Citrate anticoagulation and systemic heparin anticoagulation during continuous renal replacement therapy among critically-ill children.

BAKCGROUND: The aim of this study was to evaluate the efficacy and safety of citrate versus heparin anticoagulation for CRRT in critically-ill children. METHODS: This retrospective comparative cohort reviewed the clinical records of critically-ill children undergoing CRRT with either RCA or systemic heparin anticoagulation. The primary outcome measure was hemofilter survival time. Secondary outcomes included the comparison of complications and metabolic disorders. RESULTS: A total of 131 patients (55 RCA and 76 systemic heparin) were included, in which a cumulative number of 280 hemofilters were used (115 in RCA with 5762 h total CRRT time, and 165 in systemic heparin with 6230 h total CRRT time). Hemofilter survival was significantly longer for RCA (51.0 h; IQR: 24-67 h) compared to systemic heparin (29.5 h; IQR, 17-48 h) (p = 0.002). Clotting-related hemofilter failure occurred in 9.6% of the RCA group compared to 19.6% in the systemic heparin group (p = 0.038). Citrate accumulation occurred in 4 (3.5%) of 115 RCA sessions. Hypocalcemia and metabolic alkalosis episodes were significantly more frequent in RCA recipients (35.7% vs 15.2%, p < 0.0001; 33.0% vs 19.4%, p = 0.009). CONCLUSION: RCA is a safe and effective anticoagulation method for CRRT in critically-ill children and it prolongs hemofilter survival. IMPACT: RCA is superior to systemic heparin for the prolongation of circuit survival (overall and for clotting-related loss) during CRRT. These data indicate that RCA can be used to maximize the effective delivery of CRRT in critically-ill patients admitted to the PICU. There are potential cost-saving implications from our results owing to benefits such as less circuit downtime and fewer circuit changes.

Emergency application of extracorporeal membrane oxygenation in a pediatric case of sudden airway collapse due to anterior mediastinal mass: A case report and review of literature.

Mediastinal masses can compress the respiratory or cardiovascular system, especially when anteriorly located. Obtaining histological material for diagnosis poses a challenge due to the major risk of cardiorespiratory collapse following anesthetic procedure. Our case shows the utility of rescue with venovenous extracorporeal membrane oxygenation (VV-ECMO) after occurrence of such an event and demonstrates the feasibility of administering chemotherapy during VV-ECMO. A 4-year-old boy was referred to the pediatric oncology clinic of our hospital after a large mediastinal mass was observed on chest radiography ordered due to persistent cough. Computed tomography of the thorax revealed a 100×85 mm mass in the anterior mediastinum, surrounding the heart, and showed that there was compression to the trachea, bronchiole, and vascular structures. Percutaneous needle biopsy accompanied by ultrasonography was planned for diagnostic purposes. Low-dose ketamine and midazolam were administered for procedural sedation in the operating room. After the biopsy procedure, the patient developed sudden airway obstruction requiring intubation. Despite 100% oxygen support with a mechanical ventilator, pulse oximeter saturation remained below 80%. Chest X-ray revealed total collapse of the left lung, and the patient's oxygen saturation did not increase with selective left bronchial intubation. Bi-caval dual-lumen ECMO cannula was placed in the internal jugular vein and VV-ECMO was initiated, resulting in swift improvement in hypoxemia. The patients's anterior mediastinal mass shrank rapidly and left lung improved with chemotherapy. The patient remained on ECMO for a total of 9 days and was extubated 2 days after ECMO termination, followed by discharge to the pediatric oncology ward on the 20th day of pediatric intensive care unit stay. It is well known that large, anteriorly-located mediastinal masses carry a considerable risk of causing cardio-pulmonary collapse during procedures involving anesthesia. All life-saving options, including emergency ECMO, should be available before any planned invasive procedures in these patients.

Controlling Nutritional Status Score Predicts In-Hospital Mortality in Acute Pulmonary Embolism.

