Benan Bayrakci

Hyperferritinemia in the critically ill child with secondary hemophagocytic lymphohistiocytosis/sepsis/multiple organ dysfunction syndrome/macrophage activation syndrome: what is the treatment?

IntroductionHyperferritinemia is associated with increased mortality in pediatric sepsis, multiple organ dysfunction syndrome (MODS), and critical illness. The International Histiocyte Society has recommended that children with hyperferritinemia and secondary hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS) should be treated with the same immunosuppressant/cytotoxic therapies used to treat primary HLH. We hypothesized that patients with hyperferritinemia associated secondary HLH/sepsis/MODS/MAS can be successfully treated with a less immunosuppressant approach than is recommended for primary HLH.MethodsWe conducted a multi-center cohort study of children in Turkish Pediatric Intensive Care units with hyperferritinemia associated secondary HLH/sepsis/MODS/MAS treated with less immunosuppression (plasma exchange and intravenous immunoglobulin or methyl prednisolone) or with the primary HLH protocol (plasma exchange and dexamethasone or cyclosporine A and/or etoposide). The primary outcome assessed was hospital survival.ResultsTwenty-three children with hyperferritinemia and secondary HLH/sepsis/MODS/MAS were enrolled (median ferritin = 6341 μg/dL, median number of organ failures = 5). Univariate and multivariate analyses demonstrated that use of plasma exchange and methyl prednisolone or intravenous immunoglobulin (n = 17, survival 100%) was associated with improved survival compared to plasma exchange and dexamethasone and/or cyclosporine and/or etoposide (n = 6, survival 50%) (P = 0.002).ConclusionsChildren with hyperferritinemia and secondary HLH/sepsis/MODS/MAS can be successfully treated with plasma exchange, intravenous immunoglobulin, and methylprednisone. Randomized trials are required to evaluate if the HLH-94 protocol is helpful or harmful compared to this less immune suppressive and cytotoxic approach in this specific population.

Acute cardiac effects of carbon monoxide poisoning in children

Objective Carbon monoxide (CO)-induced cardiotoxicity has been investigated infrequently in children and reports of its cardiovascular effects are limited to isolated case reports. Our aims were to describe acute cardiac effects and associated factors with myocardial injury in children with CO poisoning. Methods We reviewed the medical records of children below 17 years of age who were diagnosed with CO poisoning at pediatric emergency department between July 2004 and June 2007. Patients who had carboxyhemoglobin level at least 10% were included. Myocardial injury was defined as elevated cardiac biomarkers (creatine kinase-MB or troponin-t). Carboxyhemoglobin level, electrocardiogram (ECG) findings, cardiac biomarkers, and echocardiograph results were recorded for each patient. Results Cardiac biomarkers were drawn in 107 patients, of which 16 patients (15%) had cardiac biomarkers confirmed diagnosis of myocardial injury. Sinus tachycardia was present in 32% of patients on baseline ECG. None of the patients had ischemic changes on ECG. Echocardiograph was performed in 27 patients (25% of patients with biomarkers drawn), of which nine patients had low ejection fraction and abnormal left ventricular function. Determinators of myocardial injury included a Glasgow Coma Scale (GCS) score ≤14 and hypotension (for GCS score ≤14 and hypotension, relative risk: 90 and 95% confidence interval: 9.9–813. Conclusion Myocardial injury may exist in children with CO poisoning without abnormal ECG findings. GCS score ≤14 and hypotension were associate factors with myocardial injury.

The glycocalyx and Trauma: A Review

ABSTRACT In the United States trauma is the leading cause of mortality among those under the age of 45, claiming approximately 192,000 lives each year. Significant personal disability, lost productivity, and long-term healthcare needs are common and contribute 580 billion dollars in economic impact each year. Improving resuscitation strategies and the early acute care of trauma patients has the potential to reduce the pathological sequelae of combined exuberant inflammation and immune suppression that can co-exist, or occur temporally, and adversely affect outcomes. The endothelial and epithelial glycocalyx has emerged as an important participant in both inflammation and immunomodulation. Constituents of the glycocalyx have been used as biomarkers of injury severity and have the potential to be target(s) for therapeutic interventions aimed at immune modulation. In this review, we provide a contemporary understanding of the physiologic structure and function of the glycocalyx and its role in traumatic injury with a particular emphasis on lung injury.

Oxygenation index for extracorporeal membrane oxygenation: is there predictive significance?

Although extracorporeal membrane oxygenation (ECMO) is known to improve survival in neonates with respiratory failure, there has been a significant decrease in the use of ECMO in recent years. Alternative modalities such as high-frequency oscillatory ventilation (HFOV), inhaled nitric oxide (iNO), and surfactant therapy are associated with this decline. The criteria for the initiation of ECMO, developed about 20 years ago, are likely no longer relevant. We examined the predictive significance of the oxygenation index (OI) as a patient entry criterion for ECMO use. We sought a critical OI level predicting death or chronic lung disease (CLD) with and without ECMO use. We also examined whether patients with certain OIs are more likely to have worse outcomes. One hundred and seventy-four term-newborn admissions between 1995 and 2000 requiring mechanical ventilation were enrolled in the study. Receiver operating curve analysis was performed to find a cutoff value of OI for ECMO initiation. Mortality rates and CLD probability were compared to the worst OIs. Our 6-year ECMO administration experience showed that an OI of 33.2 is a suitable cutoff value for ECMO initiation with high sensitivity and specificity as a predictive criterion. The critical OI value associated with the CLD risk when ECMO is not used is in the 40s. OI is a good predictor of CLD; the probability of CLD increases with higher OIs. Our data support the trend toward the use of new interventions over ECMO, especially for patients with OI scores of less than 33.2. Only when the probability of ventilator-associated lung injury becomes significant is it better to consider ECMO than conventional modalities.

