Journal Jpcc Jan2014

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http://slidepdf.com/reader/full/journal-jpcc-jan2014 2/91J O U R NA L O F P E DI AT R I C C R I T IC A L C A R EVOL 1 - NO. 1 Jan - March 2014 1

CONTENTS

Education

Technology

Advances in Transplantation

From Editors Desk 3

M e s s ag e f r o m c h a i rp e r s o n I AP i n t e ns i v e c a r e c h a pt e r 2 0 1 3 ` 4

M e s s ag e f r o m s e c r et a r y I A P i n t e ns i v e c a r e c h a pt e r 2 0 1 3 5

M e s s ag e f r o m c h a i rp e r s o n I AP i n t e ns i v e c a r e c h a pt e r 2 0 1 4 6

N C P CC 2 0 1 3 Re p o r t 7

E x e c ut i v e B o ar d I A P i n t e ns i v e c a re c h a p t e r 2 0 1 3 8

Editorial board 9

Editorial

Research in Pediatric critical care in India : The way forward… 10

Prof Sunit Singhi, PGIMER, Chandigarh

Best Evidence

Journal scan : Top 5 articles of 2013 13

Dr. K.Chugh, Dr. Sanjeev Kumar, Dr. Vikas Taneja

F o r t is m e m o ri a l r e s e ar c h i n s t i t ut e , G u r g a o n, H a r y a n a .

Simulation in Pediatric critical care training: 16

Dr. Rakshay Shetty and Dr. Sujatha Thyagarajan

Rainbow Childrens Hospital, Vijaywada, HCG, Banglore

ECMO Indian scenario: 24Dr. Praveen Khilnani, Dr. Pranay Oza, Dr. Suneel Pooboni,

Dr. Soonu Udani, Dr. Pradeep Sharma

B L K S u p e rs p e c i al i t y H o s p i t a l , D e l h i , R i d h i v in a y a k H o s p it a l , M u m b a i ,

K I M S H o s p i ta l , H y d e r ab a d , P D H i n d uj a H o s p i t a l, M u m b a i ,

BLK Superspeciality Hospital, Delhi

Liver Translantation: Indian scenario : 34

Dr. Anupam Sibal, Dr. Vidyut Bhatia, Dr. Akshay Kapoor,

: N e w e r i n n o v at i o n s i n P e d ia t r i c C ri t i c al C a r eympos um





Greetings and best wishes for a happy new year.I would like to express a deep sense of gratitude for selecting

me to be the founding editor in chief for our journal of IAP intensive care: Journal of Pediatric Critical Care.

It gives me great pleasure to bring out the first issue of our IAP intensive care journal: Journal of Pediatric criticalcare(JPCC) with symposium entitled “Newer innovations in Pediatric critical care”

O u r m ai n g o a l i s t o i n i ti a t e a nd c o n t in u e r e gu l a r q ua r t e rl y p u b l ic a t i o n o f p e e r r e v i ew e d o ri g i n a l a r t i cl e s

,abstracts, case reports, reviews, quiz, editorials and journal scans related to field of Pediatric critical care with

eventual aim to get it indexed, published monthly and listed in Pubmed over the next few years.

T h e E d i to r i a l b o a r d c on s i s ts o f s e n i or e d i t o ri a l a d v i s or s a n d r ev i e w e rs , i n a d d i ti o n t o e d i to r i a l t e a m o f y o u n g

and enthusiastic pediatric intensivists entering into the field of academics with main focus on Pediatric critical

care.

It is hoped that various articles and original research work of many institutions will be submitted for peer review

and publication to make this journal get the best impact factor and become the leading publisher of Indianpediatric critical care data for the rest of the world.

Sincerely

Praveen khilnani M D F AA P F C C M

Edit or in chief JPCC

Vice President I SCCM and Direct or Pediat ric Crit ical Care

and Pulmonology Services

BLK Super Specialit y Hospital, New Delhi

E-mail: khilnanip@hot mail. com

www. journalof pediat riccrit calcare. com

Tel : 09810159466

January 1st , 2014

From Editors Desk

J O U R NA L O F P E DI AT R I C C R I T IC A L C A R EVOL 1 - NO. 1 Jan - March 2014 3



Dear Colleagues

I am delighted to know that IAP Intensive Care Chapter (ICC) is bringing out the maiden issue of Journal of

Pediatric Critical Care with Dr. Praveen Khilnani as its Founding Editor and I am grateful to him for inviting me

to write this message.

' M e d i ca l J o u r na l ' i s a n i n d i s p e n sa b l e p a r t o f o u r p r o f e ss i o n . I t i s o u r p r i n c i p a l t o o l f o r d i s s e mi n a t i ng k n o w l e d ge ,

propagating new discoveries and latest advances, gaining peer recognition and much more. Over the years,

ICC has been publishing its newsletter 'The Intensivist' (which I had the privilege to edit for three years from

2005 to 2008) and the rich experience thus gained has enabled us to upgrade it in to a Journal. Our new Journal

should not only fulfill its basic role of being an effective house bulletin, but also it should gradually mature into an

authoritative professional reference guide serving the needs of practitioners and researchers alike. Hence this

is a proud moment, a significant milestone for ICC and I congratulate Dr Praveen Khilnani and our entire

e d i t or i a l b o a r d . I a m s u r e u n d er h i s a b l e l e a d e r sh i p , w e s h a l l b e a b l e t o t a k e t h i s i n i t i at i v e t o t h e n e x t l e ve l a n d

soon make it into an indexed journal too.

I t g i v e s o n e g r e a t j oy t o n o t e t h at I C C h a s b e e n s c al i n g n e w p e a k s a t r eg u l a r i n te r v a l s. A ft e r t h e m em o r a bl e

conference at Mahabaleshwar which attracted over 700 delegates and was a grand success, came the news

that our chapter has been awarded with the 'Second Best Chapter' recognition by IAP. And now embarking on

a n o r g a n i za t i o n i d e nt i t y p r o g ra m m e w i th t h e a d o p t i o n o f a l o g o a n d t h e l a u n c h o f a j o u r n a l - A l l t h e s e a r e

pointers indicating a vibrant organization dedicated to its cause of making quality intensive care available to

every child in the country with the combined efforts of its member body.

I wish you all a Happy and Prosperous New Year.

With regards,

Dr. Santhosh T. Soans

Chairman, IAP – ICC

January 1st, 2014

Message from Chairperson 2013




Message from Secretary 2013

Dear Academicians, Greetings from Mumbai!

It is great moment of pride that marks the beginning of Journal of Pediatric critical care, an official journal of IAP

intensive care chapter under the editorship of Dr Praveen khilnani and the editorial and review board.

The Pediatric Intensive Care Chapter of IAP is a professional organization with nearly 1115 members (all life

m e m b er s ) w h o a r e c o mm i t t ed t o t h e h e a l t h a n d w e l l b e i n g o f a l l c h i l d re n . I A P P e d i a tr i c I n t e ns i v e C a r e c h ap t e r

also conducts CME updates, workshops, and conferences for its members to provide opportunity to improve

their knowledge and skills, which ultimately percolates to better care of all children.

Whatever the Chapter has achieved to date is due to the selfless and sincere efforts of some dedicated

members. The year 2013 has been an active one, with new ideas and programs being implemented by the IAP-

Intensive Care Chapter while maintaining and carrying out its routine annual events. The year 2013 has indeed

been a milestone year for our IAP- intensive care chapter. It began on a very auspicious note with the grand

success of the annual conference at Mangalore organized by Dr. Santosh Soans, our chairperson, 2013. Since

t h e l a s t A nn u a l G e n e ra l M e e t in g , 7 2 n e w m e m b er s w e r e a p p r o v ed a n d a d m i t t e d i n t o t h e I A P - I n t en s i v e C a r e

Chapter as life members.We participated in a Sub -specialty chapter symposium at PEDICON in Jan. 2013 atKolkata.IAP- Intensive Care Chapter as been very active in promoting the interests of its members in the field of

Pediatric Intensive care in smaller places throughout country, in the form of National and Zonal CMEs. We haves t

f o r th e 1 t i m e st a r t ed n a t i on a l C M E a n d 4 z on a l C M ES . We o r g a ni z e d , on e N a ti o n a l C M E a t B a ng a l o r e a n d , 4

Zonal CMEs at Solapur, Bijapur, Jaipur, and Guwahati.

We must appreciate Dr. Karunakara BP EB ,Dr. Pradeep Gupta from Ranchi, Dr. Dayanand Nakate, Solapur

MS EB, Dr. Bidari from Bijapur, Dr.Rashna Dass Hazarika, Guahati, EB, Dr.Manish Sharma Jaipur for

o r g a ni z i n g w o n d e rf u l p r o g ra m s . A 4 - d a y c o u r se “ M a s t e r c l a s s o n P e d i a t r ic I n t e ns i v e C a r e ” w a s o r g a n i ze d a tth

M um ba i b y D r. U ma Al i a nd D r. S oo nu U d an i . 15 N at io na l C on fe re nc e w as h el d a t Ma ha ba le sh wa r,s t

Maharashtra 21 Nov – 24th Nov.2013, attended by 750 members. IAP- Intensive Care Chapter is grateful to

the organizing team especially Dr. Sanjay Ghorpade and Dr. Kadam and Dr. Kopre.What we have achieved

would not have been possible with out the support of Dr. Santosh Soan, the Chairperson IAP- Intensive Care

Chapter. I wish you well. I wish you a Merry Christmas and a Happy New Year!

This is the point where I sign off and welcome Dr. Madhu Otiv and her team to take over.

With warm personal regards and best wishes.

Dr. Kamlesh Shrivastava

Secretary, IAP- Intensive Care Chapter 2013

s tJ a nu a ry 1 , 2 01 4



Greetings. It is my pleasure and privilege to be part of this exciting event of launching of the first issue of

'Journal of Pediatric Critical Care'.

Friends, mindful practice with commitment to excellence, scholarship and advancement is one of the hallmarks

o f m e d i c a l p r o f es s i o n al i s m . T h i s a l s o e n ta i l s a d u t y t o c r i t i c a l l y a p p r ai s e c l i n i c a l p r a c ti c e s t h a t a r e p r o v en ,

promising or futile. A clinician – faced with diagnostic or therapeutic uncertainty resorts to empiricism based on

understanding of pathophysiology, where as a researcher – faced with uncertainty will assess probability based

on the best available evidence. Acli nician who wears the hat of researcher will best be able to serve the interests

of the patient.

I congratulate Dr. Praveen Khilnani and the entire editorial team for their commendable efforts in launching the

first Indian Journal in the field of Pediatric Critical Care under the auspices of IAP Intensive care chapter.

C u r re n t l y P e d i at r i c c r i ti c a l c a r e i s a t i t s i n f l e xi o n p o i n t i n I n d i a w it h a n e x p o n e nt i a l i n c r e as e i n P I C U s a cr o s s

India. Introducing a journal dedicated to Pediatric Critical Care could not have been more timely .

T h e j o u r n al w i l l s e r v e a s a c o m m o n p l a nk f o r r e p o rt i n g u n u s ua l c a s e s , r es e a r ch s t u d i e s a n d o u tc o m e s t h at a r erelevant to all pediatricians and pediatric intensivists involved in taking care of critically ill children in India and

surrounding countries. Although exacting scientific and statistical standards are de rigueur for medical journals

that often excludes valuable experience of clinicians at the grass root level who are unfamiliar with nuances of

statistics but are able to connect the dots in the larger picture. It is hoped that the journal will bring a proper mix

of anecdotes, vignettes, news, recent advances, case reports and series, debates, controversies,

observational studies, trials, systematic reviews and guidelines that are valuable to practicing clinicians,

teachers and students.

T h e jo u r n a l w i l l t h e n e n c o ur a g e r e s e ar c h pr o d u c ti v i t y b y a tt r a c ti n g mo t i v a te d r es e a r ch e r s h e l p e d b y a b l e

c l i n i c al l e a d e rs h i p a n d e n a b l i ng i n s t i tu t i o na l p o l i c i es .

I w i s h t h e t e a m a t t h e J o u rn a l a l l t h e b e s t a n d a m c e r ta i n i t s s u b s c ri b e r s hi p w i l l s p r e ad r a p i d l y a c r o s s I nd i a a n dbeyond, for the good of the critically ill child.

D r M a d h u ma t i O t i v

Chairperson,

Pediatric Intensive Care Chapter,

Indian Academy of Pediatrics

January 1st, 2014

Message from Chairperson 2014




th1 5 A nn ual C on fe re nc e of I AP I nt en si ve C are C ha pt er

N C PC C 2 0 13 , M a h a ba l es h w ar

Report

M ah ar as ht ra S ta te I AP I nt en si ve C ar e C ha pt er a lo ng w i th I A P S at ar a o rg an iz ed N C PC C 2 01 3( th em e :st th

“ L e a rn i n g t h e S c i e n ce t o Pe r f e c t t h e A r t ” ) a t Ho t e l D r e a m la n d , M a ha b a l es h w a r, M a ha r a s ht r a o n 21 t o 24

Nov. 2013.Total 765 delegates participated in the conference with 82 National and 6 International Faculty

members :Dr Peter Cox, Toronto,Canada, Dr Andrew Argent, Cape Town,South Africa, Dr Mohan R. Mysore,

Omaha, NE,USA, Dr Suneel Pooboni, UK and DrUtpal Bhalala, Baltimore,USA..

T h re e w o rk s ho p s w e re c o nd u ct e d f o r p r e- c on f er e nc e s e ss i on : B as i c P e di a tr i c I n te n si v e C a re C o ur s e( B PI C C

Workshop)- attended by 64 delegates. Respiratory Support with Simulation (Workshop) - attended by 50

d e l e ga t e s S e p s is w i t h A d v a nc e I m a g in g ( Wo r k s ho p ) - a t t e n d e d b y 4 0 d e l e g a te s . A d v an c e d P e d i at r i c I n t e ns i v e

C ar e a nd B a s ic P ed ia tr ic I nt en si ve C ar e C ME 's w er e a ls o c o nd uc te d i n t h e p re co nf er en ce s es si on w i th a n

o v e r wh e l m in g r e s p on s e b y 5 0 0 d e l e ga t e s .T h e s c i e nt i f i c s e s si o n s f o r t h e c o n f er e n c e w e r e i n t h r e e c o n c ur r e n t

h a l ls ( A , B & C ) w i t h e x c e l le n t f e e d ba c k f r o m t h e d e l e ga t e s . S c i en t i f ic P a p e r a n d P o s t er P r e s e n t at i o n s e s si o n s

h ad a g oo d r es po ns e a nd 3 po st er s a nd 3 p ap er s w er e s el ec te d fo r b es t a wa rd s . Th e i na ug ur at io n o f th e

conference was done by Chief Guest- Dr. Sunit Singhi, President (elect), Word federation of Pediatric Intensive

C a r e a n d C r i t ic a l C a r e S o c i et i e s a n d G u e s t o f H o n o ur D r . A c hy u t G o d b ol e . C u l tu r a l p r o g ra m m e w a s o r ga n i z ed

at Hotel Fountain, Mahabaleshwar. Faculty hospitality and Accommodation was very well managed by

Abhinava events (Mr. Vidyashankar). As a part of recreation activity Mahabaleshwar Hill Mini Marathon wasth

c o n du c t e d on 2 4 N o v 2 0 13 a t 0 6 . 0 0a m .

Organizing Team

N C P CC 2 0 1 3

S o me g l im ps e s o f NC P CC 2 0 13



Executive Board 2013


I A P I n t e n si v e C a r e C h a p t er

Prabhat Maheshwar i Praktish Bora Kundan Mi ttal

Madhum at i Ot i v Ani l Sachdev Vi kasTanej aSantosh T. Soans

Kamlesh Srivastava

D. P. Na kate

Avinash Bansal

K a r u na k a ra B P

M. Ar i f Ahm ed

R a s h na D a s H a z ar i k a

Banani Poddar

Vishram Buche

S.K. Ghor pade

Sanj ay Baf na

Executive Members

Maritunjay Pao

Executive Members

Chairman

[email protected]

Ch a irma n Elect

ma d h u _otiv@h otma il.com

V ice Ch a irma n

a n ilcritica re@h otma il.com

V ice Ch a irma n

[email protected]

Secreta ry

[email protected]

Join t Secreta ry

[email protected]

Join t Secreta ry

a veeja in a @ya h oo.co.in

Treasurer

[email protected]



Executive members :

Dr Aru n Ba n sa l

D r B a na n i P o dd a r Dr Eb o r Ja co b

Dr L o ke sh Tiwa ri

Dr Pa rth a Bh a tta ch a rya

Dr Pra b h a t Ma h e sh wa ri

Dr Din e sh Ch irla

D r D e v a ra j R a i c hu r

Dr Ka ru n a ka ra

Dr Mritu n ja y p a o

Dr De e p ika Ga n d h i

Dr Bh a ska r Sa ikia

Dr Sh ip ra Gu la ti

Dr. Vikas Taneja

Dr In d ira Ja ya ku ma r

Dr Sa n ja y Ba fn a

Dr Sa n ja y Gh o rp a d e

Dr Sa g a r L a d

Biostatistics :

Dr M Ja ysh re e

Dr Jh u ma Sa n ka rDr Aru n Ba ra n wa l

Ethics :

Dr Urmila Jh a mb

Dr Ra ke sh L o d h a

Dr Me e ra Ra ma krish n a n

Dr Vin a y Jo sh i

Website :

Dr Ma n in d e r Dh a liwa lDr Vin a ya k Pa tki

D r An j ul D a ya l

Publication :

Dr Ra ch n a Sh a rma

Dr Pra d e e p Sh a rma

Dr Sa n je e v Ku ma r

Editorial Board

Senior Editors and Reviewers :

Dr(Pro f) Su n it Sin g h i

D r K C hu gh

D r S U da ni

D r S R a nj i t

Dr Ra jiv Uttta mD r A ni l S a ch d ev

Dr Ma d h u Otiv

D r S D e op u ja r i

Dr Ba la Ra ma ch a n d ra n

D r S S oa ns


Editor-In-Chief :

D r Pra ve e n K h i ln a n i

Associate Editors :

Dr Na me e t Je ra th

Dr Ku n d a n Mitta l

Dr. Rakshay Shetty

Dr Ba sa va ra j

Dr Gn a n a m

E x e cu t i ve E d i to r :

Dr V S V Pra sa d

M a n ag i n g E d i to r :

Dr Dh ire n Gu p ta

International Advisory

Board :

Dr Nira n ja n Kisso o nDr Je rry Zimme rma n

Dr Jo se p h Ca rcillo

Dr Ash o k Sa rn a ik

Dr Pe te r Co x

Dr Sh e kh a r Ve n ka ta ra ma n

Dr Vin a y Na d ka rn i

Dr Mo h a n Myso re

D r U t p al B h al a la

D r S u n ee l P o ob o ni

National Advisors :

D r Y A m d e ka r

Dr S C Ar ya

D r R N S ri va st av a

D r C P B an sa l

D r V Ye w a l e

D r M P J a in

Journal of Pediatric Critical Care (JPCC)



R e s ea rc h i n Pe d ia t ri c c r i ti c al c a re i n I nd i a :

T h e w ay f or w ar d…

P edi atr i c cr i t ical car e i s r el ati vel y a new s peci al t y, but i t has t aken gr eat s t r ides i n the pas t t w o decades

i n I n di a . T h e f i rs t p e d ia t ri c i n te n si v e c a re u n it s ( P IC U s) w e re e s ta b li s he d i n t h e e a rl y 9 0 s a n d m a n y

m or e P IC Us c am e u p s ub se qu en tl y, pr ed om in an tl y i n t he p ri va te s ec to r a nd so me i n t ea ch in g

i ns t it ut i ons . T hes e P I C U s have def i nit el y rai s ed t he bar i n pr ovi di ng high qual i ty care f or cr i t i cal l y i l l

chi l dren t o as s ur e opt i mal r ecover y f r om l i f e t hr eateni ng pr obl em s. T he avai l abi l i ty of com plex and

e xp en si ve m ed ic al in te rv en ti on s i n m an y o f th e P IC Us i n I nd ia a nd t he g lo ba l co ll ab or at io n a nd

g ui de li ne s h a s e xp a nd ed th e d is ci pl in e c o ns id e ra b ly. H ow ev e r, we a re s ti ll st an d f ar be hi nd t he

opt i mum . B es i des s t r engt hening t he r es ources an i m port ant f act or t hat coul d t ake us t o t he next l evel

i s r es earch. U nder taki ng r es earch t hat ai ms t o f ind w ays t o deli ver opt i mal care t o ever y chi l d w i t hin

e c o no m ic c o ns t ra i nt s , an d i n no v a ti v e s o lu t io n s t o u n iq u e g e o -r e gi o na l h e al t h is s ue s i n g i ve n s o ci o -

e co n om ic m il lu e i s t he t he o n ly wa y t o m ov e f or wa rd . T h e i mp ro ve d c a re i n t he w es te rn IC U i s t he

result of consistent advanced research from most of their centres.

R e se a rc h i n o u r s e t ti n g i s c h al l en g in g , p a rt l y b e ca u se o f t h e w i de v a ri e ty o f d i se a se s p r ev a le n t i n o u r

count ry and the l i m i ted res ources w i t h a pr of ound s hor tage of per s onnel and equi pm ent s . H ence i t i s

o b vi o us t h at t h e m o d el o f p r o vi s io n o f p e d ia t ri c i n te n si v e c a re a n d t he r eb y r e se a rc h i n I n di a h a s t o b e

di ff er ent f r om devel oped i ndus t r i ali zed nat i ons . W hi le t he w es t er n w or l d s hi f t ed f ocus f r om i nci dence

d at a t o t he ra p eu ti c a d va n ce s, c ri ti ca l c a re r es ea rc h i n I nd ia s ti ll h as a l on g j ou rn e y a he a d. F or

Editorial



example, several of the critical tropical infections including malaria, enteric fever, leptospirosis, scrub

t y ph u s a n d e n ce p h al i ti s a r e w i de l y p r ev a le n t i n m a ny p a rt s o f I n di a y e t w e l a ck d a ta r e ga r di n g t h e

e p id e mi o lo g y a n d t h e e x a ct bu r de n of th e se i l ln e ss e s i n ou r c h il d re n . We l a ck d at a o n va r io u s

t h er a pe u ti c i n te r ve n ti o ns t h at a re m o st n ee d e d a n d u t il i ze d b y ou r pa t ie n ts . Si m pl e o b se r va t io n a l

s t udies , r et ros pecti ve or pr os pect i ve, repor t ing of t he cas es s een and m anaged coul d pr ovi de val uable

i nf orm at i on t hat can hel p i n cr eat i ng a l ocal dat abas e and f or m ulat i ng m anagement gui del ines .

A n i m port ant f act or t hat dif f erent i ates our P I C Us f r om w es t er n uni t s i s t he neces si t y of cost ef f ect i ve

practice. It is a matter of great concern for us that critical care is delivered to our children at an

a ff or da b le c o st . I s i t p o ss ib le t o p r ov id e h ig h q u al it y c a re o u ts id e t he ' do u bl e d oo rs ' w h er e t he re i s n o

I CU ? M an y l ow c os t in te rv e nt io n s l ik e s ho rt t e rm m a nu a l ve nt il at io n , na sa l b ub b le C PA P a nd

peritoneal dialysis are utilized with greater benefits but outcome of such interventions are not

r o ut i ne l y r e po r te d . C o mp a ra t iv e s t ud i es a n d c o st e ff e ct i ve a n a ly s is c a n h e lp i n d e v el o pi n g a n

evi dence bas e f or s uch i nt er vent i ons t o be adapt ed int o w i der cl i nical pr acti ce.

O n e o f t h e s t ra t eg i es t o s t re n g th e n t h e c l in i ca l r e se a rc h i s t o e s ta b li s h r eg i on a l a n d n a ti o na l b o d ie s i n

t he f i el d of i nt ensi ve car e m edi cine t o as s is t and s upport res ear ch act i vi ti es . T he i nt ensi ve car e chapt er

o f I nd ia n a ca d em y o f p ed ia tr ic s a nd t he p ed ia tr ic s ec ti on o f t he I nd ia n S o ci et y o f C ri ti ca l C ar e

M ed ic in e c o nn e ct p e d ia tr ic i nt en si vi st s a ll o v e r In d ia w it h t he g oa l t o d i ss em in at e s ci en ti fi c a n d

educational information, set the standards in patient care and safety, training, equipment design, and to

e nc o ur ag e r es ea rc h i n t hi s f ie ld . O pp or tu n it ie s a re n o w a va il ab le f or l ar ge m ul ti -c en tr e r es ea rc h

acr oss nat i onal boundar i es s o as t o f i nd t he bes t l ocal s olut i ons t o com m on pr oblem s , and t o i ncreas e

r el evance and ef f ect i venes s of avai l abl e opt i ons .

C l i nical res ear ch l ags behi nd t he r api d pr ogres s i on of the f i eld of pedi at ri c cr i t ical care i n I ndi a. It has

EDI TORI AL Research in Pediat ric crit ical care in I ndia : The way f orward…





Best Evidence

Journal ScanDr. Kri shan Chugh, Dr. Sanjeev Kumar, Dr. Vi kas Taneja

Fortis Memorial Research institute, Gurgaon.

1 . Pr o n e P o s it i o n in g i n A c u t e R e s p ir a t o ry D is t r es s s y n d ro m e

G u er i n C , Re i gn i er J , R i ch a rd J C , e t a l. P r on e P o si t io n in g i n S e ve re A c ut e R e sp i at o ry D i st r es s

Syndrome. N Engl J Med 2013; 368:2159-68.

Summary: M os t o f t h e e a r l ie r t r i a ls i n v ol v i ng pa t i e nt s w i t h t h e a c u t e r e s p ir a t o ry d i s tr e s s s y n dr o m e ( A R D S)

have failed to show a beneficial effect of prone positioning during mechanical ventilatory support on outcomes.

In a multicenter, prospective, randomized, controlled trial, authors randomly assigned 466 patients with severe

ARDS to undergo prone-positioning sessions of at least 16 hours or to be left in the supine position. The primary

o u t co m e w a s t h e p r o po r t i on o f p a t i en t s w h o d i e d f r o m a n y c a u s e w i t hi n 28 da y s a f t e r i n c l us i o n . T h e 2 8 - d ay

mortality was 16.0% in the prone group and 32.8% in the supine group (P<0.001). Unadjusted 90-day mortality

w a s 2 3 . 6 % i n t h e p r o n e g r o u p v e r s us 4 1 % in su p i ne g r o u p ( P < 0 . 00 1 ) . T h e i n c id e n c e o f c o m p li c a t io n s d i d n o t

d i ff e r s i gn i f ic a n t ly b e t we e n t he g r o up s , e x ce p t f or t h e i n c i de n c e o f c a r di a c a r r e st s , w hi c h w as h i g he r i n th e

s u p in e g r o up .

Comments: P ro n e p o si t io n in g i s o n e o f t h e m e th o ds o f r e cr u it m en t w i th so u nd th e or e ti c al re a so n in g .

P r a c ti c a l ly, i t h a s b e e n u s e d f o r m a n y y e a r s i n p a t i en t s w h o r e q u ir e m e c h an i c a l v e n t il a t o r s u p p or t fo r

m a n a ge m e n t o f t h e A R D S . P r e v io u s t r i a ls h a v e a l r e ad y c o n f i r me d t h a t i t i m p r o v es o x y ge n a t io n a n d d e c r e a se s

ventilator associated lung injury, but none of them convincingly showed a mortality benefit. In this trial, these

physiological benefits translated into better patient outcomes. The study has several limitations regarding

selection of patients, difference in baseline SOFA score, effect of neuromuscular blockers, ignorance of fluid

balance and vasopressor score. There are several factors to be considered before turning the patient prone eg:

high risk of extubation, handling of oral & endotracheal secretions, changing position of infusion pump, heavysedation and frequent use of neuromuscular blockage. Usually 5-6 persons are required for positioning with

extra trained staff for ongoing care. It is challenging to perform cardiopulmonary resuscitation (CPR) and

d e f i br i l l at i o n i n p r o ne p o s it i o n. P a t i e nt h a s t o b e f i r s t c on v e r te d i n t o s up i n e p o s it i o n a nd t h e n o n ly C P R c a n b e

d o n e e f f ec t i v el y. P r o n e p o s it i o n m a y i nc r e a s e a b d o mi n a l p r es s u r e i f t h e a b d om i n a l w a ll i s n o t a l l ow e d t o h a n g

freely.

Recommendations: Thus, prone positioning should be attempted or practiced only if a clear indication exists

( e g : s e ve r e A R D S w i th p l a t ea u p r e s su r e m o r e t h a n 3 0 d es p i te l o w t i d a l vo l u m e s t r a te g y ) a n d e xt r a t r a i ne d s t a ff

i s a v a i la b l e r o u n d t h e c l o c k. We s h o ul d a l s o re m e m be r t h a t th i s s t u dy w a s p e r f or m e d i n ad u l ts ( m e a n a ge 6 0 a n d

58 in the two groups).

2. Timing of Tracheostomy in Pediatric Critically Ill PatientsGustavo C, Martin T, Ximena C, et al. Tracheostomy in pediatric critically ill patients. Journal of

P e d i at r i c I n t e ns i v e C a r e 1 ( 2 0 1 2 ) 2 0 1 – 2 05 .

Summary: T h e i n d ic a t i on s f o r a n d t im i n g o f t ra c h e os t o my i n c r i t ic a l l y il l c h i ld r e n a r e c o n s ta n t p o in t o f

discussion. In a study in pediatric critically ill patients, Gustavo et al. from Argentina reported their experience

with 18 children who underwent tracheostomy. The most common indication was neuromuscular compromise.

T h e a v e r ag e d u r a ti o n o f m e c h a ni c a l v e nt i l at i o n b e fo r e p l a c em e n t o f a t r a c he o s to m y w a s 2 3 . 8 d a ys ( 0 – 5 8 d ay s ) .

T h e c o m p li c a t io n s o b s e rv e d w e r e m i n o r, a n d n o p a t i e n ts d i e d f r o m t r a c h e os t o m y- r e l a te d c a u s e s . T h e r e w e r e n o

s e r i ou s t r a c he o s t om y - r el a t e d c o m p li c a t io n s i n c r i t ic a l l y i l l p e d ia t r i c p a t ie n t s . T h e p r o c ed u r e w a s e f f ec t i v e i n

t h e m a n a ge m e n t o f p a ti e n t s w i t h r e sp i r a to r y f a i l ur e , p a t i en t s w i t h n e ur o m u sc u l a r c o mp r o m is e a n d c h i ld r e n





a n d f o r m ul a r y g u i de l i ne s . I n th i s p o i nt p r e va l e n ce s u r ve y, a l l pa t i e nt s a d m i tt e d to t h e C C C U - PI C U d u r i ng t h e

week of October 27, 2008 (period A) and February 9, 2009 (period B) were followed until completion of their

a n t im i c r o bi a l co u r s e( s ) . Da t a w e r e c o l l ec t e d o n i nf e c t io n t yp e s a n d in d i c at i o ns , f r eq u e n cy, a n d t y p e s o f

antimicrobials used. Appropriateness of antimicrobial prescribing was assessed according to predefined criteria

by four blinded clinician assessors. Forty-two of 60 patients (70%) received antimicrobials in period A and 42 of

5 3 p a t i en t s ( 7 9 % ) r e c ei v e d a n ti m i c ro b i a ls i n p e r i od B . O f t h e p a t i en t s o n a n t i m ic r o b ia l s , 4 5 % i n p e r io d A a n d

5 2 % i n p e ri o d B h a d a d e f i ni t i ve d i a g no s i s o f i n f e ct i o n. I n a p p ro p r ia t e a n t i mi c r o bi a l u s e r a n g ed f r o m 1 6 . 7% t o

6 1 . 9 %, d e p e n di n g o n a ss e s s or s a n d s u r ve i l l an c e p e r i od . T h e m o s t c om m o n r e a so n s f o r i n a pp r o p ri a t e u s e w e r e

overly broad spectrum, wrong dosage, and unwarranted overlap of spectrum.

Comments: I t i s w i d e ly a c kn o w le d g e d t h a t n e w e r c l a s se s o f a nt i b io t i c s a r e n o t li k e ly t o b e d i s co v e r ed a n d

become available for use in near future. Antimicrobial resistance is one of our most serious health threats with

i r r a ti o n al u s e o f b r o a d s p e c tr u m a n t i bi o t ic s . A nt i m i cr o b ia l r e s i s ta n c e c a u s es a s i g ni f i c an t p u b l ic h e a l th b u r d e n

in terms of morbidity, mortality, and cost. Antimicrobial stewardship programs (ASPs) are designed to optimize

antimicrobial prescribing, to lower costs, to prevent medication errors, to improve therapeutic outcomes, and to prevent the development of antimicrobial resistance. ASPs are being vigorously pursued in many adult ICUs

a c r o ss t h e w o r ld a n d a l so i n o u r c o un t r y. H o w e ve r , i n ge n e r a l PI C U s a r e y e t t o “ wa k e u p ” t o t h re a t o f a n ti b i ot i c

resistance.

Recommendations: I t i s t i m e t h a t c o r e s t r a te g i e s o f A n ti m i c ro b i a l s t e wa r d s hi p p r o g r a ms , n a m e l y P r o s pe c t i ve

audit with feedback and Prior approval and formulary restriction are introduced in all PICUs immediately.

Supplememtary strategies like introduction of Education, Guideline and clinical pathway, Antimicrobial order

forms, Combination therapy, Streamlining or deescalation of therapy, Dosage optimization, Conversion from

parenteral to oral therapy should also become routine practice.

5. Lung Protective ventilator strategy in Non-ARDS Patients

Oguz K, Ognjen G, et al. Initial ventilator settings for critically ill patients. Critical Care 2013, 17:123Summary: The lung-protective mechanical ventilation strategy has been standard practice for management of

a c u t e r e s p ir a t o ry d i s tr e s s s y n dr o m e ( A R D S) f o r m o r e t h a n a d e c a de . P r i n ci p l es o f l u n g -p r o te c t i ve v e n t il a t i on

include: a) prevention of volutrauma (tidal volume 4 to 8 ml/kg predicted body weight with plateau pressure <30

c m H 2 O) ; b ) p r e v en t i on o f a t e l ec t a s is ( p o s it i v e e n d - ex p i ra t o r y p r e s su r e ≥ 5 c m H 2 O , a s n e e d ed r e c r u it m e n t

m a n e uv e r s ); c ) a d e q ua t e v e n t il a t i on ( r e s p ir a t o ry r a t e 2 0 t o 3 5 br e a t hs p e r m i n ut e ) ; a n d d) p r e v e nt i o n o f

hyperoxia (titrate inspired oxygen concentration to peripheral oxygen saturation (SpO2) levels of 88 to 95%).

