The Burden of Burnout Syndrome in Pediatric Intensive Care Unit and Pediatric Emergency Department: A Multicenter Evaluation

OBJECTIVE

The objective of this study was to detect variables associated with burnout syndrome (BS) in pediatric intensive care units (PICUs) and pediatric emergency medicine departments (PEDs) in high-volume centers from different parts of Turkey.

METHODS

An observational, cross-sectional multicenter study was performed. The Maslach Burnout Inventory scale was administered to all of health care providers working in PICUs and PEDs. In this study, health care providers were defined as physicians, nurses, and other staff (secretaries, cleaning and patient care staff) working in PICU and PEDs.

RESULTS

A total of 570 participants completed the survey. The major finding of this study was that 76.1% (n = 434) of PICU and PED health care professionals had BS. The most prominent subscale of BS was emotional exhaustion (62.5%). The rate of BS was higher among health care providers working in PEDs compared with PICUs (79.1% vs 73.7%, P = 0.04). The frequency of BS according to emotional exhaustion and depersonalization subscales was higher in health care providers of PEDs. The rate of BS was also significantly higher in younger employees, females, those working 51 or more hours totally in a week, those having a low monthly salary, those single or divorced, those without children, those with no childcare at home, those not owning a home, those not doing regular exercise and not having regular breakfast, those with total employment time of less than 1 year, and those not having a car or not having a hobby. In PEDs, when the daily evaluated number of patients was equal to or more than 44 (sensitivity, 88%; specificity, 66%), it predicted the occurrence of BS. In PICUs, when the number of patients cared for by 1 nurse was equal to or more than 3, it predicted the occurrence of BS (sensitivity, 78%; specificity, 62%).

CONCLUSIONS

By creating early intervention programs to prevent BS, shortages of health care professionals can be avoided and the costs of health care expenditures related to infections can be decreased.

The role of galactomannan test results in the diagnosis of pediatric invasive aspergillosis

BACKGROUND

Invasive aspergillosis (IA) is an important cause of morbidity and mortality in immunosuppressed children. Early detection of the infection can improve prognosis in this patient population.

OBJECTIVES

To investigate the utility of Aspergillus galactomannan antigen assay (GM-EIA) as a diagnostic tool for IA in at-risk paediatric patients.

PATIENTS/METHODS

For the study, 659 GM-EIA results from 59 patients diagnosed with IA and 3368 GM-EIA results from 351 subjects without evidence for IA (controls) were reviewed retrospectively. Three cut-off values (i.e. ≥0.5, ≥1, ≥1.5) were specified to determine GM-EIA positivity.

RESULTS

The median age was 6.3 years for boys and 14.5 years for girls. There was a significant difference between the girls and boys in terms of age (p < 0.01). For proven/probable/possible IA patients, sensitivity of 67.8% and specificity of 59.8% were detected when the ≥0.5 cut-off value was used for GM-EIA-positivity. The specificity increased to 80% at the cut-off of ≥1 and to 88% at the cut-off of ≥1.5. False positivity rates were 9.14, 3, and 1.45% at the ≥0.5, ≥1 and ≥1.5 cut-offs respectively. In the proven/probable IA group, sensitivity and negative predictive values were 86.9 and 97.2% at the ≥0.5 cut-off, 85.7 and 97.9%, at the ≥1 cut-off and 84.2 and 98.1% at ≥1.5 cut-off respectively. The positive likelihood ratio was 7.57 and the odds ratio was 42.67 at ≥1.5 cut-off.

CONCLUSION

The GM-EIA may be used for both screening and diagnostic purposes in paediatric patients using a cut-off value of ≥1.5 for GM-EIA positivity.

Cardiac arrest due to a fatal dose of propranolol successfully treated with intravenous lipid infusion

BACKGROUND

Beta blockers (BB) are used for very different indications in both adults and children. There can be mild adverse effects with normal doses. When taken in toxic doses, this can have fatal results in children. There are some standard therapies during BB poisoning such as insulin and glucagon but there is not enough knowledge concerning intravenous lipid infusion therapy (ILI).

CASE

Herein we present a case of propranolol poisoning in a previously healthy 2-year-old girl. In this patient, cardiac arrest developed twice, and cardiopulmonary resuscitation was performed for 5 and 20 minutes, respectively. We initiated inotropes, insulin, calcium and glucagon with a lack of response to all medical treatment. We used ILI and the patient improved after this treatment. She recovered without any disability.

