Survey of Pediatric Status Epilepticus Treatment Practices and Adherence to Management Guidelines (Pedi-SPECTRUM e-Survey).

Aim: Survey of treatment practices and adherence to pediatric status epilepticus (PSE) management guidelines in India. Methods: This eSurvey was conducted over 35 days (15th October to 20th November 2023) and included questions related to hospital setting; antiseizure medications (ASMs); ancillary treatment; facilities available; etiology; and adherence to PSE management guidelines. Results: A total of 170 respondents participated, majority of them were working in tertiary level hospitals (94.1%) as pediatric intensivists (56.5%) and pediatricians (19.4%), and were in clinical practice for 2-10 years (46.5%). Majority use intravenous (IV) midazolam and levetiracetam as first- and second-line ASMs (67.1 and 51.2%, respectively). In cases with refractory status epilepticus (RSE), the most commonly used ASM is midazolam infusion (92.4%). For super-refractory status epilepticus (SRSE), the commonly used third-line ASMs include midazolam infusion (34.1%), thiopentone infusion (26.5%), high dose phenobarbitone (18.2%), and ketamine infusion (15.3%). Overall, in cases with SRSE, 44.7% respondents use ketamine infusion, 42.5% use add-on oral topiramate, and 34.7% use high-dose phenobarbitone (1-3 mg/kg/hour) infusion. Most respondents targeted both clinical and EEG seizure control (48.8%). Ancillary treatment used for SRSE included IV pyridoxine (57.1%), methylprednisolone (45.3%), IVIG (42.4%), ketogenic diet (40.6%), and second-line immunomodulation (33.5%). Most common causes were febrile SE, viral encephalitis, and febrile illness-related epilepsy syndrome (60.6%, 52.4%, and 37.1%, respectively). Facilities available included pediatric intensive care units (PICU) (97.1%), mechanical ventilation (98.2%), pediatric neurologist (68.8%), MRI brain (86.5%), EEG (69.4%), and viral PCR (58.2%). The compliance with guidelines for timing of initiation of ASM ranged from 63.5 to 88.8%. Conclusion: Intravenous midazolam bolus/es, levetiracetam, and midazolam infusion are commonly used first-, second-, and third-line ASMs, respectively. There were wide variations in use of ASMs for RSE and SRSE, ancillary treatment, and compliance to PSE management guidelines. How to cite this article: Suthar R, Angurana SK, Nallasamy K, Bansal A, Muralidharan J. Survey of Pediatric Status Epilepticus Treatment Practices and Adherence to Management Guidelines (Pedi-SPECTRUM e-Survey). Indian J Crit Care Med 2024;28(5):504-510.

Pattern of Fluid Overload and its Impact on Mortality Among Mechanically Ventilated Children: Secondary Analysis of the ReLiSCh Trial.

OBJECTIVES: To assess the pattern of fluid overload (FO) and its impact on mortality among mechanically ventilated children. METHODS: In this secondary analysis of an open-label randomized controlled trial (ReLiSCh trial, October 2020-September 2021), hemodynamically stable mechanically ventilated children (n = 100) admitted to a tertiary level pediatric intensive care unit (PICU) in North India were enrolled. The primary outcome was pattern of FO (FO% >10% and cumulative FO% from day 1-7); and secondary outcomes were pattern of FO among survivors and non-survivors, and prescription practices of maintenance fluid. RESULTS: The median (IQR) age was 3.5 (0.85-7.5) y and 57% were males. Common diagnoses were pneumonia (27%), scrub typhus (14%), Landry-Guillain-Barré syndrome (9%), dengue (8%), central nervous system infections (7%) and staphylococcal sepsis (6%). Common organ dysfunction included acute respiratory distress syndrome (ARDS) (41%), shock (38%), and acute kidney injury (AKI) (9%). The duration PICU stay was 11 (7-17) d and mortality was 12%. The FO% >10% was noted in 19% children; and there was significant increase in cumulative FO% from day 1-7 [1.2 (0.2-2.6)% to 8.5 (1.7-14.3)%, (p = 0.000)]. Among non-survivors, higher proportion had FO% >10% (66.7% vs. 12.5%, p 0.0001); and trend towards higher cumulative FO% on first seven days. From day 1-7, the percentage of maintenance fluid received increased from 60 (50-71)% to 70 (60-77)% (p = 0.691). CONCLUSIONS: One-fifth of mechanically ventilated children had FO% >10% and there was significant increase in cumulative FO% from day 1-7. Non-survivors had significantly higher degree of FO.

