The Various Scoring Systems in Pediatric Intensive Care Units: A Prospective Observational Study.

BACKGROUND: The discrimination power of the pediatric risk of mortality (PRISM), pediatric index of mortality (PIM), sequential organ failure assessment (SOFA), and pediatric logistic organ dysfunction (PELOD) may not always be true for countries such as India due to differences in factors from those nations where these scoring systems were validated. Therefore, this study was undertaken to determine and compare severity, course of illness, and outcomes in critically ill children admitted to the pediatric intensive care unit (PICU) using different scoring systems such as PRISM 4, PIM 3, PELOD 2, and the pediatric sequential organ failure assessment (pSOFA ) score, and to analyze the clinical spectrum and demographic profile of children admitted to the PICU. MATERIALS AND METHOD: This was a prospective, single-center, observational study conducted in the PICU of the Indira Gandhi Institute of Medical Science, Patna, India, over two years. Two hundred children in the age group of one month to 14 years admitted to the PICU were recruited into the study. Prognostic scoring systems, including PRISM4 and PIM3, were used to compare the outcome, mortality, and length of PICU stay, whereas PELODS and pSOFA were descriptive scores that assessed the multiorgan dysfunction. A correlation between the different scoring systems and the outcome was determined. RESULTS: The majority of children (26.5%, n=53) were one to three years of age. The maximum number of patients was male (66.5%, n=133). Renal complications were the predominant admission diagnosis in 19% (n=38) of children. The mortality rate was found to be 18.5%. The mortality was most common in infants <1 year of age (n=11, 29.73%) and those of the male sex (n=22, 59.46%). A significant correlation was found between length of stay and mortality (p<0.00001). A significant positive correlation was observed between mortality and PRISM 4, PIM 3, PELOD 2, and pSOFA scores on the first day of admission (p<0.00001). The pSOFA and PELOD2 showed better discrimination power (area under the curve (AUC): 0.77 and 0.74, respectively). CONCLUSION: The study concluded that the pSOFA and PELOD2 scores are reliable predictors of mortality in critically ill children.

Improvement of Hand Hygiene Compliance Using the Plan-Do-Study-Act Method: Quality Improvement Project From a Tertiary Care Institute in Bihar, India.

Background Hospital-acquired infections (HAIs) are the most severe complications of intensive care stay, especially in pediatric patients. Proper hand hygiene (HH) is the cheapest, simplest, but often neglected method to prevent HAIs. The World Health Organization (WHO) has formulated and promoted a standardized recommendation for HH. Both the WHO and the Centers for Disease Control and Prevention (CDC) recommend the use of soap and water for handwashing whenever there is visible dirt on the hands. In all other situations, an alcohol-based hand rub is an effective alternative. The quality improvement (QI) methodology has been widely followed in many countries to improve basic and advanced healthcare systems. The QI strategy follows the plan-do-study-act (PDSA) method. Methodology This quasi-experimental (pre- and post-intervention), prospective, QI study was conducted at the neonatal intensive care unit and pediatric intensive care unit of the pediatrics department in a tertiary care hospital in Bihar, India. A QI team was formed. The study was divided into four phases. WHO charts for assessing HH compliance were used for observation and data collection. The EQUATOR Checklist (Squire Checklist) was used to accurately report the QI work. Epi Info™ (version 7.2.5) was used for statistical analysis. The chi-square test was used to measure the statistical difference between pre- and post-intervention HH compliance (proportions). Results In the pre-intervention phase, a total of 106 HH opportunities were observed. The HH compliance at this stage was 40.6%. The QI team conducted several meetings, and a root cause analysis was performed with the help of the Fishbone diagram. It was decided to target three probable causes, namely, (a) less awareness, (b) inconvenient locations of hand rub dispensers, and (c) forgetfulness. The QI team decided to run three PDSA cycles. In the last phase, 212 HH opportunities were observed with a compliance percentage of 69.8%. There was a significant improvement when data of pre- and post-intervention HH compliance were compared in all categories of healthcare workers (HCWs), except doctors, where the improvement was not statistically significant. When the cumulative data of all subtypes of HCWs were analyzed, there was a significant improvement (p < 0.0001). Run charts and box plots were used for the easy depiction of the results. Conclusions Adopting proper HH methods remains the most effective way of preventing nosocomial infections, especially in intensive care units. We used the WHO model of HH in our study. The pre-intervention HH compliance was 40.6%. QI methodology using root cause analysis and implementation of three PDSA cycles were used to increase the HH compliance percentage. Post-intervention HH compliance increased to 69.8% and the effect was sustained. The study highlights the usefulness of the QI methodology in bringing small but important changes in clinical practice for better patient care.

