We describe a case of life-threatening pulmonary hemorrhage in a boy with leukemia. He had episodes of massive hemoptysis for which he was intubated and resuscitated with multiple blood products, hemostatic measures (tranexamic acid and recombinant factor VIIa), and inotropes. Chest X-ray revealed left upper lobe homogeneous opacity. Within 12 h, in view of persistent massive pulmonary bleed and hypoxia, he was reintubated with a left-sided double-lumen endotracheal tube (DLT). Following reintubation with DLT, pulmonary bleed could be managed. He was treated for probable left upper lobe angioinvasive aspergillosis. He was weaned off ventilatory support and extubated after 48 h to high flow nasal canula (HFNC). This case is to highlight the importance of early use of DLTs in pulmonary hemorrhage due to suspected unilateral lung pathologies to facilitate isolation of diseased lung, improve ventilation, and prevent spillage of blood to the contralateral normal lung. It serves as a temporizing measure, while aggressive efforts to identify and control the bleed are underway.
我们描述了一个患有白血病的男孩肺出血危及生命的病例。他曾多次大咯血，为此插管并使用多种血制品、止血措施（氨甲环酸和重组因子 VIIa）和肌注药物进行抢救。胸部 X 光片显示左上叶均质混浊。12 小时内，鉴于持续大量肺出血和缺氧，他被重新插上了左侧双腔气管插管（DLT）。重新插管后，肺出血得以控制。他接受了可能是左上叶血管侵袭性曲霉菌病的治疗。48 小时后，他脱离了通气支持，拔除了插管，转用高流量鼻导管（HFNC）。本病例旨在强调在怀疑单侧肺部病变导致肺出血时尽早使用 DLT 的重要性，以利于隔离病变肺部、改善通气、防止血液溢出到对侧正常肺部。在积极查明和控制出血的同时，它也是一种临时措施。
{"title":"Double-lumen endotracheal tube in pediatric intensive care unit: A lifesaver in a leukemic child with pulmonary hemorrhage: A case report","authors":"ParvathyS Menon, Indira Jayakumar, RVikram Rajkumar, VenkateswaranVellaichamy Swaminathan, CVasantha Roopan","doi":"10.4103/jpcc.jpcc_60_23","DOIUrl":"https://doi.org/10.4103/jpcc.jpcc_60_23","url":null,"abstract":"We describe a case of life-threatening pulmonary hemorrhage in a boy with leukemia. He had episodes of massive hemoptysis for which he was intubated and resuscitated with multiple blood products, hemostatic measures (tranexamic acid and recombinant factor VIIa), and inotropes. Chest X-ray revealed left upper lobe homogeneous opacity. Within 12 h, in view of persistent massive pulmonary bleed and hypoxia, he was reintubated with a left-sided double-lumen endotracheal tube (DLT). Following reintubation with DLT, pulmonary bleed could be managed. He was treated for probable left upper lobe angioinvasive aspergillosis. He was weaned off ventilatory support and extubated after 48 h to high flow nasal canula (HFNC). This case is to highlight the importance of early use of DLTs in pulmonary hemorrhage due to suspected unilateral lung pathologies to facilitate isolation of diseased lung, improve ventilation, and prevent spillage of blood to the contralateral normal lung. It serves as a temporizing measure, while aggressive efforts to identify and control the bleed are underway.","PeriodicalId":34184,"journal":{"name":"Journal of Pediatric Critical Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139291490","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
S. Sumithra, PDiksha Kaveriappa, PY Namratha Upadhya, NKavitha Bhat
A 16-year-old boy with type 1 Diabetes Mellitus and autoimmune hypothyroidism presented with Diabetic Ketoacidosis (DKA) and severe hyperkalemia .Renal Function test were normal .Hyperkalemia resolved after increasing insulin infusion from 0.1u/kg /hr to 0.3u/kg/hr.Hyperkalemia in DKA is thought to be due to compromised renal function secondary to hypovolemia. But the higher Insulin rate needed to restore normal potassium level in this case , suggests that insulin deficit in itself could be one of the causes for hyperkalemia in DKA .
