The effect of myocardial dysfunction on mortality in children with septic shock: a prospective observational study.

Pediatric septic shock is defined as progressive multi-organ dysfunction and cardiovascular dysfunction accompanying sepsis. Studies showing myocardial dysfunction associated with pediatric septic shock are very limited. The aim of this study was to evaluate the relationship between myocardial functions calculated by echocardiography, disease severity, and clinical outcomes in children with septic shock. This observational prospective study was conducted in a pediatric intensive care at a university-affiliated tertiary hospital. The patients diagnosed with septic shock between January 2021 and February 2022 were included in the study. The study was conducted with 56 patients. The rate of myocardial dysfunction (systolic and/or diastolic dysfunction) was 50%. Of these, 39.3% (n = 22) had systolic dysfunction, 17.9% (n = 10) had diastolic dysfunction, and 8.9% (n = 5) had both systolic and diastolic dysfunction. PRISM III score (p = 0.004), VIS (p < 0.001), lactate (p = 0.002), CK-MB (p = 0.023), troponin (p = 0.038), EF (p = 0.004) EF z-score (p = 0.003), MAPSE z-score (p = 0.049), TAPSE (p = 0.010), TAPSE z-score (p = 0.003), and mitral valve E/e ´z-score (p = 0.028) were statistically significant difference with mortality. No significant difference was found for mortality with MAPSE (p = 0.090), mitral valve E/A (p = 0.624), and mitral valve E/A z-score (p = 0.327). EF z-score was found to be associated with 30-day mortality (OR = 0,681, 95% CI 0,480 to 0.991, p = 0,045). We found the TAPSE z-score to be the most significant parameter with 30-day mortality (OR = 0,690, 95% CI 0,489 to 0.998, p = 0,032).  Conclusion: We found left ventricular dysfunction associated factor with mortality. TAPSE showing right ventricular dysfunction was found to be the independent risk factor most associated with mortality. What is Known: • Studies showing myocardial dysfunction associated with pediatric septic shock are limited. • Little is known about the use of echocardiography in pediatric septic shock, and there are no specific guidelines for treatment and follow-up in pediatric patients. What is New: • Characteristics, echocardiographic measurements, and outcomes were comprehensively assessed in children with septic shock. • As a result of our analysis, we found that TAPSE, which is easily measured at the bedside, is the most critical parameter in relation to mortality. • We offer recommendations for its use in the follow-up of children with septic shock.

Clinical Features and Management of Status Epilepticus in the Pediatric Intensive Care Unit.

OBJECTIVES: Status epilepticus (SE) is associated with significant morbidity and mortality in children. SE in the pediatric intensive care unit (PICU) are not well characterized. The aim of this study is to retrospectively investigate the clinical features and treatment of seizures in children admitted to the PICU of our hospital. METHODS: We retrospectively examined the clinical characteristics of patients aged between 1 month and 18 years who were admitted to our hospital with SE or who were diagnosed with SE after hospitalization and were followed up with continuous electroencephalographic monitoring between January 2015 and December 2019. RESULTS: A total of 88 patients with SE, 50 (56.8%) boys and 38 (43.2%) girls, were included. The median age was 24 months (interquartile range, 12-80 months). When we evaluate the continuous electroencephalographic monitoring data, 27 (30.7%) were lateralized, 20 (22.7%) were multifocal, 30 (34.1%) were generalized, and 11 (12.5%) were bilateral independent epileptic activity. Seventy nine patients (89.8%) were evaluated as convulsive status epilepticus (CSE) and 9 (10.2%) as nonconvulsive status epilepticus (NCSE). Pediatric Risk of Mortality (PRISM III) score and mortality of patients with NCSE were higher ( P = 0.004 and P = 0.046, respectively). Thirteen eight patients (43.1%) were diagnosed as SE, 38 patients (43.1%) as refractory SE, and 12 patients (13.6%) as super-refractory SE. The overall mortality rate was 10.2%. CONCLUSIONS: Status epilepticus is a neurological emergency that causes mortality and morbidity. Electroencephalographic monitoring is important for the recognition of seizures and rapid intervention. No superiority of second-line treatments or combined treatments was demonstrated in patients with SE.

