Evaluation of renal near-infrared spectroscopy for predicting extubation outcomes in the pediatric intensive care setting

Background

In pediatric intensive care units, extubation failure following invasive mechanical ventilation poses significant health risks. Determining readiness for extubation in children can minimize associated morbidity and mortality. This study investigates the potential role of renal near-infrared spectroscopy (RrSO2) in predicting extubation failure in pediatric patients.

Methods

A total of 84 patients aged between 1 month and 18 years, mechanically ventilated for at least 24 h, were included in this prospective study. RrSO2 levels were measured using near-infrared spectroscopy before and during an extubation readiness test (ERT). The primary outcome measure was extubation failure, defined as a need for reintubation within 48 h.

Results

Of the 84 patients, 71 (84.6%) were successfully extubated, while 13 (15.4%) failed extubation. RrSO2 was found to be lower in the failed extubation group, also decrease in RrSO2 values during ERT was significantly greater in patients with extubation failure. ROC analysis indicated a decrease in ΔRrSO2 of more than 6.15% from baseline as a significant predictor of extubation failure, with a sensitivity of 0.984 and a specificity of 0.889.

Conclusion

Monitoring changes in RrSO2 values may serve as a helpful tool to predict extubation failure in pediatric patients. Further multi-center research is warranted to improve the generalizability and reliability of these findings.

Evaluation of 601 children with multisystem inflammatory syndrome (Turk MISC study)

PURPOSE

Due to its link with the 2019 coronavirus, the multisystem inflammatory syndrome in children (MISC) has garnered considerable international interest. The aim of this study, in which MISC patients were evaluated multicenter, and the data of the third period of the Turk-MISC study group, to compare the clinical and laboratory characteristics and outcomes of MISC patients who did and did not require admission to an intensive care unit (ICU).

METHODS

This retrospective multicenter observational study was carried out between June 11, 2021, and January 01, 2022. The demographics, complaints, laboratory results, system involvements, and outcomes of the patients were documented.

RESULTS

A total of 601 patients were enrolled; 157 patients (26.1%) required hospitalization in the intensive care unit (ICU). Median age was 8 years (interquartile range (IQR) 4.5-11.3 years. The proportion of Kawasaki disease-like features in the ICU group was significantly higher than in the non-ICU group (56.1% vs. 43.2% p = 0.006). The ICU group had considerably lower counts of both lymphocytes and platelets (lymphocyte count 900 vs. 1280 cells × μL, platelet count 153 vs. 212 cells × 103/ μL, all for p< 0.001). C-reactive protein, procalcitonin, and ferritin levels were significantly higher in the ICU group (CRP 164 vs. 129 mg/L, procalcitonin 9.2 vs. 2.2 μg/L, ferritin 644 vs. 334 μg/L, all for p< 0.001). Being between ages 5-12 and older than 12 increased the likelihood of hospitalization in the ICU by four [95% confidence intervals (CI)1.971-8.627] and six times (95% CI 2.575-14.654), respectively, compared to being between the ages 0-5. A one-unit increase in log D-dimer (µg/L) and log troponin (ng/L) was also demonstrated to increase the need for intensive care by 1.8 (95% CI 1.079-3.233) and 1.4 times (95% CI 1.133-1.789), respectively.     Conclusion: By comparing this study to our other studies, we found that the median age of MISC patients has been rising. Patients requiring an ICU stay had considerably higher levels of procalcitonin, CRP, and ferritin but significantly lower levels of lymphocyte and thrombocyte. In particular, high levels of procalcitonin in the serum might serve as a valuable laboratory marker for anticipating the need for intensive care.

WHAT IS KNOWN

• Lymphopenia and thrombocytopenia were an independent predictor factors in patients with MISC who needed to stay in intensive care unit. • The possibility of the need to stay in the intensive care unit in patients with MISC who had Kawasaki disease-like findings was controversial compared with those who did not.

WHAT IS NEW

• A one-unit increase log D dimer and log troponin was demonstrated to require for intensive care unit by 1.8 and 1.4 times, respectively. • Serum procalcitonin levels had the best performance to predict stay in the intensive care unit stay.

The effect of myocardial dysfunction on mortality in children with septic shock: a prospective observational study

Pediatric septic shock is defined as progressive multi-organ dysfunction and cardiovascular dysfunction accompanying sepsis. Studies showing myocardial dysfunction associated with pediatric septic shock are very limited. The aim of this study was to evaluate the relationship between myocardial functions calculated by echocardiography, disease severity, and clinical outcomes in children with septic shock. This observational prospective study was conducted in a pediatric intensive care at a university-affiliated tertiary hospital. The patients diagnosed with septic shock between January 2021 and February 2022 were included in the study. The study was conducted with 56 patients. The rate of myocardial dysfunction (systolic and/or diastolic dysfunction) was 50%. Of these, 39.3% (n = 22) had systolic dysfunction, 17.9% (n = 10) had diastolic dysfunction, and 8.9% (n = 5) had both systolic and diastolic dysfunction. PRISM III score (p = 0.004), VIS (p < 0.001), lactate (p = 0.002), CK-MB (p = 0.023), troponin (p = 0.038), EF (p = 0.004) EF z-score (p = 0.003), MAPSE z-score (p = 0.049), TAPSE (p = 0.010), TAPSE z-score (p = 0.003), and mitral valve E/e ´z-score (p = 0.028) were statistically significant difference with mortality. No significant difference was found for mortality with MAPSE (p = 0.090), mitral valve E/A (p = 0.624), and mitral valve E/A z-score (p = 0.327). EF z-score was found to be associated with 30-day mortality (OR = 0,681, 95% CI 0,480 to 0.991, p = 0,045). We found the TAPSE z-score to be the most significant parameter with 30-day mortality (OR = 0,690, 95% CI 0,489 to 0.998, p = 0,032).  Conclusion: We found left ventricular dysfunction associated factor with mortality. TAPSE showing right ventricular dysfunction was found to be the independent risk factor most associated with mortality. What is Known: • Studies showing myocardial dysfunction associated with pediatric septic shock are limited. • Little is known about the use of echocardiography in pediatric septic shock, and there are no specific guidelines for treatment and follow-up in pediatric patients. What is New: • Characteristics, echocardiographic measurements, and outcomes were comprehensively assessed in children with septic shock. • As a result of our analysis, we found that TAPSE, which is easily measured at the bedside, is the most critical parameter in relation to mortality. • We offer recommendations for its use in the follow-up of children with septic shock.

