Aerosolized L-epinephrine vs Budesonide for Post-extubation Stridor: A Randomized Controlled Trial.

Objective: To compare the efficacy and adverse effects of aerosolized L-epinephrine vs budesonide in the treatment of post-extubation stridor. Study design: Randomized controlled trial. Setting: Pediatric intensive care unit (PICU) of a tertiary teaching and referral hospital. Subjects: Sixty two patients with a stridor score ≥4 following extubation. Intervention: Patients were randomized to receive either aerosolized L-epinephrine (n=32) or budesonide (n =30). Respiratory rate, heart rate, stridor score, blood pressure and oxygen saturation were recorded from 0 min to 24 hours. Outcome measures: Stridor score remaining at ≥4, need for re-nebulization and re-intubation between 20 min –24 hours were primary outcome measures. Tachycardia (HR > normal for age), hypertension (BP >95th centile for age) and hypoxia (SpO2 <92% for 5 min) were secondary outcome measures. Results: Both drugs showed a significant and comparable decline in the median (95% CI) stridor scores from baseline to 60 min [4 (4.10-4.50) to 2.00 (1.46-2.67) for budesonide vs 4 (4.12-5.00) to 2.00 (1.31 -2.75) for epinephrine]. At 2 hours, the stridor scores were significantly lower in the epinephrine as compared to budesonide group [0.00 (0.69-1.81) vs 3.00(1.75-3.32); P =0.02)]. However, the proportion of patients with stridor score ≥4 at any time between 20min-24 hrs (53.3% vs 53.1%; P=0.99), need for renebulization (40 % vs 43.8 %; P=0.76) and re-intubation (20% vs 25%, P=0.638), and adverse effects were similar in both groups. Conclusions: Both aerosolized L-epinephrine and budesonide were equally effective in their initial therapeutic response in post-extubation stridor. However, epinephrine showed a more sustained effect.

Free water excess is not the main cause for hyponatremia in critically ill children receiving conventional maintenance fluids.

Objective: To examine occurrence of hyponatremia in critically ill children receiving conventional maintenance fluids (0.18% saline in 5% dextrose) and its relationship with electrolyte free water (EFW), sodium intake and natriuresis. Design: Prospective observational study. Setting: Pediatric Intensive Care Unit of a tertiary care teaching hospital. Subjects: Thirty eight patients, 3 months-12 years, consecutively admitted to PICU over 30 days. Main outcome measure was occurrence of hyponatremia (serum sodium £130 mEq/L). Serum and urinary sodium, and osmolality were measured, and type and volume of intravenous fluids and total urine output were recorded 12 hourly. Daily intake of sodium and EFW, urinary sodium excretion and net balance of fluid and sodium were estimated from above. Data of hyponatremic and non-hyponatremic patients was compared using ANOVA, Mann-Whitney U, and Chi-square tests. Results: Fourteen episodes of hyponatremia were recorded in 12 patients over 397 patient days (3.5 episodes/100 patient days). Their mean (SD) serum sodium dropped from 139 (9.3) at admission to 128 (1.0) mEq/L, over a median interval of 3.5 days (range 1-15 days). Net fluid and sodium balance in hyponatremic patients did not differ significantly from non-hyponatremic patients. Within the hyponatremic group, sodium intake, urinary sodium and sodium balance were similar before and after the occurrence of hyponatremia, while total fluid (P=0.009) and EFW intake (P=0.001) were lower in the days preceding hyponatremia. Conclusions: Fluid and sodium balance, magnitude of natriuresis and EFW intake alone did not explain occurrence of hyponatremia in critically ill children; contribution of other mechanisms needs to be studied.

Nosocomial pneumonia in a pediatric intensive care unit.

