Publications by authors named "Muralidharan Jayashree"

101 Publications

Neuroimaging Spectrum of Severe Hypernatremia in Infants with Neurological Manifestations.

Neuropediatrics 2021 08 30;52(4):316-325. Epub 2021 Jun 30.

Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: Variable neurological manifestations and imaging findings have been described in children with severe hypernatremia. We aimed to describe the spectrum of neuroimaging changes in infants with severe hypernatremia.

Methods: This retrospective study included infants with severe hypernatremia (serum sodium >160 mEq/L), abnormal neurological examination, and an abnormal magnetic resonance imaging (MRI) of the brain over a period of 2 years in a tertiary care hospital. Relevant clinical data, including the feeding practices, clinical features, complications, and biochemical and radiological parameters, were entered in a structured pro forma. MRI findings were classified as vascular (hemorrhages and cerebral sinus venous thrombosis), osmotic demyelination syndrome (pontine and extrapontine myelinolyses), and white matter changes.

Results: The common clinical features in the neonates were poor feeding ( = 4) and decreased urine output ( = 4); the older infants presented with gastrointestinal losses ( = 5). All cases had dehydration with encephalopathy. The patterns of radiological injury were vascular (hemorrhages,  = 5 and venous thrombosis,  = 3), osmotic demyelination ( = 8), and white matter changes ( = 7). Coagulopathy was correlated with the vascular complications ( = 0.8,  < 0.0001); the degree of dehydration was correlated with the venous thrombosis ( = 0.7,  < 0.04) and acute kidney injury ( = 0.8,  < 0.001). Neurological sequelae were seen in four cases and correlated with hypernatremia ( = 0.6,  = 0.03) and hyperosmolarity ( = 0.6,  = 0.03).

Conclusion: Characteristic neuroimaging findings are vascular changes in the form of venous thrombosis and hemorrhages, osmotic demyelination and white matter tract injury, and/or mostly combinations of these findings. Severe hypernatremia and resulting hyperosmolarity frequently cause neurological sequelae in neonates and infants.
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http://dx.doi.org/10.1055/s-0041-1730938DOI Listing
August 2021

Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room.

Indian J Crit Care Med 2021 May;25(5):557-565

National Institute of Nursing Education, PGIMER, Chandigarh, India.

Aim And Objective: To reduce the incidence of infiltration and phlebitis by 50% over 2 months among children admitted to the emergency room (ER) of a tertiary care hospital.

Materials And Methods: The study was conducted in the pediatric ER of a tertiary care hospital in North India. All children aged >28 days, receiving intravenous (IV) medication and/or fluids, were enrolled between June (2017) and September (2017). Existing practices of IV line insertion and maintenance were observed and recorded. The visual infusion phlebitis score and infiltration assessment scale were to grade the extent of two. The intervention classified as "IV line insertion and maintenance bundle" included the introduction of low-cost mobile sterile compartment trays, audit and feedback, organizational change, introduction of infection control nurse and quality improvement (QI) team formations were implement in different Plan-Do-Study-Act (PDSA) cycles. Reduction in the "incidence of phlebitis and infiltration" was outcome measures while "scores on checklist of IV line insertion and IV line maintenance and administration of drugs" were process measures.

Result: The process measures, for IV line insertion, maintenance and administration of drugs through IV line, revealed an increase in scores on the checklist. There was a significant decrease in the incidence of infiltration and phlebitis from 82.9 and 96.1% to 45 and 55%, respectively, postimplementation of all PDSA cycles.

Conclusion: Multifaceted QI IV line insertion and maintenance bundle reduced the incidence of infiltration and phlebitis. These interventions when integrated into daily work bundles along with continuous education and motivation help in sustaining the goal and attaining long-term success.

How To Cite This Article: Singh N, Kalyan G, Kaur S, Jayashree M, Ghai S. Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room. Indian J Crit Care Med 2021;25(5):557-565.
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http://dx.doi.org/10.5005/jp-journals-10071-23818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8196366PMC
May 2021

Intensive care needs and short-term outcome of Multisystem Inflammatory Syndrome in Children (MIS-C): Experience from North India.

J Trop Pediatr 2021 Jun 25. Epub 2021 Jun 25.

Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre.

Objectives: To describe the intensive care needs and outcome of Multisystem Inflammatory Syndrome in Children (MIS-C).

Methodology: This retrospective study was conducted in the Pediatric Emergency and Intensive Care Units and COVID-19 hospital of a tertiary care teaching and referral hospital in North India over a period of 5 months (September 2020-January 2021). Clinical details, laboratory investigations, intensive care needs, treatment, and short-term outcome were recorded.

Results: Forty children with median (IQR) age of 7 (5-10) years were enrolled. The common clinical features were fever (97.5%), mucocutaneous involvement (80%), abdominal (72.5%) and respiratory (50%) symptoms. Shock was noted in 80% children. Most cases (85%) required PICU admission where they received nasal prong oxygen (40%), non-invasive (22.5%) and invasive (22.5%) ventilation, and vasoactive drug support (72.5%). The confirmation of SARS-CoV-2 exposure was noted in the form of positive serology (66.7%), RT PCR (10%), and contact with SARS-CoV-2 positive case (12.5%). The common echocardiographic findings included myocardial dysfunction (ejection fraction <55%) (72.5%), and coronary artery dilatation or aneurysm (22.5%). The immunomodulatory treatment included IVIG (2 gm/kg) (100%) and steroids (methylprednisolone 10-30 mg/kg/day for 3-5 days) (85%). Aspirin was used in 80% and heparin (low molecular weight) in 7.5% cases. Two children died (5%) and median duration of PICU and hospital stay in survivors were 5 (2-8) and 7 (4-9) days, respectively. Children with shock showed higher total leucocyte count and higher rates of myocardial dysfunction.

Conclusion: Cardiovascular involvement and shock are predominant features in severe disease. Early diagnosis may be challenging given the overlapping features with other diagnoses. A high index of suspicion is warranted in children with constellation of fever, mucocutaneous, GI and cardiovascular involvement alongwith evidence of systemic inflammation and recent or concurrent SARS-CoV-2 infection. The short-term outcome is good with appropriate organ support therapies and immunomodulation.
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http://dx.doi.org/10.1093/tropej/fmab055DOI Listing
June 2021

Antimicrobial resistance in Shigella species: Our five years (2015-2019) experience in a tertiary care center in north India.

Indian J Med Microbiol 2021 Jun 18. Epub 2021 Jun 18.

Division of Pediatric Allergy & Immunology, Head of Department, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, 160012, India. Electronic address:

Purpose: Shigella is the second leading cause of diarrhoeal mortality especially in children <5 years of age in African and Asian countries. Rapid changes are occurring in the epidemiology of shigellosis and Shigella are increasingly becoming highly drug resistant. To determine the serogroup distribution and antimicrobial resistance of Shigella isolated at our tertiary care centre in North India.

Methods: A retrospective study was conducted where demographic details along with antimicrobial susceptibility data of Shigella isolated from stool specimens from 1 January 2015 till 31 December 2019 were retrieved from records and analyzed by WHONET 2019 software.

