With development of specialized pediatric critical care units, referral from community, district or other peripheral hospitals has gained greater momentum. Referral is a process in continuum; starting from the referring and ending at the referred hospital. Establishing a one on one communication with peripheral hospitals and healthcare providers over a wide geographical area is not an easy task. This gap can be reduced effectively using technology. An ‘electronic’ referral system can improve the two way communication and ensure completeness of requisite information about every referral. Therefore we studied the feasibility of an e-referral system to streamline the referrals coming to our Pediatric Emergency Unit. An online e-referral system may be a good initiative to connect hospitals and enable 24X7 communications over the patients being referred between them.

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Dermatopathy as an initial manifestation of cystic fibrosis (CF) in the newborn period is unusual. The eruption is usually first noted in the perineum, typically appears in infancy from age 2 weeks to 15 months after birth. It subsequently spreads to the extremities and trunk. We report a two months old male baby who presented with failure to thrive, hypoproteinaemia, anaemia and a cutaneous eruption resembling acrodermatitis enteropathica. Oral zinc supplementation resulted in temporary resolution of the dermatitis. A further work-up revealed the diagnosis of cystic fibrosis.The rash was responsive to nutritional and pancreatic enzyme supplementation.

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Mechanical ventilation both invasive and non-invasive are key requirement of any high dependency and intensive care units to provide respiratory support in emergency as well as electively. Most of the time trained residents are not available and one has to depend on trained staff and respiratory physiotherapist. One may not be well versed with advanced mode and graphics but must know basics. Thus, it is essential to understand machine, basics ventilatory settings, monitoring parameters on ventilator, and weaning criteria from mechanical ventilation.

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Objective: To study the clinical profile, the outcome and to determine clinical signs predictive of the outcome in pediatric patients admitted with non-traumatic coma. Methods: This prospective study was conducted over a period of two years on 150 children between age group 2 months and 14 years admitted with non-traumatic coma to the PICU of a tertiary care state government run hospital of eastern India. Clinical parameters at admission and at 48 hours were analysed. Relevant laboratory investigations and radiological studies were documented. Outcomes were analysed at the time of discharge or death. Results: CNS infection was the leading cause of coma in 57.3 % of the cases, out of which acute bacterial meningitis in 38.4% cases, encephalitis in 33.7% cases, cerebral malaria in 18.6% cases and tuberculous meningitis in 9.3% cases. The toxic-metabolic conditions (21.3%) were overall second followed by status epilepticus (7.4%), intracranial haemorrhage (4%), and others (10%). Among the 99 (66%) children survived, 59(39.3%) were normal, 17(11.3%) had mild, 17(11.3%) had moderate and 6(4%) had severe disability. Survival was highest in ischemic stroke patients (100%) followed by patients with CNS infection (71%). Poor pulse volume, abnormal blood pressure, respiratory pattern, poor GCS and abnormal brain stem reflexes at admission or at 48 hours showed significant correlation with mortality. The abnormal heart rate, abnormal motor pattern, the presence of papilledema and convulsion if present at 48 hrs were poor predictors of survival. Conclusion: CNS infection was the commonest aetiology and clinical signs at 48 hrs of admission were important predictors of mortality.

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Introduction: Care of critically ill children remains one of the most demanding and challenging aspects in the field of pediatrics. PICU aims at promoting early intervention with an objective of achieving good results and better prognosis. The above study aims to see the pattern of the disease at our centre. Material and Methods: A Retrospective study of the demography, clinical profile, diagnosis of children with age group of one month to eighteen years of age admitted to PICU from September 2017 to February 2018 was done. Results: Total of 467 Patients were admitted to PICU with male and female children being 60.59% & 39.4% respectively. Diagnosis included neurological diseases (31.9%), respiratory disease (23.3%), infectious diseases (25.9%), gastrointestinal (5.7%), hematological (3.8%),renal(2.9%), cardiovascular (2.43%), endocrinal (1.07%), and others(2.9%). Average duration of stay in PICU was 2 to 3 days. Multiorgan dysfunction syndrome (MODS) and co- morbidity associated with diseases are less than 10% in our PICU. Conclusion: The leading cause of admission was CNS and respiratory diseases in our PICU.

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Background: Hypernatremic dehydration is common among breast fed babies due to various reasons. Unless diagnosed early and treated properly, dehydration fever or hypernatremic dehydration is devastating condition. Hypernatremia itself or its improper treatment can cause neurological damage. Dehydration can lead to pre-renal injury which can further progress in to intrinsic renal failure, complicating the management. We present clinical profile of hypernatremic dehydration with emphasis to kidney injury among neonates. Materials and Methods: It is prospective study conducted at tertiary care neonatal intensive care unit. Babies presenting with various symptoms were screened for hypernatremia, excluding other diseases. Kidney injury is assessed using fractional excretion of sodium. Results: out of 69 neonates 30 neonates with hypernatremia were selected with male: female ratio of 1:1.14. Majority of the babies 46.7% (n=14) presented within 1st week of life with fever being the most common symptom. Exclusively breastfed neonates (63.3%) were significant in number compared to other forms of feeding like mixed feeding (23.3) or exclusively formula fed babies. Prerenal acute kidney injury (AKI) was seen in 11 babies (36.7%), whereas 7(23.3%) had intrinsic renal AKI, 12 (40%) babies had normal renal function. Pre-renal AKI was predominant renal injury among all the three grades of hypernatremia. Conclusions: Hypernatremic dehydration is important preventable, treatable dangerous condition in neonates. Central nervous system is most commonly affected, but acute renal failure is also an important complication. Early diagnosis and proper treatment gives good outcome, sometimes renal failure complicates the management.

