Background : IV line insertion and maintenance is very crucial to prevent nosocomial infection in pediatric patients visiting pediatric emergency.PGIMER is a tertiary care hospital that cater to the needs of pediatric clients by providing 24 hours services in Advance Pediatric Center (APC).Pediatric emergency department is located on the ground floor in APC and has capacity of 22 beds and 24 incubators. Daily admission of patient in pediatric emergency is approximately 30-40 children in a day, whereas as early transfer of patients to other units is not feasible. This leads to overcrowding and HCPs have to manage two to three children on single bed. Though in each shift 10-12 nursing officers and 12-14 residents are posted on duty and they strive hard to provide quality care, still there are many barriersrelated to IV line insertion and maintenance.If such barriers are identified and managed time to time the infection rates can be reduced. Keeping this fact in view we conducted this study to find out the barriers and facilitators related to IV line insertion and maintenance.A total of 8 focused group discussion were conducted with the health care personnel of pediatric emergency, out of which 5 were conducted with nursing officers and 3 were conducted with physicians (junior and senior residents). In each FGD 4 to 5 members were included. Discussions were recorded and field notes were taken. Focused group discussion guide was used to know the barriers and facilitators, it included questions aboutHCPs view about current status of infection associated with IV line, possible cause of infection that is phlebitis and infiltration, measures taken by HCPs to prevent IV line related infections, causes of not being able to adhere to infection control measures, suggestive measures to reduce incidence of infection. After conducting discussion interviews were transcribed, read and reread and themes were generated. Physician mentioned about high rates of infection in the unit. According to them themes relatedto the barriers of IV line insertionwere lack of supply of articles, difficult to manage the time, over- crowding of patient, less co-ordination between health care workers, low socioeconomic status of patients. The facilitators identified were availability of tourniquets, available and arranged articles and parental help to restrain the child. The suggested remedial measures were to improve the practices related infection prevention such as to increase hand washing/ hand rubbing and ensure liberal supply of: hand rubs, gloves, additional packs and trays. They also emphasized on the need of assistance form nursing personal to hold the child and fix the cannula. They also highlighted the routine checking of the cannula sites, its fixation and removal of blood from 100cm extensions by nurses. Related to maintenance of iv line they mentioned that HCPs should perform hand hygienebefore touching cannula hub and administering drugs as lack of handhygiene is a source of infection.

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Background : Viruses cause a significant percentage of community acquired pneumonia (CAP) especially in children less than 2 years of age. Respiratory syncytial virus (RSV), influenza A, and para-influenza types 1 are the most common causes of viral pneumonia in children. Other viral pathogens include adenovirus, rhinovirus, influenza B, and enteroviruses Methods : This is a retrospective chart review of all patients aged 1 month to 16 years admitted to PICU at Sir Ganga Ram Hospital with the diagnosis of viral pneumonia during 6 months. Patients were excluded if their nasopharyngeal and oropharyngeal secretions had not been sent for viral studies within 24 hours of admission. DNA and RNA real time PCR test was performed using Respi-Finder kit and Quisymphony extraction machine (Qaigen, Germany). Results : During the study period, 306 patients were admitted to our PICU out of which 67 (11.6%) were admitted with diagnosis of pneumonia. 25 children were excluded from the study as 12 had bacterial pneumonia, viral DNA/RNA PCR was not sent in nine patients and in four patients, the etiological agent could not be determined. The final study group comprised of 42 patients with a median age of 9.5 months (Range 6 weeks -10 years) with a male to female ratio of 2.5:1. Average duration of symptoms prior to admission was 4.3 days. Most common symptom was cough seen in around 90% of patients followed by fever (80 %); fast breathing (73%), decreased feeding (30 %).Blood culture sent at admission was sterile in all patients. RSV was the most common virus isolated in 57 of the patients followed by Rhinovirus/ enterovirus in 26%, H1N1 (9.5%), influenza B (9.5%), Boca virus (7.1%), parainfluenza virus (7.1%), coronavirus and adenovirus in 2.3 % each. Infection with a single virus was seen in 28 children and co-infection with two or more of the viruses were seen in 14 children. Supplemental oxygen therapy was used in 15 children (35.7%) and 17 children (35.7%) needed some form of ventilator assistance. Non — invasive ventilation was used in 11 children (26.2%) and invasive mechanical ventilation in 14.2 % of the study subjects. ET aspirates sent for cultures immediately after intubation were sterile in all patients. Four (9.5%) children had hypotension at the time of admission requiring inotropic support, from whom influenza B was isolated from two patients and RSV A and Adenovirus were isolated from one patient each. Two children had evidence of multiple organ dysfunction requiring continuous renal replacement therapy. Adenovirus and influenza B was isolated from these patients. OUTCOME — In our cohort of children with viral pneumonia, three patients had in-hospital mortality. Among them, two had superadded bacterial infection (Acinetobacter baumanii) and one had Severe combined immunodeficiency. Conclusion : RSV was the most common etiological agent of viral pneumonia in our study. Around 1/3 of our patients’ with viral pneumonia required ventilator assistance.

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Background : The critical-ill status of the child leaves the nurses in the state of dilemma regarding involving the family members in providing the supportive care to the child. The assessment of the caregiver’s involvement and skill in providing child care can reduce some of the nurse’s workload in an overloaded critical care setting. Methods : Research design: A descriptive study Study Setting: A Pediatric Intensive Care Unit of a tertiary care hospital in North India. Sample: A total 142 caregivers were involved in the study. All the consecutive admissions were screened for inclusion in the study (PICU admission for atleast 24 hours) and family members (caregivers) of the admitted children who remain with the child for atleast 6 hours a day were enrolled. Methodology: A structured interview schedule using a ‘Patient Care Sheet’ was conducted. A ‘Patient Care Sheet’ contains two parts: Part-A: contained demographic details of the child and the caregiver; Part –B contained list of child care activities categorized under 7 domains: Personal Care, Nutrition, Elimination, Respiratory Therapy, Medication administration, Decision-making and miscellaneous. Results : The family members/caregivers were frequently involved in number of child care activities such as arranging supplies to provide bath/skin care to the child (97.9%), providing bath to the child (97.2%), combing the hair of the child (38%), measuring the feed of the child (83.8), warming the feed to the room temperature (83.8), emptying the urine bag (40.1%), cleaning the child after defecation (86.6%), changing the diaper/ clothes of the child (88%) and weighting the diaper of the child (73.2%), bringing samples to the laboratory (60.6%), collecting reports from the laboratory (70.4%) and informing nurse/ physician regarding change in clinical status of the child (44.4%). Further it was found that caregivers were frequently involved in providing bedpan/changing diaper and weighing the diaper of the male child than female child. A significant relationship has been found with involvement of the female caregivers especially mothers in number of child care activities such as arranging supplies to provide bath/skin care to the child (χ²=14.152, p=0.028), changing diaper of the child (χ²=9.671, p=0.022), weighing the diaper of the child (χ²=27.042, p=0.003) and administering oral medications (χ²=18.165, p=0.020). It was also found that the caregivers were not involved in providing any kind of respiratory therapy to the child irrespective of the duration of mechanical ventilation and PICU stay. However, during the initial days of admission (< 5days) to PICU, they were sometimes told to bring samples to the laboratory and collect reports from them but were refrained from transporting the child for any diagnostic purpose to the other department in the hospital. Conclusion : The study concluded that the caregivers performed non-technical tasks frequently but the performance of technical tasks such as respiratory therapy lied with the nurses.

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Background : It is an acquired autoimmune mediated postsynaptic disorder that is rare in childhood with prevalence of 5 in 1,00,000. First case was reported in the year 1644 in USA of an Indian chief Opechankanough. The disease is due to circulating antibodies which bind to acetylcholine receptors at neuromuscular junction and prevent a normal action of acetylcholine in opening the calcium channel in muscle fibers. There are two types of the disease: ocular (corresponding to 10% of cases) [1] or generalized (90% of cases), although both may occur under different temporal evolution in the same patient. Myasthenia gravis geoepidemiology shows that it is a rare disorder with similar incidence and prevalence in the world, except for infantile MG, which is more common in Asia. Methods : With progressive ptosis towards the end of the day, Juvenile Myasthenia gravis was suspected. Anti cholinesterase (AChE) test was done under ECG monitoring using intravenous injection of neostigmine (Prostigmine test) which showed a dramatic response i.e. immediate elevation of both upper eyelids with resolution of ptosis[Fig. 1 and 2]. Bed side icepack test was also performed which was positive. Computerized tomography (CT scan) of thorax was done to rule out thymic hyperplasia or thymoma. We diagnosed this child as a case of juvenile myasthenia gravis and treated with intravenous neostigmine(0.04mg/ kg/dose) 4 hourly followed by atropine(0.05mg/kg/dose) to counteract ill muscarinic side effects of neostigmine. Intravenous methylprednisolone was also given as pulse therapy (30mg/ kg/day for 3 consecutive days) with multipara monitoring (for hypertension and hyperglycemia). Plasma anti-AChR antibodies though advised was not affordable. Results : The cardinal symptom in MG is muscle weakness that is typically fluctuating and fatigable. The most common initial presentation involves a specific muscle weakness, and not a generalized weakness. Symptoms are exacerbated with exercise (it may be caused by sustained muscle action) and heat, and decreased with relaxation and cooling. The disease involves striated or voluntary muscles, with a typical anatomical distribution. The weakness is usually ocular, bulbar, proximal muscle groups (most commonly the upper limbs) and neck, but may also in some patients involve the respiratory muscles. The disease can progress from mild to moderate to severe in weeks and months with episodes of exacerbations and remissions. The Myasthenia Gravis Foundation of America# proposed a clinical classification of the disease into five main classes and several subclasses, according to the location of muscle weakness and its intensity. Ptosis or extra ocular muscle weakness is the initial presentation in 75% of patients [1] and occurs during the course of the disease in 90% of cases (remaining exclusively ocular only 16% of cases [2-4]). When anti AChR antibodies are negative, MuSK receptor antibodies should be advised. Table 1 : Classification of MG according to Ossermann Scale Type 1 Ocular myasthenia characterized by ptosis and diplopia Type 2a Slow onset, frequently ocular, with gradual evolution to skeletal musculature Type 2b Slow onset with dysarthria, dysphagia, and change in mastication Type 3 Fast onset with severe bulbar and skeletal muscle fatigue with respiratory muscle compromise Type 4 Severe MG that manfests in two years Conclusion : Repetitive ulnar nerve stimulation (RNS) studies show significant decremental response in abductor digiti minimi suggestive of post synaptic neuromuscular junction (NMJ) receptor disorder[5]. Other differentials which should be considered include neuroparalytic snake bite, Miller-Fischer type of GBS and botulism. Our patient was classified as type III i.e. fast onset with severe bulbar and skeletal muscle fatigue with respiratory muscle compromise, so he had to be ventilated for 3 days. He was weaned from IPPV to T-piece over 12 hours and then to CPAP for 6 hours maintaining normal saturations and vitals. Thereafter he was referred to higher center for plasmapharesis but since then he is lost to follow up.

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Background : The utility of point-of-care ultrasound is well supported by many randomized controlled trials. Gradually pediatric emergency medicine providers and pediatricians are also embracing this technology in everyday practice. Recently American Academy of pediatrics concluded in its policy statement that evidence in support of point-of care ultrasonography as an adjunct to the clinical effectiveness of primary emergency medicine personnel including pediatricians and neonatologists is growing. It further recommended establishment of training, credentialing, and programs for point of care ultrasound to improve the care of pediatric patients. In Indian scenario there are no standard guidelines for the practice of point-of-care ultrasound by pediatricians. Results : Keeping this perspective in mind we present here a case series of five patients with cardiac masses which were detected during point of care ultrasound. First case was paraneonate who presented with pyrexia of unknown origin and refractory congestive cardiac failure .During POCUS left atrial mass was detected which was acting like mitral valve stenosis .Mass was removed surgically and was found to be myxoma . Second was known case of nephrotic syndrome presented with peritonitis and septic shock and right atrial thrombus was detected accidentally .He was started on low molecular weight heparin after stabilization and resolution of thrombus was seen on follow up. Third case was chronic renal disease on permanent dialysis with permacath in left internal jugular vein .He presented with flash pulmonary edema and right atrial mass at the tip of catheter .His blood culture grew citrobacter .He was treated for infective endocarditis but succumbed to his primary disease after 2 months. Fourth case was diagnosed case of ventricular septal defect at birth ,who presented to us with stroke and mitral valve vegetations were found during POCUS. His blood culture grew rapidly growing non-tuberculous mycobacteria .He died after 3 months of diagnosis.Fifth case was diagnosed case of acute myeloid leukemia with febrile neutropenia ,who had large right ventricular mass which was removed by open heart surgery and turned out to aspergilloma. He had stormy post operative course and died . Conclusion : Out of five patients,four patient had predisposing factors for either thrombus or infective endocarditis and three patient died during course of illness. In all these patients ,detection of cardiac mass by point of care ultrasonography accelerated the management.

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Background : Non-invasive ventilation (NIV) has been used electively after extubation in adult patients. NIV has shown benefits in comparison to oxygen (O2) therapy in mechanically ventilated COPD adults after extubation. Use of NIV after extubation has also shown reduction in the ventilator-associated pneumonia, duration of invasive mechanical ventilation and hospital stay. No paediatric study is available on this subject. Methods : A randomized, prospective study was carried out at 12 bedded PICU of a tertiary care teaching hospital over a period of 12 months. All enrolled patients received invasive mechanical ventilation for at least 48 hours and were extubated after fulfilling the weaning criteria as per the unit policy. Patients were randomized before planned extubation to receive NIV or O2 therapy with simple mask. NIV was given to the patients with appropriate size oral-nasal interface. The two groups were compared regarding gas exchange at 2 hours, 6 hours and 24 hours after extubation, reintubation rate within 48 hours of extubation and length of stay in the PICU and hospital and mortality. Results : A total of 137 patients were admitted in the PICU who required invasive mechanical ventilation for a period of more than 48 hours. 97 patients fulfilled the inclusion criteria and were to receive NIV and O2 therapy randomized into two groups. 46 patients received non-invasive BIPAP mode with appropriate size face mask. While 51 patients received O2 therapy with simple mask. SPO2 was maintained above 92% with supplemental oxygen. The mean IPAP and EPAP for the NIV group were 9.6 + 1.39 cm of H2O and 5.1 + 0.31 cm of H2O and mean flow of supplemental oxygen were 5.4 + 1.39 L/min. The primary disease, PRISM scores and duration of mechanical ventilation prior to extubation were not significantly different in two groups. 13/51 (25%) patients in the O2 therapy group had extubation failure while 6/46 (13%) patients in NIV therapy group had extubation failure (p- 0.12). The total duration of hospital and PICU stay as well as post extubation PICU stay were not significantly different in both the study groups. There were two deaths, one in each study group. Conclusion : Elective noninvasive ventilation did not show benefits over oxygen therapy in children in post extubation state.

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Background : Sepsis induced myocardial dysfunction (SIMD) is commonly seen in patients with septic shock and is often associated with poor clinical outcomes. Determining predictors of myocardial dysfunction at admission by clinical examination and simple bedside laboratory tests would help identify such patients prior to 2 D echocardiography or even in its absence. Such information would help exercise caution with fluid administration and warrant early initiation of inotropes. It would also help in predicting the clinical course and prognosis. Methods : In this retrospective review, we reviewed records of children =17 years of age, admitted with a diagnosis of septic shock in our pediatric Intensive Care Unit (ICU) between 2015 and 2017. Detailed information on demographic, clinical, laboratory variables, treatment received and clinical course were recorded in all who had undergone 2 D echocardiography at admission. SIMD was defined as presence of systolic and/or diastolic dysfunction. Systolic dysfunction was defined as an abnormal ejection fraction (EF) and diastolic dysfunction as an abnormal doppler tissue velocity (E’) and/or an abnormal Myocardial Performance Index (MPI). Data were analyzed using Stata 11 software. Results : A total of 149 children were eligible. Of these 27 had not undergone echocardiography and were excluded; 122 children (54% boys) were included in the analysis. Median (IQR) age was 5 (1, 10) years. Most common cause of sepsis was pneumonia (45; 37%). The prevalence of SIMD was 43% (95% CI: 34 to 51) in the study population. Systolic plus diastolic dysfunction was present in 30% (95% CI: 22 to 38) patients and only diastolic dysfunction was present in 13% (95% CI: 8 to 20) patients. The mean (SD) ejection fraction (EF) was 0.47 (0.13) and 0.62 (0.06) ( p Conclusion : SIMD is commonly seen in children with septic shock and the mortality and mortality are higher in those with SIMD as compared to those without. Clinical and laboratory parameters like prolonged CRT, increased lactate, lower platelet count, increased blood urea and elevated liver enzymes at admission may predict presence of SIMD in children with septic shock.

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Background : Fluid overload is common in critically ill children, especially in the post-resuscitation phase and is known to be associated with adverse outcomes. Hypoalbuminemia, also common in critically ill, contributes to interstitial edema and fluid overload by lowering vascular colloid oncotic pressure (COP). Pharmacological diuresis is often employed to reduce edema and prevent secondary organ injury and dysfunction (de-resuscitation). Role of albumin to facilitate diuresis has not been previously studied in this cohort. Methods : Single centre, double blind, placebo controlled, pilot randomized trial was conducted in a 15 bed PICU of a tertiary referral and teaching hospital in North India. Forty four mechanically ventilated children aged 2 months – 12 years in post-resuscitation phase with >10% fluid overload and serum albumin < 2.5g/dL were enrolled over a period of 12 months. Children with hemodynamic instability, chronic conditions affecting fluid/albumin status and history of prior adverse reactions to study drugs were excluded. In the intervention arm, subjects received 1g/kg 20% albumin (5ml/kg) single dose over 6hours with furosemide infusion for 48 hours, while subjects in placebo arm received 5ml/ kg 0.9% sodium chloride with furosemide infusion. Results : Median age of study cohort at enrollment was 2.75 years. Median fluid balance prior to enrollment was 132ml/kg and median baseline serum albumin at enrollment was 2.1g/dL. Median rise in serum albumin concentration at 24 hours of enrolment was 0.8 g/dL in albumin group and -0.1g/dL in placebo group (p<0.001). Median serum albumin concentration however remained <3g/dL till the end of study period (72 hours) even in albumin group. The primary outcome, 28-day ventilation free days, did not differ significantly between both groups (25 vs 24 days, p=0.24). Time to liberation from mechanical ventilation (62 vs 72 hours, p=o.34) and time to extubation (66 vs 76 hours, p=0.42) were shorter in albumin group though not statistically significant. Secondary outcomes like all-cause 28-day mortality, post-enrolment PICU stay and hospital stay were similar. No significant difference was noted between groups in ventilation parameters including mean airway pressures, lung compliance, and oxygenation index. Incidence of hemodynamic instability post-enrolment was slightly higher in placebo group compared to albumin group though not statistically significant (18% vs 5%, p=0.17). Conclusion : The use of albumin did not show any clear benefit and the evidence is insufficient to support or refute the use of albumin in fluid overloaded hypoalbuminemic mechanically ventilated critically ill children in the post-resuscitation phase. However, albumin may be safely administered with furosemide in mechanically ventilated children with probably better hemodynamic stability. We advocate a larger trial targeting a higher serum albumin to further determine the utility of albumin diuresis in this cohort.

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Background : Unintentional injuries are the sixth leading cause of death in children less than 5 years of age and the leading cause of unintentional injury is drowning. Data on children with drowning, especially in developing countries, are scarce. Such data would help in effective management, prognostication and prevention of drowning. Methods : This retrospective study was done at a tertiary care referral hospital in North India. Children younger than 12 years admitted with drowning from January 2009 to August 2017 were included. Data collected from case records or electronic medical records comprised of demographic details, circumstances and management on site, treatment before referral, clinical profile, PICU needs and outcome. Multivariate analysis was used to identify predictors of unfavourable outcome. Results : Twenty seven children were included, 14 were boys. Median age was 18 months (IQR-12, 30). No premorbid risk factors were present. Seventeen (62.9%) were from rural background. Event was witnessed in 11 (40.7%), not witnessed in 10 (37%) and not known in 6 (22.2%). Site of drowning was in or around the house in more than half (n=15, 55.5%), outdoors in 11 (40.7%), and unknown in 1. Most children (70.3%) had drowned in fresh water. Ponds outside houses (n=10) and buckets of water in bathroom (n=9) were commonest sites. When first found, 23 (85.2%) were unconscious, 15 (55.5%) were apneic and 17 (62.9%) were blue. Duration of submersion was known in 20 (74.1%), median being 4 minutes (IQR- 3,9). On site resuscitation was attempted by untrained bystanders in thirteen (48.1% - mouth to mouth breathing, back slaps, prone positioning, chest or abdominal compressions). Most common centre where health care was first sought was government hospital (48.1%). Median time lapse between the event and reaching first health care centre was 30 minutes (IQR- 22, 60) and reaching our center was 240 minutes (IQR- 94, 360). Six children (22.2%) presented in cardiac arrest, requiring cardiopulmonary resuscitation (CPR), 13 (48.1%) were hypoxic (saturation < 92% on room air) and half (51.8%) had encephalopathy (GCS < 13). Ten children (37%) had seizures, 8 (29.6%) had shock, 10 had (37%) raised intracranial pressure (ICP). Hypo/ hypernatremia was uncommon (18.5%). Ten were transferred to PICU; indications were raised ICP (n=6), ventilation (n=5) and hemodynamic monitoring (n=4). One child died, 4 survived with sequalae; rest (22=81.5%) were neurologically normal at discharge (normal cognition, no motor deficits). Predictors of unfavourable outcome (death or survival with sequalae) on univariable analysis were hypoxia, GCS<8, hypotension, requirement of CPR at admission, raised ICP, shock and mechanical ventilation but none of these could predict outcome on multivariate analysis. Conclusion : Inadequate resuscitation on site, delayed and ineffective referral, physiological destabilization or requirement of CPR at admission and raised ICP contribute to unfavourable outcome in children with drowning in developing countries.

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Background : Since there is no standard referral and feedback system available in India, we decided to study the quality of referral coming to our Pediatric Emergency before and after the introduction of an educational module with respect to demography of referral, association with severity of illness, mortality and feasibility issues. Using this data we plan to develop a standard referral format and feedback system that will help in streamlining the emergency referrals Methods : Methodology: Our study was completed in three phases in the Paediatric Emergency Unit viz the Pre intervention data collection, Intervention Phase, Post intervention data collection Quality of referral were done using structured referral proforma and comparative statistics were done for various parameters Results : A total of 1249 patients attended emergency during the pre and post intervention phases of which 4864 patients were admitted, 2359(48%) were paediatric and 2472(51%) were neonatal referrals. Thus our major chunks of inpatient admissions were ‘referred’ patients (99.3%). The two neighbouring states of Punjab (48.2%) and Haryana(22.4%) were topping the list. 80.9% referrals were from public sector hospitals of which the medical college hospitals topped the list (53.6%). 86.4% used Government ambulance services. Most common cause of referral was PICU/NICU/Mechanical ventilation (50.4%) The quality of referral had an association in terms o physiological status at the time of arrival. The proportion of patients arriving in the decompensated status in relation to poor referrals had significantly decreased in comparison of pre and post intervention period [580(79.8%) vs 1025(93.7%); p=0.0001]. The proportion of poor referrals had significantly reduced to 78% and there was a corresponding significant increase in proportion of fair (18%) and good referrals (4%). Conclusion : Referral education interventional module had significantly improved the quality of referrals coming to our Pediatric emergency in terms of better apre referral documentation of investigations, examination findings, and reasons for referral. The proportion of patients presenting in a decompensated state had significantly reduced after introduction of interventional module. Continuing education will be required for sustained and increasing benefits. There is a need for structured referral proforma and referral network among the healthcare facilities in the particular geographic area.

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Background : We conducted this prospective observational study to identify the various causes and contributory factors for children to be brought in dead (BID) state to tertiary care centre by carrying out a root cause analysis. These causes were forked out into biological and non-biological social/ system related determinants. By doing so it was intended to look beyond ‘disease and diagnosis’ into various hiatus in health care delivery system so as to identify and address potentially correctable variables. Methods : Methodology: In this study, disease related causes of mortality were analysed retrospectively and socially modifiable factors were identified prospectively in all enrolled cases. The information required for study was collected by a) direct interview and b) field observation. Results : Of the enrolled cases, more than half (55%) were neonates among which 78% were LBW. Major symptoms with which child was referred were breathing difficulty (80%), fever (21%), refusal of feed (17%). The most common referral diagnosis among neonates were LBW (78%), RDS (38%), Birth asphyxia (34.5%) and among non neonates were pneumonia (24.4%), CHD (13%), AGE (13%). Moderate to severe malnutrition was an accompanying feature in more than two-third of cases. Of referred cases, 71% of referral notes were found to be insufficient. In over three-fourth cases ambulance was used as a means of transport but umpteen lacked accessories needed for pediatric usage. Paramedic who had accompanied the cases were found to be undertrained/untrained in handling pediatric cases. Main reason for delay in transit was found to be heavy traffic (23%), poor road condition(15%) and unfamiliarity of route(7%). Rate of ROSC(2%) was poor in the study. Conclusion: A substantial number of deaths among the referred children/neonates are preventable. A proper adoption and implementation of integrated management of childhood and neonatal illness at first level of health care contact will help in curbing preventable deaths. Better outcome can be anticipated by ameliorating care at periphery by regular training of doctors and health workers/paramedics, making medicines and equipments available and strengthening support mechanism like effective pediatric transport system

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Background : We conducted this prospective observational study to identify the various causes and contributory factors for children to be brought in dead (BID) state to tertiary care centre by carrying out a root cause analysis. These causes were forked out into biological and non-biological social/ system related determinants. By doing so it was intended to look beyond ‘disease and diagnosis’ into various hiatus in health care delivery system so as to identify and address potentially correctable variables. Methods : In this study, disease related causes of mortality were analysed retrospectively and socially modifiable factors were identified prospectively in all enrolled cases. The information required for study was collected by a) direct interview and b) field observation. Results : Of the enrolled cases, more than half (55%) were neonates among which 78% were LBW. Major symptoms with which child was referred were breathing difficulty (80%), fever (21%), refusal of feed (17%). The most common referral diagnosis among neonates were LBW (78%), RDS (38%), Birth asphyxia (34.5%) and among non neonates were pneumonia (24.4%), CHD (13%), AGE (13%). Moderate to severe malnutrition was an accompanying feature in more than two-third of cases. Of referred cases, 71% of referral notes were found to be insufficient. In over three-fourth cases ambulance was used as a means of transport but umpteen lacked accessories needed for pediatric usage. Paramedic who had accompanied the cases were found to be undertrained/ untrained in handling pediatric cases. Main reason for delay in transit was found to be heavy traffic (23%), poor road condition(15%) and unfamiliarity of route(7%). Rate of ROSC(2%) was poor in the study. Conclusion: A substantial number of deaths among the referred children/neonates are preventable. A proper adoption and implementation of integrated management of childhood and neonatal illness at first level of health care contact will help in curbing preventable deaths. Better outcome can be anticipated by ameliorating care at periphery by regular training of doctors and health workers/paramedics, making medicines and equipments available and strengthening support mechanism like effective pediatric transport system

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Background : The optic nerve sheath diameter (ONSD) has been shown to increase within seconds of raised ICP, which can be measured by ultrasound. Hence, ONSD measurement can be potentially used to indirectly monitor elevated ICP. Methods : A prospective blinded observational study of all children (2-12 years) admitted to PICU undergoing ICP monitoring using intra parenchymal catheter was conducted in PGIMER, Chandigarh from November 2016 to August 2017. The ONSD from both eyes was measured using a 7.5 MHz ultrasound probe on closed eyelids. Horizontal and vertical diameters of both the optic nerves were measured and averages calculated. Repeated measurements were taken at least 3 hours apart. Observations who had measured ICP ≥20 mm Hg at the point of time were included as cases and with measured ICP ≤ 15 mm Hg were included as controls. Results : During the study period, of the total 25 children assessed for eligibility, 21 were enrolled. The median age of the cohort was 70 months. A total 95 observations were taken and the median observations per patient were 3. The total number of the observations included as cases and controls were 65 and 30 respectively. The median ICP was 27 and 7 for observations included as case and controls respectively. Compared to controls, the case group had significantly higher mean right eye ONSD (5.58±0.56 mm vs.4.08±0.55 mm, p<0.0001), mean left eye ONSD (5.61±0.66 mm vs.4.08±0.60 mm, p<0.0001) and mean binocular ONSD (5.60±0.60 mm vs.4.08±0.57 mm, p<0.0001). The spearman rank correlation coefficient of binocular ONSD and ICP was 0.71 (p<0.0005) demonstrating a significant positive correlation. Conclusion : This study demonstrates a strong correlation in between intra-parenchymal measurements of ICP with ONSD measurements and provides support for the use of ONSD measurements as a noninvasive test for elevated ICP.

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Background : Electrolyte abnormalities are common in critically ill children needing admission in intensive care unit. In view of the importance of electrolyte homeostasis and its significant impact on the final outcome of the patient, the present study was undertaken. Since sodium and potassium are the electrolytes that are most frequently deranged in critically ill patients, we have studied these electrolytes in our study. Methods : The study was carried out in the Pediatric Intensive Care Unit at a tertiary care hospital. The study enrolled all the patients admitted in PICU of age 29 days to 12 years during April 2015 to September 2017. Hyponatremia and hypernatremia was defined as serum sodium concentration below 135mEq/L and above 145mEq/L respectively. Hypokalemia and hyperkalemia shall be defined as potassium level below 3.5mEq/L and above 5.5mEq/L, respectively. Results : The prevalence of electrolyte abnormality in terms of sodium or potassium abnormality in our study was 44.31% (323 out of 729). Hyponatremia (27.43%) was the most common electrolyte abnormality in our study followed by hypokalemia (13.99%). The mortality in children with electrolyte abnormality was found to be 28.8% that was higher as compared to the mortality in the group without electrolyte abnormality which was 19.7%. This association was statistically significant (p value=0.004; Odd’s ratio- 1.640; 95% confidence interval 1.169-2.322).The mortality in the patients with hyponatremia and hypernatremia was 32.5% and 38.5% respectively, which was significantly higher than the mortality in the normonatremic patients which was 19.5%, the association being statistically significant. The mortality in the group with hypokalemia and hyperkalemia was found to be 24.5% and 30.4% which was higher than the group with normokalemia which was 23.1%. However, the association was not statistically significant. The association of primary organ system involvement with the presence of electrolyte abnormality was found statistically significant. Maximum number of study participants with hyponatremia had central nervous system involvement (48.5%) and those with hypernatremia had gastrointestinal system involvement (65.4%). Hypokalemia was most frequently observed in patients with gastrointestinal involvement (54.9%) and hyperkalemia with renal involvement (34.8%). Conclusion : Our study has demonstrated significant association of electrolyte abnormalities at admission in PICU with mortality and primary organ system involvement. Close monitoring and correction of electrolyte abnormalities is essential to reduce morbidity and mortality.

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Holoprosencephaly is a complex brain malformation resulting from incomplete cleavage of the prosencephalon,with incomplete interhemisphere fissure occurring between the 18th and the 28th day of gestation and affecting both the forebrain and the face. HPE is the most common forebrain developmental anomaly in humans with prevalence of 1/16,000 live borns. It is subdivided into; Lobar, Semilobar and Alobar varieties.The etiology of HPE includes environmental factors like maternal diabetes mellitus, maternal alcoholism, in utero infections or drugs like retinoic acid alongwith genetic factors. In this case no risk factor was known as per history.

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Background : A new born infant, born of a non-consanguineous marriage, to a diabetic mother, presented with Potter’s face ,complete fusion of the lower limbs from the perineum to ankle,rudimentary phallus with no urethral opening,deformed left ear, imperforate anus, sacral agenesis ,supernumerary toes (Images attached),with single umblical artery and vein . Antenatal ultrasonography revealed Renal agenesis and Oligohydroamnios. Till the date of delivery, the pregnancy was uneventful except for the mother’s poorly controlled diabetes mellitus. There was no history of tobacco smoking or alcohol or any other drugs.She underwent normal vaginal delivery of a live, malformed male fetus of 1700gms. Baby had delayed cry at birth and developed severe respiratory distress in the form of increased respiratory rate ,retractions. Resuscitation was done in the form of Bag and tube ventilation. However,the child deteriorated and expired two hours after birth. Conclusion : There are two hypothesis for the origin of sirenomelia: the vascular steal hypothesis and defective blastogenesishypothesis.It is a fatal disorder and the child dies within a day or two after the birth due to various abnormalities associated with kidneys,bladder,lungs and gastrointestinal system. Sirenomelic infants are classified from Type I to TypeVII,according to presence or absence of bones in the lower limbs.Our case is probably of type I,based on external examination.

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Background : Nutritional requirements in severe sepsis is dynamic varying from hypermetabolic to a hypometabolic state. We planned to study the energy balance using indirect calorimetry (IC) in critically ill children with severe sepsis Methods : Single center, prospective cohort study of children aged 5 -12 years admitted with severe sepsis to tertiary care pediatric ICU of Advanced Pediatric Center, PGIMER, India from May 2016 to June 2017. Patients with active air leak, ventilator circuit leak >10%, on FiO2>60% or on high frequency oscillatory ventilation were excluded. Demographic, anthropometric and nutritional data were collected. Resting energy expenditure (mREE) was measured once daily with portable metabolic cart (Quark RMR, COSMED@) till 7 days or till PICU discharge whichever was earlier. Results : A total of 40 patients (24 boys) with median age of 7 (5.2, 10) years and mean weight of 23 ± 8 kg were included. Tropical infections contributed majority of diagnosis with acute CNS infections in 18 (45%), severe pneumonia in 7 (17.5%), scrub typhus in 5 (12.5%), disseminated staphylococcal sepsis in 4 (10%) and dengue shock syndrome in 3 (7.5%). Mean PRISM III score was 19 ± 7 with calculated risk of mortality of 30%. All patients received enteral nutrition with a median time of initiation of feeds of12 hours. 35 patients (87.5%) received inotropic support with median day 1 vasoactive inotropic score (VIS) of 28. Median ventilation free days was 19 days and 4 children died (10%). Total of 176 IC measurements were obtained with an average of 4 per patient. The mean mREE for the cohort was 1123 ± 310 Kcal (51 ± 17 Kcal/kg) and the mean respiratory quotient was 0.77 ± 0.07. There was persistent negative energy balance from day 1 to 7 and a negative nitrogen balance which improved by day 7 to positive balance. There was poor agreement of predicted REE (using Schofield, Harris Benedict equation and FAO/WHO/UNU equations) with mREE. There was no significant correlation of PRISM III score at 24 hours, daily SOFA score and daily VIS with mean mREE. Conclusion : Consistent negative calorie and protein balance exist during acute phase of illness. There was poor agreement of predicted REE with mREE and no significant correlation with severity of illness scores.

