Kala Ebenezer

Methylene blue unresponsive methemoglobinemia

Acquired methemoglobinemia is an uncommon blood disorder induced by exposure to certain oxidizing agents and drugs. Although parents may not give any history of toxin ingestion; with the aid of pulse-oximetry and blood gas analysis, we can diagnose methemoglobinemia. Prompt recognition of this condition is required in emergency situations to institute early methylene blue therapy. We report an unusual case of severe toxic methemoglobinemia, which did not respond to methylene blue, but was successfully managed with exchange transfusion.

Estimation of the Burden of Pandemic(H1N1)2009 in Developing Countries: Experience from a Tertiary Care Center in South India

Background The burden of the pandemic (H1N1) 2009 influenza might be underestimated if detection of the virus is mandated to diagnose infection. Using an alternate approach, we propose that a much higher pandemic burden was experienced in our institution. Methodology/Principal Findings Consecutive patients (n = 2588) presenting to our hospital with influenza like illness (ILI) or severe acute respiratory infection (SARI) during a 1-year period (May 2009–April 2010) were prospectively recruited and tested for influenza A by real-time RT-PCR. Analysis of weekly trends showed an 11-fold increase in patients presenting with ILI/SARI during the peak pandemic period when compared with the pre-pandemic period and a significant (P<0.001) increase in SARI admissions during the pandemic period (30±15.9 admissions/week) when compared with pre-pandemic (7±2.5) and post-pandemic periods (5±3.8). However, Influenza A was detected in less than one-third of patients with ILI/SARI [699 (27.0%)]; a majority of these (557/699, 79.7%) were Pandemic (H1N1)2009 virus [A/H1N1/09]. An A/H1N1/09 positive test was correlated with shorter symptom duration prior to presentation (p = 0.03). More ILI cases tested positive for A/H1N1/09 when compared with SARI (27.4% vs. 14.6%, P = 0.037). When the entire study population was considered, A/H1N1/09 positivity was associated with lower risk of hospitalization (p<0.0001) and ICU admission (p = 0.013) suggesting mild self-limiting illness in a majority. Conclusion/Significance Analysis of weekly trends of ILI/SARI suggest a higher burden of the pandemic attributable to A/H1N1/09 than estimates assessed by a positive PCR test alone. The study highlights methodological consideration in the estimation of burden of pandemic influenza in developing countries using hospital-based data that may help assess the impact of future outbreaks of respiratory illnesses.

Hair Dye Poisoning in a Paediatric Patient

Hair dye ingestion with suicidal intention has increased among rural Indian population and is associated with significant mortality. We report a teenager who presented with cervicofacial edema, respiratory distress, rhabdomyolysis, and myocarditis after ingesting the hair dye Super Vasmol 33. Early and supportive treatment can prevent morbidity and mortality.

Grievous injuries in children due to tractor-related accidents

Introduction: Tractor-related accidents are common among the agricultural injuries. Children are prone to such incidents as farmers live in the vicinity of the farmland. Materials and Methods: From the Paediatric Intensive Care unit (PICU) database we extracted the details of children with unintentional injuries and poisonings during the period January 2008 to June 2009. Those with tractor-related injuries were further analyzed using outpatient and inpatient charts, computerized hospital records were accessed to obtain laboratory and radiological investigations details. The clinical characteristics, injuries, and outcome of these children are presented. Results: In the 18 months period, there were 107 children with trauma, envenomations and poisoning constituting 6.5% of all PICU admissions. Of the 31 (29%) with polytrauma, four (12.9%) children, three of them boys had sustained tractor-related injuries. The injuries included three with multiple limb fractures, two each of head, chest, musculoskeletal and perineal injury and one each of abdominal and major vascular injury. All had reached the hospital in life-threatening shock and were resuscitated. Multidisciplinary surgical intervention including craniectomy, liver resection and femoral vessels anastomosis were required along with blood transfusions, ventilatory support and inotropes. Three of them survived the injuries after a mean PICU stay of 34 days. Conclusion: Tractor-related incidents among rural children are associated with major injuries and fatalities in children. The findings call for interventions to prevent such injuries and education of the farming community involved with tractors and other agricultural machineries.

