Current State of Pediatric Intensive Care and High Dependency Care in Nepal.

OBJECTIVES: To describe the state of pediatric intensive care and high dependency care in Nepal. Pediatric intensive care is now a recognized specialty in high-income nations, but there are few reports from low-income countries. With the large number of critically ill children in Nepal, the importance of pediatric intensive care is increasingly recognized but little is known about its current state. DESIGN: Survey. SETTING: All hospitals in Nepal that have separate physical facilities for PICU and high dependency care. PATIENTS: All children admitted to these facilities. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A questionnaire survey was sent to the chief of each facility. Eighteen hospitals were eligible and 16 responded. Two thirds of the 16 units were established in the last 5 years; they had a total of 93 beds, with median of 5 (range, 2-10) beds per unit. All 16 units had a monitor for each bed but only 75% could manage central venous catheters and only 75% had a blood gas analyzer. Thirty two percent had only one functioning mechanical ventilator and another 38% had two ventilators, the other units had 3-6 ventilators. Six PICUs (38%) had a nurse-to-patient ratio of 1:2 and the others had 1:3 to 1:6. Only one institution had a pediatric intensive care specialist. The majority of patients (88%) came from families with an income of just over a dollar per day. All patients were self funded with a median cost of PICU bed being $25 U.S. dollars (interquartile range, 15-31) per day. The median stay was 6 (interquartile range, 4.8-7) days. The most common age group was 1-5. Sixty percent of units reported respiratory distress/failure as their primary cause for admission. Mortality was 25% (interquartile range, 20-35%) with mechanical ventilation and 1% (interquartile range, 0-5%) without mechanical ventilation. CONCLUSIONS: Pediatric intensive care in Nepal is still in its infancy, and there is a need for improved organization, services, and training.

Effect of normal saline and half normal saline on serum electrolytes during recovery phase of diabetic ketoacidosis.

OBJECTIVE: This study aims to describe the effect of 0.9% saline (NS) versus 0.45% saline (half NS) when used during recovery phase of diabetic ketoacidosis (DKA) in children. METHODS: A retrospective analysis of all children (1-18 years old) with DKA admitted in the pediatric intensive care unit (PICU) from 2005 to 2009 was undertaken. The primary end point was effect on serum electrolytes and acidosis. RESULTS: Compared to 47 patients who received only NS (group A) throughout the recovery period and 33 patients who received NS but were switched to half NS (group B) at some point during recovery, 41 who received only half NS (group C) had a significant decrease in corrected serum sodium (P < .01). Hyperchloremia leading to nonanion gap acidosis was significantly greater in NS groups A and B than in half NS group C (P < .01). This led to increased duration of insulin infusion and length of stay in the PICU in the NS groups. CONCLUSIONS: Hyperchloremia resulting in nonanion gap acidosis can occur and may prolong the duration of insulin infusion and length of PICU stay in patients receiving NS as post-bolus rehydration fluid. Alternatively, the use of half NS may result in a decrease in serum-corrected sodium. Providers need to be vigilant toward this while using higher or lower sodium chloride when managing children with DKA. Larger trials are required to study the clinical significance of the results of this study.

Development of a PICU in Nepal: the experience of the first year.

