Background: Prevalence of acute respiratory distress syndrome (ARDS) in PICU is high with high mortality, however data from developing country with resource limited ICU are lacking in literature. Objective: To study the sociodemographic characteristics, predisposing conditions, and complications of ARDS in a tertiary care PICU and to compare the different oxygenation and ventilator parameters with survival. Methods: This prospective observational study was conducted in a PICU from a tertiary care centre. All sick children admitted to PICU over a period of 18mo who developed ARDS based on American European consensus conference committee criteria definition were enrolled. The association of survival with demographic, clinical profile, complication, different oxygenation and ventilator parameters were analysed through SPSS 24. Results: Fourty one cases of ARDS were diagnosed with an incidence of19.4 per 1000 ICU admission. Median (IQR) age at presentation was 72(42-120 mo), 30(73.1%) were males and 32(78.0%) from rural area. Sepsis 16(39.0%) and malaria 8(19.5) were the major predisposing condition, whereas shock 34(82.9%) and pneumothorax 31(75.6%) are major complication. Only 5(12%) patients survived. No significant difference in age, sex, place of residence, predisposing factors and other complications were found between survivors and non-survivors (p > 0.05). Non-survivor ARDS had more of non-pulmonary cause (p-0.006) and remained fewer days in ventilator (p-0.010). No significant difference was found in oxygenation (paO2/FiO2), respiratory mechanics and lung injury score between both groups. Conclusion: ARDS is a serious complication in children admitted to ICU with sepsis, malaria and H1N1 with high mortality. ARDS due to non pulmonary causes and ARDS complicated with shock contribute significantly to mortality. Oxygenation (PaO2/FiO2), respiratory mechanics and lung injury score are not significantly better on survivors.

Objective: Maintenance intravenous fluid (mIVF) is cornerstone in the management of ill children. Several brain damage and mortalities in previously healthy children have been reported from traditional hypotonic fluid due to “hospital-acquired hyponatremia”. Purpose of this study is to assess the clinical practice in our pediatric emergency about mIVF. Material and Methods: Our study was conducted in the pediatric emergency room of a tertiary-care hospital in Karachi, Pakistan as a retrospective chart review. All children from 6months to 16 years of age, presented in the emergency room and required maintenance intravenous fluid therapy were included in the study. No intervention was done. Duration of this study was 3 months (April -July 2014) and was reviewed after ERC approval. All children from 6months to 16 years of age, required maintenance intravenous fluid therapy were included in the study. Primary outcome was the type of fluid prescribed as mIVF while secondary outcome was the difference of serum sodium level after 12-24hr. Results: 527 children were admitted, of those more than half (56%) were male. Median age was 43 months. Admitted patients in emergency were given three types of mIVF. Some children received all three types and some received only one. Most of the given IVF was IVF 0.9% i.e. 78.4% where as 31.7% received IVF 0.45% and only few received IVF 0.18%. Serum sodium of all patients was checked however only 22% were evaluated twice for serum sodium level. The mean sodium values were 135.6 and 137.7 for Na (0) and Na (1) respectively and mean difference between both Na was -0.97. No changes in Na (0) to Na (1) were reported in 9.6%. Conclusion: Isotonic fluid is better than hypotonic fluids in hospitalized children to prevent changes in serum sodium levels specially hyponatremia which results in morbidity as well as mortality.

Objective: It is common to see many NICU across India but well equipped separate PICU is rarity especially in smaller cities and rural hospitals. Our aim is to share our experience of PICU from a rural background catering services to 1 month to 18 years patients. Material and Methods: In this retrospective study, we present data (retrieved from medical records) of 216 mechanically ventilated children from total of 1084 PICU admissions in 3 years period. Results: Mechanical Ventilation (MV) rate was 31%. Male: Female ratio was 1.8:1 with 37.04% infants. Majority (77%) were referred cases, of which 67% required immediate endotracheal intubation on arrival at our ED. Patients who were transported in ambulance with staff and facility (22.2%) showed improved outcome in terms of mortality (6.25% Vs 14.88%: Proper Vs Improper transport). Indications for MV were Respiratory-32.4%, Neurologi- cal-29.16%, Circulatory failure-14.81% and others-23.6%. Pressure SIMV and Pressure A/C were the most preferred initial modes (80%) whereas CPAP/PSV was preferred weaning mode (75.7%). Prolonged (>7days) MV required in 14%. Endotracheal intubation and MV related events were observed in 35%, including Pneumothorax in 0%, VAP in 1.85%, Atelectasis in 2.78%, Postextubation stridor in 15.74% cases. Vasopressors, Central line insertion and RRT were offered in 73%, 12.96% and 2.3% cases respectively. Among nosocomial infections (Culture proven) BSI, VAP and CAUTI were 7%, 2% and 0.9% respectively. Overall Mean ventilator days were 3.98 (4.3 in discharged patients). Successful extubation was achieved in 107/216 (49.53%). Death rate was 12.5%. Conclusion: Our study offers comprehensive information which may assist paediatrician in the decision-making process to allow better resource allocation in rural settings.