Three-Point Ultrasonography for Confirmation of Endotracheal Tube Position in Children (TRUCE Study).

OBJECTIVES: To investigate the diagnostic accuracy of three-point ultrasonography for confirmation of endotracheal tube (ETT) position among children undergoing endotracheal intubation (ETI) with chest radiograph as reference standard. METHODS: This prospective observational study was conducted from January 2021 through December 2021 (12 mo) in the pediatric emergency room (PER) and pediatric intensive care unit (PICU), Division of Pediatric Critical Care, Advanced Pediatrics Centre (APC), Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Children aged 3 mo to 12 y, undergoing ETI in PER or PICU were included. Three-point ultrasonography (suprasternal notch and bilateral anterior chest) was done following ETI for confirmation of correct ETT position. Chest radiograph was used as a reference standard. Interobserver agreement between two investigators (IG and SKA) (kappa statistic) was determined for three-point ultrasonography to confirm the correct ETT position. RESULTS: One hundred fifty-five children with median (IQR) age of 4.5 (1-7) y were enrolled; 60% (n = 94) were males. On neck ultrasound, bilaminar sign was present in 100% of children. On lung ultrasound, bilateral and unilateral pleural sliding were present in 97.4% and 2.6% children, respectively. Three-point ultrasonography identified the correct position of ETT in 97.4% children as compared to 83.2% on chest radiograph. Sensitivity of three-point ultrasonography to identify the correct position of ETT was 98%. The interobserver agreement between two examiners was 96.8% (kappa of 0.53, p = 0.000). CONCLUSIONS: Three-point ultrasonography is an effective, sensitive, safe, and reproducible bedside method for identification of correct placement of ETT in children admitted to PER and PICU.

Recurrent Guillain-Barré Syndrome: Clinical Profile and Outcome.

OBJECTIVES: To compare clinical, neurological, treatment and outcome of recurrent Guillian-Barré Syndrome (GBS) with non-recurrent GBS. Also, to compare different episodes of recurrent GBS. METHODS: The patient's case records were retrieved retrospectively from the electronic database and case record files. Clinical profile, nerve conduction study, treatment, and outcome details of children with a diagnosis of GBS admitted in Pediatric Intensive Care Unit (PICU) from 2010 to March 2022 were screened. Recurrent GBS cases, as defined by the National Institute of Neurological and Communicative Diseases and Strokes (NINCDS) criteria, were analysed separately. The comparison was made between the first episode of recurrent GBS with non-recurrent GBS, and predictors of recurrence were identified. A comparison of course and outcome was also done between different episodes of GBS in recurrent cases. RESULTS: Recurrent GBS was observed in 11 (4.7%) out of 234 cases during the study period. The presence of respiratory (p 0.015) and gastrointestinal illness (p 0.007) as preceding illnesses were associated with recurrence. No difference was noted between the first episode of recurrent GBS and non-recurrent GBS. The first and second episodes of GBS in 11 recurrent cases were similar in course and outcome. CONCLUSIONS: Recurrent GBS is underreported but a known entity. No difference was seen between the two episodes of recurrent GBS. However, more data is required to find the features of recurrent GBS so that limited PICU resources can be used judiciously and intervention planned accordingly.

Efficacy of Teleconsultation-Based Rehabilitation in Children with Landry-Guillain-Barré Syndrome: An Open Label Randomized Controlled Trial (Tele Rehab-LGBS Trial).