OBJECTIVE: Analysis of hospitalization data can help elucidate the pattern of morbidity and mortality in any given area. Little data exist on critically ill children admitted to hospitals in the resource-limited nation of Nepal. We sought to characterize the profile, management, and mortality of children admitted to one PICU. DESIGN: Retrospective analysis. SETTING: A newly established PICU in Nepal. PATIENTS: All patients between the ages of 0 to 16 years admitted to the PICU from July 2009 to July 2010. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: In 12 months, 126 children were admitted to the PICU including 43% female patients. Sixty-three percent were under 5 years. Twenty-nine percent came from tertiary care hospitals and 38% from rural areas outside Kathmandu. Only 18% were transported by ambulance. Median distance travelled to be admitted was 30 km (interquartile range, 10-193). Highest number of admissions were in spring (40%) followed by summer (25%). Almost half were admitted for shock (45%), particularly septic shock (30%). The second commonest reason for admission was neurologic etiologies (15%). Neonatal admissions were also significant (19%). Mortality was 26% and was significantly associated with septic shock (p < 0.01), mechanical ventilation (p < 0.01), and multiple organ dysfunction (< 0.05). Almost one third of patients required mechanical ventilation; median duration was 4 days (interquartile range, 2-8). Mean length of stay in the hospital was 6.2 days (± 5.3) and median 4 (interquartile range, 2.5-9.0). Median Pediatric Risk of Mortality II score for nonsurvivors was 12 (interquartile range, 7-21), and median Pediatric Index of Mortality II for nonsurvivors was 10 (interquartile range, 3-32). CONCLUSIONS: Within a short time of opening, the PICU has been seeing significant numbers of critically ill children. Despite adverse conditions and limited resources, survival of 75% is similar to many units in developing nations. Sepsis was the most common reason for PICU admission and mortality.

Enteral Feeding for Children on Bilevel Positive Pressure Ventilation for Status Asthmaticus.

A retrospective data analysis was conducted to evaluate enteral nutrition practices for children admitted with status asthmaticus in a single-center pediatric intensive care unit. Of 406 charts, 315 were analyzed (63% male); 135 on bilevel positive airway pressure ventilation (BIPAP) and 180 on simple mask. Overall median age and weight were 6.0 (interquartile range [IQR]: 6.0) years and 24.8 (IQR: 20.8) kg, respectively. All children studied were on full feeds while still on BIPAP and simple mask; 99.3 and 100% were fed per oral, respectively. Median time to initiation of feeds and full feeds was longer in the BIPAP group, 11.0 (IQR: 20) and 23.0 hours (IQR: 26), versus simple mask group, 4.3 (IQR: 7) and 12.0 hours (IQR: 15), p = 0.001. The results remained similar after adjusting for gender, weight, clinical asthma score at admission, use of adjunct therapy, and duration of continuous albuterol. By 24 hours, 81.5% of patients on BIPAP and 96.6% on simple mask were started on feeds. Compared with simple mask, patients on BIPAP were sicker with median asthma score at admission of 4 (IQR: 2) versus 3 (IQR: 2) on simple mask, requiring more adjunct therapy (80.0 vs. 43.9%), and a longer median length of therapy of 41.0 (IQR: 41) versus 20.0 hours (IQR: 29), respectively, p = 0.001. There were no complications such as aspiration pneumonia, and none required invasive mechanical ventilation in either group. Enteral nutrition was effectively and safely initiated and continued for children admitted with status asthmaticus, including those on noninvasive bilevel ventilation therapy.

Safety, efficacy, and tolerability of early initiation of noninvasive positive pressure ventilation in pediatric patients admitted with status asthmaticus: a pilot study.

OBJECTIVES: Although noninvasive positive pressure ventilation is increasingly used for respiratory distress, there is not much data supporting its use in children with status asthmaticus. The objective of this study was to determine safety, tolerability, and efficacy of early initiation of noninvasive positive pressure ventilation in addition to standard of care in the management of children admitted with status asthmaticus. STUDY DESIGN: A prospective, randomized, controlled, clinical trial. PATIENTS: Twenty patients (1-18 yrs old) admitted to the pediatric intensive care unit with status asthmaticus. METHODS AND MAIN RESULTS: Children were randomized to receive either noninvasive positive pressure ventilation plus standard of care (noninvasive positive pressure ventilation group) or standard of care alone (standard group). Improvement in clinical asthma score was significantly greater in noninvasive positive pressure ventilation group compared to standard group at 2 hrs, 4-8 hrs, 12-16 hrs, and 24 hrs after initiation of interventions (p < .01). A significant decrease in respiratory rate at ≥ 24 hrs oxygen requirement after 2 hrs was noted in noninvasive positive pressure ventilation group as compared to standard group (p = .01 and p = .03, respectively). Although statistically not significant, fewer children in the noninvasive positive pressure ventilation group required adjunct therapy compared to standard group (11% vs. 50%; p = .07). There were no major adverse events related to noninvasive positive pressure ventilation. Nine out of ten patients tolerated noninvasive positive pressure ventilation through the duration of the study; noninvasive positive pressure ventilation had to be discontinued in one patient because of persistent cough. CONCLUSIONS: Early initiation of noninvasive positive pressure ventilation, along with short acting ß-agonists and systemic steroids, can be safe, well-tolerated, and effective in the management of children with status asthmaticus.