Introduction: Non-invasive blood pressure measurement (NIBP) is accepted as the standard monitoring modality in most clinical settings. However, whenever there is a need for accurate, reliable, beat-to-beat monitoring of blood pressure, an intra-arterial catheter (IBP) is considered the gold standard. The perceived superiority of such invasive monitoring helps justifies the placement of intra-arterial catheters and leads some intensivists to forego NIBP monitoring in patients once such a catheter is placed Objective: To study the correlation between non-invasive blood pressure (NIBP) measurements and invasive arterial blood pressure (IBP) measurements in critically ill children admitted in a Pediatric Intensive Care Unit (PICU). Methods: Data collected from critically ill children with arterial BP monitoring admitted to the PICU, Lotus Hospital for Women and Children, Hyderabad over one-year duration. Both noninvasive and invasive readings of BP including systolic, diastolic and mean BP were recorded and tabulated for comparison and statistical analysis. Results: Systolic and diastolic blood pressure values recorded at 8AM, 4PM and 12 midnight by IBP and NIBP correlate with each other significantly. The correlation values for SBP are 0.997, 0.993 and 0.991 respectively with P values being less than 0.001 at every recording while for DBP the correlation values are 0.989, 0.994 and 0.991 respectively with P values being less than 0.001 at every recording Conclusion: Significant correlation was observed between BP measured by invasive (IBP) and noninvasive method (NIBP) in patients admitted to a pediatric intensive care unit in a tertiary care center.

Dengue infection is an important tropical infection that can be responsible for serious illness and intensive care admission in children. Dengue virus belongs to Flavivirus genus and is transmitted by Aedes aegypti and Aedes al- bopictus mosquito. New World Health Organisation classification for the disease into dengue with/ without warning signs and severe dengue better identifies patients requiring in-hospital treatment and classifies atypical cases with severe end organ system involvement (liver, brain, heart, etc.) without shock or bleeding diathesis. Point of care tests for Non-Structural Protein 1 antigen and IgM based immuno-assay are important adjuncts to early diagnosis in emergency wards. Capillary leak and bleeding are central mechanism of manifestations of severe dengue. Severe capillary leakage creates intravascular hypovolemia which needs correction with aggressive but not over-jealous fluid therapy with timely tapering of high fluid rates, to maintain a fine balance of adequate resuscitation and preventing fluid overload at the same time. Indication for use of colloids upfront especially in patients with evidence of severe plasma leakage needs further evaluation. Transfusion of fresh whole blood or fresh packed red cells is important in patients with suspected severe bleeding. In view of recent evidence, prophylactic transfusion of platelets is going out of favour and platelets should be transfused for severe bleeding irrespective of platelet counts. Echocardiography and central venous pressure based fluid status evaluation act as precious adjuncts to for better assessment of intravascular volume. Atypical manifestation like neurological manifestations, renal failure, abdominal compartment syndrome, hemophagocytic lymphohistiocytosis need further documentation for better management of critically ill patients. Outcomes worldwide are improving with structured protocol based management.

Scrub typhus is an important emerging tropical infection that can have severe manifestations in children leading to intensive care admission. It is caused by Orientia tsutsugamushi, a gram negative bacterium transmitted to humans by the bite of larval trombiculid mites. The organism is endemic in south-east Asia and the disease is reported from virtually all parts of India. The hallmark of this infection is vasculitis and endothelial injury with intense inflammatory response involving myocardium, pulmonary, nervous and hematological systems. Children present often in post-monsoon season with undifferentiated fever and various degrees of organ involvement that progress to fatal multi organ failure if untreated. Presence of an eschar can be a vital diagnostic clue. Common laboratory features include thrombocytopenia, elevated transaminases and hypoalbuminemia. The diagnosis is confirmed by detection of IgM antibodies by IFA and ELISA or by PCR based assays. Definitive treatment with doxycycline or azithromycin and aggressive supportive care including ventilation, hemodynamic support, and management of AKI and raised intracranial pressure are the mainstay. The mortality ranges from 6-15%, which currently on the improving trend due to better case identification and early initiation of antibiotics along with intensive care.

Malaria in children is associated with high mortality and morbidity. High index of suspicion is required for diagnosis. Clinical assessment should be supplemented by laboratory investigations including peripheral blood smear examination and rapid diagnostic tests. Common associated life-threatening problems include coma, seizures, raised intracranial pressure (ICP), shock, respiratory failure, acute kidney injury, anemia and fluid and electrolyte abnormalities. Aggressive supportive care in pediatric emergency and pediatric intensive care unit includes control of airway, breathing and circulation; maintaining adequate intravascular volume; management of raised ICP and status epilepticus; and close monitoring for early detection of complications. Artesunate combination therapy should be administered promptly. Clinical evaluation, laboratory workup, specific antimicrobial therapy, supportive treatment and management of associated complications should go hand in hand in a protocolized way for better outcome.

