Nitrogen Reduction to Ammonia on a Fe16 Nanocluster: A Computational Study of Catalysis.

The sequence of elementary steps leading to reductive ammonia formation from N2 and H2 catalyzed by a Fe16 cluster is studied using generalized gradient approximation density functional theory and an all-electron basis set of triple-ζ quality. The computational methods are validated by comparison to experimental data such as binding energies where possible. First, the associative and dissociative attachment of N2 to Fe16 is considered, followed by exploration of the pathways leading to distal (Fe16-N-NH2) and enzymatic (NFe16-NH2) formation of an amino group. Next, the pathways leading to NH3 formation in both distal and enzymatic cases are examined. Two mechanisms for NH3 detachment have been discovered. An interesting peculiarity of the pathways is that they often proceed with total spin fluctuations, which are related to the rupture and formation of bonds on the surface of the catalyst over the course of the reactions. The reaction Fe16 + N2 + 2H2 → Fe16NH + NH3 is found to be exothermic by 1.02 eV (93.8 kJ/mol).

Mechanisms of Complete Dissociation of CO2 on Iron Clusters.

Dissociation of CO2 on iron clusters was studied by using semilocal density functional theory and basis sets of triple-zeta quality. Fe2 , Fe4 , and Fe16 clusters were selected as the representative host clusters. When searching for isomers of Fen CO2 , n=2, 4 and 16 corresponding to carbon dioxide attachment to the host clusters, its reduction to O and CO, and to the complete dissociation, it was found that the total spin magnetic moments of the lowest energy states of the isomers are often quenched with respect to those of initial reagents Fen +CO2 . Dissociation pathways of the Fe2 +CO2 , Fe4 +CO2 , and Fe16 +CO2 reactions contain several transition states separated by the local minima states; therefore, a natural question is where do the spin flips occur? Since lifetimes of magnetically excited states were shown to be of the order of 100 fs, the search for the CO2 dissociation pathways was performed under the assumption that magnetic deexcitation may occur at the intermediate local minima. Two dissociation pathways were obtained for each Fen +CO2 reaction using the gradient-based methods. It was found that the Fe2 +CO2 reaction is endothermic with respect to both reduction and complete dissociation of CO2 , whereas the Fe4 +CO2 and Fe16 +CO2 reactions are exothermic to both reduction and complete dissociation of carbon dioxide. The CO2 reduction was found to be more favorable than its complete dissociation in the Fe4 case.

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.

Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper.

Organ donation following circulatory determination of death (DCDD) has contributed significantly to the donor pool in several countries. In India, majority of deceased donations happen following brain death (BD). While existing legislation allows for DCDD, there have been only few reports of kidney transplantation following DCDD from India. This document, prepared by a multidisciplinary group of experts, reviews international best practices in DCDD and outlines the path for DCDD in India. Ethical, medical, legal, economic, procedural, and logistic challenges unique to India have been addressed. The practice of withdrawal of life-sustaining treatment (WLST) in India, laid down by the Supreme Court of India, is time-consuming, possible only in patients in a permanent vegetative state, and too cumbersome for day-to-day practice. In patients where continued medical care is futile, the procedure for WLST is described. In controlled DCDD (category-III), decision for WLST is independent of and delinked from the subsequent possibility of organ donation. Families that are inclined toward organ donation are explained the procedure including the timing and location of WLST, consent for antemortem measures, no-touch period, and the possibility of stand-down and return to the intensive care unit (ICU) without donation. In donation following neurologic determination of death (DNDD), if cardiac arrest occurs during the process of BD declaration, the protocol for DCDD category-IV has been described in detail. In DCDD category-V, organ donation may be possible following unsuccessful cardiopulmonary resuscitation of cardiac arrest in the ICU. An outline of organ-specific requisites for kidney, liver, heart, and lung transplantation following DCDD and techniques, such as normothermic regional perfusion (nRP) and ex vivo machine perfusion, has been provided. The outcomes of transplantation following DCDD are comparable to those following DBDD or living donor transplantation. Documents and checklists necessary for successful execution of DCDD in India are described. How to cite this article: Seth AK, Mohanka R, Navin S, Gokhale AGK, Sharma A, Kumar A, et al. Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper. Indian J Crit Care Med 2022;26(4):421-438.

