Özden Özgür Horoz

Use of therapeutic plasma exchange in children with thrombocytopenia-associated multiple organ failure in the Turkish thrombocytopenia-associated multiple organ failure network.

Objective: Thrombocytopenia-associated multiple organ failure can lead to high mortality in critically ill children, possibly related to consequences of thrombotic microangiopathy. Plasma exchange therapy may improve thrombotic microangiopathy. The purpose of this observational cohort study is to describe whether there is an association between use of plasma exchange therapy and outcome in the Turkish thrombocytopenia-associated multiple organ failure network. Setting-Interventions: We performed a retrospective cohort analysis in patients with thrombocytopenia-associated multiple organ failure at three different PICUs comparing those who received plasma exchange (+) plus standard therapies with those who did not receive plasma exchange (–) and only received standard therapies. Results: Among 42 of the enrolled patients with thrombocytopenia-associated multiple organ failure, all had a primary or secondary sepsis diagnosis. Fifteen received plasma exchange therapy (PE [+] group) and 27 received standard medical treatment without plasma exchange (PE [–] group). The mean age was 17.69 months (8.24–54.22) in the PE (+) group and 13.46 months (6.47–20.55) in the PE (–) group. Age (p = 0.232), gender (p = 0.206), thrombocyte count (p = 0.09), Organ Failure Index score (p = 0.111), and pediatric logistic organ dysfunction score (p = 0.177) at admission were not statistically different between groups. The overall 28-day mortality was higher in the PE (–) group (70.37%) compared with the PE (+) group (26.67%) (univariate p = 0.006; multivariate controlling for pediatric logistic organ dysfunction, Organ Failure Index, Pediatric Risk of Mortality scores, and neurological failure p = 0.048). Length of stay was increased in the PE (+) group (p = 0.004). Conclusions: The positive association found between use of plasma exchange therapy and improved survival supports the potential of this therapy in Turkish children with thrombocytopenia-associated multiple organ failure. The positive, although less so, associated treatment effect observed after controlling for illness severity provides further rationale for performing a randomized controlled trial in the pediatric Turkish thrombocytopenia-associated multiple organ failure network. Sample size calculations call for a 100-patient trial with a pre hoc interim analysis after enrollment of 50 patients with thrombocytopenia-associated multiple organ failure.

Melatonin status in pediatric intensive care patients with sepsis.

Objective: Considering the potential immunomodulatory role of melatonin and its direct antioxidant activity, disturbances of the melatonin secretion pattern in the septic conditions could be particularly unfavorable. The aim of this study was to evaluate the nocturnal melatonin concentration and total 24-hr excretion of 6-sulfatoxymelatoninsulfate, melatonins major urinary metabolite, in children with sepsis in the pediatric intensive care unit. Design: Prospective observational pilot study. Setting: A pediatric intensive care unit. Patients: Twenty septic and 20 nonseptic children admitted between February 2008 and January 2010. Interventions: None. Measurement and Main Results: Blood and urine samples were obtained from each patient on days 1, 2, 3, 5, and 10. There were no significant differences between the groups concerning age and gender. The median nocturnal melatonin concentrations were not significantly different between septic and nonseptic patients during the study period (p > .05). A subgroup analysis in septic patients showed that the nocturnal melatonin concentrations in nonsurvivors were significantly higher than in survivors, whereas total 6-sulfatoxymelatoninsulfate excretions in nonsurvivors were significantly lower than in survivors (p = .001 and p = .015, respectively). Furthermore, nocturnal melatonin concentrations of septic patients in septic shock state were statistically significantly higher than those of septic patients without septic shock state (p = .002). The 24-hr 6-sulfatoxymelatoninsulfate excretions in septic patients with liver dysfunction were found significantly lower than those in septic patients without liver dysfunction (p = .015). The presence of sedation and mechanical ventilation had no effect on the nocturnal melatonin concentrations in septic patients (p = .953 and p = .922, respectively). Conclusion: The present study shows that, in contradiction to results in adult patients, the nocturnal melatonin concentrations are not decreased in septic pediatric intensive care unit patients despite severe disease. Further investigations are needed to identify whether treatment with melatonin may have beneficial effects in pediatric intensive care unit patients with sepsis/septic shock.

Hashimoto's encephalopathy: four cases and review of literature

Hashimotos encephalopathy is a rare clinically heterogenous condition consisting of encephalopathy, seizures and variable neurological and psychiatric manifestations, accompanied by high titres of serum antithyroid antibodies. We described the clinical and laboratory findings of four children (aged 8–17 years) with Hashimotos encephalopathy. The clinical features of three patients at presentation included refractory epilepsy, and confusion, and one patient presented with behavioral and cognitive changes. During their presentation, two of them were in euthyroid, and the others were in hypothyroid status. All patients manifested increased antithyroid antibodies. Two patients improved with steroid treatment. The others responded to plasmapheresis instead of corticosteroid treatment. Physicians’ awareness of this complication is of great importance because most patients respond dramatically to the treatment.

Use of nocturnal melatonin concentration and urinary 6-sulfatoxymelatonin excretion to evaluate melatonin status in children with severe sepsis.