OBJECTIVE: The association between the nutritional status and outcomes in pulmonary embolism is unclear. This study was aimed at examining the value of the Controlling Nutritional Status (CONUT) score in assessing malnutrition among acute pulmonary embolism patients. SUBJECT AND METHODS: We retrospectively reviewed the records of adult patients with acute pulmonary embolism hospitalized through our ED. Demographic, clinical, and laboratory data on admission were recorded. Nutritional status was assessed with the CONUT score, which is calculated by the albumin, total cholesterol, and lymphocyte counts. The primary endpoint of the study was in-hospital mortality. RESULTS: A total of 308 consecutive patients (mean age 68.2 ± 12.9 years, 53.9% female) were included, and 35 of the patients (11.4%) died during their in-hospital course. Multivariate analysis showed that a pulmonary embolism severity index >148 (OR 3.12, 95% CI: 1.65-8.81, p < 0.001), the presence of heart failure (1.25, 95% CI: 1.08-1.78, p = 0.03), and a CONUT score >4 (OR 1.39, 95% CI: 1.146-3.424, p = 0.015) were independent predictors of in-hospital mortality. CONCLUSION: The present study indicates that the presence of malnutrition defined by the CONUT score predicts in-hospital mortality following acute pulmonary embolism.

Subclinical cardiovascular dysfunction in children and adolescents with asthma.

BACKGROUND: There is close association between asthma and cardiovascular functions as both diseases share common inflammatory pathways. The current study was aimed at investigating the risk factors, associated with endothelial and cardiac functions in children with newly-diagnosed mild-persistent asthma. METHODS: A total of 33 steroid-naive asthmatic children [median(interquartile-range); 9.1 years(7.8-13.5)] and 16 healthy controls [11.5 years(9.9-13.6)] were included. Their demographic, clinical and laboratory findings were recorded. Carotid Artery intima-media thickness (CIMT), stiffness, distensibility and strain were measured as atheroclerosis markers. Conventional and tissue Doppler imaging was performed to evaluate ventricular function. RESULTS: The patients with asthma had higher CIMT and stiffness and lower strain and distensibility compared to controls (p < 0.001 for all). There was a significant correlation between the duration of asthmatic symptoms and subclinical-atherosclerosis as well as peripheral eosinophil count (p < 0.001, p < 0.05). The patients had lower tricuspid-annular-plane-systolic-excursion (TAPSE), ejection time, and higher isovolumetric relaxation time (IRT), isovolumetric contraction time (ICT), and left ventricle myocardial performance index (LVMPI) than the control subjects (p < 0.001 for all). A positive correlation was also observed between the duration of asthmatic-symptoms and cardiac-function parameters. CONCLUSION: Children with mild persistent asthma had subclinical atherosclerosis and ventricular dysfunction even in the early stage of disease. Symptom duration was closely associated with both subclinical atherosclerosis and ventricular dysfunction. Myocardial performance index was abnormal in the asthmatic children when assessed by tissue Doppler Imaging even though they had normal ejection fraction in conventional echocardiography. Future prospective studies with larger sample sizes are needed to confirm these findings and to assess the possible protective effect of ICSs in the prevention of subclinical atherosclerosis.

Evaluation of an artificial intelligence system for diagnosing scaphoid fracture on direct radiography.

PURPOSE: The aim of this study is to determine the diagnostic performance of artificial intelligence with the use of convolutional neural networks (CNN) for detecting scaphoid fractures on anteroposterior wrist radiographs. The performance of the deep learning algorithm was also compared with that of the emergency department (ED) physician and two orthopaedic specialists (less experienced and experienced in the hand surgery). METHODS: A total 390 patients with AP wrist radiographs were included in the study. The presence/absence of the fracture on radiographs was confirmed via CT. The diagnostic performance of the CNN, ED physician and two orthopaedic specialists (less experienced and experienced) as measured by AUC, sensitivity, specificity, F-Score and Youden index, to detect scaphoid fractures was evaluated and compared between the groups. RESULTS: The CNN had 76% sensitivity and 92% specificity, 0.840 AUC, 0.680 Youden index and 0.826 F score values in identifying scaphoid fractures. The experienced orthopaedic specialist had the best diagnostic performance according to AUC. While CNN's performance was similar to a less experienced orthopaedic specialist, it was better than the ED physician. CONCLUSION: The deep learning algorithm has the potential to be used for diagnosing scaphoid fractures on radiographs. Artificial intelligence can be useful for scaphoid fracture diagnosis particularly in the absence of an experienced orthopedist or hand surgeon.