Successful Treatment of Propafenone, Digoxin and Warfarin Overdosage with Plasma Exchange Therapy and Rifampicin

We report here the successful treatment of a 16-year-old female who ingested 20 tablets of digoxin each containing 0.25mg (total dose ingested equivalent to 0.1 mg/kg), 32 tablets of warfarin each containing 5mg (equivalent to 3.2 mg/kg), and approximately 15 tablets of propafenone each containing 300mg (equivalent to 90 mg/kg). The patient developed hypotension and sinus bradycardia necessitating external cardiac pacing 17 hours after drug ingestion. In addition to gastric lavage, activated charcoal, blood alkalinisation, administration of vitamin K and temporary cardiac pacing, the authors performed plasma exchange for drug removal and administered rifampicin in order to increase the metabolism of digoxin, propafenone and warfarin. The patient was discharged without any sequelae. Plasma exchange may be lifesaving in drug ingestions where there is a low volume of distribution and high plasma protein binding. Rifampicin, an inducer of cytochrome p450, may be used in intoxications for elimination of drugs with inactive metabolites.

Case Reports of Successful Therapeutic Plasma Exchange in Severe Amitriptyline Poisoning

Abstract:  Severe amitriptyline toxicity may cause coma, hypotension, convulsions, supraventricular and ventricular arrhythmias, metabolic/respiratory acidosis and cardiac arrest. Management with gastric lavage, activated charcoal, alkalinization with sodium bicarbonate and supportive care with mechanical ventilation, antiarrhythmics and anticonvulsants if required, is the common approach. Herein, we report successful treatment of severe amitriptyline poisoning in three cases by plasma exchange in addition to the above supportive measures. Plasma exchange may have a beneficial role in lethal doses of amitriptyline ingestion because of the high plasma protein binding property of amitriptyline.

Preservation of organs from brain dead donors with hyperbaric oxygen

Abstract:  Hyperbaric oxygen therapy is a technology that involves oxygen treatment at supra‐atmospheric pressures in high concentrations, generating increased levels of physically dissolved oxygen in blood plasma. This form of transported oxygen, compared with oxygen chemically bound to hemoglobin, is able to enter tissues with minimal or almost no blood flow. Experimental studies have suggested that hyperoxemia provided by hyperbaric oxygen may be beneficial in the treatment of reperfusion injury. Organs procured from brain‐dead hyperbaric oxygen‐treated donors may have less cellular injury from ischemia, reperfusion, and no‐reflow phenomenon, thus yielding organs in an optimized state for transplantation. This current report consists of a gratifying experience about hyperbaric oxygen treatment playing a possible role on preservation of donor organs in vivo. In the siblings reported here, improved organ function prior to transplantation and the successful organ functioning after transplantation suggests the possible beneficial effect of hyperbaric oxygen treatment on the ischemic insult generated from brain death and repetitive cardiac arrests. Hyperbaric oxygen seems to be a promising candidate as a bridge to transplantation, keeping the donated organs viable until the harvesting procedure can take place for potential brain dead donors. This experience may lead to further investigations on hyperbaric oxygen’s role in donor organ preservation.

Arteriovenous fistula: a cause of torticollis

Torticollis is a symptom that may represent a wide spectrum of disorders ranging from a simple etiology to a life-threatening pathology. Pediatricians have to suspect central nervous system abnormalities whenever faced with torticollis. The authors report an arteriovenous fistula at the craniocervical junction in a patient presenting with torticollis.

Successful treatment of severe myasthenia gravis developed after allogeneic hematopoietic stem cell transplantation with plasma exchange and rituximab

Myasthenia gravis is among the rare complications after allogeneic hematopoietic stem cell transplantation and is usually associated with chronic GVHD. Herein, we report a 2‐year and 10 months of age female with Griscelli syndrome, who developed severe myasthenia gravis at post‐transplant +22nd month and required respiratory support with mechanical ventilation. She was unresponsive to cyclosporine A, methylprednisolone, intravenous immunoglobulin, and mycophenolate mofetil and the symptoms could only be controlled after plasma exchange and subsequent use of rituximab, in addition to cyclosporine A and mycophenolate mofetil maintenance. She is currently asymptomatic on the 6th month of follow‐up. Pediatr Blood Cancer 2014;61:928–930.

Admission time and mortality rates

ObjectiveThe objective of this study was to determine whether there there are any associations between time of admission and mortality rates in the pediatric intensive care unit.MethodsWe analyzed retrospectively 210 consecutive admissions to the PICU from November 2005 to April 2006 for patients aged 1 mth to 18 yr.ResultsThere was no significant difference for overall mortality rates between weekend and weekday admissions (12.2% vs 17.4%, p=0.245), and daytime and evening admissions (11.3 % vs 15.4%, p=0.254). There was also no significant difference between different admission times for within 24 hours, 48 hours and 72 hours mortality rates.ConclusionsIn respect of the overall mortality rates, it can be said that in a closed system PICU management under the control of a pediatric intensivist there is no association between time of admission and mortality rates.