Abstract The aim of this study was to evaluate whether nocturnal melatonin concentration (NMC) and urinary 6-sulphatoxymelatonin (aMT6s) excretion can predict melatonin status in patients with severe sepsis in the pediatric intensive care unit (PICU). Blood samples for the determination of NMC were obtained from each patient at 3 a.m. Urine samples for the determination of aMT6s excretion were obtained from each patient at 12 h intervals. We obtained 89 blood and 178 urine samples from 23 septic patients, and 52 blood and 104 urine samples from 13 non-septic patients. The NMC of septic patients in a state of septic shock was significantly higher than that of septic patients not in septic shock (p=0.017) and those of non-septic patients (p=0.019). In contrast, there was no significant difference for nocturnal (NaMT6s) and total aMT6s (TaMT6s) excretion between septic patients with and without septic shock and non-septic patients (p>0.05). The NMC was significantly higher in septic patients in shock with and without hepatic dysfunction (HD) than in non-septic patients (p=0.004 and p=0.024, respectively). NaMT6s and TaMT6s excretion was significantly lower in septic patients with HD than in septic patient without HD (p=0.040 and p=0.029, for NaMT6s and TaMT6s, respectively). Our results showed that an elevated NMC may not reflect an increased MT production in septic patients in septic shock. It seems that, to evaluate the melatonin status of septic PICU patients, it is necessary to collect both serum and urine samples.

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.

Tyrosinemia type 1 and irreversible neurologic crisis after one month discontinuation of nitisone

Tyrosinemia type I is an autosomal recessively inherited metabolic disease of tyrosine metabolism due to the deficiency of fumarylacetoacetate hydrolase. Clinical manifestations include hepatic failure, cirrhosis, hepatocellular carcinoma, renal fanconi syndrome, and neurologic crisis. With the introduction of 2-(2-nitro-4-trifluoro-methylbenzyol)-1,3 cyclohexanedione treatment the prognosis improved with reduced rate of complications. “Neurologic crisis” of tyrosinemia type I is a rare complication seen after discontinuation of treatment characterized with anorexia, vomiting, and hyponatremia in the initial phase continuing with paresthesia and paralysis of the extremities and the diaphragm. Here, we report a tyrosinemia type I patient who admitted to the hospital with nonspecific symptoms such as vomiting, anorexia, weakness, and restlessness only after one month discontinuation of nitisone and diagnosed as neurological crisis.

Fatal Agranulocytosis and Fournier’s Gangrene due to the Use of Metamizole

To the Editor:Metamizole Na (Novalgin®) is commonly used as an antipyretic, analgesic, and spasmolytic agent. There are reports of agranulocytosis in the literature even after the intake of a single dose of metamizole [1]. The aim of our case presentation is to draw attention to this severe side-effect of metamizole. A 12-y-old adolescent boy was referred for fever, diarhea and abdominal pain. History revealed that he had took a total dose of 8 gmetamizole 2 wk before. On physical examination, the patient was hypotensive and tachycardic, capillary refilling time was 4 s; abdomen was defensive, there were hyperemic areas under the scrotum and the anal region. On blood analyses; hemoglobin: 11 g/dL, platelets 43.000/mm, white blood cell 1700/mm with absolute neutrophil count (0.5 10/μL), creatinine: 2.3 mg/dL, procalcitonin: 89 ng/mL were found. The lactate level was 8 mEq/L. Viral serologies and anti-HIV antibody were negative and immunglobulin levels were within normal range. In total, 40 mL/kg fluid, broad-spectrum antibiotic therapy, vasoactive inotropes and granulocyte colony-stimulating factor (G-CSF) therapy was administered with a diagnosis of septic shock. A laparotomy was applied due to preliminary diagnosis of acute abdomen. During surgery the retroperitoneal area was predominantly edematous, the scrotumwas enlarged and tender along with palpable crepitations and there were multiple necrotic and gangrenous patches with efflux all over. Fournier’s gangrene was considered and emergency debridement was planned; however, because of the the hemodynamic instability, debridement could not be implemented. Venoarterial ECMOwas applied because of the resistant septic shock. However patient arrested at the eighth hour of admission. The wound swab, blood and peritoneal fluid culture identified Pseudomonas aeruginosa. The post-operative biopsy was concluded in agreement with Fournier’s gangrene (Fig. 1). The mechanism of metamizole-induced agranulocytosis is thought to be idiosyncratic via immune-mediated mechanisms [2, 3]. Fournier’s gangrene is an aggressive form of infective necrotizing fasciitis [4]. Winkler et al. reported agranulocytosis and Fournier’s gangrene in a patient associated with dypirone use. They performed repeated debridement procedures and applied GM-CSF for treatment [5]. In conclusion, we present an adolescent who was referred to the hospital with metamizole induced agranulocytosis, septic shock and Fournier’s gangrene which were resistant to intensive therapies including ECMO. Thus to conclude, this rapidly progressive septic shock and fatal clinical course in an immunocompetent adolescent is very important to show the severity of dipyroneassociated agranulocytosis.

