Prescription practice and clinical utility of chest radiographs in a pediatric intensive care unit: a prospective observational study.

BACKGROUND: Chest radiograph (CXR) prescribing pattern and practice vary widely among pediatric intensive care units (PICU). 'On demand' approach is increasingly recommended as against daily 'routine' CXRs; however, the real-world practice is largely unknown. METHODS: This was a prospective observational study performed in children younger than 12 years admitted to PICU of a tertiary care teaching hospital in India. Data were collected on all consecutive CXRs performed between December 2016 and April 2017. The primary outcome was to assess the factors that were associated with higher chest radiograph prescriptions in PICU. Secondary outcomes were to study the indications, association with mechanical ventilation, image quality and avoidable radiation exposure. RESULTS: Of 303 children admitted during the study period, 159 underwent a total of 524 CXRs in PICU. Median (IQR) age of the study cohort was 2 (0.6-5) years. More than two thirds [n = 115, 72.3%] were mechanically ventilated. Most CXRs (n = 449, 85.7%) were performed on mechanically ventilated patients, amounting to a median (IQR) of 3 (2-5) radiographs per ventilated patient. With increasing duration of ventilation, the number of CXRs proportionately increased in the first two weeks of mechanical ventilation. In non-ventilated children, about two thirds (68%) underwent only one CXR. Majority of the prescriptions were on demand (n = 461, 88%). Most common indications were peri-procedure prescriptions (37%) followed by evaluation for respiratory disease status (24%). About 40% CXRs resulted in interventions; adjustment in ventilator settings (13.5%) was the most frequent intervention. In 26% (n = 138) of radiographs, image quality required improvement. One or more additional body part exposure other than chest and upper abdomen were noted 336 (64%) images. Children with > 3 CXR had higher PRISM III score, more often mechanically ventilated, had higher number of indwelling devices [mean (SD) 2.6 (1.2) vs. 1.7 (1.0)] and stayed longer in PICU [median (IQR) 11(7.5-18.5) vs. 6 (3-9)]. CONCLUSION: On demand prescription was the prevalent practice in our PICU. Most non-ventilated children underwent only one CXR while duration of PICU stay and the number of devices determined the number of CXRs in mechanically ventilated children. Quality improvement strategies should concentrate on the process of acquisition of images and limiting the radiation exposure to unwanted body parts.

Portending Complications in Pediatric Diabetic Ketoacidosis.

How to cite this article: Williams V, Mohandoss V. Portending Complications in Pediatric Diabetic Ketoacidosis. Indian J Crit Care Med 2021;25(12):1339-1340.

0.9% saline versus Plasma-Lyte as initial fluid in children with diabetic ketoacidosis (SPinK trial): a double-blind randomized controlled trial.