Clinical and Echocardiographic Profile of Congenital Heart Diseases in the 0-12-Year Age Group in a Tertiary Care Medical Institute in Eastern India: A Retrospective, Cross-Sectional Study.

Background This study aimed to determine the clinical and echocardiography profile of congenital heart diseases (CHDs) among admitted children as well as patients presenting to the outpatient department of the Indira Gandhi Institute of Medical Sciences, Patna, which is a tertiary care and apex institute located in Bihar, India. Methodology A retrospective, cross-sectional study was conducted in a tertiary care hospital from January 2019 to January 2021. In total, 200 patients aged 0-12 were enrolled in the study. The study design was exploratory, with a proforma drafted to study patients with features suggestive of CHDs. All pediatric echocardiography was performed by a trained cardiologist. Records were obtained from the departmental record-keeping register, and reports were available for analyzing the data. For data collection, cardiology and pediatric department registers were reviewed and all CHD data were collected. Data analysis was done using SPSS software version 25.0 (IBM Corp., Armonk, NY, USA). Results Of the 200 children with CHDs, 142 were diagnosed to have acyanotic heart disease (ACHD), while 58 had cyanotic congenital heart disease (CCHD). Among 200 cases of CHD, ventricular septal defect (VSD) constituted 62 cases comprising 31% of the total CHD cases and 44% of all ACHD cases. Atrial septal defect (ASD) was the second most common CHD comprising 23% of all CHD cases. Tetralogy of Fallot (TOF) constituted 23 cases accounting for 11.5% of all CHD cases. It was the most common CCHD. Based on the age at the time of presentation, 90 (45%) cases were diagnosed below one year of age. Congestive heart failure (CHF) was most common in ACHD comprising 30% compared to CCHD in which only 7% of cases had CHF. This finding was statistically significant (p < 0.05). Analyzing the symptoms of different CHDs, of both ACHDs and CCHDs, the common symptoms were fast breathing (38%). Conclusions Among ACHD patients, 31% VSD and 21% ASD were noted. In CCHD, TOF was the most common with 11.5% of cases. Respiratory tract conditions were the most common comorbidities encountered. Because this is one of the first studies conducted in Bihar in the pediatric age group, it can help know the prevalence of CHDs in this region and will be useful for developing policies by stakeholders.

Successful Ventilation of Acute Respiratory Distress Syndrome Complicated by Pneumothorax Using Airway Pressure Release Ventilation: A Case Report.

Pneumothorax can develop in children being mechanically ventilated for 'severe acute respiratory distress syndrome' making the situation worse and challenging for the treating intensivist. There is no evidence on use of 'airway pressure release ventilation' mode in children with acute respiratory distress syndrome complicated by pneumothorax. We present a case of a girl who had severe acute respiratory distress syndrome and developed pneumothorax on pressure control ventilation mode. We had to use 'airway pressure release ventilation' mode in view of severe refractory hypoxemia. Fortunately, the child responded well and weaned off the ventilator over few days. We suggest that 'airway pressure release ventilation' mode may be used successfully in patients with 'acute respiratory distress syndrome' complicated by pneumothorax if intensive and close monitoring is done. KEY MESSAGES: APRV may be a useful mode of ventilation in severe ARDS with pneumothorax. HOW TO CITE THIS ARTICLE: Chandelia S, Kishore S, Nandan D. Successful Ventilation of Acute Respiratory Distress Syndrome Complicated by Pneumothorax Using Airway Pressure Release Ventilation: A Case Report. Indian J Crit Care Med 2019;23(9):437-438.

