Karthi Nallasamy

Low-Dose vs Standard-Dose Insulin in Pediatric Diabetic Ketoacidosis A Randomized Clinical Trial

IMPORTANCE The standard recommended dose (0.1 U/kg per hour) of insulin in diabetic ketoacidosis (DKA) guidelines is not backed by strong clinical evidence. Physiologic dose-effect studies have found that even lower doses could adequately normalize ketonemia and acidosis. Lowering the insulin dose may be advantageous in the initial hours of therapy when a gradual decrease in glucose, electrolytes, and resultant osmolality is desired. OBJECTIVE To compare the efficacy and safety of low-dose insulin against the standard dose in children with DKA. DESIGN, SETTING, AND PARTICIPANTS This was a prospective, open-label randomized clinical trial conducted in the pediatric emergency department and intensive care unit of a tertiary care teaching hospital in northern India from November 1, 2011, through December 31, 2012. A total of 50 consecutive children 12 years or younger with a diagnosis of DKA were randomized to low-dose (n = 25) and standard-dose (n = 25) groups. INTERVENTIONS Low-dose (0.05 U/kg per hour) vs standard-dose (0.1 U/kg per hour) insulin infusion. MAIN OUTCOMES AND MEASURES The primary outcome was the rate of decrease in blood glucose until a level of 250 mg/dL or less is reached (to convert to millimoles per liter, multiply by 0.0555). The secondary outcomes included time to resolution of acidosis, episodes of treatment failures, and incidences of hypokalemia and hypoglycemia. RESULTS The mean (SD) rate of blood glucose decrease until a level of 250 mg/dL or less is reached (45.1 [17.6] vs 52.2 [23.4] mg/dL/h) and the mean (SD) time taken to achieve this target (6.0 [3.3] vs 6.2 [2.2] hours) were similar in the low- and standard-dose groups, respectively. Mean (SD) length of time to achieve resolution of acidosis (low vs standard dose: 16.5 [7.2] vs 17.2 [7.7] hours; P = .73) and rate of resolution of acidosis were also similar in the groups. Hypokalemia was seen in 12 children (48%) receiving the standard dose vs 5 (20%) of those receiving the low dose (P = .07); the tendency was more pronounced in malnourished children (7 [88%] vs 2 [28%]). Five children (20%) and 1 child (4%) receiving standard- and low-dose infusion (P = .17), respectively, developed hypoglycemia. Treatment failure was rare and comparable. One child in the standard-dose group developed cerebral edema, and no deaths occurred during the study period. CONCLUSIONS AND RELEVANCE Low dose is noninferior to standard dose with respect to rate of blood glucose decrease and resolution of acidosis. We advocate a superiority trial with a larger sample size before 0.05 U/kg per hour replaces 0.1 U/kg per hour in the practice recommendations. TRIAL REGISTRATION ctri.nic.in Identifier: CTRI/2012/04/002548.

Approach to Headache in Emergency Department

Headache remains a frequently encountered neurological symptom in Emergency department. Secondary causes of headache outnumber the primary entities such as migraine. Most of the secondary headaches have benign etiologies. The goal of emergent evaluation is to detect those with serious or life threatening causes. Identifying the pattern of headache helps in narrowing down the possible etiological diagnosis. A single episode of acute headache usually results from an acute infection ranging from viral URI to acute meningitis. Acute recurrent headaches are typically a feature of migraine. Chronic progressive headaches often indicate a serious underlying pathology such as a brain tumor and warrant a detailed neurological examination for signs of raised intracranial pressure (ICP) and focal deficits. Children with abnormal neurological findings require a neuroimaging. CT scan usually detects most of the abnormalities. Initial stabilization and management of raised ICP takes precedence in sick children. While simple analgesics like paracetamol and ibuprofen are used for symptomatic therapy, identification and appropriate treatment of underlying conditions is necessary for complete resolution of headache.

Double-blind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-refractory Hypotensive Septic Shock.

