JPCC PDF

Intensive Care Chapter
Indian Academy of Pediatrics

P-ISSN : 2349-6592 and E-ISSN : 2455-7099
Website : www.jpcc.in
Journal of
Pediatric Critical Care Official Journal of IAP Intensive Care Chapter
CONTENTS Clinical Update

Original Articles
Cardiac Complications of Scrub Typhus With Hypernatremia
Kundan Mittal, Lalitbhuasan Waghmare, Manish Sharma,
Special Reference to Electrocardiography - A Sachin Damake.
Twelve Weeks Follow Up In Two Tertiary
Pediatric Hospital of Eastern India Postgraduate/Fellow Column
Joydeep Das, Devyani De.
OSCE: Hypokalemia
Kundan Mittal, Lalit Waghmare, H K Aggarwal, Manish
Symposium Munjal.
Guest Editorial :
Prevention is better than cure Best Evidence
Kundan Mittal, Vivek Gupta. Journal Scan
Kundan Mittal, Jayant Vagha, Lalitbhushan Waghmare, H K
Aseptic Technique In Intensive Care Unit Aggarwal, Vivek Gupta, Vinayak Patki.
Vivek Gupta.
Clostridium Difficile : Epidemiology and Critical Thinking
Prevention PICU QUIZ - HAI
Vinayak Patki.
Antariksh deep, Kundan Mittal.
Ventilator Assosciated Pneumonia Book Review
Vivek Gupta. Critical Care Nephrology
Kundan Mittal, H K Aggarwal, Rajesh Mishra, Manish
Munjal.
Review Article
Snake Bite -A review NCPCC- 2018
Manish Kumar, Lokesh Tiwari. Scientific Paper Abstracts
Case Reports
Idiopathic Acute Necrotizing Pancreatitis : A
Case Report
Mahima Rajan, Kundan Mittal, Vandana Arya, Varinder
Ghelawat
Vol.5 No. 6
Acquired Hypothyroidism
NOV-DEC 2018 Reshmi Mishra, Bandya Sahoo, Mukesh Jain, Siba Patnaik,
Palas Das.
EPIC COURSE (Essential Pediatric Intensive Care) is a most ambitious program developed by the IAP
Intensive care chapter, with an intention of providing basic intensive care training and expertise to practicing
Pediatricians, to provide much needed timely and appropriate care to sick children in the periphery; in smaller
hospital set-up and nursing homes. The module covers common and important pediatric critical care problems
and important skills, including basic ventilation.
Pending easy availability of intensive care facilities across the country, especially in the periphery, EPIC
COURSE is a step forward in realizing availability of basic intensive care to needy children.
Pediatricians with focused training in managing sick children will be able to save many seriously ill children in
their respective geographic area/s and will save many precious lives & improve health of our children.
Eight successful courses conducted in different parts of India in this year attended by around 500 participents.
Contact :- Dr. Dayanand Nakate

Secretary, IAP Intensive Care Chapter
Ashish Clinic, 347, South Kasaba, Main Road, Solapur- 413 002, Maharashtra
Ph. 0217-2627447, 9850818650, email- nakated@yahoo.com
Contents
Original Article
Cardiac Complications of Scrub Typhus With Special Reference to 15
Electrocardiography - A Twelve Weeks Follow Up In Two Tertiary Pediatric
Hospital of Eastern India
Joydeep Das, Devyani De. Jagannath Gupta Institute of Medical Science, Budge Budge, Kolkata.
Calcutta National Medical College, Kolkata
Symposium
Guest Editorial : Prevention is better than cure 20
Kundan Mittal, Vivek Gupta. Pt B D Sharma, PGIMS, Rohtak, Haryana, India, Hero DMC Heart
Institute, Ludhiana, Punjab, India
Aseptic Technique In Intensive Care Unit 21
Vivek Gupta. Hero DMC Heart Institute, Ludhiana, Punjab, India
Clostridium Difficile : Epidemiology and Prevention 25
Antariksh deep, Kundan Mittal. Pt B D Sharma, PGIMS, Rohtak Haryana, India
Ventilator Assosciated Pneumonia 30
Vivek Gupta. Hero DMC Heart Institute, Ludhiana, Punjab, India
Review Article
Snake Bite - A review 34
Manish Kumar, Lokesh Tiwari. All India Institute of Medical Sciences Rishikesh, Uttaranchal, India. All
India Institute of Medical Sciences Patna, Bihar, India
Case Reports
Idiopathic Acute Necrotizing Pancreatitis : A Case Report 42
Mahima Rajan, Kundan Mittal, Vandana Arya, Varinder Ghelawat. PGIMS Rohtak, Haryana, India
Acquired Hypothyroidism 46
Reshmi Mishra, Bandya Sahoo, Mukesh Jain, Siba Patnaik, Palas Das. KIIT University Bhubaneswar,
Odisha,India
Clinical Update
Hypernatremia 49
Kundan Mittal, Lalitbhuasan Waghmare, Manish Sharma, Sachin Damake. PGIMS Rohtak, India,
JNMC Wardha, Maharashtra, India, JKLOAN hospital Jaipur. India
Postgraduate/Fellow Column
OSCE: Hypokalemia 51
Kundan Mittal, Lalit Waghmare, H K Aggarwal, Manish Munjal. Pt. B D Sharma, PGIMS, Rohtak,
Haryana, India. JNMC Wardha, Maharashtra, India.
Best Evidence
Journal Scan 54
Kundan Mittal, Jayant Vagha, Lalitbhushan Waghmare, H K Aggarwal, Vivek Gupta, Vinayak Patki,
Pt. B D Sharma, PGIMS, Rohtak, Haryana, India, JNMC Wardha, Maharashtra, India, Hero DMC
Heart Institute, Ludhiana, Punjab, India. Wanless Hospital, Miraj, Maharashtra, India.
Vol. 5 - No.6 NOV-DEC 2018 1 (a) JOURNAL OF PEDIATRIC CRITICAL CARE

Critical Thinking
PICU QUIZ - HAI 60
Vinayak Patki. Wanless Hospital, Miraj, Maharashtra, India.
Book Review
Critical Care Nephrology 64
Kundan Mittal, H K Aggarwal, Rajesh Mishra, Manish Munjal. Pt. B D Sharma, PGIMS, Rohtak,
Haryana, India.
NCPCC- 2018 :Scientific Paper Abstracts 65
Vol. 5 - No.6 NOV-DEC 2018 1 (b) JOURNAL OF PEDIATRIC CRITICAL CARE

Journal of
Pediatric Critical Care
Official Journal of IAP Intensive Care Chapter
Editor-in-Chief
Dr Kundan Mittal
(PGIMS, Rohtak)
Managing Editor
Dr. Vinayak Patki
(Wanless Hospital, Miraj)
Executive Editor Associate Editors

Dr. Satish Deopujari (Child Hospital, Nagpur) Dr.Vishram Buche (Child Hospital, Nagpur)
Dr. Sasidaran K. (Mehta Children Hospital, Chennai)
Senior Editors & Reviewers Dr. Manindar Dhaliwal (Medanta, Gurgaon)
Dr. Atul Jindal (AIIMS, Raipur)
Dr. (Prof) Sunit Singhi (Medanta,Gurgaon) Dr. Govind Bennakatti (Bidari Hospital, Bijapur)
Dr. Uma Ali (Wadia Hospital, Mumbai)
Dr. Karunakara BP (Ramayya Hospital,Banglore)
Dr. Sachin Shah (Surya Hospital ,Pune) International Advisory Board
Dr. Basavaraj GV (IGIMS, Banglore)
Dr. Arun Bansal (PGI,Cahndigarh) Dr. Mark C.Rogers (USA)
Dr. Jerry Zimmerman (USA)
Dr. Peter Cox (Canada)
Executive Members Dr. Niranjan Kissoon (Vancouver , Canada)
Dr. Rameshkumar R. (JIPMER, Puduccherry) Dr. Suneel Pooboni (UK)
Dr. Mahammad Ali (Mission Hospital, Durgapur, WB) Dr. Paolo Biban (Italy)
Dr. Lokesh Tiwari (AIIMS,Patna) Dr. Swee Phong Tang (Kualalampur, Malaysia)
Dr. Mihir Sarkar (PGIPS, Kolkotta) Dr. Phuc H Phan (Hanoi, Vietnam)
Dr. Raghavendra Vanaki (SNM-HSK Hospital, Bagalkot) Dr. Mark Peters (London, UK)
Dr. Sameer Sadawarte (Fortis Hospital, Mumbai) Dr. Traci Wolbrink (Boston Children's Hospital, USA)
Dr. Sapna Kudchakar (John Hopkins, USA )
Dr. Vijay Srinivasan (Philadelphia, USA)
Ethical Committee Members
Dr. M. Jayshree (PGI, Chandigarh)
Dr. Preetha Joshi (K. Ambani Hospital, Mumbai) National Advisers
Dr. Santosh Soans (AJIMS,Mangalore) (President CIAP)
Biostatistics Dr. Anupam Sachdev (Sir GangaRam Hospital New Delhi)
Dr. Dighant Shastri (Surat) (President Elect-CIAP )
Dr. Satyen Gyani (Sparsh Hospital, Bhilai) Dr. Pratibha Singhi (Medanta Hospital, Gurgaon)
Dr. Lalitha A V (St.John's Hospital,Banglore) Dr. Narendra Rungta (JNUIRC, Jaipur)
Vol. 5 - No.6 NOV-DEC 2018 2 JOURNAL OF PEDIATRIC CRITICAL CARE

Executive Committee 2018
Dr. Bakul Parekh Dr. Kamalesh Srivastava Dr. Ebor Jacob James
Chairperson Past Chairperson Vice-chairperson
Dr. Dayanand Nakate Dr. Arun Baranwal Dr. Vikas Taneja Dr. Kundan Mittal Dr. Vinayak Patki
Secretary Joint Secretary Tresurer Editor in chief Managing Editor
Dr. Mahesh Mohite Dr. Sunil Vaidya Dr. Rachna Sharma Dr. Manish Sharma Dr. Anjul Dayal
(West Zone) (West Zone) (North Zone) (North Zone) ( Central Zone)
(Mumbai) (Solapur) (New Delhi) (Jaipur) (Hyderbad)
Dr. Dinesh Chirla Dr. Raghunath C N Dr. Shishu Kamath Dr. Prakshita Bora Dr. Vinod Ratgiri
(Central Zone) (South Zone) (South Zone) ( East Zone) (Nominated)
(Hyderabad) (Banglore) (Chennai) (Assam) (Hubali)

From the Editors Desk
Dear Colleagues and readers,

Wish you a very happy and healthy new year 2019.
November and December2018 issue of the Journal of Pediatric Critical Care is now published and available on line.
Highlight of this issue is a special symposium “Healthcare Associated infections (HAI) - Prevention is better than
Cure”By Guest Editors: Drs Kundan Mittal and Vivek Gupta. Editorial team hopes that this symposium delivers a
comprehensive evidence based detailed reviewed by experts. HAI Symposium includes articles on Aseptic Technique
in PICU and Ventilator Associated Pneumonia by Dr. Vivek Gupta and Clostridium Difficile: Epidemiology and
Prevention by Dr. Antariksh deep et al.
Amongst other highlights of the issue include Special Review Article by Lokesh Tiwari et al on Snake Bite. We have
original article on Cardiac Complications of Scrub Typhus with special reference to electrocardiography - A Twelve
Weeks Follow Up In Two Tertiary Pediatric Hospital of Eastern India by Joydeep Das et al.
In present issue you will also find interesting rare case reports on Idiopathic Acute Necrotizing Pancreatitis by Mahima
Rajan et al from PGIMS Rohtak, Harayana and Acquired Hypothyroidism by Reshmi Mishra et al from KIIT
University Bhubaneswar, Odisha.
In our regular segments, you will find clinical update on Hypernatremia, postgraduate column on OSCE on
hypokalemia. There is interesting collection of recently published original articles related to HAI in Journal scan
section and PICU quiz on sepsis. Lastly, we have Book review on critical care Nephrology.
We have included Scientific Paper Abstracts of National Conference of Pediatric Critical Care conducted in November
2018 at Coimbatore.
As you all understand Journal has reached ICV value of 100.0 in recent evaluation by Index Copernicus International
recently, this is the highest ICV value for any Journal. JPCC also is now indexed with Cite Factor and soon each article
will get impact factor.
Editorial team is working hard to index the Journal with other international Indexing authorities like PubMed, Scopus
and Embase.
We are very thankful to Dr. Santosh Soans, President and Executive Board Members of Central IAP for the Permission
of circulating soft copy of JPCC to almost twenty-seven thousand paediatricians across the country. While hard copy
will continue to be published for the IAP Intensive Care Chapter members and subscribers.
On line submission by authors and prompt review by esteemed reviewers are highly appreciated for timely publication
of Journal of Pediatric Critical Care.
Happy Reading
Kundan Mittal
MD, PGDMLS, MBA, FISCD, FIAP, FICCM, FCCM (SCCM, USA), FNNF,
MAMS, FIAMS, Honorary Prof IMA-AMS, PFCCS & FCCS Consultant (SCCM, USA)
Senior Professor
In-charge Paediatric Intensive Care, Respiratory Services & Genetic Clinic,
Department of Paediatrics Fellowship in Pediatric Critical Care & Clinical Genetics,
Pt. B D Sharma, PGIMS, Rohtak-124001

Author Instructions
Journal of Pediatric Critical Care (JPCC)
Journal of Pediatric Critical Care (JPCC) is an international, online and print journal published quarterly
(January, April, July and October) by IAP intensive care chapter. Journal’s full text is available at http://jpcc.in.
Journal allows free access (open access) to its contents; therefore authors are to self-archive the final accepted
version of the article.
Manuscript Submission:
All manuscripts must be submitted on-line through the journal’s online manuscript submission system.
Manuscript should also be submitted simultaneously as an e-mail attachment to jpccjournal@gmail.com
Copyright:
Submissions considered for publication in JPCC are received on the understanding that they have not been
accepted for publication elsewhere and that all of the authors agree to the submission. The journal requires
approval of manuscript submission by all authors. A cover letter signed by all authors constitutes submission
approval. Manuscripts will not receive a final decision until a completed Copyright Status Form has been
received. As soon as the article is published, the author is to have considered transferred his right to the publisher.
This transfer will ensure the widest possible dissemination of information. All concepts, ideas, comments,
manuscripts, illustrations, and all other materials disclosed or offered to the IAP intensive care chapter on or
in connection with this Journal are submitted without any restrictions or expectation of confidentiality. The
IAP intensive care chapter shall have no financial or other obligations to you when you do not submit such
information, nor shall you assert any proprietary or moral right of any kind with respect to such submissions.
The IAP intensive care chapter shall have the right to use, publish, reproduce, transmit, download, upload post,
display or otherwise distribute your submissions in any manner without notice or compensation to you.
Unauthorized Use:
The copyright of all accepted and published manuscripts lies with JPCC; these cannot be reproduced elsewhere
or distributed in any form, in whole or part, without the written permission from the Editor-in-Chief. Mass
photocopying of published article would also amount to copyright violation. The name, logo, thumbnail, cover
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Unauthorized use will attract penalty and/or/ legal action. For permission to use copyrighted material, the
editor-in-chief may be contacted at jpccjournal@gmail.com.
Ethics, Informed Consent And Patient Anonymity

Investigations on human subjects should conform to accepted ethical standards. Fully informed consent
should be obtained and noted in the manuscript. For all manuscripts dealing with experimental work involving
human subjects, specify that informed consent was obtained following a full explanation of the procedure (s)
undertaken, and if requested by the journal’s editorial board, the authors should produce the copy of ethical
clearance. Patients should be referred to by number; do not use real names or initials. Also the design of special
scientific research in human diseases or of animal experiments should be approved by the ethical committee
of the institution or conform to guidelines on animal care and use currently applied in the country of origin. It
is the author’s responsibility to ensure patient’s anonymity. In images or illustrations, patient’s eyes should be
masked. However, if the eye area is the focus of illustration, patient’s nose and mouth should be masked and
written consent must be obtained from the patients/legal guardian. Patients’ names should be removed from the
figures, radiographs, and CT scans, unless written consent is obtained.
Vol. 5 - No.6 Nov-Dec 2018 8 JOURNAL OF PEDIATRIC CRITICAL CARE

Duplicate Submission And Plagiarism:
Manuscripts are considered with the understanding that they have not been published previously in print or
electronic format and are not under consideration by another publication or electronic medium. The authors
should alert the editor if the work includes participants about which a previous report has been published. A
paper submitted to the JPCC should not overlap by more than 10% with previously published work, or work
submitted elsewhere. If in doubt, authors may submit copies of earlier published work or material submitted
elsewhere to the editorial board of JPCC to take the decision. If plagiarism or duplicate publication is detected,
authors should expect prompt rejection/retraction and editorial board’s action such as barring the author from
submitting articles in future, notification in the journal/website, and informing the authors’ institute or other
medical editors. A previously rejected article should not be resubmitted again under the original or modified
title, especially if the content remains substantially same. Authors should provide full information regarding
previous submission, if any.
Previous Publication:
JPCC would not publish material that has already appeared elsewhere; but could consider papers that have
been published as abstracts or have been partially reported by the media at scientific meetings
Embargo Policy:
Authors need to maintain confidentiality of contents of their manuscript, once accepted for publication.
Information contained in or about the accepted articles should not be released in print/electronic form to any
individual/media/agency, till the manuscript is published in JPCC.
The Editorial Process

All manuscripts submitted to the journal must be original contributions submitted to JPCC alone, must not
be previously published, already accepted for publication, or under consideration for publication elsewhere.
After acceptance in the journal, the manuscript must not be published elsewhere in any form, without prior
permission of the editor-in-chief or publisher. All the manuscript submitted to the JPCC receives individual
identification code and would initially be reviewed by the editors for suitability for publication. Manuscripts
with insufficient originality, serious scientific or technical flaws, or lack of a significant message are returned
back before proceeding for formal peer-review. Manuscripts found suitable for publication are sent to two or
more expert reviewers for peer-review. The selection of these reviewers is at the sole discretion of the editor.
The journal follows a double-blind review process, wherein the reviewers and authors are unaware of each
other’s identity. After receiving the reviewer’s report/comments, the report will be communicated to the authors
for possible corrections. Authors will be directed to submit revised manuscript within the time limit, along with
a point by point response to reviewers’ comments. We ensure speedy publication of the submitted articles and
target to finish the initial review process within 8 weeks. However, this time period can change depending
upon the quality of the manuscript submitted, reviewer’s response and time taken by the authors to submit the
revised manuscript.
Article Proofs And Reprints:

Manuscripts accepted for publication are copy edited for grammar, punctuation, print style, and format Proofs
are sent to the corresponding author, together with a reprint order form approximately 6 weeks prior to the
publication. Authors should retain a copy of the original manuscript. Only printer’s errors may be corrected;
no changes in, or additions to, the edited manuscript will be allowed at this stage, unless in reply to specific
editorial queries or requests. Corrected proofs must be returned within 48 hours of receipt, preferably by e
mail or fax. If the publisher has not received a reply after 15 days, the assumption will be made that there
are no errors to correct, and the article will be published after in-house correction. The reprint order form
(with number of reprints requested, invoice and delivery address) should be returned with the corrected proof.

Reprints may be ordered prior to publication on the form provided. The designated reviewing author will
be responsible for ordering reprints for all authors. Reprints ordered after publication of the journal can be
ordered at increased cost by special arrangement. The publisher (IOS press) will provide to authors with a free
watermarked PDF file of their article.
Authorship Criteria:
All the authors should have substantial contributions to each of the following three components: 1. Concept
and design of study or acquisition of data or analysis and interpretation of data; 2. Drafting the article or
revising it critically for important intellectual content; and 3. Final approval of the version to be published.
Participation solely in the acquisition of funding or the collection of data does not justify authorship as the
general supervision of the research group.
Contribution Details:
Authors should provide a description of contributions made by each of them towards the manuscript. At least
one author should take the responsibility for the integrity of the work and should be designated as ‘guarantor’.
Authors’ contributions will be published along with the article.
Conflicts Of Interest/ Competing Interests:

All authors must disclose any conflicts of interest they may have with publication of the manuscript or an
institution or product that is mentioned in the manuscript and/or is important to the outcome of the study
presented.
Copies Of Any Permission(S):

It is the responsibility of authors/contributors to obtain permissions for reproducing any copyrighted material.
A copy of the permission obtained must accompany the manuscript.
Clinical Trial Registry:

JPCC recommends registration of clinical trials and preference would be given to registered clinical trials.
Trials can be registered in any of the following trial registers: http://www.ctri.in/; http://www.actr.org.au/;
http://www.clinicaltrials.gov/; http://isrctn.org/.
Preparation Of Manuscript:
Manuscripts must be prepared in accordance with “Uniform requirements for Manuscripts submitted to
Biomedical Journals” developed by the International Committee of Medical Journal Editors (October 2006).
Manuscript should be typewritten in 12 font size using Times New Roman font, with margins of at least one
inch on all sides. Pages should be numbered consecutively on the top right corner of the pages, starting with the
title page. The matter should be arranged in the following order: Title page, Abstract, Introduction, Materials
and Methods, Results, Discussion and Conclusions, Acknowledgement, References, Tables and Figures along
with caption and legends. The manuscript should be submitted in two separate files: 1. Title page, and 2.
Blinded article file
Title Page:
This file should provide - 1. Type of the manuscript (original article, review article, short communication,
case report, letter to editor, etc.) 2. Title of the manuscript 3. Short running title (upto 50 characters) 4. Names
of all the authors/ contributors (with their highest academic degrees, designation and affiliations) 5. Name(s)
of department(s) and/ or institution(s) to which the work should be credited 6. Corresponding author details
including full address, e-mail address and phone number or mobile number 7. The total number of pages,

figures and tables 8. Word counts (separately for abstract and the text excluding the abstract, references,
tables and figure legends). 9. Source(s) of support in the form of grants/ funding, equipment, drugs, or all of
these. 10. Registration number, in case of a registered clinical trial 11. Conflicts of interest of each author. 12.
Contribution details
Blinded Article File:
The manuscript must not contain any mention of the authors’ names, initials or the institution. The main text of
the article, beginning from Abstract till References (including tables) should be in this file. Use doc files and
do not zip the files.
Abstract: An abstract (not exceeding 250 words) should be provided typed on a separate sheet. Abstract
should be structured (except for case reports) and include objective, methods, results and conclusion.
Keywords: Up to 4-6 keywords must be provided related to the work .These keywords should be typed at the
end of the abstract.
Introduction: It should be a concise statement of the background to the work presented, including relevant
earlier work, suitably referenced. It should be started in a new page.
Materials and Methods: It shall be started as a continuation to introduction on the same page. All important
materials and equipments, the manufacturer’s name and, if possible, the location should be provided. The main
methods used shall be briefly described, citing references. New methods or substantially modified methods
may be described in sufficient detail. The statistical methods and the level of significance chosen shall be
clearly stated.
Results: The important results of the work should be clearly stated and illustrated where necessary by tables
and figures. The statistical treatment of data and significance level of the factors should be stated wherever
necessary. Data that is not statistically significant need only to be mentioned in the text and no illustration is
necessary.
Discussion: This section should deal with the interpretation of results, making readers to understand the
problem taken and should be logical. The discussion should state the scope of the results, which need to be
further explored.
Conclusions: Concisely summarize the principal conclusions of the work and highlight the wider implications.
This section should not merely duplicate the abstract.
Types Of Manuscripts:
Original articles: Randomized controlled trials, intervention studied, studies of screening and diagnostic test,
outcome studies, cost effectiveness analyses, case-control series, and surveys based studies can be sent under
this heading. Reports of randomized clinical trials should present information on all major study elements,
including the protocol, assignment of interventions, methods of randomization, and masking (blinding). Text
should be divided into following sections: Abstract, Introduction, Material and Methods, Results, Discussion,
References, Tables and Figure legends. Recommended word limit is upto 3000 words excluding abstract,
tables, figures and about 40 references.
Review Articles: Review articles are systemic critical evaluation of already published material. It is expected
that these articles would be written by experts or individuals who have done substantial work on the subject. A
review article should be written in following steps - define the problem, summarize previous investigations to
define the state of current research, identify relations, contradictions, gaps and inconsistencies in the literature
reviewed, suggest clinical practice based on the current evidence and suggest further areas of research.
Recommended word limit is upto 4000 words excluding about abstract, tables, figures and upto 50 references.
Systematic Reviews & Meta-analysis: JPCC also encourages publication of systematic reviews and meta-
analysis on various topics of clinical significance. These should provide information on search strategies to
retrieve relevant studies, methods used to assess the scientific validity of retrieved studies, and the process of
generating a bias-free list of citations to answer the topic under review. Recommended word limit is upto 4000

words excluding about abstract, tables, figures and upto 75 references.
Short Communications: Short correspondence pertaining to research can be sent under this heading. Word
count should not exceed 2000 words with an abstract of upto 200 words and upto 25 references. Letters
must not duplicate other material published, submitted or planned to be submitted for publication. The matter
should be divided into introduction, methods, results and discussion and should follow all other guidelines in
‘Preparing the Manuscript’
Case reports: New, interesting or rare cases of clinical significance can be reported. However, mere reporting
of a rare case may not be considered. Prescribed word limit is upto 1500 words excluding upto 15 references
and abstract. Case reports should be written under the following headings: Abstract (unstructured), Key-words,
Introduction, Case report, Discussion, References, Tables and Legends in that order.
Letter to the Editor: These should be short and decisive observation, preferably be related to articles previously
published in the journal. Word limit is upto 1000 words and upto 10 references.
Reporting Guidelines for Specific Study Designs:

1. Randomized controlled trials - CONsolidated Standards Of Reporting Trials (CONSORT) - http://www.
consort-statement.org
2. Studies of diagnostic accuracy - STAndards for Reporting of Diagnostic accuracy (STARD) - http://www.
stard-statement.org/
3. Meta-analyses of observational studies - Meta-analysis Of Observational Studies in Epidemiology (MOOSE)
- http://www.equator-ntework.org
4. Systematic reviews/ Meta-analyses of RCT - Preferred Reporting Items for Systematic reviews and Meta-
Analyses (PRISMA) - http://www.prisma-statement.org
5. Observational studies in epidemiology - STrengthening the Reporting of OBservational studies in
Epidemiology (STROBE) - http://www.strobe-statement.org
References:
References should be numbered consecutively in the order in which they are first mentioned in the text (not
in alphabetic order). Identify references in the text, tables, and legends by Arabic numerals as superscript (e.g.
Jpcc1) after the punctuation marks. References cited only in tables or figure legends should be numbered in
accordance with the sequence established by the first identification in the text of the particular table or figure.
The titles of journals should be abbreviated according to the style used in Index Medicus. Use complete name
of the journal for non-indexed journals. Avoid using abstracts as references.
Standard Journal Articles:

a. For up to six authors: Agrawal A, Singh VK, Varma A, Sharma R. Intravenous arginine vasopressin infusion
in refractory vasodilatory shock: clinical study. Indian J Pediatr. 2012;79(4):488-493.
b. For more than six authors: List the first six authors followed by et al. Nobili V, Marcellini M, Giovannelli
L, Girolami E, Muratori F, Giannone G, et al. Association of serum interleukin-8 levels with the degree of
fibrosis in infants with chronic liver disease. J Pediatr Gastroenterol Nutr. 2004;39(5):540-4.
Personal author (book): Leung AK. Common Problems in Ambulatory Pediatrics: Symptoms and Signs, 1st
ed. New York: Nova Science Publishers, Inc.; 2011.
Chapter in a book: Leung AK. Oral rehydration therapy and early refeeding in the management of childhood
gastroenteritis. In: Overton LT, Ewente MR, eds. Child Nutrition Physiology. New York: Nova Biomedical
Books; 2008. p. 127-152.
Conference proceedings: Harnden P, Joffe JK, Jones WG, editors. Germ cell tumours V. Proceedings of the
5th Germ Cell Tumour Conference; 2001 Sep 13-15; Leeds, UK. New York: Springer; 2002.