Comparison of antistreptolysin O and anti-deoxyribonucleic B titers in healthy children to those with acute pharyngitis, acute rheumatic fever, and rheumatic heart disease aged 5-15 years.

BACKGROUND: Acute rheumatic fever (ARF) affects millions of children in the third world countries like India. The diagnosis of rheumatic fever is based on the Jones criteria with serological titers, antistreptolysin O titer (ASO), and anti-deoxyribonucleic B (ADB), taken as evidence of recent streptococci infection. There is a lack of recent data available on ASO and ADB titers in children from the Delhi/NCR and thus adequate geographical area-specific cutoffs for the region are not available. AIMS AND OBJECTIVES: The aim of this study is to determine and compare the ASO and ADB antibody titers in children with acute pharyngitis, ARF, rheumatic heart disease (RHD), and in healthy children of the Delhi/NCR region. MATERIALS AND METHODS: Twenty-six cases of ARF, 51 cases of RHD, 50 cases of acute pharyngitis, and 84 healthy normal children were included in the study. A single ASO and ADB titer measurement was done in these children. RESULTS: The ASO titers was raised in acute pharyngitis - 303 IU/ml (interquartile range [IQR], 142-520 IU/ml) and ARF - 347.5 IU/ml (IQR, 125-686 IU/ml) children in comparison to healthy controls - 163.5 IU/ml (IQR, 133-246.5 IU/ml) and RHD patients - 163 IU/ml (IQR, 98.250-324.500). The ADB titers were highest in ARF patients - 570.5 IU/ml (IQR, 276-922 IU/ml) followed with RHD - 205 IU/ml (IQR, 113.6-456.5), healthy controls - 78.25 IU/ml (IQR, 53.39-128.15 IU/ml), and acute pharyngitis - 75.12 IU/ml (IQR, 64.5-136 IU/ml). The upper limit of normal (ULN) values of ASO and ADB computed from normal healthy children were 262.4 IU/ml and 134.44 IU/ml, respectively, and these can be used as cutoff values for recent streptococcal infection in this geographical area. CONCLUSIONS: The median ASO titers in acute pharyngitis group and ARF were significantly raised compared to that of the control group. The ADB titers were raised in ARF and RHD patients albeit the levels were higher in ARF patients. The derived ULN values can be used as cutoff reference.

Atypical Articular Presentations in Indian Children With Rheumatic Fever.

BACKGROUND: The objective of the study was to describe the clinical characteristics of atypical articular presentations during the initial outbreak and recurrence in patients with acute rheumatic fever (ARF) in the paediatric age group. METHODS: This was a retrospective, observational study conducted between January 2012 and December 2014 on all suspected cases of acute rheumatic fever (ARF) fulfilling either WHO 2004 or Australian guidelines with atypical articular manifestations ie, presence of at least one of the following features: duration of symptoms more than 3 weeks; monoarthritis/arthralgia; involvement of small joints of hand and feet and/or cervical spine and/or hip joint; and, not responding to salicylates in 1 week. RESULTS: 'Atypical' pattern was present in 63% (39/62) of patients with articular manifestations, of which arthralgia was a common manifestation (57%). Polyarticular afflictions were predominately non-migratory (additive) in both atypical (74%; 29/39) and typical (82%; 18/23) groups. Monoarticular (33%) affliction of the joints constituted a significant disease manifestation. Time from onset to diagnosis was >3 weeks in 79% of patients while small joints involvement and axial joint involvement occurred in half of the cases (51%). Inadequate response to NSAIDs was found in three (7%) cases. CONCLUSION: Atypical manifestations in ARF may well be mistaken for a connective tissue disorder, post streptococcal reactive arthritis and septic arthritis. Physicians should be made aware of these features to prevent diagnostic dilemma, and to effect institution of appropriate management including penicillin prophylaxis.

Holt-Oram Syndrome: A Rare Variant.