Dissociation of dinitrogen on iron clusters: a detailed study of the Fe16 + N2 case.

The coalescence of two Fe8N as well as the structure of the Fe16N2 cluster were studied using density functional theory with the generalized gradient approximation and a basis set of triple-zeta quality. It was found that the coalescence may proceed without an energy barrier and that the geometrical structures of the resulting clusters depend strongly on the mutual orientations of the initial moieties. The dissociation of N2 is energetically favorable on Fe16, and the nitrogen atoms share the same Fe atom in the lowest energy state of the Fe16N2 species. The attachment of two nitrogen atoms leads to a decrease in the total spin magnetic moment of the ground-state Fe16 host by 6 µB due to the peculiarities of chemical bonding in the magnetic clusters. In order to gain insight into the dependence of properties on charge and to estimate the bonding energies of both N atoms, we performed optimizations of Fe16N and the singly charged ions of both Fe16N2 and Fe16N. It was found that the electronic properties of the Fe16N2 cluster, such as electron affinity and ionization energy, do not appreciably depend on the attachment of nitrogen atoms but that the average binding energy per atom changes significantly. The lowering in total energy due to the attachment of two N atoms was found to be nearly independent of charge. The IR and Raman spectra were simulated for Fe16N2 and its ions, and it was found that the positions of the most intense peaks in the IR spectra strongly depend on charge and therefore present fingerprints of the charged states. The chemical bonding in the ground-state Fe16N20,±1 species was described in terms of the localized molecular orbitals.

Evolution of Ferromagnetic and Antiferromagnetic States in Iron Nitride Clusters FenN and FenN2 (n = 1-10).

First-principles density functional theory calculations on neutral and singly negatively and positively charged iron clusters Fen and iron nitride clusters FenN and FenN2 (n = 1-10) in the range of 1 ≤ n ≤ 10 revealed that there is a strong competition between ferromagnetic and antiferromagnetic states especially in the FenN20,±1 cluster series. This phenomenon was related to superexchange via a bridging N atom between two iron atoms in the FenN20,±1 cluster series and to a double superexchange effect via a Fe atom shared by two N atoms in the FenN20,±1 series. A thorough examination of the structure-energy-spin state relationships in these clusters is conducted, leading to new insights and confirmation of available experimental results on structural parameters and dissociation energetics. The bond energies of both nitrogen atoms in the FenN2 series are approximately the same. They weakly depend on the charge of the host cluster and fluctuate around 5.5 eV when moving along the series. The energy of N2 desorption is relatively small; it varies by about 1.0 eV and depends on the charge of the cluster. The experimental finding that N2 dissociates on the Fen+ clusters beginning with n = 4 was supported by the results of our computations. Our computed values of the Fen+-N bonding energies agree with the experimental data within the experimental uncertainty bars. It was found that the attachment of one or two N atoms does not seriously affect the polarizability, electron affinity, or ionization energy of the host iron clusters independent of the charge.

Superhalogens Among 3d-Metal Compounds: MF4, MF6, MF12, and MF18 (M = Sc-Zn).

The ground states of the neutral and anionic tetrafluoride and hexafluoride series of 3d-metal atoms from Sc to Zn were assigned by using a double-check approach in which the pure and hybrid density functional methods were interchangeably used. It was confirmed that all these neutral fluorides are superhalogens except for TiF4. The electron affinities of the hexafluorides were shown to be consistently higher than those of the tetrafluorides in accordance with the superhalogen conception of the extra electron delocalization over a larger number of the electronegative ligands. In the search for mononuclear fluorides possessing higher electron affinities, we considered the M(F2)6- and M(F3)6- series where M = Sc-Zn. We found that the optimized geometrical structures in both series may be described as MF6-- k(F2), k = 3 and 6, of which the geometry of the MF6- core mimics that of the corresponding hexafluoride anion and the F2 dimers are kept in a bound state by polarizing forces. In these cases, the electron affinity is decreased by tenths of eV with respect to the electron affinity of the core hexafluorides due to a confinement of the extra electron by the F2 environment.

