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The objective of study was to find an association between the timing of tracheostomy with duration of mechanical ventilation (MV) and length of stay (LOS) in pediatric intensive care unit (PICU) and hospital.The data were collected prospectively from 2000 to 2018 and were analyzed retrospectively. Data included clinical diagnosis, indication, and duration (days) of MV, LOS in PICU and hospital before and after tracheostomy. Patients who did not receive MV or underwent MV for24 h were excluded. According to the indication of tracheostomy enrolled patients were divided into four groups-airways anomalies (AA), central neurological impairment (CNI), cardiopulmonary insufficiency (CPI), and neuromuscular disorders (NMD). Patients in each group were divided into early (ET) and late tracheostomy (LT) category based on the median (interquartile range interquartile range [IQR]) days of pretracheostomy MV.Two hundred and fifty six patients were analyzed. The frequency and median [IQR] days of pretracheostomy MV were -AA 54 [7(3,16)], CNI 120 [12(9,16)], CPI 51 [25(16.5,30.5)], and NMD 31[12(8,16.5)]. In AA patients, median (IQR) durations of posttracheostomy MV [2(1,5.2) versus 3.5(2,12); p = 0.032], PICU [7(5,8.2) versus11(7,18); p = 0.004] and hospital [12(9.7,21) versus 21.5(12,28); p = 0.027] stays were lower in ET as compared with LT group. Posttracheostomy MV duration was significantly short in ET patients with CNI and NMD (p 0.005). The total days of MV, PICU and hospital stay were significantly lower in ET as compared with LT patients in all four groups (p 0.01).As compared with LT, ET patient had shorter durations of total MV and PICU and hospital stay.

Objective The aim of the study was to identify early predictors of mortality in children with severe dengue fever admitted to pediatric intensive care unit (PICU). Materials and methods All consecutive children with laboratory-confirmed severe dengue fever were enrolled in this prospective observational study. Besides demographic data, disease severity and organ dysfunction scores, laboratory investigations and interventions are done in PICU were recorded and analyzed. Results During the study period of 42 months, 172 patients with dengue fever were admitted to PICU. A total of 78 (45.3%) patients with severe dengue fever were included and analyzed. There were 20 (25.6%) deaths. There were significant differences in disease severity and organ dysfunction scores, transaminases, blood lactate level and serum creatinine between survivors and nonsurvivors. A significantly higher number of nonsurvivors required interventions in first 24 hours of admission. Platelet counts (P value 0.22) and hematocrit (P value 0.47) were not statistically different in 2 groups. There was a significantly high vasopressor-inotrope score (VIS) ( 10% (0.002) in nonsurvivors. Multivariate stepwise logistic regression analysis identified serum glutamic pyruvic transaminases (≥ 284 IU/L; odds ratio [OR] 1.002, 95% confidence interval [CI]: 1.001-1.003), blood lactate level (≥2.73 mmol/L; OR 2.08, 95% CI: 1.354-3.202), Pediatric Risk of Mortality score at 12 hours (≥14.5; OR 1.35, 95% CI: 1.077-1.693), VIS (≥22.5, OR 1.129, 95% CI: 1.059-1.204) and positive fluid balance >10% (OR 22.937, 95% CI: 2.393-219.84) at 24 hours of admission as independent predictors of mortality. Conclusion Disease severity, hyperlactatemia at admission, need for multiple vasoactive drugs and positive fluid balance are predictors of mortality in severe dengue infection in children admitted to PICU.

Background Consensus Guidelines for Pediatric Intensive Care Units (PICUs) were published in Indian Pediatrics in 2002. Objective The current document represents a recent update in the Indian context, regarding unit design, equipment, organization, staffing as well as admission and discharge criteria for different levels of Pediatric Intensive Care and teaching units with PICU training programs, as well as nonteaching units. Process The Pediatric Intensive Care College Council (PICC), an academic wing of the Indian Academy of Pediatrics (IAP) Intensive Care Chapter took the initiative to update the guidelines with members of the PICU guidelines Committee writing group. After a great deal of discussion at conferences and through mailing and feedback with listed members, as well as with the guidance and feedback of senior PICU guidelines advisory committee members, The consensus is now updated. These guidelines are intended to serve as a reference for health Care institutions wishing to establish a new PICU or to modify an existing PICU. As a resource, experience of those members who have worked extensively in western PICUs was also taken into consideration, in addition to published guidelines in the medical literature. PICUs with teaching programs run by the IAP Intensive Care Chapter must follow these criteria for unit accreditation and teaching curricula as applicable. Recommendations Unit design, equipment, organization, staffing as well as admission and discharge criteria for different levels of pediatric intensive care are updated.

