621

623

EVALUATION OF CORTICOSTEROID REPLACEMENT THERAPY IN CHILDREN WITH SEVERE SEPTIC SHOCK A RANDOMISED INTERVENTION TRIAL

VIRUSES IN CHILDREN WITH BURNS INJURY IN THE PICU

AT THE RED CROSS WAR MEMORIAL CHILDRENS HOSPITAL (RCWMCH)

H. de Graaf1, K.A. Ramakrishnan2, J. Pappachan2, S. Nadel3, M. Levin4, A.

Wolf5, A. Finn6, K. Morton1, H. Gale1, M. Allan7, D. Gibb8, S. Walker8, B. Arch9,
C. Gamble9, S. Lightman10, P. Thomas11, Y. Gao12, A.P. Williams12, R.S. Heyderman13, S.N. Faust1; 1NIHR Wellcome Trust Clinical Research Facility, University
Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
2
Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom 3Paediatric Intensive Care Unit, St.
Marys Hospital, London, United Kingdom 4Paediatrics, St. Marys Hospital,
London, United Kingdom 5Paediatric Intensive Care Unit, Bristol Royal Childrens Hospital, Bristol, United Kingdom 6Bristol Childrens Vaccine Centre,
Bristol Royal Childrens Hospital, Bristol, United Kingdom 7NIHR Medicines
for Children Network, Bristol Royal Childrens Hospital, Bristol, United Kingdom 8Medical Research Council Clinical Trials Unit, Medical Research Counsil,
London, United Kingdom 9Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom 10School of Clinical Sciences, University of
Bristol, Bristol, United Kingdom 11Department of Clinical Biochemistry, Bristol
Royal Childrens Hospital, Bristol, United Kingdom 12Cancer Sciences Division,
University of Southampton, Southampton, United Kingdom 13Clinical Research
Programme, Malawi-Liverpool-Wellcome Trust, Liverpool, United Kingdom
Background and aims: Sepsis remains an important cause of death and disability
among children. Low-dose corticosteroid replacement therapy is used on PICU
for children with severe septic shock, without evidence of benefit or of no harm.
Aims: We aimed to explore potential endocrine and immune-modulatory effects
of corticosteroids to inform a potential phase 3 trial. Methods: Children with
severe septic shock were recruited from three UK PICUs. After an ACTH test,
patients were randomised 2:1 to standard care plus hydrocortisone (25mg/m2/q
6 hourly for 48 hours) or to standard care. Clinical data and study laboratory samples (endocrine and cytokine) were collected through day 6 and in
convalescence. The study was approved by the UK Research Ethics Service.
Results: 29 children, median age 60 months (range 5177) were recruited.
In descriptive preliminary analysis, there were no clinically significant differences in baseline data between the intervention and control groups, (median
PIM score 5.9 (range 0.119.6) and 12.7 (1.531.6) respectively (whole group
6.3). ACTH test was negative in 6/29 of whom 67% died (n=4) compared to
patients with a normal ACTH test of whom 4% died (n=1). Twenty patients
received corticosteroid replacement therapy. Mortality in the corticosteroid and
control groups was 22% and 17% respectively (not significant), and the median
Composite-Time-to-Complete-Organ-Failure-Resolution (CTCOFR) scores
were 4 in both groups. Preliminary data on cortisol levels did not significantly
differ between groups. Conclusions: These preliminary data suggest that corticosteroid replacement therapy does not influence the cortisol levels in children
with severe septic shock. Detailed analysis of cytokine response and gene array
data are under analysis.

