SpO2/FiO2 and PaO2/FiO2 for Predicting Intensive Care Admission in Wheezy Children: An Observational Study.

OBJECTIVE: To determine the sensitivity of cut-off of SpO2/FiO2 (SF ratio) < 300 at hospital admission for predicting the need for admission in the pediatric intensive care unit (PICU) in wheezy children. Secondary objectives were to determine the sensitivity of cut-off of SF ratio < 300 for predicting in-hospital mortality and that of PaO2/FiO2 (PF ratio) < 200 for predicting intensive care admission and in-hospital mortality. We also ascertained the correlation between SF ratio and PF ratio in the above population. METHODS: This prospective observational study was conducted on 315 wheezy children aged 6 months to 12 years requiring admission in the pediatric emergency department. Oxygen saturation (SpO2) and fraction of oxygen in inspired air (FiO2) were recorded at admission while the partial pressure of oxygen (PaO2) was measured using arterial blood gas analysis performed within half an hour of admission. All children were managed as per protocol and followed up during hospital stay. Outcome was defined as the need for admission in the pediatric intensive care unit (PICU) or in-hospital mortality. RESULTS: Cut -offs of SF ratio < 300 and PF ratio < 200 were able to determine the need PICU admission with a sensitivity of 97.30% and 62.16% respectively. The best cut-off of SF ratio for predicting PICU admission was < 178.79 [AUC (95% CI) 0.841 (0.767, 0.914)], while that for PF ratio was < 201.81 [AUC (95% CI) of 0.849 (0.775, 0.924)]. Cut-offs of < 300 for SF ratio and < 200 of PF ratio, were able to predict in-hospital mortality with sensitivity of 100%, but specificity of only 3.33% and 46.67%, respectively. There was only a moderate correlation between SF ratio and PF ratio (r = 0.44, P < 0.001). CONCLUSION: SpO2/FiO2 cut-off of < 300 had a good sensitivity in determining need for PICU admission. SF ratio has only a moderate correlation with PF ratio.

Hematological Indices for Identifying Adverse Outcomes in Children Admitted to Pediatric ICUs.

BACKGROUND: The pediatric ICU (PICU) is a specialized area where critically sick children are managed. The mortality rates in PICUs are higher in developing countries as compared to developed nations. Many of these deaths could be prevented if very sick children were identified soon after they arrived at the health facility. Hematological indices like platelet lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) have been frequently used in adults as indicators of mortality. However, their use in the pediatric population is limited due to a lack of validated reference intervals. OBJECTIVE: The objective of the study is to assess the role of hematological indices in identifying adverse outcomes in terms of mortality in children admitted to the PICU. MATERIALS AND METHODS: It is a prospective, observational study done at a tertiary care hospital. All children aged one year to 12 years admitted to the PICU were enrolled in the study. A sample for complete blood count was taken within one hour of admission to the PICU. Children who had received blood products in the last two months, those on chronic medications (>two weeks) that can affect bone marrow cellularity, and known cases of hematological disorders such as megaloblastic anemia, hematological malignancies, immune thrombocytopenia, and aplastic anemia were excluded from the study. PLR, NLR, and platelets to mean platelet volume ratio (PLT/MPV) were determined and compared among the survivors and non-survivors. RESULTS:  Out of 275 enrolled patients, 119 (43.3%) patients expired during the study period. While PLR had high sensitivity and NLR had high specificity (85.71% and 92.31%, respectively) for predicting mortality, none of these parameters had a good area under the curve (AUC) in our study. PLT/MPV of ≥32 had a sensitivity of 39.5% and a specificity of 56.41% for predicting mortality. CONCLUSIONS: Hematological parameters have been used across the world to predict ICU mortality. PLR and NLR are simple hematological biomarkers, easy to calculate, and cost-effective, and ratios are better than individual parameters. More studies and stratified samples are required to evaluate the role of hematological markers in identifying the risk of mortality in children admitted to PICUs.

Comparison of Emergency Severity Index Version 4 and Modified Pediatric Early Warning Score as Triage Models in the Pediatric Emergency of a Tertiary Care Public Sector Hospital.

