Introduction: The label and off-label use of intravenous immunoglobulin (IVIG) in pediatric intensive care unit (PICU) is done as a replacement therapy also for immunomodulation. As there are no standard guidelines for the use of IVIG in PICU; hence, the need to study the pattern of indications for which IVIG has been used in critically ill children and review the quality of evidence as per the available data. Materials and Methods: The retrospective chart review of indications for IVIG therapy in children over a period of 4 years in a tertiary care PICU from January 2015 to December 2018. Collection of data included demographic profile, indication of transfusion of IVIG, dose of IVIG received, and outcome of the patients. Results: The IVIG therapy was given to 301 children under the following groups, 120 children for neuroimmunologic disorders, 73 children for cardiology-related indications, 65 children for infection and infection-related causes, 31 children for autoimmune diseases, seven and five children each for primary immunodeficiency and dermatological causes, respectively. The indications, for which IVIG therapy given included, approved by the Food and Drug Administration in 56 children, under evidence category Level Ia in 50 children and with strength of recommendation Grade A in 51 children. Conclusion: There is a rise in off-label use of IVIG as the quality of evidence is variable for different indications hence there is a need for better quality of evidence and more multicentric randomized control trials to define the precise impact of IVIG on various conditions.

Background and Objectives: The risk factors are associated with surgical outcomes of cardiac surgery. This study was aimed to correlate the effect of preoperative risk factors in children with congenital heart diseases (CHDs) on the outcome of cardiac surgery. Materials and Methods: This 1-year prospective observational study was conducted in a tertiary referral hospital. A total of 200 children with congenital cardiac diseases undergoing cardiac surgery were studied pre- and post-operatively for 3 months. Results: Cyanotic and acyanotic CHDs were noted in 33% and 67%, respectively. The most common acyanotic CHD was ventricular septal defect (35%) and the common cyanotic CHD was tetralogy of Fallot (17%). Majority of the children (75.5%) presented with risk factors. 63% of the children were under risk-adjusted classification for congenital heart surgery (RACHS)-II category while 19% were in RACHS-IV. 7.5% of the children expired. Conclusion and Interpretation: Significantly high mortality was recorded in children aged <1 year, those who presented with cyanotic CHDs, those having a risk factor, and children with RACHS-IV criteria.

Objective: Metabolic acidosis (MA) is the most frequent acid-base disorder in the pediatric intensive care unit (PICU). The aim of this study is to determine the frequency of MA in children on admission in the first 24 h of PICU. Methods: A prospective observational cohort study was conducted in a closed PICU from August 2015 to June 2016. All consecutive children who admitted to PICU were screened for MA. MA is defined as base deficit (BD) ≥−5 mEq/l. Demographic data, clinical variables, and blood gas data were collected on structured data collection sheet and appropriate statistical test applied for analysis. Results: A total of 200 children were enrolled in the study. The mean age was 63.20 ± 61.31 months and males were 56%. The frequency of MA in our cohort was 44%. The mean BD was 10.4 ± 4.9 in a group of MA as compared to −2.34 ± 5.4 in group without MA. The use mechanical ventilation, inotropic support, and renal support were higher in MA cohort as compared to cohort without MA. The mortality rate was also high in group of MA as compared to other groups (25% vs. 12.5%) (P = 0.014). Conclusion: The frequency of MA is high in critically ill children on admission to PICU, and it is associated with increased length of stay and high mortality rate.