Evaluation of nutritional status in pediatric intensive care unit patients: the results of a multicenter, prospective study in Turkey

Introduction

Malnutrition is defined as a pathological condition arising from deficient or imbalanced intake of nutritional elements. Factors such as increasing metabolic demands during the disease course in the hospitalized patients and inadequate calorie intake increase the risk of malnutrition. The aim of the present study is to evaluate nutritional status of patients admitted to pediatric intensive care units (PICU) in Turkey, examine the effect of nutrition on the treatment process and draw attention to the need for regulating nutritional support of patients while continuing existing therapies.

Material and Method

In this prospective multicenter study, the data was collected over a period of one month from PICUs participating in the PICU Nutrition Study Group in Turkey. Anthropometric data of the patients, calorie intake, 90-day mortality, need for mechanical ventilation, length of hospital stay and length of stay in intensive care unit were recorded and the relationship between these parameters was examined.

Results

Of the 614 patients included in the study, malnutrition was detected in 45.4% of the patients. Enteral feeding was initiated in 40.6% (n = 249) of the patients at day one upon admission to the intensive care unit. In the first 48 h, 86.82% (n = 533) of the patients achieved the target calorie intake, and 81.65% (n = 307) of the 376 patients remaining in the intensive care unit achieved the target calorie intake at the end of one week. The risk of mortality decreased with increasing upper mid-arm circumference and triceps skin fold thickness Z-score (OR = 0.871/0.894; p = 0.027/0.024). The risk of mortality was 2.723 times higher in patients who did not achieve the target calorie intake at first 48 h (p = 0.006) and the risk was 3.829 times higher in patients who did not achieve the target calorie intake at the end of one week (p = 0.001). The risk of mortality decreased with increasing triceps skin fold thickness Z-score (OR = 0.894; p = 0.024).

Conclusion

Timely and appropriate nutritional support in critically ill patients favorably affects the clinical course. The results of the present study suggest that mortality rate is higher in patients who fail to achieve the target calorie intake at first 48 h and day seven of admission to the intensive care unit. The risk of mortality decreases with increasing triceps skin fold thickness Z-score.

Acute Respiratory Infection Incidence and Outpatient Antibiotic Prescription Patterns in People With or Without Human Immunodeficiency Virus Infection: A Virtual Cohort Study

Background

Inappropriate antibiotic use in acute respiratory infections (ARIs) is a major public health concern; however, data for people with human immunodeficiency virus (PWH) are limited.

Methods

The HIV Virtual Cohort Study is a retrospective cohort of adult Department of Defense beneficiaries. Male PWH cases (n = 2413) were matched 1:2 to controls without HIV (n = 4826) by age, gender, race/ethnicity, and beneficiary status. Acute respiratory infection encounters between 2016 and 2020 and corresponding antibiotic prescriptions were characterized as always, sometimes, or never appropriate based on International Classification of Diseases, Tenth Revision coding. Incidence of ARI encounters and antibiotic appropriateness were compared between PWH and controls. Subgroup analyses were assessed by CD4 count and viral load suppression on antiretroviral therapy.

Results

Mean rates of ARI encounters were similar for PWH (1066 per 1000 person-years) and controls (1010 per 1000 person-years); however, the rate was double among PWH without viral load (VL) suppression (2018 per 1000 person-years). Antibiotics were prescribed in 26% of encounters among PWH compared to 34% for controls (P ≤ .01); antibiotic use was "never" appropriate in 38% of encounters with PWH and 36% in controls. Compared to controls, PWH received more sulfonamides (5.5% vs 2.7%; P = .001), and variation existed among HIV subgroups in the prescription of sulfonamides, fluoroquinolones, and β-lactams.

Discussion

Acute respiratory infection encounters were similar for PWH and those without HIV; however, PWH with lower CD4 counts and/or nonsuppressed VL had more frequent ARI visits. Inappropriate antibiotic use for ARIs was high in both populations, and focused interventions to improve antibiotic appropriateness for prescribers caring for PWH should be pursued.

