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Objective The aim of the study was to identify early predictors of mortality in children with severe dengue fever admitted to pediatric intensive care unit (PICU). Materials and methods All consecutive children with laboratory-confirmed severe dengue fever were enrolled in this prospective observational study. Besides demographic data, disease severity and organ dysfunction scores, laboratory investigations and interventions are done in PICU were recorded and analyzed. Results During the study period of 42 months, 172 patients with dengue fever were admitted to PICU. A total of 78 (45.3%) patients with severe dengue fever were included and analyzed. There were 20 (25.6%) deaths. There were significant differences in disease severity and organ dysfunction scores, transaminases, blood lactate level and serum creatinine between survivors and nonsurvivors. A significantly higher number of nonsurvivors required interventions in first 24 hours of admission. Platelet counts (P value 0.22) and hematocrit (P value 0.47) were not statistically different in 2 groups. There was a significantly high vasopressor-inotrope score (VIS) ( 10% (0.002) in nonsurvivors. Multivariate stepwise logistic regression analysis identified serum glutamic pyruvic transaminases (≥ 284 IU/L; odds ratio [OR] 1.002, 95% confidence interval [CI]: 1.001-1.003), blood lactate level (≥2.73 mmol/L; OR 2.08, 95% CI: 1.354-3.202), Pediatric Risk of Mortality score at 12 hours (≥14.5; OR 1.35, 95% CI: 1.077-1.693), VIS (≥22.5, OR 1.129, 95% CI: 1.059-1.204) and positive fluid balance >10% (OR 22.937, 95% CI: 2.393-219.84) at 24 hours of admission as independent predictors of mortality. Conclusion Disease severity, hyperlactatemia at admission, need for multiple vasoactive drugs and positive fluid balance are predictors of mortality in severe dengue infection in children admitted to PICU.

The prevalence of asthma is increasing rapidly, worldwide, due to changing gene-environment interactions. The rate of rise is more in resource poor nations due to lack of knowledge and non-availability of expertise. Monitoring of lung functions is mandatory for diagnosis and further management of asthmatic patients. Spirometry, the widely available investigation, is the gold standard test used for mapping pulmonary dynamicity. It has got its own limitations in the form of operational difficulties in children, the elderly, and in those with neuromuscular or behavioral issues. In the current era of COVID-19 pandemic, the utility of spirometry has been further restricted to selected cohort only, due to potential risk of viral transmission during the procedure. Oscillometry technique has been used previously, to monitor lung functions, with promising results. Ultrasonic waves of various frequencies accompany the tidal breath of patients and respiratory impedance is calculated by measured pressure and flow signals from exhaled breath. The results are interpreted in the form of resistance, reactance, resonant frequency, and reactance area. Various manufacturers have developed different mechanical models with slight variation in impulse pattern till date. There are certain distinct advantages of oscillometry over spirometry. Being tidal breath-based maneuver, it is more child friendly. People with neuromuscular weakness, cognitive limitations, and the elderly can easily perform it with only minor understanding and effort. Oscillometry is more sensitive than spirometry in detecting peripheral airway diseases. Post-bronchodilator reversibility can be evaluated by comparing with the baseline respiratory characteristics. Their utility in restrictive diseases and vocal cord dysfunction has also been explored. Less aerosol generation during the normal tidal breath is another advantage of oscillometry, over spirometry needing forceful efforts, which makes it more suitable for use in viral pandemic situations for monitoring patients with both asthma and pneumonia. More research is needed, in various geographic locations and heterogeneous populations, to devise the normative data of oscillometric parameters. Simultaneously, there is an urgent need for standardization of available machines at global platform.

The aim of this report is to discuss an eye-opening case about the complication in oromaxillofacial region in COVID-19 recovered youth. The aftermath of COVID infection lead to various complexities in multiple organs. Recurrent follow ups of such recovered patients are necessary to identify early dreadful effects and combat them in time. Hence, present study throws a light on one such post-COVID complication occurring in oromaxillofacial region, its pathophysiology and treatment to overcome its worsening upshot.

