Venovenous Versus Venoarterial Extracorporeal Membrane Oxygenation: Pediatric Acute Respiratory Distress Syndrome.

OBJECTIVE: This study aimed to compare the efficacy, complication, and mortality of patients who were supported by venovenous (VV) extracorporeal membrane oxygenation (ECMO) and venoarterial (VA) ECMO for pediatric acute respiratory distress syndrome (PARDS). MATERIALS AND METHODS: This study is a single-center, retrospective cohort study between 2014 and 2022. We evaluated to indication of ECMO support, ECMO type, patients' demographic features, complications, and children's outcomes supported by ECMO for PARDS. RESULTS: Twenty-two patients with PARDS, 12 (54%) with VV, and 10 (46%) with VA ECMO were selected. The median number of days to be intubated before ECMO cannulation was 5 (0-16) days. The distribution of intubated days before the patients underwent ECMO was as follows: 0-1 days, 7 (31.8%) patients; 2-3 days, 2 (9.1%) patients; 4-7 days, 7 (31.8%) patients; 8-14 days, 5 (22.8%) patients; >14 days, 1 (4.5%) patient. The median ECMO cannulation day after admission to the pediatric intensive care unit was 3 (range, 1-9) days in the VV ECMO patient group, whereas it was 8 (range, 0-19) days in the VA ECMO group (P = .02). Considering hospital survival, 4 (45%) patients who underwent double-lumen VV ECMO, 1 (33%) patient who underwent VV ECMO, and 3 (30%) patients who supported by VAECMO survived. There was no difference between the groups in terms of hospital discharge rates. CONCLUSION: The highest survival rate was found in the VV ECMO patient group established with double-lumen cannulas, similar to the literature. There was no difference in mortality between the groups whose intubation time before ECMO was 14 days or less.

Impact of the COVID-19 pandemic on diabetic ketoacidosis management in the pediatric intensive care unit.

BACKGROUND: Diabetic ketoacidosis (DKA) is a common endocrine emergency in pediatric patients. Early presentation to health facilities, diagnosis, and good management in the pediatric intensive care unit (PICU) are crucial for better outcomes in children with DKA. METHODS: This was a single-center, retrospective cohort study conducted between February 2015 and January 2022. Patients with DKA were divided into two groups according to pandemic status and diabetes diagnosis. RESULTS: The study enrolled 59 patients, and their mean age was 11±5 years. Forty (68%) had newly diagnosed type 1 diabetes mellitus (T1DM), and 61% received follow-up in the pre-pandemic period. Blood glucose, blood ketone, potassium, phosphorus, and creatinine levels were significantly higher in the new-onset T1DM group compared with the previously diagnosed group (P=0.01, P=0.02, P<0.001, P=0.01, and P=0.08, respectively). In patients with newly diagnosed T1DM, length of PICU stays were longer than in those with previously diagnosed T1DM (28.5±8.9 vs. 17.3±6.7 hours, P<0.001). The pandemic group was compared with pre-pandemic group, there was a statistically significant difference in laboratory parameters of pH, HCO3, and lactate and also Pediatric Risk of Mortality (PRISM) III score. All patients survived, and there were no neurologic sequelae. CONCLUSIONS: Patients admitted during the pandemic period were admitted with more severe DKA and had higher PRISM III scores. During the pandemic period, there was an increase in the incidence of DKA in the participating center compared to that before the pandemic.

Acute kidney injury in critically ill children with COVID-19 and MIS-C.

