NCPCC 2015: Posters - Journal of Pediatric Critical CareVol. 3 - No.1 January - March 2016 40...

JOURNAL OF PEDIATRIC CRITICAL CAREVol. 3 - No.1 January - March 2016 38

NCPCC 2015: Posters

[Award Poster: First Position]Lactate Clearance as a Predictor of

Mortality in Children with Septic ShockNitin Manwani, Sumant Prabhudesai, K Ravikumar,

Bala RamachandranDepartment of Pediatric Intensive Care, Kanchi Kamakoti

CHILDS Trust Hospital, Chennai

Objective: To study the utility of lactate clearance as a predictor of mortality in children with septic shock

Methods: Lactate was measured at admission and on days 2 and 3 in children aged 30 days - 18 years admitted to the PICU with septic shock. Demographic, clinical and laboratory data were collected. Lactate clearance was defi ned as (admission lactate-current lactate) x 100 /admission lactate.

Results: Twenty fi ve children were included (median age 28.5 [14.25- 66.75] months, 36% female, median PRISM III score 15.5[10.25-22.5]). Median lactate at admission, day-2 and day-3 were 2.6 [2.0-3.5], 1.8 [1.2-2.75] and 1.7 [1.2-2.8] mmol/L respectively. Four children had a rise in lactate by day-2, while 7 children had a rise by day-3. A day-2 lactate clearance of -25% (rise by 25%) predicted mortality with a sensitivity of 100% and specifi city of 50% (area under the receiver operating characteristics curve [AUROC] 0.77). A day-3 lactate clearance of -30% (rise by 30%) predicted mortality with a sensitivity of 93.3% and specifi city of 83.3% (AUROC= 0.91). Admission lactate correlated poorly with PRISM III score (r= 0.15).

Discussion: Few similar Indian studies in children have shown lactate clearance to be a good indicator of mortality. Signifi cance of a negative lactate clearance has not been reported though it is assumed that the associated outcome would be poor.

Conclusion: An initial rise in lactate may not affect outcomes. Lactate clearance by 72 hours of shock may be a good predictor of mortality in children with septic shock.

Type of study: Prospective observational study.

[Award Poster: Second Position]Empty Sella Syndrome Resulting into Short Stature in Two Siblings - A case

report with review of literatureJamunashree B*, Seema Sharma, Milap SharmaDepartment of Pediatrics, Dr Rajendra Prasad Government

Medical College, Tanda, Kangra, H.P.*Email: [email protected]

Abstract: Empty sella syndrome (ESS) is the herniation of the subarachnoid space into the sella through the sellar diaphragm with some degree of fl attening of pituitary gland. Primary ESS occurs when a hole in diaphragmatic sella covering the pituitary allows fl uid in, which presses on pituitary. Secondary empty sella syndrome occurs when the pituitary glandis injured secondary to surgery, tumour or radiation.We present two siblings with

features of hypopituitarism.

Case Report: A 9 year old female and her 7 year old male sibling presented with complaints of failure to gain weight and height from the age of one year, diagnosed as failure to thrive. Hormonal analysis was suggestive of hypopituitarism and Contrast enhanced MRI of pituitary gland revealed empty sella syndrome. On follow up, child gradually gained height with growth hormone supplements.

Discussion: The incidence of empty sella syndrome varies 8-35% in the general population and 1.2% in children. However high incidence up to 68% has been described in children with known endocrinopathy. Clinical features include hypogonadism, Growth hormonedefi ciency, and multiple pituitary hormone defi ciency. Gadolinium enhanced MRI pituitary gland is the investigation of choice.Primary ESS is treated with hormonal supplementation. In secondary ESS, treatment depends upon etiology.

Conclusion: The rare causes like ESSshould be considered in children presenting with failure to thrive because early initiation of GH treatment gives good results.

[Award Poster: Third Position]Comparison of External Jugular Venous

access to Internal Jugular Venous access in Pediatric septic shock: An

observational, prospective studyChintan Patel, Kushal Shah, Utkarsh Pandya,

Krutika Tandon**Professor in Pediatrics & PICU Incharge, Department of

Pediatrics, P S Medical College, Karamsad-388325, Dist. Anand (Gujarat)

*M: 9879531972; Email: [email protected]

Background: Intravenous lines are lifelines for patients with shock. Central venous access is preferred but not possible always. So we undertook this study of comparison of External Jugular Venous(EJV) access to Internal Jugular Venous(IJV) access for its effi cacy, ease of procedure, complications and cost effectiveness.

Methods: A Prospective, Observational study from January 2014 to June 2015 at PICU. Seventy pediatric patients with shock were enrolled. Parents were explained about both EJV and IJV routes. Depending on their affordability and consent one route was chosen. Required details were noted and descriptive analysis was done as per objectives.

Results & Discussion: EJV and IJV had 50 and 16 subjects respectively. Mean duration of reaching shock free status was 69.2 hours in EJV group versus 53.33 hours of IJV group. Mean improvement in base defi cit at the end of 24 hours as 4.3 and 6.6 in EJV & IJV groups respectively. Successful hospital discharge was 36% and 37.5% of patients of EJV & IJV groups respectively. No life threatening complications in any group and local site problems were similar in both groups. Overall attempts

Received:10-Jan-2016/Accepted:17-Jan-2016 /Published online:15-Feb-2016

DOI-10.21304/2016.0301.00111

JOURNAL OF PEDIATRIC CRITICAL CARE39Vol. 3 - No.1 January - March 2016

were similar in both groups whereas duration of procedure and cost effectiveness of procedure was better in EJV group. Earlier none of this type of study published especially comparing two diverse intravenous routes in pediatric shock.

Conclusion: External jugular venous route is easy, cost effective route with comparable results when central venous access is not feasible, though central venous route is standard of care in pediatric septic shock.

Active CRE Surveillance as a means of Decreasing the Incidence of CRE

Infections in a PICURavikumar K*, Alok E, Ajay A, Prabhudesai S,

Putlibai S, Subburaju N, Nambi S, Ramachandran BDepartments of Pediatric Intensive Care, Pediatric Infectious Diseases & Microbiology, Kanchi Kamakoti CHILDS Trust

Hospital, Chennai*Email: [email protected]

Background: Carbapenem resistant enterobacteriaceae (CRE) infections are increasing in hospitalised patients. CRE surveillance & contact/cohort isolation has been shown to decrease the incidence of CRE infections.

Methods: CRE surveillance using rectal swabs was started in our PICU from July 2013 since there was an increase in CRE infections. Rectal swabs were sent on admission and weekly thereafter until patient discharge from PICU. Over an 18 month period, 976 rectal swabs were sent and 164 were found to be positive. Patients with positive CRE swabs were placed under contact isolation.

The incidence of CRE infection (per 1000 patient days) before and after starting surveillance was analysed retrospectively.

Results: Prior to initiation of surveillance, 4 CRE infections (2.65/1000 patient days) were identifi ed from January-June 2013 (Season 1). After initiation of surveillance from July 2013, the incidence of CRE infections gradually decreased. There were 3 CRE infections (1.69/1000 patient days) from July-December 2013 (Season 2), 3 CRE infections (1.97/1000 patient days) from January-June 2014 (Season 3) and no infections from July-December 2014 (Season 4). There was a statistically signifi cant reduction (p 0.03) in the incidence of CRE infections in Season 4 (post surveillance) when compared with Season 1 (pre-surveillance).

Discussion: Isolation of patients infected with CRE by itself may not be enough to decrease the spread of these organisms. It is also essential to identify and isolate patients who are colonized with CRE.

Conclusion: Containment of CRE infection is possible with active surveillance combined with proper isolation

Type of study: Retrospective descriptional study

Study of Impact of Introduction of “Restricted Antimicobials” Use

Justifi cation form in Pediatric Intensive Care Unit of Tertiarycare Hospital

Deepak RFellow-Pediatric Intensive Care, Rainbow Hospital for Women

and Children, Banjara Hills, HyderabadEmail: [email protected]

Objective: To study whether introduction of a “antimicrobial justifi cation form” deter clinicians from prescribing restricted antimicrobials and result in de-escalation of these antimicrobials.

Setting: PICU of Rainbow Children’s Hospital, Banjara Hills, Hyderabad.

Design: Ours was a case control study where subjects from two phases were compared.

Methods: We identifi ed group of antimicrobials as “restricted” and clinicians prescribing antimicrobial from the restricted group were asked to fi ll a justifi cation form.

In Phase one “retrospective” controls were taken between 1st June, 2012 to 31st March 2013 and in Phase two “prospective” cases were taken from 1st June, 2013 to 31st March, 2014. In both the phases, only those patients who received antibiotics from the “restricted” group were included.

Phase one was an observation on the use of antimicrobials. In phase two, the doctors prescribing the “restricted” antibiotics fi lled a “justifi cation” form.

After 72 hours they were asked either to de-escalate the antibiotic or justify not de-escalating.

Results: A signifi cant overall decrease in antimicrobial usage in Group B as compared to Group A (p = 0.01) was seen. We noticed a signifi cant de-escalation of Piperacillin - Tazobactum (p<0.0001), Meropenem (p=0.002) and Linezolid (p=0.00) in Group B.

Conclusion: Introduction of a simple intervention like fi lling up of a justifi cation form before prescribing antimicrobials or at the time of deferring de-escalation can be a useful tool in making a positive impact in restricting the use of broad-spectrum antimicrobials in PICU.

Critical Illness Corticosteroid Insuffi ciency(CIRCI) in Children - A

single centre, prospective cohort study Vinayak K.Patki*, Sanket Agarwal, Jennifer Antin

Department of Pediatrics, *Pediatric intensivist, Head, Department of Pediatrics, Wanless Hospital,

Miraj, 416410, Dist-Sangli, Maharashtra*Email: [email protected]

Introduction: Although guidelines for diagnosis and management of CIRCI in adults are developed there is paucity of data available on CIRCI in children.


Aims and Objective: To study the incidence, risk factors, mechanism and associations of CIRCI in children using ACTH stimulation test.

Methods: single centre prospective cohort study was conducted in eight bedded PICU of teaching hospital over a period of one year. Serum total cortisol concentration were measured in 110 critically ill children before and after stimulation with 250μg adrenocorticotropic hormone (ACTH). CIRCI was defi ned by post ACTH increment in serum cortisol ≤9 μg/dl. Children with and without CIRCI were compared.

Results: Incidence of CIRCI was 38.2%. Children with CIRCI had higher median age(34 vs 18 months) higher PRISM score (17.79±2.60 Vs16.37±3.68 ) and signifi cantly higher basal cortisol levels (27.37±11.64 Vs22.02±7.26) (p-0.004) than those without CIRCI. There was signifi cantly higher (p-0.000) requirement of catecholamines (2.71±0.457 Vs2.00±0.792) and higher fl uid boluses(15.79±4.7Vs 10.65±4.60) in children with CIRCI. But duration of catecholamine use was not signifi cantly different between two groups. Presence of CIRCI was not found to be independent risk factor for mortality. For each additional use of catecholamine the risk of CIRCI increased to 5.6 times and for each extra fl uid bolus risk increased to 1.2 times.

Conclusion: CIRCI occurs in a wide spectrum of diseases in critically ill children associated with increased need for catecholamine and fl uids. CIRCI likely to be multi-factorial in etiology and associated with high basal cortisol.

Keywords: adrenal function, cortisol, adrenocorticotropic hormone, critically ill children

Comparison of Noninvasive Oscillometric and Intra-Arterial Blood Pressure

Measurements in Children Admitted to Pediatric ICU

Kaur J, Pooni P, Bains H, Thakkar T**PICU Fellow, DMCH, Ludhiana

Email: [email protected]

Background: Direct intra-arterial readings are considered the gold standard for Blood Pressure measurements. Because arterial cannulation is diffi cult and associated with risks, alternative non-invasive blood pressure (NIBP) measurements are routinely used in emergency and critical care setups. However, the accuracy of NIBP determinations in critically sick children is variable.

Aim: To fi nd the difference, limits of agreement and correlation between simultaneously recorded invasive and oscillometric non-invasive BP measurements in critically ill children.

Methods: Prospective observational study carried out in children aged 1 month to 18 years admitted to 10 bedded Level III PICU at DMCH, Ludhiana in a 18 month study period. Agreement and correlation between IABP and NIBP was assessed using Bland-Altman analysis.

Results: Overall, 4447 pairs of simultaneous recorded

oscillometric and invasive BP measurements were collected in 65 patients. The mean difference between invasive and non-invasive techniques were - 3.6 ± 12.85, - 4.7 ± 9.3 and - 3.12 ± 9.30 mm Hg respectively for systolic, diastolic and mean arterial BP (p < 0.05 ), with wide limits of agreement. Overestimation of BP using NIBP was more evident in infants, children on inotropic support and obese children.

Conclusion: Although there is a good correlation between IABP and NIBP measurements but as Oscillometric BP measurements tend to overestimate IABP readings especially in case of hypotensive shock, they cannot be regarded as reliable alternatives to IABP measurements.

Rapid Onset Obesity and Ondine’s Curse: A Deadly Syndrome

Shalini A AkunuriPICU Fellow, Narayana Health, Bangalore


Introduction: ROHHADNET is a rare disorder defi ned by rapid onset obesity, hypoventilation, hypothalamic dysregulation, autonomic dysfunction and neural-crest tumors. We report a case of 2.4 years old girl who presented with obtundation due to hypoventilation, carbon-dioxide narcosis and on evaluation found to have features of ROHHADNET syndrome.

Case Report: 2.4 years old girl presented with obtundation. At admission, she was hypoventilating with severe hypercarbia. Her sensorium and ABG normalized after 10 hours of BIPAP. She was obese with high blood-pressure, had exotropia and diminished pain sensitivity. History revealed hyperphagia, excess weight gain, constipation from preceding 6 months. Growth charts showed rapidly increasing weight after 1½ year of age with normal height centiles.

Investigations revealed normal plasma cortisol, appropriately suppressed with dexamethasone; hyperprolactinemia, central hypothyroidism, low IGF-1, suboptimal GH response to clonidine; normal leptin, urinary catecholamines and OGTT. MRI brain showed bilateral centrum semiovale, fronto-parietal white-matter hyperintensities. Thoraco-abdominal CT showed pre-sacral mass which was FDG avid. Polysomnography was abandoned due to desaturations. 2D-Echo showed PAH keeping with hypercarbic respiratory failure.

She had several episodes of hypoventilation during hospital stay. Based on above features, a diagnosis of ROHHADNET was made. She is discharged on home BIPAP and thyroxine.

Discussion: ROHHADNET is a rare syndrome with about 100 cases reported till date. The acronym ROHHAD describes the typical sequence of symptoms experienced, in the order of their appearance. Presently no genetic testing is available, mandating a clinical diagnosis. About 40% develop neuro-endocrinal tumors and 50%-60% suffer cardiac arrest. Hence early recognition is important.


Subclavian Artery Pseudoaneurysm After Internal Jugular Vein Cannulation

Presenting as Diffi cult Ventilation and Repeated Extubation Failure

Shalini APICU Fellow, Narayana Health, Bangalore


Introduction: Central lines have become a common procedure, but they are not without complications. We report a case of subclavian artery pseudoaneurysm that followed right IJV cannulation which compressed trachea leading to problems with ventilation and multiple extubation failures.

Case report: Eight months child underwent surgical correction for interrupted aortic arch, aorto-pulmonary window and was extubated next day. Two weeks later she developed respiratory distress requiring intubatation. CXR showed right upper zone haziness interpreted as collapse due to aspiration.

Few days later extubated was attempted, but she developed gasping immediately requiring re-intubation. She had three more episodes of similar extubation failures.

Serial CXRs showed persistent haziness in right upper zone which in due course developed a rounded contour. Meanwhile ventilation posed a challenge as she had intermittent episodes of hypercarbia, increase in Ppeak and airway resistance. Despite suctioning, changing the endotracheal tube, nebulisations, there was no improvement. Later she was observed to have chest rise only with neck abnormally fl exed in a particular position. Mass lesion was suspected causing dynamic airway compression. CECT Chest revealed right subclavian artery pseudoaneurysm with tracheal compression.

