Adrian Yu Teik Goh

Fatal enterovirus 71 encephalomyelitis

During an outbreak of hand-foot-mouth disease caused by enterovirus 71 (EV-71) in 1997, 4 children presented with sudden cardiopulmonary collapse and minimal neurologic features. All children received cardiopulmonary resuscitation but died within a few hours of admission. Postmortem studies showed infection by EV-71 with extensive damage to the medulla and pons. We postulate an etiologic link between EV-71 and brainstem encephalomyelitis as the cause of pulmonary edema and death.

Impact of 24 hour critical care physician staffing on case-mix adjusted mortality in paediatric intensive care

The 24 h availability of intensive care consultants (intensivists) has been shown to improve outcomes in adult intensive care units (ICU) in the UK. We tested whether such availability would improve standardised mortality ratios when compared to out-of-hours cover by general paediatricians in the paediatric ICU setting of a medium-income developing country. The standardised mortality ratio (SMR) improved significantly from 1.57 (95%CI 1.25-1.95) with non-specialist care to 0.88 (95%CI 0.63-1.19) with intensivist care (rate ratio 0.56, 95% CI 0.47-0.67). Mortality odds ratio decreased by 0.234, 0.246 and 0.266 in the low, moderate and high-risk patients. 24 h availability of intensivists was associated with improved outcomes and use of resources in paediatric intensive care in a developing country.

Preventive transfusion in dengue shock syndrome–is it necessary?

We compared 53 patients with Dengue shock syndrome (DSS) who received preventive transfusions with 53 who did not. Significant differences in the development of pulmonary edema and length of hospitalization (P<.05) and none in hemorrhage (P=.136) were observed. Preventive transfusions did not produce sustained improvements in the coagulation status in DSS.

Echovirus 7 associated encephalomyelitis.

BACKGROUND Hand, foot, and mouth disease (HFMD) is endemic in Malaysia. In 1997, a large outbreak of enterovirus 71 (EV-71) associated HFMD resulted in 41 deaths due to severe left ventricular dysfunction and central nervous system infection with extensive damage to the medulla and pons. The clinical presentation in all these patients were rapid cardio-respiratory decompensation leading to cardiac arrest. Another large outbreak of HFMD with 55 fatal cases and a similar clinical picture was reported in Taiwan in 1998. In 2000, an outbreak of HFMD resulted in the deaths of three children who had rapid cardio-respiratory decompensation and one child who survived a central nervous system infection. OBJECTIVES We set out to study the etiologic agent and mechanism involved in three children who presented to our hospital, two of whom died and one survived a central nervous system infection. STUDY DESIGN The clinical course of the disease was described. Throat, rectal swab and cerebrospinal fluid samples were subjected to viral isolation and viral isolates were identified by immunofluorescence, micro-neutralisation using human rhabdomyosarcoma (RD) cells, and reverse transcritpase polymerase chain reaction. Magnetic resonance imaging was performed on two of the patients. RESULTS Echovirus 7 was the sole pathogen isolated from three cases of acute encephalomyelitis, two of which were fatal due to severe left ventricular dysfunction resistant to inotropic support. The survivor had residual bulbar palsy, but is considered to have had a good neurological outcome. CONCLUSION Echovirus 7 infection associated with encephalomyelitis could be fatal due to indirect involvement of the heart resulting in severe left ventricular dysfunction. In addition one of the children presented with hand, foot, and mouth disease, a syndrome that has not been previously associated with echovirus 7 infection.