BACKGROUND: This study's objective was to investigate the incidence of acute kidney injury (AKI) in children with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and multisystem inflammatory syndrome (MIS-C) and to report our clinical experience. METHODS: Acute COVID-19 and MIS-C-diagnosed patients observed in two pediatric intensive care units (PICUs) between 2019 and 2021 were examined for AKI and retrospectively compared to children with AKI. RESULTS: The study comprised 163 children, of whom 98 (60.1%) were diagnosed with acute COVID-19 and 65 (39.9%) with MIS-C. AKI was observed in 40 (40.8%) of the acute COVID-19 patients and 18 (27.7%) of the MIS-C patients. Low calcium level and hypotension were linked with AKI at initial presentation (OR: 0.56, 95% CI: 0.369-0.560, p = 0.006 and OR: 3.64, 95% CI: 1.885-7.152, p = 0.001, respectively). A history of nephrotoxic medication usage played an essential role in the development of AKI in patients who acquired AKI after hospitalization (p = 0.001, odds ratio: 9.32, confidence interval: 3.106-27.973). In clinical practice, individuals with respiratory distress and cough had a high chance of having AKI (OR: 4.47, 95% confidence interval: 2.25-8,892 and OR: 3.48, 95% confidence interval: 1.76-6.88). AKI patients had a greater demand for respiratory assistance and a longer period of stay in the PICU. CONCLUSIONS: AKI in the COVID-19 and MIS-C patient groups is related with increased mortality and extended hospitalization, according to the findings. These statistics imply that identifying and preventing risk factors is necessary. A higher resolution version of the Graphical abstract is available as Supplementary information.

Prolonged extracorporeal membrane oxygenation in pediatrics: How long did we wait?

BACKGROUND: In this study, we aimed to evaluate the duration of extracorporeal membrane oxygenation (ECMO) and its effect on outcomes. Also, we sought to identify hospital mortality predictors and determine when ECMO support began to be ineffective. METHODS: This was a single-center, retrospective cohort study conducted between January 2014 and January 2022. The prolonged ECMO (pECMO) cut-off point was accepted as 14 days. RESULTS: Thirty-one (29.2%) of 106 patients followed up with ECMO had pECMO. The mean follow-up period of the patients who underwent pECMO was 22 (range, 15-72) days, and the mean age was 75 ± 72 months. According to the results of our heterogeneous study population, life expectancy decreased dramatically towards the 21st day. Hospital mortality predictors were determined in the logistic regression analysis in all ECMO groups in our study as high Pediatric Logistic Organ Dysfunction (PELOD) two score, continuous renal replacement therapy (CRRT) use, and sepsis. The pECMO mortality was 61.2% and the overall mortality was 53.0%, with the highest mortality rate in the bridge-to-transplant group (90.9%) because of lack of organ donation in our country. CONCLUSIONS: In our study, the PELOD two score, presence of sepsis, and use of CRRT were found to be in the predictors of in-hospital ECMO mortality model. Considering the complications, in the COX regression model analysis, the factors affecting the probability of dying in patients followed under ECMO were found to be bleeding, thrombosis, and thrombocytopenia.

Hybrid extracorporeal membrane oxynegation in pediatric intensive care patients: A single center experience: More is better?

BACKGROUND: The initial extracorporeal membrane oxygenation (ECMO) configuration is inefficient for patient oxygenation and flow, but by adding a Y-connector, a third or fourth cannula can be used to support the system, which is called hybrid ECMO. METHODS: This was a single-center retrospective study consisting of patients receiving hybrid and standard ECMO in our PICU between January 2014 and January 2022. RESULTS: The median age of the 12 patients who received hybrid ECMO and were followed up with hybrid ECMO was 140 (range, 82-213) months. The total median ECMO duration of the patients who received hybrid ECMO was 23 (8-72) days, and the median follow-up time on hybrid ECMO was 18 (range, 3-46) days. The mean duration of follow-up in the PICU was 34 (range, 14-184) days. PICU length of stay was found to be statistically significant and was found to be longer in the hybrid ECMO group (p = 0.01). Eight (67%) patients died during follow-up with ECMO. Twenty-eight-day mortality was found to be statistically significant and was found to be higher in the standard ECMO group (p = 0.03). The hybrid ECMO mortality rate was 66% (decannulation from ECMO). The hybrid ECMO hospital mortality rate was 75%. The standard ECMO mortality rate was 52% (decannulation from ECMO). The standard ECMO hospital mortality rate was 65%. CONCLUSIONS: Even though hybrid ECMO use is rare, with increasing experience and new methods, more successful experience will be gained. Switching to hybrid ECMO from standard ECMO at the right time with the right technique can increase treatment success and survival.