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Background : Despite improvement in health care over last few decades diarrhoea is still one of the leading causes of death in developing countries. While there have been few studies on risk factors for fatal acute gastroenteritis (AGE) before 2000, mostly from developing countries, there is a paucity of studies in the current era. In the past few decades despite increased awareness and understanding about diarrhoea and dehydration, use of reduced osmolarity ORS and zinc, children continue to die with severe dehydration. It is therefore important to determine the risk factors for diarrhoea-associated deaths in children in the current era so as to be able to identify and resuscitate these children early and timely. Such data would help in the formulation of better prevention strategies and the eventual reduction of mortality rate. Methods : This was a retrospective chart review of all cases of AGE with dehydration and shock admitted to the Paediatric intensive care unit (PICU) over the last 5 years. Records were retrieved after obtaining ethical clearance. Children who died during hospital stay were compared with those who survived. Information including demographic details, nutritional status, clinical features, laboratory parameters and clinical course were recorded in a structured proforma. WHO criteria/guidelines were used for assessment of dehydration and management. Surviving sepsis campaign guidelines were used for the management of shock. Data was analysed using stata11. Results : A total of 39 / 1249 (3%) children were admitted to the PICU with AGE with severe dehydration and shock during this period of whom 22 (56%) were males. Majority (83%) were from urban slums and had watery stools (95%). Fever, vomiting (96% each) and poor oral intake (95%) were the commonest complaints. Twelve children (31%) had seizures and 89% were lethargic. One third had received ORS before admission. Forty seven percent had severe acute malnutrition. Sixty four percent and 72% required inotropes and ventilation at admission respectively. Of the 39 children, 14 children (36%) died. The following variables were found to be significantly associated with death: younger age (p=0.02), dysentery (0.1), use of diluted cows milk (0.03), pallor (0.01), thrombocytopenia (0.002), acidosis (0.03), hyperchloremia (0.01), increased lactate (>2 mmol/L) (0.002), shock index (0.004), elevated leucocyte count (0.05) and hypoalbuminemia (p=0.02). Other variables like nutritional status and duration of illness were not different between survivors and non-survivors. Non-survivors had longer duration of inotrope requirement and shorter ICU stay as compared to survivors. On multivariate analysis, only age (OR (95% CI); p value): 0.76( 0.55, 0.92); 0.04) presence of acidosis (3.14 (1.1, 16.8); 0.04) and hypoalbuminemia (6.3 (1.16, 13.9); p=0.02) were found to be associated with death. Conclusion : The case fatality rate of AGE with severe dehydration continues to be high despite increased awareness and better formulations of ORS available in the current era. Younger age, presence of acidosis and hypoalbuminemia increase the risk of death in these patients.

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Background : Recently, sepsis-3 definition has been advocated in adults to identify septic shock. The new definition is more specific and includes hypotension requiring vasopressors to target age appropriate mean arterial pressure (MAP) and a lactate value of ≥2 mmol/L. Thus, it appears that, it may identify only the sicker children and not those who are not so sick and have not yet developed hypotension or elevated blood lactate levels. The importance of ‘misclassifying’ these children as not having septic shock is not known. Methods : In this retrospective review, we reviewed records of all children ≤17 years of age, admitted with a diagnosis of septic shock as per Goldstein-B definitions to our unit from 2013 to 2015. As per Goldstein B definitions, septic shock is defined as sepsis plus cardiovascular dysfunction. Children having PICU stay of less than 6 hours were excluded. We applied Sepsis-3 definition to all these children to identify cases of septic shock by Sepsis-3 definition. We compared important clinical outcomes such as proportion attaining shock reversal, fluid volumes received, need for inotropes and mechanical ventilation in 1st 6 hours, organ dysfunction score, duration of ventilation, ICU stay and mortality between those fulfilling Sepsis-3 criteria and those not fulfilling the same. Data were analyzed using Stata 11 software. Results : A total of 115 children were enrolled and males were in majority (58%). Median (IQR) age of the study population was 6 (2, 10.5) years. Most common cause of sepsis was pneumonia (44; 38%). The mean MAP was 64 mmhg and PIM-2 probability was 62%. Of 115 children fulfilling Goldstein-B definition only 50.43% (n=58) fulfilled Sepsis-3 criteria for septic shock. There was no difference in the age, admission diagnosis or PIM-2 score between the two groups. Fifty five children died (47.8%). When compared to those not fulfilling Sepsis-3 criteria (Group 2), significantly greater proportion of children fulfilling sepsis -3 criteria (Group-1) had disseminated intravascular coagulation (p=0.03), sepsis induced myocardial dysfunction (0.04), Acute Respiratory Distress Syndrome (0.02) and multi organ dysfunction syndrome (0.039). Group-1 children had lower ScvO2 (0.01), elevated liver enzymes (p<0.0001), higher PELOD (0.01) and SOFA score at 24 hours ( 0.02). Duration between fluid boluses and inotrope administration was prolonged (0.01) in Group-1 patients (45 vs. 12 min; p=0.002). Fewer children in Group-1 (54%) showed shock reversal by 6 hours of resuscitation when compared to Group-2 (72%) but the difference was not significant (p=0.24). There was no significant difference in mortality between the two groups - 31/58 (53%) vs. 24/57 (42%) (RR 1.27; 95% CI 0.86 to 1.87). Conclusion : When compared to children not fulfilling Sepsis-3 definition, children fulfilling Sepsis-3 criteria for septic shock had delayed initiation of inotrope therapy and greater organ dysfunction possibly indicating higher sickness level when detected.

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Background :

• Critical illnesses are associated with numerous endocrine and metabolic disturbances, among which are alterations in carbohydrate metabolism.[1] Hyperglycemia, hypoglycemia (isolated/persistent) and glucose variability are associated with unfavourable outcome in critically ill children.[49,50]
• Hyperglycemia is considered a stress response in critically ill patients.[2] During any acute illness, glucose regulation is lost and hyperglycemia develops due to insulin resistance or an absolute or relative insulin deficiency.[3,4] Counter regulatory hormones (growth hormone, glucagon, cortisol, catecholamines) and inflammatory cytokines promote lipolysis, proteolysis and thus gluconeogenesis. Hepatic insulin resistance prevails and there is abundant endogenous production of glucose inspite of elevated glucose levels.
• During acutely stressed state, hyperglycaemia is considered adaptive, both by providing glucose dependent organ substrate for energy needs and by preserving intravascular volume with increased serum osmolarity.[5] Despite these potentially beneficially effects, hyperglycemia is associated with increased risk of mortality in critically ill adult and pediatric patients.[6]

Methods : STUDY DESIGN- It was a prospective observational study. SOURCE OF DATA - In our study, source of data were the patients admitted to 10 bedded Pediatric Intensive Care Unit (PICU), Dayanand Medical College & Hospital, DMCH, Ludhiana. It was a prospective observational study of 1 year duration which was conducted in Pediatric Intensive Care Unit – PICU in a tertiary care hospital (DMCH, Ludhiana), from January 1, 2012 to December 31, 2012. INCLUSION CRITERIA- Following criteria were considered for patient inclusion in the study

1. All patients more than 1 month of age and with more than 24 hrs of ICU stay were included in the study. The presenting complaints were medical, surgical or both.
2. In case of multiple PICU admissions, only the first admission was considered.
3. All patients transferred from pediatrics casuality or ward to the PICU were included in the study. The PICU admissions were primarily through the emergency room. Admission blood glucose was done and all relevant parameters were recorded.

EXCLUSION CRITERIA Following cases were excluded from the study group.

1. Neonates
2. Patients with less than 24 hrs of ICU stay
3. Diagnosed cases of diabetic ketoacidosis.

Since the blood glucose homeostasis and reference range of blood glucose is different in neonates from children, so they were excluded from the study. Diagnosed cases of diabetes mellitus were excluded. Minimum of 24 hrs of PICU stay was mandatory for inclusion. Results :

• Out of total 307 patients, 30.29% were between 1 month to 1 year of age, 30.94% were between 1-5 years, 20.19% were between 5-10 years and 18.58% were above 10 years of age.
• At admission, more than half the patients had normoglycemia (~ 56%), followed by hyperglycemia.
• During the PICU stay, majority of patients (~ 55%) had abnormal blood glucose levels, hyperglycemia being most common.
• There was no correlation of hyperglycemia or hypoglycemia at admission and during PICU stay with age of the patients
• There was higher incidence of hyperglycemia seen in surgical patients as compared to those with medical ailments both at admission and during PICU stay.
• Trauma patients had higher incidence of hyperglycemia at admission as compared to all other primary systems (p=0.027).
• There was no significant correlation of blood glucose abnormality and underlying system involved during the course of illness.
• Patients with abnormal blood glucose at admission had a higher incidence of abnormal records during the PICU stay (p<0.001).
• During the PICU stay, 32.24% patients required inotropic support and had significantly more glucose variation compared to patients without inotropes. (p=0.030)
• During the PICU stay, 46.58% patients were on ventilatory support and majority had abnormal blood glucose records (~ 72%), most common being hyperglycemic episodes (p<0.001)
• Feeds were started in 93.48% cases and patients in whom feeds were initiated within 72 hours, there was less incidence of abnormal blood glucose records (p = 0.027)
• In our study 39.42% patients had PRISM II score ≥ 10. Higher the PRISM score, more was the incidence of abnormal blood glucose particularly hyperglycemia(p <0.001)
• Abnormal blood glucose levels, especially hyperglycemia was associated with higher incidence of nosocomial sepsis (p=0.011).
• In our study 188 patients were under 5 years of age, out of which 38.3% had protein energy malnutrition. Children with moderate/ severe PEM, had significantly higher incidence of hypoglycemia at admission (p=0.001).
• Insulin was used in 16 cases with persistent hyperglycemia.
• In our study majority of patients (80%) were discharged, with 12% discharged against medical advice and 8% died.
• Survival was almost same in all age groups and the primary system involved had no correlation with the patient outcome.
• Patients with hypoglycemia at admission had a significant higher mortality (p<0.001).
• Patients with abnormal blood glucose during PICU stay had a higher mortality (p<0.001).
• Patients with prism II score <10 ; higher incidence of mortality was seen in abnormal group (p=0.001). In patients with PRISM II score ≥10 also higher mortality was seen in patients with abnormal blood glucose group (p= 0.205).
• In patients on ventilatory support higher incidence of mortality was seen in abnormal blood glucose group (p=0.063).
• There was significantly higher mortality in patients who were on inotropes and had abnormal blood glucose (p=0.011).•

Conclusion : Blood glucose monitoring is an important part of pediatric critical care. Normoglycemia has better outcome both in terms of morbidity (duration of stay, nosocomial sepsis) and mortality.

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Background : Staphylococcus aureus, is well known to cause varied manifestations ranging from skin and soft tissue (SSTI) to deep seated infection, invasive blood stream infection and multisystem disease. Though there is paucity of data, the last decade has seen a significant increase in the number of community acquired MRSA (CA-MRSA) infections across India. It is important to identify children with likely CA-MRSA at the outset in order to make appropriate empiric antibiotic choices, thus decreasing morbidity and mortality Methods : We identified 131 cases of clinically suspected staphylococcal infections from pediatric emergency database of a tertiary care, multi-speciality referral hospital in Northern India for the period between June 2014-17 and analyzed them for clinical features, laboratory parameters, complications, treatment and outcome. Variables between community acquired methicillin sensitive Staphylococcus aureus (CA-MSSA) and CA-MRSA infections were compared by univariate and multivariate analysis to determine the predictors of CA-MRSA infections Results : Seventy-three of the total 131 cases had blood culture positive for Staphylococcus aureus, 35(47.9%) CA- MRSA and 38(52.1%) CA-MSSA. The children in CA-MRSA were significantly younger than CA-MSSA group [median (IQR) age for CA-MRSA 36(12,62) months vs. 58(37,96) months CA-MSSA p=0.032]. Median (IQR) duration of illness prior to admission was significantly lower in CA- MRSA as compared to CA- MSSA group [6(5,7) vs. 8.5(7,10); p=0.001]. The sites of involvement were similar in both groups. The median (IQR) total leucocyte counts (TLC) were significantly lower in CA-MRSA group; 16300(11810,19000) vs. 18200(13675,24025) p=0.040. A cut off of 17300 [AUROC of 0.64 (95% CI 0.513-0.767; p=0.040) showed a sensitivity of 69% and specificity of 39% for CA-MRSA while a cut off of 22850 [AUROC of 0.36 (95% CI 0.233-0.487; p=0.040) showed a sensitivity of 71% and specificity of 85% respectively for CA-MSSA. Mortality was similar in both groups (MRSA 8.6% vs. MSSA 10.3% p=0.777) Conclusion : Children with CA-MRSA infections were younger, had a shorter duration of pre-hospital illness, and lower total leucocyte counts as compared to children with CA-MSSA infections. Identifying these may help us in deciding our empiric anti-staphylococcal therapy in sick children

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Background : The surviving sepsis campaign guidelines advocates administration of first dose of antibiotics within the first hour of resuscitation in children with septic shock as the risk of mortality increases with every hour delay in administering antibiotics from the time of recognition of shock. There is a paucity of data on the adverse effects of delayed initiation of antibiotic therapy in children from resource restricted settings Methods : We conducted this prospective-cum-retrospective study from June 2013 to August 2017. Children aged 2 months to 17 years and admitted to pediatric intensive care unit (PICU) with septic shock but without prior antibiotic therapy were enrolled in the prospective cohort (Jan to Aug 2017) while records of such children admitted in PICU between 2013 and 2016 were reviewed for the retrospective cohort. The key clinical outcomes measured were duration of inotropic support, antibiotic therapy, mechanical ventilation, ICU stay and mortality. These outcomes were compared between children who received antibiotics after the first hour with those who received within the first hour of recognition of shock. Data was analyzed using Stata 11 Results : A total of 70 children were enrolled. Median (IQR) age was 2.8 (0.8, 6) years and males (66%) were in majority. Most common diagnosis was septicemia without focus (40%) followed by gastrointestinal sepsis (23%). Median (IQR) time lag between arrival at emergency room and recognition of shock was 5 minutes (0, 10) while median time lag between shock recognition and administration of first dose of antibiotics and first fluid bolus were 30 minutes (20, 52) and 15 minutes (5, 33) respectively. A total of 16 children died (22.9%). Fifteen children (22%) received antibiotics after the first hour (Group-1) while fifty-five (78%) received antibiotics within one hour of recognition of shock (Group-2). There was no difference in the age, admission diagnosis or PIM score between the two groups. Administration of first fluid bolus after shock recognition was delayed in group-1 (45 vs. 12 min; p=0.002). Fewer children in group-1 (57%) showed shock reversal by 6 hours of resuscitation when compared to group-2 (76%) but the difference was not significant (p=0.26). When compared to children in group-2, the following durations were significantly prolonged in group-1 children - antibiotic therapy (15 vs. 8 days; p=0.01), inotropic support (126 vs. 60 hours; p=0.01), mechanical ventilation (8 vs. 4 days; p=0.05) and PICU stay (13 vs. 4 days; p=0.01). There was no significant difference in mortality between the two groups - 2/14 (14%) vs. 15/56 (27%) (RR 0.53; 95% CI 0.14 to 2.06). Conclusion : Antibiotic administration within the 1st hour of recognition of septic shock seems to prolong the duration of antibiotic therapy, inotropic support and PICU stay in children with septic shock

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Background : Severe dengue manifests with features of organ dysfunction and can progress to MODS/death if not managed effectively. Severe dengue evolving to progressive MODS can be predicted using markers like serum lactate and ferritin. Early reversal of raised level of these markers correlates with clinical improvement. Intravenous immunoglobulin therapy can be used reverse this Hyperferritinemic multi-organ dysfunction pathway. Current observational analysis aimed at assessing extent and rate of reversal of these markers and improvement of platelet count following IVIg administration as Immuno-resuscitation. Methods : 24 pediatric patients of dengue with warning signs and severe dengue were enrolled in the current observational cross-sectional analysis undertaken between May2017 and September 2017. Average changes in lactate and ferritin levels 24 hours after IVIg administration and changes in platelet count 24 hours after IVIg were noted and expressed in terms of mean + 2 standard deviation change. Results : Changes in ferritin and lactate levels from 8941.33+6332.2 to 4063.25+4491.8 for ferritin and from 5.27+4.84to 1.78+0.86for lactate were noted with change of platelet count from pre-IVIg value of 15333+7328 to 24 hour post IVIg value of 57916+40717. Conclusion : It is a known fact that the severity of dengue is dependent on host immune response and a dysregulated compensatory anti-inflammatory response can result in immunologic dissonance, immune paralysis and consequently dengue can progress to multi organ failure/ dysfunction. Markers such as lactate and serum ferritin and LDH have been shown to be useful as early markers of such disease progress and reduction in their levels fairly correlates with disease improvement. 2,3 IVIg is one of the modality of treatment which has been tried by various researchers to counter the dysregulated immune response and to note reversal of disease severity in terms of platelet and shock recovery and reversal of inflammatory markers. Positive changes in markers of inflammatory response in dengue with a rapid reversal of platelet decline following IVIg administration as seen in our study may suggest a possible role of this modality of treatment to halt disease progression and reduce mortality in dengue. The lesser number of patients enrolled in this pilot study restricts use of any comparative statistical analysis to show the exact overall impact, but precludes the need for prospective clinical trials with larger sample size to assess significance and utility of use of IVIg as Immuno-resuscitation therapy in severe dengue with Hyperferritinemic MODS

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This is a case report of a 4 year old girl, who presented with generalized edema, peri-orbital swelling, poor intake of 1 week duration. She had similar episodes five times in the past viz. 24, 36, 39, 44, 48 months of age. First two episodes were treated on OPD basis without any investigation with anti-allergic medications while 3rd & 4th episodes were investigated and proteinuria was excluded. Fifth episode was transient and was treated as viral infection with anti-allergic medication. Current sixth episode was going on for about 7 days and hence referred. On admission HR 110/min, RR 28/min, CRT 2 secs, euthermic, SpO2 100% room air associated with reduced air entry on right lower zone. Investigations showed Hb 12.8 gms%, TLC 6700/ hpf, DLC normal, platelets 3.29 L/hpf, PT & APTT normal, SGPT 21 IU/L, total protein 4.6 gms%, albumin 3.0 gms%, urea &creatinine normal, urine routine & protein / creatinine ratio normal, C3 & C4 normal, dengue serology negative, procalcitonin 0.2 ng/ml, ESR 4 mm, uric acid 3.1mg%. Imaging on admission showed bilateral pleural effusion with congestive hepatomegaly with moderate ascites. Diagnostic pleural tap showed cell count 730 (polymorphs 6%, lymphocytes 26%, monocytes 68%), LDH 254 IU/L, proteins 4 gms/dl with TB PCR negative. Child increased respiratory distress in next few hours with increasing liver size and poor peripheral pulses needing PICU admission. Cardiac echo showed pericardial tamponade needing emergency pericardiocentesis. Pericardial fluid biochemistry showed 20 cells (M 60%), with normal proteins and LDH suggestive of transudate. This combination of recurrent edema with serous cavity effusion was suggestive of capillary leak syndrome of non-infective, non cardiac, non nephrotic, non –hepatic origin, and therefore Systemic Capillary Leak Syndrome / Clearkson Disease was considered as a probable diagnosis. Pending TNF alpha levels, paraprotein levels, immunoblot analysis we administered IVIG 2 gms/kg over two days that followed rapid disappearance of serous cavity fluid. Subsequent investigations reveled TNF alpha levels were high while immunoblot and paraproteins were normal. This child on subsequent follow up had another recurrence of edema which was treated with short course of steroids. There are around 15 cases of Systemic Capillary Leak Syndrome in the literature, with two of them reporting pericardial effusion. Our patient needed emergency pericardiocentesis. The literature review of this rare disease suggests that treatment was supportive in addition to IVIG / Methyl-prednisolone in some cases. For prevention, some patients were given preventive monthly IVIG, some were given prophylactic verapamil & theophylline, while some were just closely followed up without any prophylaxis hoping that the disease will resolve spontaneously. We chose not to administer any prophylactic treatment, informed parents, and are closely following up this child. Idiopathic Systemic Capillary Leak Syndrome, although rare, must be considered in the differential diagnosis of generalized edema with serous cavity involvement because it can be reversed with appropriate strategy with high index of suspicion.

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Background : Status Epilepticus (SE) is one of the life threatening neurological emergency in children. Super refractory status epilepticus (SRSE) is defined as SE that continues for 24 hours or more after the use of anesthetic therapy, including cases that recur on weaning an anesthetic agent. There are no randomized controlled trials (RCTs) in literature for treatment of SRSE. Thus retrospective analysis is important to guide us further in prognostication and management of SRSE. Methods : We conducted a retrospective analysis on the profile of patients aged between 1 year to 16 completed years admitted in PICU from January 2010 to May 2017 with SRSE . Patients with incomplete medical documentation were excluded. The patients details were obtained from the Medical Record Department and charted in a standardized proforma. Results : Out of 1353 patients admitted during above mentioned period with diagnosis of Menigoencephalitis/Encephalopathy with seizures, 18 patients were found to have SRSE. Two participants were excluded due to incomplete records thus 16 charts were analyzed. The Mean age of our study group with SRSE was 8.19 (± 4.13) years, and males constituted 68.75% (n=11) of the study population. Infection (n=8, 50%) and Autoimmune (n=4, 25%) are the most common cause for the SRSE. In the study group, 43.75% (n=7) patients received Intravenous Immunoglobulin (IvIg) among which 85.71% (n=6) achieved seizure control. Continuous thiopentone infusion alone was given to 50% (n=8) of patients, out of which 37.5% (n=3) achieved seizure control. Out of 6 patients receiving Thiopentone plus Ketamine infusion 3 had remission of seizures and one patient who received Ketamine infusion alone did not show seizure control. Only one patient was on combination of Thiopentone, Ketamine and Phenobarbitone infusion achieved seizure control. Conclusion : Our results showed SRSE was more common in older children (> 5 years of age) and the infection was the primary cause of SRSE followed by autoimmune etiology. IvIg and pulsed steroids showed promising results in our study. Thiopentone in combination with Ketamine infusion had effective seizure control in SRSE patients. Further RCTs are needed to study the combination of anticonvulsants for the effective management of SRSE

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Background : Acute bacterial meningitisis characterized by intense inflammatory reaction augmented by locally produced cytokines and chemokines in the subarachnoid space. And, the CSF analysis of these secreted cytokines and chemokines provides an insight to the inflammatory reaction occurring in the CNS. Therefore, the comparative CSF cytokine and chemokine profiling could be used to identify immunological markers for differential diagnosis of bacterial meningitis. Methods : Children Results : Among pro-inflammatory cytokines; the levels of IL-1ÃY (p=0.002), IL-12 (p=0.049) and IL-17 (p=0.002) were significantly higher in children with ABM as compared to children with AME. Anti-inflammatory cytokine IL-1ra (p=0.001) and chemokine IL-8 (pp=0.001) levels were also observed to be significantly higher in children with ABM as compared to children with AME. Conclusion : The increased levels of inflammatory cytokines and chemokines in CSF of bacterial meningitis as compared to meningoencephalitis suggested a heightened inflammatory burst in bacterial meningitis. Further, IL-1ÃY, IL-12, IL-17, IL-1ra and IL-8 can be employed for differential diagnosis of bacterial meningitis from meningoencephalitis

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Background : The invading bacterial pathogens are recognized by a class of pathogen recognition receptors (PRRs) called Toll Like receptors (TLRs) present on immune cells. PRRs play an important role in elimination of pathogens in early part of the disease but also results in unabated inflammation. There is a sparse literature on TLR transcriptome and their role in mediating immune response in bacterial meningitis. Methods : Children hospitalized with bacterial meningitis (ABM, n=30) and aseptic meningitis (ASM, n=11) were enrolled. Controls (n=15) included the children, where CSF tap didn’t yield any infection on lab investigation. The gene expression profile of forty-two genes of TLR signaling pathway was performed using PCR array platform. Further, these results were validated by estimating secretory cytokines and chemokines in CSF using Luminex platform and western blotting. Results : We observed an increased expression of TLR2 (2 folds),TLR3 (13 folds), TLR8 (3 folds), TLR9 (20 folds), CD180(8 folds), TICAM1 and TIRAP dependent signaling pathway genes including of TNF? (8 folds), IL6 (114 folds), IL12 (64 folds), IL10 (17 folds), CCL4 (18 folds), CCL5 (7 folds) and CXCL8 (31 folds) in children with ABM. The protein expression of TLR signaling genes (TLR3,TNF?,IL-1ÃY, IL-6,IL-8, IL10,IL1ra) was observed to increase in children with ABM in comparison with ASM and controls. Further, we also observed higher CSF levels of IL-1ÃY, IL-6, IL-17, IL1ra, IL-8, MCP-1 & RANTES in children with ABM as compared to ASM and controls. Conclusion : An overall upregulation of TLRs and downstream TLR signaling molecules was observed. This subsequently resulted in increased levels of inflammatory cytokines and chemokines in children with ABM. The study provides an insight to role of TLR signaling in augmentation of immune response in pediatric bacterial meningitis which can be further explored for therapeutic intervention to regulate unabated inflammatory process in bacterial meningitis.

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Background : Congenital dermal sinus is a developmental malformation which may be associated with sinus tract between the skin and the deeper tissues even spinal cord. Hence, can have complicated presentations like gait abnormalities, infections, urinary symptoms or mass lesions. We hereby describe a case series of six children with spinal abscesses complicating dermal sinus. Methods : All children with flaccid paralysis presented to our center during the period January 2016 to May 2017 were reviewed. The children were evaluated by Spinal imaging, Nerve conduction studies, and cerebrospinal fluid analysis or biochemical and microbiology investigations as indicated. The clinical symptoms, neurodeficits, radiological findings, culture of Cerebrospinal fluid or blood and treatment provided were analyzed. These children were followed up clinically for assessment of neurodeficits. Results : Of a total of 111 children of acute flaccid paralysis admitted during this period, six children had spinal abscess associated with dermal sinus. (The other diagnosis were Guillain Barre syndrome, myositis, myelitis). The median age of diagnosis and median duration of symptoms was 8.5 months and 33 days. All six children presented with progressive weakness of lower limbs; fever and urinary symptoms were present in only two children. In none of the children was spinal cord infection kept as an initial differential diagnosis. All children had evidence of intra-medullary abscess, cord edema and spinal archanoiditis. One child had holocord involvement, while rest had involvement of dorso-lumbosacral spine involvement. Two children had epidural abscess while one child had paravertebral abscess. Four children needed spinal laminotomy. The offending organism was isolated in two children (E.coli). All except one (parents declined treatment) were treated with intravenous antibiotics for 6-8 weeks. All children had motor improvement after treatment but all were left with severe deficits and residual neurogenic bladder Conclusion : The infection of the spinal cord and meninges due to a dermal sinus is rare cause of paralysis and can present without fever. In any child with flaccid paralysis, a careful examination of back for dermal sinus is critical to suspect this diagnosis.

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Background : Background Super-refractory status epilepticus (SRSE) is one of the most severe neurological emergencies, associated with a significant risk of mortality and morbidity. SRSE occurs in approximately 12-22% of the patients with Status Epilepticus. The published literature on SRSE comprise largely of case-reports or series, mostly in adults. The optimal approach to management remains controversial due to a lack of evidence from high quality clinical trials. Methods : Methods -A prospective observational study was done in the pediatric intensive care unit of a tertiary care hospital over a period of 18 months. The study was approved by the Institutional Ethics Committee for Human Research. Inclusion criteria - Age 3m-12y, Meeting the case definition of SRSE (status epilepticus that continues for 24 h or more after the onset of anesthesia, or the status epilepticus recurs on the reduction or withdrawal of anesthesia), Parents/caregivers gave informed consent for inclusion. Exclusion criteria - Age 12y, Children with major congenital anomalies, pre-existing neurological impairment. For descriptive analysis of demographic and clinical variables data of age, sex, presence and type of prodromal symptoms, presence and type of seizures and SE before admission, consciousness level on admission, duration of SE, duration of hospital and intensive care unit (ICU) stay, and ultimate control of SE were recorded. We also collected the information of number and type of ant seizure medications, anesthetics, and immune therapies received, ventilator support, ionotropes support, mean arterial pressure, blood glucose and calcium level, PRISM Score on PICU admission, common co morbidities, complications, degree of disability, functional outcome, morbidity and mortality at ICU using a semi-structured pre-designed proforma. Continuous EEG (CEEG) monitoring was done to detect occurrence or cessation of seizure activity. Functional outcome at 6 months post discharge was graded according to the Glasgow outcome scale Extended Pediatric Revision (GOS-E Peds) , and classified as good (GOS 4 and 5) and poor (GOS 1, 2 and 3) outcome groups. Results : Results - Fourteen children aged between 2 years and 10 years were diagnosed with SRSE, comprising 12.7% of all children admitted with status epilepticus. Encephalitis was the commonest etiology (6/14) followed by Nonparaneoplastic Autoimmune encephalitis (4/14), seizure disorder (2/14), acute disseminated encephalomyelitis (1/14) and Febrile infection related epilepsy syndrome (FIRES) (1/14). A median of 5(range 4—7) anticonvulsant drugs were used. Besides midazolam infusion, thiopentone was the commonest anesthetic agent used. Immune therapies were used in 9 of 14 cases (64%). The median GOS-E Peds at 6 months post-discharge was 4 (range 1-7). In multivariate analyses, higher PRISM III score at admission (P=0.013), longer duration of intensive care unit stay (P=0.041) and requirement of general anesthesia >48h (P=0.029) were associated with worse outcomes. Half of the survivors (50%) remaining on antiseizure medications. Conclusion : Conclusion - Infective encephalitis was the most commonly identified cause of Super refractory status epilepticus, followed by autoimmune encephalopathy. Outcome at discharge is poor but improves during follow-up. The role of anesthetics and immune therapies warrants further investigation.

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Background : Background - Acute bronchiolitis is the most common lower-airway viral infection in infants. Mechanical ventilation may be needed by 5(15%) of the hospitalized patients because of fatigue, apnea, or hypoxemia. Inappropriate extubation timing increases morbidity and mortality, ICU stay. To prevent it nCPAP is an established therapy. HHHFNC is an emerging therapy for respiratory support in infants in PICU which can be used as a successful alternative to CPAP. Methods : Randomised control trial, single centre trial, pilot study. Study period: from June 2015 to May 2017. Study was approved by institutional ethical committee for human research. Inclusion criteria - Infants excluding neonates mechanically ventilated due to acute Bronchiolitis fulfilling extubation criteria after performing Spontaneous breathing trial (SBT) by putting patient in CPAP of 5 cmH2o for 30 min as per standard PICU protocol. Exclusion criteria - Infants ventilated due to other respiratory cause and associated heart or neurological impairment, Immmunocompromised patient, having pre-existing chronic respiratory morbidity. The extubated infants were supplemented with face mask oxygen and monitored for HR, RR, SPO2, Respiratory Distress Assessment Index (RDAI) and Arterial Blood Gas (ABG). They were randomized and put on nCPAP or HHHFNC if they shows any one of the following : Increase in HR > 20 b/min and RR > 10/min, RDAI = 11, SpO2 - = 92%, Ph = 7.35 and Pco2= 50mHg. Comfort score and Respiratory Distress Assessment Instrument (RDAI) were recorded 12 hourly. Infants with oxygen requirement more than 70%, pCO2 >65mm of Hg combined with pH Results : Total 170 were hospitalized with the diagnosis of Bronchiolitis during the study period. Thirty six patients required mechanical ventilation and 28 infants aged between 1 month to 12 months were randomized in the study. Twenty one (21/28, 75%) of the included infants were male. Mean (±SD) age of the study population was 3.75(±1.94) months. Two (1/13, 15%) infants of the CPAP arm and two (2/15, 13%) infants of the HHHFNC arm had extubation failure. There was no statistically significant difference between the two groups. RDAI score and total duration of PICU stay between the two groups show comparable results. Comfort score comparison between the two groups shows infants on HHHFNC were more comfortable (p<0.05) Conclusion : HHHFNC is comparable to nCPAP in respect of reducing extubation failure, decreasing respiratory distress or length of hospital stay. But it is more comfortable for infants.

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Background : Inotropes and catecholamines play a major role in management of the Septic shock. The different combinations of catecholamines are used based on the hemodynamic status, to achieve the therapeutic end points. Vasopressin has a significant role in maintaining the cardiovascular homeostasis. There is paucity of literature regarding the role of Vasopressin as an alternative to Noradrenaline in septic shock among paediatric population. Methods : We conducted an open labeled randomized controlled trial over a period of 2 years (March 2015-April 2017). We randomized patients into Vasopressin and Noradrenaline groups. Low doses were started (Vasopressin = 0.02 IU/kg/hr versus Noradrenaline 0.02 mcg/kg/min) and dose titration was done to achieve the therapeutic end points at 6 hours. Data was analyzed using student’s t-test, chi-square test, Mann-Whitney test and Regression analysis. Kaplan-Meier Survival curves were used to analyze the mortality outcome. Results : Forty patients were randomized into Vasopressin and Noradrenaline groups (20 in each group). The baseline characteristics between the groups were comparable with no statistical difference. Improvement in the heart rate, lactate and base excess were better seen in the Vasopressin group, though not statistically significant (p = 0.65, p = 0.26 and p = 0.64 respectively). In the 40 participants, 37(92.5%) achieved the therapeutic end points of SBP at end of 6 hours, among which 18 (90%) were in Vasopressin group and 19 (95%) were in Noradrenaline group. However there was no statistical significance in the 28-day mortality rate among the two groups (Vasopressin = 48% and Noradrenaline = 42%, p = 0.77) Conclusion : Vasopressin showed more or less similar effects like Noradrenaline on the hemodynamic status in septic shock. However larger trials are required to authenticate the effectiveness of Vasopressin in Pediatric Septic shock.

