Evaluation of Baseline Characteristics and Prognostic Factors in Multisystemic Inflammatory Syndrome in Children: Is It Possible to Foresee the Prognosis in the First Step?

Background: Two years after the first cases, critical gaps remain in identifying prognostic factors in multisystem inflammatory syndrome in children (MIS-C). Methods: This retrospective study included 99 patients with MIS-C hospitalized between August 2020 and March 2022 in a pediatric tertiary center. The patients were divided into two groups according to clinical severity (low- and high-risk). Prognostic values of baseline clinical and laboratory characteristics were evaluated with advanced statistical analysis, including machine learning. Results: Sixty-three patients were male, and the median age was 83 (3−205) months. Fifty-nine patients (59.6%) were low-risk cases. Patients aged six years and over tended to be at higher risk. Involvement of aortic or tricuspid valve or >1 valve was more frequent in the high-risk group. Mortality in previously healthy children was 3.2%. Intensive care unit admission and mortality rate in the high-risk group were 37.5% and 7.5%, respectively. At admission, high-risk patients were more likely to have reduced lymphocyte count and total protein level and increased brain natriuretic peptide (BNP), ferritin, D-dimer, and troponin concentrations. The multiple logistic regression model showed that BNP, total protein, and troponin were associated with higher risk. When the laboratory parameters were used together, BNP, total protein, ferritin, and D-dimer provided the highest contribution to the discrimination of the risk groups (100%, 89.6%, 85.6%, and 55.8%, respectively). Conclusions: Our study widely evaluates and points to some clinical and laboratory parameters that, at admission, may indicate a more severe course. Modeling studies with larger sample groups are strongly needed.

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

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

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

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

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

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

Comparison of direct laryngoscopy and video-assisted laryngoscopy in pediatric intensive care unit.

Our objective was to compare video-assisted laryngoscopy (VAL) with direct laryngoscopy (DL) for glottic visualization in a pediatric intensive care unit in terms of the success rate in first attempts. Our study included patients aged from 1 month to 18 years who were admitted to the pediatric intensive care unit. We excluded patients with limited neck extension (C-spine immobilization, congenital abnormality), congenital anomalies (e.g., Pierre Robin syndrome, micrognathia, macroglossia), and recent airway surgery. Patients were premedicated before intubation. The time to intubation was defined as the time between the start of anesthesia and completion of intubation. The start of anesthetic induction was defined as the time the sedative was first administered. Completion of intubation was defined as the time that the end-tidal carbon dioxide tension was detected. We evaluated 120 of 135 intubations that met our inclusion criteria; 15 were excluded because in eight cases (53%) non-pediatric intensive care physicians made the initial attempts, and in seven cases (47%) the recorded intubation times were erroneous. We detected significantly higher POGO scores in the VAL group (p<0.001). VAL provided a fuller view of the glottis (Cormack and Lehane grade 1) than DL (p<0.001). Although the intubation attempts in the DL group were significantly higher (two or more attempts), no intubation failures occurred in either group.

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

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

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

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

Could you say that was an atrial flutter or not?

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

Comparison between high-flow nasal oxygen cannula and conventional oxygen therapy after extubation in pediatric intensive care unit.