Conference paper: Christensen S, Oppacher F. An analysis of Koza’s computational effort statistic for genetic
programming. In: Foster JA, Lutton E, Miller J, Ryan C, Tettamanzi AG, editors. Genetic programming.
EuroGP 2002: Proceedings of the 5th European Conference on Genetic Programming; 2002 Apr 3-5; Kinsdale,
Ireland. Berlin: Springer; 2002. p. 182-91.
Unpublished Material: Children and adolescents with chronic constipation: How many seek healthcare and
what determines it? Rajindrajith S, Devanarayana NM, Benninga MA. J Tropical Pediatr. 2011 Dec 6. [Epub
ahead of print]
Electronic Material CD-ROM: Neonatal Resuscitation Program (NRP) Training Aids [on CD-ROM].
National Neonatology Forum, New Delhi, 2006. Hemodynamics III: the ups and downs of hemodynamics
[computer program]. Version 2.2. Orlando (FL): Computerized Educational Systems;1993.
Journal article on the Internet: Abood S. Quality improvement initiative in nursing homes: the ANA acts in
an advisory role. Am J Nurs [Internet]. 2002 Jun [cited 2002 Aug 12];102(6):[about 1 p.]. Available from:http://
www.nursingworld.org/AJN/2002/june/Wawatch.htm
Article Homepage/Web site: Cancer-Pain.org [Internet]. New York: Association of Cancer Online Resources,
Inc.; c2000-01 [updated 2002 May 16; cited 2002 Jul 9]. Available from: http://www.cancer-pain.org/.
Acknowledgements: Acknowledgements as well as information regarding funding sources should be provided.
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DOI-10.21304/2018.0506.00437
Original Article
Cardiac Complications of Scrub Typhus With Special Reference to
Electrocardiography - A Twelve Weeks Follow Up In Two Tertiary Pediatric
Hospital of Eastern India
Joydeep Das*, Devyani De**
*Associate Professor of Pediatrics, Jagannath gupta Institute of Medical Science, Budge Budge, Kolkata.
**Assistant Professor, Dept. of Biochemistry, Calcutta National Medical College, Kolkata
Received: 14-Nov-18/Accepted:11-Dec-18/ Published Online:31-Dec-18
ABSTRACT
Introduction: Scrub typhus is a rickettsial disease grossly underdiagnosed in India due to lack of easily available
diagnostic test. Due to delay in the diagnosis and initiation of treatment mortality is 30%.No pediatric study highlighted
the cardiac complication.
Objective: To study the cardiac complication of scrub typhus and electrocardiographic changes.
Mathod: All scrub typhus fever between age group 5 yrs to 15 yrs who were admitted with high fever at two tertiary
pediatric referral hospital of eastern India were evaluated for cardiac complications. Those with cardiac involvement
were subjected to electrocardiography at admission, two, six and twelve weeks.
Result: Eleven out of Forty three cases showed features of myocarditis requiring vasopressor and five cases showed
long QT without progress to ventricular tachycardia.
Conclusion: Scrub typhus is a multisystem disease with a mortality upto 30% , cardiac complication is serious and
observed in 26% of cases.
Key words: Scrub typus, Cardiac, Complication, Electrocardiography.
Introduction: Rickettsia are obligate intracellular tertiary pediatric hospital of Kolkata, eastern India, to
proteobacteria spread by eukaryotic vectors like study extent of cardiac involvement of scrub typhus
ticks, mites, fleas and lice. Scrub Typhus occours with special reference to electrocardiographic(ECG)
in areas where scrub vegetations consisting of low changes.
lying trees, bushes, rice fields, poorly maintained Materials and Method: All scrub typhus fever
kitchen gardens inhibited by field rat and a rat mite between age group 5 yrs to 15 yrs admitted at The
called chiggers.1-3 When childrens plays in chigger Institute of child health Kolkata from January 2015 to
infested bushes they got bitten by the mite and December 2015 and The Jagannath Gupta Institute of
rickettsia gets entry into the body. Scrub Typhus Medical Science, Budge Budge, Kolkata from June
also known as tsutsugamushi disease4,5 is caused 2016 to May 2018, diagnosed by IgM ELISA scrub
by orientiatsutsugamushi (Japanese word tsutsuga typhus (Optical Density >0.5) with positive Weil Felix
means “dangerous” and mushi means “bug”). test titre of more than 1:80 of OX2, OX19 or OXK, plus
Diffuse endothelial infection, secondary vasculitis clinical, laboratory and echocardiographic(ECHO)
leading to microvascular leakage and vascular lumen evidence of cardiac involvement were included in the
obstruction are responsible for different clinical study. Any echocardiographic features of intrinsic
features of this multisystem disease. Very few studies muscle disease like dilated cardiomyopathy or
or case reports are there in existing littrature which congenital heart disease were excluded. Those with
depicts cardiac complications of scrub typhus. We cardiac involvement were kept in pediatric intensive
conducted a prospective observational study at two care unit (PICU) for continuous cardiac monitoring
till discharge. ECG at day three before giving
Correspondence: intravenous doxycycline were recorded. Those with
Dr. Joydeep Das, DNB(Pediatrics), MRCPCH(UK) Associate abnormal ECG features were compared with follow
Professor of Pediatrics, Jagannath gupta Institute of Medical Sci- up ECG at 2, 6 and 12weeks. Any abnormal cardiac
ence, Budge Budge, Kolkata.Email: jddasjoydeep@gmail.com.
Ph:943307664
condition were treated as per standered protocol.

ORIGINAL ARTICLE Cardiac Complications of Scrub Typhus
Table 1: Demography
Sl. Age in Sex Rural Urban Socioeconomic Dwelling Pet Animal
no yrs. status house shed closer
M F to house
1 7 + -- + -- lower Kuccha + --
2 9 + -- + -- Lower Middle Pucca + --
3 10 -- + -- + Upper middle Pucca -- --
4 11 -- + + -- Lower Kuccha -- +
5 10 -- + + -- Lower Kuccha -- +
6 12 -- + + -- Upper Middle Pucca -- --
7 8 + -- + -- Lower Kuccha -- +
8 7 + -- -- + Upper Middle Pucca -- --
9 7 + -- -- + Lower middle Pucca + --
10 6 -- + + -- Lower Kuccha + +
11 5 + -- + -- Lower Kuccha + --
Clinical parameters of cardiac involvement: A case After obtaining QT interval, corrected QT(QTc) with
of scrub typhus with or without Escher who showed respect to RR is measured by Bazzets formula7(QT
features of congestive cardiac failure (CCF) defined by interval divided by the square root of the preceding
cardiomegaly, tachycardia, gallop rhythm, enlarged RR interval ), QTc=QT/√RR. QTc value 6 of 350 –
jugular venous pulse, basal lung crepitations, pedal or 440 was considered normal, 440 – 500 is borderline
generalized edema plus cardiovascular compromise and above 500 mille second is accepted as long QT.
that require vasopressor (Dopamine or Dobutamin) Confounders:
more than 5 microgram/kg/min.
The QT interval is influenced by many factors even in
Laboratory evidence of cardiac involvement: sick patient like the physiological and or metabolic
Cases satisfying clinical picture of congestive cardiac state of the patient at the time of the ECG. These
failure were evaluated with Troponin T test. Positive variables are confounders and full spectrum of
Troponin T test is one of the important inclusion individual variability is currently unknown.
criteria.
Echocardiographic evidence of cardiac
Electrocardiographic tracing and measurement: involvement: Cases of scrub typhus which qualifies
The paper speed was set at 25mm/sec and voltage both clinical and laboratory criteria were evaluated for
gain taken at 10mm/mV (mille volte ). The reading evidence of myocarditis by ejection fraction, mitral
was interpreted manually and by machine, usuing a and tricuspid regurgitation. Depending on valvular
calibrated ruler by a pediatric cardiologist blinded to leaflet apposition, ring diameter, back flow, velocity,
cause of fever and condition of patient. Conduction area and length of jet, echocardiologist defined the
parameters (depolarization and repolarization) PR grades of mitral or tricuspid regurgitation.8 The
interval, QRS duration and QT interval were measured quantitative parameter of regurgitation with inter-
from lead II as per standered method and cross check observer variation is diameter of vena contracta8
with machine value. The ECG machine used in this which corresponds to the region in which blood passes
study was BPL Cardiart 6208. through the valve. The width of the vena contracta is
As U wave is a common finding in sick child a good marker of the severity of mitral and tricuspid
admitted in intensive care unit can easily included regurgitation because it corresponds to the diameter
in QT calculations and there by inflate the QT.6 To of the regurgitant orifice area.8 A diameter exceeding
avoid this mistake end of T wave is considered to be 7 mm indicates severe regurgitation where as 3-6 mm
the intersection of the tangent to the steepest slope of is considered moderate.9 The size of the regurgitation
the last limb of the T wave and the baseline. We refer jet by color Doppler and its temporal resolution,
it as “avoid the tail method’.6 however, are significantly affected by transducer

Table 2 : Clinical and Echocardiographic features of scrub typhus on day three of hospital admission with cardiac
complications
Sl. Edema H.R H.J reflux JVP Dilated M.R T.R E.F Pleural
No. chambers Effusion BL
1 + 109 + RA,RV Mod Mod 55% Mild
2 ++ 98 + RA,RV Mod Mod 25% Mod
3 + 128 + RA,RV Sev Sev 48% Mod
4 ++ 112 + Four Mod. Mod 25% Mod

Chambers
5 ++ 120 + ,, Sev. Sev. 30% Mod
6 ++ 117 + ,, Sev. Mod. 30% Mild
7 ++ 124 Not Not possible ,, Sev. Sev. 30% Mild

possible obese
obese
8 ++ 112 + ,, Sev. Sev. 30% Mild
9 ++ 122 + ,, Mod Sev. 25% Mod
10 ++ 100 + Not possible ,, Sev. Sev. 25% Mod

obese
11 ++ 122 + ,, Sev. Sev. 25% mod
frequency and instrument settings such as gain, chambers with moderate to severe regurgitation, but
output power, size and depth of the image sector . For due to some unknown reason left sided chambers are
grading of severity we relied on assessment of expert not dilated inspite of a volume overload. It may be
pediatric cardiologist. attributable to compensatory capacity of pediatric
Results and analysis: During study period 43 cases heart or interobserver variation. Full cohort of patients
were diagnosed with scrub typus but combine clinical, showed low ejection fraction varying from 25 to 55%.
laboratory and ECG evidence of cardiac involvement Two patients showed paradoxical response with mild
were found in 11 cases. impairment of ejection fraction of 48 & 55% with
moderate to severe dilatation of cardiac chambers
Demography showed proportion of male and female is
with bilateral pleural effusion.
almost equal, but 80 percent are from rural population.
Five patients having pet at home and four patients All eleven cases who satisfied the diagnosis of
has animal shed closer to their home. Three cases myocarditis both clinically and biochemically were
resides in pucca house with no exposures to animal subjected to ECG on day three of admission before
shed or pet had scrub with cardiac complications can starting IV doxycycline. All the cases became afebrile
be attributable to presence of mite in coir mattress or after five days of doxycycline.
broken wooden furniture. Mean heart rate and PR interval (mille second)
All the eleven cases has generalized edema of varying observed in the study was 114 & 206 across all
grade with raised jugular venous pulse (JVP)and subjects, whereas mean QT and corrected QT
positive hepatojugular reflux, but in two cases JVP interval with respect to heart rate were 320 and 440
could not be seen due to short neck and obesity. respectively. Addition of PR and QT interval is more
Apart from top three cases all had four dilated cardiac than cardiac cycle in all the cases which signifies the

Table 3 : ECG profile in individual cases at day 3 before doxycycline

Sl. Age Sex Day of HR Cardiac cycle ECG parameters in mille sec.
no (Yrs) fever Per Mille sec.
Min 60/HR PR QT Corrected
(RR) Int. QT by bezzet’s formula
QT/√RR
1 7 M 7 109 550 224 346 466
2 9 M 7 98 612 228 390 498
3 10 F 9 128 468 214 264 386
4 11 F 5 112 535 208 340 465
5 10 F 6 120 500 200 310 438
6 12 F 9 117 512 204 310 433
7 8 M 10 124 483 200 290 417
8 7 M 7 112 535 208 340 465
9 7 M 8 122 491 204 300 410
10 6 F 9 100 600 210 400 516
11 5 M 5 122 491 200 300 428
duration of Q wave. Out of eleven cases five cases Five cases of long QT were started with beta blocker
showed significant long QT >440 mille second. propranolol 1mg per kg per day in three divided doses
During interpretation of cardiac cycle with respect and evaluated at follow up visits with repeat ECG at
to Serum levels of sodium, potassium, calcium four and six weeks, none of the cases showed long
and magnesium were done at regular interval and QT and propranolol were stopped by gradual tapering
corrected as per standered pediatric intensive care over next 12 weeks.
unit (PICU) protocol.
Table 4 : Follow up ECG of five long QT at 2, 6, 12 weeks
Wks Sl. Age HR Cardiac cycle ECG parameters in mille sec
No. (Yrs) (RR) 60/HR
Mille sec. PR QT Corrected
QT by bezzet’s formula
QT/√RR
2 1 7 86 697 180 360 431
2 9 100 600 164 340 439
4 11 98 612 130 336 429
8 7 104 576 166 324 427
10 6 82 731 180 296 346
6 1 7 104 576 162 300 395
2 9 86 697 154 320 383
4 11 82 731 162 286 334
8 7 100 600 132 306 395
10 6 90 666 150 288 353
12 1 7 92 652 132 290 359
2 9 82 731 130 284 332
4 11 100 600 140 294 380
8 7 90 666 164 320 392
10 6 84 714 142 360 426

Follow up ECG at 2, 6 12 weeks of all five patients myocarditis needs genetic test.
of long QTc interval did not exhibit any evidence of This study may be a tip of iceburge in detecting long
persistence of long QT. The combination of PR and QT, VT and sudden death aggravated by systemic
QT interval falls much short of total cardic cycle febrile illness caused by rickettsia.So a message is
which can be explained by existence of inter beat well conveyed to pediatrician working in primary and
interval which increases when heart rate slows dawn. secondary health care regarding importance of ECG
Discussion: Rickettsia causes inflammation of and early detection of long QT and prevention of
myocardial fibres, particularly myocarditis, 10are death in rickettsial disease.
frequently associated with conduction disturbance and Conflict of interest: None
QTc prolongation observed in adult studies .10 Indeed, Source of Funding: None
in a patient of infective myocarditis, a prolonged
References
QTc predict the severety necro inflammation of
1. Kulkarni A. Childhood Rickettsiosis. Indian J Pediatr
the myocardium.11 An increasing body of evidence 2011;78:81-7.
indicates that inflammatory cytokines alters ionic 2. Narendra Rathi et al. IAP guidelines on Rickettsial Disease in
currents responsible for ventricular repolarisation. children, Indian Pediatrics 2017;54: 223-9,
Fever, tachycardia, hypoxia, cytokine strom and 3. DHR-ICMR. Guidelines for Diagnosis and Management of
direct cytopathic effect of rickettsia alters micro and Rickettsial Diseases in India. ICMR; 2015, February.
macrovascular perfusion of myocytes with excess 4. Manish Kumar etal. Scrub typhus in children at a tertiary
catecholamine surge perhaps prolongs repolarisation hospital in southern India: Clinical profile and complications,
of ventricular muscles thereby long QT. 26% of our Journal of Infection and Public Health 2012; 5(1):82-8.
cases exihibits long QTc, where no family histry of 5. Hornick RB. Rickettsial Diseases.Chapter371, Cecil
Textbook of Medicine. 21st ed. Philadelphia, USA: WB
sudden death, exertional, emotional or stress induced Saunders Company; 2000.P 1911–2.
cardiac symptoms were noted. 6. Johnson JN, Ackerman, MJ. QTc: how long is too long?
As most of the long QT syndromes are chanalopathy Volume 43, Issue 9, British journal of sports medicine
out of which sodium and potassium channel is most assessed on 04.07.2018 at https://bjsm.bmj.com/content /
bjsports /43/9/657 .full.pdf.
commonly involved.These abnormal transpoter
channel is inherited by autosomal recessive 7. Roguin A. “Henry Cuthbert Bazett (1885-1950)-- the man
behind the QT interval correction formula”. Pacing Clin
transmission, silent carrier may manifest under Electrophysiol 2011;34(3):384–8.
different conditions of stress and hypoxia. Borderline 8. Hall SA et al. Assessment of mitral regurgitation severity by
long QT may progress to ventricular tachycardia(VT) doppler colour flow mapping of vena contracta, Circulation
and death. The finding of our study emphasize the 1997:95, 636-42.
need of ECG monitoring to capture long QT in the 9. Quantification of mitral regurgitation. https://
early stage to avoid a catastrophe. www.123sonography.com/ebook/quantification-mitral-
regurgitation, assessed on 07.07.2018.
But reversal of prolonged QT to normalcy on three
10. Salvi A, Della GE, Silvestri F, Camerini F. Acute rickettsial
subsequent follow up within three months signifies myocarditis and advanced atrioventricular block: diagnosis
that with proper treatment and monitoring one and treatment aided by endomyocardial biopsy. Int J Cardiol
can revert the myocarditis and long QTc. Weather 198;7(4):405-9.
cytopthic effect of rickettsia menefest silent carrier to 11. Yuan Hung et al. The Prognostic Role of QTc Interval in
disease or it arises de novo by cytokine strom and Acute Myocarditis, Acta Cardiol Sin 2016 ; 32(2): 223–230,
How to cite this article: Das J, De D. Cardiac complications of scrub typhus with special reference to electrocardiography - A
Twelve weeks follow up in two tertiary pediatric hospital of eastern India. J Pediatr Crit Care 2018;5(6):15-19.
How to cite this URL: Das J, De D. Cardiac complications of scrub typhus with special reference to electrocardiography - A
Twelve weeks follow up in two tertiary pediatric hospital of eastern India. J Pediatr Crit Care 2018;5(6):15-19.
Available from: http://jpcc.in/userfiles/2018/0506-jpcc-nov-dec-2018/JPCC0506001.html

DOI-10.21304/2018.0506.00438
Symposium
Prevention is better than cure
Guest Editorial
Kundan Mittal*, Vivek Gupta**
*Senior Professor Pediatrics, Pt B D Sharma, PGIMS, Rohtak ,Haryana, India,
*Consultant Cardiac Anaesthesia & Intensive Care, Hero DMC Heart Institute, Ludhiana,Punjab,India
Received: 07-Dec-18/Accepted:24-Dec-18/ Published Online:31-Dec-18
Advances in health care have also predisposed human policy and guidelines. Various organization like CDC,
being to various threats. Health care associated Society for Health Care Epidemiology of America,
or hospital acquired infection are important cause Association for Professionals in Infection Control
of morbidity and mortality in present set up of and Epidemiology have developed the guidelines and
intensive care units (healthcare-associated infections also assist the institutions in formulating the policies.
are defined as infections that patients acquire while In present addition of journal our team has tried to
receiving treatment for other conditions within a discuss some issues related to health care associated
healthcare setting).1 Such infections also put extra infections and their prevention.
financial burden on the hospital, family and insurance References
companies. There are various sources(treatment, 1. Graves N, Weinhold D, Tong E, et al. Effect of healthcare-
irrational use of antibiotics, procedures, devices, acquired infection on length ofhospital stay and cost. Infect
Control Hosp Epidemiol 2007;28(3):280–92.
colonization, environment, hospital staff) of infection
2. Patrick SW, Kawai AT, Kleinman K, et al. Health care-
in intensive care units.2 Still various institutions do associated infections among criticallyill children in the US,
not report such infections thus causing problem in 2007-2012.Pediatrics 2014;134(4):705–12.
framing hospital policies and guidelines. Children 3. Zingg W, Hopkins S, Gayet-Ageron A, et al. Health-care-
have greater risk as compare to adults and data is associated infections in neonates,children, and adolescents:
also not available in pediatric population. Ventilator an analysis of paediatric data from the European Centre for
DiseasePrevention and Control point-prevalence survey.
associated pneumonia or ventilator associated events Lancet Infect Dis 2017;17(4):381–9.
and central-line associated blood infections are most 4. Bellissimo-Rodrigues F, Pires D, Zingg W, Pittet D. Role
common occurrence.3 Various preventive measures of parents in the promotionof hand hygiene in the paediatric
including hand hygiene and protocol policies if setting: a systematic literature review. J Hosp Infect
adopted can decrease the morbidity and mortality 2016;93(2):159–63.
related to infections. Quality of health care services of
any ICU or hospital is also determined by knowing the
How to cite this article:
occurrence of infection rate.4 Identification of health Mittal K,GuptaV. Prevention is better than cure: Guest
care associated infections help in developing the Editorial. J Pediatr Crit Care 2018;5(6):20.
Correspondence: How to cite this URL:

Dr. Kundan Mittal, Senior Professor Pediatrics, Pt B D Sharma, Mittal K,GuptaV. Prevention is better than cure: Guest
PGIMS, Rohtak Haryana, India,Phone-+919416514111, Email- Editorial. J Pediatr Crit Care 2018;5(6):20. Available from:
kundanmittal@gmail.com http://jpcc.in/userfiles/2018/0506-jpcc-nov-dec-2018/
JPCC0506002.html

DOI-10.21304/2018.0506.00439
Symposium
Aseptic Technique In Intensive Care Unit
Vivek Gupta*
*Consultant Cardiac Anaesthesia & Intensive Care, Hero DMC Heart Institute, Ludhiana,Punjab,India
Received: 01-Dec-18/Accepted: 18-Dec-18/Published online: 31-Dec-18
ABSTRACT
Maintaining asepsis is main component of intensive care. Adopting simple measures help in survival, decreasing
morbidity, preventing hospital burden and economy health of family and nation. Various simple measures are hand
washing, use of personnel protective devices, aseptic technique during procedures, and environmental cleanliness.
Key Words: Asepsis, intensive care unit, sterilization
The role of microorganisms in the health care settings contamination of susceptible sites by micro-organisms.
especially ICU (intensive care unit) and their impact This includes not only using sterile supplies but
on hospital acquired infections (HAI) is well accepted ensuring that the sterile component does not come into
in clinical practices but not fully understood. The contact with non-sterile surfaces.3 ANTT is required
microbial contamination of clinical procedures in for urinary catheterisation, accessing and dressing a
ICU causes significant number of infection due to central venous access device and changing a wound
poor infection control practices. drainage device. ANTT include consent & adequate
Aseptic technique is defined as a set of specific preparation of patient, ensuring environmental and
practices performed carefully under controlled equipment preparation, appropriate hand hygiene,
conditions aiming to reduce contamination by Disinfection and sterilisation and use of personal
pathogenic microbes.1 Minimizing infection in the protective equipment. The concept of ANTT
critically ill patients in the ICU (intensive care unit) procedure depends on the principle an agent (micro-
is the primary goal of the critical care team, and every organism), a vulnerable host (patient) and a conducive
measure taken by any team member must support environment.4
this goal. Some of these activities include patient risk Therefore, infection can be prevented by:
assessment, hand hygiene, environment cleaning, • Attacking the agent.
disinfection and sterilization of instrumentation,
• Changing and/or improving the environment.
patient antibiotic prophylaxis, and the use of standard
precautions. • Strengthening the host.
Asepsis can be grossly divided in two types: medical Hand Hygiene
and surgical asepsis. Medical or clean asepsis, used Most common mode of transmission of hospital
frequently in ICU reduces the number of organisms acquired infections (HAIs) is thought to be by
and prevents their spread; surgical or sterile asepsis the hands of healthcare workers. Therefore, hand
includes procedures to eliminate micro-organisms washing is considered to be the most effective
from an area and is practised in operating theatres and measure to reduce the risk of HCAI.5 However, using
treatment areas.2 hand washing alone to prevent HCAI may not be very
Aseptic Non Touch Technique (ANTT) effective because other variables such as inadequate
staffing levels and insufficient training and education
ANTT helps in preventing infection by avoiding the
may play an important role in infection transmission.6
Appropriate hand hygiene methods and disinfectant
Correspondence:
Dr Vivek Gupta,
solutions should be used to ensure asepsis by all health
Consultant Cardiac Anaesthesia & Intensive Care, professionals.The method of hand decontamination
Hero DMC Heart Institute, Ludhiana,Punjab,India. and disinfectant solution should be chosen as per
Phone : +919815398993, Email : dr_vivek@gmail.com the task. In general, the method used will depend on

SYMPOSIUM Aseptic Technique In Intensive Care Unit
the level of contact with the patient and the level of It is important that detergents and disinfectants
contamination that may occur. Irrespective of the solutions are prepared freshly with accurate dilution
hand hygiene method used, the preparation and other and also it is discarded appropriately on completion
requirements remains the same. The effective infection of procedure.7
control practices should ensure that all the health care Personnel Protective Equipment (PPE)
workers are using hand hygiene immediately before
Personal protective equipment helps in reducing but
and after contact with patients and equipment.
does not completely eliminate the risk of transmission
Cleaning, Disinfection & Sterilisation of Medical of infection in ICU setting. It is paramount importance
Devices that PPE is used effectively, appropriately, and
The cross infection through medical equipments and throughout the period of risk of contact with blood
devices can be minimized by decontamination. The and body fluids of patients. The availability of
decontamination is combination of processes including personal protective equipment and adequate training
cleaning, disinfection and sterilisation to ensure that for its appropriate use are essential. PPE should
reusable items are safe for further use on patients and be used whenever there are risks of transmission
during handling by the staff. These processes remove of microorganisms to the patient or the caregiver.
or destroy micro-organisms and spores and therefore Personal protective equipments which are essential
prevent contamination of susceptible sites and reduce for maintaining asepsis includes:
the risk of infection. • Gloves;
Cleaning only removes visible contamination and • Mask;
viable micro-organisms. Cleaning is only suitable for
• Apron/ gown;
low-risk items that come into contact with normal
and intact skin, for example, lifting aids. Cleaning is • Cap/hair cover
achieved by using detergent and water. Some items Enviornmental Cleanliness
may need to be cleaned first with cleaner to remove Maintenance of hygienic environment in the hospital
stains and scuff marks. Electrical equipment should is an essential and effective component for preventing
first be disconnected from the electricity supply and HAI. Unfortunately, extensive contamination of the
care taken to ensure that water does not leak into the hospital environment is known to occur.8 The patient
equipment. area must be visibly clean, free of dust and any soilage
The process of disinfection involves the use of before any aseptic procedure is being performed.
chemical substances to destroy viable microorganisms. Therefore thorough cleaning with appropriate
Some chemicals can also destroy spores. Disinfection disinfectant, clean laundry, safe collection of waste
is used for high-risk items that have come into close and food hygiene and pest control are essential
contact with breach in the patient’s skin or mucous component in the patient surroundings.
membranes, or have entered into a sterile cavity, for Several nursing procedures such as bed making and
example, endoscopes. Disinfection is only used if cleaning may lead to the spread of microorganism
autoclaving is inappropriate and could potentially in air and cause airborne infections.9 Airborne
damage the piece of equipment. Disinfectants can be contamination of sterile items may contribute to
inactivated by organic matter and will only reliably infection.10 These activities should be stopped 30
disinfect if thorough cleaning drying of the equipment minutes prior an aseptic procedure or dressing is to
has been done. be undertaken. Air movement should be kept to a
Sterilisation is used for high-risk items that have minimum during the aseptic procedures or dressing.
come into close contact with breaks in the patient’s This may be achieved by keeping the adjacent
skin or mucous membranes or in the organ cavity. windows closed and avoiding the movement of
Sterilisation is achieved by a combination of cleaning personnel within the area.
and autoclaving. Alternatively, commercial processes
such as irradiation with ethylene oxide can be used.

Achieving Asepsis During Procedure disinfectant, and use of surgical gloves and drapes as
During ICU management multiple procedures are per the procedure. These procedures include Urinary
performed on the patients. As infection prevention catheter insertion and bone marrow biopsies.15 For
strategy, these procedures broadly divided as unsterile performing sterile invasive procedures a surgical mask
(clean & aseptic) procedures and sterile procedures, the is added to sterile superficial procedures. Examples
level of sterility depends on invasiveness (superficial, include lumbar puncture, thoracentesis, paracentesis,
invasive or surgical) of the procedure. Though there laceration repair, and chronic wound care when
are no clear guidelinesregarding infection prevention sharp debridement is performed.11,16 The sterility for
strategiesfor all procedures, however with the Surgical-like procedures require full surgical attire
available evidences an outline of these procedures can (i.e sterile gown and gloves, surgical mask, and cap)
be proposed. and wide- to full-body coverage by surgical drapes
Performing a clean procedure aims to reduce the after appropriate painting with disinfectant solution.
contamination at the procedure site. The procedure These procedures include central venous catheter
site on the body should be free of dust, soil, and and arterial line placement, chest tube insertion,
debris. Standard Precautions (including hand hygiene percutaneous endoscopic feeding tubes placement,
and the use of appropriate personal protective and cath-lab interventions.17
equipment in case of splashing risk) along with Components of procedural aseptic technique:
examination gloves are used. Skin preparation • Hand washing
using disinfectant solution or the use of surgical • Surgical scrub
drapes is not required. These procedures include
• Using barriers (personal protective equipment)
endotracheal intubation, nasogastric tube insertion,
bedside gynaecologic procedures (e.g. intrauterine • Patient preparation
device placement/removal and endometrial biopsy), • Maintaining the sterile field
Care of percutaneous endoscopic gastrostomy or • Using safe procedure technique (making
jejunostomy tubeand chronic wound care without small incisions, avoiding trauma to tissue
sharp debridement.11 and surrounding structures, and controlling
Aseptic technique means the procedure site on the bleeding)
body should be free of pathogenic microorganisms. • Maintaining a safer environment in the surgical/
Standard Precautions along with skin preparation is procedure are
done using disinfectant solution preferably alcohol.12 Conflict of interest: None
Usually these procedures are performed using no-
Source of Funding: None
touch techniques. If the procedure is performed
without touching the critical area;an examination References:
gloves are worn, but if the provider is to touch the 1. Crow S. Asepsis: an indispensable part of the patient’s care
plan. Crit Care Nurse Quart 1989:11(4):11-5.
critical area of the procedure, surgical gloves are
2. Ayliffe GAJ, Fraise AP, Geddes AM, Mitchell K. Control
indicated. These procedures include venipuncture of Hospital Infection. A Practical Handbook.4th ed. Arnold,
and peripheral intravenous line placement, arterial London: 2000
blood gas measurements, skin biopsies, and fine 3. Pratt RJ, Pellowe CM, Wilson JA, et al. epic 2: national
needle aspirations, intravascular catheter care, evidence-based guidelines for preventing healthcareassociated
Percutaneous biopsy/fine needle aspirations/drainage infections in NHS hospitals in England. Journal of Hospital
procedure Superficial incision and drainage Bladder Infection 2007;65(suppl 1) S1-S64.
catheterization.13,14 4. Stirling B, Littlejohn P, Willbond ML. Nurses and the control
of infectious disease. Understanding epidemiology and
Sterile procedure means the procedure should be free of disease transmission is vital to nursing care. The Canadian
all microorganisms. These procedures can be divided Nurse 2004:100;16-20.
into 3 categories: sterile superficial procedures require 5. Gould DJ, Chudleigh J, Drey NS, Moralejo D Measuring
the use of Standard Precautions, skin preparation with handwashing performance in health service audits and

research studies. Journal of Hospital Infection, 2007:66;109- 12. Berrios-Torres S, Umscheid C, Bratzler D, Leas BE. Centers
115. for Disease Control and prevention guideline for the prevention
6. Akyol A, Ulusoy H, Ozen I . Handwashing: a simple, of surgical site infection. JAMA Surg. 2017;152:E1-8.
economic and effective method for preventing nosocomial 13. TheWorld Health Organization. WHO guidelines on drawing
infections in intensive care units. Journal of Hospital Infection blood: best practices in phlebotomy. The World Health
2006; 62(4):395-405. Organization. 2010.
7. Wilson J. Infection Control in Clinical Practice. 3rd edition. 14. O’Grady N, Alexander M, Burns LD. Guidelines for the
Baillière Tindall. London 2006. prevention if intravascular catheter-related infections, 2011.
8. Oie S, Hosokawa I, Kamiya A. Contamination of room handles USA: The Healthcare Infection Control Practices Advisory
by methicillin-sensitive/methicillin-resistant Staphylococcus Committee (HICPAC). 2011.
aureus. J Hosp Infect 2002; 51(2): 140–3. 15. Gould C, Unshield C, Agarwal RK, Pegues D. Guideline for
9. Shiomori T, Miyamoto H , Makishima K, et al. Evaluation of prevention of catheterassociated urinary tract infection 2009.
bed making-related airborne and surface methicillin resistant USA: The Healthcare Infection Control Practices Advisory
Staphylococcus aureus contamination. J Hosp Infect 2002; Committee (HICPAC). 2009.
50(1):30–5. 16. Siegel J, Rhinehart E, Jackson M, Chiarello LA. 2007
10. Dietze B, Rath A, Wendt C, Martiny H. Survival of MRSA guideline for isolation precautions: preventing transmission
on sterile goods packaging. J Hosp Infect 2001; 49(4):255–61. of infectious agents in healthcare settings. The Healthcare
Infection Control Practices Advisory Committee (HICPAC).
11. Wound, Ostomy and Continence Nurses Society & Association
2007
for Professionals in Infection Control and Epidemiology.
Clean vs. sterile dressing techniques for management of 17. American Society of Anaesthesiologists Task Force on
chronic wounds: a fact sheet. J Wound Ostomy Continence Central Venous Access. Practice Guidelines for Central
Nurse 2012;39(2S):S30-4. Venous Access. Anaesthesiology 2012;116:539-73.

