Clinical characteristics and outcome of critically ill children referred to a tertiary hospital in Indonesia: a prospective observational study.

BACKGROUND: The clinical characteristics of pediatric critically ill patients who need referral to a tertiary hospital is often unknown in resource limited settings where constraints in diagnosis capacity, resources, and infrastructures are common. There is a need to increase insight in the characteristics of these patients for capacity building strengthening and appropriate resource allocation. The aim of this study was to describe the clinical characteristics and outcomes of critically ill children who are referred to a tertiary referral teaching hospital in Yogyakarta. METHODS: A prospective observasional study was carried out from July 1st, 2022 -January 31st, 2023 which included all critically ill pediatric patients who were referred through the Integrated Referral System (SISRUTE) to the Pediatric Intensive Care Unit (PICU) of dr. Sardjito hospital. We excluded patients who were referred with a request for admission to the PICU, but were not admitted to the PICU due to their stable condition and lack of the need for intensive care. RESULT: During the study period, we received 1046 emergency referral requests for pediatric patients via SISRUTE, of those, 562 (53.7%) patients were critically ill. The reasons of PICU referral request were the need of solely intensive care 504 (89.7%), the need of multidisciplinary team care, including intensive care 57 (10.1%) and parents request 1 (0.3%). The pre-referral emergency diagnosis was shock 226 (40.3%), respiratory distress/failure 151 (26.7%), central nervous system (CNS) dysfunction 135 (24.1%), trauma 33 (5.9%) and sepsis 17 (3%). Of the 562 critically ill PICU referral requests, 473 (84.2%) requests were accepted. One hundred and eighty-one (58.7%) patients were finally admitted to the PICU, 125 (40.3%) admitted to our regular ward due to stable condition, 4 (1.3%) patients died in Emergency Departement (ED). The remaining accepted patients on request did not arrive in our facility due to various reasons. The mean (SD) response time was 9.1 (27.6) minutes. The mean (SD) transfer time was 6.45 (4.73) hours. Mean (SD) PICU and hospital length of stay was 6.7 (8.3) days and 10.2 (9.2) days respectively. PICU and hospital mortality was 24.3% and 29.7%, respectively. CONCLUSION: The mortality rate for critically ill pediatric patients referred to a tertiary PICU still high, with shock being the most common pre-referral emergency diagnosis. There is a discrepancy between the referring hospital's and the referral hospital's indication for PICU admission. The time required to reach the referral hospital is quite lengthy.

Diabetic Ketoacidosis in Adolescents and Children: A Prospective Study of Blood versus Urine Ketones in Monitoring Therapeutic Response.

BACKGROUND: diabetic ketoacidosis (DKA) is a potentially lethal complication of diabetes mellitus (DM). There is no study in Indonesia that compares the much-preferred capillary beta hydroxybutirate (ß-OHB) measurement to urine acetoacetate in monitoring therapeutic response of DKA in adolescents. METHODS: a prospective study of 37 adolescents and children with DKA in Cipto Mangunkusumo Hospital was done between June 2006 and March 2011. The patients were followed until the time of DKA resolution. Hourly measurement of random blood glucose, capillary ß-OHB concentration, and urine ketones were done, while blood gas analysis and electrolyte were measured every four hours. RESULTS: median time to resolution was 21 (9-52) hours. Compared to urine ketones, capillary ß-OHB concentration showed stronger correlation with pH (r= -0,52, p= 0,003 vs r= -0,49, p= 0,005) and bicarbonate level (r=-0,60, p=0.000 vs r= -0.48, p=0.007) during the median time of DKA resolution. All capillary ß-OHB measurement yielded negative results at median time of DKA resolution, while urine ketones were still detected up to 9 hours after resolution. CONCLUSION: blood ketone concentration showed better correlation with pH and bicarbonate level, as a tool to monitor therapeutic response in DKA in adolescent, compared to traditional urine ketones test in adolescents.

The role of passive leg raising to predict fluid responsiveness in pediatric intensive care unit patients.

