JPCC January - March 2016 PDF

Intensive Care Chapter
Indian Academy of Pediatrics

ISSN : 2349-6592
Website : www.journalofpediatriccriticalcare.com
Journal of
Pediatric Critical Care Official Journal of IAP Intensive Care Chapter
CONTENTS
From the Editors Desk
Original Article
Intravenous Immunoglobulin use in Pediatric Intensive Care Unit of a Developing Country
Humaira Jurair; et al (Karachi, Pakistan)
Latest Pearls: Guidelines

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
Infectious disease society of America (IDSA) Guidelines for invasive candidiasis
Journal Scan Chugh K (Gurgaon, India)

Fluid Resuscitation in Septic Shock: Modified PALS guidelines post FEAST trial
Oxygenation Index at Onset vs at 24 Hours in PARDS
SpO2 Target in Bronchiolitis
Appropriate Choice and Timing of Antibiotics not enough for Good Outcomes in MDR Severe Sepsis
Role of HFOV in PICU post OSCILLATE and OSCAR trials
Low Tidal Volume For Non-ARDS Also
Case Report
Post ECMO Cortical Microbleed with Good Neurological Outcome: A case report
Ohri A; et al (New Delhi, India)
NCPCC 2015: Oral Papers

1st Position: Effect of Chlorhexidine Mouth Cleanser and Head End Elevation on the Incidence of
Ventilator Associated Pneumonia - A one year randomised controlled trial Andleeb M; et al (Belgaum, India)
NCPCC 2015: Posters

1st Position: Lactate Clearance as a Predictor of Mortality in Children with Septic Shock Nitin
Manwani; et al (Chennai, India)
2nd Position: Empty Sella Syndrome Resulting into Short Stature in Two Siblings - A case report
Vol.3 No.1 with review of literature Jamunashree B; et al (Himachal Pradesh, India)
3rd Position: Comparison of External Jugular Venous access to Internal Jugular Venous access in
Jan.-Mar. 2016 Pediatric septic shock: An observational, prospective study Chintan Patel; et al (Gujarat, India)
Vol. 3 - No.1 January - March 2016 i JOURNAL OF PEDIATRIC CRITICAL CARE
Critical Thinking
PICU Quiz -Praveen Khilnani (New Delhi, India)
Manual of Basic Pediatric Intensive Care Course
(BPICC Manual)
3 rd E
N ew
ditio
BPIC n,
C Ma 2015
Publ nu
ishe al
d
Some upcoming
Basic Pediatric Intensive Care Course (BPICC)
Courses:
NCPCC 2016, Mumbai
Pedicon 2017, Bengaluru
Criticare 2017, Kochi
BPICC 2016
April 2016 Kanpur, Amritsar, lucknow, Ahmedabad…
and more
To Organize a BPICC in your area, please contact:

Dr Rajiv Uttam
National Co Convener, BPICC
M: 9810055670 • Email: rajivuttam@hotmail.com
Dr Vishram Buche
Chairperson, IAP Intensive Care Chapter
M: 9823017254 • Email: vbuche@gmail.com
Dr Anil Sachdev
Chairperson, IAP Intensive Care Chapter
M: 9810098360 • Email: anilcriticare@gmail.com
Regional Conveners:
Dr Vikas Taneja (Gurgaon)
Dr Anjul Dayal (Hyderabad)
Dr Gnanam (Bengaluru)
Dr Parthsarathi Bhattacharya (Kolkotta)
Dr Vinay Joshi (Mumbai)
Founder Conveners:
Dr Praveen Khilnani Dr Rajiv Uttam Dr Krishan Chugh
Vol. 3 - No.1 January - March 2016 ii JOURNAL OF PEDIATRIC CRITICAL CARE
Contents
Editorial Board 2
IAP IC Chapter Executive Committee 2016 3
Basic Pediatric Intensive Care Nursing Course (BPICNC) 4
From the Editors Desk 5
Chairman Message 6
Original Article
Intravenous Immunoglobulin use in Pediatric Intensive Care Unit of a Developing 7
Country
Humaira Jurair, Amber shabir, Kashif Hussain, Qalab-e- Abbas, Anwar-ul-Haque
Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
Latest Pearls
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) 11
Infectious disease society of America (IDSA) Guidelines for invasive candidiasis 12
Journal Scan
K Chugh
Fortis memorial hospital and research centre,Gurgaon
• Fluid Resuscitation in Septic Shock: Modified PALS guidelines post FEAST trial 14
• Oxygenation Index at Onset vs at 24 Hours in PARDS 17
• SpO2 Target in Bronchiolitis 19
• Appropriate Choice and Timing of Antibiotics not enough for Good Outcomes 22
in MDR Severe Sepsis
• Role of HFOV in PICU post OSCILLATE and OSCAR trials 24
• Low T V For Non-ARDS Also 25
Case Report
Post ECMO Cortical Microbleed with Good Neurological Outcome: A case report 28
Ohri A; et al (New Delhi, India) Post ECMO Cortical Microbleed with Good
Neurological Outcome: A case report
Ohri A, Maniya N, Singh MP, Sharma R, Chawla A, Khilnani P
BLK Superspeciality Hospital, New Delhi
NCPCC 2015: Oral Papers 31
NCPCC 2015: Posters 38
Critical Thinking
PICU Quiz 65
Praveen Khilnani
BLK Superspeciality Hospital, New Delhi & Mediclinic City Hospital, Dubai
Vol. 3 - No.1 January - March 2016 1 JOURNAL OF PEDIATRIC CRITICAL CARE

Journal of Pediatric Critical Care (JPCC)
Editorial Board
Editor-In-Chief:
Dr Praveen Khilnani
Senior Editors and Reviewers: Associate Editors:
Dr (Prof) Sunit Singhi Dr Nameet Jarath
Dr K Chugh Dr Kundan Mittal
Dr S Udani Dr Rakshay Shetty
Dr Basavaraj
Dr S Ranjit
Dr Gnanam
Dr Rajiv Uttam
Dr Sandeep Kanwal
Dr Anil Sachdev
Executive Editor:
Dr Madhu Otiv
Dr V S V Prasad
Dr S Deopujari
Dr Bala Ramachandran Managing Editor:
Dr S Soans Dr Dhiren Gupta
Executive Members: Biostatistics: International Advisory Board:

Dr Arun Bansal Dr M Jayshree Dr Niranjan Kissoon
Dr Banani Poddar Dr Jhuma Sankar Dr Jerry Zimmerman
Dr Ebor Jacob Dr Arun Baranwal Dr Joseph Carcillo
Dr Lokesh Tiwari Dr Ashok Sarnaik
Ethics:
Dr Partha Bhattacharya Dr Peter Cox
Dr Urmila Jhamb
Dr Prabhat Maheshwari Dr Shekhar Venkataraman
Dr Rakesh Lodha
Dr Dinesh Chirla Dr Vinay Nadkarni
Dr Meera Ramakrishnan
Dr Deveraj Raichur Dr Mohan Mysore
Dr Vinay Joshi
Dr Karunakara Dr Utpal Bhalala
Dr Mritunjay Pao Website: Dr Suneel Pooboni
Dr Deepika Gandhi Dr Maninder Dhaliwal Dr Rahul Bhatia
Dr Bhaskar Saikia Dr Vinayak Patki Dr Ravi Samraj
Dr Shipra Gulati Dr Anjul Dayal
National Advisors:
Dr Vikas Taneja Publication: Dr Y Amdekar
Dr Indira Jayakumar Dr Rachna Sharma Dr S C Arya
Dr Sanjay Bafna Dr Pradeep Sharma Dr R N Srivastava
Dr Sanjay Ghorpade Dr Sanjeev Kumar Dr C P Bansal
Dr Sagar Lad Dr V Yewale
Dr M P Jain

IAP Intensive Care Chapter
Executive Committee 2015
Dr Vishram Buche Dr B P Karunakara Dr Kundan Mittal Dr Anil Sachdev

Chairman Chairman Elect Vice-Chairman Imm. Past Chairman
Nagpur Bangaluru Rohtak Delhi
Dr Sanjay Ghorpade Dr D P Nakate Dr Praveen Khilnani Dr Bakul Parekh

Secretary Joint Secretary Editor Treasurer
Maharashtra Maharashtra Delhi Mumbai
Dr Manish Sharma Dr Arun Bansal Dr Devaraj Raichur Dr G V Basavraj Dr J Ebor Jacob

North Zone North Zone South Zone South Zone South Zone
Jaipur Chandigarh Karnataka Karnataka Vellore
Dr Hiren Patel Dr Sunil Vaidya Dr Sachin Shah Dr Agni Shekar Dr Arun Baranwal
West Zone West Zone West Zone East Zone East Zone
Gujarat Solapur Pune Kolkotta Bihar
Executive Members

Basic Pediatric Intensive Care Nursing Course (BPICNC)
One day training course has been initiated by the College of Pediatric Critical Care and
IAP Intensive Care Chapter for the critical care providers especially nurses working in the
PICU, Pediatric emergency and pediatric cardiac care units. This is a comprehensive course
that includes lectures on basic intensive care and workstations with hand on sessions in the
afternoon. A manual of pediatric critical care nursing has been prepared for the participating
candidates.
For organizing this course, you may contact:

Dr Soonu Udani
Chancellor (EX Officio),
College of Pediatric Critical Care
Mob: +919820999310
Email: drsudani@gmail.com
Dr Krishan Chugh
Chancellor
College of Pediatric Critical Care
Mob: +919810608580
Email: krishan.chugh@fortishealthcare.com
Dr Anil Sachdev
Course Co-ordinator
Mob: 9810098360
Email: anilcriticare@gmail.com

From the Editors Desk
Dear reader
In this issue of JPCC (Jan-march 2016) we have published NCPCC2015 (National conference of Pediatric Critical
care), poster and paper abstracts revealing the research in the field of Pediatric critical care from India. This includes all
abstracts including Top three posters (1st Position: Dr Nitin Manwani 2nd Position: Dr Jamunashree B 3rd Position: Dr
Chintan Patel) and Best paper judged upon oral presentation (1st Position: Dr. Andleeb Majeed).
Original article regarding experience with immunoglobulin therapy from a developing country (Dr Humaira Jurair; et al)
is high lighted. This issue highlights Extra corporeal membrane oxygenation (ECMO) experience by Dr Ankur Ohri; et
al: A relatively new life saving technology for severe hypoxemic respiratory or cardiopulmonary failure rapidly on the
rise in this part of the world.
Latest pearls highlight the 2016 Sepsis definitions and IDSA (infectious disease society of America) guidelines for the
treatment of invasive candidiasis.
Journal scan by Dr Krishan chugh scans important evidence based publications related to fluid resuscitation in septic
shock, Oxygen saturation targets in Bronchiolitis, Current status of HFOV, Oxygenation index in PARDS, Low tidal
volume for non ARDS patients and Volume of distribution of antibiotics.
Circulation of the journal is rapidly on the rise in Asia and the middle eastern region. For on line submissions log in to
www.journalofpediatriccriticalcare.com. You can also visit the Facebook page and give feed back. Soon After getting the
journal indexed after a rigorous indexing process, it is planned for the Journal to be an on line publication.
Happy reading
Praveen Khilnani
Diplomat American Board of Pediatrics and Critical Care Medicine
Editor in Chief Journal of Pediatric Critical Care
Executive Board Member and Vice Chancellor College of Pediatric Critical Care
Director Pediatric Critical Care Services and Fellowship Program
Mediclinic City Hospital, Dubai

Chairman Message
Dear friends,
To begin with I wish you all a happy and prosperous new year 2016. Indeed it’s a great privilege and honour to become
a Chairman of an esteemed, prestigious organisation to which I am attached since the birth of PICC. Thanks to all of you
for reposing faith on me by electing. Thanks to all my predecessors to bring PICC at it’s best level.
During this tenure, I would like to make PICC as “è-PICC “in the context of administration and academics. Already
a “Picu forum” platform is available initiated by young enthusiastic Intensivists, where difficult different cases with
management are discussed and innovative ideas are exchanged. Soon such expert advice for difficult cases would be
available on our official website if query arises.
Lot of mobile apps are developed by Dr Deopujari for PICC, are made available free for our members for education and
patients management. And, soon, there are many more apps in pipeline coming to our rescue.
Our BPICC program has become extremely popular and we wish and will make efforts that it would be conducted in all
corners of our country. Similarly “APICC” program, almost formulated and would be launched soon.
I congratulate Dr Krishan chugh for the commendable efforts for the conduction of fellowship programs under auspices
of college of Pediatric critical care in collaboration with PICC.
I congratulate Dr Praveen Khilnani for his extra ordinary efforts to make our journal at international level.
I shall encourage the zonal and regional CME in different parts of the country involving young Intensivists.
I appeal all to enroll new members and make our PICC more strong and vibrant.
I am confident with the help of all my colleague friends and senior advisers, PICC will be at it’s best level
Vishram Buche
Chairman
Pediatric Intensive Care Chapter of Indian Academy of Pediatrics Director,
NICU(level 3), Central India’s CHILD Hospital,
Research Institute, Mehadia Square, Dhantoli, Nagpur-440003,
M: 09823017254
Email:vbuche@gmail.com

Original Article
Intravenous Immunoglobulin use in
Pediatric Intensive Care Unit of a Developing Country
Humaira Jurair*, Amber shabir**, Kashif Hussain***, Qalab-e- Abbas****, Anwar-ul-Haque*****
*Senior Instructor, **Resident, ***Clinical specialist, ****Senior Instructor, *****Associate Professor
Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
ABSTRACT
Introduction: Intravenous immunoglobulin (IVIG) is pooled plasma product. Its use is progressively
increasing for several clinical indications.
Aim: We describe experience with IVIG use in Pediatric intensive care unit (PICU) of a developing
country.
Method: Retrospective database review was conducted at the PICU of Aga Khan Hospital, from January
2010 to June 2014. We report the demographic data, indications, efficacy and adverse effects related to
use of IVIG.
Results: A total of 56 patients received IVIG treatment. 58.9% (n = 33) patients were male. Twelve patients
(21.4%) were <1 year of age, 21 (37.5 %) were between 1year to 5 years and 23 (41.1%) were between
6 to 16 years old. Three most common indications were myocarditis, septic shock and severe capillary
leak syndrome. IVIG was found clinically efficacious in 42.9 % cases. Minor adverse events were noted
in 8.9% patients. These included 2 episodes of fever, 2 episodes of body rashes and 1 episode of fluid
responsive hypotension. Indications for IVIG use had an evidence category Ia / Ib in only 7.1%.
Conclusion: Use of IVIG was found safe in our PICU setting. However most of the indications were not
meeting high level of evidence.
Key words: Intravenous immunoglobulin, Pediatric intensive care unit, developing country
Introduction IVIG is a polyclonal immunoglobulin derived from

Immunoglobulins were initially used by Bruton in large pools of human serum (between 1000 and 15
1952 for patients with primary immune deficiency 000 donors per batch).1,5 Several reports have been
disease. Earlier it was developed as an intramuscular published on its use in adult clinical practice. Very
preparation. Later, in 1981 intravenous preparations limited data is available regarding the use of IVIG in
became commercially available.1,2 Initial use of pediatric population especially from resource limited
intravenous immune globulin (IVIG) was for settings. The purpose of this study is to report clinical
immune thrombocytopenic purpura (ITP), which is indications and adverse effects of IVIG in Pediatric
still an indicated treatment. Its use is progressively intensive care unit (PICU) of a developing country
increasing for different clinical conditions over the and to determine what proportion of its use was
last three decades.3,4 supported by strong level of evidence.
Correspondence Materials and Methods

Dr Humaira Jurair, FCPS
Senior Instructor, Department of Pediatrics and Child Health The study was retrospective database review
Aga Khan University Hospital, Stadium Road, Karachi, conducted in the Pediatric Intensive Care Unit (PICU)
74800, Pakistan of Aga Khan University Hospital, Pakistan from
Fax no: +92 213493 4294, Telephone: 02134864729
January 2010 to June 2014. Approval from ethics
Cell: 03332437492, E-mail:humaira.jurair@aku.edu,
dr_humairajurair@yahoo.com committee review (ERC # 3174-PED-ERC-14) was

ORIGINAL ARTICLE Intravenous Immunoglobulin use in Pediatric Intensive Care Unit of a Developing Country
obtained. All children between 1 month to 16 years of episodes of fever, 2 episode of allergic body rashes
age who received IVIG for various indications during (3.6%) and 1 (1.8%) episode of hypotension. Adverse
their intensive care unit stay were included. Data events were managed by reducing infusion rate,
were collected on structured data collection sheet administration of anti-histaminic drugs, antipyretics,
regarding demographics variables like age, gender, fluid bolus and or stopping the infusion. There was no
diagnosis, indication and dose of IVIG, number mortality attributed to use of IVIG. The indications
of doses of IVIG prescribed, adverse effects and for IVIG use had an evidence category Ia / Ib in 7.1%
mortality. All the data were cross-checked manually of cases.
from medical records (physician and nursing notes)
and electronic data from the hospitals computerized Discussion
systems. Descriptive statistics were used.
IVIG has wide range of clinical application and there
In our study efficacy was defined as ability of IVIG to has been rapid expansion in its utilization for number
produced desired clinical benefit. We defined adverse of disease states and life threatening conditions.4 In
reactions for study purpose as: ICU, IVIG is usually prescribed when there is failure
Fever: temperature 38.3 C within 24 hours of IVIG of other treatment options to achieve response or lack
administration of alternative treatment options.
Allergic reactions: presence of rashes, itching, In this retrospective review we describe the use of
flushing, facial redness, respiratory difficulty or IVIG in patients admitted to our ICUs over a 3.5-
abdominal pain year period. When we sought IVIG administration
with evidence-based consensus guidelines, we found
Acute kidney injury: if there is a need of dialysis for
that our increased number of consumption is lacking
renal supportive care
high evidence based support5,7. Because of the cost,
Aseptic meningitis: clinical signs and symptoms of shortages and growing use of IVIG there have been
meningitis and cerebrospinal fluid consistent with attempts in many countries to develop guidelines
abnormal pleocytosis and no growth on culture for monitoring of and indications for the use of
Hypotension: As Per Pediatric Advanced Life IVIG.8 Published Literature search revealed that
Support (PALS) guidelines (6) IVIG use beyond the clearly established indications
• For infants from 1 month to 12 months, Systolic is happening worldwide. In adult studies, the use
Blood Pressure <70 mm Hg of IVIG for non-listed indications is approximately
• For children >1 year to 10 years, Systolic Blood 30–40%.9 In another study of IVIG use in ICU in
Pressure <70+ (2×age in years) adult population by Foster et al. only 19% of IVIG
• Beyond 10 years, hypotension is defined as an prescriptions were for appropriate indications.
Systolic Blood Pressure <90 mm Hg Actions of IVIG depend on both the dose and
on the pathogenesis of the underlying disease.3,8
Dosing and frequency of IVIG administration may
Results
differ significantly depending on the underlying
Of total 2532 PICU admission during the study period condition. Dose-ranging studies for therapeutic
56 patients (2.2%) received IVIG .Demographic and IVIG have shown that clinicians are mainly using
clinical characteristics are shown in (Table 1). Three two types of doses regimen i.e course of 400 mg/kg/
most common indications were myocarditis, septic day for 5 days or high doses of 1-2 g/kg with rapid
shock and severe capillary leak syndrome. The dosing administration over 1-2 days. High doses have many
of IVIG treatment varied, most 62.5% of patients immunomodulatory and anti-inflammatory effects.2
received only a single dose. The dose administered In our study, we used rapid course of high dose.
was 1gm/kg in 53.6% cases. It was found clinically We found administration of IVIG to be relatively safe.
efficacious in 42.9% patients. Adverse events Many of the side effects are mild, self limited and can
occurred in 8.9% patients which included: 2 (3.6%) be managed easily by premedication with analgesics

and antihistamines and adjustment of infusion rate. Table 2: Use of Intravenous Immunoglobulin by
Reported side effects to IVIG infusion in majority diagnosis and evidence category References:5,7,10,11
of studies range from 3% to 15%.2,8 Jethro Wu et al Diagnostic Categories Number (%) Evidence
report adverse events of 6.5%.9. Adverse events in category
our cohort were about 8.9%. There were no mortality Myocarditis 23 (41.0) III
attributed to use of IVIG. Septic shock 12 (21.4) III
Capillary leak syndrome 05 (8.92) III
Conclusion Encephalitis 03 (5.35) III
We found that IVIG use is safe with minimal Toxic shock syndrome 03 (5.35) III
complication rates. However the use of IVIG in our Gullain Barre syndrome 03 (5.35) Ia
patients is mostly for low evidence level category. Status Epilepticus 03(5.35) IIb
This highlights the need for monitoring and more Stevenson Johnson syndrome 02 (3.57) IIa
thoughtful prescription for those conditions for Jevunile Rheumatoid Arthritis 01(1.78) IIb
which there is recognized support in the medical with HLH
literature for IVIG’s therapeutic effectiveness. If ITP with Intracranial 01(1.78) Ia
clinical benefit are experienced by individual center Hemorrhage
following use of IVIG in condition other than those
with category I/IIa level evidence, then such finding Acknowledgment
should be published in Peer reviewed literature, so We express our warm thanks to Dr. Asad Ali for
they could influence the policy recommendation. his support and guidance in grammar and language
Table 1: Demographic and clinical characteristics of patients editing.
receiving IVIG
Characteristics Number Percentage References
Gender Male 33 58.9 1. Foster R, Suri A, Filate W, Hallett D, Meyer J, Ruijs T,
Female 23 41.1 et al. Use of intravenous immune globulin in the ICU: a
1 month - 12 months 12 21.4 retrospective review of prescribing practices and patient
Age outcomes. Transfus Med. Dec;20(6):403-8.
13 months - 59 months 21 37.5 2. Prasad AN, Chaudhary S. Intravenous immunoglobulin
5 years - 15 years 23 41.1 in pediatrics: A review. Med J Armed Forces India.
Dosage 1 gm/kg 30 53.6 Jul;70(3):277-80.
3. Jolles S, Sewell WA, Misbah SA. Clinical uses of intravenous
2 gm/kg 26 46.4 immunoglobulin. Clin Exp Immunol. 2005 Oct;142(1):1-11.
Number One dose 35 62.5 4. Hartung HP, Mouthon L, Ahmed R, Jordan S, Laupland
of doses Two doses 19 33.9 KB, Jolles S. Clinical applications of intravenous
immunoglobulins (IVIg)--beyond immunodeficiencies and
More than two doses 2 3.6 neurology. Clin Exp Immunol. 2009 Dec;158 Suppl 1:23-33.
Adverse Fever 2 3.6 5. Galal NM. Pattern of intravenous immunoglobulins (IVIG)
effects Hypotension 1 1.8 use in a pediatric intensive care facility in a resource limited
setting. Afr Health Sci. Jun;13(2):261-5.
Rashes 2 3.6 6. Kleinman ME, Chameides L, Schexnayder SM, Samson RA,
Patient Cardiac 28 50.0 Hazinski MF, Atkins DL, et al. Part 14: pediatric advanced
Categories Hematology 1 1.8 life support: 2010 American Heart Association Guidelines
for Cardiopulmonary Resuscitation and Emergency
Immunology 2 3.6
Cardiovascular Care. Circulation. Nov 2;122(18 Suppl
Infectious 15 26.8 3):S876-908.
Neurology 10 17.8 7. Orange JS, Hossny EM, Weiler CR, Ballow M, Berger M,
Bonilla FA, et al. Use of intravenous immunoglobulin in
Total No 56
human disease: a review of evidence by members of the
Primary Immunodeficiency Committee of the American

Academy of Allergy, Asthma and Immunology. J Allergy population over a 10-year period. J Paediatr Child Health.
Clin Immunol. 2006 Apr;117(4 Suppl):S525-53. Aug;49(8):629-34.
8. Ramesh S, Schwartz SA. Therapeutic uses of intravenous 10. McDaneld LM, Fields JD, Bourdette DN, Bhardwaj A.
immunoglobulin (IVIG) in children. Pediatr Rev. 1995 Immunomodulatory therapies in neurologic critical care.
Nov;16(11):403-10; quiz 10. Neurocrit Care. Feb;12(1):132-43.
9. Wu J, Lee AJ, Goh AE, Chia M, Ho C, Bugarin JL, et al. 11. Lambert M, Launay D, Hachulla E, Morell-Dubois S, Soland
Use of intravenous immunoglobulin in an Asian paediatric V, Queyrel V, et al. High-dose intravenous immunoglobulins
dramatically reverse systemic capillary leak syndrome. Crit
Care Med. 2008 Jul;36(7):2184-7.
Neonatal & Pediatric Ventilation Workshop

23rd -24th April, 2016
Venue: Seminar Hall, 7th Floor, BLK Super Speciality Hospital, Pusa Road, New Delhi
Faculty: Dr Praveen Khilnani, Dr Kishan Chugh, Dr Nameeth Jeerath, Dr Rajiv Uttam, Dr Shipra Gulati,
Dr Rachna Sharma, Dr Kumar Ankur, Dr Sanjeev Chetry
Registration fee Rs 4000/-. (Last Date 12th April, 2016). All payments is to be made by DD/Cheque in
favour of Dr. B. L. Kapoor Memorial Hospital payable at Delhi or you can transfer online (please mail
your UTR no after online payment).
A/c Name: B L Kapur Memorial Hospital
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Dr Praveen Khilnani
Organizing Chairperson and Course Director
Dr Avijeet Yadav Dr Sanjeev Chetry

Organizing Secretary Co-Organizing Secretary
Email: avijeet_yadav@rediffmail.com Email: drsanjeev77@gmail.com
M: 09958262705 M: 09654493783

Latest Pearls
Compiled by Praveen Khilnani
A. The Third International Consensus Definitions convened by the Society of Critical Care Medicine
for Sepsis and Septic Shock (Sepsis-3) and the European Society of Intensive Care Medicine.
Mervyn Singer; Clifford S. Deutschman; Christopher Definitions and clinical criteria were generated
Warren Seymour; Manu Shankar-Hari; Djillali through meetings, Delphi processes, analysis of
Annane; Michael Bauer; Rinaldo Bellomo; electronic health record databases, and voting,
Gordon R. Bernard; Jean-Daniel Chiche; Craig M. followed by circulation to international professional
Coopersmith; Richard S. Hotchkiss; Mitchell M. societies, requesting peer review and endorsement
Levy; John C. Marshall; Greg S. Martin; Steven M. (by 31 societies listed in the Acknowledgment).
Opal; Gordon D. Rubenfeld; Tom van der Poll, ; Key Findings From Evidence Synthesis: Limitations
Jean-Louis Vincent; Derek C. Angus of previous definitions included an excessive focus
JAMA. 2016;315(8):801-810. doi:10.1001/jama. on inflammation, the misleading model that sepsis
2016.0287 follows a continuum through severe sepsis to shock,
and inadequate specificity and sensitivity of the
Abstract systemic inflammatory response syndrome (SIRS)
Importance: Definitions of sepsis and septic shock criteria. Multiple definitions and terminologies are
were last revised in 2001. Considerable advances currently in use for sepsis, septic shock, and organ
have since been made into the pathobiology dysfunction, leading to discrepancies in reported
(changes in organ function, morphology, cell incidence and observed mortality. The task force
biology, biochemistry, immunology, and circulation), concluded the term severe sepsis was redundant.
management, and epidemiology of sepsis, suggesting
the need for reexamination. Recommendations
Objective: To evaluate and, as needed, update Sepsis should be defined as life-threatening organ
definitions for sepsis and septic shock. dysfunction caused by a dysregulated host response
Process: A task force (n = 19) with expertise in sepsis to infection. For clinical operationalization, organ
pathobiology, clinical trials, and epidemiology was dysfunction can be represented by an increase
Table1: New Terms and Definitions

• Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
• Organ dysfunction can be identified as an acute change in total SOFA score ≥2 points consequent to the infection.
• The baseline SOFA score can be assumed to be zero in patients not known to have preexisting organ dysfunction.
• A SOFA score ≥2 reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection.
Even patients presenting with modest dysfunction can deteriorate further, emphasizing the seriousness of this condition and the
need for prompt and appropriate intervention, if not already being instituted.
• In lay terms, sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and
organs.
• Patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at
the bedside with qSOFA, ie, alteration in mental status, systolic blood pressure ≤100 mm Hg, or respiratory rate ≥22/min.
• Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to
substantially increase mortality.
• Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors
to maintain MAP ≥65 mm Hg and having a serum lactate level >2 mmol/L (18 mg/dL) despite adequate volume resuscitation.
With these criteria, hospital mortality is in excess of 40%.
Abbreviations: MAP, mean arterial pressure; qSOFA, quick SOFA; SOFA: Sequential [Sepsis-related] Organ Failure
Assessment.