Background Multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new entity affecting a small percentage of children during the COVID-19 pandemic. Materials and methods Demography, clinical, and laboratory variables of children admitted from April to September 2020 with MIS-C were studied retrospectively at eight hospitals in Delhi, India. Results We identified 120 patients [median age: 7 years (interquartile range (IQR): 4–10)] with male-to-female ratio of 2.3:1. Overall, 73 out of 120 children (60.8%) presented with shock, 63 (52.5%) required inopressor support, and 51 (43%) required respiratory support. We categorized the cohort into three observed clinical phenotypes: MIS-C with shock (n = 63), MIS-C with Kawasaki disease (KD) (n = 23), and MIS-C without shock and KD (n = 34). Atypical presentations were hypothermia, orchitis, meningoencephalitis, demyelination, polyneuropathy, pancreatitis, and appendicitis. Ninety-four percent had laboratory evidence of SARS-CoV-2 (78.3%, seropositive and 15.8%, RT-PCR positive). The median C-reactive protein (CRP) was 136 mg/L (IQR, 63.5–212.5) and ferritin was 543 ng/mL (IQR, 225–1,127). More than 90% received immunomodulatory therapy (intravenous immunoglobulins and/or steroids) with an excellent outcome (96% survived). CRP and absolute neutrophil count (ANC) were correlated statistically with severity. Conclusion MIS-C data from Delhi are presented. Rising CRP and ANC predict the severe MIS-C. How to cite this article Mehra B, Pandey M, Gupta D, Oberoi T, Jerath N, Sharma R, et al. COVID-19-associated Multisystem Inflammatory Syndrome in Children: A Multicentric Retrospective Cohort Study. Indian J Crit Care Med 2021;25(10):1176–1182.

Aim and objective To study the profile, indications, related complications, and predictors of decannulation and mortality in patients who underwent tracheostomy in the pediatric intensive care unit (PICU). Materials and methods Retrospective analysis of prospectively collected data of tracheostomies was done on patients admitted at PICU. Demographics, primary diagnosis, indication of tracheostomy, and durations of endotracheal intubation, mechanical ventilation, and tracheostomy cannulation were recorded. The indication was recorded in one of the four categories—upper airway obstruction (UAO), central neurological impairment (CNI), prolonged mechanical ventilation, and peripheral neuromuscular disorders). Results Two hundred ninety cases were analyzed. UAO (42%) and CNI (48.2%) were main indications in the halves of the study period, respectively. Decannulation was successful in 188 (64.8%) patients. Seventy-seven percentage UAO patients were decannulated successfully [OR (odds ratio); 95% CI (confidence interval), 2.647; 1.182–5.924, p = 0.018]. Age

Coronovirus-19 disease (CVOID-19) caused by severe acute respiratory syndrome-CoV2 has more than affected 3 million people worldwide, accounting for one of the largest pandemics known to humankind. Originating in China and traveling all across the globe, it spreads by droplets and fomites. Cohort intensive care units have been set up to manage critically ill CVOID-19 patients requiring organ support. Respiratory support, including low and high-flow oxygen devices, noninvasive and invasive ventilatory support have been used in the management of patients with severe acute respiratory illness. Aerosol generating procedures pose a high risk of transmission to health-care workers and need strict infection control practices and the use of personal protective equipment. Various anti-viral drugs have been tried, but there is inadequate evidence to recommend their routine use.

Objective In children, pulmonary and cardiac diseases are closely associated, and their integrated evaluation is important. Flexible fiber-optic bronchoscopy (FFB) can be used for both diagnostic and therapeutic purposes in pediatric cardiac intensive care units (PCICU). The objective of this study was to evaluate the utility of FFB in children with congenital heart disease (CHD). Materials and methods A retrospective, descriptive study was conducted at a tertiary care center in pediatric patients who underwent FFB in PCICU over a period of 6 years (2012-2017). Results Total 71 bronchoscopies were done in 58 patients with CHD with median age and weight of 2.5 months and 3.4 kg, respectively. Total of 20 different cardiac lesions were present among patients who underwent FFB. While 38 (53.5%) and 30 (42.3%) procedures were performed in pre-op and postoperative patients, respectively, 3 intraoperative bronchoscopies were also performed. The main indications for FFB were persistent atelectasis (42/71), prolonged oxygen requirement (13/71), stridor (8/71), and suspected airway anomaly (6/71). Tracheobronchitis was the commonest bronchoscopy finding (51/71, 71.8%) followed by tracheobronchomalacia (27/71, 38.3%). Cause of stridor detected in 7/8 cases. Associated preoperative and postoperative respiratory complications were detected and necessary interventions were done. These included slide tracheoplasty (5/58), tracheostomy (5/58), antibiotic change based on bronchoalveolar lavage (BAL) cultures (11/71), and continued positive pressure ventilation (4/71). Nonconsequential complications were transient hypoxemia (10/71), bleeding (2/71), and transient bradycardia (1/71). Conclusion Bedside FFB is a safe and a valuable diagnostic tool that also helps in guiding interventions in children with cardiac diseases. How to cite this article Sachdev A, Chhawchharia R, Gupta D, Gupta N, Joshi R, Agarwal N. Flexible Fiber-optic Bronchoscopy-directed Interventions in Children with Congenital Heart Diseases. Indian J Crit Care Med 2020;24(5):340-343.

