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Continuous renal replacement therapy is an extracorporeal blood purification therapy that aims to support kidney and other organ functions over an extended period. The high-quality continuous renal replacement therapy requires understanding basic mechanisms of clearance, factors influencing these processes, and the appropriate selection of treatment candidates. This article reviews the different aspects of continuous renal replacement therapy in critically ill pediatric patients.

Tam Metin / Full Text 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: 2.0021–48.3742). 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. Key words: HFNC, noninvasive positive pressure ventilation, children, respiratory failure

Multisystemic inflammatory syndrome (MIS-C) diagnosis remains difficult because the clinical features overlap with Kawasaki disease (KD). The study aims to highlight the clinical and laboratory features and outcomes of patients with MISC whose clinical manifestations overlap with or without KD. This study is a retrospective analysis of a case series designed for patients aged 1 month to 18 years in 28 hospitals between November 1, 2020, and June 9, 2021. Patient demographics, complaints, laboratory results, echocardiographic results, system involvement, and outcomes were recorded. A total of 614 patients were enrolled; the median age was 7.4 years (interquartile range (IQR) 3.9-12 years). A total of 277 (45.1%) patients with MIS-C had manifestations that overlapped with KD, including 92 (33.3%) patients with complete KD and 185 (66.7%) with incomplete KD. Lymphocyte and platelet counts were significantly lower in patients with MISC, overlapped with KD (lymphocyte count 1080 vs. 1280 cells x mu L, p = 0.028; platelet count 166 vs. 216 cells x 10(3)/mu L, p < 0.001). The median serum procalcitonin levels were statistically higher in patients overlapped with KD (3.18 vs. 1.68 mu g/L, p = 0.001). Coronary artery dilatation was statistically significant in patients with overlap with KD (13.4% vs. 6.8%, p = 0.007), while myocarditis was significantly more common in patients without overlap with KD features (2.6% vs 7.4%, p = 0.009). The association between clinical and laboratory findings and overlap with KD was investigated. Age > 12 years reduced the risk of overlap with KD by 66% (p < 0.001, 95% CI 0.217-0.550), lethargy increased the risk of overlap with KD by 2.6-fold (p = 0.011, 95% CI 1.244-5.439), and each unit more albumin (g/dl) reduced the risk of overlap with KD by 60% (p < 0.001, 95% CI 0.298-0.559). Conclusion: Almost half of the patients with MISC had clinical features that overlapped with KD; in particular, incomplete KD was present. The median age was lower in patients with KD-like features. Lymphocyte and platelet counts were lower, and ferritin and procalcitonin levels were significantly higher in patients with overlap with KD., NA

Background: The aim of this study was to evaluate the outcomes of patients with the multisystem inflammatory syndrome in children (MIS-C) according to phenotypes of disease and define the prognostic factors for the severe course. Methods: This cross-sectional study included 293 patients with MIS-C from seven pediatric rheumatology centers. A two-step cluster analysis was performed to define the spectrum of disease and their outcomes were compared between each group. Results: Four subgroups were identified as follows: cluster I, predominantly Kawasaki-like features (n = 100); cluster II, predominantly MAS-like features (n = 34); cluster III, predominantly LV dysfunction (n = 47); cluster IV, other presentations (n = 112). The duration of fever was longer in cluster II and the length of hospitalization was longer in both clusters II and III. Laboratory findings revealed lower lymphocyte and platelet counts and higher acute phase reactants (APRs) in cluster II, while patients in cluster IV showed less inflammation with lower APRs. The resolution of abnormal laboratory findings was longer in clusters II and III, while it was shortest in cluster IV. Seven patients died. Among them, four belonged to cluster II, while three were labeled as cluster III. Patients with severe course had higher levels of neutrophil–lymphocyte ratio, mean platelet volume, procalcitonin, ferritin, interleukin-6, fibrinogen, D-Dimer, BNP, and troponin-I, and lower levels of lymphocyte and platelet counts. Conclusion: As shown, MIS-C is not a single disease presenting with various clinical features and outcomes. Understanding the disease spectrum will provide individualized management.