She underwent open surgical repair and was fi nally extubated. Case records revealed IJV insertion for surgery.

Discussion: During IJV access, carotid artery is most susceptible to injury. Subclavian artery injury is rarely reported.

Extrathoracic subclavian aneurysms present with pulsatile swelling over supraclavicular fossa. Intrathoracic aneurysms can compress brachial plexus, upper limb vessels, recurrent laryngeal nerve, erode lung apex. Rarely dysphagia, horner’s syndrome and tracheal compression have been reported.

Peculiarities of our case:1. Occurrence of subclavian artery psudoaneurysm after

internal jugular vein cannulation is rare. More commonlycarotid artery pseudoaneurysm is seen.

2. Delayed presentation of pseudoaneurysm, after 2 weeks isuncommon.

3. Repeated extubation failures and especially diffi culties facedin ventilating the child due to tracheal compression by thepseudoaneurysm posed a therapeutic challenge.

Study of Functional Outcome of Patients at Discharge from Paediatric Intensive

Care UnitSujata*, Navjot, Puneet, Shekhar, Kartik

PICU at DMCH, Ludhiana*Email: [email protected]

Aims and Objectives: To study the functional outcome of patients discharged from PICU and correlation of pre admission co morbid status to the outcome of stay in PICU.

Method: The study was conducted in PICU at DMCH, Ludhiana over a period of one year. Patients admitted to ICU in the age group of 1-18 years were included. Patients less than one year of age were excluded. Total of 317 patients were enrolled, 105 patients died/ left against medical advice, so functional outcome of 212 patients was studied Data was obtained prospectively and outcome was assessed according to functional status scale. Functional performance was assessed as pre admission score and discharge score in regard to neurodevelopment disabilities in patients with/without chronic disease.

FSS domains- Mental status, sensory functioning, communication, motor functioning, feeding and respiratory status. Score range 6-30.

Outcome: More than 80% of patients achieved pre admission score in domains of mental status, sensory function, feeding and respiratory status. In communication domain, more than 50% achieved pre admission status. Motor domain was signifi cantly affected in patients who received ventilation and ionotropic support. Best outcome was in respiratory status and worst outcome was in communication status. Children who had higher admission score had poorer functional outcome (18.46% patients achieved pre admission score) as compared to low admission score (46.5% patients).

Conclusion: FSS is a useful tool to study the functional outcome at discharge in patients admitted to ICU.

Blood Component Therapy In Children Admitted To Pediatric ICU

Sujata*, Pooja, Puneet, H S Bains, Shekhar, KartikPICU at DMCH, Ludhiana

*Email: [email protected]

Aims and Objectives: To determine use of blood component therapy in critically ill children admitted in pediatric intensive care unit and to compare outcome in patients who received blood components to the patients who did not receive blood components.

Method: The study was conducted in 10 bedded PICU at DMCH, Ludhiana over a period of one year. All the patients admitted to PICU were enrolled and patients who required blood components were included as cases and patients who did not receive any blood component therapy were taken as controls. Patients who died or left against medical advice within 24 hours


of admission were excluded. Final outcome in cases and controls was compared and assessed.

Outcome: Total of 294 patients were included. Cases were 118 (40.13%) and controls were 176 (59.8%). Amongst total cases, 82 patients needed packed cells, 38 needed RDPs and 53 patients needed FFPs. Cases had prolonged duration of hospital stay with increased morbidity and mortality.

Conclusion: cases had prolonged duration of hospital stay with increased morbidity and mortality as compared to controls.

A Study to Predict Respiratory Distress Syndrome using Single Step Gastric

Aspirate Shake TestShikha Verma*, R S Jaswal

Department of Pediatrics, Dr. R. P. Govt. Medical College, Kangra (Tanda), H.P.


Introduction: Respiratory distress syndrome (RDS) is the major cause of morbidity and mortality in preterm neonates.In India, RDS occurs in 200 000 infants/year with mortality from RDS at 40%-60%. Lack of pulmonary surfactant leads to progressive atelectasis, loss of functional residual capacity, ventilation-perfusion mismatch, severe hypoxemia and lung injury.Surfactant defi ciency can be predicted with simple, cheap shake test method. The aim of this study was to fi nd surfactant defi ciency by using single step gastric aspirate shake test.

Method: This is an observational study conducted on 79 preterm neonates (28-34 weeks). Gastric aspirate was aspirated within one hour of birth before fi rstfeed. Shake test was performed by taking 0.5ml of normal saline and 1.0ml of 95% ethyl alcohol test tube, 0.5ml of gastric aspirate was added and vigorously shaken for 15 seconds and allowed to stand for 15 minutes. The surface was inspected for quantum of froth or bubbles and said to be negative when bubbles cover 1/3rd or less of liquid surface, intermediate testif 1/3rd to 2/3rd and positive if 2/3rd or more suggesting full pulmonary maturity.

Results: Out of 79 preterm neonates (44 males and 35 female), 36 were born at POG 30-34 weeks, 30 at 30-32 weeks and 13 at 28-30 weeks. 9 had negative test while 12 and 58 had intermediate and positive results respectively. All neonates with negative shake test developed RDS while 11 out of 12 neonates with intermediate test developed RDS and 1 neonate with positive shake test also developed RDS. This shake test has sensitivity of 95.2%, specifi city of 98.26%, PPV and NPV of 95.24%, 98.28% respectively.

Conclusion: A large proportion of infants with negative single step gastric aspirate shake test develop RDS. The test is worth performing as an aid tomanagement and diagnosis of RDS.

Familial Hyrecholestrolemia in Two Siblings - A case report with review of

literatureSeema Sharma, ShikhaVerma

Department of Pediatrics, Dr. R. P. Govt. Medical College, Tanda, Kangra H.P. India

Introduction: Familial hypercholesterolemia (FH) is a form of primary hyperlipoproteinemia, is an autosomal dominant disorder, characterized by an increase in serum LDL cholesterol concentrations, presence of xanthomas and premature atherosclerosis.In that the individuals with two mutant LDL receptor alleles (FH Homozygotes) are much more affected than those with one mutant allele (FH Heterozygotes). FH in Homozygous state is rare and occurs in approximately1 in 1 million persons. These patients are at a high risk of developing coronary heart disease and sudden death, unless the condition is recognized and treated promptly.

Case Report: Two siblings10 years old female and 8 years old male, born out of non consanguineous marriage with history of xanthomatous lesions for 3 and 2years, respectively. Physical examination showed subcutaneous yellow nodules over the knuckles, elbows, of size up to 2 cm, suggestive of xanthomatendinous and tuberous xanthomas along with corneal arcus.Lipid profi le was suggestive of FH.

Discussion: FH or Frederickson’s type IIa hyperlipoproteinemia is an AD disorder caused by>900 mutations in the LDL receptor gene on chromosome 19, leading to lack of functional receptors for LDL on the cell surface which results into decreased uptake of LDL into cells from liver, blood, resulting into increased serum LDL Cholesterol. There is lack of inhibition of intracellular cholesterol synthesis.Patients present with multiple types of xanthomata, tuberous, sub periosteal, tendon, elevated plaques and the rare but characteristic inter-triginous in fi rst decade of life.

Conclusion: The diagnosis of FH is important for the patient as well as family members for genetic counselling and screening of fi rst degree relatives and extended family members.

Disease Spectrum and Outcomes in Paediatric Patients requiring Mechanical Ventilation at Kenyatta National Hospital

Saini N*, Kumar R, Wamalwa D, Mungai L, Reel BDepartment of Paediatrics and Child Health, University of

Nairobi, Kenya*Email: [email protected]

Background: The burden of critical illness in developing countries is inadequately defi ned and intensive care resources are limited. We sought to describe the nature of illnesses for


which children require mechanical ventilation and risk factors associated with poor outcome.

Methods: A short longitudinal survey was conducted in paediatric medical wards and ICU at Kenyatta National Hospital. Children below 16 years of age requiring mechanical ventilation as per hospital ICU admission protocol and following ICU consultation and review were recruited into the study and followed up to discharge or death to determine exposure and outcome variables. Continuous variables were analysed as proportions and mean with medians (inter-quartile range) used for normal data.

Results: Between September 2014 and January 2015, 81 children required mechanical ventilation, of whom, 36(44.4%) gained admission to ICU. Median age of patients admitted to ICU was 33 months (range 11 to 73 months). Neurological illnesses accounted for majority of the cases (36%), followed by respiratory diseases (18%) and severe sepsis (15%). Mortality was 100% amongst patients who required but did not receive mechanical ventilation. Survival amongst ICU admissions was 58%. Hospitalization at referring facility of >48 hours prior to referral were predictive of mortality (OR=4.86; 95%CI 0.97-1.19, p=0.046).

Conclusions: Neurological illnesses are the commonest indication for mechanical ventilation amongst critically ill children at KNH. Delayed referral of more than 48 hours is associated with poor outcome. Mechanical ventilation is a life saving intervention and should be made accessible to all children who need it.

Study Type: Original Research

Pediatric Tracheostomy - A case series in A tertiary care PICU

Anupama Yerra*, Farhan Shaik, Dinesh Kumar Chirla, Sachin Unny

*Clinical Associate, Rainbow Children’s Hospital, Hyderabad*M: 08008740697; Email: [email protected]

Background: This observational study over 55 months was conducted to understand the clinical profi le of patients undergoing tracheostomy in Rainbow children’s Hospital; PICU, Banjara Hills; Hyderabad.

Methods: A retrospective plus prospective analysis of case records was done between Jan 2011 to July 2015. Data regarding age, gender, indication for tracheostomy, duration of mechanical ventilation before and after tracheostomy and complications were collected from children who underwent tracheostomy during the study period.

Results: During the study period there were 4700 admissions and 700 children received invasive mechanical ventilation. Tracheostomy was performed for 39 children.

Common age group was in infancy (14; 25 %). Males outnumbered females (24 vs 15; 61%vs 39%). Most common indication was for airway protection due to neurological disorders (17;43%). About 33 (84%) children were ventilated for less than 2 weeks prior to tracheostomy. The mean duration of ventilation after tracheostomy was 7 days.

Thirty-fi ve tracheostomizedchildren were followed up till this date by telephonic conversation and out patient records. Tracheostomy related mortality was 7 %(3) and non-tracheostomy related mortality was 35 %(14) in the study population. Non-fatal complications (e.g. wound infection, bleeding etc) due to tracheostomy were seen in 8 % (3) children. Decannulation was performed in 25 %(10) of the children.

Discussion: Pediatric tracheostomy is a relatively safe procedure and the most common indication was for airway protection due to underlying neurological disorders. Complications due to tracheostomy are similar to the evidence available in literature. Performing tracheostomy for prolonged mechanical ventilation has signifi cantly shortened the duration of artifi cial ventilation.

To Study Clinical Profi le and Outcome of Pediatric Traumatic Brain Injury (TBI)

N Hema Kumar*, Farhan Shaik, Dinesh Chirla*Senior PICU Fellow, Department of Pediatric Intensive Care

Rainbow Children’s Hospital, Banjara Hills, Hyderabad*Email: [email protected]

Place of Study: Rainbow Children’s Hospital, Hyderabad

Type of Study: Prospective observational study

Study Period: From Jan 2012 to Dec 2014

Methods: During study period, all children with TBI were included. This study reviewed nature of brain injury, clinical parameters, hospital outcome and discharge outcome of all pediatric TBI patients. All TBI children were treated as per Brain trauma foundation guidelines (BTF). Whenever the family agreed, ICP monitoring was started in patients with severe TBI.

Results: Total 130 children were enrolled. Majority of the children with TBI (n=90) were in the age group 1 to 5yrs and 87(66.9%) had fall from height (commonest cause). Mean GCS at admission was 14.3, 11.64 and 6.31 in children with mild, moderate and severe TBI respectively, 24 children (18.46%) had abnormal pupils at admission. ICP monitoring was done in 13 children (29.5%). 2 children in ICP group and 5 children in non-ICP monitored group died (P=1.00),one child in ICP group and 5 children in non-ICP group were left with disability (P=0.65). Mean ventilator days and mean hospital days were prolonged in ICP monitored group compared to clinical-imaging group (5 Vs 2.29 days, P =0.006 and 10.69 Vs 6.97 days, P=0.052). Duration of hyperosmolar therapy was less in ICP monitored group (1.654 Vs 2.73 days, P=0.0007) and no signifi cant mortality differences were found in two groups. Among children who died in severe TBI group (n=7), all 7 (100%, P=0.0031) children had abnormal pupillary size at admission and 6 (85.7%, P=0.0031) children had coagulopathy at admission.

Conclusions: ICP monitoring in severe TBI has at least partial benefi ts in therapeutic interventions. Abnormal pupillary size and coagulopathy at admission are associated with poor outcome.


Does After-Hour Admission To Pediatric ICU Affect Patient Mortality And Outcome? - The vellore experience

Suddhasatta Ghosh*, Ebor Jacob, Pragadeesh P, Jolly Chandran, Kala Ebenezer, Manivachagan MN*Post-Doctoral Fellow, Pediatric Intensive Care Unit, Christian

Medical College, Vellore, Tamil Nadu.yhf*Email: [email protected]

Background/Rationale: Patients admitted during “after-hours” in a Paediatric-ICU may be at higher risk of mortality. Our study aims to determine whether mortality and outcome measures differ according to time of admission.

Methods: A retrospective study was conducted at Christian Medical College,Vellore based on reviewing the data from the charts of patients admitted consecutively from January 2012-2015.Study population was categorized into working-hour (week days- 8.00am-4.59pm) and after-hour (week days-5.00pm-7.59am, all Saturdays, Sundays and holidays) admissions. Mortality, demographic profi le and severity score(PELOD) were compared in the them. Statistical analysis was done using SPSS version 16.0 with a signifi cance level of p<0.05.

Results: Out of 3000 patients admitted over the 36-month period, male:female ratio was 62:38, with 58% admitted during after-hours and 42% during working-hours.Amongst the after-hour admissions, 80% were emergency, 5% elective and 15% post-operative admissions, with 39% requiring ventilation. Respiratory (25%) and CNS (16%) were the major primary illness,while haematological malignancy (12%), poisoning (4%) and metabolic (2%) disorders were also present. Mean length of ICU stay for ventilated and non-ventilated patients were 4.6±1.2days and 3.4±0.9days respectively. Outcome was measured in terms of death (16%), DAMA in terminally-ill children (7%) and discharge (77%). Comparison between working-hour and after-hour admission groups showed the mean age,length of ICU stay,severity score and outcome measures were similar in the two groups(p=0.5). There was no signifi cant difference in mortality(p=0.4)between the two groups.

Discussion: Our fi ndings are consistent with recent studies by Mccrory and colleagues(2014, Nov) that showed no independent effect of after-hour admissions on mortality rates in the pediatric-ICU.

Conclusion: Admissions during after-hours are common in a

pediatric-ICU and are not associated with higher mortality or poorer clinical outcomes.

Ventilator Associated Pneumonia in Pediatric Intensive Care Unit: Incidence,

Risk Factors and Etiological AgentsVijay Gnanaguru1, Anirban Mandal1, Jhuma Sankar1,

Arti Kapil2, Rakesh Lodha1, S K Kabra1

1Department of Pediatrics, 2Department of Microbiology, All India Institute of Medical Sciences, New Delhi-110029, India

1Email: [email protected]

Objectives: There is paucity of evidence on the incidence, etiology and risk factors associated with ventilator associated pneumonia (VAP) in children.

Methods: We prospectively enrolled children aged ≤17 years from June 2012 to March 2014 who received mechanical ventilation for more than 24 hours. We estimated the incidence of VAP using the Centers for Disease Control (CDC) criteria, evaluated the etiology and risk factors for VAP. We also evaluated the cut-offs on clinical pulmonary infection score (CPIS) for diagnosis of VAP. The study was approved by the IEC. Data was analyzed using STATA 11.

