Mustafa Çolak

Objectives: We aimed to evaluate the performance of the age-adapted Pediatric Sequential Organ Failure Assessment (pSOFA) score, as a predictor of mortality in patients admitted to pediatric intensive care units (PICUs), and to compare it with the Pediatric Risk of Mortality 4 (PRISM 4) and Pediatric Index of Mortality 3 (PIM 3) scores. Methods: This single-center, retrospective study analyzed data from 1440 eligible PICU admissions to a tertiary PICU. The pSOFA, PRISM 4, and PIM 3 scores were calculated retrospectively for each patient. Results: The overall mortality was 13.1%, and the median length of stay was 11 days. The median (IQR) pSOFA score was significantly higher in non-survivors than in survivors [6 (4–10) vs. 3 (2–4), p < 0.001]. Mortality increased significantly with increasing pSOFA scores (p < 0.001). The area under the receiver operating characteristic curve (AUC) values for pSOFA, PRISM 4, and PIM 3 were 0.807, 0.847, and 0.781, respectively. The pSOFA score exhibited a significant positive correlation with both PRISM 4 and PIM 3 (p < 0.001). PRISM 4 and PIM 3 demonstrated evidence of miscalibration in this cohort, with observed mortality exceeding mean predicted mortality for both models. Conclusions: pSOFA demonstrated good discrimination for PICU mortality and a strong association with mortality in this single-center retrospective cohort. PRISM 4 showed significantly greater discrimination than pSOFA, whereas pSOFA and PIM 3 did not differ significantly. These findings support further prospective multicenter evaluation before broader clinical implementation.

The prognostic significance of mechanical power (MP) and the optimal normalization strategy in pediatric acute respiratory distress syndrome (PARDS) remains uncertain. We evaluated the association between airway and transpulmonary mechanical power normalized using different strategies and 28-day mortality in children with PARDS. In this multicenter retrospective observational study, 128 invasively ventilated subjects with PARDS were included from four tertiary pediatric intensive care units between June 2020 and December 2025. Airway MP and transpulmonary mechanical power (MPL) were calculated during pressure-controlled ventilation and normalized to predicted body weight (PBW), body surface area (BSA), and static respiratory system compliance (Cstat). The primary outcome was 28-day mortality. Associations were examined using multivariable logistic regression adjusted for age, sex, ARDS severity (PALICC-2), and Pediatric Index of Mortality-3 (PIM-3). Discriminative performance was assessed using receiver operating characteristic analysis with DeLong comparisons, and optimal thresholds were identified using the Youden index. The 28-day mortality rate was 20.3%. Absolute airway MP was not associated with mortality. In adjusted analyses, only compliance-normalized airway MP (MP/Cstat) was associated with mortality (adjusted OR 6.8, 95% CI 1.0–44.8; p = 0.044). Compliance-normalized transpulmonary MP (MPL/Cstat) was also associated with mortality (adjusted OR 30.6, 95% CI 1.5–615.7; p = 0.03). PBW- and BSA-normalized indices were not significant. Compliance-normalized indices showed numerically higher AUC values (MP/Cstat 0.68; MPL/Cstat 0.70), although the differences were not significant by DeLong testing. Mortality increased stepwise across MP/Cstat tertiles (p for trend = 0.01). Among MP components, only the compliance-normalized elastic component was significantly associated with mortality. Conclusions: Mechanical power, normalized to static respiratory system compliance rather than anthropometric parameters, was associated with mortality and showed a graded dose–response relationship in PARDS. Compliance-based normalization may provide additional physiological insight into mechanical power assessment in PARDS. What is Known: • Mechanical power integrates multiple ventilatory variables and has been associated with outcomes in adult ARDS. • Different normalization approaches, including anthropometric and physiologic methods, have been proposed to account for variability in body size and lung mechanics. The clinical relevance of these normalization strategies in PARDS remains uncertain. What is New: • In a multicenter cohort of subjects with PARDS, mechanical power normalized to static respiratory system compliance was independently associated with 28-day mortality for both airway and transpulmonary measurements. In contrast, normalization to predicted body weight or body surface area was not independently associated with mortality after adjustment. • Mortality increased progressively across tertiles of compliance-normalized airway mechanical power. Among mechanical power components, only the compliance-normalized elastic component was independently associated with mortality.

