroids is not recommended as it may prolong viral replication.
https://www.nature.com/articles/d41573-020-00016-0 Wang et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Research 2020.
9. Is there a role for therapeutic plasma exchange?
Plasma exchange is unlikely to be useful as the major reservoirs for this virus are respiratory tract and GI tract. However, as above, convalescent serum (infusion of plasma from patients with prior infection) may have a role.
10. What are potential strategies to mitigate the reported IL-6 cytokine storm?
Tocilizumab is an anti-IL6 therapy which is used in cytokine storms associated with certain oncologic therapies (for instance, CAR-T therapy). It may also be used in children with COVID-19 and is specifically being considered for those with very high levels of IL-6. It may potentiate a multitude of side effects including sepsis-like events, so should be used in conjunction with Pediatric ICU and Pediatric ID physicians.
Luo P, Liu Y, Qiu L, Liu X, Liu D, Li J. Tocilizumab treatment in COVID-19: a single center experience. J Med Virol. 2020 Apr 6.