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Background : Positive fluid balance is shown to have adverse outcomes in mechanically ventilated children with Acute Respiratory Distress Syndrome (ARDS). Our study attempts to provide an understanding of the threshold of fluid balance requiring intervention in the management of mechanically ventilated children. Methods : This retrospective study was conducted in the Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER). Medical records from January 2015 to December 2016 were screened. All medical records of children aged 1-month to 13 years admitted to PICU and mechanically ventilated for more than 24 hours with documented input-output balance for at least 48 hours from the start of mechanical ventilation were included. Patients divided into =10% Fluid overload (FO) group and > 10% FO group. Results : Study included 107 children with 84 in =10% FO group and 23 in >10% FO group. The baseline characteristics were similar in terms of age (median 11 months Vs 12 months), sex (M:F = 47:37 Vs 10:13), Pediatric Risk of Mortality (PRISM)- III score (15 Vs 16), inotrope score (20 in both) & vasoactive score (30 in both) and number of patients receiving furosemide [59 (70%) vs 16 (69 %)]. Disordered control of breathing was the most common indication for mechanical ventilation in both groups [37(44%) Vs 12(52%)]. The proportion of children having ARDS [28(35%) Vs 13(56%), p=0.06] and AKI [37(44%) Vs 15(65%), p=0.07] were higher in >10% FO group of which significant number required renal replacement therapy [15(17%) Vs 10(43%), p=0.01]. More children were found to have shock in >10% FO group [58(69%) vs 18(78%), p=0.38] and the proportion of septic shock was significantly higher [27(32%) vs 13(56%), p=0.03]. The >10% FO group had a higher mortality compared to =10% FO group [32(38%) vs 13(57%) RR=1.2, 95%CI 1.0-1.5, p=0.11]. The median (IQR) duration of invasive mechanical ventilation was 6 (4-11) days in =10% FO group and 5 (3-10) days in >10 % FO group (p=0.90). PICU stay was longer in =10% FO group [9 days (6-15) Vs 8 days (6-15) p=0.82]. Ventilator-free days were comparable (23.5 Vs 22.5) and organ dysfunction scores - Pediatric Logistic Organ Dysfunction (PELOD) [12 in both] & Sequential Organ Failure Assessment (SOFA) [8 in both] were similar. The >10% FO group had greater failed extubations (7% Vs 20%) (p=0.23) and higher respiratory morbidity (median Oxygen Saturation Indices 3.55 vs 5.4, p=0.14, Oxygenation Indices calculated for 49 and 12 children respectively were 3.5 Vs 5.15, p=0.59). Conclusion : There was no significant difference in mortality or respiratory morbidity in positive fluid overload >10 % compared to fluid overload =10%. Future prospective studies including a larger number of children are required to obtain more evidence regarding the association of fluid overload with adverse outcomes.

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Background : Severe dengue is characterized by severe vascular leakage and abnormal haemostasis which can lead to mortality. As per exciting guidelines fluid resuscitation is recognised as the critical therapeutic intervention; however these guidelines are more empirical than evidence based. Methods : This was a prospective observational study (June 2016 to august 2017), conducted in a tertiary care intensive care unit. Children aged between one month and 18 years with diagnosis of severe dengue were categorized to receive either 20%A or 5%A, in addition to routine fluid resuscitation with crystalloids as per WHO guidelines. Children admitted between June 2016 to August2017, were allocated to receive 20%A (group A) during first 6 month (June 2016 to December 2016) and 5%A (group B) during next 6 month. Arterial blood lactates were measured before and after albumin transfusion and lactate clearance were calculated using the formula (Lactate before - lactate after)/lactate before (%)(mill moles/ liter) . Children were followed up to recovery or mortality. The primary outcome was lactate clearance and the secondary outcome variables were length of hospital stay, duration of mechanical ventilation, fluid overload, mortality and inotrope requirement, which were compared between the two groups. Results : A total of 90 children with 45 in each group were enrolled in the study. The mean lactate clearance in 20%A group was 43.3±17.75% (95% CI: 33.5-53.17) and 5%A group was 19.46±19.0% (95% CI: 8.8 -30.0). This difference was found to be statistically significant (p value=0.001).The mean hospital stay was 129.5±42.1 hours (95%CI: 106.1-152.9) and 162.73±57.2 (95%CI: 131-194.4) in the 20%A and 5%A groups respectively (p value=0.081),and the net fluid overload in 20%A was 133.6±119.8ml/kg (95%CI: 67.2 -199.9) and in the 5%A group was 162.3±96.8ml/kg (95%CI: 108.7-215.9) (p value=0.47), but both were statistically not significant. The need of inotrope requirement between two groups was statistically not significant (p value=0.5). The need of ventilation and mortality (n=1) could not be statistically determined because of inadequate data. Conclusion : Children treated with 20%A had better lactate clearance and relatively lesser fluid overload when compared to 5%A. Since lactate clearance is a viable surrogate marker of resuscitation adequacy 20%A can be considered superior to 5%A as per our study for resuscitation of severe dengue cases. However, randomised control trials with larger sample size are warranted to confirm the advantage of 20%A over 5%A.

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A 1.8 year old male child born of a non-consanguineous marriage presented with loose stools and refractory seizures. He had severe hypomagnesemia (0.36mg/dl) with hypocalcaemia (4.8mg/dl,iCa 0.4mmol/l). Vitamin D (28 ng/ml) level was slightly low while serum Phosphorus (4.56mg/dl) and serum PTH (47.2 pg/ml) were normal.Fractional Excretion of Magnesium (FeMg) was less than 2% indicating intestinal losses. The index case was positive for a novel truncating TRPM6 gene mutation and the case was diagnosed as Hypomagnesemia with Secondary Hypocalcaemia (HSH). The child was started on high dose oral magnesium supplementation.Hebecame seizure free and neurologically normalwith treatment.

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Background : Hypoalbuminemia is a frequent and early biochemical derangement in critically ill-patients. Inflammatory disorders can accelerate the catabolism of albumin, while simultaneously decreasing its production with diversion of synthetic capacity to other proteins (acute-phase reactants like C-reactive protein). Although, hypoalbuminemia and raised CRP have been shown to be predictors of adverse outcomes in critically ill adult patients, the predictive value of both for outcomes in critically ill pediatric patients has not been validated. Methods : This was a prospective observational study carried out (9 months from October 2016 to June 2017) in a tertiary care PICU. Eligible patients were enrolled after obtaining parental consent. Baseline demographic and clinical information was recorded. 2 blood samples (2ml each) were collected just after admission in PICU for determination of serum albumin and C-reactive protein levels, during sampling for routine investigations. Serum albumin was determined using bromocresol green method while C-Reactive protein (CRP) was estimated using turbidometric assay. Hypoalbuminemia was defined as an albumin level of less than 3.4 g/dL for patients 7 months or older and less than 2.5 g/dL for patients younger than 7 months and raised levels of CRP were values > 10mg/l. Results : Hypoalbuminemia was present on admission in 43% patients and raised CRP was present in 53% patients. The mean serum albumin level (Mean ± SD) was 3.44 ± 0.52 gm\dl and the mean CRP level (Mean ± SD) was 33.89 ± 36.62 mg\l for the study population. A total of 37% patients had no organ failure and 63% had = one organ failure. When ROC curve was generated for hypoalbuminemia as a predictor, the area under the curve was 0.92 with a significant p value Conclusion : Hypoalbuminemia and raised CRP were found to be moderate independent predictors of organ failure &\or mortality. The addition of hypoalbuminemia to raised CRP could significantly improve the ability to predict organ failure &\or mortality. Hypoalbuminemia was found to be a very specific marker for predicting organ failure/mortality with a positive predictive value of 100%. The CRP: albumin ratio was significantly different in patients with organ failure as compared to controls, however more studies are needed to confirm this finding.

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Background : Head Trauma is very common in children. Although head trauma in children and adults have several similarities, children should not be considered as young adults, given that the pediatric patients have more susceptible cranial vault due to thinner and more pliable bones, open fontanelle, large head-to-torso ratio and less developed neck musculature.Many studies are done in developed nations with good quality of emergency care and facilities. Data is lacking in developing countries for epidemiology, mechanism of injury and different management modalities. So I would like to carry out this study in our setup to obtain data for the following lag backs. Methods : This is a prospective observational study conducted over a period of ten months from October 2017 to July 2017. All cases with head trauma requiring hospitalization in the study period(n=65) were enrolled. After a detailed primary and secondary survey, all of them were triaged and treated as per our protocol. All of them required neuroimaging. Parents or caretakers were thoroughly interrogated for the circumstances in which the children suffered head trauma, and were requested to provide the site photographs whenever possible Results : Of 65 children, 42(64.6%) were less than 5 years, 20(30.7%) were between 5-10 years and 3(4.7%) were more than 10 years. As per the protocol of our hospital, 33(50.7%) of them required admission to PICU or high dependency unit and 32(49.3%) required observation in general pediatric ward. Of 65 children, severe head trauma was seen in 8 (12.4%) children, requiring intensive management including mechanical ventilation, of which neurosurgical intervention was needed in three children. There were 3(4.6%) children with moderate head trauma and 54(83%) with mild head trauma. Neuroimaging was abnormal in all children with moderate and severe head trauma. Of those with mild head trauma, 39(72%) had abnormal neuroimaging. Results showed that 2 children expired, 3 had deficits in the form of unable to speak, not recognizing parents, not responding to verbal commands and facial nerve palsy. Remaining children were functionally normal. Analysis of circumstances leading to head trauma revealed that 38(58.5%) happened at home, 19(29.3%) on road, 8(12.3%) at play places. Poor safety precautions at home in the form of unsafe stairs (n=6, 9.2%), unsafe balconies (n=7, 10.8 %), unsupervised activities of kids (n=22, 33.9 %) were some of the preventable causes on domestic side. Unsafe road traffic, rash driving were also preventable situation. Play-places of children with insufficient supervision was the other important cause. Conclusion : Almost all the situations were preventable suggesting need to improve child safety practices. All severe and moderate head injuries and 72% of mild head injuries were associated with abnormal neuroimaging suggesting vulnerability of children to head trauma.

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Background : Severe dengue accounts for approximately 10000 deaths per year worldwide which are increasing over past two decades secondary to increased incidence of infection. Identification of risk factors of mortality can help in early classification of high risk patients and timely fluid therapy can prevent progression to multi-organ dysfunction. We conducted this retrospective review to identify predictors of mortality in critically ill children with dengue. Methods : Case records were reviewed for 31 children with dengue infection admitted to the paediatric intensive care unit of tertiary care centre from North India from January 2015 to December 2016. Demographic data, signs and symptoms, laboratory investigations, treatment details, response and outcome were recorded in predesigned pro-forma. Clinical features were compared between outcome groups (survivors vs. deaths) in bivariate followed by multivariate analysis for variables having p value Results : Out of total 31 patients (52% males) included, 20 (65%) survived. Thirty children were classified as severe dengue (97%) while one child had dengue with warning signs at admission. Expanded dengue syndrome was present in 24 (77%) children; of which most common organs involved were liver (67%), central nervous system (50%) and kidney (29%). Shock at presentation was detected in 21 (68%) children; of whom two thirds had hypotension. Of 6 (19%) children with bleeding diathesis at presentation, 4 had major bleed. On bivariate analysis of symptoms, abdominal pain was more commonly present in survivors (85% vs. 45%, p value=0.038). Pallor was present less often in patients surviving dengue infection (35% vs. 72%, p value=0.044). Decreased urine output in non-survivors was reported at admission more often in non-survivors (45% vs. 10%, p= 0.067). Admission blood gas pH, base excess and lactate were deranged more in non-survivors (p value= 0.027, 0.025, 0.027, respectively). In treatment parameters, non-survivors had higher vasopressor inotropic score, red blood cells, fresh frozen plasma and platelet transfusions (p value=0.000, 0.0.001, 0.005, and 0.008, respectively). Non-survivors more often required mechanical ventilation, inotropic support and renal replacement therapy (p value=0.004, 0.027) Conclusion : In our study, we found that admission blood gas pH, base excess, lactate and pallor are important risk factors of mortality. Among symptoms, history of decreased urine output showed trend to significance in predicting mortality which could be incorporated amongst warning signs in dengue fever.

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Background : The main purpose of the paediatric intensive care unit (PICU) is to prevent mortality by intensively monitoring and treating critically ill children who are considered at high risk of mortality. This study aims at studying the predictors of mortality in PICU patients. Methods : This is a prospective observational study of patients consecutively admitted to PICU during a 4-month period between May 2017 to August 2017. Various clinical, physiological and biochemical parameters were studied. Mortality rate and predictors of outcome were calculated. Outcome was noted as death or discharge from PICU. Results were analyzed by T test, Kaplan-Meier curve, ROC curve, Logistic regression model using SPSS 16. Results : 250 children between age group 1 month to 17 years were studied. Overall mortality rate was 19.6% (n = 49). 49% (n=122) children were below 1 year, 30 % (n=74) from age group 1 to 5 years. Majority were males (69%, n=151). Infective aetiology was predominant (32%, n=79). Maximum patients had central nervous system involvement (26%, n=65). 40% (n=100) PICU admissions were from wards, 32 % (n=79) from casualty. Mortality was highest amongst patients admitted from casualty (30%, n=24). On univariate analysis gender (p=0.013), aetiology (p=0.001), source of admission (p=0.001), time to reach full enteral feeds (p=0.001), net fluid balance (p=0.001), renal angina index (p=0.001), serum lactate level (p=0.001), ionotropic support on admission (p=0.001), mechanical ventilation (p=0.001), type and duration of mechanical ventilation (p=0.001), PRISM III score (p=0.001) and were significant predictors of mortality. On Multivariate logistic regression analysis infective etiology, higher renal angina index, higher serum Lactate level, mechanical ventilation and higher PRISM score were the independent and significant predictors of mortality (p-value<-3 Z score for weight for height) on admission and 22% were moderately malnourished (-2 to -3 Z score). But poor nutritional status was not found to be significant predictor of mortality (p=0.067). Severe malnutrition was associated with higher mortality (30%, n=15). PRISM III score was 0-9 in 73.6%, 10-19 in 20.4% and 20-30 in 6% patients. It showed increasing mortality from 7.1% in 0-10 score patients to 76.9% in 21-30 score ones. The survival time significantly decreased as PRISM score increased (p=0.001). Receiver Operator Curve (ROC) analysis for PRISM III score as predictor of mortality showed an Area under the curve = 0.889 (95% CI: 0.841 b 0.937), (n=250). Further on applying Kaplan-Meier Survival Curve depicting probability of survival showed lower PRISM score had significantly better survival compared to the cases with higher PRISM score (P<0.05) Conclusion : Thus factors such as renal angina index, serum lactate levels, etiology, mechanical ventilation and PRISM III scores are useful markers in predicting mortality risk in critically ill patients.

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Mid Aortic Syndrome is an uncommon aetiology of hypertensive urgency in children with poor outcome if left untreated, so there is a need for prompt diagnosis of hypertensive urgency followed by timely referral to a tertiary care centre which would reduce its complications and mortality Not Applicable as Case Report Case report: A 12-year-old boy presented with fever, puffiness of face and breathing difficulty. On clinical examination, he had hypertension so initially we considered renal aetiology as a cause of his hypertension, hence he was managed conservatively with intravenous antihypertensive drugs followed by oral antihypertensive drugs. As his hypertension was uncontrollable medically, he was investigated for underlying causes with USG abdomen with renal Doppler and 2D Echo which were normal. In view of differential blood pressures in upper limbs and lower limbs we suspected obstructive component in aorta, so a paediatric cardiologist was specifically asked to look at distal Aorta on 2D Echo. Later CT angiography was done which showed significant abdominal aortic constriction without involvement of renal/mesenteric vessels. Percutaneous balloon dilatation of aorta was done considering growing age of the child and normal renal, mesenteric vessels. Post operatively we could wean anti-hypertensive drugs to keep his blood pressures below 50th centile for his age, height and sex.

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Background : Raised intracranial pressure is a common neurological complication in critically ill children which leads to morbidity and mortality. Regardless of etiology of raised intracranial pressure, osmotheraphy remains the cornerstone of medical therapy for brain resuscitation. In this regard, hypertonic saline had proven benefit over mannitol. In different studies varied concentration of hypertonic saline used to achieve therapeutic hypernatremia of 145-155 meq/l to reduce raised intracranial pressure. Methods : 1. Inclusion Criteria All children aged 1 month to 18 years with clinical signs and symptoms of raised intracranial pressure who are admitted to PICU during specified duration. 2. Exclusion Criteria Those died within 24 hours k/c/o Hypertensive encephalopathy At admission serum sodium = 145 mEq/L Developmental delay or neuro-morbid children Retrospective observational study in a PICU of Tertiary Care Hospital, Hyderabad. All children aged 1 month to 18 years with clinical signs and symptoms of raised intracranial pressure who are admitted to PICU from 1st September 2016 to 31st May 2017 were included in study. All received 3% NaCl as osmotherapy. Data was extracted to patient admission record. After exclusion criteria, 36 out of 72 patients were included in the study. Outcome was measured as GCS, targeted sodium, death and discharge. Results : In this study, outcome was measured as normal GCS (15/15) and abnormal GCS (=13/15). Out of 36 patients, 25 patients (69.4%) and 11 patients (30.6%) had normal and abnormal GCS outcome. In 25 patients of normal GCS outcome, 16 patients (64%) achieved target sodium level and 9 patients (36%) did not achieved target sodium level. In 11 patients of abnormal GCS outcome, all of them achieved target sodium levels. There was a significant difference in serum electrolytes levels at 6, 12, 18,24,36,48 hours during treatment in patients with normal and abnormal GCS outcome. There was a relative high levels of serum electrolytes in patients with abnormal GCS outcome at 6, 12, 18,24,36,48 hr of treatment. Normal GCS achieving hour is negatively correlated (weakly) with target hypernatremia achieving hour. On multivariate analysis, patients with ventilation, renal dysfunction, severe hypernatremia and shock had significant abnormal GCS outcome. Conclusion : Targeted therapeutic serum sodium is associated with good outcome while hypernatremia is associated bad outcome. Patients with ventilator support, renal dysfunction, shock had abnormal GCS outcome.

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Background : The lumber puncture and CSF opening pressure in children remains an essential diagnostic test for children with suspected intra cranial pressure in children with meningitis, status epilepticus etc. The LP with accompanying OP is relatively non invasive, easily accessible and rapid procedure with few risks and adverse effects compared with invasive ICP monitoring. CSF opening pressure can give clue to raised intra cranial pressure in these children. There is no normative data available in Indian children. Hence this study was planned to see co relation of abnormally elevated opening pressure with patients clinical, laboratory and radiological parameters and their outcome Methods : Inclusion criteria : Any patient undergoing indicated CSF examination Exclusion criteria : Children with infected skin over the needle entry site, coagulopathy Patients with known CNS lesions (CNS tumour) Denial of consent for lumber puncture Unavailability of CSF manometer Children with proven metabolic encephalopathy (i.e. hepatic encephalopathy, Reyes syndrome) Neonates ( i.e babies Results : Out of 50 patients, only 8 patients ( 16 %) had CSFOP > 28 cm of H2O. maximum number of patients 11 (22%) were diagnosed as having acute bacterial meningitis and acute viral meningoencephalitisout equally . 35 ( 70 %) patients had seizures, out of them only 6 ( 17.14 % ) patients had CSFOP > 28 cms and 29 ( 82.86 %) patients have CSFOP < 28 cms H2O. Out of 9 patients who had status epilepticus, no patient had CSFOP > 28 cms of H2O. maximum number of patients 45 ( 90% ) had GCS < 8 at the time of admission and least number of patients 2 (4%) had GCS of 13-15. Out of those patients who had CSFOP > 28 cms of H2O, maximum number of patients 7 ( 87.5%) had GCS < 8. So out of 8 (100%) patients with CSFOP > 28 cms of H2O, 5 ( 62.5 % ) had bad outcome. on multivariate analysis GCS, CSF results, triage, seizures, radiological features were not significantly associated with bad outcome Conclusion : The threshold of a normal CSF opening should not be interpreted in isolation. Clinical & laboratory parameters does not correlate with CSF opening pressure in every patient. Limitations: Needs large sample size for better understanding.

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Background : Chikungunya fever is an arboviral disease characterised by triad of fever, rash and polyarthralgia. Chikungunya virus (CHIKV) is transmitted to humans primarily via the bite of an infected Aedes species mosquito. The virus was first identified some 50 years back. The interest in the research of this disease increased after an important epidemiological outbreak in 2005 on the French metropolitan island of La Reunion and in India. In the last few years some of the unknown and varied manifestations of this arthropod borne alphavirus infection were brought into light. In fact, the name â€~chikungunya’ means â€~that which bends up’ in the Makonde language of East Africa and describes the severe arthritic pains of the disease.The clinical symptoms, in most affected individuals are high fever, severe myalgia and prolonged arthralgia, with occasional history of skin rash (petechiae). Neurologic complications were reported occasionally. Methods : Case Report: A 5-month-old infant presented with high grade fever and vomiting’s for 2 days, associated with irritability and 4 episodes of generalised tonic clonic seizures. Clinical examination revealed a toxic look, bulging AF, exaggerated reflexes. CNS and other system examination were normal. Child developed progressive respiratory failure despite escalating respiratory support requiring intubation and ventilation. Her blood reports including Hemogram, liver and renal function text and electrolytes were all within normal limits initially. Her CRP was elevated. Blood and urine cultures were sterile. Test for Dengue, Leptospira, Rickettsia, HSV, JE serologies, Widal test, Malaria were negative. CSF obtained on day 5 of illness showed 3mononuclear cells/mm3, sugar and protein level were 38 mg/ dl and 45.7 mg/dl respectively. Culture of CSF was negative for bacteria, fungi and mycobacteria. Result of a CSF PCR test for HSV DNA, Enterovirus RNA, VZV DNA, Neisseria meningitis DNA, Haemophilus species, Streptococcus pneumonia DNA, Cytomegalo virus DNA, Mycobacterium tuberculosis complex DNA were negative. During the stay in PICU the child developed rash on day 1 of illness which was maculopapular initially then vesicles appeared in perennial & peri-anal region which later spread to trunk and limbs. Subsequently the child had septic shock, DIC, with MODS (Transaminitis, AKI etc.). Inotropic support was optimised accordingly. Serum (MAC-IgM ELISA) collected 7 days after disease onset showed IgM antibodies to chikungunya virus. After initial antibiotic support, she was managed conservatively. She started showing progressive improvement, her inotropes were weaned and stopped, ventilator support was weaned and child was extubated successfully. Her rash subsided, sensorium and oral acceptance improved. At discharge, there were no neurological sequale noted. On follow up, after 3 months, child was asymptomatic. MRI Brain showed no detectable abnormalities. VEP and BERA were normal. Conclusion : This report highlights that, although rare, Chikungunyavirus may show neurotropism with very severe clinical presentation, including in young patients with unremarkable medical history in endemic regions. The virus can cause severe meningoencephalitis like our patient.

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Background : Chikungunya fever has unexpectedly re-emerged in the form of epidemics in many tropical African and Asian countries. Delhi witnessed worst epidemic of chikungunya fever in year 2016. It is benign diseases with few complicated or severe manifestation reported previously. Methods : Study design: retrospective observational The study population included all PCR positive cases of Chikungunya admitted from September 2016 to December 2016 in PICU. The information recorded included demographic features, clinical features, laboratory parameters, hospital stay and mortality. Results : Of the 49 children with PCR positive chikungunya, 36 had common form and 13 had severe disease. In severe group, 11 had illness consistent with case definition of severe sepsis and septic shock and rest 2 had acute liver failure. Though not statistically significant we observed that the two age groups (< 1 year and 11-14 year) had more likely to have severe form. There was male preponderance in both forms. Frequency of fever, body ache, arthralgia and vomiting were similar in both forms. Although not significant rash, bleeding manifestations and abdominal pain was more common in severe disease and seizures were more in non-severe form. Peripheral cyanosis along with mottling of skin was significantly higher in severe disease (76.9% vs 5.5%; p- 0.00). Values of haemoglobin, platelet counts, serum urea, creatinine and alanine and aspartate transaminase were similar. Total leukocyte count was higher in severe form (median 11200 vs 8195) although not significant. The serum albumin was significantly low in severe form (3 vs 3.75g/dl). Median PT, INR and aPTT in severe form were 22.3s (18.5-117), 1.77(1.3-12.4) and 41.7s (27-247) respectively. Hospital days were significantly high in severe form (5 vs 3, p-0.0015). In the severe form, 23% required mechanical ventilation and 84.6% required inotropic support. One, 2 and 3 vasoactive agents were used in 6, 3 and 2 children respectively. Dopamine was used in 8 followed by dobutamine in 5, and epinephrine and norepinephrine in 2 cases each. Median duration of inotropic support was 56 hours(31-114hours) and median Vasoactive Inotropic Score (VIS) in first 24 hours was 10(5-90). VIS score of >20 was seen in two cases. Mean pH, lactate and mixed venous saturation was 7.26, 5.1mmol/L, was 55%. respectively. Two children also had multiorgan failure and one expired. Out of 2 ALF cases one had stage III and another had stage II hepatic encephalopathy. One of these had coinfection with dengue virus and another hepatitis E virus. Conclusion : Although chikungunya usually has a mild course, severe life-threatening complications can develop during the acute phase of the disease. In our study, none of the septic shock patients had another organism identified as a potential cause of sepsis. This finding strongly suggests chikungunya virus can cause severe sepsis and septic shock in children. Although we observed two age groups as risk factors for severe forms further, studies are required especially in paediatric population.

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Background : The oxygen support forms the cornerstone in the management of sick children. Though there are various modalities to provide oxygen, High flow oxygen devices are commonly used in very sick children. If children are not improving with High flow oxygen therapy, the respiratory support will be escalated to invasive ventilation. This scenario have changed a lot in the past two decades because of the increased and prompt usage of Heated Humidified High Flow Nasal cannula therapy (HHHFNC) and Non-Invasive ventilation (NIV). Methods : We conducted a retrospective study on the profile of patients who received HHHFNC therapy and NIV as a primary mode of respiratory support over a period of 22 months (October 2015 — July 2017). Patients who received HHHFNC/ NIV as a weaning mode are excluded. The patient’s details are obtained from the Medical Record Department and charted in a standardized proforma. Results : During our study period, 1388 children were admitted in PICU, among which 375 (27 %) required HHHFNC therapy and 149 (11 %) required NIV therapy as primary mode of respiratory support. Pneumonia, Bronchiolitis, and asthma are the predominant causes (28%) for which HHHFNC /NIV was provided. In HHHFNC group, 60% (224 out of 375) were successfully treated with HHHFNC, while remaining 40% (150 out of 375) required escalation of respiratory support to either NIV or Invasive ventilation. In the NIV group (n=149), 82(55%) received Mask NIV, two received Nasal pillow and 65 (44%) received Nasopharyngeal CPAP (NP CPAP). In the NIV group, 50% (75 out of 149) improved with NIV and the remaining 50% required escalation to Invasive ventilation. In both the groups, the escalation of respiratory support happened predominantly within 24 hours of starting the HHHFNC /NIV. Conclusion : The early and prompt usage of HHHFNC and NIV as a primary respiratory support had effectively decreased the need for Invasive ventilation in children admitted in PICU, thereby decreasing the morbidity associated with the invasive ventilation.

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Background : Fever after acute brain injury adversely affect neuronal function and recovery. Aggressive fever control measures are recommended for patients with acute neurocritical illnesses. Standard therapies including Paracetamol, fan and application of ice are commonly used but may not be very effective to control hyperthermia in this population. They may have an unpredictable response in terms of time taken to cool, target temperature reached and the rate of rewarming when stopped. External active surface cooling systems are not commonly used for temperature control in Indian PICUs. The current study was conducted to study the safety and efficacy of a cooling blanket as an external surface cooling device in this population. Methods : All children admitted to the PICU with acute brain injury requiring temperature control were included. Children admitted to our hospital more than 120 hours after a cardiac arrest or any other indication for neuro-protection, and those declared brain dead were excluded. Data were collected retrospectively in the pre-intervention group from July 2015 to June 2016. Data were collected prospectively for the intervention group from July 2016 to June 2017, after implementation of the targeted temperature control protocol. We collected data about temperature and use of temperature control therapies in both groups. In the pre-intervention period, cooling therapies were limited to use of Paracetamol, application of ice and fans. The intervention protocol included these therapies and use of a cooling blanket for 72-120 hours after hospital admission or the brain injury event, whichever was earlier. Results : Sixty-eight children were enrolled in the study. Of these, 38 were in the pre-intervention period and 30 in the intervention period. Out of 68 children, 46 (67.6%) had hyperthermia. Of these only 17 (37%) had a proven infectious cause of fever. In pre-intervention group, 34.2 % of children were normo-thermic and did not require any cooling. Mean time spent outside targeted temperature range was 5.6% (5.5% in hyperthermia and 0.1% in hypothermia) of the total Targeted Temperature period. In the intervention group, 26.2% of children were normo-thermic and did not require cooling. Mean time spent outside targeted temperature range was 2.5% (2.1% in hyperthermia and 0.4% in hypothermia). Conclusion : The incidence of hyperthermia in children requiring neuroprotection was high in this study, and only 1/3 had an identifiable infectious cause. The time spent outside targeted temperature range was greater in the pre-intervention group compared to the intervention group. Using a targeted temperature control protocol with a cooling blanket decreased the time spent outside the desired temperature range by 50%. No adverse events were noted with cooling blanket.

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Background : The use of ECMO in the recent times has been increasing significantly. According to one source, there are more than 54 centres doing ECMO with more than 600 cases per year. Still data reporting is a problem. ECMO Society of India has been making efforts to collect the data and conduct training programs on regular basis. With the initiation of Pediatric critical care wing of Indian Academy of Pediatrics, a new initiative called INSPIRE has been much helpful in collecting data from all those doing Pediatric and neonatal ECMO in India.A standard Data sheet was filled by all participating centres collecting following: demographic data, PRISM III score, indication of ECMO ,respiratory or cardiac,VV or VA,diagnosis ,duration of ventilation,duration of ECMO,Survival from ECMO ,survival to discharge,complications if any.Preliminary data as of feb2017 for past three years is collated and presented in this abstract. Our expectations in near future include streamlining training programs, Integration, Simulation, reporting and sharing information and dealing with tropical problems. Thorough understanding and practice of ECMO will help in bringing the costs of the equipment down with innovations and developing support to work together. Table 1 Pediatric Respiratory ECMO Institution Total no(52) survivors(21)40% Apollo childrens,Chennai 11--------------8 Apollo Indrapastha,Delhi 1---------------0 BLKsuperspeciality,Delhi 3---------------1 KIMS Hyderabad 11--------------1 KB Ambani 5---------------1 Ridhivinayak, Hinduja hospital 9------------5 Fortis MRI Gurgaon 1...............0 SGRH ,Delhi 10..............5 Medantamedicity Gurgaon 1...............0 Table2 Pediatric cardiac ECMO Institution Number(34) survivors(25) 73.5% Apollo childrenschennai 1----------------1 BLK,Delhi 1----------------1 JayPee,Noida 2----------------1 Kb ambani,Mumbai 21---------------16 KIMs hyderabad 3----------------1 Narayan hrudalaya,bengaluru 1----------------1 SPS Ludhiana 1----------------1 Medantamedicity Gurgaon 4....................3 INSPIRED(Indian network of Specialist Pediatric intensivists for research Education and data) Participating institutions(in alphabetical order)

1. Apollo childrens hospital, Chennai Indira jayakumar, Rajeshwari, Suchitraranjit
2. BLK Superspecialityhospital,Delhi Praveen Khilnani, Rachna Sharma, Ajay Kaul, Naresh Lal
3. Fortis memorial research institute, Gurgaon Vikas Taneja, Krishanchugh
4. Indra prastha Apollo hospital, Delhi Nameet jerath, Anita Bakshi
5. Jaypee hospital, Noida, Vishal singh Rajesh Sharma
6. Krishna Institute of Medical sciences Hyderabad, Nanda Kishore, Suneel Pooboni
7. Kokilaben Ambani Hospital, Mumbai. Preetha Joshi, vinay Joshi, Rao
8. Medanta Medicity, Gurgaon, Maninder S Dhaliwal, Rajeshkumar Sharma
9. Narayana Hrudalya hospital, Bengaluru Abhijit Bagde, Anil kumar Sapare, Binoy Chattuparambil, Muralidhar Krishna
10. PD Hinduja hospital, Mumbai Soonu Udani, Rekha solomon
11. Ridhivinayak hospital, Mumbai Pranayoza,Venkat Goyal
12. Sir Ganga ram hospital, Delhi Anil sachdev, Dhiren Gupta, Raja Joshi
13. SPS Hospital, Ludhiana Mehal Bansal,Vikas Bansal

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Monitoring blood beta-hydroxybutyrate is essential in the diagnosis and management of pediatric diabetic-ketoacidosis. Point-of-care capillary beta-hydroxybutyrate testing requires further evaluation in monitoring ketonemia. Study design: Prospective observational analytical study. Setting: Division of Pediatric Critical Care, Department of Pediatrics, JIPMER in collaboration with the Department of Biochemistry, JIPMER from July 2015 to March 2017. Participants: 48 children

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Background : Gastroesophageal reflux (GER) is fairly common in children and mechanically ventilated children are at increased risk for the development of GER. Information on GER and development of ventilator associated pneumonia (VAP) is limited. Methods : A prospective observational cohort study was performed in mechanically ventilated children aged 1 year to 15 years within first 24 hrs of (initiation of mechanical ventilation) in Pediatric Intensive Care Unit (PICU), AIIMS using 24 hr esophageal pH metry and were followed up for 7 days for development of VAP using CDC criteria. Presence of GER was defined as fall in esophageal pH < 4 for more than 4% of total time . Results : A total of 61 patients (mean age (median): 73 (30-132), boys: 44 (72.1%), girls: 17 (27.9%)) were enrolled in the study. Total number of reflux episodes were 1855 and at least 1 episode of reflux was seen in 32 (52.46%) patients. As per definition of GER, 12 (19.7%) children had GER. Of the enrolled children, 17 (27.87%) patients developed VAP; 7 patients had VAP and at least 1 episode of acidic reflux however, no patient had both GER (as per definition) and VAP. Of 44 patients who did not develop VAP, at least 1 episode of reflux was seen in 25 patients while 12 patients (27.27%) had GER positive and 32 patients (72.72%) did not have GER. There was no correlation of age, sex, weight, mode of ventilation and PRISM score with GER. Conclusion : Acid reflux was common in ventilated patients but GER was less common and presence of acid reflux or GER did not increase the risk of development of ventilator associated pneumonia.