CONCLUSIONS

ILI treatment should be considered with life-threatening BB poisoning which is unresponsive to standard therapies.

Influenza Virus Associated Pediatric Acute Respiratory Distress Syndrome: Clinical Characteristics and Outcomes

BACKGROUND AND OBJECTIVE

The aim of this multicenter retrospective study was to determine the clinical characteristics, treatment approaches and the course of pediatric acute respiratory distress syndrome (PARDS) which developed associated with the influenza virus in the 2019-20 season.

METHODS

Patients included 1 month to 18 years who were diagnosed with PARDS associated with the influenza virus in the 2019-20 season.

RESULTS

Sixty-seven patients were included in the study. The mean age of the patients was 64.16 ± 6.53 months, with 60% of the group <5 years. Influenza A was determined in 54 (80.5%) patients and Influenza B in 13 (19.5%). The majority of patients (73.1%) had a comorbidity. Fifty-eight (86.6%) patients were applied with invasive mechanical ventilation, Pediatric Acute Lung Injury Consensus Conference classification was mild in 5 (8.6%), moderate in 22 (37.9%) and severe in 31 (52.5%) patients. Ventilation was applied in the prone position to 40.3% of the patients, and in nonconventional modes to 24.1%. A total of 22 (33%) patients died, of which 4 had been previously healthy. Of the surviving 45 patients, 38 were discharged without support and 7 patients with a new morbidity.

CONCLUSION

Both Influenza A and Influenza B cause severe PARDS with similar characteristics and at high rates. Influenza-related PARDS cause 33% mortality and 15.5% morbidity among the study group. Healthy children, especially those aged younger than 5 years, are also at risk.

Immobilization-induced symptomatic hypercalcemia treated with zoledronate in a child with a left ventricular assist device

Differential diagnosis of hypercalcemia in children includes confirmation of hyperthyroidism, infection, inflammatory processes, and malignant tumors. Immobilization-induced hypercalcemia is rare in healthy individuals, although it can occur in adolescent males, especially after fracture. Immobility can cause increased skeletal calcium release and hypercalcemia, and this condition is also known as resorptive hypercalcemia. We present a case of a 10-year-old adolescent girl with advanced heart failure who underwent implantation with a HeartMate 3 left ventricular assist device. She had symptoms of abdominal pain, vomiting, and constipation on the fifth month of hospitalization. She subsequently developed immobilization-induced symptomatic hypercalcemia (serum calcium, 12.1 mg/dL; corrected calcium 12.8 mg/dL; parathormone, 1.9 pg/mL; calcium/creatinine ratio in spot urine, 1.21). However, hypercalcemia is uncommon in children with advanced heart failure. Bisphosphonate therapy was initiated because our patient did not respond to hydration and furosemide treatment, and she had persistent abdominal pain, vomiting, and constipation. The patient&apos;s complaints were resolved on the second day after administrating bisphosphonate, and hypercalcemia did not recur.

Pediatric extracorporeal cardiopulmonary resuscitation: single-center study

Background/aim

Extracorporeal cardiopulmonary resuscitation (ECPR) is defined as the venoarterial extracorporeal membrane oxygenation (VA-ECMO) support in a patient who experienced a sudden pulseless condition attributable to cessation of cardiac mechanical activity and circulation. We aimed to evaluate the clinical outcomes of our ECPR experience in a pediatric patient population.

Materials and methods

Between September 2014 and November 2017, 15 children were supported with ECPR following in-hospital cardiac arrest (IHCA) in our hospitals. VA-ECMO setting was established for all patients. Pediatric cerebral performance category (PCPC) scales and long-term neurological prognosis of the survivors were assessed.

Results

The median age of the study population was 60 (4–156) months. The median weight was 18 (4.8–145) kg, height was 115 (63–172) cm, and body surface area was 0.73 (0.27–2.49) m². The cause of cardiac arrest was a cardiac and circulatory failure in 12 patients (80%) and noncardiac causes in 20%. Dysrhythmia was present in 46%, septic shock in 13%, bleeding in 6%, low cardiac output syndrome in 13%, and airway disease in 6% of the study population. Median low-flow time was 95 (range 20–320) min. Central VA-ECMO cannulation was placed in only 2 (13.3%) cases. However, the return of spontaneous circulation (ROSC) was obtained in 10 (66.6%) patients, and 5 (50%) of them survived. Overall, 5 patients were discharged from the hospital. Finally, survival following ECPR was 33.3%, and all survivors were neurologically intact at hospital-discharge.

