Amit Varma

Therapeutic applications of vasopressin in pediatric patients

ContextReports of successful use of vasopressin in various shock states and cardiac arrest has lead to the emergence of vasopressin therapy as a potentially major advancement in the management of critically ill children.ObjectiveTo provide an overview of physiology of vasopressin, rationale of its use and dose schedule in different disease states with special focus on recent advances in the therapeutic applications of vasopressin.Data SourceMEDLINE search (1966–September 2011) using terms “vasopressin”, “terlipressin”, “arginine-vasopressin”, “shock”, “septic shock”, “vasodilatory shock”, “cardiac arrest”, and “resuscitation” for reports on vasopressin/terlipressin use in children and manual review of article bibliographies. Search was restricted to human studies. Randomized controlled trials, cohort studies, evaluation studies, case series, and case reports on vasopressin/terlipressin use in children (preterm neonates to 21 years of age) were included. Outcome measures were analysed using following clinical questions: indication, dose and duration of vasopressin/terlipressin use, main effects especially on systemic blood pressure, catecholamine requirement, urine output, serum lactate, adverse effects, and mortality.Results51 reports on vasopressin (30 reports) and terlipressin (21 reports) use in pediatric population were identified. A total of 602 patients received vasopressin/terlipressin as vasopressors in various catecholamine-resistant states (septic - 176, post-cardiotomy - 136, other vasodilatory/mixed shock — 199, and cardiac arrest - 101). Commonly reported responses include rapid improvement in systemic blood pressure, decline in concurrent catecholamine requirement, and increase in urine output; despite these effects, the mortality rates remained high.ConclusionIn view of the limited clinical experience, and paucity of randomized controlled trials evaluating these drugs in pediatric population, currently no definitive recommendations on vasopressin/terlipressin use can be laid down. Nevertheless, available clinical data supports the use of vasopressin in critically ill children as a rescue therapy in refractory shock and cardiac arrest.

eICU reduces mortality in STEMI patients in resource-limited areas.

Highlights Timely healthcare access poses a formidable challenge in the semiurban and rural areas of the developing world. This is particularly noticeable in emergency situations such as ST-segment elevation myocardial infarction (STEMI). We explored whether a remotely monitored intensive care unit (electronic ICU [eICU]) would bridge this demand-supply gap. To evaluate the efficacy of an eICU model of service and intervention for the early diagnosis of STEMI and prompt initiation of thrombolytic therapy, mortality during 12-month eICU period was compared with the mortality in the same period preceding the eICU establishment. Not only initiation of thrombolytic treatment was supported remotely by eICU, but the door-to-needle time in STEMI was reduced by 85% to 26.23 min, resulting in a substantial 70% mortality benefit.

Infective endocarditis in an Indian setup: Are we entering the ‘modern’ era?

Background: The clinical profile of infective endocarditis (IE) has been continuously evolving over last 3-4 decades as highlighted by many studies from developed world. Objectives: To evaluate the recent changes in the spectrum and clinical profile, and outcome of IE in an Indian setup. Materials and Methods: This was a descriptive, cross-sectional study. Demographic, clinical, characteristics, treatment, and outcome were examined in ‘definite’ cases of IE admitted at our institute between July 2005 and December 2010. Results: 61 ‘definite’ cases were identified. Mean patient age was 49.3 ± 13.7 years. Male to female ratio was 3.3:1. Rheumatic heart disease was the underlying heart disease in 23 (37.7%) patients. 33 (54.1%) patients had already received antibiotic therapy before presentation to us. Blood cultures were positive in 41 (67.2%) patients. Streptococci and staphylococci were the commonest microbial isolates, 9 (21.4%) patients each. Transesophageal echocardiography (TEE) was done for all the patients. Vegetations were detected in 54 (88%) patients. Surgery was done in 30 (49.2%) patients. In-hospital mortality happened in 4 (6.5%) patients. Conclusions: We recorded several new trends, like: 1) an increasing age, 2) an increasing proportion of patients with no previously known heart disease, 3) improving culture positivity rates, 4) rise in staphylococcal infections, 5) increased usage of TEE, 6) high elective surgical rate, and 7) apparent improved survival rates. These changes point to the fact that ‘modern era’ changes in the profile of IE have started to appear in a selected population in India.

Candida glabrata candidemia: An emerging threat in critically ill patients

Background: Candidemia is an important nosocomial blood stream infection in critically ill patients. Although several studies have addressed candidemia, very few have reviewed the impact of Candida glabrata candidemia in Intensive Care Unit (ICU) patients. Materials and Methods: The medical records of ICU patients between 2006 and 2010 were reviewed retrospectively. The epidemiology, clinical features and mortality related risk factors among our adult ICU patients were seen. Results: Among 144 episodes of candidemia, C. glabrata (n = 26; 18.05%) was the third most common species isolated. The incidence of C. glabrata candidemia was 0.21/1000 ICU admissions. The most common risk factors were prior exposure to broad spectrum antibiotics (100%), central venous catheter (100%), mechanical ventilation (76.9%), diabetes mellitus (50%), age >65 years (46.15%). Urine (23%) was the most common source of C. glabrata candidemia. Overall in hospital 30 days mortality rate due to C. glabrata fungemia was 53.8%. Patients who were treated with fluconazole showed better outcome than patients treated with amphotericin B. Renal failure requiring hemodialysis was the significantly associated with mortality in our study. Conclusion: Candida glabrata was the 3rd most common Candida causing candidemia in our ICUs with a incidence of 0.21/1000 ICU admissions. The outcome of ICU acquired C. glabrata candidemia was poor with 30 days mortality rate of 53.8%. Renal failure requiring hemodialysis was the only risk factor associated with mortality. Further studies are required to identify the other risk factors associated with mortality in C. glabrata candidemia.