BACKGROUND: Acute kidney injury (AKI) is an important complication encountered during the course of diabetic ketoacidosis (DKA). Plasma-Lyte with lower chloride concentration than saline has been shown to be associated with reduced incidence of AKI in adults with septic shock. No study has compared this in DKA. METHODS: This double-blind, parallel-arm, investigator-initiated, randomized controlled trial compared 0.9% saline with Plasma-Lyte-A as initial fluid in pediatric DKA. The study was done in a tertiary care, teaching, and referral hospital in India in children (> 1 month-12 years) with DKA as defined by ISPAD. Children with cerebral edema or known chronic kidney/liver disease or who had received pre-referral fluids and/or insulin were excluded. Sixty-six children were randomized to receive either Plasma-Lyte (n = 34) or 0.9% saline (n = 32). MAIN OUTCOMES: Primary outcome was incidence of new or progressive AKI, defined as a composite outcome of change in creatinine (defined by KDIGO), estimated creatinine clearance (defined by p-RIFLE), and NGAL levels. The secondary outcomes were resolution of AKI, time to resolution of DKA (pH > 7.3, bicarbonate> 15 mEq/L & normal sensorium), change in chloride, pH and bicarbonate levels, proportion of in-hospital all-cause mortality, need for renal replacement therapy (RRT), and length of ICU and hospital stay. RESULTS: Baseline characteristics were similar in both groups. The incidence of new or progressive AKI was similar in both [Plasma-Lyte 13 (38.2%) versus 0.9% saline 15 (46.9%); adjusted OR 1.22; 95% CI 0.43-3.43, p = 0.70]. The median (IQR) time to resolution of DKA in Plasma-Lyte-A and 0.9% saline were 14.5 (12 to 20) and 16 (8 to 20) h respectively. Time to resolution of AKI was similar in both [Plasma-Lyte 22.1 versus 0.9% saline 18.8 h (adjusted HR 1.72; 95% CI 0.83-3.57; p = 0.14)]. Length of hospital stay was also similar in both [Plasma-Lyte 9 (8 to 12) versus 0.9% saline 10 (8.25 to 11) days; p = 0.39]. CONCLUSIONS: The incidence of new or progressive AKI and resolution of AKI were similar in both groups. Plasma-Lyte-A was similar to 0.9% Saline in time to resolution of DKA, need for RRT, mortality, and lengths of PICU and hospital stay. TRIAL REGISTRATION: Clinical trial registry of India, CTRI/2018/05/014042 (ctri.nic.in) (Retrospectively registered).

Blood component utilization before and after implementation of good transfusion practice measures in a pediatric emergency department.

OBJECTIVES: We aimed to determine the pattern of blood component utilization in pediatric Emergency Department (ED) and compare the utilization rate before and after the implementation of simple good transfusion practice measures. MATERIAL AND METHODS: This was a prospective pre/post interventional study conducted between February 2015 and April 2016. The study included 3 phases [1] Pre-intervention phase (6 weeks) consisting of baseline data collection [2] Intervention phase (3 months) involving education on transfusion triggers and periodic mailers about good practice and designated 'transfusion resident' for supervision. [3] Post- intervention phase (6 weeks) collecting data while continuing interventions. RESULTS: During pre-intervention, 379 blood components [Packed red cells(PRBC) - 227, Platelet concentrate(PC) - 78, Fresh Frozen Plasma(FFP) - 74] were requested for 280 children; 195 were transfused with an overall utilization rate of 51.5 %. PRBC had the poorest utilization rate (30 %) followed by PC (72 %) and FFP (96 %). About 79 % of the requisitions sent by residents in first training year were not utilized before intervention. Indications such as anticipated surgery, congenital heart disease, pneumonia and sepsis had lower utilization rate. Post intervention, there was 14 % reduction in blood component requests (325 requests in 258 patients). Both overall utilization rate (56 %) and PRBC utilization (37.4 %) showed improvement but the difference was statistically not significant. CONCLUSIONS: Red blood cells were the most frequently requested blood components yet poorly utilized in ED. Simple interventions targeting providers in early stages of training could potentially improve the blood component utilization and transfusion practices in busy emergency departments.

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.

Clinical Profile and Predictors of Intensive Care Unit Admission in Pediatric Scrub Typhus: A Retrospective Observational Study from North India.