Comparison of chlorhexidine impregnated dressing and standard dressing for the prevention of central-line associated blood stream infection and colonization in critically ill pediatric patients: A randomized controlled trial.

BACKGROUND: The aim of this study was to compare chlorhexidine gluconate (CHG)-impregnated dressing and standard dressing with respect to the frequency of central-line-associated bloodstream infection (CLABSI), catheter-related bloodstream infection, primary bloodstream infection, and catheter colonization in critically ill pediatric patients with short-term central venous catheters. METHODS: Children who were admitted to the pediatric intensive care unit of a tertiary institution between May 2018 and December 2019 and received placement of a short-term central venous catheter were included in this single-center randomized controlled trial. Patients were grouped according to the type of catheter fixation applied. RESULTS: A total of 307 patients (151 CHG-impregnated dressing, 156 standard dressing), with 307 catheters (amounting to a collective total of 4,993 catheter days), were included in the study. The CHG-impregnated dressing did not significantly decrease the incidence of CLABSI (6.36 vs 7.59 per 1,000 catheter days; hazard ratio (HR): 0.93, P = 0.76), catheter related bloodstream infection (3.82 vs 4.18 per 1,000 catheter days; HR: 0.98; P = 0.98), and primary bloodstream infection (2.54 vs 3.42 catheter days; HR: 0.79; P = 0.67). The CHG-impregnated dressing significantly decreased the incidence of catheter colonization (3.82 vs 7.59 per 1,000 catheter days; HR: 0.40; P = 0.04). In both groups, the most frequent microorganisms isolated in CLABSI or catheter colonization were Gram-positive bacteria (the majority were coagulase-negative staphylococci). CONCLUSIONS: The use of CHG-impregnated dressing does not decrease CLABSI incidence in critically ill pediatric patients but it significantly reduced catheter colonization. Coagulase-negative staphylococci were the most common microorganisms causing CLABSI or catheter colonization.

Oral mucosal mouthwash with chlorhexidine does not reduce the incidence of ventilator-associated pneumonia in critically ill children: A randomised controlled trial.

BACKGROUND: Ventilator-associated pneumonia (VAP) is one of the most frequently encountered causes of hospital-acquired infection and results in high morbidity among intubated patients. Few trials have investigated the efficacy of oral care with chlorhexidine (CHX) mouthwash for the prevention of VAP in the paediatric population. OBJECTIVES: The objective of this study was to assess the efficacy of CHX mouthwash in the prevention of VAP and to determine risk factors for VAP in children aged 1 month to 18 years admitted to the paediatric intensive care unit (PICU). METHODS: This was a prospective, randomised, controlled, double-blind trial performed in the PICU. Patients were randomised into two groups receiving CHX (0.12%) (n = 88) or placebo (0.9% NaCl) (n = 86) and were followed up for VAP development. The main outcome measures were incidence of VAP, duration of hospital stay, duration of PICU stay, duration of ventilation, mortality, and the characteristics of organisms isolated in cases with VAP. RESULTS: No difference was observed in the incidence of VAP and the type and distribution of organisms in the two groups (p > 0.05). In the CHX and placebo groups, we identified 21 and 22 patients with VAP, respectively. Incidence per 1000 ventilation days was 29.5 events in the CHX group and 35.1 events in the placebo group. Gram-negative bacteria were most common (71.4% in CHX vs. 54.5% in placebo). The use of 0.12% CHX did not influence hospital stay, PICU stay, ventilation, and mortality (p > 0.05). Multivariate analysis identified duration of ventilation as the only independent risk factor for VAP (p = 0.001). CONCLUSION: The use of 0.12% CHX did not reduce VAP frequency among critically ill children. The only factor that increased VAP frequency was longer duration on ventilation. It appears that low concentration of CHX is not effective for VAP prevention, especially in the presence of multiresistant bacteria. GOV IDENTIFIER: NCT04527276.

Anaphylactoid reaction during hemodiafiltration on AN69 membrane in a patient with atypical hemolytic uremic syndrome: A pediatric case report.