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Background : Sepsis in children is a noteworthy cause of morbidity and mortality all over the world. Given the crucial need to reduce the mortality from sepsis, conflicting results from adult studies and lack of high quality pediatric controlled study warrant a trial to examine the effectiveness of early goal directed therapy (EGDT) versus standard care in Indian patients. Methods : The trial was a prospective open labeled randomized controlled trial conducted from 1st July 2015 to 30th June 2017. All children from one month of age to 12 years with septic shock fulfilling the inclusion criteria were enrolled in the study. Eligible patients were randomized and allocated one of the two study groups (EGDT Group and standard care group). If the patient was assigned to EGDT, the EGDT protocol adapted from Rivers et al. was commenced by the treating team within one hour of enrollment. If the patient was assigned to standard care, no changes were made to the plan of the treating team. Results : The 110 patients were recruited from July 2015 to June 2017. Out of 110 patients, 54 patients were randomized to the EGDT group and 56 randomized to the standard care group. The trial had to be stopped after an interim analysis by the independent data monitoring committee indicated the futility of the study. The overall all-cause mortality at 28 days of the study population was 53.6%. Children in the EGDT group had 46.3% mortality while children in the standard care group had 60.7% mortality (p=0.13). There was 14.4% absolute risk reduction of mortality in the EGDT group. There was no difference in any secondary outcome regarding the proportion of patients achieving therapeutic end points at 6 hours, use and duration of organ support, SOFA and PeLOD score and length of PICU and hospital stay. Conclusion : Our study suggests that the implementation of the early goal directed therapy (EGDT) by the addition of intermittent ScvO2 monitoring and protocolized management did not improve mortality in the EGDT group compared to standard care group. The implementation of EGDT needed the greater intensity of treatment in the form of inotrope and packed RBCs transfusion requirement.

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Background : Diabetes ketoacidosis (DKA) is a severe complication of diabetes in children. Acute kidney injury (AKI) is one of the factors which has shown to increase the mortality and morbidity in sick children. As DKA is associated with both volume depletion and conservative fluid administration, these children are potentially at high risk for AKI. There is paucity of literature on AKI in paediatric DKA patient, hence we conducted this study to analyse the clinical profile of paediatric DKA patients with AKI Methods : We conducted a retrospective audit on patient admitted with DKA in PICU from March 2008 to February 2017. Inclusion Criteria: All paediatric cases hospitalised in PICU with DKA (blood glucose = 200 mg/dl, pH = 7.3, Bicarbonate level = 15mEq/L, and elevation of urine Ketone.) with AKI. Primary variable, AKI is defined by pRIFLE criteria. Estimated creatinine clearance (eCCl) is calculated by the Schwartz formula. For baseline eCCl, the patient is assumed to have normal renal function and assigned a baseline eCCl of 120 mL/min/1.73 m2. Exclusion criteria: Incomplete medical documentation and underlying any kidney disease Results : Among the 190 DKA patients admitted during the study period, 43 patient fulfilled inclusion criteria. Twenty children were excluded due to incomplete documentation and remaining 23 were analysed. In our study mean age of patient was 12.7 years with female preponderance 65.22% (n=15). Among 23 patient with AKI, 16 (69.57%) was newly diagnosed. Out of 23 patient 20 had AKI at admission and remaining 3 patients developed AKI during the course of hospital stay. According to pRIFLE criteria at Admission, 7 had RISK, 5 had INJURY and 8 had FAILURE. Four patient required renal replacement therapy, in the form of peritoneal dialysis (n=2) or Haemodialysis (n=2). In our study, 65.22% (n=15) patient discharged with complete recovery of AKI, 21.74% (n=5) patient discharge with persistent AKI and 13.04% (n=3) patient died. Among the 5 patient who were discharged with persistent AKI, 80 %( n=4) had FAILURE stage (pRIFLE criteria) at admission. Conclusion : Patient with DKA is prone for AKI due to many factors like volume depletion state, hyperchloremia etc. The severity of renal dysfunction at admission plays significant role in the outcome of the DKA patients. Hence early recognition of AKI and appropriate management improves the mortality and morbidity in DKA patients.

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Background : Septic shock is associated with complex pathophysiology and hence the consequential challenges in clinical management. . Traditional clinical examination would help in diagnosis of shock but has limitations in optimizing fluid and vasoactive therapy as two or more pathophysiological components may co exist.. Intervention of one component can be detrimental on the other if not appropriately diagnosed. Several monitoring tools are available but every tool has its own limitations. Methods : We conducted a prospective observational blinded study in our mixed 12 bedded Pediatric Intensive care unit of a tertiary-referral teaching children’s hospital in Chennai, India. Children with unresolved shock despite 30 ml/kg fluid were evaluated by eMMM[including clinical examination, invasive monitoring, focused cardio-respiratory imaging (CRI) and ultrasound cardiac-output monitor(USCOM)]. The therapeutic plan based on clinical exam was compared to decisions following eMMM. The final decision regarding further fluids, inotropes and pressorswas based on the presence of at least 2 eMMM parameters demonstrating fluid responsiveness (in absence of fluid intolerance), abnormal cardiac function or reduced SVR respectively. Results : Regarding fluid, 26/32(81%) would have received fluid based on clinical examination, but only 6 finally received additional fluid following eMMM. Inotropy based on echocardiography/ USCOM was administered in 20(62%) patients;however, clinically only 7 patients had suspected myocardial dysfunction. SVRI was low in 21(65.5%)patients warranting pressors which was clinically obvious only in 7(21% ) based on the presence of warm shock. Early diuretics (within 24 hrs) were commenced in the presence of large number of B lines in 30% children. Conclusion : Benefits of eMMM in septic shock included precise titration of inotropes and pressors in unresolved shock, where clinical exam was unreliable. Additional important advantages included greatly minimized fluid overload, both by limiting administration and early removal. USCOM provided value addition principally to identify low SVR and titrate early pressors, which not only improved SVRI but also improved preload and inotropy.

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Background : Medical tubing like ventilator endotracheal tubes ETT) contain several phthalate plasticizers in the polyvinyl chloride (PVC) matrix. Several phthalates are known for their human toxicities, but the effect of these in ventilator conditions are not studied. Methods : Medical grade ETT tubes were subjected to simulated ventilator conditions in vitro. The effluents were analyzed by mass spectrometry to identify specific phthalates. The toxicities of the effluent phthalates were analyzed by targeted metabolomics. Results : We determined biologically active levels of phthalates including diisononyl phthalate (DINP), Di-2- ethylhexyl phthalate (DEHP), and methyl ethylhexyl phthalate (MEHP), in ETT effluent fluids. Although these pthalates did not ellicit short-term acute pathologies, systematic global metabolomics of human lung cells incubated with pthalates in vitro revealed these phthalates modulate at least 12 discrete metabolic pathways including amino acid metabolism, energy metabolism and Th2 phenotype in immune cells. Conclusion : ETT- phthalates may present clinically relevant toxicities on patients under long term mechanical ventilation.

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Background : Ventilator Associated Pneumonia (VAP) continues to be one of the most significant causes of mortality and morbidity in pediatric ICUs. The infection is mediated by pathogenic biofilms on endotracheal tubes (ETT). These biofilms exhibit significant antimicrobial resistance and unique mechanisms of pathogenesis which are poorly understood and extremely difficult to treat. Methods : ETTs from VAP patients and uninfected controls were subjected to mult-point analyses. The etiological agents were isolated and biofilms cultured on ETT in vitro. These biofilms and VAP-ETT were analyzed by scanning electron microscopy, antibiotic sensitivity assays and expression of pathogenic protease(s). The pathogenecity of the biofilms were examined on human lung epithelial cells lines in vitro on the A549 cell-line model. Results : Biofilms of potent VAP pathogens like Pseudomonas aeruginosa form sophisticated, highly structured communities on regular ETT under typical ventilator conditions. These biofilms exhibit >100 fold resistance against conventional antibiotics than their planktonic counterparts. Mature ETT biofilms lead to turbulent flow in the ventilator with risk for occlusion, release quorum regulated proteases and other pathogenic factors that lead to profound toxicity on human lung epithelial cells. Conclusion : Bacterial biofilms present a potent mechanisms of pathogenesis in VAP that are little explored and important to treat pediatric VAP. Anti-biofilm strategies in VAP management need to be explored.

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Background : Renal angina index (RAI) is a clinical guide that identifies patients at high risk for acute kidney injury(AKI) by integrating baseline, contextual and clinical evidence of renal injury. It may serve well to optimize biomarker utility. Methods : We performed a prospective observational study of 285 critically ill children aged 1 month to 18 years and followed them up for a minimum duration of 7 days to 28 days with daily documentation of fluid overload, creatinine values, need for renal replacement therapy(RRT), total duration of mechanical ventilation and hospital stay. RAI score of 8 or more was considered as fulfillment of renal angina. Results : Incidence rate for a Day 0 RAI of 8 or more was 49.4% and Day-3 AKI was 10.2%. Day-3 AKI rates were higher in patients with an RAI of 8 or more with the area under the curve of RAI for predicting Day-3 and Day-7 AKI of 0.815 and 0.727 respectively. An RAI under 8 had high negative predictive values (96.5%) for Day-3 AKI. RAI outperformed traditional markers of pediatric severity of illness (Pediatric Index of Mortality-II) for prediction of Day-3 AKI. Additionally, the RAI outperformed all Kidney diseases improving global outcomes (KDIGO) stages for prediction of Day-3 AKI. Conclusion : Renal angina index can predict development of subsequent severe AKI. Fulfillment of renal angina was associated with longer hospital stay, higher mortality, longer duration of mechanical ventilation and higher need for renal replacement therapy.

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Background : Hemodynamic shock is a life-threatening yet reversible condition in children admitted to ICU. Early detection of shock can prevent the cascading sequelae of secondary organ failure. While existing literature reports Shock Index as a reliable indicator of shock, this requires accurate measurement of Heart Rate and Blood Pressure. A non-contact, non-invasive method for shock detection is highly desirable, especially for pediatric and neonatal age groups. Imaging is an underutilized modality and literature-evidence exists for computational extraction of heart rate from head-bobbing and forehead-flushing from normal videos. However, heart rate alone is not a reliable indicator of shock, and other physiological markers of shock such as centre-to-periphery difference (CPD) of temperature in body surface temperature are underexplored. Methods : The study was conducted between September 2016 and February- April 2017 in the PICU of a tertiary care hospital in India. Images were recorded using an affordable commercial device- Seek Compact Thermal Imager for Android [Seek Thermal Inc., CA, USA)] attached to an android phone. A standard operating procedure was followed for recording the images to minimize the device, patient or environmental factors. CPD was manually extracted by 3 independent annotators using FIJI, an image processing software platform. Shock index adjusted by age was computationally extracted from the continuous BP, Heart Rate and patient age stored in the SAFE-ICU warehouse, the first Big-data resource for PICU in India. Age-specific thresholds for shock index were used to label patients into positive/negative classes. The predictors were checked for assumption of normality and Generalised Linear Mixed Effects Models using Penalized Quasi-Likelihood were constructed to account for the longitudinal structure and non-normal distribution of data. Results : 307 images from 62 patients were used for the study (34 males, 28 females, age range = 0.2 - 144 months). Since CPD were non-normally distributed (and negative in some cases), log-transformation could not be applied. Hence, a Penalized Quasi- likelihood approach to General Linear Mixed Effects models was taken. Data were randomly partitioned into 10-fold 75% training and 25% testing sets. CPD was found to be a statistically significant predictor of thresholded and age-adjusted shock- index (p-value < 0.005) and with a positive coefficient (0.023), thus, indicating that a positive CPD is an important indicator of higher shock index. Model prediction on the testing set showed an accuracy of 79 ± 0.04% (AUC = 83 ± 0.06%, sensitivity = 0.73±0.09, specificity = 0.83±0.04). Conclusion : Computational modeling upon thermal imaging is a potentially useful method for non-contact detection of shock in children. Since our model required only age and manual identification of abdomen and foot in the thermal image, our method is potentially applicable in tele-diagnostic settings for detection of shock in the community, in the absence of domain experts through the application of computational models.

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Background : Aneurysm in the extracranial segment of internal carotid artery is extremely rare in the pediatric age group. They can assume large size and have catastrophic complications of thromboembolism and hemorrhage. We present a 12 year old child with recurrent oropharyngeal hemorrhage leading to massive hematemesis and shock. A distal embolism causing malignant ipsilateral cerebral infarct further complicated the management options. He was treated with an emergency placement of stent within the artery to exclude the flow in the pseudo aneurysm. A right decompressive craniectomy was performed to control the raised intra-cranial pressure secondary to malignant cerebral infarction. The tentorial herniation was relieved in the follow up CT scan of the brain and the child made progressive recovery with residual paralysis of the left side. Aim of our case report is to increase awareness and inclusion of this rare pathology in the differential diagnosis of oropharyngeal hemorrhage which would facilitate the early diagnosis and prevent devastating complications.

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Background : Triple A syndrome (All grove syndrome) is a rare autosomal recessive disorder characterized by the clinical triads of adrenal insufficiency, achalasia cardia and alacrima.It was first described by Allgrove in 1978 but in 1995, it was diagnosed as a syndrome with variable association of autonomic and neurological manifestations. This disorder manifests in the early childhood with life threatening complications like severe hypoglycemia, shock and recurrent infection.The syndrome usually presents during the first decade of life with dysphagia, while other signs may be delayed until adulthood. The onset of adrenocortical Impairment is usually before puberty. We present 13 years old boy with chronic recurrent sinusitis with failure to thrive without lacrimation since birth who has presented pneumonia, septic shock, and acute meningoencephalitis with adrenal insufficiency. He had all three cardinal features and underwent cardiomyotomy and was started on oral hydrocortisone replacement therapy. He recovered well and gaining weight now. Catastrophic complications can be prevented with adequate cortisol and specific measures such as cardiac pneumatic dilatation or myotomy along with other supportive management. The prognosis for health and quality of life can be significantly improved by early diagnosis and treatment.

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Background : For almost half a century,most of the Paediatricians around the world were using hypotonic solution(0.2% saline in 5% dextrose) for maintenance fluids according to the guidelines set by Holliday and Segar .The wisdom of this approach has been questioned recently, especially in the hospitalised children who have various osmotic and non-osmotic stimuli for vasopressin release, leading to clinically symptomatic hyponatremia.We hypothesized that use of isotonic maintenance fluid (0.9% saline in 5% dextrose) would be more safer than hypotonic fluid (0.14% saline in 5% dextrose) in sick children at standard maintenance rate. Methods : This open-labelled randomized controlled trial was conducted on 125 admitted children of secondary care hospital,in the age group of 0.6 to 12 years who were anticipated to receive maintenance intravenous fluid for first 24 hours.63 were randomized to receive isotonic fluid(0.9% saline in 5% dextrose) and 62 for hypotonic fluid(0.14% saline in 5% dextrose)at standard maintenance rate by computer generated tables.Baseline investigation,serum sodium,serum potassium,blood sugar,renal function tests and those relevant to the patient illness were done. Serum osmolality was calculated at the time of enrolment and after 24 hours.Serum sodium was repeated after 24 hours of intravenous fluid therapy. All enrolled patients were monitored for signs and symptoms of sodium imbalance,signs of dehydration during first 24 hours. Results : Baseline variables were comparable in two groups. Hyponatremia at 24 hours was seen in 11(17.4%)patients in isotonic and in 29(47%)patients of hypotonic group (P=0.02).The odds ratio for developing hyponatremia in hypotonic group was 4.32(95%CI: 1.89, 9.90)as compared to isotonic group.There were 25 patients (59.5%) of respiratory tract illness who developed hyponatremia in hypotonic group as compared to 6 patients (13.9%)of isotonic group (P=0.001).At 24 hours,both mean serum sodium and mean serum osmolality were significantly lower in hypotonic group as (P=0.002) and (P=0.001) respectively Conclusion : To conclude,the type of fluid is important in deciding the incidence of hyponatremia in hospitalized children.Among the fluids,isotonic fluids are safer choice than the traditional hypotonic fluids in hospitalized children requiring maintenance fluid therapy.

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Background : Maintenance intravenous fluids are most commonly necessary in hospitalised children who cannot be fed by enteral route,preoperative and postoperative patients.For almost half a century,most of the Paediatricians around the world were using hypotonic solution(0.2% saline in 5% dextrose) for maintenance fluids according to the guidelines set by Holliday and Segar . The wisdom of this approach to intravenous fluid therapy has been questioned recently ,especially in the hospitalised children who have various osmotic and non-osmotic stimuli for vasopressin release, leading to impaired ability to excrete free water along with secondary natriuresis due to suppression of aldosterone release ,thereby increasing the probability of developing clinically symptomatic hyponatremia.We hypothesized that use of isotonic maintenance fluid (0.9% saline in 5% dextrose) would be more safer than hypotonic fluid (0.14% saline in 5% dextrose) in decreasing the incidence of hospital acquired hyponatremia in the sick children at standard maintenance rate. Methods : This open-labelled randomized controlled trial was conducted in the Paediatric emergency of a secondary care hospital.Children in the age group of 0.6 to 12 years who were admitted and anticipated to receive maintenance intravenous fluid for 24 hours were included into the study.Written informed consent was obtained from the parent or guardian of all the patients before participation in the trial.The study protocol was approved by the Institute Ethics Committee.Children with baseline hyponatremia (serum sodium < 135 mEq/L),hypernatremia(serum sodium >145 mEq/L),neurological disorders,acute diarrhoea and dehydration,shock,head trauma,severe acute malnutritrion,those with pre-existing chronic diseases,diabetic ketoacidosis and suspected poisoning were excluded.Children with fluid overload conditions(like cirrhosis, congestive heart failure,acute and chronic renal failure and nephrotic syndrome)or receiving drugs like diuretics,mannitol,vasopressin, carbamazepine which can cause abnormality in the serum sodium were also excluded.Based on findings of Montanana et al,which showed the incidence of hyponatremia in hypotonic group to be 20.6% and in the isotonic group to be 5.1%,with power of 80% and applying 95%confidence interval,a sample size of 125 patients was calculated by web based power/sample size calculator,out of which 63 were randomized to receive isotonic fluid(0.9% saline in 5% dextrose) and 62 for hypotonic fluid(0.14% saline in 5% dextrose)at standard maintenance rate.Both fluids had potassium in the concentration of 20 mEq/L.Randomisation was done by computer generated random number tables. The allocated intervention was kept in sequentially labelled sealed envelopes and was opened after enrolment of the patient.Baseline demographic, hemodynamic characteristics and level of consciousness were noted at presentation.Level of consciousness,heart rate,respiratory rate,blood pressure andSpO2 were monitored every 6 hourly for first 24 hours of admission.Baseline investigations like complete blood counts,serum sodium,serum potassium,blood sugar,renal function tests and those relevant to the patient illness were done. Serum osmolality was calculated at the time of enrolment and after 24 hours by the formula:Serum osmolality=(2 × serum sodium) + (blood sugar/18) + (blood urea/2.8).Serum sodium was repeated after 24 hours of intravenous fluid therapy. All enrolled patients were monitored for signs and symptoms of sodium imbalance,signs of dehydration during first 24 hours. Results : Baseline variables were comparable in two groups. Hyponatremia at 24 hours was seen in 11(17.4%)patients in isotonic and in 29(47%)patients of hypotonic group (P=0.02).The odds ratio for developing hyponatremia in hypotonic group was 4.32(95%CI: 1.89, 9.90)as compared to isotonic group.There were 25 patients (59.5%) of respiratory tract illness who developed hyponatremia in hypotonic group as compared to 6 patients (13.9%)of isotonic group (P=0.001).At 24 hours,both mean serum sodium and mean serum osmolality were significantly lower in hypotonic group as (P=0.002) and (P=0.001) respectively Conclusion : To conclude,the type of fluid is important in deciding the incidence of hyponatremia in hospitalized children. Among the fluids,isotonic fluids are safer choice than the traditional hypotonic fluids in hospitalized children requiring maintenance fluid therapy.Current clinical situations demand such a maintenance solution and volume which maintains tonicity and balance in acute illness,rather than one which merely provides a daily sodium or calorie requirement.

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Background : It is a prospective and retrospective observational study done in 150 children admitted to paediatric intensive care unit with thrombocytopenia. Clinical profile and outcomes of children with thrombocytopenia were studied.Platelet count done on 1st day and 4th day of admission were analyzed between survivors and non survivors .Platelet transfusion practices followed in PICU were studied Methods : It is a prospective and retrospective observational study done in 150 children admitted to paediatric intensive care unit with thrombocytopenia. Clinical profile and outcomes of children with thrombocytopenia were studied.Platelet count done on 1st day and 4th day of admission were analyzed between survivors and non survivors. Platelet transfusion practices followed in PICU were studied. Results : Among 150 childreninfection was most common cause of thrombocytopenia followed by sepsis. No statistical difference was noted in platelet count and platelet indices at admission among survivors and non survivors. Rise in platelet count among survivors and non survivors on 4th day of hospitalization was 79.1% and 15.9% respectively. Platelet transfusion trigger among children with and without bleeding manifestation 18500 (IQR 31000,14000) and 20500 (IQR 25750,11000) respectively. Conclusion : This study illustrates that failure of rise in platelet count on 4th day of admission was significantly associated with mortality. (p value .001).

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Background : Serious adverse reactions to ASV are common in India resulting in significant mortality and morbidity. Methods : A retrospective case review of all children admitted in the pediatric department of a tertiary care hospital from January 2013 to December 2016 was carried out. Clinical presentation of snake envenomation and reactions to ASV were studied. Results : During the study period, 68 children received ASV. Hemotoxic (52.9%) envenomation was more common than neurotoxic (35.2%). Major adverse reactions were present in 42.6% of patients, hypotension in 38.2% and bronchospasm in 4.4% of the children. Adrenaline premedication was administered in 91.17% of children before ASV . Mortality rate was 16.1% with 11 deaths, out of which 4 (36.3%) deaths were directly attributed to anaphylaxis resulting from ASV. All the deaths were in cases of hemotoxic snake envenomation. Mortality was significantly higher in cases with major adverse reactions (p=0.005). Only risk factor for ASV reaction identified was the year of admission, with higher rates observed in those admitted before January 2016. Conclusion : There is a high frequency of occurrence of severe adverse reactions (42.6%) to ASV resulting in significant morbidity and mortality.

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Background : Hemophagocytic Lymphohistiocytosis (HLH) is a life-threatening syndrome of immune dysregulation leading to excessive cytokine production and multi-organ dysfunction. The Incidence of HLH varies between 1 per 5,000 to 1 per 1,00,000 in different studies. Diagnosis of HLH requires high suspicion as severe sepsis with organ dysfunction is a close differential. Differentiation of primary & secondary HLH is also difficult. Early recognition is very important for the timely institution of the treatment Methods : We conducted a retrospective analysis of children admitted to the PICU between January 2007 to July 2017 who were diagnosed to have HLH using HLH-2004 criteria. Demographic, clinical & laboratory parameters, treatment details & outcomes were recorded. Outcomes of secondary HLH treated with cytotoxic chemotherapy were compared with those treated with immuno-modulatory therapy alone. Results : Out of 6678 children admitted to the PICU during the study period, 47 were diagnosed with HLH. Ten children had primary HLH and 37 had secondary HLH. Forty two (89%) children had fever, 40 (85%) splenomegaly, 43 (91%) bicytopenia, 45 (95%) hyperferritinemia, 41 (87%) hemophagocytosis in the bone marrow, 44 (93%) low fibrinogen levels and 32 (68%) had high triglyceride levels. Among those with primary HLH, 6 were familial and 4 were immunodeficiency related. Mutation analysis by next generation sequencing was positive in 2 children with familial HLH. In our analysis, the different aetiologies for secondary HLH were Dengue (12 patients), Epstein Barr Virus (6 patients), Scrub typhus, Staphylococcus aureus, Sphingomonas, Typhoid and Adenovirus (each 1 patient) and the rest (14 patients) had culture negative sepsis. The overall PICU mortality rate was 55.3%. Mortality rate of primary HLH was 80% when compared to 48.6% in secondary HLH. In children with secondary HLH, 14 were treated with corticosteroids & Intravenous Immune Globulin (IVIG) only (immune-modulatory therapy group) and the remaining 27 children received Steroids, Etoposide, Cyclosporine +/- IVIG (Cytotoxic chemotherapy group). Mortality was higher in children with secondary HLH who received cytotoxic chemotherapy (52%) when compared to immunomodulatory therapy (28%) alone. Conclusion : The incidence of HLH in this population of critically ill children (7/1000) is higher than those reported elsewhere. Secondary HLH was more common than primary. Outcomes of secondary HLH were better in those treated with Immunomodulatory therapy alone.

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Background : Increased intracranial pressure (ICP), also known as intracranial hypertension is defined as cerebrospinal fluid (CSF) pressure = 20 mm Hg. It is a common neurological emergency seen in children with a wide variety of underlying etiologies such as brain tumors, obstructive hydrocephalus, posttraumatic intracranial hemorrhage, meningoencephalitis, and toxic encephalitis [1,2]. If left untreated, it can produce adverse and often irreversible neurological consequences and damage the brain through compression of its structures or restriction of its blood flow. Hence, early identification of elevated ICP is critical to ensuring timely and appropriate management [3].Evaluation in critically ill patients requires complicated procedures, creating a need for rapid diagnosis and treatment of these patients along with frequent re-evaluation of raised ICP [1,4-6]. The current standard of care for diagnosing raised ICP is invasive which involves intracranial placement of a monitoring device. The ideal ICP monitor would therefore be non-invasive, portable, easy to use, cost effective and allow for continuous monitoring.There has been a longstanding quest for a reliable, non-invasive technique to assess ICP.The opportunity to make the diagnosis of raised ICP earlier using an appropriate non-invasive technique, makes the applicability of such a method broader than just neurocritical care patients. The accessible, natural bony windows in the human skull, i.e. orbit, auditory canal and AF (neonates), can potentially allow access to important information about the brain and ICP, making transorbital ultrasound measurement of the optic nerve sheath diameter (ONSD) as a surrogate marker of raised ICP [11-22]. The direct cerebrospinal fluid (CSF) connection between the peri-optic and intracranial subarachnoid spaces, makes this technique a particularly appealing option for assessing ICP [23]. The favourable acoustic properties and superficial anatomical location of the eye, make transorbital sonographic assessment of the optic nerve sheath (ONS) very suitable, futher enhancing its use. The region of the ONS located 3mm posterior to the lamina cribrosa of the retina is considered the most distensible and is recommended as the most consistent region to acquire the ONSD measurement [24]. Changes in the ONSD can be visualized using images from ultrasound, MRI and CT scans. Several studies have demonstrated a strong association between distension of the ONSD and an increase in ICP [13,14,25,26-28]. It should also be noted that, with RICP, the optic nerve diameter increases initially, later leading to papilledema, so transorbital sonography is able to show the increased ICP earlier than ophthalmoscopy. Methods : The optic nerve diameter was measured by transorbital sonography in transverse view, 3 mm posterior to the papilla in both eyes, and the mean was calculated. Two groups were examined: a control group (children with normal ICP) and a case group (increased ICP as clinically suspected and later confirmed by an alternative method). Results : In a sample of 100 children, 50 (50%) belonged to case group and 50 (50%) to control group. 68 subjects (68%) were male, and 32(32%) were female. The mean ± SD ages were 8.82 ± 4.23 years in the case group and 9.16 ± 3.86 years in the control group. The mean optic nerve diameters were 4.40 ± 0.97 mm in the case group and 2.35 ± 0.27 mm in the control group. The difference in the means was significant (P <0.05) Conclusion : Optic nerve diameter, measured by transorbital sonography, was significantly greater in patients with increased ICP compared with control group. The evaluation of the optic nerve sheath diameter is a simple non-invasive procedure, which is potentially useful in the assessment and monitoring of children suspected of having raised intracranial pressure.

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Background : Mumps is an acute contagious viral illness. Mumps Meningoencephalitis usually develops at least 3-10 days after mumps parotitis. Hydrocephalus secondary to aqueductal stenosis following a mumps meningoencephalitis is an extremely rare occurrence. The present case report is case of a hydrocephalus due to aqueductal stenosis as a consequence of mumps meningoencephalitis presented with respiratory failure & recovered fully after surgical intervention. Methods : Case description:A 10year-old girl was admitted with the complaints of fever, swelling in submandibular region for 3 days followed by headache, vomiting, altered sensorium for 3 days & posturing with loss of consciousness since 1 day. The child had not received MMR vaccination& history of a recent infection with mumps was present. Examination revealed a pulse of 86/min, respiratory rate of 20/min, blood pressure of 139/54 mm of Hg & spo2: 99%. Examination of CNS revealed a GCS 8/15 (E2V1M5), pupil middilated, sluggishly reacting , increased muscle tone, brisk deep tendon reflexes in all limbs with extensor plantar reflex & other systems was unremarkable. CSF cytology revealed 110 cells,lymphocyte 90%; sugar of 77 mg/dl, and protein of 54 mg/dl. Blood culture and CSF culture were sterile.Mantoux’s test, tuberculosis CSFPCR were negative. Blood investigations for malaria ,scrub typhus, mycoplasma & EBVVCA IgM were negative.Csf PCR for mumps was positive. CSF PCR for Enterovirus were negative .X-ray chest was normal. MRI of the brain revealed partial obstruction at cerebral aqueduct with proximal dilatation of 3rd &lateral ventricle with periventricular edema & no enhancement.On admission cerebral decongestive therapy( hypertonic saline ) was given. Patient managed with supportive care ,however, patient GCS deteriorated (GCS6/15) ,developed decerebrate posturing, bradycardia & jerky breathing on 2nd day of admission. Patient intubated ,ventilated & brief hyperventilation done. Emergency EVD done, Post EVD sensorium improved & signs of raised intracranial pressure decreased.EVD followed by right VP shunt, patient improved markedly and weaned from ventilator.The patient is doing well on follow up. Results : Case report Conclusion : Discussion:Mumps is usually an acute self-limited viral infection.Mumps meningoencephalitis usually follows after 3-10 days of a mumps parotitis . Acute hydrocephalus following mumps meningoencephalitis is very rare. The development of hydrocephalus due to aqueductal stenosis may occur after 1 day to 19 years following onset of mumps encephalitis. However, in our case, aqueductal stenosis developed within a week after onset of mumps infection. It is most commonly seen in children aged 5-9 years.In absence of successful viral culture, serological markers provide a definitive diagnosis. The serological confirmation is based on detection of virus-specific IgM antibodies measured by enzyme linked immune sorbent assay (ELISA) at an optimal time interval of 7-10 days after the onset of symptom. In our case, the diagnosis of mumps meningoencephalitis was confirmed by Mumps PCR done in CSF sample. Ventriculoperitoneal and ventriculoatrial shunt are the treatment of choice in acute cases. Percutaneous ventriculostomy from the third ventricle is another treatment modality. Our case responded well to the Emergency EVD followed by shunt surgery and is doing well on follow up.Thus, it is concluded that mumps meningoencephalitis is usually a self-limited infection, but may rarely develop serious and fatal complications.

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Background : Spectrum of Epstein Barr virus (EBV) associated central nervous system infection in children is not fully recognized. Methods : In a prospective cohort study conducted at a tertiary care teaching institute of North India consecutive children with acute febrile encephalopathy were enrolled. Clinical details, etiology, investigations and outcome were recorded. For etiological evaluation cerebrospinal fluid (CSF) multiplex PCR for viral and bacterial agents was done. Children with positive EBV DNA PCR from CSF are presented in detail. Results : A total 330 children with acute febrile encephalopathy were enrolled during the study period from April 2012 to December 2015. Cerebrospinal fluid EBV DNA PCR was positive among 44 children. All these children were HIV negative. Clinical presentation was acute encephalitis in 33(75%), and aseptic meningitis in 11 (25%) children. Isolated EBV infection was present in 15(34.1%) and EBV with other infectious agent in 29(65.9%) children. Co-infectious agent included other viruses in 18(41%) and bacteria in 11(25%) children. The clinical characteristics of children with isolated EBV infection were similar. Children with EBV and bacterial coinfections had significantly elevated CSF protein and hypoglycorrhachia (p<0.01). Children with EBV and other virus coinfection had poor neurological outcome, 66.7% were left with neurological sequelae. Conclusion : EBV is an important yet less recognized cause of acute febrile encephalopathy in children. It can present with acute encephalitis or acute meningitis in immunocompetent children. An EBV co-infection with other bacterial and viral pathogens is commoner than isolated EBV infection and possibly reflects reactivation of latent virus infection.