Encephalitis is a major cause of acute neurological dysfunction among children and constitutes a medical emergency. Acute infectious encephalitis is usually viral in etiology. However, immune-mediated encephalitis, which are eminently treatable also forms asignificant proportion. The evaluation and management have evolved with the advances in diagnostic studies, neuromonitoring techniques and antimicrobials. Early recognition, systematic approach and institution of timely appropriate symptomatic and specific therapy are essential to improve outcomes. Cerebrospinal fluid examination and neuroimaging may point to a specific diagnosis. With few exceptions, no specific therapy is available for most forms of viral encephalitis. Morbidity and mortality can be significantly reduced in HSV encephalitis by adequate treatment with acyclovir while delays in treatment can be devastating. Long term sequelae are common among survivors.

Enteric fever is a major public health problem especially for India due to poor sanitation, lack of clean drinking water and poor food hygiene. It can affect all age groups, but recent shift towards infants and young children is worrisome. The majority of patients improve with ambulatory treatment, supportive care, and administration of appropriate antibiotics early during course of the disease. Hospitalization is indicated in patients with persistent vomiting, poor oral intake or severe diarrhea or any of the serious complications. Patients with shock, encephalopathy, intestinal perforation or hemorrhage and toxemia should be managed in the intensive care unit. Diagnosis is often based on serological tests but blood culture remains the gold standard. Ceftriaxone is the drug of choice for complicated enteric fever. A short course of dexamethasone for 2 days may decrease the mortality in children with serious complications. Early surgical intervention is warranted in intestinal perforation. The emergence of multidrug-resistant strains, is a serious concern thus necessitating more focus on preventive measures. Integrated preventive approach like improvement in sanitation, hygienic food practices and mass vaccination will go a long way in decreasing the incidence of these infections.

Diphtheria is an acute localized infection of the throat associated with systemic manifestations caused by the toxin producing Corynebacterium diphtheriae. Diphtheria continues to remain a serious public health problem in children largely related to lack of effective immunisation. The grey, brown, and dirty pseudo membrane is pathognomonic of this disease. The exotoxin produced by the pathogen is responsible for systemic effects. Severity of infection is determined by site of infection, immunization status of the patient, and extent of systemic involvement. Airway obstruction, myocarditis, acute kidney injury, thrombocytopenia and neuropathy are some of the serious complications associated with this disease. Of these, myocarditis is the most dreaded complication and carries a very high mortality. Diphtheria is a clinical diagnosis and specific antitoxin is the mainstay of therapy and should be administered as early as possible. Antibiotics are used to eradicate residual organisms, stop toxin production and decrease infectivity. The indications for PICU transfer include severe pharyngo tonsillar disease, delayed presentation to hospital (> 5 days), delayed antitoxin therapy, signs of airway obstruction and/ormyocarditis. Extremes of ages, severe disease, unimmu- nized children, myocarditis and delayed administration of antitoxin are all poor prognostic factors.

Leptospirosis is a zoonotic infection with ubiquitous distribution caused by spirochete leptospira and humans are incidental hosts. Leptospirosis is mostly reported during rainy season when there is freshwater flooding and water logging with poor sewage drainage. Leptospira are transmitted to humans by exposure to a water environment contaminated by urine of the infected animals. There are two distinct phases of leptospirosis, the initial “septicemic phase” due to leptospira mediated injury is closely followed by “immune phase”. Clinical symptoms include fever, headache, myalgia, vomiting, respiratory symptoms, and thus it is difficult to differentiate from other viral illnesses. Leptospira have a predilection for kidneys and causes acute tubular necrosis and interstitial nephritis. The sever form of Leptospirosis is characterized by hepatic, respiratory and renal dysfunctions, hemorrhagic manifestations, cardiovascular collapse and CNS dysfunction. Microscopic Agglutination Test (MAT) is the gold standard for diagnosis, however ELISA is a pragmatic alternative to MAT for confirming the diagnosis. Majority (90%) of leptospirosis cases are mild and can resolve spontaneously. Early initiation of antimicrobials can lead to faster recovery and may prevent from progression to severe leptospirosis. Penicillin, oral or intravenous, are the first lines of therapy. Supportive care is of utmost importance for management of leptospirosis and associated organ dysfunctions.

Childhood chickenpox is usually a benign infection with mortality rate in healthy children aged 1-14 years is around 2 deaths per 100,000 cases. Among children with leukaemia mortality rate of varicella is up to 55%. We describe a 7-year-old child of acute lymphoblastic leukaemia presenting with disseminated varicella. This child was also found to have severe tracheobronchitis. Severe tracheobronchitis is rare however, an important complication. It needs to be recognized early as it has the potential to alter the course, duration, therapy and outcome of these cases.

