Nandkishore Dubey

Early goal-directed therapy in pediatric septic shock: comparison of outcomes "with" and "without" intermittent superior venacaval oxygen saturation monitoring: a prospective cohort study*.

Objective: To evaluate the effect of intermittent central venous oxygen saturation monitoring (ScvO2) on critical outcomes in children with septic shock, as continuous monitoring may not be feasible in most resource-restricted settings. Design: Prospective cohort study. Setting: PICU of a tertiary care teaching hospital. Patients: Consecutive children younger than 17 years with fluid refractory septic shock admitted to our ICU from November 2010 to October 2012 were included. Interventions: Enrolled children were subjected to subclavian/internal jugular catheter insertion. Those in whom it was successful formed the “exposed” group (ScvO2 group), whereas the rest constituted the control group (no ScvO2 group). In the former group, intermittent ScvO2 monitoring at 1, 3, and 6 hours was used to guide resuscitation, whereas in the latter, only clinical variables were used. Measurements and Main Results: The major outcomes were in-hospital mortality and achievement of therapeutic goals within first 6 hours. One hundred twenty children were enrolled in the study–63 in the ScvO2 group and 57 in the no ScvO2 group. Baseline characteristics including the organ dysfunction and mortality risk scores were comparable between the groups. Children in the ScvO2 group had significantly lower in-hospital mortality (33.3% vs 54%; relative risk, 0.61; 95% CI, 0.4, 0.93; number needed to treat, 5; 95% CI, 3, 27). A greater proportion of children in exposed group achieved therapeutic endpoints in first 6 hours (43% vs 23%, p = 0.02) and during entire ICU stay (71% vs 51%, p = 0.02). The mean number of dysfunctional organs was also significantly lesser in ScvO2 group in comparison with no ScvO2 group (2 vs 3, p < 0.001). Conclusion: Early goal-directed therapy using intermittent ScvO2 monitoring seemed to reduce the mortality rates and improved organ dysfunction in children with septic shock as compared with those without such monitoring.

Prevalence and outcome of diastolic dysfunction in children with fluid refractory septic shock--a prospective observational study.

Objectives: Our primary objective was to determine the prevalence and outcome of diastolic dysfunction in children with fluid refractory septic shock. The secondary objective was to determine possible early predictors of diastolic dysfunction. Design: Prospective observational study. Setting: PICU of a tertiary care teaching hospital. Patients: Consecutive children 17 years old or younger with fluid refractory septic shock and not on mechanical ventilation admitted to our ICU from June 2011 to August 2012 were included. Survivors were followed up till 1 year of discharge (July 2013). Interventions: Children were subjected to 2D echocardiography and qualitative cardiac troponin-T test within the first 6 hours of admission. Measurements and Main Results: A total of 56 children were included. Median age was 7 years (interquartile range, 1.5, 14) and majority (52%) were males. Most common underlying diagnoses were meningitis and pneumonia. The prevalence of diastolic dysfunction was 41.1% (95% CI, 27.8–54.4), and mortality rate was 43% in those with diastolic dysfunction. At 1-year follow-up, residual dysfunction was present in only one of 11 of the survivors (11%). On univariable analysis of possible early predictors of diastolic dysfunction, we observed that these children tended to have higher mean central venous pressure (13 vs 6; p < 0.0001) and greater positivity for cardiac troponin-T (70% vs 36%; p = 0.01) compared with others. Although factors such as duration of illness and diastolic blood pressure were also lower in children with diastolic dysfunction compared with others, the difference was not statistically significant. On multivariable analysis, only the variable central venous pressure remained significant (adjusted odds ratio, 1.6; 95% CI, 1.12–2.14; p = 0.008). Conclusions: Diastolic dysfunction is common in children with fluid refractory septic shock, and immediate outcomes may be poorer in such patients. Increased central venous pressure after initial fluid resuscitation may be an early indicator of diastolic dysfunction and warrant urgent bedside echocardiography to guide further management.

Knowledge and skill retention of in-service versus preservice nursing professionals following an informal training program in pediatric cardiopulmonary resuscitation: a repeated-measures quasiexperimental study.