Akyildiz B, Öztürk S, Ülgen-Tekerek N, Doganay S, Görkem SB. Comparison between high-flow nasal oxygen cannula and conventional oxygen therapy after extubation in pediatric intensive care unit. Turk J Pediatr 2018; 60: 126-133. The aim of this study was to compare the efficiency, safety, and outcomes of the high-flow nasal oxygen cannula (HFNC) and conventional oxygen therapy (COT) after extubation in children. A randomized controlled trial was conducted in a 13 bed pediatric intensive care unit. One-hundred children who underwent extubation were eligible for the study. Patients were divided into HFNC (n=50) and COT (n=50) groups. Basal variables including heart rate (HR), noninvasive blood pressure, respiratory rate (RR), SpO < sub > 2 < /sub > , SpO < sub > 2 < /sub > /FiO < sub > 2 < /sub > (SF) ratio, and end tidal CO < sub > 2 < /sub > (EtCO < sub > 2 < /sub > ) were obtained initially and recorded at 15, 30, and 45 minutes and at 1, 6, 12 hours, 24 and 48 hours after extubation. SF ratio and SpO < sub > 2 < /sub > increased during the first hour in the HFNC group (p=0.005 and p=0.03, respectively). HR and RR decreased during follow-up in the HFNC group (p=0.001 and p=0.048, respectively). There was no statistically significant difference for PCO < sub > 2 < /sub > after extubation between the two groups. PCO < sub > 2 < /sub > (p=0.008) and EtCO2 (p=0.018) values at 24-h were different between two groups. At follow-up, HR decreased only in the HFNC group (p=0.001) and was different at 12 and 48 hours (p=0.047 and p=0.01, respectively). Initial modified radiologic atelectasis scores (m-RAS) were higher for the HFNC group and decreased steadily (p=0.001). Extubation failure rates were 4% and 22% for the HFNC and COT groups, respectively (p=0.007). In conclusion, HFNC is better than COT, especially for the restoration of the respiratory and radiologic parameters. Although more expensive, the use of HFNC may have more advantages to reduce the risk of extubation failure in critically ill children compared with COT.

Ogilvie syndrome presenting with septic shock.

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

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

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

A case of DRESS syndrome associated with carbamazepine treatment.

Fever and rash associated in a wide clinical spectrum, drug rash with eosiophilia and systemic symptoms syndrome (DRESS) is a potentially life-threatening hypersensitivity reaction. Early diagnosis and treatment and removal of the offending agent can be life-saving. Physicians should be aware of DRESS syndrome, particularly in patients receiving antiepileptic medication and admitted with a symptoms of fever and skin rash. In this study, a girl aged three years who had been under carbamazepine therapy for one month was admitted to our hospital with symptoms of fever and rash and was diagnosed as having DRESS syndrome, is presented to increase awareness of DRESS syndrome among physicians.

New Biomarkers to Diagnose Ventilator Associated Pneumonia: Pentraxin 3 and Surfactant Protein D.

OBJECTIVE: To detect the most effective biomarker to confirm ventilator associated pneumonia (VAP). METHODS: Fifty patients with VAP suspicious diagnosis and 30 healthy patients were recruited. Suspicion of VAP was established if patients met the modified CPIS score ≥ 6 points. The confirmation of VAP was defined by the quantitative culture of nonbronchoscopic bronchoalveolar lavage (BAL) >105 CFU/ml of pathogenic microorganism. Serum samples for determination of C-reactive protein (CRP), procalcitonin (PCT), pentraxin 3 (PTX3), surfactant protein D (SPD) were collected on suspected VAP. RESULTS: Twenty seven of 50 patients were accepted as confirmed VAP group whose nonbronchoscopic BAL cultures were positive and rest of them were accepted as unconfirmed VAP group. PTX3, PCT and SPD levels were significantly higher in confirmed VAP group, (P = 0.021, P = 0.007, P < 0.001 respectively). There were no significant differences in CRP levels between the two groups (P = 0.062). The most sensitive marker for diagnosing VAP was SPD (P < 0.001). Receiver operating characteristic (ROC) curve for modified clinical pulmonary infection score (CPIS) to confirm VAP was evaluated (AUC 0.741 ± 0.07, P < 0.001) and the optimal cutoff value was >7 with a sensitivity of 51.85% and a specificity of 91.3%. SPD levels were significantly higher in Acinetobacter baumannii and Pseudomonas aeruginosa infected patients than culture negative patients (P < 0.001). CONCLUSIONS: The index findings suggest that serum SPD is the most sensitive biomarker in diagnosis of VAP and it can be used as an early and organism specific marker for Acinetobacter baumannii and Pseudomonas aeruginosa.

Comprehensive Analysis of Liberal and Restrictive Transfusion Strategies in Pediatric Intensive Care Unit.

