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Therapeutic plasma exchange has been used as a primary or supportive treatment in many diseases in recent years and has achieved satisfactory results in lots of diseases in children. Therapeutic plasma exchange procedure is changing plasma component of a patient's blood with the new plasma as a replacement solution. The aim of this study is to share our experience of therapeutic plasma exchange on varying indications in critically ill children who were accepted to our pediatric intensive care unit.We conducted this study between December 2010 and February 2020, retrospectively. Patients' data such as age, sex, indication, number of sessions, vascular access route, and type of replacement fluid used were obtained from medical records. Indications for therapeutic plasma exchange were classified according to the 2019 American Society for Apheresis categorization. The patient's follow-up, clinical courses, therapeutic plasma exchange season count, complications, and outcome were evaluated according to each indications and their overall condition.This study included a total of the 84 patients who underwent therapeutic plasma exchange, and their median (minimum-maximum) ages were 7.07 years (0.2-18), 57.1% were male (n = 48) and 42.9% were female (n = 36). A total of 463 sessions of therapeutic plasma exchange were performed in 84 patients. The most common indication was thrombocytopenia-associated multi-organ failure with sepsis (40.4%, n = 34) followed by liver failure/hepatic encephalopathy (28.5%, n = 24) and autoimmune encephalitis (9.5%, n = 8), and according to The American Society for Apheresis 2019 category, patients distributions were as follows: 15.4% of the patients were placed in category 1 (n = 13), 5.9% in category 2 (n = 5), 77.3% in category 3 (n = 65), and 1.1% in category 4 (n = 1). Therapeutic plasma exchange was combined to extracorporeal membrane oxygenation in 10 patients (11.9%) and continuous renal replacement therapies in 39 (46.4%) patients. Finally, the survival rate was 50% in all patients, and the lowest survival rate was 41.5% (n = 27) in category 3 group.Therapeutic plasma exchange is enlarging to varying indications and showing to be more effective on a lot of disorders in children. Also, it is available in pediatric age groups and in different states like combined with other extracorporeal therapies.

Purpose: The clinical applications of intravenous immunoglobulin (IVIG) therapy in critically ill children are increasing. Here we share our single-center experience with the use of IVIG in the pediatric intensive care unit (PICU). Methods: This retrospective study included patients treated with at least one dose of IVIG in the PICU between November 2019 and April 2022. Results: A total of 68 patients (44 males) were included in the study. The most common indications for IVIG were rheumatologic (43%), infectious (34%), and neurological diseases (14.5%). Twenty-one patients (30%) died. The frequency of chronic disease was 28% among survivors and 76% among non-survivors (p=0.0001). The indication for IVIG was septic shock in 71% of non-survivors (p=0.0001) and multisystem inflammatory syndrome in children in 57% of survivors (p=0.0001). Non-surviving patients had lower median IVIG dose per actual body weight (0.5 vs. 1 g/kg, p=0.02) and cumulative IVIG dose (30 vs. 60 g, p=0.04). In multivariate logistic regression analysis to determine mortality predictors in patients using IVIG, the presence of chronic disease was found to strongly increase mortality (odds ratio: 5.7, 95% confidence interval: 1.5-21, p=0.01). IVIG-related parameters (body weight, number of IVIG doses, cumulative IVIG dose) were not predictors of mortality (p>0.05). Conclusions: Although we observed that the surviving patients in our study received more IVIG than non-survivors, the amount of IVIG was not found to be associated with mortality.

