Very-early-onset Inflammatory Bowel Disease in an Infant with a Partial RIPK1 Deletion

The monogenic causes of very-early-onset inflammatory bowel disease (VEO-IBD) have been defined by genetic studies, which were usually related to primary immunodeficiencies. Receptor-interacting serine/threonine-protein kinase-1 (RIPK1) protein is an important signalling molecule in inflammation and cell death pathways. Its deficiency may lead to various clinical features linked to immunodeficiency and/or inflammation, including IBD. Here, we discuss an infant with malnutrition, VEO-IBD, recurrent infections and polyathritis who has a homozygous partial deletion in RIPK1 gene.

Correlation between early computed tomography findings and neurological outcome in pediatric traumatic brain injury patients

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Head computed tomography (CT) is frequently utilized for evaluating trauma-related characteristics, selecting treatment options, and monitoring complications in the early stages. This study assessed the relationship between cranial CT findings and early and late neurological outcomes in pediatric TBI patients admitted to the pediatric intensive care unit (PICU). The study included children aged 1 month to 18 years who were admitted to the PICU due to TBI between 2014 and 2020. Sociodemographic data, clinical characteristics, and cranial CT findings were analyzed. Patients were categorized based on their Glasgow Coma Scale (GCS) score. Of the 129 patients, 83 (64%) were male, and 46 (36%) were female, with a mean age of 6.8 years. Falls (n = 51, 39.5%) and in-vehicle traffic accidents (n = 35, 27.1%) were the most common trauma types observed. Normal brain imaging findings were found in 62.7% of the patients, while 37.3% exhibited intracranial pathology. Hemorrhage was the most frequent CT finding. Severe TBI (n = 26, p = 0.032) and mortality (n = 9, p = 0.017) were more prevalent in traffic accidents. The overall mortality rate in the study population was 10.1%. In children with TBI, cranial CT imaging serves as an essential initial method for patients with neurological manifestations. Particularly, a GCS score of ≤ 8, multiple hemorrhages, diffuse cerebral edema, and intraventricular bleeding are associated with sequelae and mortality.

The impact of fragmented QRS on clinical findings and outcomes in children with dilated cardiomyopathy with or without left ventricular non-compaction

OBJECTIVE

The aim of this study is to investigate the frequency of fragmented QRS and its associations with clinical findings and prognosis in children diagnosed with dilated cardiomyopathy with or without left ventricular non-compaction.

METHODS

This retrospective study was conducted between 2010 and 2020. Patients with dilated cardiomyopathy were classified into two groups according to the presence of left ventricular non-compaction: Dilated cardiomyopathy with left ventricular non-compaction and dilated cardiomyopathy without left ventricular non-compaction. Patients were also divided into two groups according to the presence of fragmented QRS (fragmented QRS group and non-fragmented QRS group).

RESULTS

Twenty-three of 44 patients (52.3%) were male. Among left ventricular non-compaction patients, the fragmented QRS group had more complex ventricular arrhythmias (p = 0.003). Patients with fragmented QRS had a significantly higher rate of major adverse cardiac events and/or cardiac death in both cardiomyopathy groups (p = 0.003 and p = 0.005). However, the rate of major adverse cardiac events and/or cardiac death was similar between dilated cardiomyopathy patients with and without left ventricular non-compaction. Multivariate logistic regression analysis showed that the presence of fragmented QRS strongly predicts major adverse cardiac events and/or cardiac death (odds ratio, 31.186; 95% confidence interval, 2.347-414.307). Although the survival rates between cardiomyopathy groups were similar, patients with fragmented QRS had a markedly lower survival rate during the follow-up period, as mean of 15 months (p = 0.001).

CONCLUSION

Our study showed that the presence of fragmented QRS may be an important ECG sign predicting an major adverse cardiac event and/or cardiac death in patients with dilated cardiomyopathy. We believe that recognising fragmented QRS could be valuable in forecasting patient prognosis and identifying high-risk patients who require additional support.

Cardiovascular manifestations and cardiac magnetic resonance follow-up of multisystem inflammatory syndrome in children (MIS-C)

OBJECTIVE

This study aimed to evaluate the cardiovascular manifestations and surveillance of multisystem inflammatory syndrome in children (MIS-C) and to determine the correlation of echocardiographic findings with cardiac magnetic resonance imaging findings.

METHODS

Forty-four children diagnosed as MIS-C with cardiac involvement were enrolled in this observational descriptive study. The diagnosis of MIS-C was made according to the criteria of Centers for Disease Control and Prevention. Clinical findings, laboratory parameters, and electrocardiographic and echocardiographic findings at the time of diagnosis and during follow-up were evaluated. Cardiac magnetic resonance was performed on 28 (64%) cases. The 1-year follow-up imaging was performed in all cases with abnormal initial cardiac magnetic resonance findings.

RESULTS

Forty-four patients (56.8% male) with a mean age of 8.5 ± 4.8 years were enrolled in this study. There was a significant positive correlation between high-sensitivity cardiac troponin T (mean: 162 ± 444.4 pg/ml) and N-terminal pro b-type natriuretic peptide (mean: 10,054 ± 11,604 pg/ml) (p < 0.01). Number of cases with an electrocardiographic and echocardiographic abnormality was 34 (77%) and 31 (70%), respectively. Twelve cases (45%) had left ventricular systolic dysfunction and 14 (32%) cases had pericardial effusion on admission. Three cases (11%) had cardiac magnetic resonance findings that may be attributed to the presence of myocardial inflammation, and pericardial effusion was present in seven (25%) cases. Follow-up cardiac magnetic resonances of all cases were normal. Cardiac abnormalities were completely resolved in all except two cases.

CONCLUSIONS

Myocardial involvement can be seen during acute disease, but MIS-C generally does not lead to prominent damage during a year of surveillance. Cardiac magnetic resonance is a valuable tool to evaluate the degree of myocardial involvement in cases with MIS-C.

