Multisystem Inflammatory Syndrome (MIS-C) Clinical Pathway — Emergency, ICU and Inpatient

Monitoring Response Clinical, Laboratory and Imaging Response for ICU Patients with Suspected MIS-C with or without Shock

Monitor Clinical Response

Resolution of fever, other clinical features and improving markers of inflammation
Lack of clinical response: Further immunomodulator recommendations per Rheumatology and DIRT on a case-by-case basis, consider alternative diagnosis

Lab Testing

The following are recommended at least daily for monitoring of hyperinflammation while patients have evidence of shock and/or fever and/or persistence of symptoms (e.g., rash, conjunctivitis, diarrhea, etc).

Daily labs can be discontinued when clinical symptoms have substantially improved and laboratory markers are improving (but do not have to be normal) – these decisions should be individualized and considered with the primary team and multidisciplinary consultants (e.g., ID, rheumatology).

Labs
Lab test	Initial schedule – should be reassessed daily and de-escalated as clinically indicated
CBC with differential	Daily, attention to platelets, lymphocyte count, neutrophil count
CMP	Daily, attention to renal function, transaminases, albumin
CRP	Daily
Procalcitonin	Daily
ESR	PRN
Triglycerides	Daily if abnormal and concern for MAS
Ferritin	Daily
PT/PTT/INR	Daily if abnormal
D-dimer	Daily if abnormal
Fibrinogen	Dailyif abnormal
LDH	PRN, consider daily if initial is abnormal
Troponin	Daily until down trending
Brain type natriuretic peptide	1-2 times per week or with clinical changes
Super gas with lactate	Schedule TBD, most useful for children in shock or with concern for shock

Follow-up Echocardiogram

Schedule depending on severity of initial dysfunction, presence of coronary artery dilation, and clinical course, TBD in discussion with cardiology.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.