Section 1: ORAL PRESENTATIONS (ADULTS)
Section 2: ORAL PRESENTATIONS (PAEDIATRICS)
Section 3: POSTER PRESENTATIONS
Dr Afzal Azim,Dr Sukhen Samanta, Dr A. K. Baronia
LUNG ULTRASOUND AS A DIAGNOSTIC TOOL FOR VENTILATOR ASSOCIATED PNEUMONIA: A PROSPECTIVE OBSERVATIONAL STUDY FROM A TERTIARY CARE CENTRE
Early diagnosis of ventilator associated pneumonia (VAP) remains elusive for most of the clinicians. We explored the utility of bedside lung ultrasonography (LUS) based on a scoring system to diagnose VAP.
After ethical clearance and informed consent this prospective single centre observational study was conducted from January 2015 to June 2016. 110 patients with suspected VAP were enrolled. We investigated the diagnostic accuracy of LUS using the findings of subpleural consolidation, lobar consolidation, and dynamic air bronchogram. Quantitative mini broncho-alveolar lavage (mBAL) fluid was taken for microbiological diagnosis. We designed a sono-pulmonary infection score (SPIS) based on LUS, clinical and microbiology parameters and used it as a substitute for clinical pulmonary infection score (CPIS). Descriptive data was summarized as mean (SD), median (interquartile range), or number (%). Two groups were compared using Mann – Whitney test and Fisher exact test.
Prevalence of VAP was 72.7% amongst the suspected patients. Overall LUS performance for diagnosis of VAP (microbiologically confirmed) had a sensitivity, specificity, positive/negative predictive value and positive/negative likelihood ratios of 91.3%, 70%, 89%, 75%, 3 and 0.1 respectively. Adding microbiology to LUS improved diagnostic accuracy with sensitivity, specificity, positive/negative predictive value and positive/negative likelihood ratios of 95%, 90%, 96.2%, 87%, 9.5 and 0.06 respectively. The area under curve for CPIS and modified CPIS (CPIS-microscopy & CPIS-culture) and SPIS and modified SPIS were 0.617, 0.689, 0.801, 0.808, 0.815 and 0.913 respectively.
Lung ultrasound is valuable tool for early diagnosis of VAP. Larger trials are warranted to establish its utility.
Wan Fadzlina Wan Muhd Shukeri, Azrina Md. Ralib, Mohd Basri Mat-Nor
THE DIAGNOSTIC VALUE OF MODELLED INSULIN SENSITIVITY IN SEPSIS
Low insulin sensitivity (SI) and sepsis are strongly linked, but the effectiveness of SI as a diagnostic test of sepsis is largely unknown. We aim to study the diagnostic value of modelled SI in sepsis in a mixed cohort of diabetic and non-diabetic critically ill patients.
In this cross-sectional study, we analysed SI levels in septic (n = 45) and non-septic (n = 41) patients upon their ICU admission. The SI levels were derived by fitting blood glucose levels, insulin infusion and glucose input rates into the Intensive Control of Insulin-Nutrition-Glucose model.
In the overall cohort, SI levels were significantly lower in patients with sepsis than those without sepsis (0.560 ± 0.676 versus 1.097 ± 1.473 x 10-4 L/mU/min, P = 0.037). Analysis of the area under the curve (AUC) revealed that modelled SI was a poor diagnostic test of sepsis [AUC 0.588 (95% CI, 0.477-0.693)]. The result from multivariate logistic regression analysis showed that modelled SI could not independently predict sepsis. In a separate analysis among the non-diabetic cohort (n = 19), modelled SI was found to be useful as a diagnostic test of sepsis [AUC 0.911 (95% CI, 0.690-0.992)] with a cut-off of 0.880x 10-4 L/mU/min, sensitivity of 90% and specificity of 78%. There was no significant difference in SI levels among the diabetic cohort.
Presence of sepsis significantly reduced SI but a low SI could not independently predict sepsis in a mixed cohort of diabetic and non-diabetic critically ill patients. Low SI can equally mark the presence of sepsis, other severe conditions or the result of treatment effects which are indicated in sepsis. Only when applied to the non-diabetic cohort that modelled SI was useful as a diagnostic test of sepsis in the critically ill patients.
Mohd Zulfakar Mazlan, Tengku Abdul Kadir Tengku Zainal Abidin, Saedah Ali, Dr Shubashini Thevadas.Mahamarowi Omar
THE EFFECTS OF PASSIVE LEG RAISING TEST AND FLUID CHALLENGE ON HAEMODYNAMIC PARAMETERS TO ASSESS FLUID RESPONSIVENESS IN INTENSIVE CARE UNIT
Passive leg raising (PLR) test and fluid challenge (FC) are two reliable techniques to determine preload responsiveness in Intensive Care Unit (ICU). We evaluated the correlation of cardiac output(CO), heart rate (HR), mean arterial pressure (MAP), stroke volume variation (SVV), stroke volume (SV) during (PLR) and after (FC). The FloTrac/Vigileo system (Edwards Lifesciences, Irvine, CA, USA) is a minimally invasive device used to measure CO in this study.
This is a prospective study in general intensive care unit (ICU) and surgical ICU in a university hospital. Thirty-seven septic patients who were mechanically ventilated, deeply sedated, equipped with theFloTrac/Vigileo and decided for fluid bolus were recruited in this study. Recordings of heart rate (HR), mean arterial pressure (MAP), SVV, stroke volume (SV), and CO were obtained at the baseline, after PLR, baseline FC and after FC. Fluid responder was defined as changes of CO (Δco) more than 13%.
Out of 37 patients, 31 (84%) were in septic shock and receiving vasoactive agents. The median Acute Physiology and Chronic Health II (APACHE II) and Sequential Organ Failure Assessment (SOFA) score were 24 (IQR=13) and 14 (IQR=5) respectively. The haemodynamic changes (pre and post-test) in heart rate (HR) and mean arterial pressure (MAP) were significant in FC group (P=0.013 and <0.001 respectively) but not significant in PLR group (P=0.190 and 0.620). However the changes of SV, SVV and CO were significant for both groups.
In haemodynamically unstable patients such with higher (APACHE II) and (SOFA) score, the routine use of HR and MAP changes post PLR to assess fluid responsiveness were not accurate as compared to FC methods. However, both groups reveals the use of changes in SV, SVV and CO were useful in assessing fluid responsiveness.
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YS Chee, KP Eg, CS Gan
ASSESSMENT OF PAIN DURING PAINFUL PROCEDURES WITH ANALGESIA NOCICEPTION INDEX (ANI) MONITOR IN PAEDIATRIC ICU
Pain is considered as the 5th vital sign and studies have shown that pain alters neurodevelopment with increased risk of cardiovascular and metabolic diseases. In critically ill children, pain assessment is based on behavioural evaluations such as COMFORT-B scale which has excellent face validity but is time consuming and subject to inter-rater variability. The Analgesia Nociception Index (ANI) monitor offers an objective assessment of the parasympathetic autonomic nervous system where a high index is indicative of comfort. A prospective observational study was conducted to validate the use of ANI monitoring for assessment of pain during painful procedures which include suctioning, vascular access and capillary blood sampling. Forty-nine patients were included in this study. The ANI and COMFORT-B score were obtained at 3 time points, before, during and after painful stimulus. COMFORT-B scoring was done by two trained medical personnel. Kappa statistics showed good inter-rater agreement (k=0.833, p<0.001). A significant inverse correlation was observed between ANI and COMFORT-B (r=-0.538, p<0.001). ANI was comparable to COMFORT-B for detection of pain during painful procedures (r=0.632, p<0.001) with a sensitivity of 86.2% and specificity of 85.6% corresponding to an area under the ROC curve of 0.898. Subgroup analysis showed that ANI and COMFORT-B had a strong inverse correlation during suctioning (r=-0.643, p<0.001) compared to needle pricking (r=-0.424, p<0.001). This study showed a significant inverse correlation between ANI and COMFORT-B with similar trend pattern over time interval. Given the ease of use and efficiency of the ANI monitor, it is a superior method for assessment of pain and discomfort at rest and during painful procedures to guide analgesic and sedation requirements in critically ill children.
Xin Yang, Yingchao Liu, Lijuan Wang, Suyun Qian, Kaihu Yao
CLONAL AND DRUG RESISTANCE DYNAMICS OF MRSA IN PEDIATRIC POPULATIONS IN CHINA
Suyun Qian, Pediatric Intensive Care Unit, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100045, China
Kaihu Yao, Beijing Pediatric Research Institute, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100045, China
*These authors contributed equally to this work.
This study was funded by National Natural Science Foundation of China (No. 81571948) and the Beijing Natural Science Foundation (No.7172075).
To evaluate the clonal and drug resistance dynamics of methicillin-resistant Staphylococcus aureus (MRSA) in Chinese children from 2010 to 2017.
MRSA was isolated from patients in Beijing Children’s Hospital from 2010 to 2013 and from 2016 to 2017.The molecular characteristics andantibiotic resistance were determined.
In total, 211 MRSA isolates were collected, and 104 isolates were classified as community-associated MRSA (CA-MRSA). ST59-SCCmec IV was the most prevalent type in both CA-MRSA (65.4%) and healthcare-associated-MRSA (HA-MRSA) (46.7%). ST239-SCCmec III accounted for 21.5% of all HA-MRSA, which were not detected in 2016, and only three isolates were detected in 2017. The pvl genecarrying rate of CA-MRSA was significantly higher than that of HA-MRSA (42.3% vs. 29.0%, P = 0.0456). Among CA-MRSA, resistance rate to all tested antibiotics excluding chloramphenicol remained stable over the periods of 2010–2013 and 2016–2017. HA-MRSA displayed an overall trend of decreased resistance to oxacillin, gentamicin, tetracycline, ciprofloxacin, and rifampin, and increased resistance to chloramphenicol, consistent with the difference of antibiotic resistance patterns between ST59-SCCmec IV and ST239-SCCmec III isolates. Vancomycin minimal inhibitory concentration (MIC) creep was found in the study period in all MRSA and ST59-SCCmec IV isolates.
ST59-SCCmec IV has spread to hospitals and replaced the traditional ST239-SCCmec III clone, accompanied by changes in drug resistance. Furthermore, vancomycin MIC creep indicated that the rational use of antibiotics should be seriously considered.