A Child with Unilateral Pulmonary Edema due to Mitral Valve Rupture Following Blunt Trauma.

A 7-year-old boy was admitted with a history of cough and tachypnea for 1 day. There was a history of a fall from a motorcycle with some abrasions over the left arm. The child was found to have tachypnea and tachycardia and was started on noninvasive ventilation. Auscultation revealed a pansystolic murmur over the precordium. Chest X-ray revealed unilateral pulmonary edema on the right side. Echocardiography showed severe mitral regurgitation (MR) with the tear of the anterior leaflet. The child improved with diuretics and supportive care. After 3 months, he underwent surgical repair of the mitral valve. Traumatic mitral valve tear is quite rare in children. Unilateral pulmonary edema is a feature of MR with eccentric jet and is frequently misinterpreted. How to cite this article: Mukherjee S, Ravikumar K, Kapalavai SK, Ramachandran B. A Child with Unilateral Pulmonary Edema due to Mitral Valve Rupture Following Blunt Trauma. Indian J Crit Care Med 2021; 25(6):729-731.

A Survey of Humidified High-flow Nasal Cannula Usage in Indian Pediatric Intensive Care Units.

How to cite this article: Sadasivam K, Ramachandran B. A Survey of Humidified High-flow Nasal Cannula Usage in Indian Pediatric Intensive Care Units. Indian J Crit Care Med 2020;24(10):996-998.

Structure and properties of iron oxide clusters: From Fe6 to Fe6 O20 and from Fe7 to Fe7 O24.

Geometrical and electronic structures of the neutral and singly negatively charged Fe6 On and Fe7 Om clusters in the range of 1 ≤ n ≤ 20 and 1 ≤ m ≤ 24, respectively, are computed using density functional theory with the generalized gradient approximation. The largest clusters in the two series, Fe6 O20 and Fe7 O24 , can be described as Fe(FeO4 )5 and Fe(FeO4 )6 or alternatively as [FeO5 ](FeO3 )5 and [FeO6 ](FeO3 )6 , respectively. The Fe6 O20 and Fe7 O24 clusters possess adiabatic electron affinities (EAad ) of 5.64 eV and 5.80 eV and can be attributed to the class of hyperhalogens since FeO4 is an unique closed-shell superhalogen with the EAad of 3.9 eV. The spin character of the lowest total energy states in both series changes from ferromagnetic to ferrimagnetic or antiferromagnetic when the first FeOFe bridge is formed. Oxidation decreases substantially the polarizability per atom of the initial bare clusters; namely, from 5.98 Å(3) of Fe6 to 2.47 Å(3) of Fe6 O20 and from 5.67 Å(3) of Fe7 to 2.38 Å(3) of Fe7 O24 . The results of our computations pertaining to the binding energies of O, Fe, O2 , and FeO in the Fe7 Om series provide an explanation for the experimentally observed abundance of the iron oxide nanoparticles with stoichiometric compositions. © 2016 Wiley Periodicals, Inc.

Accuracy of a real-time continuous glucose monitoring system in children with septic shock: A pilot study.

AIMS: The aim of this prospective, observational study was to determine the accuracy of a real-time continuous glucose monitoring system (CGMS) in children with septic shock. SUBJECTS AND METHODS: Children aged 30 days to 18 years admitted to the Pediatric Intensive Care Unit with septic shock were included. A real-time CGMS sensor was used to obtain interstitial glucose readings. CGMS readings were compared statistically with simultaneous laboratory blood glucose (BG). RESULTS: Nineteen children were included, and 235 pairs of BG-CGMS readings were obtained. BG and CGMS had a correlation coefficient of 0.61 (P < 0.001) and a median relative absolute difference of 17.29%. On Clarke's error grid analysis, 222 (94.5%) readings were in the clinically acceptable zones (A and B). When BG was < 70, 70-180, and > 180 mg/dL, 44%, 100%, and 76.9% readings were in zones A and B, respectively (P < 0.001). The accuracy of CGMS was not affected by the presence of edema, acidosis, vasopressors, steroids, or renal replacement therapy. On receiver operating characteristics curve analysis, a CGMS reading <97 mg/dL predicted hypoglycemia (sensitivity 85.2%, specificity 75%, area under the curve [AUC] =0.85). A reading > 141 mg/dL predicted hyperglycemia (sensitivity 84.6%, specificity 89.6%, AUC = 0.87). CONCLUSION: CGMS provides a fairly, accurate estimate of BG in children with septic shock. It is unaffected by a variety of clinical variables. The accuracy over extremes of blood sugar may be a concern. We recommend larger studies to evaluate its use for the early detection of hypoglycemia and hyperglycemia.