GIMAP5 deficiency reveals a mammalian ceramide-driven longevity assurance pathway

Preserving cells in a functional, non-senescent state is a major goal for extending human healthspans. Model organisms reveal that longevity and senescence are genetically controlled, but how genes control longevity in different mammalian tissues is unknown. Here, we report a new human genetic disease that causes cell senescence, liver and immune dysfunction, and early mortality that results from deficiency of GIMAP5, an evolutionarily conserved GTPase selectively expressed in lymphocytes and endothelial cells. We show that GIMAP5 restricts the pathological accumulation of long-chain ceramides (CERs), thereby regulating longevity. GIMAP5 controls CER abundance by interacting with protein kinase CK2 (CK2), attenuating its ability to activate CER synthases. Inhibition of CK2 and CER synthase rescues GIMAP5-deficient T cells by preventing CER overaccumulation and cell deterioration. Thus, GIMAP5 controls longevity assurance pathways crucial for immune function and healthspan in mammals.

Successful Treatment with Ascorbic Acid in a Case of Methemoglobinemia Due to Glucose-6-Phosphate Dehydrogenase Deficiency

Cite this article as: Karaçoban G, Gurbanov A, Özen H, Gün E, Çakmaklı HF, Kendirli T. Successful treatment with ascorbic acid in a case of methemoglobinemia due to glucose-6-phosphate dehydrogenase deficiency. Turk Arch Pediatr. 2024;59(1):112-113.

Prospective Cohort Study of Incidence and Risk Factors for Catheter-associated Urinary Tract Infections in 212 Intensive Care Units of Nine Middle Eastern Countries

Objectives

To identify urinary catheter (UC)-associated urinary tract infections (CAUTI) incidence and risk factors (RF) in nine Middle Eastern countries.

Methods

We conducted a prospective cohort study between 1 January 2014 and 2 December 2022 in 212 intensive care units (ICUs) of 67 hospitals in 38 cities in nine Middle Eastern countries (Bahrain, Egypt, Jordan, Kuwait, Lebanon, Morocco, Saudi Arabia, Turkey, and the UAE). To estimate CAUTI incidence, we used the number of UC days as denominator and the number of CAUTIs as numerator. To estimate CAUTI RFs, we analyzed the following 10 variables using multiple logistic regression: patient sex, age, length of stay (LOS) before CAUTI acquisition, UC-days before CAUTI acquisition, UC-device utilization (DU) ratio, hospitalization type, ICU type, facility-ownership, country income level classified by World Bank, and time period.

Results

Among 50 637 patients hospitalized for 434 523 patient days, there were 580 cases of acquired CAUTIs. The pooled CAUTI rate per 1000 UC days was 1.84. The following variables were independently associated with CAUTI: age, rising risk 1.0% yearly (adjusted odds ratio [aOR] = 1.01, 95% CI: 1.01-1.02; p < 0.0001); female sex (aOR = 1.31, 95% CI: 1.09-1.56; p < 0.0001); LOS before CAUTI acquisition, rising risk 6.0% daily (aOR = 1.06, 95% CI: 1.05-1.06; p < 0.0001); and UC/DU ratio (aOR = 1.11, 95% CI: 1.06-1.14; p < 0.0001). Patients from lower-middle-income countries (aOR = 4.11, 95% CI: 2.49-6.76; p < 0.0001) had a similar CAUTI risk to the upper-middle countries (aOR = 3.75, 95% CI: 1.83-7.68; p < 0.0001). The type of ICU with the highest risk for CAUTI was neurologic ICU (aOR = 27.35, 95% CI: 23.03-33.12; p < 0.0001), followed by medical ICU (aOR = 6.18, 95% CI: 2.07-18.53; p < 0.0001) when compared to cardiothoracic ICU. The periods 2014-2016 (aOR = 7.36, 95% CI: 5.48-23.96; p < 0.001) and 2017-2019 (aOR = 1.15, 95% CI: 3.46-15.61; p < 0.001) had a similar risk to each other, but a higher risk compared to 2020-2022.

Conclusions

The following CAUTI RFs are unlikely to change: age, sex, ICU type, and country income level. Based on these findings, it is suggested to focus on reducing LOS, UC/DU ratio, and implementing evidence-based CAUTI prevention recommendations.

Venovenous Versus Venoarterial Extracorporeal Membrane Oxygenation: Pediatric Acute Respiratory Distress Syndrome

OBJECTIVE

This study aimed to compare the efficacy, complication, and mortality of patients who were supported by venovenous (VV) extracorporeal membrane oxygenation (ECMO) and venoarterial (VA) ECMO for pediatric acute respiratory distress syndrome (PARDS).

MATERIALS AND METHODS

This study is a single-center, retrospective cohort study between 2014 and 2022. We evaluated to indication of ECMO support, ECMO type, patients' demographic features, complications, and children's outcomes supported by ECMO for PARDS.

RESULTS

Twenty-two patients with PARDS, 12 (54%) with VV, and 10 (46%) with VA ECMO were selected. The median number of days to be intubated before ECMO cannulation was 5 (0-16) days. The distribution of intubated days before the patients underwent ECMO was as follows: 0-1 days, 7 (31.8%) patients; 2-3 days, 2 (9.1%) patients; 4-7 days, 7 (31.8%) patients; 8-14 days, 5 (22.8%) patients; >14 days, 1 (4.5%) patient. The median ECMO cannulation day after admission to the pediatric intensive care unit was 3 (range, 1-9) days in the VV ECMO patient group, whereas it was 8 (range, 0-19) days in the VA ECMO group (P = .02). Considering hospital survival, 4 (45%) patients who underwent double-lumen VV ECMO, 1 (33%) patient who underwent VV ECMO, and 3 (30%) patients who supported by VAECMO survived. There was no difference between the groups in terms of hospital discharge rates.

CONCLUSION

The highest survival rate was found in the VV ECMO patient group established with double-lumen cannulas, similar to the literature. There was no difference in mortality between the groups whose intubation time before ECMO was 14 days or less.