622
IS LIVER TRANSPLANTATION APPROPRIATE FOR NEONATAL HSV FULMINANT LIVER FAILURE. A CASE REPORT

T. Detaille1, X. Stephenne2, S. Clment de Clty1, R. Reding3; 1Soins intensifs

pdiatriques, Cliniques universitaires Saint Luc, Brussels, Belgium 2Hpatologie pdiatrique, Cliniques universitaires Saint Luc, Brussels, Belgium 3Chirurgie
digestive pdiatrique, Cliniques universitaires Saint Luc, Brussels, Belgium

Background and aims: Neonatal HSV 2 infection is a rare but life threatening
condition. Fulminant liver failure is one of the most severe forms of the disease,
associated with a high mortality rate. Treatment involves supportive care and acyclovir therapy. However, even appropriately diagnosed and treated, liver function
will continue to deteriorate in many patients. Risks of neurological involvement
as well as recurrence of the infection still question the role of liver transplantation
(LT) in those patients. Aims: Since only a few HSV infected newborn have been
transplanted, reporting it is important in order to decide whether this option is
valuable. Methods: We describe a successful LT in a neonate with HSV 2 related
acute liver failure. Results: A 3,7kg term male newborn was admitted at day 7 of
life for alteration of mental status, poor feeding and jaundice. He presented with
leucopenia and thrombocytopenia, respiratory insufficiency, acute kidney injury
and liver failure. He was treated with Aciclovir. The full work-up concluded
to severe neonatal HSV 2 infection. He was referred for LT assessment. In the
absence of neurological contra-indication, he underwent a deceased donor LT at
day 30 of life, under Aciclovir treatment. His postoperative course was favorable,
even on the neurological point of view. Conclusions: We report successful LT in
a HSV 2 neonatal fulminant liver failure. We think that LT should be offered to
those patients when no irreversible neurological lesions are detected and when
infection is controlled under Aciclovir treatment.

K. Dimitriades1, B.M. Morrow1, D.R. Hardie2, A.C. Argent1; 1Intensive Care

Unit, Red Cross War Memorial Childrens Hospital, Cape Town, South Africa
2
Virology, National Health Laboratory Services, Cape Town, South Africa
Background and aims: Children with burn injuries are commonly admitted to
the PICU at RCWMCH, especially during winter when respiratory viruses are
prevalent. Aims: To investigate the prevalence, spectrum and seasonality of respiratory viruses in children admitted to PICU with burn injuries, and describe the
clinical outcomes of these children. Methods: Retrospective review of all children admitted to PICU with burn injuries over 55 months. The institutional
human research ethics committee approved this study with waived consent.
Results: Two-hundred admissions were recorded in 174 children (63.5% male)
with burn injury. Fifty-one viruses were isolated in 45 admissions of 43 patients
(24.7%). Sixteen viruses (31.3%) were isolated more than 48 hours after admission to PICU. Commonly identified viruses were Rhinovirus A (n=20 isolates),
Adenovirus (n=15) and respiratory syncytial virus (n=5). A seasonal peak in burn
injury and viral observations occurred over the winter months. Children with
viral infections were younger (median (interquartile range, IQR,) age 18.7 (12.2
40.4) versus 33.3 (14.3 70.4) months, p=0.02) and had longer PICU admissions (median (IQR) 7 (4 11) vs. 3 (1 7) days, p<0.0001). There was no
association between inhalational thermal injury and viral identification. Overall
mortality was 12%, with no significant difference between those with and without positive viral isolates. Conclusions: Respiratory viruses are commonly isolated from children admitted to the PICU with burn injury who have symptoms
compatible with respiratory infections and are associated with increased PICU
length of stay. Further studies are required to examine the role of specific viruses
in these children.

624
UMBILICAL VENOUS CATHETER RELATED PORTAL
VENOUS THOROMBOSIS IN NEWBORN BABIES: A PROSPECTIVE STUDY

A. Dursun1, G. Cinar1, B. Ucan1, N. Hakan1, S. Eksioglu1, D. Dilli1, N. Okumus1, A. Zenciroglu1; 1neonatology, dr. sami ulus pediatric research and training
hospital, Ankara, Turkey