OBJECTIVE: To identify the sensitivity of emergency severity index (ESI) version 4 and modified pediatric early warning score (PEWS) in identifying high urgency patients. METHODS: This cross-sectional study was conducted between November, 2019 and October, 2021 in the pediatric emergency department of tertiary hospital in Delhi. 250 patients aged 0-12 years coming to pediatric emergency on pre-decided days for health-related complaints were enrolled. These were assessed with both triage systems within 30 minutes of their arrival by a single researcher. 'High urgency' patients were defined as the ones who either required admission in pediatric ICU or died or had critical value of vital parameters as per institution protocol. RESULTS: ESI version 4 had a sensitivity of 95.5%, specificity of 80.3%, with AUC of 0.879 (95%CI 0.834-0.925) in identifying high urgency patients at levels 1 and 2. Modified PEWS had comparatively lower sensitivity of 79.1%, specificity of 97.8%, with AUC of 0.885 (95%CI 0.825-0.994) in identifying high urgency patients at score of ≥3. The ESI version 4 was found to be a better predictor of admission than the modified PEWS, with a sensitivity of 98.2%. Both the scores were able to identify patients at risk of mortality with a sensitivity of 100%. CONCLUSION: ESI version 4 is a better triage tool than modified PEWS in pediatric population in a tertiary care public hospital setting in this region.

Efficacy of fixed-dose phenylephrine bolus for treating post-spinal hypotension: Comparison between pre-eclamptics and normotensives.

Background and Aims: Pre-eclamptic parturients may have an exaggerated response to vasopressors. This study compares the efficacy of a 50 µg fixed bolus of phenylephrine for treatment of post-spinal hypotension in pre-eclamptic versus normotensive parturients. Material and Methods: After written informed consent and ethics committee approval, 30 normotensive and 30 pre-eclamptic parturients between 18 and 40 years with singleton term pregnancy about to undergo cesarean section (CS) under spinal anesthesia were included. Post-spinal hypotension was treated with a 50 µg fixed bolus of phenylephrine. The cumulative dose of phenylephrine, the number of boluses, and the median dose required to treat the first hypotensive episode, total number of hypotensive episodes, maternal side effects, neonatal appearance, pulse, grimace, activity, and respiration (APGAR) scores, and umbilical arterial cord blood pH were noted. Statistical analysis was done using Student's t-test, Mann-Whitney U-test, Chi-square test/Fisher's exact test as appropriate. A P <0.05 was considered significant. Results: The cumulative dose and number of boluses of phenylephrine required to treat post-spinal hypotension were comparable. The median dose required to treat the first episode of post-spinal hypotension was also similar (p = 0.792). The time to develop the first hypotensive episode was significantly earlier for group N (p = 0.002). The efficacy of a single fixed bolus of 50 µg phenylephrine was similar in both groups (p = 1.000). Neonatal median APGAR scores at 1 min after birth were significantly higher for group N (p = 0.016). Conclusion: A fixed-dose bolus of 50 µg phenylephrine is safe and effective in treating post-spinal hypotension in pre-eclampsia. The efficacy of phenylephrine is comparable in pre-eclamptic and normotensive parturients.

A Quality Improvement Study to Improve Oxygen Prescription in the PICU of a Tertiary Care Centre in Delhi, India.

