Role of Intravenous Magnesium Sulphate in Term Neonates with Hypoxic Ischemic Encephalopathy (HIE) in a Low-income Country: A Randomised Clinical Trial.

OBJECTIVE: To determine the effects of magnesium sulphate in term neonates with hypoxic ischemic encephalopathy (HIE) in reducing mortality and morbidity. STUDY DESIGN: Randomised clinical trial. PLACE AND DURATION OF STUDY: Department of Neonatology, Services Hospital, Lahore, Pakistan from April to December 2019. METHODOLOGY: Term babies (inborn or outborn), fulfilling the operational definition of hypoxic ischemic encephalopathy, reaching within 6 hours of delivery in Nursery Department of Pediatric Medicine Unit-II, Services Hospital, Lahore, were included. Sarnat score was used for staging the severity of HIE. Cases were administered magnesium sulphate (MgSO4) as intravenous infusion. Rest of the management was similar for cases and controls. Mortality was defined as death due to birth asphyxia; whereas, morbidity was assessed by comparing the following at discharge: the grade of hypoxic ischemic encephalopathy, presence and frequency of seizures, duration of seizures, ability to suck feed and neurological problems such as abnormalities of muscle tone and neonatal reflexes. Babies with prematurity, dysmorphism comorbidities or arriving after 6 hours of birth, were excluded. Chi-square test was used for comparison; and p value <0.05 was considered significant. RESULTS: Gender, mode of delivery, mode of resuscitation at birth, major risk factors (prolonged labour, premature rupture of membranes, presence of meconium-stained amniotic fluid) were comparable in both groups. The duration of seizures, ability to suck feed and presence of neurological problems at discharge were significantly better in magnesium sulphate group as compared to control group. CONCLUSION: Magnesium sulphate is better in establishing earlier suck feed and reducing the duration of seizures and neurological problems in babies with birth asphyxia. Key Words: Hypoxic ischemic encephalopathy, Magnesium sulphate, Outcome, Term, Low income country.

Mortality in meconium aspiration syndrome in hospitalized babies.

OBJECTIVE: To determine the outcome of the babies in terms of mortality with the diagnosis of Meconium Aspiration Syndrome (MAS). STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: The Neonatal Unit of Services Institute of Medical Sciences and Services Hospital, Lahore, Pakistan, from February 2008 to January 2009. METHODOLOGY: All the babies admitted to the neonatal unit during the period of study with the diagnosis of MAS were included. At admission, demographic, maternal, antenatal and natal data were recorded on a specific form. The progress of the baby, including need for ventilation, medications, complications and outcome were also followed and documented. RESULTS: One hundred and nine babies admitted with MAS, 32% died. Most of the babies (n=73) were admitted from our obstetrical unit and the rest through the emergency department. Majority (60 of 109) were admitted within the 1st hour of life. Most (14 of 15) of the newborns requiring intubation within 1st hour of life, died. Forty four babies were ventilated and 35 of these babies succumbed. Of ventilated babies, 11 developed pneumothoraces. Seventy two percent (13 out of 18) of expired babies stayed for less than 24 hours. CONCLUSION: Mortality rate for MAS was higher in the study group as compared to international figures. It was especially high in babies requiring mechanical ventilation in 1st hour of life or with co-existing severe hypoxic ischemic encephalopathy.

Risk factors for hypoxic ischemic encephalopathy in children.

OBJECTIVE: To determine underlying risk factors in neonates with hypoxic ischemic encephalopathy. STUDY DESIGN: Case-control study. PLACE AND DURATION OF STUDY: Neonatology Unit at the Children's Hospital and the Institute of Childhealth, Lahore, from March to July 2005. PATIENTS AND METHODS: All neonates (153) with the diagnosis of Hypoxic Ischemic Encephalopathy (HIE) were included in the study. Controls (187) were selected from admissions on the same day. Possible risk factors such as maternal age, parity, antenatal monitoring, place of delivery, prolonged second stage of labour, type of delivery, type of attendant at delivery and the gestational age were noted and compared. RESULTS: Sixty one (39.9%) mothers of asphyxiated babies reported no antenatal visits compared to 24.1% in the control group (OR 2.1, 95% CI 1.3-3.2; p=0.002). Only 6.5% of cases were born in government hospitals (teaching and district) in comparison to 20.9% of controls (OR 3.8, 95% CI 1.9-7.6; p=0.001). In 28.1% of cases, mothers had history of prolonged 2nd stage of labour in comparison to 5.9% of controls (OR 6.3, 95% CI 3.3-11.9; p<0.001). Fifty five cases (35.9%) were delivered by unskilled birth attendants compared to 28 (14.9%) controls (OR 3.2, 95% CI 1.9-5.3; p<0.001). No significant difference was found in maternal age, maternal parity, gestational age and the mode of delivery between the two groups. CONCLUSION: Delivery by unskilled birth attendant, prolonged second stage of labour, birth in a non-government hospital setup and absence of antenatal care were significant risk factors for hypoxic ischemic encephalopathy in neonates. Improvement in antenatal and intrapartum care may be helpful in decreasing the frequency of this problem.

