Evaluation of Cerebrovascular Events Followed in Pediatric Intensive Care Unit.

AIM: To evaluate the effect of intensive care follow-up and treatment methods on the prognosis of 28 patients admitted to the pediatric intensive care unit (PICU) due to stroke. MATERIAL AND METHODS: The data of patients aged between 28 days and 18 years followed up between 2011 and 2021 were recorded retrospectively. RESULTS: Thirteen (48.1%) patients were diagnosed with hemorrhagic stroke (HS), 11 (40.7%) patients were diagnosed with acute ischemic stroke (AIS), and three (11.1%) patients were diagnosed with cerebral sinus vein thrombosis. One patient was followed up for non-ruptured arteriovenous malformation (AVM) and was excluded from the HS group. The HS group consisted of eight patients with ruptured AVMs and five patients with ruptured intracranial aneurysms. The patients had male predominance, and seizures and headache were the most common complaints on admission. The rate of admissions due to seizures was higher in the AIS group. In the HS group, there was more involvement of the right side of the brain. Middle cerebral artery (MCA) involvement was higher in the AIS group. The AIS group had longer PICU hospitalization days and mechanical ventilator days. While unfractionated heparin was preferred for the treatment in the AIS group, endovascular embolization was preferred in the HS group. Decompressive surgery was performed in five patients. The overall mortality rate was 7.1%. CONCLUSION: Although cerebrovascular events are rare in the pediatric population, achieving low mortality and morbidity is possible with the correct diagnostic and treatment methods.

Assessment of the Clinical Course of Human Rhinovirus/Enterovirus Infections in Pediatric Intensive Care.

BACKGROUND: This study aims to evaluate the clinical course of human rhinovirus/enterovirus (HRV/EV) infections in the pediatric intensive care unit. METHODS: The study was conducted as a multicenter, prospective observational study from September 2022 to December 2022. Cases with positive polymerase chain reaction testing for HRV/EV of nasopharyngeal swab samples within the first 24 hours of pediatric intensive care unit admission were recorded. There were 2 groups: 1-24 months and >24 months. RESULTS: A total of 75 cases (39 male) were included in the study. The median age for all cases was 21 months. The highest polymerase chain reaction positivity rates were observed in October (37.33%). Among the cases, 32 (42.67%) presented with bronchopneumonia/pneumonia, 24 (32%) presented with acute bronchiolitis/bronchitis and 7 (9.33%) presented with sepsis/septic shock. The frequency of pediatric acute respiratory distress syndrome was found to be 6.67%. In the age group of 1-24 months, mean lymphocyte and liver enzyme levels were higher, while in the age group of >24 months, mean hemoglobin and mean kidney function test levels were higher ( P ≤ 0.05). Continuous oxygen therapy was provided to 65.3% of the cases, noninvasive ventilation to 33.3%, high-flow nasal cannula-oxygen therapy to 32% and invasive mechanical ventilation to 16%. CONCLUSIONS: HRV/EV infections primarily affect the respiratory system and generally exhibit a clinical course with low mortality rates (1, 1.3%). In cases with underlying chronic diseases, more severe clinical conditions such as pediatric acute respiratory distress syndrome and septic shock may occur.

Is the prognosis of traumatic critically ill pediatric patients predictable? : A multicenter retrospective analysis.

BACKGROUND: In this retrospective study the effects of the neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), mean platelet volume to platelet count ratio (MPV/PC) values as well as C­reactive protein (CRP) and procalcitonin (PCT) levels on the severity and mortality in critically ill child trauma cases were evaluated. METHODS: A total of 80 trauma cases aged 31 days to 16 years that were followed-up in the pediatric intensive care unit (PICU) were included in the study. The data of the patients on the first day of hospitalization (T1), the median day of intensive care admission (T2), and before discharge or exitus (T3) were analyzed. The cases were divided into three groups according to the injury severity score (ISS) as minor, moderate, and severe. RESULTS: Of the 80 cases 59 (73.75%) were male and 21 (26.25%) were female. The mean age of all the cases was 54.5 ± 47.8 months, and the mean PICU stay was 7.35 ± 6.64 days. Of the cases 19 (23.75%) due to motor vehicle accidents and 61 (76.25%) due to falling from heights were followed-up. The mortality rate was found to be 13.75% (11 cases). The T1, T2 and T3 NLR, MLR, MPV/PC and PCT values did not differ between the groups. The T1 and T2 CRP levels were higher in the moderate trauma group than in the severe trauma group. Also, ISS and pediatric risk of mortality 3 (PRISM-3) scores were higher while the revised injury severity classification version II (RISC II), RISC II survival and Glasgow coma scale (GCS) scores were lower in the nonsurvivors. While the T3 MLR value was lower in nonsurvival cases, the T3 MPV/PC value was found to be higher. CONCLUSION: The NLR, MLR, and MPV/PC values do not predict the severity of the trauma in children. In children with severe trauma, low MLR and high MPV/PC values can be used to predict mortality.

