Effect of Ondansetron on QT Interval in Patients Cared for in the PICU.

OBJECTIVES: There is no evidence regarding the effect of ondansetron on the QT interval in pediatric patients in the ICU. This study aimed to describe the effect of ondansetron on the corrected QT interval in patients cared for in the PICU. DESIGN: Retrospective cohort, consecutive enrollment study. SETTING: Single-center, tertiary-level, medical/surgical PICU. PATIENTS: All patients less than 8 years old who received ondansetron over an 11-month period were included. Exclusion criteria were atrial arrhythmia, bundle-branch block, known congenital long QT syndrome, and concomitant administration of proarrhythmic antiarrhythmic agents. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Overall, 210 doses of ondansetron were administered to 107 patients, with a mean age 10.5 ± 4.8 years; 49% were men. Corrected QT interval increased to 460-500 ms in 29% and to more than 500 ms in 11% of events of ondansetron administration. The mean baseline corrected QT interval even before ondansetron administration was higher for these groups (460-500 and > 500 ms; 457 ± 33 and 469 ± 45, respectively; p ≤ 0.05). In multivariate analysis, both groups were associated significantly with underlying electrolyte abnormalities (odds ratio, 2.2; 95% CI, 1.1-4.4 and odds ratio, 5.1; 95% CI, 1.8-15.7, respectively); the group with corrected QT interval more than 500 ms was also significantly associated with organ dysfunction (odds ratio, 3.2; 95% CI, 1.1-9.4). As the numbers of risk factors increased from only ondansetron to three additional QT aggravating factors (electrolyte abnormalities, administration of other QT-prolonging drugs, and organ dysfunction), the likelihood of being associated with corrected QT interval more than 500 ms increased. CONCLUSIONS: Prolonged QT interval is observed commonly in PICUs following the administration of ondansetron. Underlying risk factors, such as electrolyte abnormalities and organ dysfunction, seem to pose the highest risk of prolongation of QT interval in these patients. The awareness of prevalent risk factors for increased corrected QT interval may help identify patients at high risk for arrhythmias.

Incidence of and Risk Factors For Post-Intubation Hypotension in the Critically Ill.

BACKGROUND: We aim to report the incidence of post-intubation hypotension in the critically ill, to report in-hospital mortality and length of stay in those who developed post-intubation hypotension, and to explore possible risk factors associated with post-intubation hypotension. MATERIAL/METHODS: Adult (≥18 years) ICU patients who received emergent endotracheal intubation were included. We excluded patients if they were hemodynamically unstable 60 minutes pre-intubation. Post-intubation hypotension was defined as the administration of any vasopressor within 60 minutes following intubation. RESULTS: Twenty-nine patients developed post-intubation hypotension (29/147, 20%). Post-intubation hypotension was associated with increased in-hospital mortality (11/29, 38% vs. 19/118, 16%) and length of stay (21 [10-37] vs. 12 [7-21] days) on multivariate analysis. Three risk factors for post-intubation hypotension were identified on multivariate analysis: 1) decreasing mean arterial pressure pre-intubation (per 5 mmHg decrease) (p-value=0.04; 95% CI 1.01-1.55); 2) administration of neuromuscular blockers (p-value=0.03; 95% CI 1.12-6.53); and 3) intubation complication (p-value=0.03; 95% CI 1.16-15.57). CONCLUSIONS: Post-intubation hypotension was common in the ICU and was associated with increased in-hospital mortality and length of stay. These patients were more likely to have had lower mean arterial pressure prior to intubation, received neuromuscular blockers, or suffered a complication during intubation.

Correlation of end tidal and arterial carbon dioxide levels in critically Ill neonates and children.

