Objectives: To evaluate the sensitivity of the PRISM III score in patients admitted to PICU and to find a cut off PRISM III score. Method: Four hundred children admitted to the PICU of a tertiary care hospital over a period of 18 months were enrolled in this cross-sectional observational study. PRISM III score was calculated using variables after admission in first 24 hours. The outcome was defined as survivors and deceased. Results: Out of 400 patients, 70 died and 330 survived. The male to female ratio was 219:181 (55%:45%). Majority of patients were below or equal to 12 months of age (50%). The mean age was 32.9 months for non survivors, while 37.5 months for survivors. Gender, age, residence of the patient had no association with the outcome. Referred, incompletely immunized and children requiring ventilation within 1 hour of admission had poor outcome. Average PRISM III score was higher in non survivors (14.6) as compared to survivors (4.1). The mortality was significantly higher with high PRSIM III score. The area under the receiver operating characteristics curve was 0.96. The cut-off PRISM III score was 9 (kappa coefficient 0.747). Conclusion: PRISM III score can be applied with a good degree of accuracy for severity assessment and mortality prediction to pediatric patients in PICU.

Background: India is among the countries reporting regular outbreaks of Dengue infection. Present study describes clinical profile and outcome of severe dengue cases. Methods: It is a retrospective observational study. All dengue patients admitted in PICU, from June 2015 to December 2015 were classified as per new WHO-2009 classification, and only those with severe dengue were included in the study. Clinical features, laboratory parameters and final outcome were studied and described. Results: Fever, pain abdomen and vomiting were found to be most common presenting symptoms. Thrombocytopenia was found in 100% cases and leukopenia in 20% cases. Shock was present in all the patients and average time taken for shock reversal was 2.4 days. Hepatitis (68.5%), AKI (54%) and encephalitis (14.2%) were the main complications. Survival rate was 91.4%. Conclusion: renal and CNS involvement is more common in dengue then previously reported. Use of inotropes and mechanical ventilation are associated with higher mortality.

Background: Pediatric Advanced Life Support (PALS) courses prepare candidates to respond to life-threatening emergencies in children. Objective: To describe the experiences of teaching the PALS course in a developing country. Methods: We described the experience of teaching PALS courses conducted according to guidelines of American Heart Association to physicians and nurses at Aga Khan University Hospital from January 2011 to December 2015. The outcome of the courses was recorded as passing of participants both in written test as well as skill stations. The passing score for test was 84%. We also recorded participant’s evaluation of the course. Data were entered in the excel sheet and descriptive statistics were applied. Results: During 5 years, 1044 candidates participated in 88 PALS courses. Majority were female (n=732, 70.1%). Physicians and nurses were 383 (36.6%) and 661(63.3%) respectively. Besides pediatricians, 373 participants (35.7%) were from emergency department and other clinical area. A passing grade was achieved by 936 (89.6%) of participants; the mean test score for whole sample was 88.37%. Four PALS instructor courses were also conducted and 33 new instructors were added to instructor pool. Evaluation of the course by students revealed that 98% of student felt able to respond in emergency situations while 93% felt confident in the use of taught skills. Conclusion: We found that conducting PALS courses is a positive educational experience to participants which will help in saving the lives of acutely ill children by practical implications.

Introduction: Heated Humidified High flow nasal cannula (HFNC) is a promising noninvasive respiratory support that is gaining popularity in both adults and children because of excellent patient tolerance and ease of administration in varying etiologies of respiratory distress. Objectives: of the current article are to review the physiology and practical aspects of HFNC and appraise available evidence with regard to the utility of HFNC in Pediatrics. Results: Prospective studies have established safety and feasibility of HFNC in preterm neonates with respiratory distress and infants with bronchiolitis. Studies suggest that it is equivalent to noninvasive CPAP in these conditions and may have some advantages. Recently a randomized control study in adults with acute hypoxemic respiratory failure have shown a mortality benefit, in addition to decreased intubation rates in the severely hypoxemic subgroup. Conclusions: Current evidence suggests that HFNC is a well tolerated and feasible respiratory support across different age groups and indications in the Pediatric ICU and Emergency Room. It is not inferior to the alternate modes of noninvasive positive pressure ventilation and may have some advantages over conventional forms of non-invasive respiratory support.

