Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial

OBJECTIVE

To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock.

DESIGN

Parallel-group, blinded multicenter trial.

SETTING

PICUs of four tertiary care centers in India from 2017 to 2020.

PATIENTS

Children up to 15 years of age with septic shock.

METHODS

Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality.

INTERVENTIONS

MES solution ( n = 351) versus 0.9% saline ( n = 357) for bolus fluid resuscitation during the first 7 days.

MEASUREMENTS AND MAIN RESULTS

The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusion-related AEs such as fever, thrombophlebitis, or fluid overload between the groups.

CONCLUSIONS

Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization.

Bubble Continuous Positive Airway Pressure Oxygen Therapy in Children Under Five Years of Age with Respiratory Distress in Pediatric Intensive Care Unit

Background

Continuous positive airway pressure (CPAP) has been used in children with bronchiolitis for a long time. Currently in the low-resource settings, the method of providing oxygen therapy via bubble CPAP (bCPAP) to children with respiratory distress is not standardized and the existing low-flow oxygen therapy has a high mortality rate.

Objectives

To study the effectiveness and safety of bCPAP as a respiratory support in children with respiratory distress.

Materials and methods

This prospective observational study was conducted in a tertiary care pediatric intensive care unit (PICU) over a period of 3 months. Children with respiratory distress were administered with bCPAP oxygen therapy. Baseline demographic data, such as age, sex, weight, severity of illness was collected. Changes in heart rate, respiratory rate, saturation, respiratory distress score and failure rate after bCPAP therapy were studied.

Results

During the study period, 30 children were recruited. Most common cause of respiratory distress requiring bCPAP was pneumonia (66.7%) followed by pleural effusion (20%) and bronchiolitis (13.3%). The median (IQR) CPAP duration and PICU stay in the study was 48 hours (27-48) and 4 days (4-8), respectively. Heart rate and respiratory rate, respiratory distress score improved significantly after CPAP therapy (p < 0.05). CPAP therapy failed in one child and required invasive ventilation. We did not observe any complications due to bCPAP therapy.

Conclusion

The use of bCPAP in the treatment of respiratory distress is safe and effective.

How to cite this article

Lalitha AV, Pujari CG, Raj JM. Bubble Continuous Positive Airway Pressure Oxygen Therapy in Children Under Five Years of Age with Respiratory Distress in Pediatric Intensive Care Unit. Indian J Crit Care Med 2023;27(11):847-854.

Association of Scrub Typhus in Children with Acute Encephalitis Syndrome and Meningoencephalitis, Southern India

Scrub typhus is an established cause of acute encephalitis syndrome (AES) in northern states of India. We systematically investigated 376 children with AES in southern India, using a stepwise diagnostic strategy for the causative agent of scrub typhus, Orientia tsutsugamushi, including IgM and PCR testing of blood and cerebrospinal fluid (CSF) to grade its association with AES. We diagnosed scrub typhus in 87 (23%) children; of those, association with AES was confirmed in 16 (18%) cases, probable in 55 (63%), and possible in 16 (18%). IgM detection in CSF had a sensitivity of 93% and specificity of 82% compared with PCR. Our findings suggest scrub typhus as an emerging common treatable cause of AES in children in southern India and highlight the importance of routine testing for scrub typhus in diagnostic algorithms. Our results also suggest the potential promise of IgM screening of CSF for diagnosis of AES resulting from scrub typhus.

Initial Immunomodulation and Outcome of Children with Multisystem Inflammatory Syndrome Related to COVID-19: A Multisite Study from India

OBJECTIVE

To determine the outcomes in children with MIS-C receiving different immunomodulatory treatment.

METHODS

In this multicentric, retrospective cohort study, data regarding treatment and outcomes of children meeting the WHO case definition for MIS-C, were collected. The primary composite outcome was the requirement of vasoactive/inotropic support on day 2 or beyond or need of mechanical ventilation on day 2 or beyond after initiation of immunomodulatory treatment or death during hospitalization in the treatment groups. Logistic regression and propensity score matching analyses were used to compare the outcomes in different treatment arms based on the initial immunomodulation, i.e., IVIG alone, IVIG plus steroids, and steroids alone.