MRSA, Clonal lineage, Drug resistance, Pediatric, China
Farah W Aziz, Gan CS, Eg KP
COMPARISON OF PEDIATRIC INDEX OF MORTALITY 2 AND PEDIATRIC INDEX OF MORTALITY 3 SCORING IN A PAEDIATRIC INTENSIVE CARE UNIT IN A TERTIARY CENTRE IN MALAYSIA
Paediatric Intensive Care Unit (PICU) is an important subspecialty which provides support and intensive care for ill children who has potentially reversible acute life-threatening illness. Having a scoring system to predict mortality would be useful to give more supportive treatment to those with higher risk as well as for the usage of treatment modalities available in the PICU.
Aim: To assess the effectiveness of PIM2 and PIM3 scores in predicting mortality in children admitted to PICU in a tertiary centre in Kuala Lumpur, Malaysia.
Methods: This is a retrospective study involving admissions of children between the age of 1 day to 18 years old to PICU of University Malaya Medical Centre from 1st January 2016 to 31st December 2017. The PIM2 and PIM3 scores were calculated using formula available online and results were tabulated. Actual outcome was noted as survivor and non-survivor.
Results: The final study sample comprised of 929 admissions. More than half (58.8%) of them were males and of Malay ethnicity (55.8%). A higher proportion (76%) of them were less than 5 years old and the most common age group were between 1 month to 1 year old (29.5%). About 62.9% of the admissions were from the in-patient wards. The main reasons for admission were for respiratory support (48.5%), followed by post-surgery/procedure and observation. The most common diagnostic categories were respiratory illness (25.9%) and neurological cases (11.4%). Nearly 28.5% of the admissions were less than 24 hours followed by an average length of stay of 4 to 7 days (27.3%). The observed mortality rate was 5.1%. The expected mortality rate was 7.28% (PIM2) and 6.04% (PIM3) while the Standardized Mortality Ratio, SMR was 0.7231 (PIM2) and 0.8393 (PIM3). The main cause of death was septic shock (38%), followed by respiratory failure, haemorrhage and liver failure. The majority of deaths were from the age group of more than 12 years old (13.58%). Most of the deaths in older age group were oncology cases (47.3%). Both of the scoring systems underpredict mortality among the older age group of more than 5 years old, oncology and hepatology cases. There is also an association between respiratory, oncology, hepatology and surgical cases with death outcome as chi square test and p-value was <0.001. It was also found that there is a significant association between length of stay in PICU and survival outcome (c2 = 3.419, p-value < 0.001). The Area Under Receiver Operating Curve (AUROC) was 0.857 (95%CI: 0.807, 0.906) for PIM2 and was 0.85 (95%CI: 0.798, 0.903) for PIM3 showing good discrimination values. Hosmer-Lemeshow Goodness of Fit test for PIM2 showed c2 value of 2.938 with a p-value of 0.938 (p> 0.05) while PIM3 showed c2value of 11.31 with a p-value of 0.185 (p> 0.05) which concludes that the model of fit is good with good calibration properties.
Conclusion: PIM3 was a more accurate scoring as a mortality predictor compared to PIM2 and can be used in the current PICU setting.
Keywords : PIM2, PIM3, paediatric mortality scoring
Zhengzheng Zhang, Weili Yan, Yi Zhang, Guoping Lu
DEVELOPMENT AND VALIDATION OF A SIMPLE MODEL TO PREDICT MORTALITY IN PICU: A MULTICENTER COHORT STUDY
To develop and validate an early warning model for predicting in-hospital mortality in PICU.
A prospective observational cohort study was carried out in 8 PICUs. Patients aged over 28 days and below 18 years on admission, and staying in PICU over 24 hours were eligible. A total of 4770 eligible patients admitted to these PICUs were consecutively recruited between Aug 1, 2016 and Jul 31, 2017. A death risk prediction model was derived using Cox regression on a non-randomly selected subsample (n=2575) from five hospitals. The model was validated in another subsample (n=1382) from the other three hospitals by using discrimination (C statistics) and calibration.
Within three months after admission, 226 (4.8%) patients died in hospital, 3731 (78.2%) recovered and were transferred to general wards, and 813 (17.0%) were discharged against medical suggestion. Cox regression model identified that organ failures, lactic acid concentration, Glasgow score, PaO2/FiO2 ratio and platelet counts were significant predictors for death risk. C statistics for the constructed model was 0.84 (95% CI 0.79-0.88) in the derivation subsample, and was 0.78 (95%CI 0.71-0.85) in the validation sample. The C statistics of the model using PRISM III score as single predictor, 0.78 (95%CI 0.71-0.85), did not significantly differ from our proposed model (difference in C statistics: 0.00, 95%CI -0.05-0.06). Calibration analysis on Day 5, 10, 15 and 20 showed that the intercepts did not significantly differ from 0 (P=0.84) and the slopes did not significantly differ from 1 (P=0.57).
We propose a new model with good accuracy in predicting death risk in PICU. This model involves five predictors and is considered more feasible and low-cost for risk assessment of mortality in practice.
Saptadi Yuliarto, Antonius H. Pudjiadi, Abdul Latief
HEMODYNAMIC PROFILES OF PEDIATRIC SHOCK REGARDING THE CLINICAL CLASSIFICATION: AN PROSPECTIVE OBSERVATIONAL STUDY
Four types of shock are widely recognized: hypovolemic, cardiogenic, distributive, and obstructive. Every type has specific treatment. But, in some cases, the types cannot be clearly distinguished; it leads to challenging management. Therefore, complete hemodynamic parameters are required to guide adequate treatment.
To describe fluid responsiveness, contractility, stroke volume index (SVI) cardiac index (CI), and systemic vascular resistance (SVRI) in each type of pediatric shock following fluid resuscitation.
It was a prospective observational study conducted at tertiary level emergency room (ER) and pediatric intensive care unit (PICU) of national centre hospital. Clinically shock children were consecutively recruited. We classified into groups according to history taking and clinical manifestation, thenmeasured fluid responsiveness, contractility (inotropy index), SVI, CI, and SVRI with USCOM™ after fluid bolus therapy (FBT). Data were presented in frequency table.
A total 50 patients (25 boys) were eligible. Their median age was 35 months. Septic shock was 64%, hypovolemic was 30% and cardiogenic was 6%. The survival rate was 74%. FBT volume were not different between groups (p = 0.72), with median <40 ml/kg to achieve fluid-refractory condition. There were no differences of SVI, CI, and SVRI. Inotropy index was lower in cardiogenic than septic or hypovolemic shock (SMII 0.72 [0.7-1.6]; 1.3 [0.4-3.3]; and 1.4 [0.8-2.8] respectively; p=0.05). Most cases in septic, hypovolemic, and cardiogenic shock was fluid-refractory (53.1%, 60%, and 100%, respectively) and low SVI (75%, 53.3%, and 100%, respectively). Nonetheless, only in septic and cardiogenic shock, most subjects revealed low contractility (59.4% and 66.6%, respectively) and high SVRI (50% and 66.7%, respectively).
Pediatric septic and cardiogenic shock was non-fluid responder, low contractility, and high resistance. It has to bear in mind that most cases was refractory in 40 ml/kg of FBT.
Shock, fluid, hemodynamic parameter
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Miao-Yu Chen, Buo-Hou Huang, Huei-Lin Huang , Ching-Ming Chen, Will Chou
THE EFFECT OF REHABILITATION PROGRAM ON LONG-TERM RESPIRATOR-DEPENDENT PATIENTS
The purpose of our study was to evaluate the improvement in prognosis of patients with chronic respiratory failure via undergoing progressive and planned respiratory muscle strength training.
In this retrospective study, we collected 22 respiratory failure patients who were under respirator treatment from October 2017 to September 2018 at a local teaching hospital in southern Taiwan. They were assessed by the chest specialty and considered as stable medical condition before rehabilitation programs. And 13 people in study group and 9 patients in control group. Six weeks daily pulmonary rehabilitation programs include upper limbs’ range of motion, chest mobility, and mainly 30 minutes progressive sand-bag on upper abdomen for diaphragmatic resistant exercise with adjusted best pressure support level of respirator to maintain 8 ml/Kg tidal volume.
The study group has better Glasgow coma scale (10.3+2.2 vs 6.9+1.6; p=0.005), lower respirator pressure support (14.6+2.2 vs 17.6+2.2 cmH2O; p=0.006) than control group before rehabilitation programs. After 6 weeks’ pulmonary programs, the study group has better improvement in respirator pressure support (9.7 ± 1.8 vs. 16.2 ± 7.2 cmH2O; p = 0.005), tidal volume change (68.1 ± 66.8 vs.-14 ± 94.6 ml; p = 0.048) and rapid shallow breathing index change (-47.6 ± 36.7 v. S 16.7 ± 37.4; p=0.003). 5 patient (71.4%) in study group and 2 patients (28.6%) in control group had achieved successful weaning from respirators.
Long-term respirator-dependence patients will improve their respirator pressure support, tidal volume, and rapid shallow breathing index through appropriate lung rehabilitation programs, leading to better weaning rate. To stable medical condition respirator using patients, structural pulmonary rehabilitation is a must to enhance their motor function and life quality.
Anuradha Ragunathan, Noorjahan Haneem bt Md Hashim , Mohd Shahnaz b Hasan , Norazah bt Zahari
PILOTING TWO SIMULATION METHODS TO ENHANCE TRANSTHORACIC ECHO LEARNING
This work was carried out to evaluate the effectiveness of simulation technique in amplification of learning transthoracic echo (TTE) amongst anaesthesiology trainees to be used as a clinical tool in their day to day practices. A qualitative and quantitative assessment with pre & post test compounded with practical assessment was conducted following a half day teaching session . It includes five basic TTE views (parasternal long axis, parasternal short axis , apical four chamber, subcostal four chamber and subcostal inferior vena cava) and its related probe orientation and ergonomics. A suitable cohort of eighteen anaesthesiology trainees were recruited and results were compiled as a pilot study. A simple assessment of basic skills was also carried out by an expert TTE tutor to limit bias.
