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IntroductionHyperferritinemia is associated with increased mortality in pediatric sepsis, multiple organ dysfunction syndrome (MODS), and critical illness. The International Histiocyte Society has recommended that children with hyperferritinemia and secondary hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS) should be treated with the same immunosuppressant/cytotoxic therapies used to treat primary HLH. We hypothesized that patients with hyperferritinemia associated secondary HLH/sepsis/MODS/MAS can be successfully treated with a less immunosuppressant approach than is recommended for primary HLH.MethodsWe conducted a multi-center cohort study of children in Turkish Pediatric Intensive Care units with hyperferritinemia associated secondary HLH/sepsis/MODS/MAS treated with less immunosuppression (plasma exchange and intravenous immunoglobulin or methyl prednisolone) or with the primary HLH protocol (plasma exchange and dexamethasone or cyclosporine A and/or etoposide). The primary outcome assessed was hospital survival.ResultsTwenty-three children with hyperferritinemia and secondary HLH/sepsis/MODS/MAS were enrolled (median ferritin = 6341 μg/dL, median number of organ failures = 5). Univariate and multivariate analyses demonstrated that use of plasma exchange and methyl prednisolone or intravenous immunoglobulin (n = 17, survival 100%) was associated with improved survival compared to plasma exchange and dexamethasone and/or cyclosporine and/or etoposide (n = 6, survival 50%) (P = 0.002).ConclusionsChildren with hyperferritinemia and secondary HLH/sepsis/MODS/MAS can be successfully treated with plasma exchange, intravenous immunoglobulin, and methylprednisone. Randomized trials are required to evaluate if the HLH-94 protocol is helpful or harmful compared to this less immune suppressive and cytotoxic approach in this specific population.

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Higher mortality and morbidity are well established in children with malignancies in whom intensive care admissions are required. A retrospective cohort study was conducted to assess the risk factors for children with cancer in the pediatric intensive care unit (PICU) for short-term outcome (survival vs. nonsurvival when leaving the PICU). The records of 36 children with a median age of 5 years (range: 0.5 to 21) between August 2004 and August 2007 were reviewed. Mortality rate was 55%, higher than the yearly overall PICU mortality rate of 12% (P<0.0001). The mean Pediatric Risk of Mortality Score (PRISM) III score among survivors was lower than that among nonsurvivors (9.4+/-5.7 vs. 16.4+/-5.3, P=0.001). Comparison of observed and predicted mortality derived from the PRISM III score showed that distribution of outcome was not different and the prediction model performed well (goodness of fit test: chi=3.64, df=6, P=0.725). The mortality rates were 66.6% and 33.3% in patients with high (>10 points) and low (< or =10 points) PRISM III score, respectively (P=0.05). Mortality rate was significantly related to presence and number of organ system dysfunction (P=0.031 and P=0.013, respectively), sepsis (P=0.05), mechanical ventilation (P=0.005), and positive inotropic support (P=0.003). By using multiple logistic regressions, the independent risk factor was PRISM III score at the time of admission to PICU (P=0.05). The PRISM III score performed well as a predictor of outcome. For decision to admit such patients to the PICU or to forgo life-sustaining therapies, other factors such as need for mechanical ventilation and positive inotropic support, presence and numbers of organ system dysfunction should be taken into consideration as well.

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This study shows that the implementation of a multidimensional infection control strategy was associated with a significant reduction in the CLAB rates in the PICUs of developing countries.

Patients admitted with anatomic or functional airway problems had higher decannulation rates. Patients who were successfully decannulated also had significantly shorter PICU stays prior to tracheostomy. In patients with neurologic and muscular disease, or with chronic heart/lung disease, decannulation rates are very low, and these patients have a higher mortality risk after discharge.

Our findings demonstrated that implementing a multidimensional infection control approach is associated with a significant reduction in the CAUTI rate of PICUs in developing countries.