Background: We prospectively compared restrictive and liberal transfusion strategies for critically ill children regarding hemodynamic and laboratory parameters. Methods: A total of 180 children requiring packed red blood cells (PRBCs) were randomized into two groups: the liberal transfusion strategy group (transfusion trigger < 10 g/dL, Group 1) and the restrictive transfusion strategy group (transfusion trigger ≤ 7 g/dL, Group 2). Basal variables including venous/arterial hemoglobin, hematocrit and lactate levels; stroke volume; and cardiac output were recorded at the beginning and end of the transfusion. Oxygen saturation, noninvasive total hemoglobin, noninvasive total oxygen content, perfusion index (PI), heart rate and systolic and diastolic blood pressures were assessed via the Radical-7 Pulse co-oximeter (Masimo, Irvine, CA, USA) with the Root monitor, initially and at 4 h. Results: In all, 160 children were eligible for final analysis. The baseline hemoglobin level for the PRBC transfusion was 7.38 ± 0.98 g/dL for all patients. At the end of the PRBC transfusion, cardiac output decreased by 9.9% in Group 1 and by 24% in Group 2 (p < 0.001); PI increased by 10% in Group 1 and by 45% in Group 2 (p < 0.001). Lactate decreased by 9.8% in Group 1 and by 31.68% in Group 2 (p < 0.001). Conclusion: Restrictive blood transfusion strategy is better than liberal transfusion strategy with regard to the hemodynamic and laboratory values during the early period. PI also provides valuable information regarding the efficacy of PRBC transfusion in clinical practice.

Neuroinfluenza: evaluation of seasonal influenza associated severe neurological complications in children (a multicenter study).

PURPOSE: Although influenza primarily affects the respiratory system, in some cases, it can cause severe neurological complications. Younger children are especially at risk. Pediatric literature is limited on the diagnosis, treatment, and prognosis of influenza-related neurological complications. The aim of the study was to evaluate children who suffered severe neurological manifestation as a result of seasonal influenza infection. METHODS: The medical records of 14 patients from six hospitals in different regions of the country were evaluated. All of the children had a severe neurological manifestations related to laboratory-confirmed influenza infection. RESULTS: Median age of the patients was 59 months (6 months-15.5 years) and nine (64.3%) were male. Only 4 (28.6%) of the 14 patients had a comorbid disease. Two patients were admitted to hospital with influenza-related late complications, and the remainder had acute complication. The most frequent complaints at admission were fever, altered mental status, vomiting, and seizure, respectively. Cerebrospinal fluid (CSF) analysis was performed in 11 cases, and pleocytosis was found in only two cases. Neuroradiological imaging was performed in 13 patients. The most frequent affected regions of nervous system were as follows: cerebellum, brainstem, thalamus, basal ganglions, periventricular white matter, and spinal cords. Nine (64.3%) patients suffered epileptic seizures. Two patients had focal seizure, and the rest had generalized seizures. Two patients developed status epilepticus. Most frequent diagnoses of patients were encephalopathy (n = 4), encephalitis (n = 3), and meningitis (n = 3), respectively. The rate of recovery without sequelae from was found to be 50%. At discharge, three (21.4%) patients had mild symptoms, another three (21.4%) had severe neurological sequelae. One (7.1%) patient died. The clinical findings were more severe and outcome was worse in patients <5 years old than patients >5 years old and in patients with comorbid disease than previously healthy group. CONCLUSION: Seasonal influenza infection may cause severe neurological complications, especially in children. Healthy children are also at risk such as patients with comorbid conditions. All children who are admitted with neurological findings, especially during the influenza season, should be evaluated for influenza-related neurological complications even if their respiratory complaints are mild or nonexistent.

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

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

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.

Noninvasive Measurement of Hemoglobin Using Spectrophotometry: Is it Useful for the Critically Ill Child?