Comments: L o w t i d a l v ol u m e v e n t il a t i on i s t h e o n l y i nt e r v en t i on w h i c h s h ow e d s u r vi v a l b en e f i t i n p at i e n ts

w i th A RD S i n A R DS N e t s tu d y. B e t te r u n de r st a nd i ng o f t h e e f fe c ts o f p os i ti v e p r es s ur e v e nt i la t io n o n

r e s p ir a t o ry p h y s io l o gy a n d m e c h an i c s h a s l e d t o a n a p pr e c i a ti o n o f p ot e n t ia l s i de e f f ec t s o f p o s it i v e p r e s su r e

ventilation, in particular ventilator-associated lung injury in all critically ill patients. Thus, avoiding

conventional high tidal volume ventilation in all critically ill patients is worth investigating and trying.I n s om e s t u di e s i n v es t i g at o r s h a v e t r i e d t o e xt e n d t h e u s e o f t hi s s t r a te g y to n o n- A R D S p a t ie n t s . O n t he b a s is o f

t ho se s tu di es o bs er va ti on al da ta a nd tw o s ys te mi c r ev ie ws K il ik ay a a nd Ga ji c h av e r ec om me nd ed lu ng

protective strategies in non-ARDS patients also.

Recommendation: M i n i ma l t id a l v ol u m e a n d p re s s ur e s w h i ch a c h ie v e t h e i m m e di a t e g o a l s o f v e nt i l at i o n c a n

be the initial settings and one should come down within the range of lung protective strategy setting as soon as

possible. Conversely, one can start with lung protective strategy in all critically ill patients and go up on the

s e t t in g s o f go a l s o f ve n t il a t i on a re n o t m e t . H o w e ve r , l a r ge r a n d om i z e d c o n tr o l l ed tr i a l s w o u l d b e r e q u ir e d

before this can become a universal practice.


B E S T E V I DE N C E J o u rn a l S c a n



Simulation Based Training

i n P e di at r ic I nt e ns iv e C ar eDr. Rakshay Shetty*, Dr. Sujatha Thyagarajan**

*Lead Pediatric Intensivist, Rainbow Children's Hospital, Vijaywada

** Pediatric Intensivst, HCG, Bangalore

Introduction

I n t e ns i v e c a r e d e l iv e r y i s a c o m p le x , e xp e n si v e , e r r o r p r o ne , m e di c a l s p e c ia l t y a n d re m a i ns t h e f o c a l p o i nt o f

m a j o r i m p r ov e m e nt e f fo r t s i n h ea l t h ca r e d e l i ve r y. We a r e n o w i n a c o m p le x h e al t h c ar e s y s te m w h er e t h e s t a ke s

o f a c c o un t a bi l i ty a n d r e s p on s i bi l i ty a r e h i g h b e i t p a t ie n t s , h e a l th - c a r e p r o vi d e r s, a d m i ni s t r at o r s o r t h e l a w -

m a ke r s. A c ut e c a re e s pe c ia l ly E m er ge n cy r o om or in t en s iv e c a re t o ps t h e l i st o f t i me - bo u nd dy n am i c

c o m p le x i t ie s . T he r e i s a n e e d t o pr o v i de h e a l th c a r e w i t h th e l e a s t ha r m t o t he p a t i en t .

H i s to r i c al l y, c r i t i c a l c a r e o u t co m e s h a v e b e e n p r e d om i n a nt l y a t t r ib u t e d t o t h e p a t ie n t ' s g e n e ti c p r e d is p o si t i on ,

baseline dysfunction, and severity of insult. Data have shed light on the importance of an additional factor:

f a ul t y h ea l th c ar e d e li v er y. E p i de m io l og i c d a ta s u gg e st s t h at d e l ay e d o r o ve r ly a g g re s si v e t r ea t me n ts a n d

i a t r og e n i c c o m p li c a t io n s a r e a m o n g t h e m o s t i m p or t a n t d r iv e r s o f m u l t i or g a n f a i lu r e a n d p o o r o u t c om e s d u r i ng1,2

c ri ti ca l i ll ne ss .

S i m u la t i o n o f fe r s t r e m e nd o u s p r o m is e t o i m p r o ve h e a l th c a r e d e l i ve r y e s p e c ia l l y i n i n t e n si v e c a r e u n i t. I t c a n b e

a n e f f ic i e n t m o d e t o l e a r n c r i s is r e s o ur c e m a n a g em e n t , u n i t r i s k a s s e ss m e n t, c he c k s i t ua t i o n r e a d in e s s,

i m p le m e n t n ew p r o t oc o l s , t es t r u n n e w i n s tr u m e nt s , i m p ro v e i n t e rd e p a rt m e n ta l c o - o rd i n a ti o n , l e ar n n e w

c o n c ep t s o r p r o c e d ur a l s k i l ls a n d a l s o i n e s t a b l is h i ng a n e w u n i t.

What is simulation-based training or learning?

S i m u la t i o n i s t h e c r e a ti o n o f a r e a l -l i f e e x p e ri e n c e i n an a rt i f i ci a l ly c on t r o ll e d a n d i n t er a c t iv e e n v ir o n m en t .3

D a v id Ga b a d e s c ri b e s s i m u la t i o n m o r e a s a t e c h ni q u e r a t h er th a n t e c h no l o gy. T h o ug h i t i s r e c e nt in m ed i c a l

e n v ir o n m en t , t he c o n c ep t i s n o t a r e c e nt o n e . T h e o r i g in d a t es b a c k to m e d e iv a l t im e s w h e n so l d i er s l e a r nt t h e

art of swordsmanship on dummy soldiers.

S i m u la t i o n b a s e d t r a i ni n g i n v ol v e s c r e a ti o n o f a r e a l - li f e s c e n ar i o : a n ac u t e e n v i ro n m en t s u c h a s E R / P IC U ,

c o m m o n a c u t e e m e rg e n c ie s s u c h a s s e i z ur e s , se p t i c s h o c k , a c u te t e a m m em b e r s s u c h a s n u r s es , d o ct o r s , p a r a -

medics, parents, patient etc and the dynamic interaction in real-time with real equipment.

S i mu l at i on t h us a l lo w s t h e l e ar n er t o e x p e ri e nc e a r e al - li f e s c en a ri o i n a r i sk - fr e e e n vi r on m en t , r ef l ec t o n t h e

e x pe r ie n ce t h ro u gh f e ed b ac k a n d s t ru c tu r ed de b ri e fi n g, un d er s ta n d t h e c o nc e pt s m o re c l ea r ly a n d

e x p e ri m e n t/ p r a ct i c e i n a s a f e e n v ir o n m en t a t h i s / h er p a c e . S i m u l at i o n s e ss i o ns m a y h e l p t h e n o v ic e p r o g re s s u pthe learning curve faster and acquire the essential technical and non-technical skills in preparation for real-life.

S i mu l at i on h e nc e h a s g a in e d po p ul a ri t y as o n e o f t he p r om i si n g t e ch n iq u es t o f ac i li t at e l e ar n in g a mo n gs t

health-care providers, especially acute care without risking patient safety.

Types of Simulation based education –

4- 8Types of simulation based education are summarised in table 1.

Part-task trainers: T r ai n i ng o f s p e c i fi c s k i ll s s u c h a s a i r w ay m a n a g em e n t , a r te r i a l l in e , c e n t ra l l i n e , i n tr a -

o s s e ou s l i n e a n d c h e s t d r ai n p l a c e me n t s c a n b e t a u g ht u s i n g p a r t t a sk t r a i n e r s. C o m m o n l y a v ai l a b le a s m a n i ki n s

o r an i ma l mo d el s a n d i s u s ef u l f o r n o vi c e t r ai n ee s t o un d er s ta n d t h e t e ch n iq u es a n d p r ac t ic e i n a l o w- r is k

Education




situation without any patient-harm. Part-task trainers are widely utilised in various skills based workshops and

life support courses.

Role-play: T h i s i s a n e x c e l le n t w a y t o t r a i n a n d a s se s s c o m m u ni c a t io n s k i l ls . R o l e - p la y m a y b e a s c h i l d a c to r s ,

parents, trauma victims, pregnant mothers etc. Role-play sessions are particularly applicable for teaching

breaking the bad news, explaining a procedure, taking consent etc.

Standardised patient : I t i s u s e d t o de m o n st r a t e s p e c if i c c l i ni c a l s ki l l s a n d e l ic i t s ig n s , d is c u s s a p p r oa c h a n d

practical management. This is part of the traditional examination popular amongst various under-graduate and

post-graduate curriculum assessments.

C o m p ut e r b a s e d s i m u la t o r : I t i s c a t e rg o r is e d o n th e b a s i s o f f i d ei l i ty. F i d e li t y i s t h e c o m m on i n d us t r y te r m

u s e d i n s i m ul a t i on t o d e s c r ib e t h e d e g r ee o f r e a l i sm a n d t e c h ni c a l c o mp l e xi t y o f m o d el s . T hi s i s d i c t at e d b y t h e

n e e d s o f t h e a p p li c a t io n ; m o r e c o m p le x i s t h e t a s k , m o r e i s t h e f i d e li t y o f t h e m o d e l. Lo w f i d e li t y m o d e ls c a n b e

d e v e lo p e d an d u p da t e d r a p i dl y w hi l e h i g h- f i d el i t y m o d e ls c o s t mo r e t o e n gi n e e r a n d m a in t a i n b u t a re m o r e

flexible when applied to different uses. However, not everything needs to be taught in a high-fidelity simulation.A s c r e en t e xt s im u l a to r a nd s t at i c m a n n eq u i ns a r e e x a m pl e s f o r lo w f i d e li t y s i m u la t o r s. E x am p l e s o f m ed i u m

f i d e li t y s i m u la t o r s i n c lu d e v i r t ua l si m u l at o r s l i k e v i d e og a m e s a n d m a n n eq u i ns w i t h m e c h an i c a l m o v e me n t s

l i ke A M BU M a n. A h i gh f i d el i ty s i m ul a to r ( F ig 1 ) i s a f u ll b o dy c o m pu t er i se d m a ni k in t h a t ha v e r e al i st i c

f e a t ur e s , s u c h a s b l i nk i n g e y es w i t h r e a ct i n g p u pi l s , c h e st s t h a t r i se a n d f a l l w i th r e s p i r at i o ns , p a l p a bl e p u l se s ,

various heart and lung sounds, and the ability to cry, drool and bleed. They can respond physiologically to

interventions, such as medication administration, intravenous fluid infusions and application of oxygen. They

have procedural features to allow chest tube and tracheotomy management, defibrillation and urinary catheter

i n s er t i o n. L a e r da l , ME T I a n d G a u m ar d a re t h e m o s t p o p ul a r co m p a ni e s i n v ol v e d i n pe d i a tr i c s i m u la t i o n.

L a e d ra l as o f no w h a s a l a r ge r p re s e n ce i n In d i a .

S c o p e o f s i m u l at i o n i n P e d i a t r ic i n t e n si v e c a r e:

1 . I mp ro vi ng p a ti en t o ut co me s

2 . D is co ve ri ng s ys te m er ro rs

3 . I m pr o vi n g t h e q u al i ty o f e d uc a ti o n

4 . C re de nt ia li ng an d E xa ms

Improving patient outcomes –

C r i s is r e s o ur c e m a n a ge m e n t ( C R M ) i s a m e t h od o f te a m t ra i n i ng t h at f o cu s e s o n b eh a v i or a l s ki l l s, r e s ou r c e

u t i li z a t io n , c om m u n ic a t i on , l e a d e r s h ip , a n d t e a m w o rk . T h es e s k i ll s a r e e s s e nt i a l f o r e f f ec t i v e c l i n ic a l c a r e , y e t

few medical personnel are exposed to formal training in these areas. Team training has been found to decrease9

m e d i ca l e r r o rs . S i m u l a ti o n o ff e r s a n i d e a l s et t i ng t o p r a c t ic e m e t h od s o f C R M i n a s a f e l e a r ni n g e n vi r o n me n t . A10

s y st e ma t ic r e vi e w o f t ea m t r ai n in g s tu d ie s f o un d t ha t 8 5% o f t he s t ud i es u t il i ze d s im u la t io n . A 2 0 07 s tu d yevaluating the effectiveness of a mock code-based educational intervention on the leadership skills of pediatric

11r e s i de n t s d i s p la y e d s i g ni f i c an t l y i m p ro v e d l e a de r s h ip s k i l l s c o m p ar e d w i t h r e s i de n t s w h o d i d n o t u n d e rg o

12training. Andreatta et al, showed that conducting simulation-based mock codes significantly correlated with

improved pediatric patient cardiopulmonary arrestsurvival rates.

D i s co v e r in g s y s t e m e r r or s –

C o m m un i c a ti o n f a i l ur e s a c c o un t f o r m a n y o f t h e i s s u es i n p a t i en t s a f e t y. S i m u l a ti o n c a n b e u s e d t o i m p ro v e

c o m m un i c a ti o n a m o ng t e a m m e m b er s a n d th e o r et i c a ll y r e d u ce p a t i en t e r r o r s. I n t e r d is c i p li n a r y s im u l a ti o n

canbe used to identify institutional policies and practices that may be detrimental to patient care. For example, it

EDUCATION Sim ulat ion in Pediatric Crit ical Care Training




c a n be u s e d t o i mp r o ve t h e t r a n si t i on b e tw e e n e m e r ge n c y r o o m a n d Pe d i a tr i c I n t e ns i v e C a r e U n i t( P I C U ) o r

between anesthetists and intensivists. Running such kind of simulation can find out situation readiness and the

adequacy of handover. Over a 6-month period, Andreatta et al implemented an interdisciplinary team training13

a n d s i m u la t i o n p r o gr a m t o i m p r ov e t h e m a n a ge m e n t o f o bs t e tr i c e m e r ge n c i es . Tr a n s cr i p t s f r o m th e d e b r ie f i n g

s e s si o n s i d e n ti f i e d f i ve m a i n t y p es o f s y s t e m -l e v e l a n d s p e c ia l t y -s p e c if i c p r a c ti c e s , p o l ic i e s , a n d p r o c e du r e s

that could potentially cause conflict within the clinical team or adversely affect patient care.These included

i n s ti t u ti o n al p o l ic i e s t h a t w e r e i m p o ss i b le c a r r y o u t , p o l ic i e s b e t w ee n d e p a rt m e n ts t h a t c o n tr a d i ct e d o n e

a n o th e r, p o li c i e s t h a t p a r t ic i p a nt s d i d n o t r e a l iz e e x i s te d , a nd a v a r i et y o f c o m m un i c a ti o n s b a r r ie r s b e t w ee n

d i f fe r e n t d e p a rt m e n ts a n d s p e c i a lt i e s . T h is s t u d y s h o we d h o w i n t e rd i s ci p l in a r y c o m m u ni c a t io n s s i m u la t i o n

t r a i ni n g c a n b e u s e d t o i d e n ti f y c r it i c a l sy s t e ms - b a se d o b st a c l es a n d i s su e s t h a t d es p i te b e i ng e n d e m ic , m i g h t

o t h e rw i s e h a v e g o n e u n a dd r e s se d .

I m p ro v i n g t h e q u a l it y o f e d u c a t i o n

Curriculum based training in PICU is primarily driven by text books and clinical experience gained with real patients under supervision by trainers. Errors are inevitable and not without repercussions. The trainers and

l e ar n er s h a ve l i tt l e o p po r tu n it y t o f a c il i ta t e t r ai n in g w i th o ut t h e a d de d p r e ss u re o f t i me a n d p at i en t s a fe t y.

P r o c e du r a l s k il l s s u c h a s l i n e i n s er t i o ns a n d t h e c o m p e te n c y r e q ui r e d w i th d e x t e ri t y a n d s l ic k n e ss f o r h i g h r i sk

s i t u at i o ns c o m m on l y e n c o un t e r ed i n P I C U s u c h a s a p a t ie n t i n s h oc k g e t u n de r m i ne d m o r e f r e q ue n t l y th a n n o t

f o r n o vi c e t r a i ne e s a n d h e n c e m o r e m i s s ed o p p or t u n it i e s . Pr o c e du r a l s ki l l s m a y b e l e a r nt o n s i mu l a te d m o d el s

o r p a r t - ta s k t r a i ne r s a t t h e l e a r ne r ' s p a c e w i t h e n ou g h p r a ct i c e w i t ho u t c a us i n g p a ti e n t h a rm . L e a r n in g i n a n o n -

r i s k en v i r on m e n t f a c i li t a t es b e t te r r e f le c t i on a n d re t e n ti o n . In f a c t, s i m ul a t i on o f fe r s a u n i qu e a d v a nt a g e f o r

learning rarely performed procedures. Studies looking into the skill retention showed that a skill learnt in skill14 1 5

l a b o ra t o r ie s c a n s u s ta i n u p t o 1 ye a r. M c G h ag h i e e t a l . l o o ke d i n t o a s p e c if i c q u e s ti o n o f w h e t he r si m u l at i o n

w i t h de l i b er a t e p r a c ti c e y i e ld s b e t te r r e s ul t s t h a n tr a d i ti o n a l e d u c at i o n. T h ey s c r ee n e d ov e r 3 00 0 a r t ic l e s

published between 1990 and 2010 and demonstrated an improvement in the simulation with deliberate practice

group over traditional education. Largest metanalysis on simulation education was published by Cook et al in16

J A M A , a l s o s u p po r t e d i t s s u p e ri o r it y.

Credentialing and exams

O n e m o r e p o t e nt i a l u se o f s i m ul a t io n i s a s a t o o l to e v a l ua t e c o m p et e n c y an d c r e de n t ia l i n g. I t i s a r e l a ti v e ly n e w

c o n c ep t . T h o ug h c o m p u te r b a s e d s c e n a ri o o r i e n te d e x a m s a r e b e i n g c o nd u c t ed , t h e r e i s n o t m u c h e x p e ri e n c e17

u s i ng s c e n ar i o s b a s e d on h i g h fi d i e li t y s i mu l a to r s . R e su l t s o f t h e I s r a e li s t u dy l o o ki n g i nt o u s a ge s i m ul a t i on

f o r b o a r d c e r t if i c a ti o n f o r a n e s th e s io l o gi s t s a r e p r o m is i n g. I t m i g h t f i n d m o r e a p p li c a t io n i n t h i s r e g a rd a s m o r e

studies look into their validity.

H o w d o I a p pl y s im u la t io n i n my P I CU ?

Essential process for conducting a simulation based training session is as below:· Needs assessment and identifying target trainees or audience –

B a s e d o n w ha t h as t o b e t a u g ht o r as e s s ed , l oc a t i on f o r t h e s i m u la t i on e x e rc i s e c a n b e d e c i de d . F or

e x a m p le , i f t h e g o a l i s t o as s e s s t h e t e a m r e a d ni n e s s f o r a c o d e b l u e e v e n t, t h en p oi n t o f ca r e s i m ul a t i on

( s im u la t io n a t th e w o rk a re a ) is i d ea l . I f le a rn i ng a n e w p r oc e du r al s ki l l i s t h e g o al , th e n i t ca n be

performed in a Skill laboratory.

·S e t l e a r n in g o b j e c ti v e s – T h i s i s a v e r y i m p or t a n t s t ep . To o m a n y l e a r n in g o b j e c ti v e s m i g h t c o nf u s e t h e

learner. Hence, they should be clear and few.





·Develop training scenario – Scenario should be such that learner should be able to relate to it.

·D e t e rm i n e p e r f or m a n c e m e a s ur e s – p r e p a r e a c h e c kl i s t s o a s t o h e l p w i t h d e br i e f in g p r o c e ss .

·Prepare the location and set up of the equipment (location, manikins/part-task trainers, drugs and other

props, video set-up for feedback and control of simulation equipment according to the flow of the

s c e n ar i o ) – S e t u p s ho u l d b e a s r e a l is t i c a s p o s si b l e . I n t e ns e e x p e ri e n c e d u r i ng s i mu l a t io n e xe r c i se i s a

very essential factor in effective learning.

·E f f ec t i ve D e b r ie f i n g b y f a cu l t y – I t i s t h e h e a r t o f s i mu l a ti o n e x e r c is e . E f f e ct i v e d e b r ie f i n g c on v e r ts

e x pe r ie n ce i n to l e ar n in g . De b ri e fi n g sh o ul d t ak e a s m u ch t i me a s t h e s c en a ri o . Va r io u s d e br i ef i ng

m o d e ls a r e t a u g ht i n t h e i n s t ru c t or w o r k s h o ps .

Why Simulation based education does work?

S i m u la t i o n- b a s ed l e a r ni n g l a r g el y i n v o l ve s K o l b' s p r i nc i p l es o f a d u l t l e a r n in g . We l e a r n t h r ou g h e x p e r ie n c e .

T h i s f o r m s t h e b a s is f o r c o n c e pt b e h i n d e x p e ri n e nt i a l l e a r ni n g . E x p er i e n ce g a i n ed t h r o u g h w h at e v e r f o r m , b e i t

a t w o r k , i n l i f e o r d u r i n g f o rm a l e d u c a ti o n al p r o c e s se s w i l l p l ay a c e n t ra l r o l e i n o u r l e a r n in g . Al l e x p e r ie n c e s

o f f er l e s s o n s f o r o u r l e a r n i ng . W h e n e x p e r ie n c i ng a p r o c es s o r a p h e no m e n on , w e p e r c ei v e i t t h r o u gh o u r s e n s e s

a n d a s s oc i a t e w i t h i t t h o ug h t s a n d f e e l in g s i n o r d e r t o m a k e s e n se o f i t . We e i t h er c o n n e c t i t w it h o t h e r e v en t s a n d

e x pe r ie n ce f r om t h e p a st o r p r oj e ct i t o nt o o ur f u t ur e p l an s . A s a r e su l t ex p er i en t ia l l e ar n in g c an n ot b e

dissociated from our thoughts, feelings and emotions.

K o l b t e a c he s t h a t f o r th i s t y p e o f l ea r n i ng t o b e s u c c es s f ul , t h e c y c l ic a l mo d e l r e q u ir e s f o u r k i n ds o f a bi l i ti e s

(Fig.2):

1 . C o n c r et e e x p e ri e n c e ( C E )

2. Reflective observation (RO)

3. Abstract conceptualization (AC)

4. Active experimentation (AE)

F i rs t ly, th e l e ar n er ge t s f r ee l y i n vo l ve d i n n e w e x pe r ie n ce s ( C E) . T h e c r is i s s i mu l at i on e xe r ci s e d i re c tl y

provides this opportunity for him. Then time and space is made for him to reflect on his experience from

d i f fe r e n t pe r s p ec t i v es ( R O ) . Th i s i s u s u al l y d on e a s a d e b r ie f s e s si o n i m me d i a te l y f o ll o w in g t h e c o n c lu s i on o f

t h e s i mu l at i on a c ti v it y. I t i s t h is r e fl e ct i ve e l em e nt i n th e l e ar n er ' s c y cl e t h at w i ll b e s t ro n gl y i nf l ue n ce d b y

feedback from his peers or assessors, making the debrief session so valuable for learning.

Next, the learner will be able to construct and reconstruct his ideas and process them into sound logical theories

f o r fu t ur e l e ar n in g (A C ). T hi s m o ve s h i m to w ar d s t h e l a st p a rt o f th e c y cl e ( A E) i n wh i ch h e n o w u s e w h at h e

h a s u n d e rs t o od t o m a k e c l i ni c a l d ec i s io n s a n d s ol v e f u t ur e c r i s is p r o bl e m s . B y t e s t in g o u t i m p l ic a t i on s i n n e w

s i t ua t i o ns , h e w i l l g en e r a te n e w l e a r ni n g c o n te n t f o r t h e s t a r ti n g p o in t o f t h e n e x t c y cl e , t h e c o n c re t e e x p e r ie n c e

again.

A l l f o u r s t ag e s o f t h e p r o c es s a r e n e c e ss a r y f o r e f fe c t i ve l e a r n in g t o b e a c h i ev e d . I n s i m u la t i o n- b a s ed l e a r n i ng ,

t h e i n st r uc t io n al d e si g ne r n ee d s t o b e a b le t o u se t h e o p er a ti o na l m od e l to c r e at e i n t he t r ai n in g p ro g ra m m e

l e a r ni n g o p p or t u n it i e s t h a t a r e s e n si t i ve t o a l l t h e s e d i ff e r e n t s ta g e s o f t h e c y c l e o f l e a r n in g .

Advantages of simulation based learning - S i m u l at e d p r ac t i c e e n v i ro n m e nt s a r e u s e f ul f o r r e f le c t i on u p o n

e x p e ri e n c e i n c l in i c a l a r e a s b e c a us e i t d r aw s o u t l ea r n i ng p o i nt s , d e ve l o p s c l i n ic a l r e a so n i ng a n d i nt e g r at e s





t h e or y w i t h p r a c ti c e . M i s ta k e s m a y b e m a d e a n d l e a r ni n g c a n o c c u r w i th o u t r i sk t o p a t i e n ts . P r a c t ic a l s k i l ls c a n

be developed in a systematic supported manner. Furthermore, discussion of theoretical and ethical matters that

a r e n o r m al l y in a p pr o p r ia t e i n t he p r e s en c e o f a p a t i en t c an o c c ur i n pa r a l le l w i th t h e d e v e lo p i n g o f p ra c t i ca l

skills.

O n e s i gn i fi c an t a d va n ta g e o f s i mu l at i on i s t h at i t p e r mi t s b o th t h e t r ai n er a n d t h e l e ar n er t o s t u dy p a t ie n t

t r e a t me n t pr o c e ss e s i n w ay s t h a t n a t u re p r o h ib i t s. T he s i m ul a t i on c a n b e r u n ma n y ti m e s w i t h t h e v a l u es o f t he

parameters being modified between runs and the changes in outputs observed. It also offers unique advantage of

learning procedural skills or management of clinical situations that are of rare incidence.

Fallacies

F o r s i m u la t i o n b a se d e d u c a ti o n t o b e e f f e ct i v e, i n s t r u ct o r n e e d s t o h a v e a c o n s id e r a bl e e x p e ri e n c e i n d e s i g ni n g

a r e a l is t i c s c e n ar i o . I ns t r u ct o r s h ou l d b e a b l e t o d e li v e r a n e ff e c t i ve d e b r ie f i n g se s s io n t a i lo r i n g to t h e n e e d s o f

t h e t r a i ne e . As d i s cu s s e d a bo v e , i f a l l th e c o m p on e n ts o f c y c l es o f l e a r ni n g a r e n o t e l ic i t e d du r i ng t h e s i m u la t i on

exercise, it might be underwhelming and might not lead to a desired learning experience.

C h a l le n g e s a n d F u t u re

A s w e s t ri d e f o rw a rd t h is c e nt u ry as t h e s e co n d l a rg e st e co n om y in th e w o rl d , w e a l so e pi t om i se a s o n e o f th e

c o s t -e f f ec t i v e m o d e ls o f h e a l th c a r e. S im u l a ti o n t o o ls s u c h a s t h e h i g h- f i d el i t y s i m u la t o r s a r e v e r y e x p e ns i v e

and require trained personnel and specifically designed simulation labs equipped with the gadgets to facilitate

s i m u la t i on t r a i n in g . F e w t r a i ni n g i n st i t ut i o n s h a v e a l r e a dy t a k e n a l e a p i n t hi s d i r e ct i o n a nd h a v e s e t u p s t at e o f

t h e a r t s i mu l at i on la b or a to r y. H ow e ve r, t he r e i s a g r os s u n de r- u ti l is a ti o n o f t h es e f a ci l it i es d u e t o l a ck o f

availability of simulation instructors. We need to create a bank of simulation instructors who can then inculcate

effective training in our institutions.

P o i n t of c a r e o r i n - si t u s im u l a ti o n i s a v i a b le a n d m o re t o p ic a l a l te r n a ti v e t o t h e e x p e ns i v e s i m u la t i on l a b s i n o u r

s e t - up . We n e e d t o lo o k a t co s t - ef f e ct i v e m o d e ls t h a t c a n st i l l w o r k o n th e s a m e p r i n ci p l es o f tr a i n in g an dl e a r ni n g . We n e e d a w i d er a c c e pt a n c e o f a c u l tu r e o f q u al i t y an d p a ti e n t sa f e t y as a m a n d at o r y re s p o ns i b il i t y i n

o u r P I C U a n d b e p r e p ar e d t o e v a l ua t e o u r se l v e s p e r i od i c a ll y o f h o w w e l l w e c a n i m p r ov e b a s e d o n t h e r e g u la r

s i m u la t i o n e x e rc i s e s. T h e i n v es t m e nt i n r e s o ur c e s t h a t i m p r ov e q u a l it y o f c a r e w i l l e v e n tu a l l y i m p ro v e p a t i en t

o u t c om e s a n d h e n c e b e c o me c o s t- e f f ec t i ve .

Pediatric Simulation Training and Research Society of India (PediSTARS India, www.pedistarsindia.com) has

been formed recently to deal with the challenges and bridge the gap in the availability of simulation expertise in

P ed ia tr ic s a nd a cu te c ar e o f ch il dr en . On e o f th e m ai n go al s o f th is s oc ie ty i s t o es ta bl is h in te rn at io na l

collaboration so as to facilitate the training of trainers and develop low cost simulation alternatives.

Conclusions

S i m u la t i on o f f er s t r e m e nd o u s p r o m is e t o i m p r ov e t h e q u a li t y o f c a r e a n d e d u c at i o n i n p e d ia t r i c i n t e ns i v e c a r es c en a ri o .T h er e i s n o w a g r ow i ng b o dy o f h i gh - qu a li t y li t er a tu r e a n d ev i de n ce t o s up p or t i ts g r ow t h. I n t h e

f u t u re , i t c a n be e x p e ct e d t h at s i m ul a t i on w i l l be u s e d b y pr a c t ic a l l y ev e r y h ea l t h ca r e p r o v id e r a t s om e o r

multiple points in the training and certification process.

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F i gu r e 1 . a - c


1a

1b

1c



F i gu r e 2 . K o lb ’s C y cl e

Table 1. Types of Simulation based tools

A . Ta s k d r iv e n - Sp e ci f ic t a sk tr a in e rs

(Eg. Central line, arterial line, chest drain models)

B . E ve nt dr iv en -

· Standardized patient/ Care Actor

· H yb ri d S im ul at io n – Eg . S ta nd ar di ze d p at ie nt an d p ar t t as k t ra in er

· Computer Based - Low, medium and high Fidelity

ctive

experimentation

Reflective

Observation

bstract

Conceptualization

Concrete

Experience





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17.Ben-Menachem E, Ezri T, Ziv A, et al. Objective structured clinical examination based assessment of regional

a n e s th e s i a s k i l ls : t h e I s r ae l i N a t io n a l B o a rd E x a m i n at i o n i n A ne s t h es i o l og y e x p e r ie n c e . A n e s th A n a lg 2 0 11 ;

112:242–245





Extra Corporeal Membrane

Oxygenation (ECMO)i

Dr. Praveen Khi l nani *, Dr. Pranay Oza**, Dr. Suneel Pooboni ***,

Dr. Soonu Udani ****, Dr. Pradeep Sharma*****

*BLK Super Speciality Hosptial, Delhi **Ridhi Vinayak Hospital, Mumbai

***KIMS Hospital, Hydrabad ****PD Hinduja Hospital, Mumbai *****BLK Super Speciality Hospital, Delhi

Introduction

Extra Corporeal Membrane Oxygenation (ECMO) is a modification of conventional cardio pulmonary bypass

u s e d to s u p po r t h ea r t a n d lu n g s f o r e x te n d e d p e r i od s o f t i me t i l l th e u n d er l y i ng d i s ea s e p r o c es s i s t r e a te d . Th e

a d v e nt o f c a r d i o pu l m o na r y b y pa s s f o r o p en h e a r t s ur g e r y ha s p a v e d th e w a y f o r e st a b l is h i ng o t h e r l if e

s u p po r t in g s y s t e ms l i k e E C M O . T h ro u g h e x t en s i ve r e s e a rc h a n d d e v e l o pm e n t i n t h e a r e a o f c a r d i o pu l m o na r y

bypass, machine-managed extra-corporeal oxygenation of blood has greatly evolved. In 1937, the first attempt

a t e x tr a c o r po r e a l ox y g e na t i o n w a s m a d e b y t h e d i r e ct b u bb l i ng o f o xy g e n ga s i n t o bl o o d . T h e se o x y ge n a t or s

c a u s ed s e v e r e h e m o ly s i s a n d p r ot e i n d en a t ur a t i on , w h i ch w a s a r e s u lt o f t h e d i r e ct b l o od - g a s i n t e rf a c e . Th u s ,

t h ei r u s e w a s l i mi t ed t o o n ly a f e w h o ur s .

I n o r d er t o o v e r co m e t h i s c o m p li c a t io n , u s e o f a s e m i p er m e a b le m e m b ra n e o x y g en a t or w a s i m p l em e n t ed . T h is

prevented direct contact of blood and gas, and the concept of prolonged extracorporeal support was born.

C l i n ic a l re p o r ts o f l on g - t er m , m em b r a ne e x t r ac o r p or e a l s u p po r t of p a ti e n t s w i t h r e s p ir a t o ry f a il u r e w e r e

d e s c ri b e d i n t h e e a r l y 1 9 7 0s . By 19 7 4 , 1 5 0 a d u l t p a t ie n t s w i t h r e s p ir a t o ry f ai l u re o f di v e r se e t i o lo g i e s h a d

u n d e rg o n e e x t r ac o r p or e a l su p p or t . Th i s l e d to a m u l ti c e n te r t r ia l c om p a r in g e xt r a c or p o r e al m e m br a n e

o x y ge n a t io n ( E C M O ) v s c o n v en t i on a l v e n t i la t i o n, w h i c h s h o w e d t h a t e a r l y s u r v i va l r a t e s w e r e u n c h an g e d.

Therefore, ECMO as a treatment modality in adult respiratory failure did not gain universal popularity. In the

s a m e p e r i od , h o w e ve r , n eo n a te s [ e s p e ci a l ly t h o s e w i t h p er s i s te n t p u lm o n a ry h y p e rt e n si o n o f t he n e w b or n

(PPHN)] had improvement in outcomes secondary to ECMO, although premature babies at less than 35 weeks

g e st a ti o n h a d a n u n ac c ep t ab l y h i gh i nc i de n ce o f i n tr a cr a ni a l h e mo r rh a ge . Si n ce t h en , EC M O a s a r e sc u e

t r e a tm e n t mo d a li t y fo r i n fa n t s o v e r 3 5 w ee k s g e s ta t i o n a n d ch i l dr e n h as g r o wn a n d b e c o me i n c r ea s i n gl y

popular in intensive care units.

