Üçüncü basamak yenidoğan yoğun bakım ünitesinde yatan yenidoğanlarda akut böbrek hasarının sıklığı, risk faktörleri, klinik seyir ve mortaliteye etkisi

Üçüncü basamak yenidoğan yoğun bakım ünitesinde yatan yenidoğanlarda akut böbrek hasarının sıklığı, risk faktörleri, klinik seyir ve mortaliteye etkisi Giriş ve Amaç: Akut böbrek hasarı (ABH), zararlı atıkların vücutta birikmesi ve sıvı retansiyonu ile sonuçlanan böbrek fonksiyonlarının azalması durumudur. Perinatal bakımın gelişmesi üçüncü basamak Yenidoğan Yoğun Bakım Ünitelerinde (YYBÜ) izlenen yenidoğanlarda sağkalım oranları ile birlikte ABH insidansını da artırmıştır. Yenidoğanlarda ABH gelişiminde rol oynayan nedenler ve bunların klinik seyir ve mortalite üzerine etkisini inceleyen çalışmalar kısıtlıdır. Çalışmamızın amacı, üçüncü basamak YYBÜ'de ABH'nin insidansını, etiyolojik nedenlerini, klinik seyrini ve mortalite oranlarına etkisini saptamaktır. Hastalar ve Yöntem: Dokuz Eylül Üniversitesi Tıp Fakültesi (DEÜTF) YYBÜ'de 2007-2011 yılları arasında yatan tüm hastaların medikal kayıtları incelenerek yaşamın ilk 30 gününde ABH tanısı alan hastalar belirlendi. Akut böbrek hasarı 0-30. günlerde serum kreatinin düzeyinin >1,5 mg/dL olarak ölçülmesi ya da iki ölçüm arasında iki kat artış olması olarak tanımlandı. Hastaların sevk durumu, doğum ağırlığı, doğum haftası, doğum şekli, cinsiyeti, maternal morbidite varlığı, yoğunbakımda kalış süresi, eşlik eden morbiditeler ve mortalite durumu kaydedildi. ABH tanısı alan hastalarda diğer verilere ek olarak ABH'ye neden olan primer hastalık belirlendi, en yüksek serum kreatinin düzeyi ve prognoz kaydedildi. İstatistiksel analiz, SPSS Software 15.0 programı kullanılarak yapıldı. ABH gelişen ve gelişmeyen hastalarda mortalite oranlarını karşılaştırmak için ki-kare testi, ABH'de mortaliteyi etkileyen faktörleri belirlemek için lojistik regresyon analizi kullanıldı. Bireysel faktörlerin risklerini belirlemek için ayarlanabilir Odds Ratio (OR) ve %95 güven aralığı kullanıldı. P değeri <0,05 istatistiksel olarak anlamlı kabul edildi. Bulgular: Beş yıllık dönemde YYBÜ'de izlenen hasta sayısı 677 idi (E/K: 392/285). Bu hastaların 94 (%13,9) tanesinde yaşamın ilk 30 gününde ABH gelişti. Hastaların sevk durumu, doğum şekli, cinsiyeti ve maternal morbidite varlığı ile ABH insidansı ve mortalite arasında ilişki bulunmadı. ABH insidansı ve mortalite oranları doğum ağırlığı ?1000 gr olanlarda >1000 gr olanlara göre (sırası ile %36,5 vs %9,8 ve %27,9 vs %7,3; p<0,001) ve doğum haftası <28 hafta olanlarda ?28 hafta olanlara göre (sırası ile %38,6 vs %10,2 ve %33,0 vs %7,1; p<0,001) yüksek bulundu. Ancak ABH gelişen hastalarda mortalitenin doğum ağırlığı (?1000 gr vs >1000 g için sırası ile %42,1 vs %32,1; p=0,324) ve doğum haftasından (<28 hf vs ?28 hf için sırası ile %44,1 vs %31,7; p=0,227) bağımsız olarak yüksek olduğu belirlendi. ABH yaşamın en sık ilk 7 günü içerisinde gelişirken (%79,8), bu dönemde ABH'ye yol açan primer nedenler doğum asfiksisi, hipovolemi, kalp hastalığı, sepsis ve üriner anomaliler idi. Yaşamın ilk haftasından sonra en sık ABH nedenleri sepsis ve hipovolemi olarak belirlendi. ABH varlığı altta yatan nedenden bağımsız olarak mortaliteyi artırma eğiliminde olmakla birlikte, bu durum sadece sepsis (%33,3 vs %5,9, p<0,001; OR 7,9) ve kalp hastalıklarında (%50,0 vs %15,0, p=0,001; OR 5,6) anlamlı düzeyde bulundu. ABH gelişimi yoğunbakımda yatış süresini anlamlı ölçüde uzatırken (39,1 vs 20,5 gün, p<0,001), ABH'ye bağlı mortalite gelişen hastalarda sağkalanlara göre serum kreatinin düzeyinin daha yüksek olduğu belirlendi (sırası ile 2,0 vs 1,6 mg/dL, p<0,05). İzlemde kronik böbrek hastalığı gelişen 6 (%10) hastada altta yatan bozukluk üriner sistem anomalisi (n=3) ve doğum asfiksisi (n=3) idi. Sonuç: Üçüncü basamak YYBÜ'de ABH sıklığı yaklaşık %14 olup, vakaların %80 kadarı yaşamın ilk haftasında ortaya çıkmaktadır. ABH düşük doğum ağırlığı, prematürite, doğum asfiksisi, sepsis, hipovolemi, kalp