65% of participants found that TTE simulation mannequin a useful guide in obtaining TTE skills however majority preferred learning with the presence of a tutor on human simulators which was also carried as a comparison method to mannequin simulation .Overall there was an improvement in applied knowledge in TTE skills regardless of the technique preference between human or mannequin simulation. A sub-analysis related to the apical 4 chamber view did reveal that TTE performance was remarkable in those who performed TTE routinely in their clinical practice compared to those who didn’t. In conclusion , simulation is a useful tool of learning for application of TTE in clinical practice. Further research is required to support use of simulation in learning mastery of TTE.
Anand Kamalanathan, Shaiful Azman
ASSESSING THE COMPLIANCE TO OUR CEREBRAL PROTECTION PROTOCOL IN THE ICU AND ITS IMPACT ON EARLY CLINICAL OUTCOMES
Hospital Sungai Buloh
Despite the development of specialized neurointensive care, severe traumatic brain injury (TBI) is still a common cause of morbidity and mortality. The implementation of neuroprotection strategies is an important goal to reduce mortality. We aim to review our compliance rates to our protocol and to assess its effect on outcomes.
This cross-sectional study analysed patients who suffered TBIs and were admitted into our ICU between 1st January 2019 until 31st May 2019. We included patients aged above 12 years, managed by our ICU team and required cerebral protection. We collected demographic data such as age, race, gender and etiology of injury. We then assessed the severity of the TBI on admission, duration of cerebral protection and the compliance to our HSB Cerebral Protection Protocol and followed up to assess the 30-day mortality and morbidity using the Glasgow Outcome Scores (GOS).
80 patients were recruited out of 206 neurosurgical cases admitted during the study period of which the mean age was 33.1 years and the majority were Malays(61%), males (83.75%) and motorcyclists (77%). 72.5% of our admissions were severe TBIs and 80% had Intracranial pressure probes inserted for monitoring, with a duration of 43 hours as an average of cerebral protection.
We achieved a 65% compliance rate to our protocol with 56.25% achieving good outcomes based on GOS scores when compliance was high.
Our study suggests that good compliance rates to a structured cerebral protection protocol results in good outcomes.
PX Kuan, WK Chan
SYSTEMATIC REVIEW OF NUTRITIONAL ASSESSMENT: CAN SUBJECTIVE GLOBAL ASSESSMENT SCREEN AND DIAGNOSE MALNUTRITION IN INTENSIVE CARE PATIENTS?
Nutritional assessment in intensive care unit (ICU) is crucial as malnutrition is associated with poor clinical outcomes. ASPEN (2016) emphasized on Nutritional Risk Screening 2002 and Nutritional Risk in the Critically Ill-III (NUTRIC) score to screen for malnutrition. Subjective Global Assessment (SGA) is the gold standard for both screening and diagnosing malnutrition in general population. Recent literatures have shown that SGA could be applied in intensive care patients.
This systematic review aimed to determine the prevalence of malnutrition diagnosed by SGA and its association with clinical outcomes.
Searches in PubMed, Scopus and Cochrane Library were conducted for eligible studies from 2009 till June 2019. The search terms included nutritional assessment, intensive care, subjective global assessment and clinical outcome. Eligible studies were studies that were conducted using SGA in ICU setting with relevant clinical outcomes such as mean of ICU stay, ICU re-admission and mortality were included.
A total of 78 papers were shortlisted and only 11 papers involving 2662 patients were eligible. The prevalence of malnutrition ranged from 23.0% to 74.1%. Majority of the ICU patients were elderly. The mean ICU stay and mortality rate ranged from one to 59 days and from 18.2% to 47.5% respectively. Only one study by Fontes et al. (2014) reported of 28.6% of re-admission to ICU. Malnutrition was significantly associated with increased risk of ICU stay, ICU re-admission and mortality rate.
SGA can be used as routine bedside instrument to predict nutritional status and outcome in intensive care patients. This is important such that the appropriate nutritional therapy can be initiated early in order to improve the patients’ clinical outcomes.
Nutritional assessment; malnutrition; intensive care; subjective global assessment; clinical outcome
Wan Fadzlina Wan Muhd Shukeri, Samiullah Saeed, Azrina Md. Ralib, Mohd Basri Mat-Nor
Validation of the Modified Nutrition Risk in Critically Ill (mNUTRIC) Score in a Malaysian Intensive Care Unit
The mNUTRIC score is a feasible nutritional assessment tool to identify critically ill patients with high nutritional risk who will benefit from nutritional interventions. This study was conducted to validate the prognostic performance of the mNUTRIC score in a Malaysian ICU.
This was a retrospective cohort study conducted in the ICU of a university hospital in Malaysia from January 2017 to December 2018. Consecutive adult patients admitted to the ICU for >24 hours were included in the study. Data were collected on variables required to calculate the mNUTRIC score. Patients with mNUTRIC score ≥5 points were considered at high nutritional risk. Main outcome was 28-day mortality from all causes; ICU LOS and prolonged mechanical ventilation (MV) (>2 days) were secondary outcomes.
From a total of 432 admission, 382 (88.4%) patients fit into the study criteria. Mean age of these patients was 57 ± 16 years and majority were male (n=216, 56.5%). Seventy-seven (20.2%) patients were at high nutritional risk. These patients had longer mean ICU LOS (7.1 ± 7.5 days versus 4.2 ± 4.0 days, P=0.001), greater proportion of prolonged MV (57.1% versus 14.4%, P<0.0001) and higher 28-day mortality (44.2% versus 10.2%, P<0.0001) compared to patients with low mNUTRIC score (≤4 points). High mNUTRIC score predicted 28-day mortality with area under the curve (AUC) of 0.797 (95% CI 0.738-0.856).
High mNUTRIC score was associated with increased ICU length of stay, prolonged MV and higher 28-day mortality. The prognostic performance for 28-day mortality of the mNUTRIC score is clinically valid as indicated by AUC >0.7 and is comparable to other validation studies. Given our results, we recommend the introduction of the mNUTRIC score for the nutritional risk assessment of our critically ill patients considering its suitability and feasibility.
Suyun Qian, Yue Song, Yanxia Guo, Yan Li
CLINICAL STUDY ON THE EFFECTIVENESS AND SAFETY OF NIMODIPINE IN PREVENTING VASOSPASM IN CHILDREN WITH INTRACRANIAL HEMORRHAGE
We conducted this prospective randomized control clinical study aim to evaluate the effectiveness and safety of nimodipine in preventing vasospasm in children with intracranial hemorrhage.
We consecutively recruited intracranial hemorrhage patients who were admitted in pediatric intensive care unit (PICU) of Beijing children's hospital from January 2015 to November 2018. Patients in the nimodipine group were treated with prophylactic nimodipine. The control group accepted exact the same treatment besides the nimodipine. If vasospasm occurs during monitoring, nimodipine is administered until the spasm is relieved or the child is discharged.
There were 81 children with intracranial hemorrhage were enrolled, 38 in the nimodipine group and 43 in the control. 21 patients developed vasospasm, including 9 cases (24%) in the nimodipine group and 12 cases (28%) in the control group. The difference in the incidence of vasospasm between the two groups was not statistically significant. There were no statistically significant differences between the two groups in survival rate, length of hospitalization, and Glasgow coma scale at discharge. On the 28th day after discharge, the survival rate of the nimodipine group was significantly higher than that of the control group (97% vs. 79%, χ2=6.242, P=0.016), and the proportion of favorable brain function (PCPC score 1 to 3) was significantly higher than that of the control group (89% vs. 58%, χ2=10.011, P=0.002).
Prophylactic intravenous nimodipine fail to prevent cerebral vasospasm after intracranial hemorrhage in children. Prophylactic application of nimodipine can improve short-term survival rate and short-term brain function.
Children; Intracranial hemorrhage; Nimodipine; Vasospasm
Saptadi Yuliarto, Kurniawan T. Kadafi
THE IMPACT OF FLUID RESUSCITATION VOLUME AND BALANCE ON 28-DAYMORTALITY IN PEDIATRIC PATIENTS WITH DENGUE SHOCK SYNDROME
Fluid bolus therapy (FBT) is the main therapy for dengue shock syndrome (DSS). The WHO guidelines recommend to give 20 ml/kg crystalloid in circulatory collapse and increased hematocrite; followed by “7-5-3 rule” if there are improvements. Recent studies showed FBT and fluid overload are associated with increased morbidity and mortality in pediatric patients. Yet, this relationship in pediatric DSS was less studied.
The primary outcome is relationship between FBT and fluid balance on 28-day mortality rates. Secondary outcomes are differences in mortality rates between groups of FBT volumes and fluid balance.
This is a retrospective observational study. Data was taken from medical records January to December 2016. The inclusion criteria were patients 1 month-18 years with DSS based on WHO criteria. FBT volume is the amount of fluid resuscitation (restrictive group: <40ml/kg versus liberal group: ³40 ml/kg); while fluid balance is the difference of fluid intake and output per body weight times 100%, which is calculated in the first 48 hours (deficit versus excess balance).
Ninety-nine patient was included. The median age was 6 years old; 56% patients were female; and 91.9% patients were DHF grade III. 74.7% patients got FBT volume <40ml/kgBW, and 69.7% patients got positive fluid balance (2.68±2.2%). A total of 28-day mortality rates was 14.1%. There was no relationship between fluid volume and balance to 28-day mortality (p=0.18 and 0.35; respectively), and no difference in 28-day mortality rates between restrictive versus liberal groups and deficits versus excess balance. However, restrictive group had a clinically significant reduction in mortality compared to liberal group (ARR:12%, RRR:53%).
FBT volume <40ml/kgBW reduced 28-day mortality. Fluid balance (range of 5%) did not affect 28-day mortality in pediatric DSS.
Keywords: Fluid bolus therapy, fluid balance, mortality, DSS
Suresh Kumar Angurana, Biraj Parajuli, Puspraj Awasthi, Deepak Bansal, Amit Rawat
HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS IN A PICU OF A DEVELOPING ECONOMY: CLINICAL PROFILE, INTENSIVE CARE NEEDS, OUTCOME, AND PREDICTORS OF MORTALITY
To describe clinical profile, intensive care needs, outcome, and predictors of mortality in critically ill children with hemophagocytic lymphohistiocytosis (HLH).