OBJECTIVE: Fluid challenge is often used to predict fluid responsiveness in critically ill patients. Inappropriate fluid expansion can lead to some unwanted side effects; therefore, we need a noninvasive predictive parameter to assess fluid responsiveness. We want to assess the hemodynamic parameter changes after passive leg raising, which can mimic fluid expansion, to predict fluid responsiveness in pediatric intensive care unit patients and to get a cutoff value of cardiac index in predicting fluid responsiveness in pediatric patients. DESIGN: Nonrandomized experimental study. SETTING: Tertiary academic pediatric intensive care. PATIENTS: Children admitted to pediatric intensive care. INTERVENTION: Hemodynamic parameters were assessed at baseline, after passive leg raising, at second baseline, and after volume expansion (10 mL/kg normal saline infusion over 15 mins). MEASUREMENTS AND MAIN RESULTS: We measured the heart rate, systolic blood pressure, and stroke volume and cardiac index using Doppler echocardiography. The hemodynamic parameter changes induced by passive leg raising were monitored. Among 40 patients included in the study, 20 patients had a cardiac index increase of ≥10% after volume expansion (responders). Changes in heart rate, systolic blood pressure, and stroke volume after passive leg raising did not significantly relate to the response to volume expansion. There was significant relation between changes in cardiac index to predict fluid responsiveness (p = .012, r(2) = .22, 95% confidence interval 1.529 to 31.37). A cardiac index increase by ≥10% induced by passive leg raising predicted preload-dependent status with sensitivity of 55% and specificity of 85% (area under the curve 0.71 ± 0.084, 95% confidence interval 0.546-0.874). CONCLUSION: The concomitant measurements in cardiac index changes after the passive leg raising maneuver can be helpful in predicting who might have an increase in cardiac index with subsequent fluid resuscitation.

Characteristics of hemodynamic parameters after fluid resuscitation and vasoactive drugs administration in pediatric shock: A prospective observational study.

Background: Prior studies have shown that septic shock survivors had a normal cardiac index (CI) and systemic vascular resistance index (SVRI). However, this feature seems to be questionable in other-caused shock, since several factors are associated with the hemodynamic profile. This study aims to describe hemodynamic profiles (preload, inotropy, afterload, stroke volume, and cardiac output) after fluid resuscitation and vasoactive therapy in children with shock. Methods: Children aged 1 month to 18 years old with shock conditions were included in this study. Fluid resuscitation was administered following the American College of Critical Care Medicine (ACCM) protocol. Hemodynamic profiles were assessed at 1 and 6 h from the start of fluid resuscitation. Grouping of the subjects was determined by the USCOM examination in 1st hour until the end of the study and we divided into 3 groups. Results: At 1 h, group 1 (low CI) was 14% (CI:2.5[1.2-3.2]L/min/m2), group 2 (normal CI) was 66% (CI:4.2[3.4-5.8]L/min/m2), and group 3 (high CI) was 20% (CI:7.1[6.1-9.4]L/min/m2). SVRI was higher in groups 1 and 2 compared to group 3 (p < 0.05). Group 1 and 2 revealed fluid-refractory shock (SVV:25[12-34]% and 29(13-58)%, respectively), lower Smith-Madigan Inotropy Index (SMII) and higher Potential to Kinetic Ratio (PKR) compared to group 3 (p < 0.05). Group 3 revealed fluid-responsive shock (Stroke Volume Variation (SVV):32[18-158]%), higher SMII and lower PKR. At 6th hour, CI in all groups were normal (group 1:3.5[1.2-7.5]; group 2:4.0[1.7-6.1]; group 3:6.0[3.1-6.2]). However, 71.4% and 54.5% of subjects in groups 1 and 2, respectively, still revealed low inotropy. Group 3 revealed a significant increase in SVRI and PKR (p < 0.01). Conclusions: Most pediatric shock patients were hypodynamic. Even when the CI was normal, the preload, inotropy, and afterload may still be abnormal. It represented the inotropy as a key to hemodynamic.

Corrigendum on: Pediatric COVID-19: Report from Indonesian pediatric society data registry.

[This corrects the article DOI: 10.3389/fped.2021.716898.].

Pediatric COVID-19: Report From Indonesian Pediatric Society Data Registry.

