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   Table of Contents - Current issue
January-February 2021
Volume 8 | Issue 1
Page Nos. 1-58

Online since Friday, January 8, 2021

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Pediatric intensivists in India: The pursuit of happiness Highly accessed article p. 1
Utpal S Bhalala
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(Not) as cold as ice: Exploring mild hypothermia during circulatory arrest for congenital heart disease surgery p. 3
Monique M Gardner, Venkat R Shankar, Vijay Srinivasan
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Hyperferritinemia: An important maker in sepsis p. 5
Govind Benakatti, Javed Ismail
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Assessment of job satisfaction and quality of life among practicising pediatric intensivists of India: Results of a pediatric critical care physician survey p. 7
V S. V. Prasad, Anjul Dayal
Introduction: Pediatric intensive care specialty is a challenging field. This exposes the pediatric intensivist to various levels of stress at different stages of their career. The various precipitating factors for stress are prolonged working hours, decreased quality time with family, unsatisfactory remuneration, and increasing medicolegal litigations and physical, psychological stress, and property damage caused by unhappy families. Aim: The study was conducted to assess the quality of life, working patterns as well as socioeconomic wellbeing among pediatric intensivists working in Indian pediatric intensive care units (PICUs) in the private sector, public sector, and charitable institutions. Methods: A nationwide survey was performed in 2019 among the pediatric critical care fraternity across India to ascertain and enquire about several aspects of their work, careers, and personal lives with a Google form request with preformed questions and single answer options for this survey. Results: A total of 181 responses were received. About one-third (34%) chose this pediatric specialty for its challenging nature. Close to 40% of respondents were engaged in practice of other specialties of pediatrics apart from pediatric intensive care. Professionally, 86% of pediatric intensivists were satisfied with their work. More than half of the respondents (62%) felt that aggression against hospitals and health-care personnel was worrisome and these incidents affected their personal health with increased stress and subconscious fear. Conclusions: This survey revealed that most pediatric intensivists are satisfied with their chosen profession. Stress has been documented as a significant issue with violence in health-care settings being one of the most worrying aspects.
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Mild hypothermia with selective antegrade cerebral perfusion during cardiopulmonary bypass and short-term outcomes in children with congenital heart defects p. 13
Utpal S Bhalala, Pranali Awadhare, Malarvizhi Thangavelu, Richard Owens, Maria Zamora, Daniel Nento, Elumalai Appachi, Muhammad Ali Mumtaz
Background: Among the known risk factors for children undergoing surgery for congenital heart defect (CHD), temperature and blood flow during cardiopulmonary bypass (CPB), are two risk factors, which may be altered to improve outcomes. Moderate - to - deep hypothermia (MDH), traditionally used, has been associated with short/long-term neurologic sequelae, so there is a move towards mild hypothermia (MH) with selective antegrade cerebral perfusion (SACP). Aims and Objectives: To assess feasibility of mild hypothermia with selective antegrade cerebral perfusion during cardiopulmonary bypass as a cardiopulmonary bypass strategy in neonates and infants undergoing surgery for congenital heart defect. Materials and Methods: We conducted a retrospective chart review of neonates and infants who underwent SACP on CPB during CHD surgery at our tertiary care children's hospital between January 2014 and February 2017. We categorized all the patients into 2 groups - MH + SACP or MDH + SACP. We gathered data on preoperative, intra-operative and post-operative parameters. We analyzed comparative data using student t-test and chi-squared test with a significant p-value < 0.05. Results: There were 6 in the MH + SACP group and 7 in the MDH + SACP group, who underwent SACP on CPB during study period at our children's hospital. All the neonates and infants in the MH + SACP group survived at the hospital discharge with favorable neurologic outcomes. There was no statistically significant difference between the two groups for end organ dysfunction, ventilator days, hospital days, ICU and hospital mortality and PCPC/POPC at hospital discharge. Conclusions: Mild hypothermia with selective antegrade cerebral perfusion during cardiopulmonary bypass is a feasible cardiopulmonary bypass strategy in neonates and infants undergoing surgery for congenital heart defect.