Evaluation of renal near-infrared spectroscopy for predicting extubation outcomes in the pediatric intensive care setting.

Background: In pediatric intensive care units, extubation failure following invasive mechanical ventilation poses significant health risks. Determining readiness for extubation in children can minimize associated morbidity and mortality. This study investigates the potential role of renal near-infrared spectroscopy (RrSO2) in predicting extubation failure in pediatric patients. Methods: A total of 84 patients aged between 1 month and 18 years, mechanically ventilated for at least 24 h, were included in this prospective study. RrSO2 levels were measured using near-infrared spectroscopy before and during an extubation readiness test (ERT). The primary outcome measure was extubation failure, defined as a need for reintubation within 48 h. Results: Of the 84 patients, 71 (84.6%) were successfully extubated, while 13 (15.4%) failed extubation. RrSO2 was found to be lower in the failed extubation group, also decrease in RrSO2 values during ERT was significantly greater in patients with extubation failure. ROC analysis indicated a decrease in ΔRrSO2 of more than 6.15% from baseline as a significant predictor of extubation failure, with a sensitivity of 0.984 and a specificity of 0.889. Conclusion: Monitoring changes in RrSO2 values may serve as a helpful tool to predict extubation failure in pediatric patients. Further multi-center research is warranted to improve the generalizability and reliability of these findings.

Closed-loop oxygen control improves oxygenation in pediatric patients under high-flow nasal oxygen-A randomized crossover study.

Background: We assessed the effect of a closed-loop oxygen control system in pediatric patients receiving high-flow nasal oxygen therapy (HFNO). Methods: A multicentre, single-blinded, randomized, and cross-over study. Patients aged between 1 month and 18 years of age receiving HFNO for acute hypoxemic respiratory failure (AHRF) were randomly assigned to start with a 2-h period of closed-loop oxygen control or a 2-h period of manual oxygen titrations, after which the patient switched to the alternative therapy. The endpoints were the percentage of time spent in predefined SpO2 ranges (primary), FiO2, SpO2/FiO2, and the number of manual adjustments. Findings: We included 23 patients, aged a median of 18 (3-26) months. Patients spent more time in a predefined optimal SpO2 range when the closed-loop oxygen controller was activated compared to manual oxygen titrations [91⋅3% (IQR 78⋅4-95⋅1%) vs. 63⋅0% (IQR 44⋅4-70⋅7%)], mean difference [28⋅2% (95%-CI 20⋅6-37⋅8%); P < 0.001]. Median FiO2 was lower [33⋅3% (IQR 26⋅6-44⋅6%) vs. 42⋅6% (IQR 33⋅6-49⋅9%); P = 0.07], but median SpO2/FiO2 was higher [289 (IQR 207-348) vs. 194 (IQR 98-317); P = 0.023] with closed-loop oxygen control. The median number of manual adjustments was lower with closed-loop oxygen control [0⋅0 (IQR 0⋅0-0⋅0) vs. 0⋅5 (IQR 0⋅0-1⋅0); P < 0.001]. Conclusion: Closed-loop oxygen control improves oxygenation therapy in pediatric patients receiving HFNO for AHRF and potentially leads to more efficient oxygen use. It reduces the number of manual adjustments, which may translate into decreased workloads of healthcare providers. Clinical trial registration: [www.ClinicalTrials.gov], identifier [NCT05032365].

Automated closed-loop FiO2 titration increases the percentage of time spent in optimal zones of oxygen saturation in pediatric patients-A randomized crossover clinical trial.