OBJECTIVES: To evaluate the feasibility and efficacy of teleconsultation-based rehabilitation in children with Landry-Guillain-Barré syndrome (LGBS), measured with Medical Research Council (MRC) sum score and Hughes score. METHODS: A pragmatic, prospective, parallel open label randomized controlled trial was conducted among a total of 50 children with LGBS. The children were randomized using computer generated block randomization into 2 groups (25 in each group): Standard of care (Group A) and teleconsultation-based rehabilitation (Group B). Primary and secondary outcomes were measured with MRC sum score and Hughes score at 12- and 24-wk follow-up. RESULTS: The mean age was 6.4 ± 3.3 y; 29 (58%) were boys. Baseline MRC sum score (median, IQR), and Hughes score (median, IQR) in group A was 24 (7-31) and 5 (4-5) respectively; and in group B was 18 (9-24) and 4 (4-5) respectively. At discharge, median (IQR) MRC sum score in group A and B was 34 (28-41), and 30 (25-43) (p value = 0.31) respectively. Tele-rehabilitation was provided to group B for 24 wk with 96% compliance. At 12 wk, median MRC sum score in group A and group B were similar [48 (IQR 44-54) vs. 52 (IQR 46-60), p value = 0.08]. At 12 wk and 24 wk, median Hughes score in group A and B were similar. At 24 wk, 15 out of 23 subjects of group A and 18 out of 25 subjects of group B were ambulatory (p value = 0.61). CONCLUSIONS: Teleconsultation-based rehabilitation was feasible with a high compliance rate. The functional outcomes measured with MRC sum score and Hughes score were similar in both the groups at 12 and 24 wk follow-up. Teleconsultation-based rehabilitation has similar efficacy as physical rehabilitation.

Clinical Profile, Intensive Care Needs and Predictors of Outcome Among Children Admitted with Non-COVID Severe Acute Respiratory Illness (SARI) During the Pandemic.

OBJECTIVES: To study the epidemiology of non-coronavirus disease-2019 (non-COVID-19) respiratory viral infections with respect to their clinical profile, intensive care needs and predictors of outcome once the non-pharmacological interventions (NPI) during the coronavirus disease-2019 (COVID-19) pandemic were relaxed. METHODS: Retrospective analysis of children with Severe Acute Respiratory Illness (SARI) who were SARS-CoV-2 negative, admitted to the Pediatric Emergency/Intensive Care Unit (PICU) from July 2021 through October 2021 was conducted. RESULTS: One hundred and thirty nine children with median age of 11 (4-28.5) mo were included. Besides respiratory symptoms in all, diarrhea was reported in 90 (64.7%) children. Nearly half (n = 66; 47%) presented in hypoxemic respiratory failure (SpO2 <88%). Fifty-two (37.4%) children had co-morbidities, commonest being congenital heart disease in 12 (23.1%). Baseline parameters revealed leukopenia (specifically lymphopenia) 39 (28%), elevated aspartate transaminase [Serum glutamic-oxaloacetic transaminase (SGOT)] in 108 (77.6%), elevated N-acetyl-cysteine-activated creatinine kinase (CK-NAC) 23 (79%) and lactate dehydrogenase (LDH) 15 (88%). Intensive care needs included mechanical ventilation 51 (36.6%), vasoactive support 34 (24.5%), and renal replacement therapy 10 (7.1%). Forty-two (30.2%) children developed multi-organ dysfunction syndrome (MODS). One hundred and three (74.1%) children were discharged, 31 (22.3%) died, and 5 (3.6%) left against medical advice. On multivariate regression analysis, elevated liver enzymes (>5 times normal), hypoxemic respiratory failure at admission, hypotensive shock and MODS predicted mortality. CONCLUSIONS: A surge in non-COVID SARI was observed once lockdown measures were relaxed. Nearly 1/3rd progressed to multi-organ failure and died. Elevated liver enzymes, hypoxemic respiratory failure at admission, hypotensive shock and MODS predicted death.

Presenting Pattern and Psychiatric Comorbidities in Rural versus Urban Substance Dependent Patients: A Hospital-Based Cross-Sectional Study.