A snapshot of pediatric inpatients and outpatients with COVID-19: a point prevalence study from Turkey

This multi-center point prevalence study evaluated children who were diagnosed as having coronavirus disease 2019 (COVID-19). On February 2nd, 2022, inpatients and outpatients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were included in the study from 12 cities and 24 centers in Turkey. Of 8605 patients on February 2nd, 2022, in participating centers, 706 (8.2%) had COVID-19. The median age of the 706 patients was 92.50 months, 53.4% were female, and 76.7% were inpatients. The three most common symptoms of the patients with COVID-19 were fever (56.6%), cough (41.3%), and fatigue (27.5%). The three most common underlying chronic diseases (UCDs) were asthma (3.4%), neurologic disorders (3.3%), and obesity (2.6%). The SARS-CoV-2-related pneumoniae rate was 10.7%. The COVID-19 vaccination rate was 12.5% in all patients. Among patients aged over 12 years with access to the vaccine given by the Republic of Turkey Ministry of Health, the vaccination rate was 38.7%. Patients with UCDs presented with dyspnea and pneumoniae more frequently than those without UCDs (p < 0.001 for both). The rates of fever, diarrhea, and pneumoniae were higher in patients without COVID-19 vaccinations (p = 0.001, p = 0.012, and p = 0.027).  Conclusion: To lessen the effects of the disease, all eligible children should receive the COVID-19 vaccine. The illness may specifically endanger children with UCDs. What is Known: • Children with COVID-19 mainly present with fever and cough, as in adults. • COVID-19 may specifically threaten children with underlying chronic diseases. What is New: • Children with obesity have a higher vaccination rate against COVID-19 than children without obesity. • Among unvaccinated children, fever and pneumoniae might be seen at a higher ratio than among vaccinated children.

Clinical Features and Management of Status Epilepticus in the Pediatric Intensive Care Unit

OBJECTIVES

Status epilepticus (SE) is associated with significant morbidity and mortality in children. SE in the pediatric intensive care unit (PICU) are not well characterized. The aim of this study is to retrospectively investigate the clinical features and treatment of seizures in children admitted to the PICU of our hospital.

METHODS

We retrospectively examined the clinical characteristics of patients aged between 1 month and 18 years who were admitted to our hospital with SE or who were diagnosed with SE after hospitalization and were followed up with continuous electroencephalographic monitoring between January 2015 and December 2019.

RESULTS

A total of 88 patients with SE, 50 (56.8%) boys and 38 (43.2%) girls, were included. The median age was 24 months (interquartile range, 12-80 months). When we evaluate the continuous electroencephalographic monitoring data, 27 (30.7%) were lateralized, 20 (22.7%) were multifocal, 30 (34.1%) were generalized, and 11 (12.5%) were bilateral independent epileptic activity. Seventy nine patients (89.8%) were evaluated as convulsive status epilepticus (CSE) and 9 (10.2%) as nonconvulsive status epilepticus (NCSE). Pediatric Risk of Mortality (PRISM III) score and mortality of patients with NCSE were higher ( P = 0.004 and P = 0.046, respectively). Thirteen eight patients (43.1%) were diagnosed as SE, 38 patients (43.1%) as refractory SE, and 12 patients (13.6%) as super-refractory SE. The overall mortality rate was 10.2%.

CONCLUSIONS

Status epilepticus is a neurological emergency that causes mortality and morbidity. Electroencephalographic monitoring is important for the recognition of seizures and rapid intervention. No superiority of second-line treatments or combined treatments was demonstrated in patients with SE.

Mortality risk factors among critically ill children with MIS-C in PICUs: a multicenter study

BACKGROUND

This study evaluated of clinical characteristics, outcomes, and mortality risk factors of a severe multisystem inflammatory syndrome in children admitted to a the pediatric intensive care unit.

METHODS

A retrospective multicenter cohort study was conducted between March 2020 and April 2021 at 41 PICUs in Turkey. The study population comprised 322 children diagnosed with multisystem inflammatory syndrome.

RESULTS

The organ systems most commonly involved were the cardiovascular and hematological systems. Intravenous immunoglobulin was used in 294 (91.3%) patients and corticosteroids in 266 (82.6%). Seventy-five (23.3%) children received therapeutic plasma exchange treatment. Patients with a longer duration of the PICU stay had more frequent respiratory, hematological, or renal involvement, and also had higher D-dimer, CK-MB, and procalcitonin levels. A total of 16 patients died, with mortality higher in patients with renal, respiratory, or neurological involvement, with severe cardiac impairment or shock. The non-surviving group also had higher leukocyte counts, lactate and ferritin levels, and a need for mechanical ventilation.

CONCLUSIONS

In cases of MIS-C, high levels of D-dimer and CK-MB are associated with a longer duration of PICU stay. Non-survival correlates with elevated leukocyte counts and lactate and ferritin levels. We were unable to show any positive effect of therapeutic plasma exchange therapy on mortality.

IMPACT

MIS-C is a life-threatening condition. Patients need to be followed up in the intensive care unit. Early detection of factors associated with mortality can improve outcomes. Determining the factors associated with mortality and length of stay will help clinicians in patient management. High D-dimer and CK-MB levels were associated with longer PICU stay, and higher leukocyte counts, ferritin and lactate levels, and mechanical ventilation were associated with mortality in MIS-C patients. We were unable to show any positive effect of therapeutic plasma exchange therapy on mortality.