AIM OF THE STUDY: End tidal carbon dioxide (EtCO2) monitoring is considered to reflect real-time estimation of partial pressure of carbon dioxide in arterial blood (PaCO2) noninvasively. However, knowledge about its relationship with PaCO2 in critically ill pediatric and neonatal patients is limited. The primary objective was to evaluate predictive capability of end tidal carbon dioxide monitoring and secondary objective was to determine the influence of severity of lung disease on EtCO2 and PaCO2 relationship. MATERIALS AND METHODS: This was a prospective, nonrandomized, consecutive enrollment study carried out in neonatal and pediatric intensive care units of a tertiary care children hospital. It was conducted in 66 neonates and 35 children receiving mechanical ventilation. Severity of lung disease was estimated by ventilation index and PaO2/FiO2 (P/F) ratio. Simultaneous recording of EtCO2 and PaCO2 levels was done and data were analyzed for correlation and agreement. RESULTS: In neonates, 150 EtCO2 and PaCO2 pairs were recorded. The mean weight ± SD of patients was 2.1 ± 0.63 kg. PaCO2 had a positive correlation with EtCO2 (r = 0.836, 95% CI = 0.78-0.88). P/F ratio <200 adversely affected relationship. In infants and children, 96 pairs were recorded. Mean age ± SD of patients was 4.20 ± 4.92 years and mean weight ± SD was 13.1 ± 9.49 kg. PaCO2 had an excellent correlation with EtCO2 (r = 0.914, 95% CI = 0.87 and 0.94). P/F ratio <200 adversely affected relationship. CONCLUSION: EtCO2 monitoring displayed a good validity to predict PaCO2. Correlation was affected by low P/F ratio (<200); hence, it is recommended that blood gases be measured in these patients until such time that a good relation can be established between end tidal and arterial CO2 values.

"I Tell Her Not to Take Medicines": Understanding Engagement in the Prevention of Mother to Child Transmission (PMTCT) Care Continuum through the Socio-Ecological Model.

With ten percent of the world's children living with Human Immunodeficiency Virus (HIV/ AIDS) in India, achieving elimination of parent/mother to-child transmission (EPTCT/EMTCT) is far away. Timely initiation and optimal adherence to the prevention of parent/mother to child transmission (PPTCT/PMTCT) may reduce new paediatric HIV infections to zero. This qualitative study applies the Socio-ecological Model (SEM) to understand country, region and context-specific factors influencing mothers' engagement in the PMTCT care continuum. Maximum variation sampling and saturation tenets determined the sample size. An in-depth interview guide based on SEM "a priori" and emerging themes captured narratives of the parental dyad. The translated and transcribed audio records were coded by direct content analysis method, both manually and with Atlas Ti software. The coding reports were discussed for consensus and final analysis. Male partner, peers, community health workers (CHWs), hope for healthy baby, knowledge about HIV and preventive services, free anti-retroviral therapy, transportation and the early infant diagnosis (EID) tool influenced PMTCT care continuum. Testing and referral policies of the private sector facilitated internalized or self-stigma. Future interventions should seek to develop pregnant women's support system by engaging male partners, peers, and CHWs. Strategies addressing private sector and community awareness about freely available HIV prevention and care programs may enable optimal PMTCT utilization.

"My Life is Spoiled Because of Him " A Qualitative Study of Human Immunodeficiency Virus Disclosure and Male Involvement in Prevention of Mother-to-Child Transmission Program.

BACKGROUND: India has the third largest human immunodeficiency virus (HIV) epidemic in the world, with 15,000 newborns infected every year. Prevention of mother-to-child transmission (PMTCT) services can eliminate new HIV infections. Nondisclosure of positive HIV status and nonoptimal uptake of PMTCT are related. Therefore, understanding different aspects of HIV disclosure are necessary for program managers and careproviders for prevention and support. OBJECTIVE: The present research explores HIV disclosure narratives, the family's perspective, and theoretical framework in the context of PMTCT. METHODS: A qualitative study was conducted among 31 (16 mothers and 15 fathers) utilizers of PMTCT at an urban antiretroviral therapy center. A semi-structured in-depth interview guide based on disclosure process model (DPM) was used to explore HIV disclosure goals and outcomes by both members of parental dyad. The recorded interviews were transcribed verbatim, translated into English, and analyzed with Atlas.ti software. Directed content analysis was used to code data according to "a priori" and emerging themes. Demographic data were analyzed using descriptive statistics. RESULTS: Limited disclosure is a necessity for pregnant women and their male partners for approach coping with HIV diagnosis and pursuing positive support for PMTCT adherence. Interpersonal, society, and community contextual outcomes affect the care uptake and future likelihood of disclosure. CONCLUSIONS: DPM suggestions from the present study can be used to facilitate a goal-directed process that allows parents/PLWHA to selectively disclose their HIV status to family members and acquaintances for obtaining maximum support to eliminate newborn HIV infections while minimizing distress, stigma, and discrimination.

