Impact of Physician Inspection in the Detection of Phlebitis and Factors Contributing to it in Admitted Children of a Tertiary Care Hospital: A Prospective Study.

OBJECTIVE: To determine whether additional dedicated observations by a doctor would increase the pickup rate of phlebitis and related complications due to intravenous cannulation. Also, to identify the common demographic and clinical factors predisposing to phlebitis in children. METHODS: This prospective study was conducted from January 2019 through December 2019. A total of 184 children with 341 cannulations were enrolled. The authors added dedicated inspection of cannula by the physician during rounds in attempt to increase the detection of phlebitis. The difference in detection rates of thrombophlebitis by physician and routine observation along with the demographic and clinical variables contributing to thrombophlebitis in hospitalized children were studied. RESULTS: Total incidence of thrombophlebitis was 35/341 (10.3%), which included 2 extravasations. Nineteen events (55%) were picked up by routine nursing observations and an additional 16 (45%) by the physician. Among the factors contributing to phlebitis, maternal education status <12th standard (41.7% vs. 15.1% P = 0.018), cannula located on forearm (p value 0.008), bigger cannula size (18% vs. 8.6% P = 0.008), non-splinted cannula (14.4% vs. 7.7% P = 0.046) intravenous fluid containing potassium (15.4% vs. 2.9%, P = 0.001) and concentrated infusions in particular aminophylline and magnesium sulphate (26.3% vs. 9.3%, P = 0.018) were found to be significantly associated with the development of phlebitis. CONCLUSIONS: Physician inspection during rounds can improve phlebitis detection and will also increase the sensitivity of nursing observation.

Wheezing in Preschool Children and Total IgE Levels: A Birth Cohort Study.

OBJECTIVES: To evaluate association between total IgE levels and wheezing in preschool children from India. METHODS: Data were collected in a prospective birth cohort study related to wheezing till three years of age. Total IgE was measured at enrolment, at one year and two years of age and correlated with wheezing episodes. RESULTS: A total of 310 (167 boys) children were enrolled. Total IgE levels increased with age (P<0.001). Overall, 101 (32.6%) children had 182 episodes of wheezing. The median (IQR) total IgE levels in children with wheezing and without wheezing were similar at one year [42.1 (12.7, 93.5) vs 41.9 (17.1, 96.7) kU/L; P=0.39] and two years of age [62.8 (32.4, 212.0) vs 75 (25.8, 173.0) kU/L, P=0.92). CONCLUSION: Total IgE levels increased with age and were not different in preschool children with and without wheezing.

Successful Right Atrium-Pulmonary Artery ECMO in an Infant With Severe Necrotizing Pneumonia and Bilateral Bronchopleural Fistula.

We report an infant with necrotizing pnuemonia and bilateral broncho pleural fistula, who failed on conventional and high frequency ventilation and was managed successfully on Veno-venous Extra Corporeal Membrane Oxygenator (V-V ECMO) with a unique configuration for 12 days, and weaned off successfully.

Fatal Myocarditis in an Adolescent Girl with Evolving Connective Tissue Disease.

Connective tissue diseases are rarely suspected and diagnosed in childhood and adolescence. Rarity of occurrence and poor disease acceptance among parents make them extremely difficult to treat in the early stages. An adolescent girl presented with features of pneumonia, was worked up and diagnosed as an evolving connective tissue disease. Her clinical characteristics did not fit into any specific disease. She was started on steroids and immunoglobulin as she had fulminant myocarditis with rapid downhill clinical course. High index of suspicion and aggressive immunosuppression can be life saving in exceptional situations even though a specific diagnosis cannot be ascertained.

Acute kidney injury in children with chronic liver disease.