Pediatric Status Epilepticus Severity Score (STEPSS): Predictive Performance of Functional Outcomes: A Prospective Single-Center Study

Objective: To prospectively investigate the predictive value of the modified Status Epilepticus Severity Score (STESS) for pediatric use (STEPSS) regarding unfavorable outcomes in the short term. Methods: Patients diagnosed as status epilepticus in the emergency department between January 2019 and June 2021 at a tertiary center of the University of Health Sciences, Dr. Behcet Uz Children's Hospital, were included in the study. The patients were followed up in the emergency department, neurology clinic, and pediatric intensive care unit until discharge. Demographic and clinical characteristics, STEPSS, and Pediatric Overall Performance Category Scale (POPC) scores were calculated. We defined a Pediatric Overall Performance Category Scale score ≥3 as an unfavorable outcome. We compared the effect of STEPSS on unfavorable outcomes and mortality. Results: 124 children were included. The median age was 33 months (interquartile range 16.2-84.7). Seventy-two (58.1%) patients had acute symptomatic etiology. We found that the STEPSS score with the receiver operating characteristic curve (area under the curve  = 0.917, P < .001) could predict unfavorable outcomes (Pediatric Overall Performance Category Scale score ≥3) in children with status epilepticus. The Youden index (0.76) showed that a STEPSS score >2 was the optimal cutoff point for an unfavorable outcome. We found STEPSS useful in predicting mortality (area under the curve  = 0.853, P < .001). The Youden index (0.58) indicated that a STEPSS >2 was the optimal cutoff for mortality: sensitivity 0.90 (95% confidence interval [CI] 0.58-0.99), specificity 0.67 (95% CI 0.57-0.77), positive predictive value 0.21, negative predictive value 0.98, positive likelihood ratio 2.7, negative likelihood ratio 0.14. Conclusion: We determined that STEPSS can be predicted unfavorable outcomes and mortality. We think that STEPSS can be used as a useful clinical score with further studies and external validations.

Could lactate clearance be a marker of mortality in pediatric intensive care unit?

BACKGROUND

Hyperlactatemia is a common finding in critically ill patients and has significant prognostic implications. However, a single lactate measurement has not been correlated to mortality consistently. In this study, we aimed to correlate the clinical efficacy of lactate clearance for the prediction of mortality in pediatric intensive care unit patients.

METHODS

This retrospective observational study was performed in the pediatric intensive care unit in patients with lactate level >3 mmol/lt. Initial, 6th h, and 24th h lactate levels were recorded and lactate clearance was calculated using these values (lactate level at admission - level 6 h later × 100/lactate level at admission).

RESULTS

A total of 172 patients were included in the study. Forty-four out of 172 patients died. Median (IQR) lactate (mmol/L) at admission was low in those who survived in comparison to nonsurvivors 4.4 (3.1) vs. 5.75 (7.7) (p = 0.002). Clearance at 6th h was significantly lower in those who died (11.7%) than those who survived (36.7) (p = 0.001). 6th h lactate clearance level <20.7% predicted mortality with a sensitivity of 63.6% and specificity of 69.5% along with a positive predictive value of 41.8 and a negative predictive value of 84.8 (p = 0.004). Both lactate levels and lactate clearance values were significantly predictive factors for mortality (p < 0.05). Only a positive moderate correlation was found between the percentage of PRISM-IV % and 6th h lactate level.

DISCUSSION

The present study revealed that lactate clearance is a simple and rapid risk-stratification tool holding to be a potential biomarker of managing the treatment efficacy of children in the pediatric intensive care unit.

Closed–loop oxygen control improves oxygenation in pediatric patients under high–flow nasal oxygen—A randomized crossover study

Background

We assessed the effect of a closed–loop oxygen control system in pediatric patients receiving high–flow nasal oxygen therapy (HFNO).

Methods

A multicentre, single–blinded, randomized, and cross–over study. Patients aged between 1 month and 18 years of age receiving HFNO for acute hypoxemic respiratory failure (AHRF) were randomly assigned to start with a 2–h period of closed–loop oxygen control or a 2–h period of manual oxygen titrations, after which the patient switched to the alternative therapy. The endpoints were the percentage of time spent in predefined SpO2 ranges (primary), FiO2, SpO2/FiO2, and the number of manual adjustments.

Findings

We included 23 patients, aged a median of 18 (3–26) months. Patients spent more time in a predefined optimal SpO2 range when the closed–loop oxygen controller was activated compared to manual oxygen titrations [91⋅3% (IQR 78⋅4–95⋅1%) vs. 63⋅0% (IQR 44⋅4–70⋅7%)], mean difference [28⋅2% (95%–CI 20⋅6–37⋅8%); P &lt; 0.001]. Median FiO2 was lower [33⋅3% (IQR 26⋅6–44⋅6%) vs. 42⋅6% (IQR 33⋅6–49⋅9%); P = 0.07], but median SpO2/FiO2 was higher [289 (IQR 207–348) vs. 194 (IQR 98–317); P = 0.023] with closed–loop oxygen control. The median number of manual adjustments was lower with closed–loop oxygen control [0⋅0 (IQR 0⋅0–0⋅0) vs. 0⋅5 (IQR 0⋅0–1⋅0); P &lt; 0.001].

Conclusion

Closed-loop oxygen control improves oxygenation therapy in pediatric patients receiving HFNO for AHRF and potentially leads to more efficient oxygen use. It reduces the number of manual adjustments, which may translate into decreased workloads of healthcare providers.

Clinical trial registration

[www.ClinicalTrials.gov], identifier [NCT 05032365].

Automated closed–loop FiO2 titration increases the percentage of time spent in optimal zones of oxygen saturation in pediatric patients–A randomized crossover clinical trial

Introduction

We aimed to compare automated ventilation with closed–loop control of the fraction of inspired oxygen (FiO₂) to automated ventilation with manual titrations of the FiO₂ with respect to time spent in predefined pulse oximetry (SpO₂) zones in pediatric critically ill patients.