Background: "Locality" is a significant factor in substance initiation, maintenance, and relapse. The pattern of substance dependence among rural and urban populations varies across studies and is scarcely studied, warranting further research. To compare presenting patterns (sociodemographic and drug-related variables), reasons for substance use, and psychiatric comorbidities (prevalence, type, and severity) between rural and urban substance-dependent groups. Materials and Methods: This study was a cross-sectional analytical study in a government de-addiction center, including rural and urban patient groups aged 18-65. International Classification of Diseases, Tenth Revision (ICD-10) criteria, and severity of dependence scale were used for diagnosing substance dependence. After detoxification, psychiatric comorbidity was assessed using brief psychiatric rating scale, Young's mania rating scale, and patient health questionnaire - somatic, anxiety, and depression symptoms scale. Post-analysis was performed to assess socioeconomic variables and access to de-addiction services. Results: The final sample was 500 (250 rural and 250 urban). The post-analysis sample size was 386 (211 rural and 175 urban). The mean age was 38.2 ± 12.4 years, mostly males (n = 495, 99%). Substance frequency was opioids (92%)> benzodiazepines (24.8%) > alcohol (22%) > cannabis (1.6%) for rural and opioids (91.2%) > alcohol (29.6%) > benzodiazepines (14.8%) > cannabis (2%) for urban patients. More than half of patients had comorbid nicotine dependence. Rural patients were more benzodiazepine dependent (P = 0.007), and urban were more opioid + alcohol dependent (P = 0.001). Rural patients had higher age (P = 0.012), less education (P < 0.001), positive family history of substance (P = 0.028), daily wagers, and farmers (P < 0.001) than urban patients who were younger, students (P = 0.002), businessmen and government employed (P < 0.001). Urban patients expended more on drugs (P < 0.001), had higher treatment attempts (P = 0.008), and had better availability and accessibility of de-addiction services (P < 0.001). More rural users initiated substances to "enhance performance," whereas urban ones initiated for "stress relief/novelty" (P < 0.001). For treatment seeking, "External pressure" was a more common reason in urban patients (P < 0.001), who also had more psychiatric comorbidities (P = 0.026). Conclusion: Significant pattern differences exist between rural and urban substance dependents, warranting emphasis on locality-specific factors for appropriate intervention.

Clinical Profile, Intensive Care Needs and Outcome of Children with Dilated Cardiomyopathy Associated with Vitamin D Deficiency: A 5-year PICU Experience.

Aim: To describe the clinical profile, treatment details, intensive care needs, and long-term outcome of children with dilated cardiomyopathy (DCM) associated with Vitamin D deficiency (VDD). Materials and methods: Case records of 14 children with DCM associated with VDD [25(OH)D3 levels <20 ng/mL] admitted to the pediatric intensive care unit (PICU) of a tertiary care teaching hospital between January 2017 and December 2021 were retrospectively analyzed for clinical features, echocardiographic findings, treatment details, intensive care needs, and outcomes. Results: The median (IQR) age was 6 (2-9) months and 71% (n=10) were males. The common modes of presentation included respiratory distress or failure (78.6%), congestive cardiac failure (71.4%), cardiogenic shock (37.5%), and seizures and encephalopathy (14.3% each). The median (IQR) serum calcium was 8.7 (7-9.5) mg%, ionized calcium 0.7 (0.7-1.1) mmol/L, alkaline phosphatase 343 (316-415) IU/L, phosphate 3.5 (2.6-4.5) mg%, PTH 115 (66-228) pg/mL, and 25(OH)D3 5 (3-7) ng/mL. The median (IQR) left ventricular ejection fraction (LVEF) at admission was 22 (17-25)%. The treatment included intravenous calcium infusion (35.7%), vitamin D supplementation in all (57.1% parenteral and 42.9% oral), mechanical ventilation (35.7%), and vasoactive drugs (57.1%). There was no mortality. The median (IQR) duration of PICU and hospital stay was 76 (31-98) hours and 6 (4.7-10) days, respectively. Out of 14 children, 10 (71.4%) were followed-up till median (IQR) of 10 (7-58) months. All were asymptomatic and had normal LEVF (except one had residual moderate mitral regurgitation). Conclusion: Vitamin D deficiency is a potentially treatable and reversible cause of DCM in children. How to cite this article: Kumar S, Randhawa MS, Angurana SK, Nallasamy K, Bansal A, Kumar MR, et al. Clinical Profile, Intensive Care Needs and Outcome of Children with Dilated Cardiomyopathy Associated with Vitamin D Deficiency: A 5-year PICU Experience. Indian J Crit Care Med 2023;27(7):510-514.

Pressure support versus continuous positive airway pressure for predicting successful liberation from invasive ventilation in children: an open label, randomized non-inferiority trial.