Retrospective, single center study involving 62 children aged 2 months-12 years with diagnosis of HLH (HLH 2004 criteria) admitted to PICU of a tertiary care teaching hospital in North India from January 2012 to April 2019 (7¾ years). Primary outcome was PICU mortality and secondary outcome was to identify intensive care needs and predictors of mortality.
The median age was 82 months (IQR:50.5-124) and majority were males (59.7%). The median PRISM III score was 16 (IQR:10-23). Infections (scrub and dengue, 46.7%) were most common etiologically for HLH. Majority of the cases were treated with steroids (77.4%) and IVIG (25.8%). Various complications noted were shock (71%), acute kidney injury (AKI) (66.1%), acute respiratory distress syndrome (ARDS) (41.9%), disseminated intravascular coagulation (DIC) (24.2%), central nervous system (CNS) dysfunction (54.8%), multiorgan dysfunction syndrome (MODS) (82.3%), and healthcare associated infections (HCAIs) (14.5%). Intensive care needs included mechanical ventilation (74.2%); transfusion of PRBC (72.3%), FFP (40.3%), and platelets (48.4%); vasoactive drugs (71%); and renal replacement therapy (RRT) (24.2%). Median duration of PICU stay was 5 (2.5-9.5) days. The mortality was 59.7% (n=37). On univariate analysis, non-survivors had higher PRISM III score; higher incidence of shock, AKI, ARDS, and MODS; and more cases required mechanical ventilation, vasoactive drugs, and RRT. On multivariate analysis, none of these parameters were predictive of mortality.
HLH secondary to infections is most common in critically ill children admitted to our PICU and associated with high mortality (60%). Higher PRISM III score; presence of shock, AKI, ARDS, and MODS; and need for mechanical ventilation, vasoactive drugs, and RRT were predictors of mortality.
Lalit Takia, Suresh Kumar Angurana, Lokesh Saini, Karthi Nallasamy, Muralidharan Jayashree
NEUROLOGICAL MANIFESTATIONS OF SEASONAL INFLUENZA (H1N1)
To describe the neurological manifestations in children with seasonal H1N1 infection.
Case records of 6 children with PCR confirmed H1N1 infection and neurological manifestationsadmitted to PICU and Pediatric Neurology unit of a tertiary care teaching hospital in North India during the 2019 outbreak (January-April) were reviewed retrospectively for demographic details, clinical features, neurological signs and symptoms, neuroimaging, treatment, intensive care needs, complications, and outcome.
The subjects (5 girls, 1 boy) were in the age range of 6 months to 10 years. The pre-hospital duration of illness was 2-7 days. Fever, respiratory (cough, coryza, respiratory distress), and neurological symptoms (seizures and altered sensorium) were present in all at admission. The admission GCS ranged from 4-12 and 4 cases showed clinical signs of raised intracranial pressure (ICP). Cerebrospinal fluid analysis revealed pleocytosis in only 2 cases. CT scan revealed normal study in Cases 1 and 3, and diffuse cerebral edema in Case 2. MRI brain was suggestive of acute necrotizing encephalitis of childhood (ANEC) in Case 4; acute disseminating encephalomyelitis (ADEM) in Case 5; and bilateral symmetrical basal ganglia hyperintensities, diffuse involvement of dorsal and ventral midbrain including substantia nigra and dorsal pons in Case 6.All cases were treated with Oseltamivir for 5 days. PICU needs were raised ICP management (n=4), mechanical ventilation (n=3), and vasoactive support (n=3). Three cases (cases 4, 5, and 6) received intravenous methylprednisolone (30 mg/kg) for 5 days. Case 2 died on day 3 of PICU admission due to refractory raised ICP. Total duration of hospital stay in survivors was 10-30 days. Among survivors, 3 cases had significant neurological sequalae, while 2 returned to premorbid status.
Seasonal H1N1 can lead to varied neurological manifestations including seizures, encephalopathy, encephalitis, ADEM, ANEC. Raised ICP was the major contributor to poor outcome.
Lee Yi Hui, Tan Yen Cheng, Helmi Bin Abdul Halim. Hospital Kepala Batas, Penang
COMPARISON OF ORAL VITAMIN C AND THIAMINE GROUP WITH CONTROL GROUP FOR THE TREATMENT OF SEPSIS AND SEPTIC SHOCK IN INTENSIVE CARE UNIT
To compare the treatment outcomes of oral Vitamin C and Thiamine group with control group among sepsis and septic shock patients treated in the ICU.
All sepsis and septic shock patients admitted to ICU have been prescribed with a combination of oral Vitamin C, oral Thiamine and IV Hydrocortisone by the intensivist in view of the promising outcomes from the recent IV Vitamin C and IV Thiamine study. A retrospective, observational study was hence carried out to compare the primary outcome of in-hospital mortality, and secondary outcomes of length of ICU stay, duration of vasopressor used and renal replacement treatment for acute kidney injury, with a historical control group only prescribed with IV Hydrocortisone.
There were 24 and 19 patients in the treatment and control groups respectively, with similar baseline characteristics. The total daily dose of Oral Vitamin C administered was range from 100 to 900 mg whereas oral Thiamine administered was range from 100-200mg. The in-hospital mortality was 37.5% (9 of 24) in the treatment group compared with 57.9% (11 of 19) in the control group. The duration of vasopressor used was shorter in treatment group compared to control group, at 58.5 hours and 88.9 hours respectively. The need for renal replacement treatment was similar in both groups, at 26.7% and 25% in the treatment and control groups respectively. The differences in primary and secondary outcomes were not statistically significant.
Oral Vitamin C and oral Thiamine might reduce in-hospital mortality and duration of vasopressor used in sepsis and septic shock patients. As IV vitamin C was not readily available in local setting, future study with a fixed, higher safety dose of oral Vitamin C and oral Thiamine can be conducted.
Arif S, Rowina NM, Anuwar A
SEVERE LEPTOSPIROSIS ASSOCIATED WITH HYPOXAEMIC RESPIRATORY FAILURE SECONDARY TO PULMONARY HEMORRHAGE SUCCESFULLY TREATED WITH VENO-VENOUS EXTRACORPOREAL MEMBRANE OXYGENATION : A CASE REPORT
Leptospirosis is an infectious disease that affects worldwide, ranging from mild acute febrile illness to severe form that causes bleeding, jaundice and renal failure. Mortality rate in cases with severe pulmonary haemorrhagic syndrome (SPHS) is up to 60% even with adequate treatment.
We report a case of life threatening leptospirosis with SPHS that was successfully managed with a Veno-venous extracorporeal membrane oxygenation (V-V ECMO). A previously healthy 28 year old male presented with 3 day history of fever, vomiting, diarrhoea and poor oral intake. He worked at a construction site and had travel into the jungle, crossing the river in Kelantan on daily basis.
On admission, he had high grade fever of 39.8 degrees celcius, deranged liver function tests, CRP; 104mg/dL, WBC; 10,800/uL & platelets; 28000/ ul. He was initially treated for typhoid fever. However, the next day he developed haemoptysis with pulmonary haemorrhage and desaturated to 72% requiring emergency endotracheal intubation. ABG revealed type 2 respiratory failure with P/F ratio of 32. He required high ventilator settings of FiO2 1.0, PEEP 16, rate 18, PC 22 and PS 16. He also had lung recruitment done and put on prone position for 12 hours but his condition worsened and lactate increased to 10.57mmol/L. It was then decided to put him on V-V ECMO and his condition improved markedly. He was slowly weaned off after 11 days on ECMO. He was extubated well 1 day after that and survived to hospital discharge.
Although the mortality rate of patients with severe leptospirosis with SPHS is high, consideration in the use of V-V ECMO could possibly improve the rate of survival
Dr Farah R, Dr Mustaffa Kamil ZA, Dr Teo SC
OUTCOME OF MODIFIED EARLY WARNING SCORE ON ADMISSION TO INTENSIVE CARE UNIT SARAWAK GENERAL HOSPITAL
Critical Care Outreach Team (CCOT) was established in our hospital since 2016 to bring critical care support outside of Intensive Care Unit (ICU). Modified Early Warning Score (MEWS) is known to have good predictive value for patient deterioration including potentially ICU admission.
A descriptive retrospective study of CCOT referrals from adult surgical-based wards from 1st January 2018 to 31st June 2018, excluding follow-up patients from ICU or PACU. Data was analysed with SPSS version 25.0.
Of 110 patients referred to CCOT, 60% were male and mean age was 51.4 years old. Most common cases referred was sepsis. MEWS upon referral ranged from 3 to 10 with mean of 4. There were 10.9% who needed non-invasive ventilation, 6.4% was intubated and ICU admission was 20.9%.
CCOT service started with purpose to support critically ill patients in general ward and avert ICU admission. MEWS value ranges from 0 to a maximum of 13; higher scores representing hemodynamic instability. Earlier identification of critical illness in the wards has management implication. Most common cases referred were sepsis with one case MEWS of 10. The initial step of resuscitation for sepsis, including intravenous fluids, antibiotics and monitoring, can be delivered with potential great impact. With limited ICU bed occupancy, we manage to avoid 80% of ICU admissions.
Early identification and resuscitation of potential critically ill or deteriorating patient is the key in preventing admission to ICU. Timely identification of critical illness is a vital step towards establishing the overall burden of resource-limited setting.
KeePW, ChangHX, OoiMM, LimCH, YongCY
Effects of Intravenous Ascorbic Acid on Critically ill Patients in Septic Shock: A Retrospective Observational Study
Septic shock remains the commonest cause of morbidity and mortality in critically ill patients, who predictably have low serum ascorbic acid levels. However, evidence is lacking to justify therapeutic use of intravenous ascorbic acid (IVAA). The objective of this study is to evaluate the efficacy of IVAA on the outcomes of septic shock patients with different SAPS, SOFA and APACHEII scores.
This is a retrospective observational study involving adult patients with septic shock admitted to GICU HPP within March 2018 until January 2019. They were given IVAA 2 gram three times daily within 24 hours of GICU admission. Our primary outcome is the Survival rate at Day28.
