Mutlu Uysal Yazici

Intracardiac Thrombus in Children: The Fine Equilibrium Between the Risk and the Benefit

The medical records of 16 patients diagnosed as intracardiac thrombus were searched. The size, location and outcome of thrombus together with demographic data of patients were assessed. The median age of the patients was 2.2 years. Six patients were newborn and two patients were infant. The median size of thrombus was 9 mm. The localization was right atrium in seven, right ventricle in five, left ventricle in one, pulmonary artery in one, and superior vena cava in two patients. There was prematurity in five, ciyanotic congenital heart disease in one, blood culture positivity in three, malignancy in four, nephrotic syndrome in one, indwelling catheters in 10, and acquired or genetic thrombophilia in six patients as risk factors. In the treatment, the first choice was tissue plasminogen activator in two patients, heparin infusion in one patient and low molecular weight heparin in remaining 12 patients. In nine patients, therapy included parenteral antimicrobials together with anticoagulants. The result was complete resolution in 15 patients and in one patient thrombus was surgically removed. The median time was 16 (2–70) days for 50% resolution and 26 (3–93) days for complete resolution. There was a statistically significant (P = .027 and r = 0.5) correlation between the size and the complete resolution time. There was no anticoagulant therapy related major complication. In patients with intracardiac thrombus, selection of anticoagulant therapy may decrease the risk of complications. Surgery is rarely required and thrombolytics are not usually necessary for resolution of thrombus.

Seizures in a Pediatric Intensive Care Unit: A Prospective Study.

BACKGROUND The aim of the research is to determine the etiology and clinical features of seizures in critically ill children admitted to a pediatric intensive care unit (PICU). METHODS A total of 203 children were admitted from June 2013 to November 2013; 45 patients were eligible. Age ranged from 2 months to 19 years. Seizures were organized as epileptic or acute symptomatic. Pediatric risk of mortality score III, Glasgow coma scale, risk factors, coexistent diagnosis, medications administered before admission, type and duration of seizures, drugs used, requirement and duration of mechanical ventilation, length of stay and neuroimaging findings were collected as demographic data prospectively. RESULTS The male-female ratio was 0.8. Mean age was 5.4. The most common causes of seizures were acute symptomatic. Most frequent coexistent diagnosis was infectious diseases, and 53.3% had recurrent seizures. Medications were administered to 51.1% of the patients before admission. Seizures were focal in 21 (46.7%), generalized in 11 (24.4%) and 13 (28.9%) had status epilepticus. Intravenous midazolam was first-line therapy in 48.9%. Acute symptomatic seizures were usually new-onset, and duration was shorter. Epileptic seizures tended to be recurrent and were likely to progress to status epilepticus. However, type of seizures did not change severity of the disease. Also, laboratory test results, medications administered before admission, requirement and duration of ventilation, mortality and length of stay were not significant between epileptic/acute symptomatic patients. CONCLUSION Seizures in critically ill children, which may evolve into status epilepticus, is an important condition that requires attention regardless of cause. Intensified educational programs for PICU physicians and international guidelines are necessary for a more efficient approach to children with seizures.

Effects of Hemodialysis on Thiol-Disulphide Homeostasis in Critically Ill Pediatric Patients with Acute Kidney Injury

Aim To evaluate thiol/disulphide homeostasis as a new indicator of oxidative stress in AKI patients and to determine the effect of HD on antioxidant balance and oxidative stress through plasma thiols. Methods This study was performed in patients aged between 12 months and 18 years prospectively who underwent hemodialysis due to AKI and were followed up for a year in a 22-bed tertiary pediatric intensive care unit. 20 patients and 39 controls were included. Results No difference was present between the groups in terms of age and gender. Median values of plasma native thiol, total thiol, and percent thiol were significantly lower in AKI group both before and after dialysis when compared to control group. The median dynamic disulphide values were significantly lower in the AKI group of predialysis compared to the controls. When pre- and postdialysis values were compared, disulphide values were statistically higher after dialysis. When pre- and postdialysis native thiol, dynamic disulphide, total thiol, and percent thiol median values were compared, postdialysis values were significantly higher than the predialysis values. There was a positive correlation between albumin, total thiol, and native thiol values before dialysis in the patient group. Conclusion AKI patients have low levels of thiol species showing the presence of oxidative stress and hemodialysis has a positive effect on thiol/disulphide balance. This new method may be an inexpensive and simple tool suitable for clinical studies and can be used in routine screening as a useful indicator to show oxidative stress.