Objective Multisystemic inflammatory syndrome in children (MIS-C) is characterized by persistent fever, systemic hyperinflammation, and multiple-organ dysfunction. There are a few reports about MIS-C presenting with acute abdomen. The aim of this study was to demonstrate the clinical characteristics and treatment options for MIS-C-related acute abdomen and appendicitis. Methods This was a retrospective study conducted between April 2020 and October 2020 in our pediatric intensive care unit in Turkey. Patients between the ages of 1 month and 18 years who presented with acute abdomen and were ultimately diagnosed with MIS-C were included. Results Seven patients with a median age of 12.5 (interquartile range 10.5–13) years were enrolled. Four were females. The most frequent symptoms were fever, abdominal pain, and vomiting. Three patients had involvement of the appendix that required surgical intervention. All pathology reports were compatible with appendicitis. The other patients also had an acute abdomen. One patient had malignant hyperthermia during induction of anesthesia, so surgery was postponed and medical management was commenced. The clinical picture regressed with immunomodulation. All patients were treated with intravenous immunoglobulin and steroids. Four patients with acute abdomens improved with immunomodulation, and surgery was not needed. Conclusion MIS-C may present with an acute abdomen. Immunomodulation should be considered instead of surgery if the clinical course is not complicated.

Traumatic optic neuropathy (TON) is characterized by impaired visual function due to acute damage to the optic nerve injury related to the trauma. The predictive incidence of TON in children and adolescence is 0.7-2.5% after blunt or penetrating head injuries. Orbital trauma is often accompanied by head injury and is the most common cause of unilateral vision loss. Here, we present a case of 11-year-old child who had the complaint of vision loss in the right eye and developed TON after a motor vehicle accident. The intubated patient was admitted to the pediatric intensive care unit after trauma and was operated due to epidural hemorrhage. Visual loss was detected during follow-up and orbital computed tomography revealed multiple fractures in the orbital walls and magnetic resonance imaging showed effusion of the optic nerve sheath and contrast enhancement of the optic nerve. Clinical and imaging findings suggested TON and as there was no indication for surgery, pulse steroid treatment was given for 5 days. With this treatment, the patient's vision loss and clinical findings improved significantly.In conclusion, TON should be considered in patients with a head injury and post-traumatic vision loss. High-dose steroids should be considered in suitable patients.

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.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.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.Total plasma exchange and continuous renal replacement therapy are life-saving, and both methods may reduce morbidity and mortality, also bridging to liver transplantation.

Background We report the results of INICC surveillance study from 2013 to 2018, in 664 intensive care units (ICUs) in 133 cities, of 45 countries, from Latin-America, Europe, Africa, Eastern-Mediterranean, Southeast-Asia, and Western-Pacific. Methods Prospective data from patients hospitalized in ICUs were collected through INICC Surveillance Online System. CDC-NHSN definitions for device-associated healthcare-associated infection (DA-HAI) were applied. Results We collected data from 428,847 patients, for an aggregate of 2,815,402 bed-days, 1,468,216 central line (CL)-days, 1,053,330 mechanical ventilator (MV)-days, 1,740,776 urinary catheter (UC)-days. We found 7,785 CL-associated bloodstream infections (CLAB), 12,085 ventilator-associated events (VAE), and 5,509 UC-associated urinary tract infections (CAUTI). Pooled DA-HAI rates were 5.91% and 9.01 DA-HAIs/1,000 bed-days. Pooled CLAB rate was 5.30/1,000 CL-days; VAE rate was 11.47/1,000 MV-days, and CAUTI rate was 3.16/1,000 UC-days. P aeruginosa was non-susceptible (NS) to imipenem in 52.72% of cases; to colistin in 10.38%; to ceftazidime in 50%; to ciprofloxacin in 40.28%; and to amikacin in 34.05%. Klebsiella spp was NS to imipenem in 49.16%; to ceftazidime in 78.01%; to ciprofloxacin in 66.26%; and to amikacin in 42.45%. coagulase-negative Staphylococci and S aureus were NS to oxacillin in 91.44% and 56.03%, respectively. Enterococcus spp was NS to vancomycin in 42.31% of the cases. Conclusions DA-HAI rates and bacterial resistance are high and continuous efforts are needed to reduce them.

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.

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).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.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.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.