Guillain-Barré syndrome(GBS) is the most common and most severe acute paralytic neuropathy, with about 1,00,000 people developing the disorder every year worldwide. Under the umbrella term of Guillain-Barré syndrome are several recognisable variants with distinct clinical and pathological features. GBS is generally considered to be mono- phasic, but recurrences do occur in a presently undefined subgroup of patients. Recurrent GBS is rare but presents a diagnostic challenge. Even though not well described, reccurences have been reported, though there appears to be no significant difference between RGBS and GBS episodes with respect to similar clinical symptoms and similar or different triggering events. We describe a 10-year-old girl who presented with acute onset of ascending, symmetrical, areflexic, flaccid quadriparesis. She had a history of GBS 1 year ago from which she recovered completely over 6 months with no residual weakness except for ophthalmoplegia. Based on clinical presentation, past history and investigations, diagnosis of recurrent GBS was confirmed.

Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disease that usually occurs in infants and young children. It is characterized by severe hyper inflammation due to uncontrolled proliferation of activated lymphocytes and monocytes which are morphologically normal cells. This can lead to production and release of immense number of cytokines referred to as cytokine storm. It is typically a systemic disease with multiorgan involvement. Here we report a case of HLH in a twenty-eight days old baby presenting a clinical picture of septic shock, persistent metabolic acidosis multiple organ failure and disseminated intravascular coagulation (DIC).

Beta thalassemia with hereditary persistence of fetal hemoglobin (HPFH) is a rare disease with a clinical presentation different from thalassemia major and HPFH. The association of HPFH with beta-thalassemia mitigates the clinical manifestations which vary from a normal state to beta-thalassemia intermedia. HPFH is due to deletions in the beta-globin gene cluster or point mutations in the HBG1 and HBG2 genes (11p15.5). We are reporting a case of 6 year male child with compound heterozygous for HPFH and beta Thalassemia with Moya-moya disease. Elder sister was also compound heterozygous for HPFH and beta Thalassemia intermedia. Father was having beta Thalassemia trait and mother having HPFH.

Background : The efficacy of oral indomethacin/ ibuprofen in the closure of hemodynamically significant PDA is not extensively studied. Aim : Retrospective analysis of data on the efficacy and safety of oral cyclooxygenase (COX) inhibitors- indomethacin and ibuprofen in patent ductus arteriosus (PDA) closure. Materials and methods : All preterm (28-36.6weeks) infants born between July 2011- June 2012 who received oral cyclooxygenase inhibitors for closure of PDA were included in the study. The outcome measured was closure rate of PDA. Results : Of the 162 preterm neonates, 34 received oral COX inhibitors. Of them 27 received oral indomethacin and 7 received syrup ibuprofen. The total closure rate was 91.2% after first course and 8.8% of neonates required a second course with complete closure. No neonate required surgical closure. In the indomethacin group, 5 patients had thrombocytopenia and 1 had NEC. However, none of the cases in ibuprofen group had any significant side effects. Conclusion : Oral COX inhibitors are an effective therapy for closure of PDA.

Introduction: Childhood unintentional injuries (CUI) carry high morbidity and mortality. Little is known about epidemiology of CUI in PICU, their course and outcome. We report experience of CUI at our center. Methods: Retrospective review of medical records of children (1 mo- 16 years) admitted in PICU between Jan 2009- Dec 2014 with admitting diagnosis of unintentional injury was done. Data collected included age, gender, category and mechanism of injury, type of trauma, body region affected, place of injury, presentation, initial baseline laboratory workup, intervention done in the ER and PICU, length of stay and outcome. Results are presented as frequency/ percentages and mean ±SD. Results: A total 103 patients were admitted with the diagnosis of severe injury, 67% (69/103) were males and mean age was 90±55 months. Trauma was the major category (88%, 91/103) with road traffic accidents (RTA) comprising 37% (38/91) and fall 29% (30/91). 8 patients had poisoning, 91% (83/91) blunt trauma and 70% (64/91) had single body region involvement, isolated head being involved in 55% (50/94). 78% (81/103) of the injuries were witnessed. Coma was the main presentation in 36% (37/103) children, shock in 25% (26/103), respiratory problem in 22% (23/103), and, 67% were intubated in ER, CPR was done in 2 patient, 83.5% (86/103) patients needed mechanical ventilation, 77% (80/103) needed inotropic support and surgical intervention was done 64% of patients. PICU length of stay was 6±3 days and case fatality rate was 21% (22/103) compared to overall mortality rate of 12% during the same period. Conclusion: Severe injuries consume a lot of PICU resources and are associated with high mortality.