Oguz Dursun

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.

Findings of the International Nosocomial Infection Control Consortium (INICC), Part I: Effectiveness of a Multidimensional Infection Control Approach on Catheter-Associated Urinary Tract Infection Rates in Pediatric Intensive Care Units of 6 Developing Countries

DESIGN A before-after prospective surveillance study to assess the impact of a multidimensional infection control approach for the reduction of catheter-associated urinary tract infection (CAUTI) rates. SETTING Pediatric intensive care units (PICUs) of hospital members of the International Nosocomial Infection Control Consortium (INICC) from 10 cities of the following 6 developing countries: Colombia, El Salvador, India, Mexico, Philippines, and Turkey. PATIENTS PICU inpatients. METHODS We performed a prospective active surveillance to determine rates of CAUTI among 3,877 patients hospitalized in 10 PICUs for a total of 27,345 bed-days. The study was divided into a baseline period (phase 1) and an intervention period (phase 2). In phase 1, surveillance was performed without the implementation of the multidimensional approach. In phase 2, we implemented a multidimensional infection control approach that included outcome surveillance, process surveillance, feedback on CAUTI rates, feedback on performance, education, and a bundle of preventive measures. The rates of CAUTI obtained in phase 1 were compared with the rates obtained in phase 2, after interventions were implemented. RESULTS During the study period, we recorded 8,513 urinary catheter (UC) days, including 1,513 UC-days in phase 1 and 7,000 UC-days in phase 2. In phase 1, the CAUTI rate was 5.9 cases per 1,000 UC-days, and in phase 2, after implementing the multidimensional infection control approach for CAUTI prevention, the rate of CAUTI decreased to 2.6 cases per 1,000 UC-days (relative risk, 0.43 [95% confidence interval, 0.21-1.0]), indicating a rate reduction of 57%. CONCLUSIONS Our findings demonstrated that implementing a multidimensional infection control approach is associated with a significant reduction in the CAUTI rate of PICUs in developing countries.

Critically ill children with pandemic influenza (H1N1) in pediatric intensive care units in Turkey.

Objectives: To outline the epidemiologic features, clinical presentation, clinical courses, and outcomes in critically ill children with pandemic influenza in pediatric intensive care units. Design: Retrospective, observational, multicenter study. Setting: Thirteen tertiary pediatric intensive care units in Turkey. Patients: Eighty-three children with confirmed infection attributable to pandemic influenza detected by reverse-transcriptase polymerase chain reaction assay between November 1 and December 31, 2009 who were admitted to critical care units. Interventions: None. Measurements and Main Results: During a 2-month period, 532 children were hospitalized with pandemic influenza and 83 (15.6%) needed critical care. For the 83 patients requiring critical care, the median age was 42 (range, 2–204) months, with 24 (28.9%) and 48 (57.8%) of patients younger than 2 and 5 yrs, respectively. Twenty (24.1%) patients had no underlying illness, but 63 (75.9%) children had an underlying chronic illness. Indications for admission to the pediatric intensive care unit were respiratory failure in 66 (79.5%), neurologic deterioration in six (7.2%), and gastrointestinal symptoms in five (6.0%) patients. Acute lung injury was diagnosed in 23 (27.7%), acute respiratory distress syndrome was diagnosed in 34 (41%), and 51 (61.4%) patients were mechanically ventilated. Oseltamivir was used in 80 (96%) patients. The mortality rate for children with pandemic influenza 2009 was 30.1% compared to an overall mortality rate of 13.7% (p = .0016) among pediatric intensive care unit patients without pandemic influenza during the study period. Also, the mortality rate was 31.7% in patients with comorbidities and 25.0% in previously healthy children (p = .567). The cause of death was primary pandemic influenza infection in 16 (64%), nosocomial infection in four (16%), and primary disease progression in five (20%) patients. The odds ratio for respiratory failure was 14.7 (95% confidence interval, 1.85–111.11), and odds ratio for mechanical ventilation was 27.7 (95% confidence interval, 0.003–200). Conclusions: Severe disease and high mortality rates were seen in children with pandemic influenza. Death attributable to pandemic influenza occurred in all age groups of children with or without underlying illness. Multiple organ dysfunction syndrome is associated with increased mortality, and death is frequently secondary to severe lung infection caused by pandemic influenza.