Results: We enrolled 86 children with a median age of 30 months. The incidence of VAP according to CDC criteria was 38.4%. Acinetobacter was the most frequently isolated organism (47%) followed by Pseudomonas (28%) and Klebsiella (15%). Risk factors for VAP on bivariate analysis were use of proton pump inhibitor (PPI), enteral feeding and re-intubation. On multivariate analysis, use of PPI (8.47: 1.19 to 60.33; p=0.03) and enteral feeding (12.2: 2.58 to 57.78; p=0.0001) remained signifi cant. A CPIS of ≥4 had a sensitivity and specifi city of 88.9% and 84.4% respectively for diagnosis of VAP by CDC criteria.

Conclusion: The incidence of VAP was high in our study and the commonest organisms were gram negative bacteria such as Acineobacter and Pseudomonas. A CPIS of ≥ 4 is strongly suggestive of VAP. Use of PPI and enteral feeding are important modifi able risk factors for the development of VAP.

Key words: Ventilator associated pneumonia; VAP; Proton pump inhibitor, Enteral feeding; Clinical pulmonary infection score; CPIS


Vancomycin Dosing and Therapeutic Drug Monitoring in Pediatric Patients

with Serious InfectionsDimpi Mhatre*, Rekha Solomon**, Sonu Udani***

PD Hinduja Hospital and Research Centre, MumbaiEmail: *[email protected]*, **[email protected],

***[email protected]

Introduction: The recommended dosing to achieve therapeutic trough concentrations of vancomycinis15-20 mg/kg.

Aim: To investigate if current recommended dosing of Vancomycin achieves target trough concentrations (TTC) in pediatric patients with suspected/ known MRSA infections.

Methods: Fifty-one trough levels in 45 children aged 1 month to 18 years, receiving Vancomycin therapy in doses of 40 to 50 mg/kg/day (group A) or 55 to 65 mg/kg/day (group B)for suspected (febrile neutropenic or CRBSI) or proven serious infections were studied retrospectively.Chi-square/ Mann-Whitney Utest used for differences in characteristics between patients that achieved TTC (≥15 μg/ml)and those that did not (<15 μg/ml).

Results: Most patients (91.2%) received empiric therapy, only 4(8.8%) had positive MRSA cultures. With 12/51(23.5%) achieving TTC, dose levels did not correlate with trough levels (Spearman’s r=-0.11, p=0.43). There were 21(46.6%) and 24(53.3%) patients in group A and group B, respectively. While 8(33%) in group B achieved TTC, only 2(9.4%) in group Ahad achieved TTC. Patients that achieved TTC were more likely to be younger (p=0.07, effect size=0.32) and belong to group B (p=0.07, effect size=0.28) than those that did not achieve TTC. Achievement of TTC did not affect clinical outcomes. None of our patients showed nephrotoxicity as a result of vancomycin therapy.

Conclusion: Current recommended vancomycin dosing regimensdo not achieve recommended target trough levels. Increase in dosing to 60 mg/kg/day failed to achieve TTC ≥15 μg/ml in most patients. Alternative treatment practices such as use of loading dose or continuous infusion can be investigated further.

Early use of Albumin in Severe Dengue reduces Mortality - Myth or Reality?

1Dipali Jambhale, 2Gnanam, 3Shivakumar 1Fellow, 2,3Consultant, PICU Manipal Hospital Bangalore

[email protected]

Background: Children with Severe Dengue present with signifi cant plasma leak, resulting in shock and multiorgan failure. Early replacement of the lost plasma volume, with appropriate fl uids is the key to uneventful recovery. This is the fi rst study from India demonstrating the effectiveness of early use of albumin in severe Dengue.

Methods: This retrospective study conducted at the PICU of Manipal Hospital included children between 1 month and 18

years of age with severe Dengue (as per WHO criteria).

The pre intervention phase (Phase-1) was between July 2010 and December 2012 and the post intervention phase (Phase 2), between January 2013 and July 2015. Albumin was administered within 8 hours of admission in• Children needing >20ml/kg of crystalloid bolus for

hypotensive shock• Children needing >5 ml/kg/hour of crystalloid for > 6 hours• Children presenting with severe symptoms of third spacing

Albumin (1g/kg of 5% 0r 20%) was used as a continuous infusion over 4-8 hours.

The three dimensional approach –clinical examination, 4-6hourly Hct and blood gas was used for monitoring .

Results: A total of 507 patients were included in this study. The mortality was 6.4% ( 16 out of 250) in Phase1 as against 1.1% (3 out of 257) in Phase2.(p value of 0.002,Chi square test)

Conclusion: Although large prospective multicentric trials are further needed, it may be concluded that early use of albumin in severe Dengue is associated with reduction in mortality.

Role of Therapeutic Plasmapheresis in Hump Nosed Pit Viper Envenomation

Presenting with Hemostatic Dysfunction: A Case Report

Abdul Majeed, Roopa Vijayan, Renjith Baby, Vinod Kumar K, Anu Paul, Vivek Radahakrishan,

Rajappan Pillai P*Paediatric Intensive care unit, ASTER Medcity, Kochi, Kerala.


Hump-nosed viper bites are common in the Indian subcontinent and Sri Lanka. In the past, hump-nosed vipers (HNV) were considered moderately venomous snakes whose bites result mainly in local envenomation. However, severe local effects, haemostatic dysfunction, microangiopathic hemolysis, kidney injury and death have been reported following envenomation by HNV. No specifi c or polyvalent antivenin (ASV) is available yet for human use. A 13 year old girl sustained snake bite in her right leg and was treated with multiple doses of ASV before she developed anuric renal failure, coagulopathy and thrombotic thrombocytopenic purpura (TTP). Blood investigations showed poor increment to platelet transfusion with drop in hemoglobin with out any clinical evidence of blood loss. Further investigations revealed a LDH of 2540 U/L, high reticulocyte count, schiztocytes and giant platelets on peripheral smear. HNV envenomation was presumed in view of the clinical history, presence of HNV in the geography and poor response to ASV. She was started on haemodialysis and supported with blood products for coagulopathy. Plasmapheresis was initiated for TTP and toxin removal. Her sensorium improved signifi cantly after initiating plasmapheresis.

Her LDH dropped to 450 U/L and renal function improved over next one week.


Plasmapheresis is an effective intervention for HNV envenomation presenting with haemostatic dysfunction. In the absence of a specifi c antivenin, plasmapheresis may be the only option available to remove ophidian protiens and toxins. Plasmapheresis should be considered early in hump nosed pit viper envenomation to attain rapid recovery.

Heaptitis a Virus (Hav) and Hepatitis E Virus (Hev) Coinfection in Pediatric Age

Group: A case seriesHanda S.1, Wasim S.*, Pandita N.*,

Kalra B.P.*, Chandar V.*12nd year Pediatric Resident, *Department of Pediatrics,

Himalayan Institute of Medical Sciences (SRHU) Jolly Grant, Dehradun, Uttarakhand-248140

1M: 9760299332; Email: [email protected]

Background: Hepatitis A and Hepatitis E virus, both are entericalytransmitted, resulting into acute viral hepatitis in developing countries. They pose a major health problem in our country. We hereby present 6 cases of Hepatitis A and Hepatitis Eco-infection.

Methods: The study was conducted in department of pediatrics Himalayan hospital, Jolly Grant. It is a retrospective study. Case fi les of all hepatitis A and E were reviewed and data was analysed.

Results: In our case series of 6 patients, age group varies from 3-17years with4 males and 2 females patient. The most common presenting symptom was fever seen in all 6 patients followed by vomiting seen in a 5 out of 6 patients. Although icterus was present in all 6 patients but was a presenting symptom in only 3 patients. On examination, 5 out of 6 patients presented with hepatomegaly and with associated splenomegaly in 2 patients. Peak bilirubin, ALT and AST levels were 9.95 mg/dl, 5592 IU/ml and 4221 IU/ml respectively, ranging from bilirubin 4-9.95 mg/dl, ALT 601-5592 IU/ml and AST 356- 4221 IU/ml. 2 out of 6 patients had deranged coagulation profi le for which FFP transfusion was given. And 1 patient presented with features of hepatic encephalopathy. The duration of stay varies from 6days to 11days. No mortality was seen in are case series.

Conclusion: Although HAV and HEV co infection is associated with increased severity and mortality, this was not seen in our case series. Co-infection of HAV & HEV is more common in pediatric age group because of the absence of natural immunity in this age group. Also due topoor sanitation and contamination of water, they are exposed to both HAV and HEV, and develop

simultaneous infection by both the viruses. Lack of knowledge of community regarding the preventive measures also acts as a predisposing factor.

Profi le and practices related to Mechanical Ventilation in Rural Pediatric

Intensive Care Unit (PICU) of GujaratNikhil Shah1, Vandan Kumar, Hemal Dave,

Rahul Tandon, Krutika Tandon2

12nd year Resident, 2Professor & PICU incharge, Department of Pediatrics, Pramukh Swami Medical College,

Karamsad-388325(GUJ)2M: 9879531972; Email: [email protected]

Background: Well-equipped separate PICU and mechanical ventilator support practices are rarity in smaller cities and rural hospitals of India. Our aim is to share our experience of PICU of a rural tertiary care hospital.

Methodology: Retrospective descriptive study of 1084 PICU patients between year 2010-2013. Data were retrieved from medical record and analyzed completely in 216 patients for demographic profi le, Mechanical ventilator(MV) related practices & outcomes.

Results: 30% patients (338) required mechanical ventilation in year 2010-2013. M:F ratio was 1.8:1 with age < 1 year 37.04%, 1-11 years 51.39% and >11 years 11.58%. Majority (76.85%) of patients were referred cases & ~66% required immediate endotracheal intubation on arrival to our emergency department. Improved survival (Mortality 6.25% vs 14.88%) was seen in 22.2% patients transported in ambulance with staff & facility. Indications for MV were Respiratory-32.4%, Neurological-29.16%, Circulatory failure-14.81%, others-23.6%. PSIMV and Pressure A/C (80%) were most preferred initial modes whereas CPAP/PSV(75.7%) was preferred weaning mode. 14% required prolonged(>7days) MV. 34.67% had MV complications including VAP-1.85%, Atelectasis-2.78%, Postextubation stridor-15.74%. Vasopressors used in 73% & Central line insertion done in 12.96%. Dialysis was done for 2.3%. Culture proven BSI,VAP& CAUTI were 7%, 2% & 0.9% respectively. Mean ventilator days were 3.98 (4.3 in discharged patients). Successful weaning & extubation was achieved in 107/216 (49.53%). Death rate was 12.96%. We compared our results with other similar type of studies across the world.

Conclusion: Well-equipped separate PICU driven by trained dedicated pediatrician led team can give comparable results at rural setting.


Financial and Emotional Burden and Coping Strategies among Parents of

Children Admitted to PICUUtkarsh Pandya1, Kushal Shah, Maithily Patel, Jagdish Vankar, Krutika Tandon2, Ajay Phatak,

Somashekhar Nimbalkar12nd year Resident), 2Professor & PICU Incharge,

Department of Pediatrics, P S Medical College Karamsad-388325, Dist.Anand(Guj)

2M: 9879531972, Email:[email protected]

Background: In India, direct out of pocket expenditure on healthcare is about 70%. Taking care of ill child is also equally draining fi nancially and emotionally.

Methods: Cross-sectional observational study at PICU of rural tertiary care hospital. 75 parents were interviewed 1-2 days prior to discharge including measurement of emotional burden by Patient Health Questionnaire(PHQ-9). Descriptive statistics was used to analyzed data.

Results & Discussion: The mean age of the fathers(55) and mothers(20) were 30.8(SD 5.36) & 30.14(SD 4.28). Most mothers were housewives and fathers had Jobs. Majority were from rural background with joint family predominance(64%). The median monthly income of family was Rs.4500/-. None had health insurance in any form and12% of families had BPL status. Common reasons of PICU admission were respiratory(26.7%), neurological(22.7%), trauma(10.7%) and others(26.7%). Median PICU stay and hospital stay were 5 & 7 days.The median medical and non-medical costs were Rs. 28,500/- and 900/- respectively. The median(IQR) lost productivity for father was 6 days. One episode of illness costs almost 7 months income with Median income to cost ratio of 0.15.

Financial coping strategies were borrowing money from friends/relatives(45.3%) and from moneylenders(8%) and from saving(6.7%). Use of PHQ-9 revealed 14.9% parents had mild depression. Parents preferred friends/neighbours over other relatives for personal and emotional support. Review of literature suggested that environment and demographic characteristics of population are likely to affect the level of stress in parents of critically ill or injured child.

Conclusion: Friends/relatives/neighbours were major fi nancial and emotional support. None had healthcare insurance.

Non-Invasive Ventilation in Children - Effi cacy and complications

Ganesh Kharche1, Lakshmi Shobhavat, Shivhar Sonawane, Uma Ali

1Fellow PICU, Pediatric Intensive Care Unit, B J Wadia Hospital For Children, Mumbai


A prospective observational study was conducted in our 12-bed paediatric intensive care unit, to assess the effi cacy and complications

of NIV in acute respiratory failure and post extubation care.Twenty one children (10M-11F) with mean age of 31months (2month-10yr) received NIV, 16 as the initial mode of assisted ventilation and 5 for post extubation care. Fourteen out of 16 had type1 respiratory failure. Cardiogenic pulmonary edema in 7, mild ARDS in 2, and pneumonias in 5. Two had type 2 respiratory failure. BIPAP mode was used in all cases with an oro-nasal interface.Mean FiO2 was 0.45±0.099 with mean PEEP 6.7±0.9 cms H2O.Mean duration of daily NIV was 21hours with time off for oral and eye care and some time off due to discomfort of NIV.

Pre NIV parameters showed a mean pH-7.36±0.05, PCO2-33.5±11.1 mmHg, pO2-98.2 mmHg, HR-156±29 per min, RR-50.7±12.4 per min. Parameters after 12 -24 hours on NIV showed a pH-7.41±0.02, PCO2- 30.6± 7.5mmHg, pO2-134.5±20 mmHg, HR-115.6±14.5 per min, RR-31.7±6.5 per min respectively. There was 76% improvement in heart rate and 62% in respiratory rate. NIV was effective in preventing intubation in 17 (81%). Four patients required invasive mechanical ventilation, 2 due to worsening lung condition and 2 due to hemodynamic instability. Mean duration of ICU stay was 56.6±47 hours. Problems encountered were mask related injury in 10 (47%), asynchrony in 7 (33 %) and leak of air from interface in 6 (28%). Mild sedation was used to improve synchrony in selected cases.

NIV was effective in preventing invasive ventilation in 81% of patients when used judiciously. However close monitoring and nursing attention is needed to prevent complications and to improve comfort and acceptability of NIV.

Health Care Associated Infection Surveillance: Nurse led audit

Saiyed M, RN, Paul PM RN, Mhatre D, Solomon RPD Hinduja Hospital, Mumbai


Health Care Asssociated Infection (HAI) is an important cause of morbidity and mortality in sick patients admitted into PICUs.

Aims: Toaudit the rate of healthcare associated infection in/from our PICU.

Methods: All children 0-18 years with Ventilator Associated Pneumonia (VAP), Central Line Related Blood Stream Infection (CRBSI) and Catheter Associated Urinary Tract Infection (CAUTI) between January 2014 to June 2015were included. Diagnosis of HAI was based on Centre for Disease Control/ National Health and Safety Network(NHSN) defi nitions. Nursing staff recorded prospectively and daily the number of patients on invasive devicesas well as details of microbiology samples sent for suspected HAI.

Results: There were 537 admissions during the study period. VAP occurrence rate was 10 per 1000 ventilated days. The most common organisms were Multi Drug Resistant Acinetobacter and klebsiella. CRBSI rate was13.9 per 1000 Central line days. CAUTI rate was 24per 1000 urinary catheter days.