R o b e rt B a r t l e t t i n M i c h ig a n ( US A ) w a s t h e f i r s t p h ys i c i an t o u s e n e o na t a l E C M O s u c c e ss f u l ly i n 1 9 7 2 i n a c a s e

o f m e c o n iu m a s p i r a ti o n s y n dr o m e . T he b a b y g i r l w a s n a m e d a s E s p er a n z a ( m e a n i n g, H o p e i n s p a n is h ) . E C M O

h a s b e e n r e v o lu t i on i z e d s i n c e t h e n . F r o m v e n o a r t e ri a l EC M O , wh i c h h a s b e e n t h e n o r m f o r al l r ev e r s ib l e

pathologies, physicians are shifting towards veno venous ECMO for respiratory pathology not needing cardiac

s u p po r t , w h ic h i s m o r e p h y si o l og i c a l i n a p pl i c a ti o n f o r n o n- c a r d ia c c o n d it i o n s. T h e s i z e o f t h e c i r c u it s h a s b e e n

m i n i at u r iz e d s in c e t h e n, b e s id e s f u r t he r d e ve l o p me n t of b i o- c o m pa t i b le o x y ge n a t or s a n d co a t e d c i r c ui t s t o

r e d u ce t h e c o m p li c a t io n s o f c on s u m pt i v e c o a g ul o p at h y an d t hr o m b oc y t o pe n i a . T h e s h i ft f r o m r o l l er p u mp

E C M O m a c h in e s w h i ch a r e m a i n ly g r a v i ty d e p e n d en t f o r a c h i e vi n g f l o w t o m a g n et i c a ll y d r i v en c e n t r i fu g a l

E C MO p u mp s h a s m a de n o ti c ea b le c h an g e t o t h e p r ac t ic e . T h e a d va n ce s e n su i ng f u rt h er r e du c ti o n i n s i ze o f

t h e c o m p on e n ts r e s u lt e d i n c o m pa c t n es s o f t h e e n t i re s y s t em , m a k i ng i t m u c h m o r e f r i e nd l y t o u s e f o r t r a ns p o r t

a s m o b i le E C M O . A l l th e s e i n n o va t i o ns h a v e b e n e fi t e d o u r pa t i e nt s r e m a r ka b l y, l e a di n g to i m pr o v e me n t i n

their outcomes.


Technology



I n d i ca t i o ns o f E C M O

E C M O c a n b e u s e d f o r r e s cu i n g p a ti e n t s f o l l ow i n g r e s pi r a t or y o r c a r d i a c c o n d it i o ns . S o m e t im e s , i t c o u l d b e acombination of both.

C a r d ia c i n d ic a t i on s h a v e b e e n l im i t e d to c h i l dr e n w i th i n t r ac t a b le c a r d ia c f a i l ur e a f t e r c a rd i o th o r a ci c s u r ge r y,

but the use has been increased in patients with severe viral myocarditis,toxic myocardial depression,intractable

a r r h yt h m i as . P a t i en t o u t co m e s d e p e nd m a i n ly o n t h e e t i o lo g y o f t h e c a r d ia c f a i l ur e . O v e r al l , t h er e h a s b e e n a n

i n c r ea s e i n th e n u m be r o f t h e se i n d ic a t i on s r e s u lt i n g i n b et t e r o u t co m e s , w h i ch i s p r o ba b l y d u e t o in c r e a se d

experience.

M o s t re c e n tl y, E C M O h a s b e e n us e d a s a t o o l fo r r e su s c i ta t i o n o n p at i e n ts w i t h ca r d i op u l mo n a r y a r r e s t, a n d

s o m e c e n t er s h a v e u s e d E C M O f o r s u p p or t o f d o n o r a b d o m in a l o r g an s . T h e p r e d ic t i o n o f m o r t al i t y i n p e d i at r i c

patients is more difficult due to the coexistence of multiorgan failure. Matching for diagnosis and severity of

illness, ECMO-treated patients had a 74 percent survival vs 51 percent survival in non-ECMO-treated patients.

This study shows that when used appropriately, survival in some patients is enhanced by ECMO.

D e t e rm i n i ng t h a t a p a t i en t i s u n r e sp o n si v e t o “ m a x im a l m e d i ca l t h e r ap y ” a n d c o n si d e r in g t h e u s e o f E C M O

remains difficult and controversial. Most criteria have evolved from the neonatal ECMO experience.

Eligibility criteria forRespiratory ECMO :

R e v e r si b l e r e s p ir a t o ry f a i l ur e i s a n ab s o lu t e b a s i c r e q u ir e m e n t t o c o n s id e r E C M O i n a n y p a t i en t . S o m e ti m e s ,

t h e “ i r r e ve r s i bi l i ty f ac t o r ” m i g h t b e u n c le a r at t he t i m e o f in i t ia t i o n o f EC M O b u t m i g ht b e co m e e v i de n t at a

l a t e r s ta g e . I t e m p ha s i z es t h e f a c t t h at E C M O i s o n l y a s u p po r t m e c ha n i s m t o h el p t h e p a t ie n t w h i le a l l o wi n g t h e

u n d e rl y i ng d i s e as e p r o c es s t o h e a l .

T h e p a t ie n t s h o ul d h a v e b e e n t r ea t e d w i th m a x i m a l c on v e nt i o na l s u p p or t f o r t h e o p t i ma l t i m e p e r i od b e f o r e

c o n s id e r i ng E C M O . W h e n t h e c o n ve n t i on a l th e r a py i s n o t wo r k in g , p at i e nt s h ou l d be o f f er e d EC M O . T h e

d i a l og u e b e t we e n t r e a ti n g p h y si c i a n a n d E C M O p h y si c i a n i s o f pa r a m o un t i m p o rt a n c e t o s e l e ct th e r i g h t patient and treat them with ECMO at the right time, avoiding undue delay. Cost remains a major issue in our

country, however considering the significant mortality benefit it is a therapy worthy of serious consideration if

t h e p r i m ar y pr o b l em i s a r e v e rs i b le o n e .

Patient shouldn't have any contra-indication for anti-coagulants like heparin.

T h e r e s h o ul d n o t b e a n y i n t ra c e r e b ra l b l e e d o r i nt r a v e n t ri c u la r b l e e d g r ea t e r t h an g r a d e 2 ( i n p r e m a tu r e , t e r m

newborns or infants).

Clinical Indications for ECMO for respiratory conditions in Pediatrics:

· S ev er e A RD S r ef ra ct or y t o m ax im al c on ve nt io na l t re at me nt s ta nd s o ut a s t he m aj or f ac to r f or w hi ch

w e c o n si d e r r e sp i r a to r y E C M O. T h e e t i ol o g y o f A R D S m i gh t d i ff e r. I t c o u l d b e s e c o nd a r y t o b ac t e r ia l

pneumonias, malaria, tuberculosis or viruses. In recent days, the efficacy of ECMO in supporting patients with

H1N1 has been very well established. Other common indications include

· Meconium aspiration syndrome

· Severe bronchiolitis

· Inhalation pneumonia ( post burns)

· Post traumatic l ung contusions

· Acute c hest s yndrome ( S ickle c hest)

· Status asthmaticus

· Persistent air leaks

TECHNOLOGY Ext ra Corporeal M em brane Oxygenat ion (ECM O)




· R ea ct iv e P u lm on ar y h yp er te ns io n i n n eo na ta l p er io d ( re ve rs ib le )

· Congenital diaphragmatic h ernia

· Near drowning etc.

Respiratory ECMO selection criteria

Presence of any 2 criteria from the following, observed over a period of 4 to 6 hrs after using maximum medical

r e su s ci t at i on m e a su r es m a y h el p u s i n s e le c ti n g th e p a ti e nt s . Th e se c r it e ri a p r ov i de u s w i th g u id a nc e . T he

o v e r al l a s s e ss m e n t o f a n e x p e r ie n c e d p h ys i c ia n i n e v a l u a ti n g t h e p r o g re s s io n o f t h e d i s ea s e i s m o r e i m p o rt a n t

in selecting the right patient who will be benefited by ECMO.

· PaO / FiO r atio of < 75%2 2

· Oxygen i ndex of > 40 for 4 to 6 hours2

· Muray's score of > 3.0

· aA gradient > 600

· Lung compliance < 0.5 cc/H O/kg2

· Ventilation Index > 40 for 4 hours

Exclusion criteria:

· Irreversible disease – malignancy with poor outcome

· P at ie nt on ve nti la tor fo r > 10 da ys ( lun g f ibr osi s i s l ike ly to se t i n)

· Significant intra c ranial bleed

· Patient in gross multi organ failure (relative)

· S ev er e C NS i nj ur y i nc lu di ng e nc ep ha li ti s, p er si st en t v eg et at iv e s ta te w he re t he n eu ro lo gi ca l o ut co me

i s e x p e ct e d t o be d i s m al .

Cardiac ECMO Indications:

R e v e rs i b l e c a r d ia c f a i l ur e

· Acute reversible refractory cardiac failure situations

· Pre – operative s tabilization

· Failure to wean from Cardiopulmonary Bypass

· Low cardiac output syndrome (post operatively)

· M yoc ar dit is ( pos t v ir al , p oi so ni ng s l ike s cor pi on st in g e tc )

· Intractable a rrhythmias

· Post Cardiac arrest

· Reversible p ulm onary Hypertension

I t i s i n d ic a t e d i n i r r e ve r s i bl e c a r d ia c d i s e as e s o n l y a s a b r i dg e t o v e n t ri c u la r a s s i st de v i c es l i k e B e r l in he a r t o r

t h os e a w ai t in g u rg e nt h e ar t t r an s pl a nt a ti o n. I n c o un t ri e s s u ch a s I n di a a n d A f ri c a , s in c e p e di a tr i c h e ar tt r a n sp l a n t f a c i li t i e s a r e u n d e rd e v e lo p e d , o n l y r e v e r si b l e c a r d ia c c o n di t i on s s u c h a s p o s t c a r d ia c s u r ge r y l o w

c a r d ia c o u t p u t o r m y oc a r d it i s w o u ld b e a p p l ic a b l e i n d ic a t i on s f o r c a r d ia c E C M O .

ECMO selection criteria for cardiac support :

S tr ic t c ri te ri a f or t h e u sa ge o f E CM O i n pe di at ri c c ar di ac f ai lu re a re n ot a v ai la bl e. N on e o f t he p ub li sh ed

s e v e ri t y o f i ll n e ss m a r k er s o r c li n i ca l p ar a m e t er s h a s b e e n p r o v en t o u n i ve r s a ll y p re d i c t o u t c om e b u t m a y

r e m a in o f a s s i s t a nc e w h e n t r y in g t o i d e n t i fy p a t i e n ts w h o m i g h t b e b e n e fi t e d b y E x t r a C o r p or e a l L i f e S u p p or t .

(ECLS).





P r e s en c e o f a n y 2 c r i t e ri a f r o m t h e f o l l ow i n g, o b s e r ve d o v e r a p e r i od o f 4 t o 6 h r s a f t e r m a xi m u m c o nv e n t io n a l

management might be helpful in selecting the patients who will be benefited by ECMO.

- R ef ra ct or y a rr hy th mi as

- C a rd i og e ni c s h oc k w it h h ig h i no t ro p ic r e qu i re m en t s ( m o r e t h an 2 0 p oi n ts a s p e r in o tr o pi c s c or e )

- L a ct a te l e ve l > 5 0 m g /d l o r 5 m m ol / l o r r i si n g t i tr e o r Sc V O < 6 0%2

- p H l e ss t h an 7. 1 5 w i th ol i gu r ia ( < 1 m l/ k g/ h r) in s pi t e o f I A BP ( i nt r a a r ot i c b a ll o on pu l sa t io n ) & in o tr o pi c

supports in selective group of patients.

- Cardiac Index < 2 l/min

T h e r e i s a m i s c el l a n eo u s g r o up o f d i s or d e r s l i k e s e p ti c s h o c k, p o is o n in g du e t o be t a b l o c ke r s , ca l c i um c h an n e l

blockers overdose etc, which are refractory to maximal conventional management, that might be benefited by

Veno arterial ECMO, allowing time for recovery.

T h e r e i s r e n e we d i n te r e s t in t h e u n d e rs t a nd i n g a nd p r a c ti c e o f E C M O i n I n di a . I t i s f e a s ib l e t o d o i t in s e l e ct i v ei n t en s i ve c a r e u n i ts , g e a r e d u p t o a c ce p t t h e c h a l le n g e s, w o r k i n t e a m s a n d a c h ie v e t h e b e n e fi t s . F i gu r e 1 s h o w s

t h e c u r r en t l y p u b li s h e d i n t er n a t io n a l e x t r a c o r p or e a l l i f e s u p po r t ( E L S O) r eg i s tr y da t a o f pe d i a tr i c a n d a d u lt

d a t a s h o wi n g s u r v iv a l r a ng i n g f ro m 5 5 % t o 6 4 % in a d u l ts a n d 6 5 % to 8 5 % i n p ed i a t ri c a g e g r o up d e p e n di n g

u p o n c a r di a c o r r e s p i ra t o r y i n di c a t io n . E C P R ( E C M O p o s t C a r di a c a r r e st ) i s b e i n g c a r ri e d o u t a t m a n y w e s t er n

h o sp i ta l s w i th p e d ia t ri c s u rv i va l s a s g o od a s 5 4 -6 3 %. F e w c e nt e rs i n I n di a h a ve b e gu n p a r ti c ip a ti o n i n E L SO

registry and an asian chapter also has recently been formed.

Figure 1. ELSO Registry report 2013





Technique

T h e t w o b as i c t y p es o f E C M O a r e v e n o ar t e r ia l ( VA ) a n d v en o v en o u s ( V V ) .

T h i s t e r m i n o l o g y d e s c r i b e s t h e d i r e c t i o n o f b l o o d f l o w . T h e o u t f l o w i s a l w a y s v e n o u s ,

but the inflow can be arterial (VA) or venous (VV). Outflow of blood in VA and VV ECMO is from the right

atrium through a catheter placed through the right internal jugular vein. In older patients, other venous sites have been used. In VA mode, after oxygenation in the ECMO circuit, the blood is returned to the patient through an

a r t e ri a l c a n n u la , w h i c h i s p l a c ed i n t h e a s c e nd i n g a o r ta t h r o ug h t h e r i g ht c o m m o n c a r o t i d a r t er y. ( s e e f i g u re 2 ) A

c a nn u la c a n a l so b e p l ac e d d i re c tl y in t o t h e r i gh t at r iu m an d th e a o rt a t h ro u gh a s t er n ot o my. P a ti e nt s w i th

profound left ventricular failure need a left atrial or ventricular catheter to obtain decompression of the left heart.

T h e a r t e ry th a t w a s c a n n ul a t e d i s p e r m an e n t ly li g a t ed . T h e e f f e ct of th i s i s u n k no w n . S o m e c e n t er s h a v e b e g un

r e p a ir i n g t h e a r t e r y a t d e ca n n u la t i o n. R e p a i r s h a d a n e a r l y p a te n c y r a t e o f 9 0 p e r c e nt i n s o m e c e n t er s . P a t i en t s

w i t h no r m a l ca r d i a c f u n c ti o n , a s w e l l a s t h o se w i t h se v e r e p u l mo n a r y di s e a se , m a y b e c a n d id a t e s f o r V V E C M O

support.

C a n n ul a t i on i s d o n e a t t he b e d s id e u n d e r d e e p se d a t io n a nd a n a lg e s i a. A d o u b le l u m e n v e n ou s c a n n ul a h a s b e e n

u s e d i n n e o n at e s , a n d i n ad u l ts , t he b l o od i s r e t u rn e d t o th e d i s ta l il i a c v e i n o f th e i n f e ri o r v e n a c a v a . T h e b l o od

f i r s t e n te r s a s m a l l b la d d e r t h at i s a t t a ch e d t o a s e r v o- r e g u la t e d b o x c o n ne c t e d t o a r o l l er p u m p . I n a d e qu a t e b l o od

r e t u rn t r i g ge r s a n a l a r m o n t h e b l a d de r b o x , w h i ch i n t u r n , s h ut s t h e p u m p o ff . W h e n t he b l a d de r r e f i l ls , t h e p u m p

r e s t ar t s . T h is p r o c es s p r e v en t s e x c e ss i v e n e g a ti v e p r e s su r e , w h i c h o t he r w i se m i g ht r e s u l t f r o m a k i n ke d c a n n u l a

o r h y p o vo l e m ia , a n d m o r e i m p or t a n tl y, p r o h i b it s t h e f o r m a ti o n o f a i r b u b b l es . A f te r e x i t in g t h e b l a d de r, t h e

blood is actively pumped by a roller pump into a membrane oxygenator. The oxygenator consists of a hollow

s i li c on e n v e lo p e p l ac e d i ns i de a s i li c on e s l ee v e. T h e b l oo d f l ow s o n t h e o u ts i de o f t h e c o il e d e n ve l op e , a n d t h e

g a s f l ow s i n a c o un t er - cu r re n t d ir e ct i on i n s id e t h e m e mb r an e . T he s i ze o f t h e m e m br a ne i s c h os e n a cc o rd i ng t o

patient size. There is an effective gas exchange here. Next, the blood flows into a heat exchanger, and then, it is

F i g u re 2 . S c h e m at i c F i g u re o f B a b y o n E C M O c i r cu i t


Figure 2




i n f u se d b ac k i n t o t h e p a t i en t . T h e E C M O c i r c ui t is d e s i gn e d w i t h a b r i d ge t h a t a l l o ws t h e c h i ld a n d t h e c i r c ui t to

be isolated from one another. The blood is heparinized, and the heparin effect is measured by activated clotting

t i m e ( A C T ), w h i c h i s m a i n ta i n e d a t 1 8 0 -2 2 0 s e c o nd s . A CT c a n b e m e a s ur e d a t t h e b e d si d e .

ECMO Management

Initiation : Under sedation and neuromuscular blockade an initial bolus of heparin (100-200 units) is given just

prior to the cannulation, after which a heparin infusion is started and continued throughout the duration of the

ECMO. The flow is initially started low by 50 ml/kg/min and gradually increased by 50 ml increments. Infants

n e e d 1 0 0 - 20 0 m l / kg / m i n f o r a de q u a te p e r f us i o n a n d ox y g e na t i o n, a l th o u gh t he r e a r e p a t ie n t s w h o ma y n ee d

m o re . Pe d ia t ri c p a ti e nt s u s ua l ly n ee d 90 m l/ k g/ m in t o a c hi e ve t h e s a me g o al s . I n VA E C MO , as t h e f l ow i s

increased, the left ventricular output decreases, and the arterial waveform becomes less pulsatile. Stored blood

i s u s e d t o pr i m e t h e c i r c ui t , wh i c h m a y be a c i d ot i c a n d ca l c i um d e pl e t e d. U s in g TH A M (t r o m et h a m in e ) or bicarbonate in the priming fluid can correct acidosis. It is also recommended to measure the electrolyte

c o n c en t r a ti o n o f t h e s t o re d b l oo d . P a ti e n t s w i l l n e e d in t e r mi t t e nt b l o od p r o du c t s t r a n sf u s e d. F r e s h f r o z e n

plasma may be needed intermittently to replenish clotting factors. The ECMO circuit also sequesters platelets,

and counts of 80,000-100,000 are maintained routinely. Adequacy of nutrition is maintained by initiation of

h y p er a l i m en t a ti o n , a n d e a r l y e n te r a l f e e d s a r e n o t a c o n tr a i n di c a t io n . D i u r et i c s m a y b e n e e d ed t o p r e v e n t f l u id

retention. Renal replacement therapy with hemofilteration or hemodiafilteration can be effectively instituted in

E C M O c i r c u it . W h i le o n a v e n t il a t o r, pa t i e nt s a r e p l a c ed on re l a t iv e l y n o n -t r a u ma t i c s e t ti n g s t o p r o m ot e l u n g

h e a l in g . A P I P o f 1 8- 2 0 mm H O , w i th a P E E P o f 4 -5 m m H O , i s g e n e ra l l y u s e d . T h e v e n t il a t or r a t es a r e s e t a t 6 -2 2

1 2 b r e a th s p e r m i n ut e a n d t h e F i O i s 2 5 - 3 0 p e r c e nt . So m e t im e s o l d e r c h i l dr e n a r e m a n a ge d w i t h a P E E P o f 1 0 -2

1 2 m m H O t o p r e v en t l o ss o f f u n ct i o na l r e si d u a l c a p a c it y. P a t i en t s w i t h ba r o t ra u m a a n d a i r le a k m a y be n e f i t2

f r o m h i g h -f r e q ue n c y v e n t il a t i on , i n a d d i ti o n t o E C M O . T yp i c a ll y, n e o n a t e s b e n e fi t f r o m l o w m e a n a i r w ay

pressure and lung rest, and pediatric patients benefit from maintenance of functional residual capacity with

h i gh e r P E EP. W h en t h e u n de r ly i ng pr o ce s s i m pr o ve s , t h e p a ti e nt is w e an e d t o l o w E C MO f l ow s ( 5 0- 1 00

m l / kg / m i n) an d o p t i ma l v e n t il a t o r s e t ti n g s. A d e c i si o n t o d e c a nn u l a te i s m a d e a f t e r t h e p a t i en t m a i n ta i n s

a d e q ua t e o x y ge n a t io n a n d p e r f us i o n i n t he s e s e t ti n g s f o r 2 -4 h o ur s . T hi s w e a n in g o f fl o w c a n b e a c h i ev e d in

s l ow r e du c ti o ns o f f lo w r a te b y i nc r em e nt s o f 10 - 20 m l/ k g/ m in e v er y 1 -2 h ou r s, u p to a f l ow r a te o f 5 0- 1 00

m l / kg / m i n. D u r i ng t h e p r o c es s o f w e a ni n g , b lo o d g as e s a n d t he m i x e d ve n o u s s a t ur a t i on s s h o ul d b e f r e q ue n t ly

m o n it o r e d. A m o r e r a p i d w ea n i ng r a t e c a n b e a c h i ev e d b y d e c re a s i ng t h e f l o w i n l a r ge r i n c r e me n t s o v e r s h or t e r

t i m e i n t e rv a l s. O n c e a f l o w r a t e o f 5 0- 1 0 0 m l / k g/ m i n h a s b e e n a c h i ev e d , th e p a t ie n t i s m o n it o r e d f o r a f e w h o u r s.

I f d e t e r io r a t io n i s s e e n , h i gh f l o w i s r e - e st a b l is h e d f o r 2 4 h ou r s b e f o re a r e p e at t r i a l i s p e r f or m e d .

Complications of ECMO

Mechanical Complications

T h e m o s t c o m m o n m e c h a ni c a l p r o b le m s a r e o x y ge n a t or f a i l ur e , t u b in g r u p tu r e o r l e a k , c a n n ul a k i n ki n g ,

power failure, air in the circuit, and accidental decannulation.

Patient Complications

B l e e di n g f r o m h e p a r in i z a ti o n i s a c o m m on c o m p l i c at i o n. I n t r a c r a ni a l h e m o r rh a g e i s c a t a st r o ph i c . Da i l y h e a d





u l t r as o u nd s a r e p e r f or m e d o n i n f an t s w i t h o pe n f o n t an e l s . A s a n y o t h er s i t e c a n b e i n v ol v e d j u st a s e a s i ly, a h i g h

i n d e x of s u s p ic i o n i s n e e d ed . S i n c e i n f e ct i o n i s a l s o p ro b l e ma t i c , f re q u e nt s u r v ei l l a nc e c u l t ur e s a r e o r d e re d o n

a l l EC M O p a ti e nt s P r op h yl a ct i c a n ti b io t ic s a r e n o t us e d to t r ea t i nf e ct i on . E mb o li z at i on i s a n ot h er r i sk ,

e s p e ci a l l y w i t h VA E C M O , a n d c a n c o n s is t of a c l o t , a i r, o r p a r t ic u l a te m a t t er. A b u b bl e t r a p i s a d d e d t o th e

a rt er ia l si de o f th e c ir cu it i n an a tt em pt t o re du ce t hi s r is k. S e ns or in eu ra l he ar in g lo ss i s a l on g- te rm

c o mp l ic a ti o n w i th a r e po r te d in c id e nc e r a te a s h i gh as 2 4 p e rc e nt . A d di t io n al l y, t he r e i s t h e p o ss i bi l it y o f

catastrophic technical mishaps like catheter rupture, kinking of cannulae, power disruption, and accidental

decannulation.

Setting up an ECMO program:

E v id e nc e s h ow s b e tt e r ou t co m es i n h ig h v ol u me c e nt e rs w i th r a pi d t ur n ov e r of p a ti e nt s . Sk i ll s h a ve t o b e

m a i n ta i n e d i n l o w v o l um e c e n t er s b y a t t e nd i n g r e v i ew c o u r se s , s i m u la t i o n a n d w a t e r l a b s . A s t h e n u m be r of

patients requiring ECMO in any bigger city is going to be a fraction of ventilated cases, at present, we would

l i ke t o r ec o mm e nd i t as s t an d ar d o f ca r e i n hi g h vo l um e c a rd i o th o ra c ic c e nt e rs . Th o ug h EC M O i s a m u lt i -

d i s ci p l i na r y s p e c i al t y, i n v a r i a bl y, o n e t e n ds t o n e e d s o m e h e l p f r o m s u r ge o n s , m o r e s o f r o m c a r d i a c s u rg e o n s.

O n e w i l l n e e d e c h o ca r d i og r a p hi c g u i da n c e i n t h e f o r m o f r e g u la r a s s e s sm e n t o f c a r d ia c f u n c ti o n a n d w a t ch i n g

parameters for resolution of pulmonary hypertension.

E x t ra c o r po r e a l L if e S u p po r t O r ga n i z at i o n ( EL S O ) h a s p u b li s h e d g ui d a n ce o n e s t a bl i s hi n g E C M O c e n t er s .

Though they are universally applicable, minor modifications to suit the socio-cultural and economic climate in

r e s o ur c e l i m i te d c o u n tr i e s m a y b e n e c e ss a r y.

:ELSO guidelines regarding ECMO centers

A . E CM O c e nt e rs s h ou l d b e l o ca t ed i n te r ti a ry c e nt e rs w i th a t e rt i ar y l ev e l N e on a ta l I nt e ns i ve C a r e U n it ,

P e d i at r i c I n t e ns i v e C a r e U n i t a n d /o r A d ul t I n t e n si v e C a r e U n i t.

B . EC M O C e n t er s s h o u ld b e l o c a te d in g eo g r a ph i c a r e a s t h a t c a n s u p p or t a m i n i mu m of 6 E C M O p a t i en t s p e r

c e n t er p e r y e a r. T h e c o s t e f fe c t i ve n e s s o f p r o v i di n g f e w e r t ha n 6 c a s e s p e r y e a r c o m bi n e d w i th t h e l o s s , o r l a c k

of clinical expertise associated with treating fewer than this number of patients per year should be taken into

a c c o un t w h e n d e v e lo p i ng a n e w p r o g ra m .

C . E C M O C e nt e rs s h ou l d b e a c ti v el y i n vo l ve d i n t h e E x tr a co r po r ea l L i fe S u pp o rt O r g an i za t io n ( E LS O )

including participation in the ELSO Registry.

General Structure: T h e E C MO c e nt e r s h ou l d b e l o ca t ed i n a t e rt i ar y l e ve l i n te n si v e c a re u n it w i th t h e

following components.

1 . T he re s ho ul d b e a s in gl e p hy si ci an EC MO p ro gr am di re ct or wi th re sp on si bi li ty fo r t he o ve ra ll

o p e r at i o n o f t h e c e n t er. W h i le t h e r e m a y b e s e v e ra l a s s o ci a t e d i r e ct o r s w i t h s p e c if i c i n t e re s t s o r f o c u s

i n l i mi t ed a re a s o f EC M O c a re , th e p r im a ry m ed i ca l di r ec t or s ho u ld b e r e sp o ns i bl e f o r a s su r in g

appropriate specialist training and performance, directing quality improvement meetings and projects,

a s su r in g p r op e r an d va l id d a ta s u bm i ss i on t o EL S O, a n d s h ou l d a l so b e r e sp o ns i bl e f o r th e

c r e d e nt i a l in g o f o t he r p h y si c i a ns w h o c a re f o r E C M O p a t i en t s o r w h o m a na g e t h e E C M O c i r c ui t .

2 . T h er e s h ou l d b e a n EC M O c o or d in a to r wi t h r e sp o ns i bi l it y fo r t h e s u pe r vi s io n an d t r ai n in g of t he

technical staff, maintenance of equipment, and collection of patient data.

3 . T he m ul ti -d is ci pl in ar y E C MO Te am s ho ul d h a ve q ua li ty a s s ur an ce r ev ie w p ro ce du re s i n p l ac e f or





annual ECMO evaluation internally.

4 . F o rm a l P ol i cy a n d P ro c ed u re s o u tl i ni n g th e i n di c at i on s a n d c on t ra i nd i ca t io n s f o r E CM O , c li n ic a l

m a n a ge m e n t of t h e E C M O p a t i en t , m a in t e na n c e o f e q ui p m e nt , t e r mi n a t io n o f E CM O t h e r ap y, a n d

f o l lo w - u p o f t h e E C M O p a t ie n t s h o u ld b e a v a i la b l e f o r r e v i e w.

5 . A p p r op r i a te l a b o ra t o r y sp a c e f o r t r a in i n g a nd c o n t in u i ng m e d i c al e d u c at i o n s ho u l d b e a v a i la b l e .

I n di a n Sc e na r io a n d fu t ur e o f E CM O : I n I nd ia m an y c en te rs h av e s ta rt ed ac qu ir in g E CM O

technology,however cost remains a major issue. Survival benefit with appropriate early institution in selected

patients is the real motivating factor. With portability of the equipment and availability of personnel and proper

t r a i ni n g o f E C M O s p e c ia l i st ( i n t e ns i v is t o r a n e s t he s i ol o g i st o r a s u r ge o n ) , r o un d t h e c l o c k c r it c a l c a r e n u r se s

a n d p e r f us i o ni s t s, i t c a n be a c c o m pl i s h ed i n t er t i a ry c e n t er s w i t h ro u n d th e c l o c k cr i t ic a l c a r e a n d a n ci l l ar y

s e r v ic e s . H os p i ta l a d mi n i st r a t iv e c o m m it m e n t a n d su p p or t i s o f p r im e i m p or t a n ce f o r s u c c es s o f a ny E C M O

program.

Conclusions

P r e s en t l y, E CM O i s v i e w ed a s a n in v a si v e p r o c ed u r e w i t h s i g ni f i c an t r i s k s, a nd s ho u l d b e u s e d o n l y a f t e r

c a r e f ul e v a l u a ti o n o f r i s k s /b e n e fi t s a n d d i s c us s i on w i t h t h e f a m i l y. H o w e v e r, i t c o n ti n u e s t o r e p r e s en t a n

important support option in select critically ill infants and children. In the future, with increased experience, this

procedure will become an even safer, more effective alternative to many less efficacious conventional

therapies.

References:

1 . M a r sh T D , Wi l k er s o n S A , C o o k L N. E x t ra c o r po r e a l me m b ra n e o x y g en a t i on s e l e ct i o n c r i te r i a: P a r t ia l p r e ss u r e

of arterial oxygen versus alveolar-arterial oxygen gradient. Pediatrics 1988;82(2):162-166

2 . M an n T, A da ms K . S en so ri ne ur al He ar in g Lo ss i n E CM O S ur vi vo rs . E xt ra co rp or ea l M em br an eo us

Oxygenation. Journal of theAmerican Academy of Audiology 1998;9: 367-70

3 . P a u l in e K . Pa r k M . D ., Ja m e s M . B l u m M . D ., L e n a M . N a p ol i t a no , M. D . , G a i l A n n ic h , M . D ., J on a t h an W. Ha f t ,

M.D., and Robert H. Bartlett, M.D. University of Michigan Health System: Extracorporeal membrane

o x y g e n a t i o n ( E C M O ) i n p a t i e n t s w i t h A R D S . A m e r i c a n T h o r a c i c S o c i e t y g u i d e l i n e s .

http://www.thoracic.org/clinical/critical-care../refractory-ards/pages/ecmo.php

4 . Ve n ov e no u s e x tr a co r po r ea l m em b ra n e o x yg e na t io n f or r e sp i ra t or y f ai l ur e i n i no t ro p e d e pe n de n t ne o na t es .

American Society of Artificial Internal Organs Journal. 2003 Sep-Oct;49(5):568-715 . M e ht a U , La k s H , Sa d eg h i A , M a re l li D , O d im J , A l ej o s J , Ki m M, A t ki n so n JB , Bu i KC . Ex t ra c or p or e al

Membrane Oxygenation for Cardiac Support in Pediatric Patients. American Surgeon 2000;66:879-86

6 . T ri t t en w e in G , P a n s i H , Gr a f B , G o l e j J , Bu r d a G , H e r mo n M, M ar x M , Wo l l en e k G, Tr i t te n w ei n H, P o l l ak A .

Proposed Entry Criteria for Postoperative Cardiac Extracorporeal Membrane. Oxygenation after Pediatric Open

Heart Surgery. Artificial Organs 1999;23:1010-14

7 . L a nt o s J D , F r ad e r J . E x tr a co r po r ea l M e mb r an e O x yg e na t io n a n d t h e E th i cs o f C li n ic a l R e se a rc h i n

Pediatrics. New England Journal of Medicine 1990;323: 409-13

8 . T h al m an M , Tr a mp i ts c h , H a be r fe l ln e r N, E is e nd l e E , K ra s ch l R , K ob i ni a G . R es u sc i ta t io n i n N ea r D ro w ni n g





with Extracorporeal Membrane Oxygenation.Annals of Thoracic Surgery 2001;72:607-8

9 . D u n ca n B W, I b ra h i m A E , H r a sk a V, d e l Ni d o P J, L a u ss e n P C, We s s e l D L , M a y e r, J r. J E , B o w er L K , J o n a s R A .U s e o f R a p i d -d e p l oy m e n t E x tr a c or p o r ea l M e m b r an e O x y g en a t io n f o r t h e R e s us c i ta t i o n o f P e d i a tr i c P a t i en t s

with Heart DiseaseAfter Cardiac Arrest. Journal of Thoracic and Cardiovascular Surgery 1998;116:305-11

10. Younger JG, Schreiner RJ, Swaniker F, Hirschl RB, Chapman RA, Bartlett RH. Extracorporeal Resuscitation of

CardiacArrest. Academic Emergency Medicine 1999;6:700-07

1 1 . K O W J , C h e n Y S , Ts a i P R , L e e P H . E x t ra c o r po r e a l M e m br a n e O x y ge n a t io n S u p p or t of D on o r A b d om i n a l

Organs in Non-heart-beating Donors. Clinical Trans-plantation 2000;14:152-56

1 2 . T im m o ns O D H P, F a c k le r J C. P r ed i c t in g D e at h i n P e d i at r i c P a t i en t s w i t h A c u t e R e s pi r a to r y F ai l u r e. C h e st 1 9 9 5;

108:789

1 3 . O rt i z R M, C i l le y R E , B a rt l et t R H. E x t ra c or p or e al M e m br a ne O x yg e na t io n i n P e di a tr i c R es p ir a to r y F a il u re .