To study the utility, safety, and effects of flexible fiberoptic bronchoscopy (FFB) on oxygenation status, ventilation parameters, and hemodynamics in mechanically ventilated children.Retrospective study.Children aged1 month to 18 years suffering from critical medical and surgical diseases.First bronchoscopy data of 131 patients were analyzed. Indication, FFB findings, the microbiological yield from bronchoalveolar lavage, and medical and surgical interventions based on FFB results were recorded. Hemodynamic and ventilation parameters before, during, and 3 h after FFB were also captured. The majority of bronchoscopies were done for diagnostic purposes with a positivity rate of 90.8%. Retained mucopurulent secretion in the airways was the commonest finding in 60 patients. A cause for weaning or extubation failure could be identified in 83.3%. Post-FFB radiological resolution of atelectasis was seen in 34/59 (57.6%; p-value: 0.001) chest radiographs. Forty-seven medical and 25 surgical interventions were done depending on FFB and BAL findings. There was a significant drop in oxygenation parameters and a rise in heart rate during FFB (p-value: 0.0001). The peak inspiratory pressure, positive end-expiratory pressure, and mean airway pressure increased significantly during bronchoscopy (p value: .0001) while patients were on pressure-regulated volume-controlled ventilation. All these changes reversed to pre-FFB levels. There were minor procedure-related complications.FFB was an important diagnostic and therapeutic tool for mechanically ventilated children and the results helped plan interventions. It was a safe procedure with transient reversible cardiopulmonary alterations.

Dengue viruses (DENVs) are the viruses responsible for dengue infection which affects lungs, liver, heart and also other organs of individuals. DENVs consist of the group of four serotypically diverse dengue viruses transmitted in tropical and sub-tropical countries of world. Aedes mosquito is the principal vector which spread the infection from infected person to healthy humans. DENVs can cause different syndromes depending on serotype of virus which range from undifferentiated mild fever to dengue hemorrhagic fever resulting in vascular leakage due to release of cytokine and Dengue shock syndrome with fluid loss and hypotensive shock, or other severe manifestations such as bleeding and organ failure. Increase in dengue cases in pediatric population is a major concern. Transmission of dengue depends on various factors like temperature, rainfall, and distribution of Aedes aegypti mosquitoes. The present review describes a comprehensive overview of dengue, pathophysiology, diagnosis, treatment with an emphasis on potential of exosomes as biomarkers for early prediction of dengue in pediatrics.

Childhood allergies pose huge economic burden and adverse effects on quality of life. Serum IgE has been considered a surrogate allergy marker for decades. Availability of several over-the-counter allergy tests add to confusion of partially trained caregivers. The present review focuses on current status of allergy testing in Indian scenario. Various in-vitro and in-vivo diagnostic modalities are available for allergy detection. Skin prick tests are useful for aero-allergies whereas oral challenge tests are best for identifying suspected food allergies. An allergy test should be individualized based on clinical features, diagnostic efficacy, and cost-benefit analysis.

There is a paucity of studies on the correlation between chest radiograph and ultrasound (US) in children. Our objective was to study the correlation between bedside chest radiograph and ultrasound findings in 413 children with 1002 episodes of chest radiograph and US enrolled for a prospective, double-blinded observational study in a multidisciplinary paediatric intensive care unit. Weighted κ statistic for agreement was different for right and left lungs and varied from 50% for left pleural effusion to 98% for right pneumothorax. Pulmonary oedema, pneumothorax and pleural effusion were diagnosed by ultrasound alone in a significantly higher number of patients as compared to chest radiograph (P = 0.001). Chest ultrasound is therefore deemed more sensitive than chest radiograph in detection of pleural effusion, pulmonary oedema and pneumothorax.