Introduction: We aimed to compare automated ventilation with closed-loop control of the fraction of inspired oxygen (FiO2) to automated ventilation with manual titrations of the FiO2 with respect to time spent in predefined pulse oximetry (SpO2) zones in pediatric critically ill patients. Methods: This was a randomized crossover clinical trial comparing Adaptive Support Ventilation (ASV) 1.1 with use of a closed-loop FiO2 system vs. ASV 1.1 with manual FiO2 titrations. The primary endpoint was the percentage of time spent in optimal SpO2 zones. Secondary endpoints included the percentage of time spent in acceptable, suboptimal and unacceptable SpO2 zones, and the total number of FiO2 changes per patient. Results: We included 30 children with a median age of 21 (11-48) months; 12 (40%) children had pediatric ARDS. The percentage of time spent in optimal SpO2 zones increased with use of the closed-loop FiO2 controller vs. manual oxygen control [96.1 (93.7-98.6) vs. 78.4 (51.3-94.8); P < 0.001]. The percentage of time spent in acceptable, suboptimal and unacceptable zones decreased. Findings were similar with the use of closed-loop FiO2 controller compared to manual titration in patients with ARDS [95.9 (81.6-98.8) vs. 78 (49.5-94.8) %; P = 0.027]. The total number of closed-loop FiO2 changes per patient was 52 (11.8-67), vs. the number of manual changes 1 (0-2), (P < 0.001). Conclusion: In this randomized crossover trial in pediatric critically ill patients under invasive ventilation with ASV, use of a closed-loop control of FiO2 titration increased the percentage of time spent within in optimal SpO2 zones, and increased the total number of FiO2 changes per patient. Clinical trial registration: ClinicalTrials.gov, identifier: NCT04568642.

Pediatric Status Epilepticus Severity Score (STEPSS): Predictive Performance of Functional Outcomes: A Prospective Single-Center Study.

Objective: To prospectively investigate the predictive value of the modified Status Epilepticus Severity Score (STESS) for pediatric use (STEPSS) regarding unfavorable outcomes in the short term. Methods: Patients diagnosed as status epilepticus in the emergency department between January 2019 and June 2021 at a tertiary center of the University of Health Sciences, Dr. Behcet Uz Children's Hospital, were included in the study. The patients were followed up in the emergency department, neurology clinic, and pediatric intensive care unit until discharge. Demographic and clinical characteristics, STEPSS, and Pediatric Overall Performance Category Scale (POPC) scores were calculated. We defined a Pediatric Overall Performance Category Scale score ≥3 as an unfavorable outcome. We compared the effect of STEPSS on unfavorable outcomes and mortality. Results: 124 children were included. The median age was 33 months (interquartile range 16.2-84.7). Seventy-two (58.1%) patients had acute symptomatic etiology. We found that the STEPSS score with the receiver operating characteristic curve (area under the curve = 0.917, P < .001) could predict unfavorable outcomes (Pediatric Overall Performance Category Scale score ≥3) in children with status epilepticus. The Youden index (0.76) showed that a STEPSS score >2 was the optimal cutoff point for an unfavorable outcome. We found STEPSS useful in predicting mortality (area under the curve = 0.853, P < .001). The Youden index (0.58) indicated that a STEPSS >2 was the optimal cutoff for mortality: sensitivity 0.90 (95% confidence interval [CI] 0.58-0.99), specificity 0.67 (95% CI 0.57-0.77), positive predictive value 0.21, negative predictive value 0.98, positive likelihood ratio 2.7, negative likelihood ratio 0.14. Conclusion: We determined that STEPSS can be predicted unfavorable outcomes and mortality. We think that STEPSS can be used as a useful clinical score with further studies and external validations.

Changes in the incidence of Candida-related central line-associated bloodstream infections in pediatric intensive care unit: Could central line bundle have a role?

