Disseminated intravascular coagulation initial score as a predictor of mortality in children with dengue shock syndrome: A retrospective cohort study.

Background: The mortality of dengue shock syndrome (DSS) in children is still high at 12-44%. Assessment of DIC initial score using the International Society on Thrombosis and Haemostasis scoring system can help diagnosing and treating DIC, while also predicting mortality in pediatric patients with DSS. Methods: We retrospectively collected data of children with DSS at Dr. Sardjito Hospital between January 2017 and June 2021 with inclusion criteria such as age 1 month to 18 years and laboratory parameters taken within first 24 h after DSS workup. Results: Results showed a sample population consisting of 20 male subjects (58.8%), 24 aged >5 years (76.0%), 21 with good nutritional status (61.8%), and median length of stay 5 days (3-7), with saturation of 98% (97-99) and median pediatric Glasgow coma scale level of consciousness of 13. The laboratory profile showed median levels of hematocrit at 40.9% (32.9-44.9), thrombocytes at 20,500/L (14,000-32,000), prothrombin time of 17.8 s (14.9-25.3), fibrinogen at 123 mg/dL (106-184) and D-dimer at 832.5 ng/mL (362-1119). A DIC initial score of ≥5 25 (73.5%) resulted with a mortality of 9 children (36.0%) with a 92% survival rate in the first 6 h. The first 6-h survival according to each DIC score parameter showed 93.8%, 100%, 85.7%, and 94.1% of thrombocytes ≤50,000 µ/L, fibrinogen <100 mg/dL, D-dimer >1000 ng/mL, and prothrombin time >6 s, respectively. Conclusion: A DIC initial score ≥5 can be used as a mortality predictor in the first 6 h after DSS diagnosis.

Acute appendicitis in pediatric patients with Coronavirus Disease 2019 (COVID-19): A case series from a developing country's tertiary hospital.

INTRODUCTION: and importance: A common gastrointestinal presentation of both COVID-19 and multisystem inflammatory syndrome in children (MIS-C) is acute abdominal pain, which sometimes mimics appendicitis. Literature describing children with COVID-19 infection and concurrent acute appendicitis is growing, and understanding these patients' clinical picture is necessary for their proper treatment. CASE PRESENTATION: We present a case series of six healthy children before they developed classic symptoms of appendicitis. At the same time, they were also found to have confirmed COVID-19. All patients had fever and right lower abdominal pain. Four of six children having Alvarado score above seven had surgical treatment, while the others only received systemic antibiotic and antiviral medication. Surgical results of two patients revealed perforated appendicitis. No mortality occurred among them. CLINICAL DISCUSSION: There is increasing recognition of gastrointestinal involvement in patients with COVID-19 and MIS-C. There are several postulates to explain appendicitis in COVID-19. First, inflammatory response is exaggerated in SARS-CoV-2 infected patients. Second, obstruction of the appendiceal lumen is caused by mesenteric adenopathy, which in turn, is caused by COVID-19 infection, not fecalith. Third, hyperinflammatory response in MIS-C triggers inflammation in appendix. CONCLUSION: Clinicians must recognize that abdominal pain with fever could be the presenting symptoms of COVID-19 with MIS-C. MIS-C, which has severe presentations with gastrointestinal manifestations and high mortality rate, should be considered as a differential diagnosis for a patient with appendicitis-like symptoms and a positive SARS-CoV-2 infection.

Sepsis and disseminated intravascular coagulation are rare complications of typhoid fever: A case report.

INTRODUCTION: and importance: Typhoid fever is an infection caused by Salmonella typhi. The common complications are intestinal perforation and typhoid encephalopathy. Cases of typhoid fever with sepsis and/or disseminated intravascular coagulation (DIC) are rarely reported, even though typhoid fever is endemic in Indonesia. CASE PRESENTATION: A 4-year-old male referral case from a district hospital was experiencing fever, decrease of consciousness and massive bleeding from his gastrointestinal tract and nose. Investigation revealed results from the IgM typhoid test using Tubex®TF, with the score of +8. PELOD 2 score was 10, and PSOFA was 5. DIC score was 7. Based on these findings, the patient was diagnosed with typhoid fever, with DIC and sepsis being the complication of the typhoid fever. CLINICAL DISCUSSION: DIC is mostly a subclinical event, and severe bleeding complications found in typhoid fever are uncommon, although DIC scores which indicate an imbalance of coagulation and fibrinolysis are markedly elevated in patients with typhoid. DIC can be a part of multi-organ dysfunction due to sepsis syndrome. Acute infection can also result in systemic activation of coagulation. CONCLUSION: Sepsis and DIC are rare complications of typhoid fever. Typhoid fever can be presented with profound bleeding manifestation other than gastrointestinal bleeding, since it is a common symptom of typhoid fever. Further research should be conducted to postulate association between typhoid fever and DIC.

Factors associated with mortality in intracranial infection patients admitted to pediatric intensive care unit: A retrospective cohort study.

BACKGROUND: Intracranial infection is a major cause of emergency and death in children. To assist clinical decision-making in patient management, we conducted a study about factors associated with mortality. This study aimed to evaluate factors associated with mortality in pediatric patients with intracranial infection. METHODS: We performed a cohort retrospective study in our tertiary hospital to evaluate the outcomes of patients admitted to the pediatric intensive care unit (PICU) from 2014 to 2018. The Chi-square test was performed to determine the significance of the predictor, and p < 0.05 was considered to indicate a statistically significant result. We used multivariate logistic regression to determine relative risk (RR) with 95% confidence interval (CI). RESULTS: We recruited 112 patients who were admitted to the PICU of our tertiary hospital. A total of 38.4% were diagnosed with encephalitis, 9.8% meningitis and 51.8% meningoencephalitis. Of the 112 patients who met the inclusion criteria, 28 (25%) patients died in the PICU. The need of mechanical ventilation support variable had a statistically significant association with mortality (RR 22.76; 95% CI: 3.88-51.45). CONCLUSION: Recognition of conditions that exacerbate intracranial infection in children needs to be done as early as possible. Moreover, the need of mechanical ventilation support in the PICU needs more attention.

Factors associated with mortality of pediatric sepsis patients at the pediatric intensive care unit in a low-resource setting.

BACKGROUND: Sepsis is the leading cause of death worldwide in pediatric populations. Studies in low-resource settings showed that the majority of pediatric patients with sepsis still have a high mortality rate. METHODS: We retrospectively collected records from 2014 to 2019 of patients who had been diagnosed with sepsis and admitted to PICU in our tertiary hospital. Cox proportional hazard regression modeling was used to evaluate associations between patient characteristics and mortality. RESULTS: Overall, 665 patients were enrolled in this study, with 364 (54.7%) boys and 301 (46.3%) girls. As many as 385 patients (57.9%) died during the study period. The median age of patients admitted to PICU were 1.8 years old with interquartile range (IQR) ±8.36 years and the median length of stay was 144 h (1-1896 h). More than half 391 patients (58.8%) had a good nutritional status. Higher risk of mortality in PICU was associated fluid overload percentage of > 10% (HR 9.6, 95% CI: 7.4-12.6), the need of mechanical ventilation support (HR 2.7, 95% CI: 1.6-4.6), vasoactive drugs (HR 1.5, 95% CI: 1.2-2.0) and the presence of congenital anomaly (HR 1.4, 95% CI: 1.0-1.9). On the contrary, cerebral palsy (HR 0.3, 95% CI: 0.1-0.5) and post-operative patients (HR 0.4, 95% CI: 0.3-0.6) had lower mortality. CONCLUSION: PICU mortality in pediatric patients with sepsis is associated with fluid overload percentage of > 10%, the need for mechanical ventilation support, the need of vasoactive drugs, and the presence of congenital anomaly. In septic patients in PICU, those with cerebral palsy and admitted for post-operative care had better survival.

Post-herniorrhaphy extubation technique in pediatric patient with congenital diaphragmatic hernia and VACTERL association: A case report.

INTRODUCTION: and importance: Congenital diaphragmatic hernia (CDH) is a condition characterized by a defect in the diaphragm causing protrusion of abdominal organs into the thoracic cavity. Comprehensive management, definitive surgical procedures and postoperative care are able to significantly reduce morbidity and mortality in post-herniorrhaphy patients. Here, we reported a case of post herniorrhaphy pediatric patient with a challenge in extubation. CASE PRESENTATION: A 4-month-old girl with a chief complaint of respiratory distress from was admitted to our Pediatric Intensive Care Unit. The diagnosis of diaphragmatic hernia was confirmed through small bowel follow-through radiological examination. Definitive treatment of laparotomy and herniorrhaphy were then done. The special technique for extubation was applied. Currently, the patient survives without any sequelae awaiting stoma closure. CLINICAL DISCUSSION: Extubation is the removal of an endotracheal tube when it is no longer needed. In mechanically ventilated patients, extubation can be performed in two ways, either using the tracheal suction catheter (TSC) or positive pressure breath (PPB) techniques. Studies show that the PBB extubation technique has better patient outcomes compared to the TSC technique. However, the TSC technique is more commonly done by medical professionals. We used the PPB technique because there were recurrent atelectases in the left lung. CONCLUSION: This case report illustrates extubation technique in a post-herniorrhaphy patient with congenital diaphragmatic hernia and VACTERL association. Moreover, several options of extubation techniques can be used for extubation procedure in pediatric patient with CDH.

Obstructive shock in pediatric patient with congenital cystic adenomatoid malformation: A case report.