Evaluation of the efficacy and associated complications of regional citrate anticoagulation in neonates: experience from a fourth level neonatal intensive care unit

Continuous kidney replacement therapy (CKRT) use has increased in recent years, but anticoagulation is a challenge for neonates. Regional citrate anticoagulation (RCA) is rarely preferred in neonates because of citrate accumulation (CA) and metabolic complications. We aimed to demonstrate the efficacy and safety of RCA in neonates. We retrospectively analyzed the medical records of 11 neonates treated with RCA-CKRT between 2018 and 2023. The initial dose of RCA was 2.1-3 mmol/l, and then, its dose was increased according to the level of ionized calcium (iCa+2) in the circuit and patients. The total/iCa+2 ratio after-treatment > 2.5 was indicated as CA. We evaluated to citrate dose, CA, circuit lifespan, and dialysis effectivity. The median gestational age was 39 (36.4-41.5) weeks, the median body weight (BW) was 3200 (2400-4000) grams, and the mean postnatal age was 4 (2-24) days. The most common indication for CKRT was hyperammonemia (73%). All neonates had metabolic acidosis and hypocalcemia during CKRT. Other common metabolic complications were hypophosphatemia (90%), hypokalemia (81%), and hypomagnesemia (63%). High dialysate rates with a median of 5765 ml/h/1.73 m2 allowed for a rapid decrease in ammonia levels to normal. Four patients (36.3%) had CA, and seven (63.7%) did not (non-citrate accumulation, NCA). Mean BW, median postnatal age, biochemical parameters, coagulation tests, and ammonia levels were similar between the CA and NCA groups. Low pH, low HCO3, high lactate, and SNAPPE-II scores could be associated with a higher T/iCa ratio.

CONCLUSION

 RCA was an efficient and safe anticoagulation for neonates requiring CKRT. Metabolic complications may occur, but they could be managed with adequate supplementation.

WHAT IS KNOWN

• Continuous kidney replacement therapy (CKRT) has become popular in recent years due to its successful treatment of fluid overload, electrolyte imbalance, metabolic acidosis, multi-organ failure, and hyperleucinemia/hyperammonemia associated with inborn errors of metabolism. • The need for anticoagulation is the major difficulty in neonatal CKRT. In adult and pediatric patients, regional citrate anticoagulation has been shown to be effective.

WHAT IS NEW

• RCA is an effective and safe anticoagulation method for neonates who require CKRT. • Electrolyte imbalances and metabolic acidosis could be managed with adequate supplementation and appropriate treatment parameters such as citrate dose, blood flow rate, and dialysate flow rate.

Acute kidney injury in critically ill children with COVID-19 and MIS-C

BACKGROUND

This study's objective was to investigate the incidence of acute kidney injury (AKI) in children with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and multisystem inflammatory syndrome (MIS-C) and to report our clinical experience.

METHODS

Acute COVID-19 and MIS-C-diagnosed patients observed in two pediatric intensive care units (PICUs) between 2019 and 2021 were examined for AKI and retrospectively compared to children with AKI.

RESULTS

The study comprised 163 children, of whom 98 (60.1%) were diagnosed with acute COVID-19 and 65 (39.9%) with MIS-C. AKI was observed in 40 (40.8%) of the acute COVID-19 patients and 18 (27.7%) of the MIS-C patients. Low calcium level and hypotension were linked with AKI at initial presentation (OR: 0.56, 95% CI: 0.369-0.560, p = 0.006 and OR: 3.64, 95% CI: 1.885-7.152, p = 0.001, respectively). A history of nephrotoxic medication usage played an essential role in the development of AKI in patients who acquired AKI after hospitalization (p = 0.001, odds ratio: 9.32, confidence interval: 3.106-27.973). In clinical practice, individuals with respiratory distress and cough had a high chance of having AKI (OR: 4.47, 95% confidence interval: 2.25-8,892 and OR: 3.48, 95% confidence interval: 1.76-6.88). AKI patients had a greater demand for respiratory assistance and a longer period of stay in the PICU.

CONCLUSIONS

AKI in the COVID-19 and MIS-C patient groups is related with increased mortality and extended hospitalization, according to the findings. These statistics imply that identifying and preventing risk factors is necessary. A higher resolution version of the Graphical abstract is available as Supplementary information.

Impact of the COVID-19 pandemic on diabetic ketoacidosis management in the pediatric intensive care unit

BACKGROUND

Diabetic ketoacidosis (DKA) is a common endocrine emergency in pediatric patients. Early presentation to health facilities, diagnosis, and good management in the pediatric intensive care unit (PICU) are crucial for better outcomes in children with DKA.

METHODS

This was a single-center, retrospective cohort study conducted between February 2015 and January 2022. Patients with DKA were divided into two groups according to pandemic status and diabetes diagnosis.

RESULTS

The study enrolled 59 patients, and their mean age was 11±5 years. Forty (68%) had newly diagnosed type 1 diabetes mellitus (T1DM), and 61% received follow-up in the pre-pandemic period. Blood glucose, blood ketone, potassium, phosphorus, and creatinine levels were significantly higher in the new-onset T1DM group compared with the previously diagnosed group (P=0.01, P=0.02, P<0.001, P=0.01, and P=0.08, respectively). In patients with newly diagnosed T1DM, length of PICU stays were longer than in those with previously diagnosed T1DM (28.5±8.9 vs. 17.3±6.7 hours, P<0.001). The pandemic group was compared with pre-pandemic group, there was a statistically significant difference in laboratory parameters of pH, HCO3, and lactate and also Pediatric Risk of Mortality (PRISM) III score. All patients survived, and there were no neurologic sequelae.

CONCLUSIONS

Patients admitted during the pandemic period were admitted with more severe DKA and had higher PRISM III scores. During the pandemic period, there was an increase in the incidence of DKA in the participating center compared to that before the pandemic.

Prolonged extracorporeal membrane oxygenation in pediatrics: How long did we wait?