Background and aims: In this study, the portal venous complications in newborns underwent umbilical venous catheterization was investigated. Aims: Aim
Methods: Sixty newborns who underwent umbilical catheterization were analyzed. All catheterized newborns were prospectively examined by Doppler ultrasound (D-USG) at 24-72h after the catheter insertion, 48h after the catheter
removal, and at the end of 3rd and 6th months. Thrombosis was graded in tree
stages. Mean pain score (between 011) during catheterization, clinical signs of
thrombosis, duration of catheterization, thrombophilia screen results, prognosis
and therapy were noted. Twenty six of the patients were excluded from the analysis. Therefore, 34 patients included to final analysis. SPSS was used for statistical
analysis. P<0.05 was considered as significant. IRB approval was taken. Results:
Gestational age was 34.84.8 weeks and mean birth weight was 24761069gr.
Mean pain score was 4.63.1. D-USG was in normal in 61.8% of the patients
while there was stage 1 thrombosis in 11.8%, stage 2 in 2.9%, and stage 3 thrombosis in 23.69% of the patients. None of the patients had any clinical signs for
thrombosis. Ten patients needed enoksaparin therapy. All cases for thrombosis
were fully regressed except 4 who showed partial regression. There were no relationship between the duration of catheterization and development of thrombosis (p>0.05). Thee patients showed MTHFR-A1298C homozygote mutation.
Conclusions: In spite of asymptomatic, one third of the newborns underwent
umbilical venous catheterization developed portal venous thrombosis and nearly
half of them needed antithrombotic therapy. Newborns should be followed after
umbilical catheterization to identify thrombotic complications

625
SERUM VITAMIN D STATUS AMONG CRITICALLY ILL CHILDREN ADMITTED TO A PAEDIATRIC INTENSIVE CARE UNIT

K. Ebenezer1, M. Natarajan1, V. Job2, A. Belavendra3, A. Dawodu4, M.A.R.K.

Steinhoff4; 1Paediatric intensive care unit, Christian Medical College, Vellore,
India 2Clinical Biochemistry, Christian Medical College, Vellore, India 3Biostatistics, Christian Medical College, Vellore, India 4Gobal health centre, Cincinnati
childrens medical centre, Cincinnati, USA
Background and aims: Low serum 25-hydroxyvitamin D (25[OH] D) level is
associated with increased illness severity and longer hospital stays among critically

Pediatr Crit Care Med 2014 Volume 15 Number 4 (Suppl.)

ill children. Aims: To determine vitamin D status and its association with the
clinical outcome of children admitted to PICU. Methods: 54 consecutive children with medical and surgical diagnoses were included with parental consent.
Severity of illness and vasopressor use were assessed using PIM-2 and CV-SOFA
respectively. Vitamin D deficiency was defined as serum 25-OHD level <20ng/
ml (50nmol/L). Primary outcome measures were serum 25-OHD level and inhospital mortality. Institutional Research Board approval was obtained prior to
commencement of the study. Results: There were 21 (40%) infants, 15 (28.8%)
between 15 years and 16 (30.4%) over 5 years of age. 60% were boys. Vitamin
D deficiency was seen in 40.1% of the critically ill children and insufficiency
(serum 25-OHD 2030ng/ml) in another 23%. Median vitamin D level was
25.1(IQR: 16.234.2). Higher age was associated with low vitamin D levels (rs=
-0.34, p=0.01). Children with a diagnosis of Shock had lower median vitamin
level of 17.8 (range 3.241.0). 10 (19.2%) children had either died or were taken
home to die. The proportion of children with an adverse outcome was 23.8%
among those with vitamin D level < 20ng/mL as compared to 16.1% in those
who had 20ng/ml (p=0.49). Higher PIM Score or SOFA score were associated
with low vitamin levels (rs=-0.29, p=0.04). Conclusions: 40% of the patients had
vitamin D deficiency. Low Vitamin D levels were associated with higher severity
of illness and maximum level of inotrope use.