{"title":"Severe hyperkalemia in a child with diabetic ketoacidosis: A case report","authors":"S. Sumithra, PDiksha Kaveriappa, PY Namratha Upadhya, NKavitha Bhat","doi":"10.4103/jpcc.jpcc_68_23","DOIUrl":"https://doi.org/10.4103/jpcc.jpcc_68_23","url":null,"abstract":"A 16-year-old boy with type 1 Diabetes Mellitus and autoimmune hypothyroidism presented with Diabetic Ketoacidosis (DKA) and severe hyperkalemia .Renal Function test were normal .Hyperkalemia resolved after increasing insulin infusion from 0.1u/kg /hr to 0.3u/kg/hr.Hyperkalemia in DKA is thought to be due to compromised renal function secondary to hypovolemia. But the higher Insulin rate needed to restore normal potassium level in this case , suggests that insulin deficit in itself could be one of the causes for hyperkalemia in DKA .","PeriodicalId":34184,"journal":{"name":"Journal of Pediatric Critical Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139304238","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The tenets of airway anatomy and management continue to be reevaluated and challenged as our knowledge increases. This has led to a better understanding of the pediatric airway and its critical differences from adults. This evolving understanding of the pediatric airway size and shape has significant clinical implications to airway management in the operating room, emergency department, and the intensive care unit. The first significant change in clinical practice was the transition to the routine use of cuffed endotracheal tubes (ETTs). This was facilitated by the availability of the Microcuff® with a polyurethane cuff and a redesigned position of the cuff on the shaft of the ETT without the Murphy's eye. Additional attention to the design and the location of the cuff on the ETT may be necessary as well as to markings for depth of intubation on the shaft of the ETT to ensure that the cuff is placed fully below the cricoid ring following endotracheal intubation. Inflation of the cuff with high intracuff pressures within the cricoid ring may compromise perfusion of the tracheal mucosa and result in airway injury.
随着我们知识的增长，气道解剖和管理的原则不断受到重新评估和挑战。这使我们对小儿气道及其与成人气道的重要区别有了更深入的了解。对小儿气道大小和形状不断发展的认识对手术室、急诊科和重症监护室的气道管理具有重要的临床意义。临床实践中的第一个重大变化是向常规使用带袖带的气管导管 (ETT) 过渡。聚氨酯充气罩囊 Microcuff® 的出现以及重新设计的充气罩囊在 ETT 轴上的位置（没有墨菲眼）为这一转变提供了便利。可能有必要对 ETT 上充气罩囊的设计和位置以及 ETT 轴上的插管深度标记给予更多关注，以确保在气管插管后将充气罩囊完全置于环甲膜环下方。充气罩囊在环状环内压力过高时可能会影响气管粘膜的灌注并导致气道损伤。
{"title":"Evolution of the concepts of pediatric airway and endotracheal intubation","authors":"Tariq Wani, M. Sundaram, Joseph Tobias","doi":"10.4103/jpcc.jpcc_91_23","DOIUrl":"https://doi.org/10.4103/jpcc.jpcc_91_23","url":null,"abstract":"The tenets of airway anatomy and management continue to be reevaluated and challenged as our knowledge increases. This has led to a better understanding of the pediatric airway and its critical differences from adults. This evolving understanding of the pediatric airway size and shape has significant clinical implications to airway management in the operating room, emergency department, and the intensive care unit. The first significant change in clinical practice was the transition to the routine use of cuffed endotracheal tubes (ETTs). This was facilitated by the availability of the Microcuff® with a polyurethane cuff and a redesigned position of the cuff on the shaft of the ETT without the Murphy's eye. Additional attention to the design and the location of the cuff on the ETT may be necessary as well as to markings for depth of intubation on the shaft of the ETT to ensure that the cuff is placed fully below the cricoid ring following endotracheal intubation. Inflation of the cuff with high intracuff pressures within the cricoid ring may compromise perfusion of the tracheal mucosa and result in airway injury.","PeriodicalId":34184,"journal":{"name":"Journal of Pediatric Critical Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139303852","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Arturo Garza Alatorre, Veronica Martínez, Yanyn Cabrera Antonio, J. Franco Fernández, Alejandra Zavala Valdes, Valeria Velázquez Ramírez, Miguel Navarrete Juarez