OBJECTIVE: Candida species are among the most prevalent microorganisms in pediatric critical care units that cause central line-associated bloodstream infections. The goal of this study was to assess the therapeutic benefit of central line bundle for the prevention of Candida species-related bloodstream infections in pediatric intensive care units. DESIGN: The study covered the period from January 1, 2009, to December 31, 2019. Pre-bundle and bundle phases were included in the research. The Clinical Microbiology Laboratory's records revealed episodes of Candida-related central line-associated bloodstream infections. SETTING: The study was conducted in the Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital's PICU (which has 24 beds and admits 350 patients per year). PATIENTS: This study included pediatric patients in the pediatric intensive care unit with non-tunneled central venous catheters. INTERVENTIONS: In the pediatric intensive care unit, a central line bundle was started. RESULTS: A total of 236 Candida-related central line-associated bloodstream infections were discovered during the study period. Non-albicans Candida accounted for 83.5% (197) of the total, whereas C.albicans accounted for 16.5%(39). During the pre-bundle period, 137 Candida species were isolated from the patients, while 99 Candida species were isolated during the bundle period. Candida-related central line-associated bloodstream infections dropped from 13.68 to 5.93 per 1000 CL-days after the central line bundle was used (p < 0.001). CONCLUSIONS: According to our findings, the central line bundle greatly reduced central line-associated Candida species bloodstream infections. Central line bundles are an effective scientific solution for preventing Candida-related central line-associated bloodstream infections in hospitals with high Candida prevalence.

Could lactate clearance be a marker of mortality in pediatric intensive care unit?

BACKGROUND: Hyperlactatemia is a common finding in critically ill patients and has significant prognostic implications. However, a single lactate measurement has not been correlated to mortality consistently. In this study, we aimed to correlate the clinical efficacy of lactate clearance for the prediction of mortality in pediatric intensive care unit patients. METHODS: This retrospective observational study was performed in the pediatric intensive care unit in patients with lactate level >3 mmol/lt. Initial, 6th h, and 24th h lactate levels were recorded and lactate clearance was calculated using these values (lactate level at admission - level 6 h later × 100/lactate level at admission). RESULTS: A total of 172 patients were included in the study. Forty-four out of 172 patients died. Median (IQR) lactate (mmol/L) at admission was low in those who survived in comparison to nonsurvivors 4.4 (3.1) vs. 5.75 (7.7) (p = 0.002). Clearance at 6th h was significantly lower in those who died (11.7%) than those who survived (36.7) (p = 0.001). 6th h lactate clearance level <20.7% predicted mortality with a sensitivity of 63.6% and specificity of 69.5% along with a positive predictive value of 41.8 and a negative predictive value of 84.8 (p = 0.004). Both lactate levels and lactate clearance values were significantly predictive factors for mortality (p < 0.05). Only a positive moderate correlation was found between the percentage of PRISM-IV % and 6th h lactate level. DISCUSSION: The present study revealed that lactate clearance is a simple and rapid risk-stratification tool holding to be a potential biomarker of managing the treatment efficacy of children in the pediatric intensive care unit.

Assessment of potential differences between pre-filled and manually prepared syringe use during vascular access device management in a pediatric intensive care unit.

BACKGROUND: Central line-associated bloodstream infection is one of the four primary health-care-associated infections applicable to pediatric intensive care units defined by The Centers for Disease Control and Prevention. According to current guidelines, it is essential to flush vascular access devices before each infusion to assess catheter function and prevent catheter-related complications. OBJECTIVE: This prospective trial aimed to assess the potential differences between pre-filled and manually prepared saline syringe use during vascular access device management in a pediatric intensive care unit. METHODS: Volunteered registered pediatric intensive care unit nurses were asked to implement the flushing solution to an extension line of a central venous catheter in vitro. After the randomization process with opaque sealed envelopes, they have started either with manual preparation or used sterile pre-filled saline syringes. Sterile application steps forms were used for monitoring the manual preparation of saline syringes versus the pre-filled saline syringes phase. Each volunteer repeated the steps for 3, 5, and 10 mL syringe volumes with the manually prepared and pre-filled saline syringes. After completing the procedures, failed steps and durations were transferred into a database to be analyzed by a blinded investigator. RESULTS: A total of 41 nurses volunteered and 123 forms for three attempts per one nurse were filled for each group. In the manual preparation group, the number of at least one failure in the necessary steps was 89 (72.3%) and the same number in the pre-filled syringe group was 6 (4.9%), and significantly lower in the pre-filled saline syringe group (p < 0.001). The overall time for preparing to flush was 86.0 ± 22.3 s (ranging from 46 to 173 s) for manual prepared syringes and 35.2 ± 9.4 s (ranging from 18 to 100 s) (p < 0.001) for pre-filled saline syringes. CONCLUSION: Our results demonstrate that the risk for breaking the aseptic no-touch technic was higher in the manual preparation group. We have also demonstrated that the flushing time was shorter with pre-filled syringes compared to manually prepared ones, which may contribute to decreasing the workload of the nurses and may increase the quality of care in the intensive care units. The use of pre-filled saline syringes may decrease the central line-associated bloodstream infections incidence and may increase the quality of care by saving extra time in the pediatric intensive care unit.

