Sanliay Sahin

Aim: Infections and multidrug-resistant (MDR) pathogens are concerns in pediatric palliative care (PPC) units, where children with life-limiting conditions undergo invasive procedures and prolonged hospitalization. This study evaluated clinical characteristics, microbiological profiles, and factors associated with MDR infections among pediatric patients hospitalized in a PPC unit. Methods: This retrospective observational study included 66 children aged 1 month to 18 years who were admitted to the PPC unit of our hospital due to infection between June 2023 and January 2024. Demographic data, comorbidities, device use, infection sites, and microbiological results were reviewed. Bacterial identification and antimicrobial susceptibility testing were performed using the Vitek2 system and interpreted according to EUCAST. Results: The median age was 48 months (IQR 19–106); 63.6% were male. Lower respiratory tract infection was most common (68.2%), followed by sepsis (13.6%) and urinary tract infection (12.1%). Pseudomonas aeruginosa (36.4%) and Klebsiella pneumoniae (27.3%) predominated. MDR organisms represented 15.2% of isolates. MDR infections were significantly associated with percutaneous endoscopic gastrostomy or mechanical ventilation use (p = 0.033). Prolonged hospitalization and multiple comorbidities tended to increase the MDR risk but did not reach statistical significance. Conclusions: Gram-negative MDR infections constitute an important problem in PPC units. Frequent exposure to invasive devices and antibiotics increases susceptibility to resistant pathogens. Reinforcing infection prevention, optimizing antimicrobial stewardship, and monitoring device-related infections are essential to reduce morbidity and improve care quality in pediatric palliative care.

Objective: The clinical profiles of child victims admitted to hospitals following earthquakes, as well as the characteristics associated with hospital stay, are important. This study aimed to analyze the clinical outcomes of pediatric victims admitted following a sudden earthquake to enhance preparedness for accessing essential health services to reduce losses in future disasters. Methods: Among 2158 patients referred to the pediatric emergency department (PED), 356 children followed at our tertiary inpatient clinic were included. Demographics, surgical interventions, and the presence of life‐threatening conditions like crush syndrome and fasciotomy/amputation were investigated. Crush syndrome was defined as clinical and laboratory evidence of muscle injury accompanied by systemic complications odds ratios (OR) with 95% confidence intervals (CI) were calculated. Results: Among the patients, 56.5% were male. The median length of hospital stay was 4 days (range: 1–120). The most common injury mechanism was entrapment under rubble, and the lower extremities were the most frequently affected injury site. Compartment syndrome developed in 31.7% of patients, and 2.8% underwent amputation. Crush syndrome was identified in 75.3% of hospitalized patients and was significantly more common among children admitted on the second day or later after the earthquake. Elevated creatine phosphokinase (CPK) levels significantly increased the likelihood of developing crush syndrome (OR: 61.7, 95% CI) and the need for fasciotomy (OR: 16.9, 95% CI). Fasciotomy was required in 28.9% of patients. Dehydration was associated with an increased risk of fasciotomy (OR: 7.2) and amputation (OR: 5.4). Elevated levels of myoglobin, uric acid, blood urea nitrogen/creatinine, and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were significantly associated with crush syndrome and fasciotomy ( p < 0.001). Conclusion: The high burden of crush‐related complications in pediatric earthquake victims underscores the need for pediatric‐specific trauma protocols in disaster settings. Early identification of risk factors and rapid intervention may reduce severe outcomes such as fasciotomy, renal failure, and amputation.

Pediatric palliative care (PPC) is an evolving field that focuses on supporting children with life-limiting conditions, where the quality of care is vital. This study is a retrospective observational investigation that examines the experiences of caregivers to inform health and social service planning and enhance PPC quality. Methods: Data of pediatric patients aged 3 months to 18 years admitted to a PPC inpatient unit over two years were retrospectively reviewed. Sociodemographic characteristics of primary caregivers, including age, gender, number of siblings, education, income, occupation, and marital status, were recorded. Caregiver burden and burnout were assessed using the Zarit Burden Interview and the Maslach Burnout Inventory, respectively. Associations between caregiver characteristics and these measures were analyzed. Results: A total of 118 patients and caregivers were evaluated; 54.2% of patients were male. The most common diagnoses were neurological diseases (44.9%), followed by syndromic–genetic disorders (28.8%). About 34% of patients required more than three medical devices. Most caregivers were female (91.5%), mainly mothers and 53% had only primary education. No significant differences in care burden or burnout were found based on caregiver gender, marital status, or child’s diagnosis. However, the use of nasogastric tubes and multiple medical devices was associated with higher burnout. Lower income was significantly linked to higher care burden, while longer caregiving duration correlated with both increased burden and burnout. A moderate positive correlation was found between Zarit and Maslach scores. Conclusions: The complexity of PPC patients’ care increases caregiver burden and burnout. Expanding specialized PPC services is crucial to support caregivers and sustain home-based care.

