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Introduction. We aimed to determine the burden of respiratory disease by examining clinical profiles and associated predictors of morbidity and mortality of patients admitted to a Pediatric Intensive Care Unit (PICU) in Pakistan, a resource limited country. We also stratified the respiratory diseases as defined by the Pediatric Advanced Life Support (PALS) Classification. Methods. A retrospective study was conducted on children aged 1 month to 18 years who were diagnosed with respiratory illness at the PICU in a tertiary hospital in Karachi, Pakistan. Demographics, essential clinical details including immunization status, and the outcome in terms of mortality or survival were recorded. Predictors of mortality and morbidity including prolonged intubation and mechanical ventilation in the PICU were analyzed using the chi‐square test or Fischer's exact test as appropriate. Results. 279 (63.8% male; median age 9 months, IQR 4–36 months) patients were evaluated of which 44.2% were malnourished and 23.3% were incompletely immunized. The median length of stay in the PICU was 3 days (IQR 2–5 days). Pneumonia was the principal diagnosis in 170 patients (62%) and accounted for most deaths. 76/279 (27.2%) were ventilated, and 67/279(24.0%) needed inotropic support. A high Pediatric Risk of Mortality (PRISM) III score, pneumothorax, and lower airway disease were significantly associated with ventilation support. The mortality rate of patients was 14.3%. Predictors of mortality were a high PRISM III score (OR 1.179; 95% CI 1.024–1.358, P = 0.022) and a positive blood culture (OR 4.305; 95% CI 1.062‐17.448, P = 0.041). Conclusion. Pneumonia is a significant contributor of respiratory diseases in the PICU in Pakistan and is the leading cause of morbidity and mortality. A high PRISM III score, pneumothorax, and lower airway disease were predictors for ventilation support. A high PRISM III score and a positive blood culture were predictors of patient mortality in our study. [ABSTRACT FROM AUTHOR]

Introduction: Tracheal stenosis is a known complication following intubation. However, owing to its delayed presentation and symptoms of progressive wheezing and respiratory difficulty, it is often misdiagnosed as asthma. Case presentation: We present the case of a 10-year-old Asian boy who presented with cough, wheezing, and dyspnea. He was misdiagnosed with severe, uncontrolled asthma and respiratory failure, remaining unresponsive to initial asthma management. During his current admission, he had difficult intubation, necessitating an emergency tracheostomy. Further subsequent examination revealed grade III tracheal stenosis. Conclusion: This case highlights the importance of considering tracheal stenosis as a differential diagnosis in children presenting with dyspnea, cough, and wheezing, particularly if there is a history of prior intubation. The airway should be secured immediately in a controlled environment by an otolaryngologist or anesthetist. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to investigate the association between initial dysnatremia (hyponatremia and hypernatremia) and in-hospital mortality, as well as between initial dysnatremia and functional outcomes, among children with traumatic brain injury (TBI). Method: We performed a multicenter observational study among 26 pediatric intensive care units from January 2014 to August 2022. We recruited children with TBI under 18 years of age who presented to participating sites within 24 h of injury. We compared demographics and clinical characteristics between children with initial hyponatremia and eu-natremia and between those with initial hypernatremia and eu-natremia. We defined poor functional outcome as a discharge Pediatric Cerebral Performance Category (PCPC) score of moderate, severe disability, coma, and death, or an increase of at least 2 categories from baseline. We performed multivariable logistic regression for mortality and poor PCPC outcome. Results: Among 648 children, 84 (13.0%) and 42 (6.5%) presented with hyponatremia and hypernatremia, respectively. We observed fewer 14-day ventilation-free days between those with initial hyponatremia [7.0 (interquartile range (IQR) = 0.0–11.0)] and initial hypernatremia [0.0 (IQR = 0.0–10.0)], compared to eu-natremia [9.0 (IQR = 4.0–12.0); p = 0.006 and p < 0.001]. We observed fewer 14-day ICU-free days between those with initial hyponatremia [3.0 (IQR = 0.0–9.0)] and initial hypernatremia [0.0 (IQR = 0.0–3.0)], compared to eu-natremia [7.0 (IQR = 0.0–11.0); p = 0.006 and p < 0.001]. After adjusting for age, severity, and sex, presenting hyponatremia was associated with in-hospital mortality [adjusted odds ratio (aOR) = 2.47, 95% confidence interval (CI) = 1.31–4.66, p = 0.005] and poor outcome (aOR = 1.67, 95% CI = 1.01–2.76, p = 0.045). After adjustment, initial hypernatremia was associated with mortality (aOR = 5.91, 95% CI = 2.85–12.25, p < 0.001) and poor outcome (aOR = 3.00, 95% CI = 1.50–5.98, p = 0.002). Conclusion: Among children with TBI, presenting dysnatremia was associated with in-hospital mortality and poor functional outcome, particularly hypernatremia. Future research should investigate longitudinal sodium measurements in pediatric TBI and their association with clinical outcomes. [ABSTRACT FROM AUTHOR]