Results: Shigella species was isolated in 1.31% (n = 137) of a total of 10,456 stool samples. Males predominated (n = 82; 59.8%) and majority of cases were admitted (n = 94; 68.6%). Children ≤5 years of age (n = 47; 34.3%) were the most commonly affected. Adults in the 21-40 age group contributed 27% of cases (n = 37). Overall, Shigella flexneri (n = 87; 63.5%) was the most common serogroup followed by non-agglutinable Shigella (n = 28; 20.4%) while Shigella sonnei (n = 12, 8.8%) and Shigella boydii (n = 9, 6.6%) fluctuated over the years. Shigella dysenteriae reappeared in 2019 after a hiatus of ten years. Overall, 45.3% (n = 62) of isolates were multidrug resistant to CLSI recommended drugs and high resistance was noted for ampicillin/amoxicillin (68.1%), cotrimoxazole (75.8%) ciprofloxacin (61.5%) and ceftriaxone/cefotaxime (45.2%).

Conclusions: Shigella have become highly drug resistant to fluoroquinolones and cephalosporins. Community based studies are required to truly assess the burden of AMR in India.
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http://dx.doi.org/10.1016/j.ijmmb.2021.06.002DOI Listing
June 2021

Comparative Analysis of Pediatric COVID-19 Infection in Southeast Asia, South Asia, Japan, and China.

Am J Trop Med Hyg 2021 Jun 15. Epub 2021 Jun 15.

Duke-NUS Medical School, Singapore.

There is a scarcity of data regarding coronavirus disease 2019 (COVID-19) infection in children from southeast and south Asia. This study aims to identify risk factors for severe COVID-19 disease among children in the region. This is an observational study of children with COVID-19 infection in hospitals contributing data to the Pediatric Acute and Critical Care COVID-19 Registry of Asia. Laboratory-confirmed COVID-19 cases were included in this registry. The primary outcome was severity of COVID-19 infection as defined by the World Health Organization (WHO) (mild, moderate, severe, or critical). Epidemiology, clinical and laboratory features, and outcomes of children with COVID-19 are described. Univariate and multivariable logistic regression models were used to identify risk factors for severe/critical disease. A total of 260 COVID-19 cases from eight hospitals across seven countries (China, Japan, Singapore, Malaysia, Indonesia, India, and Pakistan) were included. The common clinical manifestations were similar across countries: fever (64%), cough (39%), and coryza (23%). Approximately 40% of children were asymptomatic, and overall mortality was 2.3%, with all deaths reported from India and Pakistan. Using the multivariable model, the infant age group, presence of comorbidities, and cough on presentation were associated with severe/critical COVID-19. This epidemiological study of pediatric COVID-19 infection demonstrated similar clinical presentations of COVID-19 in children across Asia. Risk factors for severe disease in children were age younger than 12 months, presence of comorbidities, and cough at presentation. Further studies are needed to determine whether differences in mortality are the result of genetic factors, cultural practices, or environmental exposures.
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http://dx.doi.org/10.4269/ajtmh.21-0299DOI Listing
June 2021

Pregabalin Toxicity Induced Encephalopathy Reverted With Hemodialysis: A Case Report.

Clin Pediatr (Phila) 2021 Jun 10:99228211023237. Epub 2021 Jun 10.

Postgraduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.1177/00099228211023237DOI Listing
June 2021

Fungaemia due to rare yeasts in paediatric intensive care units: A prospective study.

Mycoses 2021 May 3. Epub 2021 May 3.

Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: Considering the emergence of fungaemia due to rare yeasts at our centre, we performed a systematic epidemiologic study on fungaemia due to rare yeasts.

Objectives: We undertook the present prospective observational study to explore the epidemiological features and clinical characteristics of fungaemia due to rare yeasts in paediatric ICUs at our centre.

Methods: The successive yeasts isolated from blood at our PICUs during December 2017 through March 2019 were identified by molecular methods. Fungaemia due to yeasts other than C. albicans, C. tropicalis, C. glabrata, C. krusei and C. parapsilosis was categorised as rare yeast fungaemia. Antifungal susceptibility testing of the yeast isolates was performed as per clinical and laboratory standards institute (CLSI) guidelines. We also compared different clinical parameters of fungaemia due to common versus rare yeasts, and rare yeasts in neonates versus non-neonates.

Results: During the study period, 212 yeast isolates were obtained from 159 patients at PICUs of our hospital, and 127 isolates from 98 patients (61.6%) were categorised as rare yeasts. Neonates acquired fungaemia significantly earlier after ICU admission than non-neonates (median: 4 vs 6 days; p = .005). of rare yeast fungaemia, Wickerhamomyces anomalus (43.8%) and Candida utilis (40.8%) were common isolates; surgical intervention and gastrointestinal disease were significantly associated; overall, azole, echinocandin and amphotericin B resistance was at 9.1%, 1.02% and 1.02%, respectively; overall mortality was 65.3%.

Conclusions: The emergence of rare yeasts especially W. anomalus and C. utilis causing fungaemia in our children demands urgent attention to control the spread.
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http://dx.doi.org/10.1111/myc.13297DOI Listing
May 2021

Efficacy and Safety of Intravenous Labetalol in Acute Hypertensive Crisis in Children.

Indian J Pediatr 2021 Apr 24. Epub 2021 Apr 24.

Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.

Objective: To determine the efficacy and safety of intravenous (IV) labetalol in the management of hypertensive crisis in children.

Methods: A retrospective chart review of 56 consecutive children (age > 1 mo to ≤ 12 y) with hypertensive crisis admitted to a pediatric intensive care unit (PICU) from July 2009 to 2019.

Results: The proportion of children attaining the primary endpoint (target 95th percentile in > 12 to ≤ 48 h) was significantly more in the group receiving labetalol as first-line or add-on (n = 23) as compared to those not receiving labetalol (n = 33) (62% vs. 30.3%, p = 0.03). Higher proportion of neurological recovery was seen in the labetalol group (56.2% vs. 18.7%, p = 0.02). The proportion of children with hypotension before 12 h was similar in both treatment groups (13% vs. 15%, p = 0.82). The practice variations between two periods of 5 y each (2009-2013 and 2014-2019) showed significantly more use of labetalol in the latter cohort (53% for 2014-2019 vs. 25% for 2009-2013, p = 0.03).

Conclusion: Labetalol, when used alone or as an add-on drug, was more efficacious than IV nitroprusside/nitroglycerine in attaining the primary endpoint in children up to ≤ 12 y of age with hypertensive crisis. Labetalol was safe and associated with higher neurological recovery.
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http://dx.doi.org/10.1007/s12098-021-03707-7DOI Listing
April 2021

Long-term epilepsy control, motor function, cognition, sleep and quality of life in children with West syndrome.

Epilepsy Res 2021 Jul 2;173:106629. Epub 2021 Apr 2.

Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India. Electronic address:

Purpose: To assess epilepsy, motor function, cognitive, sleep, and quality of life outcomes and their predictors in a follow-up cohort with West syndrome (WS) at ≥5 years of age.