BACKGROUND: Nosocomial pneumonia (NP) is the second most common hospital acquired infection. Understanding the pattern of occurrence, risk factors and etiological agents of NP in a PICU, is essential for developing effective infection control measures. This prospective observational study was conducted in a PICU of a tertiary care teaching hospital, to determine the incidence, etiology and risk factors for NP. MATERIALS AND METHODS: Patients admitted to the PICU, over a period of 1 year who had endotracheal (ET) intubation, were enrolled consecutively into the study. Demographic details were recorded at the time of inclusion. Diagnosis of NP was based on CDC criteria (1988).Semiquantiative assay of endotracheal aspirate (ETA) with a colony count of > 10(5) cfu/mL was taken as evidence of infection. Colonisation was defined as isolation of organism with <10(5) cfu/mL. Age, nutritional status, number and duration of intubations, duration of mechanical ventilation, sedation, nasogastric feeding were the risk factors studied for development of NP. Intubation attempts of more than one were defined as reintubation. Risk factors found significant on univariate analysis, were subjected to multiple regression analysis to determine the most important predictors of NP. RESULTS: The study group comprised of 72 children with a median age of 3.7 years and boys: girls ratio of 1.9:1.Twenty two of 72 (30.5%) developed NP; the predominant isolates from ETA were Acinetobacter anitratus(12), Pseudomonas aeruginosa (5), Klebsiella sp(3) and Staphylococcus aureus and E.coli(1) each. Additionally 18(39%) had evidence of ET colonization, with Acinetobacter sp being the commonest 9(50%). Re-intubation, prolonged duration of intubation and mechanical ventilation were the significant risk factors on univariate analysis for development of NP.On multiple regression analysis, reintubation was the only independent risk factor for NP(OR 0.72, 95%CI 0.55-0.94).Overall mortality was 21%(15/72);7(47%)of these deaths were secondary to NP. CONCLUSIONS: NP developed in nearly one third of the intubated patients; Gram negative organisms were the predominant etiological agents and associated with high mortality. Re-intubation, prolonged duration of intubation and mechanical ventilation were the significant risk factors on univariate analysis for development of NP. On multiple regression analysis, reintubation was the only independent risk factor for NP.

Which clinical signs and symptoms predict hypoxemia in acute childhood asthma?

OBJECTIVE: To find the clinical signs that are the best predictors of hypoxemia (SpO2 =92%) in acute asthma in children. METHODS: Color of skin, dyspnea (by single breath counting), alertness, respiratory rate, presence of audible wheeze, wheezing on auscultation, accessory muscle use, nasal flaring, pulse rate, systolic and diastolic blood pressure, pulsus paradoxus and oxygen saturation at room air (by pulse oximetry) were recorded at the time of presentation and one hour after presentation after completion of 3 doses of nebulized salbutamol and budesonide. RESULTS: Hypoxemia (SpO2 92% pounds sterling) was seen in 45% children at presentation and 14(28.6%) after one hour. The clinical signs that correlated significantly with hypoxemia at both time points were dyspnea assessed by single breath count (OR 3.3, 95% CI 0.9-12.9), accessory muscle use score > or = 3 (OR 3.0, 95% CI 0.9-15.4) and pulsus paradoxus> 10 (OR 3.0, 95% CI 0.7-13.6). In a multiple logistic regression model accessory muscle score > or = 3 and pulsus paradoxus> 10 were identified as independent predictors of hypoxemia (sensitivity 64.3%, specificity 91%). CONCLUSION: Physical assessment in a child with acute exacerbation of asthma should at least include accessory muscle use and pulsus paradoxus, since these predict hypoxemia the best.

Predictors of outcome in children with hydrocarbon poisoning receiving intensive care.

The retrospective study included 48 children between 8.5 months--10 years, admitted to the PICU of an urban, tertiary care, teaching hospital in northern India from January 1995 to December 2001. Eighteen (38%) patients were hypoxemic on arrival, of which 8 (45%) required mechanical ventilation. Compared to the non-hypoxemic children, the hypoxemic patients were more likely to have received gastric lavage before arrival to our center (Odds Ratio 23.2, 95% CI 2.4 - 560.7) and had higher frequency of severe respiratory distress and leucocytosis (Odds Ratio 8.0, 95% CI 1.79 -38.6). On multiple regression analysis, we could not identify any particular variable that could predict hypoxemia. Secondary pneumonia developed in 16 (33.3%), with the duration of PICU stay being longer in these patients as against those who did not (144 hours vs 72 hours, p <0.05). Two (4.2%) children died and one suffered hypoxic sequelae. Prior lavage, hypoxemia at admission, need for ventilation, secondary sepsis and ventilator related complications were associated with poor outcome.

Predictors of outcome in patients with diphtheria receiving intensive care.

Forty eight patients with a clinical diagnosis of diphtheria, admitted to the Pediatric Intensive Care Unit (PICU) of a tertiary care teaching hospital, from December 1994 to 2002, were analyzed retrospectively with respect to demographic details, clinical features, immunization status, complications and mortality. Several variables were compared among the survivors and non-survivors to define the predictors of outcome More than half 27 (56.3%). of the patients were unimmunized. Complications seen were: airway compromise 34 (70.8%), myocarditis 32 (66.6%), renal failure 17 (35.4%) and thrombocytopenia 15 (31.3%). Out of the 48 patients, 21 survived and 27 died (56.3%). The immediate cause of death was myocarditis 23 (85%), airway compromise 3 (11.1%) and septic shock due to nosocomial sepsis(1). Inadequate immunization, hypotension at admission and presence of any complication like airway compromise, myocarditis and renal failure had a significant (P <0.05) adverse effect on outcome; multiple regression analysis ascertained that, development of myocarditis was the only independent predictor of death (Adjusted OR 0.061; 95% CI 0.009-0.397; P = 0.003).