Conclusion

ECPR can be a life-saving therapeutic strategy using a promising technology in the pediatric IHCA population. Early initiation and a well-coordinated, skilled, and dedicated ECMO team are the mainstay for better survival rates.

Multisystem Inflammatory Syndrome in Children Admitted to a Tertiary Pediatric Intensive Care Unit

Background  Multisystem inflammatory syndrome in children (MIS-C) is characterized by persistent fever, abdominal pain, vomiting, diarrhea, rash, conjunctivitis, headaches, and mucocutaneous manifestations and it can cause circulatory dysfunction, resulting in hypotension, shock, and end-organ injury in the heart and other organs and possibly death. In this study, we aimed to analyze the clinical spectrum, treatment options and outcomes of children with MIS-C who were admitted to our pediatric intensive care (PICU). Materials and Methods  Clinical and laboratory findings and treatment of the patients admitted to the PICU with MIS-C between April 2020 and January 2021 were recorded, and their outcomes were evaluated. Results  Nineteen patients with a median age of 12.5 years (interquartile range (IQR): 5.8-14.0 years) were admitted. Eleven (57.8%) were males. The most frequent clinical and laboratory features were fever (100%), abdominal pain (94.7%), rash (63.1%), headache (68.4%), diarrhea (47.3%), seizure (10.5%), cardiac dysfunction (52.6%), acute kidney injury (26.3%), lymphopenia (84.2%), and thrombocytopenia (36.8%). However, 8 patients needed mechanical respiratory support, 11 patients needed inotropes, 2 patients needed plasma exchange, and 1 patient needed continuous renal replacement therapy. All patients received corticosteroids, 17 patients (89.2%) received intravenous immunoglobulin, 2 patients received anakinra, 10 patients received acetylsalicylic acid, and 6 patients received enoxaparin. Median PICU length of stay was 3 days (IQR: 2-5) and only one patient died. Conclusion  In conclusion, MIS-C may present with a variety of clinical manifestations, and it can lead to life-threatening critical illness. Most children need intensive care and the response to immunomodulation is usually favorable.

Therapeutic plasma exchange in clinical pediatric neurology practice: Experience from a tertiary referral hospital

OBJECTIVE

This study aims to retrospectively evaluate the long-term efficacy, tolerability, and safety of therapeutic plasma exchange (TPE) in children with various neuroimmunological disorders.

METHODS

This analysis was a single-center, retrospective cohort study of pediatric patients with neuroimmunological events undergoing TPE procedures in a tertiary referral center.

RESULTS

There were 23 patients, 14 boys (60.9%), aged at diagnosis onset 8 months to 16.8 years. The main indications of TPE were Guillain-Barré syndrome (GBS, n = 8), autoimmune encephalitis (n = 5), febrile infection-related epilepsy syndrome (FIRES, n = 4), and acute disseminated encephalomyelitis (ADEM, n = 3). There was no life-threatening complication due to the TPE procedures. Eight (34.8%) of 23 patients experienced 13 (7%) complications in 186 TPE procedures, mostly electrolyte disturbances (n = 5). None of patients discontinued TPE due to complications. Two (8.7%) of 23 patients had marked improvement, 6 (26.1%) had moderate and 11 (47.8%) had mild improvement after TPE. The last follow-up visit revealed neurological sequelae in 12 (52.2%) patients. Therapeutic plasma exchange was found to be more effective on GBS, autoimmune encephalitis and myasthenia gravis, less effective on ADEM and FIRES. There was no correlation between improvement with TPE and clinical parameters, including age, sex, diagnosis, disease duration before TPE, presence of intubation, and length of stay in the intensive care unit and hospital.

CONCLUSION

Therapeutic plasma exchange was found to be effective and well-tolerated in children with various types of neuroimmunological disorder, with at least mild improvement in approximately 80% of the patients and no life-threatening complications.