Methods: Cross-sectional evaluation in a follow-up cohort of WS (aged 5-14 years), between July 2018 and December 2019, was performed at a tertiary-care referral center in Northern India. 164 children were assessed in-person for epilepsy severity, functional status (gross motor and hand function), social quotient, behavioral comorbidities, sleep problems, and quality of life (QoL) using Early Childhood Epilepsy Severity Scale, Gross Motor Function Classification System, Manual Ability Classification System, Vineland Social Maturity Scale, Diagnostic and Statistical Manual of Mental disorders-5 criteria, Children's Sleep Habits Questionnaire, and PedsQL-Epilepsy module respectively. Furthermore, 238 children with the inability to visit the hospital were assessed through telephonic interview along with retrospective case record review for epilepsy control, gross and fine motor measures.

Results: 402 children with WS (75 % boys) with regular follow-up were studied and the majority (80 %) had underlying structural etiology. The median age (interquartile range) of the cohort was 92 (78-107) months. Of these, 60 % had evolved to Lennox-Gastaut syndrome (LGS). The following long-term outcomes were observed: ongoing epilepsy (261/402), unfavorable motor status (130/402), moderate to profound intellectual disability (111/164), autistic spectrum disorder (42/164), attention-deficit hyperactivity disorder (18/164), poor sleep (135/164), and impaired QoL (115/164). Non-structural etiology (odds ratio [OR] = 3.8, 95 % confidence interval [CI]: 2.1-5.5, p=<0·0001) and older age (>5 months) at the onset of epileptic spasms (OR = 2·9, 95 % CI: 1.5-5.0, p=<0·0001) were associated with enduring seizure freedom for more than two years.

Conclusion: The present study revealed a preponderance of structural etiology and a high rate of transition to LGS. Early age at onset of spasms (before five months) and structural etiology were the predictors of unfavorable long-term epilepsy outcome. QoL was impaired in more than two-thirds of patients and it correlated significantly with cognitive, sleep, motor, and behavioral outcomes. However, the results of our study should be interpreted in the context of significant attrition of the original cohort.
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http://dx.doi.org/10.1016/j.eplepsyres.2021.106629DOI Listing
July 2021

Biomarkers in COVID-19: An Up-To-Date Review.

Front Pediatr 2020 30;8:607647. Epub 2021 Mar 30.

Post Graduate Institute of Medical Education and Research, Chandigarh, India.

The ongoing pandemic of coronavirus disease 2019 (COVID-19) poses several challenges to clinicians. Timely diagnosis and hospitalization, risk stratification, effective utilization of intensive care services, selection of appropriate therapies, monitoring and timely discharge are essential to save the maximum number of lives. Clinical assessment is indispensable, but laboratory markers, or biomarkers, can provide additional, objective information which can significantly impact these components of patient care. COVID-19 is not a localized respiratory infection but a multisystem disease caused by a diffuse systemic process involving a complex interplay of the immunological, inflammatory and coagulative cascades. The understanding of what the virus does to the body and how the body reacts to it has uncovered a gamut of potential biomarkers. This review discusses the different classes of biomarkers - immunological, inflammatory, coagulation, hematological, cardiac, biochemical and miscellaneous - in terms of their pathophysiological basis followed by the current evidence. Differences between children and adults are highlighted. The role of biomarkers in the diagnosis and management of Multisystem Inflammatory Syndrome in Children (MIS-C) is reviewed. The correlation of biomarkers with clinical and radiological features and the viral load, temporal evolution and the effect of treatment remain to be studied in detail. Which biomarker needs to be evaluated when and in whom, and how best this information can contribute to patient care are questions which currently lack convincing answers. With the evidence currently available broad guidelines on the rational use of available biomarkers are presented. Integrating clinical and laboratory data, monitoring trends rather than a single value, correlating with the natural course of the disease and tailoring guidelines to the individual patient and healthcare setting are essential.
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http://dx.doi.org/10.3389/fped.2020.607647DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8042162PMC
March 2021

Twenty-four-hour pretreatment with low dose (0.25 mg/kg/dose) versus high dose (0.5 mg/kg/dose) dexamethasone in reducing the risk of postextubation airway obstruction in children: A randomized open-label noninferiority trial.

Pediatr Pulmonol 2021 Jul 5;56(7):2292-2301. Epub 2021 Apr 5.

Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Objective: Multidose dexamethasone pretreatment reduces risk of postextubation airway obstruction (PEAO). However, its optimal dose is not known. We planned to compare 24 h pretreatment with low-dose dexamethasone (LDD) (0.25 mg/kg/dose) versus high-dose dexamethasone (HDD) (0.5 mg/kg/dose) in reducing risk of PEAO.

Design: Stratified (for age and intubation duration) randomized open-label noninferiority trial.

Setting: Fifteen-bed pediatric intensive care unit in a lower-middle-income country.

Patients: Children (3 months-12 years) intubated for more than or equal to 48 h and planned for first extubation (February 17-March 19). Upper airway conditions, chronic respiratory diseases, chronic NSAID therapy, steroid, or intravenous immunoglobulin in the last 7 days, presence of gastrointestinal bleeding, hypertension, and hyperglycemia were exclusions.

Interventions: LDD (n = 144) or HDD (n = 143) (q6h) for a total of six doses. Extubation was planned immediately after fifth dose. Noninferiority margin was kept at 12% from baseline.
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http://dx.doi.org/10.1002/ppul.25388DOI Listing
July 2021

Prescription practice and clinical utility of chest radiographs in a pediatric intensive care unit: a prospective observational study.

BMC Med Imaging 2021 03 9;21(1):44. Epub 2021 Mar 9.

Pediatric Emergency and Intensive Care Units, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India.

Background: Chest radiograph (CXR) prescribing pattern and practice vary widely among pediatric intensive care units (PICU). 'On demand' approach is increasingly recommended as against daily 'routine' CXRs; however, the real-world practice is largely unknown.

Methods: This was a prospective observational study performed in children younger than 12 years admitted to PICU of a tertiary care teaching hospital in India. Data were collected on all consecutive CXRs performed between December 2016 and April 2017. The primary outcome was to assess the factors that were associated with higher chest radiograph prescriptions in PICU. Secondary outcomes were to study the indications, association with mechanical ventilation, image quality and avoidable radiation exposure.

Results: Of 303 children admitted during the study period, 159 underwent a total of 524 CXRs in PICU. Median (IQR) age of the study cohort was 2 (0.6-5) years. More than two thirds [n = 115, 72.3%] were mechanically ventilated. Most CXRs (n = 449, 85.7%) were performed on mechanically ventilated patients, amounting to a median (IQR) of 3 (2-5) radiographs per ventilated patient. With increasing duration of ventilation, the number of CXRs proportionately increased in the first two weeks of mechanical ventilation. In non-ventilated children, about two thirds (68%) underwent only one CXR. Majority of the prescriptions were on demand (n = 461, 88%). Most common indications were peri-procedure prescriptions (37%) followed by evaluation for respiratory disease status (24%). About 40% CXRs resulted in interventions; adjustment in ventilator settings (13.5%) was the most frequent intervention. In 26% (n = 138) of radiographs, image quality required improvement. One or more additional body part exposure other than chest and upper abdomen were noted 336 (64%) images. Children with > 3 CXR had higher PRISM III score, more often mechanically ventilated, had higher number of indwelling devices [mean (SD) 2.6 (1.2) vs. 1.7 (1.0)] and stayed longer in PICU [median (IQR) 11(7.5-18.5) vs. 6 (3-9)].

