Background: The term Acute respiratory distress syndrome (ARDS) describes a syndrome of acute onset, characterized by respiratory distress, bilateral pulmonary infiltrates with decreased pulmonary compliance and hypoxaemia. Recent data indicate that ARDS occurs in 1-4% of PICU admissions and as many as 8-10% of children requiring mechanical ventilation. Mortality for Pediatric ARDS has varied between 20 and 75%. Despite very high incidence in PICU with high mortality and morbidity there are only few studies on Pediatric ARDS. Hence the present study is undertaken to elucidate the epidemiology, etiological profile and outcome of pediatric ARDS admitted to our PICU. Objectives: To study the Epidemiology and Outcome of Pediatric Acute Respiratory Distress Syndrome according to Pediatric Acute Lung Injury Consensus Conference 2015 (PALICC) Definition. Material and methods: This was Single centre Prospective observational study. All children between the age group of 1 month to 15 years admitted to pediatric intensive unit with respiratory distress meeting PALICC 2015 Pediatric ARDS criteria consisted as the study group. Children with mild respiratory distress were started on high flow nasal cannula or NIV. Children with moderate to severe respiratory distress were started on mechanical ventilation. Severity of ARDS was assessed with oxygenation index. All children with ARDS were managed with PALICC 2015 recommendation. All data was collected in a systematically designed proforma and analysed. Results: A total of 652 children got admitted in high dependency PICU between January 2017 to July 2017. Of these 39 (5.98%) children fulfilled the PALICC 2015 Pediatric ARDS criteria. Out of 39 children with Pediatric ARDS, majority (46%) of them were between age group of 1 to 5 years. Pneumonia was most common risk factor for ARDS (51%) in our study. Thirty one children were mechanically ventilated. Among ventilated children 8 (20.5%) had mild, 15 (38%) had moderate and 8 (41%) had severe ARDS Overall mortality was 12 (30.76%). Five out of 8 (62%) children with severe ARDS have expired. Adjunct therapies used in study group were, steroids in 5 (16%) cases, neuromuscular blockers in 6 (15.3%) cases and prone ventilation 1 case. Conclusion: Pediatric ARDS is an illness with high mortality and requires excellent supportive care. Pneumonia is the commonest risk factor for development of pediatric ARDS. Risk factors for mortality include presence of comorbidities, multi organ dysfunction and high OI at 24 hours of ARDS.

Pointers of endocrine disease play important role in the management a sick child and high index of suspicion is needed to diagnose an endocrine problem in critical care setting. Clinical features and laboratory parameters guide us to reach the diagnosis of specific hormonal problem and help in further management of a critically ill child with improved outcome. Role of steroid in shock is also important. Supplementation of GH and IGF1 in critical illness is not promising and needs further evidence to support its use in critical care setting in children.

Diabetic Ketoacidosis (DKA) is a commonly seen condition in Pediatric age group requiring admission to the PICU. The scope of this article is to discuss the management of children with moderate to severe DKA requiring hospital- ization. Electrolyte disturbances such as hypoglycemia, hypokalemia, hypocalcemia, hypomagnesemia and severe hypophosphatemia can occur during the clinical course of DKA. Additionally, DKA can be associated with sepsis with serum C-reactive protein and interleukin-6 levels being useful in excluding an underlying infection, as well as confirming and monitoring sepsis. DKA can result in serious morbidity such as cerebral edema, cerebral infarction, venous and arterial stroke. Simultaneous pulmonary and cerebral edema with multiple CNS infarctions as a complication of DKA has also been described. Severe DKA can lead to cardiac failure, pulmonary edema and spinal cord edema resulting in tetraplegia. Current review emphasizes mainly regarding all the measures to reduce morbidity and potential mortality. To minimize morbidity, early recognition of diabetes is paramount especially when polyuria, polydipsia, lethargy and weight loss is described. The clinical suspicion of DKA should be confirmed quickly by biochemical evidence and appropriate treatment instituted. The International Society of Pediatric Diabetes introduced guidelines (ISPAD 2014) as well as British Society of Pediatric Endocrinology are also discussed to put it in clinical perspective.

Altered thyroid function in non-thyroidal illness(NTI) is a well-recognized finding. The term euthyroid sick syndrome (SES) identifies abnormalities in thyroid function observed in patients with systemic nonthyroidal illnesses (NTIs). SES being most common endocrine change seen in critically ill patients, is characterized by low triiodothyronine (T3), low or normal thyroxine (T4) and normal thyroid stimulating hormone (TSH). The extent of SES is associated with prognosis, but no proof exists for causality of this association. T3 levels reflect the patient’s clinical status, T4 levels can predict survival. Initially, SES is a consequence of the acute phase response to systemic illness and macro- nutrient restriction, which might be beneficial. Pathogenesis of SES in long term critical illness is more complex and includes suppression of hypothalamic thyrotropin-releasing hormone, accounting for persistently reduced secretion of thyroid-stimulating hormone despite low plasma thyroid hormone. Distinguishing between SES and other primary thyroid disorders, can be difficult in ICU setting. Clinical benefits of supplementing thyroid hormone in SES has not been answered adequately. No evidence-based consensus or guideline advocates thyroid hormone treatment of SES at present.

