Prevalence and Time Course of Thiamine Deficiency in Critically Ill Children: A Multicenter, Prospective Cohort Study in Turkey.

OBJECTIVES: To determine the prevalence and time course of thiamine deficiency (TD) in PICU patients. DESIGN: Multicenter, prospective, cohort study between May 2019 and November 2019. SETTING: Three university-based tertiary care, mixed medical-surgical PICUs in Ankara, Turkey. PATIENTS: PICU patients 1 month to 18 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We studied 476 patients and grouped them by TD status on days 1 and 3 of the PICU admission. There might be a risk of unintended bias since we excluded 386 patients because of the absence of consent, inadequate blood samples, loss of identifier information, and recent vitamin supplementation. On day 1, TD was present in 53 of 476 patients (11.1%) and median (minimum-maximum) thiamine levels were 65.5 ng/mL (5-431 ng/mL). On day 3, TD was present in 27 of 199 patients (13.6%) with repeated measurement. The median (minimum-maximum) thiamine levels were 63 ng/mL (13-357 ng/mL). The time course of TD from day 1 to day 3 in these 199 patients was as follows. In 21 of 199 patients (10.6%) with TD on day 1, 11 of 21 (52%) continued to have TD on day 3 and the other 10 of 21 patients (48%) improved to no longer having TD. In 178 of 199 patients (89.4%) without TD on day 1, 16 of 178 (9%) went on to develop TD by day 3, and the other 162 of 178 (91%) continued to have normal thiamine status. CONCLUSIONS: In the PICU population in three centers in Turkey, the prevalence of TD in the sample of patients was 11.1%. In those TD patients who had serial studies, we also identified that by day 3 some continued to be TD, and some patients improved to normal thiamine status. Of concern, however, is the population who develop TD over the course of PICU stay.

A Case Series of Life-Threatening Complications of Central Venous Catheter Insertion.

ABSTRACT: Central venous catheters are commonly used in emergency department and the intensive care units for the treatment of critically ill patients. Reports on the rate of mechanical complications of catheter insertion are around 1%. Mechanical complications related with the insertion of the catheter mainly depend on the anatomic location, the use of ultrasound, and experience of the operator. The rate of complication is higher in places where central lines are not routinely inserted as in emergency department. Here, we report a case series of 4 patients who had life-threatening complications of central venous catheter insertion, including venous intimal injury leading to pleural effusion, kinked central venous catheter in the superior vena cava, knotted guidewire with the separation of coil and core, and a missed guidewire with their respective insertion history and imaging. Increasing the awareness of and developing strategies to prevent these rare but potentially fatal conditions may have impact on patient outcomes.

The Burden of Burnout Syndrome in Pediatric Intensive Care Unit and Pediatric Emergency Department: A Multicenter Evaluation.

OBJECTIVE: The objective of this study was to detect variables associated with burnout syndrome (BS) in pediatric intensive care units (PICUs) and pediatric emergency medicine departments (PEDs) in high-volume centers from different parts of Turkey. METHODS: An observational, cross-sectional multicenter study was performed. The Maslach Burnout Inventory scale was administered to all of health care providers working in PICUs and PEDs. In this study, health care providers were defined as physicians, nurses, and other staff (secretaries, cleaning and patient care staff) working in PICU and PEDs. RESULTS: A total of 570 participants completed the survey. The major finding of this study was that 76.1% (n = 434) of PICU and PED health care professionals had BS. The most prominent subscale of BS was emotional exhaustion (62.5%). The rate of BS was higher among health care providers working in PEDs compared with PICUs (79.1% vs 73.7%, P = 0.04). The frequency of BS according to emotional exhaustion and depersonalization subscales was higher in health care providers of PEDs. The rate of BS was also significantly higher in younger employees, females, those working 51 or more hours totally in a week, those having a low monthly salary, those single or divorced, those without children, those with no childcare at home, those not owning a home, those not doing regular exercise and not having regular breakfast, those with total employment time of less than 1 year, and those not having a car or not having a hobby. In PEDs, when the daily evaluated number of patients was equal to or more than 44 (sensitivity, 88%; specificity, 66%), it predicted the occurrence of BS. In PICUs, when the number of patients cared for by 1 nurse was equal to or more than 3, it predicted the occurrence of BS (sensitivity, 78%; specificity, 62%). CONCLUSIONS: By creating early intervention programs to prevent BS, shortages of health care professionals can be avoided and the costs of health care expenditures related to infections can be decreased.

