Objective: In recent years, there has been an increase in the use of noninvasive positive pressure ventilation (NIPPV) and high-flow nasal cannula (HFNC) in children with increased work of breathing due to acute bronchiolitis. However, there are only limited studies comparing the efficacy of these two interventions. This study was done to compare efficacy and patients' comfort while receiving HFNC and NIPPV for acute bronchiolitis. Materials and Methods: Children admitted with the first episode of acute bronchiolitis with respiratory distress (modified Wood's Clinical Asthma Score >3) were randomized to receive NIPPV and HFNC. FiO₂was titrated to achieve a SpO₂of ≥94%. If the child was agitated and had a COMFORT B score of ≥17, dexmedetomidine infusion was started. The protocol lasted for at least 24 h or till the respiratory support was required as decided by the treating physician. Outcome parameters measured were failure of intervention and patient comfort (using COMFORT B scores). Social science system version SPSS 17.0 was used for statistical testing.P < 0.05 was taken to indicate a significant difference for all statistical tests. Results: Twenty-five cases were enrolled in each study group. Failure of therapy was noted in 11 (44%) patients in the HFNC group and 6 (24%) in the NIPPV group (P = 0.18). COMFORT B score was significantly better in the HFNC group as compared to the NIPPV group (NIPPV12 vs. HFNC 8;P < 0.001). A number of cases requiring sedation and duration of sedation (dexmedetomidine) were more in the NIPPV group as compared to the HFNC group (22 vs. 10, P = 0.02, and 31.2 vs. 20.6 h, P = 0.04). Conclusion: This study suggests that possibly HFNC and NIPPV are equally efficient in the treatment of moderate-to-severe bronchiolitis. HFNC is more comfortable for bronchiolitis patients in comparison to NIPPV.

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Acid–base disturbances are common occurrence in acute care setting, their rapid assessment and analysis are important, and pH of 6.8–7.8 is compatible with life. The definition of acid and base is different for biochemist, physiologist, cook, and others. Acid–base analysis gives us information about oxygenation, ventilation, acid–base status, electrolytes, lactate level, and clue to etiology and probable diagnosis.

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Objective: The objective is to study the intra- and postoperative cardiopulmonary complications, metabolic derangements, and mortality in the recipients of orthotopic liver transplantation (OLT). Materials and Methods: Medical records of all children who underwent OLT at our institution from January 2003 to December 2019 were reviewed, and the clinical and laboratory data were collected. Results: Eighty-two patients (48 males) underwent living-related OLT and one received cadaveric liver. The median age of recipients was 6 years (range: 4 months–16 years). The two common indications for OLT were biliary atresia (n = 27, 32.9%) and Wilson's disease (n = 20, 24.3%). Common metabolic problems during intraoperative phase included hypokalemia (43.9%) and hyperglycemia (57.3%). The mean duration of postoperative ventilation was 35.8 ± 51.4 h. Fifty-two patients were extubated within 24 h of surgery. Pleural effusion was most common present in 52 patients postoperatively. It did not interfere with mechanical ventilation. Hypertension, hypotension, and oliguria were recorded in 28, 31, and 22 patients, respectively. There were 11 graft rejection episodes. Ten children required re-operations. There were 4 (4.8%) early deaths, aged ≤1 year, in the first 2 weeks of transplantation. Conclusion: Medical and surgical complications are common in patients after liver transplantation. Intensive monitoring and laboratory workup help in detection of these complications. Early and 1-year survival rates are comparable to that in the developed world.

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Rodenticides constitute 7%–11% of total poisonings in children. The rodenticide commonly available in South India is a paste made of yellow phosphorus, which causes a spectrum of clinical manifestations from gastrointestinal irritation to multiorgan dysfunction for which there is no antidote or specific treatment. There are scanty reports of this poisoning in children worldwide. Hence, we did a retrospective chart review of eight patients admitted in our unit from July 2017 to January 2019, and the demographic data, mode of poisoning, clinical manifestations, treatment modalities, and outcome of poisoning were collected from the hospital records and documented in the prestructured pro forma and analyzed. Majority of our patients were adolescent males, who had ingested the poison as an act of deliberate self-harm. The most common feature seen was acute liver failure. Clinical outcomes were better in those who received plasmapheresis for acute liver failure. However, this requires further studies for a proven benefit.

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Introduction: Confirmation of correct placement of the endotracheal tube (ETT) is as important as the procedure itself. Point-of-care ultrasound today is an indispensable modality in the intensive care unit (ICU) for augmenting the clinical assessment and guiding critical care procedures. In this study, we used point-of-care ultrasound to confirm ETT placement and compared the time taken to confirm the ETT placement by ultrasound and capnography (the gold standard of confirmatory ETT placement). Materials and Methods: The current study was a prospective study done in a tertiary care teaching hospital. Children between 1 month and 18 years of age were included in the study. Airway ultrasound was done during the intubation procedure by placing the probe transversely over the suprasternal notch, and the confirmation of placement of the tube in the trachea was done by visualizing the absence of double trachea sign, and later confirmed by capnography. The average time taken for confirmation by ultrasound and capnography was determined. Results: A total of 127 intubations were included. The average time taken for confirmation of placement of the ETT by airway ultrasound from the time of insertion of the laryngoscope blade was 26.8 ± 5.7 s, whereas by capnography, it was 35.5 ± 5.8 s. The study showed that airway ultrasound has a high sensitivity of 98.2% to detect tracheal intubation and specificity of 100% to detect esophageal intubation when compared to capnography. Conclusion: Airway ultrasound can serve as a novel method of confirming the ETT placement in the pediatric ICU with comparable sensitivity, specificity with the added advantage of a significantly faster time of confirmation with respect to capnography.