Objective: To determine the outcome of critically ill children undergoing CRRT. Study Design: Prospective Observational Study. Setting: Pediatric Intensive Care Unit at Aga Khan University Hospital. Period: Jan 2021 to Dec 2022. Material & Methods: The study comprised of collection of data of critically ill children from the age 1-18 years who were subjected to CRRT from Jan 2021 to December 2022. We reported primary diagnosis, demographics, indications, modality, and outcomes of CRRT. Statistical analyses were utilized to relate risk factors correlating with mortality among patients who underwent CRRT. Our main outcome measures were mortality among critically ill pediatric patients who were subjected to CRRT and its associated risk factors. Results: 42 patients underwent CRRT from Jan 2021 to December 2022. Mean age was 11.97 ± 4.3 years, with 64% male population. Most common primary diagnosis was infectious etiology (36%) followed by genitourinary system (27%). 83% patients were in failure according to pRIFLE criteria. 81% patients had multiorgan dysfunction (MODS) with renal, cardiovascular, and respiratory dysfunction sequentially being most common. The mean ionotropic score before & after CRRT was 38.57 & 49.71 respectively. Mean ICU duration of admission was 11.6 days. The most common indication for CRRT was fluid overload (85.71%). Median length of CRRT was 62 hours with a mean circuit life of 47.87 hours. Most common CRRT catheter site was the femoral vein (83%) followed by the internal jugular vein (14%). CVVHDF was the most used modality (64%) followed by CVVH (19%). We report an overall mortality of 71.4%, with a positive correlation with use of norepinephrine post CRRT, presence of multiorgan dysfunction, presence of cardiovascular dysfunction, respiratory dysfunction, and low platelet count (<150,000 per microliter) on univariate analysis. Only respiratory dysfunction was statistically significantly associated with mortality on multivariate analysis. Conclusion: The gross mortality in patients who underwent CRRT was high (71.4%). Norepinephrine use post-CRRT, multi-organ dysfunction, cardiovascular system, respiratory system dysfunction and low platelet counts were associated with high mortality while association of respiratory dysfunction with mortality was independently statistically significant. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to investigate the association between initial dysnatremia (hyponatremia and hypernatremia) and in-hospital mortality, as well as between initial dysnatremia and functional outcomes, among children with traumatic brain injury (TBI). Method: We performed a multicenter observational study among 26 pediatric intensive care units from January 2014 to August 2022. We recruited children with TBI under 18 years of age who presented to participating sites within 24 h of injury. We compared demographics and clinical characteristics between children with initial hyponatremia and eu-natremia and between those with initial hypernatremia and eu-natremia. We defined poor functional outcome as a discharge Pediatric Cerebral Performance Category (PCPC) score of moderate, severe disability, coma, and death, or an increase of at least 2 categories from baseline. We performed multivariable logistic regression for mortality and poor PCPC outcome. Results: Among 648 children, 84 (13.0%) and 42 (6.5%) presented with hyponatremia and hypernatremia, respectively. We observed fewer 14-day ventilation-free days between those with initial hyponatremia [7.0 (interquartile range (IQR) = 0.0–11.0)] and initial hypernatremia [0.0 (IQR = 0.0–10.0)], compared to eu-natremia [9.0 (IQR = 4.0–12.0); p = 0.006 and p < 0.001]. We observed fewer 14-day ICU-free days between those with initial hyponatremia [3.0 (IQR = 0.0–9.0)] and initial hypernatremia [0.0 (IQR = 0.0–3.0)], compared to eu-natremia [7.0 (IQR = 0.0–11.0); p = 0.006 and p < 0.001]. After adjusting for age, severity, and sex, presenting hyponatremia was associated with in-hospital mortality [adjusted odds ratio (aOR) = 2.47, 95% confidence interval (CI) = 1.31–4.66, p = 0.005] and poor outcome (aOR = 1.67, 95% CI = 1.01–2.76, p = 0.045). After adjustment, initial hypernatremia was associated with mortality (aOR = 5.91, 95% CI = 2.85–12.25, p < 0.001) and poor outcome (aOR = 3.00, 95% CI = 1.50–5.98, p = 0.002). Conclusion: Among children with TBI, presenting dysnatremia was associated with in-hospital mortality and poor functional outcome, particularly hypernatremia. Future research should investigate longitudinal sodium measurements in pediatric TBI and their association with clinical outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Children with moderate traumatic brain injury (modTBI) (Glasgow Coma Scale (GCS) 9–13) may benefit from better stratification. We aimed to compare neurocritical care utilization and functional outcomes between children with high GCS modTBI (hmodTBI, GCS 11–13), low GCS modTBI (lmodTBI, GCS 9–10), and severe TBI (sTBI, GCS ≤ 8). We hypothesized that patients with lmodTBI have higher neurocritical care needs and worse outcomes than patients with hmodTBI and are similar to patients with sTBI. Methods: Prospective observational study from June 2018 to October 2022 in 28 pediatric intensive care units (PICU) in Asia, South America, and Europe. We included children (age < 18 years) with modTBI and sTBI admitted to PICU and measured functional outcomes at 3 months using the Glasgow Outcome Scale–Extended Pediatric Revision (GOS-E Peds, scale 1–8, 1 = upper good recovery, 8 = death). Results: We analyzed 409 patients: 98 (24%) and 311 (76%) with modTBI and sTBI, respectively. Patients with lmodTBI (vs. hmodTBI) were more likely to have invasive ICP monitoring (32.3% vs. 4.5%, p < 0.001), longer PICU stay (days, median [IQR]; 5.00 [4.00, 9.75] vs 4.00 [2.00, 5.00], p = 0.007), and longer hospital stay (days, median [IQR]: 13.00 [8.00, 17.00] vs. 8.00 [5.00, 12, 25], p = 0.015). Median GOS-E Peds scores were significantly different (hmodTBI (1.00 [1.00, 3.00]), lmodTBI (3.00 [IQR 2.00, 5.75]), and sTBI (5.00 [IQR 1.00, 6.00]) (p < 0.001)). After adjusting for age, sex, presence of polytrauma and cerebral edema, lmodTBI, and sTBI remained significantly associated with higher GOS-E scores (adjusted coefficient (standard error): 1.24 (0.52), p = 0.018, and 1.27 (0.33), p < 0.001, respectively) compared with hmodTBI. Conclusions: Children with lmodTBI have higher rates of neurocritical care utilization and worse functional outcomes than those with hmodTBI but better than those with sTBI. Children with lmodTBI may benefit from guideline-based management similar to what is implemented in children with sTBI. This work was performed in hospitals within the PACCMAN and LARed networks. No reprints will be ordered. [ABSTRACT FROM AUTHOR]