© 2022 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).Aim: Multisystem inflammatory syndrome in children (MIS-C) may cause shock and even death in children. The aim of this study is to describe the clinical features, laboratory characteristics and outcome of children diagnosed with MIS-C in 25 different hospitals in Turkey. Methods: The retrospective study was conducted between 8 April and 28 October 2020 in 25 different hospitals from 17 cities. Data were collected from patients' medical records using a standardised form. Clinical and laboratory characteristics and outcomes according to different age groups, gender and body mass index percentiles were compared using multivariate logistic regression analysis. Results: The study comprised 101 patients, median age 7 years (interquartile range (IQR) 4.6–9.3); 51 (50.5%) were boys. Reverse-transcriptase polymerase chain reaction (PCR) assay was positive in 21/100 (21%) patients; 62/83 (74.6%) patients had positive serology for SARS-CoV-2. The predominant complaints were fever (100%), fatigue (n = 90, 89.1%), and gastrointestinal symptoms (n = 81, 80.2%). Serum C-reactive protein (in 101 patients, median 165 mg/L; range 112–228), erythrocyte sedimentation rate (73/84, median 53 mm/s; IQR 30–84) and procalcitonin levels (86/89, median 5 μg/L; IQR 0.58–20.2) were elevated. Thirty-eight patients (37.6%) required admission to intensive care. Kawasaki disease (KD) was diagnosed in 70 (69.3%) patients, 40 of whom had classical KD. Most patients were treated with intravenous immunoglobulin (n = 92, 91%) and glucocorticoids (n = 59, 58.4%). Seven patients (6.9%) died. Conclusion: The clinical spectrum of MIS-C is broad, but clinicians should consider MIS-C in the differential diagnosis when persistent fever, fatigue and gastrointestinal symptoms are prominent. Most patients diagnosed with MIS-C were previously healthy. Immunomodulatory treatment and supportive intensive care are important in the management of cases with MIS-C. Glucocorticoids and intravenous immunoglobulins are the most common immunomodulatory treatment options for MIS-C. Prompt diagnosis and prompt treatment are essential for optimal management.

Hereditary angioedema (HAE) is characterized by recurrent angioedema attacks with no urticaria. This disease has a high mortality due to asphyxia. Level of complement 4 (C4), C1 esterase inhibitor (C1-INH) level and function, and genetic mutations determine different endotypes of HAE. Clinical presentation and the triggers of vasogenic edema may change according to the endotypes. An adolescent girl with oligomenorrhea, obesity, hirsutism, and acanthosis nigricans was diagnosed with polycystic ovary syndrome (PCOS) and prescribed ethinyl estradiolcyproterone acetate containing oral contraceptive (OC). On the 16th day of treatment, she developed angioedema on the face, neck, and chest leading to dyspnea. Adrenaline, antihistamine, and corticosteroid treatments were ineffective. In the family history, the patient's mother and two cousins had angioedema attacks. C1-INH concentrate was administered with a diagnosis of HAE. C4, and C1-INH level and activity were normal. Genetic analysis identified a mutation of Factor XII (F12) gene, and the diagnosis of Factor 12 (F12)-related HAE was made. OC treatment discontinued. She has had no additional angioedema attacks in the follow-up period of two years. OC containing estrogen may induce the life-threatening first attack of F12-related HAE even in children. Recurring angioedema attacks in the family should be asked before prescribing estrogen-containing OC pills.

Coagulation factor XIII (FXIII) is a fibrin-stabilizing factor with additional roles in wound healing and interactions between the decidua and fetus. Congenital FXIII deficiency is rare bleeding disorder. Inhibitor development against FXIII in inherited FXIII deficency is also uncommon, but may cause severe, life-threatening bleeding. FXIII is the last step in the coagulation cascade with normal coagulation paramaters (PT, aPTT), the detection of inhibitor to FXIII is quite difficult. The treatment of inhibitor-positive congenital FXIII deficiency is challenging due to the lack of a role of by-pass agents such as FVII. The best known ways of treatment in these cases are the use of high-dose FXIII concentrates and immunosuppression. Herein, we report the management of postoperative bleeding diathesis in a patient with FXIII deficiency who developed inhibitors, and to follow the clinical course of the disease with FXIII concentrate and immunosuppression.

Objectives The hyperinflammatory state and the viral invasion may result in endothelial dysfunction in SARS-CoV-2 infection. Although a method foreseeing microvascular dysfunction has not been defined yet, studies conducted in patients diagnosed with COVID-19 have demonstrated the presence of endotheliitis. With this study, we aimed to investigate the microvascular circulation in patients diagnosed with COVID-19 and multisystem inflammatory syndrome in children (MIS-C) by nailfold videocapillaroscopy (NVC). Methods Thirty-one patients with SARS-CoV-2 infection, 25 of whom were diagnosed with COVID-19 and 6 with MIS-C and 58 healthy peers were included in the study. NVC was performed in eight fingers with 2 images per finger and 16 images were examined for the morphology of capillaries, presence of pericapillary edema, microhemorrhage, avascular area, and neoangiogenesis. Capillary length, capillary width, apical loop, arterial and venous width, and intercapillary distance were measured from three consecutive capillaries from the ring finger of the non-dominant hand. Results COVID-19 patients showed significantly more capillary ramification (p