BACKGROUND: Limited adult data suggest that airway driving pressure might better reflect the potential risk for lung injury than tidal volume based on ideal body weight, and the parameter correlates with mortality in ARDS. There is a lack of data about the effect of driving pressure on mortality in pediatric ARDS. This study aimed to evaluate the effect of driving pressure on morbidity and mortality of children with acute hypoxemic respiratory failure. METHODS: This retrospective cohort study was performed in a tertiary level pediatric ICU. Children who received invasive mechanical ventilation for acute hypoxemic respiratory failure (defined as [Formula: see text] < 300 within 24 h after intubation), in a 2-y period were included. The cohort was divided into 2 groups based on the highest dynamic driving pressure (ΔP, calculated as the difference between peak inspiratory pressure and PEEP) in the first 24 h, with a cutoff value of 15 cm H(2)O. RESULTS: Of the 380 children who were mechanically ventilated during the study period, 101 children who met eligibility criteria were enrolled. Common diagnoses were pneumonia (n = 51), severe sepsis (n = 24), severe dengue (n = 10), and aspiration pneumonia (n = 7). In comparison to the group with high ΔP (ie, ≥ 15 cm H(2)O), children in the group with low ΔP (ie, < 15 cm H(2)O) had significantly lower median (interquartile range) duration of ventilation (5 [4–6] d vs 8 [6–11] d, P < .001], ICU length of stay (6 [5–8] d vs 12 [8–15] d, P < .001], and more ventilator-free days at day 28 (23 [20–24] vs 17 [0–22] d, P < .001). Logistic regression analysis also suggested driving pressure as an independent predictor of morbidity after adjusting for confounding variables. However, there was no statistically significant difference in mortality between the 2 groups (17% in low ΔP vs 24% in high ΔP, P = .38). Subgroup analysis of 65 subjects who fulfilled ARDS criteria yielded similar results with respect to mortality and morbidity. CONCLUSIONS: Below a threshold of 15 cm H(2)O, ΔP was associated with significantly decreased morbidity in children with acute hypoxemic respiratory failure.

OBJECTIVE To study the safety profile of blind bronchial sampling in mechanically ventilated children. DESIGN Prospective interventional study. SETTING Tertiary level pediatric intensive care unit of a multispecialty hospital. PATIENTS Children aged 1 month to 16 years on mechanical ventilator for ≥48 h, were assessed by clinical pulmonary infection score for ventilator-associated pneumonia (VAP). INTERVENTIONS Blind bronchial sampling was performed following standard procedural guidelines. The hemodynamic, ventilation parameters, and arterial blood gases done before, and in next 24 h post procedure were recorded and compared. MEASUREMENTS AND MAIN RESULTS Among the 40 enrolled children, VAP was suspected at 5.8 ± 3.7 days post intubation with insignificant increase in median (IQR) PELOD score to 15 (11-23) from 13.5 (11-23) (P value 0.29). A statistically significant increase in mean blood pressure (75.5 ± 14.7 to 79.1 ± 14.2, P 0.04) and transient drop in SpO2 (98.2 ± 2.3 to 92.2 ± 9.2, P

Flexible fiberoptic bronchoscopy a vital diagnostic and therapeutic procedure for assessing the airway. Its logistics, clinical indications and utility need to be elucidated in pediatric context. Pediatric flexible fibreoptic bronchoscopy is useful for diagnosis of airway anomalies, bronchoalveolar lavage for diagnostic and therapeutic purposes, and interventions like foreign body removal. Newer ultra-thin bronchoscopes can be used to perform this procedure in children of all ages. Pediatric flexible bronchoscopy is a valuable diagnostic and therapeutic tool in the hands of skilled personnel when used judiciously.

To describe the utility of flexible fiberoptic bronchoscopy for the diagnosis and management in the neonatal ICU.A retrospective, medical chart review was conducted in neonates who underwent flexible fiberoptic bronchoscopy over a period of 7 years. Besides demographic data and diagnostic findings, the results of medical and/or surgical interventions done by treating neonatologist were recorded.88 bronchoscopies were performed in 83 neonates, of which 37 were done through endotracheal tube. Indications included persistent need for mechanical ventilation (32), persistent atelectasis (21), and stridor (27). Most common airway anomalies diagnosed included tracheobronchomalacia (20), laryngomalacia (18), subglottic stenosis (7), choanal atresia (4), laryngeal cleft (4), and tracheoesophageal fistula (4). Surgical interventions were undertaken in 17 cases (9 tracheostomies and 2 cases of slide tracheoplasty).Flexible fiberoptic bronchoscopy can be beneficial for the diagnosis and management of neonates with persistent or undiagnosed respiratory problems.