XXXXXXXXXX Latest Pearls
in the Sequential [Sepsis-related] Organ Failure have also reviewed and endorsed these guidelines.
Assessment (SOFA) score of 2 points or more, which Some of the updated recommendations address
is associated with an in-hospital mortality greater diagnosis, consultation with infectious disease
than 10%. Septic shock should be defined as a subset specialists, neonatal candidiasis, intravascular
of sepsis in which particularly profound circulatory, infections, intensive care unit prophylaxis, central
cellular, and metabolic abnormalities are associated nervous system involvement, and mucosal infections.
with a greater risk of mortality than with sepsis alone. Addressing concerns about the growing prevalence
Patients with septic shock can be clinically identified of antifungal resistance, the guideline also advocates
by a vasopressor requirement to maintain a mean testing for azole susceptibility in clinically relevant
arterial pressure of 65 mm Hg or greater and serum Candida isolates. “Testing for echinocandin
lactate level greater than 2 mmol/L (>18 mg/dL) in susceptibility should be considered in patients who
the absence of hypovolemia. This combination is have had prior treatment with an echinocandin and
associated with hospital mortality rates greater than among those who have infection with C. glabrata or
40%. In out-of-hospital, emergency department, or C. parapsilosis,” the guideline adds.
general hospital ward settings, adult patients with The update also recommends a step-down approach,
suspected infection can be rapidly identified as being initiating treatment with an intravenous antifungal
more likely to have poor outcomes typical of sepsis such as an echinocandin and then switching to an
if they have at least 2 of the following clinical criteria oral treatment, such as fluconazole.
that together constitute a new bedside clinical score Candidiasis should be considered in patients whose
termed quickSOFA (qSOFA): respiratory rate of 22/ condition deteriorates with no obvious cause, and
min or greater, altered mentation, or systolic blood in patients who have unexplained fever, have an
pressure of 100 mm Hg or less. elevated white blood cell count, have recently
Conclusions and Relevance These updated undergone abdominal surgery, or have a central
definitions and clinical criteria should replace venous catheter, according to the new guidelines. The
previous definitions, offer greater consistency for guidelines also recommend the removal of a catheter
epidemiologic studies and clinical trials, and facilitate as early as possible in candidemia if the catheter is
earlier recognition and more timely management of the presumed source and can be safely removed.
patients with sepsis or at risk of developing sepsis Other intravascular devices should also be removed.
Because a rapid specific diagnostic test remains
lacking, and diagnosis and treatment across strains
B. Infectious disease society of America (IDSA)
remain challenging, consultation with an infectious
Guidelines for invasive candidiasis
diseases specialist is recommended.
Clin Infect Dis. Published online December
Early action is key. “Time to appropriate therapy
16, 2015. http://cid.oxfordjournals.org/content/
in candidemia appears to have a significant impact
early/2015/12/15/cid.civ933.full. Accessed December
on the outcome of patients with this infection,” the
23, 2015.
guideline states. “A safe and effective prophylactic
strategy to prevent candidemia among high-risk
Invasive Candida infection is a major cause of
patients could be of great benefit.” In particular, in
morbidity and mortality in the healthcare environment.
intensive care units with rates of invasive candidiasis
Since the Infectious Diseases Society of America
elevated beyond the expected rate of less than 5%,
(IDSA) last published guidelines on this topic in
antifungal prophylaxis may be warranted in selected
2009, new data regarding diagnosis, prevention,
high-risk patients.
and treatment for proven or suspected invasive
Invasive candidiasis is one of the most serious
candidiasis resulted in significant modifications
nosocomial infections. “In fact, patients who get
of treatment recommendations. The American
candidemia are more likely to die than those whose
Academy of Pediatrics, the Pediatric Infectious
bloodstream infections are caused by bacteria,”
Diseases Society, and the Mycoses Study Group
Dr Pappas said in an IDSA statement. Also

XXXXXXXXXXXXXXXXXX Latest Pearls
according to the statement, some studies have daily should only be considered in patients
reported a mortality rate as high as 47% in affected with fluconazole-susceptible or voriconazole-
patients.The guideline notes that more than 90% of susceptible isolates (strong recommendation;
potentially life-threatening deep-tissue disease is low-quality evidence).
caused by 5 of 15 fungal pathogens: C albicans, C 6. When there is intolerance, limited availability,
glabrata, C tropicalis, C parapsilosis, and C krusei. or resistance to other antifungal agents, lipid
The new recommendations have been endorsed by formulation amphotericin B (3-5 mg/kg daily) is
the American Academy of Pediatrics, the Pediatric a reasonable alternative (strong recommendation;
Infectious Diseases Society, and the Mycoses Study high-quality evidence).
Group.Support for this guideline was provided by
IDSA. A majority of the authors have disclosed Treatment recommendations for candidemia in
financial relationships with industry outside the neutropenic patients include the following:
submitted work, including research grants, consulting 1. Initial therapy should be an echinocandin
or speaking fees, and royalties or patents. (caspofungin: loading dose 70 mg, then 50 mg
daily; micafungin: 100 mg daily; anidulafungin:
Treatment recommendations for candidemia in loading dose 200 mg, then 100 mg daily) (strong
non-neutropenic patients include the following: recommendation; moderate-quality evidence).
1. Initial therapy should be an echinocandin 2. An effective but less attractive alternative because
(caspofungin: loading dose 70 mg, then 50 mg of the potential for toxicity is lipid formulation
daily; micafungin: 100 mg daily; anidulafungin: amphotericin B, 3 to 5 mg/kg daily (strong
loading dose 200 mg, then 100 mg daily) (strong recommendation; moderate-quality evidence).
recommendation; high-quality evidence). 3. Fluconazole at a loading dose of 800 mg (12
2. For selected patients who are not critically ill mg/kg), then 400 mg (6 mg/kg) daily, is an
and are unlikely to have fluconazole-resistant alternative for patients who are not critically ill
Candida species, an acceptable alternative to an and have had no previous azole exposure (weak
echinocandin as initial therapy is fluconazole, recommendation; low-quality evidence).
intravenous or oral, 800-mg (12 mg/kg) loading Infections resulting from C krusei should be
dose, then 400 mg (6 mg/kg) daily (strong treated with an echinocandin, lipid formulation
recommendation; high-quality evidence). amphotericin B, or voriconazole (strong
3. All bloodstream and other clinically relevant recommendation; low-quality evidence).
Candida isolates should be tested for azole For candidemia without metastatic complications,
susceptibility, and possibly for echinocandin recommended minimum duration of therapy is
susceptibility in patients previously treated with 2 weeks after documented clearance of Candida
an echinocandin or infected with C glabrata or C from the bloodstream, provided neutropenia and
parapsilosis (strong recommendation; low-quality candidemia-related symptoms have resolved
evidence). (strong recommendation; low-quality evidence).
4. Patients who are clinically stable, have isolates Dilated funduscopic examinations should be
susceptible to fluconazole, and have negative performed within the first week after recovery
results on repeated blood cultures after starting from neutropenia, because ophthalmologic
antifungal therapy should transition from an findings of choroidal and vitreal infection are
echinocandin to fluconazole, usually within 5 to minimal until recovery from neutropenia (strong
7 days (strong recommendation; moderate-quality recommendation; low-quality evidence).
evidence) or from amphotericin B to fluconazole Sources of candidiasis other than a central venous
after 5 to 7 days (strong recommendation; high- catheter predominate in the neutropenic patient,
quality evidence). so catheter removal should be considered on an
5. For C glabrata infection, transition to higher- individual basis (strong recommendation; low-
dose fluconazole 800 mg (12 mg/kg) daily or quality evidence).
voriconazole 200 to 300 (3-4 mg/kg) twice

Journal Scan
Fluid Resuscitation in Septic Shock:
Modified PALS guidelines post FEAST trial
Dr Krishan chugh
Director and HOD, Pediatrics and Pediatric Intensive Care,
Fortis Memorial Hospital and Research Institute, Gurgaon, Haryana
Fluid Bolus Evidence was not considered to be specific to a

Early and rapid administration of intravenous fluid particular setting, after determining that “resource-
to reverse decompensated shock, and to prevent limited setting” is difficult to define and can vary
progression from compensated to decompensated greatly even within individual health systems and
shock, has been widely accepted based on limited small geographic regions.
observational studies – the sentinel study by Carcillo Since the standard care has been to administer
et al being the most important of them1. Mortality large boluses of fluids to septic shock patients, the
from pediatric sepsis has declined in recent years, evidence regarding the impact of restricting fluid
during which guidelines and publications (eg: PALS boluses during resuscitation on outcomes in pediatric
and Surviving Sepsis Guidelines) have emphasized septic shock was analysed by the experts and is
the role of early rapid fluid administration (along with summarized in (Figure 1). There were no studies for
early antibiotic and vasopressor therapy, and careful many specific combinations of presenting illness and
cardiovascular monitoring) in treating septic shock. outcome.
Since the 2010 PALS Guidelines, a large randomized In the majority of scenarios, there was no benefit to
controlled trial of fluid resuscitation in pediatric restricting fluid boluses during resuscitation.
severe febrile illness in a resource-limited setting The most important exception is that in 1 large study
found intravenous fluid boluses to be harmful2. This (FEAST trial) 2, restriction of fluid boluses conveyed
new information, contradicting long-held beliefs and a benefit for survival to both 48 hours and 4 weeks
practices, prompted careful analysis of the effect after presentation. This study was conducted in sub-
of fluid resuscitation on many outcomes in specific Saharan Africa, and inclusion criteria were severe
infectious illnesses. febrile illness complicated by impaired consciousness
(prostration or coma), respiratory distress (increased
work of breathing), or both, and with impaired
2015 Evidence Summary
perfusion, as evidenced by 1 or more of the following:
Specific infection-related shock states appear to a capillary refill time of 3 or more seconds, lower limb
behave differently with respect to fluid bolus therapy.
Studies Survival to Need for Need for Mechanical Time to Total IV

Hospital Transfusion Rescue Ventilation or Resolution of Fluids
Discharge or Diuretics Fluid Vasopressor Shock
Severe sepsis/ septic Santhanam 2008; No Benefit No Benefit No Studies No Benefit No Benefit No Studies
shock Carcillo 1991 Available Available
Severe malaria Maitland 2005; No Benefit No Benefit Harm No Studies No Benefit No Benefit
Maitland 2005 Available
Severe febrile illness Maitland 2011; Benefit No Benefit No Studies No Studies Harm No Benefit
with some but not all Maitland2013 Available Available
signs of shock
Figure 1. Evidence for the use of restrictive volume of intravenous fluid resuscitation, compared with unrestrictive volume, by
presenting illness and outcome. Benefit indicates that studies show a benefit to restricting fluid volume, No Benefit indicates that there
is no benefit to restricting fluid volume, and Harm indicates that there is harm associated with restricting fluid volume. No Studies
Available indicates no studies are available for a particular illness/outcome combination.

JOURNAL SCAN Fluid Resuscitation in Septic Shock: Modified PALS guidelines post FEAST trial
temperature gradient, weak radial pulse volume, or be harmful (Class IIb, LOE B-R). Providers should
severe tachycardia. In this study, administration of 20 reassess the patient after every fluid bolus (Class I,
mL/kg or 40 mL/kg in the first hour was associated LOE C-EO).
with decreased survival compared with the use of
maintenance fluids alone. Therefore, it appears that Crystalloid vs. Noncrystalloid
in this specific patient population, where critical
The use of noncrystalloid fluid was compared with
care resources including inotropic and mechanical
crystalloid fluid for the same diseases and outcomes
ventilator support were limited, bolus fluid therapy
listed in the preceding paragraphs2-8. Evidence is
resulted in higher mortality. This trial included large
summarized in (Figure 2). In most scenarios, there
number of children who were malnourished and
was no benefit to noncrystalloids over crystalloids. In
many had malaria rather than bacterial sepsis.
patients with Dengue shock, a benefit was conferred
in using noncrystalloid compared with crystalloid
2015 Recommendations—New fluid for the outcome of time to resolution of shock7.
Administration of an initial fluid bolus of 20 mL/
kg to infants and children with shock is reasonable, 2015 Recommendations—New
including those with conditions such as severe sepsis
Either isotonic crystalloids or colloids can be
(Class IIa, LOE C-LD), severe malaria and Dengue
effective as the initial fluid choice for resuscitation
(Class IIb, LOE B-R).
(Class IIa, LOE B-R).
When caring for children with severe febrile illness
Thus this update regarding intravenous fluid
(such as those included in the FEAST trial) in
resuscitation in infants and children in septic shock in
settings with limited access to critical care resources
all settings addressed 2 specific therapeutic elements:
(ie, mechanical ventilation and inotropic support),
(1) Withholding the use of bolus fluids was compared
administration of bolus intravenous fluids should
with the use of bolus fluids, and (2) noncrystalloid
be undertaken with extreme caution because it may
was compared with crystalloid fluids in various types
Studies Survival to Need for Need for Mechanical Time to Total IV Hospital
Hospital Other Rescue Ventilation or Resolution Fluids Duration of
Discharge Treatment Fluid Vasopressor of Shock Stay
Severe sepsis/ Upadhyay No Benefit No Benefit No Studies No Benefit No Benefit No Studies No Studies
septic shock 2005 Available Available Available
Severe malaria Maitland No Studies No Benefit No Studies No Studies No Benefit No Studies No Studies
2003; Available Available Available Available Available
Maitland
2005
Dengue shock Cifra 2003; No Benefit No Benefit No Benefit No Studies Benefit No Benefit No Benefit
Dung 1999; Available
Ngo 2001;
Wills 2005
Severe febrile Maitland No Benefit No Benefit No Benefit No Studies No Benefit No Benefit No Studies
illness with some 2011 Available Available
but not all signs
of shock
Figure 2: Evidence for the use of noncrystalloid intravenous fluid resuscitation, compared with cystalloid, by presenting illness and
outcome. Benefit indicates that studies show a benefit to the use of noncrystalliod intravenous fluid resuscitation compared with
crystalloid, and No Benefit indicates that there is no benefit to the use of noncrystalloid intravenous fluid resuscitation compared with
crystalloid. No studies available indicate no studies are available for a particular illness/ outcome combination.

JOURNAL SCAN Fluid Resuscitation in Septic Shock: Modified PALS guidelines post FEAST trial
of septic shock in different resource settings and References

different types of patient populations.. 1. Carcillo JA, Davis AL, Zaritsky A. Role of early fluid
This recommendation takes into consideration the resuscitation in pediatric septic shock. JAMA. 1991;
266:1242–1245.
important work of Maitland et al2, which found that
2. Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P,
fluid boluses as part of resuscitation are not safe for Akech SO, Nyeko R, Mtove G, Reyburn H, Lang T, Brent B,
all patients in all settings. This study showed that the Evans JA, Tibenderana JK, Crawley J, Russell EC, Levin M,
use of fluid boluses as part of resuscitation increased Babiker AG, Gibb DM; FEAST Trial Group. Mortality after
mortality in a specific population in a resource- fluid bolus in African children with severe infection. N Engl J
Med. 2011; 364:2483–2495. doi: 10.1056/NEJMoa1101549.
limited setting, without access to some critical care 3. Upadhyay M, Singhi S, Murlidharan J, Kaur N, Majumdar S.
interventions such as mechanical ventilation and Randomized evaluation of fluid resuscitation with crystalloid
inotrope support. (saline) and colloid (polymer from degraded gelatin in saline)
The spirit of this recommendation is a continued in pediatric septic shock. Indian Pediatr. 2005; 42:223–231.
4. Maitland K, Pamba A, Newton CR, Levin M. Response
emphasis on fluid resuscitation for both compensated
to volume resuscitation in children with severe malaria.
(detected by physical examination) and decompensated Pediatr Crit Care Med. 2003; 4:426– 431. doi: 10.1097/01.
(hypotensive) septic shock. Moreover, emphasis PCC.0000090293.32810.4E.
is also placed on the use of individualized patient 5. Cifra H, Velasco J. A comparative study of the efficacy of
evaluation before the administration of intravenous 6% Haes-Steril and Ringer’s lactate in the management of
dengue shock syndrome. Crit Care Shock. 2003; 6:95–100.
fluid boluses, including physical examination by a 6. Dung NM, Day NP, Tam DT, Loan HT, Chau HT, Minh LN,
clinician and frequent reassessment to determine Diet TV, Bethell DB, Kneen R, Hien TT, White NJ, Farrar JJ.
the appropriate volume of fluid resuscitation. The Fluid replacement in dengue shock syndrome: a randomized,
clinician should also integrate clinical signs with double-blind comparison of four intravenous- fluid regimens.
Clin Infect Dis. 1999; 29:787–794. doi: 10.1086/520435.
patient and locality-specific information about
7. Ngo NT, Cao XT, Kneen R, Wills B, Nguyen VM, Nguyen
prevalent diseases, vulnerabilities (such as severe TQ, Chu VT, Nguyen TT, Simpson JA, Solomon T, White
anemia and malnutrition), and available critical care NJ, Farrar J. Acute management of dengue shock syndrome:
resources. a randomized double-blind comparison of 4 intravenous fluid
Regarding the use of noncrystalloids in Dengue regimens in the first hour. Clin Infect Dis. 2001; 32:204–213.
doi: 10.1086/318479.
shock it must be pointed out that the WHO as well 8. Wills BA, Nguyen MD, Ha TL, Dong TH, Tran TN, Le
as IAP Infectious Disease Chapter Guidelines for TT, Tran VD, Nguyen TH, Nguyen VC, Stepniewska K,
management of dengue fever also recommend that the White NJ, Farrar JJ. Comparison of three fluid solutions
second and the third bolus of fluid for resuscitation of for resuscitation in dengue shock syndrome. N Engl J Med.
dengue hypotensive shock after the first crystalloid 2005; 353:877–889. doi: 10.1056/NEJMoa044057.
bolus of 10 – 20 ml/kg should be a colloid.

Oxygenation Index at Onset vs at 24 Hours in PARDS
Dr Krishan chugh
Summary airway pressure release ventilation, APRV), five

In a study conducted at Children’s hospital of patients escalated to ECMO (three venovenous and
Philadelphia (CHOP)1 283 children who met the two venoarterial), and one patient died. Persistently
Berlin definition criteria of ARDS and were ventilated elevated PIP (≥35 cm H2O), on-going hypercarbia
were enrolled in a prospective, observational study. (Paco2 ≥ 80), or oxygenation difficulties (inability to
The goal was to identify variables associated with wean Fio2 ≤ 0.60 despite increasing PEEP) prompted
mortality and ventilator free days (VFD) at 28 days. consideration for changing mode of ventilation or
Age ranged from 1.4 to 12.8 years (median= 4.1 escalating to extracorporeal membrane oxygenation
years). Causes of ARDS were infectious pneumonia (ECMO).
(58%), aspiration pneumonia (10%), sepsis (18%), There was no standardization of ancillary therapies
and trauma in 8%. Nineteen Per cent of the children (inhaled nitric oxide [iNO], surfactant, neuromuscular
were immune compromised. Only 2% were proned. blockade, and prone positioning), which was left to
Oxygenation and ventilation characteristics at ARDS the discretion of the attending physician.
onset and 24 hours after onset are shown in (Table 1). Initial Berlin Pao2 / Fio2 and PALICC OI categories
at ARDS onset failed to discriminate mortality;
Table 1:
however, value 24 hours afterwards, as well as the
Characteristic ARDS Onset: 24 hr after worst values in 24 hours, discriminated mortality
Median ARDS onset:
Median
(Table 2). Similar results were obtained for VFD = 0
days or VFD up to 14 days.
PaO2 / FiO2 156 (110, 205) 222 (165, 274)
Ol 10.2 (7.1, 16.3) 6.9 (5.2, 10.5) Table 2:
FiO2 0.50 (0.45, 0.80) 0.40 (0.35, 0.50) Mortality Area Under
Variable tested
PEEP (cm H2O) 10 (8, 12) 10 (8, 10) the Curve (95% CI) p
PIP (cm H2O) 30 (25, 35) 27 (24, 32) Initial PaO2/ FiO2 0.580 (0.480-0.680) 0.116
Mean airway 16 (14, 18) 15 (14, 19) 24-hr PaO2/ FiO2 0.684 (0.594- 0.774) <0.001
pressure (cm H2O) Worst PaO2/ FiO2 in first
0.691 (0.611-0.771) <0.001
Exhaled VT (mL/ kg 7.5 (6.7, 8.3) 7.3 (6.5, 8.1) 24hr
actual body weight) Initial OI 0.581 (0.472-0.689) 0.114
Exclusion criteria were 1) respiratory failure from 24-hr OI 0.661 (0.573-0.749) 0.002
cardic failure (determined by echocardiography) or Worst OI in the first 24 hr 0.661 (0.578-0.743) 0.002
fluid overload, 2) exacerbation of underlying chronic
In none of the 3 major diagnosis guidelines [AECC2,
respiratory disease, 3) chronic ventilator dependence,
Berlin3, PARDS consensus guidelines4] has the
4) mixing cyanotic heart disease, 5) mechanical
timing of oxygenation indices, PaO2/ FiO2 ratio or OI
ventilation for more than 7 days before PaO2 / FiO2
been defined. However, each one of these definition
up to 300, and 6) ARDS established outside of the
has contributed significantly to better understanding
CHOP PICU.
and bedside management of ADRS in children.
Decelerating flow (PC or PRVC) was used for
This study was initiated in 2011 before the publication
conventional ventilation. Twenty four hours after
of PALICC or Berlin study. However, all patients met
meeting ARDS criteria, 61 patients transitioned to
the Berlin definition criteria, as all of them were on
alternative modes (33 HFPV, 24 HFOV and four
PEEP of more than 5cm H2O. Thus, it is relevant

JOURNAL SCAN Oxygenation Index at Onset vs at 24 Hours in PARDS
even today. References

The authors1 convincingly show that risk 1. Yehya N, Servaes S, Thomas NJ: Characterizing Degree
stratification at ARDS onset cannot discriminate of Lung Injury in Pediatric Acute Respiratory Distress
Syndrome. Crit Care Med 2015; 43:937-946
mortality difference among the mild and moderate
2. Bernard GR, Artigas A, Brighan KL, et al: The American-
ARDS categories, while oxygen metrics at 24 hours European Consensus Conference on ARDS. Definitions,
and worst value during the first 24 hours are capable mechanism, relevant outcomes, and clinical trial coordination.
of defining severity categories that have different Am J Respir Crit Care Med 1994; 149:818-824
outcomes. 3. Ranieri VM, Rubenfeld GD, Thompson BT, et al: Acute
respiratory distress syndrome: The Berlin definition. JAMA
It has been noted earlier also that indices of 2012; 307: 2526-2533
oxygenation measured at diagnosis of ARDS 4. The Pediatric Acute Lung Injury Consensus Conference
were not as good for predicting outcomes as these Group: Pediatric Acute Respiratory Distress Syndrome
measurements made at 24 hours after the diagnosis5,6. Consensus Recommendations from the Pediatric Acute Lung
Injury Consensus Conference. Pediatr Crit Care Med 2015;
The at diagnosis data were particularly poor at
16:428-439
discriminating outcomes between mild and moderate 5. Bone RC, Maunder R Slotman G, et al: An early test of
categories as also shown by Costa et al7 in adult and survival in patients with the adult respiratory distress
De Luces et al in infants8. syndrome. The PaO2/ FiO2ratio and its differential response
Interestingly, studies on HFOV in ARDS have also to conventional therapy. Prostaglandin E1 Study Group.
Chest 1989; 96:849-851
found OI after 24 hours to better predict outcomes9,10. 6. Villar J, Pérez-Méndez L, Blanco J, et al; Spanish Initiative
A possible explanation for these results can be for Epidemiology, Stratification, and Therapies for ARDS
summarised as follows: (SIESTA) Network: A universal definition of ARDS: The
Oxygenation measured at ARDS onset may poorly PaO2/ FiO2 ratio under a standard ventilator setting- A
prospective, multicentre validation study. Intensive Care
predict outcomes because of inadequate lung
Med 2013; 39:583-592
recruitment and underresusciatation affecting PaO2; 7. Costa ELV, Amato MBP: The new definition for acute lung
the same measurement after 24 hours of attempted injury and acute respiratory distress syndrome: Is there room
stabilization may more accurately reflect lung injury. for improvement? Curr Opin Crit Care 2013; 19:16-23
Ventilation/perfusion mismatches present at ARDS 8. De Luca D, Piastra M, Chidini G, et al; Respiratory Section
of the European Society for Pediatric Neonatal Intensive
onset may be improved after 24 hours, thus allowing Care (ESPNIC): The use of the Berlin definition for acute
oxygenation metrics to more accurately reflect true respiratory distress syndrome during infancy and early
shunt. childhood: Multicenter evaluation and expert consensus,
A large cohort and use of easily available parameters Intensive Care Med 2013; 39:2083-2091
9. Arnold JH, Hanson JH, Toro-Figuero LO, et al: Prospective,
in majority of the PICUs are the strengths of this study.
randomized comparison of high-frequency oscillatory
However, generalizability of the study to all centres ventilation and conventional mechanical ventilation in
is limited by the fact that this is a single centres study Pediatric respiratory failure. Crit Care Med 1994; 22:1530-
done at CHOP where the mortality of EARDS was 1539
only 13%. Further, this study was performed before 10. Arnold JHAnas NG, Luckett P, et al: High-frequency
oscillatory ventilation in Pediatric respiratory failure: A
the Berlin and ARDS guidelines were published. multicentre experience. Crit Care Med 2000; 28:3913-3919

SpO2 Target in Bronchiolitis
Dr Krishan chugh
In the guidelines published in 2014 American symptom in bronchiolitis consistently identified by

Academy of Paediatrics (AAP)1 had advised that parents and has a duration well documented in many
Paediatricians / Clinicians may choose not to trials.
administer supplemental oxygen if the oxyhemoglobin
saturation exceeds 90% in infants and children with Methods
a diagnosis of bronchiolitis (Evidence Quality: D; This was a parallel-group, randomised, controlled,
Recommendation Strength: Weak Recommendation) equivalence trial at eight paediatric hospitals in the
. The guidelines did acknowledge that the level of UK during two 6-month winter bronchiolitis seasons
evidence in support of this statement is weak. Now, in which infants aged between 6 weeks and 12 months
this study by Cunningham’s et al2 provides strong of age (corrected for prematurity) were enrolled. To
support to the AAP statement. be eligible for recruitment, infants had to have a
clinical diagnosis of bronchiolitis (consistent with
SIGN 91 Bronchiolitis) made by receiving acute
SUMMARY
medical staff and required admission to hospital for
Background supportive care. The clinical decision to admit an
infant with bronchiolitis prompted randomisation to
In 2006, two evidence-based guidelines for the
the study.
management of bronchiolitis included contrasting
Authors excluded infants who: were preterm (<37
recommendations for oxygen saturation targets.
weeks’ gestation) and had received oxygen therapy in
The UK SIGN guideline (SIGN 91) recommended
the past 4 weeks; had cyanotic or haemodynamically
a normoxic pulse oxygen saturation (SpO2) target
significant heart disease; had cystic fibrosis or
(≥94%), whereas the American Academy of Pediatrics
interstitial lung disease; had documented immune
(AAP) 1 recommended a permissive hypoxaemic SpO2
function deficit; were directly admitted to a high
target (≥90%; reiterated 2014). The AAP’s advice is
dependency or intensive care area; or were previously
consistent with WHO’s recommended SpO2 target
randomised.
of 90% and higher in infants with LRTI. However,
Authors randomly allocated (1:1) infants to a
WHO’s recommendation is considered pragmatic
standard pulse saturation oximeter or a modified
advice for best use of scarce oxygen availability in
pulse saturation oximeter. Standard pulse oximeters
low-resource settings, and neither AAP or WHO
(Rad 8 with LNC 10 patient cable, Masimo, CA,
targets have been tested in a randomised controlled
USA) measured and displayed oxygen saturation
trial.
in the typical way. Identical-looking modified
No randomised clinical trial has assessed oxygen
oximeters measured arterial oxygen saturation as per
saturation targets in management of patients with
standard oximeters, but manufacturer-altered internal
acute viral bronchiolitis. Cunningham S et al aimed
algorithms provided a non-standard display— so
to assess whether a target oxygen saturation of 90%
that at a measured value of 90% the monitor would
or higher would be equivalent to 94% or higher for
display 94%.Therefore, infants with modified
resolution of illness in acute viral bronchiolitis. To do
oximeters would not be given supplemental oxygen
this they assessed time to resolution of cough, which
at a displayed 94% oxygen saturation, but actual 90%
is associated with airway inflammation and might
oxygen saturation.
be influenced by hypoxia. Cough is a ubiquitous

JOURNAL SCAN SpO2 Target in Bronchiolitis
Results plus or minus 4 h. Similarly, infants in the modified

The primary outcome for equivalence was time group were considered back to normal 1 day sooner
to resolution of cough. The other variables studied by parents (table) with the 95% CI of 0 to 3.
included length of stay, need and duration of oxygen
therapy, time to complete recovery, time to establish COMMENTS
satisfactory feeding and need for readmission. Costs
Modified group children did better in following
of treatment to NHS were also calculated.
variables:
Sample size required was calculated as 544
1. Costs to NHS were less.
participants. Actual number enrolled was 615 (308 in
2. Lead carers lost fewer hours to usual activities.
standard oximeter group and 307 in altered oximeter
3. Fewer children needed O2.
group). Supplemental oxygen was provided to 223
4. Those who needed O2 needed it for shorter period.
(73%) of 305 of infants in the standard group and 169
5. Were discharged sooner.
(56%) of 304 in the modified group.
6. Regained “satisfactory feeding” sooner.
Oxygen was provided for significantly longer period
7. Were “back to normal” sooner.
in the standard group than the modified group
8. Had fewer readmissions to hospital.
(table). Infants were also fit for discharge and were
discharged significantly sooner in the modified Limitations of this study include:
group (table), with benefit to those who required • Neurocognitive outcomes not assessed
supplemental oxygen. • This study included bronchiolitis patients admitted
Infants returned to adequate feeding 2・7 h sooner to wards only and not in primary care setting or
(median) in the modified group, with the 95% CI emergency room setting.
(–0・3 to 7) falling outside the pre specified limits of As far as generalizability of this study is concerned it
Table: Clinical outcomes

Median HR
Standard group (n=308) Modified group (n=307) p value
difference* estimate†
• Time to resolution
15·0 (10·0 to 42·5); n=296 15·0 (10·0 to 41·0); n=293 1·00 (−1·0 to 2·0) .. ..
cough (days)‡
• Time feeding
returned to≥75% 24·1 (6·5 to 62·1); n=304 19·5 (6·3 to 47·2); n=296 2·7 (−0·3 to 7·3) .. ..
normal (h)§
• Time back to normal
12·0 (7·0 to 25·0); n=296 11·0 (6·0 to 20·0); n=293 1·0 (0 to 3·0) .. ..
(days)¶
• Time to fit to 1·46 (1·23
44·2 (18·6 to 87·5); n=283 30·2 (15·6 to 59·7); n=276 .. <0·0001
discharge (h) to 1·73)
• Time to actual 1·28 (1·09
50·9 (23·1 to 93·4); n=303 40·9 (21·8 to 67·3); n=301 .. 0·003
discharge (h) to 1·50)
• Time to no further
1·37 (1·12
supplemental 27·6 (0 to 68·1); n=305 5·7 (0 to 32·4); n=304 .. 0·0021
to 1·68)
oxygen (h)
Data are median (IQR); n or estimate of difference (95% CI), unless otherwise stated.
* Median difference is standard–modified (<0 indicates benefit to standard practice).
† HR is standard /modified (<1 indicates benefit to standard practice).
‡ Equivalence defined as plus or minus 2 days.
§ Equivalence defined as plus or minus 4 h.
¶ Equivalence defined as plus or minus 2 days.

JOURNAL SCAN SpO2 Target in Bronchiolitis
must be emphasised that more severe cases requiring the number of admissions to the wards in infants
admission to High Dependency Unit or Pediatric suffering from bronchiolitis besides cutting down the
Intensive Care Unit were not included in this study. duration of study and hence the costs. In an editorial
Such children should still be treated by standard comment3 on this BIDS study questions have been
interventions including oxygen administration. raised about the use of supplemental oxygen in
The AAP guideline1 does not apply to children other acute hypoxic states, such as exacerbations of
with immunodeficiencies, including those with asthma and community- acquired pneumonia. The
HIV infection or recipients of solid organ or decision about acceptable oxygen saturations for
hematopoietic stem cell transplants. Children these disorders is also based on expert opinion and
with underlying respiratory illnesses, such as becomes a matter of clinical judgment, availability of
recurrent wheezing, chronic neonatal lung disease healthcare resources, and cost implications.
(also known as bronchopulmonary dysplasia),
neuromuscular disease, or cystic fibrosis and those References
with hemodynamically significant congenital 1. Ralston SL, Lieberthal AS, Meissner HC et al. Clinical
heart disease are excluded from the sections on Practice Guideline: The Diagnosis, Management, and
management. The AAP guideline does not address Prevention of Bronchiolitis. Pediatrics 2014; 134(5):e1474–
long-term sequelae of bronchiolitis, such as recurrent e1502
2. Cinningham S, Rodriguez A, Adams T et al. for the
wheezing or risk of asthma, which is a field with a
Bronchiolitis of Infancy Discharge Study (BIDS) group:
large and distinct literature. Similarly, results of this Oxygen saturation targets in infants with bronchiolitis
Cunningham study2 are also not applicable to the (BIDS): a double-blind, randomized, equivalence trail.
above specified groups. Lancet 2015; 386: 1041-1048
This study has the potential for bringing down 3. Wainwright CE, Kapur N. Oxygen saturation targets in
infants with bronchiolitis. Lancet 2015; 386: 1016-1018

Appropriate Choice and Timing of Antibiotics not enough for Good
Outcomes in MDR Severe Sepsis
Dr Krishan chugh
Background were not single-agent aminoglycosides), that was

It is well known that timing of first dose of antibiotics administered within 12 hours of when a positive
and choosing appropriate antibiotic initially itself blood culture was drawn and continued for at least
directly influence outcomes in patients with sepsis, 24 hours. For extended-spectrum β-lactamase–
severe sepsis and septic shock. But, there are other producing organisms, initial use of a carbapenem was
factors that may be related to anbiotic treatment required to be classified as appropriate treatment.
that determine outcomes. Eg: severity of disease,
multidrug- resistance (MDR), dose and method of Results
administration etc. Five hundred ten patients with sepsis, severe sepsis,
or septic shock due to Enterobacteriaceae met
Aims and Methods the inclusion criteria. Time to appropriate initial
In a retrospective cohort study from Washington antibiotic therapy was shortest for patients with
University School of Medicine, St. Louis, MO1 septic shock.
authors analysed data from adult patients with As the severity of sepsis increased, so did the LOS,
positive blood cultures for Enterobacteriaceae a ICU LOS, number of procedures, and mortality.
single organism. Thus patients with positive blood Mortality rates were 3.5%, 9.9% and 28.6% for
culture for Escherichia coli, Klebsiella, Proteus, sepsis, severe sepsis and septic shock respectively;
Enterobacter, Serratia, Citrobacter, Salmonella, P < 0.05. Kaplan-Meier curves confirmed that
Yersinia etc. were included: increasing sepsis severity was associated with greater
Primary goal of the study was to compare 30-day all- 30-day mortality. Total LOS, prevalence of MDR
cause mortality among patients with sepsis, severe pathogens, and number of procedures performed
sepsis, and septic shock treated with appropriate were not significantly different between the survivors
initial antimicrobial therapy to more directly assess and nonsurvivors. Nonsurvivors had significantly
the impact of sepsis severity on outcome. Secondary longer ICU LOS. Time to antimicrobial therapy was
objective was to examine the impact of MDR on not significantly associated with outcome.
mortality in the same cohort.
The primary endpoint was all-cause 30-day mortality, Discussion
calculated from the time that a positive blood culture Authors found that sepsis severity predicted
was drawn. Secondary endpoints included length of mortality among patients receiving appropriate
hospital stay (LOS), length of ICU stay (ICU LOS), initial antimicrobial therapy. The presence of MDR
and the number of procedures performed. did not appear to influence outcome when the initial
Patients were required to have at least one of the therapy was appropriate for the causative pathogen.
following ICD-9 codes: 995.91 (sepsis), 995.92 Interestingly, although patients with septic shock had
(severe sepsis), 038 (septicemia), 790.7 (bacteremia a significantly shorter time to appropriate antibiotic
nosocomial), or 785.52 (septic shock). administration than patients with sepsis alone,
All patients had to receive appropriate initial but still had significantly higher mortality. These
antibiotic therapy, defined as antibiotics that had results suggest that appropriate antimicrobials are
in vitro activity against the cultured organism (and insufficient to completely overcome the systemic