Background: Postextubation airway obstruction, also called postextubation stridor, is one of the most frequent complications of orotracheal intubation and the main cause of extubation failure (EF). Several potential predictors of extubation outcomes have been investigated, although their predictive value and clinical usefulness are limited. Laryngeal ultrasound and measurements are new, noninvasive, easily reproducible methods for extubation success. The objective of the study was to determine the usefulness of measuring the laryngeal air column width difference (LACWD) as a predictor of EF. Subjects and Methods: This prospective observational study was conducted from December 2022 to March 2023. Patients older than 30 days and up to 16 years of age admitted to the pediatric intensive care unit (PICU) and intubated with an endotracheal tube with a balloon for >24 h and with their first attempt at extubation were evaluated. The LACWD was measured before extubation. The first measurement was made with the balloon inflated and the second with the balloon deflated, calculating the difference between the two measurements. Results: Forty-five patients were assessed. The median number of days in the PICU was 8 (interquartile range 2–6). We found that the greater the difference in the air column, the lower the risk of EF ([P = 0.418] odds ratio [OR] =0.101 95% confidence interval [CI] =0.000–26.000), and the greater the number of days (>3), the greater the risk of EF ([P = 0.819] OR = 0.996; 85% CI = 0.965–1.028). Conclusions: No statistically significant relationship was found in the LACWD in our patients. We believe that it is important to carry out an extended study, with age group stratification, to assess its use.
{"title":"The usefulness of ultrasonographic measurement of the laryngeal air column width difference before extubation as a predictor of secondary airway obstruction after extubation in children","authors":"Arturo Garza Alatorre, Veronica Martínez, Yanyn Cabrera Antonio, J. Franco Fernández, Alejandra Zavala Valdes, Valeria Velázquez Ramírez, Miguel Navarrete Juarez","doi":"10.4103/jpcc.jpcc_71_23","DOIUrl":"https://doi.org/10.4103/jpcc.jpcc_71_23","url":null,"abstract":"Background: Postextubation airway obstruction, also called postextubation stridor, is one of the most frequent complications of orotracheal intubation and the main cause of extubation failure (EF). Several potential predictors of extubation outcomes have been investigated, although their predictive value and clinical usefulness are limited. Laryngeal ultrasound and measurements are new, noninvasive, easily reproducible methods for extubation success. The objective of the study was to determine the usefulness of measuring the laryngeal air column width difference (LACWD) as a predictor of EF. Subjects and Methods: This prospective observational study was conducted from December 2022 to March 2023. Patients older than 30 days and up to 16 years of age admitted to the pediatric intensive care unit (PICU) and intubated with an endotracheal tube with a balloon for >24 h and with their first attempt at extubation were evaluated. The LACWD was measured before extubation. The first measurement was made with the balloon inflated and the second with the balloon deflated, calculating the difference between the two measurements. Results: Forty-five patients were assessed. The median number of days in the PICU was 8 (interquartile range 2–6). We found that the greater the difference in the air column, the lower the risk of EF ([P = 0.418] odds ratio [OR] =0.101 95% confidence interval [CI] =0.000–26.000), and the greater the number of days (>3), the greater the risk of EF ([P = 0.819] OR = 0.996; 85% CI = 0.965–1.028). Conclusions: No statistically significant relationship was found in the LACWD in our patients. We believe that it is important to carry out an extended study, with age group stratification, to assess its use.","PeriodicalId":34184,"journal":{"name":"Journal of Pediatric Critical Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139295825","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Acute respiratory infections (ARIs) are an important cause of pediatric mortality–morbidity worldwide, the most common etiology being viral. This study aims to identify causative organisms for ARIs admitted in pediatric intensive care unit (PICU), when multiplex polymerase chain reaction (PCR) testing of respiratory secretions was sent; any seasonal trends detect microbiological correlation when co-infections. Subjects and Methods: This was a retrospective observational study, from July 2021 to December 2022, of children aged 1 month–18 years, whose multiplex PCR tests (nasopharyngeal, endotracheal [ET] secretion or bronchoscopic alveolar lavage [BAL]) were sent when admitted for ARI to tertiary care PICU. Results: In the study period, 372 of 1492 medical PICU admissions were ARI. Multiplex PCR of 81 respiratory secretions was sent, of which 69 (85%) were positive. Multiplex pcr sample positivity : 83% for nasopharyngeal aspirate, 78% for ET secretions, 100% for BAL samples. Forty-one percent of samples detected >1 organism. Respiratory syncytial virus (RSV)-A was the most common virus (18); other organisms included adenovirus (n = 5), influenza (n = 9), parainfluenza (n = 5), rhinovirus: 13, Pneumocystis Jerovecci (PCP): 4, Streptococcus pneumoniae: 17, pertussis: 1, and Haemophilus influenzae B: 9. ARIs were seen throughout the year with peaks in monsoon season and a peak in cases of ARI due to RSV from July to October. Of co-infections with bacteria in ET secretions and BAL samples via multiplex PCR, bacterial culture reports were sterile. Conclusions: Multiplex PCR detected organisms in 85% of ARI patients tested. Most of the ARIs getting admitted to PICU were viral in origin. RSV was the most common virus isolated showing peak from July to October, local monsoon season. With extended viral and bacterial PCR being available, mixed infections/colonization with uncertain significance are being detected.
{"title":"Etiology of acute respiratory infections using multiplex polymerase chain reaction in children admitted to pediatric intensive care unit: A single-centered retrospective observational study from Western India","authors":"Shivam Barchha, Lakshmi Shobhavat, Rekha Solomon, Shivanand Harnal","doi":"10.4103/jpcc.jpcc_61_23","DOIUrl":"https://doi.org/10.4103/jpcc.jpcc_61_23","url":null,"abstract":"Background: Acute respiratory infections (ARIs) are an important cause of pediatric mortality–morbidity worldwide, the most common etiology being viral. This study aims to identify causative organisms for ARIs admitted in pediatric intensive care unit (PICU), when multiplex polymerase chain reaction (PCR) testing of respiratory secretions was sent; any seasonal trends detect microbiological correlation when co-infections. Subjects and Methods: This was a retrospective observational study, from July 2021 to December 2022, of children aged 1 month–18 years, whose multiplex PCR tests (nasopharyngeal, endotracheal [ET] secretion or bronchoscopic alveolar lavage [BAL]) were sent when admitted for ARI to tertiary care PICU. Results: In the study period, 372 of 1492 medical PICU admissions were ARI. Multiplex PCR of 81 respiratory secretions was sent, of which 69 (85%) were positive. Multiplex pcr sample positivity : 83% for nasopharyngeal aspirate, 78% for ET secretions, 100% for BAL samples. Forty-one percent of samples detected >1 organism. Respiratory syncytial virus (RSV)-A was the most common virus (18); other organisms included adenovirus (n = 5), influenza (n = 9), parainfluenza (n = 5), rhinovirus: 13, Pneumocystis Jerovecci (PCP): 4, Streptococcus pneumoniae: 17, pertussis: 1, and Haemophilus influenzae B: 9. ARIs were seen throughout the year with peaks in monsoon season and a peak in cases of ARI due to RSV from July to October. Of co-infections with bacteria in ET secretions and BAL samples via multiplex PCR, bacterial culture reports were sterile. Conclusions: Multiplex PCR detected organisms in 85% of ARI patients tested. Most of the ARIs getting admitted to PICU were viral in origin. RSV was the most common virus isolated showing peak from July to October, local monsoon season. With extended viral and bacterial PCR being available, mixed infections/colonization with uncertain significance are being detected.","PeriodicalId":34184,"journal":{"name":"Journal of Pediatric Critical Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139299734","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pneumonia is the most common cause of mortality in under-five children worldwide. Largely, viral pneumonia is the most common cause of pneumonia in children across all age groups. We need to think outside the jukebox while dealing with cases of recurrent or persistent pneumonia. A few uncommon causes of persistent or recurrent pneumonia are primary or secondary immunodeficiencies, airway anomalies, infection with Mycobacterium tuberculosis complex, aspiration pneumonia, and severe gastroesophageal reflux. We present a few uncommon presentations of pneumonia in children, which can pose a significant diagnostic challenge in a resource-limited setting.