Clinical impact and efficacy of bedside echocardiography on patient management in pediatric intensive care units (PICUs): A prospective study

Objective: To determine the indication and necessity of echocardiographic assessment and therapeutic interventions in critically ill children. Methods: A total of 140 children, including 75 mechanically ventilated (MV) and 65 spontaneously breathing (SB) children, who were admitted consecutively from March to August 2013 were evaluated prospectively. Data regarding the indication for echocardiography and therapeutic approaches used were documented. For evaluating disease severity, the Pediatric Risk of Mortality Score III (PRISM) was ascertained. The correlation between PRISM score and the requirement of echocardiographic evaluations were analyzed. Results: Patients ages were between 45 days to 18 years. The male-to-female ratio was 1.33. In 35.4% patients who underwent echocardiographic evaluation, no definitive alteration occurred in treatment approach, whereas in the remaining 64.6% patients, decisive or supplemental information was gathered. Echocardiography was indicated in 88% MV children and 46.2% SB children. Echocardiographic evaluation was necessary in MV children and there was a positive correlation between the PRISM score and the requirement of echocardiographic assessment (p<0.001). Conclusion: Echocardiographic evaluation is an invaluable tool especially in MV children and the requirement of echocardiographic assessment increases according to clinical severity. Basic training for intensivists in this procedure is crucial and needs to be improved and supported in critically ill.

Tuberculous Meningitis in The Differential Diagnosis of Cns Infection and the Urgency of Antituberculosis Treatment

Tuberculosis is a chronic necrotizing granulomatous disease caused by Mycobacterium tuberculosis, causes morbidity and mortality worldwide, and affects children as in all age groups. Tuberculous meningitis (TM) is the most severe form of the disease. The pathogenesis of TM is poorly understood and the best management has not been established. We report 17-years old female patient, who was referred from Somalia with a suspected intracranial mass lesion accompanied by poor general condition, reduced consciousness, hypertension and bradycardia, diagnosed as TM after brain biopsy with result of positive PCR and culture for M. tuberculosis. But the patient died after diagnosis of tuberculous meningitis in the last phase. The aim of this case report is to remind that TM must be considered in the differential diagnosis of intracranial infection in patients from endemic areas and the treatment should be initiated rapidly to prevent delayed diagnosis and lethal complications.