Gupta V. Aseptic Technique In Intensive Care Unit. J Pediatr Crit Care 2018;5(6):21-24.
How to cite this URL:

Gupta V. Aseptic Technique In Intensive Care Unit. J Pediatr Crit Care 2018;5(6):21-24.

DOI-10.21304/2018.0506.00440
Symposium
Clostridium Difficile : Epidemiology and Prevention
Antariksh deep* Kundan Mittal**
*Professor, Dept of Microbiology, **Senior Professor Pediatrics, Pt B D Sharma, PGIMS, Rohtak Haryana, India
Received: 01-Dec-18/Accepted: 20-Dec-18/Published online: 31-Dec-18
ABSTRACT
C. difficile is a Gram-positive anaerobic that forms part of the normal intestinal flora of the human beings.C.
difficileinfection (CDI) is the most common cause of hospital acquired diarrhea/antibiotic associated diarrhea, in the
adult patients.It has been reported that the pediatric CDI has been associated with increased mortality, longer hospital
stay and higher costs among hospitalized children.The most important requirements to initiate active surveillance for
CDI prevention areto categorise the patients as per the standard definitions, and need to rapidly detect colonisation,
and cases of CDI.
Key Words: C. difficile, enterotoxins, cytotoxins,colonisation
Introduction And Epidemiology: patient receives antibiotic therapy, the normal colonic
Clostridium difficile was first isolated from stool in microflora gets disturbed, leading to proliferation
1935 and was termed Bacillus difficilis “because of the of C. difficile which eventually releases toxin A
unusual difficulty…..encountered in its isolation and (enterotoxin) and /or toxin B (cytotoxin). Many
study.” 1,2 Just like many other multi-drug resistant studies have documented an increase in the rates of
organisms, e.g. methicillin-resistant Staphylococcus the CDI in the children in both, the community as
aureus, vancomycin-resistant enterococci, well as the hospital settings. While asymptomatic
carbapenem- resistant enterobacteriaceae Clostridium colonisation is rare in healthy adults (prevalence, 1%
difficile (C. difficile), has also similar epidemiological to 7%), the asymptomatic colonization during the first
tenets. It is capable of getting transmitted both by two years of life may be between 2% to 75%.5,6 The
direct, as well as indirect contact.3 Also, the number infants, although don’t suffer from CDI, but may serve
of asymptomatically colonized persons far exceeds as an important reservoir for the pathogenic strains.It
the patients with symptomatic Clostridium difficile has been shown in various studies that C. difficile may
infection(CDI).C.difficile is a Gram-positive anaerobic follow either of the two patterns in colonization. C.
that forms part of the normal intestinal flora of the difficile is acquired either in the neonatal period of
human beings. The organism can be found in around life, i.e. early acquisition, or the period between the
3% of the normal healthy adults and around 20% to fourth and the sixth months of life (late acquisition).
30% of the hospitalized adults. In the human colon, It has been observed in a study that the carriage rate
the Clostridium exists as a vegetative cell, whereas, of the C. difficile increased from the first month of
outside the intestine, it survives as a spore form. The lifeon, reaching a maximum of around 70%, in the 7-9
colonization of the human intestine occurs as a result month and 10-12 month age groups. After that, there
of feco-oral contamination. C. difficile is the most is a progressive in the carriage rates, with the rates
common cause of hospital acquired diarrhea/antibiotic dropping to 6%, a value similar to that seen in the adults,
associated diarrhea, in the adult patients. However, in the age group of 24-36 months.7-10 Further, two
with the advent of the hyper-virulent strain, termed studies have revealed that the number of admissions
North American pulsed-field gel electrophoresis type the number of admissions during the period 2001 to
1 strain (NAP1), the epidemiology of the CDI, has 2006, increased from 2.4 to 4.0 per 1000 admissions
steadily evolved in the last decade.4 When a colonized and 4.4 to 6.5 per 10,000 patient days respectively, at
22 children’s hospitals in the United States. Increasing
Correspondence: rates of CDI cases requiring hospitalization (7.24 to
Dr. Kundan Mittal, Senior Professor Pediatrics, Pt B D Sharma,
PGIMS, Rohtak Haryana, India, Phone-+919416514111, 12.84 per 10,000 hospitalisations) were also reported
Email-kundanmittal@gmail.com in another study.11 This becomes more worrisome
especially when recently it has been reported that

SYMPOSIUM Clostridium Difficile : Epidemiology and Prevention
the pediatric CDI has been associated with increased Diagnosis:

mortality, longer hospital stay and higher costs 1. Routine testing of CDI is not recommended as
among hospitalized children.12 The importance of per the 2017 IDSA and SHEA Clinical Practice
undertaking active surveillance measures to identify Guidelines for Clostridium difficile infection in
colonized patients cannot be more underscored in the adults and children.
light of the above-mentioned observations to contain 2. As per the 2017 IDSA and SHEA Clinical Practice
the spread of transmission of CDI. Guidelines for Clostridium difficile infection,
The most important requirements to initiate active the patients with unexplained/new onset ≥3
surveillance for CDI prevention are: 1) to categorise unformed stools in 24 hours are the preferred
the patients as per the standard definitions, and 2) target population for testing for the CDI.
need to rapidly detect colonisation, and cases of CDI. 3. In children of 1-2 years of age, routine testing
Definitions: of CDI should not be performed unless other
1. CDI is defined by the presence of symptoms infectious and non-infectious causes have been
(usually diarrhea), and either a stool test positive ruled out.
for C. difficile toxins or detection of toxigenic 4. Testing of CDI is recommended in children of
C. difficile, or colonoscopic or histopathologic >2 years of age who have got prolonged and
findings revealing pseudomembranous colitis. worsening diarrhea, and other associated risk
2. Healthcare facility-onset, healthcare facility- factors, e.g. underlying inflammatory bowel
associated CDI (HO-HCFA CDI), defined as CDI disease or associated immunocompromising
symptom onset > 48 hours after admission. conditions, or contact with health care system or
3. Community-onset, healthcare facility-associated recent exposure to antibiotics.14
CDI (CO-HCFA CDI) defined as symptom onset As per the IDSA/SHEA guidelines, if the patients are
in the community or ≤48 hours after admission, screened carefully for the clinical symptoms likely to
provided that symptom onset was <4 weeks after be associated with CDI, then a highly sensitive test
the last discharge from a health care facility. such as NAAT (nucleic acid amplification test) alone
4. Community-associated CDI (CA-CDI), defined or following a multi-step algorithm employing GDH
as symptom onset in the community or ≤48 hours (Glutamate dehydrogenase – a highly conserved
after admission, provided that symptom onset metabolic enzyme, common antigen) plus toxin; GDH
was >12 weeks after the last discharge from the plus toxin, arbitrated by NAAT or NAAT plus toxin
healthcare facility. would be more prudent as following a 2 or 3-stage
approach increases the positive predictive value as
5. Indeterminate CDI, defined as CDI not fitting any
compared to one stage testing.14
of the above mentioned criteriafor an exposure
setting, i.e. CDI symptom onset occurred between Infection Prevention and Control:
4 and 12 weeks from a hospital dismissal. Various inherent microbiological attributes of the
6. Cases of HO-HCFA CDI and CO-HCFA CDI are C. difficile, facilitate the environmental survival and
to be taken as healthcare facility-associated CDI transmission of this organism. The vegetative cell
(HA-CDI).11,13,14 of C. difficile survives for only a short duration of
time on hospital surfaces. On dry surfaces, the bacilli
For the Pediatric patients, it is recommended to use
die rapidly, whereas on the moist surfaces, they
the same case definitions as in adult patients, that
may survive upto 6 hours. This is in contrast to the
are mentioned above. It is recommended that active
bacterial spores that are highly resistant to drying,
surveillance should be conducted for HO-CDI for
heat and chemical agents. A study reported that upto
pediatric inpatients of >2 years of age. Surveillance
49% of the rooms occupied by the symptomatic
should also be conducted for CA-CDI to detect trends
patients of the CDI and 29% of the rooms occupied
in the community.14
by the asymptomatic patients were contaminated with

the C. difficile.15,16 This is because of the prolonged with soap and water, or water and 2% chlorhexidine
survival of the spores and the inadequate terminal gluconate eliminated1.5-2.0 log10 spores after a 10s,
cleaning and disinfection practices followed by most 30s, or a 60s wash episode.23 IDSA/SHEA guidelines
of the hospitals. C. difficile has also been recovered recommend that in routine or endemic settings, hand
from the work-stations areas of the inpatient areas, hygiene should be performed before and after coming
e.g. telephones, computer keyboards, medical in contact with a patient of CDI and after removing
devices such as ultrasound machines, ECG machines, glover, with either soap and water or an alcohol
pulse oximeters, blood pressure cuffs, and personal based hand hygiene product. In CDI outbreaks /
equipments such as the stethoscopes, mobile phones hyperendemic settings or if there is a direct contact
etc.15,17,18 A study carried out in 1981 had revealed with the feces or an area where fecal contamination
that contaminated portable commode chair was is likely to be encountered, hand hygiene should
responsible secondary spread to eight other patients preferentially be performed with soap and water
in the ward within seven days.19 instead of alcohol based hand hygiene products.15,24
Therefore, it becomes imperative, that once the The patients should be encouraged to take shower/
colonized patients have been identified, all standard bath to decrease the burden of spores on the skin.
measures should be instituted to prevent the onward The use of disposable patient equipment should be
transmission to the susceptible hosts. This could be encouraged wherever possible and if not possible, a
either done by instituting broad based, “horizontal sporicidal agent that is compatible with the equipment
approaches,” like in case of all MDROs, or adopting a should be used for carrying out disinfection after
more effort-intensive “vertical approach,” like going thorough cleaning of the device. In a hospital, routine
for the active surveillance directed isolation of tough cleaning of the surfaces with a detergent should be
to deal with organisms, like C. difficile, and other undertaken. Environmental decontamination with the
MDROs.2 chlorine based disinfectants like sodium hypochlorite,
Important horizontal approaches include institution the simplest and the cheapest method have been shown
and adoption of hand hygiene practices, improved to lead to reduction in spore density, but has a serious
cleaning and terminal disinfection practices, using handicap of being corrosive and getting inhibited by
sporicidal agents, as well as “no touch” methods for organic matter.14
room decontamination.14,19 It was demonstrated in a Gaseous decontamination is another method for
study that frequency of skin contamination of patients environmental decontamination, whereby a gas
with CDI was similar to stool detection.20 Also, the or vapour form of a disinfectant such as hydrogen
rate of positivity of hand cultures from the healthcare peroxide or chlorine dioxide is generated to
staff was directly proportional to the intensity of the decontaminate a specific area or a room. Hydrogen
environmental contamination. An interesting finding peroxide, an oxidizing agent, which was initially
from a study was that handshaking transferred a mean developed for use in pharmaceutical clean rooms,acts
of the 30% of the residual C. difficile spores to the by producing highly reactive hydroxyl radicals
hands of the recipients.21 that attack cellular DNA and membrane lipids. It
As far as selection of an appropriate agent for is regarded to be relatively less toxic, since its end
employing hand hygiene is concerned, ‘none products are water and oxygen.The efficacy of
of the agents from the alcohols, chlorhexidine, decontamination of hydrogen peroxide varies form
hexachlorophene, iodophors, triclosan’etc.that are surface to surfacewhere decontamination is desired to
common ingredients of the various antiseptic hand achieved, e.g. 1.2 log10 reduction on carpet to >7.5
rubs are reliably sporicidal.22 A study employing log10 reduction on paper wallboard.25,26,27
Bacillus atrophaeus (a surrogate for C. difficile) Chlorine dioxide, another potent bactericidal,
revealed that performing an episode of hand hygiene sporicidal and fungicidal agent is used by passing
using 61% waterless alcohol based hand rub was a 2% chlorine nitrogen gas mixture over granules
ineffective in eliminating spores, but if performed of sodium chlorite, at ambient temperature and

relative humidity of >65%. This gas has been used Clinical Infectious Diseases 2013;57(12):1665–72.
for decontamination of large buildings. There is very 12. Sammons JS, Localio R, Xiao R, Coffin SE,Z aoutis T.
little data documenting its efficacy in the clinical Clostridium difficile Infection Is Associated With Increased
Risk of Death and Prolonged Hospitalization in Children.
environment. Clinical Infectious Diseases 2013;57(1):1–8.
The no-touch disinfection technologies or the 13. McDonald LC, Coignard B, Dubberke E, Song X, Horan
automated terminal disinfection methods generally T, Kutty PK. Recommendations for surveillance of
use ultra-violet radiation or hydrogen peroxide vapour Clostridium difficile–associated disease. Infect Control Hosp
Epidemiol.2007;28:140–5.
to disinfect the environment. There is scanty data that
14. McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll
is available to justify for these to included as a part of KC, Susan E. Coffin SE, et al.Clinical Practice Guidelines
CDI prevention programme. for Clostridium difficile Infection in Adults and Children:
Conflict of interest: None 2017 Update by the Infectious Diseases Society of America
(IDSA) and Society for Healthcare Epidemiology of America
Source of Funding: None (SHEA).Clinical Infectious Diseases.2018;66(7):e1–e48.
References: 15. Rutala WA. Role of hospital environment in disease
1. Rana E. El Feghalyand Phillip I. Tarr.Clostridium difficile in transmission, with a focus on Clostridium difficile. Healthcare
Children: Colonization and Consequences. Clinical Infectious Infection.2013;18;14-22.
Diseases 2013;57(1):9–12 . 16. Jump RLP, Pultz MJ, Donskey CJ. Vegetative Clostridium
2. Hall IC, O’toole E. Intestinal flora in newborn infants with a difficile survives in room air on moist surfaces and in gastric
description of a new pathogenic anaerobe, Bacillus difficilis. contents with reduced acidity: a potential mechanism to
Am J Dis Child 1935; 49:390–402. explain the association between proton pumps inhibitors
and C. difficile-associated diarrhea. Antimicrob Agents
3. L. Clifford McDonald. Looking to the Future: Vertical vs
Chemother2007; 51: 2883–7.
Horizontal Prevention of Clostridium difficile Infections.
Clinical Infectious Diseases 2013;57(8):1103–5. 17. Dumford DM, Nerandzic MM, Eckstein BC, Donskey CJ.
What is on that keyboard? Detecting hidden environmental
4. Toltzis P, Zaoutis T. Community Associated Clostridium
reservoirs of Clostridium difficile during an outbreak associated
difficile infection in children. Clinical Infectious Diseases
with North American pulsed-field get electrophoresis type l
2013;57(12):1673–5.
strains. Am J Infect Control 2009; 37: 15–9.
5. Rexach CE, Tang-Feldman YJ, Cantrell MC, Cohen SH.
18. Pulvirenti JJ, Gerding DN, Nathan C, Hafiz I, Mehra T, Marsh
Epidemiologic surveillance of Clostridium difficile diarrhea
D, et al. Differences in the incidence of Clostridium difficile
in a freestanding pediatric hospital and a pediatric hospital at
among patients infected with human immunodeficiency virus
a university medical center. Diagn Microbiol Infect Dis 2006;
admitted to a public hospital and a private hospital. Infect
56:109–14.
Control Hosp Epidemiol 2002; 23: 641–7.
6. Yamamoto-Osaki T, Kamiya S, Sawamura S, Kai M, Ozawa
19. McFarland LV, Mulligan ME, Kwok RY, Stamm WE.
A. Growth inhibition of Clostridium difficile by intestinal
Nosocomial acquisition of Clostridium difficile infection. N
flora of infant faeces in continuous flow culture. J Med
Engl J Med 1989; 320: 204–10.
Microbiol 1994; 40:179–87.
20. Sethi AK, Al-Nassar WN, Nerandzic MM, Bobulsky
7. Kim J, Smathers SA, Prasad P, Leckerman KH, Coffin S,
GS, Donskey CJ. Persistence of skin contamination and
Zaoutis T. Epidemiological features of Clostridium difficile-
environmental shedding of Clostridium difficile during and
associated disease among inpatients at children’s hospitals in
after treatment of C. difficile infection. Infect Control Hosp
the United States, 2001– 2006. Pediatrics 2008; 122:1266–70.
Epidemiol 2010; 31: 21–7.
8. Sandora TJ, Fung M, Flaherty K, et al. Epidemiology and risk
21. Jabbar U, Leischner J, Kasper D, Gerber R, Sambol SP,
factors for Clostridium difficile infection in children. Pediatr
Parada JP, et al. Effectiveness of alcohol-based hand rubs for
Infect Dis J 2011; 30:580–4.
removal of Clostridium difficile spores from hands. Infect
9. Penders J, Stobberingh EE, van den Brandt PA, van Ree R, Control Hosp Epidemiol 2010; 31: 565–70.
Thijs C. Toxigenic and non-toxigenic Clostridium difficile:
22. Centers for Disease Control and Prevention. Guideline for
determinants of intestinal colonisation and role in childhood
hand hygiene in health-care settings; recommendations of the
atopic manifestations. Gut 2008; 57:1025–6.
Healthcare Infection Control Practices Advisory Committee
10. Rousseau C, Lemée L, Le Monnier A, Poilane I, Pons J-L, and the HICPAC/ SHEA/APIC/IDSA Hand Hygiene Task
Collignon A. Prevalence and diversity of Clostridium difficile Force. MMWR Recomm Rep 2002; 51(RR-16): 1–45.
strains in infants. J Med Microbiol 2011; 60:1112–8.
23. Weber DJ, Sickbert-Bennett E, Gergen MF, Rutala WA.
11. Sutter ST, Tamma PD, Naegeli AN, Speck KA, Milstone Efficacy of selected hand hygiene agents used to remove
AM, Perl TM. Distinguishing Community-Associated Bacillus atrophaeus(a surrogate of Bacillus anthracis) from
From Hospital-Associated Clostridium difficile Infections contaminated hands. JAMA 2003; 289: 1274–7.
in Children: Implications for Public Health Surveillance.

24. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Guideline for 26. Rogers J, Sabourin C, Choi Y, et al. Decontamination
isolation precautions: preventing transmission of infectious assessment of Bacillus anthracis, Bacillus subtilis and
agents in healthcare. Atlanta, GA: Centers for Disease Geothermophilus stearothermophilus spores on indoor
Prevention and Control; 2007 Available online at: http:// surfaces using a hydrogen peroxide gas generator. J
www.cdc.gov/hicpac/pdf/isolation/ Isolation2007.pdf ApplMicrobiol 2005;99:739e748.
25. A. Davies, T. Pottage, A. Bennett, J. Walker. Gaseous and air 27. Pottage T, Richardson C, Parks S, Walker JT, Bennett AM.
decontamination technologies for Clostridium difficile in the Evaluation of hydrogen peroxide gaseous disinfection systems
healthcare environment.ournal of Hospital Infection (2010), to decontaminate viruses. J Hosp Infect 2010;74:55e61.
doi:10.1016/j.jhin.2010.08.012.

Deep A, Mittal K. Clostridium Difficile : Epidemiology and Prevention. J Pediatr Crit Care 2018;5(6):25-29.

Deep A, Mittal K. Clostridium Difficile : Epidemiology and Prevention. J Pediatr Crit Care 2018;5(6):25-29.

DOI-10.21304/2018.0506.00441
Symposium
Ventilator Assosciated Pneumonia
Vivek Gupta*
*Consultant Cardiac Anaesthesia & Intensive Care, Hero DMC Heart Institute, Ludhiana,Punjab, India
Received: 21-Nov-18/Accepted: 12-Dec-18/Published online: 31-Dec-18
A S AC
Ventilator associated pneumonia is common in adult intensive care units. Pediatric intensive care unit also faces the
issue of VAP. Various factors (exogenous and endogenous) are responsible for developing VAP in critically ill patients.
Diagnosing the VAP is also challenge to intensivist. Antibiotic resistance is major concern in the treatment of VAP and
hence preventive strategies are key factor in management of VAP.
ey ords: Ventilator Associated Pneumonia (VAP), Mechanical Ventilation
Ventilator associated pneumonia (VAP), develops development.8 Development of antibiotic resistance

after 48 hours after intubation and mechanical in VAP patients remain a major concern to infectious
ventilation is the most common nosocomial infection disease physicians, Intensivists & microbiologist
associated with mechanical ventilation in critically since it carries a higher cost of treatment and it may
ill patients and contributes in almost 50% of the total lead to use of high end antimicrobial administration
antibiotics used in intensive care unit.1,2 The chance and mortality rate and prolonged stay in the ICU.9
of developing VAP is multifactorial and it depends It is difficult to make a precise diagnosis of VAP.
on age, underlying disease, duration of mechanical The purulent secretion after the intubation may be
ventilation and the criteria used for diagnosing VAP. due to leakage of secretion of oropharyngeal cavity.
The incidence varies from 9-27% in mechanically The chest X- ray may be confused with other clinical
ventilated patients. This leads to an increased ICU and conditions such as adult respiratory distress syndrome
hospital stay with an increased risk of mortality.3 The (ARDS), pulmonary oedema, pulmonary infraction or
VAP rate in developing countries is nearly four times atelectasis.10 Probably a subjective clinical impression
as compared to western ICU’s and ranges around 13.6 seems more accurate than a set of objective criteria
per 1000 ventilator-days.4 Gram negative bacteria is for diagnosis of VAP. 11 Though suspicion and clinical
the commonest pathogen associated with VAP in diagnosis of VAP is highly sensitive method but it’s
ICU.5 The commonest reason of VAP is possibly specificity is low.The best diagnostic test as set gold
due to aspiration of secretions from oropharyngeal standard for diagnosing VAP is still lacking.
cavity contaminated with potentially pathogenic W at are t e risk actors
organisms. The aspiration of gastric content
VAP mainly occur due to entry of pathogenic
may also lead to VAP. Basically anatomical and
microorganism into the lower respiratory tract by
physiological defence mechanism against aspiration
aspiration of oropharyngeal secretions or gastric
is lost due to tracheal intubation, making positive
reflux which contain microorganisms. However
pressure ventilation a major contributor for VAP
hematogenous spread, inhalation of contaminated
development.6 The endotracheal tube not only inhibits
air, and pleural space infections also contribute in
the ciliary action, swallowing and spontaneous
the development of VAP though less commonly.
coughing but prevents the epiglottis from closing
VAP producing microorganism may be the part
also.7 There are sufficient evidences that certain
of the patient’s own upper airway flora or may be
strategies can be helpful in preventing VAP however
acquired during hospital stay.12 The endotracheal
a care bundle approach reduces the chance of VAP
intubation, tracheostomy or use of other supraglottic
devices leads to bacterial colonization of the upper
Correspondence:
Dr Vivek Gupta, Consultant Cardiac Anaesthesia & Intensive
airway. Microorganism gradually move to the lower
Care, Hero DMC Heart Institute, Ludhiana,Punjab,India. respiratory tract due minimal leak around the around
Phone : 9815398993, Email : dr_vivek@gmail.com the endotracheal tube cuff or even via lumen of the

SYMPOSIUM Ventilator Assosciated Pneumonia
endotracheal tube. The risk factors can be divided as: after four day is usually hospital acquired and the
endogenous which are non-modifiable and exogenous pathogens are usually resistant to antimicrobials. The
which probably can be reduced with appropriate risk of developing multidrug resistant VAP is more
interventions; likely in patients who received antimicrobial therapy
Table 1: Risk Factors For VAP 12- 14 in last 3 months, requiring renal replacement therapy
(RRT) for acute kidney injury management, having
ENDOGENOUS EXOGENOUS
septic shock/ ARDS or hospitalization more than five
Underlying medical condition Supine position
(COAD, ARDS, Anaemia etc) Frequent ventilator circuit days.
change How the diagnosis of VAP is made?
Advanced Age Nasogastric tube
Enteral feeding Currently there are no gold standards to diagnose
Poor Immune status Supine position VAP accurately; the matter is further complicated due
Blood transfusion to overlap of clinical presentations of several other
Bacterial colonization Burn patient/ Chest or conditions such as ARDS, Pulmonary contusion,
(Gastric &/ or upper airway) upper abdomen surgery/
Tracheostomy
pulmonary oedema or thromboembolic events. The
Smoking Use of sedation/ muscle criteria for diagnosing VAP include a combination
relaxant clinical, radiological and microbiological correlation.
Patient manipulation/ This combined evaluation improves the chance of
frequent transportation correct diagnosis of VAP.17 The individual criteria
Reintubation
Prolonged intubation/ is not sensitive in diagnosing the VAP however a
mechanical ventilation combinationof criteria provides good sensitivity
How VAP Develops? and specificity for diagnosing the VAP. The usual
symptoms are increased tracheal secretions, fever,
Prolonged intubation and mechanical ventilation
rising inflammatory marker, respiratory distress and
leads to formation of a layer on the inner surface of
worsening gas exchange (hypoxemia, hypercapnia)
endotracheal tube consists of microorganisms called
along with reduced tidal volume and increased
biofilm.This biofilm play an important role in the
respiratory rate. Samples are collected with both
development of VAP and since these pathogenic
invasive and non-invasive techniques toobtain
organisms are less active they lead to antibiotic
microbiological specimens for diagnosing VAP.
failure and are resistant to host defence mechanism.
Invasive techniquesinclude bronchoscopic alveolar
The artificial airway interferes with anatomical and
lavage (BAL) and protectedspecimen brushings
physiological barrier mechanisms. Consciousness of
(PSB), while less invasive techniques includemini
these patients is usually impaired which affects the
BALs. Tracheal aspirates can be collected less
voluntary clearance of secretions form oropharynx.
invasively there are more chances that it may get
The pooled secretions containing pathogenic
contaminated with colonizing microorganism in
organism can lead to both micro aspiration and
the oropharyngeal cavity. Quantitative cultures are
macro aspiration.14 Microbes gradually pass along
often used to differentiate between colonization and
the tracheal tube, forming an antibiotic-resistant
infection. The BALs is considered as gold standards
biofilm which finallytravels to the lower airways.
and a colony count above 104 colony forming units/
The impaired immune response of these critical
millilitre (CFU ml−1) is clinically significant. A chest
patients allows these pathogenic organisms to grow
X-ray must be done for every patient with clinical
further, which leads to the VAP development.15 This
suspicion of VAPand a respiratory tract secretion
further aggravates due to the presence of underlying
must be sent for patients having infection for Gram
predisposing factors such aspulmonary oedema.16
stain, culture, and sensitivity.18 A normal chest X-ray
VAP developing within four days of intubation and
preclude the diagnosis of VAP and an alternative
mechanical ventilation is labelled as early onset VAP
diagnosis must be considered. Sampling using the
and usually the causative organism is sensitive to
tracheal aspirates can be analysed quantitatively or
antimicrobial, however late onset VAP, occurring