RESULTS

The data of 368 children (diagnosed between April 2020 and June 2021) meeting the WHO case definition for MIS-C, were analyzed. Of the 368 subjects, 28 received IVIG alone, 82 received steroids alone, 237 received IVIG and steroids, and 21 did not receive any immunomodulation. One hundred fifty-six (42.39%) children had the primary outcome. On logistic regression analysis, the treatment group was not associated with the primary outcome; only the children with shock at diagnosis had higher odds for the occurrence of the outcome [OR (95% CI): 11.4 (5.19-25.0), p < 0.001]. On propensity score matching analysis, the primary outcome was comparable in steroid (n = 45), and IVIG plus steroid (n = 84) groups (p = 0.515).

CONCLUSION

While no significant difference was observed in the frequency of occurrence of the primary outcome in different treatment groups, data from adequately powered RCTs are required for definitive recommendations.

Risk Factors for Catheter-Associated Urinary Tract Infections (CA-UTI) in the Pediatric Intensive Care Unit

OBJECTIVE

To describe the occurrence, microbiology, and risk factors of catheter- associated urinary tract infections (CA-UTI) in critically ill children.

METHODS

We conducted a review of hospital records for CA-UTI in the pediatric intensive care unit (PICU) over a 7-year period (2014-2020).

RESULTS

62 CA-UTI cases (48% boys, median (IQR) age 36 (12,96 month) were identified during the study period with occurrence rate of 7.2/1000 catheter-days. The most common organisms were Escherichia coli (32.4%) and Enterococcus faecalis (30.6%). Using a multivariate logistic regression analysis, the significant associated variables for CA-UTI were duration of catheter drainage (a OR (95% CI) 1.14, (1.03,1.27), P=-0.009), PICU stay (aOR (95% CI) 1.13 (1.05,1.21) (P<0.001), and hospital stay (aOR (95% CI): 1.03 (1.01,1.06), P=0.015).

CONCLUSION

CA-UTI is not an uncommon nosocomial infection in PICU. The risk increases with increasing duration of catheter drainage, and hospital or PICU stay.

Epidemiology of Acute Respiratory Distress Syndrome in Pediatric Intensive Care Unit: Single-center Experience

Background

Acute respiratory distress syndrome (ARDS) is characterized by dysregulated inflammation resulting in hypoxemia and respiratory failure and causes both morbidity and mortality.

Objectives

To describe the clinical profile, outcome, and predictors of mortality in ARDS in children admitted to the Pediatric intensive care unit.

Materials and methods

This is a single-center retrospective study conducted at a tertiary referral hospital in a 12-bed PICU involving children (1 month to 18 years) with ARDS as defined by Pediatric Acute Lung Injury Consensus Conference (PALICC) guidelines, over a period of 5 years (2016–2020). Demographic, clinical, and laboratory details at onset and during PICU stay were collected. Predictors of mortality were compared between survivors and non-survivors.

Results

We identified 89 patients with ARDS. The median age at presentation was 76 months (12–124 months). The most common precipitating factor was pneumonia (66%). The majority of children (35.9%) had moderate ARDS. Overall mortality was 33% with more than half belonging to severe ARDS group (58%). On Kaplan–Meier survival curve analysis, the mean time to death was shorter in the severe ARDS group as compared to other groups. Multiorgan dysfunction was present in 46 (51.6%) of the cases. Non-survivors had higher mean pediatric logistic organ dysfunction (PELOD2) on day 1. PRISM III at admission, worsening trends of ventilator and oxygenation parameters (OI, P/F, MAP, and PEEP) independently predicted mortality after multivariate analysis.

Conclusion

High PRISM score predicts poor outcome, and worsening trends of ventilator and oxygenation parameters (OI, P/F, MAP, and PEEP) are associated with mortality.

How to cite this article

Pujari CG, Lalitha AV, Raj JM, Kavilapurapu A. Epidemiology of Acute Respiratory Distress Syndrome in Pediatric Intensive Care Unit: Single-center Experience. Indian J Crit Care Med 2022;26(8):949–955.

Clinical Profile and Outcome of Emergencies in Pediatric Chronic Kidney Disease

OBJECTIVE

To describe the clinical profile and outcome of emergencies in children with chronic kidney disease (CKD).

METHODS

This retrospective analysis studied children with CKD presenting with acute emergencies. The clinical profile, renal and patient outcomes were compared between incidentally diagnosed - iCKD, previously diagnosed not on dialysis - pCKD and those on maintenance dialysis - dCKD groups.

RESULTS

82 children (67 boys, median age - 8 years) with 99 visits were included. Uremic encephalopathy was the most common emergency in iCKD (64.7%) and pCKD (38.4 %), and access-related infections (32.1%) in dCKD group. Children with iCKD had higher Pediatric Risk of Mortality score (P<0.001), emergent initiation of dialysis (P=0.03) and discontinuation of treatment (P<0.001) when compared to the pCKD group.

