Threshold of Inotropic Score and Vasoactive–Inotropic Score for Predicting Mortality in Pediatric Septic Shock

Objective To determine the threshold of the inotropic score (IS) and vasoactive–inotropic score (VIS) for predicting mortality in pediatric septic shock. Method This retrospective cohort study included children aged 1 mo to 13 y with septic shock, requiring vasoactive medication. The area under curve receiver operating characteristic (AUROC) was calculated using mean IS and mean VIS to predict PICU mortality, and Youden index cut points were generated. Sensitivity, specifcity, and binary regression analysis were performed. Results A total of 176 patients were enrolled (survivor, n=72, 41% and nonsurvivor, n=104, 59%). For predicting the PICU mortality, AUROC (95% CI) of IS was 0.80 (0.74–0.86) [sensitivity of 88.5 (80.7–94) and specifcity of 58.3 (46.1–69.8)] and AUROC of VIS was 0.88 (0.82–0.92) [sensitivity of 83.7 (75.1–90.2) and specifcity of 80.6 (69.5–89)]. The respective cutof scores of IS and VIS were 28 and 42.5. On regression analysis (adjusted odds ratio, 95% CI), illness severity (PRISM-III) (1.12, 1.05–1.12), worst lactate value (1.31, 1.08–1.58), IS (>28) (3.98, 1.24–12.80), and VIS (>42.5) (4.66, 1.57–13.87) independently predicted the PICU mortality (r 2=0.625). Conclusion Threshold of inotropic score (>28) and vasoactive–inotropic score (>42.5) were independently associated with PICU mortality. In addition to IS and VIS, severity and worst lactate value independently predicted septic shock mortality in PICU.

Second Dose of Scorpion Antivenom in Children with Indian Red Scorpion (Mesobuthus tamulus) Sting Envenomation

Objective: To study the effect of the second dose of scorpion antivenom in children with nonresolving or worsening scorpion sting envenomation. Methods: 72 children aged ?12 yearswith scorpion sting envenomation grade 2 and above were enrolled. 61 received the first doseof three vials of antivenom at admission (group A). Children with persistent/worseningenvenomation within 6 hours received the second dose (group B). The time required forresolution of autonomic symptoms, myocardial dysfunction, predictors of the second doseand side effects were studied. Results: The mean time taken for resolution of autonomicsymptoms were comparable in Group A and B (4.1 vs. 5.3 h, P=0.4), and of myocardialdysfunction was shorter in Group A (10.8 vs. 37.6 h, P=0.02). On regression analysis,abnormal echocardiography at admission was found to be a significant predictor of thesecond dose (OR=27.6, 95% CI, 4.7–162.5; P=<0.001). Conclusion: Children with severescorpion sting envenomation with abnormal echocardiography may require a higher dose ofscorpion antivenom. Trial registration: CTRI/2015/03/005652.

Russell’s Viper Envenomation-associated Acute Kidney Injury in Children in Southern India.

Objectives: To determine the frequency and risk factors of acute kidney injury in children with Russell’s viper envenomation using Acute Kidney Injury Network definition and classification system. Methods: A prospective observational study recruiting 61 subjects managed as per the National Snakebite Protocol. Results: 45.9% of envenomed children had acute kidney injury. The median (IQR) of the maximum serum creatinine level during hospitalization was 2 (1.3-4.8) mg/dL. The distribution of stages 1, 2 and 3 of acute kidney injury was 32.1%, 17.9% and 50% respectively. Dialysis was required in 35.7% of the children with acute kidney injury. Conclusions: Acute kidney injury is common with Russell’s viper envenomation. Native treatments and bleeding manifestations were associated with acute kidney injury in our patient population.

Predictors of Myocardial Dysfunction in Children with Indian Red Scorpion (Mesobuthus tamulus) Sting Envenomation.

Objectives: To identify predictive risk factors for myocardial dysfunction in children with scorpion sting envenomation and to evaluate the effects of Scorpion antivenom and prazosin combination therapy on occurrence of myocardial dysfunction. Design: Observational. Setting: Tertiary care hospital in Southern India. Participants: 85 children aged <13 years with scorpion sting envenomation. Outcome measures: Frequency of myocardial dysfunction; predictors of myocardial dysfunction. Results: 24 children (28.2%) developed myocardial dysfunction. Hypotension at admission (P=0.003) and increased time (>4h) between sting and administration of appropriate therapy (P=0.001) were independent predictors of myocardial dysfunction on logistic regression. Scorpion antivenom plus prazosin combination therapy led to an increase in cumulative proportion of children without myocardial dysfunction. Conclusion: Early (<4 hours) administration of Scorpion antivenom along with prazosin increases the cumulative percentage of children not developing myocardial dysfunction.