Comprehensive Analysis of Severe Viral Infections of Respiratory Tract admitted to PICUs during the Winter Season in Turkey.

OBJECTIVES: To analyze the course of seasonal viral infections of respiratory tract in patients hospitalized in pediatric intensive care units (PICU) of 16 centers in Turkey. MATERIALS AND METHODS: It is a retrospective, observational, and multicenter study conducted in 16 tertiary PICUs in Turkey includes a total of 302 children with viral cause in the nasal swab which required PICU admission with no interventions. RESULTS: Median age of patients was 12 months. Respiratory syncytial virus (RSV) was more common in patients over one year of age whereas influenza, human Bocavirus in patients above a year of age was more common (p <0.05). Clinical presentations influencing mortality were neurologic symptoms, tachycardia, hypoxia, hypotension, elevated lactate, and acidosis. The critical pH value related with mortality was ≤7.10, and critical PCO2 ≥60 mm Hg. CONCLUSION: Our findings demonstrate that patients with neurological symptoms, tachycardia, hypoxia, hypotension, acidosis, impaired liver, and renal function at the time of admission exhibit more severe mortal progressions. Presence of acidosis and multiorgan failure was found to be predictor for mortality. Knowledge of clinical presentation and age-related variations among seasonal viruses may give a clue about severe course and prognosis. By presenting the analyzed data of 302 PICU admissions, current study reveals severity of viral respiratory tract infections and release tips for handling them. HOW TO CITE THIS ARTICLE: Kockuzu E, Bayrakci B, Kesici S, Citak A, Karapinar K, Emeksiz S, et al. Comprehensive Analysis of Severe Viral Infections of Respiratory Tract admitted to PICUs During the Winter Season in Turkey. Indian J Crit Care Med 2019;23(6):263-269.

Ventilator associated pneumonia due to carbapenem resistant microorganisms in children.

BACKGROUND: Infections due to carbapenem resistant pathogens have become a major health threat especially for hospitalized patients. Acinetobacter baumanii (AB) and Pseudomonas aeruginosa (PA) are important pathogens causing ventilator-associated pneumonia (VAP) with a trend of high resistance to carbapenems. The aim of this study is to investigate the risk factors for VAP due to carbapenem resistant Acinetobacter baumanii (CRAB) and Pseudomonas aeruginosa (CRPA) in children. METHODS: Between 2009 and 2013, an active, prospective observational study was conducted in Gazi University Hospital. Patients from Pediatric Intensive Care Unit (PICU), between 1 month and 12 years of age with VAP due to AB and PA were included. RESULTS: During this period, 74 children experienced 126 VAP episodes due to Acinetobacter baumanii (N.=58) and Pseudomonas aeruginosa (N.=68). Among these, 93.1% (N.=54) of AB and 51.5% (N.=35) of PA were carbapenem resistant. In univariate analysis, length of stay in PICU until the diagnosis of VAP, presence of central venous catheters, prior use of cefepime, ciprofloxacin, colistin, and teicoplanin were associated with VAP due to CRPA (P=0.02, P=0.02, P=0.006, P=0.01, P=0.001, and P=0.009 respectively). Significant association was not found between the development of VAP due to CRAB and the investigated risk factors. Regression analyses revealed previous use of cefepime (OR, 2.11; 95% CI, 0.016-0.595, P=0.039) and colistin (OR: 2.33; 95% CI: 0.061-0.789, P=0.023) to be independently associated with VAP due to CRPA. CONCLUSIONS: This study suggests that broad spectrum antibiotic usage was the most important risk factor for the development of VAP due to CRPA.

Successful application of CytoSorb® hemadsorption in an immunocompromised teenager with collapsing glomerulopathy, acute respiratory distress syndrome, and sepsis.