Early and long-term outcome after tracheostomy in children

Background:  Tracheostomy has become an increasingly important issue for children discharged with primary or secondary respiratory problems. Despite the known advantages, considerable controversy remains regarding the appropriate indications, timing, and results of tracheostomy, in the context of home care. The aims of this study were to retrospectively evaluate our experience with tracheostomy and to consider problems related to this procedure, both in the hospital and after discharge.

Surgical site infection rates in 16 cities in Turkey: findings of the International Nosocomial Infection Control Consortium (INICC)

BACKGROUND Surgical site infections (SSIs) are a threat to patient safety; however, there were no available data on SSI rates stratified by surgical procedure (SP) in Turkey. METHODS Between January 2005 and December 2011, a cohort prospective surveillance study on SSIs was conducted by the International Nosocomial Infection Control Consortium (INICC) in 20 hospitals in 16 Turkish cities. Data from hospitalized patients were registered using the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) methods and definitions for SSIs. Surgical procedures (SPs) were classified into 22 types according to International Classification of Diseases, Ninth Revision criteria. RESULTS We recorded 1879 SSIs, associated with 41,563 SPs (4.3%; 95% confidence interval, 4.3-4.7). Among the results, the SSI rate per type of SP compared with rates reported by the INICC and CDC NHSN were 11.9% for ventricular shunt (vs 12.9% vs 5.6%); 5.3% for craniotomy (vs 4.4% vs 2.6%); 4.9% for coronary bypass with chest and donor incision (vs 4.5 vs 2.9); 3.5% for hip prosthesis (vs 2.6% vs 1.3%), and 3.0% for cesarean section (vs 0.7% vs 1.8%). CONCLUSIONS In most of the 22 types of SP analyzed, our SSI rates were higher than the CDC NHSN rates and similar to the INICC rates. This study advances the knowledge of SSI epidemiology in Turkey, allowing the implementation of targeted interventions.

Impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach, over 8 years, in 11 cities of Turkey

Aims: To evaluate the effectiveness of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach in Turkey and analyse predictors of poor hand hygiene compliance. Design: An observational, prospective, interventional, before-and-after study was conducted from August 2003 to August 2011 in 12 intensive care units (ICU) of 12 hospitals in 11 cities. The study was divided into a baseline and a follow-up period and included random 30-minute observations for hand hygiene compliance in ICU. The hand hygiene approach included administrative support, supplies availability, education and training, reminders in the workplace, process surveillance, and performance feedback. Results: We observed 21,145 opportunities for hand hygiene. Overall hand hygiene compliance increased from 28.8% to 91% (95% CI 87.6–93.0, p 0.0001). Multivariate and univariate analyses showed that several variables were significantly associated with poor hand hygiene compliance: males vs. females (39% vs. 48%; 95% CI 0.79–0.84, p 0.0001), ancillary staff vs. physicians (35% vs. 46%, 95% CI 0.73–0.78, p 0.0001), and adult vs. pediatric ICUs (42% vs. 74%, 95% CI 0.54–0.60, p 0.0001). Conclusions: Adherence to hand hygiene was significantly increased with the INICC Hand Hygiene Approach. Specific programmes should be directed to improve hand hygiene in variables found to be predictors of poor hand hygiene compliance.

Severe lactic acidosis and nephrolithiasis in an infant--etiology?: type 1 glycogen storage disease (GSD).