Introduction Oxygen has been gravely misused since its inception as a therapeutic agent. There is a deficit of audits and baseline data for the Indian population, especially in the pediatric age group, which doesn't allow for standardization of protocols and guidelines. Objective Our study aimed at increasing valid prescription rates to 90% by implementation of quality improvement interventions, and assessing knowledge and perception of healthcare workers towards oxygen therapy. Methodology It followed a before-and-after prospective observational study model where baseline audit data was compared with data observed after the implementation of quality improvement strategies. The data was collected through an audit of the medical records of all pediatric patients receiving oxygen therapy in the PICU. Knowledge and perception of healthcare workers about oxygen therapy were assessed via a self-designed questionnaire. The study was undertaken in three phases, including Quality Improvement (QI) team formation and data collection, root cause analysis, and implementation of Plan-Do-Study-Act (PDSA) cycles. Observations and results In the baseline audit, 1.4% of the prescriptions were complete and valid. Subsequently, over the course of four PDSA cycles, valid prescription rates increased; 62.07% in the first, 79.51% in the second, 81.81% in the third, and 91.42% in the fourth cycle respectively. After applying the chi-square test to compare PDSA4 and baseline data, the p-values for written prescriptions and target saturation were found to be statistically significant. In the healthcare worker survey, we found that 100% of them were aware of indications of oxygen prescription, FiO2, and side effects of excessive usage of oxygen therapy, 95% were aware of conditions affecting pulse-oximetry in the pediatric age group, and 75% knew about target saturation and its significance and the procedure to change alarm settings on the monitor. Conclusion Currently, there exists a lack of effective oxygen prescription audits, especially in India, which can be attributed to a lack of awareness and partly, a lack of initiative. Quality improvement initiatives are effective in improving the valid oxygen prescription rate. However, sustained goals can be achieved through regular audits only.

Genetic Expression of CYP2B6 Gene in Phenobarbitone Responder and Non- responder Neonates.

Quantitative real-time polymerase chain reaction for identifying CYP2B6 gene expression was done on blood samples of 30 phenobarbitone responder and 30 non-responder neonates with seizures. CYP2B6 was observed to be significantly down regulated among phenobarbitone non-responders as compared to phenobarbitone responders (Mean (SD) DCt 17.97 (1.19) vs 15.40 (1.83); P<0.001).

Iron Profile in Term Small for Gestational Age Infants at 10 Weeks of Age and Correlation With Maternal Iron Profile : A Prospective Cohort Study.

BACKGROUND: Term small for gestational age (SGA) babies are at risk for developing iron deficiency anemia. The association between maternal and infant iron stores is not clear. OBJECTIVE: To assess proportion of term SGA neonates developing iron deficiency anemia by 10 weeks of age, and measure correlation between iron profile and hepcidin of babies at birth and at 10 weeks of age with maternal iron profile. DESIGN: Prospective cohort study conducted from November, 2018 to April, 2020. PARTICIPANTS: 120 term SGA babies and their mothers. INTERVENTION: Hemogram, iron profile and serum hepcidin (every fourth case) estimated in mother, cord blood and baby at 10 weeks. Babies developing anemia at 6 weeks detected by hemogram and ferritin were started on iron supplementation and excluded from the study. OUTCOME: Proportion of babies developing iron deficiency anemia at 10 weeks of age. RESULTS: 35 (29.2%) of 120 term SGA babies developed anemia (hemoglobin <9 g/dL) at 6 weeks. Proportion of infants who developed iron deficiency anemia (hemoglobin <9 g/dL and serum ferritin <40 µ/dL) at 6 and 10 weeks of age was 14.2% and 23.3%, respectively. No significant correlation was found bet-ween hemoglobin, iron and hepcidin of the baby in cord blood and at 10 weeks of age with that of mothers. Serum hepcidin in babies at birth (137.5 ng/mL) were higher than maternal values (128 ng/mL). CONCLUSION: A significant proportion of term SGA infants deve-loped anemia during early infancy, irrespective of maternal iron status.

Efficacy of Oral vs. Intravenous Calcium Supplementation for Continuation Therapy in Hypocalcemic Seizures: A Randomized, Controlled Trial.

