IC/01(P).COMPARATIVE STUDY OF EFFICACY OF ORAL MIDAZOLAM Vs ORAL
KETAMINE IN PEDIATRIC INVASIVE PROCEDURES
U C Rajput, L S Deshmukh, A B Gunal, R N Nagalgaonkar (Late)
Department of Pediatrics, Government Medical College and Hospital, Aurangabad 431 001
Children frequently receive inadequate to no treatment for painful procedures. This is because of the
dearth of empiric in pediatrics pharmacology and fear of over toxicity by drugs. We therefore
designed the study to evaluate the safety and efficacy of midazolam and ketamine in pediatric
invasive procedure for sedation. Design : Hospital based comparative prospective randomized
study. Settings and Methods : Present study was carried out in the Department of Pediatrics,
Government Medical College and Hospital, Aurangabad during March 2001 to March 2003. GroupI oral ketamine 8 mg/kg + 0.3 ml/kg 10% dextrose, Group-II oral midazolam 0.5 mg/kg + 0.3 ml/kg
10% dextrose. Prior to procedures baseline anxiety score, response to drug administration and
sedation score were recorded. Procedure was carried out and recovery assessment was done.
Adverse effects if any were noted. Statistical analysis was done Chi-square test to analyze the data
by EP Info software. Results : The children between age group 1 to 12 years were participated in
study. Mean age for midazolam and ketamine were 6.29 and 6.10 years (p>0.05) and body weight
were 16.47 and 15.99 kg (p>0.05) respectively. Thus both the groups were comparable with respect
to age and weight. Male to female ratio in midazolam group was 2.03:1 and 1.4:1 in ketamine
group. The baseline anxiety score was similar in two groups. Good acceptance was more in
ketamine group as compared to midazolam group (54% Vs 26%; p<0.005). Sedation score at 15, 30
and 60 minutes was similar in both the groups (p>0.5). The sedation score at 45 minute was better
with midazolam than ketamine group (p<0.05). Separation anxiety from parents was similar in both
the groups at 30 minutes (p>0.5). Common adverse effects observed in midazolam group were
nystagmus (6%), vomiting (6%), hypersecretion (3%) and in ketamine group hypersecretion (17%),
nystagmus (14%), vomiting (6%), hallucination (3%). Conclusion : Both oral midazolam 0.5 mg/kg
and oral ketamine 8 mg/kg are safe and effective sedatives for the invasive procedures in pediatrics
patients. However, ketamine has analgesic effect.
IC/02(P).HELIOX IN THE PAEDIATRIC EMERGENCY AND CRITICAL CARE
SETTING
Akash Deep, Mohi Chowdhury, Parviz Habibi
St. Mary's hospital, Praed Street, London. W2 1NY (U.K)
Introduction: Heliox-21 has a lower density than air which allows movement of gas with less
driving pressure and better ventilation down to the alveolar level. We have successfully used heliox21 in the management of patients with croup, asthma, upper airway obstruction, bronchiolitis and
post-extubation stridor. Heliox in Post-Extubation Stridor: 10 month old infant with developmental
delay & poorly controlled fits was admitted with respiratory failure requiring intubation. Following
extubation she developed stridor within 15 minutes with modified Syracuse stridor score being
9/11. Patient rapidly settled after starting heliox, stridor score decreased to 4/11 and after 5 hours
heliox was stopped. Patient required only 1 dose of nebulised adrenaline driven through heliox.
Heliox in Acute Severe Asthma: 2 year old child was admitted with an acute exacerbation of asthma
with RR 70/min, HR 190/min, PaCO2 6.8 kPa). Severity was assessed by the modified Wood’s
asthma score (7/10). He was started on heliox & after 20 minutes there was an improvement in the
clinical status with reduction in asthma severity score to 4/10 and improvement in ABGs. Heliox
was continued for 6 hours, requirements for bronchodilators decreased and he did not require
ventilation. Heliox in Croup: 2 year old girl with noisy breathing and fever presented to A&E with
tachypnoea ,tachycardia , saturation 90% in air. Stridor score on admission was 7/11 and heliox
was commenced immediately . There was a marked reduction in respiratory and heart rates &
increase in saturation to 94% within 10 minutes of starting heliox-21. Stridor score fell to zero after
7 hours of starting heliox and the patient did not require further adrenaline nebulisers and was
discharged after 24 hours of observation. Conclusion: Heliox reduces respiratory distress in
conditions with resistance to airflow. It has a potential for use as 1st line for many respiratory
conditions in neonates & children averting need for PICU/NICU.