Objective: To determine the incidence of newly acquired morbidity, its categorization, and to identify the associated risk factors among children upon being discharged from the PICU. Study Design: Prospective Longitudinal Cohort study. Setting: Multidisciplinary PICU of Aga Khan University Hospital. Period: October 2022 to March 2023. Material & Methods: Patients who were readmitted to the PICU, deceased, or lost to follow-up during the study were excluded. The functional status was assessed using FSS at baseline, PICU discharge, and at 3 months to measure newly acquired morbidity and dysfunction. All data was collected on a structured proforma. Categorical variables were presented as absolute values and percentages, and continuous variables were expressed as means ± SD or medians with interquartile range or proportions as applicable and considered statistically significant level if p value is = 0.05. Results: A total 96 patients were discharged alive from PICU and 85 of them were included in this study. The mean age was 5.27 ± 5.01 years. The major diagnostic categories were acute respiratory illnesses (25.89%), cardiovascular disorders (21.18%), and neurological disorders (16.47%). 43.53% of the patients underwent surgical intervention. The mean PRISM score at admission was 4.32 ± 5.84. The incidence of morbidity was 40% (34/85) at PICU discharge and 5.8% at 3 months. Longer duration of vasoactive medications, arterial catheterization, mechanical ventilation and PICU stay were associated with new morbidity in critically ill children on discharge from PICU. Conclusion: At PICU discharge, the incidence of new morbidity among critically ill pediatric patients was 40%, which reduced to 5.8% at 3 months. Patients with hemodynamic instability, longer duration of inotropic support and those on prolonged mechanical ventilation had longer PICU stay and exhibited increased risk for new morbidity development. The majority of patients (>82%) exhibited either good functional status or mild dysfunction upon discharge. [ABSTRACT FROM AUTHOR]

