Late-term cardiac magnetic resonance imaging in multisystem inflammatory syndrome in children.

BACKGROUND: Cardiac involvement in multisystem inflammatory syndrome in children may have a spectrum ranging from mild disease to severe heart failure due to fulminant myocarditis. Cardiac involvement usually resolves after clinical recovery. However, the adverse effects of myocarditis on cardiac function after recovery are not fully known. This study aims to investigate cardiac involvement by performing cardiac magnetic resonance imaging (MRI) after the acute and recovery periods. METHODS: 21 patients with clinical and laboratory signs of myocarditis, including left ventricular systolic dysfunction, mitral regurgitation, elevated troponin T, elevated N-terminal pro-B-type natriuretic peptide and electrocardiographic changes, who had given consent for cardiac MRI, underwent cardiac MRI after completion of the acute and recovery phases. RESULTS: When compared to 16 patients with normal cardiac MRI, five patients with cardiac fibrosis on MRI were older, had greater body mass indexes, lower leucocyte counts, lower neutrophil counts, higher blood urea nitrogen levels and higher creatinine levels. Cardiac fibrosis on MRI was located in the posterior right ventricle insertion point and in mid ventricular septum. CONCLUSIONS: Adolescence and obesity appear as risk factors for the development of fibrosis as a late-term sequela of myocarditis. Furthermore, future studies reporting the follow-up data of patients with fibrosis are necessary to predict and manage adverse outcomes.

Comparison of vena cava distensibility index and pulse pressure variation for the evaluation of intravascular volume in critically ill children

Abstract Objective: In this study, the authors aimed to evaluate the effectiveness of the vena cava distensibility index and pulse pressure variation as dynamic parameters for estimating intravascular volume in critically ill children. Methods: Patients aged 1 month to 18 years, who were hospitalized in the present study's pediatric intensive care unit, were included in the study. The patients were divided into two groups according to central venous pressure: hypovolemic (< 8mmHg) and non-hypovolemic (central venous pressure ≥ 8 mmHg) groups. In both groups, vena cava distensibility index was measured using bedside ultrasound and pulse pressure variation. Measurements were recorded and evaluated under arterial monitoring. Results: In total, 19 (47.5%) of the 40 subjects included in the study were assigned to the central venous pressure ≥ 8 mmHg group, and 21 (52.5%) to the central venous pressure < 8 mmHg group. A moderate positive correlation was found between pulse pressure variation and vena cava distensibility index (r = 0.475, p < 0.01), while there were strong negative correlations of central venous pressure with pulse pressure variation and vena cava distensibility index (r = -0.628, p < 0.001 and r = -0.760, p < 0.001, respectively). In terms of predicting hypovolemia, the predictive power for vena cava distensibility index was > 16% (sensitivity, 90.5%; specificity, 94.7%) and that for pulse pressure variation was > 14% (sensitivity, 71.4%; specificity, 89.5%). Conclusion: Vena cava distensibility index has higher sensitivity and specificity than pulse pressure variation for estimating intravascular volume, along with the advantage of non-invasive bedside application.

Comparison of the value of immature retyculocyte and immature platelet in the diagnosis of sepsis.

BACKGROUND: Sepsis is one of the causes of pre-treatment morbidity and mortality in the pediatric age group. In the present study, we investigated the place of the immature granulocyte percentage, (IG) immature reticulocyte fraction (IRF), and immature platelet fraction (IPF) in the diagnosis of sepsis. METHODS: Complete blood count, C-reactive protein, (CRP) procalcitonin (PCT) and blood cultures were measured in 125 critical patients who were followed-up in the intensive care unit with the suspicion of sepsis and 65 healthy children between 2017 and 2019. In addition to the complete blood counts and routine parameters, IG, IRF, and IPF were examined in the patients. RESULTS: When the critical patient group and the healthy control group were compared, it was found that the total number of leukocytes (white blood cells), neutrophil count, platelet count, CRP, PCT, IG, IRF, and IPF values were higher at statistically significant levels. When septic and non-septic patients were compared, it was found that the CRP, PCT,IGP, and IPF were higher at statistically significant levels in the septic patients. CONCLUSIONS: It was concluded that CRP, PCT, IG, and IPF were significant in determining sepsis and that PCT was the most sensitive and specific biomarker in these parameters. We believe that these parameters may be suitable for practical use in determining sepsis because they give faster results and suggest the diagnosis of sepsis.

