The Effects of Endotracheal Suctioning on Hemodynamic Parameters and Tissue Oxygenation in Pediatric Intensive Care Unit.

Airway secretions may increase in intubated patients due to the impaired mucociliary clearance, impaired cough reflex, abnormal glottic function, insufficient moisturizing, and respiratory tract infections. As with any intervention, patients should be cautiously monitored for possible complications during the endotracheal suctioning. Procedure-related changes in the cerebral and somatic tissue oxygenation, hemodynamics, and oxygen saturation can be observed in these patients. It is important to ensure maintenance of tissue oxygenation during these and other interventions performed in critically ill children. The aim of this study was to investigate the effects of the endotracheal suctioning on tissue oxygenation in patients undergoing mechanical ventilation in the pediatric intensive care unit. Cerebral and somatic near-infrared spectroscopy (NIRS) monitoring were performed noninvasively using standardized NIRS equipment as a means of monitoring regional tissue oxygenation. Vital signs, level of sedation, pain scores, and somatic and cerebral tissue oxygenation values of mechanically ventilated patients were recorded prospectively 5 minutes before, during, and after endotracheal suctioning. Cerebral NIRS measurements did not exhibit any statistically significant changes during endotracheal suctioning. Somatic NIRS levels changed significantly before, during, and after endotracheal suctioning and remained low throughout the procedure. Endotracheal suctioning is an invasive intervention that facilitates clearance of tracheal secretions and maintenance of the oxygenation and ventilation. The maintenance of the tissue oxygenation should be documented during these and other interventions performed on critically ill children. Somatic NIRS is a useful tool for monitoring tissue oxygenation during such procedures.

Frequency and Causes of Delirium in Pediatric Intensive Care Unit: A Prospective Observational Study.

BACKGROUND: The number of studies evaluating delirium and its frequency in critically ill infants, children, and adolescents is increasing day by day. The primary objective of this study was to evaluate all patients hospitalized in our pediatric intensive care unit (PICU) in terms of pediatric delirium, to determine the frequency and risk factors of pediatric delirium. PATIENTS AND METHODS: The patients included in this study had been hospitalized in the PICU between November 1, 2018, and August 31, 2019, and were followed up for more than 48 hours. RESULTS: Delirium was detected in 14 patients (9.9%) through regular evaluations. The Pediatric Index of Mortality 2 (PIM2) scores and the length of stay in the PICU were higher in patients with delirium (p = 0.03 and p = 0.01, respectively). The use of respiratory support, sedation-analgesia, vasoactive and corticosteroid treatments, and physical restraints were higher in patients with delirium and were statistically significant (p <0.05). Following admission to the PICU, psychosocial interventions were implemented for 76.1% of the whole cohort. Delirium developed in only five (4.5%) of the 108 patients who underwent psychosocial interventions, while it was detected in nine (26.5%) of the 34 patients who did not receive psychosocial interventions (p = 0.001). The psychosocial intervention was associated with a lower likelihood of delirium (odds ratio [OR], 0.237; p = 0.044). An increasing number of days in the PICU was independently associated with increasing odds of delirium (OR, 1.095; p = 0.037 for each day). CONCLUSIONS: We observed that the risk factors associated with delirium were similar to previous studies. Additionally, psychosocial intervention before delirium symptoms developed was associated with a lower risk of developing delirium. However, multicenter randomized controlled trials are needed on this subject. HOW TO CITE THIS ARTICLE: Yontem A, Yildizdas D, Horoz OO, et al. Frequency and Causes of Delirium in Pediatric Intensive Care Unit: A Prospective Observational Study. Indian J Crit Care Med 2021;25(6):715-719.

Acquired Bartter-like Syndrome Presenting with Polyuria and Reversible Hypokalemia Associated with Colistin Use in a Critically Ill Pediatric Patient.

