Frequency of cardiorenal syndrome type-I in hospitalized children with acute heart failure in a tertiary-care hospital.

OBJECTIVE: To determine the frequency of cardiorenal syndrome in hospitalized children with acute heart failure. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Paediatric Intensive Care Unit, The Aga Khan University Hospital, Karachi, from December 2010 to December 2011. METHODOLOGY: Sixty eight (68) children with acute heart failure fulfilling the selection criteria were evaluated for worsening of renal function (WRF). Serum creatinine was done at baseline and repeated at 72 hours to see the worsening of renal function. Estimated serum creatinine clearance was calculated by Schwartz formula. RESULTS: Mean age of patients was 43.6 ± 55.2 months. There were 43 (63%) males, 70% were under 57 months of age. Mean weight on admission was 14.7 ± 19.13 kg and mean height was 83 cm (± 31.08 SD). Mean serum creatinine on admission was 0.77 mg/dl (± 1.18 SD). Worsening renal function was noted in 55 (81%) of children, out of those, majority 36 (70.5%) were under 5 years of age. CONCLUSION: Worsening renal function was found in 81% of children admitted with the diagnosis of acute heart failure. Majority (70.5%) were under 5 years of age indicating a closer observation of renal status in younger age group to reduce, morbidity and mortality.

Readmission to paediatric intensive care unit: frequency, causes and outcome.

Readmission to intensive care units is considered to be an important quality indicator in ICU settings. This study was carried out at the paediatric intensive unit (PICU) and step down units of paediatric ward at the Aga Khan University Hospital, Karachi, Pakistan, to assess the frequency, common causes and outcome of patients readmitted in PICU within 48 hours after discharge from unit. During the study period, 1022 patients were admitted in PICU, out of which 24 (2.34%) patients required readmission. Male to female ratio was 1.2:1. The mean length of stay on paediatric floor before readmission was 24 hours. Fifteen (62%) patients were readmitted due to worsening of primary condition while 9 (38%) developed new problems. Respiratory problems accounted for 15 (62.5%) of readmissions, followed by cardiovascular 4 (16.5%) and sepsis related causes 3 (12.5%). The mortality rate of readmitted patients was 21% (5/24) in this study as compared to overall PICU mortality of 122 (11.93%).

A rare aetiology of respiratory failure in a 10-year-old boy: inflammatory myofibroblastic tumour.

Primary neoplasms of the respiratory tract are rarely encountered in the paediatric population. Inflammatory myofibroblastic tumour (IMT) is a rare soft tissue mesenchymal tumour but a distinct disease entity accounting for less than 1% of all primary lung tumours. We report a case of a 10-year-old boy who presented with respiratory failure and left lung collapse. On flexible fiberoptic bronchoscopy, a pedunculated mass in the lower part of the trachea originating from the left main stem bronchus was identified. The patient subsequently underwent a left-sided pneumonectomy with complete resection of the mass. The histopathological analysis was consistent with IMT. Two years of follow-up and the patient remains well.

Thrombotic microangiopathic syndrome: a novel complication of diabetic ketoacidosis.

Thrombotic microangiopathic syndrome secondary to diabetic ketoacidosis is an under reported entity in children. We describe 2 girls who developed thrombotic thrombocytopenic purpura (TTP) and thrombocytopenia associated multi organ failure (TAMOF) in new onset diabetes. Both patients presented with classical findings of DKA and were intubated due to low GCS, admitted in PICU and managed according to DKA guidelines. Later on, both patients developed thrombocytopenia, acute kidney injury, and low hemoglobin along with evidence of microangiopathy on peripheral smear. One patient developed paraparesis while other patient had high LDH levels. The clinical diagnosis of TTP and TAMOF was made respectively. Both patients were treated with plasmapharesis and renal replacement therapy. Both gradually improved and were discharged.

Botulism in children: a diagnostic dilemma in developing countries.

Botulism is a well-known disease of the neuromuscular junction. It is a rare but curable cause of paralysis in paediatric population. In addition to classical clinical signs and symptoms, the diagnosis of botulism requires laboratory confirmation of intoxication by various biological tests. These include demonstration of botulinum toxin in serum or isolation of the Clostridium botulinum from stool/gastric aspirates. However, it is not always possible to confirm intoxication due to unavailability of technical facilities, especially in resource limited countries like Pakistan. Under these circumstances, electrophysiological studies serve as an excellent diagnostic tool. These studies can provide quick diagnosis of botulism so that early administration of botulism immunoglobulin, if available, can reduce morbidity, mortality and length of stay in hospital. We report a case of botulism from Pakistan diagnosed on the basis of electrophysiological studies.