INTRODUCTION: Children with scrub typhus may present with one or more organ failures. Identifying the predictors of severe disease and need for pediatric intensive care unit (PICU) admission would help clinicians during outbreak seasons. MATERIALS AND METHODS: This observational study included 160 children admitted to the emergency department (ED) with scrub typhus confirmed by polymerase chain reaction (PCR) between January 2013 and December 2015. Demographic, clinical, and laboratory data were collected and predictors for PICU admission were identified. RESULTS: There was a seasonal trend with peak presentation in post-monsoon months between August and October. Mean (SD) age at presentation was 6.8 (3.2) years. Fever was present in all with a median (IQR) duration of 9 (6-11) days. Respiratory distress (42%), altered sensorium (24%), hepatomegaly (93%), splenomegaly (57%), and lymphadenopathy (54%) were other features. Rash and eschar were noted in 24% each. Thrombocytopenia (83%), hypoalbuminemia (63%), and hyponatremia (62%) were common laboratory abnormalities. Meningoencephalitic presentation was noted in 29%; acute kidney injury (AKI) (16%), acute respiratory distress syndrome (ARDS) (11%), and myocarditis (3%) were other organ dysfunctions. Sixty-six (41%) children required PICU admission. Intensive care needs include invasive ventilation (n = 27, 17%), vasoactive drugs therapy for hemodynamic support (n = 43, 27%), osmotherapy to treat raised intracranial pressure (n = 27, 17%), and renal replacement therapy (n = 3, 2%). Mortality was 8.8%. On multivariable analysis, lymphadenopathy, respiratory distress, shock, elevated lactate, and meningoencephalitis predicted the requirement of PICU admission. CONCLUSION: Scrub typhus presents with organ dysfunction during post-monsoon months. We identified predictors of intensive care in children with scrub typhus admitted to ED. CLINICAL SIGNIFICANCE: Our results would help clinicians identify severe cases and prioritize resources. HOW TO CITE THIS ARTICLE: Nallasamy K, Gupta S, Bansal A, Biswal M, Jayashree M, Zaman K, et al. Clinical Profile and Predictors of Intensive Care Unit Admission in Pediatric Scrub Typhus: A Retrospective Observational Study from North India. Indian J Crit Care Med 2020;24(6):445-450.

Spontaneous intracranial haemorrhage in children-intensive care needs and predictors of in-hospital mortality: a 10-year single-centre experience.

PURPOSE: Spontaneous intracranial haemorrhage (SICH) in children, although uncommon, is associated with significant mortality and morbidity. Paediatric data is however limited. MATERIAL AND METHODS: Case records of 105 children with SICH, > 1 month to 12 years, admitted to a tertiary level PICU of a teaching and referral hospital between January 2009 and May 2018 were analysed retrospectively. In-hospital mortality was the primary outcome. Variables between survivors and non-survivors were compared to  determine predictors of mortality. RESULTS: The median (IQR) age of subjects was 6 (2.25, 70) months. Common clinical features were altered sensorium (n = 87, 82.9%), seizures (n = 73, 69.5%), pallor (n = 66, 62.9%) and bulging anterior fontanelle (n = 52, 49.5%). Median (IQR) Glasgow Coma Scale (GCS) at admission was 10 (6, 13) with herniation noted in 27 (25.7%) children. Vitamin K deficiency bleeding (VKDB) and arteriovenous malformation (AVM) were the most common etiology for bleeding among infants and older children respectively. The most common site of bleeding was intracerebral (n = 47, 44.8%) followed by subdural (n = 26; 24.8%). Sixteen (15.2%) children died during hospital stay. On univariate analysis, GCS < 8, Pediatric Risk of Mortality score (PRISM III) > 20, need for intubation, thiopentone coma for refractory intracranial pressure (ICP) and progression to shock and acute kidney injury (AKI) predicted mortality. Seizures were favourably associated with survival. Age, site of bleeding, etiology or type of management for raised ICP (conservative versus decompressive craniectomy) did not affect the outcome. On multivariable analysis, progression to AKI (OR 5.86; 95% CI, 1.53-22.4; p 0.01) predicted poor outcome. Seizures, however, were associated with better odds for survival (OR 0.12; 95% CI, 0.03-0.47; p 0.002). CONCLUSIONS: VKDB and AVM were the common etiologies among infants and older children respectively. Age, site, etiology of bleeding and type of management did not affect outcome. Severe decompensation at presentation, thiopentone for refractory ICP and progression to multiorgan dysfunction determined mortality.

Subdural empyema due to Salmonella paratyphi B in an infant: a case report and review of literature.