This study compared the accuracy of noninvasively measuring hemoglobin using spectrophotometry (SpHb) with a pulse CO-oximeter and laboratory hemoglobin (Hb) measurements. A total of 345 critically ill children were included prospectively. Age, sex, and factors influencing the reliabilityof SpHb such as SpO2, heart rate, perfusion index (PI), and vasoactive inotropic score were recorded. SpHb measurements were recorded during the blood draw and compared with the Hb measurement. Thirteen patients (low PI in 9 patients and no available Hb in 4 patients) were excluded and 332 children were eligible for final analysis. The mean Hb was 8.71±1.49 g/dL (range, 5.9 to 12 g/dL) and the mean SpHb level was 9.55±1.53 g/dL (range, 6 to 14.2 g/dL). The SpHb bias was 0.84±0.86,with the limits of agreement ranging from -2.5 to 0.9 g/dL. The difference between Hb and SpHb was >1.5 g/dL for only 47 patients. Of these, 24 patients had laboratory Hb levels <7 g/dL. There was a weak positive correlation between differences and PI (r=0.349; P= 0.032). The pulse CO-oximeter is a promising tool for measuring SpHb and monitoring critically ill children. However, PI may affect these results. Additional studies investigating the reliability of the trend of continuous SpHb values compared with simultaneously measured laboratory Hb values in the same patient are warranted.

Ileus and Intra-Abdominal Hypertension due to Phosphate- Containing Enema.

The most well known complications of fleet enema solution are cardiac insufficiency, renal failure, water-electrolyte imbalance, and ileus. A 7-y-old girl with phenylketonuria and long-term constipation was admitted to the emergency department with symptoms of seizure, vomiting and abdominal distention. Laboratory results revealed hypocalcemia and hyperphosphatemia. ECG findings showed normal sinus rhythm and prolonged QT interval. At the follow-up, the patient's abdominal distention was markedly increased. She was evaluated for a surgical pathology and, this was considered unlikely. Intra-abdominal pressure (IAP) was 19.5 mmHg. Gastric and colonic decompression, intravenous 10 % calcium gluconate were applied. After 2 d of treatment, the patient's condition became stable, and serum calcium and phosporus normalized to 8.8 mg/dl and 4.0 mg/dl, respectively. Abdominal distention regressed and the last IAP measurement was 3.5 mmHg. Thus, IAP measurements are a useful adjunct in clinical follow-up of patients with progressive abdominal distention due to phosphate enema use.

Cerebrovascular complication of infective endocarditis complicated with abdominal trauma.

A 9-year-old boy presented to the emergency department with blunt abdominal trauma. Initial assessment was normal except for abdominal tenderness. On day 3, patient was transferred to the pediatric intensive care unit (PICU) for hemodynamic instability, and persistent fever despite antibiotic therapy. On PICU admission, his body temperature was 40 0C, heart rate was 160/min, respiratory rate was 36/min, blood pressure was 85/40 mmHg, and impaired consciousness was noticed. Complete blood count revealed hemoglobin of 11.5 g/dl, white blood cell count of 22,500/mm3 and platelet count of 145,000/mm3. Serum C-reactive protein and procalcitonin were 139 mg/dl and 8.80 ng/ml, respectively. Renal and liver function test results were normal. Cranial magnetic resonance imaging (MRI) was planned because of impaired consciousness and fever. On cranial MRI, multiple infarct areas were detected in both hemispheres and minimal hemorrhagic focus was found in the left temporal region. Because of the cranial MRI findings and fever echocardiographic examination was planned to exclude infective endocarditis. Transthoracic echocardiography successfully visualized mitral valve prolapse, 14x8 mm mobile vegetation on the atrial side of the posterior leaflet of the mitral valve, and severe mitral regurgitation. The left chambers were dilated. There was no evidence of a perivalvular abscess. On control transthoracic echocardiography, after 6 weeks of parenteral antibiotic treatment, there was no significant reduction of the visible vegetation therefore surgery was planned. Infective endocarditis should be considered in the differential diagnosis of fever of unknown origin. Especially during the early stage of disease, cranial MRI may be more useful to prevent fatal complications for patients with neurologic examination findings.