CONCLUSION

Uremic encephalopathy and access-related infections were the most common emergencies in children with CKD. Incidentally diagnosed CKD had a worse clinical profile and outcome.

Use of Honey Versus Standard Care for Hospital-Acquired Pressure Injury in Critically Ill Children: A Multicenter Randomized Controlled Trial

OBJECTIVES

To examine if the use of honey (medicated) for dressing is superior to standard care in terms of time to complete wound healing in stages 1-3 of pressure injuries in children admitted to the PICU.

DESIGN

Multicenter, open-label, parallel-group, randomized trial.

SETTING

Tertiary-care PICU from August 2017 to January 2019.

PATIENTS

Critically ill children, 2 months to 17 years old, who developed pressure injury (stages 1-3) were included; those on more than two inotropes or with signs of acute wound infection or wounds with greater than 5 cm diameter or known allergy to honey were excluded.

INTERVENTIONS

Children were randomized to receive either medicated honey dressing or standard (routine) wound care for the management of their pressure injury.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the time to complete wound healing. Manuka or active Leptospermum honey dressing/gel was used in the intervention group. Enrolled children were followed up until death or discharge from the hospital. A total of 99 children were enrolled: 51 in the intervention group and 48 in the standard care group. Baseline characteristics, including the nutritional status, were comparable between the groups. The most common sites of injury were bony prominences at face mask contact points. The median time to complete healing was 7 days (95% CI, 6-7 d) versus 9 days (7-10 d) in the intervention and standard care groups, respectively (p = 0.002; log-rank test). At any random time, children in the intervention group were about 1.9-fold more likely to have their pressure injury completely healed than those in the standard care group (hazard ratio 1.86; 95% CI, 1.21-2.87). There were no allergic reactions or secondary wound infections in the intervention group.

CONCLUSIONS

The use of medicated honey dressings decreased the time to wound healing in critically ill children with pressure injuries. There were no allergic reactions or secondary bacterial infections in any of these children.

Electrocardiometry for Hemodynamic Categorization and Assessment of Fluid Responsiveness in Pediatric Septic Shock: A Pilot Observational Study

Aim

To evaluate the utility of noninvasive electrocardiometry (ICON®) for hemodynamic categorization and assessment of fluid responsiveness in pediatric septic shock.

Materials and methods

Pilot prospective observational study in a 12-bedded tertiary pediatric intensive care unit (PICU) in children aged between 2 months and 16 years with unresolved septic shock after a 20 mL/kg fluid bolus. Those with cardiac index (CI) <3.3 L/min/m² and systemic vascular resistance index (SVRI) >1600 dyn sec/cm⁵/m² were classified as vasoconstrictive shock–electrocardiometry (VCEC) and those with CI >5.5 L/min/m² and SVRI <1000 dyn sec/cm⁵/m² as vasodilated shock–electrocardiometry (VDEC). Fluid responsiveness was defined as a 10% increase in CI with a 20 mL/kg fluid bolus. Sepsis-induced myocardial dysfunction (SMD) was diagnosed on echocardiography. Outcomes studied included clinical shock resolution, length of PICU stay, and mortality.

Results

Thirty children were enrolled over 6 months with a median (interquartile range) age and pediatric risk of mortality (PRISM) III score of 87(21,108) months and 6.75(1.5,8.25), respectively; 14(46.6%) were boys and 4(13.3%) died. Clinically, 19(63.3%) children had cold shock and 11(36.7%) had warm shock; however, 16(53.3%) children had VDEC (including five with clinical cold shock) and 14(46.7%) had VCEC using electrocardiometry. Fluid responsiveness was seen in 16(53.3%) children, 10 in the VCEC group and 6 in the VDEC group. In the VCEC group, the responders had a significant rise in CI and a fall in SVRI, while the responders in the VDEC group had a significant rise in CI and SVRI. Fluid responders, compared to nonresponders, had a significantly higher stroke volume variation (SVV) before fluid bolus (24.1 ± 5.2% vs. 18.2 ± 3.5%, p < 0.001) and a higher reduction in SVV after fluid bolus (10.0 ± 2.8% vs. 6.0 ± 4.5%, p = 0.006), higher lactate clearance (p = 0.03) and lower vasoactive-inotropic score (p = 0.04) at 6 hours, higher percentage of clinical shock resolution at 6 (p = 0.01) and 12 hours (p = 0.01), and lesser mortality (p = 0.002). Five (16.6%) children with VCEC had SMD and were less fluid responsive (p = 0.04) with higher mortality (p = 0.01) compared to those without SMD.

