Serum Vitamin D Status and Outcome in Critically Ill Children.

BACKGROUND: Vitamin D is a pleiotropic hormone essential for optimal health. Critical illness in children is a major cause of significant health-care utilization and mortality around the world. The association of Vitamin D deficiency (VDD) in critically ill adults has been well-studied, in comparison, the importance of Vitamin D in pediatric critical illness has been much less studied. AIM AND OBJECTIVES: This study aimed to assess Vitamin D status and its determinants in patients admitted to a pediatric intensive care unit (PICU) in North of Turkey. We also investigated the association between Vitamin D status and clinical outcomes. MATERIALS AND METHODS: All patients aged 1 month to 18 years admitted to the PICU of a tertiary care hospital who had levels of 25-hydroxy Vitamin D available within 24 h of admission were included in this retrospective study. VDD was defined as <20 ng/mL levels. RESULTS: VDD was observed in 120 (58.5*) children. In multivariable linear regression model, only identified patient age and winter season as statistically associated with VDD. Vitamin D deficient patients were older and heavier and were more likely to receive catecholamine. There was no association between Vitamin D deficiency and other illness severity factors including mortality. CONCLUSIONS: Hypovitaminosis D occurrence was high in critically ill children and was associated with higher vasopressor requirement but not with other markers of illness severity including mortality.

Nasopharyngeal encephalocele: a rare cause of upper airway obstruction.

Nasopharyngeal encephalocele is a rare, benign congenital anomaly. It has the potential to be fatal due to airway obstruction. Here, we report on a 34-day-old infant with pneumonia who underwent mechanical ventilation. An upper airway evaluation was performed due to prolonged intubation, and revealed the presence of a nasopharyngeal encephalocele. The patient tolerated extubation and oral feeding after surgical resection of the lesion. Awareness of the condition can help clinicians arrive at an earlier diagnosis and enhance management.

Iatrogenic tracheal rupture in a child: case study and review of literature.

Tracheal rupture is rare in childhood, and optimal treatment is not clear. A 14-year-old boy was admitted to a local hospital after sudden loss of consciousness. He underwent endotracheal intubation and was referred to our hospital. The patient's history revealed that he had voluntarily inhaled butane gas. The physical examination was consistent with coma and cardiogenic shock, and the chest radiograph showed pulmonary edema. The patient was admitted to the intensive care unit, and diuretic and inotropic therapy was started. In the third hour of monitoring of the patient under mechanical ventilation, subcutaneous emphysema and pneumothorax at the right hemithorax were observed without deterioration of the vital functions. Thoracic computed tomography scan findings were consistent with tracheal rupture. The patient was monitored conservatively without surgery. On the fifth day of hospitalization, his tube was removed, and he was discharged on the 12th day with a positive prognosis. In this study, a tracheal rupture case after endotracheal intubation is presented in which the patient recovered completely with conservative therapy.

Critically ill children with pandemic influenza (H1N1) in pediatric intensive care units in Turkey.

OBJECTIVES: To outline the epidemiologic features, clinical presentation, clinical courses, and outcomes in critically ill children with pandemic influenza in pediatric intensive care units. DESIGN: Retrospective, observational, multicenter study. SETTING: Thirteen tertiary pediatric intensive care units in Turkey. PATIENTS: Eighty-three children with confirmed infection attributable to pandemic influenza detected by reverse-transcriptase polymerase chain reaction assay between November 1 and December 31, 2009 who were admitted to critical care units. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During a 2-month period, 532 children were hospitalized with pandemic influenza and 83 (15.6%) needed critical care. For the 83 patients requiring critical care, the median age was 42 (range, 2-204) months, with 24 (28.9%) and 48 (57.8%) of patients younger than 2 and 5 yrs, respectively. Twenty (24.1%) patients had no underlying illness, but 63 (75.9%) children had an underlying chronic illness. Indications for admission to the pediatric intensive care unit were respiratory failure in 66 (79.5%), neurologic deterioration in six (7.2%), and gastrointestinal symptoms in five (6.0%) patients. Acute lung injury was diagnosed in 23 (27.7%), acute respiratory distress syndrome was diagnosed in 34 (41%), and 51 (61.4%) patients were mechanically ventilated. Oseltamivir was used in 80 (96%) patients. The mortality rate for children with pandemic influenza 2009 was 30.1% compared to an overall mortality rate of 13.7% (p = .0016) among pediatric intensive care unit patients without pandemic influenza during the study period. Also, the mortality rate was 31.7% in patients with comorbidities and 25.0% in previously healthy children (p = .567). The cause of death was primary pandemic influenza infection in 16 (64%), nosocomial infection in four (16%), and primary disease progression in five (20%) patients. The odds ratio for respiratory failure was 14.7 (95% confidence interval, 1.85-111.11), and odds ratio for mechanical ventilation was 27.7 (95% confidence interval, 0.003-200). CONCLUSIONS: Severe disease and high mortality rates were seen in children with pandemic influenza. Death attributable to pandemic influenza occurred in all age groups of children with or without underlying illness. Multiple organ dysfunction syndrome is associated with increased mortality, and death is frequently secondary to severe lung infection caused by pandemic influenza.