Discussion: The CRBSI and CAUTIrates in our unit is fi ve-fold


higher than that seen in the International Nosocomial Infection Control Consortium(INICC)’s ICUs (13.9vs 4.9 for CRBSI and 24 vs 5.5). The VAP rate was lower(10 vs 16.8).

Conclusion: Regular surveillance and engagement of the entire health care team is an important part of infection control along with a regular education programme.

Type of study: Retrospective audit

Vancomycin Dosing and Therapeutic Drug Monitoring in Pediatric Patients

with Serious InfectionsDimpi Mhatre, Rekha Solomon*, Soonu Udani

PD Hinduja Hospital,Mumbai*Email: [email protected]

Introduction: The recommended dosing to achieve therapeutic trough concentrations of vancomycinis15-20 mg/kg.

Aim: To investigate if current recommended dosing of Vancomycinachieves target trough concentrations (TTC) in pediatric patients with suspected/ known MRSA infections.

Methods: Fifty-one trough levels in 45 children aged 1 month to 18 years, receivingVancomycin therapy in doses of 40 to 50 mg/kg/day (group A) or 55 to 65 mg/kg/day (group B)for suspected (febrile neutropenic or CRBSI) or proven serious infections were studied retrospectively.Chi-square/ Mann-Whitney Utest used for differences in characteristics between patients that achieved TTC (≥15 μg/ml)and those that did not (<15 μg/ml).

Results: Most patients (91.2%) received empiric therapy,only 4(8.8%) had positive MRSA cultures. With 12/51(23.5%) achieving TTC, dose levels did not correlate with trough levels (Spearman’s r=-0.11, p=0.43). There were 21(46.6%) and 24(53.3%) patients in group A and group B, respectively. While 8(33%) in group B achieved TTC, only 2(9.4%) in group Ahad achieved TTC. Patients that achieved TTC were more likely to be younger (p=0.07, effect size=0.32) and belong to group B (p=0.07, effect size=0.28) than those that did not achieve TTC. Achievement of TTC did not affect clinical outcomes. None of our patients showed nephrotoxicity as a result of vancomycin therapy.

Conclusion: Current recommended vancomycindosing regimensdo not achieve recommended target trough levels. Increase in dosing to 60 mg/kg/day failed to achieve TTC ≥15 μg/ml in most patients. Alternative treatment practices such as use of loading dose or continuous infusion can be investigated further.

Type of study: Retrospective observational

Alarming rates of cerebral edema at presentation in children with diabetic ketoacidosis (DKA)- A case to ponderRashmi Kapoor*, Anurag Bajpai, , Rishi Shukla,

Divya Agarwal, Abhishek Singh*Director Division of Pediatric Intensive Care andPulmonology, Department of Pediatric Critical care,

Regency Hospital, KanpurM: +919839027448

Background: Cerebral edema is the leading cause of morbidity and mortality in DKA. While clinical cerebral edema occurs in 1-2% children with DKA in west, limited Indian studies suggest much higher fi gures. Identifi cation of risk factors for the same would help in timely identifi cation and treatment of the condition.

Objective: To evaluate the prevalence and risk factors for cerebral edema in children with DKA.

Design: Ongoing prospective observational study (January 2014- August 31 2015).

Results: Fifty-one children (30 boys, 9 months-18 years) presented with DKA (32 fi rst episode, 19 recurrent) over the study period. Fifteen children developed cerebral edema (10 on admission) with ten requiring mechanical ventilation. Cerebral edema was present at presentation in 10, developed within 12 hours in 5 and after 12 hours in 1. All children had normal outcome with the exception of a six-year-old girl with very severe metabolic acidosis and cerebral edema at onset died at 12 hours of treatment. Risk factors of cerebral edema included fl uid/insulin treatment prior to admission (46.6% versus 8.5%), fresh diagnosis of diabetes (86.5% versus 63.3%) and severity of metabolic acidosis (base excess -23.9 ± 3.8 versus -18.8 ± 6.7, p 0.02).

Conclusion: Cerebral edema is alarmingly common in Indian children with DKA with over half having it at the time of diagnosis. Careful monitoring and management is essential for children with fresh diagnosis of diabetes, severe metabolic acidosis and those who have received treatment before admission.

Key Words: DKA, children, cerebral edema.

Serum Lactate as Marker of Severe Dengue

Sarika GuptaAssistant Professor, Department of Pediatrics, KGMU,

Lucknow, IndiaEmail: [email protected]

Background: Early diagnosis of severe dengue during febrile stage is essential for adjusting appropriate management. As severe dengue patients develop shock and experience hepatic injury also, it means that serum lactate may be elevated in such patients.The study was done to determine the association between serum lactate and severe dengue.

Methods: This was a hospital based reterospective study


conducted in the Department of Pediatrics at King George’s Medical University from July 2013 to July 2015. Included in the study were children aged 1 to 12 years with clinically suspected dengue. Laboratory confi rmed cases were confi rmed by IgM ELISA or by NS1antigen detection test. WHO classifi cation, 2009 was used for diagnosis of severe dengue. Serum lactate on the day of admission was compared among severe dengue and non-severe dengue.

Results: About 173 clinically suspected dengue patients were enrolled among which, 135 (78.0%) were laboratory-confi rmed. Among laboratory-confi rmed dengue, 89 (65.9%) developed severe dengue. The presentation of severe dengue were headache (OR=3.1; 95 % CI=1.3-7.4; p=0.005), seizures (OR=52.6; 95% CI=7.2-1072.3; p<0.001), basal crackles (OR=2.3; 95 % CI=1.0-5.4; p<0.05), prolonged capillary refi ll time (OR=4.6; 95% CI=1.5-14.7; p=0.003), tachycardia (p=0.030), decreased systolic (p=0.022), diastolic (p<0.001) and pulse pressure (p=0.001).The signifi cant laboratory fi ndings included elevated serum levels of aspartate transaminase (p=0.002), alanine transaminase (p=0.040) and lactate (p<0.001). On regression analysis, adjusting for age, gender, place of residence and duration of illness, serum lactate>3.2 mmol/L was found to be associated with severe dengue.

Conclusion: serum lactate may be used as a marker of severe dengue.

Prospective Observational Study on Pediatric Traumatic Brain Injury at

Tertiary Care CenterDarshak Makadia, Saket Zanzmera, Jignesh Patel,

Jigesh Vaidya, Nirmal ChorariaEmail: [email protected]

Background: Traumatic brain injury is the most common cause of death and acquired disability among children in developed countries. This study was planned to evaluate the correlation in clinical profi le, risk factors and outcome of Pediatric Traumatic Brain Injury at the Tertiary Care Centre.

Method: This study was conducted at Nirmal Hospital Pvt. Ltd. between 1st July, 2012 to 31st May, 2013. A total of 40 head injury children fulfi lling inclusion criteria during study period were included. After obtaining above data Patients were categorized in PTS and RTS.

Results: Boys constituted 67.5% of the study population;common age group was between 1-5 years (50%). All children had blunt head injury. 50%had history of fall from height & 35% had road traffi c accident. 82% cases presented within 1 hour of injury. GCS<9 at arrival to ER was seen in 20% cases. PTS<8 in40% &RTS<11 in 27% cases. Linear skull fracture was commonest fi nding (75%) in CT Brain. Seizure was noted in 30% of cases. 32% required mechanical ventilation &97% of the children survived.

Discussion & Conclusion: Patients with GCS<9, PTS<8, RTS<11 had signifi cantly higher morbidities, longer hospital stays, ventilation requirements and neurodefi cits at the time of discharge.

Type of study: Prospective longitudinal study

GCS- Glassgow Coma Scale, PTS- Pediatric Trauma Score, RTS- Revised Trauma Score

Is Positive Fluid Balance Increases Mortality in Children with Septic

Shock? Experience from a Tertiary Care Paediatric ICU

Tanuj*, Manivachagan, Pragathesh, Jolly, Kala, Ebor Jacob**Paediatric ICU, CMC, Vellore

Email: *[email protected], **[email protected]

Objective: We hypothesize that patients with septic shock who achieve positive fl uid balance on the fi rst 3 days are more likely to have increased mortality.

Design: Retrospective study by reviewing the charts

Setting: Eleven-bed tertiary level PICU of a tertiary care hospital.

Methods: Medical records of patients admitted over a 36-month period were reviewed. Patients with prior CKD, needed dialysis and severe dengue were not included. Admission PELODS (Paediatrics Logistic Organ Dysfunction Score) was measured. Children were stratifi ed into those who achieved positive balance at the end of 72 hours of admission and those who achieved negative balance at the end of the same time period. Survival risk ratios (RRs) were used as the measure of association between positive fl uid balance and mortality rate.

Results: Seventy patients fulfi lled the criteria for septic shock but we could review only 40 charts at present.Patients ranged in age from 7 days to 18 yrs with a median (6 SE)age of 6.3 + 2 years. Mean admission PELODS score was 25.4+ 1.4. Twenty nonsurvivors had higher mean PELODS scores (29.8 vs 16.4, respectively) and positive fl uid balance as compared to patients who survived. All 15 patients who achieved a negative balance after fi rst 3 days of treatment survived. Only 5 of 40 patients who had a positive fl uid balance by the third day of treatment survived (RR, 5.0; 95% CI, 2.3 to 10.9).Net positive fl uid balance after the fi rst 3 days of treatment is associated with increase mortality .

Conclusion:

Results suggest that positive fl uid balance achieved by the third day of treatment may be associated with increased mortality in patients with septic shock.


A Single Centre Open Labeled Randomized Controlled Trial Comparing Hemodynamic Response of Vasopressin

and Noradrenaline in Dopamine Resistant Fluid Refractory Warm Shock

in Children (Vadorest Trial)R Saxena*, Ebor Jacob**, Pragathesh, Jolly, Kala,

ManivachaganPICU, CMC, Vellore

Email: *[email protected], **[email protected]

Background: Sepsis is the most frequent cause of vasodilatory shock. Use of vasopressors in treatment of warm septic shock viz. vasopressin and norepinephrine(NE) is still open to debate.

Aims: To study the hemodynamic response (as defi ned by change in heart rate, mean arterial pressure, systolic blood pressure, sensorium, urine output, lactate, base excess) of Vasopressin and Noradrenaline at 3 and 6 hours after starting vasopressors in dopamine resistant, fl uid refractory warm shock.

Methods: This is a single centre, open labeled, randomized controlled trial with intention to treat principle.

Patients were treated according to the PALS/ACCM guidelines. When they reach the fl uid refractory dopamine resistant state they were randomized into vasopressin and norepinephrine group.

Results: Between January to June, 2015, 445 patients admitted to PICU. Among these, 17 children fulfi lled inclusion criteria; fi ve excluded. Twelve children were enrolled for the study.At the end of six hours, 7 out of 12 patients had met all the therapeutic goals. Among these, 5 were in the norepinephrine subgroup, while 2 children were in the vasopressin subgroup. In the norepinephrine group, the mortality rate was 42.8% where as in the vasopressin group, the corrected mortality was 40% .

Conclusions: As per this study, vasopressin may be as effective as norepinephrine in fl uid refractory, dopamine resistant warm shock.

Role of Steroids in Prevention of Post Extubation Stridor in Ventilated Children

Ritu*, Urmila Jhamb***Post graduate Trainee (fi nal year), **Director Professor,Incharge PICU, Department of Pediatrics, Maulana Azad

Medical College, New Delhi. *M: +91-8527841107; Email: [email protected]

Background: Post extubation stridor (PES) caused by laryngeal edema is a serious complication of extubationoccurringin 11-20% of patients.There is no consensus on role of corticosteroids in prevention of PES.

Methods: A randomized, double blind, placebo controlled study was conducted in the Pediatric Intensive Care Unit (PICU) of a tertiary care hospital to fi nd the effect of dexamethasone versus placebo on PES and reintubation. About 80 children (2 months-

12 years) ventilated for at least 48 hours were randomized to receive dexamethasone (n= 42) and placebo (n=38). Stridor scoring was done using Westley stridor score. Whenever stridor score exceeded 4, nebulized adrenaline was given. Reintubaton was done when patient had signifi cant respiratory distress / fatigue.Patient’s vitals were monitored hourly. Data was analyzed using SPSS software.

Results: There was no signifi cant difference in frequency of PES (42.8% in dexamethasone group and 55.2% in placebo group, p=0.26). The onset of stridor was earlier in placebo group but not signifi cantly different (p=0.46). The mean stridor score at all the time intervals was more in placebo group.

Discussion: The two groups had similar baseline characteristics. Anene et al (p<0.001), Malhotra et al (p=0.004) found a higher incidence of PES in placebo than dexamethasone group whereas Tellez et al (p=0.21), Saleem et al (p=0.5) didn’t fi nd any difference in PES incidence in two groups.The onset of PES was earlier in placebo group compared to dexamethasone group in study by Cesar and Baranwal et al.

Conclusion: We didn’t fi nd any difference in frequency of PES in patients receiving dexamethasone/ placebo. Onset of stridor was earlier and mean stridor score higher in placebo group but not statistically signifi cant.

Type of Study: Original research

Calcium, Phosphate and Vitamin D Abnormalities in Critically Ill Children

Shipra Agrwal*, Urmila Jhamb***Post Graduate 3rd Year, **Director Professor, Incharge PICU,

Maulana Azad Medical College, New Delhi 110002*Email: [email protected]

Background/Rationale: Abnormalities of calcium, phosphorus and vitamin D are common in critically ill children. This study was planned to determine the prevalence of these abnormalities in critically ill children and their association with the outcome.

Method: This was a cross sectional study performed in the PICU of a tertiary care hospital. Total 135 critically ill children older than 1 month were enrolled. Blood samples were collected within 24 hours of admission for serum calcium (total and ionized), phosphate and 25OH vitamin D and albumin. Data was analyzed by SPSS 16.0 software using appropriate statistical tests.

Results: Incidence of total and ionized hypocalcemia was 9.6% and 22.9% respectively. Hypophosphatemia was present in 28.8% and hyperphosphatemia in 10.3%. Vitamin D defi ciency was present in 85.9%. Total hypocalcemia was signifi cantly associated with fl uid bolus and inotrope requirement (p = 0.007 and 0.012 respectively), sepsis (p <0.001) and mortality (p = 0.006). Mortality was signifi cantly higher among the patients with abnormal serum phosphate levels (p = 0.033 and 0.009 for hypo and hyperphosphatemia respectively). There was no signifi cant association of vitamin D defi ciency with PICU morbidities and mortality.


Discussion: Incidence of hypocalcemia was lower than other studies. Other studies have also found association of hypocalcemia and hypophosphatemia with PICU mortality.

Conclusion: Calcium, phosphate abnormalities are associated with poor outcome in critically ill children. Vitamin D defi ciency is common in the critically ill children but not associated with poor outcome.

Type of Study: Original research.

Moya Moyadisease: A case reportSehgal P1, Wasim S1, Pandita N1, Kalra B.P1, Chander V1, Saini M2

1Department of Pediatrics, 2Department of Radiodiagnosis, HIMS, Dehradun.


Introduction: Moya moya diseaseis a rare, progressive cerebrovascular disorder caused by blocked arteries at the base of the brain. Magnetic resonance Angiography is the investigation of choice.

Method: We present the case of a 7 year old female presenting to the Department of Pediatrics, HIMS Dehradun with recurrent stroke who was subsequently diagnosed as Moya Moya Disease on MRA.

Case Report: A 7 year old female presented in pediatricemergency with left sided focal seizures. The patient had UMN type of left facial nerve palsy and left hemiparesis. There was history of recurrent episodes of left sided hemiplegia, the fi rst episode occurring at 3 years of age, with slowly progressive mental impairment. A diagnosis of recurrent stroke was made. A diagnostic MRA was done and there was non visualisation of ICA artery with multiple collateral formation, on the basis of which a diagnosis of Moya Moya disease was made. Patient was started on oral aspirin and neurosurgical opinion was sought. However the patient was lost to followup.