We report a case of an acquired Bartter-like syndrome (BLS) after 3 days of treatment initiation and improved after discontinuation of colistin therapy in pediatric intensive care unit. A 2-month-old girl with spinal muscular atrophy type 1 who had respiratory distress received colistin therapy with a dose of 5 mg/kg/day for Acinetobacter baumannii complex isolation from endotracheal aspirate on the 12th day follow-up. Polyuria (6 mL/kg/hour) in the presence of normal blood pressure and hypokalemic metabolic alkalosis were developed on the 3rd day of colistin treatment. Colistin was stopped on the 4th day, and 2 days after discontinuation of colistin, polyuria improved dramatically. Her metabolic alkalosis and hypokalemia discontinued after 2 and 4 days, respectively. There are very few reports about colistin-induced BLS. The onset of polyuria, hypokalemia, and metabolic alkalosis during treatment with colistin and resolution after interruption suggest a causative relationship. How to cite this article: Yavas DP, Ekinci F, Horoz OO, Gundeslioglu OO, Atmis B, Yildizdas D. Acquired Bartter-like Syndrome Presenting with Polyuria and Reversible Hypokalemia Associated with Colistin Use in a Critically Ill Pediatric Patient. Indian J Crit Care Med 2021;25(7):822-824.

Daily Practice of Mechanical Ventilation and Weaning in Turkish PICUs: A Multicenter Prospective Survey.

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.

A Relationship Between Clinical and Laboratory Characteristics in Children With Severe Scorpion Envenomation in Çukurova, Turkey.

OBJECTIVE: Scorpion stings are an important health problem in many parts of the world. The aim of this study was to retrospectively examine cases of scorpion stings to evaluate their epidemiological, clinical, and laboratory features and to determine strategies that can reduce morbidity and mortality in these cases. METHODS: Scorpion stings experienced by children between 2007 and 2013 were retrospectively reviewed. The patients were categorized into groups based on severities of toxicities, and demographic, clinical, and laboratory features were compared between the groups. RESULTS: The mean ± SD age of the 189 patients with scorpion stings was 83.43 ± 59.62 months. There was a significant difference between the clinical stages and the age distribution of the cases (P < 0.05). White blood cell counts differed significantly between the groups (P < 0.05). There was not a significant difference in mean platelet volume and platelet distribution width between the groups, but plateletcrit and low platelet count were significantly different between stage 1 and stage 3 cases (P < 0.05). Glucose, creatinine kinase-myoglobin binding, and troponin I were also significantly different (P < 0.05). The mortality rate was 0%. CONCLUSIONS: People living in regions where scorpion stings are frequent should be informed about preventive measures against these stings, cases of scorpion stings should be monitored in appropriate centers, and staff offering care to these cases should be educated about treatment methods. In addition, treatment protocols should be determined in accordance with regions where the stings occur and studies should be performed to describe prognostic indicators.

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.

Intravenous levetiracetam in critically ill children.

BACKGROUND: To report the effectiveness and safety of intravenous (IV) levetiracetam (LEV) in the treatment of critically ill children with acute repetitive seizures and status epilepticus (SE) in a children's hospital. MATERIALS AND METHODS: We retrospectively analyzed data from children treated with IV LEV. RESULTS: The mean age of the 108 children was 69.39 ± 46.14 months (1-192 months). There were 58 (53.1%) males and 50 (46.8%) females. LEV load dose was 28.33 ± 4.60 mg/kg/dose (10-40 mg/kg). Out of these 108 patients, LEV terminated seizures in 79 (73.1%). No serious adverse effects were observed but agitation and aggression were developed in two patients, and mild erythematous rash and urticaria developed in one patient. CONCLUSION: Antiepileptic treatment of critically ill children with IV LEV seems to be effective and safe. Further study is needed to elucidate the role of IV LEV in critically ill children.

Brown-Vialetto-Van Laere syndrome: two siblings with a new mutation and dramatic therapeutic effect of high-dose riboflavin.

Brown-Vialetto-Van Laere syndrome (BVVLS) is a rare and severe neurometabolic disease. We present two siblings with BVVLS with a novel homozygous mutation in SLC52A3 (formerly C20orf54) gene. The first sibling was admitted with respiratory insufficiency and required mechanical ventilation. After administration of a high dose of riboflavin, all his clinical symptoms were resolved, which also strongly suggested the diagnosis of BVVLS. The second sibling was also found to have the same genetic mutation as her brother. Although she was symptom-free, riboflavin was initiated empirically. On follow-up, she developed no neurologic or metabolic problems with entirely normal growth and development. BVVLS should be considered in the differential diagnosis of unexplained neurologic symptoms such as polyneuropathy and respiratory insufficiency, as BVVLS and multiple acyl-CoA dehydrogenation defect have broadly overlapping symptoms. Furthermore, our cases once again suggest that with proper diagnosis and early high-dose riboflavin treatment, complete reversal of neurologic deficits in BVVLS is possible.

