Protocolized Sedation Utilizing COMFORT-B Scale versus Non-protocol-directed Sedation in Mechanically Ventilated Children - An Open-label, Randomized Controlled Trial.

This study aimed to determine the effect of protocolized sedation using the COMFORT-B scale on the duration of mechanical ventilation (DMV). Eighty children with anticipated Duration of mechanical ventilation (DMV) >24 h admitted to the Pediatric intensive care unit (PICU) were randomized into one group that received protocolized sedation (PS) using the COMFORT behavioural (COMFORT-B) scale, and another group that received non-protocolized sedation (NPS). The primary outcome was the impact on the DMV. The DMV was significantly lower in PS (PS: 3.5 [3-7] vs. NPS group: 8.5 [4.25-13.75] d; p = 0.008). The cumulative dose and duration of fentanyl in the PS group was significantly lower (median [IQR]; 120 [62.88-279.12] vs. 320.4 [110.88-851.52] µg/kg; p = 0.007 and 4 [2.25-7.75] vs. 8 [4-17.5] d; p = 0.009, respectively). The authors found a decrease in DMV and sedation related adverse events (SRAE) like ventilator associated pneumonia (VAP), accidental extubation, post-extubation stridor and dose and duration of sedative agents with PS.

When the Going Gets Tough: A Case Report and Review of Calcinosis Cutis in an Infant with Pseudo-Hypoaldosteronism.

Calcium gluconate solutions are an essential part of the intensive care medication armamentarium. Calcium-related extravasations are not an infrequent occurrence. However, occult extravasation presenting solely as an isolated mass lesion with no preceding cutaneous manifestation is rare. Calcinosis cutis is an extraosseous collection of calcium deposits in the skin and subcutaneous tissues. Multiple etiopathogenetic factors play a role in its manifestations. We illustrate a case of a seven-week-old infant diagnosed with pseudo-hypoaldosteronism with a mysterious swelling on the left leg during the third week of hospitalization, which was attributed to occult iatrogenic calcinosis cutis.

A cross-sectional study to assess the anxiety and coping mechanism among primary caregivers of children admitted in PICU.

Introduction: PICU admission of a child may cause anxiety and stress among the caregivers. The criteria for admission to a PICU are terrifying and may legitimately cause parents to fear that their child may pass away or suffer a serious disability. They may be overburdened with stress and anxiety of illness and compliment medical information while trying to maintain a balance with other family demands. They must learn coping mechanisms and use resources to stay stable when they face challenges. Evidence on the coping mechanisms used by primary caregivers to control their stress and anxiety is scarce so this study assessed the anxiety and coping mechanism among the primary caregivers of children admitted in PICU. Materials and Methods: A cross-sectional study was conducted among 143 primary caregivers by using convenience sampling technique at PICU, AIIMS, Jodhpur, from April 31, 2021, to January 20, 2022. The participants were enrolled after obtaining informed consent and were interviewed by the researcher. Results: Study findings revealed that primary caregivers had 38% severe anxiety, 54% moderate anxiety, and 8% mild anxiety. They used emotion-focused coping (43.5%) followed by problem focused coping (37.2%) and avoidant coping (19.3%). Also, there was a significant association found between anxiety of primary caregivers and gender of the child (P = 0.012). Conclusion: Anxiety and stress are one of the expected psychological problems faced by caregivers of children admitted in PICU. Healthcare workers must make concerted attempts to support caregivers adaptive coping mechanisms, so they can retain a sense of balance.

Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: Few Concerns.

How to cite this article: Khera D, Suresh C. Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: Few Concerns. Indian J Crit Care Med 2023;27(8):605.

Neuroimaging Spectrum in COVID-19 Infection: A Single-Center Experience.