Reactions associated with hemodiafiltration can be life threatening if not recognized early in the course of dialysis. AN69 (acrylonitrile and sodium methallyl sulfonate copolymer) membrane-associated reactions during hemodialysis have been documented in adult patients receiving angiotensin converting enzyme inhibitors, which are thought to be triggered by the negative charge of the AN69 membrane. Here, we present a 5-month-old girl requiring continuous renal replacement therapy (CRRT) for acute kidney injury secondary to atypical hemolytic uremic syndrome who experienced acute cyanosis, angioedema, tachycardia, and impaired circulation during CRRT. After switching to a different type of hemofiltration membrane, her clinical findings improved and she was able to tolerate hemodialysis. We concluded that she had experienced an anaphylactoid reaction to the AN69 membrane. To our knowledge, this case is the first pediatric case report of AN69 membrane-associated anaphylactoid reaction.

Relationship between a Prolonged Corrected QT Interval and Mortality in Patients Presenting with Syncope at the Emergency Department.

BACKGROUND: Syncope is a common symptom in emergency department patients. Among various etiological factors, cardiac causes have the highest risk of mortality. The corrected QT interval is considered an independent predictor of mortality for many diseases. OBJECTIVES: Analyze QT interval analysis of patients presenting to the emergency department with syncope. METHODS: In this prospective observational study, patients who presented to the emergency department with syncope between January 1, 2018, and January 1, 2019 were included. RESULTS: The median age was 64 (49-78) years, and 58.8% of patients were male. The corrected QT interval (QTc) in patients with coronary artery disease and chronic obstructive pulmonary disease was longer than those without. There was no statistically significant association between hypertension, diabetes, stroke, thyroid disease, and prolonged QTc. Patients who did not survive had significantly prolonged QT intervals. According to ROC analysis, sensitivity of >440.5 ms QTc values in predicting mortality was 86% and specificity was 71% (AUC = 0.815; 95%CI = 0.71 - 0.91; p < 0.001). CONCLUSIONS: Patients admitted to emergency department with syncope and a prolonged QTc are associated with a higher mortality rate and thus can provide us with an important guide for the management of these patients.

The value of conventional manometry in the identification of normal esophageal manometry.

ABSTRACT: In the last decade, high-resolution esophageal manometry (HREM) is the main device for the management of dysphagia replacing conventional manometry (CM). Conventional manometry still seems to have some space to diagnose major motility disorders and differentiate normal from abnormal esophageal motility. The long term outcomes of patients with normal CM were analyzed in our study.Participants (patients with dysphagia and normal CM) took a questionnaire via a phone call in February 2021. Impact Dysphagia Questionnaire (IDQ) was used as an assessment tool.Only 55% (83/151) the individuals with previous normal manometric findings were reached via telephone. The group who have completed the survey was representative of the cohort. 66.2% of the participants were female (P = .40). The mean age was 57.21, mean weight was 70.69 kg, mean height was 163.74 cm and mean body mass index was 26.41. More than 40% of patients were completely asymptomatic at follow up, reflected by an IDQ score of 0. Only 28 out of 83 (33.7%) patients reported significant symptoms as reflected by an IDQ score greater than or equal to 7. The rest of responders admitted as having moderate to mild symptoms.HREM is a valid technique with comparable precision to CM. HREM measurements differ considerably to CM. The identification of normal motor function in CM is not likely a positive prognostic indicator and must be interpreted precautiously.

When is the right time to take an emergency surgery decision in Mechanical Intestinal Obstruction?

