A rare case of life-threatening traumatic carotid artery dissection in a child.

Penetrating injuries of the carotid and vertebral arteries are rare, but life-threatening conditions. There are still challenges in the first intervention management and patient treatment. Deciding which methods to apply in the first intervention, whether to perform imaging, and the preferred appropriate treatment for the patient (open surgery or endovascular intervention) plays a main role in the patient's survival without neurological deficit. The general management of trauma in penetrating neck injuries and the knowledge of special approaches to carotid artery injury are important for pediatric trauma centers. In this case report, we presented a case of penetrating carotid artery injury in a child who has recovered with no disability after a successful first intervention, surgical repair, and proper postoperative care.

The evaluation of safety and efficacy of colistin use in pediatric intensive care unit: Results from two reference hospitals and review of literature.

Colistin, an old cationic polypeptide antibiotic, have been reused due to rising incidence of infections caused by multi-drug resistant (MDR) Gram-negative microorganisms and the lack of new antibiotics. Therefore, we evaluated safety and efficacy of colistin in treatment of these infections. This study included 104 critically ill children with a median age of 55,9 months between January 2011 and January 2016. Nephrotoxicity occurred in 11 (10.5%) patients. Nephrotoxicity occurred between the third and seventh day of treatment in 63% of colistin induced nephrotoxicity episodes. The subgroup analysis between the patients who developed nephrotoxicity during colistin treatment and those that did not, showed no significant difference in terms of age, underlying disease, cause for PICU admission and type of infection required colistin treatment, P values were 0.615, 0.762, 0.621, 0.803, respectively. All patients were receiving a concomitant nephrotoxic agent (P = 0,355). The majority of the patients (52%) were having primary or secondary immune deficiency in treatment failure group and the most common cause of PICU admission was sepsis in treatment failure group, P values were 0.007 and 0.045, respectively. Mortality attributed to colistin failure and crude mortality were 14.4% and 29.8%, respectively. In conclusion, colistin may have a role in the treatment of infections caused by multidrug-resistant Gram-negative bacteria in critically ill children. However, the patients have to be followed for side effects throughout colistin treatment, not for only early stage. And the clinicians should be aware of increase in the rate of nephrotoxicity in patients those have been receiving a concomitant nephrotoxic agent.

Predictive factors for the outcome of high flow nasal cannula therapy in a pediatric intensive care unit: Is the SpO2/FiO2 ratio useful?

OBJECTIVES: To determine the predictive factors for the outcome of high-flow nasal cannula (HFNC) therapy in a pediatric intensive care unit (PICU). MATERIALS AND METHODS: We prospectively included all patients with acute respiratory distress/failure aged 1month to 18years who were admitted to the PICU between January 2015 and May 2016 and treated with HFNC as a primary support and for postextubation according to our pre-established protocol. HFNC failure was defined as the need for escalation to non-invasive ventilation (NIV) or invasive mechanical ventilation (MV). HFNC responders and nonresponders were compared based on clinical data obtained just before HFNC and at 30, 60, and 120min, 12, 24, and 48h, and at the end of therapy. RESULTS: A total of 204 patients (median age: 16.5months) participated in the study. Twenty-six (12.7%) patients required escalation (4 to NIV and 22 to MV). Age >120months, higher PRISM-III and respiratory scores, and a lower SpO2/FiO2 (S/F) ratio at admission were predictors of HFNC failure. Achievement of the S/F>200 goal at 60min significantly predicted successful HFNC. CONCLUSION: Monitoring the S/F ratio might be useful and practical to avoid delaying escalation to another ventilation support. Failure to achieve S/F>200 at 60min should be a warning for the escalation of respiratory support.

Febrile infection-related epilepsy syndrome (FIRES) treated with immunomodulation in an 8-year-old boy and review of the literature.

Alparslan C, Kamit-Can F, Anil AB, Olgaç-Dündar N, Çavusoglu D, Göç Z. Febrile infection-related epilepsy syndrome (FIRES) treated with immunomodulation in an 8-year-old boy and review of the literature. Turk J Pediatr 2017; 59: 463-466. Febrile infection-related epilepsy syndrome (FIRES) is a catastrophic epilepsy syndrome which is characterized by acute onset of refractory status epilepticus following a febrile infection occurring in previously normal children. Despite the various treatment options that have been tried, exact treatment strategy is still undetermined. This is the first pediatric case of FIRES from Turkey which was successfully treated with intravenous immunoglobulin (IVIG). A previously healthy 8-year-old boy was referred to our hospital with a pre-diagnosis of status epilepticus and encephalitis. He presented with acute onset of convulsions and unconsciousness following fever and malaise lasting 7 days. On physical examination Glasgow coma scale was 12, his pupils were miotic. He had cafe-au-lait spots on his body. His fundus examination, cerebrospinal fluid findings and cranial magnetic resonance imaging did not reveal any abnormality. Results of comprehensive search for metabolic, toxicological, infectious and autoimmune etiologies were all negative. Generalized slowing was seen on the electroencephalography (EEG) of the patient indicating possible encephalopathy. The patient developed convulsive status epilepticus and was intubated on day 5. His seizures were controlled by continuous infusion of midazolam, thiopental and used for 4 days. Phenytoin, levetiracetam, topiramate were used simultaneously. IVIG was administered as an immunomodulator for refractory seizures on day-9. The patient was extubated on day 11. The diagnosis was made after a comprehensive negative search for central nervous system infection, autoimmune and metabolic diseases. At follow up it was learnt that he had had only two seizures in two years. Status epilepticus did not recur. Clinicians should keep in mind FIRES which is a diagnosis of exclusion especially in refractory status epilepticus. IVIG treatment could have a benefit in these patients.