Background and Purpose The ongoing coronavirus disease 2019 (COVID-19) pandemic is a multisystemic disease and involvement of the nervous system is well established. The neurological and neuroimaging features of the disease have been extensively evaluated. Our study aimed to elucidate the neuroradiological findings in COVID-19 infected patients admitted to our institute during the first and second waves of the pandemic in India. Methods This was a single-center retrospective study of all COVID-19 positive patients who underwent neuroimaging between March 2020 and May 2021. The presenting neurological complaints, the imaging findings in computed tomography (CT) imaging, and/or magnetic resonance imaging (MRI) were recorded. They recorded the findings in the subheadings of ischemic stroke, hemorrhagic stroke, parainfectious demyelination, acute encephalitis syndrome, and changes of global hypoxic changes. Patients with age-related, chronic, and incidental findings were excluded. Results The study comprised of 180 COVID-19 positive patients who underwent neuroimaging. CT scan was performed for 169 patients, MRI for 28, and a combination of both CT and MRI was performed for 17 patients. Seventy percent of patients were males, and median age was 61.5 years (interquartile range: 48.25-70.75). Out of the 180 patients, 66 patients had nonspecific findings that could not be attributed to COVID-19 infection. In the remaining 114 patients, 77 (42.7%) had ischemic findings, while 22 (12.2%) had hemorrhagic stroke. Hypoxic ischemic changes were noted in five patients. The rest of the patients had a spectrum of changes including, cerebellitis (3), tumefactive demyelination (1), COVID-19-associated encephalitis (1), hemorrhagic acute demyelinating encephalomyelitis (1), transverse myelitis (1), cytotoxic lesions of corpus callosum (1), Guillain-Barre syndrome (1), and COVID-19-associated microhemorrhages (1). Conclusion Neurological manifestations of COVID-19 infection are not uncommon, and our understanding of this topic is expanding. A complex interplay of neurotropism and direct central nervous system invasion, immune activation and cytokine storm, vasculitis, and parainfectious processes are implicated in the pathophysiology. While the most common imaging finding was ischemic stroke, followed by hemorrhagic stroke, a diverse range of parainfectious findings was also noted in our study.

Clinical Profile, Follow-up, and Role of Neuroimaging in Pediatric Guillain-Barré Syndrome in the COVID Era: An Ambispective Study.

Background: To define the varied presentations of Guillain-Barré syndrome in children in the COVID era and 6 months' follow-up outcome. Methods: Ambispective study of 15 months' duration involving children with Guillain-Barré syndrome aged 1 month to 18 years at a tertiary care pediatric hospital. They were categorized into groups A and B based on COVID-19 serology testing. Hughes Disability Scale was used for disability assessment. Modified Rankin scale was used for improvement assessment in follow-up. Results: Of 19 children with Guillain-Barré syndrome, 9 (47%) were females and 10 (53%) were males. Groups A and B had children with negative (8) and positive serology (11), respectively. The most common presentation in both groups was motor weakness. Post-COVID pediatric Guillain-Barré syndrome presented with variants of Guillain-Barré syndrome rather than the classical form (P = .03). In group B, patients with elevated inflammatory markers had poor response to intravenous immunoglobulin, and 5 of 11 patients had good response to pulse steroids, probably depicting an inflammation-predominant pathology. Conclusion: Post-COVID Guillain-Barré syndrome in children presented with Guillain-Barré syndrome variants rather than the classic form. Neuroimaging is of great value in both confirming Guillain-Barré syndrome diagnosis and excluding differentials. Patients with elevated inflammatory markers and residual weakness may be given a pulse steroid trial.

Evaluation of Diaphragmatic Thickness and Dysfunction by Ultrasonography in Mechanically Ventilated Children for Assessment of Extubation Success.

OBJECTIVES: This study aimed to evaluate diaphragm thickness (DT) and diaphragmatic thickening fraction (DTF) in mechanically ventilated children, and study the association of these measurements with extubation success. METHODS: Consecutive children aged one month to 18 years, who required mechanical ventilation (MV) for more than 24 hours at our institution, were enrolled between April, 2019 to October, 2020. Ultrasonographic measure-ments of DT were documented, and DTF was calculated from baseline (within 24 hours of MV) until 14 days of MV, and up to three days post-extubation. RESULTS: Of the 54 children-enrolled, 40 underwent planned extubation trial, of which 9 (22.5%) had extubation failure. Pre-extubation and post-extubation DTF between children in extubation-success and extubation-failure groups were comparable (P=0.074). There was no significant difference in the diaphragm atrophy rate between the two groups (P=0.819). Binary logistic regression showed significantly decreased probability of successful extubation with total ventilation duration (P=0.012) and mean DTF% before extubation (P=0.033). CONCLUSION: Despite evidence of diaphragmatic atrophy in critically ill children receiving mechanical ventilation, there was no significant difference in DTF between extubation success and failure groups.

