Akut non-travmatik ve non-opere travmatik ensefalopati hastalarında uzun süreli EEG monitorizasyonu

Akut ensefalopati çocukluk çağının morbidite ve mortalitesi yüksek, acil sorunlarındandır. Uzun süreli video-monitorizasyon (sEEG) ile hastaların doğru ve etkin tıbbi tedavisi ve yönetimi gerçekleşebilmektedir. Günümüzde, yenidoğan ve erişkin hastalarda EEG’nin prognostik yerine dair çok çalışma vardır, ancak çocuk hastaya ait çalışma sayısı yetersizdir. Yapılan çalışmalara göre akut ensefalopatide nöbet sıklığının %19-28 oranında olduğu saptanmıştır. Kısa EEG çekiminde herhangi bir elektrografik patern saptanmamasına rağmen uzun süreli monitorizasyonda elektrografik patern saptanan olguların varlığı, kısa EEG çekiminin kısıtlı olduğunun göstergesidir. Ensefalopati tanısıyla yoğun bakıma yatırılan hastalarda nöbet sık görülmekle birlikte sıklıkla nonkolvülzif tiptedir. Bu nöbetler sEEG monitorizasyonu olmadan kolaylıkla gözden kaçabilmektedir. Bu çalışmada akut ensefalopati tanısı ile pediatrik yoğun bakım ünitesinde izlenen hastalarda, erken dönemde sEEG’nin prognostik değerinin araştırılması amaçlanmıştır. sEEG ile nonkonvülzif nöbet ve nonkonvülzif status epileptikusun tanınması ve hastalarda, erken, uygun tedavinin yapılması sağlanmaktadır. Bu yaklaşım nöronal hasarın önlenmesine katkıda bulunabilir. Bu prospektif çalışmaya Ege Üniversitesi Tıp Fakültesi Çocuk Sağlığı ve Hastalıkları Çocuk Yoğun Bakım Ünitesi’ne, 1 Mayıs 2018-31 Kasım 2018 tarihleri arasında 6 aylık sürede, akut non-travmatik ve non-opere travmatik ensefalopati tanısı ile yatırılan, Glasgow Koma Skoru (GKS) ≤ 8 olan 24 hasta dahil edildi. Hastalar en az 24 saat monitorize edildi. Yirmidört saat boyunca elektrografik nöbet saptanmayan olgularda izlem sonlandırıldı. Elektrografik nöbet varlığında monitorizasyon 48-72 saate kadar uzatıldı. Elektrografik veya elektroklinik nöbet varlığında kliniğimizde uygulanan status tedavi protokolü uygulandı. Taburcu olmadan önce morbidite açısından, hastalar Modifiye Pediatrik Serebral ve Genel Performans Kategorisi Ölçeği (PCOPCS) ile değerlendirildi. Dahil edilen 24 hastanın yaş ortalaması 92,24±69.5 ay (min 4 ay-maks 216 ay) idi. 24 hastanın 14’ü (%58) kız, 10’u (%42) erkekti. Hastaların ensefalopati etiyolojilerine bakıldığında, kafa travması altı hasta ile en sık neden olarak belirlendi (%25). Asfiksi (ası, yabancı cisim aspirasyonu, suda boğulma) %18, intoksikayon %13, üremik ensefalopati %8, hepatik ensefalopati %8, metabolik hastalık %8 oranla görülen diğer nedenlerdi. sEEG’nin ilk saatinde hastaların birinde konvülzif (%4), ikisinde (%8) NKN gözlendi. 24 saatlik monitorizasyon için benzer değerler %4 ve %16 olarak bulundu. Konvülzif nöbet yalnız bir hastada izlendi. 24 saatlik monitorizasyonda dört hastada 11 NKN gözlendi. Bu hastalardan ikisi, sEEG'nin ilk bir saatinde de iki nonkonvülzif nöbet geçirmişti. Tüm hastalar değerlendirildiğinde NKN’nin %18’i ilk bir saatte saptanırken %82’si 24 saat içinde gelişti. Çalışmamızda hiçbir hastada NKSE gözlenmedi. Akut ensefalopatili hastalarda 24 saat süreli monitorizasyonun yeterli olabileceği düşünüldü. Hastaların klinik veya elektrografik nöbet tanısı için en az 24 saat monitorize edilmesinin faydalı olacağı, ilk 24 saatte nöbet aktivitesi gözlenmemesi durumunda da EEG çekiminin sonlandırılabileceği sonucuna varıldı. İzlemde yalnız bir hasta kaybedildi. PCOPCS skoruna göre, 11 hasta (%46) iyi prognoz, 13 hasta (%54) kötü prognoz grubunda bulundu. Nörogörüntüleme ile lezyon saptanması, NKN geçirilmesi anlamlı kötü prognostik faktör olarak bulundu (p: 0.04 ve 0.02). sEEG, NKN ve NKSE tanısının konmasında hala altın standarttır. Diğer yandan, yoğun bakım ünitelerinde sEEG uygulaması açısından bazı güçlükler vardır. Yoğun bakım ünitesinde sEEG monitorizasyonu için multisipliner bir çalışma ve işbirliği gereklidir.Acute encephalopathy is one of the urgent problems of childhood morbidity and mortality. Continuous EEG monitoring (cEEG) provides accurate and effective management and treatment of the patients. Currently, there are many studies regarding to the prognostic value of EEG in acute encephalopathy for neonates and adult patients, but there are few studies during childhood. According to the studies, the frequency of seizures in acute encephalopathy was found to be between 19% - 28%. Although no electrographic pattern was detected in short-term EEG recording, the presence of electrographic patterns in longterm EEG monitoring indicates the limitation of short-term EEG. However seizures are common in cases with acute encephalopathy, most of them are nonconvulsive. In this study, the prognostic value of cEEG in determination during early period in acute encephalopathy cases followed in Pediatric intensive care unit. cEEG lead to the detection of nonconvulsive seizure and nonconvulsive status and early and appropriate treatment of cases. This approach may contribute to the prevention of neuronal damage. This prospective study was carried out in Ege University Medical Faculty Pediatric Intensive Care Unit, between 1 May 2018 - 31 November 2018. Twenty-four patients with Glasgow Coma Score ≤ 8 who were admitted with the diagnosis of acute non-traumatic and non-operative traumatic encephalopathy were included in the study. The patients were monitored for at least 24 hours. cEEG was discontinued in the patients who had no electrografic seizures, in the presence of electrografic seizures, cEEG was extended till 48- 72 hours. First hour of cEEG was evaluated seperately. Electrografic or electroclinic seizures were treated in according to the status epilepticus protocol used in our clinic. All patients were evaluated with Modified Pediatric Cerebral and Overall Performance Category Scale (PCOPCS) in terms of morbidity before discharge from hospital. The mean age of the 24 patients was 92.24 ± 69.5 months (4- 216 months). Of the 24 patients, 14 (58%) were female and 10 (42%) were male. From the point of the etiology, head trauma was found in six patients, it is the most common cause in our group (25%). The other causes were asphyxia (18%), intoxication (13%) , uremic encephalopathy (13%), hepatic encephalopathy (8%) and metabolic disease (8%) . During first hour of cEEG, convulsive and nonconvulsive seizures were observed 1 (4%) and 2 (8%) patients respectively. Same values for 24 hour cEEG were as 4% and 16%. Convulsive seizures were found in only one patient. During 24 hour monitoring, eleven nonconvulsive seizure were observed in four cases . Two of them also displayed two nonconvulsive seizure during first hour of cEEG. When patients were evaluated, 18% of NCN was detected in the first hour and 82% developed within 24 hours. In our study, NCSE was not observed in any patient. It was concluded that the cEEG with 24 hours duration may be sufficient in cases with encephalopathy. During follow-up, one patient died. In according to PCOPCS, 11 and 13 patients had good and bad prognosis respectively. The presence of lesion on neuroimaging and having nonconvulsive seizure were found as bad prognostic factors (p: 0.04 ve 0.02). cEEG is still gold standard for the detection of nonconvulsive seizures. On the other hand there are some difficulties for application of cEEG in intensive care units. Multidisciplinary approach and cooperation are essential