Randomized crossover trial to compare driving pressures in a closed-loop and a conventional mechanical ventilation mode in pediatric patients.

INTRODUCTION: In mechanically ventilated patients, driving pressure (ΔP) represents the dynamic stress applied to the respiratory system and is related to ICU mortality. An evolution of the Adaptive Support Ventilation algorithm (ASV® 1.1) minimizes inspiratory pressure in addition to minimizing the work of breathing. We hypothesized that ASV 1.1 would result in lower ΔP than the ΔP measured in APV-CMV (controlled mandatory ventilation with adaptive pressure ventilation) mode with physician-tailored settings. The aim of this randomized crossover trial was therefore to compare ΔP in ASV 1.1 with ΔP in physician-tailored APV-CMV mode. METHODS: Pediatric patients admitted to the PICU with heterogeneous-lung disease were enrolled if they were ventilated invasively with no detectable respiratory effort, hemodynamic instability, or significant airway leak around the endotracheal tube. We compared two 60-min periods of ventilation in APV-CMV and ASV 1.1, which were determined by randomization and separated by 30-min washout periods. Settings were adjusted to reach the same minute ventilation in both modes. ΔP was calculated as the difference between plateau pressure and total PEEP measured using end-inspiratory and end-expiratory occlusions, respectively. RESULTS: There were 26 patients enrolled with a median age of 16 (9-25 [IQR]) months. The median ΔP for these patients was 10.4 (8.5-12.1 [IQR]) and 12.4 (10.5-15.3 [IQR]) cmH2O in the ASV 1.1 and APV-CMV periods, respectively (p < .001). The median tidal volume (VT) selected by the ASV 1.1 algorithm was 6.4 (5.1-7.3 [IQR]) ml/kg and RR was 41 (33 50 [IQR]) b/min, whereas the median of the same values for the APV-CMV period was 7.9 (6.8-8.3 [IQR]) ml/kg and 31 (26-41[IQR]) b/min, respectively. In both ASV 1.1 and APV-CMV modes, the highest ΔP was used to ventilate those patients with restrictive lung conditions at baseline. CONCLUSION: In this randomized crossover trial, ΔP in ASV 1.1 was lower compared to ΔP in physician-tailored APV-CMV mode in pediatric patients with different lung conditions. The use of ASV 1.1 may therefore result in continued, safe ventilation in a heterogeneous pediatric patient group.

The Effect of COVID-19 Outbreak on the Mental Status of Health Care Professionals in the Pediatric Intensive Care Unit.

BACKGROUND: Coronavirus disease 2019 (COVID-19) may affect the mental status of health care professionals. The purpose of our study is to evaluate the mental health effects of the COVID-19 epidemic on health care professionals in the pediatric intensive care units (PICUs). SUBJECTS AND METHODS: Our study was conducted prospectively between 01.04.20 and 10.04.20. The created questionnaire was applied to health care professionals through online platforms. Thus it was involved in 5 different institutions that participated from different regions of Turkey. With the questionnaire, we applied; the participants' age, gender, the general status of contamination and the level of COVID-19 knowledge were questioned. Besides; Beck Anxiety Scale, Acute Stress Scale (PCL-5), STAI-1 and STAI-2 (State and Trait Anxiety Inventory 1-2) scales were used to determine the anxiety levels. RESULTS: A survey of 210 participants, 86 (41%) doctors, 124 (59%) nurses, were included in our study. When we evaluate the Beck anxiety levels, the majority of the participants (44%) were normal, while about one third had mild anxiety. When we evaluated the acute stress scale, all participants had a certain amount of stress levels. The majority (80 people each (38%)) experienced mild and moderate acute stress. Being female and having chronic disease poses a high risk for anxiety (OR, 0.330; 95% CI, 0.087-1.250, p<0.05 and OR, 0.246; 95% CI, 0.068-1.116, p<0.05), preoccupation (OR, 0.603; 95% CI 0.261-1.395, p<0.05 and OR, 0.433; 95% CI, 0.122-1.538, p<0.05) and acute stress (OR, 0.294; 95% CI, 0.033-2.649, p<0.05 and OR, 0.317; 95% CI 0.060-1.679, p<0.05). Professional definition, marital status and having a child do not pose any risk factors. CONCLUSION: Our study has shown that the COVID-19 outbreak affects the mental status of health care professionals working at PICU at various levels.