Intracranial infection due to Salmonella is uncommon in children. Subdural empyema (SDE) is described with Salmonella typhi as a complication of meningitis. We report a 6-month-old infant with SDE secondary to Salmonella paratyphi B who had presented with prolonged fever and enlarging head. A literature review of Salmonella SDE in infants with respect to clinical course and outcome is presented.

Acute Viral Bronchiolitis: A Narrative Review.

Acute viral bronchiolitis (AVB) is the leading cause of hospital admissions among infants in developed and developing countries and associated with increased morbidity and cost of treatment. This review was performed to guide the clinicians managing AVB in light of evidence accumulated in the last decade. We searched published English literature in last decade regarding etiology, diagnosis, treatment, and prevention of AVB using PubMed and Cochrane Database of Systematic Reviews. Respiratory syncytial virus is the most common causative agent. The diagnosis is mainly clinical with limited role of diagnostic investigations and chest radiographs are not routinely indicated. The management of AVB remains a challenge, as the role of various interventions is not clear. Supportive care in form of provision of heated and humidified oxygen and maintaining hydration are main interventions. The use of pulse oximetry helps to guide the administration of oxygen. Trials and systematic reviews evaluated various interventions like nebulized adrenaline, bronchodilators and hypertonic saline, corticosteroids, different modes of noninvasive ventilation (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and noninvasive positive pressure ventilation [NPPV]), surfactant, heliox, chest physiotherapy, and antiviral drugs. The interventions which showed some benefits in infants and children with AVB are adrenaline and hypertonic saline nebulization, HFNC, CPAP, NIV, and surfactant. The routine administration of antibiotics, bronchodilators, corticosteroids, steam inhalation, chest physiotherapy, heliox, and antiviral drugs are not recommended.

Clinicolaboratory Profile, Treatment, Intensive Care Needs, and Outcome of Pediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2: A Systematic Review and Meta-analysis.

This study was aimed to summarize the current data on clinicolaboratory features, treatment, intensive care needs, and outcome of pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2; PIMS-TS) or multisystem inflammatory syndrome in children (MIS-C). Articles published in PubMed, Web of Science, Scopus, Google Scholar, and novel coronavirus disease 2019 (COVID-19) research database of World Health Organization (WHO), Centers for Disease Control and Prevention (CDC) database, and Cochrane COVID-19 study register between December 1, 2019 and July 10, 2020. Observational studies involving patients <21 years with PIMS-TS or MIS-C were reported the clinicolaboratory features, treatment, intensive care needs, and outcome. The search identified 422 citations and finally 18 studies with 833 participants that were included in this study, and pooled estimate was calculated for parameters of interest utilizing random effect model. The median age was 9 (range: 8-11) years. Fever, gastrointestinal symptoms, rash, conjunctival injection, and respiratory symptoms were common clinical features. Majority (84%) had positive SARS-CoV-2 antibody test and only one-third had positive reverse transcript polymerase chain reaction (RT-PCR). The most common laboratory abnormalities noted were elevated C-reactive protein (CRP), D-dimer, procalcitonin, brain natriuretic peptide (BNP), fibrinogen, ferritin, troponin, interleukin 6 (IL-6), lymphopenia, hypoalbuminemia, and thrombocytopenia. Cardiovascular complications included shock (65%), myocardial dysfunction (61%), myocarditis (65%), and coronary artery abnormalities (39%). Three-fourths of children required admission to pediatric intensive care unit (PICU) where they received vasoactive medications (61%) and mechanical ventilation (25%). Treatment strategies used included intravenous immunoglobulin (IVIg; 82%), steroids (54%), antiplatelet drugs (64%), and anticoagulation (51%). Mortality for patients with PIMS-TS or MIS-C was low ( n = 13). In this systematic review, we highlight key clinical features, laboratory findings, therapeutic strategies, intensive care needs, and observed outcomes for patients with PIMS-TS or MIS-C. Commonly observed clinical manifestations include fever, gastrointestinal symptoms, mucocutaneous findings, cardiac dysfunction, shock, and evidence of hyperinflammation. The majority of children required PICU admission, received immunomodulatory treatment, and had good outcome with low mortality.