BACKGROUND

In this study, we aimed to evaluate the duration of extracorporeal membrane oxygenation (ECMO) and its effect on outcomes. Also, we sought to identify hospital mortality predictors and determine when ECMO support began to be ineffective.

METHODS

This was a single-center, retrospective cohort study conducted between January 2014 and January 2022. The prolonged ECMO (pECMO) cut-off point was accepted as 14 days.

RESULTS

Thirty-one (29.2%) of 106 patients followed up with ECMO had pECMO. The mean follow-up period of the patients who underwent pECMO was 22 (range, 15-72) days, and the mean age was 75 ± 72 months. According to the results of our heterogeneous study population, life expectancy decreased dramatically towards the 21st day. Hospital mortality predictors were determined in the logistic regression analysis in all ECMO groups in our study as high Pediatric Logistic Organ Dysfunction (PELOD) two score, continuous renal replacement therapy (CRRT) use, and sepsis. The pECMO mortality was 61.2% and the overall mortality was 53.0%, with the highest mortality rate in the bridge-to-transplant group (90.9%) because of lack of organ donation in our country.

CONCLUSIONS

In our study, the PELOD two score, presence of sepsis, and use of CRRT were found to be in the predictors of in-hospital ECMO mortality model. Considering the complications, in the COX regression model analysis, the factors affecting the probability of dying in patients followed under ECMO were found to be bleeding, thrombosis, and thrombocytopenia.

Hybrid extracorporeal membrane oxynegation in pediatric intensive care patients: A single center experience: More is better?

BACKGROUND

The initial extracorporeal membrane oxygenation (ECMO) configuration is inefficient for patient oxygenation and flow, but by adding a Y-connector, a third or fourth cannula can be used to support the system, which is called hybrid ECMO.

METHODS

This was a single-center retrospective study consisting of patients receiving hybrid and standard ECMO in our PICU between January 2014 and January 2022.

RESULTS

The median age of the 12 patients who received hybrid ECMO and were followed up with hybrid ECMO was 140 (range, 82-213) months. The total median ECMO duration of the patients who received hybrid ECMO was 23 (8-72) days, and the median follow-up time on hybrid ECMO was 18 (range, 3-46) days. The mean duration of follow-up in the PICU was 34 (range, 14-184) days. PICU length of stay was found to be statistically significant and was found to be longer in the hybrid ECMO group (p = 0.01). Eight (67%) patients died during follow-up with ECMO. Twenty-eight-day mortality was found to be statistically significant and was found to be higher in the standard ECMO group (p = 0.03). The hybrid ECMO mortality rate was 66% (decannulation from ECMO). The hybrid ECMO hospital mortality rate was 75%. The standard ECMO mortality rate was 52% (decannulation from ECMO). The standard ECMO hospital mortality rate was 65%.

CONCLUSIONS

Even though hybrid ECMO use is rare, with increasing experience and new methods, more successful experience will be gained. Switching to hybrid ECMO from standard ECMO at the right time with the right technique can increase treatment success and survival.

Clinical Management of a Pandrug-Resistant OXA-48 Klebsiella pneumoniae Infection in the Pediatric Intensive Care Unit

Background: Carbapenem-resistant Klebsiella pneumoniae (CRKP) is one of the serious forms of health care-associated infection. Pan-drug resistant (PDR) CRKP infections can cause severe infections. Mortality and treatment costs in the pediatric intensive care unit (PICU) are high. This study aims to share our experience regarding the treatment of oxacillinase (OXA)-48-positive PDR-CRKP infection in our 20-bed tertiary PICU with isolated rooms and 1 nurse for every 2-3 patients. Methods: Patient demographic characteristics, underlying diseases, previous infections, source of infection PDR-CRKP, treatment modalities, measures used, and outcomes were recorded. Findings: Eleven patients (eight men and three women) were found to have PDR OXA-48-positive CRKP. Because of the simultaneous detection of PDR-CRKP in three patients and the rapid spread of the disease, it was classified as a clinical outbreak, and strict infection control measures were taken. Combination therapy with double carbapenemase (meropenem and imipenem), amikacin, colistin, and tigecycline was used for treatment. The mean duration of treatment and isolation was 15.7 and 65.4 days, respectively. No treatment-related complication was observed, only one patient died, and the mortality rate was 9%. Conclusions: This severe clinical outbreak can be successfully treated with effective treatment with combined antibiotics and strict adherence to infection control measures. ClinicalTrial.gov ID: 28/01/2022 - 1/5.

Clinical and Laboratory Features and Factors Determining the Outcome in Poisoning Children in a Tertiary Pediatric Intensive Care Unit: Eleven Years of Experience

OBJECTIVE

This study aimed to evaluate the characteristics of patients admitted to a pediatric intensive care unit for poisoning and the factors associated with their outcomes.

MATERIALS AND METHODS

Patients who were admitted to the pediatric intensive care unit for poisoning over the 11-year period between January 2010 and December 2020 were retrospectively analyzed. The patients' demographic characteristics, poisoning agent, whether the poisoning was unintentional or intentional (suicide attempt), clinical findings at admission, indication for hospitalization, antidote administered, and supportive and extracorporeal treatments were examined.

RESULTS

During the study period, poisonings accounted for 9.4% (436/4653) of pediatric intensive care unit admissions. Of these, 419 patients with complete records were included in the analysis. Drug poisonings accounted for 81.9% of cases (multiple drugs in 38.5%). The most common drug group was central nervous system drugs (47%). Of the symptomatic patients, 56.5% had central nervous system-related findings and 55% had gastrointestinal findings. Before pediatric intensive care unit admission, 52.7% of the patients received activated charcoal and 7.4% received antidote therapy. In the pediatric intensive care unit, 68.9% of patients received no medical treatment, while 71.5% of those who received medical treatment had organ involvement. Multivariate logistic regression analysis to predict whether patients will require treatment during the intensive care follow-up showed that antidote administration before pediatric intensive care unit admission was associated with the need for medical treatment (odds ratio: 25.6, 95% CI: 6.8-96, P < .05). Three patients died, and the mortality rate was 0.72%.