Methods

This was a randomized crossover clinical trial comparing Adaptive Support Ventilation (ASV) 1.1 with use of a closed–loop FiO₂ system vs. ASV 1.1 with manual FiO₂ titrations. The primary endpoint was the percentage of time spent in optimal SpO₂ zones. Secondary endpoints included the percentage of time spent in acceptable, suboptimal and unacceptable SpO₂ zones, and the total number of FiO₂ changes per patient.

Results

We included 30 children with a median age of 21 (11–48) months; 12 (40%) children had pediatric ARDS. The percentage of time spent in optimal SpO₂ zones increased with use of the closed–loop FiO₂ controller vs. manual oxygen control [96.1 (93.7–98.6) vs. 78.4 (51.3–94.8); P < 0.001]. The percentage of time spent in acceptable, suboptimal and unacceptable zones decreased. Findings were similar with the use of closed-loop FiO₂ controller compared to manual titration in patients with ARDS [95.9 (81.6–98.8) vs. 78 (49.5–94.8) %; P = 0.027]. The total number of closed-loop FiO₂ changes per patient was 52 (11.8–67), vs. the number of manual changes 1 (0–2), (P < 0.001).

Conclusion

In this randomized crossover trial in pediatric critically ill patients under invasive ventilation with ASV, use of a closed–loop control of FiO₂ titration increased the percentage of time spent within in optimal SpO₂ zones, and increased the total number of FiO₂ changes per patient.

Clinical trial registration

ClinicalTrials.gov, identifier: NCT04568642.

The association between N-acetylcysteine treatment and hepatic healing in patients with non-acetaminophen-induced liver injury in pediatric intensive care: A single-center retrospective study

OBJECTIVE

The aim of this study was to determine the association between the use of intravenous N-acetylcysteine (NAC) and hepatic healing in pediatric intensive care unit (PICU) patients with non-acetaminophen-induced hepatic injury, except for acute liver failure.

METHODS

The data of patients who received intravenous NAC as adjuvant therapy for transaminase levels more than sixfold normal values during their PICU stay between 2010 and 2014 were retrospectively collected from the medical records database. The patients who did not receive NAC with elevated transaminase levels during their PICU stay between 2014 and 2018 were also collected as the standard of care (SOC) cohort.

RESULTS

More than 50% of the liver injuries were secondary to acute hypoxia, hypotension, sepsis, and inflammation. The median number of elevated transaminase period (ETP) days of the NAC and SOC groups were 5 (IQR: 4) and 4 (IQR: 4), respectively (p = 0.17). There was no significant difference between the groups in terms of minimum and maximum laboratory values during ETP. There was no significant difference in terms of ETP and maximum ALT levels between the NAC and SOC groups in the hypoxia-hypotension subgroup.

CONCLUSION

This study did not show an association between indirect measures of hepatic healing and post-insult use of NAC in pediatric liver injury in the PICU setting.

The Effect of COVID-19 Outbreak on the Mental Status of Health Care Professionals in the Pediatric Intensive Care Unit

BACKGROUND

Coronavirus disease 2019 (COVID-19) may affect the mental status of health care professionals. The purpose of our study is to evaluate the mental health effects of the COVID-19 epidemic on health care professionals in the pediatric intensive care units (PICUs).

SUBJECTS AND METHODS

Our study was conducted prospectively between 01.04.20 and 10.04.20. The created questionnaire was applied to health care professionals through online platforms. Thus it was involved in 5 different institutions that participated from different regions of Turkey. With the questionnaire, we applied; the participants' age, gender, the general status of contamination and the level of COVID-19 knowledge were questioned. Besides; Beck Anxiety Scale, Acute Stress Scale (PCL-5), STAI-1 and STAI-2 (State and Trait Anxiety Inventory 1-2) scales were used to determine the anxiety levels.

RESULTS

A survey of 210 participants, 86 (41%) doctors, 124 (59%) nurses, were included in our study. When we evaluate the Beck anxiety levels, the majority of the participants (44%) were normal, while about one third had mild anxiety. When we evaluated the acute stress scale, all participants had a certain amount of stress levels. The majority (80 people each (38%)) experienced mild and moderate acute stress. Being female and having chronic disease poses a high risk for anxiety (OR, 0.330; 95% CI, 0.087-1.250, p<0.05 and OR, 0.246; 95% CI, 0.068-1.116, p<0.05), preoccupation (OR, 0.603; 95% CI 0.261-1.395, p<0.05 and OR, 0.433; 95% CI, 0.122-1.538, p<0.05) and acute stress (OR, 0.294; 95% CI, 0.033-2.649, p<0.05 and OR, 0.317; 95% CI 0.060-1.679, p<0.05). Professional definition, marital status and having a child do not pose any risk factors.

CONCLUSION

Our study has shown that the COVID-19 outbreak affects the mental status of health care professionals working at PICU at various levels.

Randomized crossover trial to compare driving pressures in a closed-loop and a conventional mechanical ventilation mode in pediatric patients

INTRODUCTION

In mechanically ventilated patients, driving pressure (ΔP) represents the dynamic stress applied to the respiratory system and is related to ICU mortality. An evolution of the Adaptive Support Ventilation algorithm (ASV® 1.1) minimizes inspiratory pressure in addition to minimizing the work of breathing. We hypothesized that ASV 1.1 would result in lower ΔP than the ΔP measured in APV-CMV (controlled mandatory ventilation with adaptive pressure ventilation) mode with physician-tailored settings. The aim of this randomized crossover trial was therefore to compare ΔP in ASV 1.1 with ΔP in physician-tailored APV-CMV mode.