OBJECTIVE: CytoSorb® hemadsorption is an adjunctive therapy in order to reduce elevated cytokine levels of interleukin-6, interleukin-1, and tumor necrosis factor alpha. Here we present a successful administration of CytoSorb® hemadsorption in an immunocompromised pediatric patient with collapsing glomerulopathy, acute respiratory distress syndrome, and sepsis. DATA SOURCES: Clinical observations of one patient. STUDY SELECTION: Case report. DATA EXTRACTION: Data sources are clinical observation during patient management and patient's medical records if needed. The patient's consent was obtained prior to the study. DATA SYNTHESIS: A 17-year-old male with diarrhea was admitted to the hospital and was later found to have elevated creatinine levels and proteinuria. The renal biopsy was consistent with collapsing glomerulopathy and treatment with multi immunosuppressive agents including corticosteroids, mycophenolate mofetil, and rituximab coupled with several courses of hemodialysis and plasmapheresis were administered. During the hospital stay, Stenotrophomonas maltophilia bacteremia from the blood and the catheter cultures were identified. No clinical response was achieved, and patient developed severe sepsis despite antibiotics, intravenous immunoglobulin, and supportive management including albumin, platelet and erythrocyte concentrations, and fresh frozen plasma. CytoSorb® hemadsorption was then added to the ongoing treatment for three consecutive days. Subsequent to CytoSorb® hemadsorption, immediate laboratory and clinical response were observed. CONCLUSION: This is the successful clinical report of an immunocompromised teenager with collapsing nephropathy, sepsis, and multi-organ dysfunction syndrome treated with a combination of renal replacement therapy and CytoSorb® hemadsorption. The usage of CytoSorb® hemadsorption represents a novel approach to improve survival of the patients with multiple organ dysfunction and sepsis.

Perfil de mortalidad en una Unidad de Cuidados Intensivos Pediátricos: asociación entre la mortalidad y el período fuera del horario diurno semanal / Six year mortality profile of a Pediatric Intensive Care Unit: associaton between out-of-hours and mortality

Introducción. El personal capacitado y los avances tecnológicos mejoraron las unidades de cuidados intensivos pediátricos (UCIP); por ende, mejoraron la atención, la supervivencia y el pronóstico. Pero la calidad de la atención varía según la disponibilidad de recursos humanos y técnicos. Objetivo. Determinar la correlación de las tasas de mortalidad dentro y fuera del horario diurno en días de semana. .Métodos. Se definió horario de días de semana de 8:00 a. m. a 5:00 p. m., el período fuera del horario fueron de 5:00 p. m. a 8:00 a. m., fines de semana y feriados, con un residente en la UCIP y un médico de planta de guardia pasiva. Se clasificaron las causas de mortalidad en la UCIP. Resultados. Se hospitalizaron 2187 pacientes en la UCIP. Fallecieron 394; 151 niñas (38,3 %) y 243 varones (61,7 %). Según el horario de muerte, la mayoría ocurrió fuera del horario diurno 244 (61,9 %) versus a 150 (38,1 %) durante el turno diurno, una diferencia estadísticamente significativa (p < 0,05). La edad, el sexo y la duración de la hospitalización en la UCIP no fueron significativos (p > 0,05) al comparar el período dentro y fuera del horario diurno. Se evaluaron las afecciones que acompañaron la muerte. La relación entre el horario de médicos de planta y la muerte fue significativa (p < 0,05). Hubo más afecciones asociadas a mortalidad fuera del horario diurno . Conclusión. El período fuera del horario diurno sin médicos de planta estuvo asociado con mayor mortalidad.

Introduction.Recent improvements in pediatric intensive care units (PICUs) were achieved through trained personnel and better technology, leading to an increase in patient care, survival rates and good prognosis. Nevertheless the quality of care varies according to the availability of human and technical resources. Objective. The aim was to determine the correlation of mortality rates with daytime shifts compared to other shift periods (off-hours). Methods. Work hours were defined as week days between 8:00 a.m. and 5:00 p.m., with in-house attendance of senior staff, and off-hours as week days between 5:00 p.m. and 8:00 a.m., weekends and public holidays, with one resident covering the PICU and senior staff directly available only on-call. Mortality causes in children hospitalized in the intensive care unit were classified. Results. During this period, a total of 2,187 patients were hospitalized in the PICU. A total of 394 patients died; 151 were girls (38.3 %) and 243 boys (61.7 %). Evaluating time of mortality showed that death occurred mostly at out-off hours: 244 (61.9 %) vs. 150 (38.1 %) during the daytime shift, which was statistically significant (p < 0.05). In addition, age, gender and the length of stay in the PICU were not significant (p > 0.05) when daytime was compared to outoff hours. The conditions which accompanied death were evaluated, the relationship between working hours and death was also significant (p < 0.05). More conditions related to mortality were encountered at off-hours.