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

Placing objects in the mouth by children get accidentally implanted in the oral cavity, ingested, or aspirated. The incidence of foreign bodies is usually higher in the zone of head and neck than other regions of the human body. Usually, foreign bodies are symptomatic and signs of inflammation pain and purulent discharge are shown. This paper describes an unusual case of traumatic foreign body (pen cover) accidently moved in the retromolar area causing recurrent facial swelling, purulent discharge, and reduced mouth opening. How to cite this article Gupta G, Gupta DK, Bhat M, et al. Traumatic Impaction of Unusual Foreign Body in a 10-year-old Boy's Mouth: A Case Report. Int J Clin Pediatr Dent 2020;13(4):433-436.

How to cite this article Mehra B, Aggarwal V, Kumar P, Gupta D, Kundal M, Kumar A, et al. MIS-C is a Clinically Different Entity from Acute COVID-19 in Adults. Indian J Crit Care Med 2021;25(8):954–955.

Hemodynamic monitoring and categorization of patients based on fluid responsiveness is the key to decisions prompting the use of fluids and vasoactive agents in septic shock. Distinguishing patients who are going to benefit from fluids from those who will not is of paramount importance as large amounts of fluids used conventionally based on surviving sepsis guidelines may be detrimental. Noninvasive monitoring techniques for the assessment of various cardiovascular parameters are increasingly accepted as the current medical practice. Electrical cardiometry (EC) is one such method for the determination of stroke volume, cardiac output (CO), and other hemodynamic parameters and is based on changes in electrical conductivity within the thorax. It has been validated against gold standard methods such as thermodilution [Malik V, Subramanian A, Chauhan S, et al. World J 2014;4(7):101-108] and is being used more often as a point-of-care noninvasive technique for hemodynamic monitoring. EC is Food and Drug Administration approved and validated for use in neonates, children, and adults. A meta-analysis in 2016, including 20 studies and 624 patients comparing the accuracy of CO measurement by using EC with other noninvasive technologies, demonstrated that EC was the device that offered the most correct measurements. The article in the current issue of IJCCM by Rao et al. (2020) has extended the use of EC to categorize pediatric patients with septic shock into vasodilated and vasoconstricted states based on systemic vascular resistance and correlate the categorization clinically. The authors also studied the changes in hemodynamic parameters after an isotonic fluid bolus of 20 mL/kg was administered. This is a pilot prospective observational study of 30 patients, which has given an insight into physiological rearrangements following fluid administration in patients with septic shock. How to cite this article: Gupta D, Dhingra. Electrocardiometry Fluid Responsiveness in Pediatric Septic Shock. Indian J Crit Care Med 2021;25(2):123–125.

Multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a new entity affecting a small percentage of children during the coronavirus disease 2019 (COVID-19) pandemic. This hyperinflammatory syndrome usually presents with multiorgan dysfunction, predominantly affecting cardiovascular, mucocutaneous, and gastrointestinal systems. However, few children have mild neurological symptoms at admission. Till now, severe neurological manifestations as a part of this spectrum have hardly been reported. This case report describes an adolescent girl with severe MIS-C who presented with multiorgan failure and suffered dual neurological insult, involving both the central and peripheral nervous systems. How to cite this article: Mehra B, Aggarwal V, Kumar P, Kundal M, Gupta D, Kumar A, et al. COVID-19-associated Severe Multisystem Inflammatory Syndrome in Children with Encephalopathy and Neuropathy in an Adolescent Girl with the Successful Outcome: An Unusual Presentation. Indian J Crit Care Med 2020;24(12):1276–1278.

Childhood allergies pose huge economic burden and adverse effects on quality of life. Serum IgE has been considered a surrogate allergy marker for decades. Availability of several over-the-counter allergy tests add to confusion of partially trained caregivers. The present review focuses on current status of allergy testing in Indian scenario. Various in-vitro and in-vivo diagnostic modalities are available for allergy detection. Skin prick tests are useful for aero-allergies whereas oral challenge tests are best for identifying suspected food allergies. An allergy test should be individualized based on clinical features, diagnostic efficacy, and cost-benefit analysis.

There is a paucity of studies on the correlation between chest radiograph and ultrasound (US) in children. Our objective was to study the correlation between bedside chest radiograph and ultrasound findings in 413 children with 1002 episodes of chest radiograph and US enrolled for a prospective, double-blinded observational study in a multidisciplinary paediatric intensive care unit. Weighted κ statistic for agreement was different for right and left lungs and varied from 50% for left pleural effusion to 98% for right pneumothorax. Pulmonary oedema, pneumothorax and pleural effusion were diagnosed by ultrasound alone in a significantly higher number of patients as compared to chest radiograph (P = 0.001). Chest ultrasound is therefore deemed more sensitive than chest radiograph in detection of pleural effusion, pulmonary oedema and pneumothorax.