Conclusion: On demand prescription was the prevalent practice in our PICU. Most non-ventilated children underwent only one CXR while duration of PICU stay and the number of devices determined the number of CXRs in mechanically ventilated children. Quality improvement strategies should concentrate on the process of acquisition of images and limiting the radiation exposure to unwanted body parts.
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http://dx.doi.org/10.1186/s12880-021-00576-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941116PMC
March 2021

Tracheostomy in Critically Ill Children-Bypassing the Hurdle and Running into More!

Indian J Pediatr 2021 05 18;88(5):429-430. Epub 2021 Mar 18.

Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.

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http://dx.doi.org/10.1007/s12098-021-03716-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7971382PMC
May 2021

AHA Pediatric Advanced Life Support Update 2020 - "More Breaths, Less Fluids, and a Focus on Recovery".

Indian Pediatr 2021 03;58(3):273-278

Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India. Correspondence to: Dr Jayashree Muralidharan, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Pediatric Advanced Life Support (PALS) guidelines are updated every five years and the new 2020 guidelines were issued recently. We briefly review the important changes in terms of rates of rescue breaths, timing of epinephrine, resuscitation in septic shock, use of extracorporeal therapies, and the new component in the chain of survival - recovery.
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March 2021

Bed Utilization and Overcrowding in a High-Volume Tertiary Level Pediatric Emergency Department.

Indian Pediatr 2021 Feb 25. Epub 2021 Feb 25.

Pediatric Emergency and Intensive Care Units, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Objective: To measure bed utilization rate and overcrowding in a high-volume tertiary level pediatric emergency department (ED) and correlate with outcome.

Methods: All children beyond neonatal age attending the 22-bedded emergency were prospectively enrolled from February to December, 2019. Number of daily admissions, boarders, discharges, ward transfers, length of stay (LOS) and unfavorable outcomes (care discontinuation and deaths) were recorded. Daily bed occupancy rate (BOR) was calculated and correlated with unfavorable outcome.

Result: A total of 17,463 children visited the ED during the study period. The median (IQR) daily attendance and admission rate was 58 (51,65) and 22 (17,26) patients, respectively. The median (IQR) number of boarders and BOR was 48 (40-58) and 218 (181-263)%, respectively. The median (IQR) LOS was 42.7 (23-71.4) hours. Unfavorable outcome correlated positively with number of boarders and BOR (P<0.001).

Conclusion: Overcrowding of the ED was associated with increased frequency of care discontinuation and mortality. This data calls for systemic changes to tackle overcrowding.
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February 2021

Cost analysis of pediatric intensive care: a low-middle income country perspective.

BMC Health Serv Res 2021 Feb 23;21(1):168. Epub 2021 Feb 23.

Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India.

Background: Globally, Pediatric Intensive Care Unit (PICU) admissions are amongst the most expensive. In low middle-income countries, out of pocket expenditure (OOP) constitutes a major portion of the total expenditure. This makes it important to gain insights into the cost of pediatric intensive care. We undertook this study to calculate the health system cost and out of pocket expenditure incurred per patient during PICU stay.

Methods: Prospective study conducted in a state of the art tertiary level PICU of a teaching and referral hospital. Bottom-up micro costing methods were used to assess the health system cost. Annual data regarding hospital resources used for PICU care was collected from January to December 2018. Data regarding OOP was collected from 299 patients admitted from July 2017 to December 2018. The latter period was divided into four intervals, each of four and a half months duration and data was collected for 1 month in each interval. Per patient and per bed day costs for treatment were estimated both from health system and patient's perspective.

Results: The median (inter-quartile range, IQR) length of PICU stay was 5(3-8) days. Mean ± SD Pediatric Risk of Mortality Score (PRISM III) score of the study cohort was 22.23 ± 7.3. Of the total patients, 55.9% (167) were ventilated. Mean cost per patient treated was US$ 2078(₹ 144,566). Of this, health system cost and OOP expenditure per patient were US$ 1731 (₹ 120,425) and 352 (₹ 24,535) respectively. OOP expenditure of a ventilated child was twice that of a non- ventilated child.

Conclusions: The fixed cost of PICU care was 3.8 times more than variable costs. Major portion of cost was borne by the hospital. Severe illness, longer ICU stay and ventilation were associated with increased costs. This study can be used to set the reimbursement package rates under Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). Tertiary level intensive care in a public sector teaching hospital in India is far less expensive than developed countries.
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http://dx.doi.org/10.1186/s12913-021-06166-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901186PMC
February 2021

Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.

BMJ Open 2021 02 22;11(2):e043837. Epub 2021 Feb 22.

Department of Hospital Administration, PGIMER, Chandigarh, India.

Objectives: Healthcare personnel (HCP) are at an increased risk of acquiring COVID-19 infection especially in resource-restricted healthcare settings, and return to homes unfit for self-isolation, making them apprehensive about COVID-19 duty and transmission risk to their families. We aimed at implementing a novel multidimensional HCP-centric evidence-based, dynamic policy with the objectives to reduce risk of HCP infection, ensure welfare and safety of the HCP and to improve willingness to accept and return to duty.

Setting: Our tertiary care university hospital, with 12 600 HCP, was divided into high-risk, medium-risk and low-risk zones. In the high-risk and medium-risk zones, we organised training, logistic support, postduty HCP welfare and collected feedback, and sent them home after they tested negative for COVID-19. We supervised use of appropriate personal protective equipment (PPE) and kept communication paperless.

Participants: We recruited willing low-risk HCP, aged <50 years, with no comorbidities to work in COVID-19 zones. Social distancing, hand hygiene and universal masking were advocated in the low-risk zone.

Results: Between 31 March and 20 July 2020, we clinically screened 5553 outpatients, of whom 3012 (54.2%) were COVID-19 suspects managed in the medium-risk zone. Among them, 346 (11.4%) tested COVID-19 positive (57.2% male) and were managed in the high-risk zone with 19 (5.4%) deaths. One (0.08%) of the 1224 HCP in high-risk zone, 6 (0.62%) of 960 HCP in medium-risk zone and 23 (0.18%) of the 12 600 HCP in the low-risk zone tested positive at the end of shift. All the 30 COVID-19-positive HCP have since recovered. This HCP-centric policy resulted in low transmission rates (<1%), ensured satisfaction with training (92%), PPE (90.8%), medical and psychosocial support (79%) and improved acceptance of COVID-19 duty with 54.7% volunteering for re-deployment.

Conclusion: A multidimensional HCP-centric policy was effective in ensuring safety, satisfaction and welfare of HCP in a resource-poor setting and resulted in a willing workforce to fight the pandemic.
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http://dx.doi.org/10.1136/bmjopen-2020-043837DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902325PMC
February 2021

Hyperferritinemia in children hospitalized with scrub typhus.

Trop Med Health 2021 Feb 17;49(1):15. Epub 2021 Feb 17.