Clinical and Laboratory Features and Factors Determining the Outcome in Poisoning Children in a Tertiary Pediatric Intensive Care Unit: Eleven Years of Experience.

OBJECTIVE: This study aimed to evaluate the characteristics of patients admitted to a pediatric intensive care unit for poisoning and the factors associated with their outcomes. MATERIALS AND METHODS: Patients who were admitted to the pediatric intensive care unit for poisoning over the 11-year period between January 2010 and December 2020 were retrospectively analyzed. The patients' demographic characteristics, poisoning agent, whether the poisoning was unintentional or intentional (suicide attempt), clinical findings at admission, indication for hospitalization, antidote administered, and supportive and extracorporeal treatments were examined. RESULTS: During the study period, poisonings accounted for 9.4% (436/4653) of pediatric intensive care unit admissions. Of these, 419 patients with complete records were included in the analysis. Drug poisonings accounted for 81.9% of cases (multiple drugs in 38.5%). The most common drug group was central nervous system drugs (47%). Of the symptomatic patients, 56.5% had central nervous system-related findings and 55% had gastrointestinal findings. Before pediatric intensive care unit admission, 52.7% of the patients received activated charcoal and 7.4% received antidote therapy. In the pediatric intensive care unit, 68.9% of patients received no medical treatment, while 71.5% of those who received medical treatment had organ involvement. Multivariate logistic regression analysis to predict whether patients will require treatment during the intensive care follow-up showed that antidote administration before pediatric intensive care unit admission was associated with the need for medical treatment (odds ratio: 25.6, 95% CI: 6.8-96, P < .05). Three patients died, and the mortality rate was 0.72%. CONCLUSION: Childhood poisoning is a widespread and important problem. Effective management in pediatric emergency and intensive care units contributes to patient survival without sequelae.

Multisystem Inflammatory Syndrome in Children Admitted to a Tertiary Pediatric Intensive Care Unit.

Background Multisystem inflammatory syndrome in children (MIS-C) is characterized by persistent fever, abdominal pain, vomiting, diarrhea, rash, conjunctivitis, headaches, and mucocutaneous manifestations and it can cause circulatory dysfunction, resulting in hypotension, shock, and end-organ injury in the heart and other organs and possibly death. In this study, we aimed to analyze the clinical spectrum, treatment options and outcomes of children with MIS-C who were admitted to our pediatric intensive care (PICU). Materials and Methods Clinical and laboratory findings and treatment of the patients admitted to the PICU with MIS-C between April 2020 and January 2021 were recorded, and their outcomes were evaluated. Results Nineteen patients with a median age of 12.5 years (interquartile range (IQR): 5.8-14.0 years) were admitted. Eleven (57.8%) were males. The most frequent clinical and laboratory features were fever (100%), abdominal pain (94.7%), rash (63.1%), headache (68.4%), diarrhea (47.3%), seizure (10.5%), cardiac dysfunction (52.6%), acute kidney injury (26.3%), lymphopenia (84.2%), and thrombocytopenia (36.8%). However, 8 patients needed mechanical respiratory support, 11 patients needed inotropes, 2 patients needed plasma exchange, and 1 patient needed continuous renal replacement therapy. All patients received corticosteroids, 17 patients (89.2%) received intravenous immunoglobulin, 2 patients received anakinra, 10 patients received acetylsalicylic acid, and 6 patients received enoxaparin. Median PICU length of stay was 3 days (IQR: 2-5) and only one patient died. Conclusion In conclusion, MIS-C may present with a variety of clinical manifestations, and it can lead to life-threatening critical illness. Most children need intensive care and the response to immunomodulation is usually favorable.

Antidepressant Poisoning Trends in Pediatric Intensive Care: A Comparative Study of New- and Old-Generation Antidepressants.