Background: Lung function testing is recommended for the management of asthma. Due to certain limitations of conventional spirometry in vulnerable patients, forced oscillation technique (FOT) has been studied with promising results. As there is a paucity of data from developing world, we planned to conduct this study in children using FOT. To assess airway reversibility after inhaled salbutamol in asymptomatic children with suspected asthma. Settings: This study was conducted at pediatric asthma clinic of a tertiary care referral hospital in North India. Design: This was a prospective interventional study over 1-year period. Subjects and Methods: Asymptomatic children between 2 and 18 years of age, with history suggestive of asthma, were eligible for participation. Baseline and postbronchodilator pulmonary functions were assessed using FOT. Airway resistance and reactance were monitored at various frequencies. SPSS version 17 was used for statistical analysis. Results: Among the 345 enrolled children, baseline mean ± standard deviation total airway resistance (R5), central airway resistance (R19), peripheral airway resistance (R5–R19), reactance (X5), and resonant frequency (Fres) were 6.85 ± 2.60, 5.23 ± 1.93, 1.6 ± 1.16, and − 2.54 ± 1.36 cmH2O/L/s and 17.28 ± 3.06 Hz. The median (interquartile range) percentage change after inhaled salbutamol was 19.9 (11.40, 29.12), 22.86 (6.88, 38.76), 14.08 (3.40, 22.62), 39.20 (8.20, 62.39), and 15.79 (8.33, 27.27) in respective parameters. All changes were statistically significant. The studied respiratory variables were in maximum negative correlation with height, followed by body mass index. Conclusions: FOT is a simple technique for monitoring lung functions in children during asthma management.

Spirometry, a gold standard technique for measuring lung functions, has been restricted to a select cohort of patients in current COVID-19 pandemic due to the enhanced risk of disease dissemination. To monitor pulmonary functions in various obstructive (e.g., asthma) and restrictive diseases (e.g., COVID-19 pneumonia) on in- and out-patients serially, there is an urgent requirement of an alternate reliable test. Impulse Oscillometry (IOS) measures lung functions by working at tidal volumes and thus reduces the risk of potential aerosol generation. Feasibility of IOS in smaller children and its ability to detect parenchymal and peripheral airway involvement are other advantages over conventional spirometry. IOS could be a potential solution to periodically monitor lung functions in current pandemic situation to keep a check on diseases affecting lung functionality.

First reported in China, the 2019 novel coronavirus has been spreading across the globe. Till 26 March, 2020, 416,686 cases have been diagnosed and 18,589 have died the world over. The coronavirus disease mainly starts with a respiratory illness and about 5-16% require intensive care management for acute respiratory distress syndrome (ARDS) and multi-organ dysfunction. Children account for about 1-2% of the total cases, and 6% of these fall under severe or critical category requiring pediatric intensive care unit (PICU) care. Diagnosis involves a combination of clinical and epidemiological features with laboratory confirmation. Preparedness strategies for managing this pandemic are the need of the hour, and involve setting up cohort ICUs with isolation rooms. Re-allocation of resources in managing this crisis involves careful planning, halting elective surgeries and training of healthcare workers. Strict adherence to infection control like personal protective equipment and disinfection is the key to contain the disease transmission. Although many therapies have been tried in various regions, there is a lack of strong evidence to recommend anti-virals or immunomodulatory drugs.

Status Asthmaticus is a common reason for Emergency Room visits in children. Most of the asthma flares are successfully managed by use of β agonist and steroids. If these therapies fail to halt the progression of asthma, a number of medical therapies may be used to treat it. However, the data supporting the use of these therapies are conflicting. We present successful use of Extracorporeal Membrane Oxygenation and isoflurane in a child with Refractory Status Asthmaticus.

Extracorporeal membrane oxygenation (ECMO) is a standard modality to treat refractory hypoxemia in pediatric acute respiratory distress syndrome (ARDS) in developed countries. However, it’s usage is limited in developing countries like India, where very few tertiary care PICU centres have used it with success. We report a case of 11 months old infant with necrotising bacterial pneumonia with severe ARDS and septic shock who failed on conventional and high frequency mechanical ventilation, but was successfully managed with veno-arterial ECMO support.