Comparative evaluation of colistin susceptibility testing by Disk Diffusion and Broth Microdilution methods: An experience from a tertiary care hospital.

BACKGROUND: Recent times have seen uninhibited use of colistin due to emergence of carbapenem resistant gram-negative bacteria especially in India and the most common method still employed by most of the laboratories for in vitro testing of colistin is disk diffusion method. OBJECTIVE: The study aimed to compare two methods for colistin susceptibility testing Methods: This retrospective observational study was done on a total of 212 non-duplicate carbapenem resistant gram-negative isolates from patients attending our tertiary care hospital from April 2019 to June 2020. Colistin susceptibility testing for these isolates was done by disk diffusion method followed by broth microdilution method. RESULTS: We found out that disk diffusion method showed relatively low sensitivity [34.5%; 95%CI: 19.94-52.65] but high specificity [99.45%; 95% CI: 96.97 - 99.90] in detecting colistin resistant organisms in comparison to broth microdilution method. CONCLUSION: Disk diffusion method is an unreliable method at detecting colistin resistance. Therefore, we should always rely on susceptibility testing by standard broth microdilution or newly introduced broth disk elution method before dispatching the report even in resource limited settings. The early and accurate reporting of susceptibility results can preserve the therapeutic value of the drug until we have newer treatment options available in the country.

Post-COVID-19 Immune-Mediated Neurological Complications in Children: An Ambispective Study.

BACKGROUND: The neurological manifestation following a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is varied, and till now, only a few studies have reported the same. METHODS: We used retrospective data from May to July 2021 and prospective study data from August to September 2021, including that from children aged between one month and 18 years who presented to a tertiary care referral center with the neurological manifestation and had a history of coronavirus disease 2019 (COVID-19) infection or exposure and positive SARS-CoV-2 serology. The neuroradiological manifestations were further categorized as in a predesigned proforma. RESULTS: Case records of the 18 children who fulfilled the criteria were included in the study; among them, seven (38.8%) were male and 11 (61.1%) were female. Predominant presentation in our study group was status epilepticus (six of 18) and Guillain-Barré syndrome (five of 18). Other manifestations included stroke (two of 18), demyelinating syndromes (three of 18), and autoimmune encephalitis (two of 18). Most of the children had favorable outcomes except for one mortality in our cohort. CONCLUSIONS: Delayed complications following SARS-CoV-2 infection are seen in children. A temporal correlation was noted between the COVID-19 infection and the increasing number of neurological cases after the second wave. Steroids could be beneficial while treating such patients, especially in the presence of high inflammatory markers. Testing for SARS-CoV-2 serology during the pandemic can give a clue to the underlying etiology. Further multicentric studies are required to understand the varied neurological manifestations following SARS-CoV-2 infection in children.

Is There a Role of Presepsin as a Novel Biomarker in Pediatric Sepsis?

Background: Sepsis in children is a conundrum of diagnostic and therapeutic challenges. There is an exigent need for a novel biomarker that can serve as a clear distinguisher of sepsis from other non-septic inflammatory conditions. The role of presepsin as a biomarker of sepsis in children is still a matter of scientific inquiry. Aim and objectives: To evaluate the diagnostic accuracy of presepsin for the prediction of septic shock, in children aged 1 month to 18 years. Materials and methods: This prospective cohort study was conducted in the pediatric emergency, ward, and intensive care unit of a tertiary care hospital. We enrolled all consecutive admissions aged 1 month to 18 years with a diagnosis of sepsis and compared the presepsin, procalcitonin, and C-reactive protein (CRP) levels on admission (day 1) and 72 hours later (day 4) with the clinical outcomes. Results: The mean (±SD) presepsin values in blood culture-proven sepsis patients at admission and 72 hours later were 609.77 ± 417.30 and 839 ± 748.07, respectively. The procalcitonin and presepsin levels at 72 hours in sepsis patients with shock were significantly elevated (38.2 ± 45.55 and 1129.1 ± 1133.80, respectively) as compared to those without shock (10.7 ± 25.42 and 472.5 ± 507.81, respectively), p <0.05. The receiver operating characteristic (ROC) curve analysis of presepsin at 72 hours had an area under curve (AUC) of 0.730, suggesting a fair diagnostic accuracy. Conclusion: Elevated presepsin levels may indicate greater severity of sepsis, particularly in those with shock. However, it lacks diagnostic ability early in the disease and has limited prognostic potential in predicting mortality. How to cite this article: Khera D, Toteja N, Singh S, Singh S, Kumar P, Sharma P, et al. Is There a Role of Presepsin as a Novel Biomarker in Pediatric Sepsis? Indian J Crit Care Med 2022;26(6):712-716.