OBJECTIVE: To evaluate efficacy of oral vs. intravenous calcium supplementation for continuation therapy in hypocalcemic seizures. METHODS: Sixty children between 1 mo and 5 y presenting with hypocalcemic seizures without any other underlying febrile, chronic systemic disease, or acute neurological illness were included. Participants were randomized to receive either intravenous (IV) 10% calcium gluconate (n = 30) or oral elemental calcium (n = 30) for 48 h following initial seizure control with intravenous calcium. RESULTS: Seizures recurred in 3 (10%) children in IV group as compared to 4 (13.3%) in oral calcium group (p = 0.278) within 48 h. Serum calcium levels achieved in the two treatment groups at 24 h [7.96 (1.32) vs. 8.23 (1.58) mg/dL; p = 0.476] and 48 h [8.5 (1.01) vs. 8.63 (1.39) mg/dL; p = 0.681] were comparable. CONCLUSION: Oral calcium may be as efficacious as intravenous calcium during continuation phase of treating hypocalcemic seizures; however, further studies are needed for definite recommendations. TRIAL REGISTRATION: Trial Registration number: CTRI/2017/12/011042.

The Emergency Medicine Education and Research by Global Experts (EMERGE) Network: Challenges and Lessons Learned.

INTRODUCTION: The Emergency Medicine Education and Research by Global Experts (EMERGE) network was formed to generate and translate evidence to improve global emergency care. We share the challenges faced and lessons learned in establishing a global research network. METHODS: We describe the challenges encountered when EMERGE proposed the development of a global emergency department (ED) visit registry. The proposed registry was to be a six-month, retrospective, deidentified, minimal dataset of routinely collected variables, such as patient demographics, diagnosis, and disposition. RESULTS: Obtaining reliable, accurate, and pertinent data from participating EDs is challenging in a global context. Barriers experienced ranged from variable taxonomies, need for language translation, varying site processes for curation and transfer of deidentified data, navigating institution- and country-specific data protection regulations, and substantial variation in each participating institution's research infrastructure including training in research-related activities. We have overcome many of these challenges by creating detailed data-sharing agreements with bilateral regulatory oversight agreements between EMERGE and participating EDs, developing relationships with and training health informaticians at each site to ensure secure transfer of deidentified data, and formalizing an electronic transfer process ensuring data privacy. CONCLUSION: We believe that networks like EMERGE are integral to providing the necessary platforms for education, training, and research collaborations for emergency care. We identified substantial challenges in data sharing and variation in local sites' research infrastructure and propose potential approaches to address these challenges.

Re-visiting micro ESR as a screening tool for neonatal sepsis.

Our study evaluated the role of micro-erythrocte sedimentation rate (micro-ESR) in the early detection of neonatal sepsis.Neonates with >34 completed weeks of gestation, appropriate for gestational age, admitted in our Neonatal Intensive Care Unit with clinical suspicion of early onset sepsis were enrolled in the study. A sepsis screen and blood culture was performed on all the babies within 4 h of admission. The sensitivity of micro-ESR for detecting positive blood culture was calculated and the best cut-off was determined using the Area Under Curve.

Reduced fetal urine production rate-An early marker of fetal inflammatory response syndrome in preterm premature rupture of membranes: Prospective cohort study.

OBJECTIVE: To find association between fetal urine production rate (FUPR) and fetal inflammatory response syndrome (FIRS) in preterm premature rupture of membranes (PPROM). METHODS: A prospective cohort study of 70 pregnant women with PPROM at 28-34 weeks of pregnancy was conducted. FUPR was calculated by performing serial fetal bladder volume measurements ultrasonographically and was repeated weekly until delivery. After delivery, cord blood interleukin-6 (IL-6) levels were measured. Placental tissue histopathology was performed and neonatal outcomes were noted. RESULTS: Out of 70 recruited patients with PPROM, 44 had evidence of FIRS (62.86%). Mean FUPR at the time of delivery was significantly reduced in neonates with evidence of FIRS compared with the Non-FIRS group (13.89 ± 8.06 ml/h vs. 25.89 ± 4.94 ml/h). Out of 41 patients with reduced FUPR, 39 neonates had FIRS whereas only five out of 29 neonates with normal FUPR had FIRS (P < 0.001). Severe neonatal morbidity was found in 24 out of 41 (58.54%) neonates with reduced FUPR prenatally. The occurrence of respiratory distress syndrome, necrotizing enterocolitis, and sepsis was significantly high in neonates with reduced FUPR. CONCLUSION: Reduced FUPR is strongly associated with FIRS in cases of PPROM and hence can be used as an early predictor of adverse neonatal outcomes.