Approach to postoperative fever in pediatric cardiac patients

Fever in the postoperative period in children undergoing surgery for congenital heart disease is fairly common and tends to cause anxiety to both the surgeon and the patient. Such fever is associated with the metabolic response to trauma, systemic response to the cardiopulmonary bypass, hypothermia, presence of drainage tubes, drugs, blood transfusion as well as infections. Establishing the diagnosis requires proper assessment of the patient with focused history, targeted physical examination and judicious use of investigations with the knowledge of the common causes.

Vasopressin in the pediatric cardiac intensive care unit: Myth or reality

Pediatric cardiac surgery is undergoing a metamorphosis, with more and more critical patients being operated in our country today. Although the principles of physiology have not changed, it is imperative that care providers continue to stay abreast with developments and newer drugs that may help modify the outcome. The team dynamics have also become more complex, which necessitates the need for all care providers (surgeons, cardiologists, anesthesiologists, and intensivists) to better understand the interactions and benefits of newer drugs. Vasopressin has been used in our adult patients for more than a decade and recently has found its rightful place in the pediatric armoury. The objective of this article is to review the physiology of vasopressin and the rationale of its use in critically ill children with shock, in context of the available published data.

Point of care serum lactate levels as a prognostic marker of outcome in complex pediatric cardiac surgery patients: Can we utilize it?

Background: Post-operative course after complex pediatric cardiac surgery is unpredictable. Although, change in arterial lactate levels has been used as a surrogate marker for many years, scientific evidence correlating the early perioperative lactate levels with outcome is still lacking. Objective: To evaluate the trends in lactate levels from intraoperative period to an extended post-operative period in pediatric intensive care unit (PICU) and to assess its usefulness as a prognostic marker. Design: Prospective observational study. Setting: Tertiary pediatric cardiac surgical unit. Patients: Thirty-five non-consecutive children aged 1-140 months who underwent surgery for congenital heart diseases (CHD) on cardiopulmonary bypass (CPB). Intervention: None. Materials and Methods: Arterial blood lactate levels were obtained at the following time points: After induction of anesthesia, 15 and 45 min after institution of CPB, at the start of rewarming, after sternotomy closure, then at 1, 6, 24, and 48 h in PICU. Other hemodynamic and clinical variables, CPB variables, blood gas values, and laboratory variables were also recorded. Results: Four patients died out of 35 patients (11.4%). Non-survivors showed significant persistent elevation in lactates (>4.0 mmol/l). Peak lactates correlate significantly with longer aortic cross clamp time, CPB duration, ventilation hours and PICU stay. Conclusion: Early point of care lactate can be a useful prognostic marker in post-cardiac surgery patients in adjunct with other parameters measured in PICU. This reiterates the importance of measuring lactates and timely recognition of at-risk patients, which on early intervention can help in reducing post-operative morbidity and mortality.

1654: CASE SERIES OF SUDDEN REVERSIBLE PAROXYSMAL SHORTNESS OF BREATH CAUSED BY MITRAL VALVE OBSTRUCTION

Learning Objectives: Sudden reversible paroxysmal shortness of breath is most commonly due to underlying cardiovascular or respiratory pathology. However in the absence of objective clinical parameters and with normal baseline clinical investigations like chest x-ray and electrocardiogram, it can be challenging to determine the aetiology. We present a case of the above mentioned clinical entities admitted to intensive care unit and the importance of early echocardiogram for such conditions. Methods: First Patient case is 81 year old man who had no co-morbidities, presented with acute sudden onset non-exertional shortness of breath lasting few minutes with spontaneous resolution. There was no accompanying chest pain, no decreased effort tolerance, infective symptoms. He had stable hemodynamics, bibasal crepitations, with no pedal-edema or raised JVP. Chest x-ray shows bilateral prominent bronchovascular markings. ECG had no ischemic changes. Bedside echocardiogram done revealed an large echogenic mass of 6.73 cm X 4.7 cm is seen in the left atrium attached to the septum and obstructing the mitral valve. Peculiar to this presentation was the paroxysmal,spontaneously resolving episodes. Second patient is 59 year lady, who had a history of rheumatic mitral valve disease with PTMC(percutaneous trans-mitral commissurotomy) done, present with paroxysmal sudden onset flash shortness of breath which resolved after intravenous diuretics. She had no fast heart rates or new myocardial infarction preceding the episodes. She was admitted to critical care where handheld echocardiography performed showed a 6 * 4 cm left atrial thrombus occluding the mitral valve. She was urgently referred for surgery. Her mitral valve stenosis is ‘Mild’ on echocardiograms. Results: Mitral valve obstruction syndromes are common in prosthetic valves, rheumatic diseases and tumors. Sudden flash paroxysms often should raise clinical suspicion and echocardiography in critical care should be performed as early as possible and should be standard of care at point of entry to a critical care unit which gives high value care to the patient.

881: OVERCOMING NOSOCOMIAL INFECTION BURDEN IN A DEVELOPING COUNTRY THROUGH ELECTRONIC ICU

Copyright

Neonatal Systemic Glucocorticoids Alter the Body Weight Gain Pattern during the Pre-Weaning Stages of Development

Neonatal Systemic Glucocorticoids Alter the Body Weight Gain Pattern during the Pre-Weaning Stages of Development