Background: Patients admitted to critical care need timely interventions after evaluating all clinical parameters. This study aims to assess the impact of the comprehensive rounding checklist on physician compliance and patient-related outcomes in a multidisciplinary pediatric intensive care unit (PICU). Subjects and Methods: This prospective observational study was conducted in two phases over period of 2 months at multidisciplinary PICU from Pakistan. A structured rounding checklist of 35 components encompassing patient care was introduced and implemented in the PICU. During the preimplementation phase, a nurse took notes of relevant patient clinical details missed by the physician during the round, included them in the rounding checklist. And during the implementation phase, the nurse actively intervened when a physician did not discuss a particular component during the round. All components discussed were check marked. Results: The checklist was completed for 812 rounds (162 patients) in preimplementation and 2348 rounds (590 patients) in the postimplementation phase. Most frequently missed components in the preimplementation phase were checking for surgical site infection (8.9%), discharge plan (7.5%), deep vein thrombosis (DVT) prophylaxis (7.3%), and ventilator-associated pneumonia bundles (7.0%). Whereas, during the postimplementation phase, resident teaching (8.0%), discharge plan (7.2%), and DVT prophylaxis (6.5%) were most frequently missed. Hospital length of stay decreased from 4.5 ± 3.7 to 4.1 ± 2.9 days (P = 0.05), and overall mortality decreased from 19% to 11.4% (P < 0.05). Conclusions: Introducing the checklist with a prompter, improved physician compliance and patient-related outcomes in our PICU. [ABSTRACT FROM AUTHOR]

Background: Deep neck space infections are uncommon in infants. Retropharyngeal abscess (RPA) is a deep space neck infection that can present with subtle signs and symptoms. Delay in diagnosis can lead to life-threatening complications. Here we describe life-threatening complication of retropharyngeal abscess. Case presentation: We report a life-threatening complication of retropharyngeal abscess in 10-month old Asian infant weighing 8.2 kg. The patient presented with fever, right-sided neck swelling, hoarseness of voice, and respiratory distress. The clinical and radiological findings were suggestive of airway obstruction complicated by retropharyngeal abscess. The patient was urgently taken to the operating room and underwent (grade 3) intubation. After stabilization, the patient underwent endoscopic trans-oral incision and drainage, during which 5 cc pus was aspirated. Antibiotics were prescribed for 2 weeks following the procedure based on the sensitivity result of the pus culture. Conclusion: In retropharyngeal abscess, a delay in diagnosis can result in life-threatening complications. This report highlights the importance of prompt recognition of a threatened airway and the management of retropharyngeal abscess by emergency physicians. If an emergency physician suspects RPA with airway obstructions, the airway should be immediately secured in a secure environment by otolaryngologist and an anesthesiologist. [ABSTRACT FROM AUTHOR]

Introduction: Children infected with COVID-19 are susceptible to severe manifestations. We aimed to develop and validate a predictive model for severe/ critical pediatric COVID-19 infection utilizing routinely available hospital level data to ascertain the likelihood of developing severe manifestations. Methods: The predictive model was based on an analysis of registry data from COVID-19 positive patients admitted to five tertiary pediatric hospitals across Asia [Singapore, Malaysia, Indonesia (two centers) and Pakistan]. Independent predictors of severe/critical COVID-19 infection were determined using multivariable logistic regression. A training cohort (n = 802, 70%) was used to develop the prediction model which was then validated in a test cohort (n = 345, 30%). The discriminative ability and performance of this model was assessed by calculating the Area Under the Curve (AUC) and 95% confidence interval (CI) from final Receiver Operating Characteristics Curve (ROC). Results: A total of 1147 patients were included in this analysis. In the multivariable model, infant age group, presence of comorbidities, fever, vomiting, seizures and higher absolute neutrophil count were associated with an increased risk of developing severe/critical COVID-19 infection. The presence of coryza at presentation, higher hemoglobin and platelet count were associated with a decreased risk of severe/critical COVID-19 infection. The AUC (95%CI) generated for this model from the training and validation cohort were 0.96 (0.94, 0.98) and 0.92 (0.86, 0.97), respectively. Conclusion: This predictive model using clinical history and commonly used laboratory values was valuable in estimating the risk of developing a severe/critical COVID-19 infection in hospitalized children. Further validation is needed to provide more insights into its utility in clinical practice. [ABSTRACT FROM AUTHOR]