METHODS

Pediatric patients admitted to the PICU with heterogeneous-lung disease were enrolled if they were ventilated invasively with no detectable respiratory effort, hemodynamic instability, or significant airway leak around the endotracheal tube. We compared two 60-min periods of ventilation in APV-CMV and ASV 1.1, which were determined by randomization and separated by 30-min washout periods. Settings were adjusted to reach the same minute ventilation in both modes. ΔP was calculated as the difference between plateau pressure and total PEEP measured using end-inspiratory and end-expiratory occlusions, respectively.

RESULTS

There were 26 patients enrolled with a median age of 16 (9-25 [IQR]) months. The median ΔP for these patients was 10.4 (8.5-12.1 [IQR]) and 12.4 (10.5-15.3 [IQR]) cmH2O in the ASV 1.1 and APV-CMV periods, respectively (p < .001). The median tidal volume (VT) selected by the ASV 1.1 algorithm was 6.4 (5.1-7.3 [IQR]) ml/kg and RR was 41 (33 50 [IQR]) b/min, whereas the median of the same values for the APV-CMV period was 7.9 (6.8-8.3 [IQR]) ml/kg and 31 (26-41[IQR]) b/min, respectively. In both ASV 1.1 and APV-CMV modes, the highest ΔP was used to ventilate those patients with restrictive lung conditions at baseline.

CONCLUSION

In this randomized crossover trial, ΔP in ASV 1.1 was lower compared to ΔP in physician-tailored APV-CMV mode in pediatric patients with different lung conditions. The use of ASV 1.1 may therefore result in continued, safe ventilation in a heterogeneous pediatric patient group.

A neglected cause of recurrent rhabdomyolysis, LPIN1 gene defect: a rare case from Turkey

BACKGROUND

Rhabdomyolysis; can occur due to toxic, infectious, metabolic, and genetic causes. Severe rhabdomyolysis may progress to several clinical manifestations such as cardiac arrest and may pose a risk of mortality if it is not treated timely.

CASE

In this article, we presented a 26-month-old patient who was admitted with an acute rhabdomyolysis attack and a venovenous hemodiafiltration (CVVHDF) was initiated on the 5th hour of hospitalization. Creatine kinase (CK) levels of the patient continued to increase (max: 943 452 IU/L) until the 5th day of treatment and hereafter began to decrease. As the common causes of rhabdomyolysis were excluded and the CK levels were the highest values reported in the literature, although, LPIN1 deficiency was the most suspected diagnosis, to facilitate the diagnostic procedures a whole-exome sequencing was performed. A homozygous [c.1696G > C p. (Asp566His)] mutation was detected on LPIN1 gene. This variant has not been described previously, however, when examined with programs such as SIFT and Mutation taster, it has been considered as pathogenic.

CONCLUSION

In the pediatric age group, especially in infants presenting with severe rhabdomyolysis, LPIN1 deficiency should also be considered; as early diagnosis and appropriate treatment may reduce mortality.

Monitoring of near-infrared spectrum values during packed red blood cell transfusion in pediatric intensive care unit

OBJECTIVES

Packed red blood cell (PRBC) transfusion is one of the most common treatment options in pediatric intensive care unit (PICU) which targets a better cerebral oxygenation. This study aimed to show the cerebral near-infrared spectroscopy (cNIRS) changes during PRBC transfusions in PICU.

MATERIAL AND METHODS

In this prospective observational study, changes in regional cerebral tissue oxygen saturation (rSO2) in pediatric patients, who required PRBC transfusion were monitored. All the cNIRS and related values were classified as baseline values. The same values were measured and calculated at the end of transfusion and named as 4th-hour values. Further measurements and calculations were made three hours later and named as 7th-hour values. Changes in cNIRS, cerebral tissue fractional oxygen extraction (CTFOE), cNIRS variability index (cNIRS-VI) were compared using Friedman test.

RESULTS

A total of 53 PRBC transfusions were monitored. Baseline haemoglobin increased from 6.3 (5.9, 6.7) gr/dL to 8.6 (8.4, 9) gr/dL at the 7th-hour. cNIRS values improved during transfusion (P=0.012), with a concomitant decrease in cNIRS-VI and CTFOE values (P<0.001 and P=0.017 consecutively) CONCLUSION: Our study revealed that there is an increase in cNIRS and related values after transfusion compared to baseline values in critically ill children admitted to a PICU. Age of PRBC did not have an effect on delta-cNIRS or post-transfusion hemoglobin values. There is a moderate correlation between the baseline cNIRS values and delta-cNIRS value after the transfusion.

Assessment of potential differences between pre-filled and manually prepared syringe use during vascular access device management in a pediatric intensive care unit

BACKGROUND

Central line-associated bloodstream infection is one of the four primary health-care-associated infections applicable to pediatric intensive care units defined by The Centers for Disease Control and Prevention. According to current guidelines, it is essential to flush vascular access devices before each infusion to assess catheter function and prevent catheter-related complications.

OBJECTIVE

This prospective trial aimed to assess the potential differences between pre-filled and manually prepared saline syringe use during vascular access device management in a pediatric intensive care unit.