Pediatric acute liver failure (ALF) is a rare complex clinical syndrome with a fatal outcome, if not diagnosed and treated at the right time. ALF in children can be difficult to recognize and is very different from ALF in adults; in terms of definition, etiology, symptomatology and management. The causes of ALF in children represent a large heterogeneous list, which vary by age and geographical location. The management of ALF mandates multidisciplinary approach with comprehensive intensive and supportive care; which at times is complex and can be challenging to a pediatric intensivist. The key steps in management are to monitor and support affected organ systems; anticipate, identify and treat complications; and maintain optimal clinical condition till spontaneous recovery or liver transplantation. This review describes definitions, etiopathogenesis, clinical features and the most recent management strategies, including emergency liver transplantation considerations in pediatric ALF.

Managing children having an upper gastrointestinal bleed (UGIB) can be anxiety-provoking for an intensivist, as the differential diagnosis can vary from a benign disorder to a life-threatening condition, with the potential for high fatality if the management is delayed. Common causes in children of UGIB as a presenting complaint in the emergency department include mucosal lesions and variceal hemorrhage. While in intensive care settings, UGIB is usually secondary and is common in critically sick children with risk factors like respiratory failure, shock, organ failure and trauma. Despite the varied presentation, the primary focus in a child with UGIB is resuscitation and stabilization followed by a diagnostic evaluation. Pharmacological methods in management of UGIB include vitamin K, acid suppression agents while patients with portal hypertension warrant special consideration where splanchnic vasoconstrictors may have a role. Emergency endoscopy in acute UGIB in children can be technically difficult and risky to the patient, and it must be performed only once the patient is adequately stabilized. In this review, an attempt has been made to discuss an intensivist approach to UGIB in children.

The concept of intra-abdominal hypertension and abdominal compartment syndrome is relatively new, but increasing awareness and evolving management strategies have been instrumental in reducing mortality by nearly half in critically ill patients with this condition. The thresholds for intraabdominal hypertension and abdominal compartment syndrome in children are different from adults. When intraabdominal pressure increases, it affects both abdominal and extra-abdominal organs. This needs to be recognised, the vicious cycle of poor perfusion and increasing intraabdominal pressure which ultimately leads to ischemic cellular necrosis. Focus has gradually shifted from treatment to prevention of progress of intraabdominal hypertension. Various non invasive methods can be used effectively to decrease intra-abdominal pressure, but surgical decompression is essential when organ dysfunction and abdominal compartment syndrome set in. This review describes the definitions, risk factors, pathophysiology and management strategies for increased intra-abdominal pressure in children.

The incidence of acute pancreatitis (AP) in children is slowly increasing. Etiological pattern of AP in children is varied and unlike adults; it mainly includes trauma, infection, medications and idiopathic causes. AP is characterised by severe abdominal pain, 3 fold elevation in amylase and/or lipase & characteristic findings on imaging. Early diagnosis is essential for appropriate management; however this is challenging especially in young and sick children where symptoms may not be forthcoming. Also overlapping symptoms and laboratory investigations in certain scenarios such as diabetic ketoacidosis and head trauma may lead to diagnostic difficulties. Regardless of etiology, the evolution of AP has 2 common phases which need to be recognised by the intensivist. These include initial phase of SIRS and subsequent phase of infectious complications; both of which can be potentially lethal. Clinical severity scoring systems used in adults are not applicable to children with AP. 7 fold rise in serum lipase appears to be an accurate predictor of severity in children. Essential to management is early aggressive fluid resuscitation (within 6-12 hours of admission) which should be guided by monitoring of various hemodynamic parameters in PICU rather than fixed fluid guidelines. Intravenous contrast enhanced CT of the abdomen is required to assess the severity of AP and extent of regional complications. It is however best delayed until hemodynamic stabilisation or for at least 48-72 hours after onset of symptoms. Pain management and early nutrition are important aspects of care along with close monitoring for development of multi-organ dysfunction. This review attempts to address AP in children from a pediatric intensivist’s perspective.