Comparison of vena cava distensibility index and pulse pressure variation for the evaluation of intravascular volume in critically ill children.

OBJECTIVE: In this study, the authors aimed to evaluate the effectiveness of the vena cava distensibility index and pulse pressure variation as dynamic parameters for estimating intravascular volume in critically ill children. METHODS: Patients aged 1 month to 18 years, who were hospitalized in the present study's pediatric intensive care unit, were included in the study. The patients were divided into two groups according to central venous pressure: hypovolemic (< 8 mmHg) and non-hypovolemic (central venous pressure ≥ 8 mmHg) groups. In both groups, vena cava distensibility index was measured using bedside ultrasound and pulse pressure variation. Measurements were recorded and evaluated under arterial monitoring. RESULTS: In total, 19 (47.5%) of the 40 subjects included in the study were assigned to the central venous pressure ≥ 8 mmHg group, and 21 (52.5%) to the central venous pressure < 8 mmHg group. A moderate positive correlation was found between pulse pressure variation and vena cava distensibility index (r = 0.475, p < 0.01), while there were strong negative correlations of central venous pressure with pulse pressure variation and vena cava distensibility index (r = -0.628, p < 0.001 and r = -0.760, p < 0.001, respectively). In terms of predicting hypovolemia, the predictive power for vena cava distensibility index was > 16% (sensitivity, 90.5%; specificity, 94.7%) and that for pulse pressure variation was > 14% (sensitivity, 71.4%; specificity, 89.5%). CONCLUSION: Vena cava distensibility index has higher sensitivity and specificity than pulse pressure variation for estimating intravascular volume, along with the advantage of non-invasive bedside application.

Therapeutic Plasma Exchange in Pediatric Intensive Care Unit: A Single-center Experience.

AIM AND OBJECTIVE: To examine the clinical characteristics, indications, and complications of patients undergoing therapeutic plasma exchange (TPE) in our pediatric intensive care unit (PICU). MATERIALS AND METHODS: Patients who underwent therapeutic plasma exchange between January 2018 and January 2020 in the PICU were included in the study. Demographic, clinical, and laboratory data of patients were obtained retrospectively from medical records. A venous catheter was placed into subclavian, femoral, or jugular veins. The number of plasmapheresis sessions for each patient was determined by observing the course of the disease and clinical improvement. Patients were monitored for vital signs during the plasmapheresis process. Complications directly associated with TPE were recorded. RESULTS: During the 2-year study period, 105 TPE sessions were performed in 25 patients (15 males/10 females). The median age was 84 months (6-204), and the median body weight was 32 kg (8-75). Renal disorders and sepsis were the most common group, and about 48% of patients were in these groups. The most common diagnoses were sepsis with multi-organ dysfunction syndrome in seven patients and followed by hemolytic uremic syndrome (five patients) and Guillain-Barre syndrome (three patients). Nausea (6.7%) and hypocalcemia (6.7%) were the most common complications of patients associated with the procedure. Premature discontinuation of the procedure were not seen due to complications. Complications were treated with symptomatic therapy. CONCLUSION: TPE is an effective treatment that can be safely used for pediatric patients with developments in PICUs. Nevertheless, TPE should be performed by experienced staff at a specialized center to minimize the risk of complications. HOW TO CITE THIS ARTICLE: Özsoylu S, Dursun A, Çelik B. Therapeutic Plasma Exchange in Pediatric Intensive Care Unit: A Single-center Experience. Indian J Crit Care Med 2021;25(10):1189-1192.