Background and Objective The aim of this multicenter retrospective study was to determine the clinical characteristics, treatment approaches and the course of pediatric acute respiratory distress syndrome (PARDS) which developed associated with the influenza virus in the 2019–20 season. Methods Patients included 1 month to 18 years who were diagnosed with PARDS associated with the influenza virus in the 2019–20 season. Results Sixty-seven patients were included in the study. The mean age of the patients was 64.16 ± 6.53 months, with 60% of the group Conclusion Both Influenza A and Influenza B cause severe PARDS with similar characteristics and at high rates. Influenza-related PARDS cause 33% mortality and 15.5% morbidity among the study group. Healthy children, especially those aged younger than 5 years, are also at risk.

OBJECTIVES: More children are surviving critical illness but are at risk of residual or new health conditions. An evidence-informed and stakeholder-recommended core outcome set is lacking for pediatric critical care outcomes. Our objective was to create a multinational, multistakeholder-recommended pediatric critical care core outcome set for inclusion in clinical and research programs. DESIGN: A two-round modified Delphi electronic survey was conducted with 333 invited research, clinical, and family/advocate stakeholders. Stakeholders completing the first round were invited to participate in the second. Outcomes scoring greater than 69% "critical" and less than 15% "not important" advanced to round 2 with write-in outcomes considered. The Steering Committee held a virtual consensus conference to determine the final components. SETTING: Multinational survey. PATIENTS: Stakeholder participants from six continents representing clinicians, researchers, and family/advocates. MEASUREMENTS AND MAIN RESULTS: Overall response rates were 75% and 82% for each round. Participants voted on seven Global Domains and 45 Specific Outcomes in round 1, and six Global Domains and 30 Specific Outcomes in round 2. Using overall (three stakeholder groups combined) results, consensus was defined as outcomes scoring greater than 90% "critical" and less than 15% "not important" and were included in the final PICU core outcome set: four Global Domains (Cognitive, Emotional, Physical, and Overall Health) and four Specific Outcomes (Child Health-Related Quality of Life, Pain, Survival, and Communication). Families (n = 21) suggested additional critically important outcomes that did not meet consensus, which were included in the PICU core outcome set-extended. CONCLUSIONS: The PICU core outcome set and PICU core outcome set-extended are multistakeholder-recommended resources for clinical and research programs that seek to improve outcomes for children with critical illness and their families.

OBJECTIVE To describe and analyze the characteristics and the early risk factors for mortality of noninvasive ventilation (NIV) in critically ill children. STUDY DESIGN A multicenter, prospective, observational 2-year study carried out with critically ill patients (1 month - 18 years of age) who needed NIV. Clinical data and NIV parameters during the first 12 h of admission were collected. A multilevel mixed-effects logistic regression was performed to identify mortality risk factors. RESULTS A total of 781 patients (44.2 ± 57.7 months) were studied (57.8% male). Of them, 53.7% had an underlying condition, and 47.1% needed NIV for lower airway respiratory pathologies. Bi-level NIV was the initial support in 78.2% of the patients. Continuous positive airway pressure (CPAP) was used more in younger patients (33.7%) than in older ones (9.7%; p

Therapeutic plasma exchange (TPE) is a treatment administered with the aim of removing a pathogenic material or compound causing morbidity in a variety of neurologic, hematologic, renal, and autoimmune diseases. In this study, we aimed to assess the indications, efficacy, reliability, complications, and treatment response of pediatric patients for TPE. This retrospective study analyzed data from 39 patients aged from 0 to 18 years who underwent a total of 172 TPE sessions from January 2015 to April 2018 in a tertiary pediatric intensive care unit. Indications for TPE were, in order of frequency, macrophage activation syndrome (28.2%, n = 11), renal transplantation rejection (15.4%, n = 6), liver failure (15.4%, n = 6), Guillain–Barre's syndrome (15%, n = 6), hemolytic uremic syndrome (7.7%, n = 3), acute demyelinating disease (7.7%, n = 3), septic shock (5.1%, n = 2), and intoxication (5.1%, n = 2). No patient had any adverse event related to the TPE during the procedure. The TPE session was ended prematurely in one patient due to insufficient vascular access and lack of blood flow (2.6%). In the long term, thrombosis due to the indwelling central catheter occurred (5.1%, n = 2). TPE appears to be an effective first-stage or supplementary treatment in a variety of diseases, may be safely used in pediatric patients, and there are significant findings that its area of use will increase. In experienced hands and when assessed carefully, it appears that the rate of adverse reactions and vascular access problems may be low enough to be negligible.

