Renal replacement therapies in pediatric intensive care patients: Experiences of one center in Turkey

BACKGROUND: Despite constant improvements in caring for critically ill neonates and infants with congenital cardiac disease, sepsis, bone marrow and solid organ transplantation, acute renal failure (ARF) is an important problem in these children. ARF, severe fluid overload and inborn errors of metabolism are some of the indications for acute dialysis in infants and children. METHODS: The authors had retrospectively evaluated the medical records of Pediatric Intensive Care Unit, Ankara University School of Medicine, Ankara, Turkey patients who had required acute renal replacement therapy between the dates of January 2002 to February 2005. RESULTS: Medical records of 332 patients were reviewed. Acute renal replacement therapy was performed in 21 patients (6.3%; mean age, 9.6 +/- 7.4 years). Dialysis modalities were peritoneal dialysis in 15 patients (71.4%; mean age, 3.9 +/- 5.6 years) and hemodialysis in six patients (28.6%; mean age, 12.1 +/- 3.2 years). A total of 90% of patients had severe systemic disease leading to ARF. A total of 95% of patients had multiple organ dysfunction syndrome. The most common cause of ARF was refractory shock. At the beginning of renal replacement therapy, 10 patients were anuric, nine patients had volume overload, seven patients had decompensated metabolic acidosis and nine patients had hypotension. The average dialysis period was 4.7 +/- 6.4 days. Mortality rate was 66.7%. Eight patients recovered from ARF and chronic renal failure had developed in one patient. CONCLUSION: In the Pediatric Intensive Care Unit, ARF is frequently seen together with multiple organ dysfunction syndrome and the mortality rate is high. Both peritoneal dialysis and hemodialysis are important renal replacement treatment modalities in patients with ARF. The age and hemodynamic status of the patients are important when choosing treatment modality; generally peritoneal dialysis is preferred in infants and toddler, while hemodialysis is preferred in older children.     

Observations Questioning a Protective Role for Breast-feeding in Severe Rotavirus Diarrhea

ABSTRACT. To investigate whether breast-feeding protects children against rotavirus diarrhea (RVD), we compared rates of breast-feeding by age and enteric pathogens among 2 276 children with diarrhea 0-4 years of age who attended a diarrhea hospital in Bangladesh. Infants 0-5 months were less likely to be breast-fed than children 6-11 months of age suggesting that some protection against diarrhea with all agents was associated with early breast-feeding. In every age group studied, breast-feeding was more common among children with RVD than among children with non-RYD whereas it was less common among children with cholera and shigellosis. Twenty percent of breast milks consumed by infants less than 1 year of age had high levels of neutralizing activity (>320) to the Wa strain of rotavirus but this activity did not appear to be protective since the 30 infants with RVD consumed milk which had titers that did not differ significantly from those consumed by 44 infants with diarrhea of other cause. Despite the prolonged breast-feeding which is common in Bangladesh, the mean age of hospitalization with RYD is approximately the same as in countries where the duration of breastfeeding is quite short. None of these 3 independent observations support a protective role for breast-feeding against rotavirus diarrhea after the first months of life.     

Pregnancy and prosthetic heart valves: a French cooperative retrospective study of 155 cases

A French cooperative retrospective study analysed 155 pregnanciesin 103 women with prosthetic heart valves: 95 mechanical prosthesis(MP) and 60 bioprostheses (BP). Among them 13 MP and 10 BP werebivalvular and four were mixed implants. In all, 182 (108 MPand 74 BP) prostheses were exposed to the risk of pregnancy.Among the 108 MP-bearing patients, 16 thromboembolic accidents(TEA) were recorded: 10 thromboses in 13 mitral, two aorticand one pulmonary MP. TEA were four times more frequent underoral anticoagulant therapy. Among the 74 BP, seven sufferedpremature valve failure. Ninety-nine infants were born to 50MP-bearing women (53%) and 48 BP-bearing patients (80%) (P<0.001).Twenty miscarriages were reported; they occurred more oftenunder anticoagulant treatment (17%) than without it (4%) P<0.02).Coumarin-induced embryopathies were rare (only one definitivelyidentified). Because pregnancy with an MP under anticoagulanttherapy is dangerous for the mother and may effect the fetus,the therapeutic indications for women of child-bearing age mustbe taken into consideration. In a women already with an MP atthe time of conception, the duration of heparin therapy shouldbe limited to the following two periods: from the 6th to the12th week (coumarin-induced embryopathies) and during the last2 weeks of gestation (haemorrhages during delivery and the neonatalperiod).     