Brief report. Paediatric intensive care in Kuala Lumpur, Malaysia: a developing subspecialty

Paediatric intensive care in Malaysia is a developing subspecialty with an increasing number of specialists with a paediatric background being involved in the care of critically ill children. A part prospective and part retrospective review of 118 consecutive non-neonatal ventilated patients in University Hospital, Kuala Lumpur was carried out from 1 June 1995 to 31 December 1996 to study the clinical epidemiology and outcome in our paediatric intensive case unit (PICU). The mean age of the patients was 33.9 +/- 6.0 months (median 16 months). The main mode of admission was emergency (96.6 per cent) with an overall mortality rate of 42 per cent (50/118). The mean paediatric risk of mortality (PRISM) score was 20 +/- 0.98 SEM, with 53 per cent of patients having a score of over 30 per cent. Multiorgan dysfunction (MODS) was identified in 71 per cent of patients. Admission efficiency (mortality risk > 1 per cent) was 97 per cent. Standardized mortality rate using PRISM was an acceptable 1.06. The main diagnostic categories were respiratory (32 per cent), neurology (22 per cent), haematology-oncology (18 per cent); the aetiology of dysfunction was mainly infective. Non-survivors were older (29.5 vs. 13.8 months, p < 0.0001), had more severe illness (mean PRISM score 30 vs. 14, p < 0.0001), were more likely to develop MODS (96 vs. 53 per cent, p < 0.0001) and required more intervention and monitoring. Paediatric intensive care in Malaysia differs widely from that in developed countries in patient characteristics, severity of illness, and care modalities provided.

Transport of critically ill children in a resource-limited setting: alternatives to a specialized retrieval team

three PICUs in Kuala Lumpur comparing 827 non-specialized transports with 877 inhospital transfers, the differences in standardized mortality ratio (SMR) (1.86 vs 1.57, rate ratio 1.18, 95% CI 0.96–1.46) and adjusted odds ratio of mortality (adjusted for PRISM, length of stay and age) of 1.26 times compared with in-hospital transfers (95% CI 0.96–1.66) were not significant. Thus although adverse events were far more common in transported patients, those receiving care primarily in the tertiary centres (with fewer adverse events) did not have a superior outcome. Therefore introduction of a paediatric retrieval service (PRT) alone might not lead to improved outcomes if tertiary PICU care is not improved first. We believe improvement would come about only after improving both pre-PICU and PICU care [2]. Since the introduction in our unit of a pre-transport checklist of important physiological parameters, we have found: (1) more fluid boluses being administered, (2) earlier use of inotropes, and (3) a higher proportion of patients being intubated with appropriately sized/placed tubes prior to transport, leading to a fall in the proportion of children presenting with shock (21% vs 52.5%) and airway compromise (9% vs 30.5%). We agree with Hatherill et al.’s [3] conclusion that in developing countries with limited resources the cost-benefit of a paediatric retrieval team (PRT) needs to be balanced against very compelling and competing primary healthcare priorities. Other measures to reduce adverse events during inter-hospital transfers, such as training of transport staff (paramedics, junior doctors and nurses), adequacy of suitably equipped transport vehicles and close liaison with the tertiary PICU (before and during transport) might offer a viable alternative to a PRT in a resource-limited setting.

Severe bronchiolitis in Malaysian children.

Twenty-two (42 per cent) out of 52 patients admitted with severe bronchiolitis to our Paediatric Intensive Care Unit required ventilation. Risk factors associated with ventilation included a younger mean age, female sex, low birthweight, failure to thrive and the presence of an underlying illness. Ventilated patients were also more likely to have a higher respiratory distress assessment index (RDAI) score, pneumonic infiltration on chest X-ray, lower serum sodium and a positive respiratory syncytial virus isolation in the tracheal secretion.

Cerebral salt wasting syndrome following atlantoaxial fracture dislocation in Down syndrome

We describe cerebral salt wasting syndrome (CSWS) in a 5-year-old female child with Down syndrome who had acute myelopathy secondary to chronic atlantoaxial subluxation and fracture dislocation of the odontoid process. The patient developed hyponatraemia associated with excessive urine output and elevated urine sodium concentration following her injury. An administered volume-for-volume replacement of urine loss with 0.9% sodium chloride resulted in an excellent outcome. This patient illustrates the importance of ascertaining CSWS in children with spinal cord disorders, in addition to the syndrome of inappropriate antidiuretic hormone (SIADH) secretion and diabetes insipidus (DI) commonly encountered following a central nervous system (CNS) injury, as the specific treatment approaches is clearly associated with an excellent outcome.