Günümüzde pediatrik palyatif bakıma olan talep ve gereksinim giderek artmaktadır. Bu nedenle, Mersin'deki pediatrik palyatif merkezinde son altı ay içinde yatan hastaların klinik ve demografik özelliklerini değerlendirmeyi ve bu alanda edindiğimiz deneyimleri paylaşmayı hedefledik. Mersin Şehir Eğitim ve Araştırma Hastanesi Çocuk Palyatif Bakım Servisi'nde, 01/06/2023 ile 01/01/2024 tarihleri arasında takip edilen, 1 ay ile 18 yaş aralığındaki yatan hastaların dosyaları retrospektif olarak incelendi. Çalışmaya dahil edilen 279 hastanın (%59.1 erkek, %40.9 kız) medyan yaşı 62 ay ve medyan yatış süresi 7 gün olarak belirlendi. En yaygın yatış tanısı %42.7 ile serebral palsi ve mental motor retardasyondu. Malignite ise %0.7 ile en az görülen yatış tanılarından biri idi. Yatış nedenleri arasında alt solunum yolu enfeksiyonları (%46.2) ve nöbet sıklığında artış (%20.8) öne çıkmaktaydı. Hastaların %32.6’sı yoğun bakım sonrası tedavi için kabul edilmişti. %69.5'i Türkiye Cumhuriyeti vatandaşı iken, şehir dışından gelen hasta sayısı %15.8'di. %67.4'ü çocuk acil servisinden, %32.6'sı yoğun bakım ünitelerinden kabul edilmişti. %17.2'sinde trakeostomi mevcuttu ve ev tipi mekanik ventilatör bağımlıydı. Beslenme gereksinimi olan hastaların %10'u nazogastrik tüp, %20'si ise perkütan endoskopik gastrostomi ile beslenmekteydi. Hastaların %11’inde ventriküloperitoneal şant mevcuttu. Bası yarası %6.5'inde tespit edildi. %93.2'si taburcu edilirken, %6.1'i çocuk yoğun bakım ünitesine devredildi. Sonuç olarak, 15 hasta yaşamını yitirdi. Onkolojik hastaların takibi ve desteklenmesi için daha fazla kaynağa ihtiyaç vardır. Pediatrik palyatif bakımın daha geniş kapsamda ele alınması ve bu alandaki eksikliklerin giderilmesi için ileri çalışmalara ihtiyaç duyulmaktadır.

Pediatrik palyatif bakım ülkemizde ve dünyanın pek çok ülkesinde yeni gelişen bir alt uzmanlık alanıdır. Hayatı tehdit eden hastalığı olan çocukların sayısı ülkemizde de gün geçtikçe artmaktadır. Bu hastalara verilecek olan palyatif bakımın kalitesini belirlenmesi, verilecek hizmetin kalitesini arttıracaktır. Bu derlemenin amacı pediatrik palyatif bakımın hizmet kalite standartlarını tanımlamaktır.

The problem of EOL care of a child is very important because the recovery of a family from grief over a child’s death depends on that manner. For improving the quality of this specific care, it would be useful to assess the life expectancy/survival of congenital anomalies, life-threatening diseases, conditions that may shorten a child’s life, and the outcomes of palliative care units regarding mortality. Besides, there is an urgent need for more data on what families define as ‘good death’ and how to cope with the loss. Not only caregivers but also siblings, grandparents, relatives, and healthcare professionals are impacted by a child’s death and their needs must be explored. Pediatric palliative care staff in low/middle-income countries need educational assistance for skills of multidisciplinary training about end-of-life care to improve appropriate care for dying children and their families. It is important to provide sensitive and empathetic end-of-life care to children in a family-centered manner helping them to find comfort, meaning, and support while enhancing the quality of a child’s life and death. Many attending physicians felt inexperienced when communicating with dying patients and their families while discussing the transition to palliative care and resuscitation status. Also, the good death of a child is an emerging concept in this research domain to improve end-of-life care for dying children and their families. The goal of this review was to provide pediatric healthcare professionals and physicians with an overview of palliative care regarding end-of-life issues.