Survival rate at Day28 was 44%. The mean and median SAPS scores were 48 and 38 respectively among those survived while they were much higher at 58 and 67 respectively among those who died. Mean APACHEII score was 28 among survivors and higher at 38 among those deceased. Interestingly mean and median SOFA scores were same at 11 and 9 respectively for both survivors and deceased.
71% of deceased and 55% of survivors had refractory septic shock. 45% of survivors required RRT as opposed to a whopping 93% among those deceased. Among survivors, duration of mechanical ventilation was 15 days, ICU stay 24 days, duration of vasopressor 8 days, and lactate normalisation was within 1 day.
Survival rate at Day28 was poorer among those with higher SAPS, APACHEII scores, refractory septic shock, and those requiring RRT. IVAA may benefit those with lower SAPS or APACHEII scores without refractory shock. Further study is needed for patients with refractory septic shock in the future.
SHIVALI SHAMSHER;T PRABA; K MOHAN;TY LING; S BINA RAI
PERSPECTIVE OF SECOND YEAR MEDICAL STUDENTS ABOUT INTENSIVIST AND INTENSIVE CARE UNIT (ICU) IN A PRIVATE UNIVERSITY IN MALAYSIA
Medicine is heading towards specialization and super specialization. Our aims are to assess second-year medical students’ knowledge and awareness about Intensivist and ICU.
Cross sectional study, 82 second year medical students interviewed. Questionnaire was validated using Cronbach’s alpha. This was an internal audit with permission by Deanery. Prior written informed consent taken from all participants. Data analysed using SPSSV22.0.
Of the total, 42.7% were unsure and 28% did not know who an Intensivist is. More than 50% were unsure regarding basic qualification and designation. Majority(>50%) were aware about the role of Intensivist. But 41.5% were not sure about who decides ICU admission. Majority(84.1%) were aware that ICUs are structured differently, highly equipped (90.2%), cater to individual patient(47.6%) and not all hospitals provide ICU services(52.4%). 51.2% unsure about the percentage of ICU to total hospital beds in specialist hospitals. Of all, 52.4% thought that any critically ill patient should be shifted to ICU, though 53.7% were aware of the existence of admission criteria. In terms of management, 75.6% knew that ICU admission does not guarantee survival, prolonged stay have negative impacts (52.4%) and ICU care is expensive (76.8%).
Second Year medical students lack knowledge about the qualification of Intensivist. They wrongly assume that all critically ill patients need ICU care. We suggest to provide medical students with an insight into this super-specialty (Intensivist) early in the MBBS curriculum, helping them keep it as an option for their future specialization and provide better understanding about the ICU referencing system, admission criteria and limited availability.
CALL OF DUTY: SERVICE OUTCOME OF SOLO ON-CALL ANAESTHESIOLOGIST IN A STATE HOSPITAL- A SURVEY
Aim: To analyse solo On-call Anaesthesiologist care outcome in Intensive Care Unit (ICU) and General Operating Theatres (GOT), Tengku Ampuan Rahimah Hospital, Klang.
Methodology: All ICU and GOT cases with varying surgical categories and ASA physical status were documented by On-call Specialist in a prospective data collection form. A Survey on Medical Officers(MO) on-call were conducted to determine their expectation and actual specialist attendance. Crude Mortality Rate (CMR) and Length of Stay (LOS) in ICU data extracted from Annual Report of Malaysian Registry of Intensive Care (MIRC) 2017 and HTAR ICU record. GOT Anaesthesia Incident Reporting File data was also analysed.
774 cases were recorded during period of study (21/12/2018 to 28/2/2019), 456 in ICU (58.9%) and 318 from GOT(41.1%) respectively.
The solo Anaesthesiologist On-call fully attended 85% of the ICU cases in contrast to only 15% cases in GOT, whereby 46.2% were major high risk emergency category. Lowest attendance(33.6%) of cases is from 1600H to 1800H, vastly assisted by a registrar on-call.
The perception of MO towards the presence of specialist at all time in GOT varies with their experience in Anaesthesiology and type of surgery. The actual specialist attendance were below MOs’ expectation especially in major- high risk cases (30.1% vs 94.9%). However, in ICU the actual specialist attendance to MO expectation were higher (79.4% and 62.3% respectively.)
During the study period, LOS 4.19 days and CMR 10.57% compared to 2017 national cencus data of LOS 4.9 days and CMR of 18.3%. There was only one incident of life-threatening anaesthesia complication and was well managed.
A solo on-call Anaesthesiologist is unable to attend all major high risk emergency surgeries, however is assisted by a registrar on-call for safe anaesthesia. Their higher focus in ICU management has contributed to better LOS and CMR compared to national census.
Li Yeen Tham, Lucy Chan, Kelvin Beh
OBJECTIVE DETERMINANTS OF COGNITIVE FUNCTION IN DOCTORS: ICU VERSUS OT
Do anaesthetists experience a temporary decline in cognitive function at the end of an 8 to 5 working time slot? The intensive care unit and operating theatre is accepted as a ‘stressful environment’. Other than a stressful environment, there is exposure to pollution from inhalational agents in the operating theatre.
This project was undertaken to objectively determine whether there is a difference in cognitive function of doctors in two stressful environments: ICU versus OT.
2 groups of anaesthetists, one from ICU and the other from the OT were required to complete questionnaires: the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA) test. These questionnaires were answered at the beginning and at the end of a working day. The first Group of OT doctors completed the questionnaires at 8am, before the conduct of general anaesthesia, and later at 4pm after completion of the elective surgical list. In a similar time sequence, the second group of anaesthetic doctors recruited in ICU concluded the questionnaires.
Using the Student’s T-test, there is statistical significance between the scores of the two groups for MOCA test. Anaesthetists in the OT had a significant drop in MOCA scores compared to those from ICU. No significant difference in MMSE scores found.
Results indicate that anaesthetic doctors working in the OT environment may experience a temporary decline in cognitive function compared to their colleagues leaving the ICU at the end of a taxing day.
We hypothesize that the exposure to volatile anaesthetics in the OT is the most likely agent that influenced the difference in outcome of cognitive behaviour between OT and ICU doctors.
Sivasangari Nachamuthu; Ainaa Ismail; Lim Chew Har; Noor Airini
CARBAPENEM RESISTANT ENTEROBACTERIACEAE (CRE) BLOOD STREAM INFECTION AT GENERAL INTENSIVE CARE UNIT, HOSPITAL PULAU PINANG IN 2017 AND 2018.
To analyse the presence of predisposing factors and 28 day mortality rate in CRE bacteraemia.
The study conducted in Penang Hospital ICU which is a tertiary hospital with 24 ICU beds; This is a retrospective study, data collected from medical records of the patients.
Total GICU admission in 2017 and 2018 was 2585 while total CRE bacteraemia was 37. The incidence of CRE bacteraemia was 1.43%. 23 of the patients were male, 59.5% were in the age group between 50-70. Median SOFA and SAPS2 score were 9 and 44 respectively. Klebsiella Pneumoniae was the predominant CRE organism as it was cultured in 36 of them while Escherichia Coli was isolated in 1 patient.
21.6% of patients were alive after 28 days of CRE bacteraemia, while 29 died.
Presence of risk factors:
73% had underlying diseases, 89.2% stayed in hospital more than 2weeks, 89.2% ventilated, 46% had tracheostomy, 83.8% had CVL, 94.6% had urinary catheter.
Sixteen patients were exposed to Tazocin while nineteen and eighteen for Cefepime and Meropenem respectively prior to CRE bacteraemia.
CRE bacteraemia has high 28 days mortality rate. Most of the patients were exposed to almost all the predisposing factors. Prior usage of antibiotics is a crucial risk factor and all of them were exposed to it.
Antimicrobial stewardship, minimal invasive device usage and stringent infection control measures should be implemented to curb CRE bacteraemia.
FIRE SIMULATION IN ICU AND OT HOSPITAL MIRI; LEARN FROM THE PAST, PREPARE FOR THE FUTURE
We like to share our experiences in organising table-top exercise followed by simulation of fire with simulated ICU and OT patients. Three main meetings were done which were pre-event planning with JPBM and PDRM, evacuation details with staff & patients and debriefing. We decided the scenario to be a simulated fire near main entrance to the ICU and OT. Such scenario would have prevented hospital-designated primary evacuation route for ICU/OT via ramp to the mustering station. Consequently, it would have instead highlighted a secondary detailed vertical evacuation using the stairs, plus horizontal evacuation via the bridge to the neighbouring ward. This achieved the redistribution of critically ill ICU or open wound OT patients to the alternative locations with adequate capacity and expertise for continuation of care. We clearly emphasized that the most senior members of staff present in ICU and OT at the time of incident were to make the decisions of which patients to move first, which route to take and when was the right time to evacuate.We also evaluated the coordination and response time of local and regional agencies (e.g. Hospital Administration, PDRM, JPBM) in specialised evacuation of critically ill patients. We suggest fire simulation exercises for critical care providers be integrated within the framework of disaster preparedness plan in all hospitals.
Wong Zi Sien, Leong Ai Leng, Au Yan Qian, LEE EE LEEN, Lee See Pheng, Hj Mohd Rohisham Bin Zainal Abidin
AN OBSERVATIONAL STUDY ON THE PRACTICE AND OUTCOME OF REGIONAL ANAESTHESIA IN INTENSIVE CARE UNIT (ICU) HOSPITAL TENGKU AMPUAN RAHIMAH (HTAR), KLANG.
HTAR Klang has been certified as a pain free hospital since 2015. Regional anaesthesia has been incorporated in the management of ICU patients as multimodal analgesia. The objective of the study is to determine the benefit and complication of regional anaesthesia in ICU patients in HTAR Klang. This observational study was carried out from January to December 2018 involving all ICU patients receiving regional anaesthesia using an observational sheet.
A total of 66 patients (54 males and 12 females) were recruited from the study. Reasons for the regional anaesthesia include trauma, perioperative analgesia and medical condition. The regional anaesthesia consist of epidural (53.03%), peripheral nerve block (39.39%) and paravertebral block (7.58%). There were significant differences between reasons and types of regional anaesthesia (p< 0.03). Majority of block (18 patients) were performed for perioperative analgesia, whereas epidural (20 patients) and paravertebral block (5 patients) were performed for trauma cases.