Assessment of psychometric properties,cross-cultural adaptation,and translation of the Turkish version of the ICU mobility scale

Background/aim The aim of the study was to carry out the cultural adaptation and translation of the ICU mobility scale (IMS) into Turkish and research the psychometric properties.Materials and methods This study was based on methodological design. The IMS was translated from English to the Turkish through a regularised translation process. Two physiotherapists assessed patients independently in the coronary intensive care unit. The measures such as construct validity, intra and interrater reliability, and internal consistency of the IMS Turkish version were assessed. Results A total of 70 intensive care patients were included in the study. The intrarater and interrater reliability of the IMS was excellent. The weighted Kappa value was 0.92 (0.87–0.96) for the intrarater reliability, and 0.87 (0.80–0.93) for the interrater reliability. There were significant correlations between the IMS and functional status score for the intensive care unit (r = 0.83), Perme intensive care unit mobility score (r = 0.84), Katz activities of daily living (r = 0.73), handgrip strength (r = 0.62), knee extension strength (r = 0.46), and age (r = –0.44).Conclusion This study suggests that the IMS Turkish version is a reliable and valid scale for assessing functional status and mobility level in ICU patients.     

Is nerve stimulation needed during an ultrasound‐guided lateral sagittal infraclavicular block?

Background: The objective of the study was to evaluate the influence of ultrasound (US) guidance alone vs. neurostimulation (NS) and US (NSUS) guidance techniques on block performance time and block success rate for the lateral sagittal infraclavicular block (LSIB). Methods: In a randomized and prospective manner, 110 adult patients scheduled for distal upper limb surgery were allocated to the US or the NSUS groups. In the US group, a local anesthetic (LA) was administered only with US guidance to produce a ‘U’‐shaped distribution around the axillary artery. In the NSUS group, LA was administered under US guidance only after electrolocation of one of the median, ulnar or radial nerve‐type responses. A total of 30 ml of LA (10 ml of levobupivacaine 5 mg/ml and 20 ml of lidocaine 20 mg/ml) was administered in both groups. Sensory block was tested at 10 min intervals for 30 min. Successful block was defined as analgesia or anesthesia of all five nerves distal to the elbow. Results: Block success rate was 94.5% in both groups. Block performance time was significantly shorter in the US than the NSUS group (157 ± 50 vs. 230 ± 104 s) (P=0.000). Block onset time was similar in both groups (12.5 ± 4.8 in the US vs. 12.8 ± 5.4 min in the NSUS groups). There were two arterial punctures in the NSUS group. Conclusions: During LSIB performance US guidance alone produces block success rate identical to both US and NS guidance yet with a shorter block performance time.     

High Frequency Phenomena in Regurgitant Jets

Color Doppler echocardiography is accepted as a useful tool for evaluating valvular regurgitation but, so far, it does not allow for a precise quantification of the regurgitant volume since it is limited by the combination of velocity ambiguities, a limited resolution, and a low frame rate. The low frame rate is imposed by the sector angle, the packet size, the pulse repetition rate, the line density, and the sequential analysis of the ultrasound emissions. On the other hand, the images are supposed to depict pulsatile jets surrounded by high frequency pulsatile vortices. The present study was designed to search for the presence of high frequency phenomena in turbulent jets and to analyze the influence of the low frame rate on the jet images. An in vitro study using an aliasing-free laser Doppler and a hydraulic model simulating intracardiac jets was carried out. An analysis of flow events with a high bandwidth (500 Hz) was conducted using M-mode color displays of the velocities. It showed: (1) on the centerline, a slow propagation of the front of the jet, and low frequency velocity fluctuations (< 50 Hz); and (2) at the opposite, in the boundary layer of the jet, very rapid fluctuations with frequencies comprised between 50 and 500 Hz. On two-dimensional color images of laser Doppler data, the size of the central laminar core appeared strongly modified by a decrease in frame rate up to the maximum one commonly used in color Doppler (30 frames / sec) as well by a decrease in line density. These data demonstrate that higher frame rate could improve the accuracy of ultrasound color Doppler flow mapping.