Background: Acute liver failure (ALF) carries high mortality, and early prognostication remains challenging. We evaluated the prognostic value of serum procalcitonin (PCT) in ALF and its association with transplant‑free survival. Objectives: To investigate serum procalcitonin (PCT) as a prognostic marker for transplant‑free survival in patients with acute liver failure. Methods: We retrospectively analyzed 83 ICU patients (41 ALF; 42 major hepatectomy controls) between January 2021 and June 2025. All ALF patients received combined extracorporeal therapy—therapeutic plasma exchange (TPE) plus continuous venovenous hemodiafiltration (CVVHDF). Serum PCT was measured within 24 hours of admission and monitored throughout treatment. Results: Peak PCT (PCTmax) was associated with poor prognosis (liver transplantation or mortality): Area Under the Curve (AUC) 0.693 (P = 0.035); optimal cutoff 1.625 ng/mL (sensitivity 84.2%, specificity 63.6%). The transplant‑free survival rate following combined extracorporeal therapy was 53.7%. Conclusions: Serum PCT may serve as an adjunctive prognostic biomarker in ALF, interpreted alongside established scores (MELD, King’s College Criteria) rather than alone. Due to limited transplant events, the findings are hypothesis‑generating and require validation in independent cohorts.

The oxygenation index (OI) is widely used to assess disease severity in pediatric ARDS; however, it relies on mean airway pressure (Pmean), which does not reflect lung-distending forces relevant to ventilator-induced lung injury. Driving pressure (DP) is a determinant of lung strain. We developed and evaluated the oxygenation distension index (ODI) by substituting DP for Pmean in the OI formula. This observational study included children aged 1 month to 18 years with PARDS requiring ≥ 24 h of invasive mechanical ventilation in six centers. Lung ultrasound scores (LUS) and respiratory mechanics, including transpulmonary pressure (PL), transpulmonary driving pressure (DPL), mechanical power (MP), and transpulmonary mechanical power (MPL), were assessed 4–24 h after diagnosis according to PALICC-2 recommendations. Associations of OI and ODI with lung injury markers and clinical outcomes were analyzed. Among 56 patients, 41 (73%) had mild-to-moderate and 15 (27%) had severe PARDS. ODI demonstrated stronger correlations than OI with lung injury markers, including LUS (r = 0.818 vs. 0.501), PL (r = 0.779 vs. 0.697), DPL (r = 0.745 vs. 0.671), MP normalized to predicted body weight (r = 0.518 vs. 0.438), and MPL normalized to predicted body weight (r = 0.634 vs. 0.628). For 30-day mortality prediction, ODI showed higher discriminative performance than OI (AUC 0.740 [95% CI, 0.598–0.866] vs. 0.685 [95% CI, 0.535–0.835]; DeLong p = 0.040). Conclusions: By incorporating driving pressure, ODI more closely reflects lung injury severity than the conventional oxygenation index and improves discrimination for mortality in PARDS. What is Known: • The oxygenation index is the standard metric used for severity classification in pediatric acute respiratory distress syndrome. • Driving pressure has been increasingly recognized as a key physiological determinant of lung injury and clinical outcomes in ARDS. What is New: • A driving pressure–based oxygenation metric, the oxygenation distension index (ODI), shows stronger associations with established markers of lung injury than the conventional oxygenation index in PARDS. • ODI provides improved discrimination for 30-day mortality compared with the oxygenation index in mechanically ventilated children with PARDS.

