Um retrato de UTI Pediátricas em um recorte transversal durante a pandemia de COVID-19: uma avaliação de estrutura das unidades / A cross-sectional Portrait of Pediatric ICUs during the COVI-19 pandemic: an assessment of the structure of the units

O interesse da presente Dissertação surgiu com o intuito de avaliar as Unidades de Terapia Intensiva Pediátricas no aspecto de estrutura do serviço. O inquérito do estudo foi colhido de 01/07/2020 a 31/10/2020 através de um questionário autopreenchido pelos 29 médicos responsáveis técnicos e pelos 1084 profissionais de saúde atuantes nas unidades. O objetivo primário da Dissertação foi avaliar a adequabilidade de aspectos estruturais de 29 Unidades de Terapia Intensiva Pediátricas de sete estados no Brasil à regulamentação normativa que já estava vigente no país antes da pandemia, e às normativas e demandas impostas durante a pandemia. Foram analisados seletos indicadores de estrutura (recursos humanos, protocolos, estrutura física, orientações e rotinas na pandemia, educação continuada e treinamento, e recursos materiais). Na análise de indicadores para verificação de adequação à normativa regulamentadora, avaliou-se que na dimensão de recursos humanos e protocolos ao menos um terço das unidades não cumpriam requisitos previstos em norma. Em recursos humanos, as menores proporções observadas foram para a categoria de técnicos de enfermagem, médicos diaristas e fisioterapeutas (65.5%, 69.1%, 82.7%). Para protocolos clínicos, há 55.2% de unidades que têm protocolos de sepse, sedação e dor instalados e vigentes. Apesar de já haver essa defasagem em questões estruturais, quando se analisou a adequação para as normativas e demandas da pandemia, verificou-se que a resposta das unidades nas diferentes dimensões de estrutura analisadas foi em geral melhor ou semelhante ao observado em estudos feitos na mesma época na América Latina. Foram entrevistados 1084 profissionais de saúde e 60% tiveram disponibilidade de Equipamentos de Proteção Individual (EPI) para assistência em procedimentos geradores de aerossol. As unidades com financiamento privado obtiveram maiores proporções de adequação em recursos humanos para algumas categorias profissionais durante a pandemia como para médicos intensivistas (44.8% x 17.2%; p<0.01). Também houve diferença significativa em recursos materiais, como para assistência em procedimentos geradores de aerossol (31.3% x 28.8%; p=0.02). A categoria profissional que teve mais inadequação à normativa para disponibilidade de EPI foi a de técnicos de enfermagem (14.4% x 11.3%; p<0.01). O que se observou, portanto, foi que nos aspectos avaliados a situação pré-pandemia era razoável, mas já com espaços para melhorias, e durante a crise sanitária houve uma resposta comparável a resultados encontrados em outros estudos na região. Porém, se tivesse havido uma gestão mais eficiente com deslocamento adequado de recursos, é provável que a reação tivesse sido melhor. (AU)

The interest of this dissertation arose to evaluate Pediatric Intensive Care Units (PICU) in terms of service structure. The study survey was collected from 07/01/2020 to 10/31/2020 through a self-completed questionnaire by the 29 technical responsible physicians and 1084 health professionals working in the unit. The primary objective was to describe and evaluate the suitability of structural aspects of 29 Pediatric Intensive Care Units from seven states in Brazil to the normative regulation that was already in course in Brazil before the pandemic, and to the norms and demands imposed during the pandemic. It is proposed to analyze structure indicators (human resources, protocols, physical structure, guidelines and routines in the pandemic, continuing education and training, and material resources). In the analysis of indicators for verification of adequacy to the regulatory norms, it was evaluated that in the dimension of human resources and protocols, at least one third of the units did not fulfill requirements foressen in the norm. In human resources, the lowest proportions observed were for the category of nursing technicians, diarist doctors and physiotherapists (65.5%, 69.1%, 82.7%). For protocols and routines, there are 55.2% of units that have sepsis sedation and pain protocols installed and current. Despite this lag, already existing, when the suitability for the pandemic's regulations and demands was analyzed, it was found that the response of the units in the different structural dimensions analyzed was generally better or similar to that observed in studies carried out at that period in Latin America. There were 1084 health professionals interviewed and 60% had personal protective Equipment (PPE) available for assistance in aerosol- generating procedures. Units with private funding had higher proportions of adequacy in human resources for some professional categories during the pandemic such as intensive care physicians (44.8% x 17.2%; p<0.01), and material resources, such as assistance in aerosol-generating procedures (31.3% x 28.8%; p=0.02). The professional category that had the most inadequacy to the regulations for the availability for of PPE (personal protective equipment) was that of nursing technicians (14.4% x 11.3%; p<0.01). What was observed, therefore, was that in the aspects evaluated, the pre-pandemic situation was reasonable, but already with room for improvement, and during the health crisis there was a response comparable to results found in other studies in the region. However, if there had been more efficient management with adequate allocation of resources, it is likely that the reaction would have been better. (AU)