JOURNAL SCAN Appropriate Choice and Timing of Antibiotics not enough for Good Outcomes in MDR Severe Sepsis
calamity associated with septic shock. However, antibiotic to a patient with leaky capillaries will result
appropriate therapy is still crucial, as suggested by the in a lower concentration of the antibiotic in the serum,
low overall mortality in this cohort (13.1%) compared particularly a lower maximal concentration (Cmax).
to studies with varying levels of appropriate empiric Studies have demonstrated an increased organ blood
antimicrobial therapy. flow early in sepsis2. Clinically this means in the
presence of normal renal function, an increased
Limitations of the study are: organ, namely renal blood flow, will translate into
an increased glomerular filtration rate and hence
1. Retrospective,
an increased creatinine clearance. This clinical
2. Single- center study,
phenomenon has now been termed augmented renal
3. Did not study outcomes in patients with Gram-
clearance (ARC). ARC will result in increased
positive infections or non-Enterobacteriaceae
clearance of all renally eliminated drugs. In four
Gram-negative infections. It is possible that there
multidisciplinary ICUs across the world, ARC
would be different results in these populations,
has now been documented in more than 60% of
4. Antimicrobial minimum inhibitory concentration
patient admitted with a “normal” serum creatinine
(MIC) data to determine if the administered
concentration3. This practical implication of ARC with
antibiotics were therapeutic at a given MIC was
standard dosing of antibiotics with renal clearances
not taken into account.
(ß- lactams, aminoglycosides, and glycopeptides) will
5. Assessment of differential outcomes based on
be that the resultant serum antibiotic concentration
specific pathogens could not be assessed due to
will be low, often subtherapeutic4.
the low frequency of infection with pathogens
other than E. coli and K. pneumoniae. On the basis of above principles it can be concluded
that in patients with septic shock we should consider
• Loading doses for increased Vd and
Comments
• Increased frequency of administration to
Thus this study shows that using the correct antibiotic, compensate for ARC.
that is, that appropriate for organism susceptibility,
plus correct timings of administration, is not enough These facts also provide a strong case for therapeutic
to ensure a good outcome. drug monitoring for not only preventing toxicity but
Study emphasises that factors beyond the correct also improving efficacy.
choice of antibiotic should be considered when
treating patients with sepsis, particularly those References
requiring intensive care supports. Increased 1. Burnham JP, Lane MA, Kollef MH. Impact of Sepsis
volume of distribution (Vd) of hydrophilic drugs Classification and Multidrug-Resistance Status on Outcome
Among Patients Treated With Appropriate Therapy. Crit Care
and hyperdynamic circulatory system associated
Med 2015; 43:1580-1586
with increased renal blood flow and elevated drug 2. Di Giantomasso D, May CN, Bellomo R.Vital organ blood
clearance are knownto alter antibiotic PK exposure flow during hyperdynamic sepsis.Chest 2003; 124: 1053-
and reduce antibiotic serum concentration. 1059
Patients with severe infections are often given large 3. Udy AA, Baptista JP, Lim NL, et al. augmented renal
clearance in the ICU : Results of a multicentre observational
amounts of fluids in the initial resuscitative phase study of renal function in critically ill patients with normal
of sepsis. Leaky capillaries and hypoproteinemia plasma creatinine concentrations. Crit Care Med 2014; 42:
predispose these patients to swelling with 520-527
extravascular fluid extravasation., This increase 4. Lipman J, Roberts J. Does appropriate antibiotic therapy
mean only adequate spectrum and timing. Crit Care Med
will produce a markedly large increase in Vd of
2015; 43: 1773-1774
hydrophilic antibiotics. Due to this increased Vd,
administering the same dose of an hydrophilic

JOURNAL SCAN Role of HFOV in PICU post OSSILATE and OSCAR trials
Role of HFOV in PICU Post OSSILATE and OSCAR Trials

Dr Krishan chugh
Despite limited clinical trial data1,2, HFOV is being which may represent an attempt to provide enhanced
used in children as a rescue mode of ventilation when lung protection with HFOV.
conventional lung protective ventilatory modalities The strengths of this study are that authors have
have failed3 . complete HFOV data on all patients included in the
It is believed that HFOV provides lung protective analysis. Furthermore, they have included both small
ventilation with lower peak-to-trough pressure and large centers from North America and Western
amplitudes while simultaneously preventing alveolar Europe and therefore believe that their data provide
collapse. a robust description of current practice. The major
A meta- analysis published in 2010 concluded that weakness is that this is a retrospective, questionnaire
HFOV may decrease mortality, in adults as well as study. Comparison data and criteria for changes from
children4. However, two recent trials of HFOV in CMV to HFOV are not available. They also did not
adults (OSCAR trial5 and OSCILLATE6 trial) showed collect hemodynamic data. In addition, there are more
no benefit. Indeed, OSCILLATE trial from Canada cases from North America than from Europe. This
showed higher mortality in HFOV group compared may potentially skew the study to better represent
to CMV group. North American practices.
In PICUs across the world HFOV continues to
be used, albeit somewhat differently. Unlike the References
OSCILLATE study group where HFOV was used in 1. Arnold JH, Hanson JH, Toro-Figuero LO, et al: Prospective,
early ARDS the general practice in PICUs is to use randomized comparison of high-frequency oscillatory
HFOV as a rescue therapy when the MAP and OI are ventilation and conventional mechanical ventilation in
very high. pediatric respiratory failure. Crit Care Med 1994; 22:1530–
1539
In a retrospective study reported recently7 three
2. Samransamruajkit R, Prapphal N, Deelodegenavong J, et al:
North American and four European centres were Plasma soluble intercellular adhesion molecule-1 (sICAM-1)
surveyed regarding HFOV practices. A total of 328 in pediatric ARDS during high frequency oscillatory
case report forms of children who were on HFOV in ventilation: A predictor of mortality. Asian Pac J Allergy
2009 and 2010 were studied. Results of this study are Immunol 2005; 23:181–188
3. Arnold JH, Anas NG, Luckett P, et al: High-frequency
discussed below. oscillatory ventilation in pediatric respiratory failure: A
In the Rettig paediatric study7 representative groups, multicenter experience. Crit Care Med 2000; 28:3913–3919
greater than 70% of patients had an OI greater than 4. Sud S, Sud M, Friedrich JO, et al: High frequency oscillation
16 preceding initiation of HFOV, with the majority in patients with acute lung injury and acute respiratory
distress syndrome (ARDS): Systematic review and meta-
(> 60%) having an OI greater than 24. This implies
analysis. BMJ 2010; 340:c2327
that in current paediatric practice, HFOV is still being 5. Young D, Lamb SE, Shah S, et al; OSCAR Study Group:
used as a rescue strategy and not as a primary mode High-frequency oscillation for acute respiratory distress
of ventilatory support. Therefore, the OSCILLATE syndrome. N Engl J Med 2013; 368:806–813
data, which focuses on primary application of HFOV 6. Ferguson ND, Cook DJ, Guyatt GH, et al; OSCILLATE
Trial Investigators; Canadian Critical Care Trials Group:
in adults, may not be applicable to current paediatric High-frequency oscillation in early acute respiratory distress
practice. syndrome. N Engl J Med 2013; 368:795–805
Data of this study demonstrate that canters in North 7. Rettig JS, Smallwood CD, Walsh BK, et al. High-Frequency
America and Western Europe are using higher Hertz, Oscillatory Ventilation in Pediatric Acute Lung Injury: A
Multicenter International Experience. Crit Care Med2015;
higher delta P strategies compared to a decade back,
XX:00–00)

Low T V For Non-ARDS Also
Dr Krishan chugh
Background analysis; the main features of which are summarised

Protective mechanical ventilation with low tidal below.
volumes is standard of care for patients with acute
respiratory distress syndrome (ARDS). Would this Materials and Methods
strategy prove beneficial in non ARDs also is a In the present study authors performed an individual
question that has not been adequately answered yet. patient data meta-analysis to study the following
outcomes:
Pros and Cons of Low Tidal Volumes Primary Outcome
Ventilation with low tidal volume causes less The primary outcome was a composite of occurrence
mechanical stress on the alveolar membrane because of ARDS or pneumonia, the two most important
it prevents alveolar over distention and improves pulmonary complications in intubated and ventilated
alveolar stability. It causes less ventilator induced critically ill patients. Authors combined pneumonia
lung injury and is recognised as an important part of and ARDS into a single primary endpoint because in
lung protective strategy On the other hand, use of low the absence of specific diagnostic tools, for example,
tidal volumes could theoretically increase the feeling bronchoalveolar lavage fluid testing, ARDS can be
of dyspnea mandating more sedation. However, mistakenly diagnosed as pneumonia. Furthermore, both
this was neither found in patients with ARDS nor entities may be influenced by mechanical ventilation.
in patients without ARDS. It is also argued that the
use of higher respiratory rates, as a compensation Secondary Outcomes
for the lower tidal volumes, could cause respiratory Secondary outcomes included: 1) duration of stay
muscle fatigue. If true, these both could clearly offset in ICU and hospital, using the number of ICU –
the benefits of ventilation with low tidal volumes ,at free days and alive and hospital free days and
least in patients without ARDS. It is also argued that alive at day 28. 2) in hospital mortality, defined as
use of low tidal volumes may not be necessary in death at any time during hospital stay, 3)incidence
patients without ARDS since they do not have the rate of pulmonary complications and 4)attributable
widespread pulmonary changes including atelectasis mortality of pulmonary complications, calculated by
as observed in patients with ARDS and therefore are subtracting the in-hospital mortality rate of patients
not at risk for ventilator –associated lung injury. Use without pulmonary complications from the in hospital
of lower tidal volumes could even induce or promote mortality of patients with pulmonary complications.
development of more atelectasis, increasing the risk
of hypoxemia and hypercapnia. Hypothesis
Earlier an individual patient data analysis of all Authors hypothesized that the occurrence of pulmonary
available observational studies and RCTs1 has been complications depends on tidal volume size in ICU
published. This analysis suggested benefit of low patients without ARDS at the onset ventilation.
tidal ventilation strategy, as use of low tidal volumes
was associated with a shorter duration of ventilation.
However the authors did not evaluate whether the use Results
of tidal volumes is associated with the occurrence of Three RCTs and four observational studies were
pulmonary complication, and if so how this could included in this analysis. (N=2184) (Table). Based
affect outcome. Serpa Neto et al2 conducted another on the tertiles of tidal volume size in the first 2days

JOURNAL SCAN Low T V For Non-ARDS Also
Table: comparison of pulmonary complications rate and in-hospital mortality in the three groups
Variables Less than or Greater than 7 and less Greater than Adjusted P Adjusted Or P
equal to 7ml/ than 10 mL/kg PBW or equal to 10 OR(Low Vs (Intermediary VS
kg PBW mL//kg PBW High)(95%CI) High ) (95%CI)
Pulmonary 166(23) 21(28) 220(31) 0.72(0.52-0.98) 0.042 0.93(0.69-1.24) 0.635
complications
Acute 86(12) 121(16) 163(23) 0.48(0.32-0.71) <0.01 0.73(0.52-1.03) 0.074
respiratory
distress
syndrome
Pneumonia 122(17) 158(21) 106(15) 1.47(0.89-2.21) 0.093 1.27(0.86-1.86) 0.223
In – hospital 245(34) 279(37) 270(38) 0.82(0.65-1.02) 0.081 0.90(0.73-1.10) 0.319
mortality
of ventilation , patients were assigned to a “ low tidal have been differential misclassification which may
volume group ”(tidal volumes <_7mL/kg predicted vary among the RCTs and observational studies.
body weight) an “intermediate tidal volumes group Furthermore, patients from studies were not equally
”(>7 and <10mL/kg predicted body weight ), and a distributed between the three tidal volumes groups.
“ high tidal volume group ”(_> 10mL/kg predicted Fourth, despite the fact that author included patients
body weight and the groups compared. without ARDS in the cohort, they found a low PaO2/
FIO2 in this group of patients also. However, it
Strenghts should be emphasized that the diagnosis of ARDS
is based on several criteria and not only on PaO2/
The major strengths of the present analysis are the
FIO2. Indeed, patients could have low PaO2/ FIO2
large sample size, the appropriate statistical analyses
but no infiltrates in the chest radiographs or a
performed, and the inclusion of several patients
pulmonary edema may have been fully explained by
from diverse study types from different parts of the
cardiogenic problems. Fifth, despite the fact that the
world. Study estimated the mortality attributable
calculation of predicted body weight was the same
to pulmonary complications and its relationship
in all studies, no study described how the height was
with tidal volume used the first days of mechanical
assessed. Finally, it is important to keep in mind that
ventilation.
93% patients included in the analysis came from
observational studies, which may have introduced
Limitations bias due to a more heterogeneous population.
Although this study analysis shows a clear statistical Although comparison between the low and
difference between use of low and high tidal intermediate tidal volume groups did not achieve
volumes with respect to occurrence of pulmonary statistical significance, the 8% lower risk of
complication, the difference found between low and complications in the low tidal volume group appears
intermediate tidal volumes did not reach statistical to support a dose –response relationship between
significance. Second, there is no information about tidal volume and the pulmonary complications. By
some important risk factors that could also contribute performing an individual patient data meta –analysis,
to development of pulmonary complications, the authors were able to standardize the analysis of
including fluid overload, transfusion of blood data obtained from multiple studies, which is an
products etc. Third, since the diagnosis of ARDS important strength of this study.
and pneumonia was based on subjective criteria,
misclassifications of patients might underestimate Final Answer
the observed effect, but this factor should be equally
Well- powered RCT comparing ventilation with lower
affected the different groups. However, there could
tidal volumes with traditionally sized tidal volume in

JOURNAL SCAN Low T V For Non-ARDS Also
non-ARDS patient should provide the answer. Two tidal volume of 6mL/kg PBW and other patients
randomized controlled trials are currently enrolling ,excepting those with contraindications to lower tidal
patients and may provide additional evidence volumes, receive tidal volumes of less than 8 mL/kg
to inform the most appropriate tidal volume for PBW.
critically ill patients without ARDS. The ‘Preventive
strategies in acute respiratory distress syndrome References
trial’ is a multicentre randomized controlled trial 1. Serpa Neto A, Cadoso SO, Manetta et al. Association
comparing low tidal volume ventilation (4-6mL/kg betweenuse of lung protective ventilation with lower tidal
PBW) with high tidal volume ventilation (8-10mL/ volumes and clinical outcomesamong patients without acute
kg PBW) in patients at a risk for ARDS3. The primary respiratory distress syndrome: A meta analysis. JAMA 2012;
308: 1651-1659
outcome of this study is the development of ARDS
2. Serpa Neto A, Simonis FD, Barba CSV et al. Lung protective
during the first 7 days of mechanical ventilation. The ventilation with low tidal volumes and the occurrence
‘Protective Ventilation in patients without ARDS at of pulmonary complications in patients without acute
start of ventilation trial’ is a multicenter randomized respiratory distress syndrome: A systematic review and
controlled trial comparing low tidal volume individual patient data analysis. Crit Care Med 2015; 43:
2155-2163
ventilation (4-6mL/kg PBW ) with high tidal volume 3. Tauli CP Preventive Strategies in Acute Respiratory Distress
ventilation (8-10mL/kg PBW) in patients without Syndrome (ARDS) (EPALI). 2014 Available at: https://
ARDS who are anticipated to require mechanical clinicaltrials.gov/ct2/show/NCT02070666. Accessed June
ventilation for more than 24 hours4.The primary 12, 2015
4. Simonis FD, Binnekade JM, Braber A, et al. PReVENT—
endpoint is the number of ventilator –free days and
Protective ventilation in patients without ARDS at start of
alive at a day 28. These studies are estimated to ventilation: Study protocol for a randomized controlled trial.
complete enrolment in 2016 and 2017, respectively. Trials. 2015;16:226
Taking this Serpa Neto study and the other current 5. Ogbu OC, Martin GS, Murphy DJ. A few millilitres of
evidence into consideration, Ogbu et al5 recommend prevention: Lung protective ventilation decreases pulmonary
complications. Crit Care Med 2015; 43: 2263-2064
that mechanically ventilated ARDS patients receive

Case Report
Post ECMO Cortical Microbleed with
Good Neurological Outcome: A case report
Ohri A*, Maniya N*, Singh MP*, Sharma R**, Chawla A**, Khilnani P***
*Fellow PICU, **Consultant PICU, ***Director PICU,
ABSTRACT
Extracorporeal membrane oxygenation (ECMO) is used to support patients of all ages with acutesevere
respiratory failure which does not respond to conventional treatments. Over the years its use in older
children and adults is increasing.
We hereby report a case of 3 and a half year old girl child with primary acute respiratory distress syndrome.
She did not respond to conventional ventilation and rescue therapy underwent Venovenous (V-V) ECMO.
Post ECMO she had poor neurological status with cortical microbleeds in MRI, however she had complete
neurological recovery in due course of time.
Neurological injuries are feared complications of ECMO that result in increased patient morbidity and risk
of death. The incidence of neurological complications related to ECMO in neonates and children has been
reported to be between 9.9% and 17.3%.
Key words: Outcome, Pediatrics, ECMO, neurological complications, cerebral, microbleed
Introduction treatment and presented in our emergency department

Supportive management with mechanical ventilation with severe respiratory distress.
is the mainstay in the management of pediatric ARDS At the time of admission the child was drowsy febrile
but it also leads to further lung tissue damage due to with tachycardia, tachypnea, oxygen saturation of
overdistention, cyclic opening and closing of alveoli. 70% on free flow oxygen by oronasal mask. Child
Although this can be minimized with protective hadnasal flaring, grunting and retraction (Intercostal
ventilation techniques but in ARDS these thresholds and subcostal) and bilateral crepts on auscultation.
are often surpassed in order to maintain adequate There was no heart murmur or gallop. Abdomen was
oxygenation and ventilation. This is when ECMO soft without any hepatosplenomegaly.
is helpful in pediatric ARDS by giving the much
wanted rest to the injured lung. The key to successful
survival is implementation of ECMO early before
irreversible organ injury develops secondary to
persistent hypoxemia, unless support with ECMO is
used as a bridge to transplant.
Case History
A 3 year old female child was admitted with the
chief complaints of fever with signs and symptoms
of upper respiratory infectionfor 4 days, difficulty in
breathing for 2 days. Child worsened on the medical Figure 1: Chest X ray just before ECMO initiation
Correspondence Provisional diagnosis of acute respiratory distress

Dr Rachna Sharma syndrome was made, immediately child was
Consultant PICU intubated started on mechanical ventilation. Due
Email: rachna9us@gmail.com to severe hypoxemia despite 100 percent oxygen

CASE REPORTS Post ECMO Cortical Microbleed with Good Neurological Outcome: A case report
and adequate chest rise with PEEP of 8 cm of H2O on mechanical ventilation even after coming off
with titration she continued to have high ventilator ECMO (chest x ray shown in Figure 3 and Figure
requirement (PIP- 35, fio2 100%, PEEP 14) 4) . Child was successfully weaned from ECMO
after 10 days of initiation. Mechanical ventilator
Chest skiagram showed bilateral fluffy shadows support was continued for another 4 days.Child had
more prominent on the left side (Figure 1). Other poor neurological status. She had hypotonia, no
Investigations were normal counts, with normal appropriate response, no eye contact, no cry or smile,
CRP, with sterile cultures. menace sign negative but the pupils were normal size
Child remained stable on conventional ventilation and were reacting normally to light. Child also had
in initial 24 hrs and Fio2 was titrated to 50%with a temporary autism evident clinically. MRI brain was
PEEP of 12 and plateau pressures of 28, MAP-18. done which revealed multiple cortical micro bleeds in
Pao2/Fio2 ratio was 150. bilateral internal capsule, in the corpus callosum ,in
On day 2 child deteriorated ,became hemodynamically bilateral supra and infra tentorial brain parenchyma
unstable, Pao2/Fio2 ratio- 85. Chest skiagram predominantly involving the white matter.
showed further worsening (Figure 2). Child showed
no response to rescue therapy including recruitment
maneuvers and prone positioning.
Figure 3: Chest X ray off ECMO
Figure 2: Chest X ray on ECMO
Oxygenation index was more than 56. Pao2/fio2 ratio

has worsened to 65. At this point after discussing
with parents a decision to initiate Veno-venous(V-V)
ECMO was taken. A 16 Fr return cannula was inserted
percutaneously in to right internal jugular vein and 14
Fr drainage cannula was inserted in the left femoral
vein, however the outflow was poor (300-400ml) so
one more drainage cannula was put in the right femoral Figure 4: Chest Xray one day before discharge
vein by cut open technique. Subsequently flows
Pediatric neurology subspecialist was consulted
increased to 1litre and So2 achieved around 80%.
and he reported overall low sensorium without
Child became hemodynamically stable on V-V
any focal deficit but a potential for recovery over
ECMO. The complication faced during the V-V
time. Child had no seizures and had a normal
ECMO were hypertension, small oro-nasal mucosal
EEG. Pediatric ophthalmologist was consulted and
bleeds and feeding intolerance which were managed
reported normal fundus examination. A goggle VEP
conservatively. Child continued to require high flows
was done and was negative. Child was started on
on ECMO to maintain saturations above 80.
rehabilitation therapy including occupational therapy
On day 7 of ECMO elective tracheostomy was
and nutritional rehabilitation. As the days passed
done in view of anticipated prolonged course
child showed gradual neurological improvement.

CASE REPORTS Post ECMO Cortical Microbleed with Good Neurological Outcome: A case report
Tracheal decannulation was done on day 28 of investigations are limited to cranial ultrasound and
admission. Child was discharged home on day 45 Doppler at the bed side due to transport difficulties
after admission. On subsequent follow up child had in transporting the ECMO patient to CTscanner
complete neurological recovery. or MRI, unless a portable CT scanner is available.
Recently portable CT scanner has become available
Discussion in few countries.
ECMO is now widely used in pediatric patient
population if they don’t respond to conventional Conclusion
ventilation. Various studies have shown that the overall Neurological sequalae of ECMO can occur but
survival rate of patients on ECMO is 56%. Among close followup of neurological status while on
pediatric patients treated with ECMO mortality varies ECMO is important to detect these complications
by pulmonary diagnosis, underlying condition, other early. Management for those complications remains
non-pulmonary organ dysfunction as well as patient supportive.
age, but has remained relatively unchanged overall
(56%) over the past several decades. Additional risk References
factors associated with death include prolonged use of 1. David S Liebeskind, Nerses Sanossian, Monica L Sapo et
mechanical ventilation (>2 wk) prior to ECMO, use al:Cerebral microbleeds after use of extracorporeal membrane
of VA ECMO, older patient age, prolonged ECMO oxygenation in children: J Neuroimaging Jan 2013
support as well as complications during ECMO. 2. Deena M Nasr, Alejandro A Rabinstein: Neurological
complications of extracorporeal membrane oxygenation: J
Neurological complications occur in the range of 9.7%- Clinical neurology 2015
17.3%. Cerebral microbleeds (CMB) may be seen in 3. Zabrocki LA, Brogan TV, Statler KD, et al: Extracorporeal
children receiving ECMO. The etiology is unknown membrane oxygenation for pediatric respiratory failure:
with many studies suggesting micro air embolism as Survival and predictors of mortality. Crit Care Med 2011; 39
the possible culprit, other causes may be microvascular 4. Neurological complications of extracorporeal membrane
trauma, hypoperfusion or simply focal hemorrhages. In oxygenation in children. Shawn L Harvey-Jumper, Gail M
Annich, Andrea R Yancon et al:J Neurosurg pediatric 7: 338-
a 12 patient case review the CMB were most commonly 344, 2011
situated at the border zone within the right internal 5. Nobuyunki N, Ichiba S, Tsukahara K et al: Acute respiratory
carotid artery distribution. This spatial distribution distress syndrome in a child with severe epileptic disorder
potentially implicates embolic phenomena via the treated successfully by ECMO, a case report:BMC pediatric
recipient site of venoarterial bypass into the right 2015 April1;15:20
common carotid artery used in all their cases. 6. Orr RA, Dalton HJ. Extracorporeal membrane
oxygenation and right sided brain lesions. Pediatrics.
CMB may not lead to any change in ECMO techniques 1989;83:635-636[PubMed]
for cardiopulmonary or respiratory support but such 7. Taylor GA, Fitz CR, Miller MK et al. Intracranial
injuries may impair cognitive function and may alter abnormalities in infants treated with extracorporeal
the long term outcome of the patient. membrane oxygenation: imaging with US and CT, Radiology,
In our case child had multiple cerebral micro bleeds 1987;165:[PubMed 3317499]
but no other changes in the MRI to suggest hypoxia 8. Lago P, Rebsamen S, Clancy RR, et al. MRI, MRA and
neurodevelopmental outcome following neonatal ECMO.
or ischemia. The final neurological outcome was Pediatric Neurology, 1995;12:294-304[PubMed7546003]
good and child had complete neurological recovery. 9. Mendoza JC, Shearer LL, Cook LN, Lateralization
ECMO provides critical life support for infants and of brainlesions following extracorporeal membrane
children with cardiac and respiratory failure, but oxygenation. Pediatric, 1991;88[PubMed1945603]
neurological complications are common and major 10. Schumaker RE, Barks JD, Johnston MV, et al. Right-sided brain
intraparenchymal cerebral bleeds have been described brain lesions in infants following extracorporeal membrane
oxygenation. Pediatrics. 1988;82:[PubMed 3399288]
as the end point for ECMO continuation. While on 11. Wiznitzer M, Masaryk TJ, Lewin J, et al. Parenchymal and
ECMO it is recommended to do close neurological vascular magnetic resonance imaging of the brain after
followup regarding sensorium, pupillary size and extracorporeal membrane oxygenation. Am J Dis Child.
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tone and portable EEG. Unfortunately radiological

NCPCC 2015: Oral Papers
[Award Paper: First Position] A Comparative Study
Effect of Chlorhexidine Mouth Cleanser of per Cutaneously Placed Tenckhoff
and Head End Elevation on the Incidence Catheter Versus Rigid Catheter for
of Ventilator Associated Pneumonia - A Acute Peritoneal Dialysis in Children
one year randomised controlled trial Anand K, Mangla A, Poudel DR, Pruthi PK
Andleeb M*, Bellad RM**, Nagaprateek* Division of Pediatric Nephrology, Institute of Child Health,
*Post Graduate,**Professor, KlE Universiti’s, Department of Sir Ganga Ram Hospital, New Delhi
Pediatrics, Jawaharlal Nehru Medical College, Belgaum
Background: Peritoneal dialysis(PD) is most common form of
Background and Objectives: Ventilator associated pneumonia renal replacement therapy in children in developing world.Most
(VAP) represents the second most common Nosocomial infection commonly used catheters for performing acute PD are tenckhoff-
in the pediatric intensive care. In view of the high frequency, catheter(TC) and rigid-catheter(RC). As per literature search no
associated morbidity and mortality, prevention of VAP is the Indian study has been performed to compare PD characteristics
need of the hour. Different VAP prevention strategies have been of these two catheters.
studied worldwide mainly in adults which have been shown to Objective: To study the indications, complications and outcomes
be beneficial. There is not much evidence to demonstrate the of percutaneously inserted tenckhoff versus rigid PD catheter.
efficacy of same interventions in Pediatric ICUs especially in
Methods: In this retrospective descriptive study, data was
developing countries like India. Therefore the present study was
collected from records of all children under 18years who
planned to test the hypothesis that oral decontamination with
underwent acute PD using either percutaneously placed TC
CHX mouth cleanser and semi recumbent position could reduce
or RC between Jan-2013 to December-2014 at Sir GangaRam
the incidence of VAP in our PICU.
Hospital.
Methodology: The present study was conducted among children
Results: Acute PD was performed in 124 patients out of
admitted in the Pediatric Intensive Care Unit (PICU) of KLES
which RC was inserted in 74(59.6%) while TC in 50(40.4%)
Dr. Prabhakar Kore Hospital and Medical Research Centre,
children with age ranging from 1day-13years in TC-group and
Belgaum. All the patients ventilated for > 6 hrs were enrolled and
7days-14years in RC-group. Mean duration of use of RC and
randomized according to a cAomputerized randomized table into
TC was 4.95±2.5 1days and 7.32±6. 1days respectively. Most
Group A, who received conventional care, Group B and Group C
common indication in both groups was acute kidney injury.
who received the intervention chlorhexidine mouth Cleanser and
Other indications were fluid overload, dyselectrolytemia and
head end elevation along with the conventional care respectively.
persistent-metabolic-acidosis. Primary underlying disease in
Results: Out of the 135 patients enrolled 20 patients developed RC-group was sepsis(73%) while in TC-group was congenital
VAP with an incidence of 20%. VAP rate was 51.5 cases for heart-disease and dysplastic kidneys-(30% each). Most common
1000 ventilation days. Incidence of VAP was significantly lesser complication in both groups was intra-peritoneal bleeding
in CHX Group B when compared with conventional Group A, during catheter-insertion(RC-8/74 vs TC-11/50;p=0.08),
with an absolute risk reduction of 22.3%. Statistically significant followed-by pericatheter fluid-leakage(RC-12/74 vs TC-
difference was observed with respect to mortality with Group A 9/50;p=0.79), blockage(RC-18/74 vs TC-5/50;p=0.04) and
and Group B with a higher mortality in Group A. Also, mortality displacement(RC-1/74 vs TC-6/50;p=0.01).Peritonitis was seen
was significantly higher with Conventional Group A than in 10(13%) cases of RC-group compared to 8(16%)cases in TC-
interventional Groups B and survival On multivariate analysis, group(p=0.69). PD outcome was successful in 88% cases in TC-
male gender, Reintubation, Sedation and Altered sensorium were group and 81% in RC-group.
found to be statistically significant. Patients ventilated for > 96
Conclusion: The clinical outcomes of RC and TC are comparable
hours had 3.75 times higher risk for development of VAP when
if a meticulous preselection of the cases is done. In conditions
compared with patients ventilated for < 96 hours. (RR: 3.75, P
warranting long term dialysis TC may be preferred while RC is
= 0.0050)
cost effective and equally efficacious for indications requiring
Conclusion: Our study demonstrates the interventions like short term dialysis.
Chlorhexidine mouth cleansing and head end elevation definitely
shows benefit in reducing the incidence of VAP, especially
with the use of Chlorhexidine mouth cleanser. The secondary
outcome was better with the use of Chlorhexidine mouth wash
demonstrating a significant reduction in the mortality.

Predicting the Length of Mechanical Method: This prospective longitudinal study was done at
PICU, Nirmal Hospital Private Limited, Gujarat. A total of 30
Ventilation for Children with Landry children fulfilling sepsis criteria from June 2013 to May 2014
Guillain Barre Syndrome Admitted to were included in the study. Lactate levels were drawn and lactate
the Pediatric Intensive Care Unit of a clearance was determined at six and twenty four hours after
admission.
Resource-Limited Setting: A five-year
experience-based analysis Results: Boys constituted 53.33% of the study population,
common age group was upto two years (60%) and the mean
Bal Mukund, Saptharishi L G, Bansal A*, age of the study population was 4.3 ± 4.82 years. The source of
Suresh Kumar, Jayashree M, Singhi S sepsis was pulmonary in 26.67% of the children. Blood culture
*Additional Professor, Division of Pediatric Critical Care, was positive in 46.67% and CONS was the commonest organism
Advanced Pediatrics Center, PGIMER, Chandigarh isolated (28.57%). 70% of the children improved and mortality
*M: +919815455002; Email: drarunbansal@gmail.com
was noted in 30%. Sensitivity of lactate clearance in predicting
better outcome at six and twenty four hours after admission was
Background: Children with acute neuromuscular paralysis
found to be 88.89%.
secondary to Landry-Guillain Barre Syndrome (LGBS) require
prolonged mechanical ventilation (MV). Little is known about Discussion & Conclusion: High lactate levels and decreased
the predictors of long term ventilation in these children. lactate clearance (<10%) were associated with poor outcome
where as higher lactate clearance (>10%) predicts better outcome.
Methods: Retrospective review of all children with LGBS,
1-12 years of age, admitted in PICU from 2010-2014 was done. Type of study: Prospective longitudinal study
Data was entered into a pre-designed proforma which included
demographic details, history, clinical and ventilation details.
Univariate analysis was done using Chi-square and students’
Study of Acute Kidney Injury in Children
t test. Multivariate logistic regression was used to identify Admitted to Intensive Care Unit and the
predictors of MV for >2 and >4. Factors Predicting their Outcome -
Results: Out of 93 children with LGBS, 38 were ventilated. The A prospective observational study
mean (± SD) age was 73.9 (± 37.0) months and median [IQR] Kamalakshi G Bhat, Ashok Raju A,
PRISM III score of 13 [10, 16]. Thirty one (81.6%) and 18 (47.4%)
Jayashree K, Baliga B S
children required MV > 2 and 4 weeks respectively. Presence
Department of Pediatrics, Kasturba Medical College, Mangalore,
of cranial nerve palsy, autonomic instability, hypertension,
Manipal University
respiratory-muscle weakness, hyponatremia and upper limb
power <3/5 at admission were predictors on univariate analysis. Background: Acute kidney injury is a common complication
On multivariate logistic regression, upper limb power <3/5 associated with an increase in mortality in children admitted to
[OR=4.84;CI:1.08-21.65;p=0.039] and presence of respiratory PICU.
muscle weakness [OR=84.39;CI:9.63-739.75;p<0.001]
independently predicted need of MV for > 2 weeks. Upper limb The objective of this study was to determine the incidence of
power ≤ 2/5 at admission, independently predicted the need of acute kidney injury and identify risk factors for mortality in
MV for >4 weeks [RR= 8.57;CI:1.44-50.9;p=0.018]. critically ill patients hospitalized in our facility.
Conclusions: Respiratory-muscle weakness and upper-limb Methodology: In this prospective observational study from
power <3/5 at admission independently predicted the need of October 2013 to September 2014, 302 children admitted to the
MV for > 2 weeks at admission and upper limb power ≤ 2/5 alone PICU were screened for AKI, defined according to the AKI
reliably predicted for need of MV for > 4weeks. Network criteria. The patients with AKI were followed-up
until discharge/death. Their clinical and biochemical data were
recorded.
A Prospective Study of Serum Lactate Results: The incidence of AKI among 302 patients screened
Clearance Levels as the Predictor of was 12.6% (38). Most common diagnosis at admission were
Outcome in Pediatric Septic Shock neurological diseases (19.2%), followed by pneumonia (17.5%),
during the First 24 Hours in PICU infectious diseases (9.6%) and reactive airway disease (9.27%).
Inotropes were used in 52.6% (20) and diuretics in 23% (9) of
Darshak Makadia, Deepa Desai, Jignesh Patel, children with AKI. 13.5% (5) required renal replacement. 20
Jigesh Vaidya, Nirmal Choraria children (52.6%) suffered mortality during the hospital stay.17
cases were discharged with complete reversal of AKI and
Background: Early recognition and aggressive management one case with Hemolytic uremic syndrome was discharged as
has crucial role in the treatment of pediatric septic shock. The chronic kidney disease. On multivariate analysis there was 100%
present study was undertaken to determine the role of early mortality in children requiring mechanical ventilation and renal
lactate clearance in survival of PICU patients with severe sepsis. replacement therapy.