Acute kidney injury (AKI) is a common accompaniment in patients with liver disease. The causes, risk factors, manifestations and management of AKI in these patients vary according to the liver disease in question (acute liver failure, acute-on-chronic liver failure, post-liver transplantation or metabolic liver disease). There are multiple causes of AKI in patients with liver disease-pre-renal, acute tubular necrosis, post-renal, drug-induced renal failure and hepatorenal syndrome (HRS). Definitions of AKI in liver failure are periodically revised and updated, but pediatric definitions have still to see the light of the day. As our understanding of the pathophysiology of liver disease and renal involvement improves, treatment modalities have become more advanced and rationalized. Treatment includes reversing precipitating factors, such as infections and gastrointestinal bleeding, volume expansion, paracentesis and vasoconstrictors. This approach is tried and tested in adults. A pediatric tailored approach is still lacking due to inadequate numbers of patients, differences in causes of AKI and paucity of literature. In this review, we attempt to explore the pathophysiological basis, treatment modalities and controversies in the diagnosis and treatment of AKI in pediatric patients with chronic liver disease and discuss our own personal practice. We recognize that, although it is not a very commonly encountered entity in pediatric population, HRS has specific diagnostic criteria and treatment modalities that differ from other causes of AKI in patients with chronic liver disease; hence among the etiologies of kidney injury in patients with chronic liver disease, we focus here on HRS.

Effects of electric potential, NaCl, pH and distance between electrodes on efficiency of electrolysis in landfill leachate treatment.

This study investigated the effects of different parameters on the removal efficiencies of organic and inorganic pollutants in landfill leachate treatment by electrolysis. Different parameters were considered such as the electric potential (e.g., 24, 40 and 60 V), hydraulic retention time (HRT) (e.g., 40, 60, 80, 100 and 120 min), sodium chloride (NaCl) concentration (e.g., 1, 3, 5 and 7%), pH (e.g., 3, 7 and 9), electrodes materials [e.g., aluminum (Al) and iron (Fe)] and distance between electrodes (e.g., 1, 2 and 3 cm). The best operational condition of electrolysis was then recommended. The electric potential of 60 V with HRT of 120 min at 5% of NaCl solution using Al as anode and Fe as cathode (kept at a distance of 3 cm) was the most efficient condition which increased the removal efficiencies of various parameters such as turbidity, salinity, total suspended solids (TSS), total dissolved solids (TDS), biochemical oxygen demand (BOD), chemical oxygen demand (COD) and heavy metals (e.g., Zn and Mn). The higher removal percentages of many parameters, especially COD (94%) and Mn (93%) indicated that the electrolysis is an efficient technique for multi-pollutants (e.g., organic, inorganic and heavy metals) removal from the landfill leachate.

Impact of Malnutrition on the Outcome of Critically Ill Children.

OBJECTIVE: To assess the impact of nutritional status on outcomes like mortality rate, length of mechanical ventilation and length of Pediatric Intensive Care Unit (PICU) stay, in critically ill children. METHODS: In this retrospective study conducted at a tertiary care center, records of 332 critically ill children between 1 mo to 15 y of age for whom anthropometric parameters were available were included. Anthropometric parameters for the study subjects were used to assess the nutritional status using the WHO growth charts as the reference. The study subjects were categorized as non-malnourished, moderately, and severely malnourished, defined by Body mass index (BMI) for age 0 to -2 SD, -2 to -3 SD and less than -3 SD of WHO growth charts, respectively. Various outcomes like mortality, duration of PICU stay and duration of mechanical ventilation were assessed in the 3 groups based on the nutritional status. RESULTS: The prevalence of malnutrition in the index study was 51.2 % with an overall mortality of 38.8 %. No difference was found between mortality rates and proportion of ventilated children in the three study groups. However, more children who were severely malnourished had significantly prolonged ICU stay (>7 d) as well as duration of mechanical ventilation (>7 d). When the outcome variables were compared after adjusting for PIM2 scores, there were increasing odds of mortality, ventilation, prolonged PICU stay and duration of mechanical ventilation with increasing severity of malnutrition. CONCLUSIONS: After stabilization of the initial critical phase, PICU outcome is influenced by the nutritional status of the children.