Six year mortality profile of a Pediatric Intensive Care Unit: associaton between out-of-hours and mortality. / Perfil de mortalidad en una Unidad de Cuidados Intensivos Pediátricos: asociación entre la mortalidad y el período fuera del horario diurno semanal.

INTRODUCTION: Recent improvements in pediatric intensive care units (PICUs) were achieved through trained personnel and better technology, leading to an increase in patient care, survival rates and good prognosis. Nevertheless the quality of care varies according to the availability of human and technical resources. OBJECTIVE: The aim was to determine the correlation of mortality rates with daytime shifts compared to other shift periods (off-hours). METHODS: Work hours were defined as week days between 8:00 a.m. and 5:00 p.m., with in-house attendance of senior staff, and off-hours as week days between 5:00 p.m. and 8:00 a.m., weekends and public holidays, with one resident covering the PICU and senior staff directly available only on-call. Mortality causes in children hospitalized in the intensive care unit were classified. RESULTS: During this period, a total of 2,187 patients were hospitalized in the PICU. A total of 394 patients died; 151 were girls (38.3 %) and 243 boys (61.7 %). Evaluating time of mortality showed that death occurred mostly at out-off hours: 244 (61.9 %) vs. 150 (38.1 %) during the daytime shift, which was statistically significant (p < 0.05). In addition, age, gender and the length of stay in the PICU were not significant (p > 0.05) when daytime was compared to out-off hours. The conditions which accompanied death were evaluated, the relationship between working hours and death was also significant (p < 0.05). More conditions related to mortality were encountered at off-hours. CONCLUSION: Off-hours without 24 hour attendance of senior staff, was associated with higher mortality.

Introducción. El personal capacitado y los avances tecnológicos mejoraron las unidades de cuidados intensivos pediátricos (UCIP); por ende, mejoraron la atención, la supervivencia y el pronóstico. Pero la calidad de la atención varía según la disponibilidad de recursos humanos y técnicos. Objetivo. Determinar la correlación de las tasas de mortalidad dentro y fuera del horario diurno en días de semana. Métodos. Se definió horario de días de semana de 8:00 a. m. a 5:00 p. m., el período fuera del horario fueron de 5:00 p. m. a 8:00 a. m., fines de semana y feriados, con un residente en la UCIP y un médico de planta de guardia pasiva. Se clasificaron las causas de mortalidad en la UCIP. Resultados. Se hospitalizaron 2187 pacientes en la UCIP. Fallecieron 394; 151 niñas (38,3 %) y 243 varones (61,7 %). Según el horario de muerte, la mayoría ocurrió fuera del horario diurno 244 (61,9 %) versus a 150 (38,1 %) durante el turno diurno, una diferencia estadísticamente significativa (p < 0,05). La edad, el sexo y la duración de la hospitalización en la UCIP no fueron significativos (p > 0,05) al comparar el período dentro y fuera del horario diurno. Se evaluaron las afecciones que acompañaron la muerte. La relación entre el horario de médicos de planta y la muerte fue significativa (p < 0,05). Hubo más afecciones asociadas a mortalidad fuera del horario diurno. Conclusión. El período fuera del horario diurno sin médicos de planta estuvo asociado con mayor mortalidad.

What triggered massive hemoptysis in Goodpasture syndrome with isolated pulmonary involvement in a 14-year-old boy?