Conclusions: The incidence of acute kidney injury was 12.6% Outcome Prediction by Serial Lactate
and the need for renal replacement therapy and mechanical
ventilation were found to be independent risk factors for
Levels in Critically Ill Children
mortality. with Septic Shock and Multi Organ
Dysfunction Syndrome
Does the Heated Humidified High Flow Krishna Mohan Gulla, Anil Sachdev, Dhiren Gupta,
Nasal Cannula (HHHFNC) Oxygen Neeraj Gupta, Suresh Gupta
Division of Pediatric Emergency & Critical Care,
Therapy Perform as Equally Effective Sir Ganga Ram Hospital, New Delhi
Respiratory Support in under-5
Children with Severe Pneumonia While Background: Serum lactate elevation is an important marker
of impaired tissue perfusion. Studies had shown that serial
Comparing Those With Bronchiolitis? measurements of lactate have potential prognostic value during
- A retrospective observational study sepsis management. However, it’s not being rigorously evaluated
Reshma A, Sasidaran K, Surender S Sheeja S, in critically ill children with septic shock.
Shirley F, Thangavelu S, Nedunchelian K Aims and Objectives: To correlate serially measured serum
Mehta Hospital, Chennai lactate levels with outcome in children having Septic Shock with
Multi Organ Dysfunction Syndrome (MODS).
Objective: To compare the clinical effectiveness of humidified
high flow nasal cannula (HHNFC) oxygen therapy in under five Materials and Methods: Children having Septic Shock with
children with clinical diagnosis of severe pneumonia with those MODS admitted to a multidisciplinary, tertiary care, 12 bed
of bronchiolitis requiring oxygen therapy PICU were enrolled over 1 year period. Serum lactate values
were measured at admission to ICU and 6 hourly for initial
Methodology: It is a retrospective observational study. We 24 hours and then 12 hourly till 120 hours of stay. Once daily
enrolled under five children who have received HHFNC with Vasoactive Inotropic Score (VIS) and Paediatric Logistic Organ
the clinical diagnosis of either bronchiolitis or severe pneumonia Dysfunction score (PELODS) were measured.
between January 2014 and December 2014. We performed
an inter-group comparison of the proven surrogate outcome Results: 42 patients were enrolled (male-29). 25 patients
measures like duration of oxygen therapy, duration of HHFNC survived (59.5%). median age and weight of survivors is
therapy, duration of PICU stay, duration of hospital stay. 11months(4-84), 8kg(4.7-18.5) respectively. 35(83.3%) cases
Definitive outcome measure, incidence of intubation was also required mechanical ventilation within 24 hours of ICU arrival.
compared between the two groups. Median PRISM-24hours among survivors and non survivors
16 (12-21) and 19(10-27) respectively (p=0.417). Median
Results and Discussion: Data retrieved from hospital electronic ventilation hours in survivors is 150 (150-240) (p=0.00). Median
database and pediatric critical care case records by retrospective ICU stay (in days) among survivors was 13(7.5-18) whereas
review. Of 113 children fulfilled the enrolment criteria, 50 had in non-survivors 3(2.5-4.5). Statistically significant correlation
bronchiolitis and 63 had severe pneumonia by clinical criteria. was present between lactate levels and PELODS score among
Baseline characteristics like sex distribution and day of illness on survivors(r=0.922). Mean lactate levels at 0 hours of admission
which hospitalized were comparable among the study groups (p to PICU among survivors and non survivors were 1.74±1.15 and
0.95; p 0.12). Age distribution was significantly different (0.003) 2.98±2.83 respectively (p=0.05). Lactate clearance of 50% at 6
as anticipated because the severe pneumonia had significantly hours of admission level predicted the probability of survival by
higher mean age. While comparing the surrogate outcome 63.6%. Lactate level >1.5mmol/L at 6 hours of ICU stay predicted
measures of duration of oxygen therapy, duration of HHFNC, death with sensitivity of 73.3% and specificity of 42.3%
duration of PICU stay, there was no significant difference
observed between the groups. Number of intubation events was Conclusion: Targeting serum lactate levels <1.5mmol/L at 6
comparable in both groups, though the events were minimal in hours and 50% lactate clearance at 6 hours of ICU admission
both groups. may provide outcome benefit. However, multicentre trials are
required to show the benefit of lowering conventional target
Conclusion: HHFNC serves as an equally effective respiratory lactate (i.e,< 2mmol/L) on outcome benefit.
support therapy in children with severe pneumonia requiring
oxygen therapy while comparing those with bronchiolitis.
Complications such as empyema, progressive MODS, co-
infections may worsen the respiratory status to mandate
intubation in case of community acquired pneumonia.

A prospective interventional study to was deduced at 72 hours post admission. The sensitivity of RAI
to predict AKI was determined by ROC curve analysis
determine the effect of chlorhexidine
wipes in reducing the incidence of Results: Twenty five children were included in the study. RAI
on Day 1 had sensitivity of 100% and specificity of 66% in
hospital acquired infections among predicting AKI on Day 3 (95% CI 0.75-0.99). Compared to
critically ill children admitted to a this, admission serum creatinine had a sensitivity of 70% and
Paediatric Intensive Care Unit specificity of 46% (95% CI 0.26-0.74). Positive Predictive Value
[66% vs 46%] and Negative Predictive Value [100% vs 70%]
Madhan Kumar, Jolly Chandran, Ebor Jacob for predicting AKI on day 3 were both higher for RAI compared
Gnananayagam, Manivachagan MN, Pragathesh, with admission Creatinine
Hema Paul, Kala Ebenezer
Discussion: Critically ill children do not have clearly identifiable
PICU and HICC, CMCH, Vellore – 632004, India.
risk factors for AKI. The aim of our study was to validate RAI
Objective: To determine the effect of chlorhexidine wipes as a predictor of AKI in critically ill children in our PICU. We
in reducing the incidence of HAI among critically ill children found the results to be similar to the original study of Basu et.al.
admitted in PICU. Conclusion: RAI is a sensitive early predictor of AKI in critically
Methods: This interventional study was done in PICU of ill children and may be better than serum Creatinine.
CMCH, Vellore. In this study all enrolled children were given Type of study: Prospective Observational study
chlorhexidine wipe after routine soap bath. The incidence and
prevalence of HAIs were observed and compared with historic
controls (Same period of the previous year). A Randomized Controlled Trial of One
Results: In the intervention group the total number of ventilator Bag Vs Two Bag System of Fluid Delivery
and line- days was 777 and 1377 respectively. The incidence in Children with Diabetic Ketoacidosis
of VAP was 6.43/1000 ventilated -days with a prevalence of - A pilot study
2.5% and the incidence of CRBSI was 3.6/1000 line- days with
Dhochak N, Jayashree M, Singhi S
prevalence of 2.5%.
Pediatric Critical Care Unit, Advanced Pediatrics Centre,
In the pre- intervention period group, the number of ventilated PGIMER, Chandigarh
-days was 696 and catheter- days was 1432. The incidence of
VAP was 12.93/1000 ventilated days with prevalence of 3.2% and Rationale: Two bag system of fluid delivery in diabetic
the incidence of CRBSI was 4.2/1000 days with a prevalence of ketoacidosis (DKA) enables better titration of dextrose
2.2% with a significant p value (<0.001) in VAP. The organisms concentrations during insulin therapy. This obviates need for
were similar in both the groups. frequent fluid changes translating into reduced response time and
cost; both aspects advantageous for resource limited set-ups. As
Conclusion: The use of chlorhexidine wipes in ICU significantly
very few pediatric studies have addressed clinical outcomes of
reduced VAP among the children admitted to the PICU with non
one vs two bag system, we compared both with respect to blood
significant reduction in the CRBSI.
glucose variability (BGV), time for resolution of acidosis and
incidence of hypoglycemia and hypokalemia
Validation of Renal Angina Index (RAI) Methods: In an open label randomized controlled trial in
as a predictor of Acute Kidney Injury emergency and intensive care units of a tertiary care hospital
(AKI) in Critically Ill Children in North India, 30 consecutive DKA between July 1, 2013 to
September 30, 2014 were randomized to either one (n=15) or
Mohideen M, Khan Bilal, Ravikumar K, two bag (n=15) groups. Primary outcome was BGV measured
Prabhudesai Sumant, Sairam VK, Ramachandran B as standard deviation of BG measurements, median absolute
Departments of Pediatric Intensive Care and Pediatric change and number of undesirable events (hourly BG change
Nephrology, Kanchi Kamakoti CHILDS Trust Hospital, Chennai of > 50 mg/dl) after addition of dextrose. Hypoglycemia (BG
<50mg/dl), hypokalemia and time taken to resolution of acidosis
Background: Rising serum creatinine and decreasing urine
were secondary outcomes.
output are late markers of Acute Kidney Injury (AKI) in children.
Markers that predict kidney damage early can help in optimizing Results: The median hourly absolute BG change (mg/dl)
treatment. was higher but insignificant in one as compared to two bag
system[44(30-74.5) and 36(31-49) (p=0.54)].The two groups
Methods: Children admitted to the PICU from April 2015 to June
were similar with respect to mean of standard deviation of
2015 were studied. Urine & serum creatinine were measured and
BG measurements [one 65.1(25.1) vs. two bags 65.5(26.8);
PRISM III scores calculated at admission. Creatinine clearance
(p=0.964)] and median number of undesirable events [4.5
was measured and Renal Angina Index (RAI) scores calculated
(1.75-6.0) vs.5.0 (3.0-8.0) (p=0.31)]. One bag had higher but
at 24 hours post admission. AKI defined by the pRIFLE criteria
insignificant incidence of hypoglycemia [42.9% (n=6) vs.

26.7% (n=4); (p=0.45)].The incidence of hypokalemia [one Efficacy and Safety of Recruitment
64% (n=9) vs two bag 67% (n=10); p=0.23] and mean (SD)
time for resolution of acidosis were similar [ 20.3 (14.8) and
Manoeuvre (RM) in Children with ARDS
20.3(7.0);(p=0.59)]. None had cerebral edema. Rahul Patil, Lakshmi Shobhavat,
Discussion: The two bag system showed trends towards better
Shivhar Sonawane, Uma Ali
Pediatric Intensive Care Unit,
BGV profile and lower incidence of hypoglycaemia. Time to
B J Wadia Hospital for Children, Mumbai
resolution of acidosis was similar in both as reported in previous
studies. RM to improve gas exchange is not widely used in children. A
Conclusions: A larger controlled trial comparing the two fluid prospective pilot study was undertaken to assess the efficacy and
delivery systems may yield better answers. safety of RM in children with ARDS. RM was applied to children
with ARDS who could not sustain a SpO2 of 90 with a FiO2 of
0.6 and PEEP of 10 cms H2O in the first 72 hours after initiation
Transport-Related Adverse Events and of mechanical ventilation, where RM was not contraindicated.
Outcomes in Children Transported Stepwise incremental PEEP upto25 cm H2O was applied in
by Specialised Versus Non-Specialised pressure controlmode (PC)with PC at 15cm H2O above PEEP,
Transport Teams in India: A prospective followed by a slower decremental phase to identify the closing
observational study point. Rapid re-recruitment was then done and optimal PEEP
was set according to the best tidal volume noted during the
Nitin Manwani K. Mohanbabu, Sumant Prabhudesai, decremental phase plus 2 cm H2O. Arterial blood gases were
K. Ravikumar, Bala Ramachandran taken pre and post RM and at PEEP 25. Vital parameters, Vt and
Department of Pediatric Intensive Care Kanchi Kamakoti EtCO2 were monitored. Efficacy was assessed bychanges in the
Childs Trust Hospital, Chennai PF ratio, OI and dead space ventilation (DS)pre and post RM.
Background: Transport of critically ill children by specialised RM was applied in 7/10 children with ARDS. Median age and
transport teams is associated with fewer transport related adverse weight of the patients was 20 months, and 8 kg. Six were in shock
events (TRAEs) and better outcomes. Data from India are on admission with multi-organ dysfunction. Mean PRISM score
lacking. was 12.4 & mean SOFA score was 11.5 on day 1 of admission.
Six out of 7 (85%) showed a positive response to the RM in the
Methods: Children who were transported to our hospital and form increase in PF ranging from 12 to 247%, decrease DS by
required PICU admission were included in the study. Based on 30 -79%, 5/7 showed a decrease in OI from 6% -83%. The mean
the method of transport the patients were assigned to 3 groups: optimal PEEP was 12.4. FiO2 < 0.6 was achieved within 24 hours
ST-specialised transport teams, NST- non-specialised teams and in 71% of cases. During RM all cases required fluid boluses and
UT-unassisted transport. The occurrence of TRAEs, condition 4 required increase in inotropic support. Air leak occurred in one
upon arrival to hospital, emergency interventions, PICU course requiring ICD insertion.
and outcome were studied.
Judiciously applied, RM is safe and can improve oxygenation
Results: Totally 204 children were studied (46 in ST, 39 in NST and reduce DS ventilation in children with ARDS allowing the
and 119 in UT, median age 19.5 months [9- 69.2]). There were use of non toxic FiO2 in 70% of the cases.
TRAEs in 142 children. Compared to the ST group, NST and
UT groups had a higher incidence of TRAEs (4.3%, 97.4%,
85.7%, p<0.001). NST and UT children were more likely to Procalcitonin as a Predictor of Mortality
require intubation upon arrival (p<0.001), and ventilation in Children with Septic Shock
(p=0.002), vasoactive support (p=0.03) and invasive procedures
(p=0.009) in PICU. PICU length of stay (p=0.24) and mortality
Ravikumar K, Sumant P, Bhavik L, Anupama
were (p=0.52) comparable in all 3 groups. The Relative Risk for Y, Surendra, Uthayageetha, Ravikumar KG,
TRAEs was 20.4 for children in the NST or UT group. Ramachandran B
Department of Paediatric Intensive Care,
Discussion: Similar studies in other countries and Indian Kanchi Kamakoti CHILDS Trust Hospital
studies in neonates have shown fewer adverse events, better
physiological stability and better outcomes with specialised Objective: Procalcitonin (PCT) has been studied as an outcome
transports. Our study did not show any difference in outcome. predictor in adults with sepsis. We hypothesized that PCT trends
Conclusion: Transport of critically ill children by a specialised are useful in predicting outcome in children with septic shock.
transport team is associated with fewer transport related adverse Methods: This prospective observational study was conducted
events. in the PICU of a tertiary care teaching hospital. Children aged
Type of Study: Prospective Observational 30 days to 18 years admitted to the PICU with septic shock were
included. Serum PCT was measured on admission, Day-2 and
Day-3. Demographic, clinical and outcome data were collected.

PCT values and PCT trends were evaluated as predictors of Conclusions: As per this study, vasopressin may be as effective as
mortality using Receiver Operating Characteristics (ROC) curves. norepinephrine in fluid refractory, dopamine resistant warm shock.
Results: Twenty five patients were included. The median PCTs
on admission, Day-2 and Day-3 were 14.3 [5-66.5], 30.5 [6.8- A Study to Predict Respiratory Distress
200] and 23.3 [5.4-200] ng/mL respectively. All patients had
an admission PCT >2 ng/mL. On ROC curve analysis, a rise in
Syndrome using Single Step Gastric
PCT from Day-1 to Day-3 by >3.83 ng/mL predicted mortality Aspirate Shake Test
with a sensitivity of 76.92% and specificity 80% (area under the ShikhaVerma, R S Jaswal
curve=0.75, p=0.056). With Pearson’s correlation coefficient(r), Department of Pediatrics, Dr. R. P. Govt. Medical College,
PCT correlated poorly with PRISM III score (r=0.21), Vasoactive Kangra (Tanda), H.P.
Inotrope Score (r=0.26), Day-3 Cumulative Fluid Balance
(r=0.21), C-reactive protein (r=0.19), lactate (r=0.11), ventilator- Introduction: Respiratory distress syndrome (RDS) is the
free-days (r= 0.16) and ICU-free-days (r=0.06). major cause of morbidity and mortality in preterm neonates.
Discussion: Studies in septic adults have shown higher mortality In India, RDS occurs in 200 000 infants/year with mortality
with a persistently elevated PCT and improved survival with from RDS at 40%-60%. Lack of pulmonary surfactant leads
decreasing PCT levels. to progressive atelectasis, loss of functional residual capacity,
ventilation-perfusion mismatch, severe hypoxemia and lung
Conclusion: A rising trend in Procalcitonin in the first three days injury.Surfactant deficiency can be predicted with simple, cheap
of critical illness may be a predictor of mortality in children with shake test method. The aim of this study was to find surfactant
septic shock. deficiency by using single step gastric aspirate shake test.
Type of study: Prospective observational study Method: This is an observational study conducted on 79 preterm
neonates (28-34 weeks).Gastric aspirate was aspirated within
A Single Centre Open Labeled one hour of birth before firstfeed . Shake test was performed by
taking 0.5ml of normal saline and 1.0ml of 95% ethyl alcohol
Randomized Controlled Trial Comparing test tube, 0.5ml of gastric aspirate was added and vigorously
Hemodynamic Response of Vasopressin shaken for 15 seconds and allowed to stand for 15 minutes. The
and Noradrenaline in Dopamine surface was inspected for quantum of froth or bubbles and said
to be negative when bubbles cover 1/3rd or less of liquid surface,
Resistant Fluid Refractory Warm Shock intermediate testif 1/3rd to 2/3rd and positive if 2/3rd or more
in Children (Vadorest Trial) suggesting full pulmonary maturity.
R Saxena*, Ebor Jacob**, Pragathesh, Results: Out of 79 preterm neonates (44 males and 35 female),
Jolly, Kala, Manivachagan 36 were born at POG 30-34 weeks, 30 at 30-32 weeks and 13 at
PICU, CMC, Vellore 28-30 weeks. 9 had negative test while 12 and 58 had intermediate
and positive results respectively. All neonates with negative shake
Background: Sepsis is the most frequent cause of vasodilatory test developed RDS while 11 out of 12 neonates with intermediate
shock. Use of vasopressors in treatment of warm septic shock test developed RDS and 1 neonate with positive shake test also
viz. vasopressin and norepinephrine(NE) is still open to debate. developed RDS. This shake test has sensitivity of 95.2%,specificity
Aims: To study the hemodynamic response (as defined by change of 98.26%, PPV and NPV of 95.24%, 98.28% respectively.
in heart rate, mean arterial pressure, systolic blood pressure, Conclusion: A large proportion of infants with negative single
sensorium, urine output, lactate, base excess) of Vasopressin step gastric aspirate shake test develop RDS.The test is worth
and Noradrenaline at 3 and 6 hours after starting vasopressors in performing as an aid tomanagement and diagnosis of RDS.
dopamine resistant, fluid refractory warm shock.
Methods: This is a single centre, open labeled, randomized Critical Illness Corticosteroid
controlled trial with intention to treat principle.Patients were
treated according to the PALS/ACCM guidelines. When they
Insufficiency (CIRCI) in Children - A
reach the fluid refractory dopamine resistant state they were single centre, prospective cohort study
randomized into vasopressin and norepinephrine group. Vinayak K.Patki, Sanket Agarwal, Jennifer Antin
Results: Between January to June, 2015, 445 patients admitted Department of Pediatrics, Wanless Hospital, Miraj, 416410, Dist-
to PICU. Among these, 17 children fulfilled inclusion criteria; Sangli, Maharashtra
five excluded. Twelve children were enrolled for the study.
At the end of six hours, 7 out of 12 patients had met all the Introduction: Although guidelines for diagnosis and
therapeutic goals. Among these,5 were in the norepinephrine management of CIRCI in adults are developed there is paucity of
subgroup, while 2 children were in the vasopressin subgroup. In data available on CIRCI in children.
the norepinephrine group, the mortality rate was 42.8% where as Aims and Objective: to study the incidence, risk factors,
in the vasopressin group, the corrected mortality was 40%. mechanism and associations of CIRCI in children using ACTH
stimulation test.

Methods: single centre prospective cohort study was conducted and enteral feeding (12.2: 2.58 to 57.78; p=0.0001) remained
in eight bedded PICU of teaching hospital over a period of one significant. A CPIS of ≥4 had a sensitivity and specificity of 88.9%
year. Serum total cortisol concentration were measured in 110 and 84.4% respectively for diagnosis of VAP by CDC criteria.
critically ill children before and after stimulation with 250μg
Conclusion: The incidence of VAP was high in our study and
adrenocorticotropic hormone (ACTH).CIRCI was defined by
the commonest organisms were gram negative bacteria such
post ACTH increment in serum cortisol ≤9 μg/dl. Children with
as Acineobacter and Pseudomonas. A CPIS of ≥ 4 is strongly
and without CIRCI were compared.
suggestive of VAP. Use of PPI and enteral feeding are important
Results: Incidence of CIRCI was 38.2%. Children with modifiable risk factors for the development of VAP.
CIRCI had higher median age(34 vs 18 months) Key words: Ventilator associated pneumonia; VAP; Proton pump
higher PRISM score (17.79±2.60 Vs16.37±3.68) and inhibitor, Enteral feeding; Clinical pulmonary infection score; CPIS
significantly higher basal cortisol levels (27.37±11.64
Vs22.02±7.26) (p-0.004) than those without CIRCI.
There was significantly higher (p-0.000) requirement Administration of Fluid Bolus
of catecholamines (2.71±0.457 Vs2.00±0.792 ) and higher over 15-20 minutes versus 5-10 minutes
fluid boluses(15.79±4.7Vs 10.65±4.60) in children with
CIRCI. But duration of catecholamine use was not in the First hour of Resuscitationin
significantly different between two groups. Presence of Children with Septic Shock - A
CIRCI was not found to be independent risk factor for randomized controlled trial
mortality. For each additional use of catecholamine the
risk of CIRCI increased to 5.6 times and for each extra Jhuma Sankar1, Rameshwar S Meena2,
fluid bolus risk increased to 1.2 times. Suresh Kumar2, Anubhuti C1, M Jeeva Sankar1
1
Department of Pediatrics, All India Institute of Medical
Conclusion: CIRCI occurs in a wide spectrum of
Sciences, New Delhi, India, 2Department of Pediatrics,
diseases in critically ill children associated with 3
Department of Biochemistry PGIMER,
increased need for catecholamine and fluids. CIRCI
Dr RML Hospital, New Delhi, India
likely to be multi-factorial in etiology and associated
Email: jhumaji@gmail.com
with high basal cortisol.
Keywords: adrenal function, cortisol, Objectives: To compare the effect of administration of fluid
adrenocorticotropic hormone, critically ill children boluses over 15-20 minutes with that over 5-10 minutesin the
first hour of resuscitation on short-term outcomes in the first 6
hours of fluid resuscitationin children with septic shock.
Ventilator Associated Pneumonia in
Methods: We randomly assigned children (<18 years)with
Pediatric Intensive Care Unit: Incidence, septic shock to 15-20 minutes bolus (Group 1) or 5-10 minutes
risk factors and etiological agents bolus group (Group 2). The primary outcome was the composite
Vijay Gnanaguru1, Anirban Mandal1, Jhuma Sankar1, outcome of need for mechanical ventilation and/or impaired
oxygenation–increase in oxygenation index (OI) by 5 from
Arti Kapil2, Rakesh Lodha1, SK Kabra1
baseline; other outcomes were the risk of fluid overload at 6
1
Department of Pediatrics, 2Department of Microbiology,
hours and mortality. The outcome assessor was blinded to the
All India Institute of Medical Sciences, New Delhi 110029, India
group allocation. The study was terminated after enrolling 96
Objectives: There is paucity of evidence on the incidence, childrenbecause the interim analysis - conducted as per the
etiology and risk factors associated with ventilator associated mandate of IRB – revealed safety concerns in one of the groups.
pneumonia (VAP) in children. Results: Of the 96 children, 45 were randomly assigned to
Methods: We prospectively enrolled children aged ≤17 years Group 1 and 51 to Group 2. Key baseline characteristics were
from June 2012 to March 2014 who received mechanical not different between the groups. When compared to Group 2,
ventilation for more than 24 hours. We estimated the incidence fewer children in Group 1 needed mechanical ventilation or had
of VAP using the Centers for Disease Control (CDC) criteria, an increase in OI at 6 hours (36% vs. 57%; RR: 0.62; 95% CI0.39
evaluated the etiology and risk factors for VAP. We also evaluated to 0.99); theproportion of children developing fluid overload was
the cut-offs on clinical pulmonary infection score (CPIS) for also lowerin Group 1 (31 % vs. 49%; RR: 0.63; 0.37 to 1.06).
diagnosis of VAP. The study was approved by the IEC. Data was There was no difference inmortality (43% vs. 33%; p=0.31) or
analyzed using STATA 11. duration of mechanical ventilation between the groups.
Results: We enrolled 86 children with a median age of 30 Conclusion: Administration of fluid bolus over 15-20 minutes
months. The incidence of VAP according to CDC criteria was is associated with lesser need for mechanical ventilation and/or
38.4%. Acinetobacter was the most frequently isolated organism impaired oxygenation in the initial hours of fluid resuscitation in
(47%) followed by Pseudomonas (28%) and Klebsiella (15%). children with septic shock.
Risk factors for VAP on bivariate analysis were use of proton Key words: Fluid bolus; septic shock; duration of bolus;
pump inhibitor (PPI), enteral feeding and re-intubation. On mortality; oxygenation index; mechanical ventilation
multivariate analysis, use of PPI (8.47: 1.19 to 60.33; p=0.03)

NCPCC 2015: Posters
[Award Poster: First Position] features of hypopituitarism.
Lactate Clearance as a Predictor of Case Report: A 9 year old female and her 7 year old male
Mortality in Children with Septic Shock sibling presented with complaints of failure to gain weight and
height from the age of one year, diagnosed as failure to thrive.
Nitin Manwani, Sumant Prabhudesai, K Ravikumar, Hormonal analysis was suggestive of hypopituitarism and
Bala Ramachandran Contrast enhanced MRI of pituitary gland revealed empty sella
Department of Pediatric Intensive Care, Kanchi Kamakoti syndrome. On follow up, child gradually gained height with
CHILDS Trust Hospital, Chennai growth hormone supplements.
Objective: To study the utility of lactate clearance as a predictor Discussion: The incidence of empty sella syndrome varies
of mortality in children with septic shock 8-35% in the general population and 1.2% in children. However
high incidence up to 68% has been described in children with
Methods: Lactate was measured at admission and on days 2 and known endocrinopathy. Clinical features include hypogonadism,
3 in children aged 30 days - 18 years admitted to the PICU with Growth hormonedeficiency, and multiple pituitary hormone
septic shock. Demographic, clinical and laboratory data were deficiency. Gadolinium enhanced MRI pituitary gland is the
collected. Lactate clearance was defined as (admission lactate- investigation of choice.Primary ESS is treated with hormonal
current lactate) x 100 /admission lactate. supplementation. In secondary ESS, treatment depends upon
Results: Twenty five children were included (median age 28.5 etiology.
[14.25- 66.75] months, 36% female, median PRISM III score Conclusion: The rare causes like ESSshould be considered in
15.5[10.25-22.5]). Median lactate at admission, day-2 and day- children presenting with failure to thrive because early initiation
3 were 2.6 [2.0-3.5], 1.8 [1.2-2.75] and 1.7 [1.2-2.8] mmol/L of GH treatment gives good results.
respectively. Four children had a rise in lactate by day-2, while
7 children had a rise by day-3. A day-2 lactate clearance of
-25% (rise by 25%) predicted mortality with a sensitivity of [Award Poster: Third Position]
100% and specificity of 50% (area under the receiver operating Comparison of External Jugular Venous
characteristics curve [AUROC] 0.77). A day-3 lactate clearance
of -30% (rise by 30%) predicted mortality with a sensitivity of
access to Internal Jugular Venous
93.3% and specificity of 83.3% (AUROC= 0.91). Admission access in Pediatric septic shock: An
lactate correlated poorly with PRISM III score (r= 0.15). observational, prospective study
Discussion: Few similar Indian studies in children have shown Chintan Patel, Kushal Shah, Utkarsh Pandya,
lactate clearance to be a good indicator of mortality. Significance Krutika Tandon*
of a negative lactate clearance has not been reported though it is *Professor in Pediatrics & PICU Incharge, Department of
assumed that the associated outcome would be poor. Pediatrics, P S Medical College, Karamsad-388325,
Conclusion: An initial rise in lactate may not affect outcomes. Dist. Anand (Gujarat)
*M: 9879531972; Email: krutikart@charutarhealth.org
Lactate clearance by 72 hours of shock may be a good predictor
of mortality in children with septic shock. Background: Intravenous lines are lifelines for patients with
Type of study: Prospective observational study. shock. Central venous access is preferred but not possible
always. So we undertook this study of comparison of External
Jugular Venous(EJV) access to Internal Jugular Venous(IJV)
[Award Poster: Second Position] access for its efficacy, ease of procedure, complications and cost
Empty Sella Syndrome Resulting into effectiveness.
Short Stature in Two Siblings - A case Methods: A Prospective, Observational study from January
report with review of literature 2014 to June 2015 at PICU. Seventy pediatric patients with
Jamunashree B*, Seema Sharma, Milap Sharma shock were enrolled. Parents were explained about both EJV
Department of Pediatrics, Dr Rajendra Prasad Government and IJV routes. Depending on their affordability and consent one
Medical College, Tanda, Kangra, H.P. route was chosen. Required details were noted and descriptive
*Email: drjamuna11@gmail.com analysis was done as per objectives.
Results & Discussion: EJV and IJV had 50 and 16 subjects
Abstract: Empty sella syndrome (ESS) is the herniation of the respectively. Mean duration of reaching shock free status was
subarachnoid space into the sella through the sellar diaphragm 69.2 hours in EJV group versus 53.33 hours of IJV group.
with some degree of flattening of pituitary gland. Primary ESS Mean improvement in base deficit at the end of 24 hours as 4.3
occurs when a hole in diaphragmatic sella covering the pituitary and 6.6 in EJV & IJV groups respectively. Successful hospital
allows fluid in, which presses on pituitary. Secondary empty sella discharge was 36% and 37.5% of patients of EJV & IJV groups
syndrome occurs when the pituitary glandis injured secondary respectively. No life threatening complications in any group and
to surgery, tumour or radiation.We present two siblings with local site problems were similar in both groups. Overall attempts

were similar in both groups whereas duration of procedure and Study of Impact of Introduction
cost effectiveness of procedure was better in EJV group. Earlier
none of this type of study published especially comparing two
of “Restricted Antimicobials” Use
diverse intravenous routes in pediatric shock. Justification form in Pediatric Intensive
Conclusion: External jugular venous route is easy, cost effective Care Unit of Tertiarycare Hospital
route with comparable results when central venous access is Deepak R
not feasible, though central venous route is standard of care in Fellow-Pediatric Intensive Care, Rainbow Hospital for Women
pediatric septic shock. and Children, Banjara Hills, Hyderabad
Email: drdeepakr84@gmail.com
Active CRE Surveillance as a means Objective: To study whether introduction of a “antimicrobial

of Decreasing the Incidence of CRE justification form” deter clinicians from prescribing restricted
antimicrobials and result in de-escalation of these antimicrobials.
Infections in a PICU
Ravikumar K*, Alok E, Ajay A, Prabhudesai S, Setting: PICU of Rainbow Children’s Hospital, Banjara Hills,
Hyderabad.
Putlibai S, Subburaju N, Nambi S, Ramachandran B
Departments of Pediatric Intensive Care, Pediatric Infectious Design: Ours was a case control study where subjects from two
Diseases & Microbiology, Kanchi Kamakoti CHILDS Trust phases were compared.
Hospital, Chennai Methods: We identified group of antimicrobials as “restricted”
*Email: drravi81@rediffmail.com
and clinicians prescribing antimicrobial from the restricted group
Background: Carbapenem resistant enterobacteriaceae were asked to fill a justification form.
(CRE) infections are increasing in hospitalised patients. CRE In Phase one “retrospective” controls were taken between 1st
surveillance & contact/cohort isolation has been shown to June, 2012 to 31st March 2013 and in Phase two “prospective”
decrease the incidence of CRE infections. cases were taken from 1st June, 2013 to 31st March, 2014. In both
Methods: CRE surveillance using rectal swabs was started in the phases, only those patients who received antibiotics from the
our PICU from July 2013 since there was an increase in CRE “restricted” group were included.
infections. Rectal swabs were sent on admission and weekly Phase one was an observation on the use of antimicrobials. In
thereafter until patient discharge from PICU. Over an 18 month phase two, the doctors prescribing the “restricted” antibiotics
period, 976 rectal swabs were sent and 164 were found to be filled a “justification” form.
positive. Patients with positive CRE swabs were placed under
After 72 hours they were asked either to de-escalate the antibiotic
contact isolation.
or justify not de-escalating.
The incidence of CRE infection (per 1000 patient days) before
Results: A significant overall decrease in antimicrobial usage in
and after starting surveillance was analysed retrospectively.
Group B as compared to Group A (p = 0.01) was seen. We noticed a
Results: Prior to initiation of surveillance, 4 CRE infections significant de-escalation of Piperacillin - Tazobactum (p<0.0001),
(2.65/1000 patient days) were identified from January-June 2013 Meropenem (p=0.002) and Linezolid (p=0.00) in Group B.
(Season 1). After initiation of surveillance from July 2013, the
Conclusion: Introduction of a simple intervention like filling
incidence of CRE infections gradually decreased. There were 3
up of a justification form before prescribing antimicrobials or
CRE infections (1.69/1000 patient days) from July-December
at the time of deferring de-escalation can be a useful tool in
2013 (Season 2), 3 CRE infections (1.97/1000 patient days)
making a positive impact in restricting the use of broad-spectrum
from January-June 2014 (Season 3) and no infections from July-
antimicrobials in PICU.
December 2014 (Season 4). There was a statistically significant
reduction (p 0.03) in the incidence of CRE infections in Season
4 (post surveillance) when compared with Season 1 (pre- Critical Illness Corticosteroid
surveillance). Insufficiency(CIRCI) in Children - A
Discussion: Isolation of patients infected with CRE by itself may single centre, prospective cohort study
not be enough to decrease the spread of these organisms. It is
also essential to identify and isolate patients who are colonized
Vinayak K.Patki*, Sanket Agarwal, Jennifer Antin
Department of Pediatrics, *Pediatric intensivist, Head,
with CRE.
Department of Pediatrics, Wanless Hospital,
Conclusion: Containment of CRE infection is possible with Miraj, 416410, Dist-Sangli, Maharashtra
active surveillance combined with proper isolation *Email: patkivinayak@gmail.com
Type of study: Retrospective descriptional study
Introduction: Although guidelines for diagnosis and
management of CIRCI in adults are developed there is paucity of
data available on CIRCI in children.