{"title":"A case series of pneumonia beyond usual infections in children","authors":"Hardeep Kaur, Gaurav Mahajan, Amrapali Matte, Vivek Bhat","doi":"10.4103/jpcc.jpcc_39_23","DOIUrl":"https://doi.org/10.4103/jpcc.jpcc_39_23","url":null,"abstract":"Pneumonia is the most common cause of mortality in under-five children worldwide. Largely, viral pneumonia is the most common cause of pneumonia in children across all age groups. We need to think outside the jukebox while dealing with cases of recurrent or persistent pneumonia. A few uncommon causes of persistent or recurrent pneumonia are primary or secondary immunodeficiencies, airway anomalies, infection with Mycobacterium tuberculosis complex, aspiration pneumonia, and severe gastroesophageal reflux. We present a few uncommon presentations of pneumonia in children, which can pose a significant diagnostic challenge in a resource-limited setting.","PeriodicalId":34184,"journal":{"name":"Journal of Pediatric Critical Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139302580","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Use of laryngeal ultrasound in evaluation of the endotracheal tube in pediatric critical care post-intubation and peri-extubation","authors":"M. Sundaram, Joseph Tobias, Tariq Wani","doi":"10.4103/jpcc.jpcc_89_23","DOIUrl":"https://doi.org/10.4103/jpcc.jpcc_89_23","url":null,"abstract":"","PeriodicalId":34184,"journal":{"name":"Journal of Pediatric Critical Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139302599","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
S. Shamarao, PHarshini Bhat, Siddini Vishwanath, C. Shivaram, R. A. Ram, Reshma Aramanadka, J. Kare, Akansha Sekhsaria
Background: Therapeutic plasma exchange (TPE) can be technically challenging in critically ill children in pediatric intensive care unit (PICU). This study was done to characterize the indications, technical aspects, safety, and outcomes of TPE in critically ill children admitted to PICU. Subjects and Methods: This was a retrospective study by analyzing the electronic medical records of 33 critically ill children (1 month–18 years of age) who underwent TPE in PICU. Results: A total of 33 patients underwent 122 TPE sessions. The most common diagnosis for TPE was acute liver failure (48.48%). Invasive mechanical ventilator (MV) and renal replacement therapy (RRT-continuous RRT [CRRT]/intermittent hemodialysis) were needed in 72.7%. Vasoactive support was needed in 63.6%, of whom 76% needed ≥2 vasoactive medications. Organ dysfunction of ≥3 organs was seen in 66.6%. One patient was also on extracorporeal membrane oxygenation (ECMO) support. Survival to intensive care unit discharge was 59.3%. Mortality was highest for liver failure (9/16: 56%), followed by sepsis with multiple organ dysfunction syndrome (40%). TPE without needing dialysis had a survival rate of 75%, while TPE with CRRT had a survival rate of 45%. Survival with ≥3 organ dysfunction was 36.3%. Factors associated with increased mortality were MV (P = 0.0115), need for vasoactive medications (P = 0.0002), organ dysfunction (P = 0.005), and specific indications (P = 0.0458). Complications were noted in 2.4%. Conclusions: TPE can be performed safely in critically ill children in combination with RRT and ECMO. The need for MV, multiple vasoactive medications, liver failure, sepsis, and higher number of organ failures were significantly associated with mortality.