Holt-Oram syndrome is an autosomal dominant disorder, characterised by skeletal abnormalities of the upper limb associated with congenital heart defect, mainly atrial and ventricular septal defects. Skeletal defects exclusively affect the upper limbs in the preaxial radial ray distribution and are bilateral and asymmetrical. They range from clinodactyly, absent or digitalised thumb, hypoplastic or absent radii, and first metacarpal to hypoplastic ulna and carpal bone anomalies. Cardiac involvement ranges from asymptomatic conduction disturbances to multiple structural defects. Structural defects are seen in 75% of the cases and include both atrial and ventricular septal defect. More complex cardiac lesions such as Tetrology of Fallot, endocardial cushion defects, double outlet right ventricle, and total anomalous pulmonary venous return are observed uncommonly. An aneurysm of the interatrium septum is an infrequent finding in infants. It has been speculated that atrial septal aneurysm (ASA) is a direct source of thrombus formation. Paradoxical embolism of venous thrombi across a right to left shunt is possibly responsible for the cryptogenic stroke in a patient with ASA. However, coagulopathy associated with cyanotic congenital heart defect may also be contributory. Our patient had a rare association of complex cardiac lesion (tricuspid atresia, pulmonary stenosis, atrial septal aneurysm) with cardiac conductive defects and left parietal infarct along with the usual skeletal abnormalities.

Bicuspid Aortic Valve: An Unusual Cause of Aneurysm of Left Coronary Sinus of Valsalva.

Bicuspid aortic valve is traditionally considered an innocuous congenital anomaly. Due to a better and widespread availability of non-invasive imaging techniques, it has come to the fore that 30% of these cases develop complications, viz., valve abnormality (aortic regurgitation and stenosis), and aneurysm of aortic root and ascending aorta. Sinus of Valsalva aneurysm is an uncommon complication of bicuspid aortic valve and more so those arising from the left coronary sinus are the rarest. These complications generally occur in the third or fourth decade of life. We present a case of the left sinus of Valsalva aneurysm in conjunction with bicuspid aortic valve and ascending aorta aneurysm at a very young age in a girl in her early adolescence. This case is to remind the paediatricians about the not so "innocuous image", but the serious implications of the bicuspid aortic valve and to regularly follow these cases for early diagnosis of potential complications so as to prevent catastrophic outcomes.

Severe acute respiratory distress syndrome caused by unintentional sewing machine lubricant ingestion: A case report.

Sewing machine oil ingestion is rare but is possible due to its availability at home. Chemically, it belongs to hydrocarbon family which is toxic if aspirated, owing to their physical properties such as high volatility and low viscosity. On the contrary, sewing machine lubricant has high viscosity and low volatility which makes it aspiration less likely. The main danger of hydrocarbon ingestion is chemical pneumonitis which may be as severe as acute respiratory distress syndrome (ARDS). We report a case of a 5-year-old girl with accidental ingestion of sewing machine lubricant oil, who subsequently developed ARDS refractory to mechanical ventilation. There was much improvement with airway pressure release ventilation mode of ventilation, but the child succumbed to death due to pulmonary hemorrhage.

Baseline illness severity does not alter accuracy of neonatal sepsis screen.

We investigated the relationship between illness severity and accuracy of neonatal sepsis screen. Consecutive neonates with clinically suspected early onset sepsis (EOS) were enrolled and blood culture and sepsis screen [C-reactive protein, absolute neutrophil count, immature to total ratio (ITR) and microerythrocyte sedimentation rate] were performed. Exclusion criteria were prior antibiotic exposure, nonavailable reports, and contaminated cultures. Score for Neonatal Acute Physiology Perinatal Extension (SNAPPE-II) was used to categorize neonates into "mild to moderate" (score 40) illness. Sepsis was defined as positive blood culture, and positive screen as >or=2 parameters positive. Of 125 subjects, 86 had mild to moderate and 39, severe illness. Twenty-eight (22%) subjects had sepsis. Sensitivity, specificity, negative predictive value, positive predictive value, likelihood ratio of positive test, and likelihood ratio of negative test of the sepsis screen and screen parameters were similar between the two groups. The sensitivity of the screen was 37.5% and 25% for mild to moderate illness and severe illness, respectively. Only ITR values correlated with SNAPPE-II scores in patients with "sepsis" (rho 0.4; P = 0.036). The severity of underlying illness does not alter the performance of the sepsis screen in diagnosing culture-positive EOS.