Background: Indonesia has a high number of COVID-19 cases and mortalities relative to not only among the Asia Pacific region but the world. Children were thought to be less affected by the virus compared to adults. Most of the public data reported combined data between adults and children. The Indonesian Pediatric Society (IPS) was involved in the COVID-19 response, especially in the area of child health. One of IPS's activities is collecting data registries from each of their chapters to provide a better understanding of COVID-19 in children. Objective: The objective of this study was to share the data of suspected and confirmed COVID-19 cases in children from IPS's COVID-19 data registry. Method: This is a retrospective study from the IPS's COVID-19 registry data. We collected the data of COVID-19 in children during March to December 2020 from each of the IPS chapters. We analyzed the prevalence, case fatality rate (CFR), age groups, diagnosis, and comorbidities of the children diagnosed with COVID-19. Result: As of December 21, 2020, there were 35,506 suspected cases of children with COVID-19. In total, there were 522 deaths, with a case fatality ratio (CFR) of 1.4. There were 37,706 confirmed cases with 175 fatalities (CFR 0.46). The highest mortality in confirmed COVID-19 cases was from children ages 10-18 years (42 out of 159 cases: 26%). The most common comorbidity and diagnosis found were malignancy (17.3%) and respiratory failure (54.5%). Conclusion: The CFR of confirmed COVID-19 cases in children in Indonesia is high and should be a major public concern.

The association between plasminogen activator inhibitor type-1 and clinical outcome in paediatric sepsis.

: Acute phase protein plasminogen activator inhibitor type-1 (PAI-1) is a key element in fibrinolysis inhibition in sepsis-induced disseminated intravascular coagulation (DIC). Elevated PAI-1 level is related to worse outcome in sepsis. The aim of this study was to investigate the relationship between plasma PAI-1 level and clinical outcome in children with sepsis. A total of 35 children with sepsis were enrolled into this prospective study. Plasma PAI-1 was measured on day-1 and day-4. Systemic coagulation profile was measured on day-4. Individuals were followed up until 28 days. The mean PAI-1 from day-1 to day-4 in overt DIC children was not statistically significant. Contrarily, among nonovert DIC individuals, there was a significant difference (P ≤ 0.001) in PAI-1 levels on day-1 compared with day-4 were 95.25 ±â€Š46.57 vs. 60.36 ±â€Š37.31 ng/ml, respectively. Among survivors, mean PAI-1 level on day-1 was statistically higher than PAI-1 level on day-4 (82.47 ±â€Š44.43 vs. 58.39 ±â€Š32.98 ng/ml), P = 0.021. There was no significant difference between PAI-1 levels on day-1 compared with day-4 in nonsurvivors. PAI-1 was correlated to DIC score with r = 0.606 (P ≤ 0.001). PAI-1 levels significantly decreased on day-4 compared with day-1 among nonovert DIC individuals, and not in overt DIC individuals. Changes in PAI-1 levels in nonsurvivors did not differ. PAI-1 level was positively correlated with DIC score.

Evaluation of ventilator on lung profile of piglets (Sus scrofa) in hypovolemic shock treated with hypervolemic crystalloid resuscitation.

AIM: This study was conducted to assess the effect of ventilators on the lung profile of piglets in the hypovolemic shock before and after the excessive resuscitation of the crystalloid fluid. MATERIALS AND METHODS: Five male piglets were used in this study as the models of shock, and there are four phases of treatment: Stabilization, shock of bleeding, normovolemic resuscitation, and hypervolemic resuscitation. The application of mechanical ventilation to patients who suspected of having lung injury may worsen the patient's conditions. The purpose of this study was to set the ventilator with the set of positive end-expiratory pressure (PEEP) of 5 cm H2O, thefraction of inspired oxygen (FiO2) of 0.5, and the inspiration: expiration (I: E) ratio of 1:2, which was applied from the stabilization phase. The shock induction was performed by removing the blood until the mean arterial pressure decreasing by 20% from the stabilization. The solution of NaCl 0.9% was used for the normovolemic and hypervolemic resuscitation. The parameter of observation consisted of extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) on pulse contour cardiac output 2 and exhaled tidal volume (VTE), peak inspiratory pressure (PIP), and respiratory rate (RR) on ventilators. RESULTS: EVLWI does not indicate pulmonary edema. A significant decrease in VTE without any significant alterations in EVLWI, PIP, and RR has indicated the shallow breathing in the shock condition. Therefore, the PVPI parameter cannot be used as a parameter for capillary permeability since its formulation does not reinforce the results of data in the shock condition. The set of the ventilator may prevent the increase of EVLWI, and the uses of ventilators do not worsen the patient's conditions during the crystalloid resuscitation. CONCLUSION: The use of mechanical ventilator as the support does not worsen the hypovolemic condition and is safe to use as long as the lung profile is not indicated to have lung injury.