PURPOSE/BACKGROUND: This study aimed to compare the frequency, clinical findings, treatment practices, and outcomes of toxicity to old-generation (OG) and new-generation (NG) antidepressants in our pediatric intensive care unit (PICU) by year-to-year. METHODS/PROCEDURES: The study included patients hospitalized for antidepressant poisoning during the 11-year period of January 2010 through December 2020. Antidepressants were classified as OG and NG. The groups were compared in terms of patient demographic characteristics, type of poisoning (accidental/suicidal), clinical findings, supportive and extracorporeal treatments received, and outcomes. FINDINGS/RESULTS: The study included 58 patients (NG, n = 30; OG, n = 28). The median age of the patients was 178 months (range, 13.6-215 months) and 47 patients (81%) were female. Patients admitted for only antidepressant poisoning constituted 13.3% of all poisoning cases (58/436). Of these, 22 cases (37.9%) were accidental and 36 (62.3%) were suicidal. The most common cause of poisoning was amitriptyline (24/28) in the OG group and sertraline (13/30) in the NG group. Neurological symptoms were significantly more common in the OG group (76.2% vs 23.8%), while gastrointestinal involvement was more common in the NG group (82% vs 18%; P = 0.001 and P = 0.026, respectively). Old-generation antidepressant poisoning was associated with more frequent intubation (4 vs 0 patients, P = 0.048) and longer length of PICU stay (median, 1 day [range, 1-8] vs 1 day [range, 1-4], P = 0.019). Rates of therapeutic plasma exchange and intravenous lipid emulsion therapy did not differ ( P = 0.483 and P = 0.229, respectively). IMPLICATIONS/CONCLUSIONS: In poisoned patients, proper evaluation and management of patients requiring PICU admission are vital for favorable patient outcomes.

Diagnostic Dilemma of Lactic Acidosis in an Infant After Liver Transplant: A Case Report.

Thiamine is the cofactor of many enzymes involved in energy metabolism. Patients under total parenteral nutrition are at risk for thiamine deficiency if there is renal thiamine loss or increased thiamine requirements to mitigate systemic diseases. Thiamine deficiency symptoms include seizures, neuropathy, ataxia, peripheral vasodilation, myocardial insufficiency, sudden collapse, and death. In this report, we present an infant liver transplant recipient with progressive lactic acidosis that responded well to thiamine replacement to mitigate a lack of thiamine in total parenteral nutrition.

Extracorporeal Therapies in Children with Acute Liver Failure: A Single-Center Experience.

BACKGROUND: The aim of this study is to determine the indication, timing, and administration of extracorporeal therapies such as total plasma exchange and continuous renal replacement therapy in children with acute liver failure or acute-on-chronic liver failure. METHODS: This study is conducted as a retrospective, single-center study. Between January 2016 and December 2021, pediatric acute liver failure or acute-on-chronic liver failure patients for whom total plasma exchange and/or continuous renal replacement therapy was performed were included in this study. RESULTS: Thirty-four children with acute liver failure or acute-on-chronic liver failure were included during the study period. The children comprised 14 (41.1%) males, and the median age of the patients was 54 months (5-21). Twenty-four patients (70.6%) had pediatric acute liver failure, and 10 patients (29.4%) had acute-on-chronic liver failure. Patients' median model for end-stage liver disease and pediatric end-stage liver disease scores were 24.7/23.5, respectively. Total plasma exchange therapy was performed on all patients whereas continuous renal replacement therapy was performed on 13 patients (38.2%). The median duration of continuous renal replacement therapy was 2.5 days (2-24). The median number of the total plasma exchange sessions was 3 (1-20). The median length of stay in pediatric intensive care unit was 4.5 (2-74) days. Eleven (32.5%) patients had 1 or more improvements in hepatic encephalopathy scores after extracorporeal therapy. Eleven (32.5%) patients died. There was a significant difference between the survivors and non-survivors with respect to levels of albumin, ammonia, pediatric risk of mortality scores, and pre-hepatic encephalopathy scores. Liver transplantation was performed in 4 of 24 pediatric acute liver failure patients, and all of them survived. CONCLUSION: Total plasma exchange and continuous renal replacement therapy are life-saving, and both methods may reduce morbidity and mortality, also bridging to liver transplantation.

Characteristics and timing of mortality in children dying in pediatric intensive care: a 5-year experience.