{"title":"Indications, safety, and outcomes of therapeutic plasma exchange in critically ill children admitted to a multidisciplinary tertiary care pediatric intensive care unit","authors":"S. Shamarao, PHarshini Bhat, Siddini Vishwanath, C. Shivaram, R. A. Ram, Reshma Aramanadka, J. Kare, Akansha Sekhsaria","doi":"10.4103/jpcc.jpcc_81_23","DOIUrl":"https://doi.org/10.4103/jpcc.jpcc_81_23","url":null,"abstract":"Background: Therapeutic plasma exchange (TPE) can be technically challenging in critically ill children in pediatric intensive care unit (PICU). This study was done to characterize the indications, technical aspects, safety, and outcomes of TPE in critically ill children admitted to PICU. Subjects and Methods: This was a retrospective study by analyzing the electronic medical records of 33 critically ill children (1 month–18 years of age) who underwent TPE in PICU. Results: A total of 33 patients underwent 122 TPE sessions. The most common diagnosis for TPE was acute liver failure (48.48%). Invasive mechanical ventilator (MV) and renal replacement therapy (RRT-continuous RRT [CRRT]/intermittent hemodialysis) were needed in 72.7%. Vasoactive support was needed in 63.6%, of whom 76% needed ≥2 vasoactive medications. Organ dysfunction of ≥3 organs was seen in 66.6%. One patient was also on extracorporeal membrane oxygenation (ECMO) support. Survival to intensive care unit discharge was 59.3%. Mortality was highest for liver failure (9/16: 56%), followed by sepsis with multiple organ dysfunction syndrome (40%). TPE without needing dialysis had a survival rate of 75%, while TPE with CRRT had a survival rate of 45%. Survival with ≥3 organ dysfunction was 36.3%. Factors associated with increased mortality were MV (P = 0.0115), need for vasoactive medications (P = 0.0002), organ dysfunction (P = 0.005), and specific indications (P = 0.0458). Complications were noted in 2.4%. Conclusions: TPE can be performed safely in critically ill children in combination with RRT and ECMO. The need for MV, multiple vasoactive medications, liver failure, sepsis, and higher number of organ failures were significantly associated with mortality.","PeriodicalId":34184,"journal":{"name":"Journal of Pediatric Critical Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139293676","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Studies have shown that the airway pressures displayed on the screen of the ventilator monitor do not correlate with the actual alveolar distending pressures known as transpulmonary pressure or stress. The change in tidal volume (Vt) on top of the available functional residual capacity (FRC), also known as strain, is an essential factor directly related to stress. Even the correlation of driving pressure (DP) with ventilator-induced lung injury (VILI) needs to be interpreted in the background of what Vt, respiratory compliance (Crs) and at what positive end-expiratory pressure (PEEP) is that DP calculated and at what was the chest wall compliance, and the flow rate at that time. Stress and strain are related to all these factors, either directly or indirectly. The impact of stress and strain should be interpreted in “dynamic terms” over time rather than at one point. Hence, VILI is minimized by optimizing the Strain (using appropriate PEEP and Vt against available FRC) and stress (transpulmonary inspiratory and expiratory pressures), applied at an optimal respiratory rate and flow. In the pediatric age group, pulmonary mechanics also change as age changes. Moreover, children respond differently to lung injury than adults, adding another layer of complexity to the concept of stress and strain in the pediatric population. Despite this, most knowledge about stress and strain has come from studies in the adult population. Therefore, more extensive studies focussing on pediatric age groups are needed to improve our understanding of stress and strain in pediatric ventilated patients.