Overlap Stevens Johnson Syndrome/Toxic Epidermal Necrolysis developed due to the use of toxic-dose vinblastine in case of Langerhans Cell Histiocytosis(Letterer-Siwe)

Except for side effects expected standart dose use of the chemotherapeutics agents, toxic effects (poisoning) may occur if high doses of are mistakenly used in the treatment of haemato-oncological diseases and these toxic doses are usually fatal. Here, we report a case of Stevens Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN) following administration of toxic dose of vinblastine by mistake. A 20-month-old male patient with a diagnosis of Langerhans Cell Histiocytosis (Letterer-Siwe) at the pediatric oncology department was admitted to intensive care unit, after having received treatment protocol consisting of vinblastine, etoposide and prednisolone, with fever, altered consciousness and decompensated shock findings. Skin biopsy which performed from bullous lesions in the perianal, neck and axillary regions was resulted compatible with SJS / TEN in the patient with multiple organ failure, at 48 h of admission. It was later determined that the patient has been mistakenly given 10 times the normal dose of vinblastine he needed (60 mg/m²), which was 6 mg/m². Plasma exchange was performed 3 times for vinblastine toxicity, intravenous immunoglobulin was administered for SJS / TEN therapy and phenobarbital was initiated to increase drug metabolism. The patient whose clinical picture fully improved, was transferred to the oncology department on the 30th day of intensive care hospitalization. Vinblastine toxicity is a life-threatening condition that can cause multiple organ failure, SJS / TEN. Plasma exchange is an effective treatment method for the removal of vinblastine from the body and in these cases of toxicity.

The Evaluation of Transported Children to Pediatric Intensive Care Unit: Indications, Problems, and Outcomes

OBJECTIVE

Critically ill children often require transport to tertiary centers where higher levels of care can be provided. In this study, we aimed to evaluate the reasons for transport, complications that occurred during transport, and the clinical outcomes of the patients transferred to our tertiary pediatric intensive care unit (PICU).

METHODS

This retrospective study was conducted in a tertiary pediatric hospital with 250 beds and 20 tertiary PICU beds.

RESULTS

During the study period, 108 patients were transferred to our PICU. The mean age was 75.0 ± 70.5 months (range, 1-211 months), and 59 were female. Most patients (82.4%) were transported by land; 17.6% were transported by air ambulance. Fourteen patients were referred for liver transplantation, and 7 patients were referred because of a need for extracorporeal membrane oxygenation support and heart transplantation or left ventricular assist device placement. Two patients were transported by air while on extracorporeal membrane oxygenation. Complications occurred in 25% of patients.

CONCLUSION

Vital signs were assesed, and certain critical interventions such as intravenous fluids and respiratory support were provided more frequently during air transport, possibly due to the fact that physicians were always present during air transport. Quality improvement of transport teams and multicenter and nationwide studies on PICU transport are needed.

Temporary biventricular support as a bridge to recovery: A justifiable strategy for small children with fulminant myocarditis

Short-term mechanical circulatory support can be life-saving in the pediatric population with acute cardiogenic shock (ACS). However, recovery from MCS is a rare entity. MCS options are limited for low-body-weight children in Turkey. Over the last decade, extracorporeal membrane oxygenation (ECMO) has been the primary bridging modality for children with end-stage heart failure in our country. However, VA-ECMO may cause increased wall stress and oxygen demand, which may alter myocardial recovery. Here, we describe using a Levitronix CentriMag Systems for biventricular support as a bridge to recovery in a 16-month-old boy (weight, 11 kg; BSA, 0.5 m²) with type A influenza related-fulminant myocarditis (FM). Levitronix CentriMag System provides a safe and efficient short-term, biventricular, paracorporeal support for infants, and small children with ACS.

First Reported Cochlear Implantation in a Child with Total Artificial Heart

We report a case of 15-year-old boy with postlingual bilateral total hearing loss following ototoxic medication during his pediatric intensive care unit stay. The patient received the SynCardia total artificial heart implant (50 mL; SynCardia Systems, Inc., Tucson, AZ, USA) for end-stage biventricular heart failure as a bridge to heart transplant. During his time on the urgent heart transplant wait list, he underwent successful cochlear implantation following optimized coagulation and hemostasis status and appropriate anesthetic preparation. Our case represents the world's first successful cochlear implant in a pediatric patient who received an artificial heart. Despite complexities in this patient population, elective surgical procedures can be performed safely with acceptable morbidity using a collaborative approach with the heart transplant team, including input from cardiovascular surgery, pediatric cardiology, anes thesiology, consultation-liaison psychiatry, physical therapy and rehabilitation, infectious diseases and clinical microbiology, and intensive care unit staff.

