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   Table of Contents - Current issue
March-April 2021
Volume 8 | Issue 2
Page Nos. 59-116

Online since Wednesday, March 10, 2021

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Unplanned extubation in the pediatric intensive care unit: Alert, acknowledge, and avert Highly accessed article p. 59
Suresh Kumar Angurana
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Femoral arterial catheters for hemodynamic monitoring in infants: Is it time to look more peripheral? Highly accessed article p. 61
Manjinder Singh Randhawa, Karthi Nallasamy
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Infusion of vasoactive drug through peripheral line: A myth or fact? Highly accessed article p. 63
Muthu Chidambaram, Ramachandran Rameshkumar
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Normative data of inferior vena cava diameters of Indian children: Need of the hour p. 65
Vinayak Patki
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Clinico-etiological profile of children who had unplanned extubation and subsequent re-intubation in level-4 pediatric intensive care unit Highly accessed article p. 67
Vishnu Vardhan Kodicherla, Farhan Shaikh, Pawan Kumar Duvvana, Anupama Yerra, Yashwanth Reddy, Parag Dekate, Kapil Sachane, Dinesh Kumar Chirla
Background: There are few studies on unplanned extubation (UE) in pediatric intensive care units (PICU). This study is to identify factors associated with UE in PICUs. Subjects and Methods: In this observational study, the data of UE from January 1, 2013, to May 31, 2019, in a level-4 PICU were analyzed with an objective to study the etiology of UE and its impact on therapeutic outcomes. Results: Of 7079 patients hospitalized in PICU, 1721 were invasively ventilated (mean ventilator days 4.33 days). UE occurred in 39 patients (2.26% of intubated patients) at 0.52 UE events per 100 ventilation days. The median age was 14 months. The most common cause of UE was inadequate sedation (n = 24, 61.53%), endotracheal tube suctioning (n = 05, 20.8%), one during adjusting ET tube (4.1%), one during central venous line insertion (4.1%), and one during Foley's catheter insertion (4.1%) and 7 unexplained (29.1%). As long as the appropriate nurse: patient ratio was maintained, the incidence of UE was un-affected by day versus night shift or high versus low bed occupancy rates. Re-intubation rate in UE cohort was higher (74.35%) than planned-extubation cohort 0.11% (P < 0.001). All re-intubations were within 2 h of UE. Most common cause of re-intubation following UE was respiratory distress (72.41%), stridor (17.24%), and apnea (10.34%). Re-intubations following UE showed higher incidence of ventilator-associated pneumonia but statistically not significant (P = 0.54). Conclusion: UE is associated with a significantly high incidence of re-intubations and associated complications arising from re-intubations. Maintaining a pool of skilled nurses in adequate nurse-to-patient ratio may play an important role in preventing UE. UE can be minimized by optimizing sedation and monitoring during common ICU procedures. Multicentric studies are warranted to design a uniform standard of care of ventilated patients aimed at reducing the incidence of UE.
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Complications of femoral arterial lines in infants under 12 months p. 74
Benjamin David Carr, Sumer D Sebik, Clinton J Poling, Lindsay S Holland, Haley R Divis, Irene C St Charles, Anne E Baetzel, Samir K Gadepalli
Background: The risks of femoral arterial line placement in young children have been incompletely defined. We hypothesized that a low complication rate would be associated with ultrasound use. Subjects and Methods: Infants aged 0–12 months undergoing placement of a femoral arterial line at our institution over a 3.5-year period were identified through billing data, and their records were reviewed. Events concerning each line were recorded individually. Patients were excluded if there was incomplete documentation or if the line was in place for under 24 h. Demographics, information about line placement, and complications were recorded. Results: Three hundred and sixty-four femoral arterial lines were included. Eighty percent of lines were placed in the operating room, with the rest placed in the cardiac intensive care unit (ICU) (11%), the cardiac catheterization lab (6%), or the pediatric ICU (3%). Femoral artery occlusion occurred with 16% of lines placed, and limb ischemia in 6%. One patient had tissue loss. Occlusion was associated with lower gestational age at birth (44 [40–57] vs. 50 [41–60], P = 0.04), lower weight (3.7 [3.1–5.7] vs. 4.3 kg [3.3–6.2], P = 0.05), left-sided lines (52% vs. 66%, P = 0.05), placement in interventional catheterization lab (odds ratio [OR]: 3.28, confidence interval [CI]: 1.24–8.67, P = 0.02), >2 attempts (27% vs. 13%, P < 0.01), and catheter diameter (OR: 2.86, CI: 1.18–6.92, P = 0.02). Conclusion: Femoral arterial catheter placement in infants younger than 12 months resulted in a 16% rate of arterial occlusion at our institution, which was associated with low gestational age, larger catheter size, and left-sided lines but not ultrasound use, line duration, catheter length, use of anticoagulation, physician specialty, or physician training level.