Background: Evaluation of altered consciousness in children is a challenge and an important aspect of emergency care. There is no objective measure to communicate and document the severity of coma as distinct from vital signs. Various coma scales have been developed for recording depth of consciousness which are widely used in clinical practice in adults and children. Studies are conflicting on the best quick assessment tool for neurologic status. One of the newer tools is the Full Outline of Unresponsiveness (FOUR) score has been developed to assess the depth of coma in a more detailed manner than the Glasgow Coma Scale (GCS) scale. Objectives: The present study was taken to determine the predictive value of FOUR score and GCS in outcome of children aged 1–14 years presenting with altered sensorium. Materials and Methods: This prospective observational study was conducted in the teaching hospital of Haryana. A total of 150 children aged between 1 and 14 years were included. FOUR score and GCS were obtained within 1 h of admission. This assessment was repeated at 12^th h and 24^th h after admission. Children who left against medical advice were telephonically contacted to determine the final outcome, and they were called for 1-month follow-up. Results: The mean age was 6.64 ± 4.13 years. Seventy-nine (52.66%) patients were male and 71 (47.33%) were female. GCS at admission, 12^th h, and 24^th h was 7.76 ± 2.91, 7.22 ± 3.60, and 7.22 ± 4.57, respectively. The mean FOUR score was 10.12 ± 3.92 which decreased continuously at 12^th h, 24^th h, and finally, at discharge, i.e., 10.29 ± 8.13 (P > 0.05). A total of 53 (35.33%) patients expired and 97 (64.66%) were discharged. A total of 69 patients were admitted to the pediatric intensive care unit (PICU). The mean duration of PICU stay was 5.84 ± 5.25. Patients who expired had lesser GCS score as compared to FOUR score at the time of admission and 12^th h, i.e., 5.79 ± 2.18 and 6.54 ± 3.40 and 4.20 ± 2.62 and 4.30 ± 3.70, respectively. The mean GCS at the time of admission was 5.79 ± 2.8 which decreased significantly to 0.679 ± 2.28 and FOUR score decreased from 6.54 ± 3.40 to 0.35 ± 2.21 at the time in expired (P &#A60; 0.001). Conclusions: FOUR score can be used as good as GCS for predicting the inhospital mortality. GCS and FOUR scores both have a significant correlation with death. The study shows an excellent degree of agreement between GCS and FOUR scores at admission, at 12^th h, at 24^th h, and at discharge. FOUR score has better odds for predicting mortality on admission and at 24^th h, whereas GCS at 12^th h is better than FOUR score at 12^th h in predicting mortality.

A 27 days old neonate presented with poor feeding, severe respiratory distress and septic shock without any palpable abdominal mass. On evaluation found to have features of overt late onset neonatal sepsis and right sided pneumonia. The initial working diagnosis was poorly resolving pneumonia however upon further evaluation found to have blood gas and ultrasonographic evidence of infantile hypertrophic pyloric stenosis (IHPS). Good perioperative care is required to prevent complications.

The antiphospholipid antibody syndrome (APS) is an acquired prothrombotic state where thrombosis is related to the presence of antiphospholipid antibodies. It can occur in the absence of associated disease when it is termed primary antiphospholipid syndrome, or it can be secondary to an underlying autoimmune disease, most commonly systemic lupus erythematosus. We report a case of a male child with no underlying infectious or autoimmune disease who presented to us with a large middle cerebral artery (MCA) infarct secondary to transient APS. Although lupus anticoagulant antibodies can be detected in plasma in early-stage, their persistence should be confirmed by repeating the test again after 12 weeks as transient APS is well known in the pediatric population. The exact prevalence of pediatric APS and its manifestation in Asian and particularly Indian children are unknown and further epidemiological studies are warranted.

Acute respiratory distress syndrome (ARDS) with pulmonary hemorrhage is uncommon in severe dengue and it is multifactorial. We report here an 11-year-old patient with severe dengue who developed ARDS with pulmonary hemorrhage requiring veno-venous extracorporeal membrane oxygenation support and recovered without any major sequel. Timely intervention with extracorporeal life support (ECLS) as rescue therapy in severe dengue with ARDS can restore lung function. Hence, early recognition of ARDS in dengue and referral to a higher center with ECLS facility is paramount.

In pediatric population, accidental poisonings are not an uncommon cause for presentation as acute encephalopathy syndrome (AES). Certain plants found in India such as Ricinus Communis (Dhatura) and Cannabis are known to produce a clinical picture of AES. Hereby, we share our experience of accidental poisoning with Cassia occidentalis in three young children who presented with acute encephalopathy to the emergency department of a tertiary care center in Haryana, North India.

Persistent pulmonary hypertension (PPHN) is seen in approximately 10% of infants with respiratory failure with significant mortality and morbidity. Pulmonary hypertension in infants can be idiopathic, associated with vascular or parenchymal diseases. Thiamine deficiency is one of the reversible causes of pulmonary hypertension. 7 month old male infant presented with cough, fast breathing, decreased oral acceptance and excessive irritability. Echocardiography was suggestive of severe pulmonary hypertension without any structural heart disease. Rapid progression, history of exclusive breast feeding, persisting lactic acidosis prompted us to investigate for thiamine deficiency. Low blood thiamine levels confirmed the diagnosis. It was further confirmed by thiamine challenge (IV thiamine for 5 days) with rapid clinical improvement. Mother was also found thiamine deficient, started on oral supplements. Hence thiamine deficiency should be considered in all infants with pulmonary hypertension of unknown origin.

Magnesium is the fourth common cation in the human body and plays a crucial role in the activation of enzymes, cell metabolism, protein synthesis, and hydrolysis of adenosine triphosphate. It is mainly present in the bone and muscles, and only 1% is present in the extracellular fluid. The incidence of hypomagnesemia is high in hospitalized patients.