IC/03(P).CONTINUOUS NEGATIVE EXTRATHORACIC
VENTILATION IN CRITICAL CARE SETTING
Akash Deep, Claudine De Munter
St. Mary's hospital, Praed Street, London. W2 1NY (U.K)
PRESSURE
(
CNEP
)
Background: CNEP can be used in patients with bronchiolitis, neuromuscular disorders, heart
failure, pneumatocele, or to alleviate respiratory distress post- extubation. We use CNEP in a wide
variety of situations and present a few cases where we successfully used CNEP and avoided a
possible risk of intubation. CNEP in Staphylococcal pneumatocele : 10 month old girl presented
with 10 day history of cough and high fever. She became increasingly tired, tachypnoeic,
tachycardic with intercostals recessions, absent breath sounds on the right infra-mammary region.
Chest x-ray showed a large pneumatocele on the right side. We wanted to avoid positive pressure
ventilation, through an endotracheal tube or via non-invasive CPAP. She was started on CNEP at –
10 cm H2O and within a few hours we saw an improvement in the clinical parameters. She was
weaned slowly and discharged to the wards after 4 days. CNEP in neuromuscular disorders :12 year
old boy with congenital muscular dystrophy and multiple hospital admissions for respiratory
failure. He was admitted with another episode for which CNEP was tried. This made him feel quite
comfortable and he was subsequently discharged home with his own CNEP machine. In the next 6
months there was only 1 admission. CNEP in heart failure: MG ,14 year old boy had a few days of
upper respiratory infection with increasing fatigue and breathlessness. He had signs of congestive
heart failure with hypotension and looked increasingly tired. ECG showed low amplitude waves
suggestive of myocarditis. He was put on CNEP and there was an improvement in his clinical
status. CNEP successfully avoided endotracheal intubation which could have been difficult
considering the danger of induction agents in myocarditis. Equally CNEP seems to have sufficed to
improve the cardiac output such that inotropes were not needed. Conclusion: CNEP is an effective
alternative to invasive ventilation thus reducing the complications associated with the latter.
IC/04(O).OUTBREAK OF MRSA IN THE PAEDIATRIC INTENSIVE CARE UNIT OF A
DEVELOPING COUNTRY
Akash Deep, Radha Ghildiyal
T.N Medical College, Mumbai.
Introduction: Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of
nosocomial infections world-wide..Here we report an outbreak of MRSA nosocomial infection in a
pediatric intensive care unit of a tertiary hospital of Mumbai where portable suction pump was
implicated in the spread of MRSA .Methods : A one year prospective study was undertaken to study
the clinical and microbiological profile of nosocomial infections in the unit .In September 2000,
MRSA was isolated from the patients and the environmental samples were sent for phage typing.
During the outbreak, an MRSA case was defined as any patient in the PICU with MRSA
colonization or clinical disease. All bacterial isolates were subjected to antibiotic sensitivity testing
by standard disc diffusion Results: 6 patients had MRSA isolated from their blood. All had clinical
evidence of infection in the form of fever, leucocytosis , deteriorating underlying condition. The
duration of stay in PICU before MRSA was isolated from blood culture ranged from 5 days to 22
days. All MRSA isolates were highly drug resistant and were sensitive only to vancomycin and
rifampicin .Phage typing of MRSA isolated from these patients as well as those from portable
suction pump revealed non-typable MRSA, thus tracing the sources of outbreak to the portable
suction pump. The PICU remained closed for 2 wks until two sets of surveillance cultures and
environmental cultures were negative. Conclusion: MRSA outbreak is a serious event in an
intensive care setup which calls for urgent rigorous measures to be undertaken. It also demonstrates
the role of extensive surveillance (both environmental and personnel) in the event of an outbreak of
nosocomial infection in an intensive care unit.
IC/05(P).SPECTRUM AND ANTIMICROBIAL RESISTANCE OF MICROBIOLOGICAL
FLORA IN PEDIATRIC INTENSIVE CARE UNIT
Singhal D, Sardana R, Uttam R, Bakshi A
Apollo Centre for Advanced Pediatrics, Indraprastha Apollo Hospital, New Delhi
Background: Critically ill patients admitted in intensive care units are at increased risk of
nosocomial blood stream infections. It is important to know the pathogens causing nosocomial
bacteremia and their antimicrobial sensitivity to formulate appropriate treatment guidelines. Aims
and Objectives: To study the spectrum and sensitivity pattern of organisms causing blood stream
infections in the Pediatric intensive care unit (PICU). Methods: It was a retrospective analysis of all
PICU admissions during the period of January 2004 to June 2006. Blood cultures obtained from
patients developing clinical signs of infection after 48 hrs of admission were evaluated. Results:
552 blood cultures were sent. 156 (28.2%) of the total blood cultures were positive. Coagulase
negative staphylococcus (CONS) was the commonest organism isolated accounting for 25.6 % of
the total positive cultures. Klebsiella and Pseudomonas were seen in 14.7% and 8.3% respectively.