Aims and Objective: To study the incidence, risk factors, oscillometric and invasive BP measurements were collected in
mechanism and associations of CIRCI in children using ACTH 65 patients. The mean difference between invasive and non-
stimulation test. invasive techniques were - 3.6 ± 12.85, - 4.7 ± 9.3 and - 3.12 ±
Methods: single centre prospective cohort study was conducted 9.30 mm Hg respectively for systolic, diastolic and mean arterial
in eight bedded PICU of teaching hospital over a period of one BP (p < 0.05 ), with wide limits of agreement. Overestimation of
year. Serum total cortisol concentration were measured in 110 BP using NIBP was more evident in infants, children on inotropic
critically ill children before and after stimulation with 250μg support and obese children.
adrenocorticotropic hormone (ACTH). CIRCI was defined by Conclusion: Although there is a good correlation between
post ACTH increment in serum cortisol ≤9 μg/dl. Children with IABP and NIBP measurements but as Oscillometric BP
and without CIRCI were compared. measurements tend to overestimate IABP readings especially in
Results: Incidence of CIRCI was 38.2%. Children with CIRCI case of hypotensive shock, they cannot be regarded as reliable
had higher median age(34 vs 18 months) higher PRISM score alternatives to IABP measurements.
(17.79±2.60 Vs16.37±3.68 ) and significantly higher basal
cortisol levels (27.37±11.64 Vs22.02±7.26) (p-0.004) than Rapid Onset Obesity and Ondine’s
those without CIRCI. There was significantly higher (p-0.000)
requirement of catecholamines (2.71±0.457 Vs2.00±0.792) and
Curse: A Deadly Syndrome
higher fluid boluses(15.79±4.7Vs 10.65±4.60) in children with Shalini A Akunuri
CIRCI. But duration of catecholamine use was not significantly PICU Fellow, Narayana Health, Bangalore
Email: akunurishalini@gmail.com
different between two groups. Presence of CIRCI was not found
to be independent risk factor for mortality. For each additional
use of catecholamine the risk of CIRCI increased to 5.6 times
and for each extra fluid bolus risk increased to 1.2 times. Introduction: ROHHADNET is a rare disorder defined by rapid
onset obesity, hypoventilation, hypothalamic dysregulation,
Conclusion: CIRCI occurs in a wide spectrum of diseases
autonomic dysfunction and neural-crest tumors. We report a
in critically ill children associated with increased need for
case of 2.4 years old girl who presented with obtundation due
catecholamine and fluids. CIRCI likely to be multi-factorial in
to hypoventilation, carbon-dioxide narcosis and on evaluation
etiology and associated with high basal cortisol.
found to have features of ROHHADNET syndrome.
Keywords: adrenal function, cortisol, adrenocorticotropic
Case Report: 2.4 years old girl presented with obtundation. At
hormone, critically ill children
admission, she was hypoventilating with severe hypercarbia.
Her sensorium and ABG normalized after 10 hours of BIPAP.
Comparison of Noninvasive Oscillometric She was obese with high blood-pressure, had exotropia and
and Intra-Arterial Blood Pressure diminished pain sensitivity. History revealed hyperphagia,
excess weight gain, constipation from preceding 6 months.
Measurements in Children Admitted to Growth charts showed rapidly increasing weight after 1½ year of
Pediatric ICU age with normal height centiles.
Kaur J, Pooni P, Bains H, Thakkar T* Investigations revealed normal plasma cortisol, appropriately
*PICU Fellow, DMCH, Ludhiana suppressed with dexamethasone; hyperprolactinemia, central
Email: tanya7.hope@gmail.com hypothyroidism, low IGF-1, suboptimal GH response to
clonidine; normal leptin, urinary catecholamines and OGTT.
Background: Direct intra-arterial readings are considered the
MRI brain showed bilateral centrum semiovale, fronto-parietal
gold standard for Blood Pressure measurements. Because arterial
white-matter hyperintensities. Thoraco-abdominal CT showed
cannulation is difficult and associated with risks, alternative non-
pre-sacral mass which was FDG avid. Polysomnography was
invasive blood pressure (NIBP) measurements are routinely used
abandoned due to desaturations. 2D-Echo showed PAH keeping
in emergency and critical care setups. However, the accuracy of
with hypercarbic respiratory failure.
NIBP determinations in critically sick children is variable.
She had several episodes of hypoventilation during hospital stay.
Aim: To find the difference, limits of agreement and correlation
Based on above features, a diagnosis of ROHHADNET was
between simultaneously recorded invasive and oscillometric
made. She is discharged on home BIPAP and thyroxine.
non-invasive BP measurements in critically ill children.
Discussion: ROHHADNET is a rare syndrome with about 100
Methods: Prospective observational study carried out in children
cases reported till date. The acronym ROHHAD describes the
aged 1 month to 18 years admitted to 10 bedded Level III PICU
typical sequence of symptoms experienced, in the order of their
at DMCH, Ludhiana in a 18 month study period. Agreement and
appearance. Presently no genetic testing is available, mandating a
correlation between IABP and NIBP was assessed using Bland-
clinical diagnosis. About 40% develop neuro-endocrinal tumors
Altman analysis.
and 50%-60% suffer cardiac arrest. Hence early recognition is
Results: Overall, 4447 pairs of simultaneous recorded important.

Subclavian Artery Pseudoaneurysm Study of Functional Outcome of Patients
After Internal Jugular Vein Cannulation at Discharge from Paediatric Intensive
Presenting as Difficult Ventilation and Care Unit
Repeated Extubation Failure Sujata*, Navjot, Puneet, Shekhar, Kartik
Shalini A PICU at DMCH, Ludhiana
PICU Fellow, Narayana Health, Bangalore *Email: drsujatabhatti@yahoo.com
Email: akunurishalini@gmail.com
Aims and Objectives: To study the functional outcome of
Introduction: Central lines have become a common procedure, patients discharged from PICU and correlation of pre admission
but they are not without complications. We report a case of co morbid status to the outcome of stay in PICU.
subclavian artery pseudoaneurysm that followed right IJV Method: The study was conducted in PICU at DMCH, Ludhiana
cannulation which compressed trachea leading to problems with over a period of one year. Patients admitted to ICU in the age
ventilation and multiple extubation failures. group of 1-18 years were included. Patients less than one year
Case report: Eight months child underwent surgical correction of age were excluded. Total of 317 patients were enrolled, 105
for interrupted aortic arch, aorto-pulmonary window and was patients died/ left against medical advice, so functional outcome
extubated next day. Two weeks later she developed respiratory of 212 patients was studied Data was obtained prospectively
distress requiring intubatation. CXR showed right upper zone and outcome was assessed according to functional status scale.
haziness interpreted as collapse due to aspiration. Functional performance was assessed as pre admission score and
discharge score in regard to neurodevelopment disabilities in
Few days later extubated was attempted, but she developed patients with/without chronic disease.
gasping immediately requiring re-intubation. She had three more
episodes of similar extubation failures. FSS domains- Mental status, sensory functioning,
communication, motor functioning, feeding and respiratory
Serial CXRs showed persistent haziness in right upper zone status. Score range 6-30.
which in due course developed a rounded contour. Meanwhile
ventilation posed a challenge as she had intermittent episodes Outcome: More than 80% of patients achieved pre admission
of hypercarbia, increase in Ppeak and airway resistance. Despite score in domains of mental status, sensory function, feeding and
suctioning, changing the endotracheal tube, nebulisations, there respiratory status. In communication domain, more than 50%
was no improvement. Later she was observed to have chest rise achieved pre admission status. Motor domain was significantly
only with neck abnormally flexed in a particular position. Mass affected in patients who received ventilation and ionotropic
lesion was suspected causing dynamic airway compression. support. Best outcome was in respiratory status and worst
CECT Chest revealed right subclavian artery pseudoaneurysm outcome was in communication status. Children who had higher
with tracheal compression. admission score had poorer functional outcome (18.46% patients
achieved pre admission score) as compared to low admission
She underwent open surgical repair and was finally extubated. score (46.5% patients).
Case records revealed IJV insertion for surgery.
Conclusion: FSS is a useful tool to study the functional outcome
Discussion: During IJV access, carotid artery is most susceptible at discharge in patients admitted to ICU.
to injury. Subclavian artery injury is rarely reported.
Extrathoracic subclavian aneurysms present with pulsatile
swelling over supraclavicular fossa. Intrathoracic aneurysms can
Blood Component Therapy In Children
compress brachial plexus, upper limb vessels, recurrent laryngeal Admitted To Pediatric ICU
nerve, erode lung apex. Rarely dysphagia, horner’s syndrome Sujata*, Pooja, Puneet, H S Bains, Shekhar, Kartik
and tracheal compression have been reported. PICU at DMCH, Ludhiana
Peculiarities of our case: *Email: drsujatabhatti@yahoo.com
1. Occurrence of subclavian artery psudoaneurysm after
Aims and Objectives: To determine use of blood component
internal jugular vein cannulation is rare. More commonly
therapy in critically ill children admitted in pediatric intensive
carotid artery pseudoaneurysm is seen.
care unit and to compare outcome in patients who received
2. Delayed presentation of pseudoaneurysm, after 2 weeks is blood components to the patients who did not receive blood
uncommon. components.
3. Repeated extubation failures and especially difficulties faced
Method: The study was conducted in 10 bedded PICU at
in ventilating the child due to tracheal compression by the
DMCH, Ludhiana over a period of one year. All the patients
pseudoaneurysm posed a therapeutic challenge.
admitted to PICU were enrolled and patients who required blood
components were included as cases and patients who did not
receive any blood component therapy were taken as controls.
Patients who died or left against medical advice within 24 hours

of admission were excluded. Final outcome in cases and controls Familial Hyrecholestrolemia in Two
was compared and assessed.
Siblings - A case report with review of
Outcome: Total of 294 patients were included. Cases were 118 literature
(40.13%) and controls were 176 (59.8%). Amongst total cases,
82 patients needed packed cells, 38 needed RDPs and 53 patients Seema Sharma, ShikhaVerma
needed FFPs. Cases had prolonged duration of hospital stay with Department of Pediatrics, Dr. R. P. Govt. Medical College,
increased morbidity and mortality. Tanda, Kangra H.P. India
Conclusion: cases had prolonged duration of hospital stay with Introduction: Familial hypercholesterolemia (FH) is a form
increased morbidity and mortality as compared to controls. of primary hyperlipoproteinemia, is an autosomal dominant
disorder, characterized by an increase in serum LDL cholesterol
A Study to Predict Respiratory Distress concentrations, presence of xanthomas and premature
atherosclerosis.In that the individuals with two mutant LDL
Syndrome using Single Step Gastric receptor alleles (FH Homozygotes) are much more affected
Aspirate Shake Test than those with one mutant allele (FH Heterozygotes). FH in
Shikha Verma*, R S Jaswal Homozygous state is rare and occurs in approximately1 in 1
Department of Pediatrics, million persons. These patients are at a high risk of developing
Dr. R. P. Govt. Medical College, Kangra (Tanda), H.P. coronary heart disease and sudden death, unless the condition is
*Email: shikha351@ymail.com recognized and treated promptly.
Case Report: Two siblings10 years old female and 8 years
Introduction: Respiratory distress syndrome (RDS) is the
old male, born out of non consanguineous marriage with
major cause of morbidity and mortality in preterm neonates.
history of xanthomatous lesions for 3 and 2years, respectively.
In India, RDS occurs in 200 000 infants/year with mortality
Physical examination showed subcutaneous yellow nodules
from RDS at 40%-60%. Lack of pulmonary surfactant leads
over the knuckles, elbows, of size up to 2 cm, suggestive of
to progressive atelectasis, loss of functional residual capacity,
xanthomatendinous and tuberous xanthomas along with corneal
ventilation-perfusion mismatch, severe hypoxemia and lung
arcus.Lipid profile was suggestive of FH.
injury.Surfactant deficiency can be predicted with simple, cheap
shake test method. The aim of this study was to find surfactant Discussion: FH or Frederickson’s type IIa hyperlipoproteinemia
deficiency by using single step gastric aspirate shake test. is an AD disorder caused by>900 mutations in the LDL receptor
gene on chromosome 19, leading to lack of functional receptors
Method: This is an observational study conducted on 79 preterm
for LDL on the cell surface which results into decreased uptake
neonates (28-34 weeks). Gastric aspirate was aspirated within
of LDL into cells from liver, blood, resulting into increased serum
one hour of birth before firstfeed. Shake test was performed by
LDL Cholesterol. There is lack of inhibition of intracellular
taking 0.5ml of normal saline and 1.0ml of 95% ethyl alcohol
cholesterol synthesis.Patients present with multiple types of
test tube, 0.5ml of gastric aspirate was added and vigorously
xanthomata, tuberous, sub periosteal, tendon, elevated plaques
shaken for 15 seconds and allowed to stand for 15 minutes. The
and the rare but characteristic inter-triginous in first decade of life.
surface was inspected for quantum of froth or bubbles and said
to be negative when bubbles cover 1/3rd or less of liquid surface, Conclusion: The diagnosis of FH is important for the patient as
intermediate testif 1/3rd to 2/3rd and positive if 2/3rd or more well as family members for genetic counselling and screening of
suggesting full pulmonary maturity. first degree relatives and extended family members.
Results: Out of 79 preterm neonates (44 males and 35 female), 36
were born at POG 30-34 weeks, 30 at 30-32 weeks and 13 at 28- Disease Spectrum and Outcomes in
30 weeks. 9 had negative test while 12 and 58 had intermediate Paediatric Patients requiring Mechanical
and positive results respectively. All neonates with negative
shake test developed RDS while 11 out of 12 neonates with
Ventilation at Kenyatta National Hospital
intermediate test developed RDS and 1 neonate with positive Saini N*, Kumar R, Wamalwa D, Mungai L, Reel B
shake test also developed RDS. This shake test has sensitivity of Department of Paediatrics and Child Health, University of
95.2%, specificity of 98.26%, PPV and NPV of 95.24%, 98.28% Nairobi, Kenya
respectively. *Email: nupursaini27@gmail.com
Conclusion: A large proportion of infants with negative single Background: The burden of critical illness in developing
step gastric aspirate shake test develop RDS. The test is worth countries is inadequately defined and intensive care resources
performing as an aid tomanagement and diagnosis of RDS. are limited. We sought to describe the nature of illnesses for

which children require mechanical ventilation and risk factors Thirty-five tracheostomizedchildren were followed up till
associated with poor outcome. this date by telephonic conversation and out patient records.
Tracheostomy related mortality was 7 %(3) and non-tracheostomy
Methods: A short longitudinal survey was conducted in paediatric
related mortality was 35 %(14) in the study population. Non-
medical wards and ICU at Kenyatta National Hospital. Children
fatal complications (e.g. wound infection, bleeding etc) due to
below 16 years of age requiring mechanical ventilation as per
tracheostomy were seen in 8 % (3) children. Decannulation was
hospital ICU admission protocol and following ICU consultation
performed in 25 %(10) of the children.
and review were recruited into the study and followed up to
discharge or death to determine exposure and outcome variables. Discussion: Pediatric tracheostomy is a relatively safe procedure
Continuous variables were analysed as proportions and mean and the most common indication was for airway protection due
with medians (inter-quartile range) used for normal data. to underlying neurological disorders. Complications due to
Results: Between September 2014 and January 2015, 81 children tracheostomy are similar to the evidence available in literature.
required mechanical ventilation, of whom, 36(44.4%) gained Performing tracheostomy for prolonged mechanical ventilation
admission to ICU. Median age of patients admitted to ICU was 33 has significantly shortened the duration of artificial ventilation.
months (range 11 to 73 months). Neurological illnesses accounted
for majority of the cases (36%), followed by respiratory diseases To Study Clinical Profile and Outcome of
(18%) and severe sepsis (15%). Mortality was 100% amongst
patients who required but did not receive mechanical ventilation.
Pediatric Traumatic Brain Injury (TBI)
Survival amongst ICU admissions was 58%. Hospitalization at N Hema Kumar*, Farhan Shaik, Dinesh Chirla
referring facility of >48 hours prior to referral were predictive of *Senior PICU Fellow, Department of Pediatric Intensive Care
mortality (OR=4.86; 95%CI 0.97-1.19, p=0.046). Rainbow Children’s Hospital, Banjara Hills, Hyderabad
*Email: dr.hemkumar03@gmail.com
Conclusions: Neurological illnesses are the commonest indication
for mechanical ventilation amongst critically ill children at KNH. Place of Study: Rainbow Children’s Hospital, Hyderabad
Delayed referral of more than 48 hours is associated with poor
Type of Study: Prospective observational study
outcome. Mechanical ventilation is a life saving intervention and
should be made accessible to all children who need it. Study Period: From Jan 2012 to Dec 2014
Study Type: Original Research Methods: During study period, all children with TBI were
included. This study reviewed nature of brain injury, clinical
parameters, hospital outcome and discharge outcome of all
Pediatric Tracheostomy - A case series in pediatric TBI patients. All TBI children were treated as per
A tertiary care PICU Brain trauma foundation guidelines (BTF). Whenever the family
Anupama Yerra*, Farhan Shaik, agreed, ICP monitoring was started in patients with severe TBI.
Dinesh Kumar Chirla, Sachin Unny Results: Total 130 children were enrolled. Majority of the
*Clinical Associate, Rainbow Children’s Hospital, Hyderabad children with TBI (n=90) were in the age group 1 to 5yrs and
*M: 08008740697; Email: puttaanu@gmail.com 87(66.9%) had fall from height (commonest cause). Mean GCS
at admission was 14.3, 11.64 and 6.31 in children with mild,
Background: This observational study over 55 months moderate and severe TBI respectively, 24 children (18.46%) had
was conducted to understand the clinical profile of patients abnormal pupils at admission. ICP monitoring was done in 13
undergoing tracheostomy in Rainbow children’s Hospital; PICU, children (29.5%). 2 children in ICP group and 5 children in non-
Banjara Hills; Hyderabad. ICP monitored group died (P=1.00),one child in ICP group and
Methods: A retrospective plus prospective analysis of case 5 children in non-ICP group were left with disability (P=0.65).
records was done between Jan 2011 to July 2015. Data regarding Mean ventilator days and mean hospital days were prolonged in
age, gender, indication for tracheostomy, duration of mechanical ICP monitored group compared to clinical-imaging group (5 Vs
ventilation before and after tracheostomy and complications 2.29 days, P =0.006 and 10.69 Vs 6.97 days, P=0.052). Duration
were collected from children who underwent tracheostomy of hyperosmolar therapy was less in ICP monitored group (1.654
during the study period. Vs 2.73 days, P=0.0007) and no significant mortality differences
were found in two groups. Among children who died in severe
Results: During the study period there were 4700 admissions
TBI group (n=7), all 7 (100%, P=0.0031) children had abnormal
and 700 children received invasive mechanical ventilation.
pupillary size at admission and 6 (85.7%, P=0.0031) children
Tracheostomy was performed for 39 children.
had coagulopathy at admission.
Common age group was in infancy (14; 25 %). Males
Conclusions: ICP monitoring in severe TBI has at least partial
outnumbered females (24 vs 15; 61%vs 39%). Most common
benefits in therapeutic interventions. Abnormal pupillary size and
indication was for airway protection due to neurological disorders
coagulopathy at admission are associated with poor outcome.
(17;43%). About 33 (84%) children were ventilated for less than
2 weeks prior to tracheostomy. The mean duration of ventilation
after tracheostomy was 7 days.

Does After-Hour Admission To Pediatric pediatric-ICU and are not associated with higher mortality or
poorer clinical outcomes.
ICU Affect Patient Mortality And
Outcome? - The vellore experience
Suddhasatta Ghosh*, Ebor Jacob, Pragadeesh P,
Ventilator Associated Pneumonia in
Jolly Chandran, Kala Ebenezer, Manivachagan MN Pediatric Intensive Care Unit: Incidence,
*Post-Doctoral Fellow, Pediatric Intensive Care Unit, Christian Risk Factors and Etiological Agents
Medical College, Vellore, Tamil Nadu.yhf Vijay Gnanaguru1, Anirban Mandal1, Jhuma Sankar1,
*Email: riddhi_dg@rediffmail.com
Arti Kapil2, Rakesh Lodha1, S K Kabra1
Background/Rationale: Patients admitted during “after-hours”
1
Department of Pediatrics, 2Department of Microbiology,
in a Paediatric-ICU may be at higher risk of mortality. Our study All India Institute of Medical Sciences, New Delhi-110029, India
1
Email: vijayguru14@gmail.com
aims to determine whether mortality and outcome measures
differ according to time of admission. Objectives: There is paucity of evidence on the incidence,
Methods: A retrospective study was conducted at Christian etiology and risk factors associated with ventilator associated
Medical College,Vellore based on reviewing the data from the pneumonia (VAP) in children.
charts of patients admitted consecutively from January 2012- Methods: We prospectively enrolled children aged ≤17 years
2015.Study population was categorized into working-hour (week from June 2012 to March 2014 who received mechanical
days- 8.00am-4.59pm) and after-hour (week days-5.00pm- ventilation for more than 24 hours. We estimated the incidence
7.59am, all Saturdays, Sundays and holidays) admissions. of VAP using the Centers for Disease Control (CDC) criteria,
Mortality, demographic profile and severity score(PELOD) were evaluated the etiology and risk factors for VAP. We also evaluated
compared in the them. Statistical analysis was done using SPSS the cut-offs on clinical pulmonary infection score (CPIS) for
version 16.0 with a significance level of p<0.05. diagnosis of VAP. The study was approved by the IEC. Data was
Results: Out of 3000 patients admitted over the 36-month analyzed using STATA 11.
period, male:female ratio was 62:38, with 58% admitted during Results: We enrolled 86 children with a median age of 30
after-hours and 42% during working-hours.Amongst the after- months. The incidence of VAP according to CDC criteria was
hour admissions, 80% were emergency, 5% elective and 15% 38.4%. Acinetobacter was the most frequently isolated organism
post-operative admissions, with 39% requiring ventilation. (47%) followed by Pseudomonas (28%) and Klebsiella (15%).
Respiratory (25%) and CNS (16%) were the major primary Risk factors for VAP on bivariate analysis were use of proton
illness,while haematological malignancy (12%), poisoning pump inhibitor (PPI), enteral feeding and re-intubation. On
(4%) and metabolic (2%) disorders were also present. Mean multivariate analysis, use of PPI (8.47: 1.19 to 60.33; p=0.03)
length of ICU stay for ventilated and non-ventilated patients and enteral feeding (12.2: 2.58 to 57.78; p=0.0001) remained
were 4.6±1.2days and 3.4±0.9days respectively. Outcome significant. A CPIS of ≥4 had a sensitivity and specificity of
was measured in terms of death (16%), DAMA in terminally- 88.9% and 84.4% respectively for diagnosis of VAP by CDC
ill children (7%) and discharge (77%). Comparison between criteria.
working-hour and after-hour admission groups showed the mean
age,length of ICU stay,severity score and outcome measures Conclusion: The incidence of VAP was high in our study and
were similar in the two groups(p=0.5). There was no significant the commonest organisms were gram negative bacteria such
difference in mortality(p=0.4)between the two groups. as Acineobacter and Pseudomonas. A CPIS of ≥ 4 is strongly
suggestive of VAP. Use of PPI and enteral feeding are important
Discussion: Our findings are consistent with recent studies by modifiable risk factors for the development of VAP.
Mccrory and colleagues(2014, Nov) that showed no independent
effect of after-hour admissions on mortality rates in the pediatric- Key words: Ventilator associated pneumonia; VAP; Proton
ICU. pump inhibitor, Enteral feeding; Clinical pulmonary infection
score; CPIS
Conclusion: Admissions during after-hours are common in a

Vancomycin Dosing and Therapeutic years of age with severe Dengue (as per WHO criteria).
Drug Monitoring in Pediatric Patients The pre intervention phase (Phase-1) was between July 2010
with Serious Infections and December 2012 and the post intervention phase (Phase 2),
between January 2013 and July 2015. Albumin was administered
Dimpi Mhatre*, Rekha Solomon**, Sonu Udani*** within 8 hours of admission in
PD Hinduja Hospital and Research Centre, Mumbai • Children needing >20ml/kg of crystalloid bolus for
Email: *dimpimhatre@gmail.com*, **rekhasolomon1@gmail.com,
hypotensive shock
***drsudani@gmail.com
• Children needing >5 ml/kg/hour of crystalloid for > 6 hours
Introduction: The recommended dosing to achieve therapeutic • Children presenting with severe symptoms of third spacing
trough concentrations of vancomycinis15-20 mg/kg. Albumin (1g/kg of 5% 0r 20%) was used as a continuous infusion
Aim: To investigate if current recommended dosing of over 4-8 hours.
Vancomycin achieves target trough concentrations (TTC) in The three dimensional approach –clinical examination, 4-6hourly
pediatric patients with suspected/ known MRSA infections. Hct and blood gas was used for monitoring .
Methods: Fifty-one trough levels in 45 children aged 1 month to Results: A total of 507 patients were included in this study. The
18 years, receiving Vancomycin therapy in doses of 40 to 50 mg/ mortality was 6.4% ( 16 out of 250) in Phase1 as against 1.1% (3
kg/day (group A) or 55 to 65 mg/kg/day (group B)for suspected out of 257) in Phase2.(p value of 0.002,Chi square test)
(febrile neutropenic or CRBSI) or proven serious infections were
Conclusion: Although large prospective multicentric trials are
studied retrospectively.Chi-square/ Mann-Whitney Utest used
further needed, it may be concluded that early use of albumin in
for differences in characteristics between patients that achieved
severe Dengue is associated with reduction in mortality.
TTC (≥15 μg/ml)and those that did not (<15 μg/ml).
Results: Most patients (91.2%) received empiric therapy, only
4(8.8%) had positive MRSA cultures. With 12/51(23.5%) Role of Therapeutic Plasmapheresis in
achieving TTC, dose levels did not correlate with trough levels Hump Nosed Pit Viper Envenomation
(Spearman’s r=-0.11, p=0.43). There were 21(46.6%) and Presenting with Hemostatic Dysfunction:
24(53.3%) patients in group A and group B, respectively. While
8(33%) in group B achieved TTC, only 2(9.4%) in group Ahad A Case Report
achieved TTC. Patients that achieved TTC were more likely to Abdul Majeed, Roopa Vijayan, Renjith Baby,
be younger (p=0.07, effect size=0.32) and belong to group B Vinod Kumar K, Anu Paul, Vivek Radahakrishan,
(p=0.07, effect size=0.28) than those that did not achieve TTC. Rajappan Pillai P*
Achievement of TTC did not affect clinical outcomes. None of Paediatric Intensive care unit, ASTER Medcity, Kochi, Kerala.
our patients showed nephrotoxicity as a result of vancomycin *Email: rajappanpillai@gmail.com
therapy.
Hump-nosed viper bites are common in the Indian subcontinent
Conclusion: Current recommended vancomycin dosing and Sri Lanka. In the past, hump-nosed vipers (HNV) were
regimensdo not achieve recommended target trough levels. considered moderately venomous snakes whose bites result
Increase in dosing to 60 mg/kg/day failed to achieve TTC ≥15 mainly in local envenomation. However, severe local effects,
μg/ml in most patients. Alternative treatment practices such as haemostatic dysfunction, microangiopathic hemolysis, kidney
use of loading dose or continuous infusion can be investigated injury and death have been reported following envenomation by
further. HNV. No specific or polyvalent antivenin (ASV) is available yet
for human use. A 13 year old girl sustained snake bite in her
Early use of Albumin in Severe Dengue right leg and was treated with multiple doses of ASV before she
developed anuric renal failure, coagulopathy and thrombotic
reduces Mortality - Myth or Reality? thrombocytopenic purpura (TTP). Blood investigations
1
Dipali Jambhale, 2Gnanam, 3Shivakumar showed poor increment to platelet transfusion with drop in
Fellow, 2,3Consultant, PICU Manipal Hospital Bangalore
1
hemoglobin with out any clinical evidence of blood loss. Further
1
dnjambhale@gmail.com investigations revealed a LDH of 2540 U/L, high reticulocyte
count, schiztocytes and giant platelets on peripheral smear. HNV
Background: Children with Severe Dengue present with envenomation was presumed in view of the clinical history,
significant plasma leak, resulting in shock and multiorgan presence of HNV in the geography and poor response to ASV.
failure. Early replacement of the lost plasma volume, with She was started on haemodialysis and supported with blood
appropriate fluids is the key to uneventful recovery. This is the products for coagulopathy. Plasmapheresis was initiated for TTP
first study from India demonstrating the effectiveness of early and toxin removal. Her sensorium improved significantly after
use of albumin in severe Dengue. initiating plasmapheresis.
Methods: This retrospective study conducted at the PICU of Her LDH dropped to 450 U/L and renal function improved over
Manipal Hospital included children between 1 month and 18 next one week.