Objective: The objective of the study was to evaluate the etiology of hospital-acquired hyponatremia (HAH) and its effects on morbidity and mortality in the Pediatric Intensive Care Unit (PICU) patients. Design: This study design was a prospective observational case–control study. Setting: this study was conducted at tertiary care PICU. Materials and Methods: All consecutive cases admitted with at least one measured serum sodium (PNa) value were evaluated. Those with normal admission PNa were followed till they develop hyponatremia (PNa < 35 mEq/L) 7 days or PICU discharge whichever was earlier. Results: During the study period, 123 (19.6%) cases developed HAH and 126 patients remained isonatremic (control group). The admission PNa 138.8 ± 3.03 mEq/L decreased to 132 ± 2.58 mEq/L (drop of 6.68 ± 3.39 mEq/L, P < 0.001) in HAH cases. The use of antidiuretic hormone (ADH)-stimulating drugs (odds ratio [OR]: 2.83, P = 0.01), postsurgical status (OR: 2.95, P = 0.006), and fluid intake ml/kg (OR: 1.0, P = 0.001) were found to be significant risk factors in HAH group on multivariate analysis. HAH cases had prolonged PICU stay (P = 0.000) and mechanical ventilation (P = 0.01), but no difference in the mortality when compared to controls. Conclusions: HAH is associated with increased fluid intake, presence of ADH-stimulating drugs or conditions, and postsurgical status and has an adverse effect on the outcome of PICU patients.

Rickettsial infections are relatively less common in children, probably due to low index of suspicion and unavailability of diagnostic facilities. Scrub typhus is the predominant type of rickettsial illness identified in our country. Infections with other rickettsial species are rarely reported in Indian children. We report a case of a 3 year child with acute febrile illness with rash and multiorgan dysfunction. Weil Felix test was strongly positive for OX 19, with negative scrub typhus IgM antibody test, suggesting a murine typhus infection. There were few salient differences in clinical and laboratory parameters, compared to scrub. Treatment of rickettsial infections is inexpensive and highly effective especially in early course of the disease. Differential diagnosis of rickettsial infection should be kept in a child presenting with fever, rash and multisystem involvement and adding empirical doxycycline at admission may be considered.

Introduction: Fiberoptic flexible bronchoscopy (FFB) in neonatal intensive care units (NICU) is useful for diagnosis and guiding therapeutic interventions. Aim: To evaluate the utility of FFB for the diagnosis and interventions based on its findings. Methods and Materials: A retrospective, medical chart search was conducted in neonates who underwent FFB over a period of 7 years. Besides demographic data and FFB diagnostic findings, the results of medical and/or surgical interventions done by treating neonatologist were recorded. Results: Total 88 bronchoscopies were performed in 83 neonates of which, 37 bronchoscopies were done through endotracheal tube. Indications included persistent need for mechanical ventilation (32/88) persistent atelectasis (21/88), stridor (27/88), extubation failure (4/88), recurrent apnea (2/88) and suspected airway anomaly (2/88). Airway anomalies diagnosed by FFB were tracheobronchomalacia (20/88), laryngomalacia (18/88), subglottic stenosis(7/88), choanal atresia (4/88), laryngeal cleft (4/88), tracheoesophageal fistula (TEF) (4/88), one each of pyriform stenosis, laryngeal web, vocal cord paresis, absent and complete tracheal rings. Radiological improvement after FFB was seen in 43.1% cases. Surgical interventions were undertaken in 17 cases, including 9 tracheostomies and 2 slide tracheoplasties. Conclusion: FFB can be useful for early diagnosis of congenital airway anomalies allowing early intervention for the same.

To describe the utility of flexible fiberoptic bronchoscopy for the diagnosis and management in the neonatal ICU.A retrospective, medical chart review was conducted in neonates who underwent flexible fiberoptic bronchoscopy over a period of 7 years. Besides demographic data and diagnostic findings, the results of medical and/or surgical interventions done by treating neonatologist were recorded.88 bronchoscopies were performed in 83 neonates, of which 37 were done through endotracheal tube. Indications included persistent need for mechanical ventilation (32), persistent atelectasis (21), and stridor (27). Most common airway anomalies diagnosed included tracheobronchomalacia (20), laryngomalacia (18), subglottic stenosis (7), choanal atresia (4), laryngeal cleft (4), and tracheoesophageal fistula (4). Surgical interventions were undertaken in 17 cases (9 tracheostomies and 2 cases of slide tracheoplasty).Flexible fiberoptic bronchoscopy can be beneficial for the diagnosis and management of neonates with persistent or undiagnosed respiratory problems.

Manipulation of positive end-expiratory pressure (PEEP) has been shown to improve the outcome in pediatric acute respiratory distress syndrome (PARDS), but the “ideal” PEEP, in which the compliance and oxygenation are maximized, while overdistension and undesirable hemodynamic effects are minimized, is yet to be determined. Also, for a given level of PEEP, transpulmonary pressure (TPP) may vary unpredictably from patient to patient. Patients with high pleural pressure who are on conventional ventilator settings under inflation may cause hypoxemia. In such patients, raising PEEP to maintain a positive TPP might improve aeration and oxygenation without causing overdistension. We report a case of PARDS, who was managed using real-time esophageal pressure monitoring using the AVEA ventilator and thereby adjusting PEEP to maintain the positive TPP.