Utility of Cerebrospinal Fluid and Serum Procalcitonin for the Diagnosis of Neonatal Meningitis.

OBJECTIVE: Positive CSF culture is the gold standard for the diagnosis of meningitis but it carries poor sensitivity. CSF procalcitonin (PCT) is shown to have some utility for the diagnosis of meningitis though there are limited studies in neonatal age group. We planned this study to compare CSF, serum, and CSF to serum PCT levels in neonates with confirmed, probable, and nonmeningitis groups to determine its optimal cut-off in CSF and serum for diagnosing meningitis. STUDY DESIGN: Sixty-seven neonates who qualified for lumbar puncture were enrolled in the study. Neonates were categorized into confirmed meningitis, i.e., CSF cytochemistry and culture positive (N = 17), probable meningitis, i.e., CSF cytochemistry positive but culture negative (N = 25) and nonmeningitis, i.e., both cytochemistry and culture negative (N = 25). CSF and serum samples were stored at -80°C for PCT assay. RESULTS: Significant difference was seen in mean of CSF PCT in neonates with confirmed (0.31 ng/mL), probable (0.22 ng/mL), and nonmeningitis (0.11 ng/mL) groups. Similarly, significant difference was observed in serum PCT levels also, though the ratio of serum to CSF PCT was comparable. At cut-off of 0.2 ng/mL, CSF PCT had sensitivity of 95.2% and specificity of 96% in the diagnosis of meningitis. CONCLUSION: CSF PCT is more specific marker for the diagnosis of neonatal meningitis as compared with serum PCT and CSF to serum PCT ratio. KEY POINTS: · CSF procalcitonin is a better marker than serum procalcitonin for diagnosing neonatal meningitis.. · It is better than serum procalcitonin and CSF to serum procalcitonin ratio.. · At cut-off of >0.2 ng/mL CSF procalcitonin can diagnose neonatal meningitis with 96% specificity..

The 2021 Toolkit for Emergency Preparedness and Mitigation to Combat Surge of Pediatric COVID-19 Patients in India: The World Health Organization Collaborating Center for Emergency and Trauma in South East Asia Recommendations.

The authors of this toolkit focus on children under the age of 18 comprising approximately 41% of the total population in India. This toolkit has been created with an objective to prepare, mitigate the effects of any surge of COVID-19 in our communities, and help to optimally utilize the scarce resources. The toolkit design suggests the manpower, equipment, laboratory support, training, consumables, and drugs for a 10-bedded pediatric emergency room, 25-bedded COVID pediatric intensive care unit, and 75-bedded COVID pediatric high dependency unit/ward as defined for a 100-bedded facility. A dedicated and detailed chapter is included to address the psychological needs of the children. These data can be modified for other department sizes based on the facilities, needs, local environment, and resources available.

Unusually prolonged neuromuscular weakness caused by krait (Bungarus caeruleus) bite: Two case reports.

Snakebites are common in India and the most common neurotoxic snakebites in India are due to Common krait (Bungarus caeruleus) and cobra (Naja naja). Severe envenomation may mimic brain death or a locked-in state with flaccid paralysis in a descending manner and total ophthalmoplegia. Usually, patients who receive timely antivenom and ventilator support recover completely without any sequalae. We are reporting two cases of krait bite with an unusually long period of flaccid paralysis, which required prolong ventilation. While case 1 required 10 days of mechanical ventilation followed by 5 days of non-invasive ventilation, case 2 required 11 days of mechanical ventilation followed by 5 days of non-invasive ventilation. Both the cases had delayed recovery and residual weakness at 3-month follow up. These case reports suggest that krait bite may cause prolong neuromuscular weakness in children, which has implications for both acute and chronic management.

Identifying Serious Bacterial Infections in Febrile Young Infants.