Listeria monocytogenes is a gram-positive, facultative anaerobic, motile bacillus widely spread in the environment. However, clinical infection in humans is uncommon. The route of infection is often through ingestion of raw vegetables, meat and unpasteurised dairy products. Listeria is an uncommon cause of meningitis in immunocompetent individuals, but it should be considered strongly in neonates and the elderly, and it should also be considered in those with impaired cell-mediated immunity. 1 , 2 Only a few case reports of invasive listeriosis in humans have been reported from India. 3 – 8 In our case, a 13-year-old previously healthy boy was thus diagnosed.

Elevated soluble interleukin-2 receptor (sIL2R) is a diagnostic criterion for haemophagocytic lymphohistiocytosis (HLH). International guidelines propose a 2400 U/ml cut-off or individual laboratory-defined cut-off. However, sIL2R normal values are so far not known in Indians. So, this study was undertaken to measure sIL2R in healthy children and adults to establish age-related reference values.Healthy controls and cases (participants with persistent fever, organomegaly, cytopenias and biochemical markers of HLH) were prospectively enrolled. Serum sIL2R was measured by double-sandwich enzyme immunoassay in a standardization batch to determine the optimum cut-off value using receiver operator characteristic curve and was subsequently validated.One hundred and forty six age- and sex-matched children (80 controls and 66 suspected HLH cases) and 55 adults (49 controls and 6 suspected HLH cases) were prospectively enrolled. The optimal sIL2R cut-off ≥23 ng/ml was defined as raised sIL2R in the standardization batch. No controls had sIL2R ≥23 ng/ml in the validation batch. In healthy controls, median sIL2R (interquartile range) decreased with increasing age from 9.0 ng/ml (6.6-13.4) below five years of age to 3.2 ng/ml (2.8-5.1) in adults. Proposed upper limit of normal value for sIL2R is 17.4 ng/ml in less than five year, 12.2 ng/ml in 5-9 yr, 6.7 ng/ml in 10-17 yr and 5.2 ng/ml in ≥18 yr. sIL2R accuracy to diagnose HLH marginally improved with age-appropriate cut-off.Paediatric controls in India showed higher sIL2R levels than most studies conducted in other countries, except for some reports in Chinese and Russian populations. Age-appropriate reference values of sIL2R in a specific population may be considered to determine elevated sIL2R as a marker of HLH.

To study the association between red cell distribution width (RDW) and mortality in critically-ill children admitted in a Pediatric intensive care unit (PICU).101 participants were recruited consecutively over 3 months. Data collected included demographics, vital parameters, laboratory values, severity and organ failure scores, RDW for the first 5 days of admission, duration of PICU stay and survival outcome.11 patients died during study period. High RDW at admission (RDW D1) correlated significantly with mortality (P=0.007). The odds of death increased by 15 to 23 times with rise in RDW D1 from 18% to21%. The optimal RDW D1 cut-off value for mortality was 18.6%, which yielded sensitivity 90.9%, specificity 70.8%, positive predictive value 27.8%, negative predictive value 98.4%, and area under curve (AUC) 0.83 (95%CI 0.737, 0.925). 29 out of 60 (48.3%) patients with RDW D418% had PICU stay of ≥7 days.High (≥18.6%) RDW at admission and its persistent high levels are associated with high mortality and prolonged stay in PICU, respectively.

