Ahmed El-Nawawy

Background: Raised intracranial pressure (ICP) is a typical neurological problem in critically ill children, which is associated with poor clinical outcomes or even death. The purpose of the study was to evaluate the efficacy of optic nerve sheath diameter (ONSD) as a point-of-care testing in the pediatric intensive care units for early diagnosis of raised intracranial pressure and as a follow up tool for treatment response. Method: A prospective observational study was conducted in the pediatric intensive care unit of a tertiary care children's hospital. Consecutive children aged one month to twelve years with Glasgow Coma Scale less than or equal to 8 were included. Brain CT was performed just before or within few hours of admission to identify raised ICP. Two trained examiners in the same work place, who were blinded to the clinical details of the patients, performed the ONSD sonography concurrently. The ONSD was measured in the left and right eyes on admission, after 1 h, after 12 h, and after 24 h. Results: Forty-two patients were categorized into 29 children with raised ICP and 13 children with non-raised ICP. The ONSD was significantly higher in the raised ICP group at all times in both eyes. It showed a significant decrease over time in both groups. A cutoff value of ≥ 4.3 mm was found to be an acceptable discriminator of ICP with Area Under the ROC curve (AUC) = 0.788 (95% CI 0.740- 0.830) (p < 0.0001), sensitivity of 59.91% (95% CI: 53.30–66.27) and specificity of 83.65% (95% CI: 75.12–90.18). Conclusions: In critically ill children with non-traumatic causes of raised ICP, point of care ultrasound of ONSD shows a good diagnostic test accuracy for early diagnosis of raised ICP as well as follow up tool of treatment response if used serially. In addition, it is very good at correctly identifying individuals who do not have raised ICP to avoid unnecessary interventions.

During critical illness, children my experience various changes in their thyroid hormone levels. Such changes are termed non-thyroidal illness syndrome (NTI). The extent of change correlates with the severity of the illness and its outcomes in critically ill patients. This study aimed to investigate the correlation between the severity of shock and thyroid hormone derangement. This prospective observational study included forty patients aged one month to five years who were admitted to the pediatric intensive care unit (PICU) with shock. Thyroid function tests were conducted on admission, after shock reversal, and five days later. NTI patterns were observed in 70% of patients. The PIM2 score showed a significant negative correlation with T3 (r = − 0.353, p = 0.026) and FT3 levels on admission (r = − 0.417, p = 0.007). Furthermore, after shock reversal, the PIM2 score continued to exhibit significant negative correlations with T4 (r = − 0.444, p = 0.004), T3 (r = − 0.329, p = 0.038), FT3 (r = − 0.355, p = 0.025), and FT4 levels (r = − 0.379, p = 0.016). Conclusion: This study underscores the high prevalence of NTI in PICU shock patients and suggests monitoring thyroid hormone levels for outcome prediction and treatment guidance. Further research is needed to optimize NTI management in critically ill children. What is Known:• Non-thyroidal illness syndrome (NTIS) is a condition observed in critically ill patients.• There has been limited research on NTI in children, and existing studies have generated conflicting results regarding the relationship between thyroid hormones and clinical outcomes in cases of sepsis and septic shock. What is New:• The study has revealed dynamic changes in free triiodothyronine (FT3) levels during the process of shock reversal and recovery in children who experienced shock.• A significant negative correlation was found between the Pediatric Index of Mortality 2 (PIM2) score and several thyroid hormone levels, including FT3 on admission and T4, FT3, and FT4 on shock reversal.

Background: Rapid and accurate identification of healthcare associated pathogens is crucial for early diagnosis and treatment of infections. This study aimed to assess the performance of a point-of-care multiplex polymerase chain reaction (PCR) in diagnosis of pathogens and their antibiotic resistance genes in bloodstream infections, pneumonia and meningitis/encephalitis in a pediatric intensive care unit (PICU). Methods: A retrospective cross-sectional study was conducted on pediatric patients diagnosed with healthcare associated infections at Alexandria University PICU, Egypt. A total of 111 samples from 98 patients were subjected simultaneously to standard-of-care microbiology testing (SOCMT) and molecular testing by BioFire multiplex PCR. Results: In comparison to SOCMT, the BioFire FilmArray^® had a better diagnostic yield with broncho-alveolar lavage (BAL) (45 vs. 21) and cerebrospinal fluid (CSF) samples (five vs. none) (p ≤ 0.0001). Klebsiella pneumoniae was the most common pathogen in BAL (n = 19 by BioFire, n = 9 by SOCMT) and blood (n = 7, by SOCMT and BioFire) samples, while Streptococcus pneumoniae was the most common in CSF samples. BioFire showed 95.8% overall percent agreement, 100% positive percent agreement and 95.6% negative percent agreement with SOCMT. All phenotypically confirmed resistant isolates had resistance genes by the BioFire FilmArray^® (100%). The turnaround time (TAT) of positive results by the FilmArray panels was 1–1.5 h in comparison to 48–72 h by SOCMT (p ≤ 0.001). Conclusions: The results of the current study confirm the utility of the BioFire FilmArray^® in making early decisions regarding patients’ diagnosis and management of infection in the PICU, in terms of rapid TAT and appropriate antimicrobial use.

Alexandria University blood bank adopted double screening tests: a fully automated chemiluminescence immunoassay followed by nucleic acid testing. The aim of the study was to assess the efficiency of dual check of HCV in preventing transfusion related infection among patients admitted to PICU. A prospective cohort study was carried on patients admitted to PICU during 6 months. The included patients performed HCV RNA detection on admission by conventional reverse transcriptase polymerase chain reaction (RT-PCR) technique. Only negative cases were recruited, then patients receiving blood or its product were checked after 4 weeks from discharge by RT-PCR for HCV RNA. A total of 33 patients received 108 transfusions: 9 patients of them deceased during PICU stay and the remaining 24 patients were all found to be negative for HCV. The dual screening of HCV should be implemented in all blood banks of Egypt especially for critically ill pediatric patients.