Is serum cystatin C a better marker than serum creatinine for monitoring renal function in pediatric intensive care unit?

In critically ill patients, mild to moderate reductions in glomerular filtration rate are not instantly followed by parallel changes in serum creatinine (SCr). The aim of this study was to identify a value of serum cystatin C (cys-C) level as a marker for monitoring renal function in critically ill pediatric patients. Creatinine clearance was used to estimate glomeruler filtration rate (eGFR). The correlation between the inverse of serum cys-C and eGFR (r = -0.70, p < 0.0001) was better than the correlation between the inverse of SCr and eGFR (r = -0.27, p = 0.008). Serum cys-C was found to be superior to SCr to predict renal impairment (area under the curve for cys-C, 0.932 and for SCr, 0.658). It can be concluded that cys-C is superior to SCr for the detection of renal impairment in critically ill children.

Intracardiac thrombus case caused by blunt trauma due to child abuse.

Intracardiac thrombus is a rare condition in children, although there has recently been an increase in case reports in the literature. We here report an asymptomatic intracardiac thrombus caused by blunt trauma due to child abuse in a 4-year-old girl. On the echocardiogram, one can see pericardial fluid surrounding all of the heart, and a mobile mass, a thrombus of 5.8 × 9 mm in diameter, was observed in the right atrium and on the free border of the tricuspid valve. The thrombus and pericardial fluid disappeared on the follow-up echocardiogram performed after the 10-day heparin therapy.

Clinical and epidemiological features of Turkish children with 2009 pandemic influenza A (H1N1) infection: experience from multiple tertiary paediatric centres in Turkey.

BACKGROUND: In April 2009 a novel strain of human influenza A, identified as H1N1 virus, rapidly spread worldwide, and in early June 2009 the World Health Organization raised the pandemic alert level to phase 6. Herein we present the largest series of children who were hospitalized due to pandemic H1N1 infection in Turkey. METHODS: We conducted a retrospective multicentre analysis of case records involving children hospitalized with influenza-like illness, in whom 2009 H1N1 influenza was diagnosed by reverse-transcriptase polymerase chain reaction assay, at 17 different tertiary hospitals. RESULTS: A total of 821 children with 2009 pandemic H1N1 were hospitalized. The majority of admitted children (56.9%) were younger than 5 y of age. Three hundred and seventy-six children (45.8%) had 1 or more pre-existing conditions. Respiratory complications including wheezing, pneumonia, pneumothorax, pneumomediastinum, and hypoxemia were seen in 272 (33.2%) children. Ninety of the patients (11.0%) were admitted or transferred to the paediatric intensive care units (PICU) and 52 (6.3%) received mechanical ventilation. Thirty-five children (4.3%) died. The mortality rate did not differ between age groups. Of the patients who died, 25.7% were healthy before the H1N1 virus infection. However, the death rate was significantly higher in patients with malignancy, chronic neurological disease, immunosuppressive therapy, at least 1 pre-existing condition, and respiratory complications. The most common causes of mortality were pneumonia and sepsis. CONCLUSIONS: In Turkey, 2009 H1N1 infection caused high mortality and PICU admission due to severe respiratory illness and complications, especially in children with an underlying condition.

Gluconeogenesis defect presenting with resistant hyperglycemia and acidosis mimicking diabetic ketoacidosis.