Plasmapheresis is an effective intervention for HNV simultaneous infection by both the viruses. Lack of knowledge
envenomation presenting with haemostatic dysfunction. In the of community regarding the preventive measures also acts as a
absence of a specific antivenin, plasmapheresis may be the predisposing factor.
only option available to remove ophidian protiens and toxins.
Plasmapheresis should be considered early in hump nosed pit
viper envenomation to attain rapid recovery.
Profile and practices related to
Mechanical Ventilation in Rural Pediatric
Heaptitis a Virus (Hav) and Hepatitis E Intensive Care Unit (PICU) of Gujarat
Virus (Hev) Coinfection in Pediatric Age Nikhil Shah1, Vandan Kumar, Hemal Dave,
Rahul Tandon, Krutika Tandon2
Group: A case series 2 year Resident, 2Professor & PICU incharge, Department of
1 nd
Handa S.1, Wasim S.*, Pandita N.*, Pediatrics, Pramukh Swami Medical College,
Kalra B.P.*, Chandar V.* Karamsad-388325(GUJ)
2 year Pediatric Resident, *Department of Pediatrics,
1 nd
M: 9879531972; Email: krutikart@chrutarhealth.org
2
Himalayan Institute of Medical Sciences (SRHU) Jolly Grant,

Dehradun, Uttarakhand-248140 Background: Well-equipped separate PICU and mechanical
1
M: 9760299332; Email: dr.shikha307@gmail.com ventilator support practices are rarity in smaller cities and rural
hospitals of India. Our aim is to share our experience of PICU of
Background: Hepatitis A and Hepatitis E virus, both are a rural tertiary care hospital.
entericalytransmitted, resulting into acute viral hepatitis in
Methodology: Retrospective descriptive study of 1084 PICU
developing countries. They pose a major health problem in our
patients between year 2010-2013. Data were retrieved from
country. We hereby present 6 cases of Hepatitis A and Hepatitis
medical record and analyzed completely in 216 patients for
Eco-infection.
demographic profile, Mechanical ventilator(MV) related
Methods: The study was conducted in department of pediatrics practices & outcomes.
Himalayan hospital, Jolly Grant. It is a retrospective study.
Results: 30% patients (338) required mechanical ventilation
Case files of all hepatitis A and E were reviewed and data was
in year 2010-2013. M:F ratio was 1.8:1 with age < 1 year
analysed.
37.04%, 1-11 years 51.39% and >11 years 11.58%. Majority
Results: In our case series of 6 patients, age group varies from (76.85%) of patients were referred cases & ~66% required
3-17years with4 males and 2 females patient. The most common immediate endotracheal intubation on arrival to our emergency
presenting symptom was fever seen in all 6 patients followed department. Improved survival (Mortality 6.25% vs 14.88%)
by vomiting seen in a 5 out of 6 patients. Although icterus was was seen in 22.2% patients transported in ambulance with
present in all 6 patients but was a presenting symptom in only staff & facility. Indications for MV were Respiratory-32.4%,
3 patients. On examination, 5 out of 6 patients presented with Neurological-29.16%, Circulatory failure-14.81%, others-23.6%.
hepatomegaly and with associated splenomegaly in 2 patients. PSIMV and Pressure A/C (80%) were most preferred initial
Peak bilirubin, ALT and AST levels were 9.95 mg/dl, 5592 IU/ modes whereas CPAP/PSV(75.7%) was preferred weaning
ml and 4221 IU/ml respectively, ranging from bilirubin 4-9.95 mode. 14% required prolonged(>7days) MV. 34.67% had
mg/dl, ALT 601-5592 IU/ml and AST 356- 4221 IU/ml. 2 out MV complications including VAP-1.85%, Atelectasis-2.78%,
of 6 patients had deranged coagulation profile for which FFP Postextubation stridor-15.74%. Vasopressors used in 73% &
transfusion was given. And 1 patient presented with features of Central line insertion done in 12.96%. Dialysis was done for
hepatic encephalopathy. The duration of stay varies from 6days 2.3%. Culture proven BSI,VAP& CAUTI were 7%, 2% & 0.9%
to 11days. No mortality was seen in are case series. respectively. Mean ventilator days were 3.98 (4.3 in discharged
Conclusion: Although HAV and HEV co infection is associated patients). Successful weaning & extubation was achieved in
with increased severity and mortality, this was not seen in our 107/216 (49.53%). Death rate was 12.96%. We compared our
case series. Co-infection of HAV & HEV is more common in results with other similar type of studies across the world.
pediatric age group because of the absence of natural immunity Conclusion: Well-equipped separate PICU driven by trained
in this age group. Also due topoor sanitation and contamination dedicated pediatrician led team can give comparable results at
of water, they are exposed to both HAV and HEV, and develop rural setting.

Financial and Emotional Burden and of NIV in acute respiratory failure and post extubation care.Twenty
one children (10M-11F) with mean age of 31months (2month-10yr)
Coping Strategies among Parents of received NIV, 16 as the initial mode of assisted ventilation and 5
Children Admitted to PICU for post extubation care. Fourteen out of 16 had type1 respiratory
Utkarsh Pandya1, Kushal Shah, Maithily Patel, failure. Cardiogenic pulmonary edema in 7, mild ARDS in 2, and
Jagdish Vankar, Krutika Tandon2, Ajay Phatak, pneumonias in 5. Two had type 2 respiratory failure. BIPAP mode
Somashekhar Nimbalkar was used in all cases with an oro-nasal interface.Mean FiO2 was
1
2nd year Resident), 2Professor & PICU Incharge, 0.45±0.099 with mean PEEP 6.7±0.9 cms H2O.Mean duration of
Department of Pediatrics, P S Medical College daily NIV was 21hours with time off for oral and eye care and some
Karamsad-388325, Dist.Anand(Guj) time off due to discomfort of NIV.
2
M: 9879531972, Email:krutikart@charutarhealth.org Pre NIV parameters showed a mean pH-7.36±0.05, PCO2-
33.5±11.1 mmHg, pO2-98.2 mmHg, HR-156±29 per min, RR-
Background: In India, direct out of pocket expenditure on 50.7±12.4 per min. Parameters after 12 -24 hours on NIV showed
healthcare is about 70%. Taking care of ill child is also equally a pH-7.41±0.02, PCO2- 30.6± 7.5mmHg, pO2-134.5±20 mmHg,
draining financially and emotionally. HR-115.6±14.5 per min, RR-31.7±6.5 per min respectively.
Methods: Cross-sectional observational study at PICU of rural There was 76% improvement in heart rate and 62% in respiratory
tertiary care hospital. 75 parents were interviewed 1-2 days prior rate. NIV was effective in preventing intubation in 17 (81%).
to discharge including measurement of emotional burden by Four patients required invasive mechanical ventilation, 2 due to
Patient Health Questionnaire(PHQ-9). Descriptive statistics was worsening lung condition and 2 due to hemodynamic instability.
used to analyzed data. Mean duration of ICU stay was 56.6±47 hours. Problems
encountered were mask related injury in 10 (47%), asynchrony in
Results & Discussion: The mean age of the fathers(55) and
7 (33 %) and leak of air from interface in 6 (28%). Mild sedation
mothers(20) were 30.8(SD 5.36) & 30.14(SD 4.28). Most
was used to improve synchrony in selected cases.
mothers were housewives and fathers had Jobs. Majority were
from rural background with joint family predominance(64%). NIV was effective in preventing invasive ventilation in 81%
The median monthly income of family was Rs.4500/-. None had of patients when used judiciously. However close monitoring
health insurance in any form and12% of families had BPL status. and nursing attention is needed to prevent complications and to
Common reasons of PICU admission were respiratory(26.7%), improve comfort and acceptability of NIV.
neurological(22.7%), trauma(10.7%) and others(26.7%). Median
PICU stay and hospital stay were 5 & 7 days.The median medical
and non-medical costs were Rs. 28,500/- and 900/- respectively.
Health Care Associated Infection
The median(IQR) lost productivity for father was 6 days. One Surveillance: Nurse led audit
episode of illness costs almost 7 months income with Median Saiyed M, RN, Paul PM RN, Mhatre D, Solomon R
income to cost ratio of 0.15. PD Hinduja Hospital, Mumbai
Email: rekhasolomon1@gmail.com
Financial coping strategies were borrowing money from
friends/relatives(45.3%) and from moneylenders(8%) and from Health Care Asssociated Infection (HAI) is an important cause
saving(6.7%). Use of PHQ-9 revealed 14.9% parents had mild of morbidity and mortality in sick patients admitted into PICUs.
depression. Parents preferred friends/neighbours over other
relatives for personal and emotional support. Review of literature Aims: Toaudit the rate of healthcare associated infection in/from
suggested that environment and demographic characteristics of our PICU.
population are likely to affect the level of stress in parents of Methods: All children 0-18 years with Ventilator Associated
critically ill or injured child. Pneumonia (VAP), Central Line Related Blood Stream Infection
Conclusion: Friends/relatives/neighbours were major financial (CRBSI) and Catheter Associated Urinary Tract Infection
and emotional support. None had healthcare insurance. (CAUTI) between January 2014 to June 2015were included.
Diagnosis of HAI was based on Centre for Disease Control/
National Health and Safety Network(NHSN) definitions. Nursing
Non-Invasive Ventilation in Children - staff recorded prospectively and daily the number of patients on
Efficacy and complications invasive devicesas well as details of microbiology samples sent
Ganesh Kharche1, Lakshmi Shobhavat, Shivhar for suspected HAI.
Sonawane, Uma Ali Results: There were 537 admissions during the study period.
1
Fellow PICU, Pediatric Intensive Care Unit, VAP occurrence rate was 10 per 1000 ventilated days. The most
B J Wadia Hospital For Children, Mumbai common organisms were Multi Drug Resistant Acinetobacter
Email: gkharche26@gmail.com and klebsiella. CRBSI rate was13.9 per 1000 Central line days.
CAUTI rate was 24per 1000 urinary catheter days.
A prospective observational study was conducted in our 12-bed
paediatric intensive care unit, to assess the efficacy and complications Discussion: The CRBSI and CAUTIrates in our unit is five-fold

higher than that seen in the International Nosocomial Infection Alarming rates of cerebral edema at
Control Consortium(INICC)’s ICUs (13.9vs 4.9 for CRBSI and
24 vs 5.5). The VAP rate was lower(10 vs 16.8).
presentation in children with diabetic
Conclusion: Regular surveillance and engagement of the entire
ketoacidosis (DKA)- A case to ponder
health care team is an important part of infection control along Rashmi Kapoor*, Anurag Bajpai, , Rishi Shukla,
with a regular education programme. Divya Agarwal, Abhishek Singh
*Director Division of Pediatric Intensive Care and
Type of study: Retrospective audit
Pulmonology, Department of Pediatric Critical care,
Regency Hospital, Kanpur
Vancomycin Dosing and Therapeutic M: +919839027448
Drug Monitoring in Pediatric Patients Background: Cerebral edema is the leading cause of morbidity
with Serious Infections and mortality in DKA. While clinical cerebral edema occurs in
Dimpi Mhatre, Rekha Solomon*, Soonu Udani 1-2% children with DKA in west, limited Indian studies suggest
PD Hinduja Hospital,Mumbai much higher figures. Identification of risk factors for the same
*Email: rekhasolomon1@gmail.com would help in timely identification and treatment of the condition.
Objective: To evaluate the prevalence and risk factors for
cerebral edema in children with DKA.
Introduction: The recommended dosing to achieve therapeutic Design: Ongoing prospective observational study (January
trough concentrations of vancomycinis15-20 mg/kg. 2014- August 31 2015).
Aim: To investigate if current recommended dosing of Results: Fifty-one children (30 boys, 9 months-18 years) presented
Vancomycinachieves target trough concentrations (TTC) in with DKA (32 first episode, 19 recurrent) over the study period.
pediatric patients with suspected/ known MRSA infections. Fifteen children developed cerebral edema (10 on admission) with
Methods: Fifty-one trough levels in 45 children aged 1 month to ten requiring mechanical ventilation. Cerebral edema was present
18 years, receivingVancomycin therapy in doses of 40 to 50 mg/ at presentation in 10, developed within 12 hours in 5 and after 12
kg/day (group A) or 55 to 65 mg/kg/day (group B)for suspected hours in 1. All children had normal outcome with the exception of
(febrile neutropenic or CRBSI) or proven serious infections were a six-year-old girl with very severe metabolic acidosis and cerebral
studied retrospectively.Chi-square/ Mann-Whitney Utest used edema at onset died at 12 hours of treatment. Risk factors of
for differences in characteristics between patients that achieved cerebral edema included fluid/insulin treatment prior to admission
TTC (≥15 μg/ml)and those that did not (<15 μg/ml). (46.6% versus 8.5%), fresh diagnosis of diabetes (86.5% versus
63.3%) and severity of metabolic acidosis (base excess -23.9 ± 3.8
Results: Most patients (91.2%) received empiric therapy,only
versus -18.8 ± 6.7, p 0.02).
4(8.8%) had positive MRSA cultures. With 12/51(23.5%)
achieving TTC, dose levels did not correlate with trough levels Conclusion: Cerebral edema is alarmingly common in Indian
(Spearman’s r=-0.11, p=0.43). There were 21(46.6%) and children with DKA with over half having it at the time of
24(53.3%) patients in group A and group B, respectively. While diagnosis. Careful monitoring and management is essential
8(33%) in group B achieved TTC, only 2(9.4%) in group Ahad for children with fresh diagnosis of diabetes, severe metabolic
achieved TTC. Patients that achieved TTC were more likely to acidosis and those who have received treatment before admission.
be younger (p=0.07, effect size=0.32) and belong to group B Key Words: DKA, children, cerebral edema.
(p=0.07, effect size=0.28) than those that did not achieve TTC.
Achievement of TTC did not affect clinical outcomes. None of
our patients showed nephrotoxicity as a result of vancomycin Serum Lactate as Marker of Severe
therapy. Dengue
Conclusion: Current recommended vancomycindosing Sarika Gupta
regimensdo not achieve recommended target trough levels. Assistant Professor, Department of Pediatrics, KGMU,
Increase in dosing to 60 mg/kg/day failed to achieve TTC ≥15 Lucknow, India
μg/ml in most patients. Alternative treatment practices such as Email: sgguptasarika@gmail.com
use of loading dose or continuous infusion can be investigated
further. Background: Early diagnosis of severe dengue during febrile
stage is essential for adjusting appropriate management. As
Type of study: Retrospective observational severe dengue patients develop shock and experience hepatic
injury also, it means that serum lactate may be elevated in
such patients.The study was done to determine the association
between serum lactate and severe dengue.
Methods: This was a hospital based reterospective study

conducted in the Department of Pediatrics at King George’s Discussion & Conclusion: Patients with GCS<9, PTS<8,
Medical University from July 2013 to July 2015. Included in the RTS<11 had significantly higher morbidities, longer hospital
study were children aged 1 to 12 years with clinically suspected stays, ventilation requirements and neurodeficits at the time of
dengue. Laboratory confirmed cases were confirmed by IgM discharge.
ELISA or by NS1antigen detection test. WHO classification, Type of study: Prospective longitudinal study
2009 was used for diagnosis of severe dengue. Serum lactate on
the day of admission was compared among severe dengue and GCS- Glassgow Coma Scale, PTS- Pediatric Trauma Score,
non-severe dengue. RTS- Revised Trauma Score
Results: About 173 clinically suspected dengue patients were
enrolled among which, 135 (78.0%) were laboratory-confirmed. Is Positive Fluid Balance Increases
Among laboratory-confirmed dengue, 89 (65.9%) developed Mortality in Children with Septic
severe dengue. The presentation of severe dengue were headache
(OR=3.1; 95 % CI=1.3-7.4; p=0.005), seizures (OR=52.6;
Shock? Experience from a Tertiary Care
95% CI=7.2-1072.3; p<0.001), basal crackles (OR=2.3; 95 % Paediatric ICU
CI=1.0-5.4; p<0.05), prolonged capillary refill time (OR=4.6; Tanuj*, Manivachagan, Pragathesh,
95% CI=1.5-14.7; p=0.003), tachycardia (p=0.030), decreased Jolly, Kala, Ebor Jacob**
systolic (p=0.022), diastolic (p<0.001) and pulse pressure Paediatric ICU, CMC, Vellore
(p=0.001).The significant laboratory findings included elevated Email: *doc_tanujkgmc@yahoo.co.in, **eborjacob@yahoo.com
serum levels of aspartate transaminase (p=0.002), alanine
transaminase (p=0.040) and lactate (p<0.001). On regression Objective: We hypothesize that patients with septic shock who
analysis, adjusting for age, gender, place of residence and achieve positive fluid balance on the first 3 days are more likely
duration of illness, serum lactate>3.2 mmol/L was found to be to have increased mortality.
associated with severe dengue. Design: Retrospective study by reviewing the charts
Conclusion: serum lactate may be used as a marker of severe Setting: Eleven-bed tertiary level PICU of a tertiary care
dengue. hospital.
Methods: Medical records of patients admitted over a 36-month
Prospective Observational Study on period were reviewed. Patients with prior CKD, needed dialysis
Pediatric Traumatic Brain Injury at and severe dengue were not included. Admission PELODS
Tertiary Care Center (Paediatrics Logistic Organ Dysfunction Score) was measured.
Children were stratified into those who achieved positive balance
Darshak Makadia, Saket Zanzmera, Jignesh Patel, at the end of 72 hours of admission and those who achieved
Jigesh Vaidya, Nirmal Choraria negative balance at the end of the same time period. Survival risk
Email: d_makadia@yahoo.co.in ratios (RRs) were used as the measure of association between
positive fluid balance and mortality rate.
Background: Traumatic brain injury is the most common cause
of death and acquired disability among children in developed Results: Seventy patients fulfilled the criteria for septic shock
countries. This study was planned to evaluate the correlation in but we could review only 40 charts at present.Patients ranged
clinical profile, risk factors and outcome of Pediatric Traumatic in age from 7 days to 18 yrs with a median (6 SE)age of 6.3 + 2
Brain Injury at the Tertiary Care Centre. years. Mean admission PELODS score was 25.4+ 1.4. Twenty
nonsurvivors had higher mean PELODS scores (29.8 vs 16.4,
Method: This study was conducted at Nirmal Hospital Pvt. Ltd.
respectively) and positive fluid balance as compared to patients
between 1st July, 2012 to 31st May, 2013. A total of 40 head injury
who survived. All 15 patients who achieved a negative balance
children fulfilling inclusion criteria during study period were
after first 3 days of treatment survived. Only 5 of 40 patients who
included. After obtaining above data Patients were categorized
had a positive fluid balance by the third day of treatment survived
in PTS and RTS.
(RR, 5.0; 95% CI, 2.3 to 10.9).Net positive fluid balance after the
Results: Boys constituted 67.5% of the study population;common first 3 days of treatment is associated with increase mortality .
age group was between 1-5 years (50%). All children had blunt head
Conclusion:
injury. 50%had history of fall from height & 35% had road traffic
accident. 82% cases presented within 1 hour of injury. GCS<9 at Results suggest that positive fluid balance achieved by the third
arrival to ER was seen in 20% cases. PTS<8 in40% &RTS<11 in day of treatment may be associated with increased mortality in
27% cases. Linear skull fracture was commonest finding (75%) patients with septic shock.
in CT Brain. Seizure was noted in 30% of cases. 32% required
mechanical ventilation &97% of the children survived.

A Single Centre Open Labeled 12 years) ventilated for at least 48 hours were randomized to
receive dexamethasone (n= 42) and placebo (n=38). Stridor
Randomized Controlled Trial Comparing scoring was done using Westley stridor score. Whenever stridor
Hemodynamic Response of Vasopressin score exceeded 4, nebulized adrenaline was given. Reintubaton
and Noradrenaline in Dopamine was done when patient had significant respiratory distress /
fatigue.Patient’s vitals were monitored hourly. Data was analyzed
Resistant Fluid Refractory Warm Shock using SPSS software.
in Children (Vadorest Trial)
Results: There was no significant difference in frequency of PES
R Saxena*, Ebor Jacob**, Pragathesh, Jolly, Kala, (42.8% in dexamethasone group and 55.2% in placebo group,
Manivachagan p=0.26). The onset of stridor was earlier in placebo group but not
PICU, CMC, Vellore significantly different (p=0.46). The mean stridor score at all the
Email: *drromit@gmail.com, **eborjacob@cmcvellore.ac.in
time intervals was more in placebo group.
Background: Sepsis is the most frequent cause of vasodilatory Discussion: The two groups had similar baseline characteristics.
shock. Use of vasopressors in treatment of warm septic shock Anene et al (p<0.001), Malhotra et al (p=0.004) found a higher
viz. vasopressin and norepinephrine(NE) is still open to debate. incidence of PES in placebo than dexamethasone group whereas
Aims: To study the hemodynamic response (as defined by change Tellez et al (p=0.21), Saleem et al (p=0.5) didn’t find any
in heart rate, mean arterial pressure, systolic blood pressure, difference in PES incidence in two groups.The onset of PES was
sensorium, urine output, lactate, base excess) of Vasopressin earlier in placebo group compared to dexamethasone group in
and Noradrenaline at 3 and 6 hours after starting vasopressors in study by Cesar and Baranwal et al.
dopamine resistant, fluid refractory warm shock. Conclusion: We didn’t find any difference in frequency of PES
Methods: This is a single centre, open labeled, randomized in patients receiving dexamethasone/ placebo. Onset of stridor
controlled trial with intention to treat principle. was earlier and mean stridor score higher in placebo group but
not statistically significant.
Patients were treated according to the PALS/ACCM guidelines.
When they reach the fluid refractory dopamine resistant state they Type of Study: Original research
were randomized into vasopressin and norepinephrine group.
Results: Between January to June, 2015, 445 patients admitted Calcium, Phosphate and Vitamin D
to PICU. Among these, 17 children fulfilled inclusion criteria; Abnormalities in Critically Ill Children
five excluded. Twelve children were enrolled for the study. Shipra Agrwal*, Urmila Jhamb**
At the end of six hours, 7 out of 12 patients had met all the *Post Graduate 3rd Year, **Director Professor, Incharge PICU,
therapeutic goals. Among these, 5 were in the norepinephrine Maulana Azad Medical College, New Delhi 110002
subgroup, while 2 children were in the vasopressin subgroup. In *Email: shiprapaeds@gmail.com
the norepinephrine group, the mortality rate was 42.8% where as
in the vasopressin group, the corrected mortality was 40% . Background/Rationale: Abnormalities of calcium, phosphorus
Conclusions: As per this study, vasopressin may be as effective and vitamin D are common in critically ill children. This study
as norepinephrine in fluid refractory, dopamine resistant warm was planned to determine the prevalence of these abnormalities
shock. in critically ill children and their association with the outcome.
Method: This was a cross sectional study performed in the PICU
of a tertiary care hospital. Total 135 critically ill children older
Role of Steroids in Prevention of Post than 1 month were enrolled. Blood samples were collected within
Extubation Stridor in Ventilated Children 24 hours of admission for serum calcium (total and ionized),
Ritu*, Urmila Jhamb** phosphate and 25OH vitamin D and albumin. Data was analyzed
*Post graduate Trainee (final year), **Director Professor, by SPSS 16.0 software using appropriate statistical tests.
Incharge PICU, Department of Pediatrics, Maulana Azad Results: Incidence of total and ionized hypocalcemia was 9.6%
Medical College, New Delhi. and 22.9% respectively. Hypophosphatemia was present in
*M: +91-8527841107; Email: season.ritu9@gmail.com 28.8% and hyperphosphatemia in 10.3%. Vitamin D deficiency
was present in 85.9%. Total hypocalcemia was significantly
Background: Post extubation stridor (PES) caused by laryngeal
associated with fluid bolus and inotrope requirement (p = 0.007
edema is a serious complication of extubationoccurringin 11-
and 0.012 respectively), sepsis (p <0.001) and mortality (p =
20% of patients.There is no consensus on role of corticosteroids
0.006). Mortality was significantly higher among the patients
in prevention of PES.
with abnormal serum phosphate levels (p = 0.033 and 0.009
Methods: A randomized, double blind, placebo controlled study for hypo and hyperphosphatemia respectively). There was
was conducted in the Pediatric Intensive Care Unit (PICU) of a no significant association of vitamin D deficiency with PICU
tertiary care hospital to find the effect of dexamethasone versus morbidities and mortality.
placebo on PES and reintubation. About 80 children (2 months-

Discussion: Incidence of hypocalcemia was lower than hypertensive emergency with SIADH. We discovered upon
other studies. Other studies have also found association of laboratory investigations elevated urine porphobilinogen and low
hypocalcemia and hypophosphatemia with PICU mortality. serum sodium. The constellation of symptoms and the elevated
Conclusion: Calcium, phosphate abnormalities are associated porphobilinogen suggested the diagnosis of Porphyria. We would
with poor outcome in critically ill children. Vitamin D deficiency like to believe this is an interesting case, which demonstrates a
is common in the critically ill children but not associated with number of combined clinical features in a child.
poor outcome.
Type of Study: Original research.
Moya Moyadisease: A case report

Sehgal P1, Wasim S1, Pandita N1,
Kalra B.P1, Chander V1, Saini M2 Dry, thickned, fish scale lesion all over body more in trunk
1
Department of Pediatrics, 2Department of Radiodiagnosis,
Icthysis vulgaris
HIMS, Dehradun.
1
Email: parulsehgal9@gmail.com
Study of Clinical Profile of Patients with
Introduction: Moya moya diseaseis a rare, progressive
cerebrovascular disorder caused by blocked arteries at the base of Acute Kidney Injury and Outcome in
the brain. Magnetic resonance Angiography is the investigation PICU - A one Year Retrospective Study
of choice. Conducted in PICU of Tertiary Care
Method: We present the case of a 7 year old female presenting Medical Centre
to the Department of Pediatrics, HIMS Dehradun with recurrent Rakesh Gami*, Vanishree Tammanagoudar*,
stroke who was subsequently diagnosed as Moya Moya Disease
Prithi Inamdar**, M V Patil***, Roopa Bellad***
on MRA.
*Post Graduate, **Associate Professor,* **Professor
Case Report: A 7 year old female presented in pediatricemergency Department of Pediatrics, JN Medical College, Belgaum
with left sided focal seizures. The patient had UMN type of *Email: rggami@gmail.com
left facial nerve palsy and left hemiparesis. There was history
of recurrent episodes of left sided hemiplegia, the first episode Introduction: Acute kidney injury is characterized by a rapid
occurring at 3 years of age, with slowly progressive mental reduction in kidney functions resulting in failure to maintain
impairment. A diagnosis of recurrent stroke was made. A fluid, electrolytes and acid-base homeostasis. It is an independent
diagnostic MRA was done and there was non visualisation of predictor of mortality in children admitted in PICU. AKI has now
ICA artery with multiple collateral formation, on the basis of replaced ARF. This study is performed to know clinical profile of
which a diagnosis of Moya Moya disease was made. Patient was AKI and outcome of AKI patients in PICU.
started on oral aspirin and neurosurgical opinion was sought. Objective: To determine incidence, clinical profile and outcome
However the patient was lost to followup. of AKI in children admitted in PICU.
Discussion: The cause of Moya Moya disease is mainly Material and Method: Study design: Retrospective study,
congenital, but is also seen secondary to other conditions. Our Study Period: 1st July, 2014 to 31st June, 2015, Inclusion
patient was investigated to rule out secondary causes. Criteria: All children admitted in PICU, Exclusion Criteria:
Conclusion: A child with Moya Moya disease presents typically Children with pre-existing chronic kidney disease, Place of
with recurrent episodes of sudden hemiplegia that might occur Study: PICU, Department of Pediatrics KLE Hospital, Belgaum
on alternate sides.The disease is progressive and dynamic Result: Total 615 admitted in PICU during study period, out of
in children. MRA clinches the diagnosis and neurosurgical which 3 are excluded. Total 612 children included in study out
intervention may be required as a part of definitive management. of 71 children had AKI. Most of them are <1 year of age (49%)
followed by 1-5 years (28%). Most common cause of AKI in
Case of Porphyria with Icthyosis Vulgaris these childrens are Congenital Heart Disease followed by Renal
disease like HUS, Nephrotic syndrome. Mortality was seen in
Upendra Kumar 69% of ventilated patients with AKI.
Email: ukg444@gmail.com
Conclusion: In our study, common cause of AKI in emergency
A 9 year male child 3rd degree of consanguineous marriage care is Congeniral heart disease with 2nd most common cause
brought us complain of Fever, Abdominal pain, vomiting, seizure is Renal diseases like HUS and Nephrotic syndrome. Serum
and history of Prolong fasting in ramzan and red coloured urin creatinine is not an early marker to predict AKI in PICU setting
with ithyosis vulgaris. Admitted in PICU simultaneously treat but is a very reliable tool for assessing the progression to AKI.

Unusual Manifestation of Snake Bite in Discussion: HLH is a multisystem illness characterized
by fever, organomegaly, cytopenias, hyperferritinemia,
Children - A rare case of snake bite with hypertriglyceridemia and hemophagocytosis on bone marrow. In
multiple organ failure our analysis we found that 5 had either EBV or Dengue infection,
Vanishree T, Rakesh G, Roopa B, 1 developed HLH post tetralogy of Fallot repair, and 1 patient
Abhilasha S, Dhyanesh Dk had associated central diabetes insipidus. Fever, splenomegaly
Department of Pediatrics, JN Medical College, Belgaum and hemophagocytosis on bone marrow were the most common
findings. Liver dysfunction was found in 67% of the patients.
Abstract: In any language of the world, snake produce’s Conclusion: HLH is a multisystem illness with variable
unimaginable fear and anxiety. Right from the cases where presentations and high mortality. Clinicians should have high
earliest man lived, snakes would have caused first kind of index of suspicion regarding this illness since prompt recognition
poisoning. India has about 216 varieties of snakes of which and targeted therapy improves outcome of such patients.
about 52 are venomous and of these only 4 varieties of snakes
are commonly encountered as the cause of snakebite poisoning.
These are Russell’s viper, Echis Carinatus, Cobras and pit Outcome of Pediatric Oncological
viper. Most common presentation of snake bite in children are Emergencies Admitted to a Tertiary
local pain, swelling, ptosis, respiratory difficulty and altered
sensorium. We reported a case of 8 years of male child presented
Level Pediatric Intensive Care Unit
with history of snake bite over left ankle followed by which he Sanjay Paida*, Santanu Sen,
develoed swelling of left leg and developed Acute Kidney Injury Vinay Joshi, Preetha Joshi
after a week and gradually child had Acute Respiratory Distress Kokilaben Dhirubhai Ambani Hospital, Mumbai
Syndrome and Pancreatitis. All necessary investigations send *Email: sanjaydoc6486@gmail.com
and management done accordingly. Child is discharged after 3
Background: Outcome of pediatric oncological emergencies
weeks of hospital admission and is being followed up.
has steadily improved in last two decades. However, febrile
neutropenia and number of organ system failure are important
Clinical Profiles and Short Term prognostic factors in these patients.
Outcomes of Pediatric Hemophagocytic Methods: We conducted retrospective analysis of 27 admissions
Lymphohistiocytosis in a Tertiary Care of 24 children in the age group 1 month to 18 years with
oncological emergencies admitted to tertiary level pediatric
Hospital intensive care unit of Mumbai.
Sanjay Paida*, Santanu Sen, Preetha Joshi,
Results: Overall survival in this group was 77%. In patients with
Vinay Joshi
one and two organ system failure, survival was 100% whereas
Kokilaben Dhirubhai Ambani Hospital, Mumbai
*Email: sanjaydoc6486@gmail.com in patients with more than three organ system failure, 100%
mortality was found. We found that children with associated
Background: Hemophagocytic lymphohistiocytosis is a febrile neutropenia had 30.8% mortality as compared to 14.3%
multisystem illness with variable clinical presentation. Mortality in non-neutropenia group. Mean duration of ICU stay was more
is high in the pediatric age group, especially infants. Therefore in AML group as compared to ALL group.
early detection is a strong factor for better outcomes. Discussion: Outcome of pediatric oncological emergencies has
Methods: We conducted a retrospective analysis of 12 HLH improved form 75-80% mortality to 75-80% survival over last
patients diagnosed by HLH 2004 criteria from age group 2 few decades. In our analysis we found 77% survival of these
months to 15 years admitted to a tertiary level pediatric intensive patients which is comparable to current western literature. In our
care unit from January 2009 to July 2015. study, we found that febrile neutropenia was a bad prognostic
factor for mortality. We found that children with AML had more
Results: In our analysis we found that out of the 12 patients, 2
frequent need of advanced mode of ventilation like HFOV.
had primary HLH and 10 patients had secondary HLH. Dengue
We found that encephalopathy and shock were most common
and EBV were the two infections associated with HLH. Fever
indication of PICU stay and PRES was the most common cause
and splenomegaly were the most common clinical features in
of encephalopathy.
these patients. Out of the 12 patients, 8 had liver dysfunction and
4 went into spontaneous remission, 1 underwent bone marrow Conclusion: Overall survival of pediatric oncological
transplant and rest were treated as per HLH 2004 protocol. emergencies has greatly improved over time. In these patients,
Mortality rate was 40%. febrile neutropenia and the presence of more than 3 organ system
failure carries poor prognosis.

