IC/01(P) VASOPRESSIN IN SEPTIC SHOCK: ARE WE USING IT TOO LATE
Singhal D, Mehra S, Uttam R, Bakshi A
Indraprastha Apollo Hospital, New Delhi
Introduction: Refractory septic shock is associated with a high mortality in critically ill children. Recently vasopressin has emerged as a treatment modality for catecholamine refractory septic shock. There is limited pediatric data on its use. Aims & Objectives: To study the use of vasopressin in catecholamine refractory septic shock. Methods: The study was carried out over a period of 1 year from August 2006- August 2007. All children admitted to pediatric ICU in this time period with septic shock and hypotension refractory to infusion of high doses of 2 catecholamines (Dopamine along with adrenaline or nor adrenaline), were included. They were started on a vasopressin infusion (0.0001U/kg/min- 0.001 U/ kg/min) and monitored for hemodynamic effects. The primary outcome measures were restoration of blood pressure and survival at discharge. Results: Seven patients were treated with vasopressin in the age group ranging from 2yr- 7yr. The cause of sepsis was staphylococcus aureus in 1 patient, gram-negative organisms in 3 patients and unknown in the rest. There was no significant improvement either in the mean arterial blood pressure or in the requirement of other catecholamine infusions in 5 patients. Six out of the 7 patients succumbed to their illness. The cause of death was multiorgan failure in 5 patients and refractory septic shock in one. Vasopressin infusion allowed tapering of noradrenaline infusion in 2 patients with restoration of mean arterial blood pressure to normal values, only one of whom was discharged. Conclusion: In our experience, vasopressin did not significantly change the outcome of patients with catecholamine refractory septic shock. Larger prospective clinical trials are warranted to assess its efficacy and the timing of its introduction as a vasopressor in septic shock management.
IC/02(P) ASSESSMENT OF EFFICACY OF NON-INVASIVE VENTILATION IN CHILDREN
Shastri Vikalp, Mehra Shravan, Bakshi Anita,Uttam Rajeev
Indraprastha Apollo Hospital New Delhi
INTRODUCTION: Non-Invasive Ventilation (NIV) has experienced resurgence during the last two decades. However, data on NIV as an option in the pediatric population is limited. OBJECTIVE: To assess the use of NIV in children. MATERIAL AND METHOD: Data was collected on patients receiving NIV over a 18 month period. Data obtained included indications, details of diagnosis, duration of ventilation, co –morbidities, duration of NIV and complications. RESULT: A total of 14 children with the median age of 8 years (range 1 month to 18 years) were treated using BiPAP in the spontaneous mode via standard mask. Initially the BIPAP was set at 6 cm H2O, EPAP at 3 cm H2O to maintain O2 saturation above 90%. The levels were titrated until the child was comfortable with adequate chest expansion and satisfactory blood gases. Our patients belong to two groups, one in which BiPAP was used as primary ventilation and another where BiPAP was used as a weaning mode. In the first group, primary treatment with NIV using BiPAP resulted in avoidance of intubation in all 5 children. Reduction in FiO2, respiratory distress and respiratory and heart rate were also noticed. In 9 patients NIV was used post extubation to reduce the work of breathing. It was well tolerated and reintubation was avoided. . Median duration of NIV was 3.85 days and no adverse effects were noted. Two of our patients were oncology patients, a relapsed ALL with neutropenic sepsis and a stage IVs neuroblastoma with pneumonia. Averting intubation considerably reduced the morbidity in these children. CONCLUSION: NIV can offer effective ventilatory support and may decrease the risk of life threatening complications associated with invasive mechanical ventilation.
IC/03(O) INTERNATIONAL COLLABORATION VALIDATING SICK SCORE: A NON-INVASIVE SEVERITY-OF-ILLNESS ASSESSMENT.
Manoj Anand Gupta, Anjan Chakrabarty, Ruth Halstead, Mohit Sahni, Jayanti Rangasami, Ashish Puliyel, V. Sreenivas, David Anthony Green, Jacob Mammen Puliyel,
Department of Pediatrics, St Stephens Hospital, Tis Hazari, Delhi 110054
Objective:“Signs of Inflammation in Children that can Kill” (SICK) score is a new severity-of-illness score, using only physical criteria that are measurable on presentation without recourse to laboratory results. The development of the score used multiple logistic regression model coefficients converted to integer scores that have been published earlier. The aim of the present study was to validate the scoring system by predicting outcomes in a fresh data set.Patient and Methods: We prospectively evaluated all children under 12 years who were referred to the Paediatric team by the Emergency Department team at St Stephens Hospital in Delhi and all Paediatric admissions at West Middlesex University Hospital in London over one year, calculated SICK scores and correlated them with in-hospital mortality. We used discrimination by areas under the receiver operating characteristic (ROC) curves to measure performance.Results: We prospectively evaluated 3895 children at St Stephens Hospital and 1473 children at West Middlesex University Hospital. The probability of death was higher in India for a given SICK score but the scoring system was uniformly good in both centres. The areas under the ROC were 84.8% in India and 81.0% in UK with 84.1% for combined data. Conclusions: We found that the SICK score accurately predicted mortality. Its performance as measured by areas under ROC was consistent with that in the development cohort (area under ROC 89%) and a previous smaller validation study (area under ROC 76%). SICK score can be calculated immediately on admission and can help to prioritize care for children who need urgent aggressive management.