Evaluation of nutritional status in pediatric intensive care unit patients: the results of a multicenter, prospective study in Turkey.

Introduction: Malnutrition is defined as a pathological condition arising from deficient or imbalanced intake of nutritional elements. Factors such as increasing metabolic demands during the disease course in the hospitalized patients and inadequate calorie intake increase the risk of malnutrition. The aim of the present study is to evaluate nutritional status of patients admitted to pediatric intensive care units (PICU) in Turkey, examine the effect of nutrition on the treatment process and draw attention to the need for regulating nutritional support of patients while continuing existing therapies. Material and Method: In this prospective multicenter study, the data was collected over a period of one month from PICUs participating in the PICU Nutrition Study Group in Turkey. Anthropometric data of the patients, calorie intake, 90-day mortality, need for mechanical ventilation, length of hospital stay and length of stay in intensive care unit were recorded and the relationship between these parameters was examined. Results: Of the 614 patients included in the study, malnutrition was detected in 45.4% of the patients. Enteral feeding was initiated in 40.6% (n = 249) of the patients at day one upon admission to the intensive care unit. In the first 48 h, 86.82% (n = 533) of the patients achieved the target calorie intake, and 81.65% (n = 307) of the 376 patients remaining in the intensive care unit achieved the target calorie intake at the end of one week. The risk of mortality decreased with increasing upper mid-arm circumference and triceps skin fold thickness Z-score (OR = 0.871/0.894; p = 0.027/0.024). The risk of mortality was 2.723 times higher in patients who did not achieve the target calorie intake at first 48 h (p = 0.006) and the risk was 3.829 times higher in patients who did not achieve the target calorie intake at the end of one week (p = 0.001). The risk of mortality decreased with increasing triceps skin fold thickness Z-score (OR = 0.894; p = 0.024). Conclusion: Timely and appropriate nutritional support in critically ill patients favorably affects the clinical course. The results of the present study suggest that mortality rate is higher in patients who fail to achieve the target calorie intake at first 48 h and day seven of admission to the intensive care unit. The risk of mortality decreases with increasing triceps skin fold thickness Z-score.

Analysis of Intestinal and Nasopharyngeal Microbiota of Children with Meningococcemia in Pediatric Intensive Care Unit: INMACS-PICU Study.

Microbiota composition might play a role in the pathophysiology and course of sepsis, and understanding its dynamics is of clinical interest. Invasive meningococcal disease (IMD) is an important cause of community-acquired serious infection, and there is no information regarding microbiota composition in children with meningococcemia. In this study, we aimed to evaluate the intestinal and nasopharyngeal microbiota composition of children with IMD. Materials and Methods: In this prospective, multi-center study, 10 children with meningococcemia and 10 age-matched healthy controls were included. Nasopharyngeal and fecal samples were obtained at admission to the intensive care unit and on the tenth day of their hospital stay. The V3 and V4 regions of the 16S rRNA gene were amplified following the 16S Metagenomic Sequencing Library Preparation. Results: Regarding the alpha diversity on the day of admission and on the tenth day at the PICU, the Shannon index was significantly lower in the IMD group compared to the control group (p = 0.002 at admission and p = 0.001, on the tenth day of PICU). A statistical difference in the stool samples was found between the IMD group at Day 0 vs. the controls in the results of the Bray-Curtis and Jaccard analyses (p = 0.005 and p = 0.001, respectively). There were differences in the intestinal microbiota composition between the children with IMD at admission and Day 10 and the healthy controls. Regarding the nasopharyngeal microbiota analysis, in the children with IMD at admission, at the genus level, Neisseria was significantly more abundant compared to the healthy children (p < 0.001). In the children with IMD at Day 10, genera Moraxella and Neisseria were decreased compared to the healthy children. In the children with IMD on Day 0, for paired samples, Moraxella, Neisseria, and Haemophilus were significantly more abundant compared to the children with IMD at Day 10. In the children with IMD at Day 10, the Moraxella and Neisseria genera were decreased, and 20 different genera were more abundant compared to Day 0. Conclusions: We first found alterations in the intestinal and nasopharyngeal microbiota composition in the children with IMD. The infection itself or the other care interventions also caused changes to the microbiota composition during the follow-up period. Understanding the interaction of microbiota with pathogens, e.g., N. meningitidis, could give us the opportunity to understand the disease's dynamics.