Sublingual Atropine Sulfate Use for Sialorrhea in Pediatric Patients

Sialorrhea is a frequent problem and may lead to aspiration in patients with swallowing dysfunction. We aimed to assess the effectiveness and safety of sublingual atropine sulfate treatment in pediatric patients with sialorrhea. The medical records of patients who had received sublingual atropine sulfate between January 2015 and January 2016 were reviewed retrospectively. The demographic properties, diagnosis, invasive or noninvasive mechanical ventilation need, and the presence of tracheotomy were assessed. Response rates to sublingual atropine were measured using the Teacher Drooling Scale (TDS). Pre and post-treatment drooling scores were compared. Atropine sulfate ampoule was administered at 20 µg/kg/dose. Minimum dose was 0.25 mg, while maximum dose was 0.03 mg/kg.Thirty-five pediatric patients with sialorrhea who had received sublingual atropine sulfate were identified; however, TDS scores had been recorded in only 20 of them. The median age of the patients was 25 months (3-78 months; 7 girls, 13 boys). Sixteen (80%) patients were on invasive mechanical ventilation and seven (30%) had tracheotomy. Nineteen patients had a neurodevelopmental disorder and only one patient had oral and esophageal lesions due to corrosive material intake. The median TDS score prior to sublingual atropine sulfate treatment was 5, and it decreased to 3 on the second day of treatment, a change that was statistically significant ( p  < 0.001). No side effects were observed. Sublingual atropine sulfate is safe and effective in the short-term treatment of sialorrhea; however, randomized placebo controlled and long-term follow-up studies are necessary.

Continuous venovenous hemodiafiltration in the treatment of newborns with an inborn metabolic disease: a single center experience

Background/aim

Most inborn metabolic diseases are diagnosed during the neonatal period. The accumulation of toxic metabolites may cause acute metabolic crisis with long-term neurological dysfunction and death. Renal replacement therapy (RRT) modalities allow the efficient removal of toxic metabolites. In this study, we reviewed our experience with continuous venovenous hemodiafiltration (CVVHDF) as RRT for newborns with an inborn metabolic disease.

Materials and methods

Patients diagnosed with an inborn metabolic disease and who received CVVHDF treatment at our neonatal intensive care unit between January 2014 and December 2017 were included in this study. Their demographic and clinical data were collected, and the efficacy and safety of CVVHDF was evaluated.

Results

A total of nine continuous RRT (CRRT) sessions as CVVHDF were performed in eight newborns with a diagnosis of urea cycle defect (n = 5), maple syrup urine disease (n = 2), or methylmalonic acidemia (n = 1). The mean age at admission was 10 ± 8.6 days (range: 3–28 days). The mean plasma levels of ammonium were 1120 ± 512.6 mg/dL and 227.5 ± 141.6 mg/dL before and at the end of the treatment, respectively. Plasma levels of leucine were 2053.5 ± 1282 µmol/L and 473.5 ± 7.8 µmol/L before and at the end of the treatment, respectively. The CVVHDF duration was 32.3 ± 11.1 h (median: 37 h; range: 16–44 h), and the mean length of hospitalization was 14.6 ± 12.9 days. The mean duration of CVVHDF was 32.3 ± 11.1 h (range: 16–44 h). Circuit clotting was the most common observed complication (37.5%) and the survival rate was 50%. Among surviving patients, two developed severe and two developed mild mental and motor retardation.

Conclusion

CVVHDF is a CRRT modality that can be used to treat newborns with an inborn metabolic disease. Early diagnosis, commencement of specific medical therapy, diet, and extracorporeal support, if needed, are likely to result in improved short and long-term outcomes.

A case of fulminant pneumococcus meningoencephalitis progressing with white matter involvement despite two doses of conjugated pneumococcus vaccine

BACKGROUND

Streptococcus pneumonia is a cause of serious mortality and morbidity, especially among small children. However, currently, it causes lower rates of invasive infections due to successful vaccination programs Case. We report an exceptional case of a 6-month-old child with meningoencephalitis caused by Streptococcus pneumonia despite the administration of two doses of pneumococcal conjugate vaccine (PCV). Meningitis progressed rapidly and led to widespread damage in parenchymal brain tissue with the emergence of fulminant meningoencephalitis. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed widespread brain lesions, suggesting extensive parenchymal injury.