BACKGROUND: /Objective: Ischemia is a leading cause of morbidity in Mechanical Intestinal Obstruction (MIO) in which the timing of decisions of whether to proceed to surgical or conservative treatment is critical in emergency departments (ED). While advanced technological options are available, patients may be negatively affected by the application of contrast agents or radiation. The use of ultrasound is limited because of the air in the intestines does not allow a good field of vision. While biomarkers can be considered as a good alternative option at this point. In the present study we examine the effect of hemogram and blood gas parameters on early surgical decision-making in MIO patients. METHOD: Involved in this observational prospective study were 264 patients diagnosed with MIO who presented to the Department of Emergency Medicine, Ataturk Research and Training Hospital, Katip Celebi University between February 2018 and February 2019. Contrast-enhanced tomography (CECT) and laboratory results of the patients were recorded. Pathology reports of the patients who underwent surgery were collected. Laboratory data were analyzed by comparing CECT and pathology reports. RESULTS: In a ROC analysis of the laboratory values of the patients who were diagnosed with ileus, the sensitivity was calculated as 80% and the specificity was 57.7 in values above WBC>10.75 (109/L), 96.6%, and the specificity was 31.1% in N/L > 2.9. For intestinal ischemia, the cut-off values were WBC> 12.6 and N/L > 3.2, Lactate >2.8 mmol/L and B.E < -3.6 mmol/L. CONCLUSION: Diagnoses of ileus are based on the results examinations and imaging methods. More data are needed to support decisions on the timing of surgery in ED. WBC, N/L, Lactate and Base Excess indicate an ischemic segment. When the parameters are evaluated together, they strongly support early surgical decision-making regarding the treatment of intestinal ischemia.

Comparison of arterial CO2 estimation by end-tidal and transcutaneous CO2 measurements in intubated children and variability with subject related factors.

Transcutaneous PCO2 (PTCCO2) and end-tidal PCO2 (PETCO2) measurement methods serve as alternatives to arterial PCO2 (PaCO2), providing continuous non-invasive monitoring. The objective of this study was to evaluate the PTCCO2 and PETCO2 methods with actual PaCO2 levels, and to assess the variability of measurements in relation to subject-related factors, such as skin and subcutaneous adipose tissue thickness and presence of pulmonary diseases. PTCCO2, PETCO2 and PaCO2 were measured at the same time in intubated pediatric subjects. Subjects' demographic characteristics, clinical features, laboratory parameters, skin and subcutaneous adipose tissue thickness were identified. The study was carried out on 102 subjects with a total of 1118 values for each method. In patients with non-pulmonary disease, the mean difference between PTCCO2 and PaCO2 was - 0.29 mmHg (± 6.05), while it was 0.44 mmHg (± 6.83) bias between PETCO2 and PaCO2. In those with pulmonary diseases, the mean difference between PTCCO2 and PaCO2 was - 1.27 mmHg (± 8.32), while it was - 4.65 mmHg (± 9.01) between PETCO2 and PaCO2. Multiple linear regression demonstrated that increased subcutaneous adipose tissue thickness, core body temperature and inotropic index were related with higher PTCCO2 values relative to the actual PCO2 values. Other factors, such as skin tissue thickness, presence of pulmonary disease, measurement location and measurement times were non-significant. The PTCCO2 method has higher reliability than the PETCO2 method, and PTCCO2 measurements are not influenced by most subject-related factors; however, core body temperature, inotropic index and subcutaneous adipose tissue thickness can lead to significant differences in PCO2 measurement.

Comparing the novel microstream and the traditional mainstream method of end-tidal CO2 monitoring with respect to PaCO2 as gold standard in intubated critically ill children.

The objective of this study was to evaluate a novel microstream method by comparison with PaCO2 and the more standard mainstream capnometer in intubated pediatric patients. We hypothesized that the novel microstream method would superior compared to the traditional mainstream method in predicting PaCO2. This was a prospective single-center comparative study. The study was carried out on 174 subjects with a total of 1338 values for each method. Data were collected prospectively from mainstream and microstream capnometer simultaneously and compared with PaCO2 results. Although both mainstream PetCO2 (mainPetCO2) and microstream PetCO2 (microPetCO2) were moderately correlated (r = 0.63 and r = 0.68, respectively) with PaCO2 values, mainPetCO2 was in better agreement with PaCO2 in all subjects (bias ± precision values of 3.8 ± 8.9 and 7.3 ± 8.2 mmHg, respectively). In those with severe pulmonary disease, the mainPetCO2 and microPetCO2 methods were highly correlated with PaCO2 (r = 0.80 and r = 0.81, respectively); however, the biases of both methods increased (14.8 ± 9.1 mmHg and 16.2 ± 9.0 mmHg, respectively). In cases with increased physiologic dead space ventilation, the agreement levels of mainPetCO2 and microPetCO2 methods became distorted (bias ± precision values of 20.9 ± 11.2 and 25.0 ± 11.8 mm Hg, respectively) even though mainPetCO2 and microPetCO2 were highly correlated (r = 0.78 and r = 0.78, respectively). It was found that the novel microstream capnometer method for PetCO2 measurements provided no superiority to the traditional mainstream method. Both capnometer methods may be useful in predicting the trend of PaCO2 due to significant correlations with the gold standard measurement in cases with severe pulmonary disease or increased physiological dead space -despite reduced accuracy.