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Background : Acute respiratory diseases are common neonatal conditions leading to neonatal intensive care unit admissions (NICU). Noisy respiration with increased work of breathing, persistent need for respiratory assistance and persistent radiological opacities prompts evaluation by fibreoptic flexible bronchoscopy (FFB). FFB has several benefits in neonates, however, this modality is not widely used due to lack of expertise or non-availability of equipment. We present our 7 years of experience with neonatal FFB. Methods : A retrospective, medical chart search study was conducted at a tertiary care multispecialty hospital, in neonates who underwent FFB over a period of 7 years (2011-2017). Results : Total 88 bronchoscopies were performed in 83 neonates admitted in the NICU. Median birth weight and gestational age were 2600 grams (range 820- 3660) and 37 weeks (range 26-41). Median age at the time of FFB was 27.5 days (range 1-152). While 51 procedures were done transnasally, 37 bronchoscopies were done through endotracheal tube. Most common co-morbid condition noted was congenital heart diseases (20.4%). Indications included persistent oxygen requirement (32/88) lung collapse (21/88), stridor (27/88), extubation failure (4/88), recurrent apnea (2/88) and suspected airway anomaly (2/88). Tracheobronchitis (8/32) and tracheobronchomalacia (8/32) were the common findings in neonates with prolonged oxygen requirement. Most common cause of stridor in neonates was laryngomalacia (16/27) followed by subglottic stenosis (4/27). Myriad of congenital airway anomalies could be diagnosed by FFB including laryngomalacia (18/88) choanal atresia (4/88), laryngeal cleft (4/88), tracheoesophageal fistula (TEF) (4/88), and one each of pyriform stenosis, laryngeal web, vocal cord paresis, absent tracheal ring and complete tracheal rings. Radiological improvement was seen in 17/21 (80.9%) cases of lung collapse after FFB. Bronchoalveolar lavage was done in 52 procedures, and microbiological yield was obtained in 16 (30.7%). Change in medical management by either, adding systemic steroids or changing antibiotics, after FFB was done in 35/88 occasions. Surgical intervention were undertaken in 15 cases (17%), including tracheostomies (9/15), TEF repair (4/15), lateralization of vocal cord (1/15), excision of laryngeal web (1/15). Transient hypoxemia was seen in (4/88) occasions while 83/88 cases did not suffer any complications. Conclusion : Airway anomalies are common in newborns and their early detection by FFB can be beneficial for optimum management. FFB can be used as an important diagnostic tool that can guide medical and surgical interventions in NICU.

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Background : In children, pulmonary and cardiac diseases are closely associated, and their integrated evaluation is important. Fibreoptic flexible bronchoscopy (FFB) can be used for both diagnostic and therapeutic purposes in paediatric cardiac intensive care units (ICU). It can aid in assessing the anatomic and dynamic abnormalities in the airway by direct visual assessment. However, there is no robust data regarding use of FFB in detecting airway anomalies in paediatric patients with congenital heart disease (CHD). Methods : A retrospective, descriptive study was conducted at a tertiary care centre, in paediatric patients who underwent FFB in paediatric cardiac ICU over a period of 5 years (2013-2017). Results : Total 59 flexible bronchoscopies were performed in 51 patients with CHD. Twenty six patients had complex cardiac lesions and 25 had simple cardiac lesions. Total of 20 different cardiac lesions were found. Transposition of great arteries was most common amongst complex cardiac lesions (8/26). Ventricular septal defect was most common amongst simple cardiac lesions (8/25). Cyanotic CHD was more common with 62.7% patients. The main indications for FFB were lung collapse (34/59), prolonged oxygen requirement (11/59), stridor (8/59), suspected airway anomaly (5/59), suspected cystic lung disease (1/59). While 39/59 bronchoscopies were done transnasally, 20 bronchoscopies were done through endotracheal tube while patients were on mechanical ventilation. Tracheobronchitis with increased secretions were found in 43/59 cases, airway anomalies were present in 48/59 bronchoscopies with tracheobronchomalacia being the commonest (22/59). Other airway anomalies were extrinsic compression of bronchus (10/59), abnormal branching pattern (9/59), subglottic stenosis (3/59), laryngomalacia (2/59), vocal cord paresis (2/59) and 1 case of complete tracheal rings. Bronchoalveolar lavage was done on 45 occasions however microbiological yield was rather low (8.8%). Out of the 34 cases of atelectasis, radiological improvement was seen in 17 (50%) cases. Surgical interventions based on FFB findings were done in 11 (18.6%) patients. Slide tracheoplasty was done in 6 cases (5 of extrinsic compression of bronchus and 1 of complete tracheal rings), tracheostomy was done in 5 cases (2 of vocal cord paresis, 1 of subglottic stenosis and 2 of tracheomalacia). Transient hypoxia was observed in 6/59 cases, while 50/59 cases suffered no complications. Conclusion : Flexible bronchoscopy can prove to be a valuable diagnostic and therapeutic tool in cardiac patients with a good safety profile.

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Background : Optimum nutrition status is crucial for proper function of cells and organs, and for wound healing. The neonates undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) experiences a more profound metabolic response to stress as compared to older children and adults undergoing surgery. However neonates have less metabolic reserves as compared to older children and adults leaving them extremely vulnerable to the negative metabolic impact induced by stress. This can potentially lead to suboptimal wound healing and growth failure. Some institutes start early parenteral nutrition in all infants post cardiac surgery. However, the impact and feasibility of enteral nutrition immediately following congenital heart repairs is not well documented. Methods : All patients with the cyanotic congenital heart disease with increase pulmonary blood flow, weighing less than 5 kg and undergoing congenital heart repair during the study period were included in the study. Patients with single ventricle status, those undergoing palliative procedures (PA band),open chest, requiring ECMO before leaving operating room, having any other contraindication for starting enteral feeding or those who refuse for consent were excluded from study. INTERVENTIONS-The patients were randomized into two groups. Group 1 received trophic feeds ( 10-20 ml/kg/day) starting 4-6 hours after surgery while feeds children in group 2 were kept NPO and received feeds after 48 hours after surgery. Results : 15 children enrolled in both the groups. Both pre-operative and intraoperative variables were comparable in both the groups. There was no complication (vomiting, diarrhea, NEC, bowel necrosis) noted in the children who received feeds after surgery. Mean duration of mechanical ventilation in the feeds group was 58.2±4.71 hours, which was less then significantly less than those in the NPO group (P value 0.05). Similarly, duration of ICU stay was only 179.04 ±41.28 hours in feeds group as compared to 228.72 ± 85.44 hours in the NPO group. Conclusion : Neonates and Infants tolerate feeds immediately following congenital heart repairs. Moreover, feeds appear to decrease duration of mechanical ventilation and duration of ICU stay

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Background : Acute Kidney injury (AKI) is a leading cause of increased morbidity and an independent variable for increased risk of mortality in the PICU. AKI lacks physical signs and symptoms to trigger an alert for detection in its early stage. Therefore, there is a need for a predictive scoring system that can predict the development of AKI significantly early. Recently, the empiric concept of renal angina had been transformed into measurable factors and a renal angina index (RAI) had been calculated by some researchers as an emerging predictor to identify children at risk for AKI. A RAI score of ≥8 was observed to be associated with subsequent development of AKI. Methods : This was a prospective observational study (June 2016 to August 2017), conducted in a tertiary care intensive care unit. Children aged between one month and 18 years who were admitted to PICU for various diseases were included. Children who had died or discharged within 24hrs of PICU admission were excluded. On the day of admission, the following data were collected to calculate RAI:1) Risk (depends on presence/ or absence of ventilation and inotropes and /or stem cell transplantation) 2) Estimated Creatinine Clearance (eCCl) and 3) % of Fluid Overload. On Day 3 of PICU stay, children were categorised in two groups: 1) AKI and 2) non-AKI as per KDIGO criteria. Children were followed up to recovery or mortality. The primary outcome variable was presence of AKI 72hrs after PICU admission and the secondary variables were age, gender, height, weight, length of PICU stay, duration of mechanical ventilation, number and duration of inotropes, serum lactate, serum creatinine, requirement and duration of renal replacement therapy (RRT) and RAI. These variables were compared between the two groups. Results : A total of 81 children were included in the study of who 37 subsequently developed AKI. The mean RAI of the AKI group was 10.22±3.09 and the mean RAI of the non-AKI group was 8.14±3.15. This difference was found to be statistically significant (p=0.004). Day 0 RAI ≥8 predicted Day 3 AKI rates with a sensitivity of 78%, positive predictive value of 58%, negative predictive value of 74% and an AUC of 0.77 (95% confidence interval CI= 0.58-0.80). Conclusion : Renal Angina Index can be a useful predictor for development of AKI after 72hrs of PICU admission. Applying the RAI scores, children can be stratified as high risk for AKI and those with RAI ≥8, can be further evaluated with renal biomarkers.

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Background : Drug induced hypersensitivity syndrome (DIHS) or drug rash with eosinophilia and systemic symptoms (DRESS) is a well known condition in adults and rare in children. We report an 11 month old boy who presented with multiple seizures associated with febrile respiratory infection for which received ceftriaxone and phenobarbitone prior to referral. Following exposure to these drugs, child developed rash extensive non blanching rash and edema. Child was referred to PICU after 15 days from onset of the rash with multisystem involvement ‘for shock, encephalopathy (GCS 6) & respiratory failure’. Clinical assessment revealed that child had maculopapular rash, extensive erythematous skin lesion, lip erosions with oral mucosal involvement & hepatomegaly. The maculopapular eruption later looked edematous. There was swelling of the face, with marked periorbital involvement without necrosis of the epidermis. Over time the rash faded with exfoliation of skin. Laboratory assessment revealed severe anemia, normal total and differential count without eosinophilia with atypical lymphocytes, thrombocytopenia, raised liver enzymes with normal ammonia and bilirubin, hyponatremia, normal renal functions, CSF normal, Chest X ray normal, brain MRI normal, cardiac echo-coronaries normal. USG abdomen showing hepatomegaly with normal echo texture and normal kidney and other organs without free fluid. Other diagnostic tests revealed that rickettsial antibody, Weil felix, dengue test, leptospira antibody and widal test were negative. Blood culture was sterile. Serum quantitative procalcitonin was within normal limits on admission. With the characteristic rash on exposure to phenobarbitone associated with multiorgan failure, child was treated as Phenobarbitone induced Hypersensitivity Syndrome with methyl prednisolne, IVIG. Child had respiratory failure with renal injury requiring mechanical ventilation and peritoneal dialysis. Child extubated after 5 days, stayed in hospital for 27 days and discharged on oral steroids to be tapered after 6 weeks along with levetiracetam. In subsequent 3-4 months child had fever and tachypnea due to LRTI needing hospitalization in general pediatric ward. Around 6 months following the treatment for DIHS, child had polyphagia, polyuria, and polydipsia associated with weight loss, dehydration and acidotic breathing. On investigation he met the criteria of severe diabetic ketoacidosis (DKA), had low c peptide levels, positive GAD antibodies and high HbA1C with normal thyroid levels. Child was treated as severe DKA and discharged on insulin for long term maintenance of euglycemia. To the best of our knowledge, this is the first case report of association of DIHS with multiorgan failure who subsequently developed Type I diabetes and the youngest infant in the medical literature. This case highlights the importance of identifying DIHS which is a reversible severe drug hypersensitivity reaction and knowledge of number of drugs which can cause this.

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Background : Myocardial dysfunction in septic shock is one of the most complex organ failures. A detailed transthoracic echocardiography can provide qualitative as well as quantitative assessment of myocardial performance. Methods : This study was designed as a prospective open labeled sequential period study of 52 patients admitted to the PICU during the routine echocardiography period (October 2015 to July 2016) compared with 53 patients admitted during the DSSE period (August 2015 to June 2016) at a tertiary care centre in south India. Interventions: During the routine echocardiography period, echocardiographic examinations were performed as per the necessity and expertise of the treating team, and patients were managed as per unit protocol. The parameters assessed were Inferior vena cava (IVC) variability and ejection fraction by fractional shortening. During the first 10 months period the primary investigator underwent echocardiographic training and was validated by pediatric cardiologist. After a 2-weeks phase-out, detailed echocardiography was performed at regular intervals (2, 4, 6, 12 and 24 hours) by a single observer (study investigator) and the decision of fluid bolus, inotrope therapy or vasopressor administration was decided by treating team based on the echocardiographic assessment. The parameters assessed during the DSSE period were IVC variability, left ventricular (LV) ejection fraction by modified Simpsons biplane method, LV diastolic function by mitral E/A and E/E ratio and right ventricular (RV) function by tricuspid S’. This study was conducted as a part of DM dissertation. Results : The baseline charecteristics, severity of illness and vital parameters at admission were similar in both the groups. 32 (62%) children in routine echocardiography group and all the patients 53 (100%) in DSSE group underwent echocardiography. The 28-day all-cause mortality was less in the DSSE group 26 (49%) when compared to the routine echocardiography group 30 (58%), however the difference was not significant (p=0.267). In Kaplan-Meier analysis the difference was significant in Breslow Generalised Wilcoxon test (p=0.022) which assumes early clustering of events, in the course of study (conditions like septic shock) in contrast to log rank test which assumes equal distribution of events. The length of PICU stay 6 (95% CI - 2.24 9.41, IQR 15, 3) days and hospital stay 12 days (95% CI 8.67 14.90, IQR 31, 5) days were less in the DSSE group compared to the routine echocardiography group of 11 (95% CI - 10.86 11.48, IQR 16, 6) days and 18 (95% CI 11.17 24.82, IQR 36, 12)] days respectively with statistical significance in Breslow Generalised Wilcoxon test (p = 0.026 and 0.026 respectively) but not in log rank test. Conclusion : Our study suggests that the Detailed Systematized Serial Echocardiography based management of septic shock improved mortality and legth of PICU stay and hospital stay compared to Routine Echocardiography based management.

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Background : Continuous renal replacement therapy (CRRT) is a valuable tool in a pediatric intensive care unit (PICU), however the literature available from developing countries is scarce. Methods : Retrospective analysis of children who underwent CRRT during the past 1 year (June 2016 to May 2017). 24 sessions of CRRT was performed in 22 patients using Prismaflex® Baxter. Serum levels of urea, creatinine, and liver function tests were done in all patients. Activated clotting time (ACT) was monitored in all patients every 1 hourly till target ACT was achieved (180 – 220 seconds), thereafter every 4 hourly if the ACT continues in the target range. Unfractionated heparin was used for anticoagulation. Blood priming was done in patients with hematocrit less than 30% or in infants weighing less than 10 kg. Hemodialysis catheter (8.5Fr) was used in all patients, placed in the right internal jugular vein (IJV) under ultrasound guidance. Transthoracic echocardiography was used in all patients to confirm the position of the catheter tip within the right atrium. Central venous access in the femoral vein and arterial blood pressure monitoring was done in all patients as per unit protocol. Primary outcome measure was death during the procedure. Data collected were part of PRBC transfusion in pediatric ICU study and fluid balance study at JIPMER. Results : The median age of patients was 2 years (1 to 6 IQR). Mean bodyweight was 13.4 kg, 6.6 SD. Continuous venovenous hemofiltration (CVVH) was done in 5 patients (22.7%) and 17 patients (67.3%) were started on continuous venovenous hemodiafiltration (CVVHDF). Mortality during the procedure among the patients who underwent CRRT was 50% (n=11). Mean PRISM III score was 14. Out of 22 patients, 15 patients (68.7%) were on vasoactive medications at the time of initiation of CRRT. Median fluid overload (FO%) was 0.62 (0.45 to 1.62 IQR). Average time to start CRRT since PICU admission was 55 hours. The common indications were acute kidney injury with fluid overload (n=9), acute liver failure with hyperammonemia (n=3), organic acidemia with severe high anion gap acidosis (n=1), unknown poisoning with high anion gap acidosis (n=2), pigment nephropathy following wasp sting (n=1) and electrocution (n=1). CRRT along with venovenous extra corporeal membrane oxygenation (vv ECMO) (n=1) was done in a case of hemophagolymphohistiocytosis syndrome with ARDS. Effluent dose 35ml/kg/hour in all patients except in 2 cases of acute liver failure where the effluent dose was increased up to 42ml/kg/hour due to persistent hyperammonemia. CRRT with plasma exchange using P2 plasma filter was done with CRRT circuit modification in 2 cases of thrombocytopenia associated multiorgan failure (TAMOF). Mean duration of CRRT was (55 hours, SD 23.8). Maximum circuit life with systemic heparin as anticoagulant was 92 hours. Filter clotting and new circuit requirement was encountered in 6 patients (27.7%). Conclusion : CRRT can be used safely in critically ill children. The circuit life can be prolonged with serial ACT monitoring and titration of anticoagulation.

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Background : Von willebrand disease is the most common inherited bleeding disorder.Since milder form is the common type,many cases go undiagnosed in clinical practice.VWD is caused by a defect in Von Willebrand factor (VWF) which is a carrier of clotting factor 8 and helps in platelet adhesion during bleeding episodes.VWD has a incidence of 1 in 100.Type 1 and 2 is the most common type.The incidence of VWD type 3 is 1 in 10,00,000. Methods : Dr.S.Senthil Kumar,Consultant, Meenakshi Mission Hospital & Research centre, Madurai. Results : Here we report a one yr old male child born out of 2nd degree consanguinous parents who presented with fever,vomiting,irritable cry and generalized tonic clonic seizures. On examination the GCS was 13/15, with closed anterior fontanelle, brisk reflexes and neck stiffness. No signs of raised ICT was present. CT BRAIN was done which showed a cerebellar bleed compressing 4th ventricle and obstructive hydrocephalus. Investigations revealed a normal platelet count with normal PT and prolonged aPTT, with deficiency of factor 8 and VWF. Diagnosis of VWD type 3 was made.Suboccipital craniotomy done and bleed was evacuated after correction of bleeding diathesis with FFP and cryoprecipitate.Postoperatively child was managed with factor 8 and VWF containing concentrates. This case emphasizes the importance of considering hereditary bleeding disorder as a differential diagnosis in children presenting with intracranial bleed. Conclusion : This case emphasizes the importance of considering hereditary bleeding disorder as a differential diagnosis in children presenting with intracranial bleed.

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Background : Acute transverse myelitis and GuillainBarre Syndrome are the two most common causes of acute flaccid paralysis in children. Presence of a sensory level, early and persistent bowel and bladder dysfunction, extensor plantar reflex and absence of cranial nerve involvement have been considered to clinically favor acute transverse myelitis over GuillainBarre Syndrome Methods : A prospective observational study of all children admitted to the Pediatric Neurology Unit with a final radiological diagnosis of acute transverse myelitis was conducted. A predetermined proforma was used by the investigators to collect clinical information from these patients and their medical records. Results : During the study period, 10 cases of long-segment myelitis were admitted. The presenting symptom was sudden onset weakness in all patients. Asymmetric quadriparesis was the most common pattern of weakness (5/10) and a descending pattern was seen in 4 of these patients. Symmetric paraparesis (3/10) was the next most common pattern followed by asymmetric paraparesis (1/10). One patient presented with isolated monoparesis of the upper limb. Sensory and bowel/bladder involvement was present in only two patients. Pain/paresthesias requiring medication was seen in 4 patients. Three patients had prominent vomiting before the onset of weakness. A viral prodrome (<1 week) was present in 6/10 of patients. Conclusion : Acute transverse myelitis can havevaried clinical presentations. High clinical suspicion of acute transverse myelitis is prudent in cases of acute flaccid paralysis with atypical signs and symptoms and uncertain clinical localization. Imaging of the spine of such patients helps in early diagnosis and avoids delays in appropriate treatment as well as unnecessary investigations.

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Background : Nasogastric tube is the preferred route of feeding in the critically ill patients who are unable to take orally, as it is more convenient, well tolerated and cheap. However, intolerance to NG feeding is encountered in a no of patients because of delayed gastric emptying, raising the concern about pulmonary aspiration. Options available to provide nutrition to these patients are either to start parenteral nutrition or Nasojejunal feeding. We explored the feasibility of providing enteral nutrition to patients with intolerance to NG feeding through Ryle’s tube passed beyond the pylorus by gastric insufflation technique at the bedside. Methods : All patients, admitted at the 9-bedded PICU at Indraprastha Apollo Hospitals, New Delhi between 01 January 2017 and31 July 2017, were assessed for intolerance to NG feeding. Feeding intolerance was defined as development of abdominal distension and vomiting after NG feeds or gastric aspirate more than 200 ml. In patients with intolerance to NG feeding, post-pyloric tube was placed with gastric insufflation of air. 10 ml air was pushed in three slots, with each slot of air, feeding tube was pushed 2-3 cm. Gastric aspiration was done each time, when there was a sensation of vacuum on aspiration, it was considered an indicator of post-pyloric tube placement. The procedure was stopped andposition confirmed with radiography. All patients were assessed for complications of post-pyloric tube placement like clogging of tube, coiling of tube and aspiration pneumonia. Results : 16 patients were identified during the study period with mean age 3.4 years (range 0.25 yr-13 years). Majority of them were males (68%). Mean time for placement was 0.31 ±0.09 hrs.Time taken to start feeding was 1.3± 0.19 hours. Full enteral feeding was achieved in 20 ±18.45 hours. Only 1-patient had complication in the form of coiling of feeding tube after post-pyloric placement. All patients survived their hospital stay. Average ICU and hospital length of stay were 18.75± 25.84 and 31.18 ±21.14 days respectively. Characteristics of individual patient are given in Table 1. Conclusion : Our study shows that post-pyloric tube insertion by gastric insufflation technique is feasible and safe in pediatric intensive care unit and can provide an alternative route for providing enteral feeding. However it needs to be confirmed by a larger study.

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Background : Infections are a common reason for admission to the PICU. Sepsis and septic shock need urgent empirical coverage with appropriate broad spectrum antimicrobials. However, there must be a commitment to de-escalation once the organism and susceptibility are known. The clinician’s challenge is to maximize the chances that the infecting organism is covered by empirical therapy, while minimizing the risk of super infection with resistant organisms. Methods : Retrospective cohort analysis of children who were admitted to the PICU from January to June 2017 with presumptive sepsis and treated empirically with broad spectrum antimicrobials (Piperacillin-Tazobactam, Meropenem, Colistin, Tigecycline, Vancomycin, Teicoplanin, Azoles, Eichnocandins or Amphotericin B) were included. Children with sepsis admitted and treated with antimicrobials based on prior culture reports were excluded. Results : A total of 347 children were admitted during the study period. Empirical antimicrobial therapy was started for 80 suspected sepsis episodes in 75 children. Mean age of children in the group was 4.8 years. Male and female ratio was 1.8:1. Empirical antimicrobials were started in 44 (55%) episodes for septic shock, 24 (30%) episodes for pneumonia, 7 (8.7%) episodes for meningitis, 3 (3.7%) episodes for febrile neutropenia and 2 (2.5%) episodes for infective endocarditis. Piperacillin- Tazobactam was used in 21 episodes (26%), Meropenem in 58 episodes (72.5%), Colistin in 22 episodes (27.5%) and Vancomycin in 39 episodes (48.7%). Antifungals were also used empirically in 13 episodes (16.2%). Average duration of treatment with Piperacillin-Tazobactam was 4.4 days, Meropenem 4.3 days, Colistin 3.9 days and Vancomycin 4.5 days. Combination of 2 or more antimicrobials is used in 53 (66.2%) epesodes. Out of the 80 episodes, cultures were positive in 41 episodes (51.5%). Bacteria & Fungi were isolated in 37 and 4 episodes respectively. Twelve of 37 bacterial isolates (35%) were Carbapenem resistant. Blood culture was positive in 29 (36%), Broncho-alveolar lavage culture in 12 (15%), and Urine in 5 (6.2%). Isolates were sensitive to the initial empirical therapy in 30 episodes (73%), and antimicrobials were de-escalated in 18 (60%). In the remaining 11 culture positive episodes (27%), antimicrobials were escalated according to the culture reports. When cultures were negative, antibiotics were de-escalated to narrower spectrum or stopped in 18 (46.5%). All children who underwent de-escalation of antimicrobials had good outcomes. Conclusion : Broad-spectrum antimicrobials were used in 21% of all children admitted to the PICU. Initial antimicrobial therapy was appropriate in 30 (73%) of culture proven sepsis, out of which antimicrobials were de-escalated in 18 (60%) based upon the culture reports. In addition, de-escalation or stopping antimicrobial therapy in culture negative patients did not worsen the outcome of the children.

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Background : Rise in serum creatinine and decrease in urine output are late markers of Acute Kidney Injury (AKI) in children. Markers which can predict kidney damage early can help to intervene quickly and optimize treatment. Urinary NGAL is one of the early markers of AKI being studied widely. Methods : Children in the age group of 1 month to 18 years admitted to the PICU of our hospital from September 2016 to April 2017 were included in the study. Children with preexisting renal disease, UTI, post surgical patients and children with expected duration of stay Results : Ninety-six children were enrolled during the study period. Of these, 39 (40.6%) developed AKI. Among patients with shock, 42.8% of children developed AKI. Urine NGAL value at admission greater than 88 ng/ml had a sensitivity of 84.6% and specificity of 80.7 % in predicting AKI, with AUC of 0.86 whereas admission creatinine had an AUC of 0.66 in predicting AKI. PRISM III scores for predicting AKI had AUC of 0.752. Among children who developed AKI, 43.7% had normal creatinine at admission but had urine NGAL value > 88 ng/ml. Only 25.5% of children with AKI required Renal replacement therapy (RRT). Urine NGAL value was >500 ng/mL in 80% of children requiring RRT. Children with AKI had a mortality rate of 20.5%, compared with 4.2% in children without AKI. Conclusion : Urinary NGAL is a better and more sensitive marker for predicting the development of AKI in critically ill children compared with serum creatinine. Urine NGAL value greater than 500 ng/ml could be used to predict the requirement of RRT in critically ill children with AKI.

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Background : Chest X ray is a common and important imaging modality in critically sick children admitted in PICU for various reasons. These may be needed for diagnosis of Hospital acquired pneumonia , VAP, ARDS, pneumothorax, pericardial effusion etc. However the literature on their effect on clinical decision and outcome is scant. Methods : This was a retrospective study conducted in a tertiary care hospital, which included 30 children aged one month to 14 years selected by convenience over a month . All the chest X rays done on them during PICU stay constituted the sample size. we collected data on documentation of indication of chest X ray, diagnosis on X ray and matching of indication and diagnosis, decision and action taken after X ray. All analysis were done in r studio software for statistical computing. Results : A total of 126 chest X ray were available for 30 patients. At 1st day of admission chest X ray was done for all the patients including bronchiolitis and GBS. Longer duration of PICU stay was associated with increased number of X rays and 60% of these were associated with no decision and intervention. Indication for X rays (event wise) were respiratory deterioration in 56, post intubation in 18, pre extubation in 20, to see any improvements in lungs in 32 events. Mean number of X rays per patient were 4.2. Action taken after X ray were intercostal drainage for empyema and pneumothorax in 4, low tidal volume ventilation and prone positioning for ARDS in 2, extubation in 18, bronchoscopy for collapse in 3, Antibiotic upgradation for persistent consolidation in 6 and diuretic therapy in 2 events. There were 54 events when X ray was not associated with any action. The indication of X rays matched with the diagnosis in 80% events. Almost 70 chest X ray could have been avoided. ARDS and persistent pneumonia were associated with more chest X rays. Conclusion : A good number of chest X ray can be avoided like post intubation for endotracheal tube position, daily X rays in ARDS when no action is taken. Although pre extubation X ray were associated with intervention but we think these can be avoided and patients can be extubated on clinical judgement. Some baseline X ray for bronchiolitis and GBS could have been avoided.

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Background : Misplacement of pericardial catheters is dangerous for two reasons. One is non-correction of cardiac tamponade for which it is intended and thus resulting in decompensated state of the patient. Second, it may traverse neighbouring vital organs leading to even increased risk of life threatening complications. Methods : A 5 year old boy was referred to us with left lobe liver abscess and respiratory distress. The child had tachycardia, tachypnea, hypotension (BP-70/48 mmHg) with raised JVP and muffled heart sounds. Echocardiography confirmed cardiac tamponade (pericardial effusion 1.5cm in anterior space, 2cm in left ventricular free wall along with septal bouncing, collapse of right atrium in late diastole and collapse of right ventricular free wall). It also showed a contiguous liver abscess. So a diagnosis of liver abscess rupturing into the pericardium with cardiac tamponade was made. Immediately percutaneous pericardiocentesis was performed under echocardiographic guidance and a pig tail catheter was inserted. 60 ml of anchovy sauce pus was aspirated. the child became hemodynamically stable. Liver function tests were normal. A total of 105 ml pus was removed. His Serology was positive for Entamoeba histolytica done by ELISA with antibody titres of 5.8(normal upto 1.2). CT abdomen done to look for communication between the abscess and pericardial sac showed coiling of the pericardial catheter into the abscess cavity in left lobe liver. It was not detected in the pericardium as expected. We discuss the possible explanation for misplacement of the pericardial catheter and how this resulted in a favourable outcome. Results : Pericardial pigtail catheter , instead of traversing the pericardium; passed through the sub diaphragmatic region, coiled multiple times and reached into the left liver lobe abscess. This may be due to easy access through the frail tissue tract damaged by necrosis. As we drained the pus, the clinical condition of patient improved dramatically immediately. We thought the pus was draining from the pericardium but it was actually from the liver abscess. We opine, abscess drainage resulted in release of pressure over heart and pericardium (due to abscess mass) resulting in clinical improvement. Further as with drainage of the abscess, tension in the abscess decreased; this might have resulted in flow of pus from pericardium to the abscess cavity through hepato-pericardial fistula and thus draining the cardiac tamponade also. As the patient improved and we could collect pus from the catheter we did not bother to look at the position of the catheter on ECHO which was actually in the abscess. This was detected later on by CT. Improvement of patient blocked our thinking process and we thought procedure has gone all right. The misplaced pericardial catheter drained the cardiac tamponade as well as liver abscess. Our patient is in follow up and in good health. Conclusion : In the presence of an adjoining necrosis process, extreme caution should be taken while putting a pericardial catheter.

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Background : Abnormal eye movements can occur in patients with neurological diseases. These have been described in unconscious patients due to anoxic coma and often disappear as the patient regains consciousness. Ocular dipping movements are rarely seen in practice in pediatric patients. Methods : A one year old male patient was brought unconscious with electrocution injury. With resuscitation, he became hemodynamically stable. He could not recognize his mother or respond to visual/auditory stimuli; and had generalized hypertonia. Cranial nerves were normal. He showed abnormal involuntary conjugate vertical saccadic eye movements, consisting of slow downward movement (for 1-2 seconds) followed by a relatively faster return to the primary mid-position. These persisted continuously for 48 hours at irregular intervals of 1-2 seconds. The patient was awake but non-responsive and not interested in surroundings. Results : These eye movements are called ocular dipping (OD) . In a normal person, saccadic movements are meant for stable fixation and are maintained by pause-cell neurons positioned in the pontine raphe. These prevent the occurrence of unwanted saccadic pulses by inhibiting the saccadic premotor burst neurons in the paramedian pontine reticular formation and midbrain. Injury to pause cells leads to extraneous saccades without fixation. It appears that cortical and basal ganglia malfunction causes ocular dipping. OD is mainly seen in anoxic coma and creuztfelt Jacob disease. A 53-year-old man developed ocular dipping following prolonged hypotension.Our patient was in vegetative state with normal respiratory and cardiac function suggesting that major midbrain and medullary centers were intact. Conclusion : The self limiting nature of OD suggests that these are caused by diffuse dysfunction rather than a single structural locus.

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Background : Use of Point of care ultrasound (POCUS) for venous thrombosis is a newer approach for pediatric intensivists. Deep venous thrombosis may result from various causes and fairly common in ICU setup due to fluid deficit state in critically sick children, immobility of such patients, and on-going sepsis. It can lead to life threatening events by causing embolic events. Doppler ultrasound is done to diagnose such lesions but difficult to perform in a bed ridden critically sick patient. Transport of a critically sick patients is usually a challenge. The solution may be bedside ultrasound examination of deep vein system by the intensivist. Bedside POCUS is a quick, noninvasive and radiation free investigation. In this report we show POCUS appearance of Internal jugular vein and femoral vein thrombosis of three patients. Methods : POCUS was performed with Aloka SSD-90 machine with a frequency (7.5 MHz), linear transducer. The patient was in supine position. Transverse images below the inguinal ligament were taken by putting the probe 1 cm below the inguinal ligament the pointer towards the lateral side for FVT. For IJV scanning probe was put on lateral neck midpoint through its length with the pointer towards lateral side. Results : The thrombus was seen as a grey area (intensity towards hyperechogenicity) within the lumen of femoral vein and internal jugular vein. The IJV thrombus was very large that it displaced internal carotid artery. On performing the compressibility test the vein did not compress. The etiolology in two patients was due to severe staphylococcal sepsis while in IJV patient it was probably secondary to tuberculosis. Subcutaneous heparin therapy was started followed by warfarin. Both patients are in follow up and in good health. Conclusion : POCUS is a very useful investigation for quick diagnosis of deep vein thrombosis in critically sick patients.

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Background : Optic nerve sheath diameter(ONSD) is an indirect method of detecting raised intracranial pressure. There is paucity of literature on normal values of ONSD particularly for Indian children. Methods : Normal healthy children between ages 1month-14 years were selected by systematic random sampling. ONSD were recorded by trans-bulbar sonography of right eye, three mm behind the globe by measuring the maximal transverse diameter. Average of three best possible observations was taken as final reading. Age, gender, Height, weight and head circumference were recorded for all children to see any association between these and ONSD. Results : A total of 45 healthy children (males=25) were included in the study. The mean age was 7.9 years. The ONSD was normally distributed as evaluated by Shapiro test (p value-0.15). The 3rd, 15th, 50th, 85th and 97th centiles for ONSD were 4.3, 4.7, 5.3, 5.7 and 6.3mm respectively. There was no significant difference in ONSD of two sides (t= -0.3, pvalue-0.76) or on basis of gender (t=0.08, p value-0.93).The correlation between ONSD and age, height, weight, head circumference was 0.36, 0.36, 0.46, 0.39 respectively. Conclusion : The normal values of ONSD are 5.1mm and measurements above 6.3mm should be considered abnormal. The factors like age, weight, and height and head circumference are poorly correlated and cannot predict ONSD accurately.