Pediatric Clinics of North America 1987;34:39-46

1 4 . M a r sh T D , Wi l k e rs o n S A , C o o k L N . E x t ra c o r po r e a l M e mb r a ne O x y g en a t io n S e l e ct i o n C r i te r i a: P a r t i a l P r es s u re

of Arterial Oxygen Versus Alveolar-arterial Oxygen Gradient. Pediatrics 1988;82:162-66

1 5 . C a m pb e l l L R , B u n y ap e n C, H ol m e s G L , H o w el l , J r. C G, a n d Ka n t o , J r. W P. R ig h t Co m m on C a r ot i d A r t er y

Ligation in Extracorporeal Membrane Oxygenation. Journal of Pediatrics 1988;113:110-3

1 6 . S c h u ma c h e r R E , Ba r k s J D , Jo h n s to n M V, D o nn S M , S c h e r M S , R o l o ff D W, B a rt l e tt R H . R i g h t- s i d ed B r a in

Lesions in Infants Following Extracorporeal Membrane Oxygenation. Pediatrics 1988;82:155-61

1 7 . C r o mb l e ho l m e T M , A d z ic k N S, d e L o r im i e r A A , L o n ga k e r M T, H ar r i s on M R , C h a rl t o n V E . C a r ot i d A r t er y

Reconstruction Following Extracorporeal Membrane Oxygenation. American Journal of Diseases of Children

1990;144:872-74

1 8 . S a r i og l u A, M c G a hr e n E D , Ro d g e rs B M . E f fe c t s o f C a r ot i d Ar t e ry R e p a i r F ol l o wi n g N e o na t a l E xt r a c or p o r ea l

Membrane Oxygenation. Pediatric Surgery International 2000;16:15-18

1 9 . K e s zl e r M , S u b r am a n ia n K N , S m i t h YA , D ha n i r ed d y R , Me h t a N , M o li n a B , C o x CB , M o r o nt M G . P ul m o n ar y

Management During Extracorporeal Membrane Oxygenation. Critical Care Medicine 1989;17:495-500

2 0 . P e s e nt i A , K o l ob o w T, G a t ti n o n i L . E x t ra c o rp o r e al Re s p ir a t o ry Su p p o rt in t h e A d u lt . A S A IO T ra n s a ct i o ns

1988;34:1006-08

2 1 . M a nn T, A d am s K . S e ns o ri n eu r al H e ar i ng L o ss i n E CM O S u rv i vo r s. E x tr a co r po r ea l M e mb r an e ou s

Oxygenation. Journal of theAmerican Academy of Audiology 1998;9:367-70





A p p e nd i x :

Murray score:

T h e M u rr a y s co r e u s es t h e a v er a ge s c or e o f 4 e l e me n ts g r ad e d o n a 0 - 4 s c al e t o e s ta b li s h A R DS s e v er i ty. I t i s

calculated as follows:

Murray score web calculator: http://cesar.lshtm.ac.uk/murrayscorecalculator.htm

4I n ot ro p ic S c or e :

Pa O2 /FiO2

(FiO2

a t 1 . 0 f o r a t l ea s t 2 0

min u te s)

C h es t X r a y

N u m b er o f q u a dr a n t s w i t h

in filtra te s

PEEP

Co mp lia n ce

( ml /c m H2O)

0

>3 0 0

0

<5

>8 0

1

225-

2 9 9

1

6 -8

6 0 -7 9

2

1 7 5 -

2 2 4

2

9-11

4 0 -5 9

3

100-

1 7 4

3

1 2 -1 4

2 0 -3 9

4

<1 0 0

4

>1 5

<1 9

Dopam ine 1 microgram/kg/mnt Score of 1

Dobutamine 1 microgram/kg/mnt Score of 1

Adrenaline 0.01 m icrogram/kg/m nt Score of 1

Nor adrenaline 0.01 microgram/kg/mnt Score of 1

To t a l s c o re





Liver Transplantation in Children: Indian ScenarioDr. Anupam Si bal , Dr. Vi dyut Bhati a, Dr. Akshay Kapoor, Dr. Sarath Gopal an,

Dr. Nameet Jerath, Dr. Manav Wadhawan, Dr. Subash Gupta

I P A p ol l o H o s pi t al , N e w D e lh i

Introduction

L i v er t r a n sp l a n ta t i o n (LT ) i s n o w t h e t h e r ap y o f c ho i c e f o r e n d st a g e l i v er f a i l ur e , a n d su r v iv a l h a s i m p r ov e d1

s i g ni f i c an t l y o v e r t h e l a s t d e c a de w i t h p e d ia t r i c r e c i pi e n ts f a r i ng be t t e r t h a n a d u lt s . T h i s c a n b e a t t r ib u t ed to2

improvement in surgical techniques, better postoperative care and newer immunosuppressive drugs. Over the

y e a r s, t he r e h a s b e e n a p h e n om e n a l g r o w th i n t h i s f i e l d i n th e d e v e lo p e d c o u n tr i e s a n d 1 a nd 5 y e a r s s u r v iv a l3,4

r a t e s h a v e n o w i n c r e as e d t o 9 0 a n d 8 0 p e r c en t , r e s p ec t i v el y. T h i s s u c c e ss o f LT h a s i n c r ea s e d t h e a w a r en e s s o f5t h i s t r e a tm e n t m o d a li t y i n t h e d e v e lo p i ng wo r l d . S u c c es s f u l LT i n b o t h c h i ld r e n a n d a d u lt s h a v e n o w b e e n

6,7reported from India.

T h e N e ed

Every year, approximately 2-3 pediatric liver transplants are performed per million population in the West. At

t h i s r a t e , a r o un d t w o t o t h r e e t h o us a n d c h i ld r e n w o ul d n e e d l i v er t r a n s p la n t a ti o n i n I n d i a a n n u al l y. A s i n t h e

West, extrahepatic biliary atresia (EHBA) is the commonest indication. Nearly 60 percent of children requiring

LT a t o u r ce n t e r h a d E HB A ( Ta b l e 1 ) . I n th e I n d i an s c e na r i o , ho w e v er , mo s t c hi l d r en w i th E H B A a r e e i t he r

d i a g no s e d l a t e o r h av e n o t u n d er g o ne t h e K a s a i p r o c e du r e a t al l . A t an o t he r t er t i a ry l ev e l c e n t er , n e a r l y 7 08

percent babies with EHBA required LT based on internationally accepted criteria.

INDICATIONS

E n d S t ag e L i v e r D i s e a s e

A m on g t ho s e w i th E H BA , a ll c h il d re n w it h f ai l ed K a sa i 's p r oc e du r e w a rr a nt t r an s pl a nt a s a l so t h os e n o t

o p e r at e d d ue t o l at e r e f e r ra l . I n o t h e r c o n d it i o ns l e a d in g t o c h r o ni c l i v er f a i lu r e i n c l ud i n g b i l i ar y c ir r h o si s ,

a l p h a- 1 - a nt i t r yp s i n d e fi c i e nc y ( n o w r e p o rt e d t o b e v e r y r a r e i n I n d i a b u t o n e o f t h e c o m m on e s t c o nd i t io n s i n t h e

We s t ) , a u to i m m un e h e p a ti t i s a n d Wi l s on ' s d i s e as e , t h e p r e c i se p r e d ic t i o n o f n ee d f o r LT i s d i ff i c u lt . A cc e p t ed

criteria include evidence of decompensation (fall in albumin, prolongation of prothrombin time), persistent rise

in bilirubin, refractory ascites, repeated variceal bleeding, encephalopathy and growth failure in children9

(Table 2). With improved results, transplantation is also now performed for some children to improve quality ofl i f e s u c h as p r o f ou n d l et h a rg y a n d i n t r ac t a b le p r u r it i s . Ch i l dr e n s ho u l d id e a l ly b e r e f e r re d t o th e t r a n sp l a n t

c e n t er b e f o r e s i g ni f i c an t h e p a ti c c o m p li c a t io n s ( s u c h a s v a r i ce a l b l e e di n g a n d e n c e ph a l o pa t h y ) a n d

impairment of growth and development set in.

Fulminant Hepatic Failure

P r i o r t o c o n s id e r i ng LT i n F HF, i t sh o u ld b e a s s e ss e d wh e t h er s p on t a n eo u s r e c o ve r y i s p o s si b l e a n d i f n o t , i s a

t r a n sp l a nt f e a si b l e . F u r t he r , i r r e tr i e v ab l e c o m p li c a t io n s , w h i c h p r e c lu d e a t r a n sp l a n t, s h o ul d b e r u l e d o u t


Ad v an c e s in Tr a n sp la n ta tio n





a f f ec t i n g o u t co m e f o l l ow i n g LT. M o d u la r f e e ds a l l o wi n g p ro t e in , c a r bo h y dr a t e a n d f at c o n te n t t o b e

individually prescribed for each child are recommended.

Immunization: It is essential to make sure that routine immunizations are complete. If necessary, immunization

f o r M M R a n d v a r i ce l l a s h o ul d b e b r o u gh t f o r w ar d . H o w e ve r , i n c h i l dr e n u n d e rg o i ng e m e r ge n c y l i v er

transplants, completing the immunization with live vaccines is not possible.

T r ea t m e nt o f h e p a ti c c o m p li c a t io n s : A s c i te s a n d f l u i d r e t en t i o n i s m a n a ge d b y r e s t r i c te d s o d i u m a n d f l u id

i n t a ke a n d t h e u s e o f d i u r et i c t h e r ap y. B l e e d in g v a r ic e s a r e t r e a te d w i t h in t r a ve n o us s o m a to s t at i n o r o c t r eo t i de ,

e n d o sc o p ic b a n d l i g a ti o n o r t r a n sj u g ul a r i n t ra h e p at i c p o r ta l s h u nt s . I t i s p r e f er a b l e t o e m p l oy ba n d l i g at i o n

i n s t ea d o f s c le r o t he r a p y be c a u se o f t h e p o t en t i a l ri s k o f po r t a l ve i n t hr o m b os i s a n d u lc e r a t io n . H e pa t i c

e n c e ph a l o pa t h y i s t r e a te d b y l o w - pr o t e in d i e t a n d o r a l l ac t u l os e . T h e r o l e o f b r a n c he d c h a i n a m in o a c i d s

remains controversial and use of extracorporeal liver assist devices, as a bridge to transplantation is not yet fully

established.

Counseling: Education and counseling of the family and the child is of paramount importance to sustain themt h r o ug h t h e s t r e ss f u l pr o c e du r e , t he p r o l on g e d po s t op e r a ti v e p e r i od a n d t he l i f e -l o n g im m u n os u p pr e s s iv e

t h e r ap y w i t h i t s a t t e nd a n t r i s ks a n d s i d e e f f e ct s .

C r i t ic a l C a r e I s s u es i n M a n a g e m e nt

C a r e o f a c h i l d a f t e r l i v e r t r a n s pl a n t at i o n i n vo l v es a d e d ic a t e d t r a ns p l an t t e a m . M a i n i s s ue s r e v o lv e a r o u nd g r a f t

f u nc t io n i n t h e p o st o pe r at i ve p e ri o d ( P T ( I NR ) , P T T a n d o t he r l i ve r f u nc t io n t e st s ) i n a d di t io n t o

m a i n te n a n ce o f he m o d yn a m i c p a r a m et e r s , i n t ak e o u t pu t , a b d o mi n a l d r a i n o u t pu t , b i l ia r y o u t pu t an d

o x y ge n a t io n t o e n s u re a d e q ua t e b l o od f l o w t o l i v er g r a f t . S tr i c t a s ep t i c p r e c au t i on s m u s t b e f o l l ow e d i n c a ri n g

f o r t r a ns p l a nt p a t ie n t s . P ri m a r y no n f un c t i on m u s t b e c l o se l y m o ni t o r ed f o r i n t he f i r s t 24 h o u rs ( r i s in g

transaminases, profound hypoglycemia and acidosis, coagulopathy, oliguria) requiring emergency

r e t r a ns p l a nt a t i on . H yp e r a cu t e r e j e c ti o n i s r a r e b u t ca n o cc u r ( hu m o r al r e je c t i on ) . F iv e t o t we n t y p e r c en t

patients will have vascular occlusion with accompanying graft loss. Vena cava, portal vein and more commonly

h e p a ti c a r t e ry m a y g e t o c c l ud e d b y i n t r a mu r a l t h r om b u s, o r l e s s c o m m o nl y b y e x t r i n si c c o m p re s s i on o r v e s s e l

k i n ki n g . Ve s s e ls s m a l le r t h a n 3 m m d i a m e t e r t e nd t o h a v e h i g he r i n c i d en c e o f a r t e r i al t h r o m b o si s . S i g n s a n d

symptoms consist of FHF, increased transaminase and bilirubin levels with worsening coagulopathy. Portal

t h r o mb o s is p r e s en t s w i t h f ul m i n an t n e c r os i s , i nt e s t in a l e d e ma w i t h a sc i t is . D o p p le r u l t r so n o gr a p h y a nd

a n g i og r a p hy a r e u s e f ul t o o ls . B i l e l e a k a n d p o s t op e r a ti v e b l e e di n g m u s t b e c l o se l y m o n i to r e d . E a r l y

n u t r it i o n i s i m p o rt a n t. A c u te r e j e c ti o n o c c u rs i n f i r s t f e w w e e k s a f t e r t r a n sp l a nt a t i on (a v e r ag e 2 3 d a y s a f t e r

transplant in children) characterized by fever, increased bilirubin and liver enzyme levels and encephalopathy.

T h e u s u a l i m m u no s u pp r e s si v e r e g i me n c o ns i s ts o f C a lc i n e ur i n in h i bi t o r s: C y c lo s p or i n e o r Ta c r o li m u s a n d

prednisolone along with Mycofenolate mofetil (MMF). Tacrolimus based immunosuppression is preferred

as it has been associated with less acute rejection and better long-term graft survival rates.

Duration of mechanical ventilation in transplant recipient depends upon age and preoperative condition of the

patient. A child with fulminant hepatic failure may require a longer duration of ventilation depending on the

neurological state. On the other hand, patients with normal pulmonary function preoperatively may require

s h o r t t e r m or n o v e nt i l at i o n. I n f a nt s a n d s ma l l c hi l d re n a r e m o r e l i k e ly t o n ee d p o st o p er a t v e v e n t il a t i on .

Ve n t il a t o ry m a n a ge m e n t a i m s a t a v o i di n g t h e r e s p ir a t o ry c o m p li c a t io n s o f a t e l ec t a s is , e f f us i o ns a n d

pneumonia. Some smaller patients may require a higher end expiratory pressure to compensate for a distended

a b d o me n p u s hi n g o n to t h e d i a ph r a g m . I n a s i n g le c e n t er s e r i e s t h e m e a n t i m e t o e x t ub a t io n w a s 1 1. 1 + 1 5 h o u r s

ADVANCES I N TRANSPLANTATI ON Liver Transplant at ion: I ndian Scenario






consecutive children: 20-years experience from a single center.Transplant Proc 2002;34(5):1955-7

2. Rela M, Dhawan A. Liver transplantation in children. Indian J Pediatric 2002;69(2):175-83

3 . B el le S H, Be ri ng er KC , D et re K M. A n u pd at e o n l iv er tr an sp la nt at io n i n t he U ni te d S ta te s: Re ci pi en t

characteristics and outcome. Clin Transpl 1995;19-33

4 . E c k ho f f D E , D ' A le s s a nd r o A M , K n e ch t l e S J , P i r sc h J D , P l o e g R J , J u d d R H , e t a l . H u n d re d c o n s ec u t i ve l i v er

transplants in infants and children: An 8 year experience. J Pediatric Surg 1994;29:1135-40

5. Kelly DA, Sibal A. Liver transplantation in children. Indian Pediatr. 1999;36:353-55

6. Poonacha V, Sibal A, Rajakumari DV, Soin AS, Rajasekar MR. India's first successful pediatric liver transplant.

Indian Pediatr 2001:38:287-91

7. Kelly DA, Sibal A. Current status of liver transplantation.Indian J Pediatr 2003;70 (9):731-6

8. Mehrotra P, Yachha SK. Need for liver transplantation in Indian children. Indian Pediatr 1999;36:357-62

9. Malatack JC, Schaid DJ, Urbach AH, Garter JC Jr, Zitelli BJ, Rockette H, et al. Choosing a pediatric recipient for

orthotopic liver transplantation, J Pediatr 1187;111:479-85

1 0 . O ' Gr a d y J G , A l e xa n d e r G , Ha y l la r KM , W il l i am s R . E a r ly i n di c a to r s o f pr o g n os i s i n f u l mi n a n t h e p a ti c f a i lu r e .

Gastroenterology 1989;97:439-45

11. Bendre SV, Bavdekar AR, Bhave SA, Pandit, AN, et al. Fulminant hepatic failure: Eetiology, viral markers and

outcome. Indian Pediatr 1996;36:1107-12

1 2 . A r az C , P i ra t A, To rg a y A, Z e yn e lo g lu P, A rs l an G . E a r ly p o s to p er a ti v e c o mp l ic a ti o ns o f p e di a tr i c l i ve r

transplantation: experience at one center. Transplant Proc 2004;36:214-17

13. Wadhawan M, Vij V, Goyal N, Kumar A, et al. Liver transplantation: Experience with last 50 cases at our center.

A p o l lo M e d i ci n e 2 0 0 7 ;4 : 3 3 1- 3 3

14. Kelly DA, Sibal A. Liver transplantation in children. Indian Pediatr 2006;43:389-91

1 5 . B h a t ia V, G u p t a S , S i b a l A . T h e A p o l lo , D e l hi J o u r n ey. I n : S o i n A S , e d i to r. L i v e r t ra n s p la n t at i o n . EC A B C l i ni c a lUpdate: Surgical Gastroenterology and Liver Transplantation. New Delhi: Elsevier India; 2011. p. 29-33

16. Bhatia V, Sibal A. Are Fathers Catching up with Mothers in Liver Donation? Indian Pediatr. 2013 Jan 8;50(1):158

1 7 . K a po o r A, B h a ti a V, J e r at h N , Wa d ha w an M , G u p ta S , S i ba l A. E x p an d in g i n di c at i on s f o r p ed i at r ic l i ve r

transplantation. Apollo Medicine. 2012;9(1):55-61

18. Sibal A, Gupta S, Bhatia V, Kapoor A, Wadhawan M. Liver transplant for children: Indian scenario. Indian Journal

of Transplantation. 2011;5(2):53-5

Tabl e 1: Need for l i ver transpl antati on (1/ 10/ 97 to 31/ 10/ 13)

Satisfying criteria 484

Neonatal cholestasis syndrome 208

A c u te l i v e r f a i l ur e 1 0 3

M e t a bo l i c l i v e r d i s e as e 6 8

C r y p to g e n ic 5 2

M e t a bo l i c d i s e as e s w i t h n o l i v e r f a i l ur e 2 4

O t he r s 1 8

M a l ig n a n ci e s 1 1





Ta b l e 2 : I n d i c at i o n s f o r LT i n e n d s t a g e c h r o n i c l i v e r f a i l u r e

Clinical parameters

Recurrent variceal bleeding Refractory ascites

Intractable pruritus

Growth retardation

Unacceptable quality of life

Laboratory parameters

P r o t hr o m bi n r a t io ( I N R) > 1 . 4

Indirect bilirubin > 6 mg/dl at 3 months post Kasai

Albumin < 3.5 mg/dl

Cholesterol < 100 mg/dl

Ta b l e 3 : C r i t e ri a f o r l i v e r t r a n sp l a n t at i o n in f u l m in a n t he p a t ic f a i l u re

For paracetamol poisoning

Arterial pH < 7.3 or the following three factors: Prothrombin time > 100 sec

Creatinine > 3.5 mg/dL

G r a de I I I o r I V e n c e ph a l o pa t h y

For other causes

I N R > 4

Tabl e 4: Pedi atri c l i ver transpl ant at Indraprastha Apol l o Hospi tal : Underl yi ng eti ol ogy of 118 cases

Biliary Atresia 44

Metabolic liver diseases 21

Cryptogenic 19

Acute Liver failure 13

Budd-chiari syndrome 05

NNH 04

Autoimmune hepatitis 03

Hyper oxaluria 02

Congenital hepatic fibrosis 02

Poisoning 02

PVT 01*

Hepatitis C 01

HCC 01





Ped i a tri c Ren a l Tra n sp la n ta tio nDr. Kanav Anand*, Dr. PK Pruthi **

*MBBS, MD Pediatrics, Fellowship in Pediatric Nephrology, Pediatric Nephrologist

**MBBS, MD Pediatrics, MNAMS, Senior Pediatric Nephrologist, Division of Pediatric Nephrology, Institute of

Child Health, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi

Introduction:

A l t ho u g h t h e re h a v e b e e n m a n y a d v a nc e s i n c o n s e r va t i v e r e n a l r e p la c e m e nt t h e r a p y, r e n a l t r a n s p l an t a ti o n i s

s t i ll t h e b e s t t r ea t m e nt t h a t c a n b e o f fe r e d t o c h i ld r e n w i th e n d - s ta g e r e n a l d is e a s e ( E S R D ) i n o r de r t o

i m p r ov e t h e i r q u al i t y o f l i f e . T he m o r t al i t y w i th d i a l y s is i s m u c h h i g he r c o m p a r ed t o r e n a l t r a n s p la n t a ti o n .I n t h e c u r r en t s c e n a ri o , w i t h a dv a n c em e n t i n i m m un o s up p r e ss i v e t h e r ap y a n d t h e q u a li t y o f c a r e a v a i la b l e

for young children, renal allograft and patient survival have improved tremendously. Young pre pubertal

c h i ld r e n a r e m o r e l i k el y t o h a v e i m p r ov e d g r o w th p o s t t r a n s pl a n ta t i o n c o mp a r e d t o t h o se u n d e rg o i ng

c h r o ni c d i a l ys i s . A s a r e s u lt , r e n a l t r a ns p l a nt a t i on i s t h e p r e f er r e d r e n a l r e pl a c e m en t t h e r ap y f o r c h i l dr e n

w i t h E S RD . N o w a da y s c h i l dr e n a r e e v e n g o in g i n f o r p r i m a ry o r p r e e m p ti v e t r a n sp l a nt a t i on , s o a s t o a v o i d

d i al y si s w h en a l i vi n g d o no r is a v ai l ab l e.

T h e m o s t c o mm o n c a u s e o f E S R D i n c h i l dr e n w h o u n de r g o t ra n s p la n t a ti o n i s c o n g en i t al m a l f o r ma t i o ns o f t h e

kidney and urinary tract (40 percent), followed by glomerular disorders (25 percent) and hereditary/genetic renal

diseases (15 percent), particularly focal glomerulosclerosis.

R e na l t ra n sp l an t at i on i s u s ua l ly a n el e ct i ve s u rg i ca l p ro c ed u re a s m o st o f do n or s a r e l i ve d o no r s r a th e r th a n

c a d e ve r i c d o n or s . I n p u ts f r o m t h e p e d ia t r i c n e p h ro l o gi s t , t r a n sp l a n t s u rg e o n a n d p e d ia t r i c i n t en s i vi s t a r ei m p e ra t i ve i n p r o v i d i ng o p t im u m p e r i o p e r at i v e c a r e t o t h e t r a n sp l a nt r e c i pi e n t.

U n i ts i n v ol v e d i n r e n a l t r a n sp l a n ta t i o n u s u a ll y ha v e d e t a il e d p r o t oc o l s o n pr e a n d p o s to p e r at i v e c a r e o f do n o rs

and recipients. These protocols are updated regularly depending on the prevailing standards of therapy.

I m m e di a t e P r e op e r a ti v e P e r i od

M o st p a ti e nt s o f E SR D a r e o n m ai n te n an c e d i al y si s p r io r t o tr a ns p la n ta t io n . T h e n e ed t o d ia l yz e t h e p a ti e nt

i m m e d ia t e l y b e f o re t r a n sp l a n ta t i o n i s g u i de d b y t h e p r e s en c e o f f lu i d ov e r l oa d , hy p e r ka l e m ia a n d da y o f l a s t

d i a l ys i s . Mo s t c en t e r s p r e f e r t o d i al y z e p a t ie n t s o n t h e e v e n in g p r io r t o tr a n s pl a n ta t i o n, m a i n ly t o p re v e n t

h y p e rk a l e mi a . I t i s e s s e nt i a l t o m a i n t a in s e r u m p o t a s s iu m l e v e l s b e l o w 5 . 5 m Eq / L t o p r e v e n t a r r hy t h mi a d u r i ng

a n es t he s ia a n d s u rg e ry. T h e i n ci d en c e o f p r eo p er a ti v e h y pe r ka l em i a i s a s h i gh a s 2 0 -3 8 p e r c e nt i n v a ri o usstudies. Potassium binding resins can be administered orally or rectally to prevent this complication.

S i g n if i c a nt v o l u m e r e d u ct i o n s h o ul d b e a v o i de d d u r i n g d i a l ys i s t o p r e v e n t i n t ra o p e ra t i ve h y p ov o l em i a . L o n g

standing uremia can cause platelet dysfunction resulting in excessive bleeding during surgery. Regular dialysis

preoperatively can ameliorate this abnormality. While anemia can lead to complications during surgery, blood

t r a n sf u s i on s s h o ul d be l i m i te d i n t h e p r e o pe r a t iv e p e r i od t o p r e v en t a ll o i m mu n i za t i o n a n d th e r i s k o f g ra f t

r e j e c ti o n . T r an s f us i o ns c a n b e g i v e n i f n e c es s a r y d u r in g s u rg e r y. A h e m a to c r i t l e v e l a b o v e 3 5 p e rc e n t is

acceptable. Most patients undergoing transplantation are on treatment with iron, folic acid and erythropoietin,

which maintains hematocrit in this range.


Ad v an c e s in Tr a n sp la n ta tio n



A d e t a il e d c l i n ic a l e x a m i na t i on s h o u l d b e d o n e t o e n s u r e f i t ne s s f o r s u r g er y. F r e s h c r o s s m a tc h o f p a t i e n t s e r a f o r

anti HLAantibodies, against donor mononuclear cells, is done by flowcytometry or ELISA 1-2 days prior to the

s u rg e r y. Tw o u n i ts o f b l o od a r e a r r a ng e d f r om t h e b l o od b a n k . A c h e s t X- r a y i s d o n e t o r u l e o u t a n y in f e c ti o n o r

f l u i d o v e r lo a d a n d e l e c tr o c a rd i o gr a m f o r a r r h yt h m ia . U r i n al y s is a n d c u l t ur e a r e o b t a in e d 2 - 3 d a y s b e f o re

transplantation.

B l o o d s a m p le s a r e t a k e n f o r c o m pl e t e b l o od c o u n t s , e l e ct r o l yt e s a n d b l o o d g a se s p r i or t o s u r g e r y. E s t i m a t io n o f

bleeding time, clotting time and prothrombin time is also necessary. Consent from the prospective donor and

recipient is taken on appropriate forms.

Surgery

I n i n f a n ts a n d y o u ng c h i l dr e n t h e a l l o gr a f t i s p l a c ed i n t r a -a b d o mi n a l ly. T h e r e n a l a r te r y i s c o n n ec t e d t o t h e a o r t a

a n d r e na l v e in t o t he i n f e ri o r v en a c a v a . I n o l d er c h i ld r e n th e g r a f t i s p l a c ed i n t he i l i a c f o s s a a n d t he r e n a l a r t e r y

a n d v e i n a r e c o n n ec t e d t o c o m mo n o r e x t e r na l i l i a c a r t e ry a n d v e i n r e s pe c t i ve l y. A d va n c e m en t s i n t h e v a s c ul a r

t e c h ni q u e s h a v e d e c r e as e d t h e i n c i de n c e o f a l l o gr a f t l o ss d u e t o v a s c ul a r t h r om b o s is . T h e u r e t er i s a n a s to m o s ed

t o t h e b l a dd e r u s i n g u r e t er o - n eo c y st o s to m y. T h e a r t e r ia l s u p p l y o f l o w e r u r e t e r ic s e g m e nt s h o u l d b e p r e s er v e d

a s i s ch e mi a h e re c a n c a us e u r et e ra l o bs t ru c ti o n or u r in a ry l e ak s . Wi t h st r in g en t a se p ti c p r ac t ic e s a n d us e o f

perioperative antibiotics, wound infections have become uncommon.

P r e - t ra n s p la n t n a t i ve k i d ne y n e p h r ec t o m y/ n e p h r ou r e t er e c t om y a r e n o l o n g er a r o u ti n e p r o c ed u r e . T he n a t i ve

k i d ne y s a r e l e f t i n p la c e b e c a us e t h e y s ti l l m a y p r od u c e s i g ni f i c an t v o l um e s o f u r i n e, s e c r e t e e r y t hr o p oi e t i n a nd

convert vitamin D to its active metabolites. Unilateral or bilateral nephrectomy/nephroureterectomy is done in

specific instances, such as large polycystic kidneys, significant proteinuria, poorly controlled hypertension and

chronically infected kidneys.

I n t r ao p e r at i v e m a n a ge m e n t i n c lu d e s a p p r op r i a te f l u id t h e r ap y a n d a d m i ni s t ra t i o n o f i m m u no s u pp r e s si v ed r u g s, d i u re t i c s a n d a n t i bi o t ic s . G oo d h yd r a t io n i s i m p or t a n t t o e ns u r e a d e q ua t e b l o od f l o w t o t he a l l og r a f t. A

s l u gg i s h f l o w c a n p r om o t e i t s t h r o mb o s is a n d a c ut e t u b ul a r n ec r o s is . T he c e n t r al v e n ou s p r e s su r e ( C V P ) sh o u ld

be monitored and maintained between 10-12 cms of water during and after surgery. A good peripheral venous

access should be established to deal with copious fluid replacement. Mannitol (0.5 g/kg) is given intravenously

i n t he t h e a tr e b e f o re t h e a r t e ri a l c la m p t o d o n or k i dn e y is r e l e as e d f ol l o we d b y i n t ra v e n ou s f r u s em i d e a t a d o s e

o f 1 - 2 m g /k g . T hi s c a u s es b r i s k di u r e si s a n d p r e ve n t s g r a f t is c h e mi a . T he a p p e ar a n c e o f t h e r e n a l a ll o g ra f t a f t er

c o m p le t i on o f t h e a n a s to m o si s , a n d r e l e as e o f v a s c u la r c l a m p s s h o ul d b e r e c o r de d i n t h e n o t es . I n t r a op e r a ti v e

perfusion characteristics of the graft and intraoperative urine volume are good predictors of graft function.

Postoperative Period

T h e t r a n sp l a nt t e am s h ou l d e v a l ua t e t h e p a t i en t on a r r iv a l fr o m th e o p e r at i n g r o o m . T h e i n i ti a l as s e ss m e n t

s h o ul d i n c lu d e h e m o dy n a m ic a n d r e s p i r a to r y s t a b i l it y. M o s t p a t i e n ts a r e a w a k e a n d e x t u b a t ed .

T h e p r i m ar y g o a l d u r in g i m m e di a t e p o s to p e r at i v e p e r i od is t o p r o m ot e a n d m a i n ta i n r e n a l p e r f us i o n a n d

diuresis. This is achieved by administration of a combination of crystalloid and colloid solutions to replace urine

o u t pu t , i n s en s i bl e l o s se s , g a s t ro i n te s t in a l a n d t h i rd sp a c e l o s se s . T h e p a t i en t r e q u ir e s c l o s e h e m o dy n a m ic

m o ni t or i ng a n d m et i cu l ou s f l ui d m a na g em e nt i n a n i n t en s iv e c a re u n it . D e ta i ls o f r o ut i ne m o ni t or i ng a n d

e v a l ua t i on d u r i n g t h e f i r s t 4 8 h ou r s i s m e n t io n e d i n Ta b l e 1 .

ADVANCES I N TRANSPLANTATI ON Pediat ric Renal Transplant ation




Ta b l e 1

Monitoring of transplant recipients during first 48-72 hoursU r i n e o u t pu t e v e ry 3 0 m i nu t e s f o r 6 - 8 ho u r s a n d t he n e v e ry h o u r ly

Blood pressure every 30 minutes for first 6 hours, every hourly for 24 hours and then 6 hourly

C V P * e v e ry h o u r l y f o r i n i ti a l 1 2 h o u rs a n d t h e n 4 - 6 h ou r l y

Temperature hourly for initial 4 hours and then every 6 hourly

We i gh t o n ce a d a y

H e m o gl o b in a n d co m p l et e c o u nt s d a i ly

Blood sugar, urea, creatinine, electrolytes, calcium, phosphate, bicarbonate every 12 hourly

* C V P -C e n t ra l v e n ou s p r e s su r e

Fluid Management

I t i s d e s i ra b l e t o m a i n t a i n a d e qu a t e h y d ra t i o n t o p r e v e n t h y p ov o l em i a a n d g r a f t d y s f u nc t i o n. T h e C V P s h o u ld b e

m a in t ai n ed a t 1 0 -1 2 c m s o f w a te r. C a r ef u l m on i to r in g o f h ea r t r at e a n d b lo o d pr e ss u re a l so d e te c ts a n y

hypovolemic episodes. A detailed record of urinary output and drain volumes is maintained. Pediatric recipients

o f a d u l t k i d n e y f r e q u en t l y p r o d uc e l a r ge v o l um e s o f u r i n e d u r i ng i m m e d i a t e p o s t- o p e r at i v e p e r i od . U r i n e o u t pu t

i s r e p l ac e d w i t h 5 p e r c e nt d e x t ro s e i n 0 . 4 5 p e r c e nt s a l i n e a n d 1 0 m l s o d iu m b i c a rb o n at e p e r l i t er , o n a v o l um e

f o r v o l um e , h o u r ly b a s i s . I n se n s i bl e w a t e r l o ss e s a r e e l e c t ro l y te f r e e , a n d a r e r e p l ac e d w i t h 5 p e r c e n t d ex t r os e

s o l u ti o n . B l o od l o s s i n c ur r e d d u r i ng a n d a f t e r s u r g er y i s a l s o r e p la c e d . M a i nt e n a nc e p o t a ss i u m i s a d d e d w h en

serum potassium falls below 3.5mEq/L.

M a in t ai n in g a d eq u at e s y st e mi c p r es s ur e i s i m pe r at i ve , s i nc e , t h e a l lo g ra f t i s v e ry se n si t iv e t o e v en br i ef

e p i s od e s o f hy p o pe r f u si o n . D o p a mi n e m a y be i n f u se d a t a r a t e o f 5- 8 µ g/ k g /m i n to m a in t a i n a m e a n a r t e r ia l

pressure above 80 mmHg. The rates of infusion can be increased to 10µg/kg/min. While low dose dopamine is

f r eq u en t ly u se d in a n u mb e r o f tr a ns p la n t u n it s , f o r t h e f i rs t 48 h ou r s, t he b e ne f it s o f th i s p r ac t ic e a r e

controversial.

