Objectives : To study the quality of ambulance services in medical emergencies at Pandit B D Sharma Institute of Medical Sciences, Rohtak, North India. Methodology: Type of study: Cross-sectional, by convenient sampling 50 people were included in the study. Data analysis was done by using Microsoft Excel 2007 version and proportions. Results: In present study it was seen that only 46% study subjects knew about the equipment’s present in the ambulances, 54% have received a formal training before joining this occupation. emergency drugs were present in 94% ambulances. About 70% study subjects were aware of need for checking the expiry on drugs and only 48% of ambulances have extrication services. Conclusion : ambulance services are not up to mark and there is a wide scope of improvement for better delivery of health facilities to the people in India.

Specific criteria using easily available biomarkers such as serum creatinine and urine output have been developed to define and stage acute kidney injury(AKI) at the bedside. The RIFLE criteria and the AKIN criteria are used for adults, the pRIFLE criteria for children and the KDIGO classification for both adults and children. The chief limitation in all the current criteria lies with the physiological limitations of using an insensitive functional marker such as serum creatinine as a surrogate marker for glomerular filtration rate (GFR). Varying methodologies for measuring serum creatinine and the lack of validation using isotope dilution mass spectrometry(IDMS), are additional technological limitations that challenge uniformity in India. Calculation of eGFR by the Schwartz formula is compromised by these technological limitations as well as by the lack of a validated k value for Indian children. Serum Cystatin C is superior to creatinine as a biomarker for GFR and appears at least 24 hours earlier than serum creatinine in the presence of AKI. However, expense and non- availability in clinical laboratories precludes its use. Urinary biomarkers appear very sensitive and reflect different stages of cell injury. Neutrophil Gelatinase associated Lipocalin (NGAL) has been shown to appear in the urine as early as 2 hours after renal injury. However, it is not specific for AKI alone and may also be increased in many inflammatory states and co-morbid conditions. The redefined criteria for AKI are invaluable in the critical care setup but need further refinement.

Biomarkers can be measured objectively and can assess physiological as well as pathological process or pharmacological response or helps in deciding therapeutic intervention or prognostication of disease. Biomarkers can be clinical as well as molecular. Kidney is one of the vital organs of human body and has mainly excretory functions. Acute kidney injury is independent risk factor for morbidity and mortality and early intervention has better prognosis. Defining acute kidney injury is still a big issues and various classifications have been proposed but none is suitable to define or identify sub-acute injury to such a vital organ. Measurement of serum creatinine and urine output have been used in almost all definitions but do not pick up early sub-clinical damage associated with normal serum creatinine and urine output. Recently study of general and novel biomarkers have helped in defining the sub-clinical damage, early therapeutic intervention and prognosis of child with acute kidney injury.

Acute kidney injury (AKI) is a common and potentially fatal complication of sepsis. Septic acute kidney injury (SAKI) remains an important challenge in critical care medicine. SAKI has a complex pathophysiology than previously anticipated. The pathophysiologic mechanisms of sepsis-induced AKI are different from non-septic AKI. Sepsis- induced systemic inflammation triggers protective mechanisms within the nephron, affecting tubular and glomerular functions. A varying degree of kidney impairment can be expected, from a small decrease in GFR to complete shutdown and permanent dysfunction, depending on the severity of the inflammatory response. It is likely that progression of septic AKI can be prevented by avoiding hypotension, fluid overload, and venous congestion. There is no specific therapy for septic AKI at present. Even though novel drugs and blood purification techniques for sepsis-induced AKI are being tested, supportive care to prevent further kidney insults is likely to allow kidney structure and function to more easily recover once the septic state has resolved.

Drug- induced acute kidney injury is common in critically ill patients. Understanding the mechanism of drug induced renal damage helps to decide appropriate preventive strategies. Identifying at risk patients and avoidance of nephrotoxic agents is of key importance. Drug dose adjusted for renal function should be used in clinical practice.

Pediatric AKI presents with a wide range of clinical manifestations from a minimal elevation in serum creatinine to anuric renal failure, arises from multiple causes and occurs in a variety of clinical settings. The prognosis of AKI is highly dependent on the underlying etiology of the AKI. Thrombocytopenia is one of the most common laboratory findings in the ICU. The causes of acute kidney injury associated with thrombocytopenia are very few. This chapter gives an overview of etiology, incidence, diagnosis, conservative treatment, of various causes of AKI associated with thrombocytopenia in children beyond the newborn period in the context of advances made in this field.