Aim: Children with complex chronic conditions are main candidates for pediatric palliative care (PPC). Despite the proven advantages of palliative care for these children, the literature lacks on the adequate description of the pediatric population receiving this care. The aim of this study was to describe demographic characteristics of the patients, to examine the patient survival and the factors affecting patient survival. To our knowledge, this is the first description of the cohort of children and adolescents on PPC in Turkey. Materials and methods: This retrospective chart review study examined patients receiving palliative care at University of Health Sciences, Dr. Sami Ulus Maternity and Children's Training and Research Hospital between 2.12.2019 and 31.12.2020. The data of demographics, underlying diagnosis, medical technology dependence, symptoms at admission, number of hospitalizations, number of emergency department (ED) admissions were collected. Results: 70 male and 66 female patients were admitted 259 times during the observation period. The median length of hospital stay was 7 days. Median age at referral was 44 months (range:2.7-215). Fifty-one patients (37.5%) were younger than 2 years of age. Neurological diseases were the most prevalent disease group. 56 of our patients (41%) had a tracheostomy. 82 patients (60.3%) needed respiratory support. Fifty of them were ventilated through home-type mechanical ventilator. Only 28 patients (20.6%) could be fed through oral route. Nasogastric tube (n=84, 61.8%) was the main device used by children who needed nutritional support. 52% of patients were referred from ED. Most prevalent symptoms of the patients at admission were dyspnea and tachypnea. 151 of the patients (58.3%) were diagnosed with infection, the most common infection was lower respiratory tract infection (n=103, 39.8%). Of 259 PPC center admissions 224 (86.5%) were discharged to home. Twenty-seven children (20%) died during study period. Nineteen of deceased patients died in intensive care unit (70%). The 1-year survival rate of the patients was 78.1%. In logistic regression analysis the risk of death was 3.4 times higher in patients ≤2 years of age (CI: 1.4-8.8, p=0.01) and in patients with respiratory support (CI: 1.1-11.0, p=0.04). Conclusion: Describing the cohort of patients on PPC provides important information on the complexity of their disease process, types of their illnesses, medical technology dependence, re-admission rates, mortality status and factors affecting mortality. Important research has been done but pediatric palliative care is still in infancy in Turkey. Future prospective research is needed to understand the unique challenges of PPC.

Background: To determine the factors affecting the development of pneumothorax in critically ill children admitted to pediatric intensive care unit (PICU). Methods: This was a single-centered retrospective case control study comparing the clinical features of mechanically ventilated patients, who developed pneumothorax with matched control cases. Results: The study screened 2850 patients admitted to the PICU over a 3 year period. Among 1140 patients who were mechanically ventilated, 4.4% (n = 50) developed pneumothorax. Median age was 24 months. Patients with pneumothorax were found to have median pediatric risk of mortality (PRISM):26, Pediatric logistic organ dysfunction (PELOD):22 and multiorgan disfuction (MODS):3 whereas in the control group they were 15.5, 12, and 3, respectively. PRISM and PELOD were significantly higher in pneumothorax group. Pneumothorax was observed on the 11.6th day of mechanical ventilation (MV). Pneumothorax was mainly secondary to pneumonia (n = 18, 36%) and MV-related reasons (n = 13, 26%). The risk of pneumothorax was higher when P-mean was > 14 cmH₂O and tidal volume (TV) was > 10 mL/kg (P < 0.05). The mean albumin level was 2.7 g/dL in the pneumothorax group compared with 3.6 g/dL in the control group (P < 0.001). The number of days on mechanical ventilator and the duration of hospital stay were statistically significant in pneumothorax group (P < 0.05). The mortality outcome was 44% (n = 22) in the pneumothorax group compared with 6.7% (n = 2) in the control group (P < 0.001). Conclusions: Pneumothorax in critically ill children was related to increased morbidity, mortality and prolonged length of stay in hospital. Higher pediatric risk of mortality (PRISM) and Pediatric logistic organ dysfunction (PELOD) scores were associated with increased risk of pneumothorax. Hypoalbuminemia as a reflection of malnutrition status of patients might be a risk factor. Keywords: Pneumothorax; Critically Ill Children; Albumin; Mechanical Ventilation; Pediatric Intensive Care Unit

To determine the indication and necessity of echocardiographic assessment and therapeutic interventions in critically ill children. A total of 140 children, including 75 mechanically ventilated (MV) and 65 spontaneously breathing (SB) children, who were admitted consecutively from March to August 2013 were evaluated prospectively. Data regarding the indication for echocardiography and therapeutic approaches used were documented. For evaluating disease severity, the Pediatric Risk of Mortality Score III (PRISM) was ascertained. The correlation between PRISM score and the requirement of echocardiographic evaluations were analyzed. Patients ages were between 45 days to 18 years. The male-to-female ratio was 1.33. In 35.4% patients who underwent echocardiographic evaluation, no definitive alteration occurred in treatment approach, whereas in the remaining 64.6% patients, decisive or supplemental information was gathered. Echocardiography was indicated in 88% MV children and 46.2% SB children. Echocardiographic evaluation was necessary in MV children and there was a positive correlation between the PRISM score and the requirement of echocardiographic assessment (p<0.001). Echocardiographic evaluation is an invaluable tool especially in MV children and the requirement of echocardiographic assessment increases according to clinical severity. Basic training for intensivists in this procedure is crucial and needs to be improved and supported in critically ill.