Chromobacterium violaceum septicaemia from north India.

Though Chromobacterium violaceum is a common inhabitant of soil and water in tropical and sub-tropical regions, human infections are rare but when they do occur result in high mortality. Since the first case from Malaysia in 1927, about 150 cases have been reported in world literature. Till date 6 cases have been reported from southern and eastern parts of India. We report here a case of C. violaceum septicaemia, probably the first case from north India. The patient, a 6 and a half year old boy was admitted with high fever. The patient had anaemia, neutrophilic leucocytosis and bilateral chest infiltrates. Routine and bacteriological investigations were carried out to establish the aetiological diagnosis. C. violaceum was isolated in pure culture from blood and pus. The patient was successfully treated with ciprofloxacin and amikacin. This is probably the first documented case report of C. violaceum infection from north India and the only Indian case with septicaemia which survived.

Follow up of survival and quality of life in children after intensive care.

OBJECTIVE:To evaluate the health related quality of life of children after intensive care and to assess their long term survival. DESIGN: Prospective. Setting: Tertiary Care Hospital Intensive Care Unit (ICU). SUBJECT AND METHODS: All patients admitted to ICU were enrolled prospectively over a period of 1 year. Children with ICU stay of less than 24 hrs, infants, readmission to ICU were however excluded. Survival was determined at the time of ICU discharge and 1 year later. Health status assessment was done with the help of the multiattribute health status classification (MAHSC), which has 6 domains; sensation, mobility, emotion, cognition, self care and pain. Assessment was done at two points of time - within 48 hours of admission to the ICU and 1 year after discharge. RESULTS: 150 children (mean age 5.68+/- 3.6 years) with a mean duration of ICU stay (5.7 +/- 5.5 days) were included in the study. The cumulative ICU mortality was 12.9%. Fifty-five (36.7% had no overall health impairment (no affected domains) preceding the present illness. There was overall health impairment (?1 affected domain) preceding the present illness in 95 of the 150 patients (63.3%). In the domain specific health status mobility was affected in 74 (49%) followed by pain 61 (41.2%), self care 56 (38.8%), sensation 29 (20%), cognition 21 (14.8%) and emotion 14(9.5%). After 1 year, overall state of health had improved or was equal to the premorbid state in 87 (75%). In domain specific health, the proportion improving or remaining unchanged varied from 75% (emotional) to 80% (cognition), 85.3% (pain) and 88.7% (mobility). The overall state of health had worsened as compared to the premorbid state in 29 (25%) majority with neurological illnesses. CONCLUSION: Quality of life in three-quarters of the patients was preserved and one year survival was favorable. Worsening was noted primarily in-patients with neurological illnesses.

Mannan antigen detection in the diagnosis of patients with invasive candidiasis.

BACKGROUND & OBJECTIVES: With the increase in the incidence of invasive candidiasis (IC) in recent years, there is a need to improve the sensitivity of diagnosis. A conventional technique like blood culture is positive in nearly 50 per cent of cases. To improve the diagnostic efficiency in invasive candidiasis mannan antigen detection holds promise. Hence mannan antigen detection was evaluated in patients with suspected invasive candidiasis in the Paediatric Intensive Care Unit (PICU). METHODS: A prospective study, involving 186 consecutive patients admitted to the PICU of the Advanced Paediatric Center at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh between March 1999 and November 1999 were followed up for possible invasive candidiasis. Sixty five children clinically suspected to have sepsis and at risk for developing IC and or who stayed in the hospital more than 5 days were further evaluated for the diagnosis of IC by collecting two blood culture samples 48 h apart and by mannan antigen and anti-mannan antibody detection. Both antigen and antibody were detected by in-house standardized techniques: antibody by whole cell agglutination (WCA) and antigen by sandwich enzyme linked immunosorbent assay (ELISA). RESULTS: Twenty of 65 patients (30.7%) were positive by blood culture. Mannan antigen was positive in all 20 patients and significant anti-mannan antibody titre (> or = 128) was present in 12 (60%) patients. Mannan antigen was detected in 15 more patients, who were negative for isolation of Candida from blood. Twelve of these patients had febrile episode not responding to antibacterial therapy but responding to fluconazole/itraconazole therapy indicating that the patients possibly had IC. Mannan concentration was also found to be significantly higher in the patients with Candida isolated from blood. INTERPRETATION & CONCLUSION: Thus, the present study confirms the earlier claim that mannan antigen detection possibly improves the diagnostic efficiency of IC.