Neuropsychiatric involvement in juvenile-onset systemic lupus erythematosus: A multicenter study

Introduction: Neuropsychiatric (NP) involvement is a restricted area in juvenile-onset systemic lupus erythematosus (jSLE). Aim: To investigate the prevalence, demographic and clinical features, and outcomes of the neurological involvement in the Turkish jSLE population. Methods: This study was based upon 24 referral centers’ SLE cohorts, multicenter and multidisciplinary network in Turkey. Patient data were collected by a case report form which was standardized for NP definitions according to American Collage of Rheumatology (ACR). Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) neuropsychiatric part was used to determine NP damage. Variables were evaluated Ward's hierarchical clustering analyses, univariate, and multivariate logistic regression analyses. Results: A hundred forty-nine of 1107 jSLE patients had NP involvement (13.5%). The most common NPSLE findings were headache (50.3%), seizure (38.3%), and acute confusional state (33.6%). Five clusters were identified with all clinical and laboratory findings. The first two clusters involved neuropathies, demyelinating diseases, aseptic meningitis, and movement disorder. Cluster 3 involved headache, activity markers and other SLE involvements. Idiopathic intracranial hypertension, cerebrovascular disease, cognitive dysfunction, psychiatric disorders and SLE antibodies were in the fourth, and acute confusional state was in the fifth cluster. In multivariate analysis, APA positivity; OR: 2.820, (%95CI: 1.002–7.939), P: 0,050, plasmapheresis; OR: 13.804 (%95CI: 2.785–68.432), P: 0,001, SLEDAI scores; OR: 1.115 (%95CI: (1.049–1.186), P: 0,001 were associated with increased risk for neurologic sequelae. Conclusion: We detected the prevalence of juvenile NPSLE manifestations in Turkey. We have identified five clusters that may shed light pathogenesis, treatment and prognosis of NP involvements. We also determined risk factors of neurological sequelae. Our study showed that new definitions NP involvements and sequelae for childhood period are needed

Epidemiology of surgery associated acute kidney injury (EPIS-AKI): a prospective international observational multi-center clinical study

Purpose: The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. Methods: We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (> 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72 h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. Results: We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1-3) days vs. 3 (Q1-Q3, 1-6) days) and hospital length of stay (median 14 (Q1-Q3, 9-24) days vs. 10 (Q1-Q3, 7-17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. Conclusion: In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide