Implementation of ventilator bundle in pediatric intensive care unit of a developing country

The aim of this study was to assess the frequency of VAP [ventilator associated pneumonia] after strict implementation of ventilator bundle in PICU. Medical records of all children [age 1 month - 16 years] were retrospectively reviewed, who were on mechanical ventilation [MV] for more than 48 hours and received all key components of "ventilator bundle" from January 2012 to December 2014. Out of 1050, 565 [54%] patients were enrolled. The mean age was 4.02 SD 4.29 years and 62 [69%] were male. The indications of MV were respiratory illness [54%], neurological illness [31%], shock [9%], and postoperative care [6%]. The mean duration of MV was 7.05 SD 5.4 days. Only 4 patients [0.7%] developed VAP. The incidence-density of VAP was 1.6 per 1000 ventilator days. The strict implementation of simple, inexpensive interventions [ventilator bundle] in care of mechanically ventilated children can decrease significantly VAP even in resource-limited country

Clinical profile and short-term outcome of pediatric hyperleukocytic acute leukemia from a developing country

This study was conducted to determine the frequency, clinical profile, and short-term outcome of children with hyperleukocytosis at two pediatric oncology centers in Karachi. Of a total 1,045 patients, 13.97% [n=146] patients had hyperleukocytosis. Majority [61.7%, n=90] were under 10 years of age and 76% [n=146] were male. The symptom duration before diagnosis was more than 30 days in 49.3% [n=72]. The median WBC count was 181 x109/L [IQR=130.45- 298.3] and extreme hyperleukocytosis [>200 x109/L] was observed in 44.5% [n=65] patients. Majority [94.5%, n=138] of patients were diagnosed with acute lymphoblastic leukemia. One or more complications developed in 78% [n=114] of cases. Clinical and laboratory tumor lysis syndrome [TLS] was observed in 17.1% [n=25] and 39% [n=57] patients, respectively. Pulmonary and neurological complications related to leukostasis were noted in 9.5% [n=14] and 27.3% [n=40] of cases, respectively. Infectious complications occurred in 23.2% [n=34] patients. The case-specific mortality was 20.5% [n=30]. No mortality was related to early complications of hyperleukocytosis

Accidental phosphine gas poisoning with fatal myocardial dysfunction in two families

Aluminum phosphide is commonly used as a rodenticide and insecticide and is one of the most fatal poisons. The active ingredient is Phosphine gas which inhibits cytochrome oxidase and cellular oxygen utilization. The clinical symptoms are due to multiorgan involvement including cardiac toxicity which is the most common cause of mortality. Severity of clinical manifestations depends upon the amount of the gas to which a person is exposed. There is no specific antidote available. High index of suspicion and early aggressive treatment is the key to success. We report 2 cases of aluminum phosphide toxicity in 2 families due to incidental exposure after fumigation

Clinical Profiles and Outcomes of Children Admitted to the Pediatric Intensive Care Unit from the Emergency Department

The aim of this study was to describe clinical profiles and outcomes of children admitted directly from the Emergency Room [ER] to the Pediatric Intensive Care Unit [PICU] of academic hospital. The medical records of all children [1 month to 16 years] admitted in PICU from ER, from January 2011 to December 2012 were reviewed. Of the 26, 774 patients seen in the ER during the study period, 468 [1.7%] were admitted to the PICU which constituted about 41.5% [468/1127] of all the total PICU admissions. Sixty three percent [n=294] were under-five; males were 60.9% [285], 82.3% [385] were in medical category. Neurological and respiratory illnesses were the most common groups [> 50% of all ER admissions]. Multi-organ dysfunction syndrome and co-morbidity were present in 25.2% [n=118] and 23.5% [n=110] respectively. The mean length of stay was 5 +/- 3.7 hours. The case-fatality rate was 20.3% [n=95] as compared to the overall PICU mortality rate of 11.9% [n=135]. Key Words: Pediatric intensive care unit [PICU]. Emergency room [ER]. Children. Outcome.