Introduction:In this report, we aim to present our algorithm and results of patients with congenital cardiac disorders who underwent surgical or interventional procedures during the peak phase of the pandemics in our country.Patients and methods:The first COVID-19 case was diagnosed in Turkey on 11 March, 2020, and the peak phase seemed to end by the end of April. All the patients whom were referred, treated, or previously operated but still at the hospital during the peak phase of COVID-19 pandemics in the country were included into this retrospective study. Patient’s diagnosis, interventions, adverse events, and early post-procedural courses were studied.Results:Thirty-one patients with various diagnoses of congenital cardiovascular disorders were retrospectively reviewed. Ages of the patients ranged between 2 days and 16 years. Seventeen cases were males and 14 cases were females. Elective cases were postponed. Priority was given to interventional procedures, and five cases were treated percutaneously. Palliative procedures were preferred in patients whom presumably would require long hospital stay. Corrective procedures were not hesitated in prioritised stable patients. Mortality occurred in one patient. Eight patients out of 151 ICU admissions were diagnosed with COVID-19, and they were transferred to COVID-19 ICU immediately. Three nurses whom also took care of the paediatric cases became infected with SARS-CoV-2; however, the children did not catch the disease.Conclusion:Mandatory and emergent congenital cardiac percutaneous and surgical procedures may be performed with similar postoperative risks as there are no pandemics with meticulous care and preventive measures.

Objectives: To investigate conventional mechanical ventilation weaning characteristics of patients requiring conventional mechanical ventilation support for greater than 48 hours within the PICU. Design: the prospective observational multicenter cohort study was conducted at 15 hospitals. Data were being collected from November 2013 to June 2014, with two designated researchers from each center responsible for follow-up and data entry. Setting: Fifteen tertiary PICUs in Turkey. Patients: Patients between 1 month and 18 years old requiring conventional mechanical ventilation for greater than 48 hours were included. A single-center was not permitted to surpass 20% of the total sample size. Patients with no plans for conventional mechanical ventilation weaning were excluded. Interventions: Conventional mechanical ventilation Measurements and Main Results: Pertinent variables included PICU and patient demographics, including clinical data, chronic diseases, comorbid conditions, and reasons for intubation. Conventional mechanical ventilation mode and weaning data were characterized by daily ventilator parameters and blood gases. Patients were monitored until hospital discharge. of the 410 recruited patients, 320 were included for analyses. A diagnosis of sepsis requiring intubation and high initial peak inspiratory pressures correlated with a longer weaning period (mean, 3.65 vs 1.05-2.17 d; p < 0.001). Conversely, age, admission Pediatric Risk of Mortality III scores, days of conventional mechanical ventilation before weaning, ventilator mode, and chronic disease were not related to weaning duration. Conclusions: Pediatric patients requiring conventional mechanical ventilation with a diagnosis of sepsis and high initial peak inspiratory pressures may require longer conventional mechanical ventilation weaning prior to extubation. Causative factors and optimal weaning for this cohort needs further consideration., National Institutes of HealthUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USA, Drs. Sik, Yaman, and Kendirli disclosed government work. Drs. Yaman and Davutoglu received support for article research from the National Institutes of Health. the remaining authors have disclosed that they do not have any potential conflicts of interest.

Acute leukemia in children may present with hyperleukocytosis. Symptomatic hyperleukocytosis is a medical emergency that necessitates rapid stabilization of the patient and prompt lowering of the leukocyte count. We report on a patient with intracranial hemorrhage associated with T-cell acute lymphoblastic leukemia with hyperleukocytosis, which is a rare occurrence. A 16-year-old boy with hyperleukocytosis (total white cell count; 398×103/µL) underwent repeated leukapheresis and received supportive treatment until a definite diagnosis of T-cell acute lymphoblastic leukemia was made and chemotherapy was started at 10% of the usual dose. On day 2 of treatment, he had headache, vomiting, and was agitated. Brain magnetic resonance imaging showed bilateral extensive hemispheric and cerebellar punctate areas of hemorrhage and perilesional edema. Chemotherapy intensified to a maximum dose on day 3. If supportive care for tumor lysis syndrome can be promptly provided, initial chemotherapy regimen can immediately be begun at an optimal dose.