Internal carotid artery dissection following blunt head trauma: a pediatric case report and review of the literature.

BACKGROUND: Internal carotid artery dissection (ICAD) is a rare but potentially devastating complication after trauma in the pediatric age group. The diagnosis of traumatic dissection is difficult and is usually recognized only when ischemic symptoms appear. We report a pediatric patient with ICAD due to blunt cerebrovascular injury (BCVI). CASE: A 14-year-old boy suffered major trauma due to a motor vehicle accident. When the first aid team reached the accident site, he was intubated because of his low Glasgow Coma Score (GCS) and then transported to the nearest emergency department. Cranial computed tomography (CT) showed multiple fractures at the skull base and independent bone fragments in both carotid canals. On the 6th day; a brain magnetic resonance imaging (MRI) was performed to detect diffuse axonal injury. There was a loss of signal in the left internal carotid artery (LICA) tract but the limitation of diffusion was not associated with the same side, conversely there was a limitation of diffusion on the other side, affecting a very large area. CT angiography was performed in order to detect a filling defect and showed dissection in the LICA. The patient did not have any specific neurological symptoms associated with ICAD. Low-dose aspirin was utilized as anticoagulant therapy. On the 25th day of admission, the patient`s GCS was 14, neurologic examination showed no difference between the right and left sides. He was discharged on the 55th day of the accident and was walking without support. CONCLUSION: Our patient was a rare case in pediatrics due to having a clinically silent form of ICAD. It is very difficult to diagnose ICAD dissection during the early phase in cases with BCVI accompanied by multiple trauma. Even in the absence of typical neurological deficit, the possible presence of ICAD should be explored in patients with cranial fractures encompassing the skull base.

VIRAL ETIOLOGY AND OUTCOME OF SEVERE LOWER RESPIRATORY TRACT INFECTIONS AMONG CRITICALLY ILL CHILDREN ADMITTED TO THE PICU.

OBJECTIVE: To determine the viral etiology of severe lower respiratory tract infections (LRTIs), their clinical significance and prognosis among critically ill children. DESIGN: A prospective descriptive study was carried out. SETTING: Pediatric Intensive Care Unit (PICU) of Istanbul Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey. PATIENTS: A total of 115 patients hospitalized in the PICU were evaluated for inclusion in the study. Children with underlying comorbidities and those who did not require mechanical ventilation were excluded. MAIN VARIABLES OF INTEREST: Demographic, clinical, laboratory test and radiographic data were recorded. RESULTS: A total of 63 patients were eligible for the study. The most common diagnosis was bronchiolitis (57.1%). Respiratory syncytial virus (RSV) was the most frequent causal virus (36.5%). The most common complication was acute respiratory distress syndrome (ARDS) (28.6%). Multiple viral infection was identified in 20.6% of the patients, the most common in this subgroup being rhinovirus. Patients with bocavirus infection had a higher likelihood of needing invasive mechanical ventilation (IMV) at presentation. Children who died were likely to be < 12 months old, have ARDS, hepatitis, pneumomediastinum, multiple viral infection, and required IMV support with an increased duration of MV. Additionally, they were found to have a high Pediatric Risk of Mortality III score, Predicted Death Rate and increased need for inotropic support at admission. CONCLUSIONS: Our study showed critically ill children with LRTI without known risk factors to have high mortality when aged < 12 months, in the presence of multiple agents and when certain complications (ARDS, hepatitis) and X-ray findings were identified.