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Background : The effectiveness of APRV in pediatric ARDS is not clear. The picture gets more complicated when such a patient develops pneumothorax. The use of APRV mode in a child with pneumothorax is not documented. In this case we were compelled to use APRV mode for deteriorating hypoxemia. Fortunately with rigorous monitoring, the child responded well and weaned off the ventilator. Methods : A six year old girl was admitted to our PICU for respiratory distress due to pneumonia. She had hypoxemia refractory to oxygen therapy for which she was intubated and ventilated with PCV mode. She needed high settings on PCV mode (Fio2-100%, PIP-30, PEEP-14, Ti-0.9 sec, RR-30/ min) but still hypoxemic. She had to be sedated heavily for asynchrony. PV loop suggested collapsed alveoli. Tidal volumes were still low. PF ratio was 70 and there was no hypercapnea. The chest x ray and ultrasound lung suggested ARDS findings bilaterally. Unfortunately she developed pneumothorax of right lung. Immediately intercostal chest drainage tube was put and ventilation continued but she could not maintain Spo2 and continuously deteriorated. PCo2 level was 42 with a Ph-7.30.The ventilation strategy was changed to APRV mode (Phigh - 20, Plow - 0, Thigh - 4, Tlow - 0.3 and Fio2-100%). Phigh was gradually increased to 28 mmhg with close monitoring of pneumothorax and Spo2(levels upto 85 were accepted) Results : Saturation was noticed to be increased from baseline. PF ratio improved after an hour to 85. Sedation was decreased. Fio2 could be decreased to 80% after 2-3 hours. There were no further episodes of pneumothorax and childs oxygenation status got better steadily. After three days we started weaning from APRV. For this, Thigh was increased and Phigh was decreased gradually until we got a continuous pressure at 6 mmhg for 15 seconds. The patient was given a T-piece breathing trial for two hours which she tolerated efficiently and extubated as per protocol. The child was transferred to the ward in good general condition. Conclusion : This case tells us that APRV mode can be used successfully in a patient whose ARDS is complicated with pneumothorax.

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Background : With increasing use of Point of care ultrasound (POCUS) by pediatric intensivists; newer indications are being detected. Abdominal mass/swelling developing in a critically sick patient warrants its quick and appropriate diagnosis for etiology and subsequent management. On one hand abdominal X-ray may be inadequate for diagnosis of such masses and on the other hand CT is cumbersome to do in a bed ridden critically sick patient. Bedside POCUS is a quick, noninvasive and radiation free investigation. In this report we show how POCUS resulted in diagnosis of a peritoneal fungal cyst and its management. Methods : This patient was a case of persistent pneumonia admitted in PICU with severe respiratory distress. His distress improved slowly over 10 days but he developed a mass in abdomen (right and above to umbilicus). POCUS was performed with Aloka SSD-90 machine with a frequency (5.0 MHz), curvilinear transducer. The patient was in supine position. Transverse and longitudinal images were taken by putting the probe at the level of the abdominal mass. Results : The cyst was seen as large anechoic mass with thick regular hyperechoic margins; below the peritoneum measuring 8cm×6cm. It was divided into two unequal cysts by a thick septum. The cyst was aspirated under direct visualisation on ultrasound. The straw coloured fluid was aspirated and sent for gram staining, AFB staining and culture. It grew candida albicans and smears was negative for gram staining and AFB staining. Tuberculosis work up was negative. He responded well to antifungal therapy. Conclusion : POCUS is a very useful investigation for quick diagnosis of peritoneal cyst in critically sick patients.

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Background : Acute respiratory distress syndrome (ARDS) in pediatric ICU contribute to up to 75% mortality which can be up to 90% in high risk patients. Despite of much advance in different ventilation strategies mortality remains unacceptably high. This suggests the need to define the role of newer management approaches. Airway pressure release ventilation (APRV) mode is a new strategy which looks promising in ARDS as shown in studies conducted on animals and adult patients. But its benefit has not been defined in pediatric patients with severe ARDS. Methods : This research was a retrospective comparative study using data from case files. The study period (Jan 2009 to December 2015) covered three years before the initiation of use of APRV mode to three years after its implementation. The study sample included all consecutive patients with ARDS in PICU of a tertiary care hospital during the study period. Patients admitted during APRV use period received APRV after failure of routine modes of ventilation(treatment group/APRV group) and patients admitted during pre-APRV use period received and continued on other modes of ventilation (control group/Non-APRV group). As the patients in treatment group naturally had severe ARDS; we included only severe ARDS cases in control group (equal in number to treatment group) to justify comparison. Case files were reviewed and data were recorded in terms of mortality, length of ICU stay, PaO2/FiO2 (PF) Ratio, lung injury score (LIS), PELOD score and demography. These were compared in two groups based on who received versus who did not receive APRV mode. Results : A total of 24 children in each group were analysed. Baseline PELOD score, age and gender distribution were comparable in both groups. PF Ratio were 67.21±9.74 in APRV versus 91.65(8.68) in non-APRV group (p value 0.01). Improvement in PF ratio after implication of APRV was statistically significant (mean difference of 14.36; p value=0.001). Duration of PF ratio<100 before implementation of ventilation was15.83±5.88 hours in APRV and 0.59±0.17 hours in Non- APRV group; and LIS was 3.5±0.31 in APRV Vs 2.61±0.38 in Non-APRV group; both suggesting a poor condition of lungs in APRV group at baseline. The overall In-hospital mortality in APRV group was 79% Vs 91% in non-APRV group. Use of APRV mode was associated with lower risk of mortality in unadjusted analysis (OR [95% CI] 0.39[0.06-1.84], p value of 0.24]. Penalised logistic regression technique was used for multivariable logistic regression due to sparse data. When adjusted for age, sex, baseline PELOD score, baseline PF ratio; the adjusted odds ratio (OR [95% CI] was 0.004 [8.2 - >999], p value of 0.001. The covariates which were significantly associated with mortality were baseline PF ratio and PELOD scores. Conclusion : Use of APRV mode in pediatric severe ARDS used as rescue treatment achieved improved oxygenation and was associated with lower in hospital mortality.

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Background : National Institute of Nursing Education, Neonatology Unit PGIMER Chandigarh The incidence of accidental extubations in ventilated neonates is a significant problem. The present study was undertaken with an objective to assess the effect of “Modified Y” technique of endotracheal tube fixation among neonates admitted in different neonatal units. Method: Neonates requiring intubation for mechanical ventilation were included whereas those intubated for the purpose of resuscitation alone and with facial defects were excluded. A total of 30 subjects were taken in each of the three groups. All the groups were homogenous. A convenient sampling design was adopted in which in Control group A the ETT tube was fixed using E technique throughout the study period at NSICU. In Control group B two areas were included - in one area, Neonatal Nursery the ETT was fixed using H technique throughout the study period and in the other area, NICU the ETT was fixed using H technique from 5 pm to 8 am whereas in Experimental group the ETT was fixed using “Modified Y” technique in NICU from 8am to 5pm. A check-list was prepared to assess ETT displacements till the ETT is in situ. Results: The incidence of no ETT displacements were 63.3%,56.7% and 60% in E, H and Modified Y techniques respectively. Results showed that technique of ETT fixation was not significantly different, χ²=0.276, p=0.870 (p> 0.05) at df=2 .However, variables like sedation, birth weight, gestational age, age at enrolment & shift of duty have significant influence on ETT displacements (p<0.05). Based on the findings,the study recommends the use of E technique of ETT fixation to minimize unplanned displacements among the neonates

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Background : Renal angina index (RAI) is a clinical guide that identifies patients at high risk for acute kidney injury (AKI) by integrating baseline, contextual and clinical evidence of renal injury. It may serve well to optimize biomarker utility. Methods : We performed a prospective observational study of 285 critically ill children aged 1 month to 18 years and followed them up for a minimum duration of 7 days to 28 days with daily documentation of fluid overload, creatinine values, need for renal replacement therapy(RRT), total duration of mechanical ventilation and hospital stay. RAI score of 8 or more was considered as fulfillment of renal angina. Results : Incidence rate for a Day 0 RAI of 8 or more was 49.4% and Day-3 AKI was 10.2%. Day-3 AKI rates were higher in patients with an RAI of 8 or more with the area under the curve of RAI for predicting Day-3 and Day-7 AKI of 0.815 and 0.727 respectively. An RAI under 8 had high negative predictive values (96.5%) for Day-3 AKI. RAI outperformed traditional markers of pediatric severity of illness (Pediatric Index of Mortality-II) for prediction of Day-3 AKI. Additionally, the RAI outperformed all Kidney diseases improving global outcomes (KDIGO) stages for prediction of Day-3 AKI. Conclusion : Renal angina index can predict development of subsequent severe AKI. Fulfillment of renal angina was associated with longer hospital stay, higher mortality, longer duration of mechanical ventilation and higher need for renal replacement therapy.

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Background : There is a paucity of data on nature and frequency of complications during the course of management of Tuberculous Meningitis (TBM) in developing countries. Methods : This was a single center prospectivecohort of children less than 12 years of age diagnosed with TBM from January 2011 to Aug 2015. Results : Out of 281 children with TBM, hydrocephalous was present 245 children out of which 206 children needed neurosurgical intervention.24.3%, 35.5 % and 40.2% were in stage 1, stage 2 and 3(MRC) respectively. 164children underwent ventriculo-peritoneal shunt, 32 external ventricular drainage, and 10 underwent Omayya chamber drainage. Major complications were Shunt infection/Ventriculitis-16(7.7%) and Shunt Block 11(5.3%), Shunt Tract hemmorhage 12(5.8%). Other complications that were noted includedpersisting hydrocephalous after shunt, post shunt hygroma, shunt fracture, CSF ascites/ pseudocyst, skin Problems at shunt site, and intraventricular hemorrhage. 59.6%(n=148) had serum sodium <135meq/L and 37% (n=92) had a serum sodium <130 meq/L. Furthermore, 3.6%(n=9) had cerebral salt wasting, 5.2%(n=13) had SIADH and 1.25%(n=3) had central diabetes insipidus. While more than one of these entities was seen in 3 children. Suspected hospital acquired sepsis needing adding of second line antibiotics was seen in 24.26% of the children. Conclusion : In this cohort of children in resource constraint setting who present with advanced hydrocephalous and severe encephalopathy, the major shunt complication rates like infection and malfunction were remarkably low compared to available literature.

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Background : Serum ferritin (SF) increases significantly during acute infections. However, data on its behaviour in iron-deficient children are scarce. Methods : Prospective patients (6mo-12 yrs) (n=42) with septic shock were enrolled at a tertiary-care hospital in India during Jan’2016-Jun’2017. SF was measured at enrolment and at 1 month of hospital discharge while not on iron supplementation. CRP and PeLOD score were also assessed. SF in healthy siblings of patients (n=36) sharing same kitchen was taken as surrogate of baseline value. Patients/controls with blood transfusion/iron supplement during last 6 months, or with chronic disease were excluded. Results : Mean age was 51±44 months, 31% of patients (n=13) were malnourished, majority (n=36, 86%) had anemia, and a third had microcytic hypochromic red cells. Four patients had culture-positive sepsis at admission. Enrolment SF was 1048±1281ng/ mL; two patients had values >3000ng/mL, one died and another recovered with steroid therapy. Among survivors, 1-month follow-up SF fallen significantly to 70±66ng/mL, however it was significantly higher compared to SF in controls (30±25ng/ mL; p0.01), but the same was not true for CRP (p=0.8). PeLOD and CRP at enrolment correlated well with the corresponding serum ferritin level (p=0.03 and p=0.01 respectively). Septic shock survivors (n=28) had lower ferritin levels compared to non-survivors (n=14) (866±1055 vs 1410±1628; p=0.14). Also, SF >500ng/mL was associated with higher mortality (46% vs 20%, p=0.057). Conclusion : SF rises significantly even in iron deficient patients during septic shock and correlates well with organ dysfunction. However, normalization of SF may take longer than 1 month. High SF (>500ng/mL) may be indicative of higher mortality. Study on larger sample of iron deficient children is required to confirm these initial findings.

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Background : An H1N1 (influenza A) pandemic emerged in 2009 resulting in a significant burden of illness. These patients suffered mainly from respiratory symptoms, but some also developed symptoms in other organ systems. Acute kidney injury appeared common in critically ill adult patients with H1N1 infection. A recent study revealed an incidence of 34 % of acute kidney injury among 628 ICU patients with H1N1 infection . The data available for pediatric patients mostly relates to patients with underlying kidney disease and describes a wide range in incidence. There are two case reports on children with H1N1 infection who developed acute glomerulonephritis . Here, we present the case of a child with acute interstitial nephritis with H1N1 infection. Methods : A 6Y old male child presented to ER with history of fever with chills, cough and cold for 4 days, vomiting for 4 days, decreased urine output for 2 days and h/o 2 episodes of hematuria. Physical examination revealed heart rate of 90 beats per minute, mild dehydration and normal blood pressure. Chest auscultation revealed bilateral crepitations and chest x-ray revealed bilateral opacities. He was admitted under the diagnosis of a viral infection and received supplemental oxygen. Polymerase Chain Reaction in a nasal swab was positive for influenza H1N1. ? Laboratory results on admission showed deranged Liver function test with raised serum creatinine (3.5gm/dl) corresponding to acute kidney injury p RIFLE. Urine analysis and renal ultrasound was normal. ? Child developed ARDS and was ventilated for 15 days. He required 13 cycles of hemodialysis, renal biopsy showed acute interstitial nephritis. His creatinine showed improvement after 2 weeks and normalized after 8 weeks and has been normal since. Oseltamivir was given for 10 days. ? Here we present a case of acute kidney injury with H1N1 infection. Several pathological studies have demonstrated that H1N1 virus is not restricted to the lungs. In one study H1N1 virus was found in the cytoplasm of glomerular macrophages. Nin et al demonstrated the virus in epithelial cells in the capsule of Bowman and in distal tubular cells. Still, we did not rule out other infections known to cause acute tubulointerstitial nephritis such as Cytomegalovirus, Epstein-Barr virus, Hepatitis C virus, human immunodeficiency virus, mycoplasma, or Hanta virus. Most patients with H1N1- related renal injury suffer from acute tubular necrosis during intensive care therapy. Nin et al distinguish early versus late kidney injury during H1N1 infection. The former is reversible reflecting hemodynamic instability, whereas in the latter persistent injury and/or co-morbidity might play a role . Therefore, this group bears a worse prognosis and these patients often need renal replacement therapy. ? In conclusion, we describe a 6?year-old boy with acute interstitial nephritis during an influenza H1N1 infection, with full recovery of renal function after supportive treatment. Results : A 6 Y old male child presented to ER with history of fever with chills, cough and cold for 4 days, vomiting for 4days, decreased urine output for 2days and h/o 2 episodes of hematuria. Physical examination revealed heart rate of 90 beats per minute, mild dehydration and normal blood pressure. Chest auscultation revealed bilateral crepitations and chest x-ray revealed bilateral opacities. He was admitted under the diagnosis of a viral infection and received supplemental oxygen. Polymerase Chain Reaction in a nasal swab was positive for influenza H1N1. ? Laboratory results on admission showed deranged Liver function test with raised serum creatinine (3.5gm/dl) corresponding to acute kidney injury pRIFLE. Urine analysis and renal ultrasound was normal. ? Child developed ARDS and was ventilated for 15 days. He required 13 cycles of hemodialysis, renal biopsy showed acute interstitial nephritis. His creatinine showed improvement after 2 weeks and normalized after 8 weeks and has been normal since. Oseltamivir was given for 10 days. ? Here we present a case of acute kidney injury with H1N1 infection. Several pathological studies have demonstrated that H1N1 virus is not restricted to the lungs. In one study H1N1 virus was found in the cytoplasm of glomerular macrophages. Nin et al demonstrated the virus in epithelial cells in the capsule of Bowman and in distal tubular cells. Still, we did not rule out other infections known to cause acute tubulointerstitial nephritis such as Cytomegalovirus, Epstein-Barr virus, Hepatitis C virus, human immunodeficiency virus, mycoplasma, or Hanta virus. Most patients with H1N1- related renal injury suffer from acute tubular necrosis during intensive care therapy. Nin et al distinguish early versus late kidney injury during H1N1 infection. The former is reversible reflecting hemodynamic instability, whereas in the latter persistent injury and/or co-morbidity might play a role . Therefore, this group bears a worse prognosis and these patients often need renal replacement therapy. ? In conclusion, we describe a 6?year-old boy with acute interstitial nephritis during an influenza H1N1 infection, with full recovery of renal function after supportive treatment. Conclusion : A 6Y old male child presented to ER with history of fever with chills, cough and cold for 4 days, vomiting for 4days, decreased urine output for 2days and h/o 2 episodes of hematuria. Physical examination revealed heart rate of 90 beats per minute, mild dehydration and normal blood pressure. Chest auscultation revealed bilateral crepitations and chest x-ray revealed bilateral opacities. He was admitted under the diagnosis of a viral infection and received supplemental oxygen. Polymerase Chain Reaction in a nasal swab was positive for influenza H1N1. ? Laboratory results on admission showed deranged Liver function test with raised serum creatinine (3.5gm/dl) corresponding to acute kidney injury p RIFLE. Urine analysis and renal ultrasound was normal. ? Child developed ARDS and was ventilated for 15 days. He required 13 cycles of hemodialysis, renal biopsy showed acute interstitial nephritis. His creatinine showed improvement after 2 weeks and normalized after 8 weeks and has been normal since. Oseltamivir was given for 10 days. ? Here we present a case of acute kidney injury with H1N1 infection. Several pathological studies have demonstrated that H1N1 virus is not restricted to the lungs. In one study H1N1 virus was found in the cytoplasm of glomerular macrophages. Nin et al demonstrated the virus in epithelial cells in the capsule of Bowman and in distal tubular cells. Still, we did not rule out other infections known to cause acute tubulointerstitial nephritis such as Cytomegalovirus, Epstein-Barr virus, Hepatitis C virus, human immunodeficiency virus, mycoplasma, or Hanta virus. Most patients with H1N1- related renal injury suffer from acute tubular necrosis during intensive care therapy. Nin et al distinguish early versus late kidney injury during H1N1 infection. The former is reversible reflecting hemodynamic instability, whereas in the latter persistent injury and/or co-morbidity might play a role . Therefore, this group bears a worse prognosis and these patients often need renal replacement therapy. ? In conclusion, we describe a 6?year-old boy with acute interstitial nephritis during an influenza H1N1 infection, with full recovery of renal function after supportive treatment.

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Background : Streptococcus pneumoniae, or pneumococcus, is an encapsulated Gram-positive bacterium that is the major cause of bacteremia and upper respiratory infections (eg, otitis media and sinusitis) in children and a common cause of serious invasive infections. Invasive pneumococcal disease (IPD) refers to disease in which the bacterium enters a sterile site such as blood, cerebrospinal fluid (CSF), pleural fluid, joint fluid or pericardial fluid and causes significant morbidity and mortality. Despite availability of an effective vaccine against this disease, we see a significant number of cases of IPD. Methods : All patients Results : 10 patients were diagnosed with bacteremia caused by Strep. Pneumonia and were confirmed by PCR method and identifying Lyt A gene. Two patients died (20%). Among survivors, the diseases spectrum extends from mild illness to life threatening illness. Two children had pneumococci isolated from other body fluids (CSF/ Pleural Fluids). One child had Meningitis with brain abscess. Four children had pneumonia with ARDS requiring prolonged ventilation support. Majority of children (60%) had milder version of the disease. Conclusion : Bacteremia in children is a serious condition associated. The limitations of the current polysaccharide pneumococcal vaccine in Indian population warrant the prevention against the disease. We suggest that the virulence of pneumococcal serotypes should be considered by identifying the the serotype and developing novel vaccines specific to our Indian population

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Background : Raised intracranial pressure (ICP) in non-traumatic coma (NTC) is common in children and requires urgent, protocol based management and multimodal monitoring. Initial tiers of raised ICP management are based on evidence based guidelines. However, treatment for refractory raised ICP is limited to medical measures like barbiturate coma, targeted therapeutic hypothermia or a neurosurgical procedure like decompressive craniectomy (DC). Evidence regarding the role of DC in refractory raised ICP due to NTC in children is lacking. Therefore, we planned to study the clinical profile and outcome of these patients undergoing DC. Methods : All patients aged 1 month to 12 years, admitted to a tertiary care pediatric ICU over a period of 5 years (2012 to 2017) and underwent DC for non-traumatic refractory raised ICP were retrospectively analysed. Clinical profile, course and neurological outcomes were studied. Primary outcome measures were survival to hospital discharge and neurological outcome after 3 months using Glasgow Outcome Scale (GOS). GOS of 1 & 2 were classified as good and 3 to 5 as poor. Statistical analysis was done using SPSS version 21 software. Descriptive data were summarized as mean ± SD or median (IQR). Predictors of good outcome were analysed using Chi Square test and multivariate logistic regression. Results : A total of 30 children with median age of 6.5 months (IQR 2, 50) were included. 26 (86.7%) were males. Common presenting symptoms were seizures (n=25; 83%), altered sensorium (n=19; 63%) and fever (n=12; 40%). Common clinical signs were pallor (n=20; 66.6%), asymmetric pupils (n = 15; 50%), bulging anterior fontanelle (n=12; 40%), focal deficits (n=6; 20%) and skin bleeds (n=4; 13%). Median (IQR) Glasgow Coma Score (GCS) at admission was 9 (6,11). Commonest etiology was intracranial bleed in 24 (80%) and infarct in 6 (20%). Location of bleed was parenchymal in 10 (33.3%), subdural 8 (26.7%), extradural 1 (3.3%) and multi-site in 5 (16.7%). All had a midline shift of >5mm on neuroimaging. Median (IQR) time to DC was 24 (24,72) hours of hospital admission. Twenty-six (86.7%) were ventilated for a median (IQR) duration of 96 (48, 144) hours and one patient required tracheostomy. Two patients died (6.6%) during hospital stay. Median (IQR) length of PICU and hospital stay was 5.5 (3, 10) and 17 (12, 27) days respectively. Twenty-one patients were examined at median (IQR) follow-up duration of 12 (5, 54) months. Six more patients died and one lost to follow-up. Good neurological outcome was seen in 15/29 (51.7%) patients. On univariate analysis, skin bleed (p-0.042), pupillary asymmetry (p-0.002) and focal deficit (p-0.011) at admission were significant predictors of poor outcome. On regression analysis, pupillary asymmetry at admission was predictive of poor neurological outcome [p-0.003]. Conclusion : Evidence on management of refractory raised ICP in NTC is still evolving. Timely DC can be considered as an effective treatment modality with good survival and neurological outcome.

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Background : Massive hemoptysis is a life-threatening complication of pulmonary disorders. In the presence of pulmonary tuberculosis, massive haemoptysis can result from a number of different causes. Herein we present a series of three cases of hemotysis in children with pulmonary tuberculosis; with a relatively rare diagnosis. Methods : We reviewed the records of Pediatric Pulmonology Unit at PGIMER Chandigarh, over two years duration (July 2015 to June 2017). We searched for children with confirmed tuberculosis presenting with massive hemoptysis. We identified three such cases. All three children were found to have pulmonary vascular pseudo-aneurysm. We present the clinical features, investigations, management and outcome of these children. Results : Table 1 presents clinical features, CT findings, management and outcome of the three children. Acid fast bacilli were isolated from sputum of two patients and third patient had a cold abscess in suprasternal area that showed epithelioid cell granuloma on histopathology. All the three cases were treated with antitubercular therapy. Two cases underwent coiling of psedoaneurysms and post procedure check angiography showed non-opacification of the pseudoaneurysms and patients recovered completely. Third case was also planned for coil embolization of pulmonary artery pseudoaneurysm but mean while the child developed massive haemoptysis and succumbed to the illness. Conclusion : Though rare but pseudoaneurysms can cause massive haemoptysis in children with tuberculosis so warrant high index of suspicion in such cases. Prompt identification of site of bleeding using multidetector CT angiography and management with trans-catheter arterial embolization is lifesaving in such cases.

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Background : Data on scholastic performance in HIV-infected children is scant. This study was aimed to assess scholastic performance of HIV infected children and correlation between the scholastic performance with severity of disease. Methods : This cross-sectional study was conducted in the Department of Paediatrics, KLE University’s Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi. A total of 70 HIV infected children aged between 6 to 18 years residing in special homes for HIV of Belagavi city were studied. Severity of HIV/AIDS was classified by WHO clinical staging of HIV/AIDS for children. Assessment of scholastic performance was done by checking their performance in class tests over one year and taking the average. Results : Boys constituted 51.43% and 48.57% were girls with boy to girl ratio as 1.05:1. The most common age group was 11 to 14 years (48.57%) and the mean age was 12.56±2.84 years. All the children (100%) had vertical transmission of HIV and history of ART administration was reported in 77.14% of the children. Most of the children had WHO clinical stage II HIV (45.71%). 22 children attained A and A+ grades among them 18 children had HIV stage I and II, 4 children had HIV stage III. Whereas 7 children attained C and C+ grade in which 2 had HIV stage I and II and 5 children had stage 3 (p=0.049). Conclusion : Children with HIV infection are likely to have average and below average scholastic performance. Further the poor scholastic performance is associated with increasing severity of the disease.

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Background : Posterior Circulation stroke in children are rare and often difficult to suspect.Data on this entity from India is sparse. Methods : In this retrospective case series, case record and follow up clinic files of children admitted with posterior circulation stroke from 2011 -2017 were retrieved. Clinical features, hematological, biochemical investigations and radiology details were recorded. Short term neurological outcome was assessed for residual disability. Results : During the study period, 18 children were diagnosed with posterior circulation stroke. All children of our cohort wereboys, the median age of presentation was 8 years. There was a history of preceding neck trauma in 28%. Clinical presentation included acute onset dizziness/vertigo (89%), ataxia (67%) headache (33%), hemiparesis (44%), diplopia (6%), third nerve palsy(6%) and acute onset bulbar palsy (6%). Details of MR angiogram/CT angiogram were available in all except two; The vessels involved were; vertebral artery in six (33%), both vertebral and basilar in three(17%), isolated basilar, superior cerebellar and unilateral internal carotid in one (6%) each. Cervical spine anatomical abnormality was seen in four; atlanto-axial instability (1), osodontoideum(1), cervical ligament laxity(1) and occipito-atlanto pseudo articulation of the posterior arch(1). Arterial dissection was noted in eight (44%), arterial thrombosis infour (22%), and moyamoyavasculopathy in one(6%). Hyperhomocysteinemia was seen in two (11%). Drugs used included low molecular weight heparin in 50% (3-6 months), aspirin in 39%(2-3 years). Anticoagulation with warfarin (6 months) was used in one child. Recurrence of posterior circulation stroke was seen in four (22%) patients. In two patients with cervical spinal instability, surgical vertebral fixation was done. On follow up,residual deficits were noted in 50% children [residual hemiparesis, ataxia, dystonia, equinus deformity and refractory epilepsy]. Conclusion : In our series, Posterior circulation stroke exclusively affected boys and vertebro-basilar dissection affected nearly half of the children.

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Background : The hepatopulmonary syndrome (HPS ) is characterized by the triad of liver disease, pulmonary gas exchange abnormalities leading to arterial deoxygenation and evidence of intrapulmonary vascular dilatations (IPVD) in the absence of intrinsic lung disease. The incidence of HPS varies around 10—32% of patients with portal hypertension. This disease is associated with progressive hypoxemia and a high mortality. Although liver transplantation is curative in HPS, these patients have higher postoperative complication rate particularly post transplant hypoxemia (need for 100% FiO2 to maintain a saturation of =85%) which is the major cause of prolonged ICU stay and mortality in this population. However, survivors have a complete normalization of gas exchange over time. Methods : Room air saturation was documented for children with liver disease by Pulse oximetry and those with oxygen saturation =95 % were confirmed to have HPS after positive bubble contrast echo (in absence of intracardiac shunt ) and shunt fraction was quantified by technetium-99m-labeled macroaggregated albumin scan. The children were followed up post-operatively and till resolution of HPS. Results : We report our experience in eight children with HPS. The mean duration of development of HPS post diagnosis of primary liver disease was 3.8 years. 2 patients were symptomatic. There were no major complications intra-operatively . Post-operative ventilator requirement on an average was 384 hours, however 3 patients were still hypoxemic post extubation. Nitric oxide was used in 2 patients with 100% Fio2 requirement post-operatively. The average duration of nitric oxide requirement was 876 hrs. All eight patients had reversal of HPS after a mean postoperative period of 153 days with mean ICU stay of 28 days. Conclusion : High index of suspicion is required to diagnose HPS as only 25% patients were symptomatic at presentation. HPS has no relation to severity of liver disease as 37% patients without cirrhosis of liver had HPS. Although complete resolution of HPS took 3 months , this case series shows that liver transplantation can be done successfully in severely hypoxemic children.

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Background : Hematopoietic stem cell transplantation (HSCT) is a lifesaving therapeutic option for children with multiple hematologic, oncologic, and immunologic disorders. However, a large proportion of children undergoing HSCT develop complications that necessitate admission to the pediatric intensive care unit (PICU). Methods : Study design: Retrospective chart review Setting and patient description: All children younger than 18 years of age, who received an HSCT in our hospital between August 2013 and June 2015, were identified from the HSCT database. Patients admitted to the ICU after HSCT were identified from a prospectively maintained ICU database. Patient data collected from medical charts included demographic information, pre-existing diagnosis requiring HSCT, number and type of transplantation, type of donor and source of stem cells, any complications if associated. Consent: Prior to the start of the HSCT procedure, all parents, and when appropriate, all patients, gave written informed consent to analyse clinical data for study purposes. PICU data: Indication for PICU admission, diagnosis, ventilator and inotrope requirement, if applicable and organ dysfunction. The outcome of patients, whether survival or death at discharge and follow up at 28days were done. Statistics: Descriptive and inferential statistical analysis has been carried out in the present study using SPSS 15.0. Results : During the study period, 141 children received HSCT of which 28 children required PICU admission on 33 occasions accounting for a PICU admission rate of 23.4%. Majority of patients were in the age group of 1-5yrs - 20 (60.6%), followed by 6-10yrs- 5(15.2%). The majority had a non-malignancy indication for HCST -22 (66.6%), of which thalassemia was the commonest diagnosis, followed by severe combined immunodeficiency (SCID) and adreno-leucodystrophy. The most common indications for PICU admission were seizures (n=10, 30.3%), hypotension (n=7, 21%) and respiratory distress (n=6, 18%). Sepsis or severe sepsis occurred in 75%, with pneumonia being the commonest focus in 44%. We observed a 64% (n=21) survival following PICU admission. While 26 (80%) patients with severe sepsis were culture positive, gram-negative bacilli were the commonest organisms. The most common organ dysfunction observed was respiratory failure (n=20, 60%) followed by neurological dysfunction (n=15, 45.5%). Acute kidney injury was observed in 11 (33%) patients, of which 5 (45%) required renal replacement therapy. Circulatory failure with hypotension had the highest risk of mortality. Other risk factors significantly associated with mortality were kidney injury(p-0.005), duration of mechanical ventilation (>5days)(p-0.009) and higher inotropic score (>10)(p- 0.004)). Septic shock was the most common cause of mortality in 6 (50%), followed by GVHD in 3 (25%) children. PICU survival was unaffected by the age characteristics, underlying condition or the type of HSCT. Conclusion : Immunocompromised children who need PICU admission after HSCT have high risk of death, especially in the presence of multi-organ failure, of which circulatory dysfunction appeared to have the greatest risk. In our study we observed 64% survival, which is better than previous studies in similar cohorts and comparable to western data. However, survival can be optimized by aggressive multidisciplinary ICU support.

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Background : Sepsis and septic shock poses significant burden of mortality and morbidity. There is abundant literature to state that Inotrope score(IS) and vasopressor-inotrope score(VIS) are important predictors of outcomes and need for rescue therapies such as ECMO after cardiac surgery. However, studies relating VIS to outcomes in pediatric septic shock are sparse. Methods : Retrospective review of patient charts diagnosed to have fluid refractory septic shock admitted to our tertiary care PICU between April 2014 and June 2016.Patient management with fluids and vasoactive agents were titrated using multimodal monitoring. In addition to demographics, type of infections and severity score, we collected hemodynamic data including type and dose of inotrope and/or vasopressor infusions. Max48hr-VIS in PICU was recorded and subjects were stratified in to low-VIS(score </=20) and high-VIS(score >20) groups. Data related to time to resolution of shock, days of mechanical ventilation, number of organ dysfunction, PICU length of stay and hospital length of stay were collected. Statistical analysis was performed using the Windows SPSS software version-16. Continuous and categorical variables were expressed and compared using appropriate statistical tests. Results : Twenty-three children were eligible for inclusion. The mean age was 68 months. Seven (30.4%) had pre-existing comorbidities. Fourteen(60.8%) had culture positive sepsis; of these gram-negative bacilli were the most common. 12 children(52%) had myocardial dysfunction. 17 children(73.9%) developed two or more organ dysfunction including cardiovascular system, and 8(34.7%) had three or more organ dysfunction including cardiovascular system. The average PELOD score was 15.2. Median time to resolution of shock was 24hrs(IQR 24 - 45hrs). 20 children were ventilated with median duration of ventilation was 48 hrs(IQR 36 – 90 hrs). Median length of PICU stay and hospital stay were 5 days(IQR3.5 –6.5days) and 8 days(IQR 6 – 17.5 days) respectively. Two children died with a mortality of 8.7%. The mean max 48hr-VIS was 41.29 +/-33.9 Max 48hr-VIS positively correlated with PICU stay(r=0.828, p=0.0001), organ dysfunction (r= 0.842, p=0.0001), time to resolution of shock(r= 0.525,p=0.014) and duration of mechanical ventilation(r= 0.468,p=0.037 ) but did not correlate well with hospital stay (r=0.398 ,p=0.06) . Mean max 48hr-VIS for survivors was 34.04 +/- 25.05 which was significantly less than in non-survivors 117.5 +/- 10.6(p=0.0001). There were 13 children in the high-VIS group and 10 children in the low-VIS group. The High-VIS group had worse outcomes compared to low-VIS group. All 8 children who had 3 or more organ dysfunction were in the high-VIS group (p=0.002). The median duration of mechanical ventilation and median length of PICU stay was higher in high VIS group compared to low VIS group. Mortality in the high-VIS group was 15.3%.The low mortality rate even in the high VIS group could be attributed to multimodal monitoring – tailored interventions in our patient population. Conclusion : Max 48hr -VIS positively correlated with PICU mortality, PICU stay, organ dysfunction, time to resolution of shock and duration of mechanical ventilation in children with fluid refractory septic shock. Larger prospective study is needed to identify a far higher VIS cut-off for predicting mortality and morbidity from septic shock.