Pediatrik tromboz epidemiyolojisi, patofizyolojisi ve tedavi oncelikleri nedeniyle eriskin tromboz yonetiminden cok farkli ozelliklere sahiptir. Tromboz teshisi konan cocuklar, multidisipliner bir ekip tarafindan tani, tedavi ve takip suresince degerlendirilmelidir. Burada pediatrik tromboz hastalarimizin yonetildigi 2 yillik multidisipliner tromboz konseyi deneyimimizi sunuyoruz. Kasim 2017-Agustos 2019 tarihleri arasinda 61 cocuk (95 basvuru) icin tromboz konseyi olgu sunumlarini ve konsey sonuclarini geriye donuk olarak inceledik. Degerlendirilen hastalarda erkek/kadin orani 1,54 saptandi, cocuklar ve adolesanlar cogunluktaydi. Hastalarin klinik ve radyolojik durumlarina gore tedavi ve profilaksi sureleri belirlendi. Olgularimiz icinde serebral arteriyel ve sinovenoz tromboz olgulari daha fazla idi. Kazanilmis risk faktorleri, kalitsal olanlardan daha fazla olup, infeksiyon ve Faktor VIII yuksekligi sik idi. Otuz dokuz hastaya (%64) farkli sureler boyunca K vitamini antagonistleri, aspirin veya LMVH ile primer veya sekonder profilaksi uygulandi. Pediatrik trombozda kanita dayali kilavuzlarin iyilestirilmesi icin tedavi ve profilaksi yonetimi uzerine daha fazla calismaya ihtiyac vardir. Multidisipliner tromboz konseyi komplike pediatrik trombozlu cocuk hastalarda hasta bakimini iyilestirebilir.

Objectives To describe the diversity in practice in non-invasive ventilation (NIV) in European pediatric intensive care units (PICUs). Working hypothesis No information about the use of NIV in Pediatrics across Europe is currently available, and there might be a wide variability regarding the approach. Study design Cross-sectional electronic survey. Methodology The survey was distributed to the ESPNIC mailing list and to researchers in different European centers. Results One hundred one units from 23 countries participated. All respondent units used NIV. Almost all PICUs considered NIV as initial respiratory support (99.1%), after extubation (95.5% prophylactically, 99.1% therapeutically), and 77.5% as part of palliative care. Overall NIV use outside the PICUs was 15.5% on the ward, 20% in the emergency department, and 36.4% during transport. Regarding respiratory failure cause, NIV was delivered in pneumonia (97.3%), bronchiolitis (94.6%), bronchospasm (75.2%), acute pulmonary edema (84.1%), upper airway obstruction (76.1%), and in acute respiratory distress syndrome (91% if mild, 53.1% if moderate, and 5.3% if severe). NIV use in asthma was less frequent in Northern European units in comparison to Central and Southern European PICUs (P = 0.007). Only 47.7% of the participants had a written protocol about NIV use. Bilevel NIV was applied mostly through an oronasal mask (44.4%), and continuous positive airway pressure through nasal cannulae (39.8%). If bilevel NIV was required, 62.3% reported choosing pressure support (vs assisted pressure-controlled ventilation) in infants; and 74.5% in older children. Conclusions The present study shows that NIV is a widespread technique in European PICUs. Practice across Europe is variable.

Nosocomial infections threaten hospitalized patients and can lead to complications in 25-50% of those admitted to intensive care units. Nosocomial infections increase both morbidity and mortality. Infection control has a particularly important role in pediatric intensive care units; it must take into account the specificity of critically ill pediatric patients' needs and environment. Multidrug-resistant organisms cause severe and extensive disease. The prevention and control of multidrug-resistant organisms is a national priority, one that will require that all care facilities and agencies assume responsibility. Evidence-based process improvement can lead to significant reductions in hospital-acquired infections in children. Most of the process and practices, when performed routinely and appropriately, can lead to reductions in hospital-acquired infections. This review addresses issues that characterize infection control in pediatric intensive care units.

Hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS) is a frequently fatal disease, which can result in end-organ damage and death. This condition shares features with sepsis and systemic inflammatory response syndrome. Making a diagnosis of HLH can be challenging since most of the clinical and laboratory features of HLH are quite nonspecific. Timely diagnosis is critical to start therapy before damage by hypercytokinemia becomes irreversible. The treatment for patients with suspected acquired HLH/sepsis/systemic inflammatory response syndrome/multi organ dysfunction syndrome/ MAS overlap syndrome should be guided primarily by the severity of signs and symptoms, age of the patient, and underlying conditions. It is critical that the risks of treatment or non-treatment be weighed according to the clinical presentation of each patient. In this article, the authors discuss the diagnostic similarities between sepsis/HLH/MAS and management of the critically ill child with sepsis/HLH/MAS overlap syndrome.