From the study, the regional anaesthesia were performed by different operator at consultant (28.8%), specialist (12.1%) and medical officer (28.8%) level. there was significant difference between operator and types of regional anaesthesia provided (p < 0.007). Majority of the epidural anaesthesia (42,42%) and paravertebral block (7.58%) were performed by consultants while peripheral nerve blocks were performed by medical officers (24.24%).
Most of the patients achieved good analgesic post regional anaesthesia. They had pain score less than 4. However, there was no significant difference between the pain score according to types of regional anaesthesia. From the study, patients also had better cough and ventilation days less than 3 days, but there was no significant difference between ventilation days and type of regional anaesthesia.
Complication occur in 2 cases. Patients developed pus and inflammation in epidural site. However, inflammation subsided after catheter were removed.
There is no superiority of different types of regional anaesthesia. Overall, patients have better pain control. Patient selection is important for the successful of regional anaesthesia. Patient’s illness often complicates the management of regional anaesthesia. In conclusion, regional anaesthesia seems to be feasible and safe in ICU patients.
Mei Yang, Suyun Qian
APPLICATION AND ANALYSIS OF FLUOROQUINOLONES IN SEVERE INFECTION IN CRITICALLY ILL CHILDREN
National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, Beijing 100045, China
Mei Yang, Email:firstname.lastname@example.org
To analyze the efficacy and safety of fluoroquinolones in children. Methods
Retrospective analysis of the patients with severe infections in the pediatric intensive care unit of Beijing Children's Hospital in November 2016 - June 2019. The clinical data were collected to determine the clinical efficacy and to observe the safety of drug.
55 children were treated with fluoroquinolones, including levofloxacin, ciprofloxacin and moxifloxacin. Patients with poor initial treatment were treated with levofloxacin or ciprofloxacin on the basis of drug sensitivity for bacterial infections. Moxifloxacin was used in the treatment of Mycoplasma pneumoniae infection in patients with poorly treated by macrolides antibiotics or macrolide-resistance gene positive . Among the 55 cases, 11 cases (20 %) were cured, 34 cases (61.9 %) were effective, 2 cases were no response (3.6 %), 6 cases (10.9 %) were discharged automatically during treatment, 2 cases were dead, and the response rate was 81.9%. The consciousness, skin, joint and gastrointestinal function were closely observed ; Blood routine test, liver and kidney function were closely monitored. There were no adverse drug reactions during the period of medication.
Fluoroquinolones can improve efficacy and prognosis for pediatric patients with severe infections. There are no drug related adverse reactions, indicating that short-term use is safe. Furthermore, these children should be followed up for a long time to monitor if there will be arthropathy. Pediatric patients use quinolones is off-label drug use, and clinical pharmacists should assist doctors in doing related work and reduce medical risks.
Key words Fluoroquinolones; Critically ill children; Severe infections; Off-label drug use; Clinical pharmacists
Lijuan Wang, Suyun Qian
IDENTIFICATION AND CHARACTERIZATION OF MRSA ST59 WITH NEGATIVE Α-HAEMOLYSIS ISOLATED FROM CHINESE CHILDREN
Keywords: Methicillin-resistant Staphylococcus aureus; ST59 clone; negative α-haemolysis; invasive infection; β haemolysin.
Methicillin-resistant Staphylococcus aureus (MRSA) causes severe invasive diseases. The role of α-haemolysin in MRSA has been well known while only a few studies have reported the association of α-haemolysis with human clinical isolates.
This study was performed to investigate the haemolytic activities of the MRSA isolates from children in a hospital in North China, especially the haemolytic activities of the prevalent ST59 MRSA.
Clinical samples were isolated from 259 patients (≤ 18 years old) with MRSA infection during 3 periods in a hospital in Northern China. Polymerase chain reaction (PCR) amplification was used for multilocus sequence typing (MLST), SCCmec typing, agr typing and spa typing of the isolates. The haemolytic activities and the haemolytic genes were determined. The clinical characteristics of 40 invasive isolates were included in the analysis.
The incidence of ST59 type infections increased significantly from 48% in 2005-2011 and 46.7% in 2012-2013 to 79.8% in 2016. Ninety-one ST59 isolates exhibited β and δ haemolysis, while 95.3% ST239 and other clones showed αδ haemolysis. The intact hlβ gene was found in 97.4% isolates exhibiting β and δ haemolysis. The int gene was detected in 94.1% of the isolates that showed α and δ haemolysis. Forty cases were classified under invasive MRSAinfection. There was no significant correlation between haemolysis type of invasive MRSA isolates and the periods of study, age, sex of infected children, admission to paediatric intensive care unit (PICU) and diagnosis (P>0.05).
Conclusion.α-haemolysis negative ST59 had become the predominant CA- and HA-MRSA clone in the hospital. The haemolytic types of the isolates were not related to the clinical characteristics of the infected children.
Olive Pei Ee, LEE CHOR Yek KeeCONFIRMATION OF ENDOTRACHEAL TUBE POSITION USING ULTRASOUND : A NOVEL APPROACH
Tracheal intubation is a common procedure in the intensive care unit and thus regularly there will be endotracheal tube(ETT) malposition. Chest radiography (CXR) has been the gold standard to confirm endotracheal tube position but bedside ultrasound has been gaining importance as an adjunct.
A pilot study has been done in our PICU to study the feasibility of using bedsides ultrasound to confirm optimum ETT position. ETT tip was confirmed using linear ultrasound probe L15-7io by counting the corresponding tracheal ring both in the longitudinal and transverse plane. The ultrasound was done by the intensivist of the unit with the neck of patients in neutral position.The number of tracheal rings is then compared with the ETT tip on the CXR with optimal position on X-ray being at the level of 2nd to 4th thoracic vertebrae. Those with congenital malformation of the head and neck or dysmorphic features were excluded from this study.
Ho KL, Anis Siham, H’ng SY, M.Sufian Ardi, Chuah MJ
CASE REPORT : DENGUE FEVER WITH POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME
Dengue can cause neurologic complications in addition to the more common manifestations of plasma leakage and coagulopathy. Most commonly seen was Dengue encephalitis or Acute Disseminated Encephalomyelitis (ADEM). Posterior Reversible Encephalopathy Syndrome (PRES) has rarely been described in Dengue, although the patho-physiology of endothelial dysfunction likely underlies both. Here we describe a case of Dengue associated Posterior Reversible Encephalopathy Syndrome. He is an 11 years old obese boy, who presented to us at day 4 of febrile illness with gastroenteritis, who then was complicated with Upper Gastro-Intestinal Bleed and subsequently went into shock, requiring fluids and blood products resuscitation and intensive care. During this period, his Dengue Serology reported to be positive and was managed as Dengue Haemorrhagic Shock. During the recovery phase, he developed hypertensive crisis due to fluids overload resulting in multiple episodes of seizures. Series of investigations were done including bloods and CSF sampling but all reported to be normal. Brain imaging concluded that the patient had PRES. His seizures ceased once hypertension resolved and he regained a normal neurological status. This poster illustrates the need for clinicians to consider PRES in Dengue patients with neurologic symptoms and that PRES should be distinguished from other forms of neurological disorder associated with Dengue.
Radwika Swastanti Wijaya, Kurniawan T. Kadafi, Saptadi Yuliarto
SUCCESSFUL CONSERVATIVE TREATMENT IN INOPERABLE CONGENITAL CYSTIC ADENOMATOID MALFORMATION: A CASE REPORT
Congenital Cystic Adenomatoid Malformation (CCAM) is a rare lung abnormality which is presents usually in early childhood. CCAM carries a poor prognosis but survival rates of 70% can be achieved by thoraco-amniotic drainage in those with macrocystic lesions. This case presented with lung tuberculosis and bilateral lung cysts and have favorable outcome without surgery.
We present a five-month-old boy presented with respiratory distress. He had history of cough and dyspnea for 4 months. He had contact with positive tuberculosis patient and never got any immunization. On examination, grunting, chest retraction and tachypnea were present. Chest X-ray showed bilateral lung opacity. Rapid molecular test for tuberculosis revealed positive result. Due to worsening respiratory distress, he moved to PICU and got controlled mechanical support (RR 40 Breath per minutes, Pcontrol 13cmH20, PEEP 8mmHg, Fi02 80%). The patient got medication of R75H50Z150E20,, however no improvement was seen after evaluation for one month. Although chest xray shown reducing infiltrates, it revealed multiloculated cystic lesions in both lung. Chest MRI confirmed a Congenital Cystic Adenomatoid Malformation. Because of extensive size of the cyst, the case was inoperable. Initialy, the weaning ventilator trial always failed. We performed chest physiotheraphy daily, 45 degree positioning for 3-4 hours daily and enteral nutrition. Fortunately after 2 months, he can showed a clinical improvement and was discharged home on nasal cannula oxygenation.
We report a case of inoperable CCAM with favorable outcome in spite of prolonged mechanical ventilator.
Congenital Cystic Adenomatoid Malformations, mechanical ventilation
Florence Bala, Normah Madehi, Chor Yek Kee
NURSES AND ALLIED HEALTH PERCEIVED REGARDING WITHDRAWAL AND WITHHOLDING CARE IN PAEDIATRIC INTENSIVE CARE (PICU) , SARAWAK GENERAL HOSPITAL
Nurses in critical care Units spend the most time with patients whom are at their critical ill period as compare to the rest of the health care provider and sometime parents. This might contribute to significant impact in emotional disturbance especially decision of withhold or withdrawal of care is made. This study explores the experience and perception of the Nurses and Allied Health in handling the dehumanizing aspect of dying in a technological environment.
A survey form with multiple choice answer in Google form was distributed to the PICU nurses at PICU, Sarawak General Hospital via WhatsApp. The nurses whom responded to the questionnaire are consented to the study. Total of 54 nurses and allied health participated in the questionnaire.
The survey is conducted in PICU and the samples are nurses at PICU. There is only one male nurse in the survey. 70% of the sample are younger than 35-year-old. Only 5 (9.1%) nurse work in PICU for more than 10 years. 44(80%) of them are married. Majority of them (34, 71.8%) are not comfortable with withdrawal or withholding care and 14.5% of them feel that their religion does not allow the process. 23.6% of them feel uncomfortable to talk about the issues with family and nearly all of them (52,94.5%) affected emotionally by the process
Majority of nurses working in PICU are young married lady and has less than 10 years’ experience in PICU. Majority of them are emotionally affected with the process of withdrawal and withholding life support. Psychological support is needed to assist this group of health care worker.