Arterial Thrombosis in Children - in reducing the incidence of HAI among critically ill children
admitted in PICU.
What Can We Offer?
Methods: This interventional study was done in PICU of
Jolly Chandran*, Pragathesh, Manivachagan,
CMCH, Vellore. In this study all enrolled children were given
Kala E and Ebor Jacob chlorhexidine wipe after routine soap bath. The incidence and
Paediatric ICU, CMC, Vellore
*M: 91-416 228 3366; Email: jolls@cmcvellore.ac.in
prevalence of HAIs were observed and compared with historic
controls (Same period of the previous year).
We describe three children with femoral arterial thrombus Results: In the intervention group the total number of ventilator
managed successfully with thrombolytic therapy in all and and line- days was 777 and 1377 respectively. The incidence
thrombectomy in one child. of VAP was 6.43/1000 ventilated -days with a prevalence of
Case History: Nine month old baby with congenital rubella 2.5% and the incidence of CRBSI was 3.6/1000 line- days with
syndrome with PDA in cardiogenic shock was ventilated. Central prevalence of 2.5%.
venous catheter was inadvertently placed into the femoral artery In the pre- intervention period group, the number of ventilated
which developed thromboses confirmed by Doppler. He was -days was 696 and catheter- days was 1432. The incidence of
initiated on Heparin infusion in the same catheter at 5 units/kg/ VAP was 12.93/1000 ventilated days with prevalence of 3.2% and
hr and 6 hours later tPA (tenecteplase @0.05mg- 0.1/kg/hr) was the incidence of CRBSI was 4.2/1000 days with a prevalence of
infused for a period of 24 hours. Limb perfusion improved and 2.2% with a significant p value (<0.001) in VAP. The organisms
repeat Doppler showed no residual thrombus. were similar in both the groups.
Five months old baby with Acyanotic heart disease was admitted Conclusion: The use of chlorhexidine wipes in ICU significantly
with Acute gastroenteritis and hypovolemic shock. Central reduced VAP among the children admitted to the PICU with non
venous catheter was inadvertently placed into the right femoral significant reduction in the CRBSI.
artery which was removed immediately. Developed thrombus
which was confirmed by Doppler. Initiated on heparin infusion
@ 10units/kg/hour and tenecteplase (tPA) @0.05mg-0.1mg/kg/ Disorders of Sex Development with Genital
hr. Repeat Doppler showed dissolution of the thrombus. Ambiguity: Real Social Emergencies
Two years old boy with PDA underwent device closure was Santosh B Kurbet, Harshasree G, M V Patil,
noticed to have cold peripheries with absent pulses of the right Abhilasha S, Prashanth G P, N S Mahantshetti,
lower limb with common iliac artery thrombotic occlusion. Mahesh Kamate, V D Patil, R M Bellad, S M Jali, S
Heparin infusion was started; subsequently he underwent Chate, P Malur, Andaleeb, Mukul
thrombectomy. His lower limb perfusion improved. J N Medical College, KLES Dr. Prabhakar Kore Hospital,
Discussion: Thromboses of arterial line is a known complication KLE University, Belgaum, Karnataka
in children especially with risk factors. It is interesting to note all Email: harshasreeg@gmail.com
children had underlying congenital heart disease. Thrombolytic
Aims: To study the management and psychosocial issues
therapy `helps in dissolution of the clot as well as restoring the
with respect to early assignment of sex in Disorders of Sex
perfusion of the ischemic limb. Recombinant TPA along with heparin
Development (formerly, -pseudo/hermaphrodite/intersex) with
infusion has been recommended for clot lysis by International
ambiguous-genitalia.
society of thromboses and hemostasis. Congenital heart disease and
cardiac cathetrisation pose a higher risk for arterial thromboses. Methods: A prospective observational-study was planned. The
study population included all children presenting to tertiary-
care-centre with ambiguous-genitalia. Managed by team-of
A Prospective Interventional Study to pediatricians, pediatric-surgeon, endocrinologist, pediatric-
Determine the Effect of Chlorhexidine neurologist, pathologist and psychiatrist. The study protocol
Wipes in Reducing the Incidence of included prospective recording of presenting-complaints,
family history, sex of rearing and behavioral-pattern. External
Hospital Acquired Infections among genital-examination and laboratory work-up findings were also
Critically Ill Children Admitted to a noted. Karyotyping, hormonal-studies, pelvic ultrasonography,
Paediatric Intensive Care Unit genitogram, genitoscopy, skin biopsy, laparoscopy and gonadal-
Madhan Kumar*, Jolly chandran, Ebor Jacob biopsy were done in these patients accordingly. Children were-
assigned appropriate-sex at the earliest and genitoplasty was
Gnananayagam, Manivachagan MN, Pragathesh,
carried out. All children were followed up regularly.
Hema paul, Kala Ebenezer**
PICU and HICC, CMCH, Vellore – 632004, India Results: A total of 11 children were recruited between Jan
Email: dr_madhankumar@yahoo.com 2009-Dec 2014. Age at presentation ranged from newborn to
14-years. Repeated and thorough counseling was major part of-
Objective: To determine the effect of chlorhexidine wipes management. Four patients were assigned male-sex, maculinising

genitoplasty was done, and four were assigned female sex with Conclusion: High index of suspicion for hypermagnesemia
feminizing-genitoplasty. Three children are currently under should be kept in children with appropriate clinical signs and
observation. The patients were followed up for a mean period magnesium should be checked along with other electrolytes.
of 3 years. All children who underwent surgical reconstruction
had good results except one patient who had fistula requiring
redosurgery. Most parents of treated children are satisfied with
Prevalence of Vitamin D Deficiency
the cosmetic-outcome and assigned sex. in PICU
Conclusion: Our study strongly suggests expeditious Dr Jhuma Sankar
investigations to determine the sex & early gender assignment All India Institute of Medical Sciences, New Delhi
Tel.: 01126593209; Email: jhumaji@gmail.com
may relieve these pts & parents of social stigma and has a good
psychosocial impact. Our study may serve as a pilot work for
Objectives:To evaluate the prevalence of vitamin D deficiency
long-term studies comparing early assignment of sex with
at admission and after 72 hours of ICU stayin children with fluid
delayed approach in children with DSD.
refractory septic shock. We also evaluated the association of vitamin
D deficiency at admission with clinically important outcomes.
Grandma’s Constipation Concoction Methods: In this prospective cohort study we enrolled children
Causes Devastation aged ≤ 17 years admitted to PICU over a period of 6 months.
Kunal Kumar*, Rajesh Kumar**, Krishna Kumar*** We estimated serum 25 (OH) D levels at admission and after
*Registrar MD (Pediatrics), IDPCCM, MRCPCH, **Medical 72 hours of stay and collected information for evaluating the
Director MD (Pediatrics), DM (Neonatology), ***Senior association of vitamin D deficiency with clinically important
outcomes. Data was analysed using STATA 11.
Consultant Pediatrician MD (Pediatrics), MRCPCH,
Department of Pediatrics, Pediatric Critical Care unit,Rani Results: Thirty-seven children were enrolled in the study. The
Hospital, Ranchi prevalence of vitamin D deficiency at admission was 73%
*Email: drkunalkumar@yahoo.com (n=27/37; 95% CI:57 to 85). On day 3 it was 70 % (n=23/33; 53
to 83). The mean (SD) vitamin D levels declined from 8.7 (4.3)
Background: Symptomatic hypermagnesemia is rare in absence to 6.5 (2.8) after 72 hours of ICU stay and the difference was
of renal failure and usually goes undetected as it is not routinely statistically significant (p=0.04). On univariate analysis the need
tested. for fluid boluses and inotrope score at 24 hours of ICU stay were
Case Characteristics: A 3yr old female child presented in an significantly higher in the group with Vitamin D deficiency (p
unresponsive state with gasping respiratory efforts with a history <0.05). However, on multivariate analysis only the need for fluid
of loose stools and vomiting for 1 day and one episode of seizure. boluses remained significant (OR (95% CI): 1.85 (1.45 to 4.06)).
Was immediately intubated and put on mechanical ventilation. Conclusion: The prevalence of vitamin D deficiency is high
Examination revealed a GCS of E1M1Vtube , bilateral mid dilated in children with fluid refractory septic shock admitted to PICU
pupils, absent DTR’s, hypotensive shock, pallor, crackles in right and the levels decline further during the course of illness. Need
axillary region and signs of dehydration.Vitals were stabilized for fluids may be higher in children with septic shock who are
after fluid resuscitation and vasopressors(dopamine@10mic/kg/ vitamin D deficient.
min and adrenaline @0.15mic/kg/min).Initially managed as a case
of suspected acute encephalitis/intracranial bleed and aspiration Keywords: Vitamin D deficiency; 25 (OH) D; Septic shock;
pneumonia.Investigations:Hb:5.7,TLC:30920(N80L16), Fluid refractory; Inotrope score; Outcomes; Prevalence
CRP<5, ABG:pH 7.267/paO2:72.9/paCO2 :19.6/HCO3 :8.7/
BE-16.7, creatinine:0.67,CXR:right lower zone consolidation, A Case Report Suggesting Role of N
CT head: Normal.Given intravenous fluids, blood transfusion
(2 units), systemic antibiotics, antiviral and anticonvulsants.
Acetyle Cystine in Management of Hepatic
On further history she was found to be on self medication with Encephalopathy due to Wilsons Disease
milk of magnesia (in varying amounts) for past 11/2 years for Lokesh Tiwari*, Gaurav Vishal, Chhitiz Anand,
constipation. Thyroid profile, TTG IgA, total IgA and lead levels Pratap Patra, Arun Baranwal
were normal. Taking clue from the history and clinical signs Department of Pediatrics,
(hypotensive shock/absent DTR/ respiratory/CNS depression), All India Institute of Medical Sciences, Patna
magnesium intoxication was considered and serum magnesium *Email: lokeshdoc@yahoo.com
level done which was elevated (7.12meq/L).She was given 1.5
times maintenance iv fluids, diuretics and parenteral calcium Background: Management of hepatic encephalopathy in
gluconate. There was serial decline in magnesium levels with children remains supportive. Use of N acetyle cystine (NAC) is
improvement in sensorium and decreasing pressor requirement. recommended in case of drug induced liver failure and some other
She was extubated on day 3 of admission (Mg 1.54meq/L) and conditions. We could not find any study supporting or refuting
had an uneventful further hospital course. role of NAC in hepatic encephalopathy due to Wilsons disease.
Case Report and Results: An 8 year old male child with hepatic

encephalopathy grade II, who was resuscitated in PICU, showed “information” for the nurses. The items those were included to
progressive worsening of encephalopathy with fall of GCS from the questionnaire concerning developing country situations were
13 to 8 over a week on recommended supportive therapy. His ranked high in importance.
viral markers for hepatitis A, B, C and E were negative. He Conclusion: The CCFNI with minor modifications can be used
was started on NAC infusion while serum ceruloplasmin level in developing countries for assessing the needs of families of
was awaited. Child showed progressive improvement even ICU children. The responses to needs relating to availability
before Wilson’s disease was confirmed and he was started on D of care ranked higher substantiating the heterogeneity of the
penicillamine. Child showed consistent clinical and biochemical population in places where third party payer system is not the
improvement and he was discharged after 4 weeks of hospital norm. Making sure the patient feels assured about the care
stay with GCS of 15. Presently under follow up, he has resumed given to the child should be the area of prime focus and timely
his school and he is able to perform all age appropriate activities. information regarding the child’s condition should be given the
Discussion: Role of N acetyle cystine in hepatic encephalopathy utmost importance in alleviating family anxiety.
has not been established in cases other than drug induced liver
failure but it seemed to be beneficial in this case. This case was
unique as his encephalopathy progressed over one week in spite
Viral Aetiology of Under 5 Children
of standard supportive management and rapidly improved after Admitted with Acute Respiratory
starting NAC even before starting chelation therapy for Wilsons Infection In PICU – A Prospective
disease.
Observational Study
Conclusion: It will be interesting to further investigate role of Saranya C, Sasidaran K, Reshma A, Ayyammal P,
NAC in management of hepatic encephalopathy due to Wilsons
Thangavelu S, Gowrishankar NC, Nedunchelian K
disease.
Mehta hospital, Chennai
Psychosocial Needs in a Pediatric Critical Background: Acute respiratory infections (ARI) are one of
the major causes of morbidity and mortality in young children.
Care Unit - A comparative study of The epidemiology of acute respiratory infection is constantly
careseekers’ and caregivers’ perspectives changing in which both viral and bacterial causal agents play
from a developing country various roles. This study was done to identify viruses associated
with primary acute respiratory tract infection among children
Reshma A, Sasidaran K*, Niranjan V, Ayyammal P,
less than 5 years admitted to PICU and requiring respiratory
Thangavelu S, Nedunchezhian K support or oxygen therapy.
Mehta hospital, Chennai
*M: +91 9940587408; sasidarpgi@gmail.com Methods: It is a prospective observational study. We enrolled
children aged 1 to 60 months admitted to PICU with primary
Background: Children in critical care units put an immense acute respiratory infection requiring minimum 12 hours of
psychological burden on the family members of the child. oxygen therapy between August 2014 and March 2015. Throat
Assessing the psychosocial needs of family members becomes swabs were taken for all children enrolled and viruses isolated
of paramount importance in this regard. This study was by RtPCR technique. We also performed a comparison between
designed to explore the needs of family member of children viral isolate positive and negative children with regards to
unexpectedly admitted to an Intensive Care Unit and rank the surrogate diagnostic markers and outcome measures
needs and compare with the perspectives of doctors, nurses and
Results and Discussion: Of 70 children who fulfilled the
administrators.
enrolment criteria, 35(50%) were found to have viral etiology.
Methods: This is an exploratory comparative study done Rhino virus was found to be the most common isolated in15
prospectively using a modified version of the Critical Care (42.85%) children followed by RSV accounting for 14(40 %)
Family Needs Inventory (CCFNI) to measure, rank and compare children. Of 22 children requiring advanced invasive ventilator
the needs and the Needs Met Inventory (NMI) to assess the level support, 9 children were found to have respiratory virus isolate.
of satisfaction of the needs. The study was done in a private Commonly used surrogate diagnostic markers like CRP, ALC,
sector pediatric ICU in south India. Responses of 35 consecutive and ANC were found to be not significantly different between
family members, 30 Pediatric acute care Nurses, 30 pediatricians the groups.
involved in intensive care and 30 administrators responsible for
Conclusion: Viral pneumonia is one of the common causes of
ICU decisions were recorded.
ARI in children mandating intensive care unit admission and
Results: The responses were ranked by means and analysed for viral pneumonia need not always be mild and self-limiting in
variance by univariate analysis and the responses were compared immunocompetent. In our observation, Human rhino virus and
between the care seekers’ and care providers. The needs ranked RSV were the two most common viral isolates and H1N1 was
highest by domain were “Assurance” for families, doctors and associated with disease severity.

Critical Care without Walls”- Impact Of period. Examination on admission showed dolichocephaly,
frontal bossing, hyperpigmented lesions over right cheek, nevus
A“Pediatric Emergency Team” on right side of neck and right gluteal region, hypertrophy of right
on Patient Outcomes half of face and right buttock. There was bilateral macrodactyly
Tahir Rehmatullah of great, Ist, IInd and IIIrd toe with hypertrophy of plantar surfaces
Fellow, PICU, Manipal Hospital, Bangalore with increased rugosities. Routine blood investigations were
tahirrehmatullah@gmail.com within normal limits. EEG showed generalized epileptiform
discharges. MRI brain suggested unilateral megalencephaly with
Background: Cardiopulmonary arrest in children is often a white matter changes and enlarged and distorted right ventricle.
gradual process, preceded by critical period of physiologic
instability, during which lifesaving interventions can decrease Child was diagnosed with PS on the basis of dysmorphic
the mortality and morbidity. we report the impact of a Pediatric growth and characteristic skin abnormalities. There are very
Emergency team (PET) on patient outcomes. We hypothesised few reports of association of PS patients with both epilepsy and
that introduction of such teams would improve patient outcomes. hemimegalencephaly. No specific treatment option is available
for PS. Management includes multidisciplinary treatment
Methods: This study was conducted at Manipal Hospital, approach involving Geneticist, Neurologist, Dermatologist along
comparing outcomes before and after introduction of the Pediatric with family support.
emergency team. The pre-intervention period was between
October 2011 and March 2013(phase-1) and post-implementation Conclusion: In our study we value the importance of
period was between April 2013 and October 2014(phase-2). early detection of association of PS with epilepsy and
children admitted to the wards were considered participants. hemimegalencephaly so as to prevent/minimize the neurological
complications, disability, morbidity and mortality associated
The following outcomes were compared- the number of patients with PS.
having cardiopulmonary arrest in the ward, the number of
patients transferred to the PICU from the wards,the number
needing intubation on D1 of transfer , and the mortality of patients Breast Feeding Experience in Inborn
transferred in the team comprised of the PICU consultants, Errors of Metabolism
fellows, and 2 PALS trained nurses. Umamaheswari B
Results: Mortality was significantly higher during phase M: 9941853855; Email: drumarajakumar@gmail.com
1(6.2%) when compared to phase 2, with no mortality(p value
<0.01). During phase 1, 17.9% of patients transferred to the Introduction: Breast feeding (BF) has been recommended
PICU were intubated on Day 1, compared bto 5.8% during phase for certain inborn errors of metabolism (IEM) such as
2. Cardiopulmonary arrest in the wards was almost nonexistent phenylketonuria. Studies or case series sharing the experience
in our hospital(1 in 10088 only in phase-1).145 of 10088(1.43%) with breast feeding in other IEM are few. In India, especially
patients had to be transferred to the PICU because of worsening with the non availability of special formula and aminoacid
clinical status during phase 1 as against 103103 0f 7737(1.33%) mixture, the experience of sharing the use of breast milk (BM) in
during phase 2. selected IEM would help the medical fraternity.
Conclusions: In a first such study from india, we demonstrate Method: Three infants with propionic acidemia PA (n=1),
the feasibility of implementing a pediatric equivalent of Medical citrullinemia (n=1) and multiple carboxylase deficiency (n=1) who
Emergency Team(MET), that has the potential for reducing the were given breast milk and prospectively followed were included.
mortality and morbidity in children admitted to a tertiary hospital. Results
Case 1: A 13 month old boy diagnosed to have propionic
Proteus Syndrome With Epilepsy: A Rare academia on 20 day of life (dol), was continued on BF after
Presentation the acute management of the crisis. He is on BF till date and
supplemented on special formula. He had 2 episodes of acute
Pallavi1 S. Sitaraman1, Manisha Goyal2 crisis so far and developmentally normal.
¹Department of Pediatrics, SMS Medical College, Jaipur,
²Clinical Geneticist, Jaipur Case 2: A 9 month old boy diagnosed to have multiple
1
Email: psachdeva1988@gmail.com carboxylase on y 7 dol, presented antenatally with cyst, was
continued on BF after discharge. He was on exclusive BF till 6
Background: Proteus syndrome (PS) is an overgrowth syndrome months of age and developmentally normal.
characterized by segmental overgrowth, vascular malformations, Case 3: A 7 month old girl diagnosed to have citrullinemia on
nevi, lipoma and hyperpigmentation. The exact cause and 1 dol, in view of sibling with IEM, was continued on expressed
embryologic origin of PS is still not known. BM after acute management. She is developmentally normal.
Case presentation: A seven year old boy presented with seizures Conclusion: Breast feeding was successful in all three babies
and overgrowth of right half of the body. He was third born to non- with IEM. Metabolic decompensation should be watched for
consanguineous couple with uneventful antenatal and postnatal

while on BF. Nutritional status, development and biochemical fluid were evaluated by eMMM[including clinical examination,
parameters should be frequently monitored. BF has specific invasive monitoring, focused cardio-respiratory imaging (CRI)
advantages and should be encouraged in selected cases of IEM. and ultrasound cardiac-output monitor(USCOM)].
The therapeutic plan based on clinical exam was compared to
A Study of Left Ventricular Functions in decisions following eMMM. The final decision regarding further
fluids, inotropes and pressorswas based on the presence of at
Hypocalcemic Infants least 2 eMMM parameters demonstrating fluid responsiveness
Palak Gupta*, Samit Raj Prasad, Manohar Lal Gupta (in absence of fluid intolerance), abnormal cardiac function or
*3rd Year Resident, Department of Pediatrics, reduced SVR respectively.
SMS Medical College, Jaipur
*Email: palak_anokhi@yahoo.co.in Results: Regarding fluid, 24/26(92%) would have received fluid
based on clinical examination, but only 4 finally received additional
Background: Congestive Heart Failure and Cardiomyopathy fluid following eMMM. Inotropy based on echocardiography/
due to hypocalcemia are rare however,chronic hypocalcemia has USCOM was administered in 14(53%) patients;however,
been found to be associated with left ventricular dysfunction.Few clinically only 4 patients had suspected myocardial dysfunction.
reports are available on the issue of Left ventricular function in SVRI was low in 18(69%)patients warranting pressors which was
hypocalcemic infants hence present study was undertaken. Aims clinically obvious only in 19% based on the presence of warm
and Objectives: To study left ventricular functions in hypocalcemic shock. Early diuretics (within 24 hrs) were commenced in the
infants. To study the relation between age at the time of diagnosis presence of large number of B lines in 30% children.
of hypocalcemia and left ventricular dysfunction. Conclusion: Benefits of eMMM in septic shock included
Methods: Hospital based observational study, Department of precise titration of inotropes and pressors in unresolved shock,
Pediatrics, SMS Medical College, Jaipur from October 2012 to where clinical exam was unreliable. Additional important
September 2013. 75 infants admitted with clinical features of advantages included greatly minimized fluid overload, both by
hypocalcemia were studied. Clinical examination and relevant limiting administration and early removal. USCOM provided
investigation were done, they all underwent Echocardiography value addition principally to identify low SVR and titrate early
to reveal cardiac functions and dimensions. pressors, which not only improved SVRI but also improved
preload and inotropy.
Results: Hypocalcemia was common in males (72%) and
associated with exclusive breast feeding infants(60.34%). Mean
ejection fraction ( 43.08 +/- 9.34) and mean fractional shortening Microalbuminuria as a Predictor of
(20.42 +/- 4.70) of hypocalcemic infants associated with left
ventricular systolic dysfunction was statistically significant
Mortality in Children with Sepsis
(P<0.05) in infants less than 3 months and more than 6 months. Karan Raheja*, Anil Sachdev, Dhiren Gupta,
On correlation regression analysis these were negatively Suresh Gupta, Neeraj Gupta
correlated (R= -0.66). Cardiomegaly in chest Xray(90%) and PICU, Sir Ganga Ram Hospital, New Delhi
QTc prolongation(33.03%) was significant in infants with *Email: aquariankaran@ymail.com
reduced left ventricular systolic function.
Background: Microalbuminuria (ACR), is a marker of systemic
Discussion: The result of present study was in complete inflammation, and reflects the glomerular component of a
agreement with Pankaj Gupta et al and Munesh Tomar et al systemic capillary leak. To date, correlation of ACR with organ
which state hypocalcemia as a cause of ventricular dysfunction. system dysfunction (OSD) and mortality in children with sepsis
Conclusion: This study shows that reduced left ventricular systolic has not been evaluated.
function was an important feature of hypocalcemia in infants. Objective: To study the relationship between ACR with OSD
and mortality in septic children.
Extended Multimodal Monitoring is Methods: Children between age 1 month and 16 years admitted
Useful for Optimizing Hemodynamics in with sepsis, and with anticipated stay of >24 hrs in PICU were
enrolled prospectively. Patients with primary nephropathies
Pediatric Septic Shock were excluded. ACR was obtained at admission (ACR1), 12 hrs
Rajeswari Arali (ACR2) and 24 hrs (ACR3). ACR >180 mcg/mg of creatinine
Email: rajiarali@googlemail.com was considered significant. PELOD score and PRISM 12 and 24
hrs calculated for all.
Extended multimodal-monitoring (eMMM) including cardio-
respiratory ultrasound and cardiac-output monitor (USCOM) Results: 138 patients with varied severity of sepsis were enrolled
was used in 26 children In order to streamline the decision- prospectively. The median PRISM12 and 24 hr with ACR (1,2,3)
making in unresolved shockdespite initial fluid resuscitation, and levels >180 were significantly higher as compared to those with
results were compared to clinical assessment alone. ACR<180. [(8 vs 4, p<0.05), (6 vs 2, p<0.05);(8.5 vs 4, p<0.05),
(7.5 vs 2 p<0.05);(9 vs 4, p<0.05), (8 vs 2 p<0.05) and median
Methods: Children with unresolved shock despite 30 ml/kg

PELOD scores at 24 and 48 hrs was higher in group with ACR of PICU stay among survivors (n=16) was 22.2 (10.3) days,of
>180 at admission, 12 and 24 hrs (21 vs 9 p<0.05), (21 vs 2 whom 2 had post cardiac arrest neurological sequelae at time of
p<0.05); (21vs 10 p<0.05), (21 vs 2, p<0.05); (22 vs 4, p<0.05), discharge.Only 12 patients were followed up for mean duration
(21 vs 2, p<0.05). Statistically significant difference noticed of 5.6 (3.8) months after PICU discharge and all except 1 were
between sepsis categories with ACR 1, 2 and 3 (P<0.05). There well. Multivariate logistic regression analysis revealed that
is statistically significant positive correlation between lactate grade IV severity (p=0.002), no intrathecal HTIG (p=0.033), and
(12 hrs) vs. ACR2, (p 0.0001) and lactate (24 hrs) vs. ACR3, (p inotrope use (0.001) were significantly associated with mortality.
0.0001). There were statistically significant different values of Conclusion: Tetanus remains a major public health problem
ACR2 and ACR3 between survivor and non-survivor (ACR2 P in the post vaccination era.Early recognition, prompt treatment
0.03and ACR3 P 0.01). Odds ratio (survivor vs non-survivor) for and intense supportive care in PICU improve morbidity and
ACR1 and ACR3 in >180 group was 1.24 and 2.49. mortality. High mortality despite intensive care brings to focus
Conclusion: The increasing trend of microalbuminuria in septic the need for good public health measures to prevent the disease.
children predicts organ dysfunction and mortality. Keywords: Tetanus, children, PICU, mortality.
Post Neonatal Tetanus:Ten-year pediatric Glucose Variability Index in Critically Ill

intensive care unitexperience from a Children with Sepsis
tertiary care teaching hospital Roop Sharma*, Anil Sachdev, Suresh Gupta,
Suresh Kumar*, Balmukund, Muralidharan Dhiren Gupta, Neeraj Gupta
Jayashree**, Arun Bansal, Sunit Singhi, Pediatric Intensive Care Unit,
Karthi Nallasamy Sir Ganga Ram Hospital, New Delhi, India
Department of Pediatrics, Postgraduate Institute of Medical *Email: roopksharma@gmail.com
Education and Research (PGIMER), Chandigarh, India, 160012
M: *9855373969, **+919815594343; Objectives: To study the effects of hyperglycemia,
Email: *sureshangurana@gmail.com, **mjshree@hotmail.com hypoglycaemia and hyper+hypoglycaemia with variabilty index
in critically ill children onoutcome.
Background: Tetanus is still a major public health problem
Materials and Methods: Prospective, observational cohort
associated with high morbidityand mortality.Data regarding its
study in a tertiary care PICU. Children agedbetween 1 month to
intensive care needs, outcome, predictors of outcome, and long
16 years with sepsis admitted from August 2013 to June 2014.
term follow up is limited.
were serially enrolled. Blood glucose estimations were done at 8
Methods: Case records of 28casesof tetanus between 3 months AM and 8 PMin initial 7 days of PICU stay.
to 12 years of age admitted to a PICU in north India over a
Results: 91 consecutive patients with sepsis, severe sepsis, septic
period of 10 years (January 2006 to August 2015) were reviewed
shock with or without multiorgan dysfunction syndrome were
for demographics, portal of entry, vaccination status, type and
enrolled. The study cohort was divided in 4 groups: euglycemia
severity, clinical features, management, complications,outcome,
(12%), hyperglycemia (37.3%), hypoglycaemia (8.7%),
and follow up data. Univariate and multivariate analysis were
hyper+hypoglycaemia (41.7%). The median PRISM score at
done to determine predictors of mortality.
12 hours and 24 hours in hyperglycaemiagroup were 13 and
Results:Three fourth(n=21; 75%) of cases were boys 11.5 while 16.5 and 17 in children with hyper+hypoglycaemia
with mean(SD) age of 7.2 (2.9) years. None were grouprespectively and weresignificantly higher as compared
completelyimmunized.The most common portal of entry was to euglycemia group (p-0.00, p-0.03). In non-survivors,
CSOM (n=15;53.6%), followed by acute trauma (n=9;32.2%) hyperglycemia, hyper+hypoglycemia and euglycemia were
and no obvious injury (n=4;14.3%). All cases had generalized observed in 13 (36.1%), 18 (50%) and 2 (5.1%) patients
tetanus with severity grades of IV (n=17, 60.7%) and III (n=11, respectively. The median PELODS values on day 1 and day
39.3%). All cases received wound debridement, tetanus toxoid, 2 in hyperglycaemia group were 31 and 32 while 17 and 31.5
HTIG, and appropriate antibiotics. Intrathecal HTIG was in children with hyper+hypoglycaemia respectively and were
incorporated in the protocol after 2012 and only 5 (17.9%) cases significantly higher as compared to euglycemia group (p-0.006,
received it. All cases had one or other complication related to p-0.003). The variability index was calculated as: (maximum -
tetanus, its treatment, and PICU stay: respiratory failure (92.9%), minimum glucose values)/ mean glucose. Positive prediction
rhabdomyolysis (78.6%), autonomic dysfunction (71.4%), acute value was calculated fromvariability index. PPV for mortality
kidney injury (64.3%), and HCAI (46.4%).The intensive care with glucose variability indices of 110% and 125% were 63%
needs were: requirement of ventilation (100%), benzodiazepine and 72.2% respectively(AUC=0.62). Similarly, increased
(100%), morphine (96.4%), and magnesium sulphate (85.7%) mortality rates werealso documented in hyperglycaemia group.
infusion, neuromuscular blockcade (67.9%), inotropes (67.9%),
Conclusions: Blood glucose variability index is higher in septic
tracheostomy (39.3%), and RRT (32.1%). Twelve (42.9%) cases
children with high disease severity score.
died after a mean(SD)PICU stay of 7.8 (5.9) days. The length