A multicentered study on efficiency of noninvasive ventilation procedures (SAFE-NIV)

Background/aim: To characterize the clinical course of noninvasive positive pressure ventilation (NIPPV) and high flow humidified nasal cannula ventilation (HFNC) procedures; perform risk analysis for ventilation failure. Material and methods: This prospective, multi-centered, observational study was conducted in 352 PICU admissions (1 month-18 years) between 2016 and 2017. SPSS-22 was used to assess clinical data, define thresholds for ventilation parameters and perform risk analysis. Results: Patient age, onset of disease, previous intubation and hypoxia influenced the choice of therapy mode: NIPPV was preferred in older children (p = 0.002) with longer intubation (p < 0.001), ARDS (p = 0.001), lower respiratory tract infections (p < 0.001), chronic respiratory disease, (p = 0.005), malignancy (p = 0.048) and immune deficiency (p = 0.026). The failure rate was 13.4%. sepsis, ARDS, prolonged intubation, and use of nasal masks were associated with NIV failure (p = 0.001, p < 0.001, p < 0.001, p = 0.025). The call of intubation or re-intubation was given due to respiratory failure in twenty-seven (57.5%), hemodynamic instability in eight (17%), bulbar dysfunction or aspiration in 5 (10.6%), neurological deterioration in 4 (8.5%) and developing ARDS in 3 (6.4%) children. A reduction of less than 10% in the respiration within an hour increased the odds of failure by 9.841 times (OR: 9.841, 95% CI: 2.0021­48.3742). FiO2 > 55% at 6th hours and PRISM-3 >8 were other failure predictors. Of the 9.9% complication rate, the most common complication was pressure ulcerations (4.8%) and mainly observed when using full-face masks (p = 0.047). Fifteen (4.3%) patients died of miscellaneous causes. Tracheostomy cannulation was performed on 16 children due to prolonged mechanical ventilation (8% in NIPPV, 2.6% in HFNC) Conclusion: Absence of reduction in the respiration rate within an hour, FiO2 requirement >55% at 6th hours and PRISM-3 score >8 predict NIV failure.

Outcomes and prognostic factors for pediatric cancer patients admitted to an intensive care unit in a university hospital.

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the factors predicting Pediatric Intensive Care Unit (PICU) mortality and the outcomes in cancer patients admitted to PICU. METHODS: We conducted a retrospective study in 48 consecutive cancer patients admitted to the PICU between January 1, 2015 and January 1, 2018. A total of 48 patients (21 males and 27 females) were enrolled in this study. RESULTS: The median age was 77 (33,5-149) months. The median duration of PICU stay was 5 (2-9) days. Patients were classified according to their stage of disease. Ten (20.8%) patients were in the remission group, 9 (18.8%) patients were in the induction period and 29 (60.5%) patients were in the progressive diseasegruops. Thirtynine patients (81.2%) had hematological malignancies, 6 (12.5%) had extracranial solid tumors and 3 (6.3%) had intracranial solid tumors. Thirty-seven patients died and the mortality rate was found to be 77.1%. mortality rates were 11%, 88% and 93% for patients in remission,during induction period and in the progressive disease group, respectively (p < 0.01).The most frequent reasons of PICU admission were respiratory failure in 29 (60.4%), sepsis in 12 (25%), circulatory collaps in 2 (4.2%), and other reasons in 5 patients (10.4%). The median PRISM III among survivors was significantly lower than non-survivors (13.1 ± 6.4; vs. 20.7 ± 5.2; p < 0.001). At a cut-off value of 13, the sensitivity of the PRISM III was 94.4% and the specificity was 58.3% (AUC: 0.821). OSDwas present in 41 (85%) patients, 82% of them died (34/41). The presence of MOF, the use of mechanical ventilation and inotrop support were significantly related with mortality. Univariate logistic regression analysis showed that male gender [odds ratio (OR)=5.588, P= 0.041, 95% confidence interval (95%CI) 1.070-29.191], presence of organ system dysfunction[OR=12.143, P= 0.008, 95%CI 1.947- 75.736], need for mechanical ventilation[OR=34.000, P= 0.001, 95%CI 5.272-219.262], IS [OR=8.5, P= 0.001, 95%CI 1.318-54.817]were the predictors ofhigh mortality in pediatric cancer patients. PRISM III score ≥ 13 was a predictive criteria of PICU mortality. CONCLUSION: We conclude that the key to improving survival rates is to pick up on this group of patients as soon as possible.We, believe that cancer patients could be saved by earlier evaluation and intervention by the PICU team when they have a less severe disease.

Could you say that was an atrial flutter or not?