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Background and Aim: There is limited data on the outcome of mechanically ventilated critically ill children in low- and middle-income countries. The aim was to study the association of fluid balance in mechanically ventilated critically ill children and outcomes. Methodology: This retrospective study was conducted in an academic hospital's pediatric intensive care unit (PICU) from January 2015 to December 2016. Children aged 1 month to 12 years ventilated for more than 24 h with 48-h fluid balance were included in the study. Patients were divided into ≤10% and >10% fluid overload (FO) groups. The primary outcome was all-cause PICU mortality. The secondary outcomes were the durations of mechanical ventilation, PICU and hospital stay; organ failure; and extubation failure. Results: A total of 107 patients (23 in >10%-FO and 84 in ≤10%-FO groups) were enrolled. The median (interquartile range) age and pediatric risk of mortality III score were similar in both groups (12, 7–36 months vs. 11, 3–32 months; P = 0.37; and 16, 12–20 vs. 15, 12–18; P = 0.71, respectively). The most common indication for ventilation was disordered control of breathing (55% vs. 42%) followed by respiratory pathology (30% vs. 39%). In >10%-FO group, higher proportion of patients had acute respiratory distress syndrome (13 [56%] vs. 28 [35%], P = 0.06) and acute kidney injury (15 [65%] vs. 37 [44%)], P = 0.07), of which a significant number required renal replacement therapy (10 [43%] vs. 15 [17%], P = 0.01). More patients had septic shock in >10%-FO group (13 [56%] vs. 27 [32%], P = 0.03). There was no significant difference in all-cause PICU mortality in >10%-FO groups (13 [57%]) as compared to ≤10%-FO group (32 [38%]) (relative risk = 1.2, 95% confidence interval [CI]: 1.0–1.5, P = 0.11; and adjusted hazard ratio = 1.52, 95% CI: 0.78–2.97, P = 0.22). No differences were noted in other outcome variables. Conclusion: There was no significant difference in mortality and morbidity noted in 10% FO cutoff in critically ill mechanically ventilated children. A larger sample size, preferably a multicentric study, is warranted.

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The metabolic crisis due to inborn error of metabolism can present as an isolated entity or along with the underlying sepsis at any age in children. Here, we present 14 months old boy born of third-degree consanguinity, apparently healthy in the past, admitted with encephalopathy, low GCS, hyperammonemia, and recurrent pulmonary hemorrhage in our hospital, requiring initial resuscitation with stabilization of airway, breathing, circulation, and disability. He required neuroprotective measures including intubation, ventilation with hyperosmolar therapy, and vasoactive drug infusion through the femoral central line for the shock due to metabolic crisis. His urine gas chromatography/mass spectroscopy (MS) for organic acids analysis and blood tandem MS for the plasma amino acids profile, carnitine, and acylcarnitine profile suggested propionic acidaemia, which is rare autosomal recessive disorder and he required dietary modification with metabolic cocktail therapy through a central line with peritoneal dialysis initially for hyperammonemia but subsequently requiring renal replacement therapy to decrease the raised ammonia levels, gradually his sensorium improved, extubated, and sent home with inborn error of metabolism oral cocktail therapy but a few days later, he succumbed to death.

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Coronavirus disease 2019 (COVID-19) is an acute infectious respiratory disease with manifestations ranging from mild respiratory symptoms to severe acute respiratory distress syndrome. The severity and mortality have been found to be higher in elderly people and those with comorbidities. Data on the pediatric population affected by the pandemic are limited. Most pediatric COVID-19 cases reported so far in the literature are mild or asymptomatic ones. Management of critically ill children is associated with a high risk of aerosol generation and secondary infection. We report a case of an infant with severe COVID pneumonia who was successfully managed in the pediatric critical care unit of a dedicated COVID hospital taking proper infection control measures.

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Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headache, altered mental state, seizures, and visual loss. It has a diverse etiology, of which hypertension is the most common. However, transfusion-associated PRES is being increasingly recognized, although pediatric reports are rare. We hereby report a 7-year-old boy with β thalassemia major, who developed neurological symptoms with changes suggestive of PRES on imaging after routine transfusions with an elevation of hemoglobin levels >5 g/dl posttransfusion. He required mechanical ventilation with standard therapies for raised intracranial pressure. The cerebral edema was characterized as vasogenic, due to the absence of diffusion restriction on magnetic resonance imaging of the brain and the child made a complete neurological recovery with normalization of imaging findings 4 weeks later. Interestingly, in concordance with the pressure, autoregulation disruption theory as a mechanism of hypertensive PRES, literature review on viscosity based autoregulation disruption shows that this may be one of the mechanisms among others for PRES associated with blood transfusion.

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Hemorrhagic pleural effusion secondary to pancreaticopleural fistula (PPF) due to acute-on chronic pancreatitis is a very rare cause of pediatric respiratory distress. Hemorrhagic pleural effusion secondary to PPF will be usually left sided and accounts for 1% of all cases; very rarely, it could be right sided resulting in difficulty in establishing the diagnosis if chest symptoms are disproportionately more than the abdominal symptoms. We report a 9-year-old male child who presented to us with severe respiratory distress, with insignificant history later found to have right-sided massive hemorrhagic pleural effusion with PPF secondary to acute-on chronic pancreatitis.

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