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Comparison of external jugular venous access with internal jugular venous access in pediatric shock: An observational, prospective study p. 79
Amit Kumar, Krutika Tandon, Kushal Mukeshkumar Shah, Rahul Tandon, Mamta R Patel
Background: Central venous access is usually preferred over the peripheral venous route when circulatory failure needs inotropes and vasopressors. However, in resource-limited settings with underskilled personnel, it is not feasible always and so patients are being treated with the peripheral venous route with variable results. We aimed to compare external jugular venous (EJV) access with internal jugular venous (IJV) access for effectiveness, ease of procedure, complications, and treatment cost in pediatric shock. Subjects and Methods: This was a prospective, nonrandomized, observational study from January 2014 to June 2015 in 66 pediatric patients with shock at a 7-bedded pediatric intensive care unit. Parents were explained about both routes. Depending on their affordability and consent, one route was chosen. Pertinent data were obtained, and analysis was done as per objectives. Results: EJV and IJV had 50 and 16 patients, respectively. Baseline characteristics were comparable. Death and discharge against medical advice rates are high in both the groups. No procedure-related life-threatening complications in any group and local site problems were similar in both the groups. Overall attempts and duration of procedure were similar in both the groups, and although the initial cost of the procedure of the IJV group was higher, overall final hospital bill had no significant difference. The median (Q1, Q3) hours of achieving shock-free status were 48 (24, 96) and 46 (12, 108) (P = 0.412). The median (Q1, Q3) improvement in base deficit at the end of 24 h was −4.5 (−8.1, 0.27) and −1.9 (−4.2, −0.6) (P = 0.259) in the EJV and IJV groups, respectively. Conclusion: For pediatric shock management, EJV access is an effective, easy, and cost economic procedure without significant complications as compared to IJV access.
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Normative data for inferior vena cava diameters and collapsibility index in healthy Indian children from a tertiary care hospital of Chennai p. 86
Vidya Ghosh, Suchitra Ranjit, Ramakrishnan Balasubramaniam, Shipra Agrwal
Background: An ultrasound evaluation of the inferior vena cava (IVC) collapsibility index (CI) has proven to be an excellent noninvasive method of evaluating hydration in adult patients. There is a lack of normative data on the IVC diameters and CI in Indian children. This study was planned to formulate the normative values for IVC diameter in children and adolescents and to assess its correlation with various somatic parameters in Indian children aged 6 months–16 years. Subjects and Methods: Children aged 6 months–16 years in good general health, normal hydrations, and without any significant underlying medical condition who were coming to hospital for their treatment in the outpatient department were consecutively enrolled in the study. The maximum and minimum diameters of IVC were measured during the expiratory and inspiratory phase of the respiratory cycle, respectively, using M mode ultrasonography. CI was also calculated for each subject. These values were correlated with age, gender, and body surface area (BSA). Results: One hundred patients were enrolled in the study, 48 were boys and 52 were girls. The mean (standard deviation) CI was 23.3% (11.9) among males and 20.1% (11.7) among females. The mean maximum and minimum IVC diameter increased significantly with age (r = 0.738, P = 0.00; r = 0.789 P = 0.000) and with BSA (r = 0.73, P = 0.0001; r = 0.77, P = 0.0001). CI did not show significant correlation with age or BSA. Conclusion: IVC dimensions during inspiration or expiration increases with age and BSA, but same relation does not hold for CI. These values were similar among males and females.
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Intermittent sympathetic stimulation: A clinical clue of Intussusception with altered mental status p. 91
Guruprasad Hassan Shankar, Arun Thomas, V Santhikrishna, Gurudutt Avati Venkatesha
Neurological symptoms are documented in intestinal pathologies; however pure neurological presentation in abdominal conditions are rare and presenting with intermittent autonomic disturbances are extremely rare. Here we describe two cases with intestinal obstruction and intussusception who had intermittent hypertension and tachycardia. Diagnosis in both the children were initially challenging, especially so in the first case as the child presented with only neurological symptoms. The exact pathogenesis of this sympathetic overdrive is not known and requires more studies to evaluate the cause. In both the kids, once the primary pathology was treated, the children became neurologically better and has been fine on follow up.