Background: Although inborn errors of metabolism (IEM) are rare individually, collectively IEM cause substantial morbidity and mortality and the diagnosis is challenging. Aims: To analyse epidemiological and clinical data, final diagnosis and clinical outcomes of patients with a suspected diagnosis of IEM (small molecule disorders type) admitted to a paediatric intensive care unit (PICU). Methods: We collected and analysed medical records data of all patients admitted to the PICU at Alexandria University Children's Hospital, from January 2010 to December 2014, with a suspected or confirmed diagnosis of small molecule disorders, including clinical presentations, laboratory results and clinical outcomes. Results: A total of 34 patients had a suspected or confirmed diagnosis of small molecule disorders at PICU admission. Diagnosis was confirmed in 22.7% of suspected cases at admission and in 25% of suspected cases during PICU stay. Consanguineous marriage was found in 50% of cases with confirmed small molecule disorders. Conclusions: A high index of suspicion is important for diagnosing and categorizing small molecule disorders in screening of high-risk individuals in low- and middle-income countries.

Aim: Multidrug-resistant infections are an increasingly common condition particularly in critical care units. This study aimed to determine the incidence and types of resistant bacteria acquired in a pediatric intensive care unit (PICU) of a university hospital. Subject and Methods: A prospective study was conducted during the year 2016. All children aged below 16 years were studied for infection development and pattern of susceptibility to various groups of antibiotics. Results: A total of 264 patients were admitted to the PICU: 16 patients had community-acquired infection (CAI), 23 had hospital-acquired infection, and 24 patients had PICU-acquired infection (with 36 episodes) which is equivalent to 14.75 case/1,000 patient days. The study revealed high incidence of resistant organisms in the PICU but more important is the appearance of multi- and extreme drug-resistant bacteria in CAI. The study revealed that gram-negative bacteria were more prevalent in PICU, especially Klebsiella (30.5%), Acinetobacter baumanii (22.22%), and Pseudomonas (16.67%). Infection with resistant organisms in the PICU caused initial treatment failure and increased fourfold risk of mortality. Conclusion: The incidence of resistant bacteria especially gram-negative pathogens was very high in the PICU. The top three resistant organisms of concern were Klebsiella , Acinetobacter , and Pseudomonas . This is a global concern that necessitates new strategies.

The cornerstone of emergency management of sepsis is early, goal-directed therapy. The purpose of this study was to evaluate the effect of intraosseous (IO) vs. intravenous (IV) access for resuscitation of patients with septic shock admitted to pediatric intensive care unit. This prospective interventional randomized clinical trial study was conducted on 60 patients with septic shock who need rapid administration of fluids and drugs; 30 cases were randomly chosen for IO vascular access, while the other 30 were selected for IV access. The IO route was successfully secured in all cases with a significant shorter time of vascular access insertion, shorter length of stay and reduction in mortality in IO group vs. IV group (p = 0.001, 0.045, 0.002, respectively). In pediatric emergencies, as in case of shock, the use of IO route is recommended to get rapid vascular access as soon as possible, as it revealed better outcome.

The study aimed to compare two scores: the pediatric logistic organ dysfunction (PELOD) with its updated version (PELOD-2) in describing the severity of organ dysfunction in pediatric intensive care unit (PICU) and assess the performance of PELOD-2 in the Egyptian population. A prospective cohort study of 200 patients consecutively admitted to PICU between July 2015 and A 2016 was included. The median age was 6 months, and the male to female ratio was 1.04. The median length of PICU stay was 4 days. The overall predicted number of deaths using PELOD was 76 patients whereas, by PELOD-2, it was 50 patients. The observed mortality was 50 patients. The area under the receiving operating characteristic curve was excellent for both PELOD and PELOD-2 (0.93 and 0.91, respectively). The Hosmer and Lemeshow goodness-of-fit test showed good calibration of PELOD-2 (χ² = 9.9, p = 0.27), while PELOD showed poor calibration (χ² = 42, p = 0.000) in the same studied group.

The aim of this prospective randomized study is to compare the outcomes of the early use of either high frequency oscillation (HFO) or conventional mechanical ventilation (CMV) in patients with pediatric acute respiratory distress syndrome (PARDS). We allocated two hundred PARDS patients over 5 years in 1:1 ratio to either mode. The HFO group showed a significantly higher median partial arterial oxygen pressure to fraction of inspired oxygen (PaO2/FiO2) values after 24 hours of enrollment (p=0.011), higher oxygenation index (OI) decrease percent (p=0.004) and lower cross-over rates (p < 0.001), whereas no differences in 30-day mortality, length of stay (LOS) or ventilation days (p=0.77, p=0.28, p=0.65 respectively). The second day values (after 24 hours) of both OI and PaO 2 /FiO 2 were found to be more significant discriminators for mortality when compared to the baseline values (cutoff values > 8.5, ≤139 respectively). PARDS patients with baseline OI > 16 had a better chance of survival if initially ventilated with the HFO (p=0.004). Although the HFO mode appeared to be a safe mode with a significant better oxygenation improvement (after the first 24 hours) and fewer cross-over rates, it failed to show differences as regards mortality or LOS when compared to the CMV adopting protective lung strategy. In PARDS, HFO had a superior advantage in improving oxygenation, yet with no significant mortality improvement, as multi-organ dysfunction syndrome (MODS) was the most common cause of death in our study and not refractory hypoxemia which is the main problem in PARDS; highlighting that mortality in PARDS is multi-factorial and may not depend only on how fast oxygenation improves.