BACKGROUND: Pediatric intensive care units (PICUs), where children with critical illnesses are treated, require considerable manpower and technological infrastructure in order to keep children alive and free from sequelae. METHODS: In this retrospective comparative cohort study, hospital records of patients aged 1 month to 18 years who died in the study PICU between January 2015 and December 2019 were reviewed. RESULTS: A total of 2,781 critically ill children were admitted to the PICU. The mean±standard deviation age of 254 nonsurvivors was 64.34±69.48 months. The mean PICU length of stay was 17 days (range, 1-205 days), with 40 children dying early (<1 day of PICU admission). The majority of nonsurvivors (83.9%) had comorbid illnesses. Children with early mortality were more likely to have neurological findings (62.5%), hypotension (82.5%), oliguria (47.5%), acidosis (92.5%), coagulopathy (30.0%), and cardiac arrest (45.0%) and less likely to have terminal illnesses (52.5%) and chronic illnesses (75.6%). Children who died early had a higher mean age (81.8 months) and Pediatric Risk of Mortality (PRISM) III score (37). In children who died early, the first three signs during ICU admission were hypoglycemia in 68.5%, neurological symptoms in 43.5%, and acidosis in 78.3%. Sixty-seven patients needed continuous renal replacement therapy, 51 required extracorporeal membrane oxygenation support, and 10 underwent extracorporeal cardiopulmonary resuscitation. CONCLUSIONS: We found that rates of neurological findings, hypotension, oliguria, acidosis, coagulation disorder, and cardiac arrest and PRISM III scores were higher in children who died early compared to those who died later.

Clinical features and outcomes of children admitted to the pediatric intensive care unit due to posterior reversible encephalopathy syndrome.

OBJECTIVE: The aim of this study is to analyze the clinical features, neuroimaging findings and outcomes of the children admitted to our tertiary pediatric intensive care unit (PICU) due to posterior reversible encephalopathy syndrome (PRES). METHODS: This was a retrospective study where the hospital records of children admitted to PICU due to PRES between January 1, 2011 and January 1, 2021 were reviewed. RESULTS: We enrolled 14 patients with a median age of 8 years (IQR 2.2-14.2) to study. Eight (57 %) patients were male. All patients had comorbid illnesses such as hemophagocytic lymphohistiocytosis in 3, Β-cell acute lymphoblastic leukemia in 2, and different diagnosis in other patients as one one. Three patients had cardiac arrest, 9 patients had seizures, 5 patients had SE, 12 patients had altered mental status, 8 patients had hypertensive crisis, 1 patient had visual impairment. Thirteen patients had occipital involvement, 11 had parietal involvement, 4 had temporal involvement, 1 had thalamic involvement, 2 had cerebellar involvement, 1 had involvement of the corpus callosum, 1 had brainstem involvement, 1 had hippocampus involvement and 1 had involvement of the basal ganglia. Fourteen patients had supratentorial involvement while 3 had infratentorial involvement. Electroencephalogram was performed for 7 patients, out of which 6 revealed encephalopathy. Median PICU LOS was 19.5 days (IQR 13.2-49.2, minimum 2 - maximum 84 days). Five patients had neurologic sequelae. Four (28.5 %) patients died and ten patients survived. CONCLUSION: Co-occurence of hypertension and seizures should prompt consideration of PRES and urgent neuroimaging, particularly in patients on immunosuppressants or chemotherapeutics. Hypertension should be addressed aggressively in patients with PRES. Electroencephalographic monitoring should be performed if there is suspicion of SE or nonconvulsive SE. Despite its usually good prognosis, PRES can cause serious morbidity and mortality with delay in diagnosis or treatment.

Colchicine Poisoning Cases in a Pediatric Intensive Care Unit: A Twenty-Year Study.