Background: Pressure support (PS) as a spontaneous breathing trial (SBT) was considered inferior to continuous positive airway pressure (CPAP) and T-piece because PS underestimated post-extubation work of breathing in physiologic studies. We aimed to compare PS and CPAP as SBT methods for assessing clinical outcomes in children. Methods: This was an open label randomized non-inferiority trial conducted between December 2019 and August 2021 among children aged 1 month to 12 years deemed ready for weaning after at least 48 h of invasive ventilation in PICU. Children were randomized to undergo a 2-h SBT with PS of 8 cm H2O in addition to PEEP 5-6 cm H2O or CPAP (5-6 cm H2O). The primary outcome was successful liberation from invasive ventilation for 72 h after first SBT. Secondary outcomes included first SBT pass rate, need for post-extubation respiratory support (high flow oxygen and/or non-invasive ventilation), and length of PICU stay. Findings: Of the 247 enrolled children, 244 completed the trial (121 in PS and 123 in CPAP group). Median (IQR) age was 24 (9, 84) months. Median (IQR) duration of invasive ventilation before randomization was 4.5 (3, 6.5) days. Successful liberation from invasive ventilation after first SBT occurred in 97 (80.2%) children in PS and 93 (75.6%) children in CPAP group [difference 4.6; 95% CI (-5.8, 15); p = 0.39]. First SBT pass rate between PS and CPAP [111 (91.7%) versus 105 (85.4%); difference 6.3; 95% CI (-1.6, 14.3); p = 0.12] was similar. Need for post-extubation respiratory support [52 (43%) versus 49 (40%)], rate of reintubation within 72 h [14 (11.6%) versus 12 (9.8%)] and median (IQR) length of PICU stay [9 (6, 15) versus 8 (5.5, 13) days] were comparable. Four (1.6%) children, all in CPAP group had unfavourable outcome (1 died, 3 discontinued care). Interpretation: In invasively ventilated children, 2-h SBT with pressure support was non-inferior to CPAP in predicting successful liberation from invasive ventilation. Funding: None.

Psychosocial issues among paediatric health-care workers posted in intensive care unit during COVID-19 pandemic: A questionnaire-based survey (Psy-Co-19 survey).

AIM: To understand the moral distress experienced by health-care workers (HCWs) in the COVID paediatric intensive care unit (PICU). We also aimed to assess the psychological well-being and the coping mechanisms used by HCWs. METHODS: A prospective observational cross-sectional study was conducted from July to September 2021, involving all HCWs who worked in the COVID PICU. Moral distress using Moral Distress for Health-care Professionals (MMD-HPs) scale, psychological well-being using Trauma Screening Questionnaire (TSQ) and coping strategies adopted by HCWs using Brief-COPE (Coping Orientation to Problems Experienced) were measured. RESULTS: One hundred and eighty-four HCW data were examined. The most common causes of moral distress among HCWs were compromised patient care caused by a lack of resources and caring for more patients than they could safely handle. Moral distress was the same regardless of the HCWs' job profile, marital status, number of children or age. The TSQ revealed psychological stress in 23.3% of HCWs with Post-traumatic Stress Disorder, significantly higher in HCWs under the age of 30 and without children. Few HCWs turned to substance use, self-blame or denial as coping mechanisms; instead, acceptance, self-distraction and emotional support were the most frequently used. CONCLUSION: The most common reasons for moral and psychological distress perceived by participants were insufficient staff and organisational support. Younger HCWs and those without children experienced higher levels of psychological distress. HCWs' typical coping mechanisms are constructive, such as seeking help and support from others, reframing situations and meditation. Health-care administrators must develop a framework to assist HCWs in dealing with such serious issues.

An Observational Study on Pattern of Empirical Acyclovir Therapy in Children With Acute Encephalitis From Northern India.