I n pa t i e nt s h a v in g o l i gu r i a a f t e r t h e s u r ge r y, i f th e u r i n e v o l um e i s b e l o w 2 m l/ k g /h o u r a n d C V P m e a s ur e s a b o v e

1 2 c ms t he n a s in gl e d os e o f fu ro se mi de ( 1 mg /k g) i s g iv en . If t he C VP m ea su re s b el ow 1 0 cm s, a b ol us o f 10

m l / k g n o r m al s a l i n e o r 5 - 1 0 m l / k g 5 p e r c e n t a l bu m i n i s a d m i ni s t er e d . B e s i de s t h e C V P, c l i n i c a l s t at u s a n d c h e s t

X - ra y a r e a l so g o od m e as u re o f v o lu m e o v er l oa d . I f t h e r e na l f u nc t io n s a r e d e ra n ge d a n d u r in e o u tp u t i s

d e c r e as e d , t h en t h e f l u i d i s a d m i ni s t e re d a s i n s e ns i b le w a t e r l os s e s ( 4 0 0 m l /m ² ) p l u s t h e u r i n e o u t pu t .

P o l y ur i a ( u r i ne v o l um e s o f > 4 m l / k g/ h r ) c a n r e s u lt i n d y s e l e c tr o l y te m i a . F o r t h e s e p a t ie n t s o n l y 5 0 - 75 p e r c e n t

o f t h e o u tp u t is r e pl a ce d e v er y h ou r. I f u r i ne f l ow r a te s a r e m o re t h an 8 m l / kg / hr, t h e n th e d e xt r os e c o nt e nt o f

r e p l ac e m e n t f l u i d s h o u ld b e r e d u ce d t o 2 . 5 pe r c e nt . Th i s r e p l a ce m e n t i s c o n ti n u e d f o r f ir s t 48 h ou r s . If

h y pe rg l yc e mi a o r gl u co s ur i a o c cu r s, p la i n i n su l in c an be u s ed a s a n in t ra v en o us d r ip or in t er m it t en t

s u b c u t a n e o u s b o l u s e s ( o n e u n i t o f p l a i n i n s u l i n n e u t r a l i z e s a b o u t 3 - 4 g o f d e x t r o s e ) .

H y p oc a l c e mi a m a y a l s o oc c u r a nd s h ou l d b e m o n i to r e d cl o s e ly. U r i n ar y p h os p h a te w a s ti n g o ft e n r es u l t s i n

h y p op h o sp h a t em i a . P h o s ph a t e s u p pl e m e nt s s h o ul d b e g i v e n i f s e r u m p h o sp h a t e l e v e ls a r e b e l o w 3 . 5 m g / d L.

A f t e r 4 8 h ou r s i f t he k i d ne y f u nc t i o n t e s ts a r e n o r m a l, t h e f l u i ds a r e r e d u ce d t o h a l f o f t he u r i ne o u t pu t . B y d a y 3

to 5 most children with satisfactory graft function do not require intravenous replacement of urinary fluid losses.





Fluid requirements are met with ad-lib administration of oral fluids.

H y pe r te n si o n i s c o mm o n i n th e i m me d ia t e p o st - tr a ns p la n t p e ri o d. D ur i ng t he f i rs t mo n th f ol l ow i ngtransplantation, it occurs in 80 and 60 percent of recipients of allografts from deceased and living related donors,

r e s p ec t i v el y. B u t t h e i n c i de n c e d e c r ea s e s w i t h t i m e . T h e e t i o lo g y i s m u l ti f a c to r i a l a n d i n c lu d e s p r e - e xi s t in g

h y p e rt e n si o n , v o l um e o v e r lo a d a n d m e d i c a ti o n s l i k e s t e r oi d s a n d c y c l os p o r in e . H y p e r te n s i on c a n b e m a n a ge d

w i t h t he u s e o f c a l c i um c h a n n el b l o c k er s l i k e s u s ta i n e d r el e a s e p r e p ar a t i on o f n i f e d ip i n e ( 0 . 5 -2 m g / k g d ai l y ) o r

a m lo d ip i ne ( 0 .1 - 0. 5 m g/ k g/ d ay ) . Ot h er m e di c at i on s t h at c a n b e u s ed a r e b e ta - ad r en e rg i c a n ta g on i st s l i ke

atenolol (1-2 mg/kg/d), alpha-receptor blocker prazosin (0.1-0.4 mg/kg/d) or a central adrenergic agonist

c l o n id i n e ( 1 0 - 40 µ g /k g / d) . A C E in h i bi t o r s s h o u ld b e a v o id e d i n t h e i m m e di a t e p o s t- t r a ns p l a nt p e r io d a s t h e y

m a y d e c r ea s e t h e p e r f us i o n o f t h e a l l o gr a f t .

Complications

Impaired graft function frequently complicates the initial post-transplant period. Early non-function with oligo-

a n u r ia c h i e fl y r e f l e ct s p r e - tr a n s pl a n t e v e nt s t h a t h a v e c o m p ro m i s ed g r a f t f u n c ti o n . T h es e i n c l ud e h y p ov o l e mi a

in the donor or recipient, unrecognized recipient immunity against donor tissue or complications of the surgical

procedure.

O l i go a n u ri a i n t he i m m e d ia t e p o s t- t r a ns p l an t p e ri o d sh o u ld b e t h o r ou g h ly e v a lu a t e d. Al l p r e a n d p os t - r en a l

c a u s es s h o ul d b e e x c l ud e d . D e c r e as e d i n t r av a s c ul a r v o l um e i s t h e c h i e f p r e - r en a l c a u s e o f g r a f t d y s f un c t io n .

C o m m on c a u s e s o f e a r l y g r a ft d y s f u nc t i o n a r e m e n t io n e d i n Ta b l e 2 . P r e - r e na l d y s f un c t io n i s m a n a ge d w i t h

administration of intravenous fluid boluses and is usually reversible.

Ta b l e 2

Causes of early allograft rejection

Hypovolemia

A c u te t u b u la r n e c r o s is

H y p er a c u te , a c u t e r e j e c ti o n

Catheter obstruction

Arterial or venous thrombosis

U r in e l e ak

H e m a tu r i a i s a n e x p e c t ed c o n s e q ue n c e o f u r e t e r a l t r an s p l an t a t io n a n d i f a s s o c i a te d w i t h p o o r u r i n a ry f l o w c a nresult in clot formation and obstruction of urinary catheter. Catheter obstruction also increases intraluminal

pressure in the bladder, thereby threatening the ureteral anastomosis. Bladder catheter should be irrigated,

f l u sh e d a nd i f ne c e s s ar y, c h a ng e d . If t h is d o e s n o t al l e v ia t e t h e o l i g ur i a o r g ro s s h e m a tu r i a , a r e n a l u l t r as o u nd

s h o ul d b e d o n e t o r u l e o u t ur e t e ra l o b st r u c ti o n a nd / o r di l a t at i o n o f t h e r e n a l g r a f t p e l vi s . P r es e n c e o f u r et e r a l

o b st r uc t io n ma y re q ui r e s u rg i ca l in t er v en t io n . I f ol i go a nu r ia p e rs i st s d e sp i te t h es e m e as u re s a c ut e t u bu l ar

necrosis (ATN) or vascular thrombosis (arterial or venous) should be suspected.

AT N c om mo nl y o cc ur s d ue t o p er si st en t h yp ov ol em ia o r p ro lo ng ed c o ld i s ch em ia t im e. T h is i s u su al ly

reversible.







cytomegalovirus infection and cyclosporin toxicity. Besides infection screen and cyclosporin blood levels, an

ultra-sound doppler and a nuclear scan often help in distinguishing between these conditions. Graft biopsy is

h o w e ve r e s s e n t ia l t o e s t a bl i s h t h e d i a gn o s i s o f r e j e c t i on . A b ou t 7 5 p e r c e n t o f t h e s e r e j e c ti o n e p i s od e s r e v e r se o n

treatment with methyl-prednisolone. Treatment with monoclonal antibodies (OKT3) is recommended for

treatment of patients who do not respond to treatment with steroids.

Other Complications

P a t i en t s s h o ul d b e a m b u la t e d b y 2 4- 4 8 h o u rs a n d s h ou l d s t ar t o n a l i q ui d d i e t b y t he t h i r d da y. M i l d t o m o d er a t e

pain may occur at the incision site in the first week. Severe pain or absence of bowel sounds by 48-72 hours

s h ou l d b e i n ve s ti g at e d t o e x cl u de r e je c ti o n, p e r in e ph r ic h e ma t om a a n d u ri n ar y l e ak . F e v er i n t h e f i rs t w e ek

could be due to postoperative complications like atelectasis, wound, urinary tract or central line infections. More

t h a n 9 0 p e r c e nt i n f e ct i o ns i n t h e f i r s t p o s t- t r a ns p l a nt m o n t h ar e d u e t o p r o bl e m s r e l a te d t o s ur g e ry, d r a i ns a n d

catheter.

M o s t o pp o r t un i s t ic i n f e ct i o n s a r e u n c om m o n d u ri n g t h is p e r i od a n d u s u al l y o c cu r b e y on d t h e f i r s t 2 m o nt h s o f

s u rg e ry. T h e se i n cl u de i n fe c ti o ns d u e t o c y t om e ga l ov i ru s , E bs t ei n -B a rr v i r us , B K ( p ol y om a vi r us ) v i ru s ,

m yc ob ac te ri a a nd p at ho ge ni c p ro to zo a l ik e t ox op la sm a a nd p ne um oc ys ti s. T he se p at ie nt s a re a ls o m or e

predisposed to fungal infections including cryptococcosis and aspergillosis.

Diagnosing these infections is often difficult due to concomitant immunosupression. A high index of suspicion

i s t h u s n e c e ss a r y.

Immunosuppression

T h e g o a l o f i m m u n os u p pr e s s io n i s t o p r e v e nt a c u t e r e j e c ti o n w h i l e m i n i mi z i n g t h e d r u g s i d e e f f e ct s . I n c h i l d r en

who undergo renal transplantation, immunosuppression is divided into the three following categories:

● Induction therapy – Intensive immunosuppression administered during the perioperative period to prevent

a c u t e r e j e c ti o n

● M a i n te n a n ce t h e r ap y – I m m u no s u pp r e s si v e t h e r ap y to p re v e n t a c u t e r e j e ct i o n a f t e r t h e p e r i op e r a ti v e

period

● Treatment of acute rejection – Immunosuppressive therapy to treat acute rejection

I n g e n e r a l, i m m u n o s up p r e ss i o n s h o ul d b e h i g he s t d u r i ng t h e f i r s t t h r ee m o n th s a f t e r t r a n sp l a nt a t i on w h e n t h e

risk of acute rejection and allograft loss is greatest. Immunosuppression is tapered slowly to a maintenance level

by 6 to 12 months post-transplantation.

M o s t c e nt e r s f o l lo w a n i m m u no s u pp r e s si o n p r ot o c ol c o m p r is i n g a n in d u c ti o n w it h An t i -t h y m oc y t e

globulin/OKT3/Alemtuzumab/basiliximab followed by maintenance with combination of corticosteroids,

a n t i me t a b ol i t e s ( a z a t hi o p r in e / M M F) a n d c a l c in e u r in i nh i b i to r ( cy c l os p o r in e / t ac r o l im u s ) ; h o w e ve r,

i m m u no s u pp r e s si o n m a y re q u ir e m o d if i c a t io n s a s p e r p a ti e n t 's c h a r ac t e r is t i c s. I m m u n os u p pr e s s io n i s b e g u n

1 2 h o ur s p r io r t o t h e t r an s pl a nt w i t h or a l c yc l os p or i ne a n d a za t hi o pr i ne a t d o se s o f 7 . 5m g /k g a n d 5m g /k g

r e s p ec t i v el y. I n t r a ve n o u s m e t h yl p r e dn i s o lo n e i s i n f u se d a t d os e s o f 1 0 m g/ k g ( di l u te d i n n or m a l s al i n e a n d

g i v e n o v e r 2 0 - 3 0 m i n ut e s ) , t w o h o u r s p r i or t o t h e s u rg e r y. T he n e x t d o s e o f cy c l o sp o r i ne a n d az a t h io p r i ne i s

administered 6-8 hours following surgery. Therapy with oral prednisolone is started from the next day at doses

of 2 mg/kg/day, with a gradual reduction to approximately 0.12 to 0.16 mg/kg per day within a 6 to 12 month





period. Alternate-day dosing is often administered 6 to 12 months post-transplant to minimize the effect of

c o r t ic o s te r o i ds o n g r o wt h . C yc l o sp o r i ne i s a d m i ni s t e re d a t t h e d o s e o f 1 0- 1 2 m g/ k g /d a y f or t h e f i r s t f o r t ni g h t

a n d t h en t a p er e d t o 8 -1 0 m g /k g /d a y o ve r t h e n e xt t w o w e ek s . A z at h io p ri n e i s c o nt i nu e d a t d os e s o f 1 - 2

m g / k g/ d a y. S o m e c e n t er s p r e f e r t o us e t a c r ol i m us , a n o t he r c a l c i ne u r i n i nh i b i to r i n s te a d o f c y c l os p o r in e .

Mycophenolate mofetil (MMF) has replaced azathioprine in most transplant centers in the developed countries.

T hi s d ru g i s a m or e s pe ci fi c i nh ib it or o f l ym ph oc yt e p ro li fe ra ti on a nd h as l es s b on e m ar ro w t ox ic it y.

R a n d om i z e d t r i a ls h a v e s h o wn t h a t t h e u s e o f t a c r ol i m u s a n d M M F i s s u p e ri o r t o c y cl o s po r i n e a n d a z a th i o pr i n e

r e s p ec t i v el y i n t h e p r e v en t i on o f a c u t e r e j e ct i o n e p i s o de s a n d c h r o n i c a l l o gr a f t n e p h r o p at h y.

Monitoring

U r i n e o u t pu t i s c a r e f ul l y m o n i to r e d d u r in g t h e f i r s t 3 - 4 d a y s o f s u r g e ry. T h e b l a d de r c a t h e t e r i s u s u a ll y r e m o v e d

after 48 hours. Vitals are initially monitored every 30-60 minutes and then 2 hourly. The central venous pressure

i s i n i ti a l l y m e a s u re d h o u rl y a n d t he n 6 h o u r ly. I f b l o o d p re s s ur e a n d u r in e o u t pu t i s n o r m al , t h e C V P c a t h e te r i sremoved after 48-72 hours. A rise of body temperature may occur because of infection or rejection. Blood levels

of urea, creatinine, sodium, potassium, calcium, phosphate, hemoglobin and counts are measured every 12

h o u rs i n i ti a l ly a n d t h e n o n c e d a i ly. A b l o od c y cl o s po r i n e l e v e l ( C 2 le v e l or t r o ug h ) is d o n e a t t he e n d of f i r st

week. The accepted 12-hour trough levels of cyclosporine are between 250-300 ng/ml in the first two transplant

m o n t hs . R e c e n tl y p e a k d r u g l e ve l s ( C 2 ) , 2 h o u r s a f t e r o r al d o s i n g a r e m e a s ur e d a t m a n y c e n te r s . T h es e l e v e ls

c o r r el a t e b e t t er w i th d r ug e x po s u r e a s c o m p ar e d to t r o ug h l e ve l s a n d th e a c c e p te d t a rg e t l ev e l s i n t he f i r s t t w o

months of transplant vary between 1500-2000 ng/ml. The trough levels vary with the methodology of testing.

H i g h p e r f or m a n c e l i q ui d c h ro m a t og r a p hy ( H P LC ) i s t h e m o s t s p e c if i c m e t h od t o m ea s u r e t h e u n m e ta b o l iz e d

d r u g . O t h e r m e t h o d s l i k e r a d i o i m m u n o a s s a y a n d e n z y m e l i n k e d i m m u n o a b s o r b e n t

a s s a y a re c h e a pe r a n d e a s i er t o p e r f o r m t ho u g h t h ey o v e r e st i m a te t h e d r u g l e ve l s b y a l m o st 2 0 - 3 0 p e rc e n t . A

D T PA s c a n i s d o n e t o a s s e ss g r a f t f u n c ti o n a f t e r 7 2 h o u r s. I f t h e r e a r e n o c o m p li c a t io n s i n t h e p o s t- o p e ra t i v e period, most patients are ready for the discharge by the second week of surgery.

After discharge, graft function should be assessed at least thrice weekly for 2 weeks, twice weekly and weekly

for a month each, and then at monthly intervals.

O t h e r M e d i c a t i on s

A n ti b io t ic p r op h yl a xi s w i th c e ph a lo s po r in s i s g i ve n f o r t h e i n it i al 3 - 5 d a ys . U r in a ry p r op h yl a xi s w i th

c o tr i mo x az o le ( 2 mg / kg t r im e th o pr i m) i s b e gu n w h en t h e s e ru m c r ea t in i ne f a ll s b e lo w 1 . 5 m g /d L a n d i s

c on ti nu ed f o r t hr ee t o s ix m o nt hs ; t hi s a ls o p re ve nt s o pp or tu ni st ic i nf ec ti on s w it h p ne um oc ys ti s a nd

t o x op l a sm a . O r a l a n ti f u n ga l p r o ph y l a xi s w i t h n ys t a t in / f l uc o n a z ol e i s a l s o g iv e n d u r in g t h i s p e r i od . P a i n i s

r e l i ev e d u si n g p ar a c e ta m o l . Pr o p h yl a x i s a g a i ns t a c id p e p ti c d i s e as e i s p r o vi d e d wi t h h is t a m in e - 2 re c e p to r blockers or proton pump inhibitors for 1-2 months. Ganciclovir prophylaxis for cytomegalovirus disease is

usually reserved for high-risk patients (donor positive; recipient negative serology). The prophylaxis for such

patients is given intravenously with ganciclovir for the first 2 weeks and then orally with either ganciclovir or

valganciclovir for 3 months.

Survival

O v e r f ew d e c a de s , t h er e h a s b e e n gr a d u al b u t s t e ad y i m pr o v e me n t i n gr a f t s ur v i v al a s a r e s u lt o f i n tr o d u ct i o n

a n d w i d e s pr e a d u s e o f c a l c i n e ur i n i n h i b it o r s a n d o t h e r i m m u n os u p pr e s s iv e a g e n ts . A s p e r t h e 2 0 1 0 N A P RT C S







R o le o f E c h o ca r di o gr a ph y

i n t he c r it ic al ly i ll c hi ld D r. J h u m a S a n k ar, M D

D e p ar t m en t o f P e d i at r i cs ; P GI M E R, D r RM L H o s p it a l , N e w D e l h i, I n d i a

Introduction

M o n i to r i ng o f p h y s i ol o g ic v a r i ab l e s i s a n e s s e n ti a l p a r t o f p r o vi d i n g c r it i c a l c a re . I t i s i m p o rt a n t n o t o nl y f o r

a s s e ss i n g t h e c o n di t i on o f t h e p a t i en t o n a c o n t in u o us a n d r ea l t i m e b a s i s, b u t a ls o p r ov i d e s v i t al c l u e s t h a t ma y

h e l p i n d i a g no s i s a n d t r e a t me n t . A l t ho u g h, t h e i m p o rt a n c e o f t h e c l i n ic a l m o ni t o r, i . e . t h e c r i t ic a l c a re p h y si c i a nc a n n ot b e r e p l ac e d a nd w i ll a l w ay s b e t h e c o r n er s t on e o f m o de r n d ay i n t en s i ve c a r e , it i s n o t wi t h ou t i ts s h a r e o f

i n a c cu r a c ie s . T h e re f o r e, u t i l i ty o f s i m p l e b e d s id e i n v a si v e a n d n o n -i n v a si v e m o n it o r i ng d e v i ce s t o a d d t o t h e

c l in i ca l ju d ge m en t is i n cr e as i ng l y b e in g re c og n iz e d a s i m po r ta n t. I m po r ta n t a m on g t h es e a r e t o ol s f o r

m o n i to r i ng o x yg e n a ti o n su c h a s p u l se o x i m et r y ( no w r e g a rd e d a s t h e f i f t h v i t al s i g n) , a r t er i a l bl o o d g a s e s;

d e v i ce s f o r m o n it o r i ng v e n t il a t io n s u c h as c a p n om e t r y , t r an s c ut a n e ou s C O ; t o o l s f o r m o n it o r i ng p e r f us i o n2

s u c h a s t r a n sc u t a ne o u s o x y ge n m o n it o r i ng ( P t c O / P a O ) , g a s t ri c i n t r am u c o sa l p H , m i x e d v e n ou s / c en t r a l2 2

1, 2v e n o us o x y ge n sa t u r at i o n ( c o n ti n u ou s / i n t e rm i t t en t ) e t c . . S om e o f t h e p r o c ed u r e s f o r m o n i to r i ng pe r f u si o n

a n d/ o r t i ss u e o x yg e na t io n a r e i n va s iv e a n d m a y e n d u p w i th co m pl i ca t io n s w h ic h ma y b e co m e m o re

c u m b er s o m e t h a n t he p r i m ar y i l ln e s s i t s e lf . T h e c o n c ep t o f n o ni n v a si v e h e m o dy n a m ic m o n it o r i ng i s t h e r ef o r e

g a in i ng a c ce p ta n ce a n d p o pu l ar i ty wo r ld w id e . N o n- i nv a si v e h e mo d yn a mi c m o ni t or i ng h el p s i n ea r ly

r e co g ni t io n o f lo w f l ow s t at e s t h us a l lo w in g f or e a r ly t h er a pe u ti c i n te r ve n ti o n. I t i s e a si e r, q u ic k er , le s s

expensive, and safer than invasive monitoring. Two methods of noninvasive hemodynamic monitoring widely3, 4

used and popular are bedside ultrasound (BUS) and echocardiography .

T he se a re t he e vo lv in g t oo ls f or p e di at ri c i nt en si vi st s, n o t o nl y u se fu l f or n o ni nv as iv e h em od yn am ic

m o n i to r i n g su c h a s a s s e ss m e n t o f v ol u m e s t a tu s a n d c a r di a c f u n c ti o n i n t h e p a t i en t w i t h sh o c k , b ut a l s o h a ve

wide applicability such as in evaluation of several disease processes, assist in procedural interventions, assess

t h e c o mp l i i o ns r e la t ed t o t h os e p r oc e du r es e t c. I n t h is r e vi e w w e w o ul d b e l i mi t in g o u r d i sc u ss i on t o t h e u s e3

of echocardiography in the critically ill child .

Echocardiography-principles

Echocardiography is an essential monitoring tool in critical care. It provides vital information regarding theh e m o dy n a m ic s o f a c r i t ic a l l y i ll c h i l d a nd s h o u ld b e p e r f or m e d i n a t i m e ly m a n n e r i n or d e r t o i n te r v e ne e a r l y.

E c h o ca r d i og r a p hy a l l ow s a s s e ss m e n t o f ba s e l in e c a r d ia c s t r uc t u r e a n d f u n c ti o n a n d q u i c kl y ex c l ud e s e a r l y,

t r e a ta b l e c a u s e o f s h o c k s u c h a s t a m p on a d e . I t a l s o h e l p s e s t a bl i s h i f t h e s h o c k i s o f c a r d io g e n ic n a t u re d u e t o a3

s t r u ct u r a l h e a r t d i s ea s e .

Additional hemodynamic information such as cardiac output (CO), end-diastolic volume, global and regional3, 5- 8

ventricular function, and valvular abnormalities can also be obtained . The systolic function can be assessed

by the shortening fraction and the ejection fraction measured with the use of M-mode or cross-sectional two-

d i m e ns i o na l i m a g es . M e a s u re m e n ts f r o m D o p pl e r -d e r i ve d a o r t ic v e l oc i t y c u r v es h a v e b e e n u s e d t o a s s e ss

cat

N on In va si ve L if e S av er s




systolic function, including peak velocity, acceleration time, ejection time, isovolemic contraction time, and the

v e lo c it y -t i me i n te g ra l . I n di c es d e ri v ed f ro m th e se m e as u re s i n cl u de p e ak r at e o f ac c el e ra t io n a n d m e an

a c c e le r a t io n , w h ic h c o r r e la t e w i t h sy s t o li c p e r f or m a n c e. T h e r a t i os o f a c c e le r a t i on t i m e t o e j e c ti o n t im e a n d o f3, 5, 6

i s o vo l e m ic c o n t ra c t i on t i m e t o a c c e le r a t io n t i m e a l s o m a y b e u s e d a s i n d ic e s o f v e n tr i c u la r f u n c ti o n . T h e

d i a st o l ic f u n c ti o n is a s s e ss e d by s t an d a r d m e a s u re s o f v e nt r i c ul a r r el a x a ti o n or A d e n os i n e T ri p h o sp h a t e

d e p e nd e n t pa r t o f v en t r i cu l a r di a s t ol e t h a t in c l u de - E w a ve , A w a v e , E/ A r a t i o, E ′ , A ' a n d my o c a rd i a l7, 8

performance index (MPI) or Tei index by Doppler Echocardiography . Of all these parameters, early diastolic

m i t r al a n n u la r v e l o ci t y ( E ' ), a s m e a s ur e d b y t i s su e D o p pl e r i m a gi n g ( T D I) , r e f l e ct s l e f t v e nt r i c ul a r ( LV )

r e l a x at i o n a n d i s i n d ep e n d en t o f b o t h p r e lo a d a n d h e a rt r a t e ( H R ) . T he r e f o re , i t i s o f t e n t he p r e f e rr e d p a r a me t e r7

for assessing diastolic function in patients with shock . For assessing global dysfunction MPI is often preferred

a s i t c o m bi n e s f e a t ur e s o f b o th s y st o l i c a n d d ia s t ol i c f u n c ti o n . I t i s c a l c ul a t e d b y d i vi d i ng t h e t o t a l i s o vo l e m ic8

t i m e ( I V C T + I V RT ) b y t h e E j e c ti o n T im e ( E T ) .

S e v e r al n e w t e c h ni q u e s h a v e b e e n d e v el o p e d, i n c l u d in g t i s s ue D o p pl e r i m a g in g a n d c o l o r k i n es i s i m a g in g , t o7, 8

evaluate ventricular function objectively .The correlation with myocardial indices in children however, has

n o t b e e n w e l l e s t a bl i s he d . O t h e r i m p r ov e m e nt s a n d i n n o va t i o ns i n e c h o c ar d i og r a p hy i n c l ud e t h r e e-

dimensional echocardiography with volumetric data. This technology enables the delineation of mass-volume

r e l a ti o n s hi p s a n d f un c t i on , e s pe c i a ll y o f t h e r i g ht s i de o f t he h e a r t, w h ic h a r e d i f fi c u lt t o ca l c u la t e w i t h t w o1

d i m e ns i o na l t e c h ni q u e s .

U s e s o f d i a gn o s t ic e c h o c ar d i o gr a p h y

a. In the pediatric emergency department (PED)

E c h o ca r d i og r a p hy i n t h e P E D c a n b e u s e d f or t w o m a in p u r p os e s . F ir s t , i t c an b e u s e d t o he l p d i ff e r e nt i a t e t h ec a u s es o f s h o c k. I t c a n p r o v id e i n f or m a t io n o n c a r d ia c w a l l m o ti o n , c h am b e r s i ze , a n d p e r ic a r d ia l f l u i d.

E n l a rg e d v e n tr i c u la r c h a m be r s a n d h y p ok i n es i s m a y b e e v i d en c e o f v e n t ri c u la r f a i l ur e , w h e r ea s s m a l l h e a r t

c h a m be r s a n d h y p er k i n es i s m a y s u g g es t h y p o vo l e m ic s h o ck . E c h o c ar d i o gr a p h y p er f o r m ed b y e m e r g e nc y

physicians has been shown to be able to detect even small quantities of pericardial fluid easily. The rapid

e x c l us i o n o f p e ri c a r di a l ef f u si o n as t h e c a u s e o f s ho c k c a n al l o w t h e p h y si c i a n t o en t e r ta i n ot h e r c a u s es m o r e

quickly, whereas ultrasound can be used to help guide pericardiocentesis.

A s e co n d a p pl i ca t io n o f ec h oc a rd i og r ap h y i n th e E D i s i n c a se s o f pu l se l es s e l ec t ri c al ac t iv i ty ( PE A ).

Echocardiography showing visible cardiac activity in the patient with PEA should prompt an aggressive search

for a reversible cause (ie, tension pneumothorax, hypovolemia, and cardiac tamponade). Conversely, absence

o f c a r d ia c a c t i vi t y i s a p o o r p r og n o st i c s i g n a nd m a y p r o m pt e a r l y c e ss a t i on o f r e s u s ci t a t iv e e f f or t s . T he r e h a v e

a l s o b e e n a n e c do t a l r e p o rt s o f e m e r g en t e c h o c a rd i o gr a p h y p e r f or m e d i n t h e E D c o n t ri b u ti n g t o t h e d i a g no s i s o fa n d s u r vi v a l f r om m y o c a r di a l r u p tu r e a s a r e s u lt o f b l u n t c a r di a c t r a u ma , p e n e t ra t i ng t r a u m a , o r m y oc a r d ia l

infarction (2).

b. In the pediatric intensive care unit (PICU)

B e d s id e e c h o ca r d i og r a p hy p e r f o r m e d b y i n t en s i v is t s i s g a i n in g i n c r e a si n g p o p ul a r i ty a s a w a y o f d e t e r m i ni n g

s e p s is i n d uc e d my o c a rd i a l d y s f un c t i on o r S I M D a n d v o l um e s t a t us e a r l y i n th e c o u r se o f il l n e ss . E s ti m a t in g

myocardial performance and intravascular volume status from clinical examination may be difficult in patients

w i t h s ep t i c s h o ck w h o h a v e n o t r e s po n d e d t o 40 - 6 0 m l /k g f l u id a n d a r e a l s o o n i no t r o pe a n d /o r v a s o pr e s s or

N O N I N VA SI V E L I FE S AV E RS Role of Echocardiography in t he critically ill child




c o m b in a t i on . U n d e r t he s e c i r c um s t a nc e s , e c h oc a r d io g r a ph i c a s s e ss m e n t m a y b e u s e f ul i n d e l i n ea t i ng t h e

h e te r og e ne o us c a rd i ov a sc u la r p r of i le s . H o we v er , e x pe r ie n ce w i th t h e u s e o f t h is t e ch n iq u e i s l i mi t ed i n

pediatric septic shock. The limited evidence available shows favourable outcomes in terms of mortality in

patients intervened. In a prospective observational study of patients with unresolved septic shock after infusion9

o f 40 m l/ k g f l ui d i n th e f i rs t ho u r b y R a nj i t S e t a l , t h e a u th o rs m a de t h e f o ll o wi n g o b se r va t io n s . F if t y s i x

percent were found to be in warm shock and 44% in cold shock. The most common echocardiography findings

were impaired left ventricular function with or without right ventricular function in 40% of the patients and

h y p ov o l em i a i n 3 3 % . E c h oc a r d io g r a ph y, a l o n g w i t h i n va s i v e a r t e ri a l p r e s su r e m o n i to r i n g, a l l o w e d f l ui d ,

inotropy, and vasopressors to be titrated more precisely in 87.5% of patients. Shock resolved in 46 of 48 patients

(96%) and 44 patients (91.6%) survived to discharge. The authors thus concluded that echocardiography was a

s i m pl e n o n in v a s iv e t o o l to d e t e rm i n e t h e c a u s e o f l o w c a r d ia c o u t pu t a n d t he p h y si o l o gi c a l b as i s f o r a d ju s t me n t

o f t h e r a py i n p a t i en t s w h o r e m a in e d i n s h o c k d e sp i t e 4 0 m L /k g f l u i d ( 9 ). T h e p r e v al e n c e o f S I M D i n t h e i r s t ud y

w a s 3 9 . 6 % in v o lv i n g b o t h v en t r ic l e s . I n a n o th e r s t ud y o n p r e va l e n ce a n d o u tc o m e o f d i a st o l i c d y s fu n c t io n i n

children with fluid refractory septic shock (shock despite 60ml/kg fluid boluses) by our team, we observed thatt h e p r e v al e n c e o f d ia s t o li c d y s f un c t i on w as 4 1 . 1 % ( 9 5 % CI : 27 . 8 t o 54 . 4 ) a n d t h e m o r t al i t y r a t e 4 3 % i n th o s e

10with diastolic dysfunction .We also observed that those with diastolic dysfunction tended to have higher mean

C V P ( p < 0 .0 0 0 1 ). A l t ho u g h l i m i te d , th e s e o b s e rv a t i on s r e i t er a t e t h e i m p or t a n ce o f b e d s id e e c h o ca r d i og r a p hy

e a r l y i n t h e c o u r se o f i l l n e s s o f c h i l dr e n w i t h s e p t i c s h o ck s o t h a t f u r t he r i n o t r o pe s / v as o p r es s o rs a n d f l u i ds c o u l d

be titrated optimally to achieve the desired resuscitation end points.

T h e m y oc a rd i al d y s fu n ct i on s e e n i n s e ps i s i s d i ff e re n t p hy s io l og i ca l ly f r o m t h at d u e t o a c ut e f u lm i na n t

m y o c a rd i t is o r m y o c a r di t i s d u e t o o t h e r c a u s e s. M o s t p a t i e n t s w i t h S I M D a r e u n d e r f i l le d a t i n i t i a l p r e s e nt a t i on ,11,9

a s c o mp a re d t o t h os e w i th ac u te m y oc a rd i ti s d u e t o o t he r c a us e s . A s se s sm e nt of si m ul t an e ou s v o lu m e s t at u s

therefore is of utmost importance for improving outcomes. Assessment of respiratory variation in inferior vena

c a va d i am e te r o r VT I i n t he a o rt a o r l ef t v e nt r ic u la r o u tf l ow t r ac t , a s w e ll a s q u al i ta t iv e a s se s sm e nt o f l e ft

ventricle size and motion is commonly used to identify preload-dependence. With more advanced training, theintensivist can use respiratory variation of SV(stroke volume) determined by Doppler echocardiography and

3c h an g es i n S V a f te r t h e p a ss i ve l e g m a ne u ve r t o i d en t if y v o lu m e r e sp o ns i ve n es s . In a n o n- r an d om i ze d

e x p e ri m e n ta l s t u d y of 4 0 p a t i e nt s w i t h c ir c u l at o r y f a il u r e , t he a u t h or s a s s e ss e d t h e h e m o dy n a m ic p a r a m et e r s

s u c h as s t r o ke v o l um e a n d c a rd i a c i n d ex a t b a se l i n e, a f t e r p a s s iv e l e g r a is i n g, a t s e co n d b as e l in e , a n d a f t e r12

v o l u me e x p a ns i o n ( 1 0 m l/ k g no r m a l s a l in e i n f u si o n ov e r 15 m i ns ) u si n g Do p p le r e c ho c a r di o g ra p h y . T h e

h e m o dy n a m ic c h a n ge s i n d uc e d b y p a s si v e l e g r ai s i ng w e re m o n i to r e d . N e a r ly 5 0 % o f p at i e n ts h a d a c a r d ia c

i n d e x i n c r ea s e o f > 1 0% a f t er v o l um e e x p a ns i o n. T h e re w a s s i g ni f i c an t r e la t i o n b e t we e n c h an g e s i n c a rd i a c

i n d e x t o p re d i c t f lu i d r e s p on s i ve n e s s. A n i nc r e a s e i n c a r d ia c i n d ex b y > 1 0 % i n d u c ed b y p a s s iv e l e g r a i si n g12

predicted preload-dependent status with a specificity of 85% .

A p ar t f ro m th e a b ov e i n di c at i on s , ec h oc a rd i og r ap h y i n th e I C U, h as b e en u se d f or p r oc e du r es s u ch a s

confirming cannula position during pediatric extracorporeal membrane oxygenation and even for assessing13,14

c l in i ca l ly s ig n if i ca n t ab n or m al h e mi d ia p hr a gm m o ti o n . I n a s t ud y o f 10 0 p ed i at r ic p a ti e nt s r e qu i ri n g

ECMO, in nearly 12% patients with cannula position confirmed on chest X-ray, echocardiography identified13

abnormal cannula position prompting repositioning . In the other study on comparison of fluoroscopy with 2-

D echocardiography for assessing abnormal hemidiaphragm motion in 36 pediatric cardiothoracic patients, the

authors found a sensitivity and specificity of 100% and 81% respectively for echocardiography as compared to

1 0 0 a nd 7 4 % f or f l u or o s c op y. T h e ir s t u dy r e s u lt s t h e r ef o r e s u p po r t e d t h e u s e o f e c h oc a r d io g r a ph y i n t he

assessment of diaphragm function and the authors also suggested that when the diaphragm is clearly visualized14

by echo, the addition of a fluoroscopic study would not add much to the clinical value .





Conclusion

To conclude, owing to its non-invasive, portable and widespread applicability in noninvasive hemodynamicmonitoring in the PICU, echocardiography is quickly becoming a necessity rather than an optional one. For the

pediatrician caring for the acutely ill child it would greatly add to the clinical judgement if performed in a timely

a n d c o r r e ct m a n n e r. E s t i m a ti o n o f v o l u m e s t a t us , c a r d i a c o u t pu t , a n d f u n c ti o n i n p a t i e nt s w i t h c i r cu l a t or y

failure, especially in children with fluid refractory septic shock may be considered definitive indications. While

i t s u s e f o r co n f ir m a t i on o f c a n n ul a p l a c em e n t d u r i ng E C MO a n d a s s e ss m e n t o f he m i d ia p h r ag m m ot i o n

abnormalities may be considered relative indications.

F i n a ll y, t ra n s th o r a ci c e c h o ca r d i og r a p hy is a s k i ll th a t c a n b e a c h i ev e d u p t o a c e r t ai n s t a nd a r d b y m o s t

i n t en s i vi s t s. H o w e v er , w e n e e d t o r em e m b e r th a t , i n te n s i vi s t s s h o ul d n o t p er f o r m e c ho c a r di o g r am s

i n d ep e n d en t l y u nl e s s t h e y a r e c o m p re h e n si v e l y t ra i n e d a nd a c c r e d it e d . T he r e i s n o s u c h t h in g a s a “ b a s ic e c h o ”

in children. An inexperienced operator can obtain suboptimal images and misinterpret optimal ones. The

c l i ni c a l c o n s eq u e nc e s o f t h e s e m i s t ak e s c a n b e p r o f ou n d . T h er e f o r e, p r o p e r t r a i n in g a n d e x p e r t is e a r e e s s e nt i a lf o r c a r r yi n g o u t t h i s u s e f u l p r o c e du r e a t t h e b e d si d e .

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D is e as e i n I n fa n ts , C h il d re n a n d Ad o le s ce n ts : I n cl u di n g t he F e tu s a n d Yo u ng A d ul t s. 8 t h e di t io n . L on d on ;

Lippincott'sWilliams and Willkins; p. 157

7. Cui W, Roberson DA. Left Ventricular Tei Index in Children: Comparison of Tissue Doppler Imaging, Pulsed

Wa v e D o pp l er , an d M -M o de E c ho c ar d io g ra p hy N o r ma l Va l ue s . J ou r na l o f A me r ic a n S oc i et y o f

Echocardiography. 2006;19:1438-45

8 . E id e n B W, Te i C , O ' Le a ry P W, C e tt a F, S e wa r d J B . N o ng e om e tr i c q u an t it a ti v e a s se s sm e nt o f r i gh t an d le f tventricular function: Myocardial performance index in normal children and patients with Ebstein anomaly. J Am

Soc Echocardiogr. 1998;11: 849-56

9 . R a n ji t S , Ar a m G , K i ss o o n N , K a sh i f A l i M , N a tr a j R , S h r e st i S , J a y ak u m a r I , G an d h i D . M u lt i m od a l M o n it o r i ng

f o r H em o d y na m i c C a t eg o r i za t i o n an d M a n ag e m e nt o f P e d i at r i c S e p t ic S h o c k: A P i l o t Ob s e rv a t i on a l S t ud y.

Pediatr Crit Care Med. 2013 Nov 5.[Epub ahead of print]

1 0 . S a n k ar J , D as R R , D e wa n g a n S, K h i ln a n i P, J a i n A , Ya d a v D , D u b e y N. P r e va l e n ce a n d O ut c o me o f D i as t o li c

Dysfunction in Children with Fluid Refractory Septic Shock- AProspective Observational Study (in press).

1 1. B o uf e rr a ch e K , A m ie l JB , C h im o t L , et a l: I ni t ia l re s us c it a ti o n g u id e d b y t he S u rv i vi n g S e ps i s C a mp a ig n

r e co m me n da t io n s a n d ea r ly e c ho c ar d io g ra p hi c a s se s sm e nt o f h e mo d yn a mi c s i n i n te n si v e c a re u n it s e pt i c







U l t ra s ou n d i n P e d ia t ri c I n t en s iv e C a reD r. V i k r a m G a g n e ja * , D r. D h i r en G u p t a * *

*Consultant Pediatric Intensivist, MAX Hospital, Shalimar Bagh, Delhi

** Consultant Pediatric Intensivist, SGR Hospital, Delhi

Introduction

W it h t h e a d v e nt of s op h i st i c a te d an d p o r t ab l e u l t r as o u nd m ac h i ne , us e o f u l t r as o u nd ha s m o v e d f r o m

conventional rooms to point of care. Point-of-care ultrasonography is defined as ultrasonography brought to the

patient and performed by the provider in real time. Point-of-care ultrasound images can be obtained nearly

i m m e d ia t e l y, a n d t h e c l i ni c i a n c a n u se r e a l - ti m e d y n a mi c i m a g es ( r a t he r t h a n i m a ge s r e c o r de d b y a s o n og r a p he r

a n d i n te r pr e te d l a te r ), a ll o wi n g f i nd i ng s t o b e d i re c tl y c o rr e la t ed wi t h t h e p a ti e nt ' s p r es e nt i ng si g ns a n ds y m p to m s . Po i n t- o f - c ar e u l t r as o n og r a p hy i s e a s i ly r e p ea t a b le i f t h e p a t i en t ' s c o n d it i o n c h a n ge s . I t is u s e d by

v a r i ou s s p e c ia l t i es i n d i v e rs e s i t ua t i o ns ( Ta b l e 1 ) a n d m a y b e b r o a dl y d i v id e d i n t o p r oc e d u ra l , d i a g no s t i c, a n d

screening applications.

B a s i c t e c h n ol o g y

U l t r as o u nd i s d e f i ne d a s a f r e q ue n c y a bo v e t h a t wh i c h hu m a n s c a n h e ar , or m o r e t h a n 20 , 0 0 0 H z ( 2 0 k Hz ) . T he

f r e q ue n c y o f d i a g no s t i c u l t ra s o u nd is i n th e m i l l io n s o f He r t z ( M H z ). L o we r -f r e q ue n c y u l t ra s o u nd h as b e t t er

penetration, but at lower resolution. Higher-frequency ultrasound provides better images, but it does not

v i s ua l i z e d e e p st r u c tu r e s w e l l . A t y p ic a l t ra n s - ab d o m in a l o r c a r d ia c p r o b e h a s a f r e q ue n c y in t h e r a n g e o f 2 t o 5

MHz.

U l tr a so n og r ap h y u s es a “ c ry s ta l ” — a q u ar t z o r c o mp o si t e p i ez o el e ct r ic m a te r ia l — t h at g e ne r at e s a s o un d

w a v e w h e n a n el e c t ri c c u r r e nt i s a p p l ie d . W he n t h e s o u nd w a v e r e t u rn s , t h e m a t e ri a l i n tu r n g e ne r a t e s a c u r r e nt .

T h e c r y s ta l t h u s t r a n sm i t s a n d r e c e iv e s t h e s o u nd . E a r l y u l t ra s o n og r a p hy u s e d a s i n gl e c r y s ta l t o c r e a te a o n e -

d i me n si o na l i m a ge k n ow n a s A - mo d e. T h e s t an d ar d s c r ee n i m a ge t h at m a c h in e s n o w g e ne r at e i s k n ow n a s B -

mode (also called two-dimensional or gray-scale ultrasonography), and is created by an array of crystals (often

1 2 8 o r m o r e ) ac r o s s t h e f a c e o f t h e t r a n sd u c e r. E a c h cr y s t al p r o du c e s a s c a n li n e t h a t is u s e d to c r e a te a n i m a ge o r

f r a m e , w hi c h i s r e f r e sh e d m a n y t im e s p e r s e c o nd t o p r o d uc e a m o v in g i m a g e o n t h e s c r e en ( F i g . 1 ) . U l tr a s o un d

penetrates well through fluid and solid organs (e.g., liver, spleen, and uterus); it does not penetrate well through

bone or air, limiting its usefulness in the skull, chest, and areas of the abdomen where bowel gas obscures the

image. Fluid (e.g, blood, urine, bile, and ascites), which is completely anechoic, appears black on ultrasound

images, making ultrasonography particularly useful for detecting fluid and differentiating cystic or vascular

a r e a s f r o m s o li d s t r uc t u r es . Tw o - d im e n s io n a l u lt r a s ou n d i s u s e d t o v is u a l iz e a p l a n e t h a t i s t h e n s ho w n o n t he

s c r e e n. T h i s p l a n e m a y b e d i r e ct e d b y t he u s e r i n a ny a n a t om i c a l pl a n e o n t h e p a t i en t : s a gi t t al ( o r l o n gi t u di n a l ),

t r a n sv e r s e ( o r a x i al ) , c o r o na l ( o r f r o n ta l ) , o r s o m e c o m b in a t i on ( o b l i qu e ) . An i n d i c at o r o n t h e p r o be i s u s e d t o

o r i e nt t h e u s e r t o t h e o r i e nt a t io n o f t h e p l a n e o n t h e s c r e en . B y c o n v e nt i o n, i n g e n e r a l a nd o b s t e tr i c a l i m ag i n g,

t h e i n d ic a t o r c o r r e sp o n ds t o t h e l e f t s i d e o f t h e s c r e e n a s i t i s v i e w ed . C a r d io l o gy u s e s t h e o p p os i t e c o n ve n t i on

for echocardiography, with the indicator corresponding to the right of the screen. Users should be aware of these

conventions when conducting integrated examinations that include both general and cardiac imaging.

J O U RN A L O F P E D IAT R I C C R I TI C A L C A R EVOL 1 - NO.1 Jan - March 2014 53




N O N I N VA SI V E L I FE S AV E RS Ult rasound in PI CU




Table 1. Se le cte d Ap p lica tio n s o f Po in t-o f-Ca re Ultra so n o g ra p h y, Acco rd in g to Me d ica l Sp e cia lty.

Specialty Ultrasound Applications

An e sth e sia Gu id a n ce fo r va scu la r a cce ss, re g io n a l a n e sth e s ia , in tra o p e ra tive

mo n ito rin g o f flu id sta tu s a n d ca rd ia c fu n ctio n

Ca rd io lo g y Ech o ca rd io g ra p h y, in tra ca rd ia c a sse ssme n t

Critica l ca re me d icin e P r o c e d u r a l g u i d a n c e , p u l m o n a r y a s s e s s m e n t , f o c u s e d

e ch o ca rd io g ra p h y

De rma to lo g y Asse ssme n t of skin le sio n s an d tu mo rs

Eme rg e n cy me d icin e FAST, fo cu se d e me rg e n cy a sse ssme n t, p ro ce d u ra l g u id a n ce

En d o crin o lo g y a n d

e n d o crin e su rg e ry Asse ssme n t o f th yro id a n d p a ra th yro id , p ro ce d u ra l g u id a n ce

G en e ra l s ur ge ry U lt ra s on og r ap hy o f t he b r ea s t, p r oc ed ur al g u id a nc e, i n tr a op er a ti ve

a sse ssme n t

Gy ne co lo gy As se ssm en t o f c er vi x, u te ru s, a nd a dn ex a; p ro ce du ra l g ui da nc e

Ob ste trics a n d

ma te rn a l-fe ta l me d icin e Asse ssme n t o f p re g n a n cy, d e te ctio n o f fe ta l a b n o rma litie s, p ro ce d u ra l

g u id a n ce

Ne o n a to lo g y Cra n ia l a n d pu lmo n a ry asse ssme n tsNe p h ro lo g y Va scu la r acce ss fo r dia lysis

Ne u ro lo g y Tra n scra n ia l Do p p le r, p e rip h e ra l-n e rve e va lu a tio n

Op h th a lmo lo g y Co rn e a l a n d re tin a l a sse ssme nt

O r th o pe d ic s u r g er y M u sc u lo s ke l et a l a p p li c at i on s

O to la ry ng ol og y A ss es sm en t of t hy ro i d, p ar at hy ro id , an d n ec k ma ss es ; pr oc ed ur al g ui da nc e

Pe d ia trics Asse ssme n t of bla d d e r, pro ce d u ra l g uid a n ce

P u l m on a r y m e d i ci n e T r a n s t h o r a c i c p u l m o n a r y a s s e s s m e n t , e n d o b r o n c h i a l a s s e s s m e n t ,

p r o c e du r a l g u i d a nc e

Ra d io lo g y a n d

in te rve n tio n a l ra d io lo g y Ultra so n o g ra p h y ta ke n to th e p a tie n t with in te rp re ta tio n a t th e b e d sid e ,

p r o c e du r a l g u i d a nc e

R he uma to lo gy M on ito ri ng o f syn ov iti s, p ro ce du ra l g ui da nc e

Tr au ma su rg er y FAST, p ro ce du ra l g ui da nce

Uro lo g y Re n a l, b la d d e r, a n d p ro sta te a sse ssme n t; p ro ce d u ra l g uid a n ce

Va s cu l ar s ur g er y C a ro t id , a r te r ia l , a n d v e no u s a s se s sm e nt ; p r o ce d ur a l a s se s sm e nt





F ig ur e 2

Clinical Application of Ultrasound

T h e c l i n ic a l u t i l it y o f p o i n t o f c a r e U S G c a n b e b r o a dl y d i v i de d i n t o P r o c e du r a l g u i da n c e , d i a gn o s ti c a p p r oa c h

and therapeutic intervention.

P r o c e du r a l g u i da n c e : U l t r as o u nd g ui d a nc e m a y im p r o ve s u c c es s a n d d e c r e as e c o m p li c a t io n s i n pr o c e du r e s

performed by multiple specialties, including central and peripheral vascular access, thoracentesis, paracentesis,

arthrocentesis, regional anesthesia, incision and drainage of abscesses, localization and removal of foreign

bodies, lumbar puncture, biopsies, and other procedures. Procedural guidance may be static or dynamic. With





s t at i c g u id a nc e , t he s t ru c tu r e o f i nt e re s t is i d en t if i ed , a nd t h e a n gl e r e qu i re d b y th e n e ed l e i s n o te d , wi t h th e

point of entry marked on the skin. In dynamic procedures, ultrasonography visualizes the needle in real time.

S t a t ic g u i d an c e m a y in i t ia l l y b e e a s i er t o p e r f or m , b ut p ro p e r ly p e r fo r m e d d y n a mi c g u i d an c e p r o v id e s m o r e

a c cu r at e g u id a nc e a n d i s g e ne r al l y pr e fe r re d b y e xp e ri e nc e d us e rs . T he u s e o f u lt r as o un d t o gu i de c e nt r al

v e n ou s a c c e s s h a s b e e n sh o w n to r e d uc e t h e f a i l ur e r a t e , th e r i s k of c o m p li c a t io n s , an d t he n u m b er o f a tt e m p ts ,

a s c o m p ar e d w i t h t h e l a n d ma r k t e c h ni q u e , p a r t ic u l a rl y i n t h e c a s e o f l e s s e x p e ri e n c ed us e r s o r p a t i en t s w i t h

m o re c o mp l ex c o n di t io n s. T h e e v id e nc e f o r t h es e b e ne f it s o f u l tr a so u nd g u i da n ce i s g r ea t es t f o r t h e i n te r na l

jugular site, with less evidence for the femoral and subclavian sites and in pediatric patients.

A n e ed l e m a y b e i m ag e d d y na m ic a ll y w i th th e u s e o f e i th e r a n “ i n- p la n e” o r “ o ut - of - pl a ne ” u l tr a - s o un d

a p p r oa c h ( F i g. 2 ) . F o r v a s c ul a r a c c e ss , a n i n - p la n e a p p r oa c h c o r r es p o nd s t o t h e l o n g a xi s o f t h e v e s s el . An i n -

plane, or long-axis, approach is generally preferred for dynamic vascular access, particularly for central venous

a c c e s s, b e c a u se t h e e n - t i re l e n g th o f t h e n e e d le , i n c lu d i ng t h e t i p , c an b e v i s ua l i z ed t h r o ug h o ut t h e p r o c ed u r e .

H o we v er , it m a y b e m o re d i ff i cu l t t o ke e p th e n e ed l e i n vi e w w i th t he u s e o f an i n- p la n e a p pr o ac h , an d f or

s m a l le r v e s se l s , i t ma y b e c h a l le n g in g t o i m ag e t h e e n t ir e v e s s el i n t h e l o n g a xi s . A n o u t- o f - pl a n e a p p r oa c h i s

perpendicular to the needle and corresponds to the short axis of the vessel. The advantage of this approach is

t h a t t h e n e e d le c a n be c e n t er e d ov e r th e m i d dl e o f t he v e s s el . I t i s a l s o e a s i e r t o ke e p t he v e s s el a n d t h e n e e d le i n

v i e w i n t h e s h o r t a x i s . H o w e ve r , a n o ut - o f -p l a ne a p p r oa c h m ay u n de r e s ti m a t e t h e d e p t h o f t he n e e d le t i p if t h e

u l t r as o u nd p l a ne c u t s a c r o ss t h e s h a f t of t h e n e e d le , p r o xi m a l t o th e t i p

D ia gn os ti c A pp ro ac h: T he p oi nt o f c ar e U SG u ti li ty a s d ia gn os ti c a pp ro ac h in i nt en si ve c ar e h as g ai ne d

i m p o r t a n c e f r o m l u n g U S G a s I t a l l o w s p r o m p t m a n a g e m e n t b a s e d u p o n r e p r o d u c i b l e d a t a

andgeneratesfewercomputedtomography(CT)examinations,therefore decreasing irradiation, delays, cost, and

d i s c om f o r t to t h e p a t i en t . Th e l e a r ni n g o f lu n g ul t r a so u n d ac t u a ll y c o me s f r o m u nd e r s ta n d i ng a r t if a c t s i t

produces with ultrasound. In a normal lung, the visceral and parietal pleura are closely associated, and

u l tr a so u nd s h ow s s h im m er i ng o r s li d in g a t th e p l eu r al i n te r fa c e d u ri n g re s pi r at i on a n d as U S G d o es n o t





penetrate bone and air it gives shows bat wing appearance with A lines at regular interval which is normal

reverberation artifact as shown in fig 3, 4& 5.

F i g u re 4 . I n P a n e l A , a h i g h- f r e q ue n c y l i ne a r p r o be i s p l a c ed w i t h t h e i n d ic a t o r t ow a r d t h e p a t i en t ' s h e a d ( s cr e e n

l e f t ), i n t he m i d c la v i c ul a r l in e a t a p pr o x i ma t e l y t h e t h i r d i n t er c o s ta l s pa c e . A t t he p o s te r i o r e d g e o f t h e r i b , a

h y p e re c h o ic ( b r i gh t ) p l e u ra l li n e i s s e e n , w h i c h i s t h e i n t e rf a c e b e t w ee n t h e v i s ce r a l a n d p a r i et a l p l e u ra . In a

m o v i ng i m a g e o f a n o r m al l u n g , s hi m m e ri n g o r “ s li d i ng ” w o u ld b e s e e n a t t he p l e ur a l l i n e, i n d i ca t i n g th a t t h e

v i s c er a l p l e u ra i s c l o s el y a s s o c ia t e d w i t h t h e p a r i et a l p l e ur a . A n “ A l i n e” ( a n o r m al r e v e r b er a t i on a r t i f a c t) i s a l s o

s e e n . I n P a n e l B , a p h a s ed - a r ra y s ec t o r p r o b e i s p l a c ed a t t h e s a m e a n a t om i c a l l o c a ti o n o n a d i f fe r e n t p a t i en t .

T h is s e ct o r i ma g e i s m u ch d e e pe r, b u t i t s h o ws t h e s a me s t ru c tu r es , a s w e ll a s p a th o lo g ic a l “ B l i ne s ,” a r ti f ac t s

t h a t ex t e nd t o t h e b o t to m o f t he s c r e e n (“ l u ng r o c ke t s ” ). T h i s p a t i en t h ad a l v eo l a r i nt e r s ti t i a l s y n dr o m e f r o m

congestive heart failure.

F i gu r e 5 . Normal lung pattern. Left: Longitudinal scan of an intercostal space. Only artifacts (rib shadows and

a i r ) a r e v i s ib l e . B e tw e e n t wo r i b s ( v e r ti c a l a r ro w s ), 0 . 5 c m l o w er i n t h e a d u lt , t h e p l e ur a l l i ne i s l o c a te d ( u p pe r

h o r iz o n t al a r r o w s) . T h e u p p e r r ib , p l e u ra l l i n e , a n d lo w e r r i b o ut l i n e t h e b a t s i g n. T h e h o r iz o n t al l i n e s ( l o w er

h o r iz o n t al a r r o w s ) t h a t a r i se f r o m t h e p l e u ra l l i n e a n d a r e d i s pl a y e d a t r e g u la r i n t e r v a ls , c o i n e d A - l i ne s , h a v e

c l i ni c a l a p p li c a t io n s . R i g ht : S e a s h or e s i g n ( M - m od e ) . T h e s e a s ho r e s i g n d e m on s t r at e s l u n g s l id i n g. T h e l u n g

sliding corresponds to the displacement of the lung along the cranio-caudal axis, synchronized with respiration.

T h e m o t io n l e ss s u p e rf i c i al l a y e r s g e n e ra t e h o r iz o n t al l i n e s ( w a v e p a t te r n ) . T h e d y n am i c c r e a te d b y l u n g s l i d in g

g e n e ra t e s a s a n d y p a t te r n , a r i s in g fr o m th e v e r y p l e u ra l li n e . I n t he n e w bo r n , t h e s a m e b a t pa t t e rn i s v i s ib l e i n

proportion to the size of the infant.

A b s en c e o f s l i di n g o f p l e ur a l l i ne c a n i n di c a t e p n e um o t h or a x / p le u r a l e ff u s i on ( r e - a pp e a r s a f t e r a pp r o p ri a t e

drainage), collapse or endo- bronchial intubation if the lung slide is absent on one side.





Interstitial Edema: Other artifacts (arrows) as shown in fig. 6 have seven features: comet-tail artifacts, strictly

a r i s in g f r o m t h e p l e u ra l l i n e , h y pe r e c h oi c , w e l l -d e f i ne d l a s e r- l i k e s p r e ad i n g t o t h e e d g e o f t h e s c r e en w i t h o utfading erasing normal A-lines and synchronous with lung sliding. This pattern defines B-lines and distinguishes

t h e m fr o m o t he r c o m et - t a il a r t if a c t s, s u c h a s t h e Z - l in e s , w hi c h a r e s h o r t, d o n o t e r a s e A - l i ne s , a n d ha v e n o

s i gn i fi c an c e. S e ve r al B - li n es i n a s i ng l e v i ew ( s ix h er e ) de f in e l u ng r oc k et s . D i ff u se l u ng r oc k et s i n di c at e

interstitial syndrome.

A l v eo l a r C o n so l i da t i o n: A l ve o l a r c o ns o l id a t i on i s d e fi n ed a s a n i m a g e a r i s in g f r o m t h e p l e u ra l l i n e ( o r t h e l u n g

l i n e i n t h e p r e s en c e o f p l e u ra l e f f us i o n ), y i e l d in g t h e t i s su e - l ik e s i g n a n d t he s h r e d s ig n a s s e e n f i g 7 .

F ig ur e 7 . Alveolar consolidation. The shred sign:

T h e d e e p b o r de r o f t h e c o n s ol i d a ti o n i s i n c o n n e c ti o n

w i t h ae r a t e d lu n g t i ss u e ; h en c e , a s h r e dd e d p a t te r n

( a rr o ws ) . T h e s h re d si g n d i st i ng u is h es a l ve o la r

consolidation from pleural effusion.

F ig ur e 6





Figure 9. Sh o win g stra to sp h e re p a tte rn o n M mo d e in

p n e u mo th o ra x.

Figure 10. Sh o win g Pn e u mo th o ra x a n d th e lu n g p o in t. Th e lu n gp o in t ca n b e re co rd e d u sin g th e M-mo d e . Th is ima g e sh o ws a

su d d e n (a rro w ) re p la ce me n t o f a se a sh o re sig n b y a stra to sp h e re

s i g n , a t t h e v er y l o c a t io n w h e r e t h e l u n g t o uc h e s t h e w a ll o n

in sp ira tio n .

F i g 8 s h o wi n g c o m p le t e o p a c if i c a ti o n o f l u ng o n C X R a n d s h r ed s i g n o n US G w i t h a ir b r o n c ho g r a m ( lo n g

arrow with hypoechogenic pleural line (short arrow).

F i gu re 8

P n e u m ot h o r ax : It c an b e d e t e ct e d b y ab s e n t s l i di n g s i g n, c ha n g e o f sa n d y s h o r e ( f i g 9 ) ap p e a ra n c e t o

stratosphere pattern and lung point detection (fig 10) on M mode with high sensitivity and specifity.

Figure 11.





P l e u ra l e f fu s i on ( E ) : A p l e ur a l e f fu s i on i s l i m i te d b y f o ur r e g u la r b o r de r s f o r m in g a q u a d ( th e q u a d si g n ) : th e

pleural line, the upper and lower shadows of the ribs, and the deep border, which is always regular. This border,

t h e l u n g l i ne , s h o w s t h e v i s c er a l p l e u ra ( a r r ow s ) . F i g 1 1.F i gu r e 1 2 . Pl e ur a l ef f us i on a n d th e s i nu s oi d si g n. T hi s M - mo d e i m ag e h i gh l ig h ts t h e s i nu s oi d s ig n , a b a si c

d y n a mi c s i g n s p e c if i c t o f l u i d p l e u ra l e f f us i o n , a l s o i n d ic a t i ng lo w v i s c os i t y. Th e s i n u so i d s i g n s h o ws t h e

c e nt r if u ga l i ns p ir a to r y s h if t in g o f t h e l u ng l in e t o wa r d th e p l eu r al l in e w i th a d e cr e as e i n t he i n te r pl e ur a l

d i s t an c e . A s t h e l u n g e xp a n d s i t s v o l u me t o w a rd a c o r e -s u r f ac e a x i s, t h e p a t t er n , i n M -m o d e , i s s i n us o i da l a l o ng

the respiratory cycle. I, inspiration; E, expiration; black arrows, pleural line; white arrows, lung line.

H e m o dy n a m ic M o n it o r i ng b y U S G i s a n o t he r i m p o r ta n t a s p ec t o f p o i n t o f c a re U S G a n d h a s b e e n d i sc u s se d i n

t h e a r t i cl e o n E c h o ca r d i og r a p hy ( p a ge 4 8 ) .

FAST Examination

FA S T i s a n i n t e gr a t e d, g o a l - d ir e c t ed , b e d s i de e x a m in a t i on t o d e t e c t f l u id , w h i c h i s l i k el y t o b e h e m o rr h a g ic i n

cases of trauma. The extended FAST (e-FAST) also includes examination of the chest for pneumothorax.

T h e e - FA S T e x a m in a t i on c om b i n es f i v e f o c u se d e x am i n a ti o n s f o r t h e d e t e ct i o n o f : f r e e i n t ra p e r it o n ea l f l ui d ,

free fluid in the pelvis, pericardial fluid, pleural effusion, and pneumothorax. Peritoneal fluid is detected using

v i e ws o f t h e h e p a to r e n al s p a c e ( M o r ri s o n' s p o u ch ) , s p l e n or e n a l s p a ce , a n d r e t r o v e s ic u l a r s p a c es . T h e t h o r ax i s

e v al u at e d f o r fl u id a t t he f l an k s a n d fo r p ne u mo t ho r ax a n te r io r ly. T h e p e ri c ar d iu m m a y be e v al u at e d fo r

effusion, particularly in cases of peneterating trauma.

A FA S T e x a m in a t i on m a y b e c o m p le t e d i n le s s t h a n 5 m in u t es a n d h a s b e e n s ho w n t o ha v e a s e n si t i vi t y o f 7 3 to99%, a specificity of 94 to 98%, and an overall accuracy of 90 to 98% for clinically significant intra -abdominal

i n ju r y in t r au m a. T he u s e o f t he FA S T e x am i na t io n h as b e en s h ow n t o re d uc e t h e n e ed f o r C T o r d ia g no s ti c

peritoneal lavage and to reduce the time to appropriate intervention, resulting in a shorter hospital stay, lower

costs, and lower overall mortality, although more rigorous study of patientcentered outcomes is recommended.

A c o m p le t e o r p a r t ia l FA S T e x a m in a t io n m a y a l so b e h e l p fu l i n e v a lu a t i ng p a t i e nt s w h o d o n ot h a v e t r a u ma f o r

ascites, intra-peritoneal hemorrhage, pleural effusion, pneumothorax, or pericardial effusion.

I C P m o n i to r i n g: O p ti c n e r v e s h e a th d i a m et e r h a s b e e n us e d t o pr e d i ct r a i se d I C P w i t h go o d s en s i ti v i ty a n d





specificity. USG can also detect pupillary size and their reaction in patient with closed eyes because of trauma.

T h er a pe u ti c u s es : R ea l ti m e u s e o f U SG i n dr a in i ng f lu i d f r om a n y c a vi t y o r sp a ce s h a s b e en v er y we l ld o c um e n t e d a n d n ow t h e s t a nd a r d o f ca r e i n m o st o f t h e w e s te r n I C U. I t r e d uc e s c o m p li c a t io n a n d al s o c he c k

need of unnecessary shifting the patient to operation theatre.

Conclusion

U S G i s a n e x ce l le n t to o l to c o mp l im e nt c l in i ca l e xa m in a ti o n to a s se s a n y or ga n s ys t em . I t i s f r ee o f a ny

c o m p li c a t io n a n d si d e e f f e ct s , ca n b e d o n e r a p i dl y a t t h e b e d si d e . I t h as s h o wn t o b e v e r y u s e f ul i n t r a u ma , t o

check volume responsiveness, ICP measurement and diagnosis and management of lung pathologies. Its major

limitation is operator dependence. This is a skill all intensivist must learn.

Suggested Readings

1 . M o or e C , C op e lJ . Po i nt - of - Ca r e U l t ra s on o gr a ph y. N E n gl J M e d 2 01 1; 3 64 : 74 9 -5 7

3 . K hi ln an i P. T he p ed ia tr ic B US h as a rr iv ed : I s b ed si de u lt ra so un d i n t he p ed ia tr ic i nt en si ve c ar e u ni t a f ea si bl e

option? PediatrCritCareMed 2011;12(6):681-683

4 . L a mb e rt R L , Bo k er J R , M af fe i FA . N at i on a l s ur v ey o f b e d si d e u l tr a so u nd u s e i n p e di a tr i c c r it ic a l c ar e . P ed i at r

CritCareMed 2011; 12:655–659

5 . F r o e hl i c h C, S t oc k w e ll J , Ri g b y M. U l tr a - so u n d gu i d e d c e n t ra l v e no u s a c c e ss i n c h il d r e n. P C CM 2 0 0 6; 7 : 5 20 - 3

6 . S h il o h A L , Sa v el R H , P a ul i n LM , e t al : U lt r a- s o un d g u id e d c a th e te r iz a ti o n of t h e r a di a l ar t er y : A s y st e ma t ic

review and meta analysis of randomized controlled trials. Chest 2011; 139:524–529

7 . K h i ln a n i P. B ed s i d e u l t r a s o u nd a n d e c h o ca r d io g r a ph y b y t h e p e d i at r i c i n t e ns i v is t : A n e vo l v i ng t o ol a n d a f e a s ib l e

option in a pediatric ICU. IndianJCritCareMed 2013;17: 201-202

2 . K o ez e J e t a l l. B e d si d e l u ng u l t ra s ou n d i n t h e c r it i ca l ly i l l p a ti e nt w i th p u l mo n ar y p a th o lo g y: d i ff e re n t d ia g no s es

with comparable chest X-ray opacification. Critical Ultrasound Journal 2012 4:1





No n In v a si v e Ven ti l ati o n (NIV)D r S h i p r a G u l a t i * , D r R a j i v U t t a m **

*Consultant intensivist Pediatric Critical care ,Max Superspeciality Hospital Patpar Ganj New Delhi

**Director Pediatric Critical care ,Max Superspeciality Hospital Patpar Ganj New Delhi

Introduction

Non invasive ventilation(NIV) refers to the application of ventilatory support using techniques that do not

r e q u ir e a n i n v as i v e e n d o tr a c h e al a i r w ay. M u l t ip l e f o r m s o f N I V a r e a v a i la b l e f o r u s e i n c h i ld r e n :

Continuous positive airway pressure (CPAP)

Bi-level positive airway pressure (BiPAP)

Intermittent positive pressure breathing (IPPB)

Humidified high-flow nasal cannula (HHFNC)

Bi-level nasal CPAP.