Objetivo: determinar la etiología vírica de las infecciones graves de las vías respiratorias bajas (IGVRB), su importancia clínica y su pronóstico en niños críticamente enfermos.Diseño: estudio descriptivo prospectivo.Ámbito: unidad de cuidados intensivos pediátricos (UCIP) del Hospital Universitario y de Investigación Goztepe, Universidad Medeniyet de Estambul (Turquía).Pacientes y participantes: se evaluó a un total de 115 pacientes ingresados en la UCIP para su posible inclusión en el estudio. Se excluyó a los niños con comorbilidades subyacentes y a aquellos que no requerían ventilación mecánica.Variables de interés principales: se registraron datos demográficos, clínicos, de laboratorio y radiológicos de los pacientes.Resultados: un total de 63 pacientes eran elegibles para participar en el estudio. El diagnóstico más habitual era bronquiolitis (57,1%). El virus sinticial respiratorio era el más común de los virus (36,5%). La complicación más habitual era el síndrome de dificultad respiratoria aguda (SDRA) (28,6%). Se identificaron múltiples infecciones víricas en el 20,6% de los pacientes, siendo la infección por el rinovirus la más común en este subgrupo. Los pacientes con infección por bocavirus presentaban una mayor probabilidad de necesitar ventilación mecánica invasiva (VMI) en el momento de la presentación. Los niños que murieron tenían una mayor probabilidad de presentar: edad <12 meses, SDRA, hepatitis, neumomediastino, infección multiviral y requerir MVI, con una mayor duración de la VM. Además, se observó que presentaban unos valores altos de puntuación III del riesgo pediátrico de mortalidad y tasa de mortalidad predecida, además de necesidad apoyo inotrópico en el momento del ingreso.

The Feasibility of the Ultrasound-Guided Femoral Nerve Block Procedure with Low-Dose Local Anesthetic in Intracapsular and Extracapsular Hip Fractures.

BACKGROUND: The local anesthetic dosages used in the current literature in regional applications of local anesthetics are frequently high for surgical purposes, and there are no sufficient dosage studies for emergency department (ED) management. OBJECTIVES: The aim of this study was to determine the success of lower local anesthetic dosages capable of reducing costs and excessive exposure to drugs in pain control in patients with femoral neck fractures (FNFs) in the ED. METHODS: Patients ≥65 years of age with FNFs and reporting Wong-Baker Pain Rating Scales scores ≥8 were included in this prospective, interventional study. Patients underwent ultrasound-guided regional femoral block with 5 mL 2% prilocaine. Pain scores before the procedure and at 30 min and 2 h postprocedure were compared with the Friedman test and Wilcoxon test with Bonferroni correction. RESULTS: Forty patients, 20 with intracapsular and 20 with extracapsular FNFs, were enrolled. The initial pain scores of patients with both intra- and extracapsular fractures were 8 (range 8-10). A statistically significant 50% decrease in pain scores was observed in both groups 30 min after the regional block procedure (p < 0.001). A statistically significant 75% decrease in pain scores was observed in both groups 2 h after the regional block procedure (p < 0.001). No statistically significant difference was determined in the change in 30-min and 2-h pain scores between the groups. CONCLUSIONS: The administration of 5 mL 2% prilocaine for pain control in FNFs in elderly patients in the ED can reduce systemic analgesic requirements by establishing effective analgesia in both intracapsular and extracapsular fractures.

Effect of Changes in Intravascular Volume on Inferior Vena Cava and Aorta Diameters and the Caval/Aorta Index in Healthy Volunteers.

OBJECTIVES: Although inferior vena cava diameter (IVCD) measurement can be useful as a noninvasive method for monitoring the volume status, the benefit of abdominal aorta diameter (AAD) measurement is unclear. The purpose of this study was to determine the value of the combined use of the IVCD and AAD in blood loss monitoring. METHODS: This prospective observational study was conducted at the blood donor center of a training and research hospital. Standard blood donation criteria were followed during volunteer enrollment. Vital signs and ultrasound IVCD and AAD measurements were obtained before and after blood donation and after fluid resuscitation with 500 mL of 0.9% sodium chloride. Measurements before and after blood donation and after fluid resuscitation were compared by the paired t and Wilcoxon matched-pair tests. RESULTS: Thirty-nine volunteers were included in the study. With 500 mL of blood loss, percent changes in the shock index (SI; mean ± SD, 7% ± 6%), IVCD (6% ± 2%), and caval/aorta index (IVCD/AAD; 6.1% ± 3%) were similar and were higher (P < .001 for all parameters) than the changes in the pulse rate (3% ± 4%), AAD (0.5% ± 1.5%), systolic blood pressure (3% ± 4%), and diastolic blood pressure (2% ± 7%). Although IVCD and SI values changed significantly (P < .001 for both) after 500 mL of 0.9% sodium chloride resuscitation, no significant change was observed in the IVCD/AAD (P = .059). CONCLUSIONS: The IVCD/AAD, SI, and IVCD may have similar success rates in diagnosing early blood loss. Additionally, the SI and IVCD may be superior to the IVCD/AAD in bleeding patients requiring simultaneous fluid resuscitation.