OBJECTIVES: To identify the prevalence of herpes simplex encephalitis (HSE), factors influencing the duration of empirical acyclovir and frequency of acute kidney injury (AKI) in children with acute encephalitis syndrome (AES). DESIGN: Prospective observational study. SETTING: Pediatric Emergency Department and PICU of a tertiary hospital in Northern India. PATIENTS: All consecutive, eligible children between 1 month and 12 years old presenting with AES, defined as altered consciousness for greater than 24 hours (including lethargy, irritability, or a change in personality) and two or more of the following signs: 1) fever (temperature ≥ 38°C) during the current illness, 2) seizures or focal neurological signs, 3) cerebrospinal fluid (CSF) pleocytosis, 4) electroencephalogram, and/or 5) neuroimaging suggesting encephalitis, who received at least one dose of acyclovir. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 101 children screened, 83 were enrolled. The median (interquartile range [IQR]) age was 3 years (1-6 yr). Thirty-one children (37.3%) were diagnosed with AES, of which four were labeled as probable HSE (three based on MRI brain, one based on serology). Scrub typhus, dengue, Japanese encephalitis, and mumps were the other infective causes. The median (IQR) duration of acyclovir therapy was 72 hours (24-264 hr); 21 children (25.3%) received acyclovir for less than 24 hours and 11 (13.3%) for greater than or equal to 14 days. New-onset AKI was seen in 18 children (21.7%) but was mostly transient. Death ( n = 8, 9.6%) and discontinuation of care due to futility or other reasons ( n = 15, 18%) were noted in 23 children (28%). Factors associated with duration of acyclovir greater than 7 days, on univariable analysis, were lower modified Glasgow Coma Score at admission, requirement of invasive ventilation, invasive intracranial pressure monitoring, and CSF pleocytosis (5-500 cells). On multivariable analysis, only CSF pleocytosis of 5-500 cells was associated with duration of acyclovir greater than 7 days. CONCLUSIONS: Given the low prevalence of HSE, and the risk of AKI, this study sensitizes the need to review our practice on initiation and stopping of empirical acyclovir in children with acute encephalitis.

Multimodal Neuromonitoring in Pediatric Neurocritical Care: Current Perspectives.

Children with neurological illness in the critical care unit are always at higher risk of developing secondary brain injury (SBI). Brain insult can lead to changes in cerebral autoregulation, intracranial pressure (ICP), cerebral oxygenation, and metabolism. This can cause a raised ICP, cerebral ischemia, hypoxia, excitotoxicity, cellular energy failure, and nonconvulsive status epilepticus. Simultaneous and continuous assessment of these parameters will help to improve patient care and neurological outcomes. Even though clinical examination and neuroimaging can help in the initial diagnosis of the neurological illness, they may not be helpful in continuous monitoring of cerebral pathophysiological changes. The ideal single neuromonitoring device to detect these real-time changes is currently unavailable. However, a range of invasive and noninvasive monitors are available to monitor these cerebral functional parameters. Invasive monitoring techniques include invasive ICP monitoring, cerebral autoregulation monitoring, brain tissue partial oxygen pressure, and cerebral microdialysis. Noninvasive-monitoring techniques include pupillometry, brain and ocular ultrasonography, near-infrared spectroscopy, and electrophysiological monitoring. Multimodal (MM) neuromonitoring involves incorporating these techniques and tools for the early identification and treatment of primary and secondary brain insults. The utility and feasibility of most of these techniques are well described in adult neurocritical care. Even though the evidence on their usage in children is primarily available in pediatric traumatic brain injury, the emerging data help to further expand their utility in pediatric nontraumatic coma. MM neuromonitoring aims to provide clinical and pathophysiological information to the intensivists to improve their understanding of the child's neurological status and to formulate patient-specific treatment approaches.

Long-Term Neurological, Behavioral, Functional, Quality of Life, and School Performance Outcomes in Children With Guillain-Barré Syndrome Admitted to PICU.