OBJECTIVES: Colchicine intoxication is rare but potentially fatal. The toxic dose of colchicine is not well established; it has been reported that major toxicity starts after doses of 0.5 mg/kg. We aimed to evaluate the demographic, clinical aspects, treatments, and outcome of colchicine toxicity cases in the pediatric intensive care unit (PICU). METHODS: We collected the data of patients aged between 0 and 18 years, admitted to Ankara University Faculty of Medicine PICU for colchicine poisoning (n = 22), from October 1999 to January 2020, retrospectively. Data extracted from the cases included age, sex, chronic condition, time between intake of drug and admission to PICU, source of drug, amount of drug ingested, other drug intake, symptoms, clinical findings, cardiac involvement, laboratory results, time of stay in PICU, treatment, and outcome. RESULTS: Patients' age ranged from 7 months to 17 years. Median age was 86 months. The most common symptom at time of admission was vomiting, occurring in 13 (59%) of the patients. Two of the patients presented with change in mental status. Time between taking medication and applying to the hospital ranged from half an hour to 4 days. Medication intake of 3 of 22 patients was more than 0.5 mg/kg. One patient whose parents' best estimate of dose ingested was 0.48 mg/kg died because of the development of multiorgan failure. One patient who ingested 0.4 mg/kg of colchicine underwent plasma exchange and recovered without any complications. CONCLUSIONS: Colchicine poisoning has a high risk of mortality, and death can be seen in doses less than a single acute dose of 0.5 mg/kg. These patients need close monitoring because there is always a risk of them to require aggressive support. Prognosis is poor in patients who have rapidly developing hemodynamic failure.

Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation in Children with Liver Dysfunction/Failure.

Regional citrate anticoagulation (RCA) is an option but citrate accumulation is risk and it is a giving up cause for this situation. This retrospective study was conducted in the pediatric intensive care unit (PICU) between May 2019 and April 2021. We investigated 47 patients with liver failure (LF) in our PICU, and RCA during continuous renal replacement therapy (CRRT) was applied to 10 (21.3%) of them. Half of them were male (n: 5/10), their mean age was 104.7 ± 66.20 months. Nine of them needed vasoactive support during follow-up. The most common indication for CRRT was hepatorenal syndrome (40%). There was no significant difference between liver transaminases and liver function tests before and after CRRT (p > 0.05). In terms of citrate toxicity of the patients, there was no significant difference between total calcium/ionized calcium, lactate level, pH and bicarbonate values before and after CRRT (p > 0.05). The mean total CRRT time was 110.2 ± 118.2 h, and the mean circuit lifespan was 43.8 ± 48.7 h; the mean number of circuits was 2.7 ± 2.4. Total Ca/ionized Ca >2.5 was a clinically relevant endpoint, but no patient interrupted dialysis for this cause. There was no complication about RCA. This study did not observe any adverse effects on acid-base status, transaminases, an increase in bilirubin during RCA-CRRT treatment in pediatric patients with LF. Total calcium/ionized calcium ratio, serum lactate level and prothrombin time level should be closely monitored daily in terms of citrate accumulation in this patient group.

The Evaluation of Transported Children to Pediatric Intensive Care Unit: Indications, Problems, and Outcomes.

OBJECTIVE: Critically ill children often require transport to tertiary centers where higher levels of care can be provided. In this study, we aimed to evaluate the reasons for transport, complications that occurred during transport, and the clinical outcomes of the patients transferred to our tertiary pediatric intensive care unit (PICU). METHODS: This retrospective study was conducted in a tertiary pediatric hospital with 250 beds and 20 tertiary PICU beds. RESULTS: During the study period, 108 patients were transferred to our PICU. The mean age was 75.0 ± 70.5 months (range, 1-211 months), and 59 were female. Most patients (82.4%) were transported by land; 17.6% were transported by air ambulance. Fourteen patients were referred for liver transplantation, and 7 patients were referred because of a need for extracorporeal membrane oxygenation support and heart transplantation or left ventricular assist device placement. Two patients were transported by air while on extracorporeal membrane oxygenation. Complications occurred in 25% of patients. CONCLUSION: Vital signs were assesed, and certain critical interventions such as intravenous fluids and respiratory support were provided more frequently during air transport, possibly due to the fact that physicians were always present during air transport. Quality improvement of transport teams and multicenter and nationwide studies on PICU transport are needed.