Division of Pediatric Emergency and Intensive care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Sector-12, Chandigarh, 160012, India.

Background: Hyperferritinemia is increasingly associated with mortality in sepsis. Studies estimating the prevalence of hyperferritinemia in pediatric scrub typhus are limited.

Methods: This was a secondary analysis of a prospective observational study (FERRIS) from a tertiary care teaching hospital in North India where 72 children with confirmed scrub typhus, 4 (5.5%) PCR positive, 55 (76.4%)-IgM ELISA positive, and 13 (18.1%)-both PCR and ELISA positive, were analyzed. Serum ferritin was measured in 62 children to identify the prevalence of hyperferritinemia and determine its association with mortality.

Results: Hyperferritinemia (> 500 μg/L) was seen in 72.6% [n = 45] children; 26 (41.9%) were mild (500-2000 μg/L), 13 (21%) were moderate (2000-10,000 μg/L), and 6 (9.7%) were severe (> 10,000 μg/L). Early presentation to hospital (≤ 7 days of febrile illness) had more survivors than late presentation (> 7 days). Non-survivors had significantly higher PRISM III, PELOD-2, hyperlactatemia, hypoalbuminemia, organ dysfunction, need for mechanical ventilation, and need of RRT. Ferritin had poor sensitivity and specificity in predicting survival with AUC of 0.56. Organ dysfunction and risk scores as PRISM III, PELOD 2, and VIS at admission were better predictors with AUC (95% CI) of 0.72 (0.56, 0.89), 0.77 (0.63, 0.92), and 0.90 (0.78, 1.0) respectively.

Conclusions: Hyperferritinemia is common in scrub typhus but it did not predict survival. Organ dysfunction and risk scores were better predictors of mortality than ferritin.
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http://dx.doi.org/10.1186/s41182-021-00304-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890859PMC
February 2021

Clinical Profile, Hospital Course and Outcome of Children with COVID-19.

Indian J Pediatr 2021 Feb 13. Epub 2021 Feb 13.

Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Objectives: To describe the epidemiological and clinical characteristics and outcome of hospitalized children with COVID-19 during the initial phase of the pandemic.

Methods: This was a cross-sectional descriptive study conducted at the dedicated COVID-19 hospital of a tertiary care referral center in North India. Consecutive children aged 14 y or younger who tested positive for SARS-CoV-2 by RT-PCR from nasopharyngeal swab between 1 April 2020 and 15 July 2020 were included.

Results: Of 31 children with median (IQR) age of 33 (9-96) mo, 9 (29%) were infants. About 74% (n = 23) had history of household contact. Comorbidities were noted in 6 (19%) children. More than half (58%) were asymptomatic. Of 13 symptomatic children, median (IQR) duration of symptoms was 2 (1-5.5) d. Fever (32%) was most common followed by cough (19%), rapid breathing (13%), diarrhea (10%) and vomiting (10%). Severe [n = 4, 13%] and critical [n = 1, 3%] illnesses were noted more commonly in infants with comorbidities. Three (10%) children required PICU admission and invasive ventilation; one died. Median (IQR) length of hospital stay was 15 (11-20) d. Follow up RT-PCR before discharge was performed in 17 children and the median (IQR) duration to RT-PCR negativity was 16 (12-19) d.

Conclusions: In the early pandemic, most children with COVID-19 had a household contact and presented with asymptomatic or mild illness. Severe and critical illness were observed in young infants and those with comorbidities.
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http://dx.doi.org/10.1007/s12098-020-03572-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7881747PMC
February 2021

Validation of the pediatric refractory septic shock definition: post hoc analysis of a controlled trial.

Ann Intensive Care 2021 Feb 10;11(1):32. Epub 2021 Feb 10.

Division of Pediatric Intensive and Emergency Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Background: The European Society of Pediatric and Neonatal Intensive Care (ESPNIC) developed and validated a definition of pediatric refractory septic shock (RSS), based on two septic shock scores (SSS). Both bedside SSS (bSSS) and computed SSS (cSSS) were found to be strongly associated with mortality. We aimed at assessing the accuracy of the RSS definition on a prospective cohort from India.

Methods: Post hoc analysis of a cohort issued from a double-blind randomized trial that compared first-line vasoactive drugs in children with septic shock. Sequential bSSS and cSSS from 60 children (single-center study, 53% mortality) were analyzed. The prognostic value of the ESPNIC RSS definition was tested for 28-day all-cause mortality.

Results: In this septic shock cohort, RSS was diagnosed in 35 patients (58.3%) during the first 24 h. Death occurred in 30 RSS patients (85.7% mortality) and in 2 non-RSS patients (8% mortality), OR = 60.9 [95% CI: 10.5-676.2], p < 0.001 with a median delay from sepsis onset of 3 days [1.0-6.7]. Among patients diagnosed with RSS, the mortality was not significantly different according to vasopressors randomization. Diagnosis of RSS with bSSS and cSSS had a high discrimination for death with an area under the receiver operating curve of 0.916 [95% CI: 0.843-0.990] and 0.925 [95% CI: 0.845-1.000], respectively. High prognostic accuracy of the bSSS was found in the first hours following intensive care admission. The best interval of prognostication occurs after the 12th hour following treatment initiation (AUC 0.973 [95% CI: 0.925-1.000]).

Conclusions: The ESPNIC refractory septic shock definition accurately identifies, within the first 6 h of septic shock management, children with lethal outcome.
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http://dx.doi.org/10.1186/s13613-021-00822-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876206PMC
February 2021

Epidemiology of Acute Gastroenteritis Caused by Rotavirus among Children Less than Five Years Old Admitted in Hospital, in North India.

Indian J Pediatr 2021 03 8;88(Suppl 1):22-27. Epub 2021 Feb 8.

The Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu, India.

Objectives: To report the data of burden of rotaviral acute gastroenteritis in under-five children from two states post-introduction of the vaccine.

Methods: Children under 5 y of age hospitalized with diarrhea from the states of Haryana and Himachal Pradesh in north India were recruited in the study. Commercially available ELISA kits were used for testing rotavirus in the collected stool samples. Genotyping of the positive samples was done by reverse-transcription polymerase chain reaction.

Results: Out of 345 samples collected, 69 (20%) were found to be positive for rotavirus by ELISA. Genotyping was done and G3P[8] (31.3%), G1P[8] (13.4%), G2P[4] (13.4%) were found to be prevalent strains. Mixed strains were also found in 19.4% stool samples.

Conclusions: The study highlighted the high burden of rotavirus associated diarrhea in north Indian states. The data is helpful for evaluating the impact of vaccine on the severity of acute gastroenteritis and the changing strains after the introduction of rotavirus vaccine in the Universal Immunization Program.
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http://dx.doi.org/10.1007/s12098-020-03619-yDOI Listing
March 2021

Epidemiology of Hospitalized Intussusception Cases from Northern States in India.

Indian J Pediatr 2021 03 16;88(Suppl 1):118-123. Epub 2021 Jan 16.

The Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu, India.

Objective: To describe epidemiology of intussusception post-introduction of the rotavirus vaccine.

