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

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

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

Wernicke Encephalopathy and Lactic Acidosis in Thiamine Deficiency

Thiamine deficiency can cause encephalopathy (Wernicke) and lactic acidosis. Herein we report a 6-year-old girl on total parenteral nutrition (TPN) who developed lactic acidosis and neurological symptoms due to improper vitamin replacement, which responded to thiamine injection. The MRI brain findings were not typical for Wernicke encephalopathy

Point of care diaphragm ultrasound in mechanically ventilated children: A predictive tool to detect extubation failure

Background Children should be weaned from the ventilator once their clinical condition improves. Extubation failure is associated with poorer clinical outcomes in children. Predictive indicators of successful extubation are needed. This study aims to evaluate the predictive value of ultrasonographic diaphragm imaging could help predict weaning success. Methods In this prospective, observational study conducted between March and December 2021, children between 1 month and 10 years of age who were mechanically ventilated for more than 48 h were included. Diaphragm ultrasound (DUS) examinations were performed at the end of 2-h extubation readiness test (ERT). The end-inspiratory thickness (DTi), end-expiratory thickness (DTe), diaphragmatic thickening fraction (DTF), diaphragmatic excursion (DE), inspiratory slope (IS), and expiratory slope (ES) were evaluated. Results Twenty-four (60%) patients were successfully extubated, while 16 (40%) required invasive or noninvasive mechanical ventilation support which were classified as failed extubation group. Three of the sixteen patients in the failed extubation group required reintubation. DTF was significantly greater in the successful weaning group (55.05 +/- 23.75% vs. 30.9 +/- 10.38%) (p < 0.001). DE was significantly greater in the successful weaning group (14 +/- 4.4 mm vs. 11.05 +/- 3.25 mm) (p < 0.001). DTF and DE were found to have a sensitivity and specificity of 91.67%, 87.50%, 83.33%, and 81.25%, respectively. Conclusion Diaphragm ultrasound is a feasible and promising tool to guide physicians during weaning from invasive mechanical ventilation. Among all DUS measurements, the DE and DTF indexes showed better performance in extubation failure than other diaphragmatic parameters