U s e o f NI V i n pe d i a tr i c p a t i en t s i s i n c r ea s i ng i n t h e e m e rg e n c y d e p a rt m e n t, c r it i c a l c a r e u n i t, a n d p r e h o s pi t a l

e n v i ro n m e nt . N o ni n v a si v e p o s it i v e p r e s su r e v e n ti l a t io n r e f er s t o t h e d e l iv e r y o f a p r e s su r i z ed g a s t o t h e a i r w ay

v i a a n a sa l o r f u ll - fa c e m a sk . Th e e a rl i es t NI V d e vi c es w e re a c tu a ll y e xt e rn a l n e ga t iv e p r es s ur e v e nt i la t or s ,

i n c l ud i n g t h e b o d y v e n t il a t o r a n d i r o n l u n g. N e ga t i v e p r e s su r e v e n t il a t o rs w e r e w i d e ly u se d d u r in g th e p o l io

e p i d em i c s o f t h e 1 9 3 0s a n d 1 9 6 0s , b u t t h e s e v e n t il a t or s w e r e p r o b le m a t ic t h e y w e r e l a r ge a n d b u l ky, a n d t h e y

m a d e a c c e s s t o p a ti e n t s d i ff i c u lt . Al t e r na t i ve f o r m s o f r e s pi r a t or y s u pp o r t e me r g ed d u r i ng t h e 1 9 7 0s a n d 1 9 8 0s

along with increased interest in noninvasive positive pressure ventilation.

Pathophysiology and mechanism of action

Noninvasive positive pressure devices deliver pressurized gas to the airway via a mask or nasal prongs. This

r e s u lt s i n a n i n c r ea s e i n m e a n a i r w ay p r e s su r e , w h i ch r e c r u it s a t e l ec t a t ic a l v e ol i , i m p r ov e s g a s e x c h an g e , a n d

r e d u ce s w o r k o f b r e a th i n g. ( Ta b l e 1 . ) I n p ed i a t ri c p a t i en t s , N IV d e c r e as e s w o r k of b r e a t hi n g b y un l o a di n g t he

diaphragm and accessory muscles and reducing inspiratory energy expenditure. NIV may also help stabilize the

h i g hl y p l i ab l e c h e s t w a ll i n y o u ng i n f a n t s, r e d u c i n g r e t r ac t i o ns . N I V p r o v id e s p o s i ti v e e n d e x p i r at o r y p r e s su r e( P E E P ) wh i c h h e l p s o p e n c ol l a ps e d a l ve o l i, i n c r e as i n g fu n c t io n a l r es i d ua l c a p ac i t y a nd i m p ro v i n g

o x y ge n a t io n . N IV m a y a ls o r e ve r s e h y p ov e n t il a t io n b y in c r e as i n g ti d a l vo l u me a n d m in u t e v e n ti l a t io n i n

children with hypercapneic respiratory failure. In children with occlusive apnea, noninvasive positive pressure

m a y h e l p r e du c e t h e n u m b er o f o c c l u s iv e e v e n ts b y m a i n ta i n in g u p p e r a ir w a y p a te n c y. N I V m a y h a v e n e g a ti v e

physiologic effects, most of which are shared by invasive mechanical ventilation. Positive airway pressure

i n c r ea s e s i n t r at h o r ac i c p r e s su r e , wh i c h m a y de c r e a se v e n ou s r e t u r n a n d ca r d i ac o u t p ut i n p a t i en t s w i t h p o o r

c a rd i ac f u nc t io n . In p a ti e nt s w i th n o rm a l ca r di a c f u nc t io n , NI V m a y ac t ua l ly i m pr o ve c a rd i ac o u tp u t by

decreasing left ventricular afterload.





Table 1. NIV: Mechanisms Of Action

D e c r ea s e s w o r k o f b r e a t h in gIncreases functional residual capacity

Recruits collapsed alveoli

I m p r ov e s r e s p ir a t o ry g a s e x c h an g e

Reverses hypoventilation

Maintains upper airway patency

May increase or decrease cardiac output depending on underlying disease

Advantages Of Noninvasive Ventilation

NIV has several significant advantages over endo tracheal intubation. NIV devices leave the upper airway

i n ta c t, d e c re a si n g th e r i sk o f a ir w ay t r au m a a n d pr e se r vi n g th e n a tu r al d e fe n se m e ch a ni s ms o f t he u p pe r

a i r w ay s . Ad d i ti o n a ll y, p a t i e nt s r e c e i vi n g N I V d o n o t r e qu i r e p a r a ly t i c s, a n d t h e n e e d f or s e d a t io n i s g r e a tl y

reduced. Older children can communicate with their health care providers while receiving NIV. NIV is also less

e x p e ns i v e t h a n m e ch a n i ca l v e n ti l a t io n , a n d s t ud i e s h a v e s h o wn t h a t i t d e c re a s e s l e n gt h o f h o s pi t a l s t ay a n d

associated cost.

Noninvasive Ventilation Techniques and Equipment

(1) Continuous PositiveAirway Pressure(CPAP)

C PA P d e li v er s a c o ns t an t l e ve l o f p r e ss u re s u pp o rt t o t h e a i rw a ys d u ri n g i ns p ir a ti o n a nd e x p ir a ti o n. T h isc o n st a n t pr e s s ur e t y p ic a l l y r a n g es f r o m 5 t o 1 0 c m H 2O a n d is d e l i ve r e d wi t h ou t r e ga r d to t h e r e s p ir a t o ry

c y c l e. C PA P c a n b e d e l i ve r e d t h r o ug h s e v e r a l d i f fe r e n t e x t er n a l i n t e rf a c e s , i n c lu d i ng o r o n a s a l m a s k s, n o s e

masks, nasopharyngeal prongs, single-nasal prongs, and short bi-nasal prongs. Oronasal masks (full-face

m a s k s) a r e c o m m on l y u s e d i n o ld e r c h i ld r e n a n d a d ul t s , b u t t he s e m a s k s a r e n o t g e n er a l l y u se d i n n e o n at e s a n d

y o u ng i n f a n ts d u e t o t h e d i f fi c u l ty i n m a i n t ai n i ng a n a d e q u a te f i t a n d s e al . S h o r t b i -n a s a l p ro n g s d e l i ve r e q u a l

pressure to both nostrils and have less resistance than the single-nasal prongs. Nasal CPAP has been used

extensively in premature neonates ,infants with bronchiolitis and lower airway obstruction

(2) Bi-level Positive Airway Pressure(BIPAP)

B i - l ev e l p os i t iv e a i r w ay p r e ss u r e d e v ic e s p r o v id e t w o le v e l s o f p o si t i ve a i r w a y p r e s su r e d u r i ng t h e r e s p ir a t o ry

cycle. A higher level of pressure is provided during inspiration (IPAP), and a lower level of pressure is provided

d u r in g e x pi r a t io n ( E PA P ) . Th e a v a i la b l e I PA P r a n g e i s 2 t o 25 c m H 2O , w i th t y p ic a l s et t i ng s o f 1 0 to 1 6 c mH 2 O . T h e a v a i la b l e E PA P r a n g e i s 2 - 2 0 c m H2 O , wi t h t y p ic a l se t t in g s o f 5 t o 10 c m H 2 O . 51 B iPA P c a n be

d e l iv e r e d w it h a s e t r e s pi r a t or y r a t e o r a b a c k -u p r a t e . A d d it i o na l l y, t h e c y c l e m a y b e f i x e d as a f u n c ti o n o f t im e ,

o r i t m a y be t r i g ge r e d b y t h e p a t i en t ' s i n s pi r a t or y f l o w. As w i t h CPA P, B i PA P m a y b e p r o vi d e d b y a m a c h in e

s p e c if i c a ll y d e si g n ed f o r t hi s f o r m of N I V o r b y a t r a d it i o na l v e nt i l a to r s e t t o a p pr o p r ia t e b i - le v e l pr e s s ur e

s u p po r t s e t ti n g s. T h e l e v e l o f p r es s u r e s u p po r t i n B i PA P i s e q u i va l e n t t o t he d i f fe r e n c e b e t we e n t h e i n s pi r a t or y

a n d e x p i ra t o r y p r es s u r es ( I PA P m i n u s E PA P ) . S u p pl e m e nt a l o x y ge n m a y b e p r o v id e d t h r o ug h t h e v e n t il a t o ry

t u b in g o r d i r e c t l y t h r ou g h t h e m a s k . M a n y o f t h e n e w B i PA P d e v ic e s a l s o h a v e o x y ge n b l e n d e rs .

(3) Humidified High-Flow Nasal Cannula

N O N I N VA SI V E L I FE S AV E RS Non I nvasive Vent ilat ion (NI V)




H i g h- f l o w n a s a l ca n n u la d e v ic e s d e l i ve r w a r m ed h u m id i f i ed g a s t o t h e a i r w ay s . B e ca u s e t h e g a s i s n e a r ly 1 0 0 %

humidified, nasal mucosal irritation is greatly reduced. This permits improved tolerance of high gas flow up to 8

L / m i n i n i n f a n t s a n d 4 0 L / m in i n o l d e r c h i ld r e n .

(4) Nasal Intermittent Positive Pressure Ventilation (NIPPV)

A r e la t iv e ly n e w f o rm o f N I V f o r i nf a nt s t h at p r o vi d es p e ri o di c i n cr e as e s i n p o si t iv e p r es s ur e a b ov e a b a se l in e

f i x e d pr e s s ur e . N I P PV c a n b e d e l i ve r e d v ia a n a s a l ma s k o r na s a l p ro n g s c o n n ec t e d to a v e n t il a t o r, o r i t c a n be

d e l iv e r e d b y a f r e e - st a n di n g d e v ic e s p e c if i c a ll y d e s i gn e d f o r t h i s f o r m o f N I V. W h e r e as t h e t r a di t i on a l i n f a nt

n a sa l CPA P d e vi c e c o nt a in s a s i ng l e f l ow m et e r, t he N I PP V d e vi c e h a s a s e co n d f l ow m et e r t h at pe r io d ic a ll y

a d d s a d d it i o na l f l ow t o t h e s y s te m . Th e s e p e r i od s o f i nc r e a se d f lo w a r e k n o wn a s “ s i gh s ” a n d ca n b e d e l i ve r e d at

a p r e s et r a t e . Th e p e r i od i c i n c r ea s e s i n p o s it i v e a i r w ay p r e s su r e m a y h e lp o f f lo a d t he d i a ph r a g m a nd a c c e ss o r y

m u s c le s , d e cr e a s in g t h e i n f a nt ' s w o r k of b r e a th i n g. T h e d e v ic e e s s e nt i a l ly p r o vi d e s t w o l ev e l s o f C PA P, b u t

u n li k e B i PA P, t h e i n fa n t c an n ot t r i gg e r t he d e vi c e t o c y cl e b e tw e en t h e h i gh a n d l o w C PA P s e tt i ng s . T he s e

c y c l es a r e c o n t ro l l ed b y se t t i ng s o n t he m a c h in e . I mp r o v ed o x yg e n a ti o n ca n b e a c h i ev e d by i n cr e a s in g t hea m o u nt o f t i m e o n t h e h i g h C PA P s e t ti n g . I m pr o v e d v en t i la t i o n c an b e a c h i ev e d b y i n cr e a s in g t h e n u m b er o f

c y c l es b e t we e n th e h i g h a n d lo w C PA P s e t t in g s . I n t ab l e 2 - 6 a p p n ea t o us , c on t r a di c t i on s , si g n s o f e ff e c t iv e

r e s p on s e , m o n i t o ri n g , r e a s o ns t o d i s c o n ti n u e N I V a r e l i s te d

Ta b l e 2 .

Applications of NIV

1 ) C H R O N I C D I S E AS E S

Obstructive airway disease

O b t r uc t i v e s l e e p a p n e a ( O S A )

Adenotonsillar hypertrophy

C r a n io f a c i al m a l f o r ma t i o ns a s i n d o w n 's s y n dr o m e o r p i e r r e d r o b i n s y n dr o m e

Neurological abnormalities as in cerebral palsy

R e s t ri c t i ve a i r w ay d i s e as e

Poliomyelitis

N e u r om u s c ul a r d i s e as e s a s D u c he n e m u s c ul a r d y s tr o p h y

Central hypoventilation syndrome

2 ) A C U T E D I S E AS E S

Respiratory distress syndrome

H y a l in e m e m b r an e d i s e as e i n n e w bo r n sApnea of prematurity

Lower airway obstruction : Asthma :B ronchiolitis

Upper airway obstruction

Pneumonia

Post extubation respiratory failure

Weaning

Immunocompromised patients





Ta b l e 3 .

Contraindications To NIV

Apnea

Impaired mental status

Inability to protect the airway

Excessive oral secretions

Uncooperative or agitated patient

Poor mask fit

Hemodynamic instability

Shock

Upper gastrointestinal bleeding

Recent gastric, esophageal or upper airway

surgery

Inadequate staff to appropriately monitor patient

Ta b l e 5 .

Acute Non-invasive ventilation: Monitoring

P u l s e o x i m et r y

NIBP

Peripheral venous access

A r t e ri a l b l o od g a s / C a p il l a r y g as e s

ECG

Arterial lines

A u t h or ' s E x p e r ie n c e

We h a v e b e e n u s i ng N I V f o r th e l a s t m a n y y e a r s i n n eo n a ta l a nd p e di a t r ic a g e g r o up . I n t h e l a s t 1 y e ar w e h a v e

u s ed N I V i n a r ou n d 50 c h i ld r en w i th a l mo s t 90 % s uc c es s r a te ( F ig u re s 1 - 3) . N I V h a s d e cr e as e d th e r a te s o f

i n tu b at i on a n d ve n ti l at o r ac q ui r ed p n eu m on i a( VA P ) in o ur P I C U ; a t t he s a me t i me i t ha s d e cr e as e d th e

e m o t io n a l s tr e s s a n d f i na n c i al b u r d en o n p a r en t s . N I V i s a n e x c e ll e n t o pt i o n in c h i l dr e n & h a s m u c h w id e r

s c o pe o f u se i n b o t h a c u t e & c h ro n i c c o n d it i o ns .

Ta b l e 4 .

S i g n s o f e f f e c t iv e r e s po n s e To N I V

Decreased respiratory rate

Decreased retractions and accessory muscle use

Reduced airway occlusion events

Improved oxygenation on pulse oximetry and

blood gases

Improved lung volumes on chest radiographs



Ta b l e 6 .

Reasons To Discontinue NIV

Progressive respiratory distress

Persistent tachypnea

Persistent hypoxia despite supplemental oxygen

Hemodynamic instability

Vomiting

Excessive secretions

Increasing anxiety or agitation

Increasing lethargy or worsening mental status







Case:

8 m o n t h s o l d , f e m al e c o n jo i n e d t wi n s b o r n o u t o f a n o n co n s a ng u i no u s m a r r ia g e w e r e d e l iv e r e d t h ro u g h n or m a lv a g in a l r ou t e a t a h o s pi t a l in N i g er i a o n 2 8t h A u g 2 01 2 . C o mb i n ed B i r th w e i gh t w a s 4 . 5 k g. An t e n at a l

U l t ra s o u nd ( U S G) w a s s u g ge s t i ve o f t w in p r e gn a n c y, t h e r e w a s n o p r io r h i st o r y of t w i ns i n t h e f a m i ly. Tw i n s

w e r e k e p t i n t h e h o s pi t a l f o r a b o ut 8 m o n t h s b e f o re b e i n g r e fe r r e d f o r s u rg i c a l s e pa r a t io n . T h e y d id n o t h a v e a n y

major health related issues and were growing well with intact neurological status and bladder bowel function

a p pr o pr i at e f o r ag e . Pa r en t s w e re i n fo r me d r eg a rd i ng r i sk o f p ot e nt i al l o ss o f l if e o f o ne o f t he t w in s d u ri n g

s u rg i c a l s e p ar a t i on b y d o c to r s i n N i g e r ia . T h a t l e d t h e p a r e nt s s e e k a l t e rn a t i ve a d v a nc e d s u r gi c a l c e n t re s t o g e t

t h e b e s t p o ss i b le o u t co m e s . P a r e nt s c h o s e t o c o m e t o o u r c e n t r e l o c a te d i n c e n t r a l D e lh i ; w e l l e q ui p p ed w i t h t h e

m u l ti d i s ci p l in a r y p e d i at r i c m e d i ca l a nd s ur g i ca l te a m s , o p er a t i ng t er t i a r y c a r e f a c i li t y a n d a s t a t e o f th e a r t

pediatric intensive care.

At the time of admission , combined weight of conjoined twins was 13.8kg . General and systemic examination

w a s w i t hi n n o r m al l i m it s . Tw i n s w e r e f u s e d a t t he l e v e l o f s a cr u m , w it h b ot h c h il d r e n a l i g ne d i n op p o s it e

d i r e ct i o ns , l o w e r l i m b m o v e m en t s b e i n g n o r ma l . T h e y s h a r ed c o m m o n g e n i t al i a w i t h s i ng l e a n d d y s p la s t i c

sacrum, spina bifida at level L5 and S1 vertebrae.

Medical team was appointed by Medical administration (CEO), who took the lead in supervising the overall

planning and execution by the multidisciplinary team members, including planning of counseling by the

interpreters and liaison with the family regarding the financial and other practical logistics. Team consisted of

pediatric surgeon, pediatric intensivist as the main surgical and medical team leaders along with key

s u p er s p e ci a l i st s s u c h a s p l a s ti c s u r ge o n s , n e u r os u r ge o n s , a n e s th e s io l o g is t s , u r o l og i s ts , g a s tr o I n t e st i n al

surgeons, gynecologists, vascular surgeons, neurologists, radiologists and senior pediatricians.

C h i ld r e n w e r e i n v es t i g at e d in d e t ai l . R ou t i ne i n v es t i ga t i o ns i n c l ud e d c o m p le t e h e m o gr a m , l iv e r a nd k i dn e y

f u n c ti o n s, c o a gu l a t io n p r o f il e , t yp e a n d sc r e e ni n g , si c k l e c e l l tr a i t , c h e s t r a d i og r a p h, e c h oc a r d io g r a m,

U S G ( ul t r a so u n d) a b d o me n , C T a n g io g r a ph y, M R I l u mb o - sa c r a l s pi n e a n d c y st o u r e th r o g ra m . Tw i n s w e r e postive for sickle cell trait. To test for cross circulation between the twins an atropine test was done in the

pediatric intensive care unit before exposing the twins to parenteral sedation required for imaging studies (MRI

a n d CT s c a n ). T h e a t r o pi n e t e s t w a s n e g a ti v e a n d re v e a le d n o m a j o r c h a n ge s i n t he h e a r t r a t e o f t he s e c o nd t wi n

w h e n a t r o pi n e w a s g i v e n t o t he f i r s t t w i n. To a v oi d e r ro r s f r o m th e v e r y fi r s t d a y t wi n s w e r e m a r k ed a s f i r s t a n d

second twin and later on when they underwent surgical procedures , they were also color coded as pink and

blue.

Va r i o us i m a g in g s t u di e s c o n c lu d e d t ha t t w i n s h a d f u si o n o f l o we r c o n u s m e d u ll a r i s a t S 1 s y r i nx , s i n g l e f i l um

t e r m i na l e , b i l at e r a l t he c a l s a c s f u s e d a t S 1 a n d e n di n g a t S 2 . T h er e w a s f u s io n o f l e f t i n t e rn a l i l ia c v e i n o f r i g h t

side twin with internal iliac vein of left side twin at the level of acetabulum , with minor shunting of blood from

o n e t w in t o o t he r a nd v ic e v e rs a . B o th t wi n s h a d t h ei r re s pe c ti v e a b do m in o pe l vi c o rg a ns s u ch a s u r in a ry

bladder, urethra, both ovaries, uterus, possibly vagina, rectosigmoid colon and rectum. There was a single

puborectalis sling with single anal canal below it. Both urethras were found converging in the midline and

became imperceptible in their distal course. In the midline, the two rectums were separated by a thin

h y p oi n t e ns e s e p t um , w h e r e a s b o t h p e l v ic b o n es a p p e ar e d u n r e ma r k a bl e .

L i t e ra t u r e w a s r e v i ew e d i n d e t a il . A nt i c i pa t e d r i s ks , c o m p li c a t io n s a n d e t h ic a l i s s ue s w e r e d i s c us s e d a m o ng s t

t h e t e a m m e m b e rs a s w e l l a s w i t h t h e f a m i ly. M a jo r c on c e r ns w e r e r i s k o f po s t o p e r at i v e n e u r ol o g ic a l de f i c i t,

i n c o nt i n e nc e ( b l a dd e r a n d b o w e l d ys f u n ct i o n) , p o t e n ti a l C S F l e a k , w o un d i n f e c ti o n s a n d m e n i ng i t is a f t e r

r e co n st r uc t io n su rg e ry a s w e ll a s t h e r i sk o f mo r ta l it y . Pa r en t s w e re c o un s el e d b y th e t e am t hr o ug h a n

interpreter. An option of not going for surgery was also discussed, however, in view of potential later morbidity

and poor prognosis , family consented to go for separation surgery. After informed consent was obtained, all

P E D IAT R I C M E D IC A L A N D S U R G IC A L T E A M C H A LL E N G E A case report of Conjoined Twin(PYGOPAGUS) separat ion




m a j o r a n d m i no r r i s k s e x p l ai n e d , s u r ge r y w a s p l a n ne d i n 3 s t a g e s . Al l s t a g e s o f s u r g er y w e r e r e h e ar s e d w i t h

detailed documentation of designation of team leaders and respective members, their individual roles and all

m a j o r a n d m in o r e qu i p m en t w a s s e c u r ed . F o r st a g e 2 a n e u r o s t i m ul a t o r m o n i to r i n g t e c h no l o gy w a s a l s o

s e cu r ed t o e n su r e p r op e r s e pa r at i on o f n e rv e r o ot s i n th e s a cr a l a r ea w h ic h we r e a n ti c ip a te d to b e f u se d ,

entangled or crossing over.

Overall Plan

Stage 1: Placement of tissue expanders to obtain enough skin for wound coverage.

Stage 2: Separation of twins with reconstruction and diverting colostomy

Stage 3: Colostomy closure

A s a p ar t of s ta ge 1 , ti ss ue e xp an de rs w er e p la ce d in t he p el vi c r eg io ns t o ob ta in e xp an si on o f s ki n an d

s ub cu ta ne ou s t is su es . B a bi es t ol er at ed a n e st he si a a nd t h e e nt ir e p ro ce du re w el l a nd w e r e s ub se qu en tl yndd i s c ha r g ed . A f t e r 2 m on t h s, c h il d r e n w e r e r e a d m it t e d f o r t h e 2 s t a ge o f s ur g e ry. B a si c w o r k u p wa s r e p e a te d .

I n v i e w o f n o rm a l h e m og l o bi n w i th s i c kl e c e l l t ra i t , f re s h b lo o d w as a r r a n ge d t o r e pl a c e b l o od l o s s a s p e r t he

r e c o m me n d a ti o n s o f t r a n s f us i o n s p e c ia l i s t t o a v o i d a n y a c i d os i s l e a d in g t o r i s k o f s i c k le c r i s is a n d i s c h e mi a o f

skin or other tissues. Twins were shifted to PICU night before surgery, central venous (subclavian) and arterial (

r a d i al ) l i n es w e r e a c c e s se d i n e a ch t w i n. B o w e l wa s p r e p ar e d a n d ma i n te n a n ce i n t ra v e n ou s f l u i d w a s s t a r te d .

Va n c o my c i n , c e f tr i a x on e a n d m e t r o ni d a z ol e w e r e a d d e d f o r p e r io p e r at i v e a n t i mi c r o bi a l p r o p hy l a xi s i n v i e w

o f b o w e l, u r i n a ry a n d s p i na l d u r a l su r g er y i n t h e p e l vi c a r e a . Tw i n s w e r e k e p t n il b y m o u t h a ft e r 3 a m o n d a y o f

surgery and shifted to operating room at 6am.

F i rs t in c is i on w a s g i ve n by p la s ti c s u rg e on s , fl a ps w e re r a is e d i n p r on e a n d s u pi n e p o si t io n , s e pa r at e d t i ll

s a cr u m, s ig n if i ca n t b l oo d lo s s a n d h y po t he r mi a w e re a n ti c ip a te d . S a cr a l v e rt e br a e w e re d i vi d ed i n t h e

m i d l in e , n e ur o s u rg e o n s s e p a r at e d t h e n e r v e r o o ts u s i ng t w o m i cr o s c op e s a n d t w o ne u r o -s t i m ul a t o rs t o e n s ur e

m u s c le i n n e rv a t i on o f l o w er ex t r e mi t i e s o f r e s p ec t i v e t w i n s, co r d /f i l u m t e r m i na l e w a s d i v i de d a n d d u r a w a s

repaired.

P ed ia tr ic S ur ge on s to od a t t he f oo t e nd , b ab ie s w er e b ro ug ht t o t he e dg e o f t ab le w it h l eg s w id e s ep ar at ed

s u p po r t e d w it h p a d d in g . M u l t ip l e s t a y s u tu r e s w e r e t a k e n t o e x po s e t h e p e r i ne u m . Va g i no - u r et h r o pl a s t y w as

d o n e f o r e a c h t wi n b e f o re s e p a ra t i on .

A n o pl a s t y w a s p l a n ne d a f t e r s e pa r a t io n w h e n t he s a c r a l f la p w o u ld b e i n p l a c e. S p h i nc t e r s a n d p e r in e a l b o dy

w e r e r e c o ns t r u ct e d . R i g h t t r a n sv e r s e c o l o st o m y w a s d o n e i n s u p i n e p o s it i o n.

Tw i n s w e r e s e p a ra t e d s u c c es s f u ll y a nd f u r th e r r ep a i r w a s c a r r ie d o ut f o ll o w ed b y c l o s ur e o f w o u nd s i n t wo

s e p a ra t e o p e r at i n g r o om s w i t h t w o s u rg i c a l a n d a n es t h es i a t e a m s. T h e t o t a l d ur a t i on o f s u r g e ry w a s 1 8 h r s w i t h

estimated blood loss of around 750 ml.

C o n s ul t a n t pe d i a tr i c i n t en s i vi s t s w e r e p r e s en t t h r ou g h ou t t h e e n t i re d u r a ti o n o f s ur g e ry t o e n s ur e a s s is t a n ce i n

m e d i ca l m a na g e m e nt . B o th t w i ns w e r e s h i f te d t o pe d i a tr i c i n t en s i ve c a r e u n i t f o r e le c t i ve v e n ti l a t or y s u pp o r t

w h e r e t h e y we r e p l a c ed i n p ro n e p o s it i o n w h i c h w a s a c h a l le n g e a s c h i l dr e n h a d a b i g wo u n d a t t h e b a c k co v e r ed

by a skin flap and colostomy in the front and at all cost pressure necrosis and infection had to be avoided . In the

i m me d ia t e p o st op e ra t iv e p e ri o d , w e f o un d t h e h a nd ma d e s o ft ri n gs m a de o f s t er i le g a uz e a n d c o tt o n v e ry

useful which were so placed that they formed the groove for the colostomy wound and thus prevented any direct

pressure on it. However once children were successfully extubated after 48 hrs their preoperative habit of lying

i n t h e p r on e p o si t io n d u e t o p l ac e me n t o f t is s ue e x pa n de r s c a me i n h a nd y t o m a n ag e t h e p o st o pe r at i ve p e ri o d

successfully. One of the twins had mild metabolic acidosis postoperatively which resolved in the next 24 hours.

Pain was managed with multimodal approach, pharmocological agents used were Fentanyl and Paracetmol.





S i c k le c e l l t ra i t d id n o t p os e a n y s ig n i f ic a n t p ro b l e ms a s f r e s h bl o o d wa s t r a n sf u s e d , ac i d o si s a n d h y po x i a w a s

avoided at all times.

P o s t op e r a ti v e l y Tw i n 1 h a d m i n i ma l w e a k n es s i n r i g h t l ow e r l i m b a n d Tw i n 2 h a d a m i n o r C S F l e a ka g e w h i ch

g r a d ua l l y s t o pp e d a f t er 5 d a y s . P r es e n tl y a f t e r a p e r i od o f 3 m o n t hs o f f o l lo w u p , b o th t h e t w i ns a r e w i t ho u t a n y

neurological deficit and are continent for stools and urine. They have started walking with support.

Discussion

M a n a ge m e n t o f c o n j oi n e d t w in s r e m a in s c h a l le n g in g t a s k . I t n o t o n l y i n v ol v e s r i s k s r e l a te d t o m e d i c a l i s s ue s

but ethical justification of risk taking. It is therefore a joint decision of the medical team and the family to go

a h e a d w i t h t h e s e p a ra t i o n o r n ot , a s t h e s u r v iv a l is f i f t y p e r c en t w i t h p o s si b l e s i g ni f i c an t m or b i d it i e s s u c h a s

limb paralysis, bladder and bowel dysfunction. It requires a multidisciplinary approach, thoughtful and

m e ti c ul o us p l an n in g t o t ak e c a re o f a l l t he a s pe c ts . T hi s c o mp r is e s e x te n si v e m e di c al w o r k- u p o n p at i en t s,

m u l t ip l e m e e t in g s a n d d i s c us s i o ns w i t h a l l t h e i n v ol v e d s p e c ia l t ie s a n d s u p po r t i ng s t a ff , i n v o lv e m e nt o f parents, psychosocial counseling of parents and rehearsal of the planned surgical procedure. The rationale for

[ 3]deferring surgery should include single heart, major communicating hearts or major anomalies.

E s t im a t i on o f c r o s s c i r c ul a t i on i s v e r y i m p or t a n t f or t w o r e a s o n s, f i r s t , t o c a l c u la t e d r u g d o se s r i g h t f r om t h e

beginning as drugs administered to one twin may have unexpected effects on the other while performing various

d i a gn o s t ic p r o c ed u r e s a n d s e c o nd , to c al c u l at e t h e p e r c en t a g e o f ca r d i ac o u t pu t sh a r e d b y th e t w i ns e s p e ci a l ly

before surgery as one twin may be dependent on the other circulation for survival. Though circulatory admixing[ 4]

i s m o r e c o m m o n i n t he t h o ra c o p ag u s a n d cr a n i op a g us t w in s t h a n i n o th e r t yp e s , st i l l , a c a r e f ul a n gi o g r ap h i c o r

radio isotopic imaging of the cross-circulation is recommended for all conjoined twins.

T h e m e t h od s t o a s ce r t a in t h e c r o s s c i r c ul a t io n i n th e c o n j oi n e d tw i n s a r e b e d s id e a t r o pi n e t e s t ( w h i c h w e u s e d in[ 5]

our case) , injecting Tc-99m microcolloidal human serum albumin (HSA), Tc-99m HIDA, or indigo carmine

a n d th e e x am i na t io n o f it s e x cr e ti o n in u r in e o f t he o t he r t wi n . Sz m uk e t a l we r e f i rs t t o de s cr i be t h e r o le o f

bispectral index monitor for detection of cross-circulation in complex cyanotic heart disease in Thoracopagus[ 6]

c on jo in t t wi ns .

I n t r ao p e r at i v e p e r i od i s u n u su a l m a i n ly d u e t o a b n o rm a l p o s it i o n a n d p r es e n c e o f t w o p a t i en t s o n t h e s a m e t a b l e

s i m ul t a n eo u s ly, i n a d d it i o n t o i n v o lv e m e nt o f m u l ti p l e s p e c ia l i ti e s a l o n g w i t h d u p li c a t io n o f m e d i ca l

personnel(for each twin) and equipment to handle them independently in the same operation theatre.

P e r f or m i n g m oc k d r i l ls u s i ng m a n n e qu i n s p e c if i c a ll y f o r c h a ng e o f p o s tu r e f r o m s u pi n e t o p r o ne a n d v i c e v e r s a

, s h i f ti n g t he p a t i en t h e a d to t h e f o o t e nd o f t h e t a b le a r e r e a l ly h e l p fu l . B e si d e s t h a t i ss u e s r e l a te d t o p r ol o n ge d

surgery, massive blood loss and hypothermia need to be anticipated and managed .

P o st o pe r at i ve p e ri o d i n a n i n te n si v e c a re u n it i s c r uc i al f o r s t a bi l iz a ti o n o f t h e s e pa r at e d i nf a nt s . E le c ti v e

v e nt i la t io n a n d p a ra l ys i s i n t h e i m me d ia t e p o st o pe r at i ve p e ri o d f o r 2 4 -4 8 hr s a r e p r ef e ra b le t o a c hi e ve[ 7]

h e mo d yn a mi c s t ab i li t y a n d f l ui d a n d e l ec t ro l yt e b a la n ce . P er i op e ra t iv e a n ti b io t ic s a n d s t ri c t i n fe c ti o us

precaution are recommended as sepsis is the major contributory factor in determining the outcome of the

s e p a ra t e d in f a n ts . T he o t h e r i m p or t a n t i s s ue i s a l a r ge s k i n d e f e c t a s f l a p s a n d g ra f t h as b e e n ut i l iz e d i n c l o s ur e .

To p r e v en t p r e s su r e r e l a te d n e c r o si s a n d t o m a i n ta i n v i t al i t y o f s o ft t i s s u e v a r i ou s t e c h ni q u e s a r e e m p l oy e d l i ke

nursing in prone posture with frequent turning , supportive gel padding and immobilization when needed. Early

n u t ri t i on a l r e ha b i l it a t i on h a d a k e y r ol e a n d i t s h o ul d b e i n s ti t u te d e a r ly a s i t a u gm e n t s w o u nd h e a li n g a nd

prevents infectious complications.