Burkholderia (7%), Acinetobacter (4.4%), Alcaligenes (4.4%),Stenotrophomonas (3.2%) and
Chrysobacterium ( 3.2%) were the other atypical gram negative organisms isolated. Candida was
isolated in 10.8% of cases. 91% of CONS and 100% of staphylococcus aureus were resistant to
penicillin.All were sensitive to vancomycin and teicoplanin and there were no Methicillin resistant
S. aureus (MRSA). Pseudomonas showed resistance to ceftazidime and aminoglycosides in 20% 25%. Klebsiella was universally resistant to aminoglycosides and third generation cephalosporins
and resistant to floroquinolones in 53%.Most of the other gram negative organisms showed a high
degree of resistance to the first line antibiotics. Conclusion: A high degree of antimicrobial
resistance was encountered in the gram negative isolates of the PICU. This would warrant a strict
implementation of antibiotic prescribing policies and hospital infection control guidelines.
Reassuringly there were no MRSA.
IC/06(P).ROLE OF SERUM LACTATE LEVEL AS A PROGNOSTIC MARKER IN
CRITICALLY ILL PATIENTS
Kumar A, Pao M, Singhal D, Chaturvedi M K, Bakshi A S, Uttam R
Apollo Center for Advanced Pediatrics, Indraprastha Apollo Hospitals, New Delhi
Background: Critically ill patients admitted to Pediatric Intensive Care Unit (PICU) are likely to
have higher serum lactate levels due to associated perfusion disorders, with consequent tissue
hypoxia. Serum lactate levels have been used as a marker of the severity of illness, hence, outcome.
As there is limited data in children this study was undertaken. Aims: To assess the utility of serum
lactate level as a prognostic marker in critically ill children with severe sepsis, shock or Multi Organ
Dysfunction Syndrome (MODS) requiring mechanical ventilation. Material and methods: It was a
retrospective study of children ventilated for severe sepsis, shock or MODS in a tertiary care PICU
between 1st January 2005 and 15th September 2006. Arterial serum lactate was measured on
admission and repeated at an interval of 24 hours. Hyperlactatemia was defined as levels > 2
mmol/L. Post operative patients, cardiac patients and patients who expired within 24 hours of
admission were excluded from the study. Outcome of the patients was classified as survivors and
non-survivors. Results: Of the total 56 patients included in the study 32 showed a decreasing trend
in the serum lactate levels over 24 hours (Group A) whereas 24 patients showed a rising trend or a
persistence of high serum lactate (Group B). Out of 56 patients 18 patients expired (32.1%).
Majority of children 13/18 (72%) who died belonged to Group B. Conclusions: Persistence of high
serum lactate at 24 hours was found to correlate with higher mortality rate while a decline or
normalization of lactate level was associated with better survival. Single level of serum lactate was
poor predictor of poor outcome. Seral serum lactate needs serious consideration as a prognostic
marker in PICU.
IC/07(P).TIPS ON INTENSIVE CARE.
Hemant Joshi, Archana Joshi.
Joshi Children’s Hospital &research center. Virar-401303
1Painless i.v.set: Ask your i.v. set manufacturer to make an IV set with a latex rubber tubing in the
tubing between the i.v. bottle and the air chamber. Always add medication through this latex rubber
tubing with the help of a needle. This ensures that medicine is diluted 10- 20 times before it enters a
vein. This eliminates pain of i.v. injections and delay thrombophlebitis. 2 Use tubing of a
stethoscope to give oxygen to 2 patients from one cylinder Use it as Y connection or three way
distributor, with the chest piece limb bringing oxygen from cylinder and the two tubings that
normally go to two ears can give oxygen to 2 tubes going to 2 patients. 3.In an emergency everyone
should loudly announce what he is doing . this avoids duplication of works. 4 Make an error book.
Write all the errors occurring in practice by staff and every one else with out writing their name.
Also write solutions. This will reduce errors and improve the quality of work. 5.You are as god as
your staff is Perpetually teaching staff all possible skills ensures that your staff becomes as good as
you are. This improves survival efficiency and happiness.
