Regional citrate versus systemic heparin anticoagulation for continuous renal replacement therapy in critically ill children.

OBJECTIVES: Anticoagulation is used to prevent filter clotting in patients undergoing continuous renal replacement therapy. Regional citrate anticoagulation is associated with lower rates of bleeding complications and prolongs the filter life span; however, a number of metabolic side effects had been associated with this therapy. The aim of this study was to evaluate the effect and safety of citrate versus heparin anticoagulation for continuous renal replacement therapy in critically ill children. METHODS: A retrospective comparative cohort study. Department of Pediatric Intensive Care, Acibadem Mehmet Ali Aydinlar University School of Medicine. RESULTS: From August 2016 to August 2018, 45 patients (19 in the citrate group and 26 in the heparin group) were included. A total of 101 hemofilters were used in all therapies: 44 in the citrate group (total continuous renal replacement therapy time: 2699 h) and 57 in the heparin group (total continuous renal replacement therapy time: 2383 h). The median circuit lifetime was significantly longer for regional citrate anticoagulation (53.0; interquartile range, 40-70 h) than for heparin anticoagulation (40.25; interquartile range, 22.75-53.5 h; p = 0.025). Mortality rates were similar in both groups (31.58% vs 30.77%). The most common indication for dialysis was hypervolemia in both groups. Transfusion rates were 1.65 units (interquartile range, 0.5-2.38) with heparin and 0.8 units (interquartile range, 0.3-2.0) with citrate (p = 0.32). Clotting-related hemofilter failure occurred in 11.36% of filters in the citrate group compared with 26.31% of filters in the heparin group. CONCLUSION: Our study showed that citrate is superior in terms of safety and efficacy, with longer filter life span. Regional citrate should be considered as a better anticoagulation method than heparin for continuous renal replacement therapy in critically ill children.

The clinical characteristics and prognosis of pertussis among unvaccinated infants in the pediatric intensive care unit.

AIM: To evaluate the clinical characteristics, risk factors, and prognosis of pertussis in the pediatric intensive care unit. MATERIAL AND METHODS: Patients who were hospitalized in pediatric intensive care unit between January 2017 and January 2019 and diagnosed as having pertussis were retrospectively evaluated. Samples were taken from tracheal aspirate material in intubated patients and nasopharyngeal swabs in the other patients. Samples for Bordetella pertussis were studied using multiplex real-time polymerase chain reaction. RESULTS: Eighteen patients were admitted to our pediatric intensive care unit with a diagnosis of pertussis. Ten patients were female (55.5%), and all patients were unvaccinated. The median age was 40 (range, 38-47.5) days and the median intensive care unit stay was 9 (range, 5-14) days. All patients had respiratory distress, 14 patients had cough (77.7%), four patients had fever (22.2%), and three patients had convulsions (16.6%). Seven patients were intubated. Three patients died of multiple organ failure and cardiogenic shock despite extracorporeal treatment. Respiratory syncytial virus was found in two patients and rhinovirus was found in one patient. The median leukocyte count was significantly higher in non-survivors than in survivors. Blood exchange was performed in three patients due to hyperleukocytosis. Pulmonary hypertension was the most common cardiac pathology detected in echocardiographic examinations. CONCLUSION: We found that high leukocyte count, viral co-infection, and severe pulmonary hypertension were associated with mortality and morbidity in pertussis.

Therapeutic plasma exchange in pediatric intensive care: Indications, results and complications.

Therapeutic plasma exchange (TPE) is an effective treatment method in selective indications. Secondary to access and technical features, it is more difficult to apply in pediatric population than adults. The aim of this study is investigate safety, clinical indications, and results of this method in critically ill pediatric patients who need TPE treatment. All of the TPE procedures performed in a pediatric intensive care unit providing tertiary care during 4 years (2015-2019) were evaluated retrospectively. TPE procedures (635) were performed for 135 patients. Median age was 34 months (10-108). Ninety-seven patients had mechanical ventilation support. Sepsis with multiple organ failure was the most frequent indication and accounted for 44.4% (n = 60) of the indications followed by hematological and neurological diseases (19.2% and 9.6% respectively). TPE was performed alone in 469 cases (73.9%), in combination with continuous renal replacement therapy in 154 cases (24.2%), and additional to extracorporeal membrane oxygenation in 12 cases (1.9%). Hematological disease and sepsis subgroups had the highest intubation rate, mechanical ventilation period, PRISM score, organ failure count, and mortality. Fresh frozen plasma (FFP) was the most frequently used replacement fluid in 90.4% of the procedures. The most frequent anticoagulant used in TPE was acid citrate dextrose solution (79.3%). Procedural complications were detected in 104 cases (16.3%) and occurred during TPE sessions. Overall survival rate was 78.5%. We found that the non-survivor group had significantly higher rates of organ failures (P = 0.0001), higher PRISM scores on admission (P = 0.0001), and higher rates of invasive ventilation support needed (P = 0.012). TPE is a treatment method which can be safely provided in healthcare facilities with necessary medical and technical requirements. Although it is riskier to provide such treatment to critically ill children, complications can be minimized in experienced healthcare facilities. Overall results are good and can vary depending on indication.

Clinical and laboratory predictors of survival for pediatric patients on non-postcardiotomy extracorporeal membrane oxygenation (ECMO).