Adrenal insufficiency (AI) is a frequently discussed but inadequately understood condition among critically ill patients. Increased glucocorticoid action is an essential component of the stress response. Dysfunction of the HPA axis in critical illness may be best described by the term critical illness-related corticosteroid insufficiency (CIRCI), in preference to terms like absolute or relative adrenal insufficiency. Most of the research about CIRCI has focused on patients with septic shock and acute respiratory distress syndrome (ARDS). The diagnosis of CIRCI relies on clinical suspicion and ACTH stimulation test results. Adjunctive corticosteroids may be considered in patients with septic shock who have responded poorly to volume resuscitation and catecholamines, and for patients with ARDS. No high-quality data supporting such intervention for children is currently available. Routine ACTH testing is not recommended to identify this subset of patients with septic shock who should receive hydrocortisone therapy. Given the lack of consistent benefit and likely under appreciation of the adverse effects of this drug class, clinicians should maintain equipoise for well-designed clinical interventional trials addressing both the potential benefits and risks of adjunctive corticosteroids prescribed for septic shock and ARDS.

Dysglycemia is frequently encountered in critically ill patients in the intensive care units (ICU) and is associated with increased morbidity and mortality. Glycemic control in ICU has three important aspects - hyperglycemia, hypoglyce- mia and glucose variability. All three aspects carry equal importance in the management of critically ill patients and need to be understood. In this review, we will discuss about glucose metabolism in relation to glycemic control in critically ill patients- epidemiology, pathophysiology and management of hyperglycemia, hypoglycemia and glucose variability in critically ill patients.

There is no firm evidence that any one catecholamine is more effective or safer than other in the treatment of shock. The choice of an agent depends on the underlying hemodynamic state. Understanding the pathophysiology, metabolic effects and altered responsiveness to catecholamines during critical illness is useful for management of the same. Titration of catecholamine is essential to avoid harmful side-effects.

Robust clinical evidence for the use of vasopressin in children is scant. Low dose vasopressin infusions may be tried in catecholamine resistant shock or refractory cardiac arrest. It significantly improves hemodynamic indices without necessarily translating into clinical benefit. There appears to be a trend to greater tissue ischemia with its use. Evidence to date has not demonstrated clear efficacy for vasopressin’s routine use in management of pediatric shock. Further high-quality research is essential before it can be recommended as a routine standard of care.

Pheochromocytoma is a tumor arising out of embryological neural crest, being a tumor of adrenal medulla secreting predominantly norepinephrine as well as epinephrine(about 20% cases) leading to frequent surges of vasopressor catecholamines leading to systemic hypertension, hypertensive emergencies and associated cardiac, neurological, and renal sequalae. Though somewhat rare in pediatric age group, it remains an important etiological factor to think about when there is intractable hypertension or rapid swings of blood pressures leading to headaches and palpitations with family history of hypertension or as a part of familial endocrine neoplasia. Treatment remains laproscopic or open surgical resection under general anesthesia, however perioperative care remains a challenge for the anesthesiologist, intensivist requiring adequate medical control of hypertension with alpha blockers such as phenoxybenza- mine before undertaking anesthetic induction and important monitoring measures instituted during intraoperative and postoperative period for close monitoring of blood pressure and intravascular volume status as well as hemodynamics. We review a case report with literature review regarding perioperative management of pheochromocytoma.

The C-V junction is a transition site between mobile cranium and relatively rigid spinal column. It is also the site of the medullo-spinal junction. CV anomalies are defects of development, not necessarily congenital and may not manifest at birth. These anomalies can lead to spinal cord compression, cranial nerve compression, vertebral artery compression and obstructive hydrocephalus. Delay in diagnosis can result in irreparable damage to spinal cord and can lead to permanent disability or even death. MRI of cervical spine helps us in diagnosis of CVJ anomalies and is the investigation of choice. We are presenting a case of 12 years old female child presented with history of progressive weakness of both upper and lower limbs, difficulty in walking and history of frequent falls with transient loss of consciousness for last 4 years. She was found to have CVJ anomalies on MRI cervical spine but had already developed permanent disability due to atrophy of spinal cord due to prolonged compression.

Cytomegalovirus (CMV) retinitis is a marker of severe cellular immunodeficiency. Severe combined immunodeficiency (SCID) must be considered in infants presenting with CMV retinitis in a non-HIV setting. Severe combined immunodeficiency (SCID) is a life-threatening syndrome characterized by recurrent infections, diarrhoea, dermatitis, and failure to thrive. Clinically, most children present before the age of 3 months. Without intervention, SCID is universally fatal. SCID is considered a pediatric emergency because survival depends on expeditious hematopoietic stem cell transplantation. Cytomegalovirus (CMV) is the most common opportunistic ocular infection in children with SCID. We report a 4-month-old male infant, with extensive bilateral CMV retinitis secondary to SCID.

Objective: The aim of our study is to know the commonest and variable presentation of airway foreign bodies, to study the various parameters like site and nature of foreign body, to know the outcome and complications associated with bronchoscopy. Methods: A hospital based observational study conducted at a teritiary care hospital, Bagalkot between 1st January 2015 to 31st December 2015. Data collected using a preformed questionnaire; proportions and percentages were used to analyze the data. Results: A total of 25 patients were studied, males outnumbered females by a ratio of 6.3:1, youngest child being 9 months. Only 12 out of 25 cases presented with history of foreign body aspiration accounting to 48%. Most common symptoms are cough and hurried breathing; most common signs are retractions and decreased air entry. Most common X-ray finding is unilateral obstructive emphysema. Left main bronchus was the commonest site for foreign body impaction and commonest type was vegetative foreign body. Foreign body was successfully removed in 24 cases. Bronchial spasm was the most common immediate post bronchoscopy complication and bronchopneumonia was most common late complication. One baby expired due to aspiration of vegetative foreign body with complete airway obstruction. Conclusion: Tracheobronchial foreign bodies are difficult to diagnose in children. High index of suspicion for foreign body aspiration should be considered especially when child present with sudden onset respiratory distress and/ or unilateral chest findings, not improving with intravenous antibiotics and 100% oxygenation. Early diagnosis and treatment helps to reduce complications and mortality.