qualitatively. However, this technique misses many select the optimal antibiotic treatment it is essential
cases of pneumonia, with a reported sensitivity of to beaware of the organisms commonly associated
56-69% anda specificity of 75-95%.19 It is prudent with ventilator associated pneumonia. Most cases are
to remember that tracheal samples must be sent bacterial in origin and several organisms are often
prior to antibiotic administration. A CPIS score of 6 involved. The clinical relevance of fungal and viral
or higher out of a maximum score of 12 indicates a pneumonia is still poorly understood.
likely diagnosis of VAP. However, the sensitivity & How VAP can be prevented?
specificity of this scoring system is not great (Table
Care Bundle: A care bundle refers to a group of
2).
evidence-based interventions related to a particular
Table 2 : Clinical Pulmonary Infection Score condition which when applied togethersignificantly
(CPIS) improves patient outcome. The original document
CPIS POINT 0 1 2 consisted of daily sedation interruption, bed head
Temperature (0C) 38.5-38.9 >36 or <39 elevation(30 – 45 degree), gastric ulcer prophylaxis,
36.5-38.4 and oralcare. It was updated in 2010 to include
Leukocytes (cells/ 4,000 or .11,000 > 500 band
oral hygiene with adequatestrength anti-septic’s,
mm3) 4,000-11 000 cells
Tracheal secretions Mild/non-purulent Purulent
subglottic aspiration, and TT cuffpressure monitoring
None in addition to the initial four care interventions.
(subjective) How to treat VAP?
chest X-ray No Diffuse/patchy Localised
infiltrates infiltrates infiltrate Treatment of VAP depends on awareness of
Culture results Moderate florid Moderate/ common pathogens, patient risk factors (for
No/ Mild Growth growth Florid example immunosuppression and underlying
(Respiratory sampling) Growth respiratory condition), and previous microbiology
Oxygen Status (PaO2/ < 240 an specimens. Empirical treatment for VAP should
FiO2)>240or ARDS absence of
ARDS
include antibiotics with cover against Pseudomonas
aeruginosa, Staphylococcus aureus, and gram-
The Hospitals in Europe Link for Infection Control
negative bacilli, with antibiotics administeredin a
through Surveillance (HELICS) criteria are widely
timely fashion.15 Delaying treatment and failing to
used for surveillance of ventilator associated
select a suitable antibiotic regimen in accordance
pneumonia rates in Europe. Critical care specialist
with local policy hasbeen shown to result in higher
generally agree that pneumonia should be suspected
mortality rates.1 Antibiotics should be safely de-
when there are new or persistent infiltrates on chest
escalated once microbiology results areavailable, with
radiographyplus two or more of the following:
cessation after 7 days based on improving clinical and
• Purulent tracheal secretions biochemical markers.
• Blood leucocytosis (>12×109 white blood cells/L) Conflict of interest: None
orleukopenia (<4×109 white blood cells/L)
• Temperature greater than 38.3°C.
References
Ventilator associated pneumonia is categorised as 1. Vincent JL, Sakr Y, Sprung CL et al. Sepsis in European
pneumonia(PN) 1-5 depending on the microbiological intensive care units: results of the SOAP study. Crit Care
method used tomake the diagnosis. Med 2006; 34: 344–53.
Organisms assosciated with VAP 2. Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J,
Nicolas-Chanoin MH, et al. The prevalence of nosocomial
The pathogenic organisms associated with VAP infection in intensive care units in Europe. Results of the
depend on several factors such as case mix, underlying European Prevalence of Infection in Intensive Care (EPIC)
comorbidity, hospital, andtype of ICU. Every unit Study. EPIC International Advisory Committee. JAMA
1995;274:639-44.
must collect continuous microbiological surveillance
3. Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L,
data to ensure optimal empirical antibiotic therapy.To
Redman R, et al. Epidemiology and outcomes of ventilator-

associated pneumonia in a large US database. Chest 12. Safdar N, Crnich CJ, Maki DG. The pathogenesis of
2002;122:2115-21. ventilator-associated pneumonia: Its relevance to developing
4. Rosental VD, Maki DG, Jamulitrat S, Medeiros EA, Todi effective strategies for prevention. Respiratory Care.
SK, Gomez DY, et al. International nosocomial infection 2005;50(6):725-39.
control consortium report, data summary for 2003-2008, 13. Blot S, Koulenti D, Dimopoulos G, Martin C, Komnos A,
issued June 2009. Am J Infect Control 2010; 38:95-104. Krueger WA, et al. Prevalence, risk factors, and mortality
5. Sandiumenge A, Rello J. Ventilator associated pneumonia for ventilator-associated pneumonia in middle-aged, old,
caused by ESKAPE organisms: cause, clinical features and and very old critically ill patients. Critical Care Medicine.
management. Curr Opin Pum Med 2012; 18:187-93. 2014;42(3):601-9.
6. Kollef MH, Skubas MJ, Sundi TM: A randomized clinical 14. Charles MP, Kali A, Easow JM, Joseph NM, Ravishankar
trial of continuous aspiration of subglottic secretions in M, Srinivasan S, et al. Ventilatorassociated pneumonia. The
cardiac surgery patients. Chest 1999:116;1339-46. Australasian Medical Journal. 2014;7(8):334-44.
7. Craven D D,Chroneou A, Zias N, Hjalmarson K. Ventilator 15. Hunter JD. Ventilator associated pneumonia. Postgrad Med.
associated tracheobronchitis: the impact of targeted antibiotic 2006;82:172-8.
therapy on patient’s outcome. Chest2009:135; 521-8. 16. Kalil AC, Metersky ML, Klompas M, et al. Management
8. Zolfaghari PS, Wyncoll DL. The tracheal tube: gateway to of adults with hospital-acquired and ventilator-associated
ventilator-associated pneumonia.Crit Care2011;15:310. pneumonia: 2016 clinical practice guidelines by the
Infectious Diseases Society of America and the American
9. Paskin N, Aydemir H, Ostoprak N, Akduman D, Comert F,
Thoracic Society. Clin Infect Dis 2016;63:e61.
Kokturk F, et al. Inadequate treatment of ventilator associated
and hospital acquired pneumonia: risk factors and impact on 17. Klompas M. Does this patient have ventilator-associated
outcomes. BMC Infect Dis 2012; 12:268. pneumonia? J Am Med Assoc 2007; 297: 1583–93.
10. Fagon JY, Chastre J, Domart Y, Trouillet JL, Pierre J, 18. Kalanuria AA, Zai W, Mirski M. Ventilator-associated
Darne C, et al. Nosocomial Pneumonia in patients receiving pneumonia in the ICU. Crit Care.2014;18:208.
continuous mechanical ventilation. Am Rev Respirator Dis 19. Marquette CH, Copin MC, Wallet F, Neviere R, Saulnier F,
1989;139:877– 84. Mathieu D, et al. Diagnostic tests for pneumonia in ventilated
11. Fagon J, Chastre J. Evaluation of clinical judgement in patients: prospective evaluation of diagnostic accuracy using
identification and treatment of nosocomial pneumonia in histology as a diagnostic gold standard. Am J Respir Crit
ventilated patients. Chest 1993;103:547–53. Care Med 1995;151:1878-88.

Gupta V. Ventilator Assosciated Pneumonia. J Pediatr Crit Care 2018;5(6):30-33.

Gupta V. Ventilator Assosciated Pneumonia. J Pediatr Crit Care 2018;5(6):30-33.

DOI-10.21304/2018.0506.00442
Review Article
Snake Bite -A review
Manish Kumar*, Lokesh Tiwari**
*Assistant Professor of Pediatrics, All India Institute of Medical Sciences Rishikesh, Uttaranchal, India,
**Associate Professor of Pediatrics, All India Institute of Medical Sciences Patna, Bihar, India
Received :31-Oct-18/ Accepted:29-Nov-18 / Published Online:31-Dec-18
ABSTRACT
Snake bite is a common but under-reported medical emergency accounting for 0.5% of all deaths with greater risk of
fatal envenomation in children. In India, four species of venomous snake are most common but better classification of
medically significant species is warranted. Snake venom is a mixture of peptides with enzymatic & toxic properties
which mediate activation of cytokine cascades along with organ specific toxicities, manifesting into local and systemic
symptoms. The syndromic approach of attributing a constellation of signs & symptoms to a particular family of venomous
snake has clinical acceptance but overlaps exist. Management of snake bite victim starts with a first aid measures of
reassurance, immobilization and quick transfer to hospital. Measures such as application of tourniquet, incision and
suction are harmful & should not be done. On arrival at hospital, triage and stabilization of Airway, Breathing &
Circulation (ABC) is done followed by a focused assessment to ascertain the severity of envenomation. Antivenom
treatment is the mainstay of snake bite management. ASV should be started only when specific indications such as signs
of neurotoxicity, coagulopathy, hypotension, hematuria are present. Indiscriminate use of ASV is strongly condemned.
Currently 8-10 vials of ASV as initial dose with a maximum of 25 vials is recommended. There is no role of test dose
of ASV. Measures to treat any ASV induced anaphylaxis should be ready prior to start of ASV treatment. Supportive
treatment is as important in determining the final outcome of envenomation as ASV.
Key words: snake bite, envenomation, anti snake venom
Introduction Snakes in India

Snake bite is a common medical emergency but the Of the 236 types of snakes reported in India, only
exact estimates of consequent morbidity and mortality 15 varieties are venomous4. The 4 most common
are not known due to lack of adequate reporting. This venomous snake in India or “The Big Four”5 are
has prompted World Health Organisation (WHO) Najanaja or Indian Cobra, Bungarus caeruleus or
to include snake bite in the list of neglected tropical Krait, Echiscarinatus or Saw scaled viper, Daboia
diseases1. There is paucity of uniform management russelli or Russell’s viper. However, in view of
protocols for snake bite with controversies regarding increasing reports of fatalities due to other species
Anti Snake Venom (ASV) dose. The endemicity of like Hypnalehypnale (Hump Nosed Pit Viper),
problem, lack of consensus in management, coupled Echiscarinatussochureki (Sochurek’s Saw Scaled
to the fact that risk of fatal envenomation is highest in Viper), Trimeresurusmalabaricus; WHO has proposed
children; makes snake bite an area of special concern a new classification of medically significant species
and focus in acute pediatrics. of snakes6.
Epidemiology Pathophysiology
Global annual estimates of snake bites range from 1.2
Snake venom is a mixture of various enzymes, non-
million to 5.5 million which lead to about 1,841,000
enzymatic polypeptides and non-toxic proteins. The
envenoming and 94,000 deaths per year2. In 2005,
enzymatic and toxic properties of these peptides are
snake bite deaths in India constituted about 5% of all
responsible for pathogenesis of snake envenomation.
injury related deaths and nearly 0.5% of all deaths.
The pathogenesis is mediated primarily by activation
The risk of dying from snake bite was greater in age
of cytokine networks of inflammation & coagulation
group of 5-14 years3.
along with organ specific toxicities.
Correspondence:
Dr. Lokesh Tiwari, Associate Professor of Pediatrics, These pathophysiological mechanisms are operative
All India Institute of Medical Sciences Patna, Bihar, India- even in bites by snakes small in size; therefore, their
Phone-+919631638095, Email-lokeshdoc@yahoo.com bites should not be ignored. Another important factor to

Review Article Snake Bite -A review
Table 1: Classification of medically significant snakes in India

Category Species
Category Highest Medical Importance: Elapidae:Bungarus caeruleus (Krait); Najakaouthia, Najanaja
1 Highly venomous snakes causing (Indian Cobra)
numerous snakes bites resulting in
high levels of morbidity, disability Viperidae: Daboia russelii (Russell’s Viper), Echiscarinatus
or mortality. (Saw Scaled Viper); Hypnalehypnale (Hump Nosed Pit
Viper)
Category Secondary medical importance: Elapidae:Bungarusfasciatus, Bungarusniger,
2 Highly venomous snakes capable Bungarussindanus, Bungaruswalli; Najaoxiana
of causing morbidity or mortality ,Najasagittifera Ophiophagushannah
but are less implicated because of
their behavior or habitat preference Viperidae:Cryptelytrops albolabris, Cryptelytrops
or for which epidemiological data purpureomaculatus,Trimeresurus malabaricus
is lacking
be taken into account in pediatric snake envenomation Locked in syndrome:

is accelerated physiological derangements due to In this condition, victims of snake bite may present
higher dose of antivenom per body surface area in with quadriplegia, ophthalmoplegia and dilated
children. pupils. It is important to recognize this syndrome
Clinical features and differentiate it from brain death. Continuation of
Symptoms and signs of snake bite can be divided into definitive and supportive management in such cases
local and systemic symptoms. can result in intact survival.
Figure 1: Pathophysiology of snake bites

Syndromic Approach based on signs & symptoms: recommended aspects of first aid care to a snake bite
victim.
Table 3: Dos & Don’ts of First Aid in Snake bite victim
Do it Don’ts
R Reassurance Tight tourniquet
I Immobilisation Incision & suction of
wound
GH Get to Hospital Washing the wound
immedately
T Telling the doctor about Electro/Cryotherapy
emergence of symptoms
Immobilization is an important aspect of first aid as

Figure 2 : Syndromic approach in snakes bite movement leads to centripetal spread of venom by
“Syndromic” approach of attributing a constellation action of “muscle-pump” and lymphatics. Pressure
of symptoms to a specific snake like neurotoxicity to Immobilisation Method (PIM) was first described
elapidae and coagulopathy to viperidae, has been in in Australia by Sutherland in1974. Its applicability
clinical practice7; however, there is significant overlap has been questioned in Indian context citing lack of
of clinical symptoms. readily available resources and lack of proficiency of
lay rescuers4. However, if meticulously used at First
Table 2 : Clinical features
Referral Units, PIM may be an extremely useful first
Local Fang marks, pain, bruising, swelling, blis- aid tool for immobilization specially in bites where
tering, abscess and necrosis local tissue damage is minimal like in Elapidae
General Pain abdomen, nausea, vomiting, malaise, envenomation. PIM involves application of an elastic
prostration bandage to apply pressure between 40-70 mmHg
Neurological Drowsiness, parasthesia, ptosis, external for upper limb and 55-70 mmHg for lower limb.
ophthalmoplegia, bulbar palsy, general-
Care should be taken to ensure that a finger can be
ized flaccid paralysis including respiratory
failure easily passed underneath the bandage. PIM is of great
Coagulopathy Skin bleeds, epistaxis, gum bleeds, hemop-
utility when delay in definitive care is anticipated
tysis, malaena, visceral bleeds, cerebral although concerns regarding local tissue damage and
hemorrhage compartmental syndrome exist.
Cardiovascular Hypotension, shock, cardiac arrhythmia, Hospital Management:
pulmonary edema
Renal Hematuria, oliguria, hemoglobinuria, myo-
First steps- Maintaining ABC:
globinuria, uremia Situations warranting resuscitation are common
Endocrine Acute pituitary/adrenal insufficiency, hypo- in snake bite victims; therefore, upon arrival in
glycemia, shock, panhypopituitarism emergency department, a quick triage followed by
Management optimization of Airway, Breathing & Circulation is of
utmost importance.
First Aid
Assessment:
The principle of “Primum non nocere” or “First Do
No Harm” guides first aid in cases of snake bite. Stabilization is followed by focused assessment to
Potentially harmful practices such as, incision of ascertain envenomation and its severity; thereby
bite wounds and application of tight tourniquets establishing the need for ASV treatment. It is also
can lead to ischemic damage and are, therefore, not imperative that all cases of snake bite are kept under
recommended8. The National Snake Bite Management close observation for 24 hours as delayed appearance
Protocol4 has proposed a creative mnemonic – “Do of signs and symptoms of envenoming may occur.
It RIGHT” which summarizes all important & Envenomation due to certain species like Krait, Hump

nosed pit viper may take 6-12 hours to manifest. Ancillary investigations
Table 4 : Clinical clues in snake envenomation Ancillary investigations are important to document
History: Symptoms: Signs: systemic envenomation and consequent derangements.
• Confirmed vs • Local pain • Neurotoxic
Assumed Bite Dealing with tourniquets:
• Pain abdomen • Coagulopathy
• Site • Nausea, vomiting • Myotoxic Despite numerous advisories against use of
• Time elapsed • Blurring of vision • Local tourniquets, most patients are brought to emergency
• First Aid • Slurring of voice with tourniquet tied adjacent to site of snake bite. In
• Allergies • Muscle weakness, these patients, it is imperative that the treating team
• Last meal • Respiratory distress is prepared for catastrophe such as hypotension and
• Bleeding respiratory failure resulting from sudden release
• Dark urine of toxins after removal of the tourniquet. Sudden
• Loss of removal of tourniquets should not be done and if the
consciousness distal pulse is occluded, then a blood pressure cuff
Identification of species of snake if the killed snake should be used to reduce pressure gradually before
has been brought to the emergency is important albeit complete removal of tourniquet.
difficult; however, species identification through Specific treatment: Anti-venom treatment
pattern of fang bites is not recommended. In spite of being the mainstay of treatment of snake
Investigations bite, Anti-venom treatment suffers from lack of
Investigations are aimed at documenting the systemic universally acceptable protocols regarding its usage.9
involvement in snake bite. This lack of consensus regarding indications and
doses leads to inappropriate usage.
20 min whole blood clotting test (20WBCT) is a
simple test in which 2ml of freshly sampled venous In India, polyvalent anti snake venom serum against
blood is collected in a new/heat treated glass vial venoms of the so called “Big Four” i.e. Indian Cobra,
and is left undisturbed for 20 minutes. If, after 20 Indian Krait, Russell’s Viper and Saw-scaled Viper
minutes the blood remains unclotted; it is suggestive is available. Therefore, in envenomation by species
of hypofibrinogenemia. This method is a reliable such as Hypnalehypnale, Echiscarinatussochurek
test of envenomation induced coagulopathy and by antivenom treatment may not be as efficacious.
virtue of its simplicity; it can be done bed-side even Table 6: Indications of Antivenom treatment4
in resource constraint settings. The test is repeated
CLINICAL LAB
every 30 minutes for 3 hours after admission and then
Hemopo- Spontaneous systemic Deranged 20WBCT,
hourly. If the test is positive, it should be repeated etic bleeding abnormal clot screen
6 hours after ASV administration. It is important to CNS Ptosis, ophthalmoplegia,
ensure that the glass vial has not been cleansed by a paresis
detergent as it would hamper the surface activation CVS Hypotension, shock, Abnormal ECG
arrhythmia
of factor XI, rendering the test invalid. If uncertainty
Renal Oliguria, hematuria Rising creatinine,
exists, the test needs to be repeated with a control in dipstick test positive
form of sample from a healthy person. for hematuria`
Local Site Local swelling involving
Table 5 : Ancillary investigations more than half of bitten limb
Investigation Pointer towards within 48 hours
CBC SIRS, Infection, Microangiopathy
Clot Screen Coagulopathy Antivenom treatment is indicated in presence of
Renal Function Test Uremia
specific signs of envenomation. Given the high cost of
Liver Function Test Liver failure
Blood Gas Respiratory failure, Shock
anti snake venom serum, its limited supply and risk of
Urine Examination Myoglobinuria, Hemoglobinuria, Hematuria anaphylaxis; its indiscriminate usage is discouraged.

Dose of Antivenom: a) Freeze dried antivenom is reconstituted in 10 ml

The ideal initial dose of ASV has been subject of much of sterile water for injection per ampoule. This
controversy. Some experts classify envenomation reconstituted antivenom is then diluted in 5-10 ml/
as mild, moderate and severe on basis of clinical kg of isotonic fluid and is infused at a constant rate
manifestation and the initial dose is decided on the over 1 hour.
basis of this classification10,11. b) Freeze-dried antivenom after reconstitution or neat
Table 7: Dose of ASV based on severity of envenomation liquid antivenom is given by slow intravenous
injection at a rate not more than 2 ml/minute
SEVERITY CLINICAL FEATURES ANTIVEN-
OM DOSE Intramuscular injection of antivenom suffers from
Mild Local swelling, purpura, 5 vials drawbacks such as poor bioavailability, pain and
ecchymosis risk of hematoma. IM injections might be considered
Moderate Mild systemic manifesta- 10 vials
tions, cogulopathy, brady-
in situations such as where delay in hospital care is
cardia anticipated and if an intravenous access cannot be
Severe Rapid progression of 15 vials established even after repeated attempts.
systemic features,DIC, en-
cephalopathy, paresis Instillation of ASV at the site of bite is not efficacious
and therefore not recommended.
There is a contrary view that symptoms cannot be
used to classify envenomation as they are constantly Response to antivenom:
evolving and hence initial dose should be such that After administering antivenom, patient should be
it neutralizes average dose of venom injected. The monitored for adequacy of response. Pointers towards
National Snake Bite Management Protocol has favorable response are:
recommended this initial dose as 8-10 vials. This • Improvement in nausea, headache, myalgia by 15
dose has been suggested based on research that minutes
Russel’s Viper injects 63mg (Range 5-147 mg; SD
7mg) of venom on an average and each vial of ASV • Improvement in hypotension by 1 hour
neutralizes about 6 mg of venom. This recommended • Resolution of coagulopathy by 3 hours
dose is independent of age and weight of child as • Signs of neurotoxic envenomation like
snake injects the same dose whether the victim is ophthalmoplegia by 30 – 60 minutes
child or adult.
Role of skin hypersensitivity testing:
Indications for repeating the dose of antivenom:
Anaphylactic or serum sickness type antivenom
a. Deteriorating neurotoxic or cardiovascular signs reactions are mediated by direct complement activation
after 1-2 hours of the initial dose rather than IgE. Skin hypersensitivity tests predict
b. Deranged clot screen after 6 hours or clinically IgE mediated hypersensitivity; hence such testing
evident bleeding after 1-2 hours of the initial dose. cannot predict antivenom reactions12. Therefore skin
20-30 vials of ASV is usually sufficient to neutralize hypersensitivity testing is not recommended prior to
all unattached toxins in envenomation from Indian administration of snake antivenom.
snakes Further usage of ASV may not expedite the Antivenom reactions13
recovery time in respiratory failure and therefore, in • Early reactions
such situations, emphasis should be on supportive
measures like mechanical ventilation o Anaphylactic reactions range from urticaria,
coughing, vomiting, abdominal colic to life
threatening emergencies like hypotension,
Administering the antivenom: bronchospasm and angioedema.
Antivenom can be administered either as slow IV o Pyrogenic reactions result due to contaminants
infusion or injection. present in antivenom and manifest as fever

with rigor. renal failure; further complicating the decision to

• Late reactions administer ASV.
o Serum sickness type characterized by arthralgia, In such patients, 20WBCT should be performed and if
myalgia, mononeuritis multiplexa and rarely coagulopathy is present, ASV should be administered.
encephalopathy. If isolated derangement of renal function is present,
with no evidence of coagulopathy, dialysis should be
Treatment of antivenom reactions: arranged.
• ASV infusion should be stopped immediately In case of neurotoxic envenomation arriving late at
and standard anaphylaxis management should be a health care facility, presence of symptoms such as
started ptosis or central respiratory failure, administration of
• National Snake Bite Management Protocol 8-10 vials of ASV is indicated along with institution
insists on IM epinephrine being tried prior to IV of supportive measures.
epinephrine in view of potential risk of arrhythmia. Role of anti-cholinesterases in neurotoxicity:
The guidelines insists that IV epinephrine be used
only in ICU settings. Anti-cholinesterase drugs have been documented to
have a useful albeit variable response. Atropine in a
• For late serum sickness type reactions, dose of 0.05mg/kg followed by neostigmine is given
chlorpheniramine maleate 0.25mg/kg/day for 5 in a dose of 0.04mg/kg. Patient is observed for next
days is given. If there is no response in 48 hours, 60 minutes for resolution of neurotoxicity. If there is
a 5 day course of oral prednisolone in a dose of convincing response, neostigmine can be instituted
0.7mg/kg/day is recommended. along with atropine every 2-4 hours.
Box 1: Management of Anaphylaxis Pain management:
• IM epinephrine (1:1000) in a dose of 0.01 ml/kg or by auto
For pain management, paracetamol or tramadol is
injectors should be given.
• A second dose or IV epinephrine infusion may be needed recommended. NSAIDS or aspirin may exacerbate
after 10 minutes in severe anaphylaxis. coagulopathy.
• If needed isotonic fluid boluses to ensure adequacy of pe-
ripheral perfusion should be administered.
Role of antibiotics:
• Anti histamincs Chlorpheniramine maleate (0.2mg/kg) IV The clinical benefits of prophylactic antibiotics are
along with Ranitidine should be given questionable & therefore, routine use of antibiotics in
Contraindication to anti-venom: snake bite is not recommended except for cases with
There are no absolute contraindications to use of signs of infection or necrosis/abscess14.
antivenom; special precaution needs to be taken in Role of tetanus toxoid:
case of patients with history of reaction to equine Tetanus toxoid is considered in patients with local
serum and those with history of atopic diseases like tissue necrosis after taking into account previous
asthma. immunization status.
Role of ASV in victims arriving late at a healthcare Supportive treatment:
facility:
Antivenom treatment neutralizes the free circulating
Delayed arrival at a healthcare facility is common venom; thereby halting further deterioration.
in countries like India where a large population, However, complete recovery takes time and till
especially those with higher incidence of snake bite, then patient requires supportive therapy to maintain
live in remote inaccessible areas. Although there is homeostasis in form of treatment of shock, renal
no time limit for administration of ASV, but it should dialysis or assisted ventilation. In fact, this supportive
be remembered that antivenom only acts against the management along with antivenom treatment
unbound venom. Also, patients who arrive late after determines the final outcome.
snakebite (in particular viperine) are often in acute

Table 8 : Supportive treatment in a snake bite victim Surgical considerations:

Respiratory paralysis Assisted ventilation • In victims with coagulopathy and need for surgical
Coagulopathy ASV along with FFP, Cryoprecipi- intervention for intracranial bleeds, high dose i.e.
tate, Platelets as indicated
upto 25 vials of ASV should be given empirically
Shock Fluid boluses, Inotropes
before neurosurgical intervention.
AKI Fluid restriction, Electrolytes man-
agement, Dialysis • Compartment syndrome should be considered
Myoglobinuria Correction of acidosis, Diuresis in victims with severe local tissue damage with
features such as pallor, parasthesia& pulselessness
of the limb, pain on passive stretch of the

extremity or disproportionate pain. In such cases Neonatal Emergencies. 3rd ed. New Delhi: Jaypee; 2011. P.
fasciotomy should be considered after correction 439-444.
of coagulopathy. 6. Warrell DA. Guidelines for management of Snake Bites.
WHO. 2010.
Prognosis: 7. Ariaratnam CA. Syndromic approach to treatment of snake
Hospital based studies report mortality rates ranging bite in Sri Lanka based on results of a prospective national
from 3 – 20%15,16. The major predictors of mortality17 hospital-based survey of patients envenomed by identified
snakes. Am J Trop Med Hyg. 2009 Oct; 81(4): 725-31.
in snake bite are:
8. Simpson ID. The Pediatric Management of Snakebite: The
• Bite to hospital time National Protocol. Indian Pediatrics 2007; 44:173-176.
• Bite to hospital distance 9. Das RR, Sankar J, Dev N. High-dose versus low-dose
antivenom in the treatment of poisonous snake bites:
• Neurotoxicity A systematic review. Indian J Crit Care Med. 2015
• Vomiting Jun;19(6):340-9.
10. Paul VK, Jatana V. Animal and insect bites. In: Singh M.
• Uremia Medical emergencies in children. 3rd ed. New Delhi: Sagar,
• Respiratory failure 2000;554-78.
11. Mohammad Alizadeh A et al. The Protocol of Choice for
Delay in definitive treatment i.e. institution of Treatment of Snake Bite. Adv Med. 2016;2016:7579069.
antivenom treatment and supportive measures for
12. Cupo P, Azevedo-Marques MM, de Menezes JB, Hering SE.
organ dysfunction has been implicated as the prime Immediate hypersensitivity reactions after intravenous use
reason for adverse outcomes. of antivenin sera: prognostic value of intradermal sensitivity
tests Rev Inst Med Trop Sao Paulo 1991; 33: 115–22.
Source of funding: None
13. Warrell DA. Snake bite. Lancet. 2010; 376: 77-88.
Conflict of Interest: None
14. Dexter D Tagwireyi, Douglas E Ball, Charles FB Nhachi.
References Routine prophylactic antibiotic use in the management of
1. Neglected tropical diseases. Available from: URL: http:// snakebite. BMC Clin Pharmacol. 2001; 1: 4.
www.who.int/neglected_diseases/en Accessed October 27, 15. Sharma N, Chauhan S, Faruqi S, Bhat P & Varma S Snake
2016. envenomation in a north Indian hospital. Emergency Medicine
2. Kasturiratne A, Wickremasinghe AR, de Silva N, Journal 2005;22:118–20.
Gunawardena NK, Pathmeswaran A, Premaratna R, et al. 16. Hansdak SG, Lallar KS, Pokharel P, Shyangwa P, Karki P
The global burden of snakebite: A literature analysis and & Koirala S (1998) A clinico-epidemiological study of snake
modelling based on regional estimates of envenoming and bite in Nepal. Tropical Doctor 28, 223–6.
deaths. PLoS Med 2008;5:e218
17. Kalantri S, Singh A, Joshi R, Malamba S, Ho C, Ezoua J,
3. Mohapatra B, Warrell DA, Suraweera W et al. Snakebite Morgan M. Clinical predictors of in-hospital mortality in
mortality in India : A nationally representative mortality patients with snake bite: a retrospective study from a rural
survey. PLoSNegl Trop Dis. 2011 Apr 12;5(4). hospital in central India. Trop Med Int Health. 2006 ;11(1):22-
4. National Snake Bite Management Protocol – 2009. 30
Available from: URL: http://164.100.130.11:8091/ 18. KS Narayan Reddy. The Essentials of Forensic Medicine and
nationalsnakebitemanagementprotocol.pdf Accessed October Toxicology. 29th edition. K Suguna Devi; 2010
27, 2016
19. Anti snake venom serum. Available from: URL: http://www.
5. Mathew JL, Gera T. Snake Bite. In: Choudhary P, Bagga medlineindia.com/vaccines/anti-snake_venom_serum.htm
A, Chugh K, Ramji S, Gupta P. Principles of Pediatric & Accessed November 7, 2016.

Kumar M, Tiwari L.Snake Bite -A review. J Pediatr Crit Care 2018;5(6):34-41.

Kumar M, Tiwari L. Snake Bite -A review. J Pediatr Crit Care 2018;5(6):34-41.