Emblica officinalis improves glycemic status and oxidative stress in STZ induced type 2 diabetic model rats

OBJECTIVE@#To evaluate the antidiabetic and antioxidant potential of Emblica officinalis (E. officinalis) fruit on normal and type 2 diabetic rats.@*METHODS@#Type 2 diabetes was induced into the male Long-Evans rats. The rats were divided into nine groups including control groups receiving water, type 2 diabetic controls, type 2 diabetic rats treated with glibenclamide (T2GT) and type 2 diabetic rats treated with aqueous extract of fruit pulp of E. officinalis. They were fed orally for 8 weeks with a single feeding. Blood was collected by cutting the tail tip on 0 and 28 days and by decapitation on 56 day. Packed red blood cells and serum were used for evaluating different biochemical parameters.@*RESULTS@#Four weeks administration of aqueous extract of E. officinalis improved oral glucose tolerance in type 2 rats and after 8 weeks it caused significant (P<0.007) reduction in fasting serum glucose level compared to 0 day. Triglycerides decreased by 14% but there was no significant change in serum ALT, creatinine, cholesterol and insulin level in any group. Furthermore, reduced erythrocyte malondialdehyde level showed no significant change (P<0.07) but reduced glutathione content was found to be increased significantly (P<0.05).@*CONCLUSIONS@#The aqueous extract of E. officinalis has a promising antidiabetic and antioxidant properties and may be considered for further clinical studies in drug development.

Frequency of cardiorenal syndrome type-I in hospitalized children with acute heart failure in a tertiary-care hospital

To determine the frequency of cardiorenal syndrome in hospitalized children with acute heart failure. Descriptive study. Paediatric Intensive Care Unit, The Aga Khan University Hospital, Karachi, from December 2010 to December 2011. Sixty eight [68] children with acute heart failure fulfilling the selection criteria were evaluated for worsening of renal function [WRF]. Serum creatinine was done at baseline and repeated at 72 hours to see the worsening of renal function. Estimated serum creatinine clearance was calculated by Schwartz formula. Mean age of patients was 43.6 +/- 55.2 months. There were 43 [63%] males, 70% were under 57 months of age. Mean weight on admission was 14.7 +/- 19.13 kg and mean height was 83 cm [ +/- 31.08 SD]. Mean serum creatinine on admission was 0.77 mg/dl [ +/- 1.18 SD]. Worsening renal function was noted in 55 [81%] of children, out of those, majority 36 [70.5%] were under 5 years of age. Worsening renal function was found in 81% of children admitted with the diagnosis of acute heart failure. Majority [70.5%] were under 5 years of age indicating a closer observation of renal status in younger age group to reduce, morbidity and mortality

Readmission to paediatric intensive care unit: frequency, causes and outcome

Readmission to intensive care units is considered to be an important quality indicator in ICU settings. This study was carried out at the paediatric intensive unit [PICU] and step down units of paediatric ward at the Aga Khan University Hospital, Karachi, Pakistan, to assess the frequency, common causes and outcome of patients readmitted in PICU within 48 hours after discharge from unit. During the study period, 1022 patients were admitted in PICU, out of which 24 [2.34%] patients required readmission. Male to female ratio was 1.2:1. The mean length of stay on paediatric floor before readmission was 24 hours. Fifteen [62%] patients were readmitted due to worsening of primary condition while 9 [38%] developed new problems. Respiratory problems accounted for 15 [62.5%] of readmissions, followed by cardiovascular 4 [16.5%] and sepsis related causes 3 [12.5%]. The mortality rate of readmitted patients was 21% [5/24] in this study as compared to overall PICU mortality of 122 [11.93%]

Clinical profile and outcome of children admitted with status epileptics in PICU of a developing country