Background: The aim of this case report is to discuss diagnostic workup and clinical management of cytomegalovirus reactivation in a critically ill immunocompetent pediatric patient. Case presentation: A 2-year-old white boy who had no medical history presented with respiratory distress and fever. His Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores were 20 and 11, respectively. Our preliminary diagnosis was multiple organ dysfunction secondary to sepsis. Antibiotic treatment was started; he was intubated and artificially ventilated. Norepinephrine infusion was started. Hemophagocytic lymphohistiocytosis was diagnosed because our patient had elevated levels of serum ferritin, bicytopenia, splenomegaly, fever (> 38.5 °C), and hemophagocytosis shown in a bone marrow sample. Therapeutic plasma exchange and intravenously administered high-dose corticosteroid for hemophagocytic lymphohistiocytosis and continuous renal replacement treatment for acute renal failure were initiated. Following 5-day high-dose corticosteroid administration, therapeutic plasma exchange, and continuous renal replacement treatment, his clinical status and kidney and liver functions improved, and vasoactive requirement and ferritin levels decreased. He was extubated on the seventh day. On the tenth day of hospitalization he had a seizure and was diagnosed as having septic encephalopathy. His immune functions were found to be normal. Although his medical condition improved continuously, he had left spontaneous pneumothorax on the 21st day of admission as a complication of necrotizing pneumonia. Since pneumothorax persisted, left upper lobectomy surgery was performed on the 30th day of hospitalization. In the pathological examination of the excised lung tissue, features of cytomegalovirus infection were observed. Ganciclovir treatment was started. Serological tests indicated that our patient had cytomegalovirus reactivation. Antiviral treatment was stopped after 17 days, when cytomegalovirus deoxyribonucleic acid (DNA) polymerase chain reaction results became negative. He fully recovered and was discharged on the 50th day of admission. Conclusions: Cytomegalovirus reactivation in critically ill patients is a prevalent problem and shown to be associated with higher mortality and morbidity. In a case of serologic detection of cytomegalovirus reactivation without any clinical sign of infection, pre-emptive treatment could be considered with assessment of risks and benefits for each patient. Antiviral therapy is highly recommended for patients who have risk factors identified., NA

Background: Prolonged hyperammonemia, as a result of its toxic effect, may cause irreversible damage in the central nervous system.

Boğulayazma çocuklar ve erişkinlerde yüksek morbidite ve mortalite nedeni olmaya devam etmektedir. Çocuk yoğunbakım ünitelerinin ve teknolojinin gelişmesiyle boğulayazma olgularının yaşatılabilirliği de artmıştır. Boğulayazmanınkısa vadeli sağ kalımındaki gelişmeye karşın, kurbanlarda akut solunum yetmezliği sendromu ve kalıcı hipoksik-iskemikmerkezi sinir sistemi hasarında artışa neden olmuştur. Bu nedenle, batma olayı sonrası kurbanların akut dönemdeyoğun bakımdaki tedavisi önemlidir. Bu yazıda, sodyum hipoklorit ve deterjan içeren su dolu kova içinde gerçekleşenboğulayazma olgusu sunulmuştur CAYD 2015;2(1):49-54. Near-drowning continuesto be associated with high mortality and morbidity in both children and adults. With the availability of sophisticated technologies and pediatric intensive care units, victims of near-drowning are now more likely to survive. However this improvement in short-term survival of near-drowning, victims after an acute submersion episode has also resulted in an increase of acute respiratory distress syndrome and persistent hypoxic-ischemic central nervous system injury. Therefore, it is important both to know the acute intensive care unit management of victims of neardrowning and also to understand the progression of the disease. We report a patient who had been near-drowned in bucket lled with sodium hypochlorite and detergent containing water CAYD 2015;2(1):49-54

Background: The objective of this study is to investigate the efficacy of continuous renal replacement therapy (CRRT), mainly continuous venovenous hemodiafiltration (CVVHDF), and evaluate vasoactive requirements in hyperammonemic neonates and infants. Methods: Patients who underwent CRRT for hyperammonemia were retrospectively analyzed. Measurements and Main Results: Patients in 7 of the encounters were treated solely by CVVHDF. During 3 encounters, patients who received continuous venovenous hemodialysis (CVVHD) were transitioned to CVVHDF. CVVHD was used in 3 encounters. The median 50% reduction time for ammonia was 8 h (range 3–15 h). The median duration of CRRT treatment was 40 h (range 24–89 h). Survival to hospital discharge occurred in 12 encounters (92.3%). Eleven encounters (84.6%) were treated with different vasoactive agents. In those encounters, the median vasoactive medications’ start time was the 6th hours (range 2–60 h) of CRRT. There was no association between the vasoactive index score and pre-dialysis ammonia concentration. Conclusions: CRRT achieves timely control of hypeammonemic states. Hemodynamic instability necessitating intervention with vasoactive medications is a common finding in patients with hyperammonemia.