Objective: Central venous catheter (CVC) placement in children in resource-limited settings (RLSs) can be a difficult task. Timely administration of vasopressor medications (VMs) through peripheral intravenous line (PIV) can help overcome this limitation. We aim to determine the safety of administration of vasopressor medications through PIVs in children admitted to pediatric intensive care unit (PICU) in a RLS.Design: Prospective observational study. Setting. An eight-bedded PICU of a tertiary care hospital. Patients. Children aged 1 month to 18 years admitted to the PICU. Intervention. None. Measurements and Main Results. All children (aged 1 month-18 years) who received VMs through PIV line from January 2019 to December 2019 were prospectively followed for the development of extravasation, conversion to CVC, duration of infusion, maximum dose of VMs used, maximum vasopressor inotropic score (VIS), and coadministration of vasopressor medication through PIV line. Results are presented as means with standard deviation and frequency with percentages. A total of 369 patients were included in the study, 221 (59.9%) were males, and the median age of the study population was 24 months (IQR; 6-96). Epinephrine was the most frequently used vasopressor medication (n = 279, 75.6%), followed by milrinone (n = 93, 25.2%), norepinephrine (n = 42, 11.4%), and dopamine (n = 32, 8.7%). The maximum dose of vasopressor medication was 0.25 µg/kg/min (epinephrine), 0.2 µg/kg/min (norepinephrine), 15 µg/kg/min (dopamine), and 0.8 µg/kg/min (milrinone). Extravasation was observed in 8 (2.2%) patients, while PIV line was converted to CVC in 127 (34.4%) children. Maximum dose of epinephrine, norepinephrine, VIS score, and PRISM Score was associated with conversion to CVC (p < 0.001), while none of them was associated with risk for extravasation.Conclusion: Vasopressor medication through PIV line is a safe option in patients admitted to the PICU. [ABSTRACT FROM AUTHOR]

Background: To compare the Paediatric RIFLE (p-RIFLE) and Kidney Disease Improving Global Outcomes (KDIGO) definitions of acute kidney injury (AKI) for frequency of (AKI) and in-hospital mortality in critically ill children. Methods: Retrospective review of medical records of all patients (aged 1 month - 16 years) admitted in Paediatric Intensive Care Unit from January 2015-December 2016, with length of stay >48 hours, was done. Patients with chronic kidney disease were excluded. Receiver operating characteristic (ROC) curves were used to evaluate the performance of the p-RIFLE and KDIGO criteria to predict the AKI related mortality. Logistic regression analysis was done to determine the association of different variables with mortality in AKI patient based on p-RIFLE, KDIGO. A p-value of <0.05 was considered significant. Results: Out of total 823 patients admitted during the study period, 562 patients were included in the study. Median age was 2 years (Interquartile range 8 years). Acute kidney injury frequency according to p-RIFLE and KDIGO were 391 (70%), and 372 (66%) respectively. Overall, 106/823 (12.8%) children died during study period, 78 (19.9%) in AKI by p-RIFLE and 76 (20.4%) in AKI by KDIGO died. The area-under- curve for in-hospital mortality for p-RIFLE and KDIGO criteria were 0.525 (p=0.427), and 0.534 (p=0.276), respectively. Conclusion: P-RIFLE is more sensitive compared to KDIGO in diagnosing AKI in critically ill children; identifying a greater number of moderate staged AKI cases. Greater AKI severity is associated with higher mortality in critically ill children [ABSTRACT FROM AUTHOR]

Objectives: To determine clinical, laboratory features and outcomes of Multisystem Inflammatory Syndrome in children (MIS-C) and its comparison with historic Kawasaki Disease (KD) and Viral Myocarditis (VM) cohorts. Methods: All children (1 month– 18 years) who fulfilled the World Health Organization criteria of MIS-C presenting to two tertiary care centers in Karachi from May 2020 till August 31st were included. KD and VM admitted to one of the study centers in the last five years prior to this pandemic, was compared to MIS-C. Results: Thirty children with median age of 24 (interquartile range (IQR)1–192) months met the criteria for MIS-C. Three phenotypes were identified, 12 patients (40%) with KD, ten (33%) VM and eight (26%) had features of TSS. Echocardiography showed coronary involvement in 10 (33%), and moderate to severe Left Ventricular dysfunction in 10 (33%) patients. Steroids and intravenous immunoglobulins (IVIG) were administered to 24 (80%) and 12 (41%) patients respectively while 7 (23%) received both. Overall, 20% children expired. During the last five years, 30 and 47 children were diagnosed with KD and VM, respectively. Their comparison with MIS-C group showed lymphopenia, thrombocytosis, and higher CRP as well as more frequent atypical presentation in MIS-C KD group with less coronary involvement. The MIS-C VM was more likely to present with fulminant myocarditis. Conclusions: Our MIS-C cohort is younger with higher mortality compared to previous reports. MIS-C is distinct from historic cohorts of KD and VM in both in clinical features and outcomes. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of Ventilator associated Pneumonia (VAP), Central Line Associated Blood Stream Infection (CLABSI) and Catheter Associated Urinary Tract infection (CAUTI) by using standardized criteria established by Center of disease control and prevention. Study Design: Cross-sectional study. Setting: Pediatric Intensive Care Unit (PICU) of Aga Khan University Hospital (AKUH). Period: (August 2015 to January 2016). Material & Methods: Data was collected on a pre-coded proforma. Data was entered and analyzed through SPSS. Results: 156 patients were enrolled. 102 (65.4%) were male. Mean age was 57.59 months. Mean length of stay was 5.6 days. Patient and Device days were 546 and 958 respectively. Device utilization ratio was 0.56. Four Device Associated Infections (DAI) were identified during study period with a DAI Rate of 4.17 per 1000 device days. All DAI were CLABSIs. Enterococcus was the most frequent bacterial isolate. Conclusion: DAI are highly prevalent in low resource countries, especially in intensive care areas including PICUs. In our setup, CLABSI are increasing while VAP and CAUTI are decreasing. [ABSTRACT FROM AUTHOR]

