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   Table of Contents - Current issue
September-October 2020
Volume 7 | Issue 5
Page Nos. 229-302

Online since Monday, September 14, 2020

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Candidemia in pediatric intensive care unit: A new common and complicated comorbidity Highly accessed article p. 229
Rakshay Shetty, Swarnika Mishra
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Secondary bacterial infection in dengue fever in children: A reality or illusion? p. 231
Pradeep Kumar Sharma
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Necrotizing pneumonia in children: Is it rare anymore? p. 233
Govind Benakatti
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Prevention is better than cure: The vital role of the clinical pharmacist in the pediatric intensive care unit to prevent medication errors p. 235
Bridget Blowey, Karla V Resendiz, Angela Grachen, Vijay Srinivasan
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Candidemia in the pediatric intensive care unit in Eastern India p. 237
Chinmay Behera, Reshmi Mishra, Pratap Kumar Jena, Surya Mishra, Bandya Sahoo, Siba Brata Patnaik, Mukesh Jain
Background: Nosocomial infection, due to Candida, contracted in the pediatric intensive care unit (PICU), is emerging as a significant healthcare challenge. The incidence of non-albicans Candida as a cause of candidemia is on the rise, unlike in previous decades. Materials and Methods: All the cases of candidemia confirmed by culture, admitted to the PICU during the study period of January 2017 to December 2019, were retrospectively studied. The prevalence, speciation, sensitivity pattern and risk factors of candidemia mortality were recorded and analyzed. Results: There were 1034 admissions to the PICU in the study period, of which 926 blood samples were sent for culture and sensitivity. A total of 31 Candida non-albicans and five Candida albican species were isolated. C. tropicalis was the most common type (44.4%) of Candida species found, followed by C. glabrata (16.7%), C. parapsilosis (16.7%) and C. krusei (5.6%). The sensitivity of all Candida isolates to Amphotericin B, Clotrimazole, Voriconazole, Itraconazole, Ketoconazole, Nystatin, and Fluconazole was 94.4%, 91.7%, 88.9%, 86.1%, 77.8%, 52.8%, and 38.9% respectively. The use of a central venous catheter was a statistically significant contributor to mortality due to candidemia. Conclusion: Non-albican Candida species are the predominant cause of candidemia this study. They are associated with higher fatality rates. Sensitivity of the Candida spp. was more common to Amphotericin-B than azoles.
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Secondary bacterial infection in dengue fever and associated risk factors – An observational study in children p. 243
Sridhurga Udayasankar, Vijayanand Sivakumar, Raja Sundaramurthy
Background: Dengue fever remains one of the leading causes of hospitalization among children in endemic areas. Clinical manifestations of dengue fever are highly variable. There are only a few pediatric dengue fever cases reported with secondary bacterial infection. Knowledge of prevalence, risk factors, and predictors of bacterial infection among children with dengue fever is essential to initiate antibiotics. Objective: The objective of this study was to assess the prevalence of bacterial infection, analysis of risk factors, and predictors of bacterial infection among dengue fever patients with prolonged or recurrent fever after critical phase of illness. Design: This was a retrospective observational study. Setting: This study was conducted in the pediatric department of a tertiary hospital. Patients: Children with dengue fever who present with persistent or prolonged fever even after critical phase were included in the study. Results: Eighty-three children with dengue fever who had persistent fever for more than 5 days or recurrent fever were included in our study. Twenty-nine patients (34.9%) had definite secondary bacterial infection confirmed by positive culture and seven patients had probable secondary bacterial infection. The risk of secondary bacterial infection was higher in infants (P = 0.054), children who had fever >5 days on admission (P = 0.020), and children who had severe dengue (P = 0.016). The duration of hospital stay increased significantly in those with secondary bacterial infection (P = 0.041). No mortality was reported in culture-positive group. Conclusion: Our study highlights the increased risk of multidrug-resistant secondary bacterial infection among infants and in children who presented with fever >5 days and severe dengue fever. Hence, a low threshold to work up for secondary bacterial infections and early initiation of empirical antibiotics is warranted in these patients.