Konjenital nefrotik sendromlu bir infantta periton diyalizine bağlı olarak görülen nadir bir komplikasyon olarak şiloz asit

Şiloz asit; periton diyalizi yapilan hastalarda nadir gorulen fakat onemli bir non-enfeksiyoz komplikasyondur. Konjenial nefrotik sendromlu 1,5 aylik erkek hasta genel durumunda kotulesme, diffuz odematoz gorunum ve solunum sikintisi nedeni ile cocuk yogun bakim unitesine kabul edildi. Yatisinin ucuncu gununde periton diyaliz kateteri takilarak periton diyalizi uygulanmaya baslandi. Periton diyaliz kateteri takildiktan bes gun sonra (yatisinin sekizinci gununde) diyaliz sivisi sut gorunumu almaya basladi. Sut gorunumundeki sivinin biyokimyasal analizi siloz asit karakteri gosteriyordu: trigliserit 468 mg/dl. Şiloz asit kisa zincirli yag asitlerinden zengin dusuk lipidli diyet ve somatostatin analogu (octreotid) infuzyonu ile tedavinin 5. gununde duzeldi ve hasta tedavinin devami icin pediatri servisine transfer edildi.

Urolithiasis Frequency and Risk Factors in Home Ventilated Patients with Tracheostomy

©Telif Hakkı 2017 Çocuk Acil Tıp ve Yoğun Bakım Derneği Çocuk Acil ve Yoğun Bakım Dergisi, Galenos Yayınevi tarafından basılmıştır. Yazışma Adresi/Address for Correspondence: Dr. İlknur Tolunay, Çukurova Üniversitesi Tıp Fakültesi, Çocuk Yoğun Bakım Bilim Dalı, Adana, Türkiye E-posta: ilknurtolunay@gmail.com ORCID ID: orcid.org/0000-0002-3454-8483 Geliş Tarihi/Received: 30.07.2017 Kabul Tarihi/Accepted: 14.09.2017 Giriş: Bu çalışmada, ev tipi ventilatör ile izlenen trakeostomili hastalarda ürolitiazis sıklığı ve risk faktörlerinin değerlendirilmesi amaçlanmıştır. Yöntemler: Ocak 2014 ve Aralık 2015 tarihleri arasında çocuk yoğun bakım ünitemize yatırılan ve ev tipi ventilatörü olan trakeostomili 30 hasta geriye dönük olarak değerlendirilmiştir. Hastalara ait yaş, cinsiyet, altta yatan hastalık, kullanmakta olduğu ilaçlar, beslenme şekli, beslenme ürünü, kan biyokimyası, parathormon, 25(OH) vitamin D düzeyi, spot idrarda kalsiyum/kreatin, üriner sistem ultrasonografisi bilgileri hastaların arşiv dosyaları ve bilgisayar sisteminden elde edilmiştir. Bulgular: Hastaların %30’u (9/30) kız, %70’i (21/30) erkek olup yaş ortanca 70 ay (15-197 ay) idi. Motor fonksiyon sınıflama sistemine göre hastaların %33,3’ü (10/30) skor 4, %66,7’si (20/30) skor 5 olup tamamı immobil hastalar idi. Üriner sistem ultrasonografisi ile hastaların %30’unda (9/30) üst üriner sistem taşı saptandı. Hastaların %56,7’sinde (17/30) spot idrar kalsiyum/kreatin 0,21’in üzerinde bulundu. Yaşa göre spot idrar kalsiyum/kreatin hastaların %66,6’sında (20/30) yüksek saptandı. Hastaların günlük kalsiyum alımı 541±182 (336-1200) mg/gün; vitamin D alımı 25,9±10,6 (7,8-51,4) μg/gün idi. Hastaların tamamında kan kalsiyum düzeyi normal sınırlarda (8,5-10,5 mg/dL) olup kan 25(OH) vitamin D düzeyi 8 hastada >30 ng/mL, 13 hastada 20-30 ng/mL ve 9 hastada <20 ng/mL idi. Sonuç: Ev tipi ventilatör ile izlenen trakeostomili hastalarda immobilizasyon ürolitiazis açısından önemli bir risk faktörü olup bu hastaların eşlik eden metabolik bozukluklar açısından düzenli olarak takip edilmesi gerekmektedir. Anahtar Kelimeler: Çocuk, immobilizasyon, ürolitiazis, ev tipi ventilatör hastas

A Rare Diagnosis in an Infant with Upper Airway Obstruction: Lymphangioma

89 ©Telif Hakkı 2017 Çocuk Acil Tıp ve Yoğun Bakım Derneği Çocuk Acil ve Yoğun Bakım Dergisi, Galenos Yayınevi tarafından basılmıştır. Yazışma Adresi/Address for Correspondence: Dr. Nagehan Aslan, Çukurova Üniversitesi Tıp Fakültesi, Çocuk Yoğun Bakım Bilim Dalı, Adana, Türkiye Tel.: +90 322 338 33 77 E-posta: nagehan_aslan@hotmail.com ORCID ID: orcid.org/0000-0002-6140-8873 Geliş Tarihi/Received: 20.01.2017 Kabul Tarihi/Accepted: 03.03.2017 Giriş