Background: To determine the rate of conversion of abstracts presented at conferences into full-text articles published in peer-reviewed journals in the field of pediatric critical care medicine (PCCM) in a developing country. Methods: We retrospectively reviewed PCCM abstracts from Pakistan presented at national and international pediatric and critical care conferences over 10 years (January 2010 to March 2020). Data included abstract characteristics, such as presentation (poster/oral), presenter (fellow/resident), time of meeting (month and year), type of meeting, study design and topic; and publication characteristics, such as journal name, time (month and year) and first author. The primary outcome was publication rate of PCCM abstracts presented in meetings and time (months) from presentation to publication. Results: A total of 79 PCCM abstracts were presented in 20 meetings during the study period. There were 65 poster presentations (82.28%), of which 63 (79.74%) were presented at international critical care conferences and all presenters were PCCM fellows. In total, 64 (81%) abstracts were descriptive observational studies (retrospective: 50, 63.29%) and prospective (14, 17.72%). Only one was an interventional randomized controlled trial. The publication rate of PCCM abstracts was 63.3% (50/79) and the mean time to publication was 12.39±13.61 months. The publication rate was significantly correlated to the year of publication (P<0.001). Conclusions: The PCCM abstract publication rate and mean time from presentation to publication was 63.3% and 12.39±13.61 months, respectively, in a developing country. [ABSTRACT FROM AUTHOR]

Background: Critically ill individuals have an increased risk of acute symptomatic seizures secondary to systemic illnesses; unrecognized or untreated seizures can quickly convert into status epilepticus, which is associated with high morbidity and mortality. Objective: The aim of this study was to determine frequency, etiology, and outcome of seizures in critical ill children admitted in intensive care unit of a tertiary care hospital. Materials and Methods: Retrospective review of medical records of all children admitted in pediatric intensive care unit (PICU) of the Aga Khan University from January 2016 to December 2018 and who had a new-onset seizure irrespective of underlying diagnosis was carried out after ethical review committee approval. Data were collected on a structured proforma; it included demographic information as well as relevant clinical and outcome information. The data were analyzed on Statistical Package for the Social Sciences (SPSS) software program, version 19.0. The descriptive statistics frequency and percentage was computed for qualitative variable. Mean and standard deviation were computed for quantitative variable, and univariate analysis was performed. Results: During the study period, a total 2053 patients were admitted in the PICU. One hundred six (5%) had seizure. Sixty-three (59.5%) were males. Meningitis 21 (20%), sepsis 21 (20%), complicated pneumonia 18 (17%) were the major primary diagnosis in these children. Mean age of the study population was 75 months (standard deviation [SD] ± 54.4) and 72 (68%) were <5 years of age, whereas 63 (59.5%) were males. The seizures lasted >10min in 10 (10%) and were associated with high had neurological deficit (P = 0.001). We did not observe any correlation with electrolyte imbalance, renal failure, need of ventilator support with duration of seizure, and type of seizure (P > 0.005). Conclusion: Infection was the most common etiology associated with a new-onset seizure in children admitted in our PICU. Seizures lasting for >10min were observed with high neurological deficit. We did not find any association of mortality with seizure duration. [ABSTRACT FROM AUTHOR]