B-type natriuretic peptide is a useful biomarker predicting disease severity in children with isolated bronchiolitis in the emergency department.

The aim of the study was to determine whether the B-type natriuretic peptide (BNP) plasma level predicted the severity of bronchiolitis without additional pathology in children admitted to an emergency department (ED). A total of 232 children (mean age: 7.7±1.2 months [range: 1-23 months]) presenting to ED with isolated bronchiolitis and 32 age- and gender-matched control subjects were included in the study. BNP levels differed significantly among the control (8.5±1.1 pg/ml) and mild (27.7±2.6 pg/ml), moderate (51.4±0.5 pg/ml), and severe (106.8±4.8 pg/ml) bronchiolitis groups (p < 0.001). Clinical severity score (p < 0.001; OR: 2.524; 95% CI: 1.826-3.487) and plasma BNP level (p < 0.001; OR: 2.231; 95% CI: 1.583-3.242) were independent risk factors for hospitalization. The length of hospital stay was significantly correlated with BNP level (p < 0.001; r: 0.698). In conclusion, the plasma BNP level may be a potent biomarker predicting disease severity in ED.

Factors affecting the decision to hospitalise children admitted to the emergency department due to non-fatal suicide attempts by pills.

OBJECTIVE: Suicide attempts (SAs) in the paediatric age group represent an important cause of morbidity and mortality. Our aim was to examine the factors affecting the decision to hospitalize children with a diagnosis of non-fatal SA by pills. METHODS: Children <18 years of age admitted with SA by pills during 2014 were evaluated retrospectively. Patients were divided into two groups: Group-I comprised hospitalised patients and Group-II included those who were discharged from the PED. These two groups were compared in terms of clinical and demographic characteristics recorded upon PED admission. RESULTS: A total of 196 patients were included in the study. The number of pills taken for self-poisoning in Group-I (median: 20 pills) was higher than that in Group-II (median: 12 pills) (p < 0.001), and the rate of pathological findings during the first paediatric psychiatric consultation was higher in Group-I (91.1%) than in the Group-II (54.8%) (p < 0.001). CONCLUSION: Factors affecting the disposition decision in cases of children who performed non-fatal SA via pills included the amount of medication taken for the suicide attempt and the presence of psychiatric disorders, as determined by a paediatric psychiatrist during the acute phase.

The need for mechanical ventilation in a child exposed to a laundry detergent pod.

Laundry detergent pods (LDPs) are a new, concentrated form of detergent covered by a membrane of polyvinyl alcohol or other water-soluble material. In contrast to traditional laundry detergents, the spectrum of responses to exposure to LDPs ranges from mild to life-threatening events. This is a case report of a 3-year-old male who ingested part of an LDP, leading to a depressed level of consciousness, upper airway obstruction, and severe respiratory distress. The patient required intubation and mechanical ventilation for 2 days before being discharged. This rare, severe clinical pattern demonstrates the potential toxicity of these laundry detergents. In the literature, few cases that required intubation and ventilation have been reported. To our knowledge, this is also the first case of LDP exposure reported from Turkey.

The importance of microalbuminuria in predicting patient outcome in a PICU.

OBJECTIVE: To evaluate the prognostic significance of microalbuminuria in critically ill children. DESIGN: Prospective study. SETTING: PICU of a teaching hospital. PATIENTS: Admitted critically ill children. INTERVENTIONS: The urine albumin-creatinine ratio was measured at admission and at 24 hours. Pediatric Risk of Mortality, Pediatric Index of Mortality II, Pediatric Logistic Organ Dysfunction, and Inotrope Score were calculated. MEASUREMENTS AND MAIN RESULTS: In total, 102 patients (median age, 19 mo) were included in the study, among whom were 30 mortalities. Microalbuminuria was identified in 62 patients (64%). The patients were classified into three groups: patients with sepsis, patients with noninfectious systemic inflammatory response syndrome, and patients without systemic inflammatory response syndrome. The highest clinical scores, albumin-creatinine ratio levels, mortality rate, and duration of mechanical ventilation were found in the sepsis group, and the lowest values were seen in patients without systemic inflammatory response syndrome (p < 0.05). Significant correlations were observed between the albumin-creatinine ratio levels and the clinical scores (p < 0.05). The receiver operating characteristics curve analysis showed that the areas under the curves were 0.818 and 0.781, respectively, for albumin-creatinine ratio measured at admission and at 24 hours to identify PICU mortality. At a cutoff value of 34.2 mg/g, albumin-creatinine ratio measured at admission may be able to discriminate between patients a with sensitivity of 63.3%, specificity of 93.3%, positive predictive value of 95%, and negative predictive value of 56%. CONCLUSIONS: Microalbuminuria is a simple, inexpensive, and useful tool for predicting mortality and morbidity in critically ill children in the PICU.