CONCLUSION

Childhood poisoning is a widespread and important problem. Effective management in pediatric emergency and intensive care units contributes to patient survival without sequelae.

Early period intensive care follow-up after liver transplantation in children: a single center experience

BACKGROUND

Liver transplantation (LT) is a well-established, life-saving treatment for children with irreversible acute and chronic liver failure (LF). We aimed to evaluate the factors associated with morbidity and mortality in the early period of LT in children by reviewing our pediatric intensive care unit (PICU) experience.

METHODS

We reviewed children`s medical records followed in the PICU after LT between May 2015-August 2021, including demographic parameters, indications for LT, operative variables, respiratory and circulatory support requirements, LT-related complications and survival.

RESULTS

During this period, 40 pediatric patients who underwent LT were evaluated. LT was performed in 35 (87.5%) cases of chronic liver disease and 5 (12.5%) cases of acute liver failure. Twenty-four patients had chronic liver failure due to cholestatic liver disease. The patients` Pediatric Risk of Mortality (PRISM) III score was 18.82±SD (2-58) at PICU admission. 1-year survival was 87.5%, and overall survival was 85%. Younger age, low body weight, preoperative pediatric end-stage liver disease (PELD), and model for end-stage liver disease (MELD) values of 20 and higher were important risk factors for unfavorable outcomes after living donor liver transplantation (LDLT). These risk factors are both associated with technically more challenging vascular and bile duct reconstruction and higher complication rates, and increased mortality during the early period after LT.

CONCLUSIONS

The early period of optimum PICU management in pediatric LT recipients is crucial for successful outcomes, which is also related to the patients` characteristics, disease severity scores, and surgical procedures.

Extracorporeal Therapies in Children with Acute Liver Failure: A Single-Center Experience

BACKGROUND

The aim of this study is to determine the indication, timing, and administration of extracorporeal therapies such as total plasma exchange and continuous renal replacement therapy in children with acute liver failure or acute-on-chronic liver failure.

METHODS

This study is conducted as a retrospective, single-center study. Between January 2016 and December 2021, pediatric acute liver failure or acute-on-chronic liver failure patients for whom total plasma exchange and/or continuous renal replacement therapy was performed were included in this study.

RESULTS

Thirty-four children with acute liver failure or acute-on-chronic liver failure were included during the study period. The children comprised 14 (41.1%) males, and the median age of the patients was 54 months (5-21). Twenty-four patients (70.6%) had pediatric acute liver failure, and 10 patients (29.4%) had acute-on-chronic liver failure. Patients' median model for end-stage liver disease and pediatric end-stage liver disease scores were 24.7/23.5, respectively. Total plasma exchange therapy was performed on all patients whereas continuous renal replacement therapy was performed on 13 patients (38.2%). The median duration of continuous renal replacement therapy was 2.5 days (2-24). The median number of the total plasma exchange sessions was 3 (1-20). The median length of stay in pediatric intensive care unit was 4.5 (2-74) days. Eleven (32.5%) patients had 1 or more improvements in hepatic encephalopathy scores after extracorporeal therapy. Eleven (32.5%) patients died. There was a significant difference between the survivors and non-survivors with respect to levels of albumin, ammonia, pediatric risk of mortality scores, and pre-hepatic encephalopathy scores. Liver transplantation was performed in 4 of 24 pediatric acute liver failure patients, and all of them survived.

CONCLUSION

Total plasma exchange and continuous renal replacement therapy are life-saving, and both methods may reduce morbidity and mortality, also bridging to liver transplantation.

Interhospital Aircraft/Ground Extracorporeal Membrane Oxygenation Transportation by a Mobile Extracorporeal Membrane Oxygenation Team: First Turkish Pediatric Case Series

OBJECTIVE

Extracorporeal membrane oxygenation is a life-saving treatment for patients with circulatory and respiratory failure refractory to standard therapy. However, safe and timely patient transport to the referral extracorporeal membrane oxygenation center is critical for better patient outcomes in patients with acute cardiogenic shock. This study aimed to describe children's features who were transferred to our center under extracorporeal membrane oxygenation by aircraft/ground vehicle and demonstrated the importance of extracorporeal cardiopulmonary resuscitation for transported children.

MATERIALS AND METHODS

We report the first Turkish pediatric case series of patients with acute cardiogenic shock transported by aircraft and ground ambulances on extracorporeal membrane oxygenation support to a referral extracorporeal membrane oxygenation center between January 2016 and January 2021.

RESULTS

Overall, 6 patients on venoarterial extracorporeal membrane oxygenation support were transported by aircraft and ground vehicles to our pediatric intensive care unit. Transport was achieved by fixed-wing aircraft in 5 patients and commercial aircraft in 1. Our mobile extracorporeal membrane oxygenation team cannulated 3 patients, and 3 patients were cannulated by the team at the hospital they applied to. The median age was 112 (range: 14-204) months and the median weight was 28.6 kg (range: 8.6-57.2 kg). The etiology of acute cardiogenic shock was fulminant myocarditis in 4 patients, dilated cardiomyopathy in 1, and transposition of great arteries and atrial flutter in 1. The median distance of travel for the patients to our hospital was 618 (407-955) km. No adverse events were detected during aircraft or ground vehicle transport.

CONCLUSION

Mobile pediatric extracorporeal membrane oxygenation transport teams may provide safe aircraft and ground vehicle transportation in high-risk patients with acute cardiogenic shock bridging to survival or long-term circulatory support.

Colchicine Poisoning Cases in a Pediatric Intensive Care Unit: A Twenty-Year Study

OBJECTIVES

Colchicine intoxication is rare but potentially fatal. The toxic dose of colchicine is not well established; it has been reported that major toxicity starts after doses of 0.5 mg/kg. We aimed to evaluate the demographic, clinical aspects, treatments, and outcome of colchicine toxicity cases in the pediatric intensive care unit (PICU).