COVID-19-associated transverse myelitis treated by therapeutic plasma exchange: A case report.

BACKGROUND: Transverse myelitis (TM) is a very uncommon condition in children which can be associated with viral infections. Acute TM cases have been reported after Coronavirus disease 2019 (COVID-19) infection during the pandemic. CASE REPORT: We report a child with TM related to severe acute respiratory syndrome coronavirus 2, who was successfully treated with therapeutic plasma exchange (TPE). Inability to walk and urinary retention were the central nervous system symptom. Spinal magnetic resonance imaging revealed signal changes in the spinal cord. Her neurological symptoms worsened despite receiving IVIG and high-dose steroids for the first 3 d. We performed 10 TPE sessions with 5% albumin replacement and the neurological symptoms rapidly improved. CONCLUSION: We demonstrated that a child diagnosed with acute TM related to COVID-19 infection, was successfully treated with TPE.

Immunoadsorption therapy for a meningococcemia patient with myocarditis, adrenal hemorrhage, and purpura fulminans: a case report

Abstract Neisseria meningitidis, also known as meningococcus, is a relatively uncommon cause of invasive infection, but when it occurs, it is frequently severe and potentially life-threatening. A ten-year-old female patient developed a purpuric rash with fever. Upon arrival to the pediatric intensive care department, she was unconscious and in a poor general condition. We combined treatment with antibiotics, volume resuscitation, hydrocortisone, and CytoSorb® therapy resulted in a stabilization of hemodynamics, as well as control of hyperinflammation. We observed a significant decrease in vasopressor dosage in this patient.

Increased Severe Cases and New-Onset Type 1 Diabetes Among Children Presenting With Diabetic Ketoacidosis During First Year of COVID-19 Pandemic in Turkey.

Introduction: There have been some significant changes regarding healthcare utilization during the COVID-19 pandemic. Majority of the reports about the impact of the COVID-19 pandemic on diabetes care are from the first wave of the pandemic. We aim to evaluate the potential effects of the COVID-19 pandemic on the severity of diabetic ketoacidosis (DKA) and new onset Type 1 diabetes presenting with DKA, and also evaluate children with DKA and acute COVID-19 infection. Methods: This is a retrospective multi-center study among 997 children and adolescents with type 1 diabetes who were admitted with DKA to 27 pediatric intensive care units in Turkey between the first year of pandemic and pre-pandemic year. Results: The percentage of children with new-onset Type 1 diabetes presenting with DKA was higher during the COVID-19 pandemic (p < 0.0001). The incidence of severe DKA was also higher during the COVID-19 pandemic (p < 0.0001) and also higher among children with new onset Type 1 diabetes (p < 0.0001). HbA1c levels, duration of insulin infusion, and length of PICU stay were significantly higher/longer during the pandemic period. Eleven patients tested positive for SARS-CoV-2, eight were positive for new onset Type 1 diabetes, and nine tested positive for severe DKA at admission. Discussion: The frequency of new onset of Type 1 diabetes and severe cases among children with DKA during the first year of the COVID-19 pandemic. Furthermore, the cause of the increased severe presentation might be related to restrictions related to the pandemic; however, need to evaluate the potential effects of SARS-CoV-2 on the increased percentage of new onset Type 1 diabetes.

Mortality Risk Factors Among Critically Ill Children With Acute COVID-19 in PICUs: A Multicenter Study From Turkish Pediatric Critical COVID-19 and MIS-C Study Group.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, the world has a large number of reported COVID-19 cases and deaths. Information on characteristics and mortality rate of pediatric intensive care unit (PICU) cases with COVID-19 remains limited. This study aims to identify the risk factors for mortality related to COVID-19 in children admitted to PICU. METHODS: A retrospective multicenter cohort study was conducted between March 2020 and April 2021 at 44 PICUs in Turkey. Children who were 1 month-18-year of age with confirmed COVID-19 admitted to PICU were included in the study. Children with multisystem inflammatory syndrome and asymptomatic for COVID-19 were excluded. RESULTS: Of 335 patients with COVID-19, the median age was 6.8 years (IQR: 1.2-14) and 180 (53.7 %) were male, 215 (64.2 %) had at least one comorbidity. Age and gender were not related to mortality. Among 335 patients, 166 (49.5%) received mechanical ventilation, 17 (5.1%) received renal replacement therapy and 44 (13.1 %) died. Children with medical complexity, congenital heart disease, immunosuppression and malignancy had significantly higher mortality. On multivariable logistic regression analysis, organ failure index [odds ratio (OR): 2.1, 95 confidence interval (CI): 1.55-2.85], and having congenital heart disease (OR: 2.65, 95 CI: 1.03-6.80), were associated with mortality. CONCLUSIONS: This study presents detailed data on clinical characteristics and outcomes of patients with COVID-19 admitted to PICU in the first pandemic year in Turkey. Our study shows that having congenital heart disease is associated with mortality. In addition, the high organ failure score in follow-up predict mortality.