CONCLUSION

Such diffuse white matter lesions among pediatric patients with Streptococcus pneumonia meningoencephalitis despite two doses of PCV have not been reported previously.

Allogeneic hematopoietic stem cell and liver transplantation in a young girl with dedicator of cytokinesis 8 protein deficiency

DOCK8 deficiency is a rare inherited combined immunodeficiency, caused by mutations in the DOCK8 gene. We describe a case with DOCK8 deficiency associated with severe CLD in whom orthotopic LT was performed successfully after allogeneic HSCT. A 5 year-old girl with DOCK8 deficiency presented with mild direct hyperbilirubinemia and abnormal GGT level and without a previous history of jaundice. She had severe growth retardation, hepatosplenomegaly and generalized eczema. Progressive worsening of CLD was observed within 4 months. Investigations for etiology of liver disease were negative. Liver biopsy showed bridging necrosis, cholestasis and, cirrhosis. Recurrent immune hemolytic crisis and several viral infections developed in follow-up. She underwent whole cadaveric LT for end-stage liver disease (ESLD) 1 year after allogenic HSCT from a full matched related donor. The postoperative course was uneventful. The patient is alive with normal liver function and moderate skin graft versus host disease for 36 months after LT. In conclusion DOCK8 deficiency can be associated with severe CLD. Successful LT following HSCT is possible in patients with ESLD in DOCK8 deficiency. The timing of LT is challenging in patients requiring both HSCT and LT since conditioning regimens for HSCT can be highly hepatotoxic and the patients with suboptimal liver function can become decompensated during HSCT.

Outcome of out-of-hospital cardiopulmonary arrest in children: A multicenter cohort study

Kurt F, Kendirli T, Gündüz RC, Kesici S, Akça H, Şahin Ş, Kalkan G, Derbent M, Tuygun N, Ödek Ç, Gültekin-Keser A, Oğuz S, Polat E, Derinöz O, Tekin D, Tekşam Ö, Bayrakcı B, Suskan E. Outcome of out-of-hospital cardiopulmonary arrest in children: A multicenter cohort study. Turk J Pediatr 2018; 60: 488-496. The aim of this study was to evaluate the demographic characteristics of children who experienced out-of-hospital cardiopulmonary arrest (CPA), and to assess the impact of the bystander cardiopulmonary resuscitation (CPR) on the survival rate of witnessed arrests and the effects of the arrest and CPR durations on the neurological outcomes. This multicenter, retrospective study included a total of 182 patients who underwent CPR for out-of-hospital CPA between January 2008 and December 2012 at six centers in Ankara, Turkey. The median [interquartile range (IQR)] age was 22 (5-54) months; 60.4% of the patients were males, and 44% were younger than one year of age. The witnessed arrest rate was 75.8% (138/182) and the rate of bystander CPR was 13.9% (13/93). In these patients the rate of the return of spontaneous circulation (ROSC) was higher (76.9%). Following resuscitation in the patients for whom the spontaneous circulation was able to be returned, the median (IQR) duration of arrest was 5 (1- 15) min, while it was 15 (5-40) min for the remaining patients (p < 0.001). The ROSC rate was 94.9% in patients who underwent CPR for less than 20 min and 22% in patients requiring CPR longer than 20 min (p < 0.001). Survival to hospital discharge was 14.3%. Of these patients, 57.7% experienced neurological disability. The short duration of an arrest and the presence of CPR are both critical for survival. We suggest that a witness to the CPA, performing early and efficient CPR, yields better results.