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.

A neonate with a spongy failing heart - What could it be?

A neonate born of third-degree consanguineous marriage presented on day 12 of life with congestive cardiac failure. A male sibling died at 3 months of age, cause of which was not known. He was treated with decongestive measures and multiple inotropes. 2D Echocardiogram revealed severe Left ventricular dysfunction with prominent trabeculations and deep recesses in the left ventricle suggestive of Left ventricular non-compaction. He was also found to have horse-shoe kidney. Considering the presence of cardiac left ventricular non compaction, horse-shoe kidney and family history of neonatal death and pregnancy loss clinical exome sequencing was done. It detected a homozygous missense variant in exon 6 of the AGK gene suggestive of Senger's syndrome. Baby was on regular follow-up and was thriving well on diuretics, sacubitril-valsartan and weekly levosimendan infusions. At 8 months of age, cardiac transplantation was successfully done and baby has been doing well post-transplantation. LVNC in children is rare with an estimated incidence of 0.11 per 100,000, the highest incidence being during infancy. Senger's syndrome is autosomal recessive in inheritance. Senger's syndrome associated with Left ventricular non compaction has been reported only once in literature so far. Renal manifestations in the form of horse shoe kidney like in our index baby has not been reported previously with Senger's syndrome.

Redox Chemistry of the Subphases of α-CsPbI2Br and ß-CsPbI2Br: Theory Reveals New Potential for Photostability.

The logic in the design of a halide-mixed APb(I1−xBrx)3 perovskite is quite straightforward: to combine the superior photovoltaic qualities of iodine-based perovskites with the increased stability of bromine-based perovskites. However, even small amounts of Br doped into the iodine-based materials leads to some instability. In the present report, using first-principles computations, we analyzed a wide variety of α-CsPbI2Br and ß-CsPbI2Br phases, compared their mixing enthalpies, explored their oxidative properties, and calculated their hole-coupled and hole-free charged Frenkel defect (CFD) formations by considering all possible channels of oxidation. Nanoinclusions of bromine-rich phases in α-CsPbI2Br were shown to destabilize the material by inducing lattice strain, making it more susceptible to oxidation. The uniformly mixed phase of α-CsPbI2Br was shown to be highly susceptible towards a phase transformation into ß-CsPbI2Br when halide interstitial or halide vacancy defects were introduced into the lattice. The rotation of PbI4Br2 octahedra in α-CsPbI2Br allows it either to transform into a highly unstable apical ß-CsPbI2Br, which may phase-segregate and is susceptible to CFD, or to phase-transform into equatorial ß-CsPbI2Br, which is resilient against the deleterious effects of hole oxidation (energies of oxidation >0 eV) and demixing (energy of mixing <0 eV). Thus, the selective preparation of equatorial ß-CsPbI2Br offers an opportunity to obtain a mixed perovskite material with enhanced photostability and an intermediate bandgap between its constituent perovskites.

Active surveillance for carbapenem resistant enterobacteriaceae (CRE) using stool cultures as a method to decrease CRE infections in the pediatric intensive care unit (PICU).