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

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

The evaluation of right and left ventricular functions in children with episodic wheezing exposed to environmental tobacco smoke.

Doksöz Ö, Nacaroglu HT, Ceylan G, Çelegen M, Asik-Nacaroglu S, Can D, Mese T, Ünal N. The evaluation of right and left ventricular functions in children with episodic wheezing exposed to environmental tobacco smoke. Turk J Pediatr 2017; 59: 42-48. The objective of this study is to examine the right and left ventricular functions in children with episodic wheezing at the ages of 1-3 exposed to environmental tobacco smoke (ETS). Thirty-two children monitored at the Pediatric Allergy and Immunology Department of a Research and Training Hospital with the diagnosis of episodic wheezing were included. The prospective assessment of the patients was performed between May 2013 and February 2014. Twenty-five children with episodic wheezing not exposed to ETS formed the control group. The two groups were compared by conducting transthoracic two-dimensional and tissue Doppler echocardiography (TDE) examination in all of the cases. The average age of the study group (24 boys, 8 girls) was 33.1 ± 8.8 months, the average age of the control group (18 boys, 7 girls) was 31.9 ± 11.9 months. There was no statistically significant difference between the two groups in terms of age, gender, weight, height, and body mass index values. There was no statistically significant difference between the two groups for the right and left ventricular systolic and diastolic functions in the conventional echocardiographic measurements, and for the measurements of TDE. Limited number of patients is a major limitation of the study. These results should be supported by more comprehensive studies.

Risk factors for recurrent central line-associated bloodstream infections in a pediatric intensive care unit

Background/aim: It is recommended that a central venous catheter (CVC) be removed if central line-associated bloodstream infection (CLABSI) has been diagnosed. The objective of this retrospective study was to evaluate the risk factors for recurrent CLABSI in reinserted catheters in a pediatric intensive care unit. Materials and methods: Patients with recurrent and nonrecurrent CLABSI were compared in terms of the catheter exchange interval, the interval between negative blood culture and reinsertion of the CVC, and the pre-/reinsertion treatment duration. Results: Thirty-one patients with initial CLABSI had reinserted CVCs, and 12 (38.7%) of these patients were diagnosed with recurrent CLABSI. In the recurrent group, the catheter exchange interval, the interval between negative blood culture and reinsertion of the second CVC, and pre-/reinsertion treatment duration were found to be shorter. Logistic regression analysis revealed that if the interval between negative blood culture and reinsertion of the second CVC was shorter than 4 days, recurrent CLABSI risk increased by 1.7-fold (P = 0.021). Sterile gauze-dressed patients had shorter cumulative catheter surveys than the polyurethane-dressed patients (P = 0.005). Conclusion: Using transparent polyurethane dressings instead of sterile gauze for maintaining the CVC and delaying the reinsertion procedure for at least 4 days after the negative culture might be helpful in preventing recurrent CLABSI.

New parameters for childhood ventilator associated pneumonia diagnosis.