Methods: Hospital-based active surveillance system was set up in three tertiary care hospitals in Chandigarh and Haryana, India, to enroll children <2 y of age admitted with intussusception as per Brighton Collaboration Level-I criteria. The clinical characteristics, treatment modalities, seasonal trends, and outcome of the illness episodes were described.

Results: A total of 224 cases were reported. Majority were males (71%) and infants (69.5%). Number of intussusception was more in summer season. Location of intussusception was ileo-colic in 85% of the cases. Nearly 54% cases were treated conservatively and 46% needed surgical intervention.

Conclusion: Surveillance data provided the epidemiological description of intussusception cases post-introduction of the rotavirus vaccine in northern India. This data could be used to assess the impact of vaccine and safety with a special focus on intussusception.
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http://dx.doi.org/10.1007/s12098-020-03609-0DOI Listing
March 2021

Thiamine Status in Children with Septic Shock from a Developing Country: A Prospective Case-Control Study.

J Trop Pediatr 2021 01;67(1)

Division of Pediatric Neurology, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Objective: Mitochondrial dysfunction is central to sepsis-induced multi-organ dysfunction. Thiamine deficiency may contribute to mitochondrial dysfunction and thus high mortality. Study was planned to assess thiamine status in children with septic shock in comparison to healthy controls from a developing country and to study the effect of thiamine levels on its outcome.

Methods: A prospective case-control study (April 2017 to May 2018) enrolling consecutive children with septic shock as 'cases' (n = 76), their healthy siblings (n = 51) and apparently healthy children from immunization clinic (n = 35) as 'controls'. Whole blood total thiamine (WBTT) level was measured on days 1, 10 and 1-month post-discharge. Outcome parameters were acute care area free days on days 14 and 28, and mortality.

Results: WBTT [nMol/l; median (interquartile range, IQR)] was significantly lower on day 1 in cases compared with sibling controls [23.1 (21.8-26.3) vs. 36.9 (33.6-40.5); p < 0.001]. It fell further on day 10 [20.8 (18.1-21.1); p < 0.02]. Levels rose significantly 1-month post-discharge [35.5 (31.2-36.6)] and became comparable to sibling controls (p = 0.4). Immunization clinic controls also had lower WBTT [42.3 (40.1-45.9)], but was significantly higher than sibling controls and cases at 1-month post-discharge (p < 0.001). Survivors and non-survivors of septic shock were similar. WBTT levels did not correlate with any of the severity indicators of septic shock or its outcomes.

Conclusions: WBTT was significantly low in all children, and fell further during septic shock. Observed severe deficiency might have precluded any further association of thiamine levels with severity of septic shock and its outcome. Data obtained may inform trials on metabolic resuscitation in paediatric septic shock in developing countries. Lay summaryThiamine deficiency may contribute to high mortality in paediatric septic shock as thiamine is an essential factor for functioning of mitochondria, the powerhouse of the cells. This prospective case-control study was conducted to assess thiamine status in children with septic shock in comparison with healthy controls in a developing country. Consecutive children with fluid-refractory septic shock were enrolled as 'cases'. Their apparently healthy siblings, and apparently healthy children from immunization clinic, were enrolled as 'controls'. The whole blood total thiamine (WBTT) level was measured on days 1, 10 and 1 month after hospital discharge. Seventy-six children were enrolled as cases, 51 children as sibling controls and 35 children as immunization clinic controls. WBTT was significantly lower on day 1 in cases as compared with their sibling controls. It fell further on day 10. The level rose significantly after a month of discharge and became comparable to sibling controls. Immunization clinic controls also had lower WBTT but was significantly higher compared with sibling controls and cases at 1-month post-discharge. Survivors and non-survivors of septic shock had similar WBTT levels. Observed severe deficiency might have precluded any further association of thiamine levels with septic shock outcome.
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http://dx.doi.org/10.1093/tropej/fmaa107DOI Listing
January 2021

Serum Ferritin Predicts Neither Organ Dysfunction Nor Mortality in Pediatric Sepsis Due to Tropical Infections.

Front Pediatr 2020 3;8:607673. Epub 2020 Dec 3.

Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India.

To evaluate serial ferritin levels measured in the initial 72 h of admission as a biomarker for new and progressive multi organ dysfunction syndrome (NPMODS) and mortality (unfavorable outcomes) in critically ill children with sepsis due to tropical infections. In this prospective observational study from a tertiary care teaching hospital in India, children 3 month to 12 years with a diagnosis of acute febrile illness and any two features suggesting tropical infections [cytopenia (platelet count <1,00,000/cu.mm, total leucocyte count <4,000/cu.mm), hepatomegaly and/or splenomegaly, lymphadenopathy, systemic signs (rash, edema), respiratory distress, and encephalopathy not accounted by localized infection] were eligible for inclusion. Children with known or suspected disorder of iron metabolism were excluded. Primary outcome was to determine the association of serial ferritin levels with mortality and NPMODS. Secondary outcomes included estimation of the prevalence of hyperferritinemia and comparison of risk prediction scores with serial ferritin measurement in predicting unfavorable outcomes. In the 202 children enrolled, diagnosis could be established in 133 (65.8%) children. Scrub typhus and dengue were the most common infections. Median (IQR) ferritin measured at admission ( = 183) and on day 3 ( = 120) of hospital stay were 798 (378, 3,205) μg/L and 429 (213,680) μg/L, respectively. Majority ( = 180, 89.1%) had MODS at admission defined as per International pediatric sepsis consensus conference. NPMODS occurred in 47 (23.3%) children of whom 37 (18.3%) died. Children with three or less organ dysfunctions had lower mortality. Neither admission ferritin values nor the percentage change over 72 h was different between children with favorable and unfavorable outcomes. Pediatric Risk of Mortality (PRISM-III) and daily Pediatric Logistic Organ Dysfunction score (dPELOD2 score) were significantly different in those with unfavorable outcomes. Admission ferritin levels and percentage change in 72 h had poor discriminatory power for mortality with AUC of 0.53 (0.53, 0.67) and 0.50 (0.50, 0.64), respectively. dPELOD2 had the best discriminatory power for mortality with AUC of 0.89 (0.89, 0.95). Serial ferritin estimation predicted neither organ dysfunction nor mortality in pediatric sepsis with tropical infections. dPELOD-2 and PRISM-III predicted unfavorable outcomes better than ferritin. The current diagnostic criteria for MODS overestimated organ dysfunctions in tropical infections and hence may need modification with further validation in this epidemiological cohort.
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http://dx.doi.org/10.3389/fped.2020.607673DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747694PMC
December 2020

Pattern Recognition Approach to Brain MRI Findings in Patients with Dengue Fever with Neurological Complications.

Neurol India 2020 Sep-Oct;68(5):1038-1047

Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Background And Purpose: Dengue can present with variable neurological complications including encephalitis, encephalopathy, acute disseminated encephalomyelitis (ADEM), and ischemic and hemorrhagic stroke. Our study describes a pattern-based approach to recognize different brain MRI findings in dengue-seropositive patients with neurological symptoms.