DOI-10.21304/2018.0506.00443
Case Report
Idiopathic Acute Necrotizing Pancreatitis : A Case Report
Mahima Rajan*, Kundan Mittal**, Vandana Arya***, Varinder Ghelawat****
*Postgraduate, ***Assistant Professor, ****Associate Professor Department of Pediatrics, **Senior Professor and Incharge PICU &
Respiratory Clinic,PGIMS Rohtak,Haryana, India
Received : 30-oct-18/ Accepted:17-Nov-18/Published Online:31-Dec-18
ABSTRACT
Acute Necrotizing pancreatitis, a severe form of pancreatitis characterized by necrosis in and around pancreas is very rare
in children and is associated with high rates of morbidity and mortality. The diagnosis of acute necrotizing pancreatitis
is largely based on imaging findings. It has an incidence of 5-10% in adults with acute pancreatitis and even lesser in
children. We present a case of a 3 years girl diagnosed with acute necrotizing pancreatitis associated with large bowel
obstruction.
Key Words: Necrotizing pancreatitis, children
Introduction: mmHg, RR was 34/min. Abdominal examination

Pediatric Onset Acute Pancreatitis as defined by revealed mild abdominal distention with generalized
INSPIRE consortium requires any 2 of the 3 criteria in a guarding. There were no palpable masses and bowel
child aged 19 years or lesser: a) Acute onset abdominal sounds were absent. Laboratory examination revealed
pain, b) serum amylase and /or lipase activity at least total leucocyte count 11,500/cmm, hematocrit-
3 times greater than the upper limit of normal, c) 26.4%, CRP positive, blood sugar 126mg/dL, serum
Imaging findings characteristic of, or compatible with amylase 213 U/L, serum lipase 2197 U/L (>7 times of
acute pancreatitis.1 It is reversible inflammation of normal), serum calcium 8.4 mg/dL, albumin 3.0 g/dl.
pancreatic parenchyma and is divided into interstitial S. Triglycerides and cholesterol were 91 and 83mg/
edematous and necrotizing pancreatitis.2 Though dl respectively. Abdominal Ultrasonography revealed
the incidence of acute pancreatitis is on a rise in free fluid in abdomen. A CECT abdomen was thus
pediatric population necrotizing pancreatitis is still ordered and it revealed bulky pancreas with non-
rarely reported in children with an incidence of less enhancing hypodense areas in body and tail region
than 1% in children with acute pancreatitis.3 A review suggestive of Necrotizing pancreatitis associated with
spanning 21 years has reported pancreatic necrosis large bowel obstruction and ascites. The CT severity
in 9 children aged 4-20 years.4 The data regarding index was found to be 8/10.
the etiology, course, management and outcome is
scarce. We report a 3 year old girl diagnosed as Acute
Necrotizing Pancreatitis associated with large bowel
obstruction and ascites.
Case Report:
Three-year old girl presentedwith history of pain in
abdomen and vomiting for last 5 days, abdominal
distention and non-passage of stools for the last
2 days. No history of any drug intake, trauma, gall
stones. Family history was insignificant as well.
On examination heart rate was 140/min, BP 92/54
Correspondence: Fig: CECT Abdomen revealing pancreatic

Dr. Kundan Mittal, Senior Professor Pediatrics, Pt B D Sharma, abnormality
PGIMS, Rohtak Haryana, India, Phone-+919416514111, Email-
kundanmittal@gmail.com The child was shifted to the Pediatric Intensive
care unit and IV fluids were started. Empirical I.V

CASE REPORT Idiopathic Acute Necrotizing Pancreatitis:A Case Report
antibiotics and opioid analgesics were given. After measles, coxsackie virus, influenza virus, HIV),
keeping the child NPO for around 48 hours and after helminth infections such as Ascaris lumbricoides and
she had passed stools enteral feeding was started and Pneumocystis carinii, Cryptosporidium parvum and
the child was encouraged to take orally. After next 4 bacterial infections. Common causes of hereditary
days the child was shifted out from the PICU in stable pancreatitis include mutations in PRSS1gene
condition. mutation and mutation in SPINK1 gene.14 Trauma and
post ERCP pancreatitis are among other etiologies.15
Discussion:
The incidence of acute pancreatitis is on the rise in 80-95% of acute pancreatitis present with abdominal
all parts of the world. It is estimated to be 3.6-13.2 pain. The most common location being the epigastric
cases per 100,000 pediatric individuals per year.3,5 region. Radiation to back and guarding is associated
Among the Indians, there has been a 5 fold increase in in a minority of cases. Another prominent symptom
incidence of acute pancreatitis over the last decade.6 is vomiting. Abdominal distention, fever, ascites,
However, pancreatitis is a disease of older children, jaundice, pleural effusion may be present. More
with mean age ranging from 7-12 years in various severe cases may present with shock and symptoms
studies.6-8 Acute Necrotizing Pancreatitis is a severe of multiorgan failure like dyspnea, oliguria, mental
form with a mortality of around 25%.9-10 The Revised status changes.16-18
Atlanta Classification 2012 divides necrotizing
Serum amylase and serum lipase are used in diagnosis
pancreatitis in three morphologic subtypes:
of acute pancreatitis. High values of amylase an ne
Parenchymal necrosis, Peripancreatic necrosis and
found in diseases of biliary tract, liver, intestines,
combined necrosis involving both parenchymal and
genitourinary tract,lungs, breast, prostate,salivary
peripancreatic tissue. The collections associated with
glands and in some metabolic derangements lone
necrotizing pancreatitis are divided according to
diabetic ketoacidosis, renal failure, hypoperfusion
time of disease onset. In the presence of pancreatic
etc.19 Serum lipase has however a sensitivity of 86.5-
necrosis, a collection that develops within 4 weeks of
100% and specificity of 84.7-99%.16 Values upto 7
onset and lacks a discrete wall is defined as an acute
times of normal have been reported within 24 hours
necrotic collection (ANC). A collection that persists
of presentation as in our case.20 Plain chest X rays to
after 4 weeks and develops a discrete wall is defined
rule out ARDS, pleural effusion and plain abdominal
as walled-off necrosis (WON). This collection could
X rays to look for ileus, colon cut off sign, sentinel
be sterile or infected. Infection contributes to high
loop sign, calcified gall stones and to rule out other
mortality of necrotizing pancreatitis.11
diseases like gastrointestinal perforation should be
The etiology of acute necrotizing pancreatitis is done. USG is a convenient non invasive tool for
similar to that of acute pancreatitis in children. screening pancreatitis,14 however, CT is essential for
According to the literature review, the causes of acute diagnosis. In addition to establishing the diagnosis, it
pancreatitis in children in order of frequency are: helps in determining the extent of necrosis, severity
biliary diseases, drug induced AP, idiopathic acute of the diseaseto evaluate complications and assess
pancreatitis, systemic diseases and trauma, followed treatment response.14,19 MRCP and ERCP are other
by metabolic, hereditary and infectious diseases.12 useful modalities.2
Anatomical anomalies of pancreas and its ductal
The most important step in management of acute
system, including gall stones are an important cause
necrotizing pancreatitis is aggressive intravenous
of acute pancreatitis accounting for 10-30% cases.13
fluid hydration to maintain pancreatic and systemic
Recent studies suggest, drugs cause almost 25% of
perfusion. Antibiotics have no prophylactic role
pediatric pancreatitis. Mesalamine, trimethoprim/
and have failed to show benefit in sterile pancreatic
sulfamethoxazole, valproate, L-asparaginase are
necrosis20 and therefore their use is reserved to patients
commonly implicated.13 Infectious etiologies
with suspected or confirmed infected necrosis. Early
include viral(mumps,enterovirus,EBV,CMV,rubella,
institution of enteral nutrition is found to improve

outcome and decrease infectious complication.21,22Two Assessment, and Outcome. Pancreas 2017;46(1):110–5.
thirds of necrotic pancreatic collections are sterile and 7. Restrepo R, Hagerott HE, Kulkarni S, Yasrebi M, Lee EY. Acute
will resolve with conservative management, while Pancreatitis in Pediatric Patients: Demographics, Etiology, and
Diagnostic Imaging. Am J Roentgenol2016;206(3):632-44.
the remainder will become infected and will require
8. Majbar AA, Cusick E, Johnson P, Lynn RM, Hunt LP, Shield
further intervention.23 Thus, the most important
JPH. Incidence and Clinical Associations of Childhood
factor to guide further interventions is the presence Acute Pancreatitis. Pediatrics2016;138(3):e20161198.
of symptoms or infected necrosis. It is not clear 9. Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ,
why acute pancreatitis progresses to necrotizing Parks RW. Association between early systemic inflammatory
pancreatitis in some patients. Antioxidant enzyme response, severity of multiorgan dysfunction and death in
gene polymorphism and glutathione depletion have acute pancreatitis. Br J Surg2006;93(6):738–44.
been associated with severity of acute pancreatitis in 10. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson
adults and it may mediate the progression from mild CD, Sarr MG, et al. Classification of acute pancreatitis-
2012: revision of the Atlanta classification and definitions by
to severe pancreatitis.24 It has also been suggested
international consensus. Gut2013;62(1):102–11.
that a combination of intravascular volume depletion,
11. Werge M, Novovic S, Schmidt PN, Gluud LL. Infection
inflammation, and high hematocrit leads to blockage increases mortality in necrotizing pancreatitis: A systematic
of pancreatic blood flow and necrosis.25 review and meta-analysis. Pancreatology 2016 ;16(5):698–
707.
Conclusion:
12. Lopez MJ. The changing incidence of acute pancreatitis
Acute necrotizing pancreatitis is severe form of
in children: A single-institution perspective. J Pediatr
pancreatitis seen in children. Prompt diagnosis and 2000;140(5):622–4.
management can prevent complications. Hydration, 13. Bai HX, Lowe ME, Husain SZ. What Have We Learned
antibiotics and surgical management are life saving. About Acute Pancreatitis in Children? J Pediatr Gastroenterol
Close follow up for late complications is as important Nutr 2011;52(3):262–70.
aspect of management. 14. Suzuki M, Sai JK, Shimizu T. Acute pancreatitis in children
and adolescents. World J Gastrointest Pathophysiol
Source of Funding:None 2014;5(4):416-6.
Conflict of Interest:None 15. Werlin SL, Kugathasan S, Frautschy BC. Pancreatitis in
children. J Pediatr Gastroenterol Nutr 2003;37(5):591-5.
References:
16. Mekitarian Filho E, Carvalho WB de, Silva FD. Acute
1. Morinville V, Husain S, Bai H, Barth B, Alhosh R, Durie P et pancreatitis in pediatrics: a systematic review of the literature.
al. Definitions of Pediatric Pancreatitis and Survey of Present J Pediatr (Rio J) 2012;88(2):101–14.
Clinical Practices. Journal of Pediatric Gastroenterology and 17. Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation
Nutrition 2012;55(3):261-5. of laboratory tests in acute pancreatitis. Am J Gastroenterol
2. Shyu JY, Sainani NI, Sahni VA, Chick JF, Chauhan NR, 2002;97(6):1309-18.
Conwell DL, et al. Necrotizing Pancreatitis: Diagnosis, 18. Coffey MJ, Nightingale S, Ooi CY. Serum Lipase as an Early
Imaging, and Intervention. RadioGraphics 2014;34(5):1218- Predictor of Severity in Pediatric Acute Pancreatitis. J Pediatr
39. Gastroenterol Nutr 2013;56(6):602–8.
3. Morinville VD, Barmada MM, Lowe ME. Increasing 19. Balthazar EJ. Acute Pancreatitis: Assessment of Severity with
Incidence of Acute Pancreatitis at an American Pediatric Clinical and CT Evaluation. Radiology 2002;223(3):603–13.
Tertiary Care Center. Pancreas 2010;39:5-8.
20. Wittau M, Mayer B, Scheele J, Henne-Bruns D, Dellinger
4. RaiznerA, Phatak UP, Baker K, Patel MG, Husain SZ, EP, Isenmann R. Systematic review and meta-analysis of
Pashankar DS. Acute Necrotizing Pancreatitis in Children. J antibiotic prophylaxis in severe acute pancreatitis. Scand J
Pediatr 2013;162(4):788–92. Gastroenterol 2011;46(3):261–70.
5. Nydegger A, Heine RG, Ranuh R, Gegati-Levy R, Crameri J, 21. Meier R, Ockenga J, Pertkiewicz M, Pap A, Milinic N, MacFie
Oliver MR.Changing incidence of acute pancreatitis: 10 year J, et al. ESPEN Guidelines on Enteral Nutrition: Pancreas.
experience at the Royal Children’s Hospital, Melbourne. Journal Clin Nutr. 2006;25(2):275–84.
of Gastroenterology and Hepatology2007;22(8):1313-6.
22. Tenner S, Baillie J, DeWitt J, Vege SS. American College
6. Poddar U, Yachha SK, Borkar V, Srivastava A, Kumar S. A of Gastroenterology Guideline: Management of Acute
Report of 320 Cases of Childhood Pancreatitis: Increasing Pancreatitis. Am J Gastroenterol 2013;108(9):1400–15.
Incidence, Etiologic Categorization, Dynamics, Severity

23. IAP/APA evidence-based guidelines for the management of 25. Whitcomb, DC.; Lowe, ME. Pancreatitis: Acute and chronic.
acute pancreatitis. Pancreatology2013 ;13(4):e1–15. In: Kleinman, RE.; Sanderson, IR.; Goulet, O., et al., editors.
24. Rahman SH, Ibrahim K, Larvin M, Kingsnorth A, McMahon Walker’s Pediatric gastrointestinal disease. Hamilton: BC
MJ. Association of antioxidant enzyme gene polymorphisms Decker Inc; 2008. p. 1213-20.
and glutathione status with severe acute pancreatitis. Source of Funding: None
Gastroenterology2004 ;126(5):1312-22. Conflict of Interest: None

Rajan M, Mittal M, Arya V, Ghelawat V. J Pediatr Crit Care 2018;5(6):42-45.

Rajan M, Mittal M, Arya V, Ghelawat V. J Pediatr Crit Care 2018;5(6):42-45.

DOI-10.21304/2018.0506.00444
Case Report
Reshmi Mishra*, Bandya Sahoo*, Mukesh Jain**, Siba Patnaik*, Palas Das**
*Associate Professor, ** Assistant Professor Dept Of Pediatrics, KIIT University Bhubaneswar, Odisha, India
Received : 17-Nov-18/ Accepted:07-Dec-18/Published Online:31-Dec-18
ABSTRACT
Infantile hemangioma (IH) is the most common benign vascular tumours of infancy. These are known to cause
consumptive hypothyroidism by transformation of T4 and T3 into their inactive metabolites. Here we are reporting
a case of a seven month old child with hypothyroidism. The ultrasonography showed presence of normal thyroid
and hemangioma in the nape of the neck. There were multiple hemangiomas of the liver. The child was treated with
Levothyroxine 10mcg/kg/d, along with Prednisolone and Propranolol (2mg/kg/d) for two months. After two months,
there was regression in the size of hemangiomas including the nape of neck. The thyroid function test was normal. She
had started regaining her milestones of development.
Key Words : Infantile hemangioma, consumptive hypothyroidism , Propranolol in hepatic hemangioma.
Introduction The initial developmental milestones like social smile

Very frequently we come across infants with and head control were normal but the remaining
hemangiomas over different parts of body. They may developmental milestones were progressively delayed.
not be very evident at birth but gradually become Investigations revealed normocytic, normochromic
prominent over the time of 2-3 weeks. Infantile anemia and evidence of gross hypothyroidism (T3/
hemangioma (IH) is the most common benign T4/ TSH – 0.33/0.46/100). The Thyroglobulin was
vascular tumours of infancy. They are known to 2.35ng/ml (1.7-56 ng/ml). The reverseT3 level could
cause consumptive hypothyroidism by transformation not be measured due to technical inadequacies. The
of T4 and T3 into their inactive metabolites. Failure ultrasonography showed presence of normal thyroid.
to recognise the hemangiomas as a possible cause There was a hemangioma in the nape of the neck
of hypothyroidism may lead to suboptimal and and multiple hemangiomas of the liver, the largest
inappropriate treatment, increasing the possibility measuring 2 cm in diameter.
of intractable hypothyroidism and its associated
complications. This case is being presented to
highlight this unusual cause of hypothyroidism which
may often be missed and to outline the appropriate
management.
Case Report
A seven months female child presented with a
history of gradually progressing lethargy, irritability
and poor feeding. On physical examination she was
pale, hypothermic and had dry and coarse skin with
a protruded tongue. A soft swelling of 5x3cm was Fig. 1: Coarse Face of hypothyroid child
present over the nape of neck. A scar of a previous The child was treated with Levothyroxine – 10mcg/
surgery which was done a few months before for a kg/d, along with Prednisolone (2mg/kg/d) for a week
similar swelling, was seen just below the right scapula. and Propranolol (2mg/kg/d) for two months. The
follow up visit at two months showed regression in
Correspondence: the size of hemangiomas in the nape of neck and only
Dr Reshmi Mishra
F-103 Kokila Garden Phase-II, Pokhariput, Bhubaneswar, one lesion of 6 mm was seen in the liver. The thyroid
Odisha ,India. Phone : +919776999257, E-mail : docreshmis@ function test was normal. She had started regaining
gmail.com her milestones of development too.

CASE REPORT Acquired Hypothyroidism
treat the consumptive hypothyroidism.8 Corticosteroid

is the first line of treatment. It is given at a dose of
2-3 mg/kg/day and results in 75% response. Doses
less than 2 mg/kg/day result in poor response and a
rebound phenomenon is seen in 70% of the cases.9,10
In view of immediate clinical effect with propranolol,
it is considered as the promising therapy in IH with
ulceration or IH involving vital structures.11
Learning Points
Health care givers should be more vigilant
Fig. 2-: Scar mark of previous operation 1. In infants with cutaneous haemangioma for
Discussion development of hypothyroidism.
Infantile hemangioma (IH) commonly affects the 2. If the requirement of Thyroxine is very high
head and neck region. It is usually associated with then child should be screened for secondary
hepatic hemangiomas or hemangioendothelioma hypothyroidism by doing thyoid scintigraphy,
which have a female predominance.1,2 High TSH thyroglobulin level and rT3.
levels and low serum T4 and T3 levels, accompanied Source of Funding: None
by high rT3 serum levels are the clinching points of Conflict of Interest: None
diagnosis. USG or MRI are the primary diagnostic
References
modality.3 Liver biopsy, may cause life threatening
1. Daller JA, Bueno J, Gutierrez J, Dvorchik I, Towbin RB,
hemorrhage and hence not indicated. In their natural Dickman PS, et al. Hepatic hemangioendothelioma: clinical
course, IH proliferate rapidly during the early infantile experience and management strategy. J Pediatr Surg.
period followed by a phase of slow and steady decline 1999;34:98–105.
over the next 5–7 years.4,5 The spectrum of these 2. Chen CC, Kong MS, Yang CP, Hung IJ. Hepatic
vascular lesions ranges from benign and self-limiting hemangioendothelioma in children: analysis of thirteen cases.
Acta Paediatr Taiwan. 2003;44:8–13.
disease to aggressive and life-threatening neoplasia.
3. Kassarjian A, Zurakowski D, Dubois J, Paltiel HJ, Fishman
Thyroxine (T4), is the major product secreted by SJ, Burrows PE. Infantile hepatic h.emagioendothelioma:
thyroid. The biologically active triiodothyronine (T3) Clinical and Imaging findings and their correlation with
is derived from the peripheral conversion of T4 into therapy. AJR Am J Roentgenol 2004;182:(3)785–95
T3. Deiodinase are enzymes involved in activation 4. Drolet BA, Esterly NB, Frieden IJ. Hemangiomas in
and inactivation of thyroid hormones (THs). Type 1 children. N Engl J Med 1999;341:173-181.
and type 2 deiodinase (D1 and D2) convert T4 into 5. Fishman SJ, Muliken JB. Hemangiomas and vascular
malformations of infancy and childhood. Pediatr Clin North
T3 whereas D3 degrades T4 and T3 into inactive Am 1993;40:1177-1200.
metabolites and is thus the major physiological
6. Luongo C, Trivisano L, Alfano F, Salvatore. DType 3
Thyroid hormone inactivator. Deiodinase and Consumptive Hypothyroidism: A Common
The aberrant uncontrolled expression of D3 induces Mechanism for a Rare Disease. Front Endocrinol (Lausanne).
a severe form of hypothyroidism by inactivating T4 2013;4:115.
and T3 (6) ,for which it is also called Consumptive 7. Huang SA, Tu HM, Harney JW, et al. Severe hypothyroidism
caused by type 3 iodothyronine deiodinase in infantile
hypothyroidism. hemangiomas. NEJM2000;343:185
There are many controversies regarding the treatment 8. Bessho K, Etani Y, Ichimori H, Miyoshi Y, Namba N,
of hemangiomas. Yoneda A, et al. Increased type 3 iodothyronine deiodinase
activity in a regrown hepatic hemangioma with consumptive
In asymptomatic patients, it is advisable to monitor hypothyroidism. Eur J Pediatr 2010;169:215–21.
with serial USG until spontaneous regression occurs.7
9. Grover C1, Kedar A, Arora P, Lal B. Efficacy of oral
In case of symptomatic patients a very high dose of prednisolone use in the treatment of infantile hemangiomas in
thyroxin as much as 22−70 μg/kg/day is required to Indian children. Pediatr Dermatol 2011;28(5):502-6.

CASE REPORT Acquired Hypothyroidism
10. Park EA, Seo JW, Lee SW, Choi HY, Lee SJ. Infantile 11. Price CJ, Lattouf C, Baum B, McLeod M, Schachner LA,
hemangioendothelioma treated with high dose methyl- Duarte AM, et al. Propranolol vs Corticosteroids for Infantile
prednisolone pulse therapy. J Korean Med Sci 2001;16(1): HemangiomasA Multicenter Retrospective Analysis Arch
127–9. Dermatol 2011;147(12):1371-6.

Mishra R, Sahoo B , Jain M, Patnaik P, Das P.Acquired Hypothyroidism. J Pediatr Crit Care 2018;5(6):46-48.

Mishra R, Sahoo B , Jain M, Patnaik P, Das P.Acquired Hypothyroidism. J Pediatr Crit Care 2018;5(6):46-48.

DOI-10.21304/2018.0506.00445
Clinical Update
Hypernatremia
Kundan Mittal*, Lalitbhuasan Waghmare**, Manish Sharma***, Sachin Damake***
*Senior Professor and Incharge PICU & Respiratory Clinic,PGIMS Rohtak ,India,**Professor, Dept.of physiology, JNMC
Wardha, ***Intensivist, JKLOAN hospital Jaipur,****Professor,Dept.of Pediatrics, JNMC,Wardha, Maharashtra, India
Received :10-Nov-18/ Accepted:28-Nov-18/Published Online:31-Dec-18
ABSTRACT
Total body water is distributed in the body as two-third in ICF and one-third in ECF which are divided by a cell
membrane. ECF is further divided into effective arterial or plasma volume (25-30%) and interstitial volume (70-75%).
Sodium is major solute in ECF and potassium in ICF. Total body sodium is determinant of arterial pressure and serum
sodium is mainly responsible for plasma osmolality. Daily sodium requirement depends on size and age of the person.
Dysnatremias are most common disorders seen in children. Hypernatremia (incidence 1-3%) is defined as plasma/serum
sodium >145mEq/L and serum osmolality >295mosm/kg H2O and always associated with hypertonicity. Serum sodium
is calculated by exchangeable serum sodium + exchangeable serum potassium/Total body water (TBW). Hypernatremia
can only occur either due to gain in sodium or loss of water or combination of two.
Key Words: Hypernatremia, ECF,ICF,Free water deficit
Various types of hypernatremia: <48hrs) and nausea, vomiting, irritability, weakness,
● Hypovolemic: Hypotonic loss leading to decrease cramps, rhabdomyolysis, hyperventilation, venous
in ECV and cell shrinkage. Urine sodium thromboembolism. Even slight increase in serum
concentration is <20mmol/L and osmolality osmolality leads to impaired insulin metabolism, thus
>100mOsm/kg/H2O. Measure urine osmolality contributing to hyperglycaemia.
[low (renal losses, osmotic diuresis, loop Assessment
diuretics), high (extrarenal losses)]. Following points should be taken in to
● Euvolemic: Pure water loss and total body sodium consideration.
remains unchanged. ECV is usually maintained ● Assess volume status, history of volume loss and
and urine sodium concentration is variable. urine output, medications and medical conditions
Measure urine osmolality <100mOsm/kg/H2O (hypo, hyper and euvolemic)
[low (central and nephrogenic diabetes insipidus),
● Calculate TFW (total free water) deficit, SFD
high (primary hypodipsia) and inappropriate
(solute free water deficit), and FWD (free water
normal (essential hypernatremia)].
deficit)
● Hypervolemic: Sodium retention leading to
● History and clinical examination
cell shrinkage and hypervolemia. Urine sodium
concentration is >20mmol/L and >100mOsm/ ● Mental status and evidence of fluid overload
kg/H2O. Common cause is excessive intake of ● Serum and urine sodium, potassium and chloride
sodium. ● Blood urea, serum creatinine and calcium
Clinical manifestations ● Plasma and urine osmolalities
Clinical manifestations are primarily neurological, ● Brain imaging as per condition
(shift of water from cells creating risk for vascular ● Differentiate hypernatremia based on normal,
rupture) including restlessness, hyperpnea, lethargy, low or high total body sodium
encephalopathy, ataxia, nystagmus, conscious
Management
impairment, hypertonia, hyperreflexia, seizure, coma,
intracranial haemorrhage (usually in acute stage Calculate free water deficit
● Free water deficit (FWD) = 4 mL x Weight in
Correspondence: Kg x (sodium concentration present- sodium
PGIMS, Rohtak Haryana, India, concentration desired)
Phone-+919416514111, Email-kundanmittal@gmail.com

CLINICAL UPDATE Hypernatremia
OR Sodium requirement
● Free water deficit = 0.6 x Weight in Kg x 1-(145/ 3mEq/100mL = 30
serum sodium) x 1000 = mL Sodium deficit
● Calculate total fluid therapy = Maintenance 8mEq/100mL = 48mEq
fluid + Free water deficit Total sodium 30 + 48 = 78mEq
● Check serum sodium 2-4 hourly and fall should be First 24hrs give maintenance fluid + ½ FWD + SFD
not more than 0.6mEq/L per hour Second 24 hrs give ½ FWD + maintenance fluid
● If serum sodium is more than 175 mEq/L Correct underlying etiology.
than resuscitation fluid should have sodium
Estimated serum sodium reduction of per litre
concentration approximately 15 mEq/L or less.
sodium chloride infusion over one hour is as under;
● Use 10ml/kg of normal saline if child is in shock
Change in serum sodium = Infusate sodium- serum
though hypotonic for such patients.
sodium/TBW + Infusate volume in litre
Child with hypernatremia (10%dehydration
Note: In conscious patient free water can be replaced
weighing 10kg, Serum sodium 155mEq/L)
orally.
Total free water deficit: 10mL/kg/ %- SFD
N/2 Saline contains 500mL/L free water
SFD (solute fluid deficit) = Total fluid deficit-
Free water deficit N/2DS contains 400mL/L of free water
(applicable in child with dehydration) Source of Funding: None
Total water deficit = Previous TBW x (actual Conflict of Interest: None
sodium/ desired sodium -1) References
OR 1. Ichai C, Quintard H, Orban JC. Metabolic Disorders and
Critically ill Patients. France: Springer;2018
Solute Fluid Deficit (SFD): Total fluid deficit 2. Reddi AS. Fluid, Electrolyte and Acid-Base Disorders. 2nd
(TFD) – Free water deficit (FWD) ed. USA: Springer;2018
Sodium deficit: SFD in litre x proportion from 3. Mount DB, Sayegh M, Singh AK. Core Concepts in the
ECF x serum concentration in ECF Disorders of Fluid, Electrolyte and Acid-Base balance. USA:
Springer;2013
Weight 10kg, Percentage of dehydration 10%
4. Hughes HK, Kahl LK. The Harriet Lane Handbook. 21st ed.
Serum Sodium 155mEq/L
Philadelphia: Elsevier;2018
Maintenance fluid 1000mL (100mL/kg) 5. Turner N, Lameire N, Goldsmith DJ, Winearls CG,
Total water deficit 1000mL (10mL/kg for each Himmelfarb J, Remuzzi G. Clinical Nephrology. 4th ed. UK:
percent) Oxford University Press; 2016
6. Feehally J, Floege J, Tonelli M, Johnson RJ. Comprehensive
Free water deficit 4 x 10 x 10 (155-145) = 400mL Clinical Nephrology. 6th ed. China: Elsevier; 2019
Solute fluid deficit
Total Fluid deficit- SFD 1000-400 = 600mL

Mittal M, Waghmare L, Sharma M, Damake S. J Pediatr Crit Care 2018;5(6):49-50.

Mittal M, Waghmare L, Sharma M, Damake S. J Pediatr Crit Care 2018;5(6):49-50.