Fructose-1, 6-bisphosphatase deficiency is an autosomal recessive disorder of gluconeogenesis caused by genetic defect in the FBP1 gene. It is characterized by episodic, often life-threatening metabolic acidosis, liver dysfunction, and hyperlactatemia. Without a high index of suspicion, it may remain undiagnosed with devastating consequences. Accurate diagnosis can be achieved either by enzyme assay or gene studies. Enzyme assay requires a liver biopsy and is tedious, invasive, expensive, and not easily available. Therefore, genetic testing is the most appropriate method to confirm the diagnosis. Molecular studies were performed on 18 suspected cases presenting with episodic symptoms. Seven different pathogenic variants were identified. Two common variants were noted in two subpopulations from the Indian subcontinent; p.Glu281Lys (E281K) occurred most frequently (in 10 patients) followed by p.Arg158Trp (R158W, in 4 patients). Molecular analysis confirmed the diagnosis and helped in managing these patients by providing appropriate genetic counseling. In conclusion, genetic studies identified two common variants in the Indian subcontinent, thus simplifying the diagnostic algorithm in this treatable disorder.

This study was aimed to evaluate the utility and benefits of flexible fiberoptic bronchoscopy (FFB) prior to tracheostomy decannulation. Besides demographic data, initial cause of tracheostomy, primary diagnosis, pre-tracheostomy and pre-decannulation bronchoscopic findings and duration of tracheostomy were collected from medical charts. The type of active intervention following bronchoscopy and outcome after decannulation were recorded. Departmental decannulation policy and procedure were used in all patients. Forty-nine tracheostomized patients who underwent decannulation attempt were included. The median age of the children at the time of decannulation was 3 years (range 4 months–16 years). The median duration of tracheostomy was 8 months (range 1–86 months). Prolonged mechanical ventilation was the commonest indication for tracheostomy. There were 45 abnormal findings on FFB in 36 patients. Airway granulation was the commonest abnormality (23/45, 51%). Successful decannulation without any intervention was possible in 23 (46.9%) cases. 12 of these had normal bronchoscopy. Fifteen (30.6%) patients required surgical interventions before attempting decannulation. In five patients decannulation failed, while in six children decannulation was not attempted after FFB. Pre-decannulation flexible fiberoptic bronchoscopy in children with tracheostomy helps in identifying the possible causes of decannulation failure and helps in deciding the appropriate intervention.

Objective: Scanty literature is available regarding continuous renal replacement therapy (CRRT) utility in severe sepsis with multiorgan dysfunction syndrome (MODS) from developing countries. Author unit's experience in pediatric CRRT is described and outcome of early initiation of CRRT with sepsis and MODS is assessed. Materials and Methods: Children aged

Immunodeficient children are more prone for invasive cryptococcal infections. A 2-year-old boy with disseminated cryptococcosis was evaluated for underlying immunodeficiency without success. Child was managed successfully. Immunocompetent children with disseminated cryptococcosis can present diagnostic or therapeutic challenge in resource-limited settings.

There is a need to validate and suggest easy clinical method for diagnosis of ventilator-associated pneumonia (VAP) in developing countries.To validate the use of simplified Clinical Pulmonary Infection Score (CPIS) for the diagnosis of VAP.Prospective study.Pediatric intensive care unit of a tertiary care teaching hospital.30 children receiving mechanical ventilation for more than 48 hours and with simplified CPIS=6.All patients underwent flexible bronchoscopy to obtain bronchoalveolar lavage which was analyzed quantitatively. Colony count = 10(4) cfu/mL was considered reference standard for definite VAP.Of the five variables used for simplified CPIS, only patients temperature (P=0.013) and PaO2/FiO2 ratio were significant (P0.001) to differentiate the presence of definite VAP. Patients with definite VAP (BAL colony count = 10(4) cfu/mL) had CPIS of 8.4 while in no definite VAP group it was 6.4 (P=0.007). CPIS of 8 was found to have sensitivity of 80%, specificity 80%, PPV 86.9%, NPV 70.5% and accuracy 80%. The area under Receiver operating characteristic curve of CPIS against reference standard was 0.81± 0.069 (P=0.001).Simplified CPIS is useful in patients on mechanical ventilation to diagnose ventilator-associated pneumonia.

Lipoid pneumonia is a rare form of pneumonia caused by aspiration of fatty substances.Acute respiratory distress syndrome in an infant due to accidental aspiration of baby oil massage.Large volume bronchoalveolar lavage.Gradual recovery over a period of 5 months.Aspiration of lipids cause prolonged and refractory hypoxemia.