Bilateral lentiform and caudate nucleus lesions in a child with COVID-19: A case report.

Neurological complications are frequently mentioned in the published reports regarding the coronavirus disease 2019 (COVID-19). Especially encephalopathy draws attention as the leading symptom or complication of COVID-19 in some reports. This article discussed a 3-year-old patient with bilateral lentiform and caudate nuclei involvement on brain imaging, who presented with mental status changes and acute muscular weakness, possibly due to COVID-19. To the best of our knowledge, this case is the first one showing pathological signal enhancement and edema in bilateral lentiform and caudate nuclei associated with COVID-19.

Therapeutic plasma exchange in pediatric patients with acute demyelinating syndromes of the central nervous system: A single-center experience.

BACKGROUND: Therapeutic plasma exchange (TPE) is an extracorporeal treatment that can be used in adult and pediatric patients with acute demyelinating syndromes of the central nervous system. In this study, the efficacy and safety of TPE was evaluated in 10 pediatric patients who underwent TPE that were unresponsive to corticosteroid treatment. METHODS: Records of 10 pediatric patients who underwent TPE in our pediatric intensive care unit (PICU) between May 2017 and June 2020 were used. Expanded Disability Status Scale (EDSS), Gait Scale (GS), and Visual Outcome Scale (VOS) were applied to the patients before and after TPE. RESULTS: Of the 10 patients who underwent TPE, five were diagnosed with multiple sclerosis (MS), three with transverse myelitis (TM), and two with acute disseminated encephalomyelitis (ADEM). The median age of the patients was 13.3 years (IQR 8-15), and the median day from symptom onset to onset of TPE was 12.5 days (IQR 7-28). A total of 104 TPE sessions were performed successfully. While no complications were encountered in three patients during the sessions, the most common complication was hypofibrinogenemia. The decrease in EDSS and GS scores was found to be consistent with the clinical response of the patients. There was no statistically significant decrease in the VOS. CONCLUSIONS: With this study, we can say that TPE is a feasible, effective, and safe treatment modality in children with acute demyelinating syndromes of the central nervous system.

New dermatological findings of MIS-C: Can mucocutaneous involvement be associated with Severe Disease Course?

BACKGROUND: Little is known about mucocutaneous involvement in critically ill patients with the multisystem inflammatory syndrome in children (MIS-C). The aim of our study was to describe the localisation and variety of rash and to investigate whether presenting with rash at admission alters the clinical course of MIS-C. METHODS: This prospective, observational cohort study was conducted amongst children under 18 years of age who were admitted to our paediatric intensive care unit (PICU) between May 2020 and May 2021 with a possible diagnosis of MIS-C. RESULTS: A total of 33 children with MIS-C, 21 boys (64%), with a median age of 9.4 years (3.4-11.5) were enrolled. Twenty-four children presented with mucocutaneous symptoms (72%). Age, male gender, PICU length of stay, presenting symptoms, inotrope requirement, the existence of myocarditis or respiratory failure were higher but not significantly different in patients with rash compared to those without rash (P > 0.05). The median duration of symptoms before admission and presence of cervical lymphadenopathy were significantly higher in patients than those without rash (P < 0.05). Children with a rash had a significantly higher neutrophil count, CRP, procalcitonin, troponin levels and lower lymphocyte counts and albumin levels than those without rash (P < 0.05). Twelve children with rash (50%) had symmetrical intertriginous distribution. Two children had erythematous lesions on the areola and the surroundings. In conclusion, intertriginous involvement, periareolar erythema and other mucocutaneous manifestations might be the first alarming symptoms of moderate to severe MIS-C. Therefore, close monitoring with a multidisciplinary approach should be considered for these patients to assess potential disease progression.