DOI-10.21304/2018.0506.00446
Postgraduate Column
OSCE: Hypokalemia
Kundan Mittal*, Lalit Waghmare**, H K Aggarwal***, Manish Munjal****
*Senior Professor and Incharge PICU & Respiratory Clinic, ***Senior Professor, Department of Medicine and Nephrology, Pt. B D
Sharma, PGIMS, Rohtak,Haryana, India.**Professor Physiology, JNMCSawangi, Wardha, Maharashtra, India,
****Intensivist. Jaipur, Rajasthan, India
Eight years female ,weighing 15 kg, known case (5%). Potassium plays crucial role in body cells,
of diabetes mellitus for one year, presented with nerves, and muscles function. Children maintain net
history of fever 3days, polyuria, vomiting and positive potassium balance needed for growth.
respiratory distress one day. HR 120/min. RR 34/ Q. Is there any medical emergency in present case?
min, CRT <3sec, SpO2 100%. Her lab reports are
Answer: This patient had persistent hypokalaemia,
Hb 6.7gm%, TLC 12000/cmm, polymorphs 85%,
hyponatremia and respiratory distress and needed
platelet count 2.0 lac, blood urea 26mg/dL, blood
emergency care. Patient with severe hypokalaemia
sugar (R)>500mg/dL, serum creatinine 1.0mg/dL,
with ECG finding is always an emergency.
sodium 155mEq/L, potassium 1.6mEq/L, chloride
74mEq/L, ionised calcium 0.89mmol/L and x-ray Q. What are the various factors that contributed
chest revealed pneumonitis right side. ABG showed to hypokalaemia in present case?
pH of 7.11, PCO2 35, PaO252%, HCO3- 7.8, BE -19, Answer: Diabetes mellitus, osmotic polyuria,
A-aO2 82 and ECG revealed T-wave inversion. Child dextrose infusion, insulin infusion, hypomagnesemia,
was put on oxygen therapy, fluid bolus, N/2 10% DS, and stress.
potassium free fluid, insulin infusion and ceftriaxone. Q. How much total potassium is present in ECF in
Repeat serum potassium was 1.7 and <2mEq/L done the index case?
after every 6hour of treatment. TTKG was 8. Serum Answer: TBW: 15 x 0.6=9L
magnesium received 24hr later was 1.2mg/dL. Urine
ECF: 1/3rd x 9L= 3L
was positive for sugar and ketone bodies and negative
for proteins and RBC’s. Potassium 1.6mEq/L x 3 = 4.8mEq
Q. Define hypokalaemia and its distribution in Q. Can you highlight few causes of hypokalaemia?
human body. Answer:
Answer: Hypokalaemia is defined as serum potassium • Renal [drugs (aminoglycosides, diuretics),
level <3.5mEq/L. Serum level 3-3.5 mEq/L or osmotic polyuria, excessive mineralocorticoids
plasma potassium 3.0mEq/L is defined as mild, activity, renal tubular defects, endocrine
2.5-3.0mEq/L moderate and 2.5mEq/L as severe derangements, magnesium deficiency]
hypokalaemia. Total body potassium is 45-50mmol/ • GIT loss (diarrhoea, vomiting, laxative use)
kg in males and 35-40mmol/kg in females. 90% • Dietary: Normal intake in children is
Potassium is located inside cells, 2% extracellular & approximately 1.5mEq/kg/d (high carbohydrate
8% inside bones and essential for generating resting diet)
potential in neuronal, cardiac and muscle tissues. It
is being regulated tightly in between extracellular • Transcellular [insulin, β-2 agonists (single
and intracellular compartments. 95% potassium is dose can reduce potassium level 0.36mEq/L),
exchangeable. Kidneys are primarily responsible for dobutamine can decrease by 0.5mEq/L, alkalosis,
potassium excretion (80%), stool (15%) and skin B12 injection]
• Skin loss [burns, excessive heat: sweat has
Correspondence:
potassium 9mEq/L, strenuous exercise (causing
PGIMS, Rohtak Haryana, India, release of catecholamines and shift of potassium
Phone-+919416514111, Email-kundanmittal@gmail.com inside cells)]

POST GRADUATE COLUMN Hypokalemia
Q. Describe diagnostic steps in hypokalaemia Answer:

management. • Abnormal ECG changes (U wave, decreased T
Answer: wave amplitude, S-T depression,prolonged Q-T
• Obtain clinical details, perform physical interval, T-wave inversion,ventricular arrythmias
examination including blood pressure and ECG (VT, VF, asystole) and atrioventricular blocks
• Rule out spurious causes of hypokalaemia • Weakness, tetany, cramps, paralysis, tetraparesia,
(leukocyte count >100000/cmm). Rise in blood constipation and urinary retention
sugar by 100mg/dL will decrease 1.6mEq/L • Insulin resistance, impaired hepatic glycogen and
sodium. protein synthesis
• Consider drugs leading to redistribution of • Decreased renal flow and GFR, rhabdomyolysis,
potassium. encephalopathy
• Acid-base analysis, serum sodium, potassium, Q. How will you treat a child with hypokalaemia?
calcium, magnesium, phosphate, alkaline Answer: Various steps in management include;
phosphatase, and uric acid.
• Identify underlying cause
• Potassium level falls by 0.3mEq/L for every 0.1
• Minimize use of kaliuretic drugs
rise in pH.
• Prefer oral route: 1-3 mEq/kg/day in two to four
• Urinary sodium, potassium, chloride and
divided doses. Assess serum K+ after 6hrs of oral
creatinine level.
dose. Potassium is irritant to gastric mucosa, thus
• Urinary Na+ < 100 mEq/24hr and urinary K+ should be given after meal. Do not crush tablets.
<20 mEq/24hr, Cl- <10mEq, suspect extrarenal
• Initial aim is to raise serum potassium >3mEq/L
losses.
• Intravenous Protocol
• Urinary Na+ is >100 mEq/24hr and urinary K+
>20 mEq/24hr, Cl- >10mEq ,suspect renal loss. o Serum Potassium 3.0-3.5 mEq/L give
0.25mEq/kg IV over one hour
• Urine potassium >20mEq/24hr indicates renal
etiology of hypokalaemia. o Serum Potassium 2.5-3.0 mEq/L give 0.5mEq/
kg IV over two hours
• Spot urine potassium/creatinine >200mEq/gm
reflects renal etiology (since urinary potassium o Serum Potassium <2.5meq/L mEq/L give
excretion is variable) and <15mEq/gm reflects 0.75mEq/kg IV over three hours and should
extrarenal loss. Normal excretion of potassium not exceed 0.75mEQ/kg in one hour
and creatinine are 1 and 0.2mEq/kg/day o Infusion in ½ NS under cardiac monitoring
respectively. and repeat frequent serum potassium level
• Measure HCO3- in patient with normal blood (one to two hourly)
pressure. If blood pressure is raised,also measure Or
serum renin and aldosterone level. In case of emergency (3- measured K+ x Body
• Trans-tubular K+ gradient TTKG (normal 8-9) weight x 0.04) as bolus in 1-2 minute followed
can be measured in children with hypokalaemia by infusion 0.015mEq/kg/min
where collection of 24hour urine is not possible o Do not raise potassium concentration
(Urinary potassium x Plasma osmolality) x >60mEq/L infusion through peripheral line
(Plasma potassium x Urine osmolality) and 80mEq/L in central line
• Fractional Excretion of Potassium o Dilute potassium chloride as much as possible
Q. Describe various clinical manifestations of o No sodium bicarbonate should be present in
hypokalaemia? infusion
o Monitor serum potassium half way of infusion

POST GRADUATE COLUMN Hypokalemia
o Avoid giving in dextrose containing solutions Q. How will you manage the present case?
to minimize insulin release Answer:
o Do not correct metabolic acidosis till serum • Target serum potassium level 3.3mEq/L initially
K+ is >2.8 mEq/L using potassium chloride infusion before initiating
o Always monitor renal functions insulin therapy
Q. What are the various potassium formulations • Continuous ECG monitoring and respiratory
available? muscle strength
Answer: • Correct fluid deficit using normal saline then
• Intravenous: 1 ml Potassium chloride contains • Start Insulin infusion in normal saline
2mEq of K+ • Give magnesium sulphate and calcium
• Potassium citrate 1ml = 2mEq • Hourly monitoring of serum potassium and six
• Potassium phosphate (94 mg PO4 and 4.4mmol hourly serum sodium
K + /mL) • Spot urinary potassium and creatine ratio
• Potassium gluconate 15mEq/20 ml • Frequent acid-base analysis
• Potassium citrate 10mEq/5ml • Broad spectrum antibiotics for pneumonitis
• Oral: syrup 1 mL contains 2 mEq of K+ • No role of sodium bicarbonate
• Food with high potassium content: Orange, Source of Funding: None
banana, baked potato, dates, milk, spinach, Conflict of Interest: None
tomato, mango.

Mittal M, Waghmare L, Aggarwal HK, Munjal M. Postgraduate Column-OSCE: Hypokalaemia . J Pediatr Crit Care 2018;5(6):51-53.

Mittal M, Waghmare L, Aggarwal HK, Munjal M. Postgraduate Column-OSCE: Hypokalaemia . J Pediatr Crit Care 2018;5(6):51-53.

DOI-10.21304/2018.0506.00447
Best Evidence
Journal Scan
Kundan Mittal*, Jayant Vagha**, Lalitbhushan Waghmare*** H K Aggarwal****,
Vivek Gupta*****, Vinayak Patki******
*Senior Professor and Incharge PICU & Respiratory Clinic, ****Senior Professor, Department of Medicine and Nephrology, Pt. B D
Sharma, PGIMS, Rohtak, Haryana, India ,**Professor Pediatrics, ***Professor Physiology JNMC, Sawangi Wardha, Maharashtra,
India,*****Consultant Cardiac Anaesthesia & Intensive Care, Hero DMC Heart Institute, Ludhiana,Punjab,India ******Chief,
Advanced Pediatric Critical Care Centre, Wanless Hospital, Miraj, Maharashtra, India.** Senior Professor Pediatrics,Pt B D Sharma,
PGIMS, Rohtak, Haryana, India
1. Oxygen therapy in acute resuscitation and hyperoxaemia.

Daniel R. Frei and Paul J. Young Reviewer’s Comment
Curr Opin Crit Care 2018, 24(6):506–511 Oxygen is essential for life and most commonly used in
DOI:10.1097/MCC.0000000000000549 emergency situations. If used in higher concentration
during acute physiological derangements it will have
Avoidance and treatment of hypoxaemia is a harmful effects. We are well aware of issues arising
cornerstone of acute resuscitation and yet the optimal due to hypoxia and hypoxemia but supra-physiological
approach to oxygen therapy in the acute care setting is level of oxygen is also associated with certain side-
uncertain. The aim of this review is to appraise recent effects (increased ventilation/perfusion mismatch,
evidence relating to the provision of supplemental impaired alveolar macrophage functions, atelectasis,
oxygen to adult patients with acute illnesses with a decreased cardiac output, alteration of myocardial
focus on the resuscitation phase. infarct size, increased systemic vascular resistance,
Recent findings decrease coronary and cerebral blood flow). In acute
Recent findings generally support the notion that care settings when saturation is below 92%, oxygen
exposure to hyperoxaemia is associated with adverse can be delivered by various methods which include
outcomes in acutely ill adults with a range of diseases variable and fixed delivery device. There is inverse
and raise the possibility that liberal provision of ratio of FiO2 delivery with variable delivery devices.
oxygen may cause harm. Several ongoing multicentre Apnoeic oxygenation (mass flow of gas from the
randomized trials aim to assess the effects of pharynx to alveoli and subsequent uptake of oxygen
different oxygen therapy regimens on patient without lung inflation occurring because of negative
outcomes to provide a foundation for evidence-based alveolar pressure produced by a greater alveolar
recommendations regarding the use of supplemental capillary uptake of oxygen than CO2 liberation) has
oxygen in Intensive Care Unit patients. demonstrated less episode of desaturation during
emergency intubation. Automated titration of oxygen
Summary therapy during emergency situation is associated
At present, evidence is lacking to support routine with less episodes of hypoxemia and hyperoxaemia.
liberal oxygen administration in acutely ill patients Excessive oxygen supplementation was associated
and, in most circumstances, a reasonable approach is with poor outcome in patients with acute respiratory
to titrate supplemental oxygen to achieve an arterial distress syndromes, chronic obstructive pulmonary
oxygen saturation measured by pulse oximetry (SpO2) disease, acute myocardial infarction, septic shock,
of 92–96% with the aim of avoiding both hypoxaemia acute neuronal injury. Similarly, it was also seen
that 90 days mortality was more in patient who
Correspondence:
Dr. Vinayak Patki, MB,DNB,FCCP,FIAP. Chief, Advanced
received supra-physiological level of oxygen.
Pediatric Critical Care Centre & Head, Dept of Pediatrics, Poor neurological outcome was associated with
Wanless Hospital, Miraj, 416101, Maharashtra, India. hyperoxaemia during and after cardiopulmonary
Phone: +919822119314, E-Mail- patkivinayak@gmail.com resuscitation. In this review many conditions have

BEST EVIDENCE Journal Scan
not been covered like hyperbaric oxygen use, oxygen and impact of these tools in this context have not
at high altitude, oxygen therapy during transport etc. been adequately assessed. The effectiveness of AFS
Guidelines published by British Thoracic Society programmes has been measured in multiple ways
in 2017 in BMJ mentioned that there is conflicting but a standardized method of evaluation remains
evidence concerning the balance of potential benefits elusive. Few studies have explored the impact of AFS
and risks of perioperative hyperoxaemia to reduce the interventions on patient outcomes.
risk of surgical site infection in elective surgery and Summary
there is no evidence for this practice in patients
having emergency surgical procedures.In another The uptake of formal AFS programmes has been
study published in Critical Care 2014 mentioned slow. New initiatives integrating AFS tools in
that hyperoxaemia should be avoided during post- programmes, and measuring the impacts on patient
resuscitation phase following cardiac arrest. Study outcomes are required given such data are not readily
by JinHeeJeong et al. in BMJ 2018 showed that available. A comprehensive approach to evaluate AFS
hyperoxaemia during the first 3 days in patients outside programmes by correlating the quantity and quality
the ICU is associated with in-hospital mortality and of antifungal prescribing with impacts on patient
ICU transfer at day 5 after arrival at the emergency outcomes is needed. Consensus definitions for core
department. Though studies mentioned in article were AFS metrics are required to benchmark performance
carried out in adults, children who have developing and are essential to the resourcing and sustainability
lung parenchyma are more vulnerable to damage of these programmes.
associated with hyperoxaemia and hypoxemia and Reviewer’s comment
need further evaluation. Antimicrobial stewardship is in place to optimize the
2. Antifungal stewardship: developments in the patient outcome. Lot of discussion is on AMS and
field there are few studies which talk about implementation
Karen F. Urbancic, Karin Thursky, David C.M. of antifungal stewardship. May it be antibiotic or
Kongbh, antifungal we have to use them judiciously. Antifungal
stewardship refers to coordinated interventions to
Paul D.R. Johnson, and Monica A. Slavin monitor and direct the appropriate use of antifungal
Curr Opin Infect Dis. 2018 Dec;31(6):490-498. doi: agents in order to achieve the best clinical outcomes
10.1097/QCO.0000000000000497. and minimize selective pressure and adverse events.
Purpose of review AFS program differs from AMS. Primarily AFS
setting is secondary in nature, fewer drug availability,
To outline key drivers and components of antifungal limited to some speciality, less multidrug resistance,
stewardship (AFS) programmes, the evidence lack of rapid and sensitive diagnostic tests, and
for specific interventions, and methods to assess having complex pharmacokinetics. Invasive fungal
performance of programmes. infections are global health problem and significant
Recent findings cause of mortality and morbidity, particularly in
Recent developments in antifungal resistance and ICU’s, immunocompromised patients, malignancy,
breakthrough invasive fungal diseases have increased low birth weight, patients on chemotherapy. The extent
the urgency for effective AFS. In practice, however, of knowledge and understanding about antimycotic
few hospitals have dedicated AFS programmes. resistance and drug-resistant fungal infections is
To date, AFS programmes have centred around still unclear. There are numerous challenges in early
the provision of expert bedside reviews and have diagnosis and treatment of invasive fungal infections,
reduced costs and consumption of antifungal agents. requiring the expertise of trained infectious diseases
Incorporating tools such as fungal diagnostics and specialists, clinical microbiologists, and other
therapeutic drug monitoring into AFS programme specialists in main prescribing departments such
models is recommended. However, the application as haematology and oncology. Further high cost,

inappropriate use, poor outcome, un-recognition of curve for in-hospital mortality beyond that of baseline
invasive fungal disease, empirical use of antifungal risk (age, sex, race/ethnicity, and comorbidity). Of
agents, rising resistance, toxic effects, non-availability 37,591 encounters with suspected infection, 1,769
of laboratory and therapeutic drug monitoring are (4.7%) died before discharge. Both the mean quick
some other factors drawing attention towards AFS. Sepsis-related Organ Failure Assessment at 48 hours
Current variability in selection of antifungal agents, (area under the receiver operating characteristic, 0.86
dosing, balancing the need, and avoiding the use of an [95% CI, 0.85–0.86]) and crude trajectory groups
antifungal when not indicated are important aspects (area under the receiver operating characteristic, 0.83
of AFS. [95% CI, 0.83–0.83]) improved predictive validity
compared with initial quick Sepsis-related Organ
3. Evaluation of Repeated Quick Sepsis-Related Failure Assessment (area under the receiver operating
Organ Failure Assessment Measurements characteristic, 0.79 [95% CI, 0.78–0.80]) (p< 0.001
Among Patients With Suspected Infection* for both). Group-based trajectory modeling found
Kievlan, DR, Zhang LiA, ChangChung-Chou H, five trajectories (quick Sepsis-related Organ Failure
AngusDC, Seymour CW. Assessment always low, increasing, decreasing,
Critical Care Medicine 2018;46(12):1906-13 moderate, and always high) with greater predictive
validity than the initial measurement (area under the
Objectives: Among patients with suspected infection, receiver operating characteristic, 0.85 [95% CI, 0.84–
a single measurement of the quick Sepsis-related 0.85]; p< 0.001).
Organ Failure Assessment has good predictive
validity for sepsis, yet the increase in validity from Conclusions: Repeated measurements of quick
repeated measurements is unknown. We sought to Sepsis-related Organ Failure Assessment improve
determine the incremental predictive validity for predictive validity for sepsis using in-hospital
sepsis of repeated quick Sepsis-related Organ Failure mortality compared with a single measurement of
Assessment measurements over 48 hours compared quick Sepsis-related Organ Failure Assessment at the
with the initial measurement. time a clinician suspects infection.
Design: Retrospective cohort study. Reviewer’s Comments:
Setting: Twelve hospitals in south-western In an integrated health system, repeated measures of

Pennsylvania in 2012. qSOFA during the 48 hours after suspected infection
had a greater predictive validity for sepsis using in-
Patients: All adult medical and surgical encounters hospital mortality than a baseline measurement alone.
in the emergency department, hospital ward, These findings were consistent among encounters
postanesthesia care unit, and ICU. outside the ICU and in multiple sensitivity analyses.
Interventions: None. Encounters with a high or increasing qSOFA were at
Measurements and Main Results: Among 1.3 greater risk than those with low or decreasing qSOFA
million adult encounters, we identified those with trajectory. Taken together, these findings suggest
a first episode of suspected infection. Using the that repeated measurements of qSOFA could help
maximum quick Sepsis-related Organ Failure prompt clinicians about patients more likely to be
Assessment score in each 6-hour epoch from onset septic. Authors evaluated the trajectory of qSOFA
of suspected infection until 48 hours later, we in three ways: 1) simple summary measures, 2)
characterized repeated quick Sepsis-related Organ crude trajectory groups of qSOFA, and 3) group-
Failure Assessment with: 1) summary measures (e.g., based trajectory modeling (GBTM).From a research
mean over 48 hr), 2) crude trajectory groups, and 3) perspective, these data suggest that trajectory
group-based trajectory modeling. We measured the modeling may identify clusters of patients at greater
predictive validity of repeated quick Sepsis-related risk for sepsis. The GBTM technique identified five
Organ Failure Assessment using incremental changes distinct groups of septic encounters. Similar to the
in the area under the receiver operating characteristic efforts of other study groups , these clusters may

provide a method to identify different pathophysiology Patients: Adult ICU patients with hypoxemic
of sepsis, leading to more clues about the underlying respiratory failure anticipated to require prolonged
mechanisms of host response and organ dysfunction. mechanical ventilation.
They may be useful in future studies evaluating the Interventions: Low tidal volume-volume control,
heterogeneity of treatment effects of new therapies airway pressure release ventilation, and low tidal
aimed at preventing organ dysfunction and shock. volume-airway pressure release ventilation.
However, GBTM groups require additional validation
in separate cohorts. Measurements and Main Results: We observed wide
variability and higher tidal (release for airway pressure
4. Randomized Feasibility Trial of a Low Tidal release ventilation) volumes in both airway pressure
Volume-Airway Pressure Release Ventilation release ventilation (8.6 mL/kg; 95% CI, 7.8–9.6) and
Protocol Compared With Traditional Airway low tidal volume-airway pressure release ventilation
Pressure Release Ventilation and Volume (8.0; 95% CI, 7.3–8.9) than volume control (6.8; 95%
Control Ventilation Protocols CI, 6.2–7.5; p = 0.005) with no difference between
Hirshberg, Eliotte L.; Lanspa, Michael J.; Peterson, airway pressure release ventilation and low tidal
Juhee; More volume-airway pressure release ventilation (p = 0.58).
Critical Care Medicine. 46(12):1943-1952, December Recognizing the limitations of small sample size, we
2018. observed no difference in 52 patients in day 3 PaO2/
FIO2 (p = 0.92). We also observed no significant
difference between arms in sedation, vasoactive
Objectives: Low tidal volume (= tidal volume ≤ 6 mL/ medications, or occurrence of pneumothorax.
kg, predicted body weight) ventilation using volume Conclusions: Airway pressure release ventilation
control benefits patients with acute respiratory distress resulted in release volumes often exceeding 12 mL/
syndrome. Airway pressure release ventilation is kg despite a protocol designed to target low tidal
an alternative to low tidal volume-volume control volume ventilation. Current airway pressure release
ventilation, but the release breaths generated are ventilation protocols are unable to achieve consistent
variable and can exceed tidal volume breaths of and reproducible delivery of low tidal volume
low tidal volume-volume control. We evaluate the ventilation goals. A large-scale efficacy trial of low
application of a low tidal volume-compatible airway tidal volume-airway pressure release ventilation is
pressure release ventilation protocol that manages not feasible at this time in the absence of an explicit,
release volumes on both clinical and feasibility generalizable, and reproducible low tidal volume-
endpoints. airway pressure release ventilation protocol.
Design: We designed a prospective randomized Reviewer’s Comments:
trial in patients with acute hypoxemic respiratory
failure. We randomized patients to low tidal volume- Prospective evaluations of the efficacy of APRV in
volume control, low tidal volume-airway pressure patients are limited. This study is the second RCT
release ventilation, and traditional airway pressure comparing APRV to VC-LTV ventilation in a mixed
release ventilation with a planned enrollment of 246 population with acute hypoxemic respiratory failure.
patients. The study was stopped early because of low This is the first multicenter randomized controlled
enrollment and inability to consistently achieve tidal trial (RCT) of an LTV ventilation APRV protocol
volumes less than 6.5 mL/kg in the low tidal volume- tracking release volumes in patients with hypoxemic
airway pressure release ventilation arm. Although respiratory failure. Authors observed no difference
the primary clinical study endpoint was PaO2/FIO2 in oxygenation on day 3 of mechanical ventilation
on study day 3, we highlight the feasibility outcomes between VC-LTV and APRV, although the study
related to tidal volumes in both arms. was underpowered. Similarly, they observed no
difference in sedation requirements, VFDs, or
Setting: Four Intermountain Healthcare tertiary ICUs. hospital mortality among the protocols. Authors

importantly demonstrate that in four ICUs with years recipients were 90% more likely to develop delirium
of ventilator protocol experience, neither the APRV- or coma in the 72 hours following the transfusion, after
LTV nor the standard APRV protocol was associated controlling for confounders (adjusted odds ratio, 1.90;
with adherence to a LTV (6 mL/kg) ventilation target; 95% CI, 1.14–3.17; p = 0.01). Anemia (represented
that both APRV protocols resulted in variable release by nadir hemoglobin prior to transfusion) was not
volumes with many greater than 12 mL/kg. Despite associated with delirium development.
high daily compliance, our APRV-LTV protocol was Conclusions: In this cohort of critically ill children,
unable to achieve LTV targets. Given the evidence there is an independent association between the
in support of LTV ventilation, authors propose receipt of an RBC transfusion and the subsequent
that in the absence of a protocol that demonstrates development of delirium. Further prospective studies
successful achievement of LTV with APRV, the use of are warranted to replicate this finding and investigate
APRV should be limited to controlled clinical trials. possible pathophysiologic mechanisms for this
Additional clinical studies measuring transalveolar association.
pressure during release breaths and spontaneous
efforts on APRV are warranted. Reviewer’s Comments:
5. Association Between Transfusion of RBCs This single-center, observational study is the first
and Subsequent Development of Delirium in pediatric cohort reported to date examining the
Critically Ill Children relationship between RBC transfusion and subsequent
development of delirium. Nearly one third of patients
Nellis ME, GoelR; FeinsteinS. with a normal mental state prior to their transfusion
Pediatric Critical Care Medicine. 19(10):925-929, went on to develop either delirium or coma within
October 2018. 72 hours following the RBC transfusion. Authors
Objectives: To determine the temporal relationship report a significant association between both dose and
between the transfusion of RBCs and the subsequent number of RBC transfusions and subsequent delirium/
development of delirium in a cohort of critically ill coma. There was no association between anemia
children. and delirium development in this cohort.Although
this association has not been explored previously in
Design: Nested retrospective cohort study within children, studies in adults have reported conflicting
prospective cohort study. effects of RBC transfusions on the development
Setting: Urban academic tertiary care PICU. of delirium.Although there are no additional
Patients: All consecutive admissions from September pediatric reports of an association between RBC
2014 through August 2015. transfusions and delirium to support their findings,
these associations are scientifically plausible. RBC
Interventions: Children were screened twice daily transfusion in children has been independently
for delirium during their PICU admission. associated with the subsequent development of new
Measurements and Main Results: Among 1,547 or progressive multiple organ dysfunction syndrome.
independent admissions screened for delirium, 166 Foremost, it is an observational study and can only
(10.7%) were transfused RBCs. Children who were suggest an association and not establish causality.
transfused RBCs were more than twice as likely to There are some limitations in study.There are factors
be delirious during their admission compared with that may contribute to the development of delirium,
children who were never transfused, after controlling such as ambient noise level, the use of restraints,
for known predictors of delirium development concurrent infections, or the transfusion of other
(adjusted odds ratio, 2.16; 95% CI, 1.38–3.37; p blood products, which author did not include in their
= 0.001). Among transfused children, a temporal analyses. In addition, although they controlled for
relationship was observed between receipt of RBCs benzodiazepine exposure in the initial cohort, they did
and the subsequent development of delirium. For not include it in their multivariate model involving
each additional 10 mL/kg of RBCs transfused, the transfused children.



Mittal K, Vagha J, Waghmare L,Aggarwal HK, Gupta V, Patki V. Best Evidence-Journal Scan.J Pediatr Crit Care 2018;5(6):54-59.

Mittal K, Vagha J, Waghmare L,Aggarwal HK, Gupta V, Patki V. Best Evidence- Journal scan. J Pediatr Crit Care 2018;5(6):54-59.