Justifying the clinical use of fresh frozen plasma - an audit.

OBJECTIVE: To determine the appropriateness of fresh frozen plasma (FFP), uses in various haematological and clinical disorders, with reference to the British Committee for Standards in Haematology (BCSH) guidelines through an audit. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Haematology and Transfusion Medicine, Shalamar Hospital, Lahore, from June 2001 to June 2004. SUBJECTS AND METHODS: The data was collected from June 2001 to June 2004 from the request forms ordered by the clinicians for the transfusion of FFP at the Department of Haematology and Transfusion Medicine, Shlamar Hospital, Lahore. A total of 2075 healthy blood donors donated their whole blood for the preparation of fresh frozen plasma (FFP). All blood donors were screened for anti HCV, HBsAg, VDRL and HIV. Those 2075 FFP units were prepared on high-speed centrifuge and were rapidly stored at -30oC freezer. A total of 587 patients were transfused 2075 units of FFP for various clinical disorders. The percentage of FFP units, transfused appropriately and inappropriately, as defined by BCSH guidelines, was estimated. RESULTS: Out of 2075 FFP units, 335 (24.41%) FFP units were transfused to patients suffering from bleeding due to disseminated intravascular coagulation (DIC), 306 (22.30%) units used for massive transfusion and surgical bleeding, 236 (17.20%) units for bleeding due to chronic liver disease, 202 (14.72%) units used to control bleeding due to coagulation factor deficiencies, 84(6.12%) units for thromobotic thrombocytopenic purpura (TTP), 75(5.46%) units prior to liver biopsy to correct prolonged prothrombin time (PT), 72(5.24%) units for haemorrhage due to haemolytic disease of newborn (HDN) and 62(4.51%) units to control bleeding due to warfarin overdosage, 425(60.45%) units used for nutritional support and hypovolaemia replacement, 131(18.63%) units for the reversal of prolonged INR in the absence of bleeding due to warfarin, 92 (13.08%) units used in ICU to correct prolonged PT without bleeding due to Vitamin K deficiency and 55(7.82%) units for chronic liver disease (CLD) to correct prolonged PT and APTT in the absence of bleeding. In summary, 1372 (66.12%) FFP units were appropriately and 703 (33. 88 %) were inappropriately used. CONCLUSION: In conclusion, 33.88% FFP was inappropriately used mainly due to lack of awareness of international guidelines and ignorance of risks.

Acute poisoning in children.

OBJECTIVE: To determine the frequency, etiology, clinical presentation and outcome of acute poisoning in children presenting to a tertiary care hospital. DESIGN: Descriptive and observational study. PLACE AND DURATION OF STUDY: Emergency Department of the Children's Hospital and the Institute of Child Health, Lahore. Over five years from September 1998 to August 2003. MATERIAL AND METHODS: All cases of suspected or confirmed acute poisoning in children (1 month to 15 years) were retrospectively analyzed by retrieving data from hospital records and from patients files where possible. Variables like demographic data, season of presentation, type of agent, route of exposure and outcome were studied for all cases. Detailed files were available for 90 patients in whom place of exposure, risk factors and clinical features were also studied. RESULTS: Three hundred and forty-six cases of acute poisoning were registered during the study period, which constitute 0.93% of all ER admission. Most (59%) were less than 2 years of age with median age of 18 months (SD+ 32.6). Majority (80%) belonged to urban areas and presented during summer and monsoon season (57%). Pharmaceutical products were the leading cause (51%) followed by petroleum products (23%), chemicals (8.4%), household substances (7.6%) and unidentifiable agents in 10% cases. Anti-diarrhoeal drugs and kerosene oil were the two most frequent agents involved and ingestion remained the primary route of exposure. Gastrointestinal system was primarily involved in 40% patients. Eighty percent patients were discharged, 6% with residual damage while 11% patients died of poisoning or its complications. CONCLUSION: Acute poisoning carries a significant impact as regards morbidity and mortality. Awareness and education about the potential toxicity of commonly used drugs and household substances may help in reducing the burden of acute poisoning in children.