METHODS

Volunteered registered pediatric intensive care unit nurses were asked to implement the flushing solution to an extension line of a central venous catheter in vitro. After the randomization process with opaque sealed envelopes, they have started either with manual preparation or used sterile pre-filled saline syringes. Sterile application steps forms were used for monitoring the manual preparation of saline syringes versus the pre-filled saline syringes phase. Each volunteer repeated the steps for 3, 5, and 10 mL syringe volumes with the manually prepared and pre-filled saline syringes. After completing the procedures, failed steps and durations were transferred into a database to be analyzed by a blinded investigator.

RESULTS

A total of 41 nurses volunteered and 123 forms for three attempts per one nurse were filled for each group. In the manual preparation group, the number of at least one failure in the necessary steps was 89 (72.3%) and the same number in the pre-filled syringe group was 6 (4.9%), and significantly lower in the pre-filled saline syringe group (p < 0.001). The overall time for preparing to flush was 86.0 ± 22.3 s (ranging from 46 to 173 s) for manual prepared syringes and 35.2 ± 9.4 s (ranging from 18 to 100 s) (p < 0.001) for pre-filled saline syringes.

CONCLUSION

Our results demonstrate that the risk for breaking the aseptic no-touch technic was higher in the manual preparation group. We have also demonstrated that the flushing time was shorter with pre-filled syringes compared to manually prepared ones, which may contribute to decreasing the workload of the nurses and may increase the quality of care in the intensive care units. The use of pre-filled saline syringes may decrease the central line-associated bloodstream infections incidence and may increase the quality of care by saving extra time in the pediatric intensive care unit.

The Differences in Viral Etiologies between Children with and without Severe Disability Admitted to the Pediatric Intensive Care Unit with Acute Respiratory Illness

Objectives The objectives of this study were to evaluate the differences in the viral etiologies and variability in the clinical course between children with and without severe disability (SD) admitted to the pediatric intensive care unit (PICU) with acute respiratory illness (ARI).

Methods The medical records of patients admitted to our PICU between June 2017 and July 2019 were retrospectively reviewed for viral etiology and clinical course.

Results Forty-eight of 136 patients included in the study had SD. The rates of requiring positive pressure ventilation (43.5% vs. 20.5%) or inotropic support (39.9% vs. 15.9%), and the median length of stay (11 [10] vs. 5 [8]) were significantly higher in children with SD (p < 0.01, each). Influenza infection was significantly higher in children with SD (20.8% vs. 2.3%; p < 0.01) whereas respiratory syncytial virus (RSV) infection was more common in children without SD (47.7% vs. 4.2%; p < 0.01). There was no statistically significant difference in terms of other viruses between study groups.

Conclusion In this present study, influenza was an important pathogen for children with SD, while RSV was the main cause of ARI-associated PICU admission in children without SD. By focusing on increasing the rate of immunization against influenza in children with SD and their caregivers the burden of influenza-associated PICU admissions could be decreased.

Clinical features and laboratory findings in children hospitalized with acute Epstein-Barr virus infection: a crosssectional study in a tertiary care hospital

Çağlar İ, Topal S, Çokboz M, Düzgöl M, Kara A, Bayram SN, Apa H, Devrim İ. Clinical features and laboratory findings in children hospitalized with acute Epstein-Barr virus infection: a cross-sectional study in a tertiary care hospital. Turk J Pediatr 2019; 61: 368-373. Epstein-Barr virus (EBV) is widespread all over the world. It causes infectious mononucleosis (IM) mostly in adolescents and adults. Although IM is considered to be rare in younger children and infants, acute EBV infection may have various manifestations in this age group. We aimed to describe the clinical features and laboratory findings of children hospitalized with acute EBV infection. All children hospitalized at Dr. Behçet Uz Children`s Hospital, between January 2010 and January 2017, who tested positive by presence of EBV-specific antibodies and had the diagnosis of acute EBV infection, were included (n=66). Thirty four of the patients (51.5%) were under 6 years of age, and 23 (34.8%) children were below 3 years of age. The most common physical finding was fever (92.4%) followed by cervical lymphadenopathy and tonsillopharyngitis. Leukocytosis (65.1%) and lymphocytosis (42.4%) were the most common laboratory findings. Reactive and atypical lymphocytes were present in 77.2% of the patients. Fifty-three (80.3%) of the patients had a doctor visit before hospitalization, and the ratio of patients using antibiotics was 77.3%. Skin rash was observed in 14 (27.4%) of the patients who used antibiotic treatment and in 2 (13.3%) of the patients who did not (p > 0.05). EBV infection resulting in admission to hospital is common in younger children, even in pre-school period. Serological tests for EBV specific antibody responses and peripheral blood smear evaluation are important diagnostic tools. In addition, rapid streptococcal antigen test and throat culture should be performed in patients presenting with tonsillopharyngitis in order to exclude Group A beta-hemolytic streptococci and reduce unnecessary antibiotic consumption.

The effect of tracheotomy on ventilator-associated pneumonia rate in children

OBJECTIVES

Data on the relationship between tracheotomy and ventilator-associated pneumonia (VAP) in children is very limited. We planned to evaluate the effect of tracheotomy on VAP rates in children.

MATERIALS AND METHODS

We evaluated patients who underwent tracheotomy during follow-up at the pediatric intensive care unit (PICU) of our hospital. Patients who were diagnosed as VAP at least once and followed by a mechanical ventilation (MV) for at least 30 days before and after tracheotomy were included in our study. The underlying diagnoses of the patients and the number of VAP diagnosis, VAP rates (VAP number x1000/day of MV) before and after tracheotomy were recorded. Logistic regression analysis was used to compare VAP rates before and following a tracheotomy.