Background Although studied widely in adulthood, little is known about endocrinological disorders during critical illnesses in childhood. The aims of this study were to define the endocrinological changes in patients admitted to pediatric intensive care unit (PICU) and to identify their effects on prognosis. Methods Forty patients with a mean age of 5.1 years admitted to PICU were enrolled in the study. Blood samples were taken at admission and at 24 and 48 h to measure cortisol, adrenocorticotropic hormone (ACTH), prolactin, growth hormone (GH), GH binding protein (GHBP), insulin-like growth factor-binding protein-3 (IGFBP-3) and interleukin-6 (IL-6). The severity of the patient's condition was assessed using pediatric risk of mortality (PRISM) and pediatric logistic organ dysfunction (PELOD) scores. Results PRISM and PELOD scores were significantly higher in non-survivors. Cortisol, ACTH, prolactin, GH, GHBP, IGFBP-3 and IL-6 were not significantly different between the survivors and non-survivors. There was a negative correlation between baseline IGFBP-3 and PRISM scores. A positive correlation was seen between cortisol level at 24 h and PRISM score. On multivariate linear regression analysis, PRISM score was best explained by ACTH and cortisol at 24 h. A positive weak correlation was detected between IL-6 at 24 h and PELOD scores. Conclusions Although there was no difference between survivors and non-survivors regarding the studied endocrine parameters, there were associations between cortisol, ACTH, IL-6 and IGFBP-3 and risk assessment scores, and, given that these scores correlated with mortality, these parameters might be useful as prognostic factors.

WOS: 000398493700005, Objective: To establish the effectiveness of noninvasive ventilation in cancer children with acute respiratory failure. Methods: The data of 33 cancer patients were obtained prospectively from six different pediatric intensive care units in Turkey between the years of 2012 and 2013. Results: The diagnosis was leukemias in 25 (75.8%), lymphomas in 3 (9.1%) and other solid tumors in 5 (15.1%) patients. Pneumonia in 12 (36.3%) and sepsis in 15 (45.4%) patients were seen as the common reasons of respiratory failure. The mean PaO2/ FiO2 ratios were (164.22 +/- 37.24) and (126.80 +/- 42.73) in noninvasive ventilation success and failure group, respectively. Noninvasive ventilation was successful in 18 (54.5%) patients. The failure group consisted of 15 patients required intubation. A total of 14 (42.4%) patients died. The clinical outcome in terms of success and failure was meaningful statistically (P = 0.0 00 1). Conclusions: Our results could encourage the use of noninvasive ventilation in children with cancer who develop acute respiratory failure. It should be considered as a useful therapeutic approach to avoid endotracheal intubation.

PubMed ID: 28882178, Background: This case report presents differential lung ventilation in an infant. The aim is to define an alternative technique for performing differential lung ventilation in children. To the best of our knowledge, this is the first report of this kind. Case presentation: A 4.2-kg, 2.5-month-old Asian boy was referred to our facility with refractory hypoxemia and hypercarbia due to asymmetric lung disease with atelectasis of the left lung and hyperinflation of the right lung. He was unresponsive to conventional ventilator strategies; different ventilator settings were required. To perform differential lung ventilation, two separate single-lumen endotracheal tubes were inserted into the main bronchus of each lung by tracheotomy; the tracheal tubes were attached to discrete ventilators. The left lung was ventilated with a lung salvage strategy using high-frequency oscillatory ventilation, and the right lung was ventilated with a lung-protective strategy using pressure-regulated volume control mode. Differential lung ventilation was performed successfully with this technique without complications. Conclusions: Differential lung ventilation may be a lifesaving procedure in select patients who have asymmetric lung disease. Inserting two single-lumen endotracheal tubes via tracheotomy for differential lung ventilation can be an effective and safe alternative method. © 2017 The Author(s).