Hyperferritinemia in children hospitalized with scrub typhus.

BACKGROUND: Hyperferritinemia is increasingly associated with mortality in sepsis. Studies estimating the prevalence of hyperferritinemia in pediatric scrub typhus are limited. METHODS: This was a secondary analysis of a prospective observational study (FERRIS) from a tertiary care teaching hospital in North India where 72 children with confirmed scrub typhus, 4 (5.5%) PCR positive, 55 (76.4%)-IgM ELISA positive, and 13 (18.1%)-both PCR and ELISA positive, were analyzed. Serum ferritin was measured in 62 children to identify the prevalence of hyperferritinemia and determine its association with mortality. RESULTS: Hyperferritinemia (> 500 µg/L) was seen in 72.6% [n = 45] children; 26 (41.9%) were mild (500-2000 µg/L), 13 (21%) were moderate (2000-10,000 µg/L), and 6 (9.7%) were severe (> 10,000 µg/L). Early presentation to hospital (≤ 7 days of febrile illness) had more survivors than late presentation (> 7 days). Non-survivors had significantly higher PRISM III, PELOD-2, hyperlactatemia, hypoalbuminemia, organ dysfunction, need for mechanical ventilation, and need of RRT. Ferritin had poor sensitivity and specificity in predicting survival with AUC of 0.56. Organ dysfunction and risk scores as PRISM III, PELOD 2, and VIS at admission were better predictors with AUC (95% CI) of 0.72 (0.56, 0.89), 0.77 (0.63, 0.92), and 0.90 (0.78, 1.0) respectively. CONCLUSIONS: Hyperferritinemia is common in scrub typhus but it did not predict survival. Organ dysfunction and risk scores were better predictors of mortality than ferritin.

Continuous Venovenous Hemofiltration as a Rescue Therapy for Severe Acetaminophen Toxicity in a Toddler.

Acetaminophen poisoning is one of the common accidental poisoning in children. Accidental administration of mismatched doses of drops for syrups can lead to life-threatening overdose. N-acetylcysteine (NAC) is the specific antidote; however, extracorporeal therapy such as continuous venovenous hemofiltration (CVVH) can be used as a rescue measure when there is no improvement despite adequate NAC therapy and can be lifesaving. We reported an 18-month-old male infant patient who presented with acetaminophen poisoning following accidental ingestion of acetaminophen drops in place of syrup and developed fulminant hepatic failure. Treatment with NAC did not lead to improvement and CVVH was used as a rescue therapy for 24 hours which led to dramatic clinical and biochemical improvement with intact neurological outcome.

Serial urinary neutrophil gelatinase associated lipocalin in pediatric diabetic ketoacidosis with acute kidney injury.