Here, we report a case of a 15-year- old girl who presented to the emergency department with symptoms of abdominal pain, nausea, vomiting and seizures. She was diagnosed with acute intermittent porphyria. Treatment was started by removing all porphogenic drugs, providing high glucose intake (oral and intravenous), which initially resulted in good clinical outcomes. However, she deteriorated again and also developed neurological manifestation (paraplegia) for which she required mechanical ventilation because of acute respiratory failure. This time she was initiated on human hemin for four consecutive days. After 2 days of therapy, her porphobilinogen levels decreased to 50% of the initial raised value. Increased lactic acid and blood urea nitrogen were the two side effects observed after the treatment, with no apparent signs of acute kidney injury. To the best of our knowledge, in paediatric population, this is the first reported case of treatment of acute intermittent porphyria with human hemin in Pakistan. [ABSTRACT FROM AUTHOR]

Background: Handoff in cardiac intensive care units has been associated with improved outcomes. We aimed to determine whether a standardized protocol for handover could be implemented using the "theory of change" model by education, introduction of a checklist, and developing feedback mechanisms, measured by better knowledge transfer and bedside care provider satisfaction. Methods: A theory of change model was developed and implemented to introduce a teamwork-driven handover process. A standardized checklist was made available at every bedside. A preintervention assessment of patient handovers was obtained by direct observation using a standardized checklist. The same checklist was used for assessment after implementation. A survey was conducted to measure intensive care unit staff perception and satisfaction with the handover process. Results: After implementation, the standardized handover process was employed in 53 of 60 patient transfers (88.3% compliance): 49 preintervention and 29 postintervention observations were performed. Postimplementation, critical knowledge omissions (total score of 25) decreased from a median of 10 (range 4–17) to 0 (range 0–4; p < 0.001). At 6 months, knowledge omission scores improved to a median of 0 (range 0–1; p < 0.001); and 96% (24/25) of staff reported improvement in the quality of information transfer, and 100% reported improvement in overall team work. Conclusion: Implementation of a standardized patient handover process improved the quality of knowledge transfer and overall staff satisfaction. The theory of change model is a unique and highly effective tool to implement and sustain behavior change. [ABSTRACT FROM AUTHOR]

Retrospective chart review of all children (aged-one month to 16 years) admitted in our paediatric intensive care from June to November 2016 was done to determine the indication of different laboratory tests. LBT indications were defined into: diagnostic/case findings/screening tests to make a diagnosis; haemostatic tests (to monitor function or identify before clinical signs and symptoms) and therapeutic /monitoring tests to get the level of drug directly or getting level of marker as a guide to therapy. Laboratory tests reports which were within normal range more than once were labelled as in-appropriate tests. In total 274 patients, Haemostatic tests were performed for mean of 35.18±56.72 times (range of 0–429), monitoring for mean of 9.38±20 times (range 0–165), and therapeutic tests (3.26±11.25). Most common tests included serum Sodium levels (7.83±12.73), Serum Potassium (8.19±12.80), bicarbonate (7.75±11.9). 13.40±9.11 tests were done on first day and 13.0±8.49/day tests were performed afterwards. Cumulatively 54.31±74.21 tests were performed/ patients out of which 18.5±37.82 were inappropriate. [ABSTRACT FROM AUTHOR]

To describe the experience of thrombolysis using tissue plasminogen activator (tPA) in critically ill children admitted to the pediatric intensive care unit (PICU), retrospective review of medical records of all children (1 month-16 years), who were admitted in PICU since January 2014 to December 2017 and received systemic tPA for thrombolysis was done. Data was collected on a structured proforma and included thrombus location, tPA dose and duration, outcome (resolution, survival) and complications (bleeding). Total 9 patients (7 males, 2 females) received systemic tPA therapy for thrombolysis with mean age of 74.64 ± 69.58 months. Two patients had thrombus in femoral artery, 3 in IVC and 4 had intra-cardiac thrombosis. Median number of doses was 2 with a range of 1-5 doses. Complete resolution of the clot was noted in all except one patient. A standard starting dose of 0.01 mg/kg/h was used in all patients. Only one patient developed melena after TPA therapy which self-resolved. Systemic tPA therapy was very safe in pediatric critically ill patients and was effective for thrombolysis and did not show any adverse effects in children with varying underlying diagnosis. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the clinical and prognostic utility of procalcitonin (PCT), C-reactive protein (CRP), and lactic acid in children admitted to the Pediatric Intensive Care Unit (PICU) of a university teaching hospital. Materials and Methods: Medical records of children (1 month-16 years) tested for serum PCT at the time of admission in the PICU of our hospital from July 1, 2013, to January 15, 2015, were reviewed. Within 24 h of admission, the Pediatric Risk of Mortality Score, blood cultures, white blood cell count, neutrophil counts, serum CRP, plasma lactic acid, and PCT were noted. Patient outcome was assessed at hospital discharge, and the patients were divided into nonsurvivors and survivors. Results: A total of 167 children being admitted to the PICU were enrolled. The median age of the study population was 3 years (0-16 years), with 58.6% being males. Nonsurvivors had significantly higher lactic acid (4.7 mmol/L [2.07-7.6]; P < 0.05) than that of the survivors (2 mmol/L [1.3-3]; P < 0.05). In addition, nonsurvivors (94.4%; P < 0.05) had greater incidence of multiple organ dysfunction syndrome (MODS) than that of the survivors (38.05%; P < 0.05). Binary logistic regression showed age, MODS, and lactic acid to be associated with mortality. Conclusions: This study found that in comparison to PCT and CRP, high plasma lactic acid levels are associated with the development of all-cause MODS and worse outcome in critically ill children admitted in PICU. Prediction of prognosis based on the lactic acid alone may contribute to improve patient management, but further studies are required to endorse our findings. [ABSTRACT FROM AUTHOR]