Differential diagnosis of hypercalcemia in children includes confirmation of hyperthyroidism, infection, inflammatory processes, and malignant tumors. Immobilization-induced hypercalcemia is rare in healthy individuals, although it can occur in adolescent males, especially after fracture. Immobility can cause increased skeletal calcium release and hypercalcemia, and this condition is also known as resorptive hypercalcemia. We present a case of a 10-year-old adolescent girl with advanced heart failure who underwent implantation with a HeartMate 3 left ventricular assist device. She had symptoms of abdominal pain, vomiting, and constipation on the fifth month of hospitalization. She subsequently developed immobilization-induced symptomatic hypercalcemia (serum calcium, 12.1 mg/dL; corrected calcium 12.8 mg/dL; parathormone, 1.9 pg/mL; calcium/creatinine ratio in spot urine, 1.21). However, hypercalcemia is uncommon in children with advanced heart failure. Bisphosphonate therapy was initiated because our patient did not respond to hydration and furosemide treatment, and she had persistent abdominal pain, vomiting, and constipation. The patient's complaints were resolved on the second day after administrating bisphosphonate, and hypercalcemia did not recur.

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.

Adenovirus is a non-enveloped, double-stranded DNA virus that can cause infections in the upper and lower respiratory tract, conjunctiva, and gastrointestinal tract. Adenovirus infections are usually mild but may cause mortality and morbidity, especially in immunocompromised patients. Cidofovir may be used to treat adenovirus. Cidofovir is an antiviral with a virostatic effect, especially effective for adenovirus and herpes virus. In this case report, we present a 15-year-old patient with adenovirus-induced severe acute respiratory distress syndrome, who was referred to us for renal failure and successfully treated with cidofovir.

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.

Botulism is a rare but potentially life-threatening neuroparalytic syndrome caused by the action of a neurotoxin caused by the bacterium Clostridium botulinum. Early diagnosis and early treatment is important. In cases where botulism occurs sporadically, there is a need for easily applicable and rapid methods for diagnosis. The patient was admitted to the emergency department with complaints of dysarthria and sleepiness at the age of 7 years. During follow-up, bilateral ptosis, nystagmus, facial asymmetry, double vision and dysphagia developed. Electroneuromyography (ENMG) was performed in our case. It was evaluated as compatible with botulismus. Antitoxin treatment was performed. Six hours after the end of the antitoxin infusion, the ocular findings regressed, swallowing function improved, and dysarthric speech improved. Inconclusion, ENMG is found to be helpful in treatment decisions before toxin detection. Although toxin cannot be detected in patients, ENMG findings play an important role in the diagnosis of botulism.

Aim: To determine the association of vitamin D with insulin resistance and obesity in children. Methods: A total of 92 obese and 58 non-obese children aged 5-17 years were evaluated. Data were collected related to anthropometric (weight, height), and biochemical parameters (fasting plasma glucose, serum insulin, serum 25-hydroxyvitamin D, lipid profile, vitamin B12, parathormone) and physical examination (blood pressure, acanthosis nigricans, stria, lipomastia). Insulin resistance (IR) was calculated using the homeostasis model assessment (HOMA). HOMA-IR = fasting insulin level (mu U/ml) x fasting glucose (mg/dL)/405. A HOMA-IR value >2.5 was defined as insulin resistance. Results: According to the US Endocrine Society classification, vitamin D deficiency (0-20 ng/ml) was determined at significantly higher rates in the obese group than in the control group (p < 0.001). The rate of subjects with a vitamin D level of 20-30 ng/ml was significantly lower in the obese group than in the control group (p < 0.001) Within the obese group a statistically significant difference was determined between the insulin resistant and non-insulin resistant groups in respect of serum 25-hydroxyvitamin D levels (p = 0.001) and vitamin B12 levels (p = 0.001). A significant negative correlation was determined between serum 25-hydroxyvitamin D and HOMA-IR (r=-0.256, p = 0.016) and insulin (r = -0.258, p = 0.015). The systolic blood pressure (p = 0.001) and diastolic blood pressure (p = 0.003) values were significantly different in the control and obese groups. A statistically significant difference was determined between the control and obese groups in terms of the levels of insulin, HOMA-IR, HbA1c, cortisol, LDL, total cholesterol, HDL, triglyceride, hemoglobin, MCV, MPV, and calcium. Conclusion: The prevalence of vitamin D deficiency was higher in obese children compared to normal weight and overweight children. Serum 25(OH)D levels showed a negative correlation with insulin and HOMA-IR. Serum 25(OH)D is associated with insulin resistance independently of obesity. (C) 2020 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved. WOS:000594532200001 2-s2.0-85087172099 PubMed: 32616391