BACKGROUND: Acute kidney injury (AKI) due to Diabetic Ketoacidosis (DKA) is rather common. Novel biomarkers to diagnose AKI are being increasingly used in different settings. The use of urinary Neutrophil Gelatinase-Associated Lipocalin (uNGAL) in predicting persistent AKI in pediatric DKA cases is still not thoroughly investigated. METHODS: This was a secondary analysis of Saline versus Plasma-Lyte in Ketoacidosis (SPinK) trial data; 66 children (> 1 month-12 years) with DKA, defined by the International Society for Pediatric and Adolescent Diabetes (ISPAD), were analyzed. Children with cerebral edema, chronic kidney disease and those who received pre-referral fluids and/or insulin were excluded. uNGAL and urine NGAL-creatinine ratio (uNCR) at 0 and 24 h were measured in all. Persistent AKI was defined as a composite outcome of continuance of AKI defined by the Kidney Disease Improving Global Outcomes (KDIGO) stage 2 or 3 beyond 48 h from AKI onset, progression of AKI from either KDIGO stage 0 or 1 to a worse stage, need of renal replacement therapy or death. MAIN OUTCOMES: Thirty-five (53%) children had AKI at admission; 32 (91.4%) resolved within 48 h. uNGAL was significantly higher in the AKI group at admission [79.8 ± 27.2 vs 54.6 ± 22.0, p = 0.0002] and at 24 h [61.4 ± 28.3 vs 20.2 ± 14.5, p = 0.0003]. Similar trend was observed with uNCR at admission [6.7 ± 3.7 vs 4.1 ± 2.6, p = 0.002] and at 24 h [6.3 ± 2.5 vs 1.2 ± 1.0, p = 0.01]. Furthermore, uNGAL at admission showed a moderate positive linear correlation with serum creatinine. Additionally, elevated uNGAL at 0 and 24 h correlated with corresponding KDIGO stages. Admission uNGAL >88 ng/ml and uNCR of >11.3 ng/mg had a sensitivity of 66% and 67%, specificity of 76% and 95%, and Area under the receiver operating characteristic curve (AUC) of 0.78 and 0.89 respectively for predicting persistent AKI at 48 h. CONCLUSIONS: Majority of AKI resolved with fluid therapy. While uNGAL and uNCR both correlated with serum creatinine and AKI stages, serial uNCR was a better predictor of persistent AKI than uNGAL alone. However, feasibility of routine uNGAL measurement to predict persistent AKI in DKA needs further elucidation. TRIAL REGISTRATION: This was a secondary analysis of the data of SPinK trial [CTRI/2018/05/014042 ( ctri.nic.in )].

Mystery of a Family with Recurrent Male Infant Deaths- Solved by Autopsy and Molecular Tests.

The authors report a case of a six weeks old boy who presented with acute febrile illness and progressive abdominal distension. There was a significant family history of early male sibling deaths. Autopsy showed multiorgan abscesses. Molecular test revealed final diagnosis of the child.

Intensive care needs and long-term outcome of pediatric toxic epidermal necrolysis - A 10-year experience.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a life-threatening severe cutaneous adverse reaction. Data on pediatric TEN is limited. METHODS: Case records of 44 children, 1 month-12 years with a diagnosis of TEN (>30% body surface area [%BSA] detachment) admitted to a tertiary pediatric intensive care unit (PICU) between 2009 and 2018 were analyzed retrospectively. The primary outcome was mortality, and secondary outcomes were organ dysfunction, length of stay (LOS), and long-term sequelae. RESULTS: Median (IQR) age was 6.5 (3.6, 8.0) years, and 25 (57%) were boys. Median (IQR) %BSA involved, SCORTEN score, and PRISM-III were 65% (45, 80); 2 (2, 3) and 13 (10, 16), respectively. Antiepileptics (n = 24, 54.6%) and antimicrobials (n = 8, 18.2%) were the most common offending agents. Twenty-four (54.5%) children had culture positive sepsis. Immunomodulatory therapy was provided in 35 (79.5%) and conservative management in nine (20.5%) children. Intravenous immunoglobulin (IVIG) was given in 22 (50%), steroids in three (6.8%), and both IVIG and steroids in 10 (22.7%) children. Respiratory failure (n = 14, 31.8%) was the commonest organ failure. Mortality was 15.9% (n = 7), and median (IQR) PICU-LOS in survivors was 8 (4, 11.75) days. There was no association between IVIG, steroids, or conservative management with mortality or LOS. Ocular sequelae (n = 20, 54.1%) were the most common long-term complication followed by skin (18, 40.1%). CONCLUSION: Immunomodulation with IVIG or steroids was not associated with any mortality benefit as compared to conservative management alone. Further research is required to determine the most effective treatment in pediatric TEN.