Jiayun Ying, Guoping Lu
STUDY ON THE EFFECT OF SULODEXIDE ON GLYCOCALYX REMODELING AND ENDOTHELIAL FUNCTION AFTER HEPARINASE III TREATMENT
To investigate the effects of sulodexide(SDX) on remodeling of endothelial glycocalyx and to find out the possible mechanisms involved.
Mouse microvascular endothelial cells were divided into control, Heparinase III(Hep), SDX, and Hep+ SDX group. UTI was administered 2h, 4h, and 8h after Heparinase III treatment. The expression of syndecan1(SDC1) on the surface of endothelial was observed by immunofluorescence. Western Blot was used to assess the changes of intercellular junction protein (ZO-1 and VE-cadherin) and NF-κB signal pathway. The permeability of endothelial barrier was assessed by transwell method. Sdc1 mRNA expression was assessed by RT-PCR.
Compared with control group, the expression of SDC1, Sdc1 mRNA, ZO-1, and VE-cadherin were decreased in Hep group, but it was partly reversed by SDX. SDX didn’t reverse Sdc1 mRNA and VE-cadherin. Furthermore, the permeability of endothelial barrier was increased in Hep group, which was suppressed by SDX. In addition, SDX inhibited Heparinase III-induced activation of NF-κB.
SDX may not remodel SDC1 on the surface of endothelial after heparinase III treatment by increasing the expression of Sdc1 mRNA, but it can increase the expression of ZO-1 and improve the endothelial barrier through inhibiting NF-κB signal pathway.
Wong Song Jie, Mohd Khairul Anwar Bin Salahuddin, Nor Alina Binti Aziz, Chew Eng Lai
REVIEW OF AIR TRANSFER BY PAEDIATRIC DEPARTMENT, HOSPITAL LANGKAWI, KEDAH, MALAYSIA
Hospital Langkawi, Kedah, Malaysia started its Medical Evacuation (MedEvac) service using a dedicated helicopter for air transfer of patients to mainland Malaysia in January 2018. All patients who were air transferred by the paediatric team from 1st January 2018 until 30th June 2019 were reviewed. A total of 116 paediatric patients utilized this service, which accounted for 38.5% of total air transfer during the corresponding period. 81% of patients were below 5 years of age and medical conditions accounted for 80% of the cases. Out of 116 patients, 98 (84.5%) were emergency cases. In terms of severity, 67 out of 116 patients (57.8%) required invasive ventilation and 9 needed inotropic/vasoactive support during air transfer. 83 out of 116 transfers (71.6%) had 30 minutes or less flight time. The biggest advantage of the air transfer was the significantly shorter travel time as Langkawi is an island with no road connection to the mainland and only ferry or air transport as the options. Another advantage was less staff fatigue due to the much shorter travel time. Problems with this service were noise, vibration, very tight space in the helicopter and no flights at night or during bad weather. In spite of its limitations, air transfer has proven to be a safe and an efficient mode of patient transfer for Hospital Langkawi.
Astarini Hidayah, Kurniawan T. Kadafi, Saptadi Yuliarto
CLINICAL VARIABLES AND OUTCOME OF PEDIATRIC HIGH CARE UNIT PATIENTS IN REFFERAL CENTER HOSPITAL MALANG, INDONESIA
Pediatric high care unit is characterized by various severity of clinical emergencies with each challenge and life threatening condition. Recently, still lack of study about pediatric critical care profiles in Indonesia.
To delineate clinical variables and outcome of children admitted to the Pediatric High Care Unit of Saiful Anwar Hospital, Malang.
This retrospective study was done in patient aged more than 1 month to 18 years admitted in HCU from 1st January 2017 to 31st December 2018 when a total of 567 patients were admitted. Results:
There was predominantly male children in 314 (55.4%) patients. Fifty one percent of the patients was 1 month to 1 year old. Undernourishment was 61 % from admission in HCU. Major complaint was respiratory distress (46 %) whereas pneumonia (14.8 %) was the most common diagnosis. Hemato-oncology disorder was the most common groups of primary system involved. The survival rate was 51.8 %.
Respiratory distress and pneumonia were the most common complaint and diagnosis. Nevertheless, Hemato-oncology disorder was the first thread of primary system involved. This profile elucidate the emergency condition, diagnosis and nutritional status in pediatric high care unit which estimate the distribution of critically ill pattern in middle income status such as Indonesia. This knowledge of critically ill children in our hospital hopes to create national data relating to child emergencies and to help in plan health policies in Indonesia.
Madon NZ, Athimoolam NK
CASE REPORT: A RARE CASE OF AIRWAY OBSTRUCTION
Congenital thymic cyst is an infrequent occurrence in childhood usually seen in the first decade of life. Though considered largely inconsequential, it can present with airway compromise in 7% of patients.
We report a case of infected thymic cyst in a term neonate. She weighed 3120 gram at birth with no risk of sepsis. She developed severe neonatal jaundice secondary to ABO incompatibility, which necessitated exchange transfusion on day 4 of life, through umbilical vein catheter (UVC).
She presents again on day 28 of life, with short history of cough, rapid breathing and mild stridor, without fever. Total white cell was 19.9 and C-Reactive protein positive at 192. A flexible nasolaryngoscope showed no sign of laryngomalacia. She was intubated for worsening respiratory distress on day 3. Chest radiograph showed homogenous opacity overlying the right lung and widened mediastinum, confirmed by ultrasound thorax as a cystic mediastinal mass. Computed Tomography (CT) scan confirmed a multiloculated cystic anterosuperior mediastinal mass with superior vena cava and tracheal compression, right upper lobe branch obliteration, differential diagnosis was possible mediastinal teratoma. She underwent median sternotomy and intraoperative finding was a large pus filled superior anterior thymic cyst. A post-operative diagnosis of infected thymic cyst was made. She recovered uneventfully and completed an 8-week course of oral and intravenous Cloxacillin and Fusidic Acid.
Infected congenital thymic cyst is rare. We believe this child had a pre-existing undiagnosed congenital thymic cyst, which inadvertently became infected after UVC. We stress on the sterile practices to prevent iatrogenic infections in intensive care setting.
We highlight a rare cause for airway obstruction in a neonate. Airway obstruction warrants urgent investigations and diagnosis, to improve patient prognosis.
Saptadi Yuliarto, Radwika S. Wijaya, Kurniawan T. Kadafi
WEANING FAILURE DUE TO NERVE PARALYSIS IN METASTATIC Neuroblastoma: A CASE REPORT
Neuroblastoma is a malignant tumor that could spread rapidly. The clinical course varies from different sign and symptom and might become aggressively and poorly response disease. Management of the patient is challenging mostly when it becomes a life-threatening condition.
We present case of one-year-old boy, who had chief complaint of seizure and unconscious. He was mechanically ventilated with synchronized intermittent mandatory ventilation mode (SIMV) [RR 25 breath per minutes, Pcontrol 9 cmH2O, PEEP 7 cmH2O, Ti 0.6, flow trigger 1, FiO2 50%]. Some extubation readiness test by T-piece trial failed due to increased work of breathing. On examination, there was multiple cranial palsies, involving nerve III, VII, and VIII. A diaphragm ultrasound showed a right phrenic nerve paralysis. The spinal magnetic resonance imaging (MRI) revealed multiple tubercles suspected spinal tuberculous meningitis or multiple spinal mass. He was given antituberculotics medication and intravenous corticosteroid. After a few days, a solid mass appeared at right neck. Fine needle biopsy revealed malignant cell suggested neuroblastoma. Unfortunately, after more than a month of intensive care, the patient still had no improvement and passed away.
We report a case of complicated neuroblastoma who failed to wean off from mechanical ventilation due to phrenic nerve paralysis.
Neuroblastoma; weaning failure; mechanical ventilation
Swee Im NG VOON, Junice Ai Wei OI, Kah Min PON
CLINICAL CHARACTERISTICS AND OUTCOMES ASSOCIATED WITH NON-INVASIVE VENTILATOR IN ACUTE PEDIATRIC RESPIRATORY FAILURE
Non-invasive ventilation (NIV) refer to administration of mechanical ventilation without using an invasive artificial airway. The use of NIV has increased in recent years and accepted as an effective way of providing ventilation to patients with acute or chronic respiratory failure without causing complication related to invasive ventilation. This study describe the clinical characteristics and outcomes associated with use of non-invasive ventilation in acute pediatric respiratory failure in paediatric intensive care unit (PICU), Hospital Pulau Pinang(HPP).
We identified 44 patients managed with NIV from December 2018 to May 2019 at PICU,HPP. Patients who utilized NIV as well as invasive ventilation during the same admission were included. Data collected includes demographics, diagnosis on admission, indications for NIV, duration of respiratory support, PICU length of stays, hospital length of stays, outcome and complications associated with use of NIV.
Out of the 44 patients, a total of 25 patients are male while the remaining 19 patients are female. Age group recruited ranged from as young as 1 month old to 16 years old with 43% of them under the age of 1 year old. About 73 % of patient recruited were using Bilevel Positive Airway Pressure (BiPAP) and the rest were using Continuous Positive Airway Pressure (CPAP). Out of the 44 patients recruited, 21 patients were also on invasive ventilation at some point of time. About 8% of the patients on NIV required intubation due to failed NIV. 2 main indications for NIV are due to respiratory diseases (63%) followed by post extubation stridor (32%). Based on the data collected, the younger the patient, the higher likelihood that the patient will require intubation. About 41% of the patients age less than 1 year old required intubation at initial presentation. No patients had experienced aspiration pneumonia, pressure sore, abdominal distension or pneumothorax associated with the use of NIV
Most of our patients improved with NIV. NIV failure is not associated with longer duration of respiratory support or any differences in hospital length of stay and mortality. Majority of patient discharged home well while 9% discharged with home NIV. 2 patients passed away due to non respiratory related underlying diseases.