BACKGROUND: Most children with Guillain-Barré syndrome (GBS) recover but may suffer from long-term sequelae, interfering with development and quality of life. Owing to the lack of published data, we aimed to assess the long-term neurological, behavioral, functional, quality of life, and school performance outcomes them. METHODS: Design: Cross-sectional observational. SETTING: Pediatric intensive care unit. PATIENTS: Children, aged one to 12 years, with GBS admitted over five years (July 2012 to June 2017) were enrolled during one year (July 2017 to June 2018). These children were assessed for the following outcomes: neurological (Hughes disability score, Pediatric Cerebral Performance Category [PCPC], Pediatric Overall Performance Category [POPC], and Glasgow Outcome Scale-Extended Pediatric version [GOS-E Peds] scales), behavioral (Childhood Psychopathology Measurement Schedule [CPMS]), functional (Vineland Social Maturity Scale [VSMS]-Indian Adaptation), quality of life (Pediatric Quality of Life [PedsQL]), and school performance (Parent-Directed Questionnaire). RESULTS: Eighty children were enrolled after a median of 3.0 (1.3-4.2) years from discharge. The majority (95%) had favorable neurological recovery (Hughes disability score 0 to 1). Favorable outcome was noted in 95% of children on PCPC, 87.5% on POPC, 60% on GOS-E Peds, 86.2% on CPMS, 92.5% on VSMS, and 98% on PedsQL. The majority (97.5%) of childre were attending schools, and 57.7% had satisfactory school performance. The presence of quadriparesis at admission, mechanical ventilation, tracheostomy requirement, poor ambulatory status at discharge, and longer pediatric intensive care unit and hospital stay predicted unfavorable neurological outcome on different tools. Absence of quadriparesis at admission and no requirement of mechanical ventilation predicted a favorable result on all outcome measures. CONCLUSIONS: On long-term follow-up, most children with severe GBS showed favorable neurological, behavioral, functional, and quality of life outcomes. Severe clinical presentation and prolonged intensive care unit stay predict poor long-term outcome.

Clinical Profile, Intensive Care Needs, and Short-Term Outcome of Toxic Shock Syndrome Among Children: A 10-Year Single-Centre Experience from North India.

OBJECTIVE: To describe the clinical and laboratory profile, management, intensive care needs, and outcome of children with toxic shock syndrome (TSS) admitted to the pediatric intensive care unit (PICU) of a tertiary care center in North India. METHODS: This retrospective study was conducted in the PICU of a tertiary care hospital in North India over a period of 10 y (January 2011-December 2020) including children < 12 y with TSS (n = 63). RESULTS: The median (interquartile range, IQR) age was 5 (2-9) y, 58.7% were boys, and Pediatric Risk of Mortality III (PRISM-III) score was 15 (12-17). The primary focus of infection was identified in 60.3% children, 44.5% had skin and soft tissue infections, and 17.5% (n = 11) had growth of Staphylococcus aureus. Common manifestations were shock (100%), rash (95.2%), thrombocytopenia (79.4%), transaminitis (66.7%), coagulopathy (58.7%), and acute kidney injury (AKI) (52.4%); and involvement of gastrointestinal (61.9%), mucus membrane (55.5%), respiratory (47.6%), musculoskeletal (41.3%), and central nervous system (CNS) (31.7%). The treatment included fluid resuscitation (100%), vasoactive drugs (92.1%), clindamycin (96.8%), intravenous immunoglobulin (IVIG) (92.1%), blood products (74.6%), mechanical ventilation (58.7%), and renal replacement therapy (31.7%). The mortality was 27% (n = 17). The duration of PICU and hopsital stay was 5 (4-10) and 7 (4-11) d, respectively. Higher proportion of nonsurvivors had CNS involvement, transaminitis, thrombocytopenia, coagulopathy, and AKI; required mechanical ventilation and blood products; and had higher vasoactive-inotropic score. CONCLUSION: TSS is not uncommon in children in Indian setup. The management includes early recognition, intensive care, antibiotics, source control, and adjunctive therapy (IVIG and clindamycin). Multiorgan dysfunction and need for organ supportive therapies predicted mortality.

Comparison of Multisystem Inflammatory Syndrome (MIS-C) and Dengue in Hospitalized Children.