PURPOSE: Our aim is to determine whether the presence of soluble triggering receptor expressed on myeloid cells-1 (s-TREM-1) of bronchoalveolar lavage fluid (BALF), serum procalcitonin levels (PCT), and Clinical Pulmonary Infection Score (CPIS) have diagnostic value in children with VAP. METHODS: All children followed in pediatric intensive care unit (PICU) who were mechanically ventilated at least for 48 hr between January 2014 and December 2015 were enrolled into our study. BALF sample was obtained via non-bronchoscopic method from the children with VAP suspicion (case group) and s-TREM-1 levels were measured. Furthermore we calculated CPIS and measured serum PCT levels. Same procedures were applied to the control group who were admitted to PICU without infectious problems and who were not under antimicrobial therapy. First we compared the case group with the control group and then we compared the quantitative culture confirmed and non-confirmed VAP cases among themselves. RESULTS: Case group (n:58) had significant higher PCT and s-TREM-1 levels compared to control group (n:58). The VAP confirmed cases had higher s-TREM-1, PCT ve CPIS levels compared to non-confirmed VAP cases. s-TREM-1, PCT ve CPIS variables were found to be independent risk factors for VAP. The cutoff values for s-TREM-1, CPIS, and PCT, are 281 pg/ml, 6, and 1.9 ng/ml, respectively. The patients whose s-TREM-1, CPIS, and PCT values above the cutoff levels were found to have higher cumulative VAP rate. CONCLUSIONS: s-TREM-1 of BALF, serum PCT levels, and CPIS are useful predictors for ventilator-associated pneumonia diagnosis in children. Pediatr Pulmonol. 2017;52:119-128. © 2016 Wiley Periodicals, Inc.

Outcome of Candida Parapsilosis Complex Infections Treated with Caspofungin in Children.

BACKGROUND: We aimed to evaluate the correlation of caspofungin E-tests with the prognosis and response to caspofungin therapy of Candida parapsilosis complex bloodstream infections in children hospitalized in a pediatric intensive care unit. METHODS: All children who had C. parapsilosis complex bloodstream infections and who were treated with caspofungin were included in this retrospective study. For each patient, the following parameters, including all consecutive blood and central venous catheter (CVC) cultures, the duration between diagnosis and CVC removal, mortality rate, relapses of the C. parapsilosis complex infections as well as the demographic features, were recorded. RESULTS: The central venous catheter survival rate was 33.3% under caspofungin treatment. In 92.4 % of the patients, the negative culture was achieved within a median duration of 12.5 days. The rate of relapses was 18.9%. The overall mortality rate was 37.7% (20 of 53 patients), and the 30-days mortality rate was 7.5% (4 of 53 patients). There was no statistically significant difference between the groups with MIC<2 mg/l and MIC =2 mg/l using CVC survival rate; rate and duration of achieving negative blood culture for C. parapsilosis complex; duration of hospital stay; rate and duration of relapses; overall mortality and 30-days mortality. CONCLUSIONS: The beneficial effects of Caspofungin on biofilms has been shown in vivo, while its impact in children for maintenance of CVC was limited in our study but should not be underestimated in children who strongly need the presence of CVCs. The clinicians should weigh their priority for their patients and choose the optimal antifungal therapy for C. parapsilosis complex infections in children.

Can mean platelet volume be used as a biomarker for asthma?

INTRODUCTION: Platelets play important roles in airway inflammation and are activated in inflammatory lung diseases, including asthma. AIM: We evaluated the mean platelet volume (MPV), used as a marker of platelet activation, in asthmatic patients during asymptomatic periods and exacerbations compared to healthy controls to determine whether MPV can be used as an indicator of inflammation. MATERIAL AND METHODS: Our patient group consisted of 95 children with exacerbation of asthma who were admitted to our allergy clinic. The control group consisted of 100 healthy children matched for age, gender, and ethnicity. Mean platelet volume values of the patient group obtained during exacerbation of asthma were compared to those of the same group during the asymptomatic period and with the control group. We investigated factors that can affect the MPV values of asthma patients, including infection, atopy, immunotherapy treatment, and severity of asthma exacerbation. RESULTS: The patient group consisted of 50 (52.6%) boys and 45 (47.4%) girls with a mean age of 125 ±38 months old. Mean MPV values in the exacerbation period, the healthy period, and in the control group were 8.1 ±0.8 fl, 8.1 ±1.06 fl, and 8.2 ±0.9 fl, respectively; there were no significant differences between groups (p > 0.05). The severity of asthma, severity of asthma exacerbation, immunotherapy, coinfection, eosinophil count, and IgE level also had no effect on MPV (p > 0.05). CONCLUSIONS: Although platelets play a role in the pathophysiology of asthma, MPV measurement is insufficient to detect inflammation through platelets.

