Burden of neurological illnesses in a pediatric intensive care unit of developing country

To assess the burden and spectrum of neurological illness in a pediatric intensive care unit and review the associated mortality. Retrospective review of medical records of children [1 mo-16 years] with acute neurological diagnosis admitted in PICU in Aga Khan University hospital from January 2008 to December 2011 was done. Basic demographic, diagnosis, neuro diagnostic procedures performed, therapies and outcomes were done on a structured datasheet. During study period, 231 [19.3%] patients were admitted with acute neurological illnesses in PICU. The mean age was 67 +/- 50 months, 54% [n=125] was under-five and 138 [59.7%] were males. Out of total, 144 [62.3%] had neurological illness and 87 [37.7%] had neurosurgical diagnosis. In acute neurological illness, 51.5% [n=119] had non-traumatic-coma [NTC] and 10.8% [n=25] had neuromuscular illness. CNS infection [26%, n=60] in structural cause and status epilepticus [10%, n=23] were the most common cause of structural and metabolic type of NTC respectively. Severe traumatic brain injury [21.2%, n=49] and postoperative neurosurgical illness [16.5%, n=38] were common neurosurgical cases in our cohort. The intensive care resources were utilized as mechanical ventilation in 78% [n=180], inotropic support in 29.4% [n=67] and therapeutic hypothermia in 33% [n=76]. Fifty children [21.6%] required PICU care for observation only. More than 500 neurodiagnostic tests/procedures were performed in this cohort of children with acute neurological disorders in PICU. The mortality rate in neurological cases was 18% [42/231] as compared to the overall mortality rate was 12% in PICU. Acute neurological disorders were common in PICU, and were associated with higher mortality. CNS infections, status epilepticus and severe traumatic brain injuries were the most common acute neurological illnesses in our cohort

Thrombotic Microangiopathic Syndrome: A Novel Complication of Diabetic Ketoacidosis.

Thrombotic microangiopathic syndrome secondary to diabetic ketoacidosis is an under reported entity in children. We describe 2 girls who developed thrombotic thrombocytopenic purpura (TTP) and thrombocytopenia associated multi organ failure (TAMOF) in new onset diabetes. Both patients presented with classical findings of DKA and were intubated due to low GCS, admitted in PICU and managed according to DKA guidelines. Later on, both patients developed thrombocytopenia, acute kidney injury, and low hemoglobin along with evidence of microangiopathy on peripheral smear. One patient developed paraparesis while other patient had high LDH levels. The clinical diagnosis of TTP and TAMOF was made respectively. Both patients were treated with plasmapharesis and renal replacement therapy. Both gradually improved and were discharged.

On admission hypomagnesemia in critically Ill children: Risk factors and outcome.

Objective. To determine the frequency and associated risk factors of hypomagnesemia in pediatric intensive care unit on admission in a developing country. Methods. It is a retrospective chart review of 179 children aged 1 mo – 15yr admitted in Pediatric Intensive Care Unit of our university during 18 months and recorded serum Mg level on admission. Patients were divided into two groups according to their Mg level (Normo-magnesemic and Hypomagnesemic) and their p-value, crude and adjusted odds ratios (AoR) were calculated. Results. Upon admission in PICU 79(44%) patients were found hypomagnesemia. There was no difference in age and gender between two groups. The important risk factors identified were age greater than one yr (p 0.05, AOR 3.71), sepsis (p 0.03, AOR 3.11), hypokalemia (p 0.06, AOR 1.8), hypocalcemia (p 0.05, AOR 1.6), diuretic use (p 0.05, AOR 1.37), Aminoglycoside use (p 0.003, AOR 3.12), and hospitalization greater than five days (p 0.03, AOR 1.71). Those with normomagnesemic had higher mortality rate (32/100 or 32%) than those with hypomagnesemia (22/79 or 27.8%). Conclusion. The present finding indicates that hypomagnesemia is a common among PICU patients and is influenced by several factors.

Surface Area In Children: A Simple Formula.

We retrospectively compared body surface area (BSA) using the Mosteller formula √ W H ×––––– and a simple weight-based BSA formula ([4Wkg+7]/ [90+Wkg]). 3600 The participants were 363 children who underwent cardiac surgery from 1991 to 2000. Their age ranged from 5 days to 18 years, weight ranged from 1.2 kg to 98 kg and height ranged from 38 cm to 178 cm. There was excellent correlation (r2=0.991) between Mosteller formula and the new formula (P <0.001). We propose that the weight-based formula is easy to use and accurate. It can safely replace Mosteller formula and dispense the need for time-consuming calculations.

Does prophylactic use of dexamethasone have a role in reducing post extubation stridor and reintubation in children.

All children aged from 4 weeks to <5 year, were intubated for at least 48 hours [n=51] during 6 months. Data of the patients treated with DEX (0.5 ml/kg every 6 hours for 3 doses, beginning 6-12 hours prior to extubation) (n=30) were compared with control patients (who had not received medication) (n=21). The DEX and control groups were similar in age i.e., mean ages of DEX group were 16.85±14 months, and that of control group were 19.02 ± 19 months, mean duration of intubation and mechanical ventilation in DEX group was 5.17 ± 4.58 days, and that in control group was 3.98 ± 3.60 days. There was no significant difference between DEX and control group in the incidence of postextubation stridor [17% (5/30) vs. 10% (2/ 21); p = 0.5] and the reintubation rate [7% (2/30) vs. 10% (2/21); p = 0.7]. Our data revealed that the prophylactic use of dexamethasone in planned extubation of high risk children were not effective.

Improving outcome in pediatric intensive care unit in academic hospital in Pakistan

To assess the impact on the clinical outcome of critically ill children before and after introduction of pediatric intensivist in an academic pediatric intensive care unit [PICU] in Pakistan. This is a retrospective audit of children [age from one month to 14 years] admitted in the PICU during two 12-month periods in PICU of Aga Khan University Hospital [AKUH]. Patients in cohort one were managed by pediatric intensivist while in cohort two were managed by general pediatricians. Patients were compared during the two 12-month cohort period. During the study, in cohort one, 314 patients were admitted, mean age was 24 months [range, one month -14 year], 37% were less than 1 -year old, 66% were male, mean PRISM Score was 13.2[3- 39] while in cohort 2, 99 patients were admitted; mean age was 29 months and 60% were male. There were similar medical diagnostic categories in both cohorts. There were significant differences in two cohort for mortality [35% vs. 14%], length of stay [7.5 days vs. 3.2 days] [p<0.01] and number of admissions [314 vs. 99]. Our data showed that implementation of full-time trained pediatric intensivist in a tertiary-care PICU of university hospital was associated with improve outcome of critically ill children