Heparin vs Saline Infusion to Maintain Patency of Arterial Catheters in Children: A Randomized, Double-Blind, Noninferiority Trial.

OBJECTIVE: To determine whether normal saline flush solution is noninferior to heparinised saline for maintaining the patency of arterial intravascular catheters in children. METHODS: A single centre, double blind, parallel group, noninferiority, randomized control study was conducted in the Pediatric Intensive Care Unit of Kanchi Kamakoti CHILDS Trust hospital, a tertiary children's hospital, Chennai, India. 92 children requiring arterial catheters for more than 12 hours were randomized to receive either normal saline or heparinized saline (1 U/ml) flush solution. Primary outcome was a noninferiority comparison between normal saline and heparinised saline in maintaining the patency of arterial catheters using the proportion of occlusion of arterial catheters as primary endpoint. Secondary outcome was mean duration of patency of arterial catheters in each treatment group. RESULTS: Ninety-two children with a median (interquartile range, age of 84 (33.5-132) months and 52% males were enrolled. 15.2% of catheters in the heparin group and 17.4% of catheters in the normal saline group were occluded (P = 0.77). The 95% upper confidence interval for the difference in proportion was 0.148 (+14.8%), establishing noninferiority (< 15%). The median (IQR) duration of a patent arterial catheter was 47 (27.75 - 94.5) hours in the heparin group and 35.50 (24.50 - 62) hours in the normal saline group (P = 0.10). Comparison of duration of patency using Kaplan Meier survival analysis and log rank test showed no statistically significant difference. There were no serious adverse events noted in either group. CONCLUSIONS: Our data suggests that normal saline is noninferior to heparinized saline infusion in maintaining the patency of arterial lines in children. This may benefit clinicians worldwide as normal saline would be a safer and cost-effective option.

Pediatric acute liver failure: An experience of a pediatric intensive care unit from resource limited settings.

Introduction: Pediatric acute liver failure is a rare and serious disease. Though liver transplantation is considered as the established treatment option for patients who are unlikely to recover with medical management, however, with the advancement of medical care there has been an increase in spontaneous regeneration of liver, obviating the need for liver transplantation. We identified the etiologies, outcome and prognostic factors of acute liver failure and the validity of the existing liver transplantation criteria to predict the outcome of pediatric acute liver failure. Materials and methods: This was a retrospective study done from January 2014 to December 2019 in a tertiary pediatric critical care unit in South India. All children aged between 1 month to 18 years admitted with acute liver failure were enrolled. Results: Of 125 children with acute liver failure, the main etiologies were infections (32%), indeterminate (23%), paracetamol toxicity (21%), metabolic (13%) and others (11%). Dengue was the most common infection (55%). The median pediatric logistic organ dysfunction score at admission was 12 (4-27). Of 125 patients, 63.2% (n = 79) had spontaneous regeneration which was higher in paracetamol induced (92.3%) compared to non-paracetamol induced acute liver failure (55.5%). Only two patients underwent liver transplantation and 35% died. Peak alanine transaminase and use of inotropes significantly predicted the outcome of disease. Of 38 children meeting King's College Hospital criteria for liver transplantation, 57.9% had spontaneous regeneration and 36.8% died. Of 74 children meeting INR > 4 criteria, 54% (n = 40) had spontaneous regeneration and 43.2% died. INR >4 criteria was more sensitive than King's College Hospital criteria for predicting the need for liver transplantation. Conclusion: Pediatric acute liver failure is caused by varied etiologies and infections were the commonest cause. Despite having a seriously ill cohort of patients, medical management resulted in spontaneous regeneration in the majority of children with acute liver failure. The use of inotropes, advanced hepatic encephalopathy, and peak alanine transaminase were predictors of poor outcome in children with acute liver failure and these patients could be considered for liver transplantation as available. Therefore, we may need to develop better predictors of pediatric acute liver failure in resource limited settings.

Usefulness of Urinary Neutrophil Gelatinase-associated Lipocalin as a Predictor of Acute Kidney Injury in Critically Ill Children.

Background: Acute kidney injury (AKI) is common among critically ill children. The current definitions of AKI rely on serum creatinine and urine output, which may not be deranged until late in the course of the illness. There has been a lot of work in search of novel biomarkers to define and predict AKI, and urinary neutrophil gelatinase-associated lipocalin (NGAL) is a promising one. We planned to study the usefulness of urinary NGAL in predicting AKI. Patients and methods: Children in the age group of 1 month to 18 years admitted to the pediatric intensive care unit (PICU) from September 2016 to December 2017 were enrolled. Children with preexisting kidney disease, urinary tract infection (UTI), postsurgical patients, or children with expected duration of stay <48 hours were excluded. Data regarding demographics, clinical features, and laboratory parameters were collected. Urinary NGAL was sent within 6 hours of admission. Children were classified to have AKI based upon the Pediatric Risk, Injury, Failure, Loss, End Stage Renal Disease (pRIFLE) criteria. Using receiver operating characteristic (ROC) curves, sensitivity, specificity, and area under the curve (AUC) for admission creatinine and urinary NGAL to predict AKI were deduced. Results: One hundred and thirty children were included. Out of 130 children, 59 (45.4%) developed AKI. Urinary NGAL at admission to the PICU >88.5 ng/mL had a sensitivity of 81.4% and specificity of 83.6% in detecting AKI while its AUC to detect AKI was 0.842 (95% confidence interval (CI) 0.765-0.918). Urinary NGAL predicted AKI in 17 (28.8%) of 59 patients at least 24 hours earlier than serum creatinine. Mortality rates in patients with and without AKI were 18.6 and 2.8%, respectively. Conclusion: Urinary NGAL has good sensitivity and specificity in detecting AKI and predicts AKI earlier than creatinine in a significant number of patients. How to cite this article: Kapalavai SK, Ramachandran B, Krupanandan R, Sadasivam K. Usefulness of Urinary Neutrophil Gelatinase-associated Lipocalin as a Predictor of Acute Kidney Injury in Critically Ill Children. Indian J Crit Care Med 2022;26(5):634-638.

Paroxysmal Sympathetic Hyperactivity: It is Time to Use the New Diagnostic Criteria.

How to cite this article: Krupanandan R. Paroxysmal Sympathetic Hyperactivity: It is Time to Use the New Diagnostic Criteria. Indian J Crit Care Med 2022;26(11):1165-1166.

Transport-related Adverse Events in Critically-ill Children: The Role of a Dedicated Transport Team.

OBJECTIVE: To compare the frequency of transport-related adverse events in children during specialized, non-specialized or unassisted transports. METHODS: Patients were grouped based on transport team involved - specialized (Group-1); non-specialized (Group-2); unassisted transport (Group-3). Demographics, events during transport and condition on arrival were recorded. RESULTS: Group-1 children had a lower incidence of adverse events compared to Group-2 and Group-3 (4.3%, 82.6% and 85.4% respectively; P<0.001). At arrival, children in Group-1 had a lower incidence of respiratory distress and airway compromise (P< 0.001). CONCLUSION: Transport of critically ill children by a specialized transport team is associated with fewer transport-related adverse events.