Acute left ventricular dysfunction in children justifies aggressive treatment because of the high potential for complete recovery. The options for providing mechanical support to the failing heart in a child include extracorporeal membrane oxygenation, left ventricular assist devices, and the use of the intra-aortic balloon pump (IABP). The IABP is a commonly used method of temporary circulatory support in adults. However, despite the availability of pediatric size balloons, the usage of IABP for temporary circulatory support in children has not been widespread. Current case report, first from India in pediatric age group, aims to aware the pediatric intensivist about the role of IABP in providing temporary mechanical cardiovascular support in managing patients with refractory low cardiac output state.

CONTEXT: Various types of allergic disorders are increasing worldwide. The diagnostic and treatment facilities are limited compared to their vast magnitude. Lack of awareness among caregivers and beneficiaries could be one of the critical factors for inadequate management especially in developing countries. AIM: This study aims to evaluate the knowledge among caregivers about various allergic disorders in a pediatric setup. SUBJECTS AND METHODS: Caregivers of children, presenting for their illness at pediatric outpatient department of a tertiary care hospital of North India, were recruited over 6 months' period using a 22-item prevalidated questionnaire. STATISTICAL ANALYSIS USED: Sigma Plot Software version 12. RESULTS: Among the 1000 participants, majority (94%) had some knowledge about allergy. Doctors were major source (55%) of information. More than half (53%) believed it to be contagious. House dust (70%) and food additives (24%) were considered major allergens. Seasonal variations (54%) and environmental pollution (48%) were considered the most common aggravating factors while steam inhalation (14%), yoga (11%), and air purifiers (10%) helped in symptom reduction. Skin and respiratory symptoms were a common knowledge amongst many study participants. Only 8% were aware about skin tests for allergy diagnosis. Alternative medicine was the treatment of choice among two-third of people. Oral route was preferred over inhaled medicines. CONCLUSION: The current study highlights limited knowledge and existence of misconceptions regarding allergic disorders in general population necessitating the need to improvise awareness campaigns.

To study the association between red cell distribution width (RDW) and mortality in critically-ill children admitted in a Pediatric intensive care unit (PICU).101 participants were recruited consecutively over 3 months. Data collected included demographics, vital parameters, laboratory values, severity and organ failure scores, RDW for the first 5 days of admission, duration of PICU stay and survival outcome.11 patients died during study period. High RDW at admission (RDW D1) correlated significantly with mortality (P=0.007). The odds of death increased by 15 to 23 times with rise in RDW D1 from 18% to21%. The optimal RDW D1 cut-off value for mortality was 18.6%, which yielded sensitivity 90.9%, specificity 70.8%, positive predictive value 27.8%, negative predictive value 98.4%, and area under curve (AUC) 0.83 (95%CI 0.737, 0.925). 29 out of 60 (48.3%) patients with RDW D418% had PICU stay of ≥7 days.High (≥18.6%) RDW at admission and its persistent high levels are associated with high mortality and prolonged stay in PICU, respectively.

Congenital central hypoventilation syndrome (CCHS) is characterized by shallow breathing during sleep due to negligible ventilatory sensitivity to hypercarbia and hypoxemia. It is diagnosed using a genetic test for PHOX2B mutation, which is not easily available. Neurally adjusted ventilatory assist (NAVA) is a spontaneous ventilatory mode that was designed basically for better adapting the ventilator to the patient by using electrical activity of diaphragm (EAdi) signals. We report a case of a 6-month-old infant who presented with recurrent apneas, where differential decrease in EAdi discharges during sleep using NAVA served as an early clue to the diagnosis of CCHS. Definitive diagnosis was later confirmed by genetic testing. How to cite this article Rauf A, Gupta D, Sachdev A, Gupta N, Gupta S, Kumar P, et al. Neurally Adjusted Ventilatory Assist: An Early Clue to Diagnosis of Congenital Central Hypoventilation Syndrome. IJCCM 2019;23(11):536–537.

Chest trauma is one of the important causes of mortality and morbidity in pediatric trauma patients. The complexity, magnitude, and type of lung injury make it extremely challenging to provide optimal oxygenation and ventilation while protecting the lung from further injury due to mechanical ventilation. Independent lung ventilation is used sporadically in these patients who do not respond to these conventional ventilatory strategies using double-lumen endotracheal tubes, bronchial blocker balloons, etc. However, this equipment may not be easily available in developing countries, especially for pediatric patients. Here, we present a case of severe chest trauma with pulmonary contusion, flail chest, and bronchopleural fistula, who did not respond to conventional lung protective strategies. She was successfully managed with bronchoscopy-guided unilateral placement of conventional endotracheal tube followed by single lung ventilation leading to resolution of a chest injury.