Characteristics and predictors of outcomes of critically Ill children with SARS-CoV-2 infection - the PICU experience

Abstract Objective To describe the clinical characteristics, laboratory parameters, treatment, and predictors of an unfavorable outcome of critically ill children with SARS-CoV-2 infection. Method This was a prospective observational study performed in a pediatric intensive care unit (PICU) of a tertiary care COVID referral hospital among critically ill children in the age group 1 month - 12 years admitted due to SARS-CoV-2 infection from June to December 2020. Demographic, clinical profile, pSOFA and PRISM III scores, laboratory parameters, treatment, and outcomes of the patients were recorded. Children who had a prolonged PICU stay (>14 days) or died were compared with those who were discharged from PICU within 14 days to assess predictors of unfavorable outcomes. Results PICU admission rate among hospitalized SARS-CoV-2 infected children was 22.1% (92/416). Infants comprised the majority of the ICU population. Invasive mechanical ventilation and inotropic support were required for 28.3% and 37% of patients, respectively. Remdesivir, IVIg, and steroids were administered to 15.2%, 26.1%, and 54.3% of the subjects, respectively. The mortality rate was 7.6 %. MIS-C patients were older, less comorbid, and required less ventilator support but more inotrope support than acute severe COVID-19 patients. Predictors of unfavorable outcomes were age < 1 year, fever duration > 5 days, respiratory distress, shock, comorbidity, elevated CRP (> 50 mg/L), procalcitonin (> 6 ng/L), D-dimer (> 6 µg/L) and arterial lactate (> 2 mmol/L). Conclusion Critically ill children with unfavorable outcomes were predominantly infants, comorbid, prolonged fever, respiratory distress, shock and elevated inflammatory markers, D-dimer and lactate. These factors may be useful for watchful monitoring and early intervention.

Analysis of predictors of response to high-flow oxygen nasal cannula therapy in a pediatric intensive care unit / Análisis de factores predictores de respuesta a la oxigenoterapia de alto flujo en una unidad de cuidados intensivos pediátricos

Abstract Background: Bronchiolitis is one of the most frequent reasons for admission to pediatric intensive care units. Medical treatment is primarily supportive. The usefulness of high-flow oxygen (HFO) nasal cannula in these patients has been described. This study evaluated the clinical and analytical variables of patients admitted to our Pediatric Intensive Care Unit (PICU) for initiation or continuation of HFO for respiratory distress and to identify any variable that may be a predictor of success or failure of this technique. Methods: We conducted a retrospective observational study that included infants aged < 24 months admitted to our PICU due to bronchiolitis between January 2015 and March 2019 for HFO. Results: We analyzed the characteristics between responders (n = 112) and non-responders (n = 37). No statistically significant differences were observed between groups regarding sex, age, weight, comorbidities, nasopharyngeal aspirate result, hours of evolution, and respiratory and heart rate. However, a pCO2 ≥ 75 mmHg (p = 0.043) and a SCORE of bronchiolitis severity (p = 0.032) were predictors of HFNC failure. Conclusions: The pCO2 level and SCORE of bronchiolitis severity are predictors of this respiratory support modality.

Resumen Introducción: La bronquiolitis es uno de los motivos más frecuentes de ingreso en las Unidades de Cuidados Intensivos Pediátricos (UCIP); el tratamiento médico es básicamente de soporte. Se ha descrito la utilidad de la oxigenoterapia de alto flujo (OAF) en estos pacientes. El objetivo de este estudio fue evaluar algunas variables clínicas y analíticas de los pacientes que ingresan en nuestra UCIP para inicio o continuación de OAF ante cuadros de dificultad respiratoria e identificar cualquier variable que pueda ser factor predictor del éxito o fracaso de esta técnica. Métodos: Se realizó un estudio retrospectivo observacional, incluyendo lactantes menores de 24 meses ingresados en la UCIP entre enero de 2015 y marzo de 2019 para OAF ante cuadros de bronquiolitis. Resultados: Se analizaron las características entre el grupo de respondedores (n = 112) y no respondedores (n = 37). No se observaron diferencias estadísticamente significativas en cuanto al sexo, edad, peso, comorbilidades, resultado del aspirado naso-faríngeo, horas de evolución, frecuencia respiratoria, frecuencia cardiaca entre ambos grupos. Sin embargo, una pCO2 ≥75 mmHg (p = 0.043) y un SCORE de gravedad de la bronquiolitis mayor (p = 0.032) fueron factores predictores de fracaso de la OAF. Conclusiones: El nivel de pCO2 y el SCORE de gravedad de la bronquiolitis son factores predictores de esta modalidad de soporte respiratorio.

Complications and neurologic deterioration after bilateral decompressive craniectomy in Gunshot penetrating brain injury in children

Background: Penetrating skull injuries in pediatrics (TPC) occupy a special place due to their rarity. The aim is to provide an overview of the current evidence on decompressive craniectomy in children, to describe the indications and to detail the complications. Reporte case: We present the case of a 12- year-old boy who suffered a TPC by a projectile that perforated his head, causing multiple brain injuries, and underwent early bilateral decompressive craniectomy, presenting the complications and neurological disabilities typical of the injury and surgery, with a reserved evolution and prognosis. Conclusions: Pediatric penetrating skull injuries should be of individualized management, type of injury and disease, experience of the treatment team, and the decision should always be consensual in front of the benefits and risks in the short and long term.

Introducción: Los traumatismos craneales penetrantes en pediatría (TPC) ocupan un lugar especial debido a su rareza. El objetivo es ofrecer una visión general de la evidencia actual sobre la craniectomía descompresiva en niños, describir las indicaciones y detallar las complicaciones. Reporte de caso: Presentamos el caso de un niño de 12 años que sufrió un TPC por un proyectil que le perforó la cabeza, causándole múltiples lesiones cerebrales, y fue sometido a craniectomía descompresiva bilateral temprana, presentando las complicaciones y discapacidades neurológicas propias de la lesión y la cirugía, con una evolución y pronóstico reservados. Conclusiones: Los traumatismos craneales penetrantes pediátricos deben ser de manejo individualizado, tipo de lesión y enfermedad, experiencia del equipo tratante, y la decisión debe ser siempre consensuada frente a los beneficios y riesgos a corto y largo plazo.

Validity of Pneumonia Severity Score in Predicting Mortality of Pediatric Patients in a Tertiary Care Hospital

Background: Pneumonia is estimated to kill 410,000 children in India every year. In India, recent estimates in under-fivessuggest that 13% of deaths and 24% of the National Burden of Disease is due to pneumonia.Very few studies have evaluatedthe predictors of mortality in children with pneumonia in developing countries.Hence, this study was planned to study predictorsof mortality in children aged 1–59 months based on pneumonia severity score (PSS) in hospitalized patients with severepneumonia.Objective: The objective of this study is to assess the factors (clinical and investigational) contributing to the mortality in patientsbased on PSS in hospitalized patients diagnosed with severe pneumonia.Materials and Methods: The present observational longitudinal study was carried out in a tertiary care PICU in a Govt. NSCBMedical College, Jabalpur for of 1 years (Ian 2019–December 2019). Children diagnosed as severe pneumonia of either sexbetween age group 1–59 months admitted in a hospital were enrolled in the study. Demographic data, clinical details, andlaboratory parameters of the enrolled cases were recorded in a predesigned pretested pro forma. PSS was calculated andcorrelated with the outcome of the patients enrolled and followed up till discharge or death.Results: Mortality was observed in 11 cases, and of them, 4 (36.4%) were males and 7 (63.6%) patients were females. This studyshowed that among clinical parameters pulse rate and SpO2 were significantly raised (63.6%) and saturation was significantly<90 (72.7%) in children who succumbed to death (P < 0.05). This study observed a statistically highly significant associationof PSS with the outcome of children (P < 0.01).

A study on mean anion gap over 6 hours after admission as a predictor of pediatric mortality in pediatric intensive care unit

Background:The aims of the study was to correlate change in anion gap at 0 and 6 hours of admission with mortality in pediatric intensive care unit (PICU).Methods:Fifty children up to 12 years of age, admitted in PICU were included in the study. Blood gas anion gap levels were taken at 0 and 6 hours of admission and change in anion gap was calculated. Final outcome was recorded.Results:Out of 50 patients enrolled in the study, 18 (36%) patients died and 32 (64%) survived. Mortality was higher in group with increased anion gap after 6 hours of admission as compared to survived. Change in anion gap was higher in expired patient as compared to survivors.Conclusions:Mortality was higher in group with increased anion gap after 6 hours of admission

Study of morbidity pattern and outcome of patients admitted in paediatric intensive care unit in a tertiary care rural teaching hospital

Background: The care of the critically ill children remains one of the most demanding and challenging aspects in the field of paediatrics. The main purpose of Paediatric Intensive care unit is to prevent mortality by intensively monitoring and treating critically ill children who are considered at high risk of mortality. In the developing countries, there is a scarce data on paediatric critical care. Evaluation of the outcome of medical interventions can assess the efficacy of treatment. This helps in better decision making, improving the quality of care and modifying the future of management if required. This study will also help to study the causes of morbidity and mortality among paediatric age group in our hospital. Aims and Objectives of the study is to evaluate the morbidity pattern and outcome of admissions in the PICU of a rural teaching hospital, and to take measures to prevent morbidity and mortality by improving critical care facilities.Methods: This was a retrospective study, the cases admitted in paediatric ICU in our teaching hospital in last two and a half considering the estimated sample size. Data will be collected from PICU and Medical record Department. Details will be studied with the help of medical record and will be analysed and interpreted according to the medical record details.Results: During a period of 30 months of the study, total of 417 patients were admitted in our PICU. Of the total cases studied, Maximum i.e. 180(43.2%) had age below 1 year. The minimum ' maximum range of age was between 1 day to 18 years. About 228(54.7%) cases were males and 189(45.3%) were females. The most common diagnosis was LRTI which was observed in 61(14.7%) of cases. The most common system involved was respiratory system which was observed in 101(21.8%) cases. Of total cases studied, 357(85.6%) were discharged, 36(8.6%) had DAMA (discharge against medical advice) and 24(5.8%) expired.Conclusions: Mortality was low in our PICU. We conclude based on the present study that in our rural set up PICU, with better treatment protocols, skilled expertise/ Paediatric Intensivist we have chances to facilitate the care of critically ill patients giving desirable outcome.

Hypomagnesemia as a predictor of mortality in critically ill pediatric patients in picu using prism score

Background: Magnesium is the fourth most abundant cation in the human body and the second most abundant intracellular cation after potassium. A potential relationship between low magnesium levels and increased mortality has been suggested in the literature. The objectives were to detect prevalence of hypomagnesemia in critically ill children, its association with sepsis and to correlate this with mortality.Methods: This study was an observational study done on 100 children who met the inclusion criteria, admitted to the PICU of Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India. Patients under the study were managed and treated according to their clinical status and supportive traditional treatment.Results: Prevalence of hypomagnesemia in critically ill pediatric patients was 53%. In this study, majority of the cases admitted to PICU were dengue (19%) and bronchopneumonia (15%) which were significantly associated with hypomagnesemia as p value was less than 0.05. As regard prognosis, Mg had an AUC of 0.576 for prediction of mortality whereas the AUC for PRISM score was 0.811. Logistic regression analysis showed that hypomagnesemia is a significant predictor for mortality among critically ill children (p value=0.028) and OR=3.180 (0.854-7.965).Conclusions: Present study has found high prevalence of hypomagnesemia in critically ill patients. Hypomagnesemia was associated with a higher mortality rate in critically ill patients and commonly associated with infections and respiratory diseases. Hypomagnesemia indicated poor outcome and higher mortality rates in critically ill patients.

Acute Hyponatremia And Hypernatremia Related To Intravenous Fluid Administration In Hospitalized Children: A Randomized Observational Study

Background: Intravenous fluid and electrolyte therapy in most of the acutely ill hospitalized children has beenthe cornerstone of medical practice for a well over 50 years.Objective: To determine optimal maintenance fluid therapy by comparing the incidence of hyponatremia orhypernatremia in hospitalised children.Methods: A prospective Randomized study done in PICU in patients admitted to paediatric emergency. The studywas conducted between September 2007 to May 2008. Children of age group 1 month to 16 years were included.The fluid groups were divided into four groups. SPSS version 18 was used for analysis.Results: The mean age in group I is 4.42, in group 2 is 3.84, in group 3 is 3.67 and in group 4 is 4.45. The meanserum sodium levels in fluid group 1 is 137.4 mmol/L, in fluid group II 138.2 mmol/L, in fluid group III is 138.9mmol/L and fluid group IV is 137.8 mmol/L. After initiating maintenance fluid therapy serum sodium levelschanged in each group. As we can see in group 1 mean serum sodium level at the start of the therapy is 137.43mmol/L and after 24 hours of hypotonic fluid infusion it reduced to 135.4 mmol. 69 patients had hyponatremiaand 44 had hypernatremia.Conclusion: Amount of free fluid in the IV maintenance fluid can be factor in causing hypernatremia. Caution iswarranted to guard off a rapid fall of serum sodium level.

A study on clinical profile and outcome of patients in PICU (paediatric intensive care unit) at tertiary care unit

Background: This study was carried out with the objectives to study the clinical profile and to find the outcome of children admitted to pediatric intensive care unit (PICU) of Kurnool medical college and hospital, Andhra Pradesh.Methods: A retrospective study was carried in children aged more than 28 days to 12 years admitted in PICU from 1st January 2016 to 31st December 2016 when a total of 600 patients were admitted.Results: Out of these, 400 (66.66%) cases were males and 200 (33.33%) cases were females. Maximum numbers of patients were in the age group of more than 28 days to 1 year which constituted 325 (54.16%) cases. This was followed by 1 year to less than 5 years age group which constituted 150 (i.e. 25%) cases. Under 5 years aged children constituted 500 (83.33%) cases. Next most common age group admitted was 5 years to 10 years with 85 (i.e. 14.16%) cases and 10 to 12 years age group constituted 40 (6.66%) cases. In this study, central nervous system was the commonest system involved (n=195, 32.5%). Other systems involved were: respiratory system (n=122, 20.33%), cardiovascular system (n=65, 10.83%), gastro-intestinal system (n=32, 5.33%), hematological (n=35, 5.83%) and renal system (n=23, 3.83%).'' Other causes include infections (n=97, 16.16%), metabolic (n=17, 2.83%), down syndrome (n=7, 1.16%) and poisoning (n=7, 1.16%) etc.Conclusions: Out of the 600 patients admitted to PICU, 168 (28%) patients died. 315 (52.5%) cases improved.' 117 (19.5%) cases constituted those who were shifted to higher centre or another department or were taken against medical advice.

Prevalence of hypomagnesemia in children admitted to pediatric intensive care unit and its correlation with patient outcome

Background: Magnesium deficiency is common in critical illness and is said to be associated with increased need for mechanical ventilation, mortality and prolonged ICU stay. The knowledge of hypomagnesemia is essential as available data is scarce and it could have prognostic and therapeutic implications. This study was undertaken to estimate the prevalence of hypomagnesemia at the time of admission in PICU and its correlation with length of PICU stay, duration on mechanical ventilator and outcome at the end of hospital stay-death or discharge.Methods: This is a prospective observational study including 343 children aged 1month to 12years admitted to PICU. Detailed history taking and clinical examination was done for all enrolled children. At admission, blood was collected for estimation of serum magnesium. Patients were categorized into three groups i.e., hypomagnesemia, normomagnesemia and hypermagnesemia and data was analysed.Results: Out of 343 children, 28% had hypomagnesemia, 7.3% had hypermagnesemia and 64.7% had normomagnesemia. Hypomagnesemia was more common in neurological disorders. No association was found between magnesium and length of mechanical ventilation. PICU stay was significantly longer in hypomagnesemia group (p=0.031). 37.5% patients with hypomagnesemia also had hypocalcemia and 35.4% had hypokalemia. Mortality rate was higher in those with hypomagnesemia (30.2%) compared to those with normomagnesemia (22.1%).Conclusions: Patients with hypomagnesemia had increased duration of PICU stay, other associated electrolyte abnormalities and higher mortality. Hence monitoring of magnesium levels in critically ill patients is indicated.

Clinical profile and outcome of shock in mechanically ventilated patients in pediatric intensive care unit of tertiary care centre

Background: The clinical syndrome of shock, a clinical state characterized by inadequate tissue perfusion, is one of the most dramatic, dynamic and life-threatening problems faced by the physician in the critical care setting.Methods: Retrospective observational study of all critically ill children between 1month-12years who were admitted and mechanically ventilated in our 8-bedded PICU between January 2015 to June 2016; and had clinical evidence of shock. PIM3 (Paediatric Index of Mortality 3) was calculated. Authors noted morbidity and mortality pattern in all types of shock including outcome in Paediatric ICU. The data collected were compiled and tabulated.Results: The frequency of shock in authors’ Paediatric intensive care unit was 8.6% (n=780). However, among mechanically ventilated patients it was present in 65.5% patients. Septic shock was the most commonly encountered shock (n=48, 61.5%). Mortality was highest in cardiogenic shock (n=12, 80%) and obstructive shock (n=4, 80%). Survival was best in Hypovolemic shock. Authors found significant correlation between LOS MV and mortality (p=0.018). Type of shock had no correlation with PIM3 score (p=0.374) and mortality (p=0.884). Blood culture yield was positive in 26.9% patients with Klebsiella pneumoniae, Pseudomonas aeruginosa and MRSA being most common organisms isolated.Conclusions: Shock is a major cause of morbidity and mortality in children especially below 5yrs of age. Septic shock was the commonest form of shock in children. Severe pneumonia was the commonest illness causing septic shock. Mortality was associated with longer length of stay on mechanical ventilation. Larger prospective multicentric study in developing countries is desirable.

Study of antibiotic prescription pattern in PICU of a tertiary care hospital

Background: Infectious disease is one of the importance causes of mortality and morbidity in India, therefore pattern of use of antibiotics requires separate study as they differ from adult, Therefore the aim of our study is to observe the antibiotic prescription in the tertiary care hospital.Methods: A prospective observational study was carried out in the children admitted in PICU. The study was started after obtaining the approval from Institutional Ethics Committee. Written informed consent was obtained from a parent or legal guardian of participants.Results: There were 50 patients were enrolled. The maximum antibiotics were prescribed from cephalosporin class (42; 40.38%) which included ceftriaxone, cefixime, cefotaxim, cefpodoxime. The majority of cephalosporins were prescribed in miscellaneous cases followed by respiratory tract infections, gastrointestinal tract, Central nervous tract infections and nil in CVS cases, secondly higher number of antibiotics prescribed was metronidazole and from Aminopenicillin class which includes amoxiclav and ampicillin and another beta lactamase which includes ureidopenicilin and carbepenem. The majority of aminopenicillin were prescribed in miscellaneous group infections followed by respiratory tract infections.Conclusions: From this study, it can conclude that commonly antibiotic were from 3rd generation cephalosporins followed by metronidazole and other ? lactamase inhibitor and all of the antibiotics were prescribed as per the national guidelines.

Diagnostic value of brain natriuretic peptide in left to right shunt congenital heart disease accompanied by heart failure / 中国小儿急救医学

Objective To investigate the diagnostic value of plasma B-type natriuretic peptide(BNP) in left to right shunt congenital heart disease accompanied by heart failure in PICU.Methods We retrospectively reviewed the clinical data of 52 cases diagnosed left to right shunt congenital heart disease in the PICU of Shengjing Hospital of China Medical University from January 2012 to June 2014.The cases were divided into negative control group(n=18) and heart failure group(n=34) according to the criteria for the diagnosis of pediatric heart failure.We respectively compared plasma BNP,size of heart defects,left ventricular end-diastolic volume index(LVEDVI),ratio of left ventricular early diastolic filling blood flow velocity and left ventricular late diastolic filling blood flow velocity(E/A),left ventricular ejection fraction(LVEF),pulmonary artery systolic pressure(PASP),and cardiothoracic ratio between the two groups.We analyzed the correlation between plasma BNP and the size of heart defects,LVEDVI,E/A,cardiothoracic ratio,LVEF,PASP.The receiver operating characteristic curve was used to determine the optimal cut-off value of plasma BNP to diagnose heart failure.Results Plasma BNP were 87.7(22.7,165.7)pg/ml in negative control group and 716.5(326.8,1813.0)pg/ml in heart failure group.The plasma BNP level of heart failure group was significantly higher than that of negative control group(Z=5.3,P<0.01).Size of heart defects were 5.0(3.0,6.8) mm in negative control group and 7.4(5.5,9.0)mm in heart failure group.Size of heart defects of heart failure group was significantly higher than that of negative control group(Z=3.5,P<0.01).LVEDVI were (44.6±18.3)ml/m3 in negative control group and (70.8±38.4)ml/m3 in heart failure group.LVEDVI of heart failure group was significantly higher than that of negative control group(t=2.7,P=0.01).E/A were 1.3±0.3 in negative control group and 1.1±0.3 in heart failure group.E/A of negative control group was significantly higher than that of heart failure group(t=2.2,P=0.04).Plasma BNP had a positive relation with cardiothoracic ratio(r=0.49,P=0.01) and a negative correlation with E/A(r=-0.28,P=0.04).The optimal cut-off value of plasma BNP was 181.8 pg/ml.The sensitivity of diagnosis of heart failure was 94% and the specificity was 88%.The area under the receiver operating characteristic curve was 0.951.Conclusion Plasma BNP may comprise a sensitive marker for heart failure of left to right shunt congenital heart disease.It is recommended that 181.8 pg/ml is the optimal cut-off value to diagnose heart failure of left to right shunt congenital heart disease.