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A less aggressive approach to the management of super refractory status epilepticus p. 95
Madhumathi Gunasekaran, Gowthami Reddi, Ayyammal Palaniappan, Velmurugan Singaravadivelu, Ramakrishnan Tirupur Chinnappan Ramalingam
Febrile infection-related epilepsy syndrome (FIRES) is a rare catastrophic encephalopathy of unknown etiology. It commonly affects previously healthy children. FIRES is a subcategory of new-onset refractory status epilepticus (NORSE), term used specifically for adult population, and FIRES is used for pediatric population. Uniformly, both FIRES and NORES have poor outcomes with chronic drug-resistant epilepsy, severe neurological sequelae, and mortality in one-fifth of patients. We report a case of FIRES in a 9-year-old previously healthy child in whom a less aggressive approach was used to manage anesthetic resistant super refractory status epilepticus, which has reduced the potentially fatal complications of prolonged use of intravenous anesthetics and also the need for tracheostomy.
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Diphenoxylate hydrochloride and atropine sulfate overdose in an infant presenting as respiratory failure p. 99
Sanchari Ghosh, Saurabh Sutradhar, Prabhas Prasun Giri
A fixed-dose combination of diphenoxylate hydrochloride and atropine sulfate marketed widely as oral tablets, is one of the most frivolously used drugs to treat diarrhea in adults. Its safety and efficacy in children younger than 2 years are not known. In this case, we came across a 45-day-old infant being maltreated with adult dose of the drug, for diarrhea, by a local charlatan, which landed him in the emergency room with lethargy, altered sensorium, and type 2 respiratory failure and ultimately had to be salvaged by mechanical ventilation. This case describes the life-threatening adverse effects of an adult drug on the pediatric age group.
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Successful use of tocilizumab in the treatment of multisystem inflammatory disease of childhood refractory to intravenous immunoglobulin and glucocorticoids p. 102
Jitendra S Oswal, Bhakti Sarangi, Guruprasad Hassan Shankar, Varsha Sharma
Multisystem inflammatory syndrome in children (MIS-C) is one of the many challenges thrown by the ongoing SARS CoV-2 pandemic. A high index of suspicion is warranted for the diagnosis of MIS-C as presenting features overlap with Kawasaki disease and toxic shock syndrome. The treatment guidance is empirical with consideration of intravenous immunoglobulin (IVIG) and glucocorticoids. However, treatment of refractory MIS-C remains eluded. We describe here a 7-year-old boy with MIS-C refractory to IVIG and pulse methylprednisolone who responded to interleukin-6 inhibition using tocilizumab.
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Paraquat poisoning case series during Covid-19 pandemic p. 106
Vipin Roach, Mangla Sood, Ishaan Sood
This case series examined the demographic details and outcome of seven pediatric paraquat (PQ) poisoning patients admitted to a teaching hospital in North India from February to October 2020 during the COVID-19 pandemic. All were adolescents and had intentionally ingested PQ for suicide; four died in spite of best recommended immunomodulator and anti-inflammatory therapy and hemodialysis (HD) due to multiorgan failure. We hope that the data would be of useful to clinicians who deal with poisoning.
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Surge in diabetic ketoacidosis in children with Type 1 diabetes during COVID-19 pandemic – A report from a tertiary care center in Pune, India p. 110
Guruprasad Hassan Shankar, Varsha Sharma, Bhakti Sarangi, Ajay Walimbe, KC Prithvichandra Markal, Venkat Sandeep Reddy
As the COVID-19 pandemic evolves, an increasing number of concurrent associations are being reported including several postinfectious phenomena. The role of diabetes mellitus (DM) and its implications in increased severity and mortality of adults with COVID-19 is established. COVID-19 is known to cause hyperglycemia and worsen glycemic control in adults with active infection. However, the association in pediatric population is not well established. The interplay between biological, psychosocial, and economic factors for increased association of COVID-19 with Type 1 DM and/or presentation with diabetic ketoacidosis (DKA) is not clear. We briefly describe a surge in the number of children with DKA as experienced in our center in the course of the ongoing pandemic with a brief evaluation of all the abovementioned factors.
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All tachypnea is not coronavirus disease 2019: A child with neglected airway foreign body p. 114
Suchit Jogu, Manjinder Singh Randhawa, Ravi Prakash Kanojia, Suresh Kumar Angurana
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Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine Eighth Edition p. 116
Kundan Mittal
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