OBJECTIVE: Multisystem inflammatory syndrome (MIS-C) in children is a febrile illness that has overlapping presentation with other locally prevalent illnesses. Clinicolaboratory profile of children admitted with MIS-C and dengue were compared to understand their presentation at the outset. METHODS: This was a retrospective study of children ≤ 12 y admitted with MIS-C (WHO definition) or laboratory-confirmed dengue between August 2020 and January 2021 at a tertiary center in North India. RESULTS: A total of 84 children (MIS-C - 40; dengue - 44) were included. The mean (SD) age [83.5 (39) vs. 91.6 (35) mo] was comparable. Rash (72.5% vs. 22.7%), conjunctival injection (60% vs. 2.3%), oral mucocutaneous changes (27.5% vs. 0) and gallop rhythm (15% vs. 0) were seen more frequently with MIS-C, while petechiae [29.5% vs. 7.5%], myalgia (38.6% vs. 10%), headache (22.7% vs. 2.5%), and hepatomegaly (68.2% vs. 27.5%) were more common with dengue. Children with MIS-C had significantly higher C-reactive protein (124 vs. 3.2 mg/L) and interleukin 6 (95.3 vs. 20.7 ng/mL), while those with dengue had higher hemoglobin (12 vs. 10.2 g/dL) lower mean platelet count (26 vs. 140 × 109/L), and greater elevation in aspartate (607 vs. 44 IU/L) and alanine (235.5 vs. 56 IU/L) aminotransferases. The hospital stay was longer with MIS-C; however, PICU stay and mortality were comparable. CONCLUSION: In hospitalized children with acute febrile illness, the presence of mucocutaneous features and highly elevated CRP could distinguish MIS-C from dengue. The presence of petechiae, hepatomegaly, and hemoconcentration may favor a diagnosis of dengue.

Epidemiology, Clinical Profile, Intensive Care Needs and Outcome in Children with SARS-CoV-2 Infection Admitted to a Tertiary Hospital During the First and Second Waves of the COVID-19 Pandemic in India.

OBJECTIVES: To compare the epidemiological, clinical profile, intensive care needs and outcome of children hospitalized with SARS-CoV-2 infection during the first and second waves of the pandemic. METHODS: This was a retrospective study of all children between 1 mo and 14 y, admitted to a dedicated COVID-19 hospital (DCH) during the first (1st June to 31st December 2020) and second waves (1st March to 30th June 2021). RESULTS: Of 217 children, 104 (48%) and 113 (52%) were admitted during the first and second waves respectively. One hundred fifty-two (70%) had incidentally detected SARS-CoV-2 infection, while 65 (30%) had symptomatic COVID-19. Comorbidities were noted in 137 (63%) children. Fifty-nine (27%) and 66 (30%) children required high-dependency unit (HDU) and ICU care respectively. Severity of infection and ICU needs were similar during both waves. High-flow oxygen (n = 5, 2%), noninvasive ventilation [CPAP (n = 34, 16%) and BiPAP (n = 8, 5%)] and invasive ventilation (n = 45, 21%) were respiratory support therapies needed. NIV use was more during the second wave (26% vs. 13%; p = 0.02). The median (IQR) length (days) of DCH stay among survivors was longer during the first wave [8 (6-10) vs. 5.5 (3-8); p = 0.0001]. CONCLUSIONS: Disease severity, associated comorbidities, PICU and organ support need and mortality were similar in the first and second waves of the pandemic. Children admitted during the second wave were younger, had higher proportion of NIV use and shorter length of COVID-19 hospital stay.

Severe dengue associated with Staphylococcus aureus sepsis in pediatric patients: a case series.

BACKGROUND: Staphylococcus aureus co-infection is seldom reported in children with severe dengue. METHODOLOGY: In this retrospective study, we reported five children with severe dengue and S. aureus co-infection admitted to pediatric intensive care unit (PICU) during July-December 2021. RESULTS: All children had prolonged fever, persistence of bilateral pleural effusion beyond the critical phase, thrombocytopenia and raised inflammatory markers [C-reactive protein (CRP) and procalcitonin]. S. aureus was isolated from pleural fluid (n = 2, 40%), blood (n = 2, 40%) and endotracheal aspirate (n = 1, 20%). Four children (80%) grew methicillin-sensitive S. aureus, while 1 (20%) had methicillin-resistant S. aureus. Two children (40%) had septic thromboemboli in skin, and 1 (20%) had limb cellulitis. One child required anterior thoracotomy, pericardiectomy and bilateral pleural decortication, while all other children required intercostal chest tube drainage. All children required prolonged targeted antibiotics, invasive mechanical ventilation and had prolong stay in PICU and all of them survived. CONCLUSION: In children with severe dengue, persistence of fever, persistence of pleural effusion beyond critical phase and raised CRP and procalcitonin should raise suspicion of bacterial/S. aureus co-infection.