Atrial fibrillation in a child with multisystem inflammatory syndrome in children.

Atrial fibrillation (AF) is a rare complication of multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A 10-year-old boy with a history of SARS-CoV-2 infection 10 weeks before presentation developed AF following the onset of MIS-C. The patient presented with high fever, conjunctival congestion, erythematous throat, and a diffuse erythematous macular rash involving the face and both legs, in addition to respiratory distress and shock requiring oxygen and vasopressor support. Echocardiography revealed poor left ventricular contractility and normal-appearing coronary vessels. The patient received intravenous immunoglobulin, pulse methylprednisolone, and aspirin. AF resolved with synchronized cardioversion and the patient's clinical condition subsequently improved. This case reports a rare phenomenon of AF in a case of MIS-C. Further research is required to verify the association.

Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial.

OBJECTIVE: To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock. DESIGN: Parallel-group, blinded multicenter trial. SETTING: PICUs of four tertiary care centers in India from 2017 to 2020. PATIENTS: Children up to 15 years of age with septic shock. METHODS: Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality. INTERVENTIONS: MES solution ( n = 351) versus 0.9% saline ( n = 357) for bolus fluid resuscitation during the first 7 days. MEASUREMENTS AND MAIN RESULTS: The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusion-related AEs such as fever, thrombophlebitis, or fluid overload between the groups. CONCLUSIONS: Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization.

Circulating Histones and Severity of Illness in Children with Sepsis: A Prospective Observational Study.

OBJECTIVES: To measure circulating histone H3 levels in children with severe sepsis and explore its relationship with severity of illness and organ failures. METHODS: Children aged 3 mo to 12 y with severe sepsis admitted to pediatric intensive care unit (PICU) were prospectively studied. Healthy controls were enrolled from the outpatient department for comparison. Levels of H3 histones were measured on day 1 and day 3. RESULTS: Thirty-seven patients and 14 controls with median (IQR) age 5 (0.67, 8) and 5 (3, 7) y, respectively were enrolled. Common diagnoses included severe pneumonia (n = 9), staphylococcal sepsis (n = 6), and seasonal tropical infections (n = 4). Two-third (n = 26, 70%) had septic shock. One third (35%) had an unfavorable outcome; 11 died and 2 discontinued care. Median (IQR) H3 levels were not statistically different among patients with sepsis and controls [0.84 (0.62, 1.13) vs. 0.72 (0.52, 0.87) ng/mL; p = 0.10]. There was no significant change in H3 between day 1 and day 3 [0.84 (0.62, 1.13) vs 0.74 (0.5, 0.98) ng/mL; p = 0.22]. Children with thrombocytopenia (n = 27) showed a trend towards higher H3 compared to those without thrombocytopenia (n = 10) [0.9 vs. 0.67 ng/mL; p = 0.06]. However, H3 levels were not elevated in patients with cardiovascular dysfunction, those needing renal-replacement therapy, or unfavorable outcomes. CONCLUSION: The present data provides early evidence that in children hospitalized with severe sepsis, histone H3 is not elevated as compared to healthy controls. H3 levels during initial days of sepsis requiring PICU admission were not different with regards to severity of illness, organ dysfunction, and clinical outcome. There was a trend towards elevated H3 in children with thrombocytopenia, which needs further evaluation.

Medical Oxygen: A Lifesaving Drug During the COVID-19 Pandemic-Source and Distribution.

Oxygen is an essential lifesaving medicine used for several indications at all levels of health care. The COVID-19 pandemic and its recent second wave have resulted in a surge in demand for necessary resources, including trained staff, hospital beds, and medical supplies like oxygen. Limited availability of these resources resulted in added risk of adverse outcomes. Also, the widespread unregulated use of oxygen by the general public in household settings poses safety concerns. This review focuses on sources of medical oxygen like cryogenic oxygen plants, pressure swing adsorption, oxygen concentrators, and oxygen cylinders. Their specifications, storage, distribution within healthcare settings, regulation, and safety concerns have been considered. Resources needed for calculating oxygen demand, surge planning, identifying the suitable source, and distribution systems for different settings have been detailed. This review aims to help the hospital administrators, biomedical engineers, and clinicians plan and rationalize oxygen usage in low- and middle-income countries during the COVID-19 pandemic.

A rare case of toxocariasis presenting with hypereosinophilic pericardial effusion and mycotic aneurysm.

Parasitic infections are the leading cause of hypereosinophilia in the paediatric population in tropical countries. We report an unusual case of Toxocara infection in an eight-year-old boy who presented with intermittent fever, hypereosinophilia complicated by massive pericardial effusion and a mycotic aneurysm. This child received treatment with four weeks of albendazole and steroids.