Bacterial meningitis in children: critical care needs.

Acute bacterial meningitis (ABM) in children is associated with a high rate of acute complications and mortality, particularly in the developing countries. Most of the deaths occur during first 48 hours of hospitalization. Coma, raised intracranial pressure (ICP), seizures, shock have been identified as significant predictors of death and morbidity. This article reviews issues in critical care with reference to our experience of managing 88 children with ABM in PICU. Attention should first be directed toward basic ABCs of life-support. Children with Glasgow Coma Scale (GSC) score < 8 need intubation and supplemental oxygen. Antibiotics should be started, even without LP (contraindicated if focal neuro-deficit, papilledema, or signs of raised ICP). Raised ICP is present in most of patients; GCS < 8 and high blood pressure are good guides. Mannitol (0.25 gm/Kg) should be used in such patients. If there are signs of (impending) herniation short-term hyperventilation is recommended; prolonged hyperventilation (> 1 hour) must be avoided. Any evidence of poor perfusion, hypovolemia and/or hypotension needs aggressive treatment with normal saline boluses and inotropes, if necessary, to maintain normal blood pressure. Empiric fluid restriction is not justified. Seizures may be controlled with intravenous diazepam or lorazepam. Refractory status epilepticus may be treated with continuous diazepam (0.01-0.06) mg/kg/min) or midazolam infusion. Ventilatory support may be needed early for associated pneumonia, poor respiratory effort and/or coma, and occasionally to reduce work of breathing in shock. Provision of critical care to children with ABM may reduce the mortality significantly as experienced by us.

Strangulation injury, a fatal form of child abuse.

Strangulation is a common method of committing murder, though underreported in Indian literature. We managed a girl child, victim of child abuse who later succumbed to its neurological complications. This case report describes the clinical features associated with such injuries and complications which should be anticipated in such cases.

Isolation of measles virus from cerebrospinal fluid of children with acute encephalopathy without rash.

OBJECTIVE: To determine the viral agent involved in cases of acute encephalopathy in children during an outbreak in Northern India. DESIGN: Virological and serological studies using serum and cerebrospinal fluid specimens from patients. METHODS: Serum and CSF specimens were tested by IgM ELISA for IgM antibodies to variety of viruses like Japanese encephalitis, West Nile, Dengue and Measles. The specimens were inoculated into Vero cell monolayer for virus isolation. The viral strains isolated were identified by indirect immunofluorescence test and qualitative in-vitro neutralization test using polyclonal and monoclonal antibodies to measles. Identity of the isolates was reconfirmed using RT-PCR method. RESULTS: Of the 28 specimens tested, 17 had IgM antibodies to measles. Commercial IgM ELISA kits confirmed the serological findings. Vero cell cultures yielded 4 isolates from CSF and 2 from serum specimens of six different patients. Cytopathic effect was typical of measles. Indirect imunofluorescence using polyclonal and monoclonal antibodies to measles HA protein, confirmed the measles etiology. Neutralization tests reconfirmed the measles strain isolation. RT-PCR amplified product was confirmed as measles. CONCLUSION: The isolation of measles virus from CSF and serum of children with acute encephalopathy without rash proved the etiological role of measles virus in this outbreak.

Post-neonatal tetanus: issues in intensive care management.

Tetanus is an acute neurological disease characterized by muscle rigidity and spasms, autonomic dysfunction and in severe forms requires respiratory and hemodynamic support. Though it is entirely preventable by immunization, it still occurs in developing countries causing significant morbidity and mortality. Intensive care management of tetanus is fraught with problems of ventilator-associated pneumonia, nosocomial sepsis and a variety of other complications. Various treatment protocols have been tried in managing diverse manifestations of severe tetanus but the consensus is yet to emerge. In this review we have discussed the pathophysiology, clinical features and management controversies and suggest on basis of our experience use of high dose diazepam (20-120 mg/kg/day) and vecuronium with mechanical ventilation if required for control of spasms, and early detection of autonomic dysfunction and use of propranolol, in our circumstances.

Phlegmonous inflammation of gastrointestinal tract autopsy study of three cases.

Three cases of Phlegmonous inflammation of gastrointestinal tract detected at necropsy are described. Predisposing factors were seen in all three cases. These were chronic alcoholism with submissive hepatic necrosis (HbsAg and HbcAg positive) in Case 1, Indian Childhood cirrhosis in Case 2 and acute on chronic Budd Chiari syndrome in Case 3. In case 1 and 3 the inflammation was limited to the large intestine where as in Case 2 it was seen both in the stomach and large intestine. In two of the three cases blood culture grew Staphylococcus aureus (Case 1) and gram negative organisms (Case 2).