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Background : Worldwide, sepsis and septic shock poses significant burden of mortality and morbidity. Several well-known algorithms are available to guide the caregiver through a stepwise approach to treat pediatric septic shock. However, the algorithms are based entirely on clinical parameters, which we have precisely reported as unreliable. The guidelines suggest advanced hemodynamic monitoring when the shock remains refractory to fluids and catecholamines. Methods : We retrospectively reviewed 23 patient charts between April 2014-June 2016 with shock refractory to initial 30ml/kg fluid. In the PICU, these patients received extensive hemodynamic monitoring [multimodal-monitoring (eMMM)] which included serial clinical, Ultrasonic cardiac output monitor (USCOM) and echocardiography monitoring to precisely determine the status of circulating volume, cardiac function and systemic vascular resistance. Based on information obtained by eMMM, cardiovascular support including further fluids, inotropes or pressors was personalized to each patient. The data collected were demographics, PELOD score, and hourly VIS for the the first 48 hours in PICU, including the maximum VIS score at 48hours (max 48hr-VIS). We compared the actual mortality of this cohort with the predicted mortality in the same patients based on PELOD scores at 24 hrs of PICU admission and max48hr-VIS. Data related to shock resolution time, ventilator-free days, PICU and hospital length of stay in survivors were collected. Statistical analysis was performed using the Windows SPSS software version 16. Results : A total of 23 children had a discharge diagnosis of fluid refractory septic shock during the study period. Seven (30.4%) had pre-existing comorbidities and 14(60.8%) had culture positive sepsis; of these gram negative bacilli were most common. All 23 underwent eMMM within the first hour of presentation by trained PICU personnel. Hemodynamic derangements delineated included uncorrected hypovolemia in 5(21.7%) pressor-responsive vasodilatory shock in 15(65.2%) and septic myocardial dysfunction in 12(52.1%). The PELOD score was 15.3 with a predicted mortality of 23.2% and the mean max-48hrVIS was 40.8 (+/- 33.9).A max 48hr -VIS of > 20 has been associated with increased mortality.Two patients died (actual mortality 8.7%). Median time to resolution of shock was 24hrs (IQR 24-45hrs). 20 children were ventilated with median duration of ventilation was 48 hrs (IQR 36-90hrs). Median length of PICU stay and hospital stay were 5 days (3.5 –6.5 days) and 8 days (6 – 17.5 days) respectively. The actual mortality was much lower than the mortality predicted from PELOD score and Mean max 48hr VIS score. Conclusion : In children with septic shock and high disease severity as indicated by a high PELOD score, elucidating the precise hemodynamic derangement in each patient using eMMM enables a more customized and flexible resuscitation approach and can result in better than predicted outcomes. Larger numbers are required to validate this approach.

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Background : Pediatric tracheostomy is always a matter of debate. There is no consensus about outcome of pediatric tracheostomy. So this study was proposed to analysis the indications, duration and outcome of pediatric tracheostomy patients in our PICU in a retrospective manner. Methods : We conducted a retrospective chart review of consecutive patients undergoing tracheostomy at PICU of medical college Kolkata, from January 2014 to December 2016. Patient age, sex, emergency or planned tracheostomy, type of tube used, average number of days patient was on ventilation before tracheostomy, indications, complications, and decannulation time were all assessed. Bronchoscopy was done in all cases of difficult decannulation and where clinician decided. Results : In this two years duration total 32 patients undergone tracheostomy in our unit. All tracheostomy procedure was done in ENT OT using open method using Protex tube. Most common indication was prolonged ventilation (87.5%) followed by difficulty in maintaining airway and airway obstruction. Most common disease needing tracheostomy due to prolonged ventilation was encephalitis (71.4%) followed by GB syndrome (14.28%). Average day of ventilation was 10 before tracheostomy. Among this patient 5(15.62%) died due to primary disease related cause and in two of case decannulation was not possible. No patient died due to complication of tracheostomy. Early side effects like hemorrhage (21.8%), accidental decannulation (6.25%) was seen and one needed bronchoscopy guided laser surgery to remove granuloma before decannulation. Conclusion : In our study it was found that tracheostomy helped in prolonged ventilation and decannulation rate is also high in comparison with other studies. Major complications like tracheoesophageal fistula, tracheocutaneous fistula, subglottic stenosis (only one case) are rare. So choosing early tracheostomy in indicated cases we can avoid complications of prolonged intubation.

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Background : Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excess of thyroid hormones- triiodothyronine (T3) and thyroxine (T4) Results : A one year old girl was noticed by her mother to be consuming levothyroxine tablets, a T4 preparation, with 5-6 tablets lying on the floor alongside the empty bottle, which had around 20 levothyroxine 100 microgram tablets in it before consumption. The tablets were prescribed to the grandmother for hypothyroidism. The child developed nausea and vomiting 1 hour later to the consumption and was brought to the paediatric emergency in conscious but irritable state (Glassgow Coma Scale-E4M6V4). Physical examination revealed tachycardia (Heart rate=157 per minute) and hypertension (BP= 134 /85mmHg in right upper limb, 95th centile=104/58 mmHg). Rest of the systemic examination was normal. ECG showed sinus tachycardia. Her 6 hour post-ingestion thyroid function tests showed suppressed Thyroid stimulating hormone (TSH) levels [ total T3 was 2.04 ng/ml (normal range : 1.05-2.45); T4 was 16.10micgm/dl (normal range :7.8 – 16.5); TSH was 0.02 micIU/ml( normal range : 0.7 – 6.4). Gastric lavage was done and she was treated with propranolol (1mg/kg/d), Prednisolone (2mg/kg/d) and intravenous fluids. Tachycardia hypertension and vomitings became passive 12 hours post admission. She child remained afebrile throughout her hospital stay. Her gastric washings sent for forensic analysis didnot reveal any noxious substance. Thyroid Function tests repeated at 24 hours and at 7 days post ingestion were found to be normal. She was discharged on day 4th day post admission. Propranolol was stopped after 7 days and steroids were given for 5 days. She was kept under close followup on outpatient basis till one month post discharge and remained well and playful. Thyroid storm is a potentially life threatening condition which should be immediately diagnosed and managed. In children, it usually follows exploratory (accidental) ingestion of levothyroxine in large doses (0.5-2mg) [1]. The child often remains asymptomatic in initial few hours post ingestion. The index child strikingly, developed symptoms of intoxication within first 2 hours of ingestion. However, there was a clinical – biochemical dissociation as the thyroid function tests showed only TSH suppression and not elevated T3/T4 levels. She improved after treatment with beta blockers and steroids and didnot develop any delayed features of thyroxine toxicity. The clinical - biochemical dissociation evident in our case has also been reported previously as worsening clinical symptoms donot correlate closely with plasma levels of total T4 and total T3 [2,3]. Delayed manifestions are also possible which are attributed to the time required for the peripheral conversion of T4 to the active component, T3 [2]. Levothyroxine ingestion in low doses usually responds to gastric decontamination and supportive management. Incase of large dose ingestion also, antithyroid medications are not required [2]. Children respond to betablockers and steroids and intravenous rehydration. Betablockers like propranolol are used to offset the symptoms of drug induced thyrotoxicosis on the heart like tachycardia and prevention of arrhythmias. Steroids are given in large dose ingestion to decrease the conversion of T4 to T3, the active hormone. Conclusion : Exploratory thyroxine ingestions donot have severe outcomes however close monitoring is needed even during asymptomatic period due to the risk of delayed toxicity symptoms beyond one week of ingestion.Serial TFTs have limited use to guide management and prognosticate outcome.

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Background : The high-flow nasal cannula (HFNC) is a novel oxygen supply device capable of delivering up to 100% humidified and heated oxygen at a maximum flow rate of 60 l/ min. It has been shown to confer many potential advantages compared with traditional oxygen delivery devices, and leads to improved physiological outcomes. Methods : The study was a retrospective chart review of children with respiratory distress/failure admitted 1 year before (period before high-flow nasal cannula therapy) and 1 year after (period after high-flow nasal cannula therapy) the introduction of high-flow nasal cannula therapy. We compared quality indicators as rate of mechanical ventilation, total duration of mechanical ventilation, pediatric intensive care unit length of stay and mortality rate between these periods. Results : Between March 2015 and April 2017,371 patients: 152 before and 219 after high-flow nasal cannula therapy (HFNC) were reviewed (median age was 30 mo). Among patients with severe respiratory distress/failure subgroup, the rate of intubation was significantly lower after using HFNC therapy as compared to other group (HFNC therapy was not used) (40.1% vs 18.3 %; P <0.001). The duration of mechanical ventilation was longer in the period before than period after high-flow nasal cannula (145hrs vs 133hrs; p<0.791). The mean length of PICU stay was slightly shorter in patients in the period after HFNC than in the period before HFNC (5.83days vs. 5.06days; P=0.07). There was no significant difference in the PRISM score between two period groups. Mortality rates were significant, higher in the period before HFNC than period after high-flow nasal cannula therapy group (7.2% vs 1.4%; P=0.004). Conclusion : Implementation of high-flow nasal cannula therapy in pediatric intensive care unit significantly improves the quality of therapy and its outcomes.

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Background : Diphtheria is still a fatal infectious disease even in this era of universal immunization. Despite the availability of antitoxin and antibiotics, mortality rate for diphtheria still remains very high. The disease has been completely eradicated in most of the developed countries. On the contrary, in developing countries, although the incidence has drastically declined, still account for 80-90% of global burden. There are so many factors which predict the mortality and outcome. The present study has been undertaken to elucidate the clinical profile and predictors of outcome of patients with diphtheria in a tertiary care pediatric center from Southern India. Methods : All children between the age group of 0 to 15 years admitted with signs and symptoms of diphtheria during January to August 2017 formed the study group. Throat swab for Albert’s stain and culture sensitivity were sent in all patients under study at the time of admission. All children were started on parenteral crystalline penicillin and Anti Diphtheritic Serum (ADS) was given in a single dose as recommended. All details i.e demographic data, clinical features, immunization status, complications and outcome was entered in systematically designed proforma and analysed. Several variables were compared among the survivors and non survivors to determine the predictors of outcome. Outcome is defined as either recovered or died. Results : A total of 42 patients were included in the study group. Among 42 patients, 21 (50 %) were between 1-5 years, 12 (28 %) were between 0-5 years and 9 patients (22 %) were more than 10 years. Among 42, 32 patients (76 %) of patients were from rural Karnataka. 45 % of patients were unimmunized. Most common symptoms were fever seen in 42 cases, throat pain in 38 cases, difficulty in swallowing in 30 cases and bull neck in 30 cases. Alberts stain was positive in 83% of cases and culture positivity in 30% of cases. Among complications myocarditis was seen in 20 patients (47%), acute kidney injury (AKI) in 17 patients (40%), airway compromise in 25 patients (59%) and thrombocytopenia in 18 patients (42%). A total number of 19 patients died. Among non survivors myocarditis was present in all patients, AKI was present in 63% (12 cases) and thrombocytopenia in 42% (8 patients) of cases. Conclusion : Diphtheria is highly fatal disease with increased mortality. Myocarditis was the commonest and most serious complication of respiratory diphtheria. Presence of myocarditis, AKI, thrombocytopenia, airway compromise and inadequate immunization are important predictors of outcome.

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Background : Multiple studies have shown outcome and prognostic factors of mortality for childhood allogeneic hematopoietic stem cell transplantation (HSCT) patients requiring pediatric intensive care unit (PICU) care but there is no such study from India. In our study we analyzed the data in our centre. Methods : Retrospective analysis of data from bone marrow unit and PICU of our hospital was done. We reviewed all charts to find out the indication of admission, outcome and probable prognostic factors. Results : A total of 152 patients underwent allogeneic HSCT in last 2 years. 22 patients were admitted in PICU out of which 17 (77.2%) patients were of non malignant disorders and 5 cases (22.7%) of acute leukemia. Admissions were for various transplant related complications including multiorgan dysfunction syndrome/MODS (40.9%), respiratory distress or failure (40.9%) and neurological complication (18.2%). Total 16 patients (72.7%) expired and 6 were discharged. 1 patient died within 1 month of PICU discharge. Bacterial sepsis and septic shock (43.7%) was the commonest etiology of death followed by disseminated adenovirus infection (18.7%). All of the MODS patients expired and those with only neurological problem were discharged. On statistical analysis delayed neutrophil recovery (p=0.01), MODS (p=0.00), use of vasoactive support (p=0.00), high plasma creatinine (p=0.00), low platelet count (p=0.00) and bacterial septic shock (p=0.02) were important predictor of mortality. Conclusion : In our study, pediatric allogeneic HSCT recipients who were admitted in PICU had high mortality. Sepsis was the one of the commonest etiology for MODS leading to poor outcome. Prevention of sepsis and early transfer in PICU can reduce overall mortality in HSCT patients.

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Background : Respiratory failure leads to inadequate delivery of oxygen to tissues (DO2) thereby causing tissue hypoxia and subsequent organ damage .Packed Red blood cell transfusions are given in children with ARDS to improve tissue oxygen delivery though the optimal hemoglobin threshold is still not defined in pediatric ARDS (PARDS). Methods : This was a open labelled feasibility trial where 40 critically ill ARDS children (1 month- 12 years) with a hemoglobin concentration of less than 9 gm/dl within 7 days of onset of ARDS were randomized into either lower hemoglobin transfusion threshold group of 7 gm/dl with targeted hemoglobin range of 7 gm/dl to 9 gm/dl or higher hemoglobin transfusion threshold group of 9 gm/dl with targeted hemoglobin range of 9 gm/dl to 11 gm/dl and intervention period was till child was mechanically ventilated or maximum 28 days of randomization or till time of death whichever occurred first. Leukocyte reduced PRBCs were transfused in both the groups once transfusion threshold was met. Results : Number of children requiring PRBC transfusion (p=0.001) and volume (ml/kg) of PRBC transfused per transfused patient (p=0.02) were significantly less in lower hemoglobin transfusion threshold group as compared to higher hemoglobin transfusion threshold group. Overall 28 days mortality was similar in both groups (p=1). New onset/progressive MODS (p=1), 28 days ventilator free days (p=0.42), length of PICU stay (p=0.29), hospital stay (p=0.35) and adverse events following transfusion (p=0.28)were similar in both groups. Conclusion : Both lower and higher hemoglobin transfusion threshold strategy in pediatric ARDS were similar with respect to mortality, The lower hemoglobin threshold strategy however decreased the rate of exposure and volume of PRBCs in pediatric ARDS patients. However to prove that lower hemoglobin threshold strategy is better than higher a multicentre superiority trial is needed.

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Background : β-ketothiolase deficiency is an organic acid disorder that result from inability to process the amino acid isoleucine and ketone bodies. Its deficiency occurs in less than 1 in 100000 births. Till date around 60cases were reported from over 25 countries. It is inherited as an Autosomal recessive disorder. Mutation in the ACAT1 gene causes β-ketothiolase deficiency. It is characterized by an increased plasma glycine levels, metabolic acidosis and ketosis. Individuals with β-ketothiolase deficiency are at risk of developing metabolic crisis, particularly after fasting, illness/infection or high protein intake. Patients usually present with lethargy, ketosis, metabolic acidosis, feeding difficulty, fever, diarrhea, hypoglycemia /hyperglycemia and sometimes as coma or death. Methods : 6 months male child born out of 3rd degree consanginous marriage presented with Acute gastroenteritis with severe dehydration and high anion gap metabolic acidosis with altered sensorium, schock and without organomegaly not responding fluid management and ionotropes. Subsequently child was found to have hyperglycemia and ketonuria for which child was treated as per protocols of DKA and also added antibiotics empirically suspecting sepsis but child had persistent severe ketoacidosis and poor GCS inspite of normoglycemia which led to suspicion of IEM for which urine for GC-MS which was suggestive of beta keto thiolase defeciency. Results : Inspite of adequate fluid and bicarbonate corrections child repeatedly had metabolic crisis and succumbed to death. Conclusion : An infant with Acute gastroenteritis with severe dehydration and presenting features of DKA if not responding to initial management and having persistent ketosis with altered sensorium could be a possible IEM and ealrly diagnosis of which would result in improved outcome with best possible interventions and also useful in perinatal diagnosis.

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Background : Pediatric Early Warning Score (PEWS) has been developed for hospital inpatients to identify patients at risk of deterioration. Beyond triage, similar systems that identify ill patients and predict requirement for a higher level of care are needed in the emergency department. Methods : Twenty one hundred patients who fulfilled the inclusion and exclusion criteria were included in this prospective observational study. A correlation between the PEWS and disposition of the patients from Emergency Room (admitted to ward or PICU, discharged to home) was made. Validity of scoring system for predicting need of critical care admission was assessed using receiver operating characteristics (ROC) analysis, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Children with PEWS of =3 were compared to children with PEWS of 0-2 with regard to age, diagnostic group and outcome. Results : Out of 2100 patients who presented to emergency room during the study period, 86.9% (n=1825) were discharged, 7.2% (n=151) were admitted in ward, 5.9 %( n=124) were admitted in PICU. Assigned scores ranged from 0 to 11.The area under curve (AUC) for predicting PICU admission was excellent [0.973 (95%CI: 0.957-0.989)]. The sensitivity and specificity in predicting PICU admission derived from the ROC curve with a cut off of PEWS =3 were 93.4% and 94.1% respectively, PPV and NPV were 51.6% and 99.5% respectively. The AUC for predicting ward admission was 0.790 (95%CI: 0.746-0.834) which was fair, compared to results in predicting PICU admission. The sensitivity and specificity in predicting overall admission derived from the ROC curve with a cut off of PEWS =1 were 74.2% and 77.1 % respectively. PPV and NPV were 21.2% and 97.3% respectively. A younger age and diagnostic group such as respiratory and cardiovascular diseases were more commonly associated with PEWS =3. Pain Abdomen and minor injuries (Clean lacerated wound) were associated with PEWS of 0-2. Conclusion : The Pediatric Early Warning Score can be implemented in a busy, dynamic ER, with well-trained nurses and with excellent data capture. Patients with elevated scores, have increased need of admission to Intensive Care Unit or paediatric ward. PEWS =3 is sensitive as well as specific for predicting need for admission to PICU from pediatric ER directly.

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Background : Sepsis forms a major cause of morbidity and mortality in children.Currently, the gold standard for diagnosis for sepsis is culture. However, they suffer from low yield, delay in providing actionable results and inability to grow fastidious organisms and fungus quickly enough to guide therapy in time. Newer molecular methods like multiplex polymerase chain reaction(PCR) systems have been recommended by Infectious Disease Society of America (IDSA) to improve the yield as well as time to intervention in these life threatening emergencies. Syndrome Evaluation System (SES) is one such test which has shown benefits in neonatal sepsis. Methods : In this retrospective case series, we analysed 57 paediatric cases admitted to our PICU during October 2015 to February 2017. The clinical presentations were sepsis, systemic infections, meningitis and febrile neutropenia. SES is a multiplex PCR based molecular diagnostics involving DNA extraction, multiplex amplification of virulence specific genes followed by sequence specific hybridization. Blood,Cerebrospinal fluid( CSF) and other focal specific samples like Bronchoalveolar Lavage(BAL), etc were tested by SES as well as routine cultures. Decision to change antimicrobial therapy was based on culture and sensitivity results, as well as SES. Outcomes were recorded. Results : 57 cases (28 males, 29 females, mean age 5.72±4.34 years) were analysed. SES and corresponding Blood cultures were done for 26 patients, of which 4 had positive blood cultures, yielding a detection rate of 15.4% vs 26.9% 7 by SES (7/26) .24 CSF and 7 other body fluid samples underwent both cultures and SES. All these cultures were negative. SES was positive in 5 (20.8%)CSF and 7 (100%) other body fluids. Overall, the yield was7.0% for cultures vs33.3% by SES. SES was positive in 89.5% and 94.7% of CRP and Procalcitonin positive cases respectively. SES was negative in 87.7% and 93.3% of CRP and procalcitonin negative cases respectively. Among CSF cell count positive and negative cases, SES was positive and negative in 30% and 81.2% cases respectively. SES results were available to us within 24 hours, as compared to 48 hours for traditional culture. Out of 19 SES positive cases, we escalated antimicrobials in 10 and de-escalated in 9. In 38 SES negatives, we de-escalated antimicrobials in 16 , escalated in 1 and made no change in remaining 21. In effect 36 /57cases (63.15%), underwent change in antimicrobial therapy based on SES results. Conclusion : In this retrospective analysis, we have seen a 4.75 fold increase in detection rates using SES, as compared to traditional culture. SES results seem to correlate with CRP and Procalcitonin. Most importantly, SES results elicited change in antimicrobial therapy in 63.15% of the cases. The fact that we de-escalated antibiotics and antivirals, with no adverse clinical course, shows that emerging molecular diagnostics like SES have good negative predictive value. We feel that molecular diagnostics in PICU setting, used in conjunction with traditional culture, may reduce antimicrobial usage and overall cost of therapy.

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Background : Dysnatremia and dyskalemia are common causes of clinical concern while managing critically ill children in Pediatric Intensive Care Unit (PICU). Methods : A retrospective audit of PICU admissions (January 2016 to December 2016) at Kalawati Saran Children’s hospital, New Delhi, was conducted. Children aged 1 month to 18 years were included and data related to age, sex, duration of hospital stay, diagnosis, and mortality was collected. Values of serum sodium and potassium at admission were recorded. Serum sodium level between 135-145 mEq/l was considered as normal. Hypernatremia was defined as serum sodium >145 mEq/l (mild: 146-149, moderate: 150-169, and severe: = 170) and hyponatremia as serum sodium concentration of < 125). Serum potassium level between 3.5-5.4 mEq/l was considered as normal. Hypokalemia was defined as a serum potassium level < 2.5) and hyperkalemia as serum potassium level =5.5 mEq/l (Mild: 5.5-6.0, Moderate: 6.1-7.0, and Severe: > 7.0). Children with dysnatremia and dyskalemia were managed as per standard treatment protocols. Univariate logistic regression analysis was performed to evaluate the relation between admission dyselectrolytemia and mortality. Results : A total 745 children (mean age 67.2±57.7 months, M:F ratio 429:316, mean duration of stay 8.6±11.4 days) were admitted in PICU during study period. Mortality was reported in 96(12.8%) children. The data for sodium values was available in 638 children. Hyponatremia was observed in 125 (19.6%) children (mild-69.6%, moderate-22.4%, and profound-8%) and hypernatremia in 124 (19.4%) children (mild-45.2%, moderate-50%, and severe-4.8%) during study period. In hyponatremic patients, the most common diagnosis were infections (42.4%) followed by renal (17.6%) and respiratory (12.8%) disorders. The most frequent diagnosis in children with hypernatremia was infections (41.9%), followed by respiratory (13.7%), and renal disorders (12.9%) respectively. Hyponatremia (OR: 1.51±0.42, p=0.137) and hypernatremia (OR: 1.04±0.322, p=0.89) were not significantly associated with mortality. Data for potassium values was available in 662 children. Hypokalemia was observed in 117 (17.7%) children (mild-50.4%, moderate-31.6%, and severe-18%) and 116 (17.5%) with hyperkalemia (mild-50%, moderate-36.2%, and severe-13.8%). The causes of hypokalemia were infections (46.1%) followed by renal (14.5%), and respiratory disorders (8.5%) and the causes of hyperkalemia were infections (38.7%), respiratory (23.2%), and renal (20.7%) disorders. Both hypokalemia (OR: 1.30±0.38, p=0.361), and hyperkalemia (OR: 0.92±0.296, p=0.8) were not significantly associated with mortality. Conclusion : Electrolyte abnormalities are common in critical children admitted to PICU. These are mostly seen in infections, followed by renal and respiratory disorders. Burden of dyselectrolytemia in PICU is significant with 39% and 35% of children having dysnatremia and dyskalemia respectively. Electrolyte derangements require definitive corrective measures and contribute to morbidity; however, we did not observe an association with increased mortality. Strengths of study include a large sample size however, our study is limited by its retrospective design and missing data in a number of included children.

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Background : Viper snake constitute 10% of overall snake bites in India. Coagulation abnormalities due to these are traditionally known, but laboratories have rarely reported derangments beyond a few days of envenomation. Neurological symptoms attributated to viperidae are one of it’s kind. Methods : A 5 year old boy presented to us with history of Viper snake bite on right middle finger. He had deranged coagulation profile to start with which warranted a dose of antisnake venom. Over the course, he had persistent and recurrent deranged bleeding profile requiring repeat dosages of antisnake venom. Later he developed hypertensive emergency exhibiting in the form of posterior reversible encephalopathy syndrome. This displayed it’s effect in form of seizures. Also its worth mentioning here that he experienced anaphylaxis to the antisnake venom which revealed itself as maculopapular rash and later progressed to acute respiratory distress syndrome mandating ventilator support. Results : This eventful post bite sequelae finally subsided gradually. The patient was discharged after three weeks. Conclusion : Patients with viper snake bite can have persistent and recurrent coagulopathy and neurotoxic effect. Frequent monitoring for same is advised. Atypical display of Viperadae, should be kept in mind.

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Background : The role of corticosteroid therapy in septic shock is ill defined. Hydrocortisone is widely used in patients with septic shock, even though a survival benefit has been reported only in patients who remained hypotensive after fluid and vasopressor resuscitation and whose plasma cortisol levels did not rise appropriately after the administration of corticotropin. Methods : Children (1 month to 18 years age) with catecholamine resistant septic shock were recruited during the study period between July 2012-December 2012. Children with low cortisol levels received hydrocortisone therapy as per septic shock guidelines. The outcome of these children were compared to the group with normal cortisol levels. Results : 60 out of 100 children with septic shock were catecholamine resistant. The proportion of children with low cortisol levels was 23/60 (38.3%). The demographic profile of the 2 goups were comparable in terms of median age in years (2(IQR 0.9,6) vs 3(IQR0.8,8)), gender ratio (M:F:: 0.8:1 vs 1:1) and median PRISM III Score [10(IQR 7,15) vs 15(IQR 8,20), p=0.17)]. Hydrocortisone therapy in the low cortisol level group improved survival as compared to the group with normal cortisol levels (52.2% vs 24.3%, p < 0.02). However, length of PICU stay [6 (IQR2,8) vs 4 (IQR 2,8)], hospital stay [8 (IQR 2,11.5) vs 4 (IQR 2,10)] in days, inotrope duration [84 (IQR 36,144) vs 72 (IQR 36,168)] and ventilation duration [84 (IQR 48,144) vs 72 (IQR 48,120)] in hours was not statistically significant (p>0.05). Conclusion : Our data strongly supports the use of hydrocortisone for catecholamine resistant septic shock. However, randomised control trials with larger sample size are warranted to define its role in the management of pediatric septic shock.

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Background : Serial electrophysiological evaluation in adults admitted to Intensive Care Unit (ICU) has shown an incidence of Critical Illness Myopathy and Polyneuropathy as 30% (CRIMYNE STUDY). There is no prospective serial electrophysiology based study in children admitted to ICU. Methods : Trial Registry Number: NCT02763709 A prospective cohort study of all children (2-12 years) admitted to PICU with Pediatric Risk of Mortality (PRISM) of > 20 for more than 24 hours was conducted in PGIMER, Chandigarh from January 2016 to December 2016. A complete electrophysiological evaluation (4 motor nerves and 2 sensory nerves) was performed at baseline. Children with preexisting or current neuromuscular disorder were excluded. Following the entry evaluation, daily simplified electrophysiological testing of unilateral sural nerve and common peroneal nerve was assessed. A 25% decrease in Sensory Nerve Action Potential and Compound Muscle Action Potential from baseline was considered as significant reduction suggestive of PED CIMP and was followed by complete electrophysiological reassessment for confirmation. Results : During the study period, of the total 481 children assessed for eligibility, 97 were enrolled. The median age of the cohort was 7 years. Sepsis (81%); Vasoactive support (43%); Multiorgan dysfunction (26%) were the common risk factors. Of the 433 eligible patient ICU days, 380 electrophysiological observations were done with a median duration of nerve conduction study of 3 days. A significant reduction of greater than twenty-five percent in CMAP of common peroneal nerve was not detected in any of the 380 observations. However, a solitary case who did not fit the inclusion criteria was diagnosed with PED CIMP during the study period. Conclusion : Unlike adults, children admitted in ICU with PRISM>20 have a very low incidence of PED CIMP by serial electrophysiological evaluation.

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Background : Dengue Fever (DF) is an important tropical infection attributing to mortality in children. Fluid therapy remained as cornerstone in management of Severe Dengue (SD). Current WHO protocol guide initial fluid therapy based on presence of Shock, Packed Cell Volume (PCV) and presence of Bleeding, while the fluid de-escalation is based on PCV reduction, shock stabilization and it is done in staggered manner. We aimed at studying the feasibility of Restrictive maintenance fluid therapy strategy (RMFTS) - where after 10 ml/kg crystalloid bolus, maintenance fluid will be immediately reduced to 50 % of Holiday Segar calculated volume and further matched to target Fluid Overload % < 1% (10 ml/Kg/Day) along with the help of early use of vasoactive drugs. Methods : Children (2months-18years age) with Severe Dengue admitted with Shock (GROUP A) and Dengue with warning signs (DWS) (GROUP B) were consecutively enrolled and initiated on RMFTS regimen of fluid therapy along with the use of early vasoactive drugs when necessary after parental consent. PCV, platelet count, Haemoglobin, BP, HR, RR, Lactate, Ferritin, SGOT, SGPT, LDH, eCrCl were measured at baseline and after starting fluid therapy serially. These measurements were compared between both groups. The study was initiated after IEC and IRB approval and enrolment happened from May 2016 to Mar 2016 (10 months). Results : Of 40 children enrolled, 20 were SD with shock and 20 were DWS received fluids in view of vomiting and abdominal symptoms. All these children were treated with RMFTS. Baseline PCV, SGOT, SGPT, Ferritin, LDH and eCrCl were comparable in both groups. Lactate was significantly higher in SD with shock group. Despite longer duration of parenteral fluid therapy in Group-A (3.2 Vs 2.3 days p0.01), total quantity of fluid given was comparable (1.4 Vs 1.2 ml/kg/hr p0.409) in both groups. This was feasible by early use of vasoactive drugs mainly as low dose adrenaline (at 0.05 mcg/kg/min). Although the percentage rise of haematocrit from the baseline was significantly different among both the groups (51.01 Vs 23.8 % p 0.00), the percentage of maintenance fluid therapy given in first 24 hours of admission in both the groups were similar (66.9 Vs 61.32% p 0.098) and the total quantum of fluid given was also similar in both the groups. The change in haematocrit did not correlate with the amount of fluids given. Fall in Ferritin, SGOT, SGPT, Lactate did not correlate with the amount of fluid received by children in either group. Conclusion : RMFTS along with the early use of low dose vasoactive drugs is feasible to be used in resuscitation of children with SD in shock even in the presence of hemoconcentration. Hence the fall or rise in haematocrit may not directly help in staggered titration of parenteral fluid therapy.

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Background : Portable chest X-rays (CXR) are done on almost daily basis to diagnose lung diseases like pulmonary edema, pneumothorax, consolidation, atelectasis and pleural effusion in critically ill patients. Bedside CXR has been reported to exhibit limited diagnostic performance as compared to CT-scan. There are lots of concerns with radiation exposure and transportation of sick child to CT-scan room. Ultrasonography (USG) has the advantage of being radiation free and can be done at bedside. But there is paucity of data on comparison of CXR and USG chest in detecting the serious lung conditions in pediatric patients. Methods : Design: Prospective, double blinded, observational study. Setting: Multidisciplinary PICU at an urban, academic, quaternary care children’s hospital in Delhi. Participants: All Children between (1 month-18 years) admitted in PICU. Four hundred sixteenpatients were enrolled, with 1002 episode numbers, over 10 months. The findings of lung USG were analyzed zone wise as described in Blue protocol and were compared with frontal view CXR. All CXR were reported by an experienced radiologist who was blinded to lung USG findings. While a pediatric intensivist, trained in point-of-care ultrasonography and was blinded to CXR findings, performed lung USG. Weighted Kappa statistics was used to assess the agreement between the two modalities. Sensitivity (Sn), Specificity (Sp), Positive predictive value (PPV), Negative predictive value (NPV) and Accuracy (Acc) of lung ultrasonography in comparison to CXR were calculated for various lung diseases in different lung zones. Categorical data was compared using Chi square test. P value < 0.05 was considered significant. Results : Inter-observer agreement (kappa value) between CXR and lung USG findings for different zones, irrespective of pathology was [right upper zone(RUZ) 77.8%,right middle zone(RMZ)75.6%,right lower zone(RLZ) 66.3%,left upper zone(LUZ) 79.2%,left middle zone(LMZ) 66.3%,left lower zone(LLZ) 61.4%]. The accuracy of USG in detecting pneumothorax in upper zones of both lungs was 100%. For pulmonary edema the Sn, Sp, PPV, NPV and Acc (94.7%,98.6%,58,99.9,0.97 respectively) were best for RUZ.The accuracy of lung USG was 100% in diagnosing atelectasis in lower zones bilaterally. The Sn, Sp, PPV, NPV and Acc for detecting pleural effusion in RLZ were (91.5%,94%,65,98,0.91 respectively). The values for RMZ, LMZ and LLZ were comparable. The accuracy of diagnosing consolidation by USG varied from 0.86 to 0.95 in different lung zones with highest PPV and NPV in LUZ. USG lung diagnosed pulmonary edema in 111/281(39.5%) episodes where CXR was reported normal (Chi square statistic 81.7,P<0.05). Similarly pneumothorax was not observed in CXR in 9/41 (22%) episodes with positive USG findings (Chi square statistic 12.3,P 0.0003). Pleural effusion was detected in 102/275 (37%) episodes without any supportive evidence from CXR (Chi square statistic 28.1,P<0.005). Conclusion : USG is atleast equal or probably better modality than CXR for diagnosing different lung pathologies in PICU.