Gastrointestinal (GI) problems occur frequently and are often considered to be just a fact of life in pediatric intensive care units; they do not usually get the importance they deserve. This is substantiated by the fact that gastrointestinal function is not included in any of the scoring systems widely used to assess organ failure in critical illness. Defining gastrointestinal failure or dysfunction is complex; however recent attempts have been made to address acute gastrointestinal injury in critical illness. This review addresses the following common GI issues in PICU: constipation, diarrhea, feeding intolerance and stress ulcer prophylaxis.

Point-of-care ultrasound provides rapid and accurate diagnostic imaging in an acute care setting. While thoracic ultrasonography has proved to be a useful technique for adults in the emergency department and intensive care units, few studies have evaluated this technique in children. In this case, we describe the presence of a pneumothorax, identified by point-of-care ultrasound in a 4-month-old infant in postoperative care after cardiac surgery. The infant presented with mild respiratory distress. A resident physician performed the exam, after recently completing ultrasound training.

Like many other infections, Dengue is known to cause myocarditis. Dengue myocarditis can be mild or fulminant. Fulminant myocarditis can rapidly lead to end organ damage and even death. We present here an adolescent girl suffering from Dengue infection who developed fulminant myocarditis. Myocarditis was diagnosed by presence of low left ventricular ejection fraction, shock and elevated cardiac enzymes. When she developed refractory shock (unresponsive to preload optimization, inotropes, positive pressure ventilation, colloids, myocardial protective strategies, Intravenous immunoglobulins etc.), she required emergency Veno-arterial ECMO (Extra Corporeal Membrane Oxygenation) support. On 6th day, as her condition improved, she was weaned from the ECMO. Echocardiography on follow up shows normal study and she is leading a normal life today. Hence, for patients with refractory shock caused by Dengue myocarditis, timely referral to higher centre with Extra-corporal life support facility should be considered.

Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening disease caused by uninhibited hyperinflammatory reaction that can lead to fulminant, life threatening multi organ failure and whose pathophysiology and clinical characteristics are somehow similar to that of severe sepsis and septic shock. Here we present a case of a 5 months old baby, admitted in our PICU in shock and was being managed initially in the lines of septic shock but ultimately was diagnosed to be a case of Familial HLH type 2 due to a homozygous missense variation in exon 2 of the PRF1 gene that results in the amino acid substitution of Serine for Tryptophan at codon 129.

The oral-facial-digital syndromes (OFDS) are rare genetic heterogenous group of disorders characterized by oral (mouth and teeth), facial and digital (fingers and toes) anomalies. OFDS are classified into 13 potential forms. OFDS Type II (Mohr syndrome) is an autosomal recessive disease characterized by oral (median cleft/pseudocleft lip, lobed tongue, high arched or cleft palate), facial (low nasal bridge with lateral displacement of inner canthi, broad nasal tip, retromicrognathia) and digital anomalies (clinodactyly, syndactly and polydactyly of hands and feet and duplication of thumb and hallux). This is the case report of an indian new born with OFDS type 2 manifestations.

The oral-facial-digital syndromes (OFDS) are rare genetic heterogenous group of disorders characterized by oral (mouth and teeth), facial and digital (fingers and toes) anomalies. OFDS are classified into 13 potential forms. OFDS Type II (Mohr syndrome) is an autosomal recessive disease characterized by oral (median cleft/pseudocleft lip, lobed tongue, high arched or cleft palate), facial (low nasal bridge with lateral displacement of inner canthi, broad nasal tip, retromicrognathia) and digital anomalies (clinodactyly, syndactly and polydactyly of hands and feet and duplication of thumb and hallux). This is the case report of an indian new born with OFDS type 2 manifestations.