Materials And Methods: Thirty-six serologically proven dengue patients with neurological symptoms and undergoing brain MRI over a 6-month period were included in this study. The diagnosis of dengue encephalopathy or encephalitis was established by presence of signs/symptoms of acute encephalitic syndrome with the presence of Immunoglobin M (IgM) antibody against dengue antibody in the serum and/or presence of dengue antigen (NS1) in serum. The MRI brain along with diffusion weighted imaging and susceptibility weighted imaging sequences were evaluated by an experienced neuroradiologist.

Results: Eleven patients had normal MRI finding. In the rest 25 patients, 12 were found to have encephalitic pattern, 4 had encephalopathic (seizure related/metabolic) pattern, 3 had features of ADEM, and isolated micro- or macro-hemorrhages were found in 6 patients. In the encephalitis group, eight had concomitant involvement of brainstem, cerebellum, and ganglio-thalamic complexes with additional involvement of cortex and subcortical white matter (WM) found in three. Isolated brainstem and cerebellar involvement were seen in three in this group, whereas one had isolated cerebellar involvement. Interspersed hemorrhage was noted in the structures involved in eight patients in encephalitis group.

Conclusion: Radiologists should be aware of various MRI brain findings in dengue and a pattern recognition approach often helps in reaching the correct diagnosis albeit after exclusion of other differentials based on laboratory studies.
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http://dx.doi.org/10.4103/0028-3886.294556DOI Listing
May 2021

Hemophagocytic Lymphohistiocytosis in a PICU of a Developing Economy: Clinical Profile, Intensive Care Needs, Outcome, and Predictors of Mortality.

Pediatr Crit Care Med 2021 01;22(1):e44-e57

Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Objectives: To describe the clinical profile, intensive care needs, outcome, and predictors of mortality in critically ill children with hemophagocytic lymphohistiocytosis.

Design: Retrospective case series.

Setting: PICU of a tertiary care teaching hospital in North India.

Patients: Children 2 months to 12 years old with the diagnosis of hemophagocytic lymphohistiocytosis admitted to PICU from January 2012 to April 2019 (7¼ yr).

Interventions: None.

Measurements And Main Results: Sixty-two children with hemophagocytic lymphohistiocytosis (60 secondary and two primary) were enrolled. The median (interquartile range) age of the study group was 82 months (50.5-124 mo). The median (interquartile range) Pediatric Risk of Mortality III score was 16 (10-23). Majority of hemophagocytic lymphohistiocytosis was infection-associated (n = 51; 82.3%). Among these, scrub typhus accounted for 29% of cases (n = 18), dengue 17.7% (n = 11), bacterial sepsis 14.5% (n = 9), enteric fever 6.5% (n = 4), and other infections 14.5% (n = 9). Systemic-onset juvenile idiopathic arthritis accounted for 9.7% of cases (n = 6) and malignancy for 4.8% patients (n = 3). Majority of cases were treated with steroids (77.4%) and IV immunoglobulin (25.8%). Various complications noted were shock (71%), acute kidney injury (66.1%), acute respiratory distress syndrome (41.9%), disseminated intravascular coagulation (54.8%), CNS dysfunction (54.8%), multiple organ dysfunction syndrome (82.3%), and healthcare-associated infections (14.5%). Intensive care needs for primary illness and/or hemophagocytic lymphohistiocytosis included mechanical ventilation (74.2%); packed RBC (72.3%), fresh frozen plasma (40.3%), and platelet (48.4%) transfusion; vasoactive drugs (71%); and renal replacement therapy (24.2%). The median duration of PICU stay was 5 days (2.5-9.5 d) and mortality was 59.7% (n = 37). On univariate analysis, nonsurvivors had higher Pediatric Risk of Mortality III score; higher proportion of shock, acute kidney injury, acute respiratory distress syndrome, disseminated intravascular coagulation, and multiple organ dysfunction syndrome; the need for blood and blood components, mechanical ventilation, vasoactive drugs, and renal replacement therapy; higher Vasoactive-Inotropic Score; and prolonged duration of mechanical ventilation compared with survivors.

Conclusions: Hemophagocytic lymphohistiocytosis in PICU is commonly secondary to tropical infections and associated with high mortality. Higher severity of illness; shock and multiple organ dysfunction syndrome; need for blood and blood products, mechanical ventilation, vasoactive drugs, and renal replacement therapy; higher Vasoactive-Inotropic Score; and prolonged mechanical ventilation predicted death. Treatment of underlying infection and a less intense immunosuppressive therapy (steroids ± IV immunoglobulin) are suggested options. A high index of suspicion for complicating hemophagocytic lymphohistiocytosis is required in children with prolonged fever, cytopenias, organomegaly, and organ dysfunction not responding to conventional treatment.
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http://dx.doi.org/10.1097/PCC.0000000000002539DOI Listing
January 2021

Intensive Care Unit-Acquired Weakness in Children: A Prospective Observational Study Using Simplified Serial Electrophysiological Testing (PEDCIMP Study).

Neurocrit Care 2021 06 7;34(3):927-934. Epub 2020 Oct 7.

Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India.

Background: To study the incidence and time of onset of intensive care unit-acquired weakness in a prospective cohort of children (2-12 years) by serial simplified electrophysiological assessment (Pediatric Critical Illness Myopathy Polyneuropathy study, PEDCIMP).

Methods: A single-center, prospective cohort study (Trial Registry Number: NCT02763709; PEDCIMP2016) was conducted at the pediatric intensive care unit of a tertiary care hospital in North India. A complete electrophysiological evaluation (4 motor nerves and 2 sensory nerves) was performed at baseline in children (2-12 years) admitted to the ICU with a pediatric risk of mortality (PRISM) of > 20 with more than 24-h stay. Following the entry evaluation, a minimal alternate day simplified electrophysiological testing of the unilateral common peroneal nerve and the sural nerve was assessed. A 25% reduction in compound muscle action potential (CMAP) and sensory nerve action potential from baseline was considered significant for ICUAW and was confirmed by complete electrophysiological re-evaluation.

Results: Of the total 481 children assessed for eligibility, 97 were enrolled. The median age of the cohort was 7 years. Sepsis (81%); need for vasoactive support (43%); multiorgan dysfunction (26%) were the common reasons for admission. Of the 433 eligible patient ICU days, 380 electrophysiological observations were done. A significant decrease of > 25% in CMAP of common peroneal nerve was not detected in any of the 380 observations. However, two children unfit for inclusion were diagnosed with ICUAW during the study period.

Conclusions: Children admitted with PRISM > 20 have a very low incidence of intensive care unit-acquired weakness by serial clinical and abbreviated electrophysiological evaluation.
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http://dx.doi.org/10.1007/s12028-020-01123-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7538369PMC
June 2021

Randomized Clinical Trial of 20% Mannitol Versus 3% Hypertonic Saline in Children With Raised Intracranial Pressure Due to Acute CNS Infections.

Pediatr Crit Care Med 2020 12;21(12):1071-1080

All authors: Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Objectives: Mannitol is a commonly used osmotherapy agent in raised intracranial pressure. However, the side effects of mannitol are significant. In traumatic brain injury (adult and pediatric), hypertonic saline (3%) shows varied results in comparison with 20% mannitol. We compared the effect of 3% hypertonic saline versus 20% mannitol (using common dosing strategies) on raised intracranial pressure in pediatric acute CNS infections.