Fructose-1,6-diphosphatase (FDPase) enzyme deficiency is a rare inherited metabolic disease. Affected patients usually present with metabolic crisis including hypoglycemia, acidosis, ketonuria, and hyperuricemia. A previously healthy 8-month-old male infant presented with fever, vomiting, and hypoactivity. He had tachycardia, tachypnea, and a tendency to sleep. The patient had signs of severe dehydration and shock. Laboratory findings revealed significant lactic acidosis, hyperuricemia, hyperglycemia, elevated liver enzyme level, and hyperlipidemia. The urine analysis had evidence of glycosuria and ketonuria. Hyperuricemia, lactic acidemia, and hyperglycemia persisted despite insulin infusion, adequate hydration, and perfusion. Consequently, peritoneal dialysis was started. About 12 hours after dialysis, his metabolic derangements were normalized, and clinical status was improved dramatically. His metabolic disease workup was compatible with FDPase deficiency. Here, we described a metabolic attack of FDPase deficiency presented with hyperglycemia mimicking diabetic ketoacidosis.

Pediatric tracheotomy: 3-year experience at a tertiary care center with 54 children.

The aim of this study was to evaluate the indications, complications and outcomes of pediatric tracheotomies at a tertiary care center. Data were obtained retrospectively from 54 patients who underwent tracheotomy from July 2007 to May 2010. Over the three-year period, 54 tracheotomies were performed. Thirty-two patients (59.3%) were male and 22 (40.7%) were female. The mean and median ages of the patients were 54 and 14 months (6 days-17 years), respectively. Twenty-six patients (48.1%) were under 1 year of age. The most common indication for tracheotomy was prolonged intubation (87%), followed by upper airway obstruction (13%). Five patients (9.2%) underwent tracheotomy under semiurgent settings. The overall complication rate was 29.6% (16/54). Early complications occurred in 7 patients (13%), including accidental decannulation in 2 patients, subcutaneous emphysema in 4 patients and hemorrhage in 1 patient. Late complications occurred in 9 patients (16.7%) (stomal granulation in 7 patients and stomal infection in 2 patients). Eight patients (14.8%) were decannulated successfully. No tracheotomy-related deaths occurred, with an overall mortality rate of 27.7% (15/54). Pediatric tracheotomy is a relatively safe procedure with a low incidence of procedure-related morbidities. The indication for the majority of the procedures was prolonged intubation (87%). The lower decannulation rate is related to the higher percentage of patients needing assisted ventilation and the relatively short follow-up period.

Pulmonary hypoplasia presenting with recurrent wheezing in an infant.

Pulmonary hypoplasia is characterized by decrease in the number and size of pulmonary airways, alveoli and vessels. In autopsy, pulmonary hypoplasia is a major cause of death in neonates and infants. The disease is usually diagnosed in childhood period. Although it mimics lung parenchymal disease and other vascular abnormalities radiologically, it is easily recognized with computed tomography angiography and magnetic resonance angiography examinations. In 50% of patients, concomitant cardiovascular, neuromuscular, gastrointestinal tract, and urogenital anomalies are also available. There are two types of pulmonary hypoplasia: primary and secondary. Primary unilateral pulmonary hypoplasia may be asymptomatic and the tendency for bronchopulmonary infections is often increased in children. In this case report, a 22-month-old male patient characterized by recurrent infections and recurrent wheezes in infantile period, whose episodes of wheezing regressed after the pulmonectomy, was presented.

The prevalance of and factors associated with intra-abdominal hypertension on admission day in critically ill pediatric patients: A multicenter study.

PURPOSE: To investigate admission prevalence of intraabdominal hypertension (IAH) and to determine clinical and laboratory characteristics on admission day associated with IAH in critically ill pediatric patients. MATERIALS AND METHODS: One hundred thirty newly admitted critically ill pediatric patients were included. Intra-abdominal pressure (IAP) was measured 4 times (every 6 hours) with the bladder pressure method. Data included the demographics, diagnostic category, pediatric logistic organ dysfunction score and pediatric risk of mortality score II, clinical concomitant factors, and conditions potentially associated with increased intra-abdominal pressure. RESULTS: Seventy patients (56.1%) had a normal IAP (≤10 mmHg, mean IAP [mmHg] 7.18 ± 1.85), while 60 patients (43.9%) had IAP >10 mmHg (mean IAP [mmHg] 15.46 ± 5.21). Hypothermia frequency, lactate levels, number of patients with oligo-anuria, and mechanical ventilation requirement were higher among patients with IAH compared to patients without IAH (both, P< .05). Hypothermia (OR, 3.899; 95% CI, 1.305-11.655; P< .03) and lactate levels (OR, 1.283 for each mmol/L increase; 95% CI, 1.138-1.447; P< .001) were only significantly associated with IAH. CONCLUSIONS: Intra-abdominal hypertension seems to affect nearly half of newly admitted critically ill pediatric patients. Lactate level and the presence of hypothermia seem to be the independent predictors of the presence of IAH.