Cerebral Phaeohyphomycosis: Subacute Meningoencephalitic Presentation in a Child.

Cerebral phaeohyphomycosis is a rare but serious fungal infection of the central nervous system caused by dematiaceous septate fungi characterized by the presence of melanin-like pigment within the cell wall that is a pale brown to black. It is associated with poor prognosis despite aggressive treatment. We report a previously well 3-year boy with cerebral phaeohyphomycosis who had subacute meningoencephalitic presentation with refractory raised intracranial pressure and had fatal outcomes. The diagnosis was confirmed by histopathological examination of brain tissue obtained by brain biopsy.

Passive Leg Raising for Fluid Responsiveness in Children: Is it Reliable?

How to cite this article: Ismail J, Bansal A. Passive Leg Raising for Fluid Responsiveness in Children: Is it Reliable? Indian J Crit Care Med 2020;24(5):291-292.

Sensitivity and Specificity of Bedside Qualitative Troponin I Test Kit as Compared with the Standardized Quantitative Lab Test for Troponin I.

Background and objective Myocardial infarction (MI) is the leading cause of mortality and morbidity worldwide. Early diagnosis of MI remains the mainstay of prompt treatment. Thus, the shorter the door-to-needle time, the more efficient is the emergency department (ED) to cope with a heart attack emergency. To improve the diagnosis of MI, this study aimed to determine the sensitivity and specificity of (qualitative) troponin I kit against the quantitative lab test for troponin I. Materials and methods Patients of both genders admitted at the Karachi Institute of Heart Diseases with acute coronary syndrome (ACS)/non-ST-elevation myocardial infarction (NSTEMI) were administered a standardized questionnaire. Quantitative analysis of troponin I was carried out by the hospital laboratory. The sample was simultaneously used for qualitative analysis of troponin I using the troponin I test kit. Results We recruited 200 patients comprising 134 (67%) males and 66 (33%) females. In total, 130 (65%) were hypertensive, 64 (32%) had dyslipidemia, 56 (28%) presented with a family history of MI, 60 (30%) had diabetes mellitus, 56 (28%) were smokers, and 24 (12%) presented with a previous history of MI. The kit showed 98% sensitivity and 100% specificity as compared to the quantitative test with a cutoff of 0.30 ng/dl, i.e., the quantitative test showed 128 positive and 72 negative cases, whereas the qualitative test showed 125 positive and 75 negative cases. The differences in test results were on values of 0.39, 0.40, and 0.42 ng/dl, as the qualitative test showed negative results. Conclusion This study showed that the qualitative kit is highly sensitive and specific at higher values of troponin I, i.e., ≥ 0.5 ng/dl. The qualitative test could be very beneficial in cost and time savings for the non-conclusive patients, like NSTEMI and ACS in the ED, and patients coming to the outreach chest pain centres where laboratory services are not adequate and whose Trop I values are not very close to the minimum cutoff values.

Decompressive craniectomy in pediatric non-traumatic intracranial hypertension: a single center experience.

Purpose: To study the clinical profile and predictors of outcome in children undergoing decompressive craniectomy (DC) for non-traumatic intracranial hypertension (ICH).Materials and methods: Mixed observational study of children, aged 1 month-12 years, who underwent DC for non-traumatic ICH in a tertiary care pediatric intensive care unit from 2012 to 2017. Data on clinical profile and outcome were retrieved retrospectively and survivors were assessed prospectively. The primary outcome was neurological outcome using Glasgow Outcome Scale-Extended (GOS-E) at minimum 6 months' post-discharge. GOS-E of 1-4 were classified as a poor and 5-8 as a good outcome.Results: Thirty children, median (IQR) age of 6.5 (2, 50) months, underwent DC; of which 26 (86.7%) were boys. Altered sensorium (n = 26, 86.7%), seizures (n = 25, 83.3%), pallor (n = 19, 63.3%) and anisocoria (n = 14, 46.7%) were common signs and symptoms. Median (IQR) Glasgow Coma Scale at admission was 9 (6,11). Commonest etiology was intracranial bleed (n = 24; 80%). Median (IQR) time to DC was 24 (24,72) h. Eight (26.7%) children died; 2 during PICU stay and 6 during follow-up. Neurological sequelae at discharge (n = 28) were seizures (n = 25; 89.2%) and hemiparesis (n = 16; 57.1%). Twenty-one children were followed-up at median (IQR) duration of 12 (6,54) months. Good neurological outcome was seen in 14/29 (48.2%) and hemiparesis in 10/21 (47.6%) patients. On regression analysis, anisocoria at admission was an independent predictor of poor outcome [OR 7.33; 95%CI: 1.38-38.87; p = 0.019].Conclusions: DC is beneficial in children with non-traumatic ICH due to a focal pathology and midline shift. Evidence on indications and timing of DC in NTC is still evolving.