Various methods have been used to evaluate the predictivity of some markers during the recovery process after cardiac surgery in children. The aim herein was to evaluate the vasoactive ventilation renal (VVR) score in predicting the clinical outcomes of children who underwent congenital cardiac surgery within the early period in the pediatric intensive care unit (PICU). Patients who underwent congenital heart surgery (CHS) between November 2016 and March 2020 were enrolled and evaluated prospectively. The VVR score was calculated as follows: vasoactive inotrope score (VIS) + ventilation index + (change in serum creatinine level based on the baseline value × 10). The relationship between the duration of mechanical ventilation and the length of stay (LOS) in the PICU was evaluated via receiver operating characteristic (ROC) curve analysis and the cut-off values were calculated. At all of the time points identified in the study, the VVR score had a higher area under the ROC curve (AUC) when compared to the VIS and serum lactate levels, and the 48-h VVR score had the highest AUC (AUC 0.851, 95% confidence interval (CI) 0.761-0.942/LOS in the PICU; AUC 0.946, 95% CI 0.885-1.000/duration of mechanical ventilation). The 48-h VVR score for the LOS in the PICU was 6.7 (sensitivity 70%, specificity 92%) and that for the duration of mechanical ventilation was 9.1 (sensitivity 87%, specificity 97%). As a result, in our study, it was found that the VVR score is a new and effective predictor of the duration of mechanical ventilation and LOS in the PICU in postoperative CHS patients.

In this study, we aimed to evaluate the clinical and laboratory features of the patients with rotavirus (RV) antigen positivity on or following admission to the pediatric intensive care unit (PICU).Patients admitted to the PICU due to community-acquired rotavirus (CA-RV) or hospital-acquired rotavirus (HA-RV)-induced gastroenteritis between January 1, 2013, and December 31, 2019 were evaluated.Thirty-four patients with a mean age of 14.00 ± 19.17 months were enrolled. Fortyfour percent were girls. Twenty (58.8%) patients had a history of chronic diseases. Nine (26.5%) patients had CA-RV and 25 (73.5%) patients had HA-RV infection. RV antigens were simultaneously found in 44.1% (n = 14) of the other patients at the time of diagnosis. In the study sample, 5 patients had hyponatremia, 8 had hypernatremia, 6 had hypokalemia, 4 had hypoalbuminemia, 21 had leukocytosis, 2 had leukopenia and 3 had thrombocytopenia, and 17 had elevatedC-reactive protein (CRP) levels. Three patients had seizures, 1 patient had cardiac arrest, and 2 patients had secondary bacteremia. The mean (SD) PICU length of stay was 6 (6.02) with CA-RV gastroenteritis. All CA-RV patients survived, but 8 of the HA-RV patients succumbed to causes other than RV.RV-related PICU admission is not rare, and occasional severe clinical consequences occur, especially in young children, with both CA-RV and HA-RV gastroenteritis. Appropriate timely intervention and meticulous follow-up improve survival.

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.