Background: The aim of this study was to describe the clinical and epidemiological characteristics of pandemic influenza in hospitalized children. Methods: A total of 114 patients with suspected H1N1 virus infection were hospitalized, and nasal swabs were sent to National Influenza Reference Laboratory for confirmation of pandemic influenza A (H1N1) virus infection by rRT–PCR assay. Results: Forty-six female and 68 male patients were included in the study. Age of the patients ranged from 40 days to 16 years. Clinical and/or radiological pneumonia were detected in 96% of all. Sixteen patients required mechanical ventilation due to hypoxemia. Previously healthy children required mechanical ventilation and oxygen therapy more than patients with chronic diseases. Elevated levels of CRP and LDH in patients with respiratory distress and patients who required mechanical ventilation were statistically significant. Conclusion: Our study showed that progress of pandemic influenza infection in previously healthy children is as severe as their counterparts with chronic underlying diseases.

Continuous renal replacement therapy (CRRT) has become an important supportive therapy for critically ill children with acute renal failure. In Turkey, commercially available diafiltration and replacement fluids cannot be found on the market. Instead, peritoneal dialysis fluids for dialysis and normal saline as replacement fluid are used. The first objective of this study was to examine metabolic complications due to CRRT treatments. The second objective was to determine demographic characteristics and outcomes of patients who receive CRRT. We did a retrospective chart review of all pediatric patients treated with CRRT between February and December 2004. Thirteen patients received CRRT; seven survived (53.8%). All patients were treated with continuous venovenous hemodiafiltration. Median patient age was 71.8 ± 78.8 (1.5–180) months. Hyperglycemia occurred in 76.9% (n = 10), and metabolic acidosis occurred in 53.8% (n = 7) of patients. Median age was younger (48.8 vs.106.2 months), median urea level (106.2 vs. 71 mg/dl) and percent fluid overload (FO) (17.2% vs. 7.6%, respectively) were higher, and CRRT initiation time was longer (8.6 vs 5.6 days) in nonsurvivors vs. survivors for all patients, although these were not statistically significant. CRRT was stopped in all survivors, and four nonsurvivors (67%) were on renal replacement therapy at the time of death. Hyperglycemia and metabolic acidosis were frequently seen in CRRT patients when commercially available diafiltration fluids were not available. Using peritoneal dialysis fluid as dialysate is not a preferable solution. Early initiation of CRRT offered survival benefits to critically ill pediatric patients. Mortality was associated with the primary disease diagnosis.

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.

PubMed ID: 26998605, No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.Background: The study aims to define the efficacy of continuous renal replacement therapy in acute metabolic decompensation treatment of maple syrup urine disease (MSUD). Methods: All the neonates, infants and children who have had life threatening conditions due to MSUD and were treated with continuous venovenous hemodiafiltration (CVVHDF) were analyzed retrospectively. Results: Fourteen patients underwent 15 sessions of CVVHDF (age range 15 days to 87 months, mean 40.8 ± 31.4 months). One patient required additional CVVHDF 1 week after cessation of CVVHDF. Twenty seven percent (n = 4) of the patients were intubated and mechanically ventilated. Twelve patients responded to treatment and dramatic neurological improvement was observed within 24 h. Two of the 14 patients required 36 h of CVVHDF for neurological improvement. The mean duration of CVVHDF was 20.2 ± 8.6 (9-36) h. The mean leucine level was 1,648 ± 623.8 (714-2,768) µmol/l before and was 256.5 ± 150.6 (117-646) µmol/l at the end of treatment. No mortality was observed. Conclusion: Continuous hemodiafiltration is an effective and safe method in correcting metabolic disturbances in MSUD. © 2016 © 2016 S. Karger AG, Basel. Copyright: All rights reserved.

Background: The aim of this study was to examine the characteristics of seizure due to poisoning. Methods: This was a retrospective analysis, throughout 4 years of hospital admissions for poisoning. Data of patients with seizures due to poisoning were evaluated with respect to the causes, frequencies and complications of seizures. Results: Among the 1561 admissions due to intoxication during the review period, seizures developed in 26 cases (1.6%). Tricyclic antidepressant overdose (n = 11, 42%) was the leading cause of seizure due to poisoning. Generalized tonic-clonic seizures were observed in 24 patients. Status epilepticus developed in six patients (23%). Mechanical ventilation was applied in 12 (46%) patients. Cardiac complications were observed in 11 (42%) patients with seizures. Two patients who had cardiac arrest due to acepromazin maleat and imipramine intoxication died. Conclusion: One of the causes of seizures in pediatric age group is intoxication. Seizures due to intoxications may cause serious clinical conditions. Intoxications should be thought when a patient is admitted with the diagnosis of afebrile seizure even if there is no history of drug intake.