Paediatric acute haemorrhagic leukoencephalitis.

We report a case of a preschool age girl, previously healthy, referred to our hospital on ventilatory support with a history of vomiting, headache, and rapid neurological worsening within 24 hours in the form of seizures, encephalopathy and loss of consciousness. On presentation, she was deeply comatose with dilated non-reactive pupils, absent brainstem reflexes and flaccid quadriplegia. Diagnosis of acute haemorrhagic leukoencephalitis was considered based on laboratory and neuroimaging findings. MRI of the brain showed fluffy white matter hyperintensities and microhaemorrhages in bilateral cerebral hemispheres and thalami. Aggressive treatment with methylprednisolone, plasmapheresis and intravenous immunoglobulin showed dramatic improvement with no neurological sequelae. Our case is unique in a way that despite the hyperacute onset and rapid deterioration, with a fulminant course in the intensive care unit, the child recovered dramatically with aggressive management.

Point-of-Care Thoracic Ultrasound in Children with Bronchiolitis.

OBJECTIVE: To characterize thoracic (lung and diaphragm) ultrasound findings in children < 2 y with bronchiolitis, evaluate correlation between lung ultrasound severity score (USS) and bronchiolitis severity score (BSS), and study the interobserver agreement of USS between study pediatrician and radiologist. METHODS: In this prospective observational study, thoracic ultrasound was performed on children with bronchiolitis by the study pediatrician and USS score was assigned. A radiologist blinded to all clinical information, performed an independent thoracic ultrasound. Demographics, clinical course, and other relevant details were recorded. RESULTS: Fifty-three children were enrolled; 29/53 patients (54.7%) were classified as mild bronchiolitis and 24/53 (45.2%) had moderate bronchiolitis as per clinical score; 13.2% (7/53) patients had both anterior and posterior subpleural consolidation and went on to require higher respiratory support either in the form of continuous positive airway pressure in 71.4% (5/7), oxygen for > 24 h in 14.2% (1/7), or heated humidified high-flow nasal cannula in 14.2% (1/7). These results were statistically significant (p < 0.001). A statistically significant correlation was found between the USS and type and duration of respiratory support (p value 0.002) and with the mean duration of hospital stay (p value < 0.001). There was significant correlation between the BSS and USS (p < 0.001). There was a very good agreement between the ultrasound findings of study pediatrician and radiologist (kappa 0.83). CONCLUSION: The findings of lung ultrasound (LUS) are not specific for bronchiolitis. However, LUS can be used as a good prognostic tool in patients with bronchiolitis.

A prospective cohort study of emergence delirium and its clinical correlates in a pediatric intensive care unit in North India.

BACKGROUND: Delirium is a common occurrence in medically compromised adults, but, research is limited in the pediatric population especially from low- and middle-income countries such as India. AIMS: This study aimed to evaluate the emergence of delirium in children aged 5-18 years admitted to a pediatric intensive care unit (PICU) of a tertiary care hospital in North India. Other objectives included delineating the clinical characteristics of delirium and its clinical correlates. METHODOLOGY: It was a prospective cohort study in which all admitted children during a calendar year were assessed and those fulfilling the inclusion criteria were enrolled for study. The Pediatric Confusion Assessment Method Intensive Care Unit (p-CAM-ICU) scale was used to diagnose delirium. RESULTS: ut of 305 total admissions to the PICU, 105 children were included. More than two third were male (68.6%) with a median age of 11 years. The incidence of delirium was 11.4% and median duration of delirium was 2 days. Majority of the children had hypoactive delirium (58.3%), followed by hyperactive (25%) and mixed type (16.7%). Metabolic or respiratory acidosis at baseline was significantly associated with delirium (p = 0.030). Presence of delirium led to significant prolongation of PICU stay (p < 0.001). CONCLUSION: The emergence of delirium elicited in this study is on the lower side incomparison to previous studies. Several etiological factors for delirium are preventable and hence protocols and guidelines for management are required.