Evaluation of preintubation shock index and modified shock index as predictors of postintubation hypotension and other short-term outcomes.

PURPOSE: Preintubation shock index (SI) and modified shock index (MSI) have demonstrated predictive capability for postintubation hypotension in emergency department. The primary aim was to explore this relationship in the critical care environment. The secondary aims were to evaluate the relationship of shock indices with other short-term outcomes like mortality and length of stay in intensive care unit. MATERIALS AND METHODS: This is a nonconcurrent cohort study, conducted in eligible 140 adult intensive care unit (ICU) patients of a tertiary care medical center. Eligibility criterion was emergent endotracheal intubation in apparently hemodynamically stable patients. RESULTS: Preintubation SI ≥ 0.90 had a significant association with postintubation hypotension as defined by systolic blood pressure < 90 mm Hg in the univariate (P = .03; odds ratio [OR], 2.13; 95% confidence interval [CI], 1.07-4.35) and multivariate analyses (P = .01; OR, 3.17; 95% CI, 1.36-7.73) after adjusting for confounders. It was also associated with higher ICU mortality in both the univariate (P = .01; OR, 4.00; 95% CI, 1.26-12.67) and multivariate analyses (P = .01; OR, 5.75; 95% CI, 1.58-26.48). There was no association of preintubation MSI with postintubation hemodynamic instability and ICU mortality. No association was found between preintubation SI and MSI, with ICU length of stay and 30-day mortality. CONCLUSIONS: Our findings indicate that preintubation SI greater than or equal to 0.90 is a predictor of postintubation hypotension (systolic blood pressure <90 mm Hg) and ICU mortality in emergently intubated adult patients in intensive care units.

Factor X deficiency--a rare disorder.

Congenital factor X deficiency is a very rare inherited coagulation disorder. The clinical phenotype is of varying bleeding manifestations depending upon the level of factor activity. We describe a one and a half year old patient with severe deficiency (factor level less than 1%) who manifested with only easy bruisability and epistaxis that does not correlate with level of deficiency.

Moya moya disease in a child: a case report.

We report a case of 8-year-old female child who was admitted at our hospital with complaints of transient ischemic attacks and left-sided hemiparesis. On MR angiography, the child was diagnosed to have Moya Moya disease. Moya Moya disease is a rare cause of cerebral stroke in children. The patient was treated conservatively and referred to a higher centre for specific neurosurgery. Neurosurgical revascularization process leads to favourable outcome.

Effect of Zinc Supplementation in Children with Acute Diarrhea: Randomized Double Blind Controlled Trial.

BACKGROUND: To test the hypothesis that daily supplementation of zinc has any effect on clinical course of acute diarrhea, i.e. frequency of stool, on stool amount and duration of acute diarrhea. METHODS: In a randomized double blind placebo controlled trial, 117 children aged 6 months to 59 months in a medical college hospital, with acute diarrhea of less than 14 days were assigned by permuted block design 1:1 to receive intervention of zinc supplemented syrup (n = 60) or placebo syrup (n = 57). RESULTS: Baseline characteristics were similar in both the groups. Mean age in zinc supplemented group was 22.14 ± 16.68 months and in placebo group 25.66 ± 17.02 months. Reduction in stool frequency per day was found 62% in zinc supplemented group and 26% reduction was found in placebo supplemented group with obvious difference of 36% between these two groups from day 1 to day 3 and day 5, which was found statistically highly significant. Similarly, significant difference was observed for reduction in amount of stool per day from day 1 to day 3 and day 5 with obvious difference of 45% between the study groups. CONCLUSIONS: Oral zinc administration in acute diarrhea reduces the frequency of diarrhea and output of stool by changing the natural course of acute diarrheal disease, causes early normalization of stool consistency, early recovery and decreases total duration of hospital stay. Zinc supplementation is simple, acceptable and affordable strategy which should be considered in management of acute diarrhea.