Evaluation of the Resources and Inequities Among Pediatric Critical Care Facilities in Pakistan.

OBJECTIVES: To evaluate nationwide pediatric critical care facilities and resources in Pakistan. DESIGN: Cross-sectional observational study. SETTING: Accredited pediatric training facilities in Pakistan. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A survey was conducted using the Partners in Health 4S (space, staff, stuff, systems) framework, via email or telephone correspondence. We used a scoring system in which each item in our checklist was given a score of 1, if available. Total scores were added up for each component. Additionally, we stratified and analyzed the data between the public and private healthcare sectors. Out of 114 hospitals (accredited for pediatric training), 76 (67%) responded. Fifty-three (70%) of these hospitals had a PICU, with a total of 667 specialized beds and 217 mechanical ventilators. There were 38 (72%) public hospitals and 15 (28%) private hospitals. There were 20 trained intensivists in 16 of 53 PICUs (30%), while 25 of 53 PICUs (47%) had a nurse-patient ratio less than 1:3. Overall, private hospitals were better resourced in many domains of our four Partners in Health framework. The Stuff component scored more than the other three components using analysis of variance testing ( p = 0.003). On cluster analysis, private hospitals ranked higher in Space and Stuff, along with the overall scoring. CONCLUSIONS: There is a general lack of resources, seen disproportionately in the public sector. The scarcity of qualified intensivists and nursing staff poses a challenge to Pakistan's PICU infrastructure.

Impact of the First Wave of COVID-19 on PICU Admissions in Pakistan.

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Safety and Efficacy of Procedural Sedation and Analgesia in Pediatric Oncology Patients.

Objective Procedural sedation and analgesia are the standard of care for painful procedures in children that require immobility. The aim is to assess the safety and efficacy of procedural sedation and analgesia in pediatric oncological patients in a large tertiary care hospital. Method An observational study performed to review medical records of children who received procedural sedation and analgesia (PSA) for pediatric oncological procedures from July 2018 to September 2018. Patients undergoing oncology procedures (lumbar puncture, intrathecal chemotherapy, bone marrow aspiration +/- trephine) were included, and non-anesthesiologist (intensive care physician/emergency physician certified in pediatric advanced life support) provided PSA. Patients were assessed according to PSA protocol guidelines by the American Society of Anesthesiology (ASA). Low-dose ketamine (0.5 mg/kg) and propofol (2 mg/kg) were administered. Results A total of 565 children underwent 1216 procedures in whom the median age was 7.4 years, and the majority (65.1%) were males. The most common procedure was the lumbar puncture (n = 956; 78.6%) followed by bone marrow aspirate only (n = 137, 11.3%) and both (n = 123, 10.1%). Eight (0.7%) patients developed transient oxygen desaturation only as an adverse effect of ketamine-propofol drug combination with 50% procedures utilizing propofol 1 mg/kg for sedation. Conclusion According to the results of our study, the majority of the pediatric patients responded and reported no adverse events during the procedure with ketamine and propofol. Therefore, we conclude that ketamine and propofol are safe and effective as both sedative and an analgesic in procedures on pediatric oncology patients.

Frequency of Exposure of Nephrotoxic Drugs and Drug-Induced Acute Kidney Injury in Pediatric Intensive Care Unit: A Retrospective Review From a Tertiary Care Centre in Pakistan.

Introduction Acute kidney injury (AKI) is one of the most common problems seen in the pediatric intensive care unit (PICU), with an overall 27% incidence. Besides many other factors, nephrotoxic medications (Nephrotoxins; Ntx) are also responsible for a large proportion of potentially avoidable pediatric AKI, directly accounting for 16% of AKI events. Objective To assess potential associations between nephrotoxic drugs and the risk of developing AKI in children admitted in PICU. Material and methods This is a retrospective cross-sectional study. Children (aged 1 month - 18 years) admitted to the PICU, with a length of stay >24 hours, were included. AKI was defined as according to KDIGO (Kidney Disease Improving Global Outcomes) criteria. Mild AKI was defined as a rise in creatinine value of 0.3 mg/dl from presenting value at a 24-hour interval. Patients were grouped according to the presence or absence of AKI. All medications administered in the ICU were assessed for nephrotoxicity through a review of adverse reactions mentioned in the Pediatric Dosage Handbook, along with consultation with a clinical pharmacist. Results Among 752 patients, the mean age was 4.8 years ± 4.37. There were 57.3% male and 42.7% female children. Among the exposed children, 37.4% received one drug, 32.4% received two drugs and 12.1% had high nephrotoxin exposure. The most commonly used drug was vancomycin (16.8%), as a single Ntx; vancomycin/colistin (12.9%), in dual nephrotoxic combination; and vancomycin/colistin/amphotericin (2.9%) in highly exposed children (i.e., with equal or more than three). Overall, the incidence of AKI was 14.9%. Conclusion Nephrotoxins are potentially avoidable risk factors in critically ill children. Whenever a combination of medications is required, it's advisable to review all medications for better protection of kidneys and preventing of acute kidney injury.

Use of Interventional Radiology in Critically Injured Children Admitted in a Pediatric Intensive Care Unit of a Developing Country.