Özsoylu S, Akyildiz BN, Dursun A, Pamukçu Ö. Could you say that was an atrial flutter or not? Turk J Pediatr 2019; 61: 608-610. Muscle-tremor artefact is a potential cause of misdiagnosis of atrial arrhythmias on electrocardiography (ECG) monitoring. Such errors may lead to inappropriate and potentially dangerous therapies in some patients. We present a case of a patient with uncontrolled seizures whose bedside electrocardiogram monitor analysis appeared to demonstrate atrial flutter with 4:1 conduction through the AV node. The ECG monitor and ECG rhythm strip additionally showed a regular ventricular rate of 94 bpm with an underlying regular `saw-tooth` baseline. We applied cardioversion to convert to sinus rhythm. Amiodarone was loaded and added to the patients therapy who had atrial flutter after cardioversion. Echocardiogram was performed by a pediatric cardiologist and they noted that the atrial rate and ventricular rate were equal. After this, we began to suspect this situation might be a pseudoflutter due to his muscle contractions. We applied rocuronium to the patient to understand whether this was a pseudo-flutter or not. We saw that the ECG returned to normal sinus rhythm. Physicians especially working in intensive care units should be aware of artifact to avoid unnecessary therapeutic procedures. As Hippocrates said centuries ago `First, do no harm.`.

Ogilvie syndrome presenting with septic shock.

Özsoylu S, Akyildiz BN, Dursun A. Ogilvie syndrome presenting with septic shock. Turk J Pediatr 2018; 60: 225-227. Acute colonic pseudo-obstruction (ACPO) is also known as Ogilvie`s. We report a 10-year-old child with an unremarkable past history who presented with septic shock including hypotension, prolonged capillary refill time, decreased urine output ( < 0.5 ml/kg/h), metabolic acidosis, liver failure, respiratory failure. The symptoms resolved with supportive therapy. In our patient septic shock contributed to Ogilvie syndrome. Although it is a rare condition in pediatric population, pediatricians should be aware of children with abdominal distention; supportive management is successful and morbidity/mortality is minimal.

Neutrophil-to-lymphocyte ratio and mean platelet volume can be useful markers to predict sepsis in children.

OBJECTIVES: Neutrophil-to-Lymphocyte Ratio (NLR) and Mean Platelet Volume (MPV) have been found to be useful indexes for the diagnosis of sepsis in adults. However, the knowledge of their roles and cut-off values in pediatric patients is limited. The primary objective of this study was to assess the ability of NLR and MPV to predict sepsis in children. A secondary aim was to evaluate the comparison of these parameters with C-reactive Protein (CRP). METHODS: The study was conducted on pediatric patients, who had two or more of the following criteria were included in the study: tachycardia, tachypnea, temperature change, leukocytosis, or leukopenia for age. Patients were classified into sepsis and non-sepsis groups. The sepsis group was defined as the presence of two or more age specific Systemic Inflammatory Response Syndrome (SIRS) criteria and increased Procalcitonin (PCT) level (>0.5 ng/ml). RESULT: The median age of the study population was 18 (6-169) months. Two hundred-sixty four episodes of sepsis were recorded in 125 patients. Eighty two were classified as sepsis and 182 as non-sepsis. CRP level and MPV value were significantly higher in the sepsis group compared to non-sepsis group. The median CRP level was 47.8 mg/dl (10.2-119.5) in the sepsis group and 18.6 mg/dl (4.9-66.1) in the non-sepsis group (p=0.006). In the sepsis group, the median MPV value was 8.4 (7.6-9.5) and it was 7.8 (7.1-8.5) in the non-sepsis group (p=0.001). Significant correlations were found between the procalcitonin (PCT) and CRP level (p<0.001; r = 0.279), NLR (p=0.02; r = 0.186) and MPV (p<0.001; r = 0.243). MPV had the highest specificity for predicting sepsis (75.8%). The largest AUC was 0.629 with a cut-off value 8.5 for MPV, while the AUC was 0.557 with a cut-off value 1.97 for NLR and 0.606 with a cut-off value 38.9 for CRP. CONCLUSIONS: NLR and MPV values should alert clinicians to the possibility of sepsis and to initiate or change antibiotic treatment.

Evaluating the basic life support knowledge among schoolteachers: A cross-sectional survey in Kayseri, Turkey.