626
OUTCOME OF INTENSIVE CARE OF CHILDREN WITH MALNUTRITION IN A DEVELOPING COUNTRY
M.A. El-Bayoumi1, M.M. El-Assmy1, A.A. Alwakeel1, A.M. Abdelkader1; 1PICU,
Mansoura University Children Hospital, Mansoura, Egypt

Background and aims: Malnutrition is prevalent in developing countries where

children with malnutrition constitute a significant proportion of admissions to
PICUs. Aims: This study aimed at comparing outcomes of PICU admission
between well and mal-nourished children. Methods: 573 children admitted over
the period of two years to a tertiary PICU in Egypt were prospectively enrolled in
the study. Nutritional assessment was performed using weight, height and BMI
for age. Children were classified into two groups; Group A included well-nourished children and Group B included malnourished children who had Z score of
their anthropometric measures less than -2. IRB Approval was waived. Results:
236/573 (41.2%) children were malnourished. There was no difference in age,
sex or PRISM score between the two groups on admissions. Group B had longer
duration of mechanical ventilation (p < 0.001), higher incidence of catheterrelate blood stream infection (p = 0.018). The two groups were not different
regarding length of PICU stay (p = 0.542). The rise of leucocytic on developing
nosocomial infection was higher in group A (p< 0.001). There was a higher mortality in Group B (33/236 = 14%) compared to Group A (30/337 = 8.9%) without statistical significance (p = 0.059). Conclusions: Malnutrition is prevalent
among children admitted to PICU. Malnourished children had higher mortality,
more catheter related-blood stream infection and longer mechanical ventilation.
Care needs to be taken while applying diagnostic criteria for hospital acquired
infection in this subset of patients as they may not mount a similar increase in
their leucocytic count compared to their well-nourished counterparts.

627
NOROVIRUS GENOGROUP II PREDOMINANCE IN INFANTS
& YOUNG CHILDREN WITH ACUTE GASTROENTERITIS IN
MANSOURA UNIVERSITY CHILDRENS HOSPITAL - EGYPT
G.M. El-Nady1, R.I. Badr1, M.F. Salama1, B. Shouman2, M.A. El-Bayoumi3;
1
Microbiology and Immunology, Mansoura Faculty of Medicine, Mansoura,
Egypt 2NICU, Mansoura University Children Hospital, Mansoura, Egypt
3
PICU, Mansoura University Children Hospital, Mansoura, Egypt

Background and aims: Norovirus is one of the leading cause of epidemics of

gastroenteritis worldwide and are an important cause of sporadic gastroenteritis illnesses in children and adults. Aims: The objective was to detect and genotype Norovirus in infants and children younger than 3 years of age presenting with acute
gastroenteritis and admitted to Mansoura University Childrens Hospital, Egypt.
Methods: Eighty six infants and children younger than 3 years of age, admitted with acute gastroenteritis over a two years period, were prospectively enrolled.
Faecal samples were collected from children within 72 hours of onset of symptoms for RT-PCR using degenerate primers for the conserved region. Genogroup
specific primers, for GI and GII, were used for genotyping. IRB approval was
waived for this non-interventional study. Results: Mean age of the studied group
of children was 14 months. All patients included complained of diarrhea while 71
(82.5%) children had fever and 79 (91.8%) children had vomiting. Norovirus was
detected in 22/86 (25.58 %) of the total fecal samples collected by PCR. Overall,
19 (86.36%) of the 22 samples positive for norovirus were identified as genogroup
GII and 3 (13.63%) as GI. The monthly NoV positivity rate showed no significant
variation. Conclusions: Norovirus is an important pathogen causing sporadic

Pediatr Crit Care Med 2014 Volume 15 Number 4 (Suppl.)

acute gastroenteritis in infants and children up to 3 years of age in a developing

country. NoV genogroup GII is the predominant genotype detected. Phylogenetic
analysis of the capsid gene is recommended in future studies.