Conclusions and clinical significance

Continuous, noninvasive hemodynamic monitoring using electrocardiometry permits hemodynamic categorization and assessment of fluid responsiveness in pediatric septic shock. This may provide real-time guidance for optimal interventions, and thus, improve the outcomes.

How to cite this article

Rao SS, Reddy M, Lalitha AV, Ghosh S. Electrocardiometry for Hemodynamic Categorization and Assessment of Fluid Responsiveness in Pediatric Septic Shock: A Pilot Observational Study. Indian J Crit Care Med 2021;25(2):185–192.

Sequential Organ Failure Assessment Score As a Predictor of Outcome in Sepsis in Pediatric Intensive Care Unit

Sequential organ failure assessment (SOFA) score is used as a predictor of outcome of sepsis in the pediatric intensive care unit. The aim of the study is to determine the application of SOFA scores as a predictor of outcome in children admitted to the pediatric intensive care unit with a diagnosis of sepsis. The design involved is prospective observational study. The study took place at the multidisciplinary pediatric intensive care unit (PICU), tertiary care hospital, South India. The patients included are children, aged 1 month to 18 years admitted with a diagnosis of sepsis (suspected/proven) to a single center PICU in India from November 2017 to November 2019. Data collected included the demographic, clinical, laboratory, and outcome-related variables. Severity of illness scores was calculated to include SOFA score day 1 (SF1) and day 3 (SF3) using a pediatric version (pediatric SOFA score or pSOFA) with age-adjusted cutoff variables for organ dysfunction, pediatric risk of mortality III (PRISM III; within 24 hours of admission), and pediatric logistic organ dysfunction-2 or PELOD-2 (days 1, 3, and 5). A total of 240 patients were admitted to the PICU with septic shock during the study period. The overall mortality rate was 42 of 240 patients (17.5%). The majority (59%) required mechanical ventilation, while only 19% required renal replacement therapy. The PRISM III, PELOD-2, and pSOFA scores correlated well with mortality. All three severity of illness scores were higher among nonsurvivors as compared with survivors ( p  < 0.001). pSOFA scores on both day 1 (area under the curve or AUC 0.84) and day 3 (AUC 0.87) demonstrated significantly higher discriminative power for in-hospital mortality as compared with PRISM III (AUC, 0.7), and PELOD-2 (day 1, [AUC, 0.73]), and PELOD-2 (day 3, [AUC, 0.81]). Utilizing a cutoff SOFA score of >8, the relative risk of prolonged duration of mechanical ventilation, requirement for vasoactive infusions (vasoactive infusion score), and PICU length of stay were all significantly increased ( p  < 0.05), on both days 1 and 3. On multiple logistic regression, adjusted odds ratio of mortality was elevated at 8.65 (95% CI: 3.48-21.52) on day 1 and 16.77 (95% confidence interval or CI: 4.7-59.89) on day 3 ( p  < 0.001) utilizing the same SOFA score cutoff of 8. A positive association was found between the delta SOFA ([Δ] SOFA) from day 1 to day 3 (SF1-SF3) and in-hospital mortality (chi-square for linear trend, p  < 0.001). Subjects with a ΔSOFA of ≥2 points had an exponential mortality rate to 50%. Similar association was-observed between ΔSOFA of ≥2 and-longer duration of inotropic support ( p  = 0.0006) with correlation co-efficient 0.2 (95% CI: 0.15-0.35; p  = 0.01). Among children admitted to the PICU with septic shock, SOFA scores on both days 1 and 3, have a greater discriminative power for predicting in-hospital mortality than either PRISM III score (within 24 hours of admission) or PELOD-2 score (days 1 and 3). An increase in ΔSOFA of >2 adds additional prognostic accuracy in determining not only mortality risk but also duration of inotropic support as well.

Tuberculosis and Tumor Lysis Syndrome-Coincidence or Coexistent: A Case Report

Extrapulmonary tuberculosis (TB) involving bone marrow can present with various manifestations, including pancytopenia, maturation arrest, hemophagocytic lymphohistiocytosis (HLH), or infiltration of the bone marrow by caseating or noncaseating granulomas causing reversible or irreversible fibrosis. Tumor lysis syndrome (TLS) is an oncologic emergency resulting from massive tumor cell lysis. Children with TB with bone marrow involvement may also present with laboratory features of TLS resulting from high catabolism and concomitant acute kidney injury (AKI), making the diagnosis difficult at times. We present a case of disseminated TB who presented to emergency with pancytopenia, AKI, and laboratory features of TLS.