Impact of pre-hospital care on the outcome of children arriving with agonal breathing to a pediatric emergency service in South India

Background: Data on the prehospital interventions received by critically ill children at arrival to Paediatric Emergency Services (PES) is limited in developing countries. This study aims to describe the pre-hospital care scenario, transport and their impact on outcome in non-traumatic, acutely ill children presenting in PES with agonal breathing. Methods: Prospective observational study done on children aged below 15 years arriving in PES with agonal breathing due to non-trauma related causes. Results: Out of 75 children studied, 69% were infants. The duration of illness among 65% of them (75) was less than 3 days. Majority of them (81%) had received treatment prior to arrival. Government sector physicians (72%), half of them (51%) being pediatricians were the major treating doctors. 37% of the children had arrived to the Emergency in an ambulance. Cardiopulmonary Resuscitation (CPR) was given to 27% on arrival in PES. Other interventions included fluid boluses to correct shock (92%) and inotrope infusion (56%). Sepsis (24%) and pneumonia (24%) were the most common diagnoses. Out of 75, 57 (76%) children who were stabilized and shifted to PICU and among them 27 (47%) survived to discharge. Normal blood pressure (p=0.0410) and non-requirement of CPR (0.0047) and inotropic infusion (0.0459) in PES were associated with a higher chance of survival. Conclusion: 36% (27/75) of children who arrived to our PES with agonal breathing survived to hospital discharge. Survival was significantly better among those who did not need CPR.

Serum Vitamin D Status and Outcome among Critically Ill Children Admitted to the Pediatric Intensive Care Unit in South India: Authors’ Reply

To the Editor : We note the concern of Dr. Angurana regarding the sample size and period of enrollment in our recent paper [1]. The sample size was calculated to be sufficient to estimate the prevalence of vitamin D deficiency among critically ill children, although we had considered the fact that it may not be enough to effectively describe its effect on the outcome variable in this pilot study. Vitamin D assays tend to be expensive and we believe, the results of our small observational study provide valuable preliminary supportive data for Indian researchers to obtain funding to conduct larger trials as suggested. Our unit is a large volume intensive care unit with an annual admission of over 1100 children. On any given day 3–5 new patients are admitted and hence, we were able to complete the data collection in a short period. The patient characteristic was representative of our regular ICU population except for the Dengue fever and Scrub Typhus which are the 2 most common fevers that are seen here from June though November. We agree that our data collection during winter period may overestimate the prevalence of vitamin D deficiency in the study population, but it does eliminate the effect of any seasonal variation in vitamin D status. We did not study prevalence of vitamin D deficiency in healthy population but agree that such a study is warranted. We considered that internal comparison of cases with low vs. normal levels of vitamin D among those critically ill children in the PICU will be more suitable than having external controls who will be healthy children. Children with clinical features of rickets were not eligible for enrollment and there was no child with clinical signs of vitamin D deficiency. Rickets is an extreme form of vitamin D deficiency. Besides, the effect of vitamin D on bone health is well known; we were interested in the presence of extraskeletal effects of vitamin D deficiency, any in our patients. Serum 25 (OH)D level is the storage form of vitamin D and is considered the best available biomarker for vitamin D status [2]. We, therefore, did not assess other parameters of vitamin D metabolism including the radiograph. Although we did not assess the socioeconomic status of our patients, we evaluated the nutritional status of the patients and presented the data [1]. VitaminD levels of children were presented separately to see if they were different from those without an underlying chronic disease as has been done in other studies. We thank Dr. Angurana for the valuable comments and agree that evaluation of association of vitamin D status, including effect of vitamin D supplementation on clinical outcome in large number of critically ill children is required.