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Can serum ferritin be employed as prognostic marker of pediatric septic shock and severe sepsis? p. 20
Mihir Sarkar, Satyabrata Roychowdhury, Mohammad Asraf Uz Zaman, Sumantra Raut, Subhajit Bhakta, Mousumi Nandy
Introduction: Serum ferritin has emerged as an independent marker predicting the outcome of critically ill patients. The cutoff value of ferritin in predicting mortality in septic children is not well established. Objective: The aim is to determine the cutoff value of ferritin which is, best predictive of mortality in patients with age from 1 month to 12 years with a diagnosis of septic shock or severe sepsis and to evaluate correlation with PRISM III score, and Pediatric Logistic Organ Dysfunction score (PELODS). Materials and Methods: A prospective observational study was conducted over a period of 2 years at pediatric intensive care unit (PICU) in children with age from 1 month to 12 years with septic shock or severe sepsis and PICU stay >24 h. Children with autoimmune diseases, primary hemophagocytic lymphohistiocytosis, blood transfusion in the past 4 months, known malignancies and immunosuppressive treatment were excluded. PRISM-III and PELODS were assessed to predict the risk of mortality and severity of disease. The highest value of ferritin was taken to draw area under the curve using receiver operating characteristic curve and determine cutoff value. Results: Out of 176 children of septic shock or severe sepsis, 132 were included in the study. Mortality rate was 22.7% (n = 30). PRISM III and PELODS-2 were significantly high in nonsurvivors (P ≤ 0.001 and 0.006, respectively). The cutoff value of ferritin at 2375 ng/dl had sensitivity 96.7% and specificity 88% to predict mortality. Ferritin level was positively correlated to the PRISM III and PELODS, correlation coefficient 0.447 and 0.601, respectively. Conclusion: Serum ferritin values ≥2375 ng/mL in children with septic shock, and severe sepsis was significantly associated with mortality. Its performance had a good correlation with PRISM III and PELODS.
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Acute leukoencephalopathy with restricted diffusion associated with Japanese encephalitis virus p. 27
Leema Pauline Cornelius, Asir Julin Paulraj, Neeraj Elango
Acute leukoencephalopathy with restricted diffusion (ALERD) is a clinicoradiological syndrome characterized by acute encephalopathy, seizures, and diffuse areas of restricted diffusion in bilateral cerebral parenchyma on magnetic resonance imaging. ALERD can occur following infections and exposure to drugs and toxins. Early recognition by neuroimaging and the institution of immunotherapy may be useful in improving neurological outcomes. We report a case of diffuse infectious ALERD associated with Japanese B encephalitis viral infection.
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Cerebral infarction in a child with congenital adrenal hyperplasia presenting as acute encephalitis syndrome p. 31
Saugata Acharyya, Kakoli Acharyya, Arnab Haldar
Congenital Adrenal Hyperplasia (CAH) is an inherited abnormality of steroid synthesis. It is usually diagnosed in the early neonatal period. Its association with white matter abnormalities in the developing brain has been reported. Cerebral infarction is one of the rarely associated complications of classical CAH. A 5-year-old child had presented with features of acute onset fever, refractory new-onset seizure, and altered sensorium. He was a known case of CAH, on regular exogenous steroid supplementation. Investigations revealed that he had extensive hemorrhagic cerebral infarction. No underlying infective or vascular cause could be detected to explain the etiology of cerebral infarction in this child. Hence, the effect of CAH on the developing brain and an inadequate escalation of steroid dose during stress have led to the cerebral infarction.
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Systemic autoimmune diseases presenting as acute myocarditis in pediatric emergency: Two case reports p. 35
Sayantan Mondal, Rituparna Das, Moumita Samanta, Madhumita Nandi
Children seldom present to the emergency with cardiac manifestations, some of which eventually are diagnosed as manifestations of rheumatological diseases such as systemic lupus erythematosus or arthropathies. While cardiac involvement is known in these cases, their presentation solely as a cardiologic event initially is not widely known. The following two case reports depict how cardiological emergencies ultimately evolve as systemic autoimmune diseases with atypical involvement such as myocarditis with heart failure and are salvaged with appropriate management.
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Febrile infection-related epilepsy syndrome treated successfully with enteral lorazepam as a substitute for intravenous midazolam as weaning drug p. 39
Amarlok Kumar, Ravi Sharma, Preeti Kharwas, Anupam Chaturvedi, Vivek Jain
Febrile infection-related epilepsy syndrome (FIRES) is an acute-onset epilepsy syndrome usually refractory to conventional antiepileptics and immunomodulation. Here, we report an adolescent male child whose seizures were refractory to multiple anticonvulsants, high-dose phenobarbitone, and ketogenic diet. He subsequently responded to coma induction with midazolam, though with seizure recurrences following multiple attempts at weaning of midazolam over the next 2½ months. Due to continuing prolonged intensive care stay, we substituted intravenous midazolam for equivalent dose of enteral lorazepam with good seizure control.