Design: Open-label randomized controlled trial.

Setting: PICU of a quaternary care academic institute.

Patients: Children 1-12 years old, with raised intracranial pressure and modified-Glasgow Coma Scale scores less than or equal to 8, were enrolled.

Interventions: Patients were randomly assigned to 20%-mannitol (n = 28), 0.5 gram/kg/dose versus 3%-hypertonic saline (n = 29), 10 mL/kg loading followed by 0.5-1 mL/kg/hr infusion. An intraparenchymal catheter was used to monitor the intracranial pressure. The primary outcome was the proportion of patients achieved target average intracranial pressure less than 20 mm Hg during 72 hours. Secondary outcomes were interventions, morbidity, and mortality.

Measurements And Main Results: The proportion of patients with target average intracranial pressure (< 20 mm Hg) was higher in hypertonic saline-group as compared to mannitol-group (79.3% vs 53.6%; adjusted hazard ratio 2.63; 95% CI: 1.23-5.61). Mean (± SE) reduction of intracranial pressure (-14.3 ± 1.7 vs -5.4 ± 1.7 mm Hg; p ≤ 0.001) and elevation of cerebral perfusion pressure (15.4 ± 2.4 vs 6 ± 2.4 mm Hg; p = 0.007) from baseline were significant in hypertonic saline-group. Mean (± SE) intracranial pressure over 72 hours was lower (14 ± 2 vs 22 ± 2 mm Hg; p = 0.009), and cerebral perfusion pressure was higher (65 ± 2.2 vs 58 ± 2.2; p = 0.032) in hypertonic saline-group. Hypertonic saline-group had higher modified-Glasgow Coma Scale score at 72 hours (median, interquartile range 10; 7-11 vs 7; 3-9; p = 0.003), lower mortality (20.7% vs 35.7%; p = 0.21), shorter duration of mechanical ventilation (5 vs 15 d; p = 0.002), and PICU stay (11 vs 19 d; p = 0.016) and less severe neurodisability at discharge (31% vs 61%; p = 0.049).

Conclusions: In pediatric acute CNS infections, 3%-hypertonic saline was associated with a greater reduction of intracranial pressure as compared to 20% mannitol.
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December 2020

Pre-extubation ultrasonographic measurement of intracricoid peritubal free space: A pilot study to predict post-extubation airway obstruction in children.

Int J Pediatr Otorhinolaryngol 2020 Nov 1;138:110348. Epub 2020 Sep 1.

Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India.

Objective: Post-extubation airway obstruction (PEAO) is common and difficult to predict in children. We hypothesized that Intracricoid Peritubal Free Space (IPFS) obtained by deducting the outer diameter of the endotracheal tube in situ (OD - provided by the manufacturer) from the ultrasonographically measured internal transverse cricoid diameter (ICD) is likely to be inversely proportional to the risk of developing PEAO. This prospective observational study was planned to evaluate this hypothesis.

Methods: This study was conducted in a Pediatric Intensive Care Unit of a tertiary care teaching hospital in a low-middle income economy. Laryngotracheal ultrasound was performed just prior to the first elective extubation in 93 patients (3mo-12yrs) intubated for ≥ 48 h, to calculate the IPFS. Patients with pre-existent upper airway conditions, chronic respiratory diseases and poor airway reflexes were excluded. Patients with Westley's Croup Score (WCS) ≥4 were classified as PEAO, and those with WCS ≥7, as extubation failure (EF).

Results: Thirty-two (34%) patients developed PEAO, while seventeen (18%) developed EF. Baseline clinical characteristics were similar in patients with and without PEAO. IPFS was lesser in patients who developed PEAO (4.16 ± 1.18 mm vs. 5.28 ± 1.51 mm, p < 0.001) and EF (4.13 ± 1.44 mm vs. 5.07 ± 1.46 mm, p = 0.019) compared to those who did not. IPFS <5.16 mm predicted PEAO [sensitivity, 84%; positive predictive value (PPV), 87%; AUC, 0.714), while IPFS <3.77 mm predicted EF (specificity, 80%; PPV, 88%; AUC, 0.679). Combining clinical risk factors (presence of clinical edema, prolonged ventilation and younger age) and lesser IPFS helped develop a clinico-sonographic prediction model with improved predictability for PEAO and EF (AUC, 0.820 for both).

Conclusions: Lesser IPFS is reasonably sensitive and specific to predict PEAO and EF respectively with high PPV. Combining clinical risk factors and IPFS improved the PPV further. Further studies with larger samples stratified for different age groups in different clinical settings are required to confirm these observations.
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http://dx.doi.org/10.1016/j.ijporl.2020.110348DOI Listing
November 2020

Clinical Profile and Predictors of Intensive Care Unit Admission in Pediatric Scrub Typhus: A Retrospective Observational Study from North India.

Indian J Crit Care Med 2020 Jun;24(6):445-450

Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Introduction: Children with scrub typhus may present with one or more organ failures. Identifying the predictors of severe disease and need for pediatric intensive care unit (PICU) admission would help clinicians during outbreak seasons.

Materials And Methods: This observational study included 160 children admitted to the emergency department (ED) with scrub typhus confirmed by polymerase chain reaction (PCR) between January 2013 and December 2015. Demographic, clinical, and laboratory data were collected and predictors for PICU admission were identified.

Results: There was a seasonal trend with peak presentation in post-monsoon months between August and October. Mean (SD) age at presentation was 6.8 (3.2) years. Fever was present in all with a median (IQR) duration of 9 (6-11) days. Respiratory distress (42%), altered sensorium (24%), hepatomegaly (93%), splenomegaly (57%), and lymphadenopathy (54%) were other features. Rash and eschar were noted in 24% each. Thrombocytopenia (83%), hypoalbuminemia (63%), and hyponatremia (62%) were common laboratory abnormalities. Meningoencephalitic presentation was noted in 29%; acute kidney injury (AKI) (16%), acute respiratory distress syndrome (ARDS) (11%), and myocarditis (3%) were other organ dysfunctions. Sixty-six (41%) children required PICU admission. Intensive care needs include invasive ventilation ( = 27, 17%), vasoactive drugs therapy for hemodynamic support ( = 43, 27%), osmotherapy to treat raised intracranial pressure ( = 27, 17%), and renal replacement therapy ( = 3, 2%). Mortality was 8.8%. On multivariable analysis, lymphadenopathy, respiratory distress, shock, elevated lactate, and meningoencephalitis predicted the requirement of PICU admission.

Conclusion: Scrub typhus presents with organ dysfunction during post-monsoon months. We identified predictors of intensive care in children with scrub typhus admitted to ED.

Clinical Significance: Our results would help clinicians identify severe cases and prioritize resources.

How To Cite This Article: Nallasamy K, Gupta S, Bansal A, Biswal M, Jayashree M, Zaman K, Clinical Profile and Predictors of Intensive Care Unit Admission in Pediatric Scrub Typhus: A Retrospective Observational Study from North India. Indian J Crit Care Med 2020;24(6):445-450.
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http://dx.doi.org/10.5005/jp-journals-10071-23445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7435082PMC
June 2020
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