The prevalance of and factors associated with intra-abdominal hypertension on admission day in critically ill pediatric patients: A multicenter study.

PURPOSE: To investigate admission prevalence of intraabdominal hypertension (IAH) and to determine clinical and laboratory characteristics on admission day associated with IAH in critically ill pediatric patients. MATERIALS AND METHODS: One hundred thirty newly admitted critically ill pediatric patients were included. Intra-abdominal pressure (IAP) was measured 4 times (every 6 hours) with the bladder pressure method. Data included the demographics, diagnostic category, pediatric logistic organ dysfunction score and pediatric risk of mortality score II, clinical concomitant factors, and conditions potentially associated with increased intra-abdominal pressure. RESULTS: Seventy patients (56.1%) had a normal IAP (≤10 mmHg, mean IAP [mmHg] 7.18 ± 1.85), while 60 patients (43.9%) had IAP >10 mmHg (mean IAP [mmHg] 15.46 ± 5.21). Hypothermia frequency, lactate levels, number of patients with oligo-anuria, and mechanical ventilation requirement were higher among patients with IAH compared to patients without IAH (both, P< .05). Hypothermia (OR, 3.899; 95% CI, 1.305-11.655; P< .03) and lactate levels (OR, 1.283 for each mmol/L increase; 95% CI, 1.138-1.447; P< .001) were only significantly associated with IAH. CONCLUSIONS: Intra-abdominal hypertension seems to affect nearly half of newly admitted critically ill pediatric patients. Lactate level and the presence of hypothermia seem to be the independent predictors of the presence of IAH.

Posterior reversible encephalopathy syndrome due to pulse methylprednisolone therapy in a child.

Posterior reversible leukoencephalopathy syndrome (PRES) is a recently described disorder with typical radiological findings of bilateral grey and white matter abnormalities in the posterior regions of the cerebral hemispheres. It has been described in children in association with some medications, renal disease, autoimmune disease, transplantation, and sepsis. In this report, we discuss an eight-year-old boy with PRES during pulse methylprednisolone therapy. In conclusion, PRES is a neurological complication of pulse methylprednisolone therapy, which responds favorably to prompt therapy withdrawal and blood pressure control.

Ambulatory blood pressure monitoring and serum nitric oxide concentration in type 1 diabetic children.

Blood pressure can be determined more precisely with the use of 24 hours ambulatory measurement in type 1 diabetics. Nitric oxide (NO) has been suggested to be responsible for the vascular changes described in early diabetic nephropathy. We aimed to investigate serum NO concentration along with ambulatory blood pressure monitoring (ABPM) parameters in type 1 diabetic patients and to find out whether there are correlation between serum NO level and ABPM parameters. Forty type 1 diabetic subjects and 35 controls were enrolled. Diabetic subjects were grouped as microalbuminuric (n=16) and normalbuminuric (n=24). Casual and ambulatory blood pressure parameters and serum NO concentrations were measured in all study population. Microalbuminuric subjects had higher nighttime systolic blood pressure (SBP), 24 hours diastolic blood pressure (DBP) and 24 hours mean arterial pressure (MAP) than controls. Both microalbuminuric and normalbuminuric subjects had also significantly higher nighttime DBP and nighttime MAP than controls. Serum NO concentrations were higher in normalbuminuric and microalbuminuric subjects than controls. Serum NO concentrations were positively correlated with daytime DBP and MAP, nighttime SBP, DBP and MAP, and 24 hours DBP and MAP in microalbuminuric subjects. Serum NO concentrations were also positively correlated with nighttime DBP in normalbuminuric subjects. Multiple linear regression analysis revealed that serum NO(2)- + NO(3)- concentrations and 24 hours DBP were independently associated with the development of microalbuminuria. Albuminuria seems to be closely associated with serum NO concentrations and ABPM parameters in type 1 DM patients. A prospective follow-up study on diabetic patients with normo- and micro- albuminuria is needed to confirm the predictive values of increased NO concentrations and ABPM parameters on the development of albuminuria.