DOI-10.21304/2018.0506.0448
Critical Thinking
PICU QUIZ -HAI
Vinayak Patki*
*Chief, Advanced Pediatric Critical Care Centre, Wanless Hospital, Miraj, Maharashtra, India.
Received: 21-Nov-18/Accepted: 08-Dec-18/Published online: 31-Dec-18
Q.1 The institution of policies to reduce hospital- Q.4 A 2-month-old infant is admitted to the
acquired infection has been least effective pediatric intensive care unit (PICU) with
in preventing which of the following in a history of fever and irritability leading
children? to a decreased level of consciousness, a
A. Catheter-associated urinary tract infection raised red rash, and increasing respiratory
(CA-UTI) distress. To decrease the spread of infectious
B. Central line–associated bloodstream agents within the PICU and hospital, what is
infection (CLA-BSI) the most important priority for this patient
upon admission?
C. Ventilator-associated pneumonia (VAP)
A. Acquisition of blood for culture and
D. Ventriculostomy-related infections sensitivity
Q.2 Wearing a mask is extremely important B. Acquisition of cerebrospinal fluid for
in the prevention of which of the following culture and sensitivity
diseases?
C. Broad-spectrum antibiotic prophylaxis of
A. Clostridium difficile-associated diarrhea exposed health care workers
B. Methicillin-resistant Staphylococcus aureus D. Isolation with negative pressure
C. Neisseria meningitides after 24 hours of Q.5: What is the most prevalent contagion
antibiotics in central line–associated bloodstream
D. Respiratory syncytial virus infection (CLA-BSI) in critically ill children
Q.3 A 4-year-old child requires placement of a with a central venous catheter?
short-term central venous catheter (CVC). A. Candida species
To assist with prevention of a central line– B. Coagulase-negative Staphylococcus
associated bloodstream infection (CLA-
BSI), the person inserting the catheter C. Enterobacteriaceae
should do which of the following? D. Pseudomonas species
A. Always use an antibiotic-coated central Q.6: A key principle for the elimination of
line. ventilator-associated pneumonia (VAP)
B. Follow maximal barrier precautions, includes which of the following?
including head-to-toe draping of the patient A. Institution of prophylactic antibiotics
and donning of a cap, mask, sterile gown, B. Minimization of aspiration of secretions
and sterile gloves. and colonization of the aerodigestive tract
C. Institute prophylactic antibiotics. C. Placement of the patient in the prone
D. Prepare the skin with an antiseptic agent position
followed by a saline solution rinse of the D. Regularly scheduled instillation and
prepared site prior to insertion. suctioning of the endotracheal tube
Correspondence: Q.7: Which of the following is the most important
Dr. Vinayak Patki, MB,DNB,FCCP,FIAP. Chief, action staff can take to prevent a urinary
Advanced Pediatric Critical Care Centre & Head, Dept of
Pediatrics, Wanless Hospital, Miraj, 416101, Maharashtra, India. tract infection (UTI) in patients in the PICU?
Phone: +919822119314, E-Mail- patkivinayak@gmail.com A. Catheterize all children with continuous

CRITICAL THINKING PICU QUIZ
morphine infusions. D. Obtain diagnostic specimens including

B. Limit the use of urinary tract instrumentation. cerebrospinal fluid for HSV polymerase
chain reaction.
C. Maintain adequate hand hygiene
Answer:
D. Insert urinary catheters using an aseptic
technique. Q.1 : A
Q.8: Standard precautions of infection control There have been fairly dramatic declines in
include hand hygiene, safe injection practices, the incidence of VAP and CLA-BSI with the
use of personal protective equipment where introduction of bundles of care that have been
appropriate, and appropriate respiratory shown in large studies to be effective at their
hygiene and cough etiquette. Hand hygiene prevention. Ventriculostomy-related infections
has been identified as a simple yet effective are not common. Hospital-acquired sinusitis
step in drastically reducing health care– is a challenging diagnosis to make without
associated infections. What is true regarding consensus criteria.
hand hygiene? The incidence of CA-UTI remains significant,
A. It is not necessary if donning surgical as the only evidence-proved intervention is
gloves. reducing indwelling catheter days. In some
situations urinary catheters must remain in situ,
B. It is limited to patient contact only.
as reflected by the persistent incidence of CA-
C. It is most effective when using soap and UTI. New techniques such as coated catheters or
water. antibiotic instillation have yet to prove effective.
D. It is recommended before touching a Q.2 :D
patient, before performing clean/aseptic
Masks to prevent acquisition of disease via the
procedures, after body fluid exposure/risk,
airborne or droplet route are useful primarily
after touching a patient, and after touching a
for respiratory viruses such as RSV or
patient’s surroundings.
influenza, as well as diseases that are potentially
Q.9: Which of the following should receive aerosolized such as measles, tuberculosis, and
prophylaxis for a patient who presents with chickenpox. Diseases that require direct contact
suspected meningococcal disease? for transmission, such as MRSA, clostridium
A. The physician who took over care 2 days difficile–associated diarrhea, and norovirus
after presentation infection do not formally need a mask for
B. The unit clerk prevention if all other precautions are maintained.
C. The initial emergency room doctor who However, many infection control programs will
intubated the patient insist that practitioners wear masks in these
conditions to avoid inadvertently touching their
D. The nurse in emergency room triage who
face with gloved, contaminated hands while
saw the patient through a window
providing care. Neisseria meningitides does
Q.10: If herpes simplex virus (HSV) encephalitis not need droplet precautions after appropriate
or neonatal disease is suspected, the most antibiotic therapy has been administered.
important initial step is to do which of the
Q.3: B
following?
Successful programs to reduce the incidence
A. Determine the source of the exposure.
of CLA-BSI have been reported; all use
B. Initiate empiric treatment with intravenous multimodal team-based systematic approaches
acyclovir. in which combinations of effective preventive
C. Initiate appropriate infection control interventions are introduced into a care setting.
precautions. The central line bundle is a compilation of eight

components broken into two separate bundles for Q. 4: D

insertion and maintenance. The insertion bundle Isolating a patient in a negative-pressure room is
components include hand hygiene, maximal the first step in preventing the spread and potential
barrier precautions, and skin antisepsis. Maximal cross-contamination of unknown contaminants.
barrier precautions for the person inserting Q. 5: B
the catheter entail strict compliance with hand
hygiene and wearing a cap that covers all hair, The most common infecting organism in persons
a mask that covers the mouth and nose securely, with CLA-BSI is the gram-positive bacteria
a sterile gown, and sterile gloves. The patient coagulase-negative Staphylococcus, a group
is covered from head to toe with a sterile drape of about 20 species, including Staphylococcus
except for a small opening for the insertion site epidermidis, which are normal flora of human
and to maintain the airway. Chlorhexidine skin skin. gram-negative bacteria, including
antisepsis is recommended over other antiseptic Enterobacteriaceae, and nonfermenting gram-
agents. With regard to the optimal site for a line, negative bacteria, such as Pseudomonas species,
practitioners are urged to consider what is best Acinetobacter species, and Stenotrophomonas
for the patient based on current and future needs, species, account for about 25% of infections.
anatomic features, and the inserter’s technical Increasingly, Candida species infections are
competence. recognized.
Other components of success include Q. 6:B
empowering nurses to enforce the use of a Strategies of prevention are directed against the
central line checklist that incorporates inclusion three mechanisms by which VAP is thought to
of all components of the insertion bundle and occur: aspiration of secretions, colonization of
constraining practice by creating central line the aerodigestive tract, and use of contaminated
insertion kits or carts that include the required equipment. General recommended measures are
equipment needed to maintain asepsis (eg, to conduct active surveillance for VAP, minimize
offering only one antiseptic-chlorhexidine). the duration of ventilation and use noninvasive
Antibiotic-impregnated CVCs are not ventilation whenever possible, perform daily
recommended for routine use unless concerted assessments of the patient’s readiness to be
efforts to implement a strategy fail to reduce weaned from ventilation, and educate health
a local institution’s infection rates below care workers who care for ventilated patients
benchmark levels. Antibiotic-impregnated CVCs about VAP.
may be considered in specific patient populations Specific precautions of the pediatric VAP bundle
such as immunosuppressed patients requiring are practicing hand hygiene before and after
long-term CVC use, although their superiority circuit manipulation, elevating the head of the
over standard CVCs in this population has never bed (the angle varies depending on positioning
been proved. limitations of the child based on his or her age),
In addition to hand hygiene, the maintenance positioning the oral or nasal gastric tube properly,
bundle to prevent CLA-BSI incorporates eliminating the routine use of instillation prior
multimodal education and training programs, to suctioning of the endotracheal tube, changing
accessing the lumens aseptically (ie, scrubbing in-line suctioning catheters only when they
the hub), checking the entry site for inflammation are visibly soiled or malfunctioning, providing
regularly (at a minimum, with each dressing regular oral care for all children, and maintaining
change), daily review of line necessity with the ventilator tubing in a dependent position.
removal if it is deemed unnecessary, and a Q.7: B
dedicated total parenteral nutrition line. Guidelines for the prevention of catheter-
associated urinary tract infection (CA-UTI)

in acute care hospitals focus on certain key initiative on hand hygiene emphasizes five
strategies, all related to urinary catheter use: moments for hand hygiene: before touching
(1) recommendations regarding which patients a patient, before performing clean/aseptic
should receive indwelling urinary catheters; procedures, after body fluid exposure/risk, after
(2) recommendations for catheter insertion; (3) touching a patient, and after touching a patient’s
recommendations for catheter maintenance; and surroundings.
(4) quality improvement programs to achieve Q.9: C
appropriate placement, care, and removal of
Meningococcal disease can rapidly cause shock
catheters. The most important action that PICU
and multiorgan failure. Hence, prevention is the
staff can take to prevent UTIs is to limit the use
most important component in managing this
of urinary tract instrumentation, particularly
severe illness. Only close contacts that were
indwelling urinary catheters. Systemic morphine
potentially exposed to nasopharyngeal secretions
infusions are not a contraindication to the
early in the treatment course are recommended
removal of the urinary catheter.
to receive antibiotic prophylaxis.
Proper technique for catheter insertion includes
Aggressive therapy for meningococcal disease
hand hygiene before and after any manipulation
has been shown to significantly improve
of the device, use of aseptic technique, use of
outcomes. Early antibiotics, appropriate
the smallest bore catheter needed, and proper
hemodynamic support, and referral to higher
securement of the catheter after insertion to prevent
levels of care are all fundamental components
movement. The catheter should be maintained
of the management of invasive meningococcal
as a closed drainage system with unobstructed
infections.
urine flow. The catheter and collecting system
should be replaced if the system is disconnected Q.10: B
or if leaks occur. Standard precautions should When it is untreated, HSV encephalitis carries
be used for any manipulation of the catheter a death rate in excess of 70%, and even when
or collecting system (eg, use of gloves and it is treated, death and complications for those
gowns as appropriate). Systemic antimicrobials, who survive remain on the order of 15% and
bladder irrigation with antimicrobial agents, and 20%, respectively. Similarly, despite treatment,
complex drainage systems with antiseptic agents neonatal HSV central nervous system disease
are not recommended to prevent CA-UTI. carries a significant risk of death and morbidity,
Special catheter materials (eg, antimicrobial- ranging from 0% to 15% and 43% to 68%,
impregnated catheters) are only recommended respectively. Early identification of patients and
if a comprehensive strategy to reduce CA-UTI rapid initiation of acyclovir have been associated
rates is unsuccessful. with a better outcome. Unless an alternative
Q.8: D cause is clear, high-dose acyclovir should be
initiated in all children with encephalitis until
The World Health Organization Patient Safety
HSV can be ruled out.
Patki V. Critical Thinking: PICU Quiz-HAI.J Pediatr Crit Care 2018;5(6):60-63.

Patki V. J Pediatr Crit Care 2018;5(6):60-63.

DOI-10.21304/2018.0505.00449
Book Review
Critical Care Nephrology
Authors : Claudio Ronco, John A Kellum, Renaldo Bellomo, Zaccaria Ricci
Publisher: Philadelphia, Elsevier Edition : 3rd Year of Publication: 2019
Price : Rs. 19747.00 ISBN: 978-0-323-44942-7 Pages : 1456
Kundan Mittal*, H K Aggarwal**, Rajesh Mishra***, Manish Munjal****

*Senior Professor and Incharge PICU & Respiratory Clinic, **Senior Professor, Department of Medicine and Nephrology, Pt. B D
Sharma, PGIMS, Rohtak, Haryana, India.***Intensivist, Ahemdabad ,Gujarat, India**** Intensivist. Jaipur, Rajasthan, India
Renal involvement is frequently seen in critically ill

patients. Excellent book explaining in depth regarding
critical care in nephrology. Book is divided into 30
sections and 231 chapters. Sections are divided from
basic science & critical care, physiological aspect,
acid base status, electrolytes, pathophysiology,
biomarkers, clinical syndromes and AKI, nutrition,
infections and sepsis, kidney and other body organs,
general management, dialysis, renal replacement
therapy to renal transplantation. Special mention of
renal diseases pediatric population and renal problems
in intensive care have also been discussed nicely. This
book is very useful to intensivist and nephrologist
who look after renal ICU.
Correspondence:
PGIMS, Rohtak Haryana, India,
Phone-+919416514111, Email-kundanmittal@gmail.com

Mittal K, Aggarwal HK, Mishra R, Munjal M. Book Review:Critical Care Nephrology.JPediatr Crit Care 2018;5(6):64.

Mittal K, Aggarwal HK, Mishra R, Munjal M. Book Review:Critical Care Nephrology.JPediatr Crit Care 2018;5(6):64.

NCPCC- 2018 :Scientific Paper Abstracts
DOI-10.21304/2018.0506.00450
Cytokine levels in critically ill children with Severe Sepsis and their
correlation with the severity of illness and mortality
Suresh Kumar Angurana, Arun Bansal, Jayashree Muralidharan, Ritu Aggarwal1, Sunit Singhi2
Department of Pediatrics, Advanced Pediatrics Centre, 1Department of Immunopathology, Postgraduate Institute of Med-
ical Education and Research (PGIMER), Chandigarh. 2Department of Pediatrics, Medanta, the Medicity, Gurugram, NCR.
Objective: To study the baseline cytokine levels and cytokine levels were IL-10: 185 (62-395) pg/ml, and
their correlation with severity of illness and mortality TGF-β1: 204 (92-290) ng/ml. The median (IQR)
in critically ill children with severe sepsis. PRISM III score was 15 (12-20). Pro-inflammatory
Design: Subgroup analysis of a randomized, double- cytokines showed positive correlation with PRISM
blind, placebo-controlled trial. III score: IL-6 (Spearman’s correlation coefficient,
ρ=0.273, p=0.06), IL-12 (ρ=0.367, p=0.01), IL-17
Setting: Pediatric intensive care unit of a tertiary care
(ρ=0.197, p=0.17), and TNF-α (ρ=0.284, p=0.05);
teaching hospital in North India.
and anti-inflammatory cytokines showed negative
Patients: Fifty children, 3 months-12 years, with correlation: IL-10 (ρ= -0.257, p=0.09), and TGF-β
severe sepsis. (ρ= -0.238, p=0.11). The mortality was 10% (n=5).
Material and Methods: Blood was collected at Among non-survivors, the levels of pro-inflammatory
admission for estimation of pro-inflammatory (IL-6, cytokines were significantly higher as compared to
IL-12p70, IL-17, and TNF-α) and anti-inflammatory survivors [IL-6: 359 (251-499) vs. 157 (97-223) pg/
(IL-10 and TGF-β1) cytokines. Primary outcome: ml, p=0.000; IL-12p70: 167 (133-196) vs. 66 (30-
To find out correlation between cytokine levels with 100), p=0.000; IL-17: 400 (333-563) vs. 237 (122-
severity of illness (PRISM III score). Secondary 318), p=0.009; and TNF-α: 409 (355-503) vs. 330
outcomes: To compare cytokine levels among (198-415), p=0.002, respectively].
survivors and non-survivors. Conclusion: In critically ill children with severe
Results: Baseline pro-inflammatory cytokine levels sepsis, pro-inflammatory cytokines showed a
[median (IQR)] were IL-6: 189 (35-285) pg/ml, IL- positive correlation with severity of illness and were
12p: 48 (28-98) pg/ml, IL-17: 240 (133-345) pg/ml, significantly higher among non-survivors.
and TNF-α: 296 (198-430) pg/ml; anti-inflammatory
DOI-10.21304/2018.0506.00451
Acute kidney injury in the pediatric ICU of a tertiary care hospital:
Cross sectional observational study
Suprita Kalra, Punam Bajracharya, Sandeep Dhingra, Amit Sood, Department of Pediatrics,
Armed Forces Medical College, Pune, Maharashtra
Objective: Acute kidney injury shown to be International guidelines. The patients were followed
commonest complication in critically ill children up till discharge/death. All children were screened
admitted to the PICU. KDIGO classification and for AKI at admission and subsequently using serum
definition now used universally. We undertook creatinine measured by modified Jaffe’s method and
prospective observational study to study the etiology urine output measurement.
and maximum stage of AKI as defined by KDIGO, its Results: 197 children were admitted to PICU. 38
complications and outcomes. (19.28%) developed AKI and 6 (15.78%) developed
Materials and Methods: All children admitted to the stage III AKI. Malignancies, serious neurological and
PICU were included in the study. The diagnosis of renal disorders and post complex surgeries accounted
sepsis and MODS was made according to the standard for most of the cases with AKI. Six were admitted

NCPCC 2018 Scientific Paper Abstracts
with primary renal condition. Sepsis with or without AKI died (47.36%) while 36 (21.38%) with no AKI
MODS was seen in 12 patients with AKI and in 8 expired.
without AKI.21 children with AKI and 3 children Conclusions: AKI in children in the PICUs of referral
were exposed to nephrotoxic drugs. 23 Children with hospitals in the armed forces have varied etiologies
AKI required inotropic support. Children with AKI and presentations. These children require early
had ALOS in PICU of 9.86 days while ALOS in identification and management with close monitoring
children without AKI was 6.23 days.18 children with to prevent long term renal morbidity and mortality.
DOI-10.21304/2018.0506.00452
A prospective observational study on practices and outcomes of
initiation of inotropes in relation to resuscitation fluids in children
with septic shock
Karanvir, Shalu Gupta, Virendra Kumar, Jagdish Chandra,
Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi
Objective: To study the practices and outcomes into N1(46), N2(10) and N3(44). Mean volume of
of initiation of inotropes in relation to resuscitation fluid required to achieve hemodynamic stability
fluids boluses used in children with septic shock. in N1(40±10 mL/Kg) was significantly less than
Material and Methods: It was a Prospective N2(70±10 mL/Kg) and N3(70±20mL/Kg);p=0.019.
observational study carried out from November 2014 Mean time taken to achieve hemodynamic stability
to April 2016 at Pediatric emergency and PICU, was significantly less in N1(115±45 minutes) than
LHMC and KSCH, New Delhi. Children aged 1 to N2(196±32minutes) and N3(212±44minutes);
18 years with septic shock were included. Primary p=0.021.Complications were lower in N1 (32%)
outcome was to look at various practices of initiation than N2(40%) and N3(47%); p=0.036. Mean volume
of inotropes; accordingly patients were categorized of Intravenous fluid required in first 24 hours of
into 3 groups; N1 received inotropes after completion treatment in N1,N2 and N3 group was 122.4 ±22mL/
of first(20mL/kg),N2 after second(40mL/kg) and N3 kg, 151±31mL/kg and 145±24mL/kg respectively.
after third (60mL/kg) bolus. Secondary outcome was Mortality difference in N1(17%), N2(30%) and
to compare time taken, amount of fluid required to N3(27%) was not significant.
achieve hemodynamic stability, total fluid required Conclusion: Early initiation of inotropes resulted
and complications in first 24 hours of treatment. Study in less total fluid volume, lesser time to achieve
was approved by IEC. hemodynamic stability, less fluid boluses, and lesser
Results: Total 100 patients enrolled were grouped complications in first 24 hours.

DOI-10.21304/2018.0506.00453
Comparison of neutral and lowered shoulder position on successful
right subclavian vein Catheterisation in children: An Interim Analysis
of a randomised controlled trial
Dhirendra Pratap Singh, Ajeet Kumar Yadav, Sudha Chandelia, Devki Nandan
PICU, Department of Pediatrics, PGIMER, Dr. RML Hospital, New Delhi.
Objectives: To compare neutral and lowered used for allocation concealment. Data on number of
shoulder position on successful right subclavian vein attempts, successful catheterization and complications
Catheterisation in children. were collected.
Materials and Methods: A randomized control trial Results: Both the groups were similar w.r.t age,
was conducted on 40 children aged upto 14 years of weight, hight and gender distribution. Rate of
age in whom central vein catheterization was planned. successful subclavian catheterization were similar in
Patients were randomized using computer generated both the groups [(neutral-90s% versus lowered-95%)
random numbers into two groups either neutral with a nonsignificant p-value 0.46].The complication
or lowered shoulder position during subclavian rates were also similar with a p value of 0.18.
vein puncture and guide wire insertion. Block Conclusion: Both the shoulder positions were
randomisation was used for allocation into groups. associated with similar success rates of subclavian
Sequentially numbered opaque sealed envelops were catheterization and complications.
DOI-10.21304/2018.0506.00454
Lung ultrasound as early diagnostic tool in Neonatal Respiratory
Distress Syndrome
Shwetha.G, Sinchana, Santosh T Soans
Department Of Pediatrics, A.J.Institute of Medical Sciences, Mangalore
Objective: To evaluate the value of lung ultrasound line abnormalities, A-line disappearance, The
in the diagnosis of respiratory distress syndrome simultaneous demonstration of lung consolidation,
(RDS) in newborn infants pleural line abnormalities and bilateral white lung,
Methods: From October 2017 to October 2018, or lung consolidation, pleural line abnormalities and
54 newborn infants were divided into two groups: A-line disappearance co-exists with a sensitivity 100
RDS group (27 cases) and control group (27 cases) % and specificity 90 % for the diagnosis of neonatal
According to the findings of chest x-ray, there were 18 RDS for studied sample size
cases of grade II RDS,7 grade III cases, and 2 grade IV *Total sample size being 40 cases & 40 control
cases in RDS group. Lung ultrasound was performed Conclusion: This study indicates that using an
at bedside by a single expert. The ultrasound indexes ultrasound to diagnose neonatal RDS can be reliable
observed in this study included pleural line, A-line, tool. A lung ultrasound has many advantages over
B-line, lung consolidation, air bronchograms, bilateral other techniques. Ultrasound is non-ionizing, low-
white lung, interstitial syndrome, lung sliding, lung cost, easy to operate, and can be performed at bedside,
pulse etc. making this technique ideal for use in NICU
Findings: In all of the infants with RDS, lung *Complete Statistical analysis to follow once the
ultrasound consistently showed compact B lines, sample size is completed
bilateral white lung or interstitial syndrome, pleural

DOI-10.21304/2018.0506.00455
Functional outcomes in Children with Severe Sepsis – A Prospective
Observational Study
Sravanthi, Kiran Kumar, Jhuma Sankar, Rakesh Lodha, S K Kabra,
Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
Objective: To evaluate functional outcomes in nine % had septic shock and 31% had severe sepsis.
children with severe sepsis and septic shock admitted Twenty four (25%) died. The Median (IQR) POPC
to the PICU using Pediatric Overall Performance and PCPC scores at admission were – 3 (1 to 4). The
Category Scale (POPC) and Pediatric Cerebral POPC and PCPC scores at discharge/death were 2 (1
Performance Category (PCPC) scales at discharge/ to 5) and 2 ( 1 to 6) respectively. At admission 49%
death as compared to baseline scores. had a baseline POPC and PCPC score of 2 and
Methods: We conducted this prospective at discharge/death 59 (61%) had a POPC and PCPC
observational study from October 2017 to June score of 2.
2018. Children aged 2 months to 17 years admitted Conclusion: The functional outcomes of children
to PICU with severe sepsis and septic shock were admitted to the PICU with severe sepsis and septic
enrolled. Data collection included demographic and shock were poor with more than half having mild to
clinical details and POPC and PCPC scores. Data was severe disability or death.
analyzed using stata 11. Keywords: Severe sepsis; POPC and PCPC scores
Results: A total of 96 children were enrolled. Sixty
DOI-10.21304/2018.0506.00456
Prognostic value of rise in neutrophil to lymphocyte ratio and platelet to
lymphocyte ratio in predicting the mortality in Pediatric Intensive Care
Siby Mathews, Aswathy Rajan, Santosh T. Soans,
Department of Pediatrics, AJ Institute of Medical Sciences, Mangalore
Objective: To assess the prognostic value of rise in for PLR rise was 4.623 (IQR 85.533). PELOD 2
NLR and PLR in pediatric intensive care as markers predicted mortality in 72.2% of the patients, while
of mortality. NLR increase predicted in 64.11% and PLR increase
Materials and methods: A retrospective study in 77.77%. A decreasing trend in NLR and PLR were
based on 2 year data from HIMS and G-HEALTH both closely related to lesser length of stay in hospital
data systems of AJ Institute of Medical Science, of and better survival.
all patients admitted to PICU after excluding those in Conclusion: The study gives an insight into the fact
whom all the study parameters were not retrievable. that simple and inexpensive markers such as rise in
NLR and PLR ratios were determined and compared NLR and PLR helps in predicting the mortality in
to PELOD 2 using SPSS version 17.0 the pediatric intensive care which is comparable to
PELOD scoring.
Results: The demographic data was matched, the
median NLR rise was 0.175 (IQR 1.714) while Key words: NLR, PLR, Mortality indicator, Pediatric
Intensive Care, Prognostic indicator

DOI-10.21304/2018.0506.00457
Dexmedetomidine versus midazolam for sedation in mechanically
ventilated children: a randomized controlled trial
Krishna Mohan Gulla; Jhuma Sankar; Kana Ram Jat; S K Kabra; Rakesh Lodha,
Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
Objectives: To compare the efficacy of Results: 49 children were randomized (24 in

dexmedetomidine and midazolam for sedation of midazolam and 25 in dexmedetomidine). There was
mechanically ventilated children admitted to PICU. no difference in the percentage of time spent in the
Secondary objectives were to compare the top up targeted sedation between the groups [midazolam
doses of fentanyl and paralytic agents, length of 67.3 (18.8) vs dexmedetomidine 56.3(28.6); p=0.12].
mechanical ventilation, ICU stay and hospital stay, The absolute difference in the percentage of time
and adverse events. spent between the groups was -10.94% [(SE=7.05);
Materials and methods: An open label, non 95% CI: -25.15 to 3.25]. The lower end of 95% CI
inferiority RCT was done from August 2016 to April for this difference breached the non-inferiority limit
2018 in PICU of a tertiary care hospital in India. of -20%. Number of fentanyl boluses, duration of
Sedation level was assessed using Penn State Children mechanical ventilation, ICU stay and hospital stay
Hospital sedation algorithm and the targeted sedation were similar between the groups. Four (17.4%)
was 4 or 5 score. Maximum dose of midazolam was 4 children in dexmedetomidine group developed
mcg/kg/min and of dexmedetomidine was 0.75 mcg/ persistent bradycardia, while none in midazolam
kg/hr. Sum of the periods (in hours) the patient was group (p=0.05).
monitored for sedation, the time periods (in hours) Conclusion: Our study could not establish the
where the patient was at level of sedation 4 or 5 were non-inferiority of dexmedetomidine compared to
calculated. Percentage of time spent in level 4 or 5 midazolam for sedation in children on mechanical
was calculated. ventilation.
DOI-10.21304/2018.0506.00458
Ultrasound appearance of lungs in patients with ventilator associated
pneumonia
Sudha Chandelia, PICU, Department of Pediatrics, PGIMER, Dr. RML Hospital, New Delhi.
Objectives: To document ultrasound appearance posterior axillary line divided lateral from posterior
of lungs in mechanically ventilated patients with area. The probe orientation was perpendicular to the
(ventilator associated pneumonia) VAP. ribs.
Methods: This was a prospective observational Results: A total of 28 patients (18 males) were
cohort, single centre study conducted in PICU of a enrolled. Median age was 6.5 years ranging from 1-13
university affiliated tertiary care hospital. A total of 28 years Dynamic linear/arborescent air-bronchograms
patients of age 1 year to 14 years who were receiving were seen in all 100% cases. Shred sign was seen in
invasive mechanical ventilation for reasons other than 28% cases. Partial loss of aeration was seen in 68%
pneumonia and other lung diseases were selected by while total loss of aeration was seen in 32% cases.
consecutive sampling technique. The lung ultrasound Hepatisation was noticed in 21 % patients. Thickened
(LUS) was performed whenever there was a suspicion pleural line heterogenous echotexture were also
of VAP and these were diagnosed as per CDC criteria. noticed. Pleural effusion was seen in two patients.
LUS was performed with Aloka SSD-90 machine Conclusion: LUS is feasible in mechanically
with both 5MHz linear and 7.5MHz linear transducer. ventilated children and Specific LUS findings are
Each lung was divided into six areas (superior and seen in VAP which can be used to diagnose it rapidly
inferior of anterior, lateral and posterior zones). at bedside.
Anterior axillary line divided anterior from lateral and

DOI-10.21304/2018.0506.00459
Evaluating pediatric early warning score (PEWS)
as a predictor of PICU admission for children visiting
emergency department in a tertiary care health centre
Rasika Priya, Jagadeesh, Soundarajan,Gunasekaran,
Department of Pediatrics, Mahatma Gandhi Medical College and Research Institute, Puducherry
Objectives: To obtain cut-off values of PEWS scores those directly admitted to ward from ED. PEWS score
that can predict need for PICU transfer at admission. was calculated and compared among the groups.
To obtain cut-off values of PEWS scores that can Results: Among 1525 patients, 738(48%) were
predict unanticipated worsening (PICU transfer from admitted, 252(34.12%) to PICU and 486(65.85%) to
ward after admission) ward. AUC for predicting overall admission was 0.69
Materials and methods: This was a prospective 12 (95%CI: 0.68–0.77), for PICU 0.86 (95%CI:0.96–1)
month observational study of patients aged 1month and for ward 0.75 (95%CI: 0.66-0.75). The sensitivity
to12 years admitted in our Emergency department. and specificity in predicting overall admission with
Approximately 738 patients were included in our study cut off of PEWS≥ 1.5 was 76% and 64%, for PICU
and all were subjected to PEWS score individually by admission with cut off PEWS ≥ 3 was 100% and
the nurses and the pediatric trainee. Interrater reliability 90%, for ward admission with cut off PEWS ≥1.5 was
between nurses and pediatric trainee was evaluated. 79% and 61% respectively. Interrater reliability was
PEWS score was measured at initial assessment (S0) excellent .
by pediatric trainee and staff nurse in emergency and Conclusions: The study found elevated PEWS serve
after one hour (S1) by pediatric trainee alone. Patients as excellent screening tool for prediction to PICU
were stratified into 3 outcome groups: those admitted admission and transfer from ward to PICU
to PICU either from ED, transferred from the ward, or
DOI-10.21304/2018.0506.00460
Health related quality of life in survivors of acute respiratory illness
who required invasive respiratory support in a tertiary Pediatric ICU
- A Prospective observational study
Siva Vyasam Prasad, Pragathesh P, Jewel Prasad, Ebor Jacob James
Paediatric Intensive Care Unit, Christian Medical College, Vellore
Objectives: To assess long term health related quality non contactable were written a postal letter. Quality of
of life in all PICU survivors with acute respiratory life assessment was done with the help of the Health
illness requiring invasive respiratory support, three to Utility Index 2 which has 6 domains; sensation,
eight years after discharge mobility, emotion, cognition, self care and pain.
Materials and Methods: All premorbidly well Functioning within each attribute is represented by
children between 1month to 15years of age who four or five levels. The assessment was done either by
were ventilated for more than 48 hours for acute telephone questionnaire or by objective assessment in
respiratory illness between March 2008- February PICU office/Out patient department(OPD) by using
2014 and who were survived and discharged were HUI2 index. By using this,the outcome is classified
included in our study. Neonates, children with as NORMAL(Score>0.99),FAIR(0.89-0.99) and
acute neurological dysfunction, premorbidly unwell POOR(Score<0.89).
children, readmission to PICU were excluded.Data Results: In our study we had total 259 children who
was collected from medical records. Those who were were admitted with acute respiratory illness requiring

invasive ventilation in PICU for more than 48 hours affected domain is ‘Sensation’. Eleven(17%) children
during our study period. Out of these, 67 children (26%) among our study group required either spectacles or
died during PICU stay due to various complications hearing aid. In the ‘Pain’ domain, only 7 children
and 46 (18%) were discharged against medical (11%) out of 66 has occasional pain and discomfort.
advice. Among 146 children, we were able to contact In the ‘selfcare’ domain, only 5 children (8%) out of
66 children and the remaining 74 children could not 66 children are affected. These children have some
be contacted through telephone or postal service. In difficulty to handle their day to day activities. Least
the study group, six children died after discharge due commonly affected domain is ‘Mobility’(1.5%)
to various causes . HUI2 questionnaire details were where only one child was affected who needs some
obtained either through personal interview (n=24) or assistance while walking.
by telephonic interview (n=42). HUI2 assesment was In our study, duration of PICU stay, complications
done for 66 children (Mean age 7.8± 2.6 years). Mean of ventilation (VAP, Pneumothorax, Pneumo-
HUI2 score was 0.94±0.062. Majority of children are mediastinum) and multiorgan dysfunction
having good quality of life (84%) and 16% having (ARF,ALF,DIC-9) had influence on the long term
poor quality of life who were affected in more than outcome but it is not statistically significant (P value
one domain. Of these 66 children, only one child was 0.128, 0.206 and 0.638 respectively). This may be due
having learning disability and was affected badly in to the decrease in effect of acute illness in long term
4 domains(Score of 0.69) of quality of life. He needs quality of life. In our study there was no correlation
spectacles to see and can walk with some limitation noted between maternal and paternal education and
and often anxious and studies less compared to peer quality of life. Majority of PICU survivors(84%) have
groups. a good long term Quality of life (HUI mean score
Most common affected domain in our study group 0.94+/0.06). Even though, factors (Duration of PICU
is ‘Cognition’. 23(35%) children are able to learn stay, complications of ventilation and multiorgan
and remember school work less than their peer dysfunction) influencing long term quality of life
groups at school otherwise there were normal in were present more in the Poor outcome group, they
all other domains. This is based on their parents are not statistically significant. This may be due to the
perspective. Second most common affected domain decrease in effect of acute illness in long term quality
is ‘Emotion’. 12(19%) children in our study group of life.
(66) are occasionally irritable, angry, depressed, Key words: Health utility index 2, Quality of life,
anxious due to various reasons.Third most common PICU
DOI-10.21304/2018.0506.00461
Intensive care needs and predictors of in hospital mortality following
Spontaneous Intracranial Hemorrhage in Children
- A ten year single centre retrospective study
Vijai Williams 1, Muralidharan Jayashree 1, Arun Bansal 1, Arun Baranwal 1, Karthi Nallasamy 1,
Sunit. C. Singhi 1, Pratibha Singhi 2, SK Gupta 3
1Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, 2Division of Pediatric
Neurology, Department of Pediatrics, 3Department of Neurosurgery, Postgraduate Institute of Medical Education and
Research (PGIMER), Chandigarh.
Objective: To study the clinical profile, intensive study in a tertiary care pediatric intensive care unit
care needs and predictors of in hospital mortality in (PICU) of a teaching and referral hospital where
children with Spontaneous Intracranial Hemorrhage 105 children aged > 1 month to 12 years with SICH
(SICH). admitted between January 2009 and May 2018 were
Material and methods: Retrospective observational assessed for in-hospital mortality as primary outcome.
Survivors and non-survivors were compared to

determine predictors of outcome. PRISM-III (>20), need for intubation at admission,