Objectives: To describe the spectrum of complications of Diabetic Ketoacidosis (DKA) observed in children admitted with severe DKA. Methods: Retrospective review of the medical records of all children admitted with the diagnosis of severe DKA in Pediatric Intensive Care Unit (PICU) of the Aga Khan University Hospital, from January 2010 to December 2015 was done. Data was collected on a structured proforma and descriptive statistics were applied. Results: Total 37 children were admitted with complicated DKA (1.9% of total PICU admission with 1.8% in 2010 and 3.4% in 2015). Mean age of study population was 8.1±4.6 years and 70% were females (26/37). Mean Prism III score was 9.4±6, mean GCS on presentation was 11±3.8 and mean lowest pH was 7.00±0.15. Complications observed included hyperchloremia (35.94%), hypokalemia (30.81%), hyponatremia (26.70%), cerebral edema (16.43%), shock (13.35%), acute kidney injury (10.27%), arrhythmias (3.8%), and thrombotic thrombocytopenic purpura (5.4%), while one patient had myocarditis and ARDS each. 13/37 children (35%) needed inotropic support, 11/37 (30%) required mechanical ventilation while only one patient required renal replacement therapy. Two patients (5.4%) died during their PICU stay. Conclusion: Hyperchloremia and other electrolyte abnormalities, cerebral edema and AKI are the most common complications of severe DKA. [ABSTRACT FROM AUTHOR]

Objectives: To determine the frequency and immediate outcome of acute neurologic complications (ANCs) in children undergoing congenital heart surgery (CHS). Materials and Methods: In this retrospective study, all patients undergoing CHS at our hospital from January 2007 to June 2016 were included. Patients were followed up for the development of seizures, altered level of consciousness (ALOC), abnormal movements, and stroke. Results are presented as mean with standard deviation and frequency with percentages. Results: Of 2000 patients who underwent CHS at our center during the study, 35 patients (1.75%) developed ANC. Seizures occurred in 28 (80%), ALOC in 5 (14%), clinical stroke in 2, brain death in 6 patients. Antiepileptic drugs (AEDs) were started in 32 patients, of which 13 patients required more than one AED. Mean length of stay was 10 ± 7.36 days. Of 35 patients who developed ANC, 7 expired during the study. Conclusion: Neurological complications are scarce but significant morbidity after CHS at our center. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to find the analgesic effects of sub mucosal tramadol after 3rdmolar extraction. Study Design: Study design was randomized, double-blind and placebo-controlled. Place and Duration of Study: The study was conducted in Armed Forces Institute of Dentistry, Rawalpindi for a period of 4 months from 23rd February 2015 up till 30th June 2015. Material and Methods: Sixty patients underwent third molar extractions (Pell & Gregory class 2, Position B, mesioangular). They were divided into two groups. Surgical site was randomly assigned to sub mucosal 100mg/2ml tramadol injection (group T) or normal saline solution (group P) immediately after surgery. Time of intake and amount of analgesic rescue drug, and postoperative pain intensity were recorded immediately after anesthesia cessation and 4, 8, 24and 48hours after surgery. Results: Anesthetic blockade duration between groups was similar. In comparison to group P, time elapsed before first intake of rescue drug was longer, and pain intensity was lower significantly in group T (p = 0.000). Conclusion: The local administration of 100mg/2ml tramadolcontributes to provide a prolonged pain-free period post-operatively and thus helps in controlling the amount of analgesics (specifically NSAIDS) consumed, increase patient comfort and compliance resulting in better quality of life. [ABSTRACT FROM AUTHOR]