628
RELIABILITY OF NEUTROPHIL CD64 FOR DIAGNOSIS OF
INFECTION IN TERM NEWBORN INFANT WITH RESPIRATORY DISTRESS

S. ELMeneza1, M. AbuShady1, A. Mohamed2, A. Abd-Elbaseer3; 1Pediatrics, faculty of Medicine for Girls ALAzhar University, Cairo, Egypt 2Clinical pathology, faculty of Medicine ALAzhar University, Cairo, Egypt 3Pediatrics, faculty of
Medicine ALAzhar University, Cairo, Egypt
Background and aims: Early onset sepsis can be presented as a fulminant, multisystemic illness during first few days of life or with nonspecific clinical signs of
infection. Therefore the diagnosis of early sepsis in newborn infants may need to
be differentiated from other conditions that mimic sepsis. Aims: The aim of this
work is to identify the reliability and utility of CD64 as novel immunological rapid
indicator in diagnosis of early-onset neonatal infection among full term infants.
Methods: Design: This prospective study was conducted on 80 term neonates. Setting: NICU of Al-Zaharaa University Hospital. Participants and Intervention: Sixty
(60) of these neonates had been suffered from respiratory distress (RD). Complete
blood count, CRP, blood gases, blood culture, and CD64 by flowcytometry were
estimated. Outcome Measures: The roles of these markers for predicting early sepsis were determined. Results: The percentage of neutrophils expressing CD64 was
highly significant increase in all respiratory distress cases with infection when compared to respiratory distress cases without infection as p < 0.001. The results of the
present study also demonstrated a highly significant rise of both CD64% and its
expression intensity in newborn infants with gram negative septicemia as compared
to those with gram positive septicemia and Candida infection (p<0.01). Conclusions: Neutrophil CD64 is superior to other sepsis markers for detecting systemic
infection or sepsis, since it is not only combines high sensitivity with high specificity
but also provides early and rapid results than cultures and CRP.

629
GUILLAIN-BARRE SYNDROME RESEMBLING PARALYTIC
RABIES CASES

S. Erdogan1, A. Gktepe2, M. Bosnak1; 1pediatric intensive care, Gaziantep University Faculty of Medicine, Gaziantep, Turkey 2pediatri, Gaziantep University
Faculty of Medicine, Gaziantep, Turkey
Background and aims: We introduce paralytic rabies with acute axonal neuropathy that closely resembled axonal Guillain- Barre syndrome (GBS). Aims:
14 year old Syrian male patients suffered vomiting, headache and fever which
started 3 days ago and quickly spread to the upper extremities with complaints
of muscle weakness was noted that refer to external center. He was hospitalized 2
days ago with a preliminary diagnosis of GBS and prophylactic administration of
antibiotics and IVIG therapy was started. But muscle weakness was progressed, he
was transferred to PICU. Respiratory failure was developed and intubated. EMG
showed severe axonal degeneration and demyelination ascending paralysis finding
and albuminocytologic dissociation in CSF examination suggested for the GBS as
a preliminary diagnosis and plasmapheresis (PF) was started, but clinical improvement wasnt found. 2 months ago in Syria, he had been bitten by a street dog
from left ankle and did not receive prophylaxis. Rabies was suspected and biopsy
samples also taken and sent to the National Reference Laboratory, the circulatory
collapse occurred and died. Postmortem brain biopsy was taken be in the tissue of
Negri inclusion bodies were found, skin biopsy was positive DFA, virus was isolated in the samples. Results: Due to Syrian civil war, the number of immigrants
in our country is increasing. Syrias health services can not be applied because of
the war, and one of the results is the increasing number of rabies cases, although
it is not an endemic region in our country. Acute onset and rapid deterioration
in the differential diagnosis of viral encephalitis, rabies should be considered too.

630
EARLY POSTNATAL HEMORRHAGIC SHOCK DUE TO
INTRAABDOMINAL HEMORRHAGE IN A NEWBORN WITH
HEMOPHILIA

S. Erol1, B. Aydin1, D. Dilli1, B. Malbora2, S. beken2, H.G. Cinar3, A. Zencirioglu1, N. Okumus1; 1neonatology, dr. sami ulus pediatric research and training
hospital, ankara, Turkey 2haematology, dr. sami ulus pediatric research and training hospital, ankara, Turkey 3radiology, dr. sami ulus pediatric research and training hospital, ankara, Turkey

Background and aims: Hemophilia A which is an X linked recessive disorder is

one of the causes of congenital bleeding diathesis in newborns. Aims: We present