Discussion: The cause of Moya Moya disease is mainly congenital, but is also seen secondary to other conditions. Our patient was investigated to rule out secondary causes.

Conclusion: A child with Moya Moya disease presents typically with recurrent episodes of sudden hemiplegia that might occur on alternate sides.The disease is progressive and dynamic in children. MRA clinches the diagnosis and neurosurgical intervention may be required as a part of defi nitive management.

Case of Porphyria with Icthyosis VulgarisUpendra Kumar


A 9 year male child 3rd degree of consanguineous marriage brought us complain of Fever, Abdominal pain, vomiting, seizure and history of Prolong fasting in ramzan and red coloured urin with ithyosis vulgaris. Admitted in PICU simultaneously treat

hypertensive emergency with SIADH. We discovered upon laboratory investigations elevated urine porphobilinogen and low serum sodium. The constellation of symptoms and the elevated porphobilinogen suggested the diagnosis of Porphyria. We would like to believe this is an interesting case, which demonstrates a number of combined clinical features in a child.

Dry, thickned, fi sh scale lesion all over body more in trunk Icthysis vulgaris

Study of Clinical Profi le of Patients with Acute Kidney Injury and Outcome in

PICU - A one Year Retrospective Study Conducted in PICU of Tertiary Care

Medical CentreRakesh Gami*, Vanishree Tammanagoudar*,

Prithi Inamdar**, M V Patil***, Roopa Bellad****Post Graduate, **Associate Professor,* **Professor

Department of Pediatrics, JN Medical College, Belgaum*Email: [email protected]

Introduction: Acute kidney injury is characterized by a rapid reduction in kidney functions resulting in failure to maintain fl uid, electrolytes and acid-base homeostasis. It is an independent predictor of mortality in children admitted in PICU. AKI has now replaced ARF. This study is performed to know clinical profi le of AKI and outcome of AKI patients in PICU.

Objective: To determine incidence, clinical profi le and outcome of AKI in children admitted in PICU.

Material and Method: Study design: Retrospective study, Study Period: 1st July, 2014 to 31st June, 2015, Inclusion Criteria: All children admitted in PICU, Exclusion Criteria: Children with pre-existing chronic kidney disease, Place of Study: PICU, Department of Pediatrics KLE Hospital, Belgaum

Result: Total 615 admitted in PICU during study period, out of which 3 are excluded. Total 612 children included in study out of 71 children had AKI. Most of them are <1 year of age (49%) followed by 1-5 years (28%). Most common cause of AKI in these childrens are Congenital Heart Disease followed by Renal disease like HUS, Nephrotic syndrome. Mortality was seen in 69% of ventilated patients with AKI.

Conclusion: In our study, common cause of AKI in emergency care is Congeniral heart disease with 2nd most common cause is Renal diseases like HUS and Nephrotic syndrome. Serum creatinine is not an early marker to predict AKI in PICU setting but is a very reliable tool for assessing the progression to AKI.


Unusual Manifestation of Snake Bite in Children - A rare case of snake bite with

multiple organ failureVanishree T, Rakesh G, Roopa B,

Abhilasha S, Dhyanesh DkDepartment of Pediatrics, JN Medical College, Belgaum

Abstract: In any language of the world, snake produce’s unimaginable fear and anxiety. Right from the cases where earliest man lived, snakes would have caused fi rst kind of poisoning. India has about 216 varieties of snakes of which about 52 are venomous and of these only 4 varieties of snakes are commonly encountered as the cause of snakebite poisoning. These are Russell’s viper, Echis Carinatus, Cobras and pit viper. Most common presentation of snake bite in children are local pain, swelling, ptosis, respiratory diffi culty and altered sensorium. We reported a case of 8 years of male child presented with history of snake bite over left ankle followed by which he develoed swelling of left leg and developed Acute Kidney Injury after a week and gradually child had Acute Respiratory Distress Syndrome and Pancreatitis. All necessary investigations send and management done accordingly. Child is discharged after 3 weeks of hospital admission and is being followed up.

Clinical Profi les and Short Term Outcomes of Pediatric Hemophagocytic Lymphohistiocytosis in a Tertiary Care

HospitalSanjay Paida*, Santanu Sen, Preetha Joshi,

Vinay JoshiKokilaben Dhirubhai Ambani Hospital, Mumbai


Background: Hemophagocytic lymphohistiocytosis is a multisystem illness with variable clinical presentation. Mortality is high in the pediatric age group, especially infants. Therefore early detection is a strong factor for better outcomes.

Methods: We conducted a retrospective analysis of 12 HLH patients diagnosed by HLH 2004 criteria from age group 2 months to 15 years admitted to a tertiary level pediatric intensive care unit from January 2009 to July 2015.

Results: In our analysis we found that out of the 12 patients, 2 had primary HLH and 10 patients had secondary HLH. Dengue and EBV were the two infections associated with HLH. Fever and splenomegaly were the most common clinical features in these patients. Out of the 12 patients, 8 had liver dysfunction and 4 went into spontaneous remission, 1 underwent bone marrow transplant and rest were treated as per HLH 2004 protocol. Mortality rate was 40%.

Discussion: HLH is a multisystem illness characterized by fever, organomegaly, cytopenias, hyperferritinemia, hypertriglyceridemia and hemophagocytosis on bone marrow. In our analysis we found that 5 had either EBV or Dengue infection, 1 developed HLH post tetralogy of Fallot repair, and 1 patient had associated central diabetes insipidus. Fever, splenomegaly and hemophagocytosis on bone marrow were the most common fi ndings. Liver dysfunction was found in 67% of the patients.

Conclusion: HLH is a multisystem illness with variable presentations and high mortality. Clinicians should have high index of suspicion regarding this illness since prompt recognition and targeted therapy improves outcome of such patients.

Outcome of Pediatric Oncological Emergencies Admitted to a Tertiary Level Pediatric Intensive Care Unit

Sanjay Paida*, Santanu Sen, Vinay Joshi, Preetha Joshi

Kokilaben Dhirubhai Ambani Hospital, Mumbai*Email: [email protected]

Background: Outcome of pediatric oncological emergencies has steadily improved in last two decades. However, febrile neutropenia and number of organ system failure are important prognostic factors in these patients.

Methods: We conducted retrospective analysis of 27 admissions of 24 children in the age group 1 month to 18 years with oncological emergencies admitted to tertiary level pediatric intensive care unit of Mumbai.

Results: Overall survival in this group was 77%. In patients with one and two organ system failure, survival was 100% whereas in patients with more than three organ system failure, 100% mortality was found. We found that children with associated febrile neutropenia had 30.8% mortality as compared to 14.3% in non-neutropenia group. Mean duration of ICU stay was more in AML group as compared to ALL group.

Discussion: Outcome of pediatric oncological emergencies has improved form 75-80% mortality to 75-80% survival over last few decades. In our analysis we found 77% survival of these patients which is comparable to current western literature. In our study, we found that febrile neutropenia was a bad prognostic factor for mortality. We found that children with AML had more frequent need of advanced mode of ventilation like HFOV. We found that encephalopathy and shock were most common indication of PICU stay and PRES was the most common cause of encephalopathy.

Conclusion: Overall survival of pediatric oncological emergencies has greatly improved over time. In these patients, febrile neutropenia and the presence of more than 3 organ system failure carries poor prognosis.


Arterial Thrombosis in Children - What Can We Offer?

Jolly Chandran*, Pragathesh, Manivachagan, Kala E and Ebor Jacob

Paediatric ICU, CMC, Vellore*M: 91-416 228 3366; Email: [email protected]

We describe three children with femoral arterial thrombus managed successfully with thrombolytic therapy in all and thrombectomy in one child.

Case History: Nine month old baby with congenital rubella syndrome with PDA in cardiogenic shock was ventilated. Central venous catheter was inadvertently placed into the femoral artery which developed thromboses confi rmed by Doppler. He was initiated on Heparin infusion in the same catheter at 5 units/kg/hr and 6 hours later tPA (tenecteplase @0.05mg- 0.1/kg/hr) was infused for a period of 24 hours. Limb perfusion improved and repeat Doppler showed no residual thrombus.

Five months old baby with Acyanotic heart disease was admitted with Acute gastroenteritis and hypovolemic shock. Central venous catheter was inadvertently placed into the right femoral artery which was removed immediately. Developed thrombus which was confi rmed by Doppler. Initiated on heparin infusion @ 10units/kg/hour and tenecteplase (tPA) @0.05mg-0.1mg/kg/hr. Repeat Doppler showed dissolution of the thrombus.

Two years old boy with PDA underwent device closure was noticed to have cold peripheries with absent pulses of the right lower limb with common iliac artery thrombotic occlusion. Heparin infusion was started; subsequently he underwent thrombectomy. His lower limb perfusion improved.

Discussion: Thromboses of arterial line is a known complication in children especially with risk factors. It is interesting to note all children had underlying congenital heart disease. Thrombolytic therapy `helps in dissolution of the clot as well as restoring the perfusion of the ischemic limb. Recombinant TPA along with heparin infusion has been recommended for clot lysis by International society of thromboses and hemostasis. Congenital heart disease and cardiac cathetrisation pose a higher risk for arterial thromboses.

A Prospective Interventional Study to Determine the Effect of Chlorhexidine

Wipes in Reducing the Incidence of Hospital Acquired Infections among Critically Ill Children Admitted to a

Paediatric Intensive Care UnitMadhan Kumar*, Jolly chandran, Ebor Jacob

Gnananayagam, Manivachagan MN, Pragathesh, Hema paul, Kala Ebenezer**

PICU and HICC, CMCH, Vellore – 632004, IndiaEmail: [email protected]

Objective: To determine the effect of chlorhexidine wipes

in reducing the incidence of HAI among critically ill children admitted in PICU.

Methods: This interventional study was done in PICU of CMCH, Vellore. In this study all enrolled children were given chlorhexidine wipe after routine soap bath. The incidence and prevalence of HAIs were observed and compared with historic controls (Same period of the previous year).

Results: In the intervention group the total number of ventilator and line- days was 777 and 1377 respectively. The incidence of VAP was 6.43/1000 ventilated -days with a prevalence of 2.5% and the incidence of CRBSI was 3.6/1000 line- days with prevalence of 2.5%.

In the pre- intervention period group, the number of ventilated -days was 696 and catheter- days was 1432. The incidence of VAP was 12.93/1000 ventilated days with prevalence of 3.2% and the incidence of CRBSI was 4.2/1000 days with a prevalence of 2.2% with a signifi cant p value (<0.001) in VAP. The organisms were similar in both the groups.

Conclusion: The use of chlorhexidine wipes in ICU signifi cantly reduced VAP among the children admitted to the PICU with non signifi cant reduction in the CRBSI.

Disorders of Sex Development with Genital Ambiguity: Real Social EmergenciesSantosh B Kurbet, Harshasree G, M V Patil,

Abhilasha S, Prashanth G P, N S Mahantshetti, Mahesh Kamate, V D Patil, R M Bellad, S M Jali, S

Chate, P Malur, Andaleeb, MukulJ N Medical College, KLES Dr. Prabhakar Kore Hospital,

KLE University, Belgaum, KarnatakaEmail: [email protected]

Aims: To study the management and psychosocial issues with respect to early assignment of sex in Disorders of Sex Development (formerly, -pseudo/hermaphrodite/intersex) with ambiguous-genitalia.

Methods: A prospective observational-study was planned. The study population included all children presenting to tertiary-care-centre with ambiguous-genitalia. Managed by team-of pediatricians, pediatric-surgeon, endocrinologist, pediatric-neurologist, pathologist and psychiatrist. The study protocol included prospective recording of presenting-complaints, family history, sex of rearing and behavioral-pattern. External genital-examination and laboratory work-up fi ndings were also noted. Karyotyping, hormonal-studies, pelvic ultrasonography, genitogram, genitoscopy, skin biopsy, laparoscopy and gonadal-biopsy were done in these patients accordingly. Children were-assigned appropriate-sex at the earliest and genitoplasty was carried out. All children were followed up regularly.

Results: A total of 11 children were recruited between Jan 2009-Dec 2014. Age at presentation ranged from newborn to 14-years. Repeated and thorough counseling was major part of-management. Four patients were assigned male-sex, maculinising


genitoplasty was done, and four were assigned female sex with feminizing-genitoplasty. Three children are currently under observation. The patients were followed up for a mean period of 3 years. All children who underwent surgical reconstruction had good results except one patient who had fi stula requiring redosurgery. Most parents of treated children are satisfi ed with the cosmetic-outcome and assigned sex.

Conclusion: Our study strongly suggests expeditious investigations to determine the sex & early gender assignment may relieve these pts & parents of social stigma and has a good psychosocial impact. Our study may serve as a pilot work for long-term studies comparing early assignment of sex with delayed approach in children with DSD.

Grandma’s Constipation Concoction Causes Devastation

Kunal Kumar*, Rajesh Kumar**, Krishna Kumar****Registrar MD (Pediatrics), IDPCCM, MRCPCH, **Medical

Director MD (Pediatrics), DM (Neonatology), ***Senior Consultant Pediatrician MD (Pediatrics), MRCPCH,

Department of Pediatrics, Pediatric Critical Care unit,Rani Hospital, Ranchi


Background: Symptomatic hypermagnesemia is rare in absence of renal failure and usually goes undetected as it is not routinely tested.

Case Characteristics: A 3yr old female child presented in an unresponsive state with gasping respiratory efforts with a history of loose stools and vomiting for 1 day and one episode of seizure. Was immediately intubated and put on mechanical ventilation.Examination revealed a GCS of E1M1Vtube , bilateral mid dilated pupils, absent DTR’s, hypotensive shock, pallor, crackles in right axillary region and signs of dehydration.Vitals were stabilized after fl uid resuscitation and vasopressors(dopamine@10mic/kg/min and adrenaline @0.15mic/kg/min).Initially managed as a case of suspected acute encephalitis/intracranial bleed and aspiration pneumonia.Investigations:Hb:5.7,TLC:30920(N80L16), CRP<5, ABG:pH 7.267/paO2:72.9/paCO2 :19.6/HCO3 :8.7/BE-16.7, creatinine:0.67,CXR:right lower zone consolidation, CT head: Normal.Given intravenous fl uids, blood transfusion (2 units), systemic antibiotics, antiviral and anticonvulsants. On further history she was found to be on self medication with milk of magnesia (in varying amounts) for past 11/2 years for constipation. Thyroid profi le, TTG IgA, total IgA and lead levels were normal. Taking clue from the history and clinical signs (hypotensive shock/absent DTR/ respiratory/CNS depression), magnesium intoxication was considered and serum magnesium level done which was elevated (7.12meq/L).She was given 1.5 times maintenance iv fl uids, diuretics and parenteral calcium gluconate. There was serial decline in magnesium levels with improvement in sensorium and decreasing pressor requirement.She was extubated on day 3 of admission (Mg 1.54meq/L) and had an uneventful further hospital course.

Conclusion: High index of suspicion for hypermagnesemia should be kept in children with appropriate clinical signs and magnesium should be checked along with other electrolytes.

Prevalence of Vitamin D Defi ciency in PICU

Dr Jhuma SankarAll India Institute of Medical Sciences, New Delhi

Tel.: 01126593209; Email: [email protected]

Objectives:To evaluate the prevalence of vitamin D defi ciency at admission and after 72 hours of ICU stayin children with fl uid refractory septic shock. We also evaluated the association of vitamin D defi ciency at admission with clinically important outcomes.

Methods: In this prospective cohort study we enrolled children aged ≤ 17 years admitted to PICU over a period of 6 months. We estimated serum 25 (OH) D levels at admission and after 72 hours of stay and collected information for evaluating the association of vitamin D defi ciency with clinically important outcomes. Data was analysed using STATA 11.