hastalıkları ve üriner sistem anomalileri ile ilişkili olup, ABH gelişen hastalarda mortalite altta yatan nedenlerden bağımsız olarak yüksektir. Frequency, risk factors, clinical course and effect on mortality of acute kidney injury in newborns in a third level neonatal intensive care units Background and Aim: Acute kidney injury (AKI) is defined as decreased renal functions resulting in retention of fluid and metabolic waste products in the body. Improved perinatal care increased not only the survival rate but also the frequency of AKI in newborns admitted to third level neonatal intensive care units (NICU). Studies evaluating the factors causing AKI and the effect of these factors on clinical course and mortality are limited. We aimed to determine the frequency, underlying etiology, clinical course and mortality related to AKI in a third level NICU. Patients and Methods: Medical records of all patients admitted to NICU in Dokuz Eylul University Medical Faculty during the years 2007-2011 were evaluated retrospectively and those who were diagnosed to have AKI within the first 30 days of life were determined. AKI was defined by a serum creatinine level >1.5 mg/dL or a maximum serum creatinine level twice any previous level measured during the first 30 days of life. Referral state, birth weight, gestational age, mode of delivery, gender, presence of maternal morbidity, hospitalization period, accompanying morbidities and mortality of all patients were recorded. In patients diagnosed to have AKI, additionally the primary disease causing AKI, highest serum creatinine level and prognosis were recorded. Statistical analyses were performed by SPPP Software 15.0. Chi-square test was used to compare the mortality rate between the patients with or without AKI, while logistic regression was used to determine the factors affecting mortality in patients with AKI. Risk of individual factors was defined by Odds Ratio (OR) and 95 percent confidence interval. A p value less than 0.05 was accepted as significant. Results: There were 677 patients (M/F: 392/285) admitted to NICU within 5-year period and 94 (13.9%) of them had AKI during the first 30 days of life. AKI incidence and mortality were not related to the patients? referral state, mode of delivery, gender and maternal morbidity status. AKI incidence and mortality rate were higher in patients with birth weight ?1000 g compared to those with >1000 g (36.5% vs 9.8% and 27.9% vs 7.3% respectively; p<0.001) and in patients with gestational age <28 week compared to those with ?28 week (38.6% vs 10.2% and 33.0% vs 7.1% respectively; p<0.001). However, mortality in patients with AKI was increased independent on birth weight (42.1% in ?1000 g vs 32.1% in >1000 g; p=0.324) and gestational age (44.1% in <28 hf vs 31.7% in ?28 hf; p=0.227). AKI mostly (79.8%) developed within the first week of life andprimary causes of AKI during this period were birth asphyxia, hypovolemia, cardiac disease, sepsis and urinary system anomalies. After the first week of life, the most frequent causes of AKI were sepsis and hypovolemia. AKI tended to increase mortality independent on the underlying cause, but this was significant only for sepsis (33.3% vs 5.9%, p<0.001; OR 7.9) and cardiac diseases (50.0%vs 15.0%, p=0.001; OR 5.6). AKI caused extended hospitalization in NICU (39.1 vs 20.5 days, p<0.001). Serum creatinine in decreased patients with AKI was higher than those with AKI who survived (2.0 vs 1.6 mg/dL, p<0.05). Underlying causes were urinary tract anomalies (n=3) and birth asphyxia (n=3) in 6 (10%) patients who developed chronic kidney disease at follow up. Conclusion: AKI incidence in third level NICU is 14% and 80% of AKI develops during the first week of life. AKI is associated with low birth weight, prematurity, birth asphyxia, sepsis, hypovolemia, cardiac diseases and urinary tract anomalies. Mortality in patients with AKI is increased independent on the underlying etiolog