Use of Continuous Renal Replacement Keywords: Mongolian blue spots, GMI gangliodosis
Therapy in Successful Management of a Introduction: GMI gangliodosis is an autosomal recessive
lysosomal storage disease caused by deficiency of the lysosomal
Neonate with Maple Syrup Urine Disease hydrolase, acid beta-galactosidase. The infantile form (type
Mangla A*, Poudel DR, Shrestha D, 1) is characterized by progressive organomegaly, dysostosis
Anand K**, Pruthi PK multiplex, facial coarsening and progressive neurologic
Division of Pediatric Nephrology, **Consultant Pediatric deterioration within the first year of life. A variety of cutaneous
Nephrologist, Institute of Child Health, signs have been described in children with GMI gangliosidosis.
Sir Ganga Ram Hospital, New Delhi, India We describe an infant with GMI gangliodosis after taking consent
**M: 9818664448; *Email: amangla101@gmail.com from his parents associated with Mongolian spots on the trunk
and extremities with ventral and dorsal distribution.
Introduction: Maple syrup urine disease is rare disorder of
inborn error of metabolism which can lead to severe neurological Case Report: A nine month old male child born by normal
manifestations and may be fatal. Herein we report a neonate delivery to non-consanguineous parents, presented with
presenting within first week of life with seizures secondary to developmental delay, coarse facial feature and seizures. Coarse
maple syrup urine disease, who showed good neurological facial features included low set ears, broad nasal bridge, a long
improvement following Continuous Renal Replacement Therapy philtrum and frontal bossing, wide open fontanel and congenital
(CRRT). hydrocele. He had hepatosplenomegaly, hypotonic with brisk
tendon reflexes and global developemental delay. In addition,
Case Summary: A term male neonate appropriate for gestational large hyper pigmented, well demarcated macules resembling
age with birth weight 2960g, born to a 28 years old primigravid. Mongolian blue spots were scattered all over the body since
He developed poor sucking, decreased activity and decreased birth. Ophthalmology examination showed cherry red spot but
urine frequency on seventh day of life. On eight day of life he no corneal clouding.
developed subtle seizures following which he was admitted in
NICU. Antenatal history was unremarkable and there was no Radiography showed rounding of vertebral body and proximal
history of consanguinity. He was investigated and his tandem pointing of metacarpals and bullet shaped phalanges, iliac flare.
mass spectroscopy showed raised levels of leucine, isoleucine MRI Brain showed bilaterally symmetrical confluent hyper
and valine and Genetic analysis revealed compound heterozygous intensities on T2/FLAIR involving periventricular; sub cortical
mutations, c.1065 delT (p.Ala355AlafsX34) and c.293T>G white matter with involvement of sub coritcal u fibre with mild
(p.Val98Gly) in exons 10 and 3, respectively in BCKDHB gene, brain atrophy and also involving bilateral internal and external
thus confirming the diagnosis of classical MSUD. This neonate capsule and bilateral cerebellar white matter. There is evidence
was successfully treated with continuous renal replacement of mild T1 hyperintensities in bilateral medial globuspallidus.
therapy (CRRT) via umbilical line, which led to decrease in the Beta galactosidase assay was done in blood by flurometry and it
blood levels of ammonia, branched chain amino acids and also showed deficient enzyme activity.
neurological improvement during acute crisis. This is the first Discussion: GM1 gangliodosis type 1 is a ganglioside storage
case report of a neonate with MSUD being successfully treated disease characterized by its early onset, rapid progression to
with CRRT from India. severe neurological impairment and poor prognosis with death
Conclusion: In a child with MSUD, in case of neurological usually occurring by the age of 2 years, It is a rare condition
depression immediate elimination of toxic metabolites is of with an incidence of about 1: 1-200 000. Inheritance is autosomal
utmost importance to prevent irreversible damage. CAVHD is recessive and antenatal diagnosis is possible. The condition is
potentially the most efficacious Renal replacement therapy for diagnosed by estimating beta-galactosidase activity in while
rapid clearance of branched chain amino acids. cells or skin fibroblasts. Mongolian blue spots are common and
are seen in up to 90% of Asian babies, and less commonly in
Large Mongolian spots in GMI other races. They are benign and have no known associations.
Histologically they are characterized by melanocyte proliferation
gangliodosis in the mid dermis. They are usually lumbo-sacral and can be
Shikha Khandelwal, B S Sharma single or multiple. They can increase in both size and density
Department of Pediatrics, but usually disaapear by the age of 5 year. They can persist
S.M.S Medical College, Jaipur, India into adult life in 3-4% of cases, this was found in a study of
healthy Japanese males2. Extensive mongolian blue spots do
A 9-month old male child with GMI gangliodosis type I certainly occur in up to 5% of cases although their extent and
presented with Mongolian spots. The cutaneous lesions were natural history have not yet been studied. The mongolian blue
present since birth before the appearance of the other features spots seen in our child were both natural history have not yet
of the diseases. Our patient, whose clinical course and physical been studied. The mongolian blue spots seen in our child
signs wre in keeping with GMI gangliodosis had extensive were both very extensive (including the ventral surface of the
Mongolian blue spots and this adds to the evidence supporting trunk) and unusual in that they were repidly increasing at the
such an association. age of 6 months. The possible chance association between GM,

gangliosidosis type 1 and extensive mongolian blue spots was Introduction: Crouzon’s syndrome is an autosomal dominant
first described in 1981 by Weissbluthet at 3 who reported a 5 disorder with complete penetrance and variable expressivity.
month-old child with extensive areas of hyper-pigmented skin Syndrome caused by mutation in the fibroblast growth factor
and the condition. A further child was reported in 1989(4) and receptor 2 (FGFR2) gene. The disease is characterized by
two more in 1990(5). These cse reports therefore suggest that premature synostosis of coronal and sagittal sutures which
there might be an association of GM1 gangliosidosis type 1 with begins in the first year of life, Crouzon syndrome accounts for
extensive and unusual mongolian blue spots. 4.8% of all craniosynostosis. Incidence of sndrome is 1 n 25000
births worldwide.
Conclusion: May be Mongolian spots are just association of
GM1 gangliosidosis but we think our patient adds to the evidence Case Presentation: 11½ months male child presented with
that patients with this disorder may manifest abnormal dermal complain of facial deformity since birth. Family history of similar
pigmentary lesions, which may be present since birth thus helping facies in mother was present. Examination showed fused sutures,
in early diagnosis. Small, light blue-green coloured spots confined frontal prominence, mid facial hypoplasia. X-ray skull showed
to lumbosacral area can be ignored but extra sacral, extensive, “silver beaten appearance”. NCCT brain showeed premature
persistent and dark coloured spots should be looked upon with fusion of sagital suture with increased AP diameter as compare
suspicion, especially in the presence of a consanguineous marriage to transverse diameter, presence of multiple convolutions in
or a strong family history of storage disorders, Future research bilateral parietal and temporal bones suggestive of lacunar skull
should focus on further quantifying and validating parameters with craniosynostosis.
like size percentage of Total body surface area, location and Conclusion: It is important to perform thorough
colour of Mongolian spot, as markers for IEMs and their place in clinicoradiographic examinations to help in differentiating
screening and disgnosis of these syndromes. between craniosynostosis syndromes and to accurately diagnose
an affected individual to aid in institution of appropriate
Short Rib-Polydactyly Syndrome: A case therapeutic and rehabilitative measures as required.
report
Kamlesh Agrwal1, Manisha Garg2, Ashok Gupta3, Plasmapheresis in Indian Children: Single
Priyanshu Mathur4, Anil Sharma5 centre experience
Poudel DR, Anand K, Mangla A, Pruthi PK
Introduction: Short rib-polydactyly syndrome (SRPS) is a
Division of Pediatric Nephrology, Institute of Child Health
group of rare, lethal skeletal dysplasias characterized by short
Sir Ganga Ram Hospital (SGRH), Delhi, India
ribs and limbs, polydactyly, hypoplastic thorax and visceral
anomalies, Classically, four different types have been described; Background: Plasmapheresis is one of the first-line treatment
SRPS I (Saldino-Noonan); SRPS II (Majeswski); SRPS III for various conditions as classified by the American Society for
(Verma-Naumoff); and SRPS IV (Beemer-Langer). All forms Apheresis(ASFA). However, it is more challenging in pediatric
of the SRPS described to date are thought to be inherited in an age group and requires greater expertise. Plasmapheresis data in
autosomal recessive manner. Prevalence as a group is unknown. Indian children is limited.
Case Presentation: A 40 days old male child presented with Objective: To present our experiences in Indian children who
complain of fast breathing and fever for 1 day. Examination underwent plasmapheresis for various indications at Institute of
showed tachypnea, saturation - 68%, CRT <3 with polydactyly Child Health, Sir Ganga Ram Hospital.
and US/LS ratio- 2:1. On Cradiovescular system- S 1 Normal, S2
Loud, ejection systolic murmur grade - 3 was present. Infentogram Methods: Data related to plasmapheresis (demographic
showed short ribs and pelvic outlet flairing. Proximal limbs characteristics, indication, number of sessions, type of replacement
were abnormal and iliac wings were flaired. Echocardiography fluid, type of filter, machine, complications and outcomes) in
showed large ostium secondum ASD (15.3mm), moderate TR children who were admitted between January 2013 and July 2015
and severe pulmonary hypertension. in the Department of Pediatrics, SGRH was analysed. Hospital
medical records were reviewed for the data collection.
Conclusion: We think that clinical and radiological findings
of our case match with SRPS, particularly Saldino-Noonan. As Results: Out of 17 children who underwent plasmapheresis,
the overlapping clinical features make SRPS cases difficult in 70.5% were male with age ranging from 9months to 15years
differential diagnosis, revealing the gene loci responsible for (mean7.8±5years). Weight of the children varied from 7kgs
them seems necessary. to 74 kgs (mean26.2±17.3kg). The most common indication
of plasmapheresis was atypical hemolytic uremic syndrome
(d-HUS)-66.7%. Other indications were poisoning, neurological
Crouzon Syndrome - A Case Report disorders and focal segmental glomerulosclerosis-11.7% each.
Manisha Garg1, Kamlesh Agrwal2, Ashok Gupta3, Total number of plasmapheresis sessions were 106 (mean 6.5
Priyanshu Mathur4, Anil Sharma5 sessions per patient). 5% albumin and Fresh Frozen Plasma both
were used as replacement fluids in d-HUS children whereas only
5% albumin was used in others. Fresenius Medical Care (4008S)

dialysis machine was used and procedure was done by continuous 2. To assess the co-morbid conditions associated with poor
flow method using plasmafluxPSu filter. Hypertension was the outcome.
most common complication seen in 6 patients (35%). Sixteen Method: A prospective, single-centre study in which a total of
patients (94%) had favourable outcomes with only one mortality. 130 inpatient children of less than 18 years of age with clinical
Conclusion: Plasmapharesis is a relatively safe procedure and radiological evidence of acute onset of pneumonia were
in children with its utility in diverse conditions and having enrolled in the study. Etiological and epidemiological profile of
favourable outcome. these cases was studied in detail and influenza virus confirmed
by using RT-PCR (APPLIED BIOSYSTEM). For purification of
viral antigen-RNA QIAGEN-KIT was used. The children were
Prevalence and Predictors of Outcome of evaluated for presence of malnutrition, congenital heart diseases,
Acute Kidney Injury in PICU allergy, asthma and congenital anomalies.
Yogesh Garg, Manish Verma, JP Soni, Result: The H1N1 epidemic had witnessed more number of
Pramod Sharma cases in age group of 1 to 5 year and in male children. There was
Department of Paediatrics, Dr SN Medical College, Jodhpur no specific laboratory characteristic shown to have a significant
association with the severity of illness or poor outcome. However
Background: AKI is associated with increased mortality in severe acidosis (pH<7.2) and Pao2/Fio2<300 was significantly
PICU, there is lack of studies regarding occurrence and outcome associated with poor outcome.
of AKI in PICU in Western Rajasthan, most studies are in adults
and retrospective. Conclusion: Statistically there was no age or sex related
predilection in mortality seen. The present study established that
Aims and Objectives: To determine prevalence of AKI in PICU there is a better outcome in patient of H1N1 pneumonia when
inmates and to follow the outcome of these patients and outline treated with oseltamivir within 72 hours of onset of illness.
the contributing determinants. The most common co-morbidity associated with swine flu
Methods: Prospective study done in PICU, Umaid Hospital, pneumonia was malnutrition although it was not significantly
Jodhpur for 1 year associated with a poor outcome. Poor prognostic factors were -
development of ARDS, use of mechanical ventilation and delay
Inclusion criteria: All children aged < 18 years admitted in
in starting antiviral therapy.
PICU and needed PICU stay for at least 24 hrs and had AKI on
admission or developed AKI during PICU stay
Exclusion criteria: Chronic kidney disease and /or ESRD Case of Coffin-Siris Syndrome a rare
Results: Prevalence in our hospital was 10.15%. Average PICU
Presentation
stay in 5.55 days in stage 1, 6.61 in stage 2, 8.1 days in stage 3 of Maheshwar Gunawat*, Suresh Goyal, Pradeep Meena
AKI and 3.7 days in Non AKI PICU cohort. Department of Pediatric, RNT Medical College,
Udaipur, Rajasthan, India
Mortality: In cases with AKI - 33.56% and 20.94% in Non AKI *Email: drmsgunawat@gmail.com
PICU cohort.
Discussion: Our results correlate with results from other PICU. Abstract: Coffin-Siris syndrome (CSS) is a rare, clinically
heterogeneous disorder often considered in the setting of prenatal
Conclusion: onset of mild to moderate growth deficiency, facial dysmorphism,
AKI is common in critically ill children which is associated cognitive/developmental delay, speech impairment, moderate to
with longer duration of PICU stay, prolonged mechanical severe hypotonia, seizures and 5th finger/nail hypoplasia.(1)
ventilation, increased morbidity and mortality.
Above results make it essential to diagnose AKI in critically ill We here by presenting a case of this rare syndrome.
patients early and institute appropriate treatment immediately. A male child of three and half years was admitted with chief
Septicemia, shock, peri-natal asphyxia and gastroenteritis complaints of global developmental delay and generalized
were the main co-morbidities associated with AKI. convulsions. The child was product of non-consanguineous
marriage with no significant antenatal, natal and family history.
Morbidity and Mortality Profile of H1N1 Parents noticed developmental delay after three months of age
Dr Minhaz Hussain, Yudhveer Singh, and subsequently child had recurrent seizures, initially infantile
spasm and followed by generalized tonic convulsion after the age
Anurag Singh, Pramod Sharma
of nine months.
Department of Pediatrics, Dr SN Medical College, Jodhpur
On examination head circumference was 48 cm (between 15th
Objectives: and 3rd percentile). He had coarse facial features like low set ears,
1. To study the demographic profile, clinical presentation, large ear pinna, depressed nasal bridge, flat nasal tip, generalized
radiological picture & complications of swine flu (H1N1) hirsutism, thick eyebrows, long eyelashes, short stubby hand
pneumonia. and genitals of tanner stage 2 with generalized hypotonia.

Developmental age of the child was approximately 1 year, Scrub Typhus Meningitis: An emerging
language milestones were more delayed compared to others.
Other neurological and systemic examination was normal.
infectious threat
Jitendra Kumar Meena*, Shikha Khandelwal,
EEG showed frequent epileptiform discharges from both
hemispheres.
Palak Gupta, B. S. Sharma
Sir Padampat Mother and Child Health Institute, Department of
Keywords: Coffin Siris Syndrome, global development delay, Pediatrics, SMS Medical College, Jaipur, India
seizures, generalized hirsutism. *Email: jkchholak@gmail.com
Background: Recent reports from several parts of India indicate

Clinical and etiological profile of that there is a resurgence of scrub typhus. Central nervous system
microcephaly in children aged 1 month to involvement was common in scrub typhus. There have been only
60 months few studies on scrub typhus meningitis, most are case report.
Neeraj Kumar, Suresh Goyal, Bhupesh Jain Methods: A prospective study done in Sir Padampat Mother
Department of Pediatric, RNT Medical College, and Child Health Institute, SMS Medical College, Jaipur from
Udaipur, Rajasthan, India August 2014 to December 2014 including all admitted cases
Email: ntyagi43@gmail.com of scrub typhus. Diagnosis was made by a positive scrub IgM
ELISA. Lumbar puncture performed in patients with headache,
Aim: To study the clinical and etiological profile of microcephaly vomiting, meningeal signs, seizures, or altered sensorium.
in children aged 1 month to 60 months admitted to Bal
Results: Forty nine cases of scrub typhus were found, and 7
Chikitsalay, Udaipur.
(~15%) had meningitis. There were 25 males and 24 females.
Materials and Methods: Children attending Bal Chikitsalay, Only one patient had an eschar. Mean CSF cell count,
Udaipur were evaluated as per protocol. Z scores of head lymphocyte percentage, CSF protein, CSF glucose/blood
circumference were calculated using WHO charts and clinical, glucose, CSF ADA were 42 cells/μL, 97%, 81 mg/dL, 0.7 and
radiological and etiological profile of those with microcephaly. 5.2 U/mL. Complications including thrombocytopenia, severe
Results: Out the 77 children with microcephaly, Most of anemia, acute kidney injury and respiratory failure are more
the children (84.42%) of microcephaly were admitted with common in scrub typhus meningitis. There were no mortality
Head circumference (HC) < - 3SD and mean age of children from meningitis, all made uneventful recovery.
with microcephaly was 17.83±12.88 months. Developmental Conclusion: Our finding is contrary to current perception that
Quotient (DQ) ≤ 70% was present in 81.82% children. scrub typhus rarely causes meningitis. Meningitis in scrub typhus
Developmental delay was present in 92.20% children. The is mild with quick and complete recovery. Clinical features and
children were classified according to the final diagnosis into 3 CSF findings can mimic tuberculous meningitis, except for ADA
groups: Primary microcephaly 10 cases (12.99%), Secondary levels. Both are endemic in india, so scrub IgM and CSF ADA
microcephaly 64 cases (83.11%) and Undiagnosed Cases 3 cases levels may be helpful in differentiating these two and in avoiding
(3.90%). Secondary microcephaly was directly due to SAM seen prolonged empirical ATT in cases of lymphocytic meningitis.
in 40 cases (51.95%) followed by cerebral palsy associated with
Keywords: Meningitis, Scrub typhus, Eschar, Orientia
perinatal asphyxia was seen in 13 cases (16.88%). Neuroimaging
tsutsugamushi
were found abnormal in 56 children (86.15%) of Severe
Microcephaly (HC<- 3SD). The most frequent MRI finding was
cerebral atrophy in 33 cases (50.76%) followed by Hypoxic Incidence of UTI in severe acute
Ischemic Encephalopathy (HIE) 14 cases (21.54%). Most of malnurished children aged 6 to 60 months
children presented with developmental delay (92.2%), anaemia
(77.92%), abnormal tone (71.43%) and convulsion (28.57%). Bharat Sharma*, R.L.Suman, Vibha Choudhary,
Suresh Goyal
Conclusion: In our study Microcephaly was most commonly Department of Pediatric, RNT Medical College,
seen in SAM followed by HIE. Microcephaly was associated Udaipur, Rajasthan, India
with developmental delay, lower DQ and higher comorbidities in *Email: drbharat077@gmail.com
children. MRI is considered as a gold standard in the evaluation
of brain abnormalities in patients with microcephaly. Introduction: Severe acute malnutrition is one of the most
common health problem, involving hundreds of millions of

children in the world. As per human development report Rajasthan kidneys etc when scanned as a part of investigation of UTI. Most
2008, 33.7% children under 3 years are stunted, 19.7% children common organism isolated was E. coli
are wasted whereas 44% children are underweight. Malnutrition
Conclusion: Since the incidence of UTI is much higher, almost
and infection is a vicious cycle. Malnutrition also affects the
43%in SAM children than well nourished when they have an
ability of kidney to acidify urine making children with SAM
acute febrile illness. So these children should be routinely
more prone for urinary tract infection. Urinary tract infection
screened to rule out urinary infections and follow up for long
is a major cause of morbidity in children and an important
term sequels.
occult infection in malnourished children. Most of severe acute
malnourished children are admitted because of complications,
mostly due to infections, usually gastrointestinal and respiratory Difficult Esophageal Stricture Dilatation
infections. Urinary tract infection is one of the hidden infection by Savary Gilliard Dilator is a better
which mostly go unnoticed until searched specifically. So, there
is a need to screen every severe acute malnourished child for
alternate of Surgery - A case series
urinary tract infection. Sonal Gupta, P.P. Gupta, Usha Aacharya, Madhu
Aims and Objective: To study the Incidence of UTI in severe
Mathur, Munish Kumar Kakkar, Mukesh Gupta,
acute malnourished children aged 6 to 60 months admitted to Nitin Trivedi, Natwar Parwal*
MTC at Bal Chikitsalay, Udaipur. Department of Pediatrics, Mahatma Gandhi
Medical College & Hospital, Jaipur, Rajasthan
Material and Methods: This study comprised of 100 Children *M: +91-9610951425; Email: dr.nats@yahoo.com
with severe acute malnutrition (according to classification by
WHO) admitted in Malnutrition treatment center (MTC), Bal Introduction: Esophageal stricture caused by accidental
Chikitsalay, Udaipur. Children were evaluated for Severe acute corrosive ingestion is seen commonly in pediatric age group. Up
malnutrition as per WHO protocol Which includes Weight for to 80% of caustic ingestion occurs in children five years of age
Height<-3SD scores and/or, visible severe wasting and /or, or younger. Other causes are Leaked battery in Esophagus, Post
MUAC<11.5cm and/or, bilateral edema of nutritional origin. op trachea-esophageal fistula, radiation and others. Accidental
They were tested for urinary tract infection by examining urine hot water ingestion causing stricture of the esophagus, rarely
for microscopy and culture and ultrasonography of KUB region. reported is also a cause in our series.
Urinary tract infection is defined as presence of more than 5 Methods: Pediatric endoscopic procedures from Sept 2014 to
pus cells per high power field in a centrifuged urine sample or October 2015 were analyzed and difficultEndoscopic Esophageal
with >25 leucocytes/microlitre or with nitrite positive or with Stricture cases were short listed.
leucocyte esterase positive with presence of at least one bacteria
and or positive urine culture. Result: Out of 155 Pediatric endoscopic procedures, Esophageal
Stricture dilatations were done 15 times (4+4+2+2+1+1+1) in
Results: Out of 100 children with severe acute malnutrition, 60% 7 patients from Sept. 2014 to October 2015. The details of 5/7
were male and 40% were female. Majority of study population difficult cases are described in (Table 1). Images of all cases are
was under <-3SD and<-4SD Z score (73.0%) followed by <-5SD attached separately.
z score (21.0%) and 4.0% children were in <-6SD z-score as per
WHO reference chart. Fifty eight percent SAM children came Conclusion: Dilatation with SavaryGilliard Dilator is safe and
to hospital for respiratory complaints, 26% for gastrointestinal effective method for esophageal strictures unrelated to etiology.
complaints, 8% had complaints suggestive of UTI and remaining We can avoid surgeries and lots of surgical complications in
came to seek medical advice because of not gaining weight and these cases. Multiple sitting is the biggest disadvantage of this
skin lesions. 43.0% children had evidence of UTI which was procedure.
significantly higher (p<0.001) than normal population. Forty five References
percent of male children with SAM were suffering from UTI 1. Poddar U, Thapa BR. Benign esophageal strictures in infants and
where as 40.0% of female children were suffering from UTI. The children: results of Savary-Gilliardbougie dilation in 107 Indian
difference between incidence of UTI among male and female children. GastrointestEndosc. 2001 Oct; 54(4):480-4.
children was not statistically significant with p value of 0.621. 2. Pearson EG1, Downey EC, Barnhart DC, Scaife ER, Rollins MD,
Incidence of UTI among various SD Z score was not significant Black RE, Matlak ME, Johnson DG., Reflux esophageal stricture--a
with p value of 0.389. Among the UTI patients 8.0% had culture review of 30 years’ experience in children. J Pediatr Surg. 2010 Dec;
positive, while 41.0% were having pus cells >25/microL and 45(12):2356-60.
38.0% children had nitrite positive on urine examination. 3. Paulo Fernando SoutoBittencourt, Simone DinizCarvalhoEndoscopic
On USG 9.3% children were also having malformations of dilatation of esophageal strictures in children and adolescents. J
genitourinary tract like ectopic kidney, hydronephrosis, cystic Pediatr (Rio J). 2006;82(2):127-31:

Table 1: Summary of difficult Endoscopic Esophageal stricture dilatation by SavaryGilliard Dilator
Case-1 Case-2 Case-3 Case-4 Case-5
Month of March 2015 July 2015 October 2015 October 2015 October 2015
presentation
Age/Sex 1.5 Year/F 4 Year/M 6 Year/ M 8 Month/F 4 year/M
History Corrosive ingestion Accidental Hot water Corrosive Ingestion Operated case of Acid ingestion
Followed by recurrent Ingestion followed by followed by persistent tracheo esophageal followed by difficulty
vomiting after 15 days mouth ulceration for vomiting Fistula in swallowing after 1
3- 4 days and difficulty month
in swallowing after
15-20 days
No. of dilatation 4 4 1 1 1
Reason of Very young age and Very small stricture Gastrograffin study Younger age with Stricture just below to
difficulties ARI and persistent Difficult to pass guide showed long segment pneumonia and cricopharynx
cough wire stricture difficulty in breathing Chances of
A sinus seen near laryngospasm
stricture which Very difficult to locate
partially disappear stricture and stabilize
on air scope and vision also
Endoscopic Stricture at 14 cm Stricture at 17 cm Stricture at 17 cm Stricture at 13 cm Stricture 13 cm from
findings from incisor in mid from incisor in mid from incisor in mid from incisor in mid incisor in upper part of
Esophagus Esophagus and lower part of Esophagus esophagus
Dilated with SGD up Dilated with SGD up Esophagus Dilated with SGD up Dilated with SGD up
to 11 mm (5mm-7mm- to 9 mm (5mm-7mm- Dilated with SGD up to 5 mm and 7 mm to 5 mm
9mm-11mm) 9mm till now) to 5 mm
Post Accepting both solids Accepting both solids Accepting Liquids Accepting Liquids Accepting Liquids
Endoscopic as well as Liquids as well as Liquids
recovery

Critical Thinking
PICU Quiz
Praveen Khilnani
BLK Superspeciality Hospital, New Delhi & Mediclinic City Hospital, Dubai
1. PTH (Parathyroid hormone) 5. Which of the following statements regarding

A. Increases H2O reabsorption thyroid hormone synthesis is correct?
B. Decreases sodium reabsorption A. Thyroid hormone is actively transported from
C. Causes tetany by reducing serum calcium the thyrocyte (thyroid follicular epithelial cell)
D. Increases sodium reabsorption to the circulation by a specific transport protein.
E. Decreases phosphate reabsorption B. The predominant hormone made by thyrocytes is
tri-iodothyronine (T3)
2. Within eight hours following large intravenous C. The synthesis of thyroxine (T4) occurs within
aldosterone infusion the following is(are) the thyrocyte.
clinically evident: D. Thyroid hormone is proteolytically cleaved
A. Unchanged sodium reabsorption by the collecting from thyroglobulin by enzymes acting within
duct the lumen of the thyroid follicle. The released
B. Decreased potassium and hydrogen excretion in hormone then diffuses from through the thyrocyte
urine and into the circulation.
C. Hypernatremia (high sodium in plasma), E. Iodine that is released from proteolytic cleavage
hypokalemia (low potassium in plasma) and of thyroglobulin can be recycled from mono and
alkalosis (low hydrogen ion activity in plasma) diiodotyrosines by the action of type I deiodinase
D. A and C are correct enzyme residing in thyroid follicular cells.
E. all are correct
6. a child has type 1 diabetes. He has had severe
3. The main barrier precluding the free passage of hypoglycemia in the past, without warning.
albumin across the glomerular capillary walls is Therefore, you have 1 mg of glucagon available
formed by: for injection in this situation. When you give the
A. The fenestrated glomerular endothelium glucagon, which of the following will happen?
B. Anionic proteoglycan clusters within the A. Glycogenolysis and gluconeogenesis will
glomerular basement membrane promptly increase.
C. The filtration slits in between visceral epithelial B. The glucose transporter GLUT4 will translocate
cells (podocytes) to the plasma membrane, causing brain glucose
D. None are correct uptake to increase.
E. All are correct C. The tyrosine kinase activity of the glucagon
receptor will be turned on.
4. Choose one correct answer. D. Lipolysis will be suppressed.
A. An increase in plasma potassium concentration E. Nothing, because you have to give some form of
will cause resting membrane potential to become glucose along with the glucagon in order for it to
more negative. work.
B. Cardioplegia solutions contain a low
concentration of potassium. 7. A child comes to you with an elevated serum free
C. The upstroke of the nerve action potential is calcium but the parathyroid hormone level (PTH)
generated by Na influx via the Na-K pump. is in the normal range (52, with a normal in this
D. Action potentials repolarize because the net ionic assay of 15-55). What is the best conclusion?
current is outward. A. The PTH is normal, therefore the problem does

not lie in the parathyroid gland. 10. If you decrease a blood vessel’s radius in half, by
B. The person must have excessive sensitivity what fraction does the blood flow change?
to PTH, since normal levels are stimulating A. 1/2
excessive calcium mobilization from bone. B. 1/4
C. The PTH should be low if the parathyroid were C. 1/8
functioning normally, thus the problem does lie D. 1/16
in the parathyroid gland. E. 1/3
D. You cannot be sure what is going on; you need to
perform a parathyroid scan. Answers
8. Which of the following does NOT regulate 1. Correct Answer: E
gastric acid secretion? 2. Correct Answer: C
3. Correct Answer: B
A. Vagus nerve stimulation. 4. Correct Answer: D
B. Cholecystokinin. 5. Correct Answer: E
C. Histamine
6. Correct Answer: A
D. Gastrin
7. Correct Answer: C
E. Acetylcholine
8. Correct Answer: B
9. Which of the following pairs is INCORRECT? 9. Correct Answer: C
A. Nitric oxide (NO): vasodilator 10. Correct Answer: D
B. Endothelin: vasoconstrictor
C. Nitric Oxide (NO): promotes cell growth
D. Endothelin: potent positive inotropic effect

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Intensive Care Chapter

Indian Academy of Pediatrics

Latest Pearls: Guidelines

Journal Scan Chugh K (Gurgaon, India)

NCPCC 2015: Oral Papers

NCPCC 2015: Posters

To Organize a BPICC in your area, please contact:

IAP IC Chapter Executive Committee 2016 3

Basic Pediatric Intensive Care Nursing Course (BPICNC) 4

From the Editors Desk 5

NCPCC 2015: Oral Papers 31

NCPCC 2015: Posters 38

Vol. 3 - No.1 January - March 2016 1 JOURNAL OF PEDIATRIC CRITICAL CARE

Executive Members: Biostatistics: International Advisory Board:

Vol. 3 - No.1 January - March 2016 2 JOURNAL OF PEDIATRIC CRITICAL CARE

Dr Vishram Buche Dr B P Karunakara Dr Kundan Mittal Dr Anil Sachdev

Dr Sanjay Ghorpade Dr D P Nakate Dr Praveen Khilnani Dr Bakul Parekh

Dr Manish Sharma Dr Arun Bansal Dr Devaraj Raichur Dr G V Basavraj Dr J Ebor Jacob

Vol. 3 - No.1 January - March 2016 3 JOURNAL OF PEDIATRIC CRITICAL CARE

For organizing this course, you may contact:

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Vol. 3 - No.1 January - March 2016 5 JOURNAL OF PEDIATRIC CRITICAL CARE

Vol. 3 - No.1 January - March 2016 6 JOURNAL OF PEDIATRIC CRITICAL CARE

Introduction IVIG is a polyclonal immunoglobulin derived from

Correspondence Materials and Methods

Vol. 3 - No.1 January - March 2016 7 JOURNAL OF PEDIATRIC CRITICAL CARE

Vol. 3 - No.1 January - March 2016 8 JOURNAL OF PEDIATRIC CRITICAL CARE

Vol. 3 - No.1 January - March 2016 9 JOURNAL OF PEDIATRIC CRITICAL CARE

Neonatal & Pediatric Ventilation Workshop

Dr Avijeet Yadav Dr Sanjeev Chetry

Vol. 3 - No.1 January - March 2016 10 JOURNAL OF PEDIATRIC CRITICAL CARE

Table1: New Terms and Definitions

Vol. 3 - No.1 January - March 2016 11 JOURNAL OF PEDIATRIC CRITICAL CARE

Vol. 3 - No.1 January - March 2016 12 JOURNAL OF PEDIATRIC CRITICAL CARE

Vol. 3 - No.1 January - March 2016 13 JOURNAL OF PEDIATRIC CRITICAL CARE

Fluid Bolus Evidence was not considered to be specific to a

Studies Survival to Need for Need for Mechanical Time to Total IV

Vol. 3 - No.1 January - March 2016 14 JOURNAL OF PEDIATRIC CRITICAL CARE

Vol. 3 - No.1 January - March 2016 15 JOURNAL OF PEDIATRIC CRITICAL CARE

of septic shock in different resource settings and References

Vol. 3 - No.1 January - March 2016 16 JOURNAL OF PEDIATRIC CRITICAL CARE

Summary airway pressure release ventilation, APRV), five

Vol. 3 - No.1 January - March 2016 17 JOURNAL OF PEDIATRIC CRITICAL CARE

even today. References

Vol. 3 - No.1 January - March 2016 18 JOURNAL OF PEDIATRIC CRITICAL CARE

In the guidelines published in 2014 American symptom in bronchiolitis consistently identified by

Vol. 3 - No.1 January - March 2016 19 JOURNAL OF PEDIATRIC CRITICAL CARE

Results plus or minus 4 h. Similarly, infants in the modified

Table: Clinical outcomes

Vol. 3 - No.1 January - March 2016 20 JOURNAL OF PEDIATRIC CRITICAL CARE

Vol. 3 - No.1 January - March 2016 21 JOURNAL OF PEDIATRIC CRITICAL CARE

Background were not single-agent aminoglycosides), that was

Vol. 3 - No.1 January - March 2016 22 JOURNAL OF PEDIATRIC CRITICAL CARE

Vol. 3 - No.1 January - March 2016 23 JOURNAL OF PEDIATRIC CRITICAL CARE

Role of HFOV in PICU Post OSSILATE and OSCAR Trials

Vol. 3 - No.1 January - March 2016 24 JOURNAL OF PEDIATRIC CRITICAL CARE

Background analysis; the main features of which are summarised

Vol. 3 - No.1 January - March 2016 25 JOURNAL OF PEDIATRIC CRITICAL CARE

Vol. 3 - No.1 January - March 2016 26 JOURNAL OF PEDIATRIC CRITICAL CARE

Vol. 3 - No.1 January - March 2016 27 JOURNAL OF PEDIATRIC CRITICAL CARE

Introduction treatment and presented in our emergency department

Correspondence Provisional diagnosis of acute respiratory distress

Vol. 3 - No.1 January - March 2016 28 JOURNAL OF PEDIATRIC CRITICAL CARE