Epoprostenol (Prostacyclin Analog) as a Sole Anticoagulant in Continuous Renal Replacement Therapy for Critically Ill Children With Liver Disease: Single-Center Retrospective Study, 2010-2019.

OBJECTIVES: Despite deranged coagulation, children with liver disease undergoing continuous renal replacement therapy (CRRT) are prone to circuit clotting. Commonly used anticoagulants (i.e., heparin and citrate) can have side effects. The aim of this study was to describe our experience of using epoprostenol (a synthetic prostacyclin analog) as a sole anticoagulant during CRRT in children with liver disease. DESIGN: Single-center, retrospective study, 2010-2019. SETTING: Sixteen-bedded PICU within a United Kingdom supra-regional center for pediatric hepatology. PATIENTS: Children with liver disease admitted to PICU who underwent CRRT anticoagulation with epoprostenol. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Regarding CRRT, we assessed filter life duration, effective 60-hour filter survival, and effective solute clearance. We also assessed the frequency of major or minor bleeding episodes per 1,000 hours of CRRT, the use of platelet and RBC transfusions, and the frequency of hypotensive episodes per 1,000 hours of CRRT. In the 10 years 2010-2019, we used epoprostenol anticoagulation during 353 filter episodes of CRRT, lasting 18,508 hours, in 96 patients (over 108 admissions). Median (interquartile range [IQR]) filter life was 48 (IQR 32-72) hours, and 22.9% of filters clotted. Effective 60-hour filter survival was 60.5%.We identified that 5.9% of filters were complicated by major bleeding (1.13 episodes per 1,000 hr of CRRT), 5.1% (0.97 per 1,000 hr) by minor bleeding, and 11.6% (2.22 per 1,000 hr) by hypotension. There were no differences in filter life or clotting between patients with acute liver failure and other liver diseases; there were no differences in rates of bleeding, hypotension, or transfusion when comparing patients with initial platelets of ≤ 50 × 109 per liter to those with a higher initial count. CONCLUSIONS: Epoprostenol, or prostacyclin, as the sole anticoagulant for children with liver disease receiving CRRT in PICU, results in a good circuit life, and complications such as bleeding and hypotension are similar to reports using other anticoagulants, despite concerns about coagulopathy in this cohort.

Flexible Fiberoptic Bronchoscopy in Non-ventilated Children in Pediatric Intensive Care Unit: Utility, Interventions and Safety.

Objective: To study the utility of flexible fiberoptic bronchoscopy (FFB), and its effects on oxygenation and hemodynamics in children while on respiratory assist devices. Materials and methods: The data of non-ventilated patients who underwent FFB during their stay in the PICU from January 2012 to December 2019 was retrieved from medical, nurses, and bronchoscopy records. The study parameters, demography, diagnosis, indication, and findings of FFB and interventions done after FFB, were noted, and also the oxygenation and hemodynamic parameters before, during and 3 hours after FFB. Results: Data from the first FFB of 155 patients were analyzed retrospectively. About 54/155 (34.8%) children underwent FFB while on HFNC. About 75 (48.4%) patients were on conventional oxygen therapy (COT) before FFB. There were 51 (33%) patients who had received mechanical ventilation and were extubated successfully. The 98 (63.2%) children had primary respiratory diseases. Stridor and lung atelectasis were indications for FFB in 75 (48.4%) cases and the commonest bronchoscopic finding was retained secretions in the airways. Based on the FFB findings, 50 medical and 22 surgical interventions were done. The commonest medical and surgical interventions were changes in antibiotics (25/50) and tracheostomy (16/22) respectively. There was a significant fall in SpO2 and a rise in hemodynamic parameters during FFB. All these changes were reversed after the procedure with no consequences. Conclusion: Flexible fiberoptic bronchoscopy is a useful tool to diagnose and guide interventions in non-ventilated pediatric intensive care unit (PICU). There were significant but transient changes in oxygenation and hemodynamics with no serious consequences. How to cite this article: Sachdev A, Gupta N, Khatri A, Jha G, Gupta D, Gupta S, et al. Flexible Fiberoptic Bronchoscopy in Non-ventilated Children in Pediatric Intensive Care Unit: Utility, Interventions and Safety. Indian J Crit Care Med 2023;27(5):358-365.

Utility and safety of flexible fiberoptic bronchoscopy in mechanically ventilated children in pediatric intensive care unit.