Unintended Consequences of Unemployment Insurance Benefits: The Role of Banks

We use disaggregated U.S. data and a border discontinuity design to show that more generous unemployment insurance (UI) policies lower bank deposits. We test several channels that could explain this decline and find evidence consistent with households lowering their deposit holdings due to reduced precautionary savings. Since deposits are the largest and most stable source of funding for banks, the decrease in deposits affects bank lending. Banks that raise deposits in states with generous UI policies reduce their loan supply to small businesses. Furthermore, counties that are served by these banks experience a higher unemployment rate and lower wage growth

Unintended Consequences of Unemployment Insurance Benefits: The Role of Banks

We use disaggregated U.S. data and a border discontinuity design to show that more generous unemployment insurance (UI) policies lower bank deposits. We test several channels that could explain this decline and find evidence consistent with households lowering their precautionary savings. Since deposits are the largest and most stable source of funding for banks, the decrease in deposits affects bank lending. Banks that raise deposits in states with generous UI policies squeeze their small business lending. Furthermore, counties that are served by these banks experience a higher unemployment rate and lower wage growth.</ns3:p

Ruptured cornual ectopic pregnancy: case report

Ectopic pregnancy, defined as the placement of an embryonic sac somewhere other than the uterine wall, is the most common life-threatening emergency seen during early pregnancy. Interstitial ectopic pregnancy is defined as the placement of an ectopic pregnancy to the uterine part of the fallopian tubes and makes up about 2-4% of all ectopic pregnancies. Compared to other tubal pregnancies, they rupture later during pregnancy and gross hemorrhage is seen as a result of this rupture. Maternal mortality risk is 2 to 5 times more in interstitial ruptured pregnancy in comparison with other tubal pregnancies. Early diagnosis and treatment of interstitial ectopic pregnancy is therefore very crucial, as they carry a very high risk of morbidity associated with the rupture. In this case report, we present a case presenting with severe abdominal pain and amenorrhea for 3 months to our clinic. After examination, the patient was diagnosed with a cornual ectopic pregnancy which was late for a case like this. We would like to discuss this case with a literature review on this subjec

Type B Lactic Acidosis in A Child with Relapsed non-Hodgkin Lymphoma

Lactic acidosis is a major cause of metabolic acidosis in critically ill patients. Herein we report a child with relapsed non-Hodgkin’s lymphoma admitted to the pediatric intensive care unit (PICU) with profound lactic acidosis. On admission, he was treated with fluid replacement and a vasopressor, followed by continuous veno-venous hemodiafiltration to correct acidosis. As lactic acid levels remained high despite all treatments, thiamine was added to the therapy, which did not influence metabolic status either. Lactic acidosis could only be corrected by aggressive chemotherapy during his stay in the PICU. The patient died on the 68th day of PICU admission due to underlying progressive disease. Clinicians should start aggressive chemotherapy as soon as possible in patients with a recurrence or advanced cancer who have type-B lactic acidosis