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Utility of a clinical pharmacist in the pediatric intensive care unit to identify and prevent medication errors p. 249
Ramaning Loni, Siddu Charki, Trimal Kulkarni, Mahesh Kamale, Laxman H Bidari
Background: Medication errors (MEs) in the pediatric intensive care units (PICUs) are common, predictable, serious, and preventable. Patients in the intensive care unit (ICU) are more vulnerable to increased MEs due to the complexity of underlying critical illness. Aim: The aim of the study was to determine the incidence, types, adverse effects, and outcome of MEs identified by a clinical pharmacist in the PICU. Subjects and Methods: This prospective observational study was conducted in the PICU of Dr. Bidari's Ashwini Hospital, Vijayapura, using daily observation of medical records from February 17, 2018, to November 30, 2019, using NCC-MERP guidelines to define the ME. Results: The incidence of MEs was 250/1000 patient days. Prescription errors were most common with 59.3% (3007), followed by administration errors with 21% (1100). Dispensing and transcription errors were 10.4% (528) and 8.6% (441), respectively. In prescription error, dosage error was predominant with 76% (2286), followed by documentation error in 15% (451), In transcription errors, incorrect drug dose was the most common error with 47% (208), followed by the wrong drug in 23% (102). In the case of dispensing errors, a supply of incorrect medicines was most common with 61% (321), followed by the unavailability of medicines with 24% (126). In administration errors, medicines given at the wrong time duration were observed in 55% (603), followed by orders not carried by nurses at an appropriate time in 23% (255). National coordination committee for ME reporting and prevention index severity classification includes Category B, the most common with 61% (3096) incidence, followed by Category C with 34% (1725).Total 23 patients developed probable adverse side effects. The mortality was only 1% (28) in this study, which was crude mortality of our PICU. Conclusions: (i) Prescription errors were the most common MEs followed by administration errors. (ii) The role of the clinical pharmacist was vital in identifying and avoiding the existing burden of MEs in the PICU. (iii) Reinforcement of structured training of the medical and paramedical staff is essential regarding the safe medication practices.
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A retrospective study of etiology, clinical features, management, and outcomes in children with necrotizing pneumonia p. 255
Maaz Ahmed, KS Sanjay, ML Keshavamurthy, GV Basavaraja
Introduction: Necrotizing pneumonia (NP) is a severe and emerging complication in children with community-acquired pneumonia (CAP). The study was conducted to analyze the etiology, clinical features, treatment strategies, and outcome of NP in children admitted in a single pediatric tertiary referral care center. Materials and Methods: The study is a retrospective chart review which included children above 1 month and below 18 years who were admitted at Indira Gandhi Institute of Child Health, from January 2015 to December 2018, with community-acquired NP. Results: During the study period, 1393 cases of CAP were admitted in our institute. Three hundred and fifty-two cases (25.2%) of complicated pneumonia were admitted which include cases of NP, lung abscess, and empyema. Children who were diagnosed with NP were 3.3% (n = 46) of all CAP cases. All the cases with NP were immunocompetent, with the most common organism isolated being Staphylococcus aureus followed by Streptococcus pneumoniae. NP is associated with complications such as empyema, pneumothorax, and bronchopleural fistula. All the children in the study group survived except for mortality in one case. Conclusion: NP can be well managed with conservative approaches such as prolonged antibiotic therapy and pleural drainage. Although there are commonly associated with local complications, in general the clinical outcome is good.
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Quality indicators and improvement measures for pediatric intensive care units Highly accessed article p. 260
Farhan Shaikh
Quality and patient safety is an integral part of pediatric critical care. Quality indicators (QIs) or key performance indicators (KPIs) are crucial to measure various aspects of quality and patient safety in pediatric intensive care. If we want a system which gives us reproducible results, it is crucial that various aspects of structure, process, and outcomes in that system are measurable and reproducible. It is crucial that the data used for measurements are accurate and they are analyzed using appropriate tools, and the KPIs/QIs calculated from the data are appropriately validated. These QIs/KPIs should be compared to the “accepted” international or national benchmarks on a periodic basis so that the team of doctors, nurses, and administrators are aware of the performance of their unit. In India, there are no national benchmarks available to compare the QIs/KPIs of our pediatric intensive care units (PICUs), and there is a dearth of such benchmarks for PICUs at international level too. In this review article, we aim to discuss the various aspects of data collection, data validation, and measurement of some important QIs of a PICU. We have also tried to gather some international benchmarks for some important QIs, which can be used by PICUs for their comparisons. Eventually, the best thing will be to develop a national database from various PICUs across India so that a national benchmark is created.
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Pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 – An emerging problem of PICU: A case series p. 271
Bal Mukund, Manoj Sharma, Ankit Mehta, Ashutosh Kumar, Vivek Bhat
Among rising number of coronavirus disease 2019 cases in children, there has been a rapid rise in cases of pediatric multisystem inflammatory syndrome associated with severe acute respiratory syndrome coronavirus 2 (PIMS-TS) with clinical features either simulating Kawasaki disease or toxic shock syndrome. We report three children who initially presented with fever, multisystem involvement, and features of hyperinflammation satisfying the World Health Organization criteria for PIMS-TS clinically and on laboratory investigations. All patients were treated with immune modulation by intravenous immunoglobulin and/or methylprednisolone and recovered to discharge.