Results: Thirty-seven children were enrolled in the study. The prevalence of vitamin D defi ciency at admission was 73% (n=27/37; 95% CI:57 to 85). On day 3 it was 70 % (n=23/33; 53 to 83). The mean (SD) vitamin D levels declined from 8.7 (4.3) to 6.5 (2.8) after 72 hours of ICU stay and the difference was statistically signifi cant (p=0.04). On univariate analysis the need for fl uid boluses and inotrope score at 24 hours of ICU stay were signifi cantly higher in the group with Vitamin D defi ciency (p <0.05). However, on multivariate analysis only the need for fl uid boluses remained signifi cant (OR (95% CI): 1.85 (1.45 to 4.06)).

Conclusion: The prevalence of vitamin D defi ciency is high in children with fl uid refractory septic shock admitted to PICU and the levels decline further during the course of illness. Need for fl uids may be higher in children with septic shock who are vitamin D defi cient.

Keywords: Vitamin D defi ciency; 25 (OH) D; Septic shock; Fluid refractory; Inotrope score; Outcomes; Prevalence

A Case Report Suggesting Role of N Acetyle Cystine in Management of Hepatic

Encephalopathy due to Wilsons DiseaseLokesh Tiwari*, Gaurav Vishal, Chhitiz Anand,

Pratap Patra, Arun BaranwalDepartment of Pediatrics,

All India Institute of Medical Sciences, Patna*Email: [email protected]

Background: Management of hepatic encephalopathy in children remains supportive. Use of N acetyle cystine (NAC) is recommended in case of drug induced liver failure and some other conditions. We could not fi nd any study supporting or refuting role of NAC in hepatic encephalopathy due to Wilsons disease.

Case Report and Results: An 8 year old male child with hepatic


encephalopathy grade II, who was resuscitated in PICU, showed progressive worsening of encephalopathy with fall of GCS from 13 to 8 over a week on recommended supportive therapy. His viral markers for hepatitis A, B, C and E were negative. He was started on NAC infusion while serum ceruloplasmin level was awaited. Child showed progressive improvement even before Wilson’s disease was confi rmed and he was started on D penicillamine. Child showed consistent clinical and biochemical improvement and he was discharged after 4 weeks of hospital stay with GCS of 15. Presently under follow up, he has resumed his school and he is able to perform all age appropriate activities.

Discussion: Role of N acetyle cystine in hepatic encephalopathy has not been established in cases other than drug induced liver failure but it seemed to be benefi cial in this case. This case was unique as his encephalopathy progressed over one week in spite of standard supportive management and rapidly improved after starting NAC even before starting chelation therapy for Wilsons disease.

Conclusion: It will be interesting to further investigate role of NAC in management of hepatic encephalopathy due to Wilsons disease.

Psychosocial Needs in a Pediatric Critical Care Unit - A comparative study of

careseekers’ and caregivers’ perspectives from a developing country

Reshma A, Sasidaran K*, Niranjan V, Ayyammal P, Thangavelu S, Nedunchezhian K

Mehta hospital, Chennai*M: +91 9940587408; [email protected]

Background: Children in critical care units put an immense psychological burden on the family members of the child. Assessing the psychosocial needs of family members becomes of paramount importance in this regard. This study was designed to explore the needs of family member of children unexpectedly admitted to an Intensive Care Unit and rank the needs and compare with the perspectives of doctors, nurses and administrators.

Methods: This is an exploratory comparative study done prospectively using a modifi ed version of the Critical Care Family Needs Inventory (CCFNI) to measure, rank and compare the needs and the Needs Met Inventory (NMI) to assess the level of satisfaction of the needs. The study was done in a private sector pediatric ICU in south India. Responses of 35 consecutive family members, 30 Pediatric acute care Nurses, 30 pediatricians involved in intensive care and 30 administrators responsible for ICU decisions were recorded.

Results: The responses were ranked by means and analysed for variance by univariate analysis and the responses were compared between the care seekers’ and care providers. The needs ranked highest by domain were “Assurance” for families, doctors and

“information” for the nurses. The items those were included to the questionnaire concerning developing country situations were ranked high in importance.

Conclusion: The CCFNI with minor modifi cations can be used in developing countries for assessing the needs of families of ICU children. The responses to needs relating to availability of care ranked higher substantiating the heterogeneity of the population in places where third party payer system is not the norm. Making sure the patient feels assured about the care given to the child should be the area of prime focus and timely information regarding the child’s condition should be given the utmost importance in alleviating family anxiety.

Viral Aetiology of Under 5 Children Admitted with Acute Respiratory Infection In PICU – A Prospective

Observational StudySaranya C, Sasidaran K, Reshma A, Ayyammal P, Thangavelu S, Gowrishankar NC, Nedunchelian K

Mehta hospital, Chennai

Background: Acute respiratory infections (ARI) are one of the major causes of morbidity and mortality in young children. The epidemiology of acute respiratory infection is constantly changing in which both viral and bacterial causal agents play various roles. This study was done to identify viruses associated with primary acute respiratory tract infection among children less than 5 years admitted to PICU and requiring respiratory support or oxygen therapy.

Methods: It is a prospective observational study. We enrolled children aged 1 to 60 months admitted to PICU with primary acute respiratory infection requiring minimum 12 hours of oxygen therapy between August 2014 and March 2015. Throat swabs were taken for all children enrolled and viruses isolated by RtPCR technique. We also performed a comparison between viral isolate positive and negative children with regards to surrogate diagnostic markers and outcome measures

Results and Discussion: Of 70 children who fulfi lled the enrolment criteria, 35(50%) were found to have viral etiology. Rhino virus was found to be the most common isolated in15 (42.85%) children followed by RSV accounting for 14(40 %) children. Of 22 children requiring advanced invasive ventilator support, 9 children were found to have respiratory virus isolate. Commonly used surrogate diagnostic markers like CRP, ALC, and ANC were found to be not signifi cantly different between the groups.

Conclusion: Viral pneumonia is one of the common causes of ARI in children mandating intensive care unit admission and viral pneumonia need not always be mild and self-limiting in immunocompetent. In our observation, Human rhino virus and RSV were the two most common viral isolates and H1N1 was associated with disease severity.


Critical Care without Walls”- Impact Of A“Pediatric Emergency Team”

on Patient OutcomesTahir Rehmatullah

Fellow, PICU, Manipal Hospital, [email protected]

Background: Cardiopulmonary arrest in children is often a gradual process, preceded by critical period of physiologic instability, during which lifesaving interventions can decrease the mortality and morbidity. we report the impact of a Pediatric Emergency team (PET) on patient outcomes. We hypothesised that introduction of such teams would improve patient outcomes.

Methods: This study was conducted at Manipal Hospital, comparing outcomes before and after introduction of the Pediatric emergency team. The pre-intervention period was between October 2011 and March 2013(phase-1) and post-implementation period was between April 2013 and October 2014(phase-2). children admitted to the wards were considered participants.

The following outcomes were compared- the number of patients having cardiopulmonary arrest in the ward, the number of patients transferred to the PICU from the wards,the number needing intubation on D1 of transfer , and the mortality of patients transferred in the team comprised of the PICU consultants, fellows, and 2 PALS trained nurses.

Results: Mortality was signifi cantly higher during phase 1(6.2%) when compared to phase 2, with no mortality(p value <0.01). During phase 1, 17.9% of patients transferred to the PICU were intubated on Day 1, compared bto 5.8% during phase 2. Cardiopulmonary arrest in the wards was almost nonexistent in our hospital(1 in 10088 only in phase-1).145 of 10088(1.43%) patients had to be transferred to the PICU because of worsening clinical status during phase 1 as against 103103 0f 7737(1.33%) during phase 2.

Conclusions: In a fi rst such study from india, we demonstrate the feasibility of implementing a pediatric equivalent of Medical Emergency Team(MET), that has the potential for reducing the mortality and morbidity in children admitted to a tertiary hospital.

Proteus Syndrome With Epilepsy: A Rare Presentation

Pallavi1 S. Sitaraman1, Manisha Goyal2

¹Department of Pediatrics, SMS Medical College, Jaipur, ²Clinical Geneticist, Jaipur


Background: Proteus syndrome (PS) is an overgrowth syndrome characterized by segmental overgrowth, vascular malformations, nevi, lipoma and hyperpigmentation. The exact cause and embryologic origin of PS is still not known.

Case presentation: A seven year old boy presented with seizures and overgrowth of right half of the body. He was third born to non-consanguineous couple with uneventful antenatal and postnatal

period. Examination on admission showed dolichocephaly, frontal bossing, hyperpigmented lesions over right cheek, nevus on right side of neck and right gluteal region, hypertrophy of right half of face and right buttock. There was bilateral macrodactyly of great, Ist, IInd and IIIrd toe with hypertrophy of plantar surfaces with increased rugosities. Routine blood investigations were within normal limits. EEG showed generalized epileptiform discharges. MRI brain suggested unilateral megalencephaly with white matter changes and enlarged and distorted right ventricle.

Child was diagnosed with PS on the basis of dysmorphic growth and characteristic skin abnormalities. There are very few reports of association of PS patients with both epilepsy and hemimegalencephaly. No specifi c treatment option is available for PS. Management includes multidisciplinary treatment approach involving Geneticist, Neurologist, Dermatologist along with family support.

Conclusion: In our study we value the importance of early detection of association of PS with epilepsy and hemimegalencephaly so as to prevent/minimize the neurological complications, disability, morbidity and mortality associated with PS.

Breast Feeding Experience in Inborn Errors of Metabolism

Umamaheswari BM: 9941853855; Email: [email protected]

Introduction: Breast feeding (BF) has been recommended for certain inborn errors of metabolism (IEM) such as phenylketonuria. Studies or case series sharing the experience with breast feeding in other IEM are few. In India, especially with the non availability of special formula and aminoacid mixture, the experience of sharing the use of breast milk (BM) in selected IEM would help the medical fraternity.

Method: Three infants with propionic acidemia PA (n=1), citrullinemia (n=1) and multiple carboxylase defi ciency (n=1) who were given breast milk and prospectively followed were included.

Results

Case 1: A 13 month old boy diagnosed to have propionic academia on 20 day of life (dol), was continued on BF after the acute management of the crisis. He is on BF till date and supplemented on special formula. He had 2 episodes of acute crisis so far and developmentally normal.

Case 2: A 9 month old boy diagnosed to have multiple carboxylase on y 7 dol, presented antenatally with cyst, was continued on BF after discharge. He was on exclusive BF till 6 months of age and developmentally normal.

Case 3: A 7 month old girl diagnosed to have citrullinemia on 1 dol, in view of sibling with IEM, was continued on expressed BM after acute management. She is developmentally normal.

Conclusion: Breast feeding was successful in all three babies with IEM. Metabolic decompensation should be watched for


while on BF. Nutritional status, development and biochemical parameters should be frequently monitored. BF has specifi c advantages and should be encouraged in selected cases of IEM.

A Study of Left Ventricular Functions in Hypocalcemic Infants

Palak Gupta*, Samit Raj Prasad, Manohar Lal Gupta*3rd Year Resident, Department of Pediatrics,

SMS Medical College, Jaipur*Email: [email protected]

Background: Congestive Heart Failure and Cardiomyopathy due to hypocalcemia are rare however,chronic hypocalcemia has been found to be associated with left ventricular dysfunction.Few reports are available on the issue of Left ventricular function in hypocalcemic infants hence present study was undertaken. Aims and Objectives: To study left ventricular functions in hypocalcemic infants. To study the relation between age at the time of diagnosis of hypocalcemia and left ventricular dysfunction.

Methods: Hospital based observational study, Department of Pediatrics, SMS Medical College, Jaipur from October 2012 to September 2013. 75 infants admitted with clinical features of hypocalcemia were studied. Clinical examination and relevant investigation were done, they all underwent Echocardiography to reveal cardiac functions and dimensions.

Results: Hypocalcemia was common in males (72%) and associated with exclusive breast feeding infants(60.34%). Mean ejection fraction ( 43.08 +/- 9.34) and mean fractional shortening (20.42 +/- 4.70) of hypocalcemic infants associated with left ventricular systolic dysfunction was statistically signifi cant (P<0.05) in infants less than 3 months and more than 6 months. On correlation regression analysis these were negatively correlated (R= -0.66). Cardiomegaly in chest Xray(90%) and QTc prolongation(33.03%) was signifi cant in infants with reduced left ventricular systolic function.

Discussion: The result of present study was in complete agreement with Pankaj Gupta et al and Munesh Tomar et al which state hypocalcemia as a cause of ventricular dysfunction.

Conclusion: This study shows that reduced left ventricular systolic function was an important feature of hypocalcemia in infants.

Extended Multimodal Monitoring is Useful for Optimizing Hemodynamics in

Pediatric Septic ShockRajeswari Arali


Extended multimodal-monitoring (eMMM) including cardio-respiratory ultrasound and cardiac-output monitor (USCOM) was used in 26 children In order to streamline the decision-making in unresolved shockdespite initial fl uid resuscitation, and results were compared to clinical assessment alone.

Methods: Children with unresolved shock despite 30 ml/kg

fl uid were evaluated by eMMM[including clinical examination, invasive monitoring, focused cardio-respiratory imaging (CRI) and ultrasound cardiac-output monitor(USCOM)].

The therapeutic plan based on clinical exam was compared to decisions following eMMM. The fi nal decision regarding further fl uids, inotropes and pressorswas based on the presence of at least 2 eMMM parameters demonstrating fl uid responsiveness (in absence of fl uid intolerance), abnormal cardiac function or reduced SVR respectively.

Results: Regarding fl uid, 24/26(92%) would have received fl uid based on clinical examination, but only 4 fi nally received additional fl uid following eMMM. Inotropy based on echocardiography/USCOM was administered in 14(53%) patients;however, clinically only 4 patients had suspected myocardial dysfunction. SVRI was low in 18(69%)patients warranting pressors which was clinically obvious only in 19% based on the presence of warm shock. Early diuretics (within 24 hrs) were commenced in the presence of large number of B lines in 30% children.

Conclusion: Benefi ts of eMMM in septic shock included precise titration of inotropes and pressors in unresolved shock, where clinical exam was unreliable. Additional important advantages included greatly minimized fl uid overload, both by limiting administration and early removal. USCOM provided value addition principally to identify low SVR and titrate early pressors, which not only improved SVRI but also improved preload and inotropy.

Microalbuminuria as a Predictor of Mortality in Children with Sepsis

Karan Raheja*, Anil Sachdev, Dhiren Gupta, Suresh Gupta, Neeraj Gupta

PICU, Sir Ganga Ram Hospital, New Delhi*Email: [email protected]

Background: Microalbuminuria (ACR), is a marker of systemic infl ammation, and refl ects the glomerular component of a systemic capillary leak. To date, correlation of ACR with organ system dysfunction (OSD) and mortality in children with sepsis has not been evaluated.

Objective: To study the relationship between ACR with OSD and mortality in septic children.

Methods: Children between age 1 month and 16 years admitted with sepsis, and with anticipated stay of >24 hrs in PICU were enrolled prospectively. Patients with primary nephropathies were excluded. ACR was obtained at admission (ACR1), 12 hrs (ACR2) and 24 hrs (ACR3). ACR >180 mcg/mg of creatinine was considered signifi cant. PELOD score and PRISM 12 and 24 hrs calculated for all.