Asthma is increasingly recognized as a heterogeneous entity, encompassing a variety of different subgroups, or phenotypes, which share clinical and inflammatory characteristics. However, it is only recently that molecular pathways have been both identified and successfully targeted in association with these clinical–inflammatory phenotypes. This integration of clinical–inflammatory and molecular pathways has enabled the broad differentiation of “asthma” into those with and without type-2 inflammation, on the basis of elevations in pathways downstream of type-2 cytokines, such as periostin, exhaled nitric oxide, and blood eosinophils. Although these rather general downstream biomarkers can identify patients more likely to respond to novel type 2–targeted therapies, they may have limited ability to determine which patients respond best to which type 2–targeted therapy, or even who will respond less than optimally, despite elevation in the biomarkers. In addition, new biomarkers and targets are required for the 50% of patients with asthma without elevations in these type-2 biomarkers. The path forward will require integrated ’omics approaches, development of more complex mouse models of asthma, as well as identification and validation of novel biomolecular pathways.

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.

Broad and deep perianal wounds are challenging in both adult and pediatric ICUs. These wounds, if contaminated with gastrointestinal flora, can cause invasive sepsis and death, and recovery can be prolonged. Controlling the source of infection without diverting stool from the perianal region is complicated. The option of protective colostomy is not well-known among pediatric critical care specialists, but it can help patients survive extremely complicated critical care management. These authors present three critically ill children who required temporary protective colostomy for perianal wounds because of various clinical conditions. Two patients were treated for meningococcemia, and the other had a total artificial heart implantation for dilated cardiomyopathy. There was extensive and profound tissue loss in the perianal region in the patients with meningococcemia, and the patient with cardiomyopathy had a large pressure injury. Timely, transient, protective colostomy was beneficial in these cases and facilitated the recovery of the perianal wounds. Temporary diverting colostomy should be considered as early as possible to prevent fecal transmission and accelerate perianal wound healing in children unresponsive to local debridement and critical care.

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.

Background: Clinical manifestations after overdose of atomoxetine are generally mild. However, it may have moderate or severe toxic effects such as drowsiness, agitation, hyperactivity, tremors, tachycardia, hyperreflexia, hypertension, and seizures. The duration of symptoms is usually short, lasting < 24 h. We report a case of atomoxetine toxicity, which can be considered of value, as intravenous lipid emulsion therapy has not been previously reported in an overdose of atomoxetine. This is a case of atomoxetine toxicity initially thought to be sertraline. Case Report: The case is presented of a 14-year-old girl with seizures following an overdose of atomoxetine who was unresponsive to intravenous benzodiazepine, but showed an improvement in overall condition after intravenous lipid emulsion therapy. To the best of our knowledge, there has been no previous report in the literature of the use of intravenous lipid therapy after atomoxetine overdose. Why Should an Emergency Physician Be Aware of This?: Intravenous lipid emulsion therapy is used as an alternative therapy in acute lipophilic drug intoxications. In children and adults, there is an increase in the use of intravenous lipid emulsion therapy in the life-threatening toxicity of many lipophilic drugs. Intravenous lipid emulsion therapy provides 'lipid sink' for toxic, lipophilic drugs, thereby effectively keeping toxic and lipophilic drugs out of the periphery. Intravenous lipid emulsion therapy reduces the distribution of lipophilic drugs. (C) 2020 Elsevier Inc. All rights reserved. WOS:000572677200003 2-s2.0-85085772010 PubMed: 32505448

Background Beta blockers (BB) are used for very different indications in both adults and children. There can be mild adverse effects with normal doses. When taken in toxic doses, this can have fatal results in children. There are some standard therapies during BB poisoning such as insulin and glucagon but there is not enough knowledge concerning intravenous lipid infusion therapy (ILI). Case Herein we present a case of propranolol poisoning in a previously healthy 2-year-old girl. In this patient, cardiac arrest developed twice, and cardiopulmonary resuscitation was performed for 5 and 20 minutes, respectively. We initiated inotropes, insulin, calcium and glucagon with a lack of response to all medical treatment. We used ILI and the patient improved after this treatment. She recovered without any disability. Conclusions ILI treatment should be considered with life-threatening BB poisoning which is unresponsive to standard therapies.