Fever is one of the most common presenting complaints among infants brought to pediatric emergency. Although most of the infants have benign, self-limiting viral infections, approximately 10% of all may have serious bacterial infection. Clinical examination alone is insufficient to detect serious bacterial infection in well appearing infants, and a standardized approach is always sought for. However, guidelines used in the United States or European countries may not be applicable in a tropical country like India. Deviation from these guidelines leads to challenges of unwarranted hospitalization and antibiotic usage, extra cost of care and risk of antimicrobial resistance. Various prediction rules can detect a low risk infant with negative predictive values ranging from 93.7-100%. While use of biomarkers such as C reactive protein and procalcitonin can be reliable, it is costly and may not be applicable to the local population. Validation studies over varied population are needed in future.

Changing epidemiology of poisoning in children: A retrospective study from a tertiary care center in New Delhi, India.

Poisoning is the fourth leading cause of unintentional injuries in children. With continuously changing environment, the epidemiology of poisoning keeps on changing. The present study was undertaken to describe the clinical and epidemiological profile of childhood poisoning in a tertiary care center of New Delhi, India. All children <12 years of age admitted to pediatric ward with a history of ingestion of poison or envenomation between January 2019 and June 2020 were identified, and their medical records were obtained from medical records department. A total of 203 patients were enrolled in the study. Drugs and medications were the most common agents (19.2% cases), followed by prallethrin (13.7% cases). Majority of the cases were asymptomatic. Vomiting (25%) was the most common symptom. Drugs and medications were the leading cause of poisoning, followed by liquid mosquito repellant. This study highlights the change in characteristics of acute poisoning in Indian children.

Prevalence and predictors of hypocalcaemia in severe acute malnutrition.

OBJECTIVE: To determine the prevalence and predictors of hypocalcaemia in under-five children (1-59 months) hospitalised with severe acute malnutrition (SAM). DESIGN: A cross-sectional study was designed to determine the prevalence of hypocalcaemia among children hospitalised with SAM. Serum Ca and 25-hydroxycholecalciferol (25-(OH)D) were estimated. Hypocalcaemia was defined as serum Ca (albumin-adjusted) <2·12 mmol/l. To identify the clinical predictors of hypocalcaemia, a logistic regression model was constructed taking hypocalcaemia as a dependent variable, and sociodemographic and clinical variables as independent variables. SETTING: A tertiary care hospital in Delhi, between November 2017 and April 2019. PARTICIPANTS: One-hundred and fifty children (1-59 months) hospitalised with SAM were enrolled. RESULTS: Hypocalcaemia was documented in thirty-nine (26 %) children hospitalised with SAM, the prevalence being comparable between children aged <6 months (11/41, 26·8 %) and those between 6 and 59 months (28/109, 25·7 %) (P = 0·887). Vitamin D deficiency (serum 25-(OH)D <30 nmol/l) and clinical rickets were observed in ninety-eight (65·3 %) and sixty-three (42 %) children, respectively. Hypocalcaemia occurred more frequently in severely malnourished children with clinical rickets (OR 6·6, 95 % CI 2·54, 17·15, P < 0·001), abdominal distension (OR 4·5, 95 % CI 1·39, 14·54, P = 0·012) and sepsis (OR 2·6, 95 % CI 1·00, 6·57, P = 0·050). CONCLUSION: Rickets and hypocalcaemia are common in children with SAM. Routine supplementation of vitamin D should be considered for severely malnourished children. Ca may be empirically prescribed to severely malnourished children with clinical rickets, abdominal distension and/or sepsis.

Neonatal ventriculitis: a case series and review of literature.

Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of intraventricular antibiotics in treatment is controversial. We present five such cases which were refractory to conventional intravenous antibiotic therapy, had persistent features of ventriculitis and in whom raised intracranial pressure (ICP) necessitated insertion of an external ventricular drain (EVD). Three of the five infants required intraventricular antibiotics but also developed EVD-related complications. Early diagnosis of ventriculitis and treatment is necessary to avoid a fatal outcome. Intravenous antibiotics are the treatment of choice, but intraventricular therapy may be considered in refractory cases. As the incidence of EVD-associated ventriculitis is high, proper care of EVDs and their early removal is mandatory.