Results: 138 patients with varied severity of sepsis were enrolled prospectively. The median PRISM12 and 24 hr with ACR (1,2,3) levels >180 were signifi cantly higher as compared to those with ACR<180. [(8 vs 4, p<0.05), (6 vs 2, p<0.05);(8.5 vs 4, p<0.05), (7.5 vs 2 p<0.05);(9 vs 4, p<0.05), (8 vs 2 p<0.05) and median


PELOD scores at 24 and 48 hrs was higher in group with ACR >180 at admission, 12 and 24 hrs (21 vs 9 p<0.05), (21 vs 2 p<0.05); (21vs 10 p<0.05), (21 vs 2, p<0.05); (22 vs 4, p<0.05), (21 vs 2, p<0.05). Statistically signifi cant difference noticed between sepsis categories with ACR 1, 2 and 3 (P<0.05). There is statistically signifi cant positive correlation between lactate (12 hrs) vs. ACR2, (p 0.0001) and lactate (24 hrs) vs. ACR3, (p 0.0001). There were statistically signifi cant different values of ACR2 and ACR3 between survivor and non-survivor (ACR2 P 0.03and ACR3 P 0.01). Odds ratio (survivor vs non-survivor) for ACR1 and ACR3 in >180 group was 1.24 and 2.49.

Conclusion: The increasing trend of microalbuminuria in septic children predicts organ dysfunction and mortality.

Post Neonatal Tetanus:Ten-year pediatric intensive care unitexperience from a

tertiary care teaching hospitalSuresh Kumar*, Balmukund, Muralidharan

Jayashree**, Arun Bansal, Sunit Singhi, Karthi Nallasamy

Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, 160012

M: *9855373969, **+919815594343; Email: *[email protected], **[email protected]

Background: Tetanus is still a major public health problem associated with high morbidityand mortality.Data regarding its intensive care needs, outcome, predictors of outcome, and long term follow up is limited.

Methods: Case records of 28casesof tetanus between 3 months to 12 years of age admitted to a PICU in north India over a period of 10 years (January 2006 to August 2015) were reviewed for demographics, portal of entry, vaccination status, type and severity, clinical features, management, complications,outcome, and follow up data. Univariate and multivariate analysis were done to determine predictors of mortality.

Results:Three fourth(n=21; 75%) of cases were boys with mean(SD) age of 7.2 (2.9) years. None were completelyimmunized.The most common portal of entry was CSOM (n=15;53.6%), followed by acute trauma (n=9;32.2%) and no obvious injury (n=4;14.3%). All cases had generalized tetanus with severity grades of IV (n=17, 60.7%) and III (n=11, 39.3%). All cases received wound debridement, tetanus toxoid, HTIG, and appropriate antibiotics. Intrathecal HTIG was incorporated in the protocol after 2012 and only 5 (17.9%) cases received it. All cases had one or other complication related to tetanus, its treatment, and PICU stay: respiratory failure (92.9%), rhabdomyolysis (78.6%), autonomic dysfunction (71.4%), acute kidney injury (64.3%), and HCAI (46.4%).The intensive care needs were: requirement of ventilation (100%), benzodiazepine (100%), morphine (96.4%), and magnesium sulphate (85.7%) infusion, neuromuscular blockcade (67.9%), inotropes (67.9%), tracheostomy (39.3%), and RRT (32.1%). Twelve (42.9%) cases died after a mean(SD)PICU stay of 7.8 (5.9) days. The length

of PICU stay among survivors (n=16) was 22.2 (10.3) days,of whom 2 had post cardiac arrest neurological sequelae at time of discharge.Only 12 patients were followed up for mean duration of 5.6 (3.8) months after PICU discharge and all except 1 were well. Multivariate logistic regression analysis revealed that grade IV severity (p=0.002), no intrathecal HTIG (p=0.033), and inotrope use (0.001) were signifi cantly associated with mortality.

Conclusion: Tetanus remains a major public health problem in the post vaccination era.Early recognition, prompt treatment and intense supportive care in PICU improve morbidity and mortality. High mortality despite intensive care brings to focus the need for good public health measures to prevent the disease.

Keywords: Tetanus, children, PICU, mortality.

Glucose Variability Index in Critically Ill Children with Sepsis

Roop Sharma*, Anil Sachdev, Suresh Gupta, Dhiren Gupta, Neeraj Gupta

Pediatric Intensive Care Unit, Sir Ganga Ram Hospital, New Delhi, India


Objectives: To study the effects of hyperglycemia, hypoglycaemia and hyper+hypoglycaemia with variabilty index in critically ill children onoutcome.

Materials and Methods: Prospective, observational cohort study in a tertiary care PICU. Children agedbetween 1 month to 16 years with sepsis admitted from August 2013 to June 2014. were serially enrolled. Blood glucose estimations were done at 8 AM and 8 PMin initial 7 days of PICU stay.

Results: 91 consecutive patients with sepsis, severe sepsis, septic shock with or without multiorgan dysfunction syndrome were enrolled. The study cohort was divided in 4 groups: euglycemia (12%), hyperglycemia (37.3%), hypoglycaemia (8.7%), hyper+hypoglycaemia (41.7%). The median PRISM score at 12 hours and 24 hours in hyperglycaemiagroup were 13 and 11.5 while 16.5 and 17 in children with hyper+hypoglycaemia grouprespectively and weresignifi cantly higher as compared to euglycemia group (p-0.00, p-0.03). In non-survivors, hyperglycemia, hyper+hypoglycemia and euglycemia were observed in 13 (36.1%), 18 (50%) and 2 (5.1%) patients respectively. The median PELODS values on day 1 and day 2 in hyperglycaemia group were 31 and 32 while 17 and 31.5 in children with hyper+hypoglycaemia respectively and were signifi cantly higher as compared to euglycemia group (p-0.006, p-0.003). The variability index was calculated as: (maximum - minimum glucose values)/ mean glucose. Positive prediction value was calculated fromvariability index. PPV for mortality with glucose variability indices of 110% and 125% were 63% and 72.2% respectively(AUC=0.62). Similarly, increased mortality rates werealso documented in hyperglycaemia group.

Conclusions: Blood glucose variability index is higher in septic children with high disease severity score.


Use of Continuous Renal Replacement Therapy in Successful Management of a Neonate with Maple Syrup Urine Disease

Mangla A*, Poudel DR, Shrestha D, Anand K**, Pruthi PK

Division of Pediatric Nephrology, **Consultant Pediatric Nephrologist, Institute of Child Health,

Sir Ganga Ram Hospital, New Delhi, India**M: 9818664448; *Email: [email protected]

Introduction: Maple syrup urine disease is rare disorder of inborn error of metabolism which can lead to severe neurological manifestations and may be fatal. Herein we report a neonate presenting within fi rst week of life with seizures secondary to maple syrup urine disease, who showed good neurological improvement following Continuous Renal Replacement Therapy (CRRT).

Case Summary: A term male neonate appropriate for gestational age with birth weight 2960g, born to a 28 years old primigravid. He developed poor sucking, decreased activity and decreased urine frequency on seventh day of life. On eight day of life he developed subtle seizures following which he was admitted in NICU. Antenatal history was unremarkable and there was no history of consanguinity. He was investigated and his tandem mass spectroscopy showed raised levels of leucine, isoleucine and valine and Genetic analysis revealed compound heterozygous mutations, c.1065 delT (p.Ala355AlafsX34) and c.293T>G (p.Val98Gly) in exons 10 and 3, respectively in BCKDHB gene, thus confi rming the diagnosis of classical MSUD. This neonate was successfully treated with continuous renal replacement therapy (CRRT) via umbilical line, which led to decrease in the blood levels of ammonia, branched chain amino acids and also neurological improvement during acute crisis. This is the fi rst case report of a neonate with MSUD being successfully treated with CRRT from India.

Conclusion: In a child with MSUD, in case of neurological depression immediate elimination of toxic metabolites is of utmost importance to prevent irreversible damage. CAVHD is potentially the most effi cacious Renal replacement therapy for rapid clearance of branched chain amino acids.

Large Mongolian spots in GMI gangliodosis

Shikha Khandelwal, B S SharmaDepartment of Pediatrics,

S.M.S Medical College, Jaipur, India

A 9-month old male child with GMI gangliodosis type I presented with Mongolian spots. The cutaneous lesions were present since birth before the appearance of the other features of the diseases. Our patient, whose clinical course and physical signs wre in keeping with GMI gangliodosis had extensive Mongolian blue spots and this adds to the evidence supporting such an association.

Keywords: Mongolian blue spots, GMI gangliodosis

Introduction: GMI gangliodosis is an autosomal recessive lysosomal storage disease caused by deficiency of the lysosomal hydrolase, acid beta-galactosidase. The infantile form (type 1) is characterized by progressive organomegaly, dysostosismultiplex, facial coarsening and progressive neurologic deterioration within the first year of life. A variety of cutaneous signs have been described in children with GMI gangliosidosis. We describe an infant with GMI gangliodosis after taking consent from his parents associated with Mongolian spots on the trunk and extremities with ventral and dorsal distribution.

Case Report: A nine month old male child born by normal delivery to non-consanguineous parents, presented with developmental delay, coarse facial feature and seizures. Coarse facial features included low set ears, broad nasal bridge, a long philtrum and frontal bossing, wide open fontanel and congenital hydrocele. He had hepatosplenomegaly, hypotonic with brisk tendon reflexes and global developemental delay. In addition, large hyper pigmented, well demarcated macules resembling Mongolian blue spots were scattered all over the body since birth. Ophthalmology examination showed cherry red spot but no corneal clouding.

Radiography showed rounding of vertebral body and proximal pointing of metacarpals and bullet shaped phalanges, iliac flare. MRI Brain showed bilaterally symmetrical confluent hyper intensities on T2/FLAIR involving periventricular; sub cortical white matter with involvement of sub coritcal u fibre with mild brain atrophy and also involving bilateral internal and external capsule and bilateral cerebellar white matter. There is evidence of mild T1 hyperintensities in bilateral medial globuspallidus. Beta galactosidase assay was done in blood by flurometry and it showed deficient enzyme activity.

Discussion: GM1 gangliodosis type 1 is a ganglioside storage disease characterized by its early onset, rapid progression to severe neurological impairment and poor prognosis with death usually occurring by the age of 2 years, It is a rare condition with an incidence of about 1: 1-200 000. Inheritance is autosomal recessive and antenatal diagnosis is possible. The condition is diagnosed by estimating beta-galactosidase activity in while cells or skin fibroblasts. Mongolian blue spots are common and are seen in up to 90% of Asian babies, and less commonly in other races. They are benign and have no known associations. Histologically they are characterized by melanocyte proliferation in the mid dermis. They are usually lumbo-sacral and can be single or multiple. They can increase in both size and density but usually disaapear by the age of 5 year. They can persist into adult life in 3-4% of cases, this was found in a study of healthy Japanese males2. Extensive mongolian blue spots do certainly occur in up to 5% of cases although their extent and natural history have not yet been studied. The mongolian blue spots seen in our child were both natural history have not yet been studied. The mongolian blue spots seen in our child were both very extensive (including the ventral surface of the trunk) and unusual in that they were repidly increasing at the age of 6 months. The possible chance association between GM,


gangliosidosis type 1 and extensive mongolian blue spots was first described in 1981 by Weissbluthet at 3 who reported a 5 month-old child with extensive areas of hyper-pigmented skin and the condition. A further child was reported in 1989(4) and two more in 1990(5). These cse reports therefore suggest that there might be an association of GM1 gangliosidosis type 1 with extensive and unusual mongolian blue spots.

Conclusion: May be Mongolian spots are just association of GM1 gangliosidosis but we think our patient adds to the evidence that patients with this disorder may manifest abnormal dermal pigmentary lesions, which may be present since birth thus helping in early diagnosis. Small, light blue-green coloured spots confi ned to lumbosacral area can be ignored but extra sacral, extensive, persistent and dark coloured spots should be looked upon with suspicion, especially in the presence of a consanguineous marriage or a strong family history of storage disorders, Future research should focus on further quantifying and validating parameters like size percentage of Total body surface area, location and colour of Mongolian spot, as markers for IEMs and their place in screening and disgnosis of these syndromes.

Short Rib-Polydactyly Syndrome: A case report

Kamlesh Agrwal1, Manisha Garg2, Ashok Gupta3, Priyanshu Mathur4, Anil Sharma5

Introduction: Short rib-polydactyly syndrome (SRPS) is a group of rare, lethal skeletal dysplasias characterized by short ribs and limbs, polydactyly, hypoplastic thorax and visceral anomalies, Classically, four different types have been described; SRPS I (Saldino-Noonan); SRPS II (Majeswski); SRPS III (Verma-Naumoff); and SRPS IV (Beemer-Langer). All forms of the SRPS described to date are thought to be inherited in an autosomal recessive manner. Prevalence as a group is unknown.

Case Presentation: A 40 days old male child presented with complain of fast breathing and fever for 1 day. Examination showed tachypnea, saturation - 68%, CRT <3 with polydactyly and US/LS ratio- 2:1. On Cradiovescular system- S 1 Normal, S2 Loud, ejection systolic murmur grade - 3 was present. Infentogram showed short ribs and pelvic outlet flairing. Proximal limbs were abnormal and iliac wings were flaired. Echocardiography showed large ostium secondum ASD (15.3mm), moderate TR and severe pulmonary hypertension.

Conclusion: We think that clinical and radiological fi ndings of our case match with SRPS, particularly Saldino-Noonan. As the overlapping clinical features make SRPS cases diffi cult in differential diagnosis, revealing the gene loci responsible for them seems necessary.

Crouzon Syndrome - A Case ReportManisha Garg1, Kamlesh Agrwal2, Ashok Gupta3,

Priyanshu Mathur4, Anil Sharma5

Introduction: Crouzon’s syndrome is an autosomal dominant disorder with complete penetrance and variable expressivity. Syndrome caused by mutation in the fibroblast growth factor receptor 2 (FGFR2) gene. The disease is characterized by premature synostosis of coronal and sagittal sutures which begins in the first year of life, Crouzon syndrome accounts for 4.8% of all craniosynostosis. Incidence of sndrome is 1 n 25000 births worldwide.

Case Presentation: 11½ months male child presented with complain of facial deformity since birth. Family history of similar facies in mother was present. Examination showed fused sutures, frontal prominence, mid facial hypoplasia. X-ray skull showed “silver beaten appearance”. NCCT brain showeed premature fusion of sagital suture with increased AP diameter as compare to transverse diameter, presence of multiple convolutions in bilateral parietal and temporal bones suggestive of lacunar skull with craniosynostosis.

Conclusion: It is important to perform thorough clinicoradiographic examinations to help in differentiating between craniosynostosis syndromes and to accurately diagnose an affected individual to aid in institution of appropriate therapeutic and rehabilitative measures as required.

Plasmapheresis in Indian Children: Single centre experience

Poudel DR, Anand K, Mangla A, Pruthi PKDivision of Pediatric Nephrology, Institute of Child Health

Sir Ganga Ram Hospital (SGRH), Delhi, India

Background: Plasmapheresis is one of the fi rst-line treatment for various conditions as classifi ed by the American Society for Apheresis(ASFA). However, it is more challenging in pediatric age group and requires greater expertise. Plasmapheresis data in Indian children is limited.

Objective: To present our experiences in Indian children who underwent plasmapheresis for various indications at Institute of Child Health, Sir Ganga Ram Hospital.

Methods: Data related to plasmapheresis (demographic characteristics, indication, number of sessions, type of replacement fl uid, type of fi lter, machine, complications and outcomes) in children who were admitted between January 2013 and July 2015 in the Department of Pediatrics, SGRH was analysed. Hospital medical records were reviewed for the data collection.

Results: Out of 17 children who underwent plasmapheresis, 70.5% were male with age ranging from 9months to 15years (mean7.8±5years). Weight of the children varied from 7kgs to 74 kgs (mean26.2±17.3kg). The most common indication of plasmapheresis was atypical hemolytic uremic syndrome (d-HUS)-66.7%. Other indications were poisoning, neurological disorders and focal segmental glomerulosclerosis-11.7% each. Total number of plasmapheresis sessions were 106 (mean 6.5 sessions per patient). 5% albumin and Fresh Frozen Plasma both were used as replacement fl uids in d-HUS children whereas only 5% albumin was used in others. Fresenius Medical Care (4008S)


dialysis machine was used and procedure was done by continuous fl ow method using plasmafl uxPSu fi lter. Hypertension was the most common complication seen in 6 patients (35%). Sixteen patients (94%) had favourable outcomes with only one mortality.