T h e i n c id e n c e o f C S F l e a k i n p o s t o p e r at i v e p e r i od i n p y g op a g us t w i ns w i t h c o n j oi n e d c o r d s w h o s u r vi v e[ 8]

s u rg e ry i s a b ou t 4 0% . I n o u r c as e o n e o f t he t w in s a l so h a d C SF l e a k wh i ch g r a du a ll y s ub s id e d a ft e r 5 d ay s ,







[8-16]Ta b l e : P y go p a gu s t w i ns wi t h u n i on in v o lv i n g n e u ra l s t r uc t u re s


R e fe r e nc e Y e a r o fsurgery

Sex Sharedneuralelements

Other anomalies

T im i ng o foperation

Outcome

Luc e 1956 Male Twosensor yr oots

Singlesharedanus

Elective,17days old

Unknown

Gupta 1962 Female Lowerspinal cor d,meningesand

caudaequina wer ecommon

Singlesharedanus;car diac

anomaly inB ”

Emergency,5 monthsold

“ A” nor malat 5 year s.“ B” diedintr a-

op

Votteler

1981 Female Spinal cor din continuity

Singlesharedanus

Elective,2months old

Nor malautonomic&motorfunction

Kalo

1985 Female Caudaequina par tiallyadhered

Singlesharedanus.br ain deathin “ B

Emergency,

6 days old“ A”unknown“ B” died 35days post-oper atively

Fowler

1994 Female Shar ed distalcor d “ A” patentr ectum; nouter us/vagina;one kidney.“ B” multiple:imper for atefistula; absentkidneys

“ A”neur ogenicbladderincontinent ofstool,positionalscoliosis.“ B” died day 3

Hockly

2001 Female Fusedlower spinalcor ds

B” nocommunication withanus

Elective,3 monthsold

Sur vived;neur ologically intact

Fieggen

2003 Female Distally

fused spinalcor ds

Single

sharedanus

Elective,

8 monthsold

Sur vived;

neur ologically intact;CSF

leak

Badr

2009 Male Fusedlower spinalcor ds

Singlesharedanus,

Elective,8 monthsold

Sur vived;neur ologically intact

Cur r ent

Report

2013

Female

Fusedlower

Spinal cor d

Singleanus,

Ur ethr alopening

Elective8monthsold

Sur vived;

Neur ologically intact




PYGOPAGUS Twins separation

case pictures

Fig 1. PYGOPAGUS conjoined lower backFig 2 Common genit o urinary and anal openings

due t o f usion at t he dist al ends of rect um, vagina

and uret hra

Fig 3a common genit ourinary opening and inf eriorly

common anal opening

Fig 3b shows a schemat ic diagram of f usion of dist al

ends of uret hra and vagina and t wo rect ums f used at

d i s t al c o m m on a n a l o p e n in g





Fig 4. CT reconst ruct ed images of Bony f usionat lower back showing common sacrum

Fig 6. MRI image of lower spine showing f usion oft h e s p i n al c o r d a n d f i l u m t e r mi n a l e a t th e le v e l o fsacrum

F i g 5 . L ow e r e n d o f sp i n e a nd s p i n a l c o r dshowing f usion on MRI

Fig 7. CT angiography showed a common iliacvein crossing over(f illing up) t o other t win at t hel e v e l o f a c e ta b u l um

Fig 8. Two t eams of anest hesia handling t he t wins f oranest het ic induct ion

Fig 9. Surgical f ield with open dura showing dist al endo f S p in a l c o r d a nd n e r v e ro o t s fu s e d a nd c r i s scrossing, being separat ed by t he neurosurgeon undermagnif icat ion by microscope using nerve st imulat orm o n i to r i n g o f d i st a l m u s c ul a r i n n e rv a t i on s o f l e gmuscles of each twin.





rdF i g 1 3. S e p ar a t e d t w i n s do i n g we l l i n P e di a t r ic I C U 3 p o s t o pe r a t iv e d a y

Fig 10. Twin af t er separat ion being managed in prone

posit ion in t he PI CU

ndF i g 11 . S e p a ra t e d T wi n o n 2 p o s t op e r a t iv e d a y a f t e r

elect ive vent ilat ion for 36 hours just bef ore ext ubat ion

Fig 12. Happy parent s wit h t he separat ed t win just af t er ext ubat ion

receiving nebulisat ion







Material and methods: T h i s s t u dy w a s c o n du c t e d in p a e d ia t r i c n e u r ol o g y c li n i c a n d e m er g e nc y r o o m( E R ) ,

department of paediatrics, Umaid hospital , Dr. S.N. Medical college, jodhpur.

Study type: P r o s pe c t i ve s t u dy

9 4 e p i le p s y p a t i en t s r e g i st e r e d i n t h e n e u r ol o g y c l i ni c w e r e e n r o ll e d i n t h e s t u dy.

A s a p a r t o f d o m ic i l ia r y s e iz u r e m a n a ge m e n t pr o t o co l , p a r e nt s a n d c a re g i v er s w e r e i n s tr u c t ed t o u s e l o r a ze p a m

m o u th d i s s ol v i ng t a b l e ts s u b li n g ua l l y i n a d o s e o f 0 . 1 m g / kg ( n o t m o r e t h a n 4 m g/ d o se ) f o r a s e i z ur e l a s ti n g > 5

m i n ut e s o r > 3 s e i z u r e s i n 3 0 m i n u t es .

Results: W h i le o n a n t i c on v u ls a n t s, 5 4 p a t i e n t s o u t o f 9 4 h a d s e i z u r es o n o n e o r m o r e o c c a si o n s. 2 2 p a t i en t s u s e d

buccal lorazepam for seizure management outside hospital.In 17 patients, seizures aborted within 1 minute; no

r e s p on s e i n r e m ai n i ng 5 . 11 p a t ie n t s u s e d bu c c a l l o r a ze p a m m ul t i pl e t i m e s f o r a r e c u r re n c e o f s e i zu r e , ou t o f

which 9 reported cessation of seizure every-time. None of these landed in status epilepticus.No serious adverse

effect of the drug was seen in any patient.

Conclusion: T h e s t u dy d e m o ns t r a te d b u c c a l l o r a ze p a m a s a c h e a p, e f f e c t i ve , s a f e a n d u s e f ul d r u g w i t h m i n i m a l

adverse effects for acute management of seizures together with effective domiciliary management training.Pre-

h o s p it a l / d o m ic i l ia r y m a n ag e m e nt o f a c u t e s e i z ur e i s r e c o mm e n d ed t o b e i n c lu d e d a s a p a r t o f b as i c l i f e s u p po r t

training of care-givers, emergency room personnel and paramedics.

ndAWA R D P O S T E R 2 . A ss e s s me n t o f p a re n t a l a nx i e t y in a t e r t i a ry c a r e P I C U

Mihir Patel, Farhan Shaikh, Preetham P, Roma Anand , Dinesh Chirla

Rainbow children's hospital,Hyderabad

Objective: A d m i ss i o n o f a c h i l d t o t h e p e d i at r i c i n t en s i v e c a r e u n i t ( P I C U ) c a n c r e a t e p a r e n ta l a n x i et y. We

e x a m in e d t h e f a c t or s t h a t c o nt r i b ut e t o p a r e n ta l a n x i e ty a n d t h e i r p a t t er n s .

Design: Prospective cohort study with a sample of parents of critically ill children admitted in the Level 3 PICU

a t R a i nb o w c h i ld r e n 's h o s pi t a l, H y d er a b a d.

Material and Method: T h e p a r e nt s o f 9 9 c h i l d re n w i t h P e d ia t r i c R i s k o f M o r ta l i t y 3 s c o re s ≥5 admitted to the

PICU. Parental anxiety was assessed with the State-Trait Anxiety Inventory, a validated tool used to measure

both the temporary (State) and long-standing (Trait) anxiety in adults. Both parents were assessed (total198r d

i n d iv i d u al s ) w it h i n 1 2 h o u r s o f a d m is s i on , o n 3 d a y o f a dm i s s io n a n d at t h e t i m e d i s c ha r g e.

Results: We f o u n d t h a t t h e a n x ie t y of t h e m o t h er w a s s i g ni f i c an t l y h i g he r t h an f a th e r ( p= < 0 . 00 0 1 ). H i g he r

P R I S M 3 s c o r e w a s a s s o ci a t e d wi t h h i gh e r p a r e nt a l a n xi e t y ( p <0 . 0 0 01 ) . T h e a n x i et y w a s h i g h w he n t h e c h i l dr e q u ir e d i n o tr o p e s ( p = 0 . 0 00 5 ) o r m e c h a ni c a l v e n ti l a t io n ( p < 0 .0 0 0 1) . A n x ie t y w a s l e s s i n m o r e e d u c at e d

families (p=0.0419). A doctor in the family reduced anxiety (p=0.0001). Gender, birth order, whether from the

city or outside, mode of payment, previous hospitalization, were all not significantly associated.

Conclusion: M o d e o f p ay m e n t ( I n s ur a n c e c o v e r p r e s en t or n o t) , g en d e r, b i rt h o rd e r of t h e c h i l d e t c a r e n o t

l i n ke d t o de g r e e o f a n xi e t y. P a r e nt s d o c o mp r e h en d w e ll i n s pi t e o f a n xi e t y an d a r e m o r e a n x io u s w i t h s i c k er

children. Such a study can help us plan our counseling methods better.

AWARD PAPERS AND POSTERS ABSTRACTS NCPCC 2013






PRISM2 score was correlated with T4 in expired children.

Conclusion- T T l e ve l s w e re l o w i n c r it i ca l ly il l p a ti e nt s . P e rs i st e nt l y l o w T w i th no n i m pr o ve m en t wa s3 , 4 3

a s s oc i a t ed w i t h p o o r o u t c o m e .

stH a l l B 1 . P re d i c to r s o f ex t u b a ti o n f a i lu r e i n me c h a n ic a l ly v en t i l at e d ch i l d re n i n P I C U

Siddharth Bhargava, PAPooni, Daljit Singh, Supreet Khurana, Harsh Sharma

Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Objectives: To p r o s p e c ti v e l y s t ud y b a s e l i ne r a t e o f e x t u b a ti o n f a i l u re a n d t o i d e n t i fy f a c t o r s t h a t p l a c e a p a t i en t

at greater risk.

Methods: C h i l d r e n n ee d i n g m e ch a n ic a l v e n ti l a t io n f o r > 2 4 h o ur s a d m i tt e d i n P I C U o v e r a p e r i od o f 1 y e a r

were included. Standard criteria were used for extubation.Results: Th e r e w e r e 7 6 c h i ld r e n w i t h m e a n a g e o f 50 m on t h s. M al e t o f e m a l e r a t i o w a s 3 : 1 . 2 8 % p a t ie n t s w e r e

brought in respiratory arrest. Average duration of ventilation was 6.9 days. Primary indication of ventilation

w a s r e s p ir a t o ry ( 6 5 % ) , C N S ( 2 7 %) , n e u r o m us c u l ar ( 8 % ) . M u l t io r g an f a i l u r e w a s t h e c o m m o ne s t m o r b id i t y

among respiratory causes followed by pneumonia and ARDS. Among CNS conditions, meningoencephalitis

w a s m o st co m mo n f o ll o we d b y s t at u s e p il e pt i cu s a n d I C H, in ne u ro m us c ul a r L G BS , sn a ke b i te a n d

o rg a no p ho s ph o ru s p o is o ni n g w e r e i n cl u de d . E x t ub a ti o n f a i lu r e r a te w a s 1 7 %. A m o ng v a ri o us p a ra m et e rs ,

t h e r e w a s n o s i gn i f i ca n t d if f e r en c e i n u nd e r l yi n g c on d i ti o n , ag e o f t h e p a t i en t , d ur a t i on o f v e nt i l a ti o n , us e o f

inotropes, severity of illness, sedation, GCS, x-ray abnormality in patients with extubation failure. Factors that

significantly correlated with extubation failure were previous episode of accidental extubation (p=0.0015), and

presence of stridor after extubation (p=0.0023). Accidental extubation was significantly related to stridor

(p=0.0061). Mortality was not significantly increased in patients with failed extubation.

Conclusion: I n s p i t e o f a l l e x t ub a t i on c r i t e r ia b e i n g m e t, e x t u ba t i o n f a il u r e w a s 1 7 % . A c c i de n t a l e xt u b a ti o n

a n d p r e s en c e o f s t ri d o r af t e r e xt u b a ti o n w er e s i g ni f i c an t r i sk f a c to r s n e e d in g r e in t u ba t i o n. S t e p s t o p r ev e n t

accidental extubation need to be taken.

stH a ll C 1 . Tu b er c ul o si s i n P I CU

Dr. Soonu Udani, Dr Rekha Solomon, Dr. Khanjan Shah

P D H i n du j a h o s pi t a l, M u m b a i

D r u g r e s i st a n t t u b er c u l os i s ( T B ) i n c h i l d re n i s i n c r ea s i n gl y b e i n g s e e n i n c h i l dr e n . M u l t id r u g r e s is t a n ce i n

c h i l dr e n i s t h o ug h t t o i nd i c a te r e c e n t t r a n sm i s si o n of d r ug r e si s t a nt s t ra i n s f r o m a d u l ts . Th e r e i s s p a r se d a t a i n

c h i l dr e n a n d t h i s i s p a r t ly d u e t o d i f f ic u l ty i n o b t a i n in g s a m p l es a n d s l o w g r o w th i n c u l t u r e .

Aim: To a n a l ys e t h e p r o f il e o f t u b e rc u l os i s a s s e e n i n t h e P I C U . To d e t e rm i n e t h e i n c i de n c e o f d r u g r e s i st a n t

t u b e rc u l o si s i n t h i s r e f e r re d p o p u l a t io n o f p a t i en t s

Methods: All children admitted in PICU with bacteriologically proven TB (smear, culture, PCR, or genotypic

t e s t in g ) b e t w ee n J a n u a r y 2 0 07 a n d J u n e 2 0 1 3 w e re r e t r o sp e c ti v e l y s t ud i e d. D r u g r e s i s t an c e w a s c l a s si f i e d a s

per WHO definitions.

Results: 25 children were admitted with bacteriologically proven tuberculosis during this period with a median

a g e o f 6 y e a r s ( r a n ge 0 . 5 to 1 7 y e a r s) . Th e r e w e r e 1 0 bo y s a n d 15 g ir l s . 1 9 of t h es e c h i l dr e n we r e a d m i tt e d fo r





m o n i to r i ng o f n e u r ol o g ic a l s t a tu s , 5 f o r p o st - o pe r a t i ve m o n i to r i n g, a n d 1 w i t h a c ut e r e s p ir a t o ry d i s t re s s

syndrome. More than half the children (13/25) had a past history of treatment with antituberculosis drugs and 5h a d a h i s to r y o f co n t a ct w it h a c a s e o f t ub e r c ul o s is . N on e h a d c u l tu r e s o r ti s s ue / f l ui d sa m p l in g do n e a s p a r t o f

t h e i r w or k u p f o r T B b e f o re r e f e r ra l . Tu b e r cu l o si s w a s c o n f ir m e d b y T B c u l t ur e i n 2 1 c h i l dr e n , g e n ot y p ic t e s t in g

i n 2, P C R i n 1, a n d Z N s t a i ni n g i n 1. 2 0 c h i l dr e n h a d t u b e rc u l o us m e n i ng i t is ( T B M ) o f w hi c h 1 0 ha d

d i s se m i n a te d T B . D r u g s e n si t i vi t y t e s ti n g ( D S T) w a s d o n e i n 1 8 c a s e s, o f w h i c h r e s is t a n ce t o a t l e a s t o ne a n t i -

t u b e rc u l ou s d r u g s e en i n w a s s e e n i n 1 4 /1 8 ( 7 7 % ) p at i e n ts ; t h e r e w e r e 3 M D RT B , 6 p r e X D RT B , a n d 1 X D R T B

case. Of the 20 children with TBM 5 children died, 8 improved, 3 worsened, and 4 were lost to follow-up.

Discussion: T h e h i gh i n ci d en c e o f D R- T B s e en h e re m a y b e d u e t o t he f a ct t h at m a ny ( 5 0% ) o f t he s e c h il d re n

w e re r e fe r re d a ft e r fa i lu r e o f f ir s t l i ne t h er a py. W hi l e i t do e s n o t r e fl e ct t he t r ue i n ci d en c e o f M DR T B i n th e

c o m m un i t y, t h i s a n a l ys i s o u t li n e s t h e f a c t t h a t u nl e s s a t i s su e d i a g no s i s a n d g o o d l a bo r a t or y s u p p or t i s a v a i la b l e ,

it would be very difficult to treat this disease appropriately.

Conclusion: 1 . T h e r e i s v e r y h i gh p r e v a l e nc e o f d r u g r e s i st a n c e ( 7 7 % ) t o f i r st l i n e A TT i n t h i s s t u dy.

2 . A l l e ff o r t s s h o ul d b e m a d e t o o b ta i n f l ui d a n d ti s s u e s a m p le s f o r c u lt u r e a n d D S T





S e l e c t O n e b e s t a n s w er :

1 . A n 8 - y e ar - o ld b o y h a s s t a p hy l o co c c a l s e p ti c s h o ck r e f r a ct o r y t o f l u i ds a n d v a s o pr e s s or s . H e h a s r e c e i ve ds t e r oi d s a l r e ad y. H i s c l i n ic a l h e m o d y na m i c p a r a m et e r s i n c l ud e t h e f o l l ow i n g : H R , 1 7 0 / m in ; B P, 6 5 / 33 m m H g ;mean arterial pressure, 42 mm Hg; central venous pressure, 15 mm Hg; cardiac index, 4.7 L/min/m2; systemicvascular resistance index, 6.25 Wood units; pulmonary vascular resistance index, 2 Wood units; SaO2, 96%.

W h i c h t r e a t m e n t i s t h e m o s t a p p ro p r ia t e f o r t h i s c l i ni c a l s i t ua t i on ?

A. Fluid resuscitation with packed red blood cellsB. Milrinone

C. Adrenaline

D. Noradrenaline

E. Dopamine

2 . A 4 - y e ar - o ld c h il d p re s e n ts t o th e e m e rg e n c y i n sh o c k . H e i s a s s e ss e d an d a de q u a te l y re s u s ci t a te d . H is

h e m o dy n a m ic s t a t e i s p l o tt e d o n t he C a r d ia c O u t pu t ( o r Ve n o us r e t u rn ) v s R i g ht a t r i a l pr e s s ur e s a s s h o wn b e l o w

a n d m ov e s f r o m A t o F t o B . W h i c h o f t h e s t a t em e n t s B E S T d e s c r i b e s h i s p r o g re s s :

A. Cardiogenic shock, improved with fluid bolus and inotropesB. Cardiogenic shock, worsened with fluid bolus and inotropesC. Cardiogenic shock, worsened with fluid bolus and improved with inotropesD. Hypovolemic shock, improved with fluid bolus and inotropesE. Hypovolemic shock, worsened with inotropes and improved with fluids

3 . S c i e n ti s t s d i s co v e r a n e w c h e m ic a l w i t h o xy g e n c a r ry i n g c a pa c i t y a n d c al l i t H b X . Yo u p e r f or m s o m e

e xp er im e nt s t o d is ce rn i t s n at ur e a nd p l ot t h e O 2- di ss oc ia ti on c u rv e o f H bX ( li ne B ). T he l in e A s ho ws O 2

P IC U Q ui zD r. N a m e e t J e ra t h M D

S r C o n s ul t a n t P e di a t r ic I n t e ns i v is t , I P A p o l lo H o s p it a l , N e w D e l hi


Critical Thinking



d i s so c i a ti o n c u rv e o f H b A . Wh i c h o f t he s t a te m e n ts i s t r u e r e g a r di n g t h e n e w m o l e c ul e ?

A . H b X c o n ta i n i ng b l o od t r a n sf u s i on w i l l im p r o ve o x y ge n a t io n i n a c h i l d w i t h A R D SB . H b X c o n ta i n i ng b l oo d tr a n s fu s i on w i ll N OT i m p r ov e o x y ge n a t io n in a c h i l d w i t h A R D S

C . H bX s ho ws t he p ro pe rt ie s o f m yo gl ob in

D . C h il d w i th H b X a n d l o w S p O 2 , wi l l sh o w d r a m at i c r e sp o ns e t o s up p le m en t al O 2 .

E . H bX s ho ws e xa gg er at ed H a ld an e E f f ec t.

4 . O n e - wa y t i c ke t s a r e n o w a v a i la b l e t o g o t o p l an e t X Y Z a nd s t a r t a n e w c i v i li z a t io n . T he a t m o sp h e r ic p r e s su r e

on planet XYZ is half of what it is on earth but the O2 concentration is double. Considering all other parameters

remain unchanged which of the following is true for the astronaut going there?

a . He w il l be t ac hy pn ei c b. A-a gradient will be higher

c . Wi l l n e ed O2 fr o m s o me o t he r s o ur c e t o s u rv i ve

d. Will be O K

e . H ig he r O 2 w il l d am ag e t h e l un gs

5 . A c h i l d w i t h s e v e r e A R D S i s b e i ng v e n t i l at e d i n y o u r P I C U . Yo u d e c i d e t o t u r n t h e c h i ld p r o n e a n d d i s c us s t h e

s a m e w i t h y ou r c o l l ea g u e . H e i s c o n c er n e d o f t h e c l i n ic a l s i t ua t i on a n d i n s t ea d s a y s t h a t p u tt i n g w e ig h t s o n t h e

c h i l d' s c h e s t wi l l h a ve t h e s a m e o r e v e n be t t e r ef f e c ts o n t h e v e n t il a t i on / p e rf u s io n r e l at i o ns h i ps . W h at d o y o u

t h i n k o f t h is i d e a o f h i s ?

A. Stupid

B. Moron

C. Star

D. Genius

E. Einstein

6 . S i x m o n th o l d c h i ld , d a y 5 p o s t VS D r e p a ir i s v e n t il a t e d a nd i s o n a f u r o se m i d e i n f u si o n f o r m o de r a t e m i t r al

CRI TICAL THI NKING PI CU Quiz




regurgitation. His ABG on partial ventilatory support shows

pH 7.52, pCO2 45, PO2 79, BE 15, HCO3 36, Na 133, K 3.1, Cl 88.

W h i c h of t h e f o l l ow i n g is t r u e f o r t h is c h i l d:

A . A c et a zo l am i de i f g i ve n w i ll i m p ro v e t h e a l ka l os i s

B . K l os s b ec au se o f F u ro se mi de i s t h e r ea so n f o r t he a lk al os is

C . C l l o ss b e ca u se o f F u ro s em i de i s t h e r e a s on fo r t h e a l k a lo s is

D . S h e w o u l d n ee d a h i gh e r p CO 2 f o r s po n ta n eo u s b r e a th i ng

E. Al l o f t he a bov e

7 . 5 y e ar o ld b oy i s b r ou g ht t o th e e m er ge n cy d e pa r tm e nt ( E D) h i t b y a c a r wh i le p l ay i ng o n th e r o ad . He i s

u n r e sp o n si v e a n d in d i st r e s s, H R 1 8 0 , RR 7 0 , S pO 2 8 2% w i th O 2 by m a s k, B P 7 0 / 40 m m H g a n d pu p i ls

bilaterally equal and reacting. He is fluid resuscitated, intubated and ventilated in the ED. Reduced air entry onr i g h t p r o m pt s a c h e s t t u b e o n t ha t s i de w h i c h i s b u b bl i n g v i g or o u s ly. H e c o n t in u e s t o h av e S p O 2 in 8 0 s i n s pi t e o f

F i O 2 1 a n d h i g h p r e ss u r e s. C X R s h o ws s i g ni f i c an t p n e u mo t h or a x p e r s is t i n g o n t h e r i g h t s id e . W h a t i s M O S T

APPROPRIATE in the current situation?

A . R e d u c e p r e s su r e s o n v e n ti l a t or to re d u c e a i r l e a k f r o m t h e d a m a ge d l u n g

B . I n s e rt an o t he r c h e s t t u b e i m m e di a t e ly a s o n e d r a i n i s n o t s u ff i c i en t

C . P u t t he d r ai n u n de r n e ga t iv e s u ct i on t o e x pa n d th e l u ng

D . S h i f t h i m to t h e o p e r at i n g r o o m f o r u rg e n t e x p lo r a t io n

E . G e t a n u r g en t C T h e a d t o r u l e o u t m a s s iv e i n t r ac r a n ia l b l e e d.

8. A12-year-old girl is admitted with cough and lung congestion for 2 days and

worsening respiratory distress. Examination reveals diminished air entry bilaterally with intercostal retractions,

distant heart tones, and pulses +1. Chest radiograph shows an enlarged cardiac silhouette and pleural effusions

bilaterally. Echocardiography reveals a dilated and poorly functioning left ventricle. The decision is made to

i n t ub a t e h e r. W h a t e ff e c t w il l p o s it i v e- p r e s su r e v e n ti l a t io n a n d p o si t i ve e n d - ex p i ra t o r y p re s s ur e h a v e o n h e r

heart?

A. Raises left ventricular preload and afterload

B. Raises left ventricular afterload and reduces contractility

C. Increases left ventricular contractility and reduces left ventricular afterload

D. Reduces heart rate and increases left ventricular contractility

E. Reduces left ventricular afterload

9 . A 1 5 -m o nt h -o l d c h il d un d er go e s c o mp l et e r e pa i r o f Te t ra l og y o f Fa l lo t . H e c o me s b a ck to yo u r P I CU

v en ti la te d. H e i s o n i nf us io ns o n M il ri no ne @ 0 .5 , D op am in e @ 1 0 a nd A dr en al in e @ 0 .7 m cg /k g/ mi n

r e s p ec t i v el y. H i s v i t a ls a r e : HR 1 8 8 , B P 5 2 / 36 m m H g ( m e a n 4 2 ) , C V P 9 a n d C V O 2 o f 4 4% . A n e ch o do n e





s h o ws g o o d c o n t ra c t i li t y a n d an t e gr a d e b l o od f l ow i n t o p u l mo n a r y a r t e r y d u r in g di a s t ol e . W h i c h o f th e

following is a logical explanation of the condition and its management?

A. Adrenaline induced tachycardia- reduce adrenaline

B. Poor coronary perfusion of the hypertrophied right ventricle- add Noradrenaline

C . D i a s t o li c d y s fu n c t io n , l o w C V P - g i v e f l u i d b o lu s

D. Good function, Milrinone induced hypotension- reduce Milrinone

E. Spontaneous ventilation will help cardiac output- Extubate

1 0 . A 6 - ye a r- o ld c h il d i s v e nt i la t ed on PRV C m o de a f te r s u rg e ry fo r h i s b r ai n st e m t u mo r. A s t h e m u sc l e

r e l a x an t s w e a r o f f t h e v e n t il a t o r g r a ph i c s s h o w t h e f o l l ow i n g p a t te r n . W h a t i s t h e m o s t a p p ro p r ia t e a c t i on ?

A . I n cr e as e s e da t io n o r mu s cl e r e la x an t s

B . S wi tc h t o S IM V ( P C )+ PS

C . S wi tc h t o VC b re at h ty pe

D . D ec re ase Ti

E. Extubate





Q u iz A n sw e rs a n d e x pl a na t io n s

Q 1 . a n s we r D

Explanation: The scenario is of vasodilatory shock, with low SVR and high cardiac output. With CVP 15 bolus

( f l ui d o r b l o od ) i s n o t r e qu i re d . N o r a d re n a li n e a s a v a s o p re s s o r i s n e e d ed h e r e .

Q 2 . an s w e r C

Explanation: The movement of the physiological state is from A-F-B. Point A is the normal balanced

h o m eo s t at i c s t a te . P o i n t F i s o n t h e l i n e o f i n c re a s e d VR ( w i t h a f l ui d b o l us ) . N o t e t h i s i s a l s o o n a l o we r c a rd i a c

c o n tr a c t il i t y c u r v e L i n e 5 , i . e . f l u id b o l u s n o t w e ll t o l e ra t e d b y t h e h e a rt . P o i n t B s ho w s i m p ro v e d c o nt r a c ti l i ty

o f h e a rt o n t h e h i g he r V R l i n e ( e f f ec t o f i n o t ro p e s a f t e r t h e f l u id b o l u s) . O p t i on C i s t h e m o s t l og i c a l a ns w e r.

Q 3 . a ns w e r D

Explanation: The line B shows a dramatic and rapid increase in saturations beyond a PaO2. If PaO2 were

i n c re a s e d w it h s u p p le m e n ta l O 2 , w e w o u l d e xp e c t a v e r y d r a ma t i c i n c re a s e i n S p O 2 ( s te e p p o r ti o n o f l i n e B ) .

Moreover, HbA or HbX will not improve saturations but only the oxygen carrying capacity in a patient of ARDS.

Q 4 . a ns w e r D

Explanation: Application of alveolar gas equation with double the FiO2 and half the atmospheric pressure

shows no significant change in PAO2. Astronaut (or Cosmonaut) should have similar PaO2 as on earth and will

not be tachypneic.

Q 5 . a ns w e r C

Explanation: The idea of turning prone is to improve the V/Q imbalance and allow more perfusion in the

healthier ventral lungs when turned prone. Putting weights on the chest will in effect increase the gravitational

force on the chest and its contents. Perfusion would be forced to dependent areas- already collapsed and

u n l i ke l y t o b e o f m u c h b e n ef i t . B u t i t w o u ld a l s o c o m p re s s t h e v e n t ra l l u n g s, a n d m o v e b l o od a w a y - i m p ro v i n g

t h e V / Q m i s ma t c h . A ll i n a l l , n o t a g r e a t i d e a b u t d e fi n i te l y w o r t h s om e a p p la u s e .

Q 6 . an s w e r E

Explanation: The ABG shows partially compensated metabolic alkalosis. Furosemide causes K and Cl loss

b o th o f w h i ch i n t u r n a re r es p on s ib l e f o r a l ka l os i s. A c e ta z ol a mi d e c a n i mp ro v e t h e g a s “ c os m et i ca l ly ” b y

i n d u ci n g me t a b ol i c a c i d os i s . Su c h a c hi l d w ou l d n ee d a h ig h e r C O 2 t o dr op t h e p H t o a l ev e l t o tr i g g er

breathing and should not be ventilated to normocarbia.





Q 7 . a ns w e r D

Explanation: Massive air leaks persisting after appropriately placed and functioning drains and causingcardiorespiratory compromise after any trauma should alert the clinician to the possibility of tracheo-bronchial

airway rupture. This rare condition is fatal unless thought of and urgently operated upon.

Q 8 a n s we r E

Explanation: PEEP reduces the afterload to the left ventricle improving cardiac output in an adequately fluid

resuscitated child.

Q 9 . A n s w e r C

Explanation: Tetralogy of Fallot is a condition with restrictive right ventricle(RV). The RV so far has beenhypertrophic. Contractility is usually not the issue, relaxation is. In a very restrictive RV, blood pouring into RV

from RightAtrium during diastole doesnot stay in the RV but moves on to PA(PulmonaryArtery)- the antegrade

b l o od f lo w i n t o PA d u r in g di a s to l e . T h i s i s s u g ge s t iv e o f se v e re d i a s to l i c d y s f un c t i on . I n s u c h a s c en a r io w i th

“ l ow e r” C VP t h e a p pro a ch w ou l d b e t o in c re a se v e no u s r et u rn a nd i mp ro v e d i as t ol i c d y sf u nc t io n . M o re

v a s oc o n s tr i c to r s a n d p u re i n o tr op e s ( w i t h w o rr i s om e c h ro n o tr op y ) a re n o t n e e de d . T h e b e s t r es p o ns e i s – C .

Q 1 0 . An s w e r D

Explanation: The patient's expiratory efforts begin just prior to the end of mechanical inspiratory time, causing

t h e p re s s ur e s p i k e. T h e s i m u lt a n e ou s f l o w -t i m e s h o ws z e ro f l o w p r i or t o m e c h a n ic a l e x p i r a ti o n . S l i g h t r e du c t i on

of inspiratory time will correct this.





F o rt h c om i ng e v en t s

1. IAP central Delhi organizesC M E o n P e d ia t ri c B o ne m a rr ow t r an s pl a nt a ti o nD a t e : J a n 2 5 t h( s a t ) 2 0 14Venue : Jaypee Siddarth hotel,Patel Nagar,DelhiFor information Contact Dr Ankur 9818283165Email: [email protected]

2 . E CM O s oc ie ty o f In di a o rg an iz esInternational ECMO conferenceD a t e s : J a n 2 9 t h- f e b 2n d 2 0 1 4

Venue: KIMS hospital, HyderabadFor information Contact Dr Suneel Pooboni 09642562218Email: [email protected]

3 . I SC CM o rg an iz esth

C r it i ca re 2 0 14 ( 20 a n nu a l c on f er en c e o f I S CC M )th th

Dates Feb 14 -18 2014Venue: Birla Auditorium, JaipurContact : Dr Manish Munjal 9829062550Email: [email protected] web: www.criticare 2014.com

4 . D e p a rt m e n t o f P e d i at r i c s n e o na t o l og y a n d a d o le s c e nt me d i c in e B L K H o s pi t a l a n d I A P C e n t ra l D e l h i o r ga n i z es

Pediatric and neonatal ventilation workshopD a te s : M a r ch 2 2 ,2 3 rd 2 0 14Venue: BLK Superspeciality Hospital,Pusa road,DelhiFor Information Contact Dr Ankur 9818283165/Dr Praveen Khilnani 9810159466Email: [email protected]

5 . We st B en ga l IA P I C c ha pt er o rg an iz esB a si c P e di a tr i c i n te n si v e c a re c o ur s e ( B PI C C)D a t e s: M a r c h 2 4 ,2 5 2 0 1 4Ve n u e : B C R o y C h i l d r e ns h o s p it a l , Ko l k ot t aFor Information Contact Dr Sukanta Chatterji9830275685/

Dr Partha Bhattacharya9830072984E mail: [email protected]

6 . I A P i n t en s i ve c a r e c h a p te r , D e l hi o r g an i z e sth

1 6 N C PC C 2 0 14 ( N at i on a l C o nf e re n ce o f P e di a tr i c C r it i ca l c a re )th t h th th

D at es : No v 6 a nd 7 ( wo rk sh op s) No v 8 a nd 9 ( ma in co nf er en ce )Ve n u e : M an e k S h a w C o n v en t i on C e nt r e , D e l h iFor information contact : Anil Sachdev:9810098360D r K C h u g h9 8 1 06 0 8 58 0 / Dr P K h i ln a n i 9 8 1 0 15 9 4 66Email: [email protected] /[email protected]@ hotmail. com Web: www.ncpcc2014.c om




Indian Academy of Pediatrics

I nt en si ve C are C ha pt er

Application Form

Name: _____________________________________________________________________ Age: _____________

Address for Correspondence Offi ce/ H ospi tal Address

____________________________________________ ____________________________________________

____________________________________________ ____________________________________________

____________________________________________ ____________________________________________

Tel No. ______________________________________ E-mail ID ___________________________________

IAP Membership No. ___________________________

D o y o u h a ve a s e pa r at e P I CU i n y o ur h o sp i ta l . Ye s N o . B e ds : __ _ __ _ __

Is your unit accredited by Pediatric Intensive Care Council. Yes No.

I s y o ur u n it a c cr e di t ed b y P e d i at r ic I n te n si v e C ar e C o un c il

for certificate or fellowship program. Yes No.

Are you formally trained in Pediatric Intensive Care. Yes No.

Place of training: ______________________________ Duration of training: ___________________________

Information regarding equipment being used by you

SI No. N o. Manufacturer

1. Ventilator _______________ _____________________________________

2 . In va si ve BP Mo nit ors _ __ __ __ __ __ ___ _ _ __ __ __ __ ___ __ __ __ __ __ ___ __ __ __ __ __ __

3 . N on -I nv as iv e M on it or s _ __ __ __ __ __ __ __ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

4. Pulse Oximeters _______________ _____________________________________

5. Arterial blood gas analyser _______________ _____________________________________

6. Infusion Pumps _______________ _____________________________________

7 . O xy ge n a na ly se rs ( Fi O2 ) _ __ __ __ __ __ __ __ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

8. O thers _______________ _____________________________________

D.D No._________________ Date________________ Bank__________________________Place__________

( P l e as e s e n d t h i s f o r m d u l y fi l l e d w i t h D . D f o r Rs . 1 0 0 0 /- i n fa v o r o f “ IA P I N T EN S I VE C AR E CH A P TE R ” p a y a bl e a t

DELHI and a copy of brief bio-data.)

Mail to:

Dr. Anil Sachdev

Vi c e C h a i rm a n

Institute of Child Health, Department of Pediatrics

S i r G an g a R a m H os p i ta l , O l d R aj i n d er N a g a r, N e w D e l hi - 11 0 0 6 0

Mobile: 9810098360 • Email: [email protected]



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