Factores de riesgo asociados a infecciones por Acinetobacter baumannii en una unidad de cuidados intensivos pediátricos / Risk factors associated to Acinetobacter baumannii in a PICU

El Acinetobacter baumannii (Ab) es un germen nosocomial, multiresistente, afecta especialmente a pacientes críticamente enfermos, contribuyendo en la mortalidad; su impacto en nuestro medio es desconocido. Objetivos: el presente estudio pretende determinar la incidencia de infección por Ab y los principales factores de riesgo asociados. Métodos: se realizó un estudio observacional, de tipo caso y control en 257 niños internados en la UTIP del Hospital del Niño Manuel Ascencio Villarroel. Resultados: encontrándose 4 brotes a lo largo del año y una incidencia de 7,8/100 internados; el germen fue aislado en superficies inanimadas, no así en el personal. Se evidenciaron los siguientes factores de riesgo tras 10 días de exposición: Días de internación en UTIP (OR=10,09; p=0,000), uso de ventilador mecánico (OR=15,75; p=0,000), intubación endotraqueal (OR=17,09; p=0,000), catéter urinario (OR=11,9; p=0,000), catéter venoso central (OR=12,9; p=0,000), catéter venoso periférico (OR=14,2; p=0,000), sonda naso u orogástrico (OR=13; p=0,000). La mortalidad observada no varía significativamente de la mortalidad general. Conclusiones: concluimos que el Ab es el principal agente bacteriano nosocomial en la UTIP, la estancia prolongada en el servicio, y los días de invasividad aumentan el riesgo de adquirir este germen; se requieren medidas de control de los brotes para disminuir su incidencia.

Acinetobacter baumannii (Ab) is a nosocomial, multiresistent pathogen, affecting especially critically ill patients, leading to mortality; is unknown its impact in our hospital. Objectives: this study pretends to determinate infection incidence of Ab and its risk factors associated. Methods: it was performed an observational, case and control study, in 257 children admitted to Manuel Ascencio Villarroel Children Hospital; we found 4 spreads in a year, the incidence was 7,8/100 of admitted patients. Ab was isolated in environmental cultures, but was not found in personal cultures. Results: we found following risk factors after 10 days exposure: PICU days internship (OR=10,09; p=0,000), mechanical ventilation (OR=15,75; p=0,000), endothacheal tube (OR=17,09; p=0,000), urinary catheter (OR=11,9; p=0,000), central venous catheter (OR=12,9; p=0,000), peripherical venous catheter (OR=14,2; p=0,000), oro or nasogastric catheter (OR=13; p=0,000); mortality found associated to Ab was similar to the found in the control group Conclusions: we concluded that Ab is the most frequent pathogen isolated in our PICU, prolonged stay and invasive methods increase risk to be infected by this pathogen; control measures are necessary to decrease its incidence.

Healthcare associated infections in Paediatric Intensive Care Unit of a tertiary care hospital in India: Hospital stay & extra costs.

Background & objectives: Healthcare associated infections (HAIs) increase the length of stay in the hospital and consequently costs as reported from studies done in developed countries. The current study was undertaken to evaluate the impact of HAIs on length of stay and costs of health care in children admitted to Paediatric Intensive Care Unit (PICU) of a tertiary care hospital in north India. Methods: This prospective study was done in the seven bedded PICU of a large multi-specialty tertiary care hospital in New Delhi, India. A total of 20 children with HAI (cases) and 35 children without HAI (controls), admitted to the PICU during the study period (January 2012 to June 2012), were matched for gender, age, and average severity of illness score. Each patient’s length of stay was obtained prospectively. Costs of healthcare were estimated according to traditional and time driven activity based costing methods approach. Results: The median extra length of PICU stay for children with HAI (cases), compared with children with no HAI (controls), was seven days (IQR 3-16). The mean total costs of patients with and without HAI were ` 2,04,787 (US$ 3,413) and ` 56,587 (US$ 943), respectively and the mean difference in the total cost between cases and controls was ` 1,48,200 (95% CI 55,716 to 2,40,685, P<0.01). Interpretation & conclusions: This study highlights the effect of HAI on costs for PICU patients, especially costs due to prolongation of hospital stay, and suggests the need to develop effective strategies for prevention of HAI to reduce costs of health care.

Clinical Characteristics of Patients with Bronchopulmonary Dysplasia Admitted to Pediatric Intensive Care Unit

PURPOSE: As the incidence of bronchopulmonary dysplasia (BPD) has increased, it is important to understand the clinical outcomes of BPD patients discharged from neonatal intensive care units (NICU). The purpose of our study was to describe the characteristics of BPD patients who are re-hospitalized in a pediatric intensive care unit (PICU) and to evaluate the prognostic outcome factors. METHODS: We retrospectively reviewed the medical records of BPD patients who were admitted to our PICU between May 2006 and November 2014. In total, we identified 101 cases which were divided into two groups, group 1, those who required intensive care for an acute illness or disease aggravation (n=62), and group 2, those who were admitted for post-operative care unrelated to having BPD as a control group (n=39). We subsequently compared the characteristics. RESULTS: Most patients in group 1 were aged less than 1 year, with weight below the 3rd percentile for age at the time of their PICU admission. The main cause for their admission was respiratory failure, requiring mechanical ventilation. When comparing the two groups, group 1 showed higher gestational age at birth, and a longer duration of mechanical ventilation, oxygen support, and NICU hospitalization than group 2. However, we failed to identify any factor significantly associated with the duration of the PICU stay, hospital stay, and mortality. Further large-scale, long-term follow-up studies will be necessary. CONCLUSION: As the majority of patients are admitted to PICU because of respiratory symptoms during their infantile period, careful follow-up with supportive care and prevention of respiratory infection are required.