This study was aimed to evaluate the utility and benefits of flexible fiberoptic bronchoscopy (FFB) prior to tracheostomy decannulation. Besides demographic data, initial cause of tracheostomy, primary diagnosis, pre-tracheostomy and pre-decannulation bronchoscopic findings and duration of tracheostomy were collected from medical charts. The type of active intervention following bronchoscopy and outcome after decannulation were recorded. Departmental decannulation policy and procedure were used in all patients. Forty-nine tracheostomized patients who underwent decannulation attempt were included. The median age of the children at the time of decannulation was 3 years (range 4 months–16 years). The median duration of tracheostomy was 8 months (range 1–86 months). Prolonged mechanical ventilation was the commonest indication for tracheostomy. There were 45 abnormal findings on FFB in 36 patients. Airway granulation was the commonest abnormality (23/45, 51%). Successful decannulation without any intervention was possible in 23 (46.9%) cases. 12 of these had normal bronchoscopy. Fifteen (30.6%) patients required surgical interventions before attempting decannulation. In five patients decannulation failed, while in six children decannulation was not attempted after FFB. Pre-decannulation flexible fiberoptic bronchoscopy in children with tracheostomy helps in identifying the possible causes of decannulation failure and helps in deciding the appropriate intervention.

Objective: Scanty literature is available regarding continuous renal replacement therapy (CRRT) utility in severe sepsis with multiorgan dysfunction syndrome (MODS) from developing countries. Author unit's experience in pediatric CRRT is described and outcome of early initiation of CRRT with sepsis and MODS is assessed. Materials and Methods: Children aged

Immunodeficient children are more prone for invasive cryptococcal infections. A 2-year-old boy with disseminated cryptococcosis was evaluated for underlying immunodeficiency without success. Child was managed successfully. Immunocompetent children with disseminated cryptococcosis can present diagnostic or therapeutic challenge in resource-limited settings.

There is a need to validate and suggest easy clinical method for diagnosis of ventilator-associated pneumonia (VAP) in developing countries.To validate the use of simplified Clinical Pulmonary Infection Score (CPIS) for the diagnosis of VAP.Prospective study.Pediatric intensive care unit of a tertiary care teaching hospital.30 children receiving mechanical ventilation for more than 48 hours and with simplified CPIS=6.All patients underwent flexible bronchoscopy to obtain bronchoalveolar lavage which was analyzed quantitatively. Colony count = 10(4) cfu/mL was considered reference standard for definite VAP.Of the five variables used for simplified CPIS, only patients temperature (P=0.013) and PaO2/FiO2 ratio were significant (P0.001) to differentiate the presence of definite VAP. Patients with definite VAP (BAL colony count = 10(4) cfu/mL) had CPIS of 8.4 while in no definite VAP group it was 6.4 (P=0.007). CPIS of 8 was found to have sensitivity of 80%, specificity 80%, PPV 86.9%, NPV 70.5% and accuracy 80%. The area under Receiver operating characteristic curve of CPIS against reference standard was 0.81± 0.069 (P=0.001).Simplified CPIS is useful in patients on mechanical ventilation to diagnose ventilator-associated pneumonia.

Cerebrovascular complications are being frequently recognized in the pediatric intensive care unit in the recent few years. The epidemiology and risk factors for pediatric stroke are different from that of the adults. The incidence of ischemic stroke is almost slightly more than that of hemorrhagic stroke. The list of diagnostic causes is increasing with the availability of newer imaging modalities and laboratory tests. The diagnostic work up depends on the age of the child and the rapidity of presentation. Magnetic resonance imaging, computerized tomography and arteriography and venography are the mainstay of diagnosis and to differentiate between ischemic and hemorrhagic events. Very sophisticated molecular diagnostic tests are required in a very few patients. There are very few pediatric studies on the management of stroke. General supportive management is as important as the specific treatment. Most of the treatment guidelines and suggestions are extrapolated from the adult studies. Few guidelines are available for the use of anticoagulants and thrombolytic agents in pediatric patients. So, our objective was to review the available literature on the childhood stroke and to provide an insight into the subject for the pediatricians and critical care providers.