A Comparison of Intravenous Levetiracetam and Valproate for the Treatment of Refractory Status Epilepticus in Children.

Because of the lack of studies comparing the efficacy and safety of levetiracetam and valproate before the induction of general anesthesia in the treatment of convulsive refractory status epilepticus in children, we aimed to compare the effectiveness of these antiepileptic drugs in patients with convulsive status epilepticus admitted to the Pediatric Intensive Care Unit between 2011 and 2014. Forty-six (59%) of the 78 patients received levetiracetam, and 32 (41%) received valproate for the treatment of refractory status epilepticus. The response rate was not significantly different between the 2 groups. Although no adverse event was noted in patients who received levetiracetam, 4 (12.5%) patients in the valproate group experienced liver dysfunction (P = .025). According to our results, levetiracetam and valproate may be used in the treatment of refractory status epilepticus before the induction of general anesthesia. Levetiracetam appears as effective as valproate, and also safer.

Clinical impact and cost-effectiveness of a central line bundle including split-septum and single-use prefilled flushing devices on central line-associated bloodstream infection rates in a pediatric intensive care unit.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are among the most frequent health care-associated infections. Central line bundle (CLB) programs are useful for reducing CLABSIs. METHODS: A retrospective study was designed to compare 2 periods: the prebundle and bundle periods. We evaluated the impact of a CLB including implementation of split-septum (SS) devices and single-use prefilled flushing (SUF) devices in critically ill children. RESULTS: During the prebundle period, the overall rate was 24.5 CLABSIs per 1,000 central line (CL) days, whereas after the initiation of the CLB, the CLABSIs per 1,000 CL days dropped to 14.29. In the prebundle period, the daily cost per patient with CL and CLABSI were $232.13 and $254.83 consecutively. In the bundle period, the daily cost per patient with CL and CLABSI were $226.62 and $194.28 consecutively. Compared with the period with no CLB, the CLB period, which included SUF and SS devices, resulted in more costs saving by lowering the daily total costs of patients and indirectly lowering total drug costs by decreasing antibacterial and more significantly antifungal drugs. CONCLUSIONS: CLB programs including SS and SUF devices were found to be effective in decreasing the CLABSI rate and decreasing the daily hospital costs and antimicrobial drug expenditures in children.

A Valuable Tool in Predicting Poor Outcome due to Sepsis in Pediatric Intensive Care Unit: Tp-e/QT Ratio.

OBJECTIVE: To assess the feasibility of 12-lead electrocardiographic (ECG) measures such as P wave dispersion (PWd), QT interval, QT dispersion (QTd), Tp-e interval, Tp-e/QT and Tp-e/QTc ratio in predicting poor outcome in patients diagnosed with sepsis in pediatric intensive care unit (PICU). METHODS: Ninety-three patients diagnosed with sepsis, severe sepsis or septic shock and 103 age- and sex-matched healthy children were enrolled into the study. PWd, QT interval, QTd, Tp-e interval and Tp-e/QT, Tp-e/QTc ratios were obtained from a 12-lead electrocardiogram. RESULTS: PWd, QTd, Tp-e interval and Tp-e/QT, Tp-e/QTc ratios were significantly higher in septic patients compared with the controls. During the study period, 41 patients had died. In multivariate logistic regression analyses, only Tp-e/QT ratio was found to be an independent predictor of mortality. CONCLUSION: The ECG measurements can predict the poor outcome in patients with sepsis. The Tp-e/QT ratio may be a valuable tool in predicting mortality for patients with sepsis in the PICU.