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Background: Since decades there has been growth in pediatric critical care hence there is a need to have a standard way of assessing severity of illness and the risk of mortality. PRISM score is based on the physiological derangement by disease process which is determined within 24 hrs of admission and includes 14 variables including clinical and laboratory measures. The score has been found to have good assessment of the risk of mortality Aims: to determine the relationship between mortality & different PRISM scores. The present study aims at PICU admissions with sample size of 100. Methodology: An observational prospective study was carried out at a tertiary care center in Moradabad Uttar Pradesh targeting children aged 1 month to 12 years in PICU. A thorough and focused clinical examination was done and blood samples were drawn within 24 hrs of admission to assess the PRISM score variables. Results: A total of 100 children between 6months to 12 years with a median of 10 months were enrolled into the study between the months of January 2018 and march 2018. 90% deaths were noted with score more than 39 as compared to 35% with PRISM score of 20-29. Conclusion- there is increased in number of deaths score with increasing PRISM score.

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In the field of blood gas interpretation, confusion about PaO₂, SaO₂ and oxygen content is second only to confusion about mixed acid-base disturbances. This article attempts to clear the concepts of PaO₂, SaO₂ and Oxygen Content to answer the question of “How much oxygen is in the blood?” with clinical problem solving.

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Sepsis is one of the life-threatening condition affecting many children. A continuum of severity from sepsis to septic shock and MODS exists. The emergence of MODS as a clinical entity is one of the hallmark challenges of the modern era of critical care medicine. The clinical process usually begins with infection, which potentially leads to sepsis and organ dysfunction. Despite advances in pediatric intensive care and the widespread use of protocols and standard guidelines, sepsis remains a leading cause of mortality. Focus shifted from one organ to multiorgan support as these children die of multiorgan dysfunction and not the primary disease. MODS reflects a continuum of dysfunction rather than a dichotomous state of normal function versus failure which is potentially reversible, and the degree of organ dysfunction could change over time. The current consensus criteria of pediatric sepsis based on the concept of SIRS do not play an effective role in identifying clinically hazardous patients. It is strongly desirable that pediatric sepsis should be redefined on the basis of organ dysfunction scoring. This review intends to summarize sepsis and organ dysfunction and discusses potential directions for future research.

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Sepsis remains one of the leading causes of mortality in children all over the world, especially in the developing nations. Early recognition of sepsis and septic shock facilitate the resuscitation, further reducing the morbidity and mortality related to septic shock in children.Current evidence and guidelines emphasize on goal-directed therapy and institution-specific bundles in the management of septic shock in children. There is an emerging evidence for the use of newer monitoring and therapeutic modalities in the various phases of septic shock in children - especially the de-resuscitation phase, which need validation by further trials.

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Severe sepsis and septic shock are complications of infection leading to high morbidity and mortality. Hemodynamic outcomes are considered surrogate markers for survival- an ultimate goal of treatment strategies. The goal of vasoactive agents is to improve arterial blood pressure (age related norms) without associated adverse effects. Early initiation of a vasoactive agent in fluid-refractory septic shock has a significant role in the outcome; initiation within an hour of presentation is recommended and is associated with favorable outcomes. The choice of the correct vasoactive agent in a given scenario has a pivotal role on the desired outcome as well as the duration to achieve it. Cardiac dysfunction is a well recognized complication of septic shock, occurring in about 60% of the patients. So ionotropes may play a role in septic shock patients with associated myocardial dysfunction and signs of organ hypoperfusion despite achieving adequate preload and mean arterial pressure. In children presentation of septic shock is more complex, predominantly vasoconstricted with low cardiac output. Sometimes they can have deranged myocardial contractility and SVR problems requiring combination of inotropes and vasopressors. Hence the choice of inotrope remains empirical. Vasoactive therapy should be guided by clinical end points.

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Source control encompasses a spectrum of interventions whose objective is to eradicate a focus of infection, to eliminate ongoing microbial contamination, and to render a site in hospitable to microbial growth and invasion. Adequate source control in conjunction with antibiotics, resuscitation and support of vital organ function - is a cornerstone of the successful management of the septic patient.The principles of source control in the management of sepsis and septic shock include rapid diagnosis of the specifi c site of infection. A careful history and physical examination often yield clues to the source of sepsis and help guide subsequent microbiologic evaluation. Healthcare professionals should engage specialists in other disciplines, such as radiology, surgery, pulmonary medicine, and gastroenterology, to obtain diagnostic samples and to drain, debride, or remove the infection source as appropriate.

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The journey of sepsis management has evolved over last two decades with background of continuous evidenced based guidelines and their timely updation through serving sepsis campaign (SSC). Every update in the SSC guideline has made significant positive impact over sepsis related morbidity and mortality.Care bundles are a group of best evidence- based interventions which when instituted together,gives maximum outcome benefit. These are simple, uniform and have universal practical applicability.Sepsis bundles represent key elements of care regarding the diagnosis and treatment of patients with septic shock. These bundles allows to convert complex guidelines into meaningful changes in behaviour. The most recent bundle update bundle requires quick action to rescue patients and when necessary escalate care rapidly to reduce mortality and morbidity. But recommendations from these bundles/guidelines cannot replace the clinician’s decision-making capability who is monitoring the dynamic changes in clinical variable of patient at bedside.

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