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

Objectives: Thrombocytopenia is commonly observed in critically ill patients. This study was undertaken to evaluate the variation in platelet counts and the risk factors associated with thrombocytopenia and mortality in pediatric intensive care patients. In addition, prognostic value of platelet counts for outcome in pediatric intensive care unit was studied. Study Design: Prospective, observational cohort analysis. Setting: 8- bedded pediatric intensive care unit of a tertiary care teaching hospital. Patients: All consecutively admitted patients (n=138) staying in the pediatric intensive care unit (PICU) for at least 48h over a 7 months period were studied. Measurements and Main Results: Thrombocytopenia was defined as platelet counts < 150.0/nL. Median 1 st day Pediatric Risk of Mortality Score (PRISM) was 5 (range 0-30) and median ICU stay was 4 days (range 2-98 days). Twenty five percent patients had at least one episode of thrombocytopenia during the stay. Twenty percent of these patients had thrombocytopenia on admission and rest (80%) developed it during the PICU stay. Seventy one percent (19) of the patients developed thrombocytopenia by fourth day of admission. Patients with PICU acquired thrombocytopenia had statistically significant lower baseline, nadir and 4th day platelet counts and a significantly higher drop in platelet counts (56% vs. 6% P< 0.001) as compared to non thrombocytopenic patients. PRISM score, long PICU stay, sepsis, coagulopathy, and creatinine levels were significantly associated with occurrence of thrombocytopenia. Patients with thrombocytopenia had higher probability of bleeding (34% vs. 15%, P=0.01). Higher platelet counts on admission were associated with significantly reduced risk of thrombocytopenia (P=0.00) Baseline, nadir and day-4 platelet counts, presence of thrombocytopenia on admission, sepsis, coagulopathy and a higher mean PRISM score on univariate analysis were significantly associated with mortality. Leucopenia or leucocytosis, thrombocytopenia and coagulopathy were found to significantly affect outcome. Drop in platelet counts was found to have slightly higher discriminative value for mortality prediction than PRISM on the ROC curve. The survivors had higher platelet counts throughout the PICU stay and after an initial fall in platelet counts in the PICU showed a significantly higher rise in the platelet counts in the following days than the non-survivors. Conclusions: Thrombocytopenia is common in PICU. Patients requiring cardiopulmonary resuscitation or with circulatory shock, coagulopathy, sepsis and with more severe disease have higher risk of developing thrombocytopenia. Thrombocytopenic patients have a higher risk of bleeding. Drop in platelet counts> 27% and thrombocytopenia were independently related to mortality. Serial measurements of platelet counts are better predictors of pediatric intensive care outcome than one-time values. Any drop in platelet counts even without thrombocytopenia needs an urgent and extensive evaluation.

Lipoid pneumonia is a rare form of pneumonia caused by aspiration of fatty substances.Acute respiratory distress syndrome in an infant due to accidental aspiration of baby oil massage.Large volume bronchoalveolar lavage.Gradual recovery over a period of 5 months.Aspiration of lipids cause prolonged and refractory hypoxemia.

Mechanical ventilation is a life-saving therapy used in children in PICU. These critically ill children are usually extensively investigated in PICU. Chest radiograph is an irreplaceable investigation in these patients prior to ventilation. AIM: We studied the impact of initial chest radiograph on the final outcome of ventilated children. DESIGN: Retrospective. SETTING: Tertiary care teaching hospital. METHOD: One hundred and forty-one children were included in the study. Initial chest radiograph of all the ventilated children was evaluated and outcome of these children was correlated with the initial radiograph at admission. RESULTS: Abnormal initial radiograph was recorded in 60% (n = 84) ventilated children. Overall mortality in ventilated children was 24% (n = 34). Ventilated children with abnormal initial radiograph had significantly greater mortality (28/84) than those with initial normal chest radiograph (6/57) (P CONCLUSION: Initial chest radiograph at the beginning of ventilation may be useful to predict the outcome of these children

Dengue virus infection can cause a wide spectrum of illness. Thrombocytopenia with concurrent haemoconcentration differentiates dengue haemorrhagic fever from classical dengue fever. Only cases with shock or unstable vitals signs need admission in the pediatric intensive care. The management is essentially supportive and symptomatic. The key to success is frequent monitoring and changing strategies. A rise in hematocrit of 20% along with a continuing drop in platelet count is an important indicator for the onset of shock. Patients in grade I and II should be closely monitored for signs of shock. The management of dengue shock syndrome (grade III and IV) is a medical emergency needing prompt and adequate fluid replacement for the rapid and massive plasma losses through increased capillary permeability. Early and effective replacement of plasma losses with plasma expanders or fluid and electrolyte solutions results in a favourable outcome in most cases. The ideal fluid management should include both cystalloids and colloids (including albumin). Cystalloids are given as boluses as rapidly as possible, and as many as 2 to 3 boluses may be needed in profound shock. Colloidal fluids are indicated in patients with massive plasma leakage and in whom a large volume of cystalloids has been given. Frequent recording of vital signs and determinations of haematocrit are important in evaluating the results of treatment. Apart from correction of electrolyte and metabolic disturbances, oxygen is mandatory in all patients of shock. Some patients develop DIC and need supportive therapy with blood products (blood, FFP and platelet transfusions). Polyserositis, in the form of pleural effusion and ascitis, are common in cases of dengue shock syndrome, and if possible, drainage should be avoided as it can lead to severe hemorrhages and sudden circulatory collapse. The prognosis depends mainly on the early recognition and treatment of shock.