Objective: We compared efficacy of dopamine and epinephrine as first-line vasoactive therapy in achieving resolution of shock in fluid-refractory hypotensive cold septic shock. Design: Double-blind, pilot, randomized controlled study. Setting: Pediatric emergency and ICU of a tertiary care teaching hospital. Patients: Consecutive children 3 months to 12 years old, with fluid-refractory hypotensive septic shock, were enrolled between July 2013 and December 2014. Intervention: Enrolled children were randomized to receive either dopamine (in incremental doses, 10 to 15 to 20 &mgr;g/kg/min) or epinephrine (0.1 to 0.2 to 0.3 &mgr;g/kg/min) till end points of resolution of shock were achieved. After reaching maximum doses of test drugs, open-label vasoactive was started as per discretion of treating team. Primary outcome was resolution of shock within first hour of resuscitation. The study was registered (CTRI/2014/02/004393) and was approved by institute ethics committee. Measurements and Main Results: We enrolled 29 children in epinephrine group and 31 in dopamine group. Resolution of shock within first hour was achieved in greater proportion of children receiving epinephrine (n = 12; 41%) than dopamine (n = 4; 13%) (odds ratio, 4.8; 95% CI, 1.3–17.2; p = 0.019); the trend persisted even at 6 hours (48.3% vs 29%; p = 0.184). Children in epinephrine group had lower Sequential Organ Function Assessment score on day 3 (8 vs 12; p = 0.05) and more organ failure–free days (24 vs 20 d; p = 0.022). No significant difference in adverse events (16.1% vs 13.8%; p = 0.80) and mortality (58.1% vs 48.3%; p = 0.605) was observed between the two groups. Conclusion: Epinephrine is more effective than dopamine in achieving resolution of fluid-refractory hypotensive cold shock within the first hour of resuscitation and improving organ functions.

Child with Headache

Headache is a common complaint for which parents seek pediatrician’s consult. Headaches are seen in increasing frequency from 3 y of age onwards with peaks in older children and adolescents. In children, secondary headaches due to underlying etiologies are far more common than primary headaches due to migraine. Recognition of temporal pattern of headache along with focused neurological examination will help in narrowing down the etiology. The key goal in urgent care assessment is to identify children with underlying serious illnesses that require stabilization and urgent referral. For benign causes, symptomatic treatment with analgesics like paracetamol or ibuprofen would suffice initially, while identification of the underlying condition would lead to further appropriate management, particularly in primary headaches.

Child with Abdominal Pain

Abdominal pain is one of the common symptoms reported by children in urgent care clinics. While most children tend to have self-limiting conditions, the treating pediatrician should watch out for underlying serious causes like intestinal obstruction and perforation peritonitis, which require immediate referral to an emergency department (ED). Abdominal pain may be secondary to surgical or non-surgical causes, and will differ as per the age of the child. The common etiologies for abdominal pain presenting to an urgent care clinic are acute gastro-enteritis, constipation and functional abdominal pain; however, a variety of extra-abdominal conditions may also present as abdominal pain. Meticulous history taking and physical examination are the best tools for diagnosis, while investigations have a limited role in treating benign etiologies.

Subdural empyema due to Salmonella paratyphi B in an infant: a case report and review of literature

Intracranial infection due to Salmonella is uncommon in children. Subdural empyema (SDE) is described with Salmonella typhi as a complication of meningitis. We report a 6-month-old infant with SDE secondary to Salmonella paratyphi B who had presented with prolonged fever and enlarging head. A literature review of Salmonella SDE in infants with respect to clinical course and outcome is presented.

Tropical fevers in Indian intensive care units: A prospective multicenter study

Background and Aims: Infections in tropics often present as undifferentiated fevers with organ failures. We conducted this nationwide study to identify the prevalence, profile, resource utilization, and outcome of tropical fevers in Indian Intensive Care Units (ICUs). Materials and Methods: This was a multicenter prospective observational study done in 34 ICUs across India (July 2013–September 2014). Critically ill adults and children with nonlocalizing fever >48 h and onset < 14 days with any of the following: thrombocytopenia/rash, respiratory distress, renal failure, encephalopathy, jaundice, or multiorgan failure were enrolled consecutively. Results: Of 456 cases enrolled, 173 were children <12 years. More than half of the participants (58.7%) presented in postmonsoon months (August–October). Thrombocytopenia/rash was the most common presentation (60%) followed by respiratory distress (46%), encephalopathy (28.5%), renal failure (23.5%), jaundice (20%), and multiorgan failure (19%). An etiology could be established in 365 (80.5%) cases. Dengue (n = 105.23%) was the most common followed by scrub typhus (n = 83.18%), encephalitis/meningitis (n = 44.9.6%), malaria (n = 37.8%), and bacterial sepsis (n = 32.7%). Nearly, half (35% invasive; 12% noninvasive) received mechanical ventilation, a quarter (23.4%) required vasoactive therapy in first 24 h and 9% received renal replacement therapy. Median (interquartile range) ICU and hospital length of stay were 4 (3–7) and 7 (5–11.3) days. At 28 days, 76.2% survived without disability, 4.4% had some disability, and 18.4% died. Mortality was higher (27% vs. 15%) in patients with undiagnosed etiology (P < 0.01). On multivariate analysis, multiorgan dysfunction syndrome at admission (odds ratio [95% confidence interval]-2.8 [1.8–6.6]), day 1 Sequential Organ Failure Assessment score (1.2 [1.0–1.3]), and the need for invasive ventilation (8.3 [3.4–20]) were the only independent predictors of unfavorable outcome. Conclusions: Dengue, scrub typhus, encephalitis, and malaria are the major tropical fevers in Indian ICUs. The data support a syndromic approach, point of care tests, and empiric antimicrobial therapy recommended by Indian Society of Critical Care Medicine in 2014.