A 4.5-month-old girl was admitted to the pediatric emergency room with dyspnea and tachypnea. Two weeks prior to admission the patient presented to a local hospital with restlessness and was diagnosed with a urinary tract infection; she later developed gastroenteritis. She was feeding with breast milk only. No history of increased susceptibility to infections was described. Her brother died because of sepsis and metabolic acidosis at the age of three months. There was also consanginuity between the parents. She exhibited Kussmaul breathing with a respiratory rate of 60/min, and tachycardia (176/min) without fever or any finding of heart failure. Height, weight and blood pressure percentiles were in the normal ranges. Marked hepatosplenomegaly was detected on physical examination. The eye examination was normal. Laboratory studies revealed blood pH of 7.05, pCO2 9.6 mm Hg, bicarbonate 2.4 mmol/L, base excess −25.1 mmol/L, sodium 143 mmol/L, potassium 3.9 mmol/L, chloride 94 mmol/L, anion gap 50.5 mmol/L, blood urea nitrogen 15 mg/dL, serum creatinine 0.44 mg/dL, total protein 4.6 g/dL and albumin 3.0 g/dL. Serum had lipemic appearance with a triglyceride level of 1988 mg/dL and cholesterol of 296 mg/dL, HDL 68 mg/dL; SGOT 570 U/L (0–50), SGPT 200 U/L (0–40), total bilirubin 0.15 mg/dL, calcium 9.7 mg/ dL, phosphorus 4.3 mg/dL, uric acid 17.9 mg/dL, ammonia 200 μg/dL, lactic acid 17.3 mmol/L (0.5–2.2), initial blood glucose 63 mg/dL (while hypoglycemia levels of 22 and 35 mg/dL glucose values were obtained during hospitalization period), hemoglobin 10.2 g/dl, WBC 12,200/mm with 56% lymphocyte, thrombocyte count 733,000 mm (control 133,000). Urine pH was 6, specific gravity 1.030; glucose, reducing substances and ketone bodies were negative. Urinary system ultrasonography demonstrated enlarged (80–81 mm) kidneys with normal echogenity and hyperdense areas of 7 mm diameter on left inferior region, 3 mm on middle calicea and 5 mm on right middle calicea; liver 115 mm, spleen 91 mm (Fig. 1). During follow-up she passed a stone, which revealed Weddellite (CaC2O4. 2.25 H20) upon infrared spectroscopy analysis. Amino acid/acylcarnitine profile tests by tandem mass spectrometry were found to be normal.

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.

The effectiveness of environmental strategies on noise reduction in a pediatric intensive care unit: Creation of single-patient bedrooms and reducing noise sources

PURPOSE Noise is a substantial problem for both patients and healthcare workers in hospitals. This study aimed to determine the effectiveness of environmental strategies (creating single-patient rooms and reducing noise sources) in noise reduction in a pediatric intensive care unit. DESIGN AND METHODS Noise measurement in the unit was conducted in two phases. In the first phase, measurements aimed at determining the units present level of noise were performed over 4 weeks in December 2013. During the month following the first measurement phase, the intensive care unit (ICU) was moved to a new location and noise-reducing strategies were implemented. The second phase, in May 2014, measured noise levels in the newly constructed environment. RESULTS The noise levels before and after environmental changes were statistically significant at 72.6 dB-A and 56 dB-A, respectively (p < .05). PRACTICE IMPLICATIONS Single-patient rooms and noise-reducing strategies can be effective in controlling environmental noise in the ICU.

Extrapontine Myelinolysis in an 18-Month-Old Boy With Diabetic Ketoacidosis Case Report and Literature Review

Extrapontine myelinolysis is characterized by symmetric demyelination following rapid shifts in serum osmolality in the supratentorial compartment. Extrapontine myelinolysis in children is rare compared to adults. The most common underlying pathophysiology is rapid correction of hyponatremia. Only 2 cases were published after diabetic ketoacidosis without electrolyte imbalance in the English literature. This study presents an unusual and possibly the youngest case of extrapontine myelinolysis that occurred in the setting of diabetic ketoacidosis and complicated cerebral edema without electrolyte imbalance, along with a review of the literature.