RESULTS

There were a total of 47 patients including 28 (59.6%) girls and 19 (40.4%) boys in our study. The duration of MV before tracheotomy was 74.9 ± 48.9 (31-295) days and after tracheotomy, it was 103.3 ± 102.8 (30-586) days. The number of VAP before tracheotomy was 0.9 ± 1.2 (0-8) and after tracheotomy, it was 0.6 ± 0.6 (0-3). The VAP rate before tracheotomy was 5.9 ± 6.3 (0-26.5) and the VAP rate after tracheotomy was 3.2 ± 3.8 (0-11.4). Ventilator-associated pneumonia rates were lower following tracheotomy (OR:0.91,95%CI:0.826-0.981,p = 0.017).

CONCLUSION

Tracheotomy decreased the VAP rate in children receiving long-term mechanical ventilatory support.

Otologic Findings Based on no Complaints in a Pediatric Examination

Introduction  the otological evaluation is highly significant in those branches of medicine in which the general evaluation of the patient is conducted by general practitioners and pediatricians. Objectives  To investigate the otologic findings and their incidences in the sample, which consisted of patients who presented to the pediatric outpatient clinic with non-otologic complaints. Methods  Patients, aged between 2 and 16 years, who had neither otorhinolaryngological complaints nor history of surgery by the otolaryngology (ear, nose and throat, ENT) department were included in the present study. The findings detected in the external auditory system and in the tympanic membranes as well as the otorhinolaryngologists' otologic examination findings of the referred patients were recorded from the files of each patient along with the applied medical and surgical treatments, and diagnostic investigations. Results  Of a total of 973 patients evaluated, 129 (13.2%) were referred to the ENT outpatient clinic due to any otologic pathology. In the otorhinolaryngological examinations, false positivity was detected in 12 (1.2%) patients, and pathological findings were detected in 117 (12%) patients who received the following diagnoses: 68 (6.9%) had otitis media with effusion(OME); 37 (3.8%) had cerumen impactions; 8 (0.8%) had acute otitis media (AOM); 2 (0.2%) had ticks in the external auditory canal; 2 (0.2%) had a retraction pocket in tympanic membrane; 1 (0.1%) had unilateral central dry perforation of the tympanic membrane; and 1(0.1%) had congenital cholesteatoma. Conclusion Any complications and sequelae that may develop due to any pathologies and predominantly infections can be prevented by an early diagnosis, which can be made by means of a simple examination, performed merely with an otoscope. Pediatricians and general practitioners should be in close contact with otorhinolaryngologists regarding the pathologies they identify.

The Role of Electrocardiography in Follow up of Pulmonary Thromboembolism

Objective

Electrocardiography (ECG) is a simple, valuable and easily applicable test that can be used in supporting the diagnosis and assessing the severity of pulmonary thromboembolism (PTE). In this study, it was aimed to identify the role of ECG scoring in diagnosis and follow up of PTE in comparison with community acquired pneumonia (CAP).

Methods

Patients with the diagnosis of PTE and CAP were included in the study prospectively between January 2007 and January 2009. ECG scorings were evaluated by two different cardiologists by the method described by Daniel et al at admission (day 0) and day 3, 10 and one month of treatment. Median values of ECG scorings were compared between days and between groups.

Results

Forty-five patients with PTE, 35 patients with CAP were included in the study. Although no statistically significant difference was identified between the ECG scorings of the two groups in each measurement point, ECG scores decreased more rapidly in PTE group within days. Within the PTE group, day 0 ECG score was identified higher in submassive patients than nonmassive ones (p=0.001).

Conclusions

Although ECG score did not differentiate PTE from CAP, depending on its rapid decrease in PTE, it can be used in the follow up. For submassive PTE patients that must be diagnosed and treated immediately, ECG scorings can be used to support the diagnosis and to assess the clinical severity.

Remifentanil without muscle relaxants for intubation in microlaryngoscopy: a double blind randomised clinical trial

OBJECTIVES

We aimed to compare the effect of remifentanil without muscle relaxant with succinylcholine for intubation in microlaryngoscopy.

PATIENTS AND METHODS

Eighty patients were randomly divided into two groups: Group R (n=40) and S (n=40) received remifentanil 4 µg/kg intravenously or 1 µg/kg respectively. Anesthesia was induced with 2 mg/kg propofol in both groups. Intubation was performed after bolus administration of 10 ml saline as a placebo or 1 mg/kg of succinylcholine in Group R and S respectively. Remifentanil infusion was initiated at 0.025 μg/kg in each groups.

RESULTS

Intubation conditions were similar in both groups. The mean arterial pressure (MAP) values at post-induction period were significantly lower in the Group S than in the Group R (p = 0.001). The requirement for ephedrine in Group R was found to be significantly lower than Group S (p = 0.023). Recovery times were significantly shorter (p = 0.001) and recovery scores were significantly higher (p = 0.021) in Group R. Time to patient could respond to commands was significantly longer in the Group S (p = 0.001). The surgeon's satisfaction score was significantly higher in Group R (p = 0.001).

CONCLUSIONS

It was concluded that remifentanil without muscle relaxants provides similar intubating conditions as that provided by succinylcholine, and remifentanil is superior to succinylcholine with regard to haemodynamic stability and recovery duration.