Non-Invasive Ventilation in a Pediatric Intensive Care Unit: An Experience of Tertiary Care Hospital Over 4 Years in Oman.

Background: Noninvasive ventilation (NIV) has now become an integral tool in the treatment of both acute and chronic respiratory failure, and at the same time reducing the need for invasive ventilation. Aim: To determinate the efficacy of NIV in pediatrics whom admitted to Pediatric intensive care unit (PICU) with respiratory failure (Short term evaluation). Subjects and Methods: Based on a retrospective review of electronic medical records (EPR) of patients who underwent NIV in the period between January 2007 and December 2010, demographic and clinical data were collected before and after applying the NIV. The data included heart rate (HR), respiratory rate (RR), oxygen concentration (PO2) and CO2 concentration (PCO2). Results: NIV was used for a total of 61 pediatric patients admitted to PICU during the period of the study. Pneumonia was the commonest indication for the NIV (n=25, 40.9%), and continuous positive airway pressure (CPAP) was used in 52(85.2%) patients. The mean duration of NIV was 8±7.2 days, there was a significant clinical improvement after one hour from application of NIV. The mean improvement in RR was from 48.4±2.2 to 35.0±1.5 (P=0.000), SPO2 was improved from 88.1±1.8 to 96.5±0.7 (P= 0.000), and the PCO2 was improved from 61.4±6.1 to 48.7±3.7 (P=0.002). Five patients were failing to respond to the NIV and shifted to mechanical ventilation. Conclusion: The NIV is a useful tool for treatment of respiratory failure in pediatrics, especially under the age of one year. Pneumonia was the commonest indication for the use of the NIV.

Admission Patterns and Outcome in a Pediatric Intensive Care Unit in Nepal.

Aims: To study the admission patterns and outcome of children in a Pediatric Intensive Care Unit (PICU) in Nepal. Methods: Demographic profile, diagnosis, treatment, supportive measures and outcome of children admitted to the PICU of B P Koirala Institute of Health Sciences from April 2011 to March 2012 were reviewed. Results: 230 children were admitted to the PICU with male to female ratio of 1.7:1. Diagnoses included respiratory diseases (n=76, 33%), central nervous system diseases (n=43, 18.6%), infectious diseases (n=26, 11.3%), surgical problems (n=18, 7.8%), gastrointestinal diseases (n=17, 7.4%), cardiovascular diseases (n=15, 6.5%), poisonings (n=11, 4.8%), renal (n=9, 3.9%), hematological (n=3, 1.3%) and others (n=12, 5.4%). Out of 230 admitted children, 29 (12.6%) died, 19 (8.2%) left against medical advice and 5 (2%) were referred to other centers. Forty-one (17.8%) children received mechanical ventilation, among which 23 (56%) improved, 14 (34.1%) died and 4 (9.7%) children were taken away by caretakers against medical advice. Conclusion: Respiratory, central nervous system and infectious disease were the common reasons for admission. Children with infectious diseases and need for mechanical ventilation had higher mortality. Therefore, these patients require early referral and timely institution of therapy for better outcome; and intensive care facilities should be expanded to decrease child mortality.

Epidemiological Study of Morbidity Pattern of Critically Ill Children Admitted in Child Intensive Therapy Unit.

Background : In India 34.3% of the total population is constituted by the most vulnerable segment of our society i.e. infants and children. Malnutrition, respiratory and diarrhoeal diseases are three main scourges of the children but the great devils hovering upon them are lack of proper treatment and management. The present study was conducted to find out the morbidity pattern of our vulnerable children. Aims and Objectives : 1. To find out the prevalence of critically ill children admitted in the hospital. 2. To find out the morbidity pattern of critically ill children admitted in the child intensive therapy unit, in a hospital. Research Question : What is the epidemiological pattern of morbidity in critically ill children of age 1 month to 12 years? Study Design : Cross-sectional Study. Study Participants : All critically ill children coming to the emergency unit of the hospital during study period. Statistical Analysis : Simple percent and proportions, Chi square test.