METHODS

We collected the data of patients aged between 0 and 18 years, admitted to Ankara University Faculty of Medicine PICU for colchicine poisoning (n = 22), from October 1999 to January 2020, retrospectively. Data extracted from the cases included age, sex, chronic condition, time between intake of drug and admission to PICU, source of drug, amount of drug ingested, other drug intake, symptoms, clinical findings, cardiac involvement, laboratory results, time of stay in PICU, treatment, and outcome.

RESULTS

Patients' age ranged from 7 months to 17 years. Median age was 86 months. The most common symptom at time of admission was vomiting, occurring in 13 (59%) of the patients. Two of the patients presented with change in mental status. Time between taking medication and applying to the hospital ranged from half an hour to 4 days. Medication intake of 3 of 22 patients was more than 0.5 mg/kg. One patient whose parents' best estimate of dose ingested was 0.48 mg/kg died because of the development of multiorgan failure. One patient who ingested 0.4 mg/kg of colchicine underwent plasma exchange and recovered without any complications.

CONCLUSIONS

Colchicine poisoning has a high risk of mortality, and death can be seen in doses less than a single acute dose of 0.5 mg/kg. These patients need close monitoring because there is always a risk of them to require aggressive support. Prognosis is poor in patients who have rapidly developing hemodynamic failure.

Neisseria Meningitidis Serogroup Z–Induced Meningitis: The First Case from Turkey

Neisseria meningitidis is a significant worldwide cause of bacterial meningitis and sepsis. High case-fatality rates and severe complications in survivors can occur. We present a 1-month 23-day-old case diagnosed with meningococcal meningitis and sepsis, in which serogroup Z of N. meningitidis was isolated from cerebrospinal fluid and blood cultures and treated with ceftriaxone for 7 days. Our patient is the first case of N. meningitidis serogroup Z–induced invasive meningococcal infection in Turkey. N. meningitidis serogroup Z is not included in the current meningococcal vaccines. It is concerning that a nonvaccine serogroup caused this invasive meningococcal disease and that even if the vaccine would cover this serogroup, it has happened before the usual age of administration. Therefore, meningococcal disease surveillance should continue, and an effective prevention and control strategy for nonvaccine serogroups should be implemented.

Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation in Children with Liver Dysfunction/Failure

Regional citrate anticoagulation (RCA) is an option but citrate accumulation is risk and it is a giving up cause for this situation. This retrospective study was conducted in the pediatric intensive care unit (PICU) between May 2019 and April 2021. We investigated 47 patients with liver failure (LF) in our PICU, and RCA during continuous renal replacement therapy (CRRT) was applied to 10 (21.3%) of them. Half of them were male (n: 5/10), their mean age was 104.7 ± 66.20 months. Nine of them needed vasoactive support during follow-up. The most common indication for CRRT was hepatorenal syndrome (40%). There was no significant difference between liver transaminases and liver function tests before and after CRRT (p > 0.05). In terms of citrate toxicity of the patients, there was no significant difference between total calcium/ionized calcium, lactate level, pH and bicarbonate values before and after CRRT (p > 0.05). The mean total CRRT time was 110.2 ± 118.2 h, and the mean circuit lifespan was 43.8 ± 48.7 h; the mean number of circuits was 2.7 ± 2.4. Total Ca/ionized Ca >2.5 was a clinically relevant endpoint, but no patient interrupted dialysis for this cause. There was no complication about RCA. This study did not observe any adverse effects on acid-base status, transaminases, an increase in bilirubin during RCA-CRRT treatment in pediatric patients with LF. Total calcium/ionized calcium ratio, serum lactate level and prothrombin time level should be closely monitored daily in terms of citrate accumulation in this patient group.

Comparison of pre-PICU and per-PICU interventions, clinical features and neurologic outcomes of motor vehicle collision trauma and other mechanisms of trauma in children

BACKGROUND

Motor vehicle collisions (MVCs) are the number one cause of death in the pediatric age group. The aim of this study was to determine the differences between MVCs and other trauma mechanisms (OTMs) in patients who were followed up at a pediatric intensive care unit (PICU).

METHODS

Data were retrospectively collected for pediatric trauma patients hospitalized at a third level PICU between 2014 and 2018. Patients have been divided into two groups as MVC and OTM. Demographic data, pre-PICU interventions (cardiopulmonary resuscitation, intubation, injury severity scores, time period before intensive care), intensive care interventions (invasive mechanical ventilation, non-invasive mechanical ventilation, need for surgery, type of surgery, need for transfusion, and inotrope therapy) were compared between two groups. Outcomes were evaluated by survival, discharge from hospital, Pediatric Cerebral Performance Cate-gory (PCPC) at discharge, tracheotomy presence, and amputation performed.

RESULTS

During the 5-year study period, 135 patients were hospitalized for trauma. The injured body regions were the head and neck (61.5%), abdomen and lumbar spine (39.4%), and extremities and pelvis (36.3%). Multiple trauma was mostly seen in the MVC trauma group (p=0.001). The need for invasive mechanical ventilation and inotrope therapy was greater in the MVC group (p=0.002, 0.001 respectively). One hundred and twenty-three patients (91.1%) survived. The mortality rate was higher in the MVC group (p=0.026). The PCPC results were better in the OTM group (p=0.017).

CONCLUSION

MVCs lead to more multiple trauma cases than OTMs. Invasive mechanical ventilation, inotropes, and other inten-sive care interventions were necessary much more often in MVC victims than in OTM patients.

Use of Therapeutic Plasma Exchange in the Pediatric Intensive Care Unit

Objective: Therapeutic plasma exchange has been used as a primary or supportive treatment in many diseases in recent years and has achieved satisfactory results in lots of diseases in children. Therapeutic plasma exchange procedure is changing plasma component of a patient's blood with the new plasma as a replacement solution. The aim of this study is to share our experience of therapeutic plasma exchange on varying indications in critically ill children who were accepted to our pediatric intensive care unit.