OBJECTIVES: To study the utility, safety, and effects of flexible fiberoptic bronchoscopy (FFB) on oxygenation status, ventilation parameters, and hemodynamics in mechanically ventilated children. DESIGN: Retrospective study. PATIENTS: Children aged >1 month to 18 years suffering from critical medical and surgical diseases. RESULTS: First bronchoscopy data of 131 patients were analyzed. Indication, FFB findings, the microbiological yield from bronchoalveolar lavage, and medical and surgical interventions based on FFB results were recorded. Hemodynamic and ventilation parameters before, during, and 3 h after FFB were also captured. The majority of bronchoscopies were done for diagnostic purposes with a positivity rate of 90.8%. Retained mucopurulent secretion in the airways was the commonest finding in 60 patients. A cause for weaning or extubation failure could be identified in 83.3%. Post-FFB radiological resolution of atelectasis was seen in 34/59 (57.6%; p-value: 0.001) chest radiographs. Forty-seven medical and 25 surgical interventions were done depending on FFB and BAL findings. There was a significant drop in oxygenation parameters and a rise in heart rate during FFB (p-value: <0.0001). The peak inspiratory pressure, positive end-expiratory pressure, and mean airway pressure increased significantly during bronchoscopy (p value: <.0001) while patients were on pressure-regulated volume-controlled ventilation. All these changes reversed to pre-FFB levels. There were minor procedure-related complications. CONCLUSION: FFB was an important diagnostic and therapeutic tool for mechanically ventilated children and the results helped plan interventions. It was a safe procedure with transient reversible cardiopulmonary alterations.

Chest sonography versus chest radiograph in children admitted to paediatric intensive care - A prospective study.

There is a paucity of studies on the correlation between chest radiograph and ultrasound (US) in children. Our objective was to study the correlation between bedside chest radiograph and ultrasound findings in 413 children with 1002 episodes of chest radiograph and US enrolled for a prospective, double-blinded observational study in a multidisciplinary paediatric intensive care unit. Weighted κ statistic for agreement was different for right and left lungs and varied from 50% for left pleural effusion to 98% for right pneumothorax. Pulmonary oedema, pneumothorax and pleural effusion were diagnosed by ultrasound alone in a significantly higher number of patients as compared to chest radiograph (P = 0.001). Chest ultrasound is therefore deemed more sensitive than chest radiograph in detection of pleural effusion, pulmonary oedema and pneumothorax.

Congenital tuberculosis: a review article

TB remains a leading cause of morbidity and mortality in developing countries. The incidence of congenital TB is underestimated. Current recommendations regarding the management of neonates of mothers with tuberculosis are variable and no tangible guidelines have been advised. Congenital TB is fatal if untreated, moreover the mortality and morbidity is increased if the diagnosis and treatment is delayed. Therefore, the treating clinician should be aware of the unusual presentation of congenital TB. A high suspicion and good screening of mothers and neonates is of paramount importance. Congenital tuberculosis is diagnosed by Cantwell criteria. Isoniazid prophylaxis for 6 months is recommended in neonates born to mothers with TB who are infectious. Breastfeeding should be continued, and isolation is recommended only in certain circumstances such as mother is infectious, has multidrug resistant tuberculosis or non-adherent to treatment. BCG vaccine is recommended in all neonates however, the timing of administration varies according to various guidelines. Neonate diagnosed with congenital TB should be treated with anti-tubercular drug regimen.

Iron deficiency and febrile seizures: a retrospective analysis

Background: Febrile seizures (FS) are the commonest cause of seizures in children, with 2-5% of neurologically healthy children experiencing at least 1 episode. Iron deficiency is reported to be one of the most prevalent nutritional problems in the world today, especially in developing countries, with an estimated 46%-66% people affected. Our study is an attempt to clarify the relation between iron deficiency and first febrile seizure.Methods: The present study was a case control study carried from December 2016 till June 2018 in a tertiary care hospital at Aurangabad, Maharashtra, India. The study was done after obtaining approval from Institutional ethical Committee.Results: 77 cases and equal number of controls were included. Males were most commonly affected (>50%) as compared to females in both groups. Highest number of cases and controls were in the age group 0.5 to 1 year group, followed by 1-2 and 2-3 years group. Upper respiratory tract infection was most common etiological factor. Anemia (Hb<11 gm/dl) was seen in in 84% of the cases and 65% of the controls. Serum iron and total iron binding capacity (TIBC) was reduced in cases as compared to controls and this difference was highly statistically significant.Conclusions: Iron deficiency is a modifiable risk factor for first episode of febrile seizures in Indian children of age group 6 months to 5 years its early detection and timely correction may be an important determinant for prevention of febrile seizure in children.