BACKGROUND: The incidence of Carbapenem Resistant Enterobacteriaceae (CRE) infections is increasing worldwide. Due to dearth of alternative antibiotics, prevention of infection transmission is a part of CRE infection management strategy. Early detection of CRE by active surveillance coupled with contact isolation is much more appropriate compared to contact isolation upon receipt of routine cultures dictated by the patient's clinical condition. OBJECTIVES: To determine whether active CRE surveillance will decrease CRE infection rates in the Pediatric Intensive Care Unit (PICU). METHODS: Retrospective observational study done in the 10-bed PICU of a tertiary care teaching children's hospital from July 2013 to June 2015. Rectal swabs for CRE were sent from all PICU patients except stable post-operative patients. Contact isolation precautions were followed for rectal swab positive patients. CRE colonization and infection rates were calculated and compared. RESULTS: Total of 1262 rectal swabs were sent from 1022 patients. CRE colonization rate was 19.5%. Post intervention, ICU acquired CRE colonization decreased by 36% and ICU acquired CRE infection rates decreased by 100%, both showed significant decrease (p â€‹< â€‹0.0001). CONCLUSION: Active CRE surveillance and institution of contact isolation in appropriate situations is helpful in decreasing CRE colonization and infection rates in the PICU.

Socioeconomic impact on device-associated infections in pediatric intensive care units of 16 limited-resource countries: international Nosocomial Infection Control Consortium findings.

OBJECTIVES: We report the results of the International Nosocomial Infection Control Consortium prospective surveillance study from January 2004 to December 2009 in 33 pediatric intensive care units of 16 countries and the impact of being in a private vs. public hospital and the income country level on device-associated health care-associated infection rates. Additionally, we aim to compare these findings with the results of the Centers for Disease Control and Prevention National Healthcare Safety Network annual report to show the differences between developed and developing countries regarding device-associated health care-associated infection rates. PATIENTS: A prospective cohort, active device-associated health care-associated infection surveillance study was conducted on 23,700 patients in International Nosocomial Infection Control Consortium pediatric intensive care units. METHODS: The protocol and methodology implemented were developed by International Nosocomial Infection Control Consortium. Data collection was performed in the participating intensive care units. Data uploading and analyses were conducted at International Nosocomial Infection Control Consortium headquarters on proprietary software. Device-associated health care-associated infection rates were recorded by applying Centers for Disease Control and Prevention National Healthcare Safety Network device-associated infection definitions, and the impact of being in a private vs. public hospital and the income country level on device-associated infection risk was evaluated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Central line-associated bloodstream infection rates were similar in private, public, or academic hospitals (7.3 vs. 8.4 central line-associated bloodstream infection per 1,000 catheter-days [p < .35 vs. 8.2; p < .42]). Central line-associated bloodstream infection rates in lower middle-income countries were higher than low-income countries or upper middle-income countries (12.2 vs. 5.5 central line-associated bloodstream infections per 1,000 catheter-days [p < .02 vs. 7.0; p < .001]). Catheter-associated urinary tract infection rates were similar in academic, public and private hospitals: (4.2 vs. 5.2 catheter-associated urinary tract infection per 1,000 catheter-days [p = .41 vs. 3.0; p = .195]). Catheter-associated urinary tract infection rates were higher in lower middle-income countries than low-income countries or upper middle-income countries (5.9 vs. 0.6 catheter-associated urinary tract infection per 1,000 catheter-days [p < .004 vs. 3.7; p < .01]). Ventilator-associated pneumonia rates in academic hospitals were higher than private or public hospitals: (8.3 vs. 3.5 ventilator-associated pneumonias per 1,000 ventilator-days [p < .001 vs. 4.7; p < .001]). Lower middle-income countries had higher ventilator-associated pneumonia rates than low-income countries or upper middle-income countries: (9.0 vs. 0.5 per 1,000 ventilator-days [p < .001 vs. 5.4; p < .001]). Hand hygiene compliance rates were higher in public than academic or private hospitals (65.2% vs. 54.8% [p < .001 vs. 13.3%; p < .01]). CONCLUSIONS: Country socioeconomic level influence device-associated infection rates in developing countries and need to be considered when comparing device-associated infections from one country to another.

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.

Comparison of bedside and laboratory blood glucose estimations in critically ill children with shock.