INTRODUCTION: and importance: Congenital cystic adenomatoid malformation (CCAM) is a rare cystic lesion in the lungs. CCAM might present in the early neonatal period with symptoms of respiratory distress. CASE PRESENTATION: A 2-year-old girl was admitted to our Pediatric Intensive Care Unit with signs of severe respiratory distress. She had been diagnosed with CCAM since she was three months old. She also had undergone several procedures such as thoracotomy and decortication since then, but she still suffered some episodes of pulmonary infection. In this admission, her computerized thoracic tomography revealed a pleuropulmonary blastoma (PPB). CLINICAL DISCUSSION: An obstruction of blood outflow from the left ventricle could happen when an intrathoracic mass exists, leading to a decrease of cardiac output and resulting in an obstructive shock, which could be fatal. One of the malignancy types commonly occurring is pleuropulmonary blastoma (PPB), which has a poor prognosis. Early detection on CCAM can be done by prenatal ultrasound. CONCLUSION: Obstructive shock is one of complication that might occur in pleuropulmonary blastoma.

Diagnostic challenges of hemophagocytic lymphohistiocytosis in child with multiorgan dysfunction in a low-resource setting: A case report.

INTRODUCTION: and importance: Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome as a result of dysregulation of the immune system. Physicians in the intensive care unit (ICU), especially pediatricians, need to know how to recognize the diagnostic criteria and spectrum of HLH clinical presentations because early detection and timing of initial therapy affect the survival rate of the patient. CASE PRESENTATION: A 7-year-old female patient was referred to the pediatric ICU (PICU) at our tertiary hospital because of the suspicion of severe sepsis with shock and disseminated intravascular coagulation. On the fifth day of treatment, the patient was intubated and given a mechanical ventilator after experiencing respiratory failure. On the seventh day in the PICU, high fever persisted and the patient developed worsening acute kidney injury with oliguria. When worsening conditions continued, the patient experienced hypotension and cardiac arrest. The patient died on the 8th day of treatment at PICU due to severe shock and multiorgan failure. CLINICAL DISCUSSION: HLH complications can be life-threatening with documented ICU mortality of 35%, even with an appropriate initial therapeutic approach. Patients with HLH can have rapid progression of disease and often require a significant amount of ICU supportive care, including vasopressor support, significant amount of blood products, ventilator support, and renal replacement therapy. CONCLUSION: The diagnosis of HLH should be considered if there are cases with persistent, prolonged fever, organomegaly, cytopenias and evolving Multi Organ Dysfunction Syndrome. It is important for pediatricians to know the diagnostic criteria and possible clinical presentations of HLH.

Nitric oxide influences red blood cell velocity independently of changes in the vascular tone.

Nitric oxide (NO) plays a key role in regulation of vascular tone and blood flow. In the microcirculation blood flow is strongly dependent on red blood cells (RBC) deformability. In vitro NO increases RBC deformability. This study hypothesized that NO increases RBC velocity in vivo not only by regulating vascular tone, but also by modifying RBC deformability. The effects of NO on RBC velocity were analysed by intra-vital microscopy in the microcirculation of the chorioallantoic membrane (CAM) of the avian embryo at day 7 post-fertilization, when all vessels lack smooth muscle cells and vascular tone is not affected by NO. It was found that inhibition of enzymatic NO synthesis and NO scavenging decreased intracellular NO levels and avian RBC deformability in vitro. Injection of a NO synthase-inhibitor or a NO scavenger into the microcirculation of the CAM decreased capillary RBC velocity and deformation, while the diameter of the vessels remained constant. The results indicate that scavenging of NO and inhibition of NO synthesis decrease RBC velocity not only by regulating vascular tone but also by decreasing RBC deformability.

Red blood cells express a functional endothelial nitric oxide synthase.

The synthesis of nitric oxide (NO) in the circulation has been attributed exclusively to the vascular endothelium. Red blood cells (RBCs) have been demonstrated to carry a nonfunctional NO synthase (NOS) and, due to their huge hemoglobin content, have been assumed to metabolize large quantities of NO. More recently, however, RBCs have been identified to reversibly bind, transport, and release NO within the cardiovascular system. We now provide evidence that RBCs from humans express an active and functional endothelial-type NOS (eNOS), which is localized in the plasma membrane and the cytoplasm of RBCs. This NOS is regulated by its substrate L-arginine, by calcium, and by phosphorylation via PI3 kinase. RBC-NOS activity regulates deformability of RBC membrane and inhibits activation of platelets. The NOS-dependent conversion of L-arginine in RBCs is comparable to that of cultured human endothelial cells. RBCs in eNOS-/- mice in contrast to wild-type mice lack NOS protein and activity, strengthening the evidence of an eNOS in RBCs. These data show an eNOS-like protein and activity in RBCs serving regulatory functions in RBCs and platelets, which may stimulate new approaches in the treatment of NO deficiency states inherent to several vascular and hematologic diseases.