Energy Balance in Critically Ill Children With Severe Sepsis Using Indirect Calorimetry: A Prospective Cohort Study.

OBJECTIVES: Energy needs in critically ill children are dynamic and variable. Data on energy balance in children with severe sepsis using indirect calorimetry (IC) is lacking. Thus, we planned to study the energy needs and balance of this cohort. METHODS: Prospective observational study conducted in ventilated children aged 5 to 12 years, admitted in pediatric intensive care unit with severe sepsis from May 2016 to June 2017. Measured resting energy expenditure (mREE) was measured with IC (Quark RMR, COSMED) till 7 days or pediatric intensive care unit discharge. Predicted energy expenditure (pREE) was estimated using Schofield, Harris and Benedict, and FAO/WHO/UNU equations. Primary outcome was to study the daily energy balance. Secondary outcome was to determine nitrogen balance and agreement of mREE with pREE. RESULTS: Forty children (24 boys) with median age of 7 (5.2, 10) years were enrolled. All received enteral nutrition; 35 (87.5%) received inotropic support. Median ventilation-free days were 19 days and 4 children died (10%). A total of 176 IC measurements were obtained with an average of 4 per patient. The mean mREE was 51 ±â€Š17 kcal/kg and mean respiratory quotient was 0.77 ±â€Š0.07. There was persistent negative energy balance from days 1 to 7 and negative nitrogen balance from days 1 to 5. There was poor agreement of pREE with mREE using Bland Altman plots. None of severity of illness scores (PRISM III, daily Sequential Organ Function Assessment, daily Vasoactive Inotropic Score) showed correlation with mREE. CONCLUSIONS: Persistent negative energy and nitrogen balance exist during acute phase of severe sepsis. Predictive equations are inaccurate compared with IC as the criterion standard.

Effect of Severe Vitamin D Deficiency at Admission on Shock Reversal in Children With Septic Shock: A Prospective Observational Study.

OBJECTIVES:: To evaluate the association of severe vitamin D deficiency with clinically important outcomes in children with septic shock. METHODS:: We enrolled children ≤17 years with septic shock prospectively over a period of 6 months. We estimated 25-hydroxyvitamin D [25 (OH) D] levels at admission and 72 hours. Severe deficiency was defined as serum 25 (OH) <10 ng/mL. We performed univariate and multivariate analysis to evaluate association with clinically important outcomes. RESULTS:: Forty-three children were enrolled in the study. The prevalence of severe vitamin D deficiency was 72% and 69% at admission and 72 hours, respectively. On univariate analysis, severe vitamin D deficiency at admission was associated with lower rates of shock reversal, 74% (23) versus 25% (3); relative risk (95% confidence interval [CI]): 2.9 (1.09-8.08), at 24 hours and greater need for fluid boluses (75 vs 59 mL/kg). On multivariate analysis, nonresolution of shock at 24 hours was significantly associated with severe vitamin D deficiency after adjusting for other key baseline and clinical variables, adjusted odds ratio (95% CI): 12 (2.01-87.01); 0.01. CONCLUSION:: The prevalence of severe vitamin D deficiency is high in children with septic shock admitted to pediatric intensive care unit. Severe vitamin D deficiency at admission seems to be associated with lower rates of shock reversal at 24 hours of ICU stay. Our study provides preliminary data for planning interventional studies in children with septic shock and severe vitamin D deficiency.

Advances in the Management of Pediatric Septic Shock: Old Questions, New Answers.

Septic shock in children is associated with high mortality, especially in developing countries. Management includes early recognition, timely antibiotics, aggressive fluid resuscitation, and appropriate vasoactive therapy, to achieve the therapeutic end points. The evidence at each step in management has evolved over the past decade with a paradigm shift in emphasis from a 'protocolized care' to an 'individualized physiology-based care'. This shift mirrors the general trend one observes in critical care with respect to various treatment modalities i.e. moving away from a liberal to a more conservative approach be it fluids, ventilation, transfusion, antibiotics or insulin. The age-old questions of how much fluid to give, what inotropes to start, when to administer antibiotics, are steroids indicated and when to consider extracorporeal therapies in refractory shock are finding new answers from the recent spate of evidence. It is therefore imperative for all of us to be aware of the recent changes in management, to enable us to adopt an evidenced based approach while managing children with septic shock. In this review, we have tried to summarize the key changes in evidence that have occurred over the past decade at various steps in the management of pediatric septic shock.