Sismanlar-Eyüboglu T, Aslan AT, Gezgin-Yildirim D, Buyan N, Emeksiz S, Kalkan G. What triggered massive hemoptysis in Goodpasture syndrome with isolated pulmonary involvement in a 14-year-old boy? Turk J Pediatr 2019; 61: 611-614. Goodpasture syndrome is a rare, autoimmune disease associated with the development of antibodies against a specific antigen both in glomerular basement membrane and alveolar basement membrane. It is very rare in childhood and its incidence is not known. Although the mechanism of the disease is the same in lung as in the kidney, sometimes it presents with involvement of only one organ. Pulmonary involvement may be lifethreatening in patients with massive hemoptysis. Herein we report a 14-yearold boy with isolated lung involvement. He had massive hemoptysis following bronchoscopy and recovered succesfully with treatment.

Outcome of out-of-hospital cardiopulmonary arrest in children: A multicenter cohort study.

Kurt F, Kendirli T, Gündüz RC, Kesici S, Akça H, Sahin S, Kalkan G, Derbent M, Tuygun N, Ödek Ç, Gültekin-Keser A, Oguz S, Polat E, Derinöz O, Tekin D, Teksam Ö, Bayrakci B, Suskan E. Outcome of out-of-hospital cardiopulmonary arrest in children: A multicenter cohort study. Turk J Pediatr 2018; 60: 488-496. The aim of this study was to evaluate the demographic characteristics of children who experienced out-of-hospital cardiopulmonary arrest (CPA), and to assess the impact of the bystander cardiopulmonary resuscitation (CPR) on the survival rate of witnessed arrests and the effects of the arrest and CPR durations on the neurological outcomes. This multicenter, retrospective study included a total of 182 patients who underwent CPR for out-of-hospital CPA between January 2008 and December 2012 at six centers in Ankara, Turkey. The median [interquartile range (IQR)] age was 22 (5-54) months; 60.4% of the patients were males, and 44% were younger than one year of age. The witnessed arrest rate was 75.8% (138/182) and the rate of bystander CPR was 13.9% (13/93). In these patients the rate of the return of spontaneous circulation (ROSC) was higher (76.9%). Following resuscitation in the patients for whom the spontaneous circulation was able to be returned, the median (IQR) duration of arrest was 5 (1- 15) min, while it was 15 (5-40) min for the remaining patients (p < 0.001). The ROSC rate was 94.9% in patients who underwent CPR for less than 20 min and 22% in patients requiring CPR longer than 20 min (p < 0.001). Survival to hospital discharge was 14.3%. Of these patients, 57.7% experienced neurological disability. The short duration of an arrest and the presence of CPR are both critical for survival. We suggest that a witness to the CPA, performing early and efficient CPR, yields better results.

Early initiated feeding versus early reached target enteral nutrition in critically ill children: An observational study in paediatric intensive care units in Turkey.

AIM: Although early enteral nutrition (EN) is strongly associated with lower mortality in critically ill children, there is no consensus on the definition of early EN. The aim of this study was to evaluate our current practice supplying EN and to identify factors that affect both the initiation of feeding within 24 h after paediatric intensive care unit (PICU) admission and the adequate supply of EN in the first 48 h after PICU admission in critically ill children. METHODS: We conducted a prospective, multicentre, observational study in nine PICUs in Turkey. Any kind of tube feeding commenced within 24 h of PICU admission was considered early initiated feeding (EIF). Patients who received more than 25% of the estimated energy requirement via enteral feeding within 48 h of PICU admission were considered to have early reached target EN (ERTEN). RESULTS: Feeding was initiated in 47.4% of patients within 24 h after PICU admission. In many patients, initiation of feeding seems to have been delayed without an evidence-based reason. ERTEN was achieved in 43 (45.3%) of 95 patients. Patients with EIF were significantly more likely to reach ERTEN. ERTEN was an independent significant predictor of mortality (P < 0.001), along with reached target enteral caloric intake on day 2 associated with decreased mortality. CONCLUSIONS: There is a substantial variability among clinicians' perceptions regarding indications for delay to initiate enteral feeding in critically ill children, especially after the first 6 h of PICU admission. ERTEN, but not EIF, is associated with a significantly lower mortality rate in critically ill children.

Alteration of thiol-disulphide homeostasis in acute tonsillopharyngitis.