IC/04(P) DENGUE HEMORRHAGIC SHOCK SYNDROME WITH HEPATITIS IN AN INFANT.
Manisha Mukhija, Shobha Sharma
Lilavati Hospital and Research Centre, Bandra, Mumbai
Introduction: Dengue haemorrhagic fever and dengue shock syndrome are well known entities. However in infants less than 6 months age it is extremely rare and often not thought of in an infant presenting with shock and deranged bleeding profile. A 2 ½ month male child presented with history of fever since 5 days with lethargy, poor feeding and listlessness since a day. On examination he was found to have cold clammy extremities, delayed capillary refill, an enlarged liver, ascites and few petechiae over the legs. This was the first febrile episode in the patient, who had an eventful birth history and was on exclusive breast feeds.On investigations, he showed an initial rise in hematocrit followed by a drop and persistently falling platelet count (from 2.8 lac/cumm to 28000/cumm on day 3).He also had evidence of hepatic involvement with raised liver enzymes and hyperbilirubinemia-mixed type. Malarial parasites were not detected and blood culture did not isolate any organisms. CRP was mildly elevated (16.8 mg/l) and CSF examination was normal. Bleeding profile was grossly deranged with an elevated PT and PTT and increased D-dimers. Paired sera for Dengue IgM & IgG showed a fourfold rise in titres and maternal IgG was also positive, thus confirming secondary dengue infection in patient because of transplacentally acquired maternal enhancing antibodies.Patient received after supportive treatment with fluids, inotropes, plasma, cryoprecipitate and Vit K.
IC/05(O) VALIDATION OF PAEDIATRIC INDEX OF MORTALITY SCORE 2(PIM2) FOR PREDICTION OF MORTALITY IN A PAEDIATRIC INTENSIVE CARE UNIT IN A TERTIARY CARE HOSPITAL IN S.INDIA.
Muthulakshmi , Kala Ebenezer
Department of Child Health, Christian Medical College, Vellore.
Objective. To assess the performance of Pediatric Index of Mortality Score 2 (PIM 2) for prediction of mortality in a Paediatric intensive care Unit (PICU) in a Tertiary care hospital in S.India. Study Design:- Prospective collection of data of consecutive admissions from 1st Feruaury 2007 to 31st May 2007. Methods: The inclusion criteria and the PIM calculations were performed as set out in the original article and using the formula as published. Statistical analysis for model evaluation was done using standardised mortality rate (SMR), Hosmer –lemeshow goodness –of- fit test and ROC ( receiver operating characteristics) curve test. Setting. A eleven –bedded PICU in Christian medical college hospital in S.India. Main outcome measures: PIM 2 Score expected mortality compared with observed mortality. Results. A total of 300 children were admitted to the paediatric intensive care unit during the study period of four months The median age was 12 months, with an interquartile range of 3 months to 60 months. The male to female ratio was 173:127 (1.4:1). The median length of hospital stay was 2 days( IQ 1- 3 days). The overall predicted number of deaths using the Pediatric Index of Mortality 2 Score was 90.6. The observed mortality was 79. The standardized mortality ratio was 0.87 (95% CI 0.81 – 0.94).Hosmer –lemeshow test gave a chi square of 48.71(p < 0.001) for PIM 2 score. The area under the receiver operating characteristics (ROC) curve was 0.751 with 95% confidence interval of (0.687 -0.816). Conclusion: Our observed mortality was less than the predicted mortality. PIM 2 score had good discriminatory capacity for survivors and moribund patients. It is a tool with comparable performance for prognostic evaluation of paediatric intensive care patients.
IC/06(P) A SIMPLE CIRCUIT TO DELIVER BUBBLING CPAP.
Charanjit Kaur, Akatoli Sema, Rajbir S Beri, Jacob M Puliyel.
Department of Paediatrics, St Stephens Hospital, Tis Hazari, Delhi 110054.