Prolonged sinoatrial block in an infant with respiratory syncytial viral bronchiolitis.

Complete heart block in children admitted to the pediatric intensive care unit with respiratory syncytial viral (RSV) infections has been described. This report describes a prolonged sinoatrial block exceeding 4 s in an infant with RSV, which, to the authors' knowledge, is the longest such event described in the published literature. This block was followed by shorter episodes within the next 24 h. An extensive workup showed no other known cause of bradycardia or sinoatrial block. The infant was discharged home with 48 h Holter monitoring, which was normal. At this writing, the infant has remained asymptomatic since discharge. Respiratory syncytial viral infections may cause prolonged sinoatrial block in an otherwise healthy child.

Challenges of implementing the Paediatric Surviving Sepsis Campaign International Guidelines 2020 in resource-limited settings: A real-world view beyond the academia.

The Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children was released in 2020 and is intended for use in all global settings that care for children with sepsis. However, practitioners managing children with sep sis in resource-limited settings (RLS) face several challenges and disease patterns not experienced by those in resource-rich settings. Based upon our collective experience from RLS, we aimed to reflect on the difficulties of implementing the international guidelines. We believe there is an urgent need for more evidence from RLS on feasible, efficacious approaches to the management of sepsis and septic shock that could be included in future context-specific guidelines.

Experience of Treating COVID-19 With Remdesivir and Convalescent Plasma in a Resource-Limited Setting: A Prospective, Observational Study.

BACKGROUND: Convalescent plasma therapy (CPT) and remdesivir (REM) have been approved for investigational use to treat coronavirus disease 2019 (COVID-19) in Nepal. METHODS: In this prospective, multicentered study, we evaluated the safety and outcomes of treatment with CPT and/or REM in 1315 hospitalized COVID-19 patients over 18 years in 31 hospitals across Nepal. REM was administered to patients with moderate, severe, or life-threatening infection. CPT was administered to patients with severe to life-threatening infections who were at high risk for progression or clinical worsening despite REM. Clinical findings and outcomes were recorded until discharge or death. RESULTS: Patients were classified as having moderate (24.2%), severe (64%), or life-threatening (11.7%) COVID-19 infection. The majority of CPT and CPT + REM recipients had severe to life-threatening infections (CPT 98.3%; CPT + REM 92.1%) and were admitted to the intensive care unit (ICU; CPT 91.8%; CPT + REM 94.6%) compared with those who received REM alone (73.3% and 57.5%, respectively). Of 1083 patients with reported outcomes, 78.4% were discharged and 21.6% died. The discharge rate was 84% for REM (n = 910), 39% for CPT (n = 59), and 54.4% for CPT + REM (n = 114) recipients. In a logistic model comparing death vs discharge and adjusted for age, gender, steroid use, and severity, the predicted margin for discharge was higher for recipients of remdesivir alone (0.82; 95% CI, 0.79-0.84) compared with CPT (0.58; 95% CI, 0.47-0.70) and CPT + REM (0.67; 95% CI, 0.60-0.74) recipients. Adverse events of remdesivir and CPT were reported in <5% of patients. CONCLUSIONS: This study demonstrates a safe rollout of CPT and REM in a resource-limited setting. Remdesivir recipients had less severe infection and better outcomes.ClinicalTrials.gov identifier. NCT04570982.

COVID-19 Containment Efforts of a Low-Resource Nation: The First Four Months in Nepal.