Status epilepticus [SE] is a common, life-threatening neurologic disorder. The exact incidence is not known. The frequency of occurrence of status epilepticus is 17-23 per 100, 000 persons per year, with the higher incidences occurring in developing countries. In children the mortality from SE ranges from 3-10%. To describe the etiology, clinical profile and immediate-outcome of children with status epilepticus at a Tertiary Care Hospital in Karachi. This is a descriptive and retrospective cohort study on all children admitted in our institution with diagnosis of status epileptics [ICD 9 code 3453]. Demographic, pertinent clinical variables and outcomes were collected on structured questionnaire. During the study period, fifty patients were identified. Mean age was 51 months [age range was 1-168 months with SD +/- 41 months]. There were 29 male: and 21 female. Generalized tonic clonic seizures were the most common [86%] form of seizures observed. Twenty- five [50%] patients were newly diagnosed with no prior history of seizure. Acute febrile illness or infections were the most common etiology [52%]. No biochemical abnormalities were observed in our study. Abnormal EEG was reported in 62% of patients. CSF abnormalities were observed in 22%. Minimum 2 and maximum 8 anti-epileptic drugs were used [mean= 4.33]. The most commonly parenteral drugs included phenytoin, phenobarbitone, levetiracetam and valproic acid. Thirty- one [62%] patients required continuous midazolam infusion. In majority [44%], status was controlled after more than 60mins. Thirty-three patients [66%] required PICU admission for seizure control. Thirty one [62%] required mechanical ventilation, twenty five [50%] required inotropic support. Mean PICU stay duration was 3.89 days [range=1-15 days]. Survival rate was 92%. The cause of death [n=4] was related to underlying systemic illness. No complications were observed in forty-one [82%] patients. In our report, young children had a high incidence of SE and the most common etiology was acute febrile illness. Majority of cases were refractory SE although the mortality rate was low

Botulism in children: a diagnostic dilemma in developing countries

Botulism is a well-known disease of the neuromuscular junction. It is a rare but curable cause of paralysis in paediatric population. In addition to classical clinical signs and symptoms, the diagnosis of botulism requires laboratory confirmation of intoxication by various biological tests. These include demonstration of botulinum toxin in serum or isolation of the Clostridium botulinum from stool/gastric aspirates. However, it is not always possible to confirm intoxication due to unavailability of technical facilities, especially in resource limited countries like Pakistan. Under these circumstances, electrophysiological studies serve as an excellent diagnostic tool. These studies can provide quick diagnosis of botulism so that early administration of botulism immunoglobulin, if available, can reduce morbidity, mortality and length of stay in hospital. We report a case of botulism from Pakistan diagnosed on the basis of electrophysiological studies

Elective tracheostomy in mechanically ventilated children

Tracheostomy is an important procedure in children requiring prolonged mechanical ventilation. We conducted a retrospective study to assess the frequency, indications, postoperative course and short-term outcome of elective tracheostomy in a Paediatric Intensive Care Unit [PICU] of Pakistan. Twenty-five patients underwent tracheostomy in last 5 years [2.2% of all PICU admissions]. Mean age of patients was 6 years and 60% were male. The most common indication for tracheostomy was prolonged mechanical ventilation secondary to neurological disease [60%], followed by upper airway obstruction [40%]. Major complications included accidental decannulation [20%] and tube obstruction [20%]. Three patients [12%] developed ventilator-associated pneumonia after tracheostomy change while persistent bacterial colonization of trachea was observed in 8 patients [32%]. Decannulation was achieved in 40% [10/25]. There was no mortality related to tracheostomy in this series

Acute necrotizing encephalopathy of childhood: a fatal complication of swine flu

Acute necrotizing encephalopathy of childhood [ANEC] is a rare condition characterized by the presence of multifocal symmetrical brain lesions involving mainly thalami, brainstem, cerebellum and white matter. ANEC is a serious and life threatening complication of simple viral infections. We present a case of a young child who developed this condition with classical clinical and radiological findings consistent with ANEC, secondary to swine flu [H1N1]. He needed ventilatory support and had profound motor and intellectual deficit on discharge. We report this case with aim of raising awareness about this fatal complication of swine flu which has become a global health care issue these days

Clinical profile and outcome in a paediatric intensive care unit in Pakistan

Paediatric critical care medicine is a relatively new subspecialty in Pakistan. The clinical profile and outcomes of children admitted in the PICU [paediatric intensive care unit] were retrospectively reviewed from January to December 2007. Mean age of the studied 314 patients was 24 months; 37% were less than one-year-old and 66% was male. Mean PRISM score was 13.2. There were almost equal distribution of medical [46%] and surgical [54%] cases. Ninety percent of patients received mechanical ventilation, while more than 50% received vasoactive drugs. The rate of nosocomial infection was 4.7%. The average length of PICU stay was 3.2 [1-49] days. The overall mortality rate was 14%. The results are encouraging and efforts should be made to establish more PICUs