BACKGROUND : Use of nasopharyngeal CPAP especially bubbling CPAP is known to reduce need for invasive ventilation by transmitting mechanical vibrations to the chest secondary to non uniform flow of gas bubbles across the downstream of a waterseal. The chest vibrations produced contribute to gas exchange by facilitated diffusion. OBJECTIVE : We describe a circuit that can deliver bubbling CPAP that is safe to be used by nurses, easy to assemble and easily adaptable in any healthcare facility where oxygen and compressed air are available. SETTING : Tertiary care neonatal unit in North India. MATERIALS AND METHODS : Pressurised oxygen from oxygen cylinder is delivered to nasopharynx of the baby via an underwater T-tube which acts as a blow off valve. Adjusting the height of water column above the lower end of T-tube can vary the amount of CPAP delivered to the baby. Oxygen can be delivered to the baby by inserting an 8F suction catheter ( cheaper alternative to nasal prongs ) into the nasopharynx to a depth equal to the distance between the tragus and ala nasi. Since 100% oxygen is harmful to premature babies, this system can be modified by using a Y-tube to deliver a mixture of air and oxygen from two separate cylinders. RESULTS : Keeping a total flow rate of 8 litres/min, by varying the flow rates of air and oxygen as measured by flowmeter, oxygen concentrations from 21 to 100% can be delivered to the baby. The use of a humidifier to provide moist air at body temperature decreases the oxygen concentrations from 1 to 5% as tested in our unit. CONCLUSIONS : Using this model of bubble CPAP is safe, economical and decreases ventilatory requirements in babies with respiratory distress prior to ventilation and for weaning from ventilation and provides oxygen concentrations from 21 to 100%.
IC/07(O) ROLE OF GLASGOW COMA SCALE IN PEDIATRIC NON TRAUMATIC COMA
Balaji M.D, M.B.Koujalagi, M.L.Kulkarni
Department of pediatrics, J.J.M.Medical college,Davangere
Background: Acute non-traumatic coma is a common problem in pediatric population accounting for 10 – 15% of all hospital admissions and is associated with significant mortality.Assessment of the severity of coma is essential to comment on the likelihood of survival. Objectives: To assess the relationship between Modified Glasgow Coma Scale,its components, brainstem reflexes and predicting the immediate outcome in children with acute non-traumatic coma. Methodology: It is a prospective observational study conducted at PICU of tertiary care hospitals,wherein consecutive 100 children between 5 months- 15years admitted with acute non-traumatic coma formed the study group.MGCS and brainstem reflexes were assessed and the lowest score of the MGCS and worst brainstem reflexes were used for analyzing outcome. Results: The likelihood of death in patients with MGCS score <8 was much higher than when MGCS score was ³ 8(odds ratio 21.4%,p < 0.001).Among the individual components of MGCS, lower ocular response scores (p < 0.001) and motor response scores (p < 0.001) were better predictors of death than the verbal response scores (p, 0.01).Absence of one or more brainstem reflexes was associated with adverse outcome and death (p <0.001).There was statistically significant correlation between MGCS and brainstem reflexes in predicting the immediate outcome.Conclusion: Ocular, motor response scores and brainstem reflexes were more predictive of the short term outcome than the total MGCS scores. A score incorporating ocular response, motor response and brainstem reflexes should be evaluated to assess the outcome in non-traumatic coma in the pediatric population.
IC/08(P) HOME BIPAP ON TRACHEOSTOMY
Anita Bakshi , Shravan Mehra , Deepika Singhal, Rajiv Uttam, Arvind Sindwani
Senior Consultant Pediatric Intensivist , Room no 1107 , 1st floor OPD, IP Apollo Hospital, Sarita Vihar, New Delhi
Background: BIPAP has been used in pediatrics in diseased in which minimal respiratory support is required over a prolonged period .The best known are children with sleep disordered breathing (OSAS) .There are studies of BIPAPuse in children with cystic fibrosis awaiting lung transplantation. Report : We report a series of cases of home BIPAP in children with CLD .The patients were considered for home BiPAP in view of the chronicity of their diseases and the financial constraints of treatment .One patient is a seven year old girl who was first admitted at age 3 years for evaluation of bony deformities and short stature She was diagnosed as congenital hypophosphatasia . She has significant restrictive impairment of the bony lung cage and had repeated chest infections. At age 5 years she had acute respiratory failure and needed mechanical ventilation .Post extubation she was oxygen dependent for several months. In a few weeks she was readmitted in respiratory failure . In view of her diagnosis she was tracheostomised after 2 weeks of ventilation . She was put on BIPAP via tracheotomy and discharged on the same In follow up she weaned to night BIPAP and finally off over the next six months. She is doing well and presently has no oxygen requirement. The other two patients are on follow up .One is an 8 year old girl with CP and chest deformities and the third and youngest is a 3 year male with CCHS .We have recently discharged them on home BiPAP and they are doing well. Conclusion : Children with need for long ventilatory support maybe good candidates for home BIPAP .