OBJECTIVE: Thiol-disulphide homeostasis (TDH) has a critical role in various clinical disorders. We aimed to assess the association of TDH with acute tonsillopharyngitis (AT) in children. METHODS: This study included 94 (73 viral and 21 bacterial) tonsillopharyngitis patients and 88 control children. Their native thiol, total thiol, and disulphide levels were measured. RESULTS: Viral and bacterial tonsillopharyngitis patients had lower native thiol levels compared with healthy children (P < 0.001 and P = 0.008, respectively). Both groups had lower total thiol levels compared with control children (P = 0.002 for viral, P = 0.011 for bacterial). The disulphide levels were lower in bacterial than in viral tonsillopharyngitis patients (P = 0.04), and there was a significant difference between viral tonsillopharyngitis patients and the control group (P < 0.001). The native/total thiol ratio in each patient group was lower than in the control group (P < 0.001 for viral, P = 0.017 for bacterial). The disulphide/native thiol and disulphide/total thiol ratios were significantly higher in viral (P < 0.001 for both) and bacterial tonsillopharyngitis patients (P = 0.017 for both) than in healthy children. In all patients, a correlation was found between the levels of C-reactive protein (CRP) and native thiol (r = -0.211, P = 0.04), CRP and total thiol (r = -0.217, P = 0.036), white blood cell (WBC) and native thiol (r = -0.228, P = 0.002), WBC and total thiol (r = -0.191, P = 0.01), and WBC and disulphide (r = 0.160, P = 0.03). DISCUSSION: TDH is altered in AT in children. The alteration is more prominent in viral than in bacterial tonsillopharyngitis.

Diagnostic Value of Upar, IL-33, and ST2 Levels in Childhood Sepsis.

BACKGROUND: The aim of this study was to evaluate the diagnostic value of Upar, IL-33, and ST2 in comparison with C-reactive protein, TNF-α, and Interleukin-6 in childhood sepsis. METHODS: A total of 128 children were included and 20 of them were the control group. We used only data showing a high probability of sepsis with blood culture positive children, because of this reason 68 children were excluded. Blood was collected from children from first day of sepsis (1st value) and 48 - 72 hours later (2nd value). RESULTS: There were significant differences between control and sepsis (1st value) for IL-33 levels (1.1 ± 0.28 ng/ mL and 5.23 ± 1.80 ng/mL, p = 0.01), for sST2 levels (6.73 ± 5.3 ng/mL and 53.23 ± 28.30 ng/mL, p = 0.01), for sUpar levels (3.3 ± 1.7 ng/mL and 15.2 ± 6.3 ng/mL, p = 0.01), respectively. There were significant differences between sepsis (1st value) and sepsis (2nd value) for IL-33 levels, for sST2 levels, and for suPAR levels. CONCLUSIONS: In the light of these results, it may be suggested that Upar, IL-33, and ST2 can be used as an acute phase reactant like C-reactive protein, TNF-α, and Interleukin-6 in the diagnosis of childhood sepsis.

Cardiopulmonary Resuscitation in Children With In-Hospital and Out-of-Hospital Cardiopulmonary Arrest: Multicenter Study From Turkey.

OBJECTIVES: The objectives of this study were to determine the causes, location of cardiopulmonary arrest (CPA) in children, and demographics of cardiopulmonary resuscitation (CPR) in Turkish pediatric emergency departments and pediatric intensive care units (PICUs) and to determine survival rates and morbidities for both in-hospital and out-of-hospital CPA. METHODS: This multicenter descriptive study was conducted prospectively between January 15 and July 15, 2011, at 18 centers (15 PICUs, 3 pediatric emergency departments) in Turkey. RESULTS: During the study period, 239 children had received CPR. Patients' average age was 42.4 (SD, 58.1) months. The most common cause of CPA was respiratory failure (119 patients [49.8%]). The location of CPA was the PICU in 168 (68.6%), hospital wards in 43 (18%), out-of-hospital in 24 (10%), and pediatric emergency department in 8 patients (3.3%). The CPR duration was 30.7 (SD, 23.6) minutes (range, 1-175 minutes) and return of spontaneous circulation was achieved in 107 patients (44.8%) after the first CPR. Finally, 58 patients (24.2%) were discharged from hospital; survival rates were 26% and 8% for in-hospital and out-of-hospital CPA, respectively (P = 0.001). Surviving patients' average length of hospital stay was 27.4 (SD, 39.2) days. In surviving patients, 19 (32.1%) had neurologic disability. CONCLUSION: Pediatric CPA in both the in-hospital and out-of-hospital setting has a poor outcome.