Dursun A, Özsoylu S, Emeklioglu B, Akyildiz BN. Evaluating the basic life support knowledge among schoolteachers: A cross-sectional survey in Kayseri, Turkey. Turk J Pediatr 2018; 60: 702-708. Children spend a significant proportion of their day in school when they are not with their families.Therefore they might experience medical emergency situations due to injuries, complications of chronic health conditions, or unexpected major illnesses that occur in school. In cases of emergencies, school teachers are expected to play a key role in performing basic life support (BLS) on school children. Very limited data are present in the literature that address the knowledge of the schoolteacher regarding BLS. The primary objective of this study was to asses the BLS knowledge, training status and attitude towards pediatric BLS among schoolteachers. The study had a cross-sectional research design and was conducted between January and March 2017. A self administered questionnaire was used for data collection to assess the knowledge of teachers. The questionnaires were filled in by 541 teachers (243 male and 298 women). The median age of the study population was 39 (34-45) years. One-third of the respondents reported having taken a BLS class in the past (33.1%). The mean for the correct answers for the study population was 5/14 (4/14-7/14). For trained teachers, it was 6/14 (4/14-8/14) and for untrained teachers, it was 5/14 (3/14-7/14)(P < 0.001). There were no differences between teachers who had attended different BLS courses. Significant differences between teachers were observed: 62% of teachers with previous BLS training felt capable of providing cardio pulmonary resusitation (CPR) to their students compared to 48% in the group without previous training (P =0.001). Ninety- five percent of the teachers were eager to attend a BLS course and 92% reported that BLS training should be mandatorily given for teacher certification. Teachers are aware of the importance of BLS and they are willing to attend BLS training programs and improve their knowledge. Despite the fact that the knowledge of trained teachers was found to be better than those of untrained teachers, school teachers in Turkey have a low level of knowledge and skills regarding BLS.

A fatal case caused by massive honey bee stings.

Bee venom is a complex substance which acts in different ways; local or systemic anaphylaxis associated with IgE and direct toxic effects of the large volume of injected venom. We report a 10- year-old boy who was the vulnerable of 5989 honey bee attacks. To the best of our knowledge, this case had the ultimate number of honey bee stings in the literature, until now. He was admitted to pediatric intensive care unit after 3 hours of incident. Plasmapheresis was started to remove circulating venom that can cause many systemic side effects. Unfortunately, multiorgan failure developed on the 2nd day of admission due to severe hemolysis and rabdomyolysis. Additional therapies modalities, mechanical ventilation, hemodialysis, and antihypertensive drugs were added to the treatment during the disease process. Despite all of the treatments, the patient was failed on 12th day of hospitalization.

Intracranial hemorrhage in infants as a serious, and preventable consequence of late form of vitamin K deficiency: a selfie picture of Turkey, strategies for tomorrow.

PURPOSE: Vitamin K deficiency bleeding is one of the most common causes of acquired hemostatic disorder in early infancy. Although vitamin K is practiced routinely after every birth in Turkey, children with type of vitamin K deficiency bleedings (L-VKDB) can be encountered. We aimed to evaluate the clinical features of the children with L-VKDB reported from Turkey. METHODS: Between 1995 and 2013, 48 studies reporting 534 children with L-VKDB were evaluated in this study. RESULTS: Of the 534 reported children (178 girls, 356 boys), 486 (91 %) were extremely breastfed. The most common bleeding sites were intracranial hemorrhage, gastrointestinal, and umbilical in 414 (77.4 %), 33 (6.2 %), and 33 (6.2 %) children, respectively, and 35 (6.6 %) children had been diagnosed incidentally without any bleeding. The etiology of 399 (74.7 %) children were classified as idiopathic, whereas 135 (25.3 %) were secondary. Intramuscular vitamin K was administered in 248 (46.4 %), not administered in 228 (42.7 %), and the administration of vitamin K were not determined in 58 (10.9 %) children. The outcomes of Turkish cohort showed that 111 (20.8) children died, 257 (48.1 %) cases developed neurologic deficit (mainly epilepsy and psychomotor retardation), and only 166 (31.1 %) patients recovered without squeal. CONCLUSIONS: The compliance of prophylactic measures in Turkey does not seem to be satisfactory. As a further measure of tomorrow, we vigorously emphasize that a national surveillance program may be initiated. An additional intramuscular dose or oral supplementation of vitamin K especially for exclusively breast-fed infants may reduce this catastrophic problem in our country.