Morbidity pattern of sick hospitalized preterm infants in Karachi, Pakistan.

Despite recent advances, prematurity is associated with high morbidity and mortality in developing countries. We conducted a descriptive case series to identify frequency of various morbidities in premature neonates at Aga Khan University Hospital (AKUH), Karachi, from November 2008 to April 2009. All inborn premature < or = 37 weeks gestation were included in study. The frequency of preterm birth during study period was 13.3% (251/1885) of which 58% (n = 145) required admission in Neonatal Intensive Care Unit (NICU). Mean gestational age was 33 +/- 2.4 weeks and mean birth weight, was 1.88 +/- 0.5 kg. 25% of patients were small for gestational age (SGA) while 75% appropriate for gestational age (AGA). Metabolic derangement was the most common morbidity, observed in 93% of patients followed by sepsis, seen in 43.6% neonates. Respiratory distress syndrome was observed in 35.5% of neonates while intraventricular haemorrhage was seen only in 3.5% patients. Mean length of stay for preterm infants in NICU was 11.5 +/- 9.6 days, 14% (n = 20) preterm neonates expired during NICU stay.

Elective tracheostomy in mechanically ventilated children.

Tracheostomy is an important procedure in children requiring prolonged mechanical ventilation. We conducted a retrospective study to assess the frequency, indications, postoperative course and short-term outcome of elective tracheostomy in a Paediatric Intensive Care Unit (PICU) of Pakistan. Twenty-five patients underwent tracheostomy in last 5 years (2.2 % of all PICU admissions). Mean age of patients was 6 years and 60% were male. The most common indication for tracheostomy was prolonged mechanical ventilation secondary to neurological disease (60%), followed by upper airway obstruction (40%). Major complications included accidental decannulation (20%) and tube obstruction (20%). Three patients (12%) developed ventilator-associated pneumonia after tracheostomy change while persistent bacterial colonization of trachea was observed in 8 patients (32%). Decannulation was achieved in 40% (10/25). There was no mortality related to tracheostomy in this series.

Epidemiology and outcome of sepsis in a tertiary care PICU of Pakistan.

OBJECTIVE: To determine the epidemiology and outcome of sepsis in children admitted in pediatric intensive care unit (PICU) of a tertiary care hospital. METHODS: Retrospective review of children 1 mo to 14 y old, admitted to the PICU with severe sepsis or septic shock from January 2007 through December 2008 was done. Demographic, clinical and laboratory features of subjects were reviewed. The primary outcome was mortality at the time of discharge from PICU. The independent predictors of mortality were modeled using multiple logistic regression. RESULTS: In 2 years, 17.3% (133/767) children admitted to the PICU had sepsis. Median age was 18 mo (IQR 6-93 mo), with male: female ratio of 1.6:1. Mean PRISM III score was 9 (±7.8). One third had culture proven infection, majority (20%) having bloodstream infection. The frequency of multi-organ dysfunction syndrome (MODS) was 81% (108/133). The case specific mortality rate of sepsis was 24% (32/133). Multi-organ dysfunction (Adjusted OR 18.0, 95% CI 2.2-144), prism score of >10 (Adjusted OR 1.5, 95% CI 0.6-4.0) and the need for > 2 inotropes (Adjusted OR 3.5, 95% CI 1.3-9.2) were independently associated with mortality due to sepsis. CONCLUSIONS: The presence of septic shock and MODS is associated with high mortality in the PICU of developing countries.

Acute necrotizing encephalopathy of childhood: a fatal complication of swine flu.

Acute necrotizing encephalopathy of childhood (ANEC) is a rare condition characterized by the presence of multifocal symmetrical brain lesions involving mainly thalami, brainstem, cerebellum and white matter. ANEC is a serious and life threatening complication of simple viral infections. We present a case of a young child who developed this condition with classical clinical and radiological findings consistent with ANEC, secondary to swine flu (H1N1). He needed ventilatory support and had profound motor and intellectual deficit on discharge. We report this case with aim of raising awareness about this fatal complication of swine flu which has become a global health care issue these days.