Fulminant pertussis in very young infants: two cases and review of the literature.

Pertussis is one of the leading causes of death that can be prevented by vaccination. More than 600,000 deaths from pertussis occur annually, with a disproportionate number appearing in unvaccinated infants. Pertussis is particularly troublesome because it does not necessarily present itself in its commonly known classical stages. Therefore, in very young and non-immunized children, the disease may have a fulminant process characterized by severe leukocytosis, neurologic involvement and serious cardiopulmonary failure that can be accompanied by pulmonary hypertension, persistent hypoxia and death. This article describes two infants with fulminant pertussis; they were admitted for acute respiratory failure and severe leukocytosis and ultimately died from multi-organ failure.

Old agent, new experience: colistin use in the paediatric Intensive Care Unit--a multicentre study.

Nosocomial infections caused by multidrug-resistant (MDR) microorganisms are a common problem around the world, especially in Intensive Care Units. The aim of this study was to investigate the efficacy and safety of colistin therapy in paediatric patients with severe nosocomial infections caused by MDR Gram-negative bacteria. There were 87 episodes in 79 paediatric Intensive Care Unit patients in five different hospitals; each patient was treated intravenously with colistin and evaluated. Of the 79 patients, 54.4% were male and the median age was 30 months. The most commonly isolated microorganism was Acinetobacter baumannii, the most common isolation site was tracheal aspirate fluid and the most common type of infection was ventilator-associated pneumonia. The mean colistin dose in patients without renal failure was 5.4 ± 0.6 mg/kg/day, the mean therapy duration was 17.2 ± 8.4 days and the favourable outcome rate was 83.9%. Serious side effects were seen in four patient episodes (4.6%) during therapy; two patients suffered renal failure and the others had convulsive seizures. Other patients tolerated the drug well. The infection-related mortality rate was 11.5% and the probability of death within the first 9 days of treatment was 10 times higher than after the first 9 days. In conclusion, this study suggests that colistin is effective in the treatment of severe nosocomial infections caused by MDR Gram-negative bacteria and is generally well tolerated by patients, even after relatively long-term use.

Admission hyperglycemia is a reliable outcome predictor in children with severe traumatic brain injury.

OBJECTIVE: To identify the relationship between admission hyperglycemia and outcome in children with severe brain injury at hospital discharge and 6 months later. METHOD: A retrospective analysis of blood glucose levels was conducted in 61 children with severe brain injury admitted to the Pediatric Intensive Care Unit between November 1, 2005 and October 30, 2009. Hyperglycemia was considered for a cut off value of > 150 mg/dL, based on literature. Outcome was measured with the Glasgow Outcome Scale at hospital discharge and 6 months after discharge. Death was also analyzed as an outcome measure. RESULTS: Mean admission blood glucose of the patients was 251 mg/dL (68-791). Hyperglycemia was noted on admission in 51 (83.6%) patients. A moderately significant positive correlation was found between admission blood glucose and severity of head trauma according to Abbreviated Injury Score (r = 0.46). Mean admission glucose level of non-survivors was significantly higher (207 mg/dL vs. 455 mg/dL, p < 0.001). Mean blood glucose level of the patients in bad outcome group was found significantly higher compared to that of the patients in good outcome group at hospital discharge and 6 months after discharge (185 mg/dL vs. 262 mg/dL, p < 0.15 and 184 mg/dL vs. 346 mg/dL, p < 0.04, respectively). CONCLUSIONS: Hyperglycemia could be considered as a marker of brain injury and, when present upon admission, could reflect extensive brain damage, frequently associated with mortality and bad outcome. Further studies are needed to investigate the effect of strict glycemic control on mortality and outcomes.

Severe myopathy caused by the new pandemic influenza A (H1N1) in a child.

Myopathy is a rare complication of influenza infections. Here, we report on an eight-year-old girl with severe myopathy due to new pandemic influenza A (H1N1). She presented with severe myopathy following generalized tonic-clonic seizure and recovered completely within a few days.