Extracorporeal membrane oxygenation (ECMO) is used in pediatric patients with severe cardiopulmonary failure who do not respond to conventional therapy; only a few studies have been conducted in Turkey. We present the experience of pediatric ECMO with the aim of showing factors affecting mortality. We retrospectively reviewed our ECMO database to identify patients who received ECMO from October 2015 to March 2018. Our population comprised 30 pediatric patients. The mean patient age was 41.31±53.35 months and 17 (56.7%) patients were male. The median duration of ECMO support was 8.9 (6.6-10.8) days. The rates of successful ECMO weaning and survival to discharge were 70.0% (n=21) and 66.7% (n=20), respectively. Indications for ECMO were respiratory failure (40.0%), cardiac failure (33.3%), and sepsis (26.7%). We found that pre-cannulation values of pH (p=0.034), leukocytes (p=0.029), C-reactive protein (p=0.045), creatinine (p=0.047), chloride (p=0.001) and post-cannulation pH (p=0.0001), bicarbonate (p=0.014), lactate (p=0.002), chloride (p=0.0001) were associated with mortality. The results showed that preexisting sepsis and renal conditions contributed to poor outcomes. Indications, ECMO onset time, and pre- and post-cannulation laboratory values such as leukocytes, CRP, creatinine, bicarbonate, lactate, and chloride are factors that affect outcomes.

Extracorporeal membrane oxygenation for the support of pediatric patients with acute fulminant myocarditis.

Sik G, Annayev A, Demirbuga A, Deliceo E, Aydin S, Erek E, Demir HI, Çitak A. Extracorporeal membrane oxygenation for the support of pediatric patients with acute fulminant myocarditis. Turk J Pediatr 2019; 61: 867-872. Acute fulminant myocarditis, is a severe, rapidly progressive disease. The clinical outcomes of children with severe acute myocarditis who are resist to medical treatment is not well known. We studied the clinical courses of patients with acute fulminant myocarditis supported by extracorporeal membrane oxygenation (ECMO). We performed a retrospective chart review of six children with acute fulminant myocarditis who were treated with ECMO. Demographic information, clinical and vital signs, as well as laboratory results were investigated. The median age of 63 months (13-140 months), the mean ECMO duration was 164 hours (79-402 hours), and median intensive care unit stay was 24 days. The most common symptoms were chest pain (66%) and fever (66%). Severe arrhythmia were seen in two patients. One patient received extracorporeal cardiopulmonary resuscitation. In two patients, right femoral arteries and right femoral veins were used, in others, right common carotid artery and right internal jugular veins were used. Five patients (83.3 %) survived to discharge. ECMO can be used effectively in pediatric patients with acute fulminant myocarditis to support the circulation while awaiting myocardial recovery. Timely use of ECMO can improve the survival rate and may be associated with better outcomes.

Glomerular and Tubular Functions in Children and Adults with Transfusion-Dependent Thalassemia.

This study aimed at assessing renal functions in patients with transfusion-dependent thalassemia (TDT). Fifty patients and 30 controls were enrolled in this prospective study. Serum levels of electrolytes and albumin were measured by a spectrophotometer. Serum levels of cystatin-C and urinary levels of ß2-microglobulin were measured by nephelometric method. Thirty-eight patients were receiving deferasirox and 8 were on deferiprone. Serum electrolytes and albumin levels of the patients were found to be within normal ranges. Urinary ß2-microglobulin and serum cystatin-C levels were significantly higher in patients than controls. They did not significantly differ between the subgroup of patients on deferiprone and the control group, whereas they were found to be higher in patients using deferasirox compared to controls. Urinary ß2-microglobulin levels significantly increased in patients who were receiving high-dose deferasirox compared to those who were receiving a daily dose of 15-20 mg/kg or controls. Subclinical renal injury may be present in TDT patients.

Sustained hyperferritinemia in a child with macrophage activation syndrome secondary to systemic juvenile idiopathic arthritis - perforinopathy: case based review.

Çakan M, Aktay-Ayaz N, Gemici H, Annayev A, Çitak A, Akçay A, Öztürk G. Sustained hyperferritinemia in a child with macrophage activation syndrome secondary to systemic juvenile idiopathic arthritis - perforinopathy: case based review. Turk J Pediatr 2018; 60: 598-603. Systemic juvenile idiopathic arthritis is a subtype of juvenile idiopathic arthritis and characterized by arthritis and many systemic features like fever, rash, hepatosplenomegaly, lymphadenopathy and serositis. Macrophage activation syndrome is the most dreadful complication of systemic juvenile idiopathic arthritis and can cause mortality and morbidity if not recognized and treated early and aggressively. Hemophagocytic lymphohistiocytosis (HLH) is characterized by diminished or absent activities of natural killer cells and cytotoxic T lymphocytes leading to cytokine storm and uncontrolled activation of T cells and macrophages. Primary (familial) HLH is a group of autosomal recessive disorders caused by mutations in the perforin and other related genes and distinctive for onset during early infancy and high rate of mortality. Secondary HLH may be caused by infectious, oncologic and rheumatologic disorders. The term Perforinopathy is used to describe cases with classical familial HLH and also for cases with familial HLH gene mutations but not following a classical familial HLH course. Herein we report a case of chronic perforinopathy in which clinical symptoms started with systemic juvenile idiopathic arthritis and severe macrophage activation syndrome that needed plasma exchange and extracorporeal membrane oxygenation during acute period and ongoing interleukin-1 blockage for sustained hyperferritinemia.