The Effect of Tracheostomy Timing on Clinical Outcomes in Children

Introduction:Optimal timing for tracheostomy in children is not well defined. Our aim is to examine the pre-tracheostomy morbidities, indications and association of early tracheostomy on clinical outcomes.Methods:This retrospective cohort study included all patients who underwent tracheostomy in the Dokuz Eylül University Pediatric Intensive Care Unit (ICU) between January 2012 and September 2020. We categorized patients into the early and late tracheostomy groups according to time on a mechanical ventilator before tracheostomy using a cut-off of 14 days. Pre-tracheostomy morbidities [ventilator associated pneumonia (VAP), central line associated bloodstream infection], indications and clinical outcomes (including length of ICU and hospital stay, incidence of VAP and mortality) were compared between early and late groups.Results:Of the 104 patients undergone tracheostomy, 90 were included in the study: Thirty patients in the early group, 60 patients in the late group. Tracheostomy rate of our unit was 6.06%, with a median ventilator time before tracheostomy of 20 days. VAP and lung tissue disease indication for tracheostomy independently increased pre-tracheostomy mechanical ventilation time by 8 and 12.6 days, respectively. There was no statistically significant difference in VAP rate after tracheostomy, successful decannulation and mortality between early and late group. Early group had lower post-tracheostomy ICU-length of stay (LOS) (8.5 vs. 13 days p=0.041) and total ICU-LOS (17.5 vs. 45 days p<0.001). Controlling for age, tracheostomy indication, central line associated bloodstream infection and VAP; tracheostomy timing was independently associated with ICU-LOS. Late tracheostomy timing increased the ICU-LOS by 10.7 days (p=0.041).Conclusion:Our results suggest that early timing of tracheostomy is associated with reduced ICU-LOS and VAP in children, consistent with the current literature

Evaluation of two cases with round pneumonia

Round pnömoni, akciğer grafisinde yuvarlak konsolidasyon şeklinde sıklıkla çocuklarda görülen bir pnömonidir. Radyolojik olarak pulmoner kitle ile karışması nedeni ile önem teşkil etmektedir. Klinik ve laboratuar bulguları round pnomoni ile uyumlu olan çocuklarda ayırıcı tanı için ileri tetkik edilmeden önce antibiyotik tedavisi sonrası klinik ve radyolojik bulguların tekrar değerlendirilmesi gerekmektedir. Bu sunumda öksürük ve ateş yüksekliği ile başvuran, akciğer grafisinde yuvarlak konsolidasyon saptanan ve tedavi ile kliniği gerileyen iki olgu sunulmuştur. Round pneumonia is a manifestation of pneumonia which seen particular to childhood and it appears as a rounded consolidation on chest x-ray. Radiologically, it is important because of interference with the pulmonary mass. Children whose clinical and laboratory findings are compatible with round pneumonia should be eveluated again after antibiotic treatment before further evaluation for differantial diagnosis. We presented two cases who admitted with cough, fever and round consolidation on chest x-ray and whose clinical and radiological findings regressed after treatment

Evaluation of nutritional status in pediatric intensive care unit patients: the results of a multicenter, prospective study in Turkey

IntroductionMalnutrition is defined as a pathological condition arising from deficient or imbalanced intake of nutritional elements. Factors such as increasing metabolic demands during the disease course in the hospitalized patients and inadequate calorie intake increase the risk of malnutrition. The aim of the present study is to evaluate nutritional status of patients admitted to pediatric intensive care units (PICU) in Turkey, examine the effect of nutrition on the treatment process and draw attention to the need for regulating nutritional support of patients while continuing existing therapies.Material and MethodIn this prospective multicenter study, the data was collected over a period of one month from PICUs participating in the PICU Nutrition Study Group in Turkey. Anthropometric data of the patients, calorie intake, 90-day mortality, need for mechanical ventilation, length of hospital stay and length of stay in intensive care unit were recorded and the relationship between these parameters was examined.ResultsOf the 614 patients included in the study, malnutrition was detected in 45.4% of the patients. Enteral feeding was initiated in 40.6% (n = 249) of the patients at day one upon admission to the intensive care unit. In the first 48 h, 86.82% (n = 533) of the patients achieved the target calorie intake, and 81.65% (n = 307) of the 376 patients remaining in the intensive care unit achieved the target calorie intake at the end of one week. The risk of mortality decreased with increasing upper mid-arm circumference and triceps skin fold thickness Z-score (OR = 0.871/0.894; p = 0.027/0.024). The risk of mortality was 2.723 times higher in patients who did not achieve the target calorie intake at first 48 h (p = 0.006) and the risk was 3.829 times higher in patients who did not achieve the target calorie intake at the end of one week (p = 0.001). The risk of mortality decreased with increasing triceps skin fold thickness Z-score (OR = 0.894; p = 0.024).ConclusionTimely and appropriate nutritional support in critically ill patients favorably affects the clinical course. The results of the present study suggest that mortality rate is higher in patients who fail to achieve the target calorie intake at first 48 h and day seven of admission to the intensive care unit. The risk of mortality decreases with increasing triceps skin fold thickness Z-score