Caught Off Guard with COVID-19 Bowel Gangrene: A Case Report

Background

Isolated and predominant gastrointestinal presentation in coronavirus disease 2019 (COVID-19) is reported less often. With evolving evidence that gastrointestinal tract can be a portal of entry, multiplication, primary site of affliction and symptomatic manifestation, and source of infectivity through prolonged fecal shedding of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), it is essential that isolated gastrointestinal symptoms can also be a mode of presentation of this novel virus and illness.

Case description

The index case is a 10-year-old female child who presented with acute onset abdominal pain. Emergency surgery showed extensive gangrenous small bowel. The small bowel had herniated into a transmesenteric defect near the mid-ileum and was obstructed. Reverse-transcription polymerase chain reaction for SARS-CoV2 sent as preoperative work-up turned positive. The histopathology showed platelet aggregate thrombus in the venules with patent adjacent arterioles.

Conclusion

This is probably the first reported case of COVID-19-related bowel gangrene.

How to cite this article

Kenchappa Y, Hegde S, Kumar P, Lalitha AV, Bukelo M. Caught Off Guard with COVID-19 Bowel Gangrene: A Case Report. Indian J Crit Care Med 2020;24(12):1269–1271.

Pleurodesis in Pulmonary Langerhans Cell Histiocytosis in Children: A Life-Saving Measure

Isolated pulmonary Langerhans cell histiocytosis (LCH) is uncommon in children. Often recurrent pneumothorax complicates therapy and contributes to morbidity. Chemotherapy does not always prevent the complications of pneumothorax. We report here a young girl with isolated pulmonary LCH who presented with respiratory failure, successfully treated with chemotherapy, and pleurodesis. We report this case to highlight the use of pleurodesis in this setting.

2019 WACEM - Academic College of Emergency Experts Consensus Recommendations on Admission Criteria to Pediatric Intensive Care Unit from the Emergency Departments in India

There is a global variation in policies that define clear indications for pediatric intensive care unit (PICU) admissions. In resource-limited countries where PICU service availability is limited, the admission criteria to PICU are urgently needed to optimize the utilization of available intensive care services and to maximize patient benefit. The objective of these consensus recommendations on PICU admission criteria is to provide a framework and reference for future policy development by professional societies and governments.

Myocarditis in children

Myocarditis, a masquerader of common illnesses, presents with non-specific symptoms which are often missed by clinicians. The diagnosis is made based on clinical presentation and echocardiography findings and requires a high degree of clinical suspicion. The authors report seven children with myocarditis with review of spectrum of clinical presentation and management.

Transient aplastic crisis in hereditary elliptocytosis

Hereditary Elliptocytosis is a heterogeneous group of disorder with regard to clinical presentation, protein defects and mode of inheritance. Parvoviral induced transient aplastic crisis in the form of sudden onset anemia is said to be a rare manifestation of this hereditary hemolytic anemia. The authors describe a case of parvoviral induced transient aplastic crisis in a patient with hereditary elliptocytosis and review the pathogenic mechanisms of parvoviral hemolytic disease.

Spectrum of purpura fulminans

Purpura Fulminans is a severe disorder of acute onset with high morbidity and mortality. It is characterized by DIC with thrombocytopenia, hyofibrinogenemia, hypothrombinemia and anemia. It most often occurs in young with sudden appearance of symmetrical, tender, ecchymotic skin lesions usually involving the lower extremities. An infectious and noninfectious etiology has been proposed. Early recognition and early therapy with appropriate antibiotics and heparin is known to limit both morbidity and mortality. This article reports 5 cases of Purpura Fulminans treated at our centre with review of etiology, pathogenesis, clinical features and treatment.

Spinal intramedullary neuroepithelial (ependymal) cyst. A rare cause of treatable acute para paresis

An 8-yr-old female child presented with acute onset of severe pain in the lower limbs and difficulty in walking. Spine MRI showed hyperintense signals on T2 weighted images at T2-T3 level, which was intramedullary in location. The patient was operated and histopathology reported as neuroepithelial cyst. Spinal intramedullary neuroepithelial cysts are rare. Spinal cord compression due to the cyst is very uncommon and because of its rarity the present case is being reported. The clinical features, embryogenesis and literature were reviewed briefly.