Materials and Methods: We conducted this study between December 2010 and February 2020, retrospectively. Patients’ data such as age, sex, indication, number of sessions, vascular access route, and type of replacement fluid used were obtained from medical records. Indications for therapeutic plasma exchange were classified according to the 2019 American Society for Apheresis categorization. The patient’s follow-up, clinical courses, therapeutic plasma exchange season count, complications, and outcome were evaluated according to each indications and their overall condition.

Results: This study included a total of the 84 patients who underwent therapeutic plasma exchange, and their median (minimum-maximum) ages were 7.07 years (0.2-18), 57.1% were male (n = 48) and 42.9% were female (n = 36). A total of 463 sessions of therapeutic plasma exchange were performed in 84 patients. The most common indication was thrombocytopenia-associated multi-organ failure with sepsis (40.4%, n = 34) followed by liver failure/hepatic encephalopathy (28.5%, n = 24) and autoimmune encephalitis (9.5%, n = 8), and according to The American Society for Apheresis 2019 category, patients distributions were as follows: 15.4% of the patients were placed in category 1 (n = 13), 5.9% in category 2 (n = 5), 77.3% in category 3 (n = 65), and 1.1% in category 4 (n = 1). Therapeutic plasma exchange was combined to extracorporeal membrane oxygenation in 10 patients (11.9%) and continuous renal replacement therapies in 39 (46.4%) patients. Finally, the survival rate was 50% in all patients, and the lowest survival rate was 41.5% (n = 27) in category 3 group.

Conclusion: Therapeutic plasma exchange is enlarging to varying indications and showing to be more effective on a lot of disorders in children. Also, it is available in pediatric age groups and in different states like combined with other extracorporeal therapies.

Early Neurologic Complications and Long-term Neurologic Outcomes of Extracorporeal Membrane Oxygenation Performed in Children

BACKGROUND

We aimed at evaluating acute neurologic complications (ANC) and clinical outcome at a 2-year follow-up in children after extracorporeal membrane oxygenation (ECMO).

METHODS

We conducted a single-center, retrospective review of our patient cohort aged between 1 month and 18 years at the time of ECMO support (between June 2014 to January 2017). Outcome analysis included ANC and their clinical consequences.The Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) were used for neurologic assessment performed at discharge from the hospital and at 2nd year follow-up.

RESULTS

There were 35 children who required ECMO. The median ECMO time was 9 days (range 2-32 days). Decannulation from ECMO was achieved in 68.6% of patients, and overall, 42.8% survived (15 patients), The incidence of ANC in the surviving patients was 40% (6 children). ANC were intracranial hemorrhage, seizures, cerebral infarction, which occurred in one, two and three of the 15 surviving patients respectively (6.6, 13.3 and 20%). A higher rate of organ failure was related to death (p=0.043), whereas duration on ECMO was a risk factor for the development of ANC (p<0.05). At hospital discharge, the 14 patients evaluated had normal development or -mild disability in 73.2%, and at the 2-year follow-up, 93.4% had these scores.

CONCLUSION

Children who receive ECMO have a risk to develop ANC, which was related to the length of ECMO treatment, while survival was related to less organ failure, Long-term neurological outcome was good in our patient cohort.

Clinical Features and Outcomes of Children Admitted to the PICU due to Rotavirus Infection

OBJECTIVES

In this study, we aimed to evaluate the clinical and laboratory features of the patients with rotavirus (RV) antigen positivity on or following admission to the pediatric intensive care unit (PICU).

METHODS

Patients admitted to the PICU due to community-acquired rotavirus (CA-RV) or hospital-acquired rotavirus (HA-RV)-induced gastroenteritis between January 1, 2013, and December 31, 2019 were evaluated.

RESULTS

Thirty-four patients with a mean age of 14.00 ± 19.17 months were enrolled. Fortyfour percent were girls. Twenty (58.8%) patients had a history of chronic diseases. Nine (26.5%) patients had CA-RV and 25 (73.5%) patients had HA-RV infection. RV antigens were simultaneously found in 44.1% (n = 14) of the other patients at the time of diagnosis. In the study sample, 5 patients had hyponatremia, 8 had hypernatremia, 6 had hypokalemia, 4 had hypoalbuminemia, 21 had leukocytosis, 2 had leukopenia and 3 had thrombocytopenia, and 17 had elevatedC-reactive protein (CRP) levels. Three patients had seizures, 1 patient had cardiac arrest, and 2 patients had secondary bacteremia. The mean (SD) PICU length of stay was 6 (6.02) with CA-RV gastroenteritis. All CA-RV patients survived, but 8 of the HA-RV patients succumbed to causes other than RV.

CONCLUSION

RV-related PICU admission is not rare, and occasional severe clinical consequences occur, especially in young children, with both CA-RV and HA-RV gastroenteritis. Appropriate timely intervention and meticulous follow-up improve survival.

Clinical characteristics of firearm-related injuries in children in Turkey

BACKGROUND

A significant number of children are injured by or die from firearm-related incidents every year, although there is a lack of global data on the number of children admitted to pediatric emergency departments (PEDs) and pediatric intensive care units (PICU) with firearm injuries. This study is the most comprehensive analysis of firearm injuries sustained by children in Turkey to date.

METHODS

This multicenter, retrospective, cohort study was conducted between 2010 and 2020 with the contributions of the PEDs, PICUs, intensive care units, and surgery departments of university hospitals and research hospitals.

RESULTS

A total of 508 children were admitted to hospital with firearm-related injuries in the research period, although the medical records of only 489 could be obtained. Of the total admissions to hospitals, 55.0% were identified as unintentional, 8.2% as homicide, 4.5% as self-harm, and 32.3% as undetermined. The Glasgow Coma Scale (GCS) and ventilation support were found to be the most significant predictors of mortality, while head/neck injury, length of stay (LOS) in the hospital and surgical interventions were found to be the most significant predictors of disability. The overall mortality of firearm-related injuries was 6.3%, and the mortality for children admitted to the PICU was 19.8%. The probability of disability was calculated as 96.0% for children hospitalized with firearm injuries for longer than 75 days.