Treatment of Ventilator-Associated Pneumonia Using Intravenous Colistin Alone or in Combination with Inhaled Colistin in Critically Ill Children.

OBJECTIVE: The objective of this study was to compare the safety and efficacy of inhaled plus intravenous (IV) colistin with that of IV colistin alone in critically ill children with ventilator-associated pneumonia (VAP) due to colistin-only susceptible (COS) Gram-negative bacteria (GNB). STUDY DESIGN AND PATIENTS: This retrospective cohort study included critically ill children aged 1 month to 18 years with culture-documented monomicrobial VAP due to COS GNB. RESULTS: Fifty patients were included, and 32 patients received IV colistin alone, whereas 18 patients received inhaled plus IV colistin. No between-cohort differences were observed in clinical (p = 0.49) and microbiological outcomes (p = 0.68), or VAP-related mortality (p = 0.99). Although the bacterial eradication rates did not differ in either treatment group, the median time to bacterial eradication (TBE) was significantly shorter in the inhaled plus IV colistin group than in the IV colistin group. The additional use of inhaled colistin was the only independent factor associated with TBE, and it shortened the median TBE by 3 days. Only one patient in the IV colistin group developed reversible nephrotoxicity. Mild bronchoconstriction was observed in three patients at the time of administration of the first doses of inhaled colistin, which did not require discontinuation of treatment. CONCLUSIONS: The present study has demonstrated that the addition of inhaled colistin to IV colistin led to a shorter TBE in critically ill children with VAP due to COS GNB. However, it did not lead to a significant difference in the clinical and microbiological outcomes of VAP.

Inappropriate antidiuretic syndrome hypersecretion after a single dose of cisplatin.

Severe hyponatremia with seizure owing to the syndrome of inappropriate antidiuretic hormone secretion (SIADH) or cerebral/renal salt wasting syndrome related with high mortality. The correct diagnosis of the hyponatremia for each case is important because of the alteration of the treatment approach. SIADH is an important clinical manifestation that does not occur after all chemotherapy courses. We cannot estimate whether the disease will occur on, which course of the chemotherapy in this case.

High serum 25-hydroxyvitamin D levels are associated with pediatric sepsis.

Despite major advances in intensive care, sepsis continues to be a major cause of morbidity and mortality. Vitamin D is involved in various physiologic functions, including cellular responses during infection and inflammation. The aim of this study was to evaluate diagnostic value of 25-hydroxyvitamin D in childhood sepsis because it can be fatal if diagnosis delayed. The study included 40 children with sepsis and 20 children without sepsis (control group). We included only the patients with high probable sepsis, judged by clinical and laboratory findings, including positive blood culture. Blood samples were collected from patients with sepsis before treatment (pre-treatment group) and 48-72 hours later (post-treatment group). Treatment varied from ampicillin-sulbactam to cephalosporin. Blood samples were collected from control group once on admission. Serum 25-hydroxyvitamin D levels were significantly higher in sepsis (pre-treatment group) than control group (74 ± 8 ng/ml vs. 28 ± 12 ng/ml, p = 0.01) and the serum 25-hydroxyvitamin D levels were decreased to 44 ± 5 ng/ml (p = 0.01) after treatment. Moreover, we found significant positive correlation between 25-hydroxyvitamin D and each of well-know sepsis markers, C-reactive protein, tumor necrosis factor-α and interleukin-6. A cut-off point of 20 ng/mL for serum 25-hydroxyvitamin D showed 84% sensitivity and 76% specificity for sepsis diagnosis. This is the first study evaluating the diagnostic role of vitamin D in pediatric sepsis, thereby suggesting that serum 25-hydroxyvitamin D level can be used as a diagnostic marker for sepsis with high sensitivity and specificity.