CLINICAL PROFILE OF CHILDREN WITH DENGUE SHOCK SYNDROMEAT PAEDIATRIC INTENSIVE CARE UNIT (PICU) IN A DISTRICT HOSPITAL IN SANDAKAN
Sandakan has the highest number of dengue cases in Sabah, a total of 151 cases reported last year in pediatrics including 2 fatalities. This raises the need of studying its clinical profile.
To study the clinical profile of children with dengue shock syndrome admitted to pediatric intensive care unit (PICU)
The medical record of 20 patients admitted to PICU in Hospital Duchess of Kent, Sandakan from August until December 2018 were studied during the large outbreak period .
Out of the 20 dengue admission in PICU , 55% (n= 11) were serologically confirmed , NS1 positive . Main presenting feature were fever 100%, abdominal pain 65 % , vomiting 30% , diarrhea 5% , epistaxis and gum bleeding 5% .The indication of PICU admission was shock 100% , All 20 patient required fluid boluses at least of 20ml/kg .Further 95% (n=19) required packed cell transfusion , subsequently 40 % ( n= 8) required whole blood transfusion , 10% (n=2 ) required FFP and platlet transfusion . From 20 patients ,35% (n=7) had myocarditis , 30% ( n=6) had transaminitis , 50 % ( n=10) had high lactate > 2 . Upper gastrointestinal bleeding (UGIB), pulmonary hemorrhage and encephalitis were evident in 10% , 5% respectively . Complication include pleural effusion 30% ( n =6) , and ascites 10% (n =2 ) . The mean of PICU stay was 2.7 days . Mortality rate was 10 % ( n = 2) .
This highlights the disease burden of dengue shock syndromeat PICU setting and it emphasizes the important of early fluid therapy including blood product transfusion.
Thavani Thavarajasingam, Anis Zainal, Nachal Nachiappan
NOT JUST ANOTHER CASE OF HAND, FOOT AND MOUTH DISEASE: THE FIRST REPORTED CASE OF FULMINANT ENTEROVIRUS 71 COMPLICATED WITH RIGHT MIDDLE CEREBRAL ARTERY INFARCT.
Common complications of Enterovirus (EV) 71 hand foot and mouth disease are myocarditis with left ventricular dysfunction and central nervous system involvement commonly brainstem and cerebellum encephalitis. We put forth this interesting case of fulminant EV 71 complicated with right Middle Cerebral Artery (MCA) territory infarct due to thrombosis from left ventricular dysfunction.
A 3year old boy came to us with 4 days history of fever, irritability, rashes over palms and soles and herpangina. He was in cardiogenic shock with persistent tachycardia requiring fluid boluses, and ventilation. Echocardiogram (ECHO) showed a grossly dilated left heart with global wall hypokinesia. He required inotropes including milrinone and received Immunoglobulin. He developed seizures the next day. ECHO on day 4 revealed thrombus in the left ventricle. Heparin infusion was commenced and a repeat ECHO on day 6 showed thrombus resolution. He unfortunately developed right facial asymmetry with left hemiparesis on day 9. An urgent Computed Tomography Brain and Magnetic Resonance Angiography showed right acute MCA territory infarct secondary to long segment thrombosis involving right common carotid artery bulb, right internal carotid artery and right MCA. Rectal swab PCR was positive for EV 71. Cerebral spinal fluid cultures and EV 71 PCR were negative. He received 6 months of anticoagulants.
There has been no reported case of MCA territory infarct associated with enterovirus 71. This case demonstrates the association of thrombotic stroke with EV 71. Timely administration of antithrombotic therapy can help reduce the associated morbidity.
Thavani Thavarajasingam, Anis Zainal, Masnizah Mahmood, Pazlida Pauzi Radhiyah Abdul Rashid
PICU SENSORY REHABILITATION MODULE, THE FIRST OF ITS KIND: BRINGING LIGHTS, MUSIC AND FUN INTO PICU]
PICU rehabilitation involves a myriad team, ranging from the primary team of health providers and nurses, physiotherapist and occupational therapist, to the involved child and family members. Most, if not all rehabilitation models are centric towards early mobilization. This inevitably limits rehabilitation to critical but stable patients involving only gross and fine motor rehabilitation. Rehabilitation involving sensory stimulations such as auditory, touch and vision could further improve PICU outcome. We developed a PICU sensory rehabilitation module involving auditory, touch and visual stimulation.
Auditory stimulation is done using music therapy for 2 hours each during the morning, afternoon and night shifts. Family members choose the type of music to be administered to the child and when not available, classical music is played. As for visual stimulation, rotatory lights are used twice a day. In addition, hanging play toys are used for infants. For the age appropriate, children’s program on television is shown twice a day. As for touch, various textured play items are given randomly and upon request.
With the introduction of a simple and practical early sensory rehabilitation module, we were able to achieve less distress moments and better health care provider - patient interactions. Future studies should look into the sensory rehabilitation module providing pain relief, anxiety reduction and neurodevelopmental improvement.
Ika Maya Suryaningtias, Kurniawan T. Kadafi, Saptadi Yuliarto
MORTALITY RATE AMONG CRITICAL PATIENT BASED ON NUTRITIONAL AND ANEMIA STATUS: AN OBSERVATIONAL RETROSPECTIVE STUDY
Anemia can occur in critically ill children in which it is aggravated by malnutrition, chronic infection, and malignancy particularly in developing countries. These conditions can affect the outcome of patients due to decreased oxygen delivery.
The primary outcome was to describe the anemia prevalence in critical care unit. Secondary outcome was to compare mortality in undernourished and anemia group.
A retrospective study was conducted in critically ill patients in the HCU. Inclusion criteria, critically ill children were treated in the HCU, aged >30 days - 18 years old. The measured variables were hemoglobin level, nutritional status, and mortality between anemia vs non anemia group and normal vs undernourished.
Of the 568 critically ill patients in the HCU, most of them were male patients (55.5%) with the average age of patients was 3.6 years; most diagnoses were hematooncological disease 28.3%; The patients with undernourished status were 61.6%, and most of them were anemic (62.8%). The mortality rate was 26.2%. There was no difference of mortality between anemia and non anemia group (28.2% vs 23.2%; p=0.18). However there was higher mortality in undernourished than well nourished grup (31.1% vs 17.3%, p=0.001)
Conclusion. Most of our HCU patients were anemic and undernourished. The poor nutritional status was associated with higher mortality.
Suresh Kumar Angurana, Deepanjan Bhattacharya, Renu Suthar, Venkatasesan Sundaram, Praveen Kumar.
DISSEMINATED STAPHYLOCOCCAL DISEASE IN NEONATES ADMITTED TO PEDIATRIC EMERGENCY OF A DEVELOPING ECONOMY: CLINICO-MICROBIOLOGICAL PROFILE, MANAGEMENT, AND OUTCOME.
To report clinical and microbiological profile, complications, management, and short-term outcome of neonates with disseminated staphylococcal disease.
This retrospective study was conducted in Pediatric emergency of a tertiary care teaching hospital in North India involving 26 out-born neonatesadmitted with diagnosis of disseminated staphylococcal disease over 1-year period (January-December 2018).
Majority of the neonatespresented between day 7-28 of life with mean duration of illness 6.6 (2.4) days. The risk factor for disseminated staphylococcal disease were noted in 38.5% (n=10) cases (intramuscular injection, venous cannula, non-penetrative trauma, and umbilical line). Skin and subcutaneous tissue abscesses were the commonest localization (88.5%) followed by pneumonia (30.8%), meningitis (26.9%), septic arthritis (19.2%), and osteomyelitis (11.5%). Staphylococcus aureus was isolated in 76.9% cases and methicillin resistant Staphylococcus aureus (MRSA) accounted for 70% of isolates. Common complications were AKI, respiratory failure, and shock (in 26.9% each); and venous thrombosis and septic ileus (in 7.7% each). The duration of appropriate antibiotics was 16.5 (6.4) days. Incision and drainage of abscesses was done in 53.8% cases, 19.2% underwent arthrotomy, 27% needed vasoactive drugs, and 19% received invasive mechanical ventilation. The duration of hospital stay was 17.7 (8.7) days and mortality was 15.4% (n=4).
Disseminated staphylococcal disease is not uncommon in neonates. The skin and soft tissue focus with hematological spread to distant organs lead to fulminant disseminated disease. High index of suspicion, early diagnosis, prompt appropriate antibiotics, and early surgical debridement are integral part of management. The MRSA contributes to significant burden.
Kavitha TK, Arun Bansal, M. Jayashree
EFFECT OF MIDAZOLAM-FENTANYL VS. MIDAZOLAM-KETAMINE INFUSION ON CEREBRAL HEMODYNAMICS IN CHILDREN WITH RAISED ICP SECONDARY TO CNS INFECTIONS: A RANDOMIZED CONTROLLED TRIAL
To compare cerebral hemodynamics (ICP,CPP,MAP) during continuous IV infusion of midazolam-fentanyl vs. midazolam-ketamine when used as sedoanalgesia in 1-12-year-old children with raised ICP secondary to acute CNS infections.
An open label RCT conducted in PICU of a tertiary care teaching hospital between May 2018 - June 2019 where all children with acute CNS infections and raised ICP on invasive intraparenchymal ICP monitoring were randomised to receive either midazolam-ketamine (Group A) or midazolam-fentanyl (Group B) sedoanalgesia infusion. Enrolled children were followed up till 120 hours or ICP catheter removal whichever was earlier. Serial trends of ICP, CPP, MAP in both groups comprised of primary outcome while time to resolution of raised ICP, GCS at (72hours,120hours and PICU discharge) and PICU mortality were secondary outcomes.
Thirty two children were screened, of which 14 were excluded and 18 were randomised with 9 in each group. Baseline characteristics were similar in both groups. There was no significant difference in ICP (p=0.46), CPP (p=0.081) and MAP (p=0.076) between both the groups during 48 hours of infusion. Similarly the rate of change of ICP (p=0.909), CPP (p=0.615) and MAP (p=0.658) over time were also similar in both. The time to resolution of raised ICP (p=0.849), GCS, ventilation free days (p=0.912)and PICU mortality (p=0.500) in both the groups were not different.
Conclusion:Both midazolam-ketamine and midazolam- fentanyl were similar with respect to cerebral hemodynamic parameters when used as sedoanalgesia in children with raised ICP secondary to acute CNS infections.
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