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Background : Super-Refractory status epilepticus is a neurological emergency associated with mortality and morbidity. Super Refractory Status Epilepticus is defined as seizures continuing 24 hrs or more on the onset of anesthesia and seizures recurs upon treatment reduction. Methods : Retrospective review of case records over the last two and half years of all children where isoflurane was used in the management of Super Refractory Status Epilepticus in a tertiary care PICU. Demographic data, clinical profile, duration of isoflurane and their outcome was collected in a standard excel sheet. Results : Six children (3 male and 3 female) with super Refractory Status Epilepticus received Continuous Inhalation Anesthetic over the last two and half years. All these children received an average of eight to ten Antiepileptics (Mean: 9) prior to the initiation of Inhalational Anesthetic. The inhalational Anesthetic were started between 2- 17 days (Mean: 13 days) after the onset of Refractory Status Epilepticus for an average duration of 4 days. Regardless of the seizure semiology all children achieved burst suppression within minutes of initiating inhalational anesthetic therapy. Mean Minimum Alveolar Concentration where burst suppression was achieved was 1.1 MAC. All children required inotropes due to continuous inhalational Anesthetic and the mean vasotrope inotropic score was 23. Two children died and four children survived with average of Glasgow Outcome Score of 2. Complications during Inhalational Volatile Anesthetic were hypotension (7/7) and Ventilator Associated Pneumonia (5/7). None of the children had renal or liver failure secondary to isoflurane. Conclusion : Isoflurane was found to be safe and effective in suppressing Super Refractory Status Epilepticus and the mortality and long term morbidity is due to the underlying disease process.

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Background : Button battery ingestion is emerging as a potential health problem of alarming proportions in young children. An increased usage in household electronics, easy accessibility to children and switch to durable but larger diameter higher voltage lithium batteries has resulted in increased morbidity and mortality over these past few years. Moreover, the symptoms of button battery ingestion are often non-specific and can lead to delay in diagnosis, especially in unwitnessed cases. Methods : This was a retrospective chart based review of all cases admitted with alleged history of button battery ingestion between 2016 to 2017. All such cases were identified and data regarding demographic, clinical, radiological and complications profile were recorded in a proforma and analyzed using standard statistics measures. Results : A total of 7 cases of button battery ingestion were included in the study. The mean age of patients was 1.6+0.9 years with 4 males and 3 females. Admission was within 24 hours of ingestion in 2 cases, between 2-5 days in 3 cases and beyond 1 month in 2 cases. The type of battery in all cases was lithium based. The common presenting symptoms were fever, cough, vomiting and refusal to feed (n=4 each) with two patients having drooling of saliva and 1 presenting with dysphonia. Five out of seven cases had witnessed ingestion while two were diagnosed radiographically. Prompt endoscopic removal was performed in all patients with most batteries lodged at level of cricopharynx (n=5). Major complications developed in 4 patients including tracheoesphageal fistula (n=4), aspiration pneumonitis (n=4), esophageal rupture (n=2), pleural effusion (n=2), pneumothorax (n=2) and mediastinitis (n=1). Three patients expired and four were discharged without sequelae. Conclusion : Early recognition and timely endoscopic removal is mandatory in cases of esophageal button battery ingestion. The prevention of serious injuries by creating physician and parent awareness regarding the hazardous effects of button battery is the need of the hour. Stringent rules and regulations regarding safer battery compartment designs, child resistant packaging and norms for discarding used lithium batteries would help in decreasing the incidence of this preventable epidemic.

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Background : Early recognition and treatment of severe sepsis has led to improved survival outcomes. Having reliable indicators that would prognosticate the survival of these patients is important and would subsequently guide in effective triaging and targeted management. Methods : This is a prospective observational study involving 120 patients at King George’s Medical University between July 2015 to June 2016 diagnosed with severe sepsis or septic shock. Blood pressure including systolic and mean (SBP, MBP), heart rate (HR) and shock index (SI=HR/SBP) were measured at admission (X0) and hourly till 6hours (X1-6). Serum lactate was measured at 0 and 6 hours. The patients were divided into 3 groups: Group 1: Results : Septic shock was present at admission in 67 (55.8%) children. About 58 (50%) children expired within 48hours. All hourly shock indices (SI 0-6) were significantly higher among the non-survivors in group 2 (p=0.03;p=0.01;p=0.0 0;p=0.00;p=0.00;p=0.00;p=0.00) and group 3 (p=0 .00;p=0.00;p=0.00;p=0.00;p=0.00;p=0.00;p=0.00). In group1, SI after 2 hours was significantly higher in non-survivors (SI 2-6: p=0.02; p=0.01; p=0.00; p=0.00; p=0.00). AUROC (AUC ; 95% CI) for shock index was 0.7 (0.52-0.9), 0.7 (0.51-0.8) ,0.8 (0.6-0.9) at 0 hours and 0.8 (0.6-1), 0.7 (0.6-0.9) ,0.8 (0.7-1) at 6 hours in 3 groups respectively. The cut-off values of SI0 for predicting mortality (sensitivity; specificity; PPV; NPV) in 3 groups were 1.97 (77;75;35;95), 1.42 (69;57;22;92), 1.25 (90;67;33;98) and SI6 were 1.66 (85;80;44;97), 1.37 (73;70;32;94), 1.29 (79;67;34;95). SI0 had highest AUROC than HR, SBP, MBP in group 1(0.7,0.6,0.6,0.5), group 2(0.7,0.6,0.6,0.6) and group 3(0.8,0.6,0.8,0.8). SI6 also had better AUROC to predict 48 hours mortality than HR,SBP,MBP in group 1(0.8 ,0.7, 0.8,0.7), group 2(0.8,0.7,0.7,0.8) and group 3(0.8,0.7,0.8,0.8). Serum lactate was higher in nonsurvivors both at admission (5 vs 2.7; OR=1.5; 95%CI=1.2-1.9; p=0.00) and after 6 hours (4.8 vs 1.7; OR=1.8; 95% CI=1.4-2.3; p=0.00). Children with higher SI0 were significantly associated with hyperlactemia (>4mmol/L) (OR=3.2; 95%CI=1.2-8.3; p=0.01), need of priming within 24 hours (OR=5.4; 95% CI=2-14; p=0.0) and vasopressor use within 48 hours (OR=4.5; 95% CI=1.6-12.8 ; p=0.00). After 6 hours also, higher SI was statistically associated with hyperlactemia (OR=4.4;95% CI=1.6-12;p=0.00), need of mechanical ventilation (OR=7.3;95%CI=2.5-21.2;p=0.00) and requirement of priming within 24hours of admission (OR=4.8;95% CI=1.8-12.6;p=0.00). Conclusion : Shock index, a non-invasive marker can better predict early mortality in patients of severe sepsis and septic shock compared to conventional signs.

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Background : Septic shock management aims to restore tissue perfusion targeting certain therapeutic endpoints to guide adequacy of resuscitation. We aimed to detect the association between changes in these physiologic variables [collected at baseline, 1 hour(hr), 3 hr, 6 hr, 12 hr,24 hr,48 hr and 72 hr] during resuscitation in septic shock patients with fluid overload (FO) at 24, 48 and 72 hr and survival outcomes. Methods : This was a prospective observational study from June 2016 to June 2017 in an 8-bedded PICU at AIIMS, New Delhi. Twenty six paediatric patients were found to fulfil inclusion criteria for enrolment as per 2005 Goldstein’s definition for paediatric septic shock. They were prospectively evaluated until being transferred out from PICU and were managed as per the Surviving Sepsis Campaign Guidelines. Cumulative fluid overload (%) was calculated as [(total fluid in – out in L)/admission weight (kg) x 100].AKI by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines (no AKI, stages 1, 2, or 3 AKI). Results : Twenty- six children, median age 23.5 months (IQR 11–120), 16 (61.5 %) males and median PIM-II 0.9 [IQR 0.9-1.5] were enrolled. Most infections were pneumonia (9, 34 %), gastrointestinal sepsis (5, 19%), hospital acquired infections (3, 11.5%), meningitis (3, 11.5%), urosepsis (2, 7.7%) and others. The volume of bolus administered in first 6 hours was a median of 40 ml/kg [IQR 20-60]. Of the 26 patients, 19(73%) were survivors. The mean cumulative fluid balance peaked at 72 hours and was 10.7% (2.4, 26) in non-survivors and 8.8% (1.26, 20) in survivors, [P = 0.9]. In the multivariate model, the following variables were significantly associated with mortality in patients: the heart rate at admission [Odds ratio (OR) 1.06; 95% confidence interval (CI) (1.00–1.15), P = 0.02], the ScV02 at enrolment [OR 1.1; 95% CI (1.00–1.20), P = 0.04] and a fluid boluses (ml/kg) received in the first 6 hours of admission in ICU [OR 1.1; 95% CI (1.00–1.15), P = 0.02]. ICU outcomes Compared with survivors, non-survivors required a higher max. dose of epinephrine (μg/kg/min) [0.19(0.01,0.37) vs. 0.58 (0.29,0.86), P = 0.006] and had a higher incidence of acute kidney injury [1 (5%) vs. 5 (71%), P < 0.001]. The duration of invasive mechanical ventilation was also higher among non survivors [5 (2.5, 7.5) vs. 22(3.8, 40) days, P =0.002]. Among the variables of the regression model significant negative correlation was seen between CVP at 6 hours (-0.788), p= 0.006 and mortality outcome and positive correlation between ScVO2 at 1 hour (0.71), p= 0.04 and mortality outcome. Conclusion : Volume of fluid administered in the first six hours of resuscitation is a significant predictor of mortality and duration of mechanical ventilation in pediatric patients with septic shock. Further studies on effects of fluid resuscitation in pediatric septic shock patients are needed.

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Background : Hemophagocytic Lymphohistiocytosis (HLH) is a rare multisystem disorder where a diagnosis, underlying etiology and management remains a challenge for intensivists as the distinction between hyperferritinemic conditions in PICU is not clearly understood. HLH can either be genetic (primary) or triggered (secondary) due to infections, malignancy or autoimmune disorders. In this study we describe the clinical characteristics and predictors of mortality in our cohort of critically ill children with HLH of any etiology Methods : Single center, retrospective study of children aged 2 months– 12 years admitted with HLH to tertiary care pediatric ICU of Advanced Pediatric Center, PGIMER, India from January 2012 to August 2017 (5 years).We analyzed the clinical, laboratory characteristics, intensive care need like ventilation, hemodynamic support and the specific treatment from our electronic medical record. Multivariate logistic regression was used to identify the predictors of outcome Results : Total of 26 patients of HLH were observed over a period of 5 years. All but one episode were diagnosed as secondary HLH and did not have risk factors for familial HLH. Nineteen (67.9%) were males with a median age of 6.83 years (IQR 3.47, 9.64) and median PRISM 3 of 16 (IQR 13.5, 23). The underlying etiology was diagnosed in 15 patients (53.57%). Scrub typhus (n=5, 17.9%) was the commonest followed by acute encephalitic syndromes (n=3), dengue (n=2) and juvenile idiopathic arthritis (n=2).Ten patients (37.5%) had sepsis of unknown etiology. Twenty one out of 28 episodes fulfilled HLH 2004 criteria with a median Hemoglobin of 8.55 gm/dl (IQR 6.27, 9.9), total leucocyte count of 7000/uL (IQR 2725,15175), platelets of 45,000 u/L(IQR 22750,98750), triglyceride 362 mg/dL (IQR 278, 597), fibrinogen of 1.4 g/L (IQR 0.94, 1.92). Median serum ferritin in the cohort was 5238 ng/mL (IQR 4084, 44000). Nineteen patients underwent bone marrow examination out of which 16 had an evidence of hemophagocytosis. Fifteen received steroids and 7 received IVIG as treatment of HLH. Seventeen out of 26 patients died (65.3%). On univariate analysis among non-survivors vs survivors, PRISM 3 scores [23 (IQR 15, 28) vs 13 (IQR 8.5, 16); P=0.012], Vasoactive inotropes scores (97 vs 11.67; P=0.001), number of PRBC transfusion episodes [1.37 (IQR 1, 2) vs 0.33 (IQR 1, 2); P=0.008] and need for mechanical ventilation (100% vs 11.11%; P<0.001) were predictive of poor outcome. Organ involvement such as acute respiratory distress syndrome (57.89% vs 11.11%; P=0.039); disseminated intravascular coagulation (63.15% vs 22.22%; P=0.046) and septic shock (94.73% vs 11.11%; P<0.001) were higher among the non-survivors. On multivariate analysis, none of these parameters were predictive of mortality. Conclusion : Secondary HLH due to acute infections in PICU is associated with high incidence of organ failures and mortality. Prospective studies are needed to determine the effect of treatment and predictors of outcome

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Background : Severe dengue infection is the major cause of mortality in children with dengue infection. Early identification and prompt management is helpful in reducing the mortality rate. Predictive scores can be utilized to identify severe dengue early. The present study was conducted to evaluate the prognostic score chart for the prediction of profound shock and recurrent shock in children presenting with DSS. Methods : patients with DSS were enrolled and the predictive score point was applied to predict the development of profound and recurrent shock. The socio demographic data (Age gender), clinical presentation, was recorded. Diagnosis was confirmed with dengue IgM and IgG capture ELISAs and NS. The primary outcome was the development of profound or recurrent shock. The predictive risk and the probability of development of profound and recurrent shock was determined by Appling appropriate statistical methods. Results : Out of 66 patients enrolled ,48 (72.12%) patients developed profound shock. Most of the children had predicted risk of ≤ 10% and 11 to 20% (39.39% each). The mean predicted risk was noted as 16±11. The median predicted risk was 13% and ranged between 1% to 47%. All the children with predicted risk of >21 % developed profound shock. This difference was statistically significant (p<0.001). Conclusion : The prognostic score chart is a good predictor for the development of the profound shock in cases of dengue shock syndrome.

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Background : Severe dengue infection is the major cause of mortality in children with dengue infection. Early identification and prompt management is helpful in reducing the mortality rate. Predictive scores can be utilized to identify severe dengue early. The present study was conducted to evaluate the prognostic score chart for the prediction of profound shock and recurrent shock in children presenting with DSS. Methods : patients with DSS were enrolled and the predictive score point was applied to predict the development of profound and recurrent shock. The socio demographic data (Age gender), clinical presentation, was recorded. Diagnosis was confirmed with dengue IgM and IgG capture ELISAs and NS. The primary outcome was the development of profound or recurrent shock. The predictive risk and the probability of development of profound and recurrent shock was determined by Appling appropriate statistical methods. Results : Out of 66 patients enrolled ,48 (72.12%) patients developed profound shock. Most of the children had predicted risk of ≤ 10% and 11 to 20% (39.39% each). The mean predicted risk was noted as 16±11. The median predicted risk was 13% and ranged between 1% to 47%. All the children with predicted risk of >21 % developed profound shock. This difference was statistically significant (p<0.001). Conclusion : The prognostic score chart is a good predictor for the development of the profound shock in cases of dengue shock syndrome.

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Background : The role of renal replacement therapy (RRT) in critical care is expanding. It is the cornerstone in the management of critically ill children. Continuous RRT is a mainstay of treatment in PICU for acute kidney injury (AKI) due to well-maintained hemodynamic stability with slow predictable fluid and solute removal. Apart from the classic indications RRT plays a significant role in the treatment of many other disease conditions such as septic shock and other organ-supportive strategies. Methods : We conducted a retrospective analysis of all the children who underwent RRT for critical care indications over a period from July 2015 to July 2017 at Rainbow Children’s Hospital, Marathahalli, Bangalore. Results : A total of 24 children underwent RRT over a period of 2 years with 12 males (50%) and 12 females (50%). Out of these 5 children (20.8%) had background of chronic kidney disease. Mean age of children who underwent RRT was 6 years (range:4 months-16 years). Sepsis with septic shock was the diagnosis most commonly associated to needing RRT (58.3%). The most common clinical condition associated with acute kidney injury was hemodynamic instability (58%), followed by multi-organ dysfunction syndrome (41%). The most common indication for initiating RRT was Acute Kidney Injury stage 2 with fluid overload >10% (as defined by KDIGO criteria) in 50% of the cases followed by severe metabolic acidosis refractory to medical therapy (29%). Eleven (45.8%) children who underwent RRT had Multi-organ dysfunction. There were no significant complications associated to initiation of RRT. Fifty- four percent of children survived. Among the children who died 81% had Multi-organ dysfunction syndrome. Three children (23%) required intermittent hemodialysis on follow up for complete recovery. Continuous renal replacement Therapy (CRRT) was done in 11 children (45.8%). The median duration of CRRT was 30 hours with the longest duration being 194 hours. Most common mode of CRRT used was Continuous venovenous hemodiafiltration (CVVHDF) . Newer hybrid techniques like Sustained low efficiency dialysis (SLED) was used in 5 patients (20%) with complete recovery noted during PICU stay. Conclusion : We present a diverse population of pediatric patients requiring RRT. Sepsis with septic shock was the most common diagnosis requiring RRT in our study population. CVVHDF was the common mode of RRT we used in our unit followed by newer techniques like SLED. We noticed hemodynamic instability and multi-organ dysfunction syndrome are the most common clinical conditions associated with acute kidney injury in our population. We did not observe any significant complications associated with initiation for RRT which indicates CRRT is safe in hemodynamic unstable patients. We observed that new therapies and techniques can provide supportive treatment beyond the classic renal indications.

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Background : Pulmonary Hypertension is a complex entity. Despite the advances made in the management of the disease it still remains lethal and one of the causes of mortality and morbidity in children. Thiamine deficiency has been identified as a lethal reversible cause of pulmonary hypertension in exclusively breastfed infants. Epidemics of infantile beriberi are known to occur among exclusively breastfed infants of thiamine deficient mothers. Shoshin beriberi is a fulminant form of cardiovascular beriberi characterised by tachycardia, hypotension, severe pulmonary hypertension and lactic acidosis and has been designated as a rapidly curable hemodynamic disaster. Methods : We conducted a retrospective analysis of all the pulmonary hypertension cases admitted to the PICU of Rainbow Children’s Hospital, Marathahalli, Bangalore over a period of 2 years from August 2015 to August 2017. Results : A total of 9 children were admitted with pulmonary hypertension over a period of 2 years with 6 males (66%) and 3 females (33%). Mean age of presentation was 6 months. Out of this 3 children (33%) had congenital heart disease, 3 cases (33%) were secondary to severe pneumonia and 3 infants (33%) responded to IV Thiamine. All 3 babies who responded to thiamine had presented with sudden onset of unexplained bi-ventricular failure, respiratory distress, severe pulmonary hypertension and acute lactic acidosis. Mean age of presentation was 67 days. All infants were exclusively breastfed and well nourished. All mothers belonged to low-middle socioeconomic class with staple diet consisting of polished rice. Acute metabolic acidosis was a universal feature with mean pH of 6.92 ± 0.1 and average lactate of 7 ± 2.5 mmol/L. They responded to IV Thiamine dramatically with immediate improvement in pulmonary pressures and metabolic acidosis and reversal of shock in 6-12 hours. Conclusion : The onset of symptoms in thiamine deficiency is often very rapid and fatality rate is very high. Clinician awareness of the possibility of thiamine deficiency even in well-nourished infants is important for early recognition and prevention of deaths. In a baby with unexplained metabolic acidosis and high pulmonary pressures, a therapeutic trial of thiamine infusion is a reasonable option especially since it is inexpensive, safe, and can be lifesaving.

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Background : Systemic inflammatory states such as severe sepsis and septic shock result in immunologic disturbances with the release of numerous inflammatory mediators. The systemic inflammatory response, though a result of innate immunity, can become deleterious when excessive or uncontrolled, leading to the development of multi-organ failure syndrome and death. Extracorporeal blood purification therapies have been proposed to improve outcomes for patients with severe sepsis. These therapies are based on the principle that removal of inflammatory mediators or bacterial toxins (or both) from the blood will favorably modulate the host inflammatory response. Recently, significant technological progress has greatly broadened the spectrum of techniques available for blood purification. However, these techniques have not entered into mainstream clinical practice around the world. Hemoadsorption places sorbents in direct contact with blood via an extracorporeal circuit. Polymyxin B is a cyclic basic polypeptide that disrupts the permeability of the cell membrane of Gram-negative bacteria. Polymyxin B-immobilized polystyrene-derived fibres (Toramyxin, Toray Industries, Inc., Tokyo, Japan) have been developed for use in extracoporeal therapy as a means to remove endotoxin from the blood. There are not many studies showing the efficacy of extracorporeal blood purification in paediatric population in India or around the world. Methods : A six years old girl with Salmonella typhi sepsis was retrieved on day 6 of illness in a state of fluid refractory shock on ventilatory support with oxygenation index (OI) of 16.2 and Vasoactive Inotropic Score (VIS) after 2 hours of admission was 50 with a diastolic blood pressure (DBP) of 35mmHg. She had multi-organ dysfunction with SGOT 3745U/L, SGPT 1353U/L, Arterial Lactate 11mmol/L, Creatinine 1.0mg/dl, CRP 108mg/ dl, Bicytopenia - Platelet 56000/cu.mm, WBC 2200/cu.mm (with 76% Neutrophils). She was on appropriate antibiotics since past 2 days at the referral centre. Over a period of 24 hours, her VIS increased to 53 with Fluid Overload percent (FO%) reaching 12% and her kidney injury progressed to AKIN Stage 3. We started her on Continuous Veno-venous Hemo-diafiltration (CVVHDF) which resulted in improvement in her renal parameters, Creatinine 0.4mg/dl, but she continued to have very low DBP (30 -35mmHg) despite high VIS and her inflammatory markers increased CRP 132mg/dl, with persistent Bicytopenia - Platelet 23000/cu.mm, WBC 2700/cu.mm (with 80% Neutrophils). As the child was already on CRRT, a decision to start the child on extracorporeal blood purification using Toramyxin cartridge was made and initiated at 40 hours after admission and continued for 36 hours. Results : With this, the child showed improvement with VIS decreasing to 35 after twelve hours, 25 after thirty six hours and 11 after twelve hours of stopping extracorporeal blood purification. Her inflammatory markers decreased with CRP 90mg/L after twelve hours and 54mg/L twenty four hours later. Blood counts also improved with WBC rising to 9100 (80% Neutrophils) forty eight hours of starting hemoadsorption, while she received platelet transfusion for thrombocytopenia. Her OI also improved to 8.7 after forty eight hours. The patient was off inotropes within 72 hours of starting extracorporeal blood purification and was extubated within 96 hours. Conclusion : We conclude that the use of an extracorporeal blood purification device (Toramyxin) may have helped in the removal of circulating endotoxin by adsorption, thus preventing progression of the biological cascade of sepsis and resulted in improvement in our patient’s hemodynamic status and decrease in inflammatory response leading to clinical improvement. The major limitation of our report is our inability to measure endotoxin levels of our patient to demonstrate decrease in their level pre- and post- hemoadsorption. We also cannot comment on the efficacy of extracorporeal blood purification devices based on this single case. But we wish to emphasise that many new modalities exist in treatment of septic shock and can be considered when dealing with refractory septic shock.

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Background : Simulation training workshops conducted by PediSTARS (Pediatric Society for Training and Research in simulation) India over the last year identified a gap in the knowledge of having a structured approach to assessment of pediatric trauma. PediSTARS organised a nationwide pediatric trauma simulathon on world trauma day to encourage the simulation trainers across the country to conduct in-situ pediatric simulation training. Methods : Simulation trainers across the country trained through PediSTARS Training or Trainers workshop were approached via email and WhatsApp group. All the interested simulation trainers were sent a trauma scenario which could be modified to local training needs. All centres conducted the training session on world trauma day- October 17th, 2016 and shared their experiences and photos of the session on the WhatsApp group. An online survey to collate the experience was sent to all the simulation trainers. Results : 20 centres across India participated in the Simulathon. The target audience varied from Emergency nurses and doctors, paediatricians, under graduate and post graduate students, and parents. All centres uniformly identified gaps in knowledge of initial assessment and primary survey of pediatric trauma, skills such as needle thoracocentesis and team leadership. All centres uniformly reported 100% acceptance of simulation based training and the need to have more such training sessions locally to enhance their learning experience. The challenges described by the simulation trainers include time and equipment constraints for regular simulation training locally. Conclusion : Pediatric trauma training is a much needed and wanted aspect of training that can be addressed via simulation in-situ successfully. A thematic approach such as a simulathon can encourage trainers to conduct sessions more regularly.

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Background : Tracheal intubation is a common procedure in critically ill children. The safety of the procedure is multi-dimensional and involves clinical skills as well as profile of the environment including human factors. Methods : All tracheal intubation events in the emergency department and PICU were prospectively evaluated as part of NEAR- 4KIDS study, a prospective multicentre observational cohort study, over an 18 months period (Feb 2016 –Aug 2017). Human factors such as teamwork, situation awareness, communication, clear allocation of roles and responsibilities of team members and knowledge sharing and stress level of team members were rated on a scale of 1-7 by the non-intubating doctor or senior nurse. Data on systems issues such as monitoring equipment, preparation of medications and intubation equipment were collected. Results : 144 intubations occurred in 105 patients during the study period. Human factors were rated uniformly 5 and above for teamwork, situation awareness, communication, clear allocation of roles and responsibilities of team members and knowledge sharing irrespective of the timing of the day during intubation, personnel present, experience of the intubating doctor or the number of attempts required for the procedure. 28% (41/144) intubation events had complete junior doctor presence of which Tracheal intubation related adverse events (TIAE) occurred in 2 cases (5%). Consultants were present in 72% (103/144) intubation events and TIAE occurred in 18 cases (17%). The stress levels of the team members were rated as <4 (highly stressful) in 13% (14/103) in the presence of the consultant compared to 44% (18/41) during junior doctor’s presence. Monitoring problems occurred for Endtidal CO2 monitoring in 8% (12/144), availability of right size ETT in 2, absent battery backup for laryngoscope in 1 event. Conclusion : There appears to be healthy human factors interplay and safety profile during tracheal intubation in our setting. End tidal C02 monitoring remains the main equipment issue in our unit. The perception of stress by PICU team members is less when there is presence of consultant compared to the presence of only junior doctors. Further studies are needed to understand the impact of simulation based training in fostering a safe working environment and addressing the perception of stress for team members.

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Background : Professional teamwork between physicians and nurses is essential to provide quality care to patients. Interprofessional Education (IPE) as a health care policy has led to an emergence of new health care delivery models that focus on patient-centered care, improved patient outcomes, and reduced health care costs. Simulation-based approach has emerged as a powerful tool for delivering training in medical and nursing professions to promote IPE. Methods : Team training with nurses and doctors and other support staff was introduced as part of ongoing training within the newly established PICU since 2 years. In-situ simulation with low fidelity manikins and tablet based or phone based or Laptop based changes of vital signs were applied for the training. Training themes were scenario based focusing on individual skills such as assessment of critically ill, intubation, suction, CPR, drug administration and team based skills such as team leadership, communication and team preparedness. Simulation sessions were done in-situ on a monthly basis with a few additional ad-hoc sessions and led by consultant pediatric intensivists, Simulation Nurse specialists and simulation technicians. Results : During the course of 2 years (May31 2015- May 31 2017), 40 in-house PICU staff nurses and 15 visiting PICU nurses have undergone simulation team training along with Pediatric and PICU postgraduate doctors. The focus for simulation training was assessment, bedside skills and communication for novice nurses and doctors. The senior nurses and doctors with more than 2 years experience underwent training in crisis resource management skills. All the participants uniformly reported greater relevance and learning, improvement in confidence and understanding of team dynamics during the debriefing sessions. Novice nurses rated the sessions as beneficial for retaining the learnt skills. Conclusion : Simulation training of inter-professional teams especially in PICU set-up appears a well accepted mode of training in our centre. Team members felt better prepared to manage critically ill children after simulation sessions. Further formal studies are required to understand the impact of simulation training to real time performance at bedside.

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Background : Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into bedside decision making is underway. The established benefits of point-of-care ultrasound have given rise to multiple new and innovative curriculums to incorporate ultrasound teaching into medical education and quality improvement initiative. Methods : This study was done in a 24 bedded tertiary PICU in Bangalore with availability of a portable ultrasound machine in the unit. We integrated a curriculum consisting of traditional didactics combined with hands-on sessions given to the fellows over a period of 4 weeks. Following this, the PICU fellows implemented the POC ultrasound curriculum into their daily practice in managing ICU patients, under supervision from ICU staff physicians, who were instructors in POC ultrasound. They were required to fill a proforma which asked them to document the reason for the use of POCUS, their findings and the decision made based on the findings for each system examined, namely, Cardiovascular (CVS) and Hemodynamics, Lung and Abdomen. The images of the POCUS scans were stored and reviewed by experts consisting of senior PICU physicians and Radiologists every week where the proforma along with images were examined and evaluated for their quality of images, correlation of findings and justification for decisions on a weekly basis. The improvement in skill level of fellows based on the evidence of quality of images, their interpretation and decisions and also the impact on patient care including finding a new diagnosis or change in patient management was reviewed over a period of 2 months after training. Results : Fifty POC ultrasound studies were done in the 2 months period and were reviewed for analysis. The most common exams performed were CVS and hemodynamic assessment (32) followed by lung/pleural exams (15) and abdominal exams (3). The examination supported the clinical assessment in 80 % (40/50) of instances. It changed the management. It led to a significant change of management in 20% (10/50) of the cases. In CVS and Hemodynamic assessment, the major use was for determining fluid responsiveness (22/32) followed by need of optimizing inotropy (9/32) and pericardial drainage (1/32). In Lung/Pleura assessment, determining the area of the lung involved and differentiating atelectasis and consolidation was the most common use (9/15) which led to change in position (proning/lateral position) followed by documenting the residual fluid in the pleural cavity (4/15) and identifying pneumothorax (2/15). Abdominal scan was done only in cases of trauma to look for fluid collection. As a quality training initiative, on evaluation we also found that the quality of images improved during the period of study with experience of the fellows and also their interpretation of the US findings were correct. Conclusion : Implementation of POC ultrasound in the ICU with a structured fellowship curriculum is feasible and may successfully equip fellows with a fundamental understanding of ultrasound physics, anatomy, and disease recognition. The periodic evaluation of the findings by experts helps maintain the quality of the curriculum. In our study, it resulted in change of management in 1/5th of the cases.

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Background : To assess the efficacy of aseptic Intravenous line insertion and maintenance bundle on minimizing the incidence of phlebitis and infiltration by 50% over a period of 2 months Methods : Aquality improvement study was undertaken in the pediatric emergencyAPC, PGIMER, Chandigarh. Ethical approval was taken from the Institute’s Ethics Committee to conduct the study. A total of 185 children of age more than 28 days and 46 health care personnelwere enrolled in the study. The study selected the PDSA(Plan, Do, Study, and Act) model to do the quality improvement. Pre-assessment phase was conducted from 24th June 2017 to 15th July 2017 to find out current practices including facilitators and barriers related to aseptic IV line insertion and maintenance. Permission from Head of Department and Assistant Nursing Superintendent of Advanced Pediatric Centre was taken to assess practices by covert participation. A total of 105 peripheral IV line were inserted during observation time. Out of that checklist was filled for35 IV cannulation and drug administration and it was found that the score ranged between 21.7%-39.1% and 20%-54.2% respectively. Focused group discussions were conducted with the health care personnel to know the facilitators and barriers related to “Aseptic Intravenous line insertion and maintenance bundle”.On the basis of pre-assessment run chart of findings was made and root-cause analysis was done. With the use of action priority matrix 4 sets of interventions of PDSA were selected based on low efforts and high impact. In PDSA 1 sensitization of health care personnel was done on aseptic IV line insertion and maintenance bundle. Supply of articles like injection trays, sterile gauzes, tourniquets, tagaderm and increase supply of hand rubs, clean gloves was ensured. Whatsapp group of health care personnel of pediatric emergency was also made. Regular reminders were sent in the form of text and videos on techniques to be followed during bundle. HCP’s were also encouraged to function as a QI team; they are also informed about their function and responsibilities in team. In PDSA 2 Infection control nurse was introduced to regularly monitor the practices and suggest remedial measures. Positive reinforcement was given and HCPs were encouraged to follow the bundle. In PDSA 3 Health care personnel were again motivated with the findings of PDSA 1 and PDSA 2 and by giving emotional examples. In PDSA 4Reinforcement of team members and other health care personnel to take over of the responsibilities independently without direct role of investigator. After running all the four PDSA cycles health care personnel were also interviewed for their experiences on use of bundle. The process measures that are checklist for IV line insertion/ maintenance” and “administration of drugs through IV revealed increase in scores and in return the primary outcome measure that is incidence of phlebitis and infiltration was reduced. Though 50% reduction can’t be achieved for primary outcome the improvement revealed that the consistent regular efforts can bring improvement. Conclusion : Sensitization of health care personnel, introduction of infection control nurse, repeated motivation of health care personnel, framing the responsibilities of health care team were successful in achieving efficacy of the”aseptic Intravenous line insertion and maintenance bundle” and reducing the rate of infiltration and phlebitis.

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Background : Parents are the primary caregiver of the child. They take care of child’s both physiological and psychological needs. Once a child is hospitalized parents feel anxiety, fear, disappointment and guilt due to lack of confidence for caring the child. Hospitalization is a stressful situation where team approach is required for safe and satisfactory treatment of child. HCPs play an important role in caring for the sick children as they have direct contact with patients and their families. HCPs can come with suitable plans that actually work for a particular patientby sharing information with each other. Secondly good communication among HCPs leads to better results and greater satisfaction among parents. Lack of collaboration, compromise patient’s safety due to several reasons like misinterpretation of information, unclear orders and so on. The main objective behind this study was to assess the health care providers’ collaboration and satisfaction about care decisions and parents satisfaction about care provided to the patients admitted in Pediatric Intensive Care Unit, APC PGIMER, Chandigarh, India. Methods : The study was conducted by employing quantitative non experimental survey approach. 50 parents of children admitted in PICU and 32 HCPs working in PICU, APC, PGIMER, Chandigarh were selected by total enumeration sampling method during March 2017. After filling Profile data sheet and information related to parental satisfaction were gathered using a structured interview schedule. Data related to health care providers’ collaboration and satisfaction about care decisions were gathered using a structured questionnaire. The data was analysed using SPSS (version 20.0). Results : The results revealed that total 50 parents were enrolled in the study out of which maximum parents were highly satisfied (92%) with the care provided by the HCPs, while 8% were satisfied. None of them was unsatisfied with the care provided by the HCPs. Related to collaboration among HCPs, out of 32 HCPs, more than two third (87.5%) were highly satisfied with the collaboration among themselves related to care decisions while 12.5% were just satisfied with it. None of them was unsatisfied. Conclusion : It was concluded that majority of parents of children admitted in PICU, APC, PGIMER, Chandigarh were highly satisfied with the care provided to their children. On the other hand, most of the HCPs showed high level of collaboration among themselves and were satisfied with the care decisions related to the children admitted in PICU.

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