IC/08(R).VORICONAZOLE USE IN NEWBORNS: EXPERIENCE IN A CARDIAC
INTENSIVE CARE UNIT
Sachdev MS, Joshi R, Kohli V.
Pediatric Cardiology and Congenital Cardiac Surgery Unit, ACAP, Indraprastha Apollo Hospital,
New Delhi.
Background: Critically ill newborns are predisposed to infections, which may include systemic
fungal infections. The antifungal agents available till now for systemic infections have been
intravenously administered drugs exclusively. This is the first report of the safe use of this
antifungal in newborns with cardiac disease along with several cardiac medications. Methods: two
neonates with cardiac condition and prolonged stay in the pediatric cardiac ICU with isolated fungal
growth from blood cultures who received Voriconazole were included in the study. Their basic
cardiac diagnosis, stay in the hospital type of fungal species identified and its sensitivity pattern,
other bacterial growth from the culture, potential interaction with cardiac and noncardiac meds
being concomitantly administered, potential voriconazole side effects and the drug dosage used
were recorded. Results: Their were a total of two neonates aged 29 days and 4 days respectively
who received voriconazole. One was diagnosed to have Interrupted Aortic Arch with
Aortopulmonary window and operated on day 3 of life and other neonate was a 29 day old who had
ventricular tachycardia associated cardiomyopathy. The mean duration of hospital stay was 34 days.
Mean duration from hospitalization to starting of Voriconazole was 16 days. The fungal species
identified were Candida pelliculosa and Candida spp and both were sensitive to voriconazole.
Patients received other antifungal agents prior to voriconazole (liposomal amphotericin B). There
was no drug interaction with either cardiac drugs (amiodarone, propranolol, dobutamine, dopamine,
milrinone) or with noncardiac drugs used in this patient (meropenem, cefipime, piperacillin,
teicoplanin, metronidazole, linezolid, vancomycin, frusemide). There were no side effects. Dose of
voricaonazole used was 4 mg/kg in both patients and duration of therapy was 4 weeks. Negative
blood cultures for fungal species were documented at the end of treatment. Conclusion:
Voriconazole is a safe oral antifungal to be used in critically ill cardiac newborns.It can be safely
used with several cardiac drugs and non cardiac drugs and is free from any major side effects.
IC/09(R).STUDY OF PATIENT’S GUARDIAN’S SATISFACTION REGARDING
SERVICES IN A TERTIARY LEVEL III PEDIATRIC INTENSIVE CARE UNIT
Dhwanika Unadkat, Keya R. Lahiri, Milind S. Tullu
Department of Pediatrics, Seth G.S. Medical College & KEM Hospital, Parel, Mumbai 400012
Objective: To study satisfaction of patient’s relatives/ guardians in patients admitted to Pediatric
Intensive Care Unit (PICU) of KEM Hospital, Mumbai. Methods: This prospective study was
conducted over 4 months in PICU (Level III). Study subjects (n=100) included relatives / guardians/
parent of patients admitted to the Pediatric ICU (with ICU stay of more than 48 hours). One
guardian of the patient was requested to answer a questionnaire. The results were summarized as
percentages. The responses were graded as: A=Excellent; B=Good; C=Satisfactory; D=Below
Average and E=Poor. The responses A to C were considered as positive & responses D and E were
considered as negative. Results: Most of the patients’ relatives/ guardians were satisfied with the
treatment given by the doctors in the PICU and their behavior (99% and 98% respectively). Around
4-8% of the relatives were not satisfied with the behavior of and care provided by the nurses and
servants. Most of the relatives were happy with the treatment and investigation facilities (99% &
96% respectively). 21% of relatives were unhappy about the information given to them regarding
medical condition of their patient, and 44% of the relatives said that they were not explained the
condition of the patient everyday. 99% of the relatives were happy with the cleanliness. 20% of the
relatives had been involved in management decisions. The non-medical facilities were rated as
above average by 95%. Only 1% of the relatives / guardians said that they were not satisfied with
their overall experience in the PICU and rest said that they would recommend the PICU.
Conclusions: Most of the patients’ relatives / guardians were satisfied with the treatment given by
the doctors in the PICU and their behavior, but there were a few unhappy with the nursing staff.
Most guardians were happy with treatment facilities, investigations & cleanliness. This feedback
will serve to identify the deficient areas as regards patient satisfaction and steps will be planned to
rectify the same. Acknowledgement: The authors thank Dr. N.A. Kshirsagar- Dean, Seth G.S.
Medical College & KEM Hospital, for granting permission for submission of this abstract for
presentation in PEDICON 2007. This study was an ICMR-funded Short Term Studentship (2005)
research project.