Comparison of two new generation pulse oximeters with arterial oxygen saturation in critically ill children.

OBJECTIVES: To compare the performance of two new generation pulse oximeters, one with enhanced signal extraction technology (SET) and other without enhanced SET in detecting hypoxemia and to correlate it with arterial blood gas analysis. METHODS: Forty-eight patients, admitted to pediatric intensive care unit (PICU) of a teritiary care teaching hospital in India for critical care and support during the study period, who had an arterial catheter in situ were included. Children with those disease conditions known to interfere with pulse oximetry and blood gas analysis were excluded.184 set of observations were made during the study period. Each set had oxygen saturation (SpO2) measured from both the pulse oximeters and the corresponding arterial oxygen saturation (SaO2). The values were compared for occurrence of true and false alarms during periods of normal BP, hypotension and varying degrees of hypoxia. RESULTS: The mean arterial SaO2 in the study was 94.4 % ± 4.9. The mean SpO2 recorded in conventional and enhanced signal extraction technology (SET) pulse oximeters were 94.9 % ± 4.5 and 97.2 % ± 4.7 respectively. Enhanced signal extraction technology pulse oximeter detected 4/27 (15 %) of true hypoxemic events and 1 event was a false alarm. Conventional pulse oximeter detected 11/27 (41 %) true hypoxemic events but recorded 6 false alarms. CONCLUSIONS: Both pulse oximeters were not found to be performing satisfactorily in picking up hypoxemia in the study. There was good correlation with mean SpO2 from pulse oximeters and arterial SaO2. The reliability of pulse oximetry decreases with worsening hypoxemia and hypotension, and the sensitivity for picking up hypoxemia can be as low as 15 %.

Serum magnesium in overweight children.

OBJECTIVE: To determine whether overweight children and adolescents have lower serum concentration and lower dietary intake of magnesium compared to those with normal weight; and to study the correlation of serum magnesium levels with components of metabolic syndrome in children and adolescents. DESIGN: Cross-sectional, comparative study. SETTING: General/Pediatric Endocrinolgy OPD tertiary care medical centre. Study done from July 2007 to March 2009 PARTICIPANTS: 55 overweight and 53 normal weight children and adolescents aged 4 years to 14 years. METHODS: We compared fasting levels of serum magnesium, insulin, glucose, total and HDL-cholesterol, triglycerides and dietary magnesium intake. RESULTS: The serum magnesium levels were significantly lower in overweight (2.12 ±; 0.33 mg/dL) compared to normal weight group (2.56 ± 0.24 mg/dL, P<0.001), while the dietary intake of magnesium (adjusted for calorie intake) was higher in overweight group (0.20 ± 0.06 mg/kcal) compared to normal weight (0.17 ± 0.05 mg/kcal; P= 0.005). Serum magnesium levels were inversely correlated with body mass index, systolic blood pressure, diastolic blood pressure, waist circumference and fasting insulin levels. CONCLUSIONS: Serum magnesium levels were significantly lower in overweight children compared to those with normal weight in spite of a higher dietary intake.

Inflicted neuro-trauma in infancy.

Two infants with non-accidental inflicted neuro-trauma are reported. One presented with sudden onset lethargy, respiratory difficulty and unexplained seizures. There were bilateral retinal bleeds and extradural hemorrhage. Other was a well thriving child who had 2 seizures and was noted to lack visual fixation. Retinal hemorrhages and chronic subdural and intraparenchymal hemorrhages were subsequently discovered. We highlight the importance of suspecting child abuse in infants with sudden unexplained unresponsiveness, seizures or respiratory difficulty and the unusual occurrence of extradural hemorrhage.

Blood and blood component therapy in neonates.

Blood component therapy is a very common intervention practiced in newborns; nearly 85% of extremely low birth weight (ELBW) babies get transfusions during their hospital stay. However, there are no set guidelines for transfusion of blood component therapy in newborns. This protocol includes available types of blood components, their methods of preparation, indications and side effects of transfusion, in relation to newborns.