CONCLUSIONS

Head/neck injury, LOS in the hospital, and surgical interventions were found to be the most significant parameters for the prediction of disability. Hospitalization exceeding 6 days was found to be related to disability.

COVID-19 Transmission and Clinical Features in Pediatric Intensive Care Health Care Workers

OBJECTIVE

This study aims to investigate modes of transmission and clinical features of coronavirus disease 2019 in healthcare workers in pediatric intensive care units.

MATERIALS AND METHODS

This multicenter descriptive study was conducted between March and November 2020. Patient demographics, clinical characteristics, origin of coronavirus disease 2019, treatment modalities, and loss of workdays were recorded.

RESULTS

Seven hundred and sixty-eight healthcare workers from 16 pediatric intensive care units were enrolled and 114 (14.8%) healthcare workers with a mean age of 29.7 ± 6.7 years became coronavirus disease 2019 patients. Seventy-six (66.7%) patients were female. Approximately half (54.3%) of the patients were physicians, 34.2% were nurses, and 11.4% were ancillary staff. Transmission was deemed to occur through patient contact in 54.3% of the patients. Comorbid illness was present 10.5% of the patients. Transmission occurred during endotracheal intubation in 21%, cardiopulmonary resuscitation in 9.6%, and non-invasive ventilation in 12.2% of patients, while transmission was a result of multiple possible procedures in 43.8%. Intensive care admission was needed for 13.1% of the patients. Five patients needed oxygen by cannula, 7 needed oxygen with a non-rebreathing mask, 5 needed high-flow nasal cannula support, 5 needed non-invasive ventilation, and 3 needed invasive mechanical ventilation. Fortunately, no infected healthcare workers died.

CONCLUSION

Coronavirus disease 2019 in healthcare workers is a significant problem in pediatric intensive care units. Transmission seems to occur particularly frequently during patient care procedures such as intubation, ventilation and aerosol therapy, which highlights the importance of proper use of full sets of personal protective equipment during all procedures during care of coronavirus disease 2019 patients.

Characteristics of continuous venovenous hemodiafiltration in the acute treatment of inherited metabolic disorders

BACKGROUND

Continuous kidney replacement therapies (CKRT) have been reported to be an effective approach to removing toxic metabolites in inborn errors of metabolism (IEM). The present study evaluates efficiency and complications of CKRT in children with IEM.

METHODS

Patients diagnosed with IEM who underwent CKRT in pediatric and neonatal intensive care units were analyzed. CKRT were initiated in patients with persistently high blood ammonia levels (≥ 500 μmol/L), blood ammonia levels > 250 μmol/L in the presence of moderate encephalopathy, high blood leucine levels (≥ 1500 μmol/L), and blood leucine levels < 1500 μmol/L in the presence of deteriorating neurological status or persistent metabolic acidosis.

RESULTS

Of 22 patients enrolled, nine (40.9%) Maple syrup urine disease (MSUD), eight (36.4%) urea cycle disorders (UCD), and five (22.7%) organic acidemias (OA). Median age was 72.3 [9.9-1040.8] days. In total, 28 dialysis sessions were analyzed [16 (57.1%) continuous venovenous hemodialysis, and 12 (42.9%) continuous venovenous hemodiafiltration]. A significant decrease was noted in leucine levels (from 1608.4 ± 885.3 to 314.6 ± 109.9 µmol/L) of patients with MSUD, while ammonia levels were significantly decreased in patients with UCD and OA (from 1279.9 ± 612.1 to 85.1 ± 21.6 µmol/L). The most frequent complications of CKRT were thrombocytopenia (60.7%), hypotension (53.6%), and hypocalcemia (42.9%). Median age of patients with hypotension treated with vasoactive medications was significantly lower than median age of those with normal blood pressure.

CONCLUSION

CKRT is a reliable approach for effective and rapid removal of toxic metabolites in children with IEM, and CKRT modalities can be safely used and are well-tolerated in infants.

Acute Abdomen—A Clinical Presentation of MIS-C in Children

Objective Multisystemic inflammatory syndrome in children (MIS-C) is characterized by persistent fever, systemic hyperinflammation, and multiple-organ dysfunction. There are a few reports about MIS-C presenting with acute abdomen. The aim of this study was to demonstrate the clinical characteristics and treatment options for MIS-C-related acute abdomen and appendicitis.

Methods This was a retrospective study conducted between April 2020 and October 2020 in our pediatric intensive care unit in Turkey. Patients between the ages of 1 month and 18 years who presented with acute abdomen and were ultimately diagnosed with MIS-C were included.

Results Seven patients with a median age of 12.5 (interquartile range 10.5–13) years were enrolled. Four were females. The most frequent symptoms were fever, abdominal pain, and vomiting. Three patients had involvement of the appendix that required surgical intervention. All pathology reports were compatible with appendicitis. The other patients also had an acute abdomen. One patient had malignant hyperthermia during induction of anesthesia, so surgery was postponed and medical management was commenced. The clinical picture regressed with immunomodulation. All patients were treated with intravenous immunoglobulin and steroids. Four patients with acute abdomens improved with immunomodulation, and surgery was not needed.

Conclusion MIS-C may present with an acute abdomen. Immunomodulation should be considered instead of surgery if the clinical course is not complicated.

A successful treatment with intravenous lipid emulsion therapy in a child with verapamil poisoning

In recent years, intravenous lipid emulsion therapy (ILE) was used for lipophilic drug intoxications, and successful results were obtained. In the literature, there is a small number of reported cases about verapamil intoxication and ILE therapy in the pediatric age group. We used ILE therapy in a 14-year-old girl with verapamil intoxication in the 2^nd h of the pediatric intensive care unit stay, before using traditional treatments such as glucagon and hyperinsulinemic euglycemia. She had resistant bradycardia and hypotension which was unresponsive to inotropic agents and a successful result was obtained after using ILE treatment. We believe our report may contribute to the early use of ILE therapy for toxicity with calcium channel blockers such as verapamil in pediatric patients.