A novel coronavirus (severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2) was identified in hospitalized patients in Wuhan, China, in December 2019. It rapidly spread across the globe within the span of a few months. Nepal is a low-resource country with limited critical care delivery infrastructure. Coronavirus 2019 (COVID-19), the disease caused by the virus, could potentially cause a medical catastrophe in Nepal. We reviewed all pertinent documents published in the public domain by the Ministry of Health and Population of Nepal and other relevant literature. We aimed to describe the key strategies Nepal embraced in the first four months in its attempt to curtail the disease immediately following the identification of its first case and the challenges it faced. In our review, we determined that the key steps taken by Nepal included border control to prevent the importation of cases, strict quarantine in facilities for anyone entering the country, early case detection, and isolation of all infected cases irrespective of symptoms. Testing capabilities, quarantine facilities, and isolation beds were also rapidly increased. We discuss how Nepal achieved some success in the first four months between January 13, 2020, when the first case was identified, to May 13, 2020. However, it faced several challenges that ultimately led to an exponential rise in cases thereafter.

Effect of Potassium Infusions on Serum Levels in Children during Treatment of Diabetic Ketoacidosis.

A retrospective study was done to determine the effect of potassium (K + ) infusions on serum levels in children admitted to the pediatric intensive care unit (PICU) with diabetic ketoacidosis (DKA). Eighty-two percent of 92 cases studied received 40 mEq/L K + infusion over the treatment period of median 13.0 (interquartile range [IQR]: 7-18) hours. The median K + value at the end of this period was 3.9 (IQR: 3.4-4.2) mEq/L. There were 31 data points of low K + values (<3.5 mEq/L) and 4 high values (>5.5 mEq/L) during this treatment period. The K + infusions of 40 mEq/L may be sufficient to normalize serum K + when treating DKA.

Coronary vasospasm in an adolescent resulting from marijuana use.

This report is the first to describe coronary vasospasm, diagnosed by cardiac magnetic resonance imaging in an adolescent, resulting from marijuana abuse. A previously healthy 17-year-old male patient with severe chest pain, electrocardiographic changes, and urine test positive for cannabis, was diagnosed of having transient myocardial ischemia. The patient was discharged home and at this writing remains asymptomatic with a follow-up echocardiogram after 1 month showing normal left ventricular systolic function. Marijuana should be considered in the etiology of transient coronary vasospasm leading to myocardial ischemia in otherwise healthy adolescents. Cardiac magnetic resonance imaging is a safe and effective method for diagnosing coronary vasospasm.

Challenges in setting up pediatric and neonatal intensive care units in a resource-limited country.

In collaboration with a host country and international medical volunteers, a PICU and an NICU were conceptualized and realized in the developing country of Nepal. We present here the challenges that were encountered during and after the establishment of these units. The decision to develop an ICU with reasonable goals in a developing country has to be made with careful assessments of need of that patient population and ethical principles guiding appropriate use of limited resources. Considerations during unit design include space allocation, limited supply of electricity, oxygen source, and clean-water availability. Budgetary challenges might place overall sustainability at stake, which can also lead to attrition of trained manpower and affect the quality of care. Those working in the PICU in resource-poor nations perpetually face the challenges of lack of expert support (subspecialists), diagnostic facilities (laboratory and radiology), and appropriate medications and equipment. Increasing transfer of severely ill patients from other health facilities can lead to space constraints, and lack of appropriate transportation for these critically ill patients increases the severity of illness, which leads to increased mortality rates. The staff in these units must make difficult decisions on effective triage of admissions to the units on the basis of individual cases, futility of care, availability of resources, and financial ability of the family.

Fresh goat's milk for infants: myths and realities--a review.

Many infants are exclusively fed unmodified goat's milk as a result of cultural beliefs as well as exposure to false online information. Anecdotal reports have described a host of morbidities associated with that practice, including severe electrolyte abnormalities, metabolic acidosis, megaloblastic anemia, allergic reactions including life-threatening anaphylactic shock, hemolytic uremic syndrome, and infections. We describe here an infant who was fed raw goat's milk and sustained intracranial infarctions in the setting of severe azotemia and hypernatremia, and we provide a comprehensive review of the consequences associated with this dangerous practice.