Multisystem Inflammatory Syndrome in Children, or MIS-C, is a delayed complication of COVID-19 in children with features similar to toxic shock syndrome and Kawasaki disease. Children may present with fever, abdominal pain, diarrhea, rash, and conjuncitivitis, and may experience hypotension, shock, and respiratory distress. At Joe DiMaggio Children’s Hospital in Florida we have treated roughly 30 MIS-C patients since August. Our team therefore had to quickly develop inclusion criteria (Fig 1) and establish interventions (Fig 2) to rapidly identify and safely treat these patients. Identification involves both labs to confirm COVID-19 infection (PCRs), though patients with negative PCRs may still present with MIS-C symptoms that require critical care.1 Here we present a pediatric case of MIS-C demonstrating our approach in addressing the specific resuscitation needs of these patients.
A 15-year old female patient was brought to our ER with fever and reported episodes of syncope. Upon examination the patient had bilateral conjunctivitis, shortness of breath, truncal and bilateral lower extremity macular rash, shallow tachypnea and fever. The patient’s mom is an essential worker and previously tested positive for COVID-19. Our patient had a positive antibody (IgG) test with a negative PCR test, but her symptoms strongly aligned with a MIS-C diagnosis.
The patient was hypotensive with elevated heart rate (BP 81/30, HR 166). She had slurred speech and was difficult to arouse. As part of our established MIS-C algorithm (Fig 2), we provided initial NS fluid boluses at 20ml/kg using LifeFlow, each over 4 minutes, delivering a total of 1L. Careful assessment of lung sounds and heart tones were performed after each bolus. After the 3rd bolus the patient’s BP had risen to112/72. Once stable we started Vasopressin of 0.0005 mcg/kg/min and were able to move her to the PICU. We were pleased that this patient fully recovered and was discharged home on day 6 with aspirin therapy.
LifeFlow is well suited for this patient population requiring rapid fluids to reverse dangerous hypotension with the careful balance of managing total fluid volume. In providing quick, small boluses we were able to determine responsiveness throughout the course of treatment and make decisions that were specific to this patient. By adding LifeFlow to our treatment algorithm we can ensure that our entire ED staff recognizes the role this tool can play in MIS-C patient resuscitation.
- Son MF, et al. Coronavirus disease 2019 (COVID-19)-related multisystem inflammatory syndrome in children (MIS-C): Clinical features, evaluation, and diagnosis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. Last updated 25 Sep 2020.