Results: The median (IQR) age of study subjects was development of shock and Acute kidney injury (AKI)
6 (2.25, 70) months, with 76 (72.4%) boys. Altered during hospital stay and refractory status epilepticus
sensorium (n=87, 82.9%) and seizures (n=73, 69.5%), requiring thiopentone coma were found to be
and pallor (n=66, 62.9%) and bulging anterior significant predictors of mortality. Focal seizures were
fontanelle (n=52, 49.5) were common presenting however associated with better survival [OR 0.12;
symptoms and signs respectively. Median (IQR) 95% CI:0.03-0.47; p-0.002]. Age, site or etiology
Glasgow Coma Scale (GCS) at admission was 10 of bleed did not affect outcome. On multivariable
(6,13) with features of herniation in 27 (25.7%). analysis, progression to AKI [OR 5.86; 95% CI:1.53-
Arteriovenous malformation was the commonest 22.4; p-0.01] predicted poor outcome.
cause of bleed among older children whereas late Conclusions: Etiology of SICH varies with age. Age
hemorrhagic disease of newborn was predominant or site of bleed did not predict outcome. Refractory
cause among infants. Commonest site of bleed was status requiring thiopentone and development of
intracerebral (n=47, 44.8%) followed by subdural MODS (shock, AKI) were associated with poor
(n=26; 24.8%). Sixteen (15.2%) children died during outcome.
hospital stay. On univariate analysis, GCS<8, higher
DOI-10.21304/2018.0506.00462
Intensive care needs and predictors of mortality in critical pertussis
: A single center experience
Kavitha TK1, Madhusudan Samprathi 1, Namita Ravikumar 1, Muralidharan Jayashree1, V Gautam2, N Jain2,
R Kumar2, A Bansal2, A Baranwal2, N Karthi2 S.Verma3, Lucky sangal4
1Division of Pediatric Critical Care, Department of Pediatrics, 2 Department of Medical Microbiology, 3Division of
Pediatric Infectious Disease, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical
Education and Research (PGIMER), Chandigarh, 4WHO country office for India
Objective: To study the clinical profile, intensive care major complications. Intensive care needs included
needs and predictors of mortality in critical pertussis. mechanical ventilation (n=11, 30.6%), vasoactive
Material and methods: Case records of 36 children support (n=7, 19.4%) and exchange transfusion
>1 month to 5 years old with probable critical pertussis (n=3, 8.3%). Pulmonary arterial hypertension (PAH)
admitted to a tertiary care PICU of a teaching and was detected in 5 out of 15 (33.3%) children who
referral hospital between January 2016 and May 2018 underwent echocardiography. Eight (22.2%) children
were analyzed retrospectively. Clinical, laboratory died during PICU stay. Median (IQR) length of PICU
and treatment variables between survivors and non- stay in survivors was 4 (3, 5) days. On univariate
survivors were compared to determine predictors of analysis, female sex, apnea, hyperleukocytosis,
mortality. encephalopathy (GCS<14), need for vasoactive
support and mechanical ventilation predicted
Results: Subjects included 21(58.5%) boys and 15
mortality.
(41.7%) girls. The median (IQR) age was 3.5 (1.5,7)
months. Typical paroxysmal cough 31 (86.1%), Conclusions: There is a resurgence of pertussis.
apnea 15 (41.7%) and seizures 17 (47.2%) were Infants before starting or completion of their primary
presenting symptoms. Twenty-one (58.3%) children immunization schedule are at high risk for critical
were unimmunized for pertussis. Twenty-three were pertussis. Hyperleukocytosis, need for vasoactive
pertussis PCR positive. Respiratory failure (n=35, support and mechanical ventilation were predictors of
97.2%), and hyperleukocytosis (n= 22, 61.1%) were poor outcome.

DOI-10.21304/2018.0506.00463
Acute gut injury: prevalence and impact on outcome
in critically ill children.
Nitin Dhochak1, Rakesh Lodha1, Sushil K Kabra1, Jhuma Sankar1, Kana Ram Jat1, Rohan Malik1, Govind
Makharia2
1Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
2Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi
Objectives: Primary: To estimate prevalence of acute 32.5 (7.5-96) months; 32% of patients were male.
gut injury (AGI) in critically ill children during first Thirteen (42%) children died. Prevalence of AGI,
week. gut dysfunction (AGI≥2), and gut failure (AGI≥3)
Secondary: To estimate impact of AGI on mortality in was 64.5%, 41.9% and 22.6% respectively. Mortality
critically ill children. was significantly increased in patients with AGI, gut
dysfunction and gut failure (18% vs 82%, p = 0.047;
Material and Methods: Current study is a part of
22.5% vs 77.8%, p= 0.009 and 29.1% vs 70.9%, p=
larger prospective cohort study which includes all
0.008 respectively). Area under curve of receiver
children aged between 1 month to 18 years admitted
operating curve (AUC-ROC) for prediction of
to pediatric intensive care unit. Current study
mortality of worst AGI and worst PELOD-2 score in
analyzed children admitted during December 2017
first week were not significantly different (76.4 % and
to April 2018. Children with chronic gastrointestinal
81.3% respectively, p=0.67).
symptoms were excluded. European Society of
Intensive Care Medicine classification was used to Conclusion: Acute gut injury and gut dysfunction
classify for AGI into four categories. Clinical details are significant among critically ill children and
and outcome parameters were recorded. are associated with increased mortality. With new
objective AGI classification, gut dysfunction should
Results: Thirty-one children were included in the
be included as measure of organ dysfunction among
analysis. Median (IQR) age of the children was
pediatric organ dysfunction scores.
DOI-10.21304/2018.0506.00464
Diagnostic efficacy of nucleated red blood cell count in neonatal sepsis:
a prospective comparative study
Swathi S Sanjee, Aswathy Rajan, Santosh T Soans
Department of Pediatrics, A J institute of medical sciences, Mangalore
Objectives: Neonatal sepsis accounts for early-half red blood cells were analysed in all three groups with
of all neonatal deaths in India. Although the gold a cutoff value of 40cells/cumm.
standard for diagnosis is by blood culture, there is Results: 245 neonates were included in the study.
a need for a test that is cheap, accurate and easily The mean value of NRBC was 38.84, 26.45 and 5.06
performed with quick availability of reports. In in proven sepsis, probable sepsis and clinical sepsis
this study we have analysed the diagnostic value of group respectively. Nucleated RBCs had a sensitivity
nucleated red blood cells to correctly predict neonatal of 33.3%, Specificity of 95.6%, Positive predictive
sepsis. value of 75% and a negative predictive value of
Materials and Methods: A time bound, prospective 78.5% in detecting sepsis.
comparative study was done on neonates with Conclusion: NRBC is a simple and cost effective test
suspected neonatal sepsis for a 2 year period. Neonates in early diagnosis of neonatal sepsis. It will help the
were then analysed in three groups depending on clinicians in early diagnosis and treatment thereby
their blood culture and septic parameter results as no reducing the neonatal morbidity and mortality.
sepsis, probable sepsis and proven sepsis. Nucleated

DOI-10.21304/2018.0506.00465
A prospective observational study to compare the ratio of Pulse
oximetric saturation (Spo2)/Fraction of inspired oxygen (Fio2) {S/F
ratio} with the ratio of Partial pressure of oxygen(Pao2)/ Fio2 {P/F
ratio} among the critically ill children requiring respiratory support in
a Pediatric intensive care unit.
Dr.Pragathesh Palaniappan, Dr.Shajin.T, Dr.Jolly Chandran, Dr.Ebor Jacob James
Christian Medical College and Hospital, Vellore
Objectives: To compare and analyse the relationship Results: We obtained a total of 250 samples from
between Pao2/Fio2 (P/F) ratio and Spo2 /Fio2 (S/F) 125 participants. Among 125 children, 112 (89.5%)
ratio in critically ill children requiring respiratory required invasive ventilation, 5 (4%) required face
support. mask Non-invasive ventilation, 1 (0.8%) required
Materials and Methods: Our study was done nasopharyngeal CPAP and 7 (5.7%) required high
over a period of 7 months (February 2016-August flow nasal cannula therapy. In our study, 27 (21.6%)
2016) in the Paediatric Intensive care Unit (PICU), had ARDS. Our study showed, S/F ratio of less than
in a Tertiary care Hospital. All Children admitted 180 corresponds well with P/F ratio <200, with
in PICU, who require respiratory support (Non- sensitivity and specificity of 90% and 59% respectively
invasive/ Invasive) are recruited in the study. Children (AUROC-0.8). In other words, any child who require
with congenital heart disease, chronic lung disease, Fio2 of 50% or more to maintain a saturation of 90%
abnormal haemoglobin, etc., are excluded from the (S/F ratio<180) are likely to have ARDS (P/F <200).
study. Children for whom the definitive Fio2 delivery Conclusion: Our study showed a strong correlation
is not known (eg: face mask, Head box etc.) are also between S/F ratio and P/F ratio. S/F ratio (<180)
excluded. S/F ratio and P/F ratio was calculated twice helps in early identification of children at risk of
for each participant, once at the time of recruitment ARDS, especially in Paediatric Emergency and in
and again at the time of deterioration (requiring secondary level settings where arterial blood gas are
escalation in the respiratory support) or 24 hours after not available.
recruitment, whichever is the earliest.
DOI-10.21304/2018.0506.00466
Clinical profile and outcome of children with meningitis- a prospective
observational study in tertiary health care centre in Chennai
Jahnavi M, Sandip, Vimal Vijayakumar, Devaraj, S.Thangavelu, Nedunchelian K,
Department of Pediatrics, Mehta Children’s Hospital, Chennai
Objective: To study the clinical profile of children Institution from January 2017 to December 2018
admitted with meningitis were studied. The variables included were age, sex,
Design: Prospective observational study religion, residence, nutritional status, etiology of
meningitis, duration of hospital stay, requirement
Setting: Study was conducted in PICU of tertiary
of mechanical ventilation. The status of the child at
health care centre in Chennai
the time of presentation, presence of shock, bleeding
Participants: All children less than 18 years of age manifestations, raised intra cranial tension, was noted.
with a diagnosis of meningitis for a two years period The presence of sequelae and treatment and follow up
between 2017- 2018 were included in the study was also noted. The collected data were analyzed with
Methods: All children with suspected meningitis suitable statistical methods.
admitted in pediatric intensive care unit of the

Statistical analysis: Data was entered into Microsoft hospital stay was more than 2 weeks for 6 (46.1%)
excel data sheet and was analyzed using SPSS 22 children, out of whom 2 had tubercular meningitis.
version software. Categorical data was represented in Antibiotics were given for all of them while 8 (61.5%)
the form of Frequencies and proportions. Chi-square children were given steroids. 4 (30.7%) had features
test was used as test of significance for qualitative of raised Intra cranial tension, while none had features
data. Continuous data was represented as mean and of shock or bleeding manifestation or thrombosis.2
standard deviation .p value of <0.05 was considered (15.38%) children required mechanical ventilation.
as statistically significant. Out of the children,2 (15.38%) had sequelae in the
Results: A total of 4237 children were admitted in form of hydrocephalus,2 (15.38%) had subdural
the hospital out of which 13 meningitis cases in the abcess,1 (7.3%) facial nerve palsy and hydrocephalus
age group below eighteen years comprised the study and 1 (7.3%) had hemiparesis. CSF analysis was
population. 3 (23%) were infants, 4 (30.7%) were done for all of the children with meningitis, out of
between 1- 3 years of age, remaining 6 were more than whom CSF PCR showed hemophilus influenza b
3 years of age. Among the cases, 5 (38.4%) children for 3 (23.7%) children, Escherichia shigella for
were male and 8 (61.5%) were female. Among 1(7.3%) child, Pneumococcus species for 1(7.6%
them, majority were Hindu (75.42%) by religion and ) child candida for 1 (8.3%) child, enterovirus and
urban (58.11%) by residence. Majority were due to streptococcus bovis for 1 (8.3%) child each.
bacteria while 3 (23.07%) each were due to viral and Conclusion: Acute bacterial meningitis still remains
tubercular meningitis. Out of them 1 (8%) child was a major cause of mortality and morbidity in children.
undernourished who had tuberculous meningitis. Out Hemophilus influenza remains the main cause in
of the 13 children who were admitted, only 7 (53.88%) pediatric age group.
children were completely immunized. The duration of Key words: Meningitis
DOI-10.21304/2018.0506.00467
Urinary biomarkers as a predictor of outcome in pediatric sepsis
Arun Varghese1 , Lalitha AV , Mounika Reddy, John Micheal2, Anil Vasudevan3
1Paediatric Intensive Care Unit, Department of Paediatrics, 2Department of Biostatistics, 3Department of Paediatric
Nephrology, St. John’s National Academy of Health Sciences, Bangalore, India
Objectives: To determine the prognostic ability categorized into two groups: sepsis associated AKI
of urinary biomarkers in paediatric sepsis with or (SA-AKI) and sepsis without AKI (Sepsis non-AKI,
without AKI. SN-AKI) using AKIN criteria.
Methodology: A single-center pilot prospective Results: Total of 45 children were enrolled, of which
observational study was conducted in the 12-bedded 25 had AKI (SA-AKI) and 20 did not (SN-AKI).
multidisciplinary PICU of a tertiary referral and Among SA-AKI patients, 9 had Stage 1 AKI, while
teaching hospital in South India over a period of 18 rest had stage 3 AKI. Twenty patients with AKI
months. Children aged 1 month to 18 years admitted required mechanical ventilation and 16 required renal
to PICU with diagnosis of sepsis were considered for replacement therapy. PRISM III, PELOD and SOFA
inclusion. We excluded those with chronic kidney score at admission were similar among SA-AKI
disease, anuria or brain death at admission and and SN-AKI, however, PELOD and SOFA scores
hospital stay < 24 hours. Demographic and clinical on day 3 were significantly higher among SA-AKI
details, severity of illness, organ dysfunctions, details children (p<0.05). Median urinary concentrations
of PICU interventions and outcomes were recorded. of the 7 biomarkers tested were higher in SA-AKI
Urine samples were collected within 24 hours of group compared to SN-AKI group, but only KIM-1
admission to test for 7 biomarkers (α1 microglobulin, and IGFBP-7 were statistically significant (p=0.0003
FABP-1, MMP-8, NGAL, KIM-1, IGFBP-7, IL- and p=0.0024 respectively). KIM-1 ≥18.18 pg/ml had
18). All patients were followed up for 14 days and area under receiver operating characteristics curve

(AUC-ROC) of 0.85±0.07(CI0.70-0.95) with 83.3% (44% vs 5.4%, p=0.003), there was no significant
sensitivity and 88.8% specificity, while IGFBP-7 difference in length of PICU stay.
≥98pg/ml had AUC-ROC of 0.80±0.08(CI0.64-0.92) Conclusion: SA-AKI is associated with high
with 72.2% sensitivity and 83.3% specificity. None morbidity and mortality. Specific urinary biomarkers
of the biomarkers showed significant correlation with (KIM-1, IGFBP-7) were significantly elevated in the
AKI stage. In SA-AKI group, α1 microglobulin was sepsis patients who developed AKI compared to those
significantly higher in those who died compared to who did not. α1 microglobulin can predict survival in
those who survived (p=0.035). Overall mortality was SA-AKI.
more in SA-AKI group compared to SN-AKI group

Journal of Pediatric Critical Care
Contents
Vol.5 No.1 - JAN-FEB 2018
ORIGINAL ARTICLE
Clinical Profile and Outcome Of Dengue In Children Admitted In Pediatric Intensive Care Unit in
A Tertiary Center In South India
Ayyammal Palaniappan, Nithya Mani, Nedunchelian Krishnamoorthi
Predictors of Success of High Flow Nasal Cannula (HFNC) Therapy in Children with Respiratory Distress in
Pediatric Intensive care Unit
Lalitha A V, Anjankumar T K, Sumithra S
Hyperlactatemia in Critically Ill Children: The Clinical Value of Lactate for Predicting Mortality in the Pedi-
atric Intensive Care Unit
BijayKumar Meher, Devadarshini Sahoo, Deepti Damayanty Pradhan, Saroj Kumar Satpathy, Alok Satyaprakash
Nayak
CASE REPORTS
Hypohydrotic Ectodermal Dysplasia: A rare case series
Manisha Goyal, Ashok Gupta, Priyanshu Mathur, Manish Sharma
Letter to Editor
Critical Care Communication in a Busy Emergency – Are we really conveying our thoughts?
Emad uddin Siddiqui, Shahan Waheed, Walid Hussain Farooqi, Saif ul Islam Siddiqui, Zain ul Islam Siddiqui, Aga
Khan
Best Evidence
Journal Scan
Kundan Mittal, Anupama Mittal
Critical Thinking
PICU Quiz
Vinayak Patki
NCPIC 2017 ABSTRACTS

________________________________________________________________________________________________
Vol.5 No.2 - MAR-APR 2018
ORIGINAL ARTICLE
Quality care ambulance services: Rohtak in Haryana, an eye opener
Kundan Mittal, Poonam Mehta, Anupama Mittal, Anindya Mittal
SYMPOSIUM
Guest Editorial -Critical Care Nephrology - An Overview and Update
Vinayak Patki, Uma Ali
Redefining Acute Kidney Injury

Uma Ali, Nisha Krishnamurthy
Biomarkers: Acute Kidney Injury

Kundan Mittal, H K Aggarwal, Anupama Mittal
Septic Acute Kidney Injury (SAKI)
Vinayak Patki
A review of drug-induced renal injury

Paramanand Andankar, Krunal Shah, Vinayak Patki
Acute Kidney Injury with Thrombocytopenia

Lalitha AV, Suryanarayana G, Sumithra S
Contrast Induced Nephropathy in ICU settings

Raghavendra Vanaki
Cardiorenal and Hepatorenal syndrome

Anand Bhutada, Abhijit Choudhary, Atul Kapse, Vinayak Patki
Fluids in Acute Kidney Injury

Uma Ali
Principles of Renal Replacement Therapy in Critically ill children- Indian Perspective

Sidharth Kumar Sethi, Aliza Mittal, Rupesh Raina, Manindar Dhaliwal
Prevention of Acute Renal Injury and Drug Modification

Amita Kaul, Sachin Shah
CASE REPORTS
Human Bocavirus (HBoV) Infection: An associated Life Threatening Respiratory illness
Suryanarayana G, Sumithra S, Lalitha AV
Pediatric myxedema coma – presenting as surgical abdomen

Basavaraj GV, Vinayaka HS, Kiruthiga Sugumar
Spondylocostal Dysostosis with Severe ARDS and Review of Literature

Bal Mukund, Hari Prasath , Ashok K Yadav, Ashok Bhandari
BEST EVIDENCE
Journal Scan
Vinayak Patki
CRITICAL THINKING
PICU Quiz
Vinayak Patki
________________________________________________________________________________________________
Vol.5 No.3 - MAY-JUN 2018
ORIGINAL ARTICLES
Readmissions after Pediatric Cardiac Surgery
V.S.V.Prasad, S.Sreeveni ,Vinayak Patki.
Vitamin D Status in Critically ill children

Satapathy Jyoti R, Meher Bijay K, et. al.

Medical Errors: An Observational Study
Kundan Mittal.
SYMPOSIUM
Guest Editorial - Pediatric Transplant in India : Critical Care Perspective
Maninder Dhaliwal, Kundan Mittal.
Indications for Liver Transplant in Children

Mohit Kehar, Veena Raghunathan, Neelam Mohan.
Intensive Care Issues in Post-operative Pediatric Liver Transplantation

Veena Raghunathan, Maninder Dhaliwal, et. al.
Pediatric Hematopoietic stem cell transplantation

Dhwanee Thakkar, Neha Rastogi, Satya Prakash Yadav.
Critical Care Challenges and Considerations in Pediatric Hematopoietic Stem cell Transplantation Patients
Neha Rastogi, Dhwanee Thakkar, et. al.
Indications for Renal Transplantation in Children

Lalitha AV, Swathi Rao, Nivedita Kamath.
Post-operative Challenges in Pediatric Renal Transplant

Sumithra S, Lalitha AV, Priya Pais, Shubha AM.
Pediatric Cardiac Transplant in India

Vijay Agarwal, Nihal Bin Naseer.
Post-operative Management Of Pediatric Heart Transplantation

Balakrishnan KR, Suresh KG, Muralikrishna T, et. al.
Transport Of Critically Sick Children To Transplant Centres

Romit Saxena, Maninder Dhaliwal, et. al.
CASE REPORTS
An Interesting Case of Snake Bite with Necrotizing Fasciitis
Hardeep Kaur, Gaurav Mahajan.
Severe Congenital Factor X deficiency

Vigneshwaran TP, Mullai Baalaaji AR, et. al.
CLINICAL UPDATE
Non-invasive Positive Pressure Ventilation in children
Kundan Mittal , N Rungta , Vinayak Patki , H K Aggarwal.
POSTGRADUATE/FELLOW COLUMN
OSCE
Kundan Mittal, N Rungta, H K Aggarwal, Vinayak Patki.
CONFERENCE NEWS
India in Forefront of Pediatric Critical Care Research
Vinayak Patki

BEST EVIDENCE
Journal Scan
Kundan Mittal, N Rungta , Anupama Mittal, et. al.
CRITICAL THINKING
PICU Quiz (Pediatric Transplant)
Vinayak Patki.
BOOK REVIEW
Monitoring Tissue Perfusion in Shock
Kundan Mittal, Vinayak Patki.
________________________________________________________________________________________________
Vol.5 No.4 - JUL-AUG 2018
ORIGINAL ARTICLES
Predictive capability of End Tidal carbon dioxide and its correlation with arterial carbon dioxide in mechani-
cally ventilated children
Nikita Panigrahi, Maaz Ahmad, et. al.
A Study to compare digital technique and suction catheter guided technique for Insertion of Proseal Larynge-
al Mask Airway in Children
Teena Bansal, Somesh Sharma, et al.
SYMPOSIUM
Guest Editorial - Understanding Sepsis
Vinayak Patki, Kundan Mittal.
Sepsis Definitions - Changing Perspectives

Vinayak Patki.
Biomarkers in Sepsis
Amita Kaul, Sachin Shah.
Myocardial Dysfunction in Sepsis

Lokesh Tiwari, Jyoti Chaturvedi, et al.
CASE REPORTS
Arterial Tortuosity Syndrome in a Neonate
Indu Khosla, Tanushri Mukherjee.
Retropharyngeal abscess in Neonate - A misdiagnosed entity

Virender Kumar Gehlawat, Kundan Mittal, et al.
Triple “A” syndrome presenting as recurrent chronic sinusitis with Pneumonia, septic shock and meningoen-
cephalitis in a child
Ramaning Loni, Priyanka Agrawal, et. al.
CLINICAL UPDATE
Oxygen Therapy
Kundan Mittal, Amit Jain, et. al.

Anatomy of Thesis Protocol
Kundan Mittal, Sujata Sethi, et. al.
OSCE : Data Interpretation

Kundan Mittal, Prashant Kumar, et. al.
BEST EVIDENCE
Journal Scan - Sepsis
Vinayak Patki, Kundan Mittal, et. al.
CRITICAL THINKING
PICU Quiz - Sepsis
BOOK REVIEW
Point-of-care testing : Principles and Clinical Applications
Kundan Mittal, Rajesh Mishra, et. al.
________________________________________________________________________________________________
Vol.5 No.5 - SEP-OCT 2018
ORIGINAL ARTICLES
Clinical profile and the outcome of children admitted to a tertiary care hospital with non-traumatic coma
Diptirekha Satapathy, et al.
A study of morbidity pattern in PICU at tertiary care center

Shruti Jain, et al.
Clinical profile of hypernatremic dehydration in neonates with special emphasis to acute kidney injury
Maralihalli Mahesh, et al.
PRISM Score as predictor of mortality in PICU

Arjun Tandon, et al.
SPECIAL ARTICLE
Clinical Problem solving :How much oxygen is in the blood?PaO2, SaO2 and Oxygen Content
Lawrence Martin et al.
SYMPOSIUM
Guest Editorial : Sepsis Management – Battle Continues
Multiple Organ Dysfunction (MODS) in Sepsis

Basavaraja GV , et al.
Fluid Therapy and Hemodynamic Support in Septic Shock

Milind Jambagi, et al.
Vasopressors in Septic Shock

Vinay H Joshi, et al.

Source Control in Septic Shock
Raghavendra Vanaki, at al.
Bundle Approach in Sepsis Management - An Overview

Vinayak Patki, et al.
CASE REPORTS
Atypical Presentation of cystic fibrosis in an infant
Bandya Sahoo, et al.
SHORT COMMUNICATION
Feasibility of an e-Referral System for streamlining referrals to Pediatric Emergency Room of a tertiary care
teaching hospital in North India- A preliminary report
Muralidharan Jayashree, et al
CLINICAL UPDATE
Basic Ventilatory Setting and Monitoring
Kundan Mittal ,et al.
POSTGRADUATE/OSCE
Status Asthmatics
Kundan Mittal, et al.
BEST EVIDENCE
Journal Scan - Sepsis II
CRITICAL THINKING
PICU Quiz - Sepsis II
BOOK REVIEW
Core Concepts in Acute Kidney Injury
Kundan Mittal, at al.
________________________________________________________________________________________________
Vol.5 No.6 - NOV-DEC 2018
ORIGINAL ARTICLES
Cardiac Complications of Scrub Typhus With Special Reference to Electrocardiography - A Twelve Weeks
Follow Up In Two Tertiary Pediatric Hospital of Eastern India
Joydeep Das, Devyani De.
SYMPOSIUM
Guest Editorial - Prevention is better than cure
Kundan Mittal, Vivek Gupta.
Aseptic Technique In Intensive Care Unit

Vivek Gupta.
Clostridium Difficile : Epidemiology and Prevention

Antariksh deep, Kundan Mittal.

Ventilator Assosciated Pneumonia
Vivek Gupta.
REVIEW ARTICLE
Snake Bite -A review
Manish Kumar, Lokesh Tiwari.
CASE REPORTS
Idiopathic Acute Necrotizing Pancreatitis : A Case Report
Mahima Rajan, Kundan Mittal, Vandana Arya, Varinder Ghelawat
Reshmi Mishra, Bandya Sahoo, Mukesh Jain, Siba Patnaik, Palas Das.
CLINICAL UPDATE
Hypernatremia
Kundan Mittal, Lalitbhuasan Waghmare, Manish Sharma, Sachin Damake.
OSCE: Hypokalemia
Kundan Mittal, Lalit Waghmare, H K Aggarwal, Manish Munjal.
BEST EVIDENCE
Journal Scan
Kundan Mittal, Jayant Vagha, Lalitbhushan Waghmare, H K Aggarwal, Vivek Gupta, Vinayak Patki.
CRITICAL THINKING
PICU QUIZ - HAI
Vinayak Patki.
BOOK REVIEW
Critical Care Nephrology
Kundan Mittal, H K Aggarwal, Rajesh Mishra, Manish Munjal.
NCPCC- 2018
Scientific Paper Abstracts

Journal of
JOURNAL OF PEDIATRIC CRITICAL CARE

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Intensive Care Chapter

Indian Academy of Pediatrics

CONTENTS Clinical Update

Contact :- Dr. Dayanand Nakate

Vol. 5 - No.6 NOV-DEC 2018 1 (a) JOURNAL OF PEDIATRIC CRITICAL CARE

NCPCC- 2018 :Scientific Paper Abstracts 65

Vol. 5 - No.6 NOV-DEC 2018 1 (b) JOURNAL OF PEDIATRIC CRITICAL CARE

Executive Editor Associate Editors

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Dear Colleagues and readers,

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Ethics, Informed Consent And Patient Anonymity

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The Editorial Process

Article Proofs And Reprints:

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Conflicts Of Interest/ Competing Interests:

Copies Of Any Permission(S):

Clinical Trial Registry:

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Reporting Guidelines for Specific Study Designs:

Standard Journal Articles:

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Check List For Authors

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Publisher details : Journal of Pediatric Critical Care

Editor in Chief Managing Editor

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3 + 128 + RA,RV Sev Sev 48% Mod

4 ++ 112 + Four Mod. Mod 25% Mod

6 ++ 117 + ,, Sev. Mod. 30% Mild

7 ++ 124 Not Not possible ,, Sev. Sev. 30% Mild

9 ++ 122 + ,, Mod Sev. 25% Mod

10 ++ 100 + Not possible ,, Sev. Sev. 25% Mod

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Table 3 : ECG profile in individual cases at day 3 before doxycycline

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the pediatric CDI has been associated with increased Diagnosis:

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Ventilator associated pneumonia (VAP), develops development.8 Development of antibiotic resistance

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Kundan Mittal, H K Aggarwal, Rajesh Mishra, Manish Munjal****