The evaluation of geriatric patients who presented with trauma to the emergency department.

INTRODUCTION: Geriatric patients are subject to traumas more frequently due to age-related physiopathological changes. The objective of the study was to evaluate the demographic properties of geriatric patients who presented with trauma to the emergency department in addition to establishing the course of the diagnosis and treatment. MATERIAL AND METHODS: Nine hundred and twelve geriatric patients who presented with trauma to the emergency department during one year were included in this retrospective study. Cause of the presentation, demographic properties, diseases, medications, sites of trauma, departments of consultations, departments that the patients were admitted to, discharge, mortality and morbidity rates were obtained from the folders of the subjects. The subjects were assigned to age groups 65-79 years old and over 80 years old. RESULTS: 60.4% (n = 551) of the 912 subjects were female, 39.6% (n = 361) were male and the mean age of the subjects was 77.16 (65-100). Falls were the most common cause (80.3%) of traumas, and the most frequently affected parts of the body were the extremities. The over 80 group was the most frequently consulted group (p = 0.01) and women were admitted more often to the hospital (p = 0.03). Of the patients who presented with trauma, 28.9% (n = 264) were hospitalized and 2% (n = 18) died. The most common causes of death of patients were femur fractures and intracranial hemorrhages. CONCLUSIONS: Due to high mortality and morbidity, this geriatric patient group deserves a multidisciplinary approach beginning with the emergency departments.

Euglisemic diabetic ketoacidotic coma caused by dapagliflozin.

Diabetic ketoacidosis (DKA) is a serious and potentially life-threatening acute complication of diabetes mellitus (DM). Sodium-glucose co-transporter-2(SGLT-2) inhibitors are new orally administered antihyperglycemic agents. These agents are related with rarely seen euglycemic diabetic ketoacidosis (eDKA) cases, which are difficult to diagnose in emergency department (ED) because of absence of an evident hyperglycemia and may result with potentially dangerous outcomes if missed. In this study, we present a clinical case of a patient, admitted to ED with altered mental status after SGLT2 inhibitor dapagliflozin administration.

Melatonin: is it an effective antioxidant for pulmonary contusion?

BACKGROUND: The goal of the present study was to evaluate the antioxidant effects of melatonin on pulmonary contusion (PC) caused by isolated blunt thoracic trauma (BTT) in an experimental rat model. MATERIALS AND METHODS: A total of 49 rats were divided into three groups: control group (CG), trauma group (TG), and melatonin group (MG). PC was induced by isolated BTT for all the groups except the control group. Intraperitoneal melatonin was administered to the MG after trauma. Blood and tissue samples were collected from the groups. Malondialdehyde (MDA), total oxidant capacity and total antioxidant capacity (TAOC), arterial blood gas, and other biochemical parameters such as urea, creatinine, alanine aminotransferase (ALT), and aspartate aminotransferase were measured. Lung tissue samples were collected for histopathology. RESULTS: On day 2, blood MDA and total oxidant capacity levels were lower, and TAOC levels were higher in the MG compared with the TG (P < 0.001). Blood pH, PO2, and PCO2 of the MG significantly improved on day 2 compared with the TG (P ≤ 0.001). Compared with the TG, histologic damage scores of the MG decreased on day 2 (P = 0.013). Urea, creatinine, ALT, and aspartate aminotransferase levels of the MG on day 2 were lower than TG parameters (P = 0.01, P = 0.02, P = 0.05, and P < 0.001, respectively). CONCLUSIONS: Our findings demonstrate that melatonin can improve the histopathology of PC and distant organs such as liver and kidney by diminishing oxidative stress. All these findings suggest that melatonin may be an effective new therapeutic agent for PC caused by BTT.