Conclusion: Plasmapharesis is a relatively safe procedure in children with its utility in diverse conditions and having favourable outcome.

Prevalence and Predictors of Outcome of Acute Kidney Injury in PICUYogesh Garg, Manish Verma, JP Soni,

Pramod SharmaDepartment of Paediatrics, Dr SN Medical College, Jodhpur

Background: AKI is associated with increased mortality in PICU, there is lack of studies regarding occurrence and outcome of AKI in PICU in Western Rajasthan, most studies are in adults and retrospective.

Aims and Objectives: To determine prevalence of AKI in PICU inmates and to follow the outcome of these patients and outline the contributing determinants.

Methods: Prospective study done in PICU, Umaid Hospital, Jodhpur for 1 year

Inclusion criteria: All children aged < 18 years admitted in PICU and needed PICU stay for at least 24 hrs and had AKI on admission or developed AKI during PICU stay

Exclusion criteria: Chronic kidney disease and /or ESRD

Results: Prevalence in our hospital was 10.15%. Average PICU stay in 5.55 days in stage 1, 6.61 in stage 2, 8.1 days in stage 3 of AKI and 3.7 days in Non AKI PICU cohort.

Mortality: In cases with AKI - 33.56% and 20.94% in Non AKI PICU cohort.

Discussion: Our results correlate with results from other PICU.

Conclusion:AKI is common in critically ill children which is associatedwith longer duration of PICU stay, prolonged mechanicalventilation, increased morbidity and mortality.Above results make it essential to diagnose AKI in critically ill patients early and institute appropriate treatment immediately.Septicemia, shock, peri-natal asphyxia and gastroenteritiswere the main co-morbidities associated with AKI.

Morbidity and Mortality Profi le of H1N1Dr Minhaz Hussain, Yudhveer Singh,

Anurag Singh, Pramod SharmaDepartment of Pediatrics, Dr SN Medical College, Jodhpur

Objectives: 1. To study the demographic profi le, clinical presentation,

radiological picture & complications of swine fl u (H1N1)pneumonia.

2. To assess the co-morbid conditions associated with pooroutcome.

Method: A prospective, single-centre study in which a total of 130 inpatient children of less than 18 years of age with clinical and radiological evidence of acute onset of pneumonia were enrolled in the study. Etiological and epidemiological profi le of these cases was studied in detail and infl uenza virus confi rmed by using RT-PCR (APPLIED BIOSYSTEM). For purifi cation of viral antigen-RNA QIAGEN-KIT was used. The children were evaluated for presence of malnutrition, congenital heart diseases, allergy, asthma and congenital anomalies.

Result: The H1N1 epidemic had witnessed more number of cases in age group of 1 to 5 year and in male children. There was no specifi c laboratory characteristic shown to have a signifi cant association with the severity of illness or poor outcome. However severe acidosis (pH<7.2) and Pao2/Fio2<300 was signifi cantly associated with poor outcome.

Conclusion: Statistically there was no age or sex related predilection in mortality seen. The present study established that there is a better outcome in patient of H1N1 pneumonia when treated with oseltamivir within 72 hours of onset of illness. The most common co-morbidity associated with swine fl u pneumonia was malnutrition although it was not signifi cantly associated with a poor outcome. Poor prognostic factors were - development of ARDS, use of mechanical ventilation and delay in starting antiviral therapy.

Case of Coffi n-Siris Syndrome a rare Presentation

Maheshwar Gunawat*, Suresh Goyal, Pradeep MeenaDepartment of Pediatric, RNT Medical College,

Udaipur, Rajasthan, India*Email: [email protected]

Abstract: Coffi n-Siris syndrome (CSS) is a rare, clinically heterogeneous disorder often considered in the setting of prenatal onset of mild to moderate growth defi ciency, facial dysmorphism, cognitive/developmental delay, speech impairment, moderate to severe hypotonia, seizures and 5th fi nger/nail hypoplasia.(1)

We here by presenting a case of this rare syndrome.

A male child of three and half years was admitted with chief complaints of global developmental delay and generalized convulsions. The child was product of non-consanguineous marriage with no signifi cant antenatal, natal and family history. Parents noticed developmental delay after three months of age and subsequently child had recurrent seizures, initially infantile spasm and followed by generalized tonic convulsion after the age of nine months.

On examination head circumference was 48 cm (between 15th and 3rd percentile). He had coarse facial features like low set ears, large ear pinna, depressed nasal bridge, fl at nasal tip, generalized hirsutism, thick eyebrows, long eyelashes, short stubby hand and genitals of tanner stage 2 with generalized hypotonia.


Developmental age of the child was approximately 1 year, language milestones were more delayed compared to others. Other neurological and systemic examination was normal.

EEG showed frequent epileptiform discharges from both hemispheres.

Keywords: Coffi n Siris Syndrome, global development delay, seizures, generalized hirsutism.

Clinical and etiological profi le of microcephaly in children aged 1 month to

60 monthsNeeraj Kumar, Suresh Goyal, Bhupesh Jain

Department of Pediatric, RNT Medical College, Udaipur, Rajasthan, IndiaEmail: [email protected]

Aim: To study the clinical and etiological profi le of microcephaly in children aged 1 month to 60 months admitted to Bal Chikitsalay, Udaipur.

Materials and Methods: Children attending Bal Chikitsalay, Udaipur were evaluated as per protocol. Z scores of head circumference were calculated using WHO charts and clinical, radiological and etiological profi le of those with microcephaly.

Results: Out the 77 children with microcephaly, Most of the children (84.42%) of microcephaly were admitted with Head circumference (HC) < - 3SD and mean age of children with microcephaly was 17.83±12.88 months. Developmental Quotient (DQ) ≤ 70% was present in 81.82% children. Developmental delay was present in 92.20% children. The children were classifi ed according to the fi nal diagnosis into 3 groups: Primary microcephaly 10 cases (12.99%), Secondary microcephaly 64 cases (83.11%) and Undiagnosed Cases 3 cases (3.90%). Secondary microcephaly was directly due to SAM seen in 40 cases (51.95%) followed by cerebral palsy associated with perinatal asphyxia was seen in 13 cases (16.88%). Neuroimaging were found abnormal in 56 children (86.15%) of Severe Microcephaly (HC<- 3SD). The most frequent MRI fi nding was cerebral atrophy in 33 cases (50.76%) followed by Hypoxic Ischemic Encephalopathy (HIE) 14 cases (21.54%). Most of children presented with developmental delay (92.2%), anaemia (77.92%), abnormal tone (71.43%) and convulsion (28.57%).

Conclusion: In our study Microcephaly was most commonly seen in SAM followed by HIE. Microcephaly was associated with developmental delay, lower DQ and higher comorbidities in children. MRI is considered as a gold standard in the evaluation of brain abnormalities in patients with microcephaly.

Scrub Typhus Meningitis: An emerging infectious threat

Jitendra Kumar Meena*, Shikha Khandelwal, Palak Gupta, B. S. Sharma

Sir Padampat Mother and Child Health Institute, Department of Pediatrics, SMS Medical College, Jaipur, India


Background: Recent reports from several parts of India indicate that there is a resurgence of scrub typhus. Central nervous system involvement was common in scrub typhus. There have been only few studies on scrub typhus meningitis, most are case report.

Methods: A prospective study done in Sir Padampat Mother and Child Health Institute, SMS Medical College, Jaipur from August 2014 to December 2014 including all admitted cases of scrub typhus. Diagnosis was made by a positive scrub IgM ELISA. Lumbar puncture performed in patients with headache, vomiting, meningeal signs, seizures, or altered sensorium.

Results: Forty nine cases of scrub typhus were found, and 7 (~15%) had meningitis. There were 25 males and 24 females. Only one patient had an eschar. Mean CSF cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 42 cells/μL, 97%, 81 mg/dL, 0.7 and 5.2 U/mL. Complications including thrombocytopenia, severe anemia, acute kidney injury and respiratory failure are more common in scrub typhus meningitis. There were no mortality from meningitis, all made uneventful recovery.

Conclusion: Our fi nding is contrary to current perception that scrub typhus rarely causes meningitis. Meningitis in scrub typhus is mild with quick and complete recovery. Clinical features and CSF fi ndings can mimic tuberculous meningitis, except for ADA levels. Both are endemic in india, so scrub IgM and CSF ADA levels may be helpful in differentiating these two and in avoiding prolonged empirical ATT in cases of lymphocytic meningitis.

Keywords: Meningitis, Scrub typhus, Eschar, Orientia tsutsugamushi

Incidence of UTI in severe acute malnurished children aged 6 to 60 months

Bharat Sharma*, R.L.Suman, Vibha Choudhary, Suresh Goyal

Department of Pediatric, RNT Medical College, Udaipur, Rajasthan, India


Introduction: Severe acute malnutrition is one of the most common health problem, involving hundreds of millions of


children in the world. As per human development report Rajasthan 2008, 33.7% children under 3 years are stunted, 19.7% children are wasted whereas 44% children are underweight. Malnutrition and infection is a vicious cycle. Malnutrition also affects the ability of kidney to acidify urine making children with SAM more prone for urinary tract infection. Urinary tract infection is a major cause of morbidity in children and an important occult infection in malnourished children. Most of severe acute malnourished children are admitted because of complications, mostly due to infections, usually gastrointestinal and respiratory infections. Urinary tract infection is one of the hidden infection which mostly go unnoticed until searched specifi cally. So, there is a need to screen every severe acute malnourished child for urinary tract infection.

Aims and Objective: To study the Incidence of UTI in severe acute malnourished children aged 6 to 60 months admitted to MTC at Bal Chikitsalay, Udaipur.

Material and Methods: This study comprised of 100 Children with severe acute malnutrition (according to classifi cation by WHO) admitted in Malnutrition treatment center (MTC), Bal Chikitsalay, Udaipur. Children were evaluated for Severe acute malnutrition as per WHO protocol Which includes Weight for Height<-3SD scores and/or, visible severe wasting and /or, MUAC<11.5cm and/or, bilateral edema of nutritional origin.They were tested for urinary tract infection by examining urine for microscopy and culture and ultrasonography of KUB region. Urinary tract infection is defi ned as presence of more than 5 pus cells per high power fi eld in a centrifuged urine sample or with >25 leucocytes/microlitre or with nitrite positive or with leucocyte esterase positive with presence of at least one bacteria and or positive urine culture.

Results: Out of 100 children with severe acute malnutrition, 60% were male and 40% were female. Majority of study population was under <-3SD and<-4SD Z score (73.0%) followed by <-5SD z score (21.0%) and 4.0% children were in <-6SD z-score as per WHO reference chart. Fifty eight percent SAM children came to hospital for respiratory complaints, 26% for gastrointestinal complaints, 8% had complaints suggestive of UTI and remaining came to seek medical advice because of not gaining weight and skin lesions. 43.0% children had evidence of UTI which was signifi cantly higher (p<0.001) than normal population. Forty fi ve percent of male children with SAM were suffering from UTI where as 40.0% of female children were suffering from UTI. The difference between incidence of UTI among male and female children was not statistically signifi cant with p value of 0.621. Incidence of UTI among various SD Z score was not signifi cant with p value of 0.389. Among the UTI patients 8.0% had culture positive, while 41.0% were having pus cells >25/microL and 38.0% children had nitrite positive on urine examination. On USG 9.3% children were also having malformations of genitourinary tract like ectopic kidney, hydronephrosis, cystic

kidneys etc when scanned as a part of investigation of UTI. Most common organism isolated was E. coli

Conclusion: Since the incidence of UTI is much higher, almost 43%in SAM children than well nourished when they have an acute febrile illness. So these children should be routinely screened to rule out urinary infections and follow up for long term sequels.

Diffi cult Esophageal Stricture Dilatation by Savary Gilliard Dilator is a better alternate of Surgery - A case series

Sonal Gupta, P.P. Gupta, Usha Aacharya, Madhu Mathur, Munish Kumar Kakkar, Mukesh Gupta,

Nitin Trivedi, Natwar Parwal*Department of Pediatrics, Mahatma Gandhi

Medical College & Hospital, Jaipur, Rajasthan*M: +91-9610951425; Email: [email protected]

Introduction: Esophageal stricture caused by accidental corrosive ingestion is seen commonly in pediatric age group. Up to 80% of caustic ingestion occurs in children fi ve years of age or younger. Other causes are Leaked battery in Esophagus, Post op trachea-esophageal fi stula, radiation and others. Accidental hot water ingestion causing stricture of the esophagus, rarely reported is also a cause in our series.

Methods: Pediatric endoscopic procedures from Sept 2014 to October 2015 were analyzed and diffi cultEndoscopic Esophageal Stricture cases were short listed.

Result: Out of 155 Pediatric endoscopic procedures, Esophageal Stricture dilatations were done 15 times (4+4+2+2+1+1+1) in 7 patients from Sept. 2014 to October 2015. The details of 5/7 diffi cult cases are described in (Table 1). Images of all cases are attached separately.

Conclusion: Dilatation with SavaryGilliard Dilator is safe and effective method for esophageal strictures unrelated to etiology. We can avoid surgeries and lots of surgical complications in these cases. Multiple sitting is the biggest disadvantage of this procedure.

References1. Poddar U, Thapa BR. Benign esophageal strictures in infants and

children: results of Savary-Gilliardbougie dilation in 107 Indian children. GastrointestEndosc. 2001 Oct; 54(4):480-4.

2. Pearson EG1, Downey EC, Barnhart DC, Scaife ER, Rollins MD, Black RE, Matlak ME, Johnson DG., Refl ux esophageal stricture--a review of 30 years’ experience in children. J Pediatr Surg. 2010 Dec; 45(12):2356-60.

3. Paulo Fernando SoutoBittencourt, Simone DinizCarvalhoEndoscopic dilatation of esophageal strictures in children and adolescents. J Pediatr (Rio J). 2006;82(2):127-31:


Table 1: Summary of diffi cult Endoscopic Esophageal stricture dilatation by SavaryGilliard DilatorCase-1 Case-2 Case-3 Case-4 Case-5

Month of presentation

March 2015 July 2015 October 2015 October 2015 October 2015

Age/Sex 1.5 Year/F 4 Year/M 6 Year/ M 8 Month/F 4 year/M

History Corrosive ingestionFollowed by recurrent vomiting after 15 days

Accidental Hot water Ingestion followed by mouth ulceration for 3- 4 days and diffi culty in swallowing after 15-20 days

Corrosive Ingestion followed by persistent vomiting

Operated case of tracheo esophageal Fistula

Acid ingestion followed by diffi culty in swallowing after 1 month

No. of dilatation 4 4 1 1 1

Reason of diffi culties

Very young age and ARI and persistent cough

Very small strictureDiffi cult to pass guide wire

Gastrograffi n study showed long segment strictureA sinus seen near stricture which partially disappear on air

Younger age with pneumonia and diffi culty in breathing

Stricture just below to cricopharynxChances of laryngospasmVery diffi cult to locate stricture and stabilize scope and vision also

Endoscopic fi ndings

Stricture at 14 cm from incisor in mid EsophagusDilated with SGD up to 11 mm (5mm-7mm-9mm-11mm)

Stricture at 17 cm from incisor in mid EsophagusDilated with SGD up to 9 mm (5mm-7mm-9mm till now)

Stricture at 17 cm from incisor in mid and lower part of EsophagusDilated with SGD up to 5 mm

Stricture at 13 cm from incisor in mid EsophagusDilated with SGD up to 5 mm and 7 mm

Stricture 13 cm from incisor in upper part of esophagusDilated with SGD up to 5 mm

Post Endoscopic recovery

Accepting both solids as well as Liquids

Accepting both solids as well as Liquids

Accepting Liquids Accepting Liquids Accepting Liquids

NCPCC 2015: Posters - Journal of Pediatric Critical CareVol. 3 - No.1 January - March 2016 40...

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