Contrast-Induced Nephropathy (CIN) is defined as acute deterioration of renal function after the administration of Radio-contrast materials, mostly within a period of 24 to 48 hours. Most of cases are non-oliguric and reversible and rarely associated with adverse outcomes. The diagnosis of CIN is based upon the clinical presentation, including the characteristic rise in serum creatinine concentration beginning with the first 24 to 48 hours after contrast exposure, and the exclusion of other causes of acute kidney injury (AKI). Incidence of CIN varies widely depending on the definition of AKI, the presence or absence of risk factors, the amount and type of agent administered, and the type of radiologic procedure. Biomarkers Cystatin C, Neutrophil gelatinase-associated lipocalin (NGAL) in urine and plasma, 2 hr after contrast administration have been shown to be predictive biomarkers of CIN. Most cases of CIN are self-limited. Management is conservative as with any other case of AKI and dialysis is rarely required. Adequate hydration, use of low doses of contrast media especially low-osmolar or iso-osmolar type , will reduce the risk of CIN.

Cardiorenal syndrome(CRS) is an interdependent involvement of the heart and the kidney that leads to high morbidity, recurrent readmissions and grave prognosis. Early use of slow high-dose intravenous diuretics, dialysis with ultrafiltration for treatment of congestion, inotropes and left ventricular assistant device to stabilize the hemodynamics and maintenance of the renal perfusion are the vital component for a short period of time. Hepatorenal syndrome (HRS) is a unique form of functional renal failure associated with progressive liver failure. It carries worst prognosis among all causes of renal failure in children with liver disease. Liver transplantation is the definitive treatment of HRS. Vasoconstrictor therapy with albumin and Renal replacement therapy are used as a bridge to liver transplant for patients who are unresponsive to medical therapy.

Early restoration of euvolemia is the initial step in the management of critically ill children and is important for preventing acute kidney injury(AKI). Isotonic crystalloids are the preferred solutions for fluid resuscitation. Repeated boluses of normal saline may lead to hyperchloremia, renal vasoconstriction and renal injury. Balanced solutions have a physiological advantage and there is evidence to suggest that resuscitation with balanced solutions may be associated with lower incidence of AKI. Synthetic colloids such as starches cause renal injury and should be avoided. Albumin can be used judiciously along with crystalloids to limit fluid overload. Fluid resuscitation alone prevents AKI only in 50% of the critically ill patients. Fluid overload as well as rapid fluid administration may adversely affect the kidney through injury to the glycocalyx. It may lead to intrarenal edema and a compartment-like syndrome compromising renal perfusion. Repeat fluid bolus should only be given when there is evidence of ongoing hypoperfusion and the bedside hemodynamic assessment suggests fluid responsiveness, provided the patient is not at high risk for fluid overload. Moderate fluid resuscitation combined with pressors may restore renal perfusion better than fluids alone. In established AKI, diuretics have a limited role. Timely institution of renal replacement therapy leads to optimum fluid management. Overzealous fluid removal should be avoided to prevent hypovolemia and recurrent renal injury.

Life threatening complications of dyselectrolytemia, uremia and fluid overload may be prevented by early initiation of Renal Replacement Therapy(RRT).Hemodialysis and Peritoneal dialysis are the modalities available. Hemodialysis is intermittent therapy, even when prolonged beyond the standard 4-hr prescription. Continuous renal replacement therapy (CRRT) is defined as any extracorporeal blood purification therapy intended to substitute for acutely impaired renal function over an extended period of time and prescribed continuously for >24-h.Timely initiation of RRT for AKI in children with fluid overload and sepsis is considered useful in enabling recovery.

Acute kidney injury (AKI) causes increased morbidity in critically ill children and damage to the kidney affects survival. The incidence of AKI in pediatrics is significant and despite alarming data, therapeutic interventions have failed to effect a meaningful difference in outcomes. In this review, we will discuss prevention of AKI in paediatrics, drug modification, need for risk stratification and staging which would help to recognise at risk children.

Background: 10 month old infant presenting with fever, cough and coryza for 3 days progressed to acute respiratory failure. An initial clinical presentation of wheeze associated lower respiratory tract infection developed into an extremely severe course of disease characterized by acute respiratory failure requiring invasive mechanical ventilation. Bronchoalveolar Lavage fluid analysis revealed high titres of Bocavirus by PCR. Case characteristics : 10 month old infant presenting with fever, cough and coryza for 3 days progressed to acute respiratory failure. Outcome: Bronchoalveolar Lavage fluid analysis revealed high titres of Bocavirus by PCR. Message : Bocavirus infection should be suspected in case of rapidly progressing respiratory illness escalating to Type II respiratory failure

Myxedema com, also called myxedema crisis is a rare life threatening clinical condition that represents severe hypothyroidism. It may be the initial presentation in pediatric patients with prolonged untreated hypothyroidism. Myxedema coma should be suspected in pediatric patients with altered mental status, hypothermia and cardiovascular instability. This condition is fatal without treatment. Thyroid replacement should be initiated as early as possible. Early intervention in hypothyroid patients and in patients where hypothyroidism is suspected has shown to prevent morbidity and mortality associated with myxedema crisis.