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Acute febrile encephalopathy and seizures in children with diffusion restriction lesions on magnetic resonance imaging brain: A case series p. 42
Sai Divya Sasi Kumar, Venkat Sandeep Reddy, Bhakti Sarangi, Ajay Walimbe
Over the last decade, several entities within the spectrum of acute febrile encephalopathy (AFE) including acute disseminated encephalomyelitis, acute necrotizing encephalitis, fever-induced refractory epilepsy syndrome, clinically mild encephalopathy with reversible splenial lesion, and autoimmune encephalitis have been recognized, all of which now have reasonably well-established clinicoradiological diagnostic criteria and therapeutic options. This case series highlights the clinical profile and outcome of seven children with the lesser-known entity of AFE with seizures and white matter diffusion restriction lesions on magnetic resonance imaging. All children had a history of acute onset fever, altered sensorium, and refractory seizures requiring multiple antiepileptic drugs and presented in shock requiring multiple organ support. All had extensive, diffusion-restricted lesions involving white matter. The infectious trigger was identified as influenza A (H3N2) in case 1, dengue virus in cases 2 and 6, and influenza B in case 4. Five children survived, each of whom had significant neurological sequelae.
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Acute necrotizing encephalopathy of childhood: Not always devastating p. 47
Surjeet Kumar, Vijay Kumar, Bhanudeep Singanamalla, Sameer Vyas, Suresh Kumar Angurana
Acute necrotizing encephalopathy of childhood (ANEC) is an uncommon cause of acute onset febrile encephalopathy, which progresses rapidly and has poor outcomes. We reported a 4-year-old female who presented with acute febrile encephalopathy, raised intracranial pressure (ICP), and respiratory failure. The brain imaging was suggestive of ANEC. The treatment included antibiotics, antivirals, mechanical ventilation, measures to lower ICP, intravenous immunoglobulin, and supportive care in the Pediatric intensive care unit with which she made a remarkable recovery.
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Pediatric clonidine poisoning p. 50
Dipti Sanklecha, Praveen Palyam Nagendra, Basavaraja Gangasamudra Veerappa, Keshavamurthy Mysore Lakshmikantha
Clonidine, a commonly used anti-hypertensive agent, is being increasingly used in the treatment of pediatric behavioral disorders, thus increasing the incidence of pediatric poisoning. Poisoning causes somnolence, respiratory depression, hypotension, sinus bradycardia, and miosis. Clonidine overdose of >0.01 mg/kg causes bradycardia and hypotension and >0.02 mg/kg causes apnea and respiratory depression. A 13-year-old boy presented to us with ingestion of 0.073 mg/kg clonidine. He had only sinus bradycardia and drowsiness, which had resolved without any active interventions. As the life-threatening side effects of clonidine poisoning seem to be very rare even at toxic doses, it can be used safely in the pediatric age group.
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Pediatric intensivists' perspective on managing adult critically ill patients during coronavirus disease-19 pandemic p. 53
H Michael Ushay, Shivanand S Medar, Pooja Nawathe, Pavanasam Ramesh, Giovanna Chidini, Manu Sundaram, Utpal S Bhalala
The novel corona virus pandemic has stretched health-care systems globally. In parts of countries such as USA, Italy, UK, and Spain, the adult health-care system has been overwhelmed by the sheer volume of patients requiring hospital admissions. Learning from other countries that have earlier peaks, various health-care organizations came up with plans providing guidance on preserving the functioning of health-care system in anticipation of a public health crisis. Coronavirus disease (COVID-19) has been less severe in children, and fewer children have required pediatric intensive care unit (PICU). For this reason, the surge plan to care for high number of critically ill adult patients with COVID-19 was to use PICU. There are various models on how to care for these patients in the surge capacities in the PICUs. We, hereby, reflect on our experience of managing the critically ill adult patients in PICUs in USA, UK, and Spain.
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Critical care pediatric nephrology and dialysis: A practical handbook p. 58
Muhammad Shahzad
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