Perioperative factors associated with hyperglycemia after pediatric cardiac surgery and impact of hyperglycemia on morbidity and mortality

Ödek Ç, Kendirli T, Yıldırım-Yıldız N, Yaman A, Uçar T, Eyileten Z, Ateş C, Uysalel A, Tutar E, Atalay S. Perioperative factors associated with hyperglycemia after pediatric cardiac surgery and impact of hyperglycemia on morbidity and mortality Turk J Pediatr 2018; 60 497-505. This retrospective, observational, single-center study aimed to determine the perioperative factors associated with postoperative hyperglycemia (blood glucose level ≥126 mg/dl) and the impact of hyperglycemia on morbidity and mortality in a cohort of children undergoing cardiac surgery. Non-diabetic children aged between 1 month to 18 years who were consecutively admitted to pediatric intensive care unit (PICU) after cardiac surgery for congenital heart disease between January 2008 and December 2013 were included. One hundred and twenty-six patients were qualified for inclusion during the study period. Seventy-four (57.8%) of the patients had at least one glucose measurement ≥ 126 mg/dl. Higher PRISM III-24 (OR 1.1, 95% CI 1.02-1.18, p= 0.004) and PELOD (p=0.006) scores, higher Wernovsky inotropic score (p=0.027) and vasoactive-inotropic score (p=0.029) were associated with hyperglycemia. Postoperative hyperglycemia was not associated with duration of mechanical ventilation), length of PICU stay, healthcare associated infections, or mortality. Our study establishes that hyperglycemia is common after pediatric cardiac surgery but not associated with short-term morbidity and mortality. Insulin therapy can be accomplished without hypoglycemia when a permissive glycemic target is used. A large prospective multiple institution trial is necessary to facilitate defined guidelines for postoperative hyperglycemia after pediatric cardiac surgery.

Comprehensive Analysis of Severe Viral Infections of Respiratory Tract admitted to PICUs during the Winter Season in Turkey

Objectives

To analyze the course of seasonal viral infections of respiratory tract in patients hospitalized in pediatric intensive care units (PICU) of 16 centers in Turkey.

Materials and methods

It is a retrospective, observational, and multicenter study conducted in 16 tertiary PICUs in Turkey includes a total of 302 children with viral cause in the nasal swab which required PICU admission with no interventions.

Results

Median age of patients was 12 months. Respiratory syncytial virus (RSV) was more common in patients over one year of age whereas influenza, human Bocavirus in patients above a year of age was more common (p <0.05). Clinical presentations influencing mortality were neurologic symptoms, tachycardia, hypoxia, hypotension, elevated lactate, and acidosis. The critical pH value related with mortality was ≤7.10, and critical PCO₂ ≥60 mm Hg.

Conclusion

Our findings demonstrate that patients with neurological symptoms, tachycardia, hypoxia, hypotension, acidosis, impaired liver, and renal function at the time of admission exhibit more severe mortal progressions. Presence of acidosis and multiorgan failure was found to be predictor for mortality. Knowledge of clinical presentation and age-related variations among seasonal viruses may give a clue about severe course and prognosis. By presenting the analyzed data of 302 PICU admissions, current study reveals severity of viral respiratory tract infections and release tips for handling them.

How to cite this article

Kockuzu E, Bayrakcı B, Kesici S, Cıtak A, Karapınar K, Emeksiz S, et al. Comprehensive Analysis of Severe Viral Infections of Respiratory Tract admitted to PICUs During the Winter Season in Turkey. Indian J Crit Care Med 2019;23(6):263–269.

Outcome of treosulfan-based reduced-toxicity conditioning regimens for HSCT in high-risk patients with primary immune deficiencies

INTRODUCTION

HSCT is the curative therapeutic option in PIDs. Due to the increase in survival rates, reduced-toxicity conditioning regimens with treosulfan have become another alternative. The purpose of this retrospective study was to analyze the outcome of treosulfan-based conditioning before HSCT for patients with PID.

METHOD

A total of 15 patients that received a treosulfan-based conditioning regimen for HSCT were recruited. Type of diagnosis, donor and stem cell source, pretransplant organ damage, infections, engraftment, chimerism, and transplant-related toxicities were analyzed.

RESULTS

At a median follow-up time of 32 months, the overall survival was 86.7%. Following HSCT, 14 of 15 patients had engraftment, with 86.7% of the cohort having full-donor chimerism. The most common toxicity was seen on the skin (53.3%). Acute GVHD and chronic GVHD were documented in 53% and 20% of the study population, respectively. Although the cohort consisted of patients with pretransplant liver damage, SOS manifestations were documented in 20%.

CONCLUSION

Treosulfan-based conditioning regimens before HSCT are associated with lower toxicity compared to myeloablative regimens, are safe, and have high engraftment rates with full-donor chimerism in patients having PID, regardless of the specified genetic diagnosis and donor type.