Pressure-Regulated Volume Control and Pressure-Control Ventilation Modes in Pediatric Acute Respiratory Failure.

OBJECTIVE: The objective of this study is to present our experience using the pressure-regulated volume control and the pressure-control ventilation modes in children. METHODS: Patients with acute respiratory failure ventilated with pressure-regulated volume control or pressure-control modes were retrospectively evaluated. The patient's ventilation parameters (of the first 7 days of ventilation or of the whole ventilation period, if the patient had been ventilated less than 7 days), SpO2, blood gases, and demographic data were collected from the pediatric intensive care unit database. RESULTS: Sixty-one patients (median age 12 [4.8-36.4] months) were enrolled in the study. The pressure-control ventilation mode was used on 40 patients (65.6%) and the pressure-regulated volume-control mode was used on 21 (34.4%) patients. Twenty-eight patients (45.9%) had hypoxemic respiratory failure and 44 (72.1%) had hypercapnic respiratory failure. The median positive end-expiratory pressure was higher in pressure-control ventilation mode (5.4 [4.2-6.3] cmH2O) than the pressure-regulated volume-control mode (4.05 [3.68-4.41] H2O, P < .001). Pressure-control mode was used more frequently in hypoxemic cases but both modes were used equally in hypercapnic cases. Hypoxic respiratory failure (yes/no), odds ratio: 3.9 (95% CI 1.2-12.3, P=.02), Ph (nadir), odds ratio: 0.004 (95% CI 0.000-0.275, P=.01), and base excess, odds ratio: 0.88 (95% CI 0.79-0.98, P=.02) were associated with intensive care mortality. CONCLUSIONS: Although the pressure-control ventilation mode was preferred more frequently in hypoxemic respiratory failure, there was no significant difference between the 2 respiratory modes in terms of length of pediatric intensive care unit stay, MV duration, and mortality. The pressure-regulated volume-control mode seems to be a safer option for physicians who do not have enough experience in using pressurecontrol ventilation mode.

COVID-19 Transmission and Clinical Features in Pediatric Intensive Care Health Care Workers.

OBJECTIVE: This study aims to investigate modes of transmission and clinical features of coronavirus disease 2019 in healthcare workers in pediatric intensive care units. MATERIALS AND METHODS: This multicenter descriptive study was conducted between March and November 2020. Patient demographics, clinical characteristics, origin of coronavirus disease 2019, treatment modalities, and loss of workdays were recorded. RESULTS: Seven hundred and sixty-eight healthcare workers from 16 pediatric intensive care units were enrolled and 114 (14.8%) healthcare workers with a mean age of 29.7 ± 6.7 years became coronavirus disease 2019 patients. Seventy-six (66.7%) patients were female. Approximately half (54.3%) of the patients were physicians, 34.2% were nurses, and 11.4% were ancillary staff. Transmission was deemed to occur through patient contact in 54.3% of the patients. Comorbid illness was present 10.5% of the patients. Transmission occurred during endotracheal intubation in 21%, cardiopulmonary resuscitation in 9.6%, and non-invasive ventilation in 12.2% of patients, while transmission was a result of multiple possible procedures in 43.8%. Intensive care admission was needed for 13.1% of the patients. Five patients needed oxygen by cannula, 7 needed oxygen with a non-rebreathing mask, 5 needed high-flow nasal cannula support, 5 needed non-invasive ventilation, and 3 needed invasive mechanical ventilation. Fortunately, no infected healthcare workers died. CONCLUSION: Coronavirus disease 2019 in healthcare workers is a significant problem in pediatric intensive care units. Transmission seems to occur particularly frequently during patient care procedures such as intubation, ventilation and aerosol therapy, which highlights the importance of proper use of full sets of personal protective equipment during all procedures during care of coronavirus disease 2019 patients.

Immunoadsorption therapy for a meningococcemia patient with myocarditis, adrenal hemorrhage, and purpura fulminans: a case report.

Neisseria meningitidis, also known as meningococcus, is a relatively uncommon cause of invasive infection, but when it occurs, it is frequently severe and potentially life-threatening. A ten-year-old female patient developed a purpuric rash with fever. Upon arrival to the pediatric intensive care department, she was unconscious and in a poor general condition. We combined treatment with antibiotics, volume resuscitation, hydrocortisone, and CytoSorb.½ therapy resulted in a stabilization of hemodynamics, as well as control of hyperinflammation. We observed a significant decrease in vasopressor dosage in this patient.