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Pertussis: Resurgence of a forgotten entity p. 276
Mukesh Kumar Jain, Sibabratta Patnaik, Bandya Sahoo, Reshmi Mishra
Pertussis is a serious and life-threatening infection of infancy. Recurrent apnea with a paroxysm of cough is the early clue for its diagnosis. The rate of pertussis increased worldwide with the occurrence of regular outbreaks globally, including India. The resurgence of pertussis is multifactorial, and it includes antigenic shifts in bacteria, decreasing vaccine immunity, reduced duration of protection by acellular pertussis vaccine, and improved method of surveillance and diagnosis. Family members, especially mothers and siblings, are an important source of pertussis transmission to vulnerable infants. Maternal vaccination for pertussis during pregnancy should be done as many cases of infantile pertussis was found before primary immunization. A 45 days infants admitted to the pediatric intensive care unit with recurrent apnea and bradycardia, require prolonged mechanical ventilation with intense cardiorespiratory monitoring. Real-time polymerase chain reaction of the nasopharyngeal swab for pertussis was positive. Successfully discharged after a long course of hospitalization.
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A rare cause of pulmonary hemorrhage in the intraoperative period p. 279
Anurakti Dev Singla, Anil Sivadasan Radha, Girish Warrier, Meena Trehan
The perioperative morbidity and mortality in pediatric cardiac surgery can be due to a multitude of factors. Timely identification of the problem helps in altering the treatment strategy and improving the outcome.
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Acyclovir crystalluria: The utility of bedside urine routine microscopic examination p. 282
Puneet Jain, Ramachandran Rameshkumar, Ponnarmeni Satheesh, Subramanian Mahadevan
Acyclovir, an acyclic nucleoside, is commonly used for the treatment of viral infections. Acyclovir is well tolerated in children. However, severe nephrotoxicity has been shown to occur in some children. One of the mechanisms for acyclovir-induced nephrotoxicity is acyclovir-induced crystalluria. Prompt attention to urine microscopy examination can help avoid drug-induced nephrotoxicity. Here, we report a case of a seven-year-old febrile comatose child who received intravenous empirical acyclovir therapy and developed cloudy urine. Bedside urine microscopic examination shows fine-needle-shaped crystal. The urine was cleared within 12 h of stopping the acyclovir and adequate intravascular hydration. A child recovered without evidence of acute kidney injury.
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Giant asymmetrically peaked T-waves in a child with raised intracranial pressure due to acute central nervous system infection: A case report and review of the literature p. 285
Puneet Jain, Ramachandran Rameshkumar, Ponnarmeni Satheesh, Chitamanni Pavani
Although various changes in electrocardiogram (ECG) were reported with normal serum potassium levels in acute intracranial pathology, giant asymmetrical T-wave change has not been reported. We report a case of a previously healthy male child who presented with acute febrile illness and features of raised intracranial pressure. Full standardized ECG shows normal sinus rhythm and tall, broad, and giant asymmetrically peaked T-wave. Serum potassium, echocardiography, and cardiac injury marker were normal. The child managed with supportive care and antimicrobials and showed recovery in 7 days.
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Point-of-care ultrasound in pediatric cardiac masses: A case series p. 288
S Sachin Jangam, Shobhavat Lakshmi, Mishra Jayashree, Solomon Rekha, Pathak Nakul
The utility of point-of-care ultrasound (POCUS) is well supported by evidence In the Indian scenario, there are no standard guidelines or special training for POCUS in the pediatric intensive care unit. We present here a case series of nine patients with intracardiac masses in whom POCUS performed by pediatric intensivist helped in the management of critically ill patients. The final diagnosis of these patients included left atrial myxoma, two cases of thrombus, four cases of infective endocarditis (IE) with unusual organisms, and two cases with diagnostic confusion about IE/thrombus/cardiac tumor. In all these patients POCUS helped in deciding the line of management such as choice of antimicrobial therapy, site of the central venous catheter, and timely involvement of cardiologist and cardiothoracic surgeon. One of the children presented with obstructive shock and bedside ultrasound helped in the diagnosis of a left atrial mass and early surgery with a good outcome.
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Acute bronchiolitis in children p. 293
Kundan Mittal, Teena Bansal, Anupama Mittal
Bronchiolitis is the most common respiratory disease in children below 2 years of age. Primarily, the disease is caused by viral infection (respiratory syncytial virus), mainly in the month from November to April. Climate and environment both influence the season and severity of bronchiolitis. Forty percent infants are affected in 1st year of life. Diagnosis of the bronchiolitis is mainly clinical though various definitions have been suggested by different groups. Laboratory investigations including reverse transcription polymerase chain reaction, chest X-ray, and others do not contribute in diagnosing the disease. There is no effective treatment available and mortality is also low with bronchiolitis.
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Carbamazepine poisoning: A narrow escape p. 297
Mahmood Dhahir Al-Mendalawi
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PICU quiz p. 298
Pradeep Kumar Sharma
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Cases in Pediatric Acute Care: Strengthening Clinical Decision Making p. 302
Kundan Mittal
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