Dengue virus infection can cause a wide spectrum of illness. Thrombocytopenia with concurrent haemoconcentration differentiates dengue haemorrhagic fever from classical dengue fever. Only cases with shock or unstable vitals signs need admission in the pediatric intensive care. The management is essentially supportive and symptomatic. The key to success is frequent monitoring and changing strategies. A rise in hematocrit of 20% along with a continuing drop in platelet count is an important indicator for the onset of shock. Patients in grade I and II should be closely monitored for signs of shock. The management of dengue shock syndrome (grade III and IV) is a medical emergency needing prompt and adequate fluid replacement for the rapid and massive plasma losses through increased capillary permeability. Early and effective replacement of plasma losses with plasma expanders or fluid and electrolyte solutions results in a favourable outcome in most cases. The ideal fluid management should include both cystalloids and colloids (including albumin). Cystalloids are given as boluses as rapidly as possible, and as many as 2 to 3 boluses may be needed in profound shock. Colloidal fluids are indicated in patients with massive plasma leakage and in whom a large volume of cystalloids has been given. Frequent recording of vital signs and determinations of haematocrit are important in evaluating the results of treatment. Apart from correction of electrolyte and metabolic disturbances, oxygen is mandatory in all patients of shock. Some patients develop DIC and need supportive therapy with blood products (blood, FFP and platelet transfusions). Polyserositis, in the form of pleural effusion and ascitis, are common in cases of dengue shock syndrome, and if possible, drainage should be avoided as it can lead to severe hemorrhages and sudden circulatory collapse. The prognosis depends mainly on the early recognition and treatment of shock.

Malaria is very common in India. First step in management of malaria is to establish the diagnosis. It is established by using traditional smear or method like dipstick antigen captures assay which is simpler, accurate and doesn't require expertise. Next step is to look for signs and symptoms, which help cases of severe malaria should be admitted in intensive care unit (ICU) and antimalarial chemotherapy should be started through parenteral route. Complications like coma, anemia, renal failure, pulmonary edema, disseminated intravascular coagulation are not very uncommon. These complications should be anticipated and treated in time. There is no role of corticosteroids, mannitol in the treatment of cerebral edema. Therapeutic monitoring of severe malaria should involve quantitative estimation of parasite load.

Objectives To compare the available methods for the diagnosis of ventilator-associated pneumonia in intubated pediatric patients and to suggest less costly diagnostic method for developing countries. Design Prospective study. Setting Pediatric intensive care unit of a tertiary care, multidisciplinary teaching hospital located in northern India. Patients All consecutive patients on mechanical ventilation for >48 hrs were evaluated clinically for ventilator-associated pneumonia. Interventions Four diagnostic procedures (tracheal aspiration, blind bronchial sampling, blind bronchoalveolar lavage, and bronchoscopic bronchoalveolar lavage) were performed in the same sequence within 12 hrs of clinical suspicion of ventilator-associated pneumonia. The bacterial density > or =104 colony-forming units/mL in a bronchoscopic bronchoalveolar lavage sample was taken as reference standard. Measurements and main results Thirty patients with 40 episodes of ventilator-associated pneumonia were included in the study. Tracheal aspirate at the cutoff of > or =105 colony-forming units/mL was found to have sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 84%, 77%, 87.5%, 73%, and 80%, respectively. For blind bronchial sampling at > or =104 colony-forming units/mL cutoff, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 88%, 82%, 88%, 83%, and 87%, respectively; the most reliable results were obtained with blind bronchoalveolar lavage at the cutoff of > or =103 cfu/mL (sensitivity 96%, specificity 80%, positive predictive value 88%, negative predictive value 92%, and accuracy 90%). The area under the receiver operating characteristic curve of tracheal aspiration, blind bronchial sampling, and blind bronchoalveolar lavage was 0.87 +/- 0.06, 0.89 +/- 0.06, and 0.89 +/- 0.05, respectively. The cost of balloon-tip pressure catheter used for blind bronchoalveolar lavage was INR 1600.00 (US$40) whereas that for blind bronchial sampling was only INR 35.00 ( Conclusions Blind bronchoalveolar lavage was the most reliable method followed closely by blind bronchial sampling for the diagnosis of ventilator-associated pneumonia. Considering the difference of the cost in the two procedures, blind bronchial sampling may be the preferred method in the pediatric intensive care unit of a developing country.