Objective The aim of this study was to describe the outcome of the use of interventional radiological procedures (IRP) (angioembolization) in critically injured children. Methods A retrospective review of medical records of all children who underwent an IRP from January 2010 to December 2015 was done. Data were collected on a structured proforma and results are presented as mean with standard deviation and frequency with percentages. Result Eighteen patients were identified who underwent IRP during the study period. The mean age was 10.4 ± 4.3 years and 10 (55%) were males. Ten patients had a road traffic accident, four had a history of fall, one patient had glass cut pelvic injury, and two patients had blunt abdominal trauma, while one patient had bleeding secondary to hemipelvectomy. The genitourinary system was involved in five patients, liver in four, and spleen in two and pancreas in one patient. Bleeding was from branches of internal iliac artery in seven patients, hepatic artery in three patients, splenic artery in two patients, and middle colic artery in one patient, while one patient had blood oozing from the bone after hemi-pelvictomy. Four French vascular access sheath was placed under ultrasound guidance; this was followed by the placement of C1 catheter (Cordis, Miami, FL). After vessel identification, a 2.7F Progreat microcatheter (Terumo, Tokyo) was used for super-selective cannulation of the bleeding vessel. Intravascular coil, polyvinyl alcohol (PVA) particles, or gel foam was used for the embolization of bleeding vessels. No procedural complications were observed except minor oozing in one patient. One patient expired due to multiorgan dysfunction. Conclusion Angioembolization is a useful and relatively safe procedure in the management of vitally stable children with hemorrhagic abdominopelvic injuries. However, further studies may be needed to evaluate the efficacy and cost-effectiveness of this practice, especially in resource-constrained settings.

Transfusion-Related Acute Lung Injury In A Paediatric Intensive Care Unit Of Pakistan.

BACKGROUND: Transfusion-Related Acute Lung Injury (TRALI) is a major cause of transfusionrelated morbidity and mortality in the intensive care unit setting. There is a paucity of such data from Pakistan. The purpose of this study is to assess the incidence and outcome of TRALI in critically ill children admitted in a pediatric intensive care unit (PICU) of Pakistan. METHODS: This is a retrospective cohort study of all critically ill or injured children who developed TRALI or "possible" TRALI after blood transfusion based on Canadian Conference Consensus criteria in a closed multidisciplinary-cardiothoracic PICU from January 2012 to June 2016. The demographic, pertinent clinical data, transfusion-related variables and outcome of all cases of TRALI were recorded. RESULTS: Of total 2975 admissions in the PICU during study period, 35.8% (1066) received 5124 blood components. Eleven cases developed TRALI in our cohort. The incidence of TRALI was 1.03% per patient transfused and 0.19% (19/100,000 per blood product transfused). Median age was 8 (range 1-14) yr., 70 % (n=8) were male. Mean PRISM-III score was 16.3±6.7. Mean time interval for onset of TRALI was 2.73±1.67 hr. The postoperative cardiac surgical and hematology-oncology patients were most common categories (63.6%). Plasma and platelets were the most commomly identified trigger of TRALI. The case-specific mortality was 63.6% and the overall mortality was 10.7% (p<0.0001). CONCLUSIONS: The incidence of TRALI in critically ill children is low, but is associated with high mortality. Critically ill children with high PRISM-III score, postoperative cardiac surgical and hematology-oncology patients are often affected by TRALI.

Hyperlactetemia And Its Trends In Critically Ill Children Admitted In Pediatric Intensive Care Unit Of A Developing Country.

BACKGROUND: There is increasing evidence that in setting of critical ailments clinical signs lag biomarkers like Lactate and hyperlactetemia can be the only marker for this disorder. This study was conducted to describe the incidence of hyperlactatemia in critically ill children and its association with outcome. METHODS: Retrospective review of medical records of all children who had their lactic acid (LA) levels measured during their admission in PICU from January 2014 to December 2015 was done. Demographic and clinical variables were recorded along with PICU therapies, outcome (Survived or expired) and development of multi-organ dysfunction. Results are presented as frequency with percentages and mean with standard deviation. Appropriate statistical tests were applied and p-value of <0.05 was taken as significant. RESULTS: Total 300 patients had their LA measured and 202 were included in the study. Males were 130 (64%) and mean age was 5.7±4.6 years. Hyperlactatemia was found in 68 (33%) patients and another 75 (37%) had a second LA level >4 mmol/L. Increasing LA trend was found in 79 (39%) patients. Diagnostic categories included cardiovascular diseases (45, 22%), central nervous system diseases (40, 20%), respiratory diseases (31, 15%), sepsis (28, 14%), and gastrointestinal diseases14 (7%). 168 (83%) needed mechanical ventilation. Mean pH was 7.31±0.15 and metabolic acidosis was observed in 91 patients (45%). Mean LA levels in survivors and non survivors were 3.3±3.12 and 5.35±5.47 respectively. Hyperlactatemia was associated with death (p=0.01) and development of MODS (p=0.03) on univariate analysis. On multivariate logistic regression rising lactate and development of MODS were significantly associated with death (p=<0.05, odds ratio (OR) 9.24 (95% confidence interval 1.55-55.20). CONCLUSIONS: Hyperlactatemia and increasing LA trend in critically ill children are associated with worse outcome in PICU.