Our objective was to compare the impact of a training program in pediatric cardiopulmonary resuscitation (CPR) on the knowledge and skills of in-service and preservice nurses at prespecified time points. This repeated-measures quasiexperimental study was conducted in the pediatric emergency and ICU of a tertiary care teaching hospital between January and March 2011. We assessed the baseline knowledge and skills of nursing staff (in-service nurses) and final year undergraduate nursing students (preservice nurses) using a validated questionnaire and a skill checklist, respectively. The participants were then trained on pediatric CPR using standard guidelines. The knowledge and skills were reassessed immediately after training and at 6 weeks after training. A total of 74 participants—28 in-service and 46 preservice professionals—were enrolled. At initial assessment, in-service nurses were found to have insignificant higher mean knowledge scores (6.6 versus 5.8, P = 0.08) while the preservice nurses had significantly higher skill scores (6.5 versus 3.2, P < 0.001). Immediately after training, the scores improved in both groups. At 6 weeks however, we observed a nonuniform decline in performance in both groups—in-service nurses performing better in knowledge test (10.5 versus 9.1, P = 0.01) and the preservice nurses performing better in skill test (9.8 versus 7.4, P < 0.001). Thus, knowledge and skills of in-service and preservice nurses in pediatric CPR improved with training. In comparison to preservice nurses, the in-service nurses seemed to retain knowledge better with time than skills.

Short-Term Outcomes of Acute Fulminant Myocarditis in Children

Data on the clinical profile, echocardiographic findings, and outcome of acute fulminant myocarditis (AFM) in children from resource limited countries are limited. To study the clinical profile and short-term outcomes of children aged 2xa0months to 17xa0years with AFM managed with only supportive care. We enrolled all children admitted with AFM in our hospital from January 2009 to October 2010. Although the information on patients admitted from January 2009 to March 2010 were retrieved from the case records, data of children admitted from April 2010 were recorded prospectively. AFM was diagnosed based on clinical and echocardiographic criteria. We collected information regarding clinical course, treatment details, and echocardiography findings using a structured performa. All of the children, including those for whom baseline information was collected from the records, were followed-up prospectively to determine short-term outcomes. A total of 10 children, of whom 6 were male, presented with AFM. Their median age was 7.5 (interquartile range [IQR] 2 to13) years, and the mean left-ventricular ejection fraction (LVEF) was 26% (SD 11.5). Of the 10 children, 9 were discharged, and 1 child died. At discharge, all children showed improvement in the symptoms, but only 4 had improvement in LV function on echocardiography. Factors associated with poor recovery of LV function at discharge were anasarca, low LVEF, and increased serum glutamate pyruvate transaminase levels at admission. One child had died at 2-month follow-up, and another child developed dilated cardiomyopathy at 15xa0months after discharge. Children with AFM had good immediate- and short-term outcomes even without the use of mechanical assist devices. Decreased LVEF at admission was found to be one of the most important determinants of poor immediate outcomes in these children.

Pediatric Index of Mortality and PIM2 Scores Have Good Calibration in a Large Cohort of Children from a Developing Country

Objective. Our objective was to validate the Pediatric Index of Mortality (PIM) and PIM2 scores in a large cohort of children from a developing country. Design. Prospective observational study. Setting. Pediatric intensive care unit of a tertiary care teaching hospital. Patients. All children aged <18 years admitted between June 2011 and July 2013. Measurements and Main Results. We evaluated the discriminative ability and calibration as measured by the area under the receiver operating characteristic (ROC) curves, the Hosmer-Lemeshow goodness-of-fit (GOF), and standardized mortality ratio (SMR), respectively. Of the 819 children enrolled, 232 (28%) died. The median (IQR) age of the study subjects was 4 years (0.8, 10). The major reasons for ICU admission as well as mortality were sepsis/severe sepsis. The area under ROC curves for PIM and PIM2 was 0.72 (95% CI: 0.67–0.75) and 0.74 (95% CI: 0.70–0.78), respectively. The goodness-of-fit test showed a good calibration across deciles of risk for the two scores with P values being >0.05. The SMR (95% CI) was 0.99 (0.85–1.15) and 1 (0.85–1.16) for PIM and PIM2, respectively. The calibration across different age and diagnostic subgroups was also good. Conclusion. PIM and PIM2 scores had good calibration in our setup.

Non-cardiogenic pulmonary oedema following accidental electrocution in a toddler

Non-cardiogenic pulmonary oedema due to electrocution is an underdiagnosed clinical entity. The authors report a toddler who presented with symptoms and signs of respiratory failure following accidental electrocution. His chest radiography showed bilateral diffuse infiltrates and cardiac involvement was ruled out by echocardiography. The child was managed symptomatically and discharged in a stable condition. The cause of pulmonary oedema in this child was thought to be neurogenic in origin as cardiac and pulmonary causes were ruled out. Non-cardiogenic pulmonary oedema is an uncommonly recognised entity which occurs with any neurological or non-neurological event stimulating the vasomotor centres. There are divergent theories to explain the cause for this rare phenomenon but none has been proved. The authors chose to report this case to highlight this uncommon complication of electrocution hitherto unreported in children.