Characteristics of Pediatric Patients Following the Kahramanmaraş Earthquake: Experience of a Major Referral Pediatric Intensive Care Unit Outside the Disaster Zone - Istanbul Medical Journal

Amaç Solunum yetmezliği, çocuk yoğun bakım ünitesi hastalarında en sık ölüm nedenlerinden biridir. Yetişkin ve az sayıda pediatrik çalışmada akut solunum distresi sendromu (ARDS) hastalarında sürüş baskısı ile mortaliteyi ilişkilendirmiştir, ancak ARDS'si olmayan hastalarda sürüş basıncı ile mortalite arasındaki ilişkiyi gösteren çalışmalar tutarsız ve sınırlıdır. Bu çalışmada solunum yetmezliği nedeniyle mekanik ventilasyon desteği alan pediatrik ARDS (pARDS) ve non-pARDS tanılı pediatrik hastalarda sürüş basıncının mortalite ile ilişkisinin belirlenmesi amaçlandı. Gereç ve Yöntem Öngörülen ventilasyon süresi 24 saatten fazla mekanik ventilasyon uygulanan hastalar kaydedildi. pARDS ve non-PARDS gruplarındaki hastaların sürüş basıncı ve diğer ventilatör parametreleri 30 günlük mortaliteleri ile karşılaştırıldı. Bulgular Çalışmamıza toplam 116 çocuk dahil edildi. Otuz dört hasta pARDS grubunda sınıflandırılırken, 82 hasta PARDS dışı gruptaydı. Tüm hastaların mekanik ventilasyonun ilk günü parametreleri [∆P (p

Oxygen is an effective treatment for any type of respiratory failure. To prevent hypoxemia and hyperoxemia, the Pediatric mechanical ventilation consensus conference (PEMVECC) recommends monitoring oxygen saturation with pulse oximetry (SpO2) in all ventilated children and measuring partial arterial oxygen pressure (PaO2) in moderate to severe cases. However, this may require manual adjustments of inspired oxygen, which can be burdensome during high-demand periods such as the current COVID-19 epidemic. Additionally, the pandemic has highlighted the importance of optimizing oxygen use in hospitals as it may become a scarce resource during such high-demand periods. Previous studies have shown that automatic oxygen titration (AOT) is feasible in patients receiving respiratory support therapy, including those with mild acute hypoxemic respiratory failure and exercise-induced desaturation. This study aims to assess the safety and efficacy of a closed-loop FiO2 controller in comparison to traditional manual FiO2 regulation during invasive mechanical ventilation (IMV) in pediatric patients within a pediatric critical care unit (PICU). The hypothesis is that the closed-loop FiO2 controller will increase the time spent within clinically intended SpO2 ranges and decrease the time spent outside these ranges. The research is registered under NCT05714527

Liver failure represents a critical medical condition, marked by the rapid decline of hepatic functions. Emerging therapies, notably therapeutic plasma exchange (TPE) and continuous venovenous hemodiafiltration (CVVHDF), have demonstrated potential in mitigating these conditions through their roles in detoxification and hepatic support. The utility of these treatments, whether applied individually or in tandem, constitutes a significant area of research concerning the management of liver failure in pediatric patients. This study aims to evaluate the role and efficacy of TPE or TPE combined with CVVHDF in the treatment of liver failure among children. This retrospective study was conducted in a LTICU by reviewing the medical history of pediatric patients aged 1 month to 18 years. Patients were admitted between January 1, 2021 and December 1, 2023 due to acute liver failure or acute-chronic liver failure. The study evaluated those who received TPE or continuous renal replacement therapy combined with TPE. In statistical analyses, a P -value of <.05 was considered statistically significant. The study involved 24 patients with liver failure, comprising 13 males and 11 females. Sixteen patients (66.6%) received only TPE, while 8 patients (33.4%) were treated with TPE and CVVHDF. For patients treated only with TPE, the median INR reduced from 3.1 to 1.26, alanine aminotransferase from 1255 to 148, and aspartate aminotransferase from 2189 to 62. Similar significant reductions were observed in the TPE and CVVHDF group: INR from 3.9 to 1.26, alanine aminotransferase from 1749 to 1148, and aspartate aminotransferase from 1489 to 62. These changes were statistically significant with P -values of .01 for each parameter in both groups. Overall, 14 patients survived without requiring a liver transplant, while 4 patients underwent liver transplantation. Our study on pediatric liver failure treatment shows that both standalone TPE and its combination with CVVHDF are effective, especially as a bridge to transplantation. With 58% transplant-free survival, these therapies demonstrate significant clinical improvements. Future multicentric studies are needed for broader validation of these findings in liver failure management.