ABSTRACT
Septic shock in children is associated with high mortality, especially in developing countries. Management includes early recognition,timely antibiotics, aggressive fluid resuscitation, and appropriate vasoactive therapy, to achieve the therapeutic end points. The evidenceat each step in management has evolved over the past decade with a paradigm shift in emphasis from a ‘protocolized care’ to an‘individualized physiology-based care’. This shift mirrors the general trend one observes in critical care with respect to various treatmentmodalities i.e. moving away from a liberal to a more conservative approach be it fluids, ventilation, transfusion, antibiotics or insulin. Theage-old questions of how much fluid to give, what inotropes to start, when to administer antibiotics, are steroids indicated and when toconsider extracorporeal therapies in refractory shock are finding new answers from the recent spate of evidence. It is therefore imperativefor all of us to be aware of the recent changes in management, to enable us to adopt an evidenced based approach while managingchildren with septic shock. In this review, we have tried to summarize the key changes in evidence that have occurred over the pastdecade at various steps in the management of pediatric septic shock
ABSTRACT
In this retrospective study, we examined the prevalence of acute iron poisoning among children attending Pediatric Emergency service of a teaching hospital, and studied their clinical profile, treatment and outcome to define intensive care needs. During the 5 years' study period of 27125 patient visits to Pediatric Emergency, 337 (1.2%) were for accidental poisoning. Of these 21(7%) patients had iron poisoning; 18 were transferred to PICU. Three patients were asymptomatic, others had vomiting (n =15, 83%), diarrhoea (n =13, 72%), malena (n = 8, 44%), and hemetemesis (n=6, 33%) generally within 6 hours of ingestion. Nine progressed to shock and/or impaired consciousness; two had acute liver failure. Dose of ingested iron and clinical signs were most useful guide to iron toxicity and management decisions; serum iron did not help. Gastric lavage yielded fragments of iron tablets in 10 patients. On desferrioxamine infusion Vin-rose colour urine was not seen in 31% even in presence of high serum iron. Shock responded to normal saline (33 +/- 15 mL/kg) and dopamine (10 +/- 4 microg/kg/min) within 4-24 hours in 7 of 9 patients. Presence of shock or acute liver failure with coagulopathy and/or severe acidosis predicted all the four deaths. Desferrioxamine infusion and supportive care of shock was the mainstay.