Ocular Flutter in Scrub Typhus

A 9-year-old boy presented with a subacute febrile illness with bursts of conjugate horizontal saccadic oscillations on visual fixation (Figure and Video; available at www.jpeds.com) and cerebellar ataxia. Examination revealed hepatosplenomegaly and scrotal eschar. Magnetic resonance imaging of the brain was normal and lumbar cerebrospinal fluid showed lymphocytic pleocytosis (70 cells, protein 105 mg/dL). IgM enzyme-linked immunosorbent assay for scrub typhus was positive. Intravenous doxycycline and dexamethasone for 5 days resulted in complete recovery. Ocular flutter is bursts of conjugate horizontal saccades without intersaccadic interval, occurring on visual fixation, irrespective of gaze direction and eye closure. Ocular movements are present in full direction, hence ocular flutter may lead to troublesome oscillopsia. Ocular flutter is usually present with ataxia and myolconus and rarely can be isolated phenomenon. Ocular flutter is considered as a milder version of opsoclonus; ocular flutter or saccadic intrusions are usually horizontal, whereas opsoclonus are multidirectional. Pathogenesis of ocular flutter is related to dysfunction of omnipause neurons in the paramedianpontine reticular formation or fastigial nucleus of cerebellum. Damage to the GABAergic omnipause neurons or malfunction of glycine receptors causing a decrease in the efficacy of omnipause neuron-mediated inhibition leads to ocular flutter. Hydrocephalus, midbrain glioma, demyelinating disorders, enterovirus encephalitis, Lyme disease, autoimmune encephalitis, heredodegenerative disorders, and head trauma are reported with ocular flutter. Ocular flutter in an index child is a rare clinical feature of scrub typhus cerebellitis. Immune-mediated pathogenesis (anti-GQ1b, antiGADAntibodies) complements the role of steroids in early recovery. ■

Abstract P-265: ENERGY BALANCE IN CHILDREN WITH SEVERE SEPSIS USING INDIRECT CALORIMETRY – A PROSPECTIVE COHORT STUDY

Single center, prospective cohort study of children aged 5 -12 years admitted with severe sepsis to tertiary care pediatric ICU from May 2016 to June 2017. Patients with active air leak, ventilator circuit leak >10%, on FiO2>60% or on high frequency oscillatory ventilation were excluded. Demographic, anthropometric and nutritional data were collected. Resting energy expenditure (mREE) was measured once daily with portable metabolic cart (Quark RMR, COSMED®) till 7 days or PICU discharge whichever was earlier.

Post-neonatal Tetanus in a PICU of a Developing Economy: Intensive Care Needs, Outcome and Predictors of Mortality

Objectives To evaluate pediatric intensive care unit (PICU) needs, outcome and predictors of mortality in post-neonatal tetanus. Materials and methods Review of 30 consecutive post-neonatal tetanus cases aged 1 months to 12 years admitted to a PICU in north India over a period of 10 years (January 2006 to December 2015). Results Chronic suppurative otitis media was the commonest portal of entry. All received tetanus toxoid, human tetanus immunoglobulin (HTIG) and appropriate antibiotics; 7 (23.3%) received intrathecal HTIG. Common complications were respiratory failure, rhabdomyolysis, autonomic dysfunction, acute kidney injury and healthcare-associated infections. PICU needs were as follows: ventilation; benzodiazepine, morphine and magnesium sulfate infusion; neuromuscular blockers, inotropes, tracheostomy and renal replacement therapy. Mortality rate was 40%; severity Grade IIIb, autonomic dysfunction, use of vasoactive drugs and those who did not receive intrathecal HTIG were significantly associated with mortality. Conclusion Post-neonatal tetanus is associated with high mortality, and PICU needs include management of spasms, autonomic dysfunction and complications and cardiorespiratory support.