OBJECTIVES: Bedside glucometers are often used for frequent glucose measurements on capillary blood in critically ill children. However, there are concerns that capillary blood glucose estimations may not be accurate in children with shock and peripheral edema. The objective of this study was to compare simultaneously obtained laboratory values of arterial or central venous blood glucose with capillary blood glucose estimation using a glucometer in children with shock. DESIGN: Prospective observational study. SETTING: Tertiary pediatric intensive care unit in a children's hospital in Chennai. PATIENTS: All children admitted between July 2007 and September 2008 with shock as defined by the American College of Critical Care Medicine criteria were eligible for inclusion. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three hundred thirty-seven sets of simultaneous measurements were obtained from 52 children (age range, 3 months to 18 yrs; average Pediatric Risk of Mortality III score 9.6). The mean blood glucose measurement using capillary blood on a bedside glucometer was 135 ± 67 mg/dL (7.5 ± 3.7 mmol/L). The mean laboratory glucose was 130 ± 67 mg/dL (7.2 ± 3.7 mmol/L). The correlation coefficient between the measurements was 0.94. There were no differences between those with and without peripheral edema. Using Bland-Altman plots, the mean difference between capillary samples vs. laboratory glucose was 6 mg/dL (0.3 mmol/L). The spread was wider at the higher ends of blood glucose values. CONCLUSION: Capillary blood glucose estimation in children with shock was similar to the laboratory measurement in the midranges of glucose values.

Safety and Feasibility of Antibiotic De-escalation in Critically Ill Children With Sepsis - A Prospective Analytical Study From a Pediatric ICU.

Introduction: De-escalation is the key to balance judicious antibiotic usage for life-threatening infections and reducing the emergence of antibiotic resistance caused by antibiotic overuse. Robust evidence is lacking regarding the safety of antibiotic de-escalation in culture negative sepsis. Materials and Methods: Children admitted to the PICU during the first 6 months of 2019 with suspected infection were included. Based on the clinical condition, cultures and septic markers, antibiotics were de-escalated or continued at 48-72 h. Outcome data like worsening of primary infection, acquisition of hospital acquired infection, level of ICU support and mortality were captured. Results: Among the 360 admissions, 247 (68.6%) children received antibiotics. After excluding 92 children, 155 children with 162 episodes of sepsis were included in the study. Thirty four episodes were not eligible for de-escalation. Among the eligible group of 128 episodes, antibiotics were de-escalated in 95 (74.2%) and continued in 33 (25.8%). The primary infection worsened in 5 (5.2%) children in the de-escalation group and in 1 (3%) in non de-escalation group [Hazard ratio: 2.12 (95%CI: 0.39-11.46)]. There were no significant differences in rates of hospital acquired infection, mortality or length of ICU stay amongst the groups. Blood cultures and assessment of clinical recovery played a major role in de-escalation of antibiotics and the clinician's hesitation to de-escalate in critically ill culture negative children was the main reason for not de-escalating among eligible children. Conclusion: Antibiotic de-escalation appears to be a safe strategy to apply in criticallly ill children, even in those with negative cultures.

Recurrent Intestinal Perforation After Cessation of Immunosuppression in Posttransplant Lymphoproliferative Disease in Pediatric Liver Transplant Recipient.

Posttransplant lymphoproliferative disease (PTLD) is the most common malignant complication after solid organ transplantation. Gastrointestinal involvement as the presentation in early PTLD can occur in 25-30% of pediatric liver transplant recipients and can be the only system involved in 20%. Recurrent gastrointestinal perforation due to resolution of PTLD is an extremely rare complication. We report a 13-month-old male child diagnosed with PTLD, treatment of which lead to recurrent intestinal perforations. The child presented with gastrointestinal bleed 5 months after living donor liver transplantation for biliary atresia. Evaluation was suggestive of PTLD and biopsy confirmed diffuse large B-cell lymphoma. Positron emission tomography scan showed diffuse involvement of small intestine and ileum. Tacrolimus was withdrawn abruptly following diagnosis of PTLD as there was associated renal impairment. Child developed six episodes of small intestinal perforations over 3 weeks which required multiple laparotomies with closure of perforation and/or small bowel resection. Complete remission was achieved six months after diagnosis with cessation of immunosuppression alone and child is alive at 48 months follow-up without any recurrence. To avoid bowel perforation and complications related to tumor necrosis, immunosuppression reduction in PTLD should be gradual while carefully monitoring Epstein-Barr virus levels, tumor response, graft function, and general health status of the patient.