RSV Pneumonia in the Pediatric Intensive Care Unit

Özet Amaç: Respiratuar sinsityal virus (RSV); özellikle bebeklerde bronşiolit ve pnömoni gibi yaşamı tehdit eden şiddetli solunum yolu enfeksiyonlarına neden olur. Olguların çoğunda hastalığın kısa sürmesi ve kendiliğinden geçmesine rağmen, özellikle yüksek risk taşıyan çocuklarda ciddi hastalık ve ölüm riski taşımaktadır. Çalışmamızın amacı, yüksek riskli hastaları tanımlamak ve RSV pnömonisinin erken tanı ve tedavisiyle çocuk yoğun bakım ünitelerine olan yatışları ve mortaliteyi azaltmaktır. Bu nedenle özellikle risk grubundaki hastaların belirlenerek profilaksiye alınması, viral veya bakteriyel diğer pnömonilerden korunması için aşılarının ve takiplerinin eksiksiz yapılmasının öneminin bir kez daha hatırlatılmasıdır. Gereç ve Yöntemler: Ankara Çocuk Sağlığı ve Hastalıkları Hematoloji Onkoloji Eğitim Araştırma Hastanesi 14 yataklı 3. Basamak Çocuk Yoğun Bakım Ünitesinde son RSV sezonunda (Kasım-Mart) RSV pnömonisi tanısı alan hastalar çalışmaya dahil edildi. Öykü ve fizik muayene bulgularının yanında akciğer grafi, hemogram ve c-reaktif protein (CRP) sonuçları ile pnömoni tanısı alarak yoğun bakıma yatan hastalara nasal sürüntüden RSV virus izolasyonu yapılarak tanı konuldu. Bulgular: Çalışmanın yapıldığı beş aylık süre içerisinde, toplam oniki RSV’ye bağlı pnömonisi alan hasta izlenmişti. Hastaların onbirinde risk faktörü varken, sadece bir hastada yoktu. Hastaların iki tanesi 35 hafta prematüre iken, diğer hastalar miadında doğmuştu ve hiçbiri palivizumab profilaksisi almamıştı. Daha önce bir kez bronşiolit atağı geçirme öyküsü mevcut olan bir hasta dışında hepsi pnömoni açısından bir ya da daha fazla risk faktörü taşıyordu. Hastaların 9’u (%75) erkek, 3 tanesi kız hasta iken, medyan yaş değeri: 18,5 ay (min: 2 ay, maks: 53 ay) idi. Beş hastanın mekanik ventilasyon ihtiyacı oldu. İki hasta ventilatörden ayrılamadığı için trakeostomi açılarak ev tipi ventilatör ile taburcu edildi. Çalışmaya alınan hastalardan bir hastamız eksitus oldu. Abstract Objective: Respiratory syncytial virus (RSV) is the most common and fatal cause of bronchiolitis and severe pneumonia, especially in infants. Its morbidity and mortality are unpredictably high in critically ill patients. The aim of our study is to identify high-risk patients for early diagnosis and treatment of RSV pneumonia in the pediatric intensive care unit and to reduce hospitalizations and mortality. We want to emphasize the importance of vaccination and followup for the protection of other viral or bacterial pneumonia once again. Material and Methods: We present 12 cases that were diagnosed as RSV pneumonia in our tertiary pediatric intensive care unit. Besides history, physical examination, and chest radiograph findings, patients were diagnosed with laboratory tests, such as complete blood count, c-reactive protein (CRP), and virus isolation with nasal smear samples. Demographic, clinical, and laboratory data were obtained from patients’ medical files. Results: Within 5 months of the study, 12 patients were diagnosed with RSV pneumonia. Risk factors were present in 11. Two of the patients were 35 weeks premature; others were born full-term, and none of them had received palivizumab prophylaxis. Except for a patient with a history of episodes of bronchiolitis, all of the patients had one or more risk factors for pneumonia. Nine of the patients (75%) were male, while 3 were female. Median age was 18.5 months (min: 2; max: 53 months). Five of our patients required mechanical ventilation. Two patients could not be separated from the ventilator; so, tracheostomy was performed and patients were discharged with home ventilation. One of the patients included in the study died. Conclusion: We want to emphasize that RSV, seen especially in infants, is also an important factor in older children; it might be fatal, and pediatric intensive care admission might be necessary. Therefore, Çocuk Yoğun Bakım Ünitesinde RSV Pnömonisi Ganime Ayar1, Şanlıay Şahin1, Mutlu Uysal Yazıcı1, Aslınur Özkaya Parlakay2, Hasan Tezer3 1Ankara Çocuk Sağlığı ve Hastalıkları Hematoloji Onkoloji Eğitim Araştırma Hastanesi, Çocuk Yoğun Bakım Ünitesi, Ankara, Türkiye 2Ankara Çocuk Sağlığı ve Hastalıkları Hematoloji Onkoloji Eğitim Araştırma Hastanesi, Çocuk Enfeksiyon Hastalıkları Kliniği, Ankara, Türkiye 3Gazi Üniversitesi Tıp Fakültesi, Çocuk Enfeksiyon Hastalıkları Kliniği, Ankara, Türkiye Original Investigation / Özgün Araştırma 12