{"title":"Concept of stress and strain in pediatric mechanical ventilation","authors":"F. Shaikh","doi":"10.4103/jpcc.jpcc_48_23","DOIUrl":"https://doi.org/10.4103/jpcc.jpcc_48_23","url":null,"abstract":"Studies have shown that the airway pressures displayed on the screen of the ventilator monitor do not correlate with the actual alveolar distending pressures known as transpulmonary pressure or stress. The change in tidal volume (Vt) on top of the available functional residual capacity (FRC), also known as strain, is an essential factor directly related to stress. Even the correlation of driving pressure (DP) with ventilator-induced lung injury (VILI) needs to be interpreted in the background of what Vt, respiratory compliance (Crs) and at what positive end-expiratory pressure (PEEP) is that DP calculated and at what was the chest wall compliance, and the flow rate at that time. Stress and strain are related to all these factors, either directly or indirectly. The impact of stress and strain should be interpreted in “dynamic terms” over time rather than at one point. Hence, VILI is minimized by optimizing the Strain (using appropriate PEEP and Vt against available FRC) and stress (transpulmonary inspiratory and expiratory pressures), applied at an optimal respiratory rate and flow. In the pediatric age group, pulmonary mechanics also change as age changes. Moreover, children respond differently to lung injury than adults, adding another layer of complexity to the concept of stress and strain in the pediatric population. Despite this, most knowledge about stress and strain has come from studies in the adult population. Therefore, more extensive studies focussing on pediatric age groups are needed to improve our understanding of stress and strain in pediatric ventilated patients.","PeriodicalId":34184,"journal":{"name":"Journal of Pediatric Critical Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41592963","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: There is a need for pediatric scoring systems to monitor the progress in clinical outcomes, which are noninvasive, reliable, and easily measurable. Subjects and Methods: This prospective observational study evaluated the utility of a prevalidated “SICK” score for the purpose of assessing the score's efficacy in hospitalized children of age 1 month to 12 years. Results: Of the 531 cases, 145 (27.3%) were admitted to the pediatric intensive care unit (PICU) and 386 (72.7%) were admitted to the pediatric ward. The probability of PICU admission was 11.42 (95% confidence interval [CI] 6.3–20.7) when the “SICK” score was ≥2. Children with a score ≥2 had a significantly longer duration of stay (mean difference = 45.58 h, 95% CI [30.65–60.51], P = 0.001). The score performed with an area under curve of 0.691 for a cut off score. The positive predictive value of the score is 73.53% (95% CI 62.66–82.13) and the negative predictive value is 79.48% (95% CI 77.45–81.37). Conclusions: The score performed reasonably well in our center for a profile of moderately sick children and can be recommended to be used as an effective triaging tool in a similar setting.
{"title":"A prospective observational study to assess the efficacy of “SICK” score in pediatrics","authors":"Shalini Thangaraj, Ilamaran Veerappan, SVenkatesh Karthik","doi":"10.4103/jpcc.jpcc_25_23","DOIUrl":"https://doi.org/10.4103/jpcc.jpcc_25_23","url":null,"abstract":"Background: There is a need for pediatric scoring systems to monitor the progress in clinical outcomes, which are noninvasive, reliable, and easily measurable. Subjects and Methods: This prospective observational study evaluated the utility of a prevalidated “SICK” score for the purpose of assessing the score's efficacy in hospitalized children of age 1 month to 12 years. Results: Of the 531 cases, 145 (27.3%) were admitted to the pediatric intensive care unit (PICU) and 386 (72.7%) were admitted to the pediatric ward. The probability of PICU admission was 11.42 (95% confidence interval [CI] 6.3–20.7) when the “SICK” score was ≥2. Children with a score ≥2 had a significantly longer duration of stay (mean difference = 45.58 h, 95% CI [30.65–60.51], P = 0.001). The score performed with an area under curve of 0.691 for a cut off score. The positive predictive value of the score is 73.53% (95% CI 62.66–82.13) and the negative predictive value is 79.48% (95% CI 77.45–81.37). Conclusions: The score performed reasonably well in our center for a